ChanBeDu/relevant_section_length · Datasets at Hugging Face

2,427

193,348

26038

Discharge summary

report

Admission Date: [**2115-9-23**] Discharge Date: [**2115-9-27**] Date of Birth: [**2039-4-9**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Shellfish Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: ?GI bleed Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 4541**] is a 76 year-old female with past medical history of myelodysplastic syndrome (finished her third cycle of 5-Azacitidine four days prior to admission), status post recent MI who was transferred from an OSH status post one episode of brown emesis. The patient states she had not been feeling well four days prior to admission. She went for her chemotherapy with Vadasa and was found to have low hematocrit and thrombocytopenia. She states that over the past few days she has had diffuse abdominal pain with "gas pains" through her abdomen and pain in her upper back. The morning of admission she awoke with the need to vomit. She had one episode of brown emesis, but did not note streaks of blood or coffee ground emesis. She denies diarrhea and states she has been constipated over the past few days. She has occasionally noted small amounts of bright red blood on her toilet paper, but none in the toilet. The day or admission she states that she initially had constipation and then one large loose brown bowel movement. She denies melena, fevers, chills. . She presented to an OSH for the emesis and abdominal pain. At the OSH she recieved one unit of platelets for a platelet count of 10. Hematocrit was 26. She was transferred to [**Hospital1 18**] for further evaluation and management. . In the ER she received 1 L NS, anzemet and 2 mg of morphine IV. Her temperature was noted to be 100.6. She was ordered for 2 units PRBCs and receieved 1 gm tylenol. She was found to have guaiac positive brown stool on exam. . Upon arrival to the [**Hospital Unit Name 153**] her vital signs were stable. She was still receiving her first unit of PRBCs. . In the ICU the patient was initially hemodynamically stable. Her SBPs trended down to the upper 80s and she was transfused an additional unit of PRBCs for possible bleed (hematocrit was around 29 at that time and had risen appropriately). She was also transfused platelets to keep her platelet count >50. She was started on cipro/flagyl to cover for posisble diverticulitis seen on CT abdomen. She was started on stress-dose steroids and pressures improved over the next day. She was also noted to be slightly hypoxic with O2 saturations 92% off O2. Her CXR was clear and it did not appear she had an infection. The relative hypoxia was believed to be secondary to some component of volume overload. . ROS: Denies fevers, chills, dysuria, hematuria, SOB, dizziness. (+) abdominal pain (+) fatigue (+) occasional headache Past Medical History: PAST MEDICAL HISTORY: 1. Myelodysplastic syndrome in transformation to AML, with 11% blasts on peripheral smear [**4-30**], undergoing 5-azocytadine treatment with no blasts seen for three months 2. Coronary artery disease status post Cypher stent to LAD [**11-30**] off Plavix shortly thereafter with oncology input; recent MI [**7-31**] treated medically secondary to thrombocytopenia. Restarted on ASA at that time. Stress MIBI [**9-6**] showed moderate inferolateral reversible defect. 4. Hypertension 5. Hypercholesterolemia 6. Left total hip replacement 7. Partial hysterectomy 8. Left nephrectomy 20 years ago secondary to nephrolithiasis 9. Detached retina Social History: She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a 20 pack-year smoking history but quit 7 years ago. She denies alcohol use. She has two children. Family History: Mother with uterine cancer. Father with history of hypertension, died of stroke. Sister with "[**Name2 (NI) 500**] cancer." Sister died at 59 of heart disease. Brother with myocardial infarction at age 63, son in 40s. Physical Exam: VITAL SIGNS: 100.0 130/42 98 24 95% on RA GENERAL: Lying in bed, breathing comfortably, in NAD HEENT: Left pupil minimally reactive, right pupil reactive, MMM NECK: No carotid bruits, JVP not well visualized HEART: Regular rate and rhythm, 2/6 SEM LUNGS: Clear to auscultation bilaterally ABDOMEN: Hypoactive BS, soft, nondistended, + tenderness in epigastric region, RLQ and LLQ, no rebound/guarding EXTREMITIES: No c/c/e NEUROLOGIC: Alert and oriented times three, MAEW SKIN: Multiple areas of ecchymosis, petechiae Pertinent Results: Labwork on admission: [**2115-9-23**] 04:35PM WBC-34.4*# RBC-2.78*# HGB-8.4*# HCT-23.3*# MCV-84 MCH-30.2 MCHC-36.0* RDW-16.8* [**2115-9-23**] 04:35PM PLT SMR-LOW PLT COUNT-82* [**2115-9-23**] 04:35PM NEUTS-64 BANDS-4 LYMPHS-14* MONOS-12* EOS-0 BASOS-1 ATYPS-0 METAS-4* MYELOS-1* [**2115-9-23**] 04:35PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2115-9-23**] 04:35PM GLUCOSE-114* UREA N-41* CREAT-1.2* SODIUM-135 POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-15 [**2115-9-23**] 04:35PM ALT(SGPT)-38 AST(SGOT)-24 LD(LDH)-548* CK(CPK)-33 ALK PHOS-79 AMYLASE-27 TOT BILI-1.1 [**2115-9-23**] 04:35PM LIPASE-36 [**2115-9-23**] 04:35PM CK-MB-NotDone cTropnT-0.02* . [**2115-9-25**] 04:02AM BLOOD Cortsol-6.2 [**2115-9-25**] 04:28AM BLOOD Cortsol-24.2* [**2115-9-25**] 04:55AM BLOOD Cortsol-30.5* . Labwork on discharge: [**2115-9-27**] 12:10AM BLOOD WBC-11.8* RBC-3.72* Hgb-10.9* Hct-30.9* MCV-83 MCH-29.4 MCHC-35.4* RDW-16.5* Plt Ct-37* [**2115-9-27**] 12:10AM BLOOD Neuts-41* Bands-0 Lymphs-19 Monos-27* Eos-1 Baso-0 Atyps-1* Metas-6* Myelos-4* Promyel-1* NRBC-2* [**2115-9-27**] 12:10AM BLOOD Glucose-169* UreaN-40* Creat-1.0 Na-135 K-4.3 Cl-102 HCO3-23 AnGap-14 . CT ABDOMEN/PELVIS W/O CONTRAST [**2115-9-23**] IMPRESSION: 1. Inflammatory stranding adjacent to the ascending colon in the setting of pancolonic diverticulosis. These findings are highly suspicious for ascending colonic diverticulitis. 2. No evidence of retroperitoneal or other intraabdominal hemorrhage. 3. Extensive atherosclerotic disease. 4. Status post left nephrectomy. 5. Cholelithiasis without evidence of cholecystitis. 6. Severe degenerative disease throughout the lumbar spine. 7. Anemia. 8. Adrenal hyperplasia. . ECG Study Date of [**2115-9-23**] Sinus rhythm Atrial premature complex Nonspecific inferolateral ST-T wave abnormalities Since previous tracing of 9=18-06, T wave changes slightly less prominent . CHEST (PORTABLE AP) [**2115-9-24**] IMPRESSION: AP chest compared to [**2115-8-10**]: Lung volumes are now normal. Lungs are clear. There is no pleural effusion. Mild cardiomegaly is stable, and pulmonary vasculature is mildly engorged. There is no free subdiaphragmatic gas. Tip of the right subclavian infusion port projects over the upper SVC. Previous transvenous pacemaker has been removed. . CHEST (PORTABLE AP) [**2115-9-25**] IMPRESSION: AP chest compared to [**9-24**]: Borderline cardiomegaly unchanged. Lungs clear. Mediastinal fullness and leftward tracheal deviation suggest an enlarged right thyroid lobe. No pneumothorax or pleural effusion. Tip of the left subclavian line projects over the mid SVC. Brief Hospital Course: 76 year-old female with MDS on chemotherapy with several days of increasing lethargy, small amounts of BRBPR, and one episode of brown emesis transferred from OSH with worsening anemia and thrombocytopenia. . 1. Anemia/question of gastrointestinal bleed. Her anemia is likely secondary to recent chemotherapy and her underlying disease with some component of gastrointestinal losses. The patient was admitted with abdominal pain and one episode of brown emesis. She complained of occasional small amounts of bright red blood per rectum over the course of the week. Possible sources for bleed are hemorrhoids in the setting of thrombocytopenia (the patient has a history of hemorrhoids), gastritis secondary to steroids, polyps, AVMs, or diverticula. She had no episodes of overt GI bleeding during hospitalization although she was guaiac positive on admission. The patient was seen by gastroenterology, who did not wish to perform an endoscopy given that the patient was not actively bleeding, was thrombocytopenic, and was hemodynamically stable. Gastroenterology believed the presumed upper GI bleeding to be secondary to steroid gastritis versus lower GI bleeding from diverticula. The patient was continued on a PPI. The patient's aspirin was initially held; she was given one dose of aspirin in the ICU when it was clear she was not bleeding. The patient's oncologist did not want the patient to continue on aspirin with her history of MDS and thrombocytopenia and the patient was instructed not to restart aspirin. . 2. Abdominal pain. The patient complained of diffuse lower abdominal pain on admission. CT abdomen showed evidence of diverticulitis as above. No evidence for ischemia. Lactate remained elevated and was believed secondary to the patient's underlying hematologic malignancy. The patient was treated with ciprofloxacin and flagyl for a fourteen-day course. The patient was febrile to 100.6 on admission but otherwise remained afebrile. The patient's abdominal pain was resolved on discharge. . 3. Myelodysplastic syndrome. The patient was followed by her primary oncologist throughout hospitalization. The patient completed chemotherapy as above. WBC was elevated at 34 on admit with evidence of atypical cells on smear. The patient received two units packed red blood cells on admission. The patient was transfused one unit packed red blood cells and one bag of platelets prior to discharge. The patient requires HLA typed transfusions. . 4. History of recent myocardial infarction. The patient has a recent history of inferior myocardial infarction. She was asymptomatic throughout hospitalization. Cardiac enzymes were slightly elevated on admission, likely secondary to demand. The patient was continued on her statin, BB, and ACEI. ASA was held as above. . 5. Hypertension. The patient was continued on lisinopril and half of her home dose of Toprol XL with good effect. The patient was discharged home on half of her home Toprol XL. . 6. Acute renal failure. The patient's creatinine was elevated on admission; 1.2 from baseline 0.8-1.0. The patient's creatinine improved after receiving blood transfusions and IV fluids. Consistent with pre-renal etiology. . 7. Elevated lactate. The patient's lactate remained elevated on admission. The patient was not septic. The elevated lactate was likely secondary to the patient's underlying hematologic malignancy. . Code: DNR/DNI Medications on Admission: ASA 325 mg Lipitor 80 mg Lisinopril 10 mg Toprol XL 100 mg Predlo 10 mg qd Furosemide 20 mg-patient stopped taking for urinary frequency Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 21 doses. Disp:*21 Tablet(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 31 doses. Disp:*31 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. Disp:*30 Packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Anemia, likely secondary to MDS versus GI source 2. Diverticulitis, on course of antibiotics, tolerating po . Secondary: 1. Myelodysplastic syndrome in transformation to AML, with 11% blasts on peripheral smear [**4-30**], status post 5-azocytadine treatment 2. Coronary artery disease status post Cypher stent to LAD [**11-30**] off Plavix shortly thereafter with oncology input; recent MI [**7-31**] treated medically secondary to thrombocytopenia. Restarted on ASA at that time. Stress MIBI [**9-6**] showed moderate inferolateral reversible defect. 4. Hypertension 5. Hypercholesterolemia 6. Left total hip replacement 7. Partial hysterectomy 8. Detached retina Discharge Condition: Afebrile, vital signs stable. Hematocrit and platelet count stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, shortness of breath, chest pain, abdominal pain, nausea, vomiting, black stools or blood in your stools, or any other concerning symptoms. . Please take your medications as prescribed. - You should take levofloxacin and flagyl (antibiotics) for diverticulitis. Take one dose of each tonight and then as direceted for ten more days. - You should take lasix 20 mg once daily and one potassium packet once daily later in the day for potassium repletion. - Your dose of toprol XL was decreased to 50 mg once daily. - You should continue prednisone 10 mg once daily. - You should not take aspirin. . Please keep your follow-up appointments as below. Followup Instructions: Please go to [**Hospital3 7571**]Hospital on Monday morning for follow-up. You should receive a Procrit shot at that time.

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Discharge summary

report

Admission Date: [**2155-4-5**] Discharge Date: [**2155-4-14**] Date of Birth: [**2071-7-7**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Intubated Bronchoscopy History of Present Illness: 83 y/o F PMH CVA/stroke, HTN, [**Hospital 33210**] transferred from Nursing Home for respiratory distress. Overall limited history. Per ED report patient has long-standing dysphagia secondary to stroke and recurrent aspiration PNA. She had one episode of vomiting today and was hypoxic throughout the afternoon in the 80s and eventually brought into the ED for evaluation. On the resident transfer form reports 82% on RA and reported baseline mental status alert, disoriented and cannot follow simple instructions and risk alert of aspiration. . On arrival to the ED VS 91% NRB, HR 91, BP 126/77, Tm 98.4. Per report patient's sat's ranged 80-90% on NRB. No ABG done prior to intubation. She was given 500 cc NS bolus and vancomycin, levaquin and flagyl for antibiotics (levaquin and flagyl not signed off on). Tmax 99.4 rectal. Vital on transfer 90s, 121/73 (per report no episodes of hypotension). EKG demonstrated sinus 96, no right heart strain. Patient transferred to MICU s/p intubation. . Patient's family reports patient recently discharged from [**Hospital 2587**] last friday following CVA (recurrent) she has been somnelent/sleepy at [**Hospital3 2558**] but otherwise no compliants. Denie history of fever, chills, cough, abdominal pain. They report that patient's communication is limited but did not notice any recent changes. Past Medical History: - H/O Aspiration PNA - family deny - H/O right CVA/Stroke/TIA - several, recurrent - HTN - HLD - Dysphagia - family deny - Right Humeral fracture - History of depression Social History: Lives at [**Location **]. Non-smoker. Family History: NC Physical Exam: On Admission: GEN: Intubated and sedated. Not arousable to voice. HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, RESP: Clear to auscultation anteriorly. CV: RR, + 3/6 systolic ejection murmur ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: Pupils equal and reactive to light. RECTAL: Full of stool. . On Discharge: VS: 97.6 152/73 60 20 100% RA GEN: awake, alert, no distress, able to respond in 1-word answers to repeated prompting (Russian-speaking) HEENT: PERRL, EOMI, anicteric, dry MM RESP: right lung clear to auscultation, left lung with rales at base, good air entry and in no respiratory distress CV: RR, + 3/6 systolic ejection murmur ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no edema in upper extremities, R PICC line removed, L PIV in place with no surrounding infiltration SKIN: no rashes/no jaundice/no splinters NEURO: awake and alert, as above non-verbal, pupils 4mm and reactive b/l, EOMI, follows 1-step commands with repeated prompts, tracks with eyes Pertinent Results: On Admission to ICU: [**2155-4-5**] 01:25AM BLOOD WBC-8.8 RBC-4.91 Hgb-14.1 Hct-43.6 MCV-89 MCH-28.6 MCHC-32.2 RDW-15.2 Plt Ct-343 [**2155-4-5**] 01:25AM BLOOD Neuts-79.0* Lymphs-17.4* Monos-2.5 Eos-0.5 Baso-0.5 [**2155-4-5**] 01:40AM BLOOD PT-11.9 PTT-19.2* INR(PT)-1.0 [**2155-4-5**] 01:25AM BLOOD Glucose-144* UreaN-25* Creat-0.7 Na-139 K-5.2* Cl-104 HCO3-23 AnGap-17 [**2155-4-6**] 02:51AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.8 . On Discharge from ICU: [**2155-4-9**] 03:44AM BLOOD WBC-5.4 RBC-3.38* Hgb-10.0* Hct-28.8* MCV-85 MCH-29.7 MCHC-34.9 RDW-14.9 Plt Ct-202 [**2155-4-9**] 03:44AM BLOOD Neuts-74.3* Lymphs-15.9* Monos-5.1 Eos-4.5* Baso-0.2 [**2155-4-9**] 03:44AM BLOOD PT-11.8 PTT-25.5 INR(PT)-1.0 [**2155-4-9**] 03:44AM BLOOD Glucose-88 UreaN-7 Creat-0.3* Na-138 K-3.5 Cl-106 HCO3-30 AnGap-6* [**2155-4-9**] 03:44AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.2 . ABG: [**2155-4-9**] 11:58AM BLOOD Type-ART pO2-108* pCO2-41 pH-7.44 calTCO2-29 Base XS-3 . Other pertinent labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2155-4-14**] 07:15 6.4 3.96* 11.1* 34.8* 88 28.0 31.8 15.2 329 . Microbiology: Blood Culture, Routine (Pending): NGTD . Urine Culture: ESCHERICHIA COLI | ESCHERICHIA COLI | | AMIKACIN-------------- <=2 S <=2 S AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- =>32 R =>32 R CEFAZOLIN------------- <=4 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 NITROFURANTOIN-------- <=16 S <=16 S TOBRAMYCIN------------ 8 I 8 I TRIMETHOPRIM/SULFA---- =>16 R =>16 R . Sputum/BAL: STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S . Respiratory Viral Culture (Final [**2155-4-8**]): No respiratory viruses isolated. . Bronchoscopy: Airways: The observed trachea and carina were normal. The left mainstem, LUL, lingula and LLL segments and observed subsegments were normal with minimal purulent secretions that were easily suctioned. The right mainstem, RML and RLL were normal in appearance with minimal to moderate mucous that was easily suctioned. The respiratory mucosa in the take-off of the RUL was inflamed and erythematous. The bronchosopce was advanced to the apical segment of the RUL. A BAL was performed with 90cc of sterile saline infused and ~40cc of purulent secretions were aspirated. There were no complications and the patient tolerated the procedure well with stable oxygenation (SpO2 94-96% on stable vent settings - FiO2 100%). General impression: Inflamed, irritated RUL with purulent secretions aspirated on BAL. Sample sent for bacterial, AFB, viral and fungal cultures as well as cytology. . Imaging: CTA: IMPRESSION: 1. No acute pulmonary embolism. 2. Ectasia of the ascending thoracic aorta, without acute thoracic aortic pathology. 3. Chronic scarring and fibrosis in the right upper lobe, minimally in the right lower and left upper lobe. 4. Bibasal central ground-glass opacities, differential diagnosis includes infection, mild edema, or aspiration. 5. ET tube and nasogastric tube are in optimal position. . [**4-11**]: RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler son[**Name (NI) **] of the right internal jugular, subclavian, axillary, brachial, basilic and cephalic veins was performed. There is a PICC in one of the right brachial veins. There is non-occlusive thrombus in the brachial vein extending into the axillary and subclavian vein. There is occlusive thrombus in the cephalic vein. . CXR [**4-10**]: FINDINGS: Right apical pleural thickening and right hilar superior displacement is unchanged since [**2155-4-5**]. Right upper, left lower and lingular opacity have improved since [**2155-4-9**]. A small left pleural effusion is new. There is no evidence of pulmonary edema. The cardiac size is normal. Thoracic spine scoliosis, convex to the left is mild. IMPRESSION: Improving multifocal consolidation; new small left pleural effusion. . Brief Hospital Course: MICU Course: 83 y/o F PMH CVA/stroke complicated by dysphagia, HTN, [**Hospital 33210**] transferred from Nursing Home for respiratory distress requiring intubation, found to have MRSA pneumonia and urinary tract infection. . ACTIVE ISSUES: ============== # MRSA pneumonia: patient is at a high risk of aspiration due to dysphagia secondary to several strokes, her most recent stroke was 1 week prior to this admission and patient developed vomiting (likely due to UTI, see below) and likely aspirated. She required intubation on arrival and was intubated from [**4-5**] to [**4-8**], had successful extubation. She was found to have multifocal pneumonia on imaging and treated for HCAP coverage with vancomycin and cefepime. She had a CTA which ruled out PE (study performed given high oxygen requirement on first day of admission). Bronchoscopy was done and showed purulent secretions in the RUL; FiO2 significantly improved following suction of secretions. BAL and sputum returned positive for MRSA and patient was narrowed to vancomycin. She should complete a 2-week course of vancomycin (last day = [**4-18**]). Upon transfer to the floor, patient was quickly weaned to room air and did not have any cough or shortness of breath. She was afebrile and had no leukocytosis. Speech and swallow initially evaluated patient and recommended keeping her NPO on maintenance fluids. She was re-evaluated on [**4-14**] prior to discharge and was found to do well with honey thickened liquids and pureed solids, which was her diet at [**Hospital3 2558**] prior to admission. We had an extensive discussion with the family about goals of care and patient's functional status and her son decided to make her DNR/DNI; he additionally said that he would not want to place feeding tubes to maintain nutrition and would rather feed for comfort. Patient was seen by palliative care prior to discharge. She was discharged back to [**Hospital3 2558**] with 4 more days of antibiotics and updated speech/swallow recommendations. . # UTI: urine culture grew two different strains of E. Coli and presumptive S. bovis. She completed a 3-day course of ceftriaxone without any symptoms. At time of discharge, she was afebrile with no leukocytosis. . # Catheter-induced upper extremity DVT: pt had PICC line placed in MICU for antibiotic therapy. She was found to have dependent edema around right elbow and an U/S was done which found a right side upper extremity DVT. The PICC line was removed and a peripheral line was replaced in the other arm. The arm was elevated and the swelling improved. Anticoagulation was not initiated given many recent strokes, including one 1 week prior to admission, and increased risk of intracranial hemorrhage. Coumadin would not be a good option for patient given poor nutritional state and initiating lovenox at this time seemed to outweigh the benefits. This was discussed with the family in the larger context of goals of care for the patient. . # H/O CVA/Stroke: patient has had recurrent CVAs this year with baseline poor functional status, largely non-verbal. A goals of care discussion was held with the patient's son and his wife given recurrent aspiration pneumonia and dysphagia. The son wished to make patient DNR/DNI. He had never discussed her end-of-life wishes prior to her cognitive impairment but believes she would not want any aggressive or invasive measures. Given her dysphagia and nutritional status we discussed with the family options for feeding. They expressed that she would not have wanted a feeding tube or NG tube for feeding. Pt was maintained on maintenance fluids and prior to discharge, was at baseline swallowing (puree solids and honey thickened liquids). The son said that in the event the patient's swallowing capabilities worsened, he would like to feed for comfort and accept the aspiration risks. Patient should have repeat swallow evaluation at [**Hospital3 2558**]. She is currently on full dose ASA which was continued. . # Constipation: Required disimpaction on admission and had subsequent large BM. Continued bowel regimen with senna, colace, and miralax. . INACTIVE ISSUES: ================ # HLD: Continued lipitor. . # Depression: continued Remeron 30 mg qhs. . TRANSITION OF CARE: =================== # Goals of care - would continue to discuss with family the larger goals of care for patient and whether risk of aspiration pneumonia and possibility of recurrent hospitalizations is consistent with these goals. [**Name (NI) **] son is now processing the decline of his mother's health and decided to make DNR/DNI on this admission. As above, he additionally expressed that he would not want to feed her invasively with a feeding tube or NG tube, and that if her swallowing capacity were to decline he would want to feed for comfort and to accept aspiration risk. We did not specifically address whether he would like to consider no longer re-hospitalizing her though this is something he will think about. Our palliative care team evaluated the patient prior to discharge and will contact son to continue discussing goals of care. Recommend social work support to help the son think through end of life issues, consideration of a do not hospitalize order and consideration of transition to hospice care. Medications on Admission: - Diet - puree, honey-thick liquids - Colace [**Hospital1 **] - Remeron 30 mg qhs - Senna qhs - Lipitor 40 mg qd - ASA 325 mg qd - Bisacodyl 10 mg supp M-W-F - Plain yogurt daily - prn: Tylenol, MOM, [**Name (NI) 20342**] enema Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Remeron 30 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day. 9. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days: please start on [**4-15**]; last day on [**4-18**]. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary: Aspiration pneumonia Urinary tract infection Secondary: Hypertension Hyperlipidemia Recurrent CVAs 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 Ms. [**Known lastname 41617**], You were admitted to [**Hospital1 18**] with an aspiration pneumonia which likely occurred when you vomited at home. Your vomiting was probably caused by a urinary tract infection. You were intubated for a few days to maintain your breathing and then extubated successfully. We gave you antibiotics to treat both of your infections and your improved. You passed the swallow evaluation prior to discharge. We are providing your facility with recommendations about your feeding and swallowing. You will also continue 4 more days of antibiotics when you leave. You should follow up with your PCP or physician at [**Name9 (PRE) 7137**]. We have made the following changes to your medications: - START doxycycline 100mg twice daily for 4 more days (last day = [**4-18**]) for your lung infection - TAKE senna, miralax and colace to keep your stool soft Followup Instructions: Please follow up with your PCP or physician at [**Hospital3 2558**]. Completed by:[**2155-4-14**]

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icd9cm

[ [ [] ] ]

[ "33.24", "96.04", "38.97", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

13939, 14009

7590, 7816

323, 347

14162, 14162

3097, 4052

15255, 15355

1983, 1987

13142, 13916

14030, 14141

12889, 13119

14342, 15042

2002, 2002

4254, 7567

2399, 3078

15071, 15232

263, 285

7831, 11709

375, 1718

11726, 12863

4074, 4220

2016, 2385

14177, 14318

1740, 1912

1928, 1967

79,754

168,979

39935

Discharge summary

report

Admission Date: [**2117-3-3**] Discharge Date: [**2117-3-14**] Date of Birth: [**2069-8-6**] Sex: M Service: SURGERY Allergies: Ciprofloxacin / Penicillins Attending:[**First Name3 (LF) 2836**] Chief Complaint: PICC line infection Major Surgical or Invasive Procedure: none History of Present Illness: 47yM well known to the surgical service, with history of distal panc/spleen by Dr. [**First Name (STitle) **] [**2116-12-3**] for inflammatory mass. This was complicated by postoperative pain control issues requiring persistent pain medication, as well as inability to tolerate POs requiring TPN. His abdominal pain has been worked up by MRCP and CT scan. Most recent imaging was a CT scan done two days ago which was unremarkable. He also underwent C-scope the same day because of some LGIB issues. This was normal other than diverticulosis and some hyperplastic polyps. He presents today with 12 hours of fevers and chills and rigors at home, reports to 106! Then went to [**Hospital3 4107**] today where he was transfered here for further evaluation. Here he complains of rigors and some RUQ pain which is new from his chronic abdominal pain. No nausea/vomiting, no diarrhea, BRBPR or melena. Past Medical History: HTN, Asthma and renal stones PSH:distal pancreatectomy and splenectomy, umbilical hernia repair without mesh([**2116**]) Social History: Smoked 1.5 packs x 25 yrs which he stopped the day when the nausea began. Pt drank a 6-pack of beer per day for one year approximately 3 years ago. He drank socially prior to that. He attributes his drinking to constant stress and worry during his son's military deployment to [**Country 2451**]. Pt reports cessation of drinking with return of son. [**Name (NI) **] drugs. Family History: Mother with [**Name2 (NI) **] CA and NIDDM Physical Exam: Vitals:T= 97.5,HR= 63,BP=130/78,RR=18,SAT= 96%/RA GEN:a+ox3 HEENT:PERRL Chest:CTABL Abd:soft,mildly tender,mildly distended,no rebound/guarding Ext:no c/c/e stable erythema L arm Pertinent Results: [**2117-3-12**] 03:45PM BLOOD WBC-12.2* RBC-3.28* Hgb-10.7* Hct-31.2* MCV-95 MCH-32.5* MCHC-34.2 RDW-14.2 Plt Ct-692* [**2117-3-11**] 05:08AM BLOOD WBC-11.8* RBC-3.29* Hgb-10.7* Hct-30.8* MCV-94 MCH-32.6* MCHC-34.8 RDW-14.0 Plt Ct-588* [**2117-3-10**] 05:28PM BLOOD WBC-11.5* RBC-3.33* Hgb-11.1* Hct-31.1* MCV-93 MCH-33.2* MCHC-35.5* RDW-13.8 Plt Ct-562* [**2117-3-9**] 09:20AM BLOOD WBC-15.1* RBC-3.48* Hgb-11.5* Hct-33.1* MCV-95 MCH-33.0* MCHC-34.7 RDW-13.9 Plt Ct-433 [**2117-3-7**] 07:45AM BLOOD WBC-11.3* RBC-3.44* Hgb-11.3* Hct-32.0* MCV-93 MCH-32.8* MCHC-35.3* RDW-13.6 Plt Ct-329 [**2117-3-5**] 03:02AM BLOOD WBC-6.5 RBC-3.61* Hgb-12.1* Hct-33.7* MCV-93 MCH-33.5* MCHC-35.9* RDW-13.6 Plt Ct-286 [**2117-3-3**] 01:20PM BLOOD WBC-10.5 RBC-4.22* Hgb-14.0 Hct-39.9* MCV-95 MCH-33.2* MCHC-35.0 RDW-14.0 Plt Ct-333 [**2117-3-12**] 03:45PM BLOOD Neuts-61.3 Lymphs-25.4 Monos-5.9 Eos-6.6* Baso-0.8 [**2117-3-9**] 09:20AM BLOOD Neuts-65 Bands-0 Lymphs-16* Monos-13* Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2117-3-3**] 01:20PM BLOOD Neuts-85.0* Lymphs-11.6* Monos-2.6 Eos-0.4 Baso-0.3 [**2117-3-14**] 04:57AM BLOOD Glucose-154* UreaN-19 Creat-1.0 Na-137 K-4.5 Cl-102 HCO3-26 AnGap-14 [**2117-3-7**] 07:45AM BLOOD Glucose-137* UreaN-5* Creat-0.9 Na-138 K-3.7 Cl-99 HCO3-29 AnGap-14 [**2117-3-5**] 03:02AM BLOOD Glucose-122* UreaN-7 Creat-0.8 Na-140 K-4.0 Cl-104 HCO3-28 AnGap-12 [**2117-3-4**] 07:15AM BLOOD Glucose-147* UreaN-9 Creat-0.8 Na-134 K-4.0 Cl-100 HCO3-26 AnGap-12 [**2117-3-3**] 01:20PM BLOOD Glucose-101* UreaN-13 Creat-0.9 Na-135 K-6.2* Cl-101 HCO3-22 AnGap-18 [**2117-3-6**] 07:25AM BLOOD ALT-95* AST-48* LD(LDH)-197 AlkPhos-140* Amylase-20 TotBili-0.3 [**2117-3-4**] 07:15AM BLOOD ALT-160* AST-126* AlkPhos-120 TotBili-0.4 [**2117-3-3**] 01:20PM BLOOD ALT-154* AST-160* AlkPhos-127 TotBili-0.3 [**2117-3-7**] 07:45AM BLOOD Lipase-60 [**2117-3-6**] 07:25AM BLOOD Lipase-151* [**2117-3-5**] 03:02AM BLOOD Lipase-377* [**2117-3-4**] 07:15AM BLOOD Lipase-1161* [**2117-3-11**] 05:08AM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.5 Mg-2.5 Iron-59 [**2117-3-3**] 06:00PM BLOOD Albumin-3.4* Calcium-8.1* Phos-2.8 Mg-1.4* [**2117-3-11**] 05:08AM BLOOD calTIBC-192* Ferritn-[**2041**]* TRF-148* [**2117-3-11**] 05:08AM BLOOD Triglyc-190* [**2117-3-11**] 03:38PM BLOOD Vanco-25.8* [**2117-3-5**] 07:15AM BLOOD Vanco-8.4* Brief Hospital Course: The patient was admitted to the [**Hospital1 18**] with a PICC line infection.He initially kept in the ICU because of hypotension with SBP to the low 80s.His PICC line was d/ced.He was intially started on vanc and zosyn. He was moved out of the unit on HD3. His blood cultures from [**Hospital3 4107**] as well as at the [**Hospital1 18**] grew MSSA.HIs vanc and zosyn were d/ced and was started on Naficillin for the same but he soon got erythema at the iv site.It seemed to be an allergic reaction to naficillin.USG of the LUE was negative for dvt.The erythema resolved with arm elevation,warm packs and NSAIDS.As per ID recs he was restarted on vancomycin that needs to be continued till [**2117-3-17**].The patient also got a TTE on [**2117-3-9**] which was negative for any vegetations.He also underwent an MRI of cervical spine as he complained of cervical pain which was negative for an abscess. A new PICC line was inseterted by IR on [**2117-3-9**]. Chronic pain was consulted as the patient complained of abdominal pain.He was started on pregabalin,tizanidine and iv dilaudid for the same.His pain meds were converted to po meds once the patient's diet was advanced.As the patient was unable to support his nutritional needs by po diet, he was started on TPN on [**2117-3-11**]. On the day of discharge, the patient was on po diet as well as on home TPN,voiding normally,ambulating without any difficulty and his pain was well controlled. He would follow up with Dr [**First Name (STitle) **] and pain clinic on an outpatient basis. Medications on Admission: Nexium 40', ASA 325', MVI, oxycodone [**5-11**] q4 PRN, albuterol inhaler PRN, simvastatin 20', Humulin-R 25u in each bag TPN, Humalog SSI, colace 100'' Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 2. insulin regular human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 3. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 8. tizanidine 2 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 9. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 10. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 12. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* 13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 14. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous every eight (8) hours for 3 days: Patient needs IV vancomycin till [**2117-3-17**]. Disp:*12 soln* Refills:*0* 15. tpn Non-Standard TPN Volume(ml/d)2500 Amino Acid(g/d)100 Dextrose(g/d) 250 Fat(g/d) 50 Trace Elements will be added daily Standard Adult Multivitamins NaCL NaAc NaPO4 KCl KAc KPO4 MgS04 CaGluc 100 0 0 40 0 5 10 5 Insulin(units) 10 Cycle over 18 (hrs.) Start at 1800 Decrease rate to half(ml/h) at 1000 Stop at 1200 16. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous once a day: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Disp:*90 units* Refills:*2* 17. Sodium Chloride 0.9% Flush Sig: Three (3) ml once a day: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . Disp:*60 syringes* Refills:*2* 18. Outpatient Lab Work serum sodium,potassium,chloride,bicarbonate,BUN,creatinine,glucose once a week and fax to Dr [**Last Name (STitle) **],[**First Name3 (LF) **] W.Phone: [**Telephone/Fax (1) 4475**].Fax: [**Telephone/Fax (1) 23978**] Discharge Disposition: Home With Service Facility: Home Care Solutions Discharge Diagnosis: PICC line infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the [**Hospital1 18**] for a PICC line infection. You received IV antibiotics for the same. Please go to the ER or call Dr[**Name (NI) 5067**] office if you have any of the following: Increased redness from the PICC site, pus drainage from the PICC site,Abdominal pain,Abdominal swelling,Nausea and vomiting,Vomiting blood,Diarrhea,Blood in stool,Black stool,Fever greater than 101,Chills or any other symptoms that concern you. You are also being discharged on a lot of pain meds. Please donot operate heavy machinery while you are on them. You would need home TPN for your nutritional needs. You will have a visiting nurse for the same. Followup Instructions: Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2117-3-16**] 4:20 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2117-3-22**] 9:30 Provider:[**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Phone:([**Telephone/Fax (1) 6347**] .please call for an appointment in [**2-4**] weeks. Provider:[**Name10 (NameIs) 1193**] pain clinic. Phone: ([**Telephone/Fax (1) 30702**].please call for an appointment in [**2-4**] weeks. Completed by:[**2117-3-15**]

[ "305.1", "692.3", "751.5", "038.11", "338.29", "789.03", "E879.8", "999.31", "401.9", "458.29", "995.92", "305.03", "493.90", "E930.0", "V45.79" ]

icd9cm

[ [ [] ] ]

[ "38.97", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

8770, 8820

4400, 5944

305, 311

8884, 8884

2057, 4377

9720, 10340

1798, 1842

6148, 8747

8841, 8863

5970, 6125

9035, 9697

1857, 2038

246, 267

339, 1245

8899, 9011

1267, 1391

1407, 1782

83,128

159,696

32472

Discharge summary

report

Admission Date: [**2117-8-10**] Discharge Date: [**2117-8-12**] Date of Birth: [**2045-10-30**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 106**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms [**Known lastname 12130**] is a 71 year old woman with history of silent MI ([**2103**]) that was complicated with left ventricular aneurysm (s/p repair) and mural thrombus, STEMI ([**9-16**]), CAD s/p CABG x 4 (LIMA to LAD, SVG to OM1, OM2 and RCA) [**10-17**], recent NSTEMI ([**12-18**]), insulin dependent diabetes, peripheral [**Month/Year (2) 1106**] disease, and hyperthyroidism. She is presenting with bloating and abdominal pain that started 1-2 weeks ago. Her abdominal pain is diffuse, crampy in nature, not increased with exertion, and relieved by Gas-X or flatus. She denies vomiting but has some mild nausea today. She had loose stools secondary to Miralax for constipation but denies melena or hematochezia. Patient has noticed feeling increasingly more weak with exertion. She has increased dyspnea when on exercise bike during cardiac rehab or when climbing flight of [**9-23**] stairs recently at her grandson's wedding. She has orthopnea at baseline that has not worsened recently. Patient also has a mild cough with whitish-pink sputum. Denies fevers/chills, sweats, flushing, syncope, dizziness, lightheadedness, chest pain, palpitations, shoulder pain (except baseline pain in R shoulder secondary to OA) or defibrillator firing. Patient presented initially to her PCP with these symptoms. Her PCP thought they could be related to fluid overload and increased her Lasix dose to 80mg and, because she presented with similar symptoms during her NSTEMI in [**12-18**], her PCP checked troponin. Today the troponin I level came back at 0.14 (previous troponin T <0.01 in [**3-18**]). Her PCP called her and told her to come to the ED. In ED initial VS were: 98.3 96 117/64 99. She complained of mild abdominal pain which improved after placement of a foley. On exam no evidence of fluid overload with only 1+ edema, no JVD, and no crackles. EKG showed no changes but patient has ICD. Heparin was not started because she has h/o spontaneous bleed when she was placed on heparin previously. Initially the plan was for her to be admitted to the [**Hospital Unit Name 196**] floor but then in the ED she had a transient drop in her BP (nadir = 76/45). She was bolused 250mL NS X2 and BP came up to 109/35. She remained asymptomatic throughout this episode. Past Medical History: PAST CARDIAC HISTORY: - Silent MI in [**2103**] c/b ventricular aneurysm and apical thrombus - CABG: in [**2116-10-31**] x4 LIMA to LAD, SVG to OM1, SVG to OM2, SVG to RCA, LCx endarterectomy - s/p left ventricular aneurysm repair (Dor procedure?) - NSTEMI [**2116-12-31**] s/p PCI with PTCA and stenting of the left main - proximal left circumflex with a Xience drug eluting stent and PTCA of the proximal left anterior descending artery. - ICD placement: [**4-/2117**] [**Company 1543**] Virtuoso DR D1548WG, AAI<->DDD . PAST MEDICAL HISTORY: -- PAD s/p left SFA angioplasty and stent ([**2114**]) -- DM2, well-controlled -- HTN -- OA -- spinal stenosis -- Hyperthyroidism -- s/p cholecystectomy -- s/p appendectomy -- s/p TAH . CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia, (+)Hypertension Social History: Lives with her husband in [**Name (NI) 392**], [**Name6 (MD) **] is NP and is very involved in her care. Denies EtOH. Quit tobacco 12 yrs ago (smoked 1/2ppd x 20+ yrs). Family History: Brother died of MI at age 59. Physical Exam: VS: T 98 HR 82 BP 82/36 (114/50 manually) RR 16 O2sat 96% on 2L General - NAD, AAO HEENT - JVD to angle of jaw, MMM, no scleral icterus CVS - irreg. irreg, S1 and S2 present, no m/r/g Pulm - bibasilar crackles, no wheezes Abdomen - soft, NT, ND, b.s. present, no bruits Extremities - no c/c/e. 2+ PT pulses b/l. On discharge: 97.4 66 18 103/56 97% RA General - NAD, AAO HEENT - JVD non elevated, MMM, no scleral icterus CVS - irreg. irreg, S1 and S2 present, no m/r/g Pulm - CTA bilat, with rare rales right base Abdomen - soft, NT, ND, b.s. present, no bruits Extremities - no c/c/e. 2+ PT pulses bilaterally Pertinent Results: labs upon discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.1 4.09* 11.6* 36.3 89 28.3 31.8 13.7 202 Glucose UreaN Creat Na K Cl HCO3 AnGap 147* 22* 0.9 142 4.3 104 26 16 trop T 0.03 Mg 2 TTE on admission ([**2117-8-10**]) The left atrium is dilated. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate regional left ventricular systolic dysfunction with apical aneurysm which is dyskinetic. A left ventricular mass/thrombus cannot be excluded. Right ventricular chamber size is normal. with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. 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. Moderate (2+) 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 a small pericardial effusion. Compared with the prior study (images reviewed) of [**2117-5-14**], mitral regurgitation and tricuspid regurgitation are now more prominent and the estimated pulmonary artery systolic pressure is now higher. Brief Hospital Course: 71 year old woman with insulin dependent diabetes, 3 vessel CAD s/p CABG, presenting with abdominal pain and increase in troponins, admitted to CCU for exacerbation of systolic heart failure . # Acute on Chronic SYSTOLIC HEART FAILURE: Dyspnea and abdominal discomfort could be secondary to CHF exacerbation. Etiology ACS/NSTEMI versus dietary indiscretion. Patient was continued on ASA, Plavix, Lipitor, metoprolol, ACE-I. Serial troponins/CK-MB were followed and were never elevated. Etiology thought to be due to dietary indiscretion. ECG showed NSR with many PVCs. TTE showed similar finding to prior (see above) consistent with mild systolic failure. Patient was dosed with short-acting metoprolol in setting of mild hypotension, which was reason for admission to CCU. Persantine Thallium test was scheduled for 2 weeks after discharge to evaluate for ischemia. Patient responded well to additional doses of lasix, with increased urine output and net (-) fluid balance of [**12-11**] liters/day. Patient was transferred from unit to floor and continued to do well. The addition of spironolactone to her regimen was deferred in the setting of systolic blood pressure in the 100s. The patient was discharged on [**2117-8-12**] in improved and stable condition. . # RHYTHM: PVC's present but ICD in place. Rate was well-controlled during admission on metoprolol. . # HYPOTENSION: Manual cuff BP of 115/50. Automated BP measurements were thought to be artifically low secondary to multiple premature ventricular contractions. The patient was converted to short-acting metoprolol and ACE inhibitor for improved control, and was discharged on her home regimen of toprol XL and lisinopril at decreased dose of 10 mg. . # DIABETES: Patient was continued on home insulin regimen with Lantus and Novolog with good glycemic control. . # HYPERTHYROIDISM: Methimazole was continued. . # CODE: full (confirmed) Medications on Admission: ASA 325mg daily Lipitor 80mg daily Lisinopril 20mg daily Metoprolol Succinate 75mg daily Plavix 75mg daily Protonix 40mg daily Tapazole 10mg daily Insulin -- Detemir 34 units at night -- Lispro 6 with breakfast, 14 with dinner. Clorazepate 3.75 mg qday KCl 20mEq daily Furosemide 40mg daily (took 80mg day PTA) MVI daily APAP PRN Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop taking unless Dr. [**Last Name (STitle) **] tells you to. . 5. Methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 12. Tranxene T-Tab 3.75 mg Tablet Sig: One (1) Tablet PO once a day. 13. Insulin Detemir 100 unit/mL Solution Sig: Thirty Four (34) units Subcutaneous at bedtime. 14. Insulin Lispro 100 unit/mL Solution Sig: Six (6) units Subcutaneous once a day: 14 units at night. 15. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute on Chronic Systolic Heart Failure Secondary Diagnoses: - Coronary Artery Disease - Peripheral Artery Disease - Diabetes Mellitus - Hypertension - Osteoarthritis - Spinal stenosis - Hyperthyroidism Discharge Condition: stable and improved Discharge Instructions: You came to the hospital with abdominal pain. While you were evaluated in the ED, you developed low blood pressure, and you were then admitted to the ICU for further monitoring. You had received extra doses of lasix before coming to the hospital and some additional Lasix here. We feel that your congestive heart failure was because you ate some high salt foods. You will need to avoid these in the future. . Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight > 3 lbs in 1 day of 6 pounds in 3 days. Adhere to 2 gm sodium diet, information about this was discussed with you at discharge. , Medication changes: 1. Your Lisinopril was decreased to 10 mg daily because of low blood pressure 2. Your Protonix was changed to Famotidine because the Protonix interferes with the Plavix. Please see below for follow up appointments. You will be scheduled for a stress test in 2 weeks. Please call your PCP [**Last Name (NamePattern4) **] 911 if you develop chest pain, shortness of breath, abdominal pain, a dry cough, dizziness with standing or any other unusual symptoms. Followup Instructions: [**Last Name (NamePattern4) **] Surgery: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2118-7-4**] 10:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2118-7-4**] 11:20 . Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 4105**] Date/time: [**9-15**] at 11;30am You have an appt for a stress test at [**Hospital1 **] on Thursday [**9-2**] at 9:00am. . Primary Care: Dr. [**Last Name (STitle) **] [**Name (STitle) 75782**] Phone: [**Telephone/Fax (1) 7164**] Date/Time: Tuesday [**8-17**] at 2:15pm.

[ "V58.67", "428.23", "V45.02", "V45.81", "250.00", "458.9", "715.90", "412", "V45.82", "428.0", "414.01", "401.9", "724.00", "242.90", "443.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9396, 9402

5704, 7621

283, 290

9669, 9691

4311, 4316

10833, 11526

3627, 3659

8002, 9373

9423, 9423

7647, 7979

9715, 10331

3674, 3987

9504, 9648

4001, 4292

10351, 10810

229, 245

4332, 5681

318, 2599

9442, 9483

3166, 3424

3440, 3611

64,262

126,773

39198

Discharge summary

report

Admission Date: [**2102-6-7**] Discharge Date: [**2102-6-10**] Date of Birth: [**2039-3-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: suprapubic pain Major Surgical or Invasive Procedure: intubation History of Present Illness: From ICU admission note: 63 y.o male with cerebral palsy wheelchair bound, high functioning, with a chronic indwelling foley catheter presenting with fevers and chills. The patient was complaining of suprapubic discomfort beginning earlier this evening and some left-sided hip pain that he describes as a pressure-like and nonradiating. Pt noticed that his foley was not draining for most of the day and described some "leakage" around the catheter site. Pt was seen in ED [**5-11**] requiring foley placement by urology. Lives alone in apartment, uses wheelchair. He reported also having fevers earlier He believes he had subjective fevers earlier in the day prior to admission. Denies chest pain, shortness of breath, lower extremity pain. Has chronic lower extremity edema. . In the ED, initial VS were: 97.4 104 172/72 20 96%. The patient initally looked well and the above hx was obtained.However about 45 minutes in his ED stay he became increasingly tachycardic and rigoring. He also vomited normal-appearing stomach contents. The decision was made to intubate him as he was vomiting, rigoring, heart rate 140 and appeared incredibly uncomfortable. Rapid sequence intubation done. He was sedated with Propofol initially but pressures started to drop, so was switched to fentanyl and versed + gave 2.5L NS and pressures improved. prior to transfer, vitals were 100, 85, 131/69, 100% PEEP 8, FiO2 60. 7.33/40/182/22 lactate 3.4 WBC 20K with 90% leuk Foley bag filled with air only on inspection and foley balloon was deflated to remove it and return of dark red urine into bag was noted. Of note patient initially complained of diarrhea for 2 days but no further hx could be obtained before acute clinical decompensation. . On arrival to the MICU:vitals were 100, HR 96, 151/68, rr 20 100% on CMV 50% with Tv 400 and 8 PEEP. He is arousable to voice. Review of systems:Could not be obtained given patient was intubated Past Medical History: CEREBRAL PALSY, DIPLEGIC Neurogenic urinary bladder disorder adjustment disorder GOUT MONOCLONAL GAMMOPATHY OSTEOPENIA ANEMIA HYPERURICEMIA Hypertension, Essential ABSCESS / CELLULITIS - LEG TENDONITIS / CAPSULITIS / PERIARTHRITIS PARAPLEGIA OSTEOARTHRITIS ESOPHAGEAL REFLUX EDEMA OVERWEIGHT Social History: Wheelchair bound, Lives alone with visiting nurse services (3x/day). Works for DCF as legislation liason. Family History: mother died of breast cancer, father died of throat cancer no h/o of diabetes Physical Exam: Vitals: 100, 85, 131/69, 100% PEEP 8, FiO2 60. General: intubated, sedated, obese HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: scattered wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, trace edema, foot deformation b/l Neuro: grossly intact, awakes to voice Discharge: Vitals: 98.8 (Tm) 164/77 75 94%RA Gen - Obese man, sleeping comfortably in bed, easily aroused in NAD. Heart - RRR Lungs - Difficult to auscultate secondary to body habitus, but crackles noted at the bases. Abdomen - soft, non-tender ext - marked edema of the hands, feet, legs, b/l lateral feet noted to have deformities. R wrist tender and swollen. neuro - patient diffusely weak, as per baseline. Pertinent Results: [**2102-6-7**] 12:41PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP [**2102-6-7**] 12:41PM LACTATE-1.7 [**2102-6-7**] 12:29PM GLUCOSE-124* UREA N-25* CREAT-1.3* SODIUM-144 POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-28 ANION GAP-10 [**2102-6-7**] 12:29PM CALCIUM-7.8* PHOSPHATE-4.2 MAGNESIUM-1.5* [**2102-6-7**] 12:29PM WBC-19.9* RBC-3.49* HGB-10.7* HCT-32.5* MCV-93 MCH-30.6 MCHC-32.9 RDW-16.6* [**2102-6-7**] 12:29PM NEUTS-82.0* LYMPHS-11.1* MONOS-5.4 EOS-1.2 BASOS-0.2 [**2102-6-7**] 12:29PM PLT COUNT-238 [**2102-6-7**] 01:30AM TYPE-ART PO2-182* PCO2-40 PH-7.33* TOTAL CO2-22 BASE XS--4 [**2102-6-7**] 01:30AM LACTATE-3.4* [**2102-6-7**] 12:45AM URINE COLOR-RED APPEAR-CLOUDY SP [**Last Name (un) 155**]-1.015 [**2102-6-7**] 12:45AM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-N KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-LG [**2102-6-7**] 12:45AM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2102-6-6**] 10:35PM GLUCOSE-184* UREA N-24* CREAT-1.0 SODIUM-142 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-22 ANION GAP-18 [**2102-6-6**] 10:35PM estGFR-Using this [**2102-6-6**] 10:35PM WBC-20.7*# RBC-4.34* HGB-12.9* HCT-39.8* MCV-92 MCH-29.7 MCHC-32.4 RDW-16.4* [**2102-6-6**] 10:35PM NEUTS-91.8* LYMPHS-4.7* MONOS-2.4 EOS-0.9 BASOS-0.3 [**2102-6-6**] 10:35PM PLT COUNT-272 MICRO: [**6-7**] BCx: NGTD [**6-7**] UCx: Fecal contaminiation [**6-7**] UA: Grossly positive for infection . Studies: CXR [**6-7**] Endotracheal tube terminates in the mid trachea, as before with nasogastric tube coursing into the stomach and out of view. Bibasilar opacities and likely small pleural effusions are unchanged. Stable cardiomegaly and aortic tortuosity are again noted. . CT Abd/Pelvis: 1. Findings compatible with known cystitis. 2. No acute bowel pathology. 3. Cholelithiasis/biliary sludge. 4. Large fat-containing umbilical hernia. 5. 1.8-cm right adrenal nodule, likely adenoma. . [**6-9**] CXR: FINDINGS: New right PICC terminates in expected location of the mid to distal SVC. The examination is otherwise unchanged with bibasilar opacities, most compatible with atelectasis and perhaps trace right effusion and mild vascular congestion. Cardiomediastinal structures remains slightly shifted to the right, partially probably due to rotation. IMPRESSION: New right PICC terminates in the mid SVC . Discharge labs: [**2102-6-10**] 05:34AM BLOOD WBC-11.3* RBC-3.67* Hgb-10.6* Hct-34.0* MCV-93 MCH-29.0 MCHC-31.3 RDW-16.2* Plt Ct-260 [**2102-6-10**] 05:34AM BLOOD Glucose-194* UreaN-9 Creat-0.8 Na-143 K-3.4 Cl-103 HCO3-27 AnGap-16 [**2102-6-10**] 05:34AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.9 Brief Hospital Course: SUMMARY: 63 year old man with neurogenic bladder secondary to cerebral palsy with chronic foley who was initially admitted to the ICU for sepsis secondary to UTI, improved with antibiotics. . #) Sepsis: Resolved, likely urinary source, unfortunately cultures were [**Last Name (LF) 86788**], [**First Name3 (LF) **] patient was narrowed to cefepime IV for a 10 day course. He was briefly intubated in the ICU for airway protection but quickly extubated. . # R wrist pain: Consistent with acute gout flare. His allopurinol was discontinued and he was restarted on his home dose of standing TID indomethacin which was initially held for acute renal failure that resolved with hydration. . #) Mild acute pulmonary edema: Developed in setting of hypertensive episode and IVF administration. Improved with 10mg IV lasix x1 very quickly. The patient was stable on room air at his baseline level of breathing . #) Diabetes: Held oral anti-hyperglycemics and used insulin sliding scale while in house. # Hyperlipidemia: Continued statin, and 81mg ASA as primary prophylaxis. #) Cerebral palsy: Complicated by neurogenic bladder requiring chronic foley, which was replaced this admission. . ========= TRANSITIONAL ISSUES: -Continue cefepime for 10 day course and pull PICC line after completion -Some anti-biotic related loose stool treated with psyllium wafers, can consider loperimide if needed. -Restart allopurinol after acute gout flare (right wrist) has resolved. Medications on Admission: Allopurinol 100 mg Oral Tablet take [**12-26**] tab daily with 300 mg Baclofen 10 mg Oral Tablet 1 tablet tid Potassium Chloride 10 mEq Oral Tablet Extended Release 3 PO QD Indomethacin 50 mg Oral Capsule Take 1 capsule three times daily with food Lisinopril 40 mg Oral Tablet Take 1 tablet daily Metformin 850 mg Oral Tablet Take 1 tablet twice daily Glipizide 5 mg Oral Tablet Take 1 tablet daily, 30 minutes before breakfast Simvastatin 20 mg Hydrochlorothiazide 50 mg Omeprazole 20 mg Aspirin 81 mg Discharge Medications: 1. GlipiZIDE 5 mg PO DAILY Take 1 tablet daily, 30 minutes before breakfast 2. MetFORMIN (Glucophage) 850 mg PO BID 3. Baclofen 10 mg PO TID 4. Potassium Chloride 10 mEq PO DAILY Take 3 tabs daily 5. Indomethacin 50 mg PO TID Please take with food 6. Lisinopril 40 mg PO DAILY 7. Simvastatin 20 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Hydrochlorothiazide 50 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze 12. CefePIME 2 g IV Q8H Duration: 7 Days Complete 10 day course on [**2102-6-16**] 13. Heparin 5000 UNIT SC Q8H prophylaxis 14. Hydrocerin 1 Appl TP QID:PRN dry dkin 15. Psyllium Wafer 1 WAF PO BID While having loose stool on antibiotic Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted for fevers and chills, which was most likely related to a urine infection. We are treating this infection with an antibiotic called cefepime. You are being discharged to a facility where they can administer your IV antibiotic. You also had wrist pain and swelling, which was most likely related to a gout flare. To treat this you should continue to take the pain killer three times per day. Please note the following medication changes: -Please START Cefepime through the veins until [**2102-6-16**] -Please STOP allopurinol until instructed to restart (when your gout improves) Followup Instructions: Name: [**Last Name (LF) 7363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location:[**Location (un) 2274**] [**University/College **]--Primary Care Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 86789**] Appt: [**6-20**] at 11:40am Completed by:[**2102-6-11**]

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Discharge summary

report

Admission Date: [**2171-9-15**] Discharge Date: [**2171-9-21**] Service: MEDICINE Allergies: [**Location (un) **] Juice / Nsaids / Morphine Attending:[**First Name3 (LF) 2186**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: ERCP with stent placment on [**9-15**] History of Present Illness: 88yoF NH resident with history of Parkinson's disease, HTN, recurrent UTIs (e. coli, proteus, klebsiella, enterbobacter), hyponatremia, paroxysmal afib and gallstones who initially presented to [**Hospital1 **] [**Location (un) 620**] with 1d hx of AMS and abdominal pain per family transferred to [**Hospital1 18**] now with concern for cholangtis and need for ERCP. Patient reported abdominal pain and was found to be confused by family (baseline A+O x 2, on exam A+O x 1). She presented to BIN with tender abdomen, HR in 70s but BP dropped to 80s/50s. At the time, labs were notable for WBC 27.5 (N 94.2%, L 1%, Mo 3.8%), Hct 32.9 (baseline ~31), Lactate 2.9, Na 126, Cl 88, BUN 27, Tbili 4.09, ALP 800, ALT 600, AST 2558. UA notable for Ubili 1, UBLG 150, protein 75. CT abd/pelvis showed a distended gallbladder with a small amount of pericholecystic fluid, and a distended CBD of 9mm. She received vanc/ceftriaxone/zosyn and also 2L NS and was transferred to [**Hospital1 18**] for ERCP evaluation. In the ED here, initial VS were 83 90/50 100%. Exam notable for A+Ox1, abd pain. ERCP and Surgery were consulted. WBC 28.8, Na 129, ALT 466 AST 1541, AP 561, TB 3.2, Lactate 3.5, UA showed negative nitrite, >182 WBC, 18 RBC, Few bacteria, 5 epi. UCx/BCx sent and CXR and RUQ ultrasound ordered. While in the ED, BP dropped to the 70s/40s-50s, and patient was started on norepinephrine (at time of transfer 0.12). Received zofran for nausea, and an additional dose of vancomycin, lorazepam, fentanyl, 2L NS. ED team attempted to place subclavian CL (pt wouldn't tolerate IJ) but punctured subclavian artery, got pulsatile flow, pulled back needle and held pressure 45 min. Dilator never introduced. Vascular surgery evaluated pt; found no effusion or pneumothorax, and did R femoral line, 2 PIVs. On arrival to the MICU, patient's VS: BP 134/51 (112/34), T 97.7, P 70bpm, R 17-24, O2 Sat 100% on 2L. Pt received a-line and is undergoing ERCP. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: #. Hypertension #. CVA in [**2166-8-6**] #. Hyponatremia: SIADH vs reset osmostat #. Urinary Incontinence #. HOH #. Recurrent UTIs, ecoli, proteus, klebsiella, enterobacter #. PAF one documented episode [**6-14**], ?no AC (h/o stroke) #. h/o eosinophilic PNA [**6-14**], Rx with steroid taper #. GERD #. Spinal Stenosis - s/p lumbar laminectomy #. History of SBO #. Diverticulosis #. Macular degeneration #. s/p left eye cataract extraction #. s/p appy #. s/p hysterectomy #. Diabetes Social History: Lives with son in [**Hospital3 **] community [**Location (un) 4528**]. Uses a walker and occasionally a wheelchair at home. Occasional EtOH use, remote tobacco use, denies recreational drug use. Family History: Mother "heart condition", father diabetes. Physical Exam: Admission Exam: Vitals: T 97.7, P 79, BP 112/34, RR 24, O2 Sat 100% on NC General: A+O x self (baseline A+O x 2 as per son), thin, NAD HEENT: Sclera jaundice, Dry MM, oropharynx clear, PERRL Neck: supple, JVP elevated to angle of jaw, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles at bases Abdomen: hypoactive BS, soft, mildly tender, mildly distended, no organomegaly, no rebound or guarding GU: Foley in place draining frothy urine Ext: Cool, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Moving all extremities spontaneuously Pertinent Results: Admission Labs: [**2171-9-15**] 02:00AM BLOOD WBC-28.8*# RBC-3.40* Hgb-9.7* Hct-29.3* MCV-86 MCH-28.4 MCHC-32.9 RDW-13.4 Plt Ct-196 [**2171-9-15**] 02:00AM BLOOD Neuts-80* Bands-15* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2171-9-15**] 02:00AM BLOOD PT-11.8 PTT-27.4 INR(PT)-1.1 [**2171-9-15**] 02:00AM BLOOD Glucose-109* UreaN-27* Creat-0.9 Na-129* K-4.0 Cl-96 HCO3-21* AnGap-16 [**2171-9-15**] 02:00AM BLOOD ALT-466* AST-1541* AlkPhos-561* Amylase-36 TotBili-3.2* [**2171-9-15**] 02:00AM BLOOD Albumin-2.9* . [**2171-9-15**] 2:15 am BLOOD CULTURE: Pending . [**2171-9-15**] 6:23 am MRSA SCREEN: Pending . Imaging: [**9-15**] CXR: In comparison with the study of earlier in this date, there is little change. No evidence of pneumothorax or definite pleural effusion. Obliquity of the patient towards the right is probably responsible for the relative prominence of soft tissues in the superior mediastinum. Otherwise, no interval change. . [**9-15**] CXR: Cardiac and mediastinal silhouettes are unchanged from [**2170-2-27**] with cardiomegaly noted. No definite effusion or pneumothorax is noted. No focal consolidations are identified. Prominence of interstitial markings; mild edema cannot be excluded. . [**9-15**] ERCP: A single periampullary diverticulum with large opening was found at the major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in partial opacification. Pus was seen flowing out of the CBD after cannulation. A mild diffuse dilation was seen at the main duct with the CBD measuring 8 mm. Given cholangitis only limited contast injection was made. Limited pancreatogram is normal. Given cholangitis, a 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully in the main duct. Large amount of pus was seen exuding after placement of stent. Otherwise normal ercp to third part of the duodenum. . [**2171-9-20**] 07:30AM BLOOD WBC-9.8 RBC-3.18* Hgb-9.0* Hct-26.3* MCV-83 MCH-28.4 MCHC-34.3 RDW-13.5 Plt Ct-111* [**2171-9-20**] 07:30AM BLOOD Plt Ct-111* [**2171-9-20**] 07:30AM BLOOD Glucose-68* UreaN-10 Creat-0.5 Na-128* K-3.5 Cl-98 [**2171-9-20**] 07:30AM BLOOD ALT-86* AST-30 LD(LDH)-217 AlkPhos-232* TotBili-0.6 [**2171-9-20**] 07:30AM BLOOD Albumin-2.6* Calcium-7.5* Phos-2.5* Mg-1.9 Brief Hospital Course: 88yoF with history of dementia, Parkinson's disease, HTN, recurrent UTIs, hyponatremia, paroxysmal afib and gallstones transferred with cholangitis and E. coli bacteremia . #CHOLANGITIS: She presented to [**Hospital1 **] [**Location (un) 620**] with 1 day history of altered mental status and abdominal pain radiating to the back where she was found to have leukocytosis, transaminitis, cholestasis, CBD dilation on CT and possible common bile duct stone. She underwent ERCP where pus was seen draining from the CBD with mild diffuse dilation of the CBD. A biliary stent was placed in the common bile duct. She was maintained on IV antibiotics (initially zosyn, vancomycin then changed to ceftriaxone). Following the procedure her diet was advanced and she was tolerating a low fat diet. Occasionally she reported abdominal discomfort intermittently for about an hour following a large meal. Her liver function tests improved (t-bili normalized, transaminases trending down). Her white blood cell count normalized on [**2171-9-20**]. Her antibiotics were changed to oral ciprofloxacin on [**2171-9-19**] with plan for 14 day course (ending [**2171-9-29**]). She was monitored for over 24 hours on oral antiboitics and did well worsening symptoms. She was seen by general surgery and family declined urgent cholecystectomy. The need for percutaneous biliary drainage was discussed with ERCP and given her clinical improvement following ERCP it was not recommended. She will follow up as an outpatient with general surgery for further consideration of elective cholecystectomy per family request. She will follow up with repeat ERCP for stent removal and likely sphincterotomy in 4 weeks (scheduled prior to d/c and communicated to son [**Name (NI) **] and [**Name (NI) **]). Please note that she should have transportation arranged to these appoinments as she is a two person assist. . # SEPSIS/E. COLI BACTEREMIA: She presented with SIRS criteria (leukocytosis w/bandemia, tachycardia, tachypnea), hypotensive requiring transient vasopressors peri-procedurally during the ERCP, and blood culture from the OSH grew pan-sensitive E.Coli. Following the procedure her blood pressure normalized and she remained hemodynamically stable for the remainder of her hospitalization. The presumed source of bacteremia/sepsis was biliary. While her urine culture also grew E.coli it was a different species, resistant to several antibiotics. She was initially treated with IV zosyn and vancomycin, which was then changed to ceftriaxone. The ceftriaxone was changed to oral ciprofloxacin with plan for 14 day total course (ending [**9-29**]). Surveillance blood cultures were negative. The decision to transition to oral antibiotics was discussed with infectious disease who agreed with the decision. . # HYPONATREMIA: Baseline sodium appears to be ~130 likely due to SIADH as per prior workup. TSH was WNL. Cortisol was WNL. She developed a drop in sodium to mid-120s in the setting of lifting fluid restriction post-ERCP. With fluid restriction to 1.5L her sodium slowly improved back towards baseline and was ..... at discharge. Her lisinopril was held but can be restared with return of sodium to baseline. Would recommending checking chem-7 in [**4-11**] days to ensure stability. The importance of fluid monitoring and gentle restriction was discussed with patient and family. . #UTI: She had a positive urine culture from OSH growing resistant E.coli species. She was treated with three days of ceftriaxone (sensitive) for uncomplicated urinary tract infection per ID recommendation. . # Subclavian Arterial Puncture: During attempted CVL placement there was a subclavian arterial puncture. There were no signs of hematoma and pt not complaining of neck pain or swelling. CXR did not show signs of bleeding such as apical cap or sulcus sign. Vascular surgery has examined the patient and feels that there is nothing more to do. . # AMS: Likely delirium superimposed on dementia; [**2-7**] septic shock vs. hyponatremia. Mental status improved with treatment of infection as above, and hyponatremia resolved with fluids. Per son, at baseline she is [**Name (NI) 21371**], not oriented to date, and has short-term memory difficulty. . #HYPERTENSION: Initially held in setting of sepsis, then amlodipine restarted. Holding lisinopril pending improvement in sodium and can be restarted once back to baseline. . #HEADACHE: Intermittent headache, controlled with tylenol and tramadol PRN. . CONTACT INFORMATION: -HCP is [**Name (NI) **] [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 21372**] -Code status: DNR/DNI . TRANSITIONAL ISSUES: -f/u final results of blood cultures -f/u with general surgery regarding elective cholecystectomy -f/u with ERCP for stent removal -check chem-7 in [**4-11**] days to follow sodium -if worsening abdominal pain or fever or inability to tolerate oral nutrition, please seek immediate medical evaluation as will need further labs and likely abdominal imaging Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from NH. 1. PredniSONE 5 mg PO DAILY 2. Amlodipine 5 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Carbidopa-Levodopa (25-100) 1 TAB PO BID 6. Acetaminophen 650 mg PO BID 7. Omeprazole 40 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 10. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **] 11. Magnesium Oxide 50 mg PO BID 12. Senna 1 TAB PO BID 13. Polyethylene Glycol 17 g PO DAILY 14. [**Last Name (un) **]-Max *NF* (cranberry extract) 425 mg Oral [**Hospital1 **] 15. Magnesium Citrate 2 Oz PO DAILY:PRN constipation 16. TraMADOL (Ultram) 50 mg PO TID:PRN headache 17. Ondansetron 4 mg PO Q8H:PRN nausea 18. Milk of Magnesia 30 mL PO DAILY:PRN constipation 19. Guaifenesin 10 mL PO Q4H:PRN cough 20. Cal-[**Last Name (un) **] Antacid *NF* (calcium carbonate) 200 mg calcium (500 mg) Oral tid:prn epigastric discomfort 21. Bisacodyl 10 mg PR DAILY:PRN constipation 22. Acetaminophen 650 mg PO Q4H:PRN pain 23. Boost *NF* (food supplement, lactose-free) 120 ml Oral tid 24. Lubiprostone 24 mcg PO BID 25. Meladox *NF* (melatonin) 1 mg Oral qHS Discharge Medications: 1. Carbidopa-Levodopa (25-100) 1 TAB PO BID 2. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **] 3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 4. Omeprazole 40 mg PO BID 5. Aspirin 81 mg PO DAILY 6. Acetaminophen 650 mg PO BID 7. TraMADOL (Ultram) 50 mg PO TID:PRN headache 8. Milk of Magnesia 30 mL PO DAILY:PRN constipation 9. Guaifenesin 10 mL PO Q4H:PRN cough 10. [**Last Name (un) **]-Max *NF* (cranberry extract) 425 mg Oral [**Hospital1 **] 11. Cal-[**Last Name (un) **] Antacid *NF* (calcium carbonate) 200 mg calcium (500 mg) Oral tid:prn epigastric discomfort 12. Magnesium Oxide 50 mg PO BID 13. Bisacodyl 10 mg PR DAILY:PRN constipation 14. Acetaminophen 325-650 mg PO Q8HR PRN pain 15. Boost *NF* (food supplement, lactose-free) 120 ml Oral tid 16. Polyethylene Glycol 17 g PO DAILY 17. PredniSONE 5 mg PO DAILY 18. Senna 1 TAB PO BID 19. Multivitamins 1 TAB PO DAILY 20. Amlodipine 5 mg PO DAILY 21. Lubiprostone 24 mcg PO BID 22. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days Ending [**2171-9-29**] 23. Meladox *NF* (melatonin) 1 mg Oral qHS 24. Magnesium Citrate 2 Oz PO DAILY:PRN constipation Discharge Disposition: Extended Care Facility: [**Location (un) **] - [**Location (un) 620**] Discharge Diagnosis: Cholangitis Sepsis UTI Hyponatremia Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care. You were admitted with fever and abdominal pain. You were found to have a common bile [**Last Name (un) **] stone on imaging that was likely causing an obstruction and an infection. You underwent ERCP that confirmed an infection (cholangitis) and a biliary stent was placed. You were admitted to the intensive care unit. You were given IV antibiotics. Your condition improved. Your antibiotics were changed to medication you can take by mouth. You will need to complete a 14 day total course of antibiotics. You will need to follow up with the ERCP doctors [**First Name (Titles) **] [**10-21**] for further evaluation. Your sodium level was found to be low. Your fluids were restricted to 1.5 liters per day. Your sodium improved. Followup Instructions: 1.DEPARTMENT: ERCP WHEN: [**2171-10-21**] 07:30AM WITH: [**First Name8 (NamePattern2) **] [**Name8 (MD) **] M.D. WHERE: [**Hospital Ward Name **] 4 [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **] ENDOSCOPY SUITES 2. Department: SURGICAL SPECIALTIES When: FRIDAY [**2171-10-18**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD [**Telephone/Fax (1) 3201**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage 3. Name: [**Last Name (LF) 21373**],[**First Name3 (LF) **] Address: [**Street Address(2) 21374**], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 6163**] Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.

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icd9cm

[ [ [] ] ]

[ "51.87" ]

icd9pcs

[ [ [] ] ]

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261, 301

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152,601

41555

Discharge summary

report

Admission Date: [**2196-5-16**] Discharge Date: [**2196-5-23**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 106**] Chief Complaint: elective core-valve Major Surgical or Invasive Procedure: CoreValve implantation for replacement of stenotic aortic valve History of Present Illness: Ms [**Known lastname 90392**] is an 87 year old female with PMH severe AS and Hx of afib, CHF EF 65%, pacemaker (SSS), moderate LVH, who is admitted electively for CoreValve placement [**5-17**]. She recently was transferred to [**Hospital1 18**] in [**Month (only) 958**] from [**Hospital 35462**] for evaluation of AVR vs valvuloplasty. She initially presented to [**Hospital3 **] [**3-25**] with worsening dyspnea and cough x 1 week. She was found to be in AF/RVR and acute CHF. Diuresed and started on metoprolol for rate control which improved her SOB. Her cough was thought secondary to CHF and she was started on Tessilon perles for control. She also developed [**Last Name (un) **] with diuresis and diuretics were held at discharge with f/u labs. Workup for AVR found no significant CAD, [**Location (un) 109**] of 0.8, AV gradient of 41mmHg across the valve which persisted with dobutamine challenge. Her aorta was noted to be severely calcified excluding her from open surgical repair of the aortic valve. Valvuloplasty as deferred. She was discharged home with a plan to discuss aortic valve replacement with her cardiologist. Over the next few months she and her family opted for percutaneous AV replacement. Her cough improved with continued diuresis. . She currently complains of minimal shortness of breath at rest and is able to ambulate around home slowly with mod to severe DOE after ambulating [**10-27**] steps. She is limited to only occasional trips outside of home and needs help wtih ADL's [**2-10**] dementia. She is NYHA Class II-III. Sleeps with one pillow. Her metoprolol was d/c'ed because of hypotension by Dr. [**Last Name (STitle) 24717**] but Losartan was continued per family. She is quite forgetful and needs frequent cues and reminders of current events. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. She has bilat knee pain attributed to OA. She was recently transitioned to Pradaxa instead of coumadin to avoid blood draws. Her insurance does not cover this and family is considering switching back. Pt went to urologist as an [**Last Name (STitle) 3782**] for evaluation of renal mass who recommended no furhter tests at this time, she will return in about one month. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: [**3-18**]: Clean coronaries - Pacemaker implanted on [**2186**] ([**Company 1543**] St. [**Male First Name (un) 923**], 1336T) Device changed in [**2193**] ([**Company 1543**] NWR20022LH, SESR01) for sick sinus syndrome # AF: on coumadin # Severe AS 3. OTHER PAST MEDICAL HISTORY: # Dementia # Hyperthyroid s/p radioactive iodine Social History: Lives with husband. -Tobacco history: 7 pack year history, quit 70 years ago -ETOH: Denies -Illicit drugs: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission: VS: T= 97.6 BP= 102/62 HR= 90 AF RR= 16 O2 sat= 94 RA Height: 64 inches weight: 76.8 kg GENERAL: WDWM in NAD. Oriented x1-2 only. Mood, affect appropriate. Uses confabulation and evasion to answer questions. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 6 cm. no LAD CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irreg irreg rhythm. [**2-14**] holosystolic murmur at RUSB, radiating to LUSB but not to carotids. LUNGS: No chest wall deformities, scoliosis, mild kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. Obese. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits.. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Intact, multiple raised PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 1+ . On Discharge: . . Tc 97.6, Tmax 99.8 132/68 (119/52-134/56) 51-70 98% on 2L, Gen: alert, NAD, pleasantly demented HEENT: supple,IJ area mild bruise stable, somewhat TTP. JVP = 10-12cm CV: RRR, 2/6 systolic murmur throughout precordium, loudest RUSB. No gallops or rubs. RESP: faint bibasilar crackles. no wheezes ABD: soft, NT, ND EXTR: trace ankle edema, NEURO: Extremeties: right and left groin with no echymosis or hematoma, no bruit. Pulses: Right: DP 2+ PT 1+ Left: DP 2+ PT 1+ Skin: intact Pertinent Results: admission labs: . [**2196-5-16**] 07:28PM BLOOD WBC-8.4 RBC-4.33 Hgb-12.7 Hct-35.9* MCV-83 MCH-29.2 MCHC-35.3* RDW-13.9 Plt Ct-212 [**2196-5-16**] 07:28PM BLOOD PT-13.4 PTT-22.7 INR(PT)-1.1 [**2196-5-16**] 07:28PM BLOOD Glucose-217* UreaN-25* Creat-1.3* Na-137 K-3.2* Cl-95* HCO3-28 AnGap-17 [**2196-5-16**] 07:28PM BLOOD ALT-34 AST-47* AlkPhos-84 TotBili-0.5 [**2196-5-16**] 07:28PM BLOOD proBNP-1214* [**2196-5-16**] 07:28PM BLOOD Albumin-4.4 Calcium-8.8 Phos-2.5* Mg-1.7 [**2196-5-16**] 07:28PM BLOOD %HbA1c-7.0* eAG-154* [**2196-5-16**] 07:28PM BLOOD TSH-13* . Discharge labs: [**2196-5-21**] 07:40AM BLOOD WBC-10.2 RBC-3.71* Hgb-10.8* Hct-31.7* MCV-85 MCH-29.2 MCHC-34.2 RDW-14.9 Plt Ct-170 [**2196-5-23**] 10:40AM BLOOD PT-13.5* INR(PT)-1.2* [**2196-5-23**] 06:25AM BLOOD Glucose-131* UreaN-38* Creat-1.2* Na-135 K-3.4 Cl-97 HCO3-26 AnGap-15 [**2196-5-18**] 05:56AM BLOOD ALT-21 AST-40 LD(LDH)-256* AlkPhos-79 TotBili-0.7 [**2196-5-23**] 06:25AM BLOOD proBNP-1893* [**2196-5-23**] 06:25AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.9 [**2196-5-20**] 12:50PM BLOOD %HbA1c-7.0* eAG-154* . Imaging: . . Echocardiography [**5-17**] Pre-TAVI: The left atrium is markedly dilated. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**1-10**]+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. Post-TAVI: The patient is on a phenylephrine infusion. An aortic valve implant is seen, there is trave aortic insufficiency. The mitral regurgitation is unchanged. . . Pre-discharge: The left atrium is mildly dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is dilated with normal free wall contractility. There is abnormal septal motion/position. An aortic CoreValve prosthesis is present. The transaortic gradient is normal for this prosthesis. Mild (1+) 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 to severe [3+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2196-5-21**], the degree of MR [**First Name (Titles) **] [**Last Name (Titles) **] have slightly increased. The Corevalve appears similar. . ECG Study Date of [**2196-5-21**] 8:13:30 AM: Underlying atrial fibrillation with a slow ventricular rate of 57 beats per minute which is regular and has a right bundle-branch block/right axis deviation morphology. In the absence of apparent pacemaker spikes, this is consistent with complete heart block. Inferior and anterolateral ST-T wave changes are non-diagnostic and could be due to prior ventricular pacing, ischemia, etc. Compared to the previous tracing of [**2196-5-18**] atrial fibrillation appears to be unchanged with the previous tracing showing probable right ventricular pacing at a rate of 69 beats per minute. Clinical correlation is suggested regarding pacemaker function on the present tracing, etc. Brief Hospital Course: A/87 yo F with severe AS who was admitted electively for CoreValve (percutaneous aortic valve replacement) on [**5-17**]. . # severe AS, s/p core-valve placemnt: Has done well post procedure with good result on echocardiography and only slight fluid retention in her post-procedure course which was treated with duresis. Has pacer so CHB was not a concern. Aspirin and Plavix were started for anti-platelet therapy and coumadin was continued for AF. Will likely need 1 month course of plavix, 3 months of aspirin and subsequently may be covered with coumadin alone which is indicated for her atrial fibrilation. Will follow-up with Dr. [**Last Name (STitle) **] who will guide her out patient medication regimen as appropriate. . OUTPATIENT ISSUES; - follow-up with Dr. [**Last Name (STitle) **] . #Hyperglycemia: No history of diabetes prior to this admission, but hyperglycemia noted during this hospitalization, HbA1c = 7.0 consistent with new diagnosis of type 2 DM. Patient was treated with ISS during her hospital stay. Metformin was not started as had borderline renal function. Team communicated with husband, daughter and [**Name2 (NI) 3782**] provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24717**] who [**First Name8 (NamePattern2) **] [**Last Name (un) 90393**] anti-hyperglycemics in the out patient setting. . OUTPATIENT ISSUES; - follow-up with Dr. [**Last Name (STitle) 24717**] . # CHF: Has known prior dCHF. Post procedure echo demonstrated biatrial dilatation right > left, mild symmetric left ventricular hypertrophy, LVEF>55%. Dilated RV. Presence of aortic CoreValve prosthesis is presence with normal gradient for this prosthesis with mild AR. Moderate (2+) mitral regurgitation and Moderate to severe [3+] tricuspid regurgitation which have slightly increased compared to pre-procedure. Had slight fluid retention in her post-procedure course which manifested as trace bil pre-tibial edema and mild DOE. She was treated with IV furosamide and appeared euvolemic at discharge. Discharged on PO Furosamide 40mg [**Hospital1 **]. OUTPATIENT ISSUES; - follow-up with Dr. [**Last Name (STitle) 24717**] - TEDS stockings are recommended. . # Atrial Fibrillation. CHADS 3. Paced. Was followed by EP with pacemaker interrogations and readjustments as needed. Discharge on settings for ventricular pacing at 60 BPM during day and 50 nocturnal mode. Patient had previously been on pradexa but started on coumadin in house. Restarted warfarin [**5-19**] at 2.5 mg increased to 5mg daily on [**5-22**]. INR 1.2 at discharge. Will continue following INR with VNA and dose adjustment for goal INR [**2-11**]. OUTPATIENT ISSUES; - continue following INR with VNA and dose adjustment for goal INR [**2-11**]. . #CKD: Baseline 1.0-1.2, trended up during this admission to 1.5, likely due to poor forward flow in the setting of some fluid overload. Improved with duresis. Cr. 1.2 on discharge. OUTPATIENT ISSUES; -- Monitor chemistry panel as an outpatient . #Dementia: # Dementia: Throughout hospitalization patient at baseline. Occassional confused and easily re-oriented. While in house [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 69084**] enacted; patient was frequently re-oriented, benzos were avoided and fall precautions were in place. Restarted memantine at discharge. . # Hyperlipidemia. Continued on home pravastatin in house. . # Hypertension. Patient largely normotensive in house. Patient continued on home losartan. Due to concern for mild volume overload patients diuretic regimn was increased from 40mg QD to 40mg PO BID x4 days. OUTPATIENT ISSUES: -- Follow-up blood pressure as outpatient at 5/19 appt . # CT findings of lung nodules and left renal mass found on last admission on [**3-18**]. Recommended 3 month CT chest follow up and Renal Ultrasound. As above, pt has seen urologist and will f/u after procedure. OUPATIENT ISSUES: -- Need for follow-up imaging of pulmonary nodules. . # DVT prophylaxis - recieved SQ heparin during this admission. . # CODE STATUS: Full during this admission, discussed with daughter/HCP . Medications on Admission: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. rivastigmine 6 mg Capsule Sig: One (1) Capsule PO twice a day. 3. memantine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lumigan 0.03 % Drops Sig: One (1) drop in each eye Ophthalmic once a day. 6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. 7. Losartan 50 mg daily 8. lasix 40 mg daily 9. Pradaxa 150 mg [**Hospital1 **] 10. Spiriva 1 capsule inhaled daily 11. Advair 1 puff [**Hospital1 **] 12. Fish oil 13. multivitamin Discharge Medications: 1. Outpatient Lab Work Please check Chem-7 and INR on Wednesday [**5-25**] with results to [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: 27 [**Location (un) 24719**] DR, [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 24721**] Fax: [**Telephone/Fax (1) 24722**] 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rivastigmine 6 mg Capsule Sig: One (1) Capsule PO twice a day. 4. memantine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Fish Oil Concentrate Oral 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Lumigan 0.03 % Drops Sig: One (1) gtt Ophthalmic once a day: each eye. 15. Advair Diskus Inhalation Discharge Disposition: Home With Service Facility: VNA of Southeastern CT Discharge Diagnosis: Critical Aortic Stenosis s/p CoreValve placement Hyperglycemia Acute on Chronic Kidney Disease Coronary Artery disease Chronic Diastolic Congestive Heart Failure Atrial Fibrillation Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). ECG: V paced ECHO: Discharge Instructions: You had a tight aortic valve and receieved a CoreValve to replace the old valve. This procedure went very well and you had no complications. You will need to take aspirin and plavix every day until Dr. [**Last Name (STitle) **] tells you to stop. You will need to have regular checkups with your doctors at [**Name5 (PTitle) **] and with the cardiologists at [**Hospital1 18**] to monitor you per the study protocol. Your blood sugars were high during your hospital stay. We checked a A1C, a measure of your blood sugar over a few months and it was 7.0. You will need to talk to Dr. [**Last Name (STitle) 24717**] about this measurment and he will start a medicine to lower your blood sugar. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . We made the following changes to your medicines: 1. Start taking aspirin and Plavix to prevent blood clots on the valve. You will need to take this every day without fail until Dr. [**Last Name (STitle) **] tells you to stop. 2. STOP taking Pradaxa, start warfarin again to prevent a stroke from the atrial fibrillation. You will be started on 5.0 mg per day and will need to have your INR checked on Wednesday [**5-25**]. 3. Decrease Losartan to 25 mg daily 4. Increase lasix to 40 mg twice daily 5. Discontinue digoxin for now 6. continue your other medicines at home. Followup Instructions: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: 27 [**Location (un) 24719**] DR, [**Location (un) **],[**Numeric Identifier **] Phone: [**Telephone/Fax (1) 24721**] Fax: [**Telephone/Fax (1) 24722**] [**5-26**] at noon . Department: CARDIAC SERVICES When: THURSDAY [**2196-6-23**] at 11:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: THURSDAY [**2196-6-23**] at 2:00 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**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 Completed by:[**2196-5-23**]

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icd9cm

[ [ [] ] ]

[ "37.22", "35.22", "88.42", "35.96" ]

icd9pcs

[ [ [] ] ]

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270, 336

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3775, 4734

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3432, 3483

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3499, 3615

27,014

155,245

46770

Discharge summary

report

Admission Date: [**2162-11-29**] Discharge Date: [**2162-12-7**] Date of Birth: [**2100-12-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Acute coronary artery dissection Major Surgical or Invasive Procedure: [**2162-11-29**] - Emergency coronary bypass grafting x3 (left internal mammary artery to left anterior descending artery, saphenous vein graft to diagonal branch, saphenous vein graft to posterior descending coronary artery). [**2162-11-29**] - Cardiac Catheterization History of Present Illness: The patient is a 61-year-old man who suffered inferior myocardial infarction during attempt at right coronary angioplasty. Dissection ensued and the right coronary artery totally occluded. An intra-aortic balloon pump was placed and he was referred for emergency bypass surgery.The patient required pressor support with epinephrine and neosynephrine The patient was taken to the operating and neosynephrine in the OR prior to surgery for hypotension. Past Medical History: CAD MI HTN Hyperlipidemia Hypogonadism s/p pituitary adenoma resection Hypothyroid Panhypopituitarism Obesity Social History: In process of quitting smoking. He has smoked 1.5-2ppd since the age of 14. Married and works in management. Social alcohol use. Family History: Noncontributory Physical Exam: PRECATH AVSS CV:RRR, No M/R?G LUNGS: CTA ABD: Benign EXT: Pulsed [**1-19**]+ without carotid or femoral bruits. NEURO: Nonfocal Pertinent Results: [**2162-12-6**] 09:10AM BLOOD WBC-11.3* RBC-3.43* Hgb-10.4* Hct-30.3* MCV-88 MCH-30.2 MCHC-34.2 RDW-16.0* Plt Ct-310# [**2162-11-29**] 12:40PM BLOOD WBC-9.0 RBC-4.24* Hgb-13.1* Hct-38.8* MCV-92 MCH-31.0 MCHC-33.8 RDW-13.6 Plt Ct-259 [**2162-11-29**] 12:40PM BLOOD Neuts-74.9* Lymphs-18.4 Monos-3.0 Eos-3.2 Baso-0.5 [**2162-12-7**] 09:20AM BLOOD PT-13.2 INR(PT)-1.1 [**2162-12-6**] 09:10AM BLOOD Plt Ct-310# [**2162-11-29**] 12:40PM BLOOD Plt Ct-259 [**2162-11-29**] 12:40PM BLOOD PT-12.9 PTT-150* INR(PT)-1.1 [**2162-11-29**] 05:35PM BLOOD Fibrino-131* [**2162-12-6**] 09:10AM BLOOD Glucose-84 UreaN-17 Creat-1.0 Na-135 K-5.0 Cl-100 HCO3-24 AnGap-16 [**2162-11-29**] 12:40PM BLOOD Glucose-161* UreaN-17 Creat-0.9 Na-135 K-3.7 Cl-102 HCO3-25 AnGap-12 [**2162-12-3**] 03:27AM BLOOD ALT-83* AST-62* AlkPhos-48 Amylase-19 TotBili-0.4 [**2162-12-1**] 02:00AM BLOOD ALT-67* AST-102* LD(LDH)-512* AlkPhos-38* Amylase-21 TotBili-0.4 [**2162-12-3**] 03:27AM BLOOD Lipase-12 [**2162-12-3**] 03:27AM BLOOD Mg-2.2 [**2162-11-29**] 12:40PM BLOOD %HbA1c-5.9 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2162-12-3**] 9:41 AM CHEST (PORTABLE AP) Reason: assess for infiltrates/effusions [**Hospital 93**] MEDICAL CONDITION: 61 year old man s/p cabg REASON FOR THIS EXAMINATION: assess for infiltrates/effusions HISTORY: 61-year-old male status post CABG. COMPARISON: Chest radiographs of [**2162-12-2**], dating back to [**2162-11-29**]. PORTABLE UPRIGHT CHEST X-RAY: ET tube, left IJ Swan-Ganz catheter, and NG tube are in unchanged positions. Counting from the top, the sixth out of 7 sternal wires is newly broken and the ends are distracted by approximately 2 cm. The lung volumes remain low although there is resolution of right middle lung atelectasis and improved aeration in the left lower lobe. No pneumothorax or pleural effusions are present. Mild cardiomegaly is stable. No new pulmonary infiltrates or pleural effusions are identified. IMPRESSION: No new pulmonary infiltrates or pleural effusions. Interval improvement in lung aeration. New broken sternal wire. Findings were discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at the time of dictation. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: SAT [**2162-12-4**] 9:41 AM Baseline artifact. Atrial fibrillation. Since the previous tracing earlier on [**2162-11-29**] atrial fibrillation is new. ST-T wave abnormalities are more marked. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 98 0 94 368/434 0 -36 127 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 99257**] (Complete) Done [**2162-11-29**] at 4:40:42 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 1112**] W. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2100-12-13**] Age (years): 61 M Hgt (in): 71 BP (mm Hg): / Wgt (lb): 250 HR (bpm): BSA (m2): 2.32 m2 Indication: Intraoperative TEE for CABG ICD-9 Codes: 410.91, 440.0 Test Information Date/Time: [**2162-11-29**] at 16:40 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Suboptimal Tape #: 2007AW4-: Machine: 4 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: *3.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Descending Thoracic: *2.8 cm <= 2.5 cm Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Overall normal LVEF (>55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Suboptimal image quality. The patient appears to be in sinus rhythm. Results were Conclusions PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). 3. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. 4. The aortic root is mildly dilated at the sinus level. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. T 6. he mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Post-bypass: On infusion of epi, phenylephrine. Pt with atrial fibrillation requiring multiple cardioversions, amiodarone bolus and infusion. Preserved LV systolic function. RV function remains moderately depressed on inotropic support. Mild TR. Trace MR. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2162-11-29**] 18:20 Brief Hospital Course: Mr. [**Known lastname 49346**] was admitted to the [**Hospital1 18**] on [**2162-11-29**] for a cardiac catheterization. During his catheterization, he had an acute dissection of his right coronary artery. An intra-aortic balloon pump was placed and the cardiac surgical service was consulted. Mr. [**Known lastname 49346**] was then taken to the OR emergently where he underwent emergent coronary artery bypass grafting to three vessels. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He remained on pressors over the next several days for poor hemodynamics. He developed atrial fibrillation which was converted with amiodarone. He was transfused with packed red blood cells for postoperative anemia. He was aggressively diuresed for volume overload. His pressors were slowly weaned over the next few days and his acidosis and mixed venous saturations improved. On postoperative day four, Mr. [**Known lastname 49346**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. He continued to be gently diuresed. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He was transferred to the step down unit on postoperative day six. Amiodarone was continued and started on coumadin. Cleared for discharge to home with VNA services on POD #8. Coumadin follow up with [**Company 191**] coumadin clinic first draw [**12-10**] call results to [**Telephone/Fax (1) 2173**] Medications on Admission: ASA Levothyroxine 100 daily Lovastatin 80 daily Toprol xl 25 daily MVI NTG prn Norvasc 10 daily Prednisone 5 daily Pepcid OTC Androgel 50/5 gel daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please take 400mg once a day for 6 days then decrease to 200mg daily and follow with cardiology . Disp:*40 Tablet(s)* Refills:*0* 9. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 12. Lovastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 13. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) Transdermal once a day. Disp:*qs qs* Refills:*0* 14. Outpatient [**Name (NI) **] Work PT/INR first draw [**12-10**] call results to [**Telephone/Fax (1) 2173**] [**Company 191**] coumadin clinic for further dosing INR goal 2-2.5 Atrial Fibrillation 15. Warfarin 1 mg Tablet Sig: goal INR 2-2.5 Tablets PO DAILY (Daily): dosing by coumadin clinic [**Telephone/Fax (1) 2173**]. Disp:*90 Tablet(s)* Refills:*0* 16. Warfarin 2 mg Tablet Sig: goal INR 2-2.5 Tablets PO once a day: dosing by coumadin clinic [**Telephone/Fax (1) 2173**]. Disp:*90 Tablet(s)* Refills:*0* 17. Coumadin You have been given two different doses of coumadin 1mg and 2mg tablets Please take 3mg on [**10-16**], [**12-9**] with [**Month/Year (2) **] draw [**11-30**] with results to coumadin clinic for further dosing Discharge Disposition: Home With Service Facility: vna assoc. of [**Hospital3 635**] Discharge Diagnosis: CAD s/p emergency cabg Post op atrial fibrillation Coronary artery dissection HTN Hyperlipidemia Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. SHOWER daily and wash incision. Gently pat the wound dry. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. [**Telephone/Fax (1) 170**] 8) Coumadin Dosing by [**Company 191**] coumadin clinic first draw [**12-10**] call results to [**Telephone/Fax (1) 2173**] for further dosing INR goal 2-2.5 Atrial Fibrillation Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 1016**] in [**1-19**] weeks. [**Telephone/Fax (1) 2386**] Please follow-up with Dr. [**Last Name (STitle) 4844**] in 2 weeks. [**Telephone/Fax (1) 250**] PT/INR first draw [**12-10**] call results to [**Telephone/Fax (1) 2173**] [**Company 191**] coumadin clinic for further dosing INR goal 2-2.5 Atrial Fibrillation (spoke with [**Doctor First Name 16883**] in coumadin clinic) Scheduled Appointments: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2163-3-23**] 8:50 Completed by:[**2162-12-7**]

[ "272.4", "276.2", "998.2", "285.9", "458.29", "410.41", "244.9", "276.6", "427.31", "997.1", "V15.82", "414.01", "401.9", "790.29" ]

icd9cm

[ [ [] ] ]

[ "37.61", "37.22", "00.40", "99.05", "39.61", "88.56", "97.44", "36.12", "99.04", "96.6", "00.66", "36.15", "89.60" ]

icd9pcs

[ [ [] ] ]

12411, 12475

8347, 9824

356, 628

12616, 12623

1585, 2767

13549, 14214

1404, 1421

10024, 12388

2804, 2829

12496, 12595

9850, 10001

12647, 13526

1436, 1566

284, 318

2858, 8324

656, 1109

1131, 1242

1258, 1388

10,222

190,871

52958

Discharge summary

report

Admission Date: [**2181-12-16**] Discharge Date: [**2182-1-7**] Service: MEDICINE Allergies: Coreg / Lopressor Attending:[**First Name3 (LF) 898**] Chief Complaint: dyspnea and hypoxia Major Surgical or Invasive Procedure: Catheterization for PFO closure History of Present Illness: 88 yo f with known ASD, CHF (EF 35%), paroxysmal a-fib, s/p DDD pacemaker/icd and multiple admission for hypoxia, presented from [**Last Name (un) 14991**] NH with episodes of hypoxia/hypotension (Sbp of 80s). Patient with 18 month history of intermittent hypoxia which was last evaluated here in [**2181-9-14**] with echo showed possible ASD and PFTs showed restrictive lung pattern. She was discharged on O2 supplement at 4L NC. Since her echo showed 35% ef, her hypoxia was thought to be multifactorial. She was also evaluated at [**Location (un) **] 4 weeks ago for similar episode and discharged to NH on 6 L non-rebreather. Patient also reports L rib pain. In ED, EKG showed left bundle without new ST/T changes. However, trop was elevated at 0.12, which was new compared to last admission. Her chest CT was negative for PE or pneumonia. ABG: 7.45/39/61. Patient was given prednisone for possible reactive airway disease and levofloxacin for possible UTI given positive urinalysis. She was also given 1.2L of fluid for resuscitation with (BP up to 90s). However, she still has intermittent hypoxic episodes that spontaneously resolve. She remained afebrile with normal lactate level of 1.2. Past Medical History: 1. CHF (EF 30%, 1+ MR, 1+ TR, significant pulmonary regurgitation, multifocal AK/HK on TTE [**7-14**]) 2. DDD pacemaker and ICD placement for sick sinus syndrome and NSVT 3. paroxysmal atrial fibrillation 4. pre-syncope 5. pneumonia 5. hypothyroidism 6. hyperparathyroidism 7. GERD 8. L3 fracture and cauda equina syndrome s/p L2/L3 laminectomy c/b residual severe LBP 9. osteopenia 10. obstructive sleep apnea 11. urinary retention 12. dysphagia 13. depression Social History: The patient normally lives at home with husband, who has Alzheimer??????s dementia. She has a full-time male aide for her husabnd, and "a woman" who comes into the home a few times a week. She has been at an extended care facility in the recent months due to intermittent hypoxia and hypotension. She's never smoked cigarettes, and denies any alcohol use. The patient has 3 married daughters, one of whom is an anesthesiologist at this hospital. Family History: No known history of coronary artery disease, otherwise non-contributory. Physical Exam: Vitals: 96.5, 95/49. 64. 17. 95%4LNC Gen: cachectic but comfortable HEENT: no JVP CV: RRR Lungs: CTAB Abd: soft, NT Ext: no edema neur: A&A and able to answer questions appropriately Pertinent Results: [**2181-12-17**] echo: LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. A catheter or pacing wire is seen in the RA and/or RV. Aneurysmal interatrial septum. Rght-to-left shunt across the interatrial septum at rest. LEFT VENTRICLE: Mildly dilated LV cavity. Moderate global LV hypokinesis. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size. AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Conclusions: 1. The left atrium is dilated. The right atrium is dilated. The interatrial septum is aneurysmal. A right-to-left shunt across the interatrial septum is seen at rest. 2. The left ventricular cavity is mildly dilated. There is moderate global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed. 3. The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Cath [**2182-1-3**]: COMMENTS: 1. Venous access via the RFA using a 8F short sheath. 2. Initial hemodynamics demonstrated a mean RA pressure of 6 mm hg, RV pressure 37/5 mm hg. 3. Successful closure of the PFO with a 35 mm amplatzer PFO occluded device. Post procedure bubble study with cough was positive, but the o2 saturation remained >95% in the sitting position. FINAL DIAGNOSIS: 1. PFO with symptomatic orthodeoxia. 2. Successful closure of the PFO. [**2182-1-7**]: Hct 30.1, INR 2.1 Brief Hospital Course: She remained stable on the floor during the first 2 days and finished 48 hrs of IV heparin drip for NSTEMI with trop trended downwards. However, on the scheduled day of discharge, she had a prolonged episode of hypoxia with O2 sat down to 70s% while on NRB in the morning. However, she remained relatively asymptomatic (normal mental status, normotensive, speaking full sentences, no tachycardia, tachypnea, chest pressure or dyspnea) despite the severe hypoxia until she was given a slNTG for trial of vasodilator for presumed pulmonary hypertension when her O2 sat went down to 50s% with development of chest pain and dyspnea. She quickly improved, however, with some IVF. She had remained stable since the early afternoon until the next morning when she had another similar episode of hypoxia. She was seen by Dr. [**Last Name (STitle) **] and noted to have orthodeoxia. Bedside echo showed functional tricuspid stenosis in the sitting position, which causes increased right to left shunt via the known PFO due to the increased right side pressure. She was instructed to lying flat to minimize the right to left shunt to avoid severe hypoxia. She was evaluated by cardiac surgery and interventional cardiology for PFO repair. Because the patient was deemed a poor surgical candidate due to incrased risks from comorbidities, she was referred for percutaneous closure of the PFO. The device, however, had been recalled by the manufaturer, and would not be available for two weeks. The patient remained in the hospital given her poor functional status, and the device arrived early. She was anticoagulated with heparin pending hte procedure, and Coumadin was restarted thereafter. Successful procedure was performed [**2182-1-3**] and pt was able to sit up without desaturating thereafter. She tolerated the procedure well with a small hematoma ensuing. Current Condition By Problem: 1) PFO: Now s/p procedure. Light activity tolerated in terms of O2 sats, patient able to sit up. Limitation is primarily deconditioning. 2) Afib: Continue Coumadin, beta-blocker, Amiodarone. Note: pt has ICD, DD pacer. 3) Cardiomyopahty: Asymptomatic, continue BB, ACE-I, ASA, Statin 4) + UA: Asymptomatic, but + UA, no fever/elevated wbc, cx contaminated. Bactrim x 7 day course. 5) Hypothyroid: Continue Levothyroxine 6) Hyperparathyroid: Calcitonin 7) Vaginal itching: Treat minor yeast infxn, imidazole cream x 7 days 8) Anemia: Stools guaiac negative, pt transfused one unit [**1-6**]. Anemia likley [**2-12**] phlebotomy, chronic disease and poor nutrition. Pt also had small, stbale hematoma s/p cath. 9) Depression/Anxiety: Continue Ativan (prn) and Paxil, social work following. 8) FEN: Low sodium plus shakes 9) PPx: bowel regimen 10) Code: DNR/DNI, has ICD Medications on Admission: Amio, pantoprazole, Levothyroxine, Calcitonin, Metoprolol, Lipitor, Bowel meds, Lisinopril Discharge Medications: 1. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) Nasal DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for sbp<95, hr<55. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): hold for sbp<100. 10. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 14. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 16. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. 18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. 19. Clotrimazole-Betamethasone 1-0.05 % Cream Sig: One (1) Appl Topical HS (at bedtime) for 5 days. 20. Aspirin 81 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: Non-ST Elevation Myocardial Infarction Hypoxia due to right to left shunt via known patent foramen ovale Functional Tricuspid Stenosis CHF (EF 30%, 1+ MR, 1+ TR, significant pulmonary regurgitation, multifocal AK/HK on TTE [**7-14**]) DDD pacemaker and ICD placement for sick sinus syndrome and NSVT Paroxysmal atrial fibrillation Hypothyroidism Hyperparathyroidism Gastoesophageal Reflux Disease Hx of L3 fracture and cauda equina syndrome s/p L2/L3 laminectomy c/b residual Low back pain Osteopenia Obstructive sleep apnea Urinary retention Dysphagia Depression Urinary Tract Infection Yeast Infection Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please have INR rechecked in 2 days and then biweekly until stable in target range of 2 to 3. Coumadin dose should be adjusted accordingly. Please repeat a chest CT in 3 months to reevaluate the pulmonary nodules seen on this admission. Please have INR rechecked in 2 days and then biweekly until stable in target range of 2 to 3. Coumadin dose should be adjusted accordingly. Followup Instructions: 1) Please follow up with your primary care physician [**Last Name (NamePattern4) **] 1 to 2 weeks. [**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 3329**] 2) Follow-up with Dr. [**Last Name (STitle) **] in [**1-12**] weeks: ([**Telephone/Fax (1) 5862**] Completed by:[**2182-1-7**]

[ "V45.02", "V45.01", "530.81", "780.57", "425.4", "427.31", "414.01", "428.0", "285.9", "745.5", "112.1", "593.9", "458.9", "244.9", "410.71", "599.0", "300.4", "493.20", "414.10" ]

icd9cm

[ [ [] ] ]

[ "99.04", "35.52", "88.43", "88.72" ]

icd9pcs

[ [ [] ] ]

9190, 9263

4449, 7223

244, 277

9912, 9920

2773, 4301

10451, 10758

2481, 2555

7364, 9167

9284, 9891

7249, 7341

4318, 4426

9944, 10428

2570, 2754

185, 206

305, 1515

1537, 2000

2016, 2465

30,114

192,860

853

Discharge summary

report

Admission Date: [**2116-6-1**] Discharge Date: [**2116-6-10**] Date of Birth: [**2037-5-2**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Bright red blood loss per rectum Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Ms. [**Known lastname 5903**] is a 79 yo female with h/o CAD, PVD, DM2, CKD and diverticulosis, who presented on [**2116-6-1**] with BRBPR on multiple BMs starting the day of arrival. She had no cramping, pain, nausea, or other symptoms at the time. VS were stable in the ED, and Hct was noted to be dropping from 35 recently to 30 and then to 27 with continued bloody BMs. ROS was negative for fevers, chills, unintentional weight changes, orthopnea, chest pain, dyspnea, abdominal pain, easing bruising, dysuria, and rashes. Past Medical History: - CAD s/p CABG [**2107**] - PVD - CKD, stage III - HTN - DM2 complicated by retinopathy, nephropathy - diverticulosis; pt denied prior episodes of GIB - s/p toe amputation Social History: She is a retired administrator at [**Street Address(1) 5904**] Inn. She works out at a senior gym three times a week. She does not smoke cigarettes, drink alcohol, or use any recreational drugs. Her diet does contain a moderate amount of salt. Family History: Diabetes mellitus-- mother, brother, and sister [**Name (NI) 5905**] mother, father. There is no history of kidney disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS on arrival to the floor: 98.4, 159/83, 82, 16, 98% RA General: Pleasant, conversant, overweight female in NAD Heent: MMM. Partial dentures. Neck: JVP flat. Cardiac: rate regular, soft II/VI systolic murmur at apex Lungs: : CTA b/l, No wheeze. Abdomen: obese, soft, + BS, NTND, no HSM. Rectal deferred Enxtremities: no edema 2+ R DP pulse, 1+ L DP pulse. SVG harvest scar left leg, s/p hallux amputation Neuro: AAO x 3, appropriate affect, CN grossly intact. Pertinent Results: ADMISSION LABS: [**2116-6-1**] 06:00PM BLOOD WBC-12.4* RBC-3.46* Hgb-10.1* Hct-30.1* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.5 Plt Ct-307 [**2116-6-2**] 01:52AM BLOOD Neuts-79.0* Lymphs-16.5* Monos-2.3 Eos-1.7 Baso-0.4 [**2116-6-1**] 06:00PM BLOOD Glucose-145* UreaN-48* Creat-1.9* Na-141 K-4.5 Cl-107 HCO3-24 AnGap-15 [**2116-6-2**] 01:52AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.0 CARDIAC ENZYMES [**2116-6-3**] 02:01AM BLOOD CK(CPK)-215* [**2116-6-3**] 05:50PM BLOOD CK(CPK)-469* [**2116-6-4**] 03:00AM BLOOD CK(CPK)-508* [**2116-6-4**] 05:50AM BLOOD CK(CPK)-479* [**2116-6-5**] 05:50AM BLOOD CK(CPK)-398* [**2116-6-3**] 02:01AM BLOOD CK-MB-7 cTropnT-<0.01 [**2116-6-3**] 05:50PM BLOOD CK-MB-15* MB Indx-3.2 cTropnT-0.09* [**2116-6-4**] 03:00AM BLOOD CK-MB-11* MB Indx-2.2 cTropnT-0.07* [**2116-6-4**] 05:50AM BLOOD CK-MB-10 MB Indx-2.1 cTropnT-0.05* [**2116-6-5**] 05:50AM BLOOD CK-MB-9 cTropnT-0.04* [**2116-6-4**] URINALYSIS: [**2116-6-4**] 03:19AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2116-6-4**] 03:19AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [**2116-6-4**] 03:19AM URINE RBC-4* WBC-123* Bacteri-MANY Yeast-NONE Epi-1 [**2116-6-4**] URINE CULTURE: CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). 10,000-100,000 ORGANISMS/ML.. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ADMISSION ECG: NSR at 74 bpm, nl axis, nl intervals, no ischemic ST/Twave changes, one PVC, no concerning changes [**2116-6-3**] COLONOSCOPY: Impression: Polyp in the sigmoid colon Diverticulosis of the sigmoid colon Stool in the whole colon The colon was long and tortuous. Grade 1 internal hemorrhoids Otherwise normal colonoscopy to proximal ascending colon Poor visualization of the cecum, ascending colon and sigmoid colon [**2116-6-5**] TAGGED RBC BLEEDING SCAN: No active gastrointestinal bleeding is identified. [**2116-6-8**] TAGGED RBC BLEEDING SCAN: No evidence of GI bleed at 90 min and at 6 hours. Brief Hospital Course: LOWER GI BLEED, LIKELY FROM DIVERTICULOSIS: Ms. [**Known lastname 5903**] was admitted with BRBLPR, which began the day of admission and, per the patient, was the first time this had happened. She had an NG lavage performed in the ED, which was negative. Aspirin, metoprolol and lisinorpil were held on admission. She remained hemodynamically, but was admitted to the MICU for observation. She required two units of RBC's after having ongoing blood BM's with the colonoscopy prep. Colonosocpy performed on [**2116-6-3**] prior to transfer to the floor showed multiple divertculi but no active bleeding. A single sessile polyp was noted but was not biopsied due to concern for causing bleeding; one-year follow-up was recommended for the polyp. After the colonoscopy she had no more blood loss for two days and was about to be discharged on [**2116-6-5**] when she rebled. GI deferred an emergent scope. A STAT tagged RBC bleeding scan was performed and was negative for ongoing bleeding. IR angio embolization was deferred because of the negative RBC scan. She required one unit of RBC's on [**2116-6-5**] to maintain Hct > 28 (the higher transfusion threshold was chosen because of the cardiac ischemia earlier in the week (see below)). Again, she rebled on [**2116-6-7**] and required a unit of blood. The morning of [**2116-6-8**], she rebled a fourth time and received another unit (for a total of four over the course of the admission). Another tagged RBC scan was ordered, which was negative. Although she did not have blood loss from below thorughout the day, the scan was repeated about six hours after the morning study in the hopes that the source could be found (unfortunately, it was not). General surgery was also consulted, but felt emergent surgery was not indicated beause she remained hemodynamically stable. Her last episode of blood loss was in the morning of [**2116-6-8**]. She remained hemodynamically stable throughout. Serial Hct's were stable and she was discharged with a Hct of 31.1. she did have a bowel movement that was semi-formed and non-bloody prior to discharge. She was sent home on metoprolol 12.5 mg [**Hospital1 **] (compared to 50 mg [**Hospital1 **] that she was on at admission), but lisinopril and aspirin were held. Ultimately, it was suspected that her bleeding was secondary to diverticulosis, although the source was never definitely found on colonoscopy or tagged RBC scans. CHEST PAIN: On [**6-2**] in the evening, she also complained of chest pain. The first set of enzymes on [**6-3**] at 2 am showed trop < 0.01, CK 215. EKG showed diffuse ST changes, but unchanged from priors. Cyclic cardiac enzymes did increase, and it was flet she had some demand ischemia in the setting of the bleed. Aspirin, which was initially discontinued on admission, was restarted on [**2116-6-4**] given the ischemia. However, on [**2116-6-5**] when she rebled, it was discontinued. She was not sent home on aspirin, and the decision to restart has been deferred to the PCP. [**Name10 (NameIs) 616**] the one episode of chest pain, she remained asymptomatic throughout the rest of the hospitalization. A higher transfusion threshold was kept (at Hct 28) given the cardiac ischemia. UTI: Although she denied symptoms, she was found to have an E. coli UTI. She was initially treated empirically with ciprofloxacin, but was changed to Bactrim when sensitives were returned and showed ciprofloxacin resistance. She was treated with a three day course. ISSUES FOR FOLLOW-UP: (1) VNA was given instructions to check Hct and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5906**], on [**2116-6-11**], the day after discharge. (2) She was scheduled to see Dr. [**Last Name (STitle) **] in cardiology as a new patient. This appointment was originally scheduled for [**2116-6-9**], but was canceled when Ms. [**Known lastname 5903**] remained in the hospital after the rebleed. Housestaff were unable to make a new appointment wiht Dr.[**Name (NI) 5907**] office, and Ms. [**Known lastname 5903**] was given their phone number to make an appointment for the next 1 - 2 weeks. (3) Aspirin and lisinopril were held and not restarted at discharge. Her dose of metoprolol on discharge was also kept low at 12.5 mg [**Hospital1 **]. Titration of her BP meds and the decision to restart aspirin will be left to her PCP. (4) Ms. [**Known lastname 5903**] needs a follow-up colonoscopy in one year with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] to remove sigmoid polyp (area was not biopsied at time of in-patient colonocopy given bleeding risk). Medications on Admission: - aspirin 81 daily - lisinopril 40 daily - simvastatin 80 daily - metoprolol 50 twice daily - HCTZ 12.5 daily (?) - insulin lantus - cosopt eye gtt - xalatan eye gtt - naproxen prn ([**12-25**]/month) - ca / vit d Discharge Medications: 1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: You can take this to help keep your stools soft. Disp:*60 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Calcium Oral 5. Vitamin D Oral 6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: Please take a half tablet (12.5 mg) twice a day. Disp:*30 Tablet(s)* Refills:*2* 9. Insulin Glargine Subcutaneous Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: (1) Lower GI bleed (2) Diverticulosis (3) Anemia Secondary Diagnoses: (1) Chronic kidney disease Discharge Condition: Stable-- satting in the mid to upper 90's on room air; no shortness of breath; no blood loss from below in 48+ hours prior to discharge; hematocrit stable and hemodynamically stable. Discharge Instructions: You were admitted with a bleed from your GI tract which was likely from your diverticuli, although the exact source of the bleeding could not be found on the colonoscopy or tagged red blood cell scans. Your blood counts have been stable over the last two days, but your primary care doctor needs to check your blood counts later this week. You should call your doctor if you notice any more blood loss. If you cannot reach your doctor or if you have a lot of blood loss, feel dizzy or feel weak, you should return to the emergency room for an evaluation. You should follow the medication given to you on discharge. Your aspirin was stopped because of your bleeding; you should ask your primary care doctor when this should be restarted. One of your blood pressure medications (lisinopril) was also stopped because of the risk of low blood pressure with bleeding. Your dose of metoprolol was decreased to 12.5 mg twice a day. You will talk to your primary care doctor on [**6-12**] about restarting the lisinopril and increasing the metoprolol dose (she will check your blood pressure to see if the medications need to be increased). You will also have home physical therapy for strengthening and balance exercises. Please take your insulin at the same dose you were taking before you came into the hospital. Followup Instructions: You have the following appointments: (1) You have an appointment with your primary care doctor, Dr. [**Last Name (STitle) 5908**], on [**Last Name (LF) 2974**], [**6-12**], at 11:15 am. The phone number is [**Telephone/Fax (1) 133**]. (2) You should call to make an appointment with Dr. [**Last Name (STitle) **] in cardiology. Please try to be seen in the next 1 - 2 weeks. Their office is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**] of [**Hospital1 **] Hospital. The phone number is ([**Telephone/Fax (1) 5909**]. Also, you are having your blood counts checked on Thursday, [**6-9**]. The visiting nurse will draw your blood and fax the results to Dr. [**Last Name (STitle) 5906**] to review. She will call you if there are any problems.

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icd9cm

[ [ [] ] ]

[ "99.04", "96.07", "45.23" ]

icd9pcs

[ [ [] ] ]

10149, 10206

4494, 9142

345, 359

10367, 10552

2040, 2040

11916, 12734

1392, 1518

9407, 10126

10227, 10296

9168, 9384

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1558, 2021

10317, 10346

273, 307

387, 918

2056, 4471

940, 1113

1129, 1376

19,716

106,745

8173

Discharge summary

report

Admission Date: [**2108-12-7**] Discharge Date: [**2109-1-10**] Service: MICU CHIEF COMPLAINT: Shortness of breath. HISTORY OF THE PRESENT ILLNESS: The patient is an 81-year-old female with a history of coronary artery disease, peripheral vascular disease, COPD, and CHF, who presented to [**Hospital3 1443**] Hospital on [**2108-11-29**] with roughly one week of shortness of breath, weight gain, fatigue. There, she was found to be in new onset atrial fibrillation and congestive heart failure. An aggressive rate control and diuresis were attempted; however, her condition with regards to her oxygen requirement continued to worsen. A transthoracic echocardiogram was performed which revealed no clot, aortic stenosis, with a valve area of 0.65 cm squared and a valve gradient of approximately 15 mm. Cardioversion was then attempted which required the patient to be intubated due to worsening respiratory distress. She was transferred to [**Hospital1 18**] for valvuloplasty and further evaluation and management. Per outside hospital records, the patient also was febrile with an increased leukocytosis with possible pulmonary infiltrates. She was treated with ceftriaxone, Zosyn, Flagyl, moxifloxacin, with persistent fever. Apparently, all cultures there including sputum, blood, and urine cultures were negative. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post CABG times two, last one performed in [**2103**]. 2. COPD, on home oxygen, 2 liters nasal cannula. 3. CHF, EF of approximately 45-50%. 4. Peripheral vascular disease. 5. Chronic anemia. 6. Depression. 7. Status post cholecystectomy. ALLERGIES: The patient is allergic to morphine. TRANSFER MEDICATIONS: 1. Combivent. 2. Protonix. 3. Amiodarone. 4. Lasix. 5. Vancomycin. 6. Moxifloxacin. 7. Flagyl. PHYSICAL EXAMINATION ON TRANSFER: Vital signs: Temperature 102.0 rectally, blood pressure 133/42, heart rate 70, normal sinus rhythm. Ventilatory settings: Assist control, tidal volume 650, respiratory rate 16, 100% FI02, PEEP 18. General: The patient is intubated, sedated, and unresponsive. HEENT: The pupils were equal, round, and reactive to light, anicteric sclerae. Cardiovascular: Regular rate and rhythm, [**Year (4 digits) 1105**]/VI systolic murmur, crescendo/decrescendo, loudest at the right upper sternal border, no rubs or gallops. Lungs: Crackles bilaterally to the midlung fields. No wheezes. Abdomen: Obese, nondistended, hypoactive bowel sounds. Extremities: Right groin without hematoma, trace pitting edema bilaterally. Lower extremities: Feet cool to the touch, 1+ dorsalis pedis pulses bilaterally. Neurological: Toes upgoing. LABORATORY STUDIES: White count 14.2, hematocrit 23.9, platelets 244,000. Sodium 149, potassium 3.1, chloride 110, C02 26, BUN 52, creatinine 1.4, glucose 138, calcium 8, magnesium 2.0, phosphorus 4.1. ALT 68, AST 43, CK 93, troponin 1.4, albumin 2.7. ABGs 7.36, PC02 50, P02 155. EKG revealed a normal sinus rhythm at a rate of 75, normal axis, PR slightly prolonged at 0.24, QRS, QT within normal limits. Q in [**Last Name (LF) 1105**], [**First Name3 (LF) **] depressions in V4 through V6. Microbiology studies from the outside hospital include sputum, urine, and blood cultures all negative. Chest x-ray revealed bilateral infiltrates. HOSPITAL COURSE: 1. AORTOVALVULOPLASTY: The patient was brought emergency to the Catheterization Laboratory with successful valvuloplasty. 2. ACUTE RESPIRATORY DISTRESS SYNDROME: The patient had difficulty with her respiratory requirements and difficulty coming off the ventilator requiring high amounts of oxygen content as well as difficulty coming off pressors for her low blood pressure. It was felt that this combination of respiratory distress was from a cardiac as well as a pulmonary etiology. A pulmonary artery catheter was placed for further monitoring of her hemodynamics which revealed a wedge pressure of 30 as well as elevated right atrial and right ventricular pressures, right atrial pressure being 23/18, right ventricular pressure being 55/12, pulmonary artery pressure being 60/29/ On hospital day number ten, she was transferred from the CCU Service to the Medical Intensive Care Unit Service for management of her acute respiratory distress syndrome despite having a capillary wedge pressure of 20. She was placed on Ardonette protocol and throughout her hospital course, attempts were made to decrease the oxygen content as well as the end-expiratory pressures without success. Tracheostomy was deferred secondary to her critically ill state and it was felt that she would not survive the procedure. Serial chest x-rays revealed clearing of her acute respiratory distress syndrome; however, given her comorbidities and requiring aggressive fluid hydration, she progressed to congestive heart failure, again requiring high levels of ventilatory support, and was never successfully taken off of mechanical ventilation. 3. HYPOTENSION: It was felt that the etiology of her hypotension was again multifactorial with a decreased cardiac output requiring multiple pressors as well as a distributive shock picture from an infectious cause of an unknown source. Throughout her CCU stay, she required Levophed, Neo-Synephrine, and dobutamine. Throughout her hospital course trending into the Medical Intensive Care Unit course she never was successfully weaned off of pressors, requiring quadruple pressors at her time of expiration. It was also felt that these pressors were causing an exacerbation of her ischemic colitis; however, given her extremely low hypotension she was unable to successfully wean and remained on quadruple pressors at the time of expiration. 4. FEVERS: Since prior to admission, the patient was noted to have fevers of unknown etiology despite multiple cultures drawn. She continued to experience multiple episodes of fevers despite an unknown etiology despite an exhaustive amount of cultures including her blood, urine, sputum, and stool. She was placed empirically on antibiotics despite a known source. During which time, she seemingly responded and her fevers dropped. However, approximately two weeks after initiation of antibiotics, she continued to have fevers up to 103.0 Fahrenheit, despite broadening her antibiotic coverage to include antifungals. Multiple drugs were withdrawn for a suspected drug fever, but she continued to experience fevers. However, with the comorbid diagnosis of ischemic colitis, it was felt that she was having translocation of bacteria from her colon that may have been causing her fevers and was continued to be covered broadly up to the time of her expiration. 5. ISCHEMIC COLITIS: It was noted on hospital day number 21 that the patient had a significant increase in the amount of her stool. Her stool was Guaiac positive throughout her hospital course but the appearance of her stool turned bright red. A Gastrointestinal consult was obtained for further evaluation, at which time a CT of the abdomen was obtained which revealed edema throughout her transverse, descending, and sigmoid colon. A flexible sigmoidoscopy was performed which revealed changes that are consistent with ischemia. At this time, she was aggressively hydrated to maintain her blood pressures above a mean of 60 for adequate perfusion. Despite this strategy, however, she continued to have massive amounts of stool output, approaching 4 liters per day, and became increasingly acidotic despite aggressive bicarbonate repletement. Surgery was declined by both the patient's family as well as the Surgery Team secondary to an extremely high operative risk. She continued to have high volumes of stool output up to the time of her expiration. 6. ANEMIA: The patient was noted to have blood loss through her GI tract and was supported with multiple units of packed cells for blood transfusions to maintain a hematocrit above 30. 7. ADRENAL INSUFFICIENCY: Random cortisol levels were drawn throughout her hospital course; with a value of 12 it was felt that she was adrenally insufficient and was started on an empiric course of steroid replacement. However, this had no effect on her blood pressures and after approximately seven days her steroids were discontinued. 8. VENTILATOR-ASSOCIATED PNEUMONIA: The patient was noted to have an acute increase in secretions while on the ventilator and required increased suctioning as well as an antibiotic course for adequate treatment. 9. NUTRITION: Because of her ischemic colitis, she was placed on total parental nutrition for the remainder of her hospital course up until her date of expiration. 10. HYPERNATREMIA: On admission, the patient was noted to be hypernatremic. Free water deficit was repleted over the time course of her hospital stay and her sodium was maintained with TPN. Of note, the patient was made comfort measures only two days prior to her expiration after a long family meeting with her husband and three daughters present as well as her son. The husband stated that he wished to make her comfort measures only and was moved to this directive by the husband's wishes. The patient expired on [**2109-1-10**] at 4:30 p.m. An autopsy was declined at this time. CONDITION: Expired. DIAGNOSIS: 1. Aortic stenosis, status post valvuloplasty. 2. Acute respiratory distress syndrome. 3. Cardiogenic and distributive shock requiring multiple pressors. 4. Ischemic colitis. 5. Anemia. 6. Adrenal insufficiency. 7. Ventilator-associated pneumonia. 8. Hypernatremia. 9. Total parenteral nutrition. 10. Coronary artery disease. 11. Chronic obstructive pulmonary disease. 12. Congestive heart failure. 13. Peripheral vascular disease. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-685 Dictated By:[**Name8 (MD) 5406**] MEDQUIST36 D: [**2109-1-22**] 03:34 T: [**2109-1-22**] 20:38 JOB#: [**Job Number 29074**]

[ "428.0", "785.59", "396.2", "785.51", "557.0", "997.3", "518.5", "486", "038.9" ]

icd9cm

[ [ [] ] ]

[ "37.23", "89.64", "38.93", "00.11", "42.92", "99.15", "38.91", "45.24", "35.96" ]

icd9pcs

[ [ [] ] ]

3355, 9959

106, 1342

1717, 3337

1364, 1695

10,188

162,557

9011+55992

Discharge summary

report+addendum

Admission Date: [**2110-4-3**] Discharge Date: [**2110-5-2**] Date of Birth: [**2047-12-12**] Sex: M Service: MEDICINE Allergies: Methotrexate / Penicillins / Heparin Agents Attending:[**First Name3 (LF) 297**] Chief Complaint: Fungemia Major Surgical or Invasive Procedure: s/p tracheostomal intubation s/p thoracentesis s/p arterial line placement and removal s/p PICC line placement History of Present Illness: 62 yo man with h/o homograft repair of coarcted aorta at age 13 who underwent ascending-to-descending aorta bypass with Gelweave graft here [**1-29**] for progressive stenosis of his coarctation. Post-op course complicated by HIT. He was ultimately d/c'd on [**2-17**]. . He returned to the ED [**2-20**] with three days of fever, chills, cough, and dyspnea. Looked toxic in the ED, got vanc and meropenem (despite PCN allergy). Coughing on the floor [**2-20**], he dehisced his sternum and likely ruptured his RV at the same time. [**2-20**] went to OR for exploration, debridement, and repair of RV rupture with pericardium. Returned to the OR hours later for relief of cardiac and chest wall edema that were compressing his RV; the chest was left open. Swab from this procedure later grew SCN. He was in the unit with a tegaderm over his chest for 4 days on broad spectrum abx. He returned to the OR for omental flap (to the area that his sternum previously occupied) [**2-24**] and cultures of an "aortic clot" extracted later grew SCN x2 and gamma strep. We narrowed his antibiotics to vancomycin alone with the thought that these were true pathogens (got there during his 4 days of tegaderm to the chest). We have assumed that this has infected his graft. . He did well for several days (weaned off pressors, stayed afebrile and had norwal WBC count). Unfortunately, he spiked a temp on [**3-2**]; by [**3-3**] blood cultures from fem a-line grew VRE. He was started on linezolid and vancomycin was d/c'd. He returned to the OR on [**3-6**] and had a STSG placed over the omental flap in his chest. Unfortunately, omentum sample taken intra-op grew VRE. We decided to treat for 4 weeks with linezolid ([**Date range (1) 31213**]) to clear the tissue under the graft and to help the graft take. . He was slow to wean from the vent after this and was ultimately trach'd [**3-21**]. He continued to have intermittent low grade fevers of unclear source (likely PICC line, but primary team refused to remove it). He was d/c'd to rehab on [**3-26**], but only made it [**Street Address(1) 31214**] before having resp. distress. He was readmitted the same day febrile to 102. The team got blood cultures, but discharged him again [**3-27**] without identifying the etiology of his fever. The following day, [**3-28**], blood cultures drawn through PICC grew yeast. The CT surgery team and rehab people decided not to readmit him. ID consultants called the rehab and got the PICC line pulled, more cultures drawn and fluc 400 iv Q24h started (they did not want to start caspo). The yeast was later speciated as [**Female First Name (un) 564**] parapsilosis. He did OK at rehab and was actually switched from linezolid to suppressive doxycycline (for the SCN/gamma strep graft infection) on [**4-2**]. . On [**4-3**] he developed fever and rigors. The CT surgery team did not want to readmit him, so he was admitted to MICU. Overnight he spiked to 102.6. He had copious secretions; cefepime was added empirically for VAP. Sputum grew ESBL Klebs susceptible only to meropenem; cefepime was changed to [**Last Name (un) 2830**] [**4-5**]. . Fungemia w/u included ophtho exam and TTE, both negative. . At rehab, he has been stable. However, his blood cultures from [**3-26**] grew [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 31215**] (from R PICC line). The PICC was removed and another placed on the left. He has been treated with fluconazole (400 IV per ID recs) since [**3-28**]. He was transferred here for further evaluation and management. His other issues at rehab have been mainly renal, as he has been hypernatremic and hypokalemic which was felt by their renal consult to be due to overdiuresis, and improved with backing off on diuretics. Past Medical History: -Status-post ascending aorta to descending aorta bypass graft with 18mm gelweave [**2110-1-29**] -Repair of right ventricular laceration and sternal wound debridement [**2-10**] -Coarctation of the distal Arch s/p Surgical Repair of Arch/Desc. -Aorta w/ Homograft via Left Thoracotomy at age 13 -Bicuspid Aortic Valve -Congestive Heart Failure: most recent echo was TEE [**2-21**] done after RV laceration repair, but at that time EF was >55% -Hypercholesterolemia -Psoriatic Arthritis -Osteoarthritis -Asthma -Sciatica -Hemorrhoids -Meckel's Diverticulum s/p surgery -Right Lung Nodule -s/p L2-L3, L4-L5 sacral fusion -s/p L Subacromial decompression via arthroscopy -s/p Appendectomy -s/p Open Cholecystectomy -s/p R Inguinal Hernia Repair -s/p Nasal surgery for deviated septum -s/p Lens Implants -h/o HIT -recent MRSA pneumonia -h/o atrial fibrillation during hospitalization -h/o VRE bacteremia (linezolid through [**2110-4-2**]) -recent MRSE aortic graft infection -s/p open jejunostomy tube placement [**2110-2-24**] -s/p percutaneous tracheostomy [**2110-3-21**] Social History: No tobacco, no etoh. Married with 2 children. Family History: Maternal Uncles died in 50's from MI Physical Exam: PE: T: 100.0 P: 85 BP: 122/54 Vent: SIMV 0.4 600 8 (15) 18/6 PIP 29 Plat 26 100% Trach cuff pressure 20 Gen: chronically ill appearing male but in NAD HEENT: anicteric, MM dry Neck: trach collar in place, appears well-healed Chest: visible heart movements, mild bibasilar crackles anteriorly, no wheezes/rhonchi, good air movement. Granulation tissue over sternum with no dehiscence or evidence of infection. CV: distant heart sounds, regular rate/rhythm, II/VI systolic flow murmur at LUSB Abd: soft, distended, hypoactive bowel sounds, nontender. Ext: [**12-9**]+ pitting edema bilateral lower extremities Pertinent Results: [**2110-5-1**] 03:36AM BLOOD WBC-11.4* RBC-2.75* Hgb-8.3* Hct-25.8* MCV-94 MCH-30.1 MCHC-32.1 RDW-23.7* Plt Ct-375 [**2110-4-27**] 04:30AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-2+ [**2110-5-1**] 03:36AM BLOOD Plt Ct-375 [**2110-4-30**] 04:05AM BLOOD PT-14.0* PTT-24.9 INR(PT)-1.2* [**2110-5-1**] 03:36AM BLOOD Glucose-96 UreaN-11 Creat-0.5 Na-143 K-4.0 Cl-103 HCO3-32 AnGap-12 [**2110-4-16**] 07:10AM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-3446* [**2110-5-1**] 03:36AM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.9 Mg-2.2 [**2110-5-1**] 03:59AM BLOOD Type-[**Last Name (un) **] pO2-52* pCO2-55* pH-7.40 calHCO3-35* Base XS-6 . Chest CT [**4-21**] IMPRESSION: There is no evidence of pulmonary embolism. Interval increase of the extension of the pulmonary consolidations. Interval increase in size in the dehiscence of the sternum. Stable right pleural effusion and collection with peripheral enhancement located around the aortic graft. NG tube with tip in the stomach. Bilateral pleural effusions right greater than left. Interval increase in size and number of mediastinal lymphadenopathy. Interval increase in the amount of the pericardial effusion. Interval increase of the stranding and inflammatory process in the anterior upper chest wall. . TTE: Conclusions: 1.The left atrium is dilated. A left-to-right shunt across the interatrial septum is seen through a small secundum atrial septal defect at rest. 2. Overall left ventricular systolic function is mildly depressed, with mild global hypokinesis. 3.The right ventricular cavity is small. Right ventricular systolic function is normal. 4.There are simple atheroma in the aortic root and in the descending aorta. The distal ascending aorta and aortic arch are incompletely visualized, probably owing to the presence of a surgical aortic bypass conduit. 5.The aortic valve is bicuspid. The aortic valve leaflets are mildly thickened, with focal calcification at the base of the more posterior cusp. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis or regurgitation. 6.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. 7. No vegetation/mass is seen on the pulmonic valve. 8.There is a small pericardial effusion. . IMPRESSION: No echocardiographic evidence of endocarditis. Moderate mitral regurgitation. Bicuspid aortic valve. Small ASD present. . Brief Hospital Course: A/P: 62 M with a h/o aortic coarctation s/p bypass in [**3-13**] compliucated by sternal wound dehiscnece and RV laceration s/p repair, recently discharged to vent facility with trach, returns with fevers and fungemia. . 1. Fevers/sepsis: The patient was initially admitted with fevers suspected from fungemia noted on cultures at rehab. He was treated with broad spectrum antibiotics and sources of infection were sought out. The patient continued to have daily high fevers depite broad antibiotics. He did appear to have a pneumonia with an infiltrate on CXR. He was treated with meropenem for ESBL Klebsiella pneumonia. TTE was negative for endocarditis. Initial CT chest had R > L effusion and RUL opacities, so thoracentesis was done [**4-9**] to rule out empyema. (there were some antecedent issues with a supratherapeutic INR). This was negative. . Despite appropriate treatment of his pneumonia and Candidemia, he has remained persistently febrile. Evaluations and treatments have included: (1) L PICC (placed on admission here) was removed [**4-10**] and new LIJ placed; (2) metronidazole was empirically started [**4-9**] despite lack of leukocytosis or diarrhea; it was stopped [**4-14**] given lack of improvement; (3) TEE [**4-11**] was unremarkable; (4) repeat CT chest [**4-11**] showed fluid around the inferior aspect of the aortic graft and anterior mediastinal stranding without change; and (5) his doxy was empirically changes back to linezolid [**4-13**]. . Of note, during the course of his hospital stay, Mr. [**Known lastname 951**] [**Last Name (Titles) 9456**] septic physiology intermittently. He requiered close monitoring of blood pressure and fluid boluses during which his total body balance was up to 50L positive for length of stay. He briefly required pressors, but was soon weaned off. . A CT abd/pelvis done as part of a shotgun approach to his fevers showed rim-enhancement around his small left pleural effusion worrisome for empyema. Worse, this collection may be contiguous with the fluid around his graft. Further, he has herniated bowel into the space where his sternum used to be, although there is no current evidence of strangulation, incarceration, or anything worrisome. . The left pleural effusion was drained [**4-17**] and reportedly pus was drained,(although cultures were negative and there was only 1 PMN on stain)although no catheter was left in place. The serous right effusion was also drained at the same time and a pigtail was left in this side. Cultures from both remain negative. During the last 1 week of the hospital stay, the patient remained afebrile and hemodynamically stable. . 2. Resp Failure: The patient remains with trach from his previous admission when he was discharged to vent facility for long-term weaning. His pneumonia was treated as noted above. He demonstrated poor respiratory mechanics during the admission and was unable to be weaned from positive pressure ventilation. . # CHF: The patient has no previous history of CHF. He became very total body overloaded suring the stay, up to 50L positive for length of stay, because of his septic physiology and low blood pressure he was given fluid boluses several times per day. His Echo did show mildly depressed EF. He never showed evidence of pulmonary edema. Once his blood pressure stablilized and his fever resolved, he was diursed daily for roughly one week which improved his volume situation gradually. Although he remains significantly fluid overloaded. He has hypoalbuminemia as well because of his poor nutritional status which we managed aggressively with tube feeding. He was continued on his home dose of amiodarone and he remained in NSR during the stay. . #. s/p numerous cardiac surgery procedures: The thoracics team saw the patient while he was on the medicine service. The surgery team emphasized that the graft was chronically infected and that there were no plans for further surgery since this would be of greater risk than benefit to the patient. There is also a wound in the Left axilla from the prior admission which the surgery team recommended dry dressings. . #. previous HIT: The patient was anti-coagulated for his history of recent HIT. This was held for procedures. Given that the patient's platelet count had resolved and that he was out of the window for thrombotic events, the anti-coagulation was stopped. . #. Anemia: Likely from chronic disease. Epoetin was discontinued given that the patient does not have renal failure or cancer. . #. FEN: He was continued on tube feeds for nutrition. He has poor nutritional status, with an albumin around 2.0. . #. Ppx: p-boots, PPI, HOB elevated # Access: L IJ # Code: Full # Communication: with pt and wife [**Name (NI) 14175**] [**Telephone/Fax (1) 31216**] # Dispo: screening for rehab Medications on Admission: aspirin 81 qd singulair 10 qd fluticasone 110mcg 1 puff [**Hospital1 **] lipitor 10 qd amiodarone 200 qd prevacid 30 qd amitriptyline 25 qhs zaroxolyn 5 [**Hospital1 **] lasix 40 iv bid klonepin 0.5 tid fluconazole 400 IV for total 4 weeks potassium 40 qd coumadin 7.5 qd epogen 15,000 units 2x a week colace 100 [**Hospital1 **] dulcolax 1 qd prn duoneb 1 neb q6hr Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): This must be continued indefinitely for suppression of chronic aortic graft infection. 15. [**Hospital1 31217**] [**Hospital1 31217**] sliding scale, [**Name6 (MD) **] accepting MD [**First Name (Titles) **] [**Last Name (Titles) **] 18U qAM [**Last Name (Titles) **] [**Last Name (Titles) **] 10U qPM Discharge Disposition: Extended Care Facility: [**Hospital 31218**] hospital Discharge Diagnosis: Fungemia Respiratory Failure Persistent Pleural effusion Discharge Condition: stable, improved, oxygenating and ventillating well on supp O2 Discharge Instructions: -doxycycline should be continued indefinitely -please make sure patient takes all medications as directed -wean patient's respiratory support to CPAP/trach collar as tolerated -get pt out of bed, agressive lower / upper extremity physical therapy Followup Instructions: You should follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks You should have an Infectious disease follow-up within one month. Our ID physicians will contact you. Completed by:[**2110-5-2**] Name: [**Known lastname 904**],[**Known firstname 126**] A Unit No: [**Numeric Identifier 5437**] Admission Date: [**2110-5-7**] Discharge Date: [**2110-5-9**] Date of Birth: [**2047-12-12**] Sex: M Service: MEDICINE Allergies: Methotrexate / Penicillins / Heparin Agents Attending:[**First Name3 (LF) 1225**] Addendum: Patient's stay was indeed very complicated. The patient has a hx of aortic coarct that was repaired previously, he is thought to have a chronically infected graft. During the course of the hospital stay, the patient developed various infections that have contributed to the fevers and septic physiology: kliebsiella (multi-drug resistant) pneumonia, PICC line was proven to be infected, candidemia (proven by cx and the original reason for the previous admission). The patient developed multiple fluid collections in his pleural space that had to be drained by IR--the patient had JP drains in bilaterally Brief Hospital Course: Patient's stay was indeed very complicated. The patient has a hx of aortic coarct that was repaired previously, he is thought to have a chronically infected graft. During the course of the hospital stay, the patient developed various infections that have contributed to the fevers and septic physiology: kliebsiella (multi-drug resistant) pneumonia, PICC line was proven to be infected, candidemia (proven by cx and the original reason for the previous admission). The patient developed multiple fluid collections in his pleural space that had to be drained by IR--the patient had JP drains in bilaterally Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] - [**Location (un) 42**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1226**] MD [**Last Name (un) 1227**] Completed by:[**2110-5-14**]

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icd9cm

[ [ [] ] ]

[ "88.72", "99.04", "38.93", "00.17", "00.14", "96.72", "34.91", "99.07" ]

icd9pcs

[ [ [] ] ]

17618, 17851

16985, 17595

311, 424

15410, 15475

6083, 8530

15770, 16962

5397, 5435

13770, 15230

15330, 15389

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15499, 15747

5450, 6064

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5333, 5381

11,236

185,878

52418

Discharge summary

report

Admission Date: [**2193-5-24**] Discharge Date: [**2193-5-31**] Date of Birth: [**2112-2-19**] Sex: F Service: MEDICINE Allergies: Belladonna Alkaloids Attending:[**First Name3 (LF) 898**] Chief Complaint: acute onset of SOB following transfusion Major Surgical or Invasive Procedure: None History of Present Illness: 81 Russian speaking F with h/o anemia, Crohn's, PE; admit from ED with dyspnea following blood transfusion. Patient with history of myelodysplasia/multifactorial anemia requiring transfusions at least once monthly. Presented to hematology clinic today for planned transfusion (recent hct 22.3) of 1 unit PRBCs, given over 2.5 hours. Per heme notes, patient completed transfusion, walked to BR and reported dyspnea and palpitations. Per daughter she developed symptoms during transfusion, which was "sped up". In clinic O2 sat 85% RA increasing to 97% on 3L by FM. BP 190/50, HR 100. Later had episode of diarrhea and vomiting at clinic. Given 10 IV lasix x 2 at clinic. Prior to clinic visit had been feeling very well, in USOH. Has VNA and O2 sats on RA at home range 92-96%. . In ED vitals were T99.2, P90, BP 170/72. O2 sat 80% on RA, then 83% on 4L, then 96% on NRB. Briefly on CPAP (sats 99%), then back to NRB, and down to 4L NC with sats 96-98%. Labs included Hct 27.3, creat 1.8, BNP 1590, trop 0.05. Received benadryl, zofran, nitro paste. CXR with cardiomegaly without pulm edema. Satting 97% on 4L but tachypneic, prompting ICU admit. . Currently feeling much better in ICU, denies nausea, shortness of breath, chest pain. Past Medical History: #. Anemia, due to renal failure, anemia of chronic disease, and myelodysplastic syndrome; previously on epo weekly and requiring regular transfusions, multiple positive anti-RBC antibodies. #. Chronic bilat LE edema #. Crohn's disease #. breast CA s/p s/p R lumpectomy and XRT 13 yrs ago #. GERD #. CAD s/p NSTEMI '[**89**] #. s/p CCY 10 yrs ago #. HTN (does not appear to be on home meds) #. hx of bilateral DVTs and saddle embolus in [**2190**], had been on warfarin. #. CRI, baseline cr 1.5-1.8 #. MVA 20 years ago with intracranial bleed Social History: Lives with daughter; husband currently at rehab. Long smoking history quit 5 years ago. No EtOH. In wheelchair at baseline. Former physician. Family History: N/C Physical Exam: VS: T102.8, BP 128/51, P88, R48, 96% on 4L General: Appears comfortable, NAD, resp rate currently 24 HEENT: PERRL, NC/AT, conjunctiva with slight pallor. Neck: difficult to appreciate JVD Lungs: bibasilar rales, currently R>L while lying on R side Cardiac: RRR, S1 S2, [**3-6**] SM best at LSB Abdomen: soft, denies TTP, reducible ventral hernia, +BS Extrem: [**3-3**]+ gross bilat edema; however only trace pitting. Warm, well perfused. Pertinent Results: CXR: 1. The acute onset of alveolar infiltrates, likely edema and the left lower lobe consolidation with the patient's history of transfusion suggest a transfusion related acute lung injury. ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 70-80%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with normal free wall contractility. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: 81 F with anemia/myelodysplasia receiving regular transfusions with known RBC antigen antibodies admitted with dyspnea and hypoxemia following transfusion. SOB: It was felt that the patient had a TRALI reaction. The blook bank was going to perform further testing on the donor blood as confirmation. The patient does have chronic anemia secondary to a chronic myeloplastic disorder. She is transfusion dependent and receives packed red blood cell transfusions about once per month. She did have an additional transfusions (3 units) after admission to the intensive case unit without further incident. Also, there was concern about a PE. A V/Q scan was performed and showed a moderate to high probablity for a PE. She was started on presumptive treatment with lovenox daily. She will followup with her PCP to determine the length of treatment. Fever/Altered mental status: During her hospital course she was treated with a 3 day course of bactrim. Her mental status improved to baseline with treatment of the UTI. Crohns: The patients crohns was stable. She was seen by Dr [**Last Name (STitle) 3708**] (her Gastroenterolgoist) who said she is overdue for colonoscopy/EGD but this was to be scheduled as an outpatient. Of note, the patient remained FULL CODE during her hospital course. Medications on Admission: omeprazole 20 mg twice daily prednisone 17 mg daily (for crohn's) cipro 250 mg [**Hospital1 **] (for crohn's) folate 1 mg daily asacol 1200 mg tid (though daughter states not taking regularly) B12 monthly Discharge Medications: 1. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q24H (every 24 hours). Disp:*1800 mg* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 6. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Likely transfusion reaction Discharge Condition: Stable, with Hct of 31 Discharge Instructions: You were admitted to the hospital with shortness of breath after a blood transfusion. You were initially treated in the ICU and were then transferred to the medicine floor. We also performed a V/Q scan which shows that there may be a pulmonary embolism contributing to your shortness of breath. You were started on a blood thinner called lovenox (60mcg per day). You will need to continue this for at least 6 months. Please discuss this with your primary care doctor. You received a total of 3 units of blood while you were hospitalized. Please continue to have your blood checked and have transfusions as needed as an outpatient. Also, you were treated for a urinary tract infection. You received 3 days of bactrim. Please return to the hospital for worsening shortness of breath, difficulty breathing, chest pain, fevers, or chills. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2191**] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2193-6-7**] 11:00 Please follow up with Dr. [**Last Name (STitle) 3357**] within two weeks after discharge. The phone number is [**Telephone/Fax (1) 4606**].

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6149, 6224

3872, 4739

321, 327

6314, 6339

2827, 3849

7232, 7525

2349, 2354

5432, 6126

6245, 6245

5201, 5409

6363, 7209

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241, 283

355, 1606

6264, 6293

4755, 5175

1628, 2171

2187, 2333

22,083

153,664

50473+59261

Discharge summary

report+addendum

Admission Date: [**2189-4-20**] Discharge Date: [**2189-5-27**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1781**] Chief Complaint: SOB and Abdominal Pain Major Surgical or Invasive Procedure: Retroperitoneal repair of a juxtarenal abdominal aortic aneurysm with an 18 mm Dacron tube graft. Exploration of right inguinal canal. Right inguinal hernia repair. Flexible gastroscopy, attempted percutaneous endoscopic gastrostomy tube placement -- abandoned. Bed side swallow exam x 4 [**First Name3 (LF) 282**] placement History of Present Illness: 89 yo M w hx CAD, CHF, AF, prostate [**Hospital **] transfered from [**Location (un) 620**]. Initally presented for abdomnal pain, SOB and was found to have AAA 7.5cm on abd CT done for abd pain. Patient confirms orthpopnia, DOE with mild movement. Patient also complains of 2 weeks worseneing LE edema with pain on the right lower calf. Patient denies f/c/n/v/ since last admission. Of note the patient travelled by plain from [**Last Name (un) **] end of [**Month (only) **]. Also patient is s/p recent dc/ [**2189-3-24**] w/community aquired pna/UTI s/p abx (ceftriaxone, azithro 6/10days). Abd pain/diarrhea was worked up at that time all cultures were negative including C-diff. Past Medical History: 1. CAD s/p CABG in [**2183**] at [**Hospital3 2358**] 2. CHF w/ EF of 40% on TEE in [**2187**], 1+ AR, 2+MR 3. Hypothyroidism 4. L THR [**5-/2182**] 5. Prostate CA s/p resection+XRT 6. AFib s/p d/c cardioversion [**2182**], on coumadin 7. GERD 8. Hiatal hernia 9. OA 10. Hypertension 11. Dyslipidemia 1. AAA Repair Social History: Widower, former furniture washer. Smoked 3ppd until 20 years ago. No alcohol use. Family History: not elicited Physical Exam: GENERAL: Cachectic white male, NAD NUERO: Pt slightly confused at times, but alert and oriented x 2, non focal HEENT: NCAT, PERRL, EOMI neg lesions nares, oral pharnyx, auditory canal supple, FAROM, neg lyphandopathy, supraclavicular nodes LUNGS: CTA B/L, with slight crakles at bases CARDIAC: RRR without murmers ABD: soft, NTTP, ND, pos BS, right inguinal hernia scar - healing well without redness, discharge, or [**Last Name (LF) 105146**], [**First Name3 (LF) 282**] placed EXT neg cyanosis, clubbing, edema Fem 2 plus B/L, dopplerable PT/DP B/L Pertinent Results: [**2189-5-8**] VIDEO OROPHARYNGEAL SWALLOW: Study performed in conjunction with the speech and swallow division. Varying consistencies of barium were given and video fluoroscopy was performed during all phases of swallowing. The patient had significant difficulty initiating the oropharyngeal phase of the swallow. No penetration or aspiration was identified, however, significant barium was retained within the valleculae, which could not be cleared with coughing. During the exam the patient continued to regurgitate barium and the esophagus was noted to be markedly dilated, tapering at the lower esophageal sphincter. A 13 mm barium tablet was administered, which became lodged within the valleculae, and could not be cleared. Several attempts to pass the tablet were unsuccessful. Eventually, the patient vomited the residual barium and the tablet, upon which the exam was terminated. IMPRESSION: 1) No evidence of aspiration or penetration; however, significant difficulty initiating the oropharyngeal swallow with barium and barium tablet retained within the vallecula. See speech pathologist report. 2) Significantly dilated esophagus tapering distally, suggesting the lower esophageal sphincter spasm. Correlate clinically. [**2189-4-24**] ECHO Findings: LEFT ATRIUM: Marked LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Overall normal LVEF (>55%). [Intrinsic LV systolic function depressed given the severity of valvular regurgitation.] AORTA: Moderately dilated aortic root. Moderately dilated ascending aorta. AORTIC VALVE: Mild AS. Mild to moderate ([**2-8**]+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate to severe (3+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Severe [4+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions: 1.The left atrium is markedly dilated. The left atrium is elongated. 2.The right atrium is markedly dilated. 3.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] 4.The aortic root is moderately dilated. The ascending aorta is moderately dilated. 5.There is mild aortic valve stenosis. Mild to moderate ([**2-8**]+) aortic regurgitation is seen. 6.The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. 7.Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. 8. There is no pericardial effusion. 9. There is an echogenic density in the right ventricle consistent with a pacemaker lead. [**2189-4-23**] 9 RENAL U.S. PORT FINDINGS: The right kidney measures 12.4 cm. There is a 6 x 6.1 x 5.5 simple cyst at the upper pole. The right renal artery and vein are patent. Doppler exam is technically limited, blood flow is detected at the upper pole, interpolar region, and lower pole. The left kidney measures 12.1 cm. Limited Doppler exam demonstrates blood flow throughout the kidney, but adequate waveforms could not be obtained due to respiratory motion. There are no stones in either kidney or evidence of hydronephrosis. The bladder is mildly distended with urine. IMPRESSION: Technically limited exam with blood flow detected in both kidneys. No evidence of hydronephrosis. [**2189-5-15**] CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**Hospital 93**] MEDICAL CONDITION: 89 year old man with questionable SBO / incarcerated hernia REASON FOR THIS EXAMINATION: SBO Incarcerated inguinal hernis; patient cannot get po contrast -- with achalasihernia ABDOMEN WITH CONTRAST: There are calcifications within the coronary arteries. Calcified bilateral pleural plaques are consistent with asbestos exposure. There is a small right pleural effusion with bibasilar atelectasis. Fine detail within the lung bases is limited by respiratory motion. Within the limits of this unenhanced scan, multiple calcifications are seen within the liver and spleen, consistent with previous granulomatous disease. The pancreas is atrophic. Several calcified gallstones are present within an otherwise unremarkable appearing gallbladder. There is no change in the appearance of multiple bilateral renal cysts, incompletely evaluated on this exam without intravenous contrast. The bowel is not well assessed without oral contrast material. A large infrarenal abdominal aortic aneurysm is noted measuring 6.7 x 8.0 cm, which is slightly larger than on the prior exam. The aneurysm sac contains mixed density material and some calcification. There is a 9 mm nonobstructing stone at the lower pole of the left kidney. PELVIS WITH LIMITED ORAL CONTRAST: The bladder is distended. Detail within the deep pelvis is limited by streak artifact from the patient's left metallic hip prosthesis. There is a wide based protrusion of abdominal contents into the right inguinal canal, but no evidence of bowel obstruction. Similarly, within the lower left abdominal wall, there is a soft tissue density superficial to the musculature, which may or may not be connected to bowel, and is difficult to assess on this exam without oral contrast. This may represent a subcutaneous process or a [**Doctor Last Name **] hernia containing small bowel. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. Multiplanar reformatted images redemonstrate the above findings and are of grade 4. IMPRESSION: 1) Difficult exam due to the lack of oral contrast. Probable right inguinal hernia and possible [**Doctor Last Name **] hernia within the left abdominal wall versus a subcutaneous nodule or collection. 2) Slight interval increase in size of infrarenal abdominal aneurysm sac. 3) Coronary artery calcifications. 4) Calcified pleural plaques consistent with asbestos exposure. 5) Cholelithiasis. 6) 9 mm calcified stone at the lower pole of the left kidney, nonobstructing. [**2189-4-21**] ECG Atrial fibrillation with a rapid ventricular response. Ventricular premature beat. Baseline artifact in lead V6. Poor R wave progression with QS configuration in leads V1-V2 - could be due to lead placement or left axis deviation/ left anterior fascicular block but consider prior anteroseptal myocardial infarction. Diffuse ST-T wave abnormalities are non-specific but cannot exclude ischemia. Clinical correlation is suggested. Since the previous tracing of [**2189-4-20**] ventricular rate has increased and QRS voltage is less prominent. Intervals Axes Rate PR QRS QT/QTc P QRS T 133 0 108 284/362.42 0 -46 175 RADIOLOGY Final Report [**2189-5-24**] CHEST (PORTABLE AP) Reason: hypotension, evaulate for CHF PORTABLE CHEST A PICC line is again noted terminating in the mid SVC. There is no significant change in appearance of the chest since the prior chest x-ray of [**2189-5-20**]. Pleural thickening at the left base is present. The heart is enlarged and there are post-CABG changes. The right lung is clear. IMPRESSION: No change in the chest over the past four days. WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2189-5-26**] 6.6 3.41* 10.7* 32.1* 94 31.4 33.4 16.0* 244 PT PTT INR(PT) [**2189-5-26**] 21.3* 33.0 2.9 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2189-5-26**] 104 38* 0.8 139 4.5 108 27 9 Brief Hospital Course: Pt has thinned chart Pt has had a difficult and complicated hospital stay. Pt admitted on [**2189-4-20**] Pt had Retroperitoneal repair of a juxtarenal abdominal aortic aneurysm with an 18 mm Dacron tube graft, with T10 epidural placed for post op pain mgmt. Pt tolerated the procedure well. There were no complications. Pt transfered to the PACU in stable condition. Pt remained in the PACU untill [**2189-4-21**]. Because the patient could not be extubated transfered to the SICU. Immediatly post - op pt did exprience increase creatinine (2.6) , rapid a-fib, became febrile and had an increase in troponin. During his stay in the SICU, pt was tx for a multiple of problems experienced post op. [**2189-4-21**] - [**2189-5-7**], SICU stay Nephrology consult was obtained: ARF secondary to ATN in the setting of greater than 1 hr corvis clamp. Creatinine followed. Stable on DC. Cardiology consult was obtained: Chronic A - Fib, tx with lopressor, Anti - coagulation. Lytes replenished, blood products replaced. Pt extubated [**2189-4-28**] Pt remained in the SICU for p/o confusion, not able to protect airway. Aspiration precautions. Hypernatremia tx with free water bolus's. Increase BS - RISS Pt with increase fevers, found to have UTI, tx with levoquin Pt transfered to the [**Month/Day/Year **] [**2189-5-2**] [**2189-5-2**] - [**2189-5-12**] In the [**Name (NI) **] pt was treated for the above entities. Pt also had difficulty swallowing. A KUB was obtained. Showed questionable Alchalasia. Pt experiencing blood from foley, with excessive clotting Urology Consult obtained: Recommended flushes, check sensitivites for UTI. No improvement from AB, sensitivities come back resistant to Levo, ampicillan started, Pt UTI syptoms improve. Pt failed multiple swallowing studies, DHFT tube placed bedside. TF were started. Pt pulls out DHFT, goes to flouro for relacement of DHFT, unable to place, eusophageal sphincter spasm. PPN started. GI consult was obtained: Recommended EGD / [**Name (NI) 282**] under flouro. [**2189-5-11**] Pt goes to have [**Month/Day/Year 282**] placed experience rapid A-Fib. Procedure cancelled. Pt has bout of Ventricular ectopy. Cardiology recommends amiodorone, c/w beta blockade. [**2189-5-12**] - [**2189-5-26**] Pt rtansfered to the floor. A PT / casemanagement consult was obtained, recommended Rehab. [**2189-5-13**] pt gets EGD; recommended started on protonix, checked for H- Pylori, need sesophageal manometry. [**2189-5-14**] PICC placed for TPN. [**2189-5-15**] pt c/o abdominal pain, questionable incarcerated henia. General Surgery consult obtained: Pt recieves CT Scan confirms the above diagnosis. Pt taken to surgery. Pt did not have incarcerated hernis, found to have an meshoma, a r inguinal herniorraphy was done. Pt experiences SOB / CXR obtained - pt found to have pnuemonia started back on levofloxacin for 7 day course [**2189-5-22**] Pt recieves [**Month/Day/Year 282**], tolerates the procedure well. Pt IV meds are swithed over. 24 hours after the procedure the pt is starteed on tube feeds, coumadin is restarted for chronic A-fib. Pt creatine is improved to 1.0 [**2189-5-22**] - [**2189-5-26**] Rehab screening / PT is following. INR is monitered. Heparin is DC'd when INR is at 2.0. Pt improved. On discharge pt's TF by [**Month/Day/Year 282**], has Foley, Ambulating with asst. Is able to get OOB to chair. INR 2.9, creat 1.0. Medications on Admission: ASA lisinopril lasix atenolol warfarin levothyroxine KCl Discharge Medications: 1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection Q4-6H (every 4 to 6 hours) as needed. 10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: INR goal 2 - 2.5. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Asymptomatic juxtarenal abdominal aortic aneurysm. PSBO [**Hospital1 282**] ARF AFIB Alchalasia - not diagnosed needs manometry as outpt. meshoma UTI LLL pnuemonia Discharge Condition: stable Discharge Instructions: Keep wound C/D/I, [**Hospital1 282**] Maintenance Follow INR for A-fib, goal is 2 - 2.5 Foley to gravity - may DC when pt is able to ambulate to bathroom. Bedside Swallow study needs to be done, once pt is able to swallow may advance diet to solids and wean off TPN. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] two weeks. Please call [**Telephone/Fax (1) 1784**] Pt needs to have a manometer test for alchalasia. Please schedule through GI as an outpt. Call [**Telephone/Fax (1) 59876**] Pt needs bedside swallow study at rehab, if he can not get, please call the number for GI and do as an outpt. Completed by:[**2189-5-26**] Name: [**Known lastname 10875**],[**Known firstname 2499**] Unit No: [**Numeric Identifier 17116**] Admission Date: [**2189-4-20**] Discharge Date: [**2189-5-27**] Date of Birth: [**2099-11-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3717**] Addendum: Pt hospital stay extended untill [**2189-5-27**] No beds available No change in pts staus Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**First Name11 (Name Pattern1) 798**] [**Last Name (NamePattern4) 3683**] MD [**MD Number(1) 3724**] Completed by:[**2189-5-27**]

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icd9cm

[ [ [] ] ]

[ "44.13", "96.6", "45.13", "96.72", "99.15", "96.48", "54.72", "43.11", "38.44", "42.23" ]

icd9pcs

[ [ [] ] ]

16202, 16405

10032, 13463

284, 615

15006, 15014

2447, 6055

15333, 16179

1796, 1810

13571, 14732

6093, 6154

14819, 14985

13489, 13548

15038, 15310

1825, 2428

222, 246

6184, 10009

643, 1329

1351, 1679

1695, 1780

73,039

188,272

47399

Discharge summary

report

Admission Date: [**2151-10-11**] Discharge Date: [**2151-10-30**] Date of Birth: [**2089-1-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2151-10-11**]: 1. Right hemicolectomy with ileocolostomy 2. Right salpingo-oophorectomy . [**2151-10-18**]: 1. Exploratory laparotomy. 2. Resection of ileocolic anastomosis. 3. [**Doctor Last Name **] ileostomy. 4. Transverse end-colostomy. 5. Debridement of fascial edges. History of Present Illness: Patient is a 62 year old female with a history of obstipation since last Tuesday. She had some increasing abdominal pain and nausea. Patient had a fusion of her left ankle about a week ago. She was having trouble moving her bowels and progressively worsening abdominal pain over the past 24 hours, which brought her to the Emergency Department. A CT scan revealed pneumoperitoneum, and she was admitted. Past Medical History: 1. DM 2. HTN 3. IBS 4. Rectal fistula 5. Hyperlipidemia 6. Psoriasis- rash distribution scalp, elbows, thighs, chest. 7. Osteoarthritis of ankles, knees, Right shoulder. Left ankle end stage tibiotalar osteoarthritis s/p Left ankle fusion [**2151-10-8**] 8. Fibromyalgia 9. Right meniscal injury 10. Bilateral hip trochanteric bursitis. 11. (L) index finger gout Social History: Works as administrative coordinator. Drinks 12 drinks every week, wine or vodka. Ex-smoker quit 20 years ago. Family History: Non-contributory. Physical Exam: On Admission: Vitals: 98.9F 108 119/92 mmHg 22 94 GEN: Looks uncomfortable LUNGS: Clear bilateral COR: RRR ABD: Distended. Tenderness generalized but more in RLQ. Rebound tenderness present. RECTAL: Empty. Occult blood negative. EXTREM: Warm to touch, well perfused. MS: (L)ankle splint in place. . On Discharge: VS: 98.9 102 106/60 18 96RA GEN: A+Ox3. In NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. LUNGS: CTA(B) COR: RRR ABD: -(R)LQ Ileostomy:stoma is located at the RLQ, oval, [**Male First Name (un) 239**], measuring, approx. 1 [**1-22**]" x 1 [**3-24**]", stoma is pink, and moist with Os at 2 o'clock. Mucocutaneous Junction is intact,. Peristomal skin is intact. Effluent: green semi-formed stool. -Colostomy: (mucous fistula) is located in the LLQ, measuring 2" round. The stoma is flushed against abdomen, primarily necrotic with yellow tissue sloughing off. Pink area's of flush stoma noted under slough. Os is in the center. Mucocutaneous Junction separated at 7 o'clock to 12 o'clock and at 2 o'clock to 4 o'clock, sutures present, intact where mucocutaneous junction is still intact. Peristomal skin is clean and intact, no breakdown. -Midline incisional wound: Approximately 12cm x 3cm x 2cm granulating, clean, intact without exudate. Improved. No undermining or tunneling. VAC dressing with black foam continuous pressure at 125mm Hg. -BSx4. Appropriately tender to palpation, otherwise soft/NT/ND. EXTREM: WWP. No c/c/e on the right. MS: (L) LE in ankle splint. Non-weight bearing. (L) lower extremity in the splint mildly swollen. NEURO: A+Ox3. Pleasant. Non-focal/grossly intact. Pertinent Results: On Admission: [**2151-10-11**] 07:17PM TYPE-ART PO2-127* PCO2-43 PH-7.34* TOTAL CO2-24 BASE XS--2 [**2151-10-11**] 07:17PM freeCa-1.02* [**2151-10-11**] 07:04PM GLUCOSE-183* UREA N-30* CREAT-0.9 SODIUM-140 POTASSIUM-2.8* CHLORIDE-105 TOTAL CO2-22 ANION GAP-16 [**2151-10-11**] 07:04PM CALCIUM-7.4* PHOSPHATE-3.3 MAGNESIUM-1.5* [**2151-10-11**] 07:04PM WBC-7.9 RBC-3.01* HGB-9.3* HCT-26.8* MCV-89 MCH-30.9 MCHC-34.7 RDW-13.4 . On discharge: [**2151-10-27**] WBC 10.5 RBC 3.36* HGB 9.9 HCT 29.1 PLT 143 [**2151-10-27**] GLU 111 BUN 8 CRT 0.5 NA 138 K 4.4 CL 103 HCO3 29 [**2151-10-27**] CA 7.7 [**Doctor Last Name **] 2.3 MG 1.6 Imaging: . [**2151-10-11**] ABDOMEN (SUPINE & ERECT): Large amount of pneumoperitoneum suggesting viscus perforation. Dilated colon. See concurrent abdomen/pelvis CT for further details. . [**2151-10-11**] CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST: 1. Large pneumoperitoneum suggesting hollow viscus perforation without definitive source identified, although foci of gas tracking along the right abdomen and pelvis along with irregularity of the cecum make the right colon/cecum suspect. Distended cecum, ascending colon, and transverse colon with large air-fluid levels. 2. Small amount of perihepatic and perisplenic fluid. Small amount of pelvic free fluid. 3. Hypodense right adnexal structure, likely arising from the right ovary, increased in size since the prior CT examination. Given that the patient is postmenopausal, findings are of concern and a non-emergent pelvic ultrasound for further evaluation is advised. . [**2151-10-13**] HAND (AP, LAT & OBLIQUE) BILAT: 1. Degenerative changes consistent with osteoarthritis. 2. Possible changes consistent with psoriatic arthritis in the right index finger. Uncertain finding. . [**2151-10-17**] ABD/PELVIC CT W/CONTRAST: 1. Dilated loops of small bowel with decreased mucosal enhancement and the presence of portal venous air are concerning for ischemic bowel. 2. One week status post ileocolic resection for perforated colon with pneumoperitoneum that it is more than expected for the postoperative period. In addition, there is a large amount of free fluid, stranding of the mesentery, and a defect adjacent to the ileocolic anastomosis consistent with a leak. No evidence of discrete fluid collection. 3. Interval removal hypodense right adnexal structure which was confirmed to be a simple right ovarian cyst by pathology. 4. Minimal bilateral pleural effusions and atelectasis. . [**2151-10-19**] CXR (Portable AP): Improving left lower lobe atelectasis with stable small left pleural effusion. No new consolidation. . [**2151-10-20**] CXR (Portable AP): As compared to the previous examination, the monitoring and support devices are in unchanged position. Unchanged size of the cardiac silhouette. Increase in extent of the pre-existing retrocardiac opacity, slight increase in extent of the pre-existing left pleural effusion. No evidence of newly occurred focal parenchymal opacities. The size of the cardiac silhouette is unchanged. . [**2151-10-21**] CXR (Portable AP): As compared to the previous radiograph, there is now intubation of the right main bronchus. The endotracheal tube should be pulled back by 3-4 cm. The responsible nurse [**First Name (Titles) **] [**Name (NI) 653**] by telephone at the time of dictation. The nasogastric tube is in unchanged position. Also unchanged is the size of the cardiac silhouette, the pre-existing retrocardiac atelectasis and the potential presence of a small left pleural effusion. No evidence of newly appeared focal parenchymal opacities in the right lung. Unchanged position of the right central venous access line. . [**2151-10-23**] ECHO: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular systolic function. No vegetations identified. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. . FINDINGS: Comparison is made to the intraoperative study from [**2151-10-6**]. . ANKLE (AP, MORTISE & LA: The patient is status post tibiotalar fusion via two screws. The joint space is still faintly visualized. There has been resection of distal fibula. Overall, the hardware is unchanged. There are no signs for complications. Fine bony detail is somewhat limited due to the overlying cast material. . Microbiology: [**2151-10-26**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2151-10-26**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2151-10-22**] BLOOD CULTURE, no growth final [**2151-10-22**] CATHETER TIP-IV WOUND CULTURE-FINAL-No growth [**2151-10-22**] URINE URINE CULTURE-FINAL; ANAEROBIC CULTURE-FINAL-No growth [**2151-10-22**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL; ANAEROBIC CULTURE-FINAL-PMLs, GNR. [**2151-10-20**] BLOOD CULTURE Blood Culture, FINAL-No growth [**2151-10-20**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM}; Anaerobic Bottle Gram Stain-FINAL . Blood Culture, Routine (Final [**2151-10-26**]): ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml of gentamicin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of streptomycin. Screen predicts NO synergy with penicillins or vancomycin. Consult ID for treatment options. . Daptomycin = 3 MCG/ML. Daptomycin Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R . [**2151-10-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {ESCHERICHIA COLI}; FUNGAL CULTURE-PRELIMINARY . [**2151-10-20**] 1:24 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2151-10-20**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2151-10-23**]): Commensal Respiratory Flora Absent. ESCHERICHIA COLI. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- <=1 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED . [**2151-10-19**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth [**2151-10-19**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth [**2151-10-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2151-10-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2151-10-19**] URINE URINE CULTURE-FINAL-No growth [**2151-10-18**] MRSA SCREEN MRSA SCREEN-FINAL-Negative [**2151-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth [**2151-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth [**2151-10-17**] URINE URINE CULTURE-FINAL-No growth [**2151-10-16**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL {ESCHERICHIA COLI, LACTOBACILLUS SPECIES}; ANAEROBIC CULTURE-FINAL . Time Taken Not Noted Log-In Date/Time: [**2151-10-16**] 7:59 am SWAB Source: Abdominal. **FINAL REPORT [**2151-10-20**]** GRAM STAIN (Final [**2151-10-16**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2151-10-19**]): ESCHERICHIA COLI. SPARSE GROWTH. LACTOBACILLUS SPECIES. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [**2151-10-20**]): NO ANAEROBES ISOLATED. . [**2151-10-15**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth [**2151-10-15**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth [**2151-10-13**] BLOOD CULTURE Blood Culture, Routine-FINAL-No growth [**2151-10-11**] MRSA SCREEN MRSA SCREEN-FINAL-Negative [**2151-10-11**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-PMLs, No growth. [**2151-10-11**] BLOOD CULTURE Blood Culture, Routine-FINAL-No Growth [**2151-10-11**] URINE URINE CULTURE-FINAL-No growth Brief Hospital Course: The patient was admitted to the General Surgical Service on [**2151-10-11**] for evaluation and treatment of abdominal pain. An abdominal/pelvic CT revealed a large pneumoperitoneum. The patient was brought to the Operating Room emergently, where she underwent right hemicolectomy with ileocolostomy primary anastomosis for a finding of peritonitis and ischemic right hemicolon and right colonic perforation. . The patient was taken to the surgical intensive care unit intubated in guarded condition. In the SICU pain control was adequate with a Dilaudid PCA. Propofol and fentanyl infusion given during intubation. The patient was extubated without problem, and placed on supplemental oxygen by nasal cannula. She exhibited adequate ventilatory efforts. She was NPO on IV fluids, an NG tube and foley catheter were in place. She was continued on IV Flagyl and Cipro for the perforated bowel. While in the SICU, the patient experienced (L) index finger swellin, pain , mild erythema. Rheumatology was consulted. An x-ray was perfomed of both hands, which showed degenerative changes consistent with osteoarthritis, and possible changes consistent with psoriatic arthritis in the right index finger, although this finding was uncertain. Given the patient's bowel surgery, it was determined NSAIDS should be avoided, and the pain be treated with opioid pain medications. On POD#2, the patient was transferred to the floor NPO, on IV fluids and antibiotics, with a foley catheter, and a Dilaudid PCA for pain control. The patient was hemodynamically stable at the time. Her recovery initially progressed uneventfully. The NG Tube, IV antibiotics and foley were discontinued, and the patient was started on sips on POD#3. Diet was advanced to clears on POD#4. . Early on POD#6, however, the patient began experiencing intermittent fevers, and a small incisional opening, which was being packed. House staff notified at approximately 9:00 p.m. that the patient was now tachycardiac but no frank peritonitis. In consultation with Dr. [**Last Name (STitle) 468**], proceeded with CAT scan which demonstrated portal venous air, intra-abdominal fluid, dilated small bowel, concern for vascular compromise of small bowel, no frank extravasation of contrast. These findings nevertheless were consistent with perforation and the patient was consented and brought back to the OR for urgent exploratory laparotomy and probable ileostomy, colostomy and resection. . Early on [**2151-10-18**], the patient underwent exploratory laparotomy, resection of ileocolic anastomosis, [**Doctor Last Name **] ileostomy, transverse end-colostomy, and debridement of fascial edges for identified perforation ileocolic anastomosis, which went well (see Operative Note). Post-operatively, the patient was transferred to the SICU NPO on IV fluids, back on IV Flagyl and Cipro, with a foley and NG Tube in place, intubated on mechanical ventialtion. POD#7/0, she was febrile and tachy. Required Neomycin, IVF, and albumin. The (L) ankle cast was valved. POD#[**8-21**], checked CDiff from both mucous fistula/colostomy & ileostomy, rectal tube placed. Anemic with a HCT of 22; given 2 units PRBCs, Albumin, and lasix. Bladder P 17. Cipro off, cefepime on for resistant E.coli from wound. Alkalosis improved despite lasix. Fever 101.9; Pan cultured. POD#[**9-22**], NGT output continues to be high, tip in stomach; RSB 50 however still fluid avid, remained intubated. Febrile to 101.7, restarted cipro for extended gram neg coverage. Albumin 25% 12.5g [**Hospital1 **]. POD#[**10-23**], extubated and well tolerated. PRBC per primary team. NGT losses replaced. Patient refusing confirmation film. Agitated. GPC in BCx. POD#[**11-24**], refused CXR this am. Spiked temp, ID consulted. Recommended repeat BCx. Wound cx sent. Continued on current dose of Vanco. New subclavian placed. A-line removed. Started HCTZ. TTE ordered. C/o pain, PCA started. POD#[**12-25**], started on regular diabetic diet and home medications. POD#13/6, started on IV Daptomycin for VRE (ENTEROCOCCUS FAECIUM) from blood culture dated [**2151-10-20**]. IV Vancomycin discontinued. VAC dressing placed. The patient was transferred back to the inpatient floor. . The patient arrived on the floor on a diabetic regular diet, home medications, oral pain medications, and on a comprehensive antibiotics regimen, which consisted of IV Daptomycin and cefepime and oral Flagyl and Ciprofloxacin. She had a VAC dressing with black foam at 125mmHg applied to her mid-abdominal incisional wound, an ileostomy and colostomy. Physical Therapy, Occupational Therapy, and Ostomy Nurse consults were continued. She was given repletement for her ostomy output with IV Lactated Ringer's. She was followed by Orthopedics regarding for the left ankle; she remained non-weight bearing on the left with an ankle splint in place. An x-ray of the left ankle demonstrated that the hardware is unchanged, and that there were no signs for complications. . The patient tolerated her diabetic regular diet with fair intake, but no nausea. She was also started on nutritional supplements. Pain was well controlled on oral pain medications. Midline abdominal incisional wound improved with continued use of the VAC dressing system. Colostomy and ileostomy remained patent. Ostomy output was repleted cc:cc with LR IV Q4Hours. The patient got out of bed with Nursing or Physcial Therapy to a chair. Mobility was restricted due to non-weight bearing status on the left foot. She was adherent with respiratory toilet and incentive spirrometry. Oral Cipro and Flagyl were discontinued on [**2151-10-25**]. IV Cefepime was discontinued on [**2151-10-26**]. IV Daptomycin will be continued until [**2151-10-31**]. She experienced episodic left index finger swelling and pain; she was ultimately started on a short course of Indocin with symptomatic improvement. Her blood sugar was monitored closely and covered when indicated by an insulin sliding scale. Labwork was routinely monitored; electrolytes were repleted when indicated. VAC dressing was last changed on [**2151-10-27**]. . On [**2151-10-28**], she was given a 500mL NS fluid bolus to catch up on fluid losses from the ileostomy. Ileostomy output started to decrease at approximately 1Liter per day. Imodium PRN was started to maintain an ileosotmy output around the 1L/day volume. Subsequently, imodium was discontinued on [**2151-10-29**]. The ileostomy output decreased and was approximately 600cc during the 24 hours on [**2151-10-29**], the day prior to discharge. . At the time of discharge on [**2151-10-30**], the patient is doing well, afebrile with stable vital signs. The patient is tolerating a regular diet, ileostomy and colostomy are functioning properly, and pain is well controlled. She is discharged to an extended care facility. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: AMITRIPTYLINE - 75 mg hs ATORVASTATIN CALCIUM - 10 MG qday HYDROCHLOROTHIAZIDE - 12.5mg day KETOPROFEN - 75 mg tid LISINOPRIL - 20MG qday METFORMIN - 500 MG [**Hospital1 **] OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1-2 tabs q4h prn TEMAZEPAM - 15MG hs Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation, anxiety. 7. Amitriptyline 75 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 11. Daptomycin 600 mg IV Q24H Discontinue after AM dose on [**2151-10-31**]. 12. Insulin Lispro 100 unit/mL Solution Sig: 2-12 units Subcutaneous As directed per Humalog Insulin Sliding Scale. 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchy skin. 14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for for ileostomy output > 40mL/Hr (1L/day). 15. Medication: HYDROmorphone (Dilaudid) 1 mg IV Q3H:PRN breakthrough pain or before VAC dressing change Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. Peritonitis. 2. Ischemic right hemicolon and right colonic perforation. 3. Simple right ovarian cyst 4. Perforation ileocolic anastomosis Secondary: 1. Type II DM 2. HTN 3. s/p Left ankle fusion and left tendoachilles lengthening for ankle arthritis [**2151-10-6**] (Prior hospitalization) - ankle splint in place. Non-weight bearing. Discharge Condition: Good Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of 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. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-30**] lbs until you follow-up with your surgeon. . Monitoring Ileostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ileostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ileostomy output between 1000mL to 1500mL per day. *If Ileostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**], MD [**First Name (Titles) **] [**Last Name (Titles) **]. Please call([**Telephone/Fax (1) 26840**] to schedule your appointment. . Please follow up with Dr. [**Last Name (STitle) 468**] (Surgery) in three weeks. Please call ([**Telephone/Fax (1) 471**] to schedule a follow-up appointment in [**2-23**] weeks. . Please call ([**Telephone/Fax (1) 28786**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) **] (Surgery) in [**2-23**] weeks. . Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2151-11-2**] 9:45 Completed by:[**2151-10-30**]

[ "567.9", "620.2", "997.1", "716.97", "250.00", "038.0", "540.1", "E878.2", "564.1", "569.83", "518.0", "401.9", "E849.7", "785.0", "560.1", "274.01", "564.09", "997.4", "995.91", "041.4", "568.89" ]

icd9cm

[ [ [] ] ]

[ "38.93", "46.11", "47.09", "46.93", "65.49", "45.93", "46.21", "38.91", "45.73", "46.94", "83.44", "54.4" ]

icd9pcs

[ [ [] ] ]

22104, 22183

13507, 20465

330, 609

22573, 22580

3246, 3246

24420, 25186

1573, 1592

20774, 22081

22204, 22552

20491, 20751

22604, 24397

1607, 1607

11057, 13484

3696, 11024

276, 292

637, 1043

3260, 3682

1065, 1430

1446, 1557

13,192

104,762

6152

Discharge summary

report

Admission Date: [**2147-7-4**] Discharge Date: [**2147-7-12**] Date of Birth: [**2095-7-24**] Sex: F Service: [**Hospital 259**] MEDICAL FIRM CHIEF COMPLAINT: Nausea, vomiting, and hypotension. HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old woman with a history of diabetes, coronary artery disease status post coronary artery bypass grafting, chronic renal insufficiency with a baseline creatinine of 4.5, who presented to the Emergency Department with two days of anorexia associated with nausea, vomiting, and diarrhea. She had no complaints of chest pain or shortness of breath at the time. Her son phoned [**Pager number **] to have her taken to the Emergency Department. EMTs found her blood pressure to be 70/40 with an initial fingerstick of 133. In the Emergency Department, her blood pressure was somewhat improved at 94/45, but subsequently fell to as low as 60/palp. She was given aggressive fluid resuscitation with response in her blood pressure to the 80s after 2 liters of fluid. She was also started on dopamine. A 12-lead EKG in the Emergency Department showed new T-wave inversions in leads III and aVF, and the patient was admitted to the Medical ICU for further management. PAST MEDICAL HISTORY: 1. Diabetes. 2. Chronic renal insufficiency with a baseline of 4.5 trending upward over the past year. 3. Congestive heart failure with an ejection fraction of 30% in [**2147-2-1**]. 4. Coronary artery disease status post CABG in [**1-1**] with a LIMA to left anterior descending artery, saphenous vein graft to PDA, and saphenous vein graft to OM-1. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Hydralazine 20 mg t.i.d. 2. Imdur 30 mg q.d. 3. Aspirin 325 mg q.d. 4. Valium 5 mg b.i.d. prn 5. Remeron 15 mg q.h.s. 6. Metformin 500 mg b.i.d. 7. Albuterol. 8. Lasix 40 mg q.d. 9. Lipitor 80 mg q.d. 10. Metoprolol 50 mg b.i.d. SOCIAL HISTORY: Patient is primarily Spanish speaking. She lives with her son. She is a [**2-2**] pack/day smoker, and has a remote history of alcohol abuse. PHYSICAL EXAM UPON ADMISSION TO THE MICU: Vital signs: Temperature 95.2. Heart rate 67. Blood pressure 96/45. O2 saturation 99% on room air. General: She was an obese, chronically ill-appearing Hispanic woman, who appeared older than her stated age. She was conversing appropriately and in no acute distress. HEENT: She had drooping right eyelid. Her oropharynx was extremely dry. Chest was clear to auscultation bilaterally, but noted to be dull at the right base with no wheezes, rales, or rhonchi when assessed after approximately 1.5 liters of IV fluids. However, note was made that crackles were present approximately [**2-3**] of the way up bilaterally after she had received a total of 4 liters of IV fluids. Cardiovascular: Regular, rate, and rhythm, normal S1, S2 without murmurs. Her abdomen was obese, soft, nontender, nondistended with normal bowel sounds. Extremities revealed 2+ edema bilaterally to the knees. Initial laboratories on admission revealed a white blood cell count of 11.6, hematocrit 31.3, platelets 369. Differential included 77 polys, 0 bands, 4 monocytes, and 3 eosinophils. Coags revealed the PT of 14.7, INR of 1.4, PTT of 44.8. Urinalysis revealed 500 protein, small leukocyte esterase, 21-50 RBC, [**7-11**] WBC, and few bacteria. Chem-7 was notable for a bicarb of 7, BUN of 103, and creatinine of 8.1. Calcium was 8.4, magnesium 1.8, phosphorus 8.0. LFTs were within normal limits. CK at the time of admission was initially 201, increased to 255, and up to 402. Troponin went from 2.4 to 4.9. ABG in the Emergency Department revealed a pH of 7.06, pCO2 of 29, pO2 of 67 with a lactate of 4.6. Chest x-ray showed a small to moderate sized right sided pleural effusion without evidence of pneumonia or congestive heart failure. EKG was sinus at 65 beats per minute with a prolonged P-R interval of 246 milliseconds. New T-wave inversions were noted in leads III and aVF. HOSPITAL COURSE: 1. Hypotension/shock: The patient had initially been treated with IV fluids and dopamine in the Emergency Department for blood pressure support with the addition of bicarb to the IV fluids for her acidosis. Upon admission to the MICU, a Swan-Ganz catheter was placed, which was suggestive of both cardiogenic and hypovolemic shock with PA pressure of 54/23, wedge of 20, CVP of 19. Cardiac output and cardiac index of 4.4 and 2.7 respectively with a SVR of 919. Blood pressure improved dramatically with correction of volume and acid-base status, and dopamine was quickly weaned off. After the volume resuscitation, patient was actually significantly hypertensive. 2. Cardiovascular: Patient's troponin ultimately trended to greater than 50 in the setting of her renal failure. Her peak CK was 402 with a MB of 33 leading to an index of 8. Cardiology was consulted. The patient was given aspirin, Heparin, and Lopressor after her blood pressure had stabilized. Nitropaste and hydralazine were added for afterload reduction as ACE inhibition was contraindicated. Echocardiogram revealed an EF of 30-40% with inferolateral and basal inferior akinesis, RV pressure and volume overload with 3+ TR and 1+ MR. Ischemia was thought to be secondary due to demand. Patient ultimately went to the Cath Laboratory on [**2147-7-7**], which showed subtotal occlusion of the distal RCA at the PDA, which is now status post PTCA and stent. Following catheterization, the patient was continued on aspirin and Plavix in addition to her Lipitor for her coronary artery disease. 3. Acute on chronic renal failure: This is felt to be secondary to ATN in the setting of her hypotension. Patient was started on hemodialysis in the MICU along with erythropoietin and Amphojel. All of her medications were dosed for creatinine clearance of less than 10. Renal ultrasound showed normal sized kidneys without evidence of hydronephrosis and good blood flow to the kidneys bilaterally. Metformin was held and hemodialysis was performed by Permacath which was placed on [**2147-7-6**]. Creatinine improved to 6.0 at the time of transfer out of the ICU on [**2147-7-8**], and hemodialysis was continued through the time of discharge. 4. Acid base: Patient was profoundly acidemic at the time of admission with a gap metabolic acidosis secondary to lactate from her state of hypoperfusion as well as metformin. In addition, she had a nongap metabolic acidosis likely from her uremia as well as GI losses of bicarbonate. Her initial ABG was 7.06/29/67. Patient was repleted aggressively with IV fluids containing bicarbonate as well as p.o. sodium bicarbonate. ABG prior to transfer out of the ICU was 7.44/37/89. 5. Anemia: The patient's anemia was initially thought to be due to her renal failure with an acute drop secondary to hemodilution from the aggressive volume resuscitation she initially resolved. She was started on Epo on [**2147-7-5**], and transfused a total of 3 units of packed red cells on [**6-4**], and [**2147-7-8**] to maintain her hematocrit greater than 30 given her coronary artery disease. On [**2147-7-8**], the day of transfer from the ICU, the patient's Procrit was discontinued, and iron studies were consistent with anemia of chronic disease. Patient was continued to be transfused on an as needed basis. 6. Hypertension: As noted above, the patient was quite hypertensive following her initial resuscitation. In the ICU, she had been treated with escalating doses of beta blocker, hydralazine, and nitrates, plus hemodialysis for treatment of volume overload. At the time of discharge, her blood pressure was well controlled with Lopressor 75 mg t.i.d., hydralazine 75 mg q.6h., and the nitrates were discontinued. 7. Urinary tract infection: The patient was treated with levofloxacin renally dosed for an appropriate course. 8. Diabetes: The patient had been managed as an outpatient with metformin. This was held on admission because of her acidosis and acute renal failure. She was covered by insulin-sliding scale throughout her hospital stay. 9. Disposition: Prior to discharge, the patient was evaluated by Physical Therapy, who felt that the patient was okay to go home with VNA and home PT. Hemodialysis was arranged in an outpatient setting. Ultimately, prior to discharge, there was some confusion as to where the patient would go. Case Management had worked out an arrangement with the patient's son, [**Name (NI) 24039**], that she would be discharged in the morning of the 12th to his house. However, after her son had left the hospital, her other son and her goddaughter arrived to the hospital requesting to take her home that evening. Because it was unclear exactly where she was to be going, VNA service cancelled their contract and wanted to re-evaluate in the morning when plans which were more firm could be setup. Patient assisted on leaving that evening despite numerous attempts to have her stay. Situation was discussed with Dr. [**Last Name (STitle) **], who agreed that it was okay to officially discharge the patient with plans to arrange for services in the morning, so the patient was discharged to the care of her goddaughter, who had planned to stay home to care for her. DISCHARGE DIAGNOSES: 1. Hypovolemia. 2. Acute on chronic renal failure. 3. Urinary tract infection. 4. Anemia. 5. Non-Q-wave myocardial infarction. 6. Hypertension. 7. Diabetes. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. Lopressor 75 mg p.o. t.i.d. 4. Calcium acetate two tablets t.i.d. with meals. 5. Folic acid, vitamin B complex, vitamin C 1 mg q.d. 6. Hydralazine 75 mg q.6h. 7. Levofloxacin 250 mg to be taken for one more dose. 8. Lipitor 80 mg q.d. 9. Remeron 15 mg q.h.s. 10. Zantac 75 mg p.o. q.d. 11. Senna one tablet b.i.d. prn. 12. Colace 100 mg p.o. b.i.d. FOLLOWUP: Patient is to make an appointment with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**] within the next 1-2 weeks, and to followup with Nephrology as recommended. DR.[**Last Name (STitle) 313**],[**First Name3 (LF) 312**] 12-766 Dictated By:[**Name8 (MD) 6166**] MEDQUIST36 D: [**2147-10-5**] 10:54 T: [**2147-10-6**] 04:36 JOB#: [**Job Number 24040**]

[ "785.59", "403.91", "414.02", "428.0", "410.71", "V45.82", "584.9", "414.01", "599.0" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.91", "88.56", "36.07", "37.22", "36.01", "99.20", "38.95", "89.64" ]

icd9pcs

[ [ [] ] ]

9278, 9436

9459, 10305

4006, 9257

1662, 1895

177, 213

242, 1229

1251, 1641

1912, 3989

14,158

117,088

25428

Discharge summary

report

Admission Date: [**2194-5-29**] Discharge Date: [**2194-6-5**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: shortness of breath w/ exertion- new x2 weeks Major Surgical or Invasive Procedure: Flexible bronchoscopy, diagnostic. 2. Cervical mediastinoscopy with biopsy. 3. Right thoracotomy with wedge excision and right upper lobectomy. 4. Mediastinal lymphadenectomy. 5. Attempted right thoracoscopy. History of Present Illness: delightful 83- year-old gentleman with COPD and pulmonary fibrosis with a long history of smoking. In recent years, he has been developing dyspnea, in the Spring, during the pollen season. Most recently, he developed an episode that required a visit to the Emergency Room and a three day pulmonary rehabilitation to date. The CT scan during this visit demonstrated a new 15 mm spiculated right upper lobe nodule. He denied any significant dyspnea other than these acute episodes that he has in the Spring; however, his wife reports that his wife is winded with minimal exertion, including climbing a flight of stairs. He does play golf on a daily basis but does so with a cart. He reports being reasonably active and not being particularly limited by shortness of breath. However, his wife disagrees with this. Pulmonary function tests demonstrated a FEV-1 of 2.04 which is 68% of predicted and a DLCO of 59% predicted but he has restrictive lung disease. A preoperative PET scan demonstrated activity within the lesion but not elsewhere within the body. I had a long discussion with the family preoperatively and I indicated to them that there is a high likelihood of an open resection given the extent of scarring seen on CT scan from the asbestosis. Additionally, I discussed the likelihood of performing a wedge excision for diagnosis and therapy given his extensive pulmonary disease and baseline dyspnea. Therefore, we proceeded forward with the following operation. Past Medical History: Hypertension, Coronary Artery Disease (s/p MIx2 [**2187**]), Chronic Obstructive Pulmonary Disease and restrictive lung disease (2secondary) to asbestos exposure Social History: Married x58 years, lives w/ wife on [**Hospital3 **] 2 children (son and [**Name2 (NI) 41859**]), 4 grandchildren smoker 2ppd/x60 years, quit [**2187**], aslo cigars and pipes Right eye injury from WWII, now has prosthetic eye etoh- 1/day Family History: father died 40's melanoma mother died early 60's form heart surgery brother 87- good health 4 sisters- 1 died of breast cancer, 3 other are alive and well Physical Exam: General-vibrant elderly male HEENT-R eye replaced w/ prosthesis, L eye is ERR, sclera anicteric,minor inflammation at present. No cervical or supraclav adenopathy REsp- BS clear upper left, diminished RUL, clear bases Cor-RRR, no murmer Abd- + BS, NT, ND, soft Ext- R knee w/ minor edema and erythema- resolving- gout episode [**6-1**] Neuro- A&O x3, cooperative, appropriate Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2194-6-3**] 05:45AM 8.0 3.15* 9.6* 28.1* 89 30.4 34.0 13.7 195 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2194-6-5**] 05:45AM 14.9*1 28.7 1.5 1 NOTE NEW NORMAL RANGE AS OF 12 AM [**2194-3-22**] Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2194-6-5**] 05:45AM 1.0 Cardiology Report ECG Study Date of [**2194-6-2**] 12:50:46 PM Sinus rhythm First degree A-V delay Left atrial abnormality Prior anteroseptal myocardial infarction Since previous tracing of [**2194-6-2**], Poor R wave progression is more prominent Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. RADIOLOGY Final Report CHEST (PA & LAT) [**2194-6-2**] 11:31 AM CHEST (PA & LAT) Reason: ? PTX [**Hospital 93**] MEDICAL CONDITION: 83 year old man with chest tube removal REASON FOR THIS EXAMINATION: ? PTX INDICATION: Status post chest tube removal, evaluate for pneumothorax. COMPARISON: [**2194-6-1**]. TECHNIQUE: PA and lateral chest. FINDINGS: There has been interval removal of two right-sided chest tubes. No definite pneumothorax is identified. There is pleural effusion layering along the lateral aspect of the right lung and stable parenchymal opacities within the right lung and at the left base. Left pleural effusion is unchanged. The osseous structures appear unchanged. Stable subcutaneous emphysema within the right chest wall. IMPRESSION: 1. No definite evidence of pneumothorax following chest tube removal. Stable subcutaneous emphysema. 2. Bilateral pleural effusions, right greater than left. 3. Stable patchy opacities within the right lung and left base. OPERATIVE REPORT [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] **NOT REVIEWED BY ATTENDING** Name: [**Known lastname **], [**Known firstname 275**] G Unit No: [**Numeric Identifier 63552**] Service: [**Last Name (un) 7081**] Date: [**2194-5-29**] Surgeon: [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD 2367 PREOPERATIVE DIAGNOSES: Right upper lobe lung cancer. POSTOPERATIVE DIAGNOSIS: Right upper lobe lung cancer. PROCEDURES PERFORMED: 1. Flexible bronchoscopy, diagnostic. 2. Cervical mediastinoscopy with biopsy. 3. Right thoracotomy with wedge excision and right upper lobectomy. 4. Mediastinal lymphadenectomy. 5. Attempted right thoracoscopy. ASSISTANT SURGEON: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**]. ANESTHESIA: General endotracheal supplemented by multiple intercostal nerve blocks. The patient will receive an epidural at the end of the case. INDICATIONS FOR OPERATION: The patient is a delightful 83- year-old gentleman with COPD and pulmonary fibrosis with a long history of smoking. In recent years, he has been developing dyspnea, in the Spring, during the pollen season. Most recently, he developed an episode that required a visit to the Emergency Room and a three day pulmonary rehabilitation to date. The CT scan during this visit demonstrated a new 15 mm spiculated right upper lobe nodule. He denied any significant dyspnea other than these acute episodes that he has in the Spring; however, his wife reports that his wife is winded with minimal exertion, including climbing a flight of stairs. He does play golf on a daily basis but does so with a cart. He reports being reasonably active and not being particularly limited by shortness of breath. However, his wife disagrees with this. Pulmonary function tests demonstrated a FEV-1 of 2.04 which is 68% of predicted and a DLCO of 59% predicted but he has restrictive lung disease. A preoperative PET scan demonstrated activity within the lesion but not elsewhere within the body. I had a long discussion with the family preoperatively and I indicated to them that there is a high likelihood of an open resection given the extent of scarring seen on CT scan from the asbestosis. Additionally, I discussed the likelihood of performing a wedge excision for diagnosis and therapy given his extensive pulmonary disease and baseline dyspnea. Therefore, we proceeded forward with the following operation. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed under general endotracheal anesthesia with a single lumen endotracheal tube. We performed a flexible bronchoscopy and examined the entire tracheobronchial tree. We found no endobronchial lesions and found no anatomical abnormalities. We positioned the patient supine but we were unable to extend his neck due to degenerative joint disease. We prepped and draped his neck and chest in the usual sterile fashion. We made a 1 cm transverse incision 2 cm cephalad to the sternal notch and dissected down to the pretracheal plane. We bluntly developed the pretracheal plane with the mediastinoscope down the trachea and down bilateral mainstem bronchi. There was an extensive amount of fatty tissue within the mediastinum and vicinity of the lymph nodes. We found small lymph nodes in the 4-R position and biopsied two separate areas and sent them for frozen section analysis. We biopsied a lymph node from the pre carinal lymph node. We performed extensive dissection in the left paratracheal region, identifying the course of the left recurrent laryngeal nerve and dissecting down to the esophagus but found no identifiable lymph nodes to biopsy. I was unable to extend the scope into the subcarinal region, due to the patient's inability to extend his neck and the large size of this gentleman. The mediastinoscope was placed as deep as it would go and it was barely within reach of the subcarinal space, due to the lack of extension of his neck and the depth, I was unable to safely biopsy the subcarinal lymph nodes. On frozen section, there was no evidence of malignancy and, therefore, we closed the wounds after achieving meticulous hemostasis. We then returned the patient to the anesthesia service who successfully placed a double lumen endotracheal tube. We positioned the patient in the left lateral decubitus. We took great care to avoid injury to the fascial nerve on the left side. We positioned him carefully to avoid pressure points and hyperextension of extremities. We then prepped and draped his right chest in the usual sterile fashion. We attempted to place a single thoracoscopy port in the mid axillary line at approximately the seventh intercostal space. We dissected down to the pleura and encountered a very thick fibrotic pleura that we were unable to break through but there was no pleural space to dissect within. We, therefore, aborted the idea of a thoracoscopic approach. We then made a posterior lateral thoracotomy dividing the latissimus dorsi muscle but sparing the serratus anterior as well as the trapezius and rhomboids. We entered the chest through the fourth intercostal space to shingle the fifth rib posteriorly. We immediately encountered intense adhesions from the asbestosis. We had to carve the lung down using electrocautery off of the asbestosis plaques. Eventually, we were able to completely carve free the right upper lobe apically, posteriorly along the paravertebral sulcus, laterally, anteriorly and medially off the mediastinum. We were able to develop the fissure between the upper and superior segment of the lower lobe and we developed a fissure between the middle and the lower lobe. There was an incomplete fissure between the upper and middle lobe. The middle lobe was extremely small and thin. We then palpated the tumor which measured approximately 3 cm on palpation. It was located in the periphery at the junction between the anterior and apical segments. We mobilized the pleura around the anterior apical and posterior hilum, sweeping the lung off the hilum as much as possible to gain mobility for a large wedge excision. We then used the US Surgical thoracoscopic stapler with a 6 cm long, wide mouth thick tissue staplers to perform a wedge excision down to near the hilum. We performed the wedge excision with several firings of the stapler and sent specimens for pathological analysis. This with the deepest possible wedge we could obtain safely as it was abutting the hilum. On gross analysis, the tumor came close to the margin but I felt I had a clean margin. Frozen section analysis demonstrated the margin to be free of tumor, although it was close. I broke scrub and spoke with the family and had a discussion as to whether or not we should perform a lobectomy. Our discussion was centered around the fact that a lobectomy would run the risk of pushing him into respiratory failure and worsening his dyspnea. I was particularly concerned by the fact that he had dyspnea on several occasions and at least one of them, requiring hospitalization. His wife reports that he is quite dyspneic around the house and is concerned about his breathing. His pulmonary function tests demonstrated restrictive lung disease and he has a history of pulmonary fibrosis and COPD. Although his pulmonary function tests suggest that he might tolerate a lobectomy, his physiological status and his history suggests that he would not. I spoke with his son and his wife about whether or not we should proceed forward with a lobectomy. We also discussed the possibility that it could recur locally and that if it did, a back-up option would be radiotherapy. Ultimately we came to the group's consensus that we should not proceed forward with a lobectomy but accept a compromise wedge excision. The plan will be to follow him closely with 3 month serial CT scans. I then scrubbed back into the case. Of note, prior to scrubbing out of the case, initially I performed a complete mediastinal adenectomy. We resected the right paratracheal lymph node in a complete packet with sharp dissection. We used as our margins the superior vena cava, anteriorly the esophagus posteriorly and the azygos inferiorly. Similarly, we performed a clean dissection of this subcarinal packet of lymph nodes using as our margins the left main, subcarina and right main as well as the pericardium anteriorly and the esophagus posteriorly. These were sent separately. I then also freed the lower lobe as much as I could from the chest wall, without performing a counter incision. We expanded the lung under observation and found that it completely spread the apical space. We then placed two 28 French chest tubes, one anteriorly, one posteriorly. We placed multiple intercostal nerve blocks with a total of 20 cc of [**11-26**] strength Marcaine with epinephrine. We then closed the chest in layers and expanded the lung under observation. Dr. [**Last Name (STitle) 952**] was present for the entire case. Sponge, instrument and needle counts were reported correct times 2. [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**] Intervals Axes Rate PR QRS QT/QTc P QRS T 90 [**Telephone/Fax (3) 63553**]/425.71 26 7 16 ([**-3/3308**]) Brief Hospital Course: Patient admitted SDA [**2194-5-29**] for large RUL wedge resection for RUL nodule. Patient tolerated procedure fairly well, extubated in PACU, R chest tubesx2 to sx, pain control w/epidural of bupivicaine/ dilaudid and toradol iv x4 doses. Patient admitted to SICU post-op for hypotension and low urine output requiring fluid boluses and neo gtt. These resoved and pt transferred to floor on POD#2. POD#3-CT to H2O seal w/ leak in 1 tube; good thorax pain control w/ epidural but ++R knee pain- found to be gout episode via joint aspiration by Rheumatology consult and treated initially w/ indocin w/o pain relief and changed to cochicine qod mwith close monitoring of ranl fx in settingof hx CRI.(Last attack >20yrs ago). PO intake encouraged, ivf cont, OOB/ IS/PT. POD#4- Pain control-D/C epidural and trasitioned to po meds started; HR 1st AV block as is baseline w/ episode of SB to 32, and AF/Af w/ variable block w/ c/o palpitations.- spontaneous conversion to SR in < 24 hours. Cardiology/EP consult obtained-advised NO amiodarone and treat w/ low dose atenolol 25 mg qd and anticoag for at least 3 months. Heparin gtt started w/ goal PTT 60-80, and coumadin started. CT x2 to H2o seal w/o leak;poor appetite, IVF cont, poor u/o- unable to void post foley d/c, foley replaced, flomax given. BM today; Cr 1.7 on cholchicine w/ good R knee pain relief, ambulation w/ PT and nsfg assistance, oob>chair. POD#5- Pain uncontrolled on po meds, PCA started and decreased in pm for lethergy; SR of 1 AV block, Heparin gtt cont, coumadin given iin pm; CT x2 d/c w/o complication; BS decreased at bases, IS and PT done; fair po intake, ivf @50/hr; foley d/c w/ successful void; labs Cr 1.4 on cholchicine for acute episode duration per [**Name (NI) 63554**] pt asym today.Ambulation/ IS/ PT. POD#6-Pain control w/ PCA lower dose w/ good control and transitioned totylenol and po dilaudid w/ good control; CT dsg w/ mild ser sang drainage; episode of bradycardia 50's and 1 episode to 40- cardiology called and advised no change in RX of atenolol, isordil, lipitor, lisinopril. Ambulation w/ pt and nsg, appetite improved. POD#7- Good pain cotrol on minimal dilaudid and tylenol; Cards consult prior to d/c to cont meds as above. Patient stable for d/c to [**Hospital3 **] [**Hospital **] rehab facility w/ Cardiology and INR follow-up by [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **]. Medications on Admission: asa, atorvastatin, lisinopril, atenolol, levothyroxine, isosorbide dinatrate Discharge Disposition: Extended Care Facility: Cape Regency Nursing & Rehabilitation - [**Location 41366**] Discharge Diagnosis: Hypertension, coronay disease (s/p MIx2 [**2187**]) stents placed [**2188**], Chronic obstructive pulmonary disease and restrictive lung disease (2ndary to asbestos exposure?, hypothyroidism, R eye prosthesis from WWII injury, hx prostate cancer-s/p XRT, hx skin cancer-resected now on back, s/p cholycystectomy. Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**] office for any post surgical issues questions [**Telephone/Fax (1) 170**] Followup Instructions: Appointment with Dr. [**Last Name (STitle) 952**] in 2 weeks when discharged from REhab facility- [**Telephone/Fax (1) 170**] Completed by:[**2194-6-5**]

[ "997.1", "496", "515", "274.0", "162.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "81.91", "33.23", "32.29", "34.22", "40.3", "32.4", "40.11" ]

icd9pcs

[ [ [] ] ]

16713, 16800

14174, 16586

321, 535

17157, 17163

3068, 3887

17314, 17470

2501, 2657

3924, 3964

16821, 17136

16612, 16690

17187, 17291

2672, 3049

236, 283

3993, 14151

563, 2043

2065, 2228

2244, 2485

24,536

167,916

15303+15304

Discharge summary

report+report

Admission Date: [**2162-9-10**] Discharge Date: [**2162-9-17**] Date of Birth: [**2090-11-20**] Sex: F Service: Cardiac Surgery [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (STitle) 7487**] MEDQUIST36 D: [**2162-9-17**] 11:53 T: [**2162-9-17**] 12:12 JOB#: [**Job Number 44504**] Admission Date: [**2162-9-10**] Discharge Date: [**2162-9-17**] Date of Birth: [**2090-11-20**] Sex: F Service: Cardiac Surgery PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Peripheral vascular disease 3. Congestive heart failure 4. Polyp removal (nasal) ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 325 qd 2. Diovan 160 mg qd 3. Lasix 40 mg qd 4. Glucophage 500 mg qd 5. Metoprolol 25 mg [**Hospital1 **] HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old female who presented one month ago with acute shortness of breath secondary to pulmonary edema was ruled in for acute myocardial infarction. She underwent stress test which was positive. She had a cardiac catheterization on the date of admission which showed severe three vessel disease with OM stenosis, LAD severely diseased. PHYSICAL EXAM: VITAL SIGNS: Afebrile. Vital signs stable. HEART: Regular rate and rhythm with systolic murmur. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Diminished peripheral pulses. LABS: CBC 8.5, hematocrit 43.5, platelets 260. Sodium 137, potassium 5.4, chloride 97, bicarbonate 26, BUN 32, creatinine 1.3, INR 1.12. HOSPITAL COURSE: The patient was admitted to medicine service for the weekend. She was stable, afebrile. She had appropriate preoperative work up and patient was taken to an Operating Room on [**2162-9-13**] for a coronary artery bypass graft x4 (SVG to LAD, left internal mammary artery to diagonal, saphenous vein graft to RPL, saphenous vein graft to OM was performed). Pacing wires as well as mediastinal pleural tubes were placed intraoperatively. Operation went without complication. The patient was transferred to the PACU in stable condition. On postoperative day #5, the patient received blood, platelets and fresh frozen plasma, remained on ............ pressure support, would not wean off of ventilator. On postoperative day #2, the patient was extubated successfully without complications, ............. excessive pulmonary toilet. The patient was started on Lasix and Lopressor. On postoperative day #3, the patient developed large left sided groin hematoma on .............. side. She was also found to have a urinary tract infection with more than 100,000 gram negative rods ............. She was started on Cipro. Her Lopressor was increased to 50 [**Hospital1 **]. The patient remained stable with no abnormal bleeding in the groin. The patient was transferred to the floor in stable condition. Postoperative day #4, the patient remained afebrile. Vital signs were stable. She could continue working with PT. Left groin hematoma is stable. Her beta blockers were increased to control her heart rate. No other active issues. DISCHARGE MEDICATIONS: 1. Lasix 20 mg po bid 2. Potassium chloride 20 milliequivalents po bid 3. Aspirin 325 mg po qd 4. Plavix 75 mg po qd for three months 5. Lopressor 75 mg po bid 6. Tylenol 325 mg 1 to 2 tablets po q6h prn 7. Ibuprofen 600 mg po q6h prn 8. Ranitidine 150 mg po bid 9. Glucophage 500 mg po qd DISCHARGE CONDITION: Good DISCHARGE STATUS: The patient is to be discharged home with home physical therapy. The patient is to follow up with Dr. [**Last Name (STitle) 70**] in six weeks. The patient is to follow up with her primary care doctor in three to four weeks for blood pressure follow up. DISCHARGE DIAGNOSES: 1. Coronary artery disease, status post myocardial infarction, status post coronary artery bypass graft 2. Congestive heart failure 3. Peripheral vascular disease 4. Diabetes mellitus type II 5. Carotid stenosis [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (STitle) 7487**] MEDQUIST36 D: [**2162-9-17**] 11:53 T: [**2162-9-17**] 13:06 JOB#: [**Job Number 44504**]

[ "428.0", "998.12", "250.00", "443.9", "396.2", "599.0", "433.10", "410.12", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.23", "88.56", "88.53", "36.13", "36.15" ]

icd9pcs

[ [ [] ] ]

3593, 3875

3896, 4412

3271, 3571

1703, 3248

1317, 1685

942, 1302

623, 913

31,820

111,458

6068

Discharge summary

report

Admission Date: [**2166-1-15**] Discharge Date: [**2166-1-30**] Date of Birth: [**2086-8-16**] Sex: F Service: MEDICINE Allergies: Adhesive Tape Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: diarrhea Major Surgical or Invasive Procedure: none History of Present Illness: 79F with locally advanced pancreatic CA on Xeloda and oxaliplatin (C2D1 [**2166-1-8**]) who p/w diarrhea. Ms [**Known lastname 23815**] states that over the past several days she has noted profuse watery brown diarrhea without blood. Last night she was up every hour to stool. She has had nausea although vomited only once last night. She has had abdominal crampy pain. She normally lives alone and takes care of herself and drives. Over the past couple of days she has been weak and fatigued. The symptoms correlated with the start of her second cycle of chemotherapy. She denies f/c. No CP or SOB. In the ED, she was noted to have stable vitals, although potassium was 2.4. She was given potassium repletion 60 mEq IV and 40 mEq PO. She was admitted to OMED service. Past Medical History: 1. Locally-advanced pancreatic cancer - Initially diagnosed in [**2162**] by abdominal ultrasound in the setting of crampy abdominal pain. She received 31 cycles of gemcitabine without any grade III or IV hematologic or non-hematologic toxicity, then developed radiologic and biochemical progression. She had a PORT-A-Cath placed on [**11-30**]. She commenced XelOX on [**12-19**], Oxaliplatin 100 mg/m2 every 21 days and capecitabice (Xeloda) 1000 mg/m2 [**Hospital1 **] for 14 of 21 days. 2. Hypothyroidism. 3. Cerebrovascular accident in [**2155**], now on Coumadin. 4. Knee replacement. 5. Appendectomy at the age of 15. 6. Right cataract repaired on [**2165-11-27**] Social History: She is widowed, lives alone and cares for self. She drives. She has two children, one of the age 58, the other 38. She does not drink and she never smoked. She lives by herself in [**Location (un) 10059**]. Family History: Significant at the age of 92 of heart disease. Her father died at the age of 67 and a sister died at the age of 65 because of heart disease. There is no family history of cancer that she knows of. Physical Exam: VS: Temp: 98.3 BP: 120/70 HR: 83 RR: 16 sat 96RA GEN: awake, alert, NAD, hard of hearing HEENT: surgical pupils, EOMI, anicteric, MM slightly dry NECK: JVP flat no supraclavicular or cervical lymphadenopathy, CHEST: port in place, c/d/i, CTAB CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, mild TTP diffusely EXT: no c/c/e SKIN: no rashes/no jaundice Pertinent Results: [**2166-1-15**] 10:15AM WBC-4.0 RBC-4.04* HGB-11.1* HCT-32.9* MCV-81* MCH-27.4 MCHC-33.7 RDW-17.1* [**2166-1-15**] 10:15AM NEUTS-55 BANDS-15* LYMPHS-15* MONOS-14* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [**2166-1-15**] 10:15AM PLT SMR-LOW PLT COUNT-110* [**2166-1-15**] 10:15AM PT-18.3* PTT-26.9 INR(PT)-1.7* [**2166-1-15**] 10:15AM GLUCOSE-103 UREA N-11 CREAT-0.7 SODIUM-135 POTASSIUM-2.4* CHLORIDE-97 TOTAL CO2-25 ANION GAP-15 [**2166-1-15**] 10:15AM CALCIUM-8.0* PHOSPHATE-2.0*# MAGNESIUM-1.8 [**2166-1-15**] 10:29AM LACTATE-1.5 K+-2.4* [**2166-1-15**] 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR [**2166-1-15**] 01:15PM URINE RBC-[**2-26**]* WBC-[**6-3**]* BACTERIA-OCC YEAST-NONE EPI-0-2 [**2166-1-15**] 08:31PM WBC-4.4 RBC-3.63* HGB-9.9* HCT-30.5* MCV-84 MCH-27.3 MCHC-32.6 RDW-18.1* [**2166-1-15**] 08:31PM PLT COUNT-108* [**2166-1-15**] 08:31PM MAGNESIUM-1.8 [**2166-1-15**] 08:45PM UREA N-9 CREAT-0.7 POTASSIUM-3.0* [**2166-1-20**] 12:00AM BLOOD WBC-11.3* RBC-4.31 Hgb-12.1 Hct-36.7 MCV-85 MCH-28.1 MCHC-32.9 RDW-19.0* Plt Ct-218 [**2166-1-25**] 12:00AM BLOOD WBC-16.1*# RBC-4.53 Hgb-12.2 Hct-38.6 MCV-85 MCH-26.9* MCHC-31.6 RDW-20.0* Plt Ct-211 [**2166-1-26**] 12:00AM BLOOD WBC-18.4* RBC-4.69 Hgb-12.4 Hct-39.7 MCV-85 MCH-26.4* MCHC-31.2 RDW-19.9* Plt Ct-129* [**2166-1-26**] 07:50AM BLOOD WBC-10.2 RBC-3.43*# Hgb-9.1*# Hct-28.6*# MCV-83 MCH-26.6* MCHC-31.9 RDW-20.8* Plt Ct-79* [**2166-1-29**] 03:10AM BLOOD WBC-4.0 RBC-2.31* Hgb-6.4* Hct-19.9* MCV-86 MCH-27.8 MCHC-32.3 RDW-19.3* Plt Ct-35* [**2166-1-26**] 12:00AM BLOOD Neuts-41* Bands-33* Lymphs-8* Monos-7 Eos-0 Baso-2 Atyps-2* Metas-3* Myelos-4* [**2166-1-15**] 10:15AM BLOOD Neuts-55 Bands-15* Lymphs-15* Monos-14* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2166-1-27**] 06:24PM BLOOD Neuts-90* Bands-2 Lymphs-6* Monos-1* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2166-1-15**] 10:15AM BLOOD PT-18.3* PTT-26.9 INR(PT)-1.7* [**2166-1-19**] 12:11AM BLOOD PT-37.1* PTT-33.0 INR(PT)-4.0* [**2166-1-22**] 05:41AM BLOOD PT-13.3 PTT-24.3 INR(PT)-1.1 [**2166-1-28**] 05:12AM BLOOD PT-39.4* PTT-45.9* INR(PT)-4.3* [**2166-1-29**] 03:10AM BLOOD PT-17.7* PTT-36.8* INR(PT)-1.6* [**2166-1-27**] 05:17PM BLOOD Fibrino-578* D-Dimer-2090* [**2166-1-17**] 12:15AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-145 K-3.6 Cl-116* HCO3-18* AnGap-15 [**2166-1-26**] 12:00AM BLOOD Glucose-167* UreaN-69* Creat-1.6* Na-143 K-4.0 Cl-108 HCO3-18* AnGap-21* [**2166-1-29**] 03:10AM BLOOD Glucose-138* UreaN-26* Creat-0.9 Na-146* K-3.4 Cl-112* HCO3-29 AnGap-8 [**2166-1-22**] 05:41AM BLOOD ALT-7 AST-10 LD(LDH)-171 AlkPhos-52 Amylase-7 TotBili-0.4 [**2166-1-26**] 05:17AM BLOOD ALT-25 AST-39 CK(CPK)-176* AlkPhos-103 Amylase-16 TotBili-0.8 [**2166-1-26**] 12:57PM BLOOD LD(LDH)-352* CK(CPK)-157* TotBili-1.1 [**2166-1-26**] 08:45PM BLOOD LD(LDH)-307* CK(CPK)-112 [**2166-1-26**] 05:17AM BLOOD CK-MB-12* MB Indx-6.8* cTropnT-0.03* [**2166-1-26**] 12:57PM BLOOD CK-MB-9 cTropnT-0.02* [**2166-1-26**] 08:45PM BLOOD CK-MB-8 cTropnT-0.03* [**2166-1-15**] 10:15AM BLOOD Calcium-8.0* Phos-2.0*# Mg-1.8 [**2166-1-29**] 03:10AM BLOOD Calcium-7.1* Phos-2.5* Mg-2.1 [**2166-1-26**] 07:54AM BLOOD Cortsol-114.7* ECG Study Date of [**2166-1-15**] 10:23:46 AM Baseline artifact. Sinus rhythm. Short P-R interval. Leftward axis. T wave abnormalities. Compared to the previous tracing of [**2165-11-27**] no significant change. Reports: CHEST (PORTABLE AP) [**2166-1-15**] 1:07 PM IMPRESSION: No acute cardiopulmonary process. KUB [**2166-1-21**]: Given the clinical history findings are most compatible with gastroenteritis. CT Abdomen/Pelvis [**2166-1-25**]: 1. Gross distention of the distal esophagus, as well as small and large bowel. No small bowel obstruction and no definite large bowel obstruction is seen, suggesting generalized ileus. Although nondistention of large bowel past the sigmoid may represent physiolgic process, peritoneal spread of tumor or nondistention from chronic inflammation, with obstruction at this level cannot be entirely excluded. 2. No significant interval change in size or degree of local invasion of the pancreatic head and neck mass. 3. Occlusion of the portosplenic confluence with venous collaterals, unchanged since [**10-31**]. 4. Bilateral pulmonary nodules consistent with metastases, unchanged since [**10-31**]. 5. Interval development of small bilateral pleural effusions/atelectasis, as well as perihepatic and perisplenic ascites since [**10-31**]. 6. Mild intrahepatic biliary dilitaion. CXR [**2166-1-26**]: There is a new right IJ line with tip in SVC. The right subclavian line is unchanged. The ET tube tip is 4 cm above the carina. The NG tube tip is in the stomach. There are bilateral pleural effusions, left greater than right, with bilateral lower lobe volume loss. There is no pneumothorax. CT Head [**2166-1-27**]: No CT evidence of an acute territorial infarct. No intracranial hemorrhage. No abnormal enhancing lesion identified. Area of encephalomalacia involving the right cerebellar hemisphere. Changes suggestive of chronic microangiopathic change. CXR [**2166-1-28**]: Slight increase in pulmonary edema; similar appearance of bilateral moderate pleural effusions. Brief Hospital Course: 79F with locally advanced pancreatic CA on Xeloda and oxaliplatin (C2D1 [**2166-1-8**]) admitted with diarrhea. # Diarrhea: Most likely [**1-25**] chemotherapy, though infectious cause possible. Cdiff was negative. She was given IV Fluids, prn antiemetics, and her electrolytes were corrected prn. After cdiff was negative x 1, she was given symptomatic treatment of her diarrhea with loperamide. She continued to have nausea and profuse diarrhea, and she was given tincture of opium as well as octreotide. # Sepsis: After several days in the hospital, she became acutely hypotensive, tachycardic and hypoxic. She was emergently transferred to the ICU, where NG tube was placed with immediate output of almost a liter of feculent material. She was put on broad spectrum antibiotics and central line was placed for aggressive fluid repletion. Blood pressure was supported with levophed. She was intubated for airway protection given concern for aspiration pneumonia. Cause of patient's acute decompensation was unclear. The team considered infection from bowel source (microperforation, SBP), aspiration event, or possible PE. CTA was not done given patient's worsening renal function and unstable clinical status. Surgery was consulted and did not feel that the patient was a candidate for surgical intervention. Patient remained intubated and on pressors for several days. Antibiotics were selected to cover possible bowel pathogens given concern that she could have had microperforations or perhaps SBP given new finding of ascites on imaging. Despite aggressive care, the patient continued to deteriorate. Her daughters (and health care proxy) agreed that the patient would not wish to continue aggressive care given her poor prognosis. The decision was made with the attending to make the patient comfort measures only; she was extubated and died later that day. Patient's daughters agreed that they would want an autopsy to help understand what had caused their mother to deteriorate. # Acute renal failure - Oliguric on arrival to ICU. Cr quickly improved with IV fluids and support of MAPs. # Pancreatic CA - Metastatic to lungs, although with fairly good functional status prior to admission. Onc fellow contact[**Name (NI) **] upon ICU transfer. Chemotherapy was held and patient's family agreed upon comfort care after discussing the matter with her oncologists, the ICU team, and palliative care. # Coagulopathy: Patient's INR increased during admission despite holding coumadin. DIC labs were negative. Patient's INR improved with FFP and vitamin K. #. UTI: There is a postive UA and bandemia. She was afebrile and had no urinary symptoms. UCx showed mixed flora. She was given a three day course of cipro. Communication Daughter [**Name (NI) 553**] [**Telephone/Fax (1) 23816**] Medications on Admission: coumadin 2.5 mg daily (this dosage is currently being reduced due to addition of chemotherapy agents which interact with coumadin\ synthroid 25' compazine PRN MVI Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2166-2-1**]

[ "288.66", "038.8", "244.9", "V43.65", "197.0", "276.8", "782.1", "584.9", "286.9", "558.2", "157.8", "276.51", "599.0", "E933.1", "518.81", "285.9", "511.9", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.07", "96.04", "99.04", "96.71" ]

icd9pcs

[ [ [] ] ]

10980, 10989

7913, 10734

290, 296

11041, 11051

2636, 7890

11108, 11282

2042, 2241

10947, 10957

11010, 11020

10760, 10924

11075, 11085

2256, 2617

242, 252

324, 1095

1117, 1799

1815, 2026

20,960

157,079

5136

Discharge summary

report

Admission Date: [**2171-8-24**] Discharge Date: [**2171-8-26**] Date of Birth: [**2119-5-17**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: DKA Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 52-year-old man with a history of Hepatitis C on treatment with interferon, who was sent by his PCP for evaluation of hyperglycemia. Patient reports that about ten days prior to admission he started having decreased oral intake associated with pain in his mouth and throat and some stomach discomfort. It was uncomfortable for him to eat but he was able to drink juice and soda. During this period the patient also had polydipsia and polyuria and felt fatigued. He reports he had subjective fever one day but that it went away when he took some Tylenol. He also reports having diarrhea that lasted one day. All his symptoms started around the time he started taking Neupogen. Patient denies nausea, vomiting, chest pain, and shortness of breath. He went to see his PCP [**Last Name (NamePattern4) **] [**8-21**] because of his symptoms. His doctor found an oral [**Female First Name (un) 564**] infection and prescribed nystatin. His doctor also stopped the Neupogen because of its association to the onset of symptoms. The patient had blood tests done and then went home. On [**8-23**] his doctor contact[**Name (NI) **] him because his blood sugar was 733 and advised him to go to a local ER or come to [**Hospital1 18**] to get his blood sugar checked again. Patient came to [**Hospital1 18**] ED on [**8-24**]. His initial blood sugar was 557, he had an anion gap of 28 and his urine was positive for ketones. He was given 10 units of regular insulin IV and was put on an insulin drip of 4 unit/hr. He also received 1 L of normal saline in the ED. Insulin was later increased to 10 units/hr and decreased to 6 units/hr when finger stick was 148. Patient was admitted to medicine service for further management of his hyperglycemia. Past Medical History: 1) Hepatitis C: Diagnosed six years ago. The patient underwent liver biopsy [**2171-4-2**] which revealed stage two fibrosis. He has been receiving treatment with interferon and ribavirin since [**2171-4-23**] 2) Thrush Social History: Patient is from [**Country 3992**] and has been in the United States for the past 30 years. He works at the [**Doctor Last Name **]-[**Last Name (un) 21071**] in the maintenance department. He lives with his wife and three kids. He denies alcohol or illegal drug use. He has smoked half a pack a day for 20 years. Family History: Father had DM and CAD Physical Exam: VS: T 97.6 HR 62 BP 108/70 RR 20 SaO2 99% RA General: NAD HEENT: Normocephalic/Atraumatic, sclera anicteric, MMM, PERRL, tongue has whitish exudate Neck: no lymphadenopathy, no thyromegaly, no carotid bruits, no JVD, supple neck Chest: Rose and fell with equal size, shape and symmetry, CTA Bilaterally Cor: RRR, normal S1/S2, no murmurs, rubs, or gallops Abd: bowel sounds present, soft, NT/ND Back: No spinal or costavertebral angle tenderness Extremities: no cyanosis, strong distal pulses, there??????s a wound on left foot but no signs of infection. Neuro: Mental Status: Alert and Oriented X3 Cranial Nerves: CN II-XII symmetrically intact Sensation: normal on all extremities Motor: Normal Tone, normal mass, strength 5/5 bilaterally Pertinent Results: [**2171-8-24**] 04:40PM GLUCOSE-526* UREA N-22* CREAT-1.3* SODIUM-139 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17 [**2171-8-24**] 04:40PM CALCIUM-9.0 PHOSPHATE-2.9 MAGNESIUM-2.0 [**2171-8-24**] 03:52PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035 [**2171-8-24**] 03:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2171-8-24**] 03:52PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2171-8-24**] 02:05PM GLUCOSE-557* UREA N-24* CREAT-1.4* SODIUM-136 POTASSIUM-5.31* CHLORIDE-93* TOTAL CO2-20* ANION GAP-28* [**2171-8-24**] 02:05PM ALT(SGPT)-25 AST(SGOT)-25 ALK PHOS-59 AMYLASE-62 TOT BILI-0.7 [**2171-8-24**] 02:05PM LIPASE-87* [**2171-8-24**] 02:05PM CALCIUM-10.5* PHOSPHATE-4.4 MAGNESIUM-2.2 [**2171-8-24**] 02:05PM GLUCOSE-537* K+-5.3 [**2171-8-24**] 02:05PM WBC-4.0 RBC-5.12 HGB-16.3 HCT-47.9 MCV-94 MCH-31.7 MCHC-34.0 RDW-13.6 [**2171-8-24**] 02:05PM NEUTS-58.9 LYMPHS-32.1 MONOS-6.8 EOS-1.0 BASOS-1.2 [**2171-8-24**] 02:05PM PLT COUNT-121* [**2171-8-23**] 03:40PM GLUCOSE-733* [**2171-8-23**] 03:40PM UREA N-23* CREAT-1.2 SODIUM-139 POTASSIUM-5.0 CHLORIDE-95* TOTAL CO2-25 ANION GAP-24* [**2171-8-23**] 03:40PM ALT(SGPT)-21 AST(SGOT)-20 CK(CPK)-136 ALK PHOS-60 TOT BILI-0.6 [**2171-8-23**] 03:40PM ALBUMIN-4.8 [**2171-8-23**] 03:40PM TSH-0.54 [**2171-8-23**] 03:40PM FREE T4-1.3 [**2171-8-24**] 11:50PM CHEST (PA & LAT) IMPRESSION: No evidence of acute cardiopulmonary disease CXR: No evidence of acute cardiopulmonary disease. Brief Hospital Course: 1) DKA: In the ED the patient had an anion gap of 28 and his urine was positive for ketones. He was given 10 units of regular insulin IV and was put on an insulin drip of 4 unit/hr. He also received 1 L of normal saline in the ED. Insulin was later increased to 10 units/hr and decreased to 6 units/hr when finger stick was 148. Once the gap closed and since glucose was less than 250 the insulin drip was discontinued and the patient was placed on insulin sliding scale. The patient had three sets of normal cardiac enzymes and a normal ECG to r/o MI as a possible precipitant of the DKA ([**8-25**] @ 2:30 AM CK: 125, MB: 6, Trop-*T*: <0.01; [**8-25**] @ 6:55 AM CK: 105, MB: 5, Trop-*T*: <0.01; [**8-25**] @ 8:50 PM CK: 92). 2) Diabetes Mellitus type 2: Patient's glucose was 557 on admission to the ED. He was given 10 units of regular insulin IV and was put on an insulin drip of 4 unit/hr. Insulin was later increased to 10 units/hr and decreased to 6 units/hr when finger stick was 148. Patient was placed on Lantus and Lispro sliding scale when the insulin drip was discontinued and was kept on it during his hospital stay. On the morning of [**8-25**] the patient's glucose was 302. On [**8-25**] a nutrition consult to talk with patient about diabetic diet was requested. On [**8-26**] his glucose was 344. Before dicharge a follow up with [**Hospital **] clinic as an outpatient was set up. 3) Hepatitis C: Patient was continued on his outpatient regimen of ribavirin (200 mg tablets, 3 tablets in the morning and 2 tablets in the evening) and interferon (180 mcg subcutaneous injection q. weekly) during his hospital stay. 4) Hypotension: On [**8-26**] the patient??????s BP was 84/60 with decreased urine output, so he was given a 500 cc bolus. BP went up to 93/67 and patient produced 50 cc of urine. His BP was stable until his discharge without further measures. 5) Oral candidaisis: Patient was continued on nystatin during his hospital stay. There was no evidenced of thrush on discharge. 6) Acute renal failure: Patient's Cr was 1.2 on the ED. After fluid repletion it went down to 0.7. On the second hospital day the Cr remained at 0.7. 7) Thrombocytopenia: Patient's platelet count was 121 on the ED([**8-24**] @2:05 PM). After fluid repletion in the ED the platelet count went down to 102(10/03 @6:55 AM). This level was around the patient's baseline so the patient was continued to be monitor for symptoms during his hospital stay without any further intervation. On [**8-26**] his platelet count was 82. 8) Foot wound: The patient was found to have a wound on his left foot during physical exam, which he reported was the result of a burn with hot water. The wound was monitored daily and it appeared to be healing well. 9) FEN: The patient was kept on a diabetic diet during his hospital stay. On [**8-25**] his P was 1.5 so he received Neutra-Phos 1 PKT PO BID during 2 days. On [**8-26**] his P was 2.8 Medications on Admission: Nystatin- swish and swallow to be used 4 times a day for 10 days (started [**8-21**]) Peginterferon alpha-2a- 180 mcg subcutaneous injection q. weekly Ribavirin- 200 mg tablets, 3 tablets in the morning and 2 tablets in the evening Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 3. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous Qam: monitor your blood sugar while on insulin. Disp:*1 vial* Refills:*2* 4. Lancets Misc. Kit Sig: One (1) lancet Miscell. four times a day: use to monitor your blood sugar QID. Disp:*1 box* Refills:*2* 5. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical four times a day: to sterilize your fingertip prior to testing blood sugar. Disp:*1 box* Refills:*2* 6. Syringe Syringe Sig: One (1) syringe Miscell. four times a day: please use to administer insulin. Disp:*1 box* Refills:*2* 7. one step test strips Sig: One (1) strip four times a day: please use to test your blood sugar QID. Disp:*1 box* Refills:*2* 8. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: ss unit Subcutaneous four times a day: check blood sugar QID, insulin as per sliding scale. Disp:*1 vial* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Diabetes mellitus - Hyperglycemia. 2. Acute Renal Failure. 3. Oral Candidiasis. Secondary: 1. Hepatitis C Cirrhosis. 2. Pancytopenia. Discharge Condition: - stable to home, on insulin, to f/u in [**Last Name (un) **] in morning Discharge Instructions: - Take medications as directed. You have been started on insulin. Check your blood sugar as instructed. - Follow up at [**Last Name (un) **] Diabetes Center, and with your liver and PCP as scheduled. - Call your doctor or go to emergency room for dizziness, headache, confusion, fevers, chills, nausea, vomiting, diarrhea, abdominal pain, or extremely high or low blood sugars. Followup Instructions: - Follow up in [**Last Name (un) **] Diabetes Center on [**8-27**], at 8:30 am to check in. You will have diabetes education class from 9-10:30 am, and 1:00-2:30pm. You also have appointment at 3:00 pm, with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21072**]. - Follow up with Dr. [**First Name (STitle) **] this week - call his office to make appointment. - Follow up with your PCP [**Last Name (NamePattern4) **] [**11-23**] weeks. - Please note your fasting lipids were checked while in the hospital. Recommend outpatient follow-up of lipid levels.

[ "112.0", "287.4", "584.9", "276.5", "070.70", "250.10" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9410, 9416

5087, 8020

312, 318

9606, 9680

3492, 5064

10108, 10686

2688, 2711

8303, 9387

9437, 9585

8046, 8280

9704, 10085

2726, 3290

269, 274

346, 2096

3343, 3473

3305, 3327

2118, 2340

2356, 2672

18,353

183,547

52553

Discharge summary

report

Admission Date: [**2164-1-6**] Discharge Date: [**2164-1-20**] Date of Birth: [**2101-6-19**] Sex: M Service: VSU CHIEF COMPLAINT: Ischemic left foot pain. HISTORY OF PRESENT ILLNESS: This is a 67 year old male with a history of diabetes mellitus, end stage renal disease on hemodialysis, status post common femoral to above knee popliteal bypass with PTFE who had left dorsal foot pain on awakening this a.m. which has progressed. Otherwise, he has done well and is ambulating sufficient distances. The patient was admitted for further evaluation and treatment. PAST MEDICAL HISTORY: Type 2 diabetes mellitus with triopathy. End stage renal disease on hemodialysis Monday, Wednesday and Friday. Coronary artery disease, status post myocardial infarction in [**2155**], and non Q wave myocardial infarction in [**2160**]. Dilated cardiomyopathy with an ejection fraction of 33 percent. Hypertension. Chronic obstructive pulmonary disease. Hypothyroid. Hepatitis C. Chronic pain syndrome. History of peripheral vascular disease. History of right perinephritic hematoma. Sleep apnea on continuous positive airway pressure. History of right groin abscess. History of right brachial pseudoaneurysm postcatheterization. PAST SURGICAL HISTORY: Right PFA to below knee popliteal with vein in [**2160-1-4**], with a right second toe amputation. Incision and drainage of perirectal abscess in [**2153**]. Right AV fistula placement in [**2163-1-3**]. Left common femoral to above knee popliteal with PTFE in [**2163-1-3**]. Groin exploration and hematoma evacuation. In [**2163-6-4**], laparotomy with left inguinal hernia repair and open umbilical hernia repair. ALLERGIES: Benadryl. MEDICATIONS ON ADMISSION: 1. Plavix 75 mg daily. 2. Aspirin 325 mg daily. 3. Labetalol 50 mg daily. 4. Lasix 80 mg twice a day. 5. Lipitor 20 mg daily. 6. Reglan 10 mg daily. 7. Protonix 40 mg daily. 8. Insulin 70/30 and regular insulin sliding scale. PHYSICAL EXAMINATION: General appearance - Alert, well appearing male in no acute distress. Head, eyes, ears, nose and throat examination - The neck is supple. There are no carotid bruits. The lungs are clear to auscultation bilaterally . The heart is a regular rate and rhythm. Abdominal examination is unremarkable. There are no bruits. Extremity examination - The feet are warm bilaterally. The left foot has intact sensation, intact motor and capillary refill. The pulses show palpable radials, carotids and femorals bilaterally two plus. The right popliteal is palpable two plus. The dorsalis pedis is monophasic signal and the posterior tibial on the right is a triphasic signal. On the left, the popliteal is Dopplerable signal and the dorsalis pedis and posterior tibial are monophasic signals on the left foot. HOSPITAL COURSE: The patient was initially evaluated in the Emergency Department and ultrasound was obtained which showed a proximal anastomosis graft stenosis. The patient was admitted to Dr.[**Name (NI) 7257**] service, placed on intravenous Heparinization. Coagulation studies were monitored and Heparin dosing adjusted for a partial thromboplastin time of 60 to 80. The patient was given adequate analgesic control. Renal was consulted for his history of end stage renal disease, hemodialysis dependent. Cardiology was consulted because of the patient's significant history of cardiac disease and congestive heart failure and dilated cardiomyopathy. The patient was seen by the cardiology fellow. The patient had no acute episodes of chest pain or shortness of breath. Recommendations were rule the patient out for acute myocardial infarction, cycle enzymes, continue Aspirin, Plavix, Labetalol, Lipitor and Heparin drip. The patient will be seen by Dr. [**Last Name (STitle) **], his cardiologist, the following morning. Troponin levels were 1.4, 1.5 and 1.3. The patient ruled out for acute myocardial infarction secondary to renal failure and low renal clearance. On [**2164-1-10**], the patient underwent exploration of the left external iliac and common femoral, attempted retrograde recanalization of the left common femoral stenosis via the left PTFE bypass, puncture attempt of the right common femoral artery, right common femoral cut-down and intraoperative angiogram. The procedure was aborted secondary to severely calcified vessels which were not able to be clamped for surgical intervention. The patient intraoperatively had ectopy and intraoperative hypotension requiring inotropic support. The patient intraoperatively was given volume and two units of packed red blood cells and two liters of normal saline. He had an estimated blood loss of 700 cc. An intraoperative echocardiogram demonstrated an ejection fraction of 20 percent with global hypokinesis spanning the lateral wall. The patient was begun on Dopamine and he was transferred to the Surgical Intensive Care Unit intubated for continued care. Overnight events included hyperkalemia requiring intravenous insulin, calcium and D50 with Kayexalate. There were no arrhythmias. The patient was given a dose of Vancomycin and the Dopamine was weaned off later that evening. Hematocrit was 25.6 and he was transfused two more units of packed red blood cells. The patient was given Dilaudid for analgesic control. Intravenous Heparin was continued. Nephrology continued to follow the patient. The patient was extubated. The Heparin drip was discontinued due to persistent low hematocrit and large retroperitoneal hematoma. Plavix was begun on postoperative day number three after Heparin was discontinued. His Protonix was changed to Zantac. Swan was converted to a triple lumen catheter and he remained in the Surgical Intensive Care Unit. Later that day on [**2164-1-13**], the patient was transferred to the Vascular Intensive Care Unit for continued monitoring and care. He continued to be followed by Dr. [**Last Name (STitle) **], his cardiologist, who felt it would be alright to transfer the patient to the Vascular Intensive Care Unit on telemetry. The retroperitoneal hematoma was diagnosed with CT of the abdomen. Heparin was discontinued then. The patient was begun on Plavix. On postoperative day number three, the resident was called to see the patient for confusion. A sitter was requested to help reorient the patient and monitor his activities. He remained in the Vascular Intensive Care Unit. Postoperative day number six, Zestril 5 mg daily was begun for a low ejection fraction along with his Labetalol. Aspirin and Plavix were continued. Cardiology felt that we could discontinue telemetry, that the patient's rise in his troponin levels was secondary to his renal failure and not acute infarct. He continued to be followed by the renal service for hemodialysis. The patient was transferred to the regular nursing floor on [**2164-1-17**]. PVRs of the lower extremity were obtained on [**2164-1-18**]. The foot pressures on the right were 8 millimeters and on the left 17 millimeters. On [**2164-1-19**], the patient was begun on Levofloxacin 250 mg for a total of four doses for a questionable urinary tract infection. The patient's groins were without drainage and he had no rest pain. His hematocrit stabilized at 35.9. Consideration for exploration-bifemoral was discussed with the patient. He underwent upper arterial studies which were read as normal. The patient was discharged in stable condition. Wounds were clean, dry and intact. He will follow- up with Dr. [**Last Name (STitle) **] on Wednesday, [**2164-1-25**], for staple removal. At that time, further recommendations regarding surgery will be discussed with the patient and arrangements made appropriately. DISCHARGE DIAGNOSES: Ischemic left foot pain secondary to failed graft. Blood loss anemia secondary to retroperitoneal hematoma, transfused, corrected. Postoperative hypertension secondary to hypovolemia, corrected. Hyperkalemia corrected. Troponin leak of 0.14, no myocardial infarction. Urinary tract infection, treated. SURGICAL INTERVENTION: Arteriogram [**2164-1-9**]. Left groin exploration on [**2164-1-10**], attempted angioplasty left common femoral artery, with a right groin exploration. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg daily. 2. Atorvastatin 20 mg daily. 3. Plavix 75 mg daily. 4. Calcium Aspartate 667 mg tablets, two with meals. 5. Reglan 10 mg before meals and at bedtime. 6. Colace 100 mg p.o. twice a day. 7. Senna tablets 8.6 mg tablets one twice a day. 8. Protonix 40 mg daily. 9. Labetalol 50 mg twice a day. 10. Acetaminophen 325 mg one to two tablets q4-6hours p.r.n. for pain. 11. Lisinopril 5 mg daily. 12. Oxycodone Acetaminophen 5/325 tablets one to two q4- 6hours p.r.n. for pain. 13. Dulcolax tablets two p.r.n. daily. 14. Levofloxacin 250 mg tablets q48hours times a total of three doses. 15. Insulin N 70/30 5 units q.breakfast and 5 units at dinner with a regular insulin sliding scale before meals. FOLLOW UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] on [**2164-1-27**]. He has an appointment at 7:45 a.m. Dr. [**Last Name (STitle) **] will be covering for Dr. [**Last Name (STitle) **] at that time. The patient should take showers only, no tub baths. Call the office if he develops a temperature greater than 101.5, wound becomes red, swollen or drains. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7258**], [**MD Number(1) 7263**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2164-1-19**] 17:13:41 T: [**2164-1-21**] 11:40:19 Job#: [**Job Number 108532**]

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icd9cm

[ [ [] ] ]

[ "38.91", "54.0", "99.04", "89.64", "39.95" ]

icd9pcs

[ [ [] ] ]

7752, 8239

8265, 9027

1753, 1981

2830, 7730

1281, 1727

9039, 9683

2004, 2812

153, 179

208, 590

613, 1257

31,958

161,277

52939

Discharge summary

report

Admission Date: [**2107-10-16**] Discharge Date: [**2107-10-26**] Date of Birth: [**2049-8-10**] Sex: F Service: MEDICINE Allergies: Cipro / Dilaudid / Mexiletine / Bactrim Ds / Cephalexin / Bactrim / Avelox / Levaquin / Amoxicillin / Oxycodone / Keflex / Hydrochlorothiazide / Minocycline / Cleocin / Percocet Attending:[**First Name3 (LF) 7055**] Chief Complaint: PEA arrest, complete heart block Major Surgical or Invasive Procedure: DDD pacer placement History of Present Illness: Patient is a 58 year old woman with a history of chronic dyspnea, breast cancer, AML with bone marrow transplant, recurrent sinusitis, IgA deficit with monthly IVIG injections. Per report the patient was exercising on a treadmill at home when she collapsed and became unresponsive. Her husband performed CPR and the patient woke up briefly and then again became unresponsive. MET intubated the patient at home and continued CPR and found to be in PEA. On arrival she was found to have complete heart block on ECG. She was externally paced and placed on a dopamaine drip and pulses returned, she was hypothermic while in the ED as well. Bedside echo showed normal ventricular function. CT angio was negative for PE. CT head was normal. She had an SVT that then developed into complete heart block and temp wire was placed. Initial vitals were t 102 (after bearhugger) p 89 BP 104/74 rr 20 ox 96% FIO2 60%. While there patient was started on neosynephrine, dopamine, protonix and hep sc. Also received clinda 600 mg iv q8 for leukocytosis and propofol for sedation. Neuro consultation diagnosed anoxic encephalopathy and recommended repeat CT and eeg. Patient remained febrile up to 105 prior to transfer. She wasn't tachycardic throughout most of the hospital course and remianed with good urine output. Temporary pacing wire was placed on [**10-15**] for persistent complete heart block, but per report the patient was not pacer dependent. On transfer, the patient was intubated and sedated. Additional history was obtained from the patient's husband. [**Name (NI) **] describes that she walked 15 minutes on the treadmill and was on the floor stretching when she collapsed and became unresponsive. The husband started CPR and called 911. Intermittently the patient was awake and wanted to get dressed, but quickly collapsed and he restarted CPR. Per husband, prior review of systems was positive as known with chronic shortness of breath x years with fatigue. And ROS was negative including any recent infective symptoms including fever, chills, headache, syncope, joint or muscle pains, nausea, vomiting, diarrhea. As far as he knows she was in her usual state of health until Sat AM. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: 1. History of AML with bone marrow transplant and total body radiation in [**2098**]. 2. History of left breast cancer, status-post modified mastectomy and left chest XRT in [**2083**]. 3. Bilateral breast implants. 4. Post transplant lymphoproliferative disorder. 5. Recurrent sinusitis with low IgA on monthly IVIG. 6. Hemochromatosis, status-post phlebotomies. 7. Noncaseating granulomas on liver biopsy. 8. Progressive exertional dyspnea. 9. Previous concern of restrictive or constrictive cardiomyopathy (though last cath in [**2104**] did NOT confirm this) 10. New enlarged cervical right-sided lymph node. 11. Multiple drug allergies, including to multiple antibiotics. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. She works at [**Company **] [**Location (un) **]. Family History: There is no family history of premature coronary artery disease but there is a family history of colon cancer. Physical Exam: VS: T 101.4, BP 87/56 , HR 99 , RR 32, O2 96% on 50% FiO2 AC 450 x12, PEEP 5 Gen: WDWN middle aged female. Intubated and sedated, withdraws to pain and occasionally opens eyes. Does not respond to commands. HEENT: NCAT. Sclera anicteric. PERRL though sluggish. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple without JVD CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Systolic murmur at LLSB possible loud p2? Chest: No chest wall deformities, scoliosis or kyphosis. Somewhat rapid breathing with abdominal muscles. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: carotid 2+ without bruits, Femoral 2+ without bruit; 2+ DP Left: carotid 2+ without bruits, Femoral 2+ without bruit; 2+ DP Neuro: pupils slow to react, opens eyes occasionally, withdraws to pain, has equivocal plantar reflexes. Pertinent Results: CXR [**10-21**]: Portable AP chest radiograph compared to previous study before the procedure obtained on the same-day at 08:45 p.m. The temporary pacemaker is removed in the meantime interval. The left hemithorax pacemaker was inserted with two leads terminating in the right atrium and right ventricle with expected course and no signs of discontinuity. The Port-A-Cath catheter inserted through the right subclavian vein terminates at the cavoatrial junction. Bilateral perihilar opacities are consistent with pulmonary edema and grossly unchanged as well as bibasilar retrocardiac atelectasis. Small bilateral pleural effusion is present. An external devise with a rectangular shape overlies the mid chest. The chest radiograph has to be repeated without this artifact when the patient's condition allows. EKG [**10-22**]: Sinus tachycardia. Marked left axis deviation. Left anterior fascicular block. Right bundle-branch block. Q-T interval prolongation. ST-T wave abnormalities. Since previous tracing of [**2107-10-21**] atrial pacing is no longer present. Rib Films: Three mildly displaced left-sided rib fractures. No evidence of pneumothorax. [**10-16**] CT Head w/ and w/o contrast: 1. No acute intracranial hemorrhage. 2. Worsening soft tissue changes of the maxillary sinuses compared to [**2102-11-10**]. [**10-16**] CT Neck w/ and w/o contrast: No definite abscess or fluid collection of the neck. Air- secretion level noted within the maxillary sinuses in the setting of intubation. New patchy opacities of the visualized lungs bilaterally and a new small left pleural effusion, which may represent aspiration or pneumonia. CTA CHEST AT OSH NEGATIVE FOR PE, CT w/ contrast lower extremities negative for DVT. [**2107-10-16**] 10:00PM FDP-10-40 [**2107-10-16**] 08:49PM TYPE-ART RATES-[**10-27**] PO2-86 PCO2-25* PH-7.48* TOTAL CO2-19* BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED [**2107-10-16**] 08:49PM LACTATE-2.0 [**2107-10-16**] 08:49PM O2 SAT-97 [**2107-10-16**] 04:34PM %HbA1c-5.9 [**2107-10-16**] 04:30PM GLUCOSE-122* UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-19* ANION GAP-14 [**2107-10-16**] 04:30PM ALT(SGPT)-183* AST(SGOT)-198* LD(LDH)-395* CK(CPK)-791* ALK PHOS-150* TOT BILI-1.1 [**2107-10-16**] 04:30PM CK-MB-16* MB INDX-2.0 cTropnT-0.04* [**2107-10-16**] 04:30PM ALBUMIN-2.8* CALCIUM-8.1* PHOSPHATE-2.4* MAGNESIUM-1.9 IRON-16* [**2107-10-16**] 04:30PM calTIBC-199* FERRITIN-1444* TRF-153* [**2107-10-16**] 04:30PM WBC-10.3# RBC-3.50* HGB-10.0* HCT-30.2* MCV-87 MCH-28.7 MCHC-33.2 RDW-15.7* [**2107-10-16**] 04:30PM NEUTS-81* BANDS-9* LYMPHS-5* MONOS-3 EOS-0 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 [**2107-10-16**] 04:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-1+ TEARDROP-1+ ELLIPTOCY-1+ [**2107-10-16**] 04:30PM PLT SMR-LOW PLT COUNT-84* [**2107-10-16**] 04:30PM PT-16.3* PTT-31.2 INR(PT)-1.5* [**2107-10-16**] 04:30PM FIBRINOGE-608*# D-DIMER-6777* Lyme serologies negative Urine culture negative to date [**10-24**] Blood cultures negative to date [**10-24**] Stool C diff negative x 2 Stool Campylobacter negative, shigella and salmonella negative Discharge labs [**10-24**]: CBC: WBC 6.8, HCT 25.4, PLT 176, MCV 87, RDW 17.2, B12 1361, FOLATE 19.5 TSH 2.7 CORTISOL 25 ACE LEVEL 8 (NORMAL) Brief Hospital Course: Cardiac- pulseless electrical activity, patient was in a bradycardic rhythm without visible P waves and with wide QRS complexes, unclear as to initial rhythm strip as to whether it was a ventricular rhythm or a complete heart block rhythm. When the patient arrived to the outside hospital via ambulance her rhythm was complete heart block. Prior the patient had received CPR from her husband was in a sinus tachycardia subsequent to complete heart block EKGs. She was ruled out for PE with CTA, found to be hypothermic to 94.1F and transferred to [**Hospital1 18**] for further care. Here she was in sinus tachycardia and temporary pacer wires were placed. She was ruled out for any infection and treated initially empirically with broad spectrum antibiotics. ID was consulted, no etiology was found for her hypothermia, eventually her antibiotics were stopped and she showed no further signs of infection. DDD permanent pacer placed by Dr. [**Last Name (STitle) 13177**]. She will follow up in device clinic in 1 week and follow up with her cardiologist within 2 weeks of discharge. Possible etiologies include radiation injury to electrical system of heart, at baseline she has a bifasicular block. Other causes ? sarcoidosis, ACE and calcium levels normal, unlikely. Lyme serologies negative. No evidence for infarct and clean coronaries in [**2104**]. You developed a hematoma at the placement of your hematoma. This hematoma was stable at discharge. Pt is schedule to follow up in device clinic in 3 days. Pt to continue pressure dressing of hematoma. . Neurologic: anoxic brain injury from arrest causing short term memory loss otherwise intact. She had shown improvement by the end of her stay but still has much difficulty with short term memories / new memories. Neurology consulted and recommended neuro rehab for traumatic brain injury. She should see some improvement especially over the next 3 months and some over the next 1 year; after which she would not be expected to improve further. It is impossible to predict the degree of her improvement. . Anemia- baseline anemia with hct around 30, post procedure hct stable but roughly 25. Patient asymptomatic. Not iron deficient, B12 or folate. She should follow up with her primary care physician and should have her hct checked in 1 week from discharge. Guiac +, no frank blood, should have endoscopy / colonoscopy as outpatient. . Diarrhea: Much improved. Intially guaic pos, but brown. No infectious etiology. Given the anoxic memory impairment as a marker for ischemia during arrest, patients diarrhea may have been due to ischemia in watershed area of bowel during arrest. No infectious etiolgy found. Either way improving.C. diff neg x3 . Liver:Hx of non-caseating granulomas of liver. Patient with a history of possible hemachromatosis and s/p multiple phelebotomies. Patient has significantly elevated ferritin consistent with this diagnosis. . Follow Up issues: -Patient to F/U with Dr. [**First Name (STitle) 437**] on [**11-7**] -Patient to f/u in pacemaker clinc with in one week for monitoring of hematoma. -patient needs follow up for liver function abnormalities. Medications on Admission: Baclofen 5 mg daily doxycycline 100 mg [**Hospital1 **] (to finish [**10-19**]) [**Doctor First Name **] 1 pill Cleocin T gel for face Famvir 500 mg [**Hospital1 **] Fosamax 70 mg weekly Folic acid 1 mg daily lipitor 10 mg daily lisinopril 2.5 mg daily metoprolol succinate xr 50 mg daily MVI pentamidine monthly premarin vaginal cream tobradex opthal. left eye at night ativan 0.5 mg nightly darvocet N 100 acinesia 300 mg prn fioricet zantac xanax 0.5 mg tid prn Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary Diagnosis cardiac arrest Complete heart block Anoxic brain injury Secondary IGA deficiency BMT in [**2098**] Discharge Condition: stable, memory improving, no pacer complications Discharge Instructions: Mrs. [**Known lastname 4467**], you were admitted to the hospital after collapsed at home, received CPR. You were noted to have developed complete heart block. During this time your heart was not delivering blood to your brain. You were noted to have very low blood pressure "hypotension" and low body temperature "hypothermia." You were intubated. You were externally paced and placed on medications to raise your blood pressure. A CT of the chest at the outside hospital showed no blood clot in your lungs. You received a temporary wire pacemaker. You were then diagnosed with an anoxic brain injury, meaning there was damage to your brain as a result of insufficient oxygen delivery- this is what caused your short term memory loss, this should improve somehwhat over the next year, but it is impossible to predict how much it will improve. When you arrived at [**Hospital1 18**] you had your temporary pacemaker wire adjusted. You had an echocardiogram of your heart which showed normal mechanical heart activity. You were noted to have a fever, elevated white blood cell count and a diarrhea. You were started on antibiotics, but an infectious source for your diarrhea or fever was never found and antibiotics were discontinued. You did receive a Head CT which did not show and intracranial hemorrage, but did show some inflamation in your sinuses. You were extubated with out any problem. You were also noted to have some elevations in your liver enzymes, but these normalized during your stay. You should follow these tests up with your primary care physician. During your stay you were given a DDD pacemaker that paces both your atrium and ventricle. There were no complications with the placement of your pacemaker. Please follow up with your cardiologist in regards to your pacemaker. You developed a hematoma or blood collection near the entrance of your pacemaker site. This is stable and not growing in size. If it gets any larger please call your cardiologist or come to the emergency room. Please continue to use your pressure dressing for the next 3 days. In regards to your short term memory impairment, you were seen by our neurology team. They think that your memory will continue to improve. They are recommending that you stay at a neuro rehab facility, to aid in your recovery. You also complained of chest pain while in the hospital. This was likely due to trauma from the chest compressions you received during CPR. x-rays showed you to have several right sided rib fractures. You should continue to take ibuprofen for pain. During your hospital stay you were seen by the hematologists for your low platelet count. You were also given your monthly IVIG dose and pentamidine dose. You were discharged from the hospital on your home medications of fosamax 70mg weekly, famvir 500mg [**Hospital1 **], [**Doctor First Name **] 60mg daily, lisinopril 2.5mg daily, ativan 0.5mg q4-6h PRN, metoprolol XL 50mg daily, baclofen 10mg [**Hospital1 **] PRN, lipitor 10mg, folic acid. You can continue to take ibuprofen for your rib pain. Please call your primary care physician or go straight to the emergency room, if you develop chest pain, fever, tenderness around your pacemaker site, dizziness, vomiting or any overall worsening of your condition. Followup Instructions: Please follow up with the following appointments: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2107-10-25**] 8:30 BMT CHAIR 6 Date/Time:[**2107-10-25**] 8:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2107-10-25**] 11:30 You have an appointment in pacemaker device clinic at 10:30 a.m. on Friday [**10-28**] for a wound check., the [**Hospital **] Clinic' is located on the [**Hospital Ward Name 516**] at [**Hospital1 18**] on [**Hospital Ward Name 23**] 7. ([**Telephone/Fax (1) 30924**] You should also follow up with your cardiologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] office at [**Telephone/Fax (1) 3512**]. You have an appointment at 145pm on the [**Location (un) 436**] of [**Hospital1 18**] [**Hospital Ward Name 516**] in the [**Hospital Ward Name 23**] building with Dr. [**First Name (STitle) 437**]. Please also make a follow up appointment with Dr. [**Last Name (STitle) 5263**] [**Telephone/Fax (1) 109128**]. Also, follow up with your primary care physician [**Name Initial (PRE) 176**] [**12-26**] weeks of discharge.

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icd9cm

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icd9pcs

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29,317

125,749

50903

Discharge summary

report

Admission Date: [**2130-5-8**] Discharge Date: [**2130-5-12**] Date of Birth: [**2075-11-18**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 1377**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None. History of Present Illness: Briefly, pt is 54 yo f with HIV, HepC cirrhois, on liver transplant list, adrenal insuff on decadron, who lives at [**Location **], admitted to the MICU on [**2130-5-8**] more lethargy and confusion. In the ED, the patient received stress dose steroids and amp glc for low FS. UA showing UTI rx'd with cipro. Cr was 2, up from 1.3. Head CT neg. CXR neg. She had episode of hypotension down to SBP 80s which responded back to 110s with fluids. . In the ICU, the patient recieved IVF hydration and her BP remained stable without additional stress dose steroids. She had hepatic encephalopathy which improved with lactulose and rifaximin. She was also found have hypercalcemia which improved with hydration. Her ARF resolved, Ca improving, mental status back to baseline so patient transferred to the liver service for continued care. Past Medical History: 1. Cirrhosis: - MELD of 27 with poor synthetic function (INR 1.7 and albumin 2.8) - AFP 19.9 ([**8-10**]) - Reports "normal" EGD in past year (done at [**Hospital1 2177**]) 2. Hepatitis C: - Viral load 3,270,000 IU/mL ([**8-10**]) 3. HIV: - Viral load <50 copies/ml and CD4 1258 ([**8-10**]) 4. SLE 5. Depression: Has seen a psychotherapist at [**Hospital1 2177**] x5 yrs and was previously on meds; not currently on any. Social History: Currently lives at [**Hospital3 537**]. Not working, former medical assistant. No alcohol, tobacco or illicit drugs. Uses cane to ambulate. Family History: Non-contributory. Physical Exam: Tmax: 36.6 ??????C (97.9 ??????F) Tcurrent: 36.6 ??????C (97.9 ??????F) HR: 78 (78 - 78) bpm BP: 102/26(44) {102/26(44) - 102/26(44)} mmHg RR: 19 (19 - 19) insp/min SpO2: 100% . General Appearance: central adiposity with peripheral and temporal wasting Eyes / Conjunctiva: PERRL, + icterus Head, Ears, Nose, Throat: Poor dentition, mucous membranes dry Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur: Systolic), II/VI early systolic murmur Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Diminished: ) Abdominal: Soft, Non-tender, Bowel sounds present, no fluid wave Extremities: Right: Absent, Left: Absent Musculoskeletal: Muscle wasting Skin: Warm, Jaundice Neurologic: Follows simple commands, Responds to: Tactile stimuli, Oriented (to): person and "hospital", Movement: Not assessed, Tone: Not assessed, + asterixis Pertinent Results: ADMISSION LABS [**2130-5-8**] 03:30PM BLOOD WBC-8.6 RBC-4.04* Hgb-13.7 Hct-40.2 MCV-100* MCH-33.8* MCHC-34.0 RDW-16.6* Plt Ct-245 [**2130-5-8**] 03:30PM BLOOD Neuts-68.5 Lymphs-17.7* Monos-13.4* Eos-0.2 Baso-0.2 [**2130-5-8**] 03:30PM BLOOD PT-15.6* PTT-37.2* INR(PT)-1.4* [**2130-5-8**] 03:30PM BLOOD Glucose-79 UreaN-43* Creat-2.0* Na-129* K-5.1 Cl-101 HCO3-16* AnGap-17 [**2130-5-8**] 03:30PM BLOOD ALT-42* AST-65* AlkPhos-205* TotBili-8.7* DirBili-5.2* IndBili-3.5 [**2130-5-8**] 03:30PM BLOOD Albumin-2.9* Calcium-12.4* Phos-2.9 Mg-2.5 [**2130-5-8**] 03:30PM BLOOD Ammonia-69* OTHER LABS [**2130-5-9**] 05:13AM BLOOD TSH-1.7 [**2130-5-9**] 05:13AM BLOOD PTH-25 [**2130-5-8**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2130-5-11**] 06:28AM BLOOD Lactate-1.8 VITAMIN D 25 HYDROXY Results Pending DISCHARGE LABS [**2130-5-12**] 05:45AM BLOOD WBC-9.3 RBC-3.76* Hgb-12.6 Hct-38.1 MCV-101* MCH-33.4* MCHC-33.0 RDW-16.3* Plt Ct-155 [**2130-5-11**] 06:15AM BLOOD Neuts-83.3* Lymphs-8.2* Monos-8.3 Eos-0.2 Baso-0.1 [**2130-5-11**] 06:15AM BLOOD Neuts-83.3* Lymphs-8.2* Monos-8.3 Eos-0.2 Baso-0.1 [**2130-5-12**] 05:45AM BLOOD PT-16.0* PTT-37.7* INR(PT)-1.4* [**2130-5-12**] 05:45AM BLOOD Plt Ct-155 [**2130-5-12**] 05:45AM BLOOD Glucose-82 UreaN-21* Creat-1.1 Na-128* K-4.4 Cl-101 HCO3-20* AnGap-11 [**2130-5-12**] 05:45AM BLOOD Albumin-2.5* Calcium-10.2 Phos-1.8* Mg-2.5 MICROBIOLOGY: [**2130-5-9**] ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING CT head: [**2130-5-8**]: IMPRESSION: No acute intracranial process or edema. CXR [**2130-5-8**]: IMPRESSION: 1. RLL opacity, possibly represents early pneumonia. 2. Anterior wedge deformity of T11 vertebra is new since [**Month (only) **] [**2130**]. CXR [**2130-5-9**] As compared to the previous radiograph, the right lung base has increased in transparency. A focal parenchymal opacity at the right lung base is no longer seen. The size of the cardiac silhouette is unchanged. The transparency of the lung parenchyma is now normal, without signs of hyperhydration and focal parenchymal opacities. No evidence of pleural effusion. ABD US: CONCLUSION: Cirrhosis of the liver. No ascites. No focal mass lesions. No change from the prior study of [**2130-3-17**]. THYROID US [**2130-5-10**]: IMPRESSION: No solid focal mass lesion in either thyroid lobe, no parathyroid tissue identified in the expected locations. Brief Hospital Course: A/P 54F with HIV (VL <50, CD4 506), Hep C cirrhosis (MELD 25), now with altered mental status and UTI. . # Altered Mental Status: Impression on arrival to the ICU was for hepatic encephalopathy with further exacerbation by hypercalcemia, urinary tract infection, and acute renal failure. Patient was hydrated with subsequent improvement in her calcium and renal failure. Patient had repeat CXR that showed no evidence of pneumonia. Mental status improved with lactulose and rifaxamin and asterixis resolved by day number two. By transfer to the floor, the patient was back to her baseline mental status, AOx3 with 6 bowel movements per day. . # ARF: elevated BUN:Cr ratio suggests prerenal azotemia; hypercalcemia can also cause significant dehydration. Urine lytes after hydration with Fe Urea 65%, but Cr improved substantially with IV fluids. Cr on call out from ICU was 1.3 (baseline 0.8). Diuretics held. Her diuretics at home dosing were restarted and by discharge her ARF had resolved and her discharge Cr was back to baseline of 1.0-1.1. . # Hypercalcemia: Ca 12.4 with Alb 2.7 corrects to corrCa 13.4. Likely cause of hypercalcemia is multifactorial including adrenal insufficiency, vitamin D supplementation and HCTZ diuretic. Her HCTZ and vitamin D was discontinued. Work-up notable for normal PTH which is inappropriate in the context of hypercalcemia and could suggest primary hyperparathryoidism. Patient had thyroid ultrasound for evaluation of thyroid adenoma which was negative for any masses. On discharge, her Ca was decreased to 10.2, corrected of 11.48. She was scheduled for close follow up with her PCP to recheck Ca level and follow up on pending vitamin D level. If the patient persists to have a high calcium, further workup should be pursued to look for other etiologies such as primary hyperparathyroidism or less likely malignancy. . # Adrenal insufficiency: has been on maintenance of 0.75mg dexamethasone every other day for several months and received 10mg dexamethasone in the ED for relative hypotension. [**Name2 (NI) 227**] the risks of high doses of steroids and the quick resolution of her hypotension with fluids the patient was not given stress dose steroids in the ICU and was maintained on her home dose of dexamethasone. She maintained her blood pressure on this regimen. . # Hep C cirrhosis: no significant ascites on exam, so cannot safely tap. MELD 25, with poor synthetic function. Bowel regimen as above. USD showed cirrhosis, no focal lesions and no ascites. She was restarted on her diuretics prior to discharge and has follow up with the liver transplant center. . # HIV: VL undetectable with CD4 >450, continue outpt regimen. . #UTI: Started on Ciprofloxacin and UCx were sent which grew out E coli. On [**2130-5-12**], sensitivities came back resistant to ciprofloxacin, bactrim, but sensitive to 3rd generation cephalosporins. She was started on cefpodoxime on [**2130-5-12**] and needs to finish a 7 day course of antibiotics (last day is [**2130-5-18**]). . # Hyponatremia - Patient was at her baseline Na of 125-130. She will need to continue on 1500ml fluid restriction. . # Neck and upper back pain - Patient has continued cervical neck and upper back pain likely secondary to immobility during her period of altered mental status. No cervical or lumbar vertebral tenderness on exam, no neurologic deficits, numbness or tingling in arms. Dr. [**Last Name (STitle) 5351**] at [**Hospital3 537**] is aware of this and does not request any further imaging or workup. Patient will restart physical therapy for her neck, upper back for this. Baclofen was discontinued as it could have contributed to AMS. Medications on Admission: DEXAMETHASONE - 0.75 mg Tablet - 1 Tablet(s) by mouth every other day EMTRICITABINE [EMTRIVA] - 200 mg Capsule - 1 Capsule(s) by mouth daily EPOETIN ALFA [PROCRIT] - 30,000 unit/mL Solution - 40,000 units weekly FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth weekly HYDROXYCHLOROQUINE - 200 mg Tablet - 2 Tablet(s) by mouth once a day IPRATROPIUM-ALBUTEROL [COMBIVENT] - (18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs inhaled PRN LACTULOSE - 10 gram/15 mL Solution - 15 ML by mouth three times a day titrate to 3-4BMS/day LOPINAVIR-RITONAVIR - 200 mg-50 mg Tablet - 2 Tablet(s) by mouth twice daily NAFTIFINE [NAFTIN] - 1 % Gel - [**Hospital1 **] to facial lesions x 1 month twice a day INDICATION: TINEA FACEI; PT. FAILED ECONAZOLE. NYSTATIN - 100,000 unit/mL Suspension - 4 ML by mouth four times a day retain in mouth as long as possible before swallowing RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice a day SPIRONOLACTONE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day TENOFOVIR DISOPROXIL FUMARATE [VIREAD] - 300 mg Tablet - 1 Tablet(s) by mouth daily TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth every four (4) hours as needed for PRN pain ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for sleep Novolin SS CALCIUM CARBONATE - 500 mg Tablet, Chewable - 1 Tablet(s) by mouth three times a day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 unit Capsule - 1 Capsule(s) by mouth once a day INSULIN REGULAR HUMAN - 300 unit/3 mL Insulin Pen - per sliding scale four times a day MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - 1 Tablet(s) by mouth once a day SENNA - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for constipation Discharge Medications: 1. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: Last day will be [**2130-5-18**]. 2. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): Titrate to maintain at least 4 bowel movements per day and clear mental status. 4. Dexamethasone 0.75 mg Tablet Sig: One (1) Tablet PO once a day. 5. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO once a day. 6. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Procrit 40,000 unit/mL Solution Sig: One (1) injection Injection once a week. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO once a day. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO twice a day as needed for oral thrush. 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO three times a day. 15. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every eight (8) hours as needed for shortness of breath or wheezing. 16. Novolin R 100 unit/mL Solution Sig: as directed subcutaneous Injection twice a day: as directed by sliding scale. 17. Baclofen Oral 18. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain: Hold for sedation. 20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 22. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Final diagnosis Hepatic encephalopathy E coli urinary tract infection Hypercalcemia Secondary diagnosis Hepatitis C cirrhosis Adrenal insufficiency Chronic human immunodeficiency virus infection Discharge Condition: Mental status back to baseline Discharge Instructions: You were admitted for increased confusion and weakness at your facility, and found to have hepatic encephalopathy, high levels of calcium, and a urinary tract infection. Your mental status improved with fluid hydration, lactulose and rifaximin for increased bowel movements, and antibiotic treatment for your urinary tract infection. Your blood pressure was also found to be low, but you improved with fluids and one higher dose of steroids. Your blood pressure remained at a good level on your home steroid dosing. . It is important for you to follow up with your primary care physician regarding your calcium levels as below. . Please continue all your home medications except for the follow additions and changes: - your thiazide diuretic and vitamin D supplementation was stopped due to your high levels of calcium - you need to finish a 7 day course of cefpodoxime antibiotics for your urinary tract infections - you were started on a new medication called rifaximin and your lactulose was increased. It is important for you to take these two medications to have at least 4 bowel movements per day. . Please call your physician or return to the hospital if you experience any fever, chills, increased confusion, pain or burning on urination after the course of antibiotics, bone pain, weakness, lightheadedness, or other new or worrisome symptoms Followup Instructions: You have an appointment to see your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**], on Friday [**2130-5-19**] at 4pm. ([**Telephone/Fax (1) 57366**]. At this appointment, you will need to recheck and follow up on your calcium levels and on your urinary tract infection. You have a follow up appointment with [**2130-5-24**] at 3:40pm at the transplant liver clinic. ([**Telephone/Fax (1) 105818**] Please keep your other appointments as below: Provider TRANSPLANT [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2130-6-28**] 9:40 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2130-6-28**] 10:00 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

[ "723.1", "571.5", "255.41", "599.0", "584.9", "041.4", "276.1", "275.42", "276.2", "710.0", "070.44", "724.5", "V08" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13435, 13506

5975, 6090

292, 299

13746, 13779

2852, 5032

15179, 16053

1781, 1800

11461, 13412

13527, 13725

9667, 11438

13803, 15156

1815, 2833

231, 254

327, 1161

5041, 5952

6105, 9641

1183, 1607

1623, 1765

19,169

134,255

16519

Discharge summary

report

Admission Date: [**2200-12-27**] Discharge Date: [**2200-12-27**] Date of Birth: [**2156-2-17**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 46917**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: laproscopic abdominal exploration History of Present Illness: This is a 44 year-old woman G5P3 with history of chronic abdominal pain, known ovarian cysts, ectopic pregnancy two years ago, catemenial epilepsy x 18 years, L pontine infarct in [**5-/2199**], left cavernous angioma who presented today to gyn urgent care clinic with abdominal pain. . Work-up initially included normal pelvic exam. Patient's pain worsened over the course of the day, pelvic U/S revealed enlarged right ovary. Patient developed acute abdomen and decision was made to take the patient to OR. On patient being staffed, noted to have seizure activity by nursing (as per gyn note "patient became unresponsive, fixed stare, squeezing hands, and mild tremor; lasted approx 3 mins"). Neurology was consulted and recommended [**Year (4 digits) 4338**] given past history. Repeat abdominal exam by gynecology revealed slight improvement without peritoneal signs noted previously. Therefore CT abdomen/pelvis was performed and was essentially negative for intra-abdominal process. Patient then underwent [**Year (4 digits) 4338**] which was read as no infarct, bleed. Patient was then taken to the OR for ex-lap. . In the OR ex-lap performed, no pathology. . Transferred to us s/p ex-lap, intubated. Did not extubate post-op because no PACU available and had a seizure before surgery . When seen patient sedated, intubated, arousable. Past Medical History: 1. NSVD x3, all at term, no complications 2. SAB x1 s/p MVA 3. Ectopic x1 a little over 2yrs ago 4. Anxiety 5. Depression 6. GERD 7. L pontine hemorrhage ([**5-/2199**]) 8. L pontine cavernous angioma 9. Catemenial Epilepsy x 18 yrs, has noctunal sz q2mo related to menses 10. s/p ccy 11. back surgery x3 for herniated disk s/p fall [**2194**]2. Painful ovarian cysts Social History: Lives in [**Hospital1 **] with 3 kids/husband, from [**Country 7192**]. No history of smoking, no EtoH, no drugs Family History: No hx of stroke Mother seizures-died when pt was 15 (? fall sec to seizure) no CAD or DM Physical Exam: VS: Temp: 98 BP: 108 /68 HR:65 RR:12 100% on vent O2sat . Vent: AC 500x12 Fio2 of 40, peep 5 I/O: 1100 intra-op/300out . general: intubated, sedated, arousable, moves all four extremities HEENT: PERLLA, EOMI, anicteric lungs: CTA b/l with good air movement throughout heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated abdomen: nd, +b/s, soft, grimaces to deep palpation, small incision site appears well, dressing C/D/I extremities: no edema, pneumoboots skin/nails: no rashes/no jaundice neuro: intubated, sedated, arousable, moves all four extremities Pertinent Results: Radiologic: [**2199-12-26**] CT abdomen: IMPRESSION: Limited examination without IV and oral contrast; however, no acute intra-abdominal pathology. Focal atelectasis in the right lower lobe abutting the pleura, to which attention to be paid on followup exams. . [**2199-12-26**] Pelvic U/S: 1. Asymmetric, large right ovary measuring up to 5.6 cm which previously measured up to 3 cm. Although normal color blood flow and Doppler waveform is identified, intermittent torsion cannot be excluded. 2. Small amount of free fluid in the right lower quadrant and the cul-de-sac. EKG: NSR. No ischemic changes. [**2200-12-26**] 01:02PM BLOOD WBC-4.8 RBC-4.38 Hgb-12.7 Hct-35.5* MCV-81* MCH-29.1 MCHC-35.9* RDW-13.7 Plt Ct-184 [**2200-12-27**] 05:27AM BLOOD WBC-6.1 RBC-3.97* Hgb-11.4* Hct-32.1* MCV-81* MCH-28.7 MCHC-35.6* RDW-13.6 Plt Ct-128* [**2200-12-26**] 01:02PM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-138 K-4.3 Cl-104 HCO3-25 AnGap-13 [**2200-12-27**] 05:27AM BLOOD Glucose-128* UreaN-7 Creat-0.6 Na-137 K-3.3 Cl-105 HCO3-26 AnGap-9 [**2200-12-26**] 01:02PM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0 [**2200-12-27**] 05:27AM BLOOD Albumin-3.7 Calcium-8.4 Phos-1.7*# Mg-1.6 [**2200-12-26**] 01:02PM BLOOD HCG-<5 [**2200-12-26**] 01:02PM BLOOD Phenyto-8.8* [**2200-12-27**] 05:27AM BLOOD Phenyto-15.6 Brief Hospital Course: This is a 44 year-old woman with a history of chronic abdominal pain, seizure disorder who presented with abdominal pain, acute abdomen now s/p witnessed seizure and unrevealing ex-lap, intubated. . # Intubation/Respiratory: Patient intubated for surgery, some concern that patient had had seizure pre-op as noted and was kept intubated post operatively. No respiratory issues. She was extubated without complication the following morning and had no oxygen requirement following extubation. She was bolused 300 mg of IV dilantin prior to extubation. . # seizure disorder: patient has a history of pontine cavernous angioma and epilepsy on dilantin as an outpatient. There was observed seizure activity in the emergency department and her dilantin level was found to be low. An [**Year/Month/Day 4338**]/MRA of the brain was performed which showed findings consistent with prior subarachnoid hemorrhage but no new changes. She received a Dilantin bolus of 300 mg IV. The following morning, her Dilantin level was therapeutic. She was also continued on her home dose Neurontin. She had no further seizure activity during the course of admission. She was discharged on an increased Dilantin dose per Neurology recommendations and was instructed to call her PCP and Neurologist the following week to set up follow up appointments. She was also instructed to have her dilantin level rechecked the following week and have her results faxed to her Neurologist's office. . # Acute abdomen: Initially there was some concern of an acute abdomen and she was brought for exploratory laparoscopy by OB/GYN. However, following surgery patient's abdomen was soft with tenderness only to deep palpation. She had a negative Ct abdomen, pelvic exam, U/S, and ex-lap. She did complain of abdominal pain at her surgical site following extubation which was initially managed with dilaudid and was then changed to percocet and ibuprofen. An EKG was performed which was negative for ischemic changes. She was continued on her home dose protonix for possible contribution of GERD to her abdominal pain. OB/GYN evaluated on postoperative day #1 and felt that patient was ready to be discharged to home. She was scheduled for follow up with OB/GYN in 1 month. She was instructed to call her primary care provider to follow up her chronic abdominal discomfort as an outpatient. . # Anxiety/Depression: She was restarted on her home dose citalopram/nortryptyline once she began tolerating pos. . DVT prophylaxis:subcu heparin . Code:full Medications on Admission: 1. Neurontin 300 mg t.i.d. 2. Dilantin 100 mg t.i.d. 3. Protonix 4. Naprosyn 5. citalopram 6. nortriptyline 20 mg at bedtime Discharge Medications: 1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. [**Year/Month/Day **] 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO once a day: with 1 30 mg capsule to make a total of 330 mg of Dilantin once each day. Disp:*90 Capsule(s)* Refills:*2* 7. Dilantin 30 mg Capsule Sig: One (1) Capsule PO once a day: with 3 100 mg capsules to make a total of 330 mg of Dilantin once each day. Disp:*30 Capsule(s)* Refills:*2* 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. Nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO at bedtime. 10. Outpatient Lab Work Dilantin level Please have your Dilantin level drawn on Monday [**2199-12-29**] prior to taking that days dose. Please call Dr.[**Name (NI) 34043**] office ([**Telephone/Fax (1) 15319**]) and have the results faxed to her office. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. abdominal pain 2. seizure Secondary: 1. epilepsy 2. anxiety 3. depression 4. GERD 5. Chronic abdominal pain Discharge Condition: Ambulatory. Conversant. Afebrile. Stable vitals. Discharge Instructions: Please continue to take all medications as prescribed. Please note that your Dilantin dose has been increased to 330 mg each day. You may take Percocet and Ibuprofen as needed for abdominal pain. Please do not take Tylenol with your Percocet as the combination can damage your liver. You have also been given a prescription for [**Telephone/Fax (1) **] which you should continue to take while on Percocet to help prevent constipation. . Please follow up with Gynecology as listed below. . It is very important to call your Neurologist Dr. [**First Name (STitle) **] to set up a follow up appointment in the next week. . You need to have blood drawn next week to have your Dilantin level checked. . Please call your Primary Care Provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to set up a follow up appointment in the next week. . Please call your doctor or return to the hospital if you experience chest pain, shortness of breath, fever, chills, worsening abdominal pain, bloody urine, bloody stools, or any other concerns. . . Continue por favor tomando todas las medicaciones segun lo prescrito. Observe por favor que se ha aumentado [**Doctor First Name **] dosis de Dilantin a 330 mg [**Last Name (un) 33424**] dia. Usted puede tomar Percocet e Ibuprofen segun lo necesitado para el dolor abdominal. No tome por favor Tylenol con [**Doctor First Name **] Percocet como [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46918**] puede da??????ar [**Doctor First Name **] higado. Tambien le [**First Name8 (NamePattern2) **] [**Last Name (un) **] [**Name2 (NI) **] prescripcion para [**Name (NI) **] que usted debe continuar para tomar mientras que en Percocet a ayudar a prevenir el estrenimiento. . Por favor continuacion con Gynecology segun lo enumerado abajo. Llame por favor a [**Doctor First Name **] Dr. [**Last Name (STitle) 41152**] [**Name (STitle) **] [**Doctor First Name **] abastecedor [**Doctor First Name **] cuidado para instalar [**Doctor First Name **] cita [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46919**]??????n en [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46920**] proxima. . Es muy importante llamar a Dr. [**Last Name (STitle) **] [**Doctor First Name **] neurologo para instalar [**Doctor First Name **] cita [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46921**] en [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46920**] pr??????xima. . Usted [**First Name9 (NamePattern2) 46922**] [**Last Name (un) 7214**] sangre [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46920**] proxima dibujada hacer [**Doctor First Name **] nivel de Dilantin comprobar. . Llame por favor a [**Doctor First Name **] doctor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 46923**] [**Hospital **] hospital si usted experimenta el dolor de pecho, si faulta respiraciones, fiebre, frialdades, empeorando dolor abdominal, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] sangrienta, taburetes sangrientos, o cualquier otro preocupacion. Followup Instructions: Gynecology: Dr. [**Last Name (STitle) **] [**2200-2-3**] at 8:30 [**Initials (NamePattern5) **] [**Last Name (NamePattern5) 23**] Clinical Center [**Location (un) **] Please call your Neurologist Dr. [**Last Name (STitle) **] to set up a follow up appointment in the next week. Phone: ([**Telephone/Fax (1) 15319**] Please call your Primary Care Provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to set up a follow up appointment in the next week. Phone ([**Telephone/Fax (1) 46924**]

[ "345.90", "311", "300.00", "530.81", "620.2", "625.9" ]

icd9cm

[ [ [] ] ]

[ "54.21" ]

icd9pcs

[ [ [] ] ]

8338, 8344

4311, 6838

318, 354

8508, 8560

2988, 4288

11642, 12151

2276, 2367

7013, 8315

8365, 8487

6864, 6990

8584, 11619

2382, 2969

264, 280

382, 1737

1759, 2129

2145, 2260

24,638

186,968

23667

Discharge summary

report

Admission Date: [**2122-6-8**] Discharge Date: [**2122-6-12**] Date of Birth: [**2046-11-3**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Amoxicillin Attending:[**First Name3 (LF) 297**] Chief Complaint: urosepsis Major Surgical or Invasive Procedure: none History of Present Illness: This is a 75yo F from [**Doctor First Name 391**] Bay with h/o AAA s/p repair c/b spinal shock with resulting parplegia presents with lethargy and nausea x 2 days. She was in her usual state of health until baclofen to 30 [**Hospital1 **]. She subsequnetly became lethargic and NH decreased baclofen to 15 on [**6-5**]. Her lethargy did not improve. On [**6-7**] UA positive for gram negative organism. SHe was started on levofloxacin. Her lethargy persisted and on [**6-8**], she was minimally responsive and hence was transferred to [**Hospital1 18**]. In ED, patient was stuporous and dropped her blood pressure to 80s. Her initial vitals are T99.2 P68 BP 97/47 R 20 98%RA. She recieved one dose of vancomycin at 1100. Sepsis protocol was initiated and got 6L NS so far. She is at baseline A+O x3. According to family, she fell out of bed. The patient is at baseline wheelchair bound and continued to have significant bilateral lower extremity spasticity Past Medical History: AAA s/p repair c/b spinal shock with resulting parplegia gout depression/adjustment d/o recurrent UTI paraplegia (spinal infarct) history of Afib on coumadin and amiodarone stage 3 decubitus ulcer at coccyx CVA-embolic to MCA Social History: does not smoke/no alcohol Family History: noncontributory Physical Exam: Gen-somnolent, mumbling, disoriented HEENT-anicteric, neck supple, oral mucosa dry CV-rrr, no r/m/g resp-CTAB [**Last Name (un) 103**]-soft, NT/ND, ?right CVA tenderness ext-lower extremity contracted, no edema Pertinent Results: CT head 1) Large chronic infarct involving the right posterior cerebral artery territory. Chronic lacunar infarct in the left caudate nucleus. 2) Small lacunar infarct involving the right thalamus of unknown age. Questionable area of low density seen in the left thalamus. An acute infarction cannot be entirely excluded, if clinically indicated, MRI is more sensitive to determine an acute infarction echo: EF 45% Conclusions: The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis without regionality. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation may be present. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2122-6-8**] 10:30AM PT-21.6* PTT-35.1* INR(PT)-3.1 [**2122-6-8**] 10:30AM PLT COUNT-346 [**2122-6-8**] 10:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2122-6-8**] 10:30AM NEUTS-79* BANDS-9* LYMPHS-9* MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-6-8**] 10:30AM WBC-31.4* RBC-3.82* HGB-10.5* HCT-32.1* MCV-84 MCH-27.4 MCHC-32.6 RDW-16.2* [**2122-6-8**] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-11.7 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2122-6-8**] 10:30AM ALBUMIN-2.9* CALCIUM-8.5 PHOSPHATE-4.2 MAGNESIUM-1.9 [**2122-6-8**] 10:30AM CK-MB-5 [**2122-6-8**] 10:30AM cTropnT-0.18* [**2122-6-8**] 10:30AM LIPASE-10 [**2122-6-8**] 10:30AM ALT(SGPT)-9 AST(SGOT)-18 LD(LDH)-174 CK(CPK)-712* ALK PHOS-71 AMYLASE-34 TOT BILI-0.3 [**2122-6-8**] 10:30AM GLUCOSE-151* UREA N-60* CREAT-3.6* SODIUM-140 POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-22 ANION GAP-19 [**2122-6-8**] 10:45AM URINE 3PHOSPHAT-MANY [**2122-6-8**] 10:45AM URINE RBC-0 WBC-0 BACTERIA-MANY YEAST-NONE EPI-0 [**2122-6-8**] 10:45AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-MOD [**2122-6-8**] 10:45AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019 [**2122-6-8**] 10:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2122-6-8**] 10:45AM URINE HOURS-RANDOM [**2122-6-8**] 10:49AM LACTATE-5.0* [**2122-6-8**] 01:41PM FIBRINOGE-548* [**2122-6-8**] 01:41PM PT-23.0* PTT-47.0* INR(PT)-3.5 [**2122-6-8**] 01:41PM PLT SMR-NORMAL PLT COUNT-285 [**2122-6-8**] 01:41PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL [**2122-6-8**] 01:41PM NEUTS-76* BANDS-12* LYMPHS-10* MONOS-1* EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-6-8**] 01:41PM WBC-22.5* RBC-3.14* HGB-8.6* HCT-26.6* MCV-85 MCH-27.4 MCHC-32.3 RDW-16.1* [**2122-6-8**] 01:41PM CRP-GREATER TH [**2122-6-8**] 01:41PM CORTISOL-17.0 [**2122-6-8**] 01:41PM TSH-0.66 [**2122-6-8**] 01:41PM ALBUMIN-2.2* CALCIUM-7.1* PHOSPHATE-3.5 MAGNESIUM-1.5* [**2122-6-8**] 01:41PM CK-MB-7 [**2122-6-8**] 01:41PM cTropnT-0.10* [**2122-6-8**] 01:41PM LIPASE-9 [**2122-6-8**] 01:41PM ALT(SGPT)-6 AST(SGOT)-15 LD(LDH)-150 CK(CPK)-703* ALK PHOS-55 AMYLASE-24 TOT BILI-0.2 [**2122-6-8**] 01:41PM GLUCOSE-112* UREA N-56* CREAT-3.0* SODIUM-143 POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14 [**2122-6-8**] 01:55PM LACTATE-2.5* [**2122-6-8**] 02:27PM LACTATE-2.3* [**2122-6-8**] 04:44PM URINE RBC-159* WBC-383* BACTERIA-MOD YEAST-NONE EPI-0 [**2122-6-8**] 04:44PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [**2122-6-8**] 04:44PM URINE COLOR-LtAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015 [**2122-6-8**] 04:44PM URINE OSMOLAL-338 [**2122-6-8**] 04:44PM URINE HOURS-RANDOM CREAT-34 SODIUM-73 CHLORIDE-67 [**2122-6-8**] 04:45PM CALCIUM-7.3* PHOSPHATE-3.4 MAGNESIUM-1.7 [**2122-6-8**] 04:45PM CK-MB-12* MB INDX-1.5 cTropnT-0.08* [**2122-6-8**] 04:45PM LD(LDH)-180 CK(CPK)-825* [**2122-6-8**] 04:45PM GLUCOSE-103 SODIUM-143 POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14 [**2122-6-8**] 05:02PM HGB-9.1* calcHCT-27 O2 SAT-68 [**2122-6-8**] 05:02PM LACTATE-1.7 [**2122-6-8**] 05:02PM TYPE-MIX [**2122-6-8**] 07:02PM URINE OSMOLAL-398 [**2122-6-8**] 07:02PM URINE HOURS-RANDOM CREAT-44 SODIUM-81 Brief Hospital Course: 75yo F with likely Ecoli sepsis and UTI enrolled [**Doctor Last Name **] MUST protocol. Patient was initially septic with fever, lactate 5.5 and 9% band and hypotensive requiring levophed. Sepsis protocol was initiated. Her blood pressure became stable with aggressive fluid resuscitation and she was off levophed on the same day. Blood culture grew [**2-27**] gram Ecoli(resistant to quinolones)and [**1-27**] GPC(likely contaminant); urine culture + proteus(resistant to quinolones and bactrim). Her white blood cell was decreasing, lactate decreasing, blood pressure stable off levophed. Surveillance blood culture was negative so far. She was initially continued on zosyn. She also had acute renal failure with creatinine peaked at 3.6. That resolved quickly with aggressive fluid resuscitation and was eventually down to 1.1. CT abdomen showed nonobstructive stone in proximal right ureter and no hydronephrosis Due to the fluid resusciation, she went into rapid atrial fibrillation and developed flash pulmonary edema. Lasix, metoprolol to control her heart rate helped her. Echocardiogram was done and it showed EF of 45%. Cardiac enzymes were unremarkable. She was restarted on amiodarone 200 QD. Her coumadin for AF was held due to high INR. Her mental status improved and she communicated with her family that this is not the quality of life that she wanted. Her quality of life had been on the downslop ever since her AAA repair followed by paraplegia. After extensive family meeting and also with the patient, it was clear that she is very unhappy with her current quality of life and she would only want comfort measure. she was only on medication to keep her comfortable and all other medication has been discontinued. SHe will be discharged back to her nursing home and continue comfort measure Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Papain-Urea 830,000-10 unit-% Spray, Non-Aerosol Sig: One (1) Appl Topical DAILY (Daily). 3. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Morphine Sulfate 10 mg/5 mL Solution Sig: 5-10 mg PO Q2-4 as needed for pain. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay - [**Hospital1 392**] Discharge Diagnosis: urinary tract infection and sepsis Discharge Condition: stable Discharge Instructions: PLease let your doctor/nurses know if there are anything they can do to keep you comfortable and pain free Followup Instructions: none Completed by:[**2122-6-12**]

[ "041.6", "707.03", "995.91", "584.5", "428.0", "574.20", "599.0", "041.04", "038.42", "427.31", "416.8", "790.92", "780.09", "263.9", "038.19", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8538, 8618

6344, 8160

303, 309

8697, 8705

1871, 6321

8860, 8896

1607, 1624

8183, 8515

8639, 8676

8729, 8837

1639, 1852

254, 265

337, 1298

1320, 1548

1564, 1591

54,795

109,454

2370

Discharge summary

report

Admission Date: [**2188-5-30**] Discharge Date: [**2188-6-4**] Date of Birth: [**2107-7-25**] Sex: M Service: NEUROSURGERY Allergies: Sulfonamides Attending:[**First Name3 (LF) 1271**] Chief Complaint: fall Major Surgical or Invasive Procedure: Burr hole evacuation of SDH History of Present Illness: This is a 80 year old Russian speaking male who presents to the Emergency Department after experiencing dizziness and falling at home between 9pm on [**2188-5-29**] to 9am [**2188-5-30**] per his son in law who accompanies the patient. The patient was found at his home on the floor, incontinent of urine. It is unknown whether there was a loss of consciousness. He lives alone and his family had to break down the door to reach him. He denies use of anticoagulant medication. He stated that he was ambulating to the bathroom with his walker and fell twice. One time he hit his head. The patient denied nausea or vomiting, hearing or visual changes, speech difficulty, weakness, or numbness and tingling. The patients son in law reports that he fell back in [**2188-3-3**] at which time he was admitted to [**Hospital3 **] and was diagnosed with a left Subdural hematoma and was discharged 3 days later without intervention. Past Medical History: dm-oral,HTN, hypercho,kidney stones, gallstones, LBP, fatty liver, anemia, renal insuff, edema, tendinitis, prostatism Social History: lives at home alone. next of [**Doctor First Name **] id daughter [**Name (NI) 3968**] [**Name (NI) 12305**] Family History: non contributory Physical Exam: On admission: O: T:98.9 BP:141 /60 HR:102 R:16 O2Sats:99% Gen: Russian speaking only comfortable, NAD. HEENT: Pupils:2.5-2 EOMs intact Neck:hard collar on Extrem: Warm and well-perfused. left elbow pain on palpation Neuro: Mental status: Russian speaking only, Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date.but patient is confused as he is stating there is a "metal device" on his left leg and there is not one. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2.5 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to 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 [**5-7**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally No clonus rectal tone intact point tenderness: T 10/L [**4-7**] Coordination: Dysmetria bilaterally finger-nose-finger, intact rapid alternating movements. On discharge: AOx3, PERRL, EOM intact, face symm, tongue midline. MAE [**5-7**] except left grasp [**4-7**]. No pronator. Russian speaking. Head incision C/D/I. Pertinent Results: CT head [**2188-5-30**]: 1. Acute-to-subacute on chronic subdural hematomas in the right frontoparietal and left temporoparietal regions with 6 mm of right-to-left midline shift and early subfalcine herniation. 2. No evidence of fracture. CT C-spine [**2188-5-30**]: 1. No evidence of fracture or malalignment. 2. Severe degenerative changes of the cervical spine with posterior osteophytes which places the patient at increased risk for spinal cord injury. Pelvis X-ray [**2188-5-30**] No evidence of acute fracture or dislocation. Ovoid area of relative lucency along the superior aspect of the left femoral neck may be artifactual, although lesion in this area is not excluded. If pain is referred to this site, recommend dedicated views of the left hip. X-ray shoulder [**5-30**] 1. Suboptimal axillary view for evaluation of dislocation. If clinical concern for left shoulder dislocation, recommend repeat axillary view or Y view. No evidence of acute fracture. 2. Calcific tendinosis. X-ray knee [**5-30**]: 1. Suprapatellar joint effusion with question of a small fat fluid level versus artifact, which raises concern for possible knee fracture. While no fracture line is identified radiographically, it is not excluded. Recommend clinical correlation and consider CT. CT Head [**5-31**]: 1. Decreased shift of midline structures, status post right subdural hematoma drainage with catheter in situ, in the subdural compartment overlying the right cerebral convexity. 2. Stable left temporoparieto-occipital subdural hematoma, with maximal thickness of 9 mm. CT head [**6-1**]: Interval right drainage catheter removal with slight decrease in size of right pneumocephalus and subdural hematoma. Stable left parietal occipital subdural hematoma. Carotid Series [**2188-6-3**]: Findings: Duplex evaluation was performed of bilateral carotid arteries. On the right there is no plaque in the ICA. On the left there is no plaque seen in the ICA. On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 53/11, 61/20, 55/17 cm/sec. CCA peak systolic velocity is 78 cm/sec. ECA peak systolic velocity is 79 cm/sec. The ICA/CCA ratio is .8. These findings are consistent with no stenosis. On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 53/13, 57/19, 47/14 cm/sec. CCA peak systolic velocity is 104 cm/sec. ECA peak systolic velocity is 104 cm/sec. The ICA/CCA ratio is .5. These findings are consistent with no stenosis. Right antegrade vertebral artery flow. Left antegrade vertebral artery flow. Impression: Right ICA no stenosis. Left ICA no stenosis. ECHO & EEG [**Location (un) 1131**] still pending. Brief Hospital Course: Mr. [**Known lastname 12306**] was admitted to [**Hospital1 18**] on [**2188-5-30**]. He was seen by the trauma team and cleared of acute injuries. He was taken to the OR with Dr. [**Last Name (STitle) 739**] and a subdural drain was palce. He was monitored in the ICU. On [**5-31**] the subdural drain was discontinued. He was neurologically stable and was transfered to the floor. On 5.30 his C-spine was cleared. A syncope workup was in place and completed. He was screened by PT/OT who felt patient needed acute rehab. On [**2188-6-4**] he was discharged to the [**Location (un) 583**] House. Medications on Admission: Glyburide 5 mg tid, Lipitor 40 mg qd,atenolol, atorvastatin, citalopram, clonazepam, Glyburide, ketoconazole, lisinopril, metformin, Nasonex, Actos, Colace Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-5**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 583**] House Rehab & Nursing Center Discharge Diagnosis: Right SDH Left SDH Suprapatellar joint effusion Left shoulder Calcific tendinosis DDD C-spine 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: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-12**] days for removal of your staples or sutures. You may also have them removed at rehab. ??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in [**4-8**] weeks. ??????You will need CT of the brain without contrast. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2188-6-4**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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43714

Discharge summary

report

Admission Date: [**2104-3-18**] Discharge Date: [**2104-3-23**] Date of Birth: [**2050-9-18**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 3913**] Chief Complaint: afib RVR Major Surgical or Invasive Procedure: Cardioversion [**3-19**] History of Present Illness: 53 with recurrent non-hodgkin's lympoma currently started new round of chemo presents with afib RVR. Pt reports that for the past week he has felt weak and unwell, and two days ago he felt pre-syncopal. He denies any chest pain or shortness of [**Month/Year (2) 1440**]. He presented today to clinic today for routine pre-chemotherapy echocardiogram and was found to be in afib RVR with HR 150. He was sent to the ED from clinic. Incidentally, per [**Name (NI) **], pt had a fever several days ago, was pan-cultured in [**Hospital3 4298**] and empirically started on Levofloxacin. . In the ED, he was placed on a diltiazem drip. Per report he was breifly hypotensive to SBP 70 but his pressures then improved. Past Medical History: Onc History: Patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12375**]. Found to have mesenteric mass [**10-1**] during workup after a fall from a tree. Biopsy [**12-2**] revealed mixed lymphocytes, CD19/20 +, CD5 -, CD10 weakly positive, BCL-2/BCL-6 positive. PET scan demonstrated uptake in the abdomen and rectal area. Underwent R-CHOP * 6 ([**Date range (1) 22097**]) with complete remission. PET scan in [**5-3**] demonstrated recurrent disease (L retrocrural area 2.5 cm c SCV 8.8 c/w lymphomatous recurrence). . Treated with R-ICE [**2103-5-23**] and then had a second cycle of R-ICE [**2022-6-17**], autologous BMT [**2103-7-31**]. PET scan [**2103-9-11**] showed resolution of lesion in L retrocrual area, but repeat PET [**2103-12-10**] suggested recurrence. . PAST MEDICAL HISTORY: -Low Testosterone - Presented with muscle weakness, improved with testosterone injections. Injections discontinued secondary to elevated LFTs and lymphoma -GERD -Paroxysmal Atrial Fibrillation - was on digoxin. Then on metoprolol. One episode in the setting of caffeine intake + adderrall use. Now not on any meds -Rectal Hemorrhoids -Sleep apnea on CPAP - does not use CPAP machine at home -Elevated LFTs, elevated CPK - Had been seen by Dr. [**Last Name (STitle) 497**]. He was concerned that chronically elevated CPK may represent muscle etiology [**12-29**] IM injections of testosterone. However, liver biopsy [**3-3**] showed mild steatosis without balloon degeneration / intracellular hyalin, and mild portal/lobular mononuclear cell inflammation. Chronically elevated CPK is not currently explained as far as we can find. Social History: [**Hospital3 4298**] ([**Location 93951**]) resident. Married. 2 children (daughter, son) in their early 20s. Smoked 8 years, quit 25 years prior. No history of IVDU. Distant history of polysubstance abuse. Goes to 12-step groups. Works as [**Location (un) 7453**] representative of Invisible Fence, also as bus driver for [**Hospital3 4298**] bus system. Family History: Mother with ovarian cancer. Brother died of esophageal cancer. CAD in family Physical Exam: Admission: VITALS: 98.3 HR 140 BP 103/65 SaO2 94% RA GEN: NAD, well appearing, Aox3 HEENT: thick neck w/o JVD CV: tachycardic and irregular, no MRG, unable to palpate PMI PULM: CTAB ABD:obese, soft, NT/ND EXT: no edema . Discharge Pertinent Results: Echo #1: 2D-ECHOCARDIOGRAM: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is difficult to assess given marked resting tachycardia, but may be mildly depressed (LVEF= 50 %). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic 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. IMPRESSION: Suboptimal image quality. Marked resting tachycardia renders study difficult to interpret. Possibly mildly reduced global left ventricular function. Recommend repeat evaluation when heart rate slower. Compared with the prior study (images reviewed) of [**2103-7-5**], the heart rate is faster. Left ventricular function is less vigorous. . Echo #2: results pending Brief Hospital Course: ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: 53 with recurrent non-hodgkin's lympoma currently started new round of chemo presents with afib RVR. . # Rhythm: Aflutter w/ RVR now resolved. In the past the patient has been on digoxin (stopped) then Toprol Xl 25mg for PAF which appears to have been discontinued. Pt had also been on coumadin which was recently discontinued when PLT began decreasing after chemotherapy. The patient received TEE and then successful D/C cardioversion on [**3-19**]. It sucessfully converted to normal sinus rhythm. He was continued on heparin gtt for anticoagulation and was converted to Lovenox for ease of stopping as his platelets may drop with further treatment. Due to his size, his dose was titrated to an appropriate factor Xa level. He will continue this anticoagualation for 30 days. He was also started on Toprol XL 25mg for better rate control. He will follow up with Dr. [**Last Name (STitle) **]. . # Fever?: Pt had fever to 101.8 several days ago with malaise but no focal symptoms was seen in [**Hospital3 4298**] and cultured. Was started on levofloxacin epirically at that time. Blood Cx from MV were negative. Ucx negative. An initial CXR was w/o evidence of PNA but a repeat CXR showed bibasilar interstitial infiltrates. He was initially broadened to cefepime after he spiked again but was rapidly switched back to high dose levofloxacin. He remained afebrile for >24hrs on PO antiobiotics. He will complete 10 day course and follow up with Dr. [**Last Name (STitle) **]. . # Lymphoma: The patient had dropping counts after his navelbine and gemcitabine but his nadir was about 1.6K. He was continued on his allopurinol and his prophylactic bactrim and acyclovir. He will follow up with Dr. [**Last Name (STitle) **] in [**1-29**] days. . # CAD/Ischemia: None . # Pump: possibly mildly reduced EF but no heart failure at this time . # Valves: No abnormalities . # DM: N/A . # Sleep apnea: cont on CPAP at night . # Anxiety: - cont venlaflaxine daily - cont Xanax TID PRN panic attacks . # FEN: heart healthy diet . # Prophylaxis: heparin gtt, PPI . # Code: full . # Communication: wife [**Telephone/Fax (1) 93952**] Medications on Admission: acyclovir 400 tid allopurinol 300 gabapentin 100 [**Hospital1 **] larazepam 0.5-1 PRN oxycodone [**4-5**] prn protonix 40 compazine prn effexor 150 XR bactrim DS qMWF Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Alprazolam 1 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for anxiety. 4. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 5. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 6. Prochlorperazine Maleate 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for nausea. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 13. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 14. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day for 30 days. Disp:*60 syringes* Refills:*0* 15. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day for 30 days: Take one 100mg and one 80mg syringe at the same time. . Disp:*60 syringes* Refills:*0* 16. Lovenox instructions You must take a total of 180mg of Lovenox twice a day. This means that you need to take 1 injection of 100mg Lovenox and 1 injection of 80mg Lovenox in the mornings and repeat the same 2 injections in the evenings. Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation status post cardioversion Bacterial Pneumonia Lymphoma Sleep apnea Discharge Condition: all vital signs stable, afebrile, ambulatory, in normal sinus rhythm Discharge Instructions: You were admitted with a rapid heart rate called atrial fibrillation. Your heart rate was initially controlled with medications and then it was shocked back into a normal rhythm. You will need to continue to take the blood thinning medication, Lovenox, for 1 month after this to prevent blood clots from forming in the heart. You also have a mild pneumonia for which you were treated with antibiotics. You will continue these antibiotics for several days after you are discharged. Please take all your medications as prescribed. Please make all of your follow up appointments. Please call your doctor or return to the emergency room if you have a fever, chills, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] pain, nausea, vomitting, diarrhea, painful urination, numbness, weakness, tingling or any other symptom that concerns you. Followup Instructions: Please call Dr.[**Name (NI) 3930**] office at [**Telephone/Fax (1) 3237**] on Monday morning to set up a follow up appointment for Tuesday. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2104-3-28**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2104-4-22**] 3:00

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icd9cm

[ [ [] ] ]

[ "93.90", "88.72", "99.62" ]

icd9pcs

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Discharge summary

report+report

Admission Date: [**2179-2-10**] Discharge Date: [**2179-2-25**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 81 year old woman with a history of atrial fibrillation, coronary artery disease status post angioplasty, status post total abdominal hysterectomy, who presents with a several week history of chest pain worsening in frequency and duration over the last several days. The patient describes this pain as drowning and suffocating with shortness of breath lasting five to 30 minutes. The symptoms typically like her old angina. No radiation, no nausea or vomiting; non-pleuritic chest pain. Prior to current episode, last angina was many years ago. No tearing or ripping sensation. No diaphoresis, no orthopnea or paroxysmal nocturnal dyspnea. The patient presented to [**Hospital3 **] on [**2-9**], and had pain which was relieved with sublingual Nitroglycerin. The patient was started on a heparin drip and Nitropaste in the Intensive Care Unit. An EKG showed no acute ST or T changes, with atrial fibrillation at 80. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Angioplasty. 3. Hernia repair. 4. Total abdominal hysterectomy, oophorectomy 35 years ago. ALLERGIES: Codeine, which causes nausea. SOCIAL HISTORY: No tobacco, no alcohol. Lives with her husband. FAMILY HISTORY: Mother died at 66 with an myocardial infarction. Brother, at 77, had a bypass graft. MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Lopressor 25 mg p.o. q. day. 3. Norvasc 5 mg p.o. q. day. 4. Nitropatch 0.04 mg times 12 hours. 5. Coumadin 2 mg times five days and 4 mg times two days. PHYSICAL EXAMINATION: Temperature 97.6 F.; 130/82; pulse is 92; respiratory rate 18; 91% on room air and 93% on two liters. The patient is in no acute distress. Crackles bilaterally at the bases; scattered wheezes. Cardiac: Irregularly irregular rate; no murmurs. No carotid bruit. Belly is soft, nontender, guaiac negative. Lower extremities with mild edema bilaterally and two plus dorsalis pedis and posterior tibial pulses. LABORATORY: EKG showed atrial fibrillation at 66; no acute ST or T changes. Chest x-ray showed cardiomegaly without evidence of failure. White blood cell count of 5.5, hematocrit of 38.2, platelets 222. Chem-7 142, 4.1, 103, 30, 14, 0.8 and 95. HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**] Service and was continued on a heparin drip, Lopressor, aspirin and Norvasc. The patient was kept on heparin and cardiac catheterization was performed when the patient's INR was less than 2.0. Cardiac catheterization was performed on [**2179-2-12**], which showed three-vessel disease. At that time, it was decided that the patient should undergo minimally invasive non-bypass coronary artery bypass graft. On [**2179-2-15**], the patient underwent coronary artery bypass graft times three vessels with left internal mammary artery to the left anterior descending, saphenous vein graft to the diagonal and then sequentially to obtuse marginal 1. On postoperative day number one, the patient did well and had her Swan-Ganz catheter removed. The patient was transferred to the Floor on postoperative day number one. On postoperative day number two, it was noted that the patient had right arm weakness and confusion. A Neurology consultation was called and a stroke was diagnosed which was most likely related to the patient's atrial fibrillation. The patient was transferred back to the Unit on postoperative day number two after this event. CT scan which was obtained after this embolic event showed a left thalamic hypodensity likely representing a subacute chronic infarction. On postoperative day number three, the patient's chest tubes were removed and the patient was sent for a swallow evaluation. The swallow study was clinically suspicious for aspiration, so the patient was made strictly NPO. The patient also underwent a carotid artery study which showed significant plaque through the left internal carotid artery with no focal stenosis and severe narrowing throughout the left ICA. The right ICA suggests 80 to 99% stenosis. On [**2179-2-18**], a Vascular Surgery consultation was called and their recommendation was for an MRA. On [**2179-2-19**], the patient was started on tube feeds with fiber at 10 cc an hour towards a goal of 55 cc an hour. On postoperative day number six, it was noted that the patient's neurologic examinations were improving. On postoperative day number seven, the patient underwent an MRA of her carotids which demonstrated a left ICA with total occlusion and a right ICA with 80 to 99% stenosis. Vascular Surgery made the recommendation for intervention at six weeks postoperatively. The patient underwent a video swallow on [**2179-2-22**], which she failed and she was to remain NPO with tube feeds through her NG tube. On [**2179-2-23**], a family discussion was initiated regarding plans for a PEG, however, the family wished to wait to see whether or not her swallowing would improve before placing a PEG. For this reason, the patient was started back on her Coumadin on [**2179-2-23**]. On [**2179-2-24**], a Dobbhoff tube was placed for the comfort of the patient instead of an NG tube for tube feeds. On postoperative day number ten, rehabilitation screens were called as it was felt that the patient was stable for rehabilitation. DISCHARGE INSTRUCTIONS: 1. The patient was to return for follow-up with swallow studies in a week to ten days after discharge. At that time, evaluation would be made as to whether or not she could resume p.o. diet. 2. The patient was to follow-up with Dr. [**Last Name (STitle) **] in Vascular Surgery in four weeks with regard to carotid artery surgery. 3. The patient was to follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks for a postoperative visit. DISPOSITION: The patient was discharged to Rehabilitation on [**2179-2-25**], on the following medications. DISCHARGE MEDICATIONS: 1. Colace 100 mg per NG tube twice a day. 2. Aspirin 81 mg per NG tube q. day. 3. Dulcolax one p.r. p.r.n. 4. Plavix 75 mg per NG tube q. day. 5. Heparin drip 700 units an hour until therapeutic on Coumadin with an INR of 2.0 to 2.5. 6. Albuterol, Atrovent nebulizers q. four hours p.r.n. 7. Tylenol 650 mg p.o. q. four hours p.r.n. 8. Lasix 20 mg per NG tube twice a day times seven days. 9. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq per NG tube twice a day times seven days. 10. Lopressor 25 mg p.o. twice a day. 11. Coumadin 2 mg p.o. q. day times five days; 4 mg p.o. times two days. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times three. CONDITION AT DISCHARGE: Good. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2179-2-24**] 13:06 T: [**2179-2-24**] 13:18 JOB#: [**Job Number 19370**] Admission Date: [**2179-2-10**] Discharge Date: [**2179-3-1**] Service: ADDENDUM: Since prior discharge summary, the patient remained in house due to lack of suitable rehabilitation placement. The family of the patient wished to have the patient in a TCU closer to home. This was found at [**Hospital1 **] ECU, but the patient did not have a bed at this facility until Monday, [**2179-3-1**]. For this reason, the patient remained in house on a heparin drip waiting for her Coumadin level to be therapeutic. The patient was discharged to rehabilitation on [**2179-3-1**] in good condition on the same discharge medications as was previously stated in the discharge summary. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2179-3-1**] 08:23 T: [**2179-3-1**] 08:38 JOB#: [**Job Number 41325**]

[ "427.31", "434.11", "997.02", "401.9", "E878.2", "433.10", "414.01", "411.1" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.61", "37.22", "36.12", "36.15", "96.6", "88.53" ]

icd9pcs

[ [ [] ] ]

1330, 1623

6656, 6725

5999, 6635

2326, 5393

5417, 5976

1646, 2308

6741, 7997

113, 1057

1079, 1246

1263, 1313

9,248

183,800

21413

Discharge summary

report

Admission Date: [**2174-4-24**] Discharge Date: [**2174-5-6**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: AAA Major Surgical or Invasive Procedure: AAA repair HD placement of central line placement of a-line History of Present Illness: 81yM w/known AAA presented to ED w/chest pain, typical for the patient. Ultrasound demonstrated no significant change in the size of his AAA but CTA demonstrated possible early renal artery stenosis. Past Medical History: 1.)HTN 2.)CAD -- Taxus stent to LAD/LCX ostia in [**6-19**], Cypher for LAD instent restenosis [**11-19**] 3.)Diastolic chf with 2 intubations for overload-related respiratory failure 4.)Paroxysmal afib 5.)PVD 6.)AAA -- infrarenal, largest diameter is 5.3cm x 5.5cm, unchanged since [**10/2173**] CT 7.)CVA -- Episode of aphasia in [**2172**], MRI/MRA with chronic small vessel changes, no acute infarct, totally occluded right ICA 8.)COPD 9.)CRF -- steadily climbing from 1's in [**2172**], 4's in [**6-20**]'s in [**10-20**] 10.)Depression 11.)PTSD 12.)Query etoh abuse with possible withdrawal at [**2172**] admission Social History: Lives by himself in an apartment for seniors on [**Location (un) 7453**]. His mother died and he was left by his father at a young age, and was raised by multiple, different families. He served in the Marines. Has a heavy smoking hx, with 2ppd x 30yrs, quit 2 yrs ago. Says he was a heavy drinker in the past, [**3-19**]/night for years; he says none recently but was thought to go into withdrawal at a prior admission. Family History: Unknown, as he did not know his parents. Physical Exam: Gen nad afebrile with stable vitals Heent eomi, perrl, nares patent, oropharynx without erythema/exudate Neck supple no masses CV rrr Resp cta bilaterally Abd soft, ntnd, incision c/d/i Ext no LE edema Neuro aao x 4 Pertinent Results: [**2174-5-6**] 03:53AM BLOOD WBC-6.3 RBC-3.04* Hgb-9.6* Hct-29.6* MCV-97 MCH-31.6 MCHC-32.4 RDW-16.4* Plt Ct-166 [**2174-5-6**] 03:53AM BLOOD Plt Ct-166 [**2174-5-6**] 03:53AM BLOOD PT-18.9* INR(PT)-1.8* [**2174-5-6**] 03:53AM BLOOD Glucose-82 UreaN-49* Creat-8.4*# Na-130* K-4.0 Cl-96 HCO3-19* AnGap-19 [**2174-5-4**] 03:45AM BLOOD CK(CPK)-50 [**2174-4-24**] 04:05PM BLOOD Lipase-29 [**2174-5-6**] 03:53AM BLOOD Calcium-8.3* Phos-6.7* Mg-2.5 [**2174-5-4**] 08:37PM BLOOD Lactate-1.0 Brief Hospital Course: Patient admitted and underwent uncomplicated open AAA repair. He was transferred to the recovery room and then to the ICU with an epidural in place for pain. He remained intubated at this time. He was extubated on POD1 and continued to do well. Renal and cardiology were both following the patient for his other comorbidities. POD2 and POD3, pt remained in the SICU, in stable condition he was diuresed, epidural was removed without difficulty. POD4 he was transferred to the step down unit, he had regained bowel function and was tolerating regular diet. Hemodialysis was continued. He did have an episode of chest pain on POD4, EKG did not reveal any acute changes and cardiac enzymes remained relatively flat albeit elevated from normal. POD5 PT consult, pt allowed OOB to chair, diet was advanced. POD6 /11 pt with acute mental status changesa dysarthric. CT scan negative, labs within normal limits, afebrile. Nuerology consulted This was thought to be secondary to TIA, pt mental status changes resolved within 6 hours. In the interim opt recieved MRI, this was also negative, carotid US done, no significant carotid artery stenosis. EEG show seizure activity. Pt started on coumadin, INR followed. POD12 pt with with prolapse bout of diarrhea, c-diff negative x 3. CT scan of abdomen showed mild cecal thickening, Flagyl stated emperically. IV fluid resusitation, POD13 INR 6.7 / vit K givewn. POD 14 diarhea improves. INR stabalizes. Pt stable for DC Taking PO / HD / pos BM / wound c/d/i / Medications on Admission: [**Month/Day/Year **] 325', folate 1', vit d3 400', atrovent, vit e 400', nifedipine 30', sevelamer 1600''', lipitor 20', lisinopril 5', toprol xl 25' Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*25 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:*30 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*qs Tablet, Chewable(s)* Refills:*2* 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 6. Outpatient [**Hospital1 **] Work Patient taking Coumadin. Dose adjusted per INR. Please draw INR/pt two times per week and prn. Call results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 36558**] 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Your primary care physican will manage your Coumadin dosage. Please have your blood drawn 2x/week at Dr. [**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 36558**]. Disp:*30 Tablet(s)* Refills:*2* 8. Outpatient [**Name (NI) **] Work Pt. has been started on anti-seizure medication an needs LFT checked weekly. Please check LFTs qMonday or qTuesday and have results called to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 36558**]. 9. Oxcarbazepine 300 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 11. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Home With Service Facility: [**Location (un) **] VNA Discharge Diagnosis: s/p AAA repair end stage renal disease on HD post operative hypotension responsive to fliud EEG demonstrated seizure activity possible TIA Discharge Condition: good Discharge Instructions: -please come to the emergency room if you have fever >101.4F, nausea or vomiting, shortness of breath, dizziness or weakness, or persistent redness/pain/bleeding from your surgical site -keep your surgical incision clean and dry -you may shower normally but no tub bathing or swimming Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**6-23**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**2-18**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions -no heavy lifting for 6 weeks -do not drive while taking pain medications and make sure you take a stool softener while taking pain medications Followup Instructions: - Please follow up with Dr. [**Last Name (STitle) 3407**] in one month. Call his office at [**Telephone/Fax (1) 1241**] for an appointment. - Your primary physican Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 36558**] he will need to follow several things for you. He will need to: 1. manage your INR level by drawing frequent blood levels and adjusting your coumadin dose accordingly 2. arrange for you to get a CTA of your head and neck to assess you carotid arteries for question of occlusion 3. may take out your staples one week after your day of discharge from the hospital ([**2174-5-13**]) 4. follow weekly LFT levels because of the new medication you have starter per the neurology doctors that believe [**Name5 (PTitle) **] to have had seizures while in the hospital 5. review your medications and adjust them accordingly - You also need to have a follow-up Neurology appointment with Drs. [**Last Name (STitle) 56547**] and [**Name5 (PTitle) 4638**]. The clinic phone number is [**Telephone/Fax (1) 56548**] - please call for an appointment in the next 7-10 days. Completed by:[**2174-6-27**]

[ "441.4", "V12.59", "V11.3", "584.9", "428.0", "287.5", "433.10", "311", "276.7", "435.9", "414.01", "285.9", "276.2", "412", "V45.82", "787.91", "443.9", "309.81", "427.31", "496", "784.5", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.44", "39.95" ]

icd9pcs

[ [ [] ] ]

6180, 6235

2455, 3959

264, 326

6418, 6425

1947, 2432

9594, 10713

1653, 1696

4160, 6157

6256, 6397

3985, 4137

6449, 8998

9024, 9571

1711, 1928

221, 226

354, 555

577, 1200

1216, 1637

31,697

159,693

49120

Discharge summary

report

Admission Date: [**2152-8-4**] Discharge Date: [**2152-8-11**] Date of Birth: [**2103-5-6**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 6021**] Chief Complaint: Fever, neutropenia, now transferred out of [**Hospital Unit Name 153**]. Major Surgical or Invasive Procedure: Central line placement and removal PICC line placement History of Present Illness: 49 yo woman undergoing chemo for breast cancer who presents with fever to 102 and severe hemorrhoids. Last night she awoke with shaking chills and fever to 102. Incidentally she had severe rectal pain over the past 4 days at home thought to be due to hemorrhoids and had no relief with [**Last Name (un) **] baths. She noted that her last dose of neulastin [**7-27**] as half was accidently spilled. Her last BM was yesterday, small. She was treated with keflex prior to her azithromycin treatement for strep pharyngitis. . In the ED VS: T 103.1 HR 143 BP 166/78, RR 18 SpO2 100% RA. Her BP rapidly fell to 86/43 with HR 120-150. She improved to 91/59 with HR 130 after IVF (4L). UA neg, CXR unremarkable. She received 2gm ceftazidime iv, 1gm tylenol, 800mg ibuprofen, ativan 1mg iv and 300 mcg neupogen sc. Seen by surgery: non-thrombosed hemmorrhoid->anusol and sugar. ECG unchanged. PIV x2. UOP in ED 300cc. She was transferred to [**Hospital Unit Name 153**] given persistent tachycardia/SBP 90's despite IVF (baseline 110/70 HR 84). Past Medical History: ONCOLOGIC HISTORY: - Stage I infiltrating ductal carcinoma of the breast with lobular features (ER/PR positive, Her2-Neu negative), s/p left mastectomy with reconstruction ([**2152-3-28**]) and 2 cycles of adjuvant chemotherapy with Cytoxan and Taxotere (last treated with Cycle #2, [**2152-7-25**]). No Tamoxifen. . PAST MEDICAL HISTORY: 1. Prior cyst removal. 2. Prior history of abnormal Pap smears requiring colposcopy which was negative. 3. History of parvovirus. 4. History of meniscal tears in the right knee in [**2141**]. 5. History of vaginal damage after her first childbirth in [**2139**]. The patient subsequently has cesarean section in [**2147**]. 6. History of herniated disk at L4-L5. 7. GYN history, the patient's age at menarche was 15. She is currently menstruating. She is G3, P2, first child born at the age of 34. She breastfed both children. She has not been on hormone replacement therapy. She was on birth control pills for approximately 2 years. 8. Genital herpes. 9. Throat culture sparse + group A strep [**7-27**], s/p z-pak 10. Right 5th PIP injury, s/p surgical repair Social History: She is married, with two daughters, ages 4 and 14. She is a mediator in the court for a nonprofit agency. She lives in [**Hospital1 8**]. She reports occasional tobacco while in college but none currently. Occasional alcohol use. Family History: Mother diagnosed with breast cancer at 45 and paternal aunt had breast cancer at 70. There is no family history of ovarian cancer. On her father's side, there is a history of prostate cancer. Also, paternal grandfather who has a history of [**Name (NI) 4278**] disease and brain tumor. She has no sisters. Ashkenazi [**Hospital1 **] descent. Physical Exam: Vitals: T 98.5, HR 72, RR 18, BP 122/65, Sat 92%RA Gen: Fatigued appearing, no acute distress HEENT: Conj pale, sclera anicteric, MM dry, OP clear, PERRL Neck: Supple, no JVD appreciated Resp: Bibasilar rales, left breast s/p radical mastectomy CV: RRR, no murmurs, rubs, gallops Abdomen: Soft, nontender, nondistended. No hepatosplenomegally, no masses. Rectal: + hemorrhoids, no bleeding, erythema Back: no CVA tenderness, no spinal tenderness on palpation Ext: no cyanosis, clubbing, edema Neuro: A & O x 2 (date/time wrong), lethargic Skin: No rashes. Pertinent Results: [**2152-8-4**] 11:00AM GRAN CT-150* [**2152-8-4**] 11:00AM PLT COUNT-231 [**2152-8-4**] 11:00AM NEUTS-31.9* LYMPHS-55.5* MONOS-10.7 EOS-0.5 BASOS-1.3 [**2152-8-4**] 11:00AM WBC-0.5*# RBC-3.77* HGB-10.6* HCT-29.7* MCV-79* MCH-28.3 MCHC-35.9* RDW-14.1 [**2152-8-4**] 11:00AM LACTATE-1.7 [**2152-8-4**] 11:00AM COMMENTS-GREEN [**2152-8-4**] 11:00AM estGFR-Using this [**2152-8-4**] 11:00AM GLUCOSE-125* UREA N-11 CREAT-0.7 SODIUM-139 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14 [**2152-8-4**] 12:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2152-8-4**] 12:06PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2152-8-4**] 12:06PM URINE UHOLD-HOLD [**2152-8-4**] 12:06PM URINE HOURS-RANDOM [**2152-8-4**] 01:19PM LACTATE-0.7 [**2152-8-4**] 01:19PM COMMENTS-GREEN [**2152-8-4**] 05:59PM PT-14.7* PTT-30.5 INR(PT)-1.3* [**2152-8-4**] 05:59PM PLT COUNT-154 [**2152-8-4**] 05:59PM WBC-0.3* RBC-3.09* HGB-8.7* HCT-25.0* MCV-81* MCH-28.2 MCHC-35.0 RDW-13.7 [**2152-8-4**] 05:59PM CORTISOL-36.0* [**2152-8-4**] 05:59PM TSH-0.97 [**2152-8-4**] 05:59PM ALBUMIN-2.7* CALCIUM-6.9* PHOSPHATE-1.7* MAGNESIUM-1.2* [**2152-8-4**] 05:59PM LIPASE-14 . U/A: SpecGr 1.020, pH 6.0, Tr blood, Tr prot, 14 RBC, 3 WBC, Epi <1 . CXR [**8-4**]: No acute cardiopulmonary process (though reticular nodular pattern appreciated). . KUB [**2152-8-4**]: No free air under diaphragm, normal bowel. . ECG [**8-4**]: Sinus tach (142); axis, intervals NL, no acute ST-T changes. . CT Neck [**8-7**]: 1. No evidence of abscess in the neck. 2. Large bilateral pleural effusions with dependent densities, presumably atelectasis, although underlying pneumonia is not entirely excluded. . CXR [**8-9**]: Low lung volumes following tracheal extubation probably exaggerate persistent mild pulmonary edema, and the radiodensity of the moderate right pleural effusion, but azygous distention indicates persistent volume overload even though heart size is normal. No pneumothorax. [**2152-8-4**] 05:59PM ALT(SGPT)-18 AST(SGOT)-23 LD(LDH)-116 ALK PHOS-41 AMYLASE-30 TOT BILI-0.7 [**2152-8-4**] 05:59PM GLUCOSE-101 UREA N-7 CREAT-0.6 SODIUM-144 POTASSIUM-3.1* CHLORIDE-116* TOTAL CO2-19* ANION GAP-12 [**2152-8-4**] 06:20PM LACTATE-1.2 [**2152-8-4**] 06:20PM TYPE-MIX COMMENTS-GREEN TOP [**2152-8-4**] 08:07PM O2 SAT-67 [**2152-8-4**] 08:07PM TYPE-MIX . Brief Hospital Course: Briefly, Ms. [**Known lastname 47716**] is a 49 year old woman with stage I infiltrating ductal carcinoma of the breast who presented to the ED with perirectal pain since [**8-2**] and fever to 102. She missed treatment with Neulasta (improper administration). She attributed her rectal pain to hemorrhoids, but was severe enough to require Percocet. She also noted crampy abdominal pain and decreased appetite. In the ED, she received ceftazidime and Neupogen, but then developed progressive hypotension with systolic pressures in the 90's with tachycardia 120's-130's. She was transferred to the ICU and labs revealed neutropenia (ANC 150). She had recently been treated for strep pharyngitis with Keflex/azithromycin. Surgery was consulted, but determined that she had no peritoneal signs and her partially thrombosed external hemorrhoid was likely not responsible for her symptoms. Blood cultures grew 4/4 bottles of Group A strep, and she was started on clindamycin and penicillin for concern for TSS. She developed respiratory distress after receiving fluid and was eventually intubated on [**8-8**]. She was on Levophed/vasopressin and has been extubated for two days prior to transfer to the floor. PICC was placed for long-term antibiotics, and she was discharged home with close follow up. Medications on Admission: Colace Percocet Motrin Anusol Discharge Medications: 1. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] PRN () as needed for hemorrhoid pain. Disp:*1 tube* Refills:*3* 2. Penicillin G Potassium 1,000,000 unit Recon Soln Sig: 4 million units Injection every four (4) hours for 9 days: Last day is [**2152-8-19**]. Disp:*qs days' worth* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for stool softener. Disp:*30 Capsule(s)* Refills:*2* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. PICC care PICC care per protocol Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Group A Strep bacteremia Stage I breast cancer Discharge Condition: Stable, afebrile, tolerating PO, ambulating Discharge Instructions: You were admitted with sepsis due to Group A streptococcus. Please take all of your medications as prescribed. If you develop weakness, dizziness, fevers, chills, nausea, vomiting, or other concerning symptoms, please seek medical attention immediately. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] as scheduled: . Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2152-8-15**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2152-8-15**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2152-8-15**] 11:30

[ "410.71", "511.9", "995.92", "174.9", "040.82", "455.4", "518.5", "288.04", "276.51", "785.52", "038.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8539, 8591

6265, 7566

340, 397

8682, 8728

3788, 6242

9031, 9600

2853, 3196

7647, 8516

8612, 8661

7592, 7624

8752, 9008

3211, 3769

228, 302

425, 1465

1826, 2590

2606, 2837

26,184

127,458

19876

Discharge summary

report

Admission Date: [**2103-10-17**] Discharge Date: [**2103-10-22**] Date of Birth: [**2038-4-2**] Sex: M Service: CHIEF COMPLAINT: Pedestrian struck. HISTORY OF PRESENT ILLNESS: Patient is a 65-year-old male status post pedestrian struck at unknown speeds. Patient was trapped under the car for an unknown amount of time. Patient was unconscious at the scene. Patient was intubated at the scene with initial [**Location (un) 2611**] coma score of 3. Patient was transported to [**Hospital6 34976**], and then transferred to [**Hospital1 69**] for further evaluation. PAST MEDICAL HISTORY: Unknown. PAST SURGICAL HISTORY: Unknown. MEDICATIONS: Unknown. ALLERGIES: Unknown. INITIAL PHYSICAL ON PRESENTATION AT [**Hospital1 **]: T max 97.6, 73, 110/70, and 100% intubated, [**Location (un) 2611**] coma score 3-intubated. Pupils: Equal, sluggish. C collar intact. Negative facial deformities. Pupils bilaterally sluggish. Chest: No deformities. Back: No step-offs or abrasions. Abdomen is soft, nondistended, rectal tone, decreased. No high riding prostate and heme positive. Extremities: Left lower extremity in traction. Positive thigh deformity. Right hand laceration. Dopplerable DP in right and PT on left. LABORATORIES: Initial white cell count 20, hematocrit 34, platelets 296. Coags 12, 29, and 1. Initial Chem-7: 132, 5.1, 102, 20, 43, 2.7, and 237. HOSPITAL COURSE: Patient was admitted to the Trauma Intensive Care Unit and had a head CT which showed a left parietal bleed, and a right frontotemporal bleed. X-rays also revealed a left femur fracture. Neurosurgery and Orthopedics were consulted at that time. The patient is admitted to the Trauma ICU. Had an Orthopedic and Neurosurgery consult. Orthopedic's assessment was that the patient had a left femur fracture with a concomitant large head bleed with early subuncal herniation. The patient, if he survives, will require an IM rodding of the left femur fracture. Neurosurgery was consulted at the same time and due to the bilateral temporal subarachnoid and early herniation seen on the CT scan, they deemed the patient in guarded condition. Repeat head CT showed a worsening of the bleed and also herniation. Patient was continued with maximal support within the ICU setting. Renal was also consulted due to acute versus chronic renal failure. During the patient's hospitalization stay, his neurologic status did not improve. On day three, Neurosurgery had a meeting with the family to discuss the chance of a very poor prognosis and very little chance of recovery. It was decided on [**10-22**] that the patient's care will be switched to care measures only. A Morphine drip was started for comfort, and the patient was removed from the respirator. At 18:00 on the [**10-22**], the patient expired. The family and ICU team were present at the time of death. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2104-1-1**] 17:25 T: [**2104-1-2**] 06:32 JOB#: [**Job Number 53700**]

[ "593.9", "250.40", "584.5", "E814.7", "518.5", "851.05", "276.0", "401.9", "821.01" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "93.46", "01.59", "99.04", "96.72", "02.2", "99.07", "99.15", "38.91" ]

icd9pcs

[ [ [] ] ]

1425, 3165

646, 1407

146, 166

195, 589

612, 622

60,849

112,375

2267

Discharge summary

report

Admission Date: [**2127-11-3**] Discharge Date: [**2127-11-3**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 99**] Chief Complaint: Fever, cough Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]F with h/o MGUS, CHF [**2-12**] severe MR/TR (EF >55%), afib not on coumadin, presents with fever and cough. Patient is currently not conversant, therefore details of HPI are obtained from family. Per her family, pt was in her USOH until a fall 4 days ago. Fall was witnessed, no head trauma or LOC. She appeared to be back at her baseline until the following morning when she developed fevers at home to 101.3 and cough x 2 days. She did not seek medical attention because she has preferred not to see a doctor for the past 2 years. Family notes that she was generally at her baseline (AAOx3, playing cards), but was intermittently "out of it" for the past 2 days. This AM she was more lethargic, and they persuaded her to go to the ED for evaluation. . In the ED, initial vitals were T 100.0, HR 101, BP 104/58, RR 16, O2 sat 94% 2L. BP gradually decreased to 80s/50s and she became increasingly tachypneic, switched to NRB. Received 1.5L NS in boluses, SBP increased to 90s. CXR showed e/o LLL pna. She was given 2g IV cefepime and 500mg IV levofloxacin. She was transferred to MICU for further management. . On arrival to MICU vitals were T 102.6, HR 93, BP 73/35, RR 26, O2 sat 100% on NRB. Currently she appears awake but is not conversant. Family states that she was always very clear about her decision to be DNR/DNI and would not want aggressive interventions, including central lines or pressors. . ROS: Unable to obtain. To family's knowledge, only notable as described in HPI. Past Medical History: - Chronic pancytopenia seconary to suspected underlying myelodysplastic syndrome, followed by Heme/Onc until [**2125**] (pt elected not to continue f/u) - IgM kappa monoclonal gammopathy of unknown significance - Atrial fibrillation, not on coumadin [**2-12**] thrombocytopenia - H/o CHF [**2-12**] severe MR/TR (last EF in [**2125**] >55%) - Hypertension - Hyperlipidemia Social History: Lives with daughter and son-in-law in [**Name (NI) 2312**]. Per family, independent in ADLs at baseline. Non-smoker. Family History: NC Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: CBC: [**2127-11-3**] 10:35AM WBC-13.9*# RBC-3.43* HGB-9.5* HCT-28.3* MCV-83 MCH-27.6 MCHC-33.4 RDW-17.0* [**2127-11-3**] 10:35AM NEUTS-80* BANDS-3 LYMPHS-6* MONOS-8 EOS-0 BASOS-0 ATYPS-1* METAS-1* MYELOS-1* [**2127-11-3**] 10:35AM PLT SMR-VERY LOW PLT COUNT-61* [**2127-11-3**] 10:35AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-1+ Chem-7: [**2127-11-3**] 10:35AM GLUCOSE-158* UREA N-52* CREAT-1.4* SODIUM-129* POTASSIUM-3.1* CHLORIDE-91* TOTAL CO2-25 ANION GAP-16 UA: [**2127-11-3**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.0 LEUK-NEG [**2127-11-3**] 10:50AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 [**2127-11-3**] 10:50AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013 CXR [**2127-11-3**]: FINDINGS: Portable AP radiograph of the chest was obtained. Low lung volumes. There is airspaze opacity seen over the left mid lung most likely representing a pneumonia. There is stable cardiomegaly. The aorta is tortuous with calcifications seen in the aortic knob. There are no pleural effusions or pneumothorax. Bony structures are unremarkable. IMPRESSION: Left mid lung consolidation consistent with pneumonia. Recommend followup to resolution. Brief Hospital Course: Primary Reason for MICU Admission: Hypotension, hypoxia Brief Hospital Course: On arrival to MICU vitals were T 102.6, HR 93, BP 73/35, RR 26, O2 sat 100% on NRB. Currently she appears awake but is not conversant. Family states that she was always very clear about her decision to be DNR/DNI and would not want aggressive interventions, including central lines or pressors. She continued to receive IV NS, however her blood pressure continued to decline to 50s-60s/30s. At 6:38PM, Ms. [**Known lastname 11949**] passed away with daughter and son-in-law at bedside. Family declined autopsy. Medications on Admission: -Furosemide 40mg qAM, 20mg qPM -Metoprolol tartrate 25mg PO BID -Timolol maleate -Valsartan 160mg PO daily -Acetaminophen 500mg PO BID prn hip pain -Docusate 100mg [**Hospital1 **] Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Sepsis Community-acquired pneumonia (organism unknown) Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A

[ "427.31", "038.9", "785.52", "401.9", "273.1", "V49.86", "272.4", "428.0", "424.2", "995.92", "424.0", "486", "518.81", "284.19", "238.75" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5187, 5196

4412, 4928

262, 269

5295, 5306

2995, 4309

5358, 5365

2363, 2367

5159, 5164

5217, 5274

4954, 5136

5330, 5335

2382, 2976

210, 224

297, 1817

1839, 2213

2229, 2347

30,008

165,055

26428

Discharge summary

report

Admission Date: [**2169-11-13**] Discharge Date: [**2169-11-14**] Date of Birth: [**2134-5-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Scheduled venous access device placement Major Surgical or Invasive Procedure: 1. Venous access device placement, complicated by possible aspiration event. 2. Bronchoscopy in PACU History of Present Illness: 35yo male with adenoid mass, c/w undifferentiated squamous cell carcinoma, congenital glaucoma - legally blind, and depression, here for port placement. Past Medical History: glaucoma Legally blind kidney stones depression Social History: unemployed attends a day treatment program 3 times a week for 6 hrs Lives with mother and sister Family History: n/a Physical Exam: VS: T 97.8 BP 122/88 HR 88 RR 16 O2Sat 96% RA Gen - NAD HEENT - sclera anicteria. Left TM green myringotomy tube. Right TM clear, no bulge Neck - supple, < 1cm mobile right cervical ln Pulm - CTAB, no wheezes, crackles, rhonchi CV - RRR, normal S1, S2, no m/r/g Abd - soft, NT, ND, +BS Ext - no clubbing, edema Pertinent Results: [**2169-11-14**] 02:18AM BLOOD WBC-10.1# RBC-4.16*# Hgb-10.7*# Hct-32.1*# MCV-77* MCH-25.8* MCHC-33.4 RDW-14.2 Plt Ct-190 [**2169-11-14**] 02:18AM BLOOD WBC-10.1# RBC-4.16*# Hgb-10.7*# Hct-32.1*# MCV-77* MCH-25.8* MCHC-33.4 RDW-14.2 Plt Ct-190 [**2169-11-14**] 02:18AM BLOOD Plt Ct-190 [**2169-11-14**] 02:18AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-138 K-3.3 Cl-101 HCO3-30 AnGap-10 [**2169-11-13**] 04:48PM BLOOD Glucose-122* UreaN-11 Creat-0.7 Na-140 K-3.9 Cl-103 [**2169-11-14**] 02:18AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2 [**2169-11-13**] 04:48PM BLOOD Phos-3.6 Mg-2.0 [**2169-11-14**] 02:31AM BLOOD Type-ART pO2-94 pCO2-46* pH-7.45 calTCO2-33* Base XS-6 [**2169-11-13**] 05:07PM BLOOD Type-ART Temp-38.8 pO2-151* pCO2-30* pH-7.44 calTCO2-21 Base XS--1 Intubat-INTUBATED [**2169-11-13**] 01:17PM BLOOD Type-ART Temp-38.1 Tidal V-600 PEEP-5 FiO2-40 pO2-148* pCO2-50* pH-7.35 calTCO2-29 Base XS-1 Intubat-INTUBATED Vent-IMV [**2169-11-13**] 05:07PM BLOOD Lactate-0.9 [**2169-11-13**] 01:17PM BLOOD Glucose-112* Lactate-1.2 Na-139 K-3.9 Cl-104 [**2169-11-13**] 05:07PM BLOOD freeCa-0.92* [**2169-11-13**] 01:17PM BLOOD freeCa-1.15 Brief Hospital Course: Mr. [**Known lastname 16905**] presented for outpatient port placement to the [**Hospital Ward Name 23**] clinical center. Initially the patient was under MAC anesthesia. Once the procedure started, the patient appeared to vomit. After suctioning the oropharynx, the patient was intubated and placed under general anesthesia. The procedure was completed without complication. During attempt at extubation, the patient vomited again and appeared to aspirate. Anesthesia elected to keep the patient intubated. In the PACU, bronchoscopy was performed with finding of mucous plugs. Patient continued to remain stable on the vent. CXR in the PACU was difficult to interpret secondary to patient positioning, however revealed increased opacity behind the heart and at the right base, no pneumothorax. The patient was transferred to the TSICU on the ventilator. Repeat CXR was much improved. On POD#1, the patient was extubated without complication. He was discharged home in stable condition. Medications on Admission: Fluoxetine 40mg qday Betagen Diamox 500mg qam Diamox 250mg qhs Klonopin 0.5mg Abilify Discharge Medications: 1. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 2. Betagen 10 % Solution Sig: One (1) Topical once a day. 3. Diamox Sequels 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO QAM. 4. Diamox Sequels 500 mg Capsule, Sustained Release Sig: [**12-27**] Capsule, Sustained Release PO QHS. 5. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 6. Abilify Oral Discharge Disposition: Home Discharge Diagnosis: Aspiration event during VAD placement Discharge Condition: stable Discharge Instructions: General Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * 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 becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. Incision Care: *You may shower. Pat incision dry. *Avoid swimming and baths until further instruction at your followup appointment. *Leave the steri-strips on. They will fall off on their own, or be removed during your followup. *Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: 1. Follow up with your oncologist as scheduled. 2. Follow up with Dr. [**Last Name (STitle) **] in [**1-28**] weeks. # [**Telephone/Fax (1) 1864**] 3. Follow up with your PCP as needed. [**Last Name (LF) **],[**First Name3 (LF) 8741**] [**Telephone/Fax (1) 2205**]

[ "327.23", "V58.81", "V44.1", "934.9", "311", "530.81", "E849.7", "147.8", "E915", "743.20" ]

icd9cm

[ [ [] ] ]

[ "33.22", "86.07" ]

icd9pcs

[ [ [] ] ]

3941, 3947

2353, 3352

357, 460

4029, 4038

1196, 2330

5276, 5544

844, 849

3488, 3918

3968, 4008

3378, 3465

4062, 4914

4929, 5253

864, 1177

277, 319

488, 642

664, 713

729, 828

79,564

111,848

3404

Discharge summary

report

Admission Date: [**2162-5-2**] Discharge Date: [**2162-5-11**] Date of Birth: [**2105-11-8**] Sex: F Service: NEUROLOGY Allergies: Taxol Attending:[**First Name3 (LF) 8850**] Chief Complaint: Peripheral Edema. Major Surgical or Invasive Procedure: Thoracentesis. History of Present Illness: Ms. [**Known firstname 1439**] [**Known lastname **] is a 56-year-old woman with history of metastatic breast cancer affecting brain and lungs, sarcoidosis, coagulopathy, presenting with lower extremity edema for the last 3 weeks. Patient reports that she has noticed the lower extremity edema since starting dexamethasone as part of her chemotherapy, as was noted in her neuro-oncology visit note. Patient reports she began having pain in her right leg that was worse with walking. She also reports having "cold like symptoms" with a [**Known lastname **] and some runny nose, denies any fevers or chills. Patient decided to come into the ED after her symptoms were not improved with Tylenol. In the emergency department patient vitals were T: 97 HR: 114 BP: 127/103 O2 Sat:93% on 4L. Lower extremity ultrasound was obtained to evaluate for DVT, CTA of the chest ordered to rule out PE. Patient received vancomycin and levofloxacin for suspected post obstructive pneumonia. Patient also given 500 ml of saline bolus. Patient noted to have transient desaturations to mid 80's with movement. Given tenuous stauts, patient admitted to [**Hospital Unit Name 153**] for close monitoring. Past Medical History: ONCOLOGICAL HISTORY: Breast cancer with metastases to cerebellum -completed whole brain cranial irradiation on [**2160-8-6**], -s/p a third ventriculostomy by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2161-4-22**], -s/p Cyberknife radiosurgery on [**2161-4-30**] to a left cerebellar metastasis to 1,800 cGy at 82% isodose line and to a right cerebellar metastasis to 1,600 cGy at 73% isodose line on [**2161-4-30**], and -has been getting lapatinib and carboplatin every 3 weeks since [**2161-9-11**] for her progressive disease; delayed because of her surgeries. -s/p second third ventriculostomy procedure by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2162-1-14**]. -she was scheduled to receive Doxil on [**2162-2-24**] but did not go. OTHER PAST MEDICAL HISTORY: h/o Factor VIII deficiency Hypertension Sarcoidosis s/p Right lumpectomy [**2146**], L lumpectomy [**2149**] s/p Lung biopsy [**2156**] Social History: She does not smoke cigarettes, drink alcohol or use illicit drugs. She lives alone but her father has been staying with her and helping to take care of her. Family History: Her mother died of breast cancer. An aunt from the maternal side has breast cancer. She has 2 uncles, one died of smoking-related lung cancer while another is alive with non-smoking-related cancer. There are other members of her family with diabetes. Physical Exam: VITAL SIGNS: Tmax: 35.6 ??????C (96.1 ??????F) Tcurrent: 35.6 ??????C (96.1 ??????F) HR: 118 (118 - 118) bpm BP: 142/88(101) {142/88(101) - 142/88(101)} mmHg RR: 7 (7 - 7) insp/min SpO2: 90% Heart rhythm: ST (Sinus Tachycardia) PHYSICAL EXAMINATION GENERAL: Pleasant, well appearing woman with cushinoid features. SKIN: Rash along posterior surface of right leg. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. obese neck. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops LUNGS: Decreased breath sounds at right base, (+) Egophony. Anterior rhonchi on right. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Massive lower extremity edema to the thigh. NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 50. She is awake, alert, and able to follow commands. Her language is fluent with good comprehension. Her recent recall is fair. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [**6-15**] at all muscle groups, except for 2/5 strength in proximal lower extremities and triceps. She has 3/5 strength in foot dorsiflexors. Her muscle tone is normal. Her reflexes are 0 and symmetric bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. She cannot walk. Pertinent Results: ADMISSION LABS: CBC: [**2162-5-1**] 09:50PM BLOOD WBC-8.7 RBC-3.15*# Hgb-11.0* Hct-33.6* MCV-107* MCH-35.1* MCHC-32.9 RDW-20.6* Plt Ct-134* [**2162-5-2**] 09:41AM BLOOD Neuts-86* Bands-6* Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-2* [**2162-5-2**] 09:41AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-OCCASIONAL Macrocy-2+ Microcy-1+ Polychr-1+ Tear Dr[**Last Name (STitle) 833**] LACTATE: [**2162-5-1**] 09:50PM BLOOD Lactate-3.5* [**2162-5-2**] 12:02PM BLOOD Lactate-2.6* CHEMISTRIES: [**2162-5-1**] 09:50PM BLOOD Glucose-133* UreaN-21* Creat-0.7 Na-140 K-3.2* Cl-105 HCO3-22 AnGap-16 PLEURAL FLUID: [**2162-5-2**] 01:31PM PLEURAL WBC-225* RBC-315* Polys-7* Lymphs-37* Monos-7* Meso-2* Macro-43* Other-4* [**2162-5-2**] 01:31PM PLEURAL TotProt-2.4 Glucose-105 Creat-0.4 LD(LDH)-428 Albumin-1.7 URINE ANALYSIS: [**2162-5-2**] 12:50AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]->=1.035 [**2162-5-2**] 12:50AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.5 Leuks-MOD [**2162-5-2**] 12:50AM URINE RBC-0-2 WBC->50 Bacteri-MOD Yeast-NONE Epi-1 ======= DISCHARGE LABS: [**2162-5-7**] 06:40AM BLOOD WBC-9.5 RBC-2.84* Hgb-9.6* Hct-30.9* MCV-109* MCH-33.7* MCHC-31.0 RDW-20.8* Plt Ct-118* [**2162-5-7**] 06:40AM BLOOD Glucose-106* UreaN-18 Creat-0.4 Na-141 K-4.1 Cl-107 HCO3-28 AnGap-10 [**2162-5-7**] 06:40AM BLOOD ALT-136* AST-144* AlkPhos-245* TotBili-1.2 ======= MICROBIOLOGY: Time Taken Not Noted Log-In Date/Time: [**2162-5-2**] 11:46 am URINE Site: CLEAN CATCH ADDED TO 0052J. **FINAL REPORT [**2162-5-4**]** URINE CULTURE (Final [**2162-5-4**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ <=1 S ------------ ================== IMAGING STUDIES: [**2162-5-1**] LENIs: No DVT [**2162-5-1**] CTA chest: 1. No definite evidence of pulmonary emboli. 2. Extensive lung masses and nodules involving both lungs, which appears to have increased when compared to prior exam. Some of these masses appear to encase the distal segmental pulmonary arteries. 3. Extensive ground-glass opacity and septal thickening. This could represent lymphangitic spread or edema. 4. Hypodense lesions in the liver concerning for metastasis and fluid within the perihepatic space. 5. Sclerotic lesions in the lower thoracic vertebral bodies with compression deformities. 6. Large left pleural effusion and small right pleural effusion. [**2162-5-1**] CT head: 1. Unchanged small hyperdense foci in the right cerebellar hemisphere within a known metastasis. Otherwise, no acute hemorrhage. 2. The extent of metastatic disease is better assessed on the [**2162-4-26**] MRI. [**2162-5-4**] CT Abd/Pelv (to r/o IVC obstruction) IMPRESSION: 1. Attenuation of the intrahepatic IVC due to extensive hepatic metastatic disease, without evidence of severe stenosis or thrombus. The infrahepatic IVC and iliac veins remain patent. 2. Known pulmonary metastases. Worsened ground-glass opacity within the right middle and lower lobes which may represent edema or tumor spread. 3. Decreased size of right pleural effusion which is now moderate. Unchanged small left pleural effusion. 4. Pelvic free fluid. 5. Osseous metastatic disease with T9 vertebral body compression fracture. Brief Hospital Course: This is a 56-year-old woman with metastatic breast cancer to bone, lung and brain, presenting with worsening lower extremity edema, found to be hypoxic and with new large right pleural effusion. (1) RESPIRATORY DISTRESS: On admission the pt required 4L O2, while her baseline is 100%on RA. The patient did not have a fever, had minimal [**Last Name (LF) **], [**First Name3 (LF) **] pneumonia seemed less likely, and CTA was negative for PE. Since the patient did have significantly increased size of her pulmonary metastases it seemed the most likely cause of the pt's hypoxia was the metastasis combined with the large right pleural effusion. On [**2162-5-2**] the pt had a therapeutic thoracentesis which per the patient provided an improvement in symptoms. Despite therapeutic thoracentesis patient has continued to have a [**5-16**] liter oxygen requirement. CXR on [**2162-5-5**] demonstrated some re-accumulation of the right sided pleural effusion and interval increase in the left sided pleural effusion. Interventional radiology was consulted for possible repeat thoracentesis or pleurX catheter placement but did not feel there was enough fluid on ultrasound to safely attempt thoracentesis. Patient has remained comfortable with her breathing despite her oxygen requirement. (2) LOWER EXTREMITY EDEMA: On admission the patient had bilateral pitting edema to the thighs, with petechiae on the right side that appeared to be dependent petechiae. Admission lower extremity dopplers were negative for DVT, so the patient's extremities were kept elevated. Given history of liver mets near the IVC there was concern for obstruction of venous return, though abdominal imaging did not demonstrate any IVC obstruction though the read did comment on intra-hepatic attenuation of the IVC likelyy due to extensive liver metastases. The patient also had an X-ray of the right ankle as it was quite tender on admission, and the X-ray was negative for fracture and foreign body. (3) METASTATIC BREAST CANCER: OMED team in contact with primary oncologist Dr. [**Known lastname **] [**Last Name (NamePattern1) 15759**] who did not support further chemotherapy given patient's poor prognosis. A family meeting was held which also included the palliative care team and patient and family felt comfortable with discharge to hospice. (4) URINARY TRACT INFECTION: On admission on [**2162-5-2**] the patient was started on Levaquin for a three-day course of antibiotic treatment for UTI. However, urine grew enterococcus so patient started on vancomycin which was changed to amoxicillin to complete a 7 day course. Patient was DNR/DNI during this admission. Medications on Admission: Iron Diovan Dexamathasone 4gm [**Hospital1 **] Vitamin D Vitamin B6 Nexium Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO twice a day. 9. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice Discharge Diagnosis: Primary: Metastatic Pleural Effusions, Urinary Tract Infection Secondary: Metastatic Breast Cancer, Hypertension, Sarcoidosis, Factor VIII Deficiency Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital for work up of your low blood oxygen level and lower extremity swelling. We determined that you had fluid around your lungs and some of this fluid was drained. You continue to require oxygen because some of this fluid has reaccumulated. We are not exactly sure what is causing your lower leg swelling but feel that it is likely related to your cancer. During your admission we also found that you had a urinary tract infection which was treated. Please take all medications as directed. You are going home with hospice care. Followup Instructions: Please follow up with your oncologist as below: RADIOLOGY MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-6-21**] 11:15 [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2162-6-21**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2162-7-2**] 11:00 Completed by:[**2162-5-13**]

[ "401.9", "286.0", "112.0", "782.3", "198.3", "197.0", "041.04", "578.9", "198.5", "599.0", "135", "197.7", "348.5", "518.81", "511.81", "V10.3", "485" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

12347, 12405

8492, 11161

284, 300

12599, 12607

4868, 4868

13219, 13662

2713, 2968

11286, 12324

12426, 12578

11187, 11263

12631, 13196

6004, 6953

2983, 4849

227, 246

328, 1523

7659, 8469

4884, 5988

2385, 2522

2538, 2697

6970, 7650

21,603

155,200

13726

Discharge summary

report

Admission Date: [**2138-11-10**] Discharge Date: [**2138-11-23**] Service: Gold Surgery HISTORY OF PRESENT ILLNESS: The patient is an 82 year old male with a history of diabetes mellitus Type 2, chronic renal insufficiency and glaucoma who was recently admitted to [**Hospital6 256**] in [**Month (only) **] with complaints of weakness and fatigue with an episode of dark tarry stool one week prior to admission in [**Month (only) **]. The patient had an outpatient colonoscopy which reportedly was negative. The patient was seen by Dr. [**Last Name (STitle) 41326**] his primary care physician and underwent an esophagogastroduodenoscopy during admission and was found to have a fungating ulcerating infiltrating nonbleeding 5 to 6 cm mass of malignant appearance at the lesser curvature. It was noted to start approximately 4 to 5 cm below the esophageal gastric junction and reach the incisure angularis distally and the patient was also found to have several sessile nonbleeding polyps in the antrum and the body of the stomach and findings that were consistent with chronic gastritis. Pathology from the biopsy revealed a moderately differentiated adenocarcinoma of intestinal type and Helicobacter pylori. During the earlier admission, the patient was evaluated by the Surgical Service and was referred to Dr. [**Last Name (STitle) **] for surgical intervention. The patient was discharged on [**2138-10-31**] and was seen by Dr. [**Last Name (STitle) **] and was evaluated by surgical intervention. The patient clearly understood the benefits as well as the risks of surgical intervention, given his age of 82 and after a long discussion and also a discussion with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41326**]. The patient desired to undergo a partial gastrectomy and presented to the Operating Room on [**2138-11-10**]. PAST MEDICAL HISTORY: Significant for Type 2 diabetes mellitus, treated with insulin, chronic renal insufficiency, elevated CEA, glaucoma, Helicobacter pylori, chronic gastritis and adenocarcinoma of the stomach as mentioned above. The patient is allergic to Penicillin causing anaphylaxis. MEDICATIONS: Insulin 70/30 40 units in the AM and 18 units in the PM, Norvasc 10 mg p.o. q.d., Colace 10 mg p.o. b.i.d. while on iron, Ferrous Sulfate 325 mg p.o. q.d., Biaxin 500 mg p.o. b.i.d. for two weeks, Flagyl 500 mg p.o. b.i.d. for two weeks and Protonix 40 mg p.o. b.i.d., Dorzolamide 2% drops b.i.d., Brimonidine tartrate .2% eyedrops every 12 hours. SOCIAL HISTORY: Significant for a 20 pack year history of smoking which the patient had quit approximately 30 years ago. The patient denies any alcohol use. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile, vital signs stable, alert and oriented times three. Well-appearing not in any apparent distress. Head, eyes, ears, nose and throat examination was within normal limits with anicteric sclera. Neck was supple. Cardiac examination was regular with normal S1 and S2, no murmurs appreciated. Lungs were clear to auscultation bilaterally. Abdomen was with sounds, soft, nontender, nondistended. The patient had 1+ bilateral pitting edema in the lower extremities. Neurologic examination was grossly intact. LABORATORY DATA: Laboratory values preoperatively were white count 8.1 with hematocrit of 30.1, platelets 430, PT 12.6, PTT 27.3 with an INR of 1.1. Chemistries revealed sodium 139, potassium 4.7, chloride 109, carbon dioxide 25, BUN 23, creatinine 1.7 and glucose of 120. AST was 14, ALT 13, alkaline phosphatase was 100 with total bilirubin of 0.3. HOSPITAL COURSE: The patient presented to the Operating Room on [**2138-11-10**], and underwent Billroth II distal gastrectomy with Dr. [**Last Name (STitle) **]. Postoperatively the patient left the Operating Room and arrived at the Post Anesthesia Care Unit intubated with decreased urine output and increased central venous pressure to 25 mm of mercury. The patient was also found to be in metabolic acidosis based on arterial blood gases. The patient underwent chest x-ray in the Post Anesthesia Care Unit which was consistent with the findings of pulmonary edema. Transthoracic echocardiogram performed by Cardiology showed a preserved left ventricular function. The patient received 10 mg of intravenous Lasix with good response. Urine output increased to 265 cc/hr. The patient's central venous pressure responded by dropping to 15 to 17. Intraoperative and perioperative event was ruled out by blood test with troponin levels less than 0.01 and CKMB of 4. The patient's postoperative hematocrit was 28.8 and the patient was transfused 2 units of packed red blood cells. Coming out of the Operating Room the patient was sedate with Propofol and was also on Dopamine drip with the diuresis with intravenous Lasix. The patient was weaned off of the Dopamine drip and remained hemodynamically stable. The patient was transferred to the Surgical Intensive Care Unit for further monitoring. The patient remained stable on Propofol drip and intubated on a ventilator and remained hemodynamically stable. On postoperative day #2 the patient remained hemodynamically stable with adequate diuresis. The patient's metabolic acidosis improved and the patient was extubated on postoperative day #2. The patient was transferred to the floor in stable condition on postoperative day #3. The patient continued to be gently diuresed given his overload of volume status. The patient was started on sips on postoperative day #5 and was advanced to full liquid diet by operation day #7. The patient tolerated a full liquid diet by postoperative day #7 and had passed flatus, however, his abdomen remained moderately distended. Therefore the patient was kept on a full liquid diet and was further evaluated to see if the abdominal distention would worsen or not. The patient was complaining of constipation and was given Dulcolax suppository with good effect. By postoperative day #9 the patient continued on a soft diet and by postoperative day #11 was fully advanced to a diabetic diet. Although the patient's abdomen remained moderately distended the patient did not have any nausea or vomiting and by the date of discharge the patient's abdomen had improved in its distention and the patient was having bowel movements. The patient was initially evaluated by physical therapy and was recommended to be discharged to a rehabilitation facility, however, the patient refused to be discharged to rehabilitation and was re-evaluated by the physical therapist considering the fact that the patient has a son who can be with him 24 hours seven days a week to assist him at home. The patient was found to be able to ambulate with assistance without difficulty and given his supervision available at home, the patient was deemed safe to be discharged to home. The patient was discharged on postoperative day #14. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Discharged to home, given constant supervision by family members. DISCHARGE DIAGNOSIS: 1. Gastric adenocarcinoma, T3N2 moderately differentiated 2. Chronic gastritis 3. Status post Billroth II distal gastrectomy 4. Diabetes mellitus Type 2 5. Hypertension 6. Chronic renal insufficiency 7. Glaucoma DISCHARGE MEDICATIONS: 1. Percocet 1 to 2 tablets p.o. q. 4-6 hours prn pain 2. Colace 100 mg p.o. b.i.d., while taking Percocet 3. Brimonidine Tartrate 0.2% eyedrops one drop to the eyes b.i.d. 4. Dorzolamide 2% drops one drop b.i.d. 5. Lopressor 50 mg p.o. b.i.d. 6. Protonix 40 mg p.o. q.d. 7. Humalog 75/25 40 units q. AM, 15 units q. PM and Humalog sliding scale as ordered 8. Dulcolax 10 mg suppository q.h.s. prn, dispense 5 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**] Dictated By:[**Last Name (NamePattern1) 10201**] MEDQUIST36 D: [**2138-11-23**] 12:44 T: [**2138-11-23**] 15:03 JOB#: [**Job Number 41327**]

[ "V14.0", "365.9", "518.5", "196.2", "250.00", "151.4", "535.10", "276.2", "593.9" ]

icd9cm

[ [ [] ] ]

[ "43.7" ]

icd9pcs

[ [ [] ] ]

6979, 7074

7338, 8034

7095, 7315

3656, 6957

129, 1897

2750, 3638

1920, 2554

2571, 2735

26,563

172,668

5811

Discharge summary

report

Admission Date: [**2143-2-11**] Discharge Date: Date of Birth: Sex: M Service: [**Location (un) 2655**] DATE OF DEATH: [**2143-2-14**] CHIEF COMPLAINT BRIEF HOSPITAL COURSE: This is a 57 year-old male with history of end stage renal disease secondary to diabetes and hypertension, peripheral vascular disease status post multiple revascularizations and amputations, CAD status post multi vessel CABG in 7/98 who presented with recurrent staph aureus bacteremia. The patient initially presented to [**Hospital3 1280**] Hospital on [**2143-1-17**] with fevers to 102, chills and right shoulder pain and was diagnosed with staph aureus bacteremia, treated with Vancomycin and Rifampin. He was re-admitted on [**2143-1-31**] after surveillance cultures were still positive. The patient was spiking temperatures. At this time his dialysis catheter was changed over from the right IJ to right subclavian and the patient has persisted to have fevers and positive cultures. The patient also has had an AICD placed and it was suspected that this was the source despite a negative [**Male First Name (un) **]. The patient was transferred to [**Hospital1 1444**] on [**2143-2-11**] for further management. PAST MEDICAL HISTORY: 1. Type I diabetes. 2. End stage renal disease on hemodialysis. 3. Peripheral vascular disease right transmetatarsal amputation, left AKA, CAD status post CABG in 07/98 with LIMA to LAD, saphenous vein graft to OM, distal PDA and right posterior lateral artery. An echo in 08/98 revealed right atrial enlargement mild to moderate MR, moderate to severe Treated and released. 4. Left hip fracture with hardware. 5. Left cataract. 6. Bilateral vitrectomies for intraocular hemorrhages secondary to diabetic retinopathy. 7. Status post defibrillation arrest. 8. Status post ICD placement in [**2140**]. ALLERGIES: No known drug allergies. MEDICATIONS: 1. NPH 25 in the morning, 15 units q P.M., 6 units of regular q A.M. 2. Protonix 40 milligrams po q day. 3. Zestril 5 milligrams po q day. 4. Nephrocaps one tab po q day. 5. Metoprolol 25 milligrams po bid. 6. Aspirin 81 milligrams po q day. 7. Vitamin C 500 milligrams po q day. 8. Colace 100 milligrams po bid. 9. PhosLo 1 tab po tid. 10. Colace 100 milligrams po bid. 11. Amiodarone 200 milligrams po q day. 12. Neurontin 200 milligrams po post dialysis. 13. MS Contin 15 milligrams po bid. 14. Zocor 40 milligrams po q HS. 15. Vancomycin 50 milligrams po post dialysis. BRIEF HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**] service after having his ICD leads pulled in the operating room with thoracic surgery support. Notably a piece of myocardium came out with the ICD lead. However post procedure echocardiogram revealed no evidence of tamponade. The patient was stable on [**Hospital Unit Name 196**] service hemodynamically and on 8th he was transferred to the Medicine service for further management of persisting positive blood cultures. The patient was afebrile since his transfer to Medicine. He was noted to have digital necrosis over the index finger of the right hand. His staph aureus appeared to be of intermediate sensitivity for Vancomycin. The patient was at hemodialysis on [**2143-2-14**] after which he developed a PEA arrest of unclear etiology. Despite aggressive attempts the patient could not be resuscitated. The patient was pronounced dead at roughly 6 P.M. on [**2143-2-14**]. The proximate cause of death was a PEA arrest. The cause of which was unclear. The patient's family refused an autopsy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Name8 (MD) 2653**] MEDQUIST36 D: [**2143-4-17**] 10:54 T: [**2143-4-17**] 11:11 JOB#: [**Job Number 23072**]

[ "996.61", "511.9", "707.0", "038.11", "421.0", "403.91", "040.0", "250.41", "427.5" ]

icd9cm

[ [ [] ] ]

[ "38.95", "37.99", "42.23", "39.95", "34.91", "88.72" ]

icd9pcs

[ [ [] ] ]

2523, 3858

1255, 2499

29,092

112,497

43450

Discharge summary

report

Admission Date: [**2170-1-18**] Discharge Date: [**2170-2-2**] Date of Birth: [**2129-6-22**] Sex: M Service: MEDICINE Allergies: Aspirin / Hydralazine / Pyridium / Bactrim / Nitrofurantoin / Dapsone / Quinine / Quinidine / Methylene Blue Attending:[**First Name3 (LF) 19193**] Chief Complaint: fatigue, poor PO intake, abdominal discomfort Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 1557**] is a 40-year-old man with medical history of [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**] disease (glycogen storage disease) who presented with fatigue, poor PO intake, and abdominal pain. Per his father, [**Name (NI) **] has not been doing well since he completed alpha interferon at the end of [**10/2169**] for treatment of his liver adenomas. He has been more exhausted and his PO intake has been extremely poor. He denies any fevers, chills, chest pain, shortness of breath, or diarrhea. The patient does admit to increasing bilateral lower extremity edema over the past 2 weeks. His BS's have been difficult to control at home since he is not always compliant with his cornstarch due to fatigue. Given his constellation of symptoms he was recommended to go to the ED by his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**]. Initial vitals in the ED were T 98.1, BP 118/65, HR 107, RR 27, O2 sat 100% RA. Initial labs revealed a leukocytosis of 25 and lactate of 13. Patient was initially started on D10W with close monitoring of his blood sugars which was then changed to 1/2 NS given his lactic acidosis. He was also given Zosyn 3.375gm IV and Ceftriaxone 1gm IV. Repeat labs showed an increase in WBC to 45.3 and lactate of 16. He was transferred to MICU for closer monitoring. His Hct was noted to be 18. . Mr. [**Known lastname 1557**] also underwent a CT scan abd/pelvis in ED which showed a possible ruptured adenoma. Patient's family did not want any further procedures to be done. Of note, the patient was recently admitted in mid-[**Month (only) 404**] for anemia and was admitted for blood transfusions. Past Medical History: 1)[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] disease 2)s/p porto-caval shunt 3)Anemia Social History: Lives independently in [**Location (un) 745**]. No current tobacco, alcohol, or IVDA. Family History: Brother passed away from complications of [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 93502**] diease. Physical Exam: ADMISSION EXAM: T 97.0 BP 129/67 HR 116 RR 25 O2 sat 100% RA Gen: Patient appears acutely ill, severely cachectic, older than stated age HEENT: MMM Heart: Sinus tachycardia, no audible m,r,g Lungs: CTAB, no crackles Abdomen: Markedly distended, hard to palpation, visible veins. Extremities: [**1-30**]+ bilateral pitting edema, 1+ DP/PT pulses Pertinent Results: ADMISSION LABS: WBC-25.0*# RBC-2.43*# HGB-5.4*# HCT-20.4* MCV-84 NEUTS-78* BANDS-2 LYMPHS-8* MONOS-11 EOS-0 BASOS-0 PT-17.6* PTT-37.2* INR(PT)-1.6* GLUCOSE-19* UREA N-39* CREAT-0.6 SODIUM-142 POTASSIUM-4.3 CHLORIDE-93* CO2-12* ALT(SGPT)-73* AST(SGOT)-514* ALK PHOS-4623* TOT BILI-3.0* LIPASE-702* CALCIUM-10.4* PHOSPHATE-2.5* MAGNESIUM-2.5 TRIGLYCER-364* LACTATE-13.0* . IMAGING STUDIES: 1)Cxray ([**1-18**]): No evidence of pneumonia. No acute cardiopulmonary abnormalities. 2)CT abd/pelvis ([**1-18**]): 1. Massively enlarged liver with innumerable heterogenous masses most consistent with adenomas. Extraluminal pooling of contrast are concerning for active intra- tumoral hemorrhage in the most inferiorly located tumor mass in the right hepatic lobe. Minimal normal appearing liver parenchyma remains. A targeted ultrasound of this area is recommended for further evaluation of possible intra- tumoral hemorrhage vs. venous lakes. 2. Marked tumor neovascularity within the liver, especially the left lobe which is near completely replaced with tumor. Hepatocellular carcinoma within these areas cannot be excluded. 3)RUQ U/S ([**1-18**]): Well-defined, focal hypoechoic areas which show slow internal flow within the most inferior right-sided hepatic mass most likely represent internal venous lakes Brief Hospital Course: Mr. [**Known lastname 1557**] is a 40-year-old man with history of glycogen storage disease who presented with worsening fatigue, poor PO intake, and abdominal discomfort. . * Glycogen storage disease: AG metabolic acidosis on presentation, secondary to hypoglycemia. Patient was admitted to the MICU. Infusion of D10W then D10 1/2NS was started, and as hypoglycemia resolved, his lactate acidosis improved. The regimen was discussed with his specialist, Dr. [**Last Name (STitle) **]. Goal blood sugar is between 70-100. As he started the cornstarch the D10 gtt was weaned off. When patient was hypoglycemic he was encouraged to eat small meals. By discharge lactate had decreased from a peak of 15 to 6.6. Due to loose stools, the patient could not tolerate cornstarch for several days, but by discharge diarrhea had resolved, and the patient had been taking cornstarch for 2 days, with stable fingersticks. . * Leukocytosis: Patient initially presented with WBC of 25. No apparent source of infection was identified. CXR and urinalysis were unremarkable. Abdominal CT revealed no abscess. Blood and urine cultures were negative. He was empirically started on Zosyn on admission which was stopped after 48 hours because of no evidence for an active infection. When he developed loose stools later in the hospital course, metronidazole was started for presumed C. diff and completed by discharge. C. diff came back negative. The WBC trended down but remained elevated at 15 by discharge. Patient was afebrile during hospitalization. . * Recent diarrhea: with persistent leukocytosis. He was empirically treated with a short course of metronidazole. C. diff came back negative. Stool studies were unremarkable, and no clear cause was found. The diarrhea gradually improved, allowing the patient to better absorb the cornstarch by discharge. . * Anemia: Mr. [**Known lastname 1557**] had extensive workup in the past. Concern for anemia of chronic disease, in setting of hepatic adenomas. The patient's Hct was 18 on admission, and he subsequently received pRBCs to increase Hct to high 20s. . * Hepatic adenomas: known multiple adenomas per CT scan report. Family declined further work-up at this time. . * Elevated LFTs/coagulopathy: presented with elevated ALT/AST/alk phos, likely in setting of extensive hepatic adenomas. INR remained elevated around 1.6-1.7, suggesting underlying synthetic dysfunction. . * LE and scrotal edema: likely from low albumin, and with infusion of IVF during hospital stay. . * Code: Full Medications on Admission: Allopurinol 300mg PO daily Cornstarch Discharge Medications: 1. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day). Disp:*90 Powder in Packet(s)* Refills:*2* 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Dextrose (Diabetic Use) 300 mg Tablet Sig: 2-4 Tablets PO PRN (as needed) as needed for FS < 60. 9. Corn Starch (Bulk) Powder Sig: see comment Miscellaneous q4 (): 45 gm at 6am, 10am, 2pm, 6pm; 55 g at 10pm, 2am . Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: lactic acidosis Secondary diagnosis: glycogen storage disease Discharge Condition: Stable Discharge Instructions: You presented to [**Hospital1 18**] with fatigue, abdominal discomfort, and poor appetite. You were found to have hypoglycemia (low blood sugar) and lactic acidosis, consistent with your glycogen storage disease. You refused infusion of D10 1/2NS for glucose control. Cornstarch was started then stopped due to diarrhea. Work-up for the diarrhea revealed no apparent cause. You were empirically treated with an antibiotic called metronidazole. Your diarrhea improved, and the cornstarch was restarted, the dextrose infusion was discontinued, and your blood sugar remained stable. Please take your medications as instructed. If you develop any fevers, chills, shortness of breath, chest pain, recurrent diarrhea, or any other symptoms that concern you, please call your doctor or go to the nearest Emergency Room. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**], [**Telephone/Fax (1) 19196**], for a follow-up appointment within two weeks.

[ "276.2", "578.9", "271.0", "251.1", "577.0", "285.29", "008.45", "211.5" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

7970, 8028

4251, 6775

415, 422

8154, 8163

2913, 2913

9025, 9211

2414, 2532

6863, 7947

8049, 8049

6801, 6840

8187, 9002

2547, 2894

330, 377

450, 2163

8106, 8133

2929, 3284

8068, 8085

2185, 2295

2311, 2398

3301, 4228

71,878

106,069

23506

Discharge summary

report

Admission Date: [**2147-1-24**] [**Year/Month/Day **] Date: [**2147-1-30**] Service: SURGERY Allergies: Penicillins / Optiray 350 Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: Paravertebral cathether placement History of Present Illness: 89 yo male s/p trip and fall at home in bathroom falling onto toilet striking his left chest. He was transported to [**Hospital1 18**] for further care. Past Medical History: Parkinson's disease DM2 c/b neuropathy on neurontin diplopia x one year, horizontal, no clear etiology per patient, followed by ophtho HTN Migraines s/p MI [**57**] yrs ago s/p cataract [**Doctor First Name **] bilat s/p laminectomy in [**2089**] Social History: Recent move to [**Location (un) 86**] from NY 10 days ago. lives with wife in senior citizen home, + tob 30yrs x 1ppd, quit 30 yrs ago, no etoh, no drugs, has 2 sons Family History: Father with strokes, no seizures, no parkinsons, sons are healthy Pertinent Results: [**2147-1-24**] 02:30PM GLUCOSE-125* UREA N-57* CREAT-2.1* SODIUM-141 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-19 [**2147-1-24**] 02:30PM CALCIUM-9.3 PHOSPHATE-4.4# MAGNESIUM-2.0 [**2147-1-24**] 02:30PM WBC-11.3* RBC-4.69 HGB-12.1* HCT-37.9* MCV-81* MCH-25.8* MCHC-31.9 RDW-17.0* [**2147-1-24**] 02:30PM NEUTS-73.1* LYMPHS-21.5 MONOS-3.8 EOS-1.2 BASOS-0.4 [**2147-1-24**] 02:30PM PLT COUNT-236 [**2147-1-24**] CT Head IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. 2. Air-fluid level within the left maxillary sinus without definitive fracture detected. Findings likely reflect sinusitis. [**2147-1-24**] CT C-spine IMPRESSION: 1. No evidence of acute fracture or traumatic malalignment. 2. Multilevel cervical stenosis secondary to degenerative change. If there is clinical concern for myelopathy, MRI of the cervical spine is recommended for further evaluation to evaluate for cord edema/injury. 3. Tiny left apical pneumothorax with subcutaneous emphysema. 4. Soft tissue opacity within the right lung apex is non-specific, possibly reflecting scar and is little changed since [**2145-12-28**]. [**2147-1-24**] CT Chest/Abdomen/Pelvis IMPRESSION: 1. Numerous left-sided acute rib fractures causing small left hemopneumothorax and atelectasis. Significant subcutaneous emphysema noted. 2. Significantly enlarged prostate gland. 3. Moderate-to-severe coronary artery calcifications and moderate calcification of the aortic valve of unknown hemodynamic significance. 4. Possible mild reaction to IV contrast material as detailed in technique portion of the report. [**2147-1-28**] Chest xray FINDINGS: Multiple left rib fractures are again noted, and there is evidence of left pleural fluid and atelectasis. Retrocardiac density is not significantly different. There is no PTX. Brief Hospital Course: He was admitted to the Trauma service and transferred to the Trauma ICU for close monitoring of his respiratory status because of his injuries. The Pain Service was consulted for epidural analgesia; it was decided to place a paravertebral catheter which remained in place for several days. He was also started on PCA Dilaudid initially and was then changed oral narcotics but became disoriented with the narcotics. A short trial of Ultram was started and then discontinued as his disorientation did not improve initially. Once off of all narcotics and the Ultram his mental status improved significantly. Geriatrics was also consulted and made several recommendations regarding his pain medications. His current pain regimen includes Tylenol 1 gram around the clock and Lidocaine 5% patch. He still requires supplemental nasal oxygen as he does desaturate on room air to low 90's high 80's. Most recent chest xray does show some pleural fluid and atelectasis, bu no pneumothorax. He is able to illicit a fairly strong productive cough with encouragement. On hospital day 5 he self discontinued his Foley catheter with the balloon inflated and was noted to have hematuria following this. A 3 way catheter was attempted without success and so a one way Foley was replaced. He is ordered for q shift catheter flushes with sterile water. The hematuria has decreased significantly; the catheter can be removed in the next day or so as long as the hematuria has resolved. Physical and Occupational therapy were consulted and have recommended acute level rehab after his hospital stay. Medications on Admission: Allopurinol 100, Amitriptyline 25, Atenolol 100, Carbidopa-Levodopa 25-100"", Enalapril Maleate 10, GlipiZIDE 5", Gabapentin 300 [**Month/Day/Year **] Medications: 1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). [**Month/Day/Year **] Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU [**Hospital6 **] Diagnosis: s/p Fall Left hemothorax Left rib fractures [**4-30**] Traumatic hematuria [**Month/Year (2) **] Condition: Hemodynamically stable, tolerating a regular diet, pain fairly well controlled. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery. Call [**Telephone/Fax (1) 6429**] for an appointment. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab; you or your family will need to call for an appointment. Completed by:[**2147-1-31**]

[ "584.9", "807.06", "518.0", "250.60", "357.2", "496", "860.4", "401.9", "338.11", "332.0", "867.0", "428.0", "E885.9", "428.32", "518.81", "E928.9" ]

icd9cm

[ [ [] ] ]

[ "03.90", "03.91" ]

icd9pcs

[ [ [] ] ]

2881, 4465

253, 288

1027, 2858

6155, 6475

940, 1008

4491, 6132

205, 215

316, 470

492, 740

756, 924

28,050

189,966

28555

Discharge summary

report

Admission Date: [**2145-7-29**] Discharge Date: [**2145-8-2**] Date of Birth: [**2069-7-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6021**] Chief Complaint: lightheadedness and bright red blood per rectum Major Surgical or Invasive Procedure: None History of Present Illness: 76 M with history of metastatic RCC on hospice, with known metastatic disease to duodenem, s/p R hemicolectomy, duodenal resection and repair on [**2145-3-2**], who was recently hospitalization in mid-[**2145-4-25**] for recurrent GI bleed and found to have tumor invasion of the 2nd part of the duodenum-- he was felt not to be a surgical candidate at that time,and GI felt the lesion was not amenable to endoscopic intervention. He was discharged home with hospice. He now represents with BRBPR and lightheadedness. He reports that he has had melena since discharge, and has had BRBPR x 2 days. He is unable to quantify how many bowel movements he has had, or how much blood he notices per bowel movement, but states it is a lot. . ROS was otherwise essentially negative. The pt denied recent unintended weight loss, fevers, night sweats, chills, headaches, dizziness or vertigo, changes in hearing or vision, including amaurosis fugax, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: PMHx: Clear cell renal cell carcinoma - dx [**2143-10-21**]. Right kidney, metastatic to lungs. Initially on Sorafenib and Avastin. Currently being treated with perifosine on study (started [**2144-8-24**]). Followed by Drs. [**Last Name (STitle) 39628**] and [**Name5 (PTitle) **]. HTN Memory loss Cataract surgery BPH CRI - baseline Cr=1.8 Social History: Married for 37 years, no children. Unemployed, prior administrative work in [**Location (un) **], has lived in US for 4 years. Smoked [**12-27**] cigarettes per day for 5 years, quit 5 years ago. Family History: Denies cancer in family members. Physical Exam: Vitals: T:97.9 BP:126/72 P: 68 R: 18 SaO2: 97RA General: NAD, thin HEENT: NCAT, Neck: supple, no significant JVD or carotid bruits appreciated Pulmonary:scattered wheeze, diminished BS R > L Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, NT, ND, Extremities: No edema, 2+ radial, DP pulses b/l Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Pertinent Results: [**2145-7-29**] 11:10AM BLOOD WBC-7.9 RBC-1.77*# Hgb-5.2*# Hct-16*# MCV-91 MCH-29.2 MCHC-32.1 RDW-14.1 Plt Ct-269 [**2145-7-29**] 11:10AM BLOOD Neuts-84.7* Lymphs-10.8* Monos-3.6 Eos-0.7 Baso-0.2 [**2145-7-29**] 11:10AM BLOOD Glucose-143* UreaN-58* Creat-2.6* Na-133 K-4.9 Cl-100 HCO3-22 AnGap-16 [**2145-7-29**] 11:10AM BLOOD ALT-14 AST-17 CK(CPK)-22* AlkPhos-80 TotBili-0.2 [**2145-7-29**] 11:20AM BLOOD Comment-GREEN TOP [**2145-7-29**] 11:20AM BLOOD Lactate-2.6* K-4.8 . CHESTXR: Right lower lobe haziness and large right effusion are grossly unchanged since [**6-1**]. The right upper lung and left lung appear grossly unremarkable. There is no pneumothorax. Heart size is mildly enlarged, unchanged. IMPRESSION: Stable exam although cannot rule out pneumonia in the right lower lobe. The right upper and left lung are clear. . ECG - Sinus rhythm with two ventricular premature beats of the same morphology. Low voltage. Early R wave progression. Since the previous tracing of [**2145-1-28**] QRS voltage has decreased. Ventricular premature beat is new. Brief Hospital Course: ASSESSMENT: 76 man with metastatic renal cell ca on hospice at home, with metastatic spread to duodenum presents with recurrent GIB and dizzyness Hct 16 from baseline 30. Likely due to known duodenal metastatic disease. GI feels that there be no benefit to endoscopic evaluation given extent of known disease. The surgery team does not feel the patient is a surgical candidate. . PLAN: . #GI Bleed: Pt was admitted to the ICU where a family meeting resulted in the decision to stop blood transfusions and make the patient CMO. The patient's primary oncologist, who agrees that surgical or endoscopic intervention is not indicated given the patient's tumor burden and grave prognosis overall. . #Metastatic RCC: on hospice. No further treatment options per onc notes, not surgical candidate. Only supportive care was provided. . #HTN- hold antihypertensives in setting of GIB . #CKD- Cr at baseline . #Code: DNR/DNI Patient made CMO on this admission. Vital signs were done every 12 hours and no further labs were drawn after the family meeting. Medications on Admission: AMLODIPINE 10 mg Tablet METOPROLOL 12.5 mg [**Hospital1 **] OXYCODONE 5 mg PRN PANTOPRAZOLE 40 mg [**Hospital1 **] COLACE MVI Discharge Medications: 1. Morphine 10 mg/5 mL Solution Sig: [**11-25**] Teaspoons PO Q1H PRN (). Disp:*500 Teaspoons* Refills:*0* 2. Lorazepam 2 mg/mL Concentrate Sig: [**11-25**] mL PO every six (6) hours as needed for anxiety, SOB. Disp:*50 mL* Refills:*0* 3. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed for constipation. Disp:*100 doses* Refills:*0* 4. Docusate Sodium 50 mg/15 mL Syrup Sig: One (1) dose PO twice a day. Disp:*1 bottle* Refills:*2* 5. Miralax 100 % Powder Sig: One (1) dose PO twice a day as needed for constipation: dissolved in cup of water. Disp:*30 doses* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 13684**] hospice & palliative care Discharge Diagnosis: Anemia from gastrointestinal hemorrhage Renal cell carcinoma Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted for bleeding from your cancer. You are being dicsharged to hospice. Please take all medications as prescribed. Followup Instructions: Please follow-up with your oncologist as needed. Completed by:[**2145-8-3**]

[ "197.4", "189.0", "600.00", "585.9", "578.9", "403.90", "285.1", "197.0" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

5730, 5807

3873, 4919

362, 369

5926, 5935

2786, 3850

6114, 6193

2324, 2358

5096, 5707

5828, 5905

4945, 5073

5959, 6091

2373, 2767

275, 324

397, 1728

1750, 2094

2110, 2308

44,545

176,327

12759+56401

Discharge summary

report+addendum

Admission Date: [**2146-3-7**] Discharge Date: [**2146-3-13**] Date of Birth: [**2075-3-19**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: aortic stenosis Major Surgical or Invasive Procedure: aortic valve replacement (21mm St. [**Male First Name (un) 923**] tissue)with Talon plating [**2146-3-7**] History of Present Illness: This is a 70 year old female with hypertension,hyperlipidemia, and known aortic stenosis with complaints of progressive dyspnea, lightheadedness, and rare chest discomfort. She was seen in clinic in late [**Month (only) 404**] for evaluation for aortic valve replacement and possible coronary artery bypass. Past Medical History: Severe Aortic stenosis Hypertension Hyperlipidemia Atrial Fibrillation Hypothyroidism Asthma History of GI Bleed - [**2145-7-14**] Social History: Lives with: her husband ans her daughter. Primary caregiver to husband. [**Name (NI) 6419**] daughters will be staying with her during her recovery. Tobacco: Denies ETOH: Social Family History: No premature coronary disease Physical Exam: Admission: Pulse: 80 Resp: 20 O2 sat: 97% B/P Right: 146/65 Left: 140/62 Height: 5'5" Weight:224 lbs General: Elderly female in no acute distress Skin: Dry [x] intact [x] HEENT: NCAT, PERRLA, EOMI, Anicteric sclera, OP and teeth benign Neck: Supple [x] Full ROM [x] Chest: Clear to ausculatation Heart: RRR [x] Irregular [] Murmur 4/6 SEM radiating to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [x] Edema - trace Varicosities: None [x] Slight superficial spider varicosities noted. Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 2 Carotid Bruit - transmitted murmurs noted Pertinent Results: Echo [**2146-3-7**] PREBYPASS No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is [**1-15**]+ TR. POSTBYPASS Biventricular systolic function is preserved. There is a well seated, well functioning bioprosthesis in the aortic position. No AI is visualized. The remaining study is unchanged from prebypass. [**2146-3-12**] 04:52AM BLOOD WBC-7.8 RBC-3.42* Hgb-9.3* Hct-29.4* MCV-86 MCH-27.2 MCHC-31.7 RDW-14.6 Plt Ct-198 [**2146-3-7**] 10:35AM BLOOD WBC-12.0*# RBC-2.88*# Hgb-8.5*# Hct-25.3*# MCV-88 MCH-29.6 MCHC-33.8 RDW-13.7 Plt Ct-177 [**2146-3-12**] 04:52AM BLOOD PT-12.3 PTT-25.8 INR(PT)-1.0 [**2146-3-7**] 10:35AM BLOOD PT-12.9 PTT-33.0 INR(PT)-1.1 [**2146-3-12**] 04:52AM BLOOD Glucose-94 UreaN-32* Creat-0.8 Na-141 K-4.0 Cl-101 HCO3-33* AnGap-11 [**2146-3-7**] 12:12PM BLOOD UreaN-29* Creat-0.6 Cl-110* HCO3-25 [**Known lastname 39369**],[**Known firstname **] [**Medical Record Number 39370**] F 70 [**2075-3-19**] Radiology Report CHEST (PA & LAT) Study Date of [**2146-3-12**] 9:42 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2146-3-12**] 9:42 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 39371**] Reason: eval for effusion [**Hospital 93**] MEDICAL CONDITION: 70 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for effusion Preliminary Report Preliminary reports are not available for viewing. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Imaging Lab [**Known lastname 39369**],[**Known firstname **] [**Medical Record Number 39370**] F 70 [**2075-3-19**] Radiology Report CHEST (PA & LAT) Study Date of [**2146-3-12**] 9:42 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2146-3-12**] 9:42 AM CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 39371**] Reason: eval for effusion [**Hospital 93**] MEDICAL CONDITION: 70 year old woman s/p AVR REASON FOR THIS EXAMINATION: eval for effusion Final Report PA AND LATERAL CHEST ON [**3-12**] HISTORY: Evaluate effusion after AVR. IMPRESSION: PA and lateral chest compared to [**3-9**]: Moderate right pleural effusion and right basilar atelectasis have increased. Left lower lobe is well aerated, small left pleural effusion may be present. Mild postoperative enlargement of the cardiomediastinal silhouette is stable. No pneumothorax. Right jugular line tip projects over the superior cavoatrial junction. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: SAT [**2146-3-12**] 10:05 PM Imaging Lab [**2146-3-12**] 04:52AM BLOOD WBC-7.8 RBC-3.42* Hgb-9.3* Hct-29.4* MCV-86 MCH-27.2 MCHC-31.7 RDW-14.6 Plt Ct-198 [**2146-3-7**] 10:35AM BLOOD WBC-12.0*# RBC-2.88*# Hgb-8.5*# Hct-25.3*# MCV-88 MCH-29.6 MCHC-33.8 RDW-13.7 Plt Ct-177 [**2146-3-12**] 04:52AM BLOOD PT-12.3 PTT-25.8 INR(PT)-1.0 [**2146-3-7**] 10:35AM BLOOD PT-12.9 PTT-33.0 INR(PT)-1.1 [**2146-3-12**] 04:52AM BLOOD Glucose-94 UreaN-32* Creat-0.8 Na-141 K-4.0 Cl-101 HCO3-33* AnGap-11 [**2146-3-8**] 03:31AM BLOOD Glucose-112* UreaN-27* Creat-0.8 Na-138 K-4.7 Cl-106 HCO3-26 AnGap-11 Brief Hospital Course: The patient was admitted to the hospital and brought to the Operating Room on [**2146-3-7**] where she underwent aortic valve replacement with a 21mm St. [**Male First Name (un) 923**] tissue valve, along with Talon plating for closure. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition, intubated, requiring pressors to optimize her cardiac function. POD#1 she awoke neurologically intact and was extubated without difficulty. Pressors were weaned off. Beta-Blocker/Statin/aspirin/diuretics were initiated. All lines and drains were discontinued in a timely fashion. Her creatinine rose to 1.5 (from her baseline of 0.8) on POD 2. Diuretic doses were decreased and her creatnine function improved to her baseline. Postoperatively she experienced paroxysmal atrial fibrillation. She was started on anticoagulation with Coumadin for her arrhythmia. POD#3 she was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation of strength and mobility. She continued to progress and was cleared for discharge to home on POD#6. INR/Coumadin dosing to be foloowed by Dr.[**Last Name (STitle) **]. All follow up appointments were advised. Medications on Admission: Advair 2 puffs IH daily Albuterol PRN ASA 81mg po daily Detrol 5mg po TID HCTZ 25mg po daily Prilosec 20mg po daily Synthroid 88mcg po daily Zestril 40mg po daily MVI qd Vitamin C Calcium Vitamin D2 Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 7. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation twice a day. Disp:*60 Disk with Device(s)* Refills:*2* 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*qs * Refills:*0* 10. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Outpatient Lab Work Serial PT/INR dx: atrial fibrillation goal INR 2-2.5 Results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 8539**] 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: vna carenetwork Discharge Diagnosis: Severe Aortic stenosis, s/p aortic valve replacement [**2146-3-7**] Hypertension Hyperlipidemia Atrial Fibrillation Hypothyroidism Asthma/?COPD History of GI Bleed - [**2145-7-14**] Severe Aortic stenosis s/p aortic valve replacement Hypertension Hyperlipidemia paroxysnmal Atrial Fibrillation Hypothyroidism Asthma History of GI Bleed - [**2145-7-14**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with ** prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) **] [**2146-4-14**] @ 1pm ([**Telephone/Fax (1) 170**]) Primary Care Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 8539**]) in [**1-15**] weeks Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3497**] ([**Telephone/Fax (1) 37180**]) in [**1-15**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2146-3-13**] Name: [**Known lastname 7112**],[**Known firstname **] Unit No: [**Numeric Identifier 7113**] Admission Date: [**2146-3-7**] Discharge Date: [**2146-3-13**] Date of Birth: [**2075-3-19**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 741**] Addendum: Discharge Medications Update: -5 mg po Warfarin tonight - then daily [**Name8 (MD) **] MD. [**First Name (Titles) 7114**] [**Last Name (Titles) **] >2.0 for paroxysmal Atrial fibrillation. Discharge Medications: 1. Aspirin 81 mg [**Last Name (Titles) 7115**], Delayed Release (E.C.) Sig: One (1) [**Last Name (Titles) 7115**], Delayed Release (E.C.) PO DAILY (Daily). 2. Oxybutynin Chloride 5 mg [**Last Name (Titles) 7115**] Sig: One (1) [**Last Name (Titles) 7115**] PO TID (3 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Levothyroxine 88 mcg [**Last Name (Titles) 7115**] Sig: One (1) [**Last Name (Titles) 7115**] PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg [**Last Name (Titles) 7115**] Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 [**Last Name (Titles) 7115**](s)* Refills:*0* 6. Acetaminophen 325 mg [**Last Name (Titles) 7115**] Sig: Two (2) [**Last Name (Titles) 7115**] PO Q4H (every 4 hours) as needed for fever/pain. 7. Paroxetine HCl 10 mg [**Last Name (Titles) 7115**] Sig: One (1) [**Last Name (Titles) 7115**] PO DAILY (Daily). Disp:*30 [**Last Name (Titles) 7115**](s)* Refills:*0* 8. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation twice a day. Disp:*60 Disk with Device(s)* Refills:*2* 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*qs * Refills:*0* 10. Ascorbic Acid 500 mg [**Last Name (Titles) 7115**] Sig: Two (2) [**Last Name (Titles) 7115**] PO DAILY (Daily). 11. Cholecalciferol (Vitamin D3) 400 unit [**Last Name (Titles) 7115**] Sig: Two (2) [**Last Name (Titles) 7115**] PO DAILY (Daily). 12. Amiodarone 200 mg [**Last Name (Titles) 7115**] Sig: One (1) [**Last Name (Titles) 7115**] PO DAILY (Daily). Disp:*30 [**Last Name (Titles) 7115**](s)* Refills:*0* 13. Multivitamin [**Last Name (Titles) 7115**] Sig: One (1) [**Last Name (Titles) 7115**] PO DAILY (Daily). 14. Outpatient Lab Work Serial PT/[**Last Name (Titles) 7114**] dx: atrial fibrillation [**Last Name (Titles) **] [**Last Name (Titles) 7114**] 2-2.5 Results to Dr. [**Last Name (STitle) 7116**] [**Telephone/Fax (1) 7117**] 15. Metoprolol Tartrate 25 mg [**Telephone/Fax (1) 7115**] Sig: One (1) [**Telephone/Fax (1) 7115**] PO BID (2 times a day). Disp:*60 [**Telephone/Fax (1) 7115**](s)* Refills:*2* 16. Furosemide 20 mg [**Telephone/Fax (1) 7115**] Sig: One (1) [**Telephone/Fax (1) 7115**] PO BID (2 times a day) for 7 days. Disp:*14 [**Telephone/Fax (1) 7115**](s)* Refills:*0* 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 18. Warfarin 2.5 mg [**Telephone/Fax (1) 7115**] Sig: Two (2) [**Telephone/Fax (1) 7115**] PO once for 1 doses. Disp:*2 [**Telephone/Fax (1) 7115**](s)* Refills:*0* 19. Warfarin 2.5 mg [**Telephone/Fax (1) 7115**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 7115**] [**Last Name (Titles) **] once a day: [**Last Name (Titles) 7114**] [**Last Name (Titles) **]>2.0 for Paroxysmal Atrial Fibrillation. Disp:*90 [**Last Name (Titles) 7115**](s)* Refills:*2* Discharge Disposition: Home With Service Facility: vna carenetwork [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2146-3-13**]

[ "458.29", "285.9", "244.9", "401.9", "E878.8", "493.20", "427.31", "424.1", "584.9", "997.1", "272.4" ]

icd9cm

[ [ [] ] ]

[ "35.21", "36.11", "39.61", "36.19" ]

icd9pcs

[ [ [] ] ]

14398, 14567

5609, 6857

327, 436

9481, 9571

1995, 3617

10195, 11271

1140, 1172

11294, 14375

4331, 4357

9103, 9460

6883, 7084

9595, 10172

1187, 1976

272, 289

4389, 5586

464, 774

796, 929

945, 1124

16,013

126,395

2189

Discharge summary

report

Admission Date: [**2130-3-3**] Discharge Date: [**2130-3-4**] Service: [**Location (un) 259**]-M HISTORY OF PRESENT ILLNESS: Miss [**Known lastname **] is an 87 year old Portugese-Creole speaking only woman who presented to the [**Hospital1 69**] Emergency Room on [**2130-3-3**], complaining of left lower quadrant abdominal pain, sharp or knife-like in quality, which had begun the night prior to admission and increased with bowel movements. There was no blood in the stool per the patient. She denied vaginal bleeding, urinary symptoms, dysuria, recent travel or fevers. In the Emergency Room, there was some question of whether the patient was having chest pain and in fact the patient was found to have a left bundle branch block with a tachycardia superimposed to the 140 range. In the Emergency Room, the patient was placed on a Diltiazem drip as well as heparin and her systolic blood pressure at one point was noted to be above 200, lowered to an acceptable range. She received chest CT scan for a question of a pulmonary embolism and was sent initially to the Medical Intensive Care Unit for question of hypertensive crisis. PAST MEDICAL HISTORY: 1. PPD positive. 2. Chronic renal insufficiency. 3. Diabetes mellitus. 4. Transient ischemic attacks. 5. Peripheral vascular disease. 6. Chronic obstructive pulmonary disease (asthma), home O2. 7. Coronary artery disease status post coronary artery bypass graft in [**2121**], status post cholecystectomy. 8. History of pulmonary embolism in [**2127**]; recently on Coumadin for anti-coagulation. 9. History of what were evidently had been multiple myocardial infarctions. MEDICATIONS AT THE TIME OF ADMISSION: 1. Imdur 60 mg p.o. q. day. 2. NPH [**5-16**]. 3. Lisinopril 20 mg p.o. q. day. 4. Protonix 40 mg p.o. q. day. 5. Klonopin 0.5 mg. 6. Lipitor. 7. Atenolol. 8. Paxil, 10 mg q. day. 9. Colace. 10. Diltiazem 120 mg p.o. twice a day. 11. Atenolol 25 mg p.o. q. day. PHYSICAL EXAMINATION: At the time of admission in the Emergency Department, the patient had vital signs noted 97.2 F., temperature; heart rate 139 decreasing to 110 on a Diltiazem drip; blood pressure 180/120 decreasing to 145/61, again on the Diltiazem drip; respiratory rate was 39; 99% was the pulse oxygenation. In general, a moderately obese woman in respiratory distress. She was noted to be normocephalic with raccoon eyes. Oropharynx was clear. There were no bruits appreciated. No jugular venous distention was noted. There was thought to be some accessory muscle use. Breath sounds were coarse at the bases with rare rales. The patient was, on cardiac examination, tachycardic. S1 and S2 were normal. No murmurs, rubs or gallops. The abdomen was softly distended with tenderness to palpation epigastrically and in the left lower quadrant. The rectal examination was negative with no stool. There is no cyanosis, clubbing or edema. PHYSICAL EXAMINATION: At the time of admission to the Floor some hours later was as follows: Temperature 96.9 F.; blood pressure 162/90; pulse 90; respirations 20; 96% on two liters. The patient speaking fluent Creole/Portugese, however, not clearly oriented to place or time, although difficulties with initial interpretation. Extraocular movements were intact. Pupils equally round and reactive to light bilaterally and directly and consensually with fundi obscured bilaterally with cataracts. Extraocular movements did not show evidence for nystagmus. There was some left conjunctival hemorrhage. Mucous membranes were moist. Racoon's eyes were noted again bilaterally without battle signs. Tympanic membranes were poorly visualized, but there was no clear evidence for hemotympanum. The neck was supple. There was no jugular venous distention. Cardiac examination was unremarkable. The chest was clear with a left sided pleural rub heard throughout the left side of the chest. The abdomen was soft with positive bowel sounds, not significantly distended, but some minor tenderness to palpation in the left lower quadrant. There was a bruise of the right shin and the left heel appeared to be between 1 and 3 cm lower than the right. LABORATORY DATA: CBC was as follows at admission, 7.7 was the white blood cell count, hematocrit 41.7, with 67% neutrophils, 25% lymphocytes, 5% monocytes. Platelet count of 214. PT on admission was 16.1, with an INR of 1.8. PTT was 26.9. Urinalysis was negative. Chem-7 at time of admission showed a sodium of 141, potassium of 3.7, chloride 101, bicarbonate 29, BUN 22, creatinine of 1.1, glucose 368 at first measure. Cardiac enzymes were repeatedly cycled with values all within the 20 to 25 range. Troponin were less than or equal to 0.4. Amylase was 190; lipase of 20, ALT 18, AST 18, alkaline phosphatase 117, total bilirubin 0.4, albumin 3.2, calcium 9.0, phosphate 2.8, magnesium 1.7. TSH is pending at the time of discharge. Stool studies are pending at the time of discharge. Urine culture showed 10 to 100,000 organisms of Proteus mirabilis. Chest x-ray on [**3-3**], was as follows: No acute cardiopulmonary process. A chest CT scan performed on the same day showed no pulmonary embolus, left pleural and parenchymal calcifications and left lower lobe volume loss, i.e. fibrothorax from prior inflammatory process as well as traction bronchiectasis. The head CT scan was performed on [**3-4**], with the following impression: No intracranial hemorrhage, no evidence of skull fracture. Hip x-rays are pending at the time of this dictation. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with the above-stated complaints on a heparin drip as well as a Diltiazem drip. The patient's cardiac issues rapidly settled with the patient once again developing a regular rate. The patient's EKG was felt to represent tachycardia with left bundle branch block but without other pathology. The patient ruled out by cardiac enzymes. Once the patient was stabilized, the patient was rapidly transferred to the Floor for further management. Secondary to concerns surrounding the additional history that the patient gave of a fall approximately three days prior to admission with racoon's eyes on examination, the patient was sent for a CT scan of the head to rule out intra-cranial bleeding or base of the skull fracture. This study was negative. In the absence of evidence to suggest acute cardiac process, heparin was discontinued. Stool studies were sent which are pending at the time of this discharge. The patient's urine did grow out between 10 and 100,000 organisms of Proteus mirabilis as stated above. On [**3-4**], the patient was thought to be much improved with no significant abdominal tenderness and no Telemetry events overnight with a pulse in the 80s and systolic blood pressure in the 160s. As the patient had formerly multiple times been evaluated for abdominal pain including mesenteric angiography and CT scan of the abdomen without a diagnosis being reached, the decision was made to discharge the patient home or appropriate outpatient follow-up with her outpatient provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**]. MEDICATIONS AT DISCHARGE: 1. Imdur 60 mg p.o. q. day. 2. NPH [**5-16**]. 3. Lisinopril 20 mg p.o. q. day. 4. Protonix 40 mg p.o. q. day. 5. Klonopin 0.5 mg. 6. Lipitor. 7. Atenolol. 8. Paxil, 10 mg q. day. 9. Colace. 10. Diltiazem 120 mg p.o. twice a day. 11. Atenolol 25 mg p.o. q. day. 12. Bactrim DS, one tablet p.o. three times a day times ten days for presumed Proteus mirabilis urinary tract infection. 13. Please note that the patient will also be discharged on Metered-Dose Inhalers for presumed chronic obstructive pulmonary disease with reactive component and will follow-up with her primary care physician to determine whether this treatment is necessary. DISCHARGE DIAGNOSES: 1. Ruled out for myocardial infarction. 2. No evidence for pulmonary embolism. 3. No evidence of acute intracranial process. 4. Recurrence of chronic intermittent abdominal pain of unexplained etiology. 5. Diabetes mellitus. 6. Asthma. CONDITION AT DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: [**First Name8 (NamePattern2) **] [**Doctor Last Name **] M.D [**MD Number(1) 9783**] Dictated By:[**Name8 (MD) 2058**] MEDQUIST36 D: [**2130-3-4**] 16:05 T: [**2130-3-6**] 13:55 JOB#: [**Job Number 11659**]

[ "412", "427.89", "414.00", "250.00", "493.20", "786.50", "426.3", "401.9", "789.04" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7894, 8147

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2946, 5545

8163, 8172

136, 1153

1175, 1968

74,693

123,230

41896

Discharge summary

report

Admission Date: [**2198-12-24**] Discharge Date: [**2199-1-11**] Date of Birth: [**2144-12-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1253**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Intubation Post-pyloric feeding tube placement History of Present Illness: 54 yo male with history of chronic pancreatitis admitted to [**Hospital 2725**] Hospital [**12-23**] with 5 days of increasing abdominal pain, vomiting, fever up to 105 in setting of recent alcohol use (reportedly [**3-11**] Mikes Hard Lemonade/week). Pt was diagnosed with severe pancreatitis with initial lactate of 13, now down to 2.8. Patient has been resuscitated with at least 8L fluid, blood presure has been stable with sysolics in 160s, tachycardic, fever down to 102 with cooling blanket and tylenol. Physical exam remarkable for distended abdomen, crackles on lung exam. Other labs were remarkable for amylase 314, lipase >400, a white count of 18, hct 48, initial anion gap of 19 which has since decreased to 9. His bladder pressure was measured at 35mmhg, though reportedly still making urine at 80 cc/hr. Pt was electively intubated prior to transfer to [**Hospital1 18**]. ABG prior to intubation: 7.33/35/79. He was started on zosyn q6hr. Also placed on CIWA scale, had been [**Doctor Last Name **] around 8, on standing valium and ativan PRN. . Pt has history of pancreatitis beginning in [**2196**] which was complicated by pancreatic necrosis. He required a J tube for [**7-11**] months. Since then, he has had at least 1 other episode of pancreatitis for which he was hospitalized at the [**Hospital1 756**]. The etiology of his pancreatitis is unclear, denying a history of heavy alcohol use and no history of gallstones, though he did have a cholecystectomy for chronic cholecystitis. Per family report, pt was drinking several 6 packs of beers prior to admission which raises the question again of alcoholic induced pancreatitis. He has had abnormal LFTs in the past, and has had an ERCP at [**Hospital1 756**] that revealed only mild common bile duct dilation, no other abnormalities. This procedure was complicated by post-ERCP pancreatitis. He has also had pancreas function tests performed, which showed a peak bicarb of 62 (normal >80). His chronic pain has been managed with morphine and methadone. . Pt recently established care with GI at [**Hospital1 18**]. He was seen in [**Month (only) **] with complaints of nausea, fatigue and malaise, no diarrhea or constipation. He reports at baseline, pain is [**6-12**]. Denied any alcohol use at that time. . On the floor, pt is intubated and sedated, unresponsive. . Review of systems: (+) Per HPI, 25-30 pound weight gain over past several months, decreased energy, abnormal sleeping patterns, decreased motivation. Complains of pill dysphagia, no constipation or diarrhea. (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Necrotizing pancreatitis complicated by acute fluid collection and a small pseudocyst in the tail which gradually disappeared over time. All this occurred in approximately [**2196**] and his care has been at [**Hospital2 **] [**Hospital3 6783**] Hospital, [**State 17405**], and most recently [**Hospital6 **]. 2. Prior celiac plexus block for pain control attempted [**4-/2197**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with no apparent benefit. 3. Status post ERCP in [**2196**] or [**2197**] by Dr. [**Name (NI) 90959**], apparently notable only for mild biliary dilation and no sludge- complicated by post ERCP pancreatitis according to patient 4. Status post cholecystectomy. 5. Hypertriglyceridemia. 6. Hypertension. 7. Multiple shoulder surgeries. 8. Fatty liver. 9. Schatzki's ring. 10. Gastritis. 11. Submucosal mass in the duodenum ? gastric varices, ? splenic vein thrombosis Social History: Currently on disability but former restaurant manager prior to onset of pancreatitis in [**2196**]. Lives with his sister and mother now since his wife passed away last year. Formerly very active and has completed the [**Location (un) 86**] Marathon 4 times. Has remote history of smoking, denies any heavy alcohol use, questionable recent alcohol use. Family History: He has a familial history of hypertriglyceridemia. His sister has MS. There is no family history of pancreatitis or pancreatic cancers as far as he knows. No other family history of GI or liver disease as far as he knows. Physical Exam: On Admission: General: intubated, sedated, unresponsive HEENT: pupils pinpoint, non reactive, anicteric sclera Neck: supple, obese, difficult to assess JVP Lungs: Clear to auscultation bilaterally anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, non tender though sedated, hypoactive bowel sounds, no rebound tenderness or guarding, no organomegaly GU: foley with dark amber urine Ext: cool feet, 1+ pulses bilaterally, no peripheral edema . . Discharge: Afebrile 144/86 p65 18 95%RA GEN: comfortable, non-toxic. RESP: CTA B. CV: RRR. No MRG. ABD: +BS. TTP epigastrium. Psych: pleasant, engaging. Pertinent Results: Prior Relevant Studies: MRCP ([**Hospital1 756**] [**8-/2197**]): mild chronic pancreatitis predominantly involving the pancreatic body and tail. There is a small collection of fluid that was only 1.3 cm in size near the body and tail, which had decreased in diameter from prior studies. There is evidence of fatty liver and there is also evidence of mild stable intra and extra-hepatic biliary ductal dilation without any evidence of stones. . EGD ([**11/2198**]) Nonobstructing Schatzki's ring in distal esophagus Linear erythema, petechiae and erosion in the stomach body and antrum compatible with erosive gastritis A sub-mucosal 1 cm mass was found at the second part of the duodenum. The appearance was somewhat suggestive of a lipoma, but the classic 'pillow sign' was not definitive with a biopsy forceps probe, and the area was adjacent to the ampulla. RECOMMENDATIONS: Start omeprazole 20mg [**Hospital1 **] Outpatient EUS in the next several months for further evaluation of submucosal lesion in D2. Will consider dilation of Schatzki's ring at that point as well depending on patient's symptoms Pathology consistent with chemical gastritis and chronic inflammation. . CT at OSH: severe fulminant pancreatitis, no clear necrosis ___________________________________________________ At [**Hospital1 18**]: CT ABD & PELVIS WITH CONTRAST Study Date of [**2198-12-30**] IMPRESSION: 1. Increased size and organization of pancreatic fluid collection, now extending along the greater curvature of the stomach, which may represent a forming pseudocyst. 2. Mild ascending colonic wall thickening, which is likely reactive. _____________________________ CT HEAD W/O CONTRAST Study Date of [**2198-12-30**] IMPRESSION: Ventricular prominence slightly out of proportion to degree of cortical atrophy and patient's age, raising suspicion for mild hydrocephalus. Clinical correlation is recommended for signs of increased intracranial pressure. NOTE ON ATTENDING REVIEW: While the lateral ventricels and sulci are prominent and midlly dilated and more than expected for the stated age of 54years, this appearance may relate to volume loss rather than hydrocephalus/NPH as raised in the prelim. read. To correlate clinically for risk factors for volume loss. Further workup as clinically indicated. D/w Dr.[**Last Name (STitle) **] by Dr.[**Last Name (STitle) **] on [**2198-12-30**] at 2.30pm by phone. Mild mucosal thickening is noted in the maxillary, ethmoid, frontal and sphenoid sinuses. A few dense foci are noted in the right maxillary sinus ( se 2a, im 1) which may relate to inspissated secretions or related to adjcent bone- attention on f/u with CT sinus can eb considered. _____________________________ [**2198-12-25**] 09:42AM BLOOD WBC-8.6 RBC-4.09* Hgb-13.4* Hct-40.5# MCV-99* MCH-32.7* MCHC-33.1 RDW-13.4 Plt Ct-122* [**2199-1-9**] 07:30AM BLOOD WBC-10.2 RBC-3.67* Hgb-11.7* Hct-37.4* MCV-102* MCH-32.0 MCHC-31.4 RDW-12.9 Plt Ct-613* [**2199-1-3**] 10:30AM BLOOD PT-13.5* INR(PT)-1.3* [**2198-12-24**] 08:34PM BLOOD Glucose-270* UreaN-20 Creat-0.8 Na-140 K-3.9 Cl-112* HCO3-19* AnGap-13 [**2199-1-6**] 09:00AM BLOOD Glucose-318* UreaN-10 Creat-0.7 Na-130* K-5.1 Cl-92* HCO3-28 AnGap-15 [**2199-1-7**] 07:10AM BLOOD Glucose-286* UreaN-10 Creat-0.6 Na-130* K-4.7 Cl-94* HCO3-27 AnGap-14 [**2199-1-9**] 07:30AM BLOOD Glucose-217* UreaN-10 Creat-0.7 Na-132* K-5.1 Cl-96 HCO3-25 AnGap-16 [**2198-12-24**] 08:34PM BLOOD ALT-115* AST-161* LD(LDH)-1104* AlkPhos-51 Amylase-168* TotBili-1.7* DirBili-0.8* IndBili-0.9 [**2199-1-4**] 08:05AM BLOOD ALT-27 AST-29 AlkPhos-71 TotBili-0.6 [**2198-12-28**] 08:49PM BLOOD CK-MB-2 cTropnT-<0.01 [**2198-12-29**] 02:23AM BLOOD CK-MB-2 cTropnT-<0.01 [**2198-12-25**] 09:42AM BLOOD Albumin-2.9* Calcium-6.1* Phos-1.1* Mg-2.1 [**2199-1-7**] 07:10AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.6 [**2199-1-1**] 02:55AM BLOOD VitB12-GREATER TH Folate-16.9 [**2198-12-24**] 08:34PM BLOOD Triglyc-341* HDL-8 CHOL/HD-14.0 LDLcalc-36 [**2199-1-1**] 02:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [**2199-1-1**] 02:55AM BLOOD HCV Ab-NEGATIVE [**2199-1-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2199-1-3**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2199-1-2**] URINE URINE CULTURE-FINAL INPATIENT [**2199-1-2**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram Stain-FINAL INPATIENT [**2199-1-2**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2199-1-2**] IMMUNOLOGY HCV VIRAL LOAD-HCV-RNA NOT DETECTED [**2198-12-30**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2198-12-30**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2198-12-29**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2198-12-28**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2198-12-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [**2198-12-28**] URINE URINE CULTURE-FINAL INPATIENT [**2198-12-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2198-12-27**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2198-12-26**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2198-12-25**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2198-12-25**] URINE URINE CULTURE-FINAL INPATIENT [**2198-12-24**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT Brief Hospital Course: Mr. [**Known lastname 90960**] is a 54 yo male with history of chronic pancreatitis, admitted for recurrent episode of acute pancreatitis, transferred to [**Hospital1 18**] for further management and continuity of care. # Acute pancreatitis: The patient initially presented to [**Hospital 2725**] Hospital with 5 days of increasing abdominal pain, vomiting. Found to be febrile with elevated lipase and abdominal CT showing pancreatitis. Elevated bladder pressure to 35 although making urine. Started on Zosyn due to leukocytosis and fever. Transferred to [**Hospital1 18**]. At [**Hospital1 18**], the patient was continued on IVF resus. He was intubated to protect his airway, and then successfully extubated after several days. Bladder pressure was 36 on arrival although trended down to 15 and remained low. Abdomen was not tense and surgery declined intervention. Zosyn was discontinued on HOD #1 due to abscence of infectious source; fever was thought [**3-7**] pancreatitis after extensive search revealed no obvious infectious source. Followed by panc service and severe pancreatitis protocol was adhered to. His lactate trended down from 13 on arrival to within the normal range within a few days. Social work was consulted about helping pt get sober, which will hopefully prevent future pancreatitis episodes. Patient reported acute exacerbation in etoh consumption surrounding wifes passing 3 months ago. A dobhoff was placed for tube feeding by IR in the post pyloric position. He was continued on tube feeds. The pancreatitis team followed his case closely. His abdominal pain significantly improved and was close to baseline as of [**1-6**] as he typically has [**2197-5-10**] pain at baseline and currently his pain is similar without need for any pain medication. #Encephalopathy: multi-factorial. The patient was agitated and reportedly not protecting his airway at [**Hospital 2725**] Hospital. Was intubated prior to transfer to [**Hospital1 18**]. At [**Hospital1 18**], the patient was placed on fent/midaz for sedation. Required large amounts of benzos to maintain sedation and was delerious/agitated when sedation lightened. There was likely a component of etoh withdrawal. After he was extubated he remained very sedate for 2 days and was started on olanzapine 5mg po bid with prn haldol. Haldol was ultimately increased to standing 2.5 mg [**Hospital1 **]. By day 2 post extubation he was 1+0 x 3 and haldol was d/ced. His dose of olanzapine was reduced to 2.5mg and he required intermittent use of haldol on the first few days on the floor, but he has not required further haldol and his mental status is much improved without evidence of further ETOH withdrawal. Lactulose started for possible hepatic encephalopathy. His mental status gradually improved, and all antipsychotics were discontinued. He was initially treated with lactulose, but the last dose of lactulose given [**2199-1-7**]. Pt's mental status remains clear. It remains unclear if pt had hepatic encephalopathy. Will hold off on further lactulose for now, but if pt develops acute confusion/encephalopathy in the future, may need to have resumed. Family reported his mental status is currently at baseline. He was evaluated by Occupational Therapy, who reported that he is cognitively intact, and they had no concerns. #DM2 uncontrolled without complications: Not on insulin at baseline. Likely endocrine pancreas insufficiency in setting of acute on chronic pancreatits. He had significant hypergylcemia during admission with use of over 50 units of insulin per day. [**Last Name (un) **] endocrinology service consulted and insulin was titrated during the admission. He should follow up with an endocrinologist after discharge. #Liver disease: known to have steatosis on imaging. Suspected to have component of hepatic encephalopathy given asterexis on exam so lactulose started, but never actually diagnosed with cirrhosis. Hepatitis serologies negative for HBV, HCV. Initiated vaccination with HBV series ([**1-3**], first dose). Coagulopathy and transaminitis improved. # Pain management: Pt has chronic pain from pancreatitis, at home managed with morphine 30 mg q.4h. p.r.n., methadone 20 mg three times per day. Methadone restarted on HOD #1, then stopped after extubation due to sedation. Discussed pain medication options with patient, and pt prefers not to start pain medications at this time, given current medical issues, recent encephalopathy, and his concern for addiction issues. Pt states decides needs medical management. # Alcohol use: family reports large amount of alcohol use at home. At the OSH he had been on standing valium at OSH along with ativan CIWA scale. CIWA was ultimatly discontined and he was continued on midaz. He was continued on thiamine and folate supplementation. During multiple family meetings the patient indicated his interest in stopping drinking alcohol and enrolling in a counseling program. His family was supportive of this. SW has been involved and helped with referral to substance abuse programs. Pt is being discharged to [**Location (un) 3244**] at [**Location (un) 73266**] for inpatient alcohol rehab, where they can also help the patient manage his diabetes. # Hypertension: Antihypertensives initially held in acute setting. His home meds including lisinopril and metoprolol were utlimately restarted. # Depression: team initially thought patient on SSRI so celexa 40mg continued during hospitalization. prior outpatient reports note use of fluoxetine. Patient did well on Celexa 40mg, so this was continued at discharge. Medications on Admission: ativan -0.5mg qhs lisinopril 5mg qd atenolol 50mg qd zofran PRN methadone 15mg TID sildenafil PRN MVI Discharge Disposition: Extended Care Facility: [**Location (un) 3244**] Treatment Center - [**Hospital1 1562**] Discharge Diagnosis: # Acute severe pancreatitis # Acute encephalopathy; likely hepatic vs delerium tremens # Alcohol abuse with acute alcohol withdrawl; possibly complicated by delerium tremens # New Diabetes, controlled with insulin # Chronic abdominal pain, d/t chronic pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized for acute pancreatitis related to alcohol abuse. You are strongly encouraged to stop drinking. Each episode of pancreatitis can be life threatening and lead to severe complications, including death. You were given the first dose of Hepatitis B vaccine. The second dose is due in [**2199-2-3**] and the third in [**2199-6-4**]. You will need close monitoring of your blood sugars and insulin use. Followup Instructions: Name: PARULKAR,SMITA B. Location: [**Hospital 90961**] MEDICAL GROUP Address: [**Doctor Last Name **], [**Hospital1 **],[**Numeric Identifier 71574**] Phone: [**Telephone/Fax (1) **] **Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge.** Name: [**Last Name (LF) 1252**], [**First Name3 (LF) **] S S. MD Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Appointment: FRIDAY [**1-18**] AT 8:30AM Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2199-2-13**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

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13641

Discharge summary

report

Admission Date: [**2120-9-23**] Discharge Date: [**2120-9-28**] Date of Birth: [**2058-6-2**] Sex: M Service: [**Company 191**] PRESENT ILLNESS: This is a 62-year-old male with a history of metastatic malignant melanoma metastatic to liver, lungs, and brain and small bowel who was admitted with right flank pain times two days and shortness of breath times two days. The patient had woken up from sleep four days ago with right flank pain which was pleuritic and radiated to the chest and arm. He became short of breath two days prior to admission. The patient had two recent car trips, had no leg swelling, and the review of systems was otherwise negative. Patient was first diagnosed in [**2107**] with melanoma and has been complicated by cerebral hemorrhage in [**12/2119**] with associated seizures status post craniotomy and also by the aforementioned metastases to liver and small bowel. Patient most recently has been treated on Dilantin, thalidomide, Temozolomide. This patient is status post numbers of years of chemotherapy and adjuvant treatment, including Interferon, IL2, and the most recent therapy listed above. Patient was enrolled in the current clinical trial in [**2120-6-30**], which has included whole-brain radiation, Temozolomide, and thalidomide. He recently completed the first 10-week cycle two weeks ago, and repeat CT scans and the brain MRI, which were done on [**9-12**], revealed significant regression in his ............ abdominal and pelvic disease, undetectable pulmonary nodules, and regression of the lesions in his brain. Patient had numerous risk factors for a clot, which included his known malignancy, his treatment with thalidomide, which can be prothrombotic, his long car rides, which were greater than three hours times two. In the Emergency Room the patient had a CT angiogram which showed 1) bilateral large pulmonary emboli with clot in the left main pulmonary artery bifurcation of the left and right main pulmonary arteries, 2) right-sided pulmonary effusion, and 3) collaterals of left chest wall suggesting a left subclavian clot. Patient was not started on anticoagulation given his past medical history of spontaneous bleeding and his melanoma metastases to the brain. Patient was admitted from the Emergency Room to the [**Hospital Unit Name 153**]. PAST MEDICAL HISTORY: 1. Malignancy melanoma diagnosed in [**2107**]. 2. Brain metastases status post XRT whole-brain radiation in the spring and summer of [**2120**]. 3. Cranial bleed in 12/[**2119**]. 4. Seizure in 12/[**2119**]. 5. Stereotactic radiosurgery to the frontal lobe. 6. Lung and small bowel metastases. ALLERGIES: 1. Reglan. 2. Iodine although he can take contrast. SOCIAL HISTORY: Patient is a former urologist and his oncologist fellow is [**First Name5 (NamePattern1) 402**] [**Last Name (NamePattern1) 41157**]. OUTPATIENT MEDICATIONS: 1. Dilantin 300 b.i.d. 2. Chemotherapy with Temozolomide and thalidomide, as mentioned before. EXAM ON ADMISSION: Vital signs: 94% Oxygen saturation on two liters nasal cannula. Blood pressure was 140/76. Heart rate 65. In general this was a middle-aged man lying flat post procedure. Pain with movements. HEENT showed alopecia, plethora of the head and face. Oropharynx: Clear, PERRL and bilateral nystagmus. Jugular venous distention lying flat 4 cm from clavicular line. No carotid bruits. Lungs: Right-sided one-third up reduced breath sounds, rales at the edge of the base, reduced breath sounds bilaterally, reduced fremita. Cardiovascular: Regular rate, S1, S2, elevated T2, no murmurs, gallops, rubs. Abdomen: Nontender, soft, positive bowel sounds. Extremities: No clubbing, cyanosis, edema, [**3-3**] dorsalis pedis and posterior tibial. Neuro: Alert and oriented, pleasant. There are no significant laboratory abnormalities on admission. HOSPITAL COURSE: Patient was admitted from the Emergency Room where he had a CT angiogram showing 1) bilateral large pulmonary embolus with the largest embolus seen in the left main pulmonary artery; saddle embolus is present, 2) right-sided pleural effusion, 3) collateral vessels seen within the left chest wall suggesting occlusion of the left subclavian. Patient also went directly to Interventional Radiology as he was not a candidate for coagulation for aforementioned spontaneous intracranial bleed. In [**2119-12-31**] patient had IVC filter placed as well as an echocardiogram to evaluate the hemodynamic effects of the pulmonary embolism and to guide IV fluid therapy. Patient had successful placement of Gunther-Tulip vena cava filter just below the level of the renal vein from the common femoral approach. Patient also had bilateral lower extremity Dopplers performed on [**2120-9-24**]. The results were 1) nonocclusive thrombus at the right common femoral vein which has extensions to the greater saphenous vein and the deep femoral vein, 2) no evidence of left lower extremity deep venous thrombosis. Patient also had echocardiogram on [**2120-9-23**]. The conclusions were left atrium normal in size. Left ventricular wall thickness is normal. Left ventricular cavity size is normal. Overall ventricular systolic size is normal with left ventricular ejection fraction of 50 to 70%. No masses or thrombi are seen in the left ventricle. The aortic root is moderately dilated. The mitral valve appears structurally normal, a trivial mitral regurgitation. The tricuspid leaflets are mildly thickened. Moderate 2+ TR regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion compared with the findings of prior report of [**2120-4-19**], left ventricular enlargement is no longer apparent. Given this result, deemed that right ventricular failure was not present, patient was transferred from the [**Hospital Unit Name 153**] to the floor on [**2120-9-24**] in good condition. Patient was satting approximately 95 to 96% on transfer on room air but was continuously short on breath with any walking or activity such as brushing teeth. Again, the issue of anticoagulation was addressed on [**2120-9-25**] with differing specialists suggesting alternative approaches. To better assess the patient's risk, a head CT without contrast was performed. The results of the CT were no acute hemorrhage or mass effect, stable appearance of the right frontal lobe resection bed, and left cerebral hemorrhage likely due to punctate left cerebellar tonsillar metastases. The finding of small focus of hyperdensity within the left cerebellum was consistent with the finding of susceptibility within the same region on a prior MRI and likely represented an area of old hemorrhage into a metastatic lesion. This result like the issue of anticoagulation remaining complex. There was the issue of recent hemorrhage into the cerebellar metastases. In addition, patient had large pulmonary embolus. Patient was loathed to begin anticoagulation and wanted to wait and see if he had more sequelae from clotting before addressing anticoagulation, especially given that he had a filter placed to prevent further pulmonary embolus from the lower extremities. The issue of propagation of the existing clot was discussed at length with Oncology as well as the Pulmonary team. Pulmonology does not recommend anticoagulation with the idea that Heparin would not significantly affect propagation of the existing clot and the clot would eventually be reabsorbed and the patient would still have significant risk of bleeding into his metastatic lesion. On [**2120-9-27**] the patient had sudden onset chest pain with pleuritic component. His blood pressure was unchanged. His heart rate was stable. Patient was not short of breath, and his oxygen saturation remained at 96% on room air. Patient was much worse with inspiration. EKG showed no S-T depressions, no T-wave inversions, no new Q-waves and was relatively unchanged from his admission EKG. A stat portable chest x-ray was performed on [**2120-9-27**] showing 1) improving right lower lobe atelectasis versus consolidation, 2) patchy opacity of the left lateral lung field corresponding to area of pulmonary embolus on recent CT scan. Exam was otherwise unchanged from prior study and was negative for pneumothorax or new pneumonia. Given these results pain was attributed to the existing pulmonary embolus, and pain was eventually controlled on intravenous Dilaudid. On [**2120-9-28**] patient awoke with pain relieved, intermittent nausea. Patient was otherwise stable with normal blood pressure, heart rate, oxygen saturation on room air, and desire to go home. The coverage Oncology attending agreed that the patient should be discharged. Patient was discharged home in good condition. DISCHARGE DIAGNOSES: 1. Pulmonary embolism. 2. Melanoma. DISCHARGE INSTRUCTIONS: Patient was recommended to follow up with Dr. [**Last Name (STitle) 1729**] within one week. DISCHARGE MEDICATIONS: 1. Phenytoin 300 mg p.o. b.i.d. 2. Colace 200 mg p.o. b.i.d. 3. Benadryl 25 mg p.o. q. six hours p.r.n. itching. 4. Dilaudid 4 mg tablets, three to five tablets p.o. q. four hours p.r.n. pain. 5. Zofran 8 mg tablets, one tablet p.o. t.i.d. p.r.n. nausea. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Name8 (MD) 41158**] MEDQUIST36 D: [**2120-9-28**] 14:04 T: [**2120-9-29**] 17:12 JOB#: [**Job Number 41159**]

[ "197.7", "453.8", "415.19", "198.3", "197.4", "780.39", "197.0", "V10.82" ]

icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

8822, 8861

9003, 9499

3895, 8801

8886, 8980

2904, 3007

3022, 3877

2359, 2728

2745, 2880

6,892

100,031

18444+56950

Discharge summary

report+addendum

Admission Date: [**2140-11-11**] Discharge Date: [**2140-11-24**] Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: The patient is a scheduled admission by aortic aneurysm repair. This is an 81 year old woman with a history of hypertension, who had recurrent pericarditis and pleuritis requiring percutaneous drainage in [**2137**]. An echocardiogram in [**2137-12-13**], showed normal left ventricular function with a dilated aortic root of 48mm, mildly thickened aortic valve with mild aortic regurgitation. Follow-up in [**2140-9-12**], with echocardiogram showed an ejection fraction of 60% with dilated aortic root at 55mm, mild aortic sclerosis, mild aortic regurgitation, and bilateral atrial enlargement. Cardiac catheterization done on [**2140-10-26**], showed an ejection fraction of 80% with normal wall motion, severe aneurysmal dilatation of the ascending aorta into the arch, recurrent dilatation in the descending aorta with no dissection, 1+ aortic regurgitation, normal coronaries. PAST MEDICAL HISTORY: 1. Hypertension. 2. Raynaud's disease. 3. Phlebitis. 4. Osteoporosis. 5. Tonsillectomy. 6. Spinal fusion. 7. Umbilical hernia repair. 8. Appendectomy. 9. Cholecystectomy. 10. Total abdominal hysterectomy. MEDICATIONS ON ADMISSION: 1. Metoprolol 100 mg twice a day. 2. Hydrochlorothiazide 25 mg once daily. 3. Lisinopril 10 mg once daily. 4. Enteric Coated Aspirin 81 mg once daily. 5. Centrum Silver one once daily. 6. Calcium 600 once daily. 7. Nexium 40 mg once daily. ALLERGIES: Stated allergy to Codeine which caused bad abdominal cramps and adhesive tape which causes a rash. SOCIAL HISTORY: The patient lives at home with her husband. [**Name (NI) 1139**] one half pack per day times eighteen years, quit forty-five years ago. Alcohol one drink per day, none times the past four weeks. PHYSICAL EXAMINATION: At the time of preadmission testing, the heart rate is 74 beats per minute, blood pressure 148/80, respiratory rate 18, oxygen saturation 96% in room air, height four feet eleven inches, weight 106 pounds. In general, she appears younger than stated age in no acute distress. Skin - no breaks or rashes. Head, eyes, ears, nose and throat - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Pharynx is clear. The neck is supple with no jugular venous distention, no bruits, carotid pulses are 2+ bilaterally. The chest is clear to auscultation bilaterally. The heart is regular rate and rhythm, no murmurs, rubs or gallops. The abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly, well healed surgical scars. Extremities without cyanosis, clubbing or edema. Left upper extremity with nodularity at old intravenous site near the left wrist. No varicosities in the lower extremities. Neurologically, the patient is alert and oriented times three, grossly intact. Pulses - femoral not indicated. Dorsalis pedis 1+ bilaterally. Posterior tibial not detected. Radial 2+ bilaterally. No carotid bruits bilaterally. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the operating room on [**2140-11-11**], at which time she underwent a supracoronary ascending aortic graft with a resuspension of the aortic valve. Please see the operative report for full details. The patient tolerated the operation well and was transferred from the operating room to Cardiothoracic Intensive Care Unit. Circ arrest time was eleven minutes. At the time of transfer, the patient had Milrinone at 0.4 mcg/kg/minute, Amiodarone at 1 mg per minute, Neo-Synephrine no dose indicated and Propofol, also no dose indicated. The patient did well in the immediate postoperative period. Her anesthesia was reversed. She was weaned from the ventilator. In the morning of postoperative day one, she was successfully extubated. On postoperative day number one, her cardioactive medications were begun to be weaning beginning with Amiodarone and Milrinone. By postoperative day two, the patient was maintained with minimal amounts of Amiodarone, Milrinone and Nipride. On postoperative day two, the patient's Milrinone was discontinued. Her Amiodarone was changed to p.o. Her Nipride was discontinued with initiation of beta blockade. Her chest tubes were removed. She was maintained in the Cardiothoracic Intensive Care Unit for monitoring of her hemodynamic and pulmonary status. On postoperative day three, the patient continued to do well. She remained hemodynamically stable. She was transferred from the Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] Two for continuing postoperative care and cardiac rehabilitation. Once on the floor, it was noted that the patient had gone into sustained atrial fibrillation with a heart rate of 100 to 110, hemodynamically tolerated well. She was seen by the electrophysiology service and was maintained on her p.o. Lopressor as well as her p.o. Amiodarone and continued to be monitored on the floor. Over the next two days, the patient was in and out of atrial fibrillation. She remained hemodynamically stable throughout these periods. On postoperative day five, it was noted that the patient had a drop in her hematocrit with guaiac positive stools. She was seen by the gastroenterology service. At that time, she was also transferred back to the Cardiothoracic Intensive Care Unit for close monitoring. The patient underwent a KUB which was read as normal. She also had stools sent for Clostridium difficile which were negative. She was empirically started on Flagyl at that time. The patient remained in the Intensive Care Unit for the next several days to monitor her gastrointestinal status to make sure that she had no further guaiac positive stools. On postoperative day seven, she was again transferred to the floor for continuing postoperative care. Prior to transfer from the Intensive Care Unit, it was noted that the patient had some left upper extremity swelling. She underwent ultrasonography of her upper extremities at that time to rule out a thrombosis. Ultrasound showed a right internal jugular and cephalic thrombus. Following transfer, the vascular service was consulted and they recommended oral anticoagulation with Coumadin, which was begun at that time. Over the next several days, with the exception of intermittent atrial fibrillation, the patient had an uneventful hospital course. She was again seen by the electrophysiology service given her episodes of atrial fibrillation, the last episode lasting greater than 24 hours. The patient was additionally begun on Heparin given the duration of this episode of atrial fibrillation. The patient was scheduled for a direct current cardioversion, however, prior to cardioversion, the patient spontaneously converted to normal sinus rhythm. On postoperative day twelve, it was decided that if the patient remained in a rate controlled rhythm for the next 24 hours, she would be stable and ready to be transferred to rehabilitation. At the time of this dictation, the patient's physical examination is as follows; vital signs revealed temperature 98.2, heart rate 71, sinus rhythm, blood pressure 147/68, respiratory rate 20, oxygen saturation 98% in room air. Weight preoperatively was 50 kilograms and at transfer to rehabilitation is 53 kilograms. Laboratory data on [**2140-11-23**], white blood cell count 11.7, hematocrit 34.5, platelet count 219,000. Prothrombin time 15.0, partial thromboplastin time 25.0 with Heparin off. INR is 1.5. Sodium is 129, potassium 4.8, chloride 95, CO2 29, blood urea nitrogen 16, creatinine 0.8, glucose 183. The patient is alert and oriented times three, moves all extremities, follows commands. Respiratory revealed scattered rhonchi. Cardiac is regular rate and rhythm with no murmur. The sternum is stable and incision with Steri-strips open to air, clean and dry. The abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities are warm and well perfused with no edema. Right upper arm with minimal edema which has been resolving over the last several days. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Amiodarone 200 mg p.o. three times a day times one week and then 200 mg p.o. once daily times one month. 3. Metoprolol 100 mg twice a day. 4. Lasix 20 mg once daily times ten days. 5. Potassium Chloride 20 meq once daily times ten days. 6. Prilosec 40 mg p.o. once daily. 7. Heparin 600 units per hour to keep partial thromboplastin time 40 to 60 until INR is therapeutic. 8. Warfarin to maintain an INR between 2.0 and 2.5. The patient received 2 mg of Coumadin two days prior to discharge and no Coumadin on one day prior to discharge and 2 mg of Coumadin on the night before discharge. We will check the INR in the morning and dose Coumadin on the day of transfer to rehabilitation center. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Status post supracoronary ascending aortic graft with a resuspension of the aortic valve. 2. Hypertension. 3. Raynaud's disease. 4. Phlebitis. 5. Osteoporosis. 6. Status post tonsillectomy. 7. Status post spinal fusion. 8. Status post umbilical hernia repair. 9. Status post inguinal hernia repair. 10. Status post appendectomy. 11. Status post cholecystectomy. 12. Status post total abdominal hysterectomy. DISCHARGE STATUS: The patient is to be discharged to [**Location 50742**]. FO[**Last Name (STitle) **]P: She is to have follow-up with Dr. [**First Name (STitle) **] in two to three weeks and follow-up with Dr. [**Last Name (STitle) 1159**] in one month and follow-up with Dr. [**Last Name (Prefixes) **] in one month. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2140-11-23**] 16:44 T: [**2140-11-23**] 18:31 JOB#: [**Job Number 50743**] Name: [**Known lastname 9425**], [**Known firstname **] Unit No: [**Numeric Identifier 9426**] Admission Date: [**2140-11-11**] Discharge Date: [**2140-11-24**] Date of Birth: [**2059-6-8**] Sex: F Service: The patient is to be discharged to [**Location 9427**]. At the time of transfer her medications include Colace 100 mg b.i.d.; amiodarone 200 mg t.i.d. times one week, then 200 mg q.d. times one month; Prilosec 40 mg q.d.; Lopressor 100 mg b.i.d.; heparin 650 units per hour; Lasix 20 mg q.d. times 10 days; potassium chloride 20 mEq q.d. times 10 days; Coumadin to maintain INR of 2 to 2.5. The patient received 2 mg on [**11-23**] for INR of 1.5. Her INR on the day of discharge, [**11-24**], is 1.2. She is to receive 5 mg on the day of discharge. The patient previously received 5 mg q.d. preoperatively. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**] Dictated By:[**Name8 (MD) 3027**] MEDQUIST36 D: [**2140-11-24**] 09:54 T: [**2140-11-24**] 09:57 JOB#: [**Job Number 9428**]

[ "424.1", "733.00", "530.81", "578.1", "453.8", "441.2", "443.0", "427.31", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.45", "89.68", "39.61", "35.11", "99.07" ]

icd9pcs

[ [ [] ] ]

9003, 11107

8207, 8950

1280, 1640

3109, 8181

1877, 3091

131, 1017

1039, 1254

1657, 1854

8975, 8982

61,033

116,966

15264

Discharge summary

report

Admission Date: [**2120-5-14**] Discharge Date: [**2120-5-24**] Service: MEDICINE Allergies: Tetanus Toxoid / Bee Pollens Attending:[**First Name3 (LF) 5123**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 85M with complete heart block s/p pacer, HTN, diastolic CHF, IDDM, gout, COPD, PVD s/p LLE stents several weeks ago transferred from [**Hospital3 **] ED from NH for hypoxia. . Today at his nursing home, he was found around 1:30pm to be more lethargic, short of breath with BP 70/50 and difficult to assess radial pulses. O2sat 86% on RA. Pt was BIBA to [**Hospital3 **] ED, VS at EMS evaluation was P 50, BP 70/P, RR 20, unable to get a pulse ox, FSBS 114. In the [**Name (NI) 46**] [**Name (NI) **], pt was alert but noted to be cyanotic and pallid with mottled skin. Pt c/o diffuse abdominal pain. VS were not recorded. Labs notable for WBC 21.1 (88.3N, no bands), CPK 48 but trop I 0.6 (ref 0-0.04) - ?0.47 when confirmed; pt remained CP free and EKG showed a paced rhythm at 80 bpm. CXR was read as unremarkable with pacing leads in place. Noncontrast CT chest showed "small patchy interstitial infiltrates with focal bronchiectasis and nodularity in the posterior left lung base" and emphysematous changes. Noncontrast CT abdomen was unremarkable other than for mild diverticulosis. Pt was given vanco/zosyn and 3L IV fluid without improvement in his Started on peripheral levophed for SBP 70/palpable and given hydrocortisone 100mg IV. He was transferred to our ED for further management. . In the ED, initial VS were: T97.8 P80 SBP135 R18 100% on NRB. Transferred on 13 mcg of peripheral levophed but pt was given another 1L NS, and pressures remained stable after levophed weaned off. CXR with increased infiltrate in LLL. WBC 17, Hct 25, guaiac negative. Lactate 2.1. EKG paced at 80. Pt given combivent neb. Only complaint was foot pain. Has 2 PIV in. On transfer, HR80, 100/61, 20, 96% on NRB CXR. . On arrival to the ICU, pt without any complaints other than L toe pain. Earlier abdominal pain had resolved at some point in the [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]; not c/w GERD. He does recall feeling more dyspneic on exertion for several days. No CP, shoulder/jaw pain, palpitations, N/V, LH. Per son, pt was recently admitted to [**Hospital3 3583**] on [**5-3**] for dyspnea and L toe pain. Per his son, there was concern for DVT and PE, but LENIs and d-dimer were negative. He was treated with nitro, lasix, ASA, plavix, lovenox, and bronchodilators initially and sx improved while in the ED. Cardiology c/s attributde mildly elevated troponins attributed to demand. Per his son, he underwent a nuclear stress test that was unremarkable and was discharged. He was started on prednisone for presumed gout with no improvement in his sx since. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: (1) Syncope/presyncope (2) complete AV block, status post [**Company 1543**] pacemaker [**2112-11-11**] (3) Hypertension (4) Diastolic CHF and possible restrictive cardiomyopathy (5) AEA/VEA/CAD (6) IDDM with albuminuria (7) Gout on prednisone (8) COPD Social History: - Tobacco: Quit 45 years ago - Alcohol: Denies - Illicits: Denies Family History: Non-contributary Physical Exam: Vitals: T 95.6, P 80, BP 123/78, RR 17, O2sat 97 on 4L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally with only minimal wheezes at bases, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Extremities slightly mottled b/l, 2+ pulses, L toe tender on plantar surface but not erythematous, warm, or swollen. Neuro: AAOx3, nonfocal exam. Pertinent Results: [**2120-5-14**] 11:24PM GLUCOSE-136* UREA N-57* CREAT-1.9* SODIUM-138 POTASSIUM-5.7* CHLORIDE-108 TOTAL CO2-19* ANION GAP-17 [**2120-5-14**] 11:24PM ALT(SGPT)-3211* AST(SGOT)-3169* LD(LDH)-6280* CK(CPK)-98 ALK PHOS-72 TOT BILI-0.7 [**2120-5-14**] 11:24PM CK-MB-NotDone cTropnT-0.15* [**2120-5-14**] 11:24PM CALCIUM-8.1* PHOSPHATE-4.4 MAGNESIUM-2.1 IRON-172* [**2120-5-14**] 11:24PM calTIBC-221 VIT B12-GREATER TH FOLATE-GREATER TH HAPTOGLOB-209* FERRITIN-GREATER TH TRF-170* [**2120-5-14**] 11:24PM WBC-21.9* RBC-3.55*# HGB-10.6*# HCT-34.3*# MCV-97 MCH-30.0 MCHC-31.0 RDW-14.0 [**2120-5-14**] 11:24PM NEUTS-93.8* LYMPHS-3.0* MONOS-2.6 EOS-0.3 BASOS-0.2 [**2120-5-14**] 11:24PM PLT COUNT-304 [**2120-5-14**] 11:24PM PT-14.8* PTT-28.7 INR(PT)-1.3* [**2120-5-14**] 11:24PM FIBRINOGE-339 [**2120-5-14**] 11:24PM RET AUT-1.1* [**2120-5-14**] 07:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2120-5-14**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2120-5-14**] 07:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2120-5-14**] 07:00PM URINE AMORPH-FEW [**2120-5-14**] 06:18PM COMMENTS-GREEN TOP [**2120-5-14**] 06:18PM LACTATE-2.1* [**2120-5-14**] 06:05PM GLUCOSE-92 UREA N-38* CREAT-1.1 SODIUM-144 POTASSIUM-3.4 CHLORIDE-123* TOTAL CO2-12* ANION GAP-12 [**2120-5-14**] 06:05PM estGFR-Using this [**2120-5-14**] 06:05PM CK(CPK)-48 [**2120-5-14**] 06:05PM CK-MB-NotDone cTropnT-0.10* [**2120-5-14**] 06:05PM CALCIUM-4.3* PHOSPHATE-3.1 MAGNESIUM-1.2* [**2120-5-14**] 06:05PM WBC-17.3*# RBC-2.57*# HGB-7.6*# HCT-25.5*# MCV-99* MCH-29.4 MCHC-29.7* RDW-13.9 [**2120-5-14**] 06:05PM NEUTS-95.4* LYMPHS-2.7* MONOS-1.6* EOS-0.2 BASOS-0.1 [**2120-5-14**] 06:05PM PLT COUNT-238 CXR (Portable) [**2120-5-14**]: HISTORY: This is an 85-year-old male with elevated white blood cell count, hypotension and wheeze. Evaluate for acute process. COMPARISON: Chest radiograph [**2114-7-3**]. SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: There is no change in the cardiomediastinal contour, with mild cardiomegaly, but no evidence for CHF. A left chest pacing device is in unchanged position in comparison to [**2114**]. There is left lung base atelectasis, but developing infection cannot be completely excluded. The bony thorax appears unremarkable. IMPRESSION: Left lung base atelectasis, but developing pneumonia cannot be excluded. PA and lateral may be helpful for further evaluation if clinically feasible. Brief Hospital Course: # Shock: Patient with hypotension requiring pressors at OSH ED with a lactate 2.1. At [**Hospital1 18**] patient was responsive to IVF and weaned off levophed. Most likely septic given mild hypothermia, WBC 17.3 and neutrophilia, hypoxia, and CT chest finding c/w pneumonia. While it is possible that the leukocytosis may be secondary to prednisone, the prednisone may also be masking a fever. Treated empirically with vanc, zosyn with rapid improvment. There may have also been a component of hypovolemia in setting of decreased oral intake at [**Hospital1 1501**] given response to IVF. Pt has only been on short taper of prednisone so less likely adrenal insufficiency although did receive hydrocortisone at OSH. Pt with elevated troponin but less likely cardiogenic shock - may more likely represent end organ damage from hypoperfusion; no evidence of CHF and BP unlikely to reverse so quickly. He was never again hypotensive on the floor and his white count resolved with IV Abx. We were never 100% convinced that this was from pneumonia and a foot CT was checked prior to discharge to r/o osteomyelitis which showed no evidence of osteomyelitis. All cultures were negative. . Plan going forward: -Complete 14day course of broad spectrum abx (last day [**5-28**]) -Patient must have CXR in 1 month to f/u for complete resolution of his PNA/r/o underlying malignancy. . # Hypoxia: Patient quickly weaned from NRB to NC to room air. This was likely related to pneumonia, though volume overload from resuscitation can not be excluded, or any contribution from his underlying lung disease. . # CAD: Nl CK but elevated trop likely represents demand in setting of ARF and hypoperfusion rather than an occlusive lesion. The patient peaked and ruled out on labs in house. EKG was paced and c/w prior. Per son, recent stress test unremarkable. . # DM: Patient had issues with o/n low blood sugars, [**Last Name (un) **] was consulted, we dialed back his PM humalog and lantus and his blood sugar control optimized. . # Anemia: Hct here 25.5, was 32.3 at OSH. Pt is on ASA and plavix but guaiac negative, no evidence of active bleeding. Concern for DIC in setting of sepsis although pt currently appears well. [**Month (only) 116**] have been hemoconcentrated at OSH and now diluted in setting of 4L IVF. Patient drifted back up to 33 without intervention . # Toe pain: Recently s/p LLE stenting; embolic event possible, but this was thought to be most likely Gout in house. Prior noted mottling more likely d/t shock than embolus however as b/l and appears to be improving w/ fluid resuscitation. No acute inflammation concerning for gout although has been on prednisone. Pain unchanged per pt. He underwent CT foot to r/o osteomyelitis or osteonecrosis as a source, this instead showed evidence of pseudogout and osteoarthritis. . Plan going forward: Patient has follow-up scheduled with rheumatology . #DVT/?PE: Patient found to have RUE DVT on exam, later found to have LLL consolidation with resolution of RUE swelling. Most likley PE. Patient to continue lovenox. . Plan going forward: Patient to continue [**Hospital1 **] lovenox for [**4-13**] mo, pending PCP f/u . Urinary Retention: Patient developed new urinary retention while in house. This was felt to be secondary to oxycodone which was stopped. A foley was placed on the day prior to d/c and the patient was started on flomax. . Plan going forward: Foley to be d/c'd in 3 days, patient must void spontaneously 8-10 hours following the removal. If he does not void the floor physician must be consulted. Medications on Admission: Medications: Per NH notes Prednisone 40mg x 2 days, 30mg x 3 days (completed), then prednisone 20mg x 3 days, 10mg x 3days Vicodin 5/500 [**2-10**] tab q6h prn pain Lantus 50 units SQ qhs (previously on 28 units) Diovan 20mg daily Verapamil 120mg daily Pulmicort 200 mcg 2 puffs inh [**Hospital1 **] (4 puffs [**Hospital1 **] per pt) [**Name (NI) 44405**] 50 mcg 2 puffs [**Hospital1 **] Spiriva 18 mcg q puff inhaler daily ASA 81mg daily Plavix 75mg daily Metoprolol 50mg [**Hospital1 **] Erythromycin 500mg q8h x 7 days (unclear why) Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: last dose 4/20. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 Grams Intravenous Q8H (every 8 hours) for 4 days: last dose 4/20. 12. Vancomycin 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous Q 24H (Every 24 Hours) for 4 days: should finish [**5-28**]. . 13. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Four (24) units Subcutaneous at bedtime. 14. Pulmicort Flexhaler 180 mcg/Inhalation Aerosol Powdr Breath Activated Sig: Two (2) puffs Inhalation twice a day. 15. Salmeterol 50 mcg/Dose Disk with Device Sig: Two (2) puffs Inhalation twice a day. 16. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) puff Inhalation once a day. 17. Insulin Aspart 100 unit/mL Cartridge Sig: One (1) as directed Subcutaneous qACHS: as per attached sliding scale. 18. Valsartan 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 21. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) units Subcutaneous Q12H (every 12 hours). 22. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 23. Chest XRAY Patient must have f/u CXR 1 mo. following discharge from hospital. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at Silver [**Doctor Last Name **] Commons Discharge Diagnosis: Septic Shock Pneumonia Gout Flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 **] after you were found to be severly ill at your rehabilitation center. You were briefly in the ICU where you were found to be hypotensive and have a condition known as septic shock. This was thought to be caused by pneumonia. You improved quickly with IV antibiotics. You also developed a blood clot in the hospital for which you are being treated with a blood thinner called lovenox. You were monitored on the floor and aside from toe pain you had not other major issues. . The following changes were made to your medication regimen: Your antibiotics will be completed on [**2120-5-28**] You completed your prednisone course We believe that oxycodone was causing you to retain urine, we stopped the oxycodone and started you on tylenol. Your Bedtime lantus was reduced to 24mg. Your metoprolol was reduced to 12.5mg twice per day You were started on lovenox 90mg twice per day Followup Instructions: Department: RHEUMATOLOGY When: WEDNESDAY [**2120-5-29**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Unit Name **] [**Location (un) 861**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE . Department: [**Last Name (un) **] Diabetes Center When: [**2120-6-3**] 10:00am With: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**] Location: [**Last Name (un) 3911**], [**Location (un) 86**] MA Phone: [**Telephone/Fax (1) 2384**] Completed by:[**2120-5-24**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13424, 13516

6972, 10555

245, 251

13594, 13594

4397, 6949

14720, 15307

3729, 3747

11142, 13401

13537, 13573

10581, 11119

13777, 14697

3762, 4378

2904, 3352

197, 207

279, 2885

13609, 13753

3374, 3629

3645, 3713

8,002

148,543

14821

Discharge summary

report

Admission Date: [**2141-8-26**] Discharge Date: [**2141-9-14**] Service: Medicine - [**Hospital1 212**] CHIEF COMPLAINT: This is a transfer from [**Hospital **] Hospital for [**Hospital **]. HISTORY OF PRESENT ILLNESS: This is an 83-year-old male with a history of interstitial pulmonary fibrosis, asbestosis, reactive airway disease, paroxysmal atrial fibrillation, prostate cancer, who presented initially on [**8-25**] after being found obtunded at home, in respiratory distress, and hypoxic. He was intubated in the field and transferred to [**Hospital **] Hospital where he was hypotensive and started on Levophed and Dopamine pressors. Blood cultures grew out gram-negative bacteremia; AST was 533, ALT was 399, alkaline phosphatase was 268, total bilirubin was 14.6, direct bilirubin was 12.1; INR 1.3; white blood cell count 40.6, A right upper quadrant ultrasound was positive for gallstones and positive for mild intrahepatic duct dilatation. The common bile duct was not visualized. An electrocardiogram showed normal sinus at 100 with left axis deviation, a primary AV block, however, no ST changes. The patient was referred to [**Hospital6 256**] for [**Hospital6 **] for obstructive cholangitis secondary to cholelithiasis. PHYSICAL EXAMINATION: Vital signs: On admission his heart rate was 97, blood pressure 121/66, temperature 96.4??????, respiratory rate was 16-17. General: The patient was intubated and in no apparent distress. HEENT: He had scleral icterus. His pupils were equal 3-4 mm, although sluggishly reactive to light. Cardiovascular: Normal S1 and S2. Regular, rate and rhythm. He had a 2 out of 6 holosystolic murmur. Positive S4. Lungs: Mild bibasilar rales. Abdomen: Normoactive bowel sounds. Soft, nontender, nondistended. There was no right upper quadrant tenderness. Extremities: Without edema. He had 2+ pedal pulses. His right hip had a swollen ecchymotic lesion. Neurological: He was not able to follow commands, but he was able to nod to questions regarding pain. Skin: Notable for jaundice. PAST MEDICAL HISTORY: 1. Interstitial pulmonary fibrosis. He has a history of asbestosis exposure secondary to work. 2. Asthma. 3. Prostate cancer. He has had negative bone scans for metastases. 4. Spinal stenosis. 5. Atrial fibrillation. He is not on anticoagulation secondary to fall risk. 6. Recent fall in early [**Month (only) 216**] where he suffered a right hip ecchymosis and swelling; however, there was no fracture. LABORATORY DATA: As mentioned in the HPI above. HOSPITAL COURSE: The patient was transferred to [**Hospital3 **]- [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] for obstructive cholangitis secondary to cholelithiasis. [**Last Name (Titles) **] was performed on [**8-26**] that demonstrated multiple 1-3 cm stones causing partial obstruction at the common bile duct and postobstructive dilatation. The common bile duct was dilated at 2 cm, and a stent was placed. He was admitted to the MICU for gram-negative sepsis secondary to suppurative cholangitis secondary to choledocholithiasis. His MICU course was notable for resolving cholangitis status post stent and antibiotic treatment. He received a 14-day course of Zosyn for blood cultures that were positive for E-coli, as well as Aeromonas. He had no further complications during this hospital course regarding his cholangitis and his alkaline phosphatase, and total bilirubin trended downward during throughout his hospital course. His hospital course was also complicated by two pulmonary issues; he was difficult to wean off the vent with intermittent hypoxia of question etiology (mucous plugging versus congestive heart failure). He was extubated on [**8-28**], reintubated on [**8-30**], and then extubated on [**9-2**]. Chest x-ray demonstrated a question of a left lower lobe infiltrate versus atelectasis, and he was therefore treated with a course of Levofloxacin. Regarding his history of interstitial pulmonary fibrosis, he was maintained on his home dose of Prednisone at 10 mg p.o. q.d. Regarding his reactive airway disease (in the past he has been on home oxygen), he was weaned off the vent and currently maintained on 3 L nasal cannula with the patient suctioning his own secretions at the bedside. Regarding infectious disease, the patient received a 14-day course of Zosyn for the aforementioned positive blood cultures and Levofloxacin as noted above. He also received a 7-day course of Vancomycin for 1 out of 4 bottles being Streptococcus epidermis that were grown from his right IJ triple-lumen catheter. The patient also had HSV1 labialis. He received a 7- day course of intravenous Acyclovir, and he has been maintained on topical Acyclovir since. His cardiac course was complicated on [**9-1**] with diffuse T- wave inversions anterolaterally, negative cardiac enzymes, and associated with sinus bradycardia. He was anticoagulated and taken to the Cardiac catheterization Laboratory. There it was noted that there were no significant obstructive coronary artery disease. His left anterior descending had 20% origin. Of note also was moderate pulmonary hypertension, and a left ventricular ejection fraction of 55%. His home dose of Digoxin was discontinued. He also has a history of atrial fibrillation for which he is not anticoagulated secondary to fall risk. The patient remained in sinus rhythm throughout his hospital course. Renal course was complicated by acute renal failure with creatinine elevation to 2.9 (baseline 1.2), likely ATN in the setting of his presenting hypotension/hypoperfusion. He was hydrated with resolution of his creatinine to 1.4 with good urine output. This likely represents a new baseline. His neurologic course was complicated by a question of decrease in mentation postextubation. MRI with gadolinium on [**9-4**] was obtained with no evidence of herpes encephalitis. There was a 2 mm left temporoparietal lesion that was deemed to be benign. On [**9-5**], a transthoracic echocardiogram was obtained that was negative for vegetations. The thinking was perhaps the lesions noted in the temporoparietal region of the brain may have been ischemic from vegetations; however, given a negative echocardiogram, this idea was dismissed. He also had a carotid duplex ultrasound on [**9-8**] which demonstrated patent carotid arteries bilaterally (plaque was less than 40%). His ENT course was complicated by mild to moderate dysphagia. He failed a bedside swallow evaluation and video swallow evaluation on two occasions, so he was maintained as NPO with an NG tube placement and tube feeds. His most recent video-assisted swallow evaluation, on [**9-12**], demonstrated nonfunctional swallow with aspiration of a large amount of all consistencies attempted. It was felt that his failure was due to his recent severe illness and herpes labialis, and that there was hope for recovery in the near future. The GI team was consulted regarding potential PEG placement, and they felt that due to the above reasons, in addition to his recent Aspirin use, the patient would best be suited by repeating another swallow evaluation next week, and if he again fails, he is to follow-up in one week with Dr. [**Last Name (STitle) 31960**] [**Name (STitle) 3044**] for PEG placement as an outpatient. The patient was also seen by Physical Therapy and Occupational Therapy during this admission who both recommended ongoing treatment. Concerning follow-up issues, the patient was fully ambulatory prior to admission and will benefit from acute rehabilitation. He is to have close blood pressure monitoring for hypotension. He is to have monitoring of his alkaline phosphatase, LDH, and total bilirubin, and clinically for signs of further cholestasis. He also to have monitoring of white blood cell count as the patient is on steroids, and monitoring for signs of new infection. The patient will also be maintained on supplemental oxygen at nasal cannula at 3 L. He currently desaturates with ambulation on room air. He will likely need at least 2 L of home oxygen as he did in the past. The patient will also need his hematocrit monitored as he has anemia of chronic disease. Other follow-up issues regarding his dysphagia include that the patient will benefit from reevaluation by Speech and Swallow at rehabilitation. If he fails another swallow evaluation, he should call Dr. [**Last Name (STitle) 43534**] ([**Telephone/Fax (1) 1983**]) office to schedule PEG placement. He is to have ongoing physical therapy and occupational therapy. He is to have regular Insulin sliding scale and monitoring of his finger blood glucose. The patient will be maintained on tube feeds and will require NG tube care and tube feeds while his dysphagia persists. The patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32496**], [**Telephone/Fax (1) 43535**]; the patient should call for an appointment following rehabilitation. DISCHARGE MEDICATIONS: Albuterol Sulfate/Ipratropium 1-2 puffs IH q.4 hours, Albuterol nebulizer solution 1 neb IH q.4 hours p.r.n., Acyclovir ointment 5% applied TP t.i.d. to lips, Erythromycin 0.5% ophthalmic ointment applied 0.5 in O.S. q.d. for 2 weeks, start date [**9-5**], Lansoprazole 30 mg p.o. q.d., Acetaminophen 325-650 mg p.o. q.4-6 hours p.r.n. pain and fever, regular Insulin sliding scale, Prednisone 10 mg p.o. q.d. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: Suppurative cholangitis secondary to choledocholithiasis. CODE STATUS: The patient is full code. ALLERGIES: NO KNOWN DRUG ALLERGIES. Discharge destination: [**Hospital1 **] in [**Location (un) 38**] - [**Telephone/Fax (1) 19791**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD Dictated By:[**Name8 (MD) 17844**] MEDQUIST36 D: [**2141-9-13**] 09:08 T: [**2141-9-13**] 09:14 JOB#: [**Job Number 43536**]

[ "038.42", "515", "584.5", "427.31", "518.81", "574.91", "501", "576.1", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "51.87", "37.21", "96.04" ]

icd9pcs

[ [ [] ] ]

9103, 9514

9570, 10024

2587, 9079

1282, 2079

133, 204

233, 1259

2102, 2569

9539, 9548

3,372

132,391

4359

Discharge summary

report

Admission Date: [**2130-3-9**] Discharge Date: [**2130-3-29**] Date of Birth: [**2054-6-9**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 75-year-old woman admitted to the Neurosurgery Service on [**2130-3-9**] for planned craniotomy for resection of brain metastases with lung versus renal cell carcinoma. The patient was originally noted to have one to two months of changes in mental status and short-term memory loss. A CT showed a left temporal lesion with edema. The patient was loaded with Decadron and Dilantin and transferred to the [**Hospital6 2018**] from an outside hospital. She was noted to have elevated blood pressures in the 160s-200 range with saturations 93-94% on room air. The patient was being preopped for a craniotomy and then on [**2130-3-13**], the patient was more confused, had spiked to 101.2 up to 103.2 and then noted to desaturate with an ABG 7.32, 52, 67 on 3 liters. The patient was, therefore, transferred to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Right nephrectomy for renal cell carcinoma 20 years ago. 2. Hypertension. 3. Hypothyroidism. 4. Question of lung lesion. 5. Macular degeneration. ALLERGIES: The patient has no known drug allergies. LABORATORY/RADIOLOGIC DATA: Chest CT done on [**2130-3-10**] showed a preexisting lesion increased in size in the right lower lobe. A few small pulmonary nodules bilaterally. No chest lymphadenopathy or enlarging masses. An enlarging mass involving the anterior left kidney and several other lesions on partially removed kidney. HOSPITAL COURSE: On arrival to the MICU, the patient was hypoxic requiring intubation. The patient was felt to have a sepsis-like syndrome according to the ID consult with no clear source. The patient was covered empirically for nosocomial pathogens with vancomycin, ceftazidime, and levofloxacin. He also had problems with thrombocytopenia. Hematology/Oncology was consulted. The reason for the thrombocytopenia was unclear. [**Name2 (NI) 6196**] thought to be a possible cause was discontinued and the patient was not on any other medications thought to be related to this problem. The patient was transfused and a platelet count did come up and did not drop any further. There was no definite source ever found for the cause of the thrombocytopenia. The patient remained intubated and was finally extubated on [**2130-3-22**] on a 50% face mask and her sepsis resolved. She was on antibiotics for a total of seven days. Thrombocytopenia resolved and the patient was preopped for surgery. She underwent a left temporal craniotomy for tumor resection without intraoperative complication. Postoperatively, she was alert and oriented times one. Her strength was [**5-3**] in all muscle groups. She was only oriented to herself. She was pretty much at her baseline neurologically postoperatively. Her face was symmetric. EOMs full. The pupils were equal, round, and reactive to light. She had no drift. She was following commands. She had some aphasia. Her dressing was clean, dry, and intact. She was in the Recovery Room overnight and kept her blood pressure below 150 on some Nipride intermittently. She was then transferred to the regular floor on postoperative day number one where she has remained neurologically stable. The incision was clean, dry, and intact. She was seen by Physical Therapy and Occupational Therapy and found to require acute rehabilitation. She was discharged to rehabilitation in stable condition with follow-up in the Brain [**Hospital 341**] Clinic in two weeks for staple removal. DISCHARGE MEDICATIONS: 1. Nystatin swish and swallow 5 cc p.o. q.i.d. p.r.n. 2. Lisinopril 10 p.o. q.d. 3. Furosemide 40 p.o. b.i.d. 4. Decadron currently 4 p.o. q. six to be weaned to b.i.d. over five to seven days. 5. Metoprolol 50 p.o. b.i.d. 6. Percocet one to two tablets p.o. q. four hours p.r.n. 7. Tylenol 650 p.o. q. four hours p.r.n. 8. Pantoprazole 40 mg p.o. q. 12 hours. 9. Calcium carbonate 5 mg p.o. t.i.d. 10. Keppra 500 mg p.o. b.i.d. 11. Synthroid 112 micrograms NG q.d. 12. Colace 100 mg p.o. b.i.d. 13. Sarna lotion one application topically q. three to four hours p.r.n. rash. 14. Insulin sliding scale. She also had a swallow evaluation which she did pass and was able to tolerate a regular diet and thin liquids. CONDITION ON DISCHARGE: Stable. FOLLOW-UP: The patient will follow-up in the Brain [**Hospital 341**] Clinic in two weeks for staple removal and follow-up. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2130-3-28**] 02:45 T: [**2130-3-28**] 15:02 JOB#: [**Job Number 18811**]

[ "038.9", "578.1", "198.3", "995.91", "287.5", "197.0", "197.7", "780.39", "518.81" ]

icd9cm

[ [ [] ] ]

[ "01.59", "93.59", "96.04", "38.91", "88.72", "87.03", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

3651, 4375

1608, 3628

1047, 1590

4400, 4814

17,570

141,570

27026

Discharge summary

report

Admission Date: [**2183-5-1**] Discharge Date: [**2183-5-23**] Date of Birth: [**2114-12-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 297**] Chief Complaint: ? free air under diaphragm Major Surgical or Invasive Procedure: None. History of Present Illness: 68M Diaphragmatic dysfunction, DM-II, CKD, MI, CAD, CHF, A-fib, most recently admitted for respiratory failure, pulmonary hypertension, and diaphragmatic dysfunction, here w/ intubation complicated by suspected GI perforation. Had been having decreased urine output X 48 hours in addition to renal failure, prior to presentation, then noted to have transient hypoxia as well as occasional mental status changes. . Transferred to acute rehab ICU where it was felt that pt should have thoracentesis for bilateral pleural effusions [**12-26**] CHF. U/S site marked for [**Female First Name (un) 576**], and 1.6L serous fluid removed, noted to be transudate. Following this episode, became acutely hypotensive to 60s SBP, started on dopamine to mainatin MAP>60. Intubated - initially GI - then endotracheal, but CXR revealed air under diaphragm. Transferred to [**Hospital1 18**] for further care. Past Medical History: DM-II w/neuropathy and nephropathy CAD s/p CABG x 5 ([**7-29**]) CHF CRI (Cr 1.3) Atrial fibrillation PVD previously complicated by leg abscess after graft CVA Hypercholesterolemia Diaphragmatic dysfunction PEG [**12-30**] Trach [**12-30**] (now decannulated) Social History: Retired policeman. Lives in FL, former smoker (15-20pack year, stopped last year), occasional EtOH. Uses rolling walker or wheelchair. Family History: non-contributory Physical Exam: VS 82 96/44 100% AC500X20 8 0.4 GENERAL: Intubated, sedated, but rousable HEENT: PERRL, EOMI, Intubated. NECK: JVP not visible CARDIOVASCULAR: S1, S2, reg LUNGS: Junky throughout ABDOMEN: Tender (winces in RLQ), mildly firm w/ guarding in RLQ. EXTREMITIES: Cool in distal extremities UE and LE, but otherwise warm, no CCE. NEURO: Intubated and sedated, moves to pain, rouses to voice. SKIN: Multiple ecchymoses throughout. Pertinent Results: [**2183-5-1**] 11:40PM FIBRINOGE-276 [**2183-5-1**] 11:40PM PT-18.0* PTT-33.7 INR(PT)-1.7* [**2183-5-1**] 11:40PM PLT SMR-NORMAL PLT COUNT-264 [**2183-5-1**] 11:40PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2183-5-1**] 11:40PM NEUTS-70 BANDS-18* LYMPHS-7* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-1* [**2183-5-1**] 11:40PM WBC-9.2# RBC-3.37* HGB-10.8* HCT-34.5* MCV-103*# MCH-32.1* MCHC-31.3 RDW-17.8* [**2183-5-1**] 11:40PM CORTISOL-31.8* [**2183-5-1**] 11:40PM ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-7.9*# MAGNESIUM-2.2 [**2183-5-1**] 11:40PM CK-MB-NotDone cTropnT-0.22* [**2183-5-1**] 11:40PM ALT(SGPT)-17 AST(SGOT)-14 LD(LDH)-139 CK(CPK)-89 ALK PHOS-89 TOT BILI-0.6 [**2183-5-1**] 11:40PM GLUCOSE-175* UREA N-65* CREAT-4.2*# SODIUM-140 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-21* ANION GAP-19 . [**2183-5-2**] - CT Chest/Abdomen/Pelvis - . Moderate bilateral pleural effusions with consolidation of the posterior lower lobes and right middle lobe, consistent with aspiration. 2. Reflux of oral contrast from the stomach to the mid thoracic esophagus. Elevation of the head of the patient's bed is suggested to prevent further aspiration. 3. Moderate to large amount of free intraperitoneal gas, may be due to prior esophageal intubation and leakage at site of percutaneous gastrostomy. Clinical evaluation of gastrostomy continence is suggested. Evaluation for bowel perforation is limited by lack of opacification with oral contrast, but no definite evidence of this is identified. 4. Ascites. 5. Multiple small retroperitoneal paraaortic lymph nodes, measuring up to 8 mm. . [**2183-5-2**] - CT Abdomen - 1. Abnormal segmental thickening of the sigmoid colon wall. Differential possibilities include ischemic colitis or infective or inflammatory colitis, clinical correlation advised. No evidence of perforation or colonic pneumatosis. 2. Some free intra-abdominal air in the right upper quadrant could be explained by the presence of percutaneous gastrostomy tube. 3. Small bibasilar effusions and moderate associated bibasilar atelectasis, generalized subcutaneous edema and small-to-moderate amount of intra-abdominal fluid. . [**2183-5-5**] - US LOWER EXT- Patent right SFA to peroneal bypass with no evidence of stenosis. . [**2183-5-9**]- Renal U/S - Both kidneys are normal in size and echogenicity without hydronephrosis or masses, the right kidney measures 11.5 cm in length, the left kidney measures 11.3 cm. In the right kidney, there are two nonobstructing stones measuring 5 and 7 mm located in the lower and interpole collecting system. In the left kidney, there is a 4 mm nonobstructing stone in the interpole collecting system. The bladder is minimally distended with Foley catheter in its lumen. Mild quantity of perihepatic free fluid is seen. . [**2183-5-19**]: Bilateral LE noninvasive: 1. No occlusive thrombus identified within the right superficial femoral to popliteal vein, and throughout the left lower extremity. A small nonocclusive thrombus cannot be ruled out. 2. Right common femoral vein is not completely assessed. 3. Bilateral venous waveforms are consistent with right heart failure. . DISCHARGE LABS: Hct 24.8 Plt 219 . BUN/Cr: 69/2.4 Brief Hospital Course: 68M with hx of diaphragmatic dysfunction, DM, CKD, CAD admitted with hypotension, resp failure . #Septic shock: Pt was initially started on broad spectrum antibiotics and required pressors for several days for blood pressure support. [**Last Name (un) **] stim was appropriate. Further workup revealed a zosyn-resistant pseudomonal pneumonia as well as C. difficile infection. His antibiotics were changed to Meropenem and Flagyl and he received a full 14 day course of each. His blood pressure meds were held given his low BP with aggressive diuresis. Goal MAP of >65. . # Hypoxic resp failure: Likely due to pseudomonal pneumonia which lead to ARDS. Over his ICU stay, pt was not able to be weaned [**12-26**] high PEEP requirements. On hospital day #15, his pressure support and PEEP were weaned and he was extubated. However, over the course of the day, the pt's pCO2 rose from 40 to 60mmHg and he developed resp distress. He was placed on BiPAP with moderate improvement in his pCO2. After two days on and off BiPAP, pt and family agreed that given his tenuous respiratory status, he should be reintubated. He was reintubated on HD #17 and then trached on HD #22. He was doing well on [**3-28**] with 50% FiO2 on discharge. Of note, pt requires aminute ventilation of at least [**11-5**] and desaturates with very little activity. He will continue his albuterol and atrovent inhalers QID. . # Pleural effusion: Due to volume overload, pt noted to have large pleural effusions. A thoracentesis was performed on the right side on HD #20 and 140cc of serous fluid was removed. The fluid was transudative and cultures were negative. . # Abd free air: Pt was found to have free air on his CT abdomen. Surgery was consulted and given the absence of evidence of perforation on CT, there was no indication for surgical intervention. They thought his free air was most consistent with esophageal intubation / having a PEG tube. . # CRI/Acute Renal Failure: Baseline cr of 1.3 per prior notes. On admission, Cr up to 4.2. FeNa indicated that pt was pre-renal and likely ATN also contributed. Renal was consulted when pt started becoming overloaded limiting extubation. He was started on lasix and diuril to which he responded well to. Creatinine stablized around 2.4-2.5 on discharge. . # CV: ** rhythm: pt had occasional runs of NSVT while in the ICU. This was thought to be [**12-26**] the dopamine. He had no further runs when off pressors. ** Pump: EF 45-55%; severely volume overloaded. Pt was on a lasix drip with diuril towards the end of his ICU stay and he should continue to receive large doses of diuril and IV lasix during his rehab stay with the goal of [**11-24**].5L negative per day. ** ischemia: hx of CAD s/p CABG; maintain on ASA ** Pulmonary Hypertension: moderate to severe. Echo done during hospitalization shows slightly worsening of pulm artery pressure. . # Right toe ulcer: Podiatry was consulted to rule out infected toe ulcer. Wound cx grew out pseudomonas [**Last Name (un) 36**] only to meropenem. Given the presence of bone exposure, he will likely need an amputation when stable. Vascular surgery also evaluated pt as he has been seen by Dr. [**Last Name (STitle) **] in the past. His perfusion is poor but vascular studies showed that his graft was patent. However they too recommended toe amputation in the future. . # FEN: Pt received tube feeds through his PEG. Once stable, he will need a speech and swallow with pasamuir valve fitting. . # Access: Right sided PICC placed [**2183-5-21**] Medications on Admission: Digoxin 0.125 q48 Metoprolol 12.5 [**Hospital1 **] Haldol 2 TID Ativan 0.5 q4 PRN Unasyn 1.5 q8 Psyllium Papain/Urea Kaolin-pectin MVI Protonix 40 Zoloft 50 Aspirin 81 Plavix 75 Imdur 30 RISS Zinc/Peruvian balsam/ castor oil Lipitor 20 Ipratroprium Albuterol Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: as directed units Injection ASDIR (AS DIRECTED): per sliding scale. 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed. 7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 8. Chlorothiazide 500 mg IV BID 9. Furosemide 60 mg IV BID 10. Atrovent 18 mcg/Actuation Aerosol Sig: Four (4) puffs Inhalation four times a day. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary Diagnosis: 1. Pseudomonal Pneumonia 2. Respiratory Failure s/p trach 3. Clostridium difficule colitis 4. Right toe ulcer infected with Pseudomonas 5. Acute on chronic renal failure 6. systolic heart failure 7. Pulmonary Hypertension Discharge Condition: stable, oxygenating well on PS 5/5, MAP>65 Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L Take all medications as prescribed and go to all follow up appointments. Followup Instructions: Follow up with your PCP in the next one month You will likely need to have your right large toe amputated. This should be done by either vascular surgery or podiatry

[ "427.31", "285.9", "707.15", "038.9", "250.00", "V45.82", "428.0", "008.45", "585.9", "112.2", "584.9", "414.00", "785.52", "518.81", "482.1", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.6", "33.23", "38.93", "31.1", "38.91", "93.90", "99.15", "96.72", "34.91" ]

icd9pcs

[ [ [] ] ]

10177, 10277

5492, 9043

341, 348

10562, 10607

2207, 5418

10853, 11023

1729, 1747

9353, 10154

10298, 10298

9069, 9330

10631, 10830

5434, 5469

1762, 2188

275, 303

376, 1276

10317, 10541

1298, 1559

1575, 1713

14,957

162,325

44056+44057

Discharge summary

report+report

Admission Date: [**2159-11-17**] Discharge Date: [**2159-11-23**] Service: C-MED CHIEF COMPLAINT: Increased dyspnea on exertion. HISTORY OF THE PRESENT ILLNESS: [**Known firstname **] [**Known lastname 614**] is an 82-year-old woman with a history of coronary artery disease, status MI in [**2159-3-20**] with an estimated ejection fraction of 35%, history of CHF. She presented to the emergency department with seven to ten days of progressive shortness of breath, dyspnea on exertion, lower extremities edema, or orthopnea. The patient denies any chest pain, light headedness, back pain, or neck pain. The night, prior to admission, around 10 p.m. or 11 p.m. the patient felt an odd facial sensation. She was unable to elaborate, but she did not feel any change in respiratory symptoms. Symptoms at the time of previous MI were back and neck pain. She denied any recurrence of those types of symptoms. She was felt to be in CHF in the emergency department; treated with Lasix with improvement in her symptoms. She had approximately 300 cc diuresis. The patient also has a history of bright red blood per rectum with recent colonoscopy and virtual colonoscopy, which was negative per the patient's report. PAST MEDICAL HISTORY: 1. Coronary artery disease. Perfusion thallium in [**2158-3-20**] showed severe fixed inferior and lateral wall defect. 2. Congestive heart failure with an ejection fraction of 35%, echocardiogram in [**2158-3-20**] showed left atrial enlargement, mild to moderate aortic insufficiency, mild to moderate mitral regurgitation, severe hypokinesis, akinesis of the inferior and posterolateral wall. 3. Breast cancer, status post right mastectomy with right arm swelling chronically. 4. Hypertension. 5. Hemorrhoids. 6. History of atrial fibrillation after her MI in [**2158-3-20**]. She was direct-current cardioverted back to sinus rhythm at that time. 7. Anemia, secondary to GI bleeding. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Lasix 20 mg p.o.q.o.d. 2. Lipitor 10 mg. 3. Lopressor 25 mg p.o.b.i.d. 4. Fosamax 70 mg q.week. 5. Coumadin 2 mg p.o.q.d. 6. Tums p.r.n. 7. Univasc 7.5 mg p.o.q.d. SOCIAL HISTORY: The patient lives alone in [**Location (un) 55**]. She denies alcohol or drug use. FAMILY HISTORY: The patient's father had a history of coronary artery disease. The patient's sister had coronary artery disease and diabetes. PHYSICAL EXAMINATION: Examination revealed the temperature of 96.7, pulse 82 to 90, blood pressure 90 to 109/53, respiratory rate 26 to 30, oxygen saturation 97% on two liters nasal cannula. GENERAL: In general, the patient is a comfortable appearing elderly female in no acute distress. NECK: Neck revealed JVP to the angle of the jaw. LUNGS: Lungs revealed crackles bilaterally, [**1-21**] of the way up. HEART: Normal S1 and S2, 3/6 systolic murmur at the apex; no S3 appreciated. ABDOMEN: Abdomen was soft, nontender, and nondistended, normoactive bowel sounds. EXTREMITIES: Extremities showed 2+ bilateral lower extremity edema to the mid thigh. RECTAL: Examination showed heme-positive stool with no masses appreciated. LABORATORY DATA: Labs on admission showed the white count of 8.3; hematocrit 26, which is down from 31 on [**2159-7-24**]; platelet count 285,000 with MCV of 84, sodium 138, potassium 4.4, chloride 103, bicarbonate 23, BUN 40, creatinine 1.0, PT 22.3, INR 3.4, PTT 41.6. The urinalysis had 21 to 50 white blood cells, [**1-22**] red blood cells and moderate leukocyte Estrace. The CK was 208 with a MB fraction of 30 with an index of 14. Troponin was 14.5. IMAGING STUDIES: Chest x-ray showed CHF with bilateral pleural effusions, right greater than left. The EKG showed sinus rhythm with 1.5-mm ST depressions in leads V2 through V5, which are new compared with the EKG of [**2159-7-14**]. HOSPITAL COURSE: The patient was admitted to the C-Med Service for further management of likely CHF exacerbation. She also had evidence of myocardial ischemia at the time of presentation. #1. CARDIAC: The patient's enzymes were cycled. She was continued on aspirin, Lipitor, and beta blocker. The Coumadin was held as the INR was 3.4. It was anticipated that she would need cardiac catheterization. Heparin was held off until the INR fell below two. She was transfused two units of blood at the time of admission with a goal hematocrit of greater than 30. She had much improvement in her symptoms after diuresis. Initially, the ACE inhibitor was attempted to be titrated upwards, however, it was discovered that the aortic stenosis had progressed to a severe level and the increased ACE inhibitor was not tolerated along with the pre-load reduction from the Lasix. Therefore, Digoxin was also added at the time of admission for symptomatic improvement. The patient went to cardiac catheterization on [**2159-11-22**]. The morning of cardiac catheterization before going, the patient did experience some neck discomfort, which she was unable fully described, as well as some nausea. EKG was obtained, which showed new downsloping ST depressions in leads 2, 3, and AVF, which were new when compared with admission. No further intervention was taken at the time as the patient was on her way to cardiac catheterization. Cardiac catheterization showed severe aortic stenosis. Left ventriculography showed no mitral regurgitation. The left ventricular ejection fraction was 60%. There was mild focal anterolateral dyskinesis. Coronary angiography showed a right dominant system. The LMCA had a 30% to 40% ostial lesion. The LAD was calcified diffusely diseased. There was an 80% lesion at the takeoff of D1, 60% mid lesion. The left circumflex had an 80% lesion in the mid vessel. The right coronary artery showed a large PLV system. There was a calcified 30% proximal lesion. The remainder of the vessel had mild luminal irregularities. At the time of this discharge summary, a CT surgery consultation is pending in order to explain possible CABG and AVR to the patient to see if she would be amenable to this. Digoxin has been discontinued given her tight aortic stenosis and diuretics are currently being held again because of her aortic stenosis. #2. INFECTIOUS DISEASE: The patient was found to have a urinary tract infection at the time of admission and was started on Bactrim for this. She will be continued for a total of a seven day course. She remained afebrile and without any elevated white count throughout the hospital stay. #3. GI/HEMATOLOGY: As already stay, the patient has a history of anemia secondary to GI bleeding. She was found to have heme-positive stools at the time of admission. This was followed throughout her hospital stay. She received two units of blood at the time of admission. At the time of this discharge summary the patient's hematocrit is stable in the low 30s. She will likely required further GI workup as an outpatient to determine where exactly the bleeding is coming from as this was not able to be determined with the virtual colonoscopy she received in the past. MEDICATIONS ON DISCHARGE: 1. Lipitor 10 mg p.o.q.h.s. 2. Lopressor 25 mg p.o.b.i.d.; hold for systolic pressure less than 100, pulse less than 55. 3. Tums 750 mg p.o.q.d. 4. Aspirin 325 mg p.o.q.d. 5. Bactrim DS, one tablet p.o.q.d. for seven days. At the time of this discharge summary, the patient received three out of the seven day course. 6. Captopril 6.25 mg p.o.t.i.d. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Non-Q-wave myocardial infarction. 3. Status post cardiac catheterization. 4. Aortic stenosis. 5. Hypertension. 6. Urinary tract infection. 7. Anemia. DISCHARGE FOLLOWUP: The patient will followup with her primary care physician within one week after discharge. She also may need to followup with cardiothoracic surgery pending their discussion. Regarding the patient's disposition, at this time, rehabilitation placement is being sought. Final decision regarding the disposition again will depend on the outcome of the cardiothoracic consultation. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By:[**Last Name (NamePattern1) 6859**] MEDQUIST36 D: [**2159-11-17**] 08:18 T: [**2159-11-23**] 08:56 JOB#: [**Job Number **] Admission Date: [**2159-11-17**] Discharge Date: [**2159-12-6**] Service: REASON FOR ADMISSION: The patient was admitted for shortness of breath and presented with lower extremity swelling and elevated cardiac enzymes. HISTORY OF PRESENT ILLNESS: The patient was found to have an acute myocardial infarction and agreed to go to the Cardiac Catheterization Suite and was found to have multi-vessel coronary artery disease and moderate aortic stenosis. The patient was referred to the Cardiac Surgery Department. The patient was found to have moderate aortic stenosis and multi-vessel coronary artery disease. After careful consideration and given that she had a recent non-Q wave myocardial infarction, along with the catheterization findings the patient, after informed consent was obtained, decided to pursue an operative repair of these problems. The patient was taken to the Operating Room on [**2159-11-28**], where she underwent coronary artery bypass grafting times one and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] aortic valve, Size No. 19. Immediately in the perioperative period, the patient was found to have ST segment changes. A transesophageal echocardiogram was obtained immediately postoperative which showed her ventricle to have some apical hypokinesia and inadequate filling. The patient then was given volume and her blood pressure was maintained using alpha agents. Postoperatively, the patient was noted to have peak inspiratory pressures and was believed to have abdominal compartment syndrome. She was then taken back to the Operating Room where she underwent an exploratory laparotomy. She had her abdomen opened in the midline and a Shisker silo dressing was applied and was sewed to the abdominal wall. She had drainage of ascites and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain. She was also given fresh frozen plasma and a unit of packed cells. She was also followed using an oxy-Swan. Her ventilator was slowly weaned thereafter and on postoperative day three, the patient had her abdominal wound now closed in the midline, stapled, and she tolerated that. On the ventilator, there was no change in her peak inspiratory pressures. She was followed by General Surgery during this hospitalization. The patient was then extubated which she tolerated. She intermittently required Dopamine for heart rate control as she tended to be bradycardic and Neo-Synephrine was used to maintain her blood pressure. The patient has a history of atrial fibrillation and on postoperative day seven went into atrial fibrillation. She was loaded with amiodarone with the orders to change to p.o. amiodarone which was done, 400 mg p.o. three times a day. The patient was seen by Physical Therapy. As her blood pressure increased and Neo-Synephrine was weaned off, she was started on Lasix. She was awake and alert. She required some endotracheal suctioning. She had a productive cough. Her voice was hoarse, but overall her saturations were in the 90s on a face mask with an FIO2 of 0.4%. She remained afebrile with a stable hematocrit. On [**12-6**], postoperative day eight from the exploratory laparotomy for abdominal compartment syndrome, postoperative day six from abdominal wall closure, she had several self-limiting runs of ventricular tachycardia, approximately six to eight beats long, with minimum decrease in her blood pressure and shortly thereafter was seen on the evening rounds after having labs sent off and was noted to have a decrease in her blood pressure significantly, dropped approximately 20 pounds, and continued in a ventricular tachycardia. When her blood pressure dropped she had a transthoracic echocardiogram which showed good right ventricular and left ventricular filling and then shortly thereafter she went in to ventricular tachycardia and had a full code performed. Her chest was then opened, wires were cut, and after having several episodes of attempts at electro-cardioversion, externally, she had the internal lead paddles placed and was attempted internal cardioversion. She was able to generate a paced rhythm for a blood pressure of 90/60. She then had an idioventricular rhythm and then subsequently became systolic. Sh[**Last Name (STitle) **]intubated. She was given epinephrine, bicarbonate, Atropine, calcium. She continued to have intermittent periods of hypotension and she then had a #30 French intra-aortic balloon pump placed. She had her sternum irrigated with two liters of Bacitracin solution and warm saline and her chest was closed with an Isotac cover after pacing wires were placed and a chest tube was placed. Family was notified. The Attending, Dr. [**Last Name (Prefixes) **] was present as well as the chief resident of Cardiac Surgery. When the family was [**Name (NI) 653**], their decision was patient comfort measures only and the patient then, within approximately a hour and a half after the code was finished, expired at 11:40 p.m. on [**2159-12-6**]. PAST MEDICAL HISTORY: 1. Breast cancer 20 years ago status post a mastectomy. 2. History of bright red blood with a recent colonoscopy and a virtual colonoscopy. 3. History of hypertension. 4. Hemorrhoids. 5. History of atrial fibrillation after an myocardial infarction with cardioversion to sinus rhythm in [**Month (only) 116**] of [**2157**]. ALLERGIES: The patient had no known drug allergies. CONDITION: Dead. DISPOSITION: Deceased. DISCHARGE DIAGNOSES: 1. Status post non-Q wave myocardial infarction. 2. Status post coronary artery bypass graft times one, aortic valve replacement. 3. Abdominal compartment syndrome. 4. Closure of abdominal compartment after an exploratory laparotomy. 5. Ventricular tachycardia and cardiac arrest. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2159-12-7**] 00:42 T: [**2159-12-7**] 10:12 JOB#: [**Job Number 42850**]

[ "427.1", "789.5", "424.1", "414.01", "427.31", "410.71", "997.1", "998.89", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.53", "42.23", "88.57", "37.23", "36.11", "37.61", "39.61", "88.72", "35.22" ]

icd9pcs

[ [ [] ] ]

2324, 2452

14017, 14575

7161, 7519

2031, 2206

3907, 7135

2475, 3652

111, 1232

7751, 8674

8703, 13527

13549, 13996

2223, 2307

3670, 3889

5,910

130,045

6266

Discharge summary

report

Admission Date: [**2194-2-6**] Discharge Date: [**2194-2-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6195**] Chief Complaint: 79y/o M with COPD on home O2, h/o lung cancer, presented again after 2 recent admissions with a fever and shortness of breath. Major Surgical or Invasive Procedure: intravenous antibiotics History of Present Illness: Pt was recently diagnosed with an H flu pneumonia at the VA in [**12-19**], and was intubated during that hospitalization. He then presented 2 days after discharge to [**Hospital1 18**] with similar complaints, and was treated for pneumonia and a COPD exacerbation. On the day of admission, pt was at his nursing home and was complaining of SOB. Pt without complaint. Feels weak, but denies shortness of breath, chest pain, fevers, chills, pain, or discomfort. Of note, pt is a poor historian with many responses being, "I don't know" when asked about symptomatology. In the [**Name (NI) **], pt with a fib with rapid ventricular response to 160; BP 80s/30s. Was treated with a bolus, 10mg IV diltiazem with good effect. Also received ceftaz, vanco, solumedrol, and 2L IVF. Sats were 100% on 2L. PICC line found to be infiltrated and was removed, with the tip sent for culture. ABG revealed 7.38/55/91. Pt did not tolerate BiPAP. Past Medical History: 1. Recent hospitalization at the VA for pneumonia with intubation for H. flu pneumonia (grew in sputum culture) treated with Ceftazidime, Flagyl and Vancomycin 2. AAA repaired [**12/2187**] 3. COPD- on home O2 1L 4. Hx Lung Ca - [**2187**]; details of tx unavailable 5. Depression 6. Recurrent hip fx- last [**6-18**] 7. HTN 8. Hypercholesterolemia 9. Anemia - Hct at bl 31-35 Social History: Patient is retired, lives with his wife, >100 pack year hx of smoking. Was recently in a rehabilitation facility and returned home approximately two months ago. He has two daughters, both involved in his care. Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17**] and wife are health care proxy. Family History: Non-contributory Physical Exam: on admission: VS: 98.3 BP 100/60 to 85/37 to 200/113; given 10mg IV dilt, with BP 110s/60s HR 74 to 160; given dilt, with P 100 Gen: mild respiratory distress, not using accessory muscles HEENT: PERRL, EOMI, OP clear Neck: no JVD CV: irregularly irregular, tachycardic, no murmurs Pulm: coarse, expiratory wheezes bilaterally Abd: soft, NT/ND, +BS Ext: L arm swollen, erythema with 1-2+ edema Neuro: A&O X1 (knows hospital), thinks it's [**Month (only) 404**] on discharge: Gen: mild respiratory distress, unchanged Neck: no JVD CV: irregularly irregular, regular rhythm, no murmurs Pulm: coarse sounds, sound like upper airway; diffuse wheezing with mild respiratory distress but this is unchanged; no crackles appreciated Abd: soft, NT/ND, +BS Ext: 2+ pitting edema, in all 4 extremities; LUE edema appears unchanged but overall appears to have more peripheral edema; swelling in upper extremities is symmetric; no pain to palpation of left arm or left side of chest Pertinent Results: [**2194-2-6**] CXR: IMPRESSION: 1. Emphysema. 2. Persistent small left pleural effusion with left lower lobe collapse/consolidation, unchanged compared to the prior study. [**2194-2-7**] LUE ultrasound: IMPRESSION: No evidence of venous thrombosis. [**2194-2-8**] CXR: hyperinflation, cardiomegaly, small LLL effusion with underlying collapse and/or consolidation; upper zone redistribution without overt CHF; prominence of the right hilum, with a tapered appearance, suggesting some underlying pulmonary hypertension; incidental incomplete azygos lobe; no significant change from one day prior. [**2194-2-10**] bilateral upper extremity ultrasound: intraluminal thrombus with flow occlusion in left cephalic vein last echo [**2194-1-30**]: EF >= 60%, suboptimal study, mod pulm A systolic HTN EKG on admission: a fib with ventric rate 100-160, slight L axis, flat TW aVL, V2, TWI in Vi (all unchanged except for a fib, which is new) [**2194-2-6**] 04:55PM WBC-12.0* RBC-3.45* HGB-11.0* HCT-33.8* MCV-98 MCH-32.0 MCHC-32.6 RDW-15.4 [**2194-2-6**] 04:55PM NEUTS-85.8* LYMPHS-7.2* MONOS-3.8 EOS-3.1 BASOS-0.1 [**2194-2-6**] 04:55PM MACROCYT-1+ [**2194-2-6**] 04:55PM PLT COUNT-389 [**2194-2-6**] 04:55PM TSH-2.0 [**2194-2-6**] 04:55PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-2.0 [**2194-2-6**] 04:55PM CK(CPK)-23* [**2194-2-6**] 04:55PM CK-MB-3 cTropnT-0.20* [**2194-2-6**] 04:55PM GLUCOSE-113* UREA N-18 CREAT-0.9 SODIUM-145 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-37* ANION GAP-10 [**2194-2-6**] 05:08PM LACTATE-1.5 [**2194-2-6**] 06:30PM TYPE-ART PO2-91 PCO2-55* PH-7.38 TOTAL CO2-34* BASE XS-5 [**2194-2-6**] 07:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**2194-2-6**] 07:00PM URINE RBC-[**7-25**]* WBC-21-50* BACTERIA-FEW YEAST-FEW EPI-[**1-4**] [**2194-2-6**] 07:00PM URINE CA OXAL-FEW [**2194-2-6**] 10:51PM CK(CPK)-25* [**2194-2-6**] 10:51PM CK-MB-NotDone cTropnT-0.11* Brief Hospital Course: 1. COPD flare - this was thought to be the etiology of pt's acute on chronic hypercarbic respiratory failure. Pt was started on solumedrol 80mg IV q8h and placed on standing albuterol/atrovent nebs. As pt seemed to improve clinically, with good oxygen saturation with 1-2L O2 by nasal cannula (usually 97-100% O2 sat on 1L NC), a taper of the steroids was begun. On the day of discharge, pt was receiving a 40mg IV q8h dose; we recommend he begin 20mg IV q8h on [**2-14**], for 2 days, and then discontinue the steroids. 2. pneumonia - On admission, pt was on day [**1-28**] of broad spectrum antibiotics (ceftazidime, Flagyl, and vancomycin), with H flu the only reported organism growing from sputum cultures at the VA (never here). However, the PICC line was infiltrated and it was thought that he may not have received his antibiotics. The PICC line was pulled, and the tip sent for culture, which revealed coag negative Staph that was oxacillin resistant. This was thought to be likely due to a contaminant, as there were greater than 15 colonies, no bacteremia, and no leukocytosis. A Legionella urinary antigen was sent, which was negative. Pt's CXR remained unchanged. 3. atrial fibrillation - On the day of admission, pt devleloped a new onset atrial fibrillation with RVR and hypotension. Pt had good response to IVF and IV diltiazem. Cardiac enzymes were sent, which revealed an elevated troponin thought to be most likely due to demand ischemia in setting of rapid a fib. Cardiology was consulted. Due to the risk of aortic dissection with an aortic thrombus associated with some ulceration into the aortic wall, it was decided not to anticoagulate pt for a fib. In addition, it was noted that pt does not meet CHADS2 criteria for anticoagulation. Pt was rate controlled, first with metoprolol, but was then changed to verapamil in the setting of severe lung disease. Pt was monitored on telemetry, and verapamil was uptitrated as needed to maintain good rate control. 4. fever - Pt was afebrile after the first 1-2 days of admission. Sources were likely pneumonia, which may not have been adequately treated due to PICC infiltration. PICC infection was another possibility, though the PICC was removed and cultures showed coag negative Staph. Possible thrombophlebitis prompted a L upper extremity ultrasound, which did not show any evidence of DVT. 5. aortic thrombus - Pt has an aortic thrombus, which is somewhat ulcerated. In this setting, pt was not anticoagulated for atrial fibrillation. It was recommended that pt get a repeat chest CT in one month, and if there is evidence of progression, he may need to follow up with cardiothoracic surgery as an outpatient for further management decisions. This has been scheduled for [**2194-3-17**]. 6. left cephalic vein thrombosis - Pt's arm was noted to be somewhat swollen, though this was initially thought to be due to PICC infiltration. However, the family was concerned about an upper extremity DVT. Another ultrasound, performed 3 days after the first, showed a thrombosis in the L cephalic vein not previously seen. The case was again discussed with cardiology and radiology, as well as the primary attending, and it was decided not to anticoagulate the patient, since a cephalic vein clot is not considered to be a deep vein thrombosis, and the risk of anticoagulation in this pt is high. In addition, further review per cardiology the following day led the cardiologists to the conclusion that by appearance, this clot was likely old. Pt was treated with heat packs and elevation of the arm. He had symmetric range of motion and strength and denied pain. 7. hyperglycemia - pt does not have a history of diabetes; this was most likely due to high dose steroids. Pt was covered with a sliding scale insulin, and fingersticks were checked four times per day. Pt remained hyperglycemic into the 200s with every [**Location (un) 1131**], so he was begun on glargine insulin 20 units for a baseline antihyperglycemic effect. He responded well to this. It is expected that his glucose will drop as the steroids are tapered. 8. pleural effusion - pt has a pleural effusion seen on CXR. During the last hospitalization, this was tapped, and the cytology was consistent with atypical epithelial cells, favor reactive mesothelial cells. 9. nutrition - nutrition was consulted, and pt was supplied with Boost shakes to supplement nutrition. He was evaluated by the speech and swallow team, who had done a video swallow study earlier this year and found him to not be an aspiration risk. However, he does have residual food in his oropharynx. It was recommended that he sit upright for meals, alternating between bites and sips to reduce food retention in the oropharynx, and possibly be observed at mealtimes to prevent aspiration. 10. [**Name (NI) **] - pt was maintained on subcutaneous heparin for DVT prophylaxis. He was given a bowel regimen, as well, as he tends towards constipation. Medications on Admission: vancomycin 1g IV q12 ([**2-6**] was day 12) ceftazidime 1g IV q8h ([**2-6**] was day 12) Flagyl 500mg po tid ([**2-6**] was day 12) SC heparin Protonix 40mg po daily senna captopril 6.25mg po tid lipitor 40mg po daily vitamin C aspirin 81mg po daily albuterol/atrovent remeron 30mg po daily colace prednisone 10mg po daily diltiazem 30mg po 4x/day humalog SS Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Pantoprazole Sodium 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, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q4H (every 4 hours). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 8. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous Q12H (every 12 hours): last day of course is [**2-13**]. 15. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) gram Intravenous Q8H (every 8 hours): last day of course is [**2-13**]. 16. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours): last day of course is [**2-13**]. 17. Methylprednisolone Sodium Succ 1,000 mg/8 mL Recon Soln Sig: Forty (40) mg Injection Q8H (every 8 hours): [**2-14**]: 20mg IV q8 [**2-14**]: 20mg IV q8 [**2-15**]: discontinue. 18. insulin glargine insulin 20 units at lunchtime fingersticks 4 times per day, regular insulin according to sliding scale provided Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: 1. chronic obstructive pulmonary disease 2. pneumonia 3. new onset atrial fibrillation 4. supraventricular tachycardia 5. multifocal atrial tachycardia Secondary: 1. hypertension 2. hyperglycemia 3. aortic thrombus with ulceration 4. left upper extremity cephalic vein thrombosis 5. hyperlipidemia 6. recurrent hip fracture Discharge Condition: stable, tolerating po Discharge Instructions: Please take all of your medications given to you. Please let the staff know if you have any shortness of breath, chest pain, pain in your arms, or any other symptom that is concerning. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2194-2-27**] 11:40 The following is for a repeat CT scan of the chest to evaluate for any change in the aortic thrombus. If it has gotten bigger or changed, you may need to make an appointment to see a cardiothoracic surgeon. Your primary care doctor can help with this. Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2194-3-17**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]

[ "V10.11", "E879.8", "311", "447.8", "E932.0", "401.9", "482.2", "444.1", "424.1", "511.9", "593.9", "999.9", "272.0", "251.8", "453.8", "491.21", "285.9", "269.8", "518.84", "796.3", "427.89", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12472, 12544

5159, 10164

388, 414

12932, 12955

3164, 3968

13189, 14009

2138, 2156

10574, 12449

12565, 12911

10190, 10551

12979, 13166

2171, 2171

2649, 3145

222, 350

442, 1386

3982, 5136

1408, 1786

1802, 2122

12,408

188,117

5156

Discharge summary

report

Admission Date: [**2187-3-19**] Discharge Date: [**2187-5-11**] Date of Birth: [**2111-10-12**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: recent EKG changes with inverted T waves in the setting of known CAD. Interpreted through daughter, revealed he has had mult. ER visits with chest pain with a negative work-up. Major Surgical or Invasive Procedure: cabg x 4 on [**2187-3-22**] s/p trach/ PEG History of Present Illness: 74 year old Russian speaking man with a known history of CAD, s/p PTCA of LAD [**2180**]. He was admitted to [**Hospital 882**] Hosp. with NSTEMI. Cardiac cath. done [**3-19**] revealed LAD 90%, CX 70%, RCA 100%. Transferred to [**Hospital1 18**] for CABG with Dr. [**Last Name (STitle) **]. Patient has had multiple ER visits for chest pain in recent past. Echo by report showed 2+MR, 1+ TR, EF 60%. Past Medical History: CRI ( baseline 1.5-2.4) CAD LAD PTCA [**2180**] IDDM CVA (L sided weakness) HTN MI mild dementia Physical Exam: 97.3 SR 64 179/72 75 kg RR 20 100% on 3L NC awake, NAD no carotid bruit RRR no murmur CTA bilat. abd soft NT, ND Rectal guiac pos, no mass Bilat 2+ fem pulses, dopplerable DP/PT bilat. Denies chest pain, SOB, nausea and vomiting. He also currently has a headache. No recent fever or chills. Pertinent Results: [**2187-5-10**] 02:34AM BLOOD WBC-12.3* RBC-2.92* Hgb-9.0* Hct-27.3* MCV-93 MCH-30.9 MCHC-33.1 RDW-17.9* Plt Ct-317 [**2187-3-19**] 09:37PM BLOOD WBC-8.0 RBC-3.35* Hgb-10.7* Hct-31.0* MCV-93 MCH-32.0 MCHC-34.5 RDW-13.5 Plt Ct-221 [**2187-5-7**] 02:03AM BLOOD Neuts-61.5 Lymphs-22.0 Monos-4.0 Eos-11.9* Baso-0.6 [**2187-5-7**] 02:03AM BLOOD Anisocy-1+ Macrocy-1+ [**2187-5-10**] 02:34AM BLOOD Plt Ct-317 [**2187-5-10**] 02:34AM BLOOD PT-12.6 PTT-41.1* INR(PT)-1.1 [**2187-3-19**] 09:37PM BLOOD PT-12.9 PTT-43.7* INR(PT)-1.0 [**2187-3-19**] 09:37PM BLOOD Plt Ct-221 [**2187-5-10**] 02:34AM BLOOD Glucose-115* UreaN-71* Creat-2.3* Na-140 K-4.5 Cl-106 HCO3-25 AnGap-14 [**2187-3-19**] 09:37PM BLOOD Glucose-230* UreaN-41* Creat-2.6* Na-139 K-4.2 Cl-101 HCO3-27 AnGap-15 [**2187-5-7**] 02:03AM BLOOD ALT-108* AST-113* AlkPhos-569* TotBili-2.1* [**2187-5-5**] 05:06PM BLOOD ALT-122* AST-121* LD(LDH)-297* AlkPhos-620* Amylase-48 TotBili-2.6* [**2187-3-19**] 09:37PM BLOOD ALT-16 AST-17 CK(CPK)-156 AlkPhos-59 Amylase-48 TotBili-0.6 [**2187-4-15**] 04:25AM BLOOD Lipase-82* [**2187-5-7**] 02:03AM BLOOD GGT-461* [**2187-3-19**] 09:37PM BLOOD CK-MB-6 cTropnT-0.15* [**2187-4-13**] 10:53PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2187-5-10**] 02:34AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.1 [**2187-3-19**] 09:37PM BLOOD Albumin-3.9 Calcium-8.9 Phos-4.1 Mg-2.1 [**2187-5-4**] 02:56AM BLOOD calTIBC-200* TRF-154* [**2187-3-19**] 09:37PM BLOOD %HbA1c-6.7* [Hgb]-DONE [A1c]-DONE [**2187-4-24**] 02:40PM BLOOD Phenyto-6.4* [**2187-5-10**] 02:56AM BLOOD Type-ART pO2-88 pCO2-45 pH-7.40 calHCO3-29 Base XS-1 [**2187-5-9**] 05:57AM BLOOD Glucose-159* Lactate-0.9 Na-141 K-4.5 Cl-110 [**2187-5-9**] 05:57AM BLOOD freeCa-1.11* Brief Hospital Course: Admitted from [**Hospital1 882**] [**3-9**]. BP controlled with IV nitroglycerin, hydralazine, and lopressor initially. Carotid U/S performed for prior CVA preoperatively.This revealed less than 40% bilat. stenoses. Preop echo also showed apical HK and EF 55%.Pt.had poor peripheral venous access. Metoprolol changed to labetalol. Norvasc was restarted also for better BP control. Patient was also on plavix and had renal insufficiency so surgery was delayed while his creatinine was permitted to decrease as well as the effects of the plavix wearing off. Underwent cabg x4 by Dr. [**Last Name (STitle) **] on [**3-22**] with LIMA to LAD, SVG to diag, SVG to OM2, and SVG to PDA. Intraop TEE showed EF 60% and 1+ MR. Transferred to CSRU on titrated propofol and neosynephrine drips. Initial chest tube drainage was 220 cc sero-sang. CXR later showed large left hemothorax. A new CT was placed and old one removed. This drained 1.5 L of blood. Received 1 u prbc. CXR did not improve. Thoracic was consulted and bronchoscopy was clear. Clot was presumed per Dr. [**Last Name (STitle) **]. Weaned and extubated. On NTG for bp control. Initial Sat 93% on 60% FT. IV Labetalol and hydralazine also added. He had some confusion. Lasix diuresis was started. Required SS reg. insulin. L apical PTX on AM CXR on POD#3. Postop creatinine elev. to 2.8. Aggressive pulm. toilet was done for increased secretions, poor cough, rhonchi and nebs added. Swallow OK per eval. on POD #4. Using [**Doctor Last Name 2598**] lift to chair. Resp. distress on POD #9 - reintubated and sedated. New left subclav. line and nasal feeding tube. Pacing wires DCed. Creat still rising to 3.1. Bronch. again [**4-1**]. Open trach and PEG done [**4-3**]. WBC rose to 23. CT removed. Neo weaning. Received bicarb for some acidosis and wound nurse consulted for right gluteal pressure sore. On POD #18, the patient stopped moving his left side. There was question of seizure activity and his neuro status deteriorated. Dilantin was started. He withdrew to tactile stimuli and neuro was consulted. CT scan and EEG were done and neuro workup was negative. Impression was a metabolic leukoencephalopathy. Tube feeds were now at goal via PEG. ABX switched to linezolid, and then changed to a 14 day course of meropenem 1000mg IV q12 hours. Pathogen is Burkholdera cepacia. Tolerating tube feeds. Occasionally follows commands. Now using trach mask 2 hours at a time with minimal pressure support rest at 5/5 and [**4-3**]. His encephalopathy is clearing slowly. Day 10 of 14 abx today [**5-10**]. Last dose is [**5-14**]. Stable and ready for discharge to rehab today. Medications on Admission: ASA 81 mg qd Plavix 75 mg qd Labetalol 100mg qd Norvasc 5 mg qd Protonix 40 mg qd Lasix 20mg Mon,Wed,Fri Zoloft 25 mg qd Trazadone Thiamine 100 qd NPH insulin 24u q AM; 14u q PM Sliding scale regular insulin (on transfer) Discharge Medications: 1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day). 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 units Injection TID (3 times a day): SQ only- give until ambulatory. 6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 8. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation [**Hospital1 **] (2 times a day). 9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) 30 mg suspension PO once a day: per NG. 10. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 11. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Ascorbic Acid 90 mg/mL Drops Sig: One (1) 500 mg PO twice a day: per PEG. 13. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours): last dose 6/20 to complete 14 day course. 14. Bumex 1 mg Tablet Sig: One (1) Tablet PO twice a day: per PEG. 15. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: per PEG. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: s/p coronary artery bypass grafting x4 s/p trach and Percutaneous endoscopic gastrostomy coronary artery disease with LAD stent [**2180**] myocardial infarction insulin-dependent diabetes mellitus Hypertension history of cerebrovascular accident Chronic renal insufficiency failure to wean from ventilator resolving encephalopathy Discharge Condition: stable Discharge Instructions: no lotions, creams or powder on incisions sternal precautions Followup Instructions: follow up with PCP after discharge from rehab follow up with Dr. [**Last Name (STitle) **] after discharge from rehab [**Telephone/Fax (1) 170**] Completed by:[**2187-5-11**]

[ "482.41", "V09.0", "348.31", "997.3", "285.1", "997.5", "998.11", "518.5", "482.1", "250.00", "584.5", "707.05", "518.0", "414.01", "599.0", "V45.82", "403.91", "276.3", "410.71", "041.3", "E878.2", "511.8", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "33.23", "34.04", "36.15", "96.6", "38.93", "96.04", "03.31", "43.11", "99.04", "89.68", "88.73", "39.64", "31.1", "39.61", "99.07", "99.15", "99.05", "34.09", "96.72", "33.24", "36.13", "00.14" ]

icd9pcs

[ [ [] ] ]

7519, 7598

3153, 5788

499, 545

7973, 7981

1427, 3130

8091, 8268

6060, 7496

7619, 7952

5814, 6037

8005, 8068

1112, 1408

283, 461

573, 975

997, 1097

10,853

190,115

7016

Discharge summary

report

Admission Date: [**2141-3-17**] Discharge Date: [**2141-3-21**] Date of Birth: [**2064-5-21**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Chronic renal insufficiency, status post MI, status post CABG x5, hypertension, and dyslipidemia admitted with hypotension, acute renal failure, and altered mental status for approximately three days. The patient was recently diagnosed with pansensitive E. coli UTI on [**2-27**]. She was started on Bactrim double strength b.i.d. for a 10-day course. Her last dose was on the [**3-5**]. Several days prior to admission, the patient reportedly developed rhinorrhea, myalgia. No cough or fevers, however. The patient was noted by family to be increasingly confused, lethargic, weak, and required increased assistance. On presentation, the patient was hypotensive with a systolic blood pressure ranging between 70-80s with a BUN and creatinine of 84 and 7 respectively. Her baseline creatinine varies between 1.4-2. Her tox screen was negative. She received IV fluids, Solu-Medrol, and empiric ceftriaxone. After 4 liters of IV fluids, the patient was still hypotensive with a systolic blood pressure range in the 80s. CT of the head was negative. Renal ultrasound did show mild right hydronephrosis. The patient was transferred to the MICU. She was started on sepsis protocol. She was given stress dose IV steroids and empiric antibiotic coverage. PAST MEDICAL HISTORY: As mentioned above. 1. Systemic lupus erythematosus. Remote history of lupus nephritis. 2. Chronic prednisone. 3. Chronic renal insufficiency. 4. CAD status post CABG in [**2136**]. 5. Peripheral vascular disease status post right BK to peroneal. 6. Type 2 diabetes diet controlled. 7. Glaucoma. 8. Cataract. 9. History of thrombocytopenia. ADMISSION MEDICATIONS: 1. Spironolactone 25 mg p.o. q.d. 2. Aspirin 325 mg p.o. q.d. 3. Folic acid. 4. Moexipril 50 mg p.o. q.d. 5. Atorvastatin 40 mg p.o. q.d. 6. Lasix 20 mg p.o. q.d. 7. Atenolol 25 mg p.o. q.d. 8. Prednisone 10 mg p.o. q.d. 9. Multivitamin. 10. Glaucoma eyedrops. SOCIAL HISTORY: The patient denies any history of tobacco or alcohol use. She lives alone. Her family is involved in her care. ALLERGIES: Flu vaccine. FAMILY HISTORY: Noncontributory. PHYSICAL EXAM FROM ADMISSION: Vital signs: Blood pressure 71/44, heart rate 62, temperature 97.5, respiratory rate 18, and oxygen saturation stable. Physical exam is notable for a thin black female with alopecia, awake and oriented to person and place. HEENT: Left-sided cataract. Oropharynx is dry. No lymphadenopathy. No bruits. Cardiac examination: Regular rate, no rub, gallops, S1, S2 and a S4. Pulmonary examination: Clear. Abdominal examination is benign. Extremity examination: Notable for ulnar deviation as well as prominent metacarpophalangeal joints. No joint swelling or pain noted. No rashes. No clubbing, cyanosis, or edema. Neurologically: Toes are downgoing bilaterally. Moves all extremities. No asterixis. Cranial nerves intact. LABORATORY DATA FROM ADMISSION: White blood cell count 8.3, hematocrit 38, normal differential, platelets 121,000. Chemistry profile notable for a BUN of 84, creatinine is 7.0, most recent creatinine was 1.4 from [**2140-4-21**]. CK 325, MB 3, troponin less than 0.01. Patient's anion gap was 20. INR 1.2, PTT 23.8. Urinalysis was negative. Urine culture was unremarkable. Serum tox screen was negative. HOSPITAL COURSE BY PROBLEM: 1. The patient was admitted to the MICU. She started stress dose IV steroids. Her a.m. cortisol was noted to be 22, which was borderline low. She rapidly responded to IV fluid hydration in both her blood pressure as well as her renal function. Patient was transferred to the floor on [**3-18**]. Her hypotension was likely related from hypovolemia in addition to her poor p.o. intake as well as diuretic therapy possibly also relating to her borderline adrenal insufficiency upon presentation in the setting of acute URI. There was no evidence of sepsis, however, based on the patient's laboratory data and her overall improvement without antibiotic therapy, the patient was able to take p.o. She was given IV fluids on a prn basis and her hypotension resolved quickly. 2. Acute renal failure on chronic renal insufficiency: The patient was presenting with a BUN and creatinine well above her baseline. This quickly resolved with IV fluid hydration. Renal service was consulted, however, there was no need for emergent dialysis. The patient's mental status improved dramatically upon improvement in her renal function. Question was could this have been related to Bactrim-induced ATN versus ischemic injury in the setting of hypotension or possibly dehydration in the setting of diuretic therapy. Patient remained good urine output. Foley catheterization was discontinued on hospital day three. Ultrasound did show mild right-sided hydronephrosis, however, this was not aggressively followed per the Renal team given the patient's overall improvement in renal function with IV fluid hydration. Patient's acidemia resolved with bicarb nadir of 15. She was treated with sodium bicarbonate in the ICU. 3. Delta MS: The patient had a head CT without any acute changes. Mental status significantly improved on the day of her discharge from the ICU. Her neurologic exam was nonfocal. 4. Adrenal insufficiency: The patient was maintained on stress-dose steroids for approximately three days. This was discontinued in light of the fact that the patient's blood pressure was stable. Overall clinical picture had improved dramatically, and therefore she was maintained on her p.o. regimen at home of 10 mg of prednisone. 5. Lupus: The patient was kept on prednisone. There is no evidence of any cardiac or pulmonary complications relating to her lupus. Fingersticks were monitored while the patient was on extra steroid doses. She had a minimal insulin requirement. 6. CAD: The patient had an elevated CK on admission, however, she did have myalgias as well as a URI recently, which could have contributed to this as well as being on a statin. She did not have any evidence of acute ischemic injury on EKG and with followup cardiac enzymes. She was maintained on atorvastatin, beta-blocker was added once she became normotensive. Aspirin was also resumed once her renal function improved. 7. Hematologic: The patient presented with a 6-point hematocrit drop in the setting of hemodilution as well as thrombocytopenia with a platelet nadir of 96,000 on admission. Her baseline is anywhere from 130,000 to 150,000 since [**2137**]. Again the concern was could this have been related to Bactrim versus hemodilution. The patient quickly rebounded in both counts without any intervention. Patient remained guaiac negative. Heparin was discontinued for DVT prophylaxis in the setting of her decreased platelet count. Patient did not require any transfusions. DISCHARGE DIAGNOSES: 1. Acute renal failure. 2. Coronary artery disease status post coronary artery bypass graft. 3. Status post urinary tract infection treatment with Bactrim. 4. Lupus nephritis. 5. Type 2 diabetes. 6. Questionable adrenal crisis. RECOMMENDED FOLLOWUP: The patient is instructed to followup with her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**] on [**3-29**] at 4 p.m. Patient is also instructed to followup with Dr. [**Last Name (STitle) 26238**], Vascular Surgery for routine follow-up visit, which was scheduled prior to this admission. MAJOR SURGICAL OR INVASIVE PROCEDURES PERFORMED DURING THIS HOSPITALIZATION: None. DISCHARGE CONDITION: Patient is with improved renal function, is no longer hypotensive, and is mentating clearly. DISCHARGE STATUS: The patient will be discharged to either a [**Hospital 3058**] rehab facility or home with aggressive Physical Therapy. DISCHARGE MEDICATIONS: 1. Atorvastatin 20 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Folic acid 1 mg p.o. q.d. 4. Senna 8.6 mg p.o. b.i.d. 5. Multivitamin one cap p.o. q.d. 6. Dorzolamide timolol drops b.i.d. 7. Atenolol 12.5 mg p.o. q.d. 8. Prednisone 10 mg p.o. q.d. 9. Protonix 40 mg p.o. q.d. 10. Moexipril 7.5 mg p.o. q.d. The following medications have been held upon discharge and should be reinitiated per PCP's recommendations and they include spironolactone and Lasix, both of which were held during this hospital course. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 1600**] MEDQUIST36 D: [**2141-3-21**] 09:11 T: [**2141-3-21**] 09:11 JOB#: [**Job Number 26239**]

[ "276.5", "591", "412", "710.0", "287.5", "V45.81", "583.81", "584.9", "255.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7651, 7885

2248, 3446

6979, 7629

7908, 8697

1811, 2074

3474, 6958

160, 1422

1445, 1788

2091, 2231

30,805

146,057

43610

Discharge summary

report

Admission Date: [**2191-11-25**] Discharge Date: [**2191-12-1**] Date of Birth: [**2122-10-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2356**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Pericardiocentesis Thoracentesis History of Present Illness: 69 yo M w/ PMH of CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2 to the LAD and D1, DMII, HTN, hyperlipidemia and OSA presents with dyspnea, left-sided chest pain and cough. Symptoms began 10 days ago when he was on a trip to [**Country 6607**]. At that time, he developed a severe non-productive cough with intermittent SOB. He admits to sick contacts with similar symptoms. With his cough, he developed left-sided flank/chest pain, which he attributes to musculoskeletal pain from constant coughing. He presented to his cardiologist/PCP for and was sent to [**Hospital1 18**] for a CXR (which he did not get due to time constraints.) D-dimer was elevated, and his PCP [**Name (NI) 653**] him and asked him to go to the ED for further evaluation. . In the ED: his initial vitals were: 98.2, 93, 139/18, 16. A CTA was negative for PE but showed a large pericardial effusion; a CXR showed bilateral pleural effusion and cardiomegaly. A pulsus in the ED was 7. . ROS: denies fevers. He has a dry cough and left sided-CP. He reports a 10lb weight gain over 10-15 days. Denies abd pain, although he reports feeling bloated. Past Medical History: CAD--known anterolateral hypokinesis Cath [**5-27**]: PTCA/Taxus x 2 --> LAD (restenosis) and D1 Cath [**2179**]: mid-LAD stent DMII HTN hyperlipidemia OSA (BiPAP 21/18) nephrolithiasis . ALLERGIES: NKDA Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He is married with 3 children. He is bisexual. Family History: Mother had rheumatic heart disease. Father had brain tumor. No fam hx of CAD. Physical Exam: VS - T 99.6 BP 128/76 HR 84 RR 32 02sat 97 on 4L Fs 92 pulsus 10 Gen: pleasant overweight M, slight SOB with speaking, paroxysmal dry cough. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 10cm. CV: RRR, no murmurs, no rub. Chest: decreased BS at bases, no crackles. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2191-11-25**] 03:00PM BLOOD WBC-8.0 RBC-3.53* Hgb-10.7* Hct-31.5* MCV-89 MCH-30.3 MCHC-34.0 RDW-13.8 Plt Ct-374# [**2191-12-1**] 07:05AM BLOOD WBC-6.2 RBC-4.07* Hgb-12.0* Hct-35.9* MCV-88 MCH-29.4 MCHC-33.4 RDW-14.2 Plt Ct-541* [**2191-11-25**] 03:00PM BLOOD PT-15.1* PTT-26.8 INR(PT)-1.4* [**2191-11-30**] 07:30AM BLOOD PT-13.4* PTT-23.6 INR(PT)-1.2* [**2191-11-26**] 05:10AM BLOOD ESR-22* [**2191-11-25**] 03:00PM BLOOD Glucose-131* UreaN-19 Creat-1.1 Na-141 K-3.6 Cl-104 HCO3-27 AnGap-14 [**2191-11-26**] 05:10AM BLOOD ALT-39 AST-22 LD(LDH)-271* AlkPhos-58 TotBili-0.5 [**2191-12-1**] 07:05AM BLOOD LD(LDH)-224 [**2191-11-25**] 03:00PM BLOOD CK-MB-4 cTropnT-<0.01 [**2191-11-26**] 05:10AM BLOOD cTropnT-<0.01 [**2191-11-26**] 05:09PM BLOOD CK-MB-5 cTropnT-<0.01 [**2191-12-1**] 07:05AM BLOOD TotProt-5.6* Albumin-3.5 Globuln-2.1 Mg-2.3 [**2191-11-26**] 05:10AM BLOOD calTIBC-252 Ferritn-397 TRF-194* [**2191-11-26**] 05:09PM BLOOD TSH-4.6* [**2191-11-27**] 06:16AM BLOOD Free T4-1.3 [**2191-11-28**] 07:51PM BLOOD [**Doctor First Name **]-NEGATIVE [**2191-11-28**] 07:51PM BLOOD RheuFac-9 [**2191-11-26**] 05:10AM BLOOD CRP-125.1* [**2191-11-28**] 07:51PM BLOOD HIV Ab-NEGATIVE . EKG [**2191-11-25**] shows NSR with rate of 90. Inverted P in v1, TWI in III, TW flattening in aVF, v2, v3. Unchanged from previous ([**3-28**]) except slightly decreased voltage in inferior leads ?[**2-25**] to lead placement. . ETT performed on [**3-28**] demonstrated: INTERPRETATION: 66 yo man was referred for a CAD evaluation. The patient completed 13.5 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol representing an excellent functional exercise tolerance. The exercise was stopped due to fatigue. No chest, back, neck or arm discomforts were reported during the procedure. No significant ST segment changes were noted. The rhythm was sinus with rare isolated aea noted. The hemodynamic response to exercise was appropriate. IMPRESSION: No anginal symptoms or ischemic ST segment changes. Nuclear report sent separately. . CTA ([**2191-11-25**]): No pulmonary embolism. Large pericardial effusion with bilateral pleural effusions, left greater than right. . CXR ([**2191-11-25**]): TWO VIEWS OF THE CHEST: Cardiomegaly has increased, and is now associated with small bilateral pleural effusions. There is no evidence of overt pulmonary edema. There is no pneumonia. The aorta is tortuous. The bony thorax is normal. IMPRESSION: Increase in cardiomegaly; bilateral small pleural effusion. . Echo [**2191-11-26**]: The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40-45%) with anteroseptal/anterior/apical hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a moderate sized pericardial effusion that is smaller adjacent to the right heart. NOTE: Additional images obtained (cells 53 and higher) with 30 degrees head up. Report edited at 1:15 pm. Additional views reveal right ventricular outflow diastolic collapse. The effusion is 1cm at the apex. . Pericardiocentesis report [**11-28**]: 1. Pericardiocentesis was performed with removal of 770 ml of bloody fluid. Initial hemodynamics revealed evidence of pericardial tamponade, with increased right sided filling pressures with mean RA pressure 18 mm Hg. There was also elevated left sided filling pressure with PCWP mean of 22 mm Hg. Initial pericardial pressure was 18 mm Hg, with a pulsus paradoxus of 15 mm Hg. Pre-procedure cardiac index was 2.7 l/min/m2. 2. Post-pericardiocentesis, RA pressure decreased to 10 mm Hg with the reappearance of y descents on the tracing. There was also a substantial increase in cardiac index to 5.0 l/min/m2. Pericardial pressure decreased to 0 mm Hg. An Echocardiogram revealed minimal residual pericardial fluid with normal RA and RV diastolic wall motion. . Echo [**2191-11-30**]: There is mild regional left ventricular systolic dysfunction with hypokinesis of the anterior septum. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion suggestive of pericardial constriction. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. Compared with the prior study (images reviewed) of [**2191-11-29**], the effusion is similar in appearance. Septal motion is now suggestive of pericardial constriction. . Pericardial fluid cytology: NEGATIVE FOR MALIGNANT CELLS. Abundant lymphocytes, rare mesothelial cells and blood. . Pleural fluid cytology: NEGATIVE FOR MALIGNANT CELLS. Reactive mesothelial cells, lymphocytes and blood. Brief Hospital Course: 69 yo gentleman with h/o CAD, HTN, DMII presents with weight gain, cough, and moderate pericardial effusion with tamponade physiology. . # Pericardial effusion: On admission, patient had elevated JVP and distant heart sounds with a pulsus of 10. Echocardiogram was significant for tamponade physiology. He was given indomethacin and monitored with frequent pulsus checks. Repeat echocardiogram demonstrated continued tamponade physiology, and pericardiocentesis was performed. He was monitored in the CCU and follow-up echocardiograms confirmed that the pericardial effusion was not reaccumulating. . Work-up for the cause of the patient's pericardial effusion was significant for CRP of 125. Thyroid studies revealed subclinical hypothyroidism. PPD was placed and was negative, although the patient did have close contact with his grandfather, who died of tuberculosis. Pericardial fluid was bloody with many PMNs and lymphocytes. Cytology was negative for malignancy. Culture data was still pending at the time of discharge. . # Pleural effusions: Patient had b/l pleural effusions, left > right. Thoracentesis was done and revealed serous fluid that was exudative by Light's criteria. Cytology was negative for malignancy. Culture data and AFB were negative at the time of discharge. Pulmonary was consulted; the etiology of the patient's pericardial and pleural effusions remained unclear at the time of diagnosis. He will have a CT of the chest and follow-up with pulmonary in [**3-27**] weeks to monitor him for reaccumulation of his pericardial and pleural effusions. . # AFib with RVR: Patient had no prior h/o of Atrial fibrillation. He had several asymptomatic episodes of AFib with rate in the 130s to 140s. His rate was controlled by increasing his dose of metoprolol. After his pericardiocentesis, he had no further episodes, and remained in normal sinus rhythm. He was discharged with a heart monitor to confirm that his AFib had resolved. . # Chest Pain: Patient's chest pain was felt to be musculoskeletal from coughing, although it could also represent pericarditis. He was given codeine for cough suppression and indomethacin for possible pericarditis. His cough and chest pain prior to discharge. Upon discharge, his indomethacin was stopped. He was advised to take ibuprofen 400-600mg TID prn pain if his chest pain should recur. . # HTN: As discussed above, patient's home dose of metoprolol was increased to 100mg [**Hospital1 **] for control of his increased rate with AFib. After resolution of his AFib, his blood pressure ranged from 100-120 systolic with a heart rate in the 70s on the higher dose. Thus, he was discharged with a prescription for metoprolol 100mg [**Hospital1 **] and advised to discuss the change with his primary doctor upon follow-up. . # CAD: Patient's ASA, plavix, beta blocker, statin, and ACE inhibitor were continued. . # DMII Patient's oral hypoglycemics were held and he was maintained on a sliding scale of insulin. His sugars were elevated in the 200s, and he was given glipizide with improvement in his blood sugar. He was discharged on his home regimen. . # Subclinical hypothyroidism: Diagnosed by labs during work-up for pericardial effusion. Patient should have f/u with his primary doctor. . # OSA: Patient was kept on BIPAP on his home settings of 21/18. Medications on Admission: Metoprolol 75mg qAM, qPM [**1-25**] tab at lunch norvasc 10mg qdaily plavix 75mg qdaily metformin 1000mg QAM, 500mg Qlunch, 500mg QPM zestril 20mg qdaily ASA 325 qdaily glipizide 5 with L/D lipitor 40mg qdaily januvia 75mg qdaily Zetia 10 QHS "Trichol" 75mg Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): This is the medication you call "Zestril". 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO at lunch. 10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM. 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM. 12. JANUVIA 25 mg Tablet Sig: Three (3) Tablet PO once a day. 13. Ibuprofen 200 mg Tablet Sig: 2-3 Tablets PO three times a day as needed for pain for 2 weeks: Please take with food. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pericardial effusion with tamponade Secondary Diagnoses: Pleural effusions, Coronary artery disease, Hypertension, Diabetes Discharge Condition: Improved. Patient's shortness of breath and cough were better. His vital signs were stable and he was afebrile. Discharge Instructions: You were admitted with a pericardial effusion, which is fluid around the heart. This fluid was drained and we checked with echocardiograms to make sure it wasn't reaccumulating. You also had some fluid outside of your lungs; this fluid was drained as well. 1. Please take all medications as prescribed. 2. Please attend all follow-up appointments as described below. 3. Please call your doctor or return to the hospital if you develop fevers, chest pain, shortness of breath, or any other concerning symptom. 4. Medication changes: - Metoprolol increased to 100mg twice a day. We did this because of your fast heart rate when you had AFib. Dr. [**Last Name (STitle) 1270**] may readjust your dose when you see him next week. - Ibuprofen as needed for pain Followup Instructions: 1. Please call Dr. [**Last Name (STitle) 1270**] for an appointment in the next week. His number is [**0-0-**]. 2. You need another CT scan of your chest to make sure the fluid is not reaccumulating. Please do not eat or drink for 3 hours before your study: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2191-12-26**] 8:30--please arrive at 8:15am. [**Hospital Ward Name 23**] building [**Location (un) **]. Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2191-12-27**] 8:40 3. You have a follow-up appointment with Pulmonary, Dr. [**Last Name (STitle) **]. You will have breathing function tests first. [**2191-12-27**] at 8:30am. [**Hospital Ward Name 23**] Building [**Location (un) 436**], Medicine [**Hospital 4094**] clinic. [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**] Completed by:[**2191-12-1**]

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icd9cm

[ [ [] ] ]

[ "88.55", "34.91", "37.21", "37.0", "93.90" ]

icd9pcs

[ [ [] ] ]

12500, 12506

7864, 11207

328, 363

12694, 12809

2777, 7841

13617, 14602

1986, 2067

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12954

Discharge summary

report

Admission Date: [**2143-11-10**] Discharge Date: [**2143-11-24**] Date of Birth: [**2066-3-8**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: Redo sternotomy/Repair of aortic prosthetic perivalvular leak/Replacement of asc. aortic hemiarch(26mm Gelweave graft) [**2143-11-11**] History of Present Illness: Ms. [**Known lastname **] is a 77 year-old female s/p a mechanical aortic valve replacement in [**2132**] who recently was discovered to have an ascending aortic aneurysm on routine follow-up for a known paravalvular leak. Past Medical History: Ms. [**Known lastname 39758**] past medical history is significant for hypertension, osteoarthritis, and hypercholesterolemia. Her past surgical history is significant for aortic valve replacement with a mechanical valve in [**2132**] and multiple melanoma excisions. Social History: Ms. [**Known lastname **] is not a current smoker, having quit over 20 years ago. She lives with her husband. She reports that her last dental exam was over six months ago. She occasionally consumes alcohol. Family History: Her family history is significant for her mother having passed away at age 61 of a myocardial infarction. Physical Exam: Ms. [**Known lastname **] at the time of discharge was awake, alert, and oriented times three. Her lungs were clear to auscultation bilaterally. Her heart was of regular rate and rhythm, and a crisp valve click was appreciated. No sternal wound drainage or erythema was noted, and her sternum was stable. Her abdomen was soft, non-tender, and non-distended. She had bowel sounds and had moved her bowels post-operatively. Ms. [**Known lastname 39758**] extremeties were warm and without edema. Pertinent Results: [**2143-11-21**] 06:15AM BLOOD WBC-12.5* RBC-2.98* Hgb-9.2* Hct-26.3* MCV-89 MCH-30.9 MCHC-35.0 RDW-13.8 Plt Ct-511* [**2143-11-21**] 06:15AM BLOOD PT-17.6* PTT-71.6* INR(PT)-1.6* [**2143-11-21**] 06:15AM BLOOD Glucose-90 UreaN-16 Creat-1.2* Na-138 K-4.8 Cl-100 HCO3-26 AnGap-17 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2143-11-18**] 8:29 AM CHEST (PORTABLE AP) Reason: r/o inf., eff [**Hospital 93**] MEDICAL CONDITION: 77 year old woman s/p redo sternotomy/repair prosthetic aortic paravalvular leak/repl. asc. and hemiarch aorta and ct removal REASON FOR THIS EXAMINATION: r/o inf., eff AP CHEST, 8:51 A.M. HISTORY: Redo sternotomy and valve replacement. Chest tube removed. IMPRESSION: AP chest compared to [**11-13**] and 29: Small bilateral pleural effusions increased. No pneumothorax or pulmonary edema. Heart size top normal. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Cardiology Report ECHO Study Date of [**2143-11-11**] PATIENT/TEST INFORMATION: Indication: h/o AVR ? Paravalvular leak. Ascending arotic aneurysm. Height: (in) 67 Weight (lb): 125 BSA (m2): 1.66 m2 BP (mm Hg): 103/63 HR (bpm): 56 Status: Inpatient Date/Time: [**2143-11-11**] at 13:55 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW02-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.0 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *0.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%) Left Ventricle - Peak Resting LVOT gradient: 5 mm Hg (nl <= 10 mm Hg) Aorta - Valve Level: 1.9 cm (nl <= 3.6 cm) Aorta - Ascending: *4.9 cm (nl <= 3.4 cm) Aorta - Arch: 2.4 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: *2.7 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: *3.3 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 44 mm Hg Aortic Valve - Mean Gradient: 17 mm Hg Aortic Valve - Valve Area: *0.9 cm2 (nl >= 3.0 cm2) Aortic Valve - Pressure Half Time: 381 ms INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal LV wall thickness. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Moderately dilated ascending aorta. Normal aortic arch diameter. There are complex (>4mm) atheroma in the aortic arch. Mildly dilated descending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Mechanical aortic valve prosthesis (AVR). AVR leaflets move normally. Paravalvular leak. Moderate AS. Eccentric AR jet. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **]S. Physiologic MR (within normal limits). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally post-bypass data Conclusions: Pre Bypass: 1. The left atrium is mildly dilated. The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Left ventricular wall thicknesses are normal. 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is moderately to severely dilated, measuring 4.8 cm. There is a discrete sinotubular junction measuring 2.9-3.0 cm. . There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. A mechanical aortic valve prosthesis is present. 5. The aortic prosthesis leaflets appear to move normally. A paravalvular aortic valve leak is present, originating where the noncoronary cusp would be and comprising about 25% of the ring. The jet is eccentric, directed perpidicular to the usual direction of flow through the LVOT and hugging the anterior and anteroseptal wall. The jet is likely mild to moderate in severity. There is moderate aortic valve stenosis. The aortic regurgitation jet is eccentric. 6. The mitral valve appears structurally normal with trivial mitral regurg itation. Physiologic mitral regurgitation is seen (within normal limits). 7. There is no pericardial effusion. Post- Bypass: Pt is being A paced and is on an infusion of epinephrine and phenylephrine. 1. A mechanical valve is well seated in the aortic position. Trace wash in jets are noted. Mean gradient across the valve is around 25-30 mm of Hg with a CO of 6.0. An eccentric AI jet is noted, severity is hard to assess given poor echo windows and location of jet, best estimate is mild severity. Origin of jet is hard to assess. Epiaortic scan performed with similar results. Valve area calculated by continuity is 1.1 cm2. Surgeon notified and Dr. [**First Name8 (NamePattern2) 6506**] [**Name (STitle) 6507**] consulted for second evaluation of the AI jet. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2143-11-11**] 15:58. Brief Hospital Course: [**Known firstname **] [**Known lastname **] was admitted the day before her elective surgery for heparin for her mechanical valve, after her coumadin had been discontinued five days previously. On the [**11-11**] she underwent an elective redo sternotomy,repair of her prosthetic paravalvular leak and replacement of her ascending and hemiarch aorta with a 25mm Gelweave graft. This procedure was performed by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. Cross clamp time was 54 minutes and total bypass time was 86 minutes. The patient tolerated this procedure well and was transferred to the CSRU on epinepherine, phenylephrine, and propofol drips. The patient was A-paced with an underlying bradycardia. Ms. [**Known lastname **] [**Last Name (Titles) 27836**] slowly in the CSRU. She was extubated on post-operative day two. Her pressors were weaned, her chest tubes were removed, and she was gently diuresed. Ms. [**Known lastname **] was noted to be in a bradycardic atrial fibrillation with hypotension post-operatively with subsequently pauses that required pacing and therefore was seen in consultation by the cardiology service. On post-operative day two she was returned to the operating room for re-exploration secondary to a pericardial effusion. She was cardioverted in the operating room for rapid atrial fibrillation. She tolerated this procedure well and was returned to the CSRU in stable condition. By her third post-operative day she returned to rapid atrial fibrillation, with an intermittent junctional rhythm. Heparin therapy was initiated. She was transferred to the floor in stable condition. On the floor Ms. [**Known lastname 39758**] epicardial wires were removed. She was returned to the CSRU for poorly tolerated rapid atrial fibrillation with pauses where she received norpace and lopressor (as recommended by the EP service). With cessation of her pauses, she was returned to the floor for coumadinization. She had an elevated WBC, but cultures were negative, and it came down to 11.6 on the day of discharge. By [**2143-11-24**], she was ready for discharge with a therapeutic INR of 2.1 in stable condition to home. Medications on Admission: zestoretic 20/125 mg [**Hospital1 **] lanoxin 0.125 mg daily norvasc 5 mg daily lipitor 20 mg daily evista 60 mg daily persantine 25 mg [**Hospital1 **] warfarin Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 3. Ranitidine HCl 150 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). Disp:*60 Capsule(s)* Refills:*2* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Norpace CR 100 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day. Disp:*120 Capsule, Sustained Release(s)* Refills:*0* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: then to be dosed by Dr. [**Last Name (STitle) 20854**] for INR 2.5-3.0. Disp:*60 Tablet(s)* Refills:*0* 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of [**Hospital3 **] Discharge Diagnosis: Perivalvular leak of prosthetic aortic valve. Ascending aortic dilitation. Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not drive for 4 weeks. Do not lift more than 10 lbs. for 2 months. Shower daily, let water flow over wounds, par dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for temp>101.5, sternal drainage. Followup Instructions: Make an appointment with Dr. [**First Name (STitle) 16745**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) 14522**] in [**3-22**] weeks. Completed by:[**2143-11-24**]

[ "272.0", "996.02", "997.1", "427.31", "E878.2", "401.9", "427.89", "420.90", "441.2" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.45", "99.62", "99.04", "35.11" ]

icd9pcs

[ [ [] ] ]

11727, 11781

7841, 10021

330, 468

11900, 11908

1896, 2294

12237, 12498

1255, 1362

10234, 11704

2331, 2457

11802, 11879

10047, 10211

11932, 12214

2938, 7818

1377, 1877

283, 292

2486, 2912

496, 720

742, 1011

1027, 1239

11,321

141,987

763

Discharge summary

report

Admission Date: [**2119-6-14**] Discharge Date: [**2119-7-1**] Date of Birth: [**2045-3-23**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 562**] Chief Complaint: cholecystitis Major Surgical or Invasive Procedure: Intubation Cholecystomy Tube placement Thoracentesis History of Present Illness: 74 y/o female with PMH significant for COPD, CAD, and hypertension admitted to [**Hospital1 18**] on [**6-14**] to the surgery service with two days of epigastric and right upper quadrant pain. She had also been febrile to 101 and had one episode of nausea and vomiting. Per notes, her abdominal exam was significant for epitastric and right upper quadrant tenderness; positive gaurding; and no rebound. Pt was guiac negative. CT showed a distended gallbladder with wall thickening and a small amount of pericholecystic fluid. Common duct was dilated up to 11 mm and the pancreatinc duct was prominent at 5 mm. No free air or fluid. Significant atherosclerotic disease with occlusion of the [**Female First Name (un) 899**] and possible celiac and renal artery stenosis. Past Medical History: 1. [**Name (NI) 3672**] Pt has been intubated twice in the past. Her most recent PFTs from [**2119-6-14**] whoed a FVC of 30% predicted, FEV1 of 24% predicted, and FEV1/FVC of 79% predicted. Her marked obstructive ventilatory defect had worsened since PFTs from [**2115**]. Also with a concurrent restrictive process given her low-normal TLC. 2. Coronary artery disease- Pt is status post a cardiac catheterization recently at the end of [**2117**] which showed a left anterior descending artery 90% blockage which was stented and her left circumflex artery underwent angioplasty with a balloon. Stress in [**4-21**] showed a mild fixed septal defect. Recent echo from [**2119-6-6**] whoed a normal RA and LA. LVEF with 55% with normal regional LV systolic function. [**2-19**]+ AR. 1+ MR. [**First Name (Titles) 5544**] [**Last Name (Titles) **]R. Indeterminate PA systolic pressure. 3. Hypertension. 4. Hyperlipidemia. 5. Borderline pulmonary hypertension. 6. Irritable bowel syndrome. 7. S/P total abdominal hysterectomy in [**2079**]. 8. S/P bilateral hernia repair in the remote past Social History: Pt lives in an [**Hospital3 **] facility. She is no longer able to leave her home but does go down for meals. Widowed. Has six children. Her HCP is her daughter [**Name (NI) **]. The pt is a retired nurses aid. Pt smoked 1 pack per day for 60 years before quiting 1.5 years ago. No ETOH or drugs. + Pneumovax. Family History: NC Physical Exam: 97.9 103/57 114 23 100% BiPAP FiO2- .50 ePAP- 8 iPAP- 5 Gen- Lady resting in bed with BiPAP on. Appears uncomfortable. Moaning. Asking to take mask off. HEENT- NC AT. Anicteric sclera. BiPAP mask in place. Cardiac- Very faint heart sounds which are difficult to hear over pulmonary sounds. RRR. Pulm- Coars breath sounds anteriorly and laterally with very poor air movement. Abdomen- Obese. Distended. Soft. NT. Percutaneous drainage tube in place. Extremities- No c/c/e. Pertinent Results: [**2119-6-14**] 03:40PM ALT(SGPT)-17 AST(SGOT)-18 ALK PHOS-111 AMYLASE-64 TOT BILI-0.6 [**2119-6-14**] 03:40PM LIPASE-16 [**2119-6-14**] 03:40PM ALBUMIN-3.6 [**2119-6-14**] 12:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2119-6-14**] 12:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2119-6-13**] 10:20PM GLUCOSE-95 UREA N-16 CREAT-0.8 SODIUM-139 POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-19 [**2119-6-13**] 10:20PM ALT(SGPT)-21 AST(SGOT)-22 ALK PHOS-131* AMYLASE-63 TOT BILI-0.9 [**2119-6-13**] 10:20PM LIPASE-16 [**2119-6-13**] 10:20PM WBC-9.2 RBC-4.83 HGB-13.6 HCT-40.2 MCV-83 MCH-28.2 MCHC-33.9 RDW-15.1 [**2119-6-13**] 10:20PM PLT COUNT-330 [**2119-6-13**] 10:12PM LACTATE-2.1* . [**6-14**] CT 1) Distended gallbladder with wall edema and possible pericholecystic fluid. Intra and extrahepatic ductal dilatation is noted as well as prominence of the pancreatic duct. Further evaluation with ERCP or MRCP is recommended. 2) Significant atherosclerotic disease with occlusion of the [**Female First Name (un) 899**] and possible celiac and renal artery stenosis. The patient's abdominal pain could be related to intestinal angina. Further evaluation can be obtained with mesenteric CTA. 3) No evidence of diverticulitis. 4) Stable left pleural effusion. 5) Stable right renal cyst. 6) Stable small low attenuation focus in the spleen, which is too small to be characterized. . [**6-20**] CT 1. Cholecystostomy tube in good position with no evidence of fluid collection around it. 2. Ostial calcifications with narrowing of the mesenteric vessels with no evidence of bowel wall thickening, edema, or fluid. . [**6-26**] CTA 1) No evidence of pulmonary embolus. 2) Marked interval increase in left-sided pleural effusion and left lower lobe atelectasis. No evidence of central obstructing lesion. 3) Unchanged appearance of pulmonary nodules; in the absence of a known primary malignancy, one-year follow-up is recommended to ensure stability. 4) Mild upper lobe emphysematous changes. Brief Hospital Course: Although it was felt that the pt had cholycytstitis, it was felt that she was an extremely high risk surgical candidate given her significant pulmonary and cardiac disease. Therefore, a percutaneous cholecyst tube was placed on [**6-15**] instead of doing a cholecystectomy. Following this, the pt had a good decreased in her pain and her fevers decreased into the 99 range. Doing an ERCP was considered but as the pt had normal LFTs and bili this was deferred as there was a concern that it would require intubation. On [**6-19**], the pt spiked to 101.2 and redeveloped right upper quadrant tenderness. On [**6-20**], she developed an acutely more distended abdomen associated with nausea. At that time, she began to desatruate to 70% with associated tachypnea, accesory muscle use, and tachycardia into the 130s. An ABG at that time was 7.44/39/52. CXR showed minimal worsening of a left lower lobe consolidation with prominent bilateral vascular markings. At that time, the pt was transferred to the SICU for closer monitoring. . In the SICU, her oxygen saturation initially increased to 90% on 4L NC. Following transfer, she spiked to 103.6 and was started on vancomycin and zosyn for a left lower lobe PNA. She was also started on steroids for her COPD component. LFTs remained within normal limits and there continued to be good drainage from her choly tube. Pt defervesced over the nex few days and her oxygenation stablalized on 4 L NC with a sat in the high 90s and RR in the high teens. Then, on the evening of [**6-25**], the pt received 1 mg ativan and 4 mg morphine for anxiety then desatted to 100% on a NRB. In addition, pt had a low blood sugar of 65 which was treated with 1/2 amp D50. ABG obtained at that time showed 7.38/56/66. Pt also received an extra 40 mg of IV lasix. This morning, after receiving her morning nebs, the pt reported that she could not breath and her oxygen sat began to drop quickly going from 95 to 65%. Pt was given another treatment and her BiPAP settings were increased with an improvement in her sat. However, she became more tachypnic, tachycardic, and was using her accessory muscles to breath. Pulmonary saw the pt and was concerned that this acute respiratory failure coud be secondary to bronchospasm. The pt had been off of high dose steroids for 24 hours. However, PE was the primary concern to rule out given her acute hypoxia, tachycardia, and relative hypotension. A CTA was negative for PE however demonstrated a large pleural effusion. At this time the patient's respiratory status was quite tenuous requiring mask ventillation. . The effusion was tapped producing 1 L of transudative fluid which was culture negative. The patient's respiratory status markedly improved and her oxygen requirements decreased to 4L NC. She was transferred to the floor where she felt much better. The patient had one desatturation to 89% on 3L on [**6-29**] which quickly resolved with nebs. Otherwise the patient has been at her baselie which is unfortunately poor. At home she is on [**3-23**] L NC and requires freq nebs. She will complete a 14 day course of vanc/zosyn for her pneumonia. . The patient's liver funcitions decreased after tube placement and stayed down. She will complete a 14 day course of vanc/zosyn for her cholecystitis. The patient will have the tube in place for 4-6 weeks total and follow up with IR as an outpatient. . Of note the patient noticed numbness in her R hand where her a line was placed. The are was largely ecchymotic. However this improved once the line was taken out and returned to her baseline neuropathy which is equal bilaterally. . Furthemore the patient had pain in her feet. She was noted to have pitting edema to her mid calf. She was diuresed with lasix. the patient was also noted to have an ecchymosis on the dorsum of her foot, [**3-22**] a phone falling. XRays were negative. Medications on Admission: K-DUR 20 MEQ TBCR 1 tab po qd [**2119-6-12**] MORPHINE SULFATE CR 15 MG TB12 1 tab po q 12 h [**2119-6-1**] ADVAIR DISKUS 250-50 MCG/DOSE MISC 1 puff [**Hospital1 **] [**2119-6-1**] NOVOLIN N PENFILL 100 U/ML SUSP 16 units SC q am, 10 units SC before supper [**2119-3-28**] ALBUTEROL AER 90MCG 2 puffs 4 times a day as needed [**2119-3-28**] ATROVENT 18 MCG/ACT AERS 2 puffs [**Hospital1 **] [**2118-11-24**] PREDNISONE 5 MG TABS 1 po q am [**2118-11-24**] FUROSEMIDE 40 MG TABS 1 po q am [**2118-11-15**] NITROGLYCERIN 0.4 MG SL TAB 1 SL prn CP, may repeat q 5min x 2 [**2118-5-12**] ASPIRIN TAB 325MG EC 1 po qd [**2118-4-21**] LIPITOR 40 MG TABS 1 po qd [**2118-2-24**] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Insulin Regular Human 100 unit/mL Solution Sig: see attached sheet units Injection ASDIR (AS DIRECTED). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for shortness of breath or wheezing. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 6. Prednisone 20 mg Tablet Sig: As Dir Tablet PO DAILY (Daily): Give 60 mg for 3 days, then decrease by 10 every 3 days. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q3H (every 3 hours). 8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 2 days. 12. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q24H (every 24 hours) for 2 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Cholecystis COPD Exacebation Pneumonia Respiratory Failure Diabetes Discharge Condition: Stable Discharge Instructions: Please take all medications and make all appointments as listed in the discharge paper work. Followup Instructions: Patient will need to have biliary tube removed by interventional radiology in early [**Month (only) 596**] ([**7-19**]). Please call Dr. [**Last Name (STitle) 5545**]. [**Telephone/Fax (1) 5546**]. 2 day prior to this appointment the tube should be clamped. . Please follow up with Dr. [**Last Name (STitle) **] in [**2-19**] weeks. [**Telephone/Fax (1) 2393**]. . Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**] PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2119-7-6**] 4:15 . Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2119-7-6**] 4:30

[ "518.84", "V58.65", "278.00", "729.5", "491.21", "401.9", "511.9", "574.01", "250.00", "682.2", "782.0", "486", "416.8", "428.30" ]

icd9cm

[ [ [] ] ]

[ "34.91", "51.01", "87.54", "93.90" ]

icd9pcs

[ [ [] ] ]

11060, 11139

5240, 9128

281, 336

11251, 11259

3104, 5217

11400, 12158

2592, 2596

9862, 11037

11160, 11230

9154, 9839

11283, 11377

2611, 3085

228, 243

364, 1136

1158, 2249

2265, 2576

13,521

163,105

16747

Discharge summary

report

Admission Date: [**2167-11-20**] Discharge Date: [**2167-11-30**] Date of Birth: [**2091-5-23**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 76-year-old man who has about a three to four year history of palpitations and paroxysmal supraventricular tachycardia. Since being placed on cardiac medications, the frequency of these episodes has decreased significantly. The last episode was six to seven weeks ago. These palpitations will generally last ten to 30 seconds at a time, and are not related to any specific activity. Over the past several months, the patient has developed new onset exertional symptoms. He was a very active man, and quite involved in golfing and swimming. He has been noting upper mid-chest pressure with swimming, or after walking ten minutes at a brisk pace. These symptoms always resolve with rest. Prior cardiac testing has included: Echocardiogram on [**2167-7-9**], which showed an ejection fraction of 60% with mild left ventricular hypertrophy and trace mitral regurgitation. Exercise stress test on [**2167-11-10**] with eight minutes of [**Doctor First Name **] protocol, no anginal symptoms, electrocardiogram with [**Street Address(2) 1766**] depressions inferolaterally. Imaging revealed a medium in size, moderate in degree, reversible anteroseptal defect. There was also a small inferoapical reversible defect. Ejection fraction of 55%, with mild anteroseptal wall hypokinesis. Subsequent cardiac catheterization on this admission showed severe triple vessel coronary artery disease at which time Cardiothoracic Surgery was consulted for a coronary artery bypass graft. Dr. [**Last Name (STitle) 70**] met with the patient and explained the risks and benefits to the patient, and it was decided to proceed with an operation. On [**2167-11-23**], the patient was brought to the operating room, where a coronary artery bypass graft x 3 was performed. The left internal mammary artery was brought to the left anterior descending, saphenous vein graft was brought to the distal right coronary artery, and saphenous vein graft was brought to the obtuse marginal. Cardiopulmonary bypass time was 80 minutes. Cross-clamp time was 46 minutes. The patient tolerated the procedure well, and was brought to the CSRU in stable condition, extubated. On postoperative day two, the patient continued to do well, and had his chest tube and Foley removed. His Lopressor was increased to 50 mg by mouth twice a day secondary to tachycardia in the 110s to 120s. His tachycardia persisted for several days after, without symptoms. The patient had no temperature and no specific complaints of pain. His blood pressure remained in the 130s to 140s/60s. On postoperative day number five, the patient was started on atenolol 100 mg and Diltiazem 240 mg by mouth once daily, at which time his heart rate was found to be in the 70s with a blood pressure in the 100 to 110s/60s. The patient did quite well, and was discharged in good condition without any other events. CONDITION AT DISCHARGE: Good DISCHARGE STATUS: To home DISCHARGE DIAGNOSIS: Unstable angina DISCHARGE MEDICATIONS: 1. Atenolol 100 mg by mouth once daily 2. Diltiazem 240 mg by mouth once daily 3. Percocet one to two tablets by mouth every four to six hours as needed for pain 4. Nortriptyline 35 mg by mouth daily at bedtime 5. Lisinopril 10 mg by mouth once daily 6. Aspirin 325 mg by mouth once daily 7. Colace 100 mg by mouth twice a day FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] in one week, and Dr. [**Last Name (STitle) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 17480**] MEDQUIST36 D: [**2167-11-30**] 20:17 T: [**2167-12-1**] 01:43 JOB#: [**Job Number 47343**]

[ "414.01", "401.9", "411.1", "272.0", "429.9", "V15.82", "427.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3188, 3523

3148, 3165

3535, 3968

3092, 3126

187, 3077

12,093

165,335

44792

Discharge summary

report

Admission Date: [**2115-4-27**] Discharge Date: [**2115-5-7**] Service: MEDICINE Allergies: Penicillins / Budesonide Attending:[**First Name3 (LF) 2297**] Chief Complaint: melena Major Surgical or Invasive Procedure: intubation, Right IJ central venous line placement History of Present Illness: : 84 yo F h/o CVA, HTN, rectal CA, PAF, COPD, hypothyroidism p/w melena. Pt was in USOH until this AM. Niece found pt in bed asleep in melanotic stool. She cleaned the pt and noted 2 further episodes of melanotic stool. Niece contact[**Name (NI) **] EMS and pt taken to [**Name (NI) **] by ambulance. . In [**Hospital1 18**] ED: t96, hr 110, bp 133/60, rr 35, 91% on 6 L NC. Pt with increased work of breathing, elevated RR to 30s, increasing oxygen requirement. CXR with severe pulmonary edema. EKG: a fib at vr of 117, std in v5-6. Pt with prior documentation of DNR/DNI. However, pt's brother and power of attorney was contact[**Name (NI) **] who reversed code status--"do what is necessary" and consented to intubation. Pt successfully intubated and OGT placed. In ED, labs notable for Hct 22, INR >22, PT >150, PTT 83. Pt given 2 L NS, 2 units prbcs, 2 units FFP. Also given protonix 40 mg iv, levo 500 mg iv, flagyl 500 mg iv, vit K 10 mg iv x1, lasix 20 mg iv X1. SBPs to the 80s and started on peripheral levophed gtt. GI made aware of pt, to scope in MICU. Past Medical History: s/p cva Hypertension. Stage III rectal cancer, status post diversion ileostomy, status post radiation, chemotherapy in [**2107**] Hernia. Paroxysmal atrial fibrillation. COPD Hypothyroidism. Bilateral cataract surgery. Social History: lives alone in apartment building, > 50 pk-yr h/o TOB, + etoh Family History: Non contributory Physical Exam: Temp 96.3 BP 117/57 Pulse 72 Resp 16 O2 sat 99% on vent AC 350X16 Fi O2 60% peep 5 Gen - intubated, minimally responsive to voice HEENT - PERRL, anicteric, mucous membranes dry Neck - no JVD, no cervical lymphadenopathy Chest -coarse on anterior exam CV - Normal S1/S2, irreg irreg , no murmurs, rubs, or gallops appreciated Abd - Soft, nontender to deep palp, nondistended, with normoactive bowel sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Pertinent Results: CXR: with severe pulmonary edema vs. viral PNA . EKG: a fib at vr of 117, std in v5-6. . [**5-2**] Echo : RA pressure ~ 0-5mmHg. Mild symmetric LVH. Overall LV systolic function is normal (LVEF 60-70%). Unable to fully assess for wall motion abnl given suboptimal images. No AS, no AR, trivial MR. [**First Name (Titles) **] [**Last Name (Titles) **] systolic hypertension. Mild-mod TR. . BAL [**2114-4-30**]: Negative for malignant cells . CXR [**2115-5-6**]: An ET tube is present, in satisfactory position 4.1 cm above the carina. An NG tube is present, tip beneath diaphragm overlying stomach. A right IJ central line is present, tip over distal SVC, near SVC/aortic junction. There are diffusely increased interstitial markings in both lungs, which are more pronounced on the right, with confluent opacity at the right base and small, right>left, pleural effusions. There is increased retrocardiac opacity, consistent with left lower lobe collapse and/or consolidation. There may be some underlying chronic lung disease. Diffuse osteopenia and endplate scalloping is noted in the spine. Compared with [**2115-5-4**], there has been some interval improvement in the degree of opacity in the right lung, likely reflecting a partial interval improvement in CHF findings. Brief Hospital Course: Briefly, this is an 84 yo F with a h/o CVA, HTN, rectal CA, PAF, COPD, hypothyroidism who presented with melena, hypotension and intubated for respiratory distress. The following is her hospital course by problem: . #) Resp distress: The patient's initial respiratory failure was felt to be likely secondary to underlying pneumonia complicated by hemorrhage given the patient had bloody secretions. She was intubated on arrival into the ICU and remained so until [**2115-5-6**] for hypoxic respiratory failure. Bronchoscopy showed large amount of blood in airways R lung>L lung. [**Doctor First Name **], ANCA and anti-GBM serologies were negative. BAL negative for AFB, negative for malignant cells; BAL culture had no growth. There was also concern for superimposed ventilator-associated pneumonia, in the setting of fevers. She was treated with a 12 day course of vancomycin, flagyl,and levofloxacin. The patient's fever curve trended down on [**5-6**] and she has remained afebrile now for over 24 hours. Duplex of her lower extremities were obtained on [**5-6**] in the setting of persistent fevers, however this was negative for DVT. The patient now remains stable satting at 93-94% on 4L NC. . #) Melena: The patient's history was consistent with upper GI bleeding in the setting of a grossly elevated INR, likely due to misdosing Coumadin for PAF. The patient received IV vitamin K, 4u PRBC and multiple units FFP with normalized INR and stable Hct. EGD revealed old blood in stomach but no active bleed, + gastritis. She was continued on [**Hospital1 **] proton pump inhibitor. Coumadin and aggrenox were held and not restarted in the setting of elevated INR, GI bleed, and lung bleed. . #) Hypotension: Through much of the [**Hospital 228**] hospital course she remained hypotensive. This was initially concerning for sepsis and patient met SIRS criteria with tachycardia, elevated RR, high wbc. All culture data remain negative to date. Of consideration also was hypovolemia from GIB. Patient is normotensive now, off pressors. . #) Fevers: As per above, the patient had persistent fevers despite broad spectrum antibiotics, however she has now been afebrile for over 24 hrs. She was treated with a 14 day course of Vanc/Levo/Flagyl. Duplex of the lower extremities on [**5-6**] was negative for DVT. . #) Coagulopathy: Elevated INR on admission in the setting of Coumadin use for PAF. Pt. initially received IV Vit K in the ED with good response, but INR increased again despite discontinuation of Coumadin. This was thought to be due to malnutrition/antibiotics. INR is stable at 2.0. Coumadin was not restarted at the time of discharge. . #) HTN: The patient's blood pressure was low through much of her hospitalization, but she is now normotensive. . #) Atrial Fibrillation: The patient had afib with HR in the 120s-140s through much of her stay. Given lowish blood pressure, beta blockers were held. A digoxin load was initiated and maintenance dose was started. She was restarted on low dose beta blocker prior to discharge for better rate control. This will need to be titrated up after discharge. The patient was not restarted on coumadin given the multiple complications that she presented with in the setting of elevated INR of 22. . #) Hypothyroidism: The patient was continued on outpatient Synthroid . #) Rectal CA: s/p diversion ileostomy with radiation, chemotherapy in [**2107**]. Pt with recent CEA elevation but refusing further w/u. No other issues. . #) FEN: Regular diet . #) PPx: The patient has been receiving proton pump inhibitors and pneumoboots. . #) Code status: Code states changed to DNR/DNI, no pressors by brother. Medications on Admission: coumadin 7 mg daily aggrenox 1 tab [**Hospital1 **] levothyroxine 75 mcg daily cardizem 120 mg daily digoxin 125 mcg daily megace methyldopa 250 mg [**Hospital1 **] mvi triamterene/hctz 50/25 mg daily atenolol 25 mg daily Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-12**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation every 4-6 hours as needed. 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q2H (every 2 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: Last dose on [**5-8**]. 11. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous once a day for 2 days: Finish on [**5-8**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: melena, upper GI bleed, pneumonia, lung bleed Discharge Condition: stable, satting 94% on 4 L NC Discharge Instructions: Please take all medications as prescribed. Please do not restart your coumadin unless instructed to do so by your primary care provider. Followup Instructions: Please follow up with your primary care provider, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within the next 2 weeks. Please call [**Telephone/Fax (1) 719**] to schedule an appointment.

[ "V10.06", "496", "V58.61", "995.91", "518.81", "535.51", "244.9", "276.4", "427.31", "285.1", "038.9", "486", "V44.2", "786.3", "305.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "99.04", "45.13", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

8585, 8651

3550, 3737

238, 290

8741, 8773

2249, 3527

8959, 9173

1724, 1742

7496, 8562

8672, 8720

7249, 7473

8797, 8936

1757, 2230

192, 200

3765, 7223

319, 1386

1408, 1629

1645, 1708

12,502

195,313

28086+57577

Discharge summary

report+addendum

Admission Date: [**2127-5-8**] Discharge Date: [**2127-5-16**] Date of Birth: [**2059-9-22**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 1267**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2127-5-8**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Ramus, SVG to OM2, SVG to PDA) History of Present Illness: 67 y/o male with known three vessel disease. Recently admitted to OSH in [**3-22**] with heart failure. Ruled out for myocardial infarction. Now presents for surgical revascularization. Past Medical History: History of Myocardial Infarction [**10-21**], Diabetes Mellitus, Peripheral Vascular Disease (h/o non-healing ulcer LLE) s/p left popliteal to post. tibial artery bypass, Hypertension, Hypercholesterolemia, h/o Stroke [**2124**], h/o Renal Insufficiency, s/p left eye surgery (retinal tear), s/p podiatry work Social History: Denies ETOH and tobacco use. Family History: non contributary Physical Exam: VS: 61 18 115/60 99%RA Skin: Art/venous changes in lower ext., ulcers healed HEENT: Pupils small, slow reaction to light, OP benign Neck: Supple, FROM -JVD, soft right carotid bruit Chest: CTAB -w/r/r Heart: RRR, +murmur Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, trace edema, BLE cool Neuro: Intact with left arm/hand weakness Pertinent Results: [**2127-5-8**] Echo: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is an inferobasal left ventricular aneurysm. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. Post CPB preserved biventricular systolis function with improvement of the anteroseptal wall and persistent aneurysmal dilation of the inferior wall. LVEF is 45-55%. Post decannulation aortic contour is normal [**2127-5-8**] 11:57AM BLOOD WBC-4.3 RBC-2.71* Hgb-8.5* Hct-25.1* MCV-92 MCH-31.3 MCHC-33.9 RDW-15.3 Plt Ct-128*# [**2127-5-13**] 06:25AM BLOOD WBC-5.8 RBC-2.55* Hgb-8.1* Hct-22.8* MCV-89 MCH-31.9 MCHC-35.7* RDW-15.7* Plt Ct-158# [**2127-5-8**] 11:57AM BLOOD PT-16.2* PTT-43.8* INR(PT)-1.5* [**2127-5-8**] 12:43PM BLOOD UreaN-38* Creat-1.4* Cl-114* HCO3-24 [**2127-5-13**] 06:25AM BLOOD Glucose-115* UreaN-33* Creat-1.3* Na-139 K-4.5 Cl-105 HCO3-30 AnGap-9 [**2127-5-13**] 06:25AM BLOOD Calcium-7.6* Phos-3.3 Mg-2.6 Brief Hospital Course: Mr. [**Known lastname 24927**] was a same day admit after undergoing pre-op work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one his chest tubes were removed. Beta-blockers and diuretics were started and he was gently diuresed towards his pre-op weight. Later on this day he was transferred to the telemetry floor for further care. During post-op period he required blood transfusions d/t low HCT. Over the next several days his medications were titrated and physical therapy followed patient for strength and mobility. He appeared suitable for discharge to home on post-op day with the appropriate follow-up appointments and medications. Medications on Admission: Aspirin 325mg qd, Protonix 40mg qd, Provigil 100mg qd, Prozac 20mg qd, Risperdal 0.5mg qd, Lipitor 40mg qd, Restoril 15mg qhs, Lopressor 12.5mg qd, Lasix 40mg qd, Iron 325mg qd, Imdur 30mg qd, Plavix 75mg qd, MV, Humalog 75/25 25units qAM, 15units qPM Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*1* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 7. Modafinil 100 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*1* 8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 10. Risperidone 1 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 14. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 10 days. 15. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Suspension Sig: Twenty Five (25) Units Subcutaneous once a day: AM dose. 16. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Suspension Sig: Fifteen (15) Units Subcutaneous once a day: evening dose. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: History of Myocardial Infarction [**10-21**], Diabetes Mellitus, Peripheral Vascular Disease (h/o non-healing ulcer LLE) s/p left popliteal to post. tibial artery bypass, Hypertension, Hypercholesterolemia, h/o Stroke [**2124**], h/o Renal Insufficiency, s/p left eye surgery (retinal tear), s/p podiatry work Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. Please shower and wash incisions daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns [**Telephone/Fax (1) 170**]. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 68302**]) Dr. [**First Name (STitle) **] in 2 weeks [**Wardname 836**] in 2 weeks for wound check Completed by:[**2127-5-14**] Name: [**Known lastname 5188**],[**Known firstname 2892**] Unit No: [**Numeric Identifier 11742**] Admission Date: [**2127-5-8**] Discharge Date: [**2127-5-16**] Date of Birth: [**2059-9-22**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 4551**] Addendum: Mr. [**Known lastname **] was stable and ready for discharge to [**Hospital **] rehabilitation facility on post-operative day 8. Chief Complaint: see original discharge summary Major Surgical or Invasive Procedure: [**2127-5-8**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Ramus, SVG to OM2, SVG to PDA) Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**2127-5-16**]

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icd9cm

[ [ [] ] ]

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

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28171

Discharge summary

report

Admission Date: [**2182-11-27**] Discharge Date: [**2182-11-29**] Date of Birth: [**2111-9-15**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: transferred from [**Hospital 1562**] hospital for possible open lung biopsy Major Surgical or Invasive Procedure: central line placement History of Present Illness: 71 yo female with pmhx sig for dx of IPF, severe MR, CAD, COPD, hypothyroidism who is transferred to [**Hospital1 18**] for evaluation for open lung biopsy and possible valve replacement/ CABG after undergoing treatment for dyspnea, hypoxia at OSH. Pt arrived intubated, sedated, majority of history is obtained by notes from OSH. Pt initially presented [**11-22**] c/o increasing SOB, CXR revealed bilateral pulmonary infilrates. Unclear if CHF given elevated BNP and cardiomegaly vs. exacerbation of lung disease. Pt treated with nebs, high-dose steroids, abx, and Bi-pap with some improvement. Workup for lung disease included BAL, legionella, acetone, [**Last Name (LF) **], [**First Name3 (LF) **], all of which were negative. TTE on [**11-25**] revealed EF 35-40% with WMA, symmetric LVH. A Swan-Ganz cath was placed which revealed PA systolic pressures 50-60, wedge of [**1-15**]. The patient then had worsening of the BL infiltrates and an episode of hemoptysis and was subsequently intubated. . Per her medical chart, she did not have any preceding symptoms of fever, cough, weight loss or chest pain to accompany the shortness of breath. She did note increasing skin pruritis over past few months. Speaking with her sister, it was reported the pt had experienced a chronic cough and recent weight loss, thought to be secondary to thyroid disease. Past Medical History: 1. Pulmonary fibrosis- presumably dx by CT scan, no lung bx 2. Asthma 3. Severe CHF w/ severe MR [**First Name (Titles) **] [**Last Name (Titles) 113**] on [**11-25**] 4. S/P ventricular pacemaker placement for high grade AV block 5. Hypothyroidism 6. Hypertension 7. ? Parathyroid disease 8. Osteoporosis 9. Newly dx UMN disease (LLE clonus) Social History: Divorced with children, lives on cape, family nearby. No tobacco, no ETOH, no illicits. Family History: Per sister, multiple family members with cancers. One brother with lung cancer in his 40's. No known autoimmune disease. Physical Exam: PE: vitals: 96.8/ hr 92/ bp 108/56/ PAP 61/32/ PCWP 17 vent settings: GEN: intubated, sedated but arousable HEENT: atraumatic, anicteric, mmm, clear OP NECK: RIJ PA cath insertion site appears clean, no LAD CV: [**4-8**] holosystolic murmur, radiates to axilla. + L carotid bruit. Equal radial pulses B/L, palpable DP pulses B/L, brisk cap refill LUNGS: rhonci B/L, no wheeze, appears comfortable on vent ABD: soft, nt, nabs. + surgical scar in RUQ. No organomegaly EXT: warm, dry, no rashes visible. No clubbing noted on digits, no [**Location (un) **], mild chronic venous stasis changes. LUE slightly edematious and > than RUE NEURO: sedated, arousable, responds to voice, follows commands. + upgoing toes on L, mild clonus elicited on left. Pertinent Results: [**11-23**] CXR: severe CHF . [**11-25**] chest CT: Marked progression of lung disease, increased groundglass attenuation, areas of fibrosis. B/L pleural effusions (improved when compared to CXR), no hilar or mediastinal adenopathy . [**11-25**] head CT: negative . LUE US: no LUE DVT . EKG: v-paced . [**Month/Year (2) **] [**11-28**]: Mild global biventricular systolic dysfunction. Severe mitral regurgitation. Mild aortic stenosis. Moderate to severe aortic regurgitation. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension . BAL from OSH: cultures negative, cytology pending legionella: neg ACETONE: neg RPR: neg RF: neg [**Month/Year (2) **]: 27 (WNL) CRP: 110 Homocysteine: 12.8 Influenza: negative Urine culture: pan-sensitive E.coli . repeat chest CT: 1. Micronodular pulmonary abnormality could be miliary tuberculosis or fungal infection, lymphoid interstitial pneumonia, acute-on-chronic allergic alveolitis. 2. No evidence of idiopathic pulmonary fibrosis. 3. Enlarged mediastinal lymph nodes, most likely reactive in nature. 4. Extensive coronary artery and aorta atherosclerotic calcifications. . BAL: negative for PCP, [**Name10 (NameIs) 9295**] negative, fungal culture consistent with yeast. . Brief Hospital Course: 71 yo female with prior history of asthma, CAD, uncertain diagnosis IPF, CHF who was transferred to [**Hospital1 18**] from [**Hospital 1562**] Hospital for further evaluation and treatment of respiratory failure, valvular disease, and ARF. The respiratory failure was secondary to hypoxemia, cardiac vs. pulmonary etiology. The patient carried a diagnosis of IPF (based on radiologic findings) and asthma and had been on oxygen at home for the past three weeks. The initial differential dx included infection (bacterial vs. atypical vs. viral vs. PCP), inflammatory (Churg-[**Doctor Last Name 3532**], Wegener's), autoimmune, or shunt; a PE was thought to be less likely given PA measurements. She was continued on high dose steroids and given broad antibiotic coverage to include MRSA, atypicals, anaerobes. She underwent bronchoscopy which was consistent with alveolar hemorrhage, although it was unclear whether this was just related to heart failure. Cultures from the BAL were negative. She also underwent a repeat chest CT which showed micronodular pulmonary abnormalities, no evidence of idiopathic pulmonary fibrosis, enlarged mediastinal lymph nodes, and extensive coronary artery and aorta atherosclerotic calcifications. She was ruled out for influenza and legionella. [**Doctor First Name **], ANCA, Anti-GBM ab were all negative. In terms of her cardiac disease, the pt had a history of CHF w/ severe MR. She underwent repeat [**Doctor First Name 113**] which showed mild global biventricular systolic dysfunction with severe mitral, aortic, and tricuspid regurgitation. Cardiology was consulted and it was felt that she would not be a candidate for valve replacement. She was medically managed with afterload reduction and diuresis. In terms of her renal failure, the patient's creatinine doubled by 50% since admission to the OSH from 1.2-->1.8. The differential included pre-renal from over diuresis vs. AIN from antibiotics, vs. Wegener's. Urine lytes were sent along with UA, urine sediment, and urine eosinophils, which were negative. Following extubation, the patient developed tachycardia with a rhythm most likely aflutter with varying block with demand ventricular pacing, and diltiazem was utilized for rate control. The following day, she was quite stable on minimal supplemental oxygen for several hours. However, around noon she developed a sense of dread and quickly became tachycardic and hypoxic with an oxygen saturation in the 60's, requiring reintubation. The patient's a-line failed, she became hypotensive, and pressors (Levophed and Dobutamine) were initiated. She was intubated, and became pulseless. Full resuscitation was attempted with CPR, electrical defibrillation, and medications but the efforts were stop when she became unresponsively asystolic. The patient expired on [**11-29**]. Her HCP and next of [**Doctor First Name **] were notified and requested an autopsy. . Medications on Admission: meds at home: Bisoprolol 5 mg Demadex 60 mg Spiriva Asmalix Oxygen . meds on transfer: IV solu-medrol Fentanyl/Versed drips Albuterol/Atrovent nebs Levoxyl Protonix Levofloxacin Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: respiratory failure mitral regurgitation aortic regurgitation tricuspid regurgitation anemia pulmonary fibrosis acute renal failure alveolar hemorrhage congestive heart failure Discharge Condition: expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

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

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Discharge summary

report

Admission Date: [**2142-8-2**] Discharge Date: [**2142-8-9**] Date of Birth: [**2073-12-31**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 348**] Chief Complaint: Chief Complaint: LGIB . Reason for MICU transfer: syncope at OSH Major Surgical or Invasive Procedure: EDG x2 ENT scope x1 History of Present Illness: 68 yo F with hx of CAD with STEMI s/p BMS to mid-LAD [**5-/2142**], high grade metastatic neuroendocrine tumor in groin s/p chemotherapy [**2139**], esophageal spasm, presents with painless lower GIB of about [**12-21**] cups since 730am. No history of bleeding prior. Patient reports that she was walking in her home this morning when felt something warm between her legs, went to the bathroom and noted that she had a large amount of blood. Her husband came home and took her to the [**Name (NI) **]. At [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Hct 38.7 at 923. Had active bleeding. Clinically stable until scope in nuclear medicine where tagged scan positive in transvere colon and had a syncopal episode while supine though patient thinks she did not lose conciousness. . In the ED, initial VS were 96, 64, 119/55, 18, 100/NRB. No active bleeding. EKG showed NSR with anteroseptal TWI. GI and surgery were consulted. Electrolytes were normal with a creatinine of 0.9, WBC 10.6 with nl differential, Hct 38.7 at 245 pm, platelets 216. Coags normal. She was given Morphine 4mg for chronic back pain. She was also given 1L NS. Urine culture was sent. . VS on transfer were: 71, 157/72, 20, 100/RA. For access has an 18G and 16G. . On the floor, she is well. Denies any lightheadedness/dizziness, chest pain, dyspnea, abdominal pain or nausea. Said that her esophageal spasm has not been worse lately. She had a negative colonoscopy including lack of diverticulis about 8 years ago. . Review of systems: Used nitro SL 4 days ago when had a "funny" feeling in her chest after waking up and being uncomofortable. States that it worked. No current chest discomfort. Past Medical History: High grade metastatic neuroendocrine tumor [**2139**] , s/p chemotherapist and surgery Lupus Hypertension Esophageal spasm for 26 years Breast cancer in [**2119**] treated with chemotherapy and radiation with possible remission on right breast (biopsy was supposed to be done today) Endometrial cancer in [**2139**] s/p hysterectomy Social History: Social History: 10 cigarettes/day x 9years. No alcohol use. No IVDU. Married with one son who is married. Retired from job as med tech at [**Location (un) 8599**]Hospital. Lives in [**Location 5110**], MA. Family History: Family History: no premature CAD or sudden cardiac death Father and grandparents with CAD in 60s Mother died in her 50s of uterine cancer. Father died in 80s. Had small bowel obstructions. Physical Exam: Vitals: 159/78, 80, 22, 98/RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP flat, 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, hyperactive BS, no rebound tenderness or guarding, no organomegaly GU: foley in place with clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: [**2142-8-2**] 09:33PM WBC-9.0 RBC-3.83* HGB-11.9* HCT-33.2* MCV-87 MCH-31.2 MCHC-36.0* RDW-14.3 [**2142-8-2**] 09:33PM PLT COUNT-202 [**2142-8-2**] 03:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2142-8-2**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2142-8-2**] 02:43PM GLUCOSE-98 UREA N-18 CREAT-0.9 SODIUM-140 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14 [**2142-8-2**] 02:43PM WBC-10.6 RBC-4.37 HGB-14.0 HCT-38.7 MCV-89 MCH-31.9 MCHC-36.1* RDW-14.3 [**2142-8-2**] 02:43PM WBC-10.6 RBC-4.37 HGB-14.0 HCT-38.7 MCV-89 MCH-31.9 MCHC-36.1* RDW-14.3 [**2142-8-2**] 02:43PM NEUTS-75.0* LYMPHS-20.7 MONOS-2.4 EOS-1.3 BASOS-0.6 [**2142-8-2**] 02:43PM PLT COUNT-216 [**2142-8-2**] 02:43PM PT-12.0 PTT-22.5 INR(PT)-1.0 . DISCHARGE LABS: [**2142-8-9**] 06:31AM BLOOD WBC-11.7* RBC-3.84* Hgb-11.8* Hct-32.7* MCV-85 MCH-30.8 MCHC-36.1* RDW-14.9 Plt Ct-172 [**2142-8-9**] 06:31AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-138 K-4.0 Cl-103 HCO3-27 AnGap-12 . CT A/P IMPRESSION: 1. No definite intraluminal contrast seen to suggest active acute lower GI bleed, though assessment is limited due to streak artifact from the metallic hardware. Slight hyperdensity in the descending colon is equivocal and may reflect coapted enhancing mucosa. 2. Left greater than right basal opacities could reflect aspiration or infectious/inflammatory process, though short term follow up in 3 months is recommended to ensure resolution since bronchioloalveolar cell carcinoma could have a similar appearance. 3. Renal hypodensities are indeterminate and further assessment by ultrasound can be obtained when clinically relevant if not previously characterized. . EGD 9/20 Esophagus: Normal esophagus. Stomach: Mucosa: Patchy erythema of the mucosa was noted in the stomach body. These findings are compatible with gastritis. Duodenum: Normal duodenum. Impression: Erythema in the stomach body compatible with gastritis . Colonoscopy [**8-7**] Impression: Diverticulosis of the sigmoid colon . Capsule endoscopy: Pending Brief Hospital Course: 68 yo F with hx of CAD s/p BMS to LAD [**5-/2142**], metastatic neuroendocrine tumor presents with bright red blood per rectum. # GIB: Mrs [**Known lastname 13304**] [**Name (STitle) **] presented with BRBPR thought to be secondary to a lower GIB most likely from diverticuli. In the MICU she received 8 uPRBCs, 2u FFP and 1u platelets. Her plavix and aspirin were held. She underwent NG tube aspiration which showed blood in the stomach but this was believed to be from epistaxis after NG tube placement. She underwent mulitple EGDs which only showed gastritis. She also underwent colonoscopy which showed diverticuli without active bleeding. Her hematocrit remained stable >48 hours and her aspirin was restarted at 81mg daily. In consultation with her cardiologist her plavix was not continued since her bare metal stent had been placed greater than one month before. On the last day of admission she underwent capsule endoscopy. At the time of discharge the results of this exam were not available. . #Epistaxis: The patient developed epistaxis after NG tube placement. ENT placed nasal packing which remained in place for 5 days. The day of discharge the packing was removed and she had not further bleeding. . # CAD/STEMI: The patient had a ST eevation MI in [**Month (only) 205**] after which she underwent bare metal stenting of her LAD. She had been on plavix and aspirin 325 mg after the procedure. In the setting of the GIB these medications were stopped. When her bleeding stopped aspirin 81 mg was restarted. In conjunction with the cardiologist who placed her stent it was decided that she should remain on aspirin 81mg and that she should not restart plavix since she had already been on plavix for greater than one month. . # HTN: At first her home lisinopril and metoprolol were held. After she was considered stable these medications were restarted. . # Lupus: She was continued on home plaquenil. . TRANSITIONAL ISSUES: # Follow up capsule endoscopy . # Follow up ground glass opacity in lung seen on CT abdomen in 3 months. (see CFT report in pertinent results section) Medications on Admission: Plavix 75 mg Tab Oral 1 Tablet(s) Once Daily . [**Doctor Last Name 1819**] Aspirin 325 mg Tab Oral 1 Tablet(s) Once Daily . hydrochloroquine 200mg [**Hospital1 **] . alprazolam 0.5 mg Tab Oral 1 Tablet(s) Once Daily . atorvastatin 80 mg Tab Oral 1 Tablet(s) Once Daily . hydrocodone-acetaminophen 7.5 mg-750 mg Tab Oral 1 Tablet(s) 5 times a day as needed for pain . lisinopril 20 mg Tab Oral 1 Tablet(s) Once Daily . metoprolol succinate ER 25 mg 24 hr Tab Oral 1 Tablet Extended Release 24 hr(s) Once Daily . pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet, Delayed Release (E.C.)(s) Once Daily Discharge Medications: 1. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day. 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Vicodin ES 7.5-750 mg Tablet Sig: One (1) Tablet PO five times a day as needed for pain. 5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Outpatient Lab Work Please check CBC. Please fax results to: Name: [**Doctor Last Name **] [**Doctor Last Name **],[**Name8 (MD) 20085**] MD Location: [**Hospital 20086**] MEDICAL Address: [**Street Address(2) 20087**] STE 2F, [**Hospital1 **],[**Numeric Identifier 10727**] Phone: [**Telephone/Fax (1) 7164**] Fax: [**Telephone/Fax (1) 20088**] 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Gastrointestianl bleeding Epistaxis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 13304**] [**Name (STitle) **], Thank you for coming to the [**Hospital1 1170**]. It was a pleasure taking part in your medical care. You were in the hospital because you had blood in your stool that was caused by bleeding in your gastrointestinal tract. We performed upper and lower endoscopies as well as a capsule endoscopy. We did not find a definite cause of your bleeding. You should stop taking palvix and change the aspirin from 325 mg daily to 81 mg daily. You should continue pantoprazole as you were before. We did not change any of your other medications. . Medication Summary: Please STOP plavix Please CHANGE aspirin from 325 mg daily to 81 mg daily Please CONTINUE pantoprazole 40mg daily . You also had inflamation of your ankle joint which we believe may be due to Gout. As this is resolving and per your preference we did not prescribe any specific treatment for this. Please call your doctor without delay for any worsening (pain, swelling, redness, fever) or if this does not resolve completely within two days of your discharge. We made an appointment for you to follow-up with rheumatology as below. Followup Instructions: Please go to the lab to have your blood drawn prior to seeing your primary doctor . Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**], NP Location: [**Hospital 20086**] MEDICAL Address: [**Street Address(2) 20087**] STE 2F, [**Hospital1 **],[**Numeric Identifier 20089**] Phone: [**Telephone/Fax (1) 7164**] Appt: [**8-13**] at 1pm Name: [**Last Name (LF) 20090**],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital 20086**] MEDICAL GROUP Address: [**Street Address(2) 20087**], STE 3C, [**Hospital1 **],[**Numeric Identifier 10727**] Phone: [**Telephone/Fax (1) 7164**] Appt: [**8-30**] at 4:15pm

[ "412", "710.0", "V10.91", "V10.3", "414.01", "V45.82", "V10.42", "784.7", "535.50", "401.9", "E879.8", "562.12", "998.11", "V88.01" ]

icd9cm

[ [ [] ] ]

[ "38.97", "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

9467, 9473

5585, 7504

334, 355

9553, 9553

3424, 3424

10877, 11577

2692, 2867

8331, 9444

9494, 9532

7703, 8308

9704, 10854

4300, 5562

2882, 3405

7525, 7677

1918, 2079

246, 296

383, 1898

3440, 4284

9568, 9680

2101, 2436

2468, 2660

25,904

155,093

42754

Discharge summary

report

Admission Date: [**2172-6-25**] Discharge Date: [**2172-9-17**] Date of Birth: [**2133-11-20**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 7141**] Chief Complaint: postcoital bleeding Major Surgical or Invasive Procedure: 1. exploratory laparotomy, periaortic lymph node dissection, supralevator pelvic exenteration, ileal ureteral conduit + redo with side-side reanastomsis (by GU), sigmoid neovagina (by Plastics), low rectal anastamosis, J-flap omentopexy with transverse loop colostomy 2. re-exploration, repair of ileal conduit, rigid rectosigmoidoscopy 3. exploratory lapartomy for partial abd closure with [**State 19827**] patch, maturation of colostomy, tracheostomy 4. exploratory laparotomy, washout and total abdominal closure with mesh 5. reexploration of abdomen, cauterization of perforating vessel 6. Thoracentesis 7. Drainage of pelvic collection with pigtail catheter 8. PICC placement 9. Left percutaneous nephrostomy tube placement History of Present Illness: This is a 38 yo G3P1021 s/p radical hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy on [**2171-10-15**] for Stage Ib1 endometrioid adenocarcinoma of the cervix, s/p 6 cycles of cisplatin and pelvic radiation for involvement of two regional lymph nodes, who presented with vaginal bleeding. A Pap smear and biopsy of a right vaginal apex thickening on [**2172-5-21**] revealed recurrent adenocarcinoma. A PET CT [**2172-5-29**] showed no evidence of metastatic disease. Tumor Board recommendation on [**2172-6-12**] was for total pelvic exenteration. Past Medical History: cervical CA s/p exploratory laparotomy, radical hysterectomy, bilateral salpingoopherectomy and lymph node dissection [**10/2171**], s/p cisplatin/pelvic radiation; chronic back pain; breast reduction 3/[**2169**]. Social History: Denies T/E/D Family History: Significant for a father with [**Name (NI) 5668**] cell carcinoma and a maternal grandmother with breast and brain cancer. Brief Hospital Course: On [**2172-6-25**], the patient underwent exploratory laparotomy, periaortic lymph node sampling, supralevator total pelvic exenteration, low rectal anastomosis, J-flap omentopexy, transverse loop colostomy, ileal urinary conduit by the urology service and colonic neovagina reconstruction by plastic surgery service. Significant findings included an isolated lesion in R cuff and negative periaortic nodes. As described in the operative note, the ileal urinary conduit was redone due to ischemic bowel. At the end of the case, the bowel was significantly edematous and prevented primary fascial closure. Pt was brought to the ICU intubated for postop reovery. She went into septic shock on POD#2, with multiple system failure including liver, heme, and cardiac (see systems list). Her antibiotic coverage was changed to cefetime, vancomycin, levofloxacin, metronidazole and fluconazole. She was started on activated protein C from [**Date range (1) 92378**]. Pt was brought back to the OR on POD3 for re-exploration. Findings were significant for a small leak in the left ureteral-ileal conduit junction, but no collections, abscess or ischemic bowel was found. Infectious disease and general surgery was consulted. Cultures returned with E. Coli in her peritoneal fluid; her sputum also yielded E. Coli and Serratia. The pt, however, remained persistently febrile. Multiple cultures returned with no growth (bacterial or fungal) after [**6-27**]; a RUQ ultrasound and HIDA scan were neg for collections. Multiple CT torso scans showed sinusitis (cx by ENT was negative), possible fungal ball vs collection in the R renal collecting system (f/u renal U/S was negative); echocardiogram was negative for vegetations. Per ID, aspergillus antigen and beta glucan was drawn. Aspergillus was negative but the beta glucan was moderately positive. This was repeated and returned as mildly positive. Re-exploration for partial abdominal closure on [**7-7**] and re-exploration total closure on [**7-18**] also yielded no significant collections. Pleural effusions were tapped [**2172-7-15**] with no bacterial growth. She continued on her antibiotics until [**7-21**], which were discontinued due to negative cultures. Her fever curve and WBC slowly improved. A pigtail catheter was placed [**7-29**] to drain a pelvic collection seen on CT, which also yielded negative cultures. She had a brief period of no fevers from [**7-30**] to [**8-1**]. She had another elevated temp on [**8-1**] and the source was found to be Klebsiella pyelonephritis in the left kidney. She was started on levofloxacin and a percutaneous nephrostomy tube placed. Pt's WBC decreased and she defervesed. However, she developed an aspergillus infection of her wound. She was started on Voriconazole on [**8-18**] and topical terbinafine. While on the floor she continued to spike fevers and found to have an enterococcus pelvic abscess. On [**8-25**] CT-guided drainage of the pelvic collection yielded 8 cc of purulent fluid. On [**8-27**] vancomycin was started. Repeat CT of pelvis on [**9-14**] showed decreased size of fluid collection. Given pt was afebrile and clinically improving, this fluid was not drained. She will continue on vancomycin until appointment with infectious disease on [**9-29**]. On [**9-3**] urine culture grew Serratia. Per ID recommendations, ceftriaxone was started. Repeat urine culture on [**9-7**] was [**Last Name (un) **] positive for Serratia. Urine culture on [**9-10**] showed no growth. She will continue on ceftriaxone for a total of 14 day course. Klebisella grew from blood cultures on [**9-3**]. Subsequent serial blood cultures showed no growth to date. Her other issues are as follows: 1. Wound/neovagina: her fascia was partially closed with a [**State 19827**] patch by General Surgery on [**7-7**]. The patch was progressively rolled every 2-3 days until [**7-18**] when the fascia was closed with mesh by general surgery. Retention sutures were removed by POD#42 and her wound was packed with wet to dry dressings. On [**8-17**] her wound was noted to be growing fungus, later identified as aspergillus fumigata; ID was reconsulted and she was started on voriconazole on [**8-18**]. The wound was managed by general surgery. The wound improved and a VAC was placed prior to discharge. Of note, her anticoagulation was halted while the [**State 19827**] patch was in place due to bleeding. She also had a significant blood loss after her closure on [**7-18**] that required reexploration by general surgery, where 1 L clot was found in the subcutaneous layer. 2 subcutaneous arterial bleeds were identified and cauterized. The neovagina was inspected by Plastics postoperatively and there was a small separation near the introitus. This was repaired on [**7-18**]. She began vaginal dilators on [**8-15**]. 2. Neuro: due to the patient's septic coagulopathy, her epidural, which was placed preoperatively, remained in place until [**7-8**]. Pt was maintained on fentanyl and propofol gtt until [**7-22**]. She was gradually transitioned to PO pain meds with excellent pain control. Of note, she was noted to have decreased gag reflex [**7-5**]. A head CT on [**7-5**] was negative for bleed/ischemia. 3. CV: Pt required three pressors postoperatively due to septic shock. She was weaned off pressors by POD#8. Echo [**6-29**] showed global biventricular hypokinesis likely from sepsis, EF 20%. Serial echos showed improvement to an EF of 50-55% on [**7-17**]. No vegetations were noted on any of the echos. After being transferred to the floor she was tachycardic, which was controlled with metoprolol 100mg [**Hospital1 **]. 3. Pulm: a. PNA: sputum grew out serratia and E.Coli. Her radiological findings improved over hospitalization. b. Pulmonary effusions: Pt developed significant pulmonary effusions immediatley postop, which was tapped on [**7-15**]. These returned very quickly. CT surgery was consulted for possible U/S guided thoracentesis, but the effusions dramatically improved and the thoracentesis was cancelled. c. Tracheostomy: A tracheostomy was placed by general surgery on [**7-7**]. She was weaned off the ventilator and trach was discontinued [**7-31**]. She had no respiratory issues while on the floor. 4. GI: a. Liver shock: Pt's ALT and AST rose as high as the [**2165**] and her total bilirubin as high as 10 during her septic shock, which slowly resolved over her hospitalization but remained somewhat elevated. RUQ ultrasounds and HIDA scans were negative for significant pathology. b. Diet: She was started on TPN and then transitioned to TF when her transverse loop colostomy had output. TF were held intermittently for ileus. She was gradually started on POs. While on the floor she continued on the TPN with po intake as well. Her LFTs were slightly elevated on [**9-2**] and therefore her Voriconazole level was decreased. On [**9-14**] patient was switched to po Voriconazole 300 [**Hospital1 **]. She will continue on this medication until her infectious disease apppointment on [**9-29**]. Her LFT improved. She will continue to have LFT check once a week. 5. Renal: s/p L ileoureteral conduit repair on [**6-28**] due to leak. Ureteral stents were removed [**7-15**]. CT scan on [**7-28**] noted worsening left hydroureter and hydronephrosis. Per urology, a urogram was done on [**7-30**]. This showed no evidence of extravasation or reflux. Eventually her UCx returned with Klebsiella. Due to her persistent hydronephrosis, a loopogram and then lasix urogram were conducted and she was found to have a left kidney obstruction. A percutaneous nephrotomy tube was placed [**8-9**]. On [**8-14**], Interventional Radiology replaced this with a left nephroureteral stent. [**9-3**] nephrogram was done which showed a stricture in the left ureter. The stent was replaced. On [**9-4**] pt was noted to have nephroureteral stent protuding from urostomy, she also spiked a high fever at this time. GU adjusted the stent and patient subsquently clinically improved. Pt is to have outpt antegrade nephrogram in 1 month, and follow up with [**Hospital **] clinic. 6. Heme: a. leukopenia: pt's WBC dropped to 0.9 during sepsis. Neupogen was given [**6-28**] and her WBC rose appropriately to as high as 20s. This slowly improved as her fever curve improved. b. blood loss and dilutional anemia: Hct was kept above 21, which required multiple PRBCs. She was started on Epogen and Fe supplementation on [**8-11**] c. Coagulopathy: likely from sepsis. Pt received multiple units of FFP; this slowly improved. d. thrombocytopenia: persistent beyond sepsis, requiring multiple platlet transfusions. Hematology was consulted; pt was found to be HIT Ab positive, with a negative serotonin release assay. Heparin was stopped and she was started on lepirudin. This was stopped after she began bleeding with the [**State 19827**] patch rolling. Once her abdomen was closed, she was started on fondaparinux. LENIs done for persistent fever was negative for DVT on [**7-19**]. She continued to where pneumoboots while on the floor. She was discharged to acute rehab on POD #83 Medications on Admission: none Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety, before walking. Disp:*30 Tablet(s)* Refills:*0* 4. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*60 Capsule(s)* Refills:*1* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for HA. Disp:*40 Tablet(s)* Refills:*0* 8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*q/s q/s* Refills:*2* 9. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 4 days. Disp:*q/s q/s* Refills:*0* 11. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 12. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). Disp:*q/s q/s* Refills:*2* 13. Acyclovir 5 % Ointment Sig: One (1) Appl Topical prn as needed for cold sore. Disp:*1 tube* Refills:*0* 14. Vancomycin Intravenous 1250mg q 12 hours Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: recurrent cervical cancer septic shock aspergillus wound infection serratia urinary tract infection pelvic abscess left ureteral stricture Discharge Condition: stable Discharge Instructions: Acute Rehab Followup Instructions: General Surgery: Please follow up with Dr. [**First Name (STitle) 2819**] in surgery clinic in early [**Month (only) **]. Please call ([**Telephone/Fax (1) 6347**] to setup your appointment. The clinic is located at [**Last Name (NamePattern1) 439**], [**Hospital **] Medical Building 3A, [**Location (un) 86**], MA. Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 5777**] Call to schedule appointment Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2172-9-22**] 11:00 Completed by:[**2172-9-17**]

[ "998.11", "041.3", "995.92", "789.5", "287.4", "V15.3", "E934.2", "591", "593.89", "117.3", "196.6", "590.10", "593.5", "482.82", "286.6", "482.83", "511.9", "997.5", "567.21", "180.8", "560.1", "785.52", "570", "518.5", "998.59", "038.3" ]

icd9cm

[ [ [] ] ]

[ "86.22", "87.78", "87.75", "59.8", "55.93", "54.91", "31.1", "38.93", "55.03", "46.03", "70.75", "40.3", "00.11", "54.61", "48.23", "99.15", "56.52", "68.8", "96.6", "54.63", "88.73", "70.62", "39.31", "56.51" ]

icd9pcs

[ [ [] ] ]

12875, 12972

2092, 11216

323, 1055

13155, 13163

13223, 13853

1945, 2069

11271, 12852

12993, 13134

11242, 11248

13187, 13200

264, 285

1083, 1660

1682, 1898

1914, 1929

10,506

147,087

6875+55795

Discharge summary

report+addendum

Admission Date: [**2178-10-24**] Discharge Date: [**2178-10-30**] Date of Birth: [**2135-7-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with drug-eluting stent placement in LAD x 2 History of Present Illness: Patient is a 43 year-old male with HTN, Family Hx of CAD, and Tobacco use who had episode of persistent chest pain after work 2 days PTA. States sharp substernal chest pressure going from throat to the esophagus. no radiation, no associated sob, denies n/v/d. Pain constant never relieved and pt came to the ED ~ 36 hours after the onset of pain. . In the [**Name (NI) **] pt noted to have ST elevations anterolaterally and tachycardic, given IV lopressor and sent to cath lab. . On cath found to have proximal occlusion of LAD ->[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, CI 1.86 -> IABP placed and pt transferred to CCU. Pain free post cath. On admission to CCU pt had no complaints. ROS: +some doe for months, denies pnd/orthopnea/syncope. +Palpitations. Past Medical History: 1. HTN 2. Anxiety 3. Psoriasis Social History: Smoker 15 pack year history. Lives in [**Location **], social etOH, programmer at [**Hospital1 112**]. Family History: Mother died of MI at 69, Father - CVA, 2 sisters with MI, DM, 2 brother with DM. Physical Exam: GEN: Middle aged man in NAD HEENT: PERRL, MMM, JVP ~9cm at 30degrees. CHEST: CTAB anteriorly and laterally. CVR: RRR, nl s1, s2, no r/m/g ABD: Soft, nt, nd EXT: no edema, 2+ dp/pt pulses bilaterally. Groin site with soft hematoma, arterial line in place. Neuro: CNI-XII intact, A&O X 3. Skin: bilateral white plaques on forarms consistent with psoriasis. Pertinent Results: CBC: 15.3/44.2/331 Diff, N:79.6 L:15.0 M:4.5 E:0.5 Bas:0.5 Chemistry: 137/3.8/97/25/14/1.0/174 CK: 287 MB: 7 Trop-*T*: 2.43 PT: 13.2 PTT: 25.1 INR: 1.2 . DATA: ECG presentation: ST at 142, [**Apartment Address(1) 25947**],L, V1-V5. (V2-V4 >5mm). ECG post cath: ST at 100, ST normalized in 1,l,v1. STE V2 2mm, v3-V4 3mm. Cath - CO 3.24, CI 1.83, PCW 21, RA 10, PA 32/17, RV 32/8. LMCA - nl, LAD occluded at its origin, diag with thrombus and stenosis at its origin. dilation and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**]. residual 80% with normal flow. LCX - normal. RCA - normal . ECHO The left ventricular cavity size is top normal/borderline dilated. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include anteroseptal, anterior hypokinesis/akinesis and apical akinesis/dyskinesis. 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. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. No apical thrombus seen (cannot exclude). . CATH Initial angiography showed a proximally occluded LAD. We planned to recanalize the vessel. Eptifibatide was continued. A 6 French XBLAD3.5 guide provided good support. The lesion was crossed with great difficulties using a Choice PT wire, which was then exchanged for a Prowater wire. Thrombectomy was performed using an Export catheter. The lesion was then pre-dilated with a 2.0 mm balloon at 8 atm. Next, two overlapping 3.0x3 mm and 3.0x28 mm Cypher DES were deployed in the mid and proximal LAD at 14 atm. Post-dilation was performed with a 3.25x23 mm Highsail balloon at 16 atm. Angiography showed slow flow in D1, which was rescued with a 2.0 mm ACE balloon at 8 atm. Final angiography showed no residual stenosis in the LAD, some thrombus in D1 with an 80% resdual stenosis, no dissection and TIMI 3 flow in both vessels. The patient left the lab in stable condition. * COMMENTS: 1. Selective coronary angiography in this right dominant patient revealed severe single vessel CAD. The RCA was angiographically normal. The Left Main and LCX were also both angiographically normal. The LAD was completely occluded at its origin. The D1 also had thrombus and stenosis at its origin 2. Resting hemodynamics revealed mild RA pressure elevation of 10mmHG. The pulmonary pressures were slightly elevated at 32/17 and the PCWP was moderately elevated to 21mmHG consistent with abnormal diastolic function. The cardiac index was depressed at 1.83 l/min/m2. 3. Successful stenting of the LAD with two 3.0 mm Cypher drug-eluting stents, which were post-dilated to 3.25 mm. 4. Successful insertion of a 40 cc IABP with good diastolic augmentation. Brief Hospital Course: Patient is a 43 year-old male with HTN, smoking history, Family Hx of CAD who presented with anterolateral ST elevations and found to have proximal occlusion of LAD in the cath lab. The following issues were addressed during his hospital stay: 1. Cardiovascular A. Coronary Artery Disease: Given complete proximal LAD occlusion in cath lab, 2 DES were placed in the artery with significant improvement in blood flow. Patient tolerated procedure well. An intra-aortic balloon pump was also placed in the cath lab with good diastolic augmentation. Patient received integrillin drip for 18 hours post-cath. Also started on ASA/Plavix/Statin/ACEI. BB was started prior to discharge, and medications were titrated up as tolerated. Patient was evaluated by Physical Therapy and cleared for discharge home with recommendations for cardiac rehabilitation. B. Pump: At cath, CO 3.24, CI 1.86. An IABP was placed at cath for afterload reduction and better coronary perfusion. This was discontinued the following day. LVEDP was 21 on cath, however post-cath patient voided 450cc without any lasix. ECHO showed EF 35%, anterospetal, anterior hypokinesis/akinesis, apical akinesis/dyskinesis, with no overt apical thrombus visualized. Given apical akinesis, patient was started on Coumadin and bridged with heparin until therapeutic INR was achieved. C. Rhythm: Patient in sinus rhythm, with initial tachycardia of multifactorial etiology: fever, acute coronary syndrome, dehydration, and poor EF with compensatory tachycardia to maintain cardiac output. Patient's HR began to decrease gradually post-MI, with fever resolution and improved cardiac function. No significant events were noted on telemetry. Patient to follow-up with Electrophysiology in 1 month for ICD placement evaluation. 2. FEVER Patient developed fever of unclear etiology post-MI; UA, CXR negative. 1 set blood cultures with gram positive cocci clusters/pairs, coagulase negative, likley contaminant given clinical picture. Other work-up was negative, and fever curve trended down without antibiotic therapy. Impression was fever secondary to acute myocardial infarction and cytokine release. Patient was without evidence of leukocytosis, and was afebrile x 48h prior to discharge without Tylenol administration. . 3. HTN Patient initially with asymptomatic relative hypotension initially, which resolved with cardiac revascularization and gentle fluid boluses. Patient discharged on Toprol XL 50 and Lisinopril 5, to follow-up in [**Hospital 191**] clinic for further control. . 4. PSORIASIS Patient with bilateral psoriatic plaques over arms, back, legs. No acute issues as inpatient, to be followed as outpatient. . 5. HEME Blood bank contact[**Name (NI) **] team as patient with [**Name (NI) 25948**] antibody on Type and Screen, usually seen in patients with history of transfusion. Patient denies any history of blood product transfusion. Labs not consistent with hemolysis; haptoglobin 350s, adjusted retic count WNL (LDH cannot be used as marker given recent infarction) Patient reportedly with sickle cell trait, nothing to work-up further as inpatient. . 6. Prophylaxis Patient on heparin gtt while being bridged to Coumadin. Patient ambulating, had BM while inpatient. Medications on Admission: Paxil 10mg qd. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*6* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*3* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*4* 4. Paroxetine HCl 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please have your INR checked; dose may be adjusted accordingly. Disp:*30 Tablet(s)* Refills:*0* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*6* 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*6* 8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO As directed by a physician: [**Name10 (NameIs) **] is an extra prescription to be used pending any changes in your Coumadin dosage. . Disp:*60 Tablet(s)* Refills:*0* 9. Outpatient Lab Work Please have your INR drawn by VNA on Saturday and have results called to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital3 **] on [**11-2**] - Monday A.M. -- [**Telephone/Fax (1) 250**] (INR does not need require f/u over weekend) Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary 1. Acute ST Elevation MI s/p 2 DES to LAD Secondary 1. HTN 2. Hyperlipidemia 3. Tobacco use Discharge Condition: chest-pain free, hemodynamically stable, afebrile Discharge Instructions: 1. Please take all medications as prescribed -- Aspirin and Plavix MUST be taken daily. 2. Among your new medications, you have been started on Coumadin. This requires frequent visits for lab draws. Please make sure the results are sent to your PCP so that necessary dose adjustments can be made. 3. Please make all follow-up appointments. 4. Please refrain from any strenuous activity including heavy lifting for the next few weeks and until cleared by a cardiologist. 5. Please stop smoking 6. You will need to begin cardiac rehabilitation in 1 month - please arrange this with your PCP [**Name Initial (PRE) **]/or cardiologist. Followup Instructions: The following appointments have been schedule for you: 1. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-11-2**] 11:30 (To have your INR checked) -- [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 895**], North Suite 2. Provider: [**Name10 (NameIs) 640**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-11-11**] 2:30 (To establish new PCP) - [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 895**] 3. Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2178-11-17**] 1:00, [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] 4. Electrophysiology (evaluation for ICD placement). Dr. [**Last Name (STitle) **], Friday, [**2184-12-3**]:00 AM. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 3971**] Completed by:[**2178-11-2**] Name: [**Known lastname 4470**],[**Known firstname 4471**] Unit No: [**Numeric Identifier 4472**] Admission Date: [**2178-10-24**] Discharge Date: [**2178-10-30**] Date of Birth: [**2135-7-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4473**] Addendum: Patient's initial hemodynamic findings were consistent with cardiogenic shock given hypotension, elevated PCWP 21, and poor cardiac index 1.83, necessitating intra-aortic balloon pump placement. Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4474**] MD [**MD Number(1) 4475**] Completed by:[**2178-11-17**]

[ "282.5", "305.1", "427.1", "300.00", "696.1", "410.11", "785.51", "414.01", "V17.3", "780.6", "272.4", "276.51", "401.9", "458.8", "427.89", "428.0" ]

icd9cm

[ [ [] ] ]

[ "97.44", "00.46", "99.20", "88.56", "37.23", "36.07", "00.66", "37.61", "00.42" ]

icd9pcs

[ [ [] ] ]

12080, 12295

4850, 8096

327, 397

9733, 9785

1876, 4827

10465, 12057

1399, 1481

8161, 9509

9610, 9712

8122, 8138

9809, 10442

1496, 1857

277, 289

425, 1208

1230, 1262

1278, 1383

20,944

177,500

10277

Discharge summary

report

Admission Date: [**2140-11-30**] Discharge Date: [**2140-12-10**] Date of Birth: [**2063-7-22**] Sex: F Service: TRANSPLANT SURGERY HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname **] is a 77-year-old female with a history of atrial fibrillation and end-stage renal disease secondary to glomerulonephritis. She presented to the [**Hospital6 256**] on [**2140-11-30**] for a cadaveric renal transplant. Prior, she had been on hemodialysis since [**2132**] through a left arm AV fistula. PAST MEDICAL HISTORY: 1. End-stage renal disease secondary to glomerulonephritis. 2. Hypertension. 3. Atrial fibrillation. 4. Hypothyroidism. 5. Status post open cholecystectomy. 6. Right inguinal hernia repair. ADMISSION MEDICATIONS: 1. Quinine 325 mg q.d. 2. Neurontin 200 mg in the morning, 100 mg q.h.s. 3. Coumadin 2 mg on Monday and Wednesday, 3 mg on Tuesday, Thursday, Saturday, and Sunday. 4. Renagel 1,200 t.i.d. 5. PhosLo 2 mg t.i.d. 6. Iron sulfate 325 mg p.o. b.i.d. 7. Nephrocaps one capsule p.o. q.d. 8. Levoxyl 75 micrograms p.o. q.d. 9. Percocet p.r.n. ALLERGIES: The patient is allergic to penicillin. SOCIAL HISTORY: She denied any tobacco abuse, occasional ethanol. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient was afebrile, blood pressure 110/60, heart rate 88, respiratory rate 16, 93% on room air. Preoperative weight 48 kilograms. General: She was awake, alert, in no acute distress. HEENT: Normocephalic, atraumatic. The extraocular movements were intact. The oropharynx was clear. The chest was clear to auscultation bilaterally. Heart: Regular rate and rhythm. Abdomen: Soft, nondistended, normoactive bowel sounds. There was a well healed incision from a prior cholecystectomy as well as an umbilical hernia repair. Extremities were without any clubbing, cyanosis or edema. LABORATORY/RADIOLOGIC DATA: WBC 6.1, hematocrit 37.7, platelets 176,000. Sodium 146, potassium 4.8, chloride 98, bicarbonate 34, BUN 32, creatinine 5.9, glucose 76. Coagulations: PT 17.1, PTT 32.4, INR 1.4, ALT 11, AST 24, alkaline phosphatase 49, T. Bilirubin 0.5. Her blood type is A positive. HOSPITAL COURSE: Ms. [**Known lastname **] is a 77-year-old female with end-stage renal disease secondary to glomerulonephritis who presented to the [**Hospital6 256**] for a cadaveric renal transplant on [**2140-11-30**]. Surgery went without any technical complications. The patient was extubated in the PACU. However, it was noted that she was slightly hypotensive and she was tachycardiac with an irregular rhythm. She required at that point IV Lopressor for rate control. She was transferred to the ICU for close monitoring as well as for rate control and for pressure support. She was originally placed on an Amiodarone drip as well as a Neo drip. These were eventually weaned. The patient did require cardioversion and the patient has remained in normal sinus rhythm since. She was placed on a p.o. regimen of Amiodarone which was adjusted by Cardiology. The patient ruled out for a myocardial infarction. Her postoperative course was noted for delayed graft function. She required three episodes of hemodialysis as well as one ultrafiltration. Her urine output still continues to be minimal. Her creatinine at baseline was 5.9. By the time of discharge, it had decreased to 3.6. Her urine output is slowly improving. Postoperatively, she was placed on the usual Solu-Medrol taper. She was placed on CellCept 1,000 mg p.o. b.i.d. which was eventually weaned to 500 p.o. b.i.d. She received a total of four doses of ATG and was started on Tacrolimus on postoperative day number four and was transferred to the floor on postoperative day number seven. Her diet was advanced as tolerated. Physical Therapy consulted on the patient. She continued, however, to have delayed graft function. It was felt best that the patient be discharged to a rehabilitation center. The patient is to continue with her regular dialysis schedule at the rehabilitation center as she was started on her preoperative Coumadin dose as well as Amiodarone 200 p.o. q.d. She is to continue this and to be carefully monitored and followed up with her personal cardiologist. Her laboratories will be redrawn at the rehabilitation center. Of note, the patient underwent two renal ultrasounds of the transplanted kidney. The first one was on postoperative day number one which showed just a small fluid collection around the kidney, otherwise, the duplex ultrasound was normal. She had a follow-up duplex ultrasound on postoperative day number nine which indicated resolved fluid collection and indices around 0.7. CONDITION ON DISCHARGE: To rehabilitation center. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: 1. Status post cadaveric renal transplant for end-stage renal disease secondary to glomerulonephritis on [**2140-11-30**]. 2. Delayed graft function. 3. Postoperative atrial fibrillation. 4. Postoperative hypotension. DISCHARGE MEDICATIONS: 1. Bactrim SS one tablet p.o. q.d. 2. Pantoprazole 40 mg p.o. q.d. 3. Colace 100 mg p.o. b.i.d. 4. Tylenol 650 mg p.o. q. six hours p.r.n. 5. Benadryl 25 to 50 mg p.o. q. 12 hours or q.h.s. p.r.n. sleep. 6. Heparin 5,000 units subcutaneously q. eight hours. 7. Insulin sliding scale; the patient is to follow the provided sliding scale. 8. Albuterol nebulized solution, one nebulized inhalation q. six hours p.r.n. 9. Valcyte 450 mg p.o. q.o.d. 10. Nystatin swish and swallow. 11. Sevelamer 1,600 mg p.o. t.i.d. 12. Levothyroxine sodium 175 micrograms p.o. q.d. 13. Haloperidol 1 mg p.o. b.i.d. p.r.n. 14. Prednisone 20 mg p.o. q.d. 15. Coumadin 3 mg p.o. q.d. This is to be adjusted based on daily INR. 16. Amiodarone 200 mg p.o. q.d. This is to be adjusted by the patient's cardiologist. 17. Metoprolol 50 mg p.o. b.i.d., hold for systolic blood pressures less than 100 or heart rates less than 60. 18. CellCept [**Pager number **] mg p.o. b.i.d. 19. Zofran 4 mg IV q. eight hours p.r.n. nausea. 20. Of note, the patient is additionally on Tacrolimus. Her current dose is being held until her Tacrolimus level is obtained and it will be adjusted accordingly. FOLLOW-UP PLANS: The patient is to follow-up with Dr. [**Last Name (STitle) 15473**] at the Transplant Center, phone number [**Telephone/Fax (1) 673**] on [**2140-12-13**] at 9:10 a.m. She is additionally to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2140-12-20**] at 3:40 p.m. as well as with Dr. [**Last Name (STitle) **] on [**2140-12-26**] at 12:00 p.m. She is to be discharged to the rehabilitation center where she is to receive daily laboratories which should include a CBC, Chem-10, PT/PTT/INR as well as a daily tacrolimus level which should be drawn before the tacrolimus a.m. dose is given. She is to follow-up with her personal cardiologist to wean her off Amiodarone and to adjust her anticoagulation. She is to continue with her scheduled dialysis on Tuesday, Thursday, and Saturday at the rehabilitation center until her delayed graft function has resolved. Please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr. [**Last Name (STitle) **] at the Transplant Center at [**Telephone/Fax (1) 673**] with any further questions. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**] Dictated By:[**Last Name (STitle) 28927**] MEDQUIST36 D: [**2140-12-9**] 03:13 T: [**2140-12-9**] 17:02 JOB#: [**Job Number 34185**]

[ "276.7", "V58.61", "403.91", "244.9", "996.81", "458.29", "416.8", "424.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "99.62", "55.69", "99.07", "38.93", "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

5065, 6238

4819, 5042

2219, 4718

759, 1156

6256, 7636

1243, 1275

1290, 2201

539, 736

1173, 1224

4743, 4798

15,428

100,701

26083+57490

Discharge summary

report+addendum

Admission Date: [**2160-4-27**] Discharge Date: [**2160-5-15**] Service: SURGERY Allergies: Demerol / Lidocaine Attending:[**First Name3 (LF) 5880**] Chief Complaint: 81 F s/p AAA and ventral hernia repair with component separation [**2160-2-18**] p/w fever to 102.4 Major Surgical or Invasive Procedure: Percutaneous cholecystostomy tube History of Present Illness: 81 F s/p AAA repair and ventral hernia repair presenting with fever of unknown etiology admitted to the surgical service for blood cultures, CT of the abdomen, IV hydration, and r/o SBO. Past Medical History: Includes rheumatoid arthritis, prednisone dependent and on methotrexate; ischemic heart disease with a myocardial infarction in [**2155**], stress test done on [**2159-11-18**] was without ischemic changes, no perfusion deficits, ejection fraction was 72% with no wall motion abnormalities; also history of GERD; history of urinary tract infections, treated; history of skin cancer; history of MRSA infections; history of UTI sepsis with hypotension. Social History: non-contributory Family History: non-contributory Physical Exam: 101.8 103 105/48 25 99%2LNC Lethargic Lungs with mild expiratory wheeze bilaterally soft, non-distended, mild RUQ tenderness to deep palpation, midline wound healing well with granulation- minimal fibrinous exudate, soft swelling in RLQ without erythema or induration 1+ edema bilaterally pulses 2+ Pertinent Results: [**2160-4-27**] 12:15AM BLOOD WBC-25.7*# RBC-3.51* Hgb-9.9* Hct-31.3* MCV-89 MCH-28.1 MCHC-31.5 RDW-19.4* Plt Ct-531* [**2160-4-27**] 09:50AM BLOOD WBC-24.8* RBC-3.21* Hgb-9.2* Hct-28.9* MCV-90 MCH-28.5 MCHC-31.7 RDW-19.3* Plt Ct-493* [**2160-4-28**] 05:50AM BLOOD WBC-17.9* RBC-2.89* Hgb-8.3* Hct-25.5* MCV-88 MCH-28.6 MCHC-32.4 RDW-19.8* Plt Ct-474* [**2160-4-29**] 10:00AM BLOOD WBC-14.3* RBC-2.49* Hgb-7.2* Hct-22.3* MCV-89 MCH-28.7 MCHC-32.1 RDW-19.4* Plt Ct-434 [**2160-4-29**] 10:29PM BLOOD WBC-13.6* RBC-2.77* Hgb-8.0* Hct-24.6* MCV-89 MCH-28.9 MCHC-32.4 RDW-18.4* Plt Ct-411 [**2160-4-30**] 03:31AM BLOOD WBC-13.5* RBC-3.17* Hgb-9.1* Hct-27.6* MCV-87 MCH-28.9 MCHC-33.1 RDW-18.5* Plt Ct-417 [**2160-4-30**] 12:10PM BLOOD WBC-13.6* RBC-3.17* Hgb-9.2* Hct-27.8* MCV-88 MCH-28.9 MCHC-33.0 RDW-18.8* Plt Ct-434 [**2160-5-1**] 02:19AM BLOOD WBC-16.8* RBC-2.98* Hgb-8.7* Hct-26.3* MCV-88 MCH-29.2 MCHC-33.1 RDW-18.5* Plt Ct-426 [**2160-5-2**] 04:35AM BLOOD WBC-18.1* RBC-3.21* Hgb-9.2* Hct-28.6* MCV-89 MCH-28.5 MCHC-32.0 RDW-18.6* Plt Ct-504* [**2160-5-3**] 04:23AM BLOOD WBC-11.3* RBC-3.20* Hgb-9.2* Hct-28.7* MCV-90 MCH-28.8 MCHC-32.2 RDW-18.5* Plt Ct-478* [**2160-5-4**] 05:15AM BLOOD WBC-12.2* RBC-3.59* Hgb-10.4* Hct-32.9* MCV-92 MCH-29.1 MCHC-31.8 RDW-18.5* Plt Ct-506* [**2160-4-27**] 12:15AM BLOOD Glucose-55* UreaN-39* Creat-1.0 Na-143 K-5.0 Cl-105 HCO3-28 AnGap-15 [**2160-4-27**] 09:50AM BLOOD Glucose-83 UreaN-33* Creat-0.9 Na-137 K-4.9 Cl-102 HCO3-25 AnGap-15 [**2160-4-28**] 05:50AM BLOOD Glucose-59* UreaN-20 Creat-0.7 Na-140 K-4.1 Cl-102 HCO3-27 AnGap-15 [**2160-4-29**] 10:00AM BLOOD Glucose-97 UreaN-15 Creat-0.9 Na-140 K-3.8 Cl-102 HCO3-28 AnGap-14 [**2160-4-29**] 10:29PM BLOOD Glucose-94 UreaN-12 Creat-0.9 Na-139 K-3.2* Cl-101 HCO3-28 AnGap-13 [**2160-4-30**] 03:31AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-142 K-4.3 Cl-105 HCO3-27 AnGap-14 [**2160-4-30**] 12:10PM BLOOD Glucose-175* UreaN-15 Creat-1.0 Na-139 K-3.7 Cl-100 HCO3-26 AnGap-17 [**2160-5-1**] 02:19AM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-141 K-3.3 Cl-102 HCO3-25 AnGap-17 [**2160-5-2**] 04:35AM BLOOD Glucose-176* UreaN-33* Creat-1.0 Na-142 K-3.6 Cl-106 HCO3-26 AnGap-14 [**2160-5-2**] 04:37PM BLOOD Glucose-294* UreaN-36* Creat-0.9 Na-138 K-3.9 Cl-104 HCO3-25 AnGap-13 [**2160-5-3**] 04:23AM BLOOD Glucose-334* UreaN-39* Creat-0.9 Na-139 K-4.3 Cl-106 HCO3-25 AnGap-12 [**2160-5-4**] 05:15AM BLOOD Glucose-137* UreaN-39* Creat-0.8 Na-143 K-3.3 Cl-109* HCO3-26 AnGap-11 ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST CT CHEST WITH CONTRAST: The pulmonary arteries opacify without evidence for filling defects. The appearance of the aorta is stable from [**2160-3-11**]. The mediastinal lymph nodes are unchanged, none meeting pathologic criteria. NG tube is present within the stomach. The bronchi are patent to the subsegmental level. There is new right lower lobe atelectasis compared to [**2160-3-11**]. Right upper lobe pleural thickening measuring 2 x 1 cm is unchanged. There is a left upper lobe pulmonary nodule, unchanged from [**2160-3-11**]. CT ABDOMEN WITH CONTRAST: The liver enhances without focal lesions. There is new pericholecystic fluid and inflammatory change that is present between the gallbladder and head of the pancreas. This is new from [**2160-3-11**]. Given the predominance of inflammation adjacent to the pancreas, this is more likely a sequela of pancreatitis. However, cholecystitis cannot be entirely excluded and clinical correlation is recommended. The pancreas enhances homogeneously. The common bile duct is not dilated. Below the body of the pancreas is a fluid collection measuring 5 x 4.5 cm that is smaller than [**3-11**], [**2159**]. The spleen, adrenals, and small bowel are normal. Multiple air- fluid levels in the small bowel are present but within normal limits. The small bowel is not distended. Along the midline upper abdominal wall is a 3 cm fat-containing defect. More inferiorly, there is a large abdominal wall defect. Patient is status post closure of abdominal wall surgery by secondary intention. Within the subcutaneous tissues of the right anterior abdominal wall is a 10 x 2.4 cm fluid structure. It demonstrates minimal rim enhancement. This likely represents a seroma, but liquefying hematoma or abscess cannot be excluded. CT PELVIS WITH CONTRAST: The rectum and sigmoid are unchanged with marked sigmoid diverticulosis. There is marked atherosclerotic calcification of the abdominal aorta and its major branches, and surgical clips are present indicating abdominal surgery. Multiple hypodense lesions in both kidneys are unchanged and likely represent simple cysts. The distal ureters and bladder appear normal. A Foley is present within a compressed bladder. The remaining large bowel is normal caliber. There is no free fluid in the pelvis. A healed left inferior pubic ramus fracture is unchanged. Otherwise the osseous structures are only remarkable for degenerative disease throughout the osseous skeleton. IMPRESSION: 1. New pericholecystic fluid/inflammatory change is most predominant between the gallbladder and pancreas. This is likely be the sequela of pancreatitis, but cholecystitis cannot be entirely excluded. Clinical correlation is advised. 2. Persistent but improving 5 cm peripancreatic fluid collection below the body of the pancreas. 3. New 10 x 2.4 cm right abdominal wall fluid collection that likely represents seroma, but hematoma or abscess cannot be excluded. These findings were discussed with the Emergency Department house staff caring for the patient at 4 a.m. on [**4-27**], [**2159**]. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2160-4-28**] 7:14 PM IMPRESSION: Moderately distended gallbladder with wall thickening and edema. No stones or definite sludge seen within the gallbladder. Findings are nonspecific in the setting of ascites and clinical correlation is recommended. Findings discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 10:20 p.m. on [**2160-4-28**]. ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ GALLBLADDER SCAN [**2160-4-28**] IMPRESSION: Nonvisualization of gallbladder after 2.5 hours. ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ GUIDANCE PERC TRANS BIL DRAINAGE US [**2160-4-29**] 3:31 PM PROCEDURE: Preprocedure consent was obtained from the patient's two daughters, one of whom is the healthcare proxy. Abnormal INR was corrected preprocedure with 3 units of fresh frozen plasma. Preprocedure confirmation of patient identity and nature of procedure was performed. Initial ultrasound images show moderately distended gallbladder. Following aseptic technique using a right lateral intercostal approach and following local and intravenous analgesia (because of a history of lidocaine allergy, a different [**Doctor Last Name 360**] without reported crossover was used). An 8.2-French [**Last Name (un) 2823**] catheter was placed within the distended gallbladder body. The pigtail tip was formed within the gallbladder body, aspiration yielded 80 cc of dark bile. Sample has been sent for microbiological analysis as requested. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ CHEST (PORTABLE AP) [**2160-5-5**] 5:06 PM IMPRESSION: 1. Continued moderate left pleural effusion and left lower lobe atelectasis and/or pneumonia. 2. Mild congestive heart failure. Brief Hospital Course: Patient was admitted to the surgical service on [**2160-4-26**] after a CT scan of the abdomen was performed from the emergency room showing fluid and stranding around the pancreas and gallbladder in addition to an abdominal wall seroma. Her PICC line was discontinued as it was purulent appearing. A NG tube was placed in the emergency department for decompression. She was started on vancomycin/levofloxacin/flagyl and blood cultures were sent. Her NGT was discontinued on [**2160-4-28**]. On [**2160-4-29**] she continued to be febrile to 103.2 with rigors annd tachycardia. She was maintained on IV lopressor for heart rate control and started on TPN. An ultrasound showed a moderately distended gallbladder with wall thickening and edema. On the ultrasound no stones or definite sludge seen within the gallbladder. A HIDA scan was performed due to further evaluate for cholecystitis and was suspicious for cholecystitis as there was no tracer uptake in the gallbladder on delayed images. . She was taken to interventional radiology for a percutaneous cholecystostomy tube placement and drainage. She was continued on antibiotics and fluconazole was added to her regimen. Blood cultures and the biliary cultures had no growth, however antibiotics had been initiated at an early stage. She was observed in the ICU following percutaneous tube placement due to tachycardia and mild hypotension. She was noted to be in rapid atrial fibrillation on the first evening in the ICU and she was rate controlled with medication then spontaneously reverted back to sinus rhythm within 12 hours. She continued in the SICU and recovered well with stable hemodynamics following this. She was out of bed and working with physical therapy. Her diet was slowly advanced. She was transferred to the floor on post-procedure day 2. She had an uneventful course on the floor. She worked with physical therapy and nursing for increasing activity. She remained afebrile and antibiotics were discontinued. She and was monitored by nutrition for PO intake. Calorie counts for [**Date range (1) 16935**] was 1162/1292/1227 and 44/59/51gm of protein. Per inpatient nutritionist caloric goal is 1250 calories per day. She will continue on boost supplements and needs encouragement and aid with meals. She was transferred to rehab on [**2160-5-9**] where she will continue [**Hospital1 **] dressing changes and physical therapy. The drain will remain in place and she will follow-up with Dr. [**Last Name (STitle) **]. Medications on Admission: Actonel Atenolol 50 Lipitor 40 Folic Acid Methotrexate 15 po qFri Prednisone [**4-29**] ASA 81 MVI Protonix Vitamin D Colace Calcium Ativan Atrovent ?diltiazem 30qid wellbutrin 75 Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed for fever. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 12. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). 16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 17. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital6 **] TCU - [**Location (un) 86**] Discharge Diagnosis: cholestasis Discharge Condition: good Discharge Instructions: [**Name8 (MD) **] M.D. or go to the emergency room for fevers, chills, abdominal pain, breakdown or drainage from wound, redness around wound, nausea/vomitting, questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 week in the general surgery clinic. Please call clinic to schedule/confirm ([**Telephone/Fax (1) 6449**]. Follow-up with your rheumatologist about restarting methotrexate. Follow-up with primary care physician. Name: [**Known lastname 10344**],[**Known firstname **] Unit No: [**Numeric Identifier 11429**] Admission Date: [**2160-4-27**] Discharge Date: [**2160-5-15**] Date of Birth: [**2078-9-2**] Sex: F Service: SURGERY Allergies: Demerol / Lidocaine Attending:[**First Name3 (LF) 813**] Addendum: The patient was unable to go to rehab on Friday [**5-9**] due to lack of ability to transport her in the afternoon. She remained hospitalized until the [**8-14**]. She remained well however her percutaneous cholecystostomy tube fell out on [**5-11**] late in the evening. She remained without complaints. An ultrasound was obtained the following day and showed minimal gallbladder wall thickening and no pericholecystic fluid or fluid collections. A repeat HIDA scan was interpreted as chronic cholecystitis after the gallbladder failed to fill on delayed scans but filled after the administration of morphine. Her wound was further debrided on [**5-14**]. She was discharge to rehab with instructions for dressing changes and physical therapy. Discharge Disposition: Extended Care Facility: [**Hospital6 592**] TCU - [**Location (un) 42**] [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**] Completed by:[**2160-5-14**]

[ "998.13", "401.9", "998.83", "V58.65", "576.8", "575.11", "714.0", "427.31", "V43.65", "V45.82", "996.62", "511.9", "428.0", "496", "263.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "86.28", "99.15", "51.01", "38.93", "99.07", "96.08" ]

icd9pcs

[ [ [] ] ]

15194, 15427

9077, 11585

326, 362

13565, 13571

1459, 9054

13803, 15171

1103, 1121

11816, 13414

13530, 13544

11611, 11793

13595, 13780

1136, 1440

187, 288

390, 578

600, 1053

1069, 1087

56,266

151,547

5914

Discharge summary

report

Admission Date: [**2171-6-5**] Discharge Date: [**2171-6-9**] Date of Birth: [**2108-9-16**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfonamides Attending:[**First Name3 (LF) 1505**] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: Aortic Valve replacement(25mm St. [**Male First Name (un) 923**] porcine) History of Present Illness: Mr. [**Known lastname **] is a 62 year old male with known aortic stenosis followed by serial echos. His most recent echo shows severe aortic stenosis. He denies angina, syncope, SOB or presyncope. Past Medical History: aortic stenosis with bicuspid AV, ulcerative colitis, mild COPD, prostate cancer s/p radical prostatectomy [**2161**], colon cancer s/p sigmoid colectomy [**2164**], melanoma with prior resection, obstructive sleep apnea, anemia, IgM Lambda monoclonal gammopathy Social History: Mr. [**Known lastname **] lives with his wife. [**Name (NI) **] quit smoking in [**2147**] and has a 20 pack year history. He drinks alcohol in social occasions only. Family History: noncontributory Physical Exam: Pulse: 73 Resp: O2 sat: 97% RA sat B/P Right:116/78 Left: 116/78 Height: 73" Weight: 183# General:NAD, well-nourished Skin: Dry [x] intact [x];well-healed abd scar HEENT: PERRLA [x] EOMI [x]anicteric sclera,OP unremarkable Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs clear bilaterally [B] Heart: RRR [X] Irregular [] + Murmur 3/6 SEM radiates throughout precordium and to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: vein mildly dilated at left knee Neuro: Grossly intact, MAE [**5-21**] strengths Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Brief Hospital Course: Mr. [**Known lastname **] was admitted and taken to the OR on [**6-5**] for an AVR (#25 St. [**Male First Name (un) 923**] porcine). See operative note for details. Immediately postoperatively pt was admitted to the ICU intubated. On POD#1 he was weaned and extubated. He transferred to the step down unit. He was started on betablockers, diuretcis and a statin. His chest tubes and pacing wires were removed per protocol. On his post chest tube removal CXR a possible RLL pneumonia was seen. he had been having low grade fevers of 99.5 and nigth sweats. His WBC count was not elevated but he was started on a 7 day course of cipro. Mr. [**Known lastname **] also had vague but consistent complaints of visual disturbances- inability to focus when [**Location (un) 1131**], seeing white and red spots in visual fields of both eyes. He had a head CT which was normal and an opthalmology consult. Both the scan and the opthalmic exam were normal. He will notify us if his symptoms do not resolve and see his own opthalmologist. He was evaluated by physical therapy and cleared for d/c to home on POD#4. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic stenosis ulcerative colitis chronic obstructive pulmonary disease s/p colon resection for carcinoma s/p melenoma resection s/p prostatectomy IGM Lambde monoclonal gammaopathy Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] in [**1-18**] weeks ([**Telephone/Fax (1) 250**]) [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks ([**Telephone/Fax (1) 3071**]) Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] in 2 weeks Completed by:[**2171-6-9**]

[ "486", "V10.05", "V10.82", "V15.82", "997.39", "V17.3", "746.4", "556.9", "E878.8", "273.1", "496", "285.9", "V10.46", "V45.72", "V45.77", "368.9", "424.1", "327.23" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

4243, 4301

1934, 3036

291, 367

4527, 4534

5002, 5426

1084, 1101

3091, 4220

4322, 4506

3062, 3068

4558, 4979

1116, 1911

238, 253

395, 595

617, 882

898, 1068

27,237

161,637

44495

Discharge summary

report

Admission Date: [**2177-2-26**] Discharge Date: [**2177-3-3**] Date of Birth: [**2121-8-16**] Sex: F Service: MEDICINE Allergies: Ranitidine / Aldactone Attending:[**First Name3 (LF) 1828**] Chief Complaint: abd pain and melena Major Surgical or Invasive Procedure: esophagogastroduodenoscopy - [**3-3**] PRBC transfusions x 3 History of Present Illness: Ms. [**Known lastname 64151**] is a 55F with h/o CHF on home O2, atrial fibrillation on warfarin, DM, and h/o antral gastric ulcer who presented with abdominal pain and black stools. . One day prior to admission she noticed decreased energy and malise. In the evening, she developed abdominal discomfort and headache. Her abdomen was tender on the right side, with a constant achy pain [**6-19**] in intensity. There was no associated dyspnea or lightheadedness, but that evening she did experience some nausea and vomiting, without hematemesis or coffee. The day of admission, she noticed some black stool when wiping herself. She had no hematochezia. She denies any other bleeding problems or changes in her warfarin dosing. She does not use NSAIDS or drink alcohol. +Mildly lightheaded at home, no falls. Had EGD [**12-16**] that showed 3-4mm antral ulcer with path c/w "chemical gastropathy," H. pylori negative. Prior colonoscopy [**2-12**] showed diverticulosis only. . Review of systems is negative for chest discomfort, increased dyspnea, dysuria, diarrhea, or constipation. She did feel a little sweaty when having the abdominal pain and vomiting and did experience palpitations. . In the ED, vitals were T 99.2 P 60 Bp 136/45 RR 24 O2 99% on 3L. She was normotensive. Labs were notable for K of 7.2 with Cr of 3 (baseline ~1 [**9-/2176**]), Hct of 20.6 (down from 26 [**2177-1-19**]), and INR of 3.9, platelets 183. She was given kayexalate, zofran, calcium gluconate, insulin/D50, and albuterol as well as empiric unasyn 3 grams. RUQ ultrasound showed no acute findings. She was guiac positive per records. He vitals in the ED were notable for pulses in 40's but normotensive. A central line was placed, and she was admitted to the MICU. She was transfused 3 units PRBCs and given 2.5mg vitamin K. Hct nadir 19.5 reached [**2-26**] in AM. She was seen by the GI consult service who plan to perform EGD when INR ~1.5 as she has clinically stabilized. Past Medical History: 1. Nonobstructive hypertrophic cardiomyopathy with diastolic congestive heart failure: - Echo ([**10-17**]) with EF >60%, mild symmetric left ventricular hypertrophy and evidence of impaired relaxation - Uses 2L O2 with exertion - Cath with no CAD ([**11-14**]) 2. Hypertension 3. Hyperlipidemia: FLP ([**1-17**]) - TC 166, TG 163, HDL 45, LDL 88 4. Paroxysmal atrial fibrillation on coumadin 5. Diabetes mellitus, type II: A1c ([**1-17**]) - 7.4% 6. Asthma: Spirometry ([**8-17**]) - FVC 34%, FEV1 36%, MMF 20%, FEV1/FVC 102%, TLC 83% 7. Multifactorial sleep disordered breathing with hypoventilation and obstructive componenet: - Per OMR note ([**9-16**]) uses BiPAP 10/5 with 2 liters oxygen 8. Depression 9. Chronic pain (neck, headache, joints) 10. History of GI bleed secondary to antral ulcer in [**12-16**]; negative for h.pylori 11. History of positive PPD -- no INH per patient 12. History of pericarditis complicated by tamponade ([**2162**]) 13. History of thalamic stroke ([**11-13**]) 14. s/p TAH Social History: Lives with family, from Barbados. No EtoH, tobacco, illicits. Family History: n/c Physical Exam: T 98.4 P 54 BP 118/62 RR 20 I2 97% on 3L General: Pleasant, obese woman in no acute distress HEENT: Sclera white, conjunctiva pale, MMM Neck: No JVD Pulm: Lungs clear, no rales or wheezes CV: Regular bradycardic S1 S1 II/VI SEM RUSB Abd: Soft, obese, +bowel sounds, mild tender to deep palpation RUQ without rigidity or guarding Extrem: Warm, no edema, 2+ distal pulses Neuro: Alert and interactive Pertinent Results: Labs: Admission: Chem 143/4.8/103/30/46/1.7<88 Ca 9.8, Mag 2.3, Phos 4.0 CBC WBC 8.7, Hb/Hct 9.6/28.4, plts 180 INR 2.8, PTT 33.1 Discharge: 0 [**2177-3-3**] 07:30AM BLOOD WBC-9.5 RBC-3.51* Hgb-9.7* Hct-29.9* MCV-85 MCH-27.7 MCHC-32.5 RDW-16.5* Plt Ct-180 [**2177-3-3**] 07:30AM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.2* . EKG [**2-26**]: Sinus brady @55, nl axis, Tinv V3-V6, I,II,vL, +LVH similar to prior [**2177-1-18**] . RUQ U/S [**2-26**] IMPRESSION: No son[**Name (NI) 493**] evidence for cholelithiasis or acute cholecystitis. . CXR [**2-26**] Moderately enlarged heart is stable. The cardomegally has a flask shape suggesting the presence of pericardial effusion. The mediastinal and hilar contours are prominent. Mild increased interstitial marking of pulmonary edema have improved. No pleural effusion, pneumothorax, or focal consolidation is identified. The tubing projecting in the epigastrium is most likely external in nature. IMPRESSION: Improving pulmonary edema. . EGD [**3-3**]: Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Very small 2mm erosion of the mucosa was noted in the antrum. Duodenum: Normal duodenum. Impression: Very small 2mm erosion in the antrum Brief Hospital Course: The patient is a 55 year-old female with complex medical history notable for CHF, atrial fibrillation on anticoagulation, gastric ulcer, and DM admitted with abdominal pain and melena . 1. GI Bleed: The patient initially presented with evidence of melena with suspected upper GI source, especially given history of prior gastric ulcer. The patient was transfused with 3u PRBC with stabilization of hct and hemodynamics. She was also given vitamin K to decrease INR (supratherapeutic at 3.9 on admission). The GI service was consulted on admission, and performed an EGD on [**3-3**]. EGD showed a small antral erosion but no site of active or recent bleeding. The GI service recommended outpatient capsule endoscopy to further evaluate the small bowel. If negative, they suggest further workup with colonoscopy (previous normal colonoscopy in [**2173**]). The patient was continued on a PPI throughout admission and upon discharge. Aspirin and coumadin were held on discharge pending further workup of GI bleed. She will f/u in GI suite for capsule endoscopy on [**4-1**]. . 2. Acute renal failure on CRF: The patient developed ARF with maximum creatinine of 3.2 on day of admission. This was felt to be of pre-renal etiology given hypovolemia with blood loss. Cr improved post transfusions to baseline ~ 1.6. ACEI and lasix were initially held and were started back upon discharge. . 3. Bradycardia: The patient has a history of sinus bradycardia both with and without BB therapy. Admission EKG was without significant change compared to [**10-17**], at which time she had also been bradycardic in 40's. The patient's BB was held [**1-11**] bradycardia with increase of HR to the 50's. Beta-blocker was held on discharge, and should be restarted per the patient's outpatient cardiologist. . 4. Hyperkalemia: The patient had hyperkalemia to value of 6.2, which was thought to be [**1-11**] ARF. This resolved with volume-resuscitation, as above. The patient was restarted on lasix prior to discharge. . 5. CHF and nonobstructive hypertrophic cardiomyopathy: The patient is maintained on a BB for her outpatient regimen. This was held, as above, and may be restarted per her outpatient cardiologist. . 6. Atrial fibrillation: The patient remained in sinus rhythm during admission. She was continued on amiodarone, and BB was held as above. The patient was given vitamin K per supratherapeutic INR in setting of active bleeding. Coumadin was held upon discharge until further workup of GI bleed could be performed. . 7. DM: The patient was continued on home ISS while inhouse with no acute issues. . The patient was discharged to home on [**2177-3-3**] in good condition, HD stable with stable hct. Follow-up was arranged with GI and her PCP's office. Medications on Admission: Medications 1. Aspirin 81 mg daily 2. Simvastatin 10 mg daily 3. Metoprolol 25 mg daily (reports not taking; had been stopped in [**1-17**]) 4. Lisinopril 20 mg daily 5. Amlodipine 5 mg daily 6. Amiodarone 200 mg daily 7. Lasix 120 mg daily 8. Warfarin 2 mg daily 9. Humalog sliding scale 10. Lantus 30 units QHS 11. Metoclopramide 10 mg before meals 12. Pantoprazole 40 mg daily 13. Gabapentin 300 mg every other day 14. Clobetasol 0.05 % Cream [**Hospital1 **] . Meds on tx from ICU: Pantoprazole 40 mg IV Q12H Acetaminophen 325-650 mg PO Q6H:PRN Simvastatin 10 mg PO DAILY Insulin SC: glargine 30 qhs Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed Release (E.C.)(s) 4. Reglan 10 mg Tablet Sig: One (1) Tablet PO QAC. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Neurontin 300 mg Capsule Sig: One (1) Capsule PO QOD. 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. 11. Insulin sliding scale Breakfast Lunch Dinner Bedtime 151-200 mg/dL 2 Units 2 Units 2 Units 0 Units 201-250 mg/dL 4 Units 4 Units 4 Units 2 Units 251-300 mg/dL 6 Units 6 Units 6 Units 4 Units 301-350 mg/dL 8 Units 8 Units 8 Units 6 Units 351-400 mg/dL 10 Units 10 Units 10 Units 8 Units Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary 1. Gastrointestinal bleeding 2. Acute on chronic renal failure Secondary 1. CHF chronic diastolic 2. Diabetes 3. Atrial fibrillation Discharge Condition: Good, hemodynamically stable, tolerating po well Discharge Instructions: You came into the hospital because of fatigue and concern for bleeding in your stools. You were evaluated by the gastroenterology doctors who performed [**Name5 (PTitle) **] endoscopy study, which showed no evidence of ulcers or bleeding. You have been set up for another study (capsule endoscopy) to further evaluate for a possible source of bleeding. . Your heart rate was also found to be slow, so your metoprolol was stopped. You should follow up with Dr. [**Last Name (STitle) 696**] in cardiology clinic for further management of your heart disease. Your aspirin and coumadin was also temporarily stopped until further workup for the cause of your GI bleeding is done. Your lasix dose was also decreased due to your renal function. Please discuss restarting these medications with Dr. [**Last Name (STitle) **]. . Please take all of your medications as directed and keep your follow-up appointments. Please do not use pain medications such as ibuprofen (Motrin) at home as these can irritate your stomache and potentially cause worsened bleeding. You can take tylenol as directed for pain. . Call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 250**] and seek medical attention if you develop: ** worsening abdominal pain, black or bloody stools, vomiting, lightheadedness or dizziness, chest pain or worsening shortness of breath, or any other symptoms that worry you Followup Instructions: Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Dr.[**Name (NI) 29254**] office) on Wednesday [**3-5**] at 3:40pm to discuss your hospitalization. Phone: [**Telephone/Fax (1) 250**]. . Please follow-up with the [**Hospital **] Clinic as below for your capsule endoscopy. Please arrive at 7:45 am. Provider: [**Name Initial (NameIs) 2963**] (ST-4) GI ROOMS Date/Time:[**2177-4-1**] 8:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2177-4-1**] 8:00 . Please make an appointment to see Dr. [**Last Name (STitle) 696**] (cardiology) within 2 weeks to discuss your low heart rate. Phone: ([**Telephone/Fax (1) 95349**].

[ "338.29", "E942.0", "425.8", "585.9", "250.00", "V58.61", "584.9", "493.90", "427.31", "428.0", "578.1", "535.40", "V12.54", "327.26", "428.32", "404.91", "427.89", "276.7", "311", "493.20", "285.9", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.13" ]

icd9pcs

[ [ [] ] ]

9678, 9735

5140, 7890

302, 365

9920, 9971

3924, 5117

11398, 12146

3485, 3490

8544, 9655

9756, 9899

7916, 8521

9995, 11375

3505, 3905

243, 264

393, 2355

2377, 3390

3406, 3469

40,911

158,782

3894

Discharge summary

report

Admission Date: [**2122-2-20**] Discharge Date: [**2122-2-27**] Date of Birth: [**2055-10-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1257**] Chief Complaint: Joint pain Major Surgical or Invasive Procedure: None History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE . Date: [**2122-2-20**] Time: 0430 _ ________________________________________________________________ PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17385**] MD Email: [**University/College 17386**] He has never seen this PCP but he has been closely monitored in the d/c clinic. The history was obtained with the help of a Spanish interpretor. . CC: Joint pain _ ________________________________________________________________ HPI: 66M Mr. [**Known lastname **] is a 66 y/o male with a history of CAD (VF arrest post CABG with ICD/PPM inserted), systolic CHF (EF 20%), PVD s/p bilat fem-[**Doctor Last Name **] bypasses, AF s/p DC cardioversion [**2120**], DM2 on insulin recently admitted to [**Hospital1 18**] from [**Date range (1) 17387**] with a CHF exacerbation during which he was treated with agressive diuresis with a resultant 23 lb weight loss. He was discharged to radius speciality hospital. There they had difficulty diuresing during his LTAC stay which was complicated by inadequate response to lasix and metalazone in addition to acute renal failure. His weight at radius remained in the high 190s whereas his baselilne dry weight is closer to 180. He is currently on demadex 80 mg [**Hospital1 **]. He is s/p 1 U PRBCS on [**2122-2-18**]. He was guiac positive and thus ASA and pradaxa were held pending a GI evaluation. He now presents w/fever, severe L hand pain/erythema after IV Lasix infiltrated last night at rehab per paperwork. Also has pain/warmth in *R* wrist, and in both shoulders. . He received abx in the ED. Upon talking with the plastics team they do not think that this is cellulitis. The [**Doctor Last Name **] pressures obtained are reassuring that there is not an effusion that can be tapped and they are also reassuring that compartment syndrome is not present. They do not recommend continuing abx and think that this is c/w a polyarticular gout exacerbation. - In ER: (Triage Vitals:102 100 123/62 20 99% 4L NC ) Meds Given: Today 19:09 Clindamycin Phosphate 150mg/mL-4mL 1 [**Last Name (LF) 17388**],[**First Name3 (LF) **] F. Today 19:39 Acetaminophen 500mg Tablet 2 [**Last Name (LF) 17389**], [**First Name3 (LF) **] Today 20:33 Morphine Sulfate (Syringe) 4mg Syringe [class 2] 1 [**Last Name (LF) 17389**], [**First Name3 (LF) **] Today 20:33 Vancomycin 1g Frozen Bag 1 [**Last Name (LF) 17389**], [**First Name3 (LF) **] Prednisone 30 mg po x T Fluids given: NS at 200 mg/ hr Radiology Studies: consults called: Plastics: Left UE U/S - volar splint, strict elevation via pillow splint - serial exams - Pain control - check uric acid, crp - admit to medicine [**12-17**] complex medical problems, will continue to follow closely Admission Vitals: T 101.8 p 90 rr 23 bp 96/56 sa o2 100% 2 litres. . PAIN SCALE: [**7-25**] worse in L > R wrist but also in a great deal of pain in the R elbow and R wrist ________________________________________________________________ REVIEW OF SYSTEMS: CONSTITUTIONAL: [] All Normal [ +] Fever [ +] Chills [ ] Sweats [ ] Fatigue [ ] Malaise [ ]Anorexia [ ]Night sweats [ ] _____ lbs. weight loss/gain over _____ months HEENT: [X] All Normal [ ] Blurred vision [ ] Blindness [ ] Photophobia [ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums [ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ]Tinnitus [ ] Other: RESPIRATORY: [X] All Normal [ ] SOB [ ] DOE [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [X] All Normal [ ] Angina [ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ] Chest Pain [ ] Other: GI: [X] All Normal [ ] Blood in stool [ ] Hematemesis [ ] Odynophagia [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Anorexia [] Nausea [] Vomiting [ ] Reflux [ ] Diarrhea [ ] Constipation [] Abd pain [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [X] All Normal- all normal but unable to assess L wrist as it has been splinted. [ ] Rash [ ] Pruritus MS: [] All Normal [+ ] Joint pain [ +] Jt swelling [ ] Back pain [+ ] Bony pain NEURO: [X] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [X] All Normal [ ] Skin changes [ ] Hair changes [ ] Temp subjectivity HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy PSYCH: [X] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: [X]all other systems negative except as noted above Past Medical History: 1. Severe CAD s/p 4vCABG [**2107**] 2. V-Fib arrest 4-days post-CABG s/p pacemaker/ICD [**2107**] - Generator change and pocket revision in [**2120-1-14**] to right side of chest secondary to pain 3. Ischemic cardiomypoathy / systolic CHF, EF 25% 4. Peripheral vascular disease s/p bilateral femoral-popliteal bypass 5. multiple lower extremity catheterizations 6. Diabetes Type II - followed at [**Last Name (un) **] 7. Obstructive sleep apnea 8. Gout 9. Asthma 10. Mild sigmoid colonic thickening on recent CT-Abd/Plv, colonoscopy showing sessile polyps, biopsy will have to happen off plavix 11. Esophagitis, gastritis, peptic ulcer disease 12. Afib s/p TTE cardioversion [**1-/2121**] Social History: Married, lives at home with wife. Former 70 pack years tobacco use but quit in [**2107**]. Denies alcohol or IVDA. Prior to his admission to rehab he lived at home with his wife. [**Name (NI) **] walks with a cane. He does not drink or smoke. I was not able to get further information about his IADLs or ADLs as the interpretor had to go. ------ Family History: Mother with kidney problems. Father died of unknown causes. One sister died of stomach cancer, another sister also with stomach cancer. Diabetes is prevalent throughout the family. There is no family history of premature coronary artery disease or sudden death. Physical Exam: PAIN SCORE [**7-25**] VS: 99.7 T P = 88 BP 99/47 RR 20 O2Sat = 98% on RA GENERAL: Well appearing male who is in pain Nourishment: good Grooming: slightly poor Mentation: Awake, speaks appropriately to me and also through the spanish interpretor. Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: dry MMM, poor dentition. Neck: supple, no JVD Respiratory: B/l crackles at the bases but the patient is laying on his back and I didn't ask him to move because he was in so much pain. Cardiovascular: RRR, nl. S1S2, SEM at LUSB and LLSB Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Genitourinary: deferred Skin: brawn skin discoloration present on bilateral lower extremities c/w chronic venostasis Extremities: diminished DP pulses b/l. Lymphatics/Heme/Immun: No cervical lymphadenopathy noted. Neurologic: -mental status: [**2121**], doesn't know where he is but he knows he was brought here by ambulance. [**Month (only) 958**]. Able to express the presence or absence of sx to me but unable to relate the timing of events. -cranial nerves: II-XII intact -motor: normal bulk, 4/5 strength in b/l extremities. PSYCHIATRIC: Appropriate ACCESS: [X]PIV []CVL site ______ FOLEY: [X]present []none TRACH: []present [X]none PEG:[]present [X]none [ ]site C/D/I COLOSTOMY: :[]present [X]none [ ]site C/D/I Pertinent Results: [**2122-2-20**] 09:24PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2122-2-20**] 09:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2122-2-20**] 08:01PM LACTATE-1.1 [**2122-2-20**] 06:35PM GLUCOSE-117* UREA N-41* CREAT-1.8* SODIUM-135 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-28 ANION GAP-14 [**2122-2-20**] 06:35PM estGFR-Using this [**2122-2-20**] 06:35PM WBC-9.0 RBC-3.68* HGB-8.3* HCT-27.2* MCV-74* MCH-22.5* MCHC-30.3* RDW-21.1* [**2122-2-20**] 06:35PM NEUTS-81.6* LYMPHS-8.3* MONOS-7.5 EOS-2.3 BASOS-0.4 [**2122-2-20**] 06:35PM PLT COUNT-420 Brief Hospital Course: This is a 66 year old man with severe vascular disease (CAD and PVD s/p CABG), ischemic, systolic heart failure (EF 20% s/p ICD and pacer), atrial fibrillation on Dabigatran, chronic kidney disease, severe polyarticular gout, and a recent admission for acute heart failure who was admitted for severe, acute polyarticular gout flare (mainly of the joints of left arm) and severe hyperglycemia from prednisone requiring [**Hospital Unit Name 153**] insulin drip and diabetic consultation. He was initially seen in the ED by plastic surgery/hand surgery team to evaluate for possibility of septic arthritis. The team performed Styker pressure evaluation of the three compartments surrounding the wrist to evaluate for evidence of compartment syndrome and this was negative. The ED staff administered vancomycin empirically and he was admitted to the Hospitalist Service. Rheumatology was consulted and diagnosed him with acute, polyarticular gout. Antibiotics were discontinued after 48 hours as he remained culture negative and his fever resolved. Medrol PO was started and pain improved. He then developed severe hyperglycemia. Patient was then transferred to the [**Hospital Unit Name 153**] for management of hyperglycemia in setting of elevated anion gap secondary to steroids. He was started on an insulin drip which was continued until his gap closed. [**Last Name (un) **] was following and provided recommendations. Rheumatology was also following for management of polyarticular gout. His steroids were tapered and allopurinol dosing left the same. We also added Colchicine despite CKD because of poor clinical response. In regards to his heart failure, IV diuresis was continued, however, serum creatinine rose significantly and blood parameters and Fe Urea all supported a pre-renal etiology so diuresis was held. He was then placed on his home oral Torsemide. He was found to have iron-deficient anemia and iron repletion was initiated orally. There were reports of guaiac positive stools at the [**Hospital 671**] [**Hospital 4094**] Hospital. There was no evidence of overt bleeding so his dabigatran and aspirin were resumed. He remained very deconditioned. His Foley catheter, present for an unknown duration of time, was removed, however, he was unable to void with a PVR of over 900 cc of urine, so the urinary catheter was replaced and tamsulosin was initiated. Another void trial was done and was successful. PT was consulted and worked on ambulation with Mr. [**Known lastname **]. He was finally cleared for home without PT. His acute severe gout responded finally to the combination of Allopurinol, Medrol, and Colchicine. His joint swelling (left shoulder, left elbow, left wrist and metacarpophalageal joints) much improved with no residual erythema or tenderness. He also regained his range of motion. He was scheduled to see his PCP, [**Name10 (NameIs) 10368**], and [**Last Name (un) **]. He was told about the importance to follow up with his appointments. His discharge Lantus was 60 units but would need further adjustment because of tapering dose of steroids. He was given prescription for Colchicine for 2 weeks (ever other day) only because of changing creatinine. Medications on Admission: Demadex 80 mg [**Hospital1 **] Simethicone 80 mg qid Lisinopril 5 mg po qd Pradaxa 150 mg [**Hospital1 **] Toprol XL 12.5 mg po qd Tylenol 325 mg po qd Iron sulfate 325 mg po qd novolog SSI Levemir 40 IU qd Simvastatin 80 mg qhs Allopurinol 600 mg daily Discharge Medications: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0* 5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. allopurinol 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 11. methylprednisolone 8 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) for 2 days: The one tablet daily for 4 days then [**11-16**] tablet daily for 4 days then stop. Disp:*9 Tablet(s)* Refills:*0* 12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 13. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. 14. dabigatran etexilate 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 16. torsemide 20 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 17. metoprolol succinate 25 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* 18. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day) for 2 weeks. Disp:*7 Tablet(s)* Refills:*0* 19. insulin glargine 100 unit/mL Solution Sig: Sixty (60) units Subcutaneous once a day. Disp:*1 month* Refills:*2* 20. insulin lispro 100 unit/mL Solution Sig: see sliding scale Subcutaneous three times a day. Discharge Disposition: Home Discharge Diagnosis: Acute polyarticular gout Uncontrolled diabetes Chronic kidney disease. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of gout and uncontrolled diabetes (very high sugars). You received treatment with steroids, Colchicine, and Allopurinol. Your Insulin dose was increased. However, you may decrease your Insulin dose as the steroid dose being decreased. You have 3 appointments with general, diabetes, and gout doctors. Its very importnant that you keep them all as your medications need to be adjusted based on your kidney function and blood sugars. Please monitor your blood sugar 3 time a day. Call your PCP if your sugars become too high (300) or too low (80). Followup Instructions: Department: RHEUMATOLOGY When: THURSDAY [**2122-4-2**] at 9:30 AM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: FRIDAY [**2122-3-13**] at 2:35 PM With: [**Doctor First Name **] [**Doctor First Name **] [**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 Very important appointment: [**Hospital **] Clinic [**2122-3-3**] at 1:00 PM with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11712**]

[ "274.01", "327.23", "443.9", "V58.67", "280.9", "585.3", "428.0", "250.82", "788.20", "V58.65", "427.31", "276.2", "414.00", "V45.81", "428.23", "V45.02", "493.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14369, 14375

8733, 11933

316, 323

14490, 14490

8059, 8710

15236, 16062

6370, 6637

12238, 14346

14396, 14469

11959, 12215

14640, 15213

7776, 8040

6652, 7540

3432, 5277

266, 278

351, 3413

14505, 14616

5299, 5990

6006, 6354

73,371

152,991

54004+59565

Discharge summary

report+addendum

Admission Date: [**2109-2-9**] Discharge Date: [**2109-2-14**] Service: MEDICINE Allergies: Tetanus / Cipro Attending:[**Last Name (un) 32349**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 60245**] is a [**Age over 90 **] year-old woman with HTN, HLD, s/p multiple surgeries who presented from [**Location (un) 5481**] [**Hospital3 **] facility c/o nausea, vomiting and diarrhea on [**2109-2-8**]. Patient reported one day with symptoms including several episodes of non-bloody, non-bilious vomiting and non-bloody diarrhea promting presentation to [**Hospital **] hospital. On arrival to [**Hospital **] Hospital vitals were 98.0 96 101/52 16 96%RA. Labs were notable for WBC 13K and K 3.1. She was admitted with a presumtive diagosis of gastroenteritis and was given IVF. She was admitted to the medical floor where stool studies for C. Diff and blood cultures were obtained and remained NGTD until the time of transfer. An episode of increased RLQ pain prompted CT abdomen that dientified a partial small-bowel obstruction with ?transition point in the mid to distal ileum and sigmoid diverticulosis with-out evidence of diverticulitis. General surgery consult was obtained and advised IV levaquin and flagyl in addition to NGT placement. Subsequent WBC was 24K and lactate was 2.2. The decision was then made to transfer the patient to the [**Hospital1 18**] MICU. Vitals on transfer were 99.0 90 96/58 20 95% on RA. On arrival to the [**Hospital1 18**] MICU vitals are 95.9 82 97/49 18 92%. Patient appears comfortable and without additional complaint. Past Medical History: Past Medical History: SBO s/p ex-lap with LoA in [**11/2103**] Pancreatitis s/p ERCP and sphincterotomy H/O diarrhea / constipation Diverticulosis and abscess Hypertension. Hypercholesterolemia. Hypothyroidism. gallstone pancreatitis Past Surgical History s/p hysterectomy s/p cholecystectomy s/p hemicolectomy s/p surigcal repair of anal stricture and hemorrhoidectomy s/p ex-lap Social History: She lives alone but currently in [**Hospital1 1501**]. She has two children. She smoked one pack per day for 20 years, having quit 40 years ago. Alcohol, she has one drink a night. No intravenous drug use. Family History: Her kids are healthy. Her mother passed away at the age of 65. Her Dad passed away at the age of 82 from heart disease. Brother lived until the age of 91 and another brother is 91 and is alive. Physical Exam: General: A&Ox3, pleasant and cooperative HEENT: OP clear, MMM Neck: JVP 8cm, no carotid bruits Lungs: symmetric breath sounds; no wheezes/rales/ronchi CV: regular rate/rhythm, nl s1s2, no murmurs Abd: TTP throughout with invoulantary guarding and rebound tenderness, nondistended, decreased BS Extr: no edema, 2+ PT pulses Neuro: A&O x3, CN 2-12 intact Pertinent Results: Admission labs [**2109-2-10**] 02:05AM BLOOD WBC-33.5*# RBC-3.74* Hgb-10.5* Hct-31.6* MCV-84 MCH-28.1 MCHC-33.3 RDW-13.2 Plt Ct-87*# [**2109-2-10**] 02:05AM BLOOD Neuts-52 Bands-22* Lymphs-1* Monos-22* Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [**2109-2-10**] 02:05AM BLOOD PT-16.4* PTT-31.6 INR(PT)-1.5* [**2109-2-10**] 02:05AM BLOOD Glucose-115* UreaN-21* Creat-1.0 Na-136 K-4.8 Cl-107 HCO3-19* AnGap-15 [**2109-2-10**] 02:05AM BLOOD ALT-17 AST-23 TotBili-0.4 [**2109-2-10**] 02:05AM BLOOD Albumin-3.2* Calcium-8.2* Phos-2.7 Mg-1.7 [**2109-2-10**] 02:54AM BLOOD Lactate-1.9 CT Abdomen and Pelvis [**2109-2-9**]: Outside Hospital Partial small bowel obstruction with possible transition in the mid to distal ileum. Evidence of mild anasarca with mild diffuse mesenteric fat stranding and small bilateral pleural effusions, and small pelvic free fluid. Sigmoid diverticulosis without evidence of diverticulitis. Final Report CHEST RADIOGRAPH TECHNIQUE: Portable AP semi-erect chest view was read in comparison with prior chest radiograph from [**2109-2-10**]. FINDINGS: Orogastric tube tip terminates approximately at the level of the clavicles. Whether this is positioned within the esophagus or is within the airway is difficult to determine based on the single view. Consider repositioning the orogastric tube. There are no lung opacities concerning for pneumonia. Heart size, mediastinal and hilar contours are normal. Mild atherosclerotic calcification is present in the aortic arch. Findings related to the orogastric tube was discussed by [**Doctor Last Name **] with [**Doctor First Name **] on [**2109-2-11**] at 10:27 p.m. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 16988**] [**Name (STitle) 16989**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: TUE [**2109-2-12**] 2:14 PM Final Report PORTABLE ABDOMEN INDICATION: Abdominal pain and leukocytosis, shortness of breath. COMPARISON: [**2104-1-6**]. FINDINGS: Status post cholecystectomy. According clips in situ. No free air, no pathological calcifications. Nasogastric tube with side port approximately 4-5 cm distal to the gastroesophageal junction. The tip projects over the middle parts of the stomach. Normal distribution of intestinal gas. No intestinal distention. No evidence of wall thickening, no air-fluid levels. Extensive degenerative spine disease. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: SUN [**2109-2-10**] 8:58 AM Microbiology: Cultures from [**Hospital **] Hospital [**2109-2-8**]: NGTD as of [**2109-2-13**] Cdiff from [**Hospital **] Hospital negative [**2109-2-10**] URINE URINE CULTURE-FINAL INPATIENT [**2109-2-10**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2109-2-10**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT Brief Hospital Course: Patient is a [**Age over 90 **] year-old woman with HTN, HLD, s/p multiple surgeries and history of SOB requiring ExLap who was transferd from [**Hospital **] Hospital with partial SBO and marked leucocytosis. . #. Small bowel obstruction: Patient has had mulitple admissions for SBO, most recently in [**2103**] requiring exploratory laparotomy with adhesionolysis now admitted with abdoinal pain, with n/v/d and leucocytosis. Blood cultures showed no growth at [**Location (un) **] and were no growth (from [**2-10**])here at the time of discharge. She had diffuse TTP with rebound and guarding on admission exam. Patient was started on levaquin and flagyl at OSH and was continued on these medications. She was seen by the surgical service who recommended that she undergo surgery for complete small bowel obstruction. Both the patient and her family declined surgery and her goals of care were transitioned to focus on comfort while in the ICU. She was called out of the ICU on [**2-10**] and her clinical status including exam, laboratory data, improved from [**Date range (1) 110716**]. After discussion with her family and the patient, the decision was made to transition to conservative management for her SBO and IV antibiotics were restarted. She was changed from Cipro/Flagyl to Ceftriaxone/Flagyl due to itching and rash which developed up her arm with Cipro. NGT pulled night of [**2-11**] since it had been displaced. She started having BMs on [**2-11**] to the point of [**Month/Year (2) **] diarrhea [**2-12**] with some formed stools. C. diff was negative and diarrhea improved by the morning of [**2-4**]. Her diet was advanced which she tolerated well. Antibiotics were discontinued prior to discharge. . # Hypertension: Home lisinopril was initially stopped and then restarted. . Non-active issues: # hypothyroidism: continued home synthroid . # HLD: held home simvastatin and asa until better able to tolerate full diet. These medications were restarted on discharge. . # dementia: restarted home donezepil, holding namenda for now as non-formulary. This medication was restarted on discharge. . # Code: DNR/DNI (confirmed with patient). Discussed what she would want if SBO were to recur and plan would be to come to the hospital to get confortable with likely transition to comfort care (possible home hospice) . # Communication: Patient, daughter [**Name (NI) 717**] [**Telephone/Fax (1) 110717**] cell; home: [**Telephone/Fax (1) 110718**]; son: [**Telephone/Fax (1) 110719**] . TRANSITIONAL ISSUES - blood cultures were pending at the time of discharge Medications on Admission: Tylenol 650mg Q4H Aspirin 81mg daily Aricept 5mg QHS Trusopt 1gtt OD [**Hospital1 **] Xalatan 0.005% OD QHS Timolol 0.25% 1gtt [**Hospital1 **] Robitussin 200mg Q4H Levofloxacin 250mg IV daily Namenda 10mg daily Reglan 10mg IV Q8H PRN Zofran 4mg IV Q6H PRN Simvastatin 40mg QHS Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**]) Discharge Diagnosis: Primary: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 69**] because of an obstruction in your small bowel. While you were here, you were initially in the intensive care unit. You and your family made the decision to NOT have surgery and proceed with conservative management which included initial bowel rest and nasogastric tube to suction. Your bowel function improved. While you were here, some of your medications were changed. You should START: - Sarna lotion as needed for itching - Chloraseptic Throat Spray as needed for throat pain You should continue to take all other medications as instructed. Please feel free to call with any questions or concerns. Followup Instructions: After leaving the skilled nursing facility you should follow-up with your primary care doctor within 1 week. Department: [**Hospital3 1935**] CENTER When: MONDAY [**2109-5-27**] at 2:00 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 Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 18128**] Admission Date: [**2109-2-9**] Discharge Date: [**2109-2-14**] Date of Birth: [**2017-9-11**] Sex: F Service: MEDICINE Allergies: Tetanus / Cipro Attending:[**Last Name (un) 18129**] Addendum: When the patient was transferred from [**Hospital 322**] Hospital, sepsis was suspected, but ruled out later. Discharge Disposition: Extended Care Facility: Commons Residence At Orchard - [**Location (un) 271**] (a.k.a. [**Location (un) 1267**]) [**Last Name (un) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 18130**] Completed by:[**2109-4-4**]

[ "693.0", "365.9", "560.81", "V45.89", "787.91", "401.9", "272.4", "698.8", "287.5", "788.30", "286.9", "E931.9", "294.20", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10711, 10999

5831, 7636

236, 243

8934, 8934

2896, 5808

9786, 10688

2310, 2507

8878, 8913

8439, 8718

9117, 9763

2522, 2877

182, 198

7651, 8413

271, 1665

8949, 9093

1709, 2070

2086, 2294

31,439

164,290

50611

Discharge summary

report

Admission Date: [**2136-8-3**] Discharge Date: [**2136-8-11**] Date of Birth: [**2064-3-15**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: short of breath for 1 week Major Surgical or Invasive Procedure: s/p attempted RIJ, R subclavian, Left subclavian central line. Placement of Swan Ganz Catheter History of Present Illness: Ms. [**Known lastname **] is a 72 year old female with h/o severe ventricular dysfunction (EF 10%) secondary to polysubstance abuse and HIV (dx [**2116**] on HAART, last CD4 359), 2+ MR, on methadone maintenance who presents with 3 weeks of dyspnea on exertion, worsening over the past week. The patient notes that over the past week activities such as brushing her teeth have become difficult for her. She has a non-productive cough which has also been present for three weeks. At baseline she is unable to lie flat, however she says that this has worsened recently - her breathing is much worse at night and worse with lying down. She endorses orthopnea, PND and ankle edema over past 2 days. She notes occasional sharp right sided chest pain which she believes is due to "gas". The pain occurs at any time of day, no associated symptoms. She denies any medication non-compliance or dietary indiscretions. She notes weight loss of 20lbs since [**Month (only) 956**] and increased fatigue over the same time span. The patient was admitted here in [**2135-8-6**] for CHF exacerbation. Per the d/c summary from that admission she was treated with a single dose of IV lasix and sent home on PO dose. Her BNP at that time was 12,000. Also of note, on last d/c summary from [**8-/2135**], pt reported 30lb weight loss. Patient has not been placed on a beta blocker due to concern of cocaine use. On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. Other review of symptoms negative aside from above. Cardiac review of systems is notable for absence of palpitations, syncope or presyncope. In the ED, the patient was afebrile with SBP as low as 80s. An attempt at placing an IJ and subclavian was attempted but difficult due to reportedly abnormal anatomy. SBP improved to 90s and no line was placed. HR 70s, O2sat 100% on RA, afebrile. Lasix was recommended for CHF but not given due to low BP. CXR showed mild CHF. The patient was given Levaquin for ? PNA on CXR and nebulizers. She was initially admitted to the cardiology floor, however, given her Echo with severe [**4-8**]+ MR, cardiomyopathy and congestive heart failure, she was transferred to the CCU for swan ganz catheter and tailored therapy. Past Medical History: 1. HIV- Diagnosed in [**2116**], has taken HAART therapy intermittently. Stopped taking her pills three months ago because stated she had foamy vomit every time she took them. CD4 274, VL<50 in [**12-10**] 2. CHF- EF 10-15% [**8-10**]. Reports no exacerbations of SOB since admission in [**8-10**]. However one [**Hospital 1902**] clinic note states had admission to [**Hospital1 2177**] in 05. 3. HCV- VL >700K in [**12-9**], not a good candidate for interferon therapy or liver biopsy per gi note in 04. 4. mild COPD- PFTs [**7-/2129**] showed a normal study 5. IVDU--last abuse heroin several days ago, skin popping 6. Arthritis 7. chronic pancreatitis Social History: Has 20 grandchildren, tobacco: [**4-8**] cig/day, 40 py Heavy EtOH in past. States that last used heroin in the past few days (skin popping) and also used cocaine in the last month. Family History: NC Physical Exam: VS: T96.5, BP120/70, HR60, RR20, O2 99% on 3L Gen: Cachectic female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, thin. Right neck with small stable hematoma from IJ attempt in ED. CV: PMI located in 7th intercostal space, midclavicular line. Distant heart sounds, regular rhythm, normal S1, S2. [**2-11**] holosystolic murmur at apex. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at right base, left base clear. Abd: Soft, NT, ND, No HSM or tenderness. No abdominial bruits. Ext: trace edema at ankles bilaterally. No femoral bruits. Skin: Multiple well healed lesions from h/o drug abuse Back: Mildly tender to palpation in left CV angle, no R CVA tenderness Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2136-8-3**] 10:20AM BLOOD WBC-5.8 Hgb-11.9* Hct-36.0 Plt Ct-185 [**2136-8-3**] 03:00AM BLOOD PT-12.7 PTT-30.4 INR(PT)-1.1 [**2136-8-3**] 03:00AM BLOOD Glucose-101 UreaN-47* Creat-1.5* Na-137 K-4.2 Cl-105 HCO3-24 AnGap-12 [**2136-8-3**] 03:00AM BLOOD CK(CPK)-33 cTropnT-0.25* [**2136-8-3**] 08:24AM BLOOD CK(CPK)-25* cTropnT-0.19* [**2136-8-3**] 10:20AM BLOOD CK(CPK)-30 cTropnT-0.20* proBNP-[**Numeric Identifier 105347**]* [**2136-8-6**] 03:43PM BLOOD TSH-2.1 [**2136-8-6**] 03:43PM BLOOD ALT-11 AST-25 AlkPhos-58 TotBili-0.5 . [**2136-8-3**] ECHOCARDIOGRAM: The estimated right atrial pressure is 16-20 mmHg. Normal LV wall thickness with severe global LV hypokinesis. No masses or thrombi are seen in the left ventricle. RV cavity is moderately dilated with severe global right ventricular free wall hypokinesis. "Low-output" aortic stenosis is suggested (calculated [**Location (un) 109**] 1.0cm2). Moderate (2+) mitral regurgitation and moderate [2+] tricuspid regurgitation is seen. Moderate pulmonary artery systolic hypertension (PASP = 46). . [**2136-8-3**] CXR: 1) Mild CHF 2) Progression in size of cardiac silhouette. [**2136-8-3**] CXR: New moderate-sized apical pneumothorax on the right. [**2136-8-4**] CXR: Resolution of the small right apical pneumothorax. [**2136-8-6**] CXR: 1. Continued improvement in interstitial pulmonary edema. . Brief Hospital Course: The patient is a 72 year-old female with severe ventricular dysfunction (EF 10%) secondary to polysubstance abuse and HIV (last CD4 359) who presented with CHF exacerbation. . # Pump: The patient had an EF of 10% on her last echo prior to admission (07/[**2135**]). Troponin was elevated on admission, but thought likely to be secondary to demand after three sets were stable. Physical exam on admission was only slightly consistent with CHF - crackles at right lung base, minimal LE edema. CXR was concerning for pericardial effusion given that cardiac silhouette was enlarged from prior, and showed mild CHF, though not worsened compared to a previous CXR. Given her low EF, it was likely acute on chronic heart failure with poor forward flow secondary to dilated cardiomyopathy of HIV. The precipitating event was unclear. Echocardiogram [**2136-8-3**] showed no pericardial effusion although severely depressed EF with MR. BNP was [**Numeric Identifier 105347**]. The patient was diuresed with lasix. A Swan Ganz catheter was placed on [**2136-8-3**] in L brachial artery to monitor hemodynamics and for tailored therapy. Digoxin and ACEI were continued. Captopril was titrated up as blood pressure tolerated for afterload reduction. Dobutamine was started to maximize heart function/inotropic effect and titrated off on [**2136-8-6**]. Eventually, patient was weaned off oxygen and breathing comfortably on room air. . # Rhythm: Pt was admitted in sinus rhythm and was noted to have some ectopy on telemetry. On [**2136-8-4**] occasional ventricular bigeminy was noted, and by [**8-5**] this pattern became more frequent. Given her improved Cardiac index we attempted to wean the dobutamine. On [**2136-8-6**], patient developed runs of Vtach and was started on Amiodarone 400mg PO BID. TSH, LFT's, EKG were within normal limits. Digoxin dose was decreased to 0.0625mg PO Daily due to Amiodarone metabolism. By discharge, the episodes of Vtach had resolved. . # HIV: Last CD4 359 in 04/[**2136**]. Her outpatient regimen of HAART and bactrim was continued. . # Polysubstance abuse: Last use [**6-10**] mos prior to admission. The patient was continued on her outpatient methadone regimen. . #)Anticoagulation- Patient was started on a heparin drip and then bridged to coumadin due to the poor LV function and risk of clot formation. Currently on Coumadin 5mg PO Daily with theraputic goal of INR [**3-10**]. . # FEN: PO intake was poor initially. Nutrition was consulted and recommended additional supplements. Low sodium diet. . #) Difficulty swallowing- On [**2136-8-8**], patient complained of difficulty swallowing solids, painful swallowing, and regurgitation of solid food. She was started on a PPI and outpatient GI follow-up with possible EGD was recommended. . Medications on Admission: Lasix 80mg PO BID Lisinopril 20mg daily Digoxin 0.125 mg daily Methadone 90mg daily (confirmed with methadone clinic) Nevirapine 400mg daily Bactrim DS 1 tab daily Truvada 1tab daily Albuterol inhlaer Discharge Medications: 1. Outpatient Lab Work Please draw potassium, creatinine, PT/PTT/INR on Monday, [**8-13**], [**2136**]. Fax results to Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at ([**Telephone/Fax (1) 49261**]. 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*1* 3. Warfarin 1 mg Tablet [**Last Name (STitle) **]: Five (5) Tablet PO at bedtime. Disp:*150 Tablet(s)* Refills:*2* 4. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO see instructions: take 2 tablets twice daily for 9 days then take 2 tablets once daily thereafter . Disp:*39 Tablet(s)* Refills:*1* 5. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day: take 1 (one) 20 mg tablet with 1 (one) 80 mg tablet twice a day (for a total of 100mg twice a day). Disp:*60 Tablet(s)* Refills:*2* 6. Methadone 10 mg Tablet [**Last Name (STitle) **]: Nine (9) Tablet PO DAILY (Daily). Tablet(s) 7. Nevirapine 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Emtricitabine-Tenofovir 200-300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 11. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Congestive Heart Failure with Ejection fraction of less than 10% Human Immunodeficiency Virus dysphagia Discharge Condition: The patient is in stable condition. Afebrile, comfortable on room air. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 mL You were admitted with an exacerbation of congestive heart failure. Please call Dr.[**Name (NI) 3536**] office or 911 if you experience increasing shortness of breath, chest pain, leg swelling, increasing weight. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], ([**Telephone/Fax (1) 3581**]) on [**2136-8-23**] at 2:30 pm. Please follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], your cardiologist, on Monday, [**2136-8-27**] at 3:30 pm. Please call ([**Telephone/Fax (1) 7179**] if there is a problem with this appointment. You should have your labwork drawn this coming Monday, [**8-13**]. This will include your kidney function as well as your coumadin level. These results should be faxed to Dr.[**Name (NI) 3536**] office. Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2136-9-12**] 11:00

[ "304.01", "428.0", "397.0", "042", "496", "427.1", "486", "425.9", "424.0", "585.9", "070.54" ]

icd9cm

[ [ [] ] ]

[ "89.64" ]

icd9pcs

[ [ [] ] ]

10763, 10820

6154, 8947

306, 402

10968, 11041

4764, 6131

11431, 12228

3730, 3734

9198, 10740

10841, 10947

8973, 9175

11065, 11408

3749, 4745

240, 268

430, 2834

2856, 3514

3530, 3714

22,020

151,139

5563

Discharge summary

report

Admission Date: [**2145-9-23**] Discharge Date: [**2145-10-1**] Date of Birth: [**2072-12-5**] Sex: F Service: MEDICINE Allergies: Cardizem / Codeine / Optiray 300 / Heparin Agents / Atorvastatin / Spironolactone Attending:[**First Name3 (LF) 19836**] Chief Complaint: chest pain, decrease in hematocrit Major Surgical or Invasive Procedure: endoscopy with variceal banding x4 colonoscopy History of Present Illness: Pt is a 72 yo female with history of chronic GI bleeding, CAD s/p CABG, CHF w/EF 35%, diabetes, chronic renal failure, and cryptogenic cirrhosis admitted to the medical servce after presenting to the ED with chest pain and a low hematocrit. . She states that she began having episodes of chest pain frequently today. Usually she gets chest pains with a low hematocrit. She has chronic blood loss anemia as well as anemia of chronic disease, and has her Hct monitored closely. Her HCt on the day of admission was 26. She was also having marroon-colored stools. All this, along with her ongoing chest pains brought her to the ED. . In the ED her VS were 96.9 58 121/69 18 97%RA. She was noted to have guaiac positive marroon stool. GI was consulted and recommended NPO> MNm, IV protonix and transfusion. She received 2 Units PRBCS and 40mg IV protonix. She had multiple episodes of chest pains which were relieved with NTG. She had EKGs that were unchanged from baseline studies. Past Medical History: # CAD s/p CABG in [**2138**] - Followed by Dr. [**Last Name (STitle) **] - MI in [**2122**] - CABG [**2138**] = LIMA-->LAD, VG-->OM, VG--->RCA - Echo with 35% EF # AAA - [**3-2**] Abd MRI showed infrarenal AAA 5 x 6 cm with diffuse atherosclerotic change - [**2142-7-6**] - underwent endovascular repair of abdominal aortic aneurysm - complicated by left external iliac artery avulsion (? apparent intra-op rupture of iliac) s/p left iliac stent graft to left CFA, bilateral femoral endartectomies and rt CFA patch angioplasty [**2142-7-7**] with right groin washout [**2142-7-8**] (for ? lymphatic leak) # DM type II: for 20 years typically under good control unless she is sick # Cryptogenic cirrhosis (?NASH) with grade II esophageal varices, portal gastropathy, gastric angioectasias - chronic GI bleed; has required 64 transfusion over the past 6 years - last colonoscopy [**7-2**], last EGD [**6-1**] # Pancytopenia # Anemia - due to CRF and chronic GI bleed - Angina when hct <30 # CRF (1.9-2.5) # h/o PUD # h/o lower GI bleeding due to AVM: Colonocsopy in [**2143**] found diverticulosis, internal hemorrhoids, normal TI; EGD in [**2143**] with non-bleeding varices, portal gastropathy, two angioectasias in the second part of the duodenum # + HIT [**7-31**] # Ecoli UTI resistant to Bactrim and cipro Cardiac Risk Factors: + Diabetes, +Dyslipidemia, +Hypertension Social History: [**Month/Year (2) **] worked as a hairdresser. She quit tobacco 20 yrs ago (started smoking at 17 yo, 1-2pks/day, unfiltered), no EtOH. She lives w/her son who is home from [**Country 22390**] but will be leaving in 1wk. Has 2 daughters who work at [**Hospital1 18**] in [**Name (NI) 13042**]. Has another daughter. [**Name (NI) **] her children and her 7 grandchildren live in the [**Location (un) 86**] area. . Family History: Her mother had non-alcoholic liver cirrhosis and diabetes type 2. Her father had diabetes and died of lung cancer. One of her daughters and her son have both required pacemakers/defibrillators for hypertrophic cardiomyopathy. She had a brother who died of a brain tumor and has an older sister who is generally in good health. No family history of blood clots. Physical Exam: VS: 97.8 120/54 61 95%RA GEN: Chronically ill-appearing, NAD HEENT: Sclera anicteric, PERRL, EOMI, OP clear, MMM NECK: Supple, no LAD CV: regular with occasional premature beats. 2/6 SEM at USBs, no G/R PULM: crackles @ lungs bialterally ABD: Soft, NT, ND, +BS EXT: No C/C/E. 2+ distal pulses Pertinent Results: Imaging: CXR ([**9-25**]) There is no significant interval change. The lungs remain clear. There is no effusion, pneumothorax or pneumomediastinum. Cardiomediastinal silhouette is unchanged, again noted mild cardiomegaly. Post-sternotomy changes are noted. IMPRESSION: No significant interval change. No acute cardiopulmonary process. Abdominal U/S with Doppler ([**9-24**]) The liver demonstrates normal echogenicity and texture without focal hepatic lesions or masses. The CBD measures up to 5.5 mm. There is cholelithiasis without evidence of acute cholecystitis. There is no free fluid; however, the spleen is enlarged measuring 18 cm. The portal vein is patent with hepatopetal flow, however, the splenic venous and superior mesenteric vein confluence is dilated measuring up to 2.2 cm. Findings suggestive of portal hypertension. Doppler evaluation demonstrates normal hepatopetal flow in main, right and left portal veins. The systemic vasculature including middle hepatic, right and left hepatic veins is patent with normal venous waveform. The main hepatic artery commensurate normal systolic and diastolic flow. IMPRESSION: 1.Normal hepatic portal venous and arterial vasculature. 2.Cholelithiasis with cholecystitis. 3.Prominent portal confluence and splenomegaly suggestive of portal hypertension. No ascites. EGD ([**9-24**]): Impression: Varices at the lower third of the esophagus (ligation) Granularity and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Polyps in the antrum Otherwise normal EGD to second part of the duodenum Sigmoidoscopy ([**9-24**]): Impression: Grade 2 internal & external hemorrhoids There was solid black stool in the rectum which precluded advancement of the scope. Otherwise normal sigmoidoscopy to rectum ECG ([**9-24**]) Sinus rhythm. Left axis deviation. Non-specific intraventricular conduction delay. There is an abnormal precordial transition with anterior Q waves consistent with possible prior myocardial infarction. There are tiny R waves in the inferior leads consistent with possible prior inferior myocardial infarction. Non-specific ST-T wave changes. Compared to the previous tracing of [**2145-9-23**] there is no significant change. Colonoscopy ([**9-30**]) Impression: Grade 3 internal & external hemorrhoids. At least 2 cords of moderate size and branching rectal varices without signs of active bleeding. Otherwise normal colon up to the cecum. [**2145-9-23**] 07:50PM PT-16.5* PTT-39.0* INR(PT)-1.5* [**2145-9-23**] 07:50PM PLT COUNT-48* [**2145-9-23**] 07:50PM WBC-2.9* RBC-2.98*# HGB-8.5*# HCT-24.6*# MCV-83 MCH-28.6 MCHC-34.7 RDW-14.6 [**2145-9-23**] 07:50PM NEUTS-79.4* LYMPHS-15.8* MONOS-4.0 EOS-0.6 BASOS-0.2 [**2145-9-23**] 07:50PM ALT(SGPT)-9 AST(SGOT)-31 CK(CPK)-90 ALK PHOS-60 TOT BILI-0.5 [**2145-9-23**] 07:50PM GLUCOSE-210* UREA N-83* CREAT-2.9* SODIUM-129* POTASSIUM-5.4* CHLORIDE-95* TOTAL CO2-27 ANION GAP-12 [**2145-10-1**] 05:25AM BLOOD WBC-3.4* RBC-3.92* Hgb-11.5* Hct-32.9* MCV-84 MCH-29.3 MCHC-34.8 RDW-15.1 Plt Ct-47* Brief Hospital Course: 72yo female with CAD s/p CABG, CHF (EF 35%), AAA s/p repair, PVD s/p multiple bypasses, cryptogenic cirrhosis (likely [**2-27**] NASH) w/ grade II esophageal varices, portal gastropathy, and gastric angioectasias, peptic ulcer disease, and h/o lower GI bleeding [**2-27**] AVMs and diverticulosis, who presented to the hospital w/ chest pain and anemia. Seen by hepatology w/ EGD showing esophageal varices s/p banding x4, on Octeotride gtt, IV PPI [**Hospital1 **], and CTX IV daily. Transferred to the ICU with continued melanotic stools and orthostatic hypotension for closer monitoring in preparation for scope. Returned to medical floor on [**9-29**], kept NPO for colonoscopy. Colonoscopy showed colonic and rectal varices, internal and external hemorrhoids. Stable hemodynamically, stable hematocrit at discharge. . 1. Anemia: Hct lower than baseline on admission, found to be low by VNA services. After transfusion of 2 units patient's Hct went up to 27.7. Etiology most likely secondary to patient's chronic GI bleeds and anemia of chronic disease. Continued to transfuse to keep Hct >25. Hct stable [**Date range (1) 22391**]. . 2. GI Bleed: Patient had melena prior to admission. Consulted GI medicine specifically liver team. Recommended IV protonix for possible upper GI component, octreotide drip, ceftriaxone 1gm IV QD for SBP prophylaxis. Patient was transferred to the ICU for emergent EGD and colonoscopy and then transferred out of the unit back to the floor in the same day. On [**9-30**], colonoscopy was performed, found grade III rectal varices. No acute interventions at this time, to be followed up in liver clinic in 2 weeks. . 3. Chest Pain: likely cardiac ischemia in the setting of low Hct. Patient had no EKG changes during hospital stay and pain resolved with nitroglycerin. Pain became less severe and less frequent following blood transfusion. Ruled out MI with serial cardiac enzymes (troponin 0.03-0.05). Monitored on telemetry. Continued nitroglycerin and morphine PRN pain. . 4. Congestive Heart Failure: Patient has history of likely ischemic cardiomyopathy, EF 30-35%. As patient received fluid in the form of PRBCs, monitored fluid status closely with daily weights and I/Os. Lasix 160 mg [**Hospital1 **], carvedilol 12.5 mg [**Hospital1 **], lisinopril 2.5 mg QHS held and restarted on [**9-29**] pm. Carvedilol switched to nadolol 40mg qd in view of varices. . 5. DM: Gave [**1-27**] PM lantus while NPO and continued sliding scale. . 6. Acute on Chronic Renal Failure: Crn 2.9 on admission with elevation of BUN most likely secondary to UGIB. Improved slightly with IV fluids to 2.6. Monitored and replaced fluid as necessary. Improved by transition to floor back to baseline, Cr 1.7 on day of discharge. Medications on Admission: CARVEDILOL - 12.5 [**Hospital1 **] EPOETIN ALFA [EPOGEN] - 4,000 2x/week FUROSEMIDE - 160mg [**Hospital1 **] INSULIN ASPART sliding scale INSULIN GLARGINE [LANTUS] 23u qHS ISOSORBIDE MONONITRATE [IMDUR, SR] - 120 [**Hospital1 **] LISINOPRIL - 5 mg qday NITROGLYCERIN - 0.4 mg SL prn PANTOPRAZOLE [PROTONIX] - 40 mg [**Hospital1 **] PRAMIPEXOLE [MIRAPEX] - 0.125 mg qHS CALCIUM CARBONATE [TUMS] - 500 mg Tablet 4x/day CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 unit qday FERROUS SULFATE - 325(65)MG [**Hospital1 **] Discharge Medications: 1. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 3. Furosemide 80 mg Tablet Sig: one (1) Tablet PO BID (2 times a day). 4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday): Please hold administration until Hct < 30. 9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Insulin Glargine 100 unit/mL Solution Sig: Twenty Three (23) units Subcutaneous at bedtime. 12. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 13. Lactulose 10 gram Packet Sig: [**1-27**] PO once a day. 14. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. VNA Services Order Please resume telemetry monitoring Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis: Gastrointestinal bleed . Secondary Diagnosis: Coronary artery disease, chronic systolic congestive heart failure, anemia of chronic disease, chronic kidney disease, cirrhosis, type 2 diabetes mellitus Discharge Condition: Stable, ambulating, knitting, eating, drinking, voiding without complaints. Most recent Hct at 32. Discharge Instructions: You were admitted to [**Hospital1 18**] with a drop in your Hct and chest pain. You were found to be anemic and the cause of your anemia most likely was a GI bleed. You had an endoscopy and colonoscopy to determine the etiology of the bleed. You were treated with IV therapy, given blood transfusions and monitored closely. Prior to discharge your Hct was stable, you were no longer having blood in your stool and no longer having chest pain. . If you experience chest pain, shortness of breath, nausea, vomiting, abdominal pain, blood in your stool, dark tarry stool or any other worrisome symptom please seek medical attention. . Please follow up with your primary doctor, Dr. [**Last Name (STitle) 9006**], at your scheduled appointment on [**2145-11-29**] at 11:20. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Liver Center Appointment - Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2145-10-13**] 2:50 Primary Care Phyisican - Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2145-11-29**] 11:20 [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**] Completed by:[**2145-10-1**]

[ "428.0", "428.22", "250.00", "572.3", "280.0", "585.9", "584.9", "455.5", "571.5", "414.8", "441.4", "284.1", "537.89", "455.2", "456.20", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "42.33", "45.24", "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

11810, 11861

7062, 9826

378, 426

12125, 12226

3972, 7039

13150, 13638

3280, 3643

10398, 11787

11882, 11882

9852, 10375

12250, 13127

3658, 3953

304, 340

454, 1436

11947, 12104

11901, 11926

1458, 2833

2849, 3264

15,285

195,331

17855

Discharge summary

report

Admission Date: [**2169-5-27**] Discharge Date: [**2169-6-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: Intubation and extubation PICC line placement History of Present Illness: 82 M with h/o IPF (on chronic steroids), PVD, h/o VT (on dofetilide), and P.D. He was last seen at [**Hospital1 18**]-[**Location (un) 620**] cardiology clinic [**4-25**] (one month prior to admission). He was at home being cared for by his wife, daughter, and nurses and was noted to be "much improved" but using continual O2 and having increased SOB in the last few weeks. He denied chest discomfort or palpitations but did report occasional lightheadedness without falls. . On the evening of presentation, he was leaving a restaurant after father's day dinner. He sat down in the passenger seat, complained of fatigue, then became acutely SOB; changes in position did not help these sx. His family started to drive to the ED, but the patient passed out, turned blue, and his eyes rolled back in his head. He was promptly removed from the car and received CPR from his daughter who is [**Name8 (MD) **] RN until EMS arrived when he was noted to be in asystolic arrest. EMS administered epi, lido, and atropine and intubated the patient. He was brought to [**Location (un) 620**] ED where he was in SR w/NSVT. ECG demonstrated ST depression in V2-4. The patient was given amiodarone for his NSVT which decreased his HR to 100s. He was then trasferred to [**Hospital1 18**]. Labs pending at time of transfer demonstrated Na 141, K 4.3, Cl 103, CO2 22.9, Glucose 123, BUN 21, Creatinine 1.3, Ca 8.8, Mg 2.2, Albumin 3.7, Protein 6.8, TBili .66, AlkPhos 118, ALT 25, AST 27, CPK 42, INR 1.2, PTT 31, WBC 9.5, HCT 38.3, MCV 86.6, PLT 201, N59L34M7 and ABG of 7.3/33/155 on CMV550X2 40 5. ... MEDICATIONS: Sinemet 25/100 2 tabs at 9:00 a.m., 1.5 tabs 11:00 a.m., 1 tab 4:00 p.m. Prednisone 2.5. Quinaglute 325 q.12 hours. Omeprazole 20 q.a.m.. P.R.N. Colace, Senokot. ASA 81, MVI 1 daily. Zocor on hold. ... Past Medical History: Past Medical History: 1. Orthostatic hypotension (? Shy-[**Last Name (un) **]). 2. Diastolic congestive heart failure. 3. RMVT (repetitive monomorphic VT presumably from RVOT origin). 4. Coronary artery disease/CA calcification. 5. Dyslipidemia. 6. Peripheral vascular disease (status amputation right first toe [**2168-11-23**]). 7. Pulmonary fibrosis. 8. Chronic obstructive pulmonary disease. 9. Parkinsonism with probable Shy-[**Last Name (un) **]. 10. Episodic gout. 11. Chronic respiratory failure. 12. Past hypermagnesemia. 13. Last echo [**2168-7-13**] w/EF 55-60% and 1+ MR Social History: lives at home with wife, who is HCP. Former [**Name2 (NI) 1818**], quit. Blueprint shop-->chemical exposures. Family History: NC Pertinent Results: TTE ([**5-29**]) - normal LA size, 1+ MR, EF>55%, normal LV thickness Brief Hospital Course: A/P: 82 year old man with multiple medical problems admitted s/p resuscitated cardiac arrest. . Cardiac arrest- Without cardiac monitoring during the event, the cardiac arrest was initially of unclear etiology, VT/VF vs. PEA secondary to hypoxia. On admission, the patient was ruled out for an MI. He was started on ASA, statin, and beta blocker. TTE showed good systolic function, normal LA size, and no wall motion abnormalities. On telemetry, he maintained persistent ventricular premature beats without sustained VT. Upon further history, patient had multiple syncopal events before admission, and was put on quinidine empirically. The source of the presumed arrhythmia has not been identified by EP study. By history, patient's syncopal symptoms improved with quinidine. The cardiac arrest leading to the admission is is now thought to likely be PEA arrest secondary to hypoxia from his primary pulmonary disease and noncompliance with home oxygen. EP recommended restarting quinidine, keeping beta blocker at low dose, and giving the patient [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor upon discharge. Mr. [**Known lastname 21781**] had an episode of hypotension and lethargy when his beta blocker was increased. As the patient has a history of syncope, the decision was made to discontinue the beta blocker. He is to f/u with Dr. [**Last Name (STitle) 3321**] from EP. . CHF- Mr. [**Known lastname 21781**] has a diagnosis of diastolic CHF, with preserved EF. He was maintained on ASA, statin and beta blocker throughout his admission. He appeared clinically fluid overloaded on admission, but diuresed to a euvolemic state. He should f/u with his cardiologist as needed as an outpatient. . Resp failure- His cardiac arrest is thought to have been PEA secondary to hypoxia. He has had an unclear diagnosis of primary pulmonary disease. He was initially thought to have an IPF process, however CT was negative per outpatient pulmonologist, Dr. [**Last Name (STitle) **]. He has been on chronic prednisone for suspected fibrosis in the past, and has been undergoing a difficult and slow taper as an outpatient. He has been on prednisone 2.5mg for an extended period of time. He was initially maintained on prednisone and Atrovent nebs. Dr. [**Last Name (STitle) **] saw the patient during this admission and stated that the patient's primary diagnosis may be more likely hypersensitivity pneumonitis secondary to chronic aspiration, with Parkinson's disease as a predisposing factor. Prednisone was d/c'd per pulmonary recs with the expectation of slight worsening of respiratory status initially secondary to steroid dependence. The patient was given additional nebulizer treatments at this time. The patient may require home O2. He is to f/u with Dr. [**Last Name (STitle) **] as an outpatient for further assessment of his pulmonary process. . MRSA bacteremia/pneumonia- Pneumonia was found on CXR during this admission, thought to be secondary to aspiration during arrest. The patient was initially started on vancomycin, ceftriaxone and azithromycin for aspiration pneumonia coverage. Blood and sputum cultures from [**5-29**] were positive for MRSA. Ceftriaxone and azithromycin were d/c'd. Vancomycin was continued for treatment of the MRSA infection. A PICC line was placed on [**6-2**] for outpatient completion of a 14 day course of antibiotics. He has completed 7 days of treatment on the day of discharge. . Dementia/delirium- Mr. [**Known lastname 21781**] has underlying dementia secondary to Parkinson's disease. He became disoriented and somnolent during this admission, but became more alert when he received treatment for his bacteremia and pneumonia. Towards the end of his hospital stay, he appeared to be experiencing auditory and visual hallucinations, speaking to and seeing his wife in his room when she was not present. New infection was ruled out. Further discussion with his family revealed that he typically experiences some psychosis when he is admitted to the hospital for an extended period of time. Sedating medications were avoided throughout his stay. He was maintained on his outpatient dose of Sinemet. He is to follow up with his outpatient neurologist, Dr. [**Last Name (STitle) 32878**], for continuation of his Parkinson's treatment. . Dispo- Mr. [**Known lastname 21781**] was discharged to home with services. Medications on Admission: Sinemet 25/100 2 tabs at 8AM, 1.5 mg Q 1PM, 1 tab 4PM Prednisone 2.5 mg QD Quinidine 324 mg SA [**Hospital1 **] Simvastatin 20 mg QHS HCTZ/Spironolactone 25/25 Q MWF Omeprazole QD 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:*2* 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 5. 0.9% saline 5 mL IV flus SASH and prn 6. Heparin 10 u/mL IV flush - 5 mL SASH and prn 7. Please check BUN, Cr, and Vanco trough level q week 8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*2* 9. Carbidopa-Levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:*60 Tablet(s)* Refills:*2* 10. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QD (). Disp:*45 Tablet(s)* Refills:*2* 11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Vancomycin 5,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous twice a day for 7 days: Start date [**5-30**] (duration 14 days). Disp:*qs qs* Refills:*0* 13. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*2 inhalers* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: ventricular tachycardia, non-sustained diastolic congestive heart failure chronic respiratory failure Parkinsonism Discharge Condition: stable Discharge Instructions: Please call your primary care physician or cardiologist or come to the emergency room if you have chest pain, shortness of breath, palpitations, or any other symptom that bothers you. Followup Instructions: You have an appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 49524**], on [**6-6**] at 10:30am. . Please follow up with Dr. [**Last Name (STitle) 5543**] (cardiologist) on [**6-15**] at 2:30pm at the [**Hospital1 **] [**Last Name (Titles) 620**]. Dr. [**Last Name (STitle) 5543**] is covering for Dr. [**Last Name (STitle) 3321**] while he is on vacation, after you see Dr. [**Last Name (STitle) 5543**], you should make a follow up appointment with Dr. [**Last Name (STitle) 3321**]. . Please follow up with Dr. [**Last Name (STitle) **] (pulmonologist) on [**8-18**] at 9:30 am in [**Hospital Ward Name 23**] 7. This is the earliest that you could be booked for an appointment, the clinic will call you if there are any cancellations and they can get you in earlier. Completed by:[**2169-7-19**]

[ "428.0", "515", "790.7", "428.30", "V09.0", "599.0", "482.41", "332.0", "041.6", "518.81", "427.69" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

9325, 9374

3076, 7506

276, 324

9532, 9540

2982, 3053

9772, 10652

2958, 2963

7736, 9302

9395, 9511

7532, 7713

9564, 9749

222, 238

352, 2169

2216, 2814

2830, 2942

10,577

114,742

24269

Discharge summary

report

Admission Date: [**2175-6-26**] Discharge Date: [**2175-7-17**] Date of Birth: [**2102-11-10**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Central line placement (right IJ) History of Present Illness: 72 year-old female with past medical hx of Lung CA s/p lobectomy, CHF, presented from OSH w/resp distress. She was found at home in the morning of admission sitting on the couch, short of breath, right-sided "slouching", hypertensive to 225/110, tachycardic to 110-120s, unresponsive, incontinent of urine/stool. At OSH was saturating 70% on 12L NC and so was intubated. Head CT was negative at OSH. She receiving rocephin, lasix, bumex, lactulose, neomycin. Also received succinylcholine, fentanyl, and versed peri-intubation. * In our ED, she received lasix 60 IV x1 with minimal response, placed on propofol, and had a CT of her abdomen due to a distended abdomen. On ROS, family noted PND, chart noted pt w/hx URI, recent steroids use. Pt's family reports increased cough, URI symptoms, dizziness, increased sputum. Has multiple URIs, allergies, recent azithro < 2 weeks ago, prednisone < 1 month ago. Past Medical History: 1. Lung CA s/p lobectomy 2. CHF 3. Asthma 4. CRI 5. Liver hemangioma 6. Anemia 7. COPD 8. Hyperlipidemia 9. Hypothyroidism 10. Gastritis 11. Depression 12. HTN Social History: married, lives with husband/son, 35 pack yrs, no etoh Pertinent Results: CT abdomen: Large mass replacing most of the right lobe of the liver and a second smaller hypodense lesion in the left lobe of the liver that are incompletely characterized on this noncontrast study. Fat-containing right-sided abdominal wall hernia. Bilateral pleural effusions with bibasilar lung opacities with possible interlobular septal thickening consistent with CHF/fluid overload. Air bronchograms present in the right basilar opacity raise the possibility of a superimposed infectious process. MRI abdomen: 1) Giant cavernous hemangioma of the right lobe of the liver measuring 27.2 x 21.3 x 21.1 cm. A second smaller hemangioma is seen within the medial segment of the left lobe, measuring 2.3 x 2.5 x 3.1 cm. The hepatic venous and portal venous vasculature is patent. 2) Bilateral pleural effusions. 3) Lower anterior abdominal wall fat-containing hernia. Brief Hospital Course: ICU Course: Active problems on admssion included 1)hypercarbic respiratory failure, 2)oliguric acute renal failure, 3)large liver mass seen on the abdominal CT, 4)intermittent supraventricular tachycardia, 5)Hypotension. In terms of respiratory failure, pt was intubated and was treated for pneumonia, COPD exacerbation, and +/-CHF. CXR on admission showed bilateral retrocardiac opacity and later showed RUL opacity. Sputum culture from [**6-26**] grew MRSA. She was started on Vanc/Levo/Flagyl for empiric coverage. She was initially given Lasix 100 mg IV for a concern for CHF from pulmonary edema seen on CXR but was later thought unlikely since her CVP was only 10. She was also started on steroids for COPD exacerbation. In the ICU, there was difficulty extubating secondary to her agitated MS, but was successfully extubated on [**2175-7-5**]. She was able to maintain mid-90's on room air. In terms of ARF, she presented with Cr of 2.3-2.8 and became oliguric and peaked at 3.5. Renal was consulted whose impression was oligurid renal failure->ATN from hypoperfusion +[**Last Name (un) **]. Her urine output picked up and now making adequate urine. Her Creatinine normalized to 2.8. In terms of 22 cm liver mass seen on the abdominal CT, liver team was consulted. She has a hx of liver hemangioma and this is likely the expansion of the hemangioma. The family and the team decided to not pursue with any surgical procedure. She had episodes of SVT to 140's with hypotension to SBP 80's on [**2175-6-29**] of what appears as AVNRT. She was started on Diltiazem and has been adequately rate controlled. In terms of hypotension, she had intermittent episodes of hypotension which appears to be positional, likely from the liver compressing on IVC?. This in addition to the systemic illness may have worsened her renal failure on admission. Or she may have had episodes of AVNRT with hypotension prior to admission to have caused the renal insult. Floor Course by problems: . 1)Respiratory failure: Patient likely had MRSA PNA +/- COPD exacerbation. She completed a 14 day course of Vanc which was dosed by level as she was in oliguric renal failure/ATN. Pt got Albuterol/fluticasone and a very short course of steroid taper for the possible COPD exacerbation. She was stable on room air from pulmonary stand point prior to discharge. . 2)Renal failure: Pt had ischemic ATN in the ICU from presumed hypoperfusion episode. She was followed by Renal. Later, she started to make adequate urine, and her creatinine eventually came down to 2.7 which is where it stabilized. Per her PCP, [**Name10 (NameIs) **] baseline PCP [**Last Name (NamePattern4) **] 2.0 in [**2175-3-28**]. Cr 2.7 is likely her new baseline per renal. She also developed hypernatremia which was corrected with IV D5W to correct the free water deficit. She also develop metabolic acidosis and was supplemented by sodium bicarb. She was continued on Calcitriol and Sevelamer. Her Epogen dose was increased to 5000 unit qMWF from 3000 unit. . 3)Altered MS: Pt was very agitated, confused, and at times disruptive pulling out her lines. Her mental status waxed and wane. Her delirium was thought likely from toxic metabolic etiology secondary to combination of hypothyroid, ICU delirium, steroid use, hypernatremia, and acute infection. She was initially kept NPO due to aspiration risk from mental status change. She got tubefeed in the ICU and PPN on the floor. She initially required frequent PRN Haldol and Zydis for agitation. However, on [**7-11**] her MS returned to baseline. She passed swallow evaluation and was able to tolerate po diet with normal consistency and thin liquids. . 4)Hypertension: She was continued on po metorprol and Hydralazine for BP control. When she was NPO, she got the IV version. . 5)Tacchycardia: Pt had episodes of supraventricular tachycardia, likely AVNRT, in the ICU which was controlled with Diltiazem then was switched to metoprolol. On the floor, she again had an episode of SVT for 1 hr which was finally broke with IV Diltiazem. Her EKG and rhythm strips were reviewed by the EP team who recommended medical management at this time with a beta-blocker. She will follow up with her PCP/Cardiologist Dr. [**Last Name (STitle) **] regarding this. If she continues to have AVNRT despite maximal medical treatment, elective ablation should be considered. . 6)Anemia: Pt has anemia of what appears as chronic illness/renal disease. She was intitially on Epogen 3000 unit qMWF, but was later switched to 4000 unit and then to 5000 unit qMWF by renal. She had a very slow decline in Hct and got a total of 4 units of PRBC during the hospitalization (2 units in the ICU, 2 units on the floor). Hct prior to discharge after the transfusion was stable at 28-29. She needs to have her Hct checked frequently. If she continues to have a decline in Hct despite increased Epogen dose, she would need an outpatient EGD + colonoscopy to rule out GI bleed. . 7)Liver mass: Pt with known history of giant liver hemangioma that was has followed as outpatient. The CT and MRI of abdomen again demonstrated giant mass that appears as hemangioma. AFP value was normal. Spoke with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and plan is to follow closely as outpatient. . 8)Hypothyroid: Her TSH was elevated, and her free T4 was low as well. Her synthroid dose was increased to 50 mcg qd. Medications on Admission: Norvasc 5, serevent, flovent, synthroid 0.88, meclizine, procrit, xanax 0.25 tid, darvocet, effexor, lipitor 20, cozaar 150, benicar 40, prednisone < 1 month ago, nebulizers Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK ([**Doctor First Name **],TU,TH). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours) as needed. 7. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Epoetin Alfa 10,000 unit/mL Solution Sig: 5000 (5000) unit Injection QMOWEFR (Monday -Wednesday-Friday). 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 15. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Hydralazine 25 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Primary: 1)MRSA Pneumonia 2)COPD exacerbation 3)Acute renal failure 4)Delirium 5)Metabolic acidosis Secondary: 1)Giant liver hemangioma 2)Asthma 3)Chronic renal insufficiency 4)Anemia 5)Gastritis 6)Depression 7)Hypertension Discharge Condition: Hemodynamically stable, able to take PO, mental status back to baseline. Discharge Instructions: Please take all of the medications as directed. Please seek medical attention if you develop fever, chills, chest pain, palpitation, shortness of breath, cough, confusion, nausea, vomiting, or any other concerning symptoms. Please follow up with Dr. [**Last Name (STitle) **] within 1-2 weeks. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] within 1-2 weeks. Completed by:[**2175-7-17**]

[ "276.0", "V09.0", "228.04", "V10.11", "493.90", "403.91", "V58.65", "428.0", "482.41", "518.81", "427.89", "244.9", "584.5", "293.0", "491.21" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9649, 9716

2436, 7888

294, 330

9985, 10059

1542, 2413

10403, 10504

8112, 9626

9737, 9964

7914, 8089

10083, 10380

234, 256

358, 1267

1289, 1451

1467, 1523

21,866

199,419

53327

Discharge summary

report

Admission Date: [**2191-5-2**] Discharge Date: [**2190-7-9**] Service: ADMISSION DIAGNOSIS: Pericardial effusion. HISTORY OF PRESENT ILLNESS: The patient is an 87 year-old female with a past medical history significant for metastatic breast cancer who presents with shortness of breath and significant dyspnea on exertion. On [**2190-7-7**], the patient had a Pleur-X catheter placed. After the procedure, the patient felt as though her shortness of breath had improved greatly. She has had persistent drainage from the Pleur-X catheter approximately 300 cc every day or every other day. The patient reports that over the past 4 days, she has had increased shortness of breath despite drainage. The patient denies cough, fever, chills, orthopnea, leg edema or chest pain. The patient's past medical history is consistent with metastatic breast cancer, hypertension, hypothyroidism, anemia. She is status post mastectomy of the left breast including radiation therapy and 4 cycles of chemotherapy. The patient has known metastatic disease to the lungs and the pleura with recurrent malignant pleural effusions there were treated with Pleur-X catheters as previously mentioned. The patient is blind in the right eye, due to herpes simplex keratitis over 50 years ago. She also has hypercholesterolemia. The patient lives alone. She has a visiting nurse come once a week. She is a previous smoker but quit over 50 years ago. She is a social drinker. FAMILY HISTORY: Non contributory. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: The patient's temperature is 98.2; her heart rate is 100; blood pressure 115/68; respiratory rate is between 28 and 36. 0xygen saturation is 96%. She is on room air at rest. The patient has a neck with some jugulovenous distention. Chest is symmetric with decreased breath sounds of the left base at the position where the Pleur-X catheter is placed. She has tachycardia. There are no gallops, no murmurs, no rubs. The abdomen is soft, nontender, nondistended. The lymphatics are normal. The extremities are without clubbing, cyanosis or edema. The patient has normal strength and tone in her muscles of both the upper and lower extremity. The patient is oriented to time, person and place. HOSPITAL COURSE: The patient was admitted on the [**2190-11-2**] with the plan to admit to telemetry bed, check an echocardiogram, an EKG and perform a CT and also start the patient on DVT prophylaxis. The concern was for a pericardial effusion, rule out an early tamponade versus pulmonary embolism. On hospital day number 2, the patient was on no antibiotics. She had no malignancy pleural effusion, an enlarged cardiac silhouette that was concerning certainly for pericardial effusion. She was hemodynamically stable. She was started on IV fluids. On the afternoon of hospital day number 2, the patient had a pericardial drain placed which put out 200 cc of bloody drainage. Her hematocrit had dropped from 33 prior to the pericardial tap to 24.6. She was hemodynamically stable; however, she received 2 units of packed red cells, a unit of FFP and a Foley catheter was placed. A repeat hematocrit after the initial 24 demonstrated the hematocrit was actually 33.6 and the blood products were canceled. The patient had a chest x-ray which looked okay. There appeared to be no bleeding into the chest. On hospital day number 3, the patient was doing well without complaints. She was hemodynamically stable. A CT scan of the chest with contrast was [**Doctor Last Name **] in the morning and the patient was preopped for the operating room of a left video assisted thoracoscopy with a left sided subxiphoid window. The patient was seen and examined by the thoracic surgery staff, Dr. [**First Name (STitle) **] [**Name (STitle) **]. The patient ended up undergoing a right thoracotomy and a pericardial window. The patient tolerated the surgery well and was without complaints. The patient initially stayed in the cardiac surgery intensive care unit after surgery. Her hematocrit was stable. She seemed to do well. Her chest tube had put out 140 cc. There was no leak and the patient was hemodynamically stable. On postoperative day number one, the pericardial drain that had previously been placed was removed. A follow-up chest x- ray was ordered and her Pleur-X catheter was drained by the interventional pulmonology team. The patient was followed in hospital by the hematology/oncology service. On postoperative day number 2, the patient's oxygen was weaned. A physical therapy consult was ordered. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain from the operating room was clamped with the intention of it being removed. On postoperative day number 3, her [**Doctor Last Name 406**] drain was removed. Again a follow-up chest x-ray was ordered. The patient did well and was without any complaints. On postoperative day number 4, the patient's Pleur-X catheter was again drained. The plan was to remove her [**Doctor Last Name 406**] drain, have the patient ambulate with physical therapist in order to determine if the patient would be stable to go home. The physical therapist saw the patient and were involved in her care. The recommendation was that she be discharged to home when she was ready per her medical doctors. On postoperative day number 5, the patient was discharged to home. DISCHARGE MEDICATIONS: Percocet 5/325 one to two tabs q. 4 to 6 hours, 30 were dispensed. Colace 100 mg p.o. b.i.d. Ipratropium bromide 0.02% one to two inhalations every 6 hours. Atorvastatin 5 mg p.o. daily. Hexa vitamin one cap p.o. daily. Cobalamin 100 mcg 0.5 tabs p.o. daily. Aspirin 81 mg p.o. once daily. DISCHARGE DIAGNOSES: 1. Malignant pericardial effusion. 2. Hypothyroidism. 3. Aortic insufficiency. 4. Iron deficiency anemia. 5. Metastatic breast cancer. 6. Hypothyroidism. 7. Hypertension. DISCHARGE STATUS: Stable. DISCHARGE INSTRUCTIONS: She was to call her surgeon and return to the emergency room if she experienced shortness of breath, increasing fatigue, pain, fever, chills or any significant change in her medical condition. She was to continue to have her Pleur-X catheter drained per her usual routine which was once every other day. She was to shower and keep her incision clean, dry and intact. The patient was to follow-up with Dr. [**Last Name (STitle) **] in approximately 1 to 2 weeks. She was given his phone number at [**Telephone/Fax (1) 170**]. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 286**] Dictated By:[**Last Name (NamePattern1) 18027**] MEDQUIST36 D: [**2191-5-22**] 10:12:04 T: [**2191-5-22**] 15:20:14 Job#: [**Job Number 109724**]

[ "244.9", "198.89", "427.31", "V10.3", "401.9", "280.9", "424.1", "V64.42", "197.2" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "37.21", "88.55", "37.12", "37.0", "34.91", "38.93" ]

icd9pcs

[ [ [] ] ]

1482, 1539

5730, 5937

5418, 5709

2276, 5394

5962, 6728

1562, 2258

104, 127

156, 1465

2,547

139,623

15236+56627

Discharge summary

report+addendum

Admission Date: [**2185-8-25**] Discharge Date: [**2185-9-13**] Date of Birth: [**2121-3-13**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 64-year-old woman with compression fracture of C2. She has a history of coronary artery disease, anterior wall MI in [**2181**], stenting in [**2181**]. She comes in with progressive myelopathy requiring surgery for odontoidectomy and cervical fusion. PAST MEDICAL HISTORY: 1. Anxiety. 2. Diabetes mellitus. 3. Renal insufficiency. 4. Hypertension. PHYSICAL EXAMINATION: Examination revealed the following: Blood pressure 110/74, pulse 77, saturation 97% on room air. She was in a hard collar at the time of admission. LUNGS: Lungs were clear to auscultation. CARDIAC: Regular rate and rhythm. She was alert and oriented times three. Upper and lower motor strength was [**3-11**] throughout. She had positive peripheral pulses. On [**2185-8-26**], she underwent occiput to C3 fusion with iliac bone graft and transoral odontoidectomy without intraoperative complications. Postoperatively, she was monitored in the Surgical Intensive Care Unit. She was intubated and sedated on a propofol drip. She was hemodynamically stable. With the propofol drip discontinued, she was opening her eyes and following commands. Dressings were clean, dry and intact. She was on the Solu-Medrol protocol twenty-four hour postoperatively. On [**2185-8-28**], the patient was awake and alert. She was following commands. She was moving all four extremities. EOMI: Full. The patient was extubated on [**2185-8-30**]. She had a PICC line placed and she was started on TPN for nutrition secondary to inability to have a feeding tube in place due to the surgery. On [**2185-9-1**], she spiked a temperature to 103. She had blood cultures sent, which came back positive for Staphylococcus aureus, most likely from the PICC line. The PICC line was discontinued and a new PICC line was placed on the opposite site. The patient was on a two-week course of Vancomycin for Staphylococcus aureus. She also had infiltrate on chest x-ray most likely due to aspiration. She was seen by the Speech and Swallow Service. She failed her swallow examination. Therefore, she would require PEG placement, which was done on [**2185-9-6**] without complication. Neurologically, she continues to improved out of bed to the chair and ambulating with physical therapy, but requiring rehabilitation prior to discharge to home. Staples have been removed. The incision is clean, dry, and intact. She remains in a hard collar until follow up with Dr. [**Last Name (STitle) 1327**] in two to three weeks time. Neurologically, mental status, she is awake, alert, and oriented times three although she does sometimes seem confused. She is still requiring pain medication intermittently. Other vital signs have been stable throughout the hospital stay. Medications at the time of discharge were the following: MEDICATIONS ON DISCHARGE: 1. Nystatin oral suspension 5 cc PO q.i.d.p.r.n. 2. Insulin 70/30, 22 units q.a.m.; 12 units q.p.m. 3. Metoprolol 12.5 mg PO b.i.d.; hold for systolic blood pressure less than 120, heart rate less than 60. 4. Codeine 15 mg IV subcutaneously q.4h.p.r.n. pain. 5. Vancomycin 100 mg IV q.24h. pain. 6. Insulin sliding scale. 7. Tylenol 650 PO q.4h.p.r.n. 8. Nitroglycerine 0.3 mg sublingually p.r.n. She has not required. CONDITION ON DISCHARGE: Stable at the time of discharge. FOLLOW-UP CARE: The patient will follow up with Dr. [**Last Name (STitle) 1327**] in two weeks' time with repeat x-rays at that time. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2185-9-12**] 10:40 T: [**2185-9-12**] 10:50 JOB#: [**Job Number 44342**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 8111**] Admission Date: [**2185-8-25**] Discharge Date: [**2185-9-13**] Date of Birth: [**2121-3-13**] Sex: F Service: ADDENDUM: The patient's discharge was delayed until today, [**2185-9-16**] secondary to the lack of a rehabilitation bed. CONDITION ON DISCHARGE: Stable. Vital signs were stable. She was afebrile. Dressing was clean, dry, and intact. Neurologically, the patient continues to improve with improvement in the upper and lower extremity strength. The patient will follow up with Dr. [**Last Name (STitle) **] in two to three weeks' time with follow up x-rays at that time. DR.[**Last Name (STitle) 562**],[**First Name3 (LF) 863**] 14-127 Dictated By:[**Last Name (NamePattern1) 366**] MEDQUIST36 D: [**2185-9-16**] 09:43 T: [**2185-9-16**] 10:13 JOB#: [**Job Number 8112**]

[ "721.1", "285.29", "733.82", "041.11", "996.62", "507.0", "907.2", "728.89", "403.91" ]

icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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458, 538

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48756

Discharge summary

report

Admission Date: [**2156-3-16**] Discharge Date: [**2156-3-23**] Date of Birth: [**2077-10-29**] Sex: F Service: MEDICINE Allergies: Quinine / Captopril / Iodine; Iodine Containing / Reopro / Amoxicillin / Amlodipine Attending:[**First Name3 (LF) 317**] Chief Complaint: Increasing shortness of breath/ Positive stress MIBI Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Pt is a 78 yo female, h/o CAD s/p multiple caths (stents x 5), most recently in [**8-15**] (mid-LAD drug eluding stent) who presents to the ED after having increasing SOB. Pt says that since [**Month (only) **], she has noticed a slow decline in her functional status. For the past two days, she has increasing dyspnea on exertion than in the past, not even able to walk 50 feet before stopping; prior to [**Month (only) **], she could walk a few blocks. She notes that she has increased her lasix dose recently without effect. This shortness of breath only occurs during walking and is relieved by rest. Of note, pt has not had chest pain, or jaw pain at this time. Additionally, in the past prior to stenting, she has never had chest pain, only jaw pain when she presented in [**8-15**]. No recent swelling in the legs. +PND. +stable 5 pillow orthopnea. +occasional palpitations. +12 pound weight gain past month but this is attributed to recently starting Actos and having to increase food consumption to regulate blood sugars. Pt went to see PCP and was sent to [**Hospital1 18**] ED. EKG was unchanged from previous, and two sets of cardiac enzymes were flat. Pt had a stress MIBI test done today. Stress part showed no anginal with no ischemic ECG changes. Thalium nuclear showed a moderate reversible defect in the anterior wall, severe reversible defect in the apex, all similar to [**2154-8-13**] MIBI pre stenting of the mid-LAD. Pt's last Cardiac catheterization from [**8-15**] showed EF 60%, mid LAD 70% stenosis, subtotally occluded diagonal. LCx patent with 60-70% of the OM1 and OM2. The RCA had mild lumenal irregularities. There was mildly elevated left sided filling pressures (LVEDP=19 mmHg). Mid LAD was stented. Past Medical History: 1. Coronary artery disease as above 2. History of cardiac stent placement as above. 3. Asthma-h/o intubation 4. Congestive heart failure EF reduced 51->38 at last MIBI [**8-15**]. MIBI from [**2156-3-17**] could not calculate EF. 5. Hypertension. 6. h/o deep venous thrombosis. 7. Panic attacks. 8. Diabetes type 2. 9. S/p cholecystectomy. 10. Ventral hernia repair. 11. Anaphylactic reactions to contrast dye used in cardiac catheterizations Social History: Pt is married, lives with husband. She is a retired floral arranger. Quit smoking at age 47. Smoked <1 ppd x 10 years. No EtOH. No drugs. Family History: B: Heart transplant Uncles (paternal): MIs in 70s M: died of ca F: died of MI at 48 No HTN. No DM. Physical Exam: T: 98.6; BP: 135/65; HR: 67; RR: 18; O2: 97% RA Gen: Older female sitting on bed able to speak in full sentences in NAD HEENT: EOMI; sclera anicteric; OP no exudate. Neck: No JVD. CV: RRR S1S2. No murmurs. Lungs: CTA b/l. Good air entry throughout though slightly decreased at bases b/l. No crackles/wheezes/rales. Abd: Soft. +Large ventral hernia protruding from midline and small clotted blood. Non-tender. Non-distended. Ext: DP 2+. No edema. Neuro: CN II-XII grossly intact. MS preserved. Pertinent Results: Labs on admission: [**2156-3-16**] 03:30PM BLOOD WBC-7.5 RBC-4.35 Hgb-12.3 Hct-37.9 MCV-87 MCH-28.3 MCHC-32.6 RDW-15.4 Plt Ct-234 [**2156-3-16**] 03:30PM BLOOD Neuts-71.4* Lymphs-19.3 Monos-6.4 Eos-2.5 Baso-0.4 [**2156-3-16**] 03:30PM BLOOD Glucose-119* UreaN-35* Creat-1.0 Na-145 K-4.7 Cl-107 HCO3-30* AnGap-13 [**2156-3-18**] 06:55AM BLOOD Calcium-10.2 Phos-3.4 Mg-1.9 _____________________ Cardiac Labs: [**2156-3-19**] 05:46AM BLOOD Triglyc-52 HDL-58 CHOL/HD-2.2 LDLcalc-59 [**2156-3-16**] 03:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2156-3-16**] 09:30PM BLOOD CK-MB-NotDone [**2156-3-16**] 09:48PM BLOOD cTropnT-<0.01 [**2156-3-16**] 03:30PM BLOOD CK(CPK)-46 [**2156-3-16**] 09:30PM BLOOD CK(CPK)-25* _____________________ Labs on discharge: [**2156-3-23**] 06:05AM BLOOD WBC-8.5 RBC-3.63* Hgb-10.4* Hct-32.0* MCV-88 MCH-28.6 MCHC-32.5 RDW-15.5 Plt Ct-218 [**2156-3-23**] 06:05AM BLOOD Glucose-108* UreaN-19 Creat-0.8 Na-144 K-4.2 Cl-107 HCO3-33* AnGap-8 [**2156-3-23**] 06:05AM BLOOD Calcium-9.9 Phos-3.0 Mg-1.9 _____________________ Radiology [**2156-3-16**]- CXR PA/Lat-Stable radiographic appearance of the chest. Cardiomegaly without definite evidence of congestive heart failure. - - - - - - - - - - [**2156-3-17**] Persantine MIBI-There is a severe decrease in counts within the apex on the stress images. Counts in this area are normal on the rest images. There is a moderate decrease in counts in the anterior wall on the stress images. This region also normalizes on the resting images. There is suboptimal imaging of the septum. Gated images reveal normal left ventricular wall motion, but there are not enough counts to accurately calculated an ejection fraction. Review of the patient's prior examination dated [**2154-10-11**] shows severe ischemia in a similar distribution. The patient underwent cardiac catheterization on [**2154-9-11**] and had a stent placed in the LAD. No interval studies have been performed at our institution. [**Doctor First Name **] protocol stress- 4 min; RPP [**Numeric Identifier 102484**]. Max HR was 64%. There was no chest, arm, neck or back pain. There were no ECG changes. The rhythm was sinus without ectopy. The blood pressure and heart rate responses were appropriate. The Persantine was reversed with 125mg Aminophylline IV. IMPRESSSION: No angina with no ischemic ECG changes. Nuclear report will be sent separately. - - - - - - - - - - [**2156-3-18**]- Cardiac catheterization- 1. Selective coronary angiography of this right dominant system revealed branch coronary disease. The LMCA was widely patent. The LAD was patent, including the previously placed stents. The first diagonal branch was occluded as in her previous angiograpms. The RCA was a large caliber, dominant vessel without critical stenoses. 2. Left venitrculography revealed a calculated ejection fraction of 55%. 3. Resting hemodynamics were widely varied throught out the case. A Swan [**Last Name (un) 26645**] catheter was placed when the patient became hypoxic. Initially, the mean PCPW was 24mmHg and the PA sat was 48%. After treatment with lasix and nitroglycerine, the PA sat improved to 85%. 4. After completion of the LV gram, the patient complained of headache and shortness of breath. He SBP subsequently dropped from the 120s to the 80s. She was given 0.3mgSQ epinepherine which improved her blood pressure. She continued to complain of shortness of breath. She was severely agitated throughout the case. Because of the hypotension and shortness of breath, a PA catheter was placed. The patient was given a nitro gtt and lasix IV. A 100% NRB was transiently placed for O2 sats in the 70s and 80s. After approximately 20 minutes, her breathing improved and by the end of the case, she had a good O2 sat on 3L NC. Her symptoms were believed to be secondary to allergic reaction to contrast dye despite pre-treatment with 80mg IV solumedrol, 25mg Benadryl, and 20mg Pepcid. During the case, she was given an additional 125mg IV Solumderol. - - - - - - - - - - [**2156-3-19**]- Right femoral U/S-Flow in the common femoral artery and vein is identified. No pseudoaneurysm or hematoma is identified. _______________________ EKG-EKG: sinus at 58. LAD. LAFB. Poor RWP. no st changes. unchanged from previous. Brief Hospital Course: 78 yo female, h/o CAD s/p multiple caths (stents x 4), most recently in [**8-15**] (mid-LAD drug eluding stent) who presents to the ED after having increasing SOB. Stress MIBI showed reversible defects in the anterior wall, reversible defect in the apex, all similar to [**2154-8-13**] MIBI pre stenting of the mid-LAD. 1. CAD Pt had increasing dyspnea on exertion. EKG was unchanged from previous here and cardiac enzymes were negative. However, what was of great concern was the MIBI on [**2156-3-17**] showing moderate-severe reversible defects in the anterior wall and a reversible defect in the apex, which were all similar to the pre-cath MIBI in [**8-15**] when pt had her mid-LAD stented. Therefore, there was a great concern for an occlusion of the stent with a subacute occlusion in the two days prior to admission. Pt was started on heparin gtt prior to intervention. Pt had a cardiac catheterization on [**2156-3-18**]. It showed that: LMCA was widely patent, LAD patent (including previously placed stents), D1 was occluded as in previous angiograms, and the RCA was open. EF was calculated at 55%. No intervention was performed. The pt however, had a severe anaphylactic reaction (see below). We continued outpatient regimen of [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin, beta blocker and long acting nitrate. 2. Anaphylactic reaction- Pt with dye allergy--> angioedema in catheterizations in the past. For this cardiac catheterization, pt was premedicated again with prednisone (40 [**Hospital1 **] initially), famotidine, and Benadryl. During the catheterization, though, pt again developed acute shortness of breath. She was given epinephrine IV but became hypertensive to 200 then dropped her oxygen saturations requiring NTG gtt and Lasix. Gradually, her hypoxemia and shortness of breath resolved and she was transferred to CCU for overnight monitoring. In the CCU she received Solu-Medrol IV and Lasix. Pt was hypoxemic likely from a mixed reaction from the contrast and pulmonary edema after hypertension was induced by the episode and by epinephrine. Pt was given IV Lasix on the floor as well, though she was satting well and was euvolemic on discharge. Mrs. [**Known lastname 7820**] was complaining of swollen upper lip, palate irritation, whole mouth pain, and painful swallowing in the days following the reaction. The team called Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (an allergic who pt has seen in the past and has consulted on her anaphylactic reaction). He emailed the team previous consult notes which were re-put in to OMR. Allergy service was curbsided and pt was given Benadryl and famotidine, for symptomatic relief as it could take a long time for symptoms to go away. Pt was started on prednisone (40 mg po) here with the goal to taper as an outpt. She was never in respiratory failure and airway was never compromised once pt came back to the floor. She satted well and was able to breath without any problem. 3. CHF As above. Pt slightly fluid overloaded after her reaction and got diuresed in the CCU and lasix IV x 1 on the floor in addition to pt's normal dose of Lasix. Pt was euvolemic on discharge. 4. HTN- as above. 5. DM- Glipizide, Actos initially held for catheterization and then restarted. Pt was on QID fingersticks with a RISS. Blood sugars were in the 200s-300s secondary to the prednisone. Pt was sent home with regular insulin (modified scale starting at 200) for breakfast, lunch, and dinner. Husband and wife have prior knowledge of this as she has been on insulin in the past with prednisone. 6. [**Name (NI) 8134**] Pt had Ipratropium MDI prn. 7. [**Name (NI) 51814**] Pt was ambulating and on a PPI. 8. Access- PIV 9. Code status- Code status was Full Code. Medications on Admission: [**Name (NI) **] 325 mg qday [**Name (NI) **] 75 mg qday Lipitor 10 mg qday Ativan 0.5-1 mg prn Isosorbide mononitrate 90 qday Metoprolol 75 mg [**Hospital1 **] Lisinopril 40 mg GLipizide 5 mg [**Hospital1 **] Pioglitazone 30 qday Protonix 40 qday Lasix 40 qam Ipratropium inhalers. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for allergy symptoms. Disp:*30 Capsule(s)* Refills:*0* 9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO per schedule below: 2/9/05-30 mg-6 pills 2/10/05-20mg-4 pills 2/11/05-15mg-3 pills 2/12/05-10mg-2 pills 2/13/05-10mg-2 pills 2/14/05-5 mg-1 pill [**2156-3-30**]- STOP. Disp:*20 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 12. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 15. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 16. Insulin Regular Human 300 unit/3 mL Syringe Sig: per scale Subcutaneous per scale. Disp:*qs qs* Refills:*0* 17. Regular Insulin Sliding Scale Check Blood sugar breakfast, lunch, and dinner time Administer insulin if: 201-250 2 units 251-300 4 units 301-350 6 units 351-400 8 units Call your PCP Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: CAD CHF Anaphylactic reaction Secondary: Asthma HTN Anxiety T2DM Discharge Condition: Stable. Pt is able to swallow without problems and is breathing well. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Return to the emergency room or call your primary care physician/cardiologist if you have increasing shortness of breath, chest pain, palpitations, or any other symptom that bothers you. If you feel like your throat is closing up, and you cannot breathe, or cannot swallow please go to the ED. Followup Instructions: Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 133**] for a follow up appointment within one week of discharge from the hospital. Please also call Dr.[**Name (NI) 9920**] office for an appointment within one week of discharge. -Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 102485**] for an appointment in the next week. Provider: [**Name10 (NameIs) **] LAB TESTING Where: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) CARDIOLOGY Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2156-4-7**] 1:00

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icd9cm

[ [ [] ] ]

[ "88.56", "37.23", "88.53", "89.64" ]

icd9pcs

[ [ [] ] ]

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30551

Discharge summary

report

Admission Date: [**2173-6-17**] Discharge Date: [**2173-7-1**] Service: SURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Iodine / Shellfish Derived / Soy / Chocolate Flavor / Wheat Flour / Milk / Tetanus / Midazolam Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: [**2173-6-19**] percutaneous tracheostomy, IVC filter [**2173-6-22**] T1-T7 spinal fusion [**2173-6-24**] PEG History of Present Illness: [**Age over 90 **]F found at bottom of stairs 13h s/p fall c/o no LE movement, T6 sensory loss, loss of rectal tone c/w paraplegia, b/l rib fx, sternal fx, and IPH. GCS 14 on arrival, cooperative, moving UEs on command. Agitation then somnolence with hypotension to 50 in ED -> 3L IVF, neo started. Sats stable on NRB. Past Medical History: HTN, R facial paralysis Social History: works in family business, no EtOH, no tobacco Family History: NC Physical Exam: discharge exam: 98.9 88 117/41 24 98% CPAP 50% FiO2 Neuro: intermittently responsive, NAD CV: RRR Pulm: coarse breath sounds bilaterally GI: soft, nondistended, PEG incision c/d/i Ext: no movement of LE, 2+ pulses, bilat LE edema Pertinent Results: Admission Labs: [**2173-6-17**] 02:50PM BLOOD WBC-14.6* RBC-3.84* Hgb-11.7* Hct-36.5 MCV-95 MCH-30.6 MCHC-32.2 RDW-12.5 Plt Ct-183 [**2173-6-17**] 02:50PM BLOOD PT-10.6 PTT-27.5 INR(PT)-1.0 [**2173-6-17**] 07:42PM BLOOD Glucose-166* UreaN-23* Creat-0.8 Na-143 K-4.6 Cl-109* HCO3-26 AnGap-13 [**2173-6-17**] 02:50PM BLOOD CK(CPK)-2540* Discharge labs: [**2173-6-29**] 01:46AM BLOOD WBC-14.9* RBC-3.26* Hgb-10.0* Hct-32.0* MCV-98 MCH-30.7 MCHC-31.3 RDW-18.1* Plt Ct-280 [**2173-6-29**] 01:46AM BLOOD Glucose-122* UreaN-22* Creat-0.5 Na-144 K-4.1 Cl-104 HCO3-37* AnGap-7* [**2173-6-29**] 01:46AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.3 Imaging: [**6-17**] CT Torso: 1. Multiple fractures as described above, the worst of which is a T4 burst fracture with retropulsion of the fracture fragments into the spinal canal causing cord compression. 2. Hematoma in the mediastinum tracking from the thoracic inlet down to approximately the T6 vertebral level. 3. Ill-defined nodular opacities especially in the right lower lung base concerning for aspiration. Bilateral simple measuring pleural effusions, small on the right, trace on the left. 4. Incidentally noted thyroid goiter. 5. Multiple cysts in bilateral kidneys as well as an additional sub-centimeter complex hypodense lesion in the left kidney. If clinically indicated this can be assessed when the patient is more stable with ultrasound. [**6-17**] CT Head: Focus of hemorrhage in the superior aspect of the right frontal lobe, possibly intraparenchymal or subarachnoid in location. Small amount of intraventricular hemorrhage in the bilateral occipital horns. [**6-19**] MRI Spine: Extensive fractures of the cervical and thoracic spine. There is a burst fracture at T4, which causes cord compression and myelomalacia of the cord. T1 hyperintense anterior epidural lesion at T11-T12 with diagnostic possibilities as discussed above. No definite fracture in the lumbar spine is noted. Bilateral pleural effusions, correlate with CT of the chest. There is a right thyroid nodule which could represent goiter, recommend correlation with ultrasound. Brief Hospital Course: Ms. [**Known lastname 16968**] was tranferred to the ICU for close hemodynamic monitoring. She was kept in a c-collar due to her c-spine injuries. She was mentating well and responsive. She was initially breathing well on room air. She was kept NPO and placed on IV fluids. Her urine output was monitored with a foley. She did not have any sensation or movements in her lower extremities. Her ICU course by systems: Neuro: she was kept on spine logroll precautions as well as CTLSO brace. She had a c-collar in place. She went to the OR for fixation of her spine on [**6-22**]. Afterwards, she was taken off logroll precautions, although she continued to wear her brace. She was alert and responsive. Her pain was controlled with dilaudid but narcotics were minimzed during her hospital course. CV: She was placed on pressors initially in the ICU. Her pressors were weaned. She had a brief period of atrial fibrillation early in her ICU course but this resolved. After her orthopedic surgery on [**6-24**] she again went into atrial fibrillation; she was given 2u pRBC for a Hct of 20 and converted to sinus rhythm with a diltiazem drip. The dilt was weaned and she remained in sinus. Pulm: She was trached and her vent was weaned. She was tolerating CPAP. She had difficulty weaning to trach mask secondary to tachypnea and tachycardia. GI: She was kept NPO. An NGT was attempted on [**6-23**] however due to copious secretions in the back of the throat this was not possible. She was taken to the OR for a PEG placement on [**6-24**]. Tube feeds were started [**6-25**] and advanced to goal. GU: Her UOP was monitored. ID: Her WBC was elevated on [**6-30**] and an infectious workup was done, including blood culture, urine culture, and cdiff. She had a UTI and was put on Cipro, for a planned 3 day course. She was also c.diff + and was treated with flagyl and PO vancomycin. Prophy: She had an IVC filter and SQH was given. Medications on Admission: atenolol, losartan, lacrilube eye gtt, MVI Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Albuterol Inhaler [**11-30**] PUFF IH Q4H 3. Artificial Tear Ointment 1 Appl RIGHT EYE PRN dryness 4. Bisacodyl 10 mg PR DAILY:PRN constipation 5. Digoxin 0.125 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 8. Heparin 5000 UNIT SC BID 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q3H:PRN breakthrough pain 11. Insulin SC Sliding Scale Fingerstick Q6H Insulin SC Sliding Scale using REG Insulin 12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS glaucoma 13. Ondansetron 4 mg IV Q8H:PRN nausea 14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg/5 mL 5 mL by mouth every 4 hours Disp #*200 Milliliter Refills:*0 15. Senna 1 TAB PO DAILY standing 16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 18. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 3 Days 19. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Duration: 2 Weeks Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: spina cord injury, T4 cord transection, multiple spinal fractures, traumatic brain injury, bilateral rib fractures, sternal fracture, mediastinal hematoma Discharge Condition: Mental status: intermittently interactive Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the ACS service for your injuries. Diet: Tube feeds through the PEG tube. Activity: Bedrest, assistance to get out of bed to chair. You should continue to wear your [**Location (un) 2848**] J collar when out of bed. Pain control: tylenol, narcotics as needed for pain Medications: You should resume home medications unless specifically told to stop. You may take tylenol or oxycodone for pain. Followup Instructions: Follow-up with Orthopedic Spine surgery 4 weeks from your operation date. Call to make the appointment: ([**Telephone/Fax (1) 8938**] w/ Dr. [**Last Name (STitle) 1007**] Follow-up with ACS 1-2 weeks after your discharge. Call to make an appointment: [**Telephone/Fax (1) 600**] Completed by:[**2173-7-1**]

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Discharge summary

report

Admission Date: [**2160-10-9**] Discharge Date: [**2161-1-1**] Date of Birth: [**2105-5-5**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7591**] Chief Complaint: shortness of breath, [**Last Name (un) **] Major Surgical or Invasive Procedure: - Interventional Pulmonary thoracentsis and chest tube placement & removal - Intubation / extubation - Laryngoscopy History of Present Illness: HPI: Ms. [**Known lastname **] is a 55yo F with Hx of Lymphocyte Depleted Hodgkins Lymphoma s/p 6 cycles of ABVD in [**2149**]-[**2150**] and recent admission [**Date range (1) 102512**] for fatigue and fevers diagnosed with EBV who presented today to clinic for scheduled infusion of IVIg and was noted to have shortness of breath. The patient states that she has had difficulty breathing for the past few months but her dyspnea on exertion has increased. She notes an intermittant cough for the past 2 weeks with occasional sputum production which is unchanged. She denies any fever, chills, sick contacts, or recent travel. Labs were drawn in clinic which revealed [**Last Name (un) **] (Cr from baseline of around 1.2 to 1.8), elevated LDH, and hyperbilirubinemia. IVIg was held and the decsion was made to admit the patient for further evaluation. Also, pt endorsed worsening SOB with exertion. She does not use O2 at baseline, but at rehab started using 2L yesterday. In clinic, initial vitals BP 114/71, HR 114, Weight 250.5, BMI 46.6, T 98.1, RR 18, O2 sat 93-94%, improved to 96% on 2L. . Last admission, pt had an extensive workup for her systemic complaints as pt endorsed that she felt similar to her initial Dx with Hogkins disease. Including EBUS with transbronchial needle aspiration, right cervical lymph node biopsy, BMBx, renal Bx, and VATS with lung biopsy, limited thoracotomy and mediastinal lymph node biopsy. Of note, she was initially admitted to the MICU for tachycardia, hypotension, and fever in the PACU status post rigid bronchoscopy for mediastinal LN biopsy She had previously been evaluated at [**Hospital1 2177**] for these complaints prior to transferring her care to [**Hospital1 18**]. Her course last admission was also complicated by [**Last Name (un) **] and anasarca, abnormal LFTs, and pancytopenia. Ultimately, patient was found to have hypogammaglobulinemia and prolonged EBV viremia, possibly resulting in her abnormal LFTs, nephrotic syndrome, and macrophage activation syndrome. . ROS: (+) fatigue and anorexia (-) per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, chest pain, nausea, vomiting, diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: MEDICAL & SURGICAL HISTORY (adapted from OMR): 1. Lymphocyte Depleted Hodgkins Lymphoma s/p 6 cycles of ABVD in [**2148**] (treated at NWH) 2. asthma 3. pulmonary fibrosis [**2-28**] bleomycin 4. chronic history of mild anemia - sickle cell trait +/- thalassemia per oncology records 5. depression 6. EBV viremia in [**7-/2160**] 7. hypogammaglobinuliemia recieving IVIg every 4 weeks 8. macrophage activation syndrome 9. nephrotic syndrome from likely secondary FSGS Recent OR procedures: [**2160-8-6**]: Endobronchial ultrasound with ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) by Thoracic Surgery [**2160-8-8**]: Right cervical lymph node biopsy [**2160-8-25**]: Right video-assisted thoracoscopic (VATS) lung biopsy, limited thoracotomy and mediastinal lymph node biopsy by Thoracic Surgery . Social History: pack per day for 30 years; quit. She does not drink alcohol. She has two daughters and a son. She is single and lived with her son before going to [**Name (NI) **] [**Name (NI) 701**] Rehab. She formally worked as a school bus dispatcher. Family History: Mother died from ovarian cancer. Father is living. She had nine siblings, three of which have passed away, one from hepatitis, one for murder and one from unclear causes. She has two other siblings with diabetes and a son with sarcoid. She knows of no other cancers or blood diseases within the family. Physical Exam: ADMISSION PHYSICAL EXAM: VS - T 99.3 bp 100/68 HR 116 SaO2 94 2L RR 24 Wt 247.2lbs GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, EOMI, sclerae anicteric, dry mucous membranes, green tint to tongue, NECK - supple, LUNGS - normal effort with dry crackles bilateral bases > apices, no wheezes HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, obese, soft/NT/ND, no rebound/guarding EXTREMITIES - significant edema but normal perfusion bilaterally SKIN - warm NEURO - awake, A&Ox3, CNs II-XII grossly intact, no focal deficits DISCHARGE PHYSICAL EXAM: VS: Tc 98 AF, BP 151/76 (130-150/70-80s) P 87 (70-100s) Sat 92% RA Gen: Pt alert, interactive, pleasant older woman, NAD. Cardiac: RRR, S1 S2, no murmurs appreciated, no r/g Pulmonary: Good air movement, CTAB, no wheezes or rales. Abd: Soft, NT/ND, no masses or HSM Extremities: No c/c/e. LE edema largely resolved. Neuro: A+O x 3, moving all extremities independently and with purpose, sensation grossly intact. Pertinent Results: Admission labs: [**2160-10-9**] 07:30PM PT-12.5 PTT-47.9* INR(PT)-1.2* [**2160-10-9**] 10:10AM GLUCOSE-121* UREA N-37* CREAT-1.8* SODIUM-134 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-12 [**2160-10-9**] 10:10AM ALT(SGPT)-62* AST(SGOT)-214* LD(LDH)-853* ALK PHOS-534* TOT BILI-4.0* DIR BILI-3.2* INDIR BIL-0.8 [**2160-10-9**] 10:10AM ALBUMIN-1.3* CALCIUM-7.1* PHOSPHATE-3.2 MAGNESIUM-2.1 URIC ACID-9.3* [**2160-10-9**] 10:10AM FERRITIN-8957* [**2160-10-9**] 10:10AM TRIGLYCER-366* [**2160-10-9**] 10:10AM IgG-1152 [**2160-10-9**] 10:10AM WBC-10.2# RBC-3.72* HGB-10.8* HCT-33.5* MCV-90# MCH-29.1 MCHC-32.3 RDW-19.9* [**2160-10-9**] 10:10AM NEUTS-66 BANDS-3 LYMPHS-26 MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [**2160-10-9**] 10:10AM PLT SMR-LOW PLT COUNT-108*# [**2160-10-9**] 10:10AM SED RATE-16 [**2160-10-8**] 11:21AM GLUCOSE-89 [**2160-10-8**] 11:21AM UREA N-36* CREAT-1.8* SODIUM-139 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17 [**2160-10-8**] 11:21AM ALBUMIN-1.6* CALCIUM-7.4* PHOSPHATE-3.8 [**2160-10-8**] 11:21AM %HbA1c-4.8 eAG-91 [**2160-10-8**] 11:21AM PTH-55 [**2160-10-8**] 11:21AM 25OH VitD-LESS THAN [**2160-10-8**] 11:21AM URINE HOURS-RANDOM CREAT-28 TOT PROT-55 PROT/CREA-2.0* albumin-25.0 alb/CREA-892.9* Discharge labs [**2161-1-1**] 06:06AM BLOOD WBC-3.0* RBC-2.63* Hgb-7.8* Hct-24.8* MCV-94 MCH-29.6 MCHC-31.4 RDW-20.5* Plt Ct-122* [**2161-1-1**] 06:06AM BLOOD Neuts-63 Bands-1 Lymphs-19 Monos-11 Eos-0 Baso-4* Atyps-1* Metas-1* Myelos-0 NRBC-6* [**2160-12-30**] 05:45AM BLOOD PT-10.1 PTT-57.0* INR(PT)-0.9 [**2160-12-5**] 05:59AM BLOOD Fibrino-378 [**2161-1-1**] 06:06AM BLOOD Glucose-97 UreaN-13 Creat-0.4 Na-143 K-3.1* Cl-111* HCO3-23 AnGap-12 [**2161-1-1**] 06:06AM BLOOD ALT-69* AST-87* LD(LDH)-435* AlkPhos-409* TotBili-1.5 [**2161-1-1**] 06:06AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.5* UricAcd-3.6 [**2160-12-28**] 06:08AM BLOOD IgG-586* IgA-12* IgM-5* Studies: [**12-22**] RUQ US: 1. Stable mild wall thickening in a non-distended gallbladder is a non-specific finding. 2. Small amount of gallbladder sludge. No cholelithiasis or evidence of cholecystitis. 3. Small right pleural effusion. [**2160-12-20**] CT CHEST: 1. Decreased right pleural effusion. 2. 15 mm right lower lobe nodular opacity which is new or increased since [**2160-7-27**] in an area previously obscured by right pleural effusion; given size, follow-up options include repeat chest CT within three months or PET-CT. Given adjacent right hilar opacity, this could represent infection, in which case follow-up after treatment is recommended. 3. Stable underlying diffuse interstitial pulmonary changes. [**2160-12-2**] CT CHEST IMPRESSION: As compared to the previous examination from [**2160-11-10**], there is evidence of diffuse fibrotic lung parenchymal pattern with bronchiectasis and spectral distortion as main morphological components. In addition, mild fluid overload could highlight the appearance of the interstitial structures. The right pleural effusion is unchanged. Minimal newly appeared left pleural effusion. Known mediastinal lymphadenopathy, unchanged coronary calcifications and slight valvular calcifications. The appearance of the upper abdominal organs is constant. [**2160-11-27**] CHEST X-RAY: FINDINGS: Patient's clinical condition required examination in sitting position using AP frontal and left lateral views. Comparison is made with the next preceding AP single view portable chest examination of [**2160-11-17**]. Comparison of frontal views does not demonstrate any significant interval change. Position of the previously described right supraclavicular induced double-lumen catheter is unchanged and terminates overlying the atrial structures. Moderate degree of cardiomegaly appears unchanged. Bilateral basal linear atelectases are noted and the previously described pleural effusion is still present, blunting the right-sided lateral pleural sinus and extending along the right lateral chest wall similar as before. There is no evidence of new pulmonary parenchymal infiltrates as can be identified on this portable chest examination. There are two metallic structures overlying the right lung field on the frontal view; they are believed to be external. IMPRESSION: Stable chest findings. [**2160-11-17**] CHEST X-RAY: Compared to radiograph of [**2160-11-14**], no significant interval change. Persistent interstitial opacities and pulmonary edema. Moderate right pleural effusion. Low lung volumes. No PTX. [**2160-11-15**] KUB Nonspecific bowel gas pattern with no evidence of obstruction or free intraperitoneal air. [**2160-11-10**] CT Chest, Abdomen & Pelvis IMPRESSION: There is no jejunal mass identified. There is however small bowel and mesenteric lymphadenopathy as described above. These nodes are predominantly fatty and are likely not ideal targets for biopsy. There is a smaller soft tissue mass in the small bowel mesentery adherent to a bowel loop, this would likely be of higher yield to biopsy. There is also soft tissue within the region of the base of the cecum suggesting possible lymphomatous involvement. Other findings as follows: 1. Diffuse pulmonary fibrosis, reflecting chronic interstitial lung disease with an NSIP-type pattern. 2. There are discrete nodules in the left lower lobe which may represent neoplastic involvement. 3. Multiple splenic hypodensities suspicious for lymphomatous involvement. These are more prominent today compared to the previous exam. 4. Hypoperfused kidneys suggesting component of chronic renal failure. [**2160-10-30**] CT Abdomen & Pelvis IMPRESSION: 1. Interval worsening of the right-sided pleural effusion (2;8) compared to the prior CT from [**2160-10-13**]. 2. Two new mesenteric soft tissue masses adjacent to the jejunum as described in detail above. This could be secondary to lymphoma invading the fat in an infiltrative pattern; since there does seem to be some fat intermingled, extramedullary hematopoiesis could considered in the appropriate setting although the location is somewhat unusual and sequelae of an inflammatory process could also be considered. PET-CT may be of some value if clinically indicated. 3. Newly apparent thickening at the base of the cecum, not present on the prior study; this may be associated with debris but could be secondary to an inflammatory process such as CMV colitis or even potentially a further site of potential lymphoma. Please correlate clinically. [**2160-10-30**] ECHO The IVC is collapsed suggesting underfilling of the right heart. The estimated right atrial pressure is 0-5 mmHg. The left ventricular cavity is small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is a trivial to very small pericardial effusion located primarily adjacent to the atria, without echocardiographic evidence of tamponade. IMPRESSION: Suboptimal image quality. Normal [**Hospital1 **]-ventricular global systolic function with high cardiac index. Mild pulmonary artery hypertension. Trivial to very small pericardial effusion. [**2160-10-30**] Bronchial Washings: Negative for malignant cells [**2160-10-25**] CHEST (PORTABLE AP) 1. Right Port-A-Cath, endotracheal tube and nasogastric tube are unchanged in position. Although the tip of the nasogastric tube is not seen on the current study but does course below the diaphragm. 2. Interval improvement in bilateral airspace process, although there is a residual reticular nodule initial abnormality. These findings are therefore consistent with resolving pulmonary edema, but the possibility of underlying interstitial disease should also be considered. Interval decrease in size of bilateral effusions, right greater than left. No large pneumothorax is seen although the positioning of the patient is not indicated and the sensitivity to detect pneumothorax would be diminished if acquired using supine technique. Overall, cardiac and mediastinal contours are likely stable given differences in patient positioning. [**2160-10-24**] CHEST (PORTABLE AP) Extensive diffuse lung opacities have markedly worsened. Bilateral pleural effusions are difficult to evaluate, moderate on the right and small-to-moderate on the left. Cardiac size is obscured by the lung abnormality. ET tube is in the standard position. Right supraclavicular catheter tip is in the right atrium as before. NG tube tip is out of view below the diaphragm. [**2160-10-24**] ECG Sinus tachycardia. Non-specific ST-T wave changes. Compared to the previous tracing of [**2160-10-13**] heart rate has significantly increased. [**2160-10-23**] PORTABLE ABDOMEN 1. No evidence of toxic megacolon. 2. Unchanged paucity of bowel gas. [**2160-10-23**] CHEST (PORTABLE AP) The ET tube tip is 4.3 cm above the carina. The right internal jugular line tip is at the level of cavoatrial junction. Widespread parenchymal consolidations appear to be minimally improved since the prior study. The NG tube tip is in the stomach. [**2160-10-22**] CHEST (PORTABLE AP) The endotracheal tube is 1 cm above the carina. Retracting the tube by approximately 2 cm is recommended. The right pleural effusion has slightly increased compared as to the previous image this morning. Bilateral parenchymal opacities, left more than right, persist. Unchanged course of the right internal jugular vein catheter and the nasogastric tube. [**2160-10-22**] ECHO The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen but is probably normal. No significant valvular abnormality. Mild elevation of pulmonary artery systolic pressure. [**2160-10-21**] PORTABLE ABDOMEN General paucity of bowel gas and otherwise nonspecific bowel gas pattern. [**2160-10-21**] CHEST (PORTABLE AP) Right lower lobe opacity has improved consistent with decreased pleural effusion and adjacent atelectasis. There has been mild interval increase in lung opacities in the left lung. These are a combination of patient's known fibrosis and superimposed infection. Right upper lobe opacities have improved consistent with resolving atelectasis. Interstitial opacities in the right upper lobe are minimally increased consistent with increasing mild interstitial edema. Mediastinal widening is unchanged. Patient has known mediastinal lymphadenopathy. Low lung volumes persist. Cardiac size is top normal. Right central catheter tip projects in the right atrium. There is no evidence of pneumothorax. [**2160-10-20**] SPINAL FLUID Lumbar puncture: ATYPICAL. Histiocytes and lymphocytes (rare atypical forms). [**2160-10-17**] US ABD LIMIT, SINGLE OR (prelim) Two son[**Name (NI) 493**] grayscale still images were obtained during real-time evaluation of underlying perihepatic ascites for possible paracentesis prior to liver biopsy. It was noted at that time that an appropriate window of minimal fluid was noted just along the anterior right hepatic lobe, appropriate for biopsy. Thus a paracentesis was not performed. [**2160-10-17**] Tissue: LIVER CORE BIOPSY (1 JAR). DIAGNOSIS: ATYPICAL LYMPHOPROLIFERATIVE DISORDER IN THE SETTING OF PERSISTENT [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VIREMIA IN A BACKGROUND OF IMMUNODEFICIENCY, SEE NOTE. Note: Sections are of liver core biopsies with dense portal and pericentral mononuclear cell infiltrates. The infiltrate consists of an admixture of small mature appearing lymphocytes and, in lesser number, larger atypical cells with pale eosinophilic to vacuolated cytoplasm, irregular nuclear outlines, vesicular chromatin, and variably prominent nucleoli. Though atypical none of the large cells resemble [**Doctor Last Name **]-Sternberg cells or variants. Admixed, there also are scattered histiocytic, eosinophils and plasma cells, including those with [**Last Name (un) 13683**] bodies. The infiltrate extends into the periportal space, tracts along the septa and show focal central to central bridging. Prominent apoptotic debris is seen, but mitoses are only rarely seen and necrosis is absent. The background liver exhibits mixed micro and macrovesicular steatosis, ballooning degeneration, apoptotic hepatocytes, and centrilobular congestion. By immunohistochemistry, the lymphoid infiltrate is diffusely positive with CD45 (LCA). CD3 highlights a majority of small lymphocytes, which appropriately co-express CD5 and BCL2. The majority of T cells are CD4 positive helper T cells, with only a minority being CD8 positive. CD20 and PAX-5 highlight few scattered large B lymphocytes, which do not form aggregates. CD15 stains scatter granulocytes, while CD30 dimly highlights rare immunoblasts. CD138 decorates hepatocytes' membrane (also stain scatter plasma cells in the lymphoid infiltrate), while BCL1 and BCL6 stains hepatocytes' nuclei. CD10 highlights bile canaliculi and stromal elements within the lymphoid infiltrates. Latent membrane protein (LMP) stain for EBV is negative. [**First Name8 (NamePattern2) 6**] [**Last Name (un) **] RNA in situ hybridization study shows rare scattered positive nuclei within the lymphoid aggregates. By MIB1, the proliferation index is overall 30-40%. Overall, the morphological and immunophenotypic findings are those of an atypical lymphoproliferative disorder, similar to those seen in previous biopsies. Neither the morphology nor the phenotype justifies a diagnosis of Hodgkin lymphoma. As in previous biopsies the findings in the current biopsy are felt to represent an EBV-driven lymphoproliferative disorder in the setting of persistent EBV viremia and in the background of an IgA deficiency/CVID phenotype. Please correlate with clinical, imaging and laboratory findings. [**2160-10-16**] CHEST (PORTABLE AP) Worsening bibasilar consolidations consistent with effusion and atelectasis Also stable bilateral upper lobe pulmonary opacities consistent with edema. [**2160-10-13**] CHEST (PORTABLE AP) Slight worsening of pulmonary edema compared to the prior radiograph from 3 days previous. Overall morphology is very similar to the torso CT examination performed earlier on the same day. [**2160-10-13**] CT torso: 1. Bilateral pleural effusions, moderate on the right, unchanged from the prior examination, and small on the left, increase in size from most recent CT chest examination of [**2160-10-9**]. 2. On a background of fibrosis, there is increased septal thickening which is worse compared to the prior exam and likely represents mild pulmonary edema. 3. Generalized anasarca and simple-appearing ascites. 4. Mild thickening of the wall of the ascending colon of unclear etiology, likely due to third spacing in the setting of ascites. [**2160-10-13**] ECG Sinus rhythm. Low voltage in the limb leads. Diffuse non-specific T wave flattening. Compared to the previous tracing of [**2160-8-6**] low voltage is now present. [**2160-10-13**] Tissue: immunophenotyping - pleural RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. A limited panel is performed to determine B-cell clonality. B cells are scant in number precluding evaluation of clonality (2% of lymphoid gated events, <1% of total gated events). T cells comprise 10% of total gated events. INTERPRETATION: Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. Correlation with clinical findings and morphology is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. [**2160-10-12**] CT HEAD W/O CONTRAST There is no evidence of intracranial hemorrhage, mass effect, shift of normally midline structures, or vascular territorial infarct. [**Doctor Last Name **]-white matter differentiation is preserved throughout. Ventricles and sulci are normal in morphology and size. No fractures are noted. IMPRESSION: No evidence of acute intracranial process. [**2160-10-11**] MRI ABDOMEN W/O CONTRAS 1. Heterogenous signal within the liver parenchyma on diffusion weighted imaging. Assessment is limited by the lack of intravenous contrast however the appearances raise the possibilty of an infiltrative process or infection. No intra- or extra-hepatic biliary dilatation. 2. The spleen is normal in size but demonstrates heterogenous signal consistent with previous Hodgkins disease. 3. Generalized anasarca with intra-abdominal ascites and bilateral small pleural effusions. [**2160-10-10**] CHEST (PORTABLE AP) Stable chest radiograph. [**2160-10-10**] CHEST (PORTABLE AP) 1. New pigtail catheter with tip at the right lung base. 2. Improved right pleural effusion. [**2160-10-10**] PLEURAL FLUID: NEGATIVE FOR MALIGNANT CELLS. Red blood cells, lymphocytes and few mesothelial cells. [**2160-10-9**] 9:15 PM CT CHEST W/O CONTRAST Newly enlarged moderate non-hemorrhagic right pleural effusion. Fibrotic bibasilar lung disease with traction bronchiectasis unchanged. chain suture is seen suggesting prior biopsy. Airways remain patent. No lobar consolidation. Central lymphadenopathy remains, not optimally evaluated without IV contrast. Ascites. cv port tip is at the cavoatrial junction. [**2160-10-9**] 7:06 PM DUPLEX DOP ABD/PEL LIMITED; LIVER OR GALLBLADDER US 1. Borderline echogenic liver suggestive of fatty infiltration. More severe forms of liver disease including hepatic fibrosis/cirrhosis cannot be excluded. 2. No intra- or extra-hepatic biliary ductal dilatation. The common bile duct measures 2 mm. The gallbladder is collapsed. 3. Color and spectral Doppler evaluation of the liver demonstrates normal flow within the hepatic artery, hepatic veins, and portal veins. [**2160-10-9**] Radiology DUPLEX DOP ABD/PEL LIMI: study is non-diagnostic for DVT given habitus of legs [**12-4**] CK 16 MB 3 Trop < 0.01 Protein/Creatinine ratio: 14-> 3.5 -> 5.1 ([**11-17**]) -> 4.7 ([**12-4**]) [**2160-12-2**] CT CHEST - synopsis: diffuse lung fibrosis, bronchiectasis, evidence of fluid overload, unchanged R pleural effusion, minimal new left pleural effusion IMPRESSION: As compared to the previous examination from [**2160-11-10**], there is evidence of diffuse fibrotic lung parenchymal pattern with bronchiectasis and spectral distortion as main morphological components. In addition, mild fluid overload could highlight the appearance of the interstitial structures. The right pleural effusion is unchanged. Minimal newly appeared left pleural effusion. Known mediastinal lymphadenopathy, unchanged coronary calcifications and slight valvular calcifications. The appearance of the upper abdominal organs is constant. IMPRESSION: Grossly stable chest findings possibly some increased right-sided pleural effusion. The portable chest examination cannot be expected to give more detailed differential diagnostic results. Micro: [**2160-10-30**] Urine Cx: [**Female First Name (un) 564**] albicans, vancomycin-resistant enterococcus [**2160-10-24**] Sputum culture: 2+ budding yeast [**2160-10-22**] Sputum: Rare growth of yeast and fungus [**2160-10-16**] C. Dif: Positive CMV: 17,600 ([**2160-10-16**]) -> 707 ([**2160-11-3**]) -> not detected ([**2160-11-10**]) EBV: 10,275 ([**2160-10-9**]) -> 16,669 ([**2160-10-21**]) -> 604 ([**2160-11-3**]) -> <200 ([**2160-11-10**]) B-glucan ([**2160-10-31**]): 414 -> ([**2160-11-10**]): 60 -> ([**2160-11-17**]): 32 -> ([**2160-11-24**]): 31 Brief Hospital Course: 55 year old woman with history of lymphocyte deplete Hodgkins s/p 6 cycles of ABVD in [**2149**]-[**2149**], pulmonary fibrosis secondary to bleomycin, and recent diagnosis of EBV viremia. She presented from rehab with shortness of breath, hypoxia, transaminitis, direct hyperbilirubinemia, and [**Last Name (un) **]. Found to have +CMV titer >17,000, and started on ganciclovir. # Hypoxemia / respiratory distress: A CT of the chest demonstrated large pleural effusion at the time of admission. Pulmonary drained 1.2L of bloody fluid from the chest and placed a chest tube x2 days. The pleural fluid was mostly blood and cytology did not support a diagnosis of malignancy. While further infectious vs malignant work-up was in progress patient was transferred from the BMT floor to the [**Hospital Unit Name 153**] for acute hypoxemic respiratory distress and altered mental status. Initial ABG was 7.43/36/49 on 5L NC. Her acute decompensation was thought to be due to reaccumulation of known R pleural effusion since repeat CT showed no change in effusion size compared to the [**10-9**] study which was done prior to drainage of 1L pleural fluid via thoracentesis. After discussion with IP, repeat thoracentesis was held because patient's respiratory status had improved and she was at risk of bleeding from her coagulopathy. She was started on vancomycin and meropenem for HCAP coverage and completed a 8 day course. Sputum GS this admission showed GPC and GP rods and culture consistent with commensal respiratory flora. Multifactorial [**2-28**] pulmonary edema on a baseline of severe restrictive chronic lung disease (fibrosis from bleomycin), in addition to lingular PNA. Diuresis was a challenge given the patient's renal function. She was successfully extubated on [**10-27**], but 3 days later, on [**10-30**], she became hypoxic in the 80s with increased O2 requirement and was re-intubated. On CXR, she had a new opacity seen on L upper lobe not present the previous day. Bronchoscopy was performed, which showed very small amount of secretions and no significant amount of blood. A bronchial lavage was sent for culture and cytology. BL was negative for acid fast, fungal, and PCP. [**Name10 (NameIs) **] spiked a T of 101 and urine/blood cultures were sent. She was restarted on vanc and [**Last Name (un) 2830**], but abx were discontinued after 48 hours of blood cultures with no growth. Also started on atovaquone for PCP [**Name Initial (PRE) 1102**]. Patient was also restarted on CVVH the night of [**10-30**]. Her urine culture grew yeast and VRE. She completed a 7 day course of linezolid. CVVH was stopped the [**11-4**] (patient's weight has decreased from 109 Kg to 77kg) with plan to obtain tunneled line and start HD. She received HD on [**11-2**]. She did not need further HD. Pt was stabilized and preparing for discharge on [**12-20**] when she again spiked a fever to 102 w/ productive cough. Vancomycin and cefepime were started for presumed PNA, although CXR and CT chest showed no evidence of new PNA. Sputum cxs were contaminated w/ oral flora. Pt clinically improved on abx over several days. Owing to several pts w/ flu on the service, pt was swabbed for flu, and tested positive. She was started on treatment doses of Tamiflu (75 mg [**Hospital1 **]). She was switched to PO levoquin, and was sent home to finish a course of levoquin and tamiflu. She continued to have an intermittent O2 requirement during her hospitalization. Her persistent hypoxemia is due to persistent fluid overload, with interstitial infiltrates and persistent large pleural effusion. She has obstructive lung disease, interstitial fibrosis from bleomycin toxicity, bronchiectasis, and recurrent large right-sided pleural effusion. # Yeast growth at multiple sites: Grown in sputum, BL, and urine. Likely colonized given that patient is doing well clinically making our suspicion for yeast pneumonia and/or dissiminated disease less likely. However patient is immunocompromised and at risk. Beta glucan was positive but fungal cultures negative. Per ID recs, was treated with Micafungin from [**Date range (1) 102513**]. Beta glucan was trended weekly and remained negative. # Encephalopathy: At admission the patient was ambulating and communicating verbally. While an infectious vs malignant work up was underway she developed acutely altered mental status in the setting of her hypoxemic respiratory distress. CT head on [**10-12**] showed no acute intracranial process. No uncorrected electrolyte abnormalities. Differential diangosis includes EBV related meningoencephalitis or toxic/metabolic cause from underlying infection. A bedside LP was attempted after the patient returned from the [**Hospital Unit Name 153**] with Neuro Onc -- however it was unsuccessful. A CMV titer was found to be positive to 17,600 on [**2160-10-18**] and the patient was started on ganciclovir. CMV and EBV levels significantly trended down and were undetectable or negative prior to discharge. On [**11-5**], patient refused HD, tunneled line, and abdominal biopsy. She was also inappropriately answering questions with fluctuating mental status. Her encephalopathy was likely multifactorial given her prolonged admission in ICU. Her wake cycles were likely disturbed and she has been bedbound for several weeks. There was also question of possible severe depression given her prolonged hospital course and deterioration. TSH was normal, B12 high, and RPR non-reactive. Social work was consulted for support. Psych was also consulted for evaluation. Per psych, she was in a hypokinetic delirium and withdrawn. A family meeting was held on [**11-7**] with daughter ([**Name (NI) **]) who is also HCP. It was determined that she did not have capacity for decision making and medical decisions were deferred to [**Doctor First Name **]. On the bone marrow transplant service, as her respiratory status improved, and as she completed treatment for EBV, CMV, presumptive fungemia, her mental status improved as well. She was pleasant, cooperative, and participated actively in her care. Started sertraline [**11-13**], stopped [**11-28**] as her mental status improved. # Acute renal failure/FSGS: Patient had anasarca likely related to her nephrotic syndrome. Renal advised lasix 60 mg IV BID and Metolazone 10 mg PO BID. In the [**Hospital Unit Name 153**], she was started on a lasix drip and eventually metolazone was added. She had some diuresis, but her overall fluid balance continued to rise. She also had progressively worsening renal function likely from volume depletion. This was attributed to FSGS and renal hypoperfusion from sepsis and poor oncotic pressure. In consultation with renal, heme onc and ID, she was started in IV methylprednisolone (d1 = [**10-23**]) for nephrotic syndrome and liver inflammation. CVVH was initiated primarily for volume overload. She was transitioned to HD, last HD on [**11-8**]. Patient's proteinuria improved on Rituximab and prednisone. Her steroids were changed to prednisone 80 mg daily (day 1 of steroids [**10-23**]), then tapered to 40 mg PO daily by discharge. She was sent home with a slow steroid taper, and will be followed by Dr. [**Last Name (STitle) 1366**] in nephrology clinic, who will manage her continued taper. # EBV, CMV viremia: Completed a course of Ganciclovir and received several doses of Rituximab. CMV and EBV became negative/undetectable with treatment. # Abdominal ileus: Abdominal x-ray [**11-2**] showed distended bowel loops. Likely ileus as no evidence of obstruction. Started on reglan. Speech and swallow evaluated and felt it was okay to start pureed food and nectar thick liquids. Her stool output and pain improved. # Atypical Combined Variable Immunodeficiency (CVID): Patient has EBV viremia and h/o lymphoma which are both associated with HLH/MAS in adults, so this diagnosis was considered initially, but heme onc later revised the putative diagosis to atypical CVID. Her elevated ferritin (7091, previously >10,000 in [**8-7**]), transaminitis with possible hepatic infiltrate on abdominal MRI, cytopenia in two cell lines and altered mental status are also concerning for this diagnosis. Bone marrow bx from [**8-9**] showed increased macrophages with ingestion of cells and debris, as well as an increased cytotoxic T cell infiltrate with concurrent markedly elevated ferritin level. Rituximab given, last dose on [**12-31**]. IVIG was also given [**10-30**]. # Left vocal cord hypokinesis / paralysis - She had a persistent hoarse voice which was originally thought to be related to intubation. Due to concern for vocal cord paralysis, otolaryngology was consulted, and she underwent laryngoscopy. She was found to have left vocal cord hypokinesia / paralysis. She underwent a repeat speech & swallow evaluation, which revealed left vocal cord hypokinesis. She was placed on aspiration precautions and started on a PPI. Her voice symptoms improved, and she was able to swallow and manage her own secretions. ENT recommended outpatient follow up with possible injection therapy. She was sent home with ENT followup. # Coagulopathy: Patient had a pan-elevation in her coagualation studies. Likely secondary to decreased synthetic function from liver disease and nephrotic syndrome. # Transaminitis, hyperbilirubinemia: Pt noted to have persistent transaminitis, direct bilirubinemia and elevated alk phos and LDH since admission. RUQ u/s [**10-9**] showed borderline echogenic liver suggestive of fatty infiltration, no intra- or extra-hepatic biliary ductal dilatation, normal flow within the hepatic artery, hepatic veins, and portal veins. MRI abd [**10-11**] showed heterogenous signal within the liver parenchyma concerning for infiltrative process or infection. CT abd/pelvis [**10-13**] showed generalized anasarca and simple-appearing ascites as well as mild thickening of the wall of the ascending colon. Liver biopsy was reviewed and felt to be immune infiltrate with T cell predominance. # C. diff: Patient was treated with po vancomycin (day 1 was [**Date range (3) 102514**]) with resolution of her diarrhea. Surveillance testing negative for C. diff. # Hx Hogkins disease: Extensive workup including multiple LN biopsies and marrow showed no evidence of recurrent disease last admission on [**2160-10-13**]. CT abdomen on [**10-30**] with possible recurrence, surgery was been consulted for biopsy, but would have to be a laparotomy which they do not recommend at this time. A repeat CT showed stability of lesions, so a biopsy was not pursued. # Abdominal lymphadenopathy: 2 mesenteric soft tissue masses adjacent to jejunum- 3.2 x 3.0 cm and 3.7 x 2.6 cm not present on prior scan. Given history of lymphoma, and EBV viremia, there was concern for lymphoma. However, EBV VL trended down and patient has been receiving high dose steroids. Per surgery, biopsy requires laparotomy, which they do not recommend at this time. Instead, they recommend a repeat CT abdomen at a later date to assess for interval change. Repeat CT showed stability of the lesions, so a surgical biopsy was not pursued. # Vaginal bleeding, postmenapausal: Not hemodynamically significant. Could be secondary to endometrial atrophy, but need to rule out endometrial cancer. - need transvaginal ultrasound and possible endometrial biopsy in the future, will defer to outpatient workup for now. # Anemia: Pt had anemia, fatigue, shortness of breath. We supported her with blood transfusions on as needed basis. Her reticulocyte index was 1.2, suggestive of inadequate bone marrow response to level of anemia. G6PD study was normal. Because of the elevated MCV count and RDW, there was suspicion for nutritional deficiency, so we started her on a multivitamin. # VRE UTI- Completed course of Linezolid. Surveillance UCx < 10,000 cfu/mL. # Hypertension / tachycardia: She was started on diltiazem for tachycardia and hypertension with likely diastolic congestive heart failure. TRANSITION OF CARE - RECOMMENDED FOLLOW-UP - You will follow up in clinic with Dr. [**Last Name (STitle) 410**] to decide if and when to repeat your rituximab dose - You should follow up with Dr. [**Last Name (STitle) 1366**] (kidney doctor) to decide on the dosage of your prednisone for renal failure before [**2160-12-20**] - Please follow-up in the ear, nose, and throat clinic for your vocal cord paralysis ORL-HNS (ear, nose, throat) clinic for vocal cord paralysis with Dr. [**Last Name (STitle) **] in [**1-28**] weeks or as soon as he has availability. The clinic number is [**Telephone/Fax (1) 41**] ([**Hospital1 18**]) - Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (infectious diseases) 1-2 weeks after discharge TRANSITION OF CARE - MEDICAL ISSUES TO BE FOLLOWED-UP - Upon discharge, it is important that you follow-up with an outpatient OB/Gyn for further evaluation of your vaginal bleeding. - You should also have repeat imaging of your abdomen to follow-up on the abnormal mass in your small bowel - Dr. [**Last Name (STitle) 410**] will help to decide when to repeat imaging - You have fluid outside of your lungs (pleural effusion), and were seen by interventional pulmonologists during this hospitalization. A procedure called thoracentesis can be performed to remove this fluid which may help you to breathe more easily. You opted to hold off on getting this procedure for now. If you develop significant symptoms from the fluid outside your lungs, you can follow up with Dr. [**Last Name (STitle) **] in the [**Hospital 23463**] Clinic ([**Telephone/Fax (1) 76519**] to discuss possible thoracentesis TRANSITIONAL ISSUES - RECOMMENDED LABS: [] Weekly CMV VL, EBV VL on Mondays [] CBC/diff Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Rehab list. 1. Torsemide 40 mg PO DAILY 2. Aquaphor Ointment 1 Appl TP [**Hospital1 **] 3. Aluminum Hydroxide Suspension 30 mL PO Q4H:PRN dyspepsia 4. Potassium Chloride 30 mEq PO DAILY Duration: 24 Hours Hold for K > 5. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) 6. Calcium Carbonate 1250 mg PO TID 7. Famotidine 20 mg PO BID 8. Promethazine 12.5 mg IV Q4H:PRN nausea 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Senna 1 TAB PO BID:PRN constipation 11. Morphine Sulfate 2 mg IV Q2H:PRN pain 12. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain 13. Oxycodone SR (OxyconTIN) 10 mg PO Q12H 14. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN wheezing 15. Docusate Sodium 100 mg PO BID 16. Vitamin D 1000 UNIT PO DAILY 17. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 18. Furosemide 60 mg PO DAILY Discharge Medications: 1. Albuterol 0.083% Neb Soln 2 NEB IH Q4H:PRN wheezing 2. Furosemide 20 mg PO DAILY RX *furosemide 20 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*3 3. Senna 1 TAB PO BID:PRN constipation 4. Atovaquone Suspension 1500 mg PO DAILY RX *atovaquone [Mepron] 750 mg/5 mL 10 mL by mouth DAILY Disp #*500 Milliliter Refills:*0 5. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dyspnea, wheezing RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 NEB every six (6) hours Disp #*1 Pack Refills:*0 7. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule(s) by mouth DAILY Disp #*30 Capsule Refills:*0 8. Multivitamins 1 TAB PO DAILY RX *multivitamin 1 capsule(s) by mouth DAILY Disp #*30 Capsule Refills:*0 9. PredniSONE 40 mg PO DAILY Tapered dose - DOWN RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*72 Tablet Refills:*0 10. ValGANCIclovir 450 mg PO Q24H RX *valganciclovir [Valcyte] 450 mg 1 tablet(s) by mouth DAILY Disp #*60 Tablet Refills:*0 11. Vitamin B Complex w/C 1 TAB PO DAILY RX *FA-B com&C-rice bran-rose hips [B-complex with vitamin C] 400 mcg-500 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Vitamin D 50,000 UNIT PO 1X/WEEK (FR) RX *ergocalciferol (vitamin D2) 50,000 unit [**Unit Number **] capsule(s) by mouth 1x/week (Friday) Disp #*52 Capsule Refills:*0 14. Vitamin D 1000 UNIT PO DAILY 15. Outpatient Lab Work Diagnosis: Hodgkin's Lymphoma Labs: Weekly CMV, EBV viral loads, CBC/diff 16. Home O2 1-2 L continuous O2 via NC, pulsed dose for portability. Dx: 494.0 Bronchiectasis, J48.9 Interstitial lung disease RA sat ~87% 17. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 18. Fluconazole 400 mg PO Q24H RX *fluconazole 200 mg 2 tablet(s) by mouth DAILY Disp #*60 Tablet Refills:*0 19. Guaifenesin-CODEINE Phosphate [**6-5**] mL PO Q6H:PRN cough RX *codeine-guaifenesin 100 mg-10 mg/5 mL 10 mL by mouth every six (6) hours Disp #*200 Milliliter Refills:*0 20. Calcium Carbonate 1250 mg PO QHS RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 21. Pantoprazole 40 mg PO Q24H RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth q24h Disp #*30 Tablet Refills:*0 22. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3 Tablet Refills:*0 23. Oseltamivir 75 mg PO Q12H RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth Q12 Disp #*9 Capsule Refills:*0 24. PredniSONE 30 mg PO DAILY Duration: 10 Days Tapered dose - DOWN 25. PredniSONE 20 mg PO DAILY Duration: 10 Days Tapered dose - DOWN 26. PredniSONE 10 mg PO DAILY Duration: 10 Days Tapered dose - DOWN 27. PredniSONE 5 mg PO DAILY Duration: 10 Days Tapered dose - DOWN 28. PredniSONE 3 mg PO DAILY Duration: 10 Days Tapered dose - DOWN 29. PredniSONE 2 mg PO DAILY Duration: 10 Days Tapered dose - DOWN Discharge Disposition: Home Discharge Diagnosis: Primary: Macrophage activating syndrome / EBV lymphoproliferative disorder Secondary: Intsterstitial lung disease, pleural effusion, hypertension, renal failure, CMV viremia, fungemia, vocal cord paralysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care at [**Hospital1 18**]. You came to the hospital because of shortness of breath and abnormal labs tests. You had a complicated hospital course that included viral infections with CMV and EBV as well as renal failure. You were treated with Rituximab and steroids and your symptoms improved. You then developed a pneumonia; you were treated with antibiotics and felt better. You were also diagnosed with influenza A during your stay, and treated with Tamiflu. We have arranged home supplemental oxygen therapy for your chronic lung issues. You should also finish courses of levofloxacin for your pneumonia, and tamiflu for your influenza. You will also be on a steroid taper for your kidney disease. There are a number of other new medications to guard against infection and to help with your symptoms; please feel free to call Dr.[**Name (NI) 3588**] office if you have any questions about these. You can follow up with Dr. [**Last Name (STitle) 410**] and you other specialists. at the appointments below. TRANSITION OF CARE - RECOMMENDED FOLLOW-UP - You will follow up in clinic with Dr. [**Last Name (STitle) 410**] to decide if and when to repeat your rituximab dose - You should follow up with Dr. [**Last Name (STitle) 1366**] (kidney doctor) to decide on the dosage of your prednisone for renal failure before [**2160-12-20**] - Please follow-up in the ear, nose, and throat clinic for your vocal cord paralysis ORL-HNS (ear, nose, throat) clinic for vocal cord paralysis with Dr. [**Last Name (STitle) **] in [**1-28**] weeks or as soon as he has availability. The clinic number is [**Telephone/Fax (1) 41**] ([**Hospital1 18**]) - Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (infectious diseases) 1-2 weeks after discharge TRANSITION OF CARE - MEDICAL ISSUES TO BE FOLLOWED-UP - Upon discharge, it is important that you follow-up with an outpatient OB/Gyn for further evaluation of your vaginal bleeding. - You should have repeat imaging of your abdomen to follow-up on the abnormal mass in your small bowel - Dr. [**Last Name (STitle) 410**] will help to decide when to repeat imaging - You should have repeat imaging of your chest to follow-up on a nodule found in your lung - You have fluid outside of your lungs (pleural effusion), and were seen by interventional pulmonologists during this hospitalization. A procedure called thoracentesis can be performed to remove this fluid which may help you to breathe more easily. You opted to hold off on getting this procedure for now. If you develop significant symptoms from the fluid outside your lungs, you can follow up with Dr. [**Last Name (STitle) **] in the [**Hospital 23463**] Clinic ([**Telephone/Fax (1) 76519**] to discuss possible thoracentesis - Your primary care physician should [**Name9 (PRE) 702**] on your Vitamin D deficiency TRANSITIONAL ISSUES - RECOMMENDED LABS: [] Weekly CMV VL, EBV VL on Mondays [] CBC/diff [] Vitamin D levels, parathyroid hormone levels MEDICATION CHANGES: - START diltiazem 180mg ER for high blood pressure and fast heart rate - START fluconazole and atovaquone to prevent infection until Dr. [**Last Name (STitle) 410**] tells you to stop - START valgancyclovir for CMV viremia until Dr. [**First Name (STitle) **] tells you to stop Followup Instructions: Department: HEMATOLOGY/BMT When: WEDNESDAY [**2161-1-14**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2161-1-14**] at 2:00 PM With: [**First Name8 (NamePattern2) 2747**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3983**], NP [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage INFECTIOUS DISEASES [**2161-1-14**] 01:30p [**Doctor Last Name **],BMT SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Hospital **] CLINIC Dr.[**Name (NI) 4857**] office will call you with an appointment to address your kidney problems. If you do not hear from them within a few days, you can call the number below to arrange an appointment. [**Last Name (LF) **],[**First Name3 (LF) 1877**] H. DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] RENAL DIV-WSC (SB), [**Telephone/Fax (1) 721**] EAR, NOSE, AND THROAT - Appointment for vocal cord injection procedure. Please call: [**Telephone/Fax (1) **],[**Last Name (un) 15040**] S. LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **] OTOLARYNGOLOGY/AUDIOLOGY (NHB), [**Telephone/Fax (1) 41**] Please make an appointment with your primary care physician. [**Name10 (NameIs) **] should be seen in [**2-29**] weeks: Name: [**Last Name (LF) **],[**First Name3 (LF) **] U. Location: [**Hospital **] HEALTH CARE Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 34362**] Phone: [**Telephone/Fax (1) 31802**] Fax: [**Telephone/Fax (1) 90391**] Completed by:[**2161-1-4**]

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icd9cm

[ [ [] ] ]

[ "50.11", "96.6", "34.04", "03.31", "96.72", "99.15", "39.95", "31.42", "00.14", "99.25", "34.91", "33.24" ]

icd9pcs

[ [ [] ] ]

43715, 43721

25908, 39673

345, 463

43974, 43974

5188, 5188

47491, 49417

3871, 4178

40627, 43692

43742, 43953

39699, 40604

44125, 47169

4218, 4728

47189, 47468

263, 307

491, 2754

5204, 25885

43989, 44101

2776, 3596

3612, 3855

4753, 5169

15,714

114,959

29466

Discharge summary

report

Admission Date: [**2185-10-26**] Discharge Date: [**2185-11-30**] Date of Birth: [**2105-8-1**] Sex: F Service: SURGERY Allergies: Tramadol / Codeine / Kayexalate Attending:[**First Name3 (LF) 3223**] Chief Complaint: Lower GI bleed Major Surgical or Invasive Procedure: Right Colectomy, Sigmoidectomy Exploratory Laparotomy - ReClosure Fascia sp Pacemaker Placement History of Present Illness: 80F w/ h/o AAA repair admitted to [**Hospital 10478**] Hosp [**10-10**] with acute on chronic renal failure following 2-3 days N/D, [**1-7**] wks diarrhea, increasing weakness, lethargy & SOB. LGIB, C-scope & EGD performed [**10-25**] "ischemic cecum with diverticulosis & no active bleeding". "Nl EGD". CT prior to transfer showed no AE fistual (clear place, no air around the graft). At the OSH: [**10-11**] : Treated with insulin, D50, Ca+gluconate, & Kayexalate ??????multiple times?????? Intubated, pressors, renal & pulmonary consults [**10-14**] extubated Temporary dialysis 2-3x 1st week 10 days getting ready for rehab [**10-25**] : BRBPR w. clots and drop HCT C-S : ischemic area proximal colon, ulcerated cecum w/ ??????old looking leision??????, normal TI, diverticuli L>R EGD : negative for bleeding sites 6U pRBCs / 24hr HPI cont. [**10-26**] : acute bleeding episode w/ SBPs 80s, requiring dopamine & levofed; HCT 26.4 Surgery @ OSH consulted for possible Aortoenteric fistula Rec: tx to vascular surgery at [**Hospital1 18**] & CT w/ contrast Past Medical History: PMH: AFib, sp MI [**7-10**], CHF, COPD -> steroid & home O2 dependent, PVD, OSA, CRI, PUD, HTN, s/p AAA repair '[**75**], s/p B/L retinal repair '[**78**], h/o heavy smoking, moderate AS, 2cm R atrial mass adjacent tricuspid Social History: h/o tobacco occ ETOH Lives w/ daughter Family History: NC Physical Exam: MS/NEURO: A/O, FC, MAE: HEENT: PERRLA, EOMI CVS: RRR Resp: [**Month (only) **] BS B Abd: S/+ mild RLQ TTP, + mild distention Ext: +1 Edema, + diffuse skin breakdown Pertinent Results: [**2185-10-26**] 07:59PM BLOOD WBC-28.8* RBC-4.91 Hgb-15.0 Hct-43.1 MCV-88 MCH-30.5 MCHC-34.8 RDW-14.7 Plt Ct-147* [**2185-10-27**] 01:50AM BLOOD Hct-34.5* [**2185-10-28**] 04:06AM BLOOD WBC-14.8* RBC-3.54* Hgb-11.0* Hct-31.2* MCV-88 MCH-31.1 MCHC-35.2* RDW-15.0 Plt Ct-107* [**2185-10-30**] 01:51AM BLOOD WBC-8.0 RBC-3.17* Hgb-10.1* Hct-28.4* MCV-90 MCH-31.7 MCHC-35.4* RDW-14.8 Plt Ct-148* [**2185-10-30**] 11:20PM BLOOD Hct-26.3* [**2185-10-31**] 02:59AM BLOOD WBC-8.6 RBC-2.79* Hgb-8.6* Hct-25.2* MCV-90 MCH-30.9 MCHC-34.3 RDW-15.2 Plt Ct-161 [**2185-10-31**] 06:13AM BLOOD Hct-23.7* [**2185-11-2**] 01:44AM BLOOD WBC-15.6*# RBC-2.62*# Hgb-8.1*# Hct-22.9*# MCV-87 MCH-30.8 MCHC-35.2* RDW-16.4* Plt Ct-73* [**2185-11-2**] 10:36AM BLOOD Hct-31.0* [**2185-11-4**] 02:53AM BLOOD WBC-15.5* RBC-3.43* Hgb-10.5* Hct-29.5* MCV-86 MCH-30.6 MCHC-35.6* RDW-16.8* Plt Ct-48* [**2185-11-9**] 03:18AM BLOOD WBC-12.8* RBC-3.44* Hgb-10.4* Hct-30.6* MCV-89 MCH-30.2 MCHC-34.0 RDW-16.8* Plt Ct-167 [**2185-11-10**] 03:19AM BLOOD WBC-9.3 RBC-2.90* Hgb-8.7* Hct-25.9* MCV-90 MCH-30.1 MCHC-33.7 RDW-16.9* Plt Ct-162 [**2185-11-12**] 03:21AM BLOOD WBC-6.8 RBC-2.69* Hgb-8.1* Hct-24.0* MCV-89 MCH-30.2 MCHC-33.8 RDW-16.5* Plt Ct-212 [**2185-11-13**] 03:00AM BLOOD WBC-6.3 RBC-2.54* Hgb-7.8* Hct-22.5* MCV-88 MCH-30.7 MCHC-34.8 RDW-16.4* Plt Ct-192 [**2185-11-13**] 03:54PM BLOOD Hct-28.0* [**2185-11-17**] 03:00AM BLOOD WBC-11.1* RBC-4.05* Hgb-11.8* Hct-36.4 MCV-90 MCH-29.1 MCHC-32.5 RDW-15.7* Plt Ct-240 [**2185-11-19**] 03:10AM BLOOD WBC-11.6* RBC-3.66* Hgb-11.1* Hct-31.9* MCV-87 MCH-30.5 MCHC-34.9 RDW-15.8* Plt Ct-202 [**2185-11-22**] 04:23AM BLOOD WBC-10.7 RBC-3.15* Hgb-9.3* Hct-29.0* MCV-92 MCH-29.4 MCHC-31.9 RDW-16.1* Plt Ct-214 [**2185-11-22**] 10:24PM BLOOD WBC-13.1* RBC-2.93* Hgb-9.1* Hct-26.2* MCV-89 MCH-31.1 MCHC-34.8 RDW-15.7* Plt Ct-191 [**2185-11-27**] 02:58AM BLOOD WBC-6.4 RBC-3.03* Hgb-9.3* Hct-28.0* MCV-93 MCH-30.6 MCHC-33.1 RDW-15.9* Plt Ct-203 [**2185-11-29**] 07:37AM BLOOD Hct-24.7* [**2185-11-29**] 03:47PM BLOOD Hct-26.2* [**2185-11-30**] 02:00AM BLOOD WBC-8.3 Hct-26* Plt Ct-225 [**2185-10-26**] 07:59PM BLOOD PT-13.1 PTT-24.6 INR(PT)-1.1 [**2185-10-26**] 07:59PM BLOOD Glucose-130* UreaN-43* Creat-2.4* Na-149* K-3.7 Cl-105 HCO3-33* AnGap-15 [**2185-11-1**] 05:45AM BLOOD Glucose-101 UreaN-34* Creat-2.0* Na-144 K-4.4 Cl-109* HCO3-22 AnGap-17 [**2185-11-9**] 03:18AM BLOOD Glucose-73 UreaN-103* Creat-2.7* Na-140 K-5.3* Cl-109* HCO3-22 AnGap-14 [**2185-11-12**] 07:01PM BLOOD Glucose-157* UreaN-111* Creat-2.8* Na-140 K-4.3 Cl-106 HCO3-23 AnGap-15 [**2185-11-23**] 05:02AM BLOOD Glucose-71 UreaN-59* Creat-1.9* Na-142 K-5.3* Cl-113* HCO3-20* AnGap-14 [**2185-11-25**] 03:08PM BLOOD Glucose-162* K-5.7* [**2185-11-29**] 02:21AM BLOOD Glucose-98 UreaN-61* Creat-2.1* Na-141 K-5.0 Cl-108 HCO3-28 AnGap-10 [**2185-11-30**] 02:00AM BLOOD Glucose-106* UreaN-59* Creat-2.0* Na-140 K-5.4* Cl-108 HCO3-26 AnGap-11 [**2185-10-26**] 07:59PM BLOOD CK-MB-NotDone cTropnT-0.21* [**2185-11-8**] 11:03PM BLOOD CK-MB-6 cTropnT-0.21* [**2185-11-23**] 05:02AM BLOOD CK-MB-NotDone cTropnT-0.18* [**2185-11-4**] 02:53AM BLOOD calTIBC-118* Ferritn-55 TRF-91* [**2185-11-7**] 07:04PM BLOOD calTIBC-190* Ferritn-93 TRF-146* [**2185-11-21**] 03:55AM BLOOD calTIBC-161* Ferritn-214* TRF-124* [**2185-10-31**] 04:31PM BLOOD TSH-9.8* [**2185-11-16**] 02:48AM BLOOD TSH-8.9* [**2185-11-26**] 02:00AM BLOOD TSH-14* . PORTABLE ABDOMEN [**2185-10-27**] 6:35 AM PORTABLE ABDOMEN Reason: eval bowel gas pattern [**Hospital 93**] MEDICAL CONDITION: 80 year old woman with distention/bpr IMPRESSION: Mildly dilated loops of small bowel with air in the colon. Likely generalized ileus, although an early and/or partial small-bowel obstruction cannot be entirely excluded. Correlate clinically. . GI BLEEDING STUDY [**2185-10-28**] GI BLEEDING STUDY IMPRESSION: Focal active GI bleeding originating in the region of the cecum, first seen 29 minutes into the study. . CHEST (PORTABLE AP) [**2185-10-31**] 6:34 PM CHEST (PORTABLE AP) Reason: sp r cooectomy now intubated [**Hospital 93**] MEDICAL CONDITION: 80 year old woman with LLL PNA REASON FOR THIS EXAMINATION: sp r cooectomy now intubated CLINICAL HISTORY: 80-year-old female with left lower lobe pneumonia. Status post right lobectomy. Now intubated IMPRESSION: Persistent bilateral pleural effusions and perihilar haziness, consistent with unchanged moderate pulmonary vascular congestion . Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 70733**],[**Known firstname **] M [**2105-8-1**] 80 Female [**-5/4712**] [**Numeric Identifier 70734**] SPECIMEN SUBMITTED: RT. HEMICOLECTOMY. DIAGNOSIS: Ileocolectomy: 1. Marked necrosis of the cecum with focal loss of the muscularis propria, associated with foreign body crystals consistent with Kayexalate. 2. Adherent segment of sigmoid colon due to peritoneal adhesions. 3. The rest of the right colon, sigmoid colon mucosa, ileal segment and append are within normal limits. 4. No neoplasm. . Cardiology Report ECHO Study Date of [**2185-11-1**] Conclusions: 1. The left atrium is mildly dilated. 2. A large (2 cm) mass attached to the lateral aspect of the tricuspid valve annulus is seen in the right atrium. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is difficult to assess but is probably low normal (LVEF 50-55%). 4.. The aortic valve leaflets are severely thickened/deformed. There is at least moderate aortic valve stenosis (area 0.8-1.19cm2). Trace aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. . CHEST (PORTABLE AP) [**2185-11-3**] 4:25 AM CHEST (PORTABLE AP) Reason: eval for interval change IMPRESSION: Unchanged mild pulmonary edema. Decreased right pleural effusion. Suspected pulmonary hypertention. . VIDEO OROPHARYNGEAL SWALLOW [**2185-11-17**] 1:50 PM IMPRESSION: Penetration with nectar consistency liquids, and aspiration of thin liquids when attempting to swallow barium tablet which became stuck in the vallecula, but cleared with subsequent swallowing. . [**Numeric Identifier 70735**] NASAL/OROGASTRC TUBE PLMT, PRO FEE ONLY [**2185-11-18**] 9:26 AM Reason: please place dobbhoff feeding tube IMPRESSION: Uncomplicated placement of weighted 8 French feeding tube, with tip over the antrum of the stomach. . Cardiology Report ECG Study Date of [**2185-11-22**] 3:55:46 AM Regular bradycardia - probably junctional rhythm Right bundle branch block Consider lateral myocardial infarct, age indeterminate Diffuse ST-T wave changes with prominent T waves - clinical correlation is suggested Since previous tracing of [**2185-11-21**], junctional rhythm now present and further ST-T wave changes seen Intervals Axes Rate PR QRS QT/QTc P QRS T 39 0 148 544/467.15 0 -23 46 . CHEST (PORTABLE AP) [**2185-11-27**] 11:39 AM CHEST (PORTABLE AP) Reason: acute desaturation r/o PNA [**Hospital 93**] MEDICAL CONDITION: 80 year old woman s/p right colectomy in ICU -> w/desat 24 hours prior and brown sputum REASON FOR THIS EXAMINATION: acute desaturation r/o PNA HISTORY: Pneumonia. IMPRESSION: Bilateral pleural effusions and pulmonary edema, unchanged. Support lines unchanged. . Brief Hospital Course: She was transferred on [**2185-10-26**] on levofed & dopamine, not intubated. Her labs on arrival were: CBC : 28.8 / 42 / 147 Chem : 149/3.7/105/33/43/2.4/130 Coags: 13/24/1.1 Lactate 3.0 [**10-26**] Resusitated w/ IVF, NGT/NPO/ABX CT : Aortoiliac graft identified, plane between aorta & small bowel, no air around graft ?????? no evidence of fistula; blood in jejunum, ileum, & colon; no retroperitoneal hematoma or soft tissue changes; hyperdense clumped material in multiple segments of colon GI consult > EGD : normal through 4th part duodenum [**10-27**] : Weaned from pressors; WBC 21.6 HCT 34.9; amio started for Afib, V/Z/F for ?ischemic colitis [**10-28**] : Bleeding study: Focal active GI bleeding originating in the region of the cecum, first seen 29 minutes into the study. WBC 14.8 HCT 31.2 [**10-29**]: small maroon stool [**10-30**] : dark melena; go-lytely for c-s in am [**10-31**]: BRBPR, SBPs 70s, HCT 23 Got 2U pRBCs [**2185-10-31**] TO OR: En bloc resection of a portion of sigmoid with a right hemicolectomy for a bleeding cecal mass with adherent sigmoid colon PATH Marked necrosis of the cecum with focal loss of the muscularis propria, associated with foreign body crystals consistent with Kayexalate. Post-op course Pressors for a few days & ventilated for respiratory failure TTE: EF 50-55%, mod AS, 2 cm tricuspid mass vs calcification Wound dehisced on POD 8 requiring take back to OR for facial reclosure & retension sutures. Resp: She had a slow wean from the ventilator complicated by pleural effusion. She still requires Bipap at HS and intermittently through the day. . No further bleeding episodes . CV: She came out in AF with RVR. Has a h/o PAF for a month and probably fully amio loaded there. Has been on pressors this admission (came out on neo from the OR). Intubated. She got IV amio load in the OR followed by IV amio gtt. Currently in sinus. Has prolonged conversion pauses, up to 4.5 seconds and sinus brady low 40s . Echo [**11-1**] showed normal EF, mild LVH. Now coming off pressors, requiring less O2 on vent. [**11-17**] had brady to 30's and low BP requiring low-dose dopa which was able to be weaned off [**11-18**] with HR's 50s. She received a pacemaker on [**2185-11-22**] and is A-paced at 70. She is on ASA 81 mg daily . Skin: She Pt has multiple partial thickness ulcers(skin tears) on upper and lower extremities. The lower extremities are edematous and ecchymotic and are draining copious amounts of serous fluid from any open area. The right lower leg has a large intact hemorrhagic blister on the lateral aspect and a partial thickness ulcer on the posterior calf. The skin is extremely fragile and thin. The upper extremities also have partial thickness ulcers on the posterior upper arms and the wrists. The drainage there is not nearly as much as lower extremities. Her skin contiued to heal. Bilateral arms/legs with much less fluid,then past week. Decrease amount of clear exudate daily, nurse is only changing dressings daily.(adaptive,softsorb). Two days ago flexi seal fecal management system placed. Sacral area with erythema, approxiately 8x6cm,likely due to increase moisture from stool. Small amount of fecal oozing anal area, this is normal with this system. Nursing applying double guard onitment, and nystatin to site [**Hospital1 **]. Sugguest fluff guaze around anal area to wick effluent,and or softsorb. Unble to add banana flakes as patient's K+ is high. Sugguest adding more fiber to diet. All ulcers are clean, without signs of infection. . ID: She will need Meropenem for an additional 7 days for a klebsiella UTI. [**11-25**] Sputum: rare GNRs. Sensitivities are pending. [**2185-11-24**] SPUTUM GRAM STAIN-FINAL NEG . Renal: She has a Foley in place, after several void trials, and getting Lasix daily. Her Cr has stablized at 2.0. Her Potassium has been around 5 to 5.8. Do not give Kayexalate. . Endo: Her blood sugars have been well controlled. Her Levothyroxine was increased as the TSH increased. Please continue to monitor and treat her hypothyroidism. . FEN: She continues with a Dobbhoff feeding tube. Please check calories counts and wea from the tube feedings as she increases PO intake. . Code: She is DNI, but does want resuscitation for cardiac arrest (shock, CPR, pressors are OK). Medications on Admission: pred 10', lasix 20, advair, levothryoxine, MVI, vasotec 5, dilt 120 QOD, zocor 10, duonebs, prilosec 20, ASA 81 QOD, home O2 2L MOT: hydrocort 50'', zosyn [**10-22**], HCTZ 12.5, spironolactone 25, protonix, bactrim [**10-18**], synthroid 125 po, zocor 20, nystatin s/s, phosLo 667''', amiodorone 200''', cardizem ER 120, colace, mucinex 600'''', ventolin nebs, bipap @ noc, duonebs Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours). 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4-6H (every 4 to 6 hours). 8. Ascorbic Acid 90 mg/mL Drops Sig: Six (6) PO DAILY (Daily): 500 mg PO daily. 9. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): See sliding scale. 14. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Recheck TSH level in 3 days and adjust dose accordingly. 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Acute on Chronic Renal Failure Lower GI Bleed Ischemic Cecum, Diverticulosis Wound Dehiscence Bowel Necrosis due to Kayexalate Crystals Respiratory Distress requiring intubation Bradycardia requiring Pacemaker Post-op Hypotension / Hypovolemia Skin Tear/breakdown Pleural Effusion Discharge Condition: Fair Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain . Please resume all of your regular medications and take any new meds as ordered. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 519**] in 2 weeks. Return on [**2184-12-12**]. Call ([**Telephone/Fax (1) 5323**] to schedule an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2185-11-30**]

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icd9cm

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icd9pcs

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111,428

760

Discharge summary

report

Admission Date: [**2114-6-14**] Discharge Date: [**2114-6-20**] Date of Birth: [**2041-10-5**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: incontinence/lower extremity pain/weakness Major Surgical or Invasive Procedure: Posterior cervical laminectomy Decompressive lumbar laminectomy History of Present Illness: 72-year-old woman who has a history of mild mental retardation who lives and works in a monitored care setting. She has a complex past medical history including a distant left frontal meningioma resection as well as a previous anterior cervical discectomy with fusion in [**2107**] by Dr. [**Last Name (STitle) 1338**] (C4-C7). The patient is unable to recall the majority of her past medical history. She now presents with progressive urinary incontinence and fecal incontinence. Urinary incontinence was noticed for at least a year. Fecal incontinence seems to be present for about 3-4 weeks only. The patient has, in addition, felt a decrease in her ability to walk but is mobile with a walker. She complains about bilateral lower extremity paresthesias, left greater than right. She has intermittent bilateral upper extremity numbness. She also complains about progressive right-sided thigh pain when she is going down the stairs. She walks with a walker. The patient takes home medications including hydrochlorothiazide, Protonix, Fosamax, and naproxen. She is not known to have any drug allergies. She is a nonsmoker, nondrinker. Past Medical History: The patient has a past medical history that is relevant for hypertension, GERD, osteoporosis. Surgical history remains relevant for a distant left frontal meningioma resection, status post ACDF C4-C7 in [**2107**] and a right-sided THR. Social History: The patient takes home medications including hydrochlorothiazide, Protonix, Fosamax, and naproxen. She is not known to have any drug allergies. She is a nonsmoker, nondrinker. Family History: noncontributory Physical Exam: Physical examination reveals that she is awake and alert and interactive. She is slightly retarded and slow, but pleasantly interactive. She walks into the office with a walker. She has an obvious kyphosis, but is more mobile with a walker and shows no signs of imbalance. The cranial nerves are remarkable for a prominent right-sided exotropia at rest. Bilateral pupils are reactive to light and accommodation. Extraocular movements are full despite disconjugate gaze. There is no nystagmus. She has good visual fields. Facial strength and sensation are normal. Hearing is intact. Tongue is midline and shows no signs of atrophy of fasciculation. Motor exam is somewhat limited but shows mild to moderate wasting of hand intrinsic muscles as well as thenar. Tone is increased in both legs with signs of spasticity. She has weakness in the distal upper extremity approximately [**5-2**] bilaterally. She has good strength approximately bilaterally except the right-sided deltoid. She has bilateral lower extremity weakness 4/5 with more prominent weakness in the toe bilaterally. Fine motor control is not testable. She has no drift. Sensory exam reveals no obvious deficits bilaterally. She complains about dysesthesias in a nonradicular pattern. Symmetric reflexes were elicited. She has bilateral upgoing toes. Pertinent Results: [**2114-6-14**] 08:30PM WBC-12.5* RBC-3.29* HGB-10.3* HCT-29.1* MCV-88 MCH-31.3 MCHC-35.4* RDW-14.1 [**2114-6-14**] 08:30PM PLT COUNT-224 [**2114-6-14**] 08:00PM CK(CPK)-136 [**2114-6-14**] 08:00PM CK-MB-9 cTropnT-<0.01 [**2114-6-14**] 08:00PM CALCIUM-8.5 PHOSPHATE-4.6* MAGNESIUM-2.0 [**2114-6-14**] 08:00PM PT-13.0 PTT-23.8 INR(PT)-1.1 [**2114-6-20**] 03:33AM BLOOD WBC-11.8* RBC-3.37* Hgb-10.0* Hct-29.1* MCV-86 MCH-29.6 MCHC-34.3 RDW-16.2* Plt Ct-273 [**2114-6-20**] 03:33AM BLOOD Plt Ct-273 [**2114-6-20**] 03:33AM BLOOD Glucose-104 UreaN-14 Creat-0.9 Na-134 K-3.6 Cl-99 HCO3-26 AnGap-13 [**2114-6-20**] 03:33AM BLOOD Calcium-8.2* Phos-4.0# Mg-1.9 Brief Hospital Course: Pt was admitted and brought to the OR electively where under general anesthesia she underwent posterior cervical laminectomy and lumbar decompressive laminectomy. Intra-op toward end of the case she had some labile HR and BP became pressure dependent. She was transferred to the PACU and seen in consultation with cardiology who recommended EKG, echo in several days (not emergent)and to replete lytes and follow hct. She was weaned off the vent on post op day #1, she was hemodynamically stable. She had hemovacs which were placed intraop which were patent and draining - she remained on prophylactic antibxs while these were in. The drains were removed on [**6-17**] without difficulty. She had 1 unit PRBC on [**6-16**] for hct of 24. This came up to 28 post transfusion. Hct was 26 on [**6-19**] and a second PRBC was given. Her incisions were clean dry and intact with sutures. Her activity and diet were increased. She was tacycardic post op which was treated initially with fluid boluses but continued and she was started on lopressor which was gradually increased. Medicine followed her throughout her hospitalization. She had CXR on [**6-18**] which showed LLL pneumonia and levoflox was started. She also had chest CTA on [**6-19**] to r/o PE for her continued tachycardia. She was evaluated by PT/OT and needs acute rehab stay once medically cleared. She did have an episode of desaturation to the mid 80's that was relieved with iv lasix. Cardiology recommended close electrolyte monitoring to keep her potassium above 4.0. They thought her tachyarrhhythmia was likely an atrial tachycardia and that it would likely resolve over time as the patient recovers from her operation. Her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] recommended transfer to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] where she will be available to manage the patient's remaining medical issues. The patient was discharged to the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] on POD6 in stable condition and will be followed by Dr. [**Last Name (STitle) **] and will follow up in clinic with Dr. [**Last Name (STitle) **]. Medications on Admission: The patient takes home medications including hydrochlorothiazide, Protonix, Fosamax, and naproxen. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], Inc. Discharge Diagnosis: cervical stenosis lumbar stenosis pneumonia hypotension atrial tachycardia Discharge Condition: Neurologically stable Discharge Instructions: Call for fever or any signs of infection - redness, swelling or drainage from wound. No heavy lifting. Keep incisions dry while sutures are in. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] for suture removal in approximately 10 days, call [**Telephone/Fax (1) 2731**] for appt.

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icd9cm

[ [ [] ] ]

[ "99.04", "03.09", "38.93", "00.17" ]

icd9pcs

[ [ [] ] ]

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54949

Discharge summary

report

Admission Date: [**2108-10-10**] Discharge Date: [**2108-10-13**] Date of Birth: [**2033-12-28**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 74F with history of hypertension presented to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with one day history of acute onset shortness of breath. She first noticed shortness of breath while walking up the stairs on Monday. She presented to her PCP who drew [**Name Initial (PRE) **] D-dimer that was elevated. She was sent to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. In the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], she was tachycardiac to 120s and had hypoxemia to high 80s improving to low 90s on NC. ECG showed "strain" in V2 and V3 and TWI in V2 and V3. Bedside ECHO showed RV dilitation. She was given 1 mg/kg lovenox SQ empirically. CTA showed extensive bilateral segmental pulmonary embolism with no saddle embolism. Of note, she denies past medical history of cancer, estrogen usage, known hypercoagulability, recent travel. No family history fo clotting disorders. Labs were significant for troponin 0.3 and BNP 515. The patient was transferred to [**Hospital1 18**] for ICU admission. In the ED, initial VS were: 97.8 110 151/110 20 98% 4L. cTropnT 0.10, lactate 2.3, BNP of [**Numeric Identifier 961**]. Heparin infusion was started, and lovenox was discontinued. On arrival to the MICU, the patient had no complaints or concerns. In the MICU she was continued on heparin infusion and started on coumadin today. Currently patient reports mild sob but denies any chest pain, palpitations, coughing, n/v, diaphoresis, diarrhea, constipation, hematochezia, dysuria, hematuria. Denies any recent weight loss. Past Medical History: - Hypertension - Osteoarthritis Social History: Lives by herself at [**Hospital1 **]. Tiotally independnt with ADSLs - Tobacco: None - Alcohol: None - Illicits: None Family History: No history of clotting disorder or DVT/PE. No history of neoplasm. Physical Exam: VT: 98.1 HR 95 BP 140s/80 O2 98% on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Skin: diffuse hyperpigmented lesion in the her face. one crusted escahar lesion in her lower lip. Pertinent Results: Admission/Pertinent Labs: [**2108-10-10**] 07:25PM BLOOD WBC-12.7* RBC-4.60 Hgb-15.2 Hct-42.1 MCV-91 MCH-32.9* MCHC-36.0* RDW-15.3 Plt Ct-219 [**2108-10-10**] 07:25PM BLOOD Neuts-88.0* Lymphs-7.2* Monos-4.1 Eos-0.4 Baso-0.2 [**2108-10-10**] 07:25PM BLOOD PT-13.2* PTT-39.7* INR(PT)-1.2* [**2108-10-10**] 07:25PM BLOOD Glucose-125* UreaN-36* Creat-1.2* Na-134 K-7.2* Cl-99 HCO3-26 AnGap-16 [**2108-10-10**] 07:25PM BLOOD proBNP-[**Numeric Identifier **]* [**2108-10-10**] 07:25PM BLOOD cTropnT-0.10* [**2108-10-11**] 02:02AM BLOOD CK-MB-5 cTropnT-0.09* [**2108-10-11**] 08:10PM BLOOD CK-MB-6 cTropnT-0.07* [**2108-10-10**] 07:25PM BLOOD Calcium-9.8 Phos-3.6 Mg-1.9 [**2108-10-10**] 07:35PM BLOOD Lactate-2.3* K-5.6* [**2108-10-10**] 11:28PM BLOOD Lactate-1.4 . Discharged Labs: [**2108-10-13**] 09:00AM BLOOD WBC-9.6 RBC-4.05* Hgb-12.8 Hct-37.6 MCV-93 MCH-31.6 MCHC-34.1 RDW-15.2 Plt Ct-240 [**2108-10-13**] 09:00AM BLOOD PT-22.8* INR(PT)-2.2* [**2108-10-13**] 09:00AM BLOOD Glucose-92 UreaN-26* Creat-0.9 Na-138 K-4.1 Cl-101 HCO3-25 AnGap-16 [**2108-10-13**] 09:00AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.6 . TTE: [**2108-10-11**] The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 75%). Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. The right ventricular free wall thickness is normal. The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve 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: findings are consistent with hemodynamically significant pulmonary embolism with severe right ventricular dysfunction Brief Hospital Course: 74F with history of hypertension who presented with shortness of breath and found to have bilateral submassive pulmonary embolism with right heart strain. . # Submassive Pulmonary embolism: Patient initially presented to PCP's office with acute shortness of breath and tachycardia and found to have elevated d-dimer; sent to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where CTA showed bilateral pulmonary embolisms along with RV strain on EKG and on echo but hemodynamically stable. She was given one dose of Lovenox and transferred to [**Hospital1 18**] MICU service. Repeat TTE showed severe RV dysfunction but she remained hemodynamically stable therefore she did not undergo thrombolytic or surgical embolectomy. She was transferred to regular medical floor with IV heparin. She was transitioned to Lovenox injections [**Hospital1 **] dosing and started on Coumadin On the medical floor patient complained of shortness of breath on exertion but denied any chest pain, or shortness of breath. One day prior to discharge she was weaned off of oxygen and had sats in mid 90s. She was also evaluated by physical therapy and had ambulatory sats ranging 89-92. On the day of discharge patient's INR was 2.2. She will have her next INR checked at PCP's office on [**10-16**]. If her INR remains therapeutic then her PCP will discontinue lovenox injections. Patient has no obvious risk factors for PE such as stasis, recent surgery/trauma, or hypercoagulable state. Given her age, it is suspicious that she might have an underlying malignancy or other secondary process causing bilateral PE. Patient's PCP will decide to initiate further work up to screen for coagulopathies that could have caused patient's pulmonary embolism including a screening colonoscopy for colon cancer. Per patient she is also about to undergo skin biospy by dermatologist for suspicious skin lesions. . # CKD: Likely secondary to her HTN. Baseline Cr from [**2098**] is 1-1.2 at [**Hospital1 **] records (estimated eGFR 44) with admission Cr 1.2. Her discharged Cr of 0.9. . # Hypertension: Patient was hypertensive to 180s one day after admission in the setting of not received her home hypertensive medications. She was started on her regular home medications Triameterene-HCTZ and amlodipine and her blood pressures dropped to 140s. . # Emergency contact: [**Name (NI) **] [**Last Name (NamePattern1) 41841**] (daughter) Home: [**Telephone/Fax (1) 112218**]; cell: [**Telephone/Fax (1) 112219**]: [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 23096**] (daughter) Home [**Telephone/Fax (1) 112220**]; cell: [**Telephone/Fax (1) 112221**] #Code: Full . Transitions of Care: - Patient will follow up with PCP on tuesday [**10-16**] at 11am. Patient will also have her INR checked on tuesday and her coumadin dose will be adjusted based on her INR. Her lovenox injections will be discontinued if INR remains therapeutic. PCP will initiate [**Name9 (PRE) 8019**] for hypercoagulable states that may lead to patient's PE including cancer screening. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient PCP. 1. Amlodipine 5 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. triamterene-hydrochlorothiazid *NF* 37.5-25 mg Oral Daily 4. Codeine Sulfate 30 mg PO Q6H:PRN Pain Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Gabapentin 300 mg PO TID 3. triamterene-hydrochlorothiazid *NF* 37.5-25 mg Oral Daily 4. Enoxaparin Sodium 80 mg SC Q12H RX *enoxaparin 80 mg/0.8 mL 1 Injection Twice daily Disp #*20 Syringe Refills:*0 5. Outpatient Lab Work Please have your INR checked on [**2108-10-16**] at your PCP's office. 6. Codeine Sulfate 30 mg PO Q6H:PRN Pain RX *codeine sulfate 30 mg 1 tablet(s) by mouth Every 6 hours Disp #*10 Tablet Refills:*0 7. Warfarin 3 mg PO DAILY RX *warfarin 1 mg 3 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: 1. Submassive pulmonary embolism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [**Known lastname 5261**], It was a pleasure taking care of you during your hospitalization at [**Hospital1 18**]. You were initally seen at [**Hospital3 4107**] emergency room for shortness of breath where you were found to have pulmonary embolisms (blood clots in your lungs). Given the extensive nature of the pulmonary embolism you were transfered to [**Hospital1 18**] for further care. An ultrasound of your heart showed severe strain on your heart because of the pulmonary embolisms. You were started on blood thinners called coumadin and lovenox injections for treatment of your pulmonary embolism. You will need to have your coumadin levels (INR) checked on regular basis (see appointment below). Your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**] will adjust your coumadin dose based on your INR value. You should also continue to use lovenox injections until your INR becomes therapuetic for at least two days which will be determined by your primary care physician. [**Name10 (NameIs) **] also recommend that your doctor initiate work up to screen for coagulopathies that could have caused your blood clots in your lungs. You should also have a conversation with your primary care physician about getting [**Name Initial (PRE) **] screening colonoscopy since you have never had one. Please take the rest of your medications as directed in your discharge medication sheet. Followup Instructions: You have an appointment with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**] on Tuesday [**2108-10-16**] at 11am. You should also have your INR value checked at your PCP's office on the same day. If your INR is therapeutic (INR [**3-16**]) that day, your lovenox can be stopped. Completed by:[**2108-10-14**]

[ "428.0", "585.9", "428.31", "715.90", "403.90", "415.19" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9168, 9174

5196, 7877

327, 334

9251, 9251

3017, 3027

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9195, 9230

8298, 8559

9402, 10843

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268, 289

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2043, 2163

23,657

155,617

13527

Discharge summary

report

Admission Date: [**2147-1-21**] Discharge Date: [**2147-1-24**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine Attending:[**First Name3 (LF) 1145**] Chief Complaint: Nausea and Vomiting Major Surgical or Invasive Procedure: none History of Present Illness: This is a 34 year old man with PMH of T1DM, diabetic nephropathy, recurrent gastroparesis, and retinopathy presenting with nausea and vomiting of sudden onset during HD at [**Hospital1 18**] this morning. Pt began to feel nauseaous this morning during the car ride to HD and vomited before the treatment began. While in HD, Pt vomited and retched violently, which pulled the HD tubing out of his AV fistula and led to an arterial bleed. This was controlled with clamping and the patient was sent to the [**Hospital1 18**] ED. . In the ED his initial VS were 98.6, 80, 238/117, 24, and 97%. The patient reports nausea and vomiting over the last couple days of abdominal pain he has a history of gastroparesis and this feels similar to that. He denied any fevers or abdominal pain different from his previous episodes of gastroparesis. He did not have an elevated BS in ED, and his urine did not have ketones. He was given dilaudid, fluid, zofran and iv reglan to help control his abdominal pain and nausea/vomiting, but this had little effect. He was also given IV metoprolol since he reported not being able to keep down his BP meds this morning. He was sent back to the HD unit to finish his hemodialysis where he had a BP in the 220's/120's. Patient was given 2 inches of nitro paste, 25 mg SL captopril. He was also ordered for home amlodipine and carvedilol, but he vomited these up. BPs better controlled to SBP 190s, but after a few minutes, rose back up to 220s. Pt was continually somnolent, uncomfortable while on HD unit. . Currently, the patient continues to be nauseous and is vomiting green liquid. He is complaining of abdominal pain and requesting dilaudid. He denies any chest pain, palpitations, dyspnea, headache, visual changes, dizziness, somnolence. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -DM type I since age 19, followed at [**Last Name (un) **]. Complicated by nephropathy, neuropathy, gastroparesis, retinopathy. Prior episodes of DKA and hospitalization. -ESRD on HD T/Th/S: right arm fistula, [**Location (un) **] [**Location (un) **], dry weight 73kg -Hypertension -Nonischemic cardiomyopathy with EF 30-35% -Anemia: felt to be due to both iron deficiency and advanced CKD -Depression -Pulmonary hypertension -Migraines Social History: -Home: Lives with his GF. Mother lives in the area as well. -Tobacco: trying to quit; has relapsed and smokes 1 pack per week or week and a half -EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [**2144-11-14**] -Illicits: Denies other drugs. Family History: Paternal GF had DM2 but nobody with DM1. Hypertension in a few family members. Physical Exam: ON ADMISSION: VS - Temp afebrile, BP 215/124 , HR 95, R 24, 97 O2-sat % RA GENERAL - ill-appearing man, uncomfortable, moving around to try and get comfortable HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, tachypnic, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, S1 + S2 + S4. Ventricular gallop rhythm. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - AA0x3, cooperative but combative. . AT DISCHARGE: Vitals - Tm/Tc: 98/97.9 HR: 67-71 BP:111-148/69-104 RR:18 02 sat: 100% RA GENERAL: 34 yo M in no acute distress HEENT: no lymphadenopathy, JVP non elevated CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, no edema. DPs, PTs 2+. exam otherwise unchanged. Pertinent Results: CBC: [**2147-1-21**] 01:50PM BLOOD WBC-7.2 RBC-3.97*# Hgb-12.3*# Hct-36.1* MCV-91 MCH-31.0 MCHC-34.2 RDW-12.8 Plt Ct-253 [**2147-1-24**] 07:00AM BLOOD WBC-5.8 RBC-3.57* Hgb-11.0* Hct-32.1* MCV-90 MCH-30.9 MCHC-34.4 RDW-13.0 Plt Ct-231 . ELECTROLYTES: [**2147-1-21**] 01:50PM BLOOD Glucose-219* UreaN-32* Creat-7.7*# Na-138 K-4.8 Cl-94* HCO3-24 AnGap-25* [**2147-1-24**] 07:00AM BLOOD Glucose-101* UreaN-63* Creat-11.7*# Na-126* K-4.1 Cl-81* HCO3-29 AnGap-20 [**2147-1-22**] 01:04AM BLOOD Calcium-9.8 Phos-4.8*# Mg-1.9 [**2147-1-24**] 07:00AM BLOOD Calcium-8.7 Phos-6.3* Mg-1.9 . LFTs: [**2147-1-22**] 01:04AM BLOOD ALT-35 AST-82* LD(LDH)-858* AlkPhos-128 TotBili-0.5 . MICROBIOLOGY: BC x1 from [**1-22**] NGTD . STUDIES/IMAGING: ECG on arrival [**2147-1-24**] Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy. Compared to tracing #1 the findings are similar. . CXR [**2147-10-25**] COMPARISON: Multiple prior examinations, most recent dated [**2146-9-21**]. FINDINGS: No focal opacity to suggest pneumonia is seen. No pneumothorax, pulmonary edema or significant pleural effusion is present. Moderate cardiomegaly is slightly decreased. . CXR [**2147-11-24**] FINDINGS: PA and lateral chest radiographs were provided. There is no focal consolidation, pneumothorax or pleural effusion. Mild-moderate cardiomegaly persists. There is no evidence of CHF. IMPRESSION: No acute cardiopulmonary process. Stable mild-moderate cardiomegaly. Brief Hospital Course: 34 year old man with PMH of poorly controlled T1DM, diabetic nephropathy, recurrent gastroparesis, and retinopathy presenting with nausea and vomiting of sudden onset during HD treatment accompanied by hypertension and abdominal pain. . #Nausea/vomiting/abdominal pain: Pt vomited multiple times during his HD treatment and again in the ER. Infection felt to be unlikely given that pt was afebrile w/o any localizing signs, elevated WBC. Pt also does not have any ketones, ruling out DKA. Most likely differential include gastroparesis vs uremia. Nausea was controlled with zofran/ativan. WBCs trended without elevation. Serial abdominal exams were benign. Pt also has extreme abdominal pain from his gastroparesis with home regimen of dilaudid for which he has a narcotics contract with his PCP. [**Name10 (NameIs) 40902**] not ideal, since they are likely to be exacerbating gastroparesis. Pain managed with pr tylenol, IV reglan. Pt complaints improved. Pt also given pain clinic appt on discharge. . #Hypertension: Pt has well-documented essential hypertension. Patient has been hypertensive since he came to the hospital. His BP has been ranging from 190-220 systolic over 100-120 diastolic. PO BP meds (carvedilol, nitropaste, and captopril) have been ineffective in lowering his BP significantly during HD. His normal BP is 160's-180's. 3L volume was removed in HD the day of admission. It was felt that abdominal pain from n/v was likely contributing to hypertension. Pt is allergic to hydralazine. Sublingual captopril and Labetelol PRN was used overnight to control BP to target of SBP 180s. Also, pain was controlled with rectal tylenol, IV reglan. Pt was eventually restarted on all his home meds and SBP was in the 130-140s upon discharge. Minoxidil was considered however not started as BP was well-controlled on current regimen. Home Carvedilol was changed to 25mg [**Hospital1 **] as that is the max dose. . #Diabetes: Pt's sugars were in the 200 range on day of admission. Urine ketones negative so not in DKA. Normally his sugars are in high 100's or 200's. Occasionally he's in the 100s. He recently saw [**Last Name (un) **] in [**9-19**] and they had continued his lantus and SSI regimen. He's currently taking lantus 18 units in the morning at home. They increased it from 15 over the last few months. He's also using a humalog sliding scale at home. Pt was maintained on home regimen with sliding scale during this admission, [**Last Name (un) **] was following. Pt was given [**Last Name (un) **] f/u appt on discharge. . #Elevated troponins: Patient with troponin elevated to 0.16. Has been elevated to these levels on multiple prior admissions. Most likely due to renal failure and inability to clear trops. Less likely ACS as no ischemic changes on ECG or active CP. Enzymes were not cycled as this level was his baseline. . #End stage renal disease: renal failure [**2-9**] to DM. HD schedule on [**Last Name (LF) **], [**First Name3 (LF) **], Sat. Last dialyzed today with removal of 3L fluid. Continued regular dialysis as scheduled. Home sevelamer and Nephrocaps were cotninued. . #Depression: Pt has a h/o depression and passive SI. SW was consulted. Home meds were continued. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule - one Capsule(s) by mouth once a day CARVEDILOL - 25 mg Tablet - 2 Tablet(s) by mouth twice a day [**First Name3 (LF) **] - 0.2 mg/24 hour Patch Weekly - apply as directed weekly GLUCAGON (HUMAN RECOMBINANT) [GLUCAGON EMERGENCY] - 1 mg Kit - use as directed for low blood sugar or passing out HYDROMORPHONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for severe pain 28 day supply INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - 18 units every morning Daily INSULIN LISPRO [HUMALOG PEN] - (Prescribed by Other Provider) - 100 unit/mL Insulin Pen - Sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - Use as directed one hour prior to dialysis three times a week LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth once a day METOCLOPRAMIDE - 5 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for Abdominal discomfort Please take 30 minutes before meals. OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth Daily ONDANSETRON - 4 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth every eight (8) hours as needed for Nausea SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 1 Tablet(s) by mouth TID with meals SILDENAFIL [VIAGRA] - 100 mg Tablet - 0.5 (One half) Tablet(s) by mouth Daily as needed for Sexual activity Take [**1-9**] tablet 1 hour before sexual activity. SUMATRIPTAN SUCCINATE - 25 mg Tablet - 1 Tablet(s) by mouth ONCE [**Month (only) 116**] repeat in 2 hours if no effect. ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily BLOOD SUGAR DIAGNOSTIC [ONE TOUCH TEST] - Strip - To be used four times daily DEXTROSE [GLUCOSE GEL] - 40 % Gel - [**1-9**] Gel(s) by mouth for blood sugar < 60 If blood sugar < 60, take [**1-9**] gels and recheck blood sugar in 30 minutes to one hour. DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a day INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULTRA-FINE] - 30 gauge X [**1-9**]" Syringe - Use up to four times daily as directed [1 mL] LANCETS [ONE TOUCH ULTRASOFT LANCETS] - Misc - 1 Misc(s) four times a day or as directed Discharge Medications: 1. sevelamer carbonate 800 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*270 Tablet(s)* Refills:*2* 2. amlodipine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 3. B complex-vitamin C-folic acid Oral 4. [**Month/Day (2) 40899**] 0.2 mg/24 hr Patch Weekly [**Month/Day (2) **]: One (1) Patch Weekly Transdermal QWED (every Wednesday). 5. Lantus 100 unit/mL Solution [**Month/Day (2) **]: Eighteen (18) units Subcutaneous once a day. 6. lisinopril 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day. 7. lidocaine-prilocaine 2.5-2.5 % Cream [**Month/Day (2) **]: One (1) Appl Topical ASDIR (AS DIRECTED). 8. carvedilol 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day. 9. hydromorphone 4 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day as needed for pain. 10. ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 11. sildenafil 100 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO once a day as needed for as needed for sexual activity: Take 30 minutes before sexual activity. 12. aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: PRIMARY: gastroparesis hypertensive urgency SECONDARY: Diabetes End stage renal disease on hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: It was a pleasure taking care of you during your recent hospitalization. You came in with nausea and vomiting with very high blood pressure. We used medications to control your blood pressure, and we think the nausea and vomiting is due to your gastroparesis from diabetes. We'd like you to follow up at [**Last Name (un) **] to further evaluate these symptoms. Your blood pressure was controlled and we felt it was safe for you to go home. . We made the following CHANGES to your medications: CHANGED sevelamer 800mg three times a day to 1600mg three times a day. CHANGED carvedilol 50mg twice a day to carvedilol 25mg twice a day. STOP taking omeprazole and reglan as you have said they are not helpful. Followup Instructions: ****Please work with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to obtain a referral to the Pain Clinic for management of your gastroparesis pain. Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] When: WEDNESDAY [**2147-2-1**] at 9:30 AM With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: [**Hospital3 249**] When: WEDNESDAY [**2147-2-8**] at 1:45 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24385**], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Appt: [**Telephone/Fax (1) 766**], [**2-13**] at 2pm Department: TRANSPLANT SOCIAL WORK When: FRIDAY [**2147-1-27**] at 1 PM [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2147-1-27**]

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

12719, 12725

5867, 9087

333, 340

12874, 12874

4391, 5844

13712, 15476

3179, 3259

11421, 12696

12746, 12853

9113, 11398

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3983, 4372

13476, 13689

274, 295

368, 2405

3288, 3969

12889, 12958

2427, 2868

2884, 3163

18,962

154,852

51800

Discharge summary

report

Admission Date: [**2135-3-26**] Discharge Date: [**2135-3-30**] Service: MEDICINE Allergies: Penicillins / A.C.E Inhibitors / Avapro Attending:[**First Name3 (LF) 710**] Chief Complaint: incarcerated hernia Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo F h/o CAD s/p MI x2, diastolic CHF, HTN, HL, hypothyroidism, CVA '[**21**] p/w abdominal pain, transferred to MICU for respiratory depression. Pt was in her USOH until yesterday evening when found at [**Hospital1 100**] Senior Life to be in [**9-30**] abdominal pain, with nausea and NBNB emesis. Pt was afebrile and vitals were stable. Transferred to [**Hospital1 **] for further evaluation. In the ED, vitals: 97.6, 83, 235/100, rr 22, sat 95% on ? O2. SBO on CT, related to her ventral hernia. Patient was seen by surgery who manually reduced her hernia -- felt she is not a surgical candidate. Pt confirmed she was a DNR/DNI and did not want surgery even if it was offered. Cardiac enzymes were positive, and pt was started on heparin gtt. Pt given zofran, morphine 10 mg total and dilaudid 6 mg total, levo, flagyl, Aspirin 325. Pt transferred to the [**Hospital Ward Name 121**] 3. When the pt arrived on the floor, pt was unresponsive, breathing at a rate of [**12-22**] breaths per minute, satting 70% ra. Pt supported initially with ambu-bag. Pt given narcan 0.5 mg x 3 and became more reponsive. SBP initially in the 90s but increased to the 190s after narcan. Given lopressor 5 mg iv x 1, lasix 20 mg iv x 1. Sats recovered on NRB. ABG 7.37/43/188. Stat CXR with evidence of R-sided infiltrate. EKG junctional bradycardia, qtc 508. ste v2-3, twi v4-6. Transferred to MICU service for further monitoring. Past Medical History: 1. Atrial fib anticoagulated on coumadin 2. Serere scoliosis with chronic back pain 3. CAD s/p MI in [**2114**] and [**2108**] 4. Diastolic CHF 5. HTN 6. Hypercholesterolemia 7. GERD 8. Esophageal stricture s/p dilation 9. Hypothyroidism 10. S/P R hip fracture 11. S/P CVA- [**2121**] 12. PVD 13. S/P right femoral popliteal bypass 14. S/P hysterectomy 15. Bronchiectasis 16. Aspiration PNA 17. Anxiety 18. Depression 19. Left putaminal infarction- [**2118**] 20. S/P sigmoid resection for benign adenoma 21. S/P cholecystectomy Social History: Pt lives at [**Hospital1 100**] Senior Life. Has two daughters who are very involved in her care. First emergency contact and HCP is her daughter [**Name (NI) **] [**Name (NI) 30940**]. Her phone number is [**Telephone/Fax (1) 107243**]. No tobacco or ETOH. She had her pneumovax in [**11/2130**] and her flu vaccine on [**2133-10-21**]. Family History: non-contributory Physical Exam: Temp 97.3 BP 147/56 Pulse 57 Resp 22 O2 sat 97% 5L NC Gen - somnolent, answering questions HEENT - PER sluggishly RL, anicteric, mucous membranes dry Neck - JVP 12 cm, no cervical lymphadenopathy Chest - crackles at bases CV - brady regular, no murmurs Abd - Soft, mildly tender over hernia which is midline and reducible, normoactive bowel sounds Extr - No edema. 2+ DP pulses bilaterally Neuro - Ox3, following commands Skin - No rash Pertinent Results: [**2135-3-25**] 08:00PM BLOOD WBC-11.0 RBC-3.93* Hgb-13.0 Hct-38.8 MCV-99* MCH-33.0* MCHC-33.4 RDW-14.0 Plt Ct-276 [**2135-3-25**] 08:00PM BLOOD Neuts-89.9* Bands-0 Lymphs-7.0* Monos-2.5 Eos-0.5 Baso-0.2 [**2135-3-25**] 08:00PM BLOOD Glucose-147* UreaN-25* Creat-1.2* Na-143 K-4.0 Cl-96 HCO3-31 AnGap-20 [**2135-3-26**] 11:25AM BLOOD CK(CPK)-126 CK-MB-14* MB Indx-11.1* cTropnT-0.87* [**2135-3-26**] 04:25PM BLOOD CK(CPK)-141* [**2135-3-26**] 04:25PM BLOOD CK-MB-15* MB Indx-10.6* cTropnT-0.71* [**2135-3-28**] 01:15PM BLOOD CK(CPK)-551* CK-MB-11* MB Indx-2.0 cTropnT-0.41* [**2135-3-29**] 08:00AM BLOOD CK(CPK)-209* CK-MB-7 cTropnT-0.38* EKG [**2135-3-26**]: Baseline artifact. Sinus bradycardia versus slow atrial fibrillation. Anterior ST segment elevations are suggestive of myocardial infarction. Compared to the previous tracing ST segment elevation is more prominent and rhythm has changed. [**2135-3-28**]: Atrial flutter with 4:1 conduction. Possible anterolateral myocardial infarction and acute inferior ST-T wave changes may be due to myocardial ischemia. Compared to the previous tracing of [**2135-3-27**] ST segment elevations are more prominent in the lateral leads in the current tracing. Studies: CT abdomen/pelvis [**3-25**]: 1. Periumbilical hernia contains a small portion of small bowel with distention of bowel proximally and nondistention distally -- correlate clinically for suspicion of early small-bowel obstruction at this site. Though the neck of the hernia appears somewhat narrow today, it appeared wide on CT of [**2133-11-27**] and may be manually reducible. No evidence of bowel ischemia. 2. Chronic severe wedge compression fracture of T12. 3. Chronic bibasilar atelectasis. 4. Diverticulosis without acute diverticulitis. TTE [**2135-3-28**]: The left atrium is markedly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis/akinesis of the distal half of the septum and anterior walls. The apex is mildly aneurysmal and dyskinetic. No left ventricular mass/thrombus is seen. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2134-5-21**], the left ventricular wall motion anbormalities are new and c/w interim ischemia/infarction. CXR [**3-26**]: Cardiomegaly is stable. There is bibasilar atelectasis with no definite evidence of pneumonia. The pulmonary vasculature is within normal limits. IMPRESSION: No definite acute cardiopulmonary disease. CXR [**3-27**]: A single AP view of the chest is obtained on [**2135-3-27**] at 09:10 hours and compared with the prior morning's radiograph. Again is seen prominence of the interstitial markings which may represent fluid overload or early edema. Small bilateral pleural effusions are present. The patient has had a nasogastric tube placed with its tip not included on the current image but below the level of the diaphragm. CXR [**3-29**]: In comparison with the study of [**3-27**], the nasogastric tube has been removed. Otherwise, little change in the enlargement of the cardiac silhouette and fluid overload or pulmonary edema and small bilateral pleural effusions. Brief Hospital Course: The patient is a [**Age over 90 **] year-old woman with h/o CAD, diastolic CHF, HTN, and prior CVA admitted with ventral hernia, whose hospital course was complicated by MICU stay for respiratory depression in the setting of narcotics as well as STEMI, which was medically managed. # ventral hernia/SBO: The patient was evaluated by the general surgery service while in the ED, who manually reduced bowel. The patient and her family declined surgical intervention, and was deemed not a surgical candidate by surgery team. She was treated supportively with an abdominal binder. Dr. [**Last Name (STitle) 1120**] (outpatient physician) was contact[**Name (NI) **] re: further recommendations for palliative management. She will see Ms. [**Known lastname 107244**] as an outpatient for further follow-up. # STEMI: The [**Hospital 228**] hospital course was complicated by STEMI in the context of BP > 230/100, likely related to severe abdominal pain. EKG showed anterior ST elevations (V1-3), and peak troponin 0.87 on [**3-26**]. Follow-up echo showed akinesis of apex and dyskinesis/ hypokinesis of anterior septum. Per cardiology recommendations and patient/ family preferences, the patient was treated with medical management as she is poor cath candidate. She was treated with heparin gtt x 48 hours and was continued on ASA, lopressor, plavix, and statin. Despite the akinesis of her apex, she was not felt to be a candidate for anticoagulation. The patient and her family are aware of the risk of mechanical complications of MI; they are aware that a critical event might occur and discussions with palliative care are underway. Just prior to her discharge, the patient was made comfort measures only. Her cardiac meds were adjusted accordingly, and only the medications that might help prevent episodes of shortness of breath or further discomfort were continued. The palliative care team at [**Hospital 100**] Rehab have been made aware of this transition. # Respiratory distress: The patient was briefly transferred to the MICU for respiratory depression, most likely secondary to narcotic medications administered for abdominal pain. She received narcan in the MICU with significant improvement in breathing. Patient continues to have episodes of dyspnea, most likely due to volume overload in setting of impaired pump function/recent MI. DDx also includes mechanical complications of MI (although hemodynamics have been stable), PE (but was recently on heparin gtt), PNA (has not developed fevers). She has responded well to lasix, nitropaste, and morphine with significant improvement in her respiratory status. Lasix and morphine can be continued to keep her breathing comfortably. # Delirium: The patient experienced some delirium after being transferred from the MICU. Delirium was felt to be multifactorial associated with hospital setting, pain medications, and hypernatremia. She was continued on supportive treatment with removal of foley catheter and physical restraints. Benzodiazepines, anticholinergics, and sleeping medications were avoided. She responded well to frequent reoorientation. At the time of discharge, she was alert and oriented to person, time, and place. # Hypernatremia: Most likely due to free water deficit in setting of altered mental status. As the patient has been made comfort measures only, the medical team and the patient's family have decided not to follow her sodium level regularly or to contine IV fluids. # AFib: The patient was continued on home BB with good rate control. The patient does not appear to have been on coumadin by rehab records despite CHADS2 score of 3. Coumadin was not started in house given concern for high fall risk in setting of delirium. Treatment with high dose aspirin was continued, but stopped just before discharge when she was made comfort measures only. # Hypothyroidism: the patient was continued on synthroid at home dose. # Chronic renal failure: creatinine 1.2, at baseline. medications were renally-dosed. # CODE: Comfort measures only. Medications on Admission: tylenol tramodol lasix 40 mg daily toprol 25 mg daily mirtazipine omeprazole 40 mg daily KCL spironolactone xanax vit D wellbutrin levothyroxine 50 mg daily . Allergies: Penicillins / A.C.E Inhibitors / Avapro Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours): 12 hours on, 12 hours off. 4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Hold for SBP < 100. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 8. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 9. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. oxygen please provide 2L of oxygen by nasal cannula to support patient's O2 saturation and provide comfort. 12. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-5 mg PO q2h as needed for pain or shortness of breath: please titrate to patient's comfort but would start with low doses given that patient had episode of narcotic-induced respiratory depression. 13. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary: - Ventral hernia - ST elevation MI - acute systolic heart failure - respiratory failure, likely [**1-22**] narcotics Secondary: # Atrial fibrillation # CAD # Diastolic CHF # HTN # Hypercholesterolemia # Bronchiectasis # Anxiety # Depression Discharge Condition: Patient had stable vital signs and was sat'ing well on 2L of oxygen by nasal cannula. She is comfort measures only. Discharge Instructions: You were admitted with abdominal pain that was due to a hernia. You should continue wearing your abdominal binder to prevent further episodes of this. During your hospital course, you had a heart attack for which you should continue several medications as listed below. You had difficulty breathing (probably due to receiving a lot of pain medications), which resolved in the ICU. Please continue to take all of your medications as prescribed. Please attend all of your follow-up appointments. If you experience any fevers > 101, chills, abdominal pain, chest pain, palpitations, shortness of breath, or any other concerning symptoms please contact your PCP or go to the ER for further evaluation. Medication Changes: 1. We changed your lasix from 40mg daily to 80mg twice a day 2. We started the following medications to help your heart and to treat your pain: hydralazine and lidocaine patch 3. We stopped the following medications because it was unclear that you still need them. Your doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab may choose to restart them: maalox, miacalcin, calcium carbonate, cholecalciferol, spironolactone, tramadol, potassium. Followup Instructions: 1. Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within 1-2 weeks of discharge to discuss your hospitalization. Phone: [**Telephone/Fax (1) 38919**] 2. Please follow-up with Dr. [**Last Name (STitle) 1120**]. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2135-4-5**] 2:15 Completed by:[**2135-3-31**]

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icd9cm

[ [ [] ] ]

[ "96.27" ]

icd9pcs

[ [ [] ] ]

12630, 12695

6871, 10920

266, 272

12990, 13109

3156, 6848

14342, 14773

2665, 2683

11180, 12607

12716, 12969

10946, 11157

13133, 13835

2698, 3137

13855, 14319

207, 228

300, 1740

1762, 2293

2309, 2649

21,021

142,627

26942

Discharge summary

report

Admission Date: [**2146-4-3**] Discharge Date: [**2146-4-19**] Date of Birth: [**2074-7-25**] Sex: F Service: MEDICINE Allergies: Phenytoin / Phenobarbital / Augmentin / Aspirin / Zithromax / Cefazolin Attending:[**First Name3 (LF) 8487**] Chief Complaint: Respiratory distress/rash Major Surgical or Invasive Procedure: ORIF History of Present Illness: Intern Transfer Note . CC:[**CC Contact Info 66254**]. The patient is a 71 year old female with a history of COPD FEV1% 61, rheumatoid arthritis and SLE on prednisone, methotrexate and etanarcept(recently held 1.5 months ago) who presented to [**Hospital3 7571**]status post a spontaneous fracture of the left femur s/p ORIF on [**3-24**] and distal pinning on [**2146-3-31**] at [**Location (un) **]. The patient has a documented history of an allergy to augmentin resulting inpresyncope, nausea and vomiting in the past, but was treated post-op with cefazolin x 3 doses. On [**3-27**], she developed a macular rash on her back and shoulders which then spread to her palms and soles with some desquamation of the skin on her back and spread diffusely throughout her body, as well as swelling of her hands and feet. She was evaluated by dermatology at [**Location (un) **] who felt her skin findings were may have been consistent with a drug reaction as the patient has sensitivity to Augmentin and was placed on cefazolin which has cross-reactivity with pencillins. She underwent a second ortho procedure on [**2146-3-31**], the patient received one dose of vancomycin as a result. However, dermatology was also suspicious of other causes given that her rash appeared to be in multiple stages at that time and vesicular in nature and a Tzanck smear was obtained. Pertienet to her OSH course, the patient also reports that she received 3 units of blood during her ORIF. On [**2146-3-29**], the patient spiked a temperature to 103.4 with a WBC of 14.7 . At the time of her temperature spike, the patient had a UA that was positive for LE with 10-20 WBCs although not a clean sample with [**3-6**] epithelial cells. She was treated for a presumed UTI with urine cultures and blood cultures pending. . On [**2146-4-3**], the patient developed acute-onset shortness of breath with mid-sternal [**4-8**] chest pressure that resolved on its own that the patient states she believes was due to anxiety and productive cough of greenish sputum. A VQ scan was obtained given the patient's recent insufficiency at 1.4-1.6 which was low prob for a PE in the setting of a D-dimer post-operatively of 4200. A cardiology consult was considered but not formerly placed prior to transfer. CXR showed LLL atelectasis. ABG prior to transfer was 7.45/35/241 on 100% NRB. She was transferred to [**Hospital1 18**] on [**4-3**]. On arrival, the patient was felt to be in mild respiratory distress and placed on a high flow mask 35% FiO2 and did not require intubation. Ortho was consulted on [**4-4**]-6 given the patient's increased LLE pain in the setting of her recent surgery. They plan to take her back to the OR once her respiratory status and other medical issue resolve. . On [**4-6**] she was transferred to to the floor on the [**Hospital Ward Name **] where she developed acute SOB again. CXR was did not reveal CHF or PNA and a CTA was performed to r/o PE. It was negative for PE but did reveal b/l pleural effusions with atelectasis and emphysema and questionable small area of devloping PNA, and an Echo with Ef>55%, normal RV size and motionShe as strted on levo/flagyl and continued on nebs with significant improvemnt in her O2 sats to 95 % on 6 L FM. . On arrival to the floor she denied CP, SOB, N/V, abdmonimal pain, calf pain. She says that her skin continues to itch, but is felling much better. . Past Medical History: 1. RA on chronic low dose prednisone, methotrexate and etanercept which was held recently secondary to bacterial sinusitis and ORIF *SLE with no known renal involvement, on chronic prednisone 2. Raynaud's syndrome ? 3. Osteoporosis with spontaneous rib fractures in [**2143**] 4. COPD [**November 2144**] FEV1 1.46 L FEV1/FVC of 61 c/w mod COPD 5. GERD with Schatzki ring requiring endoscopy 6. Hiatal Hernia 7. Anxiety 8. Oral HSV 9. Chronic anemia, on folate, B12, colonoscopy normal 3-4 years ago, SPEP, UPEP negative 10. exercise stress test that per the patient were negative as well as multiple ED-ROMIs. 12.?Mild AS by echo per patient Social History: previous smoker, quit 16 yrs ago but 2 ppd x 30 yrs prior; no EtOH intake, no IVDA. [**Doctor First Name 66255**] (daughter) is HCP [**Telephone/Fax (1) 66256**] and [**Name (NI) 58656**] (granddaughter) [**Telephone/Fax (1) 66257**]. Family History: NC Physical Exam: T 98.4 P 97 BP = 112/60 RR = 16 O2 sat = 98% on 6 L face mask Gen- Elderly female sitting in bed able to talk in complete sentences, no accessory respiratory muscle use, very pleasant, alert and oriented x 3 HEENT - crusting lesions, right forehead with yellow, crusty macules, malar eminences with confluent, erythematous blanching rash, no JVD. Heart - RRR, no m/g/r Lung - CTAB Abdomen - Soft, NT, ND, + BS, no hepatosplenomegaly Ext - incision site C/D/I, 2+ LE edema b/l, right hand 1st digit DIP with RA nodules as well as 4th digit PIP. Ulnar deviation with 1st digit on left hand. Bilateral hand edema. Skin - Diffuse, desquamating, confluent, erythematous, blanching macular rash. Rash extends from head to foot including dorsal aspect as well. Neuro - CN II-XII intact, 5/5 strength in upper extremities. Pertinent Results: [**4-4**] Femur Xray: There is complex comminuted fracture of the proximal femur, with lateral apex angulation of the proximal fragment, with somewhat unusual alignment. The patient is status post fixation with intramedullary rods and screws. There is subcutaneous air abutting the distal femur. IMPRESSION: Status post fixation of comminuted fracture of the proximal femur with proximal lateral apex angulation with somewhat unusual alignment. Subcutaneous air adjacent to the distal femur. . [**4-6**] CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: No evidence of pulmonary embolism. There is a left-sided central venous line. Aorta and great vessels appear intact. The esophagus is mildly dilated and fluid filled. Airways appear patent. No pneumothorax. There are bilateral small pleural effusions with associated compressive atelectasis. There are severe emphysematous changes of the lungs. There is an ill-defined right lower lobe opacity. There is biapical scarring and a left apical bleb. There are multiple right- sided rib fractures. No pneumothorax is seen. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Severe emphysema. 3. Bilateral pleural effusions with compressive atelectasis. 4. Multiple right-sided rib fractures that were also present on [**2146-4-4**]. No pneumothorax identified. 5. Mildly dilated, fluid-filled esophagus. ***6. There is ill-defined opacity in the right lower lobe, possibly representing an early pneumonia. This was conveyed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66258**] at 10:20am on [**2146-4-7**]. . [**4-7**] TTE Conclusions: 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>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. . 3/17 L femur: Five fluoroscopic images are obtained intraoperatively without a radiologist present. These images demonstrate revision of the previously seen intra- medullary rod. Please refer to the surgical report for additional details. . [**4-16**] CXR: A single AP upright view at 14 hours is compared to previous examination a day ago. Since the previous exam, the endotracheal and right IJ line have been removed. The lungs are clear with changes of emphysema. Both hemidiaphragms are flattened. Note is made of old healed rib fractures on the right. The two nodular opacities seen in the right base are likely due to vasculature since there is no corresponding pulmonary abnormality on the recent CT scan dated [**2146-4-4**]. IMPRESSION: Diffuse emphysema, no evidence of acute pulmonary disease. Right-sided rib fractures. . [**4-18**] CXR: Allowing for difference in patient position, the heart size and mediastinal contours are stable. There is minimal atelectasis or scarring at the left lung base. The lungs are otherwise clear. There is no pleural effusion or pneumothorax. Multiple bilateral healed rib fractures are noted. IMPRESSION: Left base scarring or atelectasis. No acute process. [**4-18**]: CBC: WBC 12.5 hct 24.3 plt 346 Chem 10: Na 135, K 4.3, CL 104, CO2 25, BUN 13, creat 0.8, Ca 7.3, mag 1.9, phos 3.2. Multiple BCX, UCX since [**4-4**] to [**4-18**] negative to date. Brief Hospital Course: A/P: 71 yo F with COPD, RA, SLE s/p femur fracture and ORIF with significant residual displacement s/p redo [**4-15**], s/p several admissions to [**Hospital Unit Name 153**] for respiratory distress with tachypnea now with respiratory distress again with tachypnea, hypoxia, unclear etiology and trigger. . 1. Respiratory distress/tachypnea: She was admitted to ICU and transferred to the floor several times for respiratory distress/failure for unclear etiology and intubated/extubated because the patient seemed to be tiring out. She was treated for a COPD flare as chest x-ray was negative for CHF and pneumonia. The patient was ruled out PE with CTA of chest but showed b/l pleural effusions with atelectasis and emphysema and ?small area of developing PNA. Echo was done with EF of 60%. She was extubated the next day but remained tachypneic with O2 sats improved to 95% on 6L FM and was started empirically on Levo/Flagyl for ?PNA and completed course on [**4-15**] (8 day course). The patient was sent to the floor again and the floor team optimized her respiratory status optimized prior to OR with diuresis with 10 IV lasix daily and frequent nebs although diuresis did not seem to improve sxs significantly. Pt was maintained on Lovenox 30 mg SC BID for DVT ppx. Pulmonary team was consulted regarding ongoing hypoxemia and diff dx still included persistent mild CHF, fat emboli, or mucus plugging and recommended continued diuresis and IS. Pt had left femoral revision on [**4-15**], was intubated for surgery and extubated without event and actually seemed improved per floor team with pain meds. After surgery, the patient trasnferred to the floor. While on the floor, pt has been increasingly tachypneic with persistent mild non-productive cough and over the last day increased accessory muscle use. For respiratory distress, worsening tachypnea with RR 40s, the patient was transferred to MICU for further monitoring. CXR revealed no CHF or infiltrates. PE was thought to be less likely given negative CTA on [**4-6**] and on DVT prophylaxis with Lovenox. Her respiratory distress was thought to be more likely secondary to mucous plugging and anxiety as pt was able to breathe better after coughing up thick mucous sputum and placed on haldol for anxiety. ENT was also consulted given her respiratory distress,intubation and hoarse voice and noted sluggish R vocal cord and recommended decadron, nasal saline spray for 2 weeks and avoiding nasal cannula at all costs. Pt will need to f/u wtih Dr. [**Last Name (STitle) 64107**] in [**Hospital **] clinic in 1month after discharge for repeat spoke exam to check vocal cord function. The patient passed speech and swallow and can tolerate regular PO diet. For her tachypnea/anxiety, the patient may receive haldol/prn. The patient needs humidified O2 by face mask for nasal dryness and comfort temporarily. . 2. [**Initials (NamePattern4) 22721**] [**Last Name (NamePattern4) **] rash: The patient developed [**Initials (NamePattern4) 22721**] [**Last Name (NamePattern4) **] lesions after getting CEFAZOLIN at OSH. The patient should NEVER receive PENICILLIN or CEPHALOSPORINS. Per notes, greatly improved from admission. Still has ulcerations in OP but are also improving. The patient is on chronic prednisone 10 mg daily for RA which would help her rash. Continue ammonium lactate 12% to improved exfoliation and vitamin C and zinc for 2 weeks. . 3. Leukocytosis: Unclear etiology - wbc has been steadily increasing and then now trending down. Pt was on vancomycin after ORIF for 4 days. Left hip wound need to be monitored for any signs of infection. . 4. RA/SLE: Pt was on higher prednisone and was tapered down to 10mg daily which is her chronic regimen. Please do not discontinue prednisone. Continue to hold methotrexate and etanercept, and the patient will need a follow up with rheumatologist whether to restart methotrexate/etanercept. . 5. Anemia: Hct stable 28-30. Stools guaiac negative. 300 cc EBL in surgery. The patient will need to follow-up with PCP for hct check. . 6. Femoral Fracture: s/p left femoral nail revision fixation left femur subtrochanteric fracture without complications on [**4-15**]. Pt needs to be on Lovenox [**Hospital1 **] for 3 weeks and schedule a follow-up with Dr. [**Last Name (STitle) 1005**] in 2 weeks after discharge. His office number [**Telephone/Fax (1) 1228**]. Pt needs to be on strict partial weight bearing only on left leg. Continue pain control with pain med/prn. . 7. GERD/Hiatal Hernia: Cont with PPI. . 8. Osteoporosis: Cont outpt Ca, Vit D, fosamax . 9. FEN: The patient passed speech and swallow on [**4-19**] and can take full PO as tolerated. . 10. Access: PICC . 11. Full code Medications on Admission: Meds on transfer: 1. Zinc sulfate 220 daily x 2 wks 2. Vancomycin 1gm IV BID, Day #2 post-op ppx 3. MVI 4. Protonix 40 mg PO daily 5. Prednisone 20 mg PO daily per steroid taper 6. Lidocaine viscous 2% 20 mL TID for oral ulcers 7. Atrovent nebs q6hr 8 Albuterol nebs q6hr and q2hr prn 9. RISS 10. Dilaudid 1 mg IV q3-4 hr prn 11. Lasix 10 mg IV prn given today 12. Folic acid 1 mg PO daily 13. Flovent 110 mcg IH [**Hospital1 **] 14. Lovenox 30 mg SC BID 15. Benadryl prn 16. Colace 100 mg PO BID 17. Tylenol prn 18. Alendronate 5 mg PO daily 19. Ascorbic acid 500 mg PO BID 20. Beclomethasone Dipro AQ (nasal) 1 spray NU [**Hospital1 **] 21. Calcium carbonate 500 mg PO TID with meals Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: Four (4) Spray Nasal QID (4 times a day) as needed for 2 weeks. 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Ascorbic Acid 250 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day) for 2 weeks. 13. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 2 weeks. 14. Insulin Regular Human 100 unit/mL Solution Sig: 1-10 units Injection ASDIR (AS DIRECTED): Insulin sliding scale as directed. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day). 20. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 21. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours) for 3 weeks: s/p hip repair. for discontinuation. 22. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): chronically for RA. 24. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 25. Hydromorphone 2 mg/mL Syringe Sig: One (1) mg Injection Q3-4H (Every 3 to 4 Hours) as needed for pain. 26. Haloperidol Lactate 5 mg/mL Solution Sig: 2.5 mg Injection [**Hospital1 **] (2 times a day) as needed for anxiety. 27. Vaseline Gel Sig: small amount Topical at bedtime for 2 weeks: apply to anterior nares at night time. Discharge Disposition: Extended Care Facility: [**Hospital6 1970**] - [**Hospital1 1559**] Discharge Diagnosis: 1. Respiratory distress 2. Anxiety 3. COPD exacerbation 4. Diastolic CHF 5. [**Initials (NamePattern4) 22721**] [**Last Name (NamePattern4) **] syndrome secondary to Cefazolin 6. Rheumatoid Arthritis 7. SLE 8. s/p L femoral fracture and revision of ORIF 9. Osteoporosis 10. GERD 11. Chronic anemia Discharge Condition: Stable, on high flow humidified O2 mask for comfort Discharge Instructions: Please see extensive d/c summary re: medications and plan of care. Followup Instructions: Follow-up with ENT in 1 month Follow-up with Ortho: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2146-5-10**] 10:20 Follow-up with PCP [**Last Name (NamePattern4) **] 1 week (call for appt).

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Discharge summary

report

Admission Date: [**2155-2-11**] Discharge Date: [**2155-3-21**] Date of Birth: [**2110-1-16**] Sex: M Service: MEDICINE Allergies: Amphotericin B / Ambisome / Campath / Heparin Agents Attending:[**First Name3 (LF) 2297**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Tracheostomy Gastric tube placement Aterial and central venous cannulization Hemodialysis History of Present Illness: Mr. [**Known lastname 37212**] is a 45 y.o. Male with h.o. CML s/p allogenic transplant, chronic GVH, bronchiolitis obliterans s/p recent discharge for worsening dyspnea presented to the ED with hypoxia and altered mental status. . On review of the pt's records it appears as if he was recently admitted for a week for a LLL PNA, treated with a course of abx and discharged yesterday. He was noted to have consolidation on CT chest and was going to be treated at home with Levofloxacin and home O2. Unfortunately he was not able to get his oxygen set up and he was admitted for his dyspnea. During his admission it appears he was altered, remarking on voices telling him things per his wife. On review of OMR it appears he signed out AMA, refused IV antibiotics, further evaluation for his altered mental status and hypercarbia. He was discharged on a regimen of Augmentin. . In the discharge plan available it appears family wanted him home and thought he would be better in a more familiar environment. At home though pt was noted to be altered, specifically non-verbal at times; he would call his wife and when she came to see him he would not say anything. His wife decided to bring him back to the ED for further evaluation. . In the ED initial VS were noted to be BP 178/116, HR 130, Sat 91%. He underwent a CXR which showed LLL infiltration/effusion. For his altered mental status he underwent a CT head which showed an unchanged hypodensity on R fontal and a new 6 mm hyperdense focus in the left temporal lobe, ?mets versus hemorrhage. Neurology were consulted in the ED and determined that his presentation could be infectious and recommended an LP which was performed in the ED. Pt was started empirically on Acyclovir, Ceftriaxone, Vanc, Flagyl. Past Medical History: 1. History of CML (chronic myeloid leukemia). 2. Status post matched unrelated allogeneic transplant in [**2147**]. 3. Chronic GVH (graft-versus-host). 4. History of pericardial effusion and tamponade. 5. Sarcoma of right cheek, status post surgical resection and XRT. 6. History of multifocal pneumonia. 7. Status post parainfluenza pneumonia. 8. Recurrent left hydropneumothorax. 9. History of colitis prior to transplant, s/p asacol treatment 10. Status post right arthroscopic knee surgery. 11. History of ganglion cyst removal from right forearm. Social History: Patient does not smoke, drink alcohol, or use drugs. He is married with three children and lives in [**Location 7658**]. Family History: Non-contributory Physical Exam: GENERAL: Cachectic Caucasian Male lying down in bed HEENT: OS PERRL, tape noted over OD. EOMI with OS testing. Left side of face notable for scar repair. CARDIAC: Tachycardiac (120s), Regular rhythm. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Diminished over LLL otherwise CTAB ABDOMEN: NABS, Scaphoid, Soft, NT, ND. No HSM EXTREMITIES: No edema noted. NEURO: Pt non-verbal, tracks movement with eyes. During my exam pt is able to lift both legs, his left leg from the bed, [**4-11**] strength w/ b/l grip strength. PSYCH: During my examination pt is non-verbal, however pt is occasionally verbal with nurses. At discharge, trach in place. Mouths and writes words. Pertinent Results: ADMISSION LAB STUDIES: CBC: WBC-7.8 RBC-3.04* HGB-9.9* HCT-31.1* MCV-102* MCH-32.7* MCHC-31.9 RDW-16.7* PLT COUNT-232 NEUTS-67.3 LYMPHS-18.9 MONOS-12.9* EOS-0.4 BASOS-0.5 . COAGS: PT-12.7 PTT-25.1 INR(PT)-1.1 . CHEM GLUCOSE-93 UREA N-16 CREAT-1.2 SODIUM-136 POTASSIUM-3.5 CHLORIDE-89* TOTAL CO2-42* ANION GAP-9 ALBUMIN-3.2* CALCIUM-9.2 PHOSPHATE-2.5* MAGNESIUM-2.3 . LFTS: ALT(SGPT)-18 AST(SGOT)-30 LD(LDH)-199 ALK PHOS-227* TOT BILI-0.5 LIPASE-30 . LACTATE-1.6 . ABG: TYPE-ART PO2-71* PCO2-49* PH-7.48* TOTAL CO2-38* BASE XS-11 . VitB12-1567* Folate-GREATER TH Triglyc-174* HDL-23 CHOL/HD-5.3 LDLcalc-65 Prolact-9.2 TSH-7.0* b2micro-3.5* . MICRO: B-glucan and galactomannan neg . Blood cx neg urine cx neg . Sputum cx GRAM STAIN (Final [**2155-2-13**]): <10 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): BUDDING YEAST. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2155-2-15**]): SPARSE GROWTH Commensal Respiratory Flora. YEAST. MODERATE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. ACID FAST SMEAR (Final [**2155-2-14**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. . crypto Ag neg Toxo IgM and IgG neg RPR neg DISCHARGE LABS: [**2155-3-20**] 02:44PM BLOOD WBC-12.4* RBC-2.47* Hgb-7.8* Hct-25.0* MCV-101* MCH-31.5 MCHC-31.1 RDW-17.0* Plt Ct-208 [**2155-3-20**] 02:44PM BLOOD PT-12.6 PTT-23.5 INR(PT)-1.1 [**2155-3-20**] 02:44PM BLOOD Glucose-126* UreaN-18 Creat-3.0* Na-141 K-4.5 Cl-102 HCO3-34* AnGap-10 [**2155-3-17**] 04:14AM BLOOD ALT-8 AST-18 LD(LDH)-165 AlkPhos-325* TotBili-0.4 [**2155-3-20**] 02:44PM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0 [**2155-3-21**] 07:48AM BLOOD Type-ART pO2-101 pCO2-45 pH-7.49* calTCO2-35* Base XS-9 Intubat-INTUBATED [**2155-3-21**] 07:48AM BLOOD Lactate-0.7 Na-139 K-4.1 Cl-98* . ABG [**2155-3-21**] on AC pH 7.49 pCO2 45 pO2 101 HCO3 35 BaseXS 9 Na:139 K:4.1 Cl:98 freeCa:1.19 Lactate:0.7 . ABG [**2155-3-20**] after aspiration: pH 7.31 pCO2 76 pO2 93 HCO3 40 BaseXS 7 Type:Art; Not Intubated; Rate:/17; O2-Flow:40; Temp:36.8 . . . . . . . . . . ................................................................ Reports [**3-19**] CTA:IMPRESSION: 1. No CTA evidence of a tracheal innominate fistula. 2. Marked interval worsening of bilateral pleural effusions with compressive atelectasis and consolidations. 3. No evidence of high-grade stenosis, occlusion, or dissection involving the extracranial arterial vasculature. 4. Incomplete evaluation of the intracranial arterial vasculature demonstrates no evidence of high-grade stenosis, aneurysm, or arteriovenous malformation. 5. Stable calcifications and hyperdensity in the right temporal and frontal lobes, likely representing prior radiation treatment. 6. Scattered sclerotic densities within the bone marrow likely secondary to metastases. 2/910 CXR:REASON FOR EXAMINATION: Respiratory failure, rising white blood cell count. Portable AP chest radiograph was compared to [**2155-3-15**]. The tracheostomy tip is approximately 3.5 cm above the carina. The NG tube tip passes below the diaphragm with its tip not clearly seen. The right central venous line tip is at the cavoatrial junction. Cardiomediastinal silhouette is stable. Bilateral pleural effusions are unchanged as well as moderate-to-severe pulmonary edema. The above-described findings might obscure infection and if clinically warranted further evaluation with chest CT might be considered. TTE [**2155-2-27**]:The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2155-2-6**], the heart rate is now normal and LVEF is normal. Moderate pulmonary hypertension is detected. MR [**Name13 (STitle) 430**] [**2-/2155**] IMPRESSION: 1. Heterogeneous signal and enhancement with associated mass effect within the right frontotemporal lobe -partly characterized on the recent CT scan and outside neck MRI from [**Month (only) **]. While the above findings could reflect post-radiation change as previously suggested, consideration should be given to the possibility for radiation induced neoplasm, related to CML/sarcoma of the face/denovo or even graft-versus-host disease. Further characterization is suggested, which could take the form of a Thallium/PET scan and/or biopsy. Infection is less likely given it's identification on MR Neck done about 6 months earlier. 2. Punctate subacute hemorrhage within the posterior aspect of the left superior temporal gyrus associated with additional areas of hemosiderin staining throughout the subarachnoid space bilaterally with no hydrocephalus. A hemorrhagic focus, cavernoma are likely; metastatic or infectious lesion remains possible despite the lack of solid enhancement, however less likely. Attention on follow up can be considered. 3. Extensive maxillary sinus and bil. mastoid air cell disease bilaterally with air-fluid levels as well as partial visualization of the post-surgical changes within the right face. 4. Patent major intracranial arteries without flow limiting stenosis, occlusion, aneurysm more than 3mm within the resolution of MRA. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: ##. Respiratory Failure: Patient was noted to be increasingly hypercapnic on prior admission. ABG at admission showed him to be in similar range as previously. He became increasingly tachypnic as well, to RR>50. Due to concern for fatigue and altered mental status, pt was intubated. Due to jaw reconstruction and radiation changes, he had to be nasally intubated. He initially failed SBTs due to copious secretions, poor mental status, and low tidal volumes. He was treated with vanco, CTX, levaquin. He was diuresed aggressively to facilitate extubation. As his mental status improved, he was able to be extubated. He was transferred to BMT floor, however he had a witnessed aspiration event leading to eventual re-intubation on [**2-28**]. Pt likely has multifactorial chronic end-stage respiratory failure due to severe bronchiolitis obliterans and generalized muscle weakness. Patient was treated for hospital associated aspiration PNA with vanco, cefepime, Flagyl. However, CXR more c/w bibasilar collapse with bilateral pleural effusions. Patient was diuresed aggressively in attempts to clear pleural effusions and re-expand lung, however, Cr began to rise after massive diuresis with lasix gtt and further diuresis was not possible. He eventually had tracheostomy placed [**2155-3-12**]. There was some bleeding noted from trach site on [**2155-3-18**] so he had bronch which did not reveal etiology of bleeding and also had CTA which did not reveal any communication with artery. Bleeding resolved and was felt to be superficial. On discharge, he had been weaned to trach mask off vent for several hours on [**3-20**] but was placed back on AC after witnessed aspiration [**2155-3-20**]. **Patient likes to sip water and will ask anyone who enters his room to give him water. This significantly hinders his progress as he recurrently aspirates and he should be strictly NPO. He was continued on azithromycin for his bronchiolitis obliterans. At discharge, vent settings: Pressure Support 10, PEEP 5 FiO2 60%. . ##. ALTERED MENTAL STATUS Patient initially admitted with altered mental status. MRI/MRA showed right frontotemporal enhancing lesion, and left superior temporal gyrus punctate hemorrhage. Similar findings had been partially visualized on a sinus CT in [**7-16**]. Neurology and neurosurgery discussed patient at tumor board. It was felt that lesions were most likely post-radiation changes and did not require biopsy. Given ICU team's concern for seizures, patient was transitioned from fosphenytoin to Keppra. Pt has significantly waxing and [**Doctor Last Name 688**], at times highly agitated and other times unresponsive on the same amount of sedation. Neurology was consulted. EEG did not show seizure activity. LP had 7 WBC but normal protein and glucose, less concerning for bacterial meningitis. Patient was initially treated empirically with acyclovir and ampicillin until HSV PCR was negative and final cx ruled out Listeria. Patient's mental status improved gradually, and upon first extubation he was alert, oriented and appropriate. Following second intubation, mental status remained largely at baseline, with some increased waxing and [**Doctor Last Name 688**] on sedation, likely [**3-11**] ICU delirium. He was continued on fentanyl patch and prn morphine and zyprexa. . ##. Hypotension: Pt became hypotensive at MRI and required pressors. He was treated with broad spectrum antibiotics, with presumed source being previously undertreated PNA. No micro data returned positive. He was able to be weaned off pressors and remained hemodynamically stable. . ##. CML s/p transplant: complicated by chronic GVHD and bronchiolitis oblit erans. Pt was on Prednisone taper as an outpatient and continued on prednisone 5mg PO daily. Bactrim and Acyclovir for prophylaxis were held due to renal failure but could be restarted as outpatient if kidney function does not recover and he is continued on HD. . ## Atrial flutter with rapid ventricular response: Patient developed A flutter with RVR while on BMT floor. Patient was asymptomatic with rates 150-160s. He was well controlled on diltiazem drip. Cardiology was consulted for possible ablation. After several discussions with heme/onc team, cardiology and ICU team, it was determined that patient was not good candidate for ablation procedure and it would be most appropriate to treat with rate control. Patient was transitioned to PO dilt as well as metoprolol was rate controlled with HRs 80s-110s. . #. Nutrition: Patient has been nutritionally deficient at home for at least several weeks. This issue was complicated by infection, mental status, radiation changes to jaw, and overall deconditioning. He had a witnessed aspiration event and he subsequently failed speech and swallow for all PO's. Video swallow suggested diffuse muscle weakness, likely due to deconditioning. Heme/onc team thought that with improved nutrition for several weeks, patient could regain strength and be reassessed for taking POs. NGT was not realistic since patient would not tolerate tube after extubation. After several family discussions, family initially did not want to pursue PEG but they changed their mind and he ultimatley had IR guided PEG tube placed and was started on tube feeds. . #. [**Last Name (un) **]: Patient's creatinine began to rise after aggressive diuresis with lasix gtt during second intubation. Urine lytes were c/w pre-renal picture, however Cr continued to rise after diuresis was halted and he was felt to have ATN. Vanco level was also found to be elevated at 94 which may have led to nephrotoxicity as well. Cr continued to rise and he remained oliguric. Renal was consulted and he was started on hemodialysis three times per week (MWF) which will be continued at rehab. UOP continued to be low at discharge 20-30cc per day. - Follow I's/O's - Followe inter-dialysis Chem 7 to evaluate for renal recovery Medications on Admission: Acyclovir 400 mg q12hrs Folic Acid 1 mg daily Lorazepam 0.5 mg q8hrs PRN Pantoprazole 40 mg daily Polyvinyl Alcohol-Povidone 1.4-0.6 % 1-2gtts PRN Camphor-Menthol 0.5-0.5 % 1 Appl Top QID PRN Oxycodone 5 mg q6-8 hrs PRN Prednisone 5 mg daily Polyethylene Glycol 3350 17 grm daily PRN Augmentin 250-125 mg 2 tabs x 10 days Discharge Medications: 1. Miconazole Nitrate 2 % Powder [**Last Name (un) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin rash. 2. Nystatin 100,000 unit/g Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin rash. 3. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**2-8**] Sprays Nasal TID (3 times a day) as needed for dry nostrils. 4. Polyvinyl Alcohol 1.4 % Drops [**Month/Day (2) **]: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. 5. Prednisone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 10. Olanzapine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed for Agitation. 11. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO TID (3 times a day). 12. Diltiazem HCl 90 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4 times a day). 13. Clonazepam 0.5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 15. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 16. Fentanyl 75 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 17. Azithromycin 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q48H (every 48 hours). 18. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation QID (4 times a day). 19. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours). 20. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q HD (). 21. Morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mg PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: Respiratory failure, acute renal failure, altered mental status, aspiration pneumonia Secondary: atrial flutter, chronic graft versus host disease 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 37212**], You were admitted for diffuclty breathing which is secondary to your lung disease as well as recurrent aspiration. You were intubated twice for difficulty breathing and ultimatley had a tracheostomy placed because you were unable to breathe well without the help of the ventilator. A tube was also placed for nutrition and you are receiving feeds through your stomach. Please do not eat or drink via your mouth as this worsens your breathing and will decrease your ability to ever come off the ventilator. Please take all of your medications as instructed and keep all of your follow-up appointments. You will need to return to the ICU for appointments with your oncologist if you remain on the ventilator. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2155-3-27**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2155-3-27**] 1:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2155-3-27**] 1:30 Completed by:[**2155-3-21**]

[ "507.0", "518.0", "205.10", "401.9", "276.2", "427.32", "511.89", "279.52", "996.85", "053.9", "349.82", "491.8", "112.3", "263.9", "780.09", "710.1", "518.84", "584.5", "519.19" ]

icd9cm

[ [ [] ] ]

[ "33.24", "38.93", "96.6", "96.72", "03.31", "96.04", "39.95", "38.95", "33.22", "43.11", "31.1" ]

icd9pcs

[ [ [] ] ]

18234, 18334

9678, 15584

335, 427

18535, 18535

3693, 4981

19477, 20006

2949, 2967

15956, 18211

18355, 18514

15610, 15933

18707, 19454

4997, 9655

2982, 3674

274, 297

455, 2215

18549, 18683

2237, 2793

2809, 2933

57,437

144,360

15191

Discharge summary

report

Admission Date: [**2119-3-15**] Discharge Date: [**2119-3-16**] Date of Birth: [**2052-11-27**] Sex: M Service: Medicine, [**Location (un) **] Firm HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman with alcoholic hepatitis with portal hypertension, status post transjugular intrahepatic portosystemic shunt procedure in [**2117-12-10**], who presented today for redo of his transjugular intrahepatic portosystemic shunt because of concern for worsening progressive ascites. The patient usually gets serial taps every three to four weeks but recently started accumulating more rapidly requiring taps every two weeks, and now fluid reaccumulated after one week over the past weekend. Plans were made for the patient to have a repeat transjugular intrahepatic portosystemic shunt done while on the liver transplant waiting list. Otherwise, he had no complaints and was in his usual state of health. No fevers, chills, chest pain, or abdominal pain. He does have chronic dyspnea on exertion after two flights of stair; which is unchanged. Also of note, the patient with increased weight gain and increased reaccumulation of ascitic fluid. Noted to have an increase in nausea and heartburn symptoms. He had an esophagogastroduodenoscopy (per Dr. [**First Name (STitle) **] on [**3-2**] which showed grade I varices with a stricture, but otherwise normal. He tolerated transjugular intrahepatic portosystemic shunt well today but was noted to be hypotensive during the entire procedure and was on a Neo-Synephrine drip throughout with only 400 cc of intravenous fluids given. The patient reports chronic hypotension with systolic blood pressures in the 70s and reports taking all of his antihypertensive medications and diuretics in the morning prior to the procedure. At the time, examination with hypotension. The patient was maintaining appropriate portal pressures before and after stenting with 40/23 which had declined to 35/27. During his procedure, the patient also had an ultrasound-guided paracentesis during which two liters of fluid were removed, and he was admitted for observation after to re-evaluate with an ultrasound in the morning to evaluate portal flow, at which time his large right internal jugular central line could be discontinued. PAST MEDICAL HISTORY: (Past Medical History includes) 1. Alcoholic hepatitis with portal hypertension; status post transjugular intrahepatic portosystemic shunt in [**2117-2-9**]. 2. Atrial fibrillation; on digoxin and atenolol. 3. Degenerative joint disease of C3 to C7. 4. Status post left inguinal hernia repair in [**2118-2-9**]. 5. Grade I varices. MEDICATIONS ON DISCHARGE: 1. Spironolactone. 2. Lasix. 3. Atenolol. 4. Digoxin. 5. Colchicine. 6. Multivitamin. 7. Calcium replacement. 8. Magnesium replacement. 9. Zinc replacement. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: A family history of diabetes in mother. Brother with coronary artery disease. No history of liver disease. SOCIAL HISTORY: The patient is a retired truck driver who lives with long-term girlfriend. [**Name (NI) **] has a daughter near the [**Location (un) 1121**]. He quit alcohol four months ago. He smokes 40 years ago with a 40-pack-year history. No drugs. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed the patient's temperature was 96.7 degrees Fahrenheit, his heart rate was 78, his blood pressure was 90/60, his respiratory rate was 15, and his oxygen saturation was 97% on 3 liters by nasal cannula. In general, he was awake, alert, and oriented. In no acute distress. Head, eyes, ears, nose, and throat examination revealed the pupils were equal, round, and reactive to light. No scleral icterus. The mucous membranes were dry. Neck with a right internal jugular catheter in place. There was no lymphadenopathy. Chest was clear to auscultation bilaterally. Decreased breath sounds at the bases bilaterally (right greater than left). Positive gynecomastia. Cardiovascular examination revealed a regular rate and rhythm. No murmurs. The abdomen was soft and nontender but distended. Positive hepatomegaly. Positive caput medusae. Positive angiomata. Extremity examination revealed no cyanosis, clubbing, or edema. Positive chronic venous stasis changes. Dorsalis pedis pulses were 1+ bilaterally. Cranial nerves II through XII were grossly intact with good strength in all extremities. No asterixis. PERTINENT LABORATORY VALUES ON PRESENTATION: On [**3-9**], white blood cell count was noted to be 4.9, his hematocrit was 36.5, and his platelets were 145. Chemistry-7 was within normal limits. INR was 1.4. Liver function tests were normal except for an alkaline phosphatase of 106, alanine-aminotransferase was 17, aspartate aminotransferase was 36, total bilirubin was 3.4. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram with sinus bradycardia with prolonged P-R intervals. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is a 66-year-old gentleman with alcoholic hepatitis and portal hypertension here status post transjugular intrahepatic portosystemic shunt and for a paracentesis. 1. ALCOHOLIC HEPATITIS WITH PORTAL HYPERTENSION ISSUES: The patient tolerated the second transjugular intrahepatic portosystemic shunt procedure well. He had a repeat ultrasound which reflected good portal flow. Otherwise, no difficulties. He did have a repeat paracentesis and two liters were withdrawn on the day of admission and five liters were removed on the day following admission. The patient tolerated these well without difficulty. He had stable liver function tests and was continued on his Lasix and Aldactone. On the morning of discharge, prior to paracentesis, the patient did have slightly decreased urine output which resolved after paracentesis, and he was continued on his Lasix and Aldactone regimen. His blood pressure remained stable. His hematocrit remained stable status post procedure; even with hydration. Otherwise, he was stable. 2. ATRIAL FIBRILLATION ISSUES: For his atrial fibrillation, he actually remained in sinus. He has a long history of atrial fibrillation and was continued on his digoxin and atenolol. 3. HYPOTENSION ISSUES: The patient was hypotensive on admission which was likely secondary to continued cardiac medications with diuresis. However, the patient was mentating and with stable urine output. He was transiently on pressors during the procedure; however, he was fluid responsive following the procedure, and his blood pressures remained at his baseline with systolic blood pressures around 100. CONDITION AT DISCHARGE: Condition on discharge was good. The patient was ambulating without difficulty, stable urine output, and stable blood pressures. DISCHARGE STATUS: Discharge status was to home. DISCHARGE DIAGNOSES: 1. Alcoholic cirrhosis with ascites and portal hypertension. 2. Status post transjugular intrahepatic portosystemic shunt. 3. Status post paracentesis. 4. Atrial fibrillation. 5. Hypotension. MEDICATIONS ON DISCHARGE: 1. Atenolol 12.5 mg by mouth every day. 2. Digoxin 0.125 mg by mouth once per day. 3. Lasix 40 mg by mouth once per day. 4. Spironolactone 50 mg by mouth once per day. 5. Colchicine 0.6 mg by mouth every day. 6. Multivitamin one tablet by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with his primary care physician [**Last Name (NamePattern4) **] 7 to 10 days. 2. The patient was also instructed to return for an ultrasound on [**3-30**] at 9 a.m. for re-evaluation of his transjugular intrahepatic portosystemic shunt. 3. The patient was instructed to follow up with Dr. [**First Name (STitle) **] on [**2119-3-22**]. 4. The patient was instructed to follow up with his transplant surgeon (Dr. [**First Name (STitle) **] on [**2119-5-25**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Name8 (MD) 264**] MEDQUIST36 D: [**2119-3-17**] 16:55 T: [**2119-3-18**] 02:37 JOB#: [**Job Number 44235**]

[ "274.9", "571.2", "427.31", "789.5", "458.29", "572.3", "571.1" ]

icd9cm

[ [ [] ] ]

[ "39.49", "54.91" ]

icd9pcs

[ [ [] ] ]

2925, 3034

6902, 7100

7126, 7392

7425, 8160

5033, 6686

6701, 6881

194, 2300

2323, 2661

3051, 4999

7,585

164,391

46054

Discharge summary

report

Admission Date: [**2101-11-6**] Discharge Date: [**2101-11-11**] Date of Birth: [**2032-5-22**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11291**] Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: intubation CT History of Present Illness: 69 year old man with prior stroke and known seizures who presents to the ED today with several seizures this morning. Pt was seen by his Neurologist last week for ataxia and was found to have a dilantin level of 30 (exact date not known at this time). He restarted Dilantin last night. This morning, Pt had four generalized tonic clonic seizures at home. Upon EMS arrival, Pt was in the midst of another seizure. He received Ativan 2mg IV x1 at 12:36pm and another 2mg at 12:41pm. By report a total of three seizures occurred after EMS arrival (it is somewhat unclear if this was one continuous seizure or three discrete events). Difficult to arouse, minimally responsive with decreased left sided movement on initial ED evaluation. Nasal trumpet and foley placed. Past Medical History: 1. Coronary artery disease status post myocardial infarction in [**2089**]. 2. Strokes in [**2092**] and [**2093**] with left parietal occipital and right occipital hemorrhages. Also left pontine infarct. 3. Hypertension. 4. Hypercholesterolemia. 5. History of deep vein thrombosis treated with coumadin x 6 months. 6. History of small bowel obstruction. 7. Seizure disorder x 4-5 years after strokes. 8. Chronic renal insufficiency. Social History: Lives at home with wife. Former restaurant and bakery owner in [**Location (un) 686**]. History of heavy alcohol use but claims none since [**2089**]. Denies tobacco and drugs. Family History: Father - stroke and MI Mother - ?cerebral anneurysm 2 children with IDDM, adult onset 1 sister with metastatic breast ca Physical Exam: Afeb HR 105 BP 153/88 RR 12 O2sat 98% NRB GEN somnolent HEENT nasal trumpet in place, NCAT Neck supple Chest CTAB CVS tachycardic ABD soft, NT, ND, +BS EXT no c/c/e, distal pulses strong, no rash Neuro Mental status - arouses slightly to sternal rub, but no spontaneous eye opening. No vocalizations. Does not follow commands. Cranial nerves - Resists eye opening; primary gaze is midline although some roving movements are present. PERRL 4 to 2mm. Horizontal eye movements intact to doll's eye maneuver, no nystagmus. +brisk corneal reflexes bilaterally. +grimace to nasal tickle on the left (nasal trumpet in place on the right). +gag. Difficult to assess facial symmetry (trumpet, mask, etc). Motor/Sensory - has spontaneous movement on the right>left. Withdraws right and left leg briskly to nailbed pressure; slight withdrawal on the left. Decreased tone throughout. Reflexes - 3+ in upper extremities bilaterally at the biceps and brachioradialis. 2+ at the patella. Unable to elicit at the ankles. No clonus. Toes mute. Pertinent Results: [**2101-11-6**] 09:08PM PHENYTOIN-12.4 [**2101-11-11**] PHENYTOIN 13 [**2101-11-6**] 08:06PM TYPE-ART TEMP-37.7 RATES-[**11-7**] TIDAL VOL-650 PEEP-5 O2-100 PO2-409* PCO2-40 PH-7.44 TOTAL CO2-28 BASE XS-3 AADO2-295 REQ O2-53 -ASSIST/CON INTUBATED-INTUBATED [**2101-11-6**] 02:41PM LACTATE-3.8* [**2101-11-6**] 02:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-40 GLUCOSE-81 [**2101-11-6**] 02:30PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-28* POLYS-52 LYMPHS-44 MONOS-5 [**2101-11-6**] 02:30PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-[**Numeric Identifier 42606**]* POLYS-73 LYMPHS-17 MONOS-10 CSF culture negative [**2101-11-6**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2101-11-6**] 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG CT brain: No evidence of recent hemorrhage. No change since [**2101-6-16**]. Right porencephalic cyst unchanged. Plain films R shoulder and L hip: No fracture or dislocation seen. NCCT R shoulder: 1. No fracture. 2. Superior migration of the humeral head, slight supraspinatus muscle atrophy, and AC joint degenerative changes with spurring, all of which likely related to chronic rotator cuff injury, which cannot be completely evaluated by CT. 3. Emphysema and retained secretions within the bronchi bilaterally. Brief Hospital Course: Neuro: arrived in status epilepticus. Dilantin had recently been held secondary to supratherapeutic level of 30, and patient had only resumed Dilantin morning of admission. Dilantin level on arrival was 5. Patient was loaded with Dilantin IV and admitted to ICU setting. Also received IV ativan. Was intubated for airway protection. Stable overnight and no further seizures reported. Extubated the following morning without difficulty and slightly confused, but near baseline and without new neurological deficits on exam. Given low grade fever and seizures, patient had lumbar puncture from ICU service. Profile was normal, GS and cultures negative. See results section for details. Neurological examination post extubation showed L visual field cut, symmetric face and midline tongue. Full strength throughout aside from pain limitation around R shoulder. Coordination normal L and pain limited R. Dilantin levels were monitored and maintenance dose decrease. Additional doses given to keep dilatin therapeutic. Renal dose Keppra was started [**2101-11-9**] (in place of Trileptal given concerns regarding CRI and hyponatremia on Trileptal). Will remain on dual therapy of PHT and Keppra until Keppra is at full dose. Discharged on 500mg [**Hospital1 **] with plan to increase to goal 750mg [**Hospital1 **] in 1 week ie [**2101-11-18**] and check keppra level 1 week later. Appointment with Dr [**Last Name (STitle) **] and [**Doctor Last Name **] on [**2101-11-24**] and prescription given for check keppra level on that day. Will require monitoring of dilantin level to ensure continued therapeutic level on reduced maintenance dose while keppra increasing, as discussed with Dr [**First Name (STitle) 3510**]. CVS: Digoxin, and antihypertensives held on day of admission and restarted morning of day 2. No significant events on ICU telemetry. One negative set of cardiac enzymes. Antihypertensives continued and iv metoprolol x1 on [**2101-11-9**]. Blood pressure acceptable thereafter. Resp: intubated day 1 for airway protection and extubated overnight. No difficulty with extubation. No other respiratory events. Persistent moist cough. Chest x-rays negative. Note some emphysematous changes in CT shoulder. Chest PT requested. GI: treated prophylactically with protonix. Lipids repeated and elevated despite lipitor. Dose increased from 20mg to 40mg daily. Consider repeating lipid levels in future. Renal: mild/moderate renal insufficiency on admission. CR 1.9. Cr improved to 1.3 on discharge with additional fluids. Repeat chemistry to check renal function recommended as disussed with Dr [**First Name (STitle) 3510**]. Endo: covered with regular insulin sliding scale. ID: CSF results as above. Musculoskel: Right shoulder and L hip pain noted following extubation. Plain films negative for fracture or dislocation. Pain improved with acetaminophen and ibuprofen. Ortho evaluation obtained recommending CT shoulder which was suggestive of chronic right rotator cuff injury. Managed in sling with physical therapy. Plan for review with Orthopaedic specialist Dr [**Last Name (STitle) 2719**] on [**11-23**] with MRI R shoulder if remains symptomatic. Psych: Social involved in view of low mood and expressions of hopelessness. Encouragement given. Family and friends noted previous similar pattern following seizures and improvement post seizures. Consider additional psychiatric evaluation if symptoms fail to improve. Medications on Admission: Aspirin 325 mg po DAILY Dilantin 200mg [**Hospital1 **] 100mg daily Gabapentin 100 mg TID Digoxin 125 mcg PO DAILY Labetalol 400mg PO BID Hydrochlorothiazide 25 mg PO once a day Amoxycillin 500mg po QID for cough (5 doses remaining) Atorvastatin 20mg PO DAILY Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for shoulder pain. 5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO twice a day. 6. Dilantin 30 mg Capsule Sig: One (1) Capsule PO at bedtime: Take with 2 100mg capsules to make total 230mg at night. Disp:*30 Capsule(s)* Refills:*2* 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): From [**2101-11-18**] take 1 and 1/2 tablets ie. 750mg. Disp:*60 Tablet(s)* Refills:*2* 9. Outpatient Lab Work Levetiracetam level on [**11-24**]. 10. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Status Epilepticus Renal Insufficiency R shoulder strain Discharge Condition: No seizures; R shoulder remained tender and was managed with a sling and follow up PT. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Seek medical advice for any concern regarding increased seizure frequency, new weakness, speech difficulties, signs of infection or feeling of low mood. Followup Instructions: * Call for appointment with Dr [**First Name (STitle) 3510**] (ph [**Numeric Identifier 98008**]) on Monday or Tuesday next week for review and check blood chemistry and dilantin level. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2101-11-15**] 2:15 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 98009**]/Time:[**2101-11-16**] 12:00 Provider: [**Name10 (NameIs) 7548**] WEST 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2101-11-23**] 8:30 Orthopaedics Dr [**Last Name (STitle) 2719**] [**2101-11-23**] 10am [**Hospital Ward Name 23**] Building [**Hospital Ward Name 5074**] [**Location (un) 551**] * [**Month (only) 116**] cancel Radiology and Orthopaedic follow up if R shoulder completely healed. Neurology Dr [**Last Name (STitle) **] and [**Doctor Last Name **] [**11-24**] 9am Ph [**Numeric Identifier 98010**] with blood test for keppra level.

[ "V09.0", "585.6", "403.91", "V02.59", "345.90" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "89.19", "96.07" ]

icd9pcs

[ [ [] ] ]

9178, 9235

4376, 7842

337, 352

9336, 9425

3015, 4353

9728, 10741

1818, 1940

8154, 9155

9256, 9315

7868, 8131

9449, 9705

1955, 2996

279, 299

380, 1149

1171, 1607

1623, 1802

11,368

175,818

17308

Discharge summary

report

Admission Date: [**2164-4-30**] Discharge Date: [**2164-5-4**] Date of Birth: [**2108-1-22**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: rigid bronchoscopy intubation bronchial embolization History of Present Illness: 56 y/o female with PMH significant for metastatic renal cell CA with mets to the lung and multiple lymph node chains admitted to [**Hospital1 18**] on [**4-30**] with hemoptysis and now transferred to the MICU for further care after bleeding from right upper lobe during bronchoscopy. Pt was recently admitted to [**Hospital1 18**] from [**4-24**] to [**4-27**] with hemoptysis at which time she underwent rigid bronchoscopy with argon photocoagulation therapy on [**4-26**]. Following this, the pt had no further hemoptysis. CT scan obtained during this admission showed interval progression of disease. Pt was only home for a few [**Known lastname **] when she had three episodes of hemoptysis and returned to [**Hospital1 18**]. Per notes, pt had no SOB on admission. She was admitted and on the morning of [**5-1**] went to the OR for rigid bronchoscopy. This showed heavy bleeding from the posterior segment of the right upper lobe. Pt remained intubated underwent successful right bronchial artery embolization by IR. Later that morning, Pt extubated without complication and transferred to medical service. ONCOLOGICAL HISTORY(per OMR): Ms. [**Known lastname **] is a 55-year-old female with metastatic renal cell cancer to the lungs and lymph nodes noted on work-up for shortness of breath ([**1-3**]) associated with a hgb=17: CT [**5-1**] demonstrated bilateral cystic kidneys and confirmed pulmonary nodules as well as prevascular, supracarinal and infracarinal, mediastinal and bilateral hilar lymph nodes. CT-guided biopsy of the right lung nodule at [**State 48444**] Center [**5-1**] was suspicious for, but not diagnostic of malignancy. She was diangosed with metastatic renal carcinoma based on the large left kidney necrotic hypernephroma and polycystic kidney disease. After one cycle of IL-2 [**8-1**] Ms. [**Known lastname **] was followed with stable CT scans every three months until [**3-2**] when extensive periaortic adenopathy, pulmonary nodules and an 8.8 cm left renal mass were noted. At this time she had episodes of shortness of breath and hemoptysis, including an episode during bronchoscopy that required emergent intubation [**4-2**]. She began [**Doctor Last Name **] 43-9006 [**6-2**]. She has done well on [**Doctor Last Name 1819**] with resolution of hemoptysis, shortness of breath and a decrease in target lesions initially and stable since then. Her course on the trial has been complicated by high [**Doctor Last Name **] pressure, leg pain/scaliness, both of which have resolved. Her diarrhea has stabilized on immodium. Her hct has risen to pre-hemotypsis levels, but is generally under 50. In [**1-4**] she developed new onset asymptomatic Grade II a-fib requiring cardioversion s/p TEE (? virally related). The study drug was held until after procedure. She was restarted in [**2-4**]. Past Medical History: 1. Metastatic renal cell carcinoma-treated with IL-2 now on [**Doctor Last Name **] protocol, overall course c/b hemoptysis, AF, SOB 2. Adult polycystic kidney disease 3. Hypertension 4. Hyperthyroidism 5. S/P tonsillectomy 6. H/O atrial fibrillation in 01/[**2163**]. Pt was cardioverted s/p TEE with good response. 7. Acute renal failure- Pt was admitted for ARF in 04/[**2163**]. Her BUN and creatinine had increased from 33/1.7 to 83/4.4. By the time of discharge, her creatinine had decreased to 2.2. 8. h/o hemoptysis after bronch ([**2163-4-6**]) Social History: The patient lives in [**State 1727**]. She works as a bank teller for the last 29 years. She is divorced. Positive tobacco history; quit ten years ago. Alcohol with occasional use. Family History: Father died at age 72 of lung cancer. Mother living, age 76 with hypertension and cerebrovascular accident. Physical Exam: vs: Afeb, 87, 150/66, 20 94% 2LNC gen- sitting comfortably in chair, NAD heent- PERRL, EOMI, anicteric sclera, OP wnl, MMM neck- supple, no LAD cvs- RRR, nl S1/S2, no M/R/G pulm- CTAB abd- soft, NT, ND, NABS, no HSM but palpable kidneys ext- no edema, 2+ DPs skin- warm and well perfused neuro- A&O-3, CNs roughly intact, strength 5/5, sensation intact Pertinent Results: 142 100 21 97 AGap=17 3.3 28 1.4 Ca: 8.8 Mg: 1.9 P: 3.0 89 14.0 8.0 272 42.2 PT: 13.6 PTT: 32.9 INR: 1.2 CXR (PA/LAT): The heart is upper limits of normal in size. There is bulky bilateral hilar lymphadenopathy as well as mediastinal lymphadenopathy. The mediastinal nodes are most prominent in the right paratracheal, aorticopulmonary window and subcarinal regions. Numerous pulmonary nodules are seen in both lungs, ranging in size from less than a cm in diameter to several cm in diameter. The nodules appear more conspicuous than on the prior study were likely more difficult to visualize previously due to portable technique. The lungs reveal no focal areas of consolidation or areas of significant atelectasis. There are trace pleural effusions which have improved compared to [**2164-4-24**] chest radiograph. Skeletal structures reveal diffuse demineralization and degenerative changes. IMPRESSION: 1. Extensive metastatic disease involving the thoracic lymph nodes and pulmonary parenchyma. No areas of collapse are identified. 2. Improved pleural effusions with small residual effusions remaining. IR Embolization: 1) Thoracic aortogram revealed a single, hypertrophied right bronchial artery supplying the right lung field. No active extravasation was identified. However, there was significant hypervascularity from this vessel within the right lung field. Of note, the right upper lobe is collapsed with compensatory hypertrophy of the right middle and lower lobes. 2) Superselective embolization of 3 tortuous branches arising from the right bronchial artery using 3 vials of 700-900 micron-sized embosphere particles with good angiographic success. Brief Hospital Course: A/P: 56 y/o female with PMH significant for metastatic renal cell CA with mets to the lung and multiple lymph node chains admitted with hemoptysis after bleeding from right upper lobe during bronchoscopy. 1. [**Name (NI) 48445**] Pt with episodes of hemoptysis in the past and now returns with similar complaints. Underwent rigid bronchoscopy on admission where bleeding was seen from the right upper lobe. Bleeding controlled with right bronchial embolization. Transferred to medical service after successful extubation. While on the floor Pt stable without evidence of respiratory distress. Morning after embolization/bronch, Pt c/o some residual hemoptysis that resolved. Pt without evidence of further bleeding. If after D/C, Pt to have hemoptysis, she will contact Dr [**Name (NI) 48446**] and considerations made for repeat bronchoscopy in the future. 2. Metastatic renal cell carcinoma- Pt is currently on the experimental [**Doctor Last Name **] protocol followed by Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) **]. Pt to be discharged home with f/u in Oncology on Monday [**2164-5-7**]. Pt will likely resume treatment after being seen by Dr [**Last Name (STitle) **]. 3. Hypertension- hypertensive regimen held during MICU stay but quickly restarted afterwards Pt to be d/c on pre-admission regimen. 4. Hyperthyroid: Pt continued outpt regimen (Methimazole 5 mg PO Q5days) Medications on Admission: 1. Methimazole 5 mg PO Q5days 2. Bydrochlorothiazide 25 mg daily 3. Atenolol 100 mg daily 4. Amlodipine 10 mg daily 5. Experimental [**Doctor Last Name **] protocol Discharge Medications: 1. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Methimazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Renal Cell CA HTN Hemoptysis Discharge Condition: good Discharge Instructions: Please take all medications as prescribed; you will be restarted on your previous medical regimen without changes. Do not restart your [**Doctor Last Name **] protocol until told to by your oncologist. Please make all follow up appointments; if unable reschedule as soon as possible. Please call your PCP or return to ED if you have: persistent fever >101, shortness of breath, Chest pain, hemoptysis. Followup Instructions: 1) You have several Oncology follow-up appointments scheduled. Your next one is for [**2164-5-29**]. Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) 48447**] would like to see you on [**2164-5-7**]. Their office will contact you to schedule a time. Please feel free to call them at [**Telephone/Fax (1) 3237**]. a) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-5-29**] 1:40 b) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-6-25**] 1:30 c) Provider: [**Name10 (NameIs) 2502**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-6-25**] 1:30 2) Please call your PCP and update her as to your recent admission and ask if she wished to see you in follow up.

[ "197.0", "518.5", "276.5", "401.9", "189.0", "196.1", "786.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.05", "32.01", "39.79", "88.49" ]

icd9pcs

[ [ [] ] ]

8171, 8177

6248, 7653

282, 336

8249, 8255

4497, 6225

8709, 9747

3999, 4108

7868, 8148

8198, 8228

7679, 7845

8279, 8686

4123, 4478

232, 244

364, 3204

3226, 3781

3797, 3983

15,513

111,687

881

Discharge summary

report

Admission Date: [**2123-6-22**] Discharge Date: [**2123-6-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo M with HTN, s/p L [**Hospital 6024**] hospital course [**Date range (1) 6025**] for non-healing infected foot ([**1-13**] limb ischemia per non-invasives, not on record in OMR) complicated by VRE infection requiring intraoperative debridement and AKA. Patient was discharged to [**Hospital3 2732**] and Retirement Home in [**Location (un) 55**], where was in USOH until [**2123-6-21**], when noted chills, lethargy, low-grade fever; no SOB, cough or sputum production, n/v, diaphoresis, dysuria. Vitals at initial eval were P110, RR 28, BP 166/80, T 99.5. Labs remarkable for WBC 16.8 K with left shift 92P 2B, otherwise chemistries, LFTs, EKG wnl. Upon arrival to [**Hospital1 18**] ED, hypotensive to 70/50, HR 100, RR 24, 93RA => 96-3L NC. Placed R femoral line. CXR showed RLL and LML multifocal infiltrate, c/w multifocal aspiration or PNA. Dosed vanco 1 gm and ceftaz 1 gm and IVF 1500 ml, sent to [**Hospital Unit Name 153**]. Of note, chronic sacral decubitus ulcers noted, and has R femoral line for daptomycin for hx MRSA (not in our records); also with history of VRE (from AKA). No other micro available. Of note, on arrival, patient denies any localizing symptoms, including CP, SOB, congestion, neck stiffness or light sensitivity, cough or sputum production/secretions, abdominal pain, dysuria, diarrhea. He does note that he notices that he coughs frequently while drinking liquids; no associated dysphagia or odynophagia. Review of systems otherwise negative. Past Medical History: HTN PVD Hyperlipidemia R carotid stenosis, 80-99% (non-intervened) OA L BKA => AKA as noted above [**5-16**] Left hip arthroplasty x2, bilateral inguinal herniorrhaphy status post SFA angioplasty with stenting [**12-16**] Social History: SHx: no smoking, IVDU, alcohol, recent illnesses Family History: FHx: patient non-cooperative Physical Exam: T: 96.9 BP 117/48 HR 80 Sat 100-4L NC Gen: chronic ill appearing, somnolent but easily arousable, in NAD. HEENT: Pupils [**3-14**] bilaterally, OP clear with dry membranes. JVP at 8 cm +HJR. No sinus tenderness. False teeth, but clean OP. Lungs: Crackles at RML and LUL lung fields, poor entry to bases. OTW clear. Heart: RRR with frequent PVC's. III/VI SEM at RUSB to clavicle, III/VI HSM at apex to axilla. No lift, PMI displaced laterally. No gallop. Abd: Soft, +BS. No tenderness or rebound. No [**Doctor Last Name **]??????s. Back: No CVAT. Sacral decubitus 1.5 cmx 1.5 cm on tip of coccyx, no drainage or TTP. Extr: L AKA, well healed. R femoral without tenderness, drainage, or erythema, with slight amount of blood surrounding catheter. Peripherals x2 in place without s/s infection. No edema. 1+ DP on R. Lateral ulcer on dorsal-plantar margin of R foot; no probe to bone, no drainage, +TTP +erythema. Neuro: AAOx3, lethargic (hard of hearing). Pertinent Results: [**2123-6-21**] 06:50PM WBC-16.8*# RBC-3.77* HGB-10.4* HCT-32.0* MCV-85 MCH-27.6 MCHC-32.5 RDW-16.3* [**2123-6-21**] 06:50PM NEUTS-88* BANDS-8* LYMPHS-3* MONOS-0 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2123-6-21**] 7:05 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2123-6-25**]): REPORTED BY PHONE TO 4I [**Numeric Identifier 6026**] [**First Name8 (NamePattern2) **] [**Doctor Last Name 6027**] [**2123-6-22**] @ 11:10PM. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON REQUEST.. [**2123-6-21**] 06:50PM CORTISOL-25.4* [**2123-6-21**] 06:50PM ALBUMIN-3.1* CALCIUM-8.5 PHOSPHATE-4.5# MAGNESIUM-1.9 [**2123-6-21**] 06:50PM cTropnT-0.07* [**2123-6-21**] 06:50PM ALT(SGPT)-11 AST(SGOT)-20 ALK PHOS-107 TOT BILI-0.3 [**2123-6-21**] 06:50PM GLUCOSE-116* UREA N-23* CREAT-1.5* SODIUM-134 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16 [**2123-6-21**] 07:04PM LACTATE-2.0 [**2123-6-21**] 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2123-6-21**] 07:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2123-6-22**] 04:10AM RET AUT-1.7 [**2123-6-22**] 04:10AM PT-12.6 PTT-39.0* INR(PT)-1.1 [**2123-6-22**] 04:10AM PLT COUNT-430 [**2123-6-22**] 04:10AM HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+ [**2123-6-22**] 04:10AM NEUTS-83.0* LYMPHS-12.9* MONOS-3.0 EOS-0.9 BASOS-0.3 [**2123-6-22**] 04:10AM WBC-9.0 RBC-3.19* HGB-8.7* HCT-27.7* MCV-87 MCH-27.3 MCHC-31.5 RDW-16.8* [**2123-6-22**] 04:10AM URINE HOURS-RANDOM CREAT-83 SODIUM-99 [**2123-6-22**] 04:10AM CORTISOL-32.4* [**2123-6-22**] 04:10AM TSH-4.4* [**2123-6-22**] 04:10AM VIT B12-349 [**2123-6-22**] 04:10AM CALCIUM-7.4* PHOSPHATE-3.5 MAGNESIUM-2.1 [**2123-6-22**] 04:10AM proBNP-[**2084**]* [**2123-6-22**] 04:10AM GLUCOSE-102 SODIUM-140 POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-23 ANION GAP-11 [**2123-6-22**] 04:41AM VANCO-9.5* [**2123-6-22**] 04:41AM CORTISOL-39.4* [**2123-6-22**] 04:41AM calTIBC-135* VIT B12-350 FOLATE-5.5 HAPTOGLOB-290* FERRITIN-551* TRF-104* [**2123-6-22**] 04:41AM IRON-19* [**2123-6-22**] 04:41AM LD(LDH)-135 TOT BILI-0.2 [**2123-6-22**] 04:41AM UREA N-18 CREAT-1.2 [**2123-6-22**] 07:12PM PLT COUNT-394 [**2123-6-22**] 07:12PM WBC-7.0 RBC-3.08* HGB-8.6* HCT-26.8* MCV-87 MCH-28.1 MCHC-32.2 RDW-16.3* [**2123-6-22**] 07:12PM CALCIUM-7.2* PHOSPHATE-2.6* MAGNESIUM-1.9 [**2123-6-22**] 07:12PM GLUCOSE-97 UREA N-15 CREAT-1.0 SODIUM-139 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-22 ANION GAP-10 Brief Hospital Course: Sepsis: Patient afebrile with resolving WBC count through [**Hospital Unit Name 153**] stay. Sources of infection included sacral decubitus ulcer (not extending to bone, draining, or tender/erythematous), L AKA stump (well-healed, though had history of VRE), R foot ulcer (tender to palpation, not draining), or pulmonary (given CXR and exam evidence for multifocal PNA and history of choking/cough while eating). Patient was empirically covered with vancomycin (history of MRSA), ceftazidime, and levofloxacin (for nosocomial sources). Initial blood cultures on [**2123-6-21**] were 1/2 bottles positive for gram-positive cocci in clusters and pairs (speciation revealed staph epi), felt to likely be contaminant. Required several fluid boluses initially to maintain urine output, but was hemodynamically stable with good urine output throughout the remainder of his [**Hospital Unit Name 153**] course. Cultures from tip of PICC line removed on [**6-21**] at nursing home revealed gram-negative rods, but NO blood cx were positive. Vancomycin and ceftazidime were discontinued, and patient was discharged on a 14-day course of levofloxacin for presumed community acquired PNA (through [**7-6**]). In addition, UA prior to d/c appeared c/w with UTI, cultures were pending upon d/c. PCP should [**Name9 (PRE) 702**] on final cx results and sensitivities. Mental status changes: Likely infection related. RPR and B12 were negative. TSH was mildly elevated at 4.4. Respiratory: Patient denied respiratory symptoms throughout, including cough, SOB, or pleuritic chest discomfort. Oxygen requirment remained stable [**Hospital 6028**] hospital course, with saturation 96-98% on 3.5 liters. CXR on [**6-24**] had improving consolidations and decrease in bilateral pleural effusions as seen on CXR at admission. Infiltrates were thought to be consistent with pneumonia overlain on pulmonary congestion from CHF. Pt discharged with good oxygenation with plans to complete antibiotics course for his presumed pneumonia (Levofloxacin 500mg PO QD x 14 days through [**7-6**]). Speech and swallow recommended nectar thick liquids and thick/ground consistency diet given concern for aspiration. Cardiovascular: Patient was ruled out for MI by 3 sets cardiac enzymes and placed on ASA, statin. BB was held [**1-13**] initial hypotension and question of septic physiology. Rhythm was normal sinus throughout, with unifocal PVCs > 10/hr on telemetry, with no other concerning EKG changes. BNP was 1800; echocardiogram demonstrated EF 50% with evidence of increased LVEDP, pulmonary hypertension and 3+ MR. [**Name13 (STitle) **] was titrated up on captopril for afterload reduction, and switched to lisinopril on discharge. Patient was autodiuresing throughout hospital course, and may require outpatient lasix and initiation of beta-blocker for CHF. Renal/FEN: Acute renal failure with creatinine 1.2 up from baseline 0.5. Initial FeNa was 0.8% consistent with pre-renal etiology from dehydration [**1-13**] poor PO intake and infection versus CHF. Cre improved with fluid resuscitation, back to baseline 0.9 at discharge. Speech and swallow consultation performed for concern for aspiration, given history and multifocality of CXR, with evidence of no gag reflex; placed on mechanical soft diet. UTI: On discharge, complained of some urinary urgency, thought to mechanical (from foley) or infectious. Urinalysis seemed + for UTI, culture pending at discharge. Discharged on levofloxacin for CAP, likely covering UTI. Patient will also need restarting terasozin as outpatient for BPH, which may aid with BP/afterload management. Heme: Initial studies consistent with anemia of chronic disease (Fe low, TIBC low, Ferritin elevated), but difficult to interpret in setting of acute illness. Would repeat as outpatient and consider iron therapy. Depression: Patient with decreased appetite, [**1-13**] depression. On prozac and wellbutrin SR. Patient requested outpatient psychopharmacology consultation after acute issues have resolved. Medications on Admission: Lipitor 10 mg qd ASA 81 mg qd Prevacid 30 mg qd Terazosin Metoprolol 25 mg [**Hospital1 **] Pletal 100 mg qd Proscar 5 mg qd Prozac 40 mg qd Wellbutrin SR 100 mg [**Hospital1 **] Klonopin 0.5 mg tid Heparin SC 5000 U [**Hospital1 **] Vicodin prn pain Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO qd (). 4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 14 days: Complete day 14 course through [**7-6**]. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 13. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) dose subcutaneously Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Primary diagnosis: Community acquired pneumonia Mild CHF Acute on chronic renal failure Secondary diagnoses: HTN PVD Hyperlipidemia Depression BPH R carotid stenosis, 80-99% (non-intervened) OA L BKA => AKA as noted above [**5-16**] Left hip arthroplasty x2 Bilateral inguinal herniorrhaphy s/p SFA angioplasty with stent [**12-16**] Discharge Condition: Stable, afebrile, with HR in 80s-90s, BP 107/43, RR of 24 and O2 sats of 94% on RA. Discharge Instructions: Please come to the hospital if you develop any of the following symptoms: worsening cough, fever >100.4, shortness of breath, chest pain or pressure, weakness or any other complaints. Followup Instructions: Please call your PCP for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment in [**12-13**] weeks. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2123-6-25**]

[ "995.92", "428.0", "707.14", "424.0", "599.0", "707.03", "440.23", "507.0", "V49.76", "285.29", "401.9", "584.9", "272.4", "038.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11212, 11302

5766, 9798

276, 283

11681, 11766

3160, 5743

11998, 12290

2140, 2171

10099, 11189

11323, 11323

9824, 10076

11790, 11975

2186, 3141

11433, 11660

230, 238

311, 1811

11342, 11412

1833, 2057

2073, 2124

29,045

176,836

1969

Discharge summary

report

Admission Date: [**2163-2-20**] Discharge Date: [**2163-3-10**] Date of Birth: [**2115-7-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3016**] Chief Complaint: worsening pain, weakness, and low grade fever Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 47 yo F with multiple sclerosis and metastatic melanoma p/w FTT at home. Known metastatic disease to brain, spleen, spine. Patient with chronic back pain secondary to metastatic disease. The patient reports that it has been difficult to manage at home since around [**Holiday **] when she discovered the recurrence of the melanoma in her left axilla. Over the past 1-2 weeks she has had persistent lower back pain and poor PO intake. She reports low grade fevers to 99 at home with difficulty sleeping over the last few weeks. Poor PO intake over last few weeks. She was seen in the Pain [**Hospital 9085**] clinic and started on oxycontin and oxycodone for her back pain without much relief. This morning her family felt that it was becoming too difficult to manage her symptoms at home and felt it was necessary to bring her to the ED. . In the ED, initial vitals were 97.7, HR 130, BP 132/66, RR19, 96% RA. While in the ED, the patient spiked to 102. UA was negative. Blood and urine cultures were sent. An initial lactate was 4.0. She received 4L IVF and her lactate improved to 2.3. She was empirically treated with vancomycin and cefepime. A CT scan was performed and did not show any drainable abscess from her left axilla. The patient declined central access. Past Medical History: # Metastatic Melamoma - [**2162-2-8**], underwent an excisional biopsy for what was felt to be a 7.2 thick, [**Doctor Last Name 10834**] level IV, nonulcerated melanoma with 10 mitoses/m2 on her left shoulder. There was evidence of lymphovascular invasion and a question of perineural invasion. She underwent a wide local excision and left axillary sentinel lymph node biopsy on [**2162-3-12**] with pathology revealing melanoma in 4 sentinel lymph nodes with evidence of extracapsular extension. She underwent a completion left axillary node dissection on [**2162-3-26**] with pathology showing no melanoma in 3 lymph nodes identified. She received radiation therapy to the left axilla without difficulty, completing in [**2162-5-9**]. She was placed on interferon alpha-1a (Rebif) for multiple sclerosis on [**2162-7-6**]. She presented to Clinic on [**2163-1-26**] with multiple nodules in the left axilla consistent with recurrence within the radiation field. Subsequent head MRI showed multiple CNS metastases. About to begin a phase II clinical trial of sorafenib + temazolomide therapy for her CNS metastatic melanoma. # Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting Social History: The patient lives with her husband and youngest son (age 17). She has 2 older children ages 27 (daughter) and 25 (son). She used to work as a teachers aid. She denies ETOH/smoking/drugs. Family History: Father died of heart disease. Mother with hypertension. Physical Exam: Vitals - 98.0 141/100 118 17 100% RA General - ill appearing middle aged female, lying in bed HEENT - PERRL, dry MM Neck - supple, no lympadenopathy CV - tachycardic, regular, no murmur appreciated Lungs - CTA B/L Abdomen - soft, non-tender, non-distended Ext - extensive soft tissue nodularity in the left axilla with venous congestion. No drainage appreciated. Neuro - CN 2-12 intact, sensation intact upper and lower extremities, RLE [**4-13**], LLE 4+/5, RUE/LUE 4+/5 Pertinent Results: [**2163-2-20**] ADMISSION LABS: WBC-9.6# RBC-4.70# Hgb-12.9# Hct-38.0# MCV-81* MCH-27.5 MCHC-34.0 RDW-16.7* Plt Ct-131* Neuts-93* Bands-1 Lymphs-0 Monos-2 Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-1* . PT-12.0 PTT-29.7 INR(PT)-1.0 . Glucose-127* UreaN-20 Creat-0.4 Na-136 K-4.2 Cl-99 HCO3-20* AnGap-21* Calcium-10.0 Phos-4.3 Mg-1.8 . ALT-13 AST-16 LD(LDH)-595* AlkPhos-119* TotBili-0.5 Albumin-3.6 . [**2163-2-20**] 03:15PM BLOOD Lactate-4.0* [**2163-2-20**] 08:50PM BLOOD Lactate-2.3* . calTIBC-177* VitB12-1831* Folate-8.1 Ferritn-1401* TRF-136* . [**2163-2-20**] 2:00 pm BLOOD CULTURE **FINAL REPORT [**2163-2-26**]** Blood Culture, Routine (Final [**2163-2-26**]): NO GROWTH. . [**2163-2-20**] 3:05 pm URINE Site: CATHETER **FINAL REPORT [**2163-2-21**]** URINE CULTURE (Final [**2163-2-21**]): NO GROWTH. . [**2163-2-23**] 6:39 am URINE Source: Catheter. **FINAL REPORT [**2163-2-24**]** URINE CULTURE (Final [**2163-2-24**]): NO GROWTH. . [**2163-2-23**] 6:39 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT [**2163-3-1**]** Blood Culture, Routine (Final [**2163-3-1**]): NO GROWTH. . [**2163-2-24**] 9:29 pm BLOOD CULTURE Source: Line-SL PICC. **FINAL REPORT [**2163-3-2**]** Blood Culture, Routine (Final [**2163-3-2**]): NO GROWTH. [**2-20**] CT CHEST/AXILLA IMPRESSION: 1. No evidence of drainable fluid collection. 2. Extensive metastatic disease, some of which appears stable, for example in the lungs, however, some of which appears increased, for example in the vertebral bodies and spleen. 3. Cortical erosion at the T7 level along the posterior vertebral body. If concern exists for neurologic change or compromise, consider MRI imaging to help evaluate the soft tissue encroachment on the thecal sac and/or nerve roots. . [**2-20**] EKG Sinus tachycardia Normal ECG except for rate . [**2163-2-21**] IMPRESSION: Satisfactory right PICC tip placement in the proximal SVC. . [**2163-2-22**] MRI L Spine IMPRESSION: 1. Innumerable bony metastatic foci throughout the lumbar spine, the sacrum, and the visualized ilia. 2. Apparent epidural extension of tumor at the L3-4 level causing mild canal stenosis. 3. No definite signal abnormality within the distal spinal cord or nerve roots. . [**2163-2-23**] CXR IMPRESSION: No new pneumonia in the visualized portions of the lungs. Multiple melanoma metastases as on prior. . [**2163-2-25**] MRI C+T Spine IMPRESSION: 1. Bony metastatic disease. No evidence of cord compression. 2. Intrinsic signal abnormalities within the spinal cord secondary to multiple sclerosis with a possible enhancing multiple sclerosis plaque at T7-8 level. No epidural mass seen. . [**2163-2-26**] RLE Ultrasound IMPRESSION: No evidence of DVT within the right lower extremity. . [**2163-3-4**] MRI BRAIN IMPRESSION: 1. Several new enhancing lesions, less than 1 cm, consistent with further progression of metastatic melanoma. 2. Stable appearance of demyelinating disease. 3. No evidence of edema, mass effect, or hemorrhage. [**2163-3-5**] 12:00AM BLOOD WBC-3.0* RBC-3.37* Hgb-9.4* Hct-27.7* MCV-82 MCH-27.8 MCHC-33.8 RDW-18.4* Plt Ct-127* [**2163-3-4**] 12:00AM BLOOD Glucose-115* UreaN-15 Creat-0.4 Na-140 K-4.1 Cl-100 HCO3-31 AnGap-13 Brief Hospital Course: MICU COURSE: The patient was admitted initially to the ICU for pain control and presuemd septic physiology given tachycardia and elevated lactate in the ED. She was continued on Vanc and Cefepime for broad coverage given her left axillary wound and she remained hemodynamically stable. She was continued on decadron for her spinal met and dilaudid for pain control. As she remained stable, she was transfered to OMED on the [**Hospital Ward Name **] for further care. OMED COURSE: 47 F w/ metastatic melanoma to lung, liver, brain, severe MS p/w weakness and FTT. # Pain Control - Used a tremendous amount of pain medicine (IV dilaudid after first arriving to floor. Pain service was consulted. Was initially put in IV dilaudid PCA. Final acceptable pain regimen was 6-8 mg dilaudid q3h prn, Fentanyl Patch 150 mcg/hr TP Q72H, methadone 10mg q8h, naproxen 500mg tid prn, Lidocaine 5% Patch 1 PTCH TD DAILY, Neurontin 100qAM/100qPM/200qHS, and duloxetine 30mg daily. Additionally, she underwent 5 fractions of palliative XRT to the pelvis and spine. To counteract the effects of such a large pain medicine, an aggressive bowel regimen was pursued. Monitored for narcosis or depressed respiratory rate. Respirations were as low as [**11-20**] at points, but was never pathological. Pt did deomnstrate some nocturnal confusion (see below), for which ambien was discontinued. By time of discharge was stablized on an adequate regimen with an aggressive bowel regimen given her high dose narcotics. Extended care facility has been provided with a complete list. # Confusion - Briefly noted early during inpatient course. Initially thought to be most likely a side effect of medications, but patient has known brain metastases. MRI brain showed small new mets c/w melanoma, also stable demyelinating disease. Ambian discontinued and confusion resolved. Rad-onc was then consulted to evaluated if whole brain radiation vs cyberknife were appropriate for new metastases. Given that she was assymptomatic, no further treatment was pursued while inpatient. If patient does become symptomatic, she's encouraged to contact radiation oncology as needed. # Hypertension - No history of this in the past, but pt persistently hypertensive on the floor (although BPs were taken in legs because L arm with invasive melanoma, R arm with PICC, so BP likely overestimated). Hypertension was likely exacerbated by pain, so emphasized pain control to control BP as well. BPs's decreased as pain has come under better control but ultimately required continued metoprolol for BP control, discharged on this medication. # Metastatic Melanoma w/ axillary wound - Plan to continue chemo with TMZ 200mg per m2 at later date, currently not able [**3-12**] compromised health. Pan Spinal MRI showed intrinsic signal abnormalities within the spinal cord secondary to multiple sclerosis, as well as diffuse bony metastatic disease, with no evidence of cord compression seen. S/p palliative XRT to spine with great improvement in pain. Wound care was consulted for axillary wound and followed patient throughout stay. Continued dexamethasone with taper for CNS mets. Appreciate SW consult, psych and pall care consults while inpatient. # Intermittent Fever - Most likely related to malignancy. Patient presented with fever in ED. Unclear source for an infection, as CT showed no axillary abscess and all cultures either negative or with NGTD. CXRs unrevealing for infiltrate. After ICU stay, patient spiked again early [**2-23**] despite vanc/cefepime and steroids. Cultures and radiology from that date were also negative. Patient completed 5 days of vancomycin and a 7 day course of cefepime that was completed [**2-27**]. No further antibiotics were given and no further evidence of infection was found. # Multiple Sclerosis - Last med was Rebif, d/c'ed in [**Month (only) **], with no relapses. Previously on Avonex and Tysabri. Followed by Dr [**Last Name (STitle) 10835**]. Spoke with Dr. [**Last Name (STitle) 10835**], would defer all MS rx at this time while undergoing chemo; a last ditch option would be MTX or cyclophosphamide. If undergoing brain XRT may need more steroids as higher risk for MS relapse, but this is deferred to outpatient follow-up if patient becomes symptomatic from new brain metastases. # Shoulder Pain - Complained of R shoulder pain that began the day prior to admission following upper extremity physical therapy. Patient was consistent with muscle strain, which patient thought was true as well. No [**Last Name (un) 2043**] deformity. EKG not indicative of cardiac origin. Abdominal exam benign with no signs of radiating origin. Maintained current pain regimen with intermittantly complete relief. # Anxiety - Psych consulted, continued prn BZD. Duloxetine added for pain control. # Code - DNR/DNI - discussed with patient at time of admission Medications on Admission: Dexamthasone 4mg [**Hospital1 **] Ambien 10mg PRN Oxycontin 20mg [**Hospital1 **] Oxycodone 5mg prn Neurontin 300mg , uptitrating Xanax 0.5mg PRN Fiorinal 50-325-40mg cap 1 cap daily prn headache Ibuprofen 600mg q8h compazine 10mg tab q6h prn nausea Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply to lower back. please remove for 12hrs in any 24 hr period . 2. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Hydromorphone 2 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3 hours) as needed: please try to give 6mg doses during the day and 8mg at night . 4. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): hold for oversedation or confusion. 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Modafinil 100 mg Tablet Sig: One (1) Tablet PO qAM (). 11. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): continue this dosing until [**3-10**], then decrease to 2mg daily x 1 week, then taper off, or as otherwise instructed by MD. 12. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea/vomiting/anxiety. 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea/vomiting. 14. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for bsp <100, hr <50. 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet Sig: One (1) Powder in Packet PO daily (). 20. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): Hold for loose stools. 21. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed. 22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 23. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours): Can discontinue once patient is more mobile. 24. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): hold fpr SBP<105, HR<55 . Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) 1456**] Discharge Diagnosis: Primary: weakness . Secondary: # Metastatic Melanoma - mets to brain, pelvis, femurs, spleen, adrenals, and spine # Multiple Sclerosis - Diagnosed in [**2154**], relapsing/remitting Discharge Condition: stable, pain under good control Discharge Instructions: You were admitted to the hospital with worsening lower back pain, lower extremity weakness, and low grade fevers at home. You were initially admitted to our ICU for close observation because we were worried about an possible infection in your bloodstream. However, no source for an infection was ever found and you were then transferred to our oncology floor. You had some intermittent fevers but again, no infection was found. The fever may have been related to your malignancy. . We did an MRI of your spine which showed diffuse bony metastases which were likely causing your pain and weakness. Our pain service consulted and put you on an extensive pain control regimen which lowered your pain to an acceptable level. We also called our radiation oncologists, who provided you with a 5 session course of radiation to your spine and pelvis to further control your pain. . At points you were confused, which was likely a side effect of the large amount of pain medicine you were on. However, since you have known brain metastases, we imaged your head to assess for any change. This scan showed a few new small lesions that were unlikely to be responsible for the confusion. We continued to treat your cancer with a drug called temozolomide, as well as with the palliative chemotherapy. . Our physical therapists worked with you and determined that you need to go to rehab to work on regaining your strength. . Please take all of your medicines as prescribed. Please keep all of your outpatient followup appointments. If you experience any symptoms that disturb you, such as new weakness, fevers,chills, please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the ER. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10837**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-3-22**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] date/Time:[**2163-3-22**] 2:30 Provider: [**Name10 (NameIs) 10838**] [**Name11 (NameIs) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**] Date/Time:[**2163-3-22**] 2:30 [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

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Discharge summary

report

Admission Date: [**2206-2-27**] Discharge Date: [**2206-3-11**] Date of Birth: [**2124-6-9**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 158**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Exploratory laparotomy, repair of enterotomy, diverting loop ileostomy. History of Present Illness: 81M who underwent laparoscopic sigmoid colectomy for large polyps 3 days before this admission. He presented to an outside hospital the morning of this admission with acute onset of abdominal pain and was transferred to the [**Hospital1 18**] emergency room; he was febrile. His abdomen was very tender. There was a small amount of intraperitoneal air on x-ray, and a CT scan was done, showing extravasation of contrast. It was then planned to take him emergently to the OR for exploratory laparotomy. Past Medical History: PMH: colon polyps, MI x 2, HTN, HL, COPD, BPH PSH: tracheostomy [**2196**] after MVA w/cricoid fracture and laryngeal injury ([**2196**]),removal of granulation tissue at trach site, decannulation ([**2197**]); lap left colectomy ([**2206-2-24**]); Exploratory laparotomy, repair of enterotomy, diverting loop ileostomy ([**2206-2-27**]). Social History: Portuguese-speaking; supportive bilingual daughter, supportive family Family History: non-contributory Physical Exam: GEN: NAD, A&Ox3, elderly-appearing CV: RRR PULM: some coarse BS throughout, improved with coughing, decreased BS at bases ABD: soft/non-distended, mildly appropriately ttp to palpation peri-incisionally; ostomy site healthy-appearing; ostomy bag with brown/green liquid and soft solid material INCISION: clean, dry, intact, mild serous drainage, no erythema or induration EXT: WWP NEURO: grossly-intact Pertinent Results: CT ABD & PELVIS WITH CONTRAST Study Date of [**2206-2-27**] 11:40 AM 1. Large extravasation of air and contrast, of uncertain source. No evidence of extravasation at the level of the stomach, duodenum, or at the rectosigmoid anastomosis. 2. Small bowel and colonic wall thickening, likely reactive to peritonitis. 3. Enlarged prostate. 4. Left lower lobe nodule might represent atelectasis, although a true lung nodule cannot be excluded. Followup to resolution in three months is recommended. ABDOMEN (SUPINE & ERECT) Study Date of [**2206-3-5**] 2:13 PM Likely post-operative paralytic ileus, and less likely bowel obstruction. CHEST (PA & LAT) Study Date of [**2206-3-5**] 2:13 PM Stable left lower lung opacification and new right lower lung opacity may represent combination of right lower lung collapse and a small pleural effusions but cannot exclude infectious process. Brief Hospital Course: The patient re-presented shortly after his discharge from his left colectomy (for large polyps), this time for severe abdominal pain. He went to the OR for an exploratory laparomoty with primary repair of colonic perforation and diverting ileostomy. He tolerated the procedure well; for details, see the separately-dictated operative note. . Following his procedure, he was brought intubated to the TSICU, and on phenylephrine for blood pressure support. He was weaned from the phenylephrine on the same day, and he was extubated successfully on POD#1. He was stable for transfer to the floor on POD#2. . NEURO/PAIN: The patient was weaned from sedation when extubated on POD#1. His pain was well-controlled, initially with intermittent IV narcotics, and then with PO tylenol and oxycodone. He was neurologically intact, and remained A&Ox3 . CARDIOVASCULAR: Immediately post-op, his BP was supported with phenylephrine, but this was able to be weaned later on POD#0. In the TSICU, he was initially tachycardic, likely secondary to hypovolemia, and he continued to receive fluid resuscitation. With adequate fluid resuscitation, he stabilized from a cardiovascular standpoint. His home metoprolol was restarted, and his captopril was held secondary to his initial ARF. . RESPIRATORY: The patient was extubated on POD#1. By POD#2, he was ambulating well on room air, without desaturation. Throughout his stay, the patient was noted to have coarse breath sounds, with some wheezing. He does have a history of COPD. He was encouraged to continue ambulation, use incentive spirometry, and was out of bed to a chair as much as possible when resting. He was given nebulizer treatments. A CXR on POD#6 suggested basilar atelectasis and small pleural effusions; at this time it was also decided to decrease the patient's IVF to prevent fluid overload. He remained stable from a respiratory standpoint, with continual encouragement to ambulate, cough, and undergo chest PT. He was incidentally noted to have a lef tlung nodule on his chest CT, and he should see his PCP for scheduling of a 3-month follow-up CT chest to evaluate for resolution. . GASTROINTESTINAL: The patient had a new ostomy following the procedure. He received ostomy teaching. The output was monitored, and it stayed at an appropriate level. The patient was NPO following his surgery, and maintained on IVF as above. He was started on clears on POD#2, but he experienced intermitttent nausea and vomiting until POD#7, when he was finally able to consistently tolerate clears. During episodes of nausea, his diet was accordingly backed down to NPO. He was then advanced from clears to fulls and finally a regular diet, which he tolerated. Unfortunately, he consistently had little appetite, and we worked with the patient to improve PO intake. He was given Ensure supplements, and care was taken to order food that he would find palatable. His family brought in food from home. The patient did have occasional small-volume of dark/clear regurgitation or reflux, but this was not thought to be true emesis, and it was not associated with nausea. The patient had had this before, and would manage it with over-the-counter medications. He was started on ranitidine. When home, he will have VNA services help with monitoring of PO intake and ostomy output. . GENITOURINARY: He was noted to have acute renal failure, prerenal etiology, and he was successfully managed with IVF; his UOP was monitored with a foley, and his medications were initially renally-dosed; his creatinine reached his baseline by about POD#4. The patient has a history of urinary retention, and he had actually been discharged from his last admission with foley in place, with plans for outpatient urology follow-up. He kept his foley catheter for the majority of this admission, and a voiding trial was done successfully on the day of discharge. He never showed signs of urinary tract infection. His urine output was monitored, especially initially during his ARF, and he was treated with IVF accordingly. Later in his hospital course, when his IVF were decreased over concern for pulmonary manifestations of mild fluid overload, he was given IV lasix, and given intermittent doses of albumin. His creatinine was back at his baseline by POD#4. . HEME: The patient received 1 unit of PRBC intraoperatively. His hematocrit was monitored, and he received no further transfusions. . ID: Since presentation at the outside hospital and through POD#7, the patient remained on vancomycin and zosyn to cover for bowel spillage from his colonic perforation. His WBC was trended, and was as high as 13.6 on POD#3 and by POD#10 it was within normal limits at 9.8. It was not thought that he developed pneumonia, and he had no evidence for a UTI. His wound was monitored freqnently, and it did have some serous drainage, at one point purulent, but two of the middle staples were removed to allow better drainage and by POD#11 he only had minimal serous drainage at the wound. . ENDOCRINE: The patient's blood glucose was monitored, and he wa stable from an endocrine standpoint. . PROPHYLAXIS: He was maintained on subcutaneous heparin and pneumatic boots. He ambulated frequently and used incentive spirometry. His foley was changed. In the immediate postop period and when not tolerating much PO intake, he was given famotidine. . DISPOSITION: Physical therapy worked with the patient and cleared him for home with PT. VNA was set up for monitoring of PO intake and ostomy output, wound care, and ostomy care. His family was very supportive and are providing a supportive home environment to come home to. On the day of discharge, he was discharged home in stable condition with good family support, to have home VNA and PT services, ambulating with assistance, tolerating a regular diet, and with good ostomy output. He is to follow up with his PCP for scheduling of a 3-month follow up CT chest to assess the left lung nodule, and with Colorectal Surgery for the surgical issues addressed at his hospital admission. Medications on Admission: ASA 81, lipitor 10', captopril 6.25''', flomax .4', metoprolol 50', miralax prn, calcium, vitamin D Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain: No alcohol or driving. Disp:*20 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain for 5 days: No more than 12 tab in a day. No more than 4000mg acetaminophen in a day (each tab has 325mg). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 8. Ensure Liquid Sig: One (1) bottle PO three times a day: Please take in addition to meals at meal time or as a snack between meals. Disp:*30 * Refills:*1* 9. captopril 12.5 mg Tablet Sig: [**12-23**] Tablet PO TID (3 times a day). Discharge Disposition: Home With Service Facility: Steward home care and Hospice Discharge Diagnosis: bowel perforation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the colorectal surgery service for management of your bowel perforation. You had surgery for this, and you have recovered well. Your pain is now well-controlled, your ostomy is working properly, you can walk around well, your food intake is getting better. You are are now ready for discharge home, where you can continue your recovery. You have a new ileostomy. The most common complication from a new ileostomy placement is dehydration. The output from the stoma is stool from the small intestine and the water content is very high. The stool is no longer passing through the large intestine which is where the water from the stool is reabsorbed into the body and the stool becomes formed. You must measure your ileostomy output for the next few weeks. The output from the stoma should not be more than 1200cc or less than 500cc. If you find that your output has become too much or too little, please call the office for advice. The office nurse or nurse [**Month/Day (2) 3639**] can recommend medications to increase or slow the ileostomy output. Keep yourself well hydrated, if you notice your ileostomy output increasing, take in more electrolyte drink such as gatorade. Please monitor yourself for signs and symptoms of dehydration including: dizziness (especially upon standing), weakness, dry mouth, headache, or fatigue. If you notice these symptoms please call the office or return to the emergency room for evaluation if these symptoms are severe. You may eat a regular diet with your new ileostomy. You should continue to take ensure supplements with meals or between meals three times daily to increase protien intake and nutritional status. You should eat small frequent meals and make sure you are meeting your caloric and protien needs. Please monitor the appearance of the ostomy and stoma and care for it as instructed by the wound/ostomy nurses. The stoma (intestine that protrudes outside of your abdomen) should be beefy red or pink, it may ooze small amounts of blood at times when touched and this should subside with time. The skin around the ostomy site should be kept clean and intact. Monitor the skin around the stoma for buldging or signs of infection listed above. Please care for the ostomy as you have been instructed by the wound/ostomy nurses. You will be able to make an appointment with the ostomy nurse in the clinic. You will have a visiting nurse at home for the next few weeks helping to monitor your ostomy until you are comfortable caring for it on your own. At first, you will have some help at home with visiting Physical Therapy, and a visiting nurse will help with your food intake, wound monitoring, and ostomy management. Activity: 1. You should continue to walk several times per day, and sit up a chair when resting. Do not lie in bed all day. 2. Continue to cough well to clear your lungs. 3. You may shower, and let soapy water flow over your incision. Do not scrub the incision. Do not soak in a tub or bath. 4. Do not lift anything heavier than 10 pounds for at least 6 weeks Medications: 1. Resume your home medications 2. Take any new medications as prescribed. 3. You will be taking the pain medication oxycodone, do not drink alcohol or drive a car. You may also take Tylenol for pain. Do not drink alcohol while taking this medication. Incision Care: 1. Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. 2. Avoid swimming and baths until cleared by your surgeon. 3. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. 4. If you have staples, they will be removed at your follow-up appointment. Please wear abdominal binder when oyu are out of bed to support your abdominal incision. Follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week. You should be able to urinate on your own. If you have trouble urinating, or have pain with urination, please see your primary doctor or your urologist. On your CT scan, it was noted that you have a small nodule on your left lung. It is not clear what this is. We recommend you see your primary doctor about this, and schedule another CT scan of your chest in about 3 months to follow this. Followup Instructions: Please call the colorectal surgery office to make an appointment for follow-up two weeks after surgery with the colorectal surgery outpatient nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP. At this this appointment you will be set up with an appointment for your second post-operative check with Dr. [**Last Name (STitle) 1120**]. Please call [**Telephone/Fax (1) 160**] to make this appointment. Please also call [**Telephone/Fax (1) 23664**] for an appointment with the Ostomy nurse, for about 2 weeks. Completed by:[**2206-3-11**]

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icd9cm

[ [ [] ] ]

[ "46.03", "46.75" ]

icd9pcs

[ [ [] ] ]

9985, 10045

2752, 8789

316, 390

10107, 10107

1847, 2729

14590, 15202

1391, 1409

8939, 9962

10066, 10086

8815, 8916

10290, 13612

13627, 14567

1424, 1828

262, 278

418, 921

10122, 10266

943, 1287

1303, 1375

17,690

122,468

17056+17083

Discharge summary

report+report

Admission Date: [**2176-7-5**] Discharge Date: [**2176-7-12**] Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 78-year-old woman with a history of diabetes, carotid stenosis, and chronic back pain who presents with one week of lethargy. The patient was in her usual state of health until one week prior to admission when she fell. Since then, the patient had increased sluggishness of note. The family reports a new left facial droop, voice weakness, and slurred speech. Per family report, this has been going on for some time and has been waxing and [**Doctor Last Name 688**], however, it is currently at its worse. The patient states that she is dizzy but denied headache. She has had some cough for the past few days. She denied abdominal pain, diarrhea, constipation, fevers, chills, chest pain, or shortness of breath. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Right 80-100% carotid stenosis. 3. Chronic left pelvic and flank pain, status post recent nerve block. 4. CAD. ADMISSION MEDICATIONS: 1. Glucotrol 10 mg p.o. b.i.d. 2. Glucophage 500 mg p.o. b.i.d. 3. Actos 45 mg p.o. q.d. 4. Aspirin. 5. Relafen 750 mg p.o. b.i.d. 6. Lasix 20 mg p.o. q.d. 7. Effexor 150 mg. 8. Zestril 20 mg p.o. q.d. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98 degrees, heart rate 96, blood pressure 159/65, saturating 99% on 1 liter. General: The patient was slow speaking, appearing oriented but her speech is difficult to understand. HEENT: The patient has ecchymosis of the right eye. Cardiovascular: Regular rhythm, no murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Obese, soft, nontender, nondistended. Extremities: No edema. Neurologic: The patient's cranial nerves, II through XII, were intact with the exception of a mild left facial droop. She has normal sensation. She has II/V strength in the left hip flexors, III/V knee flexion, and III/V ankle flexion. She had V/V strength on the right side in the upper extremities. LABORATORY/RADIOLOGIC DATA: White count 11.9, hematocrit 37.1. CK 40, potassium 5.1, BUN and creatinine 36 and 0.9 respectively. HOSPITAL COURSE: A head CT was performed in the Emergency Department demonstrating no acute intracranial hemorrhage as the patient was felt likely to have had a stroke. An MR was performed. In fact, she had an acute right frontal lobe infarct extending to the splenule of the corpus callosum. In addition, she had diffuse atherosclerotic changes without focal high-grade stenosis in the posterior circulation, vascular occlusion, or stenosis in the anterior circulation. The patient was continued on aspirin and started on Plavix. Her blood pressure was maintained by holding her antihypertensives. Neurology was consulted. The patient was not a candidate for TPA given chronicity of her symptoms. The patient was prepared for carotid artery stenting by Dr. [**Last Name (STitle) **] which was attempted on [**2176-7-11**]. However, a stent was not placed due to the patient moving on the table. The patient will return in two weeks to have the procedure performed by Dr. [**Last Name (STitle) **]. CARDIOVASCULAR: The patient's EKG demonstrated ST elevations in II, III, and aVF, with old deep Qs in II, III, and aVF, flattened T in aVL. The patient was ruled out for a myocardial infarction. Troponins were negative. The patient's lipid panel was checked. LDL was 215. The patient was started on a statin. Aspirin and Plavix were continued. ACE inhibitor and beta blocker will be restarted upon discharge. There was a question of CHF at the outside hospital on prior admission. An echocardiogram was performed demonstrating moderate symmetric LVH with preserved regional and global biventricular systolic function. Normal aortic root and ascending aorta measurements suggest a primary hypertrophic nonobstructive cardiomyopathy. DIABETES MELLITUS: On admission, the patient's glucose was 444. Her Glipizide and Actos were continued. However, Metformin was held due to the number of studies was having. She was maintained on an insulin sliding scale. She may be started on an outpatient regimen of standing insulin. HYPERTENSION: The patient was found to have varying blood pressures on the right and left. An MRI of the chest was performed demonstrating focal moderate grade stenosis at the origin of the right subclavian artery. In addition, the right common carotid artery and left vertebral artery also demonstrate moderate grade stenosis. SWALLOWING: A bedside swallow study was performed due to the patient's dysarthria and hoarse voice to evaluate for aspiration risk. A video swallowing study was subsequently performed which the patient passed, albeit marginally. The patient was started on a soft mechanical diet with nectar-thickened liquids and will be started on aspiration precautions, including the following: 1) No thin liquids p.o. 2) Bolt upright for meals. 3) Alternate between one bite and one sip. 4) Check and clean out mouth at the end of each meal. 5) Crush meds and give in applesauce or other pureed food. Ideally, the patient's ability to swallow will improve with occupational therapy at rehabilitation. DISCHARGE DIAGNOSIS: 1. Cerebrovascular accident. 2. Diabetes mellitus. 3. Hypertrophic cardiomyopathy. 4. Carotid stenosis. 5. Subclavian stenosis. 6. Vertebral artery stenosis. DISCHARGE MEDICATIONS: To be dictated under separate cover. DR.[**Last Name (STitle) **],[**First Name3 (LF) 7853**] C.12-869 Dictated By:[**Last Name (NamePattern1) 11873**] MEDQUIST36 D: [**2176-7-11**] 06:12 T: [**2176-7-11**] 19:13 JOB#: [**Job Number 47961**] Admission Date: [**2176-7-5**] Discharge Date: [**2176-7-19**] Service: ADDENDUM: While on the floor, the patient developed hypotension and diaphoresis. A code was called. The patient was intubated and taken to the unit. At that point, the patient put out melenic stools. A NG tube was dropped with coffee ground. The patient's hematocrit stabilized and she was not scoped. Her GI bleed was felt to be related to the aspirin, Plavix, plus Relafen. All three medications were held. The patient experienced a left pneumothorax during left subclavian line attempt. She did not require a chest tube and the pneumothorax is resolving on its own. The patient was restarted on aspirin and Protonix. During this episode of hypotension, systolic to the 80s, the patient's stroke progressed as evidenced by MRI and further weakness in her left arm and loss of gag reflex. In addition, she experienced a non ST elevation MI, felt to be related to demand ischemia. Peak CK was 323, peak troponin 31.0. The patient was extubated without difficulty and called out to the floor. Her systolic blood pressures were maintained by holding antihypertensives with the exception of a beta blocker. For the loss of her gag reflex, the patient was kept n.p.o. and started on tube feeds via NG tube. A PEG was placed by Interventional Radiology on [**2176-7-17**]. The Stroke Team reevaluated the patient and felt that she would not tolerate further anticoagulation necessary for carotid stent placement. They will follow-up with her, Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **], in the stroke clinic in four to six weeks after discharge to reconsider a carotid stent with Plavix. The patient developed copious secretions with her impaired swallow mechanism and a scopolamine patch was started with excellent effect. Her blood sugars were difficult to control and the [**Last Name (un) **] Team was consulted and an acceptable regimen of NPH 30 units q.a.m. and q.h.s. with a sliding scale was deemed adequate control. The patient had a slightly elevated white count prior to discharge. Her U/A was positive with a pH of 9.0 suggesting Proteus. Ciprofloxacin was started. The patient will be discharged to [**Hospital3 7**]. ADDITIONAL DISCHARGE DIAGNOSIS: 1. Loss of gag reflex secondary to cerebrovascular accident, subsequent placement of percutaneous endoscopic gastrostomy tube by Interventional Radiology on [**2176-7-17**]. 2. Non-ST elevation myocardial infarction. 3. Upper gastrointestinal bleed in the context of aspirin, Plavix, and Relafen. 4. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Atorvostatin 20 mg p.o. q.d. 2. Metoprolol 12.5 mg p.o. b.i.d. 3. Aspirin 81 mg p.o. q.d. 4. Lansoprazole 30 mg per G tube b.i.d. 5. Scopolamine patch transdermal q. 72 hours. 6. Ciprofloxacin 500 mg p.o. q. 12 hours for a 14 day course, last dose [**2176-8-1**]. 7. Albuterol and Atrovent nebulizers p.r.n. 8. Acetaminophen p.r.n. 9. Insulin NPH 30 units q.a.m., 30 units q.h.s. 10. Insulin sliding scale as follows: Fingersticks 80-100 covered with 4 units; fingersticks 101-150 with 6 units; fingersticks 151-200 with 8 units; fingersticks 201-250 to be covered with 10 units; fingersticks 251-300 with 12 units; fingersticks 301-350 with 14 units; fingersticks 351 to 400 with 16 units; fingersticks greater than 400 with 18 units of regular insulin. All the above medications may be given per NG tube. Ideally, the patient will be restarted on an ACE inhibitor once her requirement for systolic blood pressure greater than 130 related to her CVA has passed. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern1) 11873**] MEDQUIST36 D: [**2176-7-19**] 09:39 T: [**2176-7-19**] 08:12 JOB#: [**Job Number 48025**]

[ "578.9", "410.71", "599.0", "428.0", "434.11", "433.31", "041.6", "E935.3", "E935.7" ]

icd9cm

[ [ [] ] ]

[ "43.11", "88.41", "96.71", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

8352, 9624

7999, 8329

2166, 5226

1040, 1272

1287, 2148

876, 1017

13,183

100,957

20077

Discharge summary

report

Admission Date: [**2115-11-12**] Discharge Date: [**2115-11-26**] Date of Birth: [**2048-7-14**] Sex: M Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[**First Name3 (LF) 2969**] Chief Complaint: Esophageal Cancer Major Surgical or Invasive Procedure: [**2115-11-14**] Transthoracic esophagectomy with Left cervical esophagogastrostomy History of Present Illness: This is a 67 year old gentleman with Stage IIA esophageal cancer who presented for surgical resection status-post induction chemoradiotherapy. His disease presented with regurgitation following his CABG surgery in [**10-30**], which was initially presumed to be secondary to prolonged intubation, but later workup with endoscopy revealed a T3N0Mx lesion and biopsy was positive for adenocarcinoma. PET scan revealed FDG uptake to SUV of 7.0 and CT scan did not reveal positive metastatic or nodal disease. Sympotmatically he denied nausea or vomitting and had no dysphagia. He started 1 month of neoadjuvant chemotherapy with 5-FU and cisplatin in [**7-31**]. He has been eating small meals and is currently on TPN. He had initially lost approximately 15 pounds while on chemotherapy but has since gained nearly 10 pounds. Past Medical History: Stage IIA Esophageal AdenoCA, T3N0M0 (PET positive) Status-post MVR and CABG x 3 (LIMA to LAD, SVG to OM, SVG to PDA) on [**2114-11-23**] Status-post J-tube and portacath placement [**7-31**] Hypertension Status-post pace-maker/defibrillator implantation on [**2115-2-27**] Heartburn x 20 years Atrial Fibrillation Hypothyroidism Social History: The patient is married and lives in [**Location 5110**], MA. He has three children and is a former engineer. He has never smoked and denies ever drinking alcohol. He does not use recreational drugs. Family History: Denies any h/o cancer, CAD. Parents died when he was young, unsure of causes. Physical Exam: On admission: V/S: wt 114 lbs, 20, 100% on room air, 93/66, pulse 89 Gen: frail, pleasant elderly gentleman, alert, oriented Neuro: no focal abnormalities, CN 2-12 grossly intact HEENT: moist mucous membranes, PERRLA Neck: no lypmhadenopathy Pulm: clear to auscultation bilaterally; Right port site intact Abd: soft, non-tender/non-distended, normoactive bowel sounds, J-tube site intact without erythema or discharge Extr: no edema Pertinent Results: SEROLOGIES: [**2115-11-12**] 04:37PM BLOOD WBC-5.6 RBC-2.72* Hgb-9.2* Hct-25.4* MCV-94 MCH-33.7* MCHC-36.0* RDW-16.5* Plt Ct-128* [**2115-11-13**] 09:01AM BLOOD WBC-4.7 RBC-2.69* Hgb-9.1* Hct-25.1* MCV-93 MCH-33.6* MCHC-36.1* RDW-16.1* Plt Ct-121* [**2115-11-14**] 05:02AM BLOOD WBC-4.7 RBC-3.89*# Hgb-12.6*# Hct-34.8*# MCV-89 MCH-32.3* MCHC-36.1* RDW-16.1* Plt Ct-117* [**2115-11-15**] 03:06AM BLOOD WBC-14.8* RBC-3.95* Hgb-12.5* Hct-33.4* MCV-85 MCH-31.5 MCHC-37.3* RDW-16.2* Plt Ct-90* [**2115-11-16**] 03:29AM BLOOD WBC-13.6* RBC-3.09* Hgb-9.8* Hct-27.0* MCV-88 MCH-31.8 MCHC-36.3* RDW-15.9* Plt Ct-73* [**2115-11-16**] 06:00AM BLOOD WBC-15.3* RBC-3.19* Hgb-10.2* Hct-28.5* MCV-89 MCH-32.1* MCHC-35.9* RDW-15.9* Plt Ct-71* [**2115-11-16**] 02:22PM BLOOD WBC-15.6* RBC-3.79* Hgb-11.7* Hct-31.9* MCV-84 MCH-30.8 MCHC-36.7* RDW-16.3* Plt Ct-66* [**2115-11-18**] 03:20AM BLOOD WBC-11.9* RBC-3.29* Hgb-10.2* Hct-28.1* MCV-85 MCH-31.1 MCHC-36.4* RDW-16.2* Plt Ct-89* [**2115-11-20**] 05:22AM BLOOD WBC-9.0 RBC-3.30* Hgb-10.2* Hct-29.7* MCV-90 MCH-30.8 MCHC-34.2 RDW-15.2 Plt Ct-108* [**2115-11-25**] 04:45AM BLOOD WBC-10.6 RBC-3.06* Hgb-9.3* Hct-28.3* MCV-92 MCH-30.3 MCHC-32.8 RDW-15.2 Plt Ct-218 [**2115-11-12**] 04:37PM BLOOD PT-16.5* PTT-87.4* [**Month/Day/Year 263**](PT)-1.7 [**2115-11-13**] 09:01AM BLOOD PT-15.2* PTT-66.0* [**Month/Day/Year 263**](PT)-1.5 [**2115-11-13**] 05:26PM BLOOD PT-14.3* PTT-97.5* [**Month/Day/Year 263**](PT)-1.3 [**2115-11-15**] 03:06AM BLOOD PT-14.3* PTT-150* [**Month/Day/Year 263**](PT)-1.3 [**2115-11-16**] 06:00AM BLOOD PT-13.7* PTT-60.3* [**Month/Day/Year 263**](PT)-1.2 [**2115-11-17**] 02:25PM BLOOD PT-13.4 PTT-53.9* [**Month/Day/Year 263**](PT)-1.1 [**2115-11-21**] 06:15AM BLOOD PT-21.2* PTT-110.7* [**Month/Day/Year 263**](PT)-2.8 [**2115-11-23**] 03:46AM BLOOD PT-23.2* PTT-39.8* [**Month/Day/Year 263**](PT)-3.4 [**2115-11-25**] 04:45AM BLOOD PT-21.3* PTT-39.5* [**Month/Day/Year 263**](PT)-2.9 [**2115-11-12**] 04:37PM BLOOD Glucose-98 UreaN-32* Creat-1.4* Na-138 K-4.1 Cl-108 HCO3-21* AnGap-13 [**2115-11-14**] 05:02AM BLOOD Glucose-118* UreaN-27* Creat-1.2 Na-139 K-3.5 Cl-103 HCO3-25 AnGap-15 [**2115-11-15**] 03:06AM BLOOD Glucose-158* UreaN-30* Creat-1.2 Na-133 K-4.3 Cl-109* HCO3-19* AnGap-9 [**2115-11-16**] 11:04PM BLOOD Glucose-122* UreaN-31* Creat-1.1 Na-136 K-3.7 Cl-107 HCO3-22 AnGap-11 [**2115-11-17**] 02:25PM BLOOD Glucose-127* UreaN-29* Creat-1.0 Na-134 K-3.9 Cl-104 HCO3-25 AnGap-9 [**2115-11-21**] 06:15AM BLOOD Glucose-134* UreaN-32* Creat-1.1 Na-133 K-4.3 Cl-101 HCO3-28 AnGap-8 [**2115-11-23**] 06:15PM BLOOD Glucose-134* UreaN-55* Creat-1.1 Na-140 K-4.3 Cl-102 HCO3-33* AnGap-9 [**2115-11-25**] 04:45AM BLOOD Glucose-120* UreaN-38* Creat-1.1 Na-140 K-4.2 Cl-106 HCO3-28 AnGap-10 [**2115-11-12**] 04:37PM BLOOD ALT-18 AST-30 LD(LDH)-351* AlkPhos-79 Amylase-73 TotBili-1.1 [**2115-11-20**] 05:22AM BLOOD ALT-21 AST-38 AlkPhos-156* Amylase-38 TotBili-0.8 [**2115-11-12**] 04:37PM BLOOD Albumin-3.6 Calcium-9.6 Phos-3.4 Mg-1.9 [**2115-11-14**] 05:02AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.3 [**2115-11-24**] 08:58AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.1 RADIOLOGY: [**2115-11-22**] Video Swallow Study: Aspiration secondary to impaired pharyngeal esophageal sphincter and left pharyngeal wall paralysis. [**2115-11-22**] Esophagram: Contrast flowed freely through a patent anastomosis into the stomach, duodenum, and distal small bowel. No leak was seen at the anastomosis site. [**2115-11-22**] Chest Xray: 1. No pneumothorax. 2. Bibasiilar atelectasis, and small left pleural effusion. MICROBIOLOGY: [**2115-11-22**] MRSA screen: negative [**2115-11-22**] VRE screen: negative Brief Hospital Course: This is a 67 year old gentleman with stage IIA esophageal cancer status-post neoadjuvant chemo/radiation who presented for surgical resection. He underwent a three-hole thoracic esophagectomy with cervical anastamosis on [**2115-11-13**]. He received 2 units of blood during the procedure and was extubated on [**2115-11-15**]. He remained in the surgical intensive care unit for 6 days. His immediate post-operative period was complicated by several episodes of atrial fibrillation and SVT which converted on various occasions with beta-blockade; he never required electrical cardioversion. He was started back on Coumadin post-operatively for his atrial fibrillation and mechanical mitral valve. He also underwent ultra-sound guided aspiration of 1500 cc of fluid from his left chest on post-operative day 5 which resulted in much improvement in his respiratory status. He was transfered to the floor on post-operative day 6 and tube feeding was begun, with goal reached by post-operative day 10. His chest tubes were removed on post-operative day 7. On the floor he worked with physical therapy to assist with ambulation. He had an esophogram study done on post-operative day 9 which revealed no leak from his anastamosis and his cervical JP drain was removed. A video swallow study revealed paralysis of the left pharynx resulting in aspiration and the patient was kept NPO with tube feeds. He was discharged with planned follow-up with thoracic surgery. Medications on Admission: Protonix 40 mg oral daily Zocor 10 mg oral daily Levothyroxin 0.1 mg oral daily Coumadin 1 mg oral QHS Discharge Medications: 1. Warfarin Sodium 3 mg Tablet Sig: One (1) Tablet PO once a day: goal [**Date Range 263**] 3-3.5. [**Date Range **]:*40 Tablet(s)* Refills:*2* 2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO once a day. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day) as needed for constipation. [**Date Range **]:*500 ml* Refills:*0* 4. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q3-4H () as needed for pain. [**Date Range **]:*100 Tablet(s)* Refills:*0* 5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Date Range **]:*60 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP < 95. [**Date Range **]:*30 Tablet(s)* Refills:*2* 7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day. [**Date Range **]:*20 Tablet(s)* Refills:*2* 8. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Impact/Fiber Liquid Sig: One (1) PO once a day: Per tube feeding instructions. Can substitute Nestle equivalent. [**Date Range **]:*10 Liters* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: (1) Esophageal Cancer (2) Atrial Fibrillation (3) Left Pharyngeal Paralysis Discharge Condition: Fair Discharge Instructions: Please contact the office or come to the emergeny room with any worsening shortness of breath, drainage from your incision site, pain not controlled with pain medications, worsening nausea or emesis, fever > 101.0. Please call with any questions. Do not eat or drink; all your nutrition with be provided with the tube feeding. Try to ambulate three times/day. Followup Instructions: Please call the office of Dr. [**First Name (STitle) **] [**Doctor Last Name **] at [**Telephone/Fax (1) 170**] to set up a follow-up appointment at a time of your convenience within the next 1-2 weeks. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2115-12-16**] 2:00 Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2115-12-16**] 2:30 Completed by:[**2115-11-26**]

[ "427.89", "997.1", "414.00", "V45.01", "V45.81", "150.8", "478.31", "427.31", "530.85" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.29", "96.6", "42.41", "42.52", "99.15" ]

icd9pcs

[ [ [] ] ]

8763, 8836

6044, 7505

298, 384

8956, 8962

2370, 6021

9370, 9982

1821, 1902

7658, 8740

8857, 8935

7531, 7635

8986, 9347

1917, 1917

241, 260

412, 1236

1931, 2351

1258, 1589

1605, 1805

54,945

111,044

49397

Discharge summary

report

Admission Date: [**2179-11-29**] Discharge Date: [**2179-12-10**] Date of Birth: [**2105-10-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: 1. Billroth II gastrectomy with antecolic isoperistaltic gastrojejunostomy. 2. Primary duodenal stump closure with omental patch overlay. History of Present Illness: 74 year old male with schizophrenia presenting with complaints of suprapubic abdominal pain for the last few days, which he thinks is due to eating bad chicken. He is a poor historian and is somewhat uncooperative. He complains mostly of suprapubic pain. He has had long-standing bilateral inguinal hernias for which he has refused surgical repair. He states that they are mildly tender. He has been nauseated and has tried to vomit, but cannot. He rates the pain as a 9 or [**10-29**], despite receiving 6mg of morphine in the last 45 minutes. He denies fevers or chills. He refuses to answer any more questions. Looking at the limited records we have here, it appears he was supposed to get radiation for his prostate CA , but did not make the appointment. He has a history of a small MI as well. Past Medical History: PMH: Schizophrenia, Prostate CA, Hyperlipidemia, Bilateral inguinal hernias, CAD s/p small MI. Social History: 1ppd smoker "forever". Denies EtOH or drug use. Pt??????s apartment reported as unsanitary and a fire [**Doctor Last Name 13205**]. She reports that the Health Dept and Fire Dept are working to intervene on this matter. Physical Exam: 97.2 66 127/77 16 100RA Gen: Moaning in discomfort holding lower abdomen. A&Ox2 (person and place). Cachectic. Unkempt. Foul-smelling. HEENT: Anicteric. Tacky mucosal membranes. Some brown, dried vomit around mouth. poor dentition. Neck: Thin. Mild JVD. CV: RRR. Pulm: Coarse. Diminished at bases. Abd: Thin. Rigid. Diffusely tender. ND. Hypoactive BS. More tender in suprapubic region. Bilateral, large, completely reducible inguinal hernias. Hernias non-tender. DRE: Normal tone. No masses. No gross or occult blood. Ext: Onychomycosis. Warm and well perfused. Neuro: Motor and sensation grossly intact. Follows commands. Difficult to understand secondary to mumbling. Conversant. Odd affect, but appropriate. Pertinent Results: [**2179-11-29**] 01:35AM BLOOD WBC-9.3 RBC-6.21*# Hgb-18.7*# Hct-56.3*# MCV-91 MCH-30.2 MCHC-33.3 RDW-13.4 Plt Ct-261 [**2179-12-5**] 04:20AM BLOOD WBC-10.9 RBC-3.48* Hgb-10.8* Hct-31.1* MCV-89 MCH-31.0 MCHC-34.7 RDW-13.8 Plt Ct-321# [**2179-11-29**] 11:26AM BLOOD Neuts-62 Bands-27* Lymphs-8* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2179-12-9**] 05:22AM BLOOD Glucose-107* UreaN-16 Creat-0.7 Na-141 K-3.5 Cl-108 HCO3-27 AnGap-10 [**2179-11-29**] 01:35AM BLOOD Lipase-25 [**2179-11-30**] 01:41AM BLOOD CK-MB-6 cTropnT-<0.01 [**2179-12-9**] 05:22AM BLOOD Calcium-7.4* Phos-2.4* Mg-2.1 [**2179-12-3**] 04:16AM BLOOD Triglyc-113 [**2179-11-30**] 06:40PM BLOOD Vanco-15.8 . SPECIMEN SUBMITTED: gastric antrum & perforated ulcer. DIAGNOSIS: Gastric antrum, partial gastrectomy: 1. Gastric fundus and antrum with marked chronic active gastritis. 2. Numerous bacteria morphologically consistent with H. pylori identified. 3. Pylorus/proximal duodenum with chronic active mucosal inflammation and acute serositis; no perforation identified on histologic sections (see note). Note: No definite ulceration with perforation is identified on gross or histologic examination. The presence of serositis at only the distal resection margin and pyloric/early duodenal sections is suggestive of a more distal perforation in [**Last Name (un) **]. Clinical correlation is suggested. . Radiology Report CHEST (PA & LAT) Study Date of [**2179-11-29**] 3:11 AM IMPRESSION: Free air under the diaphragm. Findings discussed with Dr. [**First Name4 (NamePattern1) 916**] [**Last Name (NamePattern1) **] at 4:15 a.m. on [**2179-11-29**]. The patient was take to surgery and a perforated duodenal ulcer was found. Clinical: Intestinal perforation. . Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of [**2179-11-29**] 4:07 AM IMPRESSION: 1. Intra-abdominal free air found at surgery to be caused by perforated duodenal ulcer. 2. Left lower quadrant and intragastric rounded densities of unclear significance. . Cardiology Report ECG Study Date of [**2179-12-5**] 9:38:54 AM Sinus rhythm with atrial premature complexes [**Month (only) 116**] be otherwise normal ECG, but baseline artifact makes assessment difficult Since previous tracing of [**2179-12-2**], atrial ectopy present and precordial lead QRS voltage more prominent Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 88 136 96 354/403 54 -13 72 . Brief Hospital Course: This is a 74-year-old gentleman Perforated pyloric channel/antral ulcer. The patient was taken emergently to the OR and is s/p a BII resection. He was admitted to the ICU post-operatively. NEUROLOGIC: Initially Sedated on propofol. He was successfully weaned. Pain: Fentanyl gtt in the ICU. Once tolerating a diet and on the floor, he was transitioned to PO pain meds. CARDIOVASCULAR: HR and BP stable, off pressors. He was triggered for SPO2 80s LLL left lower lobe atelectasis and small L pl eff. Stable R Pl eff. responds to O2. CE neg x 3. PULMONARY: Ventilated initially. Was successfully weaned. GI / ABD: NGT to suction, wound dressing is c/d/i. NGT was removed on POD 4. NUTRITION: NPO. He was on TPN. His diet was advanced as he had return of bowel funciton and TPN was weaned off. RENAL: Adequate UOP, Cr 0.8. follow-up with Dr.[**Last Name (STitle) 103429**] for catheter removal and void trial next week. HEMATOLOGY: Hct 36.5 ENDOCRINE: RISS ID: Continue broad spectrum coverage with Vanc, Zosyn and Fluc. ABX were stopped on [**2179-12-6**]. WOUNDS: abdominal wound c/d/i. The staples were removed prior to discharge. Medications on Admission: none Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Amoxicillin 250 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours) for 14 days: 14 days total. Started [**2179-12-6**]. Stop [**2179-12-20**]. 5. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 14 days: 14 days total. Started [**2179-12-6**]. Stop [**2179-12-20**]. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Perforated pyloric channel/antral ulcer. Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Take all new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2180-1-3**] at 8:30am. Call [**Telephone/Fax (1) 2835**] with questions or concerns. Call Dr. [**Last Name (STitle) 656**] (Radiation Oncology) to schedule an appointment in 3 weeks. Call ([**Telephone/Fax (1) 8082**] to schedule an appointment. Follow-up with Dr. [**Last Name (STitle) 103429**] (Urology) in 1 week for Foley catheter removal. Call to schedule an appointment. ([**Telephone/Fax (1) 93948**] Completed by:[**2179-12-10**]

[ "185", "305.1", "550.92", "E878.6", "414.01", "295.62", "567.9", "531.10", "518.0", "511.9", "412", "041.86", "272.4" ]

icd9cm

[ [ [] ] ]

[ "99.15", "43.7" ]

icd9pcs

[ [ [] ] ]

6965, 7036

4902, 6038

331, 471

7121, 7128

2414, 4879

8485, 8987

6093, 6942

7057, 7100

6064, 6070

7152, 8462

1674, 2395

277, 293

499, 1301

1323, 1420

1437, 1659

20,838

150,234

20542

Discharge summary

report

Admission Date: [**2150-3-18**] Discharge Date: [**2150-4-15**] Date of Birth: [**2076-3-7**] Sex: M Service: SURGERY Allergies: Erythromycin Base / Morphine Attending:[**First Name3 (LF) 1781**] Chief Complaint: Right foot gangrene and rest pain. Major Surgical or Invasive Procedure: 1. Right transmetatarsal amputation. 2. Incision and excisional debridement of transmetatarsal amputation infection of the right foot. 3. Right foot debridement with Vac placement of the right foot. Past Medical History: hx HTN hx CAD with angina stable, CHF compensated,S/p CABG's x4,( lima-ad, svg dg1,2,svg mo3,svg pda of rca) hx dm2, insulin dependant with neuropathy hx chronic renal insuffiency (2.4-2.6) hx A. fib, s/p av pacemaker for SSS hx GI bleed with transfusion secondary to coumadin hx carotid disease left 40-59%, s/p CEA Lt. hx PVD s/p lt. SCA angioplasty with stenting [**11-8**],s/p ABF,rt. femoral endartectomy hx hyperlipdemia Social History: married, lives with spouse nonsmoker occasional ETOH use uses cane for ambulation Family History: N/C Physical Exam: General: [**Last Name (un) **] male NAD HEENT: ncat / perrl / eomi neg lesions nares / oral oharnyx / auditory supple / farom / neg lymphandopathy or supra clavicular nodes RESP: CTA b/l CV: rrr without murmers, neg bruits ABD: soft / nttp / nd / pos bs / neg cva tenderness EXT: right foot / vac / neg erythema around wound / neg c/c/e Graft palpable. Triphasic PT left foot palpable PT / DP Pertinent Results: [**2150-4-15**] WBC-8.5 RBC-3.50* Hgb-9.7* Hct-30.9* MCV-88 MCH-27.7 MCHC-31.3 RDW-17.7* Plt Ct-108* [**2150-4-14**] PT-15.2* PTT-35.9* INR(PT)-1.5 [**2150-4-15**] Glucose-47* UreaN-20 Creat-1.0 Na-139 K-4.0 Cl-108 HCO3-27 AnGap-8 [**2150-4-15**] Calcium-8.5 Phos-2.9 Mg-2.2 [**2150-3-25**] freeCa-1.20 [**2150-4-2**] GENERAL URINE INFORMATION Yellow Clear 1.009 Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks NEG NEG NEG NEG NEG NEG NEG 6.5 NEG [**2150-4-10**] FOOT CULTURE Site: FOOT R. FOOT WOUND. GRAM STAIN (Final [**2150-4-10**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2150-4-12**]): STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # 187-8247U [**2150-4-6**]. ANAEROBIC CULTURE (Final [**2150-4-14**]): NO ANAEROBES ISOLATED. [**2150-4-1**] EKG Sinus rhythm and venricular paced rhythm with pattern of ventricular fusion complexes and probable underlying right bundle-branch block with diffuse ST-T wave abnormalities. Since the previous tracing of [**2150-3-19**] ventriciulra fusion pattern is seen in place of full ventricular pacing. Intervals Axes Rate PR QRS QT/QTc P QRS T 66 224 82 484/497 54 -67 74 [**2150-4-1**] UNILAT LOWER EXT VEINS RIGHT Reason: hematomagraph patentdvtleak in graft site INDICATION: 74-year-old male with swollen leg status post bypass. LEFT LOWER EXTREMITY DVT STUDY: [**Doctor Last Name **] scale and Doppler son[**Name (NI) 1417**] of the left common femoral, superficial femoral, and popliteal veins were performed. There is limited visualization of the femoral vein. However, visualized vessels have normal flow, compressibility, and augmentation. No intraluminal thrombus was identified. IMPRESSION: There is no evidence of DVT. RADIOLOGY Final Report [**2150-4-6**] CHEST (SINGLE VIEW) Reason: GANGRENE RIGHT SECOND TOE INDICATION: Preoperative assessment. A permanent pacemaker remains in place with leads in the right atrium and right ventricle. A right internal jugular vascular catheter terminates at the junction of the superior vena cava and right atrium. The heart is enlarged and there is upper zone vascular redistribution as well as perihilar haziness and small bilateral pleural effusions. As compared to the recent study, the pleural effusions have improved slightly in the interval and there has also likely been slight improvement in the degree of edema. IMPRESSION: Mild congestive heart failure with associated pleural effusions, slightly improved in the interval. [**2150-3-19**] [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) Reason: bilateral upper extremity vein map for possible bypass FINDINGS: The cephalic veins are visualized bilaterally. On the right measures 0.26 cm in the forearm and gradually increases to 0.52 cm in the deltoid region. Similar values in the left are 0.28 and 0.46 cm. Left basilic vein is 0.23 cm at the antecubital fossa and increases to 0.33 cm at its transition into the axillary vein. The right basilic vein is not visualized. The patient has had his left greater saphenous vein used for prior bypass. IMPRESSION: Patent bilateral cephalic and left basilic veins with dimensions as described above. Brief Hospital Course: Pt admitted [**2150-3-18**] [**2150-3-18**] - [**2150-3-23**] Podiatry consult was put in. They followed the pt during his hospital stay. Pt recieved vein mapping. Pt recieved blood pre procedure for low hct. Pt pre - op'd. cleared for surgery. [**2150-3-24**] Right common femoral artery to posterior tibial artery bypass graft with reversed right cephalic vein, angioscopy, repair of right profunda artery with patch angioplasty. Pt tolerated the procedure well. There were no complications. Pt transfered to the PACU in stable condition. Once pt recooperated from anesthesia, he was sent to the floor in stable condition. [**2150-3-25**] - [**2150-3-30**] No significant events. Pt was allowed to recover from the procedure. During this time frame antibiotics were adjusted. Pt was encouraged to get OOB to chair, foley was [**Name (NI) 1788**], pt was able to urinate. Pt was taking PO without incidence. Pt pre - op'd for TMA. [**2150-3-31**] Pt underwent a right transmetatarsal amputation. Pt tolerated the procedure well. There were no complications. Pt transfered to the PACU in stable condition. Once pt recooperated from anesthesia, he was sent to the floor in stable condition. [**2150-4-1**] - [**2150-4-6**] Pt remained stable. He started to experience fevers. The fevers came from the post operative TMA site. [**2150-4-7**] Pt underwent incision and excisional debridement of transmetatarsal amputation infection of the right foot. Pt tolerated the procedure well. There were no complications. Pt transfered to the PACU in stable condition. Once pt recooperated from anesthesia, he was sent to the floor in stable condition. [**2150-4-8**] - [**2150-4-9**] Pt required pain medications. Pt Antibiotic regime was adjusted to the sensitivities. He did recieve some diuresis during this time frame for questionable mild CHF. Pt responded well to the diuretics. To expidite wound healing it was decided to take the pt back to the OR for more debridement and vac placement. [**2150-4-10**] Pt underwent a right foot debridement with Vac placement of the right foot. Pt tolerated the procedure well. There were no complications. Pt transfered to the PACU in stable condition. Once pt recooperated from anesthesia, he was sent to the floor in stable condition. [**2150-4-11**] to DC Pt recovered from his aforementioned procedures. A PT and case management consult was put in. Pt to go to rehab with VAC. On discharge pt is eating well, urinating without difficulty, pos BM. He is able to ambulate with asst. Medications on Admission: Lasix 40', Lantus 10qam, RISS, amdiodarone 200', atenolol 75", lipitor 20', levoxyl 100', plavix 75', protonix 40', vicodin, senokot 2", glipizide 5', asa 325, lisinopril 5' Discharge Medications: 1. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Heparin Sodium Injection 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): dc [**4-29**]. 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Hydrocodone-Acetaminophen 5-500 mg Capsule Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed. 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Hydromorphone 0.5 mg IV Q4H:PRN 17. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous Q24H (every 24 hours). 18. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 19. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 20. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. INSULIN see attached med sheet Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Ischemic rest pain/gangrene of the right foot. Discharge Condition: stable Discharge Instructions: Vac changes every 3 days untill f/u with Dr [**Last Name (STitle) **]. Please check for signs of systemic infection. Fever, chills and or night sweats. If htis happens call Dr. [**Last Name (STitle) 54948**] office immediatly. Also check for wound infection. redness, discharge or a feeling of warmth around the wound. If this happens call Dr. [**Last Name (STitle) **] office immediatly. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in two weeks. Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2395**]. Completed by:[**2150-4-15**]

[ "V49.72", "730.07", "593.9", "V45.81", "V45.01", "997.62", "440.24", "244.9", "998.12", "250.60", "285.9", "427.31" ]

icd9cm

[ [ [] ] ]

[ "93.59", "84.12", "39.29", "99.04", "38.93", "39.57", "86.22" ]

icd9pcs

[ [ [] ] ]

9256, 9335

4869, 7410

322, 523

9426, 9434

1533, 4846

9873, 10036

1090, 1095

7634, 9233

9356, 9405

7436, 7611

9458, 9850

1110, 1514

248, 284

545, 974

990, 1074

51,558

105,956

39492

Discharge summary

report

Admission Date: [**2106-9-16**] Discharge Date: [**2106-9-19**] Date of Birth: [**2035-11-14**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2712**] Chief Complaint: s/p T tube placement Major Surgical or Invasive Procedure: Flexible and Rigid bronchscopy with debridement of granulation tissue and T tube placement History of Present Illness: Ms. [**Known lastname **] is a 70F with DM2, asthma, with a history of chronic respiratory failure [**1-19**] PNA/asthma (with chronic trach x3 months, previously vented at night only, now off vent) CVA, CAD, s/p recent tracheal bleed and trach change [**2106-7-4**] who was admitted after an elective IP procedure to debride granulation tissue around her stoma and distal trach site, and place a T tube. Of note patient was recently admitted to the MICU from [**Date range (1) 87240**] for tracheal bleed, and difficulty talking. She had a rigid bronchoscopy by IP which showed diffuse granulation tissue around her stoma and her trach, as well as subglottic stenosis. This was debrided and a larger size (#7 non-fenestrated) trach tube was inserted. IP performed an elective rigid and flexible bronch and placed a T tube today (12mm) without complications. Granulation tissue from the stoma was debrided. After the procedure, patient was hypoventilating on pressure support, requiring CMV. She was reportedly hypercarbic and somnolent. She was slowly transitioned to PS, CPAP, and trach mask. She was admitted to the MICU for close respiratory monitoring given concerns for airway edema. Patient denies any change in respiratory status since here recent discharge on [**8-31**]. She denies hemoptysis. She hasn't been able to speak at all. Denies fevers or chills, chest pain, shortness of breath, orthopnea or LE edema. Past Medical History: IDDM2 Asthma Chronic resp failure ([**1-19**] asthma and PNA) s/p trach and PEG ? 3 months ago s/p bronch [**7-8**], [**7-6**], cuffless trach replacement to cuffed catheter in ED [**7-4**] CVA (L weakness) CAD HTN DJD GERD h/o AFB in sputum felt to be colonizer Polypoid lesion trachea Hypothyroidism Hyperlipidemia Social History: Resident at [**Hospital1 **] Commons. Has 3 sons. previously worked as manager of group home. - Tobacco: Denies - Alcohol: rare - Illicits: None Family History: Non-contributory Physical Exam: VS: Temp: 98.2 BP: 155/62 HR:57 RR:14 O2sat 100% on 10L trach mask GEN: pleasant, comfortable, trach mask in place HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Mild expiratory wheezes bilaterally with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: Obese. ND, +b/s, soft, nt, no masses or hepatosplenomegaly. PEG tube in place. EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. 1+DTR's-patellar and biceps Pertinent Results: Admission Labs: [**2106-9-16**] 05:53PM WBC-12.8* RBC-3.87* HGB-10.6*# HCT-32.3* MCV-83 MCH-27.3 MCHC-32.7 RDW-15.5 [**2106-9-16**] 05:53PM PLT COUNT-379 [**2106-9-16**] 05:53PM PT-12.1 PTT-25.1 INR(PT)-1.0 [**2106-9-16**] 05:53PM CALCIUM-9.4 PHOSPHATE-4.4 MAGNESIUM-2.0 [**2106-9-16**] 05:53PM ALT(SGPT)-16 AST(SGOT)-28 LD(LDH)-260* ALK PHOS-77 TOT BILI-0.3 [**2106-9-16**] 05:53PM GLUCOSE-185* UREA N-35* CREAT-0.8 SODIUM-133 POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-31 ANION GAP-14 Imaging: CXR [**2106-9-18**]: As compared to the previous radiograph, there is no relevant change. Minimal increase in extent of the retrocardiac atelectasis. Minimal increase in extent of the right basal atelectasis. Unchanged course and position of the PICC line, a tracheostomy tube in situ. [**2106-9-18**] 06:11AM BLOOD WBC-23.3*# RBC-3.52* Hgb-9.7* Hct-29.7* MCV-84 MCH-27.5 MCHC-32.6 RDW-15.5 Plt Ct-431 [**2106-9-19**] 04:55AM BLOOD WBC-16.0* RBC-3.42* Hgb-9.5* Hct-29.0* MCV-85 MCH-27.6 MCHC-32.6 RDW-15.6* Plt Ct-398 [**2106-9-19**] 04:55AM BLOOD Glucose-69* UreaN-25* Creat-0.7 Na-137 K-3.8 Cl-97 HCO3-34* AnGap-10 Brief Hospital Course: 70 yo F with DM2, asthma, chronic respiratory failure s/p trach complicated by hemoptysis secondary to granulation tissue around stoma site and subglottic stenosis s/p debridement and T tube placement. 1. Acute on Chronic respiratory failure: After her debridement, she briefly required increased ventilator support with CMV that was felt to be due to oversedation. She also had a significant amount of airway edema on bronchoscopy and was admitted to the MICU for monitoring. She was kept on Mucinex twice daily and kept on her home nebulizers. After T tube placement she was able to speak. However the following day, she had difficulty speaking again. She was taken back to the OR for repeat debridement of granulation tissue around the T tube, and the T tube was removed. 2. Leukocytosis was attributed to administration of steroids while in house. Her home meds were continued. Other than the mucinex, no other changes were made to her medications. Code Status: Full code, confirmed on admission Medications on Admission: 1. Bisacodyl 10mg po daily PRN constipation 2. Docusate 100mg po liquid [**Hospital1 **] 3. Senna 8.6 mg po bid PRN constipation 4. Acetaminophen 650 mg po q6h PRN pain 5. Escitalopram 20 mg po daily 6. Hydrochlorothiazide 12.5 mg po daily 7. Levothyroxine 100 mcg po daily 8. Lorazepam 0.5 mg po q6h PRN anxiety 9. Oxycodone 5 mg/5 mL po q4h PRN pain 10. Quetiapine 25 mg po bid 11. Ropinirole 2 mg po qPM 12. Simvastatin 20 mg po daily 13. Gabapentin 300 mg po tid 14. Albuterol inh 2 puffs q2h PRN 15. Chlorhexidine Mouthwash 1mL [**Hospital1 **] 16. Omeprazole 40 mg po bid 17. Ranitidine 300 mg po qhs 18. Nystatin 100,000 unit/mL Suspension -5mL po qid PRN thrush 19. Levemir 25 units sc bid 20. Novolog sliding scale 21. Aspirin 325 mg po daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) unit PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed for SOB. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q4H (every 4 hours) as needed for pain. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 16. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 19. Insulin Detemir 100 unit/mL Solution Sig: Twenty Five (25) u Subcutaneous twice a day. 20. Humalog 100 unit/mL Solution Sig: asdir units Subcutaneous qachs: Please resume prior sliding scale. 21. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO bid (). Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 **] Commons Nursing & Rehabilitation Center - [**Location (un) 6691**] Discharge Diagnosis: Primary diagnosis: Acute on chronic respiratory failure Secondary diagnosis: Chronic respiratory failure s/p tracheostomy Type 2 Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure caring for you. You were admitted after an elective procedure to place a T tube, and remove some unnecessary tissue near your trach. The following day you were still having difficulty speaking. You were taken back to the OR for removal of granulation tissue, and the T tube was removed. Followup Instructions: Please follow up with your PCP in the next 2 weeks. Completed by:[**2106-9-19**]

[ "338.29", "715.90", "272.4", "288.60", "250.00", "519.19", "530.81", "244.9", "519.09", "414.01", "V58.67", "V44.1", "728.87", "438.89", "518.84", "300.4" ]

icd9cm

[ [ [] ] ]

[ "33.23", "31.5", "97.23", "96.71" ]

icd9pcs

[ [ [] ] ]

7965, 8075

4176, 5187

294, 387

8267, 8267

3030, 3030

8766, 8849

2365, 2383

5989, 7942

8096, 8096

5213, 5966

8402, 8743

2398, 3011

234, 256

415, 1844

8174, 8246

3046, 4153

8115, 8153

8282, 8378

1866, 2184

2200, 2349

11,055

129,286

8679

Discharge summary

report

Admission Date: [**2194-6-24**] Discharge Date: [**2194-6-27**] Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 425**] Chief Complaint: Transfer from OSH for STEMI Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: 87-year-old M with h/o HTN, hyperlipidemia presented to OSH [**Hospital1 **] [**Location (un) 620**] with SSCP. Patient woke up in the morning and went for walk/gardening then started to feel very badly around 10 am, nauseas, profuse sweating and feeling as though his chest was going to "explode". He went home and tried to vomit but couldn't so presented to the [**Hospital1 **] [**Location (un) 620**]. At baseline he is very active and can do 30 minutes on the stationary bike or 20 minutes of rowing. He has never had similar symptoms in the past. . At OSH, VS 97.2 63 135/78 20 97% RA. EKG showing STE in inferior leads. Treated with heparin bolus of 4200 units no gtt, Integrillin bolus 6.8 ml with no drip, 2 sublinqual gtt then stopped, and 2 mg of Morphine IV and 2L NS. Attempted to give Lopressor IV but after 1 mg pt's b/p dropped to 96/48 so not given. Patient transferred for cath. . Cath here showed a proximal RCA occlusion with placement of 3 BMS. Transferred to ICU for hemodynamic instability, started on Integrilin gtt and Dopamine gtt for hypotension although AO 137/75 during cath. Upon arrival to the ICU patient is totally CP free. He c/o feeling cold and thirsty/dry mouth. ROS negative for h/o stroke, GI/GU complaints. Past Medical History: - HTN - Hyperlipidemia - h/o hematuria with renal stone s/p ?lithotripsy Social History: Patient lives alone, wife recently put in [**Name (NI) **] for advanced Alzheimer's, previously looked after her at home x 1 yr. He is independent with ADL's, very active as described above. Never smoked, never drinks, no OTC meds, no illicit drugs. Has several children in the area. Family History: No early CAD. Brother died of hemorrhagic stroke. Physical Exam: VS: T 95.6 BP 151/79 HR 76 RR 14 O2 97% 4L Gen: elderly male lying flat, NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Left groin sheat in place, c/d/i, 2+ pulses, 2+ dp pulses b/l Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: EKG [**2194-6-24**] 10:51: NSR at 70, 4 mm STE II, III, F, RBBB, PR 192, nl axis Post intervention: 1-2 mm STE inferior leads, RBBB . 140 107 18 -------------< 161 4.2 25 0.9 PT: 11.9 PTT: 81.0 INR: 1.0 . trends: [**2194-6-24**] WBC-10.3 RBC-3.79* Hgb-12.6* Hct-37.6* Plt Ct-250 [**2194-6-24**] 12:00PM BLOOD CK(CPK)-217* [**2194-6-24**] 09:12PM BLOOD CK(CPK)-1042* [**2194-6-25**] 06:24AM BLOOD CK(CPK)-873* [**2194-6-24**] 12:00PM BLOOD CK-MB-10 MB Indx-4.6 cTropnT-0.04* [**2194-6-24**] 09:12PM BLOOD CK-MB-153* MB Indx-14.7* cTropnT-4.03* [**2194-6-25**] 06:24AM BLOOD CK-MB-117* MB Indx-13.4* . [**6-24**]: Cath: 1. Selective coronary angiography of this right dominant system revealed single vessel coronary artery disease. The LMCA had no angiographically apparent flow limiting stenosis. The LAD had mild diffuse disease. The LCX had no angiographically apparent flow limiting stenosis. The RCA was a dominant vessel and was totally occluded proximally. 2. Limited resting hemodynamics revealed normal systemic pressure. 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal systemic pressure. 3. Acute inferior myocardial infarction, managed by acute ptca. 3 bare metal stents placed in the RCA vessel. . [**6-26**]: ECHO: EF 45-50%. The left atrium is normal in size. The estimated right atrial pressure is >20 mmHg. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed with inferior akinesis/hypokinesis and inferolateral hypokinesis. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. At least moderate pulmonary artery systolic hypertension. Brief Hospital Course: ASSESSMENT AND PLAN, AS REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: Pt is an 87 yo M with h/o HTN, hyperlipidemia who presents with IMI s/p 3x BMS to proximal RCA lesion. . #) CAD: IMI with proximal RCA occlusion, CK here 217 Trop 0.04 - trend CK to peak - monitor on tele - start ASA desensitization protocol given allergy - Plavix - high dose statin - Integrilin x 18 hrs - wean dopamine given elevated SBP, low dose beta blocker once off dopamine - echo in AM to evaluate EF - daily EKG - bolus IVF for hypotension - start ACEI once hemodynamically stable - going check, PM Hct, plts . #) Hypotension. Transient, likely in setting of vasodilators at OSH. Started on dopamine --wean as SBP tolerates. - bolus IVF for hypotension - low dose beta blocker . #) Rhythm: NSR, RBBB, ? old - contact PCP for old EKG - monitor on tele for PR prolongation, LAFB - low dose beta blocker . #) Pump: echo in AM . #) Hyperlipidemia: high dose statin . #) HTN: holding hctz, low dose beta blocker as tolerated . #) FEN: bolus IVF prn, cardiac diet, replete lytes prn . #) PPX: PPI, bowel reg prn . #) Access: PIV x 2 . #) Dispo: ICU level of care pending hemodynamic stability . #) Code: full Medications on Admission: ALLERGIES: ASA -->facial swelling/itching . CURRENT MEDICATIONS: - Hctz ?dose ([**1-14**] pill) - Simvastatin ?dose ([**1-14**] pill) Discharge Disposition: Home Discharge Diagnosis: Primary: - Acute STEMI, inferior MI with CA occlusion - HTN - Hyperlipidemia - ASA allergy s/p successful desensitization Discharge Condition: well Discharge Instructions: You came in after experiencing a heart attack. You underwent cardiac catheterization and had three stents placed in your right coronary artery. You tolerated the procedure well. We performed an aspirin desentizitation protocol to start aspirin. . Please take all of your medications as instucted. We made the following adjustments: 1. Plavix: you MUST take this medication every day for the next month. We recommend you take it for at least 1 year or otherwise as pe your cardiologist 2. Toprol XL once daily 3. Atorvastatin 80mg daily (stop you simvastatin) 4. Stop your hydrochlorothiazide. 5. Aspirin 325mg daily 6. Lisinopril 5mg daily . Please contact your PCP or come to the [**Name (NI) **] if you experience chest pain, shortness of breath, abdominal pain. Please followup with your PCP within the next 1-2 weeks. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] on [**7-11**] at 11:00AM. Please call his office @ [**Telephone/Fax (1) 30419**] if any changes need to be made. . A follow up appointment has been made with Dr. [**Last Name (STitle) **] of Cardiology at the [**Hospital1 18**] in [**Location (un) 620**], MA. His office number is [**Telephone/Fax (1) 4105**]. The appointment is on [**7-17**] @ 3:30pm. Please call if any changes are needed to be made. Completed by:[**2194-6-27**]

[ "410.41", "458.29", "401.9", "414.01", "E942.5", "272.4" ]

icd9cm

[ [ [] ] ]

[ "88.52", "88.55", "00.40", "00.66", "00.17", "36.06", "00.47", "37.22", "99.20" ]

icd9pcs

[ [ [] ] ]

6270, 6276

4894, 6085

242, 268

6442, 6449

2836, 3910

7331, 7825

1959, 2010

6297, 6421

6111, 6155

3927, 4871

6473, 7308

2025, 2817

175, 204

6176, 6247

296, 1545

1567, 1642

1658, 1943

18,831

183,261

2619

Discharge summary

report

Admission Date: [**2166-3-31**] Discharge Date: [**2166-4-14**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 905**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: (History obtained with help of pt's son, who is physician) HPI: 86 M with PMH CAD, diastolic CHF (EF50%), AFIB on coumadin, DM2, presents with progressive SOB. Pt has not been feeling well since Thursday, no SOB, no CP, rales in bases at baseline, but on [**Name (NI) 1017**], pt started feeling very SOB, and then became acutely worse until came to ED on Mon AM. . Pt denies CP, palpitations, nausea, vomiting. Pt's HR and BP were in good control at home(pt monitors BP/HR). Pt was given lasix by son (who is MD) without any improvement in symptoms. No recent orthopnea/PND. Has not been feeling well for past 4 days. Three days PTA developed right shoulder and neck pain. [**Name (NI) 1094**] son states that he may have been gradually developing CHF over past few days, although pt was not c/o SOB. . On arrival to [**Name (NI) **], pt was noted to be hypoxic at 60% on RA --> increased to 96% on NRB, BP 206/78 brought down to SBP 130s. Pt was given lasix 60 IV x2 and lasix 40 IVx1 with -2.5L UO; started on nitro gtt. O2 sat's improved and O2 decreased to 50% FM with initial O2 sats in mid 90s. However, began to desat to high 80s and NRB was re-placed. Bipap was initiated, then placed on NRB, and ABG 7.15/97/77/36, and was placed back on bipap. Also, pt was initially noted to have CP; pt received ASA 325, nitro sl, nitro gtt, with relief of symptoms. . Cardiologist: Dr. [**Last Name (STitle) 13179**], [**Hospital1 112**] Past Medical History: PMH: (pt is followed at [**Hospital1 756**]) HTN DM CHF (EF 50% on echo from [**2165**]) AF (on coumadin) with tachy-brady episodes, HR 80-110 in AFIB, HR brady when in sinus GERD Hiatal hernia CAD (s/p stents; last [**2157**]; hx MI) lung adenoca s/p LLL resection; no chemo/xrt hx Social History: Widowed. Lives alone at home. Able to care for himself. Occasionally drive. Remote cigar use. No Etoh. Son is a physician and is very attentive Family History: No signficant hx of CAD. Physical Exam: VS: t98.5, p60, 115 Gen: Face mask on place, which pt keeps removing. Mild respiratory distress using accessory muscles, well-nourished HEENT: PERRL, EOMI, anicteric, dry MM Neck: JVP to ear CVS: RRR, no m/g/r Lungs: bilateral rales [**3-15**] of the way up Abd: soft, NT, ND, +BS Ext: 1+ edema bilaterally, warm and well perfused,1+ DP bilaterally Pertinent Results: EKG: NSR @ 61, left axis, PR prolongation, TWI 3, V!, LAFB . EKG from [**2-15**] from [**Hospital1 112**] discharge summary description: First degree AV block, L anterior fascicular block, intraventricular conduction delay, tall R V2 with flatter TW in V6. . Imaging: CXR: Heart size is borderline. There are low lung volumes producing crowding in the pulmonary vasculature. There is upper zone vascular redistribution. There is a streaky left base opacity. There is a right mid zone patchy area of consolidation. No evidence of pneumothorax. . Echo ([**2165-12-9**]): EF 50-55%, severe hypokinesis of inferior and inferolateral walls, trivial MR, LA enlargement, mild cLVH, no more hypokinesis of the septum and anterior wall . Cath [**12/2155**]: Unsuccessful PTCA of LCX . Cath [**1-/2156**]: LCX 70% - PTCA dLAD 90% - PTCA . Cath [**12/2157**]: pLAD 70% D1/D2 90% LCX subtotally occluded RCA 40% . Cath [**5-12**]: pLAD 80% PTCA to 0% LCX 100% unsuccessful stenting c/b dissection pRCA 70% PDA 80% . Ett MIBI [**10/2157**]: unknown result . [**2166-3-31**] 07:53PM TYPE-ART PO2-87 PCO2-57* PH-7.36 TOTAL CO2-34* BASE XS-4 [**2166-3-31**] 03:59PM GLUCOSE-213* UREA N-67* CREAT-2.9* SODIUM-146* POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-32 ANION GAP-19 [**2166-3-31**] 03:59PM ALT(SGPT)-19 AST(SGOT)-17 CK(CPK)-131 ALK PHOS-46 TOT BILI-0.5 [**2166-3-31**] 03:59PM CK-MB-6 cTropnT-0.09* [**2166-3-31**] 03:59PM CALCIUM-8.7 PHOSPHATE-6.1* MAGNESIUM-2.7* [**2166-3-31**] 03:59PM WBC-16.0* RBC-4.30* HGB-13.0* HCT-40.2 MCV-94 MCH-30.3 MCHC-32.4 RDW-15.5 [**2166-3-31**] 03:59PM PLT COUNT-197 [**2166-3-31**] 03:59PM PT-26.9* PTT-27.7 INR(PT)-2.8* [**2166-3-31**] 03:54PM TYPE-[**Last Name (un) **] PO2-73* PCO2-69* PH-7.31* TOTAL CO2-36* BASE XS-4 [**2166-3-31**] 03:54PM GLUCOSE-217* LACTATE-3.6* [**2166-3-31**] 03:54PM O2 SAT-94 [**2166-3-31**] 02:56PM %HbA1c-6.3*# [Hgb]-DONE [A1c]-DONE [**2166-3-31**] 11:15AM TYPE-ART PO2-77* PCO2-97* PH-7.15* TOTAL CO2-36* BASE XS-1 [**2166-3-31**] 11:15AM LACTATE-1.7 K+-4.7 [**2166-3-31**] 10:15AM GLUCOSE-214* UREA N-71* CREAT-2.9* SODIUM-145 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-30 ANION GAP-20 [**2166-3-31**] 10:15AM proBNP-1845* [**2166-3-31**] 10:15AM CHOLEST-160 [**2166-3-31**] 10:15AM TRIGLYCER-215* HDL CHOL-51 CHOL/HDL-3.1 LDL(CALC)-66 [**2166-3-31**] 06:45AM POTASSIUM-5.4* [**2166-3-31**] 06:45AM CK(CPK)-181* [**2166-3-31**] 06:45AM CK-MB-8 cTropnT-0.08* [**2166-3-31**] 01:00AM GLUCOSE-215* UREA N-73* CREAT-3.1*# SODIUM-141 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-29 ANION GAP-18 [**2166-3-31**] 01:00AM CK(CPK)-198* [**2166-3-31**] 01:00AM CK-MB-7 cTropnT-0.10* [**2166-3-31**] 01:00AM CALCIUM-8.6 PHOSPHATE-5.6* MAGNESIUM-3.2* [**2166-3-31**] 01:00AM WBC-12.9* RBC-4.25* HGB-12.8* HCT-39.7* MCV-94 MCH-30.2 MCHC-32.3 RDW-15.6* [**2166-3-31**] 01:00AM NEUTS-74.8* LYMPHS-18.8 MONOS-4.8 EOS-1.3 BASOS-0.3 [**2166-3-31**] 01:00AM HYPOCHROM-1+ MACROCYT-1+ [**2166-3-31**] 01:00AM PLT COUNT-205 [**2166-3-31**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2166-3-31**] 01:00AM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 Brief Hospital Course: 86 M with PMH diastolic CHF EF 50-55%, PAFIB on coumadin, DM2, presents with acute CHF exacerbation due to pneumonia, and UTI. . # CHF exacerbation: Pt has diastolic heart failure with EF 60% on TTE. Decompensation was rapid over hours to days before admission, likely etiology being pneumonia. Pt presented with fever and leukocytosis. Pt was approximately 10 L overloaded on admission, and responded well to lasix for diuresis. He was euvolemic by [**4-4**]. Another consideration for etiology of CHF exacerbation include HTN (SBP was 206 on admission). . Pt had no EKG changes, no chest pain or pressure, no SOB. Pt had negative cardiac enzymes, and an ischemic etiology was not investigated. Pt's ischemic history includes 3VD, stented LADx2 [**1-/2156**] and [**5-12**], stented LCX [**1-/2156**] with 100% occlusion [**5-12**] that was unsuccessfully stented c/b dissection, RCA 70%. Pt was placed on ASA, metoprolol, diovan, statin. Imdur 120 QD per home regimen was discontinued. . Pt was in NSR on admission, but reverted to AFIB within 2 days. Metoprolol was used for rate control, pt was administered no rhythm control, and Coumadin dose was readjusted for anticoagulation. Pt's home regimen of coumadin is 3 QHS; INR was 3.5 on day of discharge; holding warfarin. Will need repeat INR and resume warfarin as tolerated for goal of INR [**2-14**]. . # Pneumonia: Pt was administered Levofloxacin from [**4-2**] - [**4-4**]. Since pt continued to spike fevers for 3 days on levo, Vanc/Aztreonam was started on [**4-4**]. Completed course of vanc/aztreonam on [**4-13**]; remained afebrile. . # UTI: Pt's first urinalysis and urine culture were negative on admission. Pt started to develop incontinence during admission, and was recultured. Urine culture showed Morganella morganii that was pansensitive except to nitrofurantoin. Pt was given vanc/aztreonam, and clinically improved, he should complete 10 day course on [**2166-4-13**]. Repeat UA with no evidence for UTI at time of discharge. . # Altered mental status: Pt was disoriented in the early AM and late PM during early admission. His mental status continued to improve during admission and was at baseline when tranferred to medicine, and pt became oriented. Etiology was likely due to pna/uti and ICU disorientation. Pt was treated with Zyprexa prn. Neurontin per home regimen was discontinued. Stable head CT. No other acute pathology. . # R shoulder pain and R knee pain: Xrays of R shoulder and R knee showed degenerative changes, but no fractures. Rheumatology consult was called to see patient. Pt was treated symptomatically with percocet prn and PT. Rheumatology tapped the knee and found crystals consistent with gout. He was treated with one dose colchicine and steroid injection of R knee. . # DM2: Pt's home regimen is lantus 82 U QAM; with hypoglycemic episodes, this was decreased to discharge dose of 58units in am. . # Widened mediastinum on CXR: A question of a widened mediastinum was noted on CXR. Difference in SBPs between pt's arms was noted to be only 10. MRA chest was discussed with pt's son, and was not performed, since intervention would likely not occur. Pt was maintained with good BP management. . # Chronic renal insufficiency: Pt's baseline Cr is approximately 2.5 per pt's son. Pt was at baseline throughout admission, and meds were renally dosed. . Communication: Son, neurologist at [**Hospital1 112**]: [**Telephone/Fax (1) 13180**] (cell), [**Telephone/Fax (1) 13181**] (home), [**Telephone/Fax (1) 13182**] (pager) Medications on Admission: Lasix 80mg [**Hospital1 **] Coumadin 3mg qhs Toprol XL 100mg qAM, 50mg qPM Aspirin 81mg qd Lipitor 20mg qhs Neurontin 200mg qPM Imdur 120mg qd Colace 100mg [**Hospital1 **] Lantus 84 U qAM Diovan 40mg qd [**2166-3-4**] - norvasc was d/ced for pedal edema [**2-17**] - cardiologist increased lasix [**12-16**] - Toprol 50 [**Hospital1 **] changed to 100 AM/50 PM . Allergies: PCN 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:*2* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Senna 8.6 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). Disp:*60 Capsule(s)* Refills:*2* 5. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Lantus 100 unit/mL Solution Sig: Fifty Eight (58) units Subcutaneous QAM. Disp:*1 month supply* Refills:*2* 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*2* 8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 month supply* Refills:*2* 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical ONCE (Once): To R knee: on for 12 hours and off for 12 hours. 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. 15. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary diagnosis: CHF exacerbation, pneumonia, UTI . Secondary diagnosis: Paroxysmal AFIB on coumadin, DM2, HTN, GERD Discharge Condition: Good, VS are stable, O2 sat >90% RA, eating/drinking, up to chair Discharge Instructions: 1. Please return to the emergency room if you experience shortness of breath, increased leg swelling, increased abdominal girth, weight gain, chest pain or pressure, or other worrisome symptoms. . 2. Please follow up with your physicians as below. . 3. Please take all medications as prescribed. Followup Instructions: 1. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 13183**], [**Telephone/Fax (1) 13184**], within 1-2 weeks. . 2. Please follow up with your physicians at [**Hospital6 13185**] within 1-2 weeks. . 3. Needs INR checked; note that warfarin was held on day of discharge for INR of 3.5. Please check INR and renew warfarin as tolerated for goal INR of [**2-14**]. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "424.0", "584.9", "V58.61", "599.0", "V58.67", "V10.11", "274.0", "792.1", "V45.82", "414.01", "715.96", "427.31", "790.92", "403.91", "518.82", "428.31", "412", "276.0", "250.00", "486", "293.0", "600.01" ]

icd9cm

[ [ [] ] ]

[ "81.92", "81.91", "99.23", "93.90" ]

icd9pcs

[ [ [] ] ]

11478, 11575

5832, 7846

238, 245

11738, 11806

2602, 5809

12150, 12688

2192, 2218

9786, 11455

11596, 11596

9383, 9763

11830, 12127

2233, 2583

179, 200

273, 1709

11671, 11717

11615, 11650

7861, 9357

1731, 2015

2031, 2176

31,056

157,859

50529

Discharge summary

report

Admission Date: [**2180-7-16**] Discharge Date: [**2180-7-23**] Date of Birth: [**2113-2-2**] Sex: M Service: MEDICINE Allergies: Hmg-Coa Reductase Inhibitors (Statins) Attending:[**First Name3 (LF) 1145**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: Percutaneous coronary intervention Intubation in the CCU A-line placement in the CCU History of Present Illness: Mr. [**Known lastname 105222**] is a 67 yo man with CAD s/p CABG in [**2172**] with re-do in [**2-/2180**] admitted to [**Hospital 1121**] Hospital on [**7-15**] for "sudden onset shortness of breath." At that time, he complained of diaphoresis but denied chest pain. He was found to have pulmonary edema and was given lasix, aspirin, and nitro. He required intubation in the ED, with an ECG showing RBBB and ST-elevations. He was given azithromycin and rocephin for question of infiltrate on CXR. . Following intubation and initiation of propofol, his SBP dropped to the 80s and he had bradycardia with subsequent asystole. He received CPR for 8-10 minutes and was transferred to the ICU where he was started on cardiac cooling and initiated on dopamine gtt. UOP was approximately 30cc/hr, CEs showed trops 0.2 to 0.4 with flat CK. Cardiology was consulted and the patient was started on a heparin gtt for presumed ACS. He was diagnosed with "CHF with flash pulmonary edema" s/p cardiac arrest. [**Month/Year (2) **] was done that showed EF of 30% with severe MR, inferior akinesis and hypokinesis. Creatinine was up to 3.6 from the patient's baseline of ~3. There was concern for "anoxic encephalopathy" but neurology consult was deferred due to transfer to [**Hospital1 18**] CCU. . At time of transfer to [**Hospital1 18**] CCU, he was intubated and moving all extremities but not responsive. He was afebrile with a SBP of 110/70, HR 80, ambu-bag with transition to vent, RIJ in place, with dopamine drip running. . Of note, he had been admitted to [**Hospital1 18**] CCU [**2180-2-23**] with DOE after having been previously evaluated at [**Hospital3 1443**] for concern for unstable angina. Past Medical History: # CAD with 5-vessel CABG in [**2172**] # MI with PCI [**2172**], PCI in [**5-/2179**] (DES to RCA) # Left renal artery stenosis [**12/2179**], nuclear scan showed 82% function on R and 16% function on L; 99% stenosis on renal angiogram with BMS X1 # CRI ([**1-/2180**] Cr 2.2) # HTN # Hemmorhoids # Hypercholesterolemia # PVD # H/o liver lesions # S/p rectal prolapse repair # Known carotid disease 16-49% stenosis on R, 50-79% on left # /p herniorrhaphy . CARDIAC RISK FACTORS: Dyslipidemia, Hypertension . CARDIAC HISTORY: CABG, in [**2172**] anatomy as follows: LIMA->LAD, SVG to PDA, OM1, OM2, and diag. . PERCUTANEOUS CORONARY INTERVENTION in [**2177**] anatomy as follows: total occlusion of native vessels and LIMA, with patent SVG to diag which backfilled LAD. 40% stenosis in SVG to OM. Social History: Social history is significant for current tobacco use (52 pack year smoking history). There is no history of alcohol abuse. Family history was not elicited. Family History: NC Physical Exam: VS: T 98.0, BP 110/67, HR 80, RR 18, 98% on vent Gen: middle aged male intubated, sedated HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CV: no murmurs appreciated, distant, on vent, difficult exam Chest: No chest wall deformities, scoliosis or kyphosis. mild upper airway sounds, +crackles R base Abd: soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Neuro: PERRL, EOMI, + gag, + corneal, moves all 4 ext. spontaneously, as well as with stimulation. Pertinent Results: [**2180-7-16**] 04:58PM WBC-13.2* RBC-3.51* HGB-10.4* HCT-30.9* MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 CK-MB-NotDone cTropnT-0.32* ALT(SGPT)-35 AST(SGOT)-42* LD(LDH)-479* CK(CPK)-87 ALK PHOS-108 TOT BILI-0.5 PT-15.7* PTT-32.8 INR(PT)-1.4* GLUCOSE-94 UREA N-51* CREAT-3.9* SODIUM-139 POTASSIUM-5.6* CHLORIDE-110* TOTAL CO2-17* ANION GAP-18 . [**2180-7-16**] 10:25PM TYPE-ART TEMP-37.2 RATES-/20 PEEP-5 O2-50 PO2-106* PCO2-37 PH-7.32* TOTAL CO2-20* BASE XS--6 INTUBATED-INTUBATED VENT-SPONTANEOUS [**2180-7-16**] 04:58PM BLOOD CK-MB-NotDone cTropnT-0.32* . [**2180-7-20**] 07:31AM BLOOD Type-ART pO2-138* pCO2-53* pH-7.20* calTCO2-22 Base XS--7 [**2180-7-20**] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2180-7-20**] 12:30PM BLOOD CK-MB-NotDone cTropnT-0.16* [**2180-7-20**] 05:15AM BLOOD Glucose-97 UreaN-44* Creat-2.9* Na-143 K-3.7 Cl-112* HCO3-23 AnGap-12 . [**2180-7-21**] CK 30, trop T 0.18 . [**2180-7-22**] Hct 30.9; BUN 45, Cr 3.5; .. MRI Chest [**2180-7-19**] FINDINGS: There is no thoracic aortic dissection. The thoracic aorta is normal in caliber throughout. Ascending aorta measures approximately 3.2 cm in caliber. Incidental note is made of an aberrant right subclavian artery. The pulmonary artery is normal in caliber, with the main pulmonary artery measuring approximately 2.7 cm. The heart is not enlarged. There is no pericardial effusion. Note is made of mitral regurgitation. There is bilateral, right greater than left, effusions and atelectasis / consolidation. Note is made of a sternotomy, consistent with history of previous CABG. Please note that the graft is not evaluated. Renal arteries cannot be assessed due to patient's inability to tolerate further scanning. Limited views of the kidneys from a localizer images demonstrate atrophy of the left kidney. Left kidney measures approximately 7 cm in length. Right kidney measures approximately 9 cm in length. IMPRESSION: 1. No thoracic aortic dissection or aneurysm. 2. Bilateral, right greater than left, effusions and atalectasis versus consolidation. 3. Mitral regurgitation. .. RENAL U/S [**2180-7-19**] FINDINGS: The right kidney measures 9.6 cm. Normal color vascularity and waveforms are seen throughout the right kidney. The study of the left kidney is somewhat limited. The cortex is thinned. The left kidney measures 7.6 cm. There is a cyst located in the mid portion of the kidney measuring 1.2 x 0.8 x 0.9 cm and is stable in appearance. A normal sharp systolic upstroke is seen in the left main renal artery with a peak systolic velocity of 46 cm/sec, essentially unchanged since the prior scan. Intrarenal waveforms on the left kidney are limited. The left renal vein is patent. IMPRESSION: 1. Limited study of the left kidney. Normal waveforms in the left renal artery, not significantly changed since prior scan. Left renal vein patent. 2. Left renal cyst, unchanged. .. CARDIAC CATH [**2180-7-20**] COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated native 3 vessel coronary artery disease. The LMCA was patent. The LAD was occluded at the ostium with disteal vessel filled via SVG wth no significant distal disease. The LCX had 95% proximal lesion with vessel filling AV LCX and collaterals to distal RCA. The grafted OM branches were occluded from the LCX. The RCA was not injected. The PDA was a small vessel filled from SVG and the distal RCA was occluded filing faintly from the SVG-RPDA and from the LCX collaterals. The SVG-D1 from initial CABG revealed mild disease. The SVG-OM from prior CABG revealed long segment with mid disease to 60% and distally filled very small segment of OM. The SVG-LAD was normal. The SVG-RPDA had long segment proximal/mid idsease to less than 50A% filled small PDA. The SVG-OM had proximal 70% stenosis and 95% lesion just distal to the SVG in OM. 2. Limited resting hemodynamics were performed. The left sided filling pressures were elevated measuring 24mmHg. The systemic arterial pressures were normal measuring 119/51mmHg. There were no significant gradient across the aortic valve upon pull back of the catheter from the left ventricle into the ascending aorta. 3. Successful PTCA and stenting of the SVG-OM with 2.25x8mm Minivision stent and a 2.5x12mm Xience stent which was post dilated to 3.0mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). 4. Successful PTCA and stenting of the LCX with a 2.5x12mm Xience stent. Final angiography revealed no residual stenosis, no angiographically apparent dissection and TIMI III flow (see PTCA comments). . FINAL DIAGNOSIS: 1. Native three vessel coronary artery disease. 2. Patent SVG-OM and SVG-D from first CABG. 3. Patent SVG-LAD, SVG-OM and SVG-RCA from redo CABG. 4. Successful PTCA and stenting of the SVG-OM. 5. Successful PTCA and stenting of the proximal LCX. Brief Hospital Course: In summary, this is a 67 yo male with h/o CAD s/p CABG, PVD, who presented to OSH with acute SOB, intubated with asystole, s/p cardiac arrest, transferred to [**Hospital1 18**] on [**7-16**] for pulmonary edema, cardiac arrest and renal failure. . # CAD/ISCHEMIA: Initially he required pressors but these were quickly weaned and he was extubated by HD 2. His cardiac enzymes continued to trend down and his EKG remained stable so he was maintained on ASA and plavix and was changed to SQ heparin and transferred to the step down unit. An MRI of the chest was performed which showed no aortic dissection and no aneurysm. On [**2180-6-18**], he developed acute diaphoresis with ST depressions in the antero-lateral leads (consistent with posterior ST elevation) and he was started on a heparin and nitroglycerin drip; his diaphoresis and EKG changes improved medically. Our impressin was circumflex territory ischemia and ischemic mitral regurgitation and plans were made for cardica cath the next morning. However, that evening he developed flash pulmonary edema with hypertension and sinus tachycardia with a minor increase in cardiac enzymes; he was intubated w/o complications and he was sent to cath lab. There he underwent successful stenting of his SVG-OM graft and the proximal circumflex artery. His CE peaked at a CK of 30 and troponin of 0.19. He remained CP free after the cath and his enzymes continued to trend down. He was maintained on plavix and ASA; statins were held as he has an allergic hx and ACE inhibitor was not given as he had ARF. . # PUMP/VALVES: [**Date Range **] performed at [**Hospital1 18**] showed an EF of 40-45% with left ventricular dysfunction and mild mitral regurgitation. The mitral valve annuplasty was well-seated. Carvedilol was increased to 12.5 mg twice daily with consequent hypotension that was responsive to fluids. The dose was decreased to 6.25mg twice daily and he was maintained at that dose without further problems during his hospital stay. The evening of [**2180-6-18**], he developed pulmonary edema that was treated as above. Post cath, there were no hyper- or hypotension concerns. . # RHYTHM: His rhythm remained in sinus during his hospitalization and amiodarone was not deemed necessary, especially given his prolonged QTc. He was maintained on carvedilol for cardiac protection. . # RESPIRATORY FAILURE: He initially presented with SOB, likely due to sys/[**Last Name (un) **] CHF, now with superimposed insult s/p cardiac arrest. Although initially he was given Abx at the OSH, they were not continued as he was afebrile and without a white count. ABG at admission showed good oxygenation, PS of 5, PEEP 5; he was extubated on HD 2 and was satting well on RA. He later developed hypoxic respiratory failure during his flash pulmonary edema that resolved after diuresis and intubation. His oxygen was weaned down after extubation within 24 hrs. He continued to have O2 sats >95% on RA. He continued to have a slight right-sided pleural effusion with crackles at discharge that was non-symptomatic and likely residual from his flash edema. . # NEUROLOGICAL: Post-extubation and off sedation, his neurological status was normal and he had no further issues. . # CRI/HYPERKALEMIA: He initially presented with acute on chronic renal failure with a creatinine up to 4. The patency of his left renal artery stent was found to be normal by Doppler US and the cause was likely pre-renal due to decreased renal perfusion in the setting of myocardial ischemia and LV dysfunction. He required Kayexelate x1 and his electrolytes were repleted as necessary. Nephrology was consulted and they suggested avoidance of nephrotoxic drugs with careful diuresis; they saw no indication for dialysis. Post emergent cath, his creatinine trended down to baseline and his UOP was maintained well. We decided to discontinue his Lasix as he was not deemed a baseline CHF patient. . PPx: He was maintained on anticoagulation, either therapeutically or prophylactic doses throughout his admission. By discharge, he was ambulating well and DVT prophylaxis was discontinued. Medications on Admission: 1. amio 200mg qd 2. plavix 75mg qd 3. asa 81mg qd 4. phoslo 5. carvedilol 6.25mg [**Hospital1 **] 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. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Unstable angina Pulmonary edema due to myocardial ischemia and ischemic mitral regurgitation Acute on chronic renal insufficiency Successful PCI SVG to OM and native Circumflex Discharge Condition: Asymptomatic and hemodynamically stable. Discharge Instructions: You were admitted to [**Hospital1 69**] with shortness of breath. Your shortness of breath was due to fluid in you lungs. The trigger for this was cardiac ischemia due to blockage in arteries supplying blood to your heart. You had a procedure called cardiac catheterization. You had stents placed to these blockages. . Please take the medications as written. It is very important that you take aspirin 325 mg and plavix 75 mg daily to prevent clotting of these stents. Please do not stop either of these medications unless instructed to do so by your cardiologist. . Please keep all of your follow up appointments. . If you develop chest pain, shortness of breath or any other concerning symptoms, please call your primary care doctor or go to the nearest Emergency Department. . Please stop smoking. Information was given to you on admission regarding smoking cessation. Followup Instructions: Please follow up with your primary care doctor within one week of discharge. . Please follow up with your cardiologist (Dr. [**First Name (STitle) 3236**], phone # [**Telephone/Fax (1) 11554**]) within one week of discharge. Completed by:[**2180-7-25**]

[ "518.5", "427.5", "997.1", "584.9", "428.40", "414.01", "411.1", "403.90", "584.5", "585.9", "414.02", "428.0" ]

icd9cm

[ [ [] ] ]

[ "36.07", "99.60", "00.47", "96.04", "36.06", "37.22", "00.41", "00.66", "96.71", "38.91", "88.56" ]

icd9pcs

[ [ [] ] ]

13386, 13392

8838, 12946

319, 405

13613, 13656

3941, 8551

14582, 14838

3152, 3156

13095, 13363

13413, 13592

12972, 13072

8568, 8815

13680, 14559

3171, 3922

259, 281

433, 2140

2162, 2961

2977, 3136

3,987

106,870

25275

Discharge summary

report

Admission Date: [**2206-6-18**] Discharge Date: [**2206-7-3**] Date of Birth: [**2131-1-17**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin / Levofloxacin / Fentanyl Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest pain/Transfer for catherization Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: Mr. [**Known lastname **] is a 75 yo male with a history of significant vascular disease and CAD, including CABG in [**2194**] with LIMA to LAD and SVG to OM and SVG to PDA of RCA, s/p BMS to distal SVG to RPDA on [**3-/2206**], LCEA in [**2202**], and LAKA in [**2200**] as well as multiple PVD procedures who woke up the morning of presentation with some chest pain and heart burn after having a cup of coffee with breakfast. He states his isosorbide usually relieves anginal symptoms, but it had not worked this morning. He tried sublingual nitroglycerine x3 as well with no relief. His pain was burning/sharp in nature, centrally located, without radiation to the upper extremities. He denied nausea, vomiting, or diaphoresis with the event. Given his symptoms, his wife took him to [**Name (NI) **] for further evaluation. OF note, the patient had a similary presentation in early [**Month (only) **] where ACS workup was negative for an MI. At [**Month (only) **], his chest pain was [**4-1**] described as "indgiestion". VS at time of presentation were NIBP 107/56, Pulse 84, REspratory 22, )2sat 90 % on RA. T97.4. EKG at that time showed RBBB with new ST segment elevations in aVR, V1/V2 with STD in V4-V6 as well as AVL,I. Ol Q waves were noted in III, AVF. Troponin I at that time were elevated at 0.109 with CKMB of 7.4. Heparin gtt was started. Patient was planned to have a catherization for possible STEMI, however the [**Month/Year (2) **] lab at [**Month/Year (2) **] was down and patient requested transfer to [**Hospital1 18**] for further care. At [**Hospital1 18**], patient transferred directly to the [**Hospital1 **] lab. Received morphine prior to transfer with resolution of chest pain. There, a right radial approach was attempted, however total occlusion of the right subclavian artery was encountered. The radial approach was abandoned and femoral approach was attempted via the RFA. Angiography revealed a patent LMCA with 40% distal, 70% LAD, patent LIMA at touchdown, occluded LCX and RCA, with Patnet SVG-RCA/SVG-LCX and LIMA-LAD. Left subclavian was also noted to be occluded when imaged. Both carotids were noted to be severely diseased with origin of the right SC after spearate origin of the two carotids. Also noted were 90% occluded left and right external iliacs at CFA level. Hemodynamics revealed brachial NIBP to be about 80 mmHg lower than central blood pressures, with AO BP of about 150mmHg. No stents were placed at that time, and the patient continued to be chest pain free. He was transferred to the CCU for further monitroing and eventual initiation of heparin gtt. In the CCU, the patient is in NAD. Right groin noted to have continual oozing from recent catherization site. REVIEW OF SYSTEMS On review of systems, denies CP, SOB, nausea, vomiting. Has had diarrhea for last 4 days and took loperamide the day prior to presentation given diarrehal symptoms. No blood in bowel movements. No dysuria or hematuria but endorses frequent urinary hesitancy. Denies joint pains, cough, hemoptysis, black stools or red stools. Has chronic angina. No PND/orthopnea currently, although has had HF exacerbations several times in the last several months. Past Medical History: - NSTEMI [**2206-2-20**] - dCHF with EF 55% - hypertension - hyperlipidemia - DM2 w/ neuropathy - PVD - presumed small-bowel AVMs with recurrent GIB and anemia (recent bleed in [**3-/2206**] on dual antiplatelet therapy) - h/o erosive esophagitis and AVMs of the colon - GERD - BPH - anxiety - depression - vitamin D deficiency - hypomagnesemia - s/p appendectomy - s/p bladder cystoscopy for non cancerous bladder growths - s/p L BKA [**1-28**] - CABG: [**2194**] @ [**Hospital1 2025**] ( LIMA to LAD and SVG to OM and SVG to PDA of RCA, s/p BMS to distal SVG to RPDA on [**3-/2206**]) - PCI: [**2194**] prior to CABG, no stents placed - s/p L carotid endarterectomy [**2203-5-12**] - s/p laser eye surgery b/l ([**2204**]) Social History: He is married and lives with his 2nd wife of 23 years. They have 8 children between them, 7 in the area. They have 17 grandchildren all in the area. - Tobacco history: former, 30+ pack years, quit 10+ years ago - ETOH: denies - Illicit drugs: denies Uses a wheelchair at home, transfers independently. Family History: Mother with DM, 2x amputee, angina, died early 60s Two brothers with DM, CAD Physical Exam: Admission Exam GENERAL: Obese but NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Thick neck but supple. Patient laying supine. CARDIAC: Exteremely faint heart sounds. Barely auscultated S1/S2. No appreciated adventitious heart sounds. LUNGS: Auscultated anteriorly. No wheezes/rhonchi/rales or coarse breath sounds appreciated. Large chest wall. ABDOMEN: Distended with midline scar. NBS. Slightly tense abdomen without tenderness to palpation. No rebound. No organomegaly appreciated. EXTREMITIES: S/p LBKA. Multiple surgical scars on RLE c/w prior vascular procedures. Bilateral raidal scars consistent with vascular procedure. GU: Foley placed. Clear urine. SKIN: Scars per above. Also with midline sternotomy scar c/w CABG. Hyperpigmented macule on penis. PULSES: Right: Non palpaple/non dopplerable DPP, dopplerable PTP, faint femoral pulse with oozing around access site. 1+Carotids, 1+ Radial Left: Carotid 1+ Radial 1+ Femoral 1+ Popliteal 2+ Discharge Exam GENERAL: Obese but NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Thick neck but supple. Patient laying supine. CARDIAC: Exteremely faint heart sounds. Barely auscultated S1/S2. No appreciated adventitious heart sounds. LUNGS: Auscultated anteriorly. No wheezes/rhonchi/rales or coarse breath sounds appreciated. Large chest wall. ABDOMEN: Distended with midline scar. NBS. Slightly tense abdomen without tenderness to palpation. No rebound. No organomegaly appreciated. EXTREMITIES: S/p LBKA. Multiple surgical scars on RLE c/w prior vascular procedures. Bilateral raidal scars consistent with vascular procedure. GU: Foley placed. Clear urine. SKIN: Scars per above. Also with midline sternotomy scar c/w CABG. Hyperpigmented macule on penis. PULSES: Right: Non palpaple/non dopplerable DPP, dopplerable PTP, faint femoral pulse with oozing around access site. 1+Carotids, 1+ Radial Left: Carotid 1+ Radial 1+ Femoral 1+ Popliteal 2+ Pertinent Results: Admission Labs [**2206-6-18**] 10:00PM GLUCOSE-104* UREA N-37* CREAT-1.4* SODIUM-134 POTASSIUM-6.5* CHLORIDE-98 TOTAL CO2-27 ANION GAP-16 [**2206-6-18**] 10:00PM estGFR-Using this [**2206-6-18**] 10:00PM CK(CPK)-130 [**2206-6-18**] 10:00PM CK-MB-8 cTropnT-0.13* [**2206-6-18**] 10:00PM CALCIUM-8.4 PHOSPHATE-5.3*# MAGNESIUM-2.3 [**2206-6-18**] 10:00PM WBC-6.8 RBC-2.98* HGB-9.5* HCT-28.7* MCV-96 MCH-32.0 MCHC-33.2 RDW-14.4 [**2206-6-18**] 10:00PM PLT COUNT-127* [**2206-6-18**] 10:00PM PT-10.6 PTT-27.4 INR(PT)-1.0 [**2206-6-18**] 03:18PM PO2-112* PCO2-51* PH-7.39 TOTAL CO2-32* BASE XS-5 [**2206-6-18**] 03:18PM HGB-11.1* calcHCT-33 O2 SAT-97 Studies [**2206-6-18**] EKG: Sinus rate. RBBB morphology with LAD fasicular block. Old qwaves in inferior leads with small Qwaves in V1-V3. ST depressions in I, AVL, II, V4-6, with STE's in V1/V2 aVR. TWI in I, V4-V5. Compared to prior on [**2206-5-24**] STE's are new as well as STD's. Cardiac [**Date Range **] FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Bilateral subclavian stenoses. 3. Bilateral carotid stenoses. 4. Bilateral common femoral stenoses. 5. Right radial artery pressure ~80 mmHg lower than central aortic pressure. Discharge Labs [**2206-7-3**] 06:05AM BLOOD WBC-9.5 RBC-3.40* Hgb-11.0* Hct-32.8* MCV-96 MCH-32.3* MCHC-33.6 RDW-16.7* Plt Ct-165 [**2206-6-29**] 07:20AM BLOOD Neuts-77.0* Lymphs-12.0* Monos-8.2 Eos-2.6 Baso-0.2 [**2206-7-3**] 06:05AM BLOOD Plt Ct-165 [**2206-7-3**] 06:05AM BLOOD Glucose-127* UreaN-39* Creat-2.0* Na-143 K-4.1 Cl-111* HCO3-23 AnGap-13 [**2206-6-26**] 04:32AM BLOOD ALT-24 AST-26 AlkPhos-147* Amylase-46 TotBili-0.3 [**2206-6-26**] 04:32AM BLOOD Lipase-34 [**2206-6-19**] 05:29AM BLOOD CK-MB-7 cTropnT-0.24* [**2206-7-3**] 06:05AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 [**2206-6-23**] 06:11AM BLOOD C3-151 C4-46* [**2206-6-18**] 03:18PM BLOOD pO2-112* pCO2-51* pH-7.39 calTCO2-32* Base XS-5 [**2206-6-18**] 03:18PM BLOOD Hgb-11.1* calcHCT-33 O2 Sat-97 Brief Hospital Course: 75 yo male with a history of significant vascular disease and CAD as well as DM, HTN, HLD, presenting with NSTEMI vs STEMI from OSH now status post catherization without further stenting. Acute #TIA's/Sub-acute PCA Infarct- Patient is s/p L CEA in [**2202**]. Carotid series done [**6-20**] on this admission revealed: 1. Complete occlusion of the right CCA. Flow is noted within the right ICA, though absence of diastolic flow is concerning for distal stenosis. 2. Findings consistent with a 70-79% stenosis of the left ICA, with reversed flow within the left vertebral artery into the left subclavian artery, consistent with subclavian steal. On the AM of [**6-25**], the patient developed new onset slurring of speech and L sided weakness. This resolved over approximately 1 hour. Neurology was urgently called and a STAT CT scan was done which revealed new hypodense area in the right PCA territory consistent with acute to sub-acute infarct. At this time, the patient was placed on a heparin gtt. This was d/c'ed evening of [**6-26**] after patient had melenotic stools and a drop in Hct. He experienced a second TIA in house on [**6-27**] during which he temporarily had a slurring of speech. An MRA of the neck was obtained which revealed stenosis of multiple arteries in the neck. After an interdisciplinary meeting btw Cardiology, Neurology, and Vascular Surgery, it was decided that the risks outweighed the harms to intervene regarding his arterial disease given his other comorbidities. A family meeting took place on [**2206-7-2**] discussing the [**Hospital 228**] medical condition and disposition. It was agreed upon with the patient, family, and healthcare personnel that he go to a high skill rehab facility to strengthen the patient enough so he can transfer him self around his home. His status was made "Do Not Hospitalize" while at the rehab facility. DNR and DNI orders were also agreed upon. #Contrast-Induced Nephropathy After receiving 300 cc contrast during cardiac [**Hospital **] [**6-18**], patient had rise in creatinine from 1.4 to 6.5 (peaked [**6-23**]) and then normalized by [**6-30**]??. Renal was consulted. They recommended PRN lasix boluses for decreased urine output. The patient never required dialysis and his hyperkalemia and hyperphosphatemia were managed medically. #CAD/STEMI: Coronary angiography [**6-18**] showed no significant changes from his recent catherization in 4/[**2205**]. No culprit lesion could be identified. Cardiac enzymes were cycled and troponin rose from .13 to .24. The patient was continued on his home dose of plavix and asa in the setting of his recent BMS placement. His home dose of isosorbide nitrate (90mg qAM) was changed to 60mg qHS to due to multiple hypotensive episodes encountered during the hospital stay. Rosuvastatin was changed to atorvastatin 80 and his metoprolol succ 100mg qd was changed to metropolol tartrate 50 mg [**Hospital1 **]. #PVD/Subclavian stenosis: No intervention done during this hospital stay. As was mentioned above, the patient has severe PVD affecting the subclavian, vertebral, and carotid system. As he is not an appropriate candidate for surgery the recommendation made to the patient was medical management. #Upper GI Bleed The patient has a history of GI bleeds and AVM's with known gastric AVM's. After being placed on a heparin gtt for a TIA on [**6-25**], the patient had melenotic stools and a 5 pt drop in Hct (30 to 25) the evening of [**6-26**]. The heparin gtt was d/c'ed and due to patient's hx of angina and vascular disease, he was transfused slowly with 1UPRBC with an appropriate response. After heparin gtt d/c'ed, no more melena detected and Q6hr CBC's were stable. However, upon transfer back to the CCU on [**7-1**] the patient had 1 more episode of melena. Hcts remained stable and no invasive intervention was performed. The patient's Aspirin and clopidogrel were d/ced and dypiradimole/aspirin (Aggronox) was started in consult with neurology- the thought was to anticoagulate the patient to treat his TIAs and PVD affectively while reducing his chance for continuing GI bleed. Chronic #HTN: Discrepancy between peripheral reads and central reads by about 100 mmHg. On cardiac catheterization, it was noted that central BP was about 150 mmHg. Target BP should be about 70-80s/40s (equivalent to 170s/140s centrally). For this reason, urine output and mental status were used as a surrogate for patient's tru BP. Lisinopril was d/c'ed [**1-23**] contrast-induced nephropathy. Metoprolol was changed to 50 mg [**Hospital1 **] as above. #T2DM. Insulin-dependent, with complications of nephropathy and retinopathy. SSI was continued in house #BPH: Home finasteride and tamsulosin were continued in house. # Anxiety and depression: Patient has long history of anxiety and depression. citalopram 40 mg was continued in house and later increased to 60 mg daily. Alprazolam dose was decreased from 0.5mg to .25mg TID to allow for more reliable neuro exam as patient appeared to be having recurrent TIA's. Transitional Issues:IMPORTANT - The patient is being discharged to a high level rehab facility with the intent as described above. He has multiple ACTIVE medical conditions that you should know about. His status is "Do NOT HOSPITALIZE"- these will apply to chief complaints for chest pain, and any neurologic events. 1. Ongoing TIAs. The patient may experience slurred speech or eye deviation or weakness daily. These are not new. He is being optimized medically with Aggronox for transient neurologic ischemia. He has been evaluated by neurology, cardiology, and vascular surgery for this and the recommendation was made to not intervene. Please be aware that this is his baseline. 2. Chest pain- the patient has severe coronary artery disease that is chronic and will not benefit from intervention. He should be medically managed if chest pain should occur. Please go up on his isosorbide mononitrate as blood pressure tolerates. Sublingual nitroglycerin is also an option. 3. GI bleeds- Patient has chronic small bowel AVMs. In the event that he has a massive GI bleed, he [**Month (only) **] be considered for hospitalization because blood transfusions may help him symptomatically. However, he should only be hospitalized if he has MAJOR bleeding and if he symptomatic. Diabetes- Please follow up on blood sugars and adjust diabetes medications as necessary. Regimen has been changed multiple times since admission. Medications on Admission: Preadmissions medications listed are incomplete and require futher investigation. Information was obtained from webOMR Transfer handwritten Rx list. 1. Levemir 18 Units Breakfast 2. ALPRAZolam 0.5 mg PO TID:PRN anxiety / nausea 3. Finasteride 5 mg PO DAILY 4. esomeprazole magnesium *NF* 40 mg Oral once daily 5. Gabapentin 300 mg PO Q 12H 6. Rosuvastatin Calcium 10 mg PO DAILY 7. Aspirin 325 mg PO DAILY 8. Clopidogrel 75 mg PO DAILY 9. Metoprolol Succinate XL 100 mg PO DAILY 10. Tamsulosin 0.4 mg PO HS 11. Furosemide 40 mg PO DAILY 12. Citalopram 40 mg PO DAILY 13. Sucralfate 1 gm PO BID 14. Cyanocobalamin 50 mcg PO DAILY 15. Vitamin D [**2193**] UNIT PO DAILY 16. Ferrous Sulfate 325 mg PO DAILY 17. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses 18. Repaglinide 2 mg PO BIDWM 19. Multivitamins 1 TAB PO DAILY 20. Ascorbic Acid 500 mg PO BID 21. Fish Oil (Omega 3) 1000 mg PO BID 22. Ocuvite *NF* (vit A,C & E-lutein-minerals;<br>vit C-vit E-lutein-min-om-3) 1,000-60-2 unit-unit-mg Oral once daily 23. Nitroglycerin SL 0.3 mg SL PRN chest pain 24. HydrALAzine 50 mg PO Q8H 25. Docusate Sodium 100 mg PO BID 26. Senna 1 TAB PO BID:PRN constipation 27. Polyethylene Glycol 17 g PO DAILY 28. Prochlorperazine 10 mg PO Q6H:PRN nausea 29. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Discharge Medications: 1. ALPRAZolam 0.25 mg PO TID:PRN anxiety / nausea 2. Ascorbic Acid 500 mg PO BID 3. Citalopram 60 mg PO DAILY 4. Cyanocobalamin 50 mcg PO DAILY 5. Docusate Sodium 100 mg PO BID 6. Ferrous Sulfate 325 mg PO DAILY 7. Finasteride 5 mg PO DAILY 8. Fish Oil (Omega 3) 1000 mg PO BID 9. Gabapentin 300 mg PO BID 10. Levemir 18 Units Breakfast 11. Isosorbide Mononitrate (Extended Release) 120 mg PO QHS 12. Multivitamins 1 TAB PO DAILY 13. Nitroglycerin SL 0.3 mg SL PRN chest pain 14. Senna 1 TAB PO BID:PRN constipation 15. Sucralfate 1 gm PO BID 16. Tamsulosin 0.4 mg PO HS 17. Vitamin D [**2193**] UNIT PO DAILY 18. Metoprolol Tartrate 50 mg PO BID hold for heart rate <60 or extreme lethargy 19. Esomeprazole Magnesium *NF* 40 mg ORAL ONCE DAILY 20. Prochlorperazine 10 mg PO Q6H:PRN nausea 21. Sulfameth/Trimethoprim DS 1 TAB PO BID 22. Simethicone 40-80 mg PO QID:PRN bloating 23. Dipyridamole-Aspirin 1 CAP PO BID 24. Atorvastatin 80 mg PO DAILY 25. Acetaminophen 650 mg PO Q6H:PRN pain Do not exceed 4gm /day 26. MetFORMIN (Glucophage) 500 mg PO BID Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Primary- Unstable Angina Transient Ischemic Attacks GI bleed Secondary- Contrast-Induced Nephropathy Peripheral Vascular Disease Type II Diabetes Discharge Condition: Level of Consciousness: Mentating ok (conversant, answering questions) but with active neurological impairment Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - sometimes. Discharge Instructions: You were admitted to the hospital for chest pain and were taken to the cardiac catheterization lab. The doctors in the [**Name5 (PTitle) **] lab found no new blockages in your arteries. The vessels from your open heart surgery looked healthy. However, they did find you have other arteries around your body with significant disease, including your subclavian arteries. Dr [**Last Name (STitle) **] recommends you have a procedure to explore and possibly treat this disease. Unfortunately, the contrast used during your cardiac catheterization caused you to have kidney damage during your hospital stay. This improved over several days with fluids and IV water pills. You were found to have severe peripheral vascular disease in the arteries of your neck, which has been resulting in "transient ischemic attacks", or TIAs. This has been complicated by your GI bleeding. The vascular surgeons, neurologists, and cardiologists all agreed that any surgical intervention would only cause more harm than good to your medical condition. We had a family meeting and decided to discharge you from the hospital to a high level rehab facility to increase your strength before going home. We discussed possibly getting hospice care involved once you are home. Please see your medication list to review changes made to your medications. It was a pleasure taking care of you, Mr [**Known lastname 63255**]. Followup Instructions: Department: CARDIAC SERVICES When: THURSDAY [**2206-7-24**] at 4:00 PM With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**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 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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icd9cm

[ [ [] ] ]

[ "37.22", "88.56" ]

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Discharge summary

report

Admission Date: [**2108-5-27**] Discharge Date: [**2108-5-30**] Date of Birth: [**2041-8-27**] Sex: M Service: MEDICINE Allergies: Penicillamine / Ciprofloxacin / Vancomycin / Insulins / Lithium Attending:[**First Name3 (LF) 3984**] Chief Complaint: fever 101.3, hypoxia, tachycardia, tachypnea Major Surgical or Invasive Procedure: Right internal jugular central venous line History of Present Illness: 66 yo male chronic nursing home resident with hx recently admitted to the [**Hospital1 18**] [**Hospital Ward Name 332**] MICU with Influenza complicated by S. aureus pneumonia requiring intubation, bronchectasis, and Afib. During the last admission pt sputum speciem demonstrated MSSA on [**2108-5-15**]. Initially treated with Vanc/Zosyn for 7 days, and later switched to Oxacillin with plan to finish Oxacillin on [**2108-5-31**]. On the day of admission, the patient was found to have increased cough with fever to 102 at rehab. He experienced oxygen desaturation to the 80's. ABG showed values of 7.54/29/55/24 on 4 litres NC, with tachypneic to a rate of 30. Pt. was brought to the [**Hospital1 18**] ED where he was oxygenated with a face mask. VS 101.3 HR 141 (afib) 121/68 RR 40 SpO2 98 % NRB. He was given doses of Vanco, levoflox, and Flagyl. He was given iv NS 4 litres. Labs on admission elevated WBC 14.3.CxR with persistent RLL opacity. UA w > 50 WBC . He was transferred to the MICU. Past Medical History: Wilson's disease, bipolar disease, hx SI, hs Pica, bronchiectasis, atrial fibrillation, coronary artery disease, history of pancreatitis, status post Billroth II for peptic ulcer disease, chronic renal insufficiency baseline cr 1.9-2.4, status post mitral valve replacement, status post a cholecystectomy. He has had an exploratory laparotomy,status post bowel resection for obstruction. He is also status post partial colectomy. He is also status post gastrostomytube placement. S/P R hip fracture and THR. Cataracts. Anemia. Had flu shot this year,pneumovax [**2106-10-4**]. **MRSA/VRE** Social History: Lives at [**Hospital **] rehab, no etoh use, no tobacco Family History: Non-contributory. Physical Exam: Tm 101.3 BP 118/50 HR 140 RR 35-40 Sat 84% 4lt ---98% NRB Gen: cachectic, in respiratory distress, unable to speak in full sentences. HENNT:dry MMM, anicteric, PERRL, EOMI Neck: LAD, JVD CV: irreg irreg , systolic click LSB, No M/R/G Lungs: CTAB Abd: soft, NT/ND, +BS, No HSM Ext: no LE edema, strong DP/PT pulses bilaterally Neuro: A&Ox3, CNII-XII intact, UE/LE muscle strength 5/5 b/l Skin: no rash Pertinent Results: [**2108-5-27**] 05:13PM TYPE-[**Last Name (un) **] TEMP-37.8 PO2-40* PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2 [**2108-5-27**] 04:43PM POTASSIUM-3.9 [**2108-5-27**] 09:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2108-5-27**] 09:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-8.0 LEUK-SM [**2108-5-27**] 09:00AM URINE RBC-21-50* WBC->50 BACTERIA-MOD YEAST-NONE EPI-0 [**2108-5-27**] 08:39AM LACTATE-1.5 [**2108-5-27**] 08:30AM GLUCOSE-112* UREA N-32* CREAT-2.3* SODIUM-139 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-16 [**2108-5-27**] 08:30AM CK(CPK)-21* [**2108-5-27**] 08:30AM cTropnT-0.02* [**2108-5-27**] 08:30AM WBC-14.3* RBC-3.83* HGB-10.8* HCT-33.3* MCV-87 MCH-28.2 MCHC-32.4 RDW-17.2* [**2108-5-27**] 08:30AM NEUTS-86.6* BANDS-0 LYMPHS-7.9* MONOS-3.2 EOS-2.2 BASOS-0.1 [**2108-5-27**] 08:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2108-5-27**] 08:30AM PLT SMR-NORMAL PLT COUNT-353 [**2108-5-27**] 08:30AM PT-14.2* PTT-29.7 INR(PT)-1.3* _ _ _ _ _ _ _ ________________________________________________________________ am URINE Site: CLEAN CATCH URINE CULTURE (Preliminary): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML.. FURTHER IDENTIFICATION TO FOLLOW. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | GRAM NEGATIVE ROD #2 | | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- PND CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- PND CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S _ _ _ _ _ _ _ ________________________________________________________________ RADIOLOGY Final Report CT CHEST W/O CONTRAST [**2108-5-27**] 5:42 PM CT CHEST W/O CONTRAST Reason: r/o pulm abcess [**Hospital 93**] MEDICAL CONDITION: 66 year old man with recurrent aspiration PNA , presents c new worsening PNA despite appropriate atb REASON FOR THIS EXAMINATION: r/o pulm abcess CONTRAINDICATIONS for IV CONTRAST: renal failure INDICATION: Recurrent pneumonia, evaluate for pulmonary abscess. COMPARISON: [**2108-1-21**]. TECHNIQUE: MDCT acquired axial images of the chest were obtained without IV contrast secondary to patient's elevated creatinine level. CT OF THE CHEST WITHOUT IV CONTRAST: Linear opacities again seen at right apex, consistent with scar. New ground glass opacity and bronchiectasis seen in the right upper lobe. Diffuse patchy opacities also seen within the upper lobes bilaterally. Large consolidations are seen at the lower lobes bilaterally, right greater than left with associated pleural effusions. There is suggestion of a loculated effusion on the right (series 2, image 24). The left sided consolidation appears improved compared to [**2108-1-5**] CT. No evidence of abscess seen. 5mm rounded opacity seen in right lung (series 2, image 22), possibly secondary to infection. Coronary artery calcifications are noted. There is also evidence of mediastinal lymph nodes, none of which appear to meet CT criteria for pathological enlargement. Limited views of the upper abdomen demonstrate a gastrostomy tube. Also seen are rounded hypodensities within the kidneys, likely representing simple cysts, however not fully evaluated on this non- contrast study. IMPRESSION: 1. Large consolidations seen at the lower lungs, right greater than left, consistent with pneumonia. Associated pleural effusions. No evidence of abscess. 2. New ground glass opacity and bronchiectasis at right upper lobe. Patchy opacities seen at the upper lobes bilaterally. Probably small loculated effusion on right. 3. 5mm nodular opacity seen in right lobe, possibly secondary to infection. Discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11182**] 9pm [**2108-5-27**]. Brief Hospital Course: 66 yo male with complicated medical hx, recent aspiration pna on Oxacillin still with Subclavian line, from HRC with fever, oxygen desaturation, and continued cough. Trasnferred to MICU for hypoxia. . # PNA/Fever- patient has a h/o aspiration events (h/o VRE/MRSA/pseudomonas). Sputum on last admission was growing MSSA. Repeat CXR here was slightly better than on discharge. CT scan showed extensive bilateral lower lobe consolidations. Given that this likle represents a worsening of his previous PNA on narrow coverage with oxacillin. Coverage broadened to vancomycin and zosyin and he will compltete a 14 d course to end [**2108-6-9**]. Hypoxia improved with frequent chest PT and suctioning. . #Klebsiella UTI - On admission U/A. No symptoms but may explain some of the admission fever. Should be covered by 14 day course of zosyn. Repeat U/A should be done after abx to confirm cure. . # Bipolar disorder and Wilsons disease: continue on home meds clonazepam, olanzapine, buproprion, lamotragine. -- [**Hospital1 18**] does not carry trientine (copper chelator for Wilson's). Substitute with zinc sulfate 220mg tid while in house. . # Orthostatic hypotension: Continue midodrine and fludrocort while also giving Metoprolol for patient's underlying CAD as long as pressure can tollerate it. . # CRI: currently Cr at upper end of baseline (1.9-2.4). Cr clearance <30 - renally dose meds. Improved with hydration and medicatino doses re-adjusted. . # Nutrition: tube feeds 35 kcal /kg , 1g prot. He has PEG tube. . # IV access: pt has a L subclavian form [**2108-5-17**]. Line removed since pt was febrile. Blood cultures negative. New RIJ placed [**2108-5-28**]. Medications on Admission: 1. Bupropion 100 mg [**Hospital1 **] 2. Lamotrigine 25 mg [**Hospital1 **] 3. Midodrine 5 mg TID 4. Sucralfate 1 g QID 5. Ipratropium Bromide 0.02 % Nebs 6. Albuterol Sulfate Nebs 7. Aspirin 325 mg QD 8. Lansoprazole 30 mg QD 9. Metoprolol Tartrate 25 mg TID 10. Oxacillin 2 g q6 for 8 days (he ws discharged 5 days ago, still needs another 3 days) 11. Albuterol 90 mcg/Actuation Aerosol q4-6 12. Ipratropium Bromide 17 mcg/Actuation q6 13. Olanzapine 5 mg QD 14. Clonazepam 0.5 mg QAM 15. Trientine 250mg [**Hospital1 **] Discharge Medications: 1. Bupropion 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 12. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q4-6H (every 4 to 6 hours) as needed. 13. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed: central line care. 17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 24H (Every 24 Hours) for 10 days. 18. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital1 100**] Senior Living Discharge Diagnosis: Pneumonia Discharge Condition: Good Discharge Instructions: Please continue your anitbiotics until [**2108-6-9**]. . Please return to the emergency department if you have fevers, increased shortness of breath, or other trouble breathing. Followup Instructions: With your PCP [**Last Name (LF) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 14943**] with in [**3-9**] days. . With Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 40787**] in the [**Hospital1 18**] Pulmonary clinic on [**2108-7-16**] at 3:10 pm. ([**Telephone/Fax (1) 513**]. . Please remove right internal jugular central venous line at the conclusion of antibiotic course. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2108-5-30**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

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