ChanBeDu/relevant_section_length · Datasets at Hugging Face

21,734

135,786

10009

Discharge summary

report

Admission Date: [**2136-12-6**] Discharge Date: [**2136-12-27**] Date of Birth: [**2063-12-22**] Sex: F Service: MEDICINE Allergies: Prevacid / Adhesive Tape / Percocet Attending:[**First Name3 (LF) 11495**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Successful PTCA and stenting of the LMCA History of Present Illness: Ms. [**Known lastname **] is a 72 yo female with PMH significant for CABG, CAD, Type 2 DM, and ESRD who presented to the ED at [**Hospital3 417**] on [**12-5**] for chest pain, [**11-6**], with radiation to the neck and left arm. She states that the pain started earlier that day with no relief with sublingual nitroglycerin. Denies any prior episodes. Pain associated with nausea but no SOB or vomiting. She called 911 and was taken to the ED via ambulance. During this time she was given morphine, started on a nitro gtt and had complete relief of her chest pain. In the ED EKG showed ST depression in the inferior leads and V2-V6. No vitals are available. Inital labs: Hct 41.6, Plt 255, INR 2.2, Cr 6.4. Cardiac enzymes as follows: 1)CPK 52 CKMB 6 RI 11.5 Trop I 0.55 2)CPK 585 CKMB 122.2 RI 20.9 Trop I 9.89 3)CPK 658 CKMB 177 RI 26.9 Trop I 22.63. Plan was for pt to transferred to [**Hospital1 18**] for cardiac catheterization but given limited bed availability she was admitted to the CCU at [**Hospital3 417**] and was started on Heparin gtt, Nitro gtt, and given Morphine PRN for pain. While her chest pain has resided she continues to have jaw pain. Coumadin was d/c'ed given elevated INR. Past Medical History: 1)CABG X 4: [**2131-4-12**]: LIMA to LAD, SVG to OM1-anterior branch, SVG to OM1-lateral posterior branch, SVG to PDA 2)CAD, s/p PCI [**11-30**] with RP bleed, admitted to CCU for close monitoring 3)Type 2 DM 4)ESRD, on HD TThSa 5)Atrial fibrillation, s/p pacemaker placement [**2135**] 6)Hypothyroidism Social History: Lives with her husband. [**Name (NI) 4906**] does all the chores and shopping. Pt is a remote smoker and quit 30 years ago PTA. Family History: Father died of MI, sister has DM Physical Exam: vitals T 96.5 BP 117/67 AR 68 RR 17 O2 sat 93% on 2L Gen: Awake and alert, NAD HEENT: MMM, Neck: No JVD; pacemaker palpable in R chest; Tesio catheter with no signs of erythema or pain Heart: nl s1/s2, no s3/s4, no m,r,g Lungs: CTAB, no crackles Abdomen: soft, NT/ND, +BS Extremities: no edema, 2+ DP/PT pulses Pertinent Results: Laboratory Results: [**2136-12-6**] 06:22AM BLOOD WBC-14.8* RBC-3.75* Hgb-12.0 Hct-36.7 MCV-98 MCH-32.0 MCHC-32.7 RDW-17.1* Plt Ct-253 [**2136-12-19**] 09:35AM BLOOD WBC-25.3* RBC-3.71* Hgb-11.2* Hct-33.3* MCV-90 MCH-30.2 MCHC-33.6 RDW-18.1* Plt Ct-282 [**2136-12-7**] 03:00PM BLOOD Neuts-90.7* Bands-0 Lymphs-3.4* Monos-4.9 Eos-0.8 Baso-0.2 [**2136-12-6**] PT-26.4* PTT-85.5* INR(PT)-2.7* [**2136-12-27**] PT-44.6* PTT-59.4 INR(PT)-5.1* . [**2136-12-6**] 06:22AM BLOOD Glucose-362* UreaN-63* Creat-7.1* Na-130* K-4.5 Cl-93* HCO3-15* AnGap-27* [**2136-12-6**] 06:22AM BLOOD CK(CPK)-475* [**2136-12-6**] 10:10PM BLOOD CK(CPK)-310* [**2136-12-16**] 09:06PM BLOOD CK(CPK)-15* [**2136-12-17**] 11:40PM BLOOD CK(CPK)-14* [**2136-12-6**] 06:22AM BLOOD CK-MB-116* MB Indx-24.4* cTropnT-5.28* [**2136-12-7**] 04:15AM BLOOD CK-MB-40* MB Indx-33.6* cTropnT-3.48* [**2136-12-7**] 02:00PM BLOOD CK-MB-48* MB Indx-32.7* cTropnT-5.27* [**2136-12-17**] 11:57AM BLOOD CK-MB-NotDone cTropnT-4.51* [**2136-12-17**] 11:40PM BLOOD CK-MB-NotDone cTropnT-2.60* [**2136-12-6**] 06:22AM BLOOD Calcium-9.3 Phos-6.8* Mg-2.6 Iron-38 Cholest-155 [**2136-12-19**] 06:16AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.4 [**2136-12-6**] 06:22AM BLOOD calTIBC-226* Ferritn-227* TRF-174* [**2136-12-7**] 03:00PM BLOOD %HbA1c-5.6# [Hgb]-DONE [A1c]-DONE [**2136-12-6**] 06:22AM BLOOD Triglyc-126 HDL-51 CHOL/HD-3.0 LDLcalc-79 [**2136-12-6**] 05:03PM BLOOD PTH-562* [**2136-12-12**] 10:54AM BLOOD Cortsol-22.6* [**2136-12-12**] 11:53AM BLOOD Cortsol-34.2* [**2136-12-12**] 12:29PM BLOOD Cortsol-33.9* . [**2136-12-14**], [**2136-12-18**]: Sputum Cx: Klebsiella pneumonia (extended-spectrum beta-lactamase producer) . Relevant Imaging: 1)Cxray ([**2136-12-5**]): No evidence of acute pulmonary disease, cardiomegaly with pacemaker. . 2)LE Doppler ([**2136-12-5**]): No evidence of DVT . 3)Cardiac catheterization ([**2136-12-7**]): 1. Selective coronary angiography in this right dominant system revealed severe three vessel coronary artery disease. The LMCA was totally occluded. There was likely thrombus in the left main stent. The LAD was totally occluded proximally. The distal LAD had diffuse disease and filled via the LIMA. The LCx was totally occluded proximally. The second OM filled via a SVG and had 70% stenosis distal to the vein graft touch down. The RCA was not engaged as it was known to be totally occluded. 2. Arterial conduit angiography revealed a patent LIMA to LAD. The LIMA anastomosis was in the mid to distal LAD. The SVG to RCA was patent. The SVG to OM2 had 70% in stent restenosis. The SVG to OM1 was not engaged as it was known to be totally occluded. 3. Left ventriculography was not performed because the patient was unstable. 4. Resting hemodynamics elevated left and right sided filling pressures. The LVEDP was 18 (mean PCW 22) mmHg. The RVEDP was 18 mmHg. Systemic arterial pressures were elevated with a central aortic SBP of 140 and DBP of 56 mmHg (while on dopamine infusion). Cardiac index was perserved at 3.99 l/min/m2 (output 6.34 l/min). 5. An intra aortic ballon pump was placed. 6. Successful PTCA and stenting of the LMCA with a 3.5 BMS post dilated with a 4.0 NC balloon. Final angiography revealed a less than 10% residual stenosis with no angiographic evidence of dissection, embolization or peforation. (See PTCA comments) 7. Limited low inflation balloon angioplasty of in-stent segment of the LCx with 20% residual stenosis. 8. Patent left subclavian stent. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Successful PCI of the LMCA. 3. Balloon angioplasty of in-stent segment of LCx. . 4)ECHO ([**2136-12-10**]):The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is probably low normal (LVEF 50-55%) with basal anterior and antero-septal segmetns appearing hypokinetic on some views (sub-optimal image quality). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . 5)CT Head w/o contrast ([**2136-12-15**]): 1. No acute intracranial hemorrhage. 2. Chronic left occipital/posterior parietal infarct and diffuse chronic small vessel infarcts. No specific CT evidence to suggest acute major vascular territorial infarction, though if suspicion is high, MRI would be more sensitive to assess. . 6)ECHO ([**2136-12-17**]):The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal(LVEF>55%). No regional dysfunction is identified. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with relative immobility of the posterior leaflet (?rheumatic origin). There is no mitral valve prolapse. At least moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2136-12-10**], regional left ventricular systolic function is not suggested, the severity of mitral regurgitaiton and the severity of pulmonary artery systolic hypertension have increased. Brief Hospital Course: In brief, the patient is a 72 yo female with STEMI s/p stenting of L main complicated by cardiogenic shock requiring IABP and pressors and s/p septic shock with blood cultures positive for coag negative staph. 1)Shock: Patient initially went into cardiogenic shock in the cath lab requiring IABP placement and was started on Dopamine to maintain her blood pressure. She was slowly weaned off the Dopamine and the IABP was removed. She then proceeded to go into septic shock with 4/4 blood cultures bottles positive for coag negative staph and sputum cultures growing Proteus, Moraxella, and Klebsiella. She was started on Ceftriaxone and Vancomycin for broad coverage and she also required Levophed to maintain her blood pressures. Given the sensitivity data the Ceftriaxone was d/c'ed and she was maintained on Vancomycin, which was dosed daily by level. The Levophed was turned on and off several times until her pressures stabilized. There was some thought that she went into cardiogenic shock again given her complaint of new chest pain but it was felt that there would be no further benefit from cardiac catheterization. . CARDIAC 2)STEMI: Patient initially presented with a STEMI and underwent PCI with BMS placement in the LAD and proceeded to go into cardiogenic shock, as mentioned above. Her medical management was optimized with ASA, Plavix, and statin. She was not initally started on a beta-blocker given her labile blood pressures and she required pressors. At one point she was started on a Nitro gtt because of chest pain the patient complained of which dropped her pressures and required her to be placed on Dopamine. There was some thought that she may have thrombosed her LM stent, but after discussions between the attending and family it was thought that there would be no benefit from taking her to cath lab. EKG showed ST depressions, consistent with demand ischemia with HR~120's. . 3)Rhythm: Patient is s/p pacemaker placement in [**2135**]. On telemetry and EKG she was paced but also went into atrial fibrillation. She was maintained on her home regimen of Amiodarone 200mg daily and was initally started on Heparin for anti-coagulation. The heparin was stopped for several days given a drop in her Hct as well as a neck hematoma that she had developed as a result of a IJ central line attempt. Once her Hct stabilized the Heparin gtt was restarted and patient was bridged to coumadin. Upon discharge her INR was mildly supratherapeutic, her coumadin dose on [**2136-12-27**] should be held and resumed according to her INR which should be checked next on [**2136-12-28**]. . 4)Pump: She was thought to be positive regarding her fluid balance since admission. ECHO suggested EF~50% but this was falsely elevated since she was on pressors. PCWP in the cath lab was elevated at 22. Although she was euvolemic on exam, it was thought that she was TBW positive with extensive third spacing. She was continued on CVVH. Her CVVH was initially turned off for 1-2 days because it was thought that this would help wean her off pressors. The CVVH was restarted with goal removal of [**1-30**] liters/day. As patient's fluid status improved, she was converted to HD without complications. . 5)Respiratory: Patient was intubated in the cath lab when she went into cardiogenic shock. Cxray did not suggest presence of infiltrate or other acute process. She was maintained on mechanical ventilation in AC mode with intitial difficulty weaning her given the multitude of other problems. Sputum cultures grew Proteus, Moraxella, and Klebsiella, all of which were being covered with antibiotics. When she was initially placed on CPAP + PS the blood gases were excellent despite the poor tidal volumes that she was able to pull. As a result, it was decided that she try to be extubated. Patient was then extubated and has progressed to excellent O2 sats on room air only. By time of discharge the patient was breathing comfortably despite her rapid respiratory rate. Her oxygen saturations remained normal on room air. The patient's tachypnea was thought largely related to her prolonged hospitalization and deconditioning which would be anticipated to improve with time and physical therapy. Her respiratory status should be monitored carefully particularly with regard to her oxygenation which was normal at the time of discharge. . 6)ESRD: Patient on hemodialysis at home. She was placed on CVVH once she was intubated. The renal service followed her closely. It was thought that she was approximately 7L total body water postive and this was preventing her from being extubated as well as her poor recovery. In addition, her HD line was found to be at the junction of the brachiocepalic and SVC. IR was consulted and recommended that it be changed over a wire but given her current condition it was decided that as long as the line was functioning that no further intervention was ncessary at this time. On day of discharge, [**12-27**], pt received a shortened HD treatment, as she was scheduled for an additional treatment on 11/31, and also received 1uPRBCs during the treatment. . 7)Type 2 DM: Patient is normally diet controlled at home. She was placed on an insulin sliding scale during her hospital stay and her sugars were closely monitored. . 8)Hypothyroidism: Patient was maintained on home regimen of Levothyroxine. . 9) Anemia: The patient has a baseline anemia likely secondary to her end-stage renal disease. She was also found to be passing guaiac positive brown stools. Her hematocrit had a gradual trend down during the hospital stay but had no apparent hemodynamic consequences from the anemia. Prior to discharge her hematocrit had improved. She will continue to receive erythropoetin and iron with dialysis. She should have a follow-up hematocrit drawn in [**3-2**] days. Also, she should be considered for an outpatient colonoscopy to further evaluate the guaiac positive stools. . 10)FEN: cardiac diet, renal diet . 11)Prophylaxis: She received Pneumoboots, coumadin, PPI . 13)Code: FULL . 16)Access: PICC line for iv antibiotics, HD catheter . 15) Dispo: discharged to rehab for strength and gait training. Medications on Admission: Medications (at home): Coumadin 1mg, 2mg PO daily Imdur 30mg PO daily Amiodarone 200mg PO daily Aspirin 325 mg PO daily Nephrocaps 1 PO daily Renagel 1600mg PO TID with meals Levoxyl 175 micrograms PO daily Reglan 10mg PO QHS Lipitor 10mg PO QHS Nitroglycerin PRN Atenolol 25 PO daily Medications (on transfer): Aspirin 325mg daily Amiodarone 200mg daily Isosorbide mononitrate 30mg PO QAM Heparin gtt Morphine sulfate 1mg PRN Plavix 75mg PO QAM Atenolol 25mg PO daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 10. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day) as needed for conjunctivitis for 3 days. 11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 13. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every 8 hours) as needed for constipation. 14. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Meropenem 500 mg IV Q24H Day 1 [**12-20**] - last day [**1-2**] 21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 22. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Hold PM of [**12-27**], restart [**12-28**] based on INR. INR on [**12-27**].1. 23. Outpatient Lab Work Please draw Hematocrit on [**2136-12-30**]: forward results to PCP 24. PICC line care PICC line care per protocol Discharge Disposition: Extended Care Facility: [**Hospital 8629**] East Region Discharge Diagnosis: STEMI s/p stenting of left main Cardiogenic Shock Septic Shock Right Uper Lobe Pneumonia Presumed Clostridium Difficile colitis Discharge Condition: Stable. Patient is stable to be discharged to rehab. She is tolerating oral intake but has not had performed much physical activity while being hospitalized. Since patient has had a prolonged hospital course with very little physical activity, patient is severely deconditioned. She does become tachypneic and very tired with minimal activity. Would appreciate physical therapy to help assist patient regain her functional status. ***Pt has had changes in her blood counts. She should have a hematocrit check within 2-3 days and it should be followed subsequently. ***Pt's INR on morning of discharge, [**12-27**], was 5.1. Please hold coumadin dose on evening of [**12-27**] and recheck pt/inr daily. Readdress and reinitiate coumadin start on [**12-28**]. Discharge Instructions: - For rehab: please note that pt has been tachypnic, more at rest. She also has an extremely decompensated and deconditioned state and has difficulty with her respiratory rate with physical exertion. - Please take all medications as prescribed. Followup Instructions: - Please follow-up with your primary care physician and cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], 1 to 2 weeks after your discharge from rehab. His phone number is ([**Telephone/Fax (1) 16005**]. - When you meet with Dr. [**Last Name (STitle) **], please discuss the possibility of doing an outpatient colonoscopy since you had some blood in your stool and a decrease in your hematocrit. - Patient needs a recheck in her blood counts, namely her hematocrit, within 2-3 days and followed subsequently to maintain her Hct >27.

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icd9cm

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icd9pcs

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38031

Discharge summary

report

Admission Date: [**2171-7-11**] Discharge Date: [**2171-7-14**] Date of Birth: [**2140-5-28**] Sex: M Service: MEDICINE Allergies: Shellfish Derived Attending:[**First Name3 (LF) 2009**] Chief Complaint: GIB Major Surgical or Invasive Procedure: Intubated, EGD History of Present Illness: Mr. [**Known lastname 1538**] is a 31 year old gentleman with a PMH significant for asthma and GERD admitted to the MICU for hypotension and GI bleed. Patient initially presented to OSH this morning after developing hematemsis. He reports a 2 week history of epigastric burning pain with associated decreased PO intake, NBNB emesis, and headache. He was seen at an OSH ED twice and was told to take ibuprofen and maalox, and he states that he has been taking 2 tablets of motrin every 3 hours for the past 1 1/2 weeks. This morning at 5 am, he reports waking up with the sensation of needing to defecate and was going to the bathroom and fainted. He regained consciousness and then had a large black, tarry bowel movement. He then called 911, at which point he had multipe episodes of hematemesis. Upon arrival to the OSH, he was hypotensive with a SBP 60s and tachycardic to 120-130s with a hct of 24 with an unknown baseline. He received 2 units PRBC, 3 liters IVF, and a PPI, and was transferred to [**Hospital1 18**] for further management. . In the [**Hospital1 18**] ED, VS 76 114/66 100 2L nc. The patient was started on a PPI gtt and had an NGL that demonstrated coffee grounds that did not clear. He was then transferred to the MICU for further management. . Currently, the patient reports feeling fatigued. Denies CP/SOB, fever/chills/sweats, HA, palpitations. States that he has not had any hematemesis since this morning. . Review of systems: As per HPI, otherwise negative. Uses albuterol MDI several times a day and has a nebulizer at home. No history of intubations for asthma. Past Medical History: Asthma Spontaneous pneumothorax x3 Social History: Tobacco - 1/2-3 ppd x 15+ years. EtOH - social. Denies IV, illicit, or herbal drug use. Family History: NC Physical Exam: VS: 97.7 79 103/56 17 99%RA Gen: Thin pale age appropriate male HEENT: Perrl, eomi, sclerae anicteric. MM dry, OP clear without lesions, exudate, blood, or erythema. Neck supple without lymphadenopathy. Pulm: Faint inspiratory and expiratory wheezes bilaterally. CV: Nl S1+S2, no m/r/g Abd: Mild TTP throughout worst in left periumbical region. +bs Ext: No c/c/e, 2+ dp/pt bilaterally. Neuro: AOx3, CN II-XII intact. Pertinent Results: [**2171-7-11**] 09:30AM BLOOD WBC-19.7* RBC-3.64* Hgb-10.4* Hct-31.6* MCV-87 MCH-28.7 MCHC-33.1 RDW-15.2 Plt Ct-225 [**2171-7-12**] 04:34AM BLOOD WBC-10.7 RBC-3.13* Hgb-9.3* Hct-27.4* MCV-88 MCH-29.7 MCHC-33.9 RDW-15.3 Plt Ct-220 [**2171-7-11**] 09:30AM BLOOD PT-13.9* PTT-28.9 INR(PT)-1.2* [**2171-7-11**] 09:30AM BLOOD Glucose-80 UreaN-53* Creat-0.8 Na-141 K-4.3 Cl-109* HCO3-23 AnGap-13 Discharge Labs: [**2171-7-14**] 06:45AM BLOOD Hct-29.5* GI BX Stomach, antrum, mucosal biopsy: 1. Chronic, focally active gastritis. 2. Special stain for H. pylori will be reported as addendum. Imaging: ECG Sinus rhythm. There is an RSR' pattern in lead V1 which is probably normal. Early repolarization. No previous tracing available for comparison. EGD: Impression: Normal mucosa in the esophagus Ulcer in the antrum (biopsy, thermal therapy) Blood in the whole stomach Erythema in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum Recommendations: follow-up biopsy results please continue PPI IV Bid, and please check H. pylori Antibodies status. pt should repeat EGD in 6 weeks follow-up with endoscopist within 6 weeks Brief Hospital Course: Mr. [**Known lastname 1538**] is a 31 year old gentleman with a PMH significant for asthma admitted to the MICU for hypotension and GI bleed. . # Gastrointestinal bleed with acute blood loss anemia: The patient presented to ED with hematemesis and a nasogastric lavage produced coffee ground material. The patient was started on a PPI drip and admitted to the MICU. GI was consulted and conducted an EGD. The EGD required intubation and showed a large antral ulcer with a clot formed on it. The patient was extubated without issues. A biopsy was taken that showed chronic focally active gastritis. Special stain for H. pylori was pending at time of discharge. The H. pylori antibody blood test was negative. He was followed with serial hcts and remained stable for 24 hours prior to admission. His discharge Hct was 29.5. GI would like the patient to receive an additional EGD in 6 wks in the outpatient setting for futher biopsy. He will be maintained on high dose pantoprazole 40 mg twice a day and see GI within 6 weeks. . # Leukocytosis: At time of admission, WBC 19.7 with left shift found, likely reactive in setting of GI bleed. Good oxygenation through hospital stay making aspiration less likely. WBC trended down on own to 7.6 near time of discharge. . # Asthma: Stable, although poorly controlled. Continued on albuterol MDI and nebs as needed during hospitalization. Medications on Admission: Motrin prn Maalox prn Albuterol MDI prn Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. 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* Discharge Disposition: Home Discharge Diagnosis: Primary: Gastric Ulcer s/p GI bleed Secondary: Asthma Discharge Condition: Stable. Discharge Instructions: You were admitted because you had a gastrointestinal bleed. You required blood transfusions to help maintain your blood levels. You were found to have a large ulcer in your stomach that was the cause of this bleed. You were started on medication to prevent the formation of acid in your stomach. This will help prevent a re-bleed of the area. Your new medications include: Omeprazole 40 mg pills by mouth twice a day You should contact your doctor or go directly to the Emergency Room if you experience severe dizziness, fainting, vomiting blood or defecating blood or any other symptom that is concerning to you. Followup Instructions: You should follow up with Dr. [**First Name (STitle) 1255**] in Gastroenterology. You should call [**Telephone/Fax (1) 11048**] to book this appoinment in the next week or two.

[ "305.1", "493.90", "531.40", "796.3", "285.1", "530.81" ]

icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

5635, 5641

3802, 5185

282, 298

5739, 5749

2558, 2949

6413, 6593

2101, 2105

5276, 5612

5662, 5718

5211, 5253

5773, 6390

2966, 3779

2120, 2539

1781, 1921

239, 244

326, 1762

1943, 1980

1996, 2085

819

152,051

14123

Discharge summary

report

Admission Date: [**2116-9-21**] Discharge Date: [**2116-9-23**] Date of Birth: [**2045-1-10**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5827**] Chief Complaint: Fever and hypotension Major Surgical or Invasive Procedure: Placement of a central venous line History of Present Illness: 71 yo male resident of [**Hospital3 2558**] with multiple medical problems including a history of gastric cancer, who was admitted with hypotension requiring pressors and fever. He reportedly had guaiac positive stools as well. Past Medical History: hypertension previous CVA aphasia BPH gastric cancer DVT CHF schizophrenia Social History: lives at [**Hospital3 **] does not smoke or drink alcohol Family History: non-contributory Physical Exam: T 101.3 HR 105 BP 90/50 GEN - ill-appearing HEENT - supple neck, dry MMM, anicteric sclera CV - tachycardic, regular LUNGS - decreased BS at the bases ABD - diffusely tender, distended EXT - no LE edema NEURO - alert, responds to yes/no questions Brief Hospital Course: The patient underwent a CT scan that shwoed evidence of a perforated small intestine which was the suspected source of his sepsis. He was intubated in emergency department in the setting of aggressive volume resuscitation before entire clinical picture was clear. He was also started on vasopressors for blood pressure support inthe setting of hypovolemic shock secondary to sepsis. The patient was seen by surgery for consideration of an operative solution for his sepsis and bowel perforation. However, the patient's family did not want him to undergo surgery. After multiple family meetings in the intensive care unit, the family and health care providers agreed to extubate the patient and make his goals of care comfort only. The vasopressors were discontinued at that time. The patient was transfered to the general medicine wards where he was closely monitored for comfort on a morphine drip. He died the following morning ([**2116-9-23**]) at 8:55AM. The patient's sister and brother were called and both siblings agreed to an autopsy as long as the organs were returned to the body for burial. Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Sepsis secondary to acute peritonitis from a bowel perforation Hypovolemic shock requiring vasopressors Respiratory distress requiring intubation gastric cancer congestive heart failure schizophrenia Discharge Condition: deceased

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icd9cm

[ [ [] ] ]

[ "96.34", "99.07", "96.71", "00.17", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

2286, 2292

1121, 2234

332, 368

2536, 2547

817, 835

2257, 2263

2313, 2515

850, 1098

271, 294

396, 627

649, 726

742, 801

19,596

115,356

43751

Discharge summary

report

Admission Date: [**2174-12-16**] Discharge Date: [**2174-12-21**] Date of Birth: [**2100-3-19**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3513**] Chief Complaint: Change in mental status Major Surgical or Invasive Procedure: None History of Present Illness: 74F with mixed dementia, ESRD on HD, admitted on [**12-16**] with change in mental status/seizures at HD on the date of admission. In the ED, the patient was afebrile, with HR 61 BP 251/82. Given 10mg hydralazine with BP noted to improve to SBPs 170. Patient was started on nipride gtt and admitted to [**Hospital Unit Name 153**] for hypertensive urgency. . In the [**Name (NI) 153**], Pt. was treated with nipride gtt, then transitioned to labetalol gtt, then to CCB and [**Last Name (un) **], on which she was normotensive. AMS thought to be multifactorial, secondary to worsening dementia, hypertensive encephalopathy, hypercalcemia. Pt. also noted to have labile blood glucose in ICU. Per renal, goal SBP 140-150. Upon arrival to floor, Pt. is disoriented and refuses to answer questions. She reports that she is at a party, knows it is "[**Holiday 944**] month", does not know first name, year. Past Medical History: 1. End-stage renal disease. 2. Diabetic nephropathy. 3. Hemodialysis for years. 4. Right AV fistula. 5. Noninsulin-dependent diabetes mellitus. 6. Hypertension. 7. Encephalopathy. 8. Cholecystectomy. 9. Nephrectomy. 10. Angioplasty of AV fistula in [**2171-12-1**]. 11. s/p recent corn removals on L foot 12. mixed vascular and alzheimer's dementia Social History: Denies alcohol, drug use, smoking. Lives in the bottom floor of an apartment - family lives in floors above her. Says she is independent with her activities of daily living. Family History: Unable to obtain. Physical Exam: PE: afebrile, 241/88 73 20 99%RA HEENT: PERRL, EOMI, OP clear, not LAD CVS: nl s1s2, RRR, no m/r/g Chest: CTA b/l Abd: soft, NT/ND, +bs, no organomegaly ext: no c/c/edema; +OA in knees, AV fistula RUE. neuro: awake, orientated to person, and month. Speech coherent, though tangential; mild preservations. 4/5 strength BUE/BLE +2 patella and biceps tendon Pertinent Results: [**2174-12-16**] 06:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2174-12-16**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-NEG [**2174-12-16**] 06:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [**2174-12-16**] 12:24PM LACTATE-1.3 [**2174-12-16**] 12:12PM GLUCOSE-120* UREA N-17 CREAT-5.0*# SODIUM-144 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-34* ANION GAP-19 [**2174-12-16**] 12:12PM WBC-4.7 RBC-4.71 HGB-14.3 HCT-44.6 MCV-95 MCH-30.3 MCHC-32.0 RDW-18.4* [**2174-12-16**] 12:12PM NEUTS-62.1 LYMPHS-30.1 MONOS-4.8 EOS-1.8 BASOS-1.3 [**2174-12-16**] 12:12PM HYPOCHROM-1+ ANISOCYT-2+ MACROCYT-1+ [**2174-12-16**] 12:12PM PLT COUNT-132* [**2174-12-16**] 12:12PM PT-12.4 PTT-38.7* INR(PT)-1.0 . ECG: sinus brady with prolonged Qtc, LAD, LVH, with STE in V2/V3 likely representing repolarization abnormalities; no other acute St/T wave changes . CXR: No radiographic evidence of pneumonia. . CT head: No evidence of acute intracranial hemorrhage. Brief Hospital Course: 74F with mixed dementia, presenting with a one week history of mental status changes / increased confusion, also with hypertensive urgency. . On the floor, the Pt. was treated with hydralazine PRN for elevated systolic pressure, and was transitioned back to amlodipine and losartan, with goal SBP 140-150. Metoprolol was discontinued. Pt. was normotensive at the time of discharge. . Pt's change in mental status thought to be multifactorial: ddx included worsening dementia with possible contribution of hypertensive encephalopathy and hypercalcemia. With continued orientation and support from family members and nursing staff, Pt.'s mentation improved. Her donepezil was continued. . Per records, Pt. has chronic hypercalcemia thought to be related to her chronic renal insufficiency/failure and secondary hyperparathyroidism. Tums and Vit. D were held. Sevelamer was continued for hyperphosphatemia at an increased dose (2400mg TID), and the Pt. was started on sensipar 30mg QD. . The Pt. was seen and evaluated by social work. It is probable that Pt. will require increased amounts of support at home over the coming months/years in performing her ADLs. . The Pt. will continue hemodialysis on M,W,F. . An SPEP was checked just before discharge, at the request of the renal team. The result can be followed up at the Pt's next appointment. Medications on Admission: Norvasc 10 renal caps Zantac 150 [**Hospital1 **] Glucotrol xl 10 Tums tid aricept asa Cozaar metoprolol 100 Renagel 800 tiw calcijex Epo Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): please take with food/drink. 7. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. 9. humalog insulin sliding scale 10. Glucotrol 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. End-stage renal disease, on hemodialysis 2. NIDDM 3. dementia/encephalopathy Discharge Condition: Fair, stable. Discharge Instructions: Please continue to take all your medications exactly as prescribed. If you experience chest pain, shortness of breath, fevers, or abdominal pain, plesae call your PCP or return to the hospital. Followup Instructions: Please continue to follow up with your PCP as you have been doing. . Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Name Initial (NameIs) **]., [**Street Address(1) **]Date/Time:[**2175-2-2**] 8:00 Completed by:[**2174-12-22**]

[ "294.10", "250.40", "585.6", "588.81", "275.42", "331.0", "437.2", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5674, 5744

3368, 4721

341, 347

5868, 5884

2280, 3288

6127, 6370

1871, 1890

4910, 5651

5765, 5847

4747, 4887

5908, 6104

1905, 2261

278, 303

375, 1280

3297, 3345

1302, 1662

1678, 1855

48,149

102,223

54724

Discharge summary

report

Admission Date: [**2127-5-25**] Discharge Date: [**2127-6-18**] Date of Birth: [**2098-2-4**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: MVC Major Surgical or Invasive Procedure: [**2127-5-25**] - sternotomy RSC interpos graft, bolt, ex-fix LLE and LUE [**2127-5-26**] - IVC filter & chest closure [**2127-5-27**] - ORIF R+L femur [**2127-5-28**] - ORIF R arm, left olecranon, closed rdxn ft frx [**2127-6-6**] - trach History of Present Illness: This is a 29-year-old male who was involved in a vehicle accident requiring extrication at the scene. He had to be intubated at the field and subsequently transferred here where he had a CT scan showing an upper mediastinal hematoma and this was followed by CT with contrast showing a right subclavian arterial pseudoaneurysm. He had been relatively stable until all of a sudden he had copious amounts of bloody drainage from his right pleural chest tube. Suspecting that the bleeding was coming from this right subclavian artery injury, he was taken to the operating room emergently for exploration. Past Medical History: none Social History: Works at [**Company **]. Lives with roommate. Family supportive. Brief Hospital Course: Mr. [**Known lastname **] was found to have the following on exam and imaging: cerebral edema C7 TP frx right subclavian artery avulsion bilateral rib fractures RP hematoma bilateral femur fractures left olecranon fracture bilateral foot fractures vertebral artery injury As noted in the HPI, Mr. [**Known lastname **] was taken emergently to the operating room on admission ([**2127-5-25**]) for a joint procedure between cardiac surgery, vascular surgery, neurosurgery and orthopedics where he had a median sternotomy to repair a right subclavian artery transection with a 7mm dacron interposition graft. Due to his cerebral edema, neurosurgery placed a bolt monitor at this time. Orthopedics irrigated/debrided left open elbow fracture, his left open femur fracture, put spanning external fixators on his left elbow, left leg and right forearm, then proceded to closed reduce his left olecranon, left femur and right forearm. He was taken to the TSICU post-operatively and returned to the OR on [**2127-5-26**] for closure of his sternotomy and an IVC filter. On [**2127-5-27**] he underwent ORIF of his right femoral neck fracture, washout/debridement of his left supracondylar open frature, removal of the left knee external fixator and ORIF of the left distal femur with repair of the left quadriceps tendon tear. On [**2127-5-28**] he returned to the OR with orthopedics once again and underwent ORIF right both bone forearm fracture, washout/debridement/ORIF of left olecranon fracture, removal of his external fixators from both arms and closed reduction with percutaneous pin fixation of his first and 2nd MTP dislocations of the foot. The remainder of his ICU course by systems: Neuro: He was sedated with a combination of fentanyl/midazolam/propofol while intubated. After trach on [**2127-6-4**], his sedation was gradually weaned off. While there was initially significant concern for TBI and cerebral edema, he made quite a good recovery and was tracking, following commands and responding appropriately to stimulus. He was started on clonidine, ativan, oxycodone, and tylenol which achieved good effect and eventually just transitioned to simply oxycodone and tylenol. CV: Initially on pressors and required blood transfusions (see Heme). After the initial perioperative period however he was hemodynamically stable without further issues throughout the hospitalization. He was started and remained on aspirin for his subclavian artery graft. This medication should be continued indefinitely unless directed otherwise by his vascular surgery team. Resp: He was intubated on the scene and remained intubated in-house. He was briefly extubated on [**5-30**] but didn't succeed, thought to be due to his flail chest (bilateral rib fractures in multiple locations) and was reintubated with plans for slow wean from the vent to allow him to compensate for the chest trauma. A tracheostomy was placed on [**2127-6-6**]. Of note, he was evaluated for plating for the flail chest by the thoracic surgery team however it was deemed as unlikely to help him given the relative modest and distributed nature of his rib fractures. He had bilateral chest tubes placed on admission, as described. The chest tubes remained to suction [**2127-6-9**] when they were placed to waterseal. It was decided to keep the chest tubes in until after he was off of postive pressure ventilation. He was noted to have a small left pneumothorax despite the appropriate positioning and placement of the left chest tube. This chest tube was treated with TPA but with minimal effect. Due to the small size of the left pneumothorax and its unchanging character on CXR, it was deemed unnecessary to work up further with additional manipulation/further invasive chest tube placement and was simply observed. He was transitioned off the vent and tolerated a full day of trach collar on [**2127-6-11**]. Also on [**2127-6-11**] he had a repeat CT Chest which demonstrated resolution of the left pneumothorax (except for a small pocked next to the tube in between fissures at the base of the lung) but a very small right pneumothorax. Both pneumothoraces were very small and asymptomatic. The left chest tube was removed on [**2127-6-11**] and the right chest tube was removed on [**2127-6-12**]. As of [**2127-6-15**] he had tolerated more than 48 hours of being off of the ventilator. GI: He was NPO initially, then started on tube feeds via an NGT/dobhoff which he tolerated well. There was some initial concern over high residuals from the NGT and he was placed on reglan 10 four times daily. He was placed on a bowel regimen of colace and senna and some milk of magnesia and soon thereafter had a bowel regimen. His residuals were thereafter minimal. After a PMV evaluation and being on trach collar he was cleared to swallow and able to tolerate a soft diet. He was also started on TID nutritional shakes. The NGT was removed, reglan was dc'd. Nutrition: He had a passy-muir valve placed on [**2127-6-11**] which he tolerated well and passed a bedside swallow evaluation. His diet was advanced to thin liquids and ground/pureed solids. He did well with this and can advance as tolerated. He was also receiving replete with fiber tubefeeds which were stopped after he tolerated diet. GU: He had a foley catheter placed initially. He initially faced ATN with a rising creatinine that gradually resolved with hydration throughout his hospital course -- it was 1.2 as of [**2127-6-12**]. Foley was replaced with a condom catheter and had no issues in this regard. Heme: Placed on SQH throughout hospitalization and had an IVC filter placed on [**2127-5-26**]. Also on aspirin for graft. Hct stable at time of discharge from ICU, no active issues. ID: Did recieve intra and periop antibiotics and received a course of broad spectrum antibiotics early in the course of his hospitalization (vanc/zosyn, then vanc/cipro/flagyl for periop as well as to treat a suspected VAP). Though he had an elevated WBC count, he was afebrile for the most part. All antibiotics were discontinued on [**2127-6-6**]. On [**2127-6-10**] he did spike a fever and subsequently bronchoscopy was done with BAL. All cultures were negative or no growth to date. TLD: Right PICC([**5-29**]-), trach ([**6-6**]-), - d/c'd T/L/D: right femoral a line, left fem groin line ([**5-29**]), right fem aline ([**6-1**]), PIV, L CT ([**Date range (1) 111887**]), R CT ([**Date range (1) 111888**]), NGT ([**Date range (1) 3047**]) On [**2127-6-15**] the patient was doing sufficiently well to be transferred to the floor. His pain was controlled, he was tolerating a regular diet, and he was working with physical therapy. Psychiatry was consulted for evaluation of his depressed mood. There was initially a concern for suicidal ideation, however after attending level review of the case and discussion with the patient it was felt that he had only a remote history of suicidal ideation and that there was no criteria for psychiatric admission. He was discharged to rehabilitation in good condition on [**2127-6-17**]. Medications on Admission: none Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Trauma (Motor Vehicle Accident) Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Will require ongoing physical therapy to regain mobility. Discharge Instructions: You were admitted to the hospital after your high speed motor vehicle crash with the following injuries: 1. Cerebral Edema 2. Cervical Spine #7 transverse process fracture 3. Right Subclavian Artery avulsion 4. Bilateral Rib Fractures 5. Retroperitoneal hematoma 6. Bilateral Femur Fractures 7. Left Olecranon Fractures 8. Bilateral foot fractures 9. Vertebral Artery injury You will be discharged to an inpatient rehabilitation facility where you will work on regaining your strength and mobility after your extended hospitalization. Please keep a list of your medications with you and bring them to all your healthcare appointments. Followup Instructions: Please call Dr. [**Last Name (STitle) **] (Orthopedics) to make an appointment to be seen in 4 weeks. His office number is ([**Telephone/Fax (1) 3147**]. Please call Dr. [**Last Name (STitle) **] (Neurosurgery) to make an appointment to be seen in 4 weeks. His office number is ([**Telephone/Fax (1) 88**]. You will need to have a CT scan of your head without contrast done prior to your visit. Dr.[**Name (NI) 9034**] office can assist you with arranging that. Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (Vascular Surgery) for a follow up appointment to be seen in 4 weeks. His office number is ([**Telephone/Fax (1) 1804**]. Please call the trauma surgery clinic to make an appointment to be seen in 2 weeks. The phone number is ([**Telephone/Fax (1) 111889**]. Completed by:[**2127-6-17**]

[ "813.11", "854.01", "E879.8", "560.1", "868.04", "901.1", "807.08", "E816.0", "825.23", "276.69", "860.4", "518.51", "805.07", "584.5", "997.49", "820.09", "900.89", "825.21", "997.31", "285.1", "348.5", "821.33", "458.9", "807.4", "843.8", "825.25", "825.29", "275.3", "300.4", "813.43", "E878.8", "825.24" ]

icd9cm

[ [ [] ] ]

[ "31.1", "78.63", "79.17", "78.13", "96.04", "34.02", "39.57", "96.72", "34.04", "33.24", "38.7", "79.62", "34.91", "79.02", "79.05", "79.65", "34.79", "96.6", "38.97", "83.64", "33.23", "78.67", "01.10", "79.32", "78.17", "78.12", "79.35" ]

icd9pcs

[ [ [] ] ]

8482, 8529

1313, 8427

305, 546

8605, 8605

9433, 10263

8550, 8584

8453, 8459

8773, 9410

262, 267

574, 1179

8620, 8749

1201, 1207

1223, 1290

30,758

183,491

12821

Discharge summary

report

Admission Date: [**2151-8-23**] Discharge Date: [**2151-8-26**] Date of Birth: [**2087-10-5**] Sex: M Service: SURGERY Allergies: Metformin Attending:[**First Name3 (LF) 473**] Chief Complaint: SBO, free air, pneumotosis Major Surgical or Invasive Procedure: None History of Present Illness: This is a 63 year old male who presents with abdominal pain. In the emergency room KUB showed possible small-bowel obstruction. CT scan of the abdomen was performed which showed pneumatosis intestinalis involving the small bowel as well as some free air likely related to a cyst rupture. There was also ileus noted at the time. Past Medical History: PMH: Diabetes Peripheral neuropathy Restless Legs BPH s/p TURP x4, baseline urinary incontinence s/p artificial sphincter Obesity Osteoarthritis Chronic back pain Chronic neck pain and headache after whiplash injury 2 yrs ago Bilateral carpal tunnel syndrome Bilateral ulnar neuropathy Bronchiectasis Colonic polyps Hydrocele (scheduled for surgery [**1-23**]) Irritable bowel syndrome s/p laminectomy s/p left knee replacement s/p carpal tunnel release s/p ulnar nerve release/decompression Right heel spur surgery s/p appendectomy s/p hiatal hernia repair Social History: Lives with his wife. [**Name (NI) 1403**] in computer repairs, retired but family has non-profit organization repairing old computers. Denies tobacco, EtOH, or illicit drug use Family History: Mother-stroke in late 50's. Died of MI in early 60's Father-MI at 87yo Physical Exam: AVSS Constitutional: Well-developed, well-nourished patient in no distress appearing appropriate age. Skin: no rashes, ulcers, icterus or other lesions; no clubbing or telangiectasias. Eyes: normal conjunctivae and lids. pupils: symmetrical. ENT: external: normal external inspection of ears and nose. Mouth: normal oral mucosa, lips and gums. Normal tongue, hard and soft palate; posterior pharynx without erythema, exudate or lesions. Neck: normal motion, central trachea, thyroid: normal size, consistency and position. Respiratory: normal breath sounds; no rubs, wheezes, rales or rhonchi. Cardiovascular: Normal rhythm, S1 and S2; no rubs, murmurs or gallop. Abdominal: Abdominal aorta, no bruits. Normal bowel sounds; no tenderness, rebound, guarding or masses. Hernias: No hernias appreciated. Liver: normal size and consistency. Spleen: not palpable. Rectal: Guaiac-negative, no masses. No fistula Gait: normal gait Extremities: normal range of motion. No edema, varicosities or cyanosis. Lymphatic: axillae: not palpable. groin: not palpable. neck: not palpable. Neurologic: no evidence of depression, anxiety or agitation. orientation: oriented to time, space and person. Pertinent Results: [**2151-8-22**] 10:20PM BLOOD WBC-11.0 RBC-4.51* Hgb-14.7 Hct-42.6 MCV-95 MCH-32.5* MCHC-34.4 RDW-13.3 Plt Ct-329 [**2151-8-25**] 06:25AM BLOOD WBC-7.9 RBC-4.10* Hgb-13.1* Hct-37.7* MCV-92 MCH-32.0 MCHC-34.8 RDW-13.8 Plt Ct-279 [**2151-8-22**] 10:20PM BLOOD Glucose-446* UreaN-13 Creat-1.4* Na-135 K-4.0 Cl-100 HCO3-21* AnGap-18 [**2151-8-25**] 06:25AM BLOOD Glucose-145* UreaN-6 Creat-0.9 Na-141 K-3.7 Cl-106 HCO3-23 AnGap-16 [**2151-8-22**] 10:20PM BLOOD ALT-14 AST-24 CK(CPK)-103 AlkPhos-145* Amylase-42 TotBili-0.6 [**2151-8-23**] 11:06AM BLOOD ALT-11 AST-14 LD(LDH)-154 CK(CPK)-50 AlkPhos-92 Amylase-29 TotBili-0.7 [**2151-8-23**] 11:06AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2151-8-23**] 11:06AM BLOOD Albumin-3.5 Calcium-9.0 Phos-2.0*# Mg-1.6 [**2151-8-25**] 06:25AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.8 . CT ABDOMEN W/CONTRAST [**2151-8-23**] 3:33 AM IMPRESSION: 1. Pneumatosis cystoides intestinalis involving small bowel in the right lower quadrant with small volume of pneumoperitoneum likely related to pneumatic cyst rupture. Small volume ascites, likely reactive. 2. Dilated small bowel involving mid-jejunum to mid-ileum, may represent adynamic ileus related to pneumoperitoneum. 3. 1-cm indeterminate adrenal nodule, specifically an adenoma. 4. Mild prominence of the intrahepatic biliary ducts with no obstructing stone or mass identified. 5. 1.2 cm heterogeneous lesion within the spleen, likely an hemangioma. 6. Chronic anterior compression fracture of the T12 vertebral body. . ABDOMEN (SUPINE & ERECT) [**2151-8-23**] 12:55 AM IMPRESSION: Multiple distended loops of small bowel concerning for obstruction. CT of the abdomen is recommended for further characterization. . Cardiology Report ECG Study Date of [**2151-8-23**] 3:40:28 AM Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 90 128 106 364/411.71 62 42 34 . Brief Hospital Course: He was admitted on [**8-26**] with abdominal pain. A CT was concerning for Pneumatosis cystoides intestinalis sm. bowel in RLQ c/ sm. volume of pneumoperitoneum (likely related to pneumatic cyst rupture), Sm. volume ascites, dilated sm. bowel involving mid-jejunum to mid-ileum He was managed conservatively with NPO, IVF his pain resolved and he was ultimately discharged. He continues to have significant diarrhea and weight loss and will follow-up with his GI doctor. Medications on Admission: Januvia, levothyronine, neurontin, tylenol #3, detrol, cymbalta Discharge Medications: as above Discharge Disposition: Home Discharge Diagnosis: Ileus Pneumotosis Hyperglycemia Discharge Condition: Good Tolerating Diet 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 vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Followup Instructions: Please follow-up with Gastroenterology, Dr. [**Last Name (STitle) 2305**] in [**1-19**] weeks. Call ([**Telephone/Fax (1) 2306**] to schedule an appointment. Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6469**] Phone:[**Telephone/Fax (1) 4832**] Date/Time:[**2151-8-31**] 10:30 Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6469**] Phone:[**Telephone/Fax (1) 4832**] Date/Time:[**2151-9-2**] 10:30 Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6469**] Phone:[**Telephone/Fax (1) 4832**] Date/Time:[**2151-9-7**] 10:30 Completed by:[**2151-9-2**]

[ "357.2", "255.8", "311", "560.1", "276.51", "715.96", "V43.65", "278.00", "569.89", "V12.72", "724.5", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5294, 5300

4671, 5147

295, 302

5376, 5399

2745, 4648

6490, 7126

1452, 1524

5261, 5271

5321, 5355

5173, 5238

5423, 6467

1539, 2726

229, 257

330, 660

682, 1241

1257, 1436

43,937

146,668

1263

Discharge summary

report

Admission Date: [**2200-8-4**] Discharge Date: [**2200-8-5**] Date of Birth: [**2113-3-30**] Sex: M Service: MEDICINE Allergies: Depakote / Zarontin / Phenobarbital / Aspirin Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Respiratory distress. Major Surgical or Invasive Procedure: Intubation, CVL History of Present Illness: 87 yo wheelchair bound male with CAD s/p PCI [**2191**], CVA in [**2187**], HTN, dementia, and recurrent [**Year (4 digits) **] PNA, with recent admission for acute on chronic systolic CHF exacerbation with EF=30% in [**8-30**] who presented with respiratory distress from [**Hospital3 2558**] nursing home. Nursing home records indicated that the patient was short of breath and found to be highly congested with decreased oxygen sats and crackles. A stat CXR was ordered by the PA. The attending came in today and noted the patient was unresponsive in bed so he was referred to the ED for further managament. He is typically oriented only to self but can report if he is in pain. He was recently admitted for acute on chornic systolic CHF exacerbation and was concomitantly treated for [**Hospital3 **] pneumonia with vanco/zosyn then levofloxacin for a total course of 3 days. Antibiotics were stopped prior discharge. Per EMS patient had a recent pneumonia also has a history of CHF they were called for respiratory distress. EMS reported that the patient was full code. Upon arrival to the ED, he was on positive pressure ventilation with sats in the low 90's. He was unable to speak secondary to respiratory distress and appeared as if he was tiring. Noted to have bibasilar rales. As a result he was easily intubated with a 7.5 ETT with etomidate and succinylcholine. He was sedated with fentanyl and midazolam. He was tachycardic to the 130s and had a blood pressure in the systolics of 60, so norepinephrine was started. Paperwork was then faxed over that noted the patient is DNR/DNI. A left IJ was attempted but the line went laterally. A right IJ placed into the cavoatrial junction. He was given a total of 6L NS. His UA returned positive. He also has a 20G in his right hand. He was given vanco/zosyn. EKG was concerning for a ST elevation in lead 3, in the context of a LBBB. Cardiology was consulted and felt that these changes were likely a result of sepsis with demand ischmia as these changes improved with improved hemodynamics. They recommended serial trops, Echo, and aspirin with heparin if no evidence of DIC. On arrival to the MICU, he is intubated and unresponsive. Past Medical History: - Coronary artery disease (stenting of D1 in [**7-/2191**]) - Congestive heart failure (EF 30% as of [**8-/2199**]) - Ischemic cardiomyopathy - Cerebrovascular accident ([**2187**]) - Hypertension - Recurrent [**Year (4 digits) **] PNA - Depression - GERD - Neurogenic bladder - Gout - BPH Social History: [**Year (4 digits) 595**] speaking only. Lives in [**Hospital3 **]. # Tobacco: Past smoking history, none currently # Alcohol: None # Illicits: None Has guardian ([**Name (NI) 1005**] c [**Telephone/Fax (1) 7843**], office [**Telephone/Fax (1) 7844**]). Court appointed given discord between wife [**Doctor First Name 7847**] [**Telephone/Fax (1) 7848**]) and son [**Doctor First Name 1158**] [**Telephone/Fax (1) 7845**]). Per the nursing home PCP; apparently a "do not rehospitalize" order is currently being applied for but a court date was not sent. Family History: Noncontributory Physical Exam: Exam on admission: Vitals: 102.8 120 96/52 26 90% on PSV 5/5 40% General: Intubated, sedated, unresponsive to pain HEENT: Sclera anicteric, MMdry, pupils 5mm and reactive bilaterally Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bronchial breath sounds at left base, decreased breath sounds at right base Abdomen: +BS, soft, non-tender, non-distended Back: stage 2 decubitus ulcer on sacrum GU: foley with yellow beige pus draining Ext: dry, cool, 1+ pulses, mottled extremities without edema Neuro: unresponsive to pain Exam on discharge: Patient without brainstem reflexes, no cardiopulmonary activity. Patient expired. Pertinent Results: Labs: [**2200-8-4**] 10:15AM BLOOD WBC-12.8* RBC-5.00 Hgb-14.4 Hct-46.2 MCV-92 MCH-28.9 MCHC-31.2 RDW-15.3 Plt Ct-312 [**2200-8-4**] 03:35PM BLOOD WBC-4.2# RBC-3.95* Hgb-11.4* Hct-37.1* MCV-94 MCH-28.8 MCHC-30.6* RDW-15.3 Plt Ct-229 [**2200-8-4**] 09:26PM BLOOD WBC-5.3 RBC-3.81* Hgb-11.0* Hct-36.2* MCV-95 MCH-28.8 MCHC-30.3* RDW-15.4 Plt Ct-263 [**2200-8-4**] 10:15AM BLOOD PT-12.4 PTT-33.4 INR(PT)-1.1 [**2200-8-4**] 03:35PM BLOOD PT-16.0* PTT-69.5* INR(PT)-1.5* [**2200-8-5**] 02:09AM BLOOD PTT-150* [**2200-8-4**] 10:15AM BLOOD Fibrino-568* [**2200-8-4**] 11:44PM BLOOD Fibrino-372# [**2200-8-4**] 10:15AM BLOOD UreaN-69* Creat-2.0* [**2200-8-4**] 03:35PM BLOOD Glucose-114* UreaN-58* Creat-2.0* Na-150* K-3.7 Cl-123* HCO3-18* AnGap-13 [**2200-8-4**] 08:00PM BLOOD Glucose-116* UreaN-57* Creat-2.0* Na-150* K-3.9 Cl-124* HCO3-13* AnGap-17 [**2200-8-4**] 03:35PM BLOOD ALT-6 AST-11 CK(CPK)-117 [**2200-8-4**] 10:15AM BLOOD Lipase-12 [**2200-8-4**] 10:15AM BLOOD cTropnT-0.10* [**2200-8-4**] 03:35PM BLOOD CK-MB-5 [**2200-8-4**] 08:00PM BLOOD proBNP-GREATER TH [**2200-8-4**] 09:26PM BLOOD CK-MB-6 cTropnT-0.23* [**2200-8-4**] 03:35PM BLOOD Calcium-6.7* Phos-2.1* Mg-1.7 [**2200-8-4**] 08:00PM BLOOD Calcium-6.2* Phos-2.4* Mg-1.6 [**2200-8-4**] 10:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2200-8-4**] 10:23AM BLOOD pO2-79* pCO2-40 pH-7.33* calTCO2-22 Base XS--4 [**2200-8-4**] 11:09AM BLOOD Type-ART pO2-288* pCO2-36 pH-7.31* calTCO2-19* Base XS--7 [**2200-8-4**] 11:20AM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP [**2200-8-4**] 04:39PM BLOOD Type-ART Tidal V-400 PEEP-5 FiO2-60 pO2-67* pCO2-44 pH-7.20* calTCO2-18* Base XS--10 Intubat-INTUBATED [**2200-8-4**] 06:06PM BLOOD Type-ART Rates-30/ Tidal V-450 PEEP-10 FiO2-60 pO2-65* pCO2-37 pH-7.23* calTCO2-16* Base XS--11 -ASSIST/CON Intubat-INTUBATED [**2200-8-4**] 06:06PM BLOOD Type-ART Rates-30/ Tidal V-450 PEEP-10 FiO2-60 pO2-65* pCO2-37 pH-7.23* calTCO2-16* Base XS--11 -ASSIST/CON Intubat-INTUBATED [**2200-8-4**] 08:14PM BLOOD Type-ART pO2-60* pCO2-35 pH-7.22* calTCO2-15* Base XS--12 [**2200-8-4**] 09:51PM BLOOD Type-ART pO2-65* pCO2-37 pH-7.18* calTCO2-15* Base XS--13 [**2200-8-5**] 02:26AM BLOOD Type-[**Last Name (un) **] pO2-31* pCO2-47* pH-7.08* calTCO2-15* Base XS--17 [**2200-8-4**] 10:23AM BLOOD Glucose-133* Lactate-3.2* Na-150* K-5.3* Cl-118* calHCO3-21 [**2200-8-4**] 11:20AM BLOOD Lactate-5.2* [**2200-8-4**] 04:39PM BLOOD Lactate-2.4* [**2200-8-4**] 09:51PM BLOOD Lactate-3.9* [**2200-8-5**] 02:26AM BLOOD Lactate-8.9* [**2200-8-5**] 12:33AM BLOOD O2 Sat-58 [**2200-8-4**] 08:14PM BLOOD freeCa-1.10* Micro: Blood and sputum cultures grew oxacillin sensitive staph aureus, with culture results returning after patient expired. Imaging: [**2200-8-4**] CXR #1: ET tube position appropriately. NG tube may be advanced for more optimal positioning. Bilateral posterior lower lobe opacities likely reflect [**Month/Day/Year **]. [**2200-8-4**] CXR #2: The new left jugular line is curving back in the mid left subclavian vein. There is no pneumothorax and no pleural effusion. The side port of the NG tube is at the level or slightly above the level of the esophagogastric junction. It could be advanced. Stability of the bilateral multifocal opacities. The mediastinal and cardiac contour are unchanged. The endotracheal tube is in adequate position 5.9 cm above the carina. [**2200-8-4**] CXR #3: right IJ in cavoatrial junction, ETT 5.8cm from carina, bibasilar infiltrates, clear diaphragmatic and heart borders [**2200-8-4**] EKG: wide complex regular tachycardia at 140, LAD, biventricular block with evidence of change in lateral leads Brief Hospital Course: 87 yo wheelchair bound male with CAD s/p PCI [**2191**], ischemic cardiomyopathy with EF 30%, CVA in [**2187**], HTN, dementia, and recurrent [**Year (4 digits) **] PNA, with recent admission for acute on chronic systolic CHF exacerbation with EF=30% in [**8-30**] who presented with respiratory distress found to be hypotensive. He was admitted to the MICU intubated with hemodynamic instability requiring norepi/vasopressin and IVF. While a broad workup was pursued, this was most likely felt to be sepsis given his fever, leukocytosis, positive UA and purulent sputum. He was covered with vanco/cefepime/cipro for HCAP and urinary sources. He was also empirically started on a heparin drip for PE and in the setting of elevated troponins given his rapid decompensation. LENI's were ordered but were not completed prior to his passing. Troponins and serial EKGs were performed. He was started on a statin, continued on plavix, and not on aspirin secondary to allergy. His BB and ACE were held given his hypotension. His CXR also revealed an element of volume overload in the setting of a hx of CHF. He was sedated given dysynchrony on the vent and his PEEP was uptitrated. His course was further complicated by hypernatremia thought to be secondary to poor free water intake as an outpatient, and [**Last Name (un) **] also thought to be secondary to dehydration. His coags uptrended which was concerning for DIC, but his fibrinogen was normal. Despite all of the aggressive measures listed above, he became more hypotensive with subsequent bradycardia. As he was initially intubated in the setting of DNR/DNI order, chest compressions were not started and the patient expired. His guardian, wife and son were all called multiple times and messages were left regarding his decompensation and tenuous state. Mr. [**Known lastname 7838**] son arrived just minutes after his father's passing. Culture data that resulted after the patient expired revealed an oxacillin sensitive staph aureus in both the sputum and the blood. Medications on Admission: Medications HOME: (per NSH records) 1. Clopidogrel 75 mg PO DAILY 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Doxazosin 8 mg PO HS 4. Gabapentin 200 mg PO HS 5. Lorazepam 0.5 mg PO HS 6. Metoprolol Tartrate 25mg PO BID 7. Mirtazapine 30 mg PO HS 8. Senna 1 TAB PO BID 9. Lisinopril 5 mg PO DAILY hold for sbp <90 10. Nitroglycerin Patch 0.2 mg/hr TD Q24H 9am-9pm 11. Furosemide 20-40 mg PO DAILY 12. Multivitamin 13. Cortisporin otic 2 drops qhs Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Patient expired. Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired.

[ "428.0", "414.8", "600.00", "V12.54", "V49.86", "428.22", "486", "038.9", "414.01", "276.2", "785.52", "294.20", "995.92", "285.9", "276.0", "518.81", "584.9", "V45.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10492, 10501

7905, 9946

333, 350

10561, 10579

4212, 7882

10644, 10663

3476, 3494

10451, 10469

10522, 10540

9972, 10428

10603, 10621

3509, 3514

272, 295

378, 2574

4109, 4193

3528, 4090

2596, 2887

2903, 3460

31,792

188,499

31878

Discharge summary

report

Admission Date: [**2100-8-27**] Discharge Date: [**2100-8-30**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Central venous line placement Foley catheter placement History of Present Illness: 84yo male presents on [**2100-8-27**] from his Rehabilitation Facility with fever to 103.6 in the ED, tachycardia to the 130s in atrial fibrillation, hypotension (MAPs in the 40-50s), and a morbilliform rash after being discharged on [**2100-8-23**] from [**Hospital1 18**]. According to the outside facility records, his rash started the day prior to his presentation and his conditioned worsened the day of his presentation. His vancomycin was held the day prior to his presenting for concerns that his rash was caused by the vancomycin. A central venous line was placed in the ED and IVF resuscitation was initiated. Past Medical History: h/o PAF formerly on amiodarone and coumadin 3VD with medical management, CHF EF >60%, HTN, prostate CA, CRI PSH: gallstone pancreatitis ([**4-5**]), open CCY ([**4-5**]), s/p resection prostate. Social History: Lives on [**Location (un) **] with Wife, [**Name (NI) 3608**]. Pertinent Results: [**2100-8-27**] 11:05AM WBC-25.6*# RBC-3.73*# HGB-11.6*# HCT-35.2* MCV-94 MCH-31.1 MCHC-33.0 RDW-16.9* [**2100-8-27**] 11:05AM GLUCOSE-100 UREA N-79* CREAT-2.6*# SODIUM-143 POTASSIUM-4.2 CHLORIDE-116* TOTAL CO2-15* ANION GAP-16 [**2100-8-27**] 11:17AM LACTATE-2.1* Brief Hospital Course: Mr. [**Known lastname 74762**] had a history of a pancreatic pseudocyst which had been drained on his most recent admission here at the [**Hospital1 18**] (for details of the admission, please reference discharge summary). He was transferred from the [**Hospital3 **] Center on [**2100-8-27**] with a history of a morbiliform rash that started the day prior to admission, fevers (102.0 at the Rehab Ctr., 103.6 in the ED here), tachycardic to the 130s in Atrial fibrillation, and hypotensive (SBP~80s, MAPs40-50). The patient's family was adamant that he was DNR/DNI. He was transferred to the ICU from the ED that same day and pressors were started in addition to continuing with IV fluid resuscitation; antibiotics were continued. Dermatology was consulted for concerns of his rash and recommended that his imipenem be changed to meropenem which was done. The patient continued to be in critical condition and his condition continued to deteriorate. On Sunday, [**2100-8-29**], the patient was made CMO by his family. He was started on a morphine drip early on the morning of [**2100-8-30**] and expired at 09:25 later that same morning. The family has requested an autopsy. Discharge Disposition: Expired Discharge Diagnosis: Sepsis Discharge Condition: Expired Followup Instructions: None

[ "577.0", "585.9", "995.92", "428.0", "V10.46", "584.5", "403.90", "785.52", "427.31", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

2795, 2804

1588, 2772

267, 324

2854, 2864

1293, 1565

2887, 2895

2825, 2833

221, 229

352, 975

997, 1194

1210, 1274

40,854

161,742

42653

Discharge summary

report

Admission Date: [**2196-12-24**] Discharge Date: [**2197-1-13**] Date of Birth: [**2119-10-31**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Found down Major Surgical or Invasive Procedure: Endotracheal intubation Tracheostomy Percutaneous gastrostomy PICC placement History of Present Illness: Mr. [**Known lastname 16968**] is a 77 yo RHM with h/o CAD s/p CABG, HTN, DM2, HL who presented after being found down in front of neighbors house aphasic and weak on the R side. The patient was feeling fine on the morning of [**2196-12-24**] other than some minor nausea. He awoke around 4am, which is usual for him, then showered and tried to fall back asleep. Around 7am, he awoke again and ate breakfast. His wife was home, and she saw and spoke to him off and on throughout the morning, and did not notice any problems. At 9:30am, he went to walk the dog, which he typically does 3x/day. At 9:45, his neighbor found him down and called 911. His wife next saw him in the [**Name (NI) **] Hospital ED, where she described he was not speaking, only making some sounds, and the R arm and leg were weak, though he did lift them up off the bed briefly. The ED notes describe a NIHSS of 20, with global aphasia and R facial droop, moving the L side spontaneously, but moving the R side only occassionally (?posturing) and not withdrawing it to pain. BP was elevated with SBP 200s. EKG showed NSR. Head CT showed no hemorrhage and he was given tPA. MRI was also done, with DWI showing L subcortical restriction and MRA showed absence of intracranial L ICA. He was Medflighted to [**Hospital1 18**] for possible interventional procedure. En route, BP spiked again to 200s and tPA was stopped temporarily, nipride was started. On arrival HR was 69, BP 165/82 on 0.5mcg/kg/hr nipride. CT/CTA/CTP were performed. NIHSS was 24. The patients family thinks he seems slightly better now than before tPA in terms of alertness and trying to communicate. Later in the ED today, he was answering some yes/no questions appropriately with his family, and squeezing their hand with his L hand. Of note, the family mentions that he has carotid dopplers last week and one side was 100% occluded. This was a change from a study 6 months ago which showed 65% occlusion. He was completely asymptomatic, with no transient neurologic deficits. He did have hematuria last week, tested negative for UTI. Past Medical History: CAD s/p CABG HTN HL DM2- checks fingersticks at home, well controlled Social History: [**Known firstname **] [**Known lastname 16968**] lives with wife, has 1 daughter. Retired 10 years, worked as truck driver. Was heavy smoker, quit 25 yrs ago. Drinks about 1 alcoholic beverage per week. No illicits. Baseline function is very good, he drives, walks [**1-13**] miles per day, has no memory/cognitive impairment. Family History: Positive for DM only Physical Exam: On admission: PHYSICAL EXAM: GEN: awake, alert, NAD HEENT: sclera anicteric, mmm, hard cervical collar in place CV: regular rate, no m/r/g PULM: CTAB AB: soft, NT/ND EXT: well perfused, no edema NEURO: MSE: awake and alert, looking preferentially to the left, intermittently able to turn eyes and head to the right when called loudly. Unable to state name or age, makes few grunts. Not able to follow simple commands, midline or appendicular. CN: PERRL 3 to 2mm. Blink to threat is less consistent on R side. Eyes have preferential gaze towards L, but can cross midline. R lower facial weakness. MOTOR: Normal bulk. Tone is decreased in RUE. Tone is increased in bilateral LEs. LUE/LLE move spontaneously and purposefully, antigravity. Not consistently following commands but squeezes L hand. RUE/RLE flex slightly to nailbed pressure, does not localize. SENSATION: likely decreased to pain on R side given lack of response/grimace. DTRs: biceps triceps brachiorad patellar Achilles R 2+ 1 2 2+ 1 L 2 1 2 2 1 Toes upgoing bilaterally. Discharge PE: Pertinent Results: Admission Labs: [**2196-12-25**] 01:00AM BLOOD WBC-13.9* RBC-4.12* Hgb-11.8* Hct-34.3* MCV-83 MCH-28.6 MCHC-34.3 RDW-12.4 Plt Ct-162 [**2196-12-25**] 01:00AM BLOOD PT-12.6* PTT-22.6* INR(PT)-1.2* [**2196-12-25**] 01:00AM BLOOD Glucose-192* UreaN-21* Creat-0.8 Na-140 K-3.7 Cl-108 HCO3-21* AnGap-15 [**2196-12-25**] 01:00AM BLOOD CK(CPK)-61 [**2196-12-25**] 05:12PM BLOOD CK(CPK)-76 [**2196-12-25**] 01:00AM BLOOD CK-MB-3 cTropnT-<0.01 [**2196-12-25**] 10:14AM BLOOD CK-MB-3 cTropnT-0.02* [**2196-12-25**] 05:12PM BLOOD CK-MB-3 cTropnT-0.02* [**2196-12-25**] 01:00AM BLOOD Calcium-9.2 Phos-2.6* Mg-1.6 Cholest-103 [**2196-12-25**] 01:00AM BLOOD %HbA1c-7.4* eAG-166* [**2196-12-25**] 01:00AM BLOOD Triglyc-53 HDL-45 CHOL/HD-2.3 LDLcalc-47 [**2196-12-25**] 07:10AM BLOOD Type-ART O2 Flow-5 pO2-60* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 Intubat-NOT INTUBA [**2196-12-30**] 10:49PM BLOOD Type-ART pO2-73* pCO2-37 pH-7.46* calTCO2-27 Base XS-2 [**2196-12-26**] 12:58PM URINE Blood-LG Nitrite-POS Protein-300 Glucose-100 Ketone-40 Bilirub-LG Urobiln-1 pH-5.0 Leuks-LG [**2196-12-26**] 12:58PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.020 [**2196-12-26**] 12:58PM URINE RBC->182* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 [**2196-12-29**] 11:10AM URINE CastHy-6* [**2196-12-29**] 11:10AM URINE AmorphX-OCC MICROBIOLOGY Blood cultures ([**2196-12-26**]): No growth Urine cultures ([**2196-12-26**]): No growth Mini Broncho-alveolar lavage: [**2197-1-1**] 11:39 am Mini-BAL GRAM STAIN (Final [**2197-1-1**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Viral Culture: Respiratory Viral Antigen Screen (Final [**2197-1-2**]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing. Interpret all negative results from this specimen with caution. Negative results should not be used to discontinue precautions. Refer to respiratory viral culture results. Recommend new sample be submitted for confirmation. Reports: EKG ([**2196-12-24**]): Sinus rhythm. Anterolateral non-specific ST-T wave abnormality. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 68 192 110 460/474 43 77 92 CTA Head/Neck ([**2196-12-24**]): 1. Head CT shows no evidence of hemorrhage. Dense left middle cerebral artery is visualized. Hypodensities due to small vessel disease and chronic watershed infarcts are noted. 2. CT perfusion of the head demonstrates large area of cerebral ischemia involving the left cerebral hemisphere with small areas of infarcts in the watershed distribution. 3. CT angiography of the neck demonstrates occlusion of the left internal carotid artery beyond bifurcation with 40-50% stenosis and calcification of the right carotid bifurcation. 4. Intracranial CTA demonstrates filling defect in the left middle cerebral artery extending to the inferior division indicative of a thrombus. 5. Small retention cysts and soft tissue changes are seen in the visualized sinuses. Degenerative changes are seen in the cervical spine. Chest Film ([**2196-12-25**]): Patient is status post median sternotomy and coronary bypass surgery. Improving right basilar opacity likely reflects atelectasis. Newly developed linear left basilar atelectasis is also demonstrated. Calcified pleural plaques are evident, suggesting prior asbestos exposure. MR [**First Name (Titles) 11598**] [**Last Name (Titles) 1093**] ([**2196-12-25**]): Somewhat limited study. No signs of ligamentous disruption or bony injury identified. No evidence of significant soft tissue trauma seen. No abnormal signal in the spinal cord. Degenerative changes most pronounced at C4-5 level where moderate spinal canal narrowing and mild extrinsic indentation on the spinal cord seen. Congenital fusion at C3-4 vertebral body levels. MRI Head ([**2196-12-25**]): Acute left middle cerebral artery infarcts. A 1.5 cm area of new blood products in the right parietal subcortical region. Followup head CT is recommended. Findings discussed with Dr. [**Last Name (STitle) **]. Echo ([**2196-12-26**]): The left atrium is mildly dilated. 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 aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No definite structural cardiac source of embolism identified. CXR ([**2196-12-28**]): As compared to the previous radiograph, the nasogastric tube is unchanged. Unchanged TIPS and calcified pleural plaques, noatvbly at the right lung bases. Unchanged bilateral basal parenchymal opacities, most likely atelectatic in nature. No pleural effusions. Borderline size of the cardiac silhouette without signs of fluid overload. No newly appeared focal parenchymal opacities suggesting pneumonia. NCHCT ([**2196-12-30**]): 1. Large infarct of the left MCA territory without evidence of mass effect or hemorrhagic transformation. Ill defined hyperdensity abutting the inner table of the posterior aspect of the right parietal bone might represent artifact but small hemorrhage cannot be ruled out. Attention on follow up is recommended. CXR ([**2196-12-31**]): atelectasis is present at the left base with elevation of the left hemidiaphragm. Pleural thickening and calcification is again noted. No other significant alterations are seen since the prior chest x-ray. The position of the endotracheal tube remains satisfactory. EEG ([**2196-12-30**]): This is an abnormal EEG due to the presence of a poorly organized and slow background with apparent bifrontal triphasic waves. This pattern is consistent with a moderate encephalopathy of (usually) toxic or metabolic etiology, but the slowed background may also be suggestive of significant, subcortical lesions involving deep or midline structures. Of note, occasional sharp waves were seen involving the right posterior quadrant; although not clearly epileptiform interictal discharges, if clinical suspicion is high for seizures, continuous EEG monitoring may provide additional diagnostic information. At times, the patient was noted to have left arm shaking; no EEG changes were seen with this activity. Abdominal Xray: REASON FOR EXAM: Poor GI motility. Gas bowel pattern is unremarkable. There is no evidence of ileus or obstruction. There are no pathologic intraabdominal calcifications aside from vascular calcifications in the pelvis. Degenerative changes are in the lumbar spine. A suspecte enteric dtube is seen in the upper abdomen midline. There is no free air detectable in this supine view. Abdominal US: ABDOMINAL ULTRASOUND: Evaluation is limited by patient body habitus. Within this limitation, the liver echotexture is normal without focal mass lesion. There is no intra- or extra-hepatic bile duct dilation and the common bile duct measures 5 mm. The main portal vein is patent. The gallbladder is normal. The spleen measures 10.9 cm. The right kidney measures 11.9 cm and the left kidney measures 11.9 cm. There is no evidence of hydronephrosis. There is no ascites. IMPRESSION: Normal abdominal ultrasound within limitations of patient body habitus. CT Abd and Pelvis with contrast: IMPRESSION: 1. No definite etiology to abdominal tenderness. 2. Bilateral pleural effusions, small volume of ascites and diffuse subcutaneous edema suggesting anasarca. 3. Calcified pleural plaques. 4. Likely gallbladder sludge. 5. Diverticulosis. 6. Abdominal aortic ectasia. Brief Hospital Course: Mr. [**Known lastname 16968**] was admitted to the neuro-intensive care unit of the [**Hospital1 69**] for the acute management of his left MCA infarction s/p TPA administration. He was initially transferred to the [**Hospital1 18**] for a possible interventional clot retrieval procedure, however, his CTP showed evidence of a completed infarction, and thus intervention was deferreed. His neurological examination on admission was significant for a severe dysarthria and right facial droop, global aphasia with an inability to reliably follow simple commands, as well as a flaccid right hemiparesis. His neurological examination remained stable throughout the course of his stay. An MRI obtained on the second hospital day confirmed the extent of his cerebral infarction, and also showed on GRE sequences the presence of a right posterior parietal hemorrhage that likely occurred in the post-TPA setting. In the setting of poor swallow function, he was started on nasogastric tube feeds, and has now received a PEG. Unfortunately, he did develop a number of complications. During the 2nd and 3rd day of his stay, he did develop recurrent fevers with a leukocytosis associated with a dirty UA. Urine cultures subsequently returned negative for organisms. However, he still received a 3 day course of IV ceftriaxone for presumed UTI which improved his fevers and leukocytosis. At about this time, he started to become more hypoxic (as shown by his earlier ABGs during the stay). CXRs showed a multifactorial clinical picture consistent with volume overload combined with atelectasis and a possible infiltrate. He was diuresed with intravenous furosemide until the his serum BUN/Cr markers were elevated. He did produce a brisk diuresis. Following this, his urine output did remain poor, and this ultimately improved with intravenous infusions of albumin. Superimposed on his dysarthria and aphasia, his mental status remained poor. He would be arousable to calling his name, but at baseline would prefer to remain with his eyes closed. His left arm often remained in soft wrist restraints as he would often try to grab and pull at his lines and tubes. An EEG did not show evidence of seizure activity, but did show generalized slowing consistent with an encephalopathy process. Similarly, a NCHCT showed expected poststroke changes and no new hemorrhages. He was started on provigil therapy to help boost his level of arousal, but this modest effects if any and later was discontinued. His respiratory status continued to be more tenuous. He was formally evaluated by speech and swallow on two occasions and failed their bedside assessments on both counts. He remained quite hypoxic and tachypneic, requiring large amounts of supplemental oxygen by face mask/tents, frequent suctioning, chest physical therapy and nebulizer treatments, which were not particularly helpful. His chest X-rays at that time, showed bibasilar atelectasis, and it was thought that his inability to tolerate oropharyngeal secretions was causing reduced ventilatory space and reducing his oxygenation. We had a family meeting on [**2196-12-29**] where we discussed his current poor respiratory function, and discussed his overall prognosis. We conveyed to Mrs. [**Known lastname 16968**] that the chances of a meaningful recovery of his walking, talking and understanding language would be quite poor, but that it would be difficult to make an accurate assessment of his prognosis. She and her family insisted that we continue to provide full code and full level of care. Given his tenuous pulmonary functioning, we suggested that the patient be electively intubated urgently as a bridge to endotracheal intubation and percutaneous gastrostomy. They agreed to this plan. We proceeded with endotracheal intubation, and the patient ultimately received his tracheostomy and PEG tube on [**2196-12-31**]. He once again spiked fevers and a new elevated WBC on [**2197-1-1**]. A miniBAL at this time showed the presence of GNRs and GPCs, the latter subsequently speciated out as coag positive staph aureus. He completed a course of vancomycin/zosyn therapy, and this improved his fever curves and initially the WBC. He was transferred out of the ICU on [**2197-1-4**]. While on the floor, his WBC remained somwhat elevated [**8-28**], despite being afebrile. We asked our medicine consult team for their suggestions as well. He started having profuse watery stool. He had c. diff sent which were negative x3. The patient became rather dry with hypernatremia. This was corrected gently with IVF. He continued to have loose stool and leukocytosis without fevers. He started to grimace to deep palpation on his abdominal examm which improved without intervention over 24 hours. RUQ US and CT abdomen and pelvis were performed and were normal. We switched his TF formula to peptomen 1.5 and added cholestyramine [**Hospital1 **] in hopes this will improve his loose stool. Unfortunately due to the use of a flexiseal fecal management system, Mr. [**Known lastname 16968**] developed an anal fissure. Wound care evaluated the patient and found it to be 1 x 1.5 cm [**Doctor Last Name 352**] moist ulcer at the 6 o'clock position( toward perineum ), indurated and extending into the anal canal for up to 3 cm. We called and asked our general surgery colleagues to evaluate who recommended removal of the flexiseal and cautious/careful cleaning. No need for surgical intervention. Of note, the wound care team also made note of a linear stage 2 pressure ulcer in the gluteal cleft. Given that all infectious studies have been negative for the past week, despite the mild leukocytosis, we feel that he is now ready for transfer to rehab for further care. Medications on Admission: ASA 81 mg simvastatin 40 mg daily metoprolol 25 mg [**Hospital1 **] lisinopril 20 mg daily metformin 500 mg [**Hospital1 **] glyburide 5 mg daily MVI Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 9. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical QID (4 times a day). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB or wheeze. 11. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB or wheeze. 13. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous twice a day. 14. insulin lispro 100 unit/mL Solution Sig: as directed units Subcutaneous four times a day: sliding scale insulin. 15. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Left Middle Cerebral Artery Infarction Hypertension Coronary Artery Disease S/p tracheostomy and percutaneous gastrostomy Type II Diabetes Mellitus UTI pneumonia diarrhea Discharge Condition: Activity Status: Bedbound. Mental Status/Level of consciousness: Opens eyes, follows objects at times. Does not follow commands. Neurological Examination: Left gaze preference, left sided hand tremor, right arm and leg flaccid hemiparesis Discharge Instructions: Mr. [**Known lastname 16968**] was admitted to the Neuro-Intensive Care unit of the [**Hospital1 69**] for the management of a left sided ischemic stroke that he sustained on [**2196-12-24**]. His neurological examination has remained stable since that time. His hospital course has been notable for the development of respiratory failure likely in the setting of excessive secretions and poor airway protection requiring endotracheal intubation and subsequent tracheostomy. He also had a PEG tube placed for enteral feeding. At this time, he is able to tolerate being on trach-mask for >24hours continuously and has maintained his oxygen saturations. During his stay he has been treated for a UTI and then coag postive staph pneumonia. He has had loose stool and mild leukocytosis but an otherwise negative infectious work up. C diff is negative x 3. He has remained afebrile for the past week. We assume the loose stools are more related to tube feeds and have switched formulas and added cholestyramine. He is being discharged today to rehab today for continued rehabilitation. His primary contact and family representative is his wife, [**Name (NI) **] [**Name (NI) 16968**] ([**Telephone/Fax (1) 92229**]) Followup Instructions: Please have the patient follow up with his PCP [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 911**] Location: ASSOCIATES INTERNAL MEDICINE Address: [**State 8536**], [**Apartment Address(1) 8537**], [**Location (un) **],[**Numeric Identifier 8538**] Phone: [**Telephone/Fax (1) 59456**] Fax: [**Telephone/Fax (1) 83917**] Date/Time: [**2197-1-18**] @ 945AM Please have the patient follow up with Dr. [**Last Name (STitle) **] from Neurology [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2197-3-6**] 1:30pm [**Location (un) 830**], [**Location (un) **], [**Numeric Identifier 718**] [**Hospital Ward Name 23**] Building, [**Location (un) 858**]

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icd9cm

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13463

Discharge summary

report

Admission Date: [**2107-1-6**] Discharge Date: [**2107-1-18**] Date of Birth: [**2027-6-12**] Sex: F Service: MEDICINE Allergies: Codeine / Zocor Attending:[**First Name3 (LF) 1899**] Chief Complaint: Shortness of breath, evaluation for CABG Major Surgical or Invasive Procedure: PICC line placement Cardiac catheterization with drug eluting stent to the left anterior descending artery. History of Present Illness: 79 yo F with multiple medical conditions including HTN, DMII, HLD, PVD, carotid disease, mitral valve prolapse with trace MR, CKD, gout, RA, history of thrombocytopenia, likely ITP, rhabdomyolysis, diverticulosis of the urinary bladder, atrophic right kidney, fatty liver, who was originally admitted to [**Hospital 40796**] on [**2107-1-1**] for fall and shortness of breath, now transferred for evaluation for CABG. . Patient presented to OSH after unintentional fall that resulted in right foot bruising. No history of seizure or pre-syncope. In the weeks leading up to her admission, she had noticed increasing SOB, productive cough with sputum production, increased LE edema, and unintentional weight pain. . During her OSH hospital course she was treated emphirically for pneumonia and aggresively diuresed for CHF exacerbation. X-ray ruled out fracture of the right foot. EKG showed anterolateral ST depressions and elevated cardiac biomarkers, CK 142->135->124, CK-MB 7->6->7.1, Trop-I 0.47->0.4->2.52. Echo cardiogram showed 2+ TR, 2+ MR, 1+ PI and borderline pulmonary hypertension. She was evaluated by cardiology consult and a catheterization was performed which showed 2-vessel disease including 80% stenosis of the proximal LAD. The plan was to pursue CABG at [**Hospital1 18**]. Prior to transfer, patient developed acute on chronic renal failure with Cr up to 2.1. Today she also developed acute dyspnea requiring BiPap (flashed), 120 mg of IV lasix with good urine output. . On transfer, she had O2 sat of 91-93% on 3L NC, CXR negative, and BP of 140/42. She did not have any chest pain but her Troponin was up to 2.52. On arrival, patient was comfortable and denied any SOB or chest pain. Vital signs were 97.3, 75, 130/47, 24, 93% (3L). . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, palpitations. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: none - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Bilateral carotid endarterectomy - HTN - DMII, non-insulin dependent - HLD - PVD - carotid disease - mitral valve prolapse with trace MR - CKD - GERD - gout - RA - history of thrombocytopenia, likely ITP - rhabdomyolysis - diverticulosis of the urinary bladder - atrophic right kidney - fatty liver - obesity Social History: Lives with husband. Used to work in a variety of jobs, now retired on diability. - Tobacco history: Ex-smoker, quit 20 years ago - ETOH: denied - Illicit drugs: denied Family History: non-contributory Physical Exam: ON ADMISSION VS: 97.3, 75, 130/47, 24, 93% (3L NC). GENERAL: obese woman, sitting up in bed, NC in place, NAd HEENT: PERRL, EOMI, anicterus. NECK: Supple with JVD not appreciated while sitting CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Bibasilar crackles, few expiratory wheezes. Mouth breathing. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. EXTREMITIES: Ecchymosis in the right foot, digits [**2-5**]. 2+ edema up to mid-calf bilaterally. No femoral bruits at post-cath site SKIN: venous stasis changes, ecchymoses PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . ON DISCHARGE VS: 98.1/97.3, 73-75, 20-22, 105-122/48-54, 98% 4L, 24 h: I: 1080 O: 2455 o/n: I=460 O=400 GEN: obese woman, sitting in chair, speaking in full sentences CV: RRR, S1/S2, no m/g/r, unable to assess JVD Resp: [**Month (only) **] BS, no wheezes, no wheezes of crackles. Abd: +bs, distended, obese, NT Ext: 1+ edema bilaterally to ankle, right foot ecchyoses in digits [**1-4**] 2+ PD pulses b/l. Left groin hematoma, soft, mild tenderness on palpation. Access: PICC right AC, placed at OSH [**1-3**]. Pertinent Results: ADMISSION LABS: [**2107-1-7**] 02:41AM BLOOD WBC-5.2 RBC-2.74* Hgb-10.0* Hct-30.7* MCV-112* MCH-36.5* MCHC-32.6 RDW-18.2* Plt Ct-102* [**2107-1-7**] 02:41AM BLOOD PT-14.0* PTT-23.9 INR(PT)-1.2* [**2107-1-7**] 02:41AM BLOOD Glucose-167* UreaN-89* Creat-2.1* Na-142 K-4.4 Cl-102 HCO3-33* AnGap-11 [**2107-1-7**] 02:41AM BLOOD CK-MB-5 cTropnT-0.73* [**2107-1-7**] 02:41AM BLOOD Calcium-8.7 Phos-5.0* Mg-2.2 [**2107-1-8**] 05:05AM BLOOD %HbA1c-6.2* eAG-131* . DISCHARGE LABS: [**2107-1-18**] 04:39AM BLOOD WBC-9.5 RBC-2.32* Hgb-8.0* Hct-24.3* MCV-105* MCH-34.5* MCHC-33.0 RDW-19.9* Plt Ct-136* [**2107-1-18**] 04:39AM BLOOD Glucose-90 UreaN-64* Creat-2.6* Na-141 K-4.3 Cl-100 HCO3-35* AnGap-10 [**2107-1-18**] 04:39AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.0 . CT CHEST W/O CONTRAST: . IMPRESSION: 1. Normal size and caliber of aorta on this non-contrast examination. Coronary artery and aortic calcifications. 2. Bilateral pleural effusions and atelectasis. Additional bilateral foci of ground-glass nodular opacities more have an appearance of infection than pulmonary edema. 3. Nodular liver contour suggestive of cirrhosis. 4. Persistent contrast within the kidneys from prior catheterization suggests possible nephropathy depending on the time since last contrast. . CAROTID U/S: IMPRESSION: 1. Less than 40% stenosis of the right internal carotid artery. 2. 40-59% stenosis of the left internal carotid artery. 3. To and fro flow in the right vertebral artery may be a sign of proximal subclavian artery stenosis. . ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal basal inferior hypokinesis. The remaining segments contract normally (LVEF = 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Mild pulmonary hypertension. . CARDIAC CATH [**1-12**]: PTCA COMMENTS: Angiography from the outside hospital was reviewed. We elected not to reshoot the RCA. Under ultrasound guidance the left femoral artery and left femoral vein were canulated. A 6Fr sheath was placed in the artery and a 5Fr was placed in the vein. We advanced a 6Fr XBLAD3.5 guiding catheter. It provided good support. We wired with a CPT XS wire and advanced a 2.5x12mm apex balloon, which was predilated to 6 atm. We then deployed a 2.5x12mm Promus DES across the lesion. We post dilated with a 3.0x8mm NC quantum balloon. Final angiography revealed the Cx ostium to be preserved, no evidence of dissection, and TIMI 3 flow through the stent in the LAD. At the end of the case a 6Fr Angioseal closure device was deployed without complication. . COMMENTS: 1. Successful PCI to ostial LAD lesion with DES. 2. Aspirin and plavix for 12 months minimum. 3. Transfer back to CCU for further monitoring. . FINAL DIAGNOSIS: 1. One vessel coronary artery disease. . LEFT GROIN U/S [**2107-1-15**]: FINDINGS: Grayscale and Doppler ultrasound was performed on the left groin. There is turbulent flow within the left common femoral artery, with appearance of partially arterial waveform. An abnormal communication is noted between the common femoral artery and vein, compatible with an AV fistula. There is no fluid collection to suggest a hematoma. . IMPRESSION: Son[**Name (NI) 493**] evidence of arteriovenous fistula at the left common femoral vasculature. No hematoma in the left groin. . CXR [**2107-1-14**]: Two views. Study was initially reviewed by Dr. [**Last Name (STitle) **]. Comparison with the previous study done on [**2107-1-12**]. Bibasilar infiltrates persist. These are partially obscured by overlying soft tissue. The costophrenic sulci are indistinct. The heart appears enlarged, as before. Mediastinal structures are stable. A PICC line remains in place. . Compared with the previous study, there is increased subsegmental atelectasis at the right base. IMPRESSION: Increase in subsegmental atelectasis at the right base. No other definite change. . ADMISSION EKG [**1-6**]: Artifact is present. Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available for comparison. . EKG [**1-16**]: Sinus rhythm. Inferolateral T wave abnormalities are changes are non-specific. Compared to the previous tracing of [**2107-1-14**] no diagnostic change except for the absence of atrial premature beats on today's EKG. Brief Hospital Course: 79 yo F with 80% stenosis of proximal LAD, left main equivalent, and multiple PMH including severe COPD, HTN, DMII, HLD, PVD, carotid disease, now with respiratory distress and admitted for evaluation for CABG. . # CAD: ECG changes showed ST-depressions in the anterolateral distribution that are new compared to [**7-/2106**], consistent with finding of significant stenosis in the proximal LAD on catheterization. She was sent to [**Hospital1 18**] for CABG evaluation due to left-main equivalent disease. During the first several days of admission, she continued to be dependent on high amounts of supplemental oxygen. It was determined that due to the severity of her COPD, her baseline at home is likely O2 sats in the high 80s on room air. Pulmonary was consulted and determined that her severe COPD would make her an extremely poor surgical candidate for CABG. CT [**Doctor First Name **] agreed and declined CABG in this patient. She was taken to the cath lab for high-risk intervention, and a DES was placed to the lesion in the prox LAD. She had an 80% lesion in the prox Circumflex that was not intervened upon. She tolerated the procedure well, post-op complicated by AV-fistula in the left common femoral artery-vein but no hematoma. She remained hemodynamically stable but received 1 unit of pRBC. She was discharged on aspirin, plavix (at least 1 yr), pravastatin, toprol-xl 75 mg daily. ACE-Inhibitor was held due to blood pressures and renal function and should be started in the outpatient setting. She will also need an outpatient stress/perfusion study to see if the intervention would be warranted for the circumflex lesion. . # Severe COPD, poor pulmonary function: Patient has poor lung function at baseline, although is not on home pxygen. She was treated for CAP with 7 days of ceftriazone. She was [**Country **] diuresed on her first day of admission roughly 1L. Pulmonary edema cleared on exam and CXR, however, she continued to have a high oxygen requirement, despite nebulizers. CT scan showed bibasilar atelectasis and emphysema PFTs were performed, which showed FEV1 40%. Pulmonary was conulted, and stated that her lung disease was secondary to emphysema and restrictive disease from obese body habitus. She was placed on supplemental oxygen with goal O2 sats >88-90, and CPAP at night. Of note, she did have an episode of flash pulmonary edema on the evening of [**1-16**] which responded well to IV lasix, nitropaste, and IV morphine. She did not have any futher episodes of this. She was discharged with spiriva, combivent inh, supplemental O2, and CPAP at night, along with a 40mg/20mg alternating PO daily lasix regimen. She was also started on a prednisone taper in-house for COPD exacerbation of 20mg x5 days, 10mg x5 days, and 5mg x 5days to be completed on [**1-26**]. Please note that she often desats into the low 80s temporarily, and that we are have been tolerating sats into the low 80s. In response to these desaturations she responds well to nebulizers, and lasix if necessary. She should start with pulmonary rehabilitation on arrival to rehab. . # Diastolic HF: Admission echo showed EF 50-55%. Patient was diuresed with IV Lasix during first day of admission roughly -1-2 L. Her Cr increased, likely secondary to overdiuresis and she appeared euvolemic to dry on exam. Her diuresis was subsequently stopped, but restarted in the setting of flash pulmonary edema (see above) requiring IV lasix, and subsequent conversion to a 20mg/40mg PO regimen on alternating days. . # Acute on chronic kidney disease: Cr was 1.8 on admission at OSH. Peaked to 2.1, likely secondary to contrast from OSH. Cr then decreased to 1.4, then trended back up to 2.6 discharge, likely secondary to contrast administration during cath, along with restarting of lasix. An ACE-Inhibitor will need to be started once her Cr decreases back to baseline. . #. Compensated cirrhosis: CT scan showed nodules in liver likely indicative of cirrhosis. Hepatology was consulted and stated that cirrhosis likely secondary to fatty liver and that she was Child's [**Doctor Last Name 14477**] A, compensated. She will need outpatient follow-up to confirm the diagnosis. . # HLD: Pravastatin initially increased to 40 mg qd for ACS, decreased back to 20 mg qd on discharge due to very low LDL. Home zetia was stopped. . # Diabetes Mellitus II: Only on glipizide at home. HgA1c = 6%. Patient was maintained on ISS during admission, and was dischrged on this along with her home glipizide . # HTN: On increased dose of metoprolol (50 TID) and felodipine 5mg daily (home regimen). She will need to be put on an ACE-Inhibitor as an outpatient as above. . # Gout: Continued on Allopurinol 50 mg qd . # Macrocytic anemia: Pt noted to have a macrocytic anemia with Hct trending down to low-mid 20s over the week before discharge (30.7 on admission). B12 and Folate were both high ruling out these etiologies. An MDS workup as an outpatient may be warranted for further assess this. . # Rheumatoid arthritis: Continued on hydroxychloroquine 400 mg [**Hospital1 **], restarted methotrexate on discharge. # Code status: Pt is confirmed dnr/dni. We also discussed the possibility of "do not re-hospitalize" and a palliative care discussion at rehab which the patient agrees to and would like her family to be involved with. This has not been confirmed, but should be further discussed at rehab, and with her PCP. Medications on Admission: HOME MEDICATIONS: - lasix 20 mg qd - Metoprolol 50 mg [**Hospital1 **] - plavix 75 mg qd - pravastatin 20 mg qd - ropinirole 1 mg qd - Symbicort 1 puff [**Hospital1 **] - ezetimibe 10mg qd - Albuterol sulfate nubulized - Allopurinol 50 mg qd - Felodipine 5 mg po qd - folic acid 1 mg qs - glipizide 5 mg qd - glucosamine chondoitin 1 capsule po bid - hydroxychloroquine 400 mg [**Hospital1 **] - ferrous fumarate 55 mg qd - Lovaza 2g [**Hospital1 **] - methotrexate 10 mg qFriday . MEDICATIONS ON TRANSFER: - amlodipine 5 mg po qd - nitroglycerin 1 inch q6hr - plavix 75 mg po qd - pravastatin 10 mg po qhs - metoprolol 50 mg po tid - omeprazole 20 mg po qd - heparin 5000 units sc tid - tylenol 650 mg q4hr prn - zofran 4 mg q8hr IV prn - Maalox 30 ml q4hr prn - milk of magnesia 10 ml po qd prn - colace 100 mg po bid - guaifenesin 200 mg q4hr prn for cough - tessalon 100 mg po q6hr prn for cough - allopurinol 100 mg po qd - folic acid 1 mg qd - ropinirole 1 mg qhs - iron sulfate 325 mg po qd - Renagel 800 mg po ac tid - Rocephin 2 g IV qd - NovoLog sliding scale inculin - Levemir 10 mg sc qd 10 units - Acidophilus 2 pills po tid - Advair diskus 500/50 one puff [**Hospital1 **] - Atrovent 0.5 mg q4hr prn neb - Zopenex 0.63 mg q4hr prn neb - Methylprednisolone 80 mg IV qd Discharge Medications: 1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) vial Inhalation four times a day as needed for shortness of breath or wheezing. 3. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 4. allopurinol 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): take every day for one year. 10. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ropinirole 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. insulin lispro 100 unit/mL Solution Sig: 0-14 units Subcutaneous four times a day: qAC and HS. Please follow sliding scale attached. 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 16. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 5 days: [**1-17**] - [**1-21**] . 18. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days: [**1-22**] - [**1-26**] . 19. felodipine 5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 20. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: as directed. 21. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 22. methotrexate sodium 2.5 mg Tablet Sig: Four (4) Tablet PO once a week: Friday. 23. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 24. Outpatient Lab Work Please check chem 7 and CBC on Wed [**2021-1-19**]. furosemide 40 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): start [**2107-1-18**]. 26. furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): start [**2107-1-19**]. 27. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for cough. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: chronic Obstructive Pulmonary Disease Exacerbation Non ST Elevation Myocardial Infarction Presumed Sleep Apnea Acute on Chronic Kidney Disease Acute on chronic Diastolic congestive Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had a heart attack and was transferred here to be evaluated for bypass surgery. Instead of surgery, we were able to place a stent in the left anterior artery to open the blockage. You tolerated this well but will have to be on clopidogrel (Plavix) and aspirin every day for at least one year to keep the stent open. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 4783**] tells you it is OK. This is extremely important to prevent another heart attack or death. You had a fall and injured your right foot, there is no break but lots of bruising. This will improve slowly. You also had a urinary tract infection that was treated with antibiotics. Your breathing is worse now and you need oxygen at home. A pulmonary doctor will see you after you leave the hospital and will want to perform a sleep study and follow you long term. . We made the following changes in your medicines: 1. Start using nitroglycerin as directed under your tongue for any chest pain. 2. Start colace, senna and Miralax for constipation 3. Start Spiriva for your COPD to help your breathing 4. Stop Symbicort and start Adviar instead to treat your COPD 5. Decrease Allopurinol to 50 mg for your gout 6. Decrease Metoprolol to 75 mg and change to once daily dosing to help your heart recover from the heart attack 7. Start Omeprazole to protect your stomach 8. Start Aspirin to prevent the stent from clotting off 9. Start guaifenesin to help your cough 10. Increase pravastatin to 20 mg to treat your cholesterol 11. Stop Zetia, Lovaza and Glucosamine 12. change albuterol nebulizers to a combination of albuterol and Ipratroprium to help your breathing . Weigh yourself every morning, call Dr. [**Last Name (STitle) 40797**] if weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days. . You need to have a repeat ultrasound of your groin to monitor a connection between your artery and vein that resulted from the catheterization. Please have it done around the first week of [**2107-2-1**]. Followup Instructions: Department: Cardiology Name: Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 5017**] When: Thursday [**2107-2-10**] at 10:30 AM Location: [**Location (un) **] CARDIOLOGY Address: [**Street Address(2) **], [**Apartment Address(1) **], [**Location (un) **],[**Numeric Identifier 39854**] Phone: [**Telephone/Fax (1) 5424**] . Pulmonology: Pt needs a doctor in the [**Hospital3 **] area. Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40798**] [**Telephone/Fax (1) 40799**] is the preferred pulmonologist but office closed today. Please call the office on Tuesday and set up as new patient for pulmonology evaluation, sleep study and PFT's, thanks . [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**] Completed by:[**2107-1-18**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

19026, 19100

9532, 14982

316, 426

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21602, 22437

3429, 3447

16315, 19003

19121, 19318

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118,110

21870

Discharge summary

report

Admission Date: [**2164-8-4**] Discharge Date: [**2164-8-7**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation. History of Present Illness: 83F with MMP in USOH until 6pm on DOA when, at an outdoor fair, she began to complain of sudden SOB. Pt became tachypneic and EMS was called. EMS note significant for pt being diaphoretic with +JVD, crackles/wheezing bilaterally, sinus tachycardia, bilateral pedal edema, and a BG=238. Pt given nitro spray x 3, lasix 80mg IV, and ASA 325 and then transported to [**Hospital1 9487**] where she was found to have BP 250/118, HR 130, RR 40, an O2 sat of 56% on RA, respiratory distress, and cyanosis; she was intubated at QMC with sux, etomidate, ativan, and pavulon; CXR was significant for B pleural effusions / moderate CHF; OGT and Foley catheter were placed and patient was transferred to [**Hospital1 18**] ED. Initial VS there were 99.2, 242/91, 122, 10, 100% on 550/10/100%/10; pt was started on a nitroglycerin gtt without effect; pt then given fentanyl boluses with improvement in BP substantially (pt was paralyzed but not sedated). ED course otherwise signficant for negative CTA chest and CT head. Admitted to MICU for further mgmt of respiratory failure. Per pt's daughter, pt had been complaining of lingering chest pain in weeks past. Past Medical History: 1. hyperlipidemia 2. CAD s/p cath at [**Hospital1 112**] [**2148**] 3. arterial insufficiency 4. DM2 with neuropathy 5. OA 6. back pain Social History: lives alone in [**Location (un) 57370**] (senior housing) in [**Hospital1 392**]; former heavy smoker but quit years ago; no etoh/drugs Family History: noncontributory Physical Exam: VS: HR 92, BP 129/31, R 12 Sat 100% on AC 500/10 50% 5 gen: intubated, sedated neck: no jvd/bruits/[**Doctor First Name **] chest: no r/r/w cv: RRR, S1/S2 nml, no m/r/g abd: +BS, S/NT/ND ext: 1+ pitting edema B LE's Pertinent Results: [**2164-8-4**] 08:40PM WBC-14.5* RBC-4.01* HGB-11.9* HCT-35.2* MCV-88 MCH-29.6 MCHC-33.7 RDW-15.8* [**2164-8-4**] 08:40PM PLT COUNT-241 [**2164-8-4**] 08:40PM NEUTS-57 BANDS-16* LYMPHS-16* MONOS-9 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2164-8-4**] 08:40PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-NORMAL SPHEROCYT-1+ OVALOCYT-2+ SCHISTOCY-1+ [**2164-8-4**] 08:40PM PT-12.6 PTT-20.1* INR(PT)-1.0 [**2164-8-4**] 08:40PM GLUCOSE-368* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18 [**2164-8-4**] 09:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2164-8-4**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2164-8-4**] 09:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 [**2164-8-4**] 10:18PM TYPE-ART TEMP-37.3 RATES-/10 TIDAL VOL-550 PEEP-5 O2-100 PO2-226* PCO2-48* PH-7.40 TOTAL CO2-31* BASE XS-4 AADO2-457 REQ O2-76 -ASSIST/CON INTUBATED-INTUBATED [**2164-8-4**] 08:40PM BLOOD cTropnT-0.03* [**2164-8-5**] 05:41AM BLOOD CK-MB-6 cTropnT-0.10* [**2164-8-5**] 10:20AM BLOOD CK-MB-5 cTropnT-0.08* CTA: 1) No evidence of pulmonary embolism. 2) Cardiomegaly with bilateral pleural effusions representing mild left ventricular failure. 3) Patchy opacities in right middle and lingular lobes. Differentials include pneumonia or aspiration Head CT: No hemorrhage or mass effect EKG: Sinus tachycardia Inferior/lateral ST-T changes are nonspecific Repolarization changes may be partly due to rate Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 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 structurally normal. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad, though a loculated anterior pericardial effusion cannot be excluded. Brief Hospital Course: 1. Respiratory failure: she was intubated on transfer from outside hospital. Chest xray showed evidence of CHF; she had no signs or symptoms of infection, making pneumonia unlikely. She was admitted to the ICU and was maintained initially on pressure controlled ventilation for 1 day. Meanwhile, she was treated with ceftriaxone/azithromycin to cover for possible PNA. She was diuresed with lasix, and her respiratory function improved so that she was weaned off the ventilator on hospital day #2, and was transferred to the general Medicine team. At this time, it was clear that she had no active PNA, and antibiotics were DC. She was maintained on lasix throughout her admission, with no further respiratory distress during her hospital stay. At DC, she was breathing comfortably and maintaining good peripheral O2 saturation on room air. 2. CAD: ACS was ruled out by normal biomarkers and EKG. She was maintained on her outpatient regimen of ASA and lipitor, and showed no signs of cardiac ischemia during her hosptial stay. 3. HTN: blood pressure was normal upon admission, so her outpt anti-hypertensive meds were held. Her BP was stable and normal throughout her stay; she was discharged on no anti-hypertensive meds, and was instructed to follow-up with her Cardiologist to address the need for reinstituting medical therapy for HTN. 4. CHF: her respiratory failure was thought to be [**12-26**] CHF. She was maintained on lasix for diuresis throughout her admission, and her respiratory status improved steadily. Echocardiogram showed normal LVEF with diastolic dysfunction and moderate pulmonary hypertension, which was likely responsible for her symptoms. At DC, she is breathing comfortably with minimal peripheral edema. She will require close follow-up with her Cardiologist to manage CHF. 5. DM2: she was hyperglycemic on admission; her outpt meds were held and she was maintained on an insulin drip in the MICU for glucose control. On transfer to the general Medicine service, insulin drip was DC and her oral hypoglycemic medications were added to her regimen. Blood glucose was well-controlled on glyburide and pioglitazone during her admission, though metformin was held. At DC, she was instructed to continue taking her outpt meds at her usual dose, including metformin. Medications on Admission: 1. ASA 325mg po qd 2. diabeta 10mg po bid 3. dilacor xr 180mg po qod 4. glucophage 1000mg po bid 5. isosorbide 10mg po bid 6. lasix 40mg po qd 7. lipitor 10mg po qhs 8. nitroglycerin prn 9. pioglitazone 30mg po BID 10. pletal 100mg p o Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Pioglitazone HCl 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 9. Dilacor XR 180 mg Capsule,Degradable Cnt Release Sig: One (1) Capsule,Degradable Cnt Release PO once a day. 10. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Pletal 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain: if chest pain, take 1 tablet, if pain not relieved in 15 minutes, take a 2nd tablet, if pain not relieved after another 15 minutes, take a 3rd tablet, if pain not relieved 15 minutes after 3rd tablet, present to ED for evaluation. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Congestive heart failure exacerbation. Discharge Condition: Stable to go to home. No dyspnea or other symptoms. Discharge Instructions: Please take all medications regularly as prescribed. Avoid salty foods such as sausage, canned meats, ham; do not add salt to your foods. Present to the ED for evaluation if you have chest pain, shortness of breath, dizziness/lightheadedness, or other concerning symptoms. Followup Instructions: Follow-up with primary care physician ([**Last Name (LF) 57371**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 57372**]) in [**12-27**] weeks.

[ "357.2", "427.89", "272.4", "428.0", "715.90", "250.60", "428.32", "724.2", "414.01" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8532, 8583

4481, 6793

274, 301

8666, 8720

2078, 3522

9043, 9192

1808, 1825

7080, 8509

8604, 8645

6819, 7057

8744, 9020

1840, 2059

215, 236

329, 1479

3532, 4458

1501, 1639

1655, 1792

46,667

129,653

54960

Discharge summary

report

Admission Date: [**2192-5-8**] Discharge Date: [**2192-5-12**] Date of Birth: [**2158-5-8**] Sex: F Service: NEUROLOGY Allergies: Penicillins / Zofran / iron / Amoxicillin Attending:[**First Name3 (LF) 20506**] Chief Complaint: found unresponsive with seizure activity Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 34 y/o woman with a history of ESRD [**12-29**] IgA nephropathy, prior R occipital stroke with residual L hemianopsia, PFO, and recent finding of ?R optic nerve edema for which she underwent LP on [**5-1**]. Following the procedure she continued to have persistent positional headaches and was admitted to [**Hospital 6136**] Hospital from [**Date range (1) 29430**]. CT at that time was reportedly normal and she was discharged home with pain medications. She continue to have severe headaches and remained very lethargic over the next several days. On [**5-8**] she was found unresponsive with R sided twitching and was taken to [**Hospital3 **], where a head CT showed a L frontal subdural hygroma. She was transferred to [**Hospital1 18**] for further care. Upon arrival here she was still unresponsive and was found to be actively seizing with right eye deviation, right mouth twitching, and rhythmic R hand shaking. She was given ativan 2mg IV and was loaded with Keppra with cessation of clinical seizure activity and some improvement in her level of arousal, although she continued to be minimally verbal and perseverative. She was admitted to the ICU for close monitoring. On later obtained history she reports that she was having no symptoms such as headaches or visual changes when the optic nerve edema was found on a routine eye exam. She was referred to a neurologist who noted bilateral papilledema and recommended an MRI of her brain and an LP to assess for pseudotumor cerebri. MRI on [**2192-4-17**] showed mildly prominent fluid in the optic sheaths bilaterally with no flattening of the posterior globes. LP was performed at [**Hospital 6136**] Hospital under fluoroscopy on [**5-1**]. Opening pressure was reportedly 44. An unknown volume was removed, and CSF results showed protein 34, glucose 51, 1 WBC, 0 RBC. She then represented to the ED on [**5-2**] for intractable nausea and HA and was admitted. CT head at that time was negative, and she was treated with dilaudid/zofran. She developed severe pruritis after receiving zofran and this is now listed as an allergy. Medications were changed to fioricet & compazine with improvement in her symptoms. She was discharged home on [**5-4**] but continued to have headaches. She became more lethargic over the next several days and subsequently was found unresponsive, leading to her admission here. Past Medical History: ESRD [**12-29**] IgA nephropathy A stroke 2.5 yrs ago. Not known where or why. Hemianopsia L? HTN Post LP headache Work up for Optic neuritis? edema? Social History: Lives with 16-year-old daughter, boyfriend lives nearby. Works as a lab technician. No etoh, smokes cigarettes about once/month. Family History: noncontributory Physical Exam: Physical Exam on Admission: Vitals: Rectal 99.6 T: 98.2 P:105 R: 16 BP: 186/106 SaO2:96% General: In Distress. HEENT: NC/AT, Dry MM Neck: + nuchal rigidity Pulmonary: crackles at the bases Cardiac: tachycardic Abdomen: soft. Extremities: No edema or deformities. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Was awake, able to say her name and birthday (today) but did not know the day today. When asked if today was her birthday said yes. Kept on saying yes. Was not able to follow simple commands like show me two fingers, showed me her hand (right hand). -Cranial Nerves: II: Sluggish pupils, symmetric . III, IV, VI: no nystagmus, able to look bilaterally, does not consistently track. V: NT VII: No facial droop appreciated. VIII: NT. IX, X: NT. [**Doctor First Name 81**]: NT. XII: tongue midline. -Motor: Normal bulk, tone. The extremities are antigravity. -Sensory: Withdraws feet to tickle. -DTRs: [**Name2 (NI) **] and symmetric Plantar response was flexor bilaterally. Physical Exam on Discharge: General: Awake and alert, NAD HEENT: NC/AT, MMM Pulmonary: CTAB Cardiac: RRR Abdomen: soft, nt/nd Extremities: No edema or deformities Skin: no rashes or lesions noted Neurologic: -Mental Status: Awake and alert, oriented x 3, attentive, able to say [**Doctor Last Name 1841**] backward, speech fluent, follows commands well -Cranial Nerves: II: Pupils 3->2 b/l, +L homonymous hemianopsia III, IV, VI: EOMI without nystagmus V: Facial sensation intact VII: Face symmetric VIII: Intact b/l IX, X: Palate elevates symmetrically [**Doctor First Name 81**]: Full strength XII: tongue midline -Motor: Normal bulk and tone. Full strength throughout in upper and lower extremities. -Sensory: Intact light touch -DTRs: [**Name2 (NI) **] and symmetric Plantar response was flexor bilaterally. Gait: Normal, steady without ataxia. Pertinent Results: [**2192-5-8**] 07:58PM PT-12.8* PTT-28.7 INR(PT)-1.2* [**2192-5-8**] 05:52PM LACTATE-1.2 K+-4.8 [**2192-5-8**] 05:45PM GLUCOSE-106* UREA N-60* CREAT-16.7* SODIUM-140 POTASSIUM-6.2* CHLORIDE-95* TOTAL CO2-19* ANION GAP-32* [**2192-5-8**] 05:45PM estGFR-Using this [**2192-5-8**] 05:45PM LIPASE-49 [**2192-5-8**] 05:45PM cTropnT-<0.01 [**2192-5-8**] 05:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2192-5-8**] 05:45PM WBC-12.2* RBC-3.65* HGB-10.1* HCT-33.9* MCV-93 MCH-27.6 MCHC-29.7* RDW-17.8* [**2192-5-8**] 05:45PM NEUTS-89.0* LYMPHS-8.0* MONOS-2.2 EOS-0.4 BASOS-0.5 [**2192-5-8**] 05:45PM PLT COUNT-345 CT head [**5-8**]: IMPRESSION: Subdural hygroma extending along the left frontal convexity without significant mass effect. NOTE ADDED IN ATTENDING REVIEW: As above, there is a relatively thin subdural effusion (measuring 17 [**Doctor Last Name **], and 9 mm in maximal depth) overlying the left frontal convexity. There is no evidence of blood products. There is also a suggestion of a thin subdural effusion overlying the right frontal pole. These findings, in the context of recent lumbar puncture, raise the possibility of intracranial hypotension, which, if warranted on clinical grounds, might be confirmed by enhanced cranial MR. CXR [**5-9**]: IMPRESSION: Bilateral lower lobe pneumonia or non-cardiogenic pulmonary edema, depending on the clinical context. As per Dr. [**First Name (STitle) **], the patient has missed her scheduled dialysis appointment, therefore this may represent pulmonary edema secondary to a derangement in fluid-electrolyte homeostasis. The study can be repeated following dialysis to demonstrate improvement. Brief Hospital Course: Ms. [**Known lastname **] is a 34 y/o woman with a history of ESRD [**12-29**] IgA nephropathy, prior R occipital stroke with residual L hemianopsia, PFO, and recent finding of ?R optic nerve edema for which she underwent LP on [**5-1**]. Following the procedure she continued to have persistent positional headaches and was admitted to [**Hospital 6136**] Hospital from [**Date range (1) 29430**]. CT at that time was reportedly normal and she was discharged home with pain medications. She continue to have severe headaches and remained very lethargic over the next several days. On [**5-8**] she was found unresponsive with R sided twitching and was taken to [**Hospital3 **], where a head CT showed a L frontal subdural hygroma. She was transferred to [**Hospital1 18**] for further care. Upon arrival here she was still unresponsive and was found to be actively seizing with right eye deviation, right mouth twitching, and rhythmic R hand shaking. She was given ativan 2mg IV and was loaded with Keppra with cessation of clinical seizure activity and some improvement in her level of arousal, although she continued to be minimally verbal and perseverative. She was admitted to the ICU for close monitoring. Neuro: In the ICU she was connected to EEG monitoring which initially showed non-convulsive status. She received an additional 2mg IV ativan and was loaded with Fosphenytoin 1250mg IV with improvement. On the am of [**5-9**] she was more alert and able to answer questions appropriately although she remained inattentive and somewhat encephalopathic with asterixis on exam, likely related to significant uremia. Her neurologic exam was otherwise non-focal and there was no clinical evidence of seizure activity. No papilledema was seen on fundoscopic exam, although somewhat limited by pt cooperation. Later that day she again developed more epileptiform activity on EEG and received an extra 500mg IV Keppra and 500mg IV Fosphenytoin. She remained stable overnight with no further evidence of seizures. By [**5-10**] she was much more alert and coherent. She was continued on Keppra 500mg IV BID and Phenytoin 100mg Q8hrs. Phenytoin levels were monitored with a goal of 15-20. She was transferred to the neurology floor on [**2192-5-10**]. She did well without further seizure activity. She was monitored on EEG and the pattern normalized. She had a rather significant headache as well as some nausea that was treated symptomatically. By [**5-12**] she was doing well and was discharged home in good condition. Other notable systems as follows: Cardiovascular: She was maintained on telemetry monitoring during her admission. She was continued on aspirin 81mg, amlodipine 5mg, and metoprolol 50mg [**Hospital1 **]. Pulm: Upon admission she required a low level of supplemental O2 via NC. CXR [**5-9**] showed consolidation of b/l lower lungs, most likely pulmonary edema related to volume overload. Her respiratory status improved with dialysis and she required no further oxygen supplementation. ID: She remained afebrile with no signs of infection. Blood cultures were negative. CSF results were obtained from OSH and were also negative. Renal: Nephrology was consulted and she was continued on her home HD schedule MWF. Electrolytes were monitored closely. FEN: She passed a bedside swallow eval and was started on a regular diet. Medications on Admission: Amlodipine 5 mg ASA 81 Tums 750mg Q meakl Sensipar 90mg QHS Iron sulfate 325 daily Requip 0.5mg [**Hospital1 **] renvela 800mg qmeal Nephrocaps daily Fioriciet PRN Compazine prn Scopalamine PRN Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Calcium Carbonate 750 mg PO TID W/MEALS 4. Cinacalcet 90 mg PO DAILY 5. LeVETiracetam 500 mg PO BID RX *levetiracetam 500 mg 1 Tablet(s) by mouth twice a day Disp #*80 Each Refills:*4 6. LeVETiracetam 500 mg PO ONCE Duration: 1 Doses After dialysis 7. Metoprolol Tartrate 50 mg PO BID Hold if SBP <110 8. Phenytoin Infatab 100 mg PO TID RX *Dilantin Infatabs 50 mg 2 Tablet(s) by mouth three times a day Disp #*90 Each Refills:*3 9. sevelamer CARBONATE 2400 mg PO TID W/MEALS 10. Nephrocaps 1 CAP PO DAILY 11. Prochlorperazine 10 mg PO Q6H:PRN nausea RX *prochlorperazine maleate 5 mg [**11-28**] to 1 Tablet(s) by mouth three times a day Disp #*20 Each Refills:*0 12. Ropinirole 0.5 mg PO BID 13. Outpatient Lab Work Please draw a dilantin level prior to her dose on [**5-18**] and FAX the results to Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 33403**] Diagnosis: Epilepsy ICD-9: 345.9 Phone: [**Telephone/Fax (1) 541**] Discharge Disposition: Home Discharge Diagnosis: 1. Status epilepticus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro Exam: Left homonymous hemianopsia Discharge Instructions: Ms. [**Known lastname **], You were admitted to [**Hospital3 **] with seizures after having a persistent positional headache following a lumbar puncture. You were found to have a left frontal subdural hygroma (a fluid collection). You were admitted to the ICU at [**Hospital1 18**] for further care and required significant seizure medications to stop the seizures. You were continued on Keppra 500 mg twice daily with an extra dose given on days in which you receive dialysis. You also are getting Dilantin 100 mg three times a day. You were observed on the general neurology floor without further seizures. You were discharged home in good condition with plans to continue Keppra and Dilantin and follow up with Neurology here as detailed below. Please remember to avoid driving until you have been seizure-free for at least six months. It will be importantg to avoid potentially dangerous activities such as climbing to heights, taking baths, and swimming independently. Followup Instructions: Neurology: Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) **], [**Hospital1 18**] Neurology, [**Hospital Ward Name 23**] Bldg, [**Location (un) 86**], MA. on [**6-13**] at 4 PM. Office number is [**Telephone/Fax (1) 541**] PCP: [**Name10 (NameIs) 357**] [**Name11 (NameIs) 702**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 71087**] next week. Office number is [**Telephone/Fax (1) 9674**]

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icd9cm

[ [ [] ] ]

[ "89.19", "39.95" ]

icd9pcs

[ [ [] ] ]

11490, 11496

6762, 10123

343, 350

11562, 11562

5027, 6739

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44030

Discharge summary

report

Admission Date: [**2137-8-6**] Discharge Date: [**2137-8-30**] Date of Birth: [**2100-12-7**] Sex: M Service: MEDICINE Allergies: Dapsone / Bactrim Ds Attending:[**First Name3 (LF) 13024**] Chief Complaint: hypotension, positive blood cultures Major Surgical or Invasive Procedure: Central Femoral Line placement, now removed History of Present Illness: 36 M with end stage HIV/AIDS (last CD4 17), known PML, history of EtOH abuse; admit from [**Hospital1 **] with hypotension and positive blood and sputum cultures (from few weeks ago). No notes as to what BPs were or how usually run. [**Hospital1 **] notes state having frequent loose stools and urine cloudy. Has L PICC in place. In discussion with RN supervisor, patient seems to have been sent in for workup of low grade fevers (not for hypotension); SBP 84 last on [**8-2**] and has since been in 90's to 100s (baseline). . Recent admission to [**Hospital3 2005**] in [**2137-6-2**]. Had positive culture on [**2137-7-12**] for VSE, staph coag neg on [**2137-7-23**], blood cx negative on [**2137-7-31**], C.diff neg last on [**2137-7-28**]. Amikacin and vanco ?in recent past. . In the ED, T 99.1, HR 90, BP 90/64, R 18, 100% on 40% FiO2 TM. Received 2 L NS; SBP 92-106. Vanco and Zosyn given. Femoral CVL in place. Past Medical History: - HIV: Diagnosed [**2123**], risk factor MSM. Had been on HAART. Last CD4 count 17 in 4/[**2137**]. - PML - Diagnosed in [**2137-3-2**]. Found to have +[**Male First Name (un) 2326**] virus on LP and non-enhancing lesions consistent with progressive multifocal eukoencephalopathy - PCP [**2127**]: pt reports at that time he mostly had severe fatigue and it was not similar to this presentation. Was on Bactrim which he is allergic to but had undergone desensitization; stopped taking bactrim in [**Month (only) **] so currently on no prophylaxis. - Hx gonorrhea - anal condylomata s/p laser destruction/biopsy [**3-7**], results showed only low-grade dysplasia. Has had no follow-up. - Alcohol abuse: prior withdrawal seizures, pt reports in [**3-7**] and [**4-7**]. Entered detox [**2137-2-16**] - hx R shoulder fracture sustained during seizure in setting of alcohol withdrawal - Hx oral candidiasis - Depression - Anxiety - Trach and PEG in 6/[**2137**]. Admitted and intubated for respiratory distress and aspiration pneumonia. Unclear reason for trach. Social History: SF is a homosexual man who in the past has engaged in unprotected anal intercourse. He recently lived in [**Location 3786**], MA with his mother and grandmother. His grandmother is in ailing health and his mother has severe rheumatoid arthritis. He does not know his father and has no siblings. SF was formerly employed as a temp worker. He had abused alcohol for last 15 years with periods of sobriety as long as 6 months. He has a maternal uncle who is an alcoholic. No hx of tobacco or illicit drug use. Family History: Mother with rheumatoid arthritis Physical Exam: Vitals: T97.5, P96, BP 108/65, R28, 100% TM at 12LPM. General: No interaction or apparent awareness of surroundings. NAD, breathing comfortably on TM. HEENT: NC/AT. PERRL. Sclera anicteric. MM slightly dry. Neck: Trached on TM. No adenopathy. Chest: Poor effort, but appears clear. Heart: Somewhat diminished, regular, slightly tachy, no murmurs appreciated. Abdomen: + BS (hypoactive), soft, ND, ecchymoses from heparin, at times appears ?tender in epigastrium, no guarding. Extrem: Slightly cool, hands and feet with mild pitting edema. R CVL in place. Neuro: Moves extremities minimally to painful stimuli (?except RUE). Sensing painful stimuli only, not responsive to voice or command. Pertinent Results: [**2137-8-6**] 04:50PM URINE CA OXAL-FEW [**2137-8-6**] 04:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2137-8-6**] 04:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2137-8-6**] 04:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2137-8-6**] 04:50PM PT-14.0* PTT-32.7 INR(PT)-1.2* [**2137-8-6**] 04:50PM PLT SMR-NORMAL PLT COUNT-326 [**2137-8-6**] 04:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2137-8-6**] 04:50PM NEUTS-38* BANDS-0 LYMPHS-45* MONOS-10 EOS-6* BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2137-8-6**] 04:50PM HGB-10.6* calcHCT-32 [**2137-8-6**] 04:50PM GLUCOSE-104 LACTATE-1.5 NA+-133* K+-3.9 CL--94* [**2137-8-6**] 04:50PM ALBUMIN-3.1* CALCIUM-8.6 PHOSPHATE-4.4 MAGNESIUM-2.2 [**2137-8-6**] 04:50PM CK-MB-NotDone [**2137-8-6**] 04:50PM cTropnT-0.02* [**2137-8-6**] 04:50PM LIPASE-31 [**2137-8-6**] 04:50PM ALT(SGPT)-42* AST(SGOT)-33 CK(CPK)-23* ALK PHOS-96 TOT BILI-0.3 [**2137-8-6**] 04:50PM estGFR-Using this [**2137-8-6**] 04:50PM GLUCOSE-103 UREA N-19 CREAT-0.5 SODIUM-135 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-31 ANION GAP-10 [**2137-8-12**] 03:38AM BLOOD WBC-4.3 RBC-2.49* Hgb-9.8* Hct-28.9* MCV-116* MCH-39.4* MCHC-34.0 RDW-16.3* Plt Ct-263 [**2137-8-7**] 1:06 am SPUTUM Site: INDUCED **FINAL REPORT [**2137-8-10**]** GRAM STAIN (Final [**2137-8-7**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2137-8-10**]): SPARSE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 16 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- 8 I PIPERACILLIN---------- 32 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R [**2137-8-7**] 1:06 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2137-8-8**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-8-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2137-8-7**] 5:44 am BLOOD CULTURE Blood Culture, Routine ([**Month/Day/Year **]): [**2137-8-6**] 4:50 pm URINE Site: CATHETER **FINAL REPORT [**2137-8-7**]** URINE CULTURE (Final [**2137-8-7**]): NO GROWTH. [**2137-8-6**] 4:45 pm BLOOD CULTURE **FINAL REPORT [**2137-8-12**]** Blood Culture, Routine (Final [**2137-8-12**]): NO GROWTH. [**2137-8-10**] 4:07 pm STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2137-8-11**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-8-11**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Brief Hospital Course: Hypotension/fever/?sepsis: Per [**Hospital1 **] his baseline blood pressure appeared to be mid 90s, had one BP of 84/52 on [**8-2**] but [**Name8 (MD) **] RN supervisor appears to have been in the 90s since. We believe he was sent in more for low grade temps (up to 100.8 off and on); in ED had SBP 90 and has been in the 90's to 100's since. Has advanced HIV but no recent CD4 count (none since prior to HAART) so therefore may be at high risk for infection. Review of records with the patient showed that he had had blood cx collected [**7-23**] positive for coag negative staph (susceptible to tetracycline and vanc), as well as a catheter tip w/ coag negative staph also on [**7-23**]. He also had negative blood cx x2 on [**2137-7-31**]. He also has a history of E coli and Pseudomonas in his sputum (sensitive to cefepime and Pip/Taz) on [**7-17**]. Sputum from [**7-20**] showed moderate Pseudomonas with intermdiate resistance to Amikacin, and pt had Amikacin levels from [**7-31**], but no additional data regarding this treatment was available. He also has an indwelling PICC, it is unknown how long this has been in place. After arrival in the MICU, he was started on Vancomycin and Zosyn. He had two negative C. diff tests [**7-26**] and [**7-28**], and another was sent here, which was also negative. Blood, urine, and sputum cultures were also sent. The sputum showed no microorganisms, and the urine culture had no growth. Blood cultures [**8-6**] showed no growth. Patient spiked a temperature to 101.6 on [**2137-8-7**], and was re-cultured (blood cx still [**Date Range **] [**8-12**]), but has remained afebrile since then. Chest x-ray showed no evidence of pneumonia or acute disease. Patient's CD4 was sent and the level was 53. Given improvement in clinical appearance, further workup, including LP, was not pursued at this time. Consideration was also given to removing the PICC as a potential source of infection, but as patient had no evidence of growth on blood cultures or worsening infection, this was left in. Pt had a femoral central line placed in the ED, and this was removed on [**2137-8-9**]. Pt was afebrile for several days, but on [**8-12**]/8, began to spike recurrent fevers to 103(rectal). Sputum, blood, and urine cultures were sent on [**8-12**] and showed WBCs and bacteria in urine but never grew any bacteria. Sputum showed PSA as before. ID was called for consult regarding whether to get an LP and further workup for infectious cause of fever however they felt that PSA was likely a colonization and fever was central in origin not infections. Serologies for CMV and EBV were negative. Vanco and Zosyn were d/c'd on [**2137-8-15**]. *** Primary care provider will need to follow up [**Date Range **] blood cultures *** Sinus Tachycardia: This is believed to be long standing (though unclear etiology); records report [**Hospital1 1501**] dosing of 400 mg metoprolol daily. Of note, an H&P from [**2137-6-14**] reports his dose as Metoprolol 25 mg [**Hospital1 **]. Pt intially received multiple boluses of IVF, and had a decrease in his HR, though this would generally increase back to around 120 bpm. Patient was started on low dose metoprolol, which was gradually increased to 50 TID by [**2137-8-9**]. His HR continued to range from 90-120, with SBPs in the 90s to 100s and the metoprolol was decreased again to 37.5mg with stable SBPs in 90s and HR 110s. . H/o Positive sputum cultures: Pt has history of pseudomonas and E. coli in sputum with multiple drug resistance. No clear evidence of pneumonia on CXR, but with significant immunosuppresion. Sputum intially showed no organisms, and pt was empirically treated with zosyn/cipro. On [**8-11**], his sputum sensitivities resulted, and he was changed over to [**Month/Year (2) 21347**]. The Pseudomonas was sensitive to both Zosyn and [**Last Name (LF) 21347**], [**First Name3 (LF) **] the plan is to treat for a total of 14 days. Including the 4 days of Zosyn leaves 10 days of [**First Name3 (LF) 21347**], for a stop date of [**2137-8-20**]. Antibiotics were d/c'd on [**2137-8-15**] as it was felt they were not indicated in setting of colonization and no infection. . PML. Very poor mental status at baseline, does not appear changed per [**Hospital1 **] reports. Progressive neurologic impairment as expected. Mental status appeared unchanged per records. A CT was ordered that showed much progressed PML since [**4-9**]. Had several discussions with mother regarding goals of care, and she intially indicated she did not want patient to be intubated or have chest compressions and then after the results of the CT decided to not escalate his care further. He was thus kept on nutrition, fluids, and narcotics only. If necessary she agreed to also have him get antibiotics. . HIV/AIDS: Last CD4 count 17 was prior to HAART; now on HAART x 4 months. Recheck of CD4 was 53. Pt was continued on HAART, with atovaquone for prophylaxis. . Anemia. Macrocytic likely [**2-2**] HAART. No change in last week per records from [**Hospital1 **]. Stable during hospitalization. . History of EtOH abuse. Now at skilled nursing facility, no concern for withdrawal issues. . FEN: Pt was continued on tube feeds with equivalent formula. PPx: Pt was prophylaxed with HSQ, H2 blocker while an inpatient Communication. Mother [**Name (NI) **] is HCP; number is [**Telephone/Fax (1) 94548**]. Code: During this admission, code status was changed to DNR/DNI after discussions with mother, may need to readdress for future admissions. . At time of transfer off of MICU [**Location (un) **], Mr. [**Known lastname **] is unresponsive to pain. His pupilary reflexes are deranged. He requires frequent suctioning, is tachycardic, and at times febrile, but is stable. All of this seems to be related to autonomic dysregulation as a consequence of his PML. It is worth noting that his sputum is colonized by Psuedomonas, but he does not have a Pseudomonal infection per ID. Indeed, although he has continued empiric treatment for this colonization/infection, his fevers are unchanged as are his other vital signs. As stated above, his course has been a long and complicated decline to his current state. =======================Medicine Floor Team==================================== All medical management initiated in the ICU was continued on the general medical service. Scopolamine patches were increased to two q72h and provided good control of secretions. Electrolytes and white count were stable. Pt was transiently febrile and started on Linezolid for a positive blood culture, but Abx were discontinued b/c culture showed likely contaminant. Linezolid was discontinued and fever resolved on its own. At the time of tranfer to outside facility, the pt is unresponsive, but calm and apparently comfortable. His electrolytes and white count are unremarkable. He has been afebrile for 5 days. Medications on Admission: Albuterol/ipratrop MDI QID Atovaquone 750 mg daily Butt balm topical [**Hospital1 **] Colistin inhaled 150 mg [**Hospital1 **] E-mycin 0.5% eye ointment TID HSQ Q8H Lopinavir/ritonavir 200/50 [**Hospital1 **] Mefloquine 250 Qsaturday Metoclopramide 10 mg QID Metoprolol 100 mg Q6H Petroleum ophthalmic QID Promod 2 scoops [**Hospital1 **] Raltegravir 400 mg Q12H Scopalamine patch 1.5 mg x2 patches Q72H Tenofovir 300 mg daily Thiamine 100 mg daily Zidovudine/Lamivudine 150/300 mg [**Hospital1 **] PRN meds: acetaminophen, A/A nebs, Nacl inhalation, loperamide, zofran, zyprexa 5mg. O2 by trach collar at 35% Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:*qs 1 month * Refills:*2* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:*120 neb* Refills:*2* 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). Disp:*120 neb* Refills:*2* 8. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY (Daily). Disp:*300 mL* Refills:*2* 9. Lopinavir-Ritonavir 400-100 mg/5 mL Solution Sig: Five (5) ML PO BID (2 times a day). Disp:*150 ML(s)* Refills:*2* 10. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Scopolamine Base 1.5 mg Patch 72 hr Sig: Two (2) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 12. Erythromycin 5 mg/g Ointment Sig: One (1) ribbion Ophthalmic TID (3 times a day). Disp:*90 ribbion* Refills:*2* 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. Disp:*60 Tablet(s)* Refills:*0* 14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*500 ML(s)* Refills:*2* 15. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs month * Refills:*2* 16. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 17. 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. 18. Morphine 10 mg/0.7 mL Pen Injector Sig: 2-4 mg Intramuscular q2 prn as needed for before turning pt. 19. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day. 20. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day. 21. Artificial Tear with Lanolin Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Discharge Disposition: Extended Care Facility: [**Location (un) 511**] Sianai at [**Hospital 1263**] Hospital Discharge Diagnosis: Acquired Immunodeficiency Syndrome Progressive Multifocal Leukoencephalopathy Hypotension Anemia Sinus Tachycardia Pneumonia Discharge Condition: Fair. Pt has persistent tachycardia, which is chronic. . Discharge Instructions: You were admitted to the hospital for concern about low blood pressures, fevers, and infection. Your blood pressure responded to fluid, and you were started on antibiotics for a presumed infection. While you intially had a few fevers, these did not recur after [**8-9**]. Cultures of your blood, sputum, and urine showed no evidence of infection or bacteria by [**2137-8-10**]. Also, your red blood cell count was low, but stable, during this admission. If your clinical status deteriorates, your mother should consult your PCP about whether [**Name Initial (PRE) **] transfer to the hospital would be appropriate. Followup Instructions: Please follow-up with your PCP as necessary. Completed by:[**2137-8-30**]

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icd9cm

[ [ [] ] ]

[ "38.93", "00.14", "96.6" ]

icd9pcs

[ [ [] ] ]

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19515

Discharge summary

report

Admission Date: [**2148-5-29**] Discharge Date: [**2148-6-27**] Date of Birth: [**2103-7-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: ESLD secondary to Hepatitis C/ETOH cirrhosis and small hepatoma with h/o radiofrequency ablation. Major Surgical or Invasive Procedure: Orthotopic liver transplant [**2148-5-30**] Revision of portal vein [**2148-6-15**] portal vein stenting [**2148-6-17**] Transjugular liver biopsy [**2148-6-25**] History of Present Illness: Felt well, no fevers, chills, nausea/vomiting, diarrhea. Denies chest pain Past Medical History: 1. Cirrhosis (Hep C/etOH) 2. hepatoma -s/p ablation now on transplant list/evaluation 3. Esophageal varices 4. s/p femur/tibia/fib fx 5. h/o polysubstance abuse Social History: 44 yo man, currently unemployed who lives with girlfriend. h/o alcohol use remission for 5 years tobacco-1ppd X22 yrs h/o cocaine, heroine, amphetamine abuse - none since [**2138**] Family History: mother died of MI at 65 yo Physical Exam: 97.5-67-20 144/64, 99% gen: NAD Neck: supples, no lad Heent: eomi, perrla, Cor:RRR, no MRG Chest; CTA B ABD: s/nt/nd ext: no c/c/e skin: no lesions, no ulcers labs: ast 339, alt 317, alk phos 116, t.bili 1.8, Hct 38.3, creat 0.7 Brief Hospital Course: Taken to OR [**2148-5-30**] for OLT. See operative report. Induction immunosuppression (Simulect 20mg, solumedrol 500mg, cellcept 1g) was administered. He was admitted to the SICU intubated. He was coagulopathic. This was corrected with FFP, plts and 4 units of PRBC for hct of 26.7. Post op duplex demonstrated small clot in left portal vein. IV Heparin was started. He was extubated on POD 1. Solumedrol taper was initiated on a daily basis. On POD 2, a tube cholangiogram demonstrated "Successful tube cholangiogram demonstrating normal filling of the common bile duct and bilateral the intrahepatic bile ducts." U/S demonstrated no perihepatic fluid. The main, left portal, and anterior and posterior right portal branches showed normal color Doppler flow and waveform. The right, middle and hepatic veins appeared patent. The arterial waveforms in the right and left hepatic arteries appeared essentially unchanged, although the resistive indices were not fully assessed on that "limited examination." A CTA was obtained. This demonstrated "A small right pleural effusion is present. Bibasilar atelectasis is also noted. Two perihepatic drains are present. A biliary drainage catheter is also in place. The liver contains several cysts versus hemangiomas. Periportal edema is present. The hepatic artery, hepatic veins, and portal veins are patent. No left portal vein thrombosis is seen. There is a small amount of perihepatic fluid. The pancreas, adrenal glands, and kidneys are unremarkable. Splenomegaly is present, with the spleen measuring up to 14.9 cm in the craniocaudal dimension. There is no abnormal bowel wall thickening or bowel loop dilatation. There are multiple small celiac and paraaortic nodes that do not meet the strict criteria for pathologic enlargement." He was transferred to the transplant unit where diet was advanced and immunosuppresion consisted of tapering solumedrol, cellcept, and prograf. Hparin IV continued. BP was 170's/110. Lopressor was started with improvement of bp. Glucoses were elevated. [**Last Name (un) **] was consulted. Sliding scale and glargine insulin were given with improvement of glucose control. On POD 4,he received IV simulect once. A t-tube cholangiogram was done on [**6-4**] as lfts were slightly increased (ast 360, alt 442, alk phos 112, t.bili 3.9). This demonstrated normal filling of the common bile duct and bilateral the intrahepatic bile ducts. Lfts continued to increase. Repeat cholangiogram on [**6-4**] revealed "minimal intrahepatic biliary ductal dilatation. Mild narrowing of the common bile duct at the T-tube insertion site. No high-grade stricture or anastomotic leak." T tube was capped on POD 5. Platelets decreased to 62. HIT antibody was negative. Platelets returned to [**Location 213**] at end of discharge. POD 6, lasix was increased for persistent fluid overload. This improved daily with decreased weight and edema. A this time he developed diarrhea and abdominal discomfort. Cellcept was decreased. Stool was positive for c.diff and flagyl was started. Them edial jp was removed on pod 7. The lateral jp was removed on pod 8. Diarrhea decreased. LFTs improved although, alk phos was persistently elevated at 192. Alk phos increased to 392 on POD 9. The T-tube was opened. On [**6-9**], a repeat cholangiogram was done. This demonstrated "Minimal intrahepatic biliary ductal dilatation. Mild narrowing of the common bile duct at the T-tube insertion site. " No leak was noted. Solumedrol 500mg was administered on [**6-11**], but liver biopsy was indeterminant for rejection. Solumedrol was discontinued. Obstruction was suspected. On ERCP on [**6-13**] demonstrated normal papilla, no stricture. There was slight narrowing and irregularity of the mid-duct at the site of the anastomosis with apparent T-tube site. Ballon inflated to 6-7 mm pulled through without [**Doctor First Name **] resistance. Free flow was observed into the ducts. On [**6-13**], a liver biopsy under u/s was performed for elevated lfts. This was negative for rejection. HCV viral load was >700,000. LFts decreased slightly. On [**6-17**] " 1) Percutaneous transhepatic portal venography was performed, revealing a tight stricture at the portal venous anastomosis. 2) Successful placement of a 14-mm diameter x 6-cm long Cordis nitinol Smart stent across the portal venous anastomotic stricture, followed by dilation of the anastomotic stricture using a 12-mm balloon with good angiographic success and reduction in the portal venous pressure gradient from 6 mmHg to 2 mmHg." He was started on aspirin and plavix. " LFTs trended down slowly. Repeat duplex on [**6-20**] and [**6-22**] demonstrated normal findings. A transjugular liver biopsy was done on [**6-25**] as he was on aspirin and plavix. Preliminary results revealed evidence of recurrent Hep C and no rejection. Hepatology was consulted. He will follow up in one week at which time, treatment of Hep C will be determined. He was discharged home on prograf, cellcept, and prednisone. He will complete a 2 week course of po vanco for persistent GI upset an diarrhea despite 3 negative stools for c.diff and adjustment of cellcept. Protonix was increased to [**Hospital1 **]. He will be followed by VNA for medication and insulin management as well as the t. tube that was left to gravity drainage. He was able to empty and record output. Creatinine trended up. Lasix was discontinued on day of discharge as his weight decreased 17kg and bun was elevated. Vital signs were stable, he was ambulatory and tolerating a regular diet. Labs on discharge were as follows: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2148-6-27**] 06:12AM 6.7 3.64* 12.3* 35.6* 98 33.8* 34.5 17.4* 128* BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2148-6-27**] 06:12AM 128* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2148-6-27**] 06:12AM 96 54* 2.1* 138 4.9 108 18* 17 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2148-6-27**] 06:12AM 350* 102* 557* 1.8* CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2148-6-27**] 06:12AM 4.0 TOXICOLOGY, SERUM AND OTHER DRUGS FK506 [**2148-6-27**] 06:12AM 12.11 1 TARGET 12-HR TROUGH (EARLY POST-TX): [**5-31**] [24-HR TROUGH 33-50% LOWER Medications on Admission: nadolol 60mg qd, lactulose 30ml [**Hospital1 **], carafate 1 qid Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*42 Tablet(s)* Refills:*0* 3. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale instructions Injection every six (6) hours. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Prednisone 20 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. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 9. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD (). 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Orthotopic liver transplant [**2148-5-30**] Hepatitis C cirrhosis Hepatocellular carcinoma s/p radio frequency ablation h/o etoh/substance abuse PUD Steroid induced DM, insulin requiring portal vein stenosis, s/p stenting recurrent Hepatitis C C.diff,rx'd with flagyl/vanco Discharge Condition: stable Discharge Instructions: Call if fevers, chills, nausea, vomiting, inability to take medications, jaundice, bleeding from incision, redness of incision, increased diarrhea, abdominal pain. Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk phos, t.bili, albumin and trough prograf level. Results to be fax'd to transplant office [**Telephone/Fax (1) 697**] No driving while taking pain medication [**Month (only) 116**] shower Empty bile (PTC)drain when [**1-14**] full. record amount/color. Bring Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-4**] 10:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-11**] 10:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-7-18**] 11:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2148-6-27**]

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icd9cm

[ [ [] ] ]

[ "00.93", "88.47", "50.4", "39.50", "39.90", "99.07", "51.10", "96.41", "50.59", "88.64", "87.54", "99.05", "99.04", "38.93", "50.11" ]

icd9pcs

[ [ [] ] ]

9155, 9213

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9531, 9539

10070, 10824

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64,101

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41815

Discharge summary

report

Admission Date: [**2131-9-21**] Discharge Date: [**2131-10-2**] Date of Birth: [**2074-12-18**] Sex: F Service: MEDICINE Allergies: Iodine / Sulfa (Sulfonamide Antibiotics) / vancomycin Attending:[**First Name3 (LF) 2782**] Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: Intubation with mechanical ventilation History of Present Illness: Ms. [**Known lastname 6105**] is a 56 year-old woman with developmental delay, diabetes, asthma, Crohn's disease on prednisone, latent TB on INH and hepatitis B on lamivudine with recent MRSA bacteremia initially on vancomycin and transitioned recently transitioned to daptomycin secondary to drug rash who presented today after being found unresponsive at her facility with a blood sugar of 40s. Of note 2 days prior to admission, her oral hypoglycemics including Actos and glipizide were doubled. . Initial vital signs in the ED were 97.5 100 97/64 18 100% BG 43. She received glucagon and 1 amp of D50 and repeat BG was 80. She then ate dinner and repeat BG was 78. Prior to transfer the patient was started on D5 1/2 NS at 125mL/hr. Vitals on transfer were 98.0 84 14 100/49 14 98% on RA. . On the medical floor the patient appear comfortable and was without additional complaint. . ROS: Denied 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: Crohns Disease, newly diagnosed, on prednisone Asthma - never been intubated glaucoma DM2 - not on insulin Barretts Esophagus Systolic murmur ? s/p cholecystectomy s/p jaw surgery Social History: Pt has cognitive delay; she lives alone and attends an adult day program at Triangle Day Care (Telephone: [**Telephone/Fax (1) 90811**]) in [**Location (un) 3786**] 5 days a week. Her case manager from Nexus Inc, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28003**] (office [**Telephone/Fax (1) 90812**], cell [**Telephone/Fax (1) 90813**]) has known her for >20 years and is her HCP. Pt reportedly can shop and cook for herself, but [**First Name8 (NamePattern2) **] [**Doctor First Name **], the agency that [**Doctor First Name **] works for will often step in and help with cooking. Even when they help her cook, she winds up eating out -- mostly tuna subs, macaroni, and donuts. She has a boyfriend of 11 years who is also developmentally delayed, and she is very close to him. Family History: Her father died of heart disease around age 60; her mother was reportedly an alcoholic and is still alive, but they have not been in touch since Ms. [**Known lastname 6105**] was very young. She has many siblings (5 or 6), and at least 3 of them are also developmentally delayed / special needs. Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals: 98.3 87 70 14 100% on RA GENERAL: Comfortable in NAD, answers questions appropriately HEENT: Pupils equal, round, reactive to light. Extraocular muscles intact. Sclerae are anicteric. Mucous membranes moist. Oropharynx is clear. No oral ulcers. NECK: No lymphadenopathy. LUNGS: Clear to auscultation bilaterally. No wheezing or rhonchi noted. CARDIOVASCULAR: Regular rate, [**4-4**] holosystolic murmur, loudest at left upper sternal border. Normal S1, S2. ABDOMEN: Soft, nontender, nondistended, active bowel sounds. EXTREMITIES: Warm and well perfused. SKIN: Diffuse morbilliform rash, most prominent on the posterior aspect of her arms bilaterally. Consistently blanchable. Mild edema in lower extremities. No ulcers appreciated. PHYSICAL EXAM ON DISCHARGE: Unchanged from prior, except with mild degree of bilateral diffuse wheezing Pertinent Results: ADMISSION LABS: [**2131-9-21**] 12:55AM WBC-14.8* RBC-3.32* HGB-9.4* HCT-28.7* MCV-87 MCH-28.2 MCHC-32.6 RDW-17.6* [**2131-9-21**] 12:55AM NEUTS-84.3* LYMPHS-10.3* MONOS-2.2 EOS-2.8 BASOS-0.3 [**2131-9-21**] 12:55AM PLT COUNT-419 [**2131-9-21**] 12:55AM GLUCOSE-61* UREA N-55* CREAT-1.8*# SODIUM-136 POTASSIUM-5.8* CHLORIDE-106 TOTAL CO2-22 ANION GAP-14 [**2131-9-21**] 12:55AM ALT(SGPT)-12 AST(SGOT)-14 CK(CPK)-22* ALK PHOS-68 TOT BILI-0.1 [**2131-9-21**] 12:55AM LIPASE-33 [**2131-9-21**] 12:55AM CORTISOL-8.3 . PERTINENT LABS: [**2131-9-21**] 12:55AM BLOOD Glucose-61* UreaN-55* Creat-1.8*# [**2131-9-28**] 07:00AM BLOOD Glucose-171* UreaN-26* Creat-1.1 [**2131-9-24**] 01:46AM BLOOD CK-MB-26* MB Indx-4.2 cTropnT-0.05* proBNP-[**Numeric Identifier 37727**]* [**2131-9-27**] 03:13AM BLOOD proBNP-7626* [**2131-9-23**] 03:25PM BLOOD Type-ART pO2-62* pCO2-35 pH-7.33* calTCO2-19* Base XS--6 [**2131-9-26**] 11:43AM BLOOD Type-ART Temp-36.7 Rates-/15 FiO2-50 pO2-84* pCO2-35 pH-7.41 calTCO2-23 Base XS--1 Intubat-NOT INTUBA Comment-OPEN FACE [**2131-9-23**] 03:25PM BLOOD Lactate-2.6* [**2131-9-24**] 04:36AM BLOOD Lactate-1.3 . . DISCHARGE LABS: [**2131-10-2**] 06:35AM BLOOD WBC-13.1* RBC-2.99* Hgb-8.7* Hct-27.3* MCV-91 MCH-29.0 MCHC-31.7 RDW-17.7* Plt Ct-289 [**2131-10-2**] 06:35AM BLOOD Plt Ct-289 [**2131-10-1**] 06:35AM BLOOD Glucose-96 UreaN-21* Creat-0.7 Na-144 K-4.3 Cl-110* HCO3-23 AnGap-15 [**2131-10-1**] 06:35AM BLOOD ALT-72* AST-32 LD(LDH)-332* AlkPhos-118* TotBili-0.3 [**2131-10-1**] 06:35AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.7 . . MICROBIOLOGY: [**2131-9-23**] 12:33 am URINE Source: CVS. **FINAL REPORT [**2131-9-26**]** URINE CULTURE (Final [**2131-9-26**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | KLEBSIELLA PNEUMONIAE | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S <=16 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . [**2131-9-24**] 3:06 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. GRAM STAIN (Final [**2131-9-24**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2131-9-26**]): NO GROWTH, <1000 CFU/ml. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2131-9-25**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2131-9-25**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [**2131-9-24**] 3:06 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE. **FINAL REPORT [**2131-9-27**]** Respiratory Viral Culture (Final [**2131-9-27**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2131-9-25**]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing. Interpret all negative results from this specimen with caution. Negative results should not be used to discontinue precautions. Refer to respiratory viral culture results. Recommend new sample be submitted for confirmation. Reported to and read back by DR [**Last Name (STitle) 90814**] [**Name (STitle) **] [**2131-9-25**] 11:33AM. [**2131-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2131-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2131-9-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL NEGATIVE [**2131-9-24**] CATHETER TIP-IV WOUND CULTURE-FINAL NEGATIVE [**2131-9-24**] URINE Legionella Urinary Antigen -FINAL NEGATIVE [**2131-9-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [**2131-9-24**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2131-9-23**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [**2131-9-21**] URINE URINE CULTURE-FINAL NEGATIVE [**2131-9-21**] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2131-9-27**]): No Cytomegalovirus (CMV) isolated. REFER TO VIRAL CULTURE FOR FURTHER INFORMATION. VIRAL CULTURE (Final [**2131-9-27**]): RHINOVIRUS. PRESUMPTIVE IDENTIFICATION. Reported to and read back by DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 28089**] [**2131-9-27**] 11:20 AM. . DIAGNOSTICS =========== PA/LAT CXR [**2131-10-1**] AP and lateral radiographs of the chest were reviewed in comparison to [**2131-9-27**] as well as several prior studies dating back to [**2131-7-23**]. As compared to the most recent prior radiograph from [**9-27**] and [**2131-9-26**], there is significant improvement in widespread parenchymal opacities with the current study representing mild interstitial pulmonary edema. There is small focal opacity in the left upper lung and left lower lobe which might reflect partial resolution of the infectious process. Hilar enlargement is bilateral, unchanged and might potentially correspond to hilar lymphadenopathy, although pulmonary enlargement might be another possibility. There is no appreciable pleural effusion, and there is no pneumothorax. . Portable TTE (Complete) Done [**2131-9-24**] at 3:06:14 PM IMPRESSION: Moderate aortic valve stenosis. Pulmonary artery hypertension. Right ventricular cavity enlargement with free wall hypokinesis. Normal left ventricular cavity sizes with preserved global systolic function. Increased PCWP. Compared with the prior study (images reviewed) of [**2131-8-17**], the severity of aortic stenosis has progressed, right ventricular cavity size is now dilated with free wall hypokinesis and the estimated PA systolic pressure is much higher. The severity of mitral regurgitation seems reduced. These findings are suggestive of an interim acute pulmonary process, e.g., pulmonary embolism or other acute pulmonary process.. . Brief Hospital Course: A/P: 56 year old woman with a history of cognitive delay, DMII, recently diagnosed Crohn's disease on prednisone, probable latent TB on INH, MRSA bacteremia from PICC on daptomycin (last dose [**2131-9-24**]), who was admitted with hypoglycemia related to an increase in her antihypoglycemic medications, with course complicated by viral pneumonia and respiratory distress, now resolved. . ACTIVE ISSUES: . # Hypoglycemia: Her presentation was related to aggressive increase in oral hypoglycemics, after her hypoglycemic medication dosages had been recently increased. She was treated with D50 IV and her anti-hypoglycemics were held, glucose normalized and her mental status returned to baseline. She was maintained on a sliding scale insulin while in hospital. She was discharged on antihypoglycemic regimen from prior to medication increases prior to admission. We recommend continued monitoring of her finger glucose and gradually increase glipizide or pioglitazone as needed. . # Viral Pneumonia: On [**2131-9-23**], the patient was triggered for tachypnea and increased work of breathing. Her CXR was concerning for HCAP as well as vascular congestion. Patient received 20mg of IV lasix as well as nebs. Antibiotics broadened to cefepime, but had persistent tachypnea, with CXR demonstrating worsening bilateral infiltrates. Again received nebs, Lasix 20mg IV (last dose at MN) with UOP 1L. She continued to have worsening respiratory function and was transferred to the MICU in obvious respiratory distress with accessory muscle use and audible grunting. The decision was made to electively intubate with anesthesia/respiratory at bedside. During intubation patient paralyzed with succ with initial transient hypotension to the 70s. Uncomplicated intubation performed and patient sedated with propofol and fentanyl. The cause of her respiratory decompensation was probably multifactorial. Her antibiotics were broadened to linezolid/cefepime/levofloxacin for possible multifocal pneumonia. Given CXR evidence of bilateral pulmonary edema, cardiogenic source was suspected and she was diuresed. TTE revealed normal left ventricular function but right ventricular overload thought to be related to her acute pneumonic process. She underwent bronchoscopy on [**2131-9-24**] which revealed +yeast, +PMN, and +rhinovirus, but no PCP or bacteria. Her rhinovirus may have contributed to her diffuse inflammatory process. PCP was [**Name Initial (PRE) **] concern due to her unprophylaxed chronic steroid load of 30mg prednisone daily, and indeed a beta glucan was positive, though this was felt to represent her candidida from her lung. Her linezolid and cefepime were discontinued, and she was continued on levofloxacin 8d course for possible bacterial suprainfection. She was successfully extubated on [**9-26**] and transferred to the medicine service on [**9-27**], where she completed levofloxacin course, oxygen staturation remained in the upper 90's on room air, she ambulated the [**Doctor Last Name **] without dyspnea. She was discharged with dextromethorphan-guaifenesin as needed for cough. . # Acute kidney injury: Baseline creatinine 0.7, she was admitted with creatinine 1.8 related to dehydration. Lisinopril was held, she was treated with intervenous fluids and her creatinine improved. Lisinopril was resumed. . # Rash: Diffuse livido reticularis appearing rash. She was seen by dermatology and it was felt to be a reaction to her vancomycin, and she was switched to daptomycin and started on topical triamcinolone and hydrocortisone and the rash improved. . # Urinary Tract Infection: Her urine culture revealed pan-sensitive E. coli and Klebsiella, which was treated with her levofloxacin regimen she took for possible bacterial suprainfection of her viral pneumonia. . # MRSA bacteremia: High-grade bacteremia believed to be [**1-31**] to prior PICC now removed or endocarditis for which she was to complete a 6 weeks of vancomycin on [**2131-9-24**]. She was switched to daptomycin on [**9-17**] following the onset of a new rash that was believed to be vancomycin-related, and completed daptomycin course on [**9-24**]. . # Leukocytosis: Throughout hospital course, WBC ranged 9-19, the day prior to discharge, WBC had trended up to 15 from 13. She was kept an additional night and a basic infectious workup was performed. Chest xray looked improved, UA was negative, and blood cultures showed no growth in 24 hours. The following morning ([**2131-10-2**]), WBC trended to 13, she was clinically well appearing and was discharged. Leukocyutosis is likely related to prednisone. # Crohns disease: Increased prednisone to 40mg, and have since resumed home 30mg dose. Started on atovaquone for PCP [**Name Initial (PRE) 1102**]. . # TB treatment: Prior to admission, patient had indeterminant QuantiFERON Gold test.Patient was continued on treatment for LTBI with isoniazid/B6 Day #1 = [**2131-8-16**] for 9 months. These medicaitons should be discontinued after the 9 month course is complete. . # Depression: Held home sertraline while on linezolid to prevent serotonin syndrome. She became progressively anxious and tearful. Resumed sertraline 250mg after confirming dose with health care proxy and [**Name2 (NI) **] improved. No signs of serotonin syndrome. . # Hepatitis B: Patient is Hep B surface antigen positive. Continued home dose lamivudine 100 mg daily. . # Hypertension: Held lisinopril briefly due to [**Last Name (un) **]. Lisinopril was resumed prior to discharge with adequate control. . # Asthma: Continued home fluticasone-salmeterol and started on albuterol nebulizers. . # Glaucoma: Continued home Latanoprost . . TRANSITIONAL ISSUES: -routine follow-up with GI for Crohn's, infliximab treatment -titration of her diabetes regimen with careful monitoring of her blood glucose level -follow-up with hepatology - Follow up blood cultures [**2131-10-1**] which had shown no growth in 24 hours at the time of d/c - Follow up acid fast culture from BAL [**2131-9-24**] Medications on Admission: Isoniazid 300 mg daily Day #1 = [**2131-8-16**] for 9 months Pyridoxine 50 mg daily Day #1 = [**2131-8-16**] for 9 months Omeprazole 20 mg daily Lamivudine 100 mg daily Day #1 = [**2131-8-14**] Sertraline 250 mg daily Daptomycin for MRSA bacteremia Day 1 = [**2131-8-12**] to be complete [**2131-9-22**] Lisinopril 10 mg daily Fluticasone-salmeterol 100-50 mcg 1 puff [**Hospital1 **] Latanoprost 0.005 % OU HS Metformin 1000 mg [**Hospital1 **] Metoprolol succinate ER 75 mg daily Januvia 100 mg daily Pioglitazone 30 mg Glipizide 10 mg daily Prednisone 30 mg dialy Pancrealipiase TID Zyrtec 10 mg daily Trazodone 50 mg QHS Discharge Medications: 1. isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for 9 months, day 1 [**2131-8-16**]. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. sertraline 50 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily): total dose 250mg. 4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. latanoprost 0.005 % Drops Sig: One (1) Drop(s) in each eye Ophthalmic HS (at bedtime). 6. prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): total dose 30mg daily. 7. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Day #1 = [**2131-8-14**]. 11. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg daily PO DAILY (Daily): For PCP [**Name Initial (PRE) 1102**]. Disp:*250 mL* Refills:*2* 12. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: [**5-8**] MLs PO Q4H (every 4 hours) as needed for cough. Disp:*250 mL* Refills:*0* 13. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 16. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day. 17. Metoprolol succinate ER 75 mg daily 18. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). 19. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day: Day #1 = [**2131-8-16**] for 9 months . Discharge Disposition: Extended Care Facility: Able Home Care Discharge Diagnosis: PRIMARY DIAGNOSIS: Iatrogenic Hypoglycemia SECONDARY DIAGNOSES: Pneumonia Urinary Tract Infection Acute Kidney Injury Dehydration Drug Rash Depression Discharge Condition: Mental Status: Coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 6105**], You were admitted for treatment of low blood sugars, dehydration and renal failure. You were treated with glucose infusions and given fluids, and your condition improved. You were also seen by our dermatologists who thought your rash might be due to medication allergy to vancomycin, we treated you symptomatically with creams and benadryl and your symptoms improved. While in the hospital you had trouble breathing and had to be placed on a ventilator. We determined that you had pneumonia, we treated you with antibiotics and you improved. . While in the hospital you completed a 6 week course of antibiotics for MRSA infection. Please follow up with infectious disease for your MRSA infection, we have made an appointment for you. . Please also keep your appointment for gastroenterology follow up of your chron's disease. The following changes were made to your medications: - START Atovaquone - START Albuterol inhaled as needed for wheezing - START dextromethorphan-guaifenesin as needed for cough . - STOP Daptomycin . Please continue the rest of your medications without change. Followup Instructions: Please follow-up with your PCP at extended care facility . Please call ([**Telephone/Fax (1) 8132**] on Monday morning for follow-up appointment with [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] within one week of your discharge. . Please call([**Telephone/Fax (1) 4170**] on Monday morning for follow-up appointment with [**Last Name (LF) **], [**Name8 (MD) **] MD within one week of your discharge. . Please also keep the following appointments: . Department: LIVER CENTER When: WEDNESDAY [**2131-10-3**] at 10:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFUSION/PHERESIS UNIT When: WEDNESDAY [**2131-10-3**] at 2:00 PM [**Telephone/Fax (1) 14067**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: INFECTIOUS DISEASE When: WEDNESDAY [**2131-10-17**] at 10:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Doctor Last Name **],PINKY Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Apartment Address(1) 90815**], [**Location (un) **],[**Numeric Identifier 90816**] Phone: [**Telephone/Fax (1) 60787**] ****Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2131-10-24**] at 3:00 PM With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], 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

[ "795.52", "250.80", "285.9", "365.9", "401.9", "480.9", "783.40", "070.30", "790.7", "E932.3", "518.81", "599.0", "E930.8", "041.49", "041.3", "041.12", "584.9", "493.92", "E849.7", "276.51", "311", "693.0", "555.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "38.97", "38.91", "33.24" ]

icd9pcs

[ [ [] ] ]

19386, 19427

10905, 11295

328, 369

19622, 19622

3783, 3783

20945, 23098

2575, 2873

17600, 19363

19448, 19448

16951, 17577

19794, 20922

4945, 6984

2888, 2902

19513, 19601

7165, 10882

7020, 7131

3687, 3764

16595, 16925

276, 290

11310, 16574

397, 1536

3799, 4312

19467, 19492

2916, 3659

19637, 19770

4328, 4929

1558, 1739

1755, 2559

78,441

157,309

13000

Discharge summary

report

Admission Date: [**2174-3-22**] Discharge Date: [**2174-3-30**] Date of Birth: [**2091-5-2**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3256**] Chief Complaint: BRBPR, c diff colitis Major Surgical or Invasive Procedure: None History of Present Illness: Briefly, pt is a pleasant 82 yo male with a hx of CAD s/p MI in [**1-/2174**], CABG [**2151**], CHF, DM, HTN, atrial fibrillation on coumadin, who originally presented to [**Hospital3 417**] Medical Center on [**2174-3-12**] with diarrhea for 2 weeks, subsequently confirmed to be C diff. Hospital course was complicated by a GI bleed requiring 14 units of PRBC's, 4 units of FFP and one unit of platelets with eventual location fo the bleed to the LUQ in the colon at the splenic flexure. Pt was transferred to [**Hospital1 18**] for consideration of arterial embolization after refusing surgery. Once at [**Hospital1 18**], pt refused any further procedures and was transitioned to CMO. Past Medical History: - Atrial fibrillation on coumadin - Coronary artery disease with CABG [**2151**], MI in [**2173**] - HLD - DM - HTN - sCHF EF 45% - BPH Social History: -Tobacco history: Quit 40 years ago -ETOH: none -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Family history of non-specific cancers. Physical Exam: Physical Exam: Vitals: T: 98.8 BP: 112/67 P: 65 R: 18 O2: 96% ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Irregular irregular, 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: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: Labs on admission: [**2174-3-22**] 09:36PM BLOOD WBC-9.6# RBC-3.81* Hgb-11.1* Hct-33.0* MCV-86 MCH-29.2 MCHC-33.7 RDW-14.9 Plt Ct-125* [**2174-3-22**] 09:36PM BLOOD PT-18.0* PTT-29.9 INR(PT)-1.7* [**2174-3-22**] 09:36PM BLOOD Glucose-116* UreaN-127* Creat-3.0*# Na-146* K-3.9 Cl-116* HCO3-18* AnGap-16 [**2174-3-22**] 09:36PM BLOOD ALT-16 AST-21 LD(LDH)-181 AlkPhos-64 TotBili-0.6 [**2174-3-22**] 09:36PM BLOOD Albumin-2.8* Calcium-7.3* Phos-5.0*# Mg-1.8 [**2174-3-22**] 09:40PM BLOOD Type-ART pO2-40* pCO2-32* pH-7.37 calTCO2-19* Base XS--5 [**2174-3-22**] 09:40PM BLOOD Lactate-0.7 [**2174-3-22**] 09:37PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2174-3-22**] 09:37PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2174-3-22**] 09:37PM URINE RBC-3* WBC-2 Bacteri-FEW Yeast-NONE Epi-<1 [**2174-3-22**] 09:38PM URINE Hours-RANDOM UreaN-508 Creat-25 Na-84 K-14 Cl-85 [**2174-3-22**] 09:38PM URINE Osmolal-401 [**2174-3-22**] 9:30 pm BLOOD CULTURE Source: Line-cvl. **FINAL REPORT [**2174-3-28**]** Blood Culture, Routine (Final [**2174-3-28**]): NO GROWTH [**2174-3-22**] 9:37 pm URINE Source: Catheter. **FINAL REPORT [**2174-3-23**]** URINE CULTURE (Final [**2174-3-23**]): NO GROWTH. Labs on discharge: None CXR [**3-22**]: There is mild cardiomegaly. Right IJ catheter tip is in the upper SVC. There is no pneumothorax. Left pleural effusion is small with adjacent atelectasis Brief Hospital Course: Briefly, pt is a pleasant 82 yo male with a hx of CAD s/p MI in [**1-/2174**], CABG [**2151**], CHF, DM, HTN, atrial fibrillation on coumadin, who originally presented to [**Hospital3 417**] Medical Center on [**2174-3-12**] with diarrhea for 2 weeks, subsequently confirmed to be C diff on po vanc and IV flagyl, with hospital course complicated by GI bleed requiring 14 units of PRBC's, who refused further GI intervention, transitioned on [**3-25**] to CMO. # GI Bleed: The patient was initially brought to the ICU for melena in the setting of a supratherapeutic INR. He required many blood transfusions, and interventional radiology recommended a tagged red blood cell scan to identify the source of bleeding. Unfortunately, the amount of IV contrast that this would require would likely result in worsening renal failure and the need for dialysis, which the patient noted he would not want. With his family present, he elected to decline further interventions and work up of the bleeding, and the goals of his care were changed to comfort-oriented care. We continued to treat his c diff in an attempt to prevent uncomfortable symptoms from the infection with po vacn q6h. Pt did not endorse any abdominal pain or nausea and did not require any medications on the medical floor. After discussion with the family on [**3-29**], pt wished to remain CMO, but was restarted on torsemide 100 mg daily for symptomatic respiratory distress. Transitional Issues: -After disucssion with the family, pt was DNR/DNI. -Pt is amenable to re-hospitalization for non-invasive treatments. Medications on Admission: Lipitor 80 mg daily ASA 81 mg po qday Isosorbide 30 mg daily torsemide 100 mg po qday metolazone 5 mg 2 days a week warfarin 3 mg qday lisinopril 5 mg po qday metoprolol 25 mg qday glipizide 5 mg qday iron supplements 350 [**Hospital1 **] MV and Vitamin C (250 mg) qday Discharge Medications: 1. vancomycin 250 mg/2.5 mL Syringe Sig: Five Hundred (500) mg PO Q6H (every 6 hours) for 7 days. Disp:*[**Numeric Identifier 4731**] mg* Refills:*0* 2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Disp:*21 Tablet(s)* Refills:*0* 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) **] of [**Location (un) 701**] Discharge Diagnosis: Primary: Lower Gastrointestinal Bleed Clostridium difficile diarrhea Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], It was sincere pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were transferred for continued treatment of your gastrointestinal bleed and diarrhea. After much discussion with the medical team, you and your family decided to stop [**Hospital 17073**] medical care and pursue comfort care only. You should continue to take antibiotics for your diarrhea, as well as torsemide to prevent fluid from accumulating in your body. PLEASE NOTE THE FOLLOWING MEDICATIONS: CONTINUE METRONIDAZOLE 500 MG THREE TIMES A DAY FOR THE NEXT SEVEN DAYS CONTINUE VANCOMYCIN 500 MG FOUR TIMES A DAY FOR THE NEXT SEVEN DAYS CONTINUE PANTOPRAZOLE 40 MG TWICE A DAY CONTINUE TORSEMIDE 100 MG DAILY Followup Instructions: None

[ "V58.61", "272.4", "276.0", "008.45", "276.2", "578.1", "600.00", "V45.81", "250.00", "585.9", "403.90", "V15.82", "414.00", "428.0", "V66.7", "428.22", "V49.86", "584.5", "285.1", "427.31" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6174, 6248

3749, 5192

325, 332

6361, 6361

2170, 2175

7322, 7330

1316, 1474

5655, 6151

6269, 6340

5360, 5632

6548, 7299

1504, 2151

5214, 5334

264, 287

3545, 3726

361, 1055

2190, 3526

6376, 6524

1077, 1214

1230, 1300

47,818

197,407

36341+58075

Discharge summary

report+addendum

Admission Date: [**2198-4-23**] Discharge Date: [**2198-4-28**] Date of Birth: [**2135-9-9**] Sex: M Service: UROLOGY Allergies: Niacin Attending:[**First Name3 (LF) 11304**] Chief Complaint: Left renal mass Major Surgical or Invasive Procedure: Left debulking nephrectomy History of Present Illness: 62M w/ metastatic L renal neoplasm and L renal vein and IVC thrombus to lower edge of liver, now s/p L debulking nephrectomy and IVC thrombectomy by Dr. [**Last Name (STitle) 3748**] (with Dr.[**Name (NI) 670**] assistance for IVC mobilization and thrombectomy). No complications. IVF 4000cc, EBL 2500cc; 4U PRBC. Past Medical History: dyslipidemia; mild asthma; metastatic renal cell carcinoma Social History: 3 drinks/week; denies tob/IVDA; retired Air Force Pertinent Results: [**2198-4-27**] 07:40AM BLOOD WBC-5.3 RBC-3.01* Hgb-8.3* Hct-25.1* MCV-83 MCH-27.4 MCHC-33.0 RDW-16.2* Plt Ct-384 [**2198-4-27**] 07:40AM BLOOD Glucose-99 UreaN-12 Creat-1.7* Na-137 K-3.9 Cl-105 HCO3-24 AnGap-12 Brief Hospital Course: Pt was admitted to the ICU after undergoing debulking left radical nephrectomy. He was extubated in the early AM of POD 1 and his pain was well-controlled with an epidural. He was transferred to the floor, where his post-operative course was uncomplicated. His heart rate was controlled with metoprolol, which was discontinued upon discharge. His creatinine reached a peak of 2.5, after which it decreased to baseline. With passage of flatus, his diet was advanced and he was transitioned to PO pain meds without incident. He ambulated without difficulty and was discharged on POD 5 tolerating a regular diet, ambulating, and with his pain controlled on PO pain meds. Medications on Admission: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take to prevent constipation while taking dilaudid. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Kidney cancer Discharge Condition: Stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up. -Do not drive or drink alcohol while taking narcotics. -Resume all of your home medications, except hold NSAID (aspirin, advil, motrin, ibuprofin) until you see your urologist in follow-up. -Call your Urologist's office today to schedule a follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER. Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] to set up follow-up appointment and if you have any urological questions. [**Telephone/Fax (1) 3752**] Followup Instructions: Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] to set up follow-up appointment and if you have any urological questions. [**Telephone/Fax (1) 3752**] Completed by:[**2198-4-28**] Name: [**Known lastname 13177**],[**Known firstname 63**] B. Unit No: [**Numeric Identifier 13178**] Admission Date: [**2198-4-23**] Discharge Date: [**2198-4-28**] Date of Birth: [**2135-9-9**] Sex: M Service: UROLOGY Allergies: Niacin Attending:[**First Name3 (LF) 3840**] Addendum: Pt developed transient acute renal failure during this hospitalization. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3843**] MD [**MD Number(2) 3844**] Completed by:[**2198-5-16**]

[ "401.9", "272.4", "189.0", "198.1", "198.89", "197.0", "V15.82", "493.90", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.07", "55.51", "03.90", "38.67" ]

icd9pcs

[ [ [] ] ]

4084, 4247

1061, 1736

282, 311

2483, 2492

825, 1038

3436, 4061

1956, 2396

2446, 2462

1762, 1933

2516, 3413

227, 244

339, 657

679, 739

755, 806

46,590

159,539

9338

Discharge summary

report

Admission Date: [**2101-4-7**] Discharge Date: [**2101-4-13**] Date of Birth: [**2034-10-22**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2101-4-8**] 1. Urgent coronary artery bypass graft x4; left internal mammary artery to left anterior descending artery and saphenous vein graft to posterior descending artery and saphenous vein graft sequential grafting to ramus and obtuse marginal-1. 2. Endoscopic harvesting of greater saphenous vein. [**2101-4-7**] cardiac catheterization History of Present Illness: 66 y/o female with DM, HTN, HLD s/p acute IMI [**3-/2091**] managed with thromboylysis and succesful PTCA and stenting of the distal RCA, EF 50% on most recent echo, now transferred from [**Hospital3 3583**] with increasing chest pain, occuring at rest, relieved with Ntg spray. Troponin 0.35, 2.62. EKG with anterolateral t wave inversions. Pt has been pain free on a ntg gtt at 30mcg/min. She has been referred for cardiac cath. . On cardiac cath today: serial lesions in mid and distal RCA, 70% left main, LAD moderate mid vessel disease. Referred for CT surgery/CABG. Past Medical History: - acute myocardial infarction - Diabetes mellitus, type II, times 10 years. On insulin. - coronary artery disease - Hypertension - Hypercholesterolemia - Hysterectomy/bilateral salpingo-oophorectomy six years ago for fibroids - History of diverticulitis - History of "angina". She reports a positive thallium four years ago, which was treated medically, and a repeat positive thallium with similar symptoms four months ago - An echocardiogram on [**2091-4-20**] showed an EF greater than 50%, hypokinesis inferoposteriorly and akinetic basal inferior segment, mild aortic valve sclerosis, 1+ mitral regurgitation Social History: SOCIAL HISTORY: She lives at home with her boyfriend and works as a bank teller. She previously smoked two packs a day times 15 years, but quit smoking 45 years ago. She reports very rare alcohol use. Family History: FAMILY HISTORY: Notable for very significant coronary artery disease. Her son had an MI at age 28 and coronary artery bypass graft seven weeks ago at age 35. Her father died of 42 of an MI, her paternal grandfather died at 49 of an MI, and her uncle died at 40 of an MI. Physical Exam: VS: T=afebrile, BP=172/98, HR=78, RR=16, O2 sat=92% RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB anteriorly, unable to assess posterior lungs given recent cath ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2101-4-12**] 04:00AM BLOOD WBC-9.6 RBC-3.91* Hgb-10.9* Hct-31.7* MCV-81* MCH-27.9 MCHC-34.4 RDW-15.9* Plt Ct-178# [**2101-4-11**] 01:05AM BLOOD WBC-10.4 RBC-4.02*# Hgb-11.1*# Hct-31.7*# MCV-79* MCH-27.7 MCHC-35.1* RDW-15.7* Plt Ct-102* [**2101-4-9**] 12:58AM BLOOD PT-12.5 PTT-28.0 INR(PT)-1.1 [**2101-4-8**] 05:48PM BLOOD PT-13.1 PTT-33.4 INR(PT)-1.1 [**2101-4-12**] 04:00AM BLOOD Glucose-168* UreaN-16 Creat-0.6 Na-142 K-3.7 Cl-104 HCO3-32 AnGap-10 [**2101-4-11**] 01:05AM BLOOD Glucose-215* UreaN-17 Creat-0.6 Na-138 K-3.8 Cl-104 HCO3-25 AnGap-13 CARDIAC CATH COMMENTS: 1. Selective coronary angiography of this right-dominant system revealed three-vessel and left main coronary artery disease. The LMCA had an ostial 70% with catheter damping. The LAD had diffuse proximal and mid-vessel disease up to 60%. The LCX had a proximal 50% stenosis and the very small distal vessel was occluded. OM1 had a 70% proximal stenosis. The RCA had 2 long mid-vessel stenoses to 90% and 80% respectively; the prior stent had only mild instent restenosis. A PL branch had a 70% mid-vessel stenosis. 2. Limited resting hemodynamics demonstrated severe systemic arterial hypertension with a central aortic pressure of 209/76 mmHg, with mildly elevated left ventricular filling pressures with an LVEDP of 20 mmHg. 3. Left ventriculogram demonstrated a preserved overall ejection fraction with focal hypo- to akinesis of the basal inferior wall. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Left main coronary artery disease. 3. Left ventricular diastolic dysfunction. 4. Severe systemic arterial hypertension. . ECHO [**2101-4-8**] . The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with thinning/akinesis of the inferolateral wall and hypokinesis of the basal inferior wall. The remaining segments contract normally (LVEF = 40-45 %). 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 aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. [**2101-4-8**] intra-op Pre Bypass: The left atrium is normal in size. The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The transmitral flow propagation velocity is .67 m/s (nl <=0.45m/s) The isovolumic relaxation time is 92 ms (nl 50-100ms) There is no pericardial effusion. Post Bypass: The patient is A paced on phenylepherine infusion. Slight improvement in inferolateral wall motion, LVEF 50%. No change in valve function or aortic contours. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. Brief Hospital Course: 66 y/o female with CAD s/p acute IMI [**3-/2091**] managed with thromboylysis and succesful PTCA and stenting of the distal RCA, EF 50% on most recent echo, DM, HTN, HLD, now transferred from an outside hospital with increasing chest pain, occuring at rest, relieved with Ntg spray. She ruled in for MI with Troponin 0.35, 2.62. EKG with anterolateral t wave inversions. Cardiac cath showing 3 vessel disease. The patient was brought to the operating room on [**2101-4-8**] where the patient underwent CABGx4. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU on titrated propofol, neo and insulin drips for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to rehab in good condition with appropriate follow up instructions. Medications on Admission: -aspirin 325 mg p.o. q.d. -isosorbide mononitrite 60 mg daily -simvastatin 5 mg daily -metformin 1000 mg p.o. daily -atenolol 50 mg daily -lisinopril 20 mg daily -insulin NPH 35 units qAM, 35 units qPM -multivitamin -calcium -vitamin E Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/temp. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) as needed for sore throat. 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10 days. 16. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: One (1) Subcutaneous twice a day: ** 35 units at breakfast and 35 units at bedtime**. 17. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: See attached sliding scale. Discharge Disposition: Extended Care Facility: Life Care Center - [**Location (un) 3320**] Discharge Diagnosis: coronary artery disease Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Discharge Instructions: You were admitted to the hospital for chest pain. You underwent cardiac catheterization and were noted to have three vessel disease. You were referred for cardiac surgery and underwent coronary artery bypass grafting. 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. [**Telephone/Fax (1) 170**] [**2101-5-16**], 1pm Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 8129**] in [**1-1**] weeks Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) 177**] A. [**Telephone/Fax (1) 5315**] in [**1-1**] weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2101-4-13**]

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50713

Discharge summary

report

Admission Date: [**2124-6-21**] Discharge Date: [**2124-6-30**] Date of Birth: [**2052-2-14**] Sex: F Service: MEDICINE Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending:[**First Name3 (LF) 710**] Chief Complaint: hypotension and fever Major Surgical or Invasive Procedure: PICC placement [**2124-6-29**] History of Present Illness: 72 F resident of [**Location 105502**] with multiple medical problems including DM type II, dCHF, PVD, a.fib (on coumadin), and ICU admissions for sepsis in past who was noted to be lethargic on AM of [**6-21**]. There, pt's blood pressure was 80's systolic, rectal temp 103 F, HR in 100s. [**Name6 (MD) **] [**Name8 (MD) **] MD there was no obvious source of infection and sent to ED. Pt does not recall transfer to ED. In ED, she was noted to have SBP in 90's, HR in 100's in A fib, and CXR with chronic RLL opacity. She had a temp of 103.4. She was given 4 L of fluids with heart rate in 80's and improvement in her SBP to 120's. Femerol line attempted without success in ED. UA was positive but not a clean sample. CXR showed diffuse right sided infiltrates consistent with history of fibrosis. She was given Levofloxacin 500mg IV, Vancomycin 1gram IV, Flagyl 500mg IV. She had urine output of 1 L and resolution of delta MS. Of note, pt was admitted to ICU on [**10-10**] from HebReb with similar symptoms and treated for sepsis [**3-9**] nosocomial pneumonia. She was treated with 2 weeks of vancomycin/imipenem. Currently she is complaining of right leg pain which is old, starting in stump but then radiating to phantom leg, [**7-15**] from [**2128-4-10**] baseline. She denies diarrhea, chest pain, SOB, cough, dysuria. She complains of abdominal pain worst in RUQ but only with exam. No rash. Past Medical History: PMH: 1. CHF with diastolic dysfunction- Last LVEF was 65% with a normal MIBI in 01/[**2123**]. 2. Type 2 diabetes mellitus 3. Atrial fibrillation 4. Anemia 5. CAD s/p PTCA x3- Pt had a stent to her RCA in [**2109**], LCx in [**2110**], and RCA in [**2113**]. 6. Pulmonary HTN 7. COPD/[**Name (NI) 105500**] Pt is on intermittent oxygen at home. 8. Thyroid CA s/p resection- Pt is now hypothyroid. 9. Myoclonic tremors 10. H/O PE 11. OSA on CPAP 12. Depression 13. Anxiety 14. H/O MRSA and [**Name (NI) 105501**] Pt has two past ICU admissions for MRSA aortic valve endocarditis and pseudomonal sepsis. She has had two intubations. 15. S/P laproscopic cholecystectomy [**34**]. S/P right throcoscopy and decortication 17. S/P right lung biopsy 18. S/P right hip ORIF 19. S/P right ankle ORIF 20. s/p right AKA Social History: Social: Pt lives at [**Hospital1 100**] Senior Life. Divorced and has three children. She quit smoking in [**2104**] but has a history of 1 PPD for 15 years. No ETOH or drugs. . Family History: FHx: F: died at 47 of MI; M: died colon ca; B: DM Physical Exam: PE: Tm ED 103.4 Tc 100 P80 BP 128/89 R12 95% 3L NC Gen: NAD, converstaional, A+Ox3 HEENT: PERRLA, MM very dry Neck: LVP 8 cm above LA Resp: crackles [**2-8**] way up from bases bilaterally, with wheezes left side CV: irreg, tachy, normal S1s2 no MGR Abd: TTP RUQ > LUQ, no remound or guarding. hypoactive bowel sounds Ext: cool hands and leg. left leg with venous stasis changes, 2+ DP pulse Neuro: alert, oriented. Moving extremities to command. Pertinent Results: [**2124-6-21**] CT abd/pelvis: CT OF THE ABDOMEN WITH IV CONTRAST: The visualized portions of the lung bases demonstrate small bilateral pleural effusions and interstitial opacities consistent with CHF. There is a 9-mm vague hypodensity of the left hepatic lobe, which has not significantly changed compared to [**2123-8-6**] and is too small to definitively characterize. Otherwise, the liver is unremarkable. The patient is status post cholecystectomy. The pancreas is atrophic. There is a 1.5-cm hypodense lesion at the anterior margin of the spleen which is unchanged. There is cortical thinning of the left kidney which is chronic. The right kidney and adrenal glands are unremarkable. Again seen is diastasis of the anterior abdominal wall with protrusion of transverse colon. Otherwise, the bowels are unremarkable and there is no evidence of obstruction or free intra-abdominal air. There are extensive abdominal aortic calcifications. No intra-abdominal fluid collection or abscess is identified. There is no pathologic mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter within the urinary bladder which is decompressed. The rectum, uterus, adnexa, and intrapelvic loops of bowel are unremarkable. There is no free pelvic fluid or lymphadenopathy. BONE WINDOWS: The patient is status post right hip arthroplasty. No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. Small bilateral pleural effusions and interstitial opacity of the lung bases consistent with CHF. 2. Vague 9-mm hypodensity of the left hepatic lobe is too small to be definitively characterized but unchanged from [**2123-8-6**]. 3. Atrophic pancreas. 4. Chronic left renal cortical thinning. 5. Diastasis of the abdominal wall with protrusion of transverse colon but no evidence of obstruction. 6. Extensive abdominal arterial calcifications. 7. No change in 1.5-cm hypodensity of the spleen. . [**2124-6-21**] ECG: Atrial fibrillation Modest nonspecific ST-T wave changes Since previous tracing of [**2123-10-8**], no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 92 0 70 [**Telephone/Fax (2) 105503**]2 -5 . [**2124-6-22**] CXR Pa/La: FINDINGS: There is worsening congestive failure, with increased pulmonary [**Month/Day/Year 1106**] congestion and a left pleural effusion. Right lower lobe opacity also appears somewhat more dense. Lung volumes are reduced. Osseous structures are diffusely demineralized with degenerative changes in the thoracic spine. IMPRESSION: Worsening congestive failure. Right lower lobe pneumonia. Tiny left pleural effusion. . CT chest: FINDINGS: Diffuse bilateral hazy ground-glass opacity is seen within both lungs, new since the most recent examination. Interlobular septal thickening is also present. There are new bilateral pleural effusions. Also new is a patchy opacity in the right middle lobe. Findings of traction bronchiectasis at the bases, and central and peripheral fibrosis with architectural distortion are unchanged. There are dependent secretions in the trachea. The bronchi are patent to the segmental level. Right paratracheal lymphadenopathy measuring up to 1.5 cm in short axis and other smaller mediastinal lymph nodes are unchanged. There is no pericardial effusion. Coronary calcifications are present. The heart and pericardium are otherwise stable in appearance. Patient is post-cholecystectomy. Dense arteriosclerotic calcifications are seen within the aorta and splenic artery in the upper abdomen. Density of the liver appears decreased compared to the prior study from [**2123-4-5**], and is now within normal limits. Small hiatal hernia. Degenerative changes are seen throughout the thoracic spine. IMPRESSION: 1. New bilateral effusions and diffuse ground-glass opacification with septal thickening most likely indicates congestive failure. 2. Patchy opacity in the right middle lobe probably represents a superimposed infectious process. 3. Largely unchanged appearance of architectural distortion and fibrosis in the middle and lower lobes and traction bronchiectasis most predominantly in the lower lobes. Unchanged lymphadenopathy. 4. Coronary calcifications. . CT head: FINDINGS: There is no acute intracranial hemorrhage, shift of normally midline structures, or hydrocephalus. Age-related brain atrophy is seen. Hypodensity is seen in the cerebral periventricular white matter, consistent with chronic small vessel infarction, unchanged from the prior exam. [**Doctor Last Name **]- white matter differentiation is preserved. The mastoid air cells are clear. Minimal mucosal thickening is seen within the left ethmoid air cells and the sphenoid sinus, which has developed since the prior study. Also, the nasopharyngeal soft tissues are mildly thickened, also a new finding- this requires clinical correlation. There is no sinusitis. Osseous structures and soft tissues are unremarkable. IMPRESSION: No acute intracranial hemorrhage. See above report re: nasopharyngeal finding- clinical correlation required. . [**2124-6-29**] 04:50AM BLOOD WBC-8.2 RBC-3.80* Hgb-10.3* Hct-32.2* MCV-85 MCH-27.1 MCHC-32.0 RDW-14.7 Plt Ct-233 [**2124-6-21**] 07:10AM BLOOD PT-15.0* PTT-36.6* INR(PT)-1.3* [**2124-6-29**] 11:16PM BLOOD PT-36.5* PTT-53.3* INR(PT)-4.0* [**2124-6-21**] 06:15AM BLOOD Glucose-89 UreaN-16 Creat-1.0 Na-139 K-3.5 Cl-102 HCO3-28 AnGap-13 [**2124-6-29**] 11:16PM BLOOD Glucose-112* UreaN-20 Creat-0.8 Na-135 K-3.8 Cl-95* HCO3-33* AnGap-11 [**2124-6-21**] 06:15AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 [**2124-6-29**] 11:16PM BLOOD Calcium-8.6 Phos-2.2* Mg-2.4 [**2124-6-23**] 06:58AM BLOOD TSH-0.14* [**2124-6-23**] 06:58AM BLOOD Free T4-1.2 [**2124-6-29**] 04:50AM BLOOD Digoxin-0.5* [**2124-6-26**] 12:43AM BLOOD Type-ART pO2-158* pCO2-38 pH-7.38 calHCO3-23 Base XS--1 [**2124-6-24**] 06:35PM BLOOD Type-ART pO2-288* pCO2-40 pH-7.40 calHCO3-26 Base XS-0 Intubat-NOT INTUBA Comment-NC . [**2124-6-27**] TTE MEASUREMENTS: Left Atrium - Long Axis Dimension: *5.2 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.8 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.1 cm Left Ventricle - Fractional Shortening: 0.45 (nl >= 0.29) Left Ventricle - Ejection Fraction: 70% to 80% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aorta - Arch: *3.2 cm (nl <= 3.0 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.7 m/sec TR Gradient (+ RA = PASP): *35 to 50 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Hyperdynamic LVEF. No resting LVOT gradient. No LV mass/thrombus. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Mildly dilated aortic arch. Focal calcifications in aortic arch. AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. No MS. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid valve supporting structures. Moderate to severe [3+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 70-80%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. 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. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Assesment: 72F with fever, hypotension consistent with severe sepsis and found to have RML pneumonia. . #) Sepsis/right middle lobe pneumonia: Admitted for hypotension/fever/sepsis and found to have RML pneumonia. CT abdomen was negative for intra-abdominal processes. The patient was initially empirically placed on levo/vanco, but the patient continued to have fevers. The patient blood pressure stabilized with IVF without requiring pressors and was observed in MICU overnight and transferred to the floor once hemodynamically stable. ID was [**Month/Day/Year 4221**] and the patient was switched from levo to meropenem to cover more broadly. The patient was unable to produce any adequate sputum. UA at admission was dirty, and Ucx x 2 revealed no growth. Blood cultures grew nothing to date. On meropenem, the patient defervesced and continued to stay hemodynamically stable. After 7 days of vancomycin, it was discontinued as no apparent source of gram positives. The patient is to finish 14 day course of meropenem. . #. Mental status change: Two days after transferred to the floor, the patient was transferred back to the unit for lethargy and mental status change. CT head was negative. It was thought to be secondary to oversedation from Oxycontin/oxycodone/fentanyl/neurontin. All narcotics were initially held and her mental status returned to baseline. For chronic neuropathic pain control, restarted fentanyl 25mcg and decreased neurontin dose. . #) Afibrillation- Was difficult to control due to sepsis. Metoprolol was titrated up to 50mg TID and the patient received diltiazem drip as well with HR still hovering in the 100-120s. On diltiazem gtt, the patient became hypotensive to 80s although asymptomatic. The team did not want to start amiodarone as there was a questionable amiodarone toxicity causing pulmonary fibrosis. EP was [**Month/Day/Year 4221**] and recommended stopping diltiazem gtt and titrating up metoprolol and/or starting digoxin if hypotensive. Digoxin was started on [**6-28**] with a loading dose 0.25mg followed by 0.125mg then daily dig 0.125mg qday. Dig level the day after loading dose was 0.5 and ECG had no signs of toxicity. The patient is to take digoxin 0.125mg daily and have dig level checked on [**7-2**] (therapeutic range is 0.8-2 ng/mL). Because coumadin and digoxin may interact to increase INR, INR needs to be checked and adjust coumadin dose as needed to establish a goal INR [**3-10**]. Coumadin was decreased from 2 to 1mg qday on [**6-29**]. The patient had a TTE, and result is as above. . #) Pulmonary fibrosis - restrictive lung disease by previous CT scan and PFT's. Also with history of [**Month/Year (2) 105496**] and COPD. Continued nebs and fluticasone. The patient was started on po steroids for wheezes and to finish 10 day taper. . #) History of dCHF - After receiving IVF for hypotension, the patient was volume overloaded. The patient was diuresed with IV lasix and restarted her 80mg maintenance dose. Because pt was -1.5 to 2L on maintenace lasix 80mg and was thought to be mildly dry, decreased maintenance lasix to 40mg qday on the day of discharge. . #) Neuropathic pain in RLE - Discontinued Osycontin/oxycodone and decreased neurontin and fentanyl for mental status changes. Pt did not complain more pain than usual. . #) Hypothyroidism - Due to low TSH and tachycardia, lowered levothroxine to 175mcg from 200mcg. . #) DM- continued lantus and RISS. . #) FEN: CHF/DM diet. Follow lytes. . #) proph - SQH, bowel regimen, protonix . #) access - L PICC placed on [**2124-6-29**]. . #) code - DNR, maybe DNI per daughter Medications on Admission: 1. oxycodone 10mg PO Q4 prn, oxycodone 10mg PO Q9pm 2. Combivent nebs Q4 prn 3. mom prn 4. Tylenol 975 mg PO Q4 prn 5. Topamax 25 mg [**Hospital1 **] 6. Coumadin 1mg PO Qday 7. Artificial tears 1 drop OU [**Hospital1 **] 8. Protonix 40 Qday 9. prednisilone 1% drops to R eye Qday 10.Zocor 20mg QHS 11.Lopressor 25mg PO BID 12.MVI Qday 13.Lasix 80mg PO Qday 14. Neurontin 600mg PO BID, 900mg QHS 15. celexa 60mg Qday 16. fentyl patch 75mcg Q72 hours 17. fluticasone 110mcg 2 puffs [**Hospital1 **] 18. combivent MDI 2 puffs [**Hospital1 **] 19. asa 325 Qday 20. Ketoralc 0.5% OD [**Hospital1 **] 21. Levothroxine 200 mcg Qday 22. Ritalin 10mg QAM 23. Lantus 16 units QHS 24. RISS Discharge Medications: 1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: Three (3) mL Inhalation every four (4) hours as needed for shortness of [**Hospital1 1440**] or wheezing. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every twelve (12) hours. 11. Lantus 100 unit/mL Cartridge Sig: Sixteen (16) units Subcutaneous at [**Hospital1 21013**]. 12. Insulin Regular Human 100 unit/mL Cartridge Sig: see sliding scale instruction Injection see sliding scale instruction: 151-200 0 units 201-250 2 units 251-300 4 units 301-350 6 units 361-400 8 >400 [**Name8 (MD) **] MD . 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a day. 15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 22. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic [**Hospital1 **] (2 times a day) as needed. 23. Prednisone 20 mg Tablet Sig: see other instructions Tablet PO once a day for 5 days: Take 2 tablet on [**7-1**], then 1 tablet on [**4-25**], then [**2-7**] tablet on [**4-27**], then off. . 24. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for see other instructions days: until [**7-7**]. 25. PICC PICC care per CCS protocol Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Sepsis Congestive heart failure Atrial fibrillation Discharge Condition: Good, afebrile Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Return to emergency deparement or call your doctor if you develop fevers, chills, shortness of [**Name8 (MD) 1440**], chest pain, or any other worrisome symtoms. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2124-8-15**] 1:00

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

19122, 19187

12390, 16010

346, 378

19283, 19300

3391, 7610

19611, 19788

2857, 2908

16740, 19099

19208, 19262

16036, 16717

19324, 19588

2923, 3372

285, 308

406, 1812

7619, 12367

1834, 2645

2661, 2841

19,543

107,070

51880

Discharge summary

report

Admission Date: [**2167-1-30**] Discharge Date: [**2167-2-3**] Date of Birth: [**2095-1-29**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 759**] Chief Complaint: Esophageal Stent Migration and airway obstruction Major Surgical or Invasive Procedure: EGD with stent removal History of Present Illness: 72 yo woman with PMH sig for metastatic esophageal cancer who presented for an outpt procedure to have an esophageal stent removed after it had migrated to her stomach. A plastic stent was placed in the distal esophagus at the site of the stricture prior to removal of the original stent. The procedure became complicated when the stent became lodged on a vertebral osteophyte blocking its extraction at the level of the high cervical spine. Obvious bleeding was noted and concern for her airway prompted intubation. This was complicated by her underlying anatomy as well as the stent's position but ultimately was successful. Interventional pulmonology and ENT were immediately consulted. The trachea appeared clear of any stent debris. The stent was able to be removed endoscopically without any major trauma to the esophagus the could be seen grossly. The pt had approximately 300-400 cc of blood suctioned while in the GI suite and an NG tube was passed under direct visualization. The pt was then admitted to the [**Hospital Unit Name 153**] for further observation and mgt after getting a CT of the neck. Upon arrival to the [**Hospital Unit Name 153**], vital signs were stable and there was no sign of further bleeding. Past Medical History: 1. Esophageal CA with liver mets s/p chemotx with Taxotere, 5-FU and leucovorin with minimal residual disease 2. Irritable bowel syndrome 3. GERD 4. h/o diverticulitis 5. Colon polyps 6. Degenerative joint disease 7. Laryngeal polyps 8. Systemic lupus 9. Fibromyalgia 10. CAD s/p Anterior MI [**8-/2152**] 11. Osteoporosis 12. Macular Degeneration 13. Left patellar chondromalacia Past Surgical Hx: 1. s/p cervical decompression [**1-/2153**] 2. h/o ruptured Gallbladder repair [**8-/2157**] 3. Right medial meniscus repair [**7-/2161**] Social History: No ETOH or smoking. Married Family History: Positive for colon CA and Crohn's dz Physical Exam: T: 95.2 HR: 55 BP: 136/96 100% on FiO2 0.40 Gen: sedated but arousable, intubated HEENT: anicteric, blood noted in ET tube, NGT draining dark green fluid Neck: crepitus noted above sternum CV: bradycardic, S1S2 no murmur Chest: coarse rhonchi at bases b/l, pirt noted on left upper chest Abd: +BS soft, NT Ext: no C/C/E Pertinent Results: 72 year old woman with hx stent placement for esophageal cancer REASON FOR THIS EXAMINATION: chest fluoroscopic assistance for esophageal stent placement and retrieval INDICATION: Chest fluoroscopic assistance for endoscopic removal of esophageal stent and placement of a new esophageal stent. [**2167-1-30**] 01:00PM WBC-3.7*# RBC-2.87*# HGB-8.5*# HCT-31.1*# MCV-109*# MCH-29.5 MCHC-27.2*# RDW-15.0 [**2167-1-30**] 01:00PM PT-13.1 PTT-32.0 INR(PT)-1.1 [**2167-1-30**] 01:00PM HCV Ab-NEGATIVE [**2167-1-30**] 01:00PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab-POSITIVE [**2167-1-30**] 01:00PM UREA N-11 CREAT-0.6 SODIUM-116* POTASSIUM-2.1* CHLORIDE-92* TOTAL CO2-18* ANION GAP-8 Brief Hospital Course: 1. s/p upper airway obstruction: Pt was admitted to ICU for observation. She was maintained on intubation and ventilation for 48 hours for airway protection. On initial check for trach leak, she had some stridor, and was started empirically on steroids. The following day she was extubated without complications and streroids discontinued. 2. GI bleed: Hematocrits were stable throughout the hospitalization and the patient did not have to be transfused. Her outpatient HTN meds, as well as aspirin and coumadin were held. She was normotensive and stable, BP meds were slowly restarted as tolerated. 3. Possible esophageal perf: She was started on zosyn empirically for the possibility of esophageal perf. None was seen on CXR or CT, and she was changed over to PO antibiotics for empiric 7 days of amox/clav. 4. Afib: Off of her beta-blocker and diltiazem, she had several runs of rapid Afib (HR 150s), which ultimately required that she be placed on diltiazem drip. Upon extubation, she was restarted on her outpatient diltiazem and atenolol. As above, coumadin and ASA were held in lue of GI bleed. 5. ASA allergy: patient was desensitized to ASA in [**2152**]'s and has had periods of time off ASA (up to 10 days) and has restarted in past without incident. On some occassions, patient was started on steroids concommitantly to avoid reactions. In this situation, our allergist, Dr. [**Last Name (STitle) 2603**], recommended consideration for repeat desensitization if off ASA for > 5 days. Patient will consult with her outpatient allergist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], prior to restarting her ASA after 7 day period. 6. Malpositioned port-a-cath. On 2 subsequent CXRs the patient's L subclavian port-a-cath was noted to be malpositioned cephalad in the L brachiocephalic vein. This issue is likely ongoing and patient was referred to our "IV access" team, specifically [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23793**] for likely replacement. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was also notified of this issue. Medications on Admission: Cardizem CD 300mg QD Imdur 30mg QHS Restasis 1 gtt OU QD Nexium 20mg [**Hospital1 **] KCl 20mEq M/W/F Ativan 1mg QHS PRN Moduretic (Amiloride/HCTZ) [**5-/2112**] 1 tab M/W/F Lipitor 40mg QD MVI Coumadin 1mg QD Amitriptyline 25mg QHS Atenolol 25mg QHS ECASA 81mg QD Reglan 10mg QID PRN Mag Glycinate 200mg QD Discharge Medications: 1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) Metastatic Esophageal Cancer 2) s/p stent removal and replacement 3) Possible mediastinitis - though no evidence on CT scan or with fever, completing [**10-23**] day course of broad spectrum antibiotics empirically. 4) Ischemic heart Disease 5) Lupus 6) Fibromyalgia 7) Hypokalemia Discharge Condition: Good Discharge Instructions: Call Dr. [**Last Name (STitle) 1940**] if you develop a temperature of 100.5 degrees or higher, feel chills, chest pain, trouble breathing or otherwise unwell. Follow-up with Dr. [**Last Name (STitle) 1940**] in 7 days for a repeat CBC. Follow-up with your Cardiologist in early [**Month (only) 956**] as planned. You should remain off anticoagulation for AT LEAST seven days, or as long as possible according to Dr. [**Last Name (STitle) **]. Do not take an aspirin or coumadin or any other blood thinning medication until further directed. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 1940**] in 7 days for a repeat CBC. Follow-up with your Cardiologist in early [**Month (only) 956**] as planned. You should remain off anticoagulation for AT LEAST seven days, or as long as possible according to Dr. [**Last Name (STitle) **]. Do not restart aspirin until you see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for discussion of possible steroids prior to re-starting this medication. Please see Dr. [**Last Name (STitle) **] in next 5-7 days. Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2167-3-20**] 1:15 Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-3-16**] 1:15 Completed by:[**2167-2-3**]

[ "710.0", "729.1", "427.31", "197.7", "276.8", "998.11", "996.59", "150.8", "519.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "42.81", "45.13", "96.71" ]

icd9pcs

[ [ [] ] ]

6413, 6419

3351, 5484

316, 340

6752, 6758

2626, 2690

7351, 8247

2232, 2270

5842, 6390

6440, 6731

5510, 5819

6782, 7328

2285, 2607

227, 278

2719, 3328

368, 1607

1629, 2170

2186, 2216

5,247

166,050

22391

Discharge summary

report

Admission Date: [**2152-3-19**] Discharge Date: [**2152-4-13**] Date of Birth: [**2111-3-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 783**] Chief Complaint: fever, MS changes Major Surgical or Invasive Procedure: Hemodialysis Placement of tunneled dialysis catheters History of Present Illness: 40 yo M with HTN, hyperchol, asthma, sarcoid, initially presented with aortic dissection s/p graft repair complicated by ARF (?ATN) now on HD, multiple embolic CVAs, difficulty weaning from vent (s/p Trach/PEG), + sputum cx with serratia, hematuria from foley trauma, and ischemic hepatitis s/p celiac stent (along with L CIA/EIA stent). Patient was discharged from [**Hospital1 18**] on [**3-16**] to [**Hospital3 **] Rehab and returns on [**3-19**] after having LGT (100.9) and MS changes (not responding to verbal commands). The patient's wife reports he has been feeling slightly "warm" over the last couple of days. On Fri, he had a temperature of 101.3 after HD but no interventions were done. The patient defervesed but on Sun developed another fever to >101. In the intervening time period, the patient was slightly letheragic as per the wife. On [**Name2 (NI) **], after the febrile episode, the patient became unresponsive to verbal and physical stimuli at 3PM on [**2152-3-19**]. The patient was unresponsive for at least 30 minutes until arrival at [**Hospital1 18**]. The wife reports she was able to arouse him briefly but his eyes would "roll back" in his head and he would become unresponsive again within a minute. The wife denied any tonic clonic movements or loss of urinary or bladder continence. As per facility note, his limbs became flacid and he was unarousable. Pt was admitted directly to the MICU on [**2152-3-19**]. After one stable evening, the patient was transferred to the floor. . The patient was recently admitted to [**Hospital1 18**] for an episode of chest pain which was found to be a Type-A aortic dissection beginning above the coronary arteries with extension into the left common carotid and innominate arteries superiorly, with inferior extension to the left common femoral artery. The patient underwent an emergent aortic dissection repair (replacement of hemiarch and ascending aorta) which was complicated by altered mental status which later were found to be due to multiple small bilateral subcortical bilateral strokes, and ARF secondary to ATN requiring HD. In addition, the pt was found to have elevated LFTs which were thought to be secondary to gall bladder pathology and the patient was taken for ERCP and biliarty stent placement. The patient in fact had a compromise of celiac artery due to false lumen of aortic dissection requiring stent of celiac and left iliac artery. The patient also had a traumatic foley placement resulting in false lumen creation requiring urology consult and 3way foley placement in OR, in addition, the patient also had developed bacteremia with serratia in sputum and UTI with klebsiella tx'd with meropenum. The patient had a trach (using passy-muir valve) and PEG placed in addition to a tunneled dialysis catheter during the admission. The patient was evaluated by the Stroke service during this admission. The patient was ultimately discharged on [**2152-3-16**] to [**Hospital3 672**] Hospital for rehabilitation. . Past Medical History: 1. HTN 2. Hypercholesterolemia 3. Asthma 4. Sarcoid 5. Type A Aortic Dissection Repair (hemiarch and ascending aorta repair) 6. Altered mental status s/p dissection repair secondary to multiple embolic CVAs 7. ARF secondary to ATN on HD 8. h/o ishemic hepatitis s/p celiac stent along with L CIA/EIA stent 9. Klebsiella UTI Social History: lives with wife, comes from [**Hospital3 **] Rehab; no etoh, no tobacco Family History: + HTN, + DM (grandfather, aunts); no early CAD Physical Exam: On Admission to MICU: VS: 99.0 123/60 92 18 100% Gen: Awake, responds to commands HEENT: L disconjugate gaze (old), MMM, PERRL Neck: supple, no meningismus Chest: occ rhonchi, otw CTA b/l CV: distant + S1, +S2 Abd: obese, NT, + BS Extr: trace pre-tib edema, 1+ DPs Neuro: follows commands, mouths words, answers appropriately, moves all 4 extremities, equal DTRs, [**Name (NI) **] 3+/5, [**Name2 (NI) **] [**4-8**], RUE [**4-8**], LUE 3+/5 . . On Transfer to Floor: VS: 99.7; 118/70; 88; 20; 100% ON 35% TM over passy muir valve Gen: well nutritioned african american male lying in bed with passy muir valve in place with TM over valve, in NAD. Eyes: Pupils round but unequal, sluggishly rective to light bilaterally. Dysconjugate gaze with right eye deviated laterally, Neither eye is able to cross midline. anicteric OP: clear, mmm CV: difficult to auscultate heart sounds due to loud breathing Chest: good air movement but loud breath sounds Abd: obese, soft, NT, ND Ext: w/w/p, no c/c/e. Neuro: CN: II, V, VII, VIII, IX, X, [**Doctor First Name 81**], XII grossly intact. Dysconjugate gaze with right eye deviated laterally, neither eye is able to cross midline. No nystagmus. Tone: ?cogwheeling on left arm and left wrist, [**Month (only) **] tone on right Strength: -LUE: deltoid 3, triceps 3-, biceps 4+, wrist extensors and flexors 4, grip 4- -RUE: deltoid 3-, triceps 3-, biceps 4-, wrist extensors and flexors 4-, grip 3 -[**Month (only) **]: hip extensors/flexors: 4 -[**Month (only) **]: hip extensors/flexors: 2, barely able to wiggle toes Reflex: LE absent knee jerk and ankle jerk, bicecps, triceps, forearms bilaterally +1 . Pertinent Results: [**2152-3-19**] 09:34PM PT-18.7* PTT-82.8* INR(PT)-2.2 [**2152-3-19**] 09:34PM PLT COUNT-273 [**2152-3-19**] 09:34PM ANISOCYT-1+ MACROCYT-1+ [**2152-3-19**] 09:34PM NEUTS-70.0 LYMPHS-11.5* MONOS-3.5 EOS-14.9* BASOS-0.2 [**2152-3-19**] 09:34PM WBC-9.2 RBC-3.21* HGB-9.9* HCT-29.8* MCV-93 MCH-30.9 MCHC-33.3 RDW-16.8* [**2152-3-19**] 09:34PM ALBUMIN-2.7* CALCIUM-9.1 PHOSPHATE-4.3 MAGNESIUM-2.0 [**2152-3-19**] 09:34PM CK-MB-NotDone cTropnT-1.33* [**2152-3-19**] 09:34PM LIPASE-89* [**2152-3-19**] 09:34PM ALT(SGPT)-40 AST(SGOT)-27 LD(LDH)-278* CK(CPK)-70 ALK PHOS-170* AMYLASE-118* TOT BILI-0.6 [**2152-3-19**] 09:34PM GLUCOSE-103 UREA N-56* CREAT-7.2* SODIUM-139 POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-31* ANION GAP-18 . . STUDIES: [**2152-2-29**] TTE: no valvular disease, no endocarditis, no retained dissection flap [**2152-3-19**] CXR: tracheostomy tube, left PICC, right tunneled IJ. stable widening of mediastinum. no evidence of acute cardiopulmonay process. [**2152-3-19**] Head CT: Negative for intracranial bleed. Small foci of low attenuation within the right frontal white matter consitent with old infarct. [**2152-3-23**] Abd CT: No abnormal fluid collection seen in the abdomen and pelvis. No CT evidence of abscess [**2152-3-26**] MRI: Somewhat limited study, specifically with regard to abnormal cord signal if there is a question of cord infarction. There is no definite evidence of cord compression, epidural abscess, or diskitis. [**2152-3-28**] Bedside TTE: No pericardial effusion. No aortic regurgitation. No dissection flap seen but cannot exclude [**2152-3-28**] CTA of torso: stable configuration of the repaired segment of ascending aorta. Interval development of new area of dissection extending from the diaphragmatic hiatus to just below the right renal artery, with interval attenuation of the true lumen. The celiac trunk, superior mesenteric artery, and right renal artery arise from the true lumen. The left renal artery arises from the false lumen, a finding that is unchanged, and there appears to be symmetric enhancement of the kidneys bilaterally. Bibasilar atelectasis and small bilateral pleural effusions. No evidence of hematoma around the abdominal aorta or hemoperitoneum. . . [**2152-3-19**] blood culture: coag negative staph 1/2 bottles [**2152-3-20**] sputum gram stain: gram positive cocci - serratia and enterobacter. [**2152-3-20**] sputum culture: gram negative rods [**2152-3-20**] urine culture: yeast [**2152-3-21**] blood culture: NGTD [**2152-3-21**] PICC culture: coag negative staph sensitive to vanco [**2152-3-22**] urine culture: Klebsiella resistant to levofloxacin but sensitive to bactrim [**2152-3-22**] blood culture: NGTD [**2152-3-23**] PICC tip culture: NGTD [**2152-3-23**] blood and mycotic cultures: NGTD [**2152-3-24**] blood and mycotic cultures: NGTD (just sent) [**2152-3-25**] blood culture: gram positive cocci in pairs and clusters (grew out on [**2152-3-27**]) [**2152-3-27**] blood NGTD [**2152-3-27**] urine cultures: gram negative rods [**2152-3-28**] blood culture and cultre from dialysis line NGTD [**2152-3-28**] Decubitus swab: gram neg rods and coag neg staph [**2152-3-30**] strongyloides IgG positive. . . . [**2152-2-29**] TTE: no valvular disease, no endocarditis, no retained dissection flap . [**2152-3-19**] CXR: tracheostomy tube, left PICC, right tunneled IJ. stable widening of mediastinum. no evidence of acute cardiopulmonay process. . [**2152-3-19**] Head CT: Negative for intracranial bleed. Small foci of low attenuation within the right frontal white matter consitent with old infarct. . [**2152-3-20**] Bed side green dye swallow: regular solids and liquids, upright for all POs. . [**2152-3-20**]: +1 sputum with gram positive cocci in pairs (<10 epi and no op flora) . . [**2152-3-28**] Bed side TTE: "MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No AS. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: No pericardial effusion. No aortic regurgitation. No dissection flap seen but cannot exclude." . . CTA of Chest/Abd/Pelvis [**2152-3-29**]: "COMPARISON: [**2152-3-1**]. TECHNIQUE: Axial MDCT images were obtained from the lung apices to below the aortic dissection prior to and following the administration of 150 cc of intravenous Optiray in the arterial phase. Additional coronal and sagittal reformatted images are provided. CONTRAST: Intravenous nonionic contrast was administered due to patient debility. CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: The patient is status post repair of the ascending aortic dissection, with suture material surrounding the ascending aorta. A contour deformity of the ascending aorta just superior to the anastomosis is again seen and unchanged, consistent with post surgical appearance of the pre-anastomotic segment of ascending aorta. There are multiple surgical clips within the mediastinum. There is interval decrease in soft tissue density surrounding the superior mediastinum consistent with postoperative hematoma. The dissection involving the descending aorta just distal to the anastomotic repair site appears unchanged. There is thrombus within the false lumen within the descending thoracic aorta. At the level of the diaphragmatic crura, there is evidence of new dissection, with widening of the aortic contour and a new intimal flap. This intimal flap extends from the level of the diaphragmatic hiatus to just below the right renal artery. There is no evidence of new periaortic hematoma. The airways are patent to the level of the segmental bronchi bilaterally. No definite pathologic appearing mediastinal, hilar, or axillary lymphadenopathy is identified, although there are numerous small axillary lymph nodes bilaterally. There are small bilateral pleural effusions and bibasilar atelectasis. No pneumothorax. CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST: There is new widening of the aortic contour at the diaphragmatic hiatus with a new intimal flap which extends from the diaphragmatic hiatus to just below the right renal artery. In addition, there is new narrowing of the true lumen within the abdominal aorta. The celiac axis, superior mesenteric artery, and right renal artery appear to originate from the true lumen, unchanged from the previous examination. The left renal artery arises from the false lumen. The inferior mesenteric artery arises from the false lumen. There is a stent within the left common iliac artery in unchanged position. There is symmetric enhancement of the kidneys bilaterally. The liver, gallbladder, pancreas, spleen, and adrenal glands appear unchanged. Note is made of air within the gallbladder. A biliary stent is in place. The large and small bowel loops are normal in caliber, and there is no abnormal bowel wall thickening. There are no free fluid collections within the abdomen, no free intraperitoneal air, and no evidence of hemoperitoneum. A percutaneous gastrostomy tube is in place. The visualized portions of the bladder, rectum and sigmoid colon appear unremarkable. BONE WINDOWS: Bone windows demonstrate no evidence of suspicious lytic or sclerotic osseous lesions. IMPRESSION: 1. Status post repair of the ascending aorta with with stable configuration of the repaired segment of ascending aorta. 2. Interval development of new area of dissection extending from the diaphragmatic hiatus to just below the right renal artery, with interval attenuation of the true lumen. The celiac trunk, superior mesenteric artery, and right renal artery arise from the true lumen. The left renal artery arises from the false lumen, a finding that is unchanged, and there appears to be symmetric enhancement of the kidneys bilaterally. 3. Bibasilar atelectasis and small bilateral pleural effusions. 4. No evidence of hematoma around the abdominal aorta or hemoperitoneum." Brief Hospital Course: 1. MS changes: The patient was found to have been unresponsive in the setting of fever at [**Hospital3 **] rehab. Upon transfer to [**Hospital1 18**], the patient was already clear with baseline mental status. Throughout the remainder of his hospital stay, his mental status has been relatively clear with only signs of improvement every day. The etiology of the altered mental status remains unclear at this point, however it may represent a response to an infectious/metabolic event vs. new neuro event (CVA/TIA) or even an old embolic phenomenon that is manifesting now that pt is more awake/alert. Given the clinical history of lethargy and fever (especially with the multiple grafts and lines), as well as positive blood cultures 1/2 bottles on [**2152-3-19**], infectious event is very likely (secondary to transient bacteremic episode?). The neurology [**Last Name (un) 58231**] service was consulted (who had seem him during the earlier admission) to ascertain his baseline neurological and mental status. They were convinced the neurologic findings are old and there is little likelihood this is a new or was a CVA/TIA. A CT of the head on admission demonstrated no evidence of an acute bleed. As there were no focal neurologic findings, neurology did not feel this warranted any further workup including a head MRI or EEG. He was scheduled for follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of the stroke service after dispo to Rehab facility. 1. Fevers: Pt with persistent low grade fevers since admission, despite initiation of vancomycin therapy for >one week. Pt has only grown out coag negative staph from 3 blood cultures and klebsiella from urine. In addition, antibody for strongyloides was positive. He received 8 days of ceftriaxone for his Klebsiella UTI. He received 10 days total of Ivermectin for his strongyloides. He is in the midst of a protracted source of vancomycin for ?aortic graft infection. He will need to continue this for a total of 6 weeks (until [**5-4**]). This should be dosed by levels, with a goal trough [**11-18**]. He continued to have low grade fevers, even at time of discharge. All non-essential medications were stopped with the idea that it was possibly drug fever. Tagged WBC scan was performed and was negative for any source of infection. Imaging of chest, abdomen, pelvis was consistently negative. Hemodialysis catheter was changed and eventually removed. Only line at time of discharge was a midline that was without erythema or signs of infection. MRI of feet was obtained which was negative for signs of infection (pt with persistent foot pain). Sacral decubitus ulcer appeared relatively clean without obvious signs of infection. As above, source of low-grade fevers was unclear; he remained completely hemodynamically stable, and all follow up surveillance cultures were persistently negative. 3. Cardiac: Pt never complained of CP, palpitations, or SOB however given past history of complications a rule out was performed. Aspirin, beta blocker were continued, and he was started on an ACE prior to discharge. Cardiac enzymes were a little elevated (elevated tnt but pt with renal failure) but trended down. 4. Renal Failure: This was thought to most likely be ATN from hypotensive insult. He was followed by renal while in-house. He was initially on hemodialysis, but as his creatinine improved, this was stopped, and his hemodialysis catheter was removed. He will follow up with renal after discharge with Dr. [**First Name (STitle) 805**]. Low dose ACEI was started prior to discharge without any significant bump in his creatinine. If his creatinine bumps at rehabilitation, this medication should be discontinued. 5. Pain: Pt with acute onset bilateral foot pain. The pain is described as pins and needles and extends up to ankles. Especially worse on heel but is all over foot with hypersensitivity. The description is concerning for neuropathic pain possibly due to thalamic infarct causing pain syndromes (as per neuro can occur days-weeks later). MRI has ruled out cord compression or abscess. MRI of feet showed no signs of infection. He was started on Neurontin and Trileptal with lidocaine patches and oxycodone. This provided a small amount of relief. He will follow up with neurology after discharge. 6. GU/Hematuria: pt developed hematuria d/t placement of foley in "false urethra"; had 3 way foley in place without hematuria until morning of [**3-8**]; at which point foley irrigated, clot removed, pink urine obtained. He was treated with 8 days of ceftriaxone for klebsiella UTI. He will be discharged with foley catheter due to traumatic catheterization, and he will follow up in the urology clinic. 7. Trach removal: Pt pulled trach tube out himself and remained stable without tracheostomy during majority of hospitalization. 8. Decubitus ulcers: ulcers currently appears clean. There is no evidence of ongoing infection at site of dialysis and doubt bacteremia is seeded from here. Local wound care with daily dressing changes should be continued. 9. Anemia: Pt with stable anemia since admission. However upon further review of past admission labs, he has never been worked up for cause of anemia. Pt denies BRBPR, melana, hematemesis, coffee ground emesis. Hct currently is stable at 29.5 with normal MCV. Most likely anemia of chronic disease - although Fe is low, ferritin is high (1877). Normal B12 and folate. No need for iron supplementation. He was started on epogen prior to discharge. CBC should be checked weekly to make sure that he does not have a rebound polycythemia. 10. Ischemic Liver: s/p celiac stent, along with CBD stent for CBD dilation and sludge. This stent will need to be removed by [**Month (only) 547**], and he will need follow up with GI for this. 11. Aortic Grafts: Pt with aortic graft of hemi arch and ascending aorta. Anticoagulation was discontinued due to a hematocrit drop, and it was felt to not be necessary. ASA was continued. He will follow up with Dr. [**Last Name (STitle) 70**] after discharge. 12. HTN: Pt on lopressor 150mg [**Hospital1 **] and Lisinopril 5 mg at time of discharge. 13. FEN: Pt with PEG tube, taking TF. He is also taking PO's, but calorie counts were not sufficient to meet nutritional needs. Calorie counts should be repeated at rehabilitation to determine if PEG can be removed at some point. 14. PPx: SQ Heparin should be continued indefinitely given immobility along with aggressive bowel regimen and protonix 14. Dispo: He was discharged to [**Hospital3 672**] rehab and will follow up with multiple doctors as described. He will complete 2 additional weeks of vancomycin therapy. Medications on Admission: 1. ASA 81mg once daily 2. Coumadin 3. Colace 4. Zinc 5. Vitamin C 6. Lopressor 100 [**Hospital1 **] 7. Protonix 40mg [**Hospital1 **] 8. Reglan 5mg TID 9. Phoslo 1334mg once daily Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed. 7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed: Hold for RR<8 or extreme sedation. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed: COntinue as need for oral thrush. 12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily). 14. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day): Hold for SBP<100 or HR<55. 15. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 18. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection twice a week: total dose of 4000 U per week. 20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 21. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 22. Vancomycin HCl 750 mg IV Q24H Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary: altered mental status, fever Secondary: Aortic dissection s/p graft repair, Renal Failure, Ischemic hepatitis s/p celiac stent and L CIA stent placement, HTN, Hypercholesterolemia, Asthma Discharge Condition: Good. Discharge Instructions: 1. Please take all of your medications exactly as described in this discharge paperwork. 2. Please follow up with doctors as described below. 3. If you notice any significant chest pain, palpitations, shortness of breath, difficulty breathing, abdominal pain, fever, chills, rigors, altered mental status. Followup Instructions: 1. Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] in Nephrology ([**Telephone/Fax (1) 817**]) to schedule follow up for your kidneys within 1 week of discharge from rehabilitation. 2. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6173**] in the Infectious disease clinice ([**Telephone/Fax (1) 4170**]) to schedule an appointments in 3 weeks (beginning of [**Month (only) 547**]) 3. Please call Dr. [**Last Name (STitle) 70**] in vascular ([**Telephone/Fax (1) 1504**]) to schedule a follow up appointment within 2-3 weeks for your aortic grafts 4. Please call Dr.[**Name (NI) 5725**] office in Urology ([**Telephone/Fax (1) 13609**]) to schedule follow up for your foley catheter in [**3-9**] weeks. 5. Please call Dr.[**Name (NI) 12202**] office ([**Telephone/Fax (1) 58232**]) to schedule follow up within 2-3 weeks for removal of your common bile duct stent. They will be scheduling this, but please call the office to ensure that the appointment is made. 6. Please call [**Hospital6 733**] primary care clinic here at [**Hospital1 18**] when you are discharged from rehabilitation and ask for the first available appointment ([**Telephone/Fax (1) 1300**]) 7. Please follow-up in stroke clinic with Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 month. Call [**Telephone/Fax (1) 44**] for an appointment. [**Known firstname 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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Discharge summary

report

Admission Date: [**2171-11-4**] Discharge Date: [**2171-11-13**] Date of Birth: [**2108-1-2**] Sex: M Service: MEDICINE Allergies: Codeine / Keppra Attending:[**First Name3 (LF) 4057**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: ridig bronchoscopy with stent placement then stent removal History of Present Illness: The patient is a 63 year-old man PMH follicular/variant papillary thyroid CA s/p total thyroidectomy and radical neck dissection in [**2156**] along with radioactive iodine as recently as [**2167**], surveillance scanning revealing pulmonary nodules and hilar lymphadenopathy in [**2168-2-9**] with subsequent PET-CT demonstrating FDG-avidity to these areas as well as to bone. . Since that time, he was additionally found to have cranial metastases found to be thyroid CA mets at craniotomy, and other scattered bone mets including, among others, thoracic and lumbar vertebrae. He [**Year (4 digits) 1834**] cranial and bone XRT as well as chemotherapy with at first sorafenib then Sutent after progression of disease. Sutent was most recently stopped in [**Month (only) **] [**2171**] after he developed a peri-met intraparenchymal hemorrhage. . He presented to clinic on [**2171-10-23**] complaining of shortness of breath and wheezing with a saturation of 94% on room air. He received CTA for PE and ruled out MI, but did not want to be admitted for workup and left ED AMA. . He re-presented on [**11-4**], with progressive dyspnea at rest and wheezing and subjective fevers. CXR suggested possible post obstructive pna so he was placed on levaquin and flagyl. He felt well but kept desatting. IP consulted who felt he had a post-obstructive collapse on the left side and planned to bronch. . On [**2171-11-9**], he [**Date Range 1834**] flexible and rigid bronchoscopy which revealed a near-complete obstruction of the left mainstem bronchus endobronchial lesion with near complete obstruction of the airway. Epinephrine 1:10,000 applied followed by argon plasma coagulation done, followed by coring out and excision of the tumor. Left mainstem patency was restored, only 15% residual obstruction remained. The LUL and LLL showed near complete obstruction, So mechanical debridement and argon plasma coagulation done to the distal left mainstem and LUL and LLL bronchi with only mild improvement of the patency. Balloon dilatation to 12mm was done followed by deployment of a 12mm x 40mm after LMS dimensions measured. Balloon dilation within the stent also done. . The patient was transferred to PACU post-procedurally and was subsequently extubated. Shortly thereafter, he developed desaturations, respiratory distress, and tachypnea. He was subsequently re-intubated. CXR showed complete opacification of the left hemithorax. Bronchoscopy was performed again, and an occlusive mucuous plug of the left mainstem stent site was removed. He remained intubated post-procedure. The stent had evidence of migration, and was subsequently removed on [**11-10**]. His MICU [**Last Name (un) **] was also complicated by coffee ground emesis; EGD preformed did not demonstrate any lesions, and the finding was likely secondary to digested blood from the procedure. He was successfully extubated on [**11-10**] but was delerious overnight. His Decadron was tapered from 4mg q8 to 4mg q12 on [**11-11**]. On arrival to the floor he states that he has a slight cough with white sputum since extubation, but is AOx3 and otherwise feeling well. . ROS: denies fever, chills, weight change, headache, shortness of breath, wheezing, chest pain or tightness, nausea, vomiting, diarrhea, constipation, melena, BRBPR, focal weakness, rash. Complete ROS was otherwise negative. Past Medical History: ONCOLOGIC HISTORY: Mr. [**Known lastname 76117**] is a 63-year-old gentleman with thyroid carcinoma. In [**2156**], he noted a lump in the right side of his neck. He was found to have thyroid carcinoma and [**Year (4 digits) 1834**] a total thyroidectomy with right radical neck dissection. 20 lymph nodes were positive. Pathology was consistent with follicular versus follicular variant of papillary carcinoma. Per his report, he was not treated with radioactive iodine at that time but after a few years, when his thyroglobulin level increased, he received several courses of radioactive iodine. His last course of radioactive iodine was in 9/[**2167**]. CT in [**11/2167**] showed no recurrent or residual tumor, but there were small scattered pulmonary nodules. In [**2-/2168**], a neck ultrasound was notable for right posterior triangle lymph nodes. CT chest on [**2168-2-23**] showed multiple pulmonary nodules and bilateral hilar lymphadenopathy. PET scan on [**2168-3-15**] confirmed FDG avid right hilar lymph nodes, numerous pulmonary nodules, and a lucency in L5 concerning for metastasis. He was asymptomatic and the decision was made to follow him until he became symptomatic. CT chest in [**7-/2168**] showed a slight increase in his pulmonary nodules, along with mediastinal and right hilar lymph node enlargement. In [**9-/2168**], he developed headaches and diplopia in his right eye. Brain MRI on [**2168-9-19**] showed a large spongy-appearing lesion on the posterior fossa within the calvarium. PET scan of the brain on [**2168-9-21**] showed a lytic mass lesion involving the suboccipital skull, centered to the right of midline. Mr. [**Known lastname 76117**] [**Last Name (Titles) 1834**] craniotomy on [**2168-10-14**]. Pathology was consistent with metastatic thyroid carcinoma. He completed radiation therapy to his skull on [**2168-12-21**] (total dose of 5000cGy) but then developed low back pain. MRI L spine on [**2168-12-12**] revealed bony metastatic disease most prominent at L1 with extension into the left epidural space. Additional metastatic foci were seen at the L4 vertebral body and left T12 transverse process, pedicle and lamina. He started radiation therapy from T12 to S1 on [**2168-12-26**] and completed it on [**2169-1-13**]. He began sorafenib on [**2169-1-23**] and had a significant radiographic response in his parenchymal disease, but his osseous metastases did not respond as well. His sphenoid metastasis was treated with palliative fractionated stereotactic radiotherapy, 2400 cGy in 3 fractions, completed on [**2169-8-8**]. He also [**Year (4 digits) 1834**] standard EBXRT to his right pubic bone metastasis, performed with his local radiation oncologist and completed in late [**Month (only) **]/early [**2169-11-9**]. He progressed through sorafenib in [**3-/2170**] and developed a metastasis in his right glenoid cavity for which he [**Year (4 digits) 1834**] radiation. He completed radiation around [**2170-5-28**] and stopped sorafenib shortly thereafter. He then started sunitinib on [**2170-6-11**] at a dose of 50mg PO daily x 4 weeks, followed by 2 weeks off, until [**2171-7-23**] when he presented with an intraparenchymal hemorrhage due to a right parietal mass. Sunitinib was stopped and he [**Month/Day/Year 1834**] right craniotomy for resection of the right parietal mass on [**2171-7-26**]. He then completed Cyberknife - 2400 cGy in 3 fractions - on [**2171-8-26**]. He had progression of his disease but declined further chemotherapy. Past Medical History: -Cervical spinal laminectomy in [**2144**] and [**2146**] -Spinal fusion in [**2149**] -[**10/2156**], surgery for thyroid mass at [**Doctor Last Name 15594**] Medical Center -[**2168**], surgery for mass on his skull -[**2171-7-26**], brain tumor metastasis removed. Social History: Social History: Tobacco: 1ppd x 44 years, quit [**2170**] Alcohol: occasional Lives with wife, has 2 young adult children Occupation: worked in a bindery department of a publisher, now on [**Social Security Number 76118**]social security disability. Family History: Positive for cancer in one brother and heart disease in father. Physical Exam: On admission: . VS: Temp 98.2F, BP 100/60, HR 78, RR 20, SaO2 95% RA, pain [**11-18**] Wt 169.6#, Ht 5'6" General: lying bed, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: mild crackles at bilateral bases with normal effort, no wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley Ext: warm, well perfused, could not appreciate pulses by palpation. slight edema to midleg bilaterally. Neuro: no focal deficits A&Ox3 Psych: cooperative, interactive . On Discharge: . General: 98 (max 98.7), 160/96, 83, 20, 97% RA HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: mild crackles at bilateral bases with normal effort, no wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, could not appreciate pulses by palpation. slight edema to midleg bilaterally. Neuro: no focal deficits A&Ox3 Psych: cooperative, interactive . Pertinent Results: [**2171-11-4**] 02:55PM WBC-9.9 RBC-3.33* HGB-10.1* HCT-29.2* MCV-88 MCH-30.3 MCHC-34.5 RDW-17.0* [**2171-11-4**] 02:55PM NEUTS-85.3* LYMPHS-6.4* MONOS-7.2 EOS-0.8 BASOS-0.2 [**2171-11-4**] 02:55PM PLT COUNT-652*# [**2171-11-4**] 02:55PM PT-14.4* PTT-31.7 INR(PT)-1.2* [**2171-11-4**] 02:55PM GLUCOSE-110* UREA N-12 CREAT-0.6 SODIUM-133 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-25 ANION GAP-16 [**2171-11-4**] 02:55PM CALCIUM-8.6 PHOSPHATE-2.9 MAGNESIUM-1.9 [**2171-11-4**] 02:55PM ALT(SGPT)-20 AST(SGOT)-28 ALK PHOS-60 TOT BILI-0.4 [**2171-11-4**] 02:55PM LIPASE-8 [**2171-11-4**] 03:12PM LACTATE-1.3 . [**2171-11-4**] Portable CXR: Portable upright frontal chest radiograph demonstrates left lower lobe consolidation, which is new compared with prior. Given the soft tissue narrowing of the left main bronchus on prior imaging, it is likely that this is post obstructive. Again noted is lytic destruction of the left seventh rib. Bilateral hilar lymphadenopathy is again evident. There is no effusion or pneumothorax. There is no intraperitoneal free air. IMPRESSION: 1. Interval development of left lower lobe consolidation, which given that it developed over a period of 12 days most likely represents pneumonia. This is likely post obstructive given the appearance of recent imaging. 2. Stable appearance of metastatic thyroid cancer within the limits of the chest radiograph. . [**2171-11-4**] Head CT: There is no intracranial hemorrhage, extra-axial collection, or mass effect. The ventricles and sulci are stable in configuration without evidence of hydrocephalus. Note is made of a prominent cisterna magna. A hypodensity in the left insula is stable and probably represents a prominent perivascular space. There are post-surgical changes of right parietal craniotomy. A linear defect within the right temporal lobe is stable in appearance compared with MRI of [**2171-9-30**] and is certainly postoperative. [**Doctor Last Name **] matter/white matter differentiation elsewhere is preserved. The orbits appear normal. The visualized soft tissues are normal appearing. The mastoid air cells are clear. There is mucosal thickening of the bilateral maxillary sinuses, the sphenoid, ethmoid, and frontal sinuses are clear. There is a stable appearance of lytic osseous destruction of the right sphenoid and occipital bones. IMPRESSION: 1. No acute intracranial process. 2. Post-surgical changes in the right parietal lobe are stable-appearing. 3. Stable appearance of right sphenoid and occipital lytic osseous metastases. . [**2171-11-8**] CXR There is complete opacification of the left hemithorax with deviation of the cardiomediastinum towards the left consistent with a new left upper lobe collapse. The patient had already left lower lobe collapse. The amount of left pleural effusion cannot be evaluated, probably is small. ET tube tip is 4 cm above the carina. There is a new stent in the left main bronchus. Minimal opacities in the right upper lobe are new, could be due to atelectasis or aspiration. No evidence of right pneumothorax. . [**2171-11-9**] CT CHEST: 1. Interval placement of a left main bronchus stent with opacification within the distal aspect of the stent and resorptive atelectasis of the left lower lobe with mediastinal shift to the left. This could represent mucous plugging within the distal aspect of stent, but soft tissue mass involvement cannot be excluded as the subcarinal region and left main bronchus appear encased by soft tissue mass. 2. Small left-sided pleural effusion. 3. Numerous osseous and pulmonary metastatic lesions with small new 1.2-cm right upper lobe pulmonary parenchymal lesion and increase in size of left lateral seventh rib lytic destructive osseous mass lesion with associated soft tissue component. 4. Mediastinal and hilar lymphadenopathy, likely metastatic. . EGD [**2171-11-10**]: Blood in the esophagus Blood in the stomach Abnormal mucosa in the stomach Otherwise normal EGD to third part of the duodenum Recommendations: Prilosec 40mg [**Hospital1 **] for gastritis. This was not the etiology of his coffee ground emesis. No specific etiology of his coffee ground emesis could be found endoscopically. Given his recent IP procedure it is possible he swallowed some blood into the stomach. . CXR [**2171-11-10**]: Current study demonstrates substantial reexpansion of the left lung with resolution of the vast majority of atelectasis, but still present left perihilar consolidation. There is new right basal opacity that might reflect progression of infectious process versus aspiration. There is no pneumothorax. Pleural effusion cannot be entirely excluded on the right and most likely present on the left. The ET tube tip is in appropriate position. The NG tube tip passes below the diaphragm with its tip not included in the field of view. . CXR [**2171-11-11**] IMPRESSION: 1. Progressive improvement in left hemithorax opacification with some persistent retrocardiac opacification. Minimal right basilar atelectasis. . Lab Results on Discharge . [**2171-11-13**] 07:00AM BLOOD WBC-19.2* RBC-3.42* Hgb-10.3* Hct-31.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-17.1* Plt Ct-461* [**2171-11-13**] 07:00AM BLOOD Neuts-86* Bands-6* Lymphs-3* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2171-11-13**] 07:00AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Acantho-OCCASIONAL [**2171-11-13**] 07:00AM BLOOD Plt Smr-HIGH Plt Ct-461* [**2171-11-13**] 07:00AM BLOOD Glucose-126* UreaN-13 Creat-0.4* Na-139 K-4.0 Cl-105 HCO3-26 AnGap-12 [**2171-11-13**] 07:00AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.1 Brief Hospital Course: The patient is a 63 year-old man PMH follicular/variant papillary thyroid CA s/p total thyroidectomy and radical neck dissection in [**2156**] along with radioactive iodine as recently as [**2167**], s/p multiple chemotherapy regimens who presented with dyspnea with pulmonary mass s/p endobronchial stenting complicated by hypoxemic respiratory failure from a mucous plug requiring intubation, s/p extubation on [**11-10**]. . # Pulmonary - Patient was found to have an airway obstruction on the left side due to a mass. The mass was debrided and a stent was placed on [**11-9**]. While in the PACU, a mucus plug obstructed the stent and he desaturated. He was taken back to the suite where the mucus plug was removed and the stent was also removed secondary to migration. The patient remained intubated and stayed in the MICU for a few days. His condition improved and he was extubated and sent to the floor. After two days of stable condition on the floor, the patient was deemed ok to go home. He will require home oxygen therapy with ambulation. He is now on decadron, which will continue to taper at home. He is also using albuterol and atrovent PRN along with mucinex [**Hospital1 **] . # Lung tumor: Likely primary. Patient will be seen by RadOnc to determine if he is a candidate for radiation treatment. . GI - coffee ground emesis likely secondary to swallowed blood with procedure, as no culprit lesion appreciated on EGD on [**11-10**]. He will continue on PPI when he goes home. . # ID - POST-OBSTRUCTIVE PNEUMONIA: patient received a one week course of flagyl and levaquin, which appears to have resolved any signs of pneumonia that he had previously. The patient's CXR does not indicate pneumonia . # METASTATIC THYROID CANCER: Patient with a widespread history of mets to the brain, bone, lungs. current lesion may represent mets versus new primary, will followup pathology. Patient has declined further chemotherapy . Medications on Admission: - Vitamin D 50,000 units twice monthly - Levoxyl 275 mcg daily - lorazepam 0.5-1.0 mg PRN panic attacks - oxycodone 5-10 mg PO Q4hours PRN pain Discharge Medications: 1. home oxygen home oxygen 1-2 Litres nasal cannula with ambulation. Dx: metastatic thyroid cancer 2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO twice monthly. 3. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a day. 4. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO prn as needed. 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*1 inhaler* Refills:*2* 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*1 inhaler* Refills:*2* 9. dexamethasone 1 mg Tablet Sig: see below Tablet PO once a day for 5 days: [**11-14**]: take 4 pills daily; 10/7-8: take 2 pills daily; [**2170-11-17**]: take 1 pill daily. Disp:*10 Tablet(s)* Refills:*0* 10. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis: post-obstructive pneumonia endobronchial obstruction Secondary Diagnosis: metastatic thyroid cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 76117**], you presented to our service with trouble breathing. While with us, you were seen by the interventional pulmonologists who placed a stent in your airway. The stent plugged and did not work so it was then removed. Following removal of the stent, you recovered and were deemed healthy for discharge The following changes were made to your medications: - use albuterol and ipratropium as necessary for breathing - use oxygen when ambulating - take pantoprazole daily - take dexamethasone for 5 days; 4mg on [**11-14**]; 2mg on [**11-15**]-8; 1mg on [**2170-11-17**] Followup Instructions: Radiation Planning: Thursday [**2171-11-14**] at 3pm [**Hospital Ward Name 23**] Building [**Location (un) 442**] Treatment Planning Center. Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-12-2**] 8:35 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2171-11-19**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5778**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2171-11-19**] 11:30 Completed by:[**2171-11-14**]

[ "198.5", "535.51", "518.51", "244.0", "198.3", "V10.87", "519.19", "197.0", "486" ]

icd9cm

[ [ [] ] ]

[ "32.01", "96.05", "33.78", "96.71", "33.91", "45.13", "33.24" ]

icd9pcs

[ [ [] ] ]

18159, 18208

14866, 16806

297, 357

18371, 18371

9185, 10598

19175, 19742

7872, 7937

17001, 18136

18229, 18229

16832, 16978

18553, 19152

7952, 7952

8612, 9166

238, 259

385, 3756

18323, 18350

10607, 14843

18248, 18302

7966, 8598

18386, 18529

7318, 7588

7620, 7856

9,165

106,945

44294

Discharge summary

report

Admission Date: [**2137-1-31**] Discharge Date: [**2137-2-4**] Date of Birth: [**2091-1-5**] Sex: F Service: MEDICINE Allergies: Codeine / Percocet / Demerol / Ceftin / Toradol / Naprosyn Attending:[**First Name3 (LF) 3984**] Chief Complaint: Abdominal/back pain s/p nephrostomy tube replacement [**1-31**], also fever/chills. Major Surgical or Invasive Procedure: none History of Present Illness: 45 yo woman with recurrent Stage III papillary serous Ovarian CA s/p TAH/BSO, two subsequent tumor debulkings, chemotherapy, RT, now receiving home hospice, who is referred s/p nephrostogram/tube replacement with RLQ pain, R flank pain, fever/chills since day prior to yesterday. She also reports diarrhea that has since resolved. She denies nausea/vomiting. The remainder of her ROS is negative. Past Medical History: PAST MEDICAL HISTORY: - Stage III papillary serous ovarian cancer s/p chemotherapy currently receiving RT - recurrent UTI with e. coli and enterococcus - Recent hospitalization for pyelonephritis - migraine headaches - atrophic left kidney - congenitally atrophic right arm below the elbow - seasonal asthma - HTN PAST SURGICAL HISTORY 1. Cholecystectomy 2. Ovarian cancer cytoreduction s/p TAH-BSO & omentectomy in '[**25**], then 2 debulking surgeries in '[**31**] and '[**35**]; 3. R ureteral stent [**2136-5-18**] for right-sided hydronephrosis secondary to extrinsic ureteric compression from advanced ovarian cancer, R percutaneous nephrostomy on [**2136-6-8**], with replacement by IR [**2137-1-31**] (pyelogram revealed distal obstruction) Social History: Lives with: 27 year old daughter ([**Name (NI) **]) in [**Location (un) 2251**] Occupation: previously worked in medical billing at [**Hospital1 2025**] Tobacco: Smoked 1 pack per month x15 years; quit several yeas ago EtOH: Denies Drugs: Denies Mood: Depressed Support system: Feels support from daughter/friends "sometimes" Family History: Mother: Recurrent lung CA; DM Father: HTN, CVA at age 48 Sister: Cervical CA Physical Exam: T 98.9 84 92/44 15 98 NAD RRR CTAB Abd soft +TTP RLQ no g/r +R CVAT Nephrostomy tube in place, site intact with no erythema/exudate Pelvic deferred Pertinent Results: Labs: WBC 6.3 (68% PMNs, 0 bands), HCT 26.3 (baseline 27-31), PLT 492 (baseline 200) PT 12.9 INR 1.1 PTT 31.0 Creatinine 1.1 (baseline 1.3) Na 142, K 4.1, Cl 107, HCO3 27, BUN11, Gluc 92 Brief Hospital Course: 45 yo woman with recurrent Stage III papillary serous Ovarian CA s/p TAH/BSO, two subsequent tumor debulkings, chemotherapy, RT, now receiving home hospice, who is referred s/p nephrostogram/tube replacement with RLQ pain, R flank pain, fever/chills since [**1-29**]. At presentation on [**1-31**], there was no clear evidence of infection given that her WBC was normal and she was afebrile. Her nephrostomy pigtail was replaced and antegrade pyelogram indicated functional nephrostomy tube and persistent distal ureteral obstruction. On CXR, the lungs were clear. She was admitted for pain control. However, her UA revealed >100K WBCs and, on [**2-1**], she mounted a fever to 100.7F. She was placed on zosyn and vancomycin was added when she was persistently febrile. Despite urine WBC count as above, urine cultures revealed only yeast 10-100K. A pain consult was requested and they recommended dilaudid PCA. She was started on the dilaudid PCA, but had several episodes of hypotension while on increased narcotics for her pain requiring transfer to the ICU for monitoring. Her PCA was discontinued and her fentanyl patch was restarted. Psychiatry was consulted for management of depression and affective instability and recommendations regarding her multiple medications including clonazepam, lorazepam, mirtazapine and narcotics. During her stay, she was showing signs of mild delirium with decreased attention and concentration. Thus psychiatry recommended continuing her mirtazapine and clonazepam, but suggested limiting prn ativan and narcotics as possible, recognizing the difficulty in this given her chronic pain. They also suggested using seroquel for anxiety and insomnia. In the setting of increased pain medication, specifically narcotics, she became hypotensive to 70s systolic. She was mildly lightheaded at this time. She was transferred to the ICU where she received IV fluids to which her BP responded with systolics returning to the low 100s mmHg. Her hypotension was thought more likely [**2-8**] to her pain medication regimen and poor PO rather than hypotension [**2-8**] to sepsis. During her stay, multiple family meetings including her pastor were had to evaluate code status. She had previously been in the care of hospice prior to this admission. During her stay in the setting of hypotension, code status was readdressed and she decided that she no longer wished DNR/DNI, but wanted full code. While in the ICU, this was again readdressed with her family, pastor, and patient, and code status was changed to CMO. She requested transfer back to her home hospice care. Medications on Admission: Fentanyl 150 mcg/hr Patch Lorazepam 1mg prn Clonazepam 0.5 mg HS Hydromorphone 10 mg PRN Docusate Sodium 100 mg Capsule po bid Senna QD Reglan PRN Mirtazapine 30 mg HS Omeprazole 20 mg QD Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. Metoclopramide 10 mg IV Q6H:PRN 7. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO at bedtime: Please give at 10pm. 8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 9. Ativan 1 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours as needed for agitation. 10. Ativan 2 mg/mL Syringe Sig: 0.5-1 mg Injection every [**6-14**] hours as needed for agitation: [**Month (only) 116**] give IV or SC. 11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q4H PRN AND HS PRN as needed for insomnia. 12. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) patches Transdermal every seventy-two (72) hours. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 15. Morphine 10 mg/5 mL Solution Sig: Five (5) ml PO q4hrs: prn as needed for pain. 16. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID: prn as needed for agitation. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: ovarian cancer abdominal pain depression anxiety renal insufficiency urinary tract infection hypertension Discharge Condition: Good Discharge Instructions: Call if fever, worsening pain, other concerns/questions Followup Instructions: Home Hospice [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "599.0", "V10.43", "198.1", "585.9", "E935.8", "458.29", "707.03", "300.4", "403.90" ]

icd9cm

[ [ [] ] ]

[ "55.93" ]

icd9pcs

[ [ [] ] ]

6665, 6736

2448, 5063

402, 408

6886, 6893

2236, 2425

6997, 7139

1973, 2052

5302, 6642

6757, 6865

5089, 5279

6917, 6974

2067, 2217

278, 364

436, 835

879, 1612

1628, 1957

26,040

152,197

26255

Discharge summary

report

Admission Date: [**2164-1-15**] Discharge Date: [**2164-2-1**] Date of Birth: [**2097-3-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 297**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Thoracentesis x2 Tracheostomy History of Present Illness: Patient is a 66 yo f with pmh of stage iv renal cell ca, also s/p recent colonic perforation with igmoid colectomy/Low anterior resection with end colostomy and Hartmann's procedure, who comes in with hypercarbic respiratory acidosis. She had a recent admission for debulking nephrectomy for her RCC however, it was never performed as she developed gram negative bacteremia (B fragilis in [**12-5**] bottles) and subsequent bowel perforation. Pt was treated broadly initially, then abx were tailored to Levofloxacin, flagyl, and fluconazole. She was taken to the OR for sigmoid colectomy/LAR with end colostomy and Hartmann's procedure and jejunal feeding tube placement and then discharged to [**Hospital **] rehab facility. For the past few days patient was noted to be more hypoxic- and was treated with nebs and prednisone. Finally today was sent into the ED for worsening respiratory status. . In ED, VS were: p96.6, p105, 140/40, rr40, 87% 6L nc, 100% NRB. Pt was found to have a increased pleural effusion (L>R), LLL opacity. Lasix given without any improvement in respiratory status. Pt was noted to be in severe respiratory distress with RR in 50s ABG was found to be 7.21/104/200. Pt was urgently intubated. Started on propofol drip, maintained good blood pressures. Given cefepime, vanco, flagyl, lasix 20mg IV, etomidate, succinylcholine, fentanyl, versed. Past Medical History: 1. emphysema/COPD 2. osteoporosis 3. fibrocystic breasts 4. s/p appendectomy 5. s/p ovarian cystectomy 6. s/p shoulder surgery 7. stage IV renal cell carcinoma Social History: She is a widow. She lives alone in [**Location (un) 22287**]. She shares a two-family house with her niece. She is retired. She baby-sits two children. Tobacco, 1 pack a day, quit 7 months ago. No alcohol. Family History: Mother with cholangiocarcinoma. Father died of complications of a peptic ulcer disease. Brother died at age 12 of metastatic sarcoma. Physical Exam: vitals: tc 95.4, p78, 117/57, rr25, 94% AC 400/28/5/1 I/O: 1275/800 Gen: intubated, sedated, cachectic, chronically ill appearing HEENT: PERRL Lungs: diffuse expiratory rhonchi anteriorly Heart: RRR, nl s1 s2, no m/g/r Abd: soft, ND, J tube in place, large vertical incision, colostomy bag in place with green stool ext: 2+ edema bilaterally to hips Pertinent Results: [**2164-1-15**] 06:55PM TYPE-ART TEMP-35.3 RATES-20/ TIDAL VOL-400 PEEP-5 O2-50 PO2-165* PCO2-52* PH-7.51* TOTAL CO2-43* BASE XS-16 -ASSIST/CON INTUBATED-INTUBATED [**2164-1-15**] 05:41PM TYPE-ART PO2-311* PCO2-47* PH-7.58* TOTAL CO2-45* BASE XS-20 INTUBATED-INTUBATED [**2164-1-15**] 05:41PM LACTATE-1.9 [**2164-1-15**] 01:50PM PO2-200* PCO2-104* PH-7.21* TOTAL CO2-44* BASE XS-9 [**2164-1-15**] 01:50PM LACTATE-2.3* K+-3.8 [**2164-1-15**] 01:50PM HGB-10.6* calcHCT-32 [**2164-1-15**] 01:50PM freeCa-1.28 [**2164-1-15**] 01:35PM LACTATE-2.4* [**2164-1-15**] 01:30PM GLUCOSE-167* UREA N-15 CREAT-0.2* SODIUM-137 POTASSIUM-4.2 CHLORIDE-90* TOTAL CO2-39* ANION GAP-12 [**2164-1-15**] 01:30PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-12* ALK PHOS-175* AMYLASE-107* TOT BILI-0.2 [**2164-1-15**] 01:30PM LIPASE-61* [**2164-1-15**] 01:30PM cTropnT-<0.01 [**2164-1-15**] 01:30PM CK-MB-NotDone [**2164-1-15**] 01:30PM ALBUMIN-2.6* CALCIUM-9.1 PHOSPHATE-3.4 MAGNESIUM-1.9 [**2164-1-15**] 01:30PM WBC-12.7* RBC-3.70*# HGB-10.7*# HCT-33.2*# MCV-90# MCH-28.8 MCHC-32.2 RDW-15.5 [**2164-1-15**] 01:30PM NEUTS-96.5* LYMPHS-2.4* MONOS-1.1* EOS-0 BASOS-0 [**2164-1-15**] 01:30PM HYPOCHROM-2+ [**2164-1-15**] 01:30PM PLT COUNT-447* [**2164-1-15**] 01:30PM PT-11.4 PTT-26.8 INR(PT)-1.0 [**2164-1-15**] 01:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2164-1-15**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2164-1-15**] 01:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2164-1-15**] 01:30PM URINE GRANULAR-0-2 HYALINE-<1 [**2164-1-15**] 01:30PM URINE AMORPH-FEW Brief Hospital Course: MICU course #1: . The patient was admitted to the MICU service for close monitoring and ventilatory support. . # Hypercarbic respiratory failure. Thought to be multifactorial, including pneumonia, CHF, and COPD exacerbation. The patient was treated with cefipime and vancomycin for a CAP vs nosocomial PNA. Solumedrol was given for COPD, as well as albuterol/atrovent nebs. The patient was diuresed with lasix. A thoracentesis was performed on HD2 for the large R pleural effusion, with removal of approximately 700cc fluid which was consistent with a transudate, and negative for malignant cells. The patient remained intubated with RSBI scores around 150 suggesting she was a poor candidate for extubation, although attempts were made to optimize the chances for her success by diuresis and controlling her heart rate and blood pressure, initially with labetalol gtt then PO labetalol. The patient eventually did well with improved mechanics and was extubated on [**2164-1-21**] and has since maintained her SaO2 on 4 L NC. . # Recent colonic perforation. Not an acute issue during this hospitalization. Normal stool output through colostomy. . # RCC. Stage IV. Was scheduled for debulking surgery during previous admission which did not occur [**12-22**] colonic perforation. . # Leukocytosis. Tests for c diff sent which were positive and started Flagyl for treatment. . # Peripheral edema. Thought to be due to hypoalbuminemia. Ultrasound of the lower extremities was negative for DVT. She was diuresed. . # HTN. The patient's blood pressure was initially difficult to control, requiring a labetalol gtt which was eventually transitioned to PO. However, after PEA arrest, her blood pressure has been low, so discontinued all antihypertensives. . # FEN. Tube feedings through J-tube. . ***************** MICU Course #2 . The patient was re-admitted to the MICU service [**2164-1-25**] after a Code Blue was called for an apparent PEA arrest. The patient while on Tele on the floor was found to be agonal and bradycardic to the 30s without a palpable pulse; the patient was quickly intubated, CPR was intiated, and she received one dose of atropine with return of a palpable pulse and blood pressure. An emergent femoral line was placed during the resuscitation; this was removed once a R subclavian line was placed under controlled circumstances in the MICU. A CTA was done and was negative for PE and serial cardiac biomarkers were negative as a possible etiology of the PEA arrest. A L pleural effusionw as removed by thoracentesis at the bedside. The patient's mental status returned to baseline quickly. After discussion with the pt and the health care proxy, the patient underwent tracheostomy [**2164-1-27**]. The patient is currently on CPAP/PS 12, FIO2 40%, TV 360s, and will need to be weaned off ventilator as tolerated to trach mask. For chronic obstructive lung disease, the patient has been tapered off steroid from 60mg qday now to 20mg qday. The patient is to take prednisone 10mg x 3days and off steroid. It was then noted that the pt's urine output dropped and her creatinine rose to 1.1, thought to be [**12-22**] contrast dye nephropathy from the CTA done previously, as well as the cardiac arrest/hypotension. Renal u/s revealed new hematoma around her foley, so a three-way foley was placed and continuous bladder irrigation was done. Renal Her creatinine slowly improved, and her urine output increased slowly. The patient still has a foley currently and needs to be removed at rehab as the patient has urinary tract infection that she is getting treated with Ciprofloxacin which she will complete on [**2-9**]. For C.diff, she has been getting Flagyl and will finish 10 day course on [**2164-2-3**]. The patient will need to follow-up with her oncologist for renal cell carcinoma and decide on the date for debulking procedure. Also, the patient passed video speech and swallow and can take thick, pureed diet. Speech and swallow made the following RECOMMENDATIONS: 1. Suggest starting a PO diet of nectar thick liquids and pureed consistency solids when on Pressure support vent settings or less and with PMV in place. 2. Pt must use a chin tuck for both the purees and the nectar thick liquids. 3. Alternate between every bite and sip. 4. Continue with tube feedings for supplemental nutrition and hydration. For her anemia, iron studies were consistent with anemia of chornic disease likely [**12-22**] her renal cell carcinoma and was started on Epogen. The patient will need to follow-up with oncologist and determine whether to continue on epogen. The patient developed delirium and suicidal ideation soon after tracheostomy and psych was consulted and started haldol 1mg [**Hospital1 **]. The patient's delirium has cleared since the initiation of haldol but still intermittently sundowns, so her mental status needs to be monitored and follow-up with her primary care physician and determine on whether to continue haldol or not. Per psych, pt can take haldol/prn for delirium. For prophylaxis, the patient has been getting subcutaneous heparin, and until ambulatory, pt will likely need subcutaneous heparin given her high risk for DVT and PE due to her cancer. Medications on Admission: Prednisone 60mg qd ativan 0.5mg tid atrovent neb q6h levalbuterol neb q6h ambien 10mg qhs lopressor 50mg [**Hospital1 **] benadryl clotrimazole lansoprazole 30mg qd ondansetron prn dalteparin 5000u qd calcitonin oxycodone 5-10mg morphine 2mg fentanyl 125mcg patch lasix 20mg qd Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 3 doses. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for 20 days: for delirium. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed. 10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days: until [**2-6**]. 12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) as needed for C diff + for 3 days: until [**2164-2-3**]. 13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: on [**2-1**]. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary diagnoses: Respiratory failure s/p tracheostomy Pneumonia- treated Chronic obstructive pulmonary disease Acute renal failure Urinary tract infection C. Diff colitis Secondary diagnoses: Renal cell carcinoma Anemia of chronic disease Discharge Condition: Stable Discharge Instructions: Return to the emergency department if you develop difficulty breathing, chest pain, worsening shortness of breath, decreasing urine output, or any other concerning symptoms. . Please follow up with your primary care physician [**Last Name (NamePattern4) **] 1 week and follow-up with your oncologist to determine the date for debulking and continuation of epogen. . Please take medications as instructed. Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 1 week after discharge. Provider: [**Name10 (NameIs) 843**] [**Name8 (MD) 844**], MD Phone:[**Telephone/Fax (1) 10533**] Date/Time:[**2164-3-1**] 1:00

[ "782.3", "518.84", "599.7", "293.0", "511.9", "285.21", "599.0", "428.31", "285.22", "486", "273.8", "V45.3", "401.9", "707.03", "584.5", "V55.3", "491.21", "189.0", "008.45", "427.5" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.6", "96.48", "96.04", "34.91", "99.60", "97.03", "96.72" ]

icd9pcs

[ [ [] ] ]

11253, 11332

4430, 9642

333, 365

11617, 11626

2710, 4407

12079, 12315

2187, 2324

9971, 11230

11353, 11526

9668, 9948

11650, 12056

2339, 2691

11547, 11596

274, 295

393, 1764

1786, 1947

1963, 2171

44,220

127,664

46881

Discharge summary

report

Admission Date: [**2170-10-9**] Discharge Date: [**2170-10-13**] Date of Birth: [**2104-6-29**] Sex: F Service: CARDIOTHORACIC Allergies: Novocain / Aspirin / Strawberry / shrimp Attending:[**First Name3 (LF) 165**] Chief Complaint: dyspnea on exertion Major [**First Name3 (LF) 2947**] or Invasive Procedure: [**2170-10-9**] 1. Aortic valve replacement with a size 21 mm [**Last Name (un) 3843**]- [**Doctor Last Name **] Magna tissue valve. 2. Coronary artery bypass graft times 3, left internal mammary artery to the left anterior descending artery and saphenous vein grafts to diagonal and obtuse marginal arteries. 3. Endoscopic harvesting of the long saphenous vein. History of Present Illness: Ms. [**Known lastname 69282**] is a 66 year old woman with known AS and MR who developed sudden onset shortness of breath, wheezing diaphoresis. She denies pain. On EMS arrival she was hypertensive with a systolic blood pressure of 200mmHg. In the [**Hospital1 1474**] ED she ruled in for a myocardial infarction by enzymes. Past Medical History: Coronary Artery Disease Diabetes morbid obesity chronic diastolic heart failure moderate AS mild-moderate MR multiple back surgeries, thoracic lumbar bolts in back and neck shoulder replacement debridement of R 4th and 5th fingers s/p tenosynovectomy osteoporosis Social History: Lives with:husband, financially supports her son and his wife Contact: [**Name (NI) **] Phone #([**Telephone/Fax (1) 99456**] Occupation:retired Cigarettes: Smoked no [] yes [x] last cigarette 45 years ago Hx:for ten years Other Tobacco use: ETOH: < 1 drink/week [x] [**1-29**] drinks/week [] >8 drinks/week [] Denies illicit drug use Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Father died of prostate cancer. Mother died of colon and liver cancer. Physical Exam: Pulse:66 Resp:18 O2 sat:98% 1L B/P Right:141/84 Height: 5'2" Weight:97.4kg General: Skin: Dry [x] intact [x] Multiple raised areas across chest HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade II/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:1+ Left:1+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right: - Left:- Pertinent Results: [**2170-10-12**] 08:25AM BLOOD WBC-15.8* RBC-3.31* Hgb-9.6* Hct-29.6* MCV-89 MCH-28.9 MCHC-32.3 RDW-15.1 Plt Ct-243 [**2170-10-12**] 08:25AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-136 K-4.1 Cl-99 HCO3-27 AnGap-14 [**2170-10-11**] 03:03AM BLOOD Glucose-149* UreaN-22* Creat-1.0 Na-137 K-4.0 Cl-102 HCO3-26 AnGap-13 [**2170-10-11**] 03:03AM BLOOD WBC-17.3* RBC-3.43* Hgb-10.0* Hct-30.1* MCV-88 MCH-29.0 MCHC-33.0 RDW-15.4 Plt Ct-218 [**2170-10-12**] 08:25AM BLOOD Mg-1.9 Brief Hospital Course: The patient was brought to the Operating Room on [**2170-10-9**] where she underwent AVR, CABG x 3 with Dr. [**First Name (STitle) **]. See operative note for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Post-operative day one found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. She was started on Plavix instead of aspirin due to a history of aspirin allergy. The patient was evaluated by the physical therapy service for assistance with strength and mobility. She was restarted on her home medications of ciprofloxacin and prednisone. By the time of discharge on post-operative day four the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. She was discharged to home with appropriate follow up instructions. Medications on Admission: ATENOLOL - 25 mg Tablet - one Tablet(s) by mouth twice a day B AND D ULTRATHIN NEEDLES - - use twice a day CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day DARIFENACIN [ENABLEX] - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**]) - 15 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth once a day EXENATIDE [BYETTA] - (Prescribed by Other Provider: [**Name Initial (NameIs) **] ) - 10 mcg/0.04 mL per dose Pen Injector - 10 mcg twice a day GLYBURIDE - 5 mg Tablet - [**12-24**] Tablet(s) by mouth QAM and 1 tablet by mouth QPM LEVOTHYROXINE [LEVOXYL] - 112 mcg Tablet - 1 Tablet(s) by mouth once a day MELOXICAM - 15 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day NAPROXEN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day - No Substitution NIFEDIPINE [NIFEDICAL XL] - 60 mg Tablet Extended Rel 24 hr - 1 Tab(s) by mouth once a day increased to 90 mg per card OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 10 mg Tablet Extended Rel 24 hr - Tablet(s) by mouth OXYCODONE - 5 mg Tablet - [**12-24**] Tablet(s) by mouth Q4-6H as needed for pain Do not drive or drink alcohol while taking this medication. Sedating. OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 to 2 Tablet(s) by mouth Every 4-6 hours as needed for PAIN Do not drink alcohol, drive, or take tylenol. [**Last Name (un) **]#BB[**Telephone/Fax (5) 99457**]-OS PAROXETINE HCL - 40 mg Tablet - 1 Tablet(s) by mouth once a day PRAVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth once a day PREDNISONE - - 2 tabs once a day 5mg QUINAPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day SPIRONOLACTON-HYDROCHLOROTHIAZ - 25 mg-25 mg Tablet - 1 Tablet(s) by mouth once a day TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply to affected area twice a day for 2 weeks, avoid face skin folds and groin Discharge Medications: 1. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 2. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Enablex 15 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a day. 5. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. glyburide 5 mg Tablet Sig: One (1) Tablet PO take 0.5 tablets (2.5mg) in the morning and 1 tablet (5mg) at night. 7. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) Subcutaneous twice a day. 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 11. 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* 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*2* 13. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day. 15. meloxicam 15 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease Diabetes morbid obesity chronic diastolic heart failure moderate AS mild-moderate MR [**First Name (Titles) **] [**Last Name (Titles) 2947**] History multiple back surgeries, thoracic lumbar bolts in back and neck shoulder replacement debridement of R 4th and 5th fingers s/p tenosynovectomy osteoporosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg, left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2170-11-12**] at 1:30pm Cardiologist:Dr. [**Last Name (STitle) **] at [**Location (un) 620**] on [**2170-10-31**] at 2pm Please call to schedule appointments with your Primary Care Dr.[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 9347**]) in [**3-27**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2170-10-13**]

[ "458.29", "250.00", "401.9", "428.32", "414.01", "396.2", "244.9", "285.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "35.21", "36.15", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

7666, 7721

3107, 4381

8094, 8306

2612, 3084

9230, 9946

1753, 1911

6354, 7643

7742, 8073

4407, 6331

8330, 9207

1926, 2593

268, 727

755, 1081

1103, 1369

1385, 1737

81,558

154,689

41884

Discharge summary

report

Admission Date: [**2141-1-13**] Discharge Date: [**2141-1-20**] Date of Birth: [**2072-1-22**] Sex: M Service: CARDIOTHORACIC Allergies: Dilaudid Attending:[**First Name3 (LF) 4679**] Chief Complaint: dysphagia Major Surgical or Invasive Procedure: [**2141-1-13**] 1. Minimally-invasive esophagectomy with intrathoracic anastomosis. 2. Buttressing of anastomosis with pericardial fat. 3. Laparoscopic jejunostomy feeding tube. 4. Esophagogastroduodenoscopy. History of Present Illness: Mr. [**Known lastname 3549**] is a 68 year old male with biopsy proven T3N0MX esophageal adenocarcinoma on EGD/biopsy performed [**2140-8-11**]. Initial PET scan showed GE juntion avidity but no nodal disease. He then completed a 6-week course of neoadjuvent chemotherapy and radiation at [**Hospital3 **] hospital (chemotherapy completed [**2140-11-2**] and radiation therapy completed [**2140-11-7**]). His post-chemotherapy course was complicated by a severe episode of dehydration that warranted hospitalization at [**Hospital3 417**] hospital on [**2140-11-22**]. During that hospitalization there also was concern of G-tube infection which was subsequently removed. Mr. [**Known lastname 3549**] then spent a period of time in rehab. Prior to this admission, however, he has been able to tolerate PO and had weight gain. Recent follow-up PET scan performed several days preoperatively did not demonstrate any FDG-avid disease. Past Medical History: neck and right shoulder pain from arthritis, PE vs pulmonary infarction (Coumadin started [**2140-9-12**]) Social History: Tob: 75 pk-yrs, recent use. EtOH: denies. Asbestos exposure. Married, lives with family. Family History: Mother - colon cancer Father - colon and bladder ca Physical Exam: Discharge Physical Exam: GEN: NAD, A&Ox3 CV: RRR, no MRG PULM: CTAB ABD: S/NT/ND, no organomegaly; j-tube in place, incision site c/d/i EXT: WWP INCISIONS: C/D/I Pertinent Results: [**2141-1-20**] 07:10AM BLOOD WBC-9.1 RBC-2.61* Hgb-8.6* Hct-26.1* MCV-100* MCH-33.1* MCHC-33.1 RDW-14.5 Plt Ct-315 [**2141-1-20**] 07:10AM BLOOD PT-13.7* PTT-28.5 INR(PT)-1.3* [**2141-1-20**] 07:10AM BLOOD Glucose-124* UreaN-19 Creat-0.4* Na-139 K-4.2 Cl-106 HCO3-24 AnGap-13 [**2141-1-20**] 07:10AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.1 ____ CHEST (PA & LAT) Study Date of [**2141-1-20**] 8:48 AM FINDINGS: As compared to the previous radiograph, there is still contrast material projecting over the right upper quadrant. The extent of the pleural effusion on the right has minimally increased. Also increased are the areas of right atelectasis. Unchanged is the left pleural effusion. No pneumothorax. Unchanged size of the cardiac silhouette. Unchanged left pectoral Port-A-Cath. ____ ESOPHAGUS Study Date of [**2141-1-19**] 11:28 AM IMPRESSION: 1. Contrast freely passing through the esophagogastric anastomosis, without extraluminal contrast to suggest leak. 2. No evidence of gastric outlet obstruction. ____ CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2141-1-15**] 4:16 PM IMPRESSION: 1. No main, lobar, or proximal segmental pulmonary embolus. 2. Interval changes of a recent esophagogastrectomy with intrathoracic anastomosis. 3. Small right-sided pneumothorax with right-sided chest tube and JP drains in place. 4. Diffuse scattered moderate centrilobular emphysematous changes throughout the lungs and stable wedge resection changes in the left lower lobe. 5. Small left-sided pleural effusion with adjacent basilar atelectasis. 6. Near-complete atelectasis of the right lower lobe, which could be secondary to mucus impaction or debris within distal subsegmental bronchi in the right lower lobe bronchial tree. 7. Mild amount of fluid in the right major fissure posteriorly. ____ Pathology for esophagogastrectomy, fundus of stomach, esophageal donut, gastric donut. Report date [**2141-1-18**] DIAGNOSIS: I. Stomach, gastric donut (A): Gastric segment with oxyntic type mucosa, within normal limits. II. Esophagus, "donut" (B): Segment of squamous epithelium-lined esophagus, within normal limits. III. Gastric fundus, resection (C-D): Gastric segment with oxyntic type mucosa, within normal limits. IV. Distal esophagus and proximal stomach, esophagogastrectomy (E-[**Doctor Last Name **]): A. Residual adenocarcinoma of the gastroesophageal junction seen within the muscularis mucosae and muscularis propria (ypT2). B. Thirty-one regional lymph nodes with no carcinoma seen (0/31--ypN0). C. Submucosal fibrosis and mucosal ulceration consistent with the patient's history of neoadjuvant chemoradiation. D. No precursor dysplasia or intestinal metaplasia identified. Brief Hospital Course: On [**2141-1-13**], the patient had a minimally invasive esophagectomy. He tolerated the procedure well. For details, see the separately-dictated operative note. NEURO/PAIN: The patient's pain was initially well-controlled with an epidural. Upon discontinuatin of the epidural, he was well controlled on PO tylenol. On POD#1 and POD#2, the patient had episodes of confusion and agitation, necessitating soft restraints in the ICU; his mental status improved considerably after discontinuation of all narcotics, and he remained generally well-oriented (with only occasional periods of mild disorientation at night) through to his day of discharge. CARDIOVASCULAR: The patient remained hemodynamically stable. His vitals signs were monitored with telemetry. RESPIRATORY: The patient was extubated in the immediate post-op period successfully. On POD#2, during an episode of agitation, an ABG showed respiratory alkalosis and mild hypoxia; a CT then was negative for PE. He subsequently improved from this episode, both in terms of his mental status and respiratory status. For the remainder of his stay he maintained good oxygentation with 1-2L supplemental O2 via nasal cannula. GASTROINTESTINAL: The patient had a minimally-invasive esophagectomy on [**2141-1-13**]. He generally followed the MIE pathway. His j-tube feeds were started on POD#1 and advanced to goal. During an episode of agitation on POD#2, he did remove his NGT, and this was replaced without incident. He was NPO until POD#6, when his barium swallow study showed good passage of contrast with no leak, and he was advanced to full liquids, which he tolerated well. He is discharged with VNA and supplies to continue tube feeding at home. GENITOURINARY: The patient's urine output was monitored. A Foley catheter was placed intra-operatively and removed on POD#5, at which time the patient was able to successfully void. HEME: The patient's hematocrit was monitored daily, and he required no transfusions. His preoperative anticoagulation was resomed on POD#7 with a lovenox bridge to coumadin. ID: The patient did have a temperature of 101.2 on POD#2, but this resolved and he required no antibiotics. He had no further fevers and his white blood count remained normal. On CXR the day of discharge he did have a patchy right-sided opacity. However he remained asymptomatic, afebrile with no productive cough. He is scheduled for follow up CXR and CBC on follow up next week. ENDOCRINE: The patient's blood glucose was monitored and he had no significant endocrine issues. PROPHYLAXIS: The patient was maintained on SQ heparin, pneumoboots, and encouraged to ambulate with the help of physical therapy. He was given pantoprazole and an inspiratory spirometer. He was discharged in stable condition, pain well controlled, voiding well, and with instructions and appropriate prescriptions for supplemental oxygen and tube feeds. He was instructed to call or return to the ED with concerning symptoms. Medications on Admission: pravastatin 10', phenobarbital 1' qhs, celexa Discharge Medications: 1. Replete Liquid Sig: One (1) PO once a day: Replete full strength at 100cc/hr cycled over 14 hours. [**Date Range **]:*qs * Refills:*2* 2. pump set Misc Sig: One (1) Miscellaneous once a day: Tube feeding pump and supplies. [**Date Range **]:*1 pump* Refills:*2* 3. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) dose PO Q6H (every 6 hours) as needed for pain. [**Date Range **]:*60 dose* Refills:*0* 4. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2 times a day). [**Date Range **]:*300 ml* Refills:*2* 5. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Adjust dose as instructed by your doctor. [**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2* 6. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. phenobarbital Oral 8. O2 Sig: One (1) once a day: 1-2L continuous oxygen, pulse oxygen for portability diagnosis: s/p esophagectomy. [**Last Name (Titles) **]:*1 O2* Refills:*2* 9. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous twice a day for 1 months. [**Last Name (Titles) **]:*60 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Esophageal cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers greater than 101 or chills -Increased shortness of breath, cough or chest pain -Nausea, vomiting (take anti-nausea medication) -Increased abdominal pain -Incision develops drainage -Remove chest tube and j-tube site bandages Saturday and replace with a bandaid, changing daily until healed. -Resume your Lovenox and Coumadin. Pain -Tylenol via J-tube or orally as needed for pain -Take stool softners as needed Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily Diet: Tube feeds: Replete Full Strength 100 mL x 14 hrs from 3pm to 9am Flush J-tube with 10 mls water every 8 hours, before and after starting tube feeds and giving medications through tube Full liquid diet, may increase to soft solids over the next few days as tolerated. Eat small frequent meals. Sit up in chair for all meals and remain sitting for 30-45 minutes after meals Daily weights: keep a log bring with you to your appointment NO CARBONATED DRINKS Danger signs Fevers > 101 or chills Increased shortness of breath, cough or chest pain Incision develops drainage Nausea, vomiting (take anti-nausea medication) Increased abdominal pain Call if J-tube falls out (save the tube and bring with you to the hospital to be re-placed) or suture breaks Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2141-1-24**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [**Location (un) **] of the Clinical Center for a chest xray. Completed by:[**2141-1-21**]

[ "V12.55", "530.81", "150.5", "293.0", "716.91", "511.9", "276.4", "443.9", "458.29", "V15.84", "V58.61", "272.4", "V49.87" ]

icd9cm

[ [ [] ] ]

[ "46.32", "43.99", "40.3", "96.6", "42.52" ]

icd9pcs

[ [ [] ] ]

8881, 8942

4693, 7670

285, 499

9004, 9004

1965, 4670

10709, 11198

1715, 1768

7766, 8858

8963, 8983

7696, 7743

9155, 10686

1783, 1783

236, 247

527, 1462

9019, 9131

1484, 1593

1609, 1699

1808, 1946

5,573

133,541

47819

Discharge summary

report

Admission Date: [**2139-8-13**] Discharge Date: [**2139-8-20**] Date of Birth: [**2066-4-30**] Sex: M Service: MEDICINE Allergies: Amoxicillin / Hydrochlorothiazide Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: -Cardiac Catheterization with stenting of RAMUS History of Present Illness: 72M h/o CAD s/p CABG ([**2109**]/redo [**2120**]), CHF (EF<20) s/p BiV/ICD [**5-30**], AF, DM2 s/p stent [**4-30**] to RAMUS & LIMA anastomosis now presents with hypotension and NSTEMI, [**Hospital **] transfer from cath lab. He presented on [**8-13**] with ongoing chest pressure for a week, [**9-3**] chest pressure radiating down his R arm and to his neck, non-pleuritic, associated with nausea while working as an [**Doctor Last Name **] at [**Hospital1 778**] park. In the ED, patient ruled in for NSTEMI and cardiology was consulted. CK 273-218, MB 48-24 trop 1.48. ECG was v-paced rhythm uninterpretable for ischemia. he had ongoing pain. BP was mostly 80's systolic. He was taken for cath on [**8-13**] and found to have ISR of RI stent, treated with Taxus. Transiently required dopa during cath for maps dropping into high 40s-50s. Transferred to CCU for further monitoring. Past Medical History: CAD (CABG [**2109**] AND [**2120**]); PTCA of RAMUS takeoff and LIMA anastamosis in [**4-30**] CHF w/ EF 20%, diastolic dysfxn, s/p BiV pacer and ICD placement Atrial fibrillation (s/p ablation) DM (HBA1c [**5-30**] = 7.2) CKD GERD PUD gout claudication s/p CCY s/p cataract [**Doctor First Name **] [**1-30**] s/p back surgery R Common Iliac Artery Stenosis, s/p stent [**2131**] Social History: Pt is a retired electrial engineer for [**Company 2676**]. Currently works as [**Doctor Last Name **] at [**Hospital1 778**]. lives w/ wife, daughter and granddaughter in [**Name (NI) 8242**]. Quit tobacco >15 years ago; 50 pk-yr history. Social EtOH (2 drinks/week), no illicits. Wife is HCP. Daughter was cardiac nurse. Family History: Noncontributory. Physical Exam: VS: T: 97.2 P: 76 R: 18 BP: 90/47 SaO2: 98% RA weight: 82.3 (S) GEN: lying in bed, NAD HEENT: AT, NC, PERRLA, EOMI, anicteric, OP clear, MMM CV: RRR, nl s1, s2, no m/r/g, no carotid bruits appreciated PULM: diffuse scattered crackles, otherwise clear ABD: soft, NT, ND, + BS, no HSM EXT: warm, dry, +2 pitting edema to knees BL, L > R (which is usual for him) +1 distal pulses BL Skin: open shallow skin tear over L shin NEURO: alert & oriented x 3, CN II-XII grossly intact; no abnormal movements noted. Pertinent Results: [**2139-8-12**] 10:15PM WBC-8.7 Hct-29.6 Plt Ct-119 [**2139-8-13**] 05:25AM WBC-8.3 Hct-25.7 Plt Ct-110 [**2139-8-15**] 11:41PM Hct-29.7 Plt Ct-95 [**2139-8-16**] 06:02AM WBC-9.2 Hct-26.9 Plt Ct-89 [**2139-8-16**] 02:35PM Hct-28.7 . [**2139-8-12**] 10:15PM PT-13.8 PTT-30.4 INR(PT)-1.2 . [**2139-8-12**] 10:15PM CK-273 CK-MB-30 MB Indx-11.0 cTropnT-1.43 proBNP-[**Numeric Identifier 100943**] [**2139-8-13**] 05:25AM CK-218 CK-MB-24 MB Indx-11.0 cTropnT-1.48 [**2139-8-13**] 04:19PM CK-210 CK-MB-28 MB Indx-13.3 [**2139-8-14**] 03:48AM CK-231 CK-MB-20 MB Indx-8.7 [**2139-8-14**] 03:49PM CK-137 CK-MB-9 . [**2139-8-16**] 06:02AM calTIBC-324 Ferritn-144 TRF-249 . Cardiac catheterization: Selective coronary angiography of this right dominant system demonstrated a known three vessel coronary disease. The LMCA had a 90% in-stent restenosis of the left main-ramus bifrucation. The LAD had a known proximal occlusion. Distal LAD filled via LIMA graft. The LCx had a known total occlusion. The RCA had a known occlusion and was not injected (distal RCA filled via SVG). Arterial conduit angiography revealed that the LIMA to LAD had a less than 50% instent restenosis that was not flow limiting. The SVG to distal RCA was widely patent. Resting hemodynamics revealed elevated right and left sided filling pressured with RVEDP of 19 mmHg and a PCWP of 25 mm Hg. There was a moderate pulmonary artery systolic hypertension with a PASP of 51 mm Hg. The cardiac index was preserved at 2.5 l/min/m2. There was a significant arterial hypotension with a central aortic pressure of 74/41 mm Hg necessitating initiation of dopamine infusion. Left ventriculography was deferred give patients declining renal function. Of note, arterial and venous access was obtained via left groin given dimished right femoral pulse and a history of right iliac stent placement. Successful PTCA and stenting of the Ramus Intermedius and Left Main bifurcation with a 3.5x8 mm Taxus stent. Final angiography revealed minimal residual stenosis, no angiographically apparent dissection, and TIMI 3 flow in the vessel. Brief Hospital Course: A/P: 72M h/o CAD s/p CABG ([**2109**]/redo [**2120**]), CHF (EF<20) s/p BiV/ICD [**5-30**], AF, DM2 s/p stent [**4-30**] to RAMUS & LIMA anastomosis now presents with hypotension/NSTEMI. Had in-stent restenosis of RAMUS, which was re-stented with DES. . ## Cardiac: - Ischemia: pt had NSTEMI, underwent cardiac cath which revealed LMCA with a 90% in-stent restenosis of the left main-ramus bifrucation. This area was stented. There were other stenotic areas (see report) that were not stented as they were not felt to be culprit lesions. The pt was treated with ASA 325, clopidogrel 75, atorvastatin 20 PO qd. His carvedilol was resumed after his BP improved. Post-procedure the pt was hypotensive and required pressors; however, he was weaned off of these & was eventually re-started on 3.125 of carvedilol. - Pump/hypotension: Pt has history of severe cardiomyopathy/CHF with an EF <20%. Right heart cath revealed elevated right and left sided filling pressured with RVEDP of 19 mmHg and a PCWP of 25 mm Hg. There was a moderate pulmonary artery systolic hypertension with a PASP of 51 mm Hg. The cardiac index was preserved at 2.5 l/min/m2. There was a significant arterial hypotension with a central aortic pressure of 74/41 mm Hg necessitating initiation of dopamine infusion. The pt required dopamine off and on during his stay; however, with aggressive diuresis he was able to be weaned off it completely. The pt was significantly volume overloaded upon arrival and post-cath. Though he tolerated resumption of carvedilol, his ACE inhibitor was held during the hospitalization. His SBPs ranged from 90's-100's near time of discharge. - Rhythm: the pt was in BiVentricular paced rhythm. His coumadin was initially held because he was anemic & had dark, guiac (+) stools. After stabilization of his Hct, coumadin was restarted at 2.5 qod and 5mg qod. . ## Anemia/bleed: pt has h/o GI bleeding & was found to guaiac positive stool during admission. GI was consulted & deferred endoscopy until the pt was stabilized and an outpt. Pt also had multiple nosebleeds during hospitalization. ENT was consulted: they felt that there was no serious underlying pathology. They recommend affrin. These eventually resolved. Upon work-up of his anemia, pt was found to be iron deficient. He was started on PO iron. He was also continued on his outpt EPO dosing (for CRI). During hospitalization, he required multiple transfusions, the last of which was given the day prior to discharge. The pt's hct responded appropriately to the transfusion & he was asymptomatic. . ## Renal: ARF on CRF. Pt's baseline thought to be approximately Cr 1.9. However, his PCP reported that just prior to admission he had a Crt of 3. Upon admission, his crt was 3.5. It peaked at 3.9. He had low urine output & FeNA < 1%. Renal was consulted and they felt that the ARF was primarily due to CHF--poor forward flow. HD was deferred and the pt was aggressively diuresed. With diuresis, his SBP improved (as did his UOP), and the crt trended down to 2.3 on day of discharge. The pt did have hematuria after Foley removal, which was thought to be secondary to trauma. This resolved over a few days. Will follow closely for anuria given risk of clot. S-PEP & U-PEP were checked (upon renal's rec's) & were negative. . ## Hyponatremia: Likely [**2-26**] cardiomyopathy and ARF. The pt was free water restricted. ## Thrombocytopenia: ? HIT vs. liver dz. LFTs normal except for slight elevation of AST on admission. It was thought that perhaps low count may be due to congestive hepatopathy with CHF. Pt did not have HIT antibodies. . ## DM: The pt was maintained on RISS. His glyburide was discontinued given his renal function. We began glypizide the day of discharge. . ## PPx: pt received heparin sc and protonix. ## CODE: FULL Medications on Admission: ASA Plavix Coreg Epogen Lisinopril Zocor Glyburide Coumadin Mg Ox Lasix (120 po bid) Nexium Zaroxylyn Digoxin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) ml Injection QMOWEFR (Monday -Wednesday-Friday). 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Warfarin 5 mg Tablet Sig: 0.5 alternating with 1 Tablet PO HS (at bedtime): Please 2.5mg take every other day, alternating with 5mg. 8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): YOU [**Month (only) **] USE YOUR OLD TABLETS THAT ARE 6.25 MG, BUT BE SURE TO SPLIT THEM IN HALF!. 9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Glipizide 5 mg Tablet Sig: 0.5 in AM 1 in PM Tablet PO BID (2 times a day): Please take 2.5mg in AM and 5mg in PM. Disp:*45 Tablet(s)* Refills:*2* 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: -Non-ST-segment elevation myocardial infarction -Severe cardiomyopathy/congestive heart failure -Iron deficiency Anemia w/ GI bleed -Acute on chronic renal failure -Urinary tract infection -Atrial fibrillation Secondary: -Thrombocytopenia -Diabetes Mellitus -gastroesophageal reflux Discharge Condition: Stable Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1 liter. -Please STOP taking your magnesium supplement as your magnesium level was elevated on admission. -Please continue taking the anti-biotic ciprofloxacin for 3 more days (last day [**2139-8-23**]) for a urinary tract infection. -Please take the iron pills prescribed for your iron deficiency anemia. -Please take your coumadin as prescribed and have your INR checked on Monday [**8-24**] w/ your [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. -Please take your new medication Glipizide (for your diabetes). This will replace your glyburide. DO NOT TAKE GLYBURIDE. -Please call your doctor or go to the ER if you note any chest pain, shortness of breath, Nausea/vomiting, blood in your stool, or any other change in your health. -Continue your aspirin & plavix as prescribed. Do not stop these unless Dr. [**First Name (STitle) 437**] instructs you to do so. Followup Instructions: -Please call Dr.[**Name (NI) 3536**] office #[**Telephone/Fax (1) 3512**] by Monday [**8-24**] to make an appointment with him within 1-2 weeks after discharge from the hospital. -Please make an appointment with your primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 2 weeks of discharge from the hospital. -Please attend the following appointments: -Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2139-9-22**] 10:30 -Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2139-9-30**] 10:00 -Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2139-9-30**] 10:30

[ "287.5", "410.71", "584.5", "428.33", "428.0", "V45.02", "274.9", "250.00", "427.31", "440.21", "276.1", "599.0", "414.01", "280.0", "578.9", "414.8", "996.72", "585.9", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.45", "88.56", "00.66", "99.04", "00.17", "00.40", "88.52", "37.23" ]

icd9pcs

[ [ [] ] ]

9994, 10000

4732, 8562

313, 363

10336, 10345

2598, 4709

11432, 12298

2038, 2056

8723, 9971

10021, 10315

8588, 8700

10369, 11409

2071, 2579

263, 275

391, 1276

1298, 1681

1697, 2022

64,411

142,339

54372

Discharge summary

report

Admission Date: [**2195-10-24**] Discharge Date: [**2195-10-30**] Date of Birth: [**2130-3-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Pericardial effusion Major Surgical or Invasive Procedure: Pericardiocentesis Cardioversion History of Present Illness: Pt is a 65 yo M with PMH significant for dilated CM with EF of 30-35%, afib, BiV [**First Name3 (LF) 3941**] in [**6-28**] p/w pericardial effusion on echo admitted for pericardiocentesis. Pt. was recently seen at [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Last Name (Titles) 620**] at which time he was experiencing intermittent chest discomfort. Patient mentions that his SOB had been getting worse on exertion, and found it difficult to make it to his car. In addiion, he has had intermittent right sided chest pain that radiates to the left side of his chest. He is known to have atrial fibrillation and is on amiodarone. His [**Last Name (Titles) 3941**] was tested on [**2195-8-18**], and at that time, he was converted from atrial fibrillation to sinus rhythm with DCCV. On device interrogation on [**2195-9-2**] it appeared he remained in sinus rhythm for several days and had since reverted back to atrial fibrillation with slow ventricular response between 50-100 bpm. Patient denied lightheadedness, dizziness, presyncope, actual syncope, shortness of breath at rest. The patient had baseline 2 pillow orthopnea, and paroxysmal nocturnal dyspnea. The patient is on Coumadin for a history of atrial arrhythmias, and has had INR values that have been within the therapeutic range. . During this admission, on echo demonstrated a larger (moderate-sized) pericardial effusion. He underwent elective percardiocentesis of 400cc bloody fluid. He was observed in the CCU overnight s/p procedure and had the pericardial drain removed on [**2195-10-29**]. A repeat echo showed a small loculated effusion. He has been on heparin during his hospitalization for afib and procedures. The EP service plans to perform repeat DCCV. Past Medical History: coronary artery disease status post PTCA of LAD in [**2195-4-21**] dilated cardiomyopathy/CHF ischemic vs alcoholic, ejection fraction approximately 30-35% status post BiV [**Year (4 digits) 3941**] [**2195-6-21**] persistent atrial fibrillation s/p multiple cardioversions history of renal embolic infarct found in [**2-/2195**], with left atrial appendage thrombus at that time. hypertension history of heavy alcohol use Questionable thalmic infarct BPH Plastic surgeries for deformed ear Social History: married with no children. quit smoking 36 years ago. Now drinks two glasses of wine on weekends, reduced from prior heavy use. self-employed financial consultant. Family History: Both parents had MIs, mother age 55 and father age 65. [**Name2 (NI) **] sudden deaths in family. Physical Exam: VS - 98.9 106/75 80 18 100% RA, pulsus measured at 6mm Hg Gen: NAD, pleasant, ambulating HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Neck: Supple, no JVD was appreciated, healed scar at base of neck. CV: no friction rub, no MRG Chest: CTAB Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c. No edema b/l. wwp b/l. Skin: No concerning rashes Neuro: AAOx3, no focal motor or sensory deficits Pertinent Results: [**2195-10-24**] 05:07PM PT-32.4* PTT-38.0* INR(PT)-3.4* [**2195-10-24**] 05:07PM PLT COUNT-360 [**2195-10-24**] 05:07PM WBC-7.9 RBC-3.74* HGB-11.3* HCT-33.2* MCV-89 MCH-30.2 MCHC-34.1 RDW-15.1 [**2195-10-24**] 05:07PM CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-2.3 [**2195-10-24**] 05:07PM GLUCOSE-112* UREA N-25* CREAT-1.2 SODIUM-131* POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-25 ANION GAP-11 [**2195-10-24**] 10:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-7.0 LEUK-NEG [**2195-10-24**] 10:35PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022\ Echo ([**2195-10-29**]): Overall left ventricular systolic function is severely depressed (LVEF= 30 %). The right ventricular cavity is mildly dilated with depressed free wall contractility. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is a small pericardial effusion. The effusion appears loculated. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2195-10-28**], there is no change to the small loculated pericardial effusion present posterior to the LV and the RA. C Cath ([**2195-10-28**]): FINAL DIAGNOSIS: 1. Successful pericardiocentesis with removal of 400 cc of serousangious fluid and improvement in pericardial pressure from mean of 11 mm Hg to 0 mmHg. 2- Elevated right and left sided filling pressures with RVEDP of 13 mmHg and PCWP of 20 mmHg (unchanged after tap). Brief Hospital Course: ASSESSMENT AND PLAN: Pt is a 65 yo M with PMH significant for dilated CM with EF of 30-35%, BiV [**Month/Day/Year 3941**] with pericardial effusion and afib s/p pericardiocentisis. . #. Pericardial Effusion: Patient had a moderate sized pericardial effusion echo on [**2195-10-14**] which showed a moderate pericardial effusion that is circumferential. Patient is s/p tap and had a residual small loculated effusion on echo [**2195-10-28**]. Restarted coumadin, patient was never symptomatic. Has a scheduled echo in one week to reassess loculated effusion. . #. Atrial fibrillation: Patient has a BIV pacemaker placed and is v-paced. Also on home amiodarone for underlying atrial fibrillation. Coumadin was held for tap, placed on heparin, then discontinued heparin to coumadin when INR 2.0. Had a successful d/c cardioversion, and was discharged with follow up with outpatient electrophysiologist. Will also follow up his INR as prior to admission, discharged on warfarin (initially given vitamin K for pericardiocentesis). . #. CAD: Patient had his cardiac catheterization in [**Month (only) **] of [**2195**], had a stent placed to the LAD. No ischemic changes on EKG noted, patient complained of mild chest pain on right side no different than in the past which was relieved by sublingual nitroglycerin. Continued ASA, plavix, statin, Lisinopril, and nitroglycerin. . #. Pump: Patient is followed by Dr. [**First Name (STitle) 437**], echo on [**2195-10-28**] demonstrated EF of 20-30%. Not wet on physical exam, patient fluid restricting himself as well. Continued carvedilol, spironolactone, Digoxin. . #. BPH: Continued finasteride . #. Hx of Depression: Continued sertraline Medications on Admission: Amiodarone 200 mg twice daily carvedilol 6.25 mg twice daily Plavix 75 mg daily digoxin 0.125 mg daily, lisinopril 40 mg daily finasteride 5 mg daily aspirin 325 mg daily warfarin 2 mg daily spironolactone 12.5 mg daily, simvastatin 10 mg daily sertraline 75 mg daily vitamin B vitamin D magnesium fish oil alpha-lipoic acid. Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). Disp:*30 Tablet, Sublingual(s)* Refills:*2* 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Outpatient Lab Work Please draw your PT/PTT/INR (coagulation studies) and forward results to [**Last Name (LF) **],[**First Name3 (LF) **] D. (office number) [**Telephone/Fax (1) 3329**] Discharge Disposition: Home Discharge Diagnosis: Primary: Pericardial Effusion Atrial Fibrillation status post pacemaker placement Secondary: coronary artery disease status post percutaneous intervention dilated cardiomyopathy with congestive heart failure hypertension alcoholism BPH Plastic surgeries for deformed ear Discharge Condition: Stable, ambulating, eating, drinking, and voiding without complaints. Discharge Instructions: You were admitted for a drainage of the fluid in the sac that is around your heart. You underwent a pericardiocentesis (a procedure where they drain fluid from that sac) successfully and then transferred to the floor. You then underwent a cardioversion to convert your heart back to a normal rhythm from the fibrillation that you were in during your stay. We have given you a supply of sublingual nitroglycerin if you require it, but have not started you on any other new medications. Please also get your INR checked as you normally do and send them to your primary care provider as we discussed. If you have any sudden shortness of breath, chest pain, lightheadedness, loss of consciousness, or blood in your stool/urine, please contact your primary care provider [**Name Initial (PRE) 2227**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: 1. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-11-4**] 10:00 2. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-11-4**] 11:20 3. Provider: [**Name10 (NameIs) 3941**] CALL TRANSMISSIONS Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2196-1-18**] 9:30 4. You also will have an appointment to be scheduled with Dr. [**Last Name (STitle) **] - the secretary will contact you with the appointment if they do not have a time before your discharge. It will be in 1 to 2 weeks. 5. Dr. [**Last Name (STitle) 58**]: [**2195-11-10**] at 3pm. Completed by:[**2195-10-30**]

[ "V53.32", "414.01", "401.9", "428.0", "600.00", "V45.82", "311", "429.4", "425.4", "423.0", "427.31", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "37.21", "99.62", "37.0" ]

icd9pcs

[ [ [] ] ]

8352, 8358

4951, 6641

338, 373

8674, 8746

3377, 4641

9696, 10405

2851, 2950

7018, 8329

8379, 8653

6667, 6995

4658, 4928

8770, 9673

2965, 3358

278, 300

401, 2140

2162, 2654

2670, 2835

19,930

166,080

50464

Discharge summary

report

Admission Date: [**2173-2-19**] Discharge Date: [**2173-2-23**] Service: HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 105134**] is a [**Age over 90 **]-year-old woman with a significant history of coronary artery disease, status post myocardial infarction times three, congestive heart failure (last echo with an ejection fraction of 40%) Paroxysmal atrial fibrillation with a rapid response, presented with chest pain and a rapid rate, and respiratory decompensation. She was emergently intubated, had admitted from the emergency department to [**Hospital1 190**] CCU. The patient was noted to have ST elevations with her rapid rate which cleared when her rate was adequately controlled with beta-blockers. However, later that evening she developed sinus bradycardia. This is a known response in the patient to administration of beta-blockers. In the CCU she was diuresed with resolution of respiratory distress, CKMB fraction was positive but Troponin I was negative. She was initially started on Heparin but this was stopped due to the feeling that she was likely not suffering infarction. She was called out to the floor in stable condition. PAST MEDICAL HISTORY: 1. Coronary artery disease. Status post myocardial infarction times three. 2. Congestive heart failure. Echo [**5-/2171**] with an EF of 40 to 45% 3. Hypertension. 4. Glaucoma. 5. Depression. 6. Paroxysmal atrial fibrillation/flutter. 7. Chronic renal insufficiency. 8. Hypothyroidism. 9. Early dementia. 10. CLL. 11. Asthma. ALLERGIES: Penicillin and Codeine. MEDICATIONS ON TRANSFER TO FLOOR: 1. Protonics 40 mg p.o. q day. 2. Fentanyl intravenous p.r.n. 3. Captopril 6.25 mg three times a day. 4. Aspirin 325 mg q day. MEDICATIONS ON ADMISSION: 1. Levoxyl 100 mcg p.o. q day. 2. Cefrolucas 20 mg p.o. b.i.d. 3. Isordil 40 mg p.o. three times a day. 4. Zestril 10 mg p.o. q day. 5. Aspirin 81 mg p.o. q day. 6. Colace 100 mg p.o. b.i.d. 7. Senokot. 8. [**Doctor First Name **] 60 mg p.o. q day. 9. Azapt drops to each eye. 10. Serevent two puffs b.i.d. 11. Lasix 10 mg p.o. q day. 12. Flexeril 20 mg p.o. q day. 13. Zyprexa 2.5 mg q h.s. 14. Asthmacort two puffs p.o. twice a day. 15. Lactulose p.r.n. SOCIAL HISTORY: Lives in [**Hospital3 **]. Primary care physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. PHYSICAL EXAMINATION: On admission temperature 97.8, blood pressure 123/77, heart rate in the 60 sating at 98% on 40% FIO2 with a PEEP of 5. Nasally intubated. Awake, alert, mouthing words appropriately. Mucosa dry. Heart rate rhythm regular, no murmurs. Lungs clear to auscultation bilaterally and superiorly. Scattered expiratory wheezes. Abdomen soft, nontender, nondistended. Rectal exam: Heme negative. Extremities had 1+ edema. She was alert and oriented times three and her neurological exam was grossly nonfocal. LABORATORY: On admission initial white count 202, hematocrit 38.1, platelets 351, sodium 141, potassium 5.0, chloride 104, bicarbonate 24, BUN 52, creatinine 1.5. Glucose 242. CK 66, troponin I less then 0.3. Calcium 9.4, magnesium 2.3, phosphorus 4.7. Urinalysis with 30 protein, 3 to 5 red blood cells, 0 to 2 white blood cells. Arterial blood gases: 7.27/54/281 on 40% O2, PEEP of 5, Tidal volumes of 500. Chest x-ray showing congestive heart failure without infiltrates. Electrocardiogram: 1. Atrial flutter at 104, no Q-waves 2, [**Street Address(2) 2051**] elevations in V1 through V3. ST depressions V4 through V6, 1 and L. 2. Atrial flutter at 57. ST changes noted above had resolved. BRIEF HOSPITAL COURSE: Mrs. [**Known lastname 105134**] was initially intubated, admitted to the CCU as detailed in above note. Although her resuscitation status was DNR/DNI this was not noted at this time and she was inadvertently intubated. While in the CCU she was rapidly extubated. There was an initial concern for cardiac ischemia with the elevated CKMB fraction in the absence of Troponin I elevation. This was thought to be consistent with an enzyme leak secondary to strain. She was seen by covering physicians for her primary care cardiologist Dr. [**First Name (STitle) 1104**] and decision was made not to pursue further interventions or workup at this time. Initially her rate which was very rapid and probably precipitated her decompensation was controlled with beta-blockers. However, she did not tolerate this well although it initially decreased her rate allowing for control. She then became bradycardiac. Upon further review the patient had apparently done this in the past. However, through the rest of her admission her rate remained well controlled without the use of beta-blockers. Congestive heart failure that she initially suffered secondary to her rapid rate was thought to be from flash pulmonary edema, responded well to diuresis at the time of this dictation she is sating well on room air and able to ambulate comfortably without desaturation. Her chronic renal insufficiency was stable with a creatinine of 1.5 which was close to her baseline. This did not change even with aggressive diuresis following her pulmonary edema. She was continued on her asthma medications while in house using our formulary substitutions, Montolucast, Betamethasone, Albuterol MDI. She had no asthma exacerbations while in house. Her initial white count was elevated over 200 however, this subsequently declined to less than 100 with no interventions. It was thought this initial laboratory was actually spurious and that her white count was below 100 which is near her baseline. At the time of discharge her last white count was 97. No further workup or intervention was taken at this time and she can follow-up as an outpatient with her own hematologist. A physical therapy consult was requested to evaluate her for home safety. Their recommendations were that she could return home but would require home physical therapy to increase her functional mobility balance and endurance. Our caseworkers will assist in arranging this. The patient does have baseline anemia and given her enzyme leak she was transfused with one unit of packed red blood cells for a hematocrit of 28.7. DISCHARGE DIAGNOSIS: 1. Atrial fibrillation with a rapid ventricular response. 2. Flash pulmonary edema. 3. CLL. 4. Hypertension. 5. Congestive heart failure. 6. Chronic renal insufficiency. 7. Hypothyroidism. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: To home, [**Hospital3 **]. DISCHARGE MEDICATIONS: As upon admission with the addition of Lisinopril 10 mg p.o. q day. Follow-up: The patient should follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within the next one to two weeks. [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**] Dictated By:[**Name8 (MD) 4733**] MEDQUIST36 D: [**2173-2-22**] 16:36 T: [**2173-2-22**] 16:58 JOB#: [**Job Number 33611**]

[ "427.32", "412", "244.9", "593.9", "204.10", "493.90", "427.31", "428.0", "294.8" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

6485, 6513

3622, 6212

6452, 6461

6537, 7040

6233, 6430

1760, 2226

2381, 3598

113, 1172

1194, 1734

2243, 2358

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Discharge summary

report

Admission Date: [**2189-11-15**] Discharge Date: [**2189-11-27**] Date of Birth: [**2154-8-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Therapeutic Paracentesis [**11-15**] and [**11-26**] EGD with variceal banding [**11-19**] History of Present Illness: 35 yo M with Hx of ongoing ETOH abuse, and episodes of Alcoholic hepatitis leading to ETOH cirrhosis (c/b ascites, portal gastropathy) originally presented w/ jaundice and abdominal distension [**11-15**] to ET service, w/ a discriminant fct of 35.8 on admission, w/ an episode of 100cc hematemesis on the floor transferred to ICU for further care and EGD. . At home patient continues to consume [**1-1**] glasses of vodka/whiskey daily. He was experiencing symptoms of withdrawal upon attempting to stop ETOH consumption. In [**Name (NI) **], pt was tachycardic, otherwise VSS. On admission t bili was 10s and rose to 12s, INR rising from 1.8 to 2.1. He had a RUQ US that showed cirrhosis, ascites, hepatofugal flow, no biliary dilatation. CXR showed low lung volumes and left lower lobe opacity treated w/ levoquine. He was pan-cultured, para negative for SBP. He was started on prednisone then switched to pentoxyphilline. He was complaining of abdominal discomfort thought to be due to his reducible umbilical hernia. . On day of transfer pt had a sudden episode of hematemesis. He denies nausea, but was experiencing abdominal pain. Of note he had an EGD in [**2186**], that showed portal gastropathy and 3mm polyp at the fundus, but no varics. His VS were notable for tachycardia w/ HR in the 90s. MICU team consulted for hematemsis. . Currently, pt feels lightheaded and endorses abdominal pain. . Review of sytems: As above. Past Medical History: 1) EtOH hepatitis - diagnosed [**2186**]. (AMA neg, anti-Smooth Ab neg, [**Doctor First Name **] pos 1:160, hep A IgM neg, hepBsAg neg, hepBcAb neg, hepBsAb pos, HCV Ab neg, hepEIgM neg, ceruloplasmin elev to 205, ferritin > [**2178**], transferrin saturation 87.5%) 2) EtOH abuse 3) h/o epididymitis 4) Concussion at the age of 2 and 7 5) s/p MVC at age of 19 6) Deviated nasal septum 7) Tonsillectomy at age of 24 8) right shoulder arthroscopic Bankart repair in [**2186**] Social History: -Prior paramedic, now works in IT consulting- job involves traveling, and taking clients to dinner -ETOH: last drink this AM, has been consuming vodka daily for weeks -Tobacco: 1/2-1ppd X 7 years -Denies illicits Married, lives with wife in [**Name (NI) 1468**] Family History: Denies hx of liver disease. + ETOH abuse in father and brother. Physical Exam: On admission to the MICU: GENERAL: jaundice, speaking full sentences awake, alert HEENT: PERRL, sclerae icteric, OP clear NECK: supple, no thyromegaly, no lad, no JVD LUNGS: CTA bilat, unlabored HEART: tachy, regular, no murmurs ABDOMEN: distended though soft, diffusely tender, no rebound/guarding, umbilical hernia reducible, + caput on abdomen, + spider angiomas EXTREMITIES: no edema NEURO: no asterixis Pertinent Results: On admission: . [**2189-11-15**] 12:30PM BLOOD WBC-6.3 RBC-2.82* Hgb-10.9* Hct-31.1* MCV-110*# MCH-38.5* MCHC-34.9 RDW-15.4 Plt Ct-74*# [**2189-11-15**] 12:30PM BLOOD Neuts-77.1* Lymphs-15.3* Monos-6.1 Eos-0.6 Baso-0.8 [**2189-11-15**] 12:30PM BLOOD PT-18.9* PTT-32.0 INR(PT)-1.7* [**2189-11-15**] 12:30PM BLOOD Glucose-188* UreaN-16 Creat-1.2 Na-131* K-2.8* Cl-89* HCO3-26 AnGap-19 [**2189-11-15**] 12:30PM BLOOD ALT-66* AST-226* AlkPhos-370* TotBili-10.5* [**2189-11-15**] 12:30PM BLOOD Lipase-350* . [**11-15**] RUQ U/S: IMPRESSION: 1. Cirrhosis with increased volume of abdominal ascites. 2. Very limited assessment of the hepatic vasculature. Flow within the main portal vein appears sluggish and likely reversed with hepatofugal flow. Intrahepatic portal vein and hepatic veins not reliably assessed in this study. 3. No intra- or extra-hepatic biliary dilatation . [**11-16**] CXR: FINDINGS: As compared to the previous examination, there is a newly appeared left lower lobe opacity with several air bronchograms, better seen on the lateral than on the frontal image. In the appropriate clinical setting, the opacity could be suggestive of pneumonia. There is no evidence of accompanying pleural effusion. Borderline size of the cardiac silhouette without evidence of pulmonary edema. Overall low lung volumes. . On admission to the MICU: . [**2189-11-19**] 05:35AM BLOOD WBC-3.2* RBC-2.26* Hgb-9.0* Hct-26.4* MCV-117* MCH-39.8* MCHC-34.0 RDW-17.3* Plt Ct-81* [**2189-11-19**] 05:24PM BLOOD PT-24.4* PTT-47.6* INR(PT)-2.3* [**2189-11-19**] 05:11PM BLOOD Glucose-103* UreaN-12 Creat-0.8 Na-131* K-4.4 Cl-102 HCO3-23 AnGap-10 [**2189-11-19**] 05:35AM BLOOD ALT-43* AST-114* AlkPhos-238* TotBili-12.9* . [**11-19**] EGD: Varices at the lower third of the esophagus with stigmata of recent bleeding and active bleeding Grade 2 varices were seen diffusely in distal esophagus. 3 areas of active bleeding were found that were banded. Mosaic appearance in the fundus, stomach body and antrum compatible with portal hypertensive gastropathy (ligation) Otherwise normal EGD to third part of the duodenum . Discharge labs [**2189-11-27**] 06:40AM BLOOD WBC-10.3 RBC-2.72* Hgb-10.5* Hct-32.0* MCV-118* MCH-38.6* MCHC-32.7 RDW-17.8* Plt Ct-211 [**2189-11-26**] 06:30AM BLOOD WBC-8.9 RBC-2.32* Hgb-9.0* Hct-27.3* MCV-117* MCH-38.7* MCHC-33.0 RDW-18.3* Plt Ct-185 [**2189-11-25**] 06:10AM BLOOD WBC-7.1# RBC-2.29* Hgb-8.7* Hct-26.7* MCV-117* MCH-37.9* MCHC-32.4 RDW-18.5* Plt Ct-180 [**2189-11-15**] 12:30PM BLOOD Neuts-77.1* Lymphs-15.3* Monos-6.1 Eos-0.6 Baso-0.8 [**2189-11-27**] 06:40AM BLOOD Plt Ct-211 [**2189-11-27**] 06:40AM BLOOD PT-19.5* PTT-31.1 INR(PT)-1.8* [**2189-11-26**] 06:30AM BLOOD Plt Ct-185 [**2189-11-26**] 06:30AM BLOOD PT-19.9* PTT-33.0 INR(PT)-1.8* [**2189-11-25**] 06:10AM BLOOD Plt Ct-180 [**2189-11-27**] 06:40AM BLOOD Glucose-103* UreaN-12 Creat-1.0 Na-134 K-3.4 Cl-99 HCO3-28 AnGap-10 [**2189-11-26**] 06:30AM BLOOD Glucose-127* UreaN-15 Creat-1.0 Na-133 K-3.9 Cl-101 HCO3-26 AnGap-10 [**2189-11-25**] 06:10AM BLOOD Glucose-117* UreaN-15 Creat-1.0 Na-129* K-4.3 Cl-100 HCO3-26 AnGap-7* [**2189-11-27**] 06:40AM BLOOD ALT-85* AST-141* LD(LDH)-168 AlkPhos-200* TotBili-10.9* [**2189-11-26**] 06:30AM BLOOD ALT-74* AST-147* LD(LDH)-151 AlkPhos-178* TotBili-10.0* [**2189-11-16**] 06:10AM BLOOD CK-MB-2 cTropnT-<0.01 [**2189-11-15**] 07:00PM BLOOD CK-MB-4 cTropnT-<0.01 [**2189-11-26**] 06:30AM BLOOD Albumin-2.6* Calcium-7.7* Phos-2.2* Mg-1.8 [**2189-11-24**] 06:25AM BLOOD Albumin-3.0* Calcium-8.0* Phos-2.2* Mg-1.9 [**2189-11-23**] 07:40AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.9 [**2189-11-22**] 05:57AM BLOOD Albumin-2.6* Calcium-7.7* Phos-1.7* Mg-2.1 [**2189-11-21**] 04:24AM BLOOD Calcium-7.6* Phos-2.2* Mg-2.1 [**2189-11-16**] 06:10AM BLOOD Triglyc-156* HDL-11 CHOL/HD-11.6 LDLcalc-86 [**2189-11-15**] 03:00PM BLOOD RedHold-HOLD [**2189-11-16**] 12:40PM BLOOD HCV Ab-NEGATIVE Brief Hospital Course: 35 yo M with hx of ETOH cirrhosis c/b ascites, p/w abdominal discomfort and jaundice, elevated t bili, started on pentoxyfylline transferred to MICU for hematemesis. Bleeding varices were successfully banded and alcoholic hepatitis was improving on steroids. . #. Hematemesis: On [**11-19**], pt had 100 cc's of hematemesis. Hct dropped to 31 on admission to 24. He was transfused 1U PRBC, 2U FFP and had an EGD, which showed grade 2 varices; 3 bleeding varices in the distal esophagus were banded. The patient was maintained on an octreotide gtt and received ceftriaxone prophylactically for GI bleed. Pantoprazole drip was initially started and was changed to [**Hospital1 **] on ICU day #2. Serial Hct showed stabilization.On the floor the patient tolerated solids well and was started on Nadolol 20mg daily which he tolerated well (HR in 70's). He recieved 5 days of octreotide and 7 days of antibacterial prophylaxis. He was discharged on 2 weeks of Sucralfate suspension and Omeprazole 40mg daily. . #. Decompensated ETOH cirrhosis: Patient was initially admitted to the liver service with ascites. Paracentesis was performed and was negative for infection/bacterial growth. T. bili was initially elevated to 10.5 on admission, INR was 1.8. RUQ U/S was performed and showed cirrhosis, hepatofugal flow, and no biliary dilatation. Blood and urine cultures were negative. Pentoxifylline was started. The patient was continued on his home ursodiiol, cholestyramine, thiamine and folate. After a questionable CXR, he was started on Levofloxacin. After improved cough and no clinical signs of infection he was switched from pentoxifylline to steroids, with downtrending total bilirubin and INR. He completed 7 days of antibiotics for this questionable infection. Cholestyramine was discontinued after no complaints of pruritus. Lasix 40mg daily and Aldactone 100mg daily were started and the patient underwent a therapeutic paracentesis on [**11-26**] with 5 L removed, with 37.5 mg Albumin 25% given . . #. Hyponatremia: Sodium was stable 130-134. Home diuretics were held at times during the admission. He tolerated diuretics well days before discharge. . #. Abdominal pain: Has reducible umbilical hernia on exam. Abdomen was distended with ascites but exam was otherwise benign. . #. Anemia: Macrocytic. Likely [**12-30**] EtOH abuse. . #. Thrombocytopenia: [**12-30**] splenomegaly- trended up toward the 200's. . # The patient was on pneumoboots for DVT prophylaxis. Communication was with the patient and his wife. The patient remained full code this admission. . Of note the patient VRE rectal swab was negative on admission and turned positive after transfer back on to the floor from the ICU during the admission Medications on Admission: -Ursodiol 300 mg twice daily -Cholestyramine-Sucrose 4 gram- 1 packet by mouth twice a day taken 4 hours apart from ursodiol -Centrum 3,500 unit-[**Unit Number **] mg-0.4 mg 1 once a day -Calcium 500 + D 500 mg (1,250 mg)-200 unit [**Unit Number **] [**Hospital1 **]. -Milk Thistle 200 mg 1 once daily -Thiamine 100 mg Tab 1 DAILY -Furosemide 40 mg Tab once daily. [**Month (only) 116**] take second dose if wt incr -Omeprazole 20 mg Cap, Delayed Release- 1 once daily. -Spironolactone 100 mg once daily. -Paroxetine 20 mg once daily. -Folic Acid 1 mg Tab DAILY -Maalox Advanced - Unknown Strength -Iron SR 325 mg (65 mg Iron)1 Capsule, SR Once Daily Discharge Medications: 1. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*80 Tablet(s)* Refills:*0* 4. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. milk thistle 200 mg Capsule Sig: One (1) Capsule PO once a day. 9. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 10. Centrum 0.4-162-18 mg Tablet Sig: One (1) Tablet PO once a day. 11. Outpatient Lab Work On [**2190-12-3**] Please draw: CBC; serum electrolytes, calcium, Mg, phosphate; LFTs, total bilirubin; coagulation studies including PTT, PT/INR please fax results to Dr.[**Name (NI) 948**] office at [**Telephone/Fax (1) 4400**] 12. sucralfate 100 mg/mL Suspension Sig: Ten (10) ml PO four times a day. Disp:*2 Bottles * Refills:*2* 13. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Gastrointestinal hemorrhage from esophageal varices Alcoholic hepatitis Alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you as your doctor. You were brought to the hospital because of severe liver damage caused by alcohol. You also was found to have a pneumonia. You were treated with antibiotics and steroids and improved. During your hospital admission you developed a life threatening bleed from esophageal varices which were banded successfully. You will need close follow up and compliance with medications. You will need to have another endoscopy in [**12-31**] weeks for repeat banding of your varices. Please do not drink alcohol. We made the following changes to your home medication list: - We added Prednisone 40mg daily : Please take this medicaion until otherwise directed by your hepatologist. - We added Nadolol which is a medication to decrease any progression of esophageal varices. - Please change your prilosec to omeprazole 40mg while you are on steriods - Please take carafate four times daily for 2 weeks - Please stop your iron pills, maalox and cholestyramine Please follow up with the appointments below: Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 497**], your hepatologist, in [**12-31**] weeks for a repeat endoscopy. You should be called by his office with an appointment time. If you do not hear from the office by next wednesday, please call ([**Telephone/Fax (1) 3618**] to schedule an appointment. It is very important for your to participate in an alcohol cessation program, preferably an inpatient program. Our social worker, [**First Name8 (NamePattern2) 501**] [**Last Name (NamePattern1) 1637**], [**First Name3 (LF) **] continue to work with you following discharge.

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Discharge summary

report

Admission Date: [**2168-2-7**] Discharge Date: [**2168-3-24**] Date of Birth: [**2117-8-16**] Sex: M Service: SURGERY Allergies: Percodan / Codeine Attending:[**First Name3 (LF) 695**] Chief Complaint: Jaundice Major Surgical or Invasive Procedure: Paracentesis Combined liver and kidney transplants [**2168-3-8**] History of Present Illness: 50 year old male with hep c and ETOH cirrhosis initially seen by Dr. [**Name (STitle) 23173**] [**2167-12-11**] for decompensated liver disease as evidenced by ascites, hepatic encephalopathy, cirrhosis, pancytopenia, splenomegaly, portal hypertensive gastropathy and varices. He has chronic hepatitis C w/o treatment. Initiation of transplant work up was to begin. CTA abdomen ordered for [**2-2**] not performed. Hx includes [**2167-10-28**] EUS: Portal hypertensive gastropathy, grade 1 varices [**9-3**] Colonoscopy reported as normal [**2167-9-14**] EGD: Portal hypertensive gastropathy, grade 1 varices [**2167-9-14**] CT scan abdomen: Liver lobulated and contracted Spleen 18 cm. Marked ascites, re cannulated umbilical vein, caput Medusa, splenic varices, gastric varices. Of note CEA 40 upon initial evaluation. . He was recently discharged from U-mass [**1-21**] with hypoglycemia, ascites, liver failure, details unknown at time of writing. Reports back to baseline status, though with hx of hospital admissions for encephalopathy. Bili baseline ~4, Cr ~1-1.4. Admit [**Hospital6 80008**] for nausea, jaundice. Denied abdominal pain, confusion, fevers at that time. Bili found to be 26 in addition to a left lower extremity DVT, popliteal thrombus. Transfer to U-Mass on [**2-3**] for IVC filter placement as team concerned about anticoagulation in cirrhotic patient. . Transfer to U-Mass [**Date range (1) 80009**] for IVC placement [**2-4**] with right groin insertion site reported without complication. RUQ u/s cholelithiasis with no biliary ductal dilatation. Further report not given. MELD on admission 25. Diagnostic para [**2169-1-3**] with 50 whites, 92% PMNS. No abx started given no SBP. Blood cx no growth to date. At time of transfer bili 38.3. Creatinine also had been trending up to 2.2 at transfer. Diuretics held. Started on albumin. Type II DM with 70/30 which was held and then reduced in the setting of hypoglycemia. As per patient blood sugar as low as 17 as per patient report. No gap reported. Oxycodone given for pain. Per his report one episode of BRBPR at OSH not associated with straining or Hct drop. PT admitted to [**Hospital1 18**] given acute concerns of rising bili . No hx of trauma, infection, portal vein thrombus. Past Medical History: Seizures Depression Torn left ACL and partial tear right ACL Fractured ankle GERD Varices grade I IDDM PSurgH: Left shoulder Wired jaw Social History: Single without children. 1-2 packs/week. H/o alcohol abuse but last drink in 08/[**2163**]. H/o IVDA >20yrs. Intranasal illicit drug use until [**8-30**]. Family History: Both parents killed in a plane crash M 36/F 40. He has two brothers, one deceased from suicide. No hx of thrombus. No hx of liver disease. Physical Exam: Vitals: T: 99.6 BP: 131/70 P: 57 R: 19 O2: 95% on 5L NC General: Alert, oriented, comfortable, making jokes. Deeply jaundiced. HEENT: icteric sclera, dried blood at nares, MM dry, oropharynx clear Neck: supple, R SC HD line Lungs: diminished at R base, fine crackles b/l CV: RRR, normal S1 + S2, Abdomen: soft, non tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, Ext: Anasarca w/ 2+ LE edema b/l LE (improved from 2 days prior), Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission and Liver transplatation evaluation tests: [**2168-2-7**] WBC-3.3*# RBC-2.46* Hgb-8.8* Hct-24.7* MCV-101* MCH-36.0* MCHC-35.8* RDW-17.2* Plt Ct-32* Neuts-63.3 Lymphs-26.4 Monos-8.3 Eos-1.9 Baso-0.1 PT-19.1* PTT-35.5* INR(PT)-1.8* Fibrino-124* D-Dimer-As of [**12-28**] Ret Aut-2.6 ACA IgG-3.0 ACA IgM-PND Glucose-197* UreaN-50* Creat-1.6* Na-131* K-5.8* Cl-103 HCO3-22 AnGap-12 ALT-53* AST-100* LD(LDH)-259* AlkPhos-91 TotBili-34.5* Lipase-18 Albumin-3.3* Calcium-8.7 Phos-4.2 Mg-2.2 Cryoglb-NEGATIVE calTIBC-133* VitB12-GREATER TH Folate-12.3 Ferritn-1220* TRF-102* %HbA1c-7.5* Triglyc-138 HDL-5 CHOL/HD-11.6 LDLcalc-25 Smooth-NEGATIVE ANCA-NEGATIVE B AMA-NEGATIVE [**Doctor First Name **]-NEGATIVE RheuFac-<3 AFP-2.2 C3-52* C4-10 . LENIs - no DVT in RLE, Popliteal DVT in LLE. IVC filter in an infrarenal location. No evidence of IVC thrombosis. At Discharge: [**2168-3-24**] WBC-16.9* RBC-3.02* Hgb-9.3* Hct-27.3* MCV-90 MCH-30.9 MCHC-34.2 RDW-18.3* Plt Ct-212 PT-12.6 PTT-25.0 INR(PT)-1.1 Glucose-179* UreaN-20 Creat-1.1 Na-130* K-4.7 Cl-91* HCO3-31 AnGap-13 ALT-25 AST-15 AlkPhos-103 TotBili-3.0* Albumin-2.9* Calcium-8.9 Phos-3.2 Mg-1.6 Brief Hospital Course: Mr [**Known lastname **] is a 50 yr old male with ETOH and HCV cirrhosis with hyperbilirubinemia, acute renal failure, DVT of unknown etiology transferred to [**Hospital1 18**] from [**Hospital1 **] for further care and transplant evaluation by the Hepatology Service. He suffered rapid decompensation of his liver function, and developed hepato-renal syndrome. A trans-jugular liver biopsy was attempted on [**2-11**] to investigate the cause of his rapid decline; that was aborted as they found a possible thrombosed bilateral IJ, and possible SVC stenosis/thrombosis; however, venogram on [**2168-2-12**] then showed patent SVC with patent axillary and subclavian veins. A RIJ dialysis cath placed was placed on [**2-12**] and had first HD session [**2-13**]. He received 2 U PRBC for anemia [**2-13**] w/o appropriate bump in hct. Vanc/Zosyn were temporarily started on [**2-12**] for empiric coverage (no source) and discontinued in the MICU on [**2-14**] . An expidited transplant workup was completed and he was listed for transplant [**2168-2-14**] with a MELD >40. As respiratory status improved he was transferred out of the MICU to the floor, with persistent encephalopathy, for which he was restarted on Vancomycin IV and Zosyn IV empirically. Patient was then diagnosed w/ SBP and treated with IV Zosyn. Patient was also continued on Vancomycin for question of suspected hospital acquired pneumonia. Bilirubin increased throughout hospitalization and stabilized in 50-60 range. Mr. [**Known lastname 64545**] encephalopathy improved as did hypoxemia by [**2-19**]. He was initiated to hemodialysis on [**2-14**] secondary to fluid volume overload and development of hepatorenal syndrome. He was listed for a liver and kidney transplant. He underwent several paracentesis with large volume removal and continued on HD. On [**2-20**] he was found to be C Diff positive and was treated with PO Vanco with subsequent negative results and he was eligible for combined liver/kidney transplant. Care was transferred to the Transplant Service as he was taken to the OR on [**2168-3-8**] for a combined liver/kidney transplant by surgeons [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] and [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. At the time of the operation, he was noted to have a markedly nodular cirrhotic liver with severe portal hypertension and porta systemic collaterals. He had no ascites at the time of exploration. Throughout the case, the patient had significant blood loss due to large and extensive poor systemic collaterals. The patient remained stable during this entire time and there was never any major sudden blood loss. The patient received 4000 mL of crystalloid, received 24 units of FFP, 18 units of PRBC and 6 units of platelets. He made 100 mL of urine. He received 7.5 liters of Cell [**Doctor Last Name **] blood. His estimated blood loss was 25 liters. Please see operative note for further details. He was transferred to the SICU intubated. He remained in the ICU for 3 days and was transferred to [**Hospital Ward Name 121**] 10 with excellent kidney function and urine output. He had a small rise post op in the LFTs around POD 8, but this subsequently trended down. Bilirubin was 60 on the day of transplant and trended down to 3.0 where it stabilized. Due to some increasing abdominal pain the patient underwent CT on [**2168-3-16**] with a new right retroperitoneal hematoma seen. Hematocrit dropped to 24, but trended back up to 27. A repeat CT was done on [**3-24**] for c/o L shoulder pain, L subclavicular pain with inspiration and persistent elevation of WBC of 12 that increased to 16 on [**3-24**]. He had a h/o L shoulder pinning. CT demonstrated a new splenic infarct, slightly decreased right retroperitoneal hematoma. There was extensive left shouder degenerative chage similar to [**2168-2-12**]. He was cleared for discharge for home after reviewing findings with Dr. [**First Name (STitle) **]. Patient continued with marked lower extremity edema and was started on lasix which was increased to 80mg [**Hospital1 **] with decreased leg edema. The liver incision was without redness/drainage. There was some leakage from the RLQ incision which was ouched. Fluid was sent for creatinine and bili. Fluid Creatinine was 1.1 and bili was 2.0. Serum creatinine was 1.1 and bili was 3.0. Vanco po was continued for the previous postive c diff [**2-20**]. Repeat stool for C.diff on [**2-9**] and [**2-29**] were negative for C.diff. Vancomycin po was to continue indefinately as an outpatient per Dr. [**Last Name (STitle) 816**]. He was tolerating diet, ambulating and slowly learning his meds. Scripts were called in to CVS in [**Location (un) **], MA ([**Telephone/Fax (1) 80010**]for lopressor, dilaudid, po vancomycin, glargin, lispro, syringes, and lasix. Medications on Admission: BUMETANIDE - 2 mg daily, CHOLESTYRAMINE-ASPARTAME [CHOLESTYRAMINE LIGHT] - 4 gram Packet -one packet by mouth twice a day, CIPROFLOXACIN - 750 mg Tablet Q weekly, [**Name (NI) **] unclear dose, METOCLOPRAMIDE - 10 mg TID, NADOLOL 20 mg daily, OMEPRAZOLE - 20 mg [**Hospital1 **], SPIRONOLACTONE - 50 mg Tablet - daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Taper per transplant clinic guidelines. 2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:*120 Capsule(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO prn every 4 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. Disp:*1 vial* Refills:*2* 11. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:*1 vial* Refills:*2* 12. syringes Sig: One (1) five times a day: insulin syringes supply 1 box refill: 2. 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 14. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: End stage liver/kidney disease and cirrhosis s/p liver transplant, Diabetes DVT, Respiratory failure, Hepatorenal syndrome, C. Difficile infection Discharge Condition: Stable Discharge Instructions: please call the Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take any of your medications, incision redness, increased drainage, decreased urine output, weight gain of 2 pounds in a day or back/flank/abdominal pain worsens Labs every Monday and Thursday No heavy lifting You will be discharged with a pouch on the incision to manage drainage. Please empty and record the drainage and bring a copy with you to your clinic visits. This will dry up and the pouch will be removed when appropriate. Drink enough fluids to keep urine light yellow in color. Report decreased urine output to the transplant clinic Do not drive if taking narcotic pain medications Followup Instructions: Lab Tests Monday [**3-28**] to be faxed to transplant clinic [**Telephone/Fax (1) 697**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2168-3-30**] 2:20 [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2168-3-30**] 1:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2168-3-24**]

[ "518.81", "572.3", "070.54", "572.4", "584.9", "567.23", "345.90", "287.5", "250.02", "453.40", "571.2", "572.2", "008.45", "276.1" ]

icd9cm

[ [ [] ] ]

[ "38.95", "55.69", "00.93", "54.91", "39.95", "50.59", "96.6", "45.13", "38.93" ]

icd9pcs

[ [ [] ] ]

11680, 11753

4883, 9821

285, 353

11944, 11953

3697, 4564

12707, 13218

2995, 3135

10190, 11657

11774, 11923

9847, 10167

11977, 12684

3150, 3678

4578, 4860

237, 247

381, 2647

2669, 2807

2823, 2979

514

113,635

14373

Discharge summary

report

Admission Date: [**2135-2-27**] Discharge Date: [**2135-3-2**] Date of Birth: [**2079-12-3**] Sex: F Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 3507**] Chief Complaint: SOB, hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 55F with COPD, paranoid schizophrenia, seizure disorder presents with episode of SOB at her group home with hypoxia to the 70s, increasing cough productive of yellow sputum. Patient reports that she got up to go to the bathroom and felt SOB. She has had a productive cough for months but has recently had more sputum production. Denies sick contacts (although she lives in a group home), hemoptysis, chills, fevers, unwanted weight loss. She has had some night sweats and has been having episodes of vertigo which have been controlled with anivert. She continues to smoke [**2-15**] PPD. . In the ED, T 97.3, HR 109, BP 101/69, RR 20 O2 98% on 6 L to 94 % on RA. She had 2 episodes of hypotension to SBP high 70s-80s which initialy responded to IVF, but given second episode, was tranferred to the ICU for close monitoring. She recieved combivent nebs x3, 5 L NS, levofloxacon 500 mg IV x 1 and solumedrol 125 mg IV x1. . Per discussion with PCP; baseline BP runs in the 90s-100s. . ROS: Denies diarrhea, constipation, headache, CP. She has had a 10 lb intentional weight loss over the past months. Slight sore throat 2 days ago which resolved. She continues to hear voices. Most recently last night when people were trying to "slay her." She also sees "faces" and feel people are talking to her from the TV. Denies HI, SI. Past Medical History: Paranoid Schizophrenia Seizure disorder-unclear history COPD - no PFTs in [**Hospital1 **] system, patient's Pulmonologist is Dr. [**Last Name (STitle) 3278**] at [**Hospital **] Hospital. CXRs at [**Hospital1 18**] however demonstrate interstitial changes c/w ILD Vertigo Hypercholesterolemia Foot pain - unclear etiology Urinary incontinence s/p "bladder surgery" 8 years ago Social History: Patient lives in a group home. Smokes [**2-15**] ppd. Before this smoked PPD since age 13. Denies illicit drug use. Has 2 duaghters. Family History: 2 daughter with "mental health problems." Did not want to speak about her parents. Denies any family history of CAD or stroke. Did have a grandfather with COPD. Physical Exam: Vitals:Tm 100.5 General: Middle aged female lying flat in bed breathing comfortably in NAD HEENT: MMM, OP clear, PERRL Neck: no cervical LAD, no JVD CV: RR, nl S1, S2 no m/g/r Pulm: diffusely rhonchorous with occasional wheezes Abd: NABS, soft, NT/ND Ext: + clubbing right>>left, no LE edema, no calf tenderness, 2 + DP pulses, right forearm with slight erythema at site of PPD but no induration Neuro:AAOx3, CN intact, strength in upper and LE [**6-18**] and equal b/l Psych: reports auditory and visual hallucinations as above. No HI/SI. Somewhat flattened affect Skin: No rashes Pertinent Results: EKG: Sinus tachy, rate 100, nl axis, nl interval, <1mm St depressions in II, II, avF . CXR: b/l lateral interstitial changes. Unchanged from [**2130**]. No evidence of PNA. . [**2135-2-27**] 12:09PM BLOOD Lactate-1.6 [**2135-2-27**] 06:03PM BLOOD Phenyto-9.8* [**2135-2-27**] 09:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2135-2-27**] 06:03PM BLOOD CK-MB-2 cTropnT-<0.01 [**2135-2-27**] 09:20AM BLOOD CK(CPK)-48 [**2135-2-27**] 06:03PM BLOOD CK(CPK)-61 [**2135-2-27**] 09:20AM BLOOD Glucose-135* UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-102 HCO3-30 AnGap-13 [**2135-2-27**] 09:20AM BLOOD WBC-17.7* RBC-4.83 Hgb-14.4 Hct-43.7 MCV-91 MCH-29.9 MCHC-33.1 RDW-13.4 Plt Ct-290 [**2135-3-1**] 07:50AM BLOOD WBC-11.4* RBC-4.24 Hgb-12.3 Hct-36.6 MCV-86 MCH-29.0 MCHC-33.5 RDW-13.5 Plt Ct-228 Brief Hospital Course: 55 yo female with h/o COPD, paranoid schizophrenia, seizure disorder presenting with episode of increasing SOB and cough likely [**3-18**] bronchitis v COPD exacerbation v PNA. . # Dyspnea and hypoxia: The patient carries the dx of COPD, however, PA/Lat during this admission demonstrated unchanged interstitial pattern compared to [**2130**]. No PFTs in [**Hospital1 18**] system. She may have a component of both COPD and ILD. Nevertheless,there was a ? of a retrocardiac opacity on the lateral film. Pt to complete 7 day course of Levofloxacin for CAP. She should have her ECG monitored every few days as there is a theoretical interaction between Quinolones and her antipsychotics. She was started on Spiriva and advair for more agressive COPD regimen, and will complete a quick steroid taper. Should f/u with her Pulmonologist, Dr [**Last Name (STitle) 3278**]. . # Hypotension: Patient reports that he SBP run in high 80 to 110s usually. She may have been mildly dehydrated on admission as she says she has not been drinking much and felt dry. She receievd 5.5 L IVF. Was not truly orthostatic on the floor. Lasix held upon discharge. . # Schizophrenia: Has hallucinations at baseline. No current SI/HI. Continued abilify, clozaril, lexapro, diazepam . # Seizure disorder: Unclear history. No recent seizures. Dilantin level at goal corrected for albumin . # ST depressions: Patient had no CP, no increasing DOE and no cardiac history and is not diabetic. Very slight <1mm ST depression in the inferior leads. 2 sets CE's negative. . # Vertigo: Patient says that she has been having feeling that the "room is spinning" for the past couple of weeks. Improved with antivert. Medications on Admission: Clozaril 600 mg PO QHS Abilify 30 mg PO QAM Lexapro 15 mg PO QAM Diazepam 5 mg PO TID Vitamin E 400 mg PO BID Prednisone 10 mg PO BID x 7 days (day 2) Azmacort 4 puffs Po BID Claritin 10 mg Po QD Colace 100 mg PO BID Dilantin 200 mg Po BID Lasix 40 mg Po QAM Antivert 25 mg PO BID:PRN vertigo Lipitor 10 mg PO QD MVI PO QAM DDAVP 0.4 mg PO QHS PPD placed (needs to be read [**2-28**]) C-Pap with 1.2 liters O2 overnight Relafen 500 mg QD PRN Albuterol nebs PRN Albuterol MDI PRN Robitussion 100 cc PO Q4H PRN Tylenol PRN Ibuprofen PRN MOM PRN Nicotine gum PRN Trazadone 50 mg Po QHS PRN sleep Lidomantle cream [**Hospital1 **] for foot pain Ditropan XL 15 daily Discharge Medications: 1. Clozapine 100 mg Tablet Sig: Six (6) Tablet PO HS (at bedtime). 2. Aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Escitalopram 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Fexofenadine 60 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. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 13. Desmopressin 0.1 mg Tablet Sig: Four (4) Tablet PO QHS (once a day (at bedtime)). 14. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. 16. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 17. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhl Inhalation Q4H (every 4 hours) as needed. 18. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 2 days: Please take 20 mg on [**3-2**] and 10 mg on [**3-3**] then stop. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnoses: 1. COPD vs ILD exascerbation 2. ?Community Acquired PNA Secondary Diagnoses: Paranoid Schizophrenia Seizure disorder-unclear history Vertigo Hypercholesterolemia Urinary incontinence s/p "bladder surgery" 8 years ago Discharge Condition: stable Discharge Instructions: Please come back to the emergency room should you develop any worsening shortness of breath, fevers, chills, worsening cough, or any other serious concerns. Followup Instructions: Please call to make appiontments for the patient with the following providers. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 42596**], M.D. Specialty: Pulmonary Medicine Address 1: [**Hospital 42597**] Medical Building [**Apartment Address(1) 42598**] [**Hospital1 **], [**Telephone/Fax (1) 42599**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42600**], M.D. Specialty: Family Practice Address 1: Family Medicine Associates, PC 38R [**Hospital1 42601**], [**Telephone/Fax (1) 42602**]

[ "491.21", "345.90", "799.02", "515", "780.4", "305.1", "272.0", "486", "276.51", "295.32" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7762, 7777

3800, 5486

279, 285

8058, 8067

2999, 3777

8272, 8802

2218, 2381

6198, 7739

7798, 7874

5512, 6175

8091, 8249

2396, 2980

7895, 8037

227, 241

313, 1639

1661, 2051

2067, 2202

47,428

186,540

39267

Discharge summary

report

Admission Date: [**2130-7-3**] Discharge Date: [**2130-7-10**] Date of Birth: [**2077-1-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2130-7-3**] Thoracentesis History of Present Illness: 53 year old man with a history of recurrent/metastatic rectal adenocarcinoma (originally clinical stage IIIB uT3 uN1 cM0) s/p proctosigmoidectomy with end colostomy and chemotherapy and radiation who presents with one week of worsening shortness of breath. He has had dyspnea for the past week, but noticed it become more severe over the last 2 days. He called the heme/onc on-call fellow this AM reporting he had difficulty catching his breath last night and his SpO2 was high 80s until they increased the O2 to 3L. It was discussed that his last CT chest shows an increased right pleural effusion and that this could be the likely etiology of the increased work of breathing and oxygen requirement. It was thought taht they could keep the O2 at 3L and see if he was comfortable enough to address this as an outpatient this week or if the dyspnea progressed over the next day or 2, they would alternatively call the ambulance and present to the ED. He tried to turn up his oxygen but to apply the oxygen mask at home he had to go up to 8L or so, and he only had the ability with his compressor to go up to 5L and he wasn't able to get enough oxygen, and so his wife called EMS and went to OSH, was given 1.5L NS and nebulizers. Labs at the OSH were notable for PTT 30, INR 1.3, BNP 201. WBC 13.6, HCT 41.9, Trop < 0.01, AST 50, ALT 114. Pt was previously supplied a prednisone taper for shortness of breath/wheezing for about 1 week, which finished on [**2130-6-27**]. The patient was last seen in [**Hospital **] clinic on [**2130-6-26**]. He completed palliative radiation to L3-L4 vertebral metastasis on [**2130-6-27**]. A discussion was also held about his overall prognosis given ongoing disease progression in his lungs, despite palliative irinotecan and cetuximab. The patient was to discuss this with his family given that his son is planning an [**Month (only) 359**] wedding, that he was encouraged to move up. Lastly, during this visit, OxyContin was increased to 30 mg q12h. At that time, he was experiencing SOB with any exertion, using O2 2L NC when up and around. He was scheduled to follow up with Dr. [**Last Name (STitle) 3274**] next on [**7-4**]. In ED, the patient was initially required a non-rebreather for oxygenation, but then oxygenation improved to 95% on 3L NC. Vitals were recorded as: T 98.3 ??????F, HR 111, RR 23, BP 143/86, O2 saturation 95% on 3L NC. Physical exam was significant for wheezing, crackles, RLL decreased BS. A chest x-ray was done, which showed moderated R sided pleural effusion and bilateral interstitial abnormalities. Pt was given 2L NS. CTA on [**6-7**] for DOE was negative for PE and CT torso on [**6-26**] showed infiltrative multifocal adenocarcinoma metastatic to the lung appears slightly worse with now increased septal thickening and pleural scalloping concerning for pleural involvement as well as increased right pleural effusion since the CTA. Bronchial brushings from RUL on [**4-24**] were postiive for malignant cells, consisetn with metastatic colonic adenocarcinoma. Pathology of the RUL cellblock showed the same thing. On arrival to the MICU, patient's VS. Pt appears uncomfortable, unable to catch his breath. He was given lasix and a nebulizer and began to feel improvement. An ABG was obtained, which showed 7.42/40/75/27. He was then put on BiPAP. Past Medical History: Severe burns on both upper arms, requiring grafting. Past Oncologic History: - [**3-/2128**]: Noted progressive rectal discomfort. - [**2128-4-28**]: Underwent CT scan due to worsening rectal pain. This revealed focal wall thickening at the rectosigmoid junction, which was thought to be consistent with a perirectal abscess. He was put on a course of oral antibiotics and scheduled for a colonoscopy (he had never had a prior colonoscopy). - [**2128-5-7**]: Underwent diagnostic colonoscopy with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]; a digital rectal exam prior to the procedure revealed a "hard rectal mass" and, on colonoscopy, he was found to have "a frond-like villous nonobstructing large mass" within the distal rectum that was partially circumferential. A biopsy was taken, pathology of which demonstrated high-grade invasive adenocarcinoma with signet ring cell features. - [**2128-5-13**]: Underwent an endoscopic ultrasound with Dr. [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) 41573**]. This described the mass as being 10 cm in length, partially circumferential, non-obstructing, and located 0.5 cm from the anal verge. It localized the mass to the left posterolateral rectal wall and described "son[**Name (NI) 493**] evidence suggesting breakthrough of the muscularis propria with invasion into the perirectal fat ... there appeared to be an extension of the mass into other adjacent structures, including the internal anal sphincter". Also noted were "four malignant-appearing lymph nodes" adjacent to the rectal mass. By EUS criteria, this was described as a uT3 uN1 lesion. - [**2128-6-7**]: Began neoadjuvant chemoradiation with infusional 5FU (225 mg/m2/day); 50.4 Gy radiation given by Dr. [**Last Name (STitle) **]; completed [**2128-7-15**] - [**2128-10-4**]: Underwent abdominoperineal resection with Dr. [**Last Name (STitle) 1120**]; pathology revealed a high-grade signet ring rectal adenocarcinoma which invaded through the muscularis propria into the perirectal soft tissues (ypT3); 35 of 36 lymph nodes were involved with carcinoma (ypN2b); intra-operatively, the left pelvic sidewall was noted to have suspicious thickened tissue and radial surgical margins were positive in this area; gold fiducials were placed intra-operatively to the left pelvic sidewall; tumor was microsatellite stable (MSS); KRAS wild-type - [**11-12**] - [**2128-11-18**]: Underwent CyberKnife (25 Gy in five fractions) to the left pelvic sidewall at the site of his positive margin. - 10/26/1: Began cycle 1 of adjuvant chemotherapy with modified FOLFOX6; completed sixth/final cycle [**2129-5-3**] - [**2129-9-27**]: CT Torso done to evaluate elevated CEA revealed new retroperitoneal lymphadenopathy, two ground-glass opacities in the right upper and lower lobes of the lungs, and a new 8 mm lesion at the dome of the liver, all consistent with recurrent/metastatic disease. - [**2129-10-31**]: Began cycle 1 of palliative FOLFIRI and bevacizumab; completed 6 cycles prior to disease progression (confirmed by transbronchial biopsy of a worsening infiltrative lesion in the right upper lobe of the lung on [**2130-4-24**]) - [**2130-5-8**]: Began cycle 1 day 1 of palliative weekly irinotecan (120 mg/m2 on days 1, 8, and 15 of 28-day cycle) and cetuximab (250 mg/m2 weekly after 400 mg/m2 loading dose on cycle 1 day 1) - [**2130-6-21**]: Began palliative radiation to L4 vertebral metastasis (20 Gy given over five 4 Gy treatments); chemo held during treatment Social History: (per OMR) He lives in [**Location 47**] with his wife,[**Name (NI) **]; they have 3 grown children. His son is currently planning an [**Month (only) 359**] wedding, which his Oncologists have recommended that date be moved sooner given his prognosis. Past smoking history of at most 3 packs/week. Family History: (per OMR) Several cousins on the paternal side with breast, ovarian cancer at young ages, and there is no history of colorectal cancer or other cancers. Physical Exam: ADMISSION PHYSICAL EXAM VS: Tm 98.3, Tc 98.3, HR 101 (99-102), BP 144/77 {136/76-147/86}, R 22 (22-26) SpO2: 94%, CPAP/PSV, TV: 940s, PS: 5, PEEP 5, FiO2 40%, Ve: 13.2 L/min, PaO2 / FiO2: 188 General: Alert, oriented, in moderate distress using accessory muscles for breathing HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Poor air movement bilaterally. End-expiratory wheezes in upper lung fields bilaterally. Abdomen: soft, non-distended, bowel sounds present, ostomy pouch present on L side, no tenderness to palpation, no rebound or guarding GU: foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS [**2130-7-2**] 11:25PM BLOOD WBC-11.3* RBC-4.00* Hgb-12.9* Hct-39.4* MCV-99* MCH-32.2* MCHC-32.6 RDW-13.7 Plt Ct-353 [**2130-7-2**] 11:25PM BLOOD Neuts-87.4* Lymphs-5.5* Monos-5.1 Eos-1.7 Baso-0.3 [**2130-7-3**] 12:05AM BLOOD PT-16.3* PTT-116.9* INR(PT)-1.5* [**2130-7-2**] 11:25PM BLOOD Glucose-136* UreaN-11 Creat-0.6 Na-136 K-4.1 Cl-98 HCO3-25 AnGap-17 [**2130-7-2**] 11:25PM BLOOD ALT-101* AST-41* LD(LDH)-367* AlkPhos-142* TotBili-0.5 [**2130-7-2**] 11:25PM BLOOD cTropnT-<0.01 [**2130-7-2**] 11:25PM BLOOD TotProt-5.8* Albumin-3.4* Globuln-2.4 Calcium-7.0* Phos-2.0* Mg-1.9 [**2130-7-2**] 11:36PM BLOOD Lactate-1.4 [**2130-7-3**] 12:45PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- Negative [**2130-7-2**] 11:25PM BLOOD B-GLUCAN- Negative MICRO [**2130-7-2**] Blood Culture, Routine (Pending): [**2130-7-3**] URINE CULTURE (Pending): [**2130-7-3**] Blood Culture, Routine (Pending): [**2130-7-3**] Legionella Urinary Antigen (Final [**2130-7-3**]): NEGATIVE [**2130-7-3**] PLEURAL FLUID GRAM STAIN (Final [**2130-7-3**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2130-7-6**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2130-7-9**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2130-7-3**] SPUTUM Source: Expectorated. GRAM STAIN (Final [**2130-7-3**]): [**11-30**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE SPARSE GROWTH Commensal Respiratory Flora. IMAGING [**2130-7-3**] CHEST (PA & LAT): There are opacities throughout both lung fields some of which are more confluent in the right upper lobe. These are consistent with known metastatic deposits. There is a right-sided pleural effusion which is moderate. Findings have worsened significantly since the chest radiograph from [**2130-4-6**], however, is stable compared to the most recent CT scan from [**2130-6-27**]. There is a left-sided Port-A-Cath with the distal lead tip in the distal SVC. No pneumothoraces are seen. [**2130-7-3**] CHEST (PORTABLE AP): There are again seen airspace opacities throughout both lung fields more confluent within the right middle lobe at the site of known metastatic disease. There is a right-sided pleural effusion with some loculation along the lateral chest wall which does appear stable. There is mild improvement of the pulmonary interstitial edema since the previous study. There is a left-sided Port-A-Cath with the distal lead tip in the mid SVC, stable. [**2130-7-3**] CTA CHEST W&W/O C&RECONS, NON-CORONARY: No pulmonary embolus. Marked six-day interval increase in growth of multiple mass-like opacities within the lungs, now with diffuse peribronchovascular ground glass opacity. The bilateral pleural effusions with scalloped margins have also increased in the interim. Upon a background of metastatic adenocarcinoma, the marked interval change over six days suggests superimposed infection, recommend clinical correlation for this. Two enhancing liver lesions as described above. Unchanged adrenal lesions. [**2130-7-3**] CHEST (PORTABLE AP): There are again seen diffuse airspace opacities more confluent in the right upper lobe consistent with known metastatic disease. There has been reduction in the size of the right basilar pleural effusion and there is a right basilar chest tube. No significant pneumothorax is seen on either side. There is a left sided Port-A-Cath with the distal lead tip in the mid SVC. The heart size is within normal limits. [**2130-7-4**] CHEST (PORTABLE AP): IMPRESSION: AP chest compared to [**4-24**] through [**7-3**]: Moderately-severe pulmonary edema which was present on [**7-3**], at 1:18 a.m. has improved, but there are now greater areas of consolidation in both lungs, partially in the upper lobe on the right and in several regions of the left lung, all an indication of progressive multifocal pneumonia. Small right pleural effusion persists following insertion of a pleural drainage catheter. Tiny right apical pneumothorax is new or newly apparent. Heart size is normal. Findings were discussed at conference with the clinical care team at 8:30 a.m. this morning. [**2130-7-4**] TTE The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Brief Hospital Course: 53 year old man with a history of recurrent/metastatic rectal adenocarcinoma who presents with one week of worsening shortness of breath # hypoxic respiratory failure - Likely multifactorial and contribued to by fluid overload, increasing right-sided pleural effusion, progression of GGOs and lymphangitic spread of adenocarcinoma, as well as possibility of infection. The driving factor, however, does seem to be disease progression of his metastatic adenocarcinoma. He was diuresed initially with some improvement in respiratory status and also had his R-sided pleural effusion drained for 1L w/ pigtail placement also with very mild improvement. Additionally, repeat chest CT scan r/o PE but showed significant progression of GGOs and mets. His outpatient oncologist was contact[**Name (NI) **] who felt that decline was likley reflective of disease progression. He was treated for HCAP with vancomycin/cefepime for an 8 day course. Initial sputum culture showed gram positive rods on gram stain, but no significant organisms other than commensal respiratory flora grew out. Furthermore, pleural fluid showed no organisms. Urine legionella was negative. Bronchoscopy was considered and was ultimately decided that this would not be beneficial. He was started on a trial of steroids however this resulted in little improvement in his respiratory status and delerium. Therefore steroids were discontinued after two doses of methylprednisolone. His respiratory status remained poor. As below in conversation with the patient's family and outpatient oncologist the decision was made to focus on comfort care. He was transitioned to a morphine drip to help with dyspnea. On [**2130-7-9**], dyspnea worsened and he became increasingly hypoxic and no longer responsive. Pt's family was called to the bedside and it was determined that we continue to treat his dyspnea with morphine. He continued to become increasingly hypoxic and ultimately expired at 0830 on [**2130-7-10**]. # Metastatic rectal adenocarcinoma - Diagnosed [**5-/2128**] and is s/p proctosigmoidectomy with end colostomy with known metastases to the lung and spine. However, CT chest done this admission showed two enhancing liver lesions. He has completed 6 cycles of palliative FOLFIRI and bevacizumab, as well as 2 cycles of Ironotecan and Cetuximab and recently finished 5 sessions of palliative radiation to L3-L4 metastases. He was continued on his outpatient pain regimen with OxyContin 30 mg q12h and prn Dilaudid. Palliative care was consulted for symptom management who recommended morpine PCA which was then transtioned to a morphine drip with bolus prn. As above when the patient's respiratory status failed to improve despite diuresis and antibiotics he was transitioned to comfort measure. # Transaminitis - Previous records report that it is presumably due to hepatotoxicity from his external beam radiation, but could also be due to his chemotherapy. However, given that this CT chest showed two enhancing liver lesions, liver mets are also of concern. Hepatitis serologies were recently checked, which showed immunization to hep B and neg for hep C. # Altered Mental status: The patient developed marked confusion in the setting of recieving ativan, in addition to the initiation of steroids. He required Haldol for agitation. AMS was attributed to medication effect. Ativan and steroids were discontinued and the patient's mental status improved to baseline. However, as mentioned above, he ultimately became unresponsive as his clinical status declined. Medications on Admission: BENZONATATE [TESSALON PERLES] - 100 mg Capsule - 200 mg three times a day CLINDAMYCIN PHOSPHATE - 1 % Lotion - 1 app to affected areas of face [**Hospital1 **] MINOCYCLINE - 100 mg Tablet - 1 Tablet(s) by mouth daily ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 TAB PO TID prn nausea OXYCODONE - 5 mg Tablet - [**2-6**] Tablet(s) PO q4h prn severe pain OXYCODONE [OXYCONTIN] - 30 mg Tablet Extended Release 12 hr - 1 TAB PO q12h PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) PO QID prn nausea FLEXERIL - 10mg Tablet - 1 Tablet(s) PO TID prn back pain Medications - OTC CHOLECALCIFEROL (VITAMIN D3) - 2,000 unit Capsule - 1 Capsule(s) PO daily DOCUSATE SODIUM [STOOL SOFTENER] - 100 mg Capsule - 1 Capsule(s) PO daily MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth daily POLYETHYLENE GLYCOL 3350 [MIRALAX] PYRIDOXINE [VITAMIN B-6] - 100 mg Tablet - 1 Tablet(s) PO daily SENNOSIDES [SENNA] - 8.6 mg Capsule - 2 Capsule(s) PO daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: metastatic rectal adenocarcinoma Pneumonia Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "197.2", "486", "428.0", "198.5", "V44.3", "V66.7", "197.0", "518.81", "V10.06", "428.32", "511.81" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

18199, 18208

13619, 16771

311, 341

18294, 18303

8492, 9272

18359, 18369

7592, 7747

18167, 18176

18229, 18273

17197, 18144

18327, 18336

7762, 8473

9924, 13596

9395, 9891

264, 273

369, 3700

16786, 17171

3722, 7261

7277, 7576

32,536

171,424

54139

Discharge summary

report

Admission Date: [**2152-7-7**] Discharge Date: [**2152-7-15**] Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: Unwitnessed fall with left traumatic subarachnoid hematoma, left frontal intraparenchymal hemorrhage, and right subarachnoid hemorrhage. Major Surgical or Invasive Procedure: None History of Present Illness: 89 y/o male found down, unresponsive, by neighbor with obvious head trauma, bleeding from his right ear, and no recollction of events. Patient complains of dizziness throughout the day before his unwitnessed fall. He reports episode chest pain two days prior to admission that responded to sublingual nitroglycerin. Patient was brought to ED at [**Hospital1 18**], where the neurosurgery service was consulted. Initial imaging revealed small right subarachnoid hemorrhage with right temporal bone fracture. However, in the ED, patient developed hemataemesis, prompting repeat imaging. Repeat imaging revealed new left frontal intraparenchymal hemorrhage with mass effect. As such, the patient was admitted to the ICU for further management and monitoring. Upon admission, patient denies any chest pain, headache, weakness or paresthesia and complains of difficulty hearing from right ear with drainage from that ear. Past Medical History: Past Medical History: 1. Coronary artery disease: MI in [**2126**], STEMI in [**8-/2147**], most recent stress test WNL 2. History of hypertension. 3. Peptic ulcer disease. 4. Abdominal aortic aneurysm; status post repair. 5. Renal cell carcinoma; status post left nephrectomy. 6. Hyperlipdemia 7. Syncope in [**2143**] attributed to vasovagal reaction vs orthostatic hypotension Past Surgical History 1) Poplitial aneurym excised/bypass [**9-13**] 2) Left iliac aa [**2-13**] 3) AAA repair w bilat iliac aa repair [**11/2135**], 4) Lt. thorocoabdominal Nephrectomy [**2-/2139**], 5) Angio [**2-13**] with embolization of left hypogastric artery 6) Left inguinal hernia repari 7) Vasectomy Social History: Retired, worked in chemical company mixing compounds. Lives alone. Widowed 9 years ago, but has 5 children, 4 of whom live locally, and 16 grandchildren. Pt was a smoker, but quit in [**2126**]. Never drank much alcohol and currently drinks none. Was a singer/son[**Name (NI) 110963**] in his freetime. Family History: Father had prostate CA, mother had MI. No strokes Physical Exam: Admission Physical [**Name (NI) **] Temp: 97.6 HR: 67 BP: 137/77 Resp: 18 O(2)Sat: 100 Normal Constitutional: Nontoxic HEENT: Facial abrasions, Active bleeding from right ear Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Extr/Back: No deformities Skin: Warm and dry Neuro: Speech fluent ****** Psych: Normal mood Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Discharge Physical [**Last Name (un) **]: Vitals: 98.0 146/81 96 20 96% RA General: AAOx1.5 (person, place when given choices), NAD, comfortable HEENT: PERRL, EOMI, MMM Extrem: WWP, no C/C/E, no cords/erythema in LLE Neuro: -AAOx1.5, responds intermittently to simple commands, dysarthric, cannot say DOW forward or backward -Cranial nerves: I: not tested II,III,VI: EOMI, VFF, +end gaze nystagmus in all directions VII: face symmetric VIII: hearing intact [**Doctor First Name 81**],X: palate elevates symmetrically, tongue midline [**Doctor First Name 81**]: full strength sternocleidomastoid XII: full tongue strength -Strength: [**4-13**] BUE, [**3-13**] RLE, [**2-13**] LLE (exam waxes and wanes with concentration) -Sensation: not tested Pertinent Results: [**Month/Day (1) **] ON ADMISSION ([**2152-7-7**]): WBC-13.2*# RBC-4.61 Hgb-13.9* Hct-41.7 MCV-91 MCH-30.2 MCHC-33.4 RDW-13.1 Plt Ct-189 Neuts-87.0* Lymphs-9.0* Monos-3.2 Eos-0.5 Baso-0.3 PT-11.9 PTT-25.5 INR(PT)-1.1 Glucose-115* UreaN-37* Creat-1.8* Na-140 K-5.3* Cl-106 HCO3-24 AnGap-15 proBNP-709 cTropnT-<0.01 Calcium-8.7 Phos-2.3* Mg-2.1 BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Lactate-2.2* URINE: BLOOD-NEG NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR [**Month/Day/Year **] ON DISCHARGE ([**2152-7-15**]): LMWH-1.17 Glucose-178* UreaN-23* Creat-1.5* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 MICROBIO: -Urine cx ([**7-7**]): NEGATIVE -Blood cx ([**7-7**]): NEGATIVE Imaging: [**2152-7-7**] 1608 CT Spine w/o contrast: Right perched facet and left jumped facet with splaying of the spinous process at C6-C7 appears chronic. No definite acute fracture. If concern for superimposed acute injury or cord injury, MRI is the study of choice if patient is able to tolerate the exam. [**2152-7-7**] 1607 CT Head w/o contrast: 1. Right temporoparietal and interhemispheric fissure subarachnoid blood. Small blood product adjacent to left tentorium suggesteive of trace subdural hematoma. 3 mm right inferior frontal subdural hematoma. 2. Right temporal bone fracture with otic capsule sparing and small focus of pneumocephalus. 3. Small pneumocephalus in left temporal region. 4. Partial opacification of left mastoid air cells with adjacent chronic changes. No fracture is seen. [**2152-7-7**] 1842 CT Head w/o contrast: 1. Right temporal bone fracture extending into the mastoid air cells to the external auditory canal. No evidence of facial nerve involvement. Small pneumocephalus in the right temporal lobe. 2. Unchanged right temporal lobe subarachnoid hemorrhage. 3. Small pneumocephalus in the left temporal lobe of unclear etiology. No left temporal bone fracture identified. [**2152-7-7**] 2142 CT Head w/o contrast: 1. Newly-apparent large left frontal parenchymal hemorrhagic contusion with surrounding edema and mild mass effect. 2. New tiny left parietal subarachnoid hemorrhage. 3. New tiny intraventricular blood in the right lateral ventricle occipital [**Doctor Last Name 534**]. 4. The right frontal subdural hemorrhage, left tentorial subdural hemorrhage and right temporoparietal subarachnoid hemorrhage are stable. [**2152-7-8**] 0748 CT Head w/o contrast: 1. Interval increase in size of left frontal parenchymal hemorrhagic contusion, with 5 mm of rightward subfalcine herniation. 2. Extensive bihemispheric subarachnoid, small intraventricular hemorrhage, right middle cranial fossa subdural hematoma, all unchanged over the short-interval. 3. Grossly unchanged appearance of known right temporal bone fracture. [**2152-7-9**] 0930 CT Head w/o contrast: 1. Stable left frontal hematoma since most recent preceding exam, with persistent peripheral edema and rightward displacement of the left frontal rectus gyrus. 2. Similar extent of bilateral multi-compartmental hemorrhage including left parietal and bilateral temporal subarachnoid hemorrhage, intraventricular and supratentorial components. 3. Right temporal bone fracture, better delineated on dedicated temporal bone CT two days ago. [**2152-7-10**] Carotid Ultrasound: Right ICA no stenosis. Left ICA <40% stenosis. [**2152-7-10**] Echocardiogram: IMPRESSION: EF > 55% Suboptimal image quality. Mild aortic regurgitation. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mildly dilated aortic sinus. Compared with the prior study (images reviewed) of [**2147-9-4**], the severity of aortic regurgitation is minimally increased. [**2152-7-11**] EEG: Abnormal portable EEG due to the slow disorganized background throughout. This indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are most common causes. There were no areas of persistent focal slowing but encephalopathies may obscure focal findings. There were no epileptiform features or electrographic seizures. [**2152-7-14**] Bilateral Lower Extremity Venous Doppler: 1. Deep venous thrombosis of the left popliteal vein, which appears partially occlusive. 2. In comparison to [**2145-10-22**] exam, there is interval increase in size of a partially thrombosed right popliteal artery aneurysm, now measuring 7.5 cm. Brief Hospital Course: Patient was admitted to the neuro-ICU on [**2152-7-7**] after interval imaging in the ED revealed new left frontal intraparenchymal hemorrhage. Patient was admitted with dysarthria, confusion, and decreased hearing in his right ear, and no localizing or lateralizing signs. He was loaded with dilantin for seizure prophylaxis with concomitant gastric protection. Urinalysis was suspicious for UTI and patient was started on a 3 day course of ciprofloxacin. Repeat imaging revealed interval increase in size of left frontal parenchymal hemorrhagic contusion. The patient's neurologic [**Date Range 29765**] improved. His confusing cleared, dysarthria improved, and he continued to not exhibit lateralizing symptoms. His decreased hearing in the right ear persisted. As patient was more stable, he was transferred to the neuro stepdown unit. On [**2152-7-9**], interval head CT revealed the left frontal intraparenchymal hemorrhage to be stable. The neurological [**Date Range 29765**] continued improved and the patient was A&O x2 (hospital, self). As hearing had not returned, and ENT consult was placed. The ENT service placed an ear wick to manage the otorrhea that is to be in place x5 days and recommended ciprodex 4gtt AD [**Hospital1 **] x10 days. On [**2152-7-10**], the care team pursued work-up for syncopal episode, included carotid Doppler, EEG, and echocardiogram. EEG showed disorganized background consistent with encephalopathy with no epileptiform features or electrographic seizures. Carotid Doppler demonstrated no stenosis of the right ICA and < 40% stenosis of left ICA. Echocardiogram showed EF > 55% with mild aortic regurgitation. To ensure patient was safe to take in po, a speech and swallow evaluation was conducted. The speech therapists recommended a thin liquid and regular solid diet. On [**2152-7-11**], patient was evaluated by PT/OT. They recommended discharge to rehabilitation. The earwick placed by ENT was removed. On [**2152-7-12**], the neurosurgery team transitioned the patient to oral ciprofloxacin and discontinued the patient's Foley. Bilateral lower extremity venous Doppler [**Date Range 29765**] on [**2152-7-14**] revealed deep venous thrombosis of the left popliteal vein, which appears partially occlusive and interval increase in size of a partially thrombosed right popliteal artery aneurysm. Patient was started on Lovenox 90 mg SC BID, decreased to 90mg daily given elevated Xa level, borderline creatinine clearance, and h/o recent head bleed. He is to continuous this therapy for 6 months. He should have factor Xa level rechecked on [**2152-7-17**] in rehab to ensure that he is therapeutic on Lovenox. Mr. [**First Name (Titles) 110966**] [**Last Name (Titles) 29765**] remained unchanged and he was discharged to rehabilitation on [**2152-7-15**]. ==================================== TRANSITION OF CARE: -Please check Factor Xa level and BUN/Cr on [**2152-7-17**] to ensure therapeutic on Lovenox. If subtherapeutic, would increase to 90mg SC BID. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Simvastatin 40 mg PO QHS 3. Nitroglycerin SL 0.3 mg SL PRN chest pain 4. Aspirin 325 mg PO DAILY Discharge Medications: 1. Metoprolol Succinate XL 50 mg PO DAILY 2. Nitroglycerin SL 0.3 mg SL PRN chest pain 3. Simvastatin 40 mg PO QHS 4. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 6. Ciprofloxacin 0.3% Ophth Soln 4 DROP RIGHT EAR [**Hospital1 **] Duration: 10 Days 7. Dexamethasone Ophthalmic Soln 0.1% 4 DROP RIGHT EAR [**Hospital1 **] Duration: 10 Days 8. Docusate Sodium (Liquid) 100 mg PO BID 9. Enoxaparin Sodium 90 mg SC Q24H Duration: 6 Months First day = [**2152-7-14**]. 10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 11. Senna 1 TAB PO BID:PRN Constipation Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right traumatic subarachnoid hemorrhage, Left traumatic subarachnoid hemorrhage, left interparenchymal hemorrhage, Right temporal bone fracture Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, do not resume taking them until cleared by your surgeon. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Keep your ear dry until follow up with ENT. When showering, place cotton ball in ear and smear over with vaseline . Followup Instructions: ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. ?????? Please call ([**Telephone/Fax (1) 7138**] to make a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Plastic Surgery department. ?????? Please call ([**Telephone/Fax (1) 110967**] to schedule an appointment for an outpatient audiogram. ?????? Please call ([**Telephone/Fax (1) 6213**] to schedule an appointment with ENT, Dr [**Last Name (STitle) 3878**].

[ "412", "V45.82", "801.10", "V15.82", "401.9", "E888.9", "599.0", "801.30", "V45.73", "780.2", "453.41", "348.5", "V10.52", "801.20", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12088, 12158

8144, 11177

389, 396

12346, 12346

3663, 8121

13623, 14649

2403, 2456

11466, 12065

12179, 12325

11203, 11443

12521, 13600

3241, 3644

2471, 3224

213, 351

424, 1349

12361, 12497

1393, 2065

2081, 2387

48,118

180,335

42314

Discharge summary

report

Admission Date: [**2184-12-7**] Discharge Date: [**2184-12-11**] Date of Birth: [**2126-8-27**] Sex: M Service: UROLOGY Allergies: IV Dye, Iodine Containing Contrast Media / myeclog cream Attending:[**First Name3 (LF) 11304**] Chief Complaint: Right Renal mass Major Surgical or Invasive Procedure: Radical Right open nephrectomy w/ mobilization of liver and tumor embolectomy and then patch repair of vena cava. History of Present Illness: 58yM who presented with headache and a frontal lobe brain mass that was found to be metastatic RCC. Large R kidney tumor and IVC thrombus, as well as RP lymphadenopathy. Past Medical History: HTN HL GERD PVD PSH: L knee surgery Umbilical hernia repair Social History: Lives at home with wife and step daughter. [**Name (NI) 1403**] as a machinist for GE. Never smoked, drinks occasional alcohol. Denies illicits. Family History: Mother with [**Name (NI) 11964**] / renal cell carcinoma Father with stroke in 60's Sister with brain tumor - unknown what type, family says it is "deep" and inoperable so she is being monitored, asymptomatic and has been stable. Physical Exam: NAD incision clean, dry, intact Brief Hospital Course: Patient was admitted to Urology after undergoing Right radical open nephrectomy,with mobilization of liver and tumor embolectomy and then patch repair of vena cava. patient had a large volume blood loss during the case of approximately 7 L ; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. On POD0, the patient was taken to the ICU intubated and sedated. On POD1, the patient was extubated without any issues and his hematocrit remained stable. He remained in the ICU until the evening of POD1 when he was ambulating and pain was well controlled. On POD2, the patient was started on sips, which he tolerated well and advanced to clear liquids. On POD3 his foley was removed and the patient voided without any issues. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. [**Last Name (STitle) 3748**] in 3 weeks. Medications on Admission: Nexium 20 mg Po daily ASA 81 mg PO daily Pravastatin 40 mg Po daily Azopt 1% 1 drop OU tid Combigan 0.2-0.5% 1 drop OU tid Xalatan 0.005% 1 drop OU qhs Keppra 1125 mg PO qhs Colace 100 mg PO daily Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Renal Cell Ca Discharge Condition: Stable Discharge Instructions: You may shower but do not bathe, swim or immerse your incision. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications, except hold NSAID (aspirin, and ibuprofen containing products such as advil & motrin,) until you see your urologist in follow-up -Call your Urologist's office today to schedule/confirm your follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids Followup Instructions: -Call Dr.[**Name (NI) 11306**] office ([**Telephone/Fax (1) 8791**] ‎for follow-up AND if you have any questions (page Dr. [**Last Name (STitle) 3748**] at [**Telephone/Fax (1) 2756**]).

[ "365.9", "998.11", "401.9", "198.3", "189.0", "198.89", "E849.7", "E878.6", "V12.51", "530.81", "443.9" ]

icd9cm

[ [ [] ] ]

[ "39.56", "55.51", "40.3" ]

icd9pcs

[ [ [] ] ]

2952, 2958

1220, 2443

335, 451

3016, 3025

4271, 4468

916, 1148

2691, 2929

2979, 2995

2469, 2668

3049, 4248

1163, 1197

279, 297

479, 652

674, 737

753, 900

69,745

134,196

37168

Discharge summary

report

Admission Date: [**2188-3-17**] Discharge Date: [**2188-3-19**] Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Hypoxia, difficulty to vent, transient hypotension Major Surgical or Invasive Procedure: Bronchoscopy x 2 Tracheostomy tube exchange (UniPerc adjustable flange tracheostomy 8.0-mm inner diameter, 12.6-mm outer diameter, and 125 mm in length) History of Present Illness: [**Age over 90 **]yo M with PMHx of anoxic brain injury [**2-12**] cardiac arrest X 2 with chronic respiratory failure and tracheobronchomalasia with trach presents from rehab with hypoxia, difficult to ventilate and transient hypotension. Per records and family patient has been ventilator dependent for two years. He lives at pulmonary rehab and is on trach mask during the day, ventilator at night. Per old records his MS [**First Name (Titles) **] [**Last Name (Titles) 5348**] is very poor - he withdraws only to painful stimuli. On last admission in [**Month (only) 404**] of this year his trach was replaced ([**Last Name (un) **] #8 (120 mm) in length) after concern for tracheobronchomalasia. This was complicated by a PTX requiring a chest tube. HIs vent settings at this time were: A/C 16/400/50%/10 Overnight last night at rehab he was noted to have hypoxia and the rehab had difficulty ventilating him, even with bag mask. rehab also noticed transient hypotension (no record how low) and sent him to [**Hospital 83724**] hospital. At [**Hospital1 8**] he was given kayexalate for K 5.6. Family refused full dose only got 15 grams because it has made him vomit in the past. EKG without changes c/w hyperkalemia. ABG there was 7.35/69/543. Per family's request he was transferred to [**Hospital1 18**]. He was then transferred to our ED. On exam in the ED initial VS: HR:44 BP:159/79 O2Sat:100 on 350/25/5/100%FiO2. HIs vent settings at home are reportedly 350/35/5 - unclear FIO2. On exam noted to have a lot of wheezing and prolonged expiratory phase suggesting reactive airways disease so given nebs and methylprednisolone. CXR showed worsening of R pleural effusion and haziness of right heart border so he was treated for HAP (received vanc/zosyn/levoquin) in ED although he remained afebrile and had no wbc count. peak pressures had been upper 40s now down to upper 20s low 30s. Was on 100% FiO2 initially but now backing down to 40%FiO2. Family "incredibly" involved and he remains full code. On the way to the floor, the patient's family was concerned that he was not breathing so tehy put the suction catheter in his mouth at which point he desaturated to the 70s. This resolved quickly by removing the catheter. On arrival to the floor the patient was ventilated, withdrew to painful stimuli. Past Medical History: Paroxysmal Atrial fibrillation Parkinson's disease Chronic respiratory failure, trached ventilator dependent (due to aspiration PNA/cardiac arrest in [**1-18**] at [**Hospital 8**] Hospital) [**Hospital 5348**] PCO2 60. Vent settings at rehab: TV300-400, RR17, PS 10 PEEP 10. Spontaneously breathing at [**Hospital 5348**]. Anoxic brain injury [**2-12**] cardiac arrest DMII CKD Tracheobronchomalasia h/o C. Difficile Chronic foley due to massive inoperable inguinal hernia, gets continuous bladder irrigation Hypothyroidism Social History: chronic habitation at [**Hospital1 **] x2 years for vent weaning. Family denies any illicits (neg tobacco use, neg alcohol use or IVDU). Family History: no history of pulmonary or cardiac disease. Physical Exam: Vitals: T: BP:165/70 P:60 R:24 O2: 100 on AC TV300, RR24, Peep 5 General: Intubated, withdraws to painful stimuli HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Peg site c/d/i GU: foley in place. Scrotal enlargement [**2-12**] hernia, no erythema, foley draining clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, Pertinent Results: Admission Labs [**2188-3-17**]: CBC: WBC-10.6 RBC-3.10* Hgb-8.5* Hct-28.2* MCV-91 MCH-27.4 MCHC-30.1* RDW-14.6 Plt Ct-390 Diff: Neuts-77.6* Lymphs-16.2* Monos-3.4 Eos-2.4 Baso-0.3 Chemistries: Glucose-238* UreaN-72* Creat-2.0* Na-133 K-5.4* Cl-93* HCO3-37* AnGap-8 Albumin-3.5 Calcium-9.9 Phos-4.8*# Mg-2.5 ABG: 7.34/66/135 Imaging: [**2188-3-17**]: CHEST, AP: Visualization is suboptimal due to underpenetration, patient rotation, and low lung volumes. A tracheostomy device is again seen at the level of the thoracic inlet with tip in the proximal trachea, 6 cm from the carina. The balloon appears midline, and is distended slightly beyond the contours of the trachea. The right PICC has been removed. There has been interval development of diffuse mild interstitial congestion, as well as small-moderate bilateral pleural effusions and bibasilar atelectasis. There is no pneumothorax. Again noted is diffuse osseous demineralization. The soft tissues are unremarkable. IMPRESSION: Tracheostomy appears in appropriate position. Mild CHF and pleural effusions. Brief Hospital Course: Mr. [**Known lastname **] is a [**Age over 90 **]yo M with h/o chronic respiratory failure, tracheomalacia, anoxic brain injury admitted with hypoxia, now resolving, and hypercarbic respiratory failure. . # Hypercarbic Respiratory Failure: Patient with chronic respiratory failure at [**Age over 90 5348**] with ABG on last admission 168/67/7.33. Patient had increased peak inspiratory pressures and plateau pressures indicating possible upper airway obstruction from either worsening tracheomalacia, trach malposition, or mucous plugging. His oxygen saturation and ABG improved significantly with suctioning (7.24/84/132 -> 7.34/66/134). He was treated with standing albuterol and ipratropium MDIs, and guaifenesin. A bronchoscopy was performed, which showed a flap of granulation tissue that was partially obstructing the trachea. Interventional pulmonology was consulted, and exchanged the tracheostomy tube with a UniPerc adjustable flange tracheostomy tube which prevented the granulation tissue from blocking the trachea. After trach tube replacement, her breathing status returned to his [**Age over 90 5348**]. . # Hypotension: Resolved. Unclear etiology and severity as no record of hypotension from rehab. Patient was restarted on his home bp regimen of amlodipine 2.5 mg PO three times weekly and prazosin 1 mg PO daily. . # Hyperkalemia: Likely secondary to chronic renal insufficiency. Patient was monitored on telemetry, and serum K was checked daily. Per his Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 **], his [**Hospital1 5348**] K is 4.5-5.5 and he remained within this range throughout this hospitalization. . # Atrial Fibrillation: Patient was monitored on telemtery and remained in sinus rhythm, with rates from 50s-70s. He is not on anticoagulation as an outpatient and anticoagulation was not started during this hospitalization. . # Chronic foley [**2-12**] inoperable hernia: Patient was treated with continuous bladder irrigation per home regimen. . # Chronic Kidney Injury: patient remained at his [**Month/Day (2) 5348**] creatinine of 2.0-2.2. . # Type Two Diabetes: Patient's home glipizide was held and he was treated with a regular insulin sliding scale. Medications on Admission: Albuterol/Ipratropium 2 puffs Q6H Amlodipine 5 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO QMOWEFR (Monday -Wednesday-Friday) Bacitracin Ointment [**Hospital1 **] Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). Glipizide 2.5mg twice daily Humulin Insulin sliding scale See printed sliding scale. Lactobacillus packet [**Hospital1 **] Lacrolube ointment OU at bedtime Lansoprazole 30mg daily Levothyroxine 50mg daily Methylcellulose 2 gm QHS MVI daily PRazosin 1mg [**Hospital1 **] Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Lactulose 20gm QD and prn Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas Discharge Disposition: Extended Care Facility: [**Hospital6 85**] TCU - [**Location (un) 86**] Discharge Diagnosis: Primary: respiratory distress from impaired tracheostomy tube Discharge Condition: Mental Status: Confused - always Level of Consciousness: Lethargic and not arousable Activity Status: Bedbound Discharge Instructions: You were admitted to the hospital for difficulty with ventilation. Interventional pulmonlogy replaced your tracheotstomy tube and you were discharged back to a rehabilitation facility. Followup Instructions: None [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

[ "33.21", "97.23", "96.71" ]

icd9pcs

[ [ [] ] ]

8887, 8961

5336, 7579

297, 451

9067, 9067

4240, 5313

9413, 9557

3520, 3565

8982, 9046

7605, 8864

9204, 9390

3580, 4221

207, 259

479, 2799

9082, 9180

2821, 3348

3364, 3504

19,142

150,470

4776

Discharge summary

report

Admission Date: [**2119-3-22**] Discharge Date: [**2119-3-24**] Date of Birth: [**2058-8-3**] Sex: M Service: Thoracic Surgery Service DISCHARGE DIAGNOSES: 1. Status post right video-assisted thoracic surgery with wedge resection. 2. Hypotension. 3. Emphysema. 4. Coronary artery disease; status post coronary artery bypass graft. 5. Anxiety. 6. Idiopathic thrombocytopenic purpura. 7. Lung cancer. HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman who presented in [**2112**] in a chronic cough. A chest x-ray obtained demonstrated a left lung mass. A computed tomography scan demonstrated mediastinal lymphadenopathy. The patient was found to have stage IIIB lung cancer and was treated with chemotherapy and radiation. He has received serial computed tomography scans to follow his disease, and in [**2117-12-15**] was found to have a lesion in the right lung with a recent increase in size and a right lower lobe lesion. The patient also noted to have a work-related asbestos exposure. PAST MEDICAL HISTORY: (The patient's past medical history is significant for) 1. Emphysema. 2. Coronary artery disease. 3. Anxiety. 4. Idiopathic thrombocytopenic purpura secondary to chemotherapy. 5. Lung cancer. PAST SURGICAL HISTORY: (Past surgical history is significant for) 1. Coronary artery bypass graft in [**2114**]. 2. Left inguinal hernia repair. 3. Bronchoscopy and mediastinoscopy. MEDICATIONS ON ADMISSION: 1. Altace 10 mg by mouth once per day. 2. Lipitor 10 mg by mouth once per day. 3. Atenolol 25 mg by mouth once per day. 4. Aspirin 81 mg by mouth once per day. 5. Multivitamin. ALLERGIES: CODEINE and PERCOCET. FAMILY HISTORY: His mother died of liver cancer. His father died of alcohol abuse. Brothers are alive; all with coronary artery disease. SOCIAL HISTORY: The patient quit smoking in [**2112**]. He had a 40-pack-year history of smoking. PHYSICAL EXAMINATION ON PRESENTATION: The patient's temperature was 97 degrees Fahrenheit, his pulse was 64, his blood pressure was 138/78, he was breathing at a rate of 18, and he was saturating at 98% on room air. The patient was in no acute distress. He was alert and oriented times three. He had anicteric sclerae. There were lymph nodes palpable in his neck. The lungs were clear to auscultation bilaterally. No wheezes, rhonchi, or rales. The heart was regular in rate and rhythm. There were no murmurs, rubs, or gallops. The abdomen was soft, nontender, and nondistended. Extremities showed no peripheral edema, and no deformity. Neurologically, the patient's cranial nerves II through XII were grossly intact throughout. The patient had 5/5 strength and sensation throughout all extremities. ASSESSMENT AND PLAN: This is a 61-year-old gentleman status post chemoradiation treatment for stage IIIB lung cancer who now presents with a new enlarging right lower lobe lesion. The patient was scheduled for right video-assisted thoracic surgery and wedge resection. BRIEF SUMMARY OF HOSPITAL COURSE: The patient presented on [**2119-3-19**] for elective right video-assisted thoracic surgery and wedge resection. The patient was taken to the operating room and tolerated the procedure well. He was transported to the Postanesthesia Care Unit in stable condition. The patient was mildly hypotensive and had a reported history of hypotension after previous surgeries. While the patient had a right-sided chest tube that was to suction while in the Postanesthesia Care Unit, the nursing staff noted the patient had a sudden increase in chest tube output of bright red blood. The patient had approximately 120 cc over 15 minutes which was a dramatic increase in rate from when coming out of the Postanesthesia Care Unit. The patient was also hypotensive; however, he was mentating well and was not tachycardic. A chest x-ray was obtained which showed no evidence of an effusion or hemothorax. The patient was rolled onto dependent position which did not produce a gush of blood. The patient was examined by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] and was felt should be re-explored for control of the bleed. The patient was brought back to the operating room and was found to have bleeding from one of the port sites. This was cauterized, and the patient was transferred again back to the Postanesthesia Care Unit in stable condition. On postoperative day one, the patient required a Neo-Synephrine drip overnight to maintain mean arterial pressures above 60. The patient was given several fluid boluses and had good urine output. He was not tachycardic but continued to have persistently low blood pressures in the 90s/50 with mean arterial pressures in the 60s; requiring a Neo-Synephrine drip. Over the course of the day on postoperative day one, the patient was gradually weaned off the Neo-Synephrine drip. The patient's Foley catheter was removed. The chest tube was also removed. A postoperative chest x-ray was obtained which showed no change after removal of his chest tube. The patient's diet was advanced. The patient passed a voiding trial. He was taking oral intake. Felt that despite the patient looking good that he should stay one more night. The patient was transferred to the floor off of all drips, tolerating a regular diet, and ambulating without assistance. On postoperative day two, the patient was afebrile with stable vital signs. The patient was on a regular diet and was ambulating well. The patient's examination was unremarkable. DISCHARGE STATUS: The patient was discharged to home on postoperative day two with followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] in one week. MEDICATIONS ON DISCHARGE: 1. Altace 10 mg by mouth once per day. 2. Lipitor 10 mg by mouth once per day. 3. Atenolol 25 mg by mouth once per day. 4. Aspirin 81 mg by mouth once per day. 5. Ibuprofen 600-mg tablets by mouth three times per day (for three days). 6. Hydromorphone 2-mg tablets by mouth q.4-6h. as needed (for pain). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] in the Thoracic Surgery Clinic. The patient was to contact his office to schedule an appointment in one week. 2. The patient was to follow up with his primary care physician in one week. CONDITION AT DISCHARGE: The patient was discharged to home in stable condition; tolerating a regular diet, ambulating on his own. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Last Name (NamePattern1) 10638**] MEDQUIST36 D: [**2119-3-23**] 21:46 T: [**2119-3-23**] 21:54 JOB#: [**Job Number 20041**]

[ "V45.81", "E878.6", "998.11", "287.3", "162.5", "492.8", "V10.11" ]

icd9cm

[ [ [] ] ]

[ "34.09", "32.29" ]

icd9pcs

[ [ [] ] ]

1704, 1828

177, 428

5771, 6082

1469, 1687

6115, 6426

1280, 1443

3047, 5745

6441, 6830

457, 1035

1058, 1256

1845, 3018

31,057

160,542

16673

Discharge summary

report

Admission Date: [**2192-7-27**] Discharge Date: [**2192-8-2**] Date of Birth: [**2109-7-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: Nausea and Jaundice Major Surgical or Invasive Procedure: Esophageal Ultrasound ERCP EUS History of Present Illness: Mr. [**Known lastname 47194**] is an 83 year old Italian speaking male with multiple chronic medical problems, including AF on Coumadin, CAD, COPD, and hx multiple exposures (+PPD, asbestos) who was transferred to the MICU from the ED for managment of acute liver failure. The history was obtained from the [**Last Name (LF) **], [**First Name3 (LF) **] signout, and limited conversation with the patient. He was in his usual state of health until about [**2192-7-20**], when he began to have nausea without vomiting and soft stools. He had been to a birthday celebration two days prior, where he had eaten Chinese food. Nobody else from that party got sick. He went to his PCP, [**Name10 (NameIs) **] labs showed ALT 619, AST 249, AP 852, total bili 1.5, and INR 3.9. Hepatits C IgG was negative; Hep A IgM negative, IgG positive; Hep B surface Ag neg, surf Ab pos, core IgM negative, core IgG positive. This week, the family noticed that the patient had turned yellow. He had repeat labs, which apparently showed an INR around 10 and a Tbili also around 10. On Tuesday, three days prior to admission, he stopped taking coumadin as instructed. He does not have any acute complaints. He denies vomiting, but endorses nausea. However, he was seen to have non-bloody emesis in the ED. The family members did not think he was confused, although he had been napping more than usual. He was evaluated for increasing fatigue at his PCP's office in 6/[**2191**]. Workup in ED notable for RUQ US which showed dilated intra- and extra-hepatic ducts, and a dilated GB. In the ED, initial vitals were T:98.9, HR:64, BP:105/66, RR:18, Sat 99% ra. The patient looked comfortable, without encephalopathy, with significant jaundice and icterus, irregular heart rate, belly distended but soft/nontender, liver 7-8 cm below costal margin. No ascites appreciated. EKG showed Afib 72, old rbbb, left axis deviated. No medications given in the ED, no fluids in the ED, liver consult, ruq u/s showed "Marked intra and extrahepatic biliary dilation of uncertain etiology. Pancreas not visualized. Dilated gallbladder with no evidence of cholecystitis. MRCP/ cross sectional imaging is recommended to evaluate etiology of biliary dilation." Past Medical History: A-fib rate controlled and on coumadin. S/p RCA stent placement in [**2185**], [**2188**] for positive stress test. CAD s/p stent to RCA [**2185**] Renal insufficiency w/ variable baseline Cr 1.1-1.6 aortic valve mass [**12/2186**] HTN Hypercholesterolemia COPD Osteoarthritis impaired glucose tolerance colonic polyps [**2188-11-7**] pulmonary nodule [**2181**] chronic subdural hematoma [**7-/2176**] stroke [**10/2176**] right bundle branch block GERD PPD positive [**2180**] carotid stenoses [**10/2176**] dementia [**2-/2187**] depression low back pain basal cell CA [**5-/2186**] hip fracture Social History: Married for 50 years, former welder. Immigrated from [**Country 2559**] in [**2140**]. Quit smoking 18 years ago. Minimal alcohol. History of asbestos exposure. He has no history of recent travel. Family History: unknown Physical Exam: Physical Exam on Arrival: Vitals: T:97.6, BP:116/72, HR:78, RR:21, O2:98%/RA GEN: No apparent distress, responding appropriately to questions and commands HEENT: Jaundiced, scleral icterus, no cervical/supraclavicular Cardio: irregular, no m/r/g Chest: CTAB Abd: slight distension, soft, non-tender, the liver edge is percussed two finger breaths below the costal margin, the liver edge is not palpable. Ext: no c/c/e Neuro: no asterixis Discharge Physical Exam: Vitals: T:97.7 Tmax:97.7 BP:120/76 (100-129/60-89) P:82 (72-89) R:18 O2:95%/RA General: Alert, oriented, no acute distress Derm: jaundiced HEENT: Sclera anicteric, MMM, oropharynx clear, underside of tongue is yellow Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNs2-12 intact, motor function grossly normal Pertinent Results: CBC: [**2192-7-27**] 09:35AM BLOOD WBC-10.6 RBC-4.72 Hgb-14.2 Hct-40.8 MCV-87 MCH-30.1 MCHC-34.8 RDW-16.5* Plt Ct-297 [**2192-7-27**] 04:00PM BLOOD WBC-9.0 RBC-4.51* Hgb-13.0* Hct-38.3* MCV-85 MCH-28.8 MCHC-33.9 RDW-17.1* Plt Ct-223 [**2192-7-28**] 03:16AM BLOOD WBC-7.4 RBC-4.57* Hgb-13.1* Hct-38.0* MCV-83 MCH-28.7 MCHC-34.6 RDW-17.0* Plt Ct-225 [**2192-7-28**] 12:15PM BLOOD WBC-9.0 RBC-4.47* Hgb-12.9* Hct-37.3* MCV-83 MCH-28.8 MCHC-34.5 RDW-17.2* Plt Ct-249 [**2192-7-29**] 07:20AM BLOOD WBC-9.8 RBC-4.64 Hgb-13.5* Hct-39.3* MCV-85 MCH-29.1 MCHC-34.4 RDW-17.4* Plt Ct-241 [**2192-7-30**] 04:50AM BLOOD WBC-7.7 RBC-4.38* Hgb-13.1* Hct-38.0* MCV-87 MCH-30.0 MCHC-34.6 RDW-17.3* Plt Ct-260 [**2192-7-31**] 05:45AM BLOOD WBC-8.8 RBC-4.17* Hgb-12.1* Hct-35.4* MCV-85 MCH-29.0 MCHC-34.2 RDW-17.4* Plt Ct-254 [**2192-8-1**] 07:55AM BLOOD WBC-6.4 RBC-4.02* Hgb-11.8* Hct-35.0* MCV-87 MCH-29.4 MCHC-33.8 RDW-17.7* Plt Ct-261 [**2192-8-2**] 06:05AM BLOOD WBC-6.6 RBC-3.60* Hgb-10.5* Hct-32.0* MCV-89 MCH-29.1 MCHC-32.8 RDW-17.7* Plt Ct-246 [**2192-7-27**] 09:35AM BLOOD Neuts-76.9* Lymphs-16.7* Monos-5.2 Eos-0.7 Baso-0.5 [**2192-7-27**] 09:35AM BLOOD PT-89.5* INR(PT)-10.5* [**2192-7-27**] 09:35AM BLOOD Plt Ct-297 Coags: [**2192-7-27**] 04:00PM BLOOD PT-82.3* PTT-43.7* INR(PT)-9.5* [**2192-7-28**] 03:16AM BLOOD PT-71.2* PTT-44.6* INR(PT)-8.0* [**2192-7-28**] 12:15PM BLOOD PT-21.9* PTT-28.0 INR(PT)-2.0* [**2192-7-28**] 12:15PM BLOOD Plt Ct-249 [**2192-7-29**] 07:20AM BLOOD PT-13.0 PTT-22.1 INR(PT)-1.1 [**2192-7-29**] 07:20AM BLOOD Plt Ct-241 [**2192-7-30**] 04:50AM BLOOD PT-13.2 PTT-22.0 INR(PT)-1.1 [**2192-7-30**] 04:50AM BLOOD Plt Ct-260 [**2192-7-31**] 05:45AM BLOOD PT-13.2 PTT-22.1 INR(PT)-1.1 [**2192-7-31**] 05:45AM BLOOD Plt Ct-254 [**2192-7-31**] 05:45AM BLOOD Plt Ct-254 [**2192-8-1**] 07:55AM BLOOD PT-12.8 PTT-22.0 INR(PT)-1.1 [**2192-8-1**] 07:55AM BLOOD Plt Ct-261 [**2192-8-2**] 06:05AM BLOOD PT-13.6* PTT-31.6 INR(PT)-1.2* Lytes: [**2192-7-27**] 04:00PM BLOOD Glucose-452* UreaN-47* Creat-2.1* Na-129* K-4.0 Cl-95* HCO3-21* AnGap-17 [**2192-7-28**] 03:16AM BLOOD Glucose-227* UreaN-39* Creat-1.7* Na-135 K-3.5 Cl-102 HCO3-22 AnGap-15 [**2192-7-29**] 07:20AM BLOOD Glucose-162* UreaN-33* Creat-1.6* Na-138 K-3.6 Cl-99 HCO3-25 AnGap-18 [**2192-7-30**] 04:50AM BLOOD Glucose-210* UreaN-33* Creat-1.6* Na-133 K-3.4 Cl-98 HCO3-25 AnGap-13 [**2192-7-31**] 05:45AM BLOOD Glucose-158* UreaN-27* Creat-1.5* Na-137 K-3.7 Cl-102 HCO3-23 AnGap-16 [**2192-8-1**] 07:55AM BLOOD Glucose-192* UreaN-31* Creat-1.5* Na-139 K-3.6 Cl-104 HCO3-22 AnGap-17 [**2192-8-2**] 06:05AM BLOOD Glucose-261* UreaN-35* Creat-1.5* Na-136 K-3.6 Cl-104 HCO3-24 AnGap-12 LFT's: [**2192-7-27**] 09:35AM BLOOD ALT-482* AST-333* AlkPhos-993* TotBili-9.4* [**2192-7-27**] 04:00PM BLOOD ALT-444* AST-287* AlkPhos-911* TotBili-9.3* DirBili-7.4* IndBili-1.9 [**2192-7-28**] 03:16AM BLOOD ALT-427* AST-317* LD(LDH)-287* CK(CPK)-39* AlkPhos-925* TotBili-10.2* [**2192-7-31**] 05:45AM BLOOD ALT-205* AST-113* AlkPhos-645* TotBili-16.0* [**2192-8-1**] 07:55AM BLOOD ALT-163* AST-68* LD(LDH)-202 AlkPhos-616* TotBili-10.5* [**2192-8-2**] 06:05AM BLOOD ALT-123* AST-48* AlkPhos-536* TotBili-6.6* Lipase: [**2192-7-27**] 04:00PM BLOOD Lipase-118* GGT-1265* [**2192-7-29**] 07:20AM BLOOD Lipase-74* [**2192-7-30**] 04:50AM BLOOD Lipase-77* Albumin: [**2192-7-27**] 04:00PM BLOOD Albumin-3.4* Iron-129 Ca, Mg, Phos: [**2192-7-28**] 03:16AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9 [**2192-7-29**] 07:20AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.0 [**2192-7-30**] 04:50AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.0 [**2192-7-31**] 05:45AM BLOOD Albumin-2.9* Calcium-8.9 Phos-3.0 Mg-1.9 [**2192-8-2**] 06:05AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9 Fe studies: [**2192-7-27**] 04:00PM BLOOD Ferritn-228 [**2192-7-28**] 03:16AM BLOOD calTIBC-307 Ferritn-264 TRF-236\ Liver Studies: [**2192-7-28**] 03:16AM BLOOD Ammonia-52 [**2192-7-28**] 03:16AM BLOOD IgM HAV-NEGATIVE [**2192-7-28**] 03:16AM BLOOD AMA-NEGATIVE Smooth-POSITIVE * [**2192-7-28**] 03:16AM BLOOD CEA-7.3* AFP-2.9 [**2192-7-28**] 03:16AM BLOOD IgG-1363 IgA-345 IgM-87 [**2192-7-27**] 04:00PM BLOOD Acetmnp-NEG [**2192-7-28**] 03:16AM BLOOD HCV Ab-NEGATIVE CA [**99**]-9: 4 (normal) Ceruloplasmin: 46 (high) IgG Subclasses 1,2,3,4: Pending HCV Viral Screen: Negative MRSA Screen: Negative U/A: Negative ECG [**2192-7-27**]: Atrial fibrillation with controlled ventricular response. Right bundle-branch block with left anterior fascicular block. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2191-6-23**] no diagnostic interval change. RUQ US [**2192-7-27**]: IMPRESSION: Marked intra- and extra-hepatic biliary dilatation. Distal point of obstruction not assessed. The pancreas is not visualized on this current examination. Recommend MRCP/cross-sectional imaging for evaluation of the etiology of biliary dilation. Cxr [**2192-7-28**]: Lung volumes are relatively low. Heart size and vascularity are normal. Opacities at both lung bases appear chronic with no new infiltrates or pleural effusions. IMPRESSION: No significant interval change allowing for technique. MRCP [**2192-7-28**]: IMPRESSION: 1. Marked intrahepatic and extrahepatic biliary ductal dilatation with marked dilation of the pancreatic duct associated with pancreatic atrophy. The appearances are highly concerning for a pancreatic head tumor, although no definite tumor can be identified. The SMV, portal vein, and splenic vein appear to be patent. No lymphadenopathy or evidence of metastasis. Consider ERCP to further evaluate. 2. Bilateral renal cysts. 3. 1.9-cm hepatic cyst. 4. Small right pleural effusion. Common Bile Duct Brushings [**2192-7-30**]: Diagnosis: SUSPICIOUS FOR ADENOCARCINOMA. Very atypical glandular cells in crowded groups with high N:C ratio, irregular nuclear contours, and anisonucleosis. Brief Hospital Course: Assessment: Mr. [**Known lastname 47194**] is an 83 year old man with a history of atrial fibrillation, CAD, HTN and renal insufficiency found to have biliary obstruction due to likely pancreatic adenocarcinoma in the uncinate pancreas. Diagnoses: # Pancreatic Mass causing cholestasis and Acute Liver Failure: The patient presented with elevated ALT, AST, and lipase, with markedly elevated AlkPhos, GGT, and Tbili. Indirect bili was normal, and direct bili was increased, indicating a conjugated bilirubinema. This pattern of LFTs is suggestive of cholestasis rather than primary liver dysfunction. The patient was jaundiced and described severe pruritis, consistent with hyperbilirubinemia. The most likely diagnosis is pancreatic cancer given the absence of abdominal pain, the severe biliary dilation, diarrhea, and 6 month history of weight loss. MRCP showed massively distended gallbladder, and atrophic pancreas, consistent with a potential mass in the pancreatic head. ERCP yesterday showed an irregular stricture, consistent with tumor, with post-obstructive dilation. A stent was placed in the bile duct to allow for draining, and followup in two months is suggested for stent exchange. Cytology brushings taken during ERCP showed atypical glandular cells in crowded groups with high N:C ratio, irregular nuclear contours, and anisonucleosis, suspicious for adenocarcinoma. EUS showed a mass with cystic component in the uncinate pancreas but a biopsy could not be taken. Surgery was contact[**Name (NI) **] and they did not believe that the patient was a candidate for a Whipple procedure. Placement of the stent resulted in a decrease in bilirubin levels and relief of jaundice and pruritis. His LFTs which were elevated on admission have also been trending downwards. The patient was feeling well on the day of discharge complaining of only mild jaundice. # Atrial Fibrillation: The patient has a history of atrial fibrillation for which he takes coumadin. His CHADS score is 5. He came in with an INR of 10, in the setting of acute liver failure and coumadin therapy. His coumadin was stopped, and he was given Vitamin K, in order to reduce his INR to below 1.5 for ERCP. In the post-procedure setting we placed the patient on LMWH to bridge back to coumadin. The daughter of the patient ensured that she would bring the patient in to see his PCP on [**Name9 (PRE) 2974**] [**2192-8-2**] to check his INR. # CAD: The patient has a history of CAD and is s/p RCA stenting in [**2185**] and [**2188**]. He takes aspirin at home, and was continued on 81 mg of aspirin daily in the hospital. # Acute on chronic Renal insufficiency: His baseline creatinine is 1.1-1.6, but he came in with creatinine 2.1, and trended downwards. Initial BUN/Cr>20 suggests a prerenal cause of his decreased renal function. The most recent Cr is 1.5, and he is back to his baseline. # HTN: Patient has a history of hypertension controlled on medications at home, and he was on verapamil 40mg Q8H in the hospital. # Hypercholesterolemia: The patient a history of HL, for which he is on medications, and but we held simvastatin in the setting of acute liver failure. # COPD: The patient does not take any home medications for his COPD. # Depression: Patient has a history of depression controlled on medication at home, and we held his fluoxetine. Transitional Issues: 1. Pt has IgG classes 1,2,3,4 pending to check for autoimmune pancreatitis. 2. Pt will need a definitive treatment plan for his very likely pancreatic adenocarcinoma. He has established care with our oncology department. 3. Pt will need a lengthy discussion of goals of care at this point and will need further prognostic guidance from a specialist. Daughter is very involved in his care and she is married to a radiologist who would like to attend the radiology conference in which Mr. [**Known lastname 47195**] case is discussed. Medications on Admission: 1. ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - 1 Tablet(s) by mouth q4-6 2. BIMATOPROST [LUMIGAN] - 0.03 % Drops - 1 gtt ou once a day 3. FLUOXETINE - 20 mg Capsule - 1 Capsule(s) by mouth every day for depression 4. FLUOXETINE - 10 mg Capsule - 1 Capsule(s) by mouth once a day for depression, add 20mg plus 10mg equals 30mg per day 5. FLUTICASONE - 50 mcg Spray, Suspension - 1-2 puffs(s) intranasal once a day for sinus allergies 6. FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth every day 7. NITROGLYCERIN - 0.4 mg/Dose Spray, Non-Aerosol - spray under tongue once a day as needed for repeat q 5 min prn ut dict for chest pain 8. SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day chol 9. VERAPAMIL - 180 mg Cap,Ext Release Pellets 24 hr - 1 Cap(s) by mouth daily 10. WARFARIN - 2.5 mg Tablet - 1 (One) Tablet(s) by mouth once a day as needed for 3 days a week tues, Thurs, Sat 11. WARFARIN - 5 mg Tablet - 1/2-1 Tablet(s) by mouth once a day ut dict for afib, these are the correct instructions and cannot be altered by Bioscrip request 12. ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day prevention Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 2. verapamil 180 mg Cap,Ext Release Pellets 24 hr Sig: One (1) Cap,Ext Release Pellets 24 hr PO once a day. 3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous Q12H (every 12 hours): Please continue to take until told by your primary doctor that your INR is at an appropriate level. Disp:*14 syringes* Refills:*0* 5. acetaminophen-codeine 300-30 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 6. bimatoprost 0.03 % Drops Sig: One (1) ou Ophthalmic once a day. 7. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO once a day: Total fluoxetine dose = 30 mg. 8. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day: Total fluoxetine dose = 30 mg. 9. fluticasone Nasal 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. nitroglycerin 0.4 mg/dose Spray, Non-Aerosol Sig: One (1) spray Translingual once a day as needed for chest pain: [**Month (only) 116**] repeat after 5 mins if still have chest pain. 12. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please start taking 5 mg once daily and follow up with your primary care provideer tomorrow. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Obstructive jaundice Cholestatic liver failure Possible pancreatic adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 47194**], You were admitted to the hospital following an episode of diarrhea and concerns from your family that your skin looked yellow. While you were here we determined that your liver tests returned as abnormally high. You underwent a number of diagnostic procedures and we determined that you had a blockage of your biliary tract from a likely cancerous mass compressing it. A biliary stent was placed to try and help reopen your bilary tract. This seems to have helped somewhat as your enzymes have come back closer to normal levels, but they have not completely normalized at this time. We would like for you to follow up in our oncology clinic. Additionally, since we are restarting your anticoagulation, you will need to follow up with your primary care provider and have your INR checked both tomorrow and Monday morning. The following changes were made to your medications: 1) Restart your Warfarin at 5 mg per day and follow up closely with your primary care provider regarding further dose changes 2) START Enoxaparin (lovenox) 70 mg twice per day unitl your primary provider tells you it is safe to stop Thank you for allowing us to participate in your care. We wish you a speedy recovery. Followup Instructions: Department: ADULT SPECIALTIES When: THURSDAY [**2192-8-9**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 1142**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: WEDNESDAY [**2192-9-5**] at 1:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [**Hospital3 1935**] CENTER When: MONDAY [**2192-11-12**] at 9:30 AM With: VISUAL FIELD SCREENING [**Telephone/Fax (1) 253**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report+addendum

Admission Date: [**2197-7-16**] Discharge Date: [**2197-7-27**] Service: CCU HISTORY OF PRESENT ILLNESS: This is a 77-year-old woman with a history of coronary artery disease, noninsulin dependent diabetes mellitus, and hypertension who was admitted to the CCU with hypotension and new atrial fibrillation in the setting of urosepsis. The patient was intubated for airway protection. She was in her usual state of health which was mildly confused and occasionally agitated but able to converse and propel herself in a wheelchair until the day of admission [**2197-7-16**] when she was noted by the nursing staff in her nursing home to be somnolent and diaphoretic with elevated fingerstick blood sugars. She was also relatively hypotensive with a blood pressure of 80/60. Her white blood cell count at [**Hospital1 2670**] was 16,000 with 2% bandemia. She was transferred to [**Hospital6 649**] for evaluation. At the nursing home, she had received 500 mg of Levaquin. Upon presentation to the emergency room in the afternoon, her vital signs revealed temperature 101.8, heart rate 109, blood pressure 107/43. Intravenous fluids were initiated at that time. Head CT was negative for bleed. Blood pressure stayed in the high 90s systolic until the evening of admission when she developed atrial fibrillation with a rapid ventricular rate to 160-170. Three cycles of cardioversion were attempted with apparent atrial rhythm induced but not sustained. An Amiodarone drip with bolus, Dopamine, and Levophed were started. A right subclavian line and femoral arterial line were placed. The patient had a blood pressure of 60-90/palpable for approximately 90 minutes. A blood pressure of 150/110 was achieved with Dopamine 20, Levophed 30, and after 8 liters of normal saline. The Dopamine was weaned to off in the emergency room. The patient was transferred to the CCU. She did transiently assume what appeared to be atrial rhythm. Dr. [**Last Name (STitle) 5762**] and the CCU fellow were contact[**Name (NI) **] regarding the plan. The strategy was to intubate the patient and to use pressors/inotropics and cardioversion as needed but not to pursue catheterization. PAST MEDICAL HISTORY: The past medical history revealed coronary artery disease in [**2197-5-21**]; hypertension; noninsulin dependent diabetes mellitus; diabetic retinopathy; status post cerebrovascular accident in [**2189**]; status post cholecystectomy in [**2192**]; right cataract; obesity; chronic low back pain; urinary incontinence; dementia/mild mental retardation. MEDICATIONS: Zestril 10 mg q.d., ECASA 325 mg q.d., regular insulin sliding scale, multivitamins, Lopressor 100 mg b.i.d., vitamin E 400 international units q.d., Remeron 15 mg q.h.s., and health shakes. ALLERGIES: No known drug allergies. FAMILY HISTORY: The patient has a brother with coronary artery disease and diabetes. Her [**Last Name (LF) **], [**First Name3 (LF) **] uncle, and a sister had no known medical problems. SOCIAL HISTORY: The patient lives at [**Hospital 2670**] Nursing Home. She was previously with her sister. She has a ten pack year smoking history. She was a hotel maid. She is a widow without children. She does not drink alcohol. PHYSICAL EXAMINATION: Vital signs revealed atrial fibrillation with a ventricular rate of 130, blood pressure 120/72, O2 saturation 100%. Arterial blood gas revealed pH 7.32, pO2 415, oxygen saturation 100%. Ventilation settings were 16x600, FIO2 100, PEEP 5. In general, the patient was resting in bed, intubated and sedated. The skin was warm and dry. HEENT examination revealed normocephalic, atraumatic. The left pupil was round, regular, and reactive to light 3 to 2 mm. There was a right cataract. The patient was edentulous. There were upper isolated teeth. The neck was supple without lymphadenopathy. The lungs were clear to auscultation anteriorly with no wheezes. There was a right subclavian line. Cardiovascular examination revealed irregularly irregular, normal S1 and S2, no S3, no S4, and no murmurs. Carotids revealed normal volume and upstrokes, no bruits. The abdomen was soft, nontender, and nondistended with hypoactive bowel sounds. The extremities revealed no clubbing, cyanosis, or edema. There were 2+ dorsalis pedis and posterior tibialis pulses bilaterally. There was positive hyperpigmentation of the right shin. PERTINENT LABORATORY DATA ON ADMISSION: White blood cell count was 10 with differential of neutrophils 52%, bands 24%, lymphocytes 14%, monocytes 4%, atypical lymphocytes 4%, metas 2. Hematocrit was 44.7, platelets 328,000, PT 14.4, PTT 23.1, INR 1.4. Urinalysis was turbid, specific gravity 1.025, positive blood, positive glucose, greater than 50 white blood cells, many bacteria. Albumin was 3.3, magnesium 2.4, calcium 9.8, phosphorus 2.5, sodium 149, potassium 4.4, chloride 110, bicarbonate 22, BUN 79, creatinine 1.6, glucose 480, ALT 33, AST 74, alkaline phosphatase 126, amylase 133, total bilirubin 0.4, lipase 15, CK 362, MB 17, index 4.7, troponin greater than 50. Arterial blood gas revealed 7.31/25/578. Lactate was 6.8, potassium 3.5, calcium 0.79. The next arterial blood gas that same night revealed 7.25/27/501. The next arterial blood gas the next day revealed 7.42/35/276. On [**2197-7-16**] blood cultures twice were pending. Urine culture was pending. Electrocardiogram on [**2197-7-16**] revealed atrial fibrillation at 110, axis 97 degrees, intervals 0.128 and 0.455, ST elevation to 1 mm in III and 0.5 mm in aVF, ST elevation to 1 mm in V2-V3, 7 mm in V3-V4, [**Street Address(2) 4793**] depression in I and aVL. Another electrocardiogram revealed atrial fibrillation at 160, axis 87 degrees, intervals 0.94 and 0.485, ST elevation of 1.5 mm in III and 0.5 mm in aVF, ST elevation of 1 mm in V1 and V2-V4, and inversion in V5. The next EKG also on [**2197-7-16**] revealed normal sinus rhythm at 96, axis 68 degrees, and intervals 102, 0.88, and 0.[**Street Address(2) 95470**] elevation of 1 mm in III and 0.5 mm in aVF, ST elevation of 1 mm in V1, 2 mm in V2-V3, 1 mm in V4, and ST depression of 1 mm in I and aVL. Chest x-ray revealed left lower lobe atelectasis/consolidation, no pneumonia, right subclavian line, and ETT in right main-stem bronchus pulled back. CT of the head was negative for intracranial hemorrhage. Echocardiogram on [**2197-5-26**] revealed normal size left atrium, normal size right atrium, left ventricular thickness size normal, ejection fraction of 40%, right ventricular chamber/motion normal, no aortic stenosis or aortic insufficiency, no mitral regurgitation or mitral stenosis, no tricuspid regurgitation, mild pulmonary hypertension, and severe hypokinesis of all apical segments. In the apex, there was no thrombus. There was hypokinesis of the anterior septum, akinesis of the apex, no thrombus, and hypokinesis of the anterior septum and free wall. IMPRESSION: This is a 77-year-old woman with history of coronary artery disease (positive troponins and abnormal echocardiogram, no catheterization) who presented with hypotension, increased CK and troponin, and new atrial fibrillation in the setting of urosepsis. HOSPITAL COURSE Cardiovascular/myocardium: The patient had an ejection fraction of 40% by echocardiogram on [**2197-5-26**] with residual hypokinesis. Outpatient medication regimen consisted of ACE inhibitor and beta blocker. It was decided to reassess the myocardial function after the episode of atrial fibrillation and hypotension was passed and to restart the ACE inhibitor and beta blocker when the patient was no longer pressor or inotropic dependent. The patient's decreased blood pressure was thought to be secondary to sepsis and atrial fibrillation with good response to the Dopamine and Levophed. The Levophed was weaned off by hospital day #2 with systolic blood pressures in the 110s over diastolics in the 60s. She was maintained on Diltiazem drip for three days for atrial fibrillation but this was discontinued by hospital day #3. She was started on Captopril on hospital day #2 and titrated gently. This was held on hospital day #4 for systolic blood pressure in the 70s that responded to gentle fluid boluses. A transthoracic echocardiogram on hospital day #4 showed progressive left ventricular dysfunction with an ejection fraction of about 20%. Captopril was restarted on titrated. By the time of discharge, the patient's Captopril was at 25 mg p.o. t.i.d. and Lopressor was increased to 25 mg p.o. b.i.d. Coronary: The patient had been recently admitted to [**Hospital6 1760**] prior to this admission. At that time her troponin was elevated with negative CK. A recent history of chest pain was elicited then. She had no health care proxy and at that time the decision was made to proceed with medical management rather than catheterization. Aspirin was continued and Heparin drip was placed for 48 hours initially and Plavix was started. In addition on admission, the EKG had ST elevations in the inferior and anterior leads with pseudonormalization in T wave inversion in the anterior leads. For this admission, it was also decided to manage the patient medically and she was not considered a catheterization candidate. Her lipid panel was checked during this hospitalization with increased total cholesterol to 217. HDL was 25, LDL 149, and triglycerides 216. On [**2197-7-26**], she was started on 10 mg q. day of Lipitor. Conduction: The patient had never had a history of atrial fibrillation. Her left atrium was not enlarged on her recent echocardiogram. She developed the atrial fibrillation in the setting of fever and sepsis. Cardioversion was attempted times three. She attained an atrial rhythm that was not durable. She was loaded with Amiodarone. Repeat cardioversion again was without durable response. The patient did have 20 minutes of spontaneous conversion. She was placed on Amiodarone drip. It was considered on admission to consider an Amiodarone load of 150 mg intravenously and then follow it by cardioversion. The Diltiazem drip was stopped after 72 hours. She was initially on Heparin for 48 hours. She spiked to 102.4 degrees Farenheit on hospital day #3 and went back into atrial fibrillation at a rate of 120s and was restarted on Heparin drip at that point and Diltiazem drip and this was stopped the following morning on hospital day #4. Again on hospital day #6, the patient had a fever to 99 degrees and went back into atrial fibrillation for two hours and then self converted to atrial rhythm. On discharge, the patient had been in atrial rhythm for three days and was on Amiodarone 400 mg p.o. b.i.d. Her TSH from [**2197-5-23**] was 1.3 indicating a normal thyroid function as a baseline. She will need to have pulmonary function tests in the future. Her liver tests were also stable on discharge with an ALT of 22, AST 41, alkaline phosphatase 91, total bilirubin 0.2. Hypotension: Hypotension was deemed to be due to two causes--sepsis versus atrial fibrillation. She responded well to pressor/inotropic support with aggressive rehydration. She received intravenous fluids for a while as she was ventilated. Pulmonary: The patient was intubated and easily oxygenated and ventilated. She was gradually weaned off the oxygen. She initially had metabolic acidosis and was intentionally hypoventilated. Her acidosis was thought to be likely secondary to lactic acidosis generation during an episode of hypoperfusion. Her arterial blood gases were followed. The metabolic acidosis was also thought to be secondary to receiving 8 liters of normal saline in the emergency room. Pressure support trial on hospital day #3 failed to decreases in her tidal volume. As the patient mobilized fluid and diuresed aggressively, she developed contraction alkalosis. In the setting of increased pH, the patient failed PF trials on hospital days #6 and #7 with low tidal volumes and setting off apnea alarms. As the metabolic alkalosis resolved with decreased diuresis and potassium supplementation, the patient was extubated on hospital day #9 on [**2197-7-25**] and maintained O2 saturations of 98-100% on 100% FIO2 with a mask initially which was weaned off and by the time of discharge, she was having a good O2 saturation on room air. Infectious disease: The patient was admitted with urosepsis. She had a recent discharge in [**Month (only) 205**] during which she had an E. coli urinary tract infection at that time. She had no indwelling Foley catheter on admission. She received one dose of p.o. Levofloxacin 500 mg at the nursing home on the day of admission. Intravenous Levofloxacin was added. Gentamicin was avoided because of the concern of nephrotoxicity. The patient's urosepsis was found to be secondary to Proteus. She was on Levaquin for two days when she spiked to 102.4 and was pancultured. She was started on Vancomycin and Ceftazidime. On hospital day #3, sputum culture was positive for Methicillin-sensitive Staphylococcus aureus and she was switched to Oxacillin and Ciprofloxacin. Her white blood cell count climbed to 18.1 on hospital day #7 but eventually decreased to the point of 10.1 on [**2197-7-26**]. [**7-26**] was the last day of her Ciprofloxacin, having had a 10 day course, and her Vancomycin was switched to Oxacillin for Methicillin-sensitive Staphylococcus aureus pneumonia and upon discharge, she was on day 8 of 14. It was thought that if she spiked another fever or the white blood cell count rose again, she would have an ultrasound done of her kidneys done to rule out renal abscesses. Three Clostridium difficile tests were negative when she had diarrhea during this hospital stay. Renal: The patient had a baseline creatinine of 0.6 to 0.8. On admission, the creatinine was 1.7. It was felt to be due to obstructive uropathy secondary to retention secondary to urinary tract infection. Also there was a possibility of acute tubular necrosis secondary to ischemia or prolonged episode of decreased blood pressure. It was decided to avoid Gentamicin because of its nephrotoxic nature. She had very low urine output on admission and was hydrated aggressively. She was initially hypotensive and received a total of 8 liters of normal saline in the emergency room. The patient's BUN and creatinine stabilized over the course of her hospitalization stay with BUN of 11 and creatinine of 0.5 on [**2197-7-26**]. She autodiuresed for three days and then with decreased urine output received Lasix boluses which caused her to diurese aggressively for another three days with approximately 1-2 liters per day. On hospital day #8, the patient had contraction alkalosis and we tried to keep the patient even to slightly negative fluid balance. Gastrointestinal: The patient was placed on Protonix and Colace as prophylaxis for gastritis and constipation. She was NPO initially but started on tube feeds on hospital day #3. When she was found to have an albumin of 1.9, she was continued on tube feeds but these were held prior to extubation. She was extubated on [**2197-7-25**] and on [**2197-7-26**], she was started on a cardiac/[**Doctor First Name **] diet. The patient did suffer from diarrhea during her hospitalization stay with a rectal tube in place. This was checked for Clostridium difficile three times which were all negative. Hematology: The patient was on a Heparin drip for 48 hours. Her hematocrit and platelets were stable throughout her hospitalization without requiring transfusions. Heparin drip was restarted on hospital day #3 for recurrent atrial fibrillation but then it was discontinued. The patient's baseline hematocrit was in the upper 20s and on [**2197-7-26**] was 28.8. This anemia will need a workup as an outpatient. Endocrine: The patient has noninsulin dependent diabetes mellitus. She has been on oral antihyperglycemics in the past but most recently she was on a regular insulin sliding scale. On admission, her fingerstick blood glucoses were in the 400s. She needed 32 units of regular insulin. It was decided to start an insulin drip on admission. This was quickly changed to regular insulin sliding scale as her glycemic control became better and she was continued on this with good glycemic control. Fluids, electrolytes, and nutrition: The patient was on aggressive intravenous fluids at the beginning with bolusing as necessary. The patient had a massive diuresis and became euvolemic. Her tube feeds which were started were held prior to extubation and she was started on p.o. meals on the morning of [**2197-7-26**]. During her diuresis, she was repleted with potassium aggressively and potassium was continued to be followed. On [**2197-7-26**], potassium was 3.7 and she was repleted with 40 mEq of K-Dur. Her diet started on [**2197-7-26**] was cardiac, low sodium, 1800 kilocalorie [**Doctor First Name **] diet. Neurologic/mental status: The patient has baseline dementia versus mild mental retardation. It was decided to resume Remeron when she was taking good p.o. The patient also has a history of cerebrovascular accident in [**2189**] with a chronic right facial droop. Once she was extubated, she was able to communicate appropriately. Prophylaxis: The patient was on subcutaneous Heparin b.i.d. Lines: Initially the patient had a right wrist A-line and right subclavian line as well as a Foley catheter and rectal tube in place. Her right subclavian line was discontinued on [**2197-7-24**] and a left peripheral IV line was placed instead. On [**2197-7-26**], her radial artery line was discontinued. Her rectal tube was also discontinued prior to discharge. Code status: Full code, the patient does not have a durable Power of Attorney although she does have a sister. She has mild mental retardation. It is unclear whether the patient is competent or not. Disposition: The patient was transferred to the medical floor on [**2197-7-26**] and she was deemed to be stable at this point. A physical therapy consultation was requested. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Back to [**Hospital 2670**] Nursing Home. DISCHARGE MEDICATIONS: Amiodarone 400 mg p.o. b.i.d., Heparin 5000 units subq. b.i.d., oral medication equivalent to Oxacillin will be started--unclear at this time which one--to complete a 14 day course for Methicillin-sensitive Staphylococcus aureus pneumonia, Colace 100 mg p.o. b.i.d., Plavix 75 mg p.o. q.d., regular insulin sliding scale, Aspirin 325 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Captopril 50 mg p.o. t.i.d., Lopressor 25 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d., Protonix 40 mg p.o. q.d., Remeron 15 mg p.o. q.h.s. DISCHARGE DIAGNOSES: Proteus urosepsis; atrial fibrillation; noninsulin dependent diabetes mellitus; hypertension; coronary artery disease. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-500 Dictated By:[**Last Name (NamePattern1) 7069**] MEDQUIST36 D: [**2197-7-26**] 17:19 T: [**2197-7-26**] 17:52 JOB#: [**Job Number 95471**] Name: [**Known lastname 1193**], [**Known firstname 15121**] Unit No: [**Numeric Identifier 15122**] Admission Date: [**2197-7-16**] Discharge Date: [**2197-7-31**] Date of Birth: [**2119-9-19**] Sex: F Service: ADDENDUM: The patient's discharge was delayed until [**2197-7-31**] because on [**7-27**] Miss [**Known lastname **] was found to have mental status changes, was found to be very somnolent, only responding to voice by opening her eyes but not conversant. Her white blood cell count that day was elevated at 20.3 with a left shift and 7 bands on differential. She was afebrile but it was decided to rule out a new infection by doing a urinalysis, urine culture, blood culture, repeat chest x-ray and renal ultrasound to rule out perinephric abscess in the setting of her urosepsis on admission. She was also found to have an increased respiratory rate and O2 saturation of 93% on three liters with increased congestion and sputum production. Her blood glucose that morning was 332 for which she received 8 units of regular insulin per sliding scale. Her hematocrit and platelets were also elevated at 35.2 from 28.8 and 967 from 777, so she was thought to be dehydrated (the nurses reported poor po intake). She was started on gentle IV hydration with ?????? normal saline at 50 cc per hour. She remained in sinus rhythm until discharge. C. diff was negative for toxin times three for her diarrhea. Dehydration, hypoglycemia and restarting her Remeron on the night of [**7-26**] were also on the differential for her mental status changes. Remeron was discontinued and she was given Regular insulin as needed per sliding scale. Her urinalysis showed SG of 1.032, small blood, negative nitrite, trace protein, negative glucose, 15 ketones, small bili, PH 5, 9 red blood cells, 43 white blood cells, no bacteria, no yeast, occasional uric acid. Urine culture had no growth. Blood culture, no growth to date. Renal ultrasound negative for perinephric abscess. Chest x-ray on [**7-27**] showed left pleural effusion, question of bibasilar retrocardiac lung opacities, possibly atelectasis vs pneumonia. Chest x-ray on [**7-30**] bilateral pleural effusion. On [**7-28**] the patient had a bedside swallowing evaluation and it was felt that she was possibly aspirating both solids and fluids. However, the team decided to hold off on placing a feeding tube as the patient's po intake improved without signs of aspiration in the few days before admission. This was witnessed by her resident. The patient was started on Levofloxacin on [**7-28**] for possible new hospital acquired pneumonia. She is to complete 10 days of this. Upon discharge her room air O2 sat was greater than 92%. The patient completed her 14 day course of Oxacillin IV for her Methicillin sensitive staph aureus pneumonia and does not require any continuation of antibiotics for this. The patient was started on Lasix 20 mg q d. She was thought to be fluid overloaded. This was increased to 40 mg q d on [**7-30**] and then to 40 mg [**Hospital1 **] on [**7-31**]. She is to continue 40 mg [**Hospital1 **] for three days and then to decrease to 20 mg [**Hospital1 **]. Please check her electrolytes including SMA 7, magnesium, calcium, and phosphorus on [**8-2**]. The patient is to follow-up with her primary care physician [**Name Initial (PRE) 1091**] 1-2 weeks. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 11-500 Dictated By:[**Known lastname 15123**] MEDQUIST36 D: [**2197-7-31**] 13:52 T: [**2197-8-2**] 10:45 JOB#: [**Job Number 15124**]

[ "427.31", "250.00", "996.62", "276.3", "276.2", "285.9", "599.0", "518.82", "482.41" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2835, 3008

18747, 22741

18214, 18725

3268, 4431

118, 2197

4446, 16957

16973, 18094

2220, 2818

3025, 3245

18119, 18190

19,303

112,471

52602

Discharge summary

report

Admission Date: [**2121-12-12**] Discharge Date: [**2121-12-14**] Date of Birth: [**2043-10-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8487**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy with placement of endoclips on [**2121-12-12**] Transfused 3 units pRBCs. History of Present Illness: 78 yr old gentelman with h/o HTN, DM, hypercholesterolemia, CRI (baseline creatinine [**1-28**]), arthritis, Zenker's diverticulum, gout who presents with complaint of bright red blood per rectum. The patient underwent colosnoscopy with polypectomy on [**2121-12-4**]. He was doing well after the procedure until the day of admission, [**2121-12-12**], when he began to have BRBPR. He had a total of [**6-2**] episodes of painless bright red rectal bleeding. He was otherwise asymptomatic. He denied CP, palpitations, SOB, tachycardia, pre-syncopy, LH, nausea, vomiting, diaphoresis. He has been taking aspirin 325 mg po qd and Plavix. In the ED the patient was found to be hypotensive: BP 70/30, but responded quickly to NS boluses. Hct was 29.8 on admission but decreased to 26.9 two hours later (baseline 37). The patient was initially admitted to ICU for close hemodynamic monitoring. He was made NPO, anti-platelet agens and BP meds were held and he was briefly on DDAVP. He was transfused 3 units of pRBCs. Colonoscopy on [**2121-12-12**] identified a site of bleeding in the transverse colon at the previous polypectomy site and this was managed with endoclips. The patient was then transferred to the regular medicine floor. At the time of transfer to the floor he was asymptomatic. Denied fever/chills, N/V, CP, SOB, dizziness/LH. Had not had a BM since colonoscopy. He was tolerating clears well. Past Medical History: 1. Type II DM 2. HTN 3. CRI (baseline creatinine [**1-28**]) 4. Hemorrhoids 5. Zenker's diverticulum 6. Bilateral carotic stenosis, s/p unilateral CEA 7. PVD 8. OA 9. ? Gout 10. Basal cell skin ca [**27**]. Hypercholesterolemia Social History: Retired history professor [**First Name (Titles) **] [**Last Name (Titles) **]. Tob: 65 pack-year, quit 20 years ago. Regular EtOH. Family History: Non-contributory Physical Exam: 96.1 69 161/47 16 100% RA General: pleasant, hard of hearing, appears his stated age, NAD, alert and oriented x3 HEENT: NC, AT, sclera non-icteric, conjunctiva pale, EOM intact, PERRL, mmm, OP clear NECK: no LAD, no thyromegaly, supple PULM: CTA bilaterally CV: regular, nl S1S2, no m/g/r Abd: +BS, soft, NT, ND Extr: no c/c/e Neuro: no focal deficits Pertinent Results: Labs on admission: [**2121-12-12**] 12:25PM BLOOD WBC-6.9 RBC-3.13* Hgb-10.0* Hct-29.8* MCV-95 MCH-32.0 MCHC-33.6 RDW-15.3 Plt Ct-203 [**2121-12-12**] 12:25PM BLOOD Neuts-54.7 Lymphs-39.3 Monos-4.3 Eos-1.2 Baso-0.5 [**2121-12-12**] 12:25PM BLOOD Glucose-222* UreaN-78* Creat-2.8* Na-137 K-4.9 Cl-107 HCO3-17* AnGap-18 [**2121-12-13**] 02:23AM BLOOD ALT-8 AST-11 AlkPhos-52 TotBili-0.6 [**2121-12-13**] 02:23AM BLOOD Calcium-7.9* Phos-5.3* Mg-2.1 Labs at discharge: [**2121-12-14**] 06:25AM BLOOD WBC-4.7 RBC-3.33* Hgb-10.3* Hct-30.6* MCV-92 MCH-31.0 MCHC-33.8 RDW-16.4* Plt Ct-174 [**2121-12-14**] 06:25AM BLOOD Glucose-170* UreaN-50* Creat-2.1* Na-139 K-4.7 Cl-112* HCO3-18* AnGap-14 [**2121-12-14**] 06:25AM BLOOD Calcium-8.3* Phos-3.5# Mg-2.2 Brief Hospital Course: 1. GI bleed secondary to polypectomy while on aspirin and Plavix. The patient was admitted to the intensive care unit. The patient was made NPO and was initially supported with pRBCs transfusions (total of 3 units over hospital stay) and DDAVP. ASA and Plavix (for carotid artery stenosis) were held. GI and surgery were consulted. The patient underwent colonoscopy on [**2121-12-12**] which identified active bleeding in transverse colon at the site of previous polypectomy. Endo clips were placed with good hemostasis. The patient was then gradually restarted on clear and then on low residue diet. At the time of discharge, he had a stable HCT, was asymptomatic, and was tolerating low residue diet without difficulties. He was instructed to avoid NSAIDs, aspirin and Plavix for one week after the intervention. He will continue with low residue diet for one week. The patient was instructed to follow up in the clinic for BP check after the discharge prior to resuming HCTZ and Lasix. He will also have his CBC checked to confirm stable HCT. This plan was also discussed with the patient's daughter. 2. Diabetes: Glycemic control was maintained with FS checks and ISS. The patient was resumed on his outpatient regimen of oral hypoglycemics on the day of discharge. 3. CRI (baseline creatinine [**1-28**]: Creatinine has remained at baseline during hospitalization. 4. HTN: BP medications were held initially given active hemorrhage. The patient was restarted on his BP medications on the day of discharge except for HCTZ and Lasix. His SBP was low normal on the day of discharge. He was instructed not to resume HCTZ and Lasix until he consults his primary care physician after BP check in the clinic next week. 5. Meningioma: The patient was unaware of meningioma found on a recent head MRI. The patient will f/u with neurosurgery Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpatient. 6. Carotid stenosis: The patient will f/u with US in 3 months with vascular ([**Numeric Identifier **]). 7. Prophylaxis: PPI, pneumonitis 8. FEN: Patient was initially NPO. He was then restarted on clears which was then advanced to low residue diet. He tolerated regular consistency diet without difficulty. 9. Code: full Medications on Admission: List of current medications reviewed with the patient: Plavix 75 mg po qd ASA 325 mg po qd Lasix 40 mg po bid (dose he is currently taking per patient) Accupril 10 mg po qd Allopurinol 100 mg po qd (does not take) Pravachol 30 mg po qd Valium 5 mg q8h prn Zantac 150 mg po qd Salsalate 500 mg po bid Inderal 80mg po bid Sodium bicarbonate tabs Glipizide 5 mg po qd HCTZ 25 mg po qd Ambien prn Tylenol prn Discharge Medications: 1. Pravastatin Sodium 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): PLease do not take until you are seen by a health care provider. 4. Propranolol HCl 80 mg Capsule, Sustained Action 24HR Sig: One (1) Capsule, Sustained Action 24HR PO BID (2 times a day). 5. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO DAILY (Daily). 6. Quinapril HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: Please do not start until [**2121-12-19**]. . 9. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Please do not start until [**2121-12-19**]. 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: Do not start until seen by a health care provider in the clinic next week for BP check. 11. HCTZ Sig: 25 mg once a day: Do not start until seen by a health care provider in the clinic next week for BP check. 12. Outpatient Lab Work CBC please have done on [**2121-12-16**]. Please have the results called to Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1921**]. Please follow up on the results with Dr. [**Last Name (STitle) **]. 13. Salsalate 500 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home Discharge Diagnosis: 1. Lower gastrointestinal bleed from polypectomy 2. Hypotension secondary to gastrointestinal hemorrhage 3. Diabetes 4. Chronic renal insufficiency Discharge Condition: Stable. Patient asymptomatic. Ambulating without difficulties. Tolerating regular consistency diet. Hematocrit stable. Discharge Instructions: Please avoid medications that affect your platelets (aspirin, alleve, motrin, and other NSAIDs) and Plavix for 7 days after your colonoscopy. You then may resume taking aspirin and Plavix on [**2121-12-19**] as before. Please do not take Lasix and HCTZ until you are seen in the clinic early next week, have your blood pressure checked and are told by a primary care physician to restart diuretics. Please eat low residue (low fiber) diet for 7 days. Please call you doctor immediately or return to the hospital if you start having blood in stool, become dizzy, lightheaded, or have other worrisome symtpoms. Please have CBC drawn in the lab on [**2121-12-16**]. Follow up with Dr. [**Last Name (STitle) **] or another health care provider regarding the results. Followup Instructions: 1. Please call ([**Telephone/Fax (1) 1300**] to schedule an appointment with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] early next week. 2. Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 1113**] Date/Time:[**2122-1-6**] 11:30 3. Provider: [**First Name4 (NamePattern1) 247**] [**Last Name (NamePattern1) 248**], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-3-24**] 10:40 4. Please call ([**Telephone/Fax (1) 108593**] and schedule an appointment with Dr. [**First Name (STitle) **] in neurosurgery regarding meningioma that was found on CT scan. 5. Please call ([**Telephone/Fax (1) 88**] to schedule appointment with Dr. [**First Name (STitle) **] to follow up on the management of meningioma. Completed by:[**2122-1-3**]

[ "593.9", "401.9", "998.11", "274.9", "250.00", "578.9", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "45.43", "99.04", "45.23" ]

icd9pcs

[ [ [] ] ]

7706, 7712

3473, 5730

346, 434

7905, 8025

2701, 2706

8840, 9778

2287, 2305

6186, 7683

7733, 7884

5756, 6163

8049, 8817

2320, 2682

279, 308

3167, 3450

462, 1871

2720, 3148

1893, 2122

2138, 2271

11,061

104,060

6560

Discharge summary

report

Admission Date: [**2155-5-23**] Discharge Date: [**2155-5-28**] Date of Birth: [**2101-12-1**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Keflex / Lisinopril / Insulin Glargine Attending:[**First Name3 (LF) 106**] Chief Complaint: palpitations and flushing Major Surgical or Invasive Procedure: pacemaker insertion History of Present Illness: The patient is a 53 yoF w/ a h/o CAD s/p CABG in [**2141**], DM II c/b renal failure s/p renal tx in [**2132**] and again in [**2148**] presented to [**Hospital6 4287**] initially on [**5-22**] with symptomatic bradycardia. She had some flushing, warmth, palpitations and abdominal discomfort (initially she attributed this to Thai food which is unusual for her to eat). . At [**Hospital3 **] she was noted to have complete heart block with a rate of 38. Her rhythm improved slowly to 1:1 conduction and she was transferred to the [**Hospital1 **] for continued medication washout. (she was on lopressor 100mg po qam and 150mg po qpm). . She states prior to her admission she felt palpitations while changing and getting ready for bed, she said her pulse was fast and would skip a beat every 4 or so beats. She did not feel presyncope, no sycope then or recently. She felt warm and asked her husband to call 911. She denies CP. She has had DOE upon ambulation > 1 block x 1 week, stable [**2-26**] pillow orthopnea, no PND, no leg edema. Her normal weight is 136-139 lbs, current weight is 141.5 lbs. No abdominal pain, one episode of diarrhea in the hospital the day prior to transfer to the [**Hospital1 **]. . Initial VS: 98.3 38 150/50 12 100% RA Transfer VS: 39 151/55 17 99% RA . In the ER she was given calcium gluconate 2g for CCB reversal (also on nifedipine). She was admitted from the ER to the floor with a diagnosis of 2:1 block and bradycardia, but a normal blood pressure. Upon transfer from the ER stretcher to her floor bed she was noted to become more bradycardia, from a rate of 40 to 28. Her block had worsened from 2:1 to 3:1. Her SBP was 150. She had been experiencing nausea for 1 hour prior to her transfer (after taking aspirin). Past Medical History: Diabetes Mellitus, Coronary Artery Disease s/p CABG, HTN, s/p CRT failed '[**32**], [**Name8 (MD) **] CRT [**2148**], anemia, HCV Social History: lives with husband, works full time for [**Name (NI) 25120**] department at [**Location (un) 25121**] AFB doing administrative desk work. Recent loss of mother. [**Name (NI) 25122**] care of father at home. Normally does not use any assistive devices. Family History: non contributory Physical Exam: PHYSICAL EXAMINATION: VS: T= 98.5 BP= 150/100 HR= 30 RR= 13 O2 sat= 98% RA GENERAL: NAD, AOx3 HEENT: unable to evaluate JVP, MMM, OP clear, EOMI, sclera anicteric, conjunctiva pink CARDIAC: bradycardic, 2/6 SEM best heard at USB LUNGS: rales [**1-25**] way up bilaterally, no wheezes ABDOMEN: Soft, mildly distended, non tender, no masses or organomegaly EXTREMITIES: WWP, no c/c/e SKIN: stasis dermatitis of LE Pertinent Results: [**2155-5-28**] 05:10AM BLOOD WBC-5.2 RBC-3.38* Hgb-10.4* Hct-31.4* MCV-93 MCH-30.7 MCHC-33.0 RDW-14.3 Plt Ct-165 [**2155-5-28**] 05:10AM BLOOD Glucose-158* UreaN-60* Creat-2.0* Na-140 K-5.1 Cl-107 HCO3-23 AnGap-15 [**2155-5-24**] 07:05PM BLOOD T4-11.3 [**2155-5-24**] 07:05PM BLOOD TSH-0.036* [**2155-5-28**] 05:10AM BLOOD tacroFK-9.0 [**2155-5-27**] 05:44PM BLOOD tacroFK-8.1 . Renal ultrasound [**2155-5-26**]: HISTORY: 53-year-old woman with renal transplant. COMPARISON: Renal ultrasound, [**2152-5-24**]. FINDINGS: Renal ultrasound was performed of the renal transplant in the left hemipelvis. The renal transplant measures 12.3 cm. There is no evidence of hydronephrosis or perinephric fluid. Doppler evaluation of the transplant shows symmetric flow through the kidney, and resistive indices range from 0.85 at the upper pole, 0.82 to 0.88 at the mid pole, and 0.81 to 0.83 at lower pole, and in the main renal artery of 0.89. Normal flow is seen in the renal vein. IMPRESSION: 1. Slight increase in resistive indices in all poles of the transplant kidney compared to prior study, now ranging from 0.81 to 0.89. 2. No hydronephrosis or perinephric fluid. . CXR [**2155-5-24**]: FINDINGS: Left-sided permanent pacemaker is present, with leads terminating in the right atrium and right ventricle, with no visible pneumothorax. Heart remains enlarged, and there is mild pulmonary vascular congestion. Small pleural effusion is demonstrated on the right. Bones are demineralized and demonstrate mild decreased height in the mid thoracic spine without change since [**2154-3-13**]. IMPRESSION: 1. Pacing leads in standard position with no pneumothorax. 2. Mild CHF. . EP: placement of [**Company 1543**] ADAPTA [**Company **] Brief Hospital Course: #Complete Heart Block s/p [**Name (NI) 19721**] Pt was admitted from [**Hospital6 2561**] with bradycardia, found to be complete heart block at rate of 38. Received Calcium IV. to reverse calcium channel blocker and beta blocker was discontinued. Pt rec'd a BiV [**Hospital6 **] on [**2155-5-23**] with no complications. Her Nifedipine and Metoprolol was resumed after the [**Date Range **] was placed for BP control. She will follow up at the device clinic at [**Hospital1 18**] 1 week after placement and with her cardiologist, Dr. [**Last Name (STitle) **] for continued treatment of her CAD and hypertension. Activity restrictions were reviewed with pt before discharge. #Acute on chronic Renal Failure s/p Transplant: Creatinine increased to max of 2.4 during hospital stay and was 2.0 at discharge. It was thought that she was pre-renal and her lasix was initially held. She was followed by the renal transplant team and her Prograf was decreased for high levels. She will be followed by Dr. [**Last Name (STitle) **] after discharge and her creatinine and prograf level will be checked at her device appt. Bactrim and Prednisone was continued at previous dose. #Acute on Chronic Diastolic congestive Heart Failure: Fluid overload on lung exam over course of hospitalization in setting of acute renal failure. Responded well to low dose IV lasix. PO Lasix was restarted before discharge. Weight at discharge was 64.7 kg. #Hyperglycemia [**3-4**] A1C 7.4, likely due to dietary indiscretion. Insulin regimen from home was continued during hospital stay. #Hypertension: Pt was restarted on previous doses of Nifedipine and Metoprolol after pacemaker was placed. Clonidine was decreased to 0.1 mg daily. Medications on Admission: Lasix 20mg po daily Nifedipine 60mg po bid Prednisone 5mg po daily Prograf 2mg po bid Metoprolol 150mg po qpm, 100mg po qam HISS and NPH Clonidine 0.1mg po daily Pravachol 10mg po daily Levothyroxine 250 mcg po daily Bactrim DS one tab 3x/week Aspirin 81 mg daily Discharge Medications: 1. Outpatient Lab Work Please check Chem 7 and Tacrolimus level on Friday [**5-30**] with results to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 3618**] 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (3 times a week). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day: Resume sliding scale and NPH dose from before admission. . 11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 12. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO twice a day. Disp:*180 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Complete Heart block s/p Pacemaker Acute on Chronic Renal Failure Acute on chronic Diastolic Congestive Heart Failure diabetes mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a very slow heart rate and a pacemaker was placed. No lifting your left arm over your head or lifting more than 5 pounds for 6 weeks. You will have the device checked on [**5-30**] and will then go every 6 months. We were also concerned about your kidneys as your creatinine rose to 2.4 but is decreasing now. The Nephrology team followed you and decreased your Prograf to 1.5 mg twice daily. Please get your creatinine and Prograf level checked on Friday when you come in for your pacemaker check. Medication changes: 1. Decrease Metoprolol to 100mg twice daily 2. Decrease Tacrolimus dose to 1.5 mg twice daily. You should get your level drawn on Friday when you are at the device clinic appt. Make sure that is has been 12 hours after your last dose of Tacrolimus when you get the blood drawn. As your appt is at 9am, please take your Tacrolimus at 8pm the night before, get the blood drawn at [**Hospital Ward Name 23**] before the device clinic and then take the Tacrolimus after. 3. Decrease Clonidine to 0.1 mg once daily . Please check your blood pressure at home and call Dr. [**Last Name (STitle) **] if your blood pressure is more than 160 or less than 100. You may have to adjust your medicine. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Electrophysiology: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2155-5-30**] 9:00am. [**Hospital Ward Name 23**] [**Location (un) 436**]. . Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: Wed [**6-25**] at 2:40pm. Pulmonary: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2155-8-13**] 2:10 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2155-8-13**] 2:30 . Nephrology: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 3618**] Date/time: [**6-16**] at 4:20pm. . Completed by:[**2155-6-3**]

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icd9cm

[ [ [] ] ]

[ "37.72", "37.83" ]

icd9pcs

[ [ [] ] ]

8072, 8078

4809, 6523

340, 362

8271, 8271

3052, 4786

9792, 10586

2586, 2604

6838, 8049

8099, 8250

6549, 6815

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2619, 2619

2641, 3033

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275, 302

390, 2147

8286, 8398

2169, 2300

2316, 2570

73,388

113,099

5429

Discharge summary

report

Admission Date: [**2124-7-23**] Discharge Date: [**2124-8-23**] Date of Birth: [**2079-10-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: tracheostomy tube placement PEG tube placement History of Present Illness: 44 yo woman with hx motor neuron disease recently admitted for falls, brought to the ED on this occassion for respiratory distress. Per report, pt had a respiratory code at her nursing facility, at which time she was intubated and brought to an outside hospital. Large amounts of secretions were present in the posterior pharynx, and narcan was given without improvement in sxs. At the OSH ED, she was given ceftriaxone and azithromycin for UTI and PNA. She was then transported to [**Hospital1 18**] and became hypotensive with sats in the 80s, this improved with manual bagging. . On arrival to the ED, CXR was performed which showed a hazy R lung field, therefore she was given levofloxacin, vancomycin and flagyl. Pressures dropped and she was started on phenylepherine. 3 attempts at an IJ were unsuccessful, therefore a femoral line was placed. She was given 7 L of luid. Pressures on transfer were 99.3 104 92/67, 98% on vent. . On arrival on the floor, pt is intubated and sedated. Family is at bedside and states that the pt was in her normal state of health when they were out last night at a casino. At that time she complained of some mild general fatigue, however no SOB, cough, CP or other discomfort. Per her sister, she had recently had some difficulty with choking when eating. She does have some difficulty moving her L leg at baseline, but is mobile in a wheelchair and has full function of upper extremities. . Review of systems (per family): (+) Per HPI (-) No recent fever, chills, night sweats, recent weight loss or gain. No headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. No chest pain, chest pressure, palpitations, or weakness. No nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. No dysuria, frequency, or urgency. No rashes or skin changes. Past Medical History: -suspected motor neuron disease, likely ALS, who is followed in the [**Hospital 7817**] Clinic here with Dr. [**Last Name (STitle) **] and likely -presumptive Dx Fronto-Temporal Dementia -cervical myelopathy -anxiety disorder Social History: Does not work at present. Lives with her mother (who is in her 70s and still working), and sister. She denies tobbaco or alcohol use. Denies illicit drug use. Family History: ? Motor neuron disease in her aunt who died in her 60s Sister with emotional problems Physical Exam: ADMISSION: Vitals: T:101.2 BP:105/68 P:97 R: 10 O2: 97% on vent General: Intubated, sedated HEENT: ET tube in place, PERRL, sclera anicteric Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, interosseous line in left tibia DISCHARGE: General: Cachectic, comfortable, on trach collar HEENT: PERRL, Normocephalic Cardiovascular: RRR, nl S1/S2, no mrg Lung: poor inspiratory effort, no usage of accessory muscles of respiration, mild crackles throughout stable from prior exam Abdominal: Soft, Non-tender, naBS, G-tube site, c/d/i Extremities: No lower extremity edema; Skin: Warm Neurologic: Attentive, follows simple commands Pertinent Results: Laboratory Values: [**2124-7-23**] 01:00PM BLOOD WBC-16.5* RBC-4.25 Hgb-13.0 Hct-40.3 MCV-95 MCH-30.5 MCHC-32.2 RDW-13.1 Plt Ct-287 [**2124-8-2**] 03:07AM BLOOD WBC-28.5* RBC-3.92*# Hgb-12.0# Hct-36.8# MCV-94 MCH-30.6 MCHC-32.6 RDW-13.1 Plt Ct-725* [**2124-8-10**] 04:13AM BLOOD WBC-8.1 RBC-2.61* Hgb-7.8* Hct-24.1* MCV-92 MCH-29.9 MCHC-32.5 RDW-14.3 Plt Ct-448* [**2124-7-23**] 11:50PM BLOOD Neuts-86.1* Lymphs-9.6* Monos-4.0 Eos-0.1 Baso-0.1 [**2124-8-5**] 03:32AM BLOOD Neuts-75* Bands-10* Lymphs-7* Monos-4 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2124-8-8**] 03:52AM BLOOD Neuts-79.8* Lymphs-13.3* Monos-4.2 Eos-2.4 Baso-0.2 [**2124-7-23**] 01:04PM BLOOD PT-12.4 PTT-22.6 INR(PT)-1.0 [**2124-8-8**] 03:52AM BLOOD PT-15.5* PTT-26.5 INR(PT)-1.4* [**2124-7-23**] 01:04PM BLOOD Fibrino-640* [**2124-7-23**] 11:50PM BLOOD Glucose-152* UreaN-15 Creat-0.4 Na-147* K-3.6 Cl-117* HCO3-23 AnGap-11 [**2124-8-1**] 04:57PM BLOOD Glucose-94 UreaN-10 Creat-0.3* Na-128* K-4.1 Cl-86* HCO3-37* AnGap-9 [**2124-8-2**] 04:20PM BLOOD Glucose-82 UreaN-5* Creat-0.3* Na-146* K-3.9 Cl-110* HCO3-34* AnGap-6* [**2124-8-5**] 06:15PM BLOOD Glucose-122* UreaN-7 Creat-0.3* Na-114* K-3.8 Cl-82* HCO3-29 AnGap-7* [**2124-8-10**] 04:13AM BLOOD Glucose-95 UreaN-5* Creat-0.3* Na-137 K-3.7 Cl-100 HCO3-28 AnGap-13 [**2124-8-2**] 03:07AM BLOOD ALT-155* AST-54* LD(LDH)-394* AlkPhos-84 Amylase-224* TotBili-0.5 [**2124-7-23**] 01:00PM BLOOD Lipase-46 [**2124-8-9**] 02:40AM BLOOD CK-MB-3 cTropnT-0.04* [**2124-8-9**] 03:46PM BLOOD CK-MB-5 cTropnT-0.05* [**2124-8-9**] 11:54PM BLOOD CK-MB-3 cTropnT-0.06* [**2124-8-10**] 04:13AM BLOOD CK-MB-3 cTropnT-0.05* [**2124-7-26**] 03:42AM BLOOD Albumin-2.5* Calcium-7.6* Phos-2.0* Mg-1.8 [**2124-7-27**] 06:00PM BLOOD Osmolal-299 [**2124-8-5**] 07:16PM BLOOD Osmolal-245* [**2124-8-7**] 08:37PM BLOOD Osmolal-278 [**2124-8-2**] 09:57AM BLOOD TSH-3.6 [**2124-8-2**] 09:57AM BLOOD Free T4-1.7 [**2124-8-2**] 09:57AM BLOOD Cortsol-14.1 [**2124-7-23**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2124-7-24**] 12:35AM BLOOD Type-ART Temp-37.5 Tidal V-400 PEEP-5 FiO2-40 pO2-59* pCO2-47* pH-7.30* calTCO2-24 Base XS--3 Intubat-INTUBATED [**2124-7-23**] 01:00PM BLOOD Glucose-117* Lactate-2.8* Na-147 K-4.8 Cl-94* calHCO3-34* [**2124-8-10**] 05:15AM BLOOD Lactate-0.7 [**2124-7-23**] 01:00PM BLOOD freeCa-1.16 [**2124-7-31**] 08:48AM BLOOD freeCa-1.01* Imaging: CT HEAD W/O CONTRAST Study Date of [**2124-8-6**] 9:39 AM IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. 2. No definite CT evidence of osmotic demyelination. Note that MRI, if not contra-indicated, would be more sensitive to characterize this abnormality if clinical concern persists. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2124-8-3**] 10:03 AM IMPRESSION: 1. Immense wall thickening of the entire colon and rectum consistent with pseudomembranous colitis. Dr. [**Last Name (STitle) **] was informed of this finding. 2. Large bilateral pleural effusions with bibasilar compression atelectasis. 3. Moderate ascites and anasarca. 4. There is a small patchy density in the right upper lobe that may be infectious or inflammatory in etiology. Could also represent a focus of atelectasis. Would recommend reexamining this area on any future studies. RENAL U.S. PORT Study Date of [**2124-7-26**] 1:30 PM IMPRESSION: 1. No hydronephrosis, or perinephric fluid collection. 2. Ascites. 3. Small left pleural effusion. 4. Subcentimeter nonobstructive renal stone in the lower pole, and few punctate small nonobstructive renal stones in the left kidney Reports: TTE (Complete) Done [**2124-8-10**] at 2:23:44 PM FINAL Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. AORTIC VALVE: Aortic valve not well seen. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal mitral valve supporting structures. No MS. Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal tricuspid valve supporting structures. No TS. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is normal in size. 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 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. 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. EEG Study Date of [**2124-8-8**] IMPRESSION: This is a mildly abnormal VEEG telemetry due to the presence of a slow alpha frequency background rhythm seen throughout the recording consistent with a diffuse mild encephalopathy. Normal sleep architecture was preserved. There were no focal abnormalities or epileptiform features observed. [**2124-8-22**] Chest X-Ray IMPRESSION: Right PICC in low SVC in standard location. Brief Hospital Course: 44 yo female with hx of ALS, now presenting after respiratory code with hypotension, new R-sided infiltrate concerning for sepsis. . # Fever/PNA: She initially presented with an enterococcus UTI and HAP with a R sided pleural effusion. She was treated with broad specturm antibiotics (Vanc, Flagyl and Cefepime), and early goal directed therapy was initiated. She became febrile, and her IJ was removed since it was thought to be source of infection. She continued to spike fevers necessitating continuned antimicrobial therapy. An infectious source was not found, and blood cultures remained negative. Subsequently she developed hypotension in the setting of large quanities of stool and she was given empiric PO vanco therapy for C. Diff. Eventually, she had yeast grow out of her urine and she was placed on fluconazole for ten days. She also had Staph Aureus grow out of her sputum culture that was sensitive to vancomycin. She was placed on empiric vancomycin for treatment of a second HAP, with the plan to complete 14 days of antibiotic coverage (day 1 = [**8-16**], day 14 = [**8-30**]). Throughout her hospital course she continued to spike fevers without a known source. Blood cultures remained negative, although she did have one positive blood culture that grew out coag negative staph. It was thought to be a contaminant and repeat blood cultures did not speciate any bacteria. RUQ ultrasounds did not show acute cholecystitis. Her chest X-ray did not show any acute infiltrate or cardiopulmonary process. Her C.diff PO vanco therapy will end 10 days after her last dose of IV vanco ([**9-9**]). . # Motor Neuron Disease, Fronto-Temporal Dementia: Patient with chronic motor neuron and fronto-temporal processes of uncertain etiology. No change in current function. At baseline she is cachectic with minimal ability to move lower extremities. She currently has a trach in place for chronic respiratory failure (negative inspiratory force = 24). She was maintained on olanzapine, and diazepam for anxiety. her primary nuerologist was contact[**Name (NI) **] during her admission. . #Respiratory Failure/Tracheostomy: Patient admitted with respiratory failure in setting of chronic motor neuron disease (as discussed above) and new HAP, requiring intubation. After several failed extubations, thought to be secondary to respiratory failure and patient's anxiety (as disccused below), tracheostomy was placed. Since then patient has been weaned from ventilatory support, so that she is rested on vent at night and on trach collar / passy-muir valve during the day as tolerated (with periodic resting). . # Central Diabetes Insipidus: Ms. [**Name13 (STitle) 22016**] required vasoactive support with vasopressin for several episodes of hypotension that were believed to be secondary to sepsis and hypovolemia. After discontinuing the vasopressin, Ms. [**Name13 (STitle) 22016**] would make large quanities of dilute urine (Nadir U OSM - 127), and her serum sodium would rise. Endocrine was consulted for potential central diabetes insipidous, and requested a water deprivation test. We were unable to preform the test since initially her blood pressure remained labile. She had one episode of acute hyponatremia where her serum sodium nadired at 114 and climbed to the 140's in the span of a day. Renal was consulted to determine how to replete her free water, and she was subsequently placed on ddvap 100 mcg [**Hospital1 **]. Her serum sodium remained stable when her free water and tube feeds remained constant. Her serum sodium is now stable in the 130's and she has been switched to intranasal DDAVP. . # Hypotension: When she presented to the ICU she initially was strated on goal-directed therapy with concern for sepsis. She and required vasoactive support with levophed and vasopressin. She had several additional episodes of hypotension, and which required volume resuscitation. The first episode was secondary to sepsis in the setting of her C. diff infection, the second episode was secondary to discontinuation of her vasopressin and production of large quanities of urine. Her blood pressure has remained stable since she was placed on ddvap. She has required additional volume resuscitation with .5-1L boluses on several occasions. Her blood pressure remained stable at SBP 110's and decreases to the 90's while she sleeps. # L-sided infiltrate/R pleural effusion: Upon admission, there was concern for new HAP vs aspiration PNA in the setting of acute respiratory failure. She intially started on broad specturm antiobiotics, Vancomycine, Cefepime, and flagyl, and was intubated. She initially required vasoactive support with levophed and norepi, and eventually was left on vasopressin for several days. After becoming volume overloaded for aggressive fluid resuscitation after episodes of hypotension, she was diuresised with resolution of her L side infiltrate and R sided pleural effusion. . # Eosinophilia: After several weeks in the [**Hospital Unit Name 153**], she developed an eosinophilia of unknown etiology. It was thought to be secondary to a drug reaction. She did not have any rashes. Her eosinophils are now trending down. . # UTI: She grew enterococcus in her urine. She was treated with vancomyocin. . # Anxiety: The patient was initially extubated and re-intubated for stridor. She was thought to have laryngeal edema and started on decadron. Per the anesthesiologist performing the second intubation, her vocal chords did not appear to be edematous and a larger ET tube was placed that the initial tube. Anxiety may have played a role in her re-intubation, and it was thought that paradoxical ?laryngeal spasm. She was re-intubated for a third time after acutely becoming short of breath. Again, anxiety was thought to contribute to her dyspena. Diazepam was given PRN for the anxiety. After her tracheostomy, she required intermitent doses of diazepam. Medications on Admission: 1. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Diazepam 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 4. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Medications: 1. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): to be completed on [**9-9**]. 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. Vancomycin 1250 mg IV Q 12H 10. Desmopressin 10 mcg/spray Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-25**] Drops Ophthalmic PRN (as needed) as needed for dry eye. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal TID (3 times a day) as needed for nasal congestion. 15. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Extended Care Facility: NE [**Hospital1 **] Discharge Diagnosis: Primary Diagnosis: Respiratory Failure Secondary Diagnosis: Hospital Acquired Pneumonia Urinary Tract Infection Central Diabetes Insipidus C. dificile Colitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Non-ambulatory. Out of Bed with assistance to chair. Discharge Instructions: Ms. [**Known lastname 22013**], it was a pleasure taking part in your care at [**Hospital1 1535**]. You were diagnosed with respiratory failure, central diabetes insipidus (an inability to concentrate your urine), and several infections of your lungs, urine, and colon. You are currently on antibiotics (oral vancomycin and IV vancomycin) to treat these infections. Your IV vancomycin treatment course will end on [**8-30**]. Your oral vancomycin treatment course will end on [**9-9**]. During your stay you were unable to breathe adequately on your own, so a trachesotomy tube was placed. You also received a tube in your stomach to provide nutrition. Since a tracheostomy was placed to help you breathe, you will require regular maintenance care of your airway. Your medications were updated as follows: Mirtazapine 30 mg Tablet One Tablet PO (at bedtime). Heparin 5,000 unit/mL Solution One Injection TID Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **] Insulin Sliding Scale AS DIRECTED Diazepam 5 mg Tablet One (1) Tablet PO Q8H as needed for agitation. Olanzapine 2.5 mg Tablet One Tablet PO DAILY Vancomycin 125 mg Capsule One Capsule PO Q6H (to be completed on [**9-9**]) Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated One (1) Adhesive Patch, Daily Vancomycin 1250 mg IV Q 12H Desmopressin 10 mcg/spray Aerosol, Spray One (1) Spray Nasal [**Hospital1 **] Senna 8.6 mg Tablet One (1) Tablet PO BID as needed for constipation. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette 1-2 Drops Ophthalmic as needed for dry eye Ipratropium Bromide 0.02 % Solution One Inhalation Q6H as needed for shortness of breath or wheezing Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal TID as needed for nasal congestion. Tizanidine 2 mg One (1) Tablet PO TID Followup Instructions: Patient should have follow-up with PCP [**First Name4 (NamePattern1) 8513**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22017**] If further questions regarding neurologic prognosis, patient may follow-up with outpatient neurologists, but currently poor prognosis has been communicated to patient and there are no known interventions available to her: Neuromuscular - Dr. [**First Name (STitle) **] [**Name (STitle) 3524**] - ([**Telephone/Fax (1) 13172**] Cognitive Neurology - Dr [**First Name (STitle) **] [**Name (STitle) 8012**] - ([**Telephone/Fax (1) 1703**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

17425, 17471

9687, 15635

334, 382

17675, 17675

3767, 9664

19684, 20401

2715, 2802

16017, 17402

17492, 17492

15661, 15994

17854, 19661

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410, 2272

17553, 17654

17511, 17532

17690, 17830

2294, 2521

2537, 2699

4,670

122,939

54360+59599

Discharge summary

report+addendum

Admission Date: [**2143-6-12**] Discharge Date: [**2143-7-2**] Date of Birth: [**2072-6-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Cryptogenic cirrhosis, end-stage renal disease and umbilical hernia. Major Surgical or Invasive Procedure: 1. Orthotopic liver transplant [**2143-6-13**] 2. umbilical hernia repair [**2143-6-13**] 3. Cadaveric kidney transplant into right iliac fossa [**2143-6-13**] History of Present Illness: Mr. [**Known lastname 75483**] is a 71-year-old male with end-stage liver disease secondary to cryptogenic cirrhosis. He has had prolonged hepatorenal syndrome and he has also gone into ATN requiring dialysis. He presents for combined kidney and liver transplant. Past Medical History: 1. cirrhosis c/b hepatocellular carcinoma s/p RF ablation 2. h/o hypertension - has not had SBP>100 for awhile 3. diabetes mellitus type 2, diet controlled 4. gout - no episodes recently 5. psoriasis - no lesions recently 6. ?MDS w/ inconclusive BM bx in [**2141**] Social History: Retired, owned shopping bag distribution business. Married, lives with wife. H/o tobacco use (quit 10yrs ago, 45pack-year history). Denies regular EtOH use in the past, none at all since diagnosis of cirrhosis. Denies drug use. Family History: Father w/ pancreatic cancer, mother w/ heart valve replacement, maternal grandmother w/ DM, fraternal twin sister w/ schizophrenia Physical Exam: On discharge: NAD, AOx3 no jaundice/icterus CTA RRR +BS, NT, ND, soft. fluid filled umbilical hernia incisions c/d/i no C/C/E Pertinent Results: [**2143-6-12**] 08:45PM BLOOD WBC-3.0* RBC-3.00* Hgb-9.4* Hct-28.2* MCV-94 MCH-31.3 MCHC-33.3 RDW-18.5* Plt Ct-43* [**2143-6-13**] 12:36AM BLOOD WBC-6.2 RBC-2.52*# Hgb-7.4*# Hct-21.5*# MCV-85 MCH-29.4 MCHC-34.5 RDW-16.8* Plt Ct-101* [**2143-6-14**] 12:55AM BLOOD WBC-10.3 RBC-3.83* Hgb-11.6* Hct-30.6* MCV-80* MCH-30.4 MCHC-38.0* RDW-16.5* Plt Ct-101* [**2143-6-15**] 05:42PM BLOOD WBC-3.1* RBC-3.72* Hgb-10.9* Hct-30.5* MCV-82 MCH-29.2 MCHC-35.6* RDW-18.4* Plt Ct-67* [**2143-6-17**] 04:33AM BLOOD WBC-3.4* RBC-3.74* Hgb-11.0* Hct-31.3* MCV-84 MCH-29.5 MCHC-35.3* RDW-18.1* Plt Ct-53* [**2143-6-25**] 06:00AM BLOOD WBC-6.4 RBC-3.24* Hgb-9.9* Hct-27.3* MCV-84 MCH-30.6 MCHC-36.2* RDW-20.4* Plt Ct-87* [**2143-6-30**] 10:24AM BLOOD Hct-27.2* [**2143-6-12**] 05:10AM BLOOD PT-17.6* PTT-37.8* INR(PT)-1.6* [**2143-6-12**] 11:00PM BLOOD PT-20.6* PTT-65.8* INR(PT)-2.0* [**2143-6-13**] 03:33AM BLOOD PT-16.3* PTT-44.4* INR(PT)-1.5* [**2143-6-13**] 02:25PM BLOOD PT-15.8* PTT-35.4* INR(PT)-1.4* [**2143-6-25**] 06:00AM BLOOD PT-12.7 PTT-22.2 INR(PT)-1.1 [**2143-6-12**] 05:10AM BLOOD Plt Ct-49* [**2143-6-13**] 12:36AM BLOOD Plt Ct-101* [**2143-6-13**] 05:56PM BLOOD Plt Ct-125* [**2143-6-14**] 06:08PM BLOOD Plt Ct-74* [**2143-6-20**] 05:12AM BLOOD Plt Ct-47* [**2143-6-30**] 06:25AM BLOOD Plt Ct-105* [**2143-6-12**] 05:10AM BLOOD Glucose-228* UreaN-73* Creat-3.7* Na-133 K-4.8 Cl-108 HCO3-11* AnGap-19 [**2143-6-14**] 04:56AM BLOOD Glucose-114* UreaN-53* Creat-1.9* Na-142 K-3.7 Cl-101 HCO3-31 AnGap-14 [**2143-6-16**] 06:00AM BLOOD Glucose-97 UreaN-40* Creat-1.4* Na-140 K-3.4 Cl-107 HCO3-24 AnGap-12 [**2143-6-21**] 05:58PM BLOOD Glucose-267* UreaN-21* Creat-0.8 Na-134 K-4.4 Cl-105 HCO3-21* AnGap-12 [**2143-6-30**] 06:25AM BLOOD Glucose-162* UreaN-22* Creat-1.0 Na-137 K-4.3 Cl-108 HCO3-21* AnGap-12 [**2143-6-13**] 07:22AM BLOOD ALT-251* AST-512* AlkPhos-49 Amylase-54 TotBili-7.4* DirBili-3.1* IndBili-4.3 [**2143-6-14**] 08:44PM BLOOD ALT-132* AST-83* LD(LDH)-176 AlkPhos-53 TotBili-2.6* [**2143-6-17**] 04:33AM BLOOD ALT-204* AST-103* LD(LDH)-163 AlkPhos-161* Amylase-12 TotBili-1.8* [**2143-6-25**] 06:00AM BLOOD ALT-47* AST-23 AlkPhos-131* Amylase-9 TotBili-1.4 [**2143-6-30**] 06:25AM BLOOD ALT-38 AST-24 AlkPhos-124* TotBili-0.9 [**2143-6-21**] 06:14AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-1517* [**2143-6-21**] 02:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2143-6-27**] 05:47AM BLOOD Albumin-2.5* Calcium-7.7* Phos-2.3* Mg-2.2 Iron-40* [**2143-6-27**] 05:47AM BLOOD calTIBC-164* Ferritn-1606* TRF-126* [**2143-6-19**] 05:40PM BLOOD PTH-126* [**2143-6-27**] 08:07PM BLOOD Vanco-17.9* [**2143-6-28**] 09:00AM BLOOD FK506-7.9 [**2143-6-29**] 07:25AM BLOOD FK506-8.3 [**2143-6-30**] 06:25AM BLOOD FK506-12.3 [**2143-6-12**] 03:20PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test [**2143-6-12**] 03:20PM BLOOD HERPES SIMPLEX (HSV) 2, IGG- TEST [**2143-6-19**] 05:40PM BLOOD VITAMIN D 25 HYDROXY-Test [**2143-6-26**] 06:38AM BLOOD VITAMIN D 25 HYDROXY-Test [**2143-6-12**] 04:54AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2143-6-12**] 04:54AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2143-6-12**] 08:08AM URINE RBC-[**12-16**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 [**2143-6-26**] 08:57AM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR [**2143-6-26**] 08:57AM URINE RBC-0-2 WBC-[**12-16**]* Bacteri-MOD Yeast-NONE Epi-0-2 [**2143-6-26**] 10:33AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2143-6-12**] 4:54 am SWAB SOURCE: RECTAL SWAB. **FINAL REPORT [**2143-6-18**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2143-6-18**]): ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN------------ =>64 R VANCOMYCIN------------ =>128 R [**2143-6-26**] 8:57 am URINE **FINAL REPORT [**2143-6-30**]** URINE CULTURE (Final [**2143-6-30**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. CEFAZOLIN AND CEFUROXIME SENSITIVITY CONFIRMED BY [**Doctor Last Name **]-[**Doctor Last Name **]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 32 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- 64 I TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R [**2143-6-29**] 11:50 am URINE **FINAL REPORT [**2143-6-30**]** URINE CULTURE (Final [**2143-6-30**]): NO GROWTH. 05/30,29,22/06 7:49 pm STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2143-6-26**]** CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2143-6-26**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 111298**],[**Known firstname **] L. [**2072-6-5**] 71 Male [**-6/1936**] [**Numeric Identifier 111299**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name 27315**]/dif SPECIMEN SUBMITTED: RECIPIENT LIVER. Procedure date Tissue received Report Date Diagnosed by [**2143-6-12**] [**2143-6-13**] [**2143-6-18**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma„ Previous biopsies: [**-5/4413**] LIVER MASS [**-4/2523**] LIVER CORE BIOPSY. [**Numeric Identifier 111300**] BONE MARROW BIOPSY. [**Numeric Identifier 111301**] GI BIOPSY. DIAGNOSIS Liver, native hepatectomy: 1. Largely necrotic tumor with rare microscopic foci of residual well-differentiated hepatocellular carcinoma (status post radiofrequency ablation) . The tumor measures 2.7 cm grossly. No vascular invasion seen. 2. Vascular and bile duct margins are free of tumor. 3. Portal vein thrombosis with organization. 4. Established cirrhosis with focal sinusoidal fibrosis. Fatty change is seen in approximately 5% of hepatic parenchyma with focal intracytoplasmic hyaline. Trichrome and reticulin stains are evaluated. 5. [**Doctor Last Name 37243**] stain showed mild increased iron deposition within hepatocytes and Kupffer cells. 6. Gallbladder with chronic cholecystitis, cholelithiasis and marked autolytic changes. Clinical: ESLD secondary to cryptogenetic cirrhosis ESRD, recipient liver. RADIOLOGY Final Report -59 DISTINCT PROCEDURAL SERVICE [**2143-6-13**] 8:15 PM RENAL TRANSPLANT U.S. PORT; -59 DISTINCT PROCEDURAL SERVIC Reason: STAT US. SP cadaveric kidney transplant after liver. Now [**Last Name (un) **] [**Hospital 93**] MEDICAL CONDITION: 70 year old man with cirrhosis, hepatorenal syndrome, HCC admitted with acute on chronic renal failure REASON FOR THIS EXAMINATION: STAT US. SP cadaveric kidney transplant after liver. Now sudden drop uop. Eval for vascular flow INDICATION: 70-year-old male with cirrhosis, HCC with cadaveric kidney transplant. Now with drop in urine output. No prior studies for comparison. DOPPLER TRANSPLANT ULTRASOUND: A transplanted kidney is seen in the right lower quadrant measuring 11.2 cm with no evidence of perinephric fluid collection. Vascularity is demonstrated in the upper, mid, and lower poles of the kidneys. There are brisk systolic upstrokes with RIs ranging from 0.62-0.73. The velocity of the main renal artery is 110 cm per second. IMPRESSION: 1. No evidence of perinephric fluid collections. 2. RIs range from 0.62-0.73. Velocity of main renal artery is 110 cm per second. Conclusions: Pre transplant: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Transgastic views limited, poor, but function is grossly normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. SVC and IVC appear normal without mass or thrombus. Post transplant: Pt hyperdynamic. No change in ventricular function or wall motion Valves unchanged. Aortic and caval contours preserved. Remaining exam unchanged. Results discussed with surgeons at time of the exam. RADIOLOGY Final Report DUPLEX DOPP ABD/PEL [**2143-6-14**] 6:47 PM LIVER OR GALLBLADDER US (SINGL; -59 DISTINCT PROCEDURAL SERVIC Reason: CRIT DROP, ASSESS FOR BLOOD AROUND TX LIVER [**Hospital 93**] MEDICAL CONDITION: 70M OLT [**6-12**] with dropping Hct REASON FOR THIS EXAMINATION: please assess for blood around transplanted liver INDICATION: 70-year-old male status post liver transplant with falling hematocrit and concern for perihepatic hematoma. COMPARISON: [**2143-6-13**]. RIGHT UPPER QUADRANT ULTRASOUND: The patient is status post recent liver transplant. No focal or textural hepatic abnormality is identified. There is expected appropriate flow within the main, right, and left portal veins. The main and left hepatic arteries demonstrate normal waveforms and are patent. The right hepatic artery is again not well seen. The left, middle, and right hepatic veins are patent. There is no intrahepatic biliary ductal dilatation. Again demonstrated is a small amount of fluid in [**Location (un) 6813**] pouch and around the medial aspect of the left lobe near the porta hepatis. IMPRESSION: No hematoma found to explain the patient's falling hematocrit. No significant change from [**2143-6-13**]. Right hepatic artery not well visualized due to technical scanning difficulty. RENAL SCAN Reason: S/P OLT AND RENAL TRANSPLANT EVALUATE NATIVE RENAL FUNCTION RADIOPHARMECEUTICAL DATA: 5.5 mCi Tc-[**Age over 90 **]m MAG3; HISTORY: Hepatorenal syndrome, status post OLT as well as renal transplant. Evaluation function of native kidneys. INTERPRETATION: The tracer was administered intravenously. Flow and dynamic images were then obtained, with evaluation of both the native kidneys and transplant. Blood flow images show normal blood flow to the transplant kidney, and delayed tracer accumulation in the native kidneys. Dynamic images show gradual concentration in the native kidneys over 20 minutes without excretion into the collecting system. Dynamic images of the transplanted kidney shows normal concentration and excretion of tracer. IMPRESSION: 1. Normal function of the transplanted kidney. 2. Native kidneys concentrate tracer without visible excretion over the period of 20 minutes. Brief Hospital Course: The patient was admitted to the transplant surgery service when we recieved notice a liver and kidney were available for him. He was taken to the operating room on [**2143-6-13**] by Drs. [**First Name (STitle) **], [**Name5 (PTitle) **] and [**Name5 (PTitle) 816**]. The liver transplant and umbilical hernia were performed first. Please see the operative note for further details. There were no complications. At the completion of the liver transplant the patient was re-prepped and draped for the kidney transplant. After about 5 minutes the kidney began to look very pink and started to make urine. Please see the operative note for further details. A Double J ureteral stent was placed during the procedure. There were no complications, and the patient was transfered to the SICU intubated and sedated. Intraopertaively the patient recieved 16 units of FFP, 21 units of packed cells, 7 of platelets and 30 units of cryo. In the SICU the patient was supported maximally with ventillation, blood products, IV fluids, electrolyte repleation, and intermittent pressors. His urine output was excellent. On POD 1 the PA catheter was changed to a CVL. Social work and nutrition consults were obtained and continued to make recommendations [**Hospital 33970**] hospital stay. A routine post-op duplex revealed normal liver and renal grafts. When the sedation was lightened, the patient followed commands and nodded to questions. An insulin drip was started for tight glucose control. Immunosuppression was started. Almost immediately post-op, fluid accumulated in the redundant skin from the previous umbillical hernia. This area protruded like a softball from his abdominal wall. On POD 2 the patient was extubated. He later sat on the edge of the bed. The insulin drip was discontinued. On POD 3 a diet was started. Aggressive pulmonary toliet was continued. On POD 4 the patient was transfered out of the SICU. Diuresis was continued. The umbilical fluid collection was tapped for 60cc, but quickly reaccumulated. On POD 5 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained for help in managing his blood glucose. They continued to follow throughout his hospitalization. Physical therapy was consulted as well and continued to work with the patient throughout his hospitalization. A US of the Right leg was performed secondary to unilateral swelling and was negative for DVT. The patient slowly became disoriented and fussed with his tubes/lines/drains. A sitter was utilized overnight. Haldol was started with good effect. A routine rectal swab on [**2143-6-17**] demonstrated colonization of VRE. On the evening of POD 8 ([**2143-6-21**]) the patient's respiratory status worsened. An Echo showed no change in cardic function and enzymes were nl. He was transfered to the SICU. He improved over the next several days with RTC nebs, diuresis, and very aggressive pulmonary toliet. He was started on Levofloxacin for presumed pneumonia though a sputum sample could not be obtained. He did not require re-intubation. His mental status also cleared significantly. On [**2143-6-24**] he returned to the floor. He continued tolerating a regular diet and worked with PT. A nuclear renal scan was obtained on [**6-25**] which demonstrated the graft to be performing 100% of his renal function. [**Last Name (un) **] contined to aid in management of blood glucose. Over the next week patient worked with PT, and diet was encouraged, though adequate calories continued to be a problem. [**Name (NI) **] did spike one day and ended up growing multi resistant E COLI in his urine, for which he is being treated with vanco initially then ceftriaxone once sensitivities were known. A 7-day course of antibiotics will be completed with PO cefpodoxime. Lab values were normal. Prograf levels were monitored daily and adjusted accordingly with target goal of 10. Patient will be discharged to rehab on [**7-1**] in good condition. He is slightly disoriented to others, but is very cooperative. Medications on Admission: octreotide, clotrimazole, lactulose, cipro, folic ac, B12/B6, actigall, rifaxamin, midodrine, naltrexone, bicarb, Fe Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: Ten (10) ML PO DAILY (Daily). 3. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: [**Date range (1) 72937**], then 17.5mg on [**7-4**] for 10 days, then on [**7-14**] 15mg for 10 days then 12.5mg qd for 10 days. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation q6hours prn. 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation prn: q 6hours. 11. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO QID (4 times a day). 12. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times 15. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. 16. Outpatient Lab Work please check ast,alt,ap,tb,alb,chem10,cbc,coags, tacro level every Monday and Thursday Fax results to [**Telephone/Fax (1) 697**] attn: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] RN 17. insulin sliding scale please see attached ISS 18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 19. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. 20. Humalog 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day: see printed sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Cryptogenic cirrhosis 2. end-stage renal disease 3. umbilical hernia 4. hospital acquired pneumonia 5. Urinary tract infection, E coli 6. acute blood loss anemia 7. hypokalemia Discharge Condition: good Discharge Instructions: Take your medications as instructed. Regular diet. You may resume activity as tolerated. Labs every Monday and Thursday with results fax'd to [**Hospital1 18**] Translant [**Telephone/Fax (1) 697**] You may shower, then pat-dry incision. Do not rub incision. No tub baths or swimming for 3-4 weeks. You may leave the incision uncovered or use a light dressing for comfort. * Increasing pain * Fever (>101.5 F) or Vomiting * Inability to eat or drink/take meds * Inability to pass gas or stool * Redness/swelling/drainage from wounds * Jaundice/weight gain of 3 pounds in a day *decreased urine output. tenderness over liver or kidney Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-7-8**] 9:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-7-15**] 9:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2143-7-22**] 10:20 Name: [**Known lastname 18275**],[**Known firstname 126**] L Unit No: [**Numeric Identifier 18276**] Admission Date: [**2143-6-12**] Discharge Date: [**2143-7-2**] Date of Birth: [**2072-6-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2800**] Addendum: please see addendum below Brief Hospital Course: The patient was kept in house the night of [**2143-7-1**] secondary to bed availability at rehab. On [**2143-7-2**] his MMF was decreased to 500mg [**Hospital1 **] for persistent dirrhea. If this does not decrease his stooling within the next several days, Dr. [**First Name (STitle) **] has agreed to starting immodium as te patient has had 4 negative C Diff samples. On the evening of [**2143-7-1**] his bedtime glargine was increased as well. Discharge Medications: Please note the following revision: 18. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 20. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**] Completed by:[**2143-7-2**]

[ "250.00", "238.7", "276.8", "486", "401.9", "572.4", "293.0", "599.0", "155.0", "789.5", "553.1", "571.5", "286.9", "428.0", "285.1" ]

icd9cm

[ [ [] ] ]

[ "55.69", "99.06", "54.91", "38.93", "50.59", "00.93", "99.05", "53.49", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

22264, 22503

21559, 22006

381, 543

19973, 19980

1680, 9203

20666, 21536

1387, 1519

22029, 22241

11416, 11453

19770, 19952

17478, 17596

20004, 20642

1534, 1534

1548, 1661

272, 343

11482, 13415

571, 836

858, 1125

1141, 1371

26,356

119,283

9935

Discharge summary

report

Admission Date: [**2136-5-28**] Discharge Date: [**2136-6-19**] Date of Birth: [**2058-8-29**] Sex: M Service: Blue Surgery. HISTORY OF PRESENT ILLNESS: On [**2136-5-29**] the patient presented to the hospital with a small bowel obstruction. This patient is a 76-year-old man who had a prior partial colectomy with an ileostomy who presented to [**Hospital1 346**] with a parastomal hernia. HOSPITAL COURSE: The patient's physical examination on admission was notable that he was afebrile and also hypotensive with a blood pressure 190/100, a distended abdomen, which was diffusely tender to palpation. An incarcerated, parastomal hernia was identified in the right lower quadrant. It was decided that the patient was going to go to the operating room for repair of this hernia. The patient was taken to the operating room and repair of the parastomal hernia was performed. The ileostomy that he had prior had was taken down and a new ileostomy was created. Intraoperatively, the patient also had a PA catheter placed. A peritoneal culture at this time subsequently revealed [**Female First Name (un) 564**] albicans and Clostridium perfringens and other gastrointestinal flora. The patient was sent to the surgical ICU after the surgery, where he was given multiple fluid boluses and had a difficult time keeping up his blood pressures and his urine output. He was intubated this entire time as well. He also, unfortunately suffered from tachycardia and a number of high spiking fevers and a CT scan on [**6-2**] revealed no leak. On [**6-4**], the patient underwent a second operation because of his recurrent tachycardia and spiking fevers. During this operation, it was noted that the patient had a small bowel enterotomy, basically a hole in the small bowel right close to the previous anastomotic site. Please refer the OP note from [**2136-6-4**] for a further description of the discovery. This enterotomy was repaired and afterwards the patient was sent back to the intensive care unit. The patient was intubated after the surgery and remained intubated in the intensive care unit for the next eight days. During this time it was noted he had several fevers and during one fever he was cultured and had a positive sputum culture for methicillin resistant Staphylococcus aureus. He continued to improve in the intensive care unit and on [**6-13**] he was transferred to the floor from the intensive care unit. A swallowing study before he left the SICU showed a normal swallowing ability. The recommendations said that he was able to be advanced to a regular diet. While on the floor, the patient was slowly weaned off his total parenteral nutrition and advanced slowly to a regular diet. As of now, he is tolerating a regular diet and has been weaned off of his parenteral nutrition. He is also able to ambulate with assistance from his family members, although physical therapy has recommended that the patient should remain at a rehab facility. The patient and his family adamantly refuse this option and would much prefer to have him return home. As a result, he is being discharged home with services on [**2136-6-18**]. In addition, the [**Hospital 228**] hospital course is significant for the placement of a vacuum assisted closure device to help with granulation of the previous ostomy site. He will go home on this vacuum drainage and have services assist with his management. His condition on discharge is good. The patient's diagnoses while admitted on this admission are: 1. A parastomal hernia, status post exploratory laparotomy with a parastomal hernia repair and creation of a new ileostomy. 2. He was intubated. 3. Enterostomy closure. 4. Methicillin resistant Staphylococcus aureus sputum infection. 5. Hypertension. 6. Diabetes mellitus. 7. Vacuum drain placement. DISCHARGE MEDICATIONS: Percocet, metoprolol 150 mg twice a day, Protonix 40 mg once a day, insulin, Avandia 4 mg once a day. The insulin is NPH 2 x a day and sliding scale. Combivent as needed and Metamucil 2 packets 3 x a day. FOLLOWUP: The patient's followup plans are to arrange to contact Dr.[**Name (NI) 22019**] office to arrange an appointment in one to two weeks. He is also expected to have visiting nursing assistance come and maintain the drain and assist with his activities of daily living. [**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**] Dictated By:[**First Name3 (LF) 33295**] MEDQUIST36 D: [**2136-6-18**] 15:10 T: [**2136-6-24**] 19:44 JOB#: [**Job Number 33296**]

[ "568.0", "789.5", "V55.2", "560.9", "569.69", "568.89", "998.2", "E878.6", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "99.15", "46.41", "89.64", "45.62", "46.23", "38.93", "46.73", "54.59", "54.12" ]

icd9pcs

[ [ [] ] ]

3869, 4594

429, 3845

171, 410

83,396

114,043

45651

Discharge summary

report

Admission Date: [**2181-3-10**] Discharge Date: [**2181-3-17**] Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 2736**] Chief Complaint: shortness of breath and hypertension Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]-year-old female with past medical history of hypertension, dyslipidemia, dementia presents with acute onset shortness of breath. . The patient was in her usual state of health until a few months ago when the patient developed difficult to control hypertension with SBPs ranging from 150-180s. The patient was recently diagnosed with bronchitis and was treated with azithromycin. Her last dose was yesterday. The patient continued to feel unwell so went to PCP for appointment. At that appointment PCP felt that lungs sounded clear and sent patient home. Blood pressure at that visit was noted to be 180/70. . Later that evening, the patient awoke with shortness of breath, wheezing and difficulty sleeping. In the AM the patient felt unwell with fatigue, decreased PO intake and emesis x1. Later in the day she again became short of breath, flushed and diaphoretic. An ambulance was called. At that time blood pressure was checked and noted to be elevated with systolic pressures of 160s. She was given nitroglycerin paste with some improvement of breathing. She denies chest pain, arm or back pain, fever or chills. She denies ankle edema, orthopnea, dyspnea on exertion or weight gain. She uses a walker to ambulate at baseline. She is compliant with medications and notes recent poor PO intake. The patient was brought to [**Hospital1 18**] EW for further evaluation. . In the EW, initial vitals were: T 97.9, HR 64, BP 218/76, RR 22, SaO2 98% on 2L NC. CXR showed moderate pulmonary edema with L>R pleural effusions. She was given atenolol 25mg PO, metoprolol 5mg IV, ASA 325mg, Nitro paste, 1 SL nitro, Lasix 40mg IV, and started on a nitro gtt. Her BP remained elevated with SBP 190s in the R arm and 160s in the L arm (has had 20-30 point difference in past based on PCP [**Name Initial (PRE) 12883**]). Initial labs were notable for BNP >30,000 and trop 0.03. . On arrival to the floor, patient is comfortable and denies any pain. Past Medical History: 1 Hypertension 2 Dyslipidemia 3 hypothyroidism 4 dementia 5 bronchiectasis 6 osteoporosis 7 depression 8 diverticulosis 9 scoliosis 10 nephrolithiasis 11 GERD 12 chronic hyponatremia Social History: Lives in [**Hospital3 **]. Ambulates using walker at baseline. Tobacco history: has remote smoking history in her 20s, quit >50 years ago, ETOH: history of occasional use, Illicit drugs: none. Family History: Father had chronic heart disease and died in his 80s. Mother had fatal MI at 74. Has 4 siblings - 1 borther died in his 60's of CHF, 1 brother had MI in his 60's, 1 brother died of "rare neurological disease", 1 sister died of DM2 complications. Physical Exam: Admisson physical: VS: Temp: 96.4 BP: 216/73 HR: 58 RR: 18 O2sat: GEN: pleasant, NAD, thin HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no supraclavicular or cervical lymphadenopathy, low JVD RESP: bibasilar crackles, L>R, upper airway sounds CV: RR, nl rate, S1 and S2 wnl, II/VI systolic murmur ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no edema, warm SKIN: no rashes/no jaundice/no splinters NEURO: AAOx1. CN II-XII grossly intact with exception of hearing. . Discharge physical: VS: Tm 98, BP 141/64-195/64, HR 70, RR 18, 95% RA GEN: NAD, very thin, AOx1 HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, no supraclavicular or cervical lymphadenopathy, low JVD RESP: kyphotic thoracic spine, no rales, upper airway sounds CV: RR, nl rate, S1 and S2 wnl, II/VI systolic murmur at LUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no edema, warm SKIN: no rashes/no jaundice/no splinters NEURO: AAOx1. CN II-XII grossly intact with exception of hearing. No focal motor deficits. Dysarthric speech. Pupils equal and reactive 3mm. Pertinent Results: Pertinent labs: [**2181-3-10**] 02:30PM BLOOD WBC-7.5 RBC-4.03* Hgb-11.6* Hct-33.8* MCV-84 MCH-28.7 MCHC-34.3 RDW-15.0 Plt Ct-292 [**2181-3-17**] 06:10AM BLOOD WBC-10.7# RBC-4.42 Hgb-12.4 Hct-37.3 MCV-84 MCH-27.9 MCHC-33.2 RDW-14.9 Plt Ct-301 [**2181-3-10**] 02:30PM BLOOD Glucose-115* UreaN-28* Creat-0.8 Na-131* K-4.6 Cl-97 HCO3-24 AnGap-15 [**2181-3-17**] 06:10AM BLOOD Glucose-83 UreaN-24* Creat-1.0 Na-141 K-4.0 Cl-98 HCO3-32 AnGap-15 [**2181-3-15**] 09:50PM BLOOD ALT-28 AST-48* LD(LDH)-230 CK(CPK)-80 AlkPhos-104 TotBili-0.3 [**2181-3-10**] 02:30PM BLOOD proBNP-[**Numeric Identifier 97332**]* [**2181-3-10**] 02:30PM BLOOD cTropnT-0.03* [**2181-3-11**] 03:30AM BLOOD CK-MB-4 cTropnT-0.03* [**2181-3-15**] 09:50PM BLOOD CK-MB-6 cTropnT-0.03* [**2181-3-16**] 10:25AM BLOOD Calcium-10.5* Phos-4.1 Mg-2.2 Cholest-250* [**2181-3-16**] 10:25AM BLOOD Triglyc-92 HDL-74 CHOL/HD-3.4 LDLcalc-158* LDLmeas-149* [**2181-3-10**] 02:30PM BLOOD TSH-6.9* [**2181-3-11**] 03:30AM BLOOD Free T4-1.7 [**2181-3-15**] 05:27PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2181-3-16**] 01:13PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2181-3-16**] 01:13PM URINE RBC-0-2 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2 . [**2181-3-15**] 5:27 pm URINE Source: Catheter. **FINAL REPORT [**2181-3-16**]** URINE CULTURE (Final [**2181-3-16**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. . [**2181-3-12**] TTE: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild to moderate ([**2-4**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2176-2-28**], LVH is now present. . [**2181-3-12**] CT Head: 1. No acute intracranial hemorrhage. 2. Prominent ventricles, which appear to have gradually increased in size since [**2176-2-4**] exam. MRI exam may be considered for further evaluation. 3. Small vessel ischemic disease. . [**2181-3-15**] MRA neck/brain: FINDINGS: The neck MRA demonstrates normal appearance of the right vertebral artery with mild atherosclerotic disease at the origin of both carotid arteries. The left vertebral artery is only visualized in the distal V4 portion on the post-gadolinium arterial phase images. There is high-grade stenosis of the proximal left subclavian artery identified. Mild narrowing and/or stenosis of the origin of the left common carotid is seen from the aortic arch. The venous phase of the gadolinium-enhanced MRA demonstrates visualization of the left vertebral artery in its lower portion. These findings are indicative of subclavian steal phenomenon with retrograde flow in the left vertebral artery due to high-grade subclavian stenosis. IMPRESSION: High-grade left subclavian stenosis with retrograde flow in the left vertebral artery indicating subclavian steal phenomenon. Mild atherosclerotic disease at other levels as described above. MRA HEAD: The head MRA demonstrates irregularity of the flow signal in both middle cerebral arteries due to atherosclerotic disease. The left distal vertebral artery is not visualized given the retrograde nature of the flow and inferior saturation pulse used for MRA. The right posterior cerebral artery is somewhat irregular in appearance due to atherosclerotic disease. IMPRESSION: Head MRA shows nonvisualization of the left vertebral artery due to retrograde flow in this artery seen on the neck MRA. Atherosclerotic disease is seen in the anterior circulation involving middle cerebral arteries without occlusion. . CXR [**3-15**]: As compared to the previous radiograph, there is unchanged evidence of bilateral pleural effusions, left more than right as well as of perihilar opacities that could represent pulmonary edema or infection. New parenchymal opacities have not occurred. Unchanged size of the cardiac silhouette. . Renal ultrasound: As on prior study of [**2181-3-12**], the examination is technically limited. There are apparent tardus/parvus waveforms bilaterally, which may suggest but does not definitively diagnose renal artery stenosis, given the technical limits of this examination. Both kidneys are atrophic. . MRI brain [**3-15**]: There is an area of restricted diffusion in the right middle cerebral peduncle extending to right cerebellar hemisphere indicative of an acute infarct. There is moderate-to-severe brain atrophy and changes of periventricular small vessel disease identified. There is no midline shift or hydrocephalus. Note is made of absence of left vertebral artery flow void, which was visualized on the previous MRI of [**2173-7-5**]. These findings are suggestive of slow flow or occlusion of the left vertebral artery. MRA would help for further assessment. The sagittal T1-weighted images demonstrate degenerative changes in the cervical region. Fluid is seen and soft tissue changes in the sphenoid sinus. 1. Acute right cerebellar infarct extending from middle cerebellar peduncle to the cerebellar hemisphere. 2. Absent flow void in the left vertebral artery, a new finding since [**2173-7-5**] and indicates slow flow or occlusion of the left vertebral artery. 3. Moderate-to-severe changes of small vessel disease and brain atrophy. . Brief Hospital Course: [**Age over 90 **]F with hypertension presents with hypertensive emergency, diastolic heart failure and delirium, found to have subacute cerebellar infarct and UTI. . # Hypertensive emergency - pt presented with SBP>200 and found to have flash pulmonary edema. She was ruled out for MI with flat enzymes, no ECG changes. She was admitted to MICU for nitro drip and lasix for diuresis and her SBP was better controlled at SBP 170s. She has a discrepancy in arm blood pressures documented chronically with difference of 40-50mm Hg, MRA found high grade L subclavian stenosis which likely accounts for this. Renal U/S was suboptimal study but suggestive of possible renal artery stenosis. Due to this, ACE-i was discontinued. Her SBP continued to be elevated on carvedilol, amlodipine, and hydralazine; which may be due to higher autoregulation post stroke (see below). Her goal SBP is <180 post-stroke (measured in RIGHT ARM) and should eventually be target <140. She was discharged on hydralazine, carvedilol, and amlodipine with instructions to wean down hydralazine as tolerated at the rehab facility, as BP should trend down over the next few days. . # Pulmonary edema / CHF - came in with volume overload, dyspnea, and CXR suggestive of vascular congestion. She was diuresed in the ICU with IV lasix and clinically euvolemic on transfer to the floor. Likely flash pulmonary edema in setting of hypertensive emergency. TEE done on this admission showed mild symmetric LVH with normal size and regional/global systolic function EF>55%, [**2-4**]+ AR, 1+ MR, when compared with previous new LVH is present. Diastolic CHF likely due to longstanding HTN. Pt was euvolemic at time of discharge and lasix was discontinued, she was discharged on carvedilol, statin. ACE-i was discontinued given renal U/S suggestive of RAS, as above. . # Cerebellar stroke - MRI was done in setting of persistent altered mental status thought to be [**3-7**] delirium and mild dysarthria and showed R cerebellar CVA, subacute in nature. CT done previously on admission with initial hypertension was negative for ICH. No evidence for PRES or other infarcts were seen on MRI. Neurology was consulted and believed that likely etiology was artery-artery embolism given distribution. It is unclear whether initial presentation was in setting of CVA, which caused hypertensive emergency, or whether CVA occurred in setting of HTN or incidentally. CVA likely not contributing to overall global altered mental status, but may be causing dysarthria. No truncal or limb ataxia obvious. Neurology recommended stopping ASA and starting plavix, which pt will be discharged on. SBP control as above. MRA showed severe L subclavian stenosis and pt has underlying multi-infarct dementia, stenting is not indicated in this case given surgical risk factors and no preceding symptoms of subclavian steal, other than asymmetric BP measurement. Pt will f/u in neurology clinic in 6 weeks. Discharged on plavix and statin. . # Delirium - pt has underlying dementia, developed delirium in ICU which improved slightly on the floor. Likely [**3-7**] hospitalization and ICU stay, hypertensive encephalopathy likely contributing. Unlikely that CVA is contributing heavily, as above. Initial infectious w/u was negative for UTI or PNA, thought repeat U/A and culture on [**3-15**] was positive for coag negative staph with UTI probably exacerbating delirium. She will be discharged on 3-day course of bactrim. Delirium should improve in a more familiar setting and with control of hypertension and resolution of infection. . # UTI - urine culture from [**3-15**] >100,000 coag negative staph; started on 3-day course of bactrim (day 1 = [**3-17**]). Asymptomatic, pt had Foley catheter placed in ICU which was pulled on [**1-13**]. . # Hypothyroidism - on home synthroid . . FEN: Kosher, low Na / heart healthy; ground solids with thickened nectar liquids. Medications on Admission: ALENDRONATE-VITAMIN D3 [FOSAMAX PLUS D] 70 mg-2,800 unit once a week ATENOLOL 25 mg Tablet once a day AZITHROMYCIN 250 mg Tablet Take 2 pills first day, the 1 pill daily for 5 days (? Day 1) BUPROPION HCL [WELLBUTRIN SR] 150 mg SR qAM LEVOXYL 50 mcg Tablet once a day LISINOPRIL 15 mg daily MEMANTINE [NAMENDA] 5 mg Tablet [**Hospital1 **] MOM[**Name (NI) **] [NASONEX] 50 mcg 1 spray intranasally daily prn SIMVASTATIN 10 mg Tablet daily ASPIRIN 81 mg Tablet once a day CALCIUM CARBONATE [TUMS] 500 mg Tablet daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] daily Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for cosntipation. 6. memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 9. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO TID (3 times a day) as needed for agitation. 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days: day 1 = [**2181-3-17**]. 15. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1) spray Nasal once a day. 16. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: Hypertensive emergency Flash pulmonary edema Cerebellar stroke Delirium Subclavian stenosis Urinary tract infection . Secondary: Dementia Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to [**Hospital1 18**] with high blood pressure. You stayed in the ICU for 2 days while your blood pressure was being controlled. You were confused throughout your admission likely due to delirium from being in the hospital and your high blood pressure. We did an MRI scan of your head and neck which showed that you had a small stroke in the cerebelllar region of the brain, which controls coordination of your arm and body, and can cause difficulty with articulation. It is unlikely that the stroke is contributing to the confusion, you will follow up with our neurologist in 6 weeks. Your blood pressure is still elevated and we are discharging you on medications which should be adjusted at the rehab facility. Your blood pressure should come down over the next few days and one of the medications can be stopped. Before your discharge, we found that you had a urinary tract infection. This can also contribute to confusion and delirium. We will give you a 3-day course of antibiotics for the infection. We have made the following changes to your medications: - START bactrim 1DS tab twice a day for 3 days (day 1 = [**2181-3-17**]) - START plavix 75mg daily for your stroke - START carvedilol 12.5mg twice a day for your blood pressure - STOP lisinopril (this medication can make your blood pressure very high due to the slight narrowing of the artery going to your kidney) - STOP aspirin (because you are now on another blood thinner for your stroke called plavix) - START hydralazine 25mg every 6 hours for your blood pressure; this can be stopped at the rehab facility once your blood pressure is better controlled - INCREASE your simvastatin to 40mg daily for cholesterol - START amlodipine 5mg daily for your blood pressure - STOP atenolol - you can continue the rest of your home medications, your full list of medications is attached Followup Instructions: Please follow-up in 6 weeks in the Stroke [**Hospital 878**] Clinic with Dr. [**Last Name (STitle) 39380**] - ([**Telephone/Fax (1) 7394**]. Please follow-up with your PCP after you return to the [**Hospital3 **] facility. Completed by:[**2181-3-19**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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39277

Discharge summary

report

Admission Date: [**2109-7-10**] Discharge Date: [**2109-7-23**] Date of Birth: [**2026-6-30**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: History of vomiting x 3 month Major Surgical or Invasive Procedure: [**2109-7-16**]: Classical Whipple with open cholecystectomy. History of Present Illness: This 83-year-old woman has been very healthy, but has developed anemia over the last few months. This has led ultimately to endoscopy which showed an ulcer in the duodenum which was treated with H. pylori. However, she has now developed gastric outlet obstruction, and she vomits semi digested food 3-4 times a week. Imaging suggested a mass in the pancreatic head region enveloping the outflow of the stomach at the duodenum as well. There was a high suspicion this was duodenal cancer. This looked entirely resectable by CT imaging. Past Medical History: PMH: HTN, hyperlipidemia PSH: Tosillectomy Social History: Tobacco-17 pack years, EtOH-4 drinks per week. Lives alone in FL during the [**Doctor Last Name 6165**]. Currently lives alone in [**Location (un) **] Beach Family History: Father died of PNA, Mother died of Heart Failure. Pt denies any family history of cancer. Physical Exam: On Admission: PE:97.7/68/ 168/80 / 20/95% on RA Gen: Tan woman, not jaundice, AOx3, lying comfortably in bed, NGT in place from previous hospital Heart: RRR -m/b/g Lungs: CTAB Abdomen: nontender, nondistended, normal bowels sounds Extremities: WWP On Discharge: VS: GEN:NAD, A&OX3 CV:RRR, no m/r/r Lungs:CTAB ABD: +BS, appropriately tender around the surgical incision. Subcostal incision, steri-strips in place. Extr: warm, well perfused, no e/c/c Pertinent Results: [**2109-7-11**] 01:15AM BLOOD WBC-6.0 RBC-3.46* Hgb-9.6* Hct-30.2* MCV-87 MCH-27.9 MCHC-31.9 RDW-13.4 Plt Ct-206 [**2109-7-11**] 01:15AM BLOOD Glucose-100 UreaN-6 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-28 AnGap-12 [**2109-7-11**] 01:15AM BLOOD ALT-15 AST-21 LD(LDH)-188 AlkPhos-58 Amylase-37 TotBili-0.4 [**2109-7-11**] 01:15AM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.3* Mg-1.6 [**2109-7-20**] 06:58AM BLOOD WBC-12.2* RBC-3.25* Hgb-9.3* Hct-28.3* MCV-87 MCH-28.5 MCHC-32.8 RDW-14.8 Plt Ct-330 [**2109-7-20**] 06:58AM BLOOD Glucose-107* UreaN-24* Creat-0.9 Na-141 K-4.3 Cl-108 HCO3-26 AnGap-11 [**2109-7-20**] 06:58AM BLOOD Calcium-8.0* Phos-2.4* Mg-2.0 [**2109-7-11**] ABD CTA: IMPRESSION: 1. A 2.3 x 2.6-cm mass is present at the junction of the pancreatic head and its uncinate process. An adjacent pancreatic cystic lesion is noted, measuring approximately 1.1 x 1.9 cm. The former has direct mass effect on the adjacent duodenum. 2. The celiac trunk, superior mesenteric artery and its branches are patent. The portal vein, splenic and superior mesenteric veins are patent. 3. Prominent bilateral adrenal glands. 4. A hyperdense lesion located within the left liver lobe of the liver, most likely represents a hemangioma. Attention on followup study is advised. [**2109-7-15**] EKG: Sinus bradycardia with first degree A-V block. Left axis deviation. Intraventricular conduction defect. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 86889**],[**Known firstname **] O [**2026-6-30**] 83 Female [**-9/3116**] [**Numeric Identifier 86890**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. SHABANI/cofc SPECIMEN SUBMITTED: gall bladder, JEJUNUM, WHIPPLE. Procedure date Tissue received Report Date Diagnosed by [**2109-7-16**] [**2109-7-16**] [**2109-7-20**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl DIAGNOSIS: I. Gallbladder: 1. Chronic cholecystitis. 2. One lymph node free of tumor (0/1). II. Jejunum: Segment of unremarkable small bowel. III. Pancreaticoduodenectomy specimen, Whipple procedure: 1. Adenocarcinoma of duodenum; see synoptic report. 2. Seventeen lymph nodes free of tumor (0/17). Small intestine: Polypectomy; Segmental Resection; Whipple procedure (Pancreaticoduodenectomy, partial or complete, with or without partial Gastrectomy Synopsis MACROSCOPIC Specimen Type: Whipple procedure. Tumor Site: Duodenum. Tumor configuration: Other (specify): Annular. Tumor Size Greatest dimension: 3.4 cm. Additional dimensions: 2.0 cm x 2.0 cm. Other organs Received: Jejunum, gallbladder. MICROSCOPIC Histologic Type: Adenocarcinoma (not otherwise characterized). Histologic Grade: G1: Well differentiated. EXTENT OF INVASION Primary Tumor: pT3: Tumor invades through the muscularis propria into the subserosa of the nonperitonealized perimuscular tissue with extension of 2 cm or less; see comments. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 17. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Proximal margin: Uninvolved by invasive carcinoma. Distal margin: Uninvolved by invasive carcinoma. Circumferential/radial (mesenteric or retroperitoneal) margin: Uninvolved by invasive carcinoma. Bile duct margin: Margin involved by invasive carcinoma. Pancreatic margin: Margin involved by invasive carcinoma. Distance of carcinoma from closest margin: 3 mm. Specified margin: Posterior retroperitoneal. Venous (Large vessel) invasion: Absent. Perineural invasion: Absent. Additional Pathologic Findings: None identified. Comments: The tumor invades pancreas but appears to invade less than 2 cm. Clinical: Pancreatic cancer. Brief Hospital Course: The patient was originally admitted for substernal fullness, vomiting on [**2109-7-10**]. Her workup led to a CT scan that showed two lesions in her pancreas (a 2.3 x 2.6-cm mass at the junction of the pancreatic head and its uncinate process; an adjacent pancreatic cystic lesion measuring approximately 1.1 x 1.9 cm with direct mass effect on the adjacent duodenum). The patient was admitted to the hospital and worked up for her pancreatic lesions. CT did not indicate any metastases. Her vomiting and fullness was attributed to gastric outlet obstruction from compression of the duodenum by one of the masses, and the patient was decompressed w/ an NG tube and scheduled for a Whipple procedure. On [**2109-7-11**] patient was started on TPN which she received until her scheduled procedure. On [**7-16**] the patient was taken to the OR for a Whipple procedure. This lasted approximately 9 hours and the patient tolerated the procedure without major complications. In order to achieve adequate margins, a pyloric sparing operation was unable to be performed. Please refer to the operative note for details. A #19 [**Doctor Last Name 406**] was left in [**Location (un) **] pouch and the patient was taken to the PACU for further recovery. In the PACU the patient was noted to have low uop (5-10cc/hr) and respiratory depression. The patients UOP improved with resuscitation and her respiratory status improved on a Narcan drip. She was then transferred to the SICU for further management. In SICU patient's UOP improved with IV fluids, her creatinine became normal. Intermittent dilaudid and Fentanyl patch were d/c'd, patient received minimal dose of Dilaudid IV prn for pain control. The NGT was d/c'd. Patient was transferred to the floor in stable condition, NPO, on IV fluids, with a foley catheter and a JP drain in place, and intermittent dilaudid for pain control. The patient was hemodynamically stable. The rest of the [**Hospital 228**] hospital course was uneventful. Post-operative pain was initially well controlled with intermittent dilaudid, which was converted to oral pain medication when tolerating clear liquids. The foley catheter was discontinued at on POD#4. The patient subsequently voided without problems. The patient was started on sips of clears on POD#3, which was progressively advanced as tolerated to a regular diet by POD#6. JP amylase was sent in the evening of POD#5; the JP amylase was 146 and the JP drain was removed. During this hospitalization, the patient ambulated early and frequently with Physical Therapy assist, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly and insulin was administered when indicated. At the time of discharge on [**2109-7-23**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Staples were removed, and steri-strips placed. The patient was discharged home. She received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Benicar 20mg daily (olmesaratn) cartia xt 240mg daily hctz 25mg daily simvastatin 20 mg qhs niacin 500mg daily Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 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. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 6. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours. 8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: 1. Duodenal cancer. 2. Gastric outlet obstruction. 3. Acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-22**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2109-8-9**] 10:15 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] Completed by:[**2109-7-23**]

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Discharge summary

report

Admission Date: [**2148-9-25**] Discharge Date: [**2148-10-2**] Date of Birth: [**2103-6-23**] Sex: F Service: MEDICINE Allergies: Codeine / Amoxicillin / Blood-Group Specific Substance / Adhesive Tape Attending:[**First Name3 (LF) 106**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Cardiac catheterization [**2148-9-25**] and [**2148-9-30**] IR guided PICC line [**2148-9-26**] History of Present Illness: 45 y/o female with known CAD s/p CABG [**2140**] presenting to [**Hospital1 18**] upon transfer from [**Hospital1 34**] for shortness of breath. She was recently admitted to [**Hospital1 34**] (discharged on [**9-17**]) with CHF and eventually transferred to [**Hospital1 18**] for management. She was medically managed and discharged home. This most recent episode began two nights ago. She had some shortness of breath that resolved after she took her home dose of lasix (20mg). Denied any symptoms over the day yesterday but then woke up over night and felt quite short of breath. She took 20mg PO lasix but said she "could not urinate". Symptoms progressively worsened so she called 911 and was taken to [**Hospital1 34**]. Upon arrival to [**Hospital1 34**], O2 sat was 80% with rapid respirations. The patient was started on CPAP and sats increased to 100%. The patient was also given 20mg IV lasix at [**Hospital1 34**]. Remained pain free. Then transferred for cardiac catheterization. Prior to transfer to [**Hospital1 18**] the patient was changed to non rebreather and was satting 98-100%. . Upon arrival to [**Hospital1 18**], patient underwent cardiac cath, which showed no changes from her previous cath. No intervention performed given results. ECHO today: "compared with the prior study (images reviewed) of [**2148-9-3**], the inferolateral wall systolic dysfunction is more evident and the severity of mitral regurgitation has decreased slightly." . Upon arrival to CCU, patient was comfortable. Reported improvement of her symptoms but still was requiring non-rebreather. Satting 96%. Denies any chest pain, syncope, headaches or dizziness. VS: BP- 102/45, HR- 78, RR- 17, O2- 96% on NRB. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Reports orthopnea and shortness of breath. Past Medical History: CAD s/p coronary bypass surgery [**5-1**]- LIMA to LAD, SVG to OM, SVG to Diagonal, and SVG to PDA. SVG to the OM and diagonal occluded. Diastolic Heart Failure Diabetes Mellitus-type I s/p living-related kidney transplant [**2140-10-31**] (baseline Cr 0.8-1.1 over the last year) s/p MI tobacco use osteoporosis gastroparesis s/p right tibial fracture peripheral [**Year (4 digits) 1106**] disease: s/p right femoropopliteal bypass and left SFA drug-eluting [**Last Name (LF) **], [**2147-5-2**] retinopathy- legally blind s/p left patella open reduction and fixation, [**2147**] s/p right leg fracture (cast), [**2147**] s/p left wrist fracture, [**2147**] s/p fall and intracranial bleed, [**2147**] s/p cholecystectomy sarcoid, reported lung nodule neuropathy depression hypertension blood group specific substance. Blood products (red cells and platelets) should be leukoreduced. chronic heel ulcers hyponatremia Social History: -Tobacco history: smokes half a pack per day -ETOH: none -Illicit drugs: smokes marijuana several times per week to help with nausea and appetite Family History: There is no history of diabetes or kidney disease. Her father had an MI at 74 and mother has hypertension. Grandfather had leukemia and hypertension. Physical Exam: PE on admission: VS: T=97.7 BP=130/60 HR=77 RR=17 O2 sat= 95% on NRB GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVP CARDIAC: Regular rate and rhythm. [**4-5**] holosystolic murmur heard best at apex. PMI located in 5th intercostal space, midclavicular line. Normal S1, S2. No rubs or gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Femoral cath sites bandaged- no signs of hematoma, erythema. 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+ . PE on discharge: Vitals: Afebrile Tc 98.1, BP 133/71(100-133/57-71), HR 85 (79-85), RR 20 Sa02 95% RA Gen: NAD, AAOx3, resting comfortably in bed HEENT: NCAT, Sclera anicteric, EOMI, OP clear NECK: Supple, no JVD CARDIAC: Regular rate and rhythm. [**3-8**] holosystolic murmur heard best at LUSB. Normal S1, S2. No rubs or gallops. No thrills, lifts. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. GROIN: Left cath site with no hemotoma present. Bilateral soft femoral bruits audible. EXTREMITIES: No c/c/e. 2+ DP pulse on Rt. (left with hard cast) SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Cardiac Cath [**2148-9-25**]: COMMENTS: 1. Coronary angiography in this right dominant system revealed diffuse multivessel coronary artery disease. The LMCA had no significant stenosis. The LAD had a 70% mid-portion stenosis after the D1 branch with competitive flow from a patent LIMA that filled the distal vessel. The LCX had severe diffuse disease in the mid-portion extending into a distal branching OM that was unchanged compared with prior caths in [**2145**] and [**2141**] performed after known SVG-OM occlusion. The RCA was not injected. The SVG-->R-PDA was patent with filling of a diffusely diseased distal RCA. The LIMA-LAD was patent. 2. Resting hemodynamics performed on intravenous nitroglycerine revealed slightly [**Year (4 digits) **] left and right filling pressures with mean RA pressure of 10 mmHg and mean PCWP of 15 mmHg. FINAL DIAGNOSIS: 1. Diffuse coronary artery disease. 2. Slightly [**Year (4 digits) **] left and right filling pressures on IV nitroglycerine. . Cardiac echo [**2148-9-25**]: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with inferolateral hypokinesis and distal anterior hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). The estimated cardiac index is high (>4.0L/min/m2). Transmitral Doppler imaging is consistent with Grade II (moderate) LV diastolic dysfunction. 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 stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. . Compared with the prior study (images reviewed) of [**2148-9-3**], the inferolateral wall systolic dysfunction is more evident and the severity of mitral regurgitation has decreased slightly. . Cardiac Cath [**2148-9-30**]: 1. Limited angiography in this right dominant system demonstrated multi vessel disease. The LCx was diffusely diseased in the mid to distal vessel. The RCA was not injected. 2. Successful PTCA of the LCx with a 2.0 x 30mm Voyager balloon. Final angiography revealed 30% residual stenosis, no angiographically apparent dissection, and TIMI 3 flow. (see PTCA comments for details) FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Mild diastolic ventricular dysfunction. 3. Successful PTCA of the LCx. . Labs on Admission: [**2148-9-25**] 09:41PM BLOOD WBC-6.6 RBC-3.24* Hgb-9.3* Hct-29.1* MCV-90 MCH-28.7 MCHC-31.9 RDW-13.6 Plt Ct-454* [**2148-9-26**] 05:30AM BLOOD WBC-6.3 RBC-3.19* Hgb-9.2* Hct-28.8* MCV-90 MCH-28.7 MCHC-31.8 RDW-13.2 Plt Ct-415 [**2148-9-25**] 09:41PM BLOOD Glucose-30* UreaN-29* Creat-1.3* Na-137 K-4.2 Cl-105 HCO3-23 AnGap-13 [**2148-9-26**] 05:30AM BLOOD Glucose-185* UreaN-24* Creat-1.1 Na-138 K-4.7 Cl-105 HCO3-23 AnGap-15 [**2148-9-25**] 09:41PM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 [**2148-9-26**] 05:30AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0 [**2148-9-28**] 11:47AM BLOOD tacroFK-3.4* rapmycn-4.0* . Labs on discharge: [**2148-10-1**] 07:24AM BLOOD WBC-3.9* RBC-2.95* Hgb-8.6* Hct-27.0* MCV-91 MCH-29.0 MCHC-31.8 RDW-12.9 Plt Ct-423 [**2148-10-2**] 06:26AM BLOOD WBC-3.8* RBC-2.98* Hgb-8.3* Hct-26.9* MCV-90 MCH-27.7 MCHC-30.7* RDW-13.1 Plt Ct-493* [**2148-10-1**] 07:24AM BLOOD PT-11.5 PTT-25.5 INR(PT)-1.0 [**2148-10-2**] 06:26AM BLOOD PT-11.8 PTT-24.2 INR(PT)-1.0 [**2148-10-1**] 07:24AM BLOOD Glucose-417* UreaN-30* Creat-1.3* Na-132* K-4.2 Cl-98 HCO3-26 AnGap-12 [**2148-10-2**] 06:26AM BLOOD Glucose-252* UreaN-30* Creat-1.3* Na-137 K-4.4 Cl-101 HCO3-27 AnGap-13 [**2148-10-1**] 07:24AM BLOOD CK(CPK)-18* [**2148-10-1**] 07:24AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8 [**2148-10-2**] 06:26AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0 Tacro and rapamycin levels pending Brief Hospital Course: Patient is a 45 y/o female with CAD s/p CABG, diastolic HF and kidney transplant presenting from OSH with shortness of breath. . # CORONARIES: Known CAD s/p CABG in [**2140**]. Was cathed on admission which showed no change from previous cath in [**5-8**]. Report was as follows: Coronary angiography in this right dominant system revealed diffuse multivessel coronary artery disease. The LMCA had no significant stenosis. The LAD had a 70% mid-portion stenosis after the D1 branch with competitive flow from a patent LIMA that filled the distal vessel. The LCX had severe diffuse disease in the mid-portion extending into a distal branching OM that was unchanged compared with prior caths in [**2145**] and [**2141**] performed after known SVG-OM occlusion. The RCA was not injected. The SVG-->R-PDA was patent with filling of a diffusely diseased distal RCA. The LIMA-LAD was patent. Resting hemodynamics performed on intravenous nitroglycerine revealed slightly [**Year (4 digits) **] left and right filling pressures with mean RA pressure of 10 mmHg and mean PCWP of 15 mmHg. No intervention was performed at this time. Patient denied chest pain or anginal equivalent while in hospital. The patient underwent a repeat cardiac cath on [**9-30**] with PTCA of the left circumflex artery, which was thought to be contributing to the patient's symptoms. Final angiography revealed 30% residual stenosis, no angiographically apparent dissection, and TIMI 3 flow. Patient was continued on telemetry without events. She was continued on aspirin, atorvastatin, plavix, and metoprolol was changed to 12.5 mg XL. . # PUMP: History of diastolic dysfunction now presented with CHF exacerbation. ECHO [**9-25**] showed low normal LVEF (50-55%), Grade II (moderate) LV diastolic dysfunction, and Moderate (2+) mitral regurgitation. The patient also had an episode of flash pulmonary edema, which responded to lasix diuresis and temporary NRB mask. Patient was treated with metoprolol 12.5 XL, nifedipine was changed to Lisinopril and Lasix was increased to 40 mg daily. In addition, the patient was extensively counseled on self-monitoring fluid status with daily self weights and titration of lasix as needed to prevent further episodes of pulmonary edema. Weight at discharge was 59 kg. . # RHYTHM: Patient remained in NSR. Her metoprolol was changed from 50 mg [**Hospital1 **] to 12.5 mg extended release. . # Immune Suppression: Patient is s/p living donor kidney transplant. She was continued on sirolimus 3 mg daily and tacrolimus 2 mg twice daily, as per home regimen. Home dose of prednisone (4mg daily) and bactrim prophylaxis continued as well. . # Diabetes Mellitus Type I: Last A1C on [**9-16**] was 8.7%. During admission, pt was continued on Lantus plus sliding scale insulin with good blood glucose control. She has a follow-up appt with her endocrinologist in 1 week. . # Chronic Renal Disease: Patient is s/p kidney transplant. Her creatinine over the last year has ranged from 0.8-1.1. During the course of her hospitalization, the patient had a Cr mildly [**Month/Year (2) **] from baseline, consistent with acute on chronic renal failure, likely secondary to contrast administration from multiple cardiac catheterizations. On discharge, Cr was 1.3. . # Hypertension: Patient was initially continued on home doses of metoprolol and nifedipine extended release. After diuresis, patient had an episode of hypotension and nifedipine was discontinued, and metoprolol 50 mg [**Hospital1 **] changed to 12.5 mg XR po daily. Lisinopril was added for afterload reduction and can be tapered up as needed to keep SBP in goal range of 120-140. . # Depression: continued on home medications of bupropion and citalopram. She has f/u with her ouptpt psychiatrist. . # Pain: Questionable allergy to codeine- patient reports nausea/vomiting but has been taking oxycodone recently for ankle fracture. Discharged on Ultram for left leg pain. Note that pt has tolerated oxycodone Po for treatment of her left leg pain. . # Insomnia: Continued on home dose of trazodone. . # Nausea: Continued on reglan and zofran. . # Osteoporosis: Continued vitamin D and calcium. Medications on Admission: 1. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Please take at 5 PM everyday. 2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO [**Hospital1 12075**] (Monday-Wednesday-Friday). 4. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 13. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for left ankle pain for 5 days. Disp:*30 Tablet(s)* Refills:*0* 19. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation: Please take as needed for constipation while you are taking pain medications. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Please take if needed for constipation while you are taking pain medications. 22. Compazine 25 mg Suppository Sig: One (1) Rectal three times a day as needed for nausea. 23. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 24. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. 25. Insulin Lispro 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day: Please use according to your sliding scale. 26. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day. 27. Ergocalciferol (Vitamin D2) 400 unit Capsule Sig: One (1) Capsule PO twice a day. 28. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for cough. Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*11* 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)) as needed for nausea. 6. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO [**Hospital1 12075**] (Monday-Wednesday-Friday). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Colace 100 mg Capsule Sig: [**2-2**] Capsules PO twice a day. 11. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a day. 12. Glucerna Shake Liquid Sig: One (1) can PO up to 6 times per day. 13. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 16. Lantus 100 unit/mL Solution Sig: 18-20 units Subcutaneous once a day. 17. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day. 18. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for cough. 19. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 20. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 21. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal TID (3 times a day) as needed for nausea. 22. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 24. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for Leg pain. Disp:*60 Tablet(s)* Refills:*0* 25. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnoses: Coronary Artery Disease Acute on Chronic Diastolic Congestive Heart Failure . Secondary Diagnoses: Diabetes Mellitus Chronic Kidney Disease s/p Transplant Discharge Condition: Good; afebrile, hemodynamically stable, ambulatory Discharge Instructions: You have a diagnosis of coronary artery disease and were admitted to the hospital for shortness of breath, found to be related to your underlying heart disease. You underwent cardiac catheterization two times while in the hospital in order to open up a narrow segment found in one of your coronary arteries. In addition, your shortness of breath resolved with diuretic treatment. Information about a low sodium diet and fluid restriction was discussed with you before discharge. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. A presciption for a talking scale was given to you. Adhere to 2 gm sodium diet Medications changes: 1. DISCONTINUE Imdur 2. DISCONTINUE Nifedical 3. DISCONTINUE Zetia 4. INCREASE your Lasix (Furosemide) to 40 mg daily 5. Your Metoprolol was changed to a long acting type and decreased to 12.5 mg daily 6. START Ultram to treat the pain in your leg 7. INCREASE your Aspirin to 325 mg daily from 81 mg daily 8. START Lisinopril to treat your high blood pressure . Please call Dr. [**Last Name (STitle) **] if you have any fevers, chills, chest pain, trouble breathing, unusual swelling, cough, right groin pain or for any other concerning symptoms. . Please check your blood pressure daily at different times of the day. Record the pressures and bring them to your appts with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. Followup Instructions: Cardiology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:Tuesday [**2148-11-5**] at 11:00am Endocrinology ([**Last Name (un) **]) Provider: [**First Name4 (NamePattern1) 8990**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2148-10-14**] 2:30 Psychiatry: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20430**], MD Date/Time:[**2148-10-15**] 10:20 Primary Care: [**Last Name (LF) 2879**],[**First Name3 (LF) 2878**] A. Phone: [**Telephone/Fax (1) 250**] Date/Time: Friday [**10-11**] at 11:00.

[ "250.01", "403.91", "428.0", "707.14", "414.01", "V42.0", "514", "285.1", "585.6", "428.33" ]

icd9cm

[ [ [] ] ]

[ "88.56", "38.93", "00.42", "88.42", "00.66", "88.57", "37.23" ]

icd9pcs

[ [ [] ] ]

19209, 19260

9895, 14074

350, 448

19478, 19531

5718, 6569

21006, 21652

3886, 4037

16848, 19186

19281, 19378

14100, 16825

8372, 8494

19555, 20983

4052, 4055

19399, 19457

5039, 5699

291, 312

9128, 9872

476, 2765

8508, 9109

2787, 3706

3722, 3870

12,849

167,229

49481

Discharge summary

report

Admission Date: [**2139-9-3**] Discharge Date: [**2139-9-4**] Date of Birth: [**2090-7-7**] Sex: M Service: [**Doctor Last Name 1181**] B HISTORY OF THE PRESENT ILLNESS: The patient is a 49-year-old male with a history of scleroderma, CREST syndrome, and pulmonary hypertension on continuous IV Flolan who presents for reinsertion of his Hickman catheter after it fell out. he denied any pain, fever, chills, or nausea. He did have some emesis times three. He also denied any lightheadedness, weakness, shortness of breath, or chest pain. Of note, the patient was just discharged from [**Hospital1 18**] on the day prior to admission with pneumonia on azithromycin. PAST MEDICAL HISTORY: 1. Scleroderma (CREST) times 25-30 years. 2. Pulmonary hypertension diagnosed in [**2139-2-21**] on IV Flolan since [**2139-3-21**]. 3. Status post admission with pneumonia. ADMISSION MEDICATIONS: 1. Zaroxolyn 2.5 mg q. Monday. 2. Ibuprofen 800 mg t.i.d. p.r.n. pain. 3. Prazosin 1 mg t.i.d. 4. Sucralfate 1 gram p.o. q.i.d. 5. Diltiazem 120 mg q.d. 6. Diltiazem 300 mg q.d. 7. Aspirin 81 mg p.o. after meals. 8. Protonix 40 mg b.i.d. 9. Fluoxetine 20 mg q.a.m. 10. Flolan 88 mg per kilogram per minute. 11. Lasix 80 mg b.i.d. 12. Compazine 10 mg t.i.d. p.r.n. nausea. 13. Vicodin 1,000 mg q.i.d. p.r.n. pain. 14. Lorazepam 0.5 mg t.i.d. p.r.n. anxiety. 15. Azithromycin. ALLERGIES: Percocet causes itching. SOCIAL HISTORY: The patient denied tobacco, drugs, or ethanol abuse. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.7, heart rate 88, blood pressure 138/80, respiratory rate 18, oxygen saturation 99% on room air. General: The patient was somnolent after his procedure. HEENT: Pupils were equally round and reactive to light. The extraocular movements were intact. His oropharynx was clear. Neck: Supple. His face was flushed. Lungs: Clear to auscultation bilaterally with coarse breath sounds. Heart: Regular rate and rhythm, no murmur. Abdomen: He had normal bowel sounds, soft, nontender, nondistended. Extremities: Warm, digital ulcers on right from sclerodactyly. LABORATORY/RADIOLOGIC DATA: CBC was within normal limits. White count 7.1, hematocrit 39.1, platelet count 193,000. A chest x-ray showed stable cardiomegaly, a small right pleural effusion, and surgical clips. There was no pneumothorax. A retained catheter. HOSPITAL COURSE: The patient underwent insertion of a new single-lumen Hickman catheter without incident. He received IV Flolan overnight at 38 mg per kilogram per minute, oxygen at 4 liters, and was discharged home the next morning in good condition. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: 1. Scleroderma. 2. Pulmonary hypertension. DISCHARGE MEDICATIONS: 1. Zaroxolyn 2.5 mg q. Monday. 2. Ibuprofen 800 mg t.i.d. p.r.n. pain. 3. Prazosin 1 mg t.i.d. 4. Sucralfate 1 gram p.o. q.i.d. 5. Diltiazem 120 mg q.d. 6. Diltiazem 300 mg q.d. 7. Aspirin 81 mg p.o. after meals. 8. Protonix 40 mg b.i.d. 9. Fluoxetine 20 mg q.a.m. 10. Flolan 88 mg per kilogram per minute. 11. Lasix 80 mg b.i.d. 12. Compazine 10 mg t.i.d. p.r.n. nausea. 13. Vicodin 1,000 mg q.i.d. p.r.n. pain. 14. Lorazepam 0.5 mg t.i.d. p.r.n. anxiety. 15. Azithromycin. FOLLOW-UP PLANS: The patient is to call his pulmonologist, Dr. [**Last Name (STitle) **], for a new appointment next week. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2691**] Dictated By:[**Last Name (un) 103533**] MEDQUIST36 D: [**2139-9-6**] 09:10 T: [**2139-9-8**] 12:11 JOB#: [**Telephone/Fax (2) 103534**]

[ "710.1", "416.8", "486" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

1523, 1562

2843, 3329

2774, 2820

2455, 2692

911, 1435

3347, 3756

1577, 2437

710, 888

1452, 1506

2717, 2753

58,501

141,425

35779

Discharge summary

report

Admission Date: [**2146-12-8**] Discharge Date: [**2146-12-15**] Date of Birth: [**2096-11-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: 1. Redo sternotomy. 2. Attempted repair of mitral regurgitation. 3. Mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**] Epic tissue valve, model #E100-31M- 00. History of Present Illness: 49 yo male with endocardial cushion defect, s/p ASD closure and cleft MV repair in [**2122**]. Has developed severe recurrent MR. [**First Name (Titles) **] [**Last Name (Titles) 81363**] issues including depression,continuing ETOH and tobacco abuse, but has been compliant with medical appts. Recent echo also shows new pulmonary hypertension and RV/LV dilatation.Referred for surgery. The patient completed an alcohol detox program yesterday and was admitted for pre-op cath today. Cath did not reveal signivicant coronary disease. He will be admitted for redo sternotomy and MVR tomorrow with Dr. [**Last Name (STitle) **]. Past Medical History: RUL lung cancer [**2143**] ([**Doctor First Name **],chemo,XRT) mitral regurgitation pulmonary hypertension ETOH abuse depression (prior suicide attempt) Social History: Homeless, currently staying with his former employer Occupation:unemployed Tobacco:current [**11-27**] ppd ETOH:6-12 beers/day, occ. vodka, detox program completed as above Family History: mother and sister with CVA Physical Exam: Pulse: 80 Resp: 16 O2 sat: 98% B/P Right: 123/79 Left: Height: 5'9" Weight:155# General: NAD, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera,OP unremarkable Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs clear bilaterally [x] well-healed sternotomy and right thoracotomy incisions Heart: RRR [x] Irregular [] Murmur- [**1-29**] radiates to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact;MAE [**3-30**] strengths; nonfocal exam Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit: murmur radiates to both carotids Pertinent Results: Admission Labs: [**2146-12-8**] 08:07AM PT-10.8 PTT-22.7 INR(PT)-0.9 [**2146-12-8**] 08:07AM PLT COUNT-137*# [**2146-12-8**] 08:07AM WBC-5.0 RBC-4.28* HGB-15.0 HCT-42.2 MCV-99* MCH-35.0* MCHC-35.5* RDW-13.4 [**2146-12-8**] 08:07AM GLUCOSE-91 UREA N-16 CREAT-1.0 SODIUM-141 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [**2146-12-8**] 10:00AM %HbA1c-4.9 eAG-94 [**2146-12-8**] 10:00AM ALBUMIN-4.0 CHOLEST-119 [**2146-12-8**] 10:00AM ALT(SGPT)-40 AST(SGOT)-41* ALK PHOS-49 AMYLASE-55 TOT BILI-0.3 [**2146-12-8**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Discharge labs: [**2146-12-12**] 07:05AM BLOOD WBC-5.7 RBC-2.50* Hgb-8.3* Hct-23.6* MCV-94 MCH-33.3* MCHC-35.3* RDW-15.9* Plt Ct-106* [**2146-12-12**] 07:05AM BLOOD Plt Ct-106* [**2146-12-11**] 06:11AM BLOOD PT-12.5 PTT-28.0 INR(PT)-1.0 [**2146-12-12**] 07:05AM BLOOD Glucose-97 UreaN-10 Creat-1.0 Na-135 K-3.6 Cl-101 HCO3-25 AnGap-13 Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-12-11**] 9:04 AM [**Hospital 93**] MEDICAL CONDITION: 50 year old man with s/p mvr and tv repair Final Report One view. Comparison with the previous study done [**2146-12-9**]. A right chest tube has been removed. There is increased streaky density in the right lung likely representing subsegmental atelectasis and interval increase in a re-distribution of a small right effusion. There is streaky density at the left base most consistent with subsegmental atelectasis. Mediastinal structures are unchanged. An endotracheal tube, nasogastric tube, and Swan-Ganz line have been withdrawn. IMPRESSION: Increased streaky density on the right likely representing subsegmental atelectasis. Interval increase in or re-distribution of small right effusion. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.1 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.4 cm Left Ventricle - Fractional Shortening: *0.28 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Stroke Volume: 35 ml/beat Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: 3.1 cm <= 3.4 cm Aorta - Arch: 2.5 cm <= 3.0 cm Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 10 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *2.6 cm2 >= 3.0 cm2 Mitral Valve - MVA (P [**11-27**] T): 3.5 cm2 Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. No MS. Eccentric MR jet. Severe (4+) MR. TRICUSPID VALVE: No TS. Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The patient appears to be in sinus rhythm. patient. Conclusions Pre CPB: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler, echodense material seen at likely site of prior ASD repair. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of mitral valvular regurgitation.] The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Two eccentric jets of Severe (4+) mitral regurgitation are seen. The posteriorly directed jet originates from a prolapsing A2 leaflet and exhibits coanda effect. The anteriorly directed jet originates from the base of the anterior leaflet and is suspicious for a perforated leaflet (or failure of prior repair) Dr. [**Last Name (STitle) **] was notified in person of the results. Post CPB: The cardiac output is 4L/min on a phenylephrine infusion and A-paced. There is a well seated bioprosthetic valve in the mitral position with a centrally located trace MR jet; the mean gradient across this valve is 3mmHg. There is no aortic insufficiency. The RV systolic function is preserved. The LVEF is 45-50%. The visible contours of the thoracic aorta are intact. Brief Hospital Course: The patient was brought to the operating room on [**2146-12-9**] where the patient underwent a redo sternotomy and attempted repair of mitral regurgitation. Please see operative report for details, in summary the patient had: 1. Redo sternotomy. 2. Attempted repair of mitral regurgitation. 3. Mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**] Epic tissue valve, model #E100-31M- 00. His bypass time was 119 minutes with a crossclamp of 102 minutes. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring in stable condition. POD 1 found the patient extubated, alert and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker therapy was held secondary to post-operative juctional rhythm which recovered to a normal sinus rhythm. The patient was transferred to the telemetry floor on POD3 for further recovery. Chest tubes and pacing wires were discontinued according to cardiac surgery protocol. The patient was evaluated by the physical therapy service for assistance with strength and mobility. At the time of discharge on POD #6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to a friend's home with visiting nurses. He is to follow up with Dr [**Last Name (STitle) **] in 3 weeks. Medications on Admission: lisinopril 5 mg daily thiamine 100 mg daily folate 1 mg daily MVI daily Seroquel 100mg prn hs insomnia Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 8. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 10. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS/PRN as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: S/P Mitral valve replacement(tissue) PMH: RUL lung cancer [**2143**] ([**Doctor First Name **],chemo,XRT) mitral regurgitation pulmonary hypertension ETOH abuse depression (prior suicide attempt) Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with Percocet Sternal Incision - healing well, no erythema or drainage Edema-none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-1-4**] 9:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2147-1-4**] 1:45 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2147-1-3**] 11:30 [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2147-1-3**] 11:30 Please call to schedule appointment PCP: [**Name10 (NameIs) **] [**Name11 (NameIs) **] [**Telephone/Fax (1) 250**] for 4-5 weeks from surgery **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2146-12-15**]

[ "305.01", "780.62", "V15.3", "416.8", "V60.0", "311", "424.0", "V10.11", "V87.41" ]

icd9cm

[ [ [] ] ]

[ "88.57", "88.53", "35.23", "37.23", "39.61" ]

icd9pcs

[ [ [] ] ]

11004, 11062

8145, 9643

332, 519

11302, 11462

2441, 2441

12250, 13138

1563, 1592

9797, 10981

3539, 7740

11083, 11281

9669, 9774

11486, 12227

3106, 3502

1607, 2422

273, 294

547, 1178

2457, 3090

1200, 1356

1372, 1547

7750, 8122

75,644

163,314

42833

Discharge summary

report

Admission Date: [**2174-3-23**] Discharge Date: [**2174-4-10**] Date of Birth: [**2127-12-26**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobroncheomalacia. Major Surgical or Invasive Procedure: [**2174-3-23**] Right thoracotomy and tracheoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, right mainstem bronchus and bronchus intermedius bronchoplasty with mesh, flexible bronchoscopy with bronchoalveolar lavage. History of Present Illness: Mr. [**Known lastname **] is a 46yM who presents for evaluation of progressive SOB. He first noticed his SOB approximately 3 years ago, however it was minimal at that time. He reports that he was still able to perform all of his daily activities, work in contruction and interact with his children at that time but did notice some dyspnea with exertion. He was seen by a multitude of pulmonologists who performed a variety of PFT's and he was treated for asthma/COPD with inhalers. He reports that his symptoms continued to get worse while on this regimen. Approximately 3 months ago, his symptoms became much more severe and he can no longer walk up stairs, go to the gym or play with his children. He has had to stop working. . Mr [**Known lastname **] then came for follow up after having a stent trial for TBM. Stent was placed 5 days ago and he feels that "he was born again". He can walk on the street in the open air which he has not done in a while. His cough is better, in addition, he has much less secretions. No fevers, still has some sore throat. He is on prednisone 10mg daily, which he has been on for a while. Due to his great response to an airway stent trial. The thoracic surgery team planned to proceed with stent removal and posterior tracheobronchoplasty. Past Medical History: sleep apnea, COPD, thyroid nodules . lumbar disc herniation, R shoulder reconstruction Social History: Cigarettes: [x] ex-smoker, pack-yrs: 25, quit: [**2172**] ETOH: [x] No Drugs: denies Exposure: [x] Other: concrete dust (construction worker) Occupation: on disability Marital Status: [x] Married Lives: [x] w/ family Family History: Grandparents: DM Physical Exam: ON ADMISSION: ------------- wt 219lb T 98 HR 90 BP 145/92 RR 18 Oxygen sat 99% RA GENERAL [x] All findings normal [ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings: HEENT [x] All findings normal [ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [ ] Trachea midline [ ] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [ ] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: coarse breath sounds bilaterally, + expiratory wheezing CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [x] All findings normal [ ] No rashes/lesions/ulcers [ ] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] All findings normal [ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect [ ] Abnormal findings: OTHER: . ON DISCHARGE: ------------- T 97 HR 95 BP 123/75 RR 24 Oxygen sat 98% 2L NC or RA GENERAL [x] All findings normal [ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings: HEENT [x] All findings normal [ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [ ] Trachea midline [ ] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [ ] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: coarse breath sounds bilaterally, + expiratory wheezing CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [x] All findings normal [ ] No rashes/lesions/ulcers [ ] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] All findings normal [ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect [ ] Abnormal findings: Pertinent Results: ON ADMISSION: ------------- [**2174-3-23**] 06:48PM BLOOD WBC-14.2* RBC-4.52* Hgb-15.1 Hct-45.1 MCV-100* MCH-33.5* MCHC-33.6 RDW-13.1 Plt Ct-309 [**2174-3-23**] 06:48PM BLOOD Neuts-75* Bands-2 Lymphs-14* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2174-3-23**] 06:48PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL [**2174-3-23**] 06:48PM BLOOD PT-12.1 PTT-21.4* INR(PT)-1.1 [**2174-3-23**] 06:48PM BLOOD Glucose-149* UreaN-13 Creat-1.2 Na-138 K-3.6 Cl-101 HCO3-25 AnGap-16 [**2174-3-23**] 06:48PM BLOOD CK(CPK)-2918* [**2174-3-23**] 06:48PM BLOOD Calcium-8.6 Phos-4.5 Mg-2.0 [**2174-3-23**] 02:44PM BLOOD Type-ART Rates-/16 Tidal V-400 pO2-74* pCO2-46* pH-7.35 calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2174-3-23**] 02:44PM BLOOD Glucose-125* Lactate-0.8 Na-139 K-3.2* Cl-102 [**2174-3-23**] 02:44PM BLOOD Hgb-14.9 calcHCT-45 O2 Sat-94 [**2174-3-23**] 02:44PM BLOOD freeCa-1.17 . ON (or close to) DISCHARGE: [**2174-4-9**] 06:39AM BLOOD WBC-10.0 RBC-2.94* Hgb-9.7* Hct-29.1* MCV-99* MCH-32.8* MCHC-33.1 RDW-12.2 Plt Ct-460* [**2174-4-9**] 06:39AM BLOOD Glucose-107* UreaN-39* Creat-3.2* Na-137 K-4.0 Cl-95* HCO3-29 AnGap-17 [**2174-4-2**] 03:15AM BLOOD CK(CPK)-195 [**2174-4-9**] 06:39AM BLOOD Calcium-9.8 Phos-4.2 Mg-1.9 [**2174-4-6**] 06:50AM BLOOD calTIBC-225* Ferritn-[**2063**]* TRF-173* [**2174-4-6**] 06:50AM BLOOD PTH-83* [**2174-3-28**] 12:52PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2174-3-28**] 12:52PM BLOOD HCV Ab-NEGATIVE . IMAGING & STUDIES: ------------------ OR PATHOLOGY [**2174-3-23**]: Clinical Diagnosis: Tracheobronchomalasia. . CXR POST-OP [**2174-3-23**]: As compared to the previous radiograph, the patient has undergone tracheobronchoplasty. An endotracheal tube is in situ. The tip of the tube locates 6.5 cm above the carina and could be advanced by 1-2 cm. Areas of atelectasis in the mid right lung and at the left lung base. The lower part of the trachea appears slightly narrowed. Borderline size of the cardiac silhouette. No evidence of pneumothorax or pneumonia. However, portions of free air are seen in the right cervical soft tissues. No pleural effusions. . EKG [**2174-3-31**]: Sinus rhythm. Borderline left atrial abnormality. Incomplete right bundle - branch block. Compared to the previous tracing of [**2174-3-14**] the findings are similar. Rate PR QRS QT/QTc P QRS T 85 144 100 360/403 72 19 53 . U/S/FLUORO for RIGHT tunneled HD Catheter placement [**2174-4-4**]: IMPRESSION: Successful placement of 27 cm tip-to-cuff tunneled access catheter through a new right internal jugular vein approach. The tip is located in the right atrium and the catheter is ready for use. Pre-existing temporary HD catheter was left in place above this new catheter, secured with tegaderm. Note made of adherent, non-occlusive thrombus around the upper shaft of that catheter. . CXR [**2174-4-3**]: A small right apical pneumothorax is present. A central venous catheter remains in standard position, and cardiomediastinal contours are stable in appearance allowing for technical differences between the exams. Right upper lobe opacity has improved, but lower lobe opacities have worsened. Observed findings could represent a combination of atelectasis and aspiration given the waxing and [**Doctor Last Name 688**] appearance of these findings on serial radiographs. However, pneumonia should also be considered in the right lower lobe in particular. Small bilateral pleural effusions are present with increase on the right since prior study. Brief Hospital Course: This is the brief hospital course for a 46 year-old male with COPD and tracheobronchomalacia who presented this admission for tracheoplasty due to worsening dyspnea on exertion. Prior to this admission, the patient underwent a successful tracheal stenting trial. . The patient was intubated for the procedure on [**2174-3-23**] and remained intubated post-operatively. The case was long and complicated by an episode of low SBPs in the 80-90s which lasted about 30 minutes. Over this 30 minute interval, the patient's urine output declined to 10-20 cc/hr for which he was immediately treated with IV fluids. After the fluids, the patient kept his SBPs within a normal range and his urine output slowly increased. The case finished with an estimated blood loss of 400cc, IV fluids of 4000cc, and urine output of 1700cc. A right chest tube was placed and follow-up bronchoscopy was planned for the following morning. The acute pain service had placed an epidural for post-operative pain management prior to surgery. . Upon arrival to the ICU post-operatively, the patient's urine output ranged from 0-20 cc/hr. There were a few episodes of dropped SBPs which were all treated and resolved with fluid resuscitation. His CVP stayed near 14 throughout this time, but as the days in the ICU progressed, the patient was noted to have acute kidney injury with a rising creatinine and eventual oligouria. A renal consult was attained. Likely etiologies for his [**Last Name (un) **] included acute tubular necrosis due to hypotension intra-op or rhabdomyolysis. Muddy brown casts were seen on urine sediment supporting an ATN diagnosis, and CK levels were not in the range usually seen with rhabdomyolysis renal failure patients (peaked @ [**Numeric Identifier 6085**]) therefore ATN was ruled most likely. Granted, his urine dipstick was heme (+) with few RBCs so this could likely have been myoglobinuria. Renal recommended maintaining MAPs > 65mmHg, avoiding nephrotoxic medications, starting intermittent hemodialysis, and closely monitoring urine output; all of which were done. On [**2174-4-4**], the patient received a tunnelled dialysis catheter in his right chest for outpatient HD access. . During his ICU course, Mr. [**Known lastname **] developed ventilator dependent respiratory failure. The patient was found to be growing Serratia Marcescens on all broncheoalveolar lavages [**Date range (2) 92502**]. He was initially treated with Cefepime, but later switched to Ceftriaxone and Azithromycin for a 14 day course. During this respiratory illness, the patient was noted to have peak airway pressures > 35 despite aggressive pharmacological therapies. Serial chest x-rays revealed worsening pulmonary edema, and on the day of his post-operative bronchoscopy, renal suggested mild diuresis to which we saw very little response. He became increasingly difficult to ventilate and was paralyzed. . On [**2174-3-26**] and [**2174-3-27**], tube feeds were attempted, but not tolerated with high residuals > 200 each day. . On [**2174-3-28**], sedation was removed, and weaning from the vent progressed, however, altered mental status and non-cooperative behavior prevented the patient from being extubated. Of note, the patient was incredibly difficult to maintain sedation in throughout his hospital course. . On [**2174-3-29**], the patient's chest tube was removed and an attempt at extubation failed with tachycardia, tachypnea, and hypoxia. Laryngoscopy and bronchoscopy were performed with evidence of purulent secretions and persistent airway edema. Due to these findings, the patient was reintubated and bronched with bilateral BALs which eventually grew Serratia Marcescens. . On [**2174-3-31**], the patient was successfully extubated, but remained very agitated, pulling at all tubes and lines, grunting loudly, thrashing in bed, and not following commends regarding his care. The patient was seen the following day by speech and swallow therapy who cleared him for a regular diet which he tolerated well. . The patient received daily dialysis with half a liter fluid removal during the last week of his stay. His creatinine continued to trend downward and his urine output picked up. He was discharged to home in [**State 108**] with HD scheduled at a [**Location (un) **] facility near his home in [**Location (un) 60966**]. He was screened by physical therapy, and recommendations for rehab were not made. The patient's pulmonologist was aware of his course here, and was scheduled to follow the patient upon his return to [**State 108**]. At the time of his departure and discharge by train with his wife to [**Name (NI) 108**], the patient was tolerating an adequate oral diet, urinating and passing stool on his own, capable of making safe decisions for himself, reporting good pain control, and fully clear on and in agreement with his discharge plan. Medications on Admission: prednisone 5mg daily albuterol 90mcg inhaler, 2 puffs qid prn alprazolam 2mg omeprazole 40mg daily Ambien 10mg qhs Discharge Medications: 1. oxygen therapy Patient requires 2-4L continous, pulse dose for portability as well as POC due to oxygen saturations < 88% on RA. Dx: tracheobronchomalacia s/p reconstruction. 2. 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* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 7. alprazolam 2 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety: As you were taking prior to admission to the hospital. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO once a day. 9. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 12. olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**12-27**] Tablet, Rapid Dissolves PO as directed in comments section: Take 1 tablet in the morning and two tablets at night. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: Do not drive, drink alcohol or take other narcotics with this med. Disp:*20 Tablet(s)* Refills:*0* 14. sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO three times daily: Please take this medication with meals. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Severe diffuse tracheobronchomalacia and tracheomegaly Acute kidney failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the Thoracic surgery service for your tracheobronchoplasty. You have done well since that time you may leave to continue your recovery at home. Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or operate heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. Thank you for letting us participate in your care. We wish you a speedy recovery. Followup Instructions: Patient to follow-up with Dr. [**Last Name (STitle) 92503**] in [**State 108**] per conversations and clinical status updates with pulmonologist Dr. [**Last Name (STitle) **]. . Department: RADIOLOGY When: MONDAY [**2174-6-20**] at 10:15 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: PFT When: TUESDAY [**2174-6-21**] at 8:30 AM . Department: PULMONARY FUNCTION LAB When: TUESDAY [**2174-6-21**] at 8:30 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Completed by:[**2174-4-20**]

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Discharge summary

report

Admission Date: [**2153-10-22**] Discharge Date: [**2153-11-7**] Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: [**2153-10-29**] Coronary Artery Bypass Grafting x 3 (LIMA to LAD, SVG to OM, SVG to PDA) [**2153-10-26**] Cardiac Catheterization [**2153-10-22**] ERCP History of Present Illness: This is an 84 year old female who presented with epigastric abdominal pain and vomiting. She denied fever, chest pain, dyspnea, syncope, diarrhea, constipation, melena, hematochezia, or urinary symptoms. While in the ED, she was noted to be febrile and empirically started on antibiotics. Her pain improved with Morphine. Labs showed significant elevation in LFTs, amylase and lipase. RUQ ultrasound revealed cholelithiasis without cholecystitis. She was subsequently admitted for further evaluation and treatment. Past Medical History: Hypertension, Hyperthyroidism, Urinary incontinence s/p pessary, B12 deficiency, Cataracts s/p surgery, Ectopic pregnancy, Scarlet fever as a child, s/p Left salpingo-oophorectomy, L renal artery stenosis Social History: She is widowed and lives alone, indepedent in her ADLs. She has an involved daughter who lives in [**Location **] and a son in [**Name (NI) 4565**]. She's smoked 2-3packs per week for 30-40 yrs, quit 15 yrs ago. She drinks wine but never heavily, just with meals. Family History: Her father died at 77 from bleeding pud, and her mother, who had a history of HTN, died in her early 90's from old age. She had a sister who died at 59 of colon cancer. Physical Exam: Admission PE: T 98.3, BP 159/67, HR 72, RR 18, SPO2 100% on RA Gen: nad, appears comfortable, lying flat HEENT: anicteric, mm slightly dry, op clear Neck: Supple, no jvd, no thyromegaly CV: rrr, s1s2, no m/r/g Pul: CTA AB, no w/r/r Abd: +BS, soft, NT/ND, no hepatosplenomegaly, negative [**Doctor Last Name **], ?right sided bruit Ext: no cyanosis/edema, warm/dry Neuro: a&ox3, strength 5/5 in all 4 extrem Discharge VS: T 97.8 HR 58 BP 142/62 RR 18 O2 Sat 94% RA Gen: NAD Neuro: A&Ox3, MAE, nonfocal exam Pulm: CTA bilat CV: RRR S1-S2, sternum stable, incision CDI Abdm: soft, NT,ND,NABS Ext: warm, no pedal edema Pertinent Results: [**2153-10-21**] 12:45AM BLOOD WBC-12.5*# RBC-4.55 Hgb-13.8 Hct-38.4 MCV-84 MCH-30.4 MCHC-36.1* RDW-14.5 Plt Ct-219 [**2153-10-21**] 12:45AM BLOOD Neuts-82.1* Bands-0 Lymphs-14.5* Monos-2.5 Eos-0.6 Baso-0.2 [**2153-10-21**] 12:45AM BLOOD PT-12.9 PTT-26.4 INR(PT)-1.1 [**2153-10-21**] 12:45AM BLOOD Glucose-135* UreaN-23* Creat-1.1 Na-141 K-3.0* Cl-101 HCO3-29 AnGap-14 [**2153-10-21**] 10:10PM BLOOD ALT-874* AST-964* AlkPhos-234* Amylase-1097* TotBili-2.7* [**2153-10-21**] 10:10PM BLOOD Lipase-3197* [**2153-10-21**] 12:45AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2153-10-21**] 10:10PM BLOOD Calcium-8.9 Phos-2.1* Mg-2.4 [**2153-10-26**] 04:08AM BLOOD Triglyc-94 HDL-30 CHOL/HD-3.3 LDLcalc-51 [**2153-10-26**] 01:00PM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE [**2153-11-3**] 05:10AM BLOOD WBC-14.7* RBC-3.98* Hgb-12.1 Hct-34.6* MCV-87 MCH-30.3 MCHC-34.9 RDW-14.8 Plt Ct-306 [**2153-11-4**] 09:34PM BLOOD Glucose-97 UreaN-18 Creat-0.8 Na-136 K-3.2* Cl-102 HCO3-25 AnGap-12 [**2153-11-2**] 06:15AM BLOOD ALT-22 AST-24 LD(LDH)-267* AlkPhos-58 Amylase-62 TotBili-0.6 [**2153-11-2**] 06:15AM BLOOD Lipase-47 [**2153-10-26**] 04:08AM BLOOD Triglyc-94 HDL-30 CHOL/HD-3.3 LDLcalc-51 [**2153-10-21**] RUQ Ultrasound: Cholelithiasis without evidence for cholecystitis. No biliary duct dilatation. Pancreas not well visualized due to overlying bowel gas. [**2153-10-22**] ERCP: Nonvisualization of the common bile duct. Normal-appearing pancreatic duct. [**2153-10-23**] MRCP: Nondilated common bile duct and pancreatic duct without evidence for intrluminal stones or sludge. There is an enlarged, edematous pancreas compatible with mild pancreatitis. Single small gall stone and layering sludge; gallbladder wall edema likely from pancreatitis. Three prominent duodenal diverticulum seen surrounding the head of the pancreas. 4.0-cm infrarenal abdominal aortic aneurysm that does not extend into the iliac bifurcation. Incompletely characterized 1-cm right adrenal nodule. CHEST (PA & LAT) Reason: evaluate pneumothorax [**Hospital 93**] MEDICAL CONDITION: 84 year old woman s/p CABGx3 REASON FOR THIS EXAMINATION: evaluate pneumothorax Cardiology Report ECHO Study Date of [**2153-10-29**] PATIENT/TEST INFORMATION: Indication: cabg Status: Inpatient Date/Time: [**2153-10-29**] at 09:37 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006AW2-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] MEASUREMENTS: Left Ventricle - Septal Wall Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 2.4 cm (nl <= 2.5 cm) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Simple atheroma in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal descending aorta diameter. There are complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Conclusions: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. Epi-aortic scan showed no focal lesions. There are complex (>4mm) atheroma in the descending thoracic aorta. There are 3 aortic valve leaflets with good leaflet excursion. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Preserved biventricular systolic fxn. Trivial MR, no AI. Aorta intact. Other parameters as pre-bypass. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD on [**2153-10-29**] 11:31. [**Location (un) **] PHYSICIAN: PA AND LATERAL CHEST, [**11-3**]. HISTORY: Status post CABG. IMPRESSION: PA and lateral chest compared to [**11-2**]: Small loculated left hydropneumothorax has decreased in overall volume and contains slightly more fluid than it did on [**11-2**]. Cardiac apex is obscured. Remainder of the mediastinum is unchanged, including a generally large and tortuous thoracic aorta. Elevation of the right lung base is longstanding and view only in part to a small right pleural effusion, partially fissural. The upper lungs are clear. There is no right pneumothorax. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Brief Hospital Course: Patient was admitted with gallstone pancreatitis and was preop for cholecystectomy. During preop w/u she developed rapid AFib and ruled in fro MI. She was referred to cardiology and a cardiac catheterization revealed Left main and 3 VD with preserred EF. She was referred to Ct surgery and on [**10-29**] she was brought to the operating room where she had coronary bypass grafting. Please see OR report for full details, in summary she had CABGx3 with LIMA-LAD, SVG-OM1, SVG-PDA, she did well in the immediate postop period and was extubated on the day of surgery. She had intermittent Afib on POD1, on POD2 her chest tubes and epicardial pacing wires were removed and she was transferred to the step down unit. Over the next several days the patient continued to have intermittent afib, her activity level was advanced but it was decided the patient would benefit from a short stay at rehabilitation. On POD 9 it was decided the patient was stable and ready to be discharged to home with the care of her family. Medications on Admission: Meds at home: Cyanocobalamin 1000mcg daily, HCTZ 12.5mg daily, Metoprolol 12.5mg [**Hospital1 **] Meds on transfer: aspirin 325, metoprolol 50 [**Hospital1 **], heparin gtt, HCTZ 12.5, Ciprofloxacin 400 mg IV Q12H, Metronidazole 500 mg IV Q8H, Morphine Sulfate 2 mg IV Q4H:PRN, Dolasetron Mesylate 12.5 mg IV Q8H:PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400 mg QD x7 days then 200 mg QD x30 days. 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3 weeks. 9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 3 weeks. 10. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: target INR 2.0 Pt to receive mg on 12/. Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft Atrial fibrillation Recent Gallstone Pancreatitis Infrarenal Abdominal Aortic Aneurysm PMH: Hypertension, Hyperthyroidism, Urinary incontinence s/p pessary, B12 deficiency, Cataracts s/p surgery, Ectopic pregnancy, Scarlet fever as a child, s/p Left salpingo-oophorectomy Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks, patient to call for appt([**Telephone/Fax (1) 1504**]) Dr. [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 19978**]) please call for appt Dr [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 36654**]) please call for appt [**Doctor Last Name **] of Hearts monitor - follow up by Dr [**Last Name (STitle) **] Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 10533**]) if abdominal pain returns PT/INR first draw [**11-9**] with results to Dr [**Last Name (STitle) **] fax # [**Telephone/Fax (1) 26588**] goal INR [**12-22**] Completed by:[**2153-11-7**]

[ "519.4", "511.9", "410.41", "574.51", "788.30", "414.01", "401.9", "427.1", "427.31", "266.2", "577.0", "242.90", "443.22", "441.4" ]

icd9cm

[ [ [] ] ]

[ "51.10", "88.72", "37.22", "88.53", "88.56", "88.73", "36.15", "36.12", "39.61", "88.48" ]

icd9pcs

[ [ [] ] ]

10715, 10759

8416, 9431

242, 396

11131, 11137

2289, 4300

11602, 12220

1465, 1635

9799, 10692

4337, 4366

10780, 11110

9457, 9556

11161, 11579

4500, 7686

1650, 2270

187, 204

4395, 4474

424, 940

7721, 8393

962, 1168

1184, 1449

9574, 9776

30,139

152,289

33354

Discharge summary

report

Admission Date: [**2133-1-19**] Discharge Date: [**2133-1-23**] Date of Birth: [**2051-1-3**] Sex: F Service: MEDICINE Allergies: Heparin Agents / Succinylcholine Attending:[**First Name3 (LF) 348**] Chief Complaint: Fever/Hypotension Major Surgical or Invasive Procedure: Outside Hospital Femoral Central Line Removed ([**2133-1-20**]) PICC Placement ([**2133-1-20**]) PICC Removed ([**2133-1-23**]) History of Present Illness: 82 y/o Portuguese speaking F with PMH of severe COPD with h/o respiratory failure [**2-27**] with pseudomonas VAP, VRE bacteremia, CMV viremia requiring trach/PEG that were subsequently removed, ESRD on HD who presented from OSH [**1-19**] with hypotension, SBP 80s and low grade temp. She had been doing well until a recent COPD flare that led to an admission at [**Hospital3 **]. She was discharged to a rehab facility on [**1-17**] on 60 of prednisone for a taper. She had been complaining of some weakness since that discharge. On presentation for HD ([**1-19**], day of admission), she was reported to have SBPs in the 70s-80s, and was sent to the ED. At the OSH ED, she had a rectal temp of 100.2. She had a CXR showing bilateral infiltrates. She was given vanco, ceftriaxone and levofloxacin. She had a R femoral CVL placed and was started on levophed when her pressures were as low as systolics in the 60s. She was transferred to [**Hospital1 18**] MICU at that time. Past Medical History: -COPD -Hypertension -Hyperlipidemia -CAD - s/p MI [**6-27**], s/p stents x 3 @ [**Hospital1 **], nl EF in [**1-27**] -Hypothyroid -RA -Gout -ESRD on HD MWF -Anemia [**12-24**] CKD - on epo -DM2 - on insulin -Afib (not anticoagulated given GIB) -Asthma - not on home o2 -Pseudocholinesterase insufficiency -H/o HITT ([**2127**] [**Hospital1 2025**]) -H/o hemoptysis on heparin ([**2127**] [**Hospital1 2025**]) -H/o UGIB on heparin ([**2127**] [**Hospital1 2025**]) -H/o respiratory failure [**2-/2130**] with pseudomonas VAP, VRE bactermia and CMV viremia, necessitating trach and peg, both subsequently removed Social History: Lived in [**Doctor Last Name **] NH. Sons live close by are joint HCPs. [**Name (NI) **] [**Name2 (NI) **]/ETOH/drugs. Portugese speaking. Family History: non contributory Physical Exam: Discharge: Vitals: T97.7; BP 136/82; HR 104; RR 20; O2Sat 100% on 2L GEN: pleasant, comfortable, NAD HEENT: EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd Pulm: bibasilar crackles, diffuse ins/exp wheezes; no increase work of breathing; CV: irregular rhythm, S1 and S2 wnl, no m/r/g appreciated ABD: nd, +BS, soft, non-tender, no masses EXT: no c/c/e; Ulcer R heal, dry w/o erythema; R arm AV fistula wnl NEURO: AAOx3. Cn II-XII grossly intact. moving all extremities. Pertinent Results: Admission: [**2133-1-19**] 08:30PM BLOOD WBC-22.0*# RBC-4.03* Hgb-11.1* Hct-34.9* MCV-87 MCH-27.6 MCHC-31.9 RDW-17.1* Plt Ct-192 [**2133-1-19**] 08:30PM BLOOD Neuts-78* Bands-10* Lymphs-8* Monos-3 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2133-1-19**] 08:30PM BLOOD Glucose-46* UreaN-29* Creat-2.6* Na-137 K-4.2 Cl-97 HCO3-30 AnGap-14 [**2133-1-19**] 08:48PM BLOOD Lactate-1.8 Discharge: [**2133-1-23**] 05:40AM BLOOD WBC-14.1* RBC-3.65* Hgb-10.3* Hct-31.6* MCV-87 MCH-28.2 MCHC-32.6 RDW-17.3* Plt Ct-152 [**2133-1-23**] 05:40AM BLOOD Glucose-193* UreaN-58* Creat-4.0*# Na-133 K-5.6* Cl-93* HCO3-27 AnGap-19 [**2133-1-20**] 04:38AM BLOOD ALT-24 AST-15 AlkPhos-128* TotBili-0.4 [**2133-1-23**] 05:40AM BLOOD Calcium-8.5 Phos-4.7* Mg-2.2 [**2133-1-23**] 07:30AM BLOOD Vanco-16.7 MICRO: [**1-19**] Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S [**1-21**], [**1-22**], [**1-23**] Blood Culture, Routine (Pending): NGTD RADIOLOGY: CXR: FINDINGS: Single frontal view of the chest was obtained. Patchy right mid-to-lower lung opacity is worrisome for pneumonia. Perihilar and interstitial opacities raise concern for pulmonary edema. No large pleural effusions are seen, however, trace effusions would be difficult to exclude. The cardiac silhouette remains enlarged. TTE: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetations seen (adequate-quality study). Normal global and regional biventricular systolic function. Brief Hospital Course: 82 yo F with h/o COPD, ESRD on HD MWF, afib, CAD s/p MI and PCI, and hypothyroidism who was transfered to the MICU from an OSH for hypotension requiring pressors due to pneumonia and MRSA bacteremia. . #) Pneumonia On presentation for HD, she was reported to be hypotensive and sent to an OSH ED. She had a CXR showing bilateral infiltrates. She was given vanco, ceftriaxone and levofloxacin. She had a R femoral CVL placed and was started on levophed and transferred to the [**Hospital1 18**] MICU on arrival, her initial vitals were 96.4 102 108/49 22 97% 4L NC. She had a repeat CXR confirming the pneumonia findings. Pt was begun on vanc/cefepime/azithro on admission. Repeat CXR confirmed multifocal pneumonia. She was successfully weaned from levophed over HOD1 and the pt continued to hold her BPs (91-153/34-62) at HR of 96-110 (aFib). Due to marked clinical improvement, the patient's femoral CVL was removed and she was transferred to the general medicine floor on HOD2. She continued to improve, and was weaned from supplemental oxygen on HOD4. No successful sputum culture was ever obtained for organism identification or sensitivities. She was discharged to finish a 14 day course of ceftaz/azithro to finish on [**2133-2-1**]. The PICC was removed prior to discharge due to concerns of MRSA seeding and therefore Vancomycin treatment was extended to 14 days from d/c femoral CVL (last day of Vancomycin [**2-3**]) The azithro was switched to PO, and the vanc/ceftaz was planned to be administered at hemodialysis. -- Ceftazidime 1g QHD for 14 days (last day: [**2-1**]) -- Azithromycin 250mg q24 for 14 days (last day: [**2-1**]) -- Vancomycin 1g QHD for 14 days (last day [**2-3**]) -- please wean O2 as tolerated -- O2 sat difficult to read on fingers and more accurate readings obtained on forehead. . #) MRSA bacteremia Initial blood culture in the ED grew MRSA. Unclear whether the bacteremia was secondary to the pneumonia, or was related to the femoral CVL placement, or from hemodialysis. She was already on vancomycin emperically. All subsequent blood cultures are pending, and are NGTD. An TTE was performed and negative for endocarditis. The PICC was removed prior to discharge. #) ESRD The patient was dialysed on HOD1, HOD3, and HOD5. She had additional ultrafiltration on HOD3 due to excess fluid. The pt tolerated all sessions well. . #) COPD The patient had a recent prior admission for presumed COPD flare. At that time, she was begun on a prednisone taper. She was maintained on 60mg pred until HOD3, at which point she was started on 50mg. On HOD5 the dose was decreased to 40mg. She was also continued on albuterol and ipratropium nebs. She was discharged with a plan to taper by 10mg every three days. She still required 2L NC intermittently and should be weaned at rehab. . #) Diabetes The [**Hospital **] hospital course was complicated by hyperglycemia to the 500s the evenings of HOD3 and HOD4. It was thought that the pt's standing glargine of 14units QAM was no longer covering her insulin needs due to the prednisone. On HOD4 her morning glargine was increased to 20 units. On HOD5 her morning glargine was increased to 25 units. This should be adjusted as her prednisone is tapered. . #) Dysphagia The pt began complaining of dysphagia and voice changes on HOD3. She was initially cleared by Speech & Swallow. Oropharynx was showed evidence of thrush. Fluconazole was begun on HOD3 for possibility of thrush given she was on prednisone. . #) HTN The pt's antihypertensives were originally held due to her SIRS physiology. By HOD5 all of her antihypertensives were continued at her home dosage. Her lasix was discontinued. #) A-fib Her rate control agents were intially held given hypotension. They were restarted back to her home regimen. Her meds medications were converted to daily dosing. Toprol 100mg daily and Dilt-XL 240mg daily. #) Goals of Care: Goals of care were discussed with the patient and family. She was followed by social work. The patient remains full code and on-going goals of care discussion will occur among the patient and her family. #) HIT: Pt history of HIT and therefore not given heparin. She was continued on pneumoboots for DVT ppx. Medications on Admission: Nystatin powder [**Hospital1 **] Pred-Forte gtt L eye daily Lasix 80 mg daily Lanuts 14 u qAM with humalog sliding scale Ipratropium nebs daily Neurontin 100 mg qHS Restasis 1 ggt [**Hospital1 **] Plavix 75 mg daily ASA 81 mg daily Docusate/Senna/Ducolax suppository Ergocalciferol 50,000 IU qmonth Levothyroxine 112 mcg daily Dilatiazem 240 mg daily Cymbalta 30 mg daily Nephrocaps daily Omeprazole 20 mg daily Lopressor 50 mg [**Hospital1 **] Albuterol nebs q6hrs PRN Mucinex 1200 mg daily Predisone 60 mg daily x5 days Renagel 1600 mg TID Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 2. sevelamer HCl 400 mg Tablet [**Hospital1 **]: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 6. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 112 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. prednisolone acetate 1 % Drops, Suspension [**Hospital1 **]: One (1) Drop Ophthalmic DAILY (Daily). 9. insulin glargine 100 unit/mL (3 mL) Insulin Pen [**Hospital1 **]: One (1) 25 Subcutaneous once a day: Please decrease the dose of morning glargine back to the original 14 units in the morning as the prednisone is tapered. 10. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 11. gabapentin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO at bedtime. 12. cyclosporine 0.05 % Dropperette [**Hospital1 **]: One (1) Dropperette Ophthalmic [**Hospital1 **] (2 times a day). 13. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 14. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Dulcolax 10 mg Suppository [**Hospital1 **]: One (1) Rectal once a day as needed for constipation. 16. Diltia XT 240 mg Capsule,Ext Release Degradable [**Hospital1 **]: One (1) Capsule,Ext Release Degradable PO once a day. 17. metoprolol succinate 100 mg Tablet Extended Release 24 hr [**Hospital1 **]: One (1) Tablet Extended Release 24 hr PO once a day. 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 19. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr [**Hospital1 **]: One (1) Tablet, ER Multiphase 12 hr PO once a day. 20. azithromycin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours) for 9 days. 21. vancomycin in D5W 1 gram/200 mL Piggyback [**Hospital1 **]: One (1) Intravenous HD PROTOCOL (HD Protochol) for 11 days. 22. fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q48H (every 48 hours) for 5 days: last day [**2133-1-28**]. 23. prednisone 10 mg Tablet [**Month/Day/Year **]: Four (4) Tablet PO once a day for 30 doses: Please decrease to 30mg on [**2133-1-26**]; decrease to 20mg on [**2133-1-29**]; decrease to 10mg on [**2133-2-1**]; discontinue after [**2133-2-4**]. 24. ceftazidime 1 gram Recon Soln [**Year (4 digits) **]: One (1) Intravenous QHD for 9 days: last day [**2133-2-1**]. Dosed at HD. 25. insulin lispro 100 unit/mL Solution [**Month/Day/Year **]: as directed Subcutaneous QIDACHS: per sliding scale . Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Health Care Center Discharge Diagnosis: Primary Diagnosis: Pneumonia Secondary Diagnoses: Chronic Obstructive Pulmonary Disease (COPD), End stage renal disease, Diabetes, High Blood Pressure, Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you in the hospital. You were transfered to the [**Hospital1 18**] intensive care unit because of a pneumonia that caused low blood pressures and fever. The pneumonia was confirmed on a chest xray. While you were in the intensive care unit you were given three broad spectrum antibiotics to help treat the infection (vancomycin, cefepime, azithromycin). You were also maintained on a medicine called levophed, which was used to keep your blood pressure in a safe range. Over the course of the first day, the levophed was weaned, and you were transferred to the general medicine floor. By the second day in the hospital, your breathing began to substantially improve, and you required no supplemental oxygen after the fourth day. All of your home blood pressure medications were restarted. You also received hemodialysis in the hospital according to your usual schedule. Some changes were made to your home medicines that are noted below. If not otherwise noted, please continue all other medications. 1) Please no longer take your home Lasix 2) Your Lantus (Glargine) was increased from 14 units in the morning, to 25 units in the morning. This should be decreased back to 14 units in the morning as your prednisone dose decreases. 3) Your Lopressor (metoprolol) has been switched to a different formulation (Toprol XL 100mg daily), and is now taken once a day 4) Your prednisone has been decreased to 40mg daily here in the hospital; please decrease the dose by 10mg every 3 days. So, please decrease to 30mg daily on [**2133-1-26**], then to 20mg daily on [**2132-1-30**], then to 10mg daily on [**2133-2-1**]. Stop taking prednisone after [**2132-2-5**]. 5) You Nystatin powder has been switched to fluconazole, which should be taken once every other day for a total of 7days (last day: [**2133-1-28**]). 6) Azithromycin has been added to your medications, and should be taken once daily for 9 more days (last day: [**2133-2-1**]) 7) You were STARTED on Ceftazidime 1g dosed at HD for a total of 14 days, 9 more days (last day: [**2133-2-1**]) this will be dosed at dialysis. 8) You were STARTED on Vancomycin 1g at HD for a total of 2 weeks (last day: [**2133-2-3**]) this will be dosed at dialysis. Followup Instructions: -- You should continue your hemodialysis at your regular schedule (MWF). -- You are doing to rehab and should have folow-up with your PCP when you are discharged. Completed by:[**2133-1-24**]

[ "790.7", "427.31", "787.20", "496", "311", "585.6", "403.91", "041.12", "486", "V45.11", "244.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.97" ]

icd9pcs

[ [ [] ] ]

13987, 14052

6015, 10257

309, 439

14272, 14272

2825, 3622

16721, 16916

2253, 2271

10849, 13964

14073, 14073

10283, 10826

14448, 16698

2286, 2806

14123, 14251

3666, 4663

4697, 5992

252, 271

467, 1445

14092, 14102

14287, 14424

1467, 2080

2096, 2237

27,905

104,611

1067

Discharge summary

report

Admission Date: [**2166-7-13**] Discharge Date: [**2166-8-14**] Date of Birth: [**2135-2-7**] Sex: F Service: EMERGENCY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2565**] Chief Complaint: seizure, hypoglycemia Major Surgical or Invasive Procedure: trans-esophageal echocardiogram bronchoscopy History of Present Illness: 31yoF w/ h/o DM1, HTN, s/p left sided hemorrhagic CVA (3 yrs ago) s/p trach/PEG/chronically indwelling catheter presents to ED from [**Hospital **] rehab today after having had witnessed "tonic clonic" activity at which time her BS was found to be 30. NH staff had also noted decreased alertness today prior to her seizure activity and hypoglycemia. She has reportedly been spiking temps since [**7-8**] at rehab. In review of her med list, she was started on ceftriaxone, vancomycin and inhaled tobramycin on [**7-10**] (planned for 2 wk course); abx were changed from levaquin/vanco when sputum grew cipro resistant klebsiella (sensitive to ceftriaxone). . Of note, pt. was recently hospitalized [**Date range (1) 6957**] for sepsis (presumed pulmonary source). Course was c/b probable VAP and she is s/p tracheostomy recannulation during last hospitalization as well as s/p PEG placement as she had been having increasing dysphagia at home. Also during this past hospitalization, she was noted to be persistently febrile without clear e/o of persistet infection and in the absence of clear medication causes. . In the ED, initial VS revealed T 101.6 BP 110/71 HR 100 RR 20 O2 sat 100% on AC (Vt 450, rr 14, FiO2 0.60, PEEP 5). A CXR was obtained and did not show e/o infiltrate. UA showed moderate bacteria, but only 0-2 WBCs and she has a chronic indwelling foley. She received ceftriaxone and vancomycin in addition to approximately 2L IV NS. . ROS: Unable to obtain from patient Past Medical History: # Diabetes Mellitus type 1 (dx at age 3), hx of hypoglycemic episodes # CVA (hemorrhagic) at 27 with residual aphasia and Right hemiparesis, tracheostomy post CVA now recannulated during recent [**6-/2166**] admission # Blindness in one eye # History of aspiration pneumonia # Although patient is on valproate, no reported history of seizures # Depression # Hyperthyroidism # Anemia (BL hct 22-25) # HTN # Gastroparesis # LV dysfunction . Social History: Remote smoking history in her teens, lived in CA previously and has lived at the Greenery since coming to MA. Family History: healthy brother/sister. Maternal family history of DM. Physical Exam: T 94.2 BP 120/62 HR 83 RR 15 O2sat 100% (Vt 450, rr 14, FiO2 0.60, PEEP 5) Gen: Pt. with trach on ventilator, in NAD HEENT: Right pupil round and reactive to light, Left eye w/ what appears to be scar tissue overlying inferior [**Doctor First Name 2281**] Neck: Supple CV: RRR, no mrg Resp: Coarse BS anteriorly, unable to appreciate post. BS Abd: +BS, soft, ND, no rebound/gurding Ext: Left arm able to move spontaneously, hand in [**University/College **], right hand with contraction. Neuro: Moves LUE, does not follow commands, but opens eyes to voice/name. Pertinent Results: [**2166-7-12**] CXR: wet read without clear evidence of infiltrate. . [**2166-7-13**] sputum: sparse coag +staph = MRSA. S: gen, rifampin, tetracycline, bactrim, vanco; R: clinda, erythromycin, penicillin, and oxicillin . [**7-13**], [**7-14**], [**7-15**] stool neg. for c. diff . [**7-14**] UCx: yeasts > 100K . [**2166-7-15**] UA: +yeasts, mod leuk, no bact . [**2166-7-15**] EEG: This is a mildly abnormal portable EEG in the waking and drowsy states due to the disorganized and poorly sustained background. There was no clear electrographic correlate for clinically observed episodes of eye fluttering or leg tremor. There were no clearly focal, lateralized, or epileptiform features noted. There were no electrographic seizures. . [**2166-7-16**] CT head: no significant change since [**2166-6-27**]. no new IC bleed or infarct . [**2166-7-16**] CT abd/ pelvis: pneumonic infiltrate of RLL, no perinephric abscess, 4.5cm soft tissue mass in R breast (rec f/u with US) . [**2166-7-18**] CT head: no significant interval change. no new IC bleed . [**2166-6-12**] Echo: LVEF 30-40% [**1-10**] to severe hypokinesis/akinesis of the apical half of the left ventricle, mild pulmonary htn. . [**2166-7-19**] Echo: Mild mitral leaflet thickening but without discrete vegetation or pathologic flow. Low normal left ventricular systolic function. Compared with the prior study (images reviewed) of [**2166-6-12**], left ventricular systolic function is improved with lack of regional dysfunction. The focal thickening of the anterior mitral leaflet was also present on review of the prior study. . [**2166-7-20**] MRI/MRA: IMPRESSION: 1. Severe bilateral athermatous disease of the intracranial internal carotid arteries. 2. Similar encephalomalacic changes in the left frontal lobe. 3. Extensive T2 signal abnormality in the cerebral white matter, probably due to widespread chronic small vessel infarction. 4. Marked brain atrophy. 5. No evidence of brain abscess or abnormal meningeal enhancement. . [**2166-7-25**] RLE US: neg for DVT . [**2166-7-28**] CT head/ sinus: IMPRESSION: Similar appearance of cystic encephalomalacia and other atrophic changes in the brain. No acute intracranial hemorrhage or mass effect. Clear sinuses. . [**2166-7-28**] CT chest/ abd/ pelvis: CONCLUSION: 1. Interval improvement in extent of right lower lobe atelectasis, and development of small airspace opacity, that may represent pneumonia vs. reexpansion changes. 2. Right lower lobe airspace consolidation, likely representing atelectasis, underlying infection cannot be entirely excluded. 3. Arteriosclerosis. 4. No drainable fluid collection. . [**2166-7-30**] EEG: intermittent sharp wave, as well as spike and slow wave discharges, seen in a multifocal fashion arising sometimes in a generalized distribution but also were seen independently in the bifrontal regions and the left temporal region. Also noted were broad-based, high amplitude, blunted triphasic waves in the region of the left anterior temporal and temporal regions. Discharges were not repetitive and there were no electrographic seizures noted. These multifocal regions of discharges suggest areas of cortical irritability with potential for epileptogenesis. Also persistent slowing over the left temporal regions in the setting of a persistent slow and disorganized background. The slowing over the left hemisphere - subcortical dysfunction. The otherwise slow and disorganized background rhythm suggests a more global and diffuse process consistent with an encephalopathy likely due to deeper midline or bilateral subcortical dysfunction. Medications, metabolic disturbances, infections, and anoxia are among the most common causes of encephalopathy. . [**2166-7-30**] TEE: could not be done as probe could not be passed . [**2166-7-31**] TTE: could not be done as study is technically difficult - no additional information would be provided from previous . [**2166-8-1**] EGD: . [**2166-8-1**] GJ tube exchange . [**2166-8-3**] CT chest/abd/pelvis: IMPRESSION: 1. Multifocal pneumonia with new left upper lobe and lingular infiltrates and no significant change to left lower lobe air bronchogram containing infiltrate. Near complete resolution of previously identified patchy right lower lobe opacities. No evidence of intra-abdominal abscess. 2. Unchanged atherosclerotic disease involving the aorta and its branches as well as the coronary circulation much more prominent than expected for patient's age. . [**2166-8-3**] Bronchoscopy: LLL and RLL with some purulent secretions. no evidence of bronchial obstruction. Sent LLL BAL. . [**8-7**] Bilat LE u/s: IMPRESSION: No evidence of DVT in both lower extremities. . [**8-5**] Trans esophageal echo Conclusions: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A very small secundum atrial septal defect is present. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Trace 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 no pericardial effusion. IMPRESSION: No valvular vegetations identified. Mildly thickened mitral and aortic valve leaflets. Trivial aortic and mitral regurgitation. Mild tricuspid regurgitation. Small secundum atrial septal defect. . [**8-11**] CXR: Increased consolidation at left lung base which could represent pneumonia. New development of left pleural effusion, small. [**2166-7-12**] 09:10PM URINE RBC-[**2-10**]* WBC-0-2 BACTERIA-MOD YEAST-OCC EPI-0 [**2166-7-12**] 09:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2166-7-12**] 09:10PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020 [**2166-7-12**] 09:10PM PT-13.6* PTT-26.3 INR(PT)-1.2* [**2166-7-12**] 09:10PM PLT COUNT-655* [**2166-7-12**] 09:10PM NEUTS-77.1* LYMPHS-15.5* MONOS-6.7 EOS-0.1 BASOS-0.5 [**2166-7-12**] 09:10PM WBC-13.7*# RBC-3.06* HGB-9.6* HCT-28.0* MCV-92 MCH-31.2 MCHC-34.1 RDW-15.5 [**2166-7-12**] 09:10PM VALPROATE-44* [**2166-7-12**] 09:10PM estGFR-Using this [**2166-7-12**] 09:10PM GLUCOSE-217* UREA N-45* CREAT-1.7* SODIUM-135 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-24 ANION GAP-22* [**2166-7-12**] 09:12PM %HbA1c-5.8 [**2166-7-12**] 09:20PM COMMENTS-GREEN TOP [**2166-7-13**] 06:12AM PT-13.4* PTT-36.9* INR(PT)-1.2* [**2166-7-13**] 06:12AM NEUTS-68.5 LYMPHS-22.0 MONOS-8.8 EOS-0.2 BASOS-0.4 [**2166-7-13**] 06:12AM VANCO-8.1* [**2166-7-13**] 06:12AM OSMOLAL-293 [**2166-7-13**] 06:12AM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.5 [**2166-7-13**] 06:12AM GLUCOSE-38* UREA N-40* CREAT-1.2* SODIUM-138 POTASSIUM-2.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 [**2166-7-13**] 08:30AM URINE OSMOLAL-398 [**2166-7-13**] 08:30AM URINE HOURS-RANDOM UREA N-595 CREAT-72 SODIUM-29 [**2166-7-13**] 01:48PM GLUCOSE-78 UREA N-33* CREAT-1.1 SODIUM-139 POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-22 ANION GAP-14 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2166-8-14**] 04:39AM 8.7 3.02* 9.6* 27.9* 92 31.8 34.4 16.4* 462* [**2166-8-13**] 04:14AM 7.7 3.17* 10.0* 28.9* 91 31.6 34.7 16.1* 422 [**2166-8-12**] 04:33AM 7.1 2.80* 9.1* 25.2* 90 32.7* 36.3* 16.3* 397 Source: Line-CVC [**2166-8-11**] 05:18AM 5.7 2.80* 8.7* 25.7* 92 31.2 34.0 16.4* 378 Source: Line-L sc [**2166-7-17**] 10:57PM 14.6* 3.97* 12.2 36.0 91 30.7 33.9 16.1* 342 Source: Line-Left subclavian [**2166-7-17**] 04:00AM 10.4 3.50* 11.1* 31.7* 90 31.6 35.0 16.0* 244 [**2166-7-16**] 05:54AM 8.9 3.60*#1 11.4*#1 32.8*#1 91 31.5 34.6 17.0* 310 Source: Line-L subclavian 1 VERIFIED [**2166-7-15**] 06:20AM 7.7 2.21* 7.1* 21.0* 95 32.0 33.6 15.8* 326 . DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2166-8-14**] 04:39AM 51.5 33.3 4.2 10.8* 0.2 [**2166-8-13**] 04:14AM 67.5 18.7 5.5 7.9* 0.4 [**2166-8-12**] 04:33AM 44.4* 38.9 4.4 11.9* 0.4 Source: Line-CVC [**2166-8-11**] 05:18AM 40.5* 42.9* 3.9 12.5* 0.2 Source: Line-CVC [**2166-8-10**] 04:41AM 34.5* 49.6* 4.7 10.8* 0.4 Source: Line-CVC [**2166-8-9**] 04:30AM 56.4 32.1 3.5 7.8* 0.2 [**2166-8-2**] 04:21AM 74.9* 20.8 3.7 0.4 0.2 Source: Line-A line [**2166-7-28**] 04:56AM 69.8 24.4 4.6 0.9 0.4 Source: Line-picc [**2166-7-22**] 03:16AM 51.9 39.8 7.6 0.5 0.1 Source: Line-central [**2166-7-19**] 03:10AM 55.4 35.5 7.3 1.5 0.3 Source: Line-lsc tlcl [**2166-7-15**] 06:20AM 53.2 34.8 8.0 3.4 0.6 Source: Line-TLC [**2166-7-13**] 06:12AM 68.5 22.0 8.8 0.2 0.4 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2166-8-14**] 04:39AM 161* 13 0.6 135 4.0 102 26 11 [**2166-8-13**] 04:14AM 56* 16 0.6 138 4.7 103 28 12 [**2166-8-12**] 04:33AM 153* 11 0.5 136 4.4 104 28 8 . [**2166-8-5**] 04:30AM 84 10 0.7 138 3.7 110* 19* 13 Source: Line-left IJ [**2166-8-4**] 04:10AM 71 9 0.8 139 3.9 112* 18* 13 [**2166-8-3**] 04:06AM 64* 11 0.9 141 3.4 112* 17* 15 . [**2166-7-14**] 06:29AM 63* 20 1.0 143 4.0 111* 23 13 Source: Line-tlc; Vancomycin @ Trough [**2166-7-13**] 01:48PM 78 33* 1.1 139 4.9 108 22 14 Source: Line-groin line [**2166-7-13**] 06:12AM 38*1 40* 1.2* 138 2.6*1 101 23 17 . LFTs ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2166-7-28**] 04:56AM 14 15 143 67 146* 0.1 . Ft4 1.4 on [**8-11**] 2.0 on [**7-31**] PTH 25 on [**7-21**] . ANCA neg [**Doctor First Name **] neg dsDNA neg Brief Hospital Course: # Fever: Febrile to 101.6 in ED where she received IV ceftriaxone and vancomycin without clear infiltrate on CXR but has extensive h/o aspiration pneumonia and was recently treated for VAP for which she completed a course of meropenem and vancomycin prior to d/c on [**7-4**]. On admission, with temp. and tachycardia she met criteria for SIRS with no definitive source. Blood and urine cultures were sent in the ED. Did have elevated WBC count to 13.7, but no notable left shift and all cell lines appeared to be up suggesting hemoconcentration. In discussion w/ RN at [**Hospital1 **], she had been spiking temperatures there since [**7-8**] at which time she was started on levofloxacin and vancomycin. Her vancomycin level was noted to be elevated so was held while levels resolve. Levaquin was reportedly discontinued on [**7-10**] when her sputum was found to be growing klebsiella resistant to ciprofloxacin, but sensitive to ceftriaxone. Thus she was started on ceftriaxone and tobramycin neb at that time. She was started on vanco/zosyn for ?LLL pna here but then these were stopped given negative infectious workup and no significant LLL infiltrate on repeat CXR. However, fever spikes continued (Tm 104.6 on [**7-19**], 104.2 on [**7-21**]) with negative cultures. TTE and TEE showed no vegitations, CT abd showed no abscess. LP negative for meningitis, cryptococcus negative, viral culture still pending. Sputum grew Klebsiella pneumonia on [**7-19**] which was sensitive to Zosyn and she was treated with a full course of zosyn. She continued to spike fevers after she was treated, ID was consulted, review of culture data showed that she has a sub-population of ESBL resistant klebsiella and so she was subsequently treated with meropenem. She should continue treatment until [**8-25**]. She was also found to have pseudomonas in her sputum which was sensitive only to amikacin. She was started on amikacin and should continue until [**8-28**]. Amikacin dosing switched to 750mg q24 dosed at 4pm on day of discharge. She should have amikacin levels draw just prior to administration of third dose (on [**8-16**]). Goal trough is <4, if >4 can increase dosing interval to q36hrs. She had diarrhea of unclear etiology - it may have been due to tube feedings and she was given banana flakes to good effect. Because of fevers and prolonged antibiotics, C. diff was a concern. C.diff toxin assay was negative, however given concern a B-toxin was sent which is currently pending. She should continue flagyl for another 7 days (until [**8-21**]) or until B-toxin is negative. Patient grew MRSA in sputum which was initially treated with vancomycin then linezolid as there was concern for drug-fever with vancomycin. Linezolid then stopped because of eosinophilia (see below). Although CXR on [**8-11**] was read as having consolidation in left lower lobe, she was clinically much improved with fever curve trending down. Given much improved respiratory status, MRSA was felt to be a chronic colonizer. She had a UTI with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] which was treated with voriconazole. During her hospitalization, non-infectious sources of fever were considered as well. Vancomycin was thought to be causing a drug fever as above given that she was febrile to 106F. Vasculitis panel was negative. Neurology consulted to consider autonomic dysfunction/central causes of fevers but did not feel this would explain fevers. She does have hyperthyroidism, but this also was not though to explain fevers. At discharge she had been afebrile x4 days. She should have a repeat CXR in a few weeks to assess for resolution of pneumonia. Overall antibiotic regimen included: vancomycin [**Date range (1) 6958**]; [**7-28**] - [**8-6**] zosyn [**Date range (1) 6959**]; [**Date range (1) 6960**]; [**8-2**] - [**8-4**] meropenem 1g IV q8h [**8-4**] - [**8-18**] (planned) amikacin [**8-8**] - [**8-21**] (planned) Flagyl [**7-14**] - [**7-16**]; [**8-2**] - [**8-21**] (planned) fluconazole [**7-16**] - [**7-19**] Vori 200 PO BID [**8-4**] - [**8-8**] cipro [**7-28**]- [**7-28**] CTX [**7-13**] - [**7-13**] Bactrim [**7-17**] - [**7-21**] Linezolid [**8-8**] - [**8-11**] . # Seizure: Reportedly no h/o seizures previously despite having been maintained on depakote (presumably started post CVA). ?seizure on day of admission seems more likely [**1-10**] to severe hypoglycemia as opposed to structural abnormalities post CVA acting as epileptiform nidus. A [**2166-6-11**] EEG did not reveal e/o seizure/epileptiform activity. Pt now with increased resting tremor of LUE. [**2166-7-15**] EEG results neg. for epileptiform activity; no clear electrographic correlate for clinically observed episodes of eye fluttering or leg tremor. CT head r/o acute IC process/ new stroke since [**6-27**]. LFTs WNL. Neurology believes tremor in hand is likely action tremor due to stroke affecting basal ganglia. MRI/MRA neg. On [**7-21**] depakote changed to keppra because it may be contributing to fevers. She was continued on keppra with no further evidence of seizure activity - she has a resting tremor of the left hand which was not felt to represent epilectic activity. . # DM1/ Hypoglycemia: In review of her records, has h/o labile BS and, as above, was found to be hypoglycemic to the 30s when found to seize. Diabetes management service consulted. Initially euglycemia maintained on insulin drip. Once patient tolerating consistent tube feeds, she was transitioned to glargine (currently 24 units) and QID insulin sliding scale. Blood sugars still fairly variable, however given that she presented for hypoglycemia, we erred on the side of higher blood sugars. Josline diabetes service had been considering switching to [**Hospital1 **] lantus regimen at discharge but as blood sugars currently stable she was not changed. This could be considered if blood glucose is variable in the future. . # ARF: Baseline creatinine is 0.7-1.0 and was found to be elevated to 1.7 on ED presentation (while it was normal on d/c on [**7-4**]). Given it appears that she is hemoconcentrated by CBC, most likely reflects prerenal azotemia. U lytes consistent with prerenal ARF. She initially had a low bicarbonate (low of 17) and urine electrolytes suggested renal tubular acidosis. This had resolved on discharge. . # Respiratory failure: Has reportedly not attempted wean at [**Hospital1 **] per limited progress notes sent w/ patient. Respiratory distress has been complicated by tremors, apears to be a central process with cyclical periods of tacchypnea that had made weaning difficult. Once respiratory infection treated she was transitioned to trach collar and has stayed on that with 40% FiO2 for 4 days prior to discharge. . # Coughing Patient had intermittent paroxysms of coughing that persisted even once respiratory infection was mostly treated. Interventional pulmonology performed bronchoscopy which showed that the trach was in good position but did show largyngeal inflammation suggestive of GE reflux. She was started on [**Hospital1 **] PPI and sucralfate (for possible element of gastritis), sucalfate stopped prior to discharge. . #Aggitation she has been receiving standing clonazepam for aggitation/anxiety and occasional ativan IV with good effect. . # Hyperthyroidism: free t4 3.9 on admission, hyperthyroidism treated with PTU, free t4 normalized to 1.4. She should continue PTU until she follows up with her outpatient endocrinologist in [**Location (un) 620**] in the next few months. Free t4 should be rechecked in [**3-14**] weeks. . # HTN: antihypertensives initially held for hypotension and ARF. Metoprolol restarted at low doses and blood pressure began to increase in the week before discharge. She was started on captopril and metoprolol increased to 100mg [**Hospital1 **]. Outpatient regimen was metoprolol 175mg PO bid, lisinopril 20mg daily, and Lasix 40 mg daily. These medications should be restarted slowly at rehab to control hypertension. . # Corneal opacity Patient is blind in left eye from diabetic retinopathy. Eye noted to have corneal opacity in inferior aspect of cornea for at least a month. Ophthalmology consulted who felt this was unlikely to be a corneal ulcer but that there may be some abrasion for which they recommended erythromycin ophthalmic ointment. This was stopped for concern of systemic absorption causing eosinophilia. She should have her left eye kept closed to prevent drying out of the cornea. . # Anemia: Baseline hct appears to be 22-25. Recent iron studies during last hospitalization are c/w AOCD w/ low TIBC, elevated ferritin. Patient transfused intermittently when HCT fell below 21. No evidence of bleeding. . # Eosinophilia Eosinophils rose to 7/8 on [**8-9**] and a maximum of 12.5 on [**8-11**]. Although she was afebrile at the time, this was thought to perhaps be another representation of tendency towards drug fever. linezolid and erythromycin ophthalmic ointment stopped and eosinophilia began trending down. She should have a repeat eosinophil count in a few days to confirm that it has gone down. . # Depressed LVEF: 40% on recent echo. On lasix, BB, ACEI as outpatient (see HTN above) . # ?DVT: given cool extremities with decreased pulses noted [**7-25**] but doppler U/S was negative on two occassions. . # FEN: Tube feed continued, electrolytes repleted as needed. Reglan stopped for diarrhea. . # R breast mass: US evaluation as outpatient . Access: PICC placed [**8-13**] Medications on Admission: Meds (obtained from [**7-4**] d/c summary): Ferrous sulfate 300mg liquid daily Ceftriaxone 1g IV BID (started [**7-10**]) Cholestyramine/sucrose 4g daily Reglan 10mg PO daily ASA 81mg daily MVI Docusate Senna Folate 1mg daily Diltiazem 120mg PO qid (on d/c summary from [**7-4**], but not on med list from [**Hospital1 **]) SC heparin Artificial tears Albuterol prn SOB/wheezing Ipratropium Metoprolol Tartrate 175 mg PO bid Miconazole Nitrate 2 % Powder qid prn rash Ranitidine 150 mg q12h Lantus 30U hs, 25 qam Novolog SS Propylthiouracil 100 mg PO Q8h Lidocaine HCl 5 % Ointment [**Hospital1 **]: One (1) Appl Topical Q6h prn Lisinopril 20mg daily Lasix 20mg IV daily Lasix 80mg PO bid Valproate 1g q6h Ativan 1mg q4h prn Morphine 15mg PO q4h prn pain Acetaminophen q4h prn Beneprotein Tobramycin neb q12h (started on [**7-10**]) . All: NKDA Discharge Medications: 1. Propylthiouracil 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q8H (every 8 hours). 2. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day): last day [**8-21**]. 3. Meropenem 1 g Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Intravenous Q8H (every 8 hours): last day [**8-25**]. 4. Outpatient Lab Work amikacin level before third dose of 750mg on [**8-16**] to be drawn just prior to administration at 4pm. goal is less than 4. if greater than 4 can increase interval to q36 5. Levetiracetam 100 mg/mL Solution [**Month/Day (4) **]: Ten (10) mL PO BID (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1) inj Injection TID (3 times a day). 7. Miconazole Nitrate 2 % Powder [**Month/Day (4) **]: One (1) Appl Topical QID (4 times a day) as needed. 8. Acetaminophen 160 mg/5 mL Solution [**Month/Day (4) **]: 650-975 mg PO Q6H (every 6 hours) as needed. 9. Clonazepam 0.5 mg Tablet [**Month/Day (4) **]: .5 Tablet PO BID (2 times a day). 10. Lidocaine HCl 1 % Solution [**Month/Day (4) **]: Three (3) ML Injection Q4-6H (every 4 to 6 hours) as needed. 11. Lidocaine HCl 2 % Gel [**Month/Day (4) **]: One (1) Appl Mucous membrane PRN (as needed). 12. Codeine Sulfate 30 mg Tablet [**Month/Day (4) **]: 0.5 Tablet PO Q6H (every 6 hours) as needed. 13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 14. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 15. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 16. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 17. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation QID (4 times a day). 18. Lorazepam 2 mg/mL Syringe [**Last Name (STitle) **]: 1-2 mg Injection Q2H (every 2 hours) as needed for agitation. 19. Amikacin 250 mg/mL Solution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750) mg Injection Q24H (every 24 hours): day 1=[**8-8**] last day =[**8-28**] (current dosing started [**8-14**]) Should be given at 4pm Please follow trough, should be less than 4. 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (4) **]: Two (2) ML Intravenous DAILY (Daily) as needed. 21. Lantus 100 unit/mL Cartridge [**Month/Day (4) **]: Twenty Four (24) units Subcutaneous at bedtime. 22. Insulin Regular Human Injection Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Primary: ventilator-associated pneumonia with pseudomonas, klebsiella, and MRSA Yeast UTI hypoglycemic seizures DM type I Hyperthyroidism . secondary Hypertension Discharge Condition: Fair - stable on trach collar with 40% FiO2. afebrile x4 days. Discharge Instructions: You were admitted for a low blood sugar, seizures, and fevers. You low blood sugars were likely due fevers and to changes in your tube feeding regimen and resolved with steady tube feed intake and close monitoring of your blood sugars. You had an extensive workup for your fevers. We believe the fevers were due to infections in your lungs with two bacteria and in your urine with yeast. These were treated with antibiotics and antifungals. You should continue the antibioitics as indicated below. You are also being treated for an infectious diarrhea associated with antibiotic use called Clostridium difficile. Also, you were treated for hyperthyroidism, which is a high level of thyroid hormone. You should follow up with your outpatient endocrinologist regarding this. Please return to the hospital if you have recurrent high fevers, increased sputum production, seizures, or any other new or concerning symptoms. Followup Instructions: Please follow-up with your outpatient endocrinologist and your primary care doctor

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[ [ [] ] ]

[ "96.56", "33.21", "00.14", "96.6", "96.72", "88.72", "38.93", "03.31", "45.13" ]

icd9pcs

[ [ [] ] ]

26128, 26203

13093, 22657

337, 384

26410, 26475

3179, 3933

27454, 27540

2513, 2569

23553, 26105

26224, 26389

22683, 23530

26499, 27431

2584, 3160

276, 299

412, 1908

4181, 13070

1930, 2370

2386, 2497

52,109

139,731

1459+55286

Discharge summary

report+addendum

Admission Date: [**2197-5-16**] Discharge Date: [**2197-5-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Endoscopy, blood transfusions, platelets EGD History of Present Illness: Ms. [**Known lastname **] is [**Age over 90 **] yo female with a h/o MDS, pulmonary fibrosis, UGIB and HTN who presents with LGIB. She had been at home in her usual state of health. Got up to go to the bathroom this am, had what she thought was diarrhea, then called EMS today as she felt too weak to get off toilet. On their arrival, they found gross blood/clots in toilet in addition to bloody stool all over apartment. The pt syncopized when helped off toilet x 1 minute. Upon arrival to ED, temp was 96.6, HR 96, BP 108/53, RR 17, and pulse ox 100% on room air. She was tachycardic and in atrial fibrillation. NG lavage was performed and was negative. Labs were notable for elevated creatinine 2.6 (baseline 1 year ago ~2.0), anemic with hct to 17 (baseline 1 year ago ~ 30), trop 0.02, CK 18, INR was 1.6, not anticoagulated. She was ordered for 4 units PRBCs and 4 units FFP, had received 2 units pRBCs and 3 units FFP prior to transfer. She was transiently hypotensive 67-80/33-42, improved to >100 after 2L NS and above products. GI was consulted in ED, recommended monitoring at present as pt not prepped with consideration of tagged red blood cell scan if pt continues to bleed briskly. The general surgical service was also consulted given the degree of hematocrit drop, will see her in ICU. At time of transfer to the ICU the patient's VS: 97.3 95 (AF) 111/50 14 NRB 100% (96% on NC initially). She has 2 large bore PIVs in place, was alert and oriented x 3. Is accompanied by her son. Confirmed to be full code in ED. . On arrival to the ICU, pt is stable, resting comfortably. Only complaint is slight back ache after laying down all day. Denies having diarrhea prior to this morning, denies noting BRBPR or melena recently. No abd pain. Did have one episode of emesis this morning, did not notice if there was blood/coffee grounds. No chest pain, no palpitations. Notes that she usually has shortness of breath for which she will use supplemental 02 at home, but this is no worse than baseline. No dizziness. Has noted increase LE edema for the past 10 days or so which she has noted has started to weep. ROS was otherwise essentially negative. Past Medical History: 1. Bleeding ulcer and UGI bleed in [**2194**] 2. MDS (last labs from [**2196**]. Hct ~30s, plts ~100, worsening leukocytosis) 3. Pulmonary fibrosis on home 02 (2L) 4. Hypertension 5. CRI, baseline ~1.9 ([**6-2**]) 6. s/p Right Hip Replacement 7. s/p Right Knee Replacement 8. s/p Appendectomy Social History: - Home: lives in senior housing in [**Location (un) **], has nurse in facility who visits her regularly and administers weekly procrit. She has two sons, [**Name (NI) **] lives in [**Name (NI) 1439**], other son in [**Name (NI) 701**]. Widowed since [**2157**]. Walks with walker. - Tobacco: Smoked 1 PPD x 40 yrs, quit in [**2147**]. - EtOH: No EtOH. - Occupation: She worked many years ago as a clothing buyer. Family History: nc Physical Exam: On admission Vitals: T:9705 BP: 115/60 P:97 (AF) R: 18 SaO2: 100% NRB General: Pleasant elderly woman, younger than stated age, NAD HEENT: NCAT, pale sclera, dry mucous membranes. No icterus. Neck: JVP present to angle of jaw. Pulmonary: Poor air movement, no wheezes or crackles. Mild kyphosis. Cardiac: Irregularly irregular rhythm, regular rate. No appreciable murmurs. Abdomen: Soft, minimal distention, + BS. Non-tender. Extremities: Weeping edema bilaterally. Skin: Some pretibial skin breakdown. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. Pertinent Results: [**2197-5-16**] WBC 19.8 / Hct 17.8 / Plt 103 N 82 / L 12 / M 5 / E 0 / B 0 Na 140 / K 5.2 / Cl 112 / CO2 18 / BUN 82 / Cr 2.6 / BG 173 Ca 8.1 / mg 2.5 / Phos 4.9 PTT 30.9 / INR 1.6 . [**2197-5-16**] 08:15AM BLOOD Hct-17.8* 3 units -> Hct-25.4* -> 1 unit Hct-28.8* -> Hct-26.3* -> Hct-26.6* . [**2197-5-18**] WBC 25 / Hct 26.6 / Plt 58 Na 138 / K 3.2 / Cl 107 / CO2 21 / BUN 59 / Cr 2 / BG 91 . [**2197-5-17**] Echo - The left atrium is moderately dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. 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 markedly dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-27**]+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2194-2-3**], RV dilation and dysfunction are now seen. [**2197-5-16**] EGD - Normal mucosa in the stomach Ulceration in the duodenum (injection, endoclip, thermal therapy) Abnormal mucosa in the duodenum Otherwise normal EGD to second part of the duodenum [**2197-5-17**] CXR There is a bilateral fluid marking of the interstitium. The right costophrenic sinus is obliterated, potentially by a small pleural effusion. The pulmonary vessels show a moderate increase in caliber. Overall, the signs must be interpreted as moderate overhydration. Otherwise, no relevant changes. Severe scoliosis with resulting asymmetry of the rib cage. Moderate tortuosity of the thoracic aorta. No focal parenchymal opacity suggestive of pneumonia. Brief Hospital Course: [**Age over 90 **]yo female with history of bleeding gastric ulcers, myelodysplasia, pulmonary fibrosis, and hypertension was admitted with anemia and GI bleed. 1. GI Bleed Patient had a negative NG lavage in the Emergency Department. Upon arrival to the floor, patient underwent an upper EGD which revealed a duodenal ulcer. The ulcer was clipped. She received a total of 4 units packed RBCs and her hematocrit improved from 17 to ~26 and has remained stable since her transfusions. We would recommend that you check an H. pylori serology when she arrives at [**Hospital 100**] Rehab. 2. Coagulopathy Patient had an elevated INR of 1.6 on admission. This was thought related to a nutritional deficiency in the setting of diarrhea in the days prior to admission. This improved with Vitamin K and FFP to 1.2. 3. Atrial Fibrillation Patient was found to be in atrial fibrillation in the Emergency Department. It is unclear if this is an old or new diagnosis as patient reports having been told that she has an abnormal rhythm by her visiting nurse. [**First Name (Titles) **] [**Last Name (Titles) 8675**] was slightly elevated at 5.6. She is not a candidate for anticoagulation due to her GI bleed. She remained under adequate control with heart rates of 90-100 while off of her beta blocker. Please restart her beta blocker as her blood pressure improves. 4. Myelodysplasia She has a history of myelodysplasia and was followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**] in hematology clinic at [**Hospital1 18**]. During a recent appointment with Dr. [**Last Name (STitle) 2539**] in [**3-6**], her WBC was noted to be rising, concerning for development of a malignant process. Given her age and the limited benefit of aggressive therapy for this patient, further treatment was not pursued by Dr. [**Last Name (STitle) 2539**] at that time. 5. Pulmonary Fibrosis: Patient has a history of pulmonary fibrosis and is on 2L of home oxygen. Her O2 requirement was stable. 6. Hypertension She has a history of hypertension and is on metoprolol, amlodipine, and HCTZ-triamterene. These medications were held upon arrival and in the setting of her GI bleed. As her blood pressure improved, her HCTZ-triamterene was restarted. Please restart her metoprolol and amlodipine as her blood pressure improves. 7. Acute Renal Failure Patient was in acute renal failure upon arrival with a creatinine of 2.6. This improved to 2 upon discharge with hydration and transfusions. Her baseline creatinine appears to be 1.6-1.8. FULL CODE Communication: [**First Name8 (NamePattern2) **] [**Known lastname **], [**Telephone/Fax (1) 8676**] Medications on Admission: 1. Amlodipine 10mg PO daily 2. Epo Alpha 20, 000 unit on Wednesdays. 3. Metoprolol 12.5mg PO bid --> reports taking 25mg QHS as is unable to split pill. 4. Triamterene-HCTZ 75mg / 50mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Simethicone 80 mg Tablet, Chewable Sig: [**1-27**] Tablet, Chewables PO QID (4 times a day) as needed. 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: Two (2) Cap PO DAILY (Daily). 4. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection q Wednesday. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Upper GI bleed 2. Duodenal Ulcer 3. Acute Renal Failure . SECONDARY DIAGNOSES: 1. Hypertension 2. MDS 3. Pulmonary fibrosis on home 02 (2L) 4. Hypertension 5. CRI, baseline ~1.9 ([**6-2**]) Discharge Condition: Stable. Patient is tolerating oral intake and has returned to her baseline condition. Discharge Instructions: You were admitted to the hospital with lightheadedness due to bleeding from your gastrointestinal tract. You had an endoscopy which found a bleeding ulcer. You received several blood transfusions and your blood counts remained stable. . We have made the following changes to your medications: - metoprolol - we have discontinued this medication temporarily while you were found to have GI bleed. - amlodipine - we have discontinued this medication temporarily while you were found to have GI bleed. . Please seek immediate medical attention if you develop fevers, shaking chills, feeling light-headed, dizziness, bright red blood per rectum, black stools, vomiting, or bloody vomit, please seek immediate medical attention. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please follow-up with your primary care physician [**Name Initial (PRE) 176**] [**1-27**] weeks of her discharge from the hospital. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Name: [**Known lastname **],[**Known firstname 69**] Unit No: [**Numeric Identifier 1151**] Admission Date: [**2197-5-16**] Discharge Date: [**2197-5-22**] Date of Birth: [**2099-10-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1152**] Addendum: Pt was sent from ICU to medical [**Hospital1 **] with completed d/c summary for unclear reasons. On arrival to medical [**Hospital1 **], pt. immediately had large melanotic stool. Was converted to NPO status, given IV PPI, two units blood transfusion (with lasix in between). The following day, hct stable, hemodynamically stable. Passed one small melanotic stool, felt to represent old blood passing and likely not ongoing bleeding. Pt monitored till [**5-22**] - Hct improved to 29.5 at time of d/c. Pt had been restarted on home dose metoprolol 12.5 [**Hospital1 **] and tolerating well at time of d/c - BP at 100/59 with HR better controlled in 80s- *****will recommend to start slowly amlodipine as needed though at present no acute indication. Pt's H. pylori serology returned as negative at time of discharge. <br> Please note addended d/c instructions - pt d/c to rehab - will need daily Hct checked for next 4-5 days to assure stability - cont po ppi [**Hospital1 **] for atleast 3 months - avoid NSAIDS. TFTs were checked prior - noted mild hypothyroidism - low dose synthroid at 50mcg were started at time of d/c - *****PCP to [**Name9 (PRE) 900**] future TFTs. <br> Problems as addressed above: . Anemia, Acute blood loss duodenal ulcer with bleed chronic CHF HTN A-fib Hypothyoidism Pertinent Results: [**2197-5-17**] 03:54AM BLOOD TSH-5.6* [**2197-5-20**] 03:40PM BLOOD Free T4-0.88* Discharge Medications: 1. Simethicone 80 mg Tablet, Chewable Sig: [**1-27**] Tablet, Chewables PO QID (4 times a day) as needed. 2. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection q Wednesday. 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Tablet(s) 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Upper GI bleed 2. Duodenal Ulcer 3. Acute Renal Failure . SECONDARY DIAGNOSES: 1. Hypertension 2. MDS 3. Pulmonary fibrosis on home 02 (2L) 4. Hypothyroidism 5. CRI, baseline ~1.9 ([**6-2**]) Discharge Condition: Stable. Patient is tolerating oral intake and has returned to her baseline condition. ****Noted may still have residual mild dark stools - IF stools increase in dark/tarry (melanic-type) stools, develop new/worsening lightheadedness/dizziness OR daily Hct (at 29.3 at time of d/c) start trending down - please call provider [**Name Initial (PRE) **]/or return to the hospital, Discharge Instructions: You were admitted to the hospital with lightheadedness due to bleeding from your gastrointestinal tract. You had an endoscopy which found a bleeding ulcer. You received several blood transfusions and your blood counts remained stable. . We have made the following changes to your medications: - amlodipine - we have discontinued this medication temporarily while you were found to have GI bleed. . Please seek immediate medical attention if you develop fevers, shaking chills, feeling light-headed, dizziness, bright red blood per rectum, black stools, vomiting, or bloody vomit, please seek immediate medical attention. . Weigh yourself every morning, [**Name8 (MD) 233**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Please follow-up with your primary care physician [**Name Initial (PRE) 1091**] [**1-27**] weeks of her discharge from the hospital. Facility to call and arrange: PCP: [**Name10 (NameIs) 1153**],[**Name11 (NameIs) 717**] [**Telephone/Fax (1) 1154**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 1155**] Completed by:[**2197-5-22**]

[ "585.9", "584.9", "238.75", "428.23", "428.0", "285.1", "244.9", "427.31", "403.90", "515", "416.8", "532.40", "287.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "44.43", "96.07" ]

icd9pcs

[ [ [] ] ]

13299, 13365

6063, 8725

278, 325

13625, 14004

12631, 12715

14776, 15165

3281, 3285

12738, 13276

13386, 13386

8751, 8944

14028, 14292

3300, 3983

13487, 13604

14321, 14753

230, 240

353, 2517

13405, 13466

2539, 2834

2850, 3265

4,096

124,383

52684

Discharge summary

report

Admission Date: [**2170-7-20**] Discharge Date: [**2170-7-26**] Date of Birth: [**2091-9-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5368**] Chief Complaint: transfer from MICU for resolving sepsis Major Surgical or Invasive Procedure: Blood transfusion - you received one unit of blood. Central line placement in Right neck. History of Present Illness: 78 yo m w/ h/o HTN, DM2, PVD, rectal abscess s/p I & D on [**7-11**], and recent d/c for hemorrhagic stroke who presented on [**7-20**] with fever and altered ms. [**First Name (Titles) **] [**Last Name (Titles) **] patient was febrile to 102.4, hypotensive w/ systolics in the 60s, 82% on RA, initial lactate 2.1, and BP response to 3L. Patient was admitted to MICU where he received Abx treatment with vanco, levo, and flagyl and IVF. Now patient is normotensive, unremarkable exam, neg head ct, lactate trending down, cxr w/stable pleural effusions . Patient states that he has been feeling well. He denies headaches, chest pain, SOB, abd pain, N/V. Past Medical History: 1. HTN 2. Hyperlipidemia 3. DM2 4. GERD 5. PVD 6. degenerative joint disease 7. LLE atherectomy 8. Cholecystectomy 9. pancreatitis 10. COPD 11. h/o PE Social History: Was at rehab following recent stroke admission. quit smoking for 48 years in [**2154**]. used to drink alcohol but has not for several years. Family History: non-contributory Physical Exam: Vitals: t 97.5, p 58-104, bp 138/56-158/70, r 18-32, 96% RA. bg 131, 177, 168. Gen: Obese male, talking comfortably, in some discomfort due to positioning in bed. A&O x 2 HEENT: PERRL OP clr Neck: no JVD. no LAD. CVS: RRR, nl S1,S2. No m/r/g Lungs: improved air movement, distant breath sounds, not using accessory muscles, no crackles Abd: Obese, +bs. soft. nt. nd, rectal tube in place c greenish stool Ext: no le edema, chronic [**Year (4 digits) 1106**] changes noted over LE Neuro: confused, easily distracted Pertinent Results: 142 106 32 / 33 AGap=15 5.1 26 2.8 \ . CK: 79 MB: Notdone Trop-*T*: 0.17 Ca: 7.8 Mg: 2.2 P: 7.0 D . 91 9.9 \ 9.2 / 362 / 29.6 \ N:60.1 L:28.7 M:9.3 E:1.8 Bas:0.1 . tn 5a: 0.19 tn 10p: 0.17 pH 7.26 pCO2 60 pO2 90 HCO3 28 . CXR: Mild cardiomegaly with bibasilar atelectasis. . Head ct: No acute intracranial hemorrhage. Unchanged appearance of hypodensities in the left occipital lobe, genu of the right internal capsule, and right frontal lobe. Likely represent areas of subacute to chronic small vessel infarction. . EKG: nl axis, irregular, sinus w/ pac, low voltage, no st-tw changes Brief Hospital Course: 78 yo M with history of DM, COPD, PVD, rectal abscess, and recent d/c for hemorrhagic stroke (?), presented with altered MS, hypoglycemia, fever, and hypotension. The sepsis source was not determined; his perirectal abscess and history of C.diff was suspected. The sepsis resolved with IVF via central line and antibiotics (vanc/levo/flagyl 14 day course). The patient was on pressors for one day. He presented in acute renal failure, but this subsided with IVF (Cr of 1.1 on discharge). He received one unit of pRBCs and his Hct remained stable. A head CT was negative. An abdominal CT was done to rule out toxic megacolon, but it did show large bilateral pleural effusions. . Upon transfer to the floor on [**7-23**], he was hypertensive and afebrile. The patient had an episode of respiratory distress on [**7-23**], thought to be due to volume overload from fluid boluses in the ICU and pleural effusions. Repeat ABGs were done and this resolved with BiPAP 10/5 and IV lasix. He remained slightly tachypneic 22-26 on discharge, but was not using accessory muscles of respiration and denied shortness of breath. It was decided to postpone thoracentesis unless patient became febrile or in respiratory distress again. The patient is being discharged on lasix for 11 days for medical management of the effusions. He should have repeat chemistries to monitor his BUN and Cr. . Surgery was consulted to evaluate the patient's perirectal abscess. A rectal tube was used to avoid contamination of the wound. Wound care was consulted and recommended wet to dry dressing changes [**Hospital1 **]. His diarrhea had decreased while on the floor, and his rectal tube was removed on discharge. The patient was also negative for C.Diff times three so contact precautions were removed. . The patient had a recent history of CVA. He ruled out for a new stroke and there was no indication for LP. He has some delusional/paranoid behavior at night and was given 0.5 mg haldol prn agitation. His mental status is now likely at baseline. The patient was continued on asa and aggrenox. . The patient had new onset of atrial fibrillation this admission. Anticoagulation was discussed with his PCP. [**Name10 (NameIs) **] now we will rely on aggrenox and asa for prophylaxis; the patient has a significant risks (falls- poor eyesight, age, ?of hemorrhagic stroke) for starting anticoagulation. This will be followed up by Dr. [**Last Name (STitle) **]. His blood pressure and rate was controlled with metoprolol, isosorbide, and captopril . The patient's blood sugars were controlled on a 12 unit fixed dose of regular insulin and sliding scale. . The patient was a full code. Medications on Admission: aggrenox [**Hospital1 **] perocet prn albuterol mdi atrovent mdi asa 325 atenolol 25mg qday lasix 40mg qday prevacid 30mg qday zestril 10mg qday mvi lipitor 20mg qdya nph 10U qam nph 6U qpm vancomycin 250mg po q6h Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 6. Vancomycin HCl 1000 mg IV Q 12H Duration: 7 Days 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 11 days: Take two tablets for 2 days. Then take one tablet per day for 9 days. 8. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap, Multiphasic Release 12 HR PO bid (). 9. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 10. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. 11. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as directed Subcutaneous twice a day: 7 units in am and 4 units at night. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: sepsis perirectal abscess s/p I&D HTN hyperlipidemia DM 2 s/p CVA GERD Periph Vasc Disease COPD Discharge Condition: stable Discharge Instructions: Please return if fever >101.5, shortness of breath, or low blood pressure. Please take all medications as directed. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**12-17**] weeks. Please have your blood drawn to check your kidney function within one week (BUN and Cr).

[ "593.9", "780.09", "443.9", "995.92", "285.9", "038.9", "428.0", "250.80", "458.9", "427.31", "V12.59", "496", "715.90", "V12.51", "566", "401.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93", "96.09", "99.04" ]

icd9pcs

[ [ [] ] ]

7412, 7491

2685, 5369

355, 446

7632, 7640

2048, 2350

7805, 7970

1479, 1497

5633, 7389

7512, 7611

5395, 5610

7664, 7782

1512, 2029

276, 317

474, 1129

2359, 2662

1151, 1303

1319, 1463

58,781

186,671

45860

Discharge summary

report

Admission Date: [**2167-1-9**] Discharge Date: [**2167-1-17**] Date of Birth: [**2101-5-5**] Sex: F Service: MEDICINE Allergies: Codeine / Phenergan Attending:[**First Name3 (LF) 5037**] Chief Complaint: Dyspnea on exertion, hematemesis Major Surgical or Invasive Procedure: None History of Present Illness: 65 yo F with a history of IDDM complicated by end-stage renal disease s/p cadaveric renal transplant in [**2160**], HTN, PVD, diastolic heart failure, and atrial fibrillation who presents with SOB, DOE, fatigue, hemetemesis and hypotension. . She had been feeling progressively worse than her baseline for the past few days prior to admission. 4days PTA, she reports normal resp status. Then, 3days PTA, she saw her cardiologist, was very fatigued and felt DOE. Over next few days her DOE got worse. On morning of admission, she awoke with mid back pain, SOB, and nausea. She had emesis at 5 a.m. X 3, with 3rd one with 1 tsp bright red [**Year (4 digits) **] and some epigastric discomfort. She was coughing at the time, but does feel that the [**Year (4 digits) **] was from emesis not from sputum. She went to OSH, she was found to have stable HCT, she received FFP (? 4units), Vit K 5 mg SQ, and NS X 1. She was transferred to [**Hospital1 18**]. In ED, 98.5, 100/40, 58, 100%RA. Her BP dipped to 81/21. She received 2U FFP, 10 IV Vit K, and BP returned to 100's. CT chest and CXR revealed large new R effusion vs RLL collapse. BP in 80-90's, most likely not due to GIB. No plans for scope until other issues resolve. Transferred to MICU at [**Hospital1 18**] for possible UGIB. In MICU, guaiac negative and had stable Hct. Felt that [**Hospital1 **] was more likely due to hemoptysis rather than hematemesis. Had hypoxia, new oxygen requirement. Treated with Levofloxacin for possible CAP. On morning of transfer to MICU, patient had posttussive hemoptysis, with O2 requirement decreasing from 5L to 3L. Given RLL collapse/R effusion, there was concern for endobronchial mass not seen on CT, causing hypoxia and hemoptysis. Pt was in stable condition however, and decision was made for transfer to floor for further management. On the floor, she reports feeling fatigued and SOB. She denies LHD, fever, abd pain, further N/V. She denies any BRBPR, melena, hemoptysis. She does report feeling more gaseous with increased need for burping in last few days, but she denies any CP, palpitations, chest pressure. + orthopnea and LE swelling worsening for past few days as well. Only recent changes in meds include stopping amiodarone. + lower back pain which is new. Past Medical History: 1. s/p cadaveric renal transplant in [**2160**], baseline Cr 1.7 2. Type 2 diabetes mellitus c/b neuropathy, retinopathy, nephropathy 3. Diastolic Congestive heart failure 4. Atrial fibrillation - diagnosed in [**2166-6-27**]. S/p cardioversions x2 unsuccessful. On Warfarin. 5. Hypertension 6. Hyperlipidemia 7. Peripheral vascular disease with no claudication 8. [**Country **] stenosis 9. Cholelithiasis 10. Hypothyroidism on replacement 11. Chronic anemia (baseline thought to be approx 27) 12. GERD 13. s/p appy 14. s/p eye surgery [**72**]. H/p PNA in [**7-2**] Social History: Lives with husband, [**Name (NI) **] parent has daughter. Used to be secretary. Remote tobacco (5 pack years) but quit age 20. Occasional EtOH. Denies illicit drug use Family History: Gestational diabetes (both daughters), no htn, no heart disease. Father had [**Name2 (NI) 40342**] and skin cancer. Aunt had lung cancer. Physical Exam: IN MICU: T 36.1 HR 65 BP 121/45 RR 21 SaO2 94% on 4L NC General Appearance: Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Crackles : at bases, Diminished: at R base) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended, No(t) Tender: Extremities: Right: Trace, Left: Trace Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed ON TRANSFER TO FLOOR: Vitals: T:97.1 BP:156/60 P:65 R:20 O2:96% 3L General: Alert, orientedx3, no acute distress HEENT: Sclera anicteric, dry mouth, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi, could not appreciate dullness to percussion. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, bowel sounds present Ext: 2+ pulses, no edema Pertinent Results: [**2167-1-9**] 10:17PM LACTATE-1.2 [**2167-1-9**] 08:36PM GLUCOSE-58* UREA N-97* CREAT-3.2* SODIUM-143 POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-19* ANION GAP-21* [**2167-1-9**] 08:36PM CK(CPK)-408* [**2167-1-9**] 08:36PM CK-MB-10 MB INDX-2.5 cTropnT-0.77* proBNP-[**Numeric Identifier 85358**]* [**2167-1-9**] 08:36PM CALCIUM-9.4 PHOSPHATE-4.3 MAGNESIUM-2.5 [**2167-1-9**] 08:36PM WBC-13.1* RBC-3.19* HGB-9.4* HCT-28.1* MCV-88 MCH-29.6 MCHC-33.5 RDW-15.0 [**2167-1-9**] 08:36PM PLT COUNT-124* [**2167-1-9**] 08:36PM PT-20.7* PTT-40.8* INR(PT)-1.9* [**2167-1-9**] 05:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2167-1-9**] 05:00PM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2167-1-9**] 05:00PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2167-1-9**] 02:06PM HGB-10.5* calcHCT-32 [**2167-1-9**] 02:00PM GLUCOSE-54* UREA N-95* CREAT-3.2* SODIUM-143 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-19* ANION GAP-18 [**2167-1-9**] 02:00PM ALT(SGPT)-17 AST(SGOT)-26 CK(CPK)-247* ALK PHOS-76 TOT BILI-0.5 [**2167-1-9**] 02:00PM LIPASE-13 [**2167-1-9**] 02:00PM cTropnT-0.53* [**2167-1-9**] 02:00PM CK-MB-9 [**2167-1-9**] 02:00PM ALBUMIN-3.6 CALCIUM-9.1 PHOSPHATE-3.3 MAGNESIUM-2.6 [**2167-1-9**] 02:00PM WBC-10.3# RBC-3.48* HGB-10.0* HCT-30.7* MCV-88 MCH-28.9 MCHC-32.7 RDW-15.0 [**2167-1-9**] 02:00PM NEUTS-90.0* LYMPHS-3.0* MONOS-6.2 EOS-0.5 BASOS-0.2 [**2167-1-9**] 02:00PM PLT COUNT-132* [**2167-1-9**] 02:00PM PT-43.3* PTT-45.9* INR(PT)-4.8* [**1-9**] CXR FINDINGS: There is interval development of a large right-sided pleural effusion. Underlying consolidation cannot be excluded. Left lung remains clear. Heart size cannot be accurately assessed. There is no pneumothorax. Atherosclerotic calcifications along the aortic knob are again noted. There is no definite evidence of free air in the upper abdomen. [**1-9**] CT CHEST AND ABDOMEN IMPRESSION: 1. Limited non-contrast evaluation, but no evidence of catastrophic injury to the aorta, or esophagus. 2. Right lower lobe collapse appears secondary to mucous plug in the right lower lobe segmental bronchus. Atelectasis at both lung bases. 3. Small right pleural effusion. 4. Cholelithiasis without evidence of cholecystitis. 5. Atherosclerosis, and marked three-vessel coronary artery calcification. [**1-10**] ECHO The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with mid to distal septal hypokinesis. The remaining segmetns are hyperdynamic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. with borderline normal free wall function. 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 aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2166-12-29**], regional LV systolic dysfunction is now seen. Brief Hospital Course: This is a 65 y/o F hx end-stage renal disease s/p cadaveric renal transplant in [**2160**], HTN, PVD, diastolic heart failure, and atrial fibrillation p/w new oxygen requirement and SOB, edema and hemoptysis. Admitted to MICU initially for evaluation of possible UGIB, then transferred to floor for further management. # Hemetemesis/hemoptysis: Based upon stable HCT and history of vomiting, dry heaves and small amount of [**Last Name (LF) **], [**First Name3 (LF) **] [**Doctor Last Name **] tear was the leading diagnosis. GI did not feel that she warranted an EGD if her HCT remained stable and agreed that the most likely etiology was a MW tear. Pt was guaiac negative. Hemoptysis was likely secondary to heavy coughing in the setting of high INR on admission and RSV bronchitis. Pt was treated with IV PPI, transitioned to PO PPI and did not require any transfusions. Hct remained stable. # Hypoxia/RLL collapse/R effusion: Pt was admitted with a new oxygen requirement (5L NC) and new R lower lung collapse with elevated right hemidiaphragm. The pt was initially treated for CAP with vancomycin and levaquin. On [**1-10**] AM pt coughed-up a large brown mucus plug and instantly felt close to her baseline respiratory status. O2 requirements were decreased to 3L NC although repeat CXR only showed minimal improvement. Sputum culture initially showed 1+ gram positive cocci in pairs. Pt was started on 10 day course of PO Levofloxacin, to be completed after discharge. The pt received a bronchoscopy to evaluate hemoptysis which showed diffuse inflammation consistent with RSV bronchitis (positive viral culture) with no obstruction of bronchi and no masses. Hypoxia was also in part to pulmonary edema likely secondary to diastolic chronic heart failure. Treated with IV Lasix, and supportively, weaned O2, encouraged physical therapy and incentive spirometry. Breathing comfortably at time of discharge, with O2 sat>95% on 1.5L. Discharged with home O2 to continue weaning with VNA. # Acute on chronic renal failure - appeared to be pre-renal in nature (FEUrea 24.5%), with Cr 3.5 on admission. Returned to baseline (2.0) with IVF, with Cr 1.7 on discharge. # Gout - developed gout flare on R index finger DIP and R ankle joint. Serum uric acid 10.1 with xrays suggestive of gout. Given splint, and started Prednisone 40mg QD x 3 days (to be tapered after discharge) per Rheumatology recs, will f/u with nephrologist for uric acid monitoring and starting Allopurinol in [**12-30**] weeks. # Elevated troponin: Pt with increased troponin which peaked at 0.74 but remained with flat MB. ECHO did not show any evidence of acute wall motion abnormalities related to ACS and Cardiology felt that the troponin leak was most likely related to demand ischemia. Pt remained on ASA, beta-blocker and a statin. . # Afib: Pt takes coumadin at home and presented in sinus rhythym. HR adequately controlled throughout admission. Coumadin was held on initial presentation [**12-29**] starting antibiotics and recent bleeding, restarted after she had no more episodes of hemoptysis and UGIB ruled out. Will follow up in [**Hospital 263**] clinic on monday for INR check. . # HTN: Has history of labile HTN that was well-controlled in the unit, continued on imdur and hydralazine. On the floor, BP was adequately controlled on Clonidine alone. Discharged without Imdur and hydralazine, to be added back on as an outpatient as necessary. . # s/p Kidney transplant: Pt was continued on cellcept, prednisone and tacrolimus and followed renal transplant team recommendations, monitoring Prograf levels. ARF resolved and to continue medications after discharge as prior to admission. . # Diabetes, insulin dependent: Well controlled on home dose of levemir and SSI. . # Hypothyroid: Continued levothyroxine. # Anemia - was found to be Fe deficient on labs. Fe supplements held in light of constipation. Recommended supplements be started as an outpatient by PCP as well as colonoscopy. # Petechial rash - continued to have petechial rash bilaterally on feet. Held Heparin initially, though had low probability for HIT. Evaluated by Dermatology who felt it was secondary to increased edema and hydrostatic pressure on capillaries. Recommended leg elevation and compression stockings. Vasculitis w/u including ANCA, [**Doctor First Name **], anti-gbm were all negative. #FEN: diabetic/heart healthy diet, repleted electrolytes as necessary. #PPX: PPI, pneumoboots, PT, bowel regiment, anticoagulated at time of discharge. # Dispo: d/c to home with VNA and PT, with pulmonology, primary care and nephrology/transplant team follow-up appointments. . Medications on Admission: Simvastatin 80 mg once a day. Pantoprazole 40 mg daily Prednisone 5 mg daily Mycophenolate Mofetil 500 mg [**Hospital1 **] Aspirin EC 81 mg once a day. Levothyroxine 88 mcg daily Hydralazine 25 mg PO Q6H Ezetimibe 10 mg daily Lasix 40 mg once a day. Docusate Sodium Senna Warfarin 2 mg daily Levemir 22-28 units QHS Novolog SS Flonase Tacrolimus 1 mg [**Hospital1 **] Clonidine 0.2 mg [**Hospital1 **] Imdur 120 mg daily Discharge Medications: 1. home oxygen Please provide home fill system with conserving device. Patient requires 1 liter at rest and up to 3 liters with activity. Diagnosis RSV bronchitits, fluid overload. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): RESUME ON [**2167-1-22**]. 5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Levemir Flexpen 100 unit/mL Insulin Pen Sig: One (1) 22 units Subcutaneous HS (at bedtime). 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*2* 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 12. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 13. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO once a day. 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 19. Albuterol 90 mcg/Actuation Aerosol Sig: [**11-28**] Inhalation twice a day. 20. Novolog Flexpen 100 unit/mL Insulin Pen Sig: One (1) Subcutaneous SS. 21. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO at bedtime. 22. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 23. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 4 days: [**1-18**], 23- take 3 tablets 2/24,25- take 2 tablets then resume your usual 5 mg dose. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: RSV bronchitis Diastolic chronic heart failure Acute on chronic renal failure Gout Diabetes Discharge Condition: Improved Discharge Instructions: You were admitted for evaluation and treatment of shortness of breath, need for oxygen, and [**Hospital3 **] in your sputum, as well as [**Hospital3 **] after vomiting. Part of your lung was collapsed on xray and you had fluid in your lungs, likely due to your heart failure and renal failure. You were also dehydrated causing acute kidney failure with a creatinine level higher than your baseline. You had a bronchoscopy to determine why you had [**Hospital3 **] in your sputum. The bronchoscopy showed only inflammation of your airways consistent with a viral (RSV) bronchitis. You were treated supportively for the viral infection. You were also given antibiotics to treat an underlying bacterial lung infection. After your kidney failure resolved, your Lasix was restarted to get some water out of your lungs, which also helped to improve your breathing. To keep improving your breathing, you should continue to take your Lasix daily, as well as try to be out of bed, walking as much as possible with assistance, physical therapy, and using your incentive spirometer to open up the collapsed part of your lung. While you were in the hospital, you had a flare of gout on your finger and ankle, likely due to the fact that we were taking a lot of fluid out of your body with Lasix, and because some of the medications you have to take for your renal failure put you at risk for it. After discharge, you can take your kidney medications the same as you did prior to admission to the hospital. You are taking a higher dose of Prednisone than usual to treat the gout flare. You should measure your [**Hospital3 **] glucose 4-5 times a day and treat with your Novolog as needed and continue taking the Levemir. The Prednisone should slowly be tapered down. Follow the directions you have been given on your prescriptions. You can resume taking 5mg once a day starting on Thursday, [**2167-1-22**]. You should follow-up with your nephrologist Dr [**Last Name (STitle) **] for the gout in [**12-30**] weeks after discharge and she will start a medication to help prevent further gout attacks. Your hematocrit remained stable for the rest of your hospital stay and you did not have any more episodes of bleeding. The initial bleed that you had after vomiting was most likely caused by a small tear in your esophagus caused by the force of vomiting. Your hematocrit, although stable, was low because of the recent bleeding. In addition, you had low iron levels. At this time, giving you iron would worsen your constipation. You can discuss with your primary care physician whether to start taking iron supplements after you are discharged. It is very important that you get a colonoscopy done as soon as possible to make sure you are not losing any more [**Date Range **] in your GI tract. You are being discharged with only Clonidine for your [**Date Range **] pressure as it is well controlled without the hydralazine and Imdur. You should follow-up with your primary care physician to add them back on if necessary. You are being discharged with home physical therapy services. It is very important that you remain as active as possible at home. Should you experience shortness of breath, chest pain, decreased urine output, or more episodes of bleeding (in your sputum, in your stools, or with vomiting), call your primary care physician or call 911 for emergencies. Followup Instructions: You should have your INR and [**Date Range **] pressure checked on Monday [**2167-1-19**] at 9.45AM at the [**Hospital 197**] clinic in [**Hospital3 **]. You have an appointment with Dr [**Last Name (STitle) **] (Nephrology) on [**2167-2-16**] at 3.20PM. You have a follow-up appointment with your pulmonologist (Dr. [**Last Name (STitle) **]) on [**2-24**], at 11AM. You will have a repeat chest cat scan prior to this appointment on [**2167-2-24**] at 8.15AM on the [**Hospital Ward Name 517**], [**Location (un) 470**]. Please fast 3 hours before this scan. [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**] Completed by:[**2167-1-18**]

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Discharge summary

report

Admission Date: [**2157-8-2**] Discharge Date: [**2157-8-3**] Date of Birth: [**2074-12-4**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: none History of Present Illness: 82 year-old woman w/ pmh significant for HTN, cutaneous lupus, recent diagnosis of metastatic colon cancer to peritoneal and liver who was admitted last week for bacteremia wiht GP rods (clostridium septicum) and has been on vancomycin and Flagyl IV treatment at home. The pt was originally admitted to [**Hospital **] Hospital in [**State 1727**] [**2157-7-14**] (was there on vacation) with back pain and found on CT to have bowel wall thickening and numerous intraperitoneal and hepatic lesions consistent with metastatic disease. She was then transferred to our hospital and had colonoscopy with biopsy of the cecal lesion that showed adenocarcinoma. She had elevated WBC at presentation on [**7-21**] at 19k, she had blood culture from the [**7-21**] and from [**7-22**] that grew clostritium. This was thought to be related to colon CA, She was started on Flagyl and vancomycin IV for a total of 14 days on [**7-23**]. Pt was discharge home with a PICC and on IV antibiotics. As per patient's daughters she developed [**Last Name (un) 8527**] a few days after her last discharge and she had very poor PO intake. She also states that Flagyl made her very nauseous. In addition she has been taking oxycodone for pain 10mg around twice daily and has increase lethargy and weakness. She denies having any fever, chills, dysuria, hematuria, diarrhea, abd pain. She has daily BM with no blood or melena. She continues to have low back pain which is unchanged from prior. She came today to see Dr. [**Last Name (STitle) **] and was found to have electrolyte abnormalities with increase in her K, creatine to 1.4 from baseline of (0.4-0.5), and elevated transaminitis with increase t.bili to 2.6. She was then instructed to come to the ED for further evaluation. . In the ED her vitals were 97.2, 88/57, 86, 18, 99% on RA. Pt appeared dry on exam and she was given 1L of IV fluids and Flagyl. Her SBP responded to IV fluids and improved to 110s Her vanco level was 34 and it was held. She was found to have new small pleural effusion on her left lung base on cxray and was started on levoquin. She denies having cough, SOB, CP or other respiratory symptoms. She was also given oxycodone 2.5mg and Tylenol 1gm for pain. . On arrival to the floor, pt appears comfortable. She was afebrile and her vitals were stable with SBP 110s-120s/50s-60s, HR in 60s. She denies having any complains at this time. Her foley is to BSD with dark yellow/brown urine. . Of note during her last admission on [**8-26**] she was found to have PSVT, for which she was treaded with Adenosine 6mg, and tachycardia resolved. Within 24 hours she had two more episodes of SVTs, again requiring adenosine, so cardiology was consulted who recommended increasing her dose of metoprolol from 50 mg a day to 100 mg a day. Her heart rate has been controlled on this medication. . Review of systems is negative also for fevers, chills, nightsweats, headache, neck pain, chest pain, SOB, palpitations, abd pain, diarrhea, constipation, or changes in her bowel or bladder pattern. She denies joint pain, myalgias, confusion, or depression. Past Medical History: Past Medical History: - Metastatic colon CA to liver and malignancy, - Hypertension - Cutaneous lupus, not active (per daughter) - [**Name (NI) 64867**] setting of hospitalization Social History: Has one glass of wine several nights per week. Smoked one pack of cigarettes per week until 20 years ago. Lives in [**Hospital1 **] with her daughter. [**Name (NI) **] four daughters and a son, husband died 13 years ago. Overall very active up to recent diagnosis Family History: Mother with breast cancer. Sister with cancer but unsure of type, possibly pancreatic. Physical Exam: ADMISSION: VS: 95.6, 68, 130/74, 24, 100% on RA. GEN: NAD HEENT: EOMI, MMdry with white patches consistant with yeast, mild scleral icterus NECK: Supple, no JVP noted CHEST: CTAB, except for bil diminished BS at bases CV: RRR, normal S1 and S2, no murmurs ABD: Soft, nontender, nondistended, bowel sounds present SKIN: Facial splotchy red spots (cutaneous lupus) EXT: bil LE +1 pitting edema up to ankles NEURO: Alert, oriented x3, CN 2-12 intact, sensory intact throughout, strength 5/5 BUE/BLE, fluent speech, normal coordination PSYCH: Calm, appropriate Pertinent Results: Imaging: [**8-2**] CXR: New small bilateral pleural effusions, with left retrocardiac opacities, may reflect atelectasis. An early superimposed consolidation is not excluded. [**8-3**] Abd/Pelvis U/S 1. Patent portal venous system. 2. Redemonstration of masses in the liver and porta hepatis, which were characterized to better effect on the comparison CT. 3. No hydronephrosis or nephrolithiasis. 4. Non-specific isoechoic projection into the ascites in the pelvis. This raises the possibility of carcinomatosis in this patient with disseminated neoplastic disease. Blood Counts: [**2157-8-2**] 11:45AM BLOOD WBC-19.8* RBC-4.38 Hgb-13.0 Hct-40.2 MCV-92 MCH-29.8 MCHC-32.4 RDW-14.5 Plt Ct-450* [**2157-8-3**] 05:03AM BLOOD WBC-22.4* RBC-3.57* Hgb-10.7* Hct-33.1* MCV-93 MCH-29.9 MCHC-32.2 RDW-15.4 Plt Ct-336 Coags: [**2157-8-2**] 11:45AM BLOOD PT-18.1* PTT-37.1* INR(PT)-1.6* [**2157-8-2**] 10:48PM BLOOD PT-23.1* PTT-41.6* INR(PT)-2.2* Chemistry:[**2157-8-2**] 11:45AM BLOOD UreaN-40* Creat-1.4* Na-132* K-5.7* Cl-100 HCO3-18* AnGap-20 [**2157-8-3**] 05:03AM BLOOD Glucose-120* UreaN-50* Creat-1.8* Na-133 K-5.5* Cl-104 HCO3-18* AnGap-17 [**2157-8-3**] 09:30AM BLOOD UricAcd-8.1* [**2157-8-3**] 09:30AM BLOOD Hapto-<5* [**2157-8-2**] 11:45AM BLOOD TSH-3.0 [**2157-8-2**] 11:45AM BLOOD CEA-7.3* [**2157-8-2**] 02:56PM BLOOD Glucose-146* Lactate-5.6* K-GREATER TH [**2157-8-2**] 03:41PM BLOOD Lactate-4.7* K-5.2 [**2157-8-2**] 07:40PM BLOOD Lactate-3.4* [**2157-8-3**] 01:51AM BLOOD Lactate-2.7* K-5.3 . LFTs: [**2157-8-2**] 11:45AM BLOOD ALT-70* AST-260* LD(LDH)-738* AlkPhos-1059* TotBili-2.6* DirBili-2.0* IndBili-0.6 [**2157-8-2**] 02:50PM BLOOD ALT-155* AST-732* AlkPhos-946* TotBili-2.4* [**2157-8-2**] 10:48PM BLOOD ALT-490* AST-3004* AlkPhos-978* TotBili-2.7* [**2157-8-3**] 05:03AM BLOOD ALT-606* AST-4030* LD(LDH)-[**Numeric Identifier 34995**]* AlkPhos-1165* TotBili-4.7* Blood Gas: [**2157-8-3**] 01:51AM BLOOD Type-ART Temp-35.6 pO2-71* pCO2-25* pH-7.48* calTCO2-19* Base XS--2 Intubat-NOT INTUBA Micro: [**8-2**] Blood Cx GPCs in pairs and clusters Brief Hospital Course: 82 year-old woman w/ pmh significant for HTN, cutaneous lupus, recent diagnosis of metastatic colon cancer to peritoneal and liver who was admitted 1 week prior for bacteremia with GP rods (clostridium septicum) and returned for abnormal labs found during outpatient visit. On the day of admission, Mrs. [**Known lastname 23306**] came to see Dr. [**Last Name (STitle) **] and was found to have electrolyte abnormalities with increase in her K to 5.7, creatine to 1.4 from baseline of (0.4-0.5), and elevated transaminitis with increase t.bili to 2.6. Given lab abnormalities, she was then instructed to come in to the ED for further evaluation. She also had an elevated WBC at 19.8 with left shift. During her initial presentation in [**State 1727**] in [**7-21**] her WBC was 19k, she had blood culture from the [**7-21**] and from [**7-22**] that grew clostritium. This was thought to be related to colon CA, she was started on Flagyl and vancomycin IV for a total of 14 days on [**7-23**]. On her admission she was still on Flagyl and her vanco level was in the 30s, so this was not given in the ED. She was afebrile and had only one episode of hypotension at 88/57 for which she responded appropriately to 1 L of IV fluids. Her lactate was initially elevated at 5.6 and was trending down with IV fluids. She was found to have new small pleural effusion on her left lung base on cxray and was started on levoquin. She denies having cough, SOB, CP or other respiratory symptoms. She was admitted to the ICU for close monitoring and concern for sepsis. She remained afebrile and her vitals remained stable with SBP in 110s-120s/50s-60s, HR in 60s. Overnight, her LFTs continued to trend up (peaking ALT at 606, AST at 4030, LD [**Numeric Identifier 34995**], AlkPhos 1165 and TotBili-4.7). She also had increase in INR from 1.6->2.2. There was a concern for acute liver failure and/or portal obstruction. Pt had known metastatic disease to the liver. A liver US w/ doppler was done in the middle of the night which showed patent portal venous system, redemonstration of masses in the liver and porta hepatis, no hydronephrosis or nephrolithiasis, non-specific isoechoic projection into the ascites in the pelvis. This raises the possibility of carcinomatosis in this patient with disseminated neoplastic disease. Pt was afebrile and had no active signs of infection. She did not appear septic, she had one BP that was low 88/50s and she responded well to fluids. Her lactate was elevated and this was thought to possibly be due to hypovolemia and dehydration, since it had been trending down with IV fluids. She also had been covered with vanco and flagyl for the last 9 days. Last + blood culture was on [**8-26**] prior to starting antibiotics. However given that pt had metastatic colon cancer to liver and peritoneum pt could have GN infection. She was continued on Flagyl and then her Abx were broadened to Zosyn/Clinda. Even before receiving these antibiotics, on the morning after admission, she suddenly became bradycardic and PEA arrested. She was coded by the ICU team for ~15 minutes and then per patient's family's request, resuscitation efforts were stopped. The patient expired with daughter at the bedside. Family requested post-mortem exam. Medications on Admission: not recorded prior to patient's death Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.0", "995.91", "276.51", "280.9", "153.8", "584.9", "286.6", "038.3", "276.2", "455.0", "276.7", "197.7", "401.9", "198.7", "710.0", "562.10", "459.89", "427.5" ]

icd9cm

[ [ [] ] ]

[ "99.60", "96.04" ]

icd9pcs

[ [ [] ] ]

10137, 10146

6742, 10009

323, 329

10205, 10222

4648, 6719

10286, 10440

3968, 4056

10097, 10114

10167, 10184

10035, 10074

10246, 10263

4071, 4629

270, 285

357, 3462

3506, 3667

3683, 3952

67,636

106,433

35380

Discharge summary

report

Admission Date: [**2193-3-28**] Discharge Date: [**2193-4-4**] Service: NEUROLOGY Allergies: Darvon Attending:[**First Name3 (LF) 5018**] Chief Complaint: right putaminal hemorrhage Major Surgical or Invasive Procedure: MRI History of Present Illness: Mr. [**Known lastname **] is an 88year old right handed male with h/o hypertension, hyperlipidemia, CAD s/p CABG now presenting with sudden onset headache, left arm weakness found to have a right putaminal hemorrhage. Pt was well until this afternoon around 2pm when at lunch with his son developed the above symptoms. Taken to [**Hospital1 **] where his exam was notable for "right sided weakness." Patient was apparently fully alert and conversant. He vomited in the CT scan at the OSH and was intubated. Head CT revealed right putaminal hemorrhage. Following intubation his blood pressures dropped requiring two pressors. He was transferred to [**Hospital1 18**] via [**Location (un) **] for further care. Pt was unable to offer a ROS. According to his son he was seen at [**Hospital1 **] ~2 weeks ago for nephrolithiasis. He is somewhat sedentary at baseline, but independent of all ADL's. Past Medical History: CAD- s/p CABG in [**2174**] Pulmonary HTN systolic HF- EF 35% Hypertension hyperlipidemia nephrolithiasis Social History: pt is a car enthusiast, on the board of the [**First Name8 (NamePattern2) 4304**] [**Location (un) 4223**] Auto museum in [**Location (un) **]. never smoker, no ETOH, no illicits. Family History: NC Physical Exam: Vitals: T 98, BP 125/54 (on levophed), HR 59, R 14, 100% CMV Gen- ill appearing, intubated and sedation (recently rec'd fentanyl from [**Location (un) **]) HEENT- NCAT, anicteric sclera, MMM Neck- no carotid bruits CV- RRR Pulm- CTA B Abd- soft, nt, nd, BS+ Extrem- no CCE Neurologic exam: MS- opens eyes to voice, does not follow commands. localizes sternal rub with right hand. CN- PERRL 4-->3mm, blinks to visual threat bilat, intact corneals bilat, intact gag. Motor/sensory- moving right arm and leg spontaneously, purposefully withdraws right arm, leg and left leg to noxious. no withdrawal or left arm to noxoious stim. Reflexes: left patellar 3+, [**Hospital1 **], brachiorad 3+ on left, right with 2+ patell, [**Hospital1 **], tri. absent ankles. Plantar response was upgoing bilaterally. Pertinent Results: [**2193-4-4**] 05:48AM BLOOD WBC-10.9 RBC-4.22* Hgb-13.7* Hct-38.4* MCV-91 MCH-32.3* MCHC-35.6* RDW-13.4 Plt Ct-244 [**2193-4-3**] 06:28AM BLOOD WBC-8.9 RBC-4.53* Hgb-13.9* Hct-41.1 MCV-91 MCH-30.7 MCHC-33.8 RDW-13.9 Plt Ct-230 [**2193-4-2**] 05:55AM BLOOD WBC-8.0 RBC-4.41* Hgb-13.9* Hct-39.7* MCV-90 MCH-31.6 MCHC-35.1* RDW-13.8 Plt Ct-212 [**2193-3-30**] 12:53AM BLOOD WBC-12.6* RBC-4.30* Hgb-13.7* Hct-38.9* MCV-91 MCH-31.9 MCHC-35.2* RDW-14.1 Plt Ct-183 [**2193-3-29**] 03:55AM BLOOD WBC-11.0 RBC-4.16* Hgb-13.4* Hct-38.8* MCV-93 MCH-32.3* MCHC-34.6 RDW-13.5 Plt Ct-177 [**2193-3-28**] 06:15PM BLOOD WBC-11.8* RBC-4.68 Hgb-14.7 Hct-43.4 MCV-93 MCH-31.4 MCHC-33.9 RDW-13.7 Plt Ct-228 [**2193-4-1**] 06:20AM BLOOD PT-14.1* PTT-24.2 INR(PT)-1.2* [**2193-3-30**] 12:53AM BLOOD PT-14.1* PTT-25.3 INR(PT)-1.2* [**2193-4-4**] 05:48AM BLOOD Glucose-149* UreaN-17 Creat-0.9 Na-147* K-3.2* Cl-115* HCO3-25 AnGap-10 [**2193-4-3**] 06:28AM BLOOD Glucose-122* UreaN-16 Creat-0.9 Na-148* K-3.4 Cl-113* HCO3-23 AnGap-15 [**2193-4-2**] 05:55AM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-143 K-3.4 Cl-110* HCO3-23 AnGap-13 [**2193-4-1**] 06:20AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-144 K-3.8 Cl-107 HCO3-25 AnGap-16 [**2193-3-31**] 08:26AM BLOOD Glucose-147* UreaN-19 Creat-0.9 Na-141 K-3.7 Cl-108 HCO3-25 AnGap-12 [**2193-3-30**] 12:53AM BLOOD Glucose-98 UreaN-16 Creat-1.1 Na-142 K-3.7 Cl-109* HCO3-25 AnGap-12 [**2193-3-29**] 03:55AM BLOOD Glucose-112* UreaN-21* Creat-1.1 Na-140 K-4.4 Cl-109* HCO3-22 AnGap-13 [**2193-4-4**] 05:48AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.1 [**2193-3-29**] 03:55AM BLOOD %HbA1c-6.0* [**2193-3-29**] 03:55AM BLOOD Triglyc-48 HDL-44 CHOL/HD-2.9 LDLcalc-75 CT Head [**3-29**]:Right basal ganglia hemorrhage with mild surrounding edema. No herniation or hydrocephalus. CT ABD: 1. Three nonobstructing left renal calculi ranging in size between 4 mm and 2 cm. Multiple bladder diverticula. 2. Cholelithiasis. 3. Findings consistent with prior myocardial infarction at the aex of the left ventricle. 4. Small hiatal hernia. CT HEAD [**4-4**]: Unchanged size and appearance of right basal ganglia intraparenchymal hemorrhage. No new blood or intraventricular extension. No subfalcine herniation. Brief Hospital Course: Pt was admitted to the ICU initially for close monitoring. His hemorrahge is thought to be due to hypertension. He had serial imaging with no change in size of hemorrage. He was monitored with frequnet neuro-checks and cardiac telemtery. He was stable and sent to the neurology floor. He developed hematuria and an CT-abd revieled non-occlusive renal stones. He failed multiple speech evaluations and a PEG was placed in IR without difficulty. PT/OT were consulted. He was noted to have an UA suspicious for UTI despite 3 days of IV cipro and was thus changed to IV ceftriazone for 5 day course. Repeat urine cx is pending at discharge. He will follow-up with Dr. [**Last Name (STitle) **] as an outpt. Medications on Admission: Proscar daily Folic acid 1mg daily Folguard ? strength Atorvastatin 20mg daily Metoprolol 75mg QAM, 50mg qnoon, 50mg QHS Persantine 150mg daily Imdur 60mg daily QHS Lisinopril 10m gdaily Aspirin 325mg daily Amlodipine 5mg daily Discharge Medications: 1. Letter To whom it may concern, [**Known firstname 2174**] [**Known lastname **] is under my medical care at [**Hospital1 827**]. Due to his current condition, he is unable to sign his name or write, or otherwise communicate. Sincerely, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**], MD 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Docusate Sodium Oral 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 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. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. 11. CeftriaXONE 1 g IV Q24H Duration: 5 Days Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Cerebral Hemorrhage R Putamen Discharge Condition: Left upper extremity paresis, left neglect Discharge Instructions: You were admitted because of a bleed in your brain. It was likely due to high blood pressure. If you have any new weakness or numbness you should return to the ER. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2193-6-5**] 1:30 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "596.3", "416.8", "401.9", "574.20", "428.0", "431", "V45.81", "414.00", "592.0", "787.29", "428.20" ]

icd9cm

[ [ [] ] ]

[ "96.6", "43.11", "96.71" ]

icd9pcs

[ [ [] ] ]

6663, 6808

4597, 5311

241, 247

6882, 6927

2360, 4574

7140, 7420

1516, 1521

5591, 6640

6829, 6861

5337, 5568

6951, 7117

1536, 1810

175, 203

275, 1172

1827, 2341

1194, 1302

1318, 1500

21,093

161,483

2798

Discharge summary

report

Admission Date: [**2122-9-28**] Discharge Date: [**2122-10-5**] Date of Birth: [**2081-2-27**] Sex: F Service: [**Company 191**] HISTORY OF PRESENT ILLNESS: This is a 41 year-old woman with a five year history of pancreatitis followed by insulin dependent diabetes who presented to [**Hospital1 190**] in the Emergency Department on the 26th complaining of two days of fever with nausea and vomiting. The patient notes that she failed to use her insulin during this period. She also notes she had decrease intake and diarrhea and had also been noncompliant in her po intake. She had been eating a lot of bananas and apples during this period. During this period she states she had abdominal pain after eating, which is consistent with her prior attacks of pancreatitis. Though she denied any chest pain. She was admitted to the Intensive Care Unit in diabetic ketoacidosis. In the Intensive Care Unit she was put on an insulin drip with her anion gap being closed she was then transferred to the general medicine floor. PAST MEDICAL HISTORY: Cholecystitis performed in [**2116**], three cesarean sections, presence of history of ovarian cyst, hypertension diagnosed since age 36, heart murmur diagnosed at age 38 and also mild heart failure with left ventricular ejection fraction of 35 to 40%. The patient has a noted narcotic contract, which is described in the OMR electronic notes. SOCIAL HISTORY: Currently unemployed. She has children, one boy and two girls. No known ..................... No recent travel history. No recent sick contacts and denies ethanol or tobacco use. REVIEW OF SYSTEMS: Significant for a change in decreased in forty pounds in the past three months. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs on transfer temperature 97.9, heart rate 78, respirations 13 and blood pressure 112/60. She is sating 100% on room air. She is well developed, well nourished female in no acute distress. Lungs are bilateral clear to auscultation. Heart had a regular rate and rhythm with no murmurs, rubs or gallops. Abdomen was notable for diffuse epigastric tenderness and deep palpation with no rebound tenderness. Extremities notable for 2+ radial and 2+ dorsalis pedis pulses and no peripheral edema. LABORATORY: Hematocrit on transfer was 32.8%. Urinalysis negative for esterase, nitrate, negative for glucose and ketones. Chem 7 was notable for BUN and creatinine of 2/0.6 and glucose was 199. Potassium was 3.9. Transaminase with ALT of 12, AST 27, amylase 139. HOSPITAL COURSE: The patient complained of persistent epigastric pain as well as post prandial nausea and vomiting. Her pain was initially managed with po Percocet and later switched to a Dilaudid pump with the patient controlled anesthesia as her pain progressed. She was also made NPO during her time on the floor and eventually weaned back to clear liquids, full liquids and then eventually to full solid diet as her nausea and vomiting diminished. Even though she kept a persistent level of low grade nausea and persistent level of mild tenderness to her epigastric region. By the time of discharge on [**10-5**], the patient was able to tolerate regular po feeds and her pain had returned to baseline. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: At discharge she was put back on her regular outpatient medications of insulin at 37 NPH in the morning and 37 of regular, 37 units of NPH in the afternoon and 30 units of regular in the afternoon. She was also put back on her Zestril, Norvasc and her Hydrochlorothiazide as well as Oxycodone for pain. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 8562**] MEDQUIST36 D: [**2122-10-6**] 21:53 T: [**2122-10-13**] 09:55 JOB#: [**Job Number 13719**]

[ "401.9", "577.1", "250.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3323, 3893

2571, 3265

1775, 2553

1633, 1752

175, 1043

1066, 1412

1429, 1613

3290, 3299

16,753

176,572

29763

Discharge summary

report

Admission Date: [**2165-2-28**] Discharge Date: [**2165-3-11**] Date of Birth: [**2098-1-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2165-2-28**] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending, with vein grafts to the diagonal, obtuse marginal and posterior descending artery. History of Present Illness: Mr. [**Known lastname 71241**] is a 67 year old male with chronic angina and history of congestive heart failure. Despite extensive medical therapy, he admits to a recent increase in dyspnea on exertion and chest pain. He underwent cardiac catheterization in [**Month (only) 404**] [**2164**](part of evaluation for spinal fusion surgery) which revealed severe three vessel disease. Left ventriculogram showed no mitral regurgitation and an LVEF of 73%. Pulmonary artery pressure were elevated, measuring 71/24 mmHg. Prior echocardiogram in [**2164-12-31**] showed an LVEF of 65% with mild concentric LVH. Given his severe coronary disease, he was referred for surgical revascularization. Past Medical History: Coronary artery disease, Hypertension, Diastolic Congestive Heart Failure, Hyperlipidemia, Type II Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal Insufficiency, Ankylosing Spondylitis, Anemia, Hyperhomocystenemia, Spinal Stenosis - s/p multiple Back Surgeries, Prior Cataract Surgery, s/p Lap Chole, s/p Sinus Surgery, s/p Carpal Tunnel Surgery Social History: Denies history of tobacco and ETOH. Retired in [**2155**]. Married, lives in [**Hospital1 **]. Family History: Denies premature history of coronary artery disease. Physical Exam: Vitals: BP 120/60, HR 68, RR 12 General: obese male in no acute distress, requires cane to ambulate HEENT: oropharynx benign, Neck: supple, no JVD, carotids 2+ without bruits Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally, mildly decreased at left base Abdomen: obese, soft, nontender, normoactive bowel sounds, well healed scar Ext: warm, [**1-1**]+ edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [**2165-3-10**] 05:50AM BLOOD Hct-30.3* [**2165-3-9**] 04:48AM BLOOD WBC-8.0 RBC-3.16* Hgb-9.9* Hct-28.8* MCV-91 MCH-31.5 MCHC-34.6 RDW-15.9* Plt Ct-199 [**2165-3-11**] 07:25AM BLOOD PT-32.3* PTT-36.5* INR(PT)-3.5* [**2165-3-10**] 05:50AM BLOOD PT-20.1* INR(PT)-1.9* [**2165-3-10**] 05:50AM BLOOD Glucose-118* UreaN-39* Creat-1.6* Na-136 K-4.3 Cl-98 HCO3-31 AnGap-11 [**2165-3-9**] 04:48AM BLOOD Glucose-95 UreaN-41* Creat-1.7* Na-137 K-4.7 Cl-97 HCO3-29 AnGap-16 Brief Hospital Course: Mr. [**Known lastname 71241**] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring. The renal service was consulted to assist in the management of his chronic renal insufficiency. He was extubated later that same day. He was weaned off his vasoactive drips and transferred to the floor on POD #4. He had atrial fibrillation for which he was seen in consultation by electrophysiology. He was started on quinidine and coumadin and remained on lopressor. He continued to do well postoperatively. He will go home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor followed by Dr. [**Last Name (STitle) 73**], and will follow up with his nephrologist in 6 weeks. Medications on Admission: Avandia 8 qd, Atenolol 75 qd, Lisinopril 10 [**Hospital1 **], Lipitor 40 qd, Glipizide 10 [**Hospital1 **], Lasix 40 [**Hospital1 **], Metolazone 5 qd, Folate 2 qd, Aspirin 325 qd, B Vitamins, Fish Oil, Multivitamin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. 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:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO BID (2 times a day). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 8. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). Disp:*90 Tablet Sustained Release(s)* Refills:*0* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease - s/p CABG, Postop Atrial Fibrillation, Hypertension, Diastolic Congestive Heart Failure, Hyperlipidemia, Type II Diabetes Mellitus, Pulmonary Hypertension, Chronic Renal Insufficiency, Ankylosing Spondylitis, Anemia, Hyperhomocystenemia Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-4**] weeks. Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3845**] in [**2-2**] weeks. Local cardiologist, Dr. [**Last Name (STitle) 14522**] in [**2-2**] weeks. Completed by:[**2165-3-11**]

[ "403.90", "427.31", "428.0", "428.20", "585.9", "E878.2", "285.21", "416.8", "414.01", "250.00", "272.4", "720.0", "997.1", "413.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "36.13", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

5221, 5270

2790, 3676

331, 548

5576, 5583

2302, 2767

5902, 6169

1773, 1827

3942, 5198

5291, 5555

3702, 3919

5607, 5879

1842, 2283

281, 293

576, 1266

1288, 1645

1661, 1757

6,407

138,430

20503

Discharge summary

report

Admission Date: [**2188-3-26**] Discharge Date: [**2188-4-2**] Date of Birth: [**2125-7-11**] Sex: M Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 54864**] is a 62-year-old gentleman transferred to [**Hospital1 190**] from [**Hospital3 **]. He is a patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 54865**]. He was seen in Dr.[**Name (NI) 54866**] office complaining of a 1-month history to 2-month history of right lateral neck, chest, and shoulder pain with exertion or emotional stress. He had an exercise tolerance test done on [**3-26**] that showed inferolateral ischemia. The patient was begun on intravenous heparin, Plavix, Toprol, Lipitor, and aspirin at [**Hospital3 **] following his exercise tolerance test and transferred to [**Hospital1 346**] for cardiac catheterization. PAST MEDICAL HISTORY: (Significant for) 1. Eczema (for which he uses steroid cream). 2. Question of hypertension. 3. He is also status post appendectomy. ALLERGIES: He has no known drug allergies. MEDICATIONS AT HOME: None. MEDICATIONS ON TRANSFER: (From [**Hospital3 **]) 1. Heparin. 2. Toprol. 3. Lipitor. 4. Aspirin. 5. Plavix. 6. Integrilin. SOCIAL HISTORY: He lives half the year in [**State 108**] and half the year on [**Location (un) **]. The patient lives with his wife. [**Name (NI) **] works for a bank. He denies tobacco use. Occasional ethanol use. No other drug or marijuana use. PERTINENT RADIOLOGY/IMAGING: As stated previously, the patient was brought to [**Hospital1 69**] for a cardiac catheterization. His catheterization on the day of transfer showed an 80% middle left anterior descending artery stenosis, and 99% middle circumflex stenosis, and 80% middle right coronary artery stenosis, and an left ventricular end-diastolic pressure of 16, with an ejection fraction of 52%. Following catheterization, the patient had a carotid ultrasound which showed a right internal carotid artery stenosis of the less than 40% and no stenosis on the left internal carotid artery. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data preoperatively revealed his hematocrit was 39.5. His potassium was 4.1. His blood urea nitrogen was 14. His creatinine was 0.8. Alanine-aminotransferase was 59, his aspartate aminotransferase was 39, alkaline phosphatase was 58, amylase was 44, his total bilirubin was 0.5. PHYSICAL EXAMINATION ON PRESENTATION: The patient's physical examination at the time of consultation revealed his heart rate was 61, his blood pressure was 160/63, his respiratory rate was 15, and his oxygen saturation was 95% on room air. On neurologic examination, alert, awake, and oriented times three. He moved all extremities. Head, eyes, ears, nose, and throat examination revealed the pupils were equal, round, and reactive to light. The mucous membranes were moist. The neck was supple. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs, or gallops. Respiratory examination revealed breath sounds were clear to auscultation. No wheezes or rhonchi. The abdomen was soft, nontender, and nondistended. There were positive bowel sounds. The extremities were warm and well perfused with no varicosities or ulcerations. Pulse examination on the right, had a sheath in place. On the left were 2+ popliteal, and dorsalis pedis pulses and posterior tibialis were 2+ bilaterally, and carotids were 2+ with bruits bilaterally. Skin showed multiple small erythematous areas on the arms, legs, and trunk with scaling; consistent with eczema. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was followed by the Medicine Service for the next two days. On [**3-28**], he was brought to the operating room where he underwent coronary artery bypass grafting. Please see the Operative Report for full details. In summary, the patient had coronary artery bypass grafting times four with a left internal mammary artery to the left anterior descending artery, a right internal mammary artery to the distal right coronary artery, a saphenous vein graft to obtuse marginal, and a saphenous vein graft to the diagonal. The patient tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. His anesthesia was reversed. He successfully weaned from the ventilator and extubated. He remained hemodynamically stable throughout the remainder of his operative day requiring only a Neo-Synephrine infusion to maintain and adequate blood pressure. On postoperative day one, the patient remained hemodynamically stable. He was begun on diuretics as well as beta blockade. He was weaned off his Neo-Synephrine drip. His mediastinal chest tubes and his central venous access were removed. On postoperative day two, the patient continued to do well. The remainder of his chest tubes were removed. His beta blockade was increased, and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient had an uneventful hospital course. His activity level was increased with the assistance of the nursing staff and the physical therapist. On postoperative day four, it was decided that the following day the patient would be stable and ready to be discharged to home. At the time of this dictation, the patient's physical examination was as follows. Vital signs revealed his temperature was 99, his heart rate was 89 (sinus rhythm), his blood pressure was 118/53, his respiratory rate was 18, and his oxygen saturation was 94% on room air. Weight preoperatively was 100.5 kilograms and on discharge was 101.5 kilograms. Physical examination revealed he was alert and oriented times three. He moved all extremities. He followed commands. Respiratory examination revealed clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds with no murmurs. The sternum was stable. Incision with Steri-Strips open to air, clean and dry. The abdomen was soft, nontender, and nondistended. There were normal active bowel sounds. Extremities were warm and well perfused with no edema. Left leg saphenous vein graft site with Steri-Strips open to air, clean and dry. Laboratory data revealed his white blood cell count was 10.7, his hematocrit was 29.3, and his platelets were 317. Sodium was 139, potassium was 3.7, chloride was 100, bicarbonate was 29, blood urea nitrogen was 14, creatinine was 0.6, and his blood glucose was 114. MEDICATIONS ON DISCHARGE: 1. Metoprolol 50 mg twice per day. 2. Atorvastatin 20 mg once per day. 3. Enteric-coated aspirin 325 mg once per day. 4. Lasix 20 mg once per day (times 10 days). 5. Potassium chloride 20 mEq once per day (times 10 days). 6. Percocet 5/325 one to two tablets by mouth q.4h. as needed. CONDITION AT DISCHARGE: The patient's condition on discharge was good. DISCHARGE DIAGNOSES: 1. Coronary artery disease; status post coronary artery bypass grafting with a left internal mammary artery to the left anterior descending artery, right internal mammary artery to the distal right coronary artery, saphenous vein graft to the diagonal, and saphenous vein graft to the obtuse marginal. 2. Hypertension. 3. Status post appendectomy. DISCHARGE DISPOSITION: The patient was to be discharged to home. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to have followup in the [**Hospital 409**] Clinic in two weeks. 2. The patient was to follow up with Dr. [**Last Name (STitle) 54865**] in three to four weeks. 3. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2188-4-1**] 14:37 T: [**2188-4-1**] 14:35 JOB#: [**Job Number 54867**]

[ "414.01", "692.9", "458.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.53", "37.22", "88.56", "36.12", "36.16", "39.61" ]

icd9pcs

[ [ [] ] ]

7480, 7523

7103, 7455

6717, 7019

7556, 8150

1119, 1126

3671, 6691

7034, 7082

175, 893

1152, 1256

916, 1097

1273, 3641

51,864

191,497

16182

Discharge summary

report

Admission Date: [**2114-10-4**] Discharge Date: [**2114-10-17**] Date of Birth: [**2046-5-5**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: 68M with h/o C2fx s/p fall was discharged on [**2114-9-3**] with a c-collar and during f/u appointment found to have non-fusion of of fx. Pt refused admission from clinic [**10-3**] and presented as a direct admit. Major Surgical or Invasive Procedure: Occipital to C4 fusion Percutaneous G-J tube placement Central Line placement for abx History of Present Illness: 68M with h/o C2fx s/p fall was discharged on [**2114-9-3**] with a c-collar and during f/u appointment found to have non-fusion of of fx. Pt refused admission from clinic [**10-3**] and presents today as a direct admit. Past Medical History: ETOH abuse psychosis korsakoff syndrome GERD HTN Hypothyroidism Asthma Oral Cancer Cirrhosis R Patellar Fx SIADH Social History: lives at home alone; nonsmoker; ETOH: [**2-7**] gins/night, denied illegal drug use Sister lives in apartment above him. Other sister is legal guardian. Family History: NC Physical Exam: Gen: NAD. HEENT:Atraumatic Pupils: PERRL EOMs full Neck:Collar in place, point tenderness, neck tilted to the left Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] G Sensation: Intact to light touch On discharge, the patient's strength is intact. He is alert and oriented x 3 Pertinent Results: [**2114-10-17**] 07:40AM BLOOD WBC-8.6 RBC-3.67* Hgb-10.8* Hct-32.3* MCV-88 MCH-29.5 MCHC-33.5 RDW-14.2 Plt Ct-431 [**2114-10-17**] 07:40AM BLOOD PT-14.4* PTT-26.9 INR(PT)-1.2* [**2114-10-17**] 07:40AM BLOOD Glucose-137* UreaN-12 Creat-1.4* Na-142 K-3.7 Cl-105 HCO3-25 AnGap-16 [**2114-10-15**] 07:12AM BLOOD Glucose-126* UreaN-10 Creat-1.1 Na-139 K-3.8 Cl-101 HCO3-29 AnGap-13 [**2114-10-17**] 07:40AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.9 Brief Hospital Course: Mr. [**Name14 (STitle) 46206**] was admitted and placed in cervical traction and strict bedrest. The plan was for him to proceed to the operating room after his cervical spine became aligned in traction. On hospital day four he underwent a CT of his cervical spine did not show good alignment so the operative procedure was cancelled and ten more pounds of traction were applied. That evening a worsening chest x-ray revealing pneumonia and desaturations led to the patient being transferred to the surgical ICU and subsequent intubation. The following day, the patient was placed on Neo for blood pressure support in the setting of fevers and hypotension. Operative case was cancelled and the patient was taken out of traction, but remained in the [**Location (un) 2848**] J collar. The patient remained on Neo until [**10-11**] and was able to successfully maintain a systolic BP of 123-130. He remained extubated until [**10-11**] and tolerated extubation without difficulty. He was taken to the operating room on 11/0 for an occipital to C4 fusion. he tolerated the procedure well, and was transferred to the Neurosurgical care unit. here, he regained full strength and recovered well. RESP: The patient's cultures were positive for MRSA pneumonia; he was placed on Vancomycin/Zosyn for 8 days. The Zosyn was discontinued,and the vanc is to be continued until [**2114-10-30**] GI: Postoperatively, he was unable to swallow fluids or solids, as he aspirated or regurgitated. He has a G-J tube placed on [**10-16**] in interventional radiology, and was started on tube feeds. Medications on Admission: Medications prior to admission: Vitamin B12 100 mg daily Amlodipine 5 mg daily Folic Acid 1 tablet daily Levothyroxine 75 mcg daily MVI daily Depakote 250 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] Mg Oxide 400 mg TID NaCl tablets - 1 gram [**Hospital1 **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-8**] PO BID (2 times a day). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. 6. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for desat or cough. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for cough or desat. 9. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day) as needed. 10. Ondansetron 4 mg IV Q8H:PRN nausea 11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 12. Levothyroxine 200 mcg Recon Soln Sig: One (1) Recon Soln Injection DAILY (Daily). 13. Diazepam 5 mg/mL Syringe Sig: One (1) Injection Q8H (every 8 hours) as needed for Muscle Relaxant. 14. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q6H (every 6 hours) as needed. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 8H (Every 8 Hours): PLEASE GIVE THROUGH CENTRAL LINE. D/C on [**2114-10-30**] (patient needs 3 wk course). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: cervical spine fracture Aspiration Pneumonia; MRSA + Discharge Condition: Good Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? You are required to wear your cervical collar or back brace at all times. ?????? You may only shower with the collar or back brace on. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by your doctor. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. WEAR YOUR CERVICAL COLLAR AT ALL TIMES!!! CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office in 10 days for removal of your staples. (This may be done at rehab) ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 26803**] to be seen in 4 weeks. ??????You will need a CT-scan of your C-Spine prior to your appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2114-10-17**]

[ "805.02", "253.6", "V10.02", "530.81", "507.0", "303.91", "571.2", "V15.81", "291.1", "482.42", "E885.9", "493.90", "244.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "81.62", "46.32", "96.71", "02.94", "81.01", "38.91", "03.53", "93.41" ]

icd9pcs

[ [ [] ] ]

5589, 5668

2181, 3767

535, 622

5764, 5771

1716, 2158

7655, 8130

1196, 1200

4083, 5566

5689, 5743

3793, 3793

5795, 7632

1215, 1373

3825, 4060

280, 497

650, 872

1388, 1697

894, 1009

1025, 1180

19,265

162,814

22214

Discharge summary

report

Admission Date: [**2107-12-19**] Discharge Date: [**2108-1-26**] Date of Birth: [**2064-1-5**] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 57964**] is a 43 year old man with a history of hypertension who presented on transfer from an outside hospital with a right thalamic bleed. He was found in [**Location (un) 57965**]by a friend, who found him lying in the snow and unable to walk. He brought him to another friend's house, who called the EMS. According to the patient's outside chart, he was shoveling snow earlier in the day when he felt his legs giving out beneath him, associated with a feeling of numbness in both legs, weakness on the left side, and a right sided headache, which he had had most of the day. He admitted to one drink of brandy earlier in the day with his coffee. No other history available. Review of systems was unobtainable. PAST MEDICAL HISTORY: Cocaine use and hypertension. MEDICATIONS ON ADMISSION: Hydrochlorothiazide, clonidine, Norvasc. No known drug allergies. SOCIAL HISTORY: History of alcohol use; unclear amount. History of illicit drug use - "speed balls." Lives with ex- wife and mother. Had recently been in recovery. Family history was unobtainable. PHYSICAL EXAMINATION: Vitals were 98.1, blood pressure 224/113, heart rate 70, respirations 16, 100 percent, intubated. He was a well nourished man lying still. Neck was supple. Lungs were clear to auscultation. Heart showed a regular rate and rhythm. Abdomen nontender, nondistended. Bowel sounds were present. Extremities were warm. No edema. On neurological exam, he was sedated with Ativan and propofol. No arousal to sternal rub. Does not withdraw to painful stimuli on any extremity. Pupils were 1 mm and nonreactive. No Dolls eye movements. Weak corneal reflexes bilaterally. No facial droop appreciated. Reflexes were [**11-29**] throughout. Toes were mute. Labs from the outside hospital showed CBC 9.2, 46.3, 317. Chem 7 was 138, 3.0, 98, 30.9, 26, 2.8. Coags 11.5, 29.5, 0.8. Urinalysis showed moderate blood, positive for cocaine and opiates. CT scan of the head showed a large right thalamic bleed with intraventricular extension. HOSPITAL COURSE: He was admitted to the hospital, to the intensive care unit, with q one hour neurologic checks. A ventricular drain was placed under sterile procedure. He was also seen by Nephrology for non oliguric renal failure. He did not need any hemodialysis, but creatinine was followed and he underwent a renal ultrasound. Renal ultrasound showed bilateral echogenic kidneys with reduced corticomedullary differentiation consistent with intrinsic diffuse parenchymal process. The kidneys were of normal size, suggesting relatively acute or subacute onset. This was felt to be secondary to vasoconstriction, likely cocaine related, and his creatinine was followed and did improve. He did get an MRI of the brain, which did reveal no aneurysms or other source of bleed. Neurologically, he did slowly improve, became awake and alert and was able to follow commands, though did have a dense hemiparesis on the left. He did have issues with hypertension, and his medications were tailored to keep his systolic blood pressure less than 150. He did begin to have low grade fevers, and on the cerebrospinal fluid culture did grow out Staph, coag negative, and he was seen in consultation by Infectious Disease and started on appropriate antibiotics. He was ultimately transferred to the neuro step down unit and worked with Physical Therapy and Occupational Therapy. He did have good improvement in his left sided weakness. At this point, he was able to ambulate, but did continue to have some weakness. After multiple courses of peripheral and intrathecal vancomycin, he did have negative cultures and was okayed by ID to have a ventriculoperitoneal shunt placed. This was performed on [**2107-1-19**]. He tolerated this procedure well. Postoperatively, his activity was slowly increased. He did not complain of headache. He continued to work with occupational therapy and physical therapy and progressed. His medications at the time of discharge are Tylenol 325 - 650 p.o. q 4-6 hours p.r.n., docusate sodium 100 mg p.o. b.i.d., multivitamin one per day, folic acid one mg one per day, amlodipine 10 mg one per day, thiamine 100 mg one per day, Fioricet 1-2 tabs p.o. q 4-6 hours p.r.n., Keppra 500 mg twice per day, nicotine 21 mg transdermally every day, Ambien 5-10 mg p.r.n. at bedtime for sleep, metoprolol 25 mg p.o. b.i.d., heparin 5000 units subcutaneously b.i.d., Percocet 1- 2 tabs p.o. q 4-6 hours p.r.n., clonidine 0.1 mg p.o. b.i.d., lisinopril 5 mg p.o. every day. DISCHARGE DIAGNOSES: 1. Intracerebral hemorrhage. 2. Ventricular cerebrospinal fluid infection. 3. Renal failure. 4. Urinary tract infection. CONDITION ON DISCHARGE: Neurologically stable. FOLLOW UP: Follow up should be with Dr. [**Last Name (STitle) 1327**] in one month. The sutures can be removed ten days postoperatively, which will be [**2108-1-30**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2108-1-26**] 11:49:24 T: [**2108-1-26**] 12:28:05 Job#: [**Job Number 57966**]

[ "403.91", "275.3", "599.0", "996.63", "518.81", "276.1", "584.9", "431", "305.60", "331.4", "320.3", "780.39", "342.90", "458.29", "041.85" ]

icd9cm

[ [ [] ] ]

[ "88.41", "38.91", "02.34", "96.71", "02.39" ]

icd9pcs

[ [ [] ] ]

4746, 4869

989, 1057

2242, 4725

4930, 5334

1282, 2224

165, 908

931, 962

1074, 1259

4894, 4918

3,534

113,778

28021

Discharge summary

report

Admission Date: [**2163-7-17**] Discharge Date: [**2163-7-20**] Date of Birth: [**2087-9-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Dizziness/Lightheadedness Major Surgical or Invasive Procedure: Temporary Pacemaker Wire Placement Permanent Pacemaker Placement History of Present Illness: Patient is a 75 yo male with hx of CAD, HTN, Hypercholesterolemia who presented to [**Hospital1 18**]-[**Location (un) 620**] this am after developing dizzuness and lightheadedness at home this am. The pt reports he was getting coffee this AM when he felt lightheaded, and dizzy but no overt chest pain, palpitations, shortness of breath, syncope. He subsequently sat down and finished his coffee but appeared pale to his wife who checked his pulse and noted it to be irregular and bradycardic with a heart rate of 26. The pt was BIBA to [**Hospital1 18**] [**Location (un) 620**] where an EKG demonstrated complete heart block with junctional escape in the 20s to 30s. Otherwise his ECG was significant for LBBB with LAD. He was afebrile with HR of 30 and BP of 160/82, with RR of 10 and SaO2 of 100%. He was never hypotensive during his OSH stay. He received atropine in the [**Location (un) 620**] ED and his rhythm converted to sinus bradycardia. He was subsequently transferred to [**Hospital1 18**] for further evaluation and management. . ROS: The pt denies any chest pain, palpitations, sob, abd pain, n/v/d, URI, sick contact, insect bites - specifically tick bites, arthritis symptoms, black stools, melana, back pain. Past Medical History: 1. CAD: NSTEMI in '[**53**] when he presented with chest pain (positive top but neg CK) s/p cardiac catheterization with POBA of LCx. The pt had a neg Thallium stress test in '[**60**]. 2. Hypertension 3. Hypercholesterolemia 4. Increased intraocular pressure Social History: The pt is a retired realtor who lives in [**State **] with his wife. [**Name (NI) **] is visiting his daughter who lives in MA. He has intact ADL and IADLs at home. Tob: quit; former smoked 4-5cig/day for 40 years but quit 20+years ago EtOH: occasional Family History: Father: CAD, COPD, tob+ Mother: None [**Name (NI) 18806**] and [**Name (NI) 68213**]: none Physical Exam: Vitals: T: 96.9, HR: 56, BP: 147/52, RR: 10, SaO2: 100% RA GEN: Well appearing middle aged man who appears younger than stated age. Conversing fluently in full sentences. NAD HEENT: EOMI, anicteric, op clear, mmm NECK: No JVD, no [**Doctor Last Name **] a waves. CHEST: CTA bilaterally anteriorly CV: RRR, S1, S2. ABD: soft, NT, ND, BS+ GROIN: Right groin line in place without obvious echymosis, hematoma, bruits. EXT: wwp, no c/c/e NEURO: A+O x3, appropriate. . . Pertinent Results: [**2163-7-17**] 12:50PM WBC-10.3 RBC-4.88 HGB-15.6 HCT-43.6 MCV-89 MCH-32.0 MCHC-35.9* RDW-13.3 [**2163-7-17**] 12:50PM PLT COUNT-194 [**2163-7-17**] 12:50PM NEUTS-73.9* BANDS-0 LYMPHS-21.0 MONOS-2.9 EOS-1.4 BASOS-0.9 [**2163-7-17**] 12:50PM PT-12.0 PTT-25.0 INR(PT)-1.0 [**2163-7-17**] 12:50PM GLUCOSE-150* UREA N-11 CREAT-1.1 SODIUM-132* POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-26 ANION GAP-14 [**2163-7-17**] 12:50PM CK(CPK)-62 [**2163-7-17**] 12:50PM cTropnT-<0.01 .................. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2163-7-17**] 10:10 PM COMPARISON: [**2163-7-17**]. AP CHEST RADIOGRAPH: There has been interval placement of a pacing lead that appears to be entering via the IVC. Tip is seen overlying the right ventricle. Otherwise no significant change is seen from prior study with stable cardiac and mediastinal contours. No focal consolidations or pleural effusions identified. ................... TTE [**7-19**]: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild-moderate pulmonary artery systolic hypertension. There is a partially echo filled space anterior to the distal right ventricular free wall which most likely represents a fat pad. IMPRESSION: Preserved global and regional biventricular systolic function. No definite pericardial effusion identified. Mild-moderate pulmonary artery systolic hypertension. ...................... EXERCISE MIBI [**2163-7-20**] Reason: CAD S/P PCI, ? ISCHEMIA RADIOPHARMECEUTICAL DATA: 3.2 mCi Tl-201 Thallous Chloride; 22.0 mCi Tc-[**Age over 90 **]m Sestamibi; HISTORY: Chest pain. History of heart block and pacer placement. SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB: Exercise protocol: Modified [**Doctor First Name **] Resting heart rate: 60 Resting blood pressure: 170/90 Exercise duration: 7.5 min. Peak heart rate: 77 Percent max predicted HR: 53% Peak blood pressure: 176/90 Symptoms during exercise: none Reason exercise terminated: stopped at patient request ECG findings: uninterpretable due to left bundle branch block INTERPRETATION: Imaging Protocol: Gated SPECT Resting perfusion images were obtained with Tl-201. Tracer was injected 15 minutes prior to obtaining the resting images. Exercise images were obtained with Tc-[**Age over 90 **]m sestamibi. This study was interpreted using the 17-segment myocardial perfusion model. The image quality is good. Uptake is seen in the left axilla and arm, likely venous in etiology. Left ventricular cavity size is normal. Resting and stress perfusion images reveal uniform tracer uptake throughout the myocardium. Gated images reveal normal wall motion. The calculated left ventricular ejection fraction is 63%. No prior studies. IMPRESSION: Normal myocardial perfusion study at the level of exercise achieved. Normal ejection fraction. Brief Hospital Course: A/P: 75 yo male with history of HTN, CAD, inc chol, who presented earlier today with symptoms of dizziness and lightheadedness. Found to be in heart block, received atropine in the ED. . 1. CV: A. Bradycardia: The pt is currently in NSR, however was found to be in high degree AV block thought to be paroxysmal AV block secondary to diseased intrinsic conduction system. The pt has a history of MI in the past with LCx disease which may partially explain the conduction disease (but not well). Other etiologies of CHB include Lyme disease, viruses, med, toxins, rheumatoid disorders, however these all seem unlikely. Cardiac enzymes were negative. Precise etiology of AV block remains unclear. Temporary pacing wires were placed by EP fellow via fluoro and patient underwent placement of a permanent pacemaker on [**2163-7-17**]. Patient tolerated the procedure well. He will follow-up in the device clinic on [**2163-7-18**]. . B. CAD: The pt has a history of CAD with PTCA in the past but had normal stress test in '[**60**]. Given symptomatic bradycardia as above, we did not aggressively treat his blood pressure or heart rate given risk for further bradycardia or hypotension. He was continued on ASA 325 mg qd and Zocor 10mg qd. On [**2163-7-19**] he had an episode of chest pain which was sub-sternal, difficult to characterize, then moved to R side. Responded to SL NG x 2 and morphine. No associated SOB, N/V. EKG unrevealing. CE sent. Pulsus was 2. HD stable with SBP 130s, HR 70s. He underwent a PMIBI which showed a normal myocardial perfusion study at the level of exercise achieved. Normal ejection fraction. He was able to exercise for 7.5 mins. He did not have any anginal symptoms. No further episodes of chest pain while in-patient. Prior to discharge was restarted on atenolol and lisinopril after placement of pacer. . 2. Hypertension: Beta blocker and thiazide diuretics that patient takes as an out-patient were initially held given his bradycardia. After pacer placement these were restarted. Patient was also started on lisinopril for better blood pressure control. He will follow-up with his PCP [**Last Name (NamePattern4) **] [**1-31**] weeks for further titration of his anti-hypertensives and will have his electrolytes checked at that time. . 3. Hyperglycemia on admission labs: The pt does not carry a history of DM, and this could reflect a stress response. Fasting AM sugars was within normal limits at time of discharge, however, patient was advised to follow-up with his PCP regarding his blood sugar. He should be monitored for fasting and post prandial hyperglycemia and should have an HgA1C checked. . Medications on Admission: ALLERGIES: NKDA . MEDICATIONS: 1. Metoprolol XL 50mg once daily 2. Indapamide (Thiazide Diuretic) 2.5mg once daily 3. Zocor 10mg once daily 4. ASA 325mg once daily 5. Eye drops - Cosopts for right eye and ?Xelotan for both eyes Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Indapamide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Cosopt 2-0.5 % Drops Sig: One (1) gtt Ophthalmic twice a day: Right eye. 5. Xalatan 0.005 % Drops Sig: One (1) gtt Ophthalmic at bedtime. 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Complete heart block .. Secondary diagnoses hypertension CAD hypercholesterolemia Discharge Condition: Good Discharge Instructions: You were admitted for heart block and had a pacemaker placed. You should follow up in device clinic as arranged. You should return to the ED with increasing pain at the pacer site, fevers, chills, palpitations, fainting, chest pain, shortness of breath, or for any other problems that concern you. Followup Instructions: You have an appointment at the device clinic on [**2163-7-28**] at 10 am in the [**Hospital Ward Name 23**] building on the [**Location (un) 436**]. . You should follow up with your PCP and your primary cardiologist when you return to [**State **]. You will need to see a cardiologist that specializes in pacer makers. You should have your blood pressure checked by your PCP as you may need to have your blood pressure medications adjusted. You should also have your PCP check your blood sugar as it was intermittently elevated while you were in the hospital.

[ "426.0", "414.01", "412", "V45.82", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72", "37.78" ]

icd9pcs

[ [ [] ] ]

9610, 9616

6124, 8427

340, 406

9760, 9767

2845, 6101

10113, 10676

2250, 2342

9059, 9587

9637, 9739

8801, 9036

9791, 10090

2357, 2826

275, 302

437, 1675

8443, 8775

1697, 1963

1979, 2234

27,303

195,677

32655

Discharge summary

report

Admission Date: [**2165-1-1**] Discharge Date: [**2165-1-17**] Service: CARDIOTHORACIC Allergies: Augmentin Attending:[**First Name3 (LF) 1283**] Chief Complaint: DOE Major Surgical or Invasive Procedure: AVR(21mm [**Company 1543**] Mosaic), MVR (29mm [**Company 1543**] Mosaic Porcine) [**1-1**], AV separation/LV rupture/redo of MVR (onX)[**1-1**] History of Present Illness: 86 yo F with DOE who has had serial echos which have shown progression of AS. Also has moderate MR [**First Name (Titles) **] [**Last Name (Titles) **]. Referred for surgery. Past Medical History: PMH: Aortic stenosis ([**Location (un) 109**] 0.7cm2), severe pulm HTN, mitral stenosis, mitral regurg, CHF, COPD, HTN, ^lipids, OA/osteoporosis, asthma, breast ca, HOH, varicose veins, s/p L mastectomy [**2144**], s/p R shoulder surgery [**2162**], s/p appendectomy, s/p LLE vein ligation, 20 pack year history (quit 45years ago) Social History: works as housewife quit tobacco 45 years ago 2 etoh/night Family History: NC Physical Exam: Pleasant F in NAD HR 98 RR 14 BP 130/90 Lungs CTAB Heart RRR, SEM at RUSB, HSM LUSB Abdomen benign Extrem warm, trace edema, skin changes BLE, R GSV varicosed, L GSV absent 1+pp carotids with transmitted murmur Pertinent Results: [**2165-1-15**] 06:04AM BLOOD WBC-13.7* RBC-3.47* Hgb-10.4* Hct-31.2* MCV-90 MCH-30.0 MCHC-33.4 RDW-15.1 Plt Ct-691* [**2165-1-15**] 06:04AM BLOOD Plt Ct-691* [**2165-1-15**] 06:04AM BLOOD PT-38.2* PTT-150* INR(PT)-4.1* [**2165-1-14**] 08:00AM BLOOD PT-21.9* PTT-80.2* INR(PT)-2.1* [**2165-1-13**] 02:06AM BLOOD PT-18.2* PTT-92.0* INR(PT)-1.7* [**2165-1-12**] 03:19AM BLOOD PT-16.0* PTT-45.5* INR(PT)-1.4* [**2165-1-11**] 02:54AM BLOOD PT-16.1* PTT-28.2 INR(PT)-1.4* [**2165-1-15**] 06:04AM BLOOD Glucose-190* UreaN-29* Creat-1.1 Na-134 K-3.6 Cl-97 HCO3-28 AnGap-13 CHEST (PA & LAT) [**2165-1-15**] 1:55 PM CHEST (PA & LAT) Reason: evaluate consolidation [**Hospital 93**] MEDICAL CONDITION: 86 year old woman with REASON FOR THIS EXAMINATION: evaluate consolidation CHEST, SINGLE VIEW ON [**1-15**] HISTORY: Evaluate consolidation. FINDINGS: Frontal and lateral views demonstrate bilateral pleural effusions with dense right lower lobe infiltrate and retrocardiac opacity. There is a right-sided PICC line with tip in the SVC/RA junction. The left subclavian line has been removed. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 76095**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76096**] (Complete) Done [**2165-1-1**] at 5:58:02 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2078-3-4**] Age (years): 86 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Emergent reexploration for chest tube bleeding post MVR and AVR this morning. Limited TEE performed before going on CPB. ICD-9 Codes: V42.2, 427.31, 799.02 Test Information Date/Time: [**2165-1-1**] at 17:58 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Findings RIGHT VENTRICLE: Severe global RV free wall hypokinesis. AORTIC VALVE: AVR well seated, normal leaflet/disc motion and transvalvular gradients. MITRAL VALVE: MVR well seated, with normal leaflet/disc motion and transvalvular gradients. TRICUSPID VALVE: Moderate [2+] 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The rhythm appears to be atrial fibrillation. patient. Conclusions Pre_CPB: There is moderate to severe RV systolic dysfunction. There is trapping pockets of air along with RV free wall and in the pulmonary arteries. The m itral and aortic prosthesis are intact. The LV appears empty. Thoracic aortic contour is intact. There is NO CIRCUMFERENTIAL PERICARDIAL EFFUSION. There is a large pleural collection in the left side more than the right side. There is no echocardiographic evidence of AV separation. Brief Hospital Course: She was taken to the operating room on [**1-1**] where she underwent an AVR and MVR. She was transferred to the ICU in critical but stable condition on neo and propofol. She was given 48 hours of vanocmycin as perio prophylaxis due to PCN allergy. She underwent bronchoscopy for left lung white out on CXR. She was taken emergently back to the operating room, after sudden onset bleeding, where she underwent re-explaoration, repair of AV dissociation, explant of mitral valve, and re-do MVR with a mechanical mitral valve. She was transferred back to the ICU on levophed, milrinone, epinephrine and pitressin. She remained intubated and sedated and her drips were slowly weaned. Her vasoactive drips were weaned to off by POD #3. She failed a CPAP trial and tube feeds were started. She spiked a temp and was pancultured and started on vanco and ceftazidime. Sputum culture grew MRSA. She had afib and was started on amiodarone and diltiazem. She was started on heparin and coumadin for mechanical mitral valve. She was extubated on POD #5. She remained in the ICU for aggressive pulmonary toilet. Bedside swallow evaluation recommended thin liquids and ground solids with supplemental tube feedings for decreased PO intake. She was transferred to the floor on POD #12. A PICC line was placed on [**1-14**]. She was seen by ID. CXR showed question of pneumonia, antiobiotics were continued and bronch was planned. Bronchoscopy was performed on [**1-16**] for RML collapse with therapeutic aspiration of mucoid secretions. She remained in house overnight for aggressive chest pt. She was ready for discharge to rehab on POD #15. Medications on Admission: HCT Z 25', actonel once weekly, advair 1 puff", glucosamine, MVI, Calcium 500''', ASA 81', Vit B,C,D q48' Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks: then reassess needs for diuresis. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 1 weeks. 12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: check INR [**1-17**], goal INR 3-3.5 for mechanical mitral valve. 14. Ceftazidime 2 gram Recon Soln Sig: Two (2) grams Intravenous twice a day for 2 weeks: 2 weeks started [**1-16**]. 15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks: 2 weeks started [**1-16**]. Discharge Disposition: Extended Care Facility: Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**] Discharge Diagnosis: AS, MR/MS now s/p AVR/MVR post op AV dissociation s/p repair PMH: Aortic stenosis ([**Location (un) 109**] 0.7cm2), severe pulm HTN, mitral stenosis, mitral regurg, CHF, COPD, HTN, ^lipids, OA/osteoporosis, asthma, breast ca, HOH, varicose veins, s/p L mastectomy [**2144**], s/p R shoulder surgery [**2162**], s/p appendectomy, s/p LLE vein ligation, 20 pack year history (quit 45years ago) Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks Completed by:[**2165-1-17**]

[ "493.20", "790.7", "998.11", "997.3", "997.1", "934.1", "416.8", "427.31", "707.12", "397.0", "518.0", "428.0", "396.8", "482.41", "V09.0", "996.02" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "35.24", "37.49", "96.6", "34.03", "35.21", "39.61", "35.23", "96.05", "96.72", "33.23" ]

icd9pcs

[ [ [] ] ]

8011, 8110

4771, 6402

226, 373

8546, 8554

1273, 1933

1023, 1027

6558, 7988

1970, 1993

8131, 8525

6428, 6535

8578, 8830

8881, 9028

1042, 1254

183, 188

2022, 4748

401, 578

600, 932

948, 1007

28,946

174,345

33970

Discharge summary

report

Admission Date: [**2139-5-21**] Discharge Date: [**2139-5-27**] Date of Birth: [**2060-10-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: respiratory failure, acute stroke syndrome Major Surgical or Invasive Procedure: intubation History of Present Illness: Dr. [**Known lastname **] is a 78 yo male with a h/o atrial fibrillation, dementia, and idiopathic thrombocytopenia who is transferred from [**Hospital6 5016**] after acute onset of facial droop and dysarthria on the morning of [**5-21**]. Per information gathered from medical record and from family, patient awoke with slurring of speech and right facial droop. He was immediately transferred from the rehab facility to [**Hospital6 5016**] out of concern for CVA. Per EMS record, patient had equal grip and strength and denied any headache or chest pain at time of transfer. . On arrival to [**Hospital6 5016**] BP 121/81, HR 103-112 (afib), T 95.3, BG 160, respirations were unlabored on 2L. He was documented to be alert but with difficulty word finding, with right facial droop, and slurred speech. He was able to swallow a dose of Coreg 6.25 mg PO which was administered for rapid afib. He subsequently received 5 mg IV lopressor for HR in the 130's. Per family's report, he became increasingly agitated and confused and attempted to climb out of bed. He is next documented to have developed a 20 second period of apnea with [**Last Name (un) **]-[**Doctor Last Name 6056**] breathing and inability to speak. He was reported to be cyanotic in his lips and extremities at this time and was intubated with Versed 4 mg, Ativan 2 mg IV, and Succ 200 mg. He was transported via [**Location (un) 7622**] to [**Hospital1 18**]. . On arrival to the [**Hospital1 18**] ED, T 97.9, BP 72/42, RR 14, SpO2 99%. Levophed drip was started. Bedside FAST exam was performed and LIJ sepsis catheter was placed. CT head was negative for acute intracranial process. CT torso was negative for evidence of occult infection. He received 4 liters NS, ceftiraxone 2 gram, vancomycin 1 gram, Protonix 40 mg IV, Thaimine 100 mg IV, and Decadron 10 mg IV. Neurology was consulted. Past Medical History: Atrial fibrillation, s/p failed cardioversions x 2 at [**Hospital1 112**] Thrombocytopenia h/o nasal polyp Dementia of the Alzheimer's variant Cardiomyopathy with globally dilated heart, EF 40% (Adenosine sestaMIBI stress from [**4-30**] Mild early senial demential of the Alzheimer's type Anemia Gout CAD s/p bilateral hip and knee replacements NSVT Social History: Patient's family reports he smoked a pipe; he has no history of cigarette smoking. He drank 2+ alcoholic beverages everynight. He is married and has 8 children. He is a retired Internist. He has temporarily been living at [**Hospital3 7665**] in [**Hospital1 3597**], NH prior to this admission, recovering from recent medical illness. Family History: Father with lung cancer (smoker), MI, CVA. Mother with emphysema (smoker). His eight children are all healthy. There is no other significant family history of CVA, MI, or malignancy. Physical Exam: VS: T 97.9, HR 120, BP 127/91, RR 20, SpO2 100% Gen: intubated, minimally responsive without sedation CV: irregularly, irregular Resp: lungs CTA Abdomen: obese, soft, nt/nd Extrem: cool to touch in all four extremities; 2+ lower extremity pitting edema to shins; well-healed midline scars over both knees Skin: non-blanching purpura over lower extremities; no rashes Neuro: no obvious facial droop; pinpoint pupils with sluggish reaction to light; opens eyes to stimuli; moves left upper extremity, left lower extremity & right lower extremity; flacid tone in RUE without any purposeful or nonpurposeful movements; areflexive in patellar tendons; upgoing toes bilaterally; no clonus. Pertinent Results: [**2139-5-21**] 05:15PM WBC-11.6* RBC-3.03* HGB-9.5* HCT-31.3* MCV-103* MCH-31.3 MCHC-30.3* RDW-16.2* [**2139-5-21**] 05:15PM NEUTS-90.6* BANDS-0 LYMPHS-5.5* MONOS-3.4 EOS-0.3 BASOS-0.1 [**2139-5-21**] 05:15PM PLT SMR-VERY LOW PLT COUNT-41* [**2139-5-21**] 05:15PM PT-21.0* PTT-39.1* INR(PT)-2.0* [**2139-5-21**] 05:15PM GLUCOSE-131* UREA N-38* CREAT-1.2 SODIUM-140 POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-20* ANION GAP-14 [**2139-5-21**] 05:15PM ALT(SGPT)-197* AST(SGOT)-95* LD(LDH)-315* CK(CPK)-45 ALK PHOS-69 TOT BILI-2.9* [**2139-5-21**] 05:15PM LIPASE-44 [**2139-5-21**] 05:15PM cTropnT-0.69* [**2139-5-21**] 05:15PM CK-MB-NotDone [**2139-5-21**] 05:15PM ALBUMIN-2.9* CALCIUM-6.9* PHOSPHATE-4.2 MAGNESIUM-2.4 [**2139-5-21**] 05:15PM HAPTOGLOB-117 [**2139-5-21**] 05:15PM TSH-2.0 [**2139-5-21**] 05:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . STUDIES: * Torso CT [**5-21**]: 1. Bilateral pleural effusions, right greater than left. 2. Mesenteric fat stranding, pericholecystic fluid, periportal edema and small amount of ascites which may be due to low albumin state or third spacing. 3. Bilateral hypodense lesions, some of which are too small to characterize, others which are simple cysts. 4. Infrarenal abdominal aortic aneurysm measuring up to 4.8 x 6.2 cm in widest dimension. 5. Calcifications within the head of pancreas. . * Head CTA [**5-21**]: 1. No evidence of acute intracranial process on CT head. 2. CT perfusion shows no evidence of abnormal perfusion in the visualized portions of the brain. 3. CTA head shows persistent trigeminal artery between the basilar artery and the right cavernous carotid artery. Related narrowing of the basilar artery as well as the vertebral arteries, which feeds the PICA. No region of focal stenosis or occlusion is seen. 4. A region of apparent narrowing of the left ICA distal to its origin is likely artifactual due to a large amount of streak artifacts from dental filling at this level. . * Brain MRI [**5-22**]: 1. Findings consistent with acute infarct in the deep white matter of the left centrum semiovale. Findings suggest watershed infarct which may be related to hypotensive episode. 2. MRA again shows persistent trigeminal artery with decreased size of the basilar artery as well as the vertebral arteries which feed the PICA. No region of focal stenosis or occlusion is seen. 3. Tissue loss is again demonstrated in the left inferior frontal lobe. Old ischemic changes also seen in the pons. . * Abd U/S [**5-22**]: 1. Gallbladder remains nondistended without evidence of stone. Note is made of wall thickening and pericholecystic fluid which is non-specific and may be seen in the setting of liver dysfunction, congestive heart failure or hypoalbuminemia. Please correlate clinically. 2. Trace perihepatic ascites. 3. Pleural effusion. . * EEG [**5-22**]: This is an abnormal portable EEG due to the disorganized, low voltage and slow background admixed with bursts of generalized mixed frequency slowing. This constellation of findings is consistent with a mild to moderate encephalopathy and suggests dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, infection, and hyoxia are among the common causes of encephalopathy, but there are others. There were no areas of prominent focal slowing, although encephalopathic patterns can sometimes obscure focal findings. There were no clearly epileptiform features. The beta activity likely reflects medication effect. Note is made of the abnormal cardiac tracing. . * Echo [**5-22**]: Dilated left ventricle with severe regional and global systolic dysfunction. Dilated right ventricle with moderate systolic dysfunction. Mild aortic regurgitation. Moderate mitral regurgitation. Moderate pulmonary hypertension. Dilated thoracic aorta. . * Head MRI [**5-26**]: 1. New large vascular territory infarct involving left MCA territory and superimposed on previously seen left watershed infarct. This could be embolic or thrombolic in etiology. No hemorrhage or shift of normally midline structures is seen. Although this is not an adequate evaluation of intracranial vessels, the normal vascular flow voids are demonstrated. Brief Hospital Course: 78-year-old man with a history of atrial fibrillation, idiopathic thrombocytopenia, and dementia who presented with left-sided watershed infarct and depressed EF, with hospital course complicated by a PEA arrest requiring 7-minute CPR, epi x 1, re-intubation, and death. . # CVA: MRI on admission revealed a left centrum semiovale stroke. The patient displayed right-sided neglect. He was intermittently responsive to stimuli. His respiratory status improved temporarily and he was briefly extubated before being re-intubated again after a pulseless electrical activity arrest. Repeat head MRI then showed a left MCA embolic stroke. The patient's clinical status deteriorated with hypotension requiring pressors. With continued clinical decline, and following extensive discussions with family members (including wife and HCP), all in agreement for DNR status, and the patient quietly and comforably died in the presence of his family on [**2139-5-27**]. . # Coagulopathy: He had thrombocytopenia and required platelet and cryoprecipitate infusions. There was no evidence for TTP. Concerning for ITP, he was given steroids. The etiology was his coagulopathy was unclear. . # Acute blood loss: patient had hematemesis and epistaxis, likely precipated by his coagulopathy. He was transfused with pRBCs. . # Atrial fibrillation: he received digoxin and diltiazem prn. . # Transaminitis: LFTs elevated throughout the hospital stay. Unclear etiology. Medications on Admission: Allopurinol 150 mg daily Carvedilol 6.25 mg [**Hospital1 **] Colchicine 0.6 mg daily (d/c'd [**5-20**]) Colace 200 mg [**Hospital1 **] Aricept 10 mg daily Lisinopril 10 mg daily Prednisone taper 25 mg PO daily x 1 week NaCl nasal spray TID Zocor 20 mg qAM Lasix 40 mg qAM Zosyn 3.375 g IV q 8h (started [**5-20**]) Arixtra 2.5 mg SC daily (d/c'd [**5-20**]) Zolpidem 10 mg qHS Oxygen via NC Discharge Disposition: Expired Discharge Diagnosis: stroke Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "427.31", "348.31", "434.11", "286.9", "403.90", "428.0", "585.9", "285.21", "V16.1", "410.91", "294.10", "578.9", "331.0", "518.81", "V15.82", "790.5", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "99.07", "38.93", "99.06", "96.72", "99.05", "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

10070, 10079

8180, 9628

359, 371

10129, 10138

3909, 8157

10194, 10330

3005, 3189

10100, 10108

9654, 10047

10162, 10171

3204, 3890

277, 321

399, 2261

2283, 2635

2651, 2989

43,792

100,422

18465

Discharge summary

report

Admission Date: [**2120-2-26**] Discharge Date: [**2120-2-28**] Date of Birth: [**2034-8-16**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: Pleuritic chest pain Major Surgical or Invasive Procedure: Heimlich valve at [**Hospital3 3765**] for PTX History of Present Illness: 85M with a PMh s/f severe COPD on chronic O2, complete heart block s/p PMP [**7-21**], PVD s/p bilateral carotid endarterectomies in [**2111**], HTN, HLD presents to presented to [**Hospital3 7569**] w/chief complaint of chest pain and shortness of breath since the AM. He had a recent hospitalization for MI and PNA, and had completed a 2 week course of PNA on Sunday. At home, he denied any F, C, N/V, but endorsed pleureitic L sided chest pain and shortness of breath. . He initally was taken to [**Hospital3 **], and was given nitro gtt, briefly was on a heparin gtt, and was given Levofloxacin for a worsening LLL PNA. The plan was then to transfer to [**Hospital1 **] since this is where he receives his cardiology care, for sats 70's-80's on facemask prior to switching to nrb, then improved to low 90s for a cards evalulation. While he was in the ambulance, radiology at [**Location (un) **] stat notified our ED of a finding of a 30% left PTX. The ambulance was thus directed to the nearest hospital, which turned out to be [**Hospital1 **]. At [**Hospital1 **], his left PTX was relieved with a Heimlich valve device, which on our repeat CXR shows resolution. The patient then reported improved SOB, but still some mild L CP with inspiration. . In the ED, initial VS were: 99.0 110 170/91 20 98% cont neb . Labs were notable for HCT 36.2, INR 1.4. . He was given Aspirin 325mg, and 4 mg Morphine Sulfate. . CXR was notable for interval resolution of the PTX. . On arrival to the MICU, he is AAOx3, surrounded by his family, and comfortable. His family says that he had a slightly worse cough,a lthough he has a chronic cough at baseline, although he denies his cough is any worse. Past Medical History: Severe COPD on chronic oxygen treatment Complete heart block, status post pacemaker implantation in [**7-/2116**], peripheral vascular disease, status post bilateral carotid endarterectomies in [**2111**]. Hyperlipidemia HTN Social History: He is married. His wife lives at home. He has a former 40 pack-year history of smoking; he has not smoked for 19 years. He has rare alcohol intake. Family History: Mother and father passed from CAD. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:afebrile BP:142/63 P:90 R:20 O2:96% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar from prior surgery Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema GU:foley in place . DISCHARGE PHYSICAL EXAM Vitals: T:96.2 BP:90s-110s/40s-60s P:70s-80s R:18 O2:95% 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar from prior surgery Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema GU:foley in place Pertinent Results: [**2120-2-26**] 08:35PM GLUCOSE-133* UREA N-18 CREAT-0.9 SODIUM-137 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15 [**2120-2-26**] 08:35PM cTropnT-<0.01 [**2120-2-26**] 08:35PM ALBUMIN-4.0 [**2120-2-26**] 08:35PM WBC-11.0 RBC-4.23* HGB-12.1* HCT-36.2* MCV-86 MCH-28.7 MCHC-33.5 RDW-14.5 [**2120-2-26**] 08:35PM NEUTS-85.6* LYMPHS-9.1* MONOS-4.5 EOS-0.6 BASOS-0.2 [**2120-2-26**] 08:35PM PLT COUNT-259 [**2120-2-26**] 08:35PM PT-14.5* PTT-37.2* INR(PT)-1.4* CXR [**2-26**]: IMPRESSION: Bibasilar opacities, left greater than right, raises concern for an infection/pneumonia and/or aspiration. Blunting of the left costophrenic angle may be due to a small pleural effusion. Bibasilar atelectasis. A tubular structure/catheter extending into the left lung apex with possible tiny left apical pneumothorax remaining. However, suggest followup with removal of external artifact for better evaluation. Upright PA and lateral views may be helpful for further evaluation when/if patient able. CHEST (PORTABLE AP) Study Date of [**2120-2-28**] The left pigtail is in place. The left lower lobe consolidation has substantially improved. Heart size and mediastinum are overall unchanged. The assessment of the lung bases still demonstrate bilateral pleural effusion, small on the right and most likely small to moderate on the left. Brief Hospital Course: 85M with a PMh s/f severe COPD on chronic O2, complete heart block s/p PMP [**7-21**], PVD s/p bilateral carotid endarterectomies in [**2111**], HTN, HLD presents with pleuritic pain and found to have a L PTX. # PTX/Chest Pain: Has remained hemodynamically stable since arrival to the hosptial. Has a Heimlich valve device in place, and is oxygenating well, without new development of PTX. Most likely the pt developed a PTX from the bursting of a bleb as a complication of severe COPD. The pt was ruled out for an MI with CE. He was weaned down to 2L of O2 NC which is his home O2 requirement. Interventional pulmonology removed the Heimlich valve without complication. . # LLL infiltrate: CXR this hospitalization shows a LLL opacity. The pt just completed a two week course of antibiotics prescribed by his PCP for treatment of pneumonia. The pt was afebrile, without a leukocytosis and cough. There was no evidence of infection currently and most likely this radiographic reminence from resolving prior pneumonia. No further antibiotics were given during this hospitalization. . # Acute Urinary Retention: The pt has known BPH and is on Terazosin at home. He claims that for prior hospitalizations he has required urinary catheterization for obstruction as well. He was having difficulty voiding during this hospitalization. A bladder scan revealed >1L of urine in his bladder. A foley catheter was placed to relieve this obstruction. It was then removed and a repeat voiding trial was obtained which showed him to be retaining 600cc of urine in his bladder. A foley catheter was re-inserted and a follow up appointment was made with Urology for removal. We increased his dose of Terazosin from 2mg to 5mg daily prior to discharge. . # Severe COPD on chronic oxygen treatment: Patient was quickly weaned back down to home O2 requirements (2-3L 02 NC), without any extra wheezing on exam. We continued his home Advair, Tiotroprium and nebulizers prn. . # Elevated INR: Chronic problem noted in this pt seen on labs from [**2111**] where is INR was also noted to be 1.4. Pt is not on warfarin currently. His albumin was wnl and there was no active signs of bleeding. . # Hyperlipidemia/PVD: We continued aspirin 81 mg Daily Plavix 75 mg Daily Zocor 10 mg Daily Lisinopril 10 mg Daily . # Chronic Lower Extremity Edema- we continued Lasix 20 mg QAM Lasix 10 mg QPM . # Restless Leg Syndrome: continued Mirapex 0.5 mg QHS . # Transitional- Prior to discharge a urinary catheter was placed to relieve his urinary obstruction from BPH. He has a follow up appointment with urology to have this removed. He also has a follow up appointment with his PCP as well. Medications on Admission: Oxygen 3-liters/hr aspirin 81 mg Daily Alphagan 0.15% Eye dropps 1 [**Hospital1 **] Plavix 75 mg Daily Advair 250-50 1 inh [**Hospital1 **] Lasix 20 mg QAM Lasix 10 mg QPM Prinivil 10 mg Daily Multivitamin 1 capsule Mirapex 0.5 mg QHS Zocor 10 mg Daily Atenolol 50 mg PO/NG DAILY Tiotropium Bromide 1 CAP IH DAILY Terazosin 2.5 mg PO DAILY Discharge Medications: 1. Home Oxygen 3L / hr 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 7. furosemide 20 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in the evening)). 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. terazosin 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 14. atenolol 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary Diagnosis: Pneumothorax Urinary Retention Secondary Diagnosis: Hyperlipidemia Peripheral Vascular Disease Lower Extremity Edema Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital after having a chest tube placed at [**Hospital3 **] for a collapsed lung. The chest tube was removed and your lung has remained inflated. We also discovered that you are not completely empyting your bladder with urination. We placed a urinary catheter to help relieve this obstruction. We have made a follow up appointment for you with urology regarding this matter. The following changes have been made to your medications: INCREASE Terazosin 5mg daily START Fluticasone Propionate 1 spray per nostril daily for nasal congestion Please see below for follow up appointments that have been made on your behalf. Please call Dr. [**Last Name (STitle) 1911**] to schedule follow up. Followup Instructions: Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2515**] [**Last Name (NamePattern1) **] JR. Location: [**Name2 (NI) **] FAMILY MEDICINE Address: [**Apartment Address(1) 17034**], [**University/College **],[**Numeric Identifier 17035**] Phone: [**Telephone/Fax (1) 17030**] When: Wednesday, [**2119-3-7**]:30 AM Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2120-3-6**] at 4:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "57.94" ]

icd9pcs

[ [ [] ] ]

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198,190

26001

Discharge summary

report

Admission Date: [**2119-12-26**] Discharge Date: [**2120-1-8**] Service: MEDICINE Allergies: Atenolol Attending:[**First Name3 (LF) 783**] Chief Complaint: syncopal episode Major Surgical or Invasive Procedure: None History of Present Illness: Pt is 85 yr old female with Hx of AF/gastric AVMs/carotid stenosis who fell from sitting position with +LOC. The patient states that she was confused and thought she had been told that there was rioting in [**Location (un) **] after the superbowl. She got up very quickly to walk to the T.V. when she began feeling dizzy. She felt as though she might lose consciousness, attempted to sit down, and fell from the chair. The fall was witnessed by her son who confirms LOC. Pt. denies any concommitant palpitations, SOB, or CP. Patient denies the use of EtOH or any illegal substances prior to the fall. The patient states that she has been significantly SOB for the last 2-4 weeks, particularly in the AM. She is unable to walk more than 15feet w/o becoming SOB. The dyspnea usually resolves after a nebulizer Tx. She has also been somewhat pale over the same time period. Pt. denies any HA,F/C/N/V, changes in bowel or urinary habits, any melanotic stools. . She was taken to [**Hospital3 **] & found to have SAH, & was transferred to [**Hospital1 18**] where repeat CT scan showed left tempo parietel SAH. Pt noted to have Hct of 22.2 and INR of 1.6 on admission and had guaiac+ brown stool. Pt otherwise stable and alert upon arrival to TICU. Past Medical History: AF with h/o embolic TIA DM GERD HTN carotid stenosis hyperlipidemia h/o duodenal ulcer [**2112**], stomach AVMs hiatal hernia mesenteric ischemia s/p small bowel resection [**12/2113**] basal cell CA s/p excision [**5-22**] legally blind Social History: Retired. Lives at home with her daughter. no tobacco, no EtOH x many years. She is no longer able to cook for herself and her diet consists mostly of sandwiches and occassional fried foods. She does not exercise. Family History: Mother died at 63 from blood clot Father died at 70 Physical Exam: T98.6, HR 84 (70-80s), BP 140/60, R20, O2sat 95RA . Gen: Thin appearing pleasant female appearing stated age, in NAD HEENT: NC, 3x2 contusion lt. temporal region, sclera anicteric, no conjunctival pallor Neck: JVP 11cm, no LAD Cardio: irrg, S1S2, no M/G/R Lungs: min cracles R base Abd: mid abdominal scar, soft, round non-tender non-distended, +BS. Ext: warm/well perfused posNeuro: CN 3-12 intact, pt. legally blind Pertinent Results: Labs on admission [**2119-12-26**] 04:35PM BLOOD WBC-6.9 RBC-2.71* Hgb-7.1*# Hct-22.2*# MCV-82 MCH-26.1*# MCHC-31.9 RDW-16.6* Plt Ct-266# [**2119-12-26**] 04:35PM BLOOD PT-17.2* PTT-25.7 INR(PT)-1.6* [**2119-12-26**] 04:35PM BLOOD Glucose-177* UreaN-22* Creat-0.9 Na-144 K-4.1 Cl-107 HCO3-26 AnGap-15 [**2119-12-26**] 04:35PM BLOOD Iron-20* . [**2119-12-26**] CT angio of head IMPRESSION: No evidence of aneurysm of the circle of [**Location (un) 431**], within the limitations of this examination technique. Findings were discussed with Dr. [**Last Name (STitle) 64602**] at time of exam by Dr. [**Last Name (STitle) **]. Tham. . [**2119-12-26**] CT head without contrast FINDINGS: There is a small amount of subarachnoid blood within the left Sylvian fissure. There is no significant mass effect or shift of normally midline structures. There is no evidence of hydrocephalus. Note is made of cavum septum pellucidum at vergae. Mild hypodensity in the periventricular cerebral white matter is consistent with chronic microvascular ischemia. Osseous structures are unremarkable without evidence of skull fracture. There is a prominent left frontal subgaleal hematoma. IMPRESSION: Small amount of left-sided subarachnoid hemorrhage as described above. . [**2119-12-27**] CT head without contrast FINDINGS: Again seen is a small amount of subarachnoid blood within the left sylvian fissure. The left frontal subgaleal hematoma is again noted. No other significant changes are noted. There is no evidence of shift of normally midline structures or impending herniation. IMPRESSION: Stable small left sylvian fissure subarachnoid hemorrhage. [**2119-12-27**] EKG Atrial fibrillation - frequent multifocal PVCs or aberrant ventricular conduction Probable anteroseptal infarct - age undetermined Inferior/lateral ST-T changes Left anterior fascicular block Since previous tracing, no significant change . [**2120-1-3**] Chest X-ray PA & L CONCLUSION: 1. Single intact lead terminating at expected location of tip of right ventricle. 2. New left pleural effusion and parenchymal consolidation at the left lung base. Parenchymal consolidation could represent some atelectasis or pneumonia and radiographic followup to complete clearing is recommended to assure no underlying lesion exists. 3. COPD. 4. Atherosclerosis including severe coronary artery plaque. . [**2120-1-4**] Chest X-ray PA & L 1. Residual streaky opacity in the retrocardiac region, most likely representing atelectasis. 2. Left effusion has significantly decreased in the interim, with residual blunting of the costophrenic angle. 3. COPD. 4. Atherosclerosis involving the aorta and coronary arteries. Brief Hospital Course: 1. SAH On admission the patient was found to have a small SAH in L Sylvian fissure, w/o any evidence of aneurysm in the Circle of [**Location (un) 431**]. Her INR on admission was 1.4. Repeat CT Head demonstrated stable hemorrage.The pt. did not have any neurological Sx on admission and continued to remain neurologically stable and mentating appropriately. Per neurosurgical recs the patient was placed on Phenytoin 100mg TID for seizure prophylaxis for a total of 2wks. Her Coumadin was d/c and will be restarted as an outpatient in 4wks ([**2120-1-24**]). Plavix was initially d/c and then restarted on HD4. . 2. Syncope Given the patients's Hx of gastric AVMs her syncopal episode may have been precipitated by intravascular depletion secondary to a slow GI bleed. The patient's Hct fell from 30.4 on her last admission ([**11-7**]) to 22.2 on this admission. Given patient's history of afib with RVR and bradycardia during this admission, her syncope episode may have been secondary to a combination of cardiac factors, in addition her Hx of DM may have also had autonomic instability. The patient was ruled out for an MI x3. Her troponins remained <0.01 and her EKG was unchanged from previous exam. On transfer to the Medicine service the pt. was orthostatic w/ a 20 point drop in SBP from supine to sitting. There was no significant increase in HR given that the patient was beta blocked. The patient was monitored on telemetry throughout her hospitalization. She did have multiple tachy/brady episodes, but did not have any syncopal episodes during the admission. . 3. Cardiovascular . Cor The patient is s/p atherectomy to mid-LAD and distal LAD, DES to the LAD 2.5 X 28mm. Coumadin was held due to SAH. Plavix was also held by request of Neurosurgery but later restarted. The patient was maintained on aspirin and statin. . Pump optimal BP control: The patient was maintained on captopril and BB. Digoxin has been d/c because it is contraindicated for patient's in this age range, and it is unnecessary given that the patient remained rate controlled on BB and CCB. . Rhythm (afib w/ RVR) Pt. is in chronic Afib, and had some skipped beats and 3 episodes of bradycardia to 30s during her course, twice while sleeping and once when awake. Pt. also had approx 4 episodes in total of tachycardia with ambulation (150s) and at rest (170s). On HD3 the pt. had two tachycardic events overnight HR 179, and had 2 triggers called that AM. 10:30AM - asymptomatic tachycardia HR 150, and 11:30am - asymptomatic bradycardia HR 29 while sleeping, then 38 when awake. During her tachycardia she responded to 5 IV dilt. The bradycardic event did not require any additional diagnositc tests or intervention, and resolved spontaneously. The patient was asymptomatic during all events above mentioned events. EP was consulted and the patient was scheduled placement of a single lead pacemaker on [**1-3**]. Her Coumadin was d/c given her SAH and will be restarted on [**2120-1-24**]. After pacemaker placement the pt. continued to have episodes of asympotomatic tachycardia up to the 170s. Diltiazem was added to her regimen for rate control. The patient's HR stablized to 100s on Metroprolol 75mg [**Hospital1 **] and Diltiazem XR 180mg [**Hospital1 **]. . 4. Anemia The patient's Hct was down to 22.2 from 30.4 on her previous admission, she received 2U of PRBCs bringing her Hct up to 29.5 which held stable for several days. On HD10 The pt's Hct dropped again down to 24.6 from 28.9 the previous day. She was transfused again with 2U of PRBCs with a goal of maintaining her Hct >28. The patient underwent endoscopy, which identified a duodenal bleed which was cauterized. The patient was maintained on iron supplementation throughout her admission. . 5. UTI The patient developed a Klebsiella UTI during her hospitalization which was Tx with Ciprofloxacin. . 6. DM The patient was maintained on the following regimen FSBG QID, ISS, and her at home regimen of Metformin 500mg po QD and glyburide 5mg po TID. . 7. FEN Lytes were repleted as needed and the patient was maintained, cardiac/diabetic low sodium diet, and was placed on GI and DVT prophylaxis w/o event. . 8. Dispo Home w/ services. . In summary this is an 85yo woman w/ a hx of CAD s/p NSTEMI and LAD stent placement ([**10-22**])/gastric AVMs/DM who presents w/ a fall from sitting position +LOC and SAH. Given the patient's Hx of GIB, low Hct, and guaiac+ brown stool, it is likely that her synope was partially attributable to orthostatic hypotension secondary to intravascular depletion. However given the patient's Afib w/ tachy/brady sx during her hospital course cardiovascular factors could not be ruled out. The patient's coumadin was d/c for 4 wks, and she was maintained on ASA and plavix for anticthrombolytic therapy. Given the difficulty in adequately controlling the patient's rate by medical management only, EP was consulted. She received a single lead pacemaker and her rate was further controlled w/ Metroprolol and Diltiazem. She was also placed on an ACEi and a statin. . The patient's Hct was stabilized s/p blood transfusion, and her duodenal ulcer was visualized on EGD and cauterized. She was d/c home w/ in stable condition with services. Medications on Admission: ASA 325, digoxin, lipitor, imdur, lisinopril, glyburide, Plavix, Metformin, Lopressor 50 TID, coumadin, protonix Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*qs vials/ bottles* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Syncopal episode secondary to anemia and cardiac arrythmias Discharge Condition: Good, vitals stable Discharge Instructions: Seek medical services immediately if you should have any chest pain, fevers, lightheadness or any other worrisome symptom. . Please take your medications as prescribed and please keep all of your appointments. Followup Instructions: Follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge . Follow up with neurosurgery within 1-2 weeks of discharge. . Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2120-1-1**] 4:00 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2120-1-9**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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23940

Discharge summary

report

Admission Date: [**2175-5-12**] Discharge Date: [**2175-5-25**] Date of Birth: [**2101-8-22**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Necrotizing pancreatitis Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname **] is a 73 male transferred to [**Hospital1 18**] from [**Hospital3 **]with a admitting diagnosis of acute vs necrotizing pancreatitis. There was no gallbladder/hepatic involvement noted. There was a question whether the pancreatitis was secondary to an impacted stone. The patient arrived delerious with elevated LFTs. Past Medical History: HTN, hyperlipidemia Pertinent Results: [**2175-5-12**] 10:18PM GLUCOSE-99 LACTATE-0.7 NA+-139 K+-3.9 CL--106 [**2175-5-12**] 10:18PM TYPE-ART PO2-44* PCO2-46* PH-7.33* TOTAL CO2-25 BASE XS--1 [**2175-5-12**] 11:57PM PT-13.2 PTT-26.1 INR(PT)-1.1 [**2175-5-12**] 11:57PM PLT COUNT-240 [**2175-5-12**] 11:57PM WBC-12.5* RBC-2.93* HGB-9.3* HCT-27.5* MCV-94 MCH-31.8 MCHC-33.9 RDW-13.2 [**2175-5-12**] 11:57PM ALT(SGPT)-22 AST(SGOT)-21 ALK PHOS-62 AMYLASE-38 TOT BILI-1.2 [**2175-5-12**] 11:57PM ALBUMIN-2.2* CALCIUM-7.6* PHOSPHATE-1.5* MAGNESIUM-1.7 [**2175-5-12**] 11:57PM GLUCOSE-94 UREA N-14 CREAT-0.7 SODIUM-140 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-31* ANION GAP-7* Brief Hospital Course: Mr [**Known lastname **] was transferred to the Trauma-SICU on admission and intubated for low O2 and excessive somnalence. Hospital stay was uncomplicated. He was successfully extubated on [**2175-5-21**]. He completed 10 days of Imipenem. While in the ICU he required Haldol for sedation. He experienced numerous bowel movements and found to be C.diff negative. On [**2175-5-19**], a repeat CT showed: 1. Findings consistent with acute pancreatitis with some small areas of necrosis and multiple peripancreatic fluid collections. 2. Coronary artery calcifications. 3. Bilateral pleural effusions and atelectasis. 4. Cholelithiasis. 5. A very tiny calcified stone at the lower pole of the right kidney, nonobstructing. He remained in the SICU till [**2175-5-22**]. Once outside the ICU, he required minimal Haldol and remained unagitated with a 1:1 sitter. On [**2175-5-25**] he was deemed suitable and stable for discharge. Medications on Admission: Norvasc, Lipitor Discharge Medications: 1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic QAM (once a day (in the morning)). 2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Continue Norvasc and Lipitor at home dosages Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Necrotizing Pancreatitis Discharge Condition: Good Discharge Instructions: Go to an Emergency Room if you experience symptoms including, but not necessarily limited to: new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. Continue taking your home medications unless otherwise contraindicated and follow up with PCP. Followup Instructions: Follow up with [**Doctor Last Name 468**] in 3 weeks. Call for appt. Completed by:[**2175-5-27**]

[ "518.82", "577.0", "401.9", "574.21" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2837, 2905

1445, 2374

338, 345

2974, 2980

778, 1422

3568, 3668

2441, 2814

2926, 2953

2400, 2418

3004, 3545

274, 300

373, 716

738, 759

16,662

151,637

15005

Discharge summary

report

Admission Date: [**2165-2-18**] Discharge Date: [**2165-3-2**] Date of Birth: [**2100-8-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Aminoglycosides / Iodine Attending:[**First Name3 (LF) 11495**] Chief Complaint: Abdominal distention and pain Major Surgical or Invasive Procedure: IJ line placement Swan-ganz catheter placement Arterial line placement Dental extraction History of Present Illness: (History limited by pain, partially from prior notes) 64 y.o. female with multiple medical issues including SLE, AS and MR with resulting CHF presents with increased abdominal distention from baseline, and abdominal pain x 1 week. The patient was recently admitted in [**12-6**] and [**1-5**] with CHF exacerbations presenting as abdominal distention and pain. On her last admission a RUQ U/S demonstrated a question of perihepatic fluid collection. A CT ABD demonstrated thickened GB wall and sludge. The abdominal distention and U/S findings were thought to be secondary to right-sided failure secondary to valvular disease. She was supposed to be evaluated for AVR/MVR by Dr. [**Last Name (STitle) 36737**] but apparently did not obtain outpatient dental extractions. ROS: POSITIVE: SOB, PND, Orthopnea, cough, wt gain, nausea NEGATIVE: fevers, chills, CP, Palp Past Medical History: 1) SLE (Dx [**2162**]; Proteinuria, Pulmonary Parenchymal Disease, Pleuritis/Pericarditis, Decr C3/C4, [**Doctor First Name **] 1:1280) with Raynaud's 2) Valve Disease: AS with [**Location (un) 109**] 1.0. 1+AI, 3+MR. [**Name13 (STitle) **] 55% by echo [**12-6**]. 3) Sjogren's (?: Elevated 'Sjogrens Abs' per OSH) 4) Hypothyroidism 5) Eczema 6) Anemia (Thalassemia vs. Chronic Disease?) 7) Recurrent PNA (B/L MRSA PNA in [**2162**]) 8) H/O Dental Abscess, 9) Recent Oral/Esophageal HSV-1 and Candidiasis 10) S/P Appendectomy 1) S/P Tonsillectomy. Heart Failure: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27598**] at [**Hospital3 3583**]. Rheumatologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Location (un) 3320**]. Social History: Patient is married with three children. She previously worked for many years as a yoga instructor. She has never smoked, used ETOH (more than socially), or any illegal drugs. She has a pet dog and rabbit. [**Name2 (NI) **] family has origins in [**Country 4754**] and [**Country 19828**]. Family History: Her mother died in 60s with BRCA + Breast Ca. Her father died in his 80s of lung cancer (he had known asbestosis). She has three children and three siblings who are reportedly healthy. Physical Exam: Temp:97.0, BP:110/70, HR:110, RR:24, O2 (difficult to assess given Raynaud's): 96% RA Gen: Appears in moderate distress. A/O x 3. Can speak in full sentences. Using accessory muscles of respiration. +pallor, ashen HEENT: PEARLA. Sclera anictric. Not injected. OP:No lesions. JVP:12 cm CV: Tachy regular. III/VI SM heard throughout precordium. Chest: s/p left mastectomy Pulm: Rales at bases b/l. ABD: Distended. Soft. Diffuse tenderness. Ext: Cold. [**Name (NI) **] PT on right, DP on left Pertinent Results: [**2165-2-18**] WBC-8.8 Hgb-10.2* Hct-35.0* MCV-80* RDW-16.4* Plt Ct-728* [**2165-2-25**] WBC-17.0* Hgb-10.5* Hct-33.7* MCV-77* RDW-17.9* Plt Ct-114* [**2165-2-27**] WBC-8.8 Hgb-8.9* Hct-29.3* MCV-79* RDW-18.4* Plt Ct-112* [**2165-3-2**] WBC-16.8* Hgb-11.7* Hct-35.7* MCV-80* RDW-19.2* Plt Ct-201 [**2165-2-18**] Neuts-83.0* Bands-0 Lymphs-10.4* Monos-6.0 Eos-0.2 Baso-0.4 [**2165-2-25**] Neuts-91* Bands-0 Lymphs-3* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2165-2-18**] PT-16.1* PTT-25.9 INR(PT)-1.6 [**2165-2-28**] PT-15.5* PTT-31.9 INR(PT)-1.5 [**2165-2-18**] Glucose-120* UreaN-28* Creat-1.1 Na-131* K-5.0 Cl-93* HCO3-25 [**2165-3-2**] Glucose-68* UreaN-59* Creat-1.8* Na-136 K-5.4* Cl-98 HCO3-21* [**2165-2-18**] ALT-193* AST-183* LD(LDH)-544* CK(CPK)-54 Amylase-38 TotBili-1.6* [**2165-2-19**] ALT-290* AST-399* LD(LDH)-640* AlkPhos-143* TotBili-2.0* [**2165-2-26**] ALT-68* AST-43* AlkPhos-91 Amylase-304* TotBili-4.3* [**2165-2-27**] ALT-51* AST-25 AlkPhos-85 Amylase-179* TotBili-3.9* [**2165-2-18**] Lipase-77* [**2165-2-26**] Lipase-774* [**2165-2-27**] Lipase-372* [**2165-2-18**] Albumin-4.1 Calcium-9.5 Phos-5.9*# Mg-2.2 [**2165-2-22**] Calcium-9.2 Phos-4.2 Mg-2.9* [**2165-3-2**] Calcium-8.6 Phos-5.9* Mg-2.0 [**2165-2-22**] Iron-16* calTIBC-404 Ferritn-101 TRF-311 [**2165-2-18**] TSH-9.7* T3-38* Free T4-1.2 [**2165-2-22**] dsDNA-POSITIVE [**2165-2-22**] C3-36* C4-3* [**2165-2-18**] Lactate-10.0* [**2165-2-19**] Lactate-3.4* [**2165-3-1**] Lactate-2.7* [**2165-3-1**] BLOOD THIOCYANATE 0.4 -- REFERENCE: 0-1.0 THERAPEUTIC: [**6-11**], TOXIC: > 10 AXR [**2-18**]: Nonspecific bowel gas pattern, without definite obstruction. CXR [**2-19**]: Slight worsening of congestive heart failure. Worsening patchy and linear basilar lung opacities, which may relate to atelectasis. Underlying pneumonia is not excluded in the appropriate clinical setting. Transthoracic echo [**2-19**]: Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] with septal dyskinesis. Right ventricular chamber size is normal. Right ventricular systolic function appears depressed. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets and supporting structures are moderately thickened. There is mild mitral stenosis (?functional from mitral annulus). Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2164-12-25**], left ventricular systolic fuction is more depressed (septal dysnchrony more apparent) The severity of aortic stenosis amd mitral regurgitation are similar. CXR [**2-20**]: 1) No interval change in position of Swan-Ganz catheter tip. 2) Interval improvement in cardiopulmonary status. 3) Persistent/slightly worsened bibasilar atelectasis. 4) Patchy perihilar infiltrates persist unchanged. EKG [**2-21**]: Uncertain supraventricular tachycardia which could be non-paroxysmal junctional tachycardia versus other paroxysmal supraventricular tachycardia mechanism. Cannot exclude subtle atrial flutter with 2:1 conduction. Underlying left ventricular intraventricular conduction delay with left axis deviation. Left ventricular hypertrophy by voltage. Compared to the previous tracing of [**2165-2-19**] which showed sinus tachycardia at about the same rate, supraventricular tachy-arrhythmia is new. RUQ US [**2-22**]: There is evidence of right ventricular dysfunction on this examination. Mild increased echogenicity of the liver. Some loculated perihepatic fluid is seen as before. A thick-walled gallbladder containing debris and stones, thought to be manifestation of hypoproteinemia and adjacent ascites rather than cholecystitis. Clinical correlation is recommended. CXR [**2-25**]: Overall improvement in degree of congestive heart failure, but there is a worsening area of opacity in the left lower lobe. Although possibly due to asymmetrical pulmonary edema, superimposed process such as aspiration or infectious pneumonia should be considered in the appropriate clinical setting. MICRO: AEROBIC BOTTLE (Final [**2165-2-24**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2165-2-24**]): NO GROWTH. URINE CULTURE (Final [**2165-2-27**]): NO GROWTH. AEROBIC BOTTLE (Final [**2165-3-4**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2165-3-2**]): [**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **]. IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 43914**] FROM [**2165-2-26**]. AEROBIC BOTTLE (Final [**2165-3-5**]): [**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **]. IDENTIFICATION PERFORMED FROM ANAEROBIC BOTTLE. ANAEROBIC BOTTLE (Final [**2165-3-2**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1715 ON [**2-28**] - FA6B. [**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **]. URINE CULTURE (Final [**2165-2-28**]): YEAST. 4000 ORGANISMS/ML. CATHETER TIP (Final [**2165-3-2**]): YEAST, PRESUMPTIVELY NOT C. ALBICANS. >15 colonies OF TWO COLONIAL MORPHOLOGIES. CATHETER TIP (Final [**2165-3-1**]): YEAST, PRESUMPTIVELY NOT C. ALBICANS. >15 colonies. SPUTUM GRAM STAIN (Final [**2165-2-27**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2165-3-1**]): MODERATE GROWTH OROPHARYNGEAL FLORA. YEAST. HEAVY GROWTH. AEROBIC BOTTLE (Final [**2165-3-7**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2165-3-7**]): NO GROWTH. Brief Hospital Course: 64 y.o. female with SLE, Sjogrens, Severe AS and MR with multiple admissions for CHF with ABD distention presented with increased abdominal distention over the course of 1 week with concern for low-forward flow state, Lactate of 10.0, concern for ischemic colitis, with overall picture consistent with cardiogenic shock. On arrival to the CCU, the patient had an NG tube, IJ central line with swan-ganz catheter, and arterial line placed for closer hemodynamic monitoring. Her subsequent hospital course was as follows. Briefly, however, the patient was diuresed and maintained on inotropic support. Despite this, her condition worsened, with inability to maintain adequate blood pressure or urine output, fungemia, and ultimately, death. 1) Valvular Disease: Her valvular disease was found to be relatively unchanged, however left ventricular systolic function was further depressed. As stated in the HPI, the patient had been told months prior that she was in need of valve replacement, however needed dental work before this could be done. While in house the patient had complete tooth extraction. Unfortunately, the patient was never deemed well enough by the cardiothoracic surgeons to proceed with the surgery, and she expired prior to being able to perform the surgery. 2) Ischemic Colitis: On admission the patient had such poor forward flow that her lactate level had risen to 10, and there was concern for ischemic colitis (grossly bloody bowel movements). General surgery was consulted and recommended NG tube, NPO, and treatment of her CHF - the mesenteric ischemia was presumed secondary to low forward flow. She likely also had severe congestion from her right heart failure. Her bloody bowel movements resolved by the second day of the admission, and her abdominal pain also resolved. The cardiothoracic surgeons said that the patient could not go to surgery unless she was able to eat, and therefore after almost a week pain-free, it was decided to attempt to advance her diet. She unfortunately again developed pain a few days later, as well as clinical features and enzymes indicative of pancreatitis. She also again began having bloody stool. She was maintained on levaquin and flagyl throughout the hospitalization for prophylaxis against bowel organism transudation across the bowel wall. 3) CHF: On admission, milrinone was started for inotropic support, and she was started on lasix and natrecor for diuresis. After a few days of milrinone she unfortunately developed an atrial tachycardia that was not controlled despite lopressor, which dropped her blood pressure. She was switched to dobutamine, with less tachycardia. Her cardiac index, however, continued to fall, and as a last resort she was also started on nitroprusside for afterload reduction. In [**Last Name (un) **] to accomodate this change, her natrecor was discontinued to preserve her blood pressure. Her urine output slowly fell, however, and it was difficult to diurese her any further which such severely reduced renal perfusion. Her MAPs also declined, and the patient complained of severe discomfort. A code discussion was held between the patient and husband, and the patient decided to be made comfort measures only. Only a few minutes later, she expired. 4) ID: There was question of pneumonia on CXR during the hospitalization, however the patient was saturating well, and on levo/flagyl, and there were other etiologies to explain her white count elevation. On day 8 the patient began spiking low grade fevers. Her swan and arterial line were pulled at this time and resited, and vancomycin was begun. Blood cultures at this time grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and she was started on caspofungin. 5) SLE/Sjogren's: The patient was maintained on her outpatient dose of 5 mg prednisone daily. 6) Nutrition: This was a problem for Mrs. [**Known lastname 43915**], as she could not take POs, and we were hesitant to start TPN given her poor urine output and goal of diuresis. Eventually TPN was started, however she expired later that day. Medications on Admission: Protonix ASA Lasix 20 [**Hospital1 **] prednisone 5 (stable dose for SLE) Hydroxychloroquine Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Aortic stenosis Mitral regurgitation Tricuspid regurgitation Congestive heart failure Cardiogenic shock Ischemic colitis Fungemia Systemic lupus erythematosus Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

[ "428.0", "396.2", "285.9", "522.5", "710.0", "996.62", "707.05", "244.9", "799.4", "710.2", "785.51", "522.4", "112.85", "557.9" ]

icd9cm

[ [ [] ] ]

[ "00.13", "99.15", "99.04", "23.09", "38.93" ]

icd9pcs

[ [ [] ] ]

14000, 14009

9712, 13828

328, 418

14211, 14220

3270, 9689

14272, 14278

2546, 2733

13972, 13977

14030, 14190

13854, 13949

14244, 14249

2748, 3251

259, 290

446, 1320

1342, 2224

2240, 2530

52,875

100,261

16435

Discharge summary

report

Admission Date: [**2183-10-9**] Discharge Date: [**2183-10-25**] Date of Birth: [**2122-10-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (un) 11220**] Chief Complaint: retroperitoneal bleed s/p fall Major Surgical or Invasive Procedure: IVC filter placement Lumbar artery embolization Triple Lumen catheter placement Blood Product Transfusion PICC line placement History of Present Illness: This is a 61yoF with hx of bipolar d/o, nephrogenic diabetes insipidus, hypothyroidism, recently diagnosed RLE peroneal DVT on warfarin, admitted to the TSICU s/p fall for management of RP bleed. The pt was discharged to Rehab from [**Hospital1 18**]-[**Location (un) 620**] on [**2183-10-1**] after an admission for altered mental status that was ultimately attributed to lithium toxicity and an untreated UTI, during which time she was found to have a RLE peroneal DVT and started on warfarin. On [**10-9**] the pt had a witnessed slip and fall and was taken to [**Hospital1 **]-N for hypotension where she was found to have HCT 19. Noncon CT scan revealed a large left RP hematoma and transferred to [**Hospital1 18**] for further management. In the TSICU the pt was hemodynamically unstable despite volume resuscitation, was given ultimately 11u prbc and 8u ffp. IR was consulted and on [**10-10**] placed an IVC filter and embolized 2 bleeding lumbar arteries after which she stabilized. No further blood transfusions since [**10-10**]. Hemodynamically stable. Pt still with some delirium/agitation, though alert and oriented. The patient is currently being transferred for management of diabetes insipidus. Per the team they have been trying to free water resuscitate but having difficulty following with her large diuresis (8-10L uop daily). Na has ranged from 138-151 (currently 145). Currently, patient feels short of breath and palpitations. States that she has a cough that is productive with yellow phlegm. Denies hemoptyiss. Denies headache, chest pain (both pressure and pleuritis) nausea, vomiting, abdominal pain, distention, and leg pain. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Currently passing flatus and gas Past Medical History: hypothyroidism hypertension osteoarthritis spinal stenosis w low back pain ?parkinsonism ?PMR hypersalivation h/o dry mouth Social History: She is not working. She drinks alcohol socially. She does not smoke. She is married. Her activity level is quite low at baseline because of pain. Family History: Parents with alcoholism. Sister and brother with "issues" per husband. [**Name (NI) **] known fam history of suicide. Physical Exam: On Transfer: VS 98.7 118 153/74 24 88-92%RA GENERAL - NAD, mildly tachypneic, speaking in [**3-27**] word sentences HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM NECK - supple, no thyromegaly, no JVD, IJ site clean/dry/intact HEART - tachycardic LUNGS - poor air movement, bilateral wheezes throughout with faint rales at bases ABDOMEN - soft, obese, distended, hyperactive, initially high pitched BS, difficult to assess organomegaly given EXTREMITIES - WWP, L>R edema, no calf pain, pain with passive ROM of knee NEURO - awake, A&Ox3, CNs II-XII grossly intact Discharge Exam: 98.4 119/72, 98, 18, 94%RA GENERAL - appears unwell, pale, rigoring, clammy HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM HEART - tachycardic LUNGS - faint wheezes ABDOMEN - soft, obese, distended, nontender, normal BS, difficult to assess organomegaly given, stable subcutaneous nodule in LLQ GU: IR site, c/d/i, foley in place EXTREMITIES - WWP, trace edema, hadn exam unremarkable Pertinent Results: Admission Labs: [**2183-10-9**] 02:05PM BLOOD WBC-10.9 RBC-2.72* Hgb-8.5* Hct-25.2* MCV-93 MCH-31.4 MCHC-33.9 RDW-17.4* Plt Ct-343# [**2183-10-9**] 02:05PM BLOOD Neuts-84.0* Lymphs-11.2* Monos-4.5 Eos-0.2 Baso-0.1 [**2183-10-9**] 03:30PM BLOOD PT-18.4* PTT-51.7* INR(PT)-1.7* [**2183-10-9**] 02:05PM BLOOD Glucose-140* UreaN-18 Creat-1.2* Na-138 K-6.1* Cl-108 HCO3-17* AnGap-19 [**2183-10-9**] 02:05PM BLOOD Calcium-8.0* Phos-5.1*# Mg-1.9 Discharge Labs: [**2183-10-25**] 05:52AM BLOOD WBC-7.7 RBC-3.36* Hgb-10.0* Hct-31.0* MCV-92 MCH-29.7 MCHC-32.2 RDW-14.6 Plt Ct-854* [**2183-10-20**] 06:10AM BLOOD Neuts-81.4* Lymphs-7.6* Monos-9.8 Eos-0.8 Baso-0.4 [**2183-10-25**] 05:52AM BLOOD Glucose-89 UreaN-12 Creat-0.9 Na-142 K-4.5 Cl-108 HCO3-23 AnGap-16 [**2183-10-25**] 05:52AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.2 Other Notable Labs: Micro: [**2183-10-20**] 4:40 pm BLOOD CULTURE **FINAL REPORT [**2183-10-23**]** Blood Culture, Routine (Final [**2183-10-23**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final [**2183-10-21**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) 12708**] [**Last Name (un) 12707**] AT 8:28AM ON [**2183-10-21**]. Aerobic Bottle Gram Stain (Final [**2183-10-21**]): GRAM NEGATIVE ROD(S). [**2183-10-20**] 9:53 am URINE Site: NOT SPECIFIED **FINAL REPORT [**2183-10-23**]** URINE CULTURE (Final [**2183-10-23**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- 4 S 4 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S 1 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- I TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R Imaging: CXR: Interval placement of a right internal jugular catheter with tip projecting at the expected level of the high superior vena cava. CXR: Mild cardiomegaly is accompanied by worsening pulmonary vascular congestion. Persistent areas of patchy and linear atelectasis in the juxtahilar regions, and in the retrocardiac area. Likely layering left pleural effusion resulting in hazy increased opacity throughout the left hemithorax. TTE: The left atrium is normal in 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 aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No definite aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No definite valvular dysfunction identified. CTA Chest: 1. The exam is equivocal. There is no central PE. Left lower lobe heterogeneity in arteries is probably due to artifact and less likely to pulmonary embolism. A VQ scan can be helpful. 2. Right pleural effusion is minimal and left pleural effusion is mild-to-moderate and both have increased since [**10-9**]. The left one has hemorrhagic density. CXR: Improvement of congestive pattern, new pulmonary abnormalities. CXR: As compared to the previous radiograph, the lung volumes have decreased. As a consequence, there is crowding of the vascular and bronchial structures at the lung bases and a newly appeared retrocardiac atelectasis. However, there is no evidence for acute lung changes such as pneumonia or pulmonary edema. No pleural effusions. Unchanged borderline size of the cardiac silhouette. Brief Hospital Course: HOSPITALIZATION SUMMARY: 61yoF with history bipolar disorder, nephrogenic diabetes insipidus, hypothyroidism, recently diagnosed RLE peroneal DVT on warfarin initially presented s/p fall found to have RP bleed called out to medicine for management for diabetes insipidus who hospital course was complicated by: hypoxia, tachycardia, polyuria, delirium and Ecoli/Pseudomonas Bacteremia from UTI. ACTIVE ISSUES: # Gram Negative Rod Sepsis: On HD12, patient developed acute onset leukocytosis to 19 and spiked a fever to 103.1. Patient was pancultured and UA revealed a UTI. She was initially started CTX however patient continued to spike fevers and was broadened to Vancomycin and Zosyn. On HD13, it was found that she had GNRs in her blood. Ciprofloxacin was added. She continued to have positive blood cultures until [**10-22**]. She defervesced on [**10-22**] AM and was ultimately narrowed to cefepime. CT Torso was completed and ruled out perinephric abscess. A PICC line placed. Patient ill need 2 weeks of cefepime. Last dose will be [**11-5**]. # Retroperitoneal Bleed: Patient was admitted initially to surgical service after found to be hypotensive and with Hct of 19. She was subsequently found to have a large retroperitoneal bleed in the setting of an INR of 2.9 from anticoagulation for known DVT. Patient was given a total of 11 units of pRBCs and 8 units of FFP. Given her instability she was taken emergency to angiography from embolization to stop the bleeding. Patient was observed in the surgical ICU for several days with stable blood counts. She was then transferred to the general medicine floor for ongoing management. Given recent life threatening bleed, anticoagualtion was not restarted (see below) and IVC filter was placed. # Hypoxia/Tachypnea: Upon transfer to the medical service, patient was noted to be tachypneic and mildly hypoxic to 88-92% on room air. Chest xray revealed pulmonary congestion consistent with hypervolemic state. She was given one dose of lasix with improvement of oxygen saturations. CTA chest was completed which was equivocal for PE however given recent bleed and improvement of oxygen saturation, anticoagulation was not inititated (see below). She remained intermittently tachypneic however it seemed related to anxiety given relately normal chest xrays. She did suffer from a cough which was thought to be related to mild reactive airway disease. Her symptoms improved with nebulizer treatments. # Tachycardia: Patient developed sinus tachycardia while admitted. Initially it was thought to be related to intravascular depletion given large blood loss and underlying nephrogenic diabetes insipidis (see below). However volume repletion was difficult given hypoxia. PE was also considered given hypoxia and recent DVT. CTA was pursued however was equivocal. TSH was checked and was normal. Psychogenic causes (given history of bipolar disorder) and medication related tachycardia (largely duloxetine) were also considered however after discussion with psychiatry this appeared less likely. Patient ultimately started on metoprolol with good response. # Polyuria/Nephrogenic Diabetes Insipidus: After aggressive fluid resuscitation and in the setting of underlying nephrogenic diabetes insipidus from chronic lithium use patient developed polyuria (urinating upwards to 13L per day). She as a resulted developed hypernatremia to 151 and while in the surgical ICU was given D5W. She was also started on amloride however given hyperkalemia, it was discontinued. While on the medical floor, she continued to have polyuria. Renal was consulted and recommended increasing access to free water and allowing for autoequilibration. By HD#[**6-29**], she seemed to remain euvolemic without requiring any interventions. # Delirium: On arrival to [**Hospital1 18**], in the setting of acute illness, patient was delirious. Psychiatry was consulted who suggested using olanzapine [**Hospital1 **] with prn doses. With resolution of acute illness, delirium improved dramatically. # Recent DVT: Patient was recently diagnosed with DVT and was placed on lovenox and coumadin. It was thought that her RP bleed was related to a fall in the setting of being anticoagulated. While patient remained stable and Hct was stable, she remained a fall risk. Anticoagulation in this setting was deemed a major risk. While her CTA chest was equivocal she clinically improved without anticoagulation. A discussion was had with the patient and husband regarding the risks and benefits of anticoagulation and it was decided to hold on anticoagulation until patient becomes stronger from a mobility standpoint. This will need to be readdressed in a couple of weeks. # Deconditioning: Given extensive hospitalization, patient became deconditioned. Physical therapy saw patient and recommended rehab. It should be noted that the goal of Mrs. [**Known lastname **] is to ultimately return home once she is stronger. # Bipolar Disorder: Patient with prior history bipolar and had been on lithium in the past. Recently she had lithium toxicity and lithium was ultimately stopped. After discussion with [**Hospital1 18**] psychiatry and outpatient psychiatry, patient was started on olanzapine for mood stabilization. # IV Contrast Filitration: On HD#15, patient underwent CT torso to evaluate for abscess/fluid collection given persistent fevers (see below). While at CT, IV contrast infiltrated skin. Plastics and hand were consulted who felt hand was safe. They recommended hand elevation and frequent exams. On discharge there was no evidence of compartment syndrome or skin necrosis. TRANSITIONAL ISSUES: - RP Bleed: Patient's hematocrit has been stable. She will need follow up CBC on [**2183-11-6**] to ensure Hematocrit stability - GNR Bacteremia: Patient will continue cefepime until [**11-6**]. At this time, PICC line can be discontinued - Tachycardia: Patient should have metoprolol titrated for goal HR < 90. - Anticoagulation: Coumadin held given recent bleed and fall risk however anticoagulation should be readdressed once patient is stronger. Medications on Admission: levodopa/carbodopa 25/100mg tid, levoxyl 88mcg daily, remeron 30mg daily, colace 100mg [**Hospital1 **], neurontin 300mg tid, senna prn, cymbalta 60mg daily, protonix 40mg daily, tylenol prn, MOM prn, dulcolax prn, coumadin 5mg daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H pain 2. Carbidopa-Levodopa (25-100) 1 TAB PO TID 3. Duloxetine 60 mg PO DAILY 4. Gabapentin 300 mg PO TID 5. Mirtazapine 30 mg PO HS 6. Pantoprazole 40 mg PO Q24H 7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing 8. Benzonatate 100 mg PO TID:PRN cough 9. CefePIME 2 g IV Q12H 10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 11. Ipratropium Bromide Neb 1 NEB IH Q6H wheezing, increased WOB 12. Lidocaine 5% Patch 1 PTCH TD DAILY 13. Metoprolol Tartrate 50 mg PO TID 14. Miconazole Powder 2% 1 Appl TP QID:PRN to affected areas 15. OLANZapine (Disintegrating Tablet) 2.5 mg PO QAM 16. OLANZapine (Disintegrating Tablet) 5 mg PO QHS 17. OLANZapine (Disintegrating Tablet) 2.5 mg PO Q4H:PRN agitation 18. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 19. Docusate Sodium 100 mg PO BID 20. Levoxyl *NF* (levothyroxine) 88 mcg Oral daily 21. Milk of Magnesia 15-30 mL PO Q4H:PRN constipation/indigestion 22. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: [**Location (un) 582**] at [**Location (un) 620**] Discharge Diagnosis: retroperitoneal bleed deep vein thrombosis sinus tachycardia septicemia from urinary tract infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital because you feel and were found to have a large bleed in your belly. It required embolization of one the arteries in your belly. You also required several units of blood to replace the blood your lost. While admitted you developed a urinary tract infection which spread to your blood and made you very sick. We treated you with antibiotics and the bacteria cleared from your blood. Because of the severity of your infection however you will require IV antibiotics for several days. The last day of antibiotics will be on [**2183-11-6**]. Your heart rate was also elevated while you were admitted and we started you on a medication to slow your heart rate. You were originally on Coumadin (a blood thinning medication) to help treat the clot in your leg that you developed several weeks ago. Because of the bleed that your suffered and because you remain at risk for bleeding, we have decided to hold Coumadin until you become stronger. This will need to be readdressed when you are stronger. Followup Instructions: You will need to follow up with your PCP when you are discharged from rehab. You will also need to follow up with your psychiatrist when you are discharged from rehab. [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**] Completed by:[**2183-10-26**]

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icd9cm

[ [ [] ] ]

[ "38.7", "39.79" ]

icd9pcs

[ [ [] ] ]

16690, 16767

9302, 9698

336, 464

16912, 16912

3865, 3865

18148, 18445

2725, 2845

15677, 16667

16788, 16891

15419, 15654

17095, 18125

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2860, 3434

3450, 3846

14941, 15393

266, 298

9713, 14920

492, 2396

3881, 4305

16927, 17071

2418, 2543

2559, 2709

14,691

113,528

21409+21410

Discharge summary

report+report

Admission Date: [**2131-4-5**] Discharge Date: Date of Birth: [**2083-11-16**] Sex: F Service: TRAUMA SURGERY Of note, this discharge summary will encompass the time of admission from [**2131-4-5**] to hospital day number 17, [**2131-4-21**]. The remainder of the discharge summary will be dictated at a later time. HISTORY OF PRESENT ILLNESS: This is a 47-year-old morbidly obese woman who was transferred from an outside hospital for multiple injuries after falling from her horse three days prior. She was transferred to [**Hospital1 18**] on [**2131-4-5**]. Her injury was sustained on [**2131-3-31**]. Apparently, this patient landed on her right side. She was taken to a hospital in [**Location (un) 8641**], [**Location (un) 3844**]. The extent of her injuries there were as follows: 1. Hepatic contusion, grade III. 2. Right renal contusion. 3. Right hemothorax. 4. Right rib fractures, [**12-25**], posteriorly displaced. 5. Right scapular fracture. 6. Left transverse process fracture, L1-3. 7. Right thigh hematoma. On day number three of her hospital stay at the outside hospital, she developed abdominal pain and became hemodynamically unstable. She was taken to the OR where she was found to have a biliary leak with bile peritonitis. They were unable to close her abdomen at the outside hospital and she was transferred to [**Hospital1 18**] still intubated and sedated with an open abdomen and a right chest tube for further management. PAST MEDICAL HISTORY: 1. Morbid obesity with a BMI of 40. 2. Adult onset diabetes. 3. Asthma. 4. Hypertension. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. Total abdominal hysterectomy. 3. Umbilical hernia. ADMISSION MEDICATIONS: 1. Glucophage. 2. Monopril. 3. Albuterol. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: Upon presentation, the patient arrived intubated and sedated with a temperature of 98.8. She had a pulse of 98 and blood pressure of 100/42. She was saturating 100%. She was on SIMV 40% 02 and PEEP of 5. General: She is an obese, pale woman who was intubated and sedated. She had a normocephalic and atraumatic HEENT examination with equal and reactive pupils, full extraocular movements. She had distant heart sounds secondary to body habitus but appeared to be in a regular rate and rhythm with no murmur heard. Lungs: Her lung sounds were likewise distant with decreased sounds at the right base. Abdomen: Her abdomen was soft. There were no bowel sounds. It was obese. There was an open wound with mesh dressing and serosanguinous drainage from two JPs. She had 2+ pitting edema of her hands bilaterally, trace edema of the arms and legs, with a wrist brace on the right wrist. Neurologic: Unable to be assessed secondary to sedation. LABORATORY AND RADIOLOGIC DATA: The initial laboratories at [**Hospital1 18**] showed a white blood cell count of 15.9, hematocrit 29.7, platelets 207,000. She had a Chem-7 with a sodium of 146, potassium 3.6, chloride 118, bicarbonate 21, BUN 22, creatinine 0.9. She had glucose of 199. She had a PT of 13.8, PTT 24.5, and an INR of 1.3. Her fibrinogen was 872. She had an ALT of 230, AST 117, and LDH of 590. Her alkaline phosphatase was 88. Her amylase was 66, total bilirubin 3.0, lipase 63, albumin 2.2, calcium 7.4, phosphate 1.4. An ABG was performed and showed adequate oxygenation and ventilation. HOSPITAL COURSE: The patient remained in the ICU and was transferred to the floor on hospital day number 15. The remainder of the hospital course will be summarized by system. 1. GASTROINTESTINAL: On the first day of admission, the patient was taken to the OR for abdominal evaluation and washout. She returned to the OR for washout on hospital day number four and hospital day number 11. At each operative intervention, she was given perioperative antibiotics. JP drains were placed. Despite aggressive diuresis and repeated OR visits, the abdomen was unable to be closed. The most recent OR evaluation showed no signs of infection of the open abdominal wound with slow healing by granulation tissue. There is currently a mesh covering the abdominal wound. Please see the operative notes for more detail. At the time of this dictation, the plan is for the patient to heal by secondary intention with granulation tissue. Plastics has been consulted for future repair of the abdominal wound with flap when deemed appropriate. She had VAC dressing placement on hospital day number 17. It is anticipated that she will be discharged to rehabilitation with this VAC dressing in place and will follow-up with plastics for further reevaluation of the healing process and the appropriate timing for flap. 2. NEUROLOGIC: The patient arrived from the outside hospital intubated and sedated. Sedation was weaned daily and the patient was always responsive and moving all extremities well. She was also able to follow commands. After extubation on hospital day number 12, she was somewhat confused and required frequent reorientation. By the time she transferred to the floor, she was alert and oriented times three. 3. RESPIRATORY: The patient was maintained on mechanical assistance. She arrived intubated and sedated. She was extubated successfully on hospital day number 12. 4. CARDIOVASCULAR: The patient was maintained on a Levophed drip with a goal of mean arterial pressure under 65. This was eventually discontinued on hospital day number 11 and she was switched over to metoprolol 12.5 mg p.o. b.i.d. She was diuresed aggressively with Lasix. Diamox was added as gases indicated an alkalotic state. All diuretics were discontinued by the time that the patient was transferred to the floor. There were no events on the ICU telemetry. Telemetry was continued 24 hours while she was on the floor with no events and then discontinued. 5. HEMATOLOGY: The patient was admitted with a hematocrit of 29. This decreased and remained stable at a hematocrit of 26. She received 2 units of packed red blood cells that were transfused on [**2131-4-5**], hospital day number one, and again 1 unit of packed red blood cells was transfused on hospital day number eight. Her hematocrit has been stable at approximately 26-28 since hospital day number eight. 6. GENITOURINARY: The patient has a Foley in place with multiple urine cultures which have been negative. 7. ENDOCRINE: The patient was on insulin drip for glycemic control while she was in the ICU. This was changed to a regular insulin sliding scale when she was on the floor and having a p.o. diet. 8. INFECTIOUS DISEASE: The patient was admitted and promptly became febrile with elevated white count. She intermittently spiked fevers since the time of her admission to hospital day number three. She was initially started on Zosyn and vancomycin but this was discontinued after approximately four days of treatment. She was cultured multiple times including surveillance cultures for MRSA which were negative. All of the multiple cultures have been negative except for blood cultures from hospital day number seven. This revealed three out of four bottles positive for Staphylococcus aereus. Sensitivities were not performed. The patient was started on vancomycin on this day and is to continue for a ten day course which will be complete on [**2131-4-23**]. During this time when she was febrile, central lines were rewired and eventually resided even though catheter tips have shown no growth. She currently has a right IJ which was placed after documentation of positive blood cultures. At the time of this dictation, hospital day number 17, the patient has been afebrile for greater than 48 hours, the longest period of time since her admission. 9. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was started on TPN when she initially arrived. Tube feeds were initiated on hospital day number seven after bowel sounds were noted and flatus was observed. An insulin drip was used while the patient was in the ICU for glycemic control. Once the patient was extubated, she was started on a clear diet on hospital day number 14 and this has been slowly advanced to a full diabetic diet. The patient has had some episodes of loose stool on hospital 16 which has been sent for Clostridium difficile. She remains on a regular insulin sliding scale now that she is on the floor. 10. VASCULAR: A surveillance ultrasound of the lower extremities was performed on hospital day number 12 and revealed a thrombosis in the left greater saphenous vein. The right leg was unremarkable. The presence of this clot was close to the junction to enter the deep venous system, although it is currently not in the deep venous system. The ultrasound was repeated of the left leg two days later on hospital day number 14 and was without change. Per Vascular recommendations, the patient will continue on Lovenox at this time and she will have a repeat ultrasound in one week which will be hospital day number 21 which is [**2131-4-25**]. 11. SPINE: A CT of the L spine was obtained and a consult was also called for. The CT of the L spine showed left transverse process fractures of L1 and L2 and a thoracic disk protrusion at T11 and T12. There is also a right disk osteophyte at L2 and L3. Final recommendations are pending from the spine team at this time. She is to be fitted for a TLSO brace when her abdominal issues are stable. 12. PROPHYLAXIS: The patient was placed on Lovenox on hospital day number three. Prior to that, she had been on subcutaneous heparin. Lovenox has been maintained throughout her stay. She has received Prevacid during the times that she was n.p.o. She has been on pneumatic boots bilaterally which was changed to a pneumatic boot on the right side only given the nature of her left thrombus. 13. FINAL SUMMARY: This is a 47-year-old woman who was transferred from an outside hospital for management of her biliary peritonitis. She also has multiple other injuries. These other injuries are a hepatic contusion, grade III, a right renal contusion, right hemothorax, right rib fractures, I-12 posteriorly and displaced, a right scapular fracture, and left transverse processes fractures of L1-3 and a right thigh hematoma. She is currently status post four trips to the OR and has an open abdominal wound that is unable to be closed primarily. The plan for closure of this wound is to allow granulation tissue to form and then to have a flap placed by Plastics. During the hospital stay here, the patient became bacteremic and febrile. She is currently afebrile and will remain on a ten day course of vancomycin, the last day of which is [**2131-4-23**]. She incidentally was found to have a thrombus of her left greater saphenous vein close to the junction of the deep venous vein system; however, it is not considered to be a DVT. A repeat ultrasound for evaluation of this is to occur on [**2131-4-25**]. She is currently on Lovenox. She is being followed by Spine Surgery for management of her lumbar transverse processes fractures. Specific recommendations are pending. At the time of this dictation, she is extubated successfully, being cared for on the floor, alert and oriented times three, taking solid foods, and has been afebrile for greater than 48 hours. Her activity is currently bed rest due to the open abdominal wound and the risk of disrupting the site as well as the unknown status of her transverse processes fractures. It is anticipated that she will be able to go to rehabilitation later this week to continue VAC dressing changes and Physical Therapy evaluation. She will return per Plastic Surgery recommendations for future grafting of her abdominal wound site. The remainder of this discharge summary will be dictated upon the patient's discharge from the hospital. This discharge summary encompasses the time from the patient's admission from [**2131-4-5**] to hospital day number 17, [**2131-4-21**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**] Dictated By:[**Last Name (NamePattern1) 37631**] MEDQUIST36 D: [**2131-4-21**] 03:26 T: [**2131-4-21**] 16:17 JOB#: [**Job Number 56539**] Admission Date: [**2131-4-5**] Discharge Date: [**2131-4-30**] Date of Birth: [**2083-11-16**] Sex: F Service: TRA Of note, this discharge summary will encompass the time from [**2131-4-22**], which is hospital day number 18, until the date of discharge, [**2131-4-30**], which is hospital day number 26. For a detailed description of the [**Hospital 228**] hospital course prior to this and her initial presentation, please refer to the previous discharge summary. HOSPITAL COURSE: From hospital day 18 to date of discharge, hospital day 26, the patient continued to remain afebrile and hemodynamically stable. She was fitted for a TLSO brace which was able to be placed over her anterior abdominal wound with the VAC dressing in place. She had regular VAC dressing changes every three to four days. A good seal is noted and the wound looked clean. She was evaluated by Plastic Surgery so that her continued care may be initiated early on. At this time no operative interventions for closure are planned. This will be scheduled at a future date depending on the progression of wound healing. The patient received a Nutritional consult and had vitamin supplements added to her diet as well as a marked increase in her nutritional intake in order to maintain an optimal situation for wound healing. She also had regular physical therapy instruction. When the patient is out of bed and ambulatory she is to wear her brace at all times. Her vacuum dressing is to remain to suction. With these two barriers in place, the plastic TLSO brace anteriorly and the vacuum dressing, there is some barrier protection while the patient is ambulatory. Per Physical Therapy she is seen as ambulatory and safe to discharge home. The patient's Foley was also removed once she became ambulatory. The patient had a repeat ultrasound of her left extremity to follow up on her great saphenus vein thrombus. It was determined that this thrombus was still present, however, had not changed in size or location. She will continue on Lovenox 40 subq. b.i.d. for the remainder of the month, at which point she will follow up with Dr. [**Last Name (STitle) **] for a repeat ultrasound. DISCHARGE: Patient will be discharged home in good condition. She will have vacuum dressing material at her home as well as a visiting nurse who will help her change the dressing three times weekly. FINAL DIAGNOSES: 1. Right-sided multiple displaced rib fractures in the posterior part. 2. Right hemothorax status post tube thoracostomy. 3. Right scapular fracture. 4. Right liver laceration with contusion. 5. Right kidney contusion. 6. Right thigh contusion. 7. Transverse process fractures of L1, L2, and L3 on the left side. 8. Acute renal failure, resolved. 9. Bile peritonitis. 10. Abdominal compartment syndrome. 11. Open abdominal wound unable to close status post biliary peritonitis with washouts times four. 12. Left great saphenous vein thrombus. FOLLOW UP: 1. Patient is to follow up with Plastic Surgery, Dr. [**First Name (STitle) 3228**], at [**Telephone/Fax (1) 56307**]. She should have an appointment in two weeks either on a Monday or a Wednesday when her VAC dressing is supposed to be changed. She should travel to the appointment with her VAC dressing in place and on battery power. While at the doctor's office the dressing will be taken down for a full examination. The vacuum unit should be recharged while at the doctor's office for her ride home, and the VAC dressing should be replaced at the doctor's office and the patient will drive home using the battery-powered VAC unit. [**Unit Number **]. General Surgery: Patient will be contact[**Name (NI) **] by the hospital with a phone number and name of the doctor that will be following her abdomen. She should make an appointment with this doctor within one to two weeks. If she has any questions, patient can call [**Telephone/Fax (1) 2756**] and ask to speak to the on-call surgical resident. 3. The patient should make an appointment to see her primary care doctor in one week. 4. The patient should have an appointment in one month with vascular surgeon, Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1784**]. She should remain on Lovenox until that time. At the appointment she will have a repeat ultrasound to assess the thrombus in her left great saphenous vein and determine whether she needs to continue to need Lovenox. 5. The patient should make an appointment in one month with Orthopedic doctor, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**]. The number is [**Telephone/Fax (1) 56540**]. He will follow up on her lumbar transverse processes fractures and determine how long she will need to wear the brace. DISCHARGE MEDICATIONS: 1. Vicodin one to two tablets p.o. q. 4 to 6 hours as needed, dispense number 40. 2. Metoprolol 12.5 p.o. b.i.d. 3. Colace 100 mg p.o. b.i.d. 4. Multivitamin one capsule p.o. q.d. 5. Vitamin C 500 mg b.i.d. 6. Zinc sulfate 220 mg one tablet q.d. 7. Metformin 850 p.o. b.i.d. 8. Nystatin solution 5 ml p.o. q.i.d. p.r.n. times 7 days. 9. Albuterol inhaler one to two puffs q. 6 hours as needed. 10. Lovenox 40 mg subcutaneous b.i.d. for 30 days. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 53871**] Dictated By:[**Last Name (NamePattern1) 41037**] MEDQUIST36 D: [**2131-4-30**] 14:17:09 T: [**2131-4-30**] 16:19:26 Job#: [**Job Number 56541**]

[ "567.8", "807.08", "790.7", "E884.9", "584.9", "518.5", "958.8", "926.19", "453.8" ]

icd9cm

[ [ [] ] ]

[ "96.72", "54.25", "93.59", "96.6", "54.72", "99.04", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

17187, 17911

12834, 14728

1738, 1837

1637, 1715

14745, 15314

15325, 17164

1860, 3433

367, 1498

1520, 1614

58,781

168,015

45861

Discharge summary

report

Admission Date: [**2167-7-23**] Discharge Date: [**2167-8-21**] Date of Birth: [**2101-5-5**] Sex: F Service: MEDICINE Allergies: Codeine / Phenergan / Tylenol / Quinolones / Oxycodone / Enalapril Attending:[**First Name3 (LF) 3624**] Chief Complaint: Nausea and Vomitting in setting of NSTEMI Major Surgical or Invasive Procedure: Cardiac Catheterization Hemodialysis History of Present Illness: 66F ESRD s/p DCD renal transplant ([**2160**]) and hx of AFib s/p cardiversions X 2 (On Coumadin), CAD with stress test in [**Month (only) **] [**2165**] showing some anterior apical attenuation with possible peri-infarct ischemia, diastolic heart failure (Echo at OSH showed anteroapical akinesis with an LVEF of 45%, decreased from 60% in [**3-5**], marked pulmonary HTN, estimated pulmonary artery systolic pressure was 74, 1+ MR) and PVD transferred today from OSH with a NSTEMI with plans for cardiac cath who presents to the CCU with signficant abdominal pain. Of note, the patient was admitted for severe abdominal pain in [**3-5**] and constipation (no BM x 7days) and was much improved after bowel cleansing. She has a history of alternating constipation/diarrhea, and had a colonscopy in [**3-5**] that was wnl. . History per the patient's daughter and OSH notes. The pt recently had been seen at [**Hospital6 33**] and by her PCP. . The pt presented to OSH last weekend with a one week history of lightheadedness and low heart rate. She was believed to have tachybrady syndrome and cardiology was consulted to evaluate patient for pacemaker placement. She was monitored, her cardiac enzymes were wnl at the time. Her symptoms did not seem to be associated with the bradycardia, as they persisted with a normal HR, and a PM was not thought to be necessary. She was subsequently d/c'd on Monday evening. On Tuesday morning, however, she went to her PCP for SOB, he was concerned that she had an infection and started her on levaquin and perscribed home oxygen. . She presented to [**Hospital3 **] again the next morning ([**7-22**]) with fever (100.5), multiple arthralgias and abdominal pain, denying chest pain. VS on admission (66 18 119/41). Her EKG showed normal sinus rhythm, LVH, poor R-wave progession, question of an old anteroseptal infarct and lateral T-wave inversions in I, avL and V5 and V6. Her CE on admission: CPK - 585, CPK-MB - 40.9, troponin - 5.09. BNP - 22,864. She was not thought to need an urgent cath, and was treated with a heparin gtt, low dose BB, Repeat enzymes were (CPK - 490, 449, troponins 4.68, 4.72, CK-MB - 27.9, 24.1). Her abdominal pain was evaluated by CT which showed a distended gb as the only pathology with subsequent RUQ US showing a small amount of gb sludge, moderately distended gb, but no pericholecystic fluid, with mild dilatation of the CBD to 8mm. . Also at the hospital, her Cr was from 2.5-2.9, which is close to her baseline of [**12-30**] since [**2164-12-27**]. She was transferred to the [**Hospital1 **] with a NSTEMI for possible cath in the setting of severe renal disease as her renal transplant team is here, and accepted by CCU with severe abdominal pain and positive CEs. . On transfer to CCU, pt complaining of diffuse abdominal pain. The pain is associated with nausea, distension, and bowel urgency. It has been getting progressively worse in severity since Wednesday morning. The patient's daughter reports a few episodes of non-bloody emesis at the OSH, patient had a large normal bowel movement yesterday morning. She has been having flatus. . Patient hypertensive to SBP in 160s on arrival to the floor and was started on a nitro gtt. She was started on a heparin gtt in light of elevated CEs at OSH, and abdominal pain as a possible anginal equivalent. A stat CT abd w/o contrast was ordered [**12-29**] to poor renal function, and surgery was consulted. CT did not reveal any obvious cause for her pain. Patient given soap suds enema, had large BM, mostly watery stools with one large, hard piece with minimal improvement in abdominal pain. . On review of systems, she denies any prior history of stroke, TIA, cough, hemoptysis, black stools or red stools. All of the other review of systems were negative. . Cardiac review of systems is notable for minimal exertional activity at baseline, patient uses wheelchair [**12-29**] LE ulcer, paroxysmal nocturnal dyspnea, [**12-30**] pillow orthopnea, lightheadedness, denies chest pain, ankle edema, palpitations. Past Medical History: 1. s/p cadaveric renal transplant in [**2160**], baseline Cr 1.7 2. Type 2 diabetes mellitus complicated by neuropathy, retinopathy, nephropathy 3. Diastolic Congestive Heart Failure (LVEF 60% in [**2-/2167**]) 4. Atrial fibrillation - diagnosed in [**2166-6-27**]. S/p cardioversions x2 unsuccessful. On Warfarin. 5. Hypertension 6. Hyperlipidemia 7. Peripheral vascular disease with no claudication 8. [**Country **] stenosis 9. Cholelithiasis 10. Hypothyroidism on replacement 11. Chronic anemia (baseline thought to be approx 27) 12. GERD 13. s/p appy 14. s/p eye surgery [**72**]. gout Social History: Lives with husband, [**Name (NI) **] parent has daughter. Used to be secretary. Mother died recently. Smoking: 5py, quit at age 20yrs EtOH: occasional IVDU: denies Family History: Gestational diabetes (both daughters), no htn, no heart disease. Father had [**Name2 (NI) 40342**] and skin cancer. Aunt had lung cancer. Physical Exam: VS: afebrile, HR 75, BP 149/50, 96% NC GENERAL: Moderate Distress Oriented x3. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7cm. CARDIAC: S1 S2, [**1-2**] pan-systolic murmur, heard best at left 5th intercostal space LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Posterior exam was not performed [**12-29**] patient discomfort, anteriorly decreased breath sounds at the right lung base. ABDOMEN: Soft, Diffusely tender to palpation worse in RUQ. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. No peritoneal signs. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: ulcer RECTAL: Normal tone, stool in rectal vault, guiac negative 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: [**2167-7-23**] 09:25PM PT-44.1* PTT-124.5* INR(PT)-4.7* [**2167-7-23**] 09:25PM WBC-8.5# RBC-3.69* HGB-10.4* HCT-33.5* MCV-91 MCH-28.3 MCHC-31.2 RDW-15.4 [**2167-7-23**] 09:25PM CK-MB-16* MB INDX-8.6* cTropnT-3.96* [**2167-7-23**] 09:25PM LIPASE-10 [**2167-7-23**] 09:25PM ALT(SGPT)-24 AST(SGOT)-41* LD(LDH)-517* CK(CPK)-185* ALK PHOS-86 AMYLASE-24 TOT BILI-0.9 [**2167-7-23**] 09:25PM GLUCOSE-149* UREA N-69* CREAT-3.0* SODIUM-138 POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-18* ANION GAP-20 [**2167-7-23**] 11:25PM PT-47.6* PTT-142.6* INR(PT)-5.2* [**2167-7-25**] Liver/gall bladder US: IMPRESSION: 1. Patent hepatic and portal veins, with normal waveforms. 2. Small gallstones. No evidence of cholecystitis. . [**2167-7-25**] Renal transplant US: IMPRESSION: Markedly limited study. No hydronephrosis. Doppler evaluation of the transplant could not be obtained due to respiratory motion and body habitus. Study can be repeated if clinically warranted, when patient is able to cooperate with breathing directions. . [**2167-7-24**] CT abd/pelvis: IMPRESSION: 1. No acute intra-abdominal process. 2. Cholelithiasis without evidence of cholecystitis. 3. Pervasive calcified atherosclerotic disease. 4. Normal appearing donor kidney. [**2167-7-27**] Echo: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with mid to distal septal, anterior and apical hypokinesis to akinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2167-3-6**], the extent of regional LV systolic dysfunction has increased. There is now moderate MR [**First Name (Titles) **] [**Last Name (Titles) **]. [**2167-8-7**] Cardiac catheterization: 3 vessel disease: LMCA had a 40% ostial lesion, LAD 99% stenosis in mid-portion, , LCX had a 90% proximal stenosis, RCA heavily calcified vessel with a proximal 95% stenosis and a distal 80% stenosis. Elevated left sided filling pressures. No intervention. Brief Hospital Course: This is a 66yo F w/hx of ESRD s/p kidney transplant ([**2160**]), CAD, HTN, DM2 transferred from [**Hospital1 18**] [**7-23**] for NSTEMI. Her hospital course has been complicated by: . # ARF: On admission patient c/o abdominal pain, constipation, rising lactate 1.5 to 1.8, exam concerning for mesenteric ischemia. Given diffuse atherosclerotic disease, CTA was done which did not show any acute ischemic event. Her cr worsened secondary to contrast nephropathy and poor perfusion from cardiac disease. She subsequently developed low urine output and pulmonary edema which was unresponsive to lasix. Patient required 6L facemask and was started on a nitro gtt. She was started on HD [**Date range (1) **] and 5.1L of fluid was removed. She was then maintained with good response to lasix and Cr improved. On [**8-7**] and [**8-10**] patient underwent cardiac catheterization with a deterioration in creatine. She underwent further HD and also received 1 unit PRBCs on [**8-11**], with improvement in her urine output. On discharge her creatine was 3.2 close baseline. . # S/p renal transplant: A renal ultrasound did not show hydronephrosis. Patient was maintained on her immunosuppressive regimen of cellcept, tacrolimus, and prednisone. Her tacro doses were initially reduced but then increased 1o 1.5mg [**Hospital1 **] on discharge. Her acute renal failure was managed as outlined above. . #. NSTEMI: Patient transfered to the CCU w/ NSTEMI. On [**7-27**] echo showed reduced EF EF 30-35% and cardiac enzyme peak to troponin 5.07. The patient was started on a heparin and nitro gtt, was plavix loaded given, and maintained on asa, bb, high dose statin. She underwent cath on [**2167-8-7**] which showed 3 vessel disease: LMCA had a 40% ostial lesion, LAD 99% stenosis in mid-portion, LCX had a 90% proximal stenosis, RCA heavily calcified vessel with a proximal 95% stenosis and a distal 80% stenosis. She was evaluated by CT [**Doctor First Name **] [**8-8**] and was not considered a surgical candidate due to aortic calcifications. She then underwent repeat cath [**2167-8-10**] during which Promus stents were placed in the distal and proximal RCA lesions, and the mid LAD stenosis was ballooned but a stent could not be passed. Post cath patient remained stable. On transfer to the floor from the CCU Carvedilol was reduced from 12.5 [**Hospital1 **] to 6.5 [**Hospital1 **] because of hypotension. Imdur and hydral was initiated (see below). . # ABDOMINAL PAIN: On admisison there was concern for intestinal ischemia given severe abdominal pain with guarding, rising lactate, PVD, recent NSTEMI, diffuse athermatous plaques within the aorta and possible sensitivity to low flow state. No signs of obstruction on portable xray. CT scan, initially without, and then with, contrast was performed. This was discussed extensively with renal team and renal transplant team. Given the severity of her pain and clinical picture, it was felt that the study was warranted. Her CT abdomen/pelvis showed no evidence of mesenteric ischemia and the patient's abdominal pain seemed to resolve progressively without intervention. . # CHF: Baseline diastolic heart failure with EF 60% on 4/[**2166**]. Echo [**7-24**] showed EF 40-45%, and echo [**7-27**] showed EF 30-35%. There was also marked pulmonary HTN, estimated pulmonary artery systolic pressure 74, and 1+ MR. The patient was continued on Metoprolol 12.5 mg [**Hospital1 **]. Pauses were seen on telemetry on [**7-27**] and Metoprolol was held, ultimately being switched to Carvedilol. Hydralazine and Imdur ily were also started. On transfer to the floor, carvedilol dose was reduced and imdur and hydral were held in the setting of hypotension. Upon improvement in ARF, imdur and hydral were restarted. . # Paroxysmal atrial fibrillation: On admission she had an INR of 5.1 and received Vitamin K and warfarin was held. Heparin drip was started once the INR became subtherapeutic. Metoprolol was started, held, and ultimately switched to Carvedilol after pauses were seen on telemetry. During the admission, the patient was intermittently in a-fib. Upon transfer to the floor the patient remained in sinus rhythm. . # UTI: Microscopic hematuria with 6-10WBC and many bacteria were seen on urinalysis on [**8-2**]. The patient completed a a course of ciprofloxacin. . # Anemia: Baseline H/H was [**9-25**]. The patient was started on oral iron on admission. Erythropoetin 4000u SQ every Monday/Wednesday/Friday was started. . # Diabetes: Complicated by neuropathy, retinopathy, nephropathy. The patient was put on Lantus 30u SQ qhs and insulin sliding scale. . # Hypertension: On admission, patient was hypertensive to SBPs 160s. Amlodipine was discontinued and patient was started on metoprolol switched to carvedilol, imdur and hydral (see above) while in the CCU. Upon transfer to the floors patient had episodes of hypotension and weakness. Imdur and hydral were held and carvedilol reduced, until [**Month/Year (2) **] pressure and kidney function improved. . Hyponatremia: On the floor patient was hyponatremic (Na 125) secondary to hypervolemia from CHF and RF. She improved w/ fluid restriction. Na on discharge was 127. . # Hypothyroid: The patient was continued on Levothyroxine 88mcg. TSH was within normal limits. . # Gout: Colchicine was held in the acute setting w/o any flairs and restarted on discharge. Medications on Admission: Aspirin 81 mg PO daily Warfarin 2 mg PO daily Levothyroxine 88 mcg PO daily Amlodipine 5 mg PO daily Hydralazine 25 mg PO TID Lasix 20 mg PO daily Clonidine 0.2 mg PO TID Protonix 40 mg PO daily Levemir insulin 30 units at bed, sliding scale of lispro with meals CellCept [**Pager number **] mg PO BID Prednisone 5 mg PO daily Tacrolimus 1 mg PO BID Vytorin [**8-/2138**] PO daily Colchicine 0.6 mg PO daily Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): Take one 0.5mg and one 1mg capsule twice a day. For a total of 1.5mg twice a day. Disp:*90 Capsule(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 11. Isosorbide Mononitrate 30 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* 12. Vytorin [**8-/2138**] 10-80 mg Tablet Sig: One (1) Tablet PO once a day. 13. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous at bedtime. 14. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. 15. Insulin Lispro 100 unit/mL Cartridge Subcutaneous 16. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 17. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day for 1 months: After one month, please resume prior dosing of 81 mg daily. Disp:*30 Tablet(s)* Refills:*0* 19. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation Inhalation every six (6) hours as needed for shortness of breath or wheezing. 20. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*2* 21. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS) as needed for hyperphosphatemia. Disp:*180 Capsule(s)* Refills:*2* 22. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 23. Outpatient Lab Work Please check CBC, Chem 7, and tacrolimus level. Please have this faxed to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 21178**]. Discharge Disposition: Home with Service Discharge Diagnosis: Acute Myocardial Infarction Acute on Chronic Stystolic Congestive Heart Failure Acute Renal Failure Discharge Condition: Stable. Discharge Instructions: You were seen in the hospital for your abdominal pain. A work up revealed that you had a heart attack, for which you underwent cardiac catheterization and received stents to the vessels of your heart. We started you on a drug call plavix. Because of your poor heart function and the contrast you received when getting CT scan and catheterization, your kidneys failed. You had to undergo hemodialysis to improve your kidney function. Your kidney function is now back to baseline. Your breathing has improved since dialysis. You no longer need dialysis given the recovery of your kidneys. Please make sure to do the following: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by more than 3 lbs from the previous day. 2. Adhere to 2 gm sodium diet. 3. Fluid Restriction to less than 1L. We made the following changes to your medications: 1. We have started you on a new medication called Plavix. You must take this medicine everyday it is important that you do not forget to take this. If you do your stent may close causing an additional heart attack. 2. We have increased your Tacrolimus dose to 1.5mg twice a day. 2. You can stop your Norvasc (Amlodipine), Clonidine and Protonix 3. We have reduced your Hydralazine dose to 10mg three times daily 4. We have increased your aspirin dose to 325 mg daily for one month after stent placement; you can then return to 81 mg daily. 5. Your Lasix has been increased to 60 mg po twice daily. 6. Please continue prior insulin regimen. 7. You have been started on Calcitriol and Calcium Acetate for elevated phosporus levels. Followup Instructions: Please follow up with your cadiologist in one to two weeks. You should call his office and make an appointment to see him in [**11-28**] weeks. Additionally, please call the [**Hospital1 18**], [**Hospital Ward Name 121**] 10, at [**Telephone/Fax (1) 23827**] to provide the phone and fax number of this provider so we may send the summary of your prolonged hospitalization. Please call your primary care doctor's office to set up an appointment in the next 2 weeks. You have an appointment with Dr. [**Last Name (STitle) **] on [**2167-8-21**] at 10:30 am. Please have your [**Date Range **] drawn prior to this visit she will decide when you will need your next Epogen shot. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**] Completed by:[**2167-8-22**]

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Discharge summary

report

Admission Date: [**2113-4-11**] Discharge Date: [**2113-5-31**] Date of Birth: [**2054-12-13**] Sex: F Service: MEDICINE Allergies: Unasyn / Penicillins / Ace Inhibitors Attending:[**First Name3 (LF) 30**] Chief Complaint: Recurrent gastrointestinal bleeding & hepatic encephalopathy Major Surgical or Invasive Procedure: IR Embolization Cardiac Resuscitation Intubation and Mechanical Ventilation Insertion and subsequent removal of central venous catheters, peripherally inserted central catheter History of Present Illness: 58f with HTN, DM2, PVD, HCV cirrhosis admitted [**4-11**] for sepsis from right heel ulcer with osteo who has since undergone AKA, course complicated by presumed C. diff, brisk lower gi bleed felt secondary to rectal tube erosion with tagged rbc scan showing descending colon bleed followed by angio and embolization all around [**Date range (1) 23445**], subsequent re-bleed complicated by volume overload, respiratory distress, asystolic arrest, now re-extubated with third episode of bleeding. Pt's initial bleed was associated with hypotension and she as intubated, occuring around [**Date range (1) 23445**] and was felt to be sucessfully embolized. She was extubated and her hct dropped from 35-28, but without unclear bleeding; she was transfused prbc's and ffp, developed respiratory distress, and had an asystolic arrest, from which she was resuscitated fairly quickly. Her hct stabilized, and she was easily extubated on [**5-18**], when she again developed copious brbpr, and her hct dropped from 33-21. Her hct stabilized in the MICU with monitoring and she was found to have a rectal ulcer (likely [**1-13**] prior rectal tube). After stabilizing, she was called out to the medical floor. Past Medical History: DM2 since [**2101**] HCV cirrhosis IVDU (cocaine, heroin) - pt says she has not been using HTN Polio with L leg weakness Thrombocytopenia EtOH abuse Chronic LBP GERD Eczema S/p CCY Lichen simplex chronicus H/o recurrent UTI's Chronic watery diarrhea c. dif colitis s/p vanc course Knee pain after MVA Chronic Scalp ulcer Gastritis/PUD gastroparesis HIV negative [**2111-1-13**] Hx of angioedema likely from ACEI or Unasyn Fractures of the transverse processes of L1 and L2 Social History: The patient's husband died from HIV [**2100**]. She has a son and a daughter. She is on disability. She has a history of alcohol and smoking abuse. She has a hx of IV drug use. Currently lives w/ daughter in apartment. Family History: Significant for diabetes of her mother and coronary artery disease of her father. She denies any family history of cancer or blood disorders. Physical Exam: t 96.9, bp 118/73, hr 93, rr 18, spo2 99% 2lNC gen- chronically ill female, poor function, mod tox heent- anicteric, op with mmm neck- no jvd, lad, or thyromegaly cv- rrr, s1s2, no m/r/g chest wall- tendern to palpation pul- no resp distress or acc muscle use, moves air well, sl bibasilar rales, otherwise clear though effort poor abd- soft, nt, nd, hyperactive bs extrm- r aka, puffy, [**Doctor First Name **] site seems intact, no drainage or erythema, lle without edema, warm/dry nails- no clubbing, thickened and discolored neuro- awake, answers yes/no questions, moans and cries, cn appear intact, moves extrm but doesn't follow commands Pertinent Results: [**2113-5-25**] 12:56AM BLOOD WBC-13.3* RBC-3.24* Hgb-10.1* Hct-30.0* MCV-92 MCH-31.2 MCHC-33.8 RDW-22.1* Plt Ct-132* [**2113-5-21**] 04:18AM BLOOD Neuts-81.4* Bands-0 Lymphs-12.5* Monos-5.0 Eos-0.7 Baso-0.4 [**2113-5-25**] 12:56AM BLOOD PT-27.1* PTT-46.9* INR(PT)-2.8* [**2113-5-23**] 10:10AM BLOOD Fibrino-152 [**2113-5-25**] 12:56AM BLOOD Glucose-235* UreaN-60* Creat-1.6* Na-139 K-3.9 Cl-113* HCO3-19* AnGap-11 [**2113-5-24**] 02:15AM BLOOD ALT-8 AST-23 LD(LDH)-239 AlkPhos-127* TotBili-0.8 [**2113-5-25**] 12:56AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.3 [**2113-4-29**] 08:45AM BLOOD Cortsol-22.4* [**2113-5-18**] 04:07PM BLOOD Type-ART pO2-118* pCO2-26* pH-7.42 calTCO2-17* Base XS--5 [**2113-5-22**] 02:15PM URINE RBC-43* WBC-92* Bacteri-MOD Yeast-MANY Epi-0 [**2113-5-22**] 02:15PM URINE RBC-43* WBC-92* Bacteri-MOD Yeast-MANY Epi-0 [**2113-5-22**] 02:15PM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD . CXR ([**5-20**]): - Probable CHF (Cardiomediastinal silhouette borderline) - enlarged azygos vein, c/w RHF . Angiography ([**5-18**]): - no sign of bleeding from SMA/[**Female First Name (un) 899**]/int iliacs . TTE ([**5-17**]): - normal LV function and EF, but not adquately visualized - no AS/AR - mild PAH . Tagged RBC Scan ([**5-11**]): - active GI bleed likely from the mid-descending colon. Sigmoidoscopy ([**5-19**]): Localized ulceration measuring approximately 1 cm with no bleeding was noted in the rectum (8 cm from anal verge). There was evidence of a vissible vessel seen, but it was not actively bleeding. Other No evidence of bleeding seen in the descending or transverse colon. Impression: Ulceration in the rectum (8 cm from anal verge) No evidence of bleeding seen in the descending or transverse colon. Recommendations: Do not insert rectal tube, correct coagulopathy. Labs at discharge: Hct 29.4 creatinine 1 bicarbonate 15 chloride 123 INR 1.5 platelets 108 cryoglobulins pending Brief Hospital Course: Ms. [**Doctor First Name 99356**] is a 58 year old F with HTN, DM2, HCV cirrhosis, who was admitted on [**4-11**] with right lower extremity osteomyelitis and sepsis, and following a prolonged hospital course is now s/p RLE AKA, ICU stay complicated by recurrent GI bleeding and hepatic encephalopathy. . # GI bleed -- During her ICU stay, the patient had multiple bouts of GI bleeding which were a result of an ulcerated rectal varix (secondary to rectal tube). The patient underwent arteriogram w/ unsuccessful embolization and was tranferred to the MICU in setting of continued GIB on [**2113-5-17**]. At that time, she was hemodynamically stable. However, her hct continued to drop, requiring multiple transfusions, and GI, surgery, and IR were involved. She underwent flex-sig by GI on [**2113-5-19**], which demonstrated a rectal ulcer, likely due to previous mushroom catheter. The site was cauterized, and her hct subsequently stabilized. Since moving from the ICU to the medical floor, her hematocrit has remained stable at ~ 30. We plan to check her Hct weekly with results reported to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Should the patient have visible GI bleeding, she should be transferred back to [**Hospital1 18**] as she could have a life-threatening bleed. . #Coagulopathy -- The patient has a persistently elevated INR, likely from liver disease & malnutrition; over the past week, her INR has been improving w/ INR 3.0 --> 1.5. Initially, her coagulopathy resulted in recurrent GI bleed and bleeding from AKA stump, and the patient was given numerous units of FFP, cryo, and vitamin K. At the present time, her INR is stabilized and continues to improve. Her only bleeding issue is a small amount of oozing from the lateral aspect of her AKA wound which should continue to improve over time. . # Diarrhea -- The patient had severe diarrhea during her hospital stay. She was treated for C diff (despite negative C diff stool samples) with vancomycin and flagyl. The patient has a long history of diabetic enteropathy causing profuse diarrhea. We started the patient on clonidine 0.1 mg TID with improvement in her diarrhea to [**1-14**] BMs daily. She was previously on lactulose for her liver disease which may have been contributing to her diarrhea; this was discontinued though the patient was kept on rifaximin. Repeat C diff on [**5-29**] also negative. Her goal is [**1-14**] BMs daily. She should continue to use lomotil and tincture of opium as necessary to achieve [**1-14**] BMs daily. If she has fewer than [**1-14**] BMs daily, this may cause encephalopathy due to her known cirrhosis. The patient should be monitored closely for confusion in this setting. . # Renal insufficiency -- The patient had transient acute renal failure likely due to fluid shifts resulting in pre-renal states; on the floor, her creatinine has corrected to normal. She was transiently on CVVHD in the ICU but has been making adequate urine since arrival on the floor. Her creatinine will be monitored weekly with results reported to Dr. [**First Name (STitle) **]. . # Metabolic acidosis -- Non-gap, likely [**1-13**] to GI loss of HCO3 from diarrhea. This will be monitored on outpatient labs. This should improve as the patient's diarrhea improves. . # S/p AKA -- The patient is s/p AKA on the right and the lateral aspect is open with minimal bloody drainage. During her stay, she received a full course of dapto & meropenem for osteomyelitis. - The patient will continue PO pain meds and lidocaine patches for pain control. . # Ulcerated skin wounds: The patient has multiple skin wounds, likely [**1-13**] PVD, poor wound healing in setting of DM. These lesions are multiple small ulcerated wounds, most notable on R hand (middle finger) w/ tendon exposed--this wound had been seen by plastics early in hospital stay. - The patient was evaluated by our wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 99357**]s are contained in the discharge instructions. - The patient should follow up with the [**Hospital 3595**] clinic for further wound management. . # Liver disease/cirrhosis, recent encephalopathy, HCV, c/b coagulopathy and poor synthetic function, thrombocytopenia - The patient has decompensated disease with multiple varices. She should stay on rifaximin. Her goal BMs are [**1-14**] daily. She is not currently on lactulose. . # CAD, PVD, and h/o WMA on TTE -- The patient was seen by cardiology in early [**Month (only) **]. She was noted to have wall motion abnormalities which may relflect underlying CAD with ischemia secondary to or preceding cardiac arrest. The patient cannot tolerate asa or clopidogrel given coagulopathy with bleeding. - The patient is currently on metoprolol [**Hospital1 **] and her BPs are in the 100s-120s. - If further afterload reduction is needed, hydralazine or nitrates could be considered. - The patient can discuss with her PCP the need for cardiology follow up. . # diastolic dysfunction, h/o volume overload and respiratory failure: The patient experienced respiratory failure in the setting of sepsis but is now comfortable on room air. . # DM2 -- the patient's blood sugars were well controlled on sliding scale insulin while on the medical floor. She should continue a diabetic diet. . # Stump Pain - She should continue lidocaine patch and dilaudid prn for pain control. . # Anxiety - The patient's prolonged micu stay caused agitation and anxiety which we continue to treat with low doses of ativan as necessary. . # FEN -- The patient is now tolerating a diabetic diet without difficulty. She should be maintained on aspiration precautions. . # PPx -- she should have a pneumoboot on her left lower leg given risk of sc heparin and recurrent bleeds; cont PPI [**Hospital1 **] for GI bleed risk and gastritis. # Precautions - mrsa, vre #Code -- full; patient discussed with our attending a change in code status and is still thinking about this. # HCP - [**Name (NI) **] Medications on Admission: (Meds on MICU Transfer) -RISS -Lorazepam 0.5mg IV Q4H:PRN -Albumin 25% (12.5 g) 12.5gm IV BID -Magnesium Sulfate IV Sliding Scale -Meropenem 500 mg IV Q24H started [**4-19**] -Daptomycin 250mg IV Q48H started [**4-18**] -Metronidazole 500mg PO BID started [**5-1**] -Vancomycin Oral 250mg PO Q6H started [**5-11**] -Metoprolol 25mg PO BID -Metolazone 5mg PO DAILY -Epoetin Alfa 4000 UNIT SC QMOWEFR -Famotidine 20mg PO Q24H Discharge Medications: 1. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) U Injection QMOWEFR ([**Month/Day (4) 766**] -Wednesday-Friday). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP < 100. 5. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed: hold if patient having < 2 BMS daily. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on at 8:00 am and off at 8:00 pm daily. 7. Opium Tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q4H (every 4 hours) as needed: please hold if patient having < 2 BMs daily. 8. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety: hold for sedation, confusion. 9. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: hold for sedation, RR < 10. Tablet(s) 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. INSULIN Continue INSULIN SLIDING SCALE (attached). 12. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for fever or pain: Max 2 g daily. 13. Outpatient Lab Work Please obtain chem 7 (electrolytes, creatinine) and hematocrit once every week and fax to Dr.[**Name (NI) 14047**] attention at ([**Telephone/Fax (1) 99358**]. Thank you. First lab draw on [**Last Name (LF) 766**], [**6-5**]. Discharge Disposition: Extended Care Facility: [**Hospital6 **]-[**Hospital1 **] Discharge Diagnosis: Primary: 1. Blood Loss Anemia 2. Mechanical Rectal Ulcer - Bleed 3. RLE Necrotizing Fascititis s/p AKA 4. NSTEMI 5. Left Heart Failure. 6. Cardiac Arrest. 7. Respiratory Failure 8. Acute Renal Failure Secondary: 1. Chronic Kidney Disease Stage II 2. Lumbar Compression Fractures with Secondary Hematoma. 3. Diabetic Gastroenteropathy. 4. Refractory Diarrhea NOS. 5. Chronic Metabolic Acidosis. 6. Malnutrition Moderate Degree. 7. Chronic Scalp Ulcer. 8. Osteoporosis. 9. Angioedema - ACE v Unasyn 10. Hepatitis C Cirrhosis 11. MRSA Bacteremia 12. Urinary Retentions 13. Diabetes Mellitus Type II 14. Hypoproliferative Anemia/Chronic Disease. 15. Elevated AFP. 16. Prior IVDA. 17. Prior ETOH Abuse. 18. Hypertension. 19. Left Lower Extremity Weakness 2nd Polio. 20. Depression and Anxiety Disorder. 21. s/p Cholecystectomy. Discharge Condition: Afebrile, normotensive, comfortable on room air Discharge Instructions: You have been treated for multiple issues: * Your infection in your leg caused an overwhelming infection. Eventually, you had an amputation due to this infection. You will follow up with Dr. [**Last Name (STitle) **] in the Vascular Surgery department for further management. * You had a lower gastrointestinal bleed due to rectal varices which bled in the setting of having a rectal tube. * You had kidney failure requiring dialysis temporarily. This has improved but your kidney function should be checked intermittently. You should return to the emergency room should you have any of the following problems: fever > 101, chills, nausea or vomiting with inability to keep down liquids or medications, worsening diarrhea, blood in your stools, confusion, warmth or redness of your right leg, increased drainage from the right thigh wound, or any other concerns. Followup Instructions: Dilated endometrial cavity - followup recommended via PCP You should return to see Dr. [**Last Name (STitle) **], your vascular surgeon, on [**2113-6-21**] at 11:15 am. This appointment is on the [**Location (un) 6332**] of the [**Hospital Unit Name **]. You should return to see your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please call [**Telephone/Fax (1) 250**] to see if she has any appointments in the next 2-4 weeks. You have an appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (NP) on Tuesday, [**2113-7-25**] at 12:40 pm in the Central Suite of [**Hospital 191**] Clinic ([**Location (un) **], [**Hospital Ward Name 23**] Center). Completed by:[**2113-5-31**]

[ "578.9", "730.07", "410.71", "698.3", "263.9", "584.5", "518.81", "707.8", "731.8", "041.7", "996.79", "440.24", "428.0", "E879.8", "008.45", "682.6", "286.7", "569.41", "572.2", "250.80", "536.3", "571.2", "486", "707.14", "401.9", "038.9", "995.92", "455.2", "285.1", "728.86", "138", "070.70", "250.60" ]

icd9cm

[ [ [] ] ]

[ "45.24", "99.06", "39.95", "99.15", "99.04", "83.21", "99.60", "84.3", "86.22", "86.04", "96.72", "99.07", "00.14", "96.6", "84.15", "84.17", "99.29", "99.05", "38.93", "83.39", "88.47" ]

icd9pcs

[ [ [] ] ]

13370, 13430

5333, 11336

358, 537

14315, 14365

3339, 5195

15277, 16035

2516, 2659

11811, 13347

13451, 14294

11362, 11788

14389, 15254

2674, 3320

258, 320

5214, 5310

565, 1768

1790, 2264

2280, 2500

56,309

172,642

45237

Discharge summary

report

Admission Date: [**2123-7-13**] Discharge Date: [**2123-7-19**] Date of Birth: [**2066-6-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1115**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 57yo F w/remote h/o diverticulosis and FH of UC but no known h/o hemorrhoids p/w BRBPR x 3 this morning after 2-3 days of intermittant diarrhea. Pt noticed BRBPR early this AM 3 times. Pt reports significant amount of blood in the water the 2nd and 3rd times as well as splashes of blood all over the toilet bowl and describes feeling like she "exploded" with blood. The third time she felt the need to void but then believes she only voided blood - no stool. Past Medical History: 1. Diverticulosis found on colonoscopy x 5-10 years, no episodes of diverticulitis 2. s/p cholecystectomy 3. breast biopsy, benign, [**2101**] 4. depression, on antidepressents in past (not now) 5. urinary incontinence 6. herniated disc 7. osteo arthritis, mostly of knees 8. varicose veins s/p stripping 9. remote ?h/o ulcer in [**2084**], no tx 10. MVP, first dx at early age, asymptomatic Social History: Lives alone. Doctoral trained psychologist, in practice in [**Location (un) 86**]. No children. No smoking history, no significant alcohol use, no illicit drug use. Family History: Sister has ulcerative colitis s/p ileostomy. FH of multiple kinds of cancer but no colon CA, as well as CHF. Physical Exam: Vitals: T:98.9 BP:132/73 P:97 R:18 O2:97ra General: Alert, pleasant, oriented, no acute distress HEENT: Sclera anicteric, MMM, EOMI Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: WWP. Pulses 1+ UE B/L. Significantly swollen legs and ankles bilaterally, but without pitting. Neuro: a/ox3, CNs [**2-25**] intact Pertinent Results: [**2123-7-13**] 01:15PM GLUCOSE-101 UREA N-18 CREAT-0.7 SODIUM-137 POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17 [**2123-7-13**] 01:24PM freeCa-1.15 [**2123-7-13**] 01:24PM HGB-14.1 calcHCT-42 [**2123-7-13**] 01:24PM GLUCOSE-100 LACTATE-1.3 NA+-140 K+-4.6 CL--99* TCO2-26 [**2123-7-13**] 01:35PM PT-12.4 PTT-24.3 INR(PT)-1.0 [**2123-7-13**] 04:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2123-7-13**] 04:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2123-7-13**] 04:20PM PLT COUNT-358 [**2123-7-13**] 04:20PM NEUTS-58.0 LYMPHS-36.2 MONOS-4.4 EOS-1.1 BASOS-0.4 [**2123-7-13**] 04:20PM WBC-5.8 RBC-4.15* HGB-12.4 HCT-36.5 MCV-88 MCH-30.0 MCHC-34.0 RDW-13.7 [**2123-7-13**] 04:45PM GLUCOSE-89 UREA N-16 CREAT-0.5 SODIUM-140 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 Hematocrit [**2123-7-19**] 05:20AM 30.5* [**2123-7-18**] 05:25AM 29.5* [**2123-7-17**] 06:40AM 30.9* [**2123-7-16**] 05:00PM 29.0* [**2123-7-16**] 10:17AM 31.3* [**2123-7-16**] 04:28AM 29.1* [**2123-7-15**] 08:07PM 30.9* [**2123-7-15**] 07:00PM 27.3* [**2123-7-15**] 12:50PM 34.5* [**2123-7-15**] 07:05AM 30.8* [**2123-7-14**] 09:05PM 30.7* [**2123-7-14**] 12:55PM 32.5* [**2123-7-14**] 07:10AM 32.4* [**2123-7-14**] 01:15AM 36.5 Colonoscopy [**2123-7-15**] Indications: Gastrointestinal Bleeding Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. The efficiency of a colonoscopy in detecting lesions was discussed with the patient and it was pointed out that a small percentage of polyps and other lesions can be missed with the test. A physical exam was performed. The patient was administered conscious sedation. The patient was placed in the left lateral decubitus position and the colonoscope was introduced through the rectum and advanced under direct visualization until the cecum was reached. Careful visualization of the colon was performed as the colonoscope was withdrawn. The colonoscope was retroflexed within the rectum. The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. Findings: Contents: Large amount of red blood and clots were seen in the rectum, sigmoid colon, descending colon and transverse colon. Excavated Lesions Multiple diverticula were seen in the whole colon. Diverticulosis appeared to be severe. Other Source of bleeding could not be identified, but most likely appears to be left sided diverticulosis. Impression: Blood in the rectum, sigmoid colon, descending colon and transverse colon Diverticulosis of the whole colon Source of bleeding could not be identified, but most likely appears to be left sided diverticulosis. Recommendations: Transfer to ICU IR consult for angiogram today Check HCT and transfuse as needed. Discussed with Dr. [**Last Name (STitle) **] Brief Hospital Course: The patient is a 57 year old woman who was admitted for evaluation and management of BRBPR with an initial hematocrit of 36.5. She was placed on a diet of clear liquids and GI was consulted. She was an appropriate candidate for colonoscopy to further evaluate the source of bleeding. The patient was prepared for colonoscopy with 4 liters of magnesium citrate. She handled the colonoscopy procedure well but she was admitted to the ICU due to findings of large amount of red blood and clots in the rectum, sigmoid colon, descending colon and transverse colon as well as a drop in hematocrit from 36.3 to 27.3. Multiple diverticula were seen in the whole colon and the diverticulosis appeared to be severe. The source of bleeding could not be identified, but most likely was due to left sided diverticulosis. She remained stable in the ICU and did not requires any blood transfusion. After transfer to floor, her diet was advanced without difficulty. In regards to her anemia, the patient was found to be anemic on admission with a hematocrit of 36.5 which fell to 32.4 on day 2 of admission and 30.8 the morning of day 3. The patient, however, remained hemodynamically stable and asymptomatic throughout her stay and her hematocrit remained stable. She did not require any blood transfusions during her admission. She was discharged with warning signs for recurrent anemia and GI bleeding and with follow up arranged in [**Hospital **] clinic. Medications on Admission: Ditropan patch Tylenol, PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 3. Oxybutynin 3.9 mg/24 hr Patch Semiweekly Sig: One (1) patch Transdermal semiweekly. Discharge Disposition: Home Discharge Diagnosis: Primary: -Diverticulosis -Acute blood loss anemia Discharge Condition: Stable, tolerating regular diet Discharge Instructions: You were admitted for gastrointestinal bleeding. While you were here, you had a colonoscopy performed. The colonoscopy showed diverticulosis with fresh blood, although not actively bleeding. You were given medications for pain as well as your home medication for urinary symptoms. Your blood levels were stable while you were on the medicine floor. Please continue taking all of your home medications as prescribed. -Oxybutynin patch, 2/week Please take following medications as needed if you experience constipation. -Senna 8.6 mg Tab one tablet (2 times a day) as needed for constipation. -Docusate Sodium 100 mg Capsule, one capsule (2 times a day) as needed for constipation. Please call your physician or return to the emergency department if you develop any of the following: vomiting, recurrent bloody diarrhea, severe abdominal pain, significant dizziness or light-headedness, loss of consciousness, or any other concerning symptoms. Followup Instructions: Please see gastroenterologist, Dr. [**First Name8 (NamePattern2) 4370**] [**Name (STitle) 37455**]. ([**Telephone/Fax (1) 2233**] at 3pm on [**2123-7-27**]. Please see your PCP [**Name9 (PRE) **],[**First Name3 (LF) 2946**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 2205**] within 2 weeks after your hospitalization.

[ "424.0", "285.1", "596.51", "562.12", "625.6", "722.2", "715.36", "300.4", "V45.79" ]

icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

7131, 7137

5257, 6703

343, 356

7231, 7264

2166, 5234

8263, 8592

1459, 1569

6781, 7108

7158, 7210

6729, 6758

7288, 8240

1584, 2147

276, 305

384, 845

867, 1261

1277, 1443

23,239

106,174

13258

Discharge summary

report

Admission Date: [**2118-3-31**] Discharge Date: [**2118-4-20**] Date of Birth: [**2071-11-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: fluid overload Major Surgical or Invasive Procedure: ultrafiltration paracentesis pleurocentesis History of Present Illness: 46 yo F with history of CHF, atrial fibrillation, DMII, HTN who presented to the ED with dyspnea. * Ms. [**Known lastname **] states that she was originally diagnosed with CHF, as well as afib and DM while hospitalized at NEBH in [**2114**]. She reports no prior ETT or catheterizations, though was begun on beta-blocker and lasix. The mechanism of her CM is unknown, and she denies any pregnancies, ETOH use, or IVDU. She is unsure of her dry weight, though notes that she has weighed as little as 180lbs last fall. She has not weighed herself recently, though believes that she has gained significant weight recently (reports '[**63**] lb weight gain over 1 week', though has not weighed herself). She noted increased abdominal girth approximately 2 months ago, and was seen by her PCP/cardiologist, Dr. [**Last Name (STitle) 9751**], who doubled her lasix dose from 160 QD -> [**Hospital1 **]. However, despite the increased lasix dose, she has experienced worsening dyspnea on exertion progressively, with worsening abdominal distension, LE edema and PND (has stable 2 pillow orthopnea), early satiety and decreased PO intake. SHe has not experienced any chest discomfort or nausea. She has noted LH recently, and self d/c'd her atenolol several days ago. * ED course notable for administration of lasix IV, as well as administration of nitropaste. She was also noted to have afib with RVR, with rates in the 100-130 range, though was not given beta-blocker out of concern for further decompensating her CHF Past Medical History: CHF - diagnosed [**2114**] CM - RV/LV systolic dysfunction, etiology unknown. No prior ETT or Cath. afib diagnosed [**2114**], s/p cardioversion (reamined in SR for 24 hrs), chronically anticoagulated on coumadin obesity Social History: denies smoking/ETOH Family History: h/o pancreatic CA Physical Exam: T97 BP 80-90s/40-60s HR 70 Gen-sitting in chair eating breakfast in no acute distress HEENT-anicteric, oral mucosa moist, neck supple,JVD to ear CV-rrr, no r/m/g resp-slight decreased breath sounds R base, no wheezes/rhonchi [**Last Name (un) 103**]-distended, +ascites, active bowel sounds, nontender extremites-no femoral bruit, no peripheral edema, DP 1+bilaterally, small ulcers on distal LE in bandages, bilateral inguinal 2cm nontender LAD, no axillary or cervical LAD skin-no rash or lesions GU-pelvic exam: no cervical motion tenderness or visible lesions. normal external anatomy. no masses on bimanual exam. no breast masses. Pertinent Results: Admission Labs [**2118-3-31**]: PT-15.5* PTT-25.9 INR(PT)-1.5 WBC-8.2 RBC-6.04* HGB-10.4* HCT-36.2 MCV-60* MCH-17.3* MCHC-28.8* RDW-20.0* NEUTS-78* BANDS-0 LYMPHS-10* MONOS-10 EOS-1 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 PLT COUNT-379 GLUCOSE-208* UREA N-77* CREAT-2.1* SODIUM-130* POTASSIUM-3.3 CHLORIDE-84* TOTAL CO2-30* ANION GAP-19 CALCIUM-10.0 PHOSPHATE-5.5* MAGNESIUM-2.6 ALT(SGPT)-10 AST(SGOT)-19 CK(CPK)-46 ALK PHOS-128* AMYLASE-83 TOT BILI-1.2 LIPASE-85* LD(LDH)-188 CK(CPK)-38 CK-MB-NotDone cTropnT-0.03* URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 RBC-14* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG OSMOLAL-305 UREA N-301 CREAT-35 SODIUM-32 %HbA1c-6.4* TSH-5.3* Free T4-1.2 calTIBC-484* VIT B12-705 FOLATE-7.5 FERRITIN-29 TRF-372* RET MAN-1.0 Hb Electropheresis: Hgb A-96.9 Hgb S-0 Hgb C-0 Hgb A2-2.1* Hgb F-1.0 . Discharge Labs: [**2118-4-20**] 08:46AM BLOOD WBC-7.7 RBC-5.01 Hgb-9.2* Hct-33.0* MCV-66* MCH-18.4* MCHC-28.0* RDW-22.0* Plt Ct-488* Glucose-96 UreaN-27* Creat-1.2* Na-136 K-4.1 Cl-97 HCO3-26 AnGap-17 Calcium-9.9 Phos-2.8 Mg-1.9 . Other: HIV Ab-NEGATIVE SPEP-NO SPECIFIC ABNORMALITIES SEEN UPEP-MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING. NO MONOCLONAL IMMUNOGLOBULIN SEEN. NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN CEA-5.3* AFP-2.8 CA125-632* CA [**32**]-9=18 [**Doctor First Name **]-POSITIVE Titer-1:40 . C.CATH Study Date of [**2118-4-19**] 1. One vessel coronary artery disease. . The LAD had a total occlusion of the distal vessel with the apical LAD filling by left to left collaterals 2. Moderately elevated right and left sided filling pressures. 3. Moderately elevated pulmonary arterial hypertension. 4. Depressed cardiac output. Cardiac index was low (at 2.2 L/min/m2). . STRESS Study Date of [**2118-4-13**] No anginal symptoms or ECG changes from baseline. Left ventricular enlargement with depressed EF calculated at 32% with regional wall motion abnormalities as above involving the septum, apex and inferior walls. No reversible defects identified. . ECHO Study Date of [**2118-3-31**] LA/RA/LV/RV dilated. LVEF 20-30%. Severe apical akinesis and midventricular HK. Abnormal septal motion/position consistent with right ventricular pressure/volume overload. Branch pulmonary arteries are dilated. There is a small pericardial effusion subtending the right atrial free wall, without evidence of cardiac tamponade. PA systolic pressure is significantly elevated. 3+MR, 3+TR. . Pleural Fluid Cell Block [**2118-4-18**]: Negative. Peritoneal fluid cell block/cytology [**2118-4-11**]: Negative. . EGD [**2118-4-14**]: Duodenal mucosa with chronic inactive duodenitis and mild villous shortening. Chronic inactive duodenitis with Brunner gland hyperplasia and gastric mucous cell metaplasia. . CT ABDOMEN W/O CONTRAST [**2118-4-11**] 1) No sign of fistulous communication between the bowel and intrabdominal ascites. 2) Large amount of slightly hyperdense intra-abdominal ascites, possibly representing high proteinaceous contents vs small blood. 3) 6.0 x 3.4 cm Spigelian hernia in right abdominal subcutaneous tissue. 4) Possible omental carcinomatosis vs. fat-stranding in RLQ. 5) Left 8th old rib fracture. 6) Diffuse diverticulosis without evidence of acute diverticulitis. . US ABD LIMIT, SINGLE ORGAN [**2118-4-5**] 1) Patent intrahepatic vasculature, as discussed above. Dilated hepatic veins and IVC consistent with right heart failure. 2) Cholelithiasis. 3) Large right pleural effusion. Moderate abdominal ascites. 4) Mild splenomegaly. . PELVIS, NON-OBSTETRIC [**2118-4-12**] Normal pelvic ultrasound without evidence of ovarian or adnexal masses. Ascites. . UNILAT UP EXT VEINS US RIGHT [**2118-4-2**] Thrombosis of the right IJ and right subclavian vein. . CXR [**2118-4-12**]: Pleural effusion associated with compression atelectasis of the right lower lobe and the right middle lobe w/free layering. Several healing rib fractures on the left side are noted. Primarily involving left fifth, sixth, and seventh ribs laterally.the right upper lobe and the entire left lung are clear. No evidence of pneumothorax. . Micro Blood, Urine, Ascites, and Pleural Fluid cultures with no growth Brief Hospital Course: 46 year old female with CHF, atrial fibrillation, DMII, HTN, and asthma presents with CHF exacerbation (compaint of dyspnea in the ED) refractory to increased home lasix dosages. Admitted to the CCU for tailored therapy after failing nesiritide on the floor. * Cardiovascular Echocardiogram revealed global chamber dilation with estimated EF 20-30%. The apex was akinetic. Additionally, there was severe hypokinesis of the midventricular segments and right ventricular. Valvular abnormalities included 3+MR and 3+TR. Persantine-MIBI stress testing reported left ventricular enlargement with depressed EF calculated at 32%. Regional wall motion abnormalities involved the septum, apex and inferior walls. No reversible defects were noted. No angina or ECG changes were seen. Diagnostic cardiac catheterization showed single vessel disease with a discrete distal LAD 100% lesion with collateral supply. A large differential for dilated cardiomyopathy was possible; including ischemic cardiomyopathy, infectious cardiomyopathy (viral cardiomyopathy, HIV infection, Chagas' disease, Lyme disease), toxic cardiomyopathy(Alcohol, Cocaine, Medications,Trace elements, familial dilated cardiomyopathy, inherited disorders(Hereditary hemochromatosis, neuromuscular diseases, left ventricular noncompaction, sideroblastic anemias and thalassemias, peripartum cardiomyopathy, tachycardia-mediated cardiomyopathy, takotsubo cardiomyopathy, SLE, Sarcoidosis, or nutritional deficiencies. Tests indicated the following: TSH normal, ferritin normal, HIV negative, [**Doctor First Name **] negative. The patient was enrolled in the UNLOAD trial and randomized to Ultrafiltration, enabling removal of over 28L of fluid. In conjunction with diuresis, paracentesis, and pleurocentesis over 35L of fluid was lost over the hospital visit. A fluid restricted, low Na diet was followed. She was discharged on a diuretic regimen including aldactone and lasix. Follow up in Dr.[**Name (NI) 23312**] clinic was arranged. For coronary artery disease, the patient received ASA, metoprolol, atorvastatin, and lisinopril. For atrial fibrillation diagnoses in [**2115**] in addition to a right internal jugular venous thrombus discovered this hospital visit, she received IV heparin per sliding scale while an inpatient. Rate was controlled with metoprolol. She was discharged on coumadin with lovenox bridging. She was monitored on telemetry continuously revealing chronic atrial fibrillation with occasional tachycardia (with nebulizer therapy) and PVCs. . Pulmonary The patient had history of obstructive sleep apnea and COPD. She had chronic cough improved after nebulizer therapy. She was started on atrovent, fluticasone inhalation, and singulair. The patient had persistent right pleural effusion most likely due to CHF. Pleurocentesis was performed by interventional pulmonology service and appeared as a transudative fluid with the same consistency as the ascites. . Gastrointestinal The patient had chronic ascites with high CA-125 in 600s, prompting an extensive oncologic workup (see below). Pracentesis on [**4-6**] removed approximately 3L ascitic transudate lacking malignant cells. Approximately 5L bloody fluid was removed by paracentesis on [**4-11**] and was similarly transudative. However, the source of the blood was unclear. Fluid cultures and gram stains were all negative. Thus, an abdominal CT with oral contrast was performed that did not reveal a bleeding source. The right lower quadrant appeared to have possible omental carcinomatosis versus fat stranding. Abdominal ultrasound revealed no venous occlusion, dilated hepatic vein consistent with heart failure, cholelithiasis, large right pleural effusion, moderate ascites, and mild splenomegaly. Endoscopic gastroduodenoscopy gastritis and 2 nonbleeding anterior gastric ulcers. The biopsy was consistent with chronic inactive duodenitis with Brunner gland hyperplasia and gastric mucous cell metaplasia. No sprue was seen. Colonoscopy noted diverticulosis and hemorrhoids. She did not have transaminitis or hyperbilirubinemia. . Endocrine The patient followed a routine regimen including glargine and insulin per sliding scale for diabetes. Thyroid function tests were normal. . Hematology Hematocrit was stable with baseline in the low 30s. She had microcytic anemia with iron deficiency. She was treated with iron supplementation and vitamin C. HbA2 was reduced on electropheresis and should be rechecked after iron stores are replenished in order to evaluate for alpha thallesemia trait. SPEP/UPEP was negative. No active bleeding source was found on colonoscopy or EGD; however, a small bowel source could not be exluded. . Oncologic Workup The patient had elevated ca-125 and slightly increased CEA. She also had microcytic anemia and a thrombotic disorder. On exam, bilateral inguinal lymphadenopathy was present and the firm 2cm mobile nodes were occasionally tender. No other lymphadenopathy was found and the abdominal CT did not show enlarged mesenteric nodes. Ovaries appeared normal on ultrasound. Cytology from fluid samples were negative for malignant cells. The markers tested have limited specificity and can be elevated nonspecifically in ascites. Serum CA19-9 level was normal. The patient was recommended to aggressively continue preventative screening measures, including repeat pelvic exam/pap smear, baseline mammogram, and routine skin and breast exams. She will follow up with gynecology as an outpatient. . Renal The patient had chronic renal insufficiency with baseline creatinine near 1.6. She had transient acute failure likely prerenal (low FeUrea) from decreased perfusion from CHF exacerbation and diuresis with lasix. . Skin Self-excoriations improved on benadryl, triamcinolone, and sarna lotion. Alopecia resulted from trichotillomania that the patient has had since a teenager. . Wellbutrin was prescribed to assist with both tobacco abuse and mood. Medications on Admission: Singulair, pantoprazole, insulin , atrovent, iron gluconate 300 mg p.o. [**Hospital1 **], digoxin, aspirin, metoprolol, atorvastatin 40 mg, furosemide 160mg [**Hospital1 **], coumadin Discharge Medications: 1. Folic Acid 1 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. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 11. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) Units Subcutaneous at bedtime: Take 30 units every evening as directed. Disp:*1 vial* Refills:*0* 12. 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:*0* 13. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:*20 injections* Refills:*0* 14. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 15. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*15 Tablet(s)* Refills:*0* 16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* 17. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily). 19. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis: (Benadryl). 20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 22. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 23. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 24. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*2 MDI units* Refills:*0* 25. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day). 26. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*2 vials* Refills:*0* 27. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 28. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Disp:*15 Capsule, Sustained Release(s)* Refills:*0* 29. Insulin Syringe Syringe Sig: use as directed Miscell. as directed: Disp one box (100 count). Disp:*1 box* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Decompensated congestive heart failure, with EF 25% iron deficiency anemia hypercholesterolemia Discharge Condition: good Discharge Instructions: Please take all your medications as described on the next page. Weigh yourself each day and call your doctor if you gain more than 3 pounds. It is very important that you adhere to a low salt diet (less than 2 grams of sodium per day.) Consume no more than 1.5 liters of liquids per day. Followup Instructions: Be sure to follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 9752**] within 2 weeks. Please follow up with Dr. [**Last Name (STitle) **]. Call for appointment ([**Telephone/Fax (1) 3512**]) within 1 week. You must have your INR (coumadin effect level) measured on Friday [**4-22**]. At that time they will adjust your coumadin dose if needed. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "535.50", "796.4", "428.0", "496", "414.01", "280.9", "427.31", "584.9", "453.8", "425.4", "250.00" ]

icd9cm

[ [ [] ] ]

[ "99.78", "45.23", "88.56", "54.91", "45.16", "37.23", "45.13", "34.91", "00.13", "99.07" ]

icd9pcs

[ [ [] ] ]

16682, 16688

7208, 13170

331, 377

16828, 16834

2909, 3845

17172, 17720

2216, 2235

13404, 16659

16709, 16807

13196, 13381

16858, 17149

3861, 7185

2250, 2890

277, 293

405, 1918

1940, 2163

2179, 2200

15,602

179,811

44930

Discharge summary

report

Admission Date: [**2141-11-13**] Discharge Date: [**2141-11-17**] Date of Birth: [**2065-11-12**] Sex: F Service: MED Allergies: Penicillins / Sulfonamides / Biaxin / Heparin Agents / Levaquin / Amiodarone Attending:[**First Name3 (LF) 330**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Mechanical Ventilation and Intubation History of Present Illness: 76F h/o cardiomyopathy (EF 15-20%), CHF s/p biV PPM, 4+MR, TR, CAD, PAF, COPD, asthma, amio lung toxicity who presented with chest pain radiating to back. CTA negative for dissection, though showed LLL, LUL pneumonia. Patient had breifly been on esmolol drip prior to CTA, and noted to be hypotensive after the angiogram, despite turning esmolol off. Also got 6mg IV morphine. Febrile to 101.1, though Lactate ~2, WBC 10. Started sepsis protocol, though pressure remain low despite initially dopamine (stopped after she developed tachy to the 130s) and later levophed/vasopressin. Past Medical History: CHF, BiV, MR, CAD, PAF, COPD, Asthma. Social History: The patient is widowed, is a prior 80-pack- year smoker who quit approximately 10 years ago and who does not drink. She has a daughter named [**Name (NI) 46250**] whose phone number is [**Telephone/Fax (1) 96101**] or [**Telephone/Fax (1) 96102**]. Family History: Non-contributory. Physical Exam: GEN - MILD RESP DISTRESS. HEENT - CLEAR OP. DRY MM. RESP - DIFF SOFT RHONCHI. NO CRACKLES. DECR BS AT BASES. CV - TACHYCARDIC. II/VI LLSB SEM TO APEX. ABD - S/NT/ND. EXT - NO CCE. Pertinent Results: [**2141-11-13**] 02:55PM BLOOD freeCa-1.10* [**2141-11-15**] 12:32AM BLOOD freeCa-1.26 [**2141-11-17**] 05:09PM BLOOD freeCa-0.97* [**2141-11-13**] 10:22AM BLOOD O2 Sat-66 [**2141-11-13**] 06:57PM BLOOD O2 Sat-70 [**2141-11-14**] 11:10AM BLOOD O2 Sat-68 [**2141-11-15**] 02:05AM BLOOD Hgb-10.1* calcHCT-30 O2 Sat-65 [**2141-11-15**] 02:49PM BLOOD Hgb-9.6* calcHCT-29 [**2141-11-15**] 06:49PM BLOOD Hgb-9.3* calcHCT-28 O2 Sat-97 [**2141-11-16**] 01:54PM BLOOD Hgb-10.6* calcHCT-32 O2 Sat-55 [**2141-11-13**] 08:52AM BLOOD Lactate-2.0 [**2141-11-13**] 11:53AM BLOOD Lactate-2.3* [**2141-11-13**] 02:55PM BLOOD Lactate-2.4* [**2141-11-14**] 12:38AM BLOOD Lactate-2.5* [**2141-11-14**] 05:23PM BLOOD Lactate-2.7* [**2141-11-15**] 02:49PM BLOOD Lactate-5.9* [**2141-11-16**] 10:57AM BLOOD Lactate-5.2* [**2141-11-16**] 01:46PM BLOOD Lactate-4.6* [**2141-11-17**] 02:57PM BLOOD Lactate-3.3* [**2141-11-13**] 10:22AM BLOOD Type-MIX pO2-35* pCO2-52* pH-7.28* calHCO3-25 Base XS--3 [**2141-11-14**] 12:38AM BLOOD Type-ART Temp-38.4 Rates-26/ Tidal V-450 PEEP-5 O2-50 pO2-77* pCO2-38 pH-7.19* calHCO3-15* Base XS--12 -ASSIST/CON Intubat-INTUBATED [**2141-11-14**] 05:23PM BLOOD Type-ART Tidal V-420 PEEP-5 O2-50 pO2-100 pCO2-35 pH-7.21* calHCO3-15* Base XS--13 -ASSIST/CON Intubat-INTUBATED [**2141-11-15**] 02:03PM BLOOD Type-ART Temp-39.1 Rates-26/ Tidal V-460 PEEP-8 O2-50 pO2-72* pCO2-42 pH-7.22* calHCO3-18* Base XS--10 Intubat-INTUBATED [**2141-11-15**] 10:19PM BLOOD Type-MIX Temp-39.4 [**2141-11-16**] 01:46PM BLOOD Type-ART pO2-93 pCO2-25* pH-7.31* calHCO3-13* Base XS--11 [**2141-11-16**] 09:10PM BLOOD Type-ART Temp-38.8 Rates-27/0 Tidal V-500 PEEP-8 O2-40 pO2-85 pCO2-29* pH-7.39 calHCO3-18* Base XS--5 -ASSIST/CON Intubat-INTUBATED [**2141-11-17**] 05:09PM BLOOD pO2-191* pCO2-24* pH-7.51* calHCO3-20* Base XS--1 Comment-NONE SPECI [**2141-11-16**] 05:28PM BLOOD Digoxin-0.2* [**2141-11-17**] 04:15AM BLOOD Digoxin-0.4* [**2141-11-14**] 02:44AM BLOOD Vanco-11.7* [**2141-11-16**] 02:00AM BLOOD Vanco-16.2* [**2141-11-17**] 04:15AM BLOOD Vanco-26.4* [**2141-11-13**] 06:30AM BLOOD CRP-0.12 [**2141-11-13**] 06:30AM BLOOD Cortsol-31.7* [**2141-11-13**] 10:06PM BLOOD Cortsol-17.2 [**2141-11-13**] 12:28PM BLOOD calTIBC-363 Ferritn-132 TRF-279 [**2141-11-16**] 01:40PM BLOOD Hapto-86 [**2141-11-13**] 06:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.7 [**2141-11-14**] 05:22PM BLOOD Calcium-7.9* Phos-4.4 Mg-2.2 [**2141-11-17**] 05:01PM BLOOD Calcium-7.5* Phos-4.3 Mg-4.1* [**2141-11-13**] 08:18PM BLOOD CK-MB-6 cTropnT-0.05* [**2141-11-15**] 01:49PM BLOOD CK-MB-20* MB Indx-7.0* cTropnT-0.49* [**2141-11-16**] 02:00AM BLOOD CK-MB-25* MB Indx-1.5 cTropnT-0.73* [**2141-11-16**] 06:34AM BLOOD CK-MB-20* MB Indx-1.1 cTropnT-0.73* [**2141-11-16**] 10:30AM BLOOD CK-MB-22* MB Indx-1.0 cTropnT-0.78* [**2141-11-17**] 05:01PM BLOOD CK-MB-14* MB Indx-1.1 cTropnT-0.42* [**2141-11-13**] 08:18PM BLOOD Lipase-53 [**2141-11-13**] 06:10AM BLOOD CK(CPK)-106 [**2141-11-13**] 12:28PM BLOOD CK(CPK)-138 [**2141-11-15**] 01:49PM BLOOD LD(LDH)-215 CK(CPK)-285* TotBili-0.5 [**2141-11-16**] 06:34AM BLOOD CK(CPK)-1840* [**2141-11-16**] 01:40PM BLOOD ALT-1272* AST-2410* LD(LDH)-3921* AlkPhos-36* TotBili-1.2 [**2141-11-17**] 05:01PM BLOOD CK(CPK)-1294* [**2141-11-13**] 06:10AM BLOOD Glucose-106* UreaN-78* Creat-2.5* Na-142 K-4.6 Cl-105 HCO3-24 AnGap-18 [**2141-11-13**] 08:18PM BLOOD Glucose-105 UreaN-64* Creat-2.2* Na-139 K-3.9 Cl-119* HCO3-17* AnGap-7* [**2141-11-16**] 06:34AM BLOOD Glucose-79 UreaN-54* Creat-3.0* Na-128* K-4.2 Cl-101 HCO3-13* AnGap-18 [**2141-11-17**] 05:01PM BLOOD Glucose-99 UreaN-63* Creat-3.3* Na-138 K-4.0 Cl-105 HCO3-19* AnGap-18 [**2141-11-13**] 10:06PM BLOOD FDP-40-80 [**2141-11-15**] 06:02AM BLOOD Fibrino-541*# [**2141-11-17**] 04:15AM BLOOD Fibrino-414* [**2141-11-13**] 06:10AM BLOOD PT-12.3 PTT-21.2* INR(PT)-.9 [**2141-11-14**] 02:44AM BLOOD PT-14.3* PTT-35.3* INR(PT)-1.3 [**2141-11-17**] 05:01PM BLOOD Plt Ct-81* [**2141-11-15**] 12:18AM BLOOD Neuts-83* Bands-2 Lymphs-8* Monos-6 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2141-11-13**] 06:10AM BLOOD WBC-9.1# RBC-3.87* Hgb-12.0 Hct-35.8* MCV-93 MCH-31.1 MCHC-33.6 RDW-14.9 Plt Ct-266 [**2141-11-14**] 02:44AM BLOOD WBC-11.0# RBC-3.35* Hgb-10.5* Hct-32.2* MCV-96 MCH-31.4 MCHC-32.7 RDW-15.2 Plt Ct-179 [**2141-11-15**] 12:18AM BLOOD WBC-25.7* RBC-3.32* Hgb-10.3* Hct-32.1* MCV-97 MCH-31.0 MCHC-32.1 RDW-15.3 Plt Ct-171 [**2141-11-16**] 02:00AM BLOOD WBC-11.9* RBC-2.81* Hgb-8.8* Hct-26.7* MCV-95 MCH-31.3 MCHC-32.9 RDW-15.5 Plt Ct-130* [**2141-11-16**] 10:30AM BLOOD WBC-11.3* RBC-3.59*# Hgb-11.0*# Hct-33.7*# MCV-94 MCH-30.7 MCHC-32.7 RDW-15.6* Plt Ct-84* [**2141-11-17**] 05:01PM BLOOD WBC-14.5* RBC-2.11*# Hgb-6.6*# Hct-18.8*# MCV-89 MCH-31.5 MCHC-35.4* RDW-16.2* Plt Ct-81* Brief Hospital Course: Ms [**Known lastname **] was admitted to the MICU with septic shock, presumed secondary to an aggressive pneumococcal pneumonia. Unfortunately, she succumbed to her illness and passed away despite aggressive management. 1. Sepsis: The patient was admitted with sepsis presumed secondary to a pneumonia. She was febrile and hypotensive throughout her course. The MUST Protocol was activated on admission. She was aggresively volume resuscitated with lactated ringer's early in her course and received 10 liters on her first hospital day to target CVPs of [**11-16**] given that she was considered quite preload dependent given her severe MR. She initially required multiple vasopressors including, norepinephrine, vasopressin, phenylephrine and dobutamine. Although she stabilized in the middle of her course, requiring less vasopressor therapy, she soon required more. An initial ACTH stimulation test was abnormal and she was continued on Hydrocortisone and Fludrocortisone. Per MUST protocol, and given her APACHE II score at 28-30, she was commenced on Xigris for a four day course. Regarding the causative organism, only gram negative rods were found on her sputum gram stain. No other culture data was remarkable. She was continued on Ceftazidime, Vancomycin, and Levofloxacin for broad coverage of gram negative pneumonia, along with community-acquired pneumonia. Unfortunately, the patient had a drop in her hematocrit on her last day admission, which was secondary to a lower GI bleed and likely secondary to a septic/DIC-like coagulopathy and Xigris therapy. She then had ventricular fibrillation degenerating into pulseless electrical activity and ulitmately her death. 3. Resp Distress: Although pnemonia was the main contributing factor, she also had underlying severe MR, amio toxicity, COPD, and asthma. She was continued on Albuterol and Ipratropium. She remained on assist-controlled mechanic ventilation. 4. CAD: Although an initial cycling of her cardiac enzymes on admission were negative, she subsequently developed myocardial ischemia in the setting of persistent tachycardia and afterload augmentation on vasopressor therapy. During Xigiris therapy, her home Plavix was held. 5. ARF: Her baseline Cr was in the 2.0's and was 2.5 on admission. Over her course her Cr trended up and her urine output was poor. This was considered secondary to renal vasoconstriction secondary to septic shock, vasopressors, and worsening cardiac function. Given her fluid overload later in her course and a stabilization of her blood pressure on one to two pressors, she underwent CVVHD to optimize her cardiac status. She was followed by the renal and CHF teams. Medications on Admission: 1. Bumex 3 mg p.o. b.i.d. 2. Lisinopril 5 mg q.d. 3. Toprol XL 50 mg q.d. 4. Digoxin 0.125 mg twice a week. 5. Plavix 75 mg q.d. 6. Zithromax day 2. 7. Imdur 30 mg at h.s. 8. Prilosec. 9. Premarin 3 q.d. 10. Combivent q.i.d. 11. Advair b.i.d. 12. [**Doctor First Name **]. 13. Questran. Discharge Medications: None Discharge Disposition: Home Facility: Death Discharge Diagnosis: Primary Diagnosis: Sepsis, Pneumonia, Death. Secondary Diagnosis: Demand Cardiac Ischemia, Mitral Regurgitation, Anemia, Acute Renal Failure. Discharge Condition: Death Discharge Instructions: None Followup Instructions: None

[ "427.5", "785.52", "410.71", "995.92", "491.21", "038.3", "428.0", "414.8", "585", "584.9", "424.0", "578.9", "518.81", "481", "286.6" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "38.95", "38.93", "00.11", "89.64", "99.62", "96.72", "99.05", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

9398, 9421

6339, 9011

345, 384

9606, 9613

1573, 6316

9666, 9673

1339, 1358

9369, 9375

9442, 9442

9037, 9346

9637, 9643

1373, 1554

295, 307

412, 994

9508, 9585

9461, 9487

1016, 1055

1071, 1323

6,238

110,360

23113

Discharge summary

report

Admission Date: [**2142-12-11**] Discharge Date: [**2142-12-14**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: Peripheral vascular disease and left foot two toe gangrene Major Surgical or Invasive Procedure: 1) Abdominal aortic unilateral extremity run off, angioplasty of superficial femoral artery, popliteal tibioperoneal trunk and peroneal arteries, stent of superficial femoral artery and Cypher stent to tibioperoneal trunk and peroneal artery. 2) Amputation left 1st and 2nd toes History of Present Illness: 84yF with known bilateral lower extremity vascular disease, seen as an outpatient and scheduled for angiogram and angioplasty. She was unable to make it into the hospital on her scheduled day secondary to inclement weather. She was noted to have a fever at her nursing home, and was sent to an outside hospital for evaluation. They then transferred her from the outside hospital to [**Hospital1 18**] for evaluation. Social History: Resident of [**Hospital6 59521**] Home nonsmoker or drinker Family History: unknown Physical Exam: Vital signs: 97.6-100-24 97/46 oxygen saturation room air 97% General: no acute distress HEENT: no caroitd bruits Lungs: clear to auscultation bilaterally Heart: irregular irregular rythmn ABd: begnin PV: left ist and 2nd toe witrh ulcerations on dorasl aspect of toes with erythema to mid leg. Pulses: radial and femoral pulses 1+ bilaterally, distal [**Last Name (un) **] monophasic dopperable signal only bilaterally. Neuro: grossly intact Pertinent Results: [**2142-12-11**] 01:40PM WBC-9.3 RBC-4.23 HGB-12.0 HCT-35.9* MCV-85 MCH-28.3 MCHC-33.3 RDW-15.3 [**2142-12-11**] 01:40PM NEUTS-89.2* BANDS-0 LYMPHS-7.7* MONOS-2.6 EOS-0.4 BASOS-0 [**2142-12-11**] 01:40PM HYPOCHROM-OCCASIONAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2142-12-11**] 01:40PM PLT COUNT-282 [**2142-12-11**] 01:40PM PT-15.4* PTT-30.4 INR(PT)-1.5 [**2142-12-11**] 01:40PM GLUCOSE-91 UREA N-20 CREAT-0.4 SODIUM-141 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 [**2142-12-11**] 09:41PM WBC-6.2 RBC-3.78* HGB-10.4* HCT-31.4* MCV-83 MCH-27.4 MCHC-33.0 RDW-15.2 [**2142-12-11**] 09:41PM NEUTS-88.6* LYMPHS-7.1* MONOS-3.4 EOS-0.8 BASOS-0.1 [**2142-12-11**] 09:41PM MICROCYT-1+ [**2142-12-11**] 09:41PM PLT COUNT-268 [**2142-12-11**] 01:40PM GLUCOSE-91 UREA N-20 CREAT-0.4 SODIUM-141 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11 Brief Hospital Course: [**2142-12-11**] Evaluated in the emergency room and admitted to vascular surgical service for Iv antibiotics and wound care and bed rest. Blood cultures were drawn results no growth but not finallized. Wound culture gram positive cocci in pairs.Patient give Vancomycin 1 GM, levofloxcin 500mgmnIV and flagyl 500mg IV before admission. She underwent a arteriogram with angioplasty to left distal SFA, popliteal arteries and Tibial peroneal trunk , and peroneal arteries.Stenting of SFA,[**Doctor Last Name **] and proximal AT and peroneal arteries without complication and was transfered to ICU for moniteringover night. [**2142-12-12**] Podiatry consulted.Postoperative cadrdiac enzymes were CK 236, MB 4 Troponin <0.01 No EKG changes. Patient underwent radical debridment of bone and soft tissue of 1st and 2nd toe. [**2142-12-13**] [**2142-12-14**] continued to do well. wounds claen dry and intact with no erythema, induration of tenderness. Coumadin restarted and heparin discontinued. Patient transfered to Nursing home for continued recovery. Will continue antibiotics of augmentin 500mgm tid x 7 days. Dressing dsd to amputation site qd. Keep foot elevated when in chair or bed. Partial weight bearing left heel when ambulating essential distances. Follwup as directed in 2 weeks. Medications on Admission: new: augmentin 500mgm tid x 7 days percocet tab 5/325mgm [**12-15**] q4-6h prn Discharge Medications: 1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Discharge Disposition: Extended Care Facility: Baypointe - [**Hospital1 1474**] Discharge Diagnosis: Peripheral vascular disease and left foot two toe gangrene blood loss anemia, transfused, corrected HTN hypercholesterolemia osteoporosis arthritis h/o CVA h/o Left leg sarcoma Discharge Condition: Stable Discharge Instructions: [**Name8 (MD) **] MD for temp >101.5, redness or drainage from groin puncture site, redness or drainage from left toe amputation sites, persistent pain, or any other questions. You may put partial weight on your left heel, but do not bear weight on your left toes. moniter INR as needed to maintain goal of 2.0-3.0 Followup Instructions: With Dr. [**Last Name (STitle) **] in 2 weeks. Please call for appt. [**Telephone/Fax (1) 2625**] With Dr. [**First Name (STitle) 3209**] [**Telephone/Fax (1) 543**] Completed by:[**2142-12-14**]

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icd9cm

[ [ [] ] ]

[ "84.11", "00.55", "39.90", "39.50", "99.04" ]

icd9pcs

[ [ [] ] ]

4809, 4868

2570, 3860

322, 603

5089, 5097

1632, 2547

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49,016

166,449

1231

Discharge summary

report

Admission Date: [**2125-6-22**] Discharge Date: [**2125-6-25**] Date of Birth: [**2055-10-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: L ureteral obstructing stone Major Surgical or Invasive Procedure: Nephrostomy tube placement History of Present Illness: Mr. [**Known lastname 7747**] is a 69 year old male with history of bilateral renal stones s/p ESWL (extracorpeal shockwave lithotripsy) [**5-16**] and [**1-16**] with Dr. [**Last Name (STitle) 986**], self catheterization, HTN, hyperlipidemia who presents from OSH with L ureteral obstructing stone. Renal U/S [**4-17**] identified no hydronephrosis, 7mm RLP stone, 5mm LLP stone. On [**6-20**] he developed L flank pain radiating to groin and one episode nausea, vomiting. The pain resolved spontaneously, however it returned on [**6-21**]. Associated with this he developed a fever, chills and general malaise. This morning he presented to [**Hospital3 **] Hospital with fever and left renal colic. T 101.9 there. UA positive for infection. CT scan identified two left UVJ stones measuring 9.4x4.2mm together with moderate hydroureteronephrosis. He was given Toradol, levaquin, zofran and IVF. He was transferred to [**Hospital1 18**] for further management. In the ED, vital signs were T 98.4, BP 90/54, HR 98, RR 20, O2 sat 97% on RA. SBP noted as low as nadir to 80/54, normally in 120-130s. He was given 4L NS with moderate response in blood pressure. He was given a dose of Ceftriaxone and Levofloxacin for broad coverage. He was seen by urology in the ED and plan for left nephrostomy tube in the AM. On arrival to the [**Hospital Unit Name 153**] the patient is awake and alert. He is feeling well with no pain. The last time he experienced pain was in [**Hospital3 **] Hospital. Past Medical History: Nephrolithiasis s/p lithotripsy BL ESWL [**2125-2-5**] L ESWL [**2124-5-30**] Renal atrophy on the right Gout on allopurinol Hypertension Urinary retention with daily catheterization (QID) Hyperlipidemia Hypothyroidism Social History: He is a retired teacher, does not smoke. He drinks two Martinis several times a week and occasionally drinks heavier. Family History: He has two children who are healthy. He has no family history of kidney disease, hypertension, or kidney stones. Physical Exam: General Appearance: Well nourished, No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL, EOMI, MMM Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No murmurs appreciated. Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles at bilateral bases, otherwise clear Abdominal: Soft, Non-tender, Bowel sounds present, Distended, Obese Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Warm Back: No CVA tenderness bilaterally Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): , Movement: Purposeful, Tone: Not assessed Pertinent Results: [**2125-4-12**] Renal US: RENAL ULTRASOUND: The right kidney measures 12.2 cm and the left kidney measures 12.5 cm. A 7-mm shadowing non-obstructing calculus is seen in the lower pole of the right kidney. A 1.6-cm simple cyst is also seen in the lower pole of the right kidney, laterally. A 5-mm non-obstructing calculus is also seen in the lower pole of the left kidney. There is no evidence of hydronephrosis or renal masses in either kidney. The bladder is moderately distended and demonstrates irregular thickening in the superoanterior bladder wall. IMPRESSION: 1. Kidneys of normal size, without hydronephrosis. Non-obstructing calculi. 2. Focal thickening of the bladder wall. Comparison with prior exams is recommended if available. Otherwise, further evaluation is recommended with cystoscopy. PROCEDURE: Chest portable AP on [**2125-6-22**] at 08:59. COMPARISON: [**2125-6-22**] at 06:37. HISTORY: 69-year-old man with renal stones and sepsis with acute shortness of breath and wheezing;left lung on last film, evaluate for pulmonary edema vs. aspiration. FINDINGS: The mild pulmonary edema has decreased in both lungs. A small left pleural effusion is seen on this examination; previously the left costophrenic angle was not included. No right pleural effusion is seen. The heart size is top normal; stable. IMPRESSION: 1. Improvement of mild pulmonary edema. 2. Small left pleural effusion. 3. No aspiration. HISTORY: 69-year-old man with left obstructing calculi and pyelonephritis. Request for percutaneous left sided nephrostomy. RADIOLOGISTS: The procedure was performed by Dr. [**Last Name (STitle) 7748**] and Dr. [**Last Name (STitle) 2492**], the attending radiologist, who was an active participant during the procedure. PROCEDURE AND FINDINGS: Informed consent was obtained from the patient after the risks and benefits of the procedure were explained. Preprocedural timeout was performed documenting patient identity. Patient was placed prone on the fluoroscopic table and the left flank was prepped and draped in the normal sterile fashion. Using ultrasound guidance, a 21 Gauge Chiba type needle was used to puncture the left renal pelvis. A 0.018 wire was advanced through the needle into the renal pelvis under fluoroscopic guidance. The needle was removed and the inner portion of an Accustick sheath was advanced over the wire under fluoroscopic guidance into the renal pelvis and the inner dilator and the wire were removed. Small amount of contrast material was injected through the Accustick sheath. The nephrostogram demonstrated a markedly dilated collecting system. Another 21 Gauge needle was used to get access into a posterior superior calix, under fluoroscopic guidance. A 0.018 guidewire was advanced through the needle into the renal pelvis. The needle was removed and exchanged for an Accustick sheath. The inner dilator and the wire were removed. A small amount of contrast material was injected and confirmed good position in the renal pelvis, through posterior calix with immediate return of slightly cloudy appearing urine. At this time, a sample of urine was removed and sent for analysis and culture. A 0.035 Amplatz guidewire was advanced through the caliceal access, and coiled into the renal pelvis. The Accustick sheath was removed and the tract was dilated with 7 and 8 French dilators, and an 8 French nephrostomy catheter was advanced over the guide wire into the renal pelvis. Under fluoroscopic observation, the nephrostomy catheter was coiled in the renal pelvis, and the pigtail was locked and secured. The patient tolerated the procedure well with no immediate complications. The catheter was secured using an 0 silk sutures and a Stat lock device. Conscious sedation was provided during the procedure for patient comfort in addition to 1% lidocaine used for topical anesthetic. 75 mcg of Fentanyl and 1.5 mg of Versed were given throughout the total intraservice time of 20 minutes in divided doses during which the patient's hemodynamic parameters were continuously monitored. IMPRESSION: 1. Successful placement of 8 French left-sided percutaneous nephrostomy. The catheter is attached to a bag for external drainage. 2. Demonstration of known marked left-sided hydronephrosis and marked hydroureter. Urine samples obtaind nduring the procedure were sent for microbiological evaluation. Please follow- up on these results. Thank you. [**2125-6-22**] 06:19AM TYPE-ART TEMP-39.3 PO2-69* PCO2-51* PH-7.23* TOTAL CO2-22 BASE XS--6 INTUBATED-NOT INTUBA COMMENTS-NEBULIZER [**2125-6-22**] 06:19AM LACTATE-3.5* [**2125-6-22**] 05:39AM GLUCOSE-108* UREA N-15 CREAT-0.8 SODIUM-141 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-19* ANION GAP-18 [**2125-6-22**] 05:39AM CK(CPK)-1233* [**2125-6-22**] 06:19AM LACTATE-3.5* [**2125-6-22**] 05:39AM GLUCOSE-108* UREA N-15 CREAT-0.8 SODIUM-141 POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-19* ANION GAP-18 [**2125-6-22**] 05:39AM CK(CPK)-1233* [**2125-6-22**] 05:39AM CK-MB-15* MB INDX-1.2 cTropnT-0.04* [**2125-6-22**] 05:39AM ALBUMIN-3.6 CALCIUM-7.7* PHOSPHATE-3.4 MAGNESIUM-1.5* [**2125-6-22**] 05:39AM WBC-2.6*# RBC-3.81* HGB-11.8* HCT-36.0* MCV-95 MCH-31.0 MCHC-32.7 RDW-13.9 [**2125-6-22**] 05:39AM PLT COUNT-131* [**2125-6-22**] 05:39AM PT-14.4* PTT-25.5 INR(PT)-1.2* [**2125-6-21**] 10:16PM LACTATE-1.9 K+-3.7 [**2125-6-21**] 10:00PM GLUCOSE-126* UREA N-19 CREAT-0.9 SODIUM-136 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15 [**2125-6-21**] 10:00PM estGFR-Using this [**2125-6-21**] 10:00PM WBC-11.9*# RBC-3.93* HGB-12.5* HCT-35.7* MCV-91 MCH-31.7 MCHC-34.9 RDW-14.3 [**2125-6-21**] 10:00PM NEUTS-87* BANDS-8* LYMPHS-4* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2125-6-21**] 10:00PM HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2125-6-21**] 10:00PM PLT COUNT-195 [**2125-6-21**] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2125-6-21**] 10:00PM PLT COUNT-195 [**2125-6-21**] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 OUTSIDE HOSPITAL RECORDS: [**Hospital3 **] HOSPITAL PER PHONE REPORT ON [**6-23**]. BLOOD CULTURES DRAWN ON [**6-21**]: 4/4 BOTTLES GNR- look prelim like e coli URINE CULTURE: > 100,000 GNR 2 species 1. e coli- pansensitive (sensitive to cipro and ceftriaxone) 2. ?e coli mucoid strain, [**Last Name (un) 36**] pending repeat urine / blood cultures at [**Hospital1 18**] on [**6-22**] NGTD [**2125-6-21**] 10:00PM URINE BLOOD-MOD NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2125-6-21**] 10:00PM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 Brief Hospital Course: UPJ STONE causing pyleonephritis and hydrouretur, urosepsis: initially fluid resuscitated and given levofloxacin for urosepsis. Broaded to vanc / zosyn and then changed laterally to cefepime- vanc discontinued. Left on cefepime until final cultures returned with sensitivities included klebsiella and e coli, both [**Last Name (un) 36**] to cipro and bactrim. Discharged on ciprofloxacin. Complained of some mild rash on back, not consistent with drug allergy, but told that if rash worsens to switch to bactrim. Nephrostomy tube placed for obstructing UPJ stone on left. Plan for urology follow up as outpatient (seen inpatient) given active infection, intervention on stone will be after no longer active infection per urology. PULMONARY EDEMA: mild, echo normal, after fluid resuscitation. Auto diuresed after nephrostomy tube placed. HYPOTENSION: fluid responsive SBP to 80, after nephrostomy tube placed no longer hypotensive. Never on pressors or intubated in ICU> Medications on Admission: Allopurinol 300mg daily Atenolol 50mg daily ASA 81mg daily Simvastatin 20mg daily Synthyroid 88mcg daily MVI daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: ONLY TAKE THIS WHEN NOT TAKING BACTRIM. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: bacteremia UTI ureteral obstruction Discharge Condition: stable Discharge Instructions: Please complete antibiotics. Call PCP with abdominal or back pain, fever, or other concerning symptoms. If rash gets worse (spreads down lower on back or to chest/abdomen) please discontinue ciprofloxacin as this may indicate a drug allergy. At that point you should take Bactrim instead. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 986**] in 2 weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2125-6-25**]

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icd9cm

[ [ [] ] ]

[ "55.02" ]

icd9pcs

[ [ [] ] ]

11718, 11769

9995, 10976

345, 373

11849, 11858

3261, 9972

12196, 12416

2303, 2418

11141, 11695

11790, 11828

11002, 11118

11882, 12173

2433, 3242

277, 307

401, 1909

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53512

Discharge summary

report

Admission Date: [**2201-11-20**] Discharge Date: [**2201-12-2**] Date of Birth: [**2140-6-19**] Sex: M Service: MEDICINE Allergies: Mango Flavor / Chocolate Flavor Attending:[**First Name3 (LF) 905**] Chief Complaint: cough, myalgias, influenza-like illness Major Surgical or Invasive Procedure: mechanical intubation and ventilation bronchoscopy History of Present Illness: 61 yoM w/ h/o early onset parkinson's disease s/p placement of deep brain stimulator (with battery packs in chest), presenting with two days of fever, cough, HA and myalgias. At home he measured his temp to 102.9, describes diffuse myalgias, right frontal HA (worse than usual HA), and cough productive of a yellow sputum. He has no ill contacts, and he has had the seasonal but not the H1N1 flu vaccine. . He has a cardiac history significant for mitral valve prolapse, status post mitral annuloplasty in [**2199-6-16**]. His course was c/b RV dysfunction (which seemed to resolve per notes but he remains on lasix 20 mg QD). . In the ED, VS were 102.0, 98, 104/85, 20, 979% NRB (was marked as 96% on 2LNC with RR 43). He was placed on a NRB. He was given levofloxacin 750 mg IV x 1, ceftriaxone 1 g IV x 1, and tamiflu 75 mg QD, as well as percocet and sinemet. His CXR showed inreased interstitial markings but no cephalization, effusions or focal infiltrates. Past Medical History: - Mitral Insufficiency s/p MVR with 28-mm [**Doctor Last Name 405**] annuloplasty band in 7/99. Postoperative course was c/b progressive dyspnea with bilateral effusions as well as an admission for right ventricular failure of unknown origin that was transient and may have been [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21160**]-like syndrome. - CHF: TTE [**10-24**] showed EF 50-55% - Dyslipidemia - Parkinson disease s/p DBS placement [**11-23**], diagnosed at age 38 - Right anterior clinoid meningioma - History of RSV Pneumonia - Depression - Herniated disk (T7-T8 and C3) - s/p Vasectomy - s/p T&A - s/p Laparoscopic cholecystectomy for recurrent biliary colic [**11-22**] - s/p Hypertrophic sternal scar removal - Nephrolithiasis - Fe deficiency anemia - sleep-disordered breathing, no longer on CPAP Social History: The patient is married and lives with his wife. [**Name (NI) **] has rare alcohol, and no tobacco use. He denies any drug use. He worked in the publishing field. Family History: The patient's brother suffered from an MI at the age of 51. The patient's father died at the age of 59 secondary to melanoma. The patient's mother died of breast cancer and had a history of diabetes and CAD. His grandfather and uncle had CAD. Physical Exam: On admission: VS on arrival to the ICU: T 100.1 (s/p Tylenol), HR 109, BP 120/68, 97% NRB General: somewhat short of breath, speaking in shorter sentences though conversant (note: shortness of breath seems position and is worse after turning to side) HEENT: o/p clear; often closes eyes because is more comfortable (explained [**1-19**] PD procedure) Lungs: crackles at bases [**12-20**] on left, 1/2 up on right; rhonchorous thorughout Cardio: no JVP, RR, no m/r/g appreciated (difficult to hear with lung sounds) Abd: soft, NTND Extremities: no pedal/LE edema; WWP Skin: no rashes, no petechiae, NT to touch above DBS pockets At discharge: Pertinent Results: On admission: notable for WBC 12.9, Hct 38.7, Cr 1.0, lactate 1.0 [**2201-11-19**] 07:05PM BLOOD WBC-12.9* RBC-4.97 Hgb-12.3* Hct-38.7* MCV-78* MCH-24.7* MCHC-31.7 RDW-15.5 Plt Ct-309 [**2201-11-19**] 07:05PM BLOOD Neuts-91.5* Lymphs-4.2* Monos-3.3 Eos-0.6 Baso-0.4 [**2201-11-19**] 07:05PM BLOOD Glucose-119* UreaN-23* Creat-1.1 Na-141 K-3.9 Cl-105 HCO3-25 AnGap-15 [**2201-11-20**] 02:45AM BLOOD Calcium-8.4 Phos-2.5*# Mg-1.7 EKG: NSR 90, RA enlargement, nml axis, no ST changes TTE: IMPRESSION: Suboptimal image quality. Well seated mitral annuloplasty ring with increased gradient and mild mitral stenosis. Moderate puomonary artery systolic hypertension. Right ventricular cavity enlargement with mild free wall hypokinesis. Compared with the prior study (images reviewed) of [**2199-10-24**], the transmitral gradient is lower, but with smaller estimated mitral valve area. The right ventricular cavity is slightly larger now with free wall hypokinesis. The estimated pulmonary artery systolic pressure is similar. LVEF >55% CXR PA/LAT [**2201-11-19**]: HISTORY: Influenza-like symptoms, cough. Evaluate for pneumonia. FINDINGS: There is mild cardiomegaly, stable. There is no focal consolidation, effusion or large pneumothorax. There is slight increased fine reticular interstitial prominence which may be chronic. Bilateral pectoral stimulator devices with the leads extending off the film are unchanged in position. IMPRESSION: No focal consolidation identified. MICRO: Respiratory Viral Culture negative Influenza A/B by DFA - negative Legionella Urinary Antigen - negative Multiple blood, sputum, BAL and urine cultures - negative C. diff negative x 2 DISCHARGE LABS: [**2201-12-2**] 07:20AM BLOOD WBC-12.7* RBC-4.49* Hgb-10.9* Hct-35.0* MCV-78* MCH-24.2* MCHC-31.0 RDW-15.6* Plt Ct-609* [**2201-12-2**] 07:20AM BLOOD Neuts-73* Bands-0 Lymphs-10* Monos-8 Eos-9* Baso-0 Atyps-0 Metas-0 Myelos-0 [**2201-12-2**] 07:20AM BLOOD Glucose-119* UreaN-26* Creat-1.1 Na-138 K-4.4 Cl-99 HCO3-28 AnGap-15 Brief Hospital Course: This is a 61 yoM with parkinson's disease s/p deep brain stimulator and h/o mitral valve prolapse s/p annuloplasty, admitted with two days of influenza-like illness, later blossoming into a possible multi-focal pneumonia versus severe DFA negative influenza infection of lungs, which ultimately required admission to the ICU and subsequent intubation and respiratory failure. Patient was subsequently extubated and called out to the floor and clinically improved off abx. #. Respiratory failure: Although the patient's respiratory status seemed fairly stable when initially admitted, within the first day of admission ([**11-20**]) he had to be intubated for respiratory fatigue. He was extubated on [**11-25**] (5 days). His respiratory failure seemed due to a primary pulmonary process (his PNA), rather than a cardiogenic process, as he had fever and there is no evidence of heart failure on exam or pulm edema/congestion on CXR. He was called out to the floor with persistent O2 requirement and continuation of IV antibiotics. Although the patient was initially treated with levoquin and ceftriaxone for CAP, his antibiotics were subsequently changed to Vancomycin 1000 mg IV Q 12H (Started on [**11-23**]) and CefePIME 2 g IV Q12H (started on [**11-21**] to replace ceftriaxone) to cover aspiration pathogens, given the pt's underlying neuromuscular disorder. Vancomycin, in particular, was started due to the patient's copious brown secretions while intubated and resulting concern for MRSA pneumonia. However, it was eventually thought that after multiple negative blood cultures, sputum cultures, and even a negative BAL that pt perhaps never had a PNA and rather had a DFA negative severe influenza pulmonary infection. On the floor, antibiotics were slowly tapered off and the patient continued to do very well. His O2 requirement resolved with aggressive pulmonary physical therapy and incentive spirometry, and nebs. The patient was discharged satting in the high 90s on room air. #. CARDIAC, VOLUME STATUS: The patient was monitored carefully to maintain euvolemia. He was given prn lasix while in the MICU to maintain euvolemia. He was continued on home ASA 81 mg and crestor. He was given more lasix on the floor to assist in the O2 requirement and did not seem to improve the O2 requirement. The pt also did not seem volume overloaded and therefore lasix was discontinued. The pt was euvolemic upon discharge. #. PARKINSON's: While admitted, the patient's deep brain stimulator was interrogated and found to be without any significant problems. The patient was continued on his home regimen of Sinemet, Tamsar, and Mirapex. He underwent speech and swallow evaluation on [**11-26**], which he failed. He was started on tube feeds at that time. Speech and swallow eval was repeated while the patient was on the floor, and the patient's swallow ability was completely normal. The NG tube was pulled and the pt was started on a regular diet without any problems. #. ANXIETY: continued home klonopin PRN, Zoloft. Anxiety was found to be a significant component of the patient's occasional episodes of respiratory distress 4after extubation, and were managed successfully with prn morphine IV (as well as prn nebs and lasix). Pt was found to have some delerium overnights, which may have been multifactorial with his baseline Parkinsons, NG tube, Foley catheter, tele, waking up pt to give sinemet (which he apparently never took at night at home). Therefore, once all the tubes and monitors were pulled and stopped waking pt up for sinimet his sun-downing resolved. Medications on Admission: ASA 81 mg Colace Crestor Benefiber Lasix 20 mg QD Klonopin 1 mg !HS PRN Miralax Mirapex Nedium Sinemet 25/100 Q3 hours Tasmar 100 mg TID Zoloft 100 mg QD Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Pramipexole 1 mg Tablet Sig: One (1) Tablet PO 5 times daily (). 4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tolcapone 100 mg Tablet Sig: One (1) Tablet PO 3 times daily (). 6. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours). 9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Miralax 17 gram/dose Powder Sig: One (1) PO once a day: 1 tbsp by mouth daily in [**3-25**] ounces of water. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*2 Inhalers* Refills:*0* 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*2 Inhalers* Refills:*0* 14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for Cough. Disp:*2 Bottle* Refills:*0* 15. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for Cough. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: 1) community acquired pneumonia, 2) respiratory failure Secondary: 1) Parkinson's disease 2) Anxiety Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted for shortness of breath and were found to be in respiratory failure and transferred to the intensive care unit for intubation and continuous respiratory support. Your respiratory failure was initially thought to be due to a severe pneumonia but after multiple negative cultures and x-rays, it was thought more likely that you had a severe influenza virus infection of your lungs. Over time you improved significantly and now can be discharged home with physical therapy. It was a pleasure to take care of you here at [**Hospital1 18**]. We have made the following changes to your medications, which are mainly aimed at clearing the residual mucous build-up in your lungs from your recent infection: -START Acetylcysteine 20% 1mL every two hours as needed for secretions. -START Ipratropium bromide 1 inhalation every 6 hours as needed for wheeze -START Albuterol 1 inhalation every 6 hours as needed for wheeze -START Guaifenesin 5-10mL by mouth every 6 hours as needed for cough -START Benzonatate 1 capsule by mouth every 6 hours as needed for cough It is also important that you use a walker until you regain your strength back after physical therapy. Followup Instructions: Appointment #1 MD: Dr. [**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) **] Specialty: PCP Date and time: [**Last Name (NamePattern1) 2974**], [**12-4**] at 2:00pm Location: PERSONAL [**Hospital **] HEALTH CARE, P.C., [**Location (un) **], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**] Phone number: [**Telephone/Fax (1) 1408**] Special instructions if applicable: Dr. [**Last Name (STitle) **] works closely with Dr. [**Last Name (STitle) 1407**]. You will see Dr. [**Last Name (STitle) **] for your follow-up appt. Appointment #2 MD: Dr. [**First Name (STitle) **] [**Name (STitle) **] Specialty: Neurology Date and time: [**Last Name (LF) 2974**], [**12-25**] at 9:00am Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg [**Location (un) 858**], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 41967**] [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2201-12-17**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10642, 10700

5400, 8988

332, 385

10854, 10854

3354, 3354

12204, 13222

2431, 2676

9192, 10619

10721, 10833

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3335, 3335

253, 294

413, 1384

3368, 5032

10868, 10975

1406, 2235

2251, 2415

19,851

191,637

44298

Discharge summary

report

Admission Date: [**2125-1-22**] Discharge Date: [**2125-2-16**] Date of Birth: [**2061-2-21**] Sex: M Service: MEDICINE Allergies: Motrin / Codeine / Nortriptyline Attending:[**First Name3 (LF) 1070**] Chief Complaint: Clotted AV graft Major Surgical or Invasive Procedure: Right femoral hemodialysis line placement Left femoral line placement Incision and drainage of abscess x2 Revision of AV graft Endotracheal intubation History of Present Illness: 63 year-old gentleman with multiple medical problems including HIV, HCV, ESRD on HD, who presented to the emergency department with clotted left sided AV graft, resulting in inability to receive HD. Patient otherwise at baseline, denying systemic complaints of fevers, chills, nausea, vomiting, chest pain, or shortness of breath. Patient was afebrile in the ED. IV access was difficult to obtain, and patient refused femoral stick. Labs were obtained through ABG, which revealed K 5.2, for which patient received [**Doctor First Name 233**]-exalate. Transplant surgery consulted in ED, plan for intervention in AM. Admitted to medicine given complicated medical history. . Of note, patient recently discharged on [**2125-1-12**] after admission for leukocytosis. He was found to have an anterior chest wall abscess at the site of a previous HD fistula with subsequent incision and drainage of the abscess by surgery. The patient was discharged to finish a 14-day course of vancomycin (started [**1-4**]), last received dose on [**2125-1-17**]. Past Medical History: 1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**]. 2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy, charcot foot, nephropathy, and ? mild retinopathy. 2) Chronic renal failure on Hemodialysis and graft infections, thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**]. On HD on tues, thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit - ([**Telephone/Fax (1) 17592**] / Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94989**] 3) [**Female First Name (un) 564**] esophagitis 4) Hepatitis C: genotype IB-> last viral load [**8-/2124**] 175,000 5) Congestive heart failure: echocardiogram [**10/2123**] w/ EF 60%. 6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and circumcision during hospitalization. 7) Hypertension 8) Hypercholesterolemia 9) LE Diabetic ulcers 10) Herpes zoster of the left mandibular distribution of the trigeminal nerve. [**2115**] 11) R suprapatellar abscess: [**2115**]. 12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**] 13) Obesity 15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative colonoscopies. 16) Anemia: [**2117**]. Started Epogen. 18) Colonic Polyps 19) Gastritis with large hiatal hernia. 20) Lipodystrophy 21) Charcot foot: dx in [**9-12**]. 22) Colonic AVM: seen on [**3-8**] colonoscopy on the ileocecal valve. Treated with thermal therapy. At that time was also offerred hormonal therapy, but this was deferred. 23) Positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No abnormalities on CT chest in [**2121**]. 24) MRSA- grew out from culture from L anterior chest wound Social History: Pt. lives alone. He has a hx of tobacco abuse (quit 20 yrs ago), alcohol abuse (quit >20 yrs ago) and heroin and cocaine abuse (quit >20 yrs ago). Has a girlfriend who visits him frequently and is involved in his care. Family History: Noncontributory Physical Exam: VS: T 96.8; BP 113/72; HR 78; RR: 20; O2 96% RA; FS 101 Gen: Pleasant, well appearing, obese gentleman lying comfortably in hospital bed HEENT: Anicteric. Muddy sclerae. MMM. OP clear. NECK: Supple, No LAD, No JVD. CV: RRR. nl S1, S2. CHEST: R anterior chest with dressing C/D/I at site of prior abscess. Wound with pus. L anterior chest with surgical scars from access attempts, no palpable thrill over graft LUNGS: faint crackles at base, otherwise clear to auscultation bilaterally ABD: obese. soft, NT, ND. BS normoactive EXT: Ulceration, chronic venous stasis changes. Mild symmetric LE edema, DPs diminished. Pertinent Results: Admission Labs: [**2125-1-22**] 01:01PM freeCa-1.26 [**2125-1-22**] 01:01PM HGB-10.7* calcHCT-32 [**2125-1-22**] 01:01PM GLUCOSE-76 LACTATE-0.6 NA+-133* K+-5.2 CL--96* TCO2-25 [**2125-1-22**] 01:01PM TYPE-ART PH-7.28* INTUBATED-NOT INTUBA . Discharge Labs: Hct 25.9, WBC 6.1, Plt 198, Cr 6.7, K 3.4, Na 137, Vanco trough 22.3 . Chest CT ([**1-22**]) New 2.5 x 2 cm fluid collection with air-fluid level consistent with an abscess along the course of a resected segment of the right dysfunctionalized loop catheter. There is evidence of infection tracking along the residual loop catheter superiorly. The entire extent may not be accessed on this study. Clinical correlation is recommended. . Left Arm AV Fistulogram ([**1-25**]) Left AV fistulogram and ultrasound Doppler showed completely thrombosed AV fistula. . Fluoroscopy Guided Placement/Replacement/Removal of Central Line ([**1-26**]): Uneventful exchange of a short temporary, for a long permanent / 'tunneled' femoral hemodialysis catheter, as above. The catheter is ready to use. . Tunneled Cath Placement ([**2-2**]): 1. Successful exchange of previously placed right femoral catheter for a new 55 cm 14.5 French dual lumen tunneled hemodialysis catheter via the right common femoral vein with termination in the upper IVC at the T11/12 interspace level. 2. Unable to perform AV fistulogram and thrombectomy intervention at this time, as above. 3. Left IJ vein small in caliber with apparent occlusion inferiorly, thus tunneled neck line not placed. . CT Chest/Abd/Pelvis: IMPRESSION: 1. Previously seen small abscess in the right subcutaneous tissue appears smaller on today's study, with small amount of residual stranding. 2. Loop graft in left subcutaneous chest with surgical staples. 3. No focal consolidation seen within the lungs. No masses identified. Small amount of extrapleural fat seen in the right side. Bibasilar atelectasis. 4. Interval worsening of previously described destructive changes within the spine. 5. Large hiatal hernia. . CT Head: FINDINGS: Image quality is slightly degraded due to patient motion. Allowing for this, no intracranial mass lesion, hydrocephalus, shift of normally midline structures is apparent. There is a chronic left pontine lacunar infarct. Mild mucosal thickening in the posterior aspect of the sphenoid sinus is present. There is bilateral atherosclerotic calcification of the cavernous carotid arteries. The density values of the brain parenchyma are within normal limits. There is thickening of the posterior pharyngeal soft tissues, possibly secondary to increased lymphatic tissue, but infectious etiology cannot be entirely excluded, as opposed to a neoplastic process. Osseous structures are unremarkable. IMPRESSION: 1. No acute intracranial pathology, including no sign of intracranial hemorrhage. 2. Chronic left pontine lacunar infarct. 3. Thickening of the posterior pharyngeal soft tissues, which could be secondary to increased lymphatic tissue. An infectious etiology cannot be discriminated from a neoplastic disorder. . ECHO: Conclusions: The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2125-2-7**], no major change is evident. . Micro: C. diff negative x3. Wound swab positive for MRSA, sensitive to Vanco f/u blood cultures NGTD Brief Hospital Course: 63 y.o. male with multiple medical problems including HIV, HCV, ESRD on HD, who presents with clotted left-sided AV graft. The following issues were investigated during this hospitalization: . # Clotted graft: S/P thrombectomy of left chest AV graft, but reclotted during HD that same night. A temporary right femoral line was then placed with no complications. An order was placed to assess the left chest AV fistula, but due to a misunderstanding, a left arm AV fistulogram was performed by IR which showed a completely clotted graft. The left arm AV fistulogram had not been in use for several months. An AV fistulogram of the left chest was not performed until [**2-2**] and both this fistulogram and a possible thrombectomy were complicated by nausea/vomiting under local anesthesia. For this reason, IR felt uncomfortable proceeding unless the patient was under general anesthesia. Additional imaging at this time showed a left IJ that was small in caliber and occluded, preventing placement of a line in this location. The patient's only access, a right femoral line had been inadvertently displaced by the patient and was thus repositioned and tunneled on [**2-2**]. Because of the multiple complications with access, no more attempts were made and the patient continued HD through the tunneled right femoral line. Other access should be pursued to allow the right femoral line to come out. . # Hypotension/Resp Failure: Post op from the OR for I+D of his abscess on [**2-6**], the patient was found to be hypotensive and bradycardic. He was resusitation in the PACU and transferred to the MICU. ABG demonstrated findings consistent with hypercarbic respiratory failure. Patient was initially intubated and maintained on a ventilator. As his respiratory status improved, the patient was extubated. His hypotension was initially treated with pressors. However, he was weaned from these medications and maintained his normal BP. This event was thought related to peri-op narcotics and GNR bacteremia. He was called out to the floor in stable condition. . # ESRD on HD: The patient continued in-house HD and was maintained on Sevelamer. He has regular HD on Tues, Thurs, Sat . # ID: Pt. had a chest wall abscess, positive for MRSA on a previous hospitalization for which he was treated with Vancomycin for 14 days. On admission for this hospitalization, he was found to have a new abscess, also positive for MRSA, for which he went to the OR for an I&D on [**1-24**]. Given his lack of venous access, Linezolid was given for MRSA. However, in the MICU, blood cultures grew Serratia marcens. He was also thought to have C. diff. Patient was put on Vanco, Gent, Flagyl. He ruled out for C. diff x3 stool studies. His flagyl D/Cd. ID was consulted regarding his Serratia bacteremia. Because follow up cultures were negative, they recommended stopping his gentamicin. They recommended continuing his Vanco to complete 14 day course for MRSA abscess (through [**2125-2-19**]). He will also need follow up for his HIV/HCV care. He is discharged on 750mg vanco qHD, dosed for trough of 15. He will also need a VAC dressing for his chest wound until the wound is healed. Change every 3 days. . # Delirium: Coming out of the MICU, the patient experienced delirium, shouting out and thinking that he was driving to [**Location (un) **]. He was not aggressive. His delirium was thought due to infection. CT head was negative. He stopped his percocet but continued his Methadone. Over the course of 2 days, the patient's delirium cleared. He was pleasant and returned to baseline. . # HIV: On HAART, followed by Dr. [**Last Name (STitle) 1057**]. - Continued outpatient Indinavir, Ritonavir, Stavudine . # Depression - Continued Duloxetine . # Anemia: Likely related to ESRD. Pt is given Epo at HD. His Hct remained stable in the mid 20s. , # DM: Patient experienced multiple episodes of hypoglycemia while on NPH and an Insulin sliding scale. Per the patient's PCP, [**Name10 (NameIs) **] has occurred during previous hospitalizations, usually because the patient does not adhere to a hospital diet and relies on his family to bring him food. As a result, he is either hyperglycemic or hypoglycemic depending on how much and what kind of food he gets. NPH was discontinued because of continued hypoglycemia. As hypoglycemia continued, he was started on a regular diet to encourage PO as well as increase sugar consumption. His Insulin sliding scale was maintained so as to cover for any elevated sugars that occurred while on a regular diet. Pt. was otherwise maintained on Gabapentin for neuropathy. . # Chronic pain/hx heroin use - Continued outpatient methadone 20 [**Hospital1 **], percocet, which was down-titrated when he had mental status changes. We continued his methadone . # HTN: Pt. experienced episodes of hypotension, mostly after HD, but also separate from HD. His outpatient dose of Metoprolol 12.5 mg [**Hospital1 **] was d/c'd as he rarely ever made the SBP goal to receive it. However, it was restarted on [**1-30**] with holding parameters because of NS tachycardia and normotensive BPs. He was hypotense again during his stay in the MICU (see above). After transfer, his BP medications were added back slowly. He seemed to tolerate Metoprolol 25mg [**Hospital1 **] well. . Code: FULL for this admission. PROXY: patient changed his health care proxy during his admission to his girlfriend, [**Name (NI) **] [**Name (NI) **] Depression: has been a persistent problem. [**Name (NI) **] is now willing to trial of duloxetine. Medications on Admission: 1. Albuterol nebs Q6H as needed. 2. Indinavir 800 mg PO BID 3. B Complex-Vitamin C-Folic Acid 1 mg, 1 PO daily 4. Gabapentin 300 mg PO BID 5. Quinine Sulfate 325 mg PO HS 6. Ritonavir 100 mg PO BID 7. Oxycodone-Acetaminophen 5-325 mg, 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Senna 8.6 mg PO BID 9. Docusate Sodium 100 mg PO BID 10. Stavudine 20 mg PO Q24H 11. Sevelamer 1600 mg PO TID 12. Ammonium Lactate 12 % Lotion, apply [**Hospital1 **] 13. Duloxetine 30 mg PO daily 14. Hep SC TID to continue while patient bedbound 15. Pantoprazole 40 mg PO daily 16. Bisacodyl 10 mg po daily as needed 17. 10 U NPH in the morning with humalog scale as needed during the day. 18. Lamivudine Fifty (50) mg PO DAILY 19. Metoprolol Tartrate 12.5 mg PO BID 20. Methadone 20 mg PO BID 21. Methadone 10 mg Tablet, 1-2 Tablets PO Q12H as needed for pain. 23. Lactulose 30 mL PO daily as needed for constipation 24. Magnesium Hydroxide 400 mg/5 mL, 30 ML PO Q6H (every 6 hours) as needed for constipation Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Indinavir 400 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times a day). 3. Ritonavir 80 mg/mL Solution [**Hospital1 **]: One (1) PO BID (2 times a day). 4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 6. Stavudine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H (every 24 hours). 7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ML Injection TID (3 times a day): Subcutaneously for DVT prophylaxis. 9. Lamivudine 100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). 10. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Methadone 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 13. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 14. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 15. Prochlorperazine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 17. Heparin Flush (100 units/ml) 20 ml IV PRN 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 19. Haloperidol 1-3 mg IV Q6H:PRN agitation 20. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 1.5 Recon Solns Intravenous QHD (each hemodialysis): Please give 750mg qHD through [**2-19**] to complete 14 day course. Please dose at HD for trough of 15. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses: Clotted AV graft MRSA abscess Serratia marcesens bacteremia . Secondary Diagnoses: HIV infection HCV infection Depression End stage renal disease Type 2 Diabetes Mellitus Anemia Discharge Condition: Good, afebrile, hemodynamically stable Discharge Instructions: Please take all medications as prescribed. Please keep all follow up appointments. Please return to the hospital if you experience chest pain, shortness of breath, fevers, or any other symptoms that are concerning to you. . You will need 3 more days of Vancomycin to complete 14 day course. . You will need your VAC dressing until your wound is healed. . You will be scheduled to receive hemodialysis on your normal schedule of Tues, Thurs, Sat Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 month of discharge. [**Telephone/Fax (1) 250**] . Please follow up with your infectious disease physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1057**] regarding your HIV/HCV care . Please follow up with your dialysis schedule as indicated by your nephrologists

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icd9cm

[ [ [] ] ]

[ "88.49", "38.95", "96.71", "39.95", "39.42", "38.93", "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

16675, 16746

7963, 13536

310, 463

16987, 17028

4247, 4247

17523, 17886

3579, 3596

14590, 16652

16767, 16848

13562, 14567

17052, 17500

4512, 6268

3611, 4228

16869, 16966

254, 272

491, 1538

6277, 7940

4263, 4496

1560, 3324

3340, 3563

18,456

183,887

20333

Discharge summary

report

Admission Date: [**2169-10-12**] Discharge Date: [**2169-10-19**] Date of Birth: [**2102-6-12**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5893**] Chief Complaint: Septic/Cardiogenic Shock Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: 67 yo F with h/o CHF and amyloidosis receiving chemotherapy at [**Hospital1 18**] presents with altered mental status and increasing LBP x 5 days with some new bowel/bladder incontinence and LE weakness. . Mrs. [**Known lastname **] started her first cycle of Velcade / Decadron chemotherapy regimen 1 month ago and last dose was 10 days ago. Over the last 5 days she experienced worsening back pain and lower extremity weakness. She has become confused with an altered mental status according to her husband and developed new bowel and bladder incontinence 1 day prior to presentation. . The patient presented to [**Location (un) **] in a hypotensive state with ARDS/pul edema on CXR. Initially, pneumonia vs CHF was considered. The pt was given lasix, IVF, ceftazidime and levaquin. Because of patients acute change in mental status, the pt was given a full dose ASA and sent for head CT which was negative. A U/A positive for blood. The pt was deemed to have [**3-10**] BLE weakness and after decadron 10mg IV she was transferred to [**Hospital1 **] for possible cauda equina vs. sepsis. The patient was incontinent of stool en route. . In the ED, initial vs were: 99 76 85/41 18 100% on NRB. Initially the patient was confused but A&Ox3 and complained only of fatigue and aching in low back. Neuro exam revealed weak-normal rectal tone and LE weakness, but normal reflexes and sensation. CXR in ED was consistent with CHF. BNP was [**Numeric Identifier **] (previously [**Numeric Identifier 890**] in [**2164**]). EKG V-paced but does not ST criteria for STEMI. Troponin was 0.15 here (trop at [**Location (un) **] higher, but they may be using a different assay). Because of concern for a possible epidural abscess, the pt was sent for CT of full (C, T and L) spine that showed no obvious fluid collections. The patient cannot be sent for MRI because she has a pacemaker. She started on vancomycin and received a 500cc NS bolus, had a right IJ line place and was started on levophed. SBP rose to 110s with an SpO2 98% on 4L NC with RR 20. She was transferred to [**Hospital Unit Name 153**] for hemodynamic instability and concern for sepsis vs. cardiogenic shock. On transfer, her vitals were 95.3F 61 102/59 19 95% on 5L O2 by NC. . On the floor, pt is alert, but disoriented on 0.06mcg/kg/min levophed with a warming blanket for hypothermia. Past Medical History: 1) Primary amyloidosis diagnosed in [**2163**]. Renal biopsy showed a lambda light chain deposition and she had light chains in her urine. At that time, she has had marked lower extremity edema and recurrent infections. She ultimately had her stem cells mobilized with Cytoxan and underwent autologous stem cell transplant with melphalan as her conditioning regimen. Transplant was complicated by GI bleed and ICU admission; however, she was ultimately discharged and has been doing quite well since transplant. 2) Pacemaker for symptomatic sinus block early [**2169-5-6**] 3) CHF 4) HTN 5) High cholesterol 6) Left wrist fracture 7) History of premature ventricular complexes 8) History of duodenal ulcer 9) Multiple bilateral breast cysts: Biopsies negative for cancer. 10) tendon repair right leg in [**2139**]'s Social History: She has been married for 47 years. She has three children and five grandchildren who live locally. - Tobacco: one to two cigarettes a day. Family History: Unable to obtain secondary to confusion Physical Exam: General: Appears ill, aware she is at [**Hospital1 18**], but disoriented to time. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 3cm above sternal angle, no LAD Lungs: + upper airway transmitted sounds on expiration, a few wheezes, inspiratory crackles. CV: regular rate and rhythm, faint S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear fluid. Ext: warm, well perfused, 2+ pulses, 1+ pedal edema bilat up to knees. Neuro: PERLA, good strength of facial muscles, normal tongue movements, palate rises. strength 5/5 in ankles and elbows for extension and flexion. strength 3/5 for hip flexion bilat. DTR Patellar 3+ right, 1+ left. achilles 1+ bilat. biceps 3+ bilat. -ve babinski bilat. good sensation and equal bilat in feet. Skin: brownish discoloration above ankles bilaterally, macular non blanching rash with confluent areas over inguinal/pubic area. Pertinent Results: [**2169-10-13**] 12:00AM TYPE-MIX PO2-32* PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--3 [**2169-10-13**] 12:00AM LACTATE-1.5 [**2169-10-13**] 12:00AM O2 SAT-53 [**2169-10-13**] 12:00AM freeCa-1.07* [**2169-10-12**] 11:18PM GLUCOSE-119* UREA N-71* CREAT-1.7* SODIUM-136 POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2169-10-12**] 11:18PM ALT(SGPT)-366* AST(SGOT)-482* CK(CPK)-540* ALK PHOS-105 TOT BILI-0.8 [**2169-10-12**] 11:18PM CK-MB-8 cTropnT-0.14* [**2169-10-12**] 11:18PM CALCIUM-8.0* PHOSPHATE-6.6* MAGNESIUM-2.2 [**2169-10-12**] 11:18PM TSH-2.5 [**2169-10-12**] 11:18PM WBC-7.3 RBC-4.14* HGB-13.4 HCT-40.2 MCV-97 MCH-32.2* MCHC-33.2 RDW-16.1* [**2169-10-12**] 11:18PM PLT COUNT-60* [**2169-10-12**] 11:18PM PT-13.9* PTT-37.2* INR(PT)-1.2* [**2169-10-12**] 09:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2169-10-12**] 09:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2169-10-12**] 09:25PM URINE RBC-[**6-15**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0-2 [**2169-10-12**] 05:05PM COMMENTS-GREEN TOP [**2169-10-12**] 05:05PM LACTATE-1.4 [**2169-10-12**] 05:00PM GLUCOSE-88 UREA N-66* CREAT-1.7* SODIUM-131* POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-19* ANION GAP-16 [**2169-10-12**] 05:00PM estGFR-Using this [**2169-10-12**] 05:00PM cTropnT-0.15* proBNP-[**Numeric Identifier **]* [**2169-10-12**] 05:00PM CALCIUM-8.1* PHOSPHATE-5.4*# MAGNESIUM-2.1 [**2169-10-12**] 05:00PM WBC-5.8 RBC-4.01* HGB-12.8 HCT-38.1 MCV-95 MCH-31.9 MCHC-33.6 RDW-16.8* [**2169-10-12**] 05:00PM NEUTS-95* BANDS-3 LYMPHS-0 MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-5* [**2169-10-12**] 05:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2169-10-12**] 05:00PM PLT SMR-VERY LOW PLT COUNT-55*# Labs prior to expiration: [**2169-10-19**] 06:36AM BLOOD WBC-18.9* RBC-2.89* Hgb-9.3* Hct-27.3* MCV-95 MCH-32.3* MCHC-34.1 RDW-17.0* Plt Ct-44* [**2169-10-19**] 06:36AM BLOOD Neuts-93.9* Bands-0 Lymphs-4.3* Monos-1.5* Eos-0 Baso-0.3 [**2169-10-19**] 06:36AM BLOOD PT-21.6* PTT-40.6* INR(PT)-2.0* [**2169-10-19**] 06:36AM BLOOD Glucose-112* UreaN-114* Creat-4.3* Na-131* K-5.1 Cl-102 HCO3-16* AnGap-18 [**2169-10-19**] 06:36AM BLOOD ALT-89* AST-127* LD(LDH)-1585* AlkPhos-113* TotBili-0.9 [**2169-10-19**] 06:36AM BLOOD Calcium-6.8* Phos-6.2* Mg-2.0 [**2169-10-18**] 02:25PM BLOOD freeCa-1.01* [**2169-10-18**] 02:45PM BLOOD O2 Sat-67 [**2169-10-18**] 02:25PM BLOOD Lactate-1.0 Imaging: CT spine [**10-12**]: No evidence of fracture or fluid collection of the cervical spine. Echo [**10-13**]: IMPRESSION: amyloid heart CT head [**10-13**]: no acute process BAL cytology [**10-14**]: NEGATIVE FOR MALIGNANT CELLS. Macrophages, some hemosiderin-laden, lymphocytes and neutrophils CT head [**10-17**]: IMPRESSIONS: Newly apparent loss of [**Doctor Last Name 352**]-white matter differentiation along the posterior right MCA vascular distribution raises concern for interval infarction, not previously seen on [**2169-10-13**]. No acute intracranial hemorrhage or shift of normally midline structures. MRI recommended for more sensitive evaluation of infarction if patient's cardiac pacemaker is MRI-compatible. CT chest [**10-17**]: IMPRESSION: Extensive bilateral dependent consolidations, accompanying pleural effusions and ground-glass-like opacities in the left dependent lung regions. The findings suggest a combination of pulmonary edema and infection. Extensive lymph node calcifications, splenic calcifications and hepatic calcifications. Several nonspecific mainly subpleural pulmonary nodular lesions. The monitoring and support devices in correct position. The study and the report were reviewed by the staff radiologist. Renal US [**10-18**]: IMPRESSION: 1. Diffuse increased echogenicity of the renal cortices, compatible with chronic medical renal disease. 2. Abnormal Doppler evaluation of the kidneys bilaterally, with elevated RIs and decreased diastolic flow. 3. Echogenic foci with posterior shadowing seen in the right kidney at the corticomedullary junction. While the appearance suggests nephrocalcinosis, the unilaterality is atypical, and these may rather represent non-obstructing stones. However, of note, on prior CT of the lumbar spine dated [**2169-10-12**], scattered dense foci were seen as well on the left, not seen by ultrasound. 4. Simple right renal cysts. Micro: -Blood cultures negative -blood fungal cx negative -HSV culture negative -urine cx's negative -stool cx's negative BAL [**10-17**]: GRAM STAIN (Final [**2169-10-17**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2169-10-19**]): Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. POTASSIUM HYDROXIDE PREPARATION (Final [**2169-10-18**]): This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). TEST REQUESTED BY DR. [**Last Name (STitle) 54548**] #[**Numeric Identifier 54549**] [**2169-10-18**]. BUDDING YEAST WITH PSEUDOHYPHAE. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2169-10-18**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2169-10-30**]): YEAST. OF TWO COLONIAL MORPHOLOGIES BAL [**10-14**]: GRAM STAIN (Final [**2169-10-14**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2169-10-16**]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final [**2169-10-21**]): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2169-10-15**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2169-10-30**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2169-10-16**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Virus isolated so far. VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2169-10-23**]): No Herpes simplex (HSV) virus isolated. VARICELLA-ZOSTER CULTURE (Preliminary): No Virus isolated so far. -Cryptococcal antigen: neg -Groin swab VZV positive Brief Hospital Course: 67 yo F h/o amyloidosis, including cardiac involvement s/p pacemaker with mixed septic and cardiogenic shock and respiratory failure [**2-7**] to pneumonia of unclear etiology. pt eventually expired [**2-7**] multiorgan failure in setting of septic/cardiogenic shock. Issues throughout ICU stay included: *Shock. Likely secondary to a septic process combined with an exacerbation of chronic HF. Treated w/ dopamine, levophed and fluids. ID favored VZV pneumonia as the most likely source and also considered PCP likely possibly [**Name Initial (PRE) **]/ a bacterial superinfection. *Respiratory failure. Likely secondary to a pneumonia of unknown etiology, perhaps a VZV pneumonia. Developed large area of consolidation in RLL>LLL visible on CT and RLL bleeding observed on BAL. . *Renal failure: ATN [**2-7**] shock and worsening renal function from day to day with urine output declining to 10-15cc/hr. Renal U/S showed evidence of chronic amyloid kidney and doppler showed decreased diastolic flow. . *Possible stroke on CT head in the right posterior MCA territory. . *Decreased perfusion to feet secondary to cardiogenic failure and the requirement for levophed to maintain her blood pressure. This was treated by warming her feet and prefering dopamine over levophed as a pressor to reduce vasoconstriction and increase cardiac output. . *Tachycardia. Underlying atrial tachycardia likely with A sensed V paced pacermaker settings. Intermittent tachy into the 110s. Possibly exacerbated by her dopamine requirement. Tachycardia tolerated for HR < 130 as long as BP not affected in order to maintain foot perfusion. . *Thrombocytopenia. Likely [**2-7**] sepsis. HIT assay negative. DIC work up negative. Transfused plts to maintain platlet count > 50. . *Transaminitis. Likely [**2-7**] shock liver. Trended down during admission. . *VZV rash over left anterior thigh. Treated with acyclovir and improved. . *Leg weakness and fecal incontinence. Patient seen by ortho spine and neurology and both services agreed that there were no focal signs of cauda equine. The patient endorsed a mechanical fall a week prior to admission as source of leg pain and weakness. Hip films negative for fracture. . *At a family meeting, the patient's multiple organ failure and poor prognosis was discussed with her husband and three children. They agreed that the patient would not want her life to be prolonged without a significant hope of a return to her previous quality of life. The patient was made DNR/DNI and no escalation of care and then made CMO when her family was ready. She expired at 13:10 on [**2169-10-19**]. Medications on Admission: AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 2 Tablet(s) by mouth once a day for 7 days then 1 tablet daily ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 2 Tablet(s) by mouth once a day CITALOPRAM - (Prescribed by Other Provider) - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day DEXAMETHASONE - 4 mg Tablet - 10 Tablet(s) by mouth once per day for 4 days or as directed FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 (One) Tablet(s) by mouth twice a day POTASSIUM CHLORIDE - (Prescribed by Other Provider) - 20 mEq Tab Sust.Rel. Particle/Crystal - 2 Tab(s) by mouth once a day RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: pt expired Discharge Disposition: Expired Discharge Diagnosis: Septic and Cardiogenic shock secondary to pneumonia. Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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Discharge summary

report+addendum

Admission Date: [**2162-12-16**] Discharge Date: [**2162-12-21**] Date of Birth: [**2109-2-5**] Sex: M Service: MEDICINE Allergies: Lactose / Latex / Nafcillin / rifampin / adhesive tape Attending:[**First Name3 (LF) 10293**] Chief Complaint: jaundice, abdominal pain Major Surgical or Invasive Procedure: 1. Esophagogastroduodenoscopy History of Present Illness: 53M with h/o Hep B, Hep C and EtOH cirrhosis c/b variceal bleed and ascites, recent MSSA infected hip joint/prothesis s/p removal on doxycycline, AIN secondary to nafcillin, admitted to OSH [**2162-12-10**] for evaluation of jaundice and abdominal pain, who has developed probable HRS and is transferred to [**Hospital1 18**] now for further evaluation and treatment of decompensated cirrhosis and HRS. Patient had 1.5-2 week period of N/V (denies hematemesis) and decreased PO intake. At onset of these symptoms also had large, dark tarry stool (per his report). Did not have any fevers, diaphoresis, or chest pain, but was having chills. Reported >10 pound weight loss over past few months. Abstinent from EtOH x2 months. Limited history of abdominal pain. Vomiting resolved, but he saw his PCP several days later as he had run out of oxycodone. PCP was concerned about jaundice, and sent him to OSH. . At the OSH, was initial concern for cholecystitis given leukocytosis, elevated LFTs, and RUQ pain. Also of note, patient's SBP dropped from the 120s to 90s initially, though responded to IVF administration. He was started empirically on Zosyn. Diagnotic paracentesis was negative for SBP. The patient was seen by Surgery, who felt his exam was unremarkable. Also felt pt would not be surgical candidate given his co-morbidities. RUQ showed cirrhosis, ascites, and cholelithiasis w/mild gallbladder wall thickening, but no e/o acute cholecystitis. CT abd/pelvis also showed cholelithiasis and a distended gallbladder. A HIDA scan was performed, and was c/w hepatic dysfunction but did not show e/o acute cholecystitis. MRCP demonstrated cholelithiasis and bile sludge, mild common bile duct dilation, suggestion of mild long segmental circumferential thickening of common hepatic duct which could represent cholangitis, and no choledocolithiasis. Patient was continued on antibiotics, though was switched from Zosyn to cipro/Flagyl (has h/o AIN with nafcillin, and was concern for possible reaction to Zosyn). Blood cultures were negative. WBC trended down, but is still elevated at 12.9. . During his hopsital course, his albumin dropped to 1.2 despite nutrition consult and supplementation. His Cr was elevated on admission, transiently improved with IVF, but then began trending up to as high as 2.43 on morning of transfer. Cr was 1.14 on [**2162-10-19**]. Trend during this admission: 2.21 ([**12-10**]), 1.82 ([**12-11**]), 1.79 ([**12-12**]), 2.02 ([**12-13**]), 2.14 ([**12-14**]), 2.16 ([**12-15**]), 2.43 ([**12-16**]). Urine output significantly dropped as well. Nephrolology consulted, and was concerned for HRS. It is unclear how much albumin the patient received, but he was started on trial of midodrine/octreotide without improvement. Also of note, on day of transfer, patient was noted to become more encephalopathic. Ammonia level checked and was 77. . Currently, patient reports feeling cold. Reports hip pain and mild persistent abdominal pain. Denies any nausea at present, though does report episode of non-bloody, non-bilious emesis and loose stool within past day. Past Medical History: Hepatitis B EtOH/HCV cirrhosis, c/b variceal bleeding, ascites (last para [**7-/2162**]) Osteomyelitis R sacroiliac joint [**2160**] GERD Chronic pain DM2 MSSA infection prosthetic hip joint s/p L total hip arthroplasty [**2162-4-23**] c/b MSSA infection w/subsequent prothesis removal and spacer placement AIN [**1-6**] nafcillin BCC on nose h/o splenectomy Social History: Lives alone. Has worked as plumber. Currently smokes ~4 cigarettes/day, >20 year smoking history. Quit EtOH 9 weeks ago, previously drank >9-12 beers/day. History of marijauna use and cocaine use, last cocaine use several weeks ago. Denies h/o IVDU. Family History: Father - [**Name (NI) 91988**], EtOH abuse. Mother - skin cancer, [**Name (NI) 2481**]. Denies family hx liver or kidney disease. Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 97.9F, BP 98/58, HR 61, R 18, O2-sat 99% RA, Wgt 81.2 kg GENERAL: patient with jaundice, temporal wasting, slightly drowsy but responds quickly to voice and answers questions fairly appropriately once awake (occasionally requires redirection), NAD HEENT: NC/AT, PERRL, EOMI, + scleral icterus, slightly dry MM NECK: supple, no cervical LAD, no JVD LUNGS: decreased breath sounds at bases, no wheezing/rales/rhonchi, good air movement, respirations unlabored, no accessory muscle use HEART: RRR, nl S1-S2, no r/m/g ABDOMEN: normoactive bowel sounds, soft but distended, tender to palpation in RUQ without guarding or rebound tenderness, reducible umbilical hernia, guiac positive (light brown stool) EXTREMITIES: warm, well-perfused, [**1-7**]+ edema, 2+ peripheral pulses SKIN: jaundice, prior surgical scar on abdomen, well-healed incision on left hip w/o surrounding erythema NEURO: drowsy but arousable, oriented to person/hospital setting and city/month and year, CNs II-XII grossly intact, muscle strength 5/5 throughout, + asterixis Pertinent Results: OSH LABS [**2162-12-16**]: Na 138, K 3.8, Cl 111, CO2 21, BUN 22, Cr 2.4 AST 272, ALT 69, AP 173, Tbili 4.4 (down from 5.2 on [**12-10**]), Dbili 2.5 INR 2.4 WBC 12.9, HGB 7.9, Hct 23.6, Plt 124 Alb 1.2, Total protein 6.3 Ammonia 77 . OTHER OSH LABS: Urine Na <3, Urine K 32, Urine Cl <4 UA 1+ urobiln, neg leuk, neg nitr, neg bld, 2 WBC, 1 RBC, 1 eos . OSH MICROBIOLOGY: Urine culture [**12-13**] negative Blood cultures 1/7 negative Peritoneal fluid culture negative . Admission Labs: [**2162-12-17**] 05:53AM BLOOD WBC-12.2* RBC-2.49* Hgb-7.6* Hct-24.0* MCV-96 MCH-30.4 MCHC-31.5 RDW-19.1* Plt Ct-127* [**2162-12-17**] 05:53AM BLOOD Neuts-59.9 Lymphs-18.3 Monos-17.2* Eos-3.9 Baso-0.8 [**2162-12-17**] 05:53AM BLOOD PT-35.4* PTT-74.8* INR(PT)-3.4* [**2162-12-17**] 05:53AM BLOOD Glucose-98 UreaN-27* Creat-2.8* Na-137 K-3.6 Cl-107 HCO3-21* AnGap-13 [**2162-12-17**] 05:53AM BLOOD ALT-60* AST-229* AlkPhos-159* TotBili-5.3* DirBili-3.5* IndBili-1.8 [**2162-12-17**] 05:53AM BLOOD Albumin-2.4* Calcium-7.9* Phos-3.5 Mg-1.4* . Ascites fluid: [**2162-12-18**] 07:34PM ASCITES WBC-28* RBC-56* Polys-14* Lymphs-27* Monos-6* Macroph-53* [**2162-12-18**] 07:34PM ASCITES TotPro-1.0 Albumin-LESS THAN . Discharge Labs: . Microbiology: [**2162-12-16**] 9:17 pm SWAB Source: Rectal swab. R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Preliminary): ENTEROCOCCUS SP.. [**2162-12-18**] 4:22 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): [**2162-12-18**] 7:34 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [**2162-12-19**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): . OSH STUDIES: [**2162-12-15**] MRI for eval of cholangitis: 1. Hepatic cirrhosis with no suspicious focal lesion 2. Cholelithiasis and bile sludge 3. Mild common bile duct dilitation. There is suggestion of mild long segmental circumferential thickening of the common hepatic duct which could represent cholangitis. No choledocholithiasis. 4. Large volume ascites. 5. Moderate bilateral pleural effusions. . [**2162-12-11**] HIDA scan: 1. Findings consistent with hepatic dysfunction 2. No evidence of acute cholecystitis . [**2162-12-11**] CT abd/pelvis 1. Thickening of the distal esophagus. A barium swalllow or endoscopic correlation may be helpful for further evaluation. 2. Small biltateral pleural effusions and bibasilar consolidation. 3. Findings compatible with hepatic cirrhosis with large amount of ascites, as described 4. Cholelithiasis and distended gallbladder. When read in conjunction with the US examination this may be the source of the patient's sepsis 5. Nonobstructing bilateral renal calculi 6. Retrperitoneal adenopathy . [**2162-12-10**] RUQ US 1. Findings suggesting hepatic cirrhosis 2. Cholelithiasis with mild gallbladder wall thickening. No e/o acute cholecystitis 3. Mild increase in ascites . Imaging: CXR ([**12-16**]): IMPRESSION: AP chest reviewed in the absence of prior chest radiographs: It is unclear whether the right PIC line ends in the upper SVC or extends into the upper right atrium. Recommend repeating the current examination using conventional technique, particularly to make sure there is no retained fragment from previous line placement. Small left pleural effusion is present; the lateral view would be very helpful to exclude left lower lobe pneumonia. Heart size normal. No pneumothorax. . CXR ([**12-16**]): HISTORY: Evaluate PICC lines. A PIC line ends in the right atrium approximately 2 cm below the estimated location of the superior cavoatrial junction. In addition of small pleural effusions, there is a moderate-sized consolidation in the left lower lobe, pneumonia until proved otherwise. Heart size is normal. . XR left hip ([**12-16**]): pending . Renal ultrasound ([**12-16**]): no hydronephrosis symmetric normal sized kidneys (R 10.7 cm, L 10.9 cm) bladder difficult to visualize and incompletely distended Large-volume ascites. . CXR ([**12-21**]): PA and lateral upright chest radiographs were reviewed in comparison to [**2162-12-20**] and [**2162-12-17**]. There is substantial improvement since the most recent prior radiograph in the extent of pulmonary edema bilaterally, but in particular on the left. Still present nodular opacities are concerning for multifocal infectious process/hemorrhage, in particular given the presence of consolidation seen on [**2162-12-17**] radiograph. Still present bilateral pleural effusions are moderate. Right PICC line tip is at the level of mid SVC. Brief Hospital Course: 53M with h/o Hep B, Hep C and EtOH cirrhosis c/b variceal bleed s/p banding, ascites, recent MSSA infected hip joint/prothesis s/p removal on doxycycline, AIN secondary to nafcillin, now with decompensated cirrhosis and probably HRS. . # UGIB: Patient had episode of hematemesis on [**12-17**] leading to ICU transfer, thought to be from esophageal band ulcers vs varices. An emergent EGD was performed [**12-17**] with no intervention, although it showed four cords of grade 2 esophageal varices and esophageal ulcers, as well as multiple locations with stigmata of recent bleeding. No intervention was performed given multiple potential sources. He remained hemodynamically stable, and Hct has remained stable. He was treated with a PPI, octreotide gtt, sucralfate, ceftriaxone. Nadolol was held for GIB [**12-18**], restarted when HCT stable. He had a triple lumen PICC from OSH for access, per report is very difficult access otherwise. PICC line 2 cm past cavoatrial junction though not having ectopy. On the morning of [**12-21**], the patient experienced recurrent hematemesis and shortly thereafter BRBPR. He was scheduled for endoscopy and possible flexible sigmoidoscopy to investigate the source of bleeding. He was transferred to the ICU to perform these procedures. Prior to endoscopy, the patient experienced massive upper and lower GI bleeding. Efforts at resuscitation were fruitless and the patient died shortly thereafter. . # [**Last Name (un) **]: Cr on admission 2.8, up from baseline 1.1 and increased since beginning of recent hospitalization. Refractory to IVF, UOP now very low. Workup at OSH ruled out AIN, obstruction, pre-renal. Most likely HRS. Trigger may be infectious, although OSH paracentesis negative for SBP, UA normal, no clinical evidence of infection. One potential source is the left hip, a site of previous osteomyelitis. Trigger appears to be GIB though infection possible. Does have elevated WBC count though CXR, UA, paracentesis neg for infections. Infection of L hip spacer, or osteomyelitis possible. Renal US showed no obstruction. The patient was treated with albumin, octreotide, and midodrine. His diuretics were held. . # EtOH/HCV cirrhosis: Decompensated with ascites, possible HRS, and possible developing encephalopathy. Patient also with recent h/o variceal bleed. MELD 36 to 43 during admission. No evidence of cholangitis as a source, although mild common bile duct dilitation may indicate brewing infection. His home regimen of nadolol and lactulose was continued. Cipro and Flagyl were continued as empiric treatment for possible cholangitis until [**12-19**], at which time this was switched to Ceftriaxone. . # MSSA infection prosthetic hip joint w/subsequent prothesis removal and spacer placement: Possible etiology of leukocytosis. Doxycycline suppressive therapy continued for several days, then discontinued for concern of exacerbating liver dysfunction. Repeat XR of hip did not reveal signs of recurrent infection. . # Possible RLL PNA: Per CXR, the patient may have a RLL consolidation. Afebrile, no cough or other lung findings. [**Month (only) 116**] be atelectasis. . Inactive issues: # h/o EtOH abuse: Patient reported abstinence x9 weeks. Not currently transplant candidate. Continue folic acid 1mg daily # DM2: Held outpatient metformin. On ISS. # GERD: Continued home pantoprazole. # Chronic pain: Held oxycodone for now in setting of possible worsening encephalopathy. . # CODE: Full # CONTACT: [**Name (NI) **], Sister [**Name (NI) **] [**Name (NI) 91989**] [**Telephone/Fax (3) 91990**] Medications on Admission: Doxycycline 100mg Q12H Folic acid 1mg daily Lactulose 20gm TID prn constipation Lasix 40mg QAM Metformin 500mg daily Nadolol 20mg daily Oxycodone 5mg TID prn pain Protonix 40mg daily Sodium bicarbonate 650mg TID Spironolactone 50mg [**Hospital1 **] Discharge Disposition: Expired Discharge Diagnosis: End-stage liver failure hepatorenal syndrome esophageal ulcers Discharge Condition: The patient expired. Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14477**] Admission Date: [**2162-12-16**] Discharge Date: [**2162-12-21**] Date of Birth: [**2109-2-5**] Sex: M Service: MEDICINE Allergies: Lactose / Latex / Nafcillin / rifampin / adhesive tape Attending:[**First Name3 (LF) 6349**] Addendum: Please note the following additional information to the Hospital Course. Brief Hospital Course: # GIB: The patient was transferred to CCU for urgent endoscopy. He arrived without incident. Upon arrival to the CCU with the endoscopy cart, the nurses noted that the patient was having both hematemesis and hematochezia. An urgent endoscopy was performed while the medical team resuscitated the patient. There was a copious amount of blood in the oropharynx. EGD was successful. The esophagus was filled with red blood, and underlying lesions could not be visualized. Old blood was seen in the stomach, no obvious bleeding lesions were seen in the stomach. The duodenum was well visualized and no obvious bleeding lesions were seen. No interventions were possible on the EGD. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube was attempted without success. During this entire time, the patient continued to hemorrhage. Resuscitation was attempted with 9 units PRBCs, 4 units FFP, 1 unit platelets. The team was unable to halt the bleeding and the patient was pronounced dead at 1745 of massive gastrointestinal hemorrhage. Discharge Disposition: Expired [**First Name11 (Name Pattern1) 904**] [**Last Name (NamePattern1) 905**] MD [**MD Number(1) 6350**] Completed by:[**2162-12-22**]

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icd9cm

[ [ [] ] ]

[ "45.13", "54.91" ]

icd9pcs

[ [ [] ] ]

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342, 373

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29,343

173,565

16122

Discharge summary

report

Admission Date: [**2117-10-6**] Discharge Date: [**2117-10-12**] Date of Birth: [**2039-9-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10842**] Chief Complaint: Bradycardia, Asystole Major Surgical or Invasive Procedure: Cardiopulmonary resucitation Intubation Temporary pacing wire History of Present Illness: 78y F Cantonese-speaking only with h/o afib on [**First Name3 (LF) 197**], CAD s/p CABGx2 [**7-19**], and diastolic CHF LVEF >55% presents with abdominal pain in ED. While in ED, patient became bradycardic to the 50s and continued to the 30s when she then went into asystole. Patient coded by ED team intermittently for 20 minutes. Intubated. Cardiology fellow and EP fellow called- placed temporary pacing line. Patient's rhythm and pulse returned- then transferred to the CCU for further monitoring/evaluation. . Upon transfer to floor, patient was intubated on mechanical ventilation. HR in 80s and SBP of 109/53. Non-responsive. Again seen and evaluated by EP fellow and cardiology fellow as well as by CCU team. . Unable to obtain review of systems given patient is sedated. Past Medical History: Atrial fibrillation CHF CAD s/p CABG [**7-19**] (2VD, SVG -> OM1/PDA) s/p mitral valve repair s/p cholecystectomy s/p ERCP for CBD stone removal Social History: Never smoked, no alcohol use, no illicit drug use. She lives at home alone. During the day she spends time with family, who provide meals for her, at night she is by herself. Family History: Mother- colon CA Brother- liver CA [**Name (NI) 12238**] COPD Physical Exam: VS: T= 96.3 BP= 140/70 HR= 90s RR= 12 O2 sat= 100% RA GENERAL: lying in bed, NAD, A and O x 3 HEENT: NCAT. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no elevated JVD CARDIAC: irregularly irregular S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTA bilat ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP/PT 2+/1+ Left: DP/PT 2+/1+ Pertinent Results: CXR [**2117-10-8**]: FINDINGS: In comparison with the study of [**10-8**], the right IJ catheter has been removed. Little change in the appearance of the heart and lungs with enlargement of the cardiac silhouette and blunting of the costophrenic angles bilaterally. No definite pulmonary vascular congestion at this time. . TTE [**2117-10-8**]: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of 25 vNov ember v2008, probably no major change. . CT chest/abd/pelvis [**2117-10-7**]: IMPRESSION: 1. No pulmonary embolism. 2. Mild aneurysmal dilatation of the ascending aorta without evidence of dissection or intramural hematoma. 3. Diffuse ground-glass opacities and septal thickening within the lungs with bilateral pleural effusions, likely on the basis of pulmonary edema/fluid overload. There is also cardiomegaly. 4. Stable intrahepatic biliary ductal dilatation and air as well as common bile duct dilatation. 5. Mesenteric stranding and fluid in a peripancreatic region around the pancreatic head extending into the porta hepatis and anterior perirenal fascia. These findings may relate to pancreatitis, please clinically correlate with patient's laboratory values. 6. Poor renal cortical enhancement identified on arterial phase imaging, which is symmetric. Given patient's history of recent PEA arrest, ATN is highly considered. 7. Featureless appearance of the entire large bowel with intramural fat deposition and absence of skip lesions. No pericolonic inflammatory changes are noted. These findings may be related to burnt out/chronic ulcerative colitis, as opposed to a more acute process. 8. Ascites. Labs at discharge WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 6.9 4.25 11.9* 36.2 85 28.1 33.0 15.0 140 INR 3.1 Glucose UreaN Creat Na K Cl HCO3 AnGap 189* 22* 1.0 138 4.0 103 23 16 . Brief Hospital Course: 78 y/o F with CAD presenting with abdominal pain, bradycardia progressing to PEA arrest, s/p resuscitation, intubated and on pressors. . # RHYTHM/PEA: Has chronic history of a-fib (on anticoagulation). Patient became asystolic while in ED in the setting of bradycardia. Suspect vagal episode. Was coded by ED team, intubated, and had temporary pacer wire placed by cardiology fellow. Interestingly, unsure if the event was true asystole, as patient seems to recall the entire event. Pulse/pressure returned and patient immediately trasferred to CCU. Patient extubated on hospital day 2. In paced rhythm with HR of 90. Telemetry without other events, and temporary pacer wire was removed soon thereafter. Of note, etiology likely bradycardia/vagal reaction, as CT chest, abdomen, and pelvis not consistent with other etiologies of PEA/asystole including trauma, pneumothorax, aortic dissection, PE, AAA, MI, mesenteric ischemia, etc. Patient's HR ranged from 90s-110s, while on metoprolol 75 mg tid. Patient was discharged on the following regimen for rate control: coreg 25 mg [**Hospital1 **], dilt ER 120 mg daily. . #Hypotension: unclear etiology, but in the setting of her PEA/asystolic/bradycardia event. Patient was weaned of pressors fairly rapidly while in the CCU, did well, was soon transferred to floor. Pt continued to be normotensive upon discharge. . # Abdominal pain - CT abdomen/pelvis without clear etiology for abdominal pain. Pain resolved fairly rapidly and may have been related to incomplete obstruction/constipation. . # Hypoxia: CXR with ?LLL infiltrate, cardiomegaly, coin lesion in RLL. In setting of her leukocytosis, empiric flagyl and levofloxacin were started. Abx were continued for total of 5 days. . #Acute renal failure: Baseline Creatinine 1.0, was 2.0 on presentation, suspect etiology to be pre-renal insult in setting of her bradycardia/asystolic event. On discharge, Cr was 1, at baseline. . #Leukocytosis: WBC 20.0. Suspected from stress of cardiac arrest, epinephrine administration. Unlikely from abdominal catastophy as CT abdomen and pelvis negative for acute process. Patient to complete 5 day course of flagyl and levofloxacin. . # CORONARIES: History of CAD s/p CABG in [**2116**]. Continued on aspirin, atorvastatin. Cardiac enzymes not c/w ACS. . # PUMP: History of HTN- patient on carvedilol 25mg PO BID and lasix 40mg daily. Echo from [**10-8**] showing moderately dilated LA. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of 25 vNov ember v2008, probably no major change. . # Anticoagulation- on [**Month/Year (2) **] 2mg daily for chronic a-fib. On discharge INR was 3.1, likely elevated in setting of short course of antibiotics. Pt will have close follow up to monitor INR. Dose will be held on day of discharge, and 1 mg will be given day after discharge. Home regimen prior to admission was warfarin 2 mg daily. The patient is a full code. Medications on Admission: 1. Warfarin 2 mg daily 2. Atorvastatin 20 mg Tablet daily 3. Aspirin 325 mg Tablet daily 4. Diltiazem HCl 240 mg Capsule, Sustained Release: One (1) Capsule, Sustained Release daily. 5. Furosemide 40 mg Tablet daily. 6. Carvedilol 25mg Tablet [**Hospital1 **] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM: Take [**2-12**] tab on [**2117-10-13**] then start taking full tablet on [**2117-10-14**]. 3. Carvedilol 12.5 mg Tablet [**Date Range **]: Two (2) Tablet PO BID (2 times a day). 4. Diltiazem HCl 120 mg Capsule, Sustained Release [**Date Range **]: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Lasix 40 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 6. Outpatient Lab Work please check INR in next 1-2 days call results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 724**] at [**Telephone/Fax (1) 46092**] 7. Atorvastatin 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day. 8. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated [**Telephone/Fax (1) **]: One (1) Topical once a day for 3 days. Disp:*1 0* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: vagal episode, asystole LLL pneumonia Secondary diagnoses (prior to this hospitalization): 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: [**7-19**]- 2VD, SVG-->OM1/PDA -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: Temporary pacer placed in ED Atrial fibrillation CHF s/p mitral valve repair 3. OTHER PAST MEDICAL HISTORY: s/p cholecystectomy s/p ERCP for CBD stone removal Discharge Condition: stable and improved Discharge Instructions: You came to the hospital with abdominal pain. While being evaluated in the ED, your heart slowed to a dangerously low rate, and stopped for a short period of time. CPR was performed to help you, and you had a temporary pacemaker placed in the ED. During this time, strong medications and a breathing tube were being used to support you. You were then transferred to the ICU for more care. Your rapid heart rate was controlled, and you underwent a series of tests which were all normal. You did well, the breathing tube and strong medications were stopped, and you were transferred to the floor. Following transfer, your home medications were restarted, and you continued to do well. You were discharged on [**2117-10-12**] in good condition. The following changes were made to your medications: Diltiazem 120 mg daily (your dose was cut in half) Do not take your warfarin today. Take your warfarin in the following way: Take NO WARFARIN tonight. Take 1mg of warfarin tomorrow ([**2117-10-13**]). Then resume taking your home dose of warfarin (2mg daily) on Thursday ([**2117-10-14**]). Please have your INR checked in the next 1-2 days and fax the results to your [**Hospital3 **] so they can continue to help you with your warfarin dosing. Please see below for your follow up appointments. Please call your PCP [**Last Name (NamePattern4) **] 911 if you develop chest pain, shortness of breath, dizziness/lightheadedness, fevers, chills, abdominal pain, or any other concerning medical symptoms. Followup Instructions: Please visit Dr.[**Name (NI) 12172**] office, your cardiologist, tomorrow between 9 and 2:30 to pick up your heart monitor. Your follow up appointments: MD: [**First Name8 (NamePattern2) **] [**Doctor Last Name 724**] Specialty: Family Practice/ PCP Date and time: Tuesday, [**2118-10-26**]:30am Location: [**Location (un) 46096**], [**Location (un) 577**] Phone number: [**Telephone/Fax (1) 46092**] Dr. [**Last Name (STitle) 1147**], your cardiologist, will see you at [**2117-10-26**] at 3 p.m.

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icd9cm

[ [ [] ] ]

[ "37.78", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

9666, 9723

4814, 8384

339, 402

10215, 10237

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159,536

5060

Discharge summary

report

Admission Date: [**2126-8-1**] Discharge Date: [**2126-8-4**] Date of Birth: [**2071-6-27**] Sex: M Service: MEDICINE Allergies: Tapazole Attending:[**First Name3 (LF) 30**] Chief Complaint: found down Major Surgical or Invasive Procedure: Brief ICU stay [**Date range (1) 20864**] History of Present Illness: Mr [**Known lastname **] is a 53 yo M with PMH sig for long-standing DM I c/b insulin autoimmune syndrome in recent years, systolic CHF, and CRI who was found unresponsive at home with fs 29. . He later reported that there were no symptoms/warning signs that his blood sugar was low. He had spent the morning doing normal activities without complaint. He last remembers coming in from walking his dog. . Of note, the patient has been admitted to [**Hospital1 18**] several times in the past with the same symptoms, most recently from [**Date range (1) 20177**]; he was also admitted to [**Hospital1 2177**] with same [**7-26**]. Past Medical History: #DIABETES MELITUS-TYPE I -x 37 yrs -frequent hypoglycemic episodes -high level of anti-insulin Ab -followed by Dr.[**Doctor Last Name 4849**] of [**Last Name (un) **] -complicated by nephropathy -complicated by retinopathy (s/p right eye laser surgery, repeated [**8-3**]) #END STAGE RENAL DISEASE SECONDARY TO DIABETIC NEPHROPATHY #HYPERTENSION #ANEMIA, LIKELY DUE TO END STAGE RENAL DISEASE #HYPERURICEMIA #GRAVES' DISEASE #HYPERLIPIDEMIA #DIASTOLIC CONGESTIVE HEART FAILURE WITH LEFT VENTRICULAR HYPERTROPHY Social History: Lives with parents. Works in construction. No alcohol, drugs, or tobacco. Family History: Mother has DM2 and RA. Maternal Aunt also c DM2. Nephew c DM1 Physical Exam: Vitals: 96.5, 172/93, 66, 12, 100% 2LNC General: NAD, awake, alert, pleasant. HEENT: PERRL, EOMI, OP clear +halitosis Neck: no LAD, supple Heart: RRR no m/r/g Lungs: CTAB, rare rhonchi, clears w. cough. Abd: +BS, NT, softly distended Ext: trace edema b/l; small skin tear on RLE [**Month/Year (2) **]: appropriate Neuro: CN 2-12 intact. strength 5/5 x4. sensation grossly wnl. FTN intact. Pertinent Results: ***Admission Labs [**2126-8-1**] U/A: 100 GLUCOSE, NEG KETONE, PH-6.5, LEUK-NEG, no bacteria CBC: WBC# 5.1 | H&H 8.8/25.9 | Platelets 171 Na 139 * K 4.6 * Chlor 103 * Bicarb 25 * BUN 88 * Creatinine 6.0 * Glu 99 UTox: ASA-NEG, ETHANOL-NEG, ACETMNPHN-NEG, bnzodzpn-NEG, barbitrt-NEG, tricyclic-NEG 01:00PM CK-MB-6 cTropnT-0.37* 08:43PM CK-MB-6 cTropnT-0.34* (prior CKMB-6 cTropnT-0.[**7-3**]) PT-12.2 PTT-23.9 INR(PT)-1.0 TYPE-ART PO2-191, PCO2-41, PH-7.42, TOTAL CO2-28, BASE XS-2 Brief Hospital Course: Mr. [**Known lastname **] was given 1 amp d50 in the field (for a fsg of 29) and 100 mg thiamine without improvement. He arrived to the [**Hospital1 18**] ED and was still unresponsive with FS 69. He developed seizure activity and was given a second amp of d50 in addition to Ativan 2 mg iv which successfully broke his sz. He found to be drowsy but arousable and oriented x3. . Upon arrival to the floor the patient was again found to be unresponsive and developed a second episode of seizure. He was given Ativan 1 mg IV with resolution of sz. However, that time, the patient's cardiac enzymes returned with a CK of 296 MB 6 Trop 0.37. An EKG revealed new TWI in V5-6. The Cardiology fellow felt this was likely due to demand ischemia precipitated by seizure and hypertension. The patient was then transferred to the MICU for closer monitoring. . On arrival to the MICU the patient is somnolent but easily arousable. He was stabilized overnight with q1 hr fsg checks and D5NS @75/hr. The patient accepted ASA prophylaxis but refused Heparin gtt and transfusion. The risks of going without these therapies in the setting of ACS were carefully explained to the patient who opted to go without those therapies. . The following day the patient was stable and transferred to the floor without event for a brief observation period prior to discharge. [**Last Name (un) **], Rheum, and Heme-Onc consultants all visited with Mr. [**Known lastname **] to discuss the possibility of starting Rituximab vs. Prednisone therapy to treat his autoimmune antibody syndrome. Plans were made to finish the work-up and discussion in outpatient clinic. Medications on Admission: 1. Calcitriol 0.25 mcg PO once a day. 2. Clonidine 0.3 mg/ One (1) Patch Weekly QFRI 3. Toprol XL 150 mg PO once a day. 4. Allopurinol 100 mg PO Every other day. 5. Diltiazem HCl 180 mg PO twice a day. 6. Furosemide 40 mg PO BID 7. Doxazosin 4 mg PO HS 8. Levothyroxine 75 mcg PO DAILY 9. Minoxidil 5 mg PO DAILY 10. Ferrous Sulfate 325 mg 11. Insulin Glargine 3 units [**Hospital1 **] 12. Humalog Sliding scale 200-250 1 unit [**Unit Number **]-300 2 units 300-350 3 units 350-400 4 units 13. Glucagon Emergency 1 mg Kit Sig: One (1) Injection kit: Use as needed for hypoglycemia. 14. Rosuvastatin 20 mg PO DAILY 15. Calcium Carbonate 500 mg PO TID W/MEALS 17. Nephrocaps 1 PO DAILY 18. Amlodipine 10mg PO once a day. Discharge Medications: 1. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Minoxidil 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 13. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO twice a day: take with meals. 15. Insulin Continue Insulin per sliding scale as provided. Discharge Disposition: Home Discharge Diagnosis: **Primary: #. Type I Diabetes #. Insulin antibody syndrome #. Hypoglycemia induced seizures # NSTEMI **Secondary: #. End-stage Renal disease secondary to diabetic nephropathy #. Hypertension #. Chronic Anemia secondary to End-stage Renal disease #. Hyperuricemia #. Graves' disease #. Hyperlipidemia #. Diastolic congestive heart failure (last TTE [**2125-1-9**]) - severe symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%) - Mild (1+) mitral regurgitation - Pulm art pressure improved compared to [**2123-9-28**] Discharge Condition: stable, tolerating po's, ambulating without assistance. Discharge Instructions: You were admitted to the hospital because you had another episode of severe hypoglycemia due to Type 1 Diabetes and Insulin antibody syndrome. You had a seizure in the Emergency Room and another in the Intensive Care Unit because your sugar was so low. We were able to treat you with D50 and some anti-seizure meds emergently. . You were transitioned to your home dose Glargine [**Hospital1 **] + SSI and tranferred to the floor once your seizures resolved. However, you have some findings on your heart tracing and in your blood work that sugguest you have had some damage to your heart in the setting of these events. We have given you the best medical treatment for what we call "Acute Coronary Syndrome" except for the Heparin and blood transfusion which you declined. . Now that you have been stable for several days you are being sent home with the following instructions. . Please take your medications as prescribed. We have added some new drugs because of your heart attack. You will now take daily Aspirin in addition to the B-blocker and Statin drug you were already taking to optimize your cardiac health. . As soon as possible, please call and set-up these [**Hospital1 4314**] for sometime in the next week: 1. Your primary care doctor: Dr. [**Last Name (STitle) 2450**] ([**Telephone/Fax (1) 1300**] 2. The [**Hospital **] clinic ([**Telephone/Fax (1) 4847**] because of your diabetes 3. The Cardiology clinic ([**Telephone/Fax (1) 2037**] becuase of your recent heart attack 4. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your hematology doctor at [**Hospital1 16549**]. . It is improtant for you to make [**Hospital1 4314**] so see these specialists as soon as possible to ensure the best continuity of care. . You will need to have a PPD placed and read. There is no documentation in your medical records that you have had this in the past. This needs to be done before you can try other therapies for your insulin antibody disorder. . A follow up appointment with Rheumatology on [**2126-8-8**] at 09:00AM has already been made for you. Please go to that visit to ensure appropriate follow-up is established. Please have your blood counts checked at this appointment. . You may return to your normal activity level and normal diet. . ** If you have Chest Pain, palpatations, shortness of breath, dizziness, headache, trembles/shakes, or sweatiness [**Last Name (un) **] call your PCP for advice or return to the emergency room.** Followup Instructions: Rheumatology f/u re: 1) Possible treatment of insulin antibody syndrome w/ Infliximab NOTE- will need PPD placed prior to start Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2126-8-8**] 9:00 . Heme/Onc follow up re: 1) MGUS; needs q 6 month SPEP and free kappa:lambda monitoring 2) If infliximab started, will need monitoring of WBC# **TO BE SCHEDULED BY PATIENT** . Cardiology f/u re: 1) recent ACS with demand ischemia in setting of anemia and seizure 2) Diastolic Congestive Heart Failure +/- adding ACEI/[**Last Name (un) **] **TO BE SCHEDULED BY PATIENT** . [**Last Name (un) **] f/u re: [**Hospital 20865**] medical management of Type 1 Diabetes Completed by:[**2126-8-8**]

[ "250.83", "585.6", "242.00", "285.21", "276.51", "428.30", "410.71", "584.9", "428.0", "250.43", "288.50", "403.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6262, 6268

2631, 4274

276, 320

6872, 6930

2113, 2608

9461, 10204

1623, 1688

5044, 6239

6289, 6851

4300, 5021

6954, 9438

1703, 2094

226, 238

348, 980

1002, 1514

1530, 1607

22,743

109,848

48035

Discharge summary

report

Admission Date: [**2139-6-18**] Discharge Date: [**2139-6-26**] Date of Birth: [**2080-11-4**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Gram Negative rods in CSF. Major Surgical or Invasive Procedure: Omaya reseveroir was removed and an external ventricular drain was placed and subsequently removed. History of Present Illness: Mrs. [**Known lastname 1007**] is a 58 yo woman with metastatic breast Ca and newly dx'd leptomeningeal disease involving brain and spinal cord. She has had various chemotherapeutic regimens as listed below, but most recently has been receiving Temodar po and DepoCyte by Omaya Shunt. On [**2139-6-13**], she was admitted for nausea and vomitting and was found to have a UTI. After 48 hours, she was discharged home with levaquin. Her husband reports that she had an outpatient lumbar puncture as well as a tap of her Omaya shunt earlier today based on some findings from her MRI on saturday the 23rd. He was told that During there was a lesion suspicious for puss vs. tumor vs. blood. Today's tap per pathology, showed three tubes from the LP that were clean, and one tube from the Omaya shunt that had 3+ Gram Negative Rods. The patient was called at home and told that she would be admitted based on these findings. Past Medical History: Metastatic Breast CA with leptomeningeal disease Hypothyroidism Social History: She has a bachelor's degree. She is retired. She used to work as an insurance [**Doctor Last Name 360**]. She is married. She lives with her spouse. She does not smoke. She does not drink. She denies any recreational drug abuse. Family History: Mother died at 77 of bowel obstruction. She had a difficult surgery, and bowel obstruction was secondary to prior surgeries for colon cancer. Her father died at 77 with coronary problems. [**Name (NI) **] sister is alive at 47 in good health. She has one brother who died at 27 in a fire, and she has three other brothers, 59, 57, 15, in good health. She has two daughters, 30 and 26, in good health and a son, 32, in good health. Physical Exam: VITALS: Tc=98.0, P: 116, 110/64, 20 GEN: Appears slightly dry. Thin. Tired. Older than her stated age. Alert, attentive with exam CHEST: CTA bilaterally Back: Sacral ulcer without dressing. No puss or erythema. CV: regular rate and rhythm No MG/R ABD: soft, nontender, nondistended, +BS EXTREM: warm. Well perfused. 2+ DP Bilaterally. NEURO: Mental status: Patient is A+O times 3. She's tired but attentive, flat affect, speech fluent. Per husbands report, she is at her baseline with no changes in personality or level of alertness. Quiet, but speaks spontaneously. Memory intact. Attention good. Names low frequency objects and follows commands. HEENT: Head - left frontal region has Omaya reservoir below sub-cutaneously. No erythema, no edema, no fluctuance. No other signs of infxn at site. Eyes - Pupils reactive bilaterally 5 to 4 L and [**2-23**] Right. EOMI. VFF. No nystagmus. Mouth - Tongue midline, palate elevated symmetrically. No thrush Neck - soft, supple Cranial Nerves: II-VII, IX-XII intact. Intact hearing bilaterally Motor - good effort on exam, 4+5 in bilateral UEs LEs: I/P Legflex LegExt DF PF R [**2-25**] 4-/5 [**2-25**] 4- 4 L [**2-25**] [**2-25**] 4+/5 4+ 4+ Sensory: intact in all four extremities to LT, PP, cold. Reflexes: [**Hospital1 **] BR Tri Pat Ach Toes RT: 1 1 1 0 0 mute LEFT: 1 1 1 0 0 mute Cereberllar: Normal FNF. Gait small steps, requires assist of 1 person. At baseline per husband. Pertinent Results: [**2139-6-18**] 01:06PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-12* POLYS-32 LYMPHS-5 MONOS-0 ATYPS-1 MACROPHAG-62 [**2139-6-18**] 01:06PM CEREBROSPINAL FLUID (CSF) PROTEIN-1080* GLUCOSE-197 LD(LDH)-144 MISC-CEA=26 [**2139-6-18**] 02:40PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-130* POLYS-3 LYMPHS-39 MONOS-58 [**2139-6-18**] 02:40PM CEREBROSPINAL FLUID (CSF) PROTEIN-101* GLUCOSE-134 LD(LDH)-27 Brief Hospital Course: The patient is a 58-year-old female who is well known to the neuro-oncology/neurosurgery service at the [**Hospital **] [**Hospital **] Medical Center. She is known to have metastatic breast carcinoma. The patient suffers from meningeal carcinomatosis. She had recently had a CSF reservoir/access device placed by Dr. [**Last Name (STitle) 739**]. The patient now returns several weeks later with a ventriculitis. The patient is neurologically in good condition. The Gram stain of the recent CSF specimen revealed 3+ gram negative rods. The patient is in need of removal of the previous CSF access device and placement of a new intraventricular EVD for infiltration of intrathecal antibiotics which were never given. She was admitted to the ICU for close neuro observation and care.She was followed by ID and treated initially with Vanco and Ceftazdime. Her EVD was kept in until [**6-22**]. She was transferred to the floor on [**6-23**]. LM disease - pt received IT depocyte and 6/7 days of TMZ. - MRI of L spine shows stable disease 2) ID - pt now in step down unit. ID wants a full 14days of Vanc/Ceftaz (ceft started [**6-20**], Vanc started [**6-22**]), all of her CSF cultures have been negative (1st set done before Abxs). On Discharge ID recommened 14 days of Levaquin 3) Myopathy - in proximal thighs, probably from steroids, pt was on decadron taper before, will have husband cont it once d/c'd from hospital 4) thrush - None today, but would cont nystatin s&s as pt on decadron 5) GI - spoke to [**MD Number(3) 101312**] service and nurse who will see if pt is accurate in her statment of no BM for one week. 7) Cerebral edema - husband should cont decadron taper as brain MRI stable. He has taper schedule given to him. 8) Nausea - cont zydis 10 mg qD, pt not had any nausea since being put on zydis. Her exam on discharge was: Patient is tired but attentive, flat affect, fluent, presodic speech. A&Ox3. Registration intact. ABle to count 20-->1 without diff, serial 3's got to 21 and then stopped. Intact repetition/naming/[**12-26**]-step command. No R/L disorientation. No ideomotor apraxia. Recall: 0/3 spont, [**11-25**] with lists HEENT: Head - NC/AT, alopecic from radiation Eyes - PERRL. EOMI. VFF. No nystagmus. Mouth - Tongue midline, palate elevated symmetrically. No thrush Neck - soft, supple Cranial Nerves: II-VII, IX-XII intact. Intact hearing bilaterally Motor - good effort on exam, [**3-27**] in bilateral UEs LEs: I/P Legflex LegExt DF PF R [**2-25**] 5/5 [**3-27**] 5 5 L [**2-25**] 5/5 [**3-27**] 5 5 Sensory: Pt stated intact LT even over groin area, Cereberllar: Normal appendicular coordination. Didn't test gait Medications on Admission: Decadron 2 mg Q8H PO Dolasetron Mesylate 12.5 mg Q8H:PRN IV [**2139-6-13**] @ 1900 Insulin - Sliding Scale Sliding Scale 0 UNIT ASDIR SC [**2139-6-13**] Pantoprazole 40 mg Q24H PO [**2139-6-13**] @ 1900 Prochlorperazine 10 mg Q6H:PRN IV [**2139-6-13**] @ 1900 Prochlorperazine Maleate 10 mg Q6H:PRN PO [**2139-6-13**] @ 1900 Senna 1 TAB [**Hospital1 **]:PRN PO [**2139-6-13**] @ 1900 Docusate Sodium 100 mg [**Hospital1 **] PO [**2139-6-13**] @ [**2132**] Clotrimazole 1 TROC QID PO [**2139-6-13**] @ 2200 Olanzapine (Disintegrating Tablet) 5 mg QHS PO [**2139-6-13**] @ 2200 Levothyroxine Sodium 44 mcg QSUN ([**Doctor First Name **]) PO [**2139-6-14**] @ 1300 Pregabalin 50 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**] Pregabalin 150 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**] Levothyroxine Sodium 88 mcg QMOWEFR (MO,WE,FR) PO [**2139-6-15**] @ Levothyroxine Sodium 88 mcg QTUTHSA (TU,TH,SA) PO [**2139-6-16**] Discharge Medications: 1. hospital bed 2. one-step mattress 3. standard wheelchair 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* Decadron 2 mg Q8H PO Dolasetron Mesylate 12.5 mg Q8H:PRN IV [**2139-6-13**] @ 1900 Insulin - Sliding Scale Sliding Scale 0 UNIT ASDIR SC [**2139-6-13**] Pantoprazole 40 mg Q24H PO [**2139-6-13**] @ 1900 Prochlorperazine 10 mg Q6H:PRN IV [**2139-6-13**] @ 1900 Prochlorperazine Maleate 10 mg Q6H:PRN PO [**2139-6-13**] @ 1900 Senna 1 TAB [**Hospital1 **]:PRN PO [**2139-6-13**] @ 1900 Docusate Sodium 100 mg [**Hospital1 **] PO [**2139-6-13**] @ [**2132**] Clotrimazole 1 TROC QID PO [**2139-6-13**] @ 2200 Olanzapine (Disintegrating Tablet) 5 mg QHS PO [**2139-6-13**] @ 2200 Levothyroxine Sodium 44 mcg QSUN ([**Doctor First Name **]) PO [**2139-6-14**] @ 1300 Pregabalin 50 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**] Pregabalin 150 mg [**Hospital1 **] ORAL [**2139-6-14**] @ [**2132**] Levothyroxine Sodium 88 mcg QMOWEFR (MO,WE,FR) PO [**2139-6-15**] @ Levothyroxine Sodium 88 mcg QTUTHSA (TU,TH,SA) PO [**2139-6-16**] Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: CSF infection. Discharge Condition: Stable. Discharge Instructions: Please complete the prescribed antibiotics as prescribed. Please call or return for headache, vision changes, redness, swelling or drainage from wound, fever, chills, or any other concern. You also have a decubitus ulcer that should be cared for by a wound nurse. We are providing you a referral for that service. Followup Instructions: Please return for removal of sutures [**7-4**]. 2 weeks after completion of antibiotics, please return for clinic visit with Dr. [**Last Name (STitle) **] and MRI. Please call Brain [**Hospital 341**] Clinic to set up an appointment time. ([**Telephone/Fax (1) 6574**]. You will have an appointment with Dr. [**Last Name (STitle) 4253**] on Tuesday morning at the Infusion Center for intrathecal Depocyte. Her assistant will call you with the appointment time. Completed by:[**2139-6-26**]

[ "996.63", "197.7", "356.9", "198.3", "320.82", "276.51", "V10.3", "198.5", "285.9", "707.03" ]

icd9cm

[ [ [] ] ]

[ "02.43", "02.42" ]

icd9pcs

[ [ [] ] ]

8854, 8905

4071, 6409

347, 449

8964, 8974

3654, 4048

9338, 9832

1750, 2183

7728, 8831

8926, 8943

6771, 7705

8998, 9315

2198, 2541

280, 309

477, 1399

6425, 6745

2556, 3173

1421, 1487

1503, 1734

25,708

189,672

52320

Discharge summary

report

Admission Date: [**2179-11-7**] Discharge Date: [**2179-11-13**] Date of Birth: [**2120-6-4**] Sex: M Service: [**Year (4 digits) 662**] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 108131**] is a 59 year-old man well known to the Medical Service with multiple medical problems including end stage renal disease, severe chronic obstructive pulmonary disease and AIDS who presented to the [**Hospital1 69**] on the [**11-7**] discharged on both [**10-26**] and [**11-5**]. The [**10-26**] discharge was for hypercarbic respiratory failure, increasing potassium and this was secondary to missing dialysis. The admission from [**11-2**] to [**11-5**] was for cellulitis. Mr. [**Known lastname 108131**] was discharged two days prior to admission and was to get dialysis the day prior to admission, but refused to go to dialysis, because he had just developed difficulty breathing last night per his wife. Usually he uses 4 liters nasal cannula, but his oxygen saturation was 88% per his wife. The oxygen was increased to 5 liters on a face mask and his sats responded to 95%. On the morning of admission he felt weak, he slipped on two stairs and fell on his buttocks and sustained a small abrasion to his hand. EMS was initially called upon this fall and helped Mr. [**Known lastname 108131**] from the floor and subsequently left. The patient then developed chest pressure during the course of the morning and felt like food was getting stuck in his throat. He subsequently developed mid sternal chest pressure with associated nausea. He then presented to the Emergency Department. In the Emergency Department he was found to be hypercarbic, acidotic and hyperkalemic. BiPAP was initiated. The patient did refuse intubation. He received insulin, dextrose, calcium gluconate in the Emergency Department for his hyperkalemia and he was subsequently transferred to the Medical Intensive Care Unit for urgent dialysis. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease on home O2. 2. AIDS CD 4 count last was 137 in [**2179-7-25**], viral load was 45,600 in [**2179-7-25**]. 3. End stage renal disease on hemodialysis secondary to IJ nephropathy versus membranous proliferative glomerulonephritis. 4. History of PE - deep venous thrombosis. 5. Congestive heart failure. Echocardiogram in [**9-/2179**] revealed an EF of 60 to 65% with left ventricular hypertrophy with a decline in right ventricular function. 6. Encephalopathy. 7. Obstructive sleep apnea on BiPAP. 8. Lower gastrointestinal bleed secondary to hemorrhoids. 9. Cardiomyopathy. 10. History of ventricular tachycardia status post ablation. 11. History of open reduction and internal fixation of his left hip. 12. Benign prostatic hypertrophy. 13. MRSA last diagnosed in [**9-/2179**] by rectal swab. 14. Anxiety. 15. Depression. 16. Poor nutrition. 17. History of intravenous drug use. 18. Methadone dependence. MEDICATIONS ON ADMISSION: Olanzapine 50 mg po q day, Zoloft 100 mg po q day, Levoxyl 100 micrograms po q day, Renagel 2400 mg po t.i.d., Coumadin 2 mg po q day, Bactrim double strength every other day, Amiodarone 200 mg po q day, Nephrocaps, Lactulose 30 ml po q.i.d., Methadone 40 mg po q day, Albuterol MDI, Atrovent MDI, folate 1 q.d., Protonix 40 mg po q day, Oxycodone 5 mg q 4 to 6 hours prn, sodium bicarbonate 2 tablets every day, Midodrine 2.5 mg at hemodialysis. ALLERGIES: Haldol, codeine, Stelazine, Didanosine, histamine blockers, Clindamycin. SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] has forty to fifty pack years of smoking. He has now quit tobacco for twenty years. He has a history of intravenous drug abuse and he has used alcohol in the past. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.9. Blood pressure 109/61. Heart rate 75. Respirations 18. Saturation 100% on BiPAP. In general, the patient is ill, cachectic appearing, and agitated and swearing at examiners. HEENT BiPAP was on. Mucous membranes are moist. Neck supple. Lungs crackles throughout anterior lung fields. Cardiovascular regular rate and rhythm. 2 out of 6 systolic murmur heard best at the apex. Abdomen soft, but refused rest of the examination. Extremities 2+ edema, erythema and ulcers on his toes bilaterally. Neurological moving all extremities, agitated. PHYSICAL EXAMINATION ON DISCHARGE: Temperature 96.4, blood pressure 132/96. Heart rate 82. Respirations 20. Saturation 100% on 5 liters. In general, no acute distress, alert and oriented. HEENT pupils are equal, round and reactive to light. Extraocular movements intact. Oropharynx is clear. No thrush. Neck is supple. Lungs with bilateral rhonchi, but moving air in all fields. Heart regular rate and rhythm, 2 out of 6 systolic ejection murmur best at the apex. Abdomen soft, nontender, nondistended, active bowel sounds. Extremities minimal edema, some erythema and hyperemia. LABORATORIES ON ADMISSION: White blood cell count 2.3, 73% neutrophils, 2% bands, 15% lymphocytes, 8% monocytes, hematocrit 36.9, platelets 82, sodium 138, potassium 7.2, chloride 102, bicarbonate 24, BUN 82, creatinine 8.8, glucose 108, PT 13.6, INR 1.2, PTT 36.1. Blood gas 7.05/97/84. Blood gas number two 7.10/85/58. Chest x-ray showed worsening right middle lobe opacity. No overt congestive heart failure. Electrocardiogram was normal sinus rhythm at 89 beats per minute, the PR was slightly prolonged at 220 seconds QRS, slightly prolonged 140 milliseconds, intraventricular conduction delay, no significant changes except for an increased PR interval. HOSPITAL COURSE: 1. Renal: Upon admission Mr. [**Known lastname 108131**] again presented with hyperkalemia, fluid overload and severe acidosis. His usual pH runs approx. 7.2. He was profoundly acidotic compared to this on admission. He was admitted to the MICU and received urgent dialysis the night of admission. He also received dialysis two more times on the day after admission. During the rest of his hospital stay he continued to receive dialysis on a regular basis. He did not present of any other symptoms of fluid overload during the course of his hospital stay and did well with his dialysis and tolerated it well. He was maintained on a renal diet. He received Renagel and Mepro as previously prescribed as well as sodium bicarbonate. 2. [**Known lastname **] of breath: Mr. [**Known lastname 108131**] [**Last Name (Titles) 7186**] of breath was most likely attributed to the fluid overload, although there was no overt congestive heart failure on his chest x-ray. He did improve significantly after fluid was removed with dialysis and he was maintained on his normal home regimen of oxygen at 4 to 6 liters of nasal cannula oxygen. His saturations remained excellent throughout the rest of his hospital stay. 3. Chest pain: Mr. [**Known lastname 108131**] initially presented with substernal chest pain. He had cardiac enzymes sent to evaluate if he had an injury to his myocardium. He had numerous creatine kinases sent, which were all below 100. MB fractions were not performed. Troponin was initially 0.5, but slowly raised to 1.4, although this is nonspecific and does not suggest an acute myocardial infarction especially in the setting of renal failure. It was not felt that Mr. [**Known lastname 108131**] had any sort of myocardial ischemia during this hospital admission, but that enzyme abnormalities were related to preexisting cardiomyopathy. 4. Infectious disease: Mr. [**Known lastname 108131**] presented with a recent history of cellulitis. He still had some erythema of both his lower extremities and there was also concern for a pneumonia on his x-ray. He was treated with Vancomycin. He was dosed at dialysis for any hemoconcentration less then 15. He was also maintained on Levaquin 250 mg every other day. The antibiotics were stopped on [**2179-11-12**]. Subsequent to this stopping his antibiotics he remained afebrile and his white count did not increase. He was discharged without any active inflammatory or infectious processes. He was maintained on Bactrim for PCP [**Name Initial (PRE) 1102**]. Mr. [**Known lastname 108131**] has documented MRSA in his sputum from [**2179-1-22**]. This was reconfirmed with a rectal swab in [**2179-9-24**]. He was maintained on MRSA precautions throughout his hospital stay. 5. HIV: Mr. [**Known lastname 108131**] is not a candidate for antiretroviral therapy. He is maintained on Bactrim for PCP [**Name Initial (PRE) 1102**]. 6. Endocrine: Mr. [**Known lastname 108131**] has a history of hypothyroidism. He was being treated with Synthroid. A TSH level drawn during this hospital stay showed a level of 13. His Synthroid was subsequently increased to 125 micrograms every day. 7. Cellulitis versus peripheral vascular disease of his lower extremities: Mr. [**Known lastname 108131**] had erythema and some ulcerations on both of his feet. He had one particular ulceration on his left great toe, which measured approximately 1.5 cm. He has very poor peripheral circulation and required doppler to find his dorsalis pedis pulses and posterior tibial pulses. He does in fact have biphasic doppler signals and bilateral dorsalis pedis pulses and posterior tibial pulses. Podiatry was consulted for wound care and potential further management of his feet wounds. Their recommendations went into effect. He received wet to dry dressing changes on his left great toe lesion. He received antibiotic ointment to the other ulcers and lambs wool in the interspaces of his toes. 8. Pain and addiction: Mr. [**Known lastname 108131**] has a long history of intravenous drug abuse and Methadone use. His Methadone use makes placement into a long term living facility very difficult and Methadone was discontinued during the course of his hospital stay. He felt like he was being mistreated with this Methadone withdraw, however, the Methadone was replaced with Oxycontin at 10 mg b.i.d., which was subsequently increased to 10 mg t.i.d. Upon learning that Mr. [**Known lastname 108131**] would go back home he was placed back on his Methadone therapy at 40 mg once a day. 9. Prophylaxis: Mr. [**Known lastname 108131**] was maintained with Pneumoboots and Protonix throughout his hospital stay. 10. Hematology: Mr. [**Known lastname 108131**] came in with a subtherapeutic INR given his history of PE and deep venous thrombosis. He was maintained on Coumadin at 3 mg per day and his INR fell within the goal of 1.5 to 2.0 throughout the rest of his hospital stay. DISPOSITION: It was felt by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who are respectively Mr. [**Known lastname 108131**] [**Last Name (Titles) **] and primary care physician that Mr. [**Known lastname 108131**] was most likely developing a multifactorial dementia due to chronic disease possible AIDS dementia and other sources and he likely needed increased level of care specifically a long term care facility that could assure that he was no longer noncompliant with his dialysis. He has had multiple admissions in the past year simply because of his noncompliance with dialysis, which leads to his respiratory stress, acidosis and usually hyperkalemia. He was subsequently referred for physical therapy, occupational therapy and case management. The case manager here on CC7 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 108163**] worked to find a suitable bed for Mr. [**Known lastname 108131**] and a long term care facility. At least twenty different facilities were screened with one possibility, but required d/c methadone, which Mr. [**Known lastname 108131**] refused. At the end of his admission Mr. [**Name (NI) 108131**] wife actually decided she did not want long term care provided. DISCHARGE STATUS: Home. DISCHARGE CONDITION: Fair. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. [**Last Name (STitle) **] 2. VNA will participate in your aftercare. 3. Continue with dialysis as previously scheduled. 4. Foot care wet to dry dressing changes to left great toe b.i.d., antibiotic ointment to other foot sores and elevation of lower extremities. DISCHARGE MEDICATIONS: 1. Methadone 40 mg po q day. 2. Synthroid 125 micrograms po q day. 3. Sodium bicarbonate 1300 mg po q day. 4. Warfarin 3 mg po q day. 5. Albuterol two puffs q.i.d. 6. Atrovent two puffs q 6 hours. 7. Midodrine HCI 5 mg po q with hemodialysis. 8. Folic acid 1 mg po q day. 9. Protonix 40 mg po q day. 10. Lactulose 30 milliliters po q.i.d. 11. Nephrocaps one cap po q day. 12. Renagel 2400 mg po t.i.d. 13. Amiodarone 200 mg po q day. 14. Bactrim double strength one tab po q.o.d. 15. Olanzapine 5 mg po q day. 16. Sertraline 100 mg po q day. DISCHARGE DIAGNOSES: 1. End stage renal disease with acidosis. 2. HIV/AIDS. 3. MRSA. 4. Hepatitis C virus. 5. Hepatitis B virus. 6. Chronic obstructive pulmonary disease. 7. Obstructive sleep apnea. 8. Cardiomyopathy. 9. Encephalopathy. 10. Benign prostatic hypertrophy. 11. Anxiety. 12. Depression. [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**] Dictated By:[**Last Name (NamePattern1) 47340**] MEDQUIST36 D: [**2179-11-13**] 15:56 T: [**2179-11-19**] 09:22 JOB#: [**Job Number 108164**]

[ "428.0", "585", "496", "070.51", "276.7", "682.6", "042", "276.2", "304.90" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11955, 11962

12894, 13473

12304, 12873

2967, 3501

5610, 11933

11987, 12280

4368, 4939

182, 1950

4954, 5592

1972, 2940

3518, 3748

65,527

188,862

42057

Discharge summary

report

Admission Date: [**2117-1-13**] Discharge Date: [**2117-1-24**] Date of Birth: [**2032-2-27**] Sex: M Service: MEDICINE Allergies: Codeine / Protamine Attending:[**First Name3 (LF) 4095**] Chief Complaint: hip fracture Major Surgical or Invasive Procedure: [**2117-1-16**] - Open reduction with internal fixation of right intertrochanteric femoral fracture History of Present Illness: 84 y/o male with history of dementia, atrial fibrillation/flutter on coumadin, AVR/MVR, chronic kidney disease (baseline cr 1.3), admitted to [**Hospital1 18**] on [**2117-1-13**] for mechanical fall and hip fx. Course was complicated by. . Reportedly, hx was largely obtained from daughter and review of medical records given patient's baseline dementia. Per daughter, patient had one fall in [**Name (NI) **], one fall in [**Month (only) **], and of late, has had three falls in two days. There is no clear prodrome of lightheadedness, dizziness, nausea, chest pain, or shortness of breath prior to these falls. . on morning of [**2117-1-13**] patient reports that he was putting on his pants, when he lost his balance, and fell nearby the bed. Again, there did not appear to be a prodrome or any cardiopulmonary symptoms prior to his fall. . In [**Hospital1 18**] ED, head CT was negative, but hip imaging confirmed acute comminuted right intertrochanteric femoral fracture. He was planned as the first case for [**Hospital1 24785**] of R femur on [**2117-1-14**]. . Prior to procedure, however, he developed acute hypoxic resp failure and hypotension with desaturations to 80s overnight after eating a cookie. CXR was obtained revealing findings consistent with pneumonitis in L mid and lower lung. Temperature was 100.4, but he has since defervesced. . At baseline, per daughter, patient is not very active; however he does ambulate with a cane. He does not get SOB with this activity. He previously saw a cardiologist at the VA for his atrial fibrillation/flutter, which has been stable per daughter. . Denies any history of chest pain and denies any shortness of breath, orthopnea, ankle edema, palpitations, syncope or presyncope. . On review of systems, patient and daughter deny any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint pains, hemoptysis, black stools or red stools. There is no recent fevers, chills or rigors. There is no exertional buttock or calf pain. All of the other review of systems were negative. . ICU course: [**1-16**] melena + in setting of supratherapeutic INR. Anticoagulation stopped, reversed with VitK, and transfused 2U PRBC with appropriate increase in HCT. Family did not want to pursue endoscopy. Pt Crit has since remained stable around 30. On [**1-17**] pt had episodes of bradycardia to 30s. Determined to be secondary to AF with variable block [**2-18**] increased vagal tone. episodes have since resolved. [**Month/Day (2) 24785**] was performed on [**2117-1-16**], without complications. [**Name (NI) **] pt was in significant pain, requiring pain service consult and epidural catheter, which has since been removed. Pt also experienced worsening dyspnea likely secondary to volume overload. CXR showed vascular congestion. He was given 10mg Lasix 2pm on [**2117-1-17**] and diuresed 500ml. He was +7L for LOS in ICU. Last episode of melena was [**2117-1-16**]. Vitals on transfer - afebrile, 134/80, 74, 20, 94% on 4L NC Past Medical History: - dementia - atrial fibrillation/flutter on coumadin - AVR/MVR (mechanical) - trigger finger - chronic kidney disease Social History: lives at [**Hospital3 **] facility, daughter [**Name (NI) **] closely involved in patient's care and is health care proxy (phone [**Telephone/Fax (1) 91280**]), patient is DNR/DNI, he ambulates with a cane, he has assistance with bathing and dressing with nursing team. No tobacco for past 50 years. No EtOH. No drug use. Family History: nc Physical Exam: GENERAL: chronically ill appearing male, somewhat cachectic, NAD, appears stated age HEENT: Normocephalic, atraumatic. No scleral icterus. PERRLA/EOMI. MM somewhat dry. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: bradycardic, irregular rhythm. Mid-systolic click. No rubs or [**Last Name (un) 549**]. JVP=6 cm LUNGS: crackles at bilateral bases, left > right. Good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 1+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: oriented to person and family, unable to provide day/date, unable to provide president's name. Per daughter, patient at baseline mental status. CN 3-12 grossly intact. Preserved sensation throughout. 4/5 strength throughout. [**1-18**]+ reflexes, equal BL. Coordination not assessed. Gait assessment deferred. ROM deferred given acute fracture. PSYCH: Listens and responds to questions appropriately Pertinent Results: [**2117-1-13**] 10:10AM PT-23.3* PTT-33.5 INR(PT)-2.2* [**2117-1-13**] 10:10AM PLT COUNT-177 [**2117-1-13**] 10:10AM NEUTS-85.2* LYMPHS-8.0* MONOS-6.2 EOS-0.3 BASOS-0.3 [**2117-1-13**] 10:10AM WBC-9.9 RBC-4.22* HGB-11.9* HCT-36.7* MCV-87 MCH-28.3 MCHC-32.5 RDW-13.9 [**2117-1-13**] 10:10AM CALCIUM-9.2 PHOSPHATE-2.5* MAGNESIUM-2.0 [**2117-1-13**] 10:10AM estGFR-Using this [**2117-1-13**] 10:10AM GLUCOSE-132* UREA N-32* CREAT-1.4* SODIUM-136 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [**2117-1-13**] 10:45AM URINE MUCOUS-RARE [**2117-1-13**] 10:45AM URINE GRANULAR-3* HYALINE-3* [**2117-1-13**] 10:45AM URINE RBC-2 WBC-1 BACTERIA-MANY YEAST-NONE EPI-0 [**2117-1-13**] 10:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2117-1-13**] 10:45AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2117-1-13**] 08:50PM TYPE-ART PO2-60* PCO2-46* PH-7.39 TOTAL CO2-29 BASE XS-1 Cardiac enzymes: [**2117-1-14**] 11:47AM BLOOD CK-MB-6 cTropnT-0.01 [**2117-1-14**] 11:03PM BLOOD cTropnT-0.02* [**2117-1-15**] 03:01AM BLOOD CK-MB-6 cTropnT-0.02* [**2117-1-19**] 06:51AM BLOOD proBNP-[**Numeric Identifier 91281**]* Other relevant labs: [**2117-1-19**] 10:37AM BLOOD Type-ART pO2-74* pCO2-31* pH-7.59* calTCO2-31* Base XS-8 Intubat-NOT INTUBA . Discharge Labs: [**2117-1-23**] 08:20AM BLOOD WBC-13.9* RBC-3.39* Hgb-9.5* Hct-31.0* MCV-91 MCH-28.0 MCHC-30.7* RDW-14.6 Plt Ct-341 [**2117-1-23**] 08:20AM BLOOD Glucose-144* UreaN-62* Creat-1.7* Na-149* K-4.7 Cl-108 HCO3-33* AnGap-13 . Microbiology: Blood culture x3- Negative Urine culture x3- Negative C Diff x 2- Negative [**2117-1-18**] IMPRESSION: 1) Interval improvement in CHF findings. 2) Residual opacities in left greater than right lungs. While this could represent some residual CHF, the possibility of an underlying infiltrate cannot be entirely excluded. 3) Continued, but improved, left lower lobe collapse and/or consolidation, and probable small effusions. 4) Possible nodular opacity, right upper lobe. Close attention to this area on followup films and, if indicated, further assessment with CT would be recommended. However, this may be an artifact related to the acute process, as there is no corresponding abnormality on the film from [**2117-1-13**] at 11:48 a.m. . [**2117-1-19**] CXR IMPRESSION: AP chest compared to [**2117-1-14**] through [**2117-1-18**]: Symmetric bilateral perihilar opacifications in the mid and upper lung zones has improved since [**2117-1-17**] and previous moderate right pleural effusion has decreased substantially. The comparative changes are due to improved cardiac function. Reviewing prior chest radiographs, this admission suggests a preceding left lung pneumonia. Whether there is any contribution of fat embolism syndrome to the edema, it would depend upon the time course of therapy for the patient's long bone fractures. Right jugular line ends in the mid SVC. No pneumothorax. . [**2117-1-20**] INDICATION: New nasogastric tube placement. COMPARISON: [**2117-1-19**]. FINDINGS: As compared to the previous radiograph, the patient has received a nasogastric tube. The course of the tube is unremarkable, the tip of the tube is located at the gastroesophageal junction, the tip of the tube projects over the middle parts of the stomach. The tube could be advanced by several centimeters. Unchanged size of the cardiac silhouette. Unchanged appearance of the lung parenchyma. No evidence of complications, notably no visible pneumothorax. Brief Hospital Course: 84 y/o male resident of [**Hospital3 **], with history of dementia, atrial fibrillation/flutter on coumadin, CKD, and mechanical AVR, who presents with R hip fracture after mechanical fall, course complicated by aspiration chemical pneumonitis/pna requiring TSICU stay. Pt with aflutter with variable conduction block resulting in intermittent bradycardia and acute systolic and diastolic CHF [**2-18**] volume overload. . # Aspiration chemical pneumonitis and aspiration pneumonia: Prior to originally scheduled [**Name (NI) 24785**], pt aspirated after eating a cookie and went into acute respiratory distress and hypoxia requiring NRB mask and pressor support in surgical ICU. Serial chest x rays after the aspiration event revealed new and worsening mid and lower lung opacities consistent with an acute aspiration pneumonitis. This evolved into a left lung multifocal pneumonia. Pt was started on zosyn for aspiration pneumonia and kept NPO. His hypoxia and hypotension improved. Speech and swallow evaluation was performed after pt transferred to floor. He failed s/s eval and a Nasogastric tube was placed for tube feeds given poor nutritional status (albumin=2.8; increasingly weak). The patient became increasingly strong with tube feeds. A repeat s/s evaluation revealed that the patient tolerated pureed solids and thickened liquids. At discharge, the pt remained with an NG tube but was tolerating PO intake with above modifications. Goal is to continue advancing diet as long as is safe for patient with removal of NG tube once pt meeting nutritional goals. . # Acute GIB: In the setting of supratherapeutic INR of 5.4, pt had several episodes of melena with crit drop from 36 to 22. He was given 2u FFP and 2.5mg vit K IV and 2U prbc. GI team was consulted and recommended egd/[**Last Name (un) **] but family refused any invasive interventions for pt. He was given IV PPI drip initially and then transitioned to IV PPI [**Hospital1 **]. His melena resolved with reversal of INR and he remained hemodynamically stable with stable crit. . # Acute systolic and diastolic CHF exacerbation: After [**Name (NI) 24785**], pt hecame hypoxic again. He had been 7.5L positive for ICU stay and had signs of hypervolemia on physical exam and pulmonary edema on repeat xrays. BNP was very high at [**Numeric Identifier 7923**]. Echo revealed mild systolic dysfunction LVEF 45-50%, mild LVH, and likely diastolic dysfunction. He was transferred to medicine service and diuresed with 20mg lasix [**Hospital1 **]. He responded appropriately to this dose with greatly improved CXray findings, normalization of JVP, and resolution of o2 requirement. Pt has never had CHF before, and this was most likely iatrogenic from aggressive IV fluids. . # [**Hospital1 24785**]: s/p fall and R trochanteric fracture. Surgery was performed on [**2117-1-16**] without complications. Will follow up with orthopedics. . # Bradycardia: Patient also developed bradycardic episodes in the 30s on telemetry at night while in SICU. Cardiology was consulted and it was determined that this was secondary to atrial flutter with variable block in setting of increased vagal tone from his illness and hypoxia. Pt had flat trops and MB, not suggestive of an ischemia cause to his bradycardia. With resolution of his pneumonia, pulmonary edema, and hypoxia, the bradycardia resolved. Even during bradycardia, pt remained hemodynamically stable and per his report asymptomatic, no further w/u or pacer planned. Pt should refrain from using nodal agents (ie beta-blockers, calcium-channel blockers). . # Aflutter/mechanical valves: After GIB resolved, pt was reinitiated on anticoagulation with fondaparinux pseudobridge (only dosed at 2.5 mg daily) given high risk for CVA. Coumadin was restarted. With only two 1 mg doses of warfarin, the pt's INR shot up to 4.1. This was most likely a function of poor nutrition as the patient by this point, had been kept NPO for nearly a week. Warfarin was held, nutrition via NG tube, and his INR dipped to 1.7, at which point he restarted coumadin without bridging given the daughter's report that he was very responsive to small doses of coumadin and also given the recent GI bleed. Target INR for patient's with mechanical valve and atrial fibrillation/flutter is 2.5-3.5, but in patient with GI bleed and history of falls, I think it is likely safer to shoot for a range of 2.0-3.0. Aspirin was also restarted given its unequivocal benefit in mechanical valve patients. . # Persistent leukocytosis: Unclear cause. Pt remained afebrile, with urine and blood cultures negative. There was suspicion for C Difficile as pt had multiple loose stools, but C Diff toxin was negative x2 and the diarrhea was more likely a function of tube feeds after a long period of bowel rest. Pt was afebrile during the leukocytosis and was progressively appearing healthier; thus, a further workup for the elevated WBC was deferred. Diarrhea resolved with slowing of tube feeds. . # Mild Malnutrition: NG tube placement and tube feeds as discussed above. . # Respiratory and metabolic alkalosis: Pt had ABG drawn after appearing very somnolent one morning, most likely as a result of his weakness from malnutrition, as well as dose of morphine and haldol the previous day. The ABG revealed an alkalemia with both respiratory and metabolic alkalosis. There was most likely a respiratory alkalosis from the patient's pulmonary edema and pneumonia. The metabolic alkalosis most likely resulted from the patient's volume contraction after diuresis and being kept NPO. . # Hypernatremia: Due to lack of free water. Increased free water given with tube feeds. . # CKD: At patient's baseline. Likely mild prerenal component as well given high BUN in the setting of diuresis and poor PO intake. . # Dementia: Pt was kept on home medications. . Code: DNR/DNI #Communication: daughter [**Name (NI) **] closely involved in patient's care and is health care proxy (phone [**Telephone/Fax (1) 91280**]) . Transitional: - follow up in ortho clinic - aspiration risk - history of multiple mechanical falls, will need PT and safety eval - monitor for symptoms associated with bradycardic episodes. Possible holter monitor at PCP [**Name Initial (PRE) 8469**]. Medications on Admission: aspirin 81mg QD citalopram 20mg QD donepezil 5mg QD Cozar small unknown dose Renal Caps 1 cap QD timolol 0.5% = Both eyes, QAM Vitamin D 1000 IU QD warfarin 4mg Mon;2mg TWThFSaSu = 16mg qweek Tylenol PRN pain Discharge Medications: 1. donepezil 5 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO HS (at bedtime). 2. citalopram 20 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO DAILY (Daily). 3. timolol maleate 0.5 % Drops [**Name Initial (PRE) **]: One (1) Drop Ophthalmic QAM (once a day (in the morning)). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Name Initial (PRE) **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Vitamin D 1,000 unit Capsule [**Name Initial (PRE) **]: One (1) Capsule PO once a day. 6. Nephrocaps 1 mg Capsule [**Name Initial (PRE) **]: One (1) Capsule PO once a day. 7. amlodipine 5 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO DAILY (Daily). 8. Tylenol 325 mg Tablet [**Name Initial (PRE) **]: Two (2) Tablet PO every six (6) hours as needed for pain. 9. warfarin 2.5 mg Tablet [**Name Initial (PRE) **]: One (1) Tablet PO once a day. 10. miconazole nitrate 2 % Cream [**Name Initial (PRE) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: R intertrochanteric femoral fracture chemical pneumonitis/aspiration pneumonia acute systolic and diastolic CHF exacerbation GI bleed Malnutrition Secondary: Aflutter with RVR and SVR CKD AVR 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: Mr. [**Known lastname 91282**], it was a pleasure caring for you during your hospital stay. You were admitted to the hospital for a hip fracture. Your course was complicated by chemical pneumonitis and aspiration pneumonia requiring ICU level care. The pneumonia improved with antibiotics. During this time you experienced a GI bleed. We believe that this bleed was secondary to a supratherapeutic INR (meaning that your blood was too thin). An EGD and colonoscopy are normally used to diagnose the source of a GI bleed but you declined. You were also treated for a heart failure exacerbation. We gave you lasix which removed the excess fluid from your lungs and your breathing improved. You became very weak when we kept you from eating anything. We placed a nasogastric tube and you have gotten much stronger since we have been feeding you through this. . ORTHOPEDIC recommendations: - Keep Incision clean and dry. - You can get the wound wet or take a shower, but no baths or swimming for at least 4 weeks from [**2117-1-16**]. - Dry sterile dresssing may be changed daily. No dressing is needed if wound continues to be non-draining. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. Activity: - Continue to be partial weight bearing on your right leg - You should not lift anything greater than 5 pounds. - Elevate right leg to reduce swelling and pain. Other Instructions - Avoid nicotine products to optimize healing. . We have made the following changes to your home medications: START Nasogastric Tubefeeds START Amlodipine DISCONTINUE COZAAR Followup Instructions: ORTHOPEDIC: someone from the hospital will call with an appointment for you to see your orthopedist tomorrow Please have the nursing facility call to schedule an appt with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] in [**3-22**] days after leaving the facility at [**Telephone/Fax (1) 608**] Completed by:[**2117-1-25**]

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Discharge summary

report

Admission Date: [**2130-10-14**] Discharge Date: [**2130-10-18**] Service: MEDICINE Allergies: Neosporin Attending:[**First Name3 (LF) 1990**] Chief Complaint: fevers, loose stools, left facial droop and inability to ambulate Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 634**] is an 87 year old male with a history of atrial fibrillation, hypertension and subdural hematoma diagnosed [**2130-10-4**] in the setting of supratherapeutic INR who presents from rehab with fevers, loose stools, left facial droop and inability to ambulate. The patient was recently admitted from [**2130-10-10**] to [**2130-10-13**] for fevers, fatigue and diarrhea. Per nursing staff at that time of discharge on [**2130-10-13**] the patient had no focal neurologic deficits on exam and was ambulating with a walker but did appear to have proximal muscle weakness. He had intermittent fevers during this hospital stay to as high as 100.9 on [**2130-10-12**]. He had blood and urine cultures which were negative as well as a swab for influenza A. He was initially treated empirically for clostridium difficile given report of diarrhea but subsequently did not have additional bowel movements and c. diff toxin assay was never sent and flagyl was discontinued. He did suffer a fall on [**2130-10-11**] with trauma to the head but serial CT scans did not convincingly show worsening of his subdural hematoma. He had baseline head and [**Doctor Last Name **] pain which is improved when he lies down but this was not worsened after his fall. Per notes the patient was doing well at rehab on the night of discharge. At approximately 12PM this afternoon he was noted to be leaning towards the right and to have a left sided facial droop. At that time he was alert and oriented x 3 but was complaining of neck pain and headache. Per the patient these are chronic complaints. The pain was on the left side of his head and he was noted to be leaning towards the right side. He was transferred to [**Hospital1 18**] for further evaluation. . In the ED, initial vs were: T: 100.4 P: 107 BP: 200/90 R: 18 O2 sat 95% on RA. Labs were notable for a WBC count of 8.7 with 75% neutrophils. Chemistries were notable for a creatinine of 1.3. He had a stat head CT which did not show significant change from priors. EKG showed atrial fibrillation at a rate of 118, leftward axis, normal intervals, no acute ST segment changes, no change from prior dated [**2130-10-10**]. He had a CXR which did not show any acute abnormalities. He was seen by both neurology and neurosurgery who felt that his presentation could be consistent with an infection exacerbating his previous brain injury versus a new ischemic stroke. They did not recommend lumbar puncture given midline shift. He was thus treated empirically for meningitis with vancomycin 1 gram IV x 1, ceftriaxone 2 grams IV x 1, levofloxacin 750 mg IV x 1 and flagyl 500 mg IV x 1. He also received diltiazem 10 mg IV x 1. Foley placement was unsuccessful and he required cystocopy guided foley catheter placement. He had a CT of the abdomen, results are pending. Peripheral IV access was unable to be obtained and a central line was placed. He is admitted to the MICU for further management. . On arrival to the ICU he is alert and oriented x 3, but his speech is slurred and he has difficulty answering questions. He reports that he had a headache and neck pain today but that these are not new complaints. He does not recall having new weakness. He denies blurry vision or photophobia. No chest pain, shortness of breath, nausea, vomiting, abdominal pain, constipation, dysuria, hematuria, leg pain or swelling. He has had intermittent diarrhea. He denies cough or congestion. No new rashes. He has had intermittent low grade fevers over the past five days. He has chronic difficulty initiating urinary stream but denies frank urinary retention. All other review of systems negative in detail. Past Medical History: Subdural Hematoma [**10-4**] Atrial Fibrillation Hypertension Hypothyroidism Vertigo BPH Social History: Social History: The patient lives alone at home and is very high functioning, is the CEO of his own business. Denies tobacco, alcohol or illicit drug use. Family History: Non-contributory Physical Exam: Vitals: T: 99.8 BP: 148/78 P: 126 R: 15 O2: 99% on 4L General: Alert, oriented x3, slightly slurred speech, difficulty responding to questions linearly, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurologic: PERRL, CN II-XII tested and intact, mild left facial droop, strength 5/5 in the upper extremities bilaterally, right leg [**3-12**], left leg withdraws to pain but does not move to command, toes downgoing bilaterally, sensation intact to light touch throughout, reflexes 2+ and symmetric in the biceps, triceps, patellar, brachioradialis. Gait not tested. Finger to nose intact. Pertinent Results: [**2130-10-13**] 07:50AM BLOOD WBC-7.8 RBC-4.32* Hgb-14.2 Hct-40.8 MCV-94 MCH-32.8* MCHC-34.8 RDW-14.1 Plt Ct-198 [**2130-10-17**] 06:07AM BLOOD WBC-6.1 RBC-3.77* Hgb-12.2* Hct-35.9* MCV-95 MCH-32.2* MCHC-33.8 RDW-14.9 Plt Ct-176 [**2130-10-16**] 06:27AM BLOOD PT-15.2* PTT-25.0 INR(PT)-1.3* [**2130-10-14**] 02:05PM BLOOD PT-13.4 PTT-22.4 INR(PT)-1.1 [**2130-10-13**] 07:50AM BLOOD Glucose-91 UreaN-18 Creat-1.1 Na-136 K-3.2* Cl-99 HCO3-28 AnGap-12 [**2130-10-16**] 06:27AM BLOOD Glucose-73 UreaN-19 Creat-1.3* Na-139 K-3.3 Cl-102 HCO3-27 AnGap-13 [**2130-10-15**] 03:38AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.8 [**2130-10-14**] 05:00PM BLOOD Type-[**Last Name (un) **] Temp-38.6 pO2-71* pCO2-33* pH-7.41 calTCO2-22 Base XS--2 Intubat-NOT INTUBA [**2130-10-14**] 02:14PM BLOOD Glucose-94 Lactate-1.9 Na-138 K-4.2 Cl-97* CT head [**10-14**]: Similar appearance of CT head from [**2130-10-11**] demonstrating mild rightward shift, subarachnoid blood, left hypodense subdural collection and blood layering over the tentorium, unchanged. CT abd/pelvis [**10-14**]: Diverticulosis without diverticulitis MRI head [**10-15**]: Unchanged left-sided frontal, temporal and parietal subdural collection with similar pattern of midline shifting towards the right. Foci of hemorrhage with evidence of magnetic susceptibility, right to the midline in the frontal lobe, extending along the falx in the convexity; no other new lesions are identified. CT head [**10-15**]: No new intracranial hemorrhage or developing hydrocephalus. Unchanged left-sided subdural collection with unchanged rightward shift of midline structures. Carotid U/S: <40% stenosis bilaterally Brief Hospital Course: 87 year old male with a history of atrial fibrillation, hypertension and subdural hematoma diagnosed [**2130-10-4**] s/p in the setting of supratherapeutic INR who presents from rehab one day after hospital discharge with left facial droop, inability to ambulate found to have an ischemic stroke. . #. s/p Ischemic stroke: One day prior to admission, the patient was able to ambulate with a walker although he had significant proximal muscle weakness in the lower extremities at baseline. On admission, the patient had a left sided facial droop, was leaning to the right side, and noted left leg weakness that prohibited ambulation. He was admitted to the MICU for further care. CT on [**10-14**] demonstrated stability of his prior SDH, but MRI on [**10-15**] revealed three small ischemic strokes in MCA distribution with hemorrhagic conversion. Neurosurgery and Neurology were consulted. A repeat CT confirmed stabilization of SDH, so Neurosurgery did not feel intervention was necessary and requested 3 month f/u. Neurology posited that the stroke was unlikely to be cardiac in origin, suggesting that the SDH may have led to small vessel compression or vessel sludging and resulted in the stroke. In the interim, the patient's facial droop resolved, his left leg weakness returned to his prior basline, and q4 neuro checks were stable so he was transferred to the medicine floor. Per neurology's recommendations, he was started on Keppra for seizure prophylaxis and restarted on his home ASA with a plan to restart his Coumadin 2-3 weeks after his SDH. On the floor, he remained on q4 neuro checks, with goal sbp's in the 100-140's and an INR goal <1.5. To evaluate for a source of emboli, he had a carotid U/S that revealed <40% stenosis bilaterally. . #. Atrial Fibrillation: Patient with RVR in the ED in the setting of missed medication doses, but no evidence of cardiac ischemia or significant volume overload. Since admission, the patient has remained intermittently tachycardic to 140's, but asymptomatic. His rate was originally thought to be related to a concern for infection, but there was no obvious source of infection found as an inpatient. On the medical floor, he continued his home Amiodarone 200mg, Metoprolol 75mg PO TID, and Diltiazem 180mg SR daily. He continued to have hr's into the 130-140's, so his Diltiazem was increased to 240mg SR daily with improved heartrates below 100. . #. Fevers: Patient had low grade fevers (99~'s) and mild diarrhea for the past week of unclear etiology. He was worked up with blood cultures, urinalysis, influenza DFA, and C. diff toxin tests that were all negative. At the time of discharge, he had no diarrhea or other localizing symptoms, but continued to have occasional temperature elevations to 99.0 which the primary team thought was likely [**1-9**] to his intracranial process. Blood cultures from [**10-10**] were confirmed negative and 11/5,[**10-13**],& [**10-14**] were no growth to date, but a final result was still pending. . #. Subdural Hematoma: Patient's head CT on admission from [**10-14**] and from [**10-15**] was stable from prior to admission. He was followed by Neurology and Neurosurgery and continued on Keppra 500mg PO BID for seizure prophylaxis as well as Q4H neurologic checks. . #. Hypertension: Patient hypertensive on admission with sbp's in the 200s in the setting of not taking medications. On transfer, his blood pressure was well-controlled with sbp's in 100-110's, where it remained until discharge. He was continued on his home Metoprolol 75mg TID and Diltiazem SR was increased from 180 to 240mg daily. His home Lasix 60 mg daily was held in the context of an episode of an sbp in the 90's and in the absence of fluid overload on exam. . #. Urinary Retention/Benign Prostatic Hypertrophy: Patient with distended bladder and inability to place foley catheter in the emergency room. Urology was called to place cystoscopy guided foley. He completed 3 days of Bactrim DS for Foley trauma and Urology asked that his Foley to remain in place until Urology outpatient followup. . #. Hypothyroidism: A recent TFTs within normal limits. He was continued on his home Levothyroxine 75mcg daily. . #. Code: FULL CODE Medications on Admission: Levothyroxine 75 mcg daily Amiodraone 200 mg PO daily Diltiazem 180 mg SR daily Trazodone 12.5 mg QHS:PRN Tylenol 325 mg PRN Metoprolol Tartrate 75 mg PO TID Lasix 60 mg daily Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: 1. Ischemic stroke with hemorrhagic conversion 2. Subdural hemorrhage 3. Atrial Fibrillation 4. Hypertension Discharge Condition: Symptoms resolved. Baseline proxmial muscle weakness of lower extremities unchanged. Able to ambulate with walker. Discharge Instructions: You were admitted to the hospital due to symptoms of a left facial droop and some weakness in your left leg. In the hospital, you were found to have had a small stroke. The Neurology and Neurosurgery teams saw you and felt that you did not require any intervention. Your weakness and facial droop resolved and after being monitored for changes in your neurologic status, you were discharged to a rehabilitation facility. . In the hospital, you had a catheter placed to help drain urine from your bladder. The Urology team asked that you keep the catheter in place until you could be re-evaluated in their offices as an outpatient. Please follow-up with them as indicated below. . Medications: Diltiazem - This medication was INCREASED from 180mg daily to 240mg daily Lasix - This medication was STOPPED Coumadin - This medication should be RESTARTED in one week, [**10-25**] at a dose of 2mg once a day at bedtime Followup Instructions: Neurosurgery: Please follow-up with Dr. [**First Name (STitle) **] at his offices in the [**Hospital3 **] Deaconness on [**11-9**] at 3:30PM. . PCP: [**Name10 (NameIs) 357**] [**Name11 (NameIs) 702**] with Dr. [**Last Name (STitle) **] on [**10-24**] 3:30 PM at [**State 58071**]in [**Location (un) 1411**], MA. . Urology: Please follow-up with Dr. [**Last Name (STitle) **] in the [**Hospital 159**] Clinic [**Street Address(1) 58072**] in [**Location (un) 620**] to have your catheter removed. You can call: ([**Telephone/Fax (1) 58073**] to schedule this appointment.

[ "244.9", "585.2", "434.91", "788.20", "E885.9", "852.26", "E849.0", "600.01", "852.06", "310.2", "584.9", "E849.7", "403.90", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "57.94", "57.32", "38.93" ]

icd9pcs

[ [ [] ] ]

11457, 11534

7020, 11230

285, 291

11687, 11804

5342, 6997

12766, 13340

4282, 4300

11555, 11666

11256, 11434

11828, 12743

4315, 5323

180, 247

319, 3981

4003, 4093

4125, 4266

49,029

136,176

12643

Discharge summary

report

Admission Date: [**2150-3-25**] Discharge Date: [**2150-5-16**] Date of Birth: [**2071-12-9**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Iodine / Penicillins / Opioid Analgesics / Chocolate Flavor / [**Location (un) **] Juice / Benzodiazepines / Red Dye / Egg / Gluten / Tomato Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2150-4-3**] 1. Coronary bypass grafting x3( Left internal mammary artery to left anterior descending coronary,saphenous vein graft to first diagonal coronary artery,saphenous vein graft to first obtuse marginal coronary artery),Aortic valve replacement with a 23-mm [**Doctor Last Name **] Magna aortic valve bioprosthesis,Insertion of intra-aortic balloon pump through the right femoral artery. Tracheostomy [**4-16**] Sternal debridement [**2150-4-26**] Sternal closure with latissimus and pectoralis flaps [**2150-4-29**] History of Present Illness: This a 78 year old female with known aortic stenosis admitted to [**Hospital3 **] with chest pain and congestive heart failure. She was diuresed but continued to have chest pain, and was transferred to [**Hospital1 18**] for cardiac catheterization. Past Medical History: Hypertension Hypercholesterolemia peripheral vascular disease with dry gangrene toes bilaterally insulin dependent diabete mellitus Aortic Stenosis coronary artery disease h/o gastric ulcer Osteoarthritis morbid Obesity MRSA in abdominal wall abscess s/p cholecystectomy s/p hernia repair Social History: Ms.[**Known lastname 39056**] [**Last Name (Titles) **] tobacco use, alcohol, or drugs. She is married and lives with her husband. [**Name (NI) **] daughter lives on the [**Location (un) 17879**] of her house. She has five children. Family History: Ms. [**Known lastname 39056**] reports no family history of early myocardial infarction or coronary artery disease. Physical Exam: Admission: VS: 97.6, 154-194/56-67, 14, GENERAL: WDWN Femal in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Adentulous with prosthetics NECK: Supple with difficult to evaluate JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Harsh, late peaking 3/6 systolic murmur in all fields, worst at LUSB and radiating to carotids. No thrills, lifts. No S3 or S4. LUNGS: +Pectus, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Swollen, brawny upper extremities. No femoral bruits. SKIN: + stasis dermatitis, + healing ulcers bilateral hallux, 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: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 4617**] [**Hospital1 18**] [**Numeric Identifier 39057**] (Complete) Done [**2150-4-26**] at 11:11:46 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2071-12-9**] Age (years): 78 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Chest pain. Congestive heart failure. Coronary artery disease. H/O cardiac surgery. Hypertension. ICD-9 Codes: 402.90, 427.31, 786.05, 424.1 Test Information Date/Time: [**2150-4-26**] at 11:11 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW5-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aorta - Ascending: 2.6 cm <= 3.4 cm Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No thrombus in the RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline dilated LV cavity size. Mild regional LV systolic dysfunction. Doppler parameters are most consistent with Grade I (mild) LV diastolic dysfunction. RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move normally. No masses or vegetations on aortic valve. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Mild to moderate ([**1-3**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions Pt for Sternal Debridement. 1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. 2. No thrombus is seen in the right atrial appendage No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. There is mild regional left ventricular systolic dysfunction with anterior and anteroseptal hypokinesis. Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. 4. Right ventricular chamber size is normal. with mild global free wall hypokinesis. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis leaflets appear to move normally. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-3**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. 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) **] [**2150-4-26**] 11:19 [**2150-5-15**] 03:30AM BLOOD WBC-18.4* RBC-2.74* Hgb-8.4* Hct-25.1* MCV-92 MCH-30.5 MCHC-33.3 RDW-15.2 Plt Ct-499* [**2150-5-15**] 03:30AM BLOOD PT-13.4 PTT-27.9 INR(PT)-1.1 [**2150-5-15**] 03:30AM BLOOD Glucose-95 UreaN-47* Creat-3.8* Na-134 K-3.5 Cl-95* HCO3-31 AnGap-12 [**Known lastname **],[**Known firstname 4617**] S [**Medical Record Number 39058**] F 78 [**2071-12-9**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2150-5-11**] 6:17 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2150-5-11**] 6:17 PM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 39059**] Reason: r/o aspiration [**Hospital 93**] MEDICAL CONDITION: 78 year old woman s/p AVR/CABG REASON FOR THIS EXAMINATION: r/o aspiration Final Report HISTORY: Possible aspiration after cardiac surgery. FINDINGS: In comparison with study of [**5-10**], there has been decrease in the bilateral pleural effusions and pulmonary edema. Persistent atelectatic changes at the bases, especially in the retrocardiac region on the left. The possibility of supervening pneumonia cannot be excluded. Monitoring and support devices remain in place. Brief Hospital Course: Cardiac catheterization was done on [**3-26**] and documented severe aortic stenosis and coronary artery disease. The pt. became delerious post cath and had several "code purples" called. She also had a UTI which ID stated was chronic and was not treated. While she was waiting for surgery she experienced unstable glucoses with some low measurments. She experienced heart block and sinus pauses as well. The patient had a wound nurse consult which determined that she had a stage 2 pressure ulcer on her glutealis. Surgical evaluation was obtained and she was worked up for cardiac surgery in typical fashion. On [**2150-4-3**] Ms. [**Known lastname 39056**] was taken to the Operating Room and underwent a coronary artery bypass grafting times three and an aortic valve replacement. Please see the operative note for details. An intraaortic balloon pump was placed in the OR secondary to wide open mitral regurgitation when weaning from bypass. Fluid was removed and the regurgitation resolved. She weaned from bypass in complete heart block being pacing with temporary wires. Levophed, Epinephrine, Amiodorone and vasopressin were required to wean from bypass. She was paced via her epicardial leads with atrial fibrillation with a ventricular rate in the 30s. Her rhythm gradually improved with sinus rhythm and atrial fibrillation at times. Amiodarone was stopped and the electrophysiology servive followed her. The temporary wires were finally removed on POD 18. A Heparin infusion was initiated due to the fibrillation, but stopped when sinus persisted. Her IABP was discontinued on POD#2 and she was extubated on POD #3. She had intermittent respiratory distress and was reintubated on POD#5 after trials with BIPAP. She was followed by the wound care nurse for a large gluteal ulcer which started preop and was aggravated by being in the OR for 10 hours. Her course was complicated by renal failure requiring dialysis and respiratory failure requiring placement of a tracheostomy. She was treated with Bactrim for coag negative staph in the sputum. She was fed via a dobhoff tube. Initial PEG placment plans were deferred after an abdominal CT revealed ascites. She was seen by hepatology for her cirrhosis but no further workup was indicated. General surgery was consulted for a stage III sacral ulcer and local care with enzymatic debriding was continued. Eventually she was sharply debrided as well. Infectious disease was consulted for positive blood cultures with gram positive rods and Cefipime was added to the Meropenum she was receiving already. On [**4-26**] there was significant sternal drainage and she was taken to the Operating Room for exploration. Nonhealing of the sternum with multiple bilateral fragments was found. Debridement followed by application of a wound vac was carried out. Plastics was consulted and on [**4-29**] she returned to the Operating Room where she underwent sternal closure with pectoralis and latissimus flaps. She coninued to be ventilator and dialysis dependent and there were many family meetings with Dr. [**Last Name (STitle) 914**], his team, and social work. Eventually the family felt that Mrs. [**Known lastname 39056**] would not want to be ventilator dependent and on chronic dialysis and on [**5-15**] they decided to make her comfort measures only. She expired at 4AM on [**2150-5-16**]. The family was present and did not want a post mortem examination. Medications on Admission: HOME MEDICATIONS Tiazac 240 mg daily ASA 325 mg daily Levoquin 500 mg daily for UTI Carispodol 350 mg HS prn NPH 67 units in am and 53 untis in pm Regular Insulin 23 units in am and 32 units with dinner Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Aortic Stenosis s/p aortic valve replacement s/p coronary artery bypass grafts Coronary Artery Disease Hypertension Morbid obesity Insulin dependent Diabetes Mellitus peripheral vascular disease dry gangrene toes bilaterally hypercholesterolemia MRSA carrier s/p cholecystectomy postoperative renal failure postoperative respiratory failure deep sternal wound infection s/p sternal debridement decubitus ulcer post operative atrial fibrillation Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2150-5-18**]

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icd9cm

[ [ [] ] ]

[ "77.61", "96.72", "38.93", "35.21", "96.05", "38.95", "36.15", "86.74", "88.56", "39.95", "39.61", "31.1", "36.12", "33.24", "96.6", "37.23", "37.61" ]

icd9pcs

[ [ [] ] ]

12668, 12677

8942, 12384

424, 955

13166, 13175

2968, 8394

13229, 13264

1816, 1933

12639, 12645

8434, 8465

12698, 13145

12410, 12616

13199, 13206

1948, 2949

377, 386

8497, 8919

983, 1235

1257, 1548

1564, 1800

28,458

173,532

33164

Discharge summary

report

Admission Date: [**2121-12-3**] Discharge Date: [**2121-12-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Intubation Central Venous Access Line History of Present Illness: 87 y/o male with past medical history significant for dementia, HTN, BPH s/p TURP who presents to hospital after fall. Patient describes getting out of bed to go to the bathroom. Patient does not recall whether he tripped or felt dizzy or both. He fell and hit his head. + LOC. Intubated for airway protection on way to hospital. CT head revealed subdural hematoma of the posterior falx and tentorium right greater than left. He was admitted to [**Hospital1 18**] for airway protection, work-up of his fall, and management of his subdural hematoma. He was initially in the SICU where he was sucessfully extubated [**2121-12-4**]. He was transferred to neurosurgery due to his subdural hematoma. His CT head remained stable over several days with no mass effect visualized. He was started on dilantin for given his seizure risk with the subdural. He also was found to have T1 vertebral fracture which is not currently causing him any pain . His syncope/fall workup revealed an AV block type 1 mobitz. In the setting of his fall, a bath AV and Hiss disease pacemaker would be indicated to prevent hypotension and syncope, but in light of his dementia the family felt it is better not to have pacer placed. This decision may be reevalated at a later date. The patient is DNR -DNI. . Incidentally on work up he was found to have an ascending aortic aneurysm 4.3 cm which had no indication for repair. . His hospitalization was complicated by the development of delerium and hematuria in the setting of a traumatic foley placement. The patient remains of fall precautions and with frequent reorientation. . On transfer, the patient was stable. He states he has been feeling well. He is interested in getting home to be with his wife. A pacemaker was mentioned to he and his family again, but neither were interested in that option at this time. The patient has no complaints at this time. Patient was transferred for further medical management of his delerium and hematuria and for placement issues. . ROS: Patient denies headache, dizziness, chest pain, shortness of breath, changes in vision, dysuria. He endorses a good appetite, good mood. Past Medical History: - Dementia - HTN - First degree/Mobitz I high degree AV block - Achalasia - Renal Ca s/p R nephrectomy - Ascending aortic aneurysm - h/o past falls and L hip fx - BPH s/p TURP and botox - s/p eye surgery bilat Social History: Lives at home with wife and caretaker, family active in care (sister [**Name (NI) 717**] is HCP). Independent with activities and walking. Patient and wife walk 20-30 minutes twice a day. Quit smoking 40yrs ago. Drinks equivalent of 4 shots of gin per day. Family History: Per report, mother with throat cancer, father with MI, sister [**Name (NI) 77071**] Physical Exam: Temp 97.5 BP 141/81 HR 89 RR 16 O2 sat 98% RA BG 109-197 Gen: NAD, A&O *3 HEENT: EOMI, bruise on posterior of head, MMM, OP clear, right pupil 2 mm, left 1 mm Back: kyphotic CV: RRR, II/VI SEM RUSB, S1, S2, Brady Pulm: CTA b/l, rhonchi at base Abd: + BS, S, NT/ND Ext: no edema, 4+/5 strength b/l lower ext., 2+DP Pertinent Results: ON ADMISSION: [**2121-12-3**] 05:52AM BLOOD WBC-7.4 RBC-4.13* Hgb-13.8* Hct-38.1* MCV-92 MCH-33.3* MCHC-36.1* RDW-13.5 Plt Ct-204 [**2121-12-3**] 05:52AM BLOOD Neuts-71.6* Lymphs-21.1 Monos-6.0 Eos-1.0 Baso-0.3 [**2121-12-3**] 05:52AM BLOOD PT-13.4 PTT-29.0 INR(PT)-1.1 [**2121-12-3**] 05:40AM BLOOD Glucose-82 UreaN-21* Creat-1.5* Na-142 K-3.2* Cl-99 HCO3-29 AnGap-17 [**2121-12-10**] 05:25AM BLOOD ALT-11 AST-20 AlkPhos-48 TotBili-0.4 [**2121-12-4**] 02:00AM BLOOD Albumin-3.4 Calcium-7.6* Phos-3.9 Mg-1.8. . WORK-UP: [**2121-12-8**] 09:58PM BLOOD Hapto-167 [**2121-12-8**] 06:50AM BLOOD VitB12-722 Folate-17.3 [**2121-12-8**] 06:50AM BLOOD %HbA1c-5.3 [**2121-12-4**] 02:00AM BLOOD TSH-0.99 [**2121-12-9**] 06:30AM BLOOD Cortsol-21.2* [**2121-12-12**] 07:00AM BLOOD Vanco-13.7 . DISCHARGE: [**2121-12-16**] 06:09AM BLOOD WBC-8.5 RBC-2.95* Hgb-9.8* Hct-28.4* MCV-96 MCH-33.2* MCHC-34.5 RDW-13.9 Plt Ct-368 [**2121-12-16**] 06:09AM BLOOD Glucose-75 UreaN-9 Creat-1.3* Na-141 K-3.6 Cl-107 HCO3-29 AnGap-9 [**2121-12-15**] 04:51AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1 . STUDIES [**2121-12-3**] CT CHEST/ABD/PELVIS:IMPRESSION: 1. The apparent mediastinal widening noted on the chest radiograph is most likely due to preexisting fusiform aneurysm of the ascending aorta. Dilated esophagus might also contribute to this picture. The ascending aortic aneurysm measures 4.3 cm maximally in the transverse dimension. 2. Foley catheter has been inflated inside the prostate and based on its orientation appears to be located outside the urethra. Urologic consultation recommended. 3. Status post right nephrectomy. 4. 3mm low attenuation lesion in the body of the pancreas. There may be others not clearly demonstrated in this exam. MRI recommended once acute presentation resolves to exclude neoplasm (e.g. IPMT). . [**2121-12-3**] CT C-SPINE IMPRESSION: 1. No acute fracture or malaligment. 2. Multilevel degenerative disease with moderate spinal canal stenosis at the level of C5-6. . [**2121-12-3**] CT HEAD IMPRESSION: 1. Subdural hematoma of the posterior falx and tentorium right greater than left. No definite mass effect is visualized. . [**2121-12-4**] CT HEAD IMPRESSION: 1.Mild decrease in size of the left tentorial SDH with no change in small parafalcine subdural hemorrhage. Exam otherwise unchanged. . ECHO: IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild-moderate aortic regurgitation. Moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. Dilated ascending aorta. . PICC PLACEMENT: IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the right brachial venous approach. Final internal length is 31 cm, with the tip positioned in SVC. The line is ready to use. . RECTAL U/S :Prelim FINDINGS: Transrectal son[**Name (NI) 867**] of the prostate was performed without priors available for comparison. Seminal vesicles maintain a normal lobulated, hypoechoic appearance. The prostate is well visualized with periurethral small calcifications noted but no discrete hypoechoic collection to suggest abscess. There is homogeneous echotexture throughout a markedly enlarged gland. The patient reported no pain during the examination. Brief Hospital Course: 87 year old male with hypertension, dementia and benign prostatic hypertrophy status post TURP admitted status post fall with stable subdural hematoma. Patient febrile [**2121-12-8**], and found to have coagulase negative staphylococcus infection. . 1) Staphylococcus Bacteremia: Patient was started on vancomycin on [**2121-12-9**] and is to continue for a planned 2 week course. He was febrile on admission but this resolved several days prior to discharge and his lethargy resolved. The source of the coagulase negative staphylococcus that was methicillin resistant was difficult to determine. Initially it was felt to be due to a urinary tract infection following traumatic Foley insertion. However when the bacteria was speciated as coagulase negative staphylococcus , further investigation including a transrectal ultrasound looking for prostate abscess as possible source was performed. The transrectal ultrasound showed only an enlarged prostate without abscess. There were no other lines prior to admission that could be identified as his initial source of bacteremia. A TTE Echo did not show valve vegetations. . 2) Subdural Hematoma: Neurosurgery was consulted on patient during hospitalization. He was transitioned from dilantin to Keppra and should continue on this per Neurosurgery recommendations. He has appointment for follow-up Head CT and scheduled appointment with Dr. [**Last Name (STitle) **] within the next month. . 3) Fall: Is of unclear etiology, although suspect mechanical or cardiogenic source. He has known 2nd degree AV type 1 block. He was monitored on telemetry with several episodes of asymptomatic bradycardia. Physical therapy was consulted and recommended rehabilitation for physical therapy or home with 24 hour care and physical therapy. . 4) Delirium: Patient developed delirium in the setting of bacteremia which resolved with antibiotic treatment of the infection. . 5) Atrioventricular Block, 2nd degree, type 1: Cardiology was consulted for this finding on electrocardiogram. Cardiology felt that the patient may benefit from a pacemaker, but in his current status he and his family are not interested in this option. Beta-blockers and central acting calcium channel blockers were avoided. The patient tolerated Norvasc as a peripheral antihypertensive with addition of lisinopril. . 6) Ascending Aortic Aneurysm: No indication for surgery at this time. Cardiology recommended blood pressure management (goal SBP < 140). . 7) Vertebral Fracture: The patient was started calcium and vitamin D given recent fracture and kyphosis. Patient had no pain from the fracture. 8) Hyperglycemia: Patient does not have a diagnosis of DM, but did have elevated glucose during hospitalization. HbA1c 5.3 and did not require insulin or oral agents during hospitalization. 9) Hematuria: Patient had Foley placed with the development of hematuria. The patient's gross hematuria resolved and the Foley remained in place for 7 days. The Foley catheter was removed on [**12-15**] with minimal blood and he has had good urine output since. 10) Dementia: Continued on his home Aricept. 11) 3mm Body of Pancreas Lesion: Low attenuation lesion of unknown significance. It was recommended that the patient undergo yearly follow-up with imaging. The family is aware of this finding. 12) Anemia: B12 and Folate were within normal limits. The patient's hematocrit was stable following his rehydration for infection/sepsis. 13) Acute Renal Failure in Chronic Kidney Disease: s/p nephrectomy for renal cell carcinoma, baseline Cr 1.1-1.2. His creatinine was elevated to 1.5 on admission but decreased and remained stable during hospitalization. 14) Code: DNR/DNI 15) Disposition: Patient discharged to rehabilitation and scheduled for Head CT and outpatient Neurosurgery follow-up. Medications on Admission: HCTZ MVI amlodipine aricept prilosec Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): hold for loose stools. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 24H (Every 24 Hours) for 7 days: please continue for 7 more days STOP [**12-22**]. 6. Laboratory Testing Please check a vancomycin trough and renal function in 4 days. Please fax results to PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 45950**] 7. Calcium 600 with Vitamin D3 600 (1,500)-400 mg-unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 8. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. Multi-Day Tablet Sig: One (1) Tablet PO once a day. 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Month (only) 53281**] Rehabilitation & Nursing Center - [**Location (un) 28318**] Discharge Diagnosis: Primary: Acute Subdural Hematoma s/p Fall Bacteremia: coagulase negative staphlococcus, methacillin resistant Delerium Atrioventricular Block, Second Degree, Mobitz Type 1 Ascending Aortic Aneurysm Vertebral Fracture Hyperglycemia Dementia Hematuria Pancreatic Lesion Anemia Acute and Chronic Renal Failure Discharge Condition: Stable, SBP 130s, oxygenating well on room air Discharge Instructions: You were admitted after a fall at home. You were discovered to have a bleed in your head. You were started on seizure medication. You developed an infection in your blood that was treated with fluids and antibiotics. You are improved and are ready to regain your strength at rehabilitation. . Please take all your medication as prescribed. Please keep all of your follow-up appointments. . You were started on calcium and vitamin D for your bones. You were started on lisinopril for your blood pressure. You were continued on an adjusted dose of amlodipine for your blood pressure. You were started on VANCOMYCIN for an INFECTION in your blood. Please continue to take this until [**2121-12-22**]. You were started on Keppra to prevent seizures after your fall. . If you develop fevers, chills, chest pain, shortness of breath or any other concerning symptom please call your primary care physician or go to the local emergency room. Followup Instructions: Please follow-up with the neurologist about your recent fall: Please arrive on [**2122-1-6**] at the [**Hospital1 **] CLINICAL CENTER, [**Location (un) **] RADIOLOGY for your CAT SCAN. Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-1-6**] 1:30 . After your CAT SCAN please travel to [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY for your appointment with Dr. [**Last Name (STitle) **]. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2122-1-6**] 2:00 . Please follow-up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8964**] in the next 7-10 days. His number is [**Telephone/Fax (1) 45950**].

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11817, 11928

6751, 10569

268, 308

12279, 12328

3443, 3443

13310, 14078

3009, 3094

10657, 11794

11949, 12258

10595, 10634

12352, 13287

3109, 3424

224, 230

336, 2482

3457, 6728

2504, 2715

2732, 2993

32,203

111,420

31763

Discharge summary

report

Admission Date: [**2181-7-29**] Discharge Date: [**2181-8-15**] Date of Birth: [**2147-4-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 15237**] Chief Complaint: Fever, respiratory failure, AIDS. Major Surgical or Invasive Procedure: Endotracheal intubation (at OSH) Central Line Placement Bronchoscopy x 2 History of Present Illness: 34 y/o male with a h/o HIV, visceral Kaposi's sarcoma, Castleman's disease, and pancytopenia who presented to an OSH with weakness, anemia, and FTT. He was hydrated with IVF and closely monitored for any signs or symptoms of infection. He was recently admitted to [**Hospital 5279**] Hospital (NH) from [**Date range (3) 74583**] for FUO workup, diffuse adenopathy and splenomegaly. A left cervical LNB revealed metastatic Kaposi's sarcoma and Castleman's disease. He had a follow up appointment made with Dr. [**Last Name (STitle) 2148**] ([**Hospital1 18**]) for further management of his metastatic Kaposi's sarcoma/Castleman's disease but he did not keep that appointment. He again presented to [**Hospital 5279**] Hospital on [**2181-7-26**] with anemia, weakness, and FTT. He was ordered for a blood transfusion. There was concern that the pt sustained a transfusion reaction because shortly after receiving his first unit of blood. He spiked a temp to 103, and became tachypnic, hypotensive, HR 140. . The decision was made to transfer him to [**Hospital1 18**] for further management. . ROS: Unobtainable, pt arrived intubated and sedated at OSH. Past Medical History: 1. HIV, recent CD4 104, undetectable viral load, on HAART since [**2-4**], developed resistance to efavirenz 2. Castleman's Disease 3. Metastatic Kaposi's sarcoma, no skin lesions, Stage IIIB, plan to proceed with Cytoxan, vincristine, Doxil, and prednisone along with Rituximab 4. Massive splenomegaly 5. Pancytopenia 6. Recurrent hyponatremia (? [**1-5**] to SIADH) 7. N/V 8. Intractable hiccups 9. Recent EGD showed AFB microorganisms 10. G6PD deficiency 11. Chronic interstitial infiltrates on CXR Social History: No tobacco or alcohol. Originally he is from the [**Country 7018**]. Family History: N/C. Physical Exam: Vitals: T 103.4 HR 131 BP 106/59 RR 30 100% AC TV 500 FiO2 1.00 PEEP 5 General: 34M intubated and sedated. HEENT: NC/AT. MMM. ET tube in place. Neck: No JVD. CV: ST, S1, S2 without any m/r/g. Pulm: Coarse BS B/L. No wheezes. Abd: Soft, NT/ND with normoactive BS. Ext: No c/c/e. Neuro: Sedated. Skin: No rash. Pertinent Results: CT Abdomen: Massive splenomegaly with adenopathy . BMB: hypercellular marrow . Left cervical LNB: Castleman's disease, metastatic Kaposi's sarcoma, positive HHV-8 titers . Head CT: Negative . EKG: ST at 131, no axis deviation, no acute ST changes . CXR: B/L interstitial infiltrates. Final read pending. . PET Scan [**2181-7-25**] (performed at [**University/College **]) "Increased metabolic activity seen within the lymph nodes of the right and left anterior and posterior cervical chain extending into the supraclavicular regions. Increased activity noted in both axillary regions where lymphadenopathy is present exceeding 1 cm in size. increased metabolic activity is seen in the lymph nodes of the right paratracheal region. Mild increased metabolic activity seen in the lymph nodes of the paraaortic, left and right hilar, and subcarinal lymph nodes. Lung parenchyma is unremarkable, as is the spine. . Abdomen shows a normal-appearing liver, shows and enlarged spleen which has increased metabolic activity. Spleen length approximately 20 cm. . Increased metabolic activity seen in lymph nodes which begins at the crural level and are to the right and left and in front of the lumbar vertebrae. The increased metabolic activity within the lymph nodes is seen within the paraaortic, the common iliac, and the inguinal on the right and left. The scan extends to the proximal thigh; no abnormal increased metabolic activity is seen in the muscle or bone." . CXR [**2181-7-29**] Findings most consistent with diffuse pulmonary edema likely due to fluid overload in the setting of apparent anasarca and ascites. Underlying infectious process such as PCP is not excluded and correlation with initial outside hospital radiographs as well as follow up after diuresis may be helpful in this regard. . TTE [**2181-7-30**] The left atrium is mildly dilated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferolateral wall. The remaining segments contract normally (LVEF = 50%). Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. An eccentric, anteriorly directed jet of mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild regional left ventricular systolic dysfunction. Mild mitral regurgitation. Mild pulmonary artery systolic hypertension. . Bronchial washings were negative for malignant cells. . Abdominal U/S [**2181-8-2**] 1. Massive splenomegaly with infiltrative intrasplenic lesion concerning for lymphoma. KS would be less likely but should also be considered. 2) 1.4 cm echogenic lesion in segment II of the liver may represent a hemangioma. Though rare, hepatic Kaposi's sarcoma cannot be excluded. 3) Sludge in the gallbladder. 4) Echogenic kidneys suggesting interstitial renal disease. 5) Ascites and bilateral pleural effusions. 6) Normal Doppler examination. . Bone marrow biopsy results pending. . Bone marrow from the OSH revealed a hypercellular marrow. Brief Hospital Course: 34 y/o male with a h/o HIV, metastatic Kaposi's sarcoma, Castleman's disease, and G6PD who presented to an OSH with weakness, anemia, and FTT. He was later transferred to [**Hospital1 18**] for further management of fever and respiratory failure along with metastatic Kaposi's sarcoma and Castleman's disease. # Respiratory failure The patient was intubated [**1-5**] to respiratory distress at the OSH prior to transfer. Per OSH records, he has had B/L pulmonary infiltrates for several weeks. However, given his fever, tachycardia, and respiratory distress along with his CXR finding of B/L pulmonary infiltrates, there was an initial concern for ARDS/sepsis. He was hypotensive as well and there was concern for progression to septic shock. In addition, there was an outside hospital report of AFB organisms cultured on recent EGD as part of his FUO workup. He was moved to respiratory isolation given concern for possible pulmonary TB. After further information was obtained regarding the above pathology, it was found to be an acid-fast organism. However, he did complete a r/o for TB. He was initially started on broad spectrum ABx given concern for an infectious etiology for his respiratory failure and clinical decompensation. After all cultures returned negative, his ABx were gradually D/C. On his second bronchoscopy, there was evidence of Kaposi's sarcoma. His malignancy is the most likely etiology for his respiratory failure and B/L infiltrates on CXR. The patient was eventually weaned off of the ventilator and was transferred to the OMED service. Here, he was followed by PT, and was off of O2 with normal oxygen saturations. The patient continued on his HAART therapy and continued to improve until dishcage. # Metastatic Kaposi' sarcoma/Castleman's disease The patient was diagnosed with metastatic Kaposi's sarcoma and Castleman's disease during recent admission at the OSH when he was evaluated for FUO. A left cervical lymph node biopsy was consistent with Kaposi's sarcoma and Castleman's disease. After infection as an etiology for his clinical deterioration and respiratory failure was unrevealing, the most likely etiology for his fever and respiratory failure was his malignancy. On the second bronchoscopy that was performed, there was evidence of Kaposi's sarcoma in his bronchial tree. On [**2181-8-2**], he underwent chemotherapy with DR[**Last Name (STitle) 74584**]. He did not receive vincristine [**1-5**] to his liver failure. Thus far, he has tolerated the chemotherapy well. He no longer required pressor support for his hemodynamic. Heme/Onc was following from admission for further recommendations. He also underwent a repeat BMB on [**2181-8-1**]. He completed a course of neupogen, and was discharged with an ANC>1000. The patient will continue his current HAART therapy and will follow up with Dr. [**Last Name (STitle) 2148**] as an outpatient. Social services followed the patient and set him up with transportation to assist the patient so he can make his appointments. # Fever Initially, there was a concern for an infectious etiology causing his fever, respiratory failure, and clinical decompensation. He was started on broad spectrum ABx (vanc, zosyn, azithromycin x 1, and levofloxacin). As his cultures became negative and it was clear that his metastatic Kaposi's sarcoma was the reason for his respiratory failure and B/L infiltrates on CXR, ABx were gradually D/C. He was started on a brief course of doxycycline for concern for tick borne illness but this was also D/C. His fever curve trended down. He was ruled out for TB. All cultures to date have been negative, including his BALs. At discharge, he was afebrile and his ANC>1000. # HIV The patient was continued on his HAART regimen at the OSH and during this admission. His HAART regimen dose was adjusted for his renal function. Last CD4 count was 104 so there was no need for MAC Px with azithromycin (did receive a couple doses). He was started on Mepron for PCP Px as he has a h/o G6PD deficiency and Bactrim would not be the best choice. He continued his HAART therapy, and at discharge was given prescriptions for all of his medications. He will follow up with Dr. [**Last Name (STitle) 2148**] for further management. # Anemia/Thrombocytopenia The above are most likely [**1-5**] to his HIV and metastatic Kaposi's sarcoma/Castleman's disease. There was a question of TROLI at the OSH after receiving blood; however this is unclear and a full panel of tranfusion reactions labs were ordered at the OSH. He was given 2 units of PRBCs thus far during this admission for anemia. He has also received 3 PLT transfusions thus far. PLT goal after chemotherapy is > 20 given concern for pulmonary hemorrhage. As his bone marrow recovered, the patient's counts improved and he was no longer required transfusions at discharge. # Acute renal failure The patient's acute renal failure is thought to be [**1-5**] to ATN/intrinsic renal disease. His renal function was monitored and it has not improved or worsened as yet. He was given aggressive IVF along with diuresis to maintain adequate renal perfusion in light of his recent chemotherapy treatment. At discharge, his renal function had markedly improved. He will continue to followup as an outpatient for any changed that may be necessary in the future regarding his management. # DIC The patient had evidence of DIC on his labs. He was supported hemodynamically and was weaned off pressors. DIC was secondary to his metastatic Kaposi's sarcoma/Castleman's disease/systemic inflammatory process. At discharge, his counts had stabilized. # The patient has a girlfriend in the US as well as a daughter. They visited the patient prior to discharge. Social services contact[**Name (NI) **] the patient's case manager to discuss future options for the patient so that he can make appointments and get his medications. The patient's case manager is very involved with his case. At discharge, the patient's mental status was at baseline and he was completely congnizant of his surroundings. Medications on Admission: Medications (outpatient): Erythropoietin 40,000 units SQ Qweek Fentanyl patch 50 mcg Q72H Folic acid 2 mg PO daily Kaletra 2 TAB PO BID Combivir Viread 300 mg PO daily KCl 20 mEq PO BID Metoclopramide QID . Medications upon transfer: Tylenol PRN Benadryl PRN Fentanyl Folic Acid Lasix Hydrocortisone RISS Combivir 1 TAB [**Hospital1 **] Kaletra 2 TAB PO BID Reglan 10 mg PO QACHS Versed Protonix 40 mg IV BID Potassium Sliding Scale Sodium Chloride Tablets Tenofovir 300 mg PO daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 3. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). Disp:*qs mg* Refills:*2* 4. Lopinavir-Ritonavir 400-100 mg/5 mL Solution Sig: Five (5) ML PO BID (2 times a day). Disp:*300 ML(s)* Refills:*2* 5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QTHUR (every Thursday). Disp:*8 Tablet(s)* Refills:*2* 8. 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* Discharge Disposition: Home With Service Facility: [**Hospital 12017**] [**Hospital **] Home Health Discharge Diagnosis: Primary Diagnosis: Castleman's Disease Kaposi's Sarcoma HIV/AIDS Secondary Diagnosis: G6PD deficiency Pancytopenia Discharge Condition: good, stable, afebrile Discharge Instructions: You were admitted from an outside hospital with respiratory distress, low blood pressure requiring intubation and ICU stay. You were given antiobiotics and chemotherapy for your castleman's syndrome and kaposi's sarcoma. You were then admitted to the inpatient oncology service where you continued to improve. You were seen by physical therapy who felt you were safe to go home at discharge. Please take all medications as prescribed. You will need to followup and keep all future appointments with your physician as it is important for the management of your disease. If you develop any of the following concerning symptoms, please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2148**], or go to the ED: fevers, chills, shortness of breath, chest pain, abdominal pain, nausea, vomiting, weakness, or inability to walk. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2181-8-22**] 2:00 Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 56612**] for followup appointment within the next 2-4 weeks.

[ "282.2", "789.5", "276.0", "042", "176.4", "458.8", "785.6", "584.9", "572.8", "286.6", "518.81", "284.1" ]

icd9cm

[ [ [] ] ]

[ "41.31", "96.72", "96.6", "99.25", "96.56", "99.05", "38.93", "33.22", "99.04" ]

icd9pcs

[ [ [] ] ]

13587, 13666

5971, 12040

350, 424

13824, 13849

2588, 2760

14746, 15065

2237, 2243

12573, 13564

13687, 13687

12066, 12550

13873, 14723

2258, 2569

277, 312

452, 1609

13773, 13803

2769, 5948

13706, 13752

1631, 2135

2151, 2221

12,501

157,008

9381

Discharge summary

report

Admission Date: [**2147-10-23**] Discharge Date: [**2147-10-26**] Date of Birth: [**2074-9-4**] Sex: M Service: CARDIAC ICU HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old Russian male with no significant past medical history who presents to the Emergency Department with new acute onset of substernal chest pain of several hour duration with radiation down the left arm. Patient was reportedly in his usual state of health when he reports acute onset of left arm pain associated with "pins and needles" sensation while at rest. The patient's arm pain persisted for approximately 30 minutes before onset of substernal chest pain and pressure. The chest pain progressively worsened over several hours with associated nausea and diaphoresis. The patient denies shortness of breath, pleuritic pain, palpitations, as well as lightheadedness. The patient was transported to the Emergency Department by EMS and on route was treated with aspirin and sublingual nitroglycerin with persistent chest pain. On arrival to the Emergency Department, the patient was started on nitroglycerin drip, heparin, Plavix, and Integrilin (Lopressor was held secondary to sinus bradycardia). In the Emergency Department, the patient was found to be afebrile with a blood pressure of 114/68, heart rate 52, and oxygen saturation 93% on room air, 97% on four liters nasal cannula. The patient's initial electrocardiogram demonstrated antero-septal ST elevations with persistent chest pain. The patient was sent for emergent cardiac catheterization. PAST MEDICAL HISTORY: 1. Anxiety disorder. 2. Degenerative joint disease. 3. History of gout. 4. Status post inguinal hernia repair. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Paxil (dose unknown). 2. Diazepam (dose unknown). SOCIAL HISTORY: The patient is married and lives with his wife. The patient is a retired mechanical engineer and emigrant from [**Country 532**]. The patient has a 30 pack year tobacco history with reported occasional alcohol use. FAMILY HISTORY: No significant coronary artery disease or diabetes reported. PHYSICAL EXAM ON ADMISSION: Temperature 98.6. Heart rate 71. Blood pressure 115/67. Respiratory rate 20. Oxygen saturation 95% on three liters nasal cannula. In general, patient is a well-developed, well-nourished elderly male lying flat in no acute distress. Head, eyes, ears, nose and throat exam: Normocephalic, atraumatic, anicteric sclera, extraocular movements intact bilaterally. Pupils are equal, round, and reactive to light and accommodation, clear oropharynx, moist mucous membranes. Neck with 2+ carotid pulses bilaterally, no jugular venous distention, supple, no lymphadenopathy appreciated. Cardiovascular exam: Distant heart sounds, regular rate and rhythm, no murmurs, rubs or gallops appreciated. Pulmonary exam: Clear to auscultation bilaterally anteriorly with no wheezes, rhonchi or rales. Abdominal exam: Soft, normal active bowel sounds, nontender, nondistended, no hepatosplenomegaly. Extremities: No cyanosis, clubbing or edema, 2+ distal pulses throughout, right groin with arterial and venous catheterization sheaths with small hematoma (marked) with pressure dressing, no bruit appreciated. LABORATORY AND STUDIES ON ADMISSION: CBC with a white blood cell count of 9.8, hematocrit 44.6, platelet count 301,000. Chem-7 with sodium of 139, potassium 4.3, chloride 104, bicarbonate 20, BUN 16, creatinine 1.0, glucose 153. Cardiac enzymes: First set: CK 90, MB not done, troponin I 1.6. Second set: CK 4396, CK-MB 613, troponin I greater than 50. Third set: CK 2759, CK-MB 299, troponin I greater than 50. Chest x-ray on admission showed no overt failure, no infiltrate appreciated. Initial electrocardiogram: Normal sinus rhythm at 86, right bundle branch block with intraventricular conduction delay, left axis deviation, [**Street Address(2) 28585**] elevations in V2 and V3, [**Street Address(2) 1766**] elevations in leads V4 and V5, Q waves in V2 through V5. HOSPITAL COURSE: The patient underwent a cardiac catheterization without complication. Catheterization demonstrated a right dominant system with multivessel disease including mildly diseased left circumflex, moderate (40-50%) occluded right coronary artery, 20% left main occlusion, and total occlusion of the proximal left anterior descending artery. Right heart pressures were elevated with a right atrial pressure of 9, right ventricular pressures of 34/16, pulmonary artery pressures of 36/17 and pulmonary capillary wedge pressure of 18. The patient underwent Angio-jet to the left anterior descending artery with placement of three stents. 0% residual was reported post stent placement, however, "no reflow" was seen. The patient was subsequently treated with intra-coronary adenosine, diltiazem, and nitroglycerin with subsequent TIMI 3 flow. The patient was started on Integrilin (18 hours), Plavix, aspirin, and transferred to the Cardiac Intensive Care Unit. The patient ruled in for an ST elevation anterior wall myocardial infarction with peak CK of 4396. The patient was started on low dose beta-blocker and ACE inhibitor with low normal blood pressure, well-tolerated. The patient remained chest pain free during the remainder of the hospital course. The patient also remained in normal sinus rhythm on telemetry without signs of arrhythmia. A post myocardial infarction echocardiogram demonstrated severely decreased systolic function with an ejection fraction of 20-30%, severe hypokinesis of the inferior and anterior septum, as well as anterior free wall, and extensive apical akinesis. The echocardiogram also demonstrated mild symmetric left ventricular hypertrophy, mild pulmonary hypertension, 1+ tricuspid regurgitation, and 1+ mitral regurgitation. No thrombus was seen on echocardiogram and the patient was started on anticoagulation for akinetic/poor left ventricular function with heparin and Coumadin, goal INR [**1-1**]. There was no evidence of bleeding, complication or groin hematoma. The patient's lipid panel demonstrated a total cholesterol of 172, elevated LDL of 124, low high density lipoprotein of 25, and triglycerides of 114. The patient was started on a statin (LFTs only remarkable only for an elevated AST likely secondary to cardiac origin). CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Anterior wall myocardial infarction. 2. Ischemic cardiomyopathy with an ejection fraction of 20-30%. 3. Hypercholesterolemia. 4. Anxiety disorder. 5. Degenerative joint disease. 6. Gout. 7. Status post inguinal hernia repair. MEDICATIONS ON DISCHARGE: 1. Lisinopril 2.5 mg po q.d. 2. Lopressor 12.5 mg po b.i.d. 3. Lovenox 60 mg subcutaneous b.i.d. (until INR therapeutic). 4. Coumadin 5 mg po q.h.s. (dosed by INR level). 5. Plavix 75 mg po q.d. (total of 30 days). 6. Aspirin 325 mg po q.d. 7. Lipitor 10 mg po q.d. INSTRUCTIONS ON DISCHARGE: The patient was discharged to home with instructions to follow-up with his primary care physician/cardiologist, Dr. [**Last Name (STitle) 3357**], on Monday, [**10-30**] at 10 a.m. Patient was prescribed Lovenox, quantity sufficient for four days until next blood work and INR level. The patient was instructed to follow-up with [**Hospital1 **] Cardiology on [**11-14**] for further risk stratification including a T wave alternans test in the stress laboratory, a signal average electrocardiogram, and 24 hour Holter monitor. The risk stratification is part of an ongoing Electrophysiology study for potential placement of ICD. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**First Name3 (LF) 16296**] MEDQUIST36 D: [**2147-10-28**] 22:08 T: [**2147-10-28**] 22:33 JOB#: [**Job Number 32047**]

[ "300.00", "416.0", "401.9", "715.90", "272.0", "410.11", "414.01", "V15.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2069, 2145

6405, 6642

6668, 6955

1761, 1817

4066, 6352

6970, 7873

170, 1559

3306, 4048

1581, 1735

1834, 2052

6377, 6384

42,360

103,009

43126

Discharge summary

report

Admission Date: [**2161-8-30**] Discharge Date: [**2161-9-7**] Date of Birth: [**2093-4-15**] Sex: F Service: MEDICINE Allergies: Codeine / Sulfa (Sulfonamide Antibiotics) / Penicillins / Tylenol 8 Hour Attending:[**First Name3 (LF) 594**] Chief Complaint: Several days of melena, associated with weakness and fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 68 yo F w/PMH significant for EtOH and GERD here following recent discharge from [**Hospital1 18**] on [**2161-8-28**]. Both patient and daughter report worsening black, tarry diarrhea since discharge. Patient states that she feels weak, lethargic, fatigued, and unable to care for herself. Has had decreased PO intake today and over weekend. Of note, diarrhea stopped today after d/c'ing tube feeds. Both patient and daughter wish to go to acute rehab facility, however, patient believes that she needs to cared for in hospital prior to rehab. Reports mild abdominal pain and non-productive cough improving since last discharge. Denies N/V, fever, chills, inability to tolerate oral intake, HA, syncope, chest pain, SOB, wheeze, On the floor: Pt went into bouts of SVT to 170's w/PVC's and eventual short runs of V. tach. K WNL, but Mg not checked in ED so given 2mg Mg and other electrolytes sent. Pt entirely asymptomatic. Left pt in sinus rhythm w/single PVC's. Past Medical History: Hypertension PVD Social History: She smoked a pack a day of cigarettes for over 20 years and has hyperglycemia, although she says she does not have diabetes. She has never had a stroke or heart attack. She has had eye surgery. Family History: N/C Physical Exam: Admission Exam: VS: 98 ??????F (36.7 ??????C), Pulse: 85, RR: 18, BP: 118/67, O2Sat: 98, O2Flow: 3L NC GENERAL: Jaundiced and in no acute distress, with NC and feeding tube in place. Conversive and in good spirits HEENT: Sclera icteric. Mucous membranes dry CARDIAC: Irregularly irregular. Tachycardic. NS1&S2. NMRG LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Mild distension and firm, with mild diffuse tenderness to palpation No HSM appreciated. EXTREMITIES: 3+ pitting edema. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A+Ox3. CN 2-12 intact, sensation grossly intact. moving all extremities freely. Discharge Exam: GENERAL: Jaundiced and breathing with accessory muscles, with NC and feeding tube in place. HEENT: Sclera icteric. Mucous membranes dry CARDIAC: Irregularly irregular. Tachycardia. NS1&S2. NMRG appreciated LUNGS: rales at base bilaterally. ABDOMEN: Mild distension and firm, with mild diffuse tenderness to palpation No HSM appreciated. EXTREMITIES: 4+ pitting edema to lower back. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A+Ox3. CN 2-12 intact, sensation grossly intact. moving all extremities freely. Pertinent Results: Admission Labs: [**2161-8-30**] 12:00PM BLOOD WBC-22.0* RBC-2.63* Hgb-9.0* Hct-28.1* MCV-107* MCH-34.1* MCHC-31.9 RDW-19.2* Plt Ct-234 [**2161-8-30**] 12:00PM BLOOD Neuts-93.4* Lymphs-3.5* Monos-2.6 Eos-0.4 Baso-0.2 [**2161-8-30**] 12:00PM BLOOD PT-14.6* PTT-33.5 INR(PT)-1.4* [**2161-8-30**] 12:00PM BLOOD Glucose-105* UreaN-35* Creat-1.5* Na-132* K-4.7 Cl-95* HCO3-26 AnGap-16 [**2161-8-30**] 12:00PM BLOOD ALT-57* AST-186* AlkPhos-421* TotBili-23.1* [**2161-8-30**] 12:00PM BLOOD Albumin-2.9* Calcium-9.1 Phos-2.8 Mg-2.0 . Discharge Labs; [**2161-9-7**] 03:14AM BLOOD WBC-24.5* RBC-2.42* Hgb-8.4* Hct-26.5* MCV-110* MCH-34.9* MCHC-31.8 RDW-20.3* Plt Ct-199 [**2161-9-7**] 03:14AM BLOOD Neuts-92.5* Lymphs-3.5* Monos-3.4 Eos-0.4 Baso-0.1 [**2161-9-7**] 03:14AM BLOOD PT-17.3* PTT-39.6* INR(PT)-1.6* [**2161-9-7**] 03:14AM BLOOD Glucose-88 UreaN-72* Creat-1.8* Na-137 K-4.5 Cl-103 HCO3-22 AnGap-17 [**2161-9-7**] 03:14AM BLOOD ALT-49* AST-148* LD(LDH)-259* CK(CPK)-16* AlkPhos-261* TotBili-20.9* [**2161-9-7**] 03:14AM BLOOD Albumin-2.6* Calcium-8.7 Phos-4.9* Mg-2.3 . Pertinent Labs: [**2161-9-4**] 08:15AM BLOOD CK-MB-2 cTropnT-<0.01 [**2161-9-6**] 11:20AM BLOOD CK-MB-2 cTropnT-<0.01 [**2161-9-7**] 03:14AM BLOOD CK-MB-2 cTropnT-<0.01 [**2161-8-30**] 07:00PM BLOOD calTIBC-177* Ferritn-439* TRF-136* [**2161-9-4**] 02:11PM BLOOD Type-ART pO2-96 pCO2-33* pH-7.45 calTCO2-24 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] . Micro: [**2161-9-5**] BLOOD CULTURE-pend [**2161-9-5**] BLOOD CULTURE-pend [**2161-9-4**] BLOOD CULTURE-pend [**2161-9-4**] BLOOD CULTURE-pend [**2161-9-3**] STOOL OVA + PARASITES-neg [**2161-9-3**] STOOL OVA + PARASITES-neg [**2161-9-3**] STOOL OVA + PARASITES- MICROSPORIDIA STAIN-PRELIMINARY; CYCLOSPORA STAIN-FINAL; Cryptosporidium/Giardia (DFA)-neg [**2161-8-31**] STOOL C. difficile; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-[**2161-8-30**] URINE URINE CULTURE-neg [**2161-8-30**] BLOOD CULTURE-neg [**2161-8-30**] BLOOD CULTURE-neg Imaging; [**2161-8-30**] EKG:Sinus tachycardia with ventricular premature beats. Low QRS voltages throughout. Diffuse ST-T wave abnormalities grossly unchanged from previous tracing. . [**2161-8-30**] CHest AP: As compared to the previous radiograph, there is minimal increase in transparency of the lung parenchyma, potentially reflecting improved ventilation. At the right lung base, however, a combination of pleural effusion and parenchymal opacity persists. These changes might be consistent with pneumonia. The changes have neither increased nor decreased in severity and extent as compared to the previous examination. A prexeisting retrocardiac atelectasis is less severe than on the previous image. Unchanged moderate cardiomegaly, unchanged course and position of a nasogastric tube. . [**2161-8-31**] TTE: Small to moderate circumferential pericardial effusion without evidence for tamponade physiology. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2161-8-18**], the pericardial effusion is larger. If clinically indicated, serial evaluation is suggested. . [**2161-8-31**] RUQ U/S: Echogenic liver consistent with fatty infiltration. Other forms of liver disease, including more significant hepatic fibrosis, cirrhosis, or steatohepatitis, cannot be excluded on the basis of this examination. No evidence of biliary obstruction. Stones and gallbladder sludge, but no evidence of acute cholecystitis. Increasing splenomegaly, 15.5 cm (13.1 cm on [**8-12**]). Trace left-sided pleural effusion. . [**2161-9-1**] CT Torso: Worsening right lower lobe consolidation, superimposed on post-radiation changes, with trace right and small left simple pleural effusions. Differential considerations include increasing atelectasis or scarring, versus possibly superimposed infection. Moderate pericardial effusion, increased somewhat. Heterogeneous hepatic perfusion consistent with the history of hepatitis. Cholelithiasis without evidence of cholecystitis. . [**2161-9-2**] CT Head:No evidence of intracranial hemorrhage; given the patient's history of malignancy, if metastases are of a concern, MR is more sensitive in detecting small metastatic lesions . [**2161-9-4**] LENI Scan: No bilateral lower extremity deep venous thrombosis. Extensive superficial soft tissue edema. . [**2161-9-7**] CXR Portable: enlargement of the cardiac silhouette with pulmonary vascular congestion and bilateral pleural effusions with compressive atelectasis at the bases. Intestinal tube remains in position Brief Hospital Course: 68 year old woman with past medical history of lung cancer s/p chemotherpay and radiation 3 years prior, and alcohol abuse with acute alcoholic hepatitis recently admitted with it, who returned with worsening diarrhea and found to have worsening liver function and renal function and respiratory status despite treatment who changed her goals of care to comfort measures only given her poor prognosis and is discharged home with hospice. Active Issues: #Alcoholic hepatitis: Pt returned to [**Hospital1 18**] for worsening fatigue, lethargy, and diarrhea after being discharged 5 days prior. There was no significant change in bilirubin or leukocytosis on this admission from the last (T. bili:23, WBC:22). Increased bili and WBC originally thought to be [**2-26**] occult infection, so pt placed on broad spectrum abx. CT positive for ?RLL PNA and she was treated for HCAP with broad spectrum antibiotics. Her hepatitis continued to worsen with worsening bilirubin and she was started on pentoxyfilline without improvement in her liver function. #Tachypnea/dyspnea: Although pt had baseline need for 3L O2, she developed progressive tachypnea and SOB during her hospital stay. She was worked up for PE, pneumonia and pericardial effusion. It was felt that ultimately this worsening dyspnea was due to her anasarca and she was attempted to be diuresed. However with her worsening renal function she was not responding to IV diuretics and discussion with the renal team suggested that ultrafiltration would be the next step to diuresis. However, given that this was a form of dialysis and not in line with the patient's goals of care this was not pursued. She was discharged to home hospice with morphine sulfate for air hunger. #Acute renal failure- patient was originally pre-renal on admission, her renal function improved temporarily. In the setting of worsening liver function and IV contrast for a CT scan she developed worsening renal function with associated oliguria. Renal was consulted with her oliguria and she was no longer diuresing to higher doses of lasix. It is possible that this represented a pre-renal azotemia vs. hepatorenal syndrome. #Pneumonia- patient was found to have a possible new infiltrate on her right lower lobe in the area of previous scaring from her radiation so it was unclear if this was truely a pneumonia. Given her clinical status and worsening respiratory complaints she was treated for hospital associated pneumonia. Antibiotics were discontinued at the time of discharge given her goals of care. #Diarrhea: Multiple stool studies performed, and all negative. Diarrhea was dark, but not true melena. Thought to be [**2-26**] malabsorption from alcoholic GI insult and liver disease. #Paroxysmal A.fib: Pt had multiple episodes of atrial fibrillation with rapid ventricular rate and was started on metoprolol 25mg po TID. -She will be sent home on metoprolol 25mg po TID to control her rate Chronic Issues: #Pericardial Effusion: H/o stable effusion. Pulsus <10, and no signs/symptoms of tamponade #H/o lung cancer: H/o stage III lung cancer s/p XRT and chemo. CT findings suggest ?recurrence. Transitional Issues: Patient to be discharged to home with hospice. Medications on Admission: . Information was obtained from . 1. Isosource 1.5 Cal *NF* (lactose-free food with fiber) 40 ml/hr enteral daily Cycle 24 hours. No residual check. Flush with 30mL water q6h 2. Albuterol 0.083% Neb Soln 1 NEB IH TID 3. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Thiamine 100 mg PO DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. Bengay 1 Appl TP [**Hospital1 **]:PRN muscle pain 10. Aspirin (Buffered) 81 mg PO DAILY 11. Furosemide 40 mg PO DAILY Hold for SBP<90 12. Spironolactone 100 mg PO DAILY Hold for SBP< 90 Discharge Medications: 1. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inhalation every 6 hours Disp #*60 Cartridge Refills:*0 2. Lidocaine 5% Patch 1 PTCH TD DAILY Apply to back RX *lidocaine 5 % (700 mg/patch) apply one patch to affected area once a day Disp #*30 Transdermal Patch Refills:*0 3. Metoprolol Tartrate 25 mg PO Q8H hold for MAP<55 or hr<60 RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 4. Morphine Sulfate (Oral Soln.) 5-20 mg PO Q1-2H air hunger hold for sedation or rr<10 RX *morphine 20 mg/5 mL [**1-29**] ml by mouth q1-2h Disp #*1 Bottle Refills:*0 RX *morphine 10 mg/5 mL [**3-6**] ml by mouth q1-2h Disp #*1 Bottle Refills:*0 5. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO TID:PRN anxiety RX *olanzapine 5 mg 0.5-1 tablet(s) by mouth up to three times a day Disp #*60 Tablet Refills:*0 6. Tiotropium Bromide 1 CAP IH DAILY 7. Bengay 1 Appl TP [**Hospital1 **]:PRN muscle pain 8. Albuterol 0.083% Neb Soln 1 NEB IH TID Discharge Disposition: Home With Service Facility: Hospice of the [**Location (un) 1121**] Discharge Diagnosis: Acute Renal Failure 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 Ms. [**Known lastname **], It was a pleasure taking care of you while you were here at [**Hospital1 18**]. You were readmitted to the hospital with diarrhea and developed worsening breathing and continued worsening function of your liver. Your kidneys were then injured with your worsening liver function and you decided to refocus your care to being comfort. You are being sent home to be on hospice who will continue to help treat your symptoms to make you feel more comfortable. Followup Instructions: with hospice

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Discharge summary

report

Admission Date: [**2180-4-8**] Discharge Date: [**2180-4-13**] Date of Birth: [**2114-8-25**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10593**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 65 yo F with hx of COPD, non small cell lung cancer s/p chemo and radiation in [**2175**], OSA who presents with dyspnea. Patient reports gradual worsening dyspnea over the last week. She saw her PCP and was started on Zpack and steroid burst however she continued to feel badly. She reports productive cough. Denies fever. At baseline able to walk a few blocks but recently only able to walk 10 feet from her bed to her bathroom. Denies lower extremity swelling. . In the ED, initial vital signs were 99.2 96 140/69 24 83%. Exam was significant for diffuse rhonchi. Labs significant for WBC of 16.2 with 92% neutrophils. CXR revealed multilobar pneumonia and was given a dose of levofloxacin and methylprednisolone 125 mg x1. She was treated with nebs x 3. She was placed on 4L nasal cannula with sats around 90%. She was subsequently admitted to the MICU for further care. . On arrival to the MICU, patient felt improved. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: - Stage IIIb lung cancer diagnosed 3 years ago now s/p chemo & XRT - Asthma/COPD - [**Doctor Last Name 933**] disease s/p RAI - GERD s/p Nissen fundoplication - Hypertension - Sinusitis - Depression - Anal fissure - Tonsillectomy - Hemorrhoidectomy - Pilonidal cyst excision - Ear plastic surgery - Appendectomy Social History: - 30 pack year smoker, quit in [**2157**] - No EtOH use - No exposure to radiation or asbestos - She is single and lives alone, she works as an inspector for [**Company 80094**] Family History: - Mother: HTN, TTP, goiter - Father: [**Name (NI) 3495**] disease, CVA, lung cancer - Sister: MS - Brother: Psychiatric illness Physical Exam: Physical Exam on Admission: Vitals: T: BP:119/52 P:95 R:18 O2:96% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: No respiratory distress. Able to speak in full sentences. Rhonchorus throughout. Few wheezes. Good air movement. 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 Physical exam on discharge: T 98 BP 114/61 P 79 RR 18 96% CPAP General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, no LAD, JVD not visible while sitting upright CV: Regular rate and rhythm, normal S1 + S2, unable to appreciate murmurs but breathing very noisy Lungs: Basilar crackles, no egophony, no tactile fremitus Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Lab Results on Admission: [**2180-4-8**] 05:30PM BLOOD WBC-16.2*# RBC-5.00 Hgb-11.9* Hct-39.2 MCV-78* MCH-23.7*# MCHC-30.3* RDW-16.5* Plt Ct-253 [**2180-4-8**] 05:30PM BLOOD Neuts-92.3* Lymphs-3.8* Monos-3.4 Eos-0.3 Baso-0.2 [**2180-4-8**] 05:30PM BLOOD Plt Ct-253 [**2180-4-8**] 05:30PM BLOOD Glucose-286* UreaN-34* Creat-1.7* Na-139 K-4.6 Cl-101 HCO3-26 AnGap-17 [**2180-4-8**] 05:30PM BLOOD CK(CPK)-85 [**2180-4-8**] 05:30PM BLOOD CK-MB-2 cTropnT-<0.01 [**2180-4-9**] 05:00AM BLOOD CK-MB-2 cTropnT-<0.01 [**2180-4-9**] 03:17AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.9 Discharge Labs: [**2180-4-12**] 06:45AM BLOOD WBC-8.6 RBC-4.83 Hgb-11.8* Hct-37.9 MCV-79* MCH-24.4* MCHC-31.1 RDW-16.2* Plt Ct-104*# [**2180-4-12**] 12:45PM BLOOD Plt Ct-238# [**2180-4-12**] 06:45AM BLOOD UreaN-36* Creat-1.5* Na-139 K-3.9 Cl-102 [**2180-4-11**] 03:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2180-4-11**] 03:47PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 Imaging: Radiology Report CHEST (PORTABLE AP) Study Date of [**2180-4-8**] 4:55 PM IMPRESSION: Worsening bibasilar airspace opacities concerning for pneumonia or aspiration. Radiology Report CT CHEST W/O CONTRAST Study Date of [**2180-4-9**] 1:13 PM IMPRESSION: 1. Multifocal ground-glass opacities involving all lung lobes in a basilar predominant distribution, with multifocal consolidations in the lower lobes. Bilateral lower lobe bronchiectasis and peribronchial thickening. Findings are suggestive of multifocal pneumonia superimposed upon changes of COPD. Reimaging after resolution of symptoms is indicated to exclude underlying tumor. 2. Soft tissue density at the left hilum and mediastinum appears grossly similar to prior examinations but is suboptimally evaluated on this noncontrast examination. This may represent post treatment change although residual tumor or local recurrence cannot be ruled out and attention at repeat (preferable contrast-enhanced) examination is recommended in short interval. 3. Small airway disease with air trapping consistent with COPD. Unchanged post-radiation changes in the left upper lobe. [**2180-4-12**] Echo: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. ECG: Cardiovascular Report ECG Study Date of [**2180-4-8**] 4:55:18 PM Baseline artifact. Sinus rhythm. Relatively low voltage diffusely. Non-specific ST-T wave change. Compared to the previous tracing of [**2178-6-30**] resting heart rate is faster without overall diagnostic change. Brief Hospital Course: Patient is a 65yo female with hx of COPD, non small cell lung cancer s/p chemo and radiation in [**2175**] who presented with dyspnea found to be hypoxic and with multilobar pneumonia on CT scan. She was treated with vancomycin and levofloxacin. # Multilobar pneumonia: Pt presented with dyspnea and hypoxia. Patient was recently discharged on home oxygen from recent hospitalization but she stopped using it because she was told it was no longer required. The patient improved clinically on vancomycin and levofloxacin. Culture of mucous plug revealed MRSA. The patient was discharged for an 8 day course of levofloxacin and 9 day course of vancomycin. Because of her underlying COPD, the patient was treated with ipratropium and albuterol nebs ahd she was placed on a prednisone taper. The patient's O2 sats and dyspnea improved with treatment. She will need follow up CT scan preferably with contrast if her kidney function tolerates to r/o recurrence of tumor. # Acute on chronic kidney disease ?????? Patient presented with Cr slightly up at 1.7 from baseline (1.2-1.5) likely related to poor po intake. Her Cr was down to 1.5 on last check. . # Obstructive sleep apnea - continued CPAP at night . # Diabetes mellitus ?????? The patient's sugars were very high while on prednisone. Thus, the patient's lantus was increased and the patient was discharged on insulin sliding scale. She also remained on her home meds, as after the prednisone is stopped, the patient should most likely be able to stop the humalog as well. . # HTN, benign - The patient remained normotensive throughout her hospital stay. Her diovan and amlodipine were held. . # HLD - continued simvastatin . # hypothyroid - continued levothyroxine . # depression - continued citalopram . # GERD - continued omeprazole . # Communication: Patient, sister [**Name (NI) **] [**Name (NI) 8071**] [**Telephone/Fax (1) 80095**] # Code: Full TRANSITIONAL - Needs repeat CHEST CT scan in few weeks to evaluate for change and to rule out tumor - Needs close follow up of glucoses while on prednisone. Also, started patient on Insulin Sliding Scale for first time. - Stopped amlodpine and Diovan - She will complete a course of levofloxacin and vancomycin, the latter via PICC. - Notable labs on last check: BUN 36, Cr 1.5, MCV 79. - She is on a prednisone taper. Her blood sugars were elevated, so she will have insulin sliding scale. Her Lantus was increased. - She was discharged with oxygen to use at home. - Echocardiogram revealed an anterior space which most likely represents a prominent fat pad. ***Of note, chest CT showed: Soft tissue density at the left hilum and mediastinum appears grossly similar to prior examinations but is suboptimally evaluated on this noncontrast examination. This may represent post treatment change although residual tumor or local recurrence cannot be ruled out and attention at repeat (preferable contrast-enhanced) examination is recommended in short interval. ***CHEST CT should be repeated soon to evaluate the above-mentioned density. Medications on Admission: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Xopenex Inhalation 6. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day. (takes 2 tabs on sunday) 7. mom[**Name (NI) 6474**] 50 mcg/Actuation Spray, Non-Aerosol Sig: [**11-29**] Nasal once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: as directed Inhalation as directed. 11. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) 15. Januvia 50 mg qd 16. Diovan 80 mg qd 17 levemir 38 units qpm Discharge Medications: 1. Home O2 1-4L continuous, please give to maintain O2 sat 90-92% pulse dose for portability dx: copd, post radiation fibrosis RA sat 87% 2. vancomycin 500 mg Recon Soln Sig: 1250 mg Recon Solns Intravenous Q 24H (Every 24 Hours) for 4 days. Disp:*4 doses* Refills:*0* 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) inhalation inhalation Inhalation twice a day. 5. glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Xopenex HFA 45 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. mom[**Name (NI) 6474**] 50 mcg/actuation Spray, Non-Aerosol Sig: [**11-29**] spray Nasal once a day. 8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day. 11. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for sleep. 12. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO once a day. 13. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day. 14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 doses. Disp:*2 Tablet(s)* Refills:*0* 15. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 8 days: Take 4 tabs x 2 days then 2 tabs x 2 days then 1 tab x 2 days then 0.5 tab x 2 days. Disp:*15 Tablet(s)* Refills:*0* 16. insulin glargine 100 unit/mL Solution Sig: Forty Four (44) units Subcutaneous at bedtime. 17. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous QACHS: Please refer to sliding scale. You may need to decrease your sliding scale doses as your doses of prednisone decrease. Disp:*1 vial* Refills:*1* 18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. Disp:*7 Tablet(s)* Refills:*0* 19. Insulin Syringe 1 mL 29 x [**11-29**] Syringe Sig: One (1) injection Miscellaneous QACHS. Disp:*120 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] VNA Discharge Diagnosis: Primary: Multilobar pneumonia, COPD exacerbation, Diabetes mellitus Secondary: CKD, HTN, HLD, Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 29425**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for pneumonia. This was treated with antibiotics. You received a PICC line for administration of vancomycin. Because you were started on prednisone, your blood sugars were quite high and your insulin was increased and you were started on sliding scale insulin. You should keep taking the sliding scale insulin while you are on prednisone. Please keep a close eye on your blood sugars and as your prednisone decreases, you should discuss with your PCP or endocrinologist how to decrease your insulin sliding scale to avoid hypoglycemia. The following changes were made to your medications: STARTED Levofloxacin for pneumonia STARTED Vancomycin for pneumonia STARTED Prednisone for COPD exacerbation STARTED Humalog insulin sliding scale for diabetes INCREASED Lantus (glargine) for diabetes STOP Amlodipine since your blood pressures are normal STOP Diovan since your blood pressures are normal. Please let your doctor know about stopping this medication as she may wish to restart it. Please bring this paperwork to your doctor's office Followup Instructions: The following appointments were made for you: Name: [**First Name8 (NamePattern2) 3742**] [**Last Name (NamePattern1) **] NP When: Tuesday [**4-18**] at 11 am Location: [**Hospital 46644**] MEDICAL ASSOCIATES Address: [**Location (un) 46645**], [**Hospital1 **],[**Numeric Identifier 59250**] Phone: [**Telephone/Fax (1) 34574**] Name: [**Name6 (MD) **] [**Name8 (MD) **],MD Specialty: Pulmonary When: Thursday [**4-20**] at 1:30pm Address: [**Location (un) 80096**], [**Apartment Address(1) 31103**], [**Location (un) **],[**Numeric Identifier 39854**] Phone: [**Telephone/Fax (1) 80097**] Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Specialty: Endocrinology Address: [**Street Address(2) 80098**], [**Location (un) **],[**Numeric Identifier 76223**] Phone: [**Telephone/Fax (1) 80099**] When: Tuesday, [**4-25**], 9:30 AM Completed by:[**2180-4-16**]

[ "244.1", "584.9", "V15.82", "327.23", "272.4", "403.10", "493.22", "585.3", "482.42", "530.81", "V10.11", "287.5", "311" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

13297, 13356

7001, 10058

312, 333

13493, 13493

3647, 3659

14828, 15766

2254, 2383

11116, 13274

13377, 13472

10084, 11093

13643, 14805

4230, 6978

2398, 2412

3121, 3628

1307, 1707

265, 274

361, 1288

3674, 4214

13508, 13619

1729, 2042

2058, 2238

1,342

178,263

1593

Discharge summary

report

Admission Date: [**2107-2-27**] Discharge Date: [**2107-3-19**] Date of Birth: [**2034-3-20**] Sex: F Service: Surgery HISTORY OF PRESENT ILLNESS: The patient presented on [**2-27**] with a 4-week history of progressive malaise, anorexia, nausea, diarrhea, and food intolerance. Finally, on the day of admission, she experienced postprandial emesis. She had been treating the diarrhea with Imodium and noted fevers and a 20-pound weight loss over the past weeks. She denied any abdominal distention. On the day of admission, she developed the acute onset of right-sided abdominal pain which brought her to the Emergency Department. PAST MEDICAL HISTORY: 1. Fibromyalgia. 2. Hypothyroidism. 3. Recurrent diverticulitis. 4. Parotid cancer with radiation therapy. 5. Gastroesophageal reflux disease. PAST SURGICAL HISTORY: (Her past surgical history included) 1. Excision of a right parotid tumor. 2. Total hip replacement on the right. 3. Low anterior resection of sigmoid colon and partial rectum for recurrent diverticulitis. 4. Inguinal hernia repair. 5. Repair of a uterine prolapse in the past. MEDICATIONS ON ADMISSION: Medications on admission included Prevacid, Synthroid, trazodone, Imodium as needed. ALLERGIES: She had an allergy to X-RAY DYE (which caused itching) and was sensitive to SOME SOAPS and DETERGENTS. SOCIAL HISTORY: She had a significant smoking history, which she had quit, and rare alcohol intake. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on presentation were 100.4 F., heart rate of 112, blood pressure was 106/65, breaths 20 and oxygen saturation was 97% on room air. Her physical examination at that time was notable for a soft abdomen which was obese, a midline surgical incision, and bilateral lower quadrant tenderness. Her rectal examination was guaiac negative. PERTINENT LABORATORY VALUES ON PRESENTATION: Her laboratories at the time of admission revealed complete blood count with a white blood cell count of 5, hematocrit was 35.7, and platelets were 431. The differential on the white count with 69% neutrophils, 24 bands, and 2% lymphocytes. Chemistry revealed sodium was 135, potassium was 3.8, blood urea nitrogen was 25, creatinine was 0.8, and bicarbonate was 29. Liver function tests were drawn and were within normal limits. She had an abdominal x-ray which did not demonstrate free air. She had no dilated loops. Her urinalysis was positive for nitrites, 3 to 5 white blood cells, and 6 to 10 red blood cells. The albumin was noted to 2.3. PERTINENT RADIOLOGY/IMAGING: She had an abdominal plain x-ray which did not demonstrate free air. She had no dilated loops. HOSPITAL COURSE: At that time, it was decided to proceed with an abdominal computed tomography scan which was notable for free air and a thickened pylorus. At that point, the patient was started on resuscitative fluids. The patient had a nasogastric tube and was started broad spectrum antibiotics and was emergently taken to the operating room. The patient was taken to the operating room on [**2-27**] and had an exploratory laparotomy, a small-bowel resection times two, lysis of adhesions, placement of a feeding jejunostomy tube, and repair of a ventral hernia primarily. Intraoperative findings were that of diffuse peritonitis with purulent succus entericus and ascites, multiple intra abdominal thick adhesions, a ventral hernia, and perforated jejunum at the site of jejunal diverticula with ischemia around it. The patient had intraoperative cultures which ended up growing multiple flora including alpha streptococcus, Klebsiella, enterococcus, Morganella, Escherichia coli, some yeast in her sputum, as well as yeast in her operating room swab. She was maintained on broad spectrum antibiotics and antifungals. She required pressors around the time of her surgery. Her postoperative course was also notable for large-volume resuscitate, prolonged mechanical ventilation, and malnutrition. Her antibiotic regimen was ampicillin, gentamicin, Flagyl, and fluconazole; this was based on the findings on Gram stain in the operating room and culture data. She was supported nutritionally with total parenteral nutrition and with initiation of tube feeds on postoperative day four. It was noted on postoperative day five, the lower portion of the wound was opened for purulent drainage. On postoperative day six, she became febrile with an elevated white blood cell count. A computed tomography was obtained at that time which showed a lot of postsurgical changes, but no drainable collection. On postoperative day 11, she was extubated after a substantial amount of diuresis, and two days later she was found to have a partial thrombosis of the right internal jugular secondary to a central line. The line was removed, and systemic heparinization was begun. On postoperative day 14, tube feed like material appeared to drain from the lower portion of the wound. A wound drainage sump was placed, and the output from this (thought to be fistula) was quite low. Another computed tomography of the abdomen was obtained and resulted in the drainage of an intra-abdominal abscess. Three days later, on postoperative day 17, she was found unresponsive in her chair requiring emergent intubation. Her heparin was stopped. Her partial thromboplastin time was never greater than 63.5. An emergent computed tomography scan of the head was performed which was significant for a large posterior fossa bleed. A Neurosurgery consultation was obtained almost simultaneously with the results of the computed tomography scan. A ventriculostomy drain was placed without any improvement in her neurologic function. She was unresponsive. As a result of this course of events, and multiple family meetings, and with knowledge of the patient's wishes, it was decided that the patient would be made comfort measures only. She was extubated and shortly thereafter passed away. The patient's body was sent for autopsy. The date of the patient's death was [**2107-3-19**]. DISCHARGE/DEATH DIAGNOSES: 1. Perforated jejunum. 2. Jejunal diverticula. 3. Sepsis. 4. Pneumonia. 5. Intra-abdominal abscess. 6. Hemodynamic instability. 7. Ventilator-dependent pneumonia. 8. Ventilator-dependent respiratory distress. 9. Large posterior fossa intracranial hemorrhage with subsequent cerebrovascular accident, subsequent herniation, and death. SECONDARY DIAGNOSES: 1. Enterocutaneous fistula. 2. Anemia (treated with blood transfusions); likely due to chronic disease as well as volume loss. 3. Fibromyalgia. 4. Hypothyroidism. 5. Diverticulitis. 6. Parotid cancer. 7. Gastroesophageal reflux disease. 8. Ventral hernia. 9. History of low anterior resection. 10. History of incisional hernia repair. 11. History of hip replacement. 12. History of excision of parotid tumor. CONDITION AT DISCHARGE: Death. DISPOSITION: The patient underwent an autopsy. [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**] Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2107-5-9**] 09:52 T: [**2107-5-9**] 10:18 JOB#: [**Job Number 9247**]

[ "569.81", "567.2", "789.5", "431", "568.0", "569.83", "997.02", "553.20", "244.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "96.6", "45.62", "46.39", "54.59", "53.59", "99.15", "02.2" ]

icd9pcs

[ [ [] ] ]

1161, 1363

2695, 6431

850, 1134

6453, 6893

6908, 7244

165, 655

677, 826

1380, 2676

4,498

103,432

30468

Discharge summary

report

Admission Date: [**2114-3-21**] Discharge Date: [**2114-3-22**] Date of Birth: [**2048-9-5**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: right subdural hematoma Major Surgical or Invasive Procedure: right craniotomy and evacuation of subdural hematoma History of Present Illness: 65 yM fell on Saturday; presented to OSH today with severe headache and projectile emesis, became unresponsive and developed decorticate posturing and fixed pupils, and a head CT revealed a large R-sided subdural hematoma with midline shift. The patient was intubated for airway protection, and he was transferred to [**Hospital1 18**] for further care. Past Medical History: MS [**First Name (Titles) **] [**Last Name (Titles) **] Hypothyroidism Social History: non-contrib Family History: non-contrib Physical Exam: O: T: BP:212/80 HR:80 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: fixed @ 5cm bilat Neck: in c-collar Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: intubated and sedated, unresponsive, with decorticate posturing Pertinent Results: [**2114-3-21**] 02:25PM TYPE-ART PO2-231* PCO2-32* PH-7.46* TOTAL CO2-23 BASE XS-0 [**2114-3-21**] 12:38PM PHENYTOIN-9.1* CT HEAD W/O CONTRAST [**2114-3-21**] 12:12 AM IMPRESSION: Large acute on chronic right subdural hematoma causing marked mass effect and midline shift causing entrapment of the left lateral ventricle. Subfalcine herniation with effacement of the basal cisterns without frank uncal herniation. CT HEAD W/O CONTRAST [**2114-3-21**] 3:33 AM IMPRESSION: 1. Status post evacuation of large right subdural hematoma with interval improvement in the degree of mass effect and midline shift. Effacement of the basal cisterns is unchanged. There remains subfalcine herniation. The left lateral ventricle remains enlarge. MR HEAD W & W/O CONTRAST [**2114-3-21**] 5:19 PM IMPRESSION: 1. Status post evacuation of large right subdural hematoma with interval improvement of leftward subfalcine herniation. 2. Diffusion-weighted imaging abnormality indicating acute ischemic changes involving the medial temporal lobes bilaterally, right greater than left, mid brain, and pons. Hemorrhages associated with the abnormalities in the mid brain. These likely represent manifestations of prior herniation injury or possibly contusions from prior trauma. 3. Periventricular white matter T2/FLAIR hyperintensity which likely represents transependymal edema from hydrocephalus. More focal areas of signal abnormality within the periventricular white matter may also represent manifestation of transependymal edema or preexisting white matter disease. Brief Hospital Course: Pt arrived in the ED @ [**Hospital1 18**] intubated and unresponsive, with fixed/dilated pupils and decorticate posturing. After a head CT that showed a large right-sided subdural hematoma with 2cm midline shift, he was taken emergently to the OR for a right craniotomy and evacuation of hematoma. Post-operatively, his left pupil decreased to 3mm (but still unreactive), and his R eye remained fixed and dilated @ 5mm; he was transferred post-operatively to the SICU. There was no change in examination over the first 24 hours. An MRI was ordered to determine what brain tissue had infarcted, and DWI positive lesions consistent with infarct were seen in the temporal lobes, midbrain and pons. A stroke consult was called on [**2114-3-22**] and the stroke team evaluated the patient and informed the family of the poor prognosis. Based on their discussions with neurology and neurosurgery, the family decided to make the patient comfort measures only. This was done around 1900 [**2114-3-22**] and the patient expired at 2045. Medications on Admission: lisinopril, aspirin, atenolol, amantadine, synthroid Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: NA Followup Instructions: NA

[ "340", "244.9", "E888.9", "852.20", "401.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "01.31", "96.04" ]

icd9pcs

[ [ [] ] ]

4009, 4018

2843, 3879

342, 396

4070, 4080

1258, 2820

4131, 4136

920, 933

3982, 3986

4039, 4049

3905, 3959

4104, 4108

948, 1159

279, 304

424, 781

1174, 1239

803, 875

891, 904

46,904

103,536

30542

Discharge summary

report

Admission Date: [**2136-6-7**] Discharge Date: [**2136-6-13**] Date of Birth: [**2085-7-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Fall Multiple pulmonary emboli Major Surgical or Invasive Procedure: None History of Present Illness: 50 yo with extensive past medical history recently discharged on [**2136-6-6**] from [**Hospital1 18**] after prolonged hospitalization for CHF. The patient had a mechanical fall and is now readmitted on [**2136-6-7**]. The patient presented with worsening right sided chest pain and new rib fractures and pulmonary emboli. Past Medical History: *low back pain - Patient has narcotic contract. Please refer to letter dated [**2135-5-17**] for updated doses. He is followed by pain management and orthopedics *cryptogenic organizing pneumonitis s/p RML wedge resection *depression and PTSD *obstructive sleep apnea, reports compliance with CPAP but that machine was recently taken away due to financial issues + being hospitalized *moderate diastolic CHF *hypertension *hyperlipidemia *DMII *obesity *Squamous cell carcinoma on dorsum of right hand s/p Moh's micrographic surgery *alcohol abuse *tobacco abuse *5 GSWs in L leg, 4 GSWs in R leg, 1 GSW in buttocks *multiple orthopedic surgeries *? pericarditis with pericarial effusion requiring drainage at [**Hospital1 **] (patient report) Social History: - On disability, but formerly worked in construction doing wrecking. He was a certified asbestos remover and had significant asbestos exposure 20-30 years ago. - Tobacco history: Smokes 2pk/day x30 years, "quit" 1 month ago but has had 3 cigs over past month - ETOH: Drinks a large amount of vodka and a few beers daily, not able to quantify the vodka - Illicit drugs: marijuana as a teenager, no other drug use - Pt lives at home alone, and is minimally active. - He has a girlfried who he sees on weekends. - He is divorced, but close with his ex-wife. Two children, son died last year in [**Name (NI) 8751**]. Family History: - Brother with heart transplant for pericarditis - no other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory - mother had melanoma and died of perforated peptic ulcer at 71 - father alive and well - 3 brothers and 3 sisters alive and well Physical Exam: Upon presentation to [**Hospital1 18**]: Temp:98.8 HR:78 BP:100/49 Resp:17 O(2)Sat:82 ra low Constitutional: Comfortable HEENT: Extraocular muscles intact Oropharynx within normal limits Chest: coarse breath sounds Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: + pulses, + edema Skin: ecchymosis to abdomen from heparin injections Neuro: Speech fluent Psych: Normal mood, Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2136-6-7**] 12:25PM GLUCOSE-123* UREA N-30* CREAT-1.2 SODIUM-133 POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-28 ANION GAP-15 [**2136-6-7**] 12:25PM cTropnT-<0.01 [**2136-6-7**] 12:25PM proBNP-47 [**2136-6-7**] 12:25PM WBC-12.7* RBC-4.06* HGB-13.0* HCT-37.6* MCV-93 MCH-32.0 MCHC-34.6 RDW-16.3* [**2136-6-7**] 12:25PM NEUTS-80.3* LYMPHS-15.3* MONOS-3.7 EOS-0.3 BASOS-0.6 [**2136-6-7**] 12:25PM PLT COUNT-221 [**2136-6-6**] 03:25PM CREAT-1.3* POTASSIUM-4.4 [**2136-6-6**] 06:35AM WBC-14.7* RBC-4.01* HGB-12.7* HCT-37.5* MCV-94 MCH-31.7 MCHC-33.9 RDW-15.8* Imaging: IMPRESSION: 5/6/10CT Chest & Abdomen 1. Pulmonary emboli within the right upper lobe segmental and subsegmental pulmonary arteries, as well as the right interlobar pulmonary artery, and segmental right lower lobe pulmonary artery without evidence of right heart strain. 2. Unchanged bilateral ground-glass opacities most pronounced in the upper lobes consistent with patient's history of cryptogenic organizing pneumonia. 3. Superior endplate compression fracture of L2, new compared to [**2136-5-5**]. New acute and subacute bilateral rib fractures. Brief Hospital Course: He was admitted to the Trauma Service for pulmonary care; pain management and anticoagulation for his multiple pulmonary emboli. He was immediately bolused and started on a Heparin drip. His Coumadin was started on [**6-9**] at 5 mg and increased to 7.5 mg due to sub therapeutic INR; his last INR on [**6-13**] was 1.5. Once INR goal range of [**3-7**] reached his Heparin drip can be stopped. Mr. [**Known lastname 20400**] has a long history with chronic pain requiring long and short acting narcotics at home to manage this. With his rib fractures his pain was very difficult to manage and the decision was made to consult with the Pain Service. Both his long and short acting medications were increased; it was noted however that the Oxycodone increased breakthrough dose was not offering much relief for his rib fracture pain. He had been receiving intermittent IV Dilaudid for severe breakthrough pain and this was stopped and he was changed to oral Dilaudid. It should be noted that he is requiring larger than usual doses of this medication 12-14 mg every 3-4 hours prn. His adjunct medications, Neurontin and Topamax were increased. Tizanidine was added as well. He is on an aggressive bowel regimen. He was also evaluated by the Orthopedic Spine surgery service for the L2 compression fracture; there was no operative intervention indicated. Activity as tolerated was recommended. His oxygen saturations have ranged in the low 90's and he has made very slow progress with Physical therapy who are recommending acute rehab after his hospital stay. He requires frequent monitoring of his oxygen saturations and respiratory status in general. Medications on Admission: Prednisone 40', Asa 81', Gabapentin 300''', Glargine 10HS, Metformin 500', Albuterol nebs q6hprn, atrovent neb q6hprn, oxycodone 40q4p, oxycontin 60''', Bactrim 800/160''', Lopressor 25'', Simvastatin 80', Citalopram 10', Topiramate 25'', Prazosin 1hs, Tramadol 50''''prn,Lisinopril 5', Ca+D, Betadine + adaptic to R big toe daily, Spirinolactone 25', lasix 120' Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Prazosin 1 mg Capsule Sig: One (1) Capsule PO QHS (once a day (at bedtime)). 9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO MWF ([**Known lastname 766**]-Wednesday-[**Known lastname 2974**]). 16. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 18. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: goal INR [**3-7**]. 19. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 20. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 23. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 25. Tizanidine 6 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 26. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 27. Hydromorphone 4 mg Tablet Sig: [**4-4**] 1/2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. 28. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 1,950 units/hr Intravenous ASDIR (AS DIRECTED): [**Month (only) 116**] discontinue Hep gtt once INR goal range of [**3-7**] reached. 29. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units Subcutaneous at bedtime. 30. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale: see attached sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: s/p Fall 1)Rib fractures 2)Pulmonary Emboli 3)L2 Fracture Secondary diagnosis: Heart failure Chronic pain syndrome 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**] after falling and breaking your ribs. You were also diagnosed with pulmonary emboli. You were treated with medication for pain as well as blood thining medication for the pulmonary emboli (blood clots in your lung). For your heart failure you should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma for evaluation of your rib fractures; call [**Telephone/Fax (1) 600**] for an appointment. You will need a standing end expiratory chest xray for this appointment. Follow up in 2 weeks with Dr. [**Last Name (STitle) 1007**], orthoepdic spine for your L2 fracture, call [**Telephone/Fax (1) 1228**] for an appointment. The following appointments were made for you prior to your hospital stay: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2136-6-27**] 2:40 Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2136-6-27**] 3:00 Completed by:[**2136-6-13**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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346, 352

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50084

Discharge summary

report

Admission Date: [**2120-6-20**] Discharge Date: [**2120-6-24**] Date of Birth: [**2046-10-18**] Sex: M Service: MEDICINE Allergies: Iodine; Iodine Containing / Imdur / Lisinopril Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: unresponsiveness/s/p cardiac arrest Major Surgical or Invasive Procedure: intubation therapeutic hypothermia protocol History of Present Illness: 73M with h/o severe cardiomyopathy (EF [**9-19**]) s/p biV/ICD ([**2115**]), afib on coumadin and dig, rheumatic heart disease s/p mitral valve repair in [**2109**] with residual 3+ MR, CRI, h/o CVA, who was found unresponsive on park bench s/p cardiac arrest and loss of pulse during EMS transport on way to [**Hospital1 18**] ED. . Complex story pieced together with family report, ED records, OMR, and info from ICD interrogation. Per OMR note, patient had increasing LE edema since 6 days PTA, called Dr. [**First Name (STitle) 437**] and was told to restart lasix 20mg [**Hospital1 **]. Per family report, patient had not been feeling well for 2 days PTA with fatigue, vague symptoms. On AM of admission, pt had ICD firing for sensed VT at 11am with LOC prior to shock, with episode of incontinence. Pt called Dr. [**First Name (STitle) 437**] at 2pm who thought that patient may be hypokalemic, told to take 40meq KCL with planned f/u in [**Hospital 3782**] clinic. Patient then went to park to meet friends with possible marijuana use (?laced with cocaine) and was found unresponsive on park bench for unknown amt of time and EMS called. . No EMS records, but per ED report, pt had loss of pulse in transport, was given seconds of chest compressions, and on arrival in ED at 5:20pm, was in pulseless wide complex tachycardia concerning for polymorphic VT. CPR commenced and pt given epi 1mg x 1, atropine 1mg x 1, and intubated (initial gas 7/16/32/189), femoral line placed. During course in ED, patient went in and out of pulseless VT/WCT (loss of pulse for minutes at a time) requiring intermittent shocks by ICD (x 5 shocks per ICD interrogation between 4:46pm and 5:39pm), external defibrillation, and medications (amiodarone, epi, vasopressin, atropine). When regained pulse, pt hypotensive (SBP 36-67/26-29) so pt started on Neosynephrine and Levophed. Labs significant for INR 4.4, Hct 28.2, Cr 1.2, K 2.8. Given 30mg IV KCL, 2mg Mag sulfate, and given Hct drop from b/l of 32-35, sent for CT head for concern of bleed in setting of elevated INR. Wet read of CT head with no bleed, mass effect, or shift. Also given 4amps of Digibind after labs drawn. Patient lost pulse while down at CT scan, required one round of epi/atropine/CPR and regained pulse after 3 min, and was sent up to CCU directly on Neosynephrine at 4.8 and Levophed at 2.6. . On arrival to CCU, patient was intubated, sedated with fentanyl and versed. Met with family for update, identification, and confirmed full code. Overnight, Arctic sun cooling protocol initiated, reached goal temperature at 8:30pm. Started on dopamine, levophed and neosynephrine weaned off. ICD interrogated showing 6 episodes of ATP/shock for sensed VT/VF. Bedside ECHO done showing no large change from prior. ECG showed v-pacing and resolution of global WCT in limb leads, continued to have ACT in precordial leads with changed morphology from old ECG. Repeat ABG was 7/22/45/70, PEEP increased to 10. Cr increased from 1.2-> 1.9, INR decreased to 3.3, K was 5, lactate was 5.6. Given 20mg IV lasix with no response, then 40mg IV x 1 for volume overload by exam, CXR, no UOP ->50cc urine output. BNP [**Numeric Identifier **]. Cardiac arrest team notified, patient enrolled in IV steroid clinical trial with family consent. . Unable to obtain review of systems as patient unresponsive. Per OMR, patient with recent increase in LE edema. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: -severe dilated cardiomyopathy w/ valvular heart dz, LVEF 10-15%, -rheumatic heart dz -s/p mitral valve repair in [**2109**] with residual moderate MR [**Name13 (STitle) **] on Coumadin, status post cardioversion in the past, but in afib recently (Recent INR 1.5-2.8) -mild renal insufficiency (Cr baseline is 1.2-1.6) -hx of CVA. -PACING/ICD: BiV ICD placed in [**2115**] Social History: -Tobacco history: none -ETOH: Alcohol abuse until 25 years ago -Illicit drugs: + marijuana currently Family History: NC Physical Exam: VS: T= 94.6 BP=82/63 - 108/67 HR=72 - 91 Sat: 95-100%, AC(550/20/10/100%) GENERAL: Pt intubated. Sedated. HEENT: Sclera anicteric. Pupuls 7mm bilaterally, PERRL. NECK: Supple with JVP of 16cm. CARDIAC: Heart sounds soft and difficult to hear with ventilator. Irregular with no murmur/rubs/gallops appreciated LUNGS: Course breath sounds anterior lung fields, no rhonchi/crackles. Unable to assess lower lobes given positioning. ABDOMEN: Difficult to assess given cool suit. Soft, ND. EXTREMITIES: 1+ dependent lower extremity edema. No clubbing/cyanosis appreciated. Distal extremities cool to touch. SKIN: Hematoma right arm. No other rashes, bruising appreciated. PULSES: R: Diminished Radial, DP, PT L: Diminished Radial, DP, PT Neuro: Pupils 7mm equal and reactive to light. Increased tone in bilateral upper and lower extremity. Unable to illicit patellar, tricep, or bicep reflex. Bilateral upgoing toes. Pertinent Results: EKG: Multiple EKGs, 1723 - 1745 in ED. Rate ranged from 83 - 150 highly irregular polymorphic wide complex tachycardia. With pacer spike occasionally prior to QRS complex and occasionally within QRS complex. Multiple QRS morphology. EKG from 1744, shows possible concordance in precordial leads. [**2043**] on arrival to CCU, EKG compared to prior EKG prior negative deflection in V3 now positive. . 2D-ECHOCARDIOGRAM: [**8-11**] 1.The left atrium is moderately dilated. The left atrium is elongated. The right atrium is moderately dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. There is severe global left ventricular hypokinesis. Resting regional wall motion abnormalities include akinesis of the mid and distal septum, mid and distal inferior wall and apex. The remaining segments are severely hypokinetic. The remaining left ventricular segments are hypokinetic. 3. Right ventricular systolic function appears depressed. There is an echogenic density in the RV consistent with a pacemaker lead. 4.The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 5.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6.The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. 7.There is mild pulmonary artery systolic hypertension. 8.There is no pericardial effusion. . ETT: [**2120-4-11**] Negative dipyridamole stress test . CARDIAC CATH: [**6-8**] 1. Selective coronary angiography showed a right dominant system without evidence for angiographically significant stenoses. 2. Limited resting hemodynamics revealed moderate pulmonary hypertension (PA mean 39 mmHg). The right and left sided filling pressures were elevated (RA mean 18 mmHg, RVEDP 20 mmHg, PCW mean 24 mmHg). Cardiac output and index were reduced (CO 3.5 l/min, CI 1.7 l/min/m2). FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Elevated left and right sided filling pressures 3. Moderate pulmonary hypertension. . LABS ON ADMISSION: Initial labs in ED: 3.1\_8.4_/100 / 28.2\ ABG: 7.16/32/189/12 ( initial ABG after intubation) . K: 3.1 BUN: 22 Cr: 1.2 . PT/PTT/INR: 41.3/51.5/4.4 Fibrinogen: 146 Lip: 34 MOST RECENT LABS: [**2120-6-23**] 03:54AM BLOOD WBC-11.0 RBC-3.49* Hgb-9.5* Hct-30.9* MCV-89 MCH-27.2 MCHC-30.8* RDW-17.6* Plt Ct-133* [**2120-6-23**] 03:54AM BLOOD Plt Ct-133* [**2120-6-23**] 03:54AM BLOOD PT-31.0* PTT-40.9* INR(PT)-3.1* [**2120-6-23**] 03:54AM BLOOD FDP-80-160* [**2120-6-22**] 08:00PM BLOOD FDP-10-40* [**2120-6-23**] 03:54AM BLOOD Glucose-162* UreaN-65* Creat-4.6* Na-138 K-4.3 Cl-103 HCO3-17* AnGap-22* [**2120-6-23**] 04:18AM BLOOD Lactate-3.1* Brief Hospital Course: 73M with h/o severe cardiomyopathy (EF [**9-19**]) s/p biV/ICD ([**2115**]), afib on coumadin and dig, rheumatic heart disease s/p mitral valve repair in [**2109**] with residual 3+ MR, CRI, h/o CVA who was found unreponsive and s/p cardiac arrest from unknown etiology with multiple rounds of ICD firing and ACLS/CPR admitted on cooling protocol and pressor support. Patient found to be in polymorphic ventricular tachycardia in setting of hypokalemia and worsened severe end stage cardiomyopathy (Patient with known severe cardiomyopathy from valvular dz/NYHA IV sCHF with EF 10-15%). By ICD interrogation, patient had 6 episodes of ineffective ATP leading to shock with one episode at 11am, and one at 4:46pm which may have correlated with patient's episodes of unresponsiveness. Initial lytes showed hypokalemia, acidemia. Utox for cocaine negative and dig level normal. No evidence of ACS as etiology. Patient was s/p multiple episodes of loss of pulse with wide complex tachycardia, so started on cooling protocol on admission. Patient cooled on Arctic Sun protocol with goal cooling achieved at 8:30pm of night of admission. Continuous EEG in place, and per cardiac arrest team, per EEG and neuro exam post sedation, patient had very little chance of meaningful neurologic recovery. Patient required pressors for BP support, which was switched to milrinone and neosynephrine with no ability to achieve urine output with lasix. Patient's renal function continued to deteriorate from Cr 1.2 to 4.6, he went into DIC. Given patient's poor prognosis, critical condition, and low chance of meaningful neurologic recovery, family meeting was held on [**6-23**] and patient was made comfort measures only and kept comfortable with versed for myoclonic movements, morphine gtt, scopolamine patch, and ativan prn. His pressors were discontinued, and the patient was extubated at 5:45pm on [**6-23**]. The patient passed away at 2:20 am on [**2120-6-24**] comfortable, with family at the bedside. COMM: Daughter [**First Name8 (NamePattern2) 12556**] [**Known lastname **] ([**Telephone/Fax (1) 104570**], Sister [**Name (NI) 2048**] [**Name (NI) 6515**] ([**Telephone/Fax (1) 104571**]. Medications on Admission: - carvedilol 3.125 mg tablets three tablets in the morning, two tablets at bedtime - digoxin 0.125 mg Monday through Friday - nasal spray as needed - Lasix 20 mg twice a day (unclear if patient taking) - potassium 20 mg daily (unclear if patient taking) - Coumadin Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired

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icd9cm

[ [ [] ] ]

[ "38.91", "96.71", "99.81", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

10872, 10881

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352, 397

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4452, 4456

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4332, 4436

32,406

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46437

Discharge summary

report

Admission Date: [**2160-9-11**] Discharge Date: [**2160-9-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2610**] Chief Complaint: Coffee Ground Emesis, Abdominal Distention Major Surgical or Invasive Procedure: EGD History of Present Illness: History of Present Illness: 87-year-old male with PMH s/f afib, HTN, GERD, DM-II, and obesity who presents now as transfer from [**Hospital3 **] for evaluation of orhtostatic hypotension, intermittent dizziness x 4 days, nausea and emesis. He had had some nausea for the last 3-4 days and vomited yesterday once after lunch that seemed to be more like a regurgitation, no blood was noted. He also complained of some constipation which was confirmed on a KUB done yesterday at [**Hospital 100**] Rehab. It was negative for any free air or air-fluid levels. His stool was guaiac negative and he remained distended despite a large BM and an enema. He had an episode this morning of coffee ground emesis and was found to be orthostatic there (160/70, 93 lying; 160/90, 100 sitting, 110/60, 110 standing). He was transferred to [**Hospital1 18**]. In the ED, initial vs were: T: 98.3 P: 94 BP: 157/52 R: 20 O2 sat: 98% on 2L. Labs including a T&S were drawn and sent, he had an EKG, CXR, KUB, and an NGT was placed with heme + lavage. GI was consulted and they are planning to take him for EGD in the morning. On the floor, the patient has the NGT in place, not complaining of any pain. Denies CP or SOB/palpitations. He has occasional heartburn relieved by antacids, none now. He is otherwise comfortable. Review of sytems: (+) Per HPI: in addition, has also had a 10lb weight gain since [**2-1**] and a dry cough (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. No dysuria. Denied arthralgias or myalgias. Past Medical History: s/p R THA [**9-30**] (also pelvic fracture at that time with intraperitoneal bleed) Hypertension. Atrial fibrillation with RVR, spontaneous conversion to NSR [**9-30**]. Type 2 diabetes, 10y duration, recently started insulin Hyperlipidemia. Obesity Chronic gait instability -peripheral neuropathy? Thrombocytopenia. prev anemia. Monoclonal paraproteinemia IgM followed by hematology. GERD Chronic prostatitis/BPH. Right proximal humerus fracture. Horseshoe kidney. s/p bilateral cataract removal. Depression. Commonuted proximal humerus fracture 6th rib fracture Social History: Patient previously lived alone in his own home with the support of one of his daughters but was brought to [**Hospital3 **] nursing home in [**Month (only) 404**] of this year s/p two falls--a pelvic fracture 1.5 years ago and a R humerus fracture. Retired car salesman. Smoked 2-3 packs a day for 30 years, quit 20 years ago. Used to drink alcohol in moderation but currently does not drink. He uses a wheelchair at baseline and can only walk short distances with assistance. Family History: Mother died aged 32y hysterectomy; father died 81y Paget's disease; daughters in good health Physical Exam: Physical Exam on Admission: Vitals: T:98.4 BP:142/74 P:93 R:20 O2:92% RA, 98% on 2L, weight 210lb General: NAD, answers questions appropriately, easily arousable HEENT: Sclera anicteric, PERRL, EOM intact, MMM, oropharynx clear, NGT in place with small amount of dark brown/red drainage Neck: Supple, no JVD Lungs: CTAB, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no m/c/r Abdomen: BS present, markedly distended, no TTP, rebound, or guarding, but is somewhat tympanitic Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Ecchymoses on R hand, no rash Neuro: A+Ox2 (uncertain of place, thought it was [**Location (un) 745**]), CNII-XII intact, strength 5/5 and equal, sensation intact, DTRs 1+ and equal - patellar difficult to assees as pt. in bed. FTN slow. No focal defecits Pertinent Results: Initial Labs: [**2160-9-11**] 10:17PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2160-9-11**] 10:17PM URINE RBC-84* WBC-8* BACTERIA-NONE YEAST-NONE EPI-<1 [**2160-9-11**] 02:55PM PT-12.9 PTT-27.7 INR(PT)-1.1 [**2160-9-11**] 11:03AM LACTATE-2.6* [**2160-9-11**] 11:00AM GLUCOSE-287* UREA N-19 CREAT-0.9 SODIUM-139 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-24 ANION GAP-18 [**2160-9-11**] 11:00AM WBC-13.7* RBC-4.03* HGB-13.0* HCT-39.0* MCV-97 MCH-32.4* MCHC-33.5 RDW-13.1 [**2160-9-11**] 11:00AM NEUTS-91.7* LYMPHS-4.8* MONOS-3.3 EOS-0.1 BASOS-0.2 KUB: Dictation concerning for ileus or SBO with dilated loops of small bowel to 4.2cm. CT ABDOMEN WITH IV CONTRAST: There are trace bilateral pleural effusions, and subsegmental atelectasis. Mitral annulus calcification is seen. A nasogastric tube has been placed, with the tip terminating in the stomach. There is cholelithiasis, with no evidence of cholecystitis. The liver, spleen, and adrenal glands are unremarkable. The pancreas demonstrates fatty replacement. There is a horseshoe kidney. The large bowel and small bowel are unremarkable, with no evidence of obstruction. Oral contrast has reached the transverse colon, and there is stool and air in the rectum. There are no abnormally dilated loops of bowel or unusual gas or fluid collection in the abdomen. EGD [**2160-9-12**]: Diffuse erosion, friability, erythema and congestion, pale mucosa in the whole Esophagus compatible with severe erosive esophagitis with unknown etiology (biopsy, biopsy). Erythema in the stomach. Otherwise normal EGD to third part of the duodenum CT Angiography: No evidence for pulmonary embolism or acute aortic syndrome. Small, right greater than left, pleural effusions with associated atelectasis. Mild centrilobular emphysema Brief Hospital Course: This is an 87 yo man with multiple medical problems (afib, HTN, GERD, [**Name (NI) 21418**], and obesity, and others) presenting with a 1-day history of coffee ground emesis, intermittent dizziness, nausea and vomiting, and abdominal distention that had begun about [**3-26**] days ago. 1. GI Bleed: Patient presented with abdominal distention, constipation, nausea and vomiting of coffee ground emesis. NG lavage in emergency department was positive and patient was started on IV PPI. Aggrenox was stopped. EGD on [**9-12**] showed severe esophagitis with diffuse continuous erosion, friability, erythema and congestion. The mucosa was pale with contact bleeding. Biopsies and viral cultures were sent. The patient remained hemodynamically stable, requiring no transfusions although stool remained heme-occult positive (to be expected given slow transit time through colon). Patient should continue taking sulfacrate and protonix and avoid NSAIDs after discharge. 2. Abdominal Distention: Patient presented with increasing abdominal distention associated with nausea and vomiting of coffee ground emesis. Initially there was concern over a small bowel obstruction so an NG tube was placed and patient was made NPO. Surgery consult recommended CT scan with oral contrast which demonstrated no obstruction. Bedside disimpaction was attempted with limited success. Patient retained ability to pass gas although did have some burping. Throughout the hospital course, the patient had ongoing difficulties with constipation despite an aggressive bowel regimen, including enemas, lactulose and milk of magnesia. Drugs that slow transit through GI system were limited and PT/ OT saw patient to increase patient mobilization. By time of discharge, patient was having multiple loose stools. 4. Hypoxia/ respiratory distress: Patient had a new oxygen requirement of 2L NC upon admission from baseline of 94- 96% on room air as per nursing home notes. Upon his return from the EGD, the patient became tachycardic and went into rapid atrial fibrillation with worsening hypoxia. He was triggered, IV access obtained, and he was given Diltiazem 10mg x 2 with improvement of HR from 140s to 110s. He was requiring 4LNC and 50% shovel mask to sat >94%. Patient was transferred to the ICU for closer monitoring. Initially there was concern for possible aspiration pneumonia (started on empiric vancomycin and zosyn) given recent vomiting as well as a pulmonary embolism, given relative immobility. A CT angiogram was done which showed small bilateral pleural effusions with associated atelectasis with no evidence of PE or lung consolidation. Empriic antibiotic therapy was stopped. Hypoxia was felt to be multifactorial: [**2-25**] low tidal volumes with abdominal distention and pleural effusion, volume overload/pulmonary edema in setting of afib with RVR and dCHF, and possible COPD flair. Patient was diuresed with 20 mg lasix IV prn with goal net fluid balance of -1.0 liters/ day. A foley catheter was placed and serial CXR were obtained for closer monitoring of fluid status. Patient was transferred back to floor once repiratory status improved. Diuresis was continued and patient started on prednisone and azithromycin for possible COPD exaccerbation. At time of discharge, patient had symptomatically improved. He was saturating 93% on 3 Liters nasal cannula. 5. Atrial Fibrillation: Patient had remote history of atrial fibrillation that had converted spontaneously to normal sinus rhthym in [**9-30**]. At time of admission, patient was on aggrenox only as longterm anticoagulation secondary to history of stroke. He had an episode of atrial fibrillation with rapid ventricular response following his EGD. Patient remained hemodynamically stable, with systolic blood pressure in 120s but did develop a new oxygen requirement requiring care in the ICU (see above in hypoxia). Heart rate stabilized on diltiazem 60 mg every 6 hrs which was eventually titrated up to 90mg every 6 hrs. Patient was maintained on telemetry for the duration of hospitalization and did not have any recurrent episodes of atrial fibrillation. However, as patient likely has paroxysmal atrial fibrillation, long term anticoagulation should be considered as an outpatient given his high CHADS score. 6. Benign Prostatic Hypertrophy: Upon hospitalization, all of patient's home medications were stopped. A foley was placed during hospital stay to facilitate accurate measurement of fluid balance. When foley was discontinued, patient complained of urinary hesitancy and frequency although he retained the ability to void. Home medications of finasteride and terazosin were restarted. 7. Diabetes Mellitus: Patient initally on metformin as an outpatient. This was stopped on admission due to a slightly elevated lactate level of 1.7. Patient was normoglycemic with the addition of sliding scale insulin. However, when Prednisone was started, he developped transient hyperglycemia requiring the administration of NPH. This was discontinued at time of discharge as patient would be tapered off steriods in another 3 days. Restarted on metformin with instructions to perform glucose checks four times a day. According to patient's wishes, code status was recorded as DNR/ DNI during hospitalization. Patient's daughter [**Name (NI) **] (cell phone number ([**Telephone/Fax (1) 98651**]) was very involved in patient's care Medications on Admission: aggrenox 25mg-200mg (ASA 25mg/dipyridamole) since [**2-/2159**] TIA 1 cap [**Hospital1 **] PO cholecalcilferol (vitamin D3) 1000 unit daily PO metformin HCL 500 mg [**Hospital1 **] PO finasteride 5 mg daily po terazosin hcl 5mg qhs po diltiazem cd 120 mg daily po simvastatin 20 mg qpm po psllium seed 1 scoop po erythromycin opthalamic ointment qhs lids acetaminophen 650mg [**Hospital1 **] po Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for esophagitis. 4. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 7. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Fifteen (15) mL PO every six (6) hours as needed for constipation. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection TID (3 times a day). 14. Prednisone 10 mg Tablet Sig: see below Tablet PO see below for 3 days: Day 1: take 3 tabs Day 2: take 2 tabs Day 3: take 1 tab. 15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Terazosin 5 mg Capsule Sig: One (1) Capsule PO at bedtime. 17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Upper GI Bleed Pulmonary Edema Atrial Fibrillation Secondary: Constipation Abdominal Distention Discharge Condition: stable Discharge Instructions: You were admitted to the hospital with abdominal distention, nausea, and bloody vomit. On [**2160-9-12**], you had an endoscopy of your upper gastrointestinal tract which showed erosion and inflammation in your esophagus that was likely the cause of your bleeding. Biopsies were taken. You were started on a proton pump inhibitor and sulfacrate, two medicines which should prevent this problem from coming back. We also stopped your blood thinning medication, aggrenox that you were on to prevent recurrent stroke. You should talk to your doctor about starting this medicine again. During your hospitalization you developped a heart arrhythmia called atrial fibrillation which required closer observation in the intensive care unit. We started you on diltiazem, a medicine which slowed your heart and your heart beat returned to a normal rhythm. Because you have had this arrhythmia several times, you should talk to your doctor about starting another blood thinner (coumadin) to prevent complications from this problem. [**Name (NI) **] also developed difficulty breathing, likely from extra fluid on your lungs as well as an exacerbation of your chronic lung disease. We treated you with oxygen, diuresis, steriods and inhalers. You breathing improved and at the time of discharge, you were breathing comfortably on 3 L of oxygen by nasal cannula. You also had significant problems with [**Name2 (NI) 98652**] in the hospital, requiring several medications to have a bowel movement. At the rehab center you can stop these medications as long as you are not constipated. Please make the following changes to your medication: 1. start Sucralfate 1 gm by mouth 4 times daily 2. protonix 40 mg by mouth twice daily 3. prednisone taper (30, 20, 10 mg) by mouth for 3 days 4. azithromycin 250 mg by mouth for 2 days 5. stop aggrenox You should call your doctor immediately or return to the hospital if you should develop any fever, chills, abdominal pain, nausea, vomiting, diarrhea, chest pain, shortness of breath, or any other symptoms that concern you. Followup Instructions: You need to follow up with your doctor [**First Name (Titles) **] [**Hospital3 **] within 1-3 days of your discharge.

[ "V12.54", "514", "276.8", "564.00", "600.00", "518.81", "285.9", "799.02", "272.4", "427.31", "530.19", "250.00", "401.9", "288.60", "787.3", "278.00", "578.9", "578.0", "530.81" ]

icd9cm

[ [ [] ] ]

[ "96.07", "45.16" ]

icd9pcs

[ [ [] ] ]

13440, 13506

5888, 11321

305, 311

13656, 13665

4012, 5865

15778, 15899

3072, 3167

11766, 13417

13527, 13635

11347, 11743

13689, 15755

3182, 3196

223, 267

1662, 1972

367, 1644

3210, 3993

1994, 2561

2577, 3056