ChanBeDu/relevant_section_length · Datasets at Hugging Face

76,917

132,100

37772

Discharge summary

report

Admission Date: [**2191-12-13**] Discharge Date: [**2191-12-17**] Date of Birth: [**2134-2-16**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Bleeding hepatic lesion Major Surgical or Invasive Procedure: embolization of bleeding liver lesions History of Present Illness: 57F with ocular melanoma and biopsy proven hepatic metastases. She was to have chemoembolization today but was found to be tachycardic with a hematocrit of 27 (previous Hct was 30). She was taken to the ED to be evaluated for acute blood loss anemia. Repeat Hcts were shown to be 21.9 and then 23.4. A CT scan obtained in the ED shows hemoperitoneum with an area of active extravasation in the liver. She does report increased abdominal girth over the past two days with an increase in her abdominal pain, different from her chronic pain. The pain is in the right side of her abdomen, constant and throbbing. She also reports palpitations and dizziness today with a decrease in the volume of her urine output. She denies fever, chills, nausea, emesis, diarrhea, constipation, and melena. She has been tolerating a diet and having normal BMs. Past Medical History: ocular melanoma with hepatic metastases, hepatic hemangiomas, anxiety, depression Social History: Social History: She currently is not working. She quit smoking about 20 years ago. She currently is not drinking any alcohol because of her ongoing liver issues, but as in the past enjoyed an occasional glass of wine with dinner. She has two grown children. Family History: Family History: Notable for multiple aunts with breast cancer. Her father had coronary artery disease and her mother had arthritis. Physical Exam: Gen: mild distress, alert and oriented x 3, pale appearing HEENT: PERLA, EOMI, anicteric sclera, mucus membranes dry Chest: Tachy, no mgr. CTAB. Abdomen: protuberant, distended, large palpable liver, tender to palpation diffusely Ext: No cyanosis/edema Neuro:No neuro deficits. 5/5 strength bilat le/ue Pertinent Results: [**12-16**] LENI - R posterior tibial vein thrombus Brief Hospital Course: Pt was admitted to the hospital after IR embolization of her hepatic lesion. She tolerated the embolization without complication and was admitted to the SICU for further monitoring. Serial abdominal exams were stable, and she required one unit pRBCs after her initial bleed. Serial HCTs were stable. On PPD2 she underwent a lower extremity ultrasound for monitoring of a known LE DVT which demonstrated occlusion of her posterior tibial vein. Because of this patients surgical risk and history of bleeding, a second LENI was performed to days later to monitor for progression of her dvt, and this was stable from previous, so she was not anticoagulated, nor was a filter placed. Following this she was discharged to home with instruction to follow up with her primary care and oncologists. Medications on Admission: alprazolam 0.5mg PRN, citalopram 10mg daily, metoclopramide 10mg qid, morphine sulfate IR 0.25-0.5 of a 15 mg tablet 2-3 times daily PRN, pantoprazole 40mg daily . Discharge Medications: 1. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 2. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 3. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Pilocarpine HCl 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for nausea. 9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: vna of [**Hospital3 **] Discharge Diagnosis: metastatic melanoma Discharge Condition: stable Discharge Instructions: Please call if you experience worsening abd pain, fevers, nausea, vomiting. You have been started on lasix, you should monitor the decreasing swelling in your legs and your weights. Please call the transplant office later this week so we can discuss possibly cutting back on the dosage of your diuretic. Please call if you experience worsening abd pain, fevers, nausea, vomiting. You have been started on lasix, you should monitor the decreasing swelling in your legs and your weights. Please call the transplant office later this week so we can discuss possibly cutting back on the dosage of your diuretic. Followup Instructions: Provider: [**Name10 (NameIs) 454**],THREE [**Name10 (NameIs) 454**] Phone:[**Telephone/Fax (1) 446**] Date/Time:[**2191-12-21**] 7:00 Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**] Date/Time:[**2191-12-21**] 10:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 673**] Call to schedule appointment if needed

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Discharge summary

report+addendum

Admission Date: [**2104-7-21**] Discharge Date: [**2104-8-25**] Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transferred to [**Hospital1 18**] for evaluation for CABG and pre-operative management Major Surgical or Invasive Procedure: Carotid Catheterization Cardiac Catheterization History of Present Illness: 82 yo female with h/o hyperlipidemia, HTN, bilateral carotid stenoses, dementia who was intitially admitted to the OSH [**2104-7-16**] for exertional dyspnea, baseline dyspnea over several months. Patient ruled in for MI. ECG with diffuse ST abnormalities and T wave inversions in inferior/lateral leads with deep inversions in V3-V6. She had cardiac catheterization performed at the outside hospital that showed 3 vessel disease, LM 70% ostial with pressure dampening/ST depression, LAD 60% prox, RCA TO, and EF 45%. Also found to have mild valvular sclerosis. PCWP 10, CO Thermo 3.0 l/min, Fick 1.8 l/min, CI 2.0 Colaterals: LCX to RCA with retrograde filling to the proximal rca. intraseptal perforators to distal RCA. On [**2104-7-21**] she was transferred to [**Hospital1 18**] for medical evaluation for CABG and management prior to surgery. Past Medical History: 1. CHF/Recent MI [**2104-7-17**] 2. Htn 3. hyper chol 4. carotid stenosis (hx TIAs [**8-/2098**] carotid US demonstrated mod-marked stenosis of both common carotids extending into internal carotids) 5.recurrent epistaxis 6.mild short term memory problems 7.hypothyroid(thyroid surgery followed bby radiation therapy) 8. CHF ([**2104-7-17**] EF 45-50%) Social History: Minimal remote tobacco use, no etoh. Son, [**Name (NI) **], and daughter, [**Name (NI) **]. Physical Exam: Exam at the time of presentation to [**Hospital1 18**]: BP 173/62 P82 R17 Gen- up in chair, alert HEENT- anicteric, no nasal bleed, no oral findings, no LAD, neck supple CVS- regular, nl S1/S2, no S3/S4/murmur, no pedal edema, JVP flat, DP 1+ bilaterally no femoral bruit, no carotid bruit Resp-CTAB, stridor heard while patient is on nebs, no wheezes GI-nl BS, soft, tender, no pulsatile mass Neuro-confused, move all 4 limbs. PERRL, EOM intact, answers to questions appropriately Pertinent Results: [**2104-8-2**] 06:00AM BLOOD WBC-11.4* RBC-4.32 Hgb-12.5 Hct-37.2 MCV-86 MCH-29.0 MCHC-33.7 RDW-13.8 Plt Ct-271 [**2104-8-2**] 06:00AM BLOOD Plt Ct-271 [**2104-8-2**] 06:00AM BLOOD PT-12.4 PTT-30.2 INR(PT)-1.0 [**2104-7-30**] 05:41AM BLOOD Ret Aut-0.8* [**2104-8-2**] 06:00AM BLOOD Glucose-124* UreaN-23* Creat-0.6 Na-135 K-4.5 Cl-99 HCO3-28 AnGap-13 [**2104-7-30**] 05:41AM BLOOD ALT-21 AST-37 LD(LDH)-235 AlkPhos-100 TotBili-0.9 [**2104-7-22**] 07:55PM BLOOD Lipase-67* [**2104-7-24**] 12:19PM BLOOD CK-MB-9 cTropnT-.31* [**2104-8-2**] 06:00AM BLOOD Calcium-8.7 Phos-2.5* Mg-3.2* [**2104-7-29**] 05:11AM BLOOD Hapto-225* [**2104-7-22**] 07:55PM BLOOD %HbA1c-5.2 [**2104-7-28**] 04:43AM BLOOD Triglyc-101 HDL-30 CHOL/HD-3.6 LDLcalc-57 [**2104-7-21**] 09:29PM BLOOD TSH-1.2 [**2104-7-22**] Carotid Ultrasound: Extensive carotid plaques with a 70-79% stenosis bilaterally [**2104-7-23**] Carotid catheterization: RSCA has a 90% - 99% lesions. LVERT has an origin 60% lesion and mid segment 90% lesion. LCCA has an origin 60% lesion and 90% lesions throughout the LCCA to the bifurcation. The RCCA has an origin 50% stenosis. The [**Country **] has a focal 80% stenosis beyond the bifurcation. CO 3.9; CI 2.5; RA mean 12; RV 39/13; PA 39/18/27; PCWP mean 21. [**2109-7-24**] Cardiac Catheterization: LMCA had a 90% origin stenosis. LAD had a 40% proximal, serial 60-70% mid-vessel, and a long 60% distal lesions. LCX had a 50% mid-vessel stenosis. RCA was known to be proximally occluded, and was thus not injected. RA mean 12 mmHg, RV 39/6/16 mmHg, PAP mean 26 mmHg, PCW mean 21 mmHg, CO of 3.9, CI 2.5. Stenting of the LMCA stenosis with 3.5 x 13 mm cypher DES at 18 atms post dilated with a 4.5 x 15 mm Highsail balloon at 19 atms with no residual stenosis, no dissection and timi 3 flow. PTCA of the mid LAD with a 3.0 x 15 mm sprinter balloon at 12 atms with 30% residual stenosis, no dissection and timi 3 flow. [**2104-7-25**] Echo: Ef 45 % Mild symmetric LV hypertrophy. Mild global left ventricular hypokinesis. Overall left ventricular systolic function is mildly depressed. (1+)AR. Mild PA systolic hypertension (25-38 mmHg). Head CT [**2104-7-26**] and [**2104-7-27**] No intracranial hemorrhage or edema. No interval change in the morphologic appearance of the brain from [**7-26**] to [**7-27**]. Stable periventricular white matter hypodensities consistent with chronic microvascular infarction. Unchanged bilateral basal ganglia lacunar infarcts. Brief Hospital Course: THIS INTERIM SUMMARY COVERS HOSPITAL COURSE THROUGH [**2104-8-1**]. PLEASE SEE ADDENDUM FOR THE REMAINDER OF THE HOSPITAL COURSE. The patient was transferred to [**Hospital1 18**] on [**2104-7-21**] for medical evaluation for CABG and management prior to surgery. She underwent carotid angiogram on [**2104-7-23**] as part of her pre-op work up which showed bilateral extensive stenosis, but no intervention for carotid disease was done. She did well initially after the procedure. Then later that night, became tachy with a fib RVR 130's. EKG done and showed a fib, rt 130, [**Street Address(2) 58212**] elevations in aVR, III, aVF, and TWI in V [**2-16**], I, aVL, II. Then developed polymorphic ventricular tachycardia, became unresponsive for a few seconds, code called, pt emergently intubated, started on amio load/drip, converted to a fib, then NSR. Initially normotensive, SBP 110's, then became hypotensive 80s/40s. Started on 5mcg/hr Dopamine drip and taken emergently to cath lab where she had LM stented and PTCA to mid-LAD lesion and then CCU on IABP. 1. CAD - s/p STEMI c/b VT on [**2104-7-23**] s/p emergent cath s/p successful stenting of the LMCA stenosis with Cypher stent and successful PTCA of the mid LAD. No enzyme leak, peak CK 113. Intraaortic balloon pump was placed and then discontinued after 1 day. The patient was treated post-MI with aspirin, Plavix, lipitor, beta-blocker and ACe inhibitor. She was permissively mildly hypertensive initially because of her carotid stenoses and concern for a new stroke. Her beta-blocker and ACE inhibitor were gradually titrated up to achieve goal SBP of about 130's. Her groin checks revealed no complications and were healing well. She will need repeat catheterization in 6 months for totally occluded RCA and distal LAD disease. She is not a CABG candidate b/o carotid stenoses and now s/p LM, LAD intervention. 2. Rhythm - VT and afib were felt to be secondary to ischemia/peri-ischemia. The patient has no prior history of a fib. She has been monitored on telemetry and has been in NSR since [**2104-7-25**]. She had an episode of atrial tachycardia on [**8-3**] and her beta-blocker dose was increased. 3. PUMP - EF 45% mild hypokinesis. No indications for anticoagulation. The patient has been treated with gentle diuresis to keep her euvolemic with goal .5-1L negative every day. Her total LOS fluid balance for CCU was about 2L positive. 4. Respiratory - The patient failed extubation on [**2104-7-27**] due to tracheal edema. Interventional pulmonary consulted and she received IV steroids. Patient's airway swelling improved (+air leak) and she was extubated successfully on [**2104-7-29**]. Steroids were discontinued on [**7-29**]. She was conitinued on nebulizers for cardiac wheezing and required suctioning for copious thick secretions. 5. HTN - Patient became more hypertensive after IV steroids were started and has been controlled with IV betablocker & transiently on labetolol gtt in CCU. Titrated up metoprolol and ACEI to goal SBP 130's and HR 60, started amlodipine, and HCTZ. Of note, because of right subclavian artery stenosis, she has consistently lower BP readings in her right arm. 6. Vascular - Bilateral carotid stenoses 70-79% stenosis, no intervention warranted. There was a concern of facial assymetry and decreased left arm movement. During her CCU stay, the patient was evaluated by neurology and CT showed old lacunar infarcts and no evidence of new stroke. We were unable to do MRI of brain b/o ear surgery [**19**] years ago with wires and recent stent. Neurology recommended to optimize medical management/correct metabolic abnormalities. 7. Endocrine - the patient was covered with ISS for tight glucose control during her acute illness and while she was on IV steroids. ISS was stopped after the steroids were stopped. She was also continued on levothyroxine IV ([**12-14**] po dose) and then changed to levothyroxine po after feeding tube was placed. 8. Heme - The patient was anemic with slowly falling Hct. She received blood transfusions for Hct <30% on [**9-26**], [**7-28**] and [**7-30**] with appropriate increase in post-transfusion Hct. There was no occult bleeding and hemolysis labs were negative. She denied pain and was not hypotensive making retroperitoneal hemorrhage an unlikely cause of her falling Hct. She was trace guaiac positive x 1. Her Hct has stabilized over the last 3 days of her CCU stay. The etiology of her dropping hematocrit was not clear but could have been related to hemodilution/phlebotomy. We would recommend to continue to follow her Hct closely. 9. GU - The patient was diagnosed with E.coli UTI, Foley was changed and started on Levaquin. On [**2104-8-1**] Levaquin was changed to Cefepime to cover both UTI and ? aspiration PNA. Repeat urine culture is pending. 10. ID - On [**2104-8-1**] the patient was more lethargic, had increase in WBC and increased thick brownish secretion. CXR [**8-2**] ?infiltration in RLL. She was started on empiric coverage with cefepime 2g Q12 and was pancultured. Cultures are pending at the time of this summary. WBC continued to increase on Cefepime and Vanco was added for broad coverage. She has remained afebrile. 11. Dysphonia - the patient was seen by ENT because of dysphonia that started the day after extubation. Dysphonia was felt to be secondary to trauma post-extubation/vocal cord edema. No management changes were recommended at the time. She will need to f/u in [**Hospital **] clinic in [**2-14**] weeks after discharge. 12. FEN/GI - The patient failed swallowing evaluation [**2104-7-30**] and DH tube was placed under fluoro guidance because of laryngeal edema. She was started on tube feeds that were slowly titrated up to goal 55 cc per hours. The patient self-removed her DH tube on several occasions. 13. PPx - sc heparin, PPI 15. Code - full 16. Contact - daughter, [**Name (NI) **], is health proxy Medications on Admission: 1. atenolol 50 [**Hospital1 **] 2. lisinopril 10 QD 3. ECASA 81mg 4. lipitor 20QD 5. synthroid 0.15 QD 6. lasix 40 QD Discharge Medications: Transfer Meds: Heparin sc, Plavix, ASA, Captopril 100 mg po tid, Metoprolol 100 mg po tid, Lipitor 80 mg po qd, HCTZ 25 mg po qd, Norvasc 10 mg po qd, Levothyroxine 150 mcg po qd, Cefepime 2 gm IV q12, Vanco 1 gm IV q 24, Lanzoprazole qd, Ipratropium neb, Atrovent neb, Colace, Dulcolax prn. Discharge Disposition: Home Discharge Diagnosis: 1. Coronary artery disease, 3 vessel, s/p LM Cypher stent, and PTCA to mid LAD 2. Carotid stenoses, bilateral 70-79% 3. HTN 4. Hyperlipidemia 5. Ventricular tachycardia 6. Dementia 7. Urinary tract infection 8. Aspiration pneumonia 9. Hypothyroidism Discharge Condition: [**Hospital 58213**] transferred to [**Hospital Unit Name 196**] service Followup Instructions: 1. You will need a cardiac catheterization in 6 months to make sure that your stent remains open. 2. ENT f/u in [**2-14**] weeks for upper airway edema. Completed by:[**2104-8-3**] Name: [**Known lastname 10788**],[**Known firstname 1940**] E Unit No: [**Numeric Identifier 10789**] Admission Date: [**2104-7-21**] Discharge Date: [**2104-8-25**] Date of Birth: [**2022-4-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10790**] Chief Complaint: fever, hypoxia, ?change in MS Major Surgical or Invasive Procedure: Intubation History of Present Illness: As outlined in first part of discharge summary. Pt was transferred from the CCU to [**Hospital Unit Name 319**] and started on cefipime on [**8-1**] for ? aspiration PNA and transiently on Vanc. She was doing well on floor, but failed speech and swallow exam x 2. She was awaiting consideration of PEG when she developed fever, hypoxia, and ?change in mental status, so she was transferred to the ICU. Past Medical History: 1. CHF/Recent MI [**2104-7-17**] 2. Htn 3. hyper chol 4. carotid stenosis (hx TIAs [**8-/2098**] carotid US demonstrated mod-marked stenosis of both common carotids extending into internal carotids) 5.recurrent epistaxis 6.mild short term memory problems 7.hypothyroid(thyroid surgery followed bby radiation therapy) 8. CHF ([**2104-7-17**] EF 45-50%) Social History: Minimal remote tobacco use, no etoh.Son, [**Name (NI) **], and daughter, [**Name (NI) **]. Family History: NC Physical Exam: Febrile to 102 BP 60/P HR 130s Gen: Frail elderly woman in acute distress, delirius and confused, lying in bed, rigorous. HEENT: PERRL CVS: tachy Chest: coarse rhonchi bilaterally; decreased b/s bilat bases Abd: soft, ND; hematomata extending to bilat flanks Ext: cold, unable to palpate pulses; extremities dusky Pertinent Results: [**2104-8-1**] 05:46AM BLOOD WBC-9.8# RBC-4.20 Hgb-12.4 Hct-35.7* MCV-85 MCH-29.6 MCHC-34.7 RDW-13.7 Plt Ct-225 [**2104-8-2**] 06:00AM BLOOD WBC-11.4* RBC-4.32 Hgb-12.5 Hct-37.2 MCV-86 MCH-29.0 MCHC-33.7 RDW-13.8 Plt Ct-271 [**2104-8-3**] 04:18AM BLOOD WBC-13.5* RBC-4.33 Hgb-12.7 Hct-36.7 MCV-85 MCH-29.3 MCHC-34.5 RDW-13.8 Plt Ct-302 [**2104-8-4**] 05:12AM BLOOD WBC-16.0* RBC-4.45 Hgb-13.1 Hct-38.7 MCV-87 MCH-29.5 MCHC-34.0 RDW-13.6 Plt Ct-335 [**2104-8-5**] 07:00AM BLOOD WBC-11.9* RBC-4.06* Hgb-11.9* Hct-35.4* MCV-87 MCH-29.4 MCHC-33.7 RDW-13.7 Plt Ct-314 [**2104-8-6**] 06:19AM BLOOD WBC-16.0* RBC-4.05* Hgb-11.8* Hct-34.3* MCV-85 MCH-29.2 MCHC-34.4 RDW-13.7 Plt Ct-307 [**2104-8-7**] 06:12AM BLOOD WBC-17.8* RBC-3.66* Hgb-11.1* Hct-30.8* MCV-84 MCH-30.3 MCHC-36.0* RDW-14.1 Plt Ct-289 [**2104-8-8**] 06:20AM BLOOD WBC-17.4* RBC-3.60* Hgb-10.5* Hct-30.8* MCV-86 MCH-29.1 MCHC-34.0 RDW-14.1 Plt Ct-287 [**2104-8-9**] 06:15AM BLOOD WBC-13.4* RBC-3.35* Hgb-9.8* Hct-28.4* MCV-85 MCH-29.3 MCHC-34.6 RDW-14.6 Plt Ct-300 [**2104-8-10**] 05:40AM BLOOD WBC-13.2* RBC-3.05* Hgb-9.3* Hct-25.3* MCV-83 MCH-30.4 MCHC-36.6* RDW-15.2 Plt Ct-261 [**2104-8-11**] 06:23AM BLOOD WBC-11.2* RBC-3.48* Hgb-10.5* Hct-29.3* MCV-84 MCH-30.2 MCHC-35.9* RDW-15.1 Plt Ct-260 [**2104-8-12**] 05:00AM BLOOD WBC-13.5* RBC-3.67* Hgb-11.1* Hct-30.7* MCV-84 MCH-30.3 MCHC-36.1* RDW-15.1 Plt Ct-269 [**2104-8-13**] 06:29AM BLOOD WBC-12.1* RBC-3.72* Hgb-11.3* Hct-32.6* MCV-88 MCH-30.3 MCHC-34.6 RDW-15.8* Plt Ct-258 [**2104-8-14**] 06:15AM BLOOD WBC-15.7* RBC-3.64* Hgb-11.1* Hct-31.5* MCV-87 MCH-30.5 MCHC-35.2* RDW-15.8* Plt Ct-264 [**2104-8-15**] 05:40AM BLOOD WBC-13.3* RBC-3.55* Hgb-10.8* Hct-31.6* MCV-89 MCH-30.5 MCHC-34.3 RDW-16.3* Plt Ct-255 [**2104-8-15**] 10:48AM BLOOD WBC-11.8* RBC-3.80* Hgb-11.6* Hct-33.6* MCV-88 MCH-30.4 MCHC-34.4 RDW-16.3* Plt Ct-271 [**2104-8-16**] 12:41AM BLOOD WBC-6.0 RBC-3.56* Hgb-10.8* Hct-31.4* MCV-88 MCH-30.2 MCHC-34.3 RDW-16.0* Plt Ct-232 [**2104-8-16**] 06:33AM BLOOD WBC-4.3 RBC-2.92* Hgb-8.9* Hct-26.6* MCV-91 MCH-30.5 MCHC-33.5 RDW-16.9* Plt Ct-239 [**2104-8-16**] 11:50AM BLOOD WBC-6.8# RBC-2.70* Hgb-7.9* Hct-24.6* MCV-91 MCH-29.3 MCHC-32.1 RDW-16.2* Plt Ct-243 [**2104-8-16**] 04:36PM BLOOD WBC-11.2*# RBC-2.77* Hgb-8.2* Hct-25.4* MCV-92 MCH-29.7 MCHC-32.5 RDW-16.4* Plt Ct-237 [**2104-8-16**] 11:25PM BLOOD WBC-12.8* RBC-2.85* Hgb-8.7* Hct-26.1* MCV-92 MCH-30.6 MCHC-33.4 RDW-16.5* Plt Ct-213 [**2104-8-17**] 04:17AM BLOOD WBC-10.7 RBC-2.98* Hgb-8.9* Hct-26.9* MCV-90 MCH-30.0 MCHC-33.2 RDW-16.6* Plt Ct-190 [**2104-8-18**] 05:51AM BLOOD WBC-10.8 RBC-3.25* Hgb-10.0* Hct-29.3* MCV-90 MCH-30.9 MCHC-34.2 RDW-16.5* Plt Ct-134* [**2104-8-20**] 04:18AM BLOOD WBC-8.6 RBC-3.74* Hgb-11.5* Hct-33.4* MCV-89 MCH-30.8 MCHC-34.5 RDW-16.1* Plt Ct-115* [**2104-8-21**] 03:55AM BLOOD WBC-7.7 RBC-3.98* Hgb-12.1 Hct-34.9* MCV-88 MCH-30.3 MCHC-34.6 RDW-15.9* Plt Ct-135* [**2104-8-21**] 03:49PM BLOOD WBC-10.5 RBC-4.08* Hgb-12.4 Hct-35.7* MCV-88 MCH-30.5 MCHC-34.9 RDW-15.9* Plt Ct-173 [**2104-8-22**] 12:13AM BLOOD WBC-8.8 RBC-3.84* Hgb-12.3 Hct-33.3* MCV-87 MCH-32.0 MCHC-36.8* RDW-15.9* Plt Ct-178 [**2104-8-22**] 04:47AM BLOOD WBC-9.3 RBC-3.86* Hgb-11.9* Hct-33.8* MCV-87 MCH-30.9 MCHC-35.4* RDW-15.9* Plt Ct-184 [**2104-8-23**] 04:23AM BLOOD WBC-9.3 RBC-3.67* Hgb-11.1* Hct-32.1* MCV-87 MCH-30.2 MCHC-34.6 RDW-15.6* Plt Ct-213 [**2104-8-24**] 07:01AM BLOOD WBC-11.3* RBC-3.53* Hgb-10.5* Hct-31.8* MCV-90 MCH-29.9 MCHC-33.1 RDW-15.7* Plt Ct-227 [**2104-8-25**] 04:23AM BLOOD WBC-14.3* RBC-3.62* Hgb-10.8* Hct-32.6* MCV-90 MCH-30.0 MCHC-33.3 RDW-15.4 Plt Ct-262 [**2104-8-4**] 11:45AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2104-8-8**] 11:15AM URINE Blood-LGE Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2104-8-14**] 11:15AM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2104-8-15**] 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2104-8-20**] 12:21PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2104-8-4**] 11:45AM URINE RBC- WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 [**2104-8-8**] 11:15AM URINE RBC-60* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [**2104-8-14**] 11:15AM URINE RBC-95* WBC-11* Bacteri-NONE Yeast-MANY Epi-<1 [**2104-8-15**] 04:00PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-MANY Epi-0 [**2104-8-22**] 04:08PM PLEURAL WBC-440* RBC-400* Polys-24* Lymphs-8* Monos-11* Meso-4* Macro-53* [**2104-8-22**] 04:08PM PLEURAL TotProt-0.9 Glucose-130 LD(LDH)-121 [**2104-8-1**] 11:17 am BLOOD CULTURE RIGHT TRIPLE LUMEN. **FINAL REPORT [**2104-8-7**]** AEROBIC BOTTLE (Final [**2104-8-7**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2104-8-7**]): NO GROWTH. Brief Hospital Course: 82 yo woman with w/Moderate carotid dz and CAD s/p MI [**7-17**], HTN, chol who was initially admitted [**7-16**] to local OSH for progressive DOE and ruled in for MI. She was transferred here where cath [**7-21**]: 80% LMCA and T.O. RCA. Not great LAD touchdowns. Preserved LVEF=45%. Because of rapid afib, polymorphic CT, she had emergent LMCA stenting on [**7-24**]. Since then has had a number of issues including: mental status changes (PNA delerium, dementia, old CVAs), aspiration, uti, chf, respiratory difficulty in CCU/intubated. On [**8-8**] she had an episode of acute pulm edema for which she received iv ntg and lasix. On tranfer back to the [**Hospital Unit Name 319**] team, the plan was for gentle diuresis, HTN control, possible peg, minimize sedatives and general supportive care. Her clinical status worsened, she became septic, and was transferred to the ICU. 1) Sepsis: As pt had failed speech and swallow eval x2, it was thought that the source of her sepsis was pulmonary. On the floor, she received Vanc, Ceftazidime for ?HAP, aspiration, ?line infection. She was transferred to the ICU and was initially on nonrebreather, but developed hypoxia, hypotension, was oriented only to person (but baseline dementia, thus difficult to evaluate) electively intubated (pus came out), right subclavian placed. Pt resuscitated with 13L NS/LR, one unit of blood and plat. Became more hypoxic on 100% FiO2 possibly due to fluid overload. Pressors initiated. Dopamine made her tachycardic. Placed on vasopressin and levofed and paralytics. Her left hand and foot became hypoxic, turning blue, and pulses, which were dopplerable at admit, became non-dopplerable. Clindamycin was started for aspiration pna. Blood cultures subsequently came back +for MRSA, so the vanc was continued. Her hospital course remained relatively stable. She came off pressors briefly, but became hypotensive off pressors, so they were restarted. Pt was unable to come off the vent Because of her extensive PNA and bilat pulm effusions. A family meeting was called, as her chances for recovery diminished. It was determined that Ms.[**Known lastname **] would not wish to continue living in the current state. She was made CMO and pressors, meds, and ventilator support were withdrawn. She passed away with her family at bedside. CAD: ASA, plavix, statin. BB, ACEI held given low BP. Rhythm: Remained in SR- held amio given low BP. Hypothyroid: Levothyroxine was continued. Heme: Guaiac +. HCT was monitored [**Hospital1 **]. Hemolysis labs neg. Received 2U PRBCs. GI: OG tube was placed. PPX: SC heparin, PPI FEN: TF were initiaed; IVF were given. Code: She was initially FULL code, but after her course worsened, her family felt she would want to be made CMO. Medications on Admission: As in preeceding section of summary. Discharge Medications: None--pt deceased. Discharge Disposition: Home Discharge Diagnosis: MRSA PNA and sepsis Deceased Discharge Condition: Deceased Discharge Instructions: Pt deceased. Followup Instructions: Pt deceased. [**Doctor First Name 3354**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 3353**] MD [**MD Number(2) 10791**] Completed by:[**2104-10-24**]

[ "038.11", "785.52", "995.92", "518.82", "599.0", "410.71", "428.0", "507.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.72", "88.56", "36.05", "36.07", "37.22", "37.61", "45.13", "99.20", "99.04", "88.41", "96.04", "88.42", "34.91", "96.6" ]

icd9pcs

[ [ [] ] ]

21378, 21384

18485, 21248

12253, 12265

21457, 21467

13550, 18462

21528, 21714

13196, 13200

21335, 21355

21405, 21436

21274, 21312

21491, 21505

13215, 13531

12184, 12215

12293, 12696

12718, 13072

13088, 13180

48,388

145,867

18571

Discharge summary

report

Admission Date: [**2157-11-8**] Discharge Date: [**2157-11-11**] Date of Birth: [**2099-12-5**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) / Lisinopril Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: Fever, Rigors/chills Major Surgical or Invasive Procedure: CT-guided LLQ intraabdominal abscess drainage w/ drain placement [**2157-11-8**] LUE PICC (double lumen) placed via IR [**2157-11-10**] History of Present Illness: 57 yo M with h/o diverticular stricture s/p sigmoid colectomy and diverting ileostomy on [**8-22**] followed by long complicated hospital course requiring tracheostomy and hyperalimentation, discharged to rehab on [**2157-10-24**] who now returns with fever to 100.7 at rehab associated with rigors and hypotension. He was sent to the [**Hospital Unit Name **] for a CT torso but was found to have a BP of 60/palp and was given IVF and sent to the ED for eval. In the ED, his blood pressure recovered with IVF (approx 3 L) back to 108/72 and thus he was prepped with a bowel prep for his CT torso. His ostomy is putting out green stool and gas. He is tolerating a regular diet and has just begun to stand at PT. Of note, his INR has been fluctuating somewhat such that he has required daily INR checks and coumadin dose adjustment. His last JP came out approximately five days ago. Today he noted a burst of fluid from one of his old JP sites as well, which has been covered with an ostomy appliance and is draining a [**Doctor Last Name 352**] somewhat thickened fluid. Past Medical History: PMH: (1) Splenectomy in [**2151-11-24**] when he had resection of a benign pancreatic mass at [**Hospital1 2025**]. (2) Thrombocythemia: 800,000 - 1,000,000. No clotting or bleeding. bone marrow biopsy on [**2153-3-1**] consistent with myeloproliferative disorder (polycythemia [**Doctor First Name **])...as well as an abnormal karyotype with deletion 20q in 3 out of 20 metaphases increasing his risk of hypercoagulability. (3) Immune-mediated granulomatous disease. He is followed by Dr. [**Last Name (STitle) 50954**] at [**Hospital1 112**]. (4) Hypertension. (5) Chronic renal insufficiency of unclear etiology. (6) High-risk adenocarcinoma of the prostate treated with radical prostatectomy on [**2151-5-31**], with no evidence of disease recurrence since that time. Path revealed granulomas. (7) Diabetes mellitus (no recent A1C). (8) Gastritis, detected on EGD in [**2153-6-30**]. (9) In [**5-31**], he developed a perianal abscess with bacteremia. (10) h/o thrombophlebitis in left leg (11) uveitis (12) C4-C5 radiculopathy (13) HLD (14) HTN (15) recurrent autoimmune pericarditis (16) h/o benign pancreatic cyst s/p resection (17) diverticulosis & diverticulitis c/b polymicrobial blood stream infection (18) liver abscess (19) portal vein thrombosis (hospitalized [**Date range (1) 50029**] and [**Date range (1) 50030**]) (20) polycythemia [**Doctor First Name **] on prednisone, followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] . . PSH: Periumbilical hernia repair (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 112**], [**2157-3-6**]), splenectomy ([**2150**]), Radical prostatectomy ([**2150**]), resection of benign cyst on tail of pancreas ([**2150**]), sigmoid colectomy with diverting ileostomy ([**2157-8-22**]), ex-lap, washout, mesh removal and abdominal closure ([**2157-9-12**]), emergent hematoma evac ([**2157-9-13**]), Exlap, removal of packing, closure fascia ([**2157-9-14**]), perc trach ([**2157-9-15**]), exlap for hct drop ([**2157-9-19**]) Social History: Lives with wife, has grown children. Occupation is trial attorney. Recently has been in [**Hospital **] rehab in [**Location (un) 701**] after discharge from [**Hospital1 18**] [**2157-10-30**] Family History: Pancreatic Cancer Physical Exam: On discharge: V: T: 97.8/97.3 HR: 80 BP: 126/75 RR: 16 O2Sat: 99%RA GEN: AAOx3, NAD HEENT: EOMI, Trach intact HEART: RRR LUNGS: CTAB ABD: +BS, soft, NT, ND, low midline wound c/d/i, ostomy intact w/ stool and gas LE: no edema Pertinent Results: Labs: [**2157-11-7**] 5:10p 132 108 42 AGap=13 -------------<109 4.9 16 0.9 11.7 \ 8.5 / 814 / 28.2 \ N:84 Band:3 L:6 M:6 E:0 Bas:0 Metas: 1 Nrbc: 1 Neuts: TOXIC GRANULATIONS Neuts: DOHLE BODIES Hypochr: 3+ Anisocy: 3+ Poiklo: 2+ Macrocy: 1+ Microcy: 1+ Spheroc: 1+ Ovalocy: OCCASIONAL Target: OCCASIONAL Schisto: OCCASIONAL Stipple: OCCASIONAL Acantho: 2+ Ellipto: OCCASIONAL Comments: Plt-Smr: Giant Plt'S Seen PT: 40.9 PTT: 38.8 INR: 4.3 Lactate:1.0 . [**2157-11-8**] 07:45a 131 106 34 AGap=13 -------------< 152 4.2 16 0.8 Ca: 10.4 Mg: 1.4 P: 4.1 7.0 \ 8.5 / 821 / 28.3 \ N:77 Band:0 L:9 M:8 E:4 Bas:2 Nrbc: 10 Comments: WBC: Corrected For 10 Nrbc'S Plt-Ct: Giant Platelets Seen Neuts: TOXIC GRANULATION, DOHLE BODIES SEEN Hypochr: 2+ Anisocy: 2+ Poiklo: 3+ Macrocy: 2+ Microcy: 1+ Polychr: 1+ Spheroc: 1+ Target: 1+ Schisto: 1+ Stipple: 1+ How-Jol: OCCASIONAL Pappenh: OCCASIONAL Acantho: OCCASIONAL Fragmen: OCCASIONAL PT: 38.4 PTT: 38.5 INR: 4.0 . [**2157-11-8**] 7:30p 130 106 29 AGap=17 -------------< 127 4.9 12 0.9 Ca: 10.3 Mg: 1.4 P: 4.1 10.2 \ 7.8 / 741 / 25.6 \ . [**2157-11-10**] PT 43.5 PTT 33.7 INR(PT) 4.6 . [**2157-11-11**] 02:53a 135 109 23 AGap=12 -------------<95 5.1 19 0.9 Ca: 10.4 Mg: 1.9 P: 3.7 4.8 \ 7.5 / 803 / 25.6 \ WBC: Checked For Nrbcs PT: 46.1 PTT: 34.6 INR: 5.0 . [**2157-11-11**] 02:46a Color Yellow, Appear Clear, SpecGr 1.010, pH 5.0, Urobil Neg, Bili Neg, Leuk Neg, Bld Neg, Nitr Neg, Prot 25, Glu Neg, Ket Tr, RBC 0-2, WBC 0-2, Bact None, Yeast None, Epi 0-2 . . MICRO: [**2157-11-8**] 11:00 am ABSCESS Site: PERITONEAL GRAM STAIN (Final [**2157-11-8**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2157-11-9**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): [**2157-11-8**] 8:45 pm BLOOD CULTURE x2 Blood Culture, Routine (Pending): [**2157-11-10**] 3:22 am MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): [**2157-11-11**] 2:46 am URINE Source: CVS. URINE CULTURE (Pending): . . IMAGING: CT TORSO: [**2157-11-7**] 8:45 PM 1. Moderate to large left pleural effusion with overlying atelectasis. 2. Question residual chronic PE in the right segmental level; contrast bolus is not optimal for evaluation. Stable small clot in the right brachiocephalic vein. 3. New/increased left lower quadrant rim enhancing fluid collection, measuring up to 6.7 cm, anterior to the left iliacus muscle, where drain was placed previously. New right lower quadrant smaller collection about 2 cm, not well defined. Post-surgical appearance of the abdomen and pelvis with stranding in the mesentery and free fluid, free fluid decreased prior. 4. Stable prominence of the left collecting system and left hydroureter, most likely secondary to the downstream inflammation. New mild prominence of the right renal collecting system and right ureter without definite obstructing lesion, although ureter not opacified at time of study. 5. Subtle nodularity along the anterior contour of the left lobe of the liver is noted, with possible subtle underlying hypodensity. 6. Stable hypodense nodule at the surgical resection in pelvis. . CT-guided Intraabd abscess drainage [**2157-11-8**] 9:35 AM Technically-successful aspiration of left lower quadrant collection. Technically-successful CT-guided drainage and catheter replacement into large left posteriorly layering collection anterior to the left iliac bone along the iliacopsoas tendon. . IR PICC [**2157-11-10**] Successful placement LUE double lumen PICC . Brief Hospital Course: Mr. [**Known lastname **] was admitted to the hospital on [**2157-11-7**] for fevers, rigors and hypotension and was found to have a new/increased fluid collection along the left abdominal wall with rim enhancement where the drain was before, now measuring 6.7 x 4.1 cm on and a forming ill-defined right lower quadrant-pelvic small collection measuring around 2 cm initial CT scan. In IR, initial scan demonstrated aloculated larger collection layering posteriorly anterior to the left iliac bone tracking along the iliacopsoas tendon measuring 3.9 x 6.8 cm. A second collection was also seen more inferiorly anterior to the left external iliac artery and vein and measured 2.0 x 2.5 cm. The inferiorly located collection was aspirated to collapse of the cavity and a total of 15mLs of pus was obtained. A 10 French [**Last Name (un) 2823**] catheter was then inserted along the tract into the larger posteriorly layering collection within the pelvis. 60mL of blood-stained pus was aspirated from this collection and each collection was sent for culture and sensitivity. A 10 French [**Last Name (un) 2823**] catheter was then left indwelling in the larger collection and was left on free drainage. He was started on IV linezolid, flagyl and cefepime. He initially tolerated the procedure well however, later that evening he became hypotensive with question of tongue swelling during IV cefepime administration. Cefepime was stopped, he was given famotidine and benadryl and the patient was moved to the SICU on the evening of [**2157-11-8**] for closer monitoring. The patient received IVF resuscitation and quickly restabilized and his tongue swelling resolved. He was seen in consultation with ID and the cefepime was changed to meropenem and the flagyl also discontinued. A LUE PICC line was placed in anticipation of potentially long-term antibiotics. He did not have a leukocytosis during his stay. His INR was elevated and coumdain was held. He was otherwise tolerating a regular diabetic diet with good ostomy output (both gas and liquid stool) and voiding well. The ostomy wound care service and Dr. [**Last Name (STitle) **] of [**Hospital1 778**] Primary Care Medicine were also following throughout his course. He was to return to the floor but due to lack of beds, he remained in the SICU until discharge. Upon discharge, his abscess sample gram stain showed 4+ PMN, 2+ GNR, 1+ GPC in pairs and chains but cultures were still pending. After discussions w/ NE [**Hospital1 **] regarding their availability of IV antibiotics (i.e. they do not carry meropenem) and the ID service, it was decided that given the patient's stable condition for past few days, he was to be discharged with IV imipenem and PO linezolid. Once his cultures are speciated and final, his antibiotics will be adjusted accordingly if necessary. He will have a follow-up appointment with the ID service on [**2157-11-29**] and will follow up with Dr. [**Last Name (STitle) **]. He was discharged on [**2157-11-11**] in good condition. Medications on Admission: Medications at Rehab: nystatin swish and swallow qid, hydroxyurea 1000 daily, esomeprazole 40 daily, gabapentin 300 qhs, ipratropium IH 2 puffs QID, tiaznidine 4 tid, insulin aspart sliding scale, insulin NPH 5 [**Hospital1 **], ascorbic acid 500 [**Hospital1 **], MVI with minerals 1 daily, prednisone 10 daily, acetaminophen 650 q6h prn, zolpidem 5 qhs, artificial tears prn, ondansetron 4 q6h prn, lorazepam 0.5 qhs prn, percocet [**12-25**] q4h prn, fentanyl 25 mcg TD q72h, warfarin 10 mg daily (adjust per INR) Discharge Medications: 1. nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO QID (4 times a day). 2. hydroxyurea 500 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO DAILY (Daily). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. gabapentin 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO HS (at bedtime). 5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]: Two (2) Puff Inhalation QID (4 times a day). 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (2) **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. tizanidine 2 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times a day). 8. ascorbic acid 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day). 9. multivitamin,tx-minerals Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 10. prednisone 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 11. zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime). 12. fentanyl 25 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 13. oxycodone-acetaminophen 5-325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 14. lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 15. polyvinyl alcohol 1.4 % Drops [**Month/Day (2) **]: 1-2 Drops Ophthalmic PRN (as needed) as needed for dry eyes. 16. insulin lispro 100 unit/mL Solution [**Month/Day (2) **]: AS DIR PER SS AS DIR PER SS Subcutaneous AS DIR PER SS. 17. linezolid 600 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H (every 12 hours). 18. acetaminophen 325 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 19. imipenem-cilastatin 500 mg Recon Soln [**Month/Day (2) **]: One (1) dose Intravenous Q8H (every 8 hours). 20. Coumadin 1 mg Tablet [**Month/Day (2) **]: Adjust based on INR Tablet PO Adjust based on INR: INR check daily and adjust coumadin dose accordingly - goal 2.5. 21. insulin regular human 100 unit/mL Solution [**Month/Day (2) **]: Five (5) Units Injection Breakfast and Dinner. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: Fevers, rigors Intraabdominal Abscesses x2 s/p IR drainage w/ catheter placement x1 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair Discharge Instructions: You were admitted for an infected intraabdominal collection that was drained. Your drain and ostomy output must be monitored for quantity and quality regularly. Please continue your medications as directed. You are on IV antibiotics and will require weekly lab checks for the following: -CBC -BUN -Creatinine -Liver function tests These must be faxed to the [**Hospital1 18**] Infectious Disease Dept at [**Telephone/Fax (1) 1419**] every week. Your INR was elevated and your coumadin was held. You will need your INR checked and have your coumadin dosed appropriately. In addition, please monitor for the warning signs listed below and call/return if you have any concerns/questions. Followup Instructions: Please call Dr.[**Name (NI) 6218**] office at ([**Telephone/Fax (1) 8792**] for a follow-up appointment. You have the following appointment at Infectious Disease Clinic: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2157-11-29**] 3:30 (This is located in the basement level of the [**Hospital **] Medical Office Building [**Last Name (NamePattern1) 51019**] on the [**Hospital1 18**] [**Hospital Ward Name **]) [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]

[ "250.01", "041.4", "V58.67", "288.1", "403.90", "511.9", "453.52", "567.22", "585.9", "790.92", "238.4", "338.29", "458.29", "998.59", "041.7", "272.4", "784.2", "E934.2", "135", "E930.5", "V55.0", "723.4", "728.85", "V58.65", "E878.3", "364.3", "V55.3" ]

icd9cm

[ [ [] ] ]

[ "54.91", "00.14", "38.97" ]

icd9pcs

[ [ [] ] ]

14307, 14383

8366, 11402

323, 460

14510, 14510

4165, 6116

15386, 16044

3881, 3900

11970, 14284

14404, 14489

11428, 11947

14671, 15363

3915, 3915

6578, 6623

6658, 8343

3929, 4146

263, 285

6151, 6381

488, 1560

6417, 6544

14525, 14647

1582, 3653

3669, 3865

2,984

155,981

3927

Discharge summary

report

Admission Date: [**2187-4-30**] Discharge Date: [**2187-5-18**] Date of Birth: [**2127-9-2**] Sex: F Service: SURGERY Allergies: Percocet / Codeine / Robaxin / Lomotil / Metoprolol Tartrate / Linezolid / Synercid / Rifampin / Optiray 300 / Percodan / Vancomycin / Daptomycin Attending:[**First Name3 (LF) 3376**] Chief Complaint: Sternum Biopsy/ Suicidal Ideation Major Surgical or Invasive Procedure: Sternal Biopsy History of Present Illness: Patient is a 59yo woman w hx breast ca, s/p bilateral mastectomy being treated with carboplatin, taxotere (last [**2187-2-7**]) and herceptin (last [**2187-4-25**]). She has undergone bilateral mastectomy for breast cancer and is currently undergoing adjuvant therapy by you. A recent bone scan showed an abnormality in the sternum. On CT scan, she was noted to have a pathologic fracture involving the superior portion of her sternum. She underwent sternum biopsy on [**4-30**]. During admission for sternal biopsy, patient developed suicidal ideation and has been evaluated by psychiatry. Plan is for her to be transferred to Oncology service to receive resultys of sternum biopsy. Past Medical History: 1) Type I Diabetes mellitus 2) CAD - [**1-29**] cardiac cath: 50% mid LAD, 80% distal LCx; stents placed to LAD and LCx - [**5-30**] PMIBI: SOB w/o ischemic changes. Nl myocardial perfusion - [**12-30**] TTE: mild LA enlargement, mildly dilated RA, LVEF >55%, trivial MR, trace AR 3) Hypothyroidism [**2184-3-2**] TSH 0.78 4) Depression/anxiety 5) Breast cancer: Stage II infiltrating ductal carcinoma dx [**2182**] - s/p right lumpectomy followed by 4 cycles of Adriamycin/Cytoxan and 7 weekly Taxotere treatments. Arimidex since [**1-29**] - right mastectomy [**2183-3-26**] when mammogram showed new calcifications 6) GERD 7) Low back pain s/p placement of neural stimulator 8) Right shoulder osteomyelitis: - Right humeral fracture [**5-30**] s/p ORIF - [**2183-7-27**] MRSA bacteremia from chemo port -> right septic shoulder/osteomyelitis - initially tx with linezolid, stopped due to thrombocytopenia, changed to daptomycin changed to synercid/rifampin due to daptomycin resistance. Synercid/rifampin caused pancytopenia, so she was changed to PO minocycline. - [**3-31**] right shoulder joint and upper humerus removed by Dr. [**First Name (STitle) **] at [**Hospital1 2025**] and antibiotic spacer inserted. Intra-op cultures grew 1 colony of MRSA --> desensitized to vancomycin and d/c [**2184-3-26**] on planned 6 week course of vancomycin prior to shoulder replacement, which would be followed by an additional 4-6 weeks of vancomycin Social History: Lives with her husband in [**Name (NI) 17448**], MA. Smoked 20 pack-years, quit 20 years ago; drinks [**12-27**] cocktails per week; no illicit drug use. Retired, previously worked with troubled young adults. Family History: 1. DM type 1: 2 Siblings, both deceased 2. Mother d. Ovarian CA Physical Exam: Vitals: T: 99.5 96.7 105/61 85 20 100%RA Gen: in no acute distress HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. absent patellar reflexes b/l LE. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2187-5-3**] 07:10AM BLOOD WBC-4.1 RBC-3.23* Hgb-10.7* Hct-33.5* MCV-104* MCH-33.2* MCHC-32.0 RDW-16.2* Plt Ct-129* [**2187-5-5**] 04:31AM BLOOD WBC-5.1 RBC-2.69* Hgb-8.8* Hct-27.4* MCV-VERIFIED MCH-32.8* MCHC-32.2 RDW-15.4 Plt Ct-87* [**2187-5-4**] 10:15PM BLOOD PT-14.4* PTT-37.0* INR(PT)-1.3* [**2187-5-5**] 04:31AM BLOOD PT-16.3* PTT-36.7* INR(PT)-1.5* [**2187-5-3**] 07:10AM BLOOD Glucose-200* UreaN-15 Creat-0.9 Na-141 K-4.3 Cl-102 HCO3-29 AnGap-14 [**2187-5-4**] 10:15PM BLOOD Glucose-178* UreaN-28* Creat-1.5* Na-138 K-3.8 Cl-105 HCO3-22 AnGap-15 [**2187-5-4**] 10:15PM BLOOD ALT-12 AST-19 LD(LDH)-246 AlkPhos-80 Amylase-27 TotBili-0.3 [**2187-5-5**] 01:13PM BLOOD Calcium-7.6* Phos-2.6* Mg-1.9 [**2187-5-4**] 10:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2187-5-4**] 10:20PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2187-5-4**] 10:20PM URINE RBC-3* WBC-3 Bacteri-NONE Yeast-NONE Epi-0 [**2187-5-4**] 10:20PM URINE CastHy-20* . ABDOMEN (SUPINE & ERECT) [**2187-5-4**] 10:07 AM ABDOMEN (SUPINE & ERECT) Reason: obstruction, free air. [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with breast CA, abdominal pain REASON FOR THIS EXAMINATION: obstruction, free air. HISTORY: 59-year-old female with breast cancer, abdominal pain, evaluate for obstruction or free air. COMPARISON: CT abdomen and pelvis [**2187-3-4**]. SUPINE AND LEFT LATERAL DECUBITUS ABDOMEN: Gaseous distended colon measures up to approximately 9 cm. Additionally, significant stool impaction is present within the pelvis. There is no evidence of free intraperitoneal air. A pacer device overlies the right side of the abdomen. Osseous structures reveal degenerative changes of the lower lumbar spine. IMPRESSION: Fecal impaction within the sigmoid colon, with a gaseous distended colon. . CT ABDOMEN W/O CONTRAST [**2187-5-5**] 2:36 AM CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Reason: assess for toxic megacolon and free air Field of view: 38 [**Hospital 93**] MEDICAL CONDITION: 59 year old woman with abdominal distension & pain REASON FOR THIS EXAMINATION: assess for toxic megacolon and free air CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 59-year-old female with abdominal distention and pain. Please evaluate for toxic megacolon or free air. COMPARISON: [**2187-3-4**]. TECHNIQUE: MDCT acquired axial imaging of the abdomen and pelvis was performed after administration of oral contrast only. IV contrast was not administered due to elevated creatinine. Multiplanar reformatted images were obtained and reviewed. CT ABDOMEN: There is dependent opacity at the lung bases bilaterally, right greater than left. This appears more than would be expected for simple atelectasis, and there is likely a component of pneumonic consolidation or aspiration as well. Absence of intravenous contrast limits evaluation of the abdominal parenchymal organs and vasculature. Diffuse anasarca has worsened, and there is a moderate amount of ascites now seen throughout the abdomen. There is evidence of portal venous gas within the liver, and there is markedly abnormal appearance to the entire colon. There is moderate wall thickening in the cecum and ascending colon, and there is pneumatosis intestinalis extending from the transverse colon just distal to the hepatic flexure to the uppermost portion of the descending colon in a segmental distribution. Pneumatosis in the mid transverse colon is most severe, without evidence of mucosal sloughing. The descending colon appears intact. A few borderline distended loops of contrast opacified small bowel, with small air-fluid levels are seen in the mid abdomen, but small bowel loops are otherwise unremarkable. The liver is unremarkable except to note portal venous gas as described above. The gallbladder is mildly distended, but there is no wall thickening or pericholecystic fluid. Pancreas, spleen, adrenal glands, and kidneys have normal non-contrast appearance. There is no free intraperitoneal air, or abnormal intra-abdominal lymphadenopathy. CT PELVIS: There is a moderate amount of ascites within the pelvis. Pelvic loops of small bowel are unremarkable. Note is made of spinal stimulator device in the right abdominal wall. The uterus and adnexa appear unremarkable. OSSEOUS STRUCTURES: Mild multilevel degenerative changes, including T12 compression deformity, and multiple old rib fractures are unchanged. IMPRESSION: 1. Pneumatosis intestinalis in a territorial distribution involving mainly the transverse colon from the hepatic flexure to the descending colon. Moderate amount of free fluid, and mesenteric and portal venous gas. These findings are highly concerning for mesenteric ischemia, though vascular etiology cannot be evaluated on this non-contrast scan. Watershed ischemia is also a consideration, given the patient's reported recent history of hypotension. 2. Moderate wall thickening and pericolonic inflammatory change in the cecum and ascending colon may also represent early ischemic change, with probable lesser amounts of pneumatosis around small amounts of stool. 3. Bibasilar atelectasis, with increased right basilar consolidation, concerning for superimposed pneumonia or aspiration. Brief Hospital Course: . #)Breast Cancer: patient had recent bone scan with new lesion identified on sternum. She was therefore scheduled to undergo a sternal biopsy. The day of the sternal biopsy, the patient developed suicidal ideation and was therefore admitted to the hospital with a 1:1 sitter for closer monitoring. She was followed by psychiatry daily. The patient recieved one dose of herceptin on [**5-3**], and a second dose on [**5-17**]. . #)Abdominal Pain: The patient reported new onset of abdominal pain the morning of [**5-4**]. The patient had diffuse abdominal tenderness, along with rebound tenderness. KUB was performed which showed stool filled and distended colon. Her distension was thought secondary to fecal impaction, and she was given two soap suds enemas followed by a small bowel movement. The patient reported mild relief with the bowel movement. She spiked a fever to 101.5 and was begun on levofloxacin/flagyl. Abdominal CT was postponed because the patient had a history of acute renal failure with IV contrast, and nausea was preventing her from taking oral contrast. Later in the day the patient had a second large bowel movement with further relief of symptoms. Later inthe day the patient developed hypotension, with blood pressures 77/40. She was bolused with 4L of Normal saline with increased blood pressures to 96/60. Given her increased fluid requirements to maintan blood pressure, she was transferred to the [**Hospital Unit Name 153**]. She had a CT scan which revealed severe colitis, so was taken to the emergency room emergently for ex lap and subtotal colectomy with mucus fistula. She actually tolerated the procedure quite well, and was transferred to the floor on POD 3. Her Cdif toxin came back positive so she was started on PO flagyl and vancomycin per her mucus fistula. She regained bowel function and was advanced to regular diet. Her staples were DC'd prior to discharge. She was given a prescription for 2 additional weeks of PO flagyl. . #)Diabetes Mellitis I: Patient with difficult to control blood sugars. Was placed on standing lantus and humalog insulin sliding scale. The [**Last Name (un) 387**] service followed daily. She was directed on how to count carbs and calculate a correction factor at home. #)Depression: Psychiatry consult was called and she was treated with antidepressants. She was quite tearful immediately postoperatively, but as her condition improved she actually became quite stable and happy. Her 1:1 sitter was discontinued several days prior to discharge, and she continued to do well on her own. She was cleared for discharge to home by Dr. [**First Name (STitle) 2405**] prior to discharge. Medications on Admission: Atenolol - 25 mg Tablet - one Tablet(s) by mouth once a day Atorvastatin [Lipitor] - 10 mg Tablet - 1 Tablet(s) by mouth once a day Clonazepam - (Prescribed by Other Provider) - 1 mg Tablet - Tablet(s) by mouth at bedtime Exemestane [Aromasin] - 25 mg Tablet - one Tablet(s) by mouth once a day FOSAMAX PLUS D - 70-2,800 mg-unit Tablet - 1 Tablet(s) by mouth weekly After arising first thing in the am, with a full glass of water, nothing else to eat or drink for 30 minutes. Furosemide - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a day Gabapentin [Neurontin] - 600 mg Tablet - 1 Tablet(s) by mouth 3 times daily Insulin Aspart [Novolog] - (Prescribed by Other Provider) - 100 unit/mL Solution - to use with insulin [**First Name (STitle) 4581**] as directed LACTULOSE - (Not Taking as Prescribed: not needed during chemotherapy) - 10G/15ML Syrup - 30CC BY MOUTH EVERY DAY AS NEEDED FOR CONSTIPATION Levothyroxine [Levoxyl] - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day Lidocaine-Diphenhyd-[**Doctor Last Name **]-Mag-[**Doctor Last Name **] - 400 mg-400 mg-40 mg-25 mg-200 mg/30 mL Mouthwash - Use swish and swallow three times a day as needed for mouth sores Lorazepam - 1 mg Tablet - One Tablet by mouth three times daily Meloxicam [Mobic] - 15 mg Tablet - 1 Tablet(s) by mouth once a day Take with food Omeprazole - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day Ondansetron HCl [Zofran] - 8 mg Tablet - 1 Tablet(s) by mouth q 12 hours as needed for nausea - No Substitution Prochlorperazine Edisylate [Compazine] - 10 mg Tablet - 1 Tablet(s) by mouth q 8 hours as needed for nausea Take TID on Day 2 following chemo. Then take as needed - No Substitution Valsartan [Diovan] - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a day Venlafaxine [Effexor XR] - 150 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth three times a day WELLBUTRIN SR - 150MG Tablet Sustained Release - ONE BY MOUTH THREE TIMES A DAY Medications - OTC ASPIRIN - 325MG Tablet - ONE BY MOUTH EVERY DAY Calcium-Vitamin D3-Vitamin K [VIACTIV] - (OTC) - 500 mg-100 unit-[**Unit Number **] mcg Tablet, Chewable - 2 Tablet(s) by mouth once a day Docusate Sodium [Colace] - (OTC) - 100 mg Capsule - 1 Capsule(s) by mouth three times a day Multivitamins-Ca-Iron-Minerals [One-A-Day Womens Formula] - (OTC) - 27 mg-0.4 mg Tablet - 1 Tablet(s) by mouth once a day Senna - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Exemestane 25 mg Tablet Sig: One (1) Tablet PO QD (). 2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Wellbutrin 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 6. Venlafaxine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. 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* 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. Disp:*1 bottle* Refills:*2* 11. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous QAM: with breakfast. Disp:*10 mL* Refills:*2* 12. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous QACHS: carb count: [**1-4**] I/C CF: 1:40 mg/dL. Disp:*10 mL* Refills:*2* 13. Insulin Syringe MicroFine 0.3 mL 28 x [**12-27**] Syringe Sig: One (1) syringe Miscellaneous QACHS: for insulin administration. Disp:*100 * Refills:*3* 14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1. CDiff colitis 2. Asthma 3. Anxiety 4. Depression 5. Metastatic breast cancer 6. Hypothyroidism 7. Diabetes mellitus 8. Hypertension 9. GERD Discharge Condition: Good Discharge Instructions: 1. Please call office or go to ER if fever/chills, nausea/vomiting, abdominal pain or distention, drainage or redness around incision, significantly decreased or increased output or bleeding from ostomy. 2. Resume medications as directed. 3. Follow-up as directed. Diet: You may resume a diabetic diet Activity: You may resume your normal activity. No heavy lifting > 10 lbs. Followup Instructions: Please call Dr.[**Name (NI) 3377**] office ([**Telephone/Fax (1) 17489**]) to schedule appointment. Please call [**Last Name (un) **] at ([**Telephone/Fax (1) 17484**] to schedule a followup appointment for 1 week. Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-5-23**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-5-30**] 2:30 Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2187-5-30**] 4:00 Completed by:[**2187-5-19**]

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Discharge summary

report

Admission Date: [**2199-7-22**] Discharge Date: [**2199-8-9**] Date of Birth: [**2123-1-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: Presented with 3 day history of constipation with flatus and abdominal distention and pain. Major Surgical or Invasive Procedure: [**2199-7-23**]: Subtotal colectomy Hartmann's pouch, End ileostomy, Insertion of gastrointestinal feeding system. History of Present Illness: 76 yo M with PMHx sig for Parkinson's and history of constipation who presents with no stools for the past four days and abdominal pain and distention for the past few days. pain was initially in the lower abdomen, became increasingly severe, which caused the patient to come to the [**Hospital1 18**] ER. KUB in the ER demonstrated sigmoid volvulus - CT scan confirmed, and the patient was admitted to the SICU for decompression. Past Medical History: Parkinson disease s/p deep brain stimulator placement Hypertension Hyperlipidimia Social History: non contributory Family History: non contributory Physical Exam: VS: 122/68 P 86 RR 29 96% on FIO2 50% (after aspiration in ED) HEENT: NC/AT, PERRLA, EOMI CV: pulses 2+ bilaterally, RRR, no M/R/G LUNG: bilateral crackles and rhonchi ABD: obese, distended, firm, +BS EXT: able to MAE 5/5 strength bilaterally, notable parkinsonian tremor Pertinent Results: Admission labs --------------- [**2199-7-22**] 05:15PM URINE SPERM-FEW [**2199-7-22**] 05:15PM URINE HYALINE-[**3-4**]* [**2199-7-22**] 05:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2199-7-22**] 05:15PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2199-7-22**] 05:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.036* [**2199-7-22**] 05:30PM PT-11.9 PTT-26.0 INR(PT)-1.0 [**2199-7-22**] 05:30PM PLT SMR-NORMAL PLT COUNT-293 [**2199-7-22**] 05:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2199-7-22**] 05:30PM NEUTS-92.8* BANDS-0 LYMPHS-4.3* MONOS-2.4 EOS-0.2 BASOS-0.3 [**2199-7-22**] 05:30PM WBC-13.7*# RBC-4.54* HGB-14.7 HCT-45.2 MCV-100* MCH-32.4* MCHC-32.5 RDW-13.6 [**2199-7-22**] 05:30PM CALCIUM-9.5 PHOSPHATE-2.4* MAGNESIUM-3.3* [**2199-7-22**] 05:30PM ALT(SGPT)-45* AST(SGOT)-44* ALK PHOS-143* AMYLASE-35 TOT BILI-0.8 [**2199-7-22**] 05:30PM estGFR-Using this [**2199-7-22**] 05:30PM GLUCOSE-189* UREA N-21* CREAT-1.2 SODIUM-137 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18 [**2199-7-22**] 05:44PM LACTATE-2.7* K+-3.9 [**2199-7-22**] 08:27PM TYPE-ART TEMP-37.2 PO2-124* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1 INTUBATED-INTUBATED . . Date: [**2199-8-8**] Signed by [**Name6 (MD) 16283**] [**Name8 (MD) 13560**], MD on [**2199-8-8**] Affiliation: [**Hospital1 18**] Cosigned by [**Name (NI) 3557**] [**Name8 (MD) **], MD on [**2199-8-8**] Movement Disorders Consult Note: I have seen Mr [**Known lastname 16284**] today as requested by the Neurology Consult team for advice on management of his treatment for Parkinson's disease. The plan of care was discussed with Dr [**First Name (STitle) **] [**Name (STitle) **], MD, Movement Disorders attending, and the plan reflects her thoughts and recommendations. . Current PD Medication: Sinemet 25/100: 6:30 9:00 11:30 14:00 16:30 19:00 21:00 1 tb 1.5tb 1.5tb 1.75tb 1.5tb 2tb 1tb . [**Name (STitle) 16285**]: 6:30 9:00 11:30 14:00 16:30 2mg 2 mg 3mg 2mg 3mg . Artane 2 mg in AM . DBS IPG's investigated by me at bedside: Left: 2-, case+, 2.6V, 120mcs, 135 Hz, continuous stim with no interruptions since reset of [**7-10**], impedances OK with no short- or open-circuits, battery voltage 3.72 Right: 0-, 2+, 3V, 150mcs, 185Hz, continuous stim with no interruptions since reset of [**7-10**], impedances OK with no short- or open-circuits, battery voltage 3.72 Exam: s/p abdominal surgery, G tube in place, continuous feeds run. Drowsy but easily arousable. Follows simple commands only. Not oriented to time or place. Able to answer yes, no, and simple one-item questions. Evaluation limited by complete aphonia. Unable to see pupils due to forceful voluntary and reflex eye closure. Increased tone diffusely with cogwheeling and some spasticity. No resting tremor, but tremor of LUE and LLE emerges when the stimulator turns off mom[**Name (NI) 11711**] while checking impedances. Agile repeated hand movements, unable to do a full PD motor exam. Responds normally to pain. Toes R up, L down, DTR's increased, b/l ankle clonus present. Impression and plan: Patient with advanced PD s/p DBS surgery, now in ICU post-op. Limited data on prior history. Attempted to contact Dr [**First Name (STitle) 7951**] at BU at [**Numeric Identifier 16286**], awaiting call back after page. Evidence of some encephalopathy and systemic impairment, both confounding exam. It is expected that PD signs will be worse with the major intercurrent stressor, but adjusting medication and especially DBS settings is not appropriate in this environment. Would plan first for resolving the acute condition, and taking measures to improve and prevent delirium. To maximize gain from Sinemet, please hold feeds at least 30 min before and after giving Sinemet to increase absorbtion. Continue current dose. Continue [**Numeric Identifier 16285**]. DBS working normally, will not change settings now, and there is evidence of good benefit at least on the tremor. Doubt significant benefit from Artane, and tremor controlled by DBS. Reduce dose to 1 mg daily for 3-4 days, then D/C Artane, as it is likely to contribute to some of the confusion. If after improving the patient's general condition he remains delirious, contact us re: reducing the [**Name (NI) 16285**] dose temporarily. In response to the question regarding use of Reglan from Neuro consult resident, please note that this medication is likely to worsen the parkinsonian symptoms. Only use if vital and no alternative, and only for short term. UMN signs of unclear origin, possibly part of encephalopathy, to be addressed by Neuro consult Plan communicated to Dr [**Last Name (STitle) 623**] of Neurology and Neurology Consult Resident. We will gladly remain involved in management at the primary team's request. [**Name6 (MD) **] [**Name8 (MD) **], MD . Date: [**2199-8-9**] BEDSIDE SWALLOWING EVALUATION: SUMMARY / IMPRESSION: There were no overt signs or symptoms of aspiration at the bedside today. By patient and family report, the pt is doing well with thin liquids and puree, and repeat CXR [**2199-8-8**] shows "gradual improvement of bilateral upper lobe consolidations". It appears safe for the pt to continue on this diet. He will likely be discharged to a rehab facility, and if he continues to tolerate these consistencies it may be appropriate to introduce trials of soft solids. However, "silent" aspiration cannot be ruled out at the bedside. If there are any persistent concerns regarding aspiration, we would be happy to perform a videoswallow evaluation. RECOMMENDATIONS: 1. Continue PO trials of thin liquids and puree consistency solids. 2. 1:1 assistance for feeding. 3. The pt should only be fed when he is most alert and awake. 4. Feeding trials should be discontinued if the pt demonstrates any overt signs of aspiration such as coughing or significant desaturation after eating or drinking. 5. If the patient continues to tolerate this diet without problems, it may be appropriate to introduce trials of soft solids.[**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) **], MS [**Name13 (STitle) 16287**] . CHEST (PORTABLE AP) [**2199-8-8**] 7:46 AM Reason: f/u on pneumonia IMPRESSION: Gradual improvement of bilateral upper lobe consolidations. Discharge Labs -------------- [**2199-8-8**] 07:00AM BLOOD WBC-9.1 RBC-3.81* Hgb-12.2* Hct-37.5* MCV-99* MCH-32.0 MCHC-32.5 RDW-15.0 Plt Ct-577* [**2199-8-8**] 07:00AM BLOOD WBC-9.1 RBC-3.81* Hgb-12.2* Hct-37.5* MCV-99* MCH-32.0 MCHC-32.5 RDW-15.0 Plt Ct-577* [**2199-7-29**] 02:28AM BLOOD Neuts-88.5* Bands-3.1 Lymphs-2.1* Monos-3.1 Eos-2.1 Baso-0 Metas-1.0* [**2199-7-29**] 02:28AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-2+ Polychr-NORMAL [**2199-8-8**] 01:20PM BLOOD UreaN-30* Creat-0.9 K-5.0 [**2199-8-8**] 07:00AM BLOOD Glucose-135* UreaN-29* Creat-0.9 Na-142 K-5.2* Cl-107 HCO3-26 AnGap-14 [**2199-8-3**] 01:00AM BLOOD ALT-12 AST-58* AlkPhos-424* Amylase-47 TotBili-0.9 [**2199-8-8**] 07:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2 [**2199-8-5**] 02:21AM BLOOD calTIBC-163* Ferritn-369 TRF-125* [**2199-8-5**] 02:42AM BLOOD Type-ART Temp-37.2 FiO2-96 pO2-78* pCO2-41 pH-7.45 calTCO2-29 Base XS-3 AADO2-580 REQ O2-93 Intubat-NOT INTUBA [**2199-8-3**] 08:13AM BLOOD K-3.6 [**2199-8-3**] 08:13AM BLOOD K-3.6 Brief Hospital Course: HD#1 - presentation to ED. Sigmoid volvulus evident on radiography, aspirated in ED, requiring intubation, hypotensive - thought secondary to aspiration moreso than bowel necrosis from volvulus; transferred to SICU for volvulus reduction HD#2 - Required levophed drip overnight to maintain blood pressure, sedated on propofol, intubated on 100% FiO2, preop'ed for surgery (subtotal colectom for sigmoid volvulus), returned from surgery - sedation maintained, levophed drip continues with sbp's in 100s. Lactate 5.5 for which patient received 1L saline bolus Abdominal wound left open with 10 wicks for granulation tissue promostion and consolidation of granulous tracts. HD#3 - Patient continues to wean off levophed, sedation continues, maintains intubation, lactate level decreasing from 5.4->3.5 HD#4 - patient continues to wean off levophed, sedation continues (levophed drip @ 0.030, propofol drip @ 20), intubated on CPAP (50 FiO2) with attempts to extubate today if able to wean off pressors; neurology saw patient and recommended restarting home meds by G tube HD#5 - patient weaned from propofol, sedated on versed for agitation. following commands spontaneously but not purposefully, trophic tube feeds 25cc/hr. oxygenation with PaO2 70s-80s and SPO2 94-96 - PEEP required increase to 12, CPAP+PS continue for ventilation. FiO2 increased that afternoon to 70% due to PaO2 in 60's on PEEP 14 HD#6 - Lasix drip at 5.0/hr Continues on antibiotics Zosyn, flagyl, vancomycin, diflucan (sputum culture grew out yeast), generalized edema noted, diuresis continues, trophic tube feeds continue, respiratory status - FiO2 wean attempts continue but required 70% FiO2 HD#7 - Lasix drip continues at 5/0/hr Continues on antibiotics, no vent changes, MAP > 60, right a-line changed, difficulty maintaining ostomy seal, sedation on versed maintained intermittently HD#8 - patient changed to APRV to maintain oxygenation with improved ABG, able to wean FiO2 down to 50%, with PaO2 in the low 100s. In the evening - remained intubated on PSV 8/18, bronched x 2 for copious, thick, yellow secretions. Sedated on propofol drip HD#9 - patient weaned off all pressors, lungs appear stable although CXR still demonstrates diffuse infiltrates. BAL demonstrates NGTD, Tube feeds increased to 45 with goal of 80 @ 3/4 strength. Antibiotics continue for aspiration pneumonia HD#10 - white count decreasing with serial bronchs. stoma producing excellent stool output. CXR clearning. PT advanced to goal tube feeds. HD#11 - pt remaines intubated/sedated on PSV, diuresis continues overnight, oxygenation improving with a PEEP of 2 in the AM HD#12 - Patient was extubated, lungs sound clear, remained on 12L/min oxgyen and sat was 97%. Continued to increase Lopressor to maintain rate and blood pressure. Patient continued to be diuresis. Insulin requirements were increased based on the fingersticks ranging from 148-164. Patient received a CT Scan of the head per neurolog recommendation to evaluate for bleed, which was negative. HD13 - Neuro status continued to improve and patient is followed by the neurology service. HD16 - patient was transferred to the floor from ICU with 1:1 sitter in place to maintain patency of j-g tube and iv lines. Neurology continued to follow with recommendations to hold tube feedings 30minutes pre and post Parkinson's medications, decrease troheyphenidyl to 1 mg for next 4 days and then d/c. Patient was evaluated by speech and swallow for aspiration, they recommended starting on thin liquids and puree diet. Screening process started for rehab per physical therapy recommendations. HD17 - Parkinson's: neurologically continues to improve and has follows commands appropriately with purposeful movement, hypophonia, patient should contact primary neurology as an outpatient (Dr. [**First Name (STitle) 7951**]. Continue to wean off Artane as planned. Hemodynamically that patient has remained stable and afebrile. Aspiration pneumonia - Patient has remained on 3liters via nasal cannula and saturation maintaining sats of >94% and slightly tachypnea with a rate of 26-29. Surgical incision has been maintained via vac dressing system @ 125mmHg of suction. Nutrition - patient's tube feeding started to be cycled for 16hours daily at a rate of 100cc/hr and he is tolerating liquid oral intake. Ostomy - followed by ET nurses throughout hospitalization, the stoma is located in the RLQ, size is 1 X 1 [**1-7**] inch, slightly protruding and red, the postion of the OS is center. The mucocutanous junction is intact and the stool is pasty brown. Patient was seen by the ET nurses on the day of d/c. Skin - patient has a small right heel decubitus that has been treated with [**Last Name (un) 16288**] vista and elevation, otherwise skin is unremarkable. Patient was evaluated by physical therapy and felt it was appropriate to d.c patient to a rehab facility. Medications on Admission: Sinemet 7 times a day [**Last Name (un) 16285**] 2''3' Trihexyphenidyl 1' Zoloft75' Lipitor20' Vesicare5' Patanol 2' Dulcolax10' Remeron 15' Folplex 2.2' Seroquel 25mg Restasis Protonix 40' Florinef (new) Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO DAILY Q0630 (): Crushed down G-tube . 2. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. Trihexyphenidyl 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) for 4 days. 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for fever. 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-1**] Drops Ophthalmic Q2H (every 2 hours). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) Packet PO PRN (as needed) as needed for phos<3.0. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Aspiration pneumonia, sigmoid volvulus Discharge Condition: stable, off ventilator and all drips/pressors, able to tolerate liquid/puree diet s/p swallow eval, afebrile, hemodynamically stable; feeding tube sites functional and otherwise without problem Discharge Instructions: You, the patient, are to be discharged to an extended care facility (rehabilitation) before returning home to your residence. You are to follow-up with Dr. [**Last Name (STitle) **] in his clinic for a post-operative visit. You are to also follow-up with your outpatient primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16289**] follow-up appointment. Please return to the hospital (emergency room) for the following: * fevers > 101/5 * increasing abdominal pain * pus from wound * bleeding from wound * blackening of ostomy site * pus from any feeding tube site * any concerns or problems regarding your health status Followup Instructions: You, the patient, are to be discharged to an extended care facility (rehabilitation) before returning home to your residence. You are to follow-up with Dr. [**Last Name (STitle) **] in his clinic for a post-operative visit. You are to also follow-up with your outpatient primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 16289**] follow-up appointment. Completed by:[**2199-8-9**]

[ "997.1", "707.07", "401.9", "560.2", "332.0", "427.1", "997.3", "272.0", "569.83", "557.9", "507.0", "518.5" ]

icd9cm

[ [ [] ] ]

[ "45.95", "96.6", "96.72", "45.79", "33.23", "46.39", "45.23", "33.24", "46.21", "38.93" ]

icd9pcs

[ [ [] ] ]

15015, 15081

8935, 13837

405, 522

15164, 15360

1466, 8912

16067, 16488

1139, 1157

14092, 14992

15102, 15143

13863, 14069

15384, 16044

1172, 1447

273, 367

550, 984

1006, 1089

1105, 1123

4,012

139,326

25686

Discharge summary

report

Admission Date: [**2131-2-24**] Discharge Date: [**2131-3-21**] Date of Birth: [**2077-12-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: Right heel osteomyelitis Major Surgical or Invasive Procedure: Partial debridement of right heel osteomyelitis Hemodialysis History of Present Illness: This is a 53 year-old male with end stage renal disease, insulin dependent diabetes, coronary artery disease, congestive heart failure, and right heel chronic osteomyeltis who was admitted to an outside hospital on [**2131-2-10**] with fevers and weakness. A wound culture of his right heel grew out MRSA, providencia stuartii, and e. coli. He also had a MRSA bacteremia that has subsequently cleared. He was treated with vancomycin and ertapenem. He had a transesophageal echocardiogram that showed no vegetations and no involvement of his pacer leads. He also had a tagged white cell scan that only showed enhancement at the right heel. He was transfered to the [**Hospital1 18**] for surgical debridement of his right heel osteomyelitis. . At this time, he states that he continues to have some fevers with chills although they are less than previously. He denies any pain in his right heel as he has no sensation in either foot. He denies shortness of breath, chest pain, abdominal pain, fatigue, weakness, diarrhea, or urinary symptoms. Past Medical History: 1. Chronic osteomyelitis in his right foot for 18 months complicated by MRSA bacteremia. 2. Status post skin graft to left heel in [**2126**] for ulcer. 3. Congestive heart failure with an EF of 60% 4. Coronary artery disease status post 2 stent placements 5. Status post pacemaker placement 6. Insulin dependent diabetes diagnosed at age 37, complicated by neuropathy and retinopathy 7. Peripheral vascular disease status post bilateral lower extremity bypass grafts 8. Hypertension 9. Hypercholesterolemia 10. End stage renal disease on hemodialysis 11. GERD 12. Constipation 13. Depression 14. Insomnia Social History: He lives with his wife. [**Name (NI) **] doesn't smoke or drink. Family History: There is a history of diabetes. His mother is on hemodialysis. Physical Exam: Vitals: Temperature: Pulse: Blood Pressure: Respiratory Rate: Oxygen Saturation: General: Well appearing gentleman lying in bed in no acute distress HEENT: Pupils equal and reactive, extraoccular movements intact, moist mucous membranes. Neck: Supple. No cervical, submadibular, supraclavicular lymphadenopathy. Cardiac: Regular rate and rhythm, s1, s2 Pulmonary: Clear to ascultation bilaterally Abdomen: Normoactive bowel sounds, soft, nontender, nondistended. Extremities: Warm and well perfused without cyanosis or edema, 6 cm in diameter ulcer to bone on right heel that is about 1 cm deep. Left forearm AV fistula. Neuro: Cranial nerves II-XII grossly intact, decreased senstation in bilateral feet, otherwise exam non-focal. Pertinent Results: Outside Hospital Studies: . Cultures: 1. Blood ([**Date range (1) 24213**]): MRSA 2. Right heel: MRSA, providencia stuartii, and e. coli . Imaging: 1. CT lower extremity ([**2-9**]): osteomyelitis of right calcaneus and talus, large ulcer of plantar surface. 2. TEE: No vegetations, LA enlargement, dilated LV with concentric hypertrophy, EF = 50%. 3. Tagged white cell scan: Enhancement of right heel . Labs on Admission [**2131-2-24**] 05:35PM BLOOD WBC-14.0* RBC-3.99* Hgb-10.6* Hct-31.3* MCV-79* MCH-26.7* MCHC-34.0 RDW-19.0* Plt Ct-214 [**2131-2-24**] 05:35PM BLOOD Glucose-149* UreaN-31* Creat-6.8* Na-134 K-3.5 Cl-97 HCO3-22 AnGap-19 [**2131-2-24**] 05:35PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.6 . Labs on Discharge [**2131-3-21**] 07:25AM BLOOD WBC-10.1 RBC-3.41* Hgb-9.3* Hct-29.1* MCV-85 MCH-27.3 MCHC-32.0 RDW-18.3* Plt Ct-345 [**2131-3-21**] 07:25AM BLOOD Plt Ct-345 [**2131-3-21**] 07:25AM BLOOD PT-13.9* PTT-25.3 INR(PT)-1.2* [**2131-3-21**] 07:25AM BLOOD Glucose-99 UreaN-27* Creat-9.2*# Na-136 K-4.6 Cl-97 HCO3-26 AnGap-18 . Micro AEROBIC BOTTLE (Final [**2131-3-14**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. STRAINS #1 AND #3. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. STAPH AUREUS COAG +. FINAL SENSITIVITIES. STRAIN#2. 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 + | STAPH AUREUS COAG + | | CLINDAMYCIN----------- =>8 R =>8 R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R =>8 R OXACILLIN------------- =>4 R =>4 R PENICILLIN------------ =>0.5 R =>0.5 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S VANCOMYCIN------------ <=1 S <=1 S ANAEROBIC BOTTLE (Final [**2131-3-16**]): STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. . RADIOLOGY [**2131-2-24**] [**Hospital 93**] MEDICAL CONDITION: 53 year old man with right heel osteo REASON FOR THIS EXAMINATION: evaluate for other bone involvement INDICATION: History of right heel osteomyelitis, evaluate for bone involvement. COMPARISONS: [**2130-6-29**]. RIGHT FOOT THREE VIEWS: Again seen is a fracture through the proximal third of the calcaneus with sclerotic margins. There is evidence of destruction, osseous debris, and sclerosis in the region of the calcaneus. There has been interval development of a large soft tissue defect on the plantar aspect of the heel. Again seen is diffuse osteopenia and vascular calcifications. IMPRESSION: Old non-united fracture of the anterior calcaneus with sclerotic margins and evidence of osseous debris and destruction. Chronic infection could have a similar appearance. . [**2131-3-12**] ECHO Conclusions: Pacemaker wire is identified in the RA/RV. There is a large (>3 cm long), highly mobile echodense mass(es) associated with the RV pacing lead. The mass is adherent to the pacing lead in multiple loci, and extends from the high right atrium, along the lead, to the tricuspid valve. The mass may also involve the tricuspid valve. The mass likely represents avegetation, although the differential diagnosis includes a lead-associated thrombus. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a small circumferential pericardial effusion. IMPRESSION: Large mass/vegetation on the right ventricular pacing lead. Mild tricuspid regurgitation. Small pericardial effusion. [**2131-3-15**] CHEST PA & L IMPRESSION: 1) Pacing lead terminates in right ventricle with no pneumothorax. 2) Patchy posterior basilar right lower lobe opacity which may relate to atelectasis, aspiration or evolving pneumonia. Follow up radiographs may be helpful. Brief Hospital Course: This is a 53 year-old male with diabetes, end stage renal disease on dialysis, coronary artery disease, chronic osteomyletis complicated by MRSA bacteremia admitted for surgical debridement of his osteomyelitis. . #. Osteomyelitis: He was continued on vancomycin and imipenem because wound cultures from the outside hospital grew out MRSA, providencia stuartii, and e. coli. A repeat wound culture grew out only MRSA. He underwent a partial debridement by podiarty, and that bone tissue did not grow out anything. The pathology was consistent with chronic osteomyelitis. A post-operative CT scan showed extensive disease involving the calcaneous, talus, and some of the joint space. Podiatry felt that a limb sparing debridement was not possible, therefore, he underwent a Right below the knee amputation by vascular. His course was complicated toward the later part of his course by bleeding. Vascular was consulted and they stopped the bleeding. The surgical site was clean/dry/ and intact at the time of discharge. . #. s/p Pacemaker removal: At the outside hospital, he had cleared his bacteremia. There was no evidence of vegetations on TEE and tagged white cell scan only enhanced in right heel. Following his BKA and despite being on antibiotics, the patient continued to spike fevers. An echo was done which showed a large mass/vegetation on the right ventricular pacing lead. The pacemaker was removed on [**2131-3-13**]. A temporary pacemaker was placed. The patient's pacer was initially set to 40bpm to encourage spontaneous return of atrioventricular conduction. However due to the fact that his QTc was prolonged, the rate was increased to 60bpm to decrease the risk of torsades de pointes. The patient continues to be in complete heart block and is pacer dependent. Cardiology is aware of this. They have noted that as long as the patient remained stable hemodynamically this is fine. The patient remained HD stable for the remainder of his course. . The patient is scheduled to follow up with Dr. [**Last Name (STitle) **] in 3 weeks for placement of a permanent pacemaker. An appointment has already been set up for the patient. #. End stage renal disease: He continued his regularly scheduled dialysis on Mondays, Wednesdays, and Fridays. He was maintained on his outpatient sevelamer and nephrocaps. His lasix and zaroxylin were held as his fluid balance can be managed at dialysis. . #. Coronary artery disease: On daily clinical examinations, the patient had no evidence of active ischemia. He was maintained on his aspirin, lipitor, cozaar, norvasc. Metoprolol was started for peri-operative beta-blockade. Cardiology later advised stopping any nodal agents. . #. Diabetes: He glucose was elevated to the 200s at the other hospital. His insulin regimen was switched to 27 units lantus with regular insulin 4 and 5 units with dinner and breakfast respectively. With resolution of his infection, the patient did not require aggressive glucose management. His lantus was later decreased to 8U. He had adequate glycemic control. . #. Anemia: His baseline anemia is secondary to renal disease. He was maintained on his regular epoetin with dialysis. He also received red cell transfusions for surgical blood loss. . # Hypoxia: The patient 02 sat would fall intermittently to 88%RA and 92%RA. With deep breaths the patient's O2 sats would improve to >94% RA. A CXR was done and showed low lung volumes and atelectasis. The patient was encouraged to use an incentive spirometer. The patient's O2 sats remained stable for the remainder of his course. . # Loss of vision: The patient reported losing changes in vision following his R BKA. Optho was consulted . They noted cortical and nuclear sclerotic cataracts. They did not see any signs of infection. They recommended continuation of the current medical mgmt for the patient's bacteremia. . #. Hypercholesterolemia: He was maintained on his outpatient lipitor. . #. GERD: He was maintained on his outpatient protonix. . #. Constipation: He was maintained on his outpatient colace and senna. . #. FEN: Renal, diabetic, cardiac diet. . #. Access: Peripheral IV and right forearm AV fistula. . #. Dispo: Rehab Medications on Admission: Vancomycin 1 g with HD Etrapenem 500 mg IV qd Cozaar 25 po qd Lipitor 80 po qd Norvasc 10 mg po qd Aspirin 81 po qd Lasix 80 po bid Zaroxylin 0.5 qod Lantus 20 SC qhs 70/30 15 before dinner, 18 before breakfast Humalog sliding scale Renagel 800 po tid Colace 100 po bid Senna 2 tab po q8 Ambien 5 po hs prn Tylenol Ibuprofen Discharge Medications: 1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) as needed for pruritis. 15. Gentamicin sig: 60mg IV disp: qs for 3 weeks Please check daily trough and dose for trough less than 2. 16. Vancomycin Sig: 1250mg IV Disp: qs for 6 weeks Check daily vancomycin trough and dose for trough < 15. 17. Insulin Sig: As per insulin sliding scale Disp: qs Refills:5 18. Lantus Sig: per sliding scale Disp: qs Refills: 5 Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: MRSA Bacteremia . 1. Chronic osteomyelitis in his right foot for 18 months complicated by MRSA bacteremia. 2. Status post skin graft to left heel in [**2126**] for ulcer. 3. Congestive heart failure with an EF of 60% 4. Coronary artery diseas e status post 2 stent placements 5. Status post pacemaker placement 6. Insulin dependent diabetes diagnosed at age 37, complicated by neuropathy and retinopathy 7. Peripheral vascular disease status post bilateral lower extremity bypass grafts 8. Hypertension 9. Hypercholesterolemia 10. End stage renal disease on hemodialysis 11. GERD 12. Constipation 13. Depression 13. Insomnia Discharge Condition: vitals stable, patient afebrile, tolerating oral intake Discharge Instructions: Seek medical services immediately if you should have any chest pain, shortness of breath, fevers, chills or any other worrisome sx. If you have any temperature spikes please return to the hospital immediately. . Please take your medications as prescribed . Please keep all of your follow up appointments . Please maintain your hemodialysis schedule . Please check daily gentamycin and vancomycin troughs. . Gentamycin goal peak [**3-10**]; goal trough 2, please dose for gent trough less than 2. . Vancomycine goal trough 15-20, please dose for trough less than 15. Followup Instructions: Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week of discharge. . You are scheduled to have a permanent pacemaker placed. You have an appointment with Dr. [**Last Name (STitle) **] on [**2131-4-9**] at 10AM. Please call [**Telephone/Fax (1) 5518**] . Please call [**Telephone/Fax (1) 1393**] to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] (surgeon). [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2131-3-26**]

[ "414.01", "707.14", "428.30", "730.17", "285.21", "530.81", "V09.0", "731.8", "428.0", "403.91", "440.23", "250.70", "585.6", "041.4", "426.0", "250.80", "997.69", "996.72", "041.11", "E879.8", "790.7" ]

icd9cm

[ [ [] ] ]

[ "39.95", "37.77", "88.72", "77.69", "37.78", "84.15", "99.04" ]

icd9pcs

[ [ [] ] ]

14002, 14081

7910, 12115

340, 402

14750, 14808

3042, 5605

15423, 16007

2210, 2275

12491, 13979

5642, 5680

14102, 14729

12141, 12468

14832, 15400

2290, 3023

276, 302

5709, 7887

430, 1481

1503, 2111

2127, 2194

58,077

160,673

27651

Discharge summary

report

Admission Date: [**2129-4-27**] Discharge Date: [**2129-5-5**] Date of Birth: [**2075-5-8**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1481**] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: [**2129-4-27**] Minimally-invasive esophagectomy History of Present Illness: 53M with fairly advanced esophageal cancer w/ node + up to subcarinal regions. Had epicardial node which was PET positive. He went through intensive chemo-radiation w/ marked mprovement in FDG avidity and negative epicardial node. He was still haven't some difficulty swallowing after his treatment. He wishes to have surgical treatment. Past Medical History: PMHx: esophageal cancer PSHx: J-tube placement [**12-25**], repair of R wrist fracture Social History: Lives in [**Hospital1 3597**], NH w/ wife and son. Worked as mechanic for past 21 years. 30 pack-year h/o tobacco, 1.5 ppd. He drinks 2-3 alcoholic drinks per day. Currently on short term disability. Family History: Father - lung cancer, paternal uncle - lung cancer (smoker) Physical Exam: Discharge exam: 98.9 97.7 69 136/71 18 96% RA Gen: NAD, A&Ox3 HEENT: JP drain removed, dressed, neck incision c/d/i CV: RRR Pulm: CTAB Abd: soft, nontender, incisions c/d/i, prior chest tube site clean/intact Ext: WWP Pertinent Results: [**2129-4-27**] 04:44PM BLOOD WBC-24.5*# RBC-3.72* Hgb-12.9* Hct-36.0* MCV-97 MCH-34.7* MCHC-35.9* RDW-12.5 Plt Ct-242 [**2129-4-28**] 02:58AM BLOOD WBC-15.3* RBC-3.62* Hgb-12.4* Hct-34.7* MCV-96 MCH-34.3* MCHC-35.8* RDW-12.4 Plt Ct-227 [**2129-4-29**] 07:05AM BLOOD WBC-11.9* RBC-3.33* Hgb-11.3* Hct-32.3* MCV-97 MCH-34.0* MCHC-35.1* RDW-12.2 Plt Ct-189 [**2129-4-27**] 04:44PM BLOOD Glucose-145* UreaN-19 Creat-0.8 Na-138 K-4.3 Cl-105 HCO3-25 AnGap-12 [**2129-5-2**] 06:20AM BLOOD Glucose-103* UreaN-14 Creat-0.7 Na-136 K-3.7 Cl-102 HCO3-23 AnGap-15 Imaging: [**2129-5-2**] Swallow study: IMPRESSION: No leak at the gastric-esophageal anastomosis. No holdup of oral contrast. Brief Hospital Course: The patient was admitted to the West 3 surgery service on [**2129-4-27**] and had a minimally invasive esophagectomy by Dr. [**Last Name (STitle) **] & Dr. [**Last Name (STitle) **]. (Refer to operative note for full details). The patient tolerated the procedure well. Post-operatively, the patient was monitored closely in the ICU and remained stable and transferred to the floor on POD 1. Neuro: Post-operatively, the patient received IV pain medications with good effect and adequate pain control. These were switched to PO once tolerating diet. . CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored and the patient remained on telemetry while chest tube was in place. . Pulmonary: Pulmonary toilet including incentive spirometry and early ambulation were encouraged. The patient was stable from a pulmonary standpoint and weaned off NC. The patient had a chest tube ([**Doctor Last Name **] drain) in place, which was initially to suction, without leak. It was put to water seal on POD 3. It was discontinued on POD6, without evidence of pneumothorax. . GI/GU: Post-operatively, the patient was NPO for 5 days and monitored closely. Foley catheter was removed POD 4 and he voided without issue. Intake and output were closely monitored. Tube feeds were started on POD 2 and increased slowly to goal, as the patient could tolerate, and eventually cycled. He received colace through the J-tube to assist with bowel movements. He had a swallow study on POD 5, which did not show evidence of a leak. He was started on sips and advanced over the next 2 days to a regular soft diet, which he tolerated. . ID: The patient's temperature and surgical sites were closely watched for signs of infection of which there were none. The neck incision appeared c/d/i. JP drain was discontinued on morning of discharge. It had been putting out serosanguinous drainage throughout the hospital course. . Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD 8, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: ativan 0.5 q6 prn, oxycodone, varenicline (chantix) 0.5-1' 1 week before target quit date, colace, MTV Discharge Medications: 1. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*420 ML(s)* Refills:*0* 2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: esophageal cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the West 3 (Dr.[**Name (NI) 1482**] surgery service after your operation. Instructions: -Place a wedge under your mattress to keep head of bed elevated 30-45 degress -Chest tube site remove dressing tomorrow and cover site with a bandaid Pain -Roxicet as needed for pain -Take stool softeners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tub until incision healed -No driving while taking narcotics -No lifting greater than 10 pounds until seen in follow-up -Walk 4-5 times a day for 10-15 minutes increase to a goal of 30 minutes daily Diet: Regular soft diet as tolerated. Continue tube feeds in the evening: Jevity Tube feeds: Jevity Full Strength 2 cans cycled in evening 7 pm - 7 am Flush J-tube with water every 8 hours with 1 cup of water, before and after starting tube feeds and giving medications through tube. Regular diet as tolerated. Eat small frequent meals. Sit up in chair for all meals and remain sitting for 30-45 minutes after meals Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks after discharge. If you do not have an appointment already scheduled, please call his office: ([**Telephone/Fax (1) 1483**] Completed by:[**2129-5-5**]

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Discharge summary

report

Admission Date: [**2173-9-30**] Discharge Date: [**2173-10-12**] Date of Birth: [**2118-4-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: ETOH and medication overdose Major Surgical or Invasive Procedure: Respiratory Intubation History of Present Illness: The patient is a 55-year-old male with PMH of alcoholism who presents after a dangerous combination of alcohol intoxication and accidental medication overdose. Per report, patient's partner says he "fell off the wagon" 2-3 days ago after being sober for years. He drank large quantities of port wine and took extra medications reportedly "by mistake." The partner is pretty sure that the patient was intoxicated when he multiple tablets of wellbutrin, seroquel, propranolol and klonipin but he is uncertain of specific amount. He later stated that he was not absolutely certain whether the patient actually ingested any wellbutrin and propanolol. Ultimately, the amount and combination of pills taken was unclear. The patient's longtime partner of nearly thirty years came home and found him semi-alert and called EMS immediately. . According to his partner, Mr. [**Known lastname 6418**] had been coughing/wheezing for several months now but had no complaints of fevers or chills. He had been complaining about pain in his neck since a fall down a few stairs a few days prior to this current incident. . In our ED, initial vital signs were T97.3 BP 90/54 HR 68 RR 12 oxygen saturation of 95% via NRB. He was placed on NRB for low oxygen saturations <90. He was somnolent on arrival to hospital but still responsive to tactile stimuli. Fingerstick glucose was 140 on arrival. He quickly became hypotensive to SBP 73/47. He was given IVF x3L total. EKG was normal, without any alarming ST changes. Peripheral dopamine was started for rapid BP correction and he was intubated for hypoxia and airway protection. Toxicology consult was called and they recommended that the pressor choice be switched to Levofed. He was also given narcan x2 with no effect. Once the medication history was flushed out, he was given calcium which did increase his rate from 58 to 88 and his SBP increased by 10. He was given glucagon 1mg with no further effect. Toxicology consult recommended trying high dose glucagon 5mg and if that works, starting a glucagon gtt at 1-5mg/hr. They also recommend serial EKGs for monitoring. He was also given Vancomycin and Ceftriaxone due to initial concern for possible sepsis. . He had chest xray which showed question widened mediastinum and patient reported some chest discomfort on arrival. CTA was done which showed normal aorta. FAST scan was done which showed no pericardial effusion, and no intra-abdominal bleeds. CXR/CT did show bilateral infiltrates consistent with an aspiration. Hemodynamic instability was worrisome and he was transferred to the intensive care unit for close monitoring. . On arrival to the ICU he was hypoxic with O2 saturation of 85% on FIO2 of 50%, HR in 50's. He was suctioned, ET tube pulled back 2cm and PEEP increased to 14, FIO2 to 100% with slow recovery of O2 saturation. He was continued on Levophed and an arterial line was placed for better hemodynamic monitoring. . Past Medical History: Alcoholism Hypertension Depression Social History: The patient lives in [**Location 86**] with his partner of over 30 years. He has local family but has limited contact with them. He reports that he and his partner do not work because they have enough money to allow them not to need to work. Mr. [**Known lastname 6418**] reports drinking only one glass of wine a day, yet also endorses drinking enough prior to admission that he got confused when taking his medications. Thus, history somewhat questionable. Denies illicit drug use. He reports having been sober for a stretch of 14-15 years in the past (w/ help of rehab, AA), but started drinking again about 13 years ago in the context of a few deaths in the family. Per his partner, his drinking has been much more heavy in recent months. Family History: Noncontributory. Physical Exam: INITIAL ADMISSION EXAM: vitals: BP 110/48, HR 58 regular w/occasional PVC's, RR 15 100% FIO2 100% VC 100%/500/16/14 , weight of 97kg, 70" . General: sedated, intubated, not responding to verbal commands HEENT: NC/AT, pupils pinpoint but equal and reactive bilaterally CV: Bradycardic, regular, no appreciable murmur Lungs: decreased breath sounds at right base, otherwise good air movement bilaterally Abdomen: slightly distended, BS+, no HSM, no apparent tenderness Ext: DP's palpable bilaterally, trace edema bilaterally Neuro: unable to assess [**12-26**] sedation Pertinent Results: INITIAL ADMISSION LABS [**2173-9-30**] : . PT: 12.2 PTT: 28.5 INR: 1.0 . Na 136, Cl 102, BUN 30, Cr 2.2, Glucose 129, K 4.3, HCO3 22 AGap=16 . CK: 304 MB: 4 Trop-T: <0.1 . ALT: 38 AP: 86 Tbili: 0.2 Alb: 3.9 AST: 47 LDH: 217 [**Doctor First Name **]: 51 Lip: 143 . Serum EtOH 339* Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative . Urine Benzos Pos * Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . WBC 6.4 Hgb 11.3 HCT 34.6* Plt 329 MCV 97 N:38.9 L:54.5 M:2.6 E:3.6 Bas:0.4 . ABG: 1) 7.14/59/64/21 lactate 2.2 2) 7.22/50/123/22 lactate 1 (rate increased from 16->20) . . [**2173-9-30**] GLUCOSE-69* UREA N-30* CREAT-1.5* SODIUM-137 POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-18* ANION GAP-13, CALCIUM-7.3* PHOSPHATE-3.6 MG-2.0 [**2173-9-30**] WBC-6.7 RBC-3.31* HGB-11.0* HCT-32.7* MCV-99* MCH-33.2* MCHC-33.5 RDW-13.9, PLT COUNT-234 [**2173-9-30**] 02:58PM LACTATE-0.9 [**2173-9-30**] 12:38PM OTHER BODY FLUID WBC-0 RBC-0 POLYS-40* LYMPHS-11* MONOS-12* EOS-5* OTHER-32* [**2173-9-30**] ABG on Assist-Control Vent: PEEP-5 O2-100 PO2-123* PCO2-50* PH-7.22* TOTAL CO2-22 BASE XS--7 AADO2-561 REQ O2-90-INTUBATED [**2173-9-30**] 10:22AM LACTATE-1.0 [**2173-9-30**] 08:55AM LACTATE-2.2* [**2173-9-30**] 08:55AM O2 SAT-86 [**2173-9-30**] 03:50AM ALT(SGPT)-38 AST(SGOT)-47* LD(LDH)-217 CK(CPK)-304* ALK PHOS-86 AMYLASE-51 TOT BILI-0.2 [**2173-9-30**] 03:50AM LIPASE-143* [**2173-9-30**] 03:50AM CK-MB-4 cTropnT-<0.01 [**2173-9-30**] 03:50AM ALBUMIN-3.9 [**2173-9-30**] 03:50AM TSH-3.1 . URINE STUDIES: . [**2173-9-30**] 03:50AM URINE Benzos-POS, Barbits-NEG, opiates-NEG, cocaine-NEG amphetmines-NEG, methadone-NEG. [**2173-9-30**] 03:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2173-9-30**] 03:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . MICROBIOLOGY STUDIES: URINE CULTURE (Final [**2173-10-8**]): NO GROWTH. . RAPID PLASMA REAGIN TEST (Final [**2173-10-8**]): NONREACTIVE. . Blood Culture, Routine (Final [**2173-10-13**]): NO GROWTH Blood Culture, Routine (Final [**2173-10-7**]): NO GROWTH. Blood Culture, Routine (Final [**2173-10-6**]): NO GROWTH. Blood Culture, Routine (Final [**2173-10-6**]): NO GROWTH. . BAL LEGIONELLA CULTURE (Final [**2173-10-7**]): NO LEGIONELLA ISOLATED. . Rapid Respiratory Viral Antigen Test (Final [**2173-10-1**]): Respiratory viral antigens not detected. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. . Legionella Urinary Antigen (Final [**2173-10-1**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . [**2173-9-30**] BRONCHOALVEOLAR LAVAGE RESULTS (FINAL REPORT [**2173-10-7**]) GRAM STAIN 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2173-10-3**]): 10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S . . ADDITIONAL STUDIES AND IMAGING: [**2173-9-30**] EKG: rate 60, sinus rhythm, nml axis, no ischemic ST changes, no previous tracing for comparison . [**2173-9-30**] PORTABLE CXR: The heart size is within normal limits. There is mild prominence to the superior mediastinum. There are low lung volumes. No effusion or pneumothorax is detected. Mild prominence to the superior mediastinum. Low lung volumes without radiographic evidence of pneumonia. . [**2173-9-30**] CT CHEST WITHOUT CONTRAST: Endotracheal tube tip terminates 2 cm from the carina. NG tube courses through the mediastinum with tip and side port within the stomach. No mediastinal hematoma is present. Aortic contour follows a normal course throughout the chest without irregularity or evidence to suggest rupture. Moderate to large bibasilar consolidations are noted bilaterally. No suspicious lytic or sclerotic lesions are identified. IMPRESSION: 1. Moderate to large posterior consolidations bilaterally. Given history findings are strongly suggestive of aspiration. 2. Normal aortic contour without evidence of aortic injury on this non- contrast enhanced CT. . [**2173-10-5**] HEAD CT W/O CONTRAST: There is no evidence of hemorrhage, edema, masses, mass effect, or infarction. The ventricles and sulci are normal in caliber and configuration. No fractures are identified. The patient is status post endotracheal tube intubation. There are associated nasopharyngeal secretions.IMPRESSION:1. No evidence of edema or hemorrhage. . [**2173-10-7**] EKG: Rate 86, normal sinus rhythm, modest inferior ST-T wave changes are non-specific and may be WNL. Since the previous tracing of [**2173-10-5**] sinus tachycardia is now absent. . [**2173-10-8**] CXR: Diffuse bilateral pulmonary edema has decreased. The persistent bilateral airspace opacities may represent multifocal pneumonia. The aortic arch is mildly tortuous but unchanged. The left lower chest is excluded from the field of view; other pleural surfaces are normal. No pneumothorax is present. IMPRESSION: Interval improvement in pulmonary edema. Possible persisent multifocal pneumonia. . [**2173-10-11**] TTE ECHO: The left atrium is mildly dilated. (LVEF >55%) The estimated cardiac index is normal (>=2.5L/min/m2).Normal biventricular cavity sizes with preserved global and regional biventricular systolic function.Mild pulmonary artery systolic hypertension. Mild tricuspid regurgitation with normal valve morphology. . PRE-DISCHARGE LABS: [**2173-10-12**] 07:15AM BLOOD WBC-10.0 RBC-3.15* Hgb-10.2* Hct-30.7* MCV-98 MCH-32.4* MCHC-33.2 RDW-14.3 Plt Ct-637* [**2173-10-10**] 07:25AM BLOOD Plt Ct-464* [**2173-10-12**] 07:15AM BLOOD Glucose-97 UreaN-17 Creat-1.1 Na-143 K-4.4 Cl-105 HCO3-29 AnGap-13 [**2173-10-7**] 02:36AM BLOOD Lipase-91* [**2173-10-12**] 07:15AM BLOOD Calcium-9.4 Phos-3.9 [**2173-10-11**] 07:20AM BLOOD VitB12-1034* Folate-16.3 [**2173-10-12**] 07:15AM BLOOD ALT-26 AST-25 LD(LDH)-272* CK(CPK)-136 AlkPhos-69 TotBili-0.3 Brief Hospital Course: In summary, Mr. [**Known lastname 6418**] is a 55-year old male with PMH of alcoholism and depression who presented with somnolence, bradycardia and hypotension after ETOH intoxication and "accidental" ingestion of multiple medications. He endured some initial hypoxia secondary to severe sedation and in the setting of an aspiration event as noted via imaging studies. Additional issues outlined in detail below. . #Hypoxia/SOB: - The patient presented to the ED emergently on [**2173-9-30**] with oversedation, hypoxia and systolic blood pressures that dropped to the 70s requiring emergency pressor therapy. He was placed on a high flow non-rebreather mask initially and then needed to be intubated with immediate admit to MICU for his hemodynamic instability and hypoxia. Bilateral pulmonary infiltrates were noted on CXR/CT which were felt to be secondary to aspiration pneumonitis vs aspiration PNA. Mucous plug was also in the possible differential but there were very minimal secretions on suctioning attempts. He was given Levofloxacin initially and cultures were sent off. ABG just prior to MICU admission was pH 7.14, PO2 64, pCO2 59, Bicarb 21. Upon transfer to the regular medical floor the patient was doing well with oxygen saturations 94-95% on 2L NC and RR ranging in the low 20s. Blood cultures were negative to date but broncheoalveolar lavage showed coagulase positive staphylococcus/MSSA. Ammonia level was within normal limits , LFTs were improving and there was no real concern for hepatic encephalopathy anymore. On the medical floor he was initially continued on IV Unasyn and then gradually switched over to PO Augmentin as discharge approached. He was continued on 2L NC with oxygen saturation goal >95% which he achieved without difficulty and he was gradually weaned to room air. His initial dry cough on transfer improved as well. Repeat CXRs showed improvement in pulmonary edema but very persisent multifocal pneumonia was questioned so he was continued on antibiotics. An ECHO showed no evidence of any serious valve abnormalities or vegetations and overall EF was 55%. By time of discharge he was breathing 97% room air and his cough had nearly abated. . # Hypertension/Tachycardia/Agitation: After a few days in the MICU the patient had bouts of hypertension with SBPs >170s, sweats, fevers, and tachycardia to 120-130s range. These changes were likely due to ETOH withdrawal in conjunction with benzodiazepine withdrawal and possibly related to other toxic ingestions. These dynamic changes made weaning the patient from the vent especially challenging in the MICU. He became extremely agitated when sedating medications were tapered and was unable to be extubated successfully for several days. Moreover, he appeared to have delirium from multiple medications which were still wearing off. He received a very large amount of benzodiazepines during the first three days of admission and these were ultimately discontinued for concern of toxicity. Psychiatry and the toxicology staff were consulted and he was switched to standing and PRN Haldol which had a very good outcome and helped to ease his agitation and stabilize his tachycardia. The possibility of Neuroleptic Malignant Syndrome was considered as well. Of note, the patient got some Zyprexa for agitation and he had already ingested a large amount of Seroquel during his overdose; both of these medications can cause NMS. Ck levels returned elevated but not quite in the usual range seen in NMS so this diagnosis was unlikely. It was felt that Mr. [**Known lastname 6418**]' delirium was multifactorial in the setting of recent hypoxia, ongoing sedation and polysubstance withdrawal from his ETOH/Benzodiazepines. A few doses of morphine worked well for his agitation as well. Psychiatry continued to follow the patient with the medical service once he transferred to the medical floor from the MICU. Ammonia panel and RPR were unremarkable and soon after transfer the to medical floor he was managed on lower and lower doses of Ativan and Haldol and he gradually improved with HRs returning to 60-80 range and blood pressure normalized. LFTs and CK levels also trended downwards. . #Fevers: The patient had high persistent fevers in the 101-102 range in the MICU after admission. He also had hypotension in the ED but this felt to be directly related to his overdose and ETOH intoxication versus a sepsis picture. As noted, scattered bilateral pulmonary infiltrates were noted on CXR/CT and were felt to be the source of his fevers. IV Unasyn was given. Urine and Blood cultures all returned negative. Urine legionella was negative. BAL showed coagulase positive staphylococcus on cultures so antibiotics were continued. Neuroleptic maliganant syndrome was suspected as well but CK levels trended downward making this unlikely. There was some moderate hematuria on UA repeat but this was attributed to witnessed foley manipulation during his multiple episodes of agitation as opposed to infection. An LP was considered upon transfer to the medical floor but fortunately his fevers began to lessen and after [**12-27**] days he stopped having high spikes. Ultimately, the fevers may have been a combination of his polysubstance withdrawal in combination with fevers secondary to aspiration related pneumonia. He was afebrile and had no left shifts or leukocytosis at time of discharge. . #Altered Mental Status: As aforementioned the patient presented with hypotension and bradycardia which was attributed to the combination of propranolol, seroquel and possibly Prozac/Wellbutrin per the patient's partner. On repeated questioning the patient admitted that the overdose was an accident and an unintentional act that occured in the setting of extreme ETOH intoxication. The patient still appeared very agitated, diaphoretic and confused on transfer out of MICU. Initial confusion likely secondary to receiving 500mg Diazepam over 30hrs for presumed ETOH withdrawal while in MICU. He had some intermittent autonomic hyperactivity and HTN with SBPs to 160-170s and serious inattention on exam. He also had a slight tremor in his hands bilaterally which is likely from his sedative withdrawal. The patient's partner noted that he sometimes noticed he had a mild tremor at his baseline too. Psychiatry continued to follow the patient and advised the team to continue Haldol and Ativan for his agitation. He was started on Haldol 5mg IV PRN dosing every few hours and Haldol standing 2.5mg IV q6hrs which was slowly tapered down and he was gradually weaned down from Ativan 1mg qid to 1mg t.i.d, b.i.d., and then qdaily dosing. He became very belligerent and tried to pull out his IV lines initially so soft restraints were needed along with a 1:1 sitter on his first night out of the MICU which was only a day after being extubated. He recovered quickly and became less confused and more attentive over the subsequent hospital stay and by the time of his discharge he was still plagued by some mild irritability and some amnesia surrounding his overdose and MICU stay but he was alert and oriented to person, place and time at time of his discharge. Social work and psychiatry services offered additional counseling and despite offers to set him up with specific resources he reported he was planning to make a conscious effort to try to stop drinking after discharge with support of AA and professional supports as needed. . #Acute Renal Failure -Per records, the patient's baseline creatinine 1-1.3 and he presented in the ED with an initial Cr level of 2.2 which was likely in the setting of direct nephrotoxic influence of the multiple medications he ingested as well as the renal hypoperfusion that occurred in the setting of his SBPs dropping to the 70s prompting the need for pressor support. He also had a pre-renal component which cna be explained by recent ETOH abuse and tendency for dehydration. Mr. [**Known lastname 6418**] was given IVF resuscitation and throughout his hospital stay his renal function recovered. By the time of discharge creatinine was down to 1.1 range and BUN 17. . #Hypertension: As outlined above, the patient's blood pressure was poorly controlled in the MICU with intermittent autonomic surges of tachycardia and SBP increases to the 160s-170s. He was restarted on his daily Propranolol and his blood pressures returned to 130-140s prior to discharge. . #Pancreatitis: While in the MICU, the patient had an acute rise in his Lipase levels which eventually peaked at and then continued to trend downward. The increase was possibly due to ETOH or Propofol with increased triglycerides. Abdomen somewhat firm but not tense. He tolerating tube feeds very well and then continued on a regular diet on the regular medical floor once he transferred out of the MICU. On exam he denied any abdominal pain, no guarding and no rebound noted. . #ETOH Abuse ?????? The patient's partner endorses that patient has been sober for years, and only recently ??????fell off the wagon?????? over the last few months. The extent of his withdrawal, however, suggests that his use of alcohol is potentially much more extensive. He was continued on daily Thiamine, Folate and he was seen by psychiatry as well as the addictions consult social worker. [**Name (NI) 6419**] teams counseled him on ETOH's harmful effects and several means of support were explored with the patient Ranitidine was continued for GI protection. . #Loose stools -These loose bowel movements were initially noted on [**2173-10-10**]. Follow-up stool and C.difficile labs were all unremarkable. By time of discharge his diarrhea had stopped and he denied any abdominal pain, cramps, or changes in the color of his stool. No bloody stools. . #Anemia - The patient's baseline HCT is ~40 according to recent records, and he was also noted to be borderline macrocytic therefore anemia likely secondary to nutritional deficiency in the setting of ETOH abuse. No evidence of any GI bleeding. An order to gaiac stools was placed and daily Hcts were trended. B12 and folate levels were normal. The patient will plan to follow up with his primary care physician [**Name Initial (PRE) 176**] ~ 1 week timeframe to address his anemia in more detail. . #Fluids, electrolytes and nutrition: Tolerating PO medications well, repleting electrolytes as needed, thiamine given daily. . # Access ??????The patient had a right PICC that was placed [**2173-10-3**] for access for TPN and multiple medications as well. This was eventually pulled and a regular IV was placed. . #Prophylaxis: The patient was placed on a bowel regimen, subcutaneous heparin shots were given daily for DVT prophylaxis and Ranitidine was continued for GI protection. The patient was treated as a full code for the entirety of his hospital course and communication occurred with the patient daily and with his mother and partner of nearly 30 years. The psychiatry service felt that Mr. [**Known lastname 6418**] was safe to leave the hospital but he was advised to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6420**] and his previous counselor upon leaving the hospital. . Medications on Admission: Wellbutrin 150mg daily (decreased from twice daily) Seroquel 150mg daily klonopin 1mg [**Hospital1 **] (recently decreased) propranolol 40mg [**Hospital1 **] 55/60 (started [**9-27**]) Prozac 20mg QID (recent increase in dose from TID -QID over last week) Lotral 5/20mg one daily Diclofenac sodium 100mg daily fenofibrate 134mg daily allopurinol 300mg daily tramadol 50mg [**Hospital1 **] neurontin 300mg 1-2 tabs prn melatonin 5mg qhs advil prn for migraine Discharge Disposition: Home Discharge Diagnosis: Primary: Alcoholism Overdose Depression . Secondary: Hypertension Discharge Condition: At time of discharge the patient had more stable vital signs and he appeared less anxious and confused. Discharge Instructions: It was a pleasure taking care of you here at [**Hospital1 771**] during your hospitalization. You were admitted to the hospital after consuming a large amount of alcohol mixed with multiple medications. This impaired your breathing and your mental status. You had to stay in the medical intensive care unit for a week and then you were transferred to the general medical floor. During your hospital stay you became very confused and needed additional medications and a breathing machine called a ventilator to help you breath for about a week. . You were also treated with antibiotics for a suspected lung infection. . While you were in the hospital you were seen by a psychiatrist and a social worker in order to help with the management of your depression and your additional alcohol consumption. . The psychiatry service felt that you were safe to leave the hospital but you are advised to please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6420**] and your previous counselor upon leaving the hospital. . If you have any thoughts of wanting to harm yourself or others please go to the emergency room, call 911 immediately, or contact your primary care physician. [**Name10 (NameIs) 357**] return to the emergency room if you have worsening fevers, chills, cough, productive sputum, bloody vomit, shortness of breath, chest pains or any other concerns. Please avoid using a class of medications called benzodiazepines and please avoid alcohol consumption as it may be dangerous to your health. As discussed, please consider helpful groups such as Alcoholics Anonymous which can be a very supportive social network as you try to avoid alcohol use. Followup Instructions: Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6420**] on Friday, [**10-15**] at 8:50am at [**Hospital6 **] at phone # [**Telephone/Fax (1) 5723**], and location: [**Street Address(2) 6421**], [**Location (un) 86**], [**Numeric Identifier 6422**] . Please call to make an appointment as soon as possible with your psychiatrist, Dr. [**First Name (STitle) 6423**], at [**Hospital6 **] . (phone # [**Telephone/Fax (1) 798**]). [**Last Name (un) 6424**], [**Location (un) 86**], [**Numeric Identifier 6425**] . you also have an appointment with Rheumatology: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6426**] , MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2173-10-25**] 4:00 Completed by:[**2173-10-18**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

23349, 23355

11657, 17055

344, 369

23465, 23571

4789, 11115

25328, 26160

4166, 4184

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22864, 23326

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120,849

972

Discharge summary

report

Admission Date: [**2169-1-27**] Discharge Date: [**2169-2-12**] Date of Birth: [**2090-1-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: PICC placement ERCP History of Present Illness: 79 M with a history of lung CA, interstitial lung dz on home O2 and chronic prednisone, CHF (EF 40%), prostate cancer and afib on coumadin presents with acute onset abdominal pain x 2 hours--epigastric, RUQ, no radiation. He also reports anorexia x 1 day, +rigors. no fevers. His shortness of breath is at his baseline. In the ED: Labs with [**Doctor First Name **]: 1159 Lip: 3866. Abd u/s: cholelithiasis w/o cholecystitis. Surgery consulted. ERCP fellow notified. Given 3L NS, ZOfran 4 mg IV, KPhos 30mm/500 cc, Metoprolol 25 mg. Past Medical History: HTN Atrial Fibrillation COPD lung CA s/p LUL lobectomy 20 yrs ago for squamous cell carcinoma and LLL for large cell carcinoma prostate cancer in [**2159**] treated with radiation therapy Gout Hypertension Hypoxemia from COPD, pulmonary hypertension, CHF (chronic systolic), interstitial lung disease Chronic systolic CHF AVN on rt hip Pulmonary specialist - Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 217**] PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Social History: The patient smoked two to three packs of cigarettes per day for 40 years, but stopped 13 years ago. He has a son at home requiring large amount of family care due to multiple sclerosis. Wife [**Name (NI) **] - is the health care proxy. Family History: non-contributory Physical Exam: Exam on arrival to floor from ICU VS: 96.0, BP 159/111, 76, HR 76, RR 20, 97% 3L O2 GEN: pleasant, comfortable, sitting at 45 degrees; mildly labored breaths HEENT: EOMI, watery eyes, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd,supple RESP: dry rales on R base, otherwise moving good air; no focal ronchi or wheeze CV: irregular, variable S1, no m/r/g ABD: obese, non-tender, non-distended. NABS EXT: 1+ edema b/l le SKIN: venous stasis changes NEURO: AAOx3. language garbled (adentulous) but able to speak in full stences appropriately. Able to answer questions of orientation and follow commands without difficulty. strength 5/5 upper and lower extremities Pertinent Results: [**2169-2-10**] 06:39AM BLOOD WBC-5.7 RBC-3.43* Hgb-11.3* Hct-32.8* MCV-96 MCH-33.0* MCHC-34.4 RDW-14.1 Plt Ct-284 [**2169-2-3**] 05:25AM BLOOD WBC-3.5*# RBC-3.86* Hgb-12.6* Hct-36.9* MCV-96 MCH-32.7* MCHC-34.3 RDW-13.8 Plt Ct-176 [**2169-1-27**] 07:26PM BLOOD WBC-8.2 RBC-4.17* Hgb-14.2 Hct-41.0 MCV-98 MCH-34.2* MCHC-34.7 RDW-14.9 Plt Ct-210 [**2169-1-28**] 11:39AM BLOOD WBC-12.6* RBC-3.48* Hgb-11.7* Hct-34.0* MCV-98 MCH-33.5* MCHC-34.3 RDW-14.7 Plt Ct-142* [**2169-2-12**] 05:50AM BLOOD PT-15.4* PTT-28.9 INR(PT)-1.4* [**2169-2-8**] 11:53AM BLOOD PT-20.2* INR(PT)-1.9* [**2169-1-27**] 08:26PM BLOOD PT-22.6* PTT-25.5 INR(PT)-2.2* [**2169-2-12**] 05:50AM BLOOD Glucose-119* UreaN-10 Creat-0.8 Na-145 K-3.3 Cl-109* HCO3-30 AnGap-9 [**2169-2-6**] 05:00AM BLOOD Glucose-115* UreaN-9 Creat-0.8 Na-144 K-3.0* Cl-107 HCO3-30 AnGap-10 [**2169-1-27**] 07:26PM BLOOD Glucose-196* UreaN-22* Creat-1.1 Na-144 K-3.0* Cl-104 HCO3-31 AnGap-12 [**2169-2-9**] 05:22AM BLOOD ALT-24 AST-26 AlkPhos-74 Amylase-37 TotBili-1.0 [**2169-1-27**] 07:26PM BLOOD ALT-132* AST-177* LD(LDH)-390* AlkPhos-130* Amylase-1159* TotBili-1.4 [**2169-2-12**] 05:50AM BLOOD Calcium-10.8* Phos-2.4* Mg-1.9 [**2169-2-7**] 05:42AM BLOOD Albumin-3.3* Calcium-10.6* Phos-2.4* [**2169-1-27**] 07:26PM BLOOD Albumin-4.1 Calcium-11.4* Phos-1.6*# Mg-1.7 [**2169-1-27**] 07:26PM BLOOD Triglyc-127 [**2169-2-2**] 07:44AM BLOOD TSH-1.8 [**2169-2-1**] 01:34PM BLOOD PTH-153* [**2169-2-2**] 04:25PM BLOOD Cortsol-18.3 [**2169-2-2**] 06:20PM BLOOD Type-ART pO2-68* pCO2-33* pH-7.52* calTCO2-28 Base XS-3 [**2169-2-1**] 01:34PM BLOOD VITAMIN D 25 HYDROXY Test Result Reference Range/Units VITAMIN D, 25-OH, TOTAL 7 L 20-100 NG/ML VITAMIN D, 25-OH, D3 7 NG/ML VITAMIN D, 25-OH, D2 <4 NG/ML 25-OHD3 INDICATES BOTH ENDOGENOUS PRODUCTION AND SUPPLEMENTATION. 25-OHD2 IS AN INDICATOR OF EXOGENOUS SOURCES SUCH AS DIET OR SUPPLEMENTATION. THERAPY IS BASED ON MEASUREMENT OF TOTAL 25-OHD, WITH LEVELS <20 NG/ML INDICATIVE OF VITAMIN D DEFICIENCY WHILE LEVELS BETWEEN 20 NG/ML AND 30 NG/ML SUGGEST INSUFFICIENCY. OPTIMAL LEVELS ARE >30 NG/ML. [**2169-2-7**] 01:12AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 [**2169-2-7**] 01:12AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-NEG [**2169-1-30**] 11:46AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2169-1-30**] 11:46AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2169-1-30**] 11:46AM URINE RBC-164* WBC-0 Bacteri-NONE Yeast-NONE Epi-0 BLOOD CULTURE **FINAL REPORT [**2169-2-2**]** Blood Culture, Routine (Final [**2169-2-2**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2169-1-28**]): REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6463**] [**2169-1-28**], 9:45AM. GRAM NEGATIVE ROD(S). CXR: [**2169-1-27**] No overt CHF or pneumonia. LIVER-GALLBLADDER ULTRASOUND: There are no comparisons. The liver demonstrates normal echotexture. There is no intra- or extra-hepatic biliary duct dilatation. The gallbladder contains a shadowing 8-mm gallstone. There is, however, no evidence of acute cholecystitis. The common bile duct measures 3 mm. The right kidney measures 11.1 cm and is unremarkable without evidence of hydronephrosis. IMPRESSION: Cholelithiasis without evidence of cholecystitis ECG: Cardiology Report ECG Study Date of [**2169-1-27**] 9:49:34 PM Atrial fibrillation with a rapid ventricular response. Since the previous tracing of [**2169-1-27**] the rate is slower and ST-T wave abnormalities may be less. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 0 90 [**Telephone/Fax (2) 6464**]6 NON-CONTRAST HEAD CT: No hemorrhage, mass effect, hydrocephalus, or shift of normally midline structures. No major vascular territorial infarct is apparent. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The ventricles and sulci are prominent reflecting age-related involutional change. Subcortical periventricular white matter hypodensities are seen, most consistent with chronic microvascular ischemic disease. Calcification is seen within the cavernous carotids. Mild mucosal thickening is seen within bilateral maxillary sinuses. The remainder of the visualized paranasal sinuses and mastoid air cells remain normally aerated. CTA HEAD AND NECK: The brachiocephalic trunk and the left common carotid originate from a common trunk off the aortic arch, in what is termed a bovine arch configuration, a normal variant. The right vertebral artery is diminutive compared to the left, throughout its course. While this may be due to hypoplasia, superimposed atherosclerotic stenosis cannot be excluded given the presence of calcifications at its origin. The left vertebral artery and basilar arteries are wideley patent. The basilar and posterior cerebral arteries remain patent. There is marked medial course of the common cartoid arteries, including the bifurcation and the proximal cervical internal carotid arteries. Moderate atherosclerotic narrowing is seen involving the left proximal internal carotid after the bifurcation. Both cavernous carotids show mild atherosclerotic calcification. The anterior and middle cerebral arteries are patent. No evidence of venous sinus thrombosis. The right lung apex shows diffuse ground glass opacity , which may be related to hypoventilatory change although underlying infection cannot be excluded. Right pleural effusion is present. IMPRESSION: 1. No hemorrhage. 2. Moderate atherosclerotic disease involving the left internal carotid after the bifurcation. 3.The right vertebral artery is diminutive, which may be due to hypoplasia; however, superimposed atherosclerotic stenosis cannot be excluded given the presence of calcifications at the origin. This is a preliminary report pending Curved and VR reformations. An addendum will be dictated once these are reviewed. The curved multiplanar reformations and volume rendered reformations of the carotid and vertebral arteries were reviewed. There is short segment focal stenosis of the left proximal internal carotid artery, from fibro-fatty and calcified plaques, causing 55-65% stenosis, tortuous and over a total length of aprroximately 1.5cm. The right vertebral artery is diminutive in caliber. This can be due to hypoplasia as well as superimposed atherosclerotic disease causing near complete non-visualization of a short segment at C6 level followed by faint visualization at C% and then onwards upwards. The V3 segment is again very faintly visualized. V4 segment appears well opacified. Marked medial, tortuous course of the left common, external and internal carotid arteries which needs to be kept in mind if planning interventions in this region. Right lung apex disease worsened since the CT Chest on [**2169-1-12**] can be due to superimposed infection or other causes. To correlate clinically and consider detailed evaluation with CT Chest. CT chest: IMPRESSION: 1. No intra-abdominal abscess or source of patient's bacteremia. Bowel loops are overall normal in appearance. 2. Likely chronic lung disease at the bases with more focal area of consolidation in the right lower lobe, which may reflect developing pneumonia or recent aspiration. 3. Cardiomegaly and atherosclerosis. 4. Enlarged 2.8 x 1.6-cm subcarinal lymph node. 5. Small pericardial effusion. [**2169-1-31**]: PORTABLE SUPINE CHEST, ONE VIEW: Cardiomediastinal silhouette is enlarged, accentuated by volume loss on the left and shift of the mediastinum to the left. However, there is likely mild cardiomegaly. Again noted is chronic volume loss of the left hemithorax secondary to multiple wedge resections. Since prior study, there is an interval increase in bibasilar atelectasis as well an increase in left pleural effusion. Pulmonary vascular engorgement is consistent with moderate pulmonary edema. No pneumothorax. IMPRESSION: 1. Moderate pulmonary edema. 2. Increased size of left pleural effusion, moderate in size. EEG: IMPRESSION: This is an abnormal portable EEG due to disorganized and slow rhythm, admixed with bursts of generalized mixed frequency slowing, consistent with a mild encephalopathy or excessive drowsiness. Encephalopathy suggests dysfunction of deep midline or bilateral subcortical dysfunction. Medications, metabolic disturbances and infection are among the common causes of encephalopathy. There were no areas of prominent focal slowing. There were no epileptiform features. [**2169-2-6**]: PORTABLE UPRIGHT CHEST: Patient is status post partial resection of the left lung with volume loss and leftward shift of the mediastinum. Ill-defined retrocardiac opacity is seen and may represent a combination of pleural effusion and atelectasis or infectious consolidation. There is interval resolution of pulmonary edema with chronic right basilar interstitial abnormalities identified. Prominence of pulmonary vasculature is similar in appearance from [**2168-4-14**], and may reflect pulmonary arterial hypertension. Tip of right PICC line projects over mid SVC. IMPRESSION: 1. Interval improvement of pulmonary edema. 2. Left retrocardiac opacity, which likely reflects pleural effusion and adjacent atelectasis or consolidation. ERCP: Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal. Protruding Lesions A single sessile 8mm polyp was found in the second part of the duodenum. Cold forceps biopsies were performed for histology at the duodenum. Major Papilla: A single periampullary diverticulum with large opening was found at the major papilla. Biliary Tree: The common bile duct, common hepatic duct, right and left hepatic ducts, biliary radicles and cystic duct were filled with contrast and well visualized. The course and caliber of the structures are normal with no evidence of extrinsic compression, no ductal abnormalities, and no filling defects. Pancreas: The pancreatic duct was filled with contrast in the head of the pancreas and appeared normal. Procedures: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A 15 mm balloon was pulled through the duct - no stones were found. Impression: Polyp in the second part of the duodenum (biopsy) Periampullary diverticulum Normal biliary tree Normal pancreatic duct Given h/o gallstone pancreatitis, a biliary sphincterotomy was performed. Otherwise normal ercp to third part of the duodenum Brief Hospital Course: # Acute pancreatitis: Th epatient was diagnosed with acute pancreatitis likely from hypercalcemia or gallstones. After stabilization and other medical problems (refer below) and ERCP was done with sphincterotomy. Outpatient cholecystectomy may be considered, however, given patients cardiopulmonary state that may carry some risk. Follow up with surgeon may be considered per PCP. [**Name Initial (NameIs) **] duodenal polyp was biopsied and results pending at this timke. Will defer to PCP for follow up. The hospital course was complicated by the following issues: # Delirium: Resolved. Multifatorial from the hypercalcemia, infection, meds given peri-procedure etc. He transiently needed sitter, haloperidol. Eventually as the medical problems resolved, patient returned to [**Location 213**] mentation and was at baseline at discharge. # Hypercalcemia: was noted. On work up and endocrine evaluation, it was thought to be likely from primary hyperparathyroidism. Calcium levels were high but stable. Low phos levels as well. He was treated with lasix and IVF initially. Eventually, he was started on low dose lasix [**2169-2-7**] + oral KCl (has low K while on lasix). Follow up with endocrinology is arranged. US neck may be considered at that time. He was also Vitamin D deficiency: Per Dr [**Last Name (STitle) 818**], endocrine fellow - plan is not to replace vitamin D at this time for risk of increasing Calcium levels. They may consider it out-pt. # Hospital acquired Pneumonia: Swallow evaluation is as per OMR note. Instructions given to patient. He hasc ompleted a course of levofloxacin. On home O2. Follows up with pulmonary clinic. An enlarged lymphnode was seen on imaging whic could be reactive from infection but given h/o lung cancer, a follow up CT is recommended to assess resolution in [**2-17**] months. Will defer to PCP to arrange this. # E coli septicemia: th esource was likely biliary. Surveillance cultures negative. He has completed a course of levofloxacin. Remained afebrile. # Hypoxemia: Multifactorial from baseline COPD, pulmonary HTN, CHF, ILD. Resolving on CXR dated [**2169-2-6**]. - low dose lasix, keep on home O2, follow with Dr [**Last Name (STitle) 217**] in pulmonary. # Possible TIA: He had an acute change in responsiveness and speech in ICU and neurology was consulted. CT head did not show bleeding or acute CVA. EEG and CT neck as above. The symptoms resolved. Per neurology, could have been a TIA, and warfarin was continued. It was transiently stopped during the ERCP. Warfarin restarted [**2169-2-10**] and VNA arranged for INR checks at home, results of INR will be forwarded to PCP. # A fib: HR well controlled on metoprolol and warfarin for CVA prophylaxis. INR as above. # Lisinopril and amlodipine were stopped since his BP was well controlled on metoprolol. It is possible he may need these reintroduced at some point. He was eventually discharged home with services per PT, home O2, INR checks, nursing. His wife and nephew [**Name (NI) **] [**Telephone/Fax (1) 6465**] were the main contacts. Medications on Admission: ADVAIR DISKUS 500-50MCG [**Hospital1 **] ALLOPURINOL 100MG Tablet 2 BY MOUTH TWICE A DAY Furosemide 60 mg [**Hospital1 **] M/W/F, 60 mg daily on T/Th/Sat/Sun Lisinopril 80 mg daily Metoprolol Tartrate 25 mg Tablet [**Hospital1 **] NORVASC 10 mg daily POTASSIUM CHLORIDE 20MEQ Tab Sust.Rel. daily Prednisone 10 mg Tablet daily WARFARIN 5 MG TABLET Discharge Medications: 1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (). Disp:*3 Disk with Device(s)* Refills:*0* 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*3 inhalers* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Delirium Hypercalcemia likely from primary hyperparathyroidism Vitamin D deficiency Hospital acquired pneumonia E coli Septicemia Hypoxemia from COPD, pulmonary hypertension, CHF (chronic systolic), interstitial lung disease. Acute pancreatitis, gallstone Possible TIA Atrial fibrillation Lymph node on CT chest Discharge Condition: Stable. Discharge Instructions: Return to the hospital if you develop any fevers, chills, abdominal pain, nausea, vomiting, shortness of breath or any other symptoms of concern to you. Keep your appointments. Take the medications as stated. As you know, you are on the warfarin (coumadin) and it is very important that the INR levels be monitored closely. Visiting nurse will be checking your INR levels and send results to Dr [**Last Name (STitle) **] - your primary doctor so he can monitor the level. Physical therapy is also arranged for you at home. Continue to use the oxygen at home at all times. You are scheduled to see the endocrinologist for the high calcium levels and further work up for that. Biopsy done during the ERCP procedure last week is pending at this time. Please discuss with your primary doctor and he can look up the results in a 1 week. It is recommended by our swallow therapist that you adhere to a diet of thin liquids and soft consistency solids. The medications you were on have been changed (either stopped or dose changed). Please refer to the new discharge medication list and take medications as instructed. Followup Instructions: Primary care doctor: [**Last Name (LF) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 1579**] on [**2169-2-16**] at 10AM Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB) Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2169-2-27**] 9:50 Endocrinology: Appointment with Drs [**Last Name (STitle) **], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6466**] / Dr [**Last Name (STitle) 6467**] [**Telephone/Fax (1) 6468**] [**2169-2-27**] at 11AM. ([**Hospital Ward Name 23**] 7) Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6469**] Phone:[**Telephone/Fax (1) 4832**] Date/Time:[**2169-2-16**] 8:30 Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6469**] Phone:[**Telephone/Fax (1) 4832**] Date/Time:[**2169-2-23**] 8:30 Pulmonary: [**Last Name (LF) **],[**First Name3 (LF) **]. Please keep your appointments with the pulmonary clinic

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icd9cm

[ [ [] ] ]

[ "45.14", "38.93", "51.85" ]

icd9pcs

[ [ [] ] ]

18568, 18626

14005, 17072

330, 352

18982, 18992

2528, 7165

20159, 21141

1763, 1781

17469, 18545

18647, 18961

17098, 17446

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1796, 2509

276, 292

380, 917

7174, 13982

939, 1492

1508, 1747

70,902

175,646

10006

Discharge summary

report

Admission Date: [**2120-6-27**] Discharge Date: [**2120-6-29**] Date of Birth: [**2077-6-11**] Sex: M Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 5606**] Chief Complaint: Clonidine Overdose Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 33469**] is a 43 y/o M with a h/o bipolar and multiple hospitalizations for suicidal ideation/suicide attempts who presents after being found down by EMS today outside the [**Location (un) 86**] Public Library. He was discharged from [**Hospital 1680**] Hospital after a psychiatric stay the morning of the overdose. He admits to taking 50, 0.1mg between noon and 6pm and then taking 10 more of the 0.1mg pills at approximately 8pm, along with two shots of liquor sometime throughout the day, he admits that this was a suicide attempt. He was found with a bottle of ibuprofen, carbamazepine and clonidine. . In the ED, initial vs were: HR 64, BP 152/110, RR 12, 97% on RA and was complaining of a dry throat. He was initially naloxone 2mg x 1 for his bradycardia, toxicology was consulted who recommended using naloxone and pressors if needed should he become hypotensive, repeat electrolyte checks in case he had other co-ingestions, along with an ICU admission for monitoring should he have late hypotension and bradycardia. In the ER his labs were notable for an alcohol level of 20 otherwise negative serum tox, glucose of 109, negative urine tox screen and a U/A with 8 WBC's, small leuks and trace protein. His EKG was sinus bradycardia at 57bpm. His VS on transfer were: 72, 183/132, 16, 100% on 2LNC. . In the ICU initial VS were: 57, 151/101, 15, 99% on RA. He is currently complaining of wanting to have his oxygen off, otherwise when asked about his suicide attempt, he admits that it was a suicide attempt but does not want to discuss many details. Currently feels well, denies any CP, SOB, nausea has resolved, no abdominal pain. 10 ROS is otherwise negative. Past Medical History: Bipolar disorder with multiple admissions to psychiatric facilities for suicide attempts Splenectomy status post motorcycle accident; pt states that he is up to date on immunizations Social History: Homeless, admits to alcohol use when suicidal, denies other current coingestions. No cigarettes or IVDU. Family History: No neoplasm. Physical Exam: Physical Exam: Vitals: T: 36.1 BP: 130/85 P: 57 R: 19 O2: 100% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, 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 Rectal: No prostatitis Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2120-6-27**] 10:05PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2120-6-27**] 08:45PM ASA-NEG ETHANOL-20* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2120-6-27**] 10:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2120-6-27**] 10:05PM URINE RBC-1 WBC-8* BACTERIA-NONE YEAST-NONE EPI-0 [**2120-6-27**] 10:05PM URINE HYALINE-4* [**2120-6-27**] 10:05PM URINE MUCOUS-MOD [**2120-6-27**] 08:45PM GLUCOSE-123* UREA N-17 CREAT-1.1 SODIUM-140 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17 [**2120-6-27**] 08:50PM GLUCOSE-109* K+-4.3 [**2120-6-27**] 08:45PM WBC-8.6 RBC-4.49* HGB-14.4 HCT-42.3 MCV-94 MCH-32.0 MCHC-34.0 RDW-14.8 [**2120-6-27**] 08:45PM NEUTS-57.5 LYMPHS-31.1 MONOS-7.5 EOS-2.2 BASOS-1.6 [**2120-6-27**] 08:45PM PLT COUNT-269 . Microbiology: urine culture ([**6-28**]):negative . Imaging: CXR ([**6-28**]): IMPRESSION: Multiple prior healed rib fractures are seen on the left side. A small focal opacity in the left lung base near costophrenic angle may be either intraparenchymal or could be due to a callus formation from old rib fractures. Repeat PA and lateral radiograph may be performed for further differentiation. Otherwise, lungs are clear without effusion/pneumothorax. Heart size is top normal. Mediastinal and hilar contours are normal . EKG: sinus bradycardia at 57 bpm Brief Hospital Course: Mr. [**Known lastname 33469**] is a 43 y/o M with a h/o bipolar d/o who presents after a suicide attempt from a clonidine overdose. . #) Clonidine Overdose: The patient reported on presentation to the ED that he took 60 pills of clonidine 0.1mg in a suicide attempt; he is no longer suicidal. The toxicology team was consulted and recommended treating hypotension with naloxone and use pressors as necessary. Initial effects of clonidine overdose can include hypertension, especially in patients who also receive naloxone. Later effects include hypotension, bradycardia, CNS depression, respiratory depression and miosis. The patient received a dose of naloxone in the ED, but needed no further therapy once transferred to the ICU. He was monitored in the ICU for a day with no sign of paroxysmal hypertension or hypotension. He was not bradycardic and had no sign of respiratory depression. There were no EKG changes. A chest X-ray to check for aspiration was negative. After observation during the day, he was transferred to the medical floor for further therapy. . #) Bipolar Disorder/Suicide Attempt: The patient has had multiple hospitalizations and suicide attempts in the past, and currently admits to being very depressed. On admission he was unable to articulate many details about his care or medications, but during the first day became more alert and was able to discuss his mood with the psychiatry team. Given his recent history of relapse and serious suicide attempt, it was determined he required admission to a locked psychiatric unit. He was placed on 1:1 observation during his stay for safety and a section 12 was filed. The patient signed a release for records from his [**Hospital1 1680**] hospitalization; these records are pending. He was continued on Tegretol for his bipolar disorder. . #) Pyuria: On admission the patient was found to have signs of infection on urinalysis. Rectal exam revealed no clinical evidence for prostatitis. Antibiotics were held in the absence of symptoms or positive cultures. Final culture was negative. #) TMJ - chronic jaw pain; continued on ibuprofen. #)ID - patient had a positive MRSA screen and was placed on contact precautions. # FEN: regular diet # Prophylaxis: Subcutaneous heparin; 1:1 sitter for safety # Access: peripherals # Communication: Patient # Code: Full # Disposition: Psych bed Medications on Admission: Tegretol 400mg [**Hospital1 **] clonidine 0.1mg TID ibuprofen 600mg TID prn pain Discharge Medications: 1. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. Discharge Disposition: Home Discharge Diagnosis: Suicide attempt with clonidine ingestion Discharge Condition: Stable for transfer to psych facility Discharge Instructions: Continue to take your medications as directed by the psychiatrists Please notify your doctors if [**Name5 (PTitle) **] develop any change to your usual headache, or any dizziness, lightheadedness, or pain Followup Instructions: As per the psychiatry team

[ "V62.84", "972.6", "524.60", "791.9", "303.90", "296.80", "427.89", "V60.0", "E950.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7282, 7288

4479, 6852

321, 327

7372, 7411

3000, 3000

7664, 7693

2407, 2421

6984, 7259

7309, 7351

6878, 6961

7435, 7641

2451, 2981

262, 283

355, 2061

3016, 4456

2083, 2267

2283, 2391

69,395

199,125

53774

Discharge summary

report

Admission Date: [**2115-5-19**] Discharge Date: [**2115-5-29**] Date of Birth: [**2072-1-22**] Sex: M Service: SURGERY Allergies: lansoprazole / Zolpidem Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2115-5-21**] Closed Reduction right subcondylar Mandible Fracture History of Present Illness: 43yo man with h/o alcoholism and withdrawal seizures who reports a seizure this morning with a fall. He was brought to OSH where he received a head CT that showed a 6mm parafalcine SDH without midline shift. Other injury included left nasal bone fracture. He was medflighted to [**Hospital1 18**] for further care. Past Medical History: EtOH abuse, HTN, Anxiety, Depression, Scabies/Lice Family History: Noncontributory Physical Exam: Upon presentation to [**Hospital1 18**]: PE: 83, 150/85, 13, 95% RA NAD, in c-collar Alert and oriented to person and date but not place (knows [**Location (un) **] but not where in [**Location (un) **]) No lac's on head. Impressive left facial swelling and ecchymoses. No battle's sign No CSF leakage from ears. Tympanic membranes intact No rhinorrhea, no septal hemtoma EOMI. PERRL. CN's [**3-3**] intact No pronator drift. Able to perform [**Doctor First Name 6361**] and finger-nose-finger 5/5 strength throughout bilateral UE's. SILT r/m/u nerve distributions. [**5-25**] hip flexion, knee flex/ext and ankle dorsi/plantar flexion. Minimal toe flexion/ext which is baseline per pt (neuropathy). Decreased sensation in bilateral feet. Pertinent Results: [**2115-5-19**] 04:30PM GLUCOSE-104* UREA N-8 CREAT-0.6 SODIUM-134 POTASSIUM-3.7 CHLORIDE-90* TOTAL CO2-23 ANION GAP-25* [**2115-5-19**] 04:30PM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-1.5* [**2115-5-19**] 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2115-5-19**] 04:30PM WBC-7.6 RBC-3.92* HGB-12.9* HCT-40.3 MCV-103* MCH-33.0* MCHC-32.1 RDW-13.0 [**2115-5-19**] 04:30PM PLT COUNT-106* [**2115-5-19**] 04:30PM PT-10.9 PTT-30.5 INR(PT)-1.0 IMAGING: [**5-19**]: CT head: parafalcine subdural hematoma 6mm [**5-19**]: CT sinus: Right mandible fracture dislocation [**5-19**]: CT Cspine: No evidence of of cervical spine fracture. Fracture of the right mandibular condylar process with dislocation of the right mandibular condyle. [**5-21**]: Mandible: Right mandibular condylar process fracture. CT is recommended for further evaluation. [**5-21**]: MRI C-spine: There is no evidence of acute cervical fracture or malalignment. The signal intensity throughout the cervical spinal cord is normal with no evidence of focal or diffuse lesions. [**5-23**]: ET tube tip is 6.7 cm above the carina. NG tube tip is out of view below the diaphragm. There are low lung volumes. Bibasilar opacities consistent with atelectasis have improved. There is no evident pneumothorax or pleural effusion. Cardiac size is top normal. Brief Hospital Course: He was admitted to the Acute Care Surgery team and transferred to the Trauma ICU for close monitoring. He was placed on CIWA protocol given his alcohol use history but continued to have withdrawal symptoms including seizures. Neurology was consulted for concern that his seizures may not be related to his alcohol withdrawal and adjustments to anti seizure prophylaxis was made. Neurosurgery was consulted for the subdural hemorrhage; serial exams were followed and clinically he did not show any signs of worsening hemorrhage. His neurological status remained stable with no progression of his SDH. He eventually was stable to go for reduction of his right mandibular fracture on [**2115-5-21**] after no c-spine injury was determined on an MRI. Nasotracheal intubation was attempted in the ICU without success and oral tracheal intubation was performed for the operation. He remained intubated following his right mandibular reduction without wiring secondary to persistent agitation and inability to protect his own airway as well as concern for extensive pharyngeal edema. He was finally extubated on POD 4 without complications and remained stable during the rest of his time in the ICU on a CIWA scale for his persistent withdrawal symptoms. Indomethacin was started on POD 1 for concern of a gout flare of his right foot and was stopped on POD 4 when he had significant improvement in his right foot. He was transferred to the floor on POD 5 with improved control of his withdrawal symptoms with Ativan and the addition of clonidine. He underwent further repair of his right mandibular fracture with wiring performed on [**2115-5-26**]. At the time of transfer out-of-the-ICU to the floor, his mental status was stable with a GCS 15, alert and oriented but remained on a CIWA scale. He had no cardiovascular issues. His respiratory status was stable with no concern for airway compromise. He had been advanced to a pureed diet, which he was tolerating. His course on the regular nursing unit continued to progress slowly primarily limited by intermittent agitation and pain control issues. He required several adjustments in his pain medications and is currently on oral narcotics in liquid form. He continued on his Ativan per CIWA protocol for about 9 days and was changed to prn Ativan for anxiety issues; his Clonidine was increased as well to help stabilize any agitation. His Neurontin that he reported as taking at home for neuropathy was restarted at a slightly lower dose given his creatinine clearance. He was evaluated by Physical and Occupational therapy and initally was recommended for rehab but after a few more sessions with Physical therapy he was cleared for discharge to home. He will require follow up in Neurosurgery and OMFS clinics after discharge - appointments were made prior to his discharge. Medications on Admission: Neurontin 900''' Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day). Disp:*qs ML's* Refills:*2* 2. Milk of Magnesia 400 mg/5 mL Suspension Sig: Ten (10) ML's PO twice a day as needed for constipation. 3. oxycodone 5 mg/5 mL Solution Sig: [**6-4**] ML's PO every [**4-26**] hours as needed for pain. Disp:*350 ML's* Refills:*0* 4. gabapentin 250 mg/5 mL Solution Sig: Six Hundred (600) MG PO Q8H (every 8 hours). Disp:*qs ML's* Refills:*2* 5. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). Disp:*750 ML's* Refills:*2* 6. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day: Take 1 tablet 2x/day for 3 days then 1 tablet 1x/day for 3 days then stop after last dose. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p Fall Injuries: 1. Parafalcine subdural hemorrhage 2. Right mandibular dislocation/fracture 3. Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital following afall felt secondary to seizure activity related to your alcohol use. You sustained a bleeding injury to your brain and currently being treated with an anti-seizure medications called Keppra which will continue until [**2115-5-30**]. You will then need to come back to see the Neurosurgeon in approximately 4 weeks for a repeat head CT scan (this appointment will be made for you). You also sustained a broken jaw which required an operation to repair and your jaw is wired shut. You will need to also follow up withthe Oral surgeons in clinic to have the wires removed from your jaw. It is very important that you refrain from drinking alcohol while you are healing from your injuries and also if you are taking narcotics you should avoid alcohol. Stool softeners and laxatives are also being recommended in order to prevent constipation. Postoperative instructions following jaw surgery Wound care: Do not disturb or probe the surgical area with any objects. The sutures placed in your mouth are usually the type that self dissolve. If you have any sutures on the skin of your face or neck, your surgeon will remove them on the day of your first follow up appointment. SMOKING is detrimental to healing and will cause complications. Bleeding: Intermittent bleeding or oozing overnight is normal. Placing fresh gauze over the area and biting on the gauze for 30-45 minutes at a time may control the bleeding. If you had nasal surgery, you may have occasional slow oozing from your nostril for the first 2-3 days. Bleeding should never be severe. If bleeding persists or is severe or uncontrollable, please call our office immediately. If it is after normal business hours, please come to the emergency room and request that the oral surgery resident on call be paged. Healing: Normal healing after oral surgery should be as follows: the first 2-3 days after surgery, are generally the most uncomfortable and there is usually significant swelling. After the first week, you should be more comfortable. The remainder of your postoperative course should be gradual, steady improvement. If you do not see continued improvement, please call our office. Physical activity: It is recommended that you not perform any strenuous physical activity for a few weeks after surgery. Do not lift any heavy loads and avoid physical sports unless you obtain permission from your surgeon. Swelling & Ice applications: Swelling is often associated with surgery. Swelling can be minimized by using a cold pack, ice bag or a bag of frozen peas wrapped in a towel, with firm application to face and neck areas. This should be applied 20 minutes on and 20 minutes off during the first 2-3 days after surgery. If you have been given medicine to control the swelling, be sure to take it as directed. Hot applications: Starting on the 3rd or 4th day after surgery, you may apply warm compresses to the skin over the areas of swelling (hot water bottle wrapped in a towel, etc), for 20 minutes on and 20 min off to help soothe tender areas and help to decrease swelling and stiffness. Please use caution when applying ice or heat to your face as certain areas may feel numb after surgery and extremes of temperature may cause serious damage. Tooth brushing: Begin your normal oral hygiene the day after surgery. Soreness and swelling may nor permit vigorous brushing, but please make every effort to clean your teeth with the bounds of comfort. Any toothpaste is acceptable. Please remember that your gums may be numb after surgery. To avoid injury to the gums during brushing, use a child size toothbrush and brush in front of a mirror staying only on teeth. Mouth rinses: Keeping your mouth clean after surgery is essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass of warm water and gently rinse with portions of the solution, taking 5 min to use the entire glassful. Repeat as often as you like, but you should do this at least 4 times each day. If your surgeon has prescribed a specific rinse, use as directed. Showering: You may shower 1-2 days after surgery, but please ask your surgeon about this. If you have any incisions on the skin of your face or body, you should cover them with a water resistant dressing while showering. DO NOT SOAK SURGICAL SITES. This will avoid getting the area excessively wet. As you may physically feel weak after surgery, initially avoid extreme hot or cold showers, as these may cause some patients to pass out. Also it is a good idea to make sure someone is available to assist you in case if you may need help. Sleeping: Please keep your head elevated while sleeping. This will minimize swelling and discomfort and reduce pain while allowing you to breathe more easily. One or two pillows may be placed beneath your mattress at the head of the bed to prop the bed into a more vertical position. Pain: Most facial and jaw reconstructive surgery is accompanied by some degree of discomfort. You will usually have a prescription for pain medication. Some patients find that stronger pain medications cause nausea, but if you precede each pain pill with a small amount of food, chances of nausea will be reduced. The effects of pain medications vary widely among individuals. If you do not achieve adequate pain relief at first you may supplement each pain pill with an analgesic such as Tylenol or Motrin. If you find that you are taking large amounts of pain medications at frequent intervals, please call our office. If your jaws are wired shut with elastics, you may have been prescribed liquid pain medications. Please remember to rinse your mouth after taking liquid pain medications as they can stick to the braces and can cause gum disease and damage teeth. Diet: Unless otherwise instructed, only a cool, clear liquid diet is allowed for the first 24 hours after surgery. After 48 hours, you can increase to a full liquid diet, but please check with your doctor before doing this. Avoid extreme hot and cold. If your jaws are not wired shut, then after one week, you may be able to gradually progress to a soft diet, but ONLY if your surgeon instructs you to do so. It is important not to skip any meals. If you take nourishment regularly you will feel better, gain strength, have less discomfort and heal faster. Over the counter meal supplements are helpful to support nutritional needs in the first few days after surgery. A nutrition guidebook will be given to you before you are discharged from the hospital. Remember to rinse your mouth after any food intake, failure to do this may cause infections and gum disease and possible loss of teeth. Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes pain medications are the cause. Precede each pill with a small amount of soft food. Taking pain pills with a large glass of water can also reduce nausea. Try taking clear fluids and minimizing taking pain medications, but call us if you do not feel better. If your jaws are wired shut with elastics and you experience nausea/vomiting, try tilting your head and neck to one side. This will allow the vomitus to drain out of your mouth. If you feel that you cannot safely expel the vomitus in this manner, you can cut elastics/wires and open your mouth. Inform our office immediately if you elect to do this. If it is after normal business hours, please come to the emergency room at once, and have the oral surgery on call resident paged. Graft Instructions: If you have had a bone graft or soft tissue graft procedure, the site where the graft was taken from (rib, head, mouth, skin, clavicle, hip etc) may require additional precautions. Depending on the site of the graft harvest, your surgeon will [**Month/Day/Year 8146**] you regarding specific instructions for the care of that area. If you had a bone graft taken from your hip, we encourage you to ambulate on the day of surgery with assistance. It is important to start slowly and hold onto stable structures while walking. As you progressively increase your ambulation, the discomfort will gradually diminish. If you have any problems with urination or with bowel movements, call our office immediately. Elastics: Depending on the type of surgery, you may have elastics and/or wires placed on your braces. Before discharge from the hospital, the doctor [**First Name (Titles) **] [**Last Name (Titles) 8146**] you regarding these wires/elastics. If for any reason, the elastics or wires break, or if you feel your bite is shifting, please call our office. Followup Instructions: Where:[**Hospital6 **] at Yawkey Bldg ACC5 With: The Oral and Maxillofascial Surgery Clinic When: Friday [**2115-6-7**] at 10:00 am Phone: [**Telephone/Fax (1) 68463**] Department: RADIOLOGY When: THURSDAY [**2115-6-27**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2115-6-27**] at 11:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2115-5-29**]

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icd9cm

[ [ [] ] ]

[ "93.55", "96.71", "96.6", "76.75" ]

icd9pcs

[ [ [] ] ]

6674, 6680

2975, 5816

292, 363

6831, 6831

1590, 2099

15533, 16252

798, 815

5884, 6651

6701, 6810

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244, 254

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391, 707

2108, 2952

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730, 782

31,692

174,449

19350

Discharge summary

report

Admission Date: [**2186-3-10**] Discharge Date: [**2186-4-13**] Date of Birth: [**2130-11-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 55 yo man w/ h/o end-stage sarcoid dx on home O2 (3L NC) no longer on xplant list, on home O2, who p/w SOB, f/c x 5 days. Pt was in his USOH until 5 days ago when noted increased SOB, dry cough. Called PCPs office on [**3-8**], who directed him to go to ED, but pt waited as is having financial problems at home and wanted to wait to work out some things before coming to ED. Pt had self-titrated up O2 to 4L. Also states felt like he had a fever o/n, but did not take temp. Today pt was seen at home by OT who noted that he had decreased O2 sats to 85-90% on 4L O2. OT called PCPs office who instructed them to call ambulance. Pt initially presented to [**Hospital3 **] where initial vitals noted to be T 98.8, HR 81, BP 132/68, RR 18, O2 91% 4L NC. Labs notable for slightly elevated WBC at 10.4. CXR there demonstrated ?new infiltrate, although difficult to assess given underlying lung dx. Pt was given rocephin 1gm x 1, azithro 500mg x 1, and transferred to [**Hospital1 18**]. In ED initial vitals T 97.4, HR 104, BP 115/82, RR 20, O2 91% 4L NC. Pt admitted for further management. Currently pt c/o continued SOB, cough, no other complaints at this time. Past Medical History: 1. Hepatitis C, diagnosed as part of the lung transplant workup at the [**Hospital1 756**]. He is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in GI. He is hepatitis B core surface antibody positive and surface antigen negative. In addition, he has hepatitis C antibody plus type 2b with a viral load in [**8-/2185**], of 5.5 million. He had grade 2 fibrosis on [**2184-4-28**]. He is not thought to be a candidate currently for interferon treatment given his sarcoidosis. He has transaminitis. 2. Sarcoidosis. He is followed by Dr. [**Last Name (STitle) 2168**]. The patient has been obtaining PFTs from Dr. [**Last Name (STitle) **], and he is currently on azathioprine and prednisone with prophylaxis Bactrim. 3. Sleep apnea. 4. Erectile dysfunction. 5. Emotional lability and anxiety. 6. Status post mandible fracture [**8-20**]. 7. Status post multiple rib and clavicle fractures over the past year secondary to fall. 8. Spinal stenosis: diagnosed on MRI and is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], [**First Name3 (LF) **] orthopedic physician at the [**Hospital1 18**]. The diagnosis was established as part of a workup for progressive lower leg weakness, which led to multiple falls and currently an inability to ambulate. 9. Shingles in [**12/2184**] on the right side of the face with residual neuropathic pain. Social History: Lives in an apartment in [**Location (un) 1459**] with his 27 yo daughter who is s/p traumatic brain injury in a motor vehicle accident. Has another daughter from whom he is estranged. Recently divorced from his wife of 33 years who he says did "not want to take care of him." Patient is a former food salesman, selling restaurant supplies to pizzerias. Has been unemployed for about a year, no longer on unemployment. Recently obtained some disability benefits. Reports a 10 pack year smoking history, but quit 20 years ago. Reports no history of ethanol use or IV drug use. Pt had previous admission in which he was on high doses of methadone and benzodiazepenes that were verified by PCP to be prescribed by an outpatient physician to treat his pain from spinal stenosis; pt believed to withdraw from both on previous admissions. Family History: Non contributory of pulmonary disease. Physical Exam: Admission Vitals - T 97.9, HR 97, BP 121/70, RR 25, O2 86% --> 94% 4L NC Gen - awake, alert, eating [**Location (un) 6002**], tachypnic slightly, speaking in full sentences CVS - RRR no noted m/r/g Lungs - mild decreased BS diffusely but overall fairly good air movement w/ no noted crackles, + mild wheezing Abd - soft, NT/ND Ext - trace LE edema b/l . Discharge Vitals - T 97.9, HR 97, BP 126/86, RR 18, O2 98%6L with facemask mist supplementation Gen - awake, alert, comfortable, speaking in full sentences CVS - RRR no noted m/r/g Lungs - mild decreased BS diffusely but overall fairly good air movement w/ no noted crackles, + mild expiratory wheezes at bases, no increased work of breathing Abd - soft, NT/ND Ext - trace LE edema b/l, + mild right forearm edema Pertinent Results: CXR [**2186-3-11**]:Extensive pulmonary fibrosis and architectural distortion, presumably due to the provided history of sarcoid although basilar predominance is atypical. No findings to suggest an acute superimposed pneumonia, but subtle infection could be easily obscured by the chronic lung disease. . CXR [**2186-4-6**]: Today's study demonstrates fracture displacement of the right seventh rib laterally, other lower fractures were demonstrated along the lateral chest wall on the 9:27 a.m. film. Severe pulmonary fibrosis and marked emphysema are longstanding. There is no evidence of acute pulmonary changes though subtle findings would be missed. No appreciable pleural effusion is seen. Heart size is normal. No pneumothorax. . CT Chest [**2186-3-14**] 1. No evidence of pneumonia or other acute cardiopulmonary process. 2. Chronic severe pulmonary fibrosis, could be end- stage sarcoidosis. Chronic pulmonary hypertension. 3. Previous right upper lobe infection resolved. 4. Possible small right upper lobe mycetoma. 5. New left lower lobe 3.5 mm lung nodule warrants [**5-25**] month CT followup. . CT abd: 1. Bilateral rectus sheath hematomas as described above. Small amount of blood in the fat-containing right inguinal hernia. 2. No evidence of retroperitoneal hematoma. 3. Changes in the lung bases, incompletely evaluated, are consistent with the patient's history of sarcoid. 4. Healing bilateral rib fractures. 5. Abdominal aortic ectasia as above up to 2.8 cm. 6. Nonobstructing left nephrolithiasis. . CT Chest [**2186-4-6**]: 1. Small PE of segmental/subsegmental right upper lobe branch. This was communicated by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 24949**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3766**] by telephone in the AM on [**2186-4-10**]. 2. New minimally displaced fracture of the lateral right ninth rib. Multiple additional bilateral healing rib fractures. 3. Healing left distal clavicle fracture. 3. Resolution of right upper lobe pneumonia. 4. Chronic severe pulmonary fibrosis in the setting of sarcoidosis. . LE U/S:No evidence of DVT in either extremity. . CBC [**2186-3-11**] 05:15AM BLOOD WBC-9.2 RBC-3.74* Hgb-13.2* Hct-39.3* MCV-105* MCH-35.4* MCHC-33.6 RDW-15.3 Plt Ct-259 [**2186-3-13**] 04:40AM BLOOD WBC-10.6 RBC-3.70* Hgb-13.0* Hct-39.3* MCV-106* MCH-35.3* MCHC-33.2 RDW-15.9* Plt Ct-294 [**2186-3-14**] 04:40AM BLOOD WBC-12.0* RBC-3.53* Hgb-12.4* Hct-36.9* MCV-105* MCH-35.1* MCHC-33.6 RDW-15.4 Plt Ct-269 [**2186-3-19**] 05:11AM BLOOD WBC-10.1 RBC-3.72* Hgb-13.1* Hct-39.9* MCV-107* MCH-35.1* MCHC-32.7 RDW-16.1* Plt Ct-232 [**2186-3-21**] 04:40AM BLOOD WBC-11.3* RBC-3.71* Hgb-13.1* Hct-39.9* MCV-108* MCH-35.4* MCHC-32.9 RDW-16.2* Plt Ct-298 [**2186-3-23**] 07:30AM BLOOD WBC-11.0 RBC-3.56* Hgb-12.4* Hct-38.6* MCV-108* MCH-34.9* MCHC-32.3 RDW-16.2* Plt Ct-297 [**2186-3-25**] 06:22AM BLOOD WBC-10.8 RBC-3.40* Hgb-12.0* Hct-36.4* MCV-107* MCH-35.4* MCHC-33.1 RDW-16.3* Plt Ct-282 [**2186-3-28**] 03:58PM BLOOD Hct-32.0* [**2186-3-31**] 07:55AM BLOOD WBC-10.6 RBC-2.86* Hgb-10.0* Hct-31.1* MCV-109* MCH-35.1* MCHC-32.2 RDW-16.9* Plt Ct-361 [**2186-4-2**] 06:03AM BLOOD WBC-11.1* RBC-2.91* Hgb-10.3* Hct-32.3* MCV-111* MCH-35.2* MCHC-31.8 RDW-17.1* Plt Ct-320 [**2186-4-5**] 05:54AM BLOOD WBC-15.2* RBC-3.26* Hgb-11.6* Hct-36.2* MCV-111* MCH-35.5* MCHC-32.0 RDW-16.5* Plt Ct-367 [**2186-4-9**] 05:42AM BLOOD WBC-9.6 RBC-3.10* Hgb-11.1* Hct-33.9* MCV-109* MCH-35.8* MCHC-32.8 RDW-16.2* Plt Ct-259 [**2186-4-10**] 04:08AM BLOOD WBC-8.6 RBC-3.18* Hgb-11.2* Hct-34.7* MCV-109* MCH-35.1* MCHC-32.1 RDW-16.3* Plt Ct-277 [**2186-4-11**] 05:35AM BLOOD WBC-7.7 RBC-3.18* Hgb-11.2* Hct-34.7* MCV-109* MCH-35.3* MCHC-32.4 RDW-16.3* Plt Ct-290 . Chem 7 [**2186-3-11**] 05:15AM BLOOD Glucose-243* UreaN-16 Creat-0.5 Na-138 K-4.9 Cl-101 HCO3-28 AnGap-14 [**2186-3-13**] 04:40AM BLOOD Glucose-222* UreaN-20 Creat-0.5 Na-141 K-3.9 Cl-105 HCO3-27 AnGap-13 [**2186-3-15**] 05:31AM BLOOD Glucose-125* UreaN-18 Creat-0.5 Na-143 K-3.9 Cl-104 HCO3-29 AnGap-14 [**2186-3-19**] 05:11AM BLOOD Glucose-154* UreaN-27* Creat-0.5 Na-144 K-4.3 Cl-105 HCO3-30 AnGap-13 [**2186-3-23**] 07:30AM BLOOD Glucose-103 UreaN-23* Creat-0.6 Na-140 K-4.3 Cl-100 HCO3-32 AnGap-12 [**2186-3-26**] 05:39AM BLOOD Glucose-142* UreaN-29* Creat-0.6 Na-143 K-4.6 Cl-105 HCO3-25 AnGap-18 [**2186-3-28**] 06:42AM BLOOD Glucose-128* UreaN-23* Creat-0.4* Na-143 K-4.2 Cl-105 HCO3-34* AnGap-8 [**2186-3-30**] 05:05AM BLOOD Glucose-120* UreaN-22* Creat-0.5 Na-140 K-4.6 Cl-101 HCO3-32 AnGap-12 [**2186-4-1**] 06:06AM BLOOD Glucose-98 UreaN-17 Creat-0.5 Na-142 K-4.2 Cl-104 HCO3-36* AnGap-6* [**2186-4-3**] 05:17AM BLOOD Glucose-186* UreaN-25* Creat-0.5 Na-143 K-4.2 Cl-104 HCO3-35* AnGap-8 [**2186-4-9**] 05:42AM BLOOD Glucose-139* UreaN-24* Creat-0.6 Na-144 K-3.9 Cl-102 HCO3-36* AnGap-10 [**2186-4-10**] 04:08AM BLOOD Glucose-139* UreaN-20 Creat-0.5 Na-145 K-3.8 Cl-106 HCO3-35* AnGap-8 [**2186-4-11**] 05:35AM BLOOD Glucose-111* UreaN-20 Creat-0.5 Na-147* K-3.9 Cl-106 HCO3-36* AnGap-9 . MISC [**2186-3-11**] 05:15AM BLOOD ALT-131* AST-140* LD(LDH)-342* [**2186-3-19**] 05:11AM BLOOD ALT-96* AST-113* AlkPhos-104 TotBili-0.5 [**2186-4-8**] 03:52AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2186-4-8**] 11:50AM BLOOD CK-MB-NotDone cTropnT-0.15* [**2186-4-8**] 05:55PM BLOOD Type-ART pO2-79* pCO2-54* pH-7.44 calTCO2-38* Base XS-10 [**2186-4-8**] 05:55PM BLOOD O2 Sat-93 Brief Hospital Course: #SHORTNESS OF BREATH / VIRAL BRONCHITIS / SARCOIDOSIS / ANXIETY Mr. [**Known lastname 52653**] was admitted with worsening SOB and lower oxygen saturations. This was not felt to be a flare of sarcoidosis but more likely a viral infection on top of severe underlying lung disease caused by sarcoid. A pulmonary consultation was obtained. Prednisone was increased to 60mg PO daily in addition to his azathioprine 150mg once daily. His oxygen flow was increased to four liters, and later to 5-6 liters. He briefly went to the MICU on [**2186-4-7**] for worsening tachypnea; he remained on his baseline 6L NC with shovel mask mist support. After returning to the floor and again becoming tachypneic, he underwent CTA which showed as small subsegmental PE. LENI's were negative for DVT. As the patient had had recent bleeding with rectus sheath hematomas, anticoagulation was not started.His outpt pulmonologist was made aware and agreed with holding off on anticoagulation. At discharge, he was restarted on lower dose sc heparin 5000 [**Hospital1 **] (down from TID). He will be followed closely as an outpt with Dr. [**Last Name (STitle) **]. At discharge he was 97% on 6L NC and shovel mask mist support, slightly tachypnic. Per Dr.[**Last Name (STitle) 18309**], transtracheal oxygen catheter has been discussed to improve oxygen delivery. He was evaluated by throracic surgery during his inpt stay but a decision was defered as the surgeon was out of town. The cardiothoracic surgery clinic will call the patient with an appointment to follow up in clinic for evaluation. . #PSEUDOMONAS PNEUMONIA He stabilized after initial presentation but intermittently became tachypneic from his viral bronchitis, but later developed much more productive cough with phlegm. Sputum culture was obtained which was notable for multidrug-resistant pseudomonas. CT scan showed interval developement of new RUL consolidation. He was treated with meropenem for 14 days. Subsequent CT showed interval resolution. . #SEVERE ANXIETY He has severe anxiety related to advanced illness and is quite fearful of death, and this exacerbated respiratory symptoms. A palliative care consultation was obtained and the patient wsa tried on sublingual morphine with an increase in his anxiolytic medications. He personally was not yet ready for hospice. In terms of psychopharmacology, the patient was started on risperidone 1mg PO BID, and his duloxetine was increased to 90mg PO daily. SL Morphine aided in comfort. . #RIB FRACTURES / OSTEOPOROSIS: THe patient had several old rib fractures, but also developed a new acute rib fracture during this admission. This is due to chronic steroid use and coughing. A vitamin D level was normal in [**11-19**]. A repeat Vit D level is pending. This value should be followed up on and Vit D supplements started if low. The patient may also need bisphosphonates although the long-term benefits are doubtful given his poor prognosis. . #RECTUS SHEALTH HEMATOMA The patient developed a moderate sized rectus shealth hematoma during this admission with 8 point hematocrit drop. This was felt to be in part to coughing while on subcutaneous heparin injections. Heparin sc was discontinued. His HCT stabilized without intervention. Heparin at a lower dose of 5000 [**Hospital1 **] was restarted. If the patient has any sign of bleeding or worsening abd bruising, discontinue heparin and please use pneumoboots. . #FALL The patient fell on [**2186-4-6**] while toileting. He did not hit his head and had no LOC. New rib fracture and rectus sheath hematoma were not attributed to this fall. . #SPINAL STENOSIS The patient was continued on long and short acting morphine for pain control. His MS contin was increased to 45/15/45 mg three times per day respectively. He had sublingual morphine and percocet on PRN basis. . #PAIN MEDICATION ISSUES The patient was seen by nursing to be saving pain medication for his daughter. [**Name (NI) **] was directly observed taking all medications subsequently. There were no subsequent concerns regarding pain medication. . # MENTAL STATUS The patient is typically fully oriented, though he had frequent periods where he was unsure of surroundings. He typically became quite paranoid at night and felt that most night nurses were playing tricks on him. He was started on risperidone 1mg PO BID with PRN haldol for agitation. Medications on Admission: Albuterol PRN , Azathioprine 150mg daily Klonipin 0.5mg TID PRN Cymbalta 60mg daily Advair 500/50 INH [**Hospital1 **] Remeron 15mg qhs Morphine SR 30mg TID Omeprazole 20mg daily Percocet q6hr PRN Prednisone 40mg daily Simvastatin 20mg daily Spiriva 18mcg INH daily Trazadone 50mg qhs PRN ASA 325mg daily colace senna thiamine 100mg daily tylenol PRN Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 2. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMWF (). 14. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 16. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO q 1:00pm as needed. 20. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO QAM (once a day (in the morning)). 21. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO QPM (once a day (in the evening)). 22. Morphine Concentrate 20 mg/mL Solution Sig: 0.5-0.75 mL PO Q3H (every 3 hours) as needed. 23. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q3H PRN (). 24. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 25. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 26. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 27. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 28. Insulin 12 units NPH qAM, 6 units NPH qPM Regular Insulin Sliding scale coverage (see attached scale) 29. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 30. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray Nasal QID (4 times a day) as needed. 31. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary: - Acute exacerbation of COPD - Hospital acquired pneumonia - Rectus sheath hematoma - End stage pulmonary sarcoid Secondary: - Chronic immunosuppression - Obstructive sleep apnea - Left III nerve palsy - Anxiety; depression; paranoia - Traumatic mandibular, rib, clavicle fractures - Spinal stenosis; frequent falls - Chronic pain - Zoster - Hepatitis C Discharge Condition: Stable. On 6L NC. afebrile. Discharge Instructions: You were admitted with shortness of breath and thought to have a viral bronchitis on top of your sarcoidosis. You had a new pneumonia and were treated with IV antibiotics: 14 day course of meropenem completed. You were continued on a higher dose of predisone as well as your current dose of azathioprine. . You had a large abdominal (rectus sheath) hematoma that will improve over time. . Your medications were changed. Your prednisone was increased as above. Your pain medications have changed; please review your NEW medication list and adjust your home meds as needed. . If you develop worsening shortness of breath, low oxygen saturations on your current level of home oxygen, fevers or chills, please return to the hospital. Followup Instructions: New left lower lobe 3.5 mm lung nodule warrants [**5-25**] month CT followup. . Please make an appointment with Dr. [**Last Name (STitle) **], your outpt psychiatrist ([**Telephone/Fax (1) 52654**]) to be seen in [**12-14**] weeks. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2186-5-1**] 2:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2186-5-1**] 1:00 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2186-5-1**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]

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Discharge summary

report

Admission Date: [**2188-1-26**] Discharge Date: [**2188-1-29**] Date of Birth: [**2107-10-9**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9853**] Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: none History of Present Illness: This is an 80 year-old female with a past medical history of hypertension, type II DM and anemia who presents with increased finger sticks for the last 24 hours and is admitted to the ICU on an insulin gtt. Per report, the patient presented to her PCP [**Last Name (NamePattern4) **] [**1-24**] with complaints of cough, increased phelgm, wheezing, chest tightness and difficulty sleeping for the last few days. She had been started on azithromycin, flovent and proair the day prior for her symptoms. She was diagnosed with bronchitis/asthma exacerbation and additionally started on 60 mg prednisone with a taper over the next 12 days. The patient reports she took 60 mg on the first day and 50 the next. Since that time, the patient reports she has been feeling improved, but still with persistent cough and phlegm. Denies fevers. She presented to the ED yesterday, however, as her FSBG had been [**Location (un) 1131**] high (>500) on her home glucometer. She notes that she had been told to monitor her blood sugars more carefully while on prednisone. She denies polydipsia, polyuria, vision changes, headache, abdominal symptoms, chest pain, weakness or other symptoms. Pertinent positives as above. In the ED, initial VS were 96.7 148/66 76 24 97% on RA. She was first given 10 units of Regular insulin SQ without effect. The patient was started on an insulin gtt at 7 units/hr around 4:45 on the morning of admission, first recheck of FS still elevated over 500. She received a total of 1.5L of normal saline over her first 8 hours in the ED; this was subsequently increased after her creatinine increased over several hours. She also received combivent x4, Past Medical History: -Hypertension -Type II DM, on oral medications -Hypercholesterolemia -Recurrent vertigo/dizziness -Diverticulosis -Anemia, baseline Hct 24-26 -Osteopenia -Thyroid nodule -Asthma Social History: Lives w/ family/daughter. [**Name (NI) **] tobacco use. Rare ETOH. Family History: No h/o early MI/Stroke Physical Exam: GEN: NAD / well-appearing EYES: EOMI / conjunctiva clear / anicteric ENT: dry mucous membranes NECK: supple CV: RRR nl S1S2, no m/r/g PULM: mild diffuse wheezes GI: NABS / ND / soft / nontender EXT: warm , trace nonpitting lower extremity edema SKIN: no rashes NEURO: alert / oriented x 3/ answers ? appropriately / follows commands / normal gait PSYCH: appropriate / pleasant ACCESS: peripheral FOLEY: absent Pertinent Results: [**2188-1-25**] 10:25PM GLUCOSE-560* UREA N-52* CREAT-1.9* SODIUM-132* POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-17* ANION GAP-18 [**2188-1-25**] 10:25PM CK(CPK)-216* [**2188-1-25**] 10:25PM cTropnT-0.01 [**2188-1-25**] 10:25PM CK-MB-6 [**2188-1-25**] 10:25PM WBC-7.1 RBC-2.99* HGB-8.4* HCT-24.9* MCV-83 MCH-28.0 MCHC-33.7 RDW-15.5 [**2188-1-25**] 10:25PM NEUTS-92.0* LYMPHS-6.4* MONOS-1.0* EOS-0.5 BASOS-0.2 [**2188-1-25**] 10:25PM PLT COUNT-196 [**2188-1-26**] 03:10AM OSMOLAL-321* [**2188-1-26**] 03:10AM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-2.2 [**2188-1-26**] 03:10AM GLUCOSE-595* UREA N-58* CREAT-2.1* SODIUM-132* POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-17* ANION GAP-15 [**2188-1-26**] 04:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2188-1-26**] 04:20AM URINE RBC-0-2 WBC-[**3-13**] BACTERIA-FEW YEAST-NONE EPI-0-2 [**2188-1-26**] 05:09AM TYPE-[**Last Name (un) **] PO2-152* PCO2-32* PH-7.36 TOTAL CO2-19* BASE XS--6 COMMENTS-GREEN TOP [**2188-1-26**] 09:30AM URINE HOURS-RANDOM CREAT-166 SODIUM-12 [**2188-1-26**] 10:16AM ALT(SGPT)-16 AST(SGOT)-18 LD(LDH)-194 CK(CPK)-164* ALK PHOS-56 TOT BILI-0.2 [**2188-1-26**] 10:16AM CK-MB-5 cTropnT-<0.01 [**2188-1-26**] 10:16AM GLUCOSE-94 UREA N-57* CREAT-2.0* SODIUM-140 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-17* ANION GAP-18 ECG: Sinus rhythm at 76 bpm, normal axis, PR interval wnl, QRS with wide terminal S waves in leads I, II, avL, RBBB, poor R-wave progress, no new ischemic changes. Brief Hospital Course: 80 year-old female with a history of type II DM who presents with hyperglycemia. # Hyperglycemia: The patient presented with a hyperosmolar hyperglycemic state given that she had no ketones in her urine and history of type II DM, pH >7.30, bicarb >15 though patient has had no neurologic abnormalities. Also had a mild AG acidosis on admission which closed as her sugars were brought down. She has had relatively well-controlled DM for many years, on oral agents including glipizide and actos. Her last A1C was 6.6 in [**Month (only) 359**] of this year. Her hyperglycemia was likely the result of high doses of prednisone for her asthma exacerbation in addition to possible missed doses of her medications. She was placed on an insulin gtt and quickly weaned off it as her BSs dropped. She was given NS at 200 cc/h until her sugars fell below 300 and then given D5 1/2NS until she was off the insulin gtt and eating normally. BCx and flu test negative. UCx eventually grew out E. coli so she was started on a 7-day course of Cipro. CE were checked and her CK was mildly elevated at 216 and trended down, trops were negative. [**Last Name (un) **] was consulted and recommended that she stay on insulin rather than oral hypoglycemics. She was transitioned to lantus and sliding scale insulin and will follow up with [**Last Name (un) **] as an outpatient. # Acute on chronic renal insufficiency: Her baseline creatinine appears to be around 1.5, and on admission it was elevated to 2.1. Her ARF was likely secondary to prerenal/volume contraction from HHS. She had received 1.5L of fluid total over 8 hours in the ED. She was given NS at 200 cc/h until her sugars fell below 300 and then given D5 1/2NS until she was off the insulin gtt and eating normally. Her enalapril, Diovan, and Lasix were held. On discharge her creatinine was 1.7 and she was advised to follow up with her PCP as an outpatient for renal function monitoring and consideration of resuming these medications. # Hyponatremia: The patient's inital serum Na was 132, however the corrected serum Na is approximately 139 when accounting for hyperglycemia. Her hyperglycemia was treated and given was given IVF and her Na corrected. # Bronchitis: The patient was short of breath for the last several days, on azithro and prednisone with some improvement in her symptoms. She was treated with high dose fluticasone, salmeterol, standing atrovent, and albuterol prn. She was also given 10 mg of prednisone for a 5-day course and continued for another 3 days on azithromycin for anti-inflammatory effect. She was put a PPI for prophylaxis while she was being treated with prednisone. Her symptoms improved dramatically on this regimen, and she was advised to take Advair daily to help keep her asthma under control. # Anemia: The patient has a chronic anemia and her last iron studies were checked in [**2186-12-9**]. She appeared to be at baseline of around 24-26. She had no clinical evidence of bleeding. # Hypertension: Her lasix, enalapril, and diovan were held initally given her hypovolemic state. She was continued on diltiazem. As her BP was under control on discharge off of the above medications, she was advised to follow up with her PCP for consideration of resuming these as an outpatient. # Code: Full code Medications on Admission: Furosemide 80mg qday B12 1000 mcg IM q1 month Diltiazem 240 SR daily Doxazosin 1 mg in am, 2 mg in pm Enalapril 20 mg [**Hospital1 **] Folate 1 mg daily Glyburide 9 mg qam, 3 mg qpm Paroxetine 20 mg daily Actos 15 mg daily Prednisone taper (60 mg to start) Simvastatin 40 mg daily Diovan 320 mg daily ASA 325 mg daily Fluticasone Albuterol Discharge Medications: 1. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: One (1) mg Intramuscular once a month. 2. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 3. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 13. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) Units Subcutaneous qam. Disp:*1 month supply* Refills:*2* 14. Humalog 100 unit/mL Solution Sig: per sliding scale Units Subcutaneous qachs. Disp:*1 month supply* Refills:*2* 15. Insulin Syringe Ultrafine [**1-11**] mL 29 x [**1-11**] Syringe Sig: One (1) needle Miscellaneous four times a day. Disp:*100 needles* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Primary: hyperglycemia Secondary: diabetes mellitus Type II uncontrolled, hypertension, anemia Discharge Condition: good, stable, ambulating independently Discharge Instructions: You were admitted for high blood sugars, likely caused by the prednisone started for your COPD exacerbation. You should continue to take insulin at home as instructed. We changed the following medications: --Do NOT take your Lasix, Diovan, or enalapril for now due to your kidney function. Follow up with your primary care physician to recheck your kidney function and to restart these medications. --Do NOT take your glyburide or actos any more. You will be on insulin instead. --Do NOT finish the prednisone prescribed to you before your hospitalization, as you have improved with treatment here. --You were found to have a urinary tract infection; continue taking antibiotics (Cipro) as prescribed for five more days. --To keep your asthma under better control, take Advair daily, even if you do not have symptoms. You may take your albuterol if you are having symptoms. If you have worsening blood sugars, worsening shortness of breath, fevers, chills, lightheadedness, episodes of loss of consciousness, or any other concerning symptoms, call your doctor or seek medical attention immediately. Followup Instructions: Follow up with your primary care provider [**Last Name (NamePattern4) **] [**1-11**] weeks. You should have your kidney function rechecked. Follow up with the diabetes specialists at the [**Last Name (un) **] Center. They have given you the information for an appointment with a provider next [**Name9 (PRE) 766**] (1pm on [**2188-2-4**] with NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11712**]). You may call [**Telephone/Fax (1) 2384**] with any questions.

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icd9cm

[ [ [] ] ]

[ "99.29", "99.17" ]

icd9pcs

[ [ [] ] ]

9601, 9687

4385, 7696

329, 336

9826, 9867

2828, 4362

11016, 11500

2344, 2368

8087, 9578

9708, 9805

7722, 8064

9891, 10993

2383, 2809

276, 291

364, 2041

2063, 2243

2259, 2328

53,865

147,600

4490

Discharge summary

report

Admission Date: [**2172-3-30**] Discharge Date: [**2172-4-1**] Date of Birth: [**2100-8-7**] Sex: F Service: MEDICINE Allergies: Norvasc / Morphine / Niacin / Levaquin Attending:[**First Name3 (LF) 2387**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Right renal artery catheterization and stenting Right renal artery gelfoam embolization Temporary hemodialysis line placement Exploratory laparotamy Right hemicolectomy Intubation and mechanical ventilation History of Present Illness: Ms. [**Known lastname **] is a 71 year old with DM2, HTN, HLD, extensive vasculopathy including CAD s/p RCA stent [**2161**], bifemoral disease s/p L common iliac stent x 2, aortic stent who was transferred from [**Hospital3 1280**] Hospital for stenting of renal artery stenosis. Catheterization occurred on [**2172-3-31**] and was complicated by post-procedure hypotension and retroperitoneal bleed. She was hypotensive to SBPs in 40s tachycardic to 140s. Due to concern for perinephric/RP bleed a massive transfusion protocol was initiated. Ms. [**Known lastname **] was intubated, a dirty right femoral trauma line was placed, and she was maintained on pressors (ultimately requiring 3 pressors - dopamine, levo, and neo). ACT was 150, and 10 of protamine was given. Ms. [**Known lastname **] was taken emergenty for CTA of the abdomen which demonstrated a large perinephric hemorrhage with extension into the retroperitoneum. She was taken to IR where 3 peripheral branches of the right renal artery was embolized, and a HD line was placed under sterile procedure in the RIJ. In total 11 units of PRBCs, 4 of FFP and 2 of platelets. Due to persistent hyperkalemia (K of 6.4) she was given calcium gluconate, insulin and dextrose. Several amps of bicarb were administered for persistent lactic acidosis (HCO3 ~18-19) with ABG 7.17/43/116/17. Increasing abdominal girth and increasing peak pressures to 40 were noted during the procedure, and surgery was consulted for possible compartment syndrome. . Ms. [**Known lastname **] initially presented to [**Hospital1 **] on Thursday when her BP was elevated to 200s whilst recieving procrit, per the family her BP was in the 150s at home. She was treated for a CHF exacerbation thought to be secondary to flash pulmonary edema. Her BP was managed with labetalol 600 [**Hospital1 **], Isosorbide Mononitrate 90 mg QD, Hydralazine 25mg [**Hospital1 **], and Lasix 80 mg QD. RUS demonstrated > 60% stenosis of the R renal artery. While at [**Hospital1 **] they were able to diurese her and improve her respiratory status, but her renal function worsened from a baseline Cr of 2.4 to 3.8 on transfer. Upon transfer to [**Hospital1 18**], vitals were 97.7 163/67 84 20 91/2L. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST CARDIAC HISTORY: - CAD ---> [**12-11**]: RCA stent widely patent ---> [**4-9**]: Balloon angioplasty of distal RCA with 20% residual stenosis ---> [**11/2160**]: Rotational atherectomy, balloon angioplasty, & stenting of the ostium & proximal RCA. - Diastolic dysfunction - History of Mobitz 1 Block . PAST MEDICAL HISTORY: - Peripheral artery disease ---> [**2170-8-9**]: Right axillary bifemoral bypass graft ---> [**6-16**]: 80% stenosis of L common iliac artery with stenting of common iliac lesion with Genesis stent as well as jailing of embolized Genesis stent in the internal iliac ---> LLE angiogram with stent to L common iliac stent x2 ---> [**11-9**]: Successful PTA & stenting of infrarenal aorta ---> 40-50% subclavian artery stenosis - DM2 - HLD - HTN - Morbid obesity s/p open gastric bypass - GERD - PUD - Gastritis - Glaucoma - Raynaud's phenomenon - Anemia - Degenerative joint disease ---> Bilateral knee replacement ---> R should replacement - Appendectomy - Cholecystectomy - Ventral hernia repair - History of: ---> C. Diff colitis ---> ARDS Social History: - retired nurse. - h/o of 20-pack-year. quit in the [**2140**]. - no h/o EtOH abuse or illicit drug use. Family History: Family history is significant for father who died from an MI at age 30 and a brother who died at 38. She has another brother (alive) who received quadriple bypass at the age of 60. Physical Exam: CCU ADMISSION PHYSICAL EXAM: VS: BP= 139/56 HR=72 RR=16 O2 sat= 95 GENERAL: intubated, sedated. HEENT: Pupils equal reactive, sluggish. CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: CTAB anteriorly, no crackles, wheezes or rhonchi. ABDOMEN: Protuberant ventral hernia, distended abdomen. Hypoactive bowel sounds. Unable to assess tenderness secondary to sedation. EXTREMITIES: No edema, warm, well-perfused. NEURO: intubated, sedated Discharge Exam: Expired Pertinent Results: ADMISSION LABS: [**2172-3-30**] 05:10PM BLOOD WBC-4.1 RBC-3.62* Hgb-11.1* Hct-32.7* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.6* Plt Ct-136* [**2172-3-30**] 05:10PM BLOOD Glucose-114* UreaN-53* Creat-3.7*# Na-136 K-4.3 Cl-99 HCO3-24 AnGap-17 [**2172-3-30**] 05:10PM BLOOD CK(CPK)-40 [**2172-3-30**] 05:10PM BLOOD CK-MB-2 cTropnT-0.03* [**2172-3-30**] 05:10PM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.4 Mg-1.9 Pertinent Labs: . [**2172-3-31**] 03:38PM BLOOD Type-ART O2 Flow-4 pO2-68* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2172-4-1**] 01:04AM BLOOD Type-ART Temp-36.3 Rates-16/ Tidal V-450 PEEP-8 FiO2-100 pO2-180* pCO2-33* pH-7.30* calTCO2-17* Base XS--8 AADO2-507 REQ O2-84 Intubat-INTUBATED Vent-CONTROLLED [**2172-4-1**] 05:18AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-5 FiO2-70 pO2-80* pCO2-37 pH-7.23* calTCO2-16* Base XS--11 Intubat-INTUBATED Vent-CONTROLLED [**2172-4-1**] 09:31AM BLOOD Type-ART Rates-18/ Tidal V-450 PEEP-20 FiO2-100 pO2-43* pCO2-43 pH-7.20* calTCO2-18* Base XS--11 AADO2-623 REQ O2-100 Intubat-INTUBATED [**2172-4-1**] 07:39AM BLOOD Glucose-197* UreaN-34* Creat-2.2* Na-141 K-4.3 Cl-103 HCO3-17* AnGap-25* [**2172-4-1**] 03:40AM BLOOD ALT-372* AST-995* CK(CPK)-125 AlkPhos-65 TotBili-1.5 [**2172-4-1**] 07:39AM BLOOD WBC-5.4 RBC-2.93* Hgb-9.3* Hct-26.2* MCV-90 MCH-31.6 MCHC-35.3* RDW-14.9 Plt Ct-146* [**2172-3-31**] 06:15PM BLOOD WBC-7.9# RBC-4.13* Hgb-12.9 Hct-37.4# MCV-91 MCH-31.3 MCHC-34.5 RDW-14.1 Plt Ct-82* Pertinent Studies: CT abdomen IMPRESSION: 1. Multiple foci of active extravasation from the right kidney with extensive perinephric, and other retroperitoneal hematoma as well as extension of hematoma into the mesentery. 2. Moderate bilateral pleural effusions as well as moderate pericardial effusion, likely related to recent volume resuscitation. 3. Extensive vasculopathy as delineated above. 4. Heterogeneous hepatic attenuation, raising the possibility of partial hepatic infarction. TTE: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is trivial pericardial effusion. IMPRESSION: Emergent study with poor parasternal and apical views. With this limitation, the study is notable for normal biventricular function and trivial pericardial effusion. Cannot assess for mitral or tricuspid regurgitation. Embolization Report: HT RENAL ANGIOGRAM AND GELFOAM EMBOLIZATION, FOLLOWED BY TEMPORARY HEMODIALYSIS CATHETER PLACEMENT INDICATION: 71-year-old woman with right renal arterial bleeding, status post right renal arterial stent. Also renal insufficiency. OPERATORS: Drs. [**First Name (STitle) **] [**Name (STitle) 19199**] (fellow), Mark Ashkan (resident) and [**First Name8 (NamePattern2) **] [**Doctor Last Name 4154**] (attending physician). Dr. [**First Name (STitle) 4154**] was present throughout the procedure. SEDATION: General endotracheal anesthesia provided by the anesthesiologist. CONTRAST: Sterile 76 ml Omnipaque 240 and 80ml Omnipapque 350. OTHER MEDICATION: 1 g Kefzol. PROCEDURE: As this was on an emergent procedure, consent was not obtained for the procedure. Patient was placed supine on the imaging table in the interventional suite. Timeout was performed as per [**Hospital1 18**] protocol. Under aseptic conditions and son[**Name (NI) 493**] guidance, a micropuncture needle was placed in the right brachial artery at the level of humeral epicondyles. A 0.018 wire was advanced through the needle and into the axillary artery. Needle was exchanged for a 4.5 French microsheath. Inner cannula and wire were removed to place a 0.035 [**Last Name (un) 7648**] wire, which was advanced into the right subclavian artery. Microsheath was removed to place a 5 French [**Last Name (un) 2493**]-Tip sheath. After removing the inner cannula, the sidearm was aspirated and flushed, and arteriogram was performed to assess anatomy at the arteriotomy site. A 5 French angled glide cath was placed over the wire and within the sheath and carefully negotiated into the upper abdominal aorta, and eventually into the proximal part of the right renal artery. Arteriogram was performed in two projections. A Renegade STC microcatheter was then used to sequentially access the caudal branch of the interpolar artery, caudal branch of the lower polar branch and subsequently, a peripheral (fourth order) branch arising from the cranial branch of the interpolar artery to perform Gelfoam embolization to near stasis, with appropriate pre-embolization arteriograms from these branches via the microcatheter, and post-embolization arteriograms from the right renal artery via the main catheter. At the end of the procedure, catheters, and subsequently sheath were removed. Firm pressure was applied at the arteriotomy site for about 25 minutes to achieve complete hemostasis. Site was appropriately dressed. Attention was now directed to temporary hemodialysis catheter placement. Under aseptic conditions and son[**Name (NI) 493**] guidance, a micropuncture needle was placed in the patent right internal jugular vein just above the level of clavicle. Son[**Name (NI) 493**] images were printed prior to and following needle placement. A 0.018 wire was advanced through the needle and into the SVC. Needle was exchanged for 4.5 French microsheath. Inner cannula and wire were removed to place short [**Doctor Last Name **] wire, which was advanced into the IVC. After appropriate measurements, removal of the microsheath and sequential tract dilatation with 12- and 14-French dilators under fluoroscopy, 14 French 15 cm hemodialysis catheter was placed. Plastic stiffener and wire were removed. Catheter was confirmed under fluoroscopy to be in the lower SVC. Ports were aspirated and flushed. Catheter was secured with 0 silk sutures. Site was appropriately dressed. No immediate post-procedure complication was seen. FINDINGS: 1. Multiple angiograms performed from the right main renal artery, and from the caudal branch of interpolar artery, caudal branch of right renal lower polar artery and subsequently a peripheral branch (fourth order) branch of the cranial branch of interpolar artery demonstrated multiple foci of active extravasation (corresponding to those seen on CT dated [**2172-3-31**]), and two possible foci of contained extravasation or pseudoaneurysms. 2. Post-embolization arteriograms demonstrated good angiographic results in their appropriate territories, no significant residual extravasation, and contrast enhancement of approximately 70% of the right kidney on the final angiogram. 3. During these arteriograms, abnormal renal contrast withholding with delayed clearance was noted, most likely related to the underlying renal insufficiency. 4. Angiography re-demonstrated complete abdominal aortic occlusion below the take-off of the SMA/renal arteries. Post-intervention angiography demonstrated brisk flow into the visualized portion of the SMA. 5. Abdominal aortic and right renal artery stents were also seen. The recently placed right renal stent was patent, and no main renal artery dissection or rupture was seen. 6. Incidental note of low-lying ET tube was made, and the anesthesiologist notified during the procedure. 7. Successful placement of a temporary hemodialysis catheter, with the tip in the distal SVC, ready to use. IMPRESSION: 1. Right renal angiography demonstrated multiple foci of active extravasation, followed by successful targeted Gelfoam embolization of distal branches of right renal interpolar and lower pole arteries. 2. Uncomplicated ultrasound and fluoroscopy guided placement of 14 French 15 cm hemodialysis catheter via the patent right internal jugular vein, and with its tip in the lower SVC. It is ready for use. Pending Studies: Bowel Tissue Pathology Brief Hospital Course: Ms. [**Known lastname **] was a 71 year old woman with extensive vascular disease including coronary artery disease, peripheral vascular disease, and diastolic congestive heart failure who presented with uncontrolled hypertension and and a diastolic CHF exacerbation likely secondary to renal artery stenosis. She was transferred from an outside hospital for renal artery stenting which was unfortunately complicated by perinephric hemorrhage and hemorrhagic shock with resulting multisystem organ failure and death. . # Hypovolemic Shock/Hemorrhage: Ms. [**Known lastname **] was transferred from an outside hospital for management of resistant hypertension which had resulted in an episode of flash pulmonary edema. She was transferred to [**Hospital1 18**] on [**2172-3-30**] and was taken to the catheterization lab on [**2172-3-31**]. Following a successful stenting of a near 99% stensosis of the right renal artery, Ms. [**Known lastname **] became hypotensive in the holding area . The hypotension (to systolic BPs in the 40s) was accompanied by back pain, and given concern for a retroperitoneal/perinephric bleed a massive transfusion protocol was initiated. A stat hematocrit returned at 22 (down from 32 on admission). ACT was 150, and 10 of protamine was given. She was initially hemodynamically stable on dopamine, and a CT abdomen/pelvis was obtained which demonstrated a large perinephric hematoma with extension into the mesentery and retroperitoneum. While in the catheterization lab, her SBPs again dropped, and levophed and neosynephrine were added. Afterwards, she was emergently taken to the angiography suite where 3 peripheral branches of the right renal artery were embolized, and a HD line was placed under sterile procedure in the RIJ. In total 11 units of PRBCs, 4 of FFP and 2 of platelets. Following embolization of the three peripheral branches of the renal artery, hemostasis was able to be achieved, and pressors were weaned in the IR suite. She was transferred for further care in the CCU. While in the CCU, she remained hemodynamically stable from 9pm until approximately 12am when her pressures began to decrease, pressors were restarted, and her lactates began to rise from 5 following embolization to 7 at 3am. There was concern for septic shock given dirty right femoral line, abdominal compartment syndrome, cardiogenic shock, new bleeding, and end organ ischemia. Vancomycin and Cefepime were started for broad spectrum antibiotic coverage. A stat echo was obtained which demonstrated normal LV systolic dysfunction and a patent IVC, making cardiogenic shock and abdominal compartment sydnrome less likely. Serial hematocrits were stable in the 30s. Vascular and transplant surgery, who had been consulted prior to embolisation, were called to the bedside. Given her rising lactate, worsening acidosis, persistently distended abdomen, and high bladder pressures in the 20s an exploratory laparotomy at 7am was undertaken to evaluate possible abdominal compartment syndrome versus bowel ischemia. Intraoperatively the ascending and transverse colon was found to be necrotic, and the remaining areas of small and large bowel were discovered to be diffusely ischemic. A right colectomy was performed, and the abdominal cavity was remained open for possible re-exploration. At this point, Ms. [**Known lastname **] was dependent on 4 pressors (neo, levo, dopa, and vaso), and a fifth (epinephrine) was added at 10am. Ms. [**Known lastname 19200**] oxygenation status was also deteriorating with PaO2 of 46 while on 100% FiO2 and PEEP of 15. The dire situation of Ms. [**Known lastname 19200**] condition was communicated with Ms. [**Known lastname 19200**] family who decided to make her DNR/DNI and avoid escalation of care. Ms. [**Known lastname **] passed at 2:03pm, an autopsy was declined. . # Hypoxemic Respiratory Failure: Ms. [**Known lastname **] became increasingly hypoxemic following her initial hemorrhage. She was intubated for airway protection following the initiation of the massive transfusion protocol. The differential diagnosis of her hypoxemia includes hypervolemia from massive transfusion leading to pulmonary edema, ARDS (secondary to pro-inflammatory state vs. TRALI), aspiration in the setting of her initial intubation. Respiration was also difficult due to massive abdominal distension in the setting of intraabdominal hemorrhage. It is likely that a component of ARDS occurred in the setting of the massively pro-inflammatory state caused by bowel ischemia given her profound hypoxemia PaO2 of 40 while on 100% FiO2 and high PEEP 15. . # Metabolic acidosis: Ms. [**Known lastname **] developed a profound AG metabolic acidosis, likely from elevated lactate and renal failure. Lactic acidosis likely secondary to RP bleed and hypovolemic shock as well as bowel necrosis. sBP were in 60s for a long time. Acidosis was managed with intermittent bicarbonate boluses of 50mEq as well as a bicarbonate drip and CVVH. . # ESRD: Given hyperkalemia to 6.1, profound acidemia, and volume overload, a temporary HD line was placed at the time of her renal artery embolization and CVVH was initiated on [**2172-3-31**] when she arrived to the CCU. Medications on Admission: HOME MEDICATIONS: (confirmed with patient) - Crestor 40 mg QD - Tramadol 50 mg TID - Aspirin 81 mg QD - Vitamin D3 4000 units QD - Vitamin B12 1000 mcg QD - Folic Acid 1 mg QD - Prilosec 20 mg QD - Procrit 20,000 units every 2 weeks (last [**2172-3-26**]) - Xalatan 0.005% drop OT QHS - Timolol 0.5% 1 drop OT [**Hospital1 **] - Alphagan 0.1% OT QD - Cardura 4 mg [**Hospital1 **] (started 1 week ago) - Isordil 10 mg TID - Metolazone 25 mg QD - Toprol XL 25 mg QD . MEDICATIONS ON TRANSFER from outside hospital: - Labetalol 600 mg [**Hospital1 **] - Isosorbide Mononitrate 90 mg QD - Lasix 80 mg QD - Crestor 40 mg QD - Tramadol 50 mg [**Hospital1 **] - Aspirin 81 mg QD - Vitamin D3 4000 units QD - Vitamin B12 1000 mcg QD - Folic Acid 1 mg QD - Prilosec 20 mg QD - Procrit 20,000 units every 2 weeks (last [**2172-3-26**]) - Xalatan 0.005% drop OT QHS - Timolol 0.5% 1 drop OT [**Hospital1 **] - Alphagan 0.1% OT QD - Cardura 4 mg [**Hospital1 **] - Benadryl 25 mg QHS - Percocet 1 tab Q4H PRN pain - Hydralazine 25 mg [**Hospital1 **] Discharge Medications: Patient Deceased Discharge Disposition: Expired Discharge Diagnosis: Diastolic congestive heart failure Resistant Hypertension Hypovolemic Shock Intraabdominal hemorrhage Bowel Ischemia Discharge Condition: Deceased Discharge Instructions: Patient Deceased Followup Instructions: Patient Deceased

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icd9cm

[ [ [] ] ]

[ "45.73", "00.45", "39.95", "88.42", "39.50", "39.90", "88.45", "99.29", "38.95", "00.40" ]

icd9pcs

[ [ [] ] ]

19089, 19098

12714, 17958

305, 513

19258, 19268

4865, 4865

19333, 19352

4174, 4357

19048, 19066

19119, 19237

17984, 17984

19292, 19310

4401, 4820

18002, 19025

4836, 4846

258, 267

541, 2941

4881, 5263

5279, 12691

3292, 4034

4050, 4158

43,121

153,599

52980

Discharge summary

report

Admission Date: [**2107-11-4**] Discharge Date: [**2107-11-30**] Date of Birth: [**2037-12-10**] Sex: F Service: MEDICINE Allergies: Levofloxacin / Iodine / Premarin / Mustard / Reglan Attending:[**First Name3 (LF) 9160**] Chief Complaint: Abdominal pain, fever, elevated LFTs Major Surgical or Invasive Procedure: IR guided PTBD placement PTBD exchange Biliary stent placement History of Present Illness: This is a 69 y/o woman with hx gastric cancer s/p Roux-en-Y gastrectomy in [**8-/2107**], with recurrent hospitalizations for malnutrition, pain, and diarrhea/constipation presents from [**Hospital1 **] LTAC with new-onset elevated LFTs, new abdominal pain, and fever. Since her Roux-en-Y, she has had persistent nausea and vomiting and is unable to tolerate po intake, lost 15 lbs over past several months (baseline weight 130-135 lbs, weight before surgery 115 lb, weight now 99 lb). On TPN and tube jeeds through J-tube. Increased diarrhea over past two weeks, describes it before as being light colored and frothy, now brown and watery. Has not initiated chemotherapy due to poor nutritional status. . Over the past few days at [**Hospital1 **], her LFTs rose to AP 1500, ALT 500 and TBili 1.4. Morning of [**2107-11-4**] she had fever to 101. She has chronic LLQ pain around J-tube, has new-onset RUQ pain and increase abd pain diffusely. Pain [**2106-3-9**], relieved with Dilaudid, exacerbated by eating. Noncon CT abdomen at [**Hospital1 **] showed diffuse intrahepatic and extrahepatic ductal dilitation and distention of the gallbladder. No obvious mass lesion was identified, however contrast was not used due to hx allergy to iodine. MRCP showed dilated CBD 16mm, fullness of pancreatic head (no obvious mass), massively distended gallbladder and right hydronephrosis. . Vitals prior to transfer: 111/63, 71, 97% on room air. Given Zosyn 2.25mg as empiric coverage for cholangitis prior to transfer. . ROS otherwise negative for headache, vision changes, congestion, cough, shortness of breath, chest pain, BRBPR, melena, hematochezia, dysuria, hematuria, frequency. Past Medical History: Gastric cancer, s/p subtotal gastrectomy, Roeux-en-Y gastrojejunostomy, J-tube([**2107-8-9**]) Cervical Laminoplasty C2-C6 on [**11-12**] Left calcaneal fracture s/p ORIF [**2103**] Hypothyroidism Macular Degeneration- left eye is legally blind GERD hx of pyloric channel ulcer Essential Tremor COPD hx of left salpingo-oopherectomy-remote past appendectomy in childhood Social History: Lives in [**Location 5289**], is a retired professor [**First Name (Titles) **] [**Last Name (Titles) 9929**]. She lives alone in a house and is divorced. Has 1 son who lives out of state. Has support at home since her surgery and VNA. Smoking - Smoked 1 pack per day since [**12**] y/o, currently smokes [**1-6**] cigarettes/day Alcohol - Rare Illicits - None Family History: Father-died of CAD at 84 Mother-died of 54 shy-[**Last Name (un) **] disease Maternal grandmother-renal Ca Maternal grandfather- lung cancer Physical Exam: ADMISSION PHYSICAL EXAM: VS - 100.2 138/80 82 18 96% RA GENERAL - NAD, cachectic, states she is in pain HEENT - NC/AT, PERRLA, EOMI, MM dry, OP clear NECK - supple, no cervical LAD or JVD LUNGS - CTA bilat, no r/rh/wh, breath sounds distant, resp unlabored HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, tender with voluntary guarding RUQ and right and left mid quadrants, ND, no appreciable ascites, no masses or HSM, J tube without exudate, no rebound or involuntary guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**4-7**] throughout, sensation grossly intact throughout Pertinent Results: Studies: IR PTBD placement [**2107-11-7**] - FINDINGS: 1. High-grade obstruction at the distal CBD. 2. Left biliary tree was not opacified. Follow-up interrogation should be performed if clinically indicated. 3.Placement of 10 French internal-external drain in the right posterior ductal system. 5. Satisfactory post-procedure cholangiogram demonstrating opacification of ducts and appropriate placement of catheter. . J-tube Fluoroscopic study [**2107-11-8**] - IMPRESSION: Functioning J-tube. . CXR [**2107-11-9**]: Heterogeneous pacity in right lower lobe may either represent pneumonia or aspiration pneumonitis. . Abdomen S&E [**2107-11-9**]: Decubitus and supine views of the abdomen show no evidence of free air. There is a paucity of air within the abdomen and retained enteric contrast is seen. The J-tube and biliary drains are unchanged in position. A vague opacity seen in the right lower lobe is concerning for either pneumonia or aspiration and is better characterized on the concurrent chest x-ray. A right-sided central line is noted. There are extensive degenerative changes about the lower lumbar spine . Gastrograffin J tube check [**11-11**]: IMPRESSION: No leak. J-tube is directed retrograde. . PTBD Check/Exchange [**2107-11-13**]: 1. Occluded existing 10 French percutaneous biliary drainage catheter. 2. High-grade stricture of the distal common bile duct, 1-2 cm distal to the cystic duct insertion. 3. Uncomplicated replacement of a 10 French internal-external biliary drainage catheter . PICC Placement CXR [**2107-11-14**]: 1. Left PICC tip in mid-to-low SVC. 2. Bibasilar atelectasis with developing right apical opacity, compatible with pneumonia . Biliary Stent Placement [**2107-11-16**]: 1. Reocclusion of a 10 French internal-external biliary drainage catheter. 2. Successful deployment of 12 mm x 90 mm Wallstent across the high-grade stricture of the distal common bile duct. 3. Pre-stenting and post-stenting balloon dilatation of the high-grade stricture of the distal common bile duct using a 12 x 40 mm balloon. 4. Temporary placement of a 10 French Amplatz anchor drain into the common hepatic duct anticipated to be removed within 24-48 hours. . . Biliary Stent Check [**2107-11-17**] 1. Occlusion of the metallic stent by the soft intraluminal debris after recent metallic stent deployment and balloon dilatation. 2. 10 French Amplatz anchor drain was left in place and connected to the bag for external drainage. 3. Anticipated recanalization of the stent/sweeping and dilatation will be performed with the assistance of department of anesthesiology, either under monitored anesthesia care or general anesthesia at the earliest available time. . Biliary Dilation [**2107-11-18**] 1. Pre-procedure occlusion of mid and distal portions of CBD Wallstent. 2. Successful balloon dilatation and sweeping of CBD stent, with post-procedure demonstration of stent patency. 8 French Amplatz anchor drain left with tip in proximal CBD with orders to cap at 1800 on [**2107-11-18**]. 3. J-tube injection showing probable antegrade orientation and no leak around jejunostomy site. . Biliary Dilation: [**2107-11-21**] 1. Complete obstruction of the stent distal to this cystic duct towards the duodenum. 2. Balloon dilatation with 12 mm x 40 mm balloon and balloon sweep towards the duodenum. 3. Placement of a 12 French internal-external biliary drain, which was capped f exchanged pr internal drainage. This drain needs to be changed every 3 months. . MICROBIOLOGY. Negative except where otherwise indicated [**2107-11-22**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-PENDING INPATIENT [**2107-11-13**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2107-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2107-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2107-11-12**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT [**2107-11-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2107-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2107-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2107-11-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2107-11-9**] URINE URINE CULTURE-FINAL INPATIENT [**2107-11-9**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2107-11-9**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2107-11-9**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM, VANCOMYCIN SENSITIVE}; Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL [**2107-11-9**] URINE URINE CULTURE-FINAL INPATIENT [**2107-11-8**] BILE GRAM STAIN-FINAL; FLUID CULTURE-FINAL {ENTEROCOCCUS SP. VANCOMYCIN SENSITIVE}; ANAEROBIC CULTURE-FINAL [**2107-11-5**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP. VANCOMYCIN SENSITIVE, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)} [**2107-11-4**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT PERTINENT CHEMISTRY RESULTS: [**2107-11-4**] 11:40PM BLOOD WBC-6.8 RBC-3.57* Hgb-9.8* Hct-32.3* MCV-91 MCH-27.5 MCHC-30.4* RDW-16.4* Plt Ct-367 [**2107-11-7**] 05:28AM BLOOD WBC-4.7 RBC-3.37* Hgb-9.2* Hct-30.5* MCV-91 MCH-27.2 MCHC-30.1* RDW-16.5* Plt Ct-420 [**2107-11-9**] 05:56AM BLOOD WBC-10.5# RBC-3.37* Hgb-9.3* Hct-29.8* MCV-88 MCH-27.6 MCHC-31.2 RDW-17.4* Plt Ct-399 [**2107-11-14**] 06:30AM BLOOD WBC-7.9 RBC-3.30* Hgb-9.1* Hct-28.7* MCV-87 MCH-27.6 MCHC-31.7 RDW-17.9* Plt Ct-377 [**2107-11-17**] 04:26AM BLOOD WBC-11.3* RBC-3.61* Hgb-9.9* Hct-32.0* MCV-89 MCH-27.3 MCHC-30.8* RDW-17.7* Plt Ct-596* [**2107-11-22**] 07:40AM BLOOD WBC-11.9* RBC-3.18* Hgb-8.7* Hct-27.3* MCV-86# MCH-27.3 MCHC-31.8 RDW-18.3* Plt Ct-334 [**2107-11-4**] 11:40PM BLOOD PT-13.5* PTT-36.9* INR(PT)-1.3* [**2107-11-7**] 05:28AM BLOOD PT-14.3* PTT-41.1* INR(PT)-1.3* [**2107-11-4**] 11:40PM BLOOD Glucose-81 UreaN-12 Creat-0.6 Na-136 K-4.2 Cl-97 HCO3-31 AnGap-12 [**2107-11-8**] 05:13AM BLOOD Glucose-131* UreaN-13 Creat-0.6 Na-138 K-4.0 Cl-103 HCO3-28 AnGap-11 [**2107-11-11**] 05:27AM BLOOD Glucose-102* UreaN-16 Creat-0.4 Na-137 K-3.6 Cl-106 HCO3-27 AnGap-8 [**2107-11-16**] 06:38AM BLOOD Glucose-139* UreaN-14 Creat-0.6 Na-138 K-4.5 Cl-103 HCO3-31 AnGap-9 [**2107-11-21**] 05:32AM BLOOD Glucose-165* UreaN-24* Creat-0.5 Na-134 K-4.7 Cl-98 HCO3-31 AnGap-10 [**2107-11-22**] 07:40AM BLOOD Glucose-96 UreaN-21* Creat-0.6 Na-132* K-4.1 Cl-96 HCO3-30 AnGap-10 [**2107-11-4**] 11:40PM BLOOD ALT-657* AST-512* LD(LDH)-211 AlkPhos-[**2042**]* Amylase-40 TotBili-2.0* [**2107-11-5**] 02:09PM BLOOD ALT-605* AST-494* AlkPhos-1847* TotBili-2.4* [**2107-11-6**] 11:00AM BLOOD ALT-467* AST-296* AlkPhos-1821* TotBili-2.2* [**2107-11-8**] 05:13AM BLOOD ALT-212* AST-51* AlkPhos-1107* TotBili-0.8 [**2107-11-9**] 05:56AM BLOOD ALT-147* AST-27 LD(LDH)-121 AlkPhos-924* Amylase-386* TotBili-1.6* [**2107-11-10**] 05:43AM BLOOD ALT-82* AST-20 AlkPhos-614* TotBili-0.9 [**2107-11-12**] 06:45AM BLOOD ALT-50* AST-31 AlkPhos-626* TotBili-2.3* [**2107-11-12**] 05:38PM BLOOD AlkPhos-543* TotBili-2.6* [**2107-11-13**] 06:50AM BLOOD ALT-50* AST-32 AlkPhos-525* TotBili-1.7* [**2107-11-14**] 06:30AM BLOOD ALT-34 AST-16 AlkPhos-420* TotBili-1.2 [**2107-11-20**] 03:45AM BLOOD ALT-61* AST-33 AlkPhos-258* TotBili-0.7 [**2107-11-22**] 05:49AM BLOOD ALT-41* AST-43* AlkPhos-191* TotBili-0.6 [**2107-11-22**] 07:40AM BLOOD ALT-45* AST-30 AlkPhos-220* TotBili-0.7 [**2107-11-4**] 11:40PM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.5 Mg-1.9 [**2107-11-9**] 05:56AM BLOOD Calcium-8.4 Phos-2.0* Mg-1.8 [**2107-11-13**] 06:50AM BLOOD Calcium-7.4* Phos-2.8 Mg-1.9 [**2107-11-22**] 07:40AM BLOOD Calcium-8.3* Phos-3.5# Mg-2.0 [**2107-11-18**] 05:52AM BLOOD Albumin-2.8* Calcium-8.7 Phos-3.1 Mg-2.0 [**2107-11-14**] 06:30AM BLOOD Triglyc-195* [**2107-11-13**] 06:50AM BLOOD Vanco-22.2* [**2107-11-14**] 06:50PM BLOOD Vanco-19.2 [**2107-11-9**] 12:03PM BLOOD Type-ART Temp-38.1 pO2-77* pCO2-39 pH-7.46* calTCO2-29 Base XS-3 Intubat-NOT INTUBA [**2107-11-9**] 12:03PM BLOOD Lactate-1.1 [**2107-11-9**] 12:06PM BLOOD Lactate-1.2 [**2107-11-9**] 09:06PM BLOOD Glucose-GREATER TH Lactate-1.0 URINE CHEMISTRY: [**2107-11-5**] 11:58AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 [**2107-11-8**] 08:57PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2107-11-9**] 10:45AM URINE Color-DKAMB Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2107-11-9**] 08:58PM URINE Color-Red Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2107-11-8**] 08:57PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2107-11-9**] 10:45AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-SM [**2107-11-9**] 08:58PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2107-11-5**] 11:58AM URINE RBC-2 WBC-7* Bacteri-MOD Yeast-NONE Epi-1 [**2107-11-8**] 08:57PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2107-11-9**] 10:45AM URINE RBC-28* WBC-7* Bacteri-FEW Yeast-NONE Epi-0 [**2107-11-9**] 08:58PM URINE RBC-135* WBC-24* Bacteri-FEW Yeast-NONE Epi-0 Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION: 69 year old female with gastric cancer s/p Roux-en-Y gastrectomy [**8-/2107**] admitted with cholangitis s/p PTBD placement and failed biliary stent placement across malignant stricture. ACTIVE PROBLEMS # Pain control/nausea/anxiety/agitation/palliation - Patient with chronic abdominal pain, acutely worsened with cholangitis. She has a significant narcotic requirement, and palliative care was consulted to provide guidance with narcotic use. Regimen initially included dilaudid and methadone. Patient was ultimately continued on methadone and switched to dilaudid PCA. Patient had difficult to control nausea and emesis. Nausea was controlled with ondansetron, promethazine, and lorazepam. Additional prochlorperazine was also used occasionally. Patient was also started haldol with good effect. Later she was transitioned to thorazine for nausea with the intent of providing relief from nausea and also for sedation as patient was very agitated and restless. She continued to suffer even on the regimen of standing and PRN thorazine, dilaudid, methadone, decadron. She received ativan for sedation with paradoxical agitation. She remained delerious likely secondary to pain and steroids. Patient and her son/health care proxy [**Name (NI) 333**] both expressed wishes that she receive palliative sedation as she was restless and intermittently agitated on multiple regimens. The palliative care service recommended palliative sedation, which was consistent with the patient's wishes. On [**11-30**], there was a meeting with the primary medical team, palliative care, ethics service, social work, nursing, hospice, and hospital administration. As all other palliative measures had been exhausted, it was felt that palliateive sedation was the most appropriate and medically necessary treatment. Please see OMR notes by ethics service, palliative care, and medicine from [**11-30**] for further details. Patient was started on a pentobarbital infusion and was able to rest peacefully with marked improvement in agitation. On [**11-30**] at 16:48, patient expired. #) Cholangitis: Patient presented from LTAC with increased RUQ pain, fever, and rising T.Bili givng concern for cholangitis. She was treated empirically for cholangitis with ciprofloxacin and flagyl. PTBD drain was placed on [**11-7**] with initial resolution of fevers and T. Bili began to downtrend. Of note, cholangiogram during procedure revealed high grade obstruction of the distal CBD. On the morning of [**11-9**] she re-developed fever and blood pressures began to drop to 90'/50's initially unresponsive to IVF bolus on the floor necessitating transfer to the MICU. Antibiotics were broadened to vancomycin and zosyn and patient underwent further aggressive fluid resuscitation. Fevers and hypotension resolved and patient was transferred back to the floor on [**11-11**]. Microbiology cultures of blood, urine, and bile were notable for ampicillin-resistant enterococcus sensitive to vancomycin. Patient remained afebrile, although did require PTBD drain exchange on [**11-13**] for rising T. Bilirubin. Patient underwent biliary stent placement on [**11-15**]. Repeat PTCA showed occlusion of stent. She returned to IR for recanulization of stent, which unfortunately failed. An internal drain was placed through stent to drain into the duodenum and external drain also placed. Patient completed 14 day course of Vancomycin and Zosyn on [**2107-11-23**]. #) Nutrition: Patient was chronically malnourished with 30 lb recent weight loss, and has been on tube feeds and TPN concurrently prior to admission. TF's were initially held as to not exacerbate abdominal pain and TPN was continued. Upon reinstitution of TF's, there was concern for malfuction of J-tube due to apparent leakage. Fluoroscopic and gastrograffin studies of the J-tube revealed functioning, but retroverted positioning of J-tube. Further evaluation of J-tube revealed anterograde, funtioning tube. Following development of VSE bacteremia, TPN was held as PICC line was removed. PICC was replaced on [**11-14**] following >72 hours of negative blood cultures and TPN was resumed on [**11-15**]. TPN was discontinued on [**2107-11-22**] given patient's goals of care. #) Right hydronephrosis: Has evidence of ureteralpelvic junction obstruction on MRCP. No stone seen, renal function is normal. Urology was [**Name (NI) 653**], and recommended [**Name (NI) 109221**] scan. Given transition of goals of care, no further action was taken. CHRONIC PROBLEMS #) Gastric adenocarcinoma s/p surgical resection: Originally diagnosed after subtotal gastrectomy with roux-en-y ansatomosis on [**8-/2107**] for presumed gastric outlet obstruction. Lymph nodes and omental margins were positive, but duodenal and gastric margins were negative. Patient did not receive additional treatment due to complicated post-operative involving severe pain, nausea and malnutrition. Patient was deemed to be a poor candidate for chemotherapy, palliative or otherwise. #) Anemia: Stable, baseline low and variable. Normocytic anemia, likely ACD, however had iron studies which were normal. Stable and no signs of active bleed. Medications on Admission: tylenol 325-650mg q6H PRN albuterol inhaler PRN arixtra 2.5mg daily fluticasone 220mcg [**Hospital1 **] hydromorphone 4mg q4H PRN through jtube Jevity 1.2 full strength at 30mL/hour and 55ml/hour is target levothyroxine 100mg IV daily (just increased on [**11-5**] from 50mcg daily) lorazepam 0.5mg q4H PRN nausea through jtube methadone 7.5mg q6H through jtube nicoderm patch 14mg daily oil retention enema PR daily PRN zofran 4mg IV q4H PRN nausea pantoprazole 40mg IV daily zosyn 2.25mg IV q6H (started on [**2107-11-5**] for possible cholangitis) compazine 5mg IV q6H or 25mg PR q12H PRN nausea promote with fiber at 30mL and hour with goal of 55mL/hr and TP cycled starting at 7PM Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Primary: Cholangitis, Gastric adenocarcinoma Discharge Condition: Patient expired Discharge Instructions: Not applicable. Followup Instructions: Not applicable. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]

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Discharge summary

report

Admission Date: [**2105-7-9**] Discharge Date: [**2105-7-15**] Date of Birth: [**2046-4-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1491**] Chief Complaint: Transfer from OSH for SVT Major Surgical or Invasive Procedure: Diagnostic peritoneal fluid tap ~10cc History of Present Illness: 59 yo M with MMP including cirrhosis of unclear etiology, Hep C, CRF on HD, anemia, hypothyroidism transferred from OSH for SVT. Patient was admitted to OSH on [**7-4**] with tachycardia admitted to CCU with HR 160, narrow complex, CP [**6-22**], a/w SOB, O2 sats 88%-->97-98% on 2L NC. Patient converted with Adenosine 6 mg IV x 1, HR decreased to 98-103. Patient then had a second episode of SVT on [**7-8**], recieved Adenosine 6 mg then 12 mg and converted again. Patient's BP remained 90-100s which is his baseline. Patient then transferred for further management. Upon transfer BP 98/47 HR 95 RR 15 O2 sat 96% 2L. Today patient also spiked a temp to 102.3 treated with gent 80 mg iv x 1, vanco 1 gm x 1 then Ancef x 1. . He reports [**2-14**] lifetime episodes, each time a/w chest pressure and shortness of breath, which started a few months ago while at a rehab facility. His second episode was at dialysis. Patient denies CP or pressure otherwise. He has shortness of breath a/w COPD and abdominal distension and noticed increased LE edema over the past few months requiring increasing doses of lasix and prompting recent admission on [**6-10**] to same OSH. . Upon arrival to the CCU, patient was stable with HR in 80-90s. Denies any CP, cough, sob, sputum production, N/V, abdominal pain or other complaints at this time. Past Medical History: - etoh cirrhosis (per OSH) with h/o hepatic encephalopathy - portal hypertension +/- esophageal varices - HCV - CRF - AOCD - +TOB - LE edema - COPD - T3 hypothyroidism - h/o thrombocytopenia - DJD - h/o PNA, bronchitis . Past Surgical Hx: Periumbilical hernia s/p repair [**2101**]; lumbar laminectomy, shoulder sx, ventral hernia repair Social History: Married, lives with wife and mother-in-law. Used to work as an auto mechanic. Patient strongly denies every drinking heavily, used to have a "couple of beers" and stopped drinking anything after he was dx with liver dz. Unclear how he contracted Hep C. Smokes few cigarettes per day, ppd x 45 yrs, no IVDA. Family History: Etoh abuse, hyperlipidemia, thyroid disease, anemia Physical Exam: VS: 99.7 98/46 89 18 99% RA Ht 6'0" Wt 180 lbs Gen: ill appearing male, NAD HEENT: OP clear and moist, edentulous, slightly icteric, EOMI Neck: supple, no LAD, no JVD Chest: diffusely poor air entry, no BS at bases ~1/3 up CVS: nl S1 S2, RRR, no m/r/g Abd: distended, soft, NT x 4, diffuse echymoses and prominent veins, +ventral hernia ~5x5 cm, ?fluid wave, NABS, unable to appreciate any hepatosplenomegaly Ext: warm bilaterally, symmetric calves, 2+ pulses, decreased sensations b/l in feet, 1+ edema b/l to mid calf. Neuro: CN II-XII grossly intact, no flap, strength full throughout, sensations decreased in b/l LE Pertinent Results: ---OSH labs: [**7-8**] Na 138 K 3.6 Cl 103 CO2 29 Bun 7 Cr 3.3 Glu 129 ---CBC [**7-7**] WBC 5.8 Hct 26.6 Plts 36 ---Bl cx x 2 pending . LABS: AT ADMISSION: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2105-7-9**] 10:30PM 7.6 3.26* 10.6* 31.1* 96 32.5* 34.1 17.8* 33 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2105-7-9**] 10:30PM 153* 13 3.4* 136 3.3 99 25 15 . AT DISCHARGE: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2105-7-15**] 05:47AM 6.0 2.99* 10.1* 30.1* 101* 33.7* 33.4 20.0* 50 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2105-7-15**] 05:47AM 106* 15 3.7* 135 4.1 103 26 10 . LFTs: ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2105-7-13**] 05:35AM 18 49* 233 158* 0.7 . ASCITES FLUID: WBC RBC Polys Lymphs Monos Mesothe Macroph [**2105-7-13**] 04:42PM 160* 200* 3* 16* 58* 8* 15* ASCITES CHEMISTRY TotPro Glucose LD(LDH) Albumin [**2105-7-13**] 04:42PM 1.0 165 61 <1.0 . . CARDIAC: cTropnT [**2105-7-12**] 08:00AM 0.02 [**2105-7-10**] 04:56AM 0.02 [**2105-7-9**] 10:30PM <0.01 . CK(CPK) [**2105-7-12**] 08:00AM 19 [**2105-7-10**] 04:56AM 12 [**2105-7-9**] 10:30PM 12 . HEME: calTIBC Ferritn TRF [**2105-7-10**] 04:56AM 60* 927* 46* . TSH [**2105-7-10**] 04:56AM 3.2 . PEP IgG IgA IgM IFE [**2105-7-14**] 05:25AM MULTIPLE T1 1570 451* 301* NO MONOCLO2 . HBsAg HBsAb HBcAb [**2105-7-14**] 05:25AM NEGATIVE - - [**2105-7-10**] 04:56AM - NEGATIVE NEGATIVE . . AUTOANTIBODIESAMA Smooth [**2105-7-10**] 07:38PM NEGATIVE POSITIVE . [**Doctor First Name **] AFP [**2105-7-10**] 07:38PM NEGATIVE [**2105-7-10**] 04:56AM 3.71 . MICRO: HEPATITIS C VIRUS RNA BY PCR, QUALITATIVE Test Result HCV RNA, QUAL, PCR NOT DETECTED . IMAGING: [**2105-7-10**] ABDOMINAL U/S: IMPRESSION: Cirrhotic liver with moderate ascites and patent forward portal venous flow. No hepatic masses on this limited exam. Cholelithiasis with no evidence of cholecystitis. . [**2105-7-10**] ECHO: Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 70%). Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure (<12mmHg). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [**2105-7-10**] ECG: Sinus rhythm. Borderline left axis deviation. Possible left anterior fascicular block. No previous tracing available for comparison . [**2105-7-13**] CXR PA&LAT: Dialysis catheter remains in place with the distal lower tip within the right atrium, unchanged. There is slight worsening of opacity in the right lower lobe, particularly in the right retrocardiac region, which has an adjacent linear component. This may be due to either atelectasis or pneumonia. Small right pleural effusion is also noted on the lateral view. Brief Hospital Course: A/P: 59 yo M with cirrhosis of unclear etiology (?HepC), CRF on HD, anemia, HepC, hypothyroidism, and SVT controlled with rate control admitted for continued management of renal failure and liver transplant evaluation. . # SVT: Patient was admitted to [**Hospital1 18**] initially for continued management of SVT. Patient had two episodes of SVT at OSH which both converted with adenosine. Patient was stable with rate control since conversion. He was maintained on Propanolol with good HR control and no further episodes of SVT. His CE did not indicate active ischemia. His ECHO also showed a normal EF, without any wall motion abnormalities. . # CIRRHOSIS: Unclear etiology of patient's liver cirrhosis. Patient transferred here for further evaluation of cirrhosis and management. Formal transplant evaluation was started while patient was admitted. Hepatitis serologies were negative. Patent portal flow noted on abdominal U/S. Pt had diagnositc tap which did not show SBP. Pt was to complete liver transplant w/u as outpatient. His diuretics were not resumed at time of discharge. Pt had several episodes of hypotension requiring several boluses of 250cc NS. His BP remained 90s without any symptoms. He was to follow up with Dr. [**Last Name (STitle) 497**] in 2 weeks and possibly resume diuretics then. . # FEVER: Patient had a Tmax of 102.3 at the OSH and had one episode of a mild fever with chills and SOB. CXR demonstrated question of right lower lobe infiltrate and patient was started on cefepime and vancomycin to cover hospital-acquired pneumonia. Repeat PA and Lat done which also noted RLL infiltrate. He was switched to levofloxacin and was sent home on Levo to complete 7day course for PNA. He remained on RA with stable O2 sats. . # CRF on HD. Patient's renal failure was though to be secondary to hepatorenal syndrome, although urine Na was 20 on admission. Pt was continued on HD without incident 3x/week. His Cr at time of discharge was 3.7. . # Anemia. Patient was noted to be anemic at OSH with Hct of 26.6. Patient's anemia likely multifactorial in etiology - anemia of chronic disease and question of slow GI bleed given likely portal gastropathy. No hematemesis/melena per patient. Patient was continued on Procrit. He did not require blood transfusions, his iron studies were c/w ACD. . # COPD. Patient was maintained on albuterol and atrovent nebs. His O2 sats were stable on RA. . # Hypothyroidism. Patient was maintained on thyroid replacement per home regimen. . #. CODE: FULL Medications on Admission: - Lasix 80 mg daily - Prilosec 20 mg daily - Cytomel 25 mcg [**Hospital1 **] - Dilaudid 4 mg TID - Iron TID - Lactinex 2 tabs po TID - Lactulose 30 cc [**Hospital1 **] - Lopressor 25 daily - Magnesium 400 daily - MVI - Procrit 40,000 qwk - KCl 20 daily - Selenium - Soma - Thiamine - Folate . Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 5. Liothyronine 25 mcg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Liver Cirrhosis Chronic renal failure on HD Presumed Pneumonia DM SVT Discharge Condition: Stable Discharge Instructions: Please take all your medications as directed and keep all your follow up appointments. . If you have increasing abdominal girth, with incresed weight, shortness of breath, vomiting blood or have bright red blood from below or any other concerning symptoms please call your physician or go to the emergency room. . Followup Instructions: 1. Please follow up with your Primary care physician [**Name Initial (PRE) 176**] [**1-16**] weeks. Please call his office for an appointment. . 2. Transplant Hepatolgy: [**Name6 (MD) **] [**Name8 (MD) **], MD, Phone:[**Telephone/Fax (1) 673**], [**2105-8-10**] at 11:00am . 3. Transplant Social Work: [**Last Name (LF) **],[**First Name3 (LF) 156**], [**2105-8-10**] at 2:00pm. . Completed by:[**2105-7-19**]

[ "285.9", "599.0", "585.9", "070.70", "486", "496", "571.5", "427.89", "244.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "39.95" ]

icd9pcs

[ [ [] ] ]

10119, 10125

6651, 9165

340, 380

10238, 10247

3155, 3519

10609, 11021

2446, 2499

9509, 10096

10146, 10217

9191, 9486

10271, 10586

2514, 3136

3533, 6628

275, 302

408, 1743

1765, 2105

2122, 2430

19,410

116,240

22197

Discharge summary

report

Admission Date: [**2153-8-20**] Discharge Date: [**2153-8-22**] Date of Birth: [**2089-9-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: fevers Major Surgical or Invasive Procedure: Intubation Resuscitation for cardiac asystole History of Present Illness: 63 year-old Chinese-speaking man with a history of rheumatic heart disease status post prosthetic MVR & [**First Name3 (LF) 1291**], afib/flutter s/p MAZE on coumadin, who presents with fevers x 2days. Interpretation provided by family member. Mr. [**Known lastname **] had been in his USOH until two days prior to admission, when he devloped chills & subjective fevers. These persisted and his wife noted some confusion on the day of presentation, noting that he would not answer her questions appropriately. He was brought to the ED for further evaluation. . In the ED, vitals were rectal Temp 105, BP 99/58, then dropped in to 80s systolic, HR 90s O2sat 93%RA. Bld cx were sent. UA showed possible UTI ([**5-29**] WBC & Mod bacteria). Crt was elevated at 1.4. K was 2.9. CXR showed no infiltrates. He received 4L IVF, vanc & zosyn as well as tylenol and potassium. He is being admitted . ROS: Positive for for fevers, chills. Pt reports feeling generally weak. He denies cough, SOB, CP, although he does have chronic R shoulder/upper back pain. No abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia, hematemesis, dysuria. No HA/dizziness/paresthesias or weakness. Past Medical History: -Rheumatic heart diseaseStatus post [**First Name8 (NamePattern2) 1495**] [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] & MVR, and MAZE [**2150-3-12**], on Coumadin -Atrial fibrillation (previously on amiodarone [**2149**]-[**2150**]) -Pericardial effusion, status post pericardial window. -Peri-op pleural effusion. -[**2150-3-10**] Cath: LMCA, LAD, RCX, and RCA showed mild irregularities w/o flow limiting stenoses. 2+ MR. 2+ AR. Mild global hypokinesis. EF 43% Social History: immigrated to the US in [**2147**]; family live in area Family History: NC Physical Exam: VS: T 100.5, 88, 82/51 RR 19, 96% RA GEN: slightly tired appearing, NAD HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema or exudate or hemorrhagic lesions NECK: Supple, no LAD, no appreciable JVD CV: RRR, metallic S1S2, [**1-24**] syst murm at LUSB and apex-->axilla, no rubs or gallops PULM: CTAB, though slightly decreased at b/l bases, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, no abdominal bruit appreciated EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema Skin: Osler's Node on L big toe; ? few petechiae on RLE & L foremarm NEURO: alert and orient to self, [**Hospital1 **], [**2153-8-20**], says he's here b/c he's sick, CN 2-12 intact; moving all limbs; sensation grossly intact to light touch Pertinent Results: CT head [**2153-8-21**] Extensive bilateral subarachnoid hemorrhage without significant mass effect, edema, or shift of normally midline structures on the current study. There is also no definite evidence of intraventricular blood at this time. Brief Hospital Course: 63 year-old man w/ a history of rheumatic heart disease s/p St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] & MVR in [**2149**] with MAZE for afib, who presented with fever (as high as 105 rectal) and found have staph bacteremia. Patient with sepsis with fever, elevated WBC (11.1), and hypotension. Treated for endocarditis as source of sepsis although TEE showed no vegetations with vanco, cefepime, and gentamycin. Physical examination revealed osler's node on L big toe. He has [**1-24**] syst murmur both at LUSB & apex-->axilla (?new). Pt also does not have e/o other infections. CXR overall clear. Urine only has [**5-29**] WBC so less likely that this is source. Lactate improving w/ IVF. Pt mentating clearly & making urine until [**2153-8-21**] when he had acute event at approximately 6:30pm when he became acutely unresponsive, had flaccid paralyis, was noted to have vomited and have been incontinent of stool, left blown pupil, b/l not constricting to light. Emergently intubated and head scanned, showed large subarachnoid hemorrhage. On arrival back to the floor was tachycardic. Rapidly became hypotensive became asystolic, coded, perfusing rhythm re-established. Heparin and INR reversed. Cardiac [**Doctor First Name **] called, agreed with full reversal in this situation. Neurosurgery consulted. Recommended mannitol, no current indication for acute surgery. Pt maxed out on 5 pressors, received 13+ L IVF, given bicarb for profound acidemia, also given FFP, factors, vitamin K and protamine. Family meeting was held, family informed of gravity of pt's prognosis and expectation that he may not survive the night. Decision was made to continue aggressive care but to make pt DNR. PEEP increased as pt persistently difficult to oxygenate. On [**2153-8-22**], as patient did not regain any neurologic function and continued to be hypotensive despite maximal pressor support, and with O2 sat in 70s despite intubation, family meeting was called to discuss goals of care and patient was made comfort measures only. Pressure support was withdrawn, patient extubated, and he had a quick decline but was comfortable at time of death at 4:45pm [**2153-8-22**] with family at bedside. Medications on Admission: metoprolol 12.5 mg b.i.d., Coumadin 2-3.5mg daily MVI Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired

[ "995.92", "518.81", "430", "287.5", "785.52", "038.11", "599.0", "996.61", "V58.61", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5686, 5695

3299, 5541

321, 368

5754, 5771

3027, 3276

5835, 5853

2193, 2197

5646, 5663

5716, 5733

5567, 5623

5795, 5812

2212, 3008

275, 283

396, 1588

1610, 2103

2119, 2177

30,265

164,752

34332

Discharge summary

report

Admission Date: [**2163-8-16**] Discharge Date: [**2163-8-24**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: s/p fall due to syncopal episode after exiting car Major Surgical or Invasive Procedure: None History of Present Illness: 83 yo male who experienced a syncopal episode in his driveway after exiting his car. Per medical record, the fall was witnessed by a family member who states that the patient fell backwards onto his head and back. Pupils at that time were unequal but per patient this is a long standing issue secondary to a stroke. Patient was confused but followed commands. Neurological exam was non-focal. Patient was admitted to an OSH ([**Hospital3 15402**]) which idenfied a subarachnoid, subdural, and intraxial hemorrage. Past Medical History: 1. strokeX2 "50 years ago" 2. s/p Carotid endararectomy, complicated by "stroke" and left pupilary abnormailties and EOM abnormalitites. Social History: Denies ETOH, tobacco Family History: non-contributory Physical Exam: On Admission: PHYSICAL EXAM: T: 98 BP: 151/88 HR: 110 R 20 O2Sats 92% 2L Gen: NAD HEENT: Normocephalic. Pupils: Left fixed and non-reactive, right 3-2mm EOMs: intact on right; left upper gaze deficit Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition.. Cranial Nerves: I: Not tested II: see above Visual fields are full in upper out medial and lateral fields, but unable to see in inferior field III, IV, VI: Extraocular movements intact on right, restricted left. Per patient, deficits are longstanding on left. V, VII: Facial sensation intact, left eyelid with mild ptosis VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue deviates to left, long standing Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-16**] throughout. No pronator drift Sensation: Intact to light touch. Reflexes: Pa Ac Right 2+ 2+ Left 2+ 2+ Toes upgoing bilaterally On Discharge: AOx3, PERRL on the right, left pupil is fixed dilated(per baseline). Follows all commands, full strength throughout upper and lower extremities. Pleasant affect. Pertinent Results: [**2163-8-19**] 06:10AM BLOOD WBC-9.9 RBC-4.75 Hgb-15.1 Hct-43.3 MCV-91 MCH-31.9 MCHC-34.9 RDW-13.9 Plt Ct-233 [**2163-8-16**] 06:25PM BLOOD Neuts-92.0* Bands-0 Lymphs-5.1* Monos-2.5 Eos-0.2 Baso-0.3 [**2163-8-16**] 06:25PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2163-8-18**] 02:10AM BLOOD PT-17.0* PTT-28.9 INR(PT)-1.5* [**2163-8-19**] 06:10AM BLOOD Glucose-87 UreaN-26* Creat-1.2 Na-139 K-4.3 Cl-98 HCO3-32 AnGap-13 [**2163-8-19**] 06:10AM BLOOD Calcium-9.1 Phos-2.1* Mg-2.2 [**2163-8-18**] 02:10AM BLOOD Phenyto-11.6 Head CT: [**8-16**]: IMPRESSION: 1) Two areas of intraparenchymal hemorrhage/ hemorrhagic contusions within the frontal lobes bilaterally, each measuring 2 cm and surrounded by a small amount of edema. Bilateral anterior frontal subdural hematomas. Small left temporal subdural hematoma. Scattered areas of subarachnoid hemorrhage, predominantly within the frontal lobes, left temporal lobe. No significant associated mass effect.S Subdural hemorrhage noted along the tentorium on the left. 7 mm calcification vs bleed in right basal ganglia. 2) Dilatation of the left lateral ventricle and to minimal extent, the third ventricle. Head CT: [**8-17**]: The bilateral hematomas in the frontal lobes appear stable compared to the previous scan. Multifocal bihemispheric subarachnoid hemorrhage appears stable compared to the previous scan. The left subdural hematoma and the frontal right subdural hematoma appear stable compared to the previous scan. There is no shift of normally placed midline structures. Layering of intraventricular blood is stable compared to the previous scan. There is no change of size in ventricles compared to the previous scan. No fractures are identified. Brief Hospital Course: 83M admitted [**8-16**] s/p fall due to syncopal episode in driveway after exiting his car. He was found to have two areas of intraparenchymal hemorrhage/ hemorrhagic contusions within the frontal lobes bilaterally. Bilateral anterior frontal subdural hematomas. Small left temporal subdural hematoma. Scattered areas of subarachnoid hemorrhage, predominantly within the frontal lobes, left temporal lobe. No significant associated mass effect. Subdural hemorrhage noted along the tentorium on the left. Dilatation of the left lateral ventricle and to minimal extent, the third ventricle. Pt did not have any focal deficits, did have difficulties with EOM in L eye and left pupil was fixed and dilated, however this was his baseline due to prior stroke after CEA surgery. Pt was admited to the ICU for 24h observation and had Head CT on [**8-17**] which showed evolving bifrontal hemorrhagic contusions. More evident bihemispheric subarachnoid hemorrhage. New intraventricular blood, layering in the lateral ventricular atria without change in the ventricular size. Slightly enlarged left and stable right subdural hematomas, without mass effect. Pt did remain stable. On the [**8-18**] the Head CT was again repeated showing no interval change compared to the previous scan. He was then transferred to the floor given his stable radgiographic examination. His diet was advanced as tolerated and he was evaluated by physical therapy. They recommend [**Hospital 98**] rehab for continued strengthening and conditioning. While in the ICU, geriatric service was consulted for concerns relating to his syncopal episode. Their recommendations were negative in result during this hospital stay (no arrhythmia noted on telemetry, now EKG changes, and patient was maintained euvolemic). The did additionally recommend following up with a cardiologist for possible consideration of holter monitor as an outpatient. [**8-22**]: Geriatric service continues to follow due to pts increased confusion, dysphagia and dysarthria. Repeat CT of brain done and remains unchanged as compared from the [**8-18**] scan. It was recommended also that [**Known firstname **] continue on a regular diet, thin liquids, crush all meds. The head of bed should be up 40 degrees for at least 30 minutes following all meals. CXR stable no acute changes. [**2163-8-23**]: CTA-Brain done. There is Lt ICA complete occlusion @ cerv + Pitrious. Lt middle & ant. cerb artery are patent. Multiple aneuyrsms are present. 1. Lt P1 of post. cereb. 9mm. 2nd: P1 segment 4mm distal. 3rd: Lt Pcomm origin 5.5 mm. Mult. Beaded vessels c/w vasculitis Lt. PCA. Focal narrowing right PCA. It is felt that patient has been asymptomatic from the aneurysms to this point. He Will need to have a CT-A of the neck completed as an outpt for further evaluation. Medications on Admission: HCTZ Benzodiazapine Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for Deficiency. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 54351**] - [**Location (un) 5503**] Discharge Diagnosis: Bilateral frontal intraparenchymal hemorrhages. Bilat. small anterior frontal Subdural hematoma. [**2163-8-23**]: CTA done. Asymptomatic Lt ICA complete occlusion @ cerv + Pitrious. Lt middle & ant. cerb artery are patent. Mult. aneuyrsms. 1. Lt P1 of post. cereb. 9mm. 2nd: P1 segment 4mm distal. 3rd: Lt Pcomm origin 5.5 mm. Mult. Beaded vessels c/w vasculitis Lt. PCA. Focal narrowing right PCA. Discharge Condition: Neurologically Stable 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, and Ibuprofen etc. ??????If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ??????New onset of tremors or seizures. ??????Any confusion, lethargy or change in mental status. ??????Any numbness, tingling, weakness in your extremities. ??????Pain or headache that is continually increasing, or not relieved by pain medication. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in [**1-12**] weeks. THIS SHOULD BE THE NEXT AVAILABLE APPOINTMENT ??????You will need a CT-A scan of the neck completed which will be arranged by our office. During your hospitalization; the Geriatric Medicine Team was consulted and made the additional recommendations: 1. Please arrange for additional follow-up with a cardiologist of your PCP's choice for futher work-up of your syncopal episode, and possible consideration for Holter monitoring. Completed by:[**2163-8-24**]

[ "780.2", "437.4", "293.0", "348.8", "E885.9", "348.5", "V12.54", "433.80", "437.3", "851.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8086, 8161

4320, 7136

317, 324

8604, 8628

2531, 3111

9632, 10269

1083, 1101

7207, 8063

8182, 8583

7162, 7184

8652, 9609

1146, 1384

2348, 2512

227, 279

352, 869

1586, 2334

3752, 4297

1130, 1130

1399, 1570

891, 1029

1045, 1067

12,277

175,101

18724

Discharge summary

report

Admission Date: [**2172-7-10**] Discharge Date: [**2172-7-12**] Date of Birth: [**2115-4-30**] Sex: M Service: CU HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with known CAD, coronary artery disease who is status post PTCA/MI in [**2165**] who was doing well until he presented to an outside hospital with substernal chest pain, which had awoken him from sleep. It was nonradiating. The patient complained of associated weakness, dizziness, diaphoresis and some shortness of breath. However, there was no nausea or vomiting. He also complained of a pain in his back. An EKG revealed ST elevation in leads II, III and aVF. The patient was started on heparin and a lidocaine drip, P and K at half the dose and a 2B3A inhibitor, a baby aspirin and Lopressor 25 mg and was transferred to [**Hospital1 188**] for cardiac catheterization. When he arrived at [**Hospital1 1444**] he did have a sudden onset of SVT, supraventricular tachycardia, for which he was given lidocaine. The patient arrived to the [**Hospital1 190**] catheterization laboratory at 6 in the morning. His chest pain had resolved and he was hemodynamically stable. MEDICATIONS ON ADMISSION: He was on Lopressor 25 mg p.o. b.i.d. He was started on Lopressor on [**7-10**] after the MI. On [**7-11**] an ACE inhibitor, lisinopril was added at 5 mg q.d. The dose was titrated up on the 2nd to 10 mg q.d. ALLERGIES: No known drug allergies. PAST MEDICAL HISTORY: CAD status post MI in [**2165**] and hyperlipidemia. FAMILY HISTORY: Not significant. SOCIAL HISTORY: No alcohol. The patient reports having quit smoking and no IV or street drug abuse. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 110/60, heart rate 78, respiratory rate 16. General: Alert and oriented, lying flat in bed, in no apparent distress. HEENT: Sclerae were anicteric, mucous membranes were moist. There was no JVD or JVP appreciated. Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Respiratory: Clear to auscultation bilaterally without crackles. Abdomen: Soft. Nontender. Nondistended. Extremities: Warm. His hands were cool without edema. His pulses radial and DP were 2+ bilaterally. The right cardiac catheterization site, there was a small, soft hematoma. No bruit was heard. LABORATORY DATA: Significant laboratory from the outside hospital revealed his hematocrit was 35.1. Electrolytes were fine. CPK 176, MB 4.9, troponin I 0.37. The catheterization at [**Hospital1 69**] on the first showed 60% mid LAD lesion, 70% at the origin of LAD. The left circumflex had mild, diffuse disease. The RCA had 90% mid, 70% distal stenosis. Hepacoat stents were placed in the proximal, mid and distal RCA. Wedge pressure was 16. His RA pressure was 12. An LV ventriculogram showed 60% with normal systolic function. HOSPITAL COURSE: The patient was admitted to the CCU. Cardiac wise he was continued on the aspirin, Plavix, Lopressor 25 b.i.d. CKs were serially checked and they began to trend down. On the day of discharge his CK was 648. The patient had no further episodes of chest pain or EKG changes during his hospital course. He was on telemetry and throughout his hospital stay he was in normal sinus rhythm. There were no other ectopies. The patient's LV function was 60%. The LV had a 60% ejection fraction. He was continued on IV fluids at 150 cc per hour to maintain his preload, given his territory of his myocardial infarction. For his right groin hematoma, the Integrilin was stopped at 1800 hours on [**7-11**]. The patient showed no further signs of bleeding. The right groin hematoma was serially followed. It was stable throughout his hospital course and was beginning to decrease. There were no bruits auscultated throughout his hospital course. Hyperlipidemia. He was started on Lipitor 20 mg q.d. On discharge he was given a prescription for Lescol XL 80 mg q.d. The patient was noted to have an elevated LDL during his hospital course. The patient was seen by physical therapy and they recommended that he have outpatient cardiac rehabilitation for a week post MI. DISCHARGE INSTRUCTIONS: The patient was discharged home on [**7-12**] with the following instructions. If you experience any chest pain, nausea, vomiting or shortness of breath, please [**Name8 (MD) 138**] M.D. or return to the ER. Take all medications as instructed. Do not continue Plavix unless instructed by a cardiologist. FINAL DIAGNOSES: 1. Myocardial infarction, non ST elevation myocardial infarction, status post cardiac catheterization. 2. Coronary artery disease, status post myocardial infarction in [**2165**] and [**2171**]. 3. Hyperlipidemia. RECOMMENDED FOLLOWUP: He is to follow up with his PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within the next week. He is to be referred to a cardiologist per Dr. [**Last Name (STitle) **] and he can schedule. If he does not follow up with his cardiologist, he should schedule an appointment with Dr. [**Last Name (STitle) **], cardiology at [**Hospital1 346**] as necessary. He is to follow up and have an outpatient PMIBI to evaluate his 60% LAD stenosis and see if there is reversible ischemia. MAJOR SURGICAL OR INVASIVE PROCEDURES DURING THE HOSPITAL COURSE: Cardiac catheterization. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Clopidagrel 75 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., Lescol XL 80 mg p.o. q.d., lisinopril 10 mg p.o. q.d. The patient is also to follow up with physical therapy for outpatient cardiac rehabilitation in four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Name8 (MD) 8736**] MEDQUIST36 D: [**2172-7-12**] 12:30 T: [**2172-7-19**] 11:36 JOB#: [**Job Number 51316**] cc:[**Last Name (NamePattern4) 51317**]

[ "998.12", "272.4", "410.41", "414.01", "401.9", "V45.82", "412" ]

icd9cm

[ [ [] ] ]

[ "36.06", "36.01", "88.56", "88.53", "37.23", "99.20" ]

icd9pcs

[ [ [] ] ]

5410, 5419

1541, 1559

5443, 5995

1195, 1447

2892, 4165

4190, 4498

4515, 5388

160, 1168

1698, 2874

1470, 1524

1576, 1683

7,574

194,772

25648

Discharge summary

report

Admission Date: [**2186-4-27**] Discharge Date: [**2186-5-2**] Date of Birth: [**2143-11-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2024**] Chief Complaint: Dizziness and headache Major Surgical or Invasive Procedure: Right-sided ventriculoperitoneal shunt placement with endoscopic assistance History of Present Illness: 42y woman with metastatic breast cancer (HER-2 positive) with hepatic involvement, C-spine/L-spine and hip involvement (s/p lumpectomy in [**2180**]; radiation treatment to bony mets; ongoing chemotherapy). She now presents with mild frontal headache of 2 weeks duration, then 3 days of dizzyness with nausea and vomiting. MRI brain today showed multiple intracranial lesions including the largest in the right cerebellar hemisphere measuring 2cm in diameter with brain stem compression. . The headache has been mild and easily treated with simple analgaesics (tylenol only). Nausea developed 3d ago with single vomit 3d ago and nil since. She has been feeling slightly unsteady on her feet without falling or clearly veering to either the right or the left. After discussion with her oncologist yesterday. decadron 4mg was started [**Hospital1 **]. She has now had 2 doses and symptoms have resolved. She was admitted to the Oncology [**Hospital1 **] following MRI and received a further 10mg iv dexamethasone and 50g mannitol pending clinical review and review of imaging study. She has had no other symptoms of weakness, paraesthesias, visual including diplopia or hearing problems, speech or swallowing difficulties or facial droop. She has otherwise been well without fever, chills, respiratory symptoms or diarrhoea. Past Medical History: 1. Breast cancer 2. S/p Cholecystectomy 9 years ago . ONCOLOGIC HISTORY: She had been diagnosed metastatic disease in [**7-/2184**]; primary Her2+, ER+. Her disease progression had been dramatic and in [**Month (only) **], her CA27.29 level had been [**Numeric Identifier 3652**]. At that time, she had had severe icterus and hyperbilirubinemia due to metastatic disease. She had also been immobile because of the widely metastatic disease to the skeleton. She had at that time been hospitalized. She had then received Herceptin as well as carboplatin and Taxol in the hospital and then as an outpatient in late [**2183**]. She achieved a complete remission with CA27-29 levels in the normal range. She also had skeletal metastases that required radiation which was done in [**Location (un) 3844**] (C-spine, L-spine and hip). She is left with a weakness of the extension of the fingers. The strength in the elbow as well as shoulder area is [**4-15**] versus strength in the right hand is [**2-13**] and only [**1-16**] in the extensor portion of her fingers. She has been fully functional since the spring of [**2184**] and has been ECOG performance status 0. In [**2185-12-12**] her CA [**05**]-29 started to climb and we started Xeloda in addition to the continued Herceptin that she has taken in 3-week intervals since fall of [**2183**]. Restaging in early [**Month (only) 958**] of 07 revealed improved findings in the torso. She did not want to undergo a MRI of her head at that point. Her last CA27-29 was 99 (down from previous). Social History: Patient lives with husband in [**Name (NI) **]. She has 2 children 12 and 16. Walks around home with walked but has not been able to do more than that since the beginning of [**Month (only) 216**]. Quit smoking 3 months ago, before that smoked 1 PPD for 20 years. Family History: [**Name (NI) **] mother and father with hyperlipidemia. No cancer history. Physical Exam: T-96 BP-128/73 HR-80 RR-20 O2Sat 98% RA Wt 239.7 lb Gen: Obese. Seated on the side of the bed. Kyphosis with short appearing neck. HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation Back: No point tenderness CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. Registers [**2-11**], recalls [**2-11**] in 5 minutes. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to quiet voice. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5- 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5- 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, vibration and proprioception throughout. No extinction to DSS Reflexes: +1 UE bilat and difficult to elicit in the LE. Toes downgoing right and withdrawal. Coordination: finger-nose-finger very slight ataxia, heel to shin normal, RAMs normal. Gait: Narrow based, steady. Romberg: Negative Pertinent Results: MRI BRAIN [**2186-4-27**]: There are innumerable enhancing lesions throughout the brain and cerebellum. All of these lesions are associated with areas of vasogenic edema. The largest of these lesions is in the anterior right cerebellar hemisphere measuring 2.3 x 3.4 cm. A large amount of vasogenic edema is present with mass effect upon the fourth ventricle as well as the medulla and pons. There is no evidence of hydrocephalus at this time. There is a well-circumscribed 2-cm cystic structure in the region of the pineal, most consistent with a pineal cyst. There is also mass effect upon the cerebellar tonsils. The largest supratentorial metastasis lies within the left frontal lobe and measures 1.2 cm. There is diffusely low signal throughout the skull which would be most consistent with diffuse osseous metastases from breast cancer. IMPRESSION: Innumerable intracranial supra and infratentorial metastases. The largest lesion is in the right cerebellar hemisphere with a large amount of vasogenic edema. There is mild mass effect upon the fourth ventricle with no hydrocephalus at this time. There is mild displacement of the brainstem to the left. There is also mass effect in the posterior fossa causing inferior tonsillar migration. No evidence of tonsillar herniation at this time. . TTE [**2186-5-2**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CT CHEST/ABDOMEN/PELVIS [**2186-5-2**]: Radiology Report CT ABD W&W/O C Study Date of [**2186-5-1**] 2:00 PM [**Last Name (LF) **],[**First Name3 (LF) **] M. OMED 11R [**2186-5-1**] CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # [**Clip Number (Radiology) 63987**] Reason: baseline eval prior to starting new therapy. Please create o Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 42 year old female patient with met breast cancer REASON FOR THIS EXAMINATION: baseline eval prior to starting new therapy. Please create oncology table including all measurable disease as TARGET lesions with these as BASELINE MEASUREMENTS. thanks CONTRAINDICATIONS for IV CONTRAST: None. Final Report INDICATION: Metastatic breast cancer, to evaluate baseline prior to starting to new therapy. COMPARISON: [**2186-1-20**] CT torso. TECHNIQUE: Non-contrast axial CT images of the abdomen and pelvis were obtained followed by contrast-enhanced axial CT images of the chest, abdomen and pelvis as well as three minute delays of the kidneys only. Multiplanar reformatted images were also submitted for review. CT CHEST WITH CONTRAST: No axillary, hilar, or mediastinal lymphadenopathy is seen. The heart, great vessels, and pericardium appear unremarkable. No pleural or pericardial effusion. Previously noted platelike opacity in the medial right upper lobe is not well seen today. The remainder of the lungs appear clear and there is no evidence of mass. The airways are patent to the level of segmental bronchi bilaterally. CT OF THE ABDOMEN WITH CONTRAST: Two small round subcentimeter hypodensities within the right lobe of the liver are unchanged from prior studies (4:26, and 4:7). Linear hyperdense bands compatible with scarring are unchanged and there is no definite evidence of metastatic disease. Surgical clips related to prior cholecystectomy are again seen. The pancreas, adrenal glands, and spleen are unremarkable. The kidneys enhance symmetrically and excrete contrast normally. No pathologically enlarged lymph nodes, free fluid, or free air is identified. The peritoneal portion of a ventriculoperitoneal shunt is identified on top of the liver anteriorly. CT OF THE PELVIS WITH CONTRAST: Diverticulosis is again appreciated. The bladder, uterus, adnexa, and rectum appear unremarkable. No pathologically enlarged lymph nodes or free fluid is seen. BONE WINDOWS: The appearance of diffuse sclerotic and lytic metastasis throughout the visualized osseous structures is unchanged. Healing fracture deformity of the left ilium is again noted. Partial compression fracture of T9 is not significantly changed. Lower cervical and upper thoracic compression deformities also appear unchanged. Multiple bilateral healed rib fractures appear unchanged. IMPRESSION: 1. No evidence of disease progression with diffuse osseous metastasis again seen. Again, metastatic disease in the femur increases the risk of hip fracture. 2. Unchanged appearance of the liver with persistent treatment effect from prior metastasis. Brief Hospital Course: Ms. [**Known lastname 2152**] is a 42 yo woman with known metastatic breast cancer involving liver and bone, now with multiple intracranial mets including right cerebellar mass 2.3x3.4cm with brain stem compression, midline shift and inferior migration of cerebellar tonsils. She was initially admitted from home to the Oncology floor appearing clinically well and neurologically intact. On review of the MRI report, however, urgent consults to Radiation Oncology, Neurosurgery, and Neuro-oncology were placed. She received an IV dose of Decadron 10 mg x 1 and Mannitol 50 g x 1. All consultants arrived to evaluated her within an hour of arrival, and it was decided that she should be transferred to an ICU level bed under the care of the Neurosurgical service given the impending tonsillar herniation. The following morning she was taken to the OR for placement of a right ventriculoperitoneal shunt. Her surgical procedure was uncomplicated and she was transferred back to the Oncology service for further care. She continued on dexamethasone with famotidine as GI prophylaxis. In discussion of plans for futher care, the decision was made to enroll Ms. [**Known lastname 2152**] in an ongoing clinical trial of WBRT with Lapatinib and Trastuzumab (Herceptin). She underwent a pre-enrollment TTE and CT torso while in-patient. On the day of discharge, she had a planning meeting with Radiation Oncology. She was discharged to home, asymptomatic, and will return for XRT as an outpatient. She will undergo the first session of radiation therapy on [**5-9**] after she has completed the 14-day chemotherapy washout period. Medications on Admission: Xeloda Herceptin weekly Zomeda weekly (Trastuzamab) Discharge Medications: 1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Disp:*120 Tablet(s)* Refills:*1* 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Brain metastases Metastatic breast cancer Discharge Condition: Good, neurologically intact Discharge Instructions: You can keep your abdominal wounds open to air, without any dressings. . You can also keep your head incision open to air without dressings. You should not wash your hair for the next 10 days, or until otherwise instructed by Neurosurgery. . You should seek immediate medical attention if you experience fevers, headaches, vomiting, loss of balance, confusion, or dizziness. Followup Instructions: You are scheduled to have your sutures removed on Tuesday, [**5-9**] at 11 a.m. Dr.[**Name (NI) 9034**] office is located on the [**Location (un) 470**] of the [**Hospital Unit Name **] at [**Last Name (NamePattern1) 20120**]on [**Hospital1 18**] [**Hospital Ward Name 12837**]. Please call [**Telephone/Fax (1) 1669**] if you have questions. . You are scheduled to begin brain radiation next Tuesday [**5-9**] at 9:30 a.m. You should come to basement of the Finaird Building on the [**Hospital1 18**] [**Hospital Ward Name 516**]. Please call [**Telephone/Fax (1) 9710**] if you have questions prior to your appointment. . [**Name6 (MD) **] [**Last Name (NamePattern4) 17688**], MD Oncology Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2186-5-10**] 2:30 p.m.

[ "197.7", "331.4", "V10.3", "198.3", "198.5" ]

icd9cm

[ [ [] ] ]

[ "02.34" ]

icd9pcs

[ [ [] ] ]

12435, 12441

10457, 12096

337, 415

12527, 12557

5489, 7728

12982, 13749

3640, 3718

12199, 12412

7765, 7818

12462, 12506

12122, 12176

12581, 12959

3733, 4084

275, 299

7847, 10434

443, 1770

4496, 5470

4123, 4480

4108, 4108

1792, 3341

3357, 3624

11,603

127,265

13905

Discharge summary

report

Admission Date: [**2193-5-6**] Discharge Date: [**2193-5-13**] Date of Birth: [**2155-12-29**] Sex: F Service: SURGERY Allergies: Penicillins / Vancomycin / Benzocaine / Benadryl Attending:[**First Name3 (LF) 4111**] Chief Complaint: Colonic neuronal dysplasia Major Surgical or Invasive Procedure: Ileal pouch anal anastamosis, ileostomy History of Present Illness: 37 F, longstanding patient of Dr.[**Name (NI) 6275**], has a long history of colonic neuronal dysplasia. She has undergone numerous surgeries, dilations, and sphincterotomies with minimal improvement in her symptoms. She now presents for an ileal pouch, anal anastamosis. Past Medical History: 1. Rectal neuronal dystonia. 2. Repair of rectal prolapse. 3. Colon resection x2 ('[**89**], '[**90**]) 4. Chronic constipation. 5. rectal dilatation ('[**90**], '[**92**]) 6. sphincterotomy ('[**92**]) 7. subtotal colectomy ('[**85**]) Social History: Married Family History: NC Physical Exam: At time of discharge: A&O X 3, NAD PERRL, EOMI, anicteric RRR, mildly tachycardic at times CTAB Abd soft, appropriately tender to palpation along incision, dressing with very minimal staining inferiorly Ostomy pink with air and stool in bag Ext without c/c/e Pertinent Results: [**2193-5-9**]: WBC-13.4* RBC-3.29* Hgb-10.7* Hct-30.1* MCV-92 MCH-32.5* MCHC-35.5* RDW-13.1 Plt Ct-227 [**2193-5-13**]: Na-142 K-3.5 [**2193-5-9**]: CK-MB-7 cTropnT-<0.01 Brief Hospital Course: On [**2193-5-6**] Ms. [**Known lastname 41657**] was admitted to the surgical service under the care of Dr. [**Last Name (STitle) 957**]. She was taken to the operating room for an exploratory laparotomy, lysis of adhesions, and ileal pouch anal anastamosis (S pouch) with creation of an ileostomy. For details of the procedure please see Dr.[**Name (NI) 6275**] operative report. Postoperatively Ms. [**Known lastname 41657**] experienced some tachycardia into the 120-130's. She was also hypoxic on room air to 88%. She was admitted to the ICU for close monitoring. A CTA of her chest was negative for a pulmonary embolism. On POD 2 she was transferred to the floor in stable condition although she remained mildly tachycardic. Her pain was well controlled with an epidural and PCA dilaudid. Her diet was slowly advanced starting on POD 3 once her ostomy started functioning. She was then transitioned to po Percocet. By POD 6 she was ambulating, tolerating a regular diet and po pain medication. She was discharged home after her JP was removed. Medications on Admission: Protonix 40', Reglan, Vicodin prn Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 6. Fludrocortisone 0.1 mg Tablet Sig: [**2-4**] Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Colonic neuronal dysplasia Discharge Condition: Good Discharge Instructions: Please call your doctor or go to the ER if you experience any of the following: high fevers >101.5, severe pain, increasing nausea or emesis, or pus draining from your wound. Do not drive if taking narcotics. Take all your medications as prescribed. Please have your K+ checked tomorrow at Dr.[**Name (NI) 6275**] office. Followup Instructions: Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) 3628**] SURGICAL ASSOC [**Name11 (NameIs) 3628**]-3A (NHB) Date/Time:[**2193-5-17**] 3:00 ([**Telephone/Fax (1) 2359**]) Please have your potassium checked tomorrow in Dr.[**Name (NI) 6275**] office anytime after 9 AM.

[ "300.00", "786.06", "997.1", "427.89", "751.3", "568.0", "530.81" ]

icd9cm

[ [ [] ] ]

[ "45.95", "03.90", "46.20", "48.69", "54.59" ]

icd9pcs

[ [ [] ] ]

3316, 3322

1474, 2524

335, 377

3393, 3400

1278, 1451

3770, 4049

979, 983

2608, 3293

3343, 3372

2550, 2585

3424, 3747

998, 1259

269, 297

405, 678

700, 938

954, 963

29,056

163,573

49403

Discharge summary

report

Admission Date: [**2124-2-29**] Discharge Date: [**2124-3-4**] Date of Birth: [**2067-3-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: SCV central line placement CT guided drainage of J tube SQ abscess, hepatic abscess s/p US guided paracentesis History of Present Illness: This is a 55 yo female with metastatic pancreatic cancer who presents from clinic to OMED floor for evaluation of extreme fatigue, transferred to MICU for hypotension. . She reports weakness that developed 1 week ago. She denies dizziness, lightheadedness, LOC, falls. She denies fatigue, but feels more a lack of strength. Also reports feeling anxious x 1 week; her husband gave her oxycodone for this with good effect. Her husband notes that she has been slightly confused since Friday, but attributes it temporally to oxycodone. She states has been vomiting once per morning, bilious fluid but no blood. This has not notably improved on reglan. They also reports significant leakage from her J tube. The tube was replaced [**2124-1-13**] but without significant improvement in leakage. Recently on Taxotere with last dose received on [**2-22**]. She was directly admitted to the OMED service. . On arrival to the OMED floor, her SBP was in the 90s and she was tachycardic to the 120s. She was given 1L IVF with SBP in 70s. Blood cultures were drawn in clinic. Stat CXR done. She was empirically started on vanc, ceftaz, and flagyl. Neuro-oncology evaluated her and did not recommend repeat imaging; they advised LP if no other source suspected. . . ROS: Denies headache, photophobia, neck stiffness. No chest pain, palpitations, or SOB. Denies diarrhea, dysuria. No fevers, chills, sweats. Past Medical History: # metastatic pancreatic cancer with metastasis to ovary # type 2 diabetes # hypercholesterolemia # h/o DVT this summer. tx with lovenox # h/o palpitations thought to be PVC's treated with atenolol. Has had Holter monitoring in past # s/p TAH RSO # s/p appendectomy # s/p biliary and duodenal stent procedures . ONC HX: Ms. [**Known lastname **] is a 55-year-old female with unresectable pancreatic cancer diagnosed in [**6-13**]. CT scan and a diagnostic laparoscopy was negative for any metastatic sites in [**7-14**]. In [**8-13**], a CT showed a new pelvic mass that was rapidly growing. This turned out to be a metastasis on excision (TAH, RSO) on [**2122-11-3**]. She is S/P Biostent placement (for a total bilirubin of 15.9 and jaundice), Cyberknife radiation x3 treatments, percutaneous cholecystostomy placement (for cholecystitis). She had a L popliteal vein DVT and is currently on Lovenox. She was started on weekly IV Gemcitabine and daily po Xeloda in a 2 weeks on 2 weeks off cycle on [**2122-9-22**] but the pelvic met progressed through this regimen and she had to undergo a TAH/RSO on [**2122-11-3**]. She has since been on gemcitabine and oxalipatin with intract nausea and vomiting. She was last seen at [**Hospital1 18**] [**2122-12-29**] and was started on Emend along with Decadron in tapering doses. She has continued to have persistent nausea and emesis. Social History: Married; 3 children. non-smoker, no etoh. worked part time as clerical worker Family History: Significant for a cousin with prostate cancer. Physical Exam: T 97.9 BP 89/63 HR 109 RR 13 SpO2 98% RA pulsus 4 mm Hg General: Chronically ill appearing female, in NAD, pleasant HEENT: PERRL, EOMI, anicteric sclera. OP clear with dry MM. NECK: Supple. No cervical LAD. JVP flat with positive hepatojugular reflux. LUNGS: Decreased breath sounds to right base. crackles to left base. CARDIAC: Regular rate and rhythm. nl S1/S2, No MRG CHEST: port in left chest, c/d/i ABDOMEN: Soft, nontender, BS+. Distended with fluid. TAH/RSO scar well-healed. L-sided J-tube with ostomy bag surrounding it. ostomy bag with yellow-green serous discharge. site non-tender and without erythema. EXTREMITIES: 2+ pitting edema b/l NEURO: Alert & oriented x 3. CN ii-Xii intact; strength 3/5 in b/l UE/LE (? if effort-dependent) Pertinent Results: LABS ON ADMISSION [**2124-2-29**] 12:00PM WBC-2.4*# RBC-3.05* HGB-9.4* HCT-28.7* MCV-94 MCH-30.7 MCHC-32.6 RDW-16.2* [**2124-2-29**] 12:00PM NEUTS-59.2 BANDS-0 LYMPHS-28.8 MONOS-10.9 EOS-0.7 BASOS-0.4 [**2124-2-29**] 12:00PM PLT SMR-NORMAL PLT COUNT-157# [**2124-2-29**] 12:00PM GRAN CT-1440* [**2124-2-29**] 12:00PM GLUCOSE-172* UREA N-21* CREAT-0.4 SODIUM-135 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 [**2124-2-29**] 12:00PM ALT(SGPT)-18 AST(SGOT)-17 LD(LDH)-199 ALK PHOS-128* TOT BILI-0.8 DIR BILI-0.3 INDIR BIL-0.5 [**2124-2-29**] 12:00PM ALBUMIN-2.1* CALCIUM-7.9* PHOSPHATE-2.4* MAGNESIUM-1.9 [**2124-2-29**] 03:04PM PT-17.1* PTT-150* INR(PT)-1.5* [**2124-2-29**] 04:37PM LACTATE-1.5 [**2124-2-29**] 03:04PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.029 [**2124-2-29**] 03:04PM URINE RBC-4* WBC-0 BACTERIA-NONE YEAST-NONE EPI-20 [**2124-2-29**] 03:04PM URINE MUCOUS-OCC IMAGING CXR [**2-29**] - In comparison to study of [**2124-1-28**], the left base is sharply seen with only mild blunting of the costophrenic angle. On the right, however, there is again evidence of pleural effusion with associated atelectatic changes. The upper lung zones remain clear. Central catheter remains in position. CT abd/pelvis [**3-1**] - 1. Numerous hypodense hepatic lesions, new since [**11-12**] with appearance suspicious for hepatic abscesses. Necrotic metastases are considered, although less likely. 2. Peribiliary enhancement consistent with cholangitis. 3. New bilateral pleural effusions and adjacent atelectasis. 4. New large amount of ascites. 5. Questionable thickening of the ascending colon could relate to a serosal metastasis. 6. Subcutaneous abscess adjacent to a jejunal feeding tube entry site. 7. Bilateral filling defects in the common femoral veins consistent with deep venous thrombosis. LENIs [**3-1**] - Bilateral occlusive thrombus involving the bilateral common femoral and superficial femoral veins as well as the right popliteal vein. CT/US guided drainage of J tube abcess, hepatic abscess, paracentesis [**3-1**] - 1. Successful drainage of anterior abdominal wall abscess. 2. Successful therapeutic and diagnostic paracentesis. 3. Successful ultrasound-guided aspiration of liver abscess. Brief Hospital Course: 55 yo F with metastatic pancreatic cancer who presents from clinic to OMED floor for evaluation of extreme fatigue, altered mental status and transferred to MICU for hypotension. # Metastatic pancreatic cancer Patient was made DNR/DNI after discussion between patient, family, and attendings. Palliative care was involved as well. Patient was taken off pressors in the ICU and transferred to medical floor, antibiotics were started orally in hopes this will prolong patient's time with family members while at home. Patient was stable off pressors and decision was made for patient to go home with hospice services. Patient is comfort measures only. # Hypotension: Differential diagnosis included sepsis vs. PE vs. cardiac tamponade, vs. cardiac ischemia with all but sepsis being less likely. The patient was palced on levophed after minor BP response to 3 L IVF boluses. Other possible consideration for pt's hypotension included IVC compression secondary to mass effect from pancreatic CA. Sources of sepsis included intrabadominal abscess, J-tube site infections, SBP. Less likely causes include PNA (not seen on CXR), UTI (UA poor sample with 20 epis), or meningitis. A central line was placed and IVFs were bolused to maintain the pt's CVP between [**11-19**]. She was started on vanc/ceftaz/flayl for broad coverage. A CT abd/pelvis was obtained on the night of admission to the [**Hospital Unit Name 153**] given concern for abdominal tenderness and new onset ascites which revealed a large subcutaneous abscess around the site of the patient's J tube, multiple hepatic lesions suspicious for either abscess vs. necrotic metastases, possible cholangitis, and new large ascites. Radiology was contact[**Name (NI) **] and the pt underwent a CT guided aspiration of the SQ abscess, liver lesions and a 4 L US guided paracentesis which ruled out SBP, however GNR were growing on culture. Unfortunately, there was no clinical improvement in terms of the pt's blood pressures after the procedure and vasopressin was added to augment levophed. After further discussions with the ICU team, her oncologists, and her family, it was decided to make the patient CMO on hospital day 3. She was transferred to the floor. # Confusion: Most likely [**3-11**] hypotension in the setting of infection with some improvement in her mental status after starting pressors. Other possible causes were medication-related vs meningitis (low clinical suspicion). Neuro-onc was also contact[**Name (NI) **] who felt the utility of a LP was low and that brain mets were unlikely to be contributing as the patient had had a negative head MRI recently. # FTT / Weakness: Weakness and failure to thrive in setting of cancer and poor nutritional status. Albumin of 2.2. # J tube leakage: Patient with persistent leakage in spite of multiple IR J tube exchanges in the past. Had culture on [**1-13**] growing sparse E. coli and S. aureus. IR was contact[**Name (NI) **] who felt the tube was in good location and that there was no role in replacing the tube. # LE edema: No hx of cardiac disease. Likely secondary to hypoalbuminemic state, bilateral DVTs, and obstructive pelvic mass. Satting well on room air, started on heparin gtt for DVTs. # Anemia: Baseline Hct 25-28. # Peripheral neuropathy: Held lyrica per neuro-onc. . . # CODE STATUS: Patient was made DNR/DNI after discussion between patient, family, and attendings. Palliative care was involved as well. Patient was taken off pressors in the ICU and transferred to medical floor. Patient was stable off pressors and decision was made for patient to go home with hospice services. Patient is comfort measures only. Medications on Admission: Taxotere - last on [**2-22**] EMLA cream Metoclopramide 10mg tab PO tid before meals Omeprazole E.C. 20 mg PO daily Lyrica 75mg PO QDay Oxycodone 5 mg PO QDay MVI Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for anxiety, insomnia, nausea. 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once) as needed for secretions. 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Hospital3 **]Hospice Discharge Diagnosis: Pancreatic carcinoma with metastasis Discharge Condition: comfort measures only Discharge Instructions: You are being discharged home with hospice services. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2124-3-7**] 11:30 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3150**] Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2124-3-7**] 11:30 Provider: [**Name Initial (NameIs) **]/OSTOMY NURSE Phone:[**Telephone/Fax (1) 13760**] Date/Time:[**2124-3-7**] 1:00

[ "041.4", "198.6", "157.8", "272.0", "356.9", "038.9", "276.51", "682.2", "197.6", "572.0", "995.92", "789.51", "785.52", "250.00", "V12.51", "569.61" ]

icd9cm

[ [ [] ] ]

[ "86.01", "54.91", "38.93", "50.91" ]

icd9pcs

[ [ [] ] ]

10928, 10982

6544, 10209

322, 434

11063, 11087

4235, 6521

11188, 11579

3388, 3436

10422, 10905

11003, 11042

10235, 10399

11111, 11165

3452, 4216

275, 284

462, 1872

1894, 3275

3292, 3372

8,678

115,755

9210

Discharge summary

report

Admission Date: [**2145-6-16**] Discharge Date: [**2145-6-30**] Date of Birth: [**2072-3-4**] Sex: F Service: SURGERY Allergies: Benadryl / Vancomycin Hcl Attending:[**First Name3 (LF) 4748**] Chief Complaint: left graft stenosis by graft survillance ,symptomatic Major Surgical or Invasive Procedure: angiogram with intervention cutting baloon angioplasty of left profunda femorus to DP bpg [**2145-6-28**] History of Present Illness: 73y/o female who was recently discharged from hospital after undergoing rt. groin exploration ,debreidment and washout for rt. groin infection with sinus tract.Surgery was complicated by NSTEMI with CHF requiring cardiac cath and angioplasty with stenting of LAD with metal eluding stentsx2 . Patient known vascularpathy s/p multiple, multipe [**Month/Day/Year 1106**] surgeries . underwent left graft survillance on [**6-16**] which demonstrated high grade stensois in the left fem-at proximal anastmosis. Patient was admitted to Dr.[**Name (NI) 7446**] service ( had appointmwent arraged by her PCP to be seen)for evaluation and treatment of her graft stenosis after resolution of her heart failure. Past Medical History: histroy of perpheral [**Name (NI) 1106**] disease,s/p rt. AKA ,s/p fem-fem bpg with rt. fem endart '[**27**],s/p ABF '[**28**],s/p bilat fem-pops91,removal of fem-fembpg'[**28**],redo left [**Name (NI) 31642**] ptfe+thrombectomy of left CFA'[**38**],s/p left temp bx'[**40**],rt. jump graft from rt. fem-[**Doctor Last Name **] with ptfe to rt. distal pop'[**42**],s/p removal of lower extremiti gafts'[**42**],rt. BKA2/06,left [**Name (NI) **] pta/stent12/06,left fem-atw rt. cephalic vein [**12-21**], left 1,4th toe amps [**12-21**] history of coronary artery disease s/p drug elutin sterca [**2-18**] histroy of chronic systolic (EF 37%) and diastolic CHF history of MR, mild with severe pulmonary hypertension histroy of hypertension histroy of hypercholestremia history of GI bleed secondary to ASA histroy of MRSA, VRE infections histroy of Dm1 with neuropathy history of carotid stenosis [**Country **] 40-59%,[**Doctor First Name 3098**] 60-69% PICC line thrombosis treated with TPa [**12-22**] Social History: lives with husband former [**Name2 (NI) 1818**] 30 pkyrs d/c [**2109**] denies ETOH use Family History: noncontributory Physical Exam: Vital signs: 97.5-58-15 Os sat 92%, B/P 140/80 Gen: AAox3, no acute distress HEENT: ;eft carotid bruit Lungs clear to auscultation but diminished @ bases bilaterally Heart: RRR ABD: protuberant,soft, nonditended, nontender, BS+, no bruits or masses EXT: well healed rt.AKA. rubors skin changes/cellulitis form mid At to foot.toe 1 inch diamenter skin denuded . Pulses: rt. femoral pulse could not be accessed secondary to groin wound fibrosis.Left femorl 2+,[**Doctor Last Name **] 1+ palpable, absent pedal pulses Neuro: nonfocal Pertinent Results: [**2145-6-16**] 05:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2145-6-16**] 05:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2145-6-16**] 05:49PM URINE RBC-0-2 WBC-[**2-17**] BACTERIA-FEW YEAST-NONE EPI-0-2 [**2145-6-16**] 05:17PM GLUCOSE-289* UREA N-32* CREAT-1.4* SODIUM-139 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17 [**2145-6-16**] 05:17PM proBNP-[**Numeric Identifier 31646**]* [**2145-6-16**] 05:17PM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.1 [**2145-6-16**] 05:17PM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.1 [**2145-6-16**] 05:17PM CRP-24.6* [**2145-6-16**] 05:17PM WBC-10.1 RBC-3.90* HGB-11.1* HCT-36.3 MCV-93 MCH-28.4 MCHC-30.5* RDW-19.5* [**2145-6-16**] 05:17PM NEUTS-81.0* BANDS-0 LYMPHS-12.9* MONOS-3.2 EOS-2.3 BASOS-0.5 [**2145-6-16**] 05:17PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ SPHEROCYT-1+ BURR-OCCASIONAL FRAGMENT-1+ [**2145-6-16**] 05:17PM PLT SMR-NORMAL PLT COUNT-315 [**2145-6-16**] 05:17PM PT-14.1* PTT-23.0 INR(PT)-1.2* Brief Hospital Course: 7/2/08Admitted to Dr.[**Name (NI) 7446**] service. IV antibiotics instuted. Cardoloy:Dr.[**Last Name (STitle) **] consulted for managment of patient's CHF excerbation.IV heparin began for left leg ischemic changes.Ciprofloxcin began [**Date range (1) 31647**]/08 ID consulted for antibiotics started on Daptomycin 4mg/kg q48hrs.,Cipro d/c'd and amxocillin started. [**Last Name (un) **] consulted for her hyperglycemia and DM managment.Diuresis continued for her systolic CHF excerbation. [**6-20**] continues with antibiotics, mucomystand NaHCO3 gtt started for prepration for angio.Insulin adjustment required for improvement of continued glycemic control. [**2145-6-21**] Transfered to CIVCU for excerbation of CHF, secondary to lasix being held and fluid hydration for angio. angio cancelled IV Nitor gtt began, heparin gtt continued. Enzymes cycled. troponin 0.7. [**2145-6-22**] Improvement of cardiac and respiratory status. transfered to VICU for continued care.Diuresis continued.IV lasix dosing increase 80mgm [**Hospital1 **]. Dr. [**Last Name (STitle) **] recommends P mibi to asses for silent ischemia prior to any [**Last Name (STitle) 1106**] interventiion or surgery. [**Last Name (un) **] and ID continue to follow patient. [**2145-6-23**] Dr. [**Last Name (STitle) **] recommended patient be transfered to C-Med for continued managment of her CHF, patient's family declined recommendations. [**2145-6-24**] Patient transfered to Dr.[**Name (NI) 1392**] service per husband's request. P mibi fixed myocardial defect. No cardiac cath required. [**2145-6-25**] Patient transfered to floor. [**2145-6-28**] underwent angiogram with cutting balloonangioplpasty of left [**Month/Day/Year **]-pr bpg. [**2145-6-30**] discharged to home in stable condition.Patient instructed to followup ;with PCP?cardologist, and endocrinologist upon d/c. followup with Dr. [**Last Name (STitle) 1391**] in 2 weeks. Will remain on long term suppression of amoxcillin 250mgm [**Hospital1 **]. lasix 160mgm changed to lasix 40mgm [**Hospital1 **] Isordil Dn 20mgm qam and 40mgm qpm changed to Isordil Mn 30mgm daily,lisinopril discontinued. uriinalysis and urin c/s sent prior to d/c. Medications on Admission: omeprazole 20mgm lasix 160mg norvasc 5mg atrovistatin 80mg celexa 40mg asa EC 325mg lisijnopril 40mg isordil 30mgm qam,20mgm qpm lopressor 50mg tid lantus 20 units qam HISS Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). Disp:*30 Tablet, Sublingual(s)* Refills:*2* 9. 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* 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*qs * Refills:*0* 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous twice a day: am 5 units HS 15 units. 14. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day. 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 16. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 18. Insulin Glargine 100 unit/mL Solution Sig: as directed Subcutaneous at bedtime: 20 units. 19. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: AC: glucoses <100/no insulin 101-159/8u 160-199/10u 200-239/12u 240-279/14u 280-319/16u 320-359/18u 360-400/20u >400 [**Name8 (MD) 138**] MD u=units HS: glucoses <199/ no insulin 200-239/2u 240-279/4u 280-319/6u 320-359/8u 360-400/10u >400 [**Name8 (MD) 138**] Md. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Discharge Worksheet-Discharge Diagnosis-Finalized:[**Last Name (LF) **],[**First Name3 (LF) **], PA on [**2145-6-30**] @ 1011 left leg ischemia,symptomatic,s/p left fem-atbpg arm vein,graft stenosis by survillance [**2145-6-16**] history of PVD, s/p multiple bpg's,rt. aka,s/p fem-fembpg w rt. fem endartectomy'[**27**],s/p ABF'[**28**],s/p bilateral fem-pops''[**27**],s/p removal of fem-fem'[**28**],s/p redo left fem-bkpop wPTfeand thrombectomy of left CFA'[**28**],s/p rt. jumpgraft from rt.fem-[**Doctor Last Name **] to distal [**Doctor Last Name **] '[**42**],s/p removal of bilateral lower extremitiy grafts'[**42**], rt. BKA [**1-20**],s/p left PTAwstenting left [**Month/Year (2) **] [**11-20**],s/p left fem-at w rt. cephalic vein [**12-21**] + left toe amps 1,4 [**12-21**] history of rt. groin infection,recurrentwith sinus tract-treated, on life long atbx suppresive tx w amoxcillin,s/p rt. groin exploration,debridment and wash out [**2145-4-29**] history of chronic systolic CHF with excerbation [**6-22**] history of coronary artery disease s/p drug eluding coronary stenting [**2-18**],NSTEMI [**5-23**] with baremetal stenting of lad history of MR, severe with pulmonary hypertension history of hypertension history of hypercholestremia historyof GI bleed [**1-16**] ASA history of MRSA,VRE wound infection history of acute oliguric renal failure [**1-16**] agressive diuresis for CHF [**5-23**] history of DM2,w neuropathy, insulin dependant history of carotid disease [**Country **] 40-59%,[**Doctor First Name 3098**] 60-69% history of PICC Line thrombosis treated w TPa [**12-22**] history of chronic anemia, transfused 2 units PRBC's [**5-23**] postop NSTEMI [**2145-6-24**] Discharge Condition: stable Discharge Instructions: continue all medications as directed call if developes fever >101.5 or right groin wound developes erythema or drainage call if left foot circulation changes Followup Instructions: cardologist after d/c to home 2 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**] f/up with your endcrinologist: Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 31648**] @ [**Hospital3 **] Completed by:[**2145-6-30**]

[ "357.2", "410.72", "428.43", "V45.82", "414.01", "250.61", "416.8", "V49.76", "682.6", "272.0", "E878.2", "428.0", "401.9", "410.71", "996.74" ]

icd9cm

[ [ [] ] ]

[ "39.50", "88.48", "00.40" ]

icd9pcs

[ [ [] ] ]

8601, 8659

4053, 6234

338, 447

10402, 10411

2911, 4030

10617, 10891

2328, 2345

6457, 8578

8680, 10381

6260, 6434

10435, 10594

2360, 2892

245, 300

475, 1178

1200, 2206

2222, 2312

8,719

178,400

8708

Discharge summary

report

Admission Date: [**2145-6-9**] Discharge Date: [**2145-6-13**] Date of Birth: [**2087-11-4**] Sex: F Service: [**Last Name (un) **] ADMISSION DIAGNOSES: Left breast cancer. History of left breast cancer, status post wide excision with axillary dissection, chemotherapy and XRT. DISCHARGE DIAGNOSES: Carcinoma, left breast, status post left mastectomy with deep flap ([**Last Name (un) 5884**]). As above. HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 30486**] is a 57-year-old female who presented with a question of a recurrence of her left breast cancer who was found in [**2145-4-24**] to have an 8 mm infiltrating ductal carcinoma of the left which initially presented as a mammographic abnormality with new pleomorphic calcifications in the lateral aspect of the left breast. She had previously had a left breast cancer in [**2140**] for which she was treated with breast conserving therapy and radiation along with chemotherapy and Tamoxifen. She, therefore, presented for a left mastectomy with reconstruction after an extensive discussion on management options. PHYSICAL EXAMINATION: In terms of her initial examination, she was afebrile and otherwise hemodynamically stable. She had no cervical adenopathy. Her lungs were clear. The heart was regular. The breast had no palpable mass. Otherwise, just postsurgical changes. Otherwise, the abdomen was soft and nontender with no hepatosplenomegaly. She had no peripheral edema or calf tenderness. The patient did have a bone scan on [**2145-5-25**] which showed no evidence of MDPA metastatic disease. She also had a CT scan of the chest, abdomen, and pelvis which showed no evidence of metastatic disease. HOSPITAL COURSE: The patient was admitted on [**2145-6-9**] and underwent a left mastectomy with a left deep flap breast reconstruction by Dr. [**Last Name (STitle) 11635**] and Dr. [**First Name (STitle) **] respectively. The patient tolerated the procedure well and was extubated in the Operating Room and taken to the Postanesthesia Care Unit postoperatively for flap checks where she did well and the flap did not show any evidence of vascular compromise. By postoperative day number two, she was able to leave the Postanesthesia Care Unit and was transferred to the floor where she continued to do well and had no difficulties with advancement of her diet. She otherwise was advanced from clears to a regular diet as noted without any difficulty. Her flap continued to look good without any evidence of ischemia or infection throughout the course of her hospitalization. Otherwise, her activity level was slowly advanced secondary to pain issues but by postoperative day number four, the patient was up and ambulating with limited motion of the upper extremity given her surgery but activity range was within normal limits. Otherwise, she was tolerating a regular diet and had excellent pain control with oral pain medications. Notably, the patient did have her [**Location (un) 1661**]-[**Location (un) 1662**] drains left in place for which she was given Keflex. Otherwise, the [**Hospital 228**] hospital course was unremarkable and it was felt that by postoperative day number four she was eating and ambulating and had good pain control and it was safe to discharge her to home with follow-up. At the time of discharge, the patient was given aspirin 325 mg q.d., Keflex 500 mg p.o. q.i.d. until follow-up with Plastic Surgery, Dilaudid 2-4 mg p.o. q. three to four hours for pain, Colace 100 mg p.o. b.i.d. p.r.n. constipation, and Ranitidine 150 mg p.o. b.i.d. FOLLOW UP: The patient is to follow-up with Dr. [**Last Name (STitle) 11635**] in two weeks and Dr. [**First Name (STitle) **] in one week. Otherwise, she was sent home with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] check and for management of her drains. [**Name6 (MD) 17486**] [**Name8 (MD) 11635**], [**MD Number(1) 18026**] Dictated By:[**Doctor Last Name 3763**] MEDQUIST36 D: [**2145-6-13**] 06:41:22 T: [**2145-6-13**] 08:01:59 Job#: [**Job Number 30487**]

[ "174.4" ]

icd9cm

[ [ [] ] ]

[ "85.7", "99.04", "85.41", "99.02", "38.93" ]

icd9pcs

[ [ [] ] ]

325, 434

1730, 3594

3606, 4121

176, 303

1130, 1712

463, 1107

29,819

118,881

27857

Discharge summary

report

Admission Date: [**2150-9-10**] Discharge Date: [**2150-9-13**] Date of Birth: [**2091-11-28**] Sex: M Service: MEDICINE Allergies: Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 1145**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: Primary percutaneous coronary angioplasty with delivery of a bare metal stent to the LCx. History of Present Illness: Mr. [**Known lastname **] is a 58 year-old male with a history of hypertension and diet controlled type II diabetes mellitus, s/p MI in [**2146**] with 2 stents (baseline coronary anatomy unknown) who was in his usual state of health until earlier this morning while at work, when he began to feel a "pressure" in his anterior chest. This pressure radiated to his right arm. He also noted associated palpitations. Denies diaphoresis, nausea and vomitting. These symptoms were similar to his prior MI 4 years prior and thus he came to be seen in the emergency room. His EKG revealed an inferolateral STEMI and he received ASA, plavix 600, heparin bolus and gtt, and nitro gtt. Code STEMI was called and patient was transfered to the Cath lab. In the cath lab, he was noted to have an occluded LCX in the mid vessel. He underwent PTCA and stenting of the mid LCX with a BMS. He was enrolled in the ICE T trial and was administered the study drug as per protocol. He was transfered to the CCU on integrillin and nitroglycerin gtt. On arrival he was chest pain free and had no complaints. Past Medical History: PAST MEDICAL HISTORY: Hypertension Diet-controlled diabetes . CARDIAC HISTORY: CABG: none Percutaneous coronary intervention: MI 4 years ago, 2 stents per patient. Done at [**Hospital1 3278**]. Report unavailable. Pacemaker/ICD placed: none Social History: Works at the [**Hospital1 18**]. Smokes 1 PPD x >20 years. Occasional ETOH. No illicit drugs. Family History: Father with CAD in 50s. Hypertension runs in the family. Physical Exam: Vitals: 136/79 HR 65 98.8 16 98% 2L General: Alert and awake, NAD, lying flat following cardiac cath HEENT: MMM, OP clear Heart: S1S2 RRR, no MRG Lungs: CTAB in anterior lung fields Abdomen: soft NTND Ext: DP/PT pulses dopplerable bilaterally, no edema Groin: No hematoma or bruit Pertinent Results: LAB RESULTS: . [**2150-9-10**] 07:04PM CK(CPK)-7476* [**2150-9-10**] 07:04PM CK-MB-GREATER TH cTropnT-18.92* [**2150-9-10**] 07:04PM %HbA1c-8.4* [**2150-9-10**] 07:04PM WBC-10.5 RBC-4.92 HGB-15.9 HCT-43.3 MCV-88 MCH-32.4* MCHC-36.8* RDW-13.7 [**2150-9-10**] 07:04PM PLT COUNT-156 [**2150-9-10**] 11:21AM COMMENTS-GREEN TOP [**2150-9-10**] 11:21AM K+-3.9 [**2150-9-10**] 11:15AM GLUCOSE-239* UREA N-17 CREAT-1.3* SODIUM-143 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-16 [**2150-9-10**] 11:15AM estGFR-Using this [**2150-9-10**] 11:15AM CK(CPK)-186* [**2150-9-10**] 11:15AM CK-MB-5 [**2150-9-10**] 11:15AM cTropnT-<0.01 [**2150-9-10**] 11:15AM WBC-9.6 RBC-5.13 HGB-17.0 HCT-46.8 MCV-91 MCH-33.2* MCHC-36.3* RDW-13.8 [**2150-9-10**] 11:15AM NEUTS-51.3 LYMPHS-39.8 MONOS-5.5 EOS-2.7 BASOS-0.7 [**2150-9-10**] 11:15AM PT-12.3 PTT-25.5 INR(PT)-1.0 [**2150-9-10**] 11:15AM PLT COUNT-184 .. STUDIES: . EKG: Sinus rhythm, rate 85, normal axis, prolonged PR, STE in II, II, V5-6, reciprocal STD in aVL, V1-3. No prior EKG available for comparison. .. CORONARY ANGIOGRAPHY ([**2150-9-10**]): COMMENTS: 1. Coronary angiography in this right dominant system revealed two vessel coronary artery disease. The LMCA had a 20% distal stenosis. The LAD had minimal disease. The LCx was totally occluded proximally. The RCA had a 90% distal stenosis. 2. Limited resting hemodynamics revealed moderate systemic arterial hypertension with SBP of 173 mmHg and DBP of 99 mmHg. 3. Left ventriculography was deferred. 4. Successful PTCA and stenting of the mid LCX with a 4.0 x 12 mm VISION BMS at 16 ATM. The patient was enrolled in the ICE T trial and was administered the study drug as per protocol. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Acute inferolateral MI. 3. Successful stenting of the mid LCX. .. TRANSTHORACIC ECHOCARDIOGRAM ([**2150-9-11**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate regional left ventricular systolic dysfunction with inferior and lateral hypokinesis and inferolateral wall akinesis (left circumflex artery distribution). The remaining segments contract normally (LVEF = 40%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild to moderate regional left ventricular systolic dysfunction, c/w CAD. Mild pulmonary hypertension. Brief Hospital Course: In summary, this is a 58 y/o male with DM II, HTN, and known CAD admitted with an inferolateral STEMI s/p PCI and bare metal stenting to a totally occluded LCx. . # CAD/ISCHEMIA: He was admitted with an inferolateral STEMI with the finding of complete occlusion of the proximal LCx. As above, a bare metal stent was placed to open the occluded artery and to revascularize the inferoposterolateral myocardium. After the revascularization, his chest pain completely resolved. Subsequent TTE findings are provided above. Post-procedure, his CK peaked at 7476 and his troponin-T peaked at 18.92; EKG showed return to baseline of ST-segment. He was kept on Integrillin for 18 hours and started on aspirin as well as Plavix and Lipitor. Hemoglobin A1c came back at 8.4, at which point we started metformin. We encouraged smoking cessation. . He will return for follow-up with Dr. [**Last Name (STitle) **] and will eventually need PTCA of his distal RCA, which was found to be 90% stenosed. . # PUMP: A TTE the day after catheterization showed mild to moderate regional left ventricular systolic dysfunction, c/w CAD. There was also mild pulmonary hypertension. In addition to the ACEI on which he came in, he started metoprolol, simvastatin, and metformin for risk factor modification and prevention of progression of cardiomyopathy. LVEF was calculated to be 40%. He denied symptoms of CHF, and there was no indication to start spironolactone. . # RHYTHM: He remained in normal sinus rhythm with intermittent two to three beat runs of accelerated idioventricular tachycardia. He was monitored on telemetry throughout. . # HTN: As above, blood pressure regimen at discharge included an ACEI and BB, which were uptitrated to achieve target BP<130/80. . # DM: As above, we started metformin for better blood glucose control. Medications on Admission: Atenolol 75 [**Hospital1 **] Lisinopril 40 daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: acute ST-elevation myocardial infarction .. SECONDARY DIAGNOSIS: uncontrolled type 2 diabetes mellitus hypertension hyperlipidemia Discharge Condition: Vital signs stable. Chest-pain free. Discharge Instructions: You were admitted and treated for an acute STEMI (heart attack). You received a bare metal stent to a blocked artery that supplies the heart; you must take aspirin 325mg daily for the rest of your life and plavix (clopidogrel) 75mg daily for at least the next 30 days or you may die from a heart attack. Do not stop either of these medications without first discussing with your cardiologist. If you think you have missed a dose, it is better to take a single extra dose than to go even a day without Plavix. Please also continue to take the simvastatin as directed for anti-inflammatory benefits as we discussed. . You still need a procedure to address a different vessel around the heart with a significant decrease in flow. . Do not lift more than 10 pounds for the next week to prevent complications from the groin procedure site. . We started a medication called metformin for your diabetes. It is important to continue dietary measures to control your blood sugars as well. Please stop smoking. Information was given to you on admission regarding smoking cessation. Followup Instructions: The cardiac cath lab will call you to schedule a second procedure for the remaining stenosis in your right coronary artery. . You should call the department of cardiology to schedule an appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on a Monday in approximately 3 weeks. Completed by:[**2150-9-14**]

[ "401.9", "V45.82", "250.02", "410.21", "414.01", "V70.7" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7843, 7849

5197, 7031

309, 401

8043, 8083

2296, 4015

9204, 9540

1918, 1977

7130, 7820

7870, 7870

7057, 7107

4032, 5174

8107, 9181

1992, 2277

258, 271

429, 1524

7954, 8022

7889, 7933

1568, 1790

1806, 1902

3,225

132,112

53748

Discharge summary

report

Admission Date: [**2133-4-26**] Discharge Date: [**2133-5-1**] Date of Birth: [**2084-3-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Status post fall. Major Surgical or Invasive Procedure: None. History of Present Illness: 49 year-old male with history significant for alcohol abuse and recent stay in the [**Hospital Unit Name 153**] for withdrawal who was brought to the ED the day of admission by EMS after the patient had a seizure and a witnessed fall. A bystander called EMS. CT of the head and C-spine were obtained. The CT spine showed a lytic lesion in the spine; neurosurgery was consulted. The neurologic exam was difficult as the patient was uncooperative. A C-collar was placed. He was admitted to the ICU given the fact that he has required very large doses of valium in the past for withdrawal. . On arrival to the ICU, the patient reports having pain all over and feeling "stiff". He also reports weakness in his lower extremities. He reports that he drank vodka the day prior to admission but he cannot remember the time. Past Medical History: 1. Alcohol abuse 2. Thrombocytopenia, thought secondary to alcohol use 3. Distant nasal cocaine use 4. History of hypercholesterolemia 5. Question of coronary artery disease Social History: - Homeless - Sex with men and women, reports HIV negative - Alcohol abuse: 1-1.5 pints of liquor per day. This has been going on since age 14. He has attempted to quit in the past but has relapsed each time. - Tobacco: Smokes 1-1.5 packs of cigarettes per day (50+ pack year history) - IVDU: Denies but reports distant use of nasal cocaine Family History: Positive for lung cancer in his mother and father. His brother had HIV from sexual contact. Physical Exam: Upon arrival to MICU: T 94.9, BP 121/72, HR 80, R 18, O2 100% on 2L Gen: NAD, still intoxicated HEENT: Abrasion over right eye, PERRL, EOMI Neck: C-collar in place CV: RRR, no murmurs Chest: Crackles at bases Abd: +BS, soft, tender to palpation in RUQ Ext: No edema, warm Neuro: CN 2-12 intact, moves all extremities but decreased movement in lower extremities; DTRs 3+ in lower ext, 2+ in upper ext; sensory exam difficult due to poor cooperation though patient reports decreased sensation in left foot; down-going toes bilaterally Pertinent Results: Labwork on admission: [**2133-4-26**] 03:29AM WBC-4.4 RBC-3.90* HGB-13.0* HCT-36.6* MCV-94 MCH-33.3* MCHC-35.5* RDW-14.0 [**2133-4-26**] 03:29AM PLT COUNT-241# [**2133-4-26**] 03:29AM NEUTS-25* BANDS-0 LYMPHS-50* MONOS-15* EOS-3 BASOS-6* ATYPS-1* METAS-0 MYELOS-0 [**2133-4-26**] 03:29AM GLUCOSE-86 UREA N-9 CREAT-0.6 SODIUM-145 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-29 ANION GAP-16 [**2133-4-26**] 03:29AM ALT(SGPT)-48* AST(SGOT)-84* LD(LDH)-317* ALK PHOS-104 TOT BILI-0.2 [**2133-4-26**] 03:29AM ALBUMIN-4.2 CALCIUM-9.6 PHOSPHATE-4.4 MAGNESIUM-2.0 [**2133-4-26**] 07:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2133-4-26**] 03:29AM ASA-NEG ETHANOL-286* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG . CHEST X-RAY [**2133-4-26**] IMPRESSION: Mild vascular engorgement and upper zone redistribution, without overt pulmonary edema. . CT C-SPINE W/O CONTRAST [**2133-4-26**] IMPRESSION: 1. No cervical spine fracture. Unchanged degenerative changes at C6/7. 2. New 10 mm lytic lesion in the posterior elements of C4, with possible interuption of the right laminar cortex . CT HEAD W/O CONTRAST [**2133-4-26**] IMPRESSION: No acute intracranial process; specifically, no sign of intracranial hemorrhage. . MR CERVICAL SPINE W/O CONTRAST [**2133-4-27**] IMPRESSION: This study is inconclusive in evaluating the C4 lesion seen on the [**2133-4-26**], exam. A repeat examination should be performed if further evaluation is clinically warranted. The exam should not be performed on the Siemens Vision MRI. There is no malalignment of the cervical spine. . C-SPINE NON-TRAUMA W/FLEX & EXT 4 VIEWS [**2133-5-1**] IMPRESSION: 1. Degenerative changes of the cervical spine, best seen at C6-C7. 2. There is anterolisthesis of C4 over C5 which does not meet radiographic criteria for abnormal motion (greater than 2 mm). 3. The lytic lesion in the spinous process of C4 on the previous CT scan is not well seen on these radiographs. . Labwork on discharge: [**2133-4-29**] 09:20AM BLOOD WBC-8.0 RBC-3.59* Hgb-11.6* Hct-34.0* MCV-95 MCH-32.3* MCHC-34.1 RDW-13.8 Plt Ct-290 [**2133-4-29**] 09:20AM BLOOD Glucose-191* UreaN-12 Creat-0.7 Na-136 K-4.4 Cl-101 HCO3-27 AnGap-12 [**2133-4-28**] 04:45AM BLOOD ALT-29 AST-39 LD(LDH)-151 AlkPhos-96 TotBili-0.3 Brief Hospital Course: 49 year-old male with history of severe alcohol withdrawal and seizures presenting status post fall with neck pain and incidentally found to have a lytic bony lesion in C4. . 1. Alcohol abuse/withdrawal: The patient has a history of withdrawal seizures. The patient was initially monitored in the ICU for severe withdrawal/DT. He received standing valium with valium as needed per the CIWA scale. He received nutritional support with MVI/thiamine/folate. The patient's standing valium was slowly tapered due to the history of seizures. The patient's liver function tests were mildly elevated on admission but normalized prior to discharge. The patient was six days from his last alcoholic drink the day of discharge. The patient was again strongly advised against future alcohol use. . 2. C-spine lytic lesion: Neurosurgery followed the patient during admission. The patient's neurological exam unremarkable and the lesion did not cause cervical instability. Possible etiologies include a benign aneurysm or a metastatic lesion. The patient received an MRI C-spine on a Sieman's MRI that was unable to further characterize the lesion due to patient motion and incorrect magnet. Radiology recommended that the patient receive a repeat MRI C-spine (on a non-Sieman's machine) and a bone scan to further evaluate the lesion. The patient decided to leave against medical advice. The patient should follow-up with his new primary care physician regarding scheduling of these tests. The patient had follow-up scheduled with Neurosurgery. . 3. Neck pain: The patient complained of neck pain after the fall, likely due to spasm status post seizure activity. The patient was maintained with a cervical collar until he was able to be clinically and radiologically cleared of fracture prior to discharge. The patient had follow-up scheduled with Neurosurgery. . 4. Anemia/history of thrombocytopenia: Likely due to alcohol-induced bone marrow suppression. Stable throughout admission. Medications on Admission: None. Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Alcoholism 2. Status post fall 3. Question recent seizure activity; history of seizure activity 4. C4 lytic lesion 5. Neck pain . Secondary: 1. Degenerative disk disease 2. Anemia 3. Polysubstance abuse Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: You are leaving the hospital against medical advice. You have indicated that you understand the risks, which include serious injury and death. . You were hospitalized after a fall after drinking alcohol. You should avoid drinking any alcohol. You have an appointment to see a primary care physician at [**Hospital6 733**] (across the street from the hospital). You need to discuss alcohol and smoking cessation with your primary care doctor. . You were found to have a bony lesion in your neck. MRI of the cervical spine and bone scan were recommended for further evaluation. You no longer need to wear the hard collar for neck pain but should follow-up with neurosurgery. . Please contact a physician if you [**Name9 (PRE) **] fevers, chills, chest pain, shortness of breath, neck pain, increased headaches, or any other concerning symptoms. . Please take your medications as prescribed. - You should continue folate, thiamine, and a multivitamin because of your history of alcohol abuse. . Please keep your follow-up appointments as below. Followup Instructions: Follow-up with Primary Care: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2133-6-10**] 2:30 . Follow-up with Neurosurgery: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2133-5-27**] 2:45. Located on the [**Location (un) **] of the [**Hospital Unit Name **].

[ "285.9", "733.90", "E888.9", "724.8", "291.81", "303.91", "287.5", "780.39" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7120, 7126

4780, 6755

332, 340

7385, 7417

2420, 2428

8507, 8938

1757, 1851

6811, 7097

7147, 7364

6781, 6788

7441, 8484

1866, 2401

4463, 4757

275, 294

368, 1186

2442, 4449

1208, 1383

1399, 1741

1,700

157,047

1255

Discharge summary

report

Admission Date: [**2191-8-24**] Discharge Date: [**2191-8-30**] Service: [**Last Name (un) **] Allergies: Penicillins / Sulfonamides Attending:[**First Name3 (LF) 5880**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 83 year old femal who went out on the porch to get her mail, slipped on steps and fell about 5 feet and struck here head on the rail and ground. She denies loss of conciousness, lightheadedness, chest pain, shortness of breath, prior to fall. She complains of a headache and a large [**6-2**] centimeter laceration to her parietal/posterior aspect of her scalp. No other obvious injuries. Also complains of some back pain in upper thoracic/lower c-spine area. Patient takes coupmadin for Afib. She has also had 2 falls in the last 6 months Past Medical History: 1. Hypertension 2. Atrial fibrillation 3. Congestive heart failure, echo in [**2189**] with ejection fraction of 55%. 4. Status post cholecystectomy 5. Bilateral masectomy 6. History of appendectomy Social History: lives alone with no alcohol or no tobacco Family History: non contributory Physical Exam: Temperature 99.0, pulse 73, blood pressure 94/49, respirations 21, oxygen saturation 96% on room air General: awake, alert and oriented times 3 Head and neck: [**6-2**] centimeter laceration ot posterior scalp with some debris/[**Doctor Last Name 5691**]. No involvement of the galea. Pupils equal round and reactive to light. Extraocular movements intact. Midface stable. Tympanic membranes clear. dentition intact. C collar in place Pulmonary: clear to auscultation bilaterally Cardiac: regular rate and rhythm with no murmurs rubs or gallops Abdomen: soft, nontender, nondistended Genitourinary: Foley in place, no gross blood Rectal: normal tone, no gross blood Extremities: no clubbing, cyanosis or edema Pelvis: stable to [**Doctor Last Name **] Back: no abrasions, tender on palpation of spinous processes of upper thoracic or lower cervical spine Neuro: alert and oriented times three. Cranial nerves 2 through 12 intact. Motor and sensation intact bilaterally Pertinent Results: CT abdomen [**2191-8-24**]: There is a 1.4 x 1 cm area of low attenuation seen in the right lobe of the liver likely representing a simple cyst. It was previously seen on the study from [**2189-3-21**]. Another small subcentimeter area of low attenuation is present in the right lobe which is too small to characterize. The rest of the liver is unremarkable. The gallbladder is not visualized. The spleen, adrenals, kidneys, pancreas appear unremarkable. There is no free air or free fluid. There is no mesenteric or retroperitoneal lymph adenopathy. The evaluation of the bowel is incomplete due to lack of oral contrast. However, it grossly appears unremarkable. The inferior vena cava appears thin in the antero-posterior diameter. This is of inknown clinical significance. CT OF THE PELVIS WITH IV CONTRAST: Multiple diverticula are present in the large bowel without evidence of diverticulitis. There is no free air or free fluid. The urinary bladder and distal ureters appear unremarkable. There is no pelvic or inguinal lymph adenopathy. No suspicious lytic or blastic lesions are identified. No fractures are seen. There is a lumbar dextroscoliosis. Degenerative changes are seen in the spine. CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the absence of an acute abdominal pathology. IMPRESSION: No evidence of traumatic injury. CT cspine [**2191-8-24**]: The occipital condyles are well-aligned with the C1 lateral masses. C2 through C7 alignment is anatomic. There is multilevel degenerative disk disease from C3 to C6. There is some multilevel uncovertebral joint hypertrophic changes. No prevertebral soft tissue. IMPRESSION: Fracture of the right superior facet at C7 without associated widening or malalignment of the facet joint. No evidence of traumatic malalignment of the cervical spine. Multilevel degenerative changes. CT Head [**2191-8-24**]: IMPRESSION: 1. Extensive scalp injury near the vertex with associated subcutaneous emphysema. No associated calvarial abnormalities. Prominent diploic veins of uncertain clinical significance. Gadolinium enhanced brain MRI may be helpful for excluding underlying vascular abnormalities. Xray clavicle [**2191-8-26**]: No evidence of clavicular fracture. Poor visualization of the sternoclavicular joint MRI C-spine, [**2191-8-26**]: IMPRESSION: 1. Spinal stenosis most notably at C4-C5 and C5-C6 with evidence of bilateral neural foraminal narrowing at these levels, consistent with degenerative disease. 2. No evidence of cord impingement at C6-C7 or C7-C8. No subluxation of the component vertebrae. The alignment of the cervical spine is normal. No paraspinal pathology is seen. Brief Hospital Course: The patient had her head laceratoin closed, and was resusccitated with 2 liters of Fluid for systolic blood pressures in the 80's-90s. She also received two units of packed red blood cells. Her INR was 2.4, and she was also given FFP. She had a 10 point drop in her hematocrit. He was admitted to the intensive care unit for the transfusion and for regular neuro checks. The orthopaedic spine was consulted for a C7 Fracture, who suggested a hard C collar for 3 months, and to follow up in three weeks. She was transferred to the floor on hospital day 2 in stable condition. She remained hemodynamically and neurologically stable, and the patient was evaluated by physical therapy who suggested physical therapy rehab for strengtheniing, mobility and balance training and education regarding her recent falls and her deconditioning. The patient was tolerating regualr food. She did complain of some shoulder pain but an xray of her clavicle was negative. It was decided that the patient should not be anticoagulated for 2 weeks for spinal healing, but the patient should resume anticoagulation with her primary care physician [**Last Name (NamePattern4) **] 2 weeks. She was in stable condition and ready for transfer to rehab. On discharge the patient had asymptomatic bactiuria. We spoke to the infectious disease people at [**Hospital1 18**], and they felt that this was not a urinary tract infection and should not be treated, given that the patient is not having dysuria, an elevated white count, or fevers over the 6 days in the hospital. if the patient develops symptoms (fever, pain with urination) you can send a repeat urinalysis and treat her for a UTI, but this does not require her to come back to the hospital. She can call [**Last Name (LF) **], [**Name8 (MD) 7805**], MD, in infectious disease if there are any questions, who was consulted on this. Medications on Admission: atenolol 50 mg daily, diltiazem 240 mg daily, prilosec 20 mg daily, coumadin 4 mg daily, albuteraol, Diovan, lasix 10 mg daily, prinivil 40 mg daily, zoloft 100 mg daily, vioxx 25 mg daily, searax 15 mg nightly Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*2 inhalers* Refills:*0* 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO QD (once a day). Disp:*15 Tablet(s)* Refills:*2* 6. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. Disp:*30 Capsule(s)* Refills:*0* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*120 Tablet(s)* Refills:*1* Discharge Disposition: Extended Care Facility: [**Hospital3 7806**] Home - [**Location (un) **] Discharge Diagnosis: 1. Head laceration 2. Cervical spinal fracture 3. Cardiac arrhythmia/atrial fibrillation 4. hypertension 5. congestive heart failure 6. history of falls 7. Acute hypotension 8. Blood loss anemia requiring transfusion Discharge Condition: Good Discharge Instructions: Please [**Name8 (MD) 138**] MD with any spiking fevers, intractable nausea or inability to tolerate food, increasing dizziness, increasing neck pain, numbness, tingling, or weakness in your arms or legs You should resume taking the medication you were taking prior to this admission You need to wear the cervical collar at all times for 3 months. Followup Instructions: You should follow up with Dr. [**First Name (STitle) 1022**] in Orthopaedics in 3 weeks you should call his office to schedule any cervical spine xrays that he may want prior to the appointment. ([**Telephone/Fax (1) 7807**]) You can follow up with Dr. [**Last Name (STitle) 7808**] for your wrist injury You should follow up with your primary care physician, [**Name10 (NameIs) **] will need to restart your coumadin in 2 weeks. You can follow up in the trauma clinic in 2 weeks to have your sutures removed. ([**Telephone/Fax (1) 376**]

[ "427.31", "805.07", "E880.9", "873.0", "958.7", "573.8", "280.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "86.59", "99.04" ]

icd9pcs

[ [ [] ] ]

8096, 8171

4873, 6752

252, 259

8440, 8446

2181, 4850

8843, 9386

1152, 1170

7013, 8073

8192, 8419

6778, 6990

8470, 8820

1185, 2162

208, 214

287, 848

870, 1077

1093, 1136

57,982

178,781

38973

Discharge summary

report

Admission Date: [**2189-1-16**] Discharge Date: [**2189-1-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Percutaneous Coronary Intervention with Bare Metal Stents History of Present Illness: 87F with unknown PMH p/w LM STEMI. Pt initially evaluated at [**Location (un) 620**] for 30min crushing substernal CP while at rest. Not radiating, + diaphoresis, +/- SOB. Transferred for EKG ST elevations. . In the ED, initial vitals were HR 100, ill appearing. Pt received ASA, Plavix, Integrillin and taken to cath which revealed LMCA prox 50%, LAD TO thrombotic prox -> 80% diffuse after recanulization. LCX TO thrombotic prox. RCA mid heavily calcified with mid 80% stenosis. 5 stents were placed in prox LAD and LCX and IABP placed. Pt received 250ml contrast. RHC revealed CO 3.26, CI 1.99, PCWP 27-33, PA 44/24. Step up in oxygenation from RV 57 to PA 73. Echo was done and not officially read at time of admission. Past Medical History: 1. CARDIAC RISK FACTORS: none 2. OTHER PAST MEDICAL HISTORY: Hip fracture. Mild dementia. Social History: Lives with daughter and husband. [**Name (NI) 482**] [**Name2 (NI) 483**] and French. Husband Finnish. [**Name2 (NI) 3003**] h/o falls. Otherwise independent. Has some dementia. -Tobacco history: Unknown Family History: Unknown Physical Exam: Admission Exam: VS: T=98.8R BP=119/50 HR=98 RR=18 O2 sat= 99% 6L GENERAL: frail elderly female, comfortable, supine. Oriented x 2 (not hospital). HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without JVD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No extra sounds when IABP paused LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles bilaterally, worse at lower [**12-13**]. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. Left groin with sheath, right groin nontender, no hematoma or bruit. Right DP palp, left dopplerable, both feet cool. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2189-1-17**] 12:29AM BLOOD WBC-15.9* RBC-4.12* Hgb-12.3 Hct-36.6 MCV-89 MCH-29.8 MCHC-33.5 RDW-12.6 Plt Ct-396 [**2189-1-21**] 05:10AM BLOOD WBC-10.3 RBC-3.46* Hgb-10.6* Hct-30.4* MCV-88 MCH-30.7 MCHC-35.0 RDW-13.0 Plt Ct-251 [**2189-1-21**] 05:10AM BLOOD PT-12.6 INR(PT)-1.1 [**2189-1-17**] 12:29AM BLOOD Glucose-196* UreaN-21* Creat-0.9 Na-135 K-3.8 Cl-100 HCO3-26 AnGap-13 [**2189-1-21**] 05:10AM BLOOD Glucose-110* UreaN-23* Creat-0.6 Na-135 K-3.8 Cl-102 HCO3-27 AnGap-10 [**2189-1-17**] 12:29AM BLOOD CK(CPK)-5512* [**2189-1-17**] 06:23AM BLOOD CK(CPK)-4364* [**2189-1-19**] 04:42AM BLOOD CK(CPK)-259* [**2189-1-17**] 12:29AM BLOOD CK-MB- >500 cTropnT-23.9* [**2189-1-17**] 01:59PM BLOOD CK-MB-300* MB Indx-10.5* cTropnT-14.92* [**2189-1-19**] 04:42AM BLOOD CK-MB-14* MB Indx-5.4 cTropnT-6.78* [**2189-1-17**] 12:29AM BLOOD %HbA1c-5.2 eAG-103 [**2189-1-17**] 12:29AM BLOOD Triglyc-85 HDL-60 CHOL/HD-3.1 LDLcalc-108 [**2189-1-16**] 09:53PM BLOOD Type-ART pO2-82* pCO2-41 pH-7.31* calTCO2-22 Base XS--5 Intubat-NOT INTUBA Comment-O2 DELIVER [**2189-1-18**] 11:40AM BLOOD Type-ART pO2-58* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 [**2189-1-16**] 09:53PM BLOOD Glucose-246* Lactate-1.3 Na-133* K-3.3* Cl-98* [**2189-1-18**] 08:39AM BLOOD Lactate-1.2 [**2189-1-19**] 05:03AM BLOOD freeCa-1.13 Cardiology Report Cardiac Cath Study Date of [**2189-1-16**] INDICATIONS FOR CATHETERIZATION: STEMI HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.63 m2 HEMOGLOBIN: 12.5 gms % FICK **PRESSURES RIGHT ATRIUM {a/v/m} [**2190-11-25**] RIGHT VENTRICLE {s/ed} 44/12 PULMONARY ARTERY {s/d/m} 44/25/31 PULMONARY WEDGE {a/v/m} 27/33/25 AORTA {s/d/m} 124/65/87 **CARDIAC OUTPUT HEART RATE {beats/min} 96 RHYTHM NSR O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 43 CARD. OP/IND FICK {l/mn/m2} 4.7/2.9 **RESISTANCES SYSTEMIC VASC. RESISTANCE 1294 PULMONARY VASC. RESISTANCE 102 FICK **% SATURATION DATA (FL) SVC LOW 64 RA MID 58 RV MID 57 PA MAIN 73 AO 97 FICK **SHUNTS PULMONARY BLOOD FLOW 5.2 SYSTEMIC BLOOD FLOW 3.13 O2 STEP UP (VOL %) 15 PULMONARY/SYSTEMIC FLOW RATIO 1.6 OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed. **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA DISCRETE 80 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA NORMAL 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN DISCRETE 50 6) PROXIMAL LAD DISCRETE 100 12) PROXIMAL CX DISCRETE 100 FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate ventricular diastolic dysfunction. 3. Moderate pulmonary hypertension. 4. Possible left to right intracardiac shunt at the atrial level. 5. Successful PCI of the LAD. 6. Successeful PCI of the LCX. 7. Successful placement of IABP. 8. Successful deployment of angioseal closure device. [**Known lastname 86449**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86450**]Portable TTE (Focused views) Done [**2189-1-16**] at 11:37:07 PM FINAL The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is severe regional left ventricular systolic dysfunction with severe hypokinesis to akinesis of the anterior, septal and distal/apical segments (proximal LAD territory). The remaining segments contract normally (LVEF = 25-30%). No left ventricular thrombus seen. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. 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 leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w CAD. Mild aortic and mitral regurgitation. Limited emergency study. [**Known lastname 86449**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86450**]Portable TTE (Focused views) Done [**2189-1-18**] at 9:52:04 AM FINAL There is severe regional left ventricular systolic dysfunction with LVEF 25%. Right ventricular chamber size and free wall motion are normal. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. LVOT VTI on milrinone and IABP 1:1 was 12 cm at 115 bpm --> C.O. = 3.9 l/min LVOT VTI off milrinone and IABP 1:1 was 12.7 cm at 117 bpm --> C.O. = 4.1 l/min LVOT VTI off milrinone and IABP 1:2 was 11.1 cm at 115 bpm --> C.O. = 3.6 l/min IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w LAD-territory infarction. Mild mitral and aortic regurgitation. Minimal change in cardiac output during inotrope and IABP weaning. Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2189-1-17**] 3:39 PM IMPRESSION: 1. Streak artifact from an intra-aortic balloon pump markedly limits evaluation of the lower descending thoracic aorta and abdominal aorta, though no overt abnormality. There is atherosclerotic disease in the abdominal aorta and common iliac arteries. 2. Small bilateral pleural effusions with atelectasis and likely aspiration. 3. 1.4 x 0.8 cm nonspecific renal lesion for which further evaluation with MRI is recommended (as clinically indicated). Radiology Report CHEST (PORTABLE AP) Study Date of [**2189-1-20**] 8:25 AM IMPRESSION: 1. Worsening perihilar edema with worsening bilateral moderate pleural effusions and moderate bibasilar atelectases. 2. New left lower lobe opacity is concerning for atelectasis or pneumonia in the correct clinical setting. Cardiology Report ECG Study Date of [**2189-1-20**] 1:36:24 PM Sinus tachycardia. Right bundle-branch block. Anterior wall myocardial infarction. ST-T segment elevation in leads V1-V4 suggests acute/subacute process. Lateral ST-T wave changes suggestive of myocardial ischemia. Low QRS voltages in the limb leads. Compared to the previous tracing of [**2189-1-19**] anterior myocardial injury pattern persists. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 108 170 130 350/434 67 0 65 Cardiology Report ECG Study Date of [**2189-1-16**] 10:44:14 PM Borderline sinus tachycardia with ventricular premature beat or aberrant conduction. Indeterminate axis. Possible anterior wall myocardial infarction of indeterminate age. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 100 176 96 372/442 75 0 90 Brief Hospital Course: Mrs. [**Known lastname **] is an 87 year old woman who presented with chest pain, found to have three-vessel CAD and proximal LAD and LCX total thrombotic occlusion, transferred to [**Hospital1 18**] for cardiac catheterization. . # s/p STEMI: Patient presented from outside hospital with CKMB >500, immediately sent for Cardiac Catheterization. During the procedure, she was found to have diffuse coronary disease with 80% stenosis of the mid RCA, 50% Left Main stenosis, and 100% stenosis, total thrombotic occlusion, of the proximal LAD and proximal Circumflex. After the total thrombotic occlusion in the proximal LAD was removed, 80% stenosis was found in the mid LAD. A total of 5 bare metal stents were placed, and the patient was transferred to the CCU with an intra-aortic balloon pump still in place to help augment pressures and coronary flow. Patient was started on aspirin, plavix, heparin, statin, and finished an 18hour course of integrilin. Her cardiac enzymes trended down appropriately. She was weaned off the intra-aortic balloon pump after about 36 hours. She was transitioned to coumadin with lovenox bridging to prevent intraventricular thrombus formation. Her visiting nurse will draw her INR and send results to her new PCP who will manage her coumadin dosing. . HbA1c and lipid panel were checked to assess her cardiac risk factors, as she does not follow with a primary care physician. . # Cardiogenic Shock: The patient is s/p STEMI, found to have diffuse coronary artery disease, including the left main. Echo showed severe regional left ventricular systolic dysfunction with EF 25%. Patient was noted to have poor cardiac output, leading to low blood pressures and low urine output. A Swan-Ganz catheter was placed in order to more accurately measure her volume status and manage appropriately. She was started on a milrinone drip which initially supported her cardiac output, but when it was used again its proarrhythmic effects put her into atrial fibrillation, so it was stopped. . # Atrial Fibrillation On Day 4 of hospitalization, when the patient was re-started on a milrinone drip to improve forward cardiac flow, its pro-arrythmogenic effects put her into atrial fibrillation with rapid ventricular response in the 140s-160s with blood pressures in the 90s systolic. Her ventricular response responded to metoprolol 5mg intravenously x2, then given an intravenous amiodarone bolus of 150mg, after which she converted back to normal sinus rhythm. . # Abdominal and Back Pain: Patient concerned of vague abdominal and back pain after her Catheterization, but CT scan was negative for retroperitoneal bleed and mesenteric ischemia, and her hematocrit was stable. There had been concern for mesenteric ischemia with her history of atherosclerosis and with intra-aortic balloon pump in place. Patient's daughter mentioned that the patient had been complaining of vague pains all over her body for years. . # Goals of Care Patient has poor overall prognosis, heart with poor inotropy, allowing poor forward flow, low cardiac output. The CCU team met with the patient and her daughter to explain her prognosis. The patient herself did not wish to discuss goals of care and left decision making to her daughter. Palliative [**Name2 (NI) **] was consulted. The patient's daughter signed as her Health Care Proxy and changed the patient's code status to DNR/DNI. She was sent home with VNA services with Home Hospice services. . Medications on Admission: None Discharge Medications: 1. Oxygen 2-5L continuous pulse dose for portability 2. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-15 mg sublingual PO q1h as needed for pain, air hunger: For hospice care. Disp:*20 mL* Refills:*0* 3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous twice a day for 7 days. Disp:*14 syringes* Refills:*0* 9. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 tablets* Refills:*2* 10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 14. [**Name2 (NI) 86451**] 125 mcg Tablet Sig: [**12-13**] Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Outpatient Lab Work You need to have your INR drawn on Saturday, [**2189-1-24**], and faxed to Dr. [**Last Name (STitle) 86452**] at [**Telephone/Fax (1) 86453**]. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis: ST Elevation Myocardial Infarction Secondary Diagnoses: Cardiogenic Shock Acute Heart 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 Mrs. [**Known lastname **], You were admitted to the hospital because you had a very large heart attack and were taken for Cardiac Catheterization. You had multiple stents placed into your coronary arteries to keep them open, and you were started on some new medications, listed below, that are very important to continue. After the heart attack, your heart is weak and has difficulty pumping your blood effectively to the rest of your body. You were discharged home with oxygen as needed. You were also discharged home with blood thinning medications in order to prevent a blood clot from forming inside your heart. While on the coumadin, you will need to have your blood monitored regularly to make sure the level in your blood fits within the appropriate range; until it reaches this range, you will need twice daily Lovenox shots to help thin your blood. You will need to have the blood labs faxed to Dr. [**First Name4 (NamePattern1) 86454**] [**Last Name (NamePattern1) 86452**] at [**Telephone/Fax (1) 86455**]. Your new medications are as listed below. - Warfarin 2.5mg by mouth daily - Lovenox Injections, daily, until warfarin level at goal - discuss with your primary care physician [**Name Initial (PRE) **] [**Name Initial (NameIs) 86451**] 0.0625mg by mouth daily - Furosemide 20mg by mouth daily - Captopril 6.25mg by mouth three times a day - Colace 100mg by mouth twice a day - Senna 1 tab by mouth twice a day as needed for constipation - Lorazepam 0.25mg by mouth every 6 hours as needed for anxiety - Atorvastatin 80mg by mouth daily - Clopidogrel 75mg by mouth daily - do not stop this medication for any reason. Only your cardiologist should stop this medication. - Aspirin 325mg by mouth daily - Morphine elixir 2-15mg by mouth every hour as needed for pain or air hunger. [**Month (only) 116**] start with 2mg and then increase as necessary at a time to not over-sedate. Please be sure to keep your followup appointments. They are listed below. Followup Instructions: Please schedule an appointment with Dr. [**First Name4 (NamePattern1) 86454**] [**Last Name (NamePattern1) 86452**]. The phone number to set this appointment up is [**Telephone/Fax (1) 67509**]. He will follow your INR levels as above. You should contact him with any questions or concerns or needs for new medications or refills. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Street Address(2) **]. [**Location (un) **] ([**Telephone/Fax (1) 8937**] Wednesday, [**1-28**] at 10:00. Please arrive by 9:30am.

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icd9cm

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23065

Discharge summary

report

Admission Date: [**2147-8-7**] Discharge Date: [**2147-8-12**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2195**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Ms. [**Known lastname 59441**] is a [**Age over 90 **] y/o F with a h/o CAD s/p CABGx3 in [**2140**] that was complicated by post-op occlusion of her LIMA requiring 2 stents and AICD/Pacer placed for recurrent VT, h/o prior lower GI bleed on coumadin (during CABG), HTN and HL who presented from home with BRBPR. Last night before she went to bed and felt fine, got up in the night to go to the bathroom and she had a bloody/tarry bowel movement and had some blood on her underwear and in the toilet bowl. She then pressed her life line and was brought in by ambulance to the [**Hospital1 18**] ER, this morning she is complaining of feeling tired and fatigued. She has never had a colonoscopy. . In the ED, initial vs were: 97.8, 97, 101/55, 20, 100% on RA. In the ER her exam was notable for a grossly bloody rectal exam. Labs showed a white count of 16.6, HCT of 33.3, from a baseline of 41, and Cr of 2.1 from baseline of 1.6. Her EKG was sinus tachycardia at 103bpm, q waves in III and aVF. Per the patient and her family she is full code but does not want any heroic measures such as a colonoscopy. She received 300cc's of IVF and plan is to transfuse 2 units PRBC's, GI is aware of the patient. VS on transfer: 85, 96/54, 26, 99% on RA. . On arrival to the ICU her initial VS were: 96.9, 86, 105/57, 28, 100% on 2LNC. Shortly after arrival she had a large bowel movement with dark, red blood and clots, on returning from the commode she became lightheaded and her systolic blood pressure dropped into the 80's. She says that the last time she had a stent placed was after her CABG in [**2140**], she continues to be followed by Dr. [**Last Name (STitle) **] for her cardiac issues, she says that she has been told she has a heart murmur and has had one for awhile but she does not know which type. No GERD sx, no n/v/d, constipation. . Review of systems: (+) Per HPI and for lightheadedness/dizziness (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: CAD s/p CABG x 3 and stents x 2 to his LIMA CRI - baseline Cr is 1.6 HTN HL Heart Murmur - ?Aortic Stenosis Social History: no smoking, no ETOH, married, lives w/husband, very active Family History: non-contributory Physical Exam: Physical Exam on Admission: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Physical Exam: Pertinent Results: Labs on Admission: [**2147-8-7**] 05:30AM WBC-16.6* RBC-3.75* HGB-11.7* HCT-33.3* MCV-89 MCH-31.0 MCHC-35.0 RDW-12.7 PT-12.2 PTT-21.7* INR(PT)-1.0 cTropnT-<0.01 GLUCOSE-188* UREA N-53* CREAT-2.1*# SODIUM-142 POTASSIUM-4.5 CL-105 CO2-22 CALCIUM-7.7* PHOSPHATE-2.9 MAGNESIUM-1.9 ALT(SGPT)-16 AST(SGOT)-19 LD(LDH)-147 ALK PHOS-71 TOT BILI-0.3 Imaging: EGD ([**8-9**]): Normal esophagus. Normal stomach. Normal duodenum. Normal EGD to third part of the duodenum Colonoscopy ([**8-9**]): Diverticulosis of the whole colon Grade 1 internal hemorrhoids. In the proximal ascending colon/cecum was diffuse erythema, nodularity, ulceration and an area of fullness. this involved a 6 cm region. Proximal to this was normal mucosa and then in the distal ascending colon was another 3 cm area of erythema, ulceration. (biopsy) Otherwise normal colonoscopy to cecum and distal 8 cm of ileum Recommendations: follow up biopsies per the team. this may all be consistent with ischemic colitis, less likely malignancy to explain her GI bleeding. EKG: sinus tachycardia at 103bpm, q waves in III and aVF Microbiology: Stool cultures pending at the time of discharge, no growth to date Discharge Labs: [**2147-8-12**] 06:55AM WBC-13.1* RBC-3.87* Hgb-12.0 Hct-34.3* MCV-89 Plt Ct-165 Glucose-77 UreaN-10 Creat-1.1 Na-141 K-3.8 Cl-112* HCO3-22 AnGap-11 Brief Hospital Course: Ms. [**Known lastname 59441**] is a [**Age over 90 **] y/o F with a significant cardiac history who presents from home with BRBPR. #) BRBPR: DDx initially included diverticular disease, embolic/ischemic event, hemorrhoids (although large amount makes this less likely), AVM's or colon cancer. As her most recent Hct was 41, she had lost a substantial amount of blood at presentation given her Hct of 33. She received a total of 7 units of PRBCs, 1 unit FFP, and 1 unit platelets during her stay. By the third day of her admission, her bleeding was stabilized with no further transfusion requirement and a stable Hct at 32. She advanced her diet without evidence of further bleeding. The gastroenterology team was consulted and recommended both EGD and colonoscopy. The preparation for colonoscopy was prolonged, as she continued to produce bright red blood and clots for more than 24 hours. These tests were performed on [**8-9**], and revealed that the likely cause of her bleeding was an ulceration in the ascending colon near the cecum, possibly secondary to ischemic colitis. Malignancy could not be excluded by this study. Biopsies were sent for pathologic study and were consistent with ischemic colitis. Stool cultures were also sent and were pending at the time of discharge. On discussion with the patient's outpatient Cardiologist, Dr [**Last Name (STitle) **], it was determined that she does not require multiple anti-platelet agents, particularly given her risk of further bleeding. He recommended stopping [**Last Name (STitle) **] and continuing [**Last Name (STitle) **]. He will continue to follow her. #) Acute on Chronic Renal Failure:The patient's most recent Cr at PCP [**Name Initial (PRE) **] 1.58, but on initial presentation her Cr was 2.1. This rapidly returned to baseline with hydration. The etiology was likely acute on chronic renal failure from hypovolemia. During her stay her renal function and urine output was monitored, and her medications dosed for her renal function. #) Leukocytosis: Her white count was elevated on admission at 16.6, likely due to a stress response. This dropped rapidly. During her admission she remained afebrile with no localizing signs or symptoms of infection. As noted above, stool cultures were pending at the time of discharge, but her GI symptoms had completely resolved. #) CAD s/p CABG and stents x 2 to LIMA: On admission she had no chest pain, and reported no chest pain or other limiting symptoms with exertion at baseline. Her home statin was continued. Her [**Name Initial (PRE) **] and [**Name Initial (PRE) **] were held on admission. Per discussion with her outpatient cardiologist, Dr [**Last Name (STitle) **], her [**Last Name (STitle) **] was discontinued and her [**Last Name (STitle) **] continued (as discussed above). #) Hypertension: The patient has a history of hypertension, treated with HCTZ, Lisinopril and Diltiazem at home. In the setting of her GI bleed and hypotension these were initialy held during her stay. Her Lisinopril was re-started on [**2147-8-11**], which she tolerated well. HCTZ and Diltiazem continue to be held at discharge. The patient was instructed to follow-up with her PCP early next week for a blood pressure check and further discussion as to whether to re-start these medications. #) COPD: The patient has a history of COPD, treated with albuterol PRN. She had no hypoxia during her stay. Transitional Issues: - Follow-up pending stool cultures - Repeat blood pressure check and determine whether to re-start Diltiazem and HCTZ - Continue to hold [**Date Range **] indefinitely Medications on Admission: Aspirin 81mg daily Diltiazem 120mg daily Lipitor 20mg daily Zetia 10mg daily [**Date Range **] 75mg daily Lisinopril 5mg daily HCTZ 25mg daily Albuterol MDI prn SOB Discharge Medications: per cardiologist, d/c [**Date Range **], continue [**Date Range **] Discharge Disposition: Home Discharge Diagnosis: Ischemic Colitis Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a gastrointestinal bleed requiring blood transfusions. You underwent an endoscopy and colonoscopy that was significant for an area of ischemia in your colon (called ischemic colitis). You were treated supportively with IV fluids and blood transfusions, and over time your bleeding stopped. One of your medications, [**Date Range **], was discontinued, and you were started on a cream for your back called Sarna. Due to your bleeding, your blood pressure was lower in the hospital, and two of your blood pressure medications, Hydrochlorothiazide and Diltiazem, were held. You should not take these until your blood pressure is re-checked in your primary care doctor's office. They may decide to re-start one or both of them at that time. No other changes were made to your home medications. Followup Instructions: Please follow-up with your primary care doctor within three to five days of discharge to discuss the changes to your medications and to ensure you have not had any more bleeding.

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icd9cm

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icd9pcs

[ [ [] ] ]

8761, 8767

4836, 8262

278, 291

8851, 8851

3474, 3479

9855, 10036

2872, 2890

8669, 8738

8788, 8830

8479, 8646

9001, 9832

4663, 4813

2905, 2919

8283, 8453

2193, 2647

211, 240

319, 2174

3493, 4647

8866, 8977

2669, 2779

2795, 2856

3455, 3455

49,619

181,547

2460

Discharge summary

report

Admission Date: [**2150-6-25**] Discharge Date: [**2150-6-30**] Date of Birth: [**2080-5-8**] Sex: M Service: CARDIOTHORACIC Allergies: Ticlid Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath on exertion Major Surgical or Invasive Procedure: [**2150-6-25**] 1. Coronary artery bypass graft x4: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to ramus obtuse marginal and posterior descending arteries. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: 70yo very active male with history of CAD. He jogs daily and has noted an increase in dyspnea with jogging recently. Stress test was abnormal and cath revealed three vessel coronary artery disease. He is referred for surgical revascularization. Past Medical History: PMHx: S/P cardiac cath [**2146**] with CAD noted, medically managed Multiple Myeloma treated with chemotherapy every 3 months, most recently in [**Month (only) 547**] (Due again at the end of [**Month (only) 205**]), Hyperlipidemia Hypertension, Elbow injury in his early 20s, Tonsillectomy, left elbow surgery Past Surgical History Tonsillectomy left elbow surgery Social History: Occupation: owns dog walking business Cigarettes: None Other Tobacco use: never ETOH: None Denies IVDU Family History: Father died of MI in his early 60s Physical Exam: Pulse: 54 Resp: 27 O2 sat: 98% B/P Right: Left: 156/78 Height: 5'8" Weight: 170lb General: NAD, anxious, physically fit Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ 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 [x] Pulses: Femoral Right: cath Left: 2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit: none appreciated Pertinent Results: [**2150-6-25**] Intra-op TEE PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focalities in the apical walls. 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 descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild to Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a [**Known lastname **] pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results before surgical incision. POST-BYPASS: Normal RV systolic function. Intact thoracic aorta. LVEF 50%. Mild improvement of previously hypokinetic apex. No New valvular findings. . [**2150-6-30**] 05:30AM BLOOD WBC-4.1 RBC-2.75* Hgb-8.8* Hct-26.1* MCV-95 MCH-32.0 MCHC-33.7 RDW-13.4 Plt Ct-228 [**2150-6-29**] 05:14AM BLOOD WBC-3.9* RBC-2.77* Hgb-8.8* Hct-25.9* MCV-94 MCH-31.9 MCHC-34.1 RDW-13.3 Plt Ct-203 [**2150-6-30**] 05:30AM BLOOD UreaN-21* Creat-0.8 Na-140 K-4.3 Cl-103 [**2150-6-28**] 04:38AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-141 K-4.0 Cl-105 HCO3-30 AnGap-10 Brief Hospital Course: BRIEF HOSPITAL COURSE: The patient was admitted to the hospital and brought to the operating room on [**2150-6-25**] where the patient underwent CABG X 4. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. Immediately post-operatively, the patient had significant sanginous chest tube output. Multiple products were given including PRBCs, Plts, FFP, and Cryo. Protamine was also given for ACT in the 130's. The patient's Hct decreased to 19. SBPs were high, and a Nitro gtt was required for maintain normal BPs. CXR did not show evidence of tamponade. The patient remained intubated overnight with high PEEPs in attempts to decrease bleeding. Ultimately, the output became less and serous in nature. Hct after transfusions was 25. On POD 1, the patient was extubated. He was 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. On POD 3, Plavix was started (the patient was on Plavix before the operation, however there is no history of stent placement). Additionally, the patient had short bursts of A-Fib seen on telemetry. SBP was stable and the patient was asymptomatic. His beta-blocker was increased and Amiodarone was started orally. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He is in normal sinus rhythm. The patient was discharged to [**Hospital 745**] Health Care in good condition with appropriate follow up instructions. Medications on Admission: [**Last Name (un) 1724**]: AMLODIPINE 10', ATENOLOL 100', ATORVASTATIN 80', Plavix 75', Tricor 96', FINASTERIDE 5', ISOSORBIDE MONONITRATE ER 30', NITROGLYCERIN 0.4 PRN, Flomax 0.4' Discharge Medications: 1. Amlodipine 5 mg PO DAILY Hold for sbp<100 2. Atorvastatin 80 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. Finasteride 5 mg PO DAILY 5. Tamsulosin 0.4 mg PO HS 6. Tricor *NF* (fenofibrate nanocrystallized) 96 mg ORAL DAILY 7. Acetaminophen 650 mg PO Q4H:PRN pain 8. Amiodarone 400 mg PO BID 400mg [**Hospital1 **] x 1 week, then 400mg daily x 1 week, then 200mg dailyq 9. Aspirin EC 81 mg PO DAILY 10. Furosemide 20 mg PO DAILY Duration: 1 Weeks 11. Metoprolol Tartrate 50 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. 12. Potassium Chloride 20 mEq PO DAILY Duration: 1 Weeks Hold for K+ > 4.5 13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital 745**] Healthcare Center Discharge Diagnosis: Coronary Artery Disease, s/p CABG PMH: S/P cardiac cath [**2146**] with CAD noted, medically managed Multiple Myeloma treated with chemotherapy every 3 months, most recently in [**Month (only) 547**] (Due again at the end of [**Month (only) 205**]) Hyperlipidemia Hypertension Elbow injury in his early 20s Past Surgical History Tonsillectomy left elbow surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: The Cardiac Surgery Office will call you with the following appointments: Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Cardiologist Dr. [**Last Name (STitle) **] Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 12604**] N. [**Telephone/Fax (1) 12605**] in [**3-19**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2150-6-30**]

[ "272.4", "203.00", "998.11", "414.01", "427.31", "V87.41", "401.9", "E878.2" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6799, 6862

3779, 5791

305, 575

7271, 7441

2119, 3733

8229, 8863

1380, 1417

6024, 6776

6883, 7250

5817, 6001

7465, 8206

1432, 2100

233, 267

603, 853

875, 1244

1260, 1364

45,542

138,793

37705

Discharge summary

report

Admission Date: [**2166-10-20**] Discharge Date: [**2166-10-24**] Date of Birth: [**2135-8-29**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2836**] Chief Complaint: Abdominal pain with nausea Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 31 year old male with known pancreas divisum and a history of recurrent pancreatitis status-post laproscopic cholecystectomy with Dr. [**Last Name (STitle) **] in [**2165-3-4**] who most recently presented with severe abdominal pain beginnng at 10am on the morning of admission. The pain was described as exactly the same as the pain during his 3 prior pancreatitis episodes in [**11/2164**], [**2-/2165**] and 4/[**2165**]. The pain was located in the epigastric region and upper abdomen, described as burning in nature, was sudden in onset, and described as [**11-10**] in intensity at its worst. The pain was associated with some nausea but the patient denied vomiting. He also denied fevers, chills, and had normal bowel movements with no diarrhea or blood in addition to passing regular flatus. Past Medical History: PAST MEDICAL HISTORY: Recurrent pancreatitis with known pancreas divisum: status-post ERCP in [**6-10**] with minor papillotomy and stent placement/retrieval GERD Pericarditis in [**2158**] (unknown etiology treated with Indocin) PAST SURGICAL HISTORY: Laproscopic cholecystectomy in [**3-13**] Social History: The patient denies tobacco or intravenous drug use. He drinks alcohol socially. Works at TD bank and lives with his girlfriend Family History: Family history of gallbladder disease, and paternal grandmother with pancreatic cancer Physical Exam: VITALS: TEMPERATURE: 99.3 HEART RATE: 68-110 BLOOD PRESSURE: 128/80 RESPIRATORY RATE: 18 OXYGEN SATURATION: 94% on room air GENERAL: No acute distress; lying quietly in bed; alert and oriented; responsive and cooperative HEENT: Mucous membranes moist and pink; no scleral icterus; no ocular or nasal discharge; no throat erythema CARDIAC: Mild tachycardia when ambulating (normal rate when at rest) and normal rhythm; normal S1 S2; no murmurs PULMONARY: Clear to ausculation bilaterally ABDOMEN: Soft, non-tender, moderate distension; no rebound or gaurding; +BS EXTREMITIES: No swelling or edema bilaterally Pertinent Results: ADMISSION LABS: [**2166-10-20**] 04:20PM PLT COUNT-337 [**2166-10-20**] 04:20PM WBC-17.9*# RBC-4.67 HGB-16.0# HCT-43.9 MCV-94 MCH-34.2* MCHC-36.4* RDW-13.0 [**2166-10-20**] 04:20PM ALBUMIN-4.4 [**2166-10-20**] 04:20PM LIPASE-1173* [**2166-10-20**] 04:20PM ALT(SGPT)-50* AST(SGOT)-58* ALK PHOS-124 TOT BILI-0.6 [**2166-10-20**] 04:20PM GLUCOSE-152* UREA N-12 CREAT-0.8 SODIUM-137 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-24 ANION GAP-20 IMAGING: LIVER/GALLBLADDER ULTRASOUND ([**2166-10-20**]): FINDINGS: The liver demonstrates a normal echotexture without focal lesion or intrahepatic biliary dilatation. The portal vein is patent with directionally appropriate flow. The gallbladder is surgically absent. The CBD measures 5 mm in caliber. The spleen measures 10.6 cm in its long axis and is normal appearing. No ascites is seen. IMPRESSION: Status post cholecystectomy without evidence of intra- or extra-hepatic biliary dilatation. CHEST X-RAY (PORTABLE AP) ([**2166-10-22**]): FINDINGS: Bibasal atelectasis and bilateral pleural effusions are noted. There is volume overload seen as vascular engorgement and mild interstitial prominence, but no overt pulmonary edema is seen. Bilateral pleural effusions are small to moderate. The right lower lobe consolidation with air bronchogram is noted, may represent atelectasis, but infectious process would be another possibility, close followup is required. No pneumothorax is seen. Brief Hospital Course: The patient initially presented to the emergency room for evaluation of his severe epigastric/abdominal pain, where laboratory values were consistent with recurrent pancreatitis. Additionally he was noted to be tachycardic to the 160's - sustained. Although the patient was asymptomatic and denied chest pain/dizziness, an EKG was obtained which demonstrated sinus rhythm. He was admitted overnight to the Surgical ICU under the care of the West 2a surgical team on telemetry monitoring given his persistent sinus tachydardia. The patient was begun on aggressvie fluid recuscitation (receiving over 7 liters in fluid boluses in the first 24 hours), made NPO/bowel rest, and his pain was managed with Dilaudid. On the first hospital day he remained in sinus tachycardia but asymptomatic and hemodynamically stable. His pain improved and urine output was good. By hospital day 2 his heart rate had improved and decreased from the 140's to the low 100's - sinus rhythm - and his pain was reported to be improved. The patient was transferred out of the ICU to the floors with continued telemetry monitoring. On exam the patient was noted to have some crackles in his lung fields bilaterally, and due to concern for possible fluid-overload or pulmonary edema, IV fluids were discontinued and a chest X-ray was obtained. The chest X-ray did demonstrate some evidence of fluid overload and mild bilateral pleural effusions, however he continued to have good oxygen saturation and diuresed well. The patient did well on the floors with no acute events. On hospital day 3 the patient was begun on a clear liquid diet which he tolerated well without any nausa or vomiting. By hospital day 4 the it was deemed appropriate to discharge the patient to home under instructions to advance diet as tolerated from clears to regular. At the time of discharge his pain was well controlled on oral medications, he had a completely benign abdominal exam, was tolerating PO, voiding well, had normal bowel movements, ambulating independently, and was in all respects stable. The patient will follow-up with Dr. [**First Name (STitle) **] in one month's time following discharge, during which time he will also undergo a Secretin MRCP for further evaluation of his pancreatic dysfunction. Medications on Admission: Omeprazole 20mg daily Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Pancreatic divisum 2. Recurrent pancreatitis 3. Sinus tachycardia 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 advance your diet as tolerated. If symptoms of the pancreatitis will return: make youself NPO, call/page Dr.[**Name (NI) 5067**] team, in severe case - go in ER. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-10**] 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. . Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 11065**] Date/Time:[**2166-11-20**] 10:30. Please arrive in [**Month/Day/Year **] Department at 09:30, please do not eat or drink 6 hours prior the test. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2166-11-21**] 10:15 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] Completed by:[**2166-10-24**]

[ "577.0", "427.89", "577.1", "V45.89", "530.81", "276.69", "288.60", "511.9", "751.7", "300.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6465, 6471

3867, 6138

332, 338

6584, 6584

2400, 2400

8489, 8954

1665, 1754

6210, 6442

6492, 6563

6164, 6187

6735, 8466

1461, 1505

1769, 2381

266, 294

366, 1185

2416, 3844

6599, 6711

1229, 1438

1521, 1649

63,177

120,319

38540

Discharge summary

report

Admission Date: [**2142-7-7**] Discharge Date: [**2142-7-11**] Date of Birth: [**2067-8-3**] Sex: M Service: MEDICINE Allergies: Penicillins / Barbiturates / Tricyclic Compounds / Phenothiazines Attending:[**First Name3 (LF) 2279**] Chief Complaint: Hypothermia Major Surgical or Invasive Procedure: left subclavian CVL [**2142-7-7**] History of Present Illness: Mr. [**Known lastname 284**] is a 74 year old male with a PMH significant for dementia, hypothyroidism, pituitary adenoma s/p resection, with multiple prior episodes of hypothermia who presented from his nursing home today with increased unresponsiveness, unwillingness to take po's, hypotension, and hypothermia. At baseline per nursing home he moves all of his extremities, will grunt and make other noises for communication but is not verbal. At the nursing home his temperature was noted to be 96, blood pressure was 88/60, he had no urine output over the nursing shift prior to transfer so he was sent to the [**Hospital1 18**] ER for further evaluation. . In the ED, initial vs were: T-94.7, P-59, BP-132/65, R-16, O2 sat of 100%. Patient had a CT of his torso that preliminarily showed: Continued bibasilar atelectasis and aspiration, no acute abdominal process and marked prostatomegaly. A CT of his head showed no acute process. His initial labs were notable for a lactate of 3.8, K of 6.5, Cr of 1.5 (baseline 1.1 to 1.3), bicarb of 21, WBC of 5.5 with 77% neutrophils, HCT of 33.3, ALT of 58, AP of 135 and his U/A had WBC>50, moderate bacteria, moderate leuks and trace blood. He was given vancomycin and levofloxacin for antibiotic coverage, and was given 5 L of IVF. He was also given kayexelate, insulin, D50, albuterol and IVF with improvement in his K to 4.7. Prior to transfer to the ICU his blood pressure dropped to the 70's systolic and he had a subclavian CVL placed. . Review of systems: Unable to obtain as patient is not able to communicate. Past Medical History: - Dementia (Alzheimer's) - Hypothyroidism - Far-advanced pituitary adenoma s/p resection with subsequent adrenal insufficiency - History of CVA - Renal insufficiency - Anemia - H/o syphilis - Prostatic enlargement - Depression - Hyperlipidemia - GERD - Amputation of fingers of left hand Social History: Tobacco, ETOH and IVDU history unavailable. Lives at [**Hospital 10246**] nursing home. Health care proxy and legal guardian is sister ([**Telephone/Fax (1) 85722**]) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Per report, at baseline patient is nonverbal with occasional grunting or answering "yes". He does not maintain eye contact and is not ambulatory at baseline. He is able to eat a modified diet. Family History: Unavailable Physical Exam: General: NAD, no eye contact, responsive only to pain [**Name (NI) 4459**]: Sclera anicteric, arcus senilis, MMM, very poor dentition 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 GU: foley in place Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: . [**2142-7-6**] 11:52PM LACTATE-3.8* [**2142-7-6**] 11:40PM GLUCOSE-111* UREA N-36* CREAT-1.5* SODIUM-137 POTASSIUM-6.5* CHLORIDE-102 TOTAL CO2-21* ANION GAP-21* [**2142-7-6**] 11:40PM ALT(SGPT)-58* AST(SGOT)-40 CK(CPK)-104 ALK PHOS-135* TOT BILI-0.1 [**2142-7-6**] 11:40PM LIPASE-20 [**2142-7-6**] 11:40PM CK-MB-4 cTropnT-0 [**2142-7-6**] 11:40PM CALCIUM-9.5 PHOSPHATE-3.6 MAGNESIUM-2.1 [**2142-7-6**] 11:40PM TSH-3.4 [**2142-7-6**] 11:40PM WBC-5.6 RBC-3.49* HGB-10.4* HCT-33.3* MCV-95 MCH-29.9 MCHC-31.3 RDW-15.6* [**2142-7-6**] 11:40PM NEUTS-77.2* LYMPHS-18.6 MONOS-3.3 EOS-0.6 BASOS-0.2 [**2142-7-6**] 11:40PM PLT COUNT-217 [**2142-7-6**] 11:40PM PT-13.5* PTT-33.9 INR(PT)-1.2* [**2142-7-7**] 12:00AM URINE RBC-0-2 WBC->50 BACTERIA-MOD YEAST-NONE EPI-0 . Discharge labs: [**2142-7-11**] 09:53AM BLOOD WBC-7.9 RBC-2.68* Hgb-8.0* Hct-25.1* MCV-94 MCH-29.7 MCHC-31.7 RDW-16.1* Plt Ct-175 [**2142-7-11**] 09:53AM BLOOD Glucose-139* UreaN-14 Creat-1.1 Na-141 K-4.2 Cl-109* HCO3-26 AnGap-10 [**2142-7-11**] 09:53AM BLOOD Calcium-8.9 Phos-1.7* Mg-2.0 . Microbiology: . [**2142-7-6**] Blood cx: pending [**2142-7-7**] urine culture: PROTEUS MIRABILIS . | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . . [**2142-7-6**] EKG: sinus bradycardia, rate 56, NA, TWI aVL and V3-6, borderline QTc elongation . Images: . [**2142-7-7**] CXR: no acute pulmonary process, subclavian in place . CT head [**7-7**]: No acute intracranial process. Brain and medial temporal atrophy. . CT chest/abdomen/pelvis [**7-7**] 1. Continued bibasilar atelectasis and aspiration. 2. Enlarged prostate 6.8 X 7.5 cm 3. Possible right inguinal testis can be further evaluated by ultrasound (if clinically indicated). 4. moderate degenerative disease of the thoracolumbar spine with osteophyte formation, disc space narrowing, and disc protrusions at multiple levels. . Brief Hospital Course: Mr. [**Known lastname 284**] is a non-verbal, bed-bound 74 year old male man with poor base-line status and PMH significant for dementia, hypothyroidism, pituitary adenoma s/p resection, and mutiple hospitalizations for hypothermia and sepsis who was admitted for sepsis. . # Sepsis: Mr. [**Known lastname 284**] was initially sent to the ER d/t hypotension and low urine output at nursing home. He presented with hypotension, and hypothermia and in ER was found to have a positive UA with WBC>50, moderate bacteria, moderate leuks and trace blood; lactate of 3.8, K of 6.5, Cr of 1.5 from baseline 1.1-1.3. He also had abdominal, chest and head CTs which were unremarkable except for bibasilar atelectasis and prostatomegaly. A subclavian line was placed, the patient was given IVF, vancomycin, Miropenem, levofloxacin and kayexelate and was transffered to the ICU for further treatment.In the ICU patient required pressors for about 12h and continous IVF he was later taken off pressors and was hemodynamically stable with good urine output. He had hypothermia to a minimum of 91.7, he was treated with external heating. As the patient has pan-hypo-pit he received stress dosed steroids and IV thyroid hormone. His urine culture grew proteus mirabilis. Vanco was stopped and meropenem alone was continued per sensitivities. Blood cultures were still pending at the time of discharge. The patient was subsequently transffered to the floor where he remained stable under IV antibiotics. . #UTI: Proteus mirabilis grew in urine culture. No stones urinary stones were noted on abdominal CT. Mr. [**Known lastname 284**] has a significantly enlarged prostate which may be an underlying cause of reccurent UTI's. IV Meropenem was chosen for treatment by culture sensitivities and in consideration of his penicilline allergy. Mr. [**Known lastname 284**] will need to complete a total course of 14 days of IV antibiotics (i.e. 9 days post discharge). . # Hypothermia: Mr. [**Known lastname 284**] presented with hypothermia to a nadir of 91.7. His hypothermia may have been part his septic state. He has a long history of recurrent hospitalziations for hypothermia with and without an obvious infection. This is possibly mulit-factorial in nature and may be related to his endocrine problems (including hypothyroidism or hypoadrenalism in the setting of chronic pan-hypopituitarism), central thermoregulatory dysfunction and/or autonomic instability which may accompany his extrapyramidal syndrome. Mr. [**Known lastname 284**] was treated with external heating, his temperatures subsequently improved and stabalized with in the normal range (96-97 rectal). . . # Acute on chronic renal failure: Mr. [**Known lastname 284**] presented with Cr=1.5 from base-line of 1.1-1.2. This was likely mostly pre-renal with a possible post renal component d/t enlarged prostate. A foley catheter was placed and IVF was given. He had cummulitive I/O balance of + 10L upon transfer from the ICU. Renal functions subsequently returned to base-line and he continued to have good urine output on the floor under PO hydration. Mr. [**Known lastname 284**] was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21655**] catheter and will be followed up by a urologist following discharge. . # Hyperkalemia: Mr. [**Known lastname 284**] presented with Potassium 6.5 w/o EKG changes. His hyperkalemia was likely secondary to renal failure and acidosis and resolved with keyexalate and IVF. . # Pan-Hypo-pit: In the ICU Mr. [**Known lastname 284**] was given stress dose steroids as IV hydrocortisone 100mg TID, this was switched to prednison 60mg daily on the floor and rapidly tapered down to his home dose of 5mg per day. Levothyroxine was given IV in the ICU and then switched on the floor back to his home regimen of PO 75mg once daily. . # Extrapyramidal syndrome: Mr. [**Known lastname 284**] has advanced dimentia and appears to suffer from a presumed extrapyramidal syndrome including cogwheel rigidity in limbs, axial rigidity and Tardive-Diskenesia-like jaw movements. As he does not receive any anti-dopaminergic medication this is likely a primary neurological condition such as [**Last Name (un) 309**] Body Dementia or Parkinson's disease. His cognitive and neurological condition upon discharge is similar to his baseline state. . # T-Wave inversions: Mr. [**Known lastname 284**] presented with new TWI in V3-V5. Cardiac Enzymes were negative times two. Subjective complaints could not be illicited. This finding may be suggestive of ischemia or represent non-specific EKG changes and may warrant further out-patient work-up. Aspirin was continued. . # DM: insulin sliding scale was continued . # Anemia: Mr. [**Known lastname 284**] has a normocytic anemia with Hct 25.1 and minimaly elevated RDW. He is on chronic iron replacement. His hematocrits have been stable during this admission. Hematocrit follow up and work up for anemia may be continued in the outpatient setting. . # Nutrition: Mr. [**Known lastname 284**] successfully passed a video-swallow assessment and was seen by a nutritionist who recommended pureed solids, thin liquids, PO meds crushed in puree, TID oral care, 1:1 supervision/assist with meals, ensure supplement TID and standard aspiration precautions. . # Access: Mr. [**Known lastname 284**] was discharged with PICC-line in place for continued IV therapy post discharge. Medications on Admission: Aricept 10 mg at bedtime Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette 1-2 drops as needed for dry eyes. Docusate Sodium 100 mg twice a day. Furosemide 20 mg DAILY Aspirin 81 mg once a day. Levothyroxine 75 mcg DAILY Trazodone 50 mg - 0.5mg Tablet PO twice a day and 75mg qhs. Prednisone 5 mg once a day. Simvastatin 20 mg a day. Ferrous Sulfate 325 mg (65 mg Iron) Tablet twice a day. Discharge Medications: 1. continue home regimen of basal insulin + insulin sliding scale 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Meropenem 500 mg Recon Soln Sig: One (1) solution Intravenous every six (6) hours for 9 days. 8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 9. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once a day. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day: you should take 4 tablets of prednisone 5mg once the day after discharge and then continue taking your regular dose of prednison 5 mg 1 tablet once daily. . Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Discharge Diagnosis: Sepsis Urinary tract infection Discharge Condition: non verbal non communicative bed bound Discharge Instructions: You were admitted because of an infection in your urinary tract that spread to your blood causing low blood pressures and a low temperature. You were given antibiotics to fight the infection and mediction and fluids to raise your blood pressure and are now doing better. You will need to continue to antibiotic treatment for 9 days after your discharge. . the following changes were made to your medications: 1. intravenous Meropenem 500mg every 6 hours which will be administered to you by a nurse for 9 days following your discharge. Followup Instructions: Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week of discharge Please call the following number for [**Telephone/Fax (1) 164**] to set up a urorology appointment within 14-21 days of discharge. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**] Completed by:[**2142-7-12**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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336, 372

12784, 12825

3299, 3299

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198,952

14277

Discharge summary

report

Admission Date: [**2101-11-19**] Discharge Date: [**2101-12-13**] Date of Birth: [**2038-9-8**] Sex: M Service: NEUROLOGY Allergies: Penicillins / Cephalosporins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 6075**] Chief Complaint: dizziness Major Surgical or Invasive Procedure: intubation and mechanical ventilation tracheostomy and PEG tube placement broncheoalveolar lavage bronchoscopy x 2 History of Present Illness: 63yo man with PMH significant for CAD, HTN, DM, who had complaints of sinus infection x 5-6 days for which he was started on mucinex and Zithromax x 1 dose two days prior to admission, presented as a transfer from an OSH with dizziness and numbness. He also complained of constant headache on the right side of his head, not throbbing, without visual changes, nausea or vomiting. Two nights prior to admission, he went to void, went back to bed, but was unable to fall asleep because of the nasal congestion so he went to sit upright in chair. A short time later, he got up to go back to bed and became acutely dizzy (lightheadedness) and had a sense of disequilibrium, walking like a "drunken sailor." He felt like he would fall toward the right side. There were no symptoms of vertigo. He presented to [**Hospital 1562**] Hospital ED and was found to have episodes of bradycardia, which was felt to be associated with the episodes of dizziness. He would have episodes of sudden bradycardic epsidoes with accompanying jaw pain and lightheadedness, resolving when the heart rate increased. This was thought to be likely vagal. An EKG showed nonspecific ST changes. He was admitted to the CCU at [**Hospital 1562**] Hospital. At 8:35PM, the nurse reported that he had difficulty swallowing and decreased sensation to his right face. SBP was 180 with full strength in all extremities. An MRI showed an old frontal defect. At 10:45PM, he was noted to be questionably dysarthric. At 1:10AM, he complained of persistent right sided numbness of his face, arm, and leg. He stated that the "numbness" started at the right side of his head and progressed downward to the arm, flank, and leg. He says that he has a pins-and-needles sensation, which has been improved since its onset. A head CT showed only the old frontal infarct. ROS was negative for fevers/chills, no SOB, chest pain, abdominal pain, or dysuria. He did complain of nasal congestion. Past Medical History: CAD hypercholesterolemia HTN OSA CABG x 4 [**2-/2093**] AVR [**2-/2093**] with carbomedics and ascending aortic replacement with Vascutech graft T+A [**9-19**] Deviated septum - followed by Dr. [**Last Name (STitle) **] for potential surgery Social History: Used to drink "quite a bit" but quit 30 years ago. Smoked 3ppd x 30 years, no recreational drug use. Lives with his fiance. Works for the highway department and is also a truck driver. Family History: Not elicited Physical Exam: On admission: Vitals: T96.7 HR 77 RR 20 BP 166/65 98% on NC General: Well hydrated, central obesity, NAD HEENT: Bilateral injected conjunctival, no discharge, OP clear without lesions, MMM and pink, no bruits auscultated. CV: Valve click and a 2/6 systolic murmur Pulm: Clear bilaterally, no crackles Abd: Significant central obesity Extremities: Lower extremities cool Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, date, and president Attention: Able to recite [**Doctor Last Name 1841**] backwards until [**Month (only) 547**] and then loses train of thought. Registration intact at 30 seconds, recalled [**3-18**] objects at 5 minutes. Language: Moderately dysarthric especially with lingual and gutteral sounds but fluent without paraphasic errors. Good comprehension and repetition. Naming intact with high and low frequency objects. No apraxia, no neglect. [**Location (un) **] intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light (2 to 1.5mm). Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally with several beats of end gaze nystagmus that extinguish. V, VII: Sensation intact. Decreaed right lip excursion, symmetric eyebrow lift. Lip strength mildly weaker on the left. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. Depressed gag and weak cough. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue mildly deviated to the right without fasciculations. Slowed tongue movements. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. No pronator drift on the left, unable to test right. Grip [**5-20**] bilaterally. [**Doctor First Name **] Tri Bic WE WF FE FF IO Right 3 5 4 3 5 3 5 3 Left 5 5 5 5 5 5 5 5 IP Quads Hamstrings DF PF [**Last Name (un) 938**] TE TF Right 3 4+ 4- 5 5 5 5 5 Left 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, decreased propioception (able to sense at ankles), and decreased vibration (able to sense at ankles) bilaterally. No extinction to DSS. Reflexes: B T Br Pa Ac Right 1 1 1 0 0 Left 1 1 1 0 0 Toes downgoing bilaterally. Coordination: Normal on finger-nose-finger, rapid alternating movements, heel to shin on left. Unable to test right. Pertinent Results: Admission labs: 144 107 28 -------------<160 4.0 25 1.0 Ca: 9.3 Mg: 2.2 P: 2.7 Cholesterol:124 Triglyc: 78 HDL: 43 CHOL/HD: 2.9 LDLcalc: 65 PT: 31.4 INR: 3.3 Cardiac enzymes negative x 3 Imaging: BRAIN MRI [**11-19**]: Diffusion images demonstrate no evidence of slow diffusion to indicate acute infarct. There is an area of low signal visualized within the right side of the medulla and cervicomedullary junction on susceptibility-weighted images. This area demonstrates isointense signal to the brain with areas of hyperintense signal on T2-weighted images. There is also mild diffuse increased signal seen within the medulla and the upper cervical spinal cord at this level. There are mild changes of small vessel disease seen in the periventricular white matter with chronic lacunes in the left periventricular white matter. There are no territorial infarcts seen. There is no mass effect, midline shift, or hydrocephalus. IMPRESSION: No evidence of acute infarct. The abnormalities seen within the right side of the medulla and upper cervical cord has signal characteristics which is more compatible with a cavernous malformation with surrounding edema in the cervicomedullary junction. A focused MRI of the posterior fossa with gadolinium-enhanced images would help for further assessment. MRA OF THE HEAD [**11-19**]: Normal MRA of the head. MRA OF THE NECK [**11-19**]: No significant abnormalities on MRA of the neck with and without gadolinium. CT HEAD WITHOUT IV CONTRAST [**11-22**]: No new areas of intracranial hemorrhage are identified. There is a tiny focus of increased density within the left parietal region which likely represents volume averaging between sulci (series 2, image 24). Ventricles are symmetric, and there is no shift of normally midline structures. There has been no interval increase in the caliber of the ventricles. The basal cisterns are normal in caliber. There is an area of increased density within the right medulla, which corresponds to area of abnormality seen on the recent MRI. The foreman magnum appears patent. There is no definite supratentorial or cerebellar tonsillar herniation. The soft tissue and osseous structures are stable in appearance. IMPRESSION: Again seen is an area of increased density within the right medulla which corresponds to the cavernous malformation better evaluated on the recent MRI study. There is no definite evidence of herniation on this study. No new areas of intracranial hemorrhage are identified. Brief Hospital Course: General: 63yo man who presented to OSH with 2 days of LH/dysequilibrium and falling to the right, found to have junctional rhythm that correlated with LH, but was transferred to [**Hospital1 18**] after acute development of right sided paresthesias, slurred speech, and difficulty swallowing. Exam was notable initially for upgaze and lateral nystagmus, dyarthria, right ataxic hemiparesis, left hemibody numbness and bifacial numbness. He was directly admitted to the ICU for close monitoring. While in the ICU, his strength worsened and an MRI showed hemorrhage in the right medulla consistent with a cavernous angioma. He remained mentally clear, however, he had significant secretions and had increasing difficulty protecting his airway. During a swallow evaluation he grossly aspirated. Around the same time, he became hypoxic and required intubation for airway protection. Peri-intubation he was acidotic and had a brief episode of SVT with associated hypotension. This resolved spontaneously with restoration of his blood pressure. After intubation, he was suctioned for copious thick secretions and was presumed to have an aspiration pneumonia for which he was treated empirically with levofloxacin. The coverage was broadened to include vancomycin and flagyl when he developed a high fever (103.8) the day after intubation. Several days later, extubation was attempted with similar events; this second time he was unable to be converted from SVT and required cardioversion with success. Given these events, it was determined that he could not be extubated and required tracheostomy and PEG tube. During tracheostomy placement, he had a BAL off antibiotics; cultures from the BAL were negative so antibiotics were not restarted. Continued to have difficulty weaning from vent with CO2 retention, but gradually progressed to trach mask intermittent with CPAP on [**12-12**], with increased Co2 retention when on trach mask alone. See details below. Neuro: After intubation, his neurologic examination remained stable with intact mental status as best as could be assessed (following commands, answering questions appropriately) and right sided weakness, LE>UE. He had a head CT which did not show any evidence of herniation. Gradually improved neurologically with mental status intact, antigravity strength of right upper and lower extremity and improved extraoccular movements with only mild impairment bilaterally (right worse than left) and some right sided nystagmus. Received PT/OT while in ICU. Draining of angioma was discussed with Neurosurgery who said could be done but at high risk to the patient, and was not indicated at that time. Could be considered if patient decompensates neurologically again. CVS: Had several episodes SVT requiring cardioversion with chemical or electrical. Has been stable for 1 week on amiodoarone PO. Is anticoagulated for mechanical valve with therapeutic dose coumadin usually falling around 2.5 mg. Has received most recently 7.5, 7.5 and 5, the last three evenings as he was off anticoagulation for pleural tap prior. Some pulmonary congestion and effusions during his last week, and was thus on Lasix Drip and now lasix 40mg IV BID. Rate controlled now with lopressor and amiodarone. RESP : PNA, effusions, Edema. Failure to wean,? ARDS per CXR. Currently on Lasix dosed and Gtt, Vanc and Cipro (started [**12-5**]). Finished course. Was CPAP vs AC for a few days and tolerating trach mask since [**12-12**] afternoon. See bleow for course:- intubated - extubated [**11-23**] - reintubated [**11-24**] - increased work of breathing/acidosis -> reintubated, likely aspiration (gross aspiration during S&S eval), significant yellow sputum. - bronchoscopy [**11-25**] for hypoxia, f/u cx. trach/peg [**11-29**] Failed recent weaning trial [**Date range (1) 42404**] where retained a lot of C02. Also effusions and significant pulm edema. - RUL PNA on CT [**12-5**] and leukocytosis - started on levo [**11-20**] (?asp pna), already on azithromycin -> vanco/levo/flagyl (d/c'd azithro [**11-24**]), fluc added [**11-25**] for Scx w/ yeast. Was taken off ABX for 24 hrs then restarted on Vanc/Cipro [**12-5**]. Fnished 7 day course. BALs from [**12-5**] GS: G+cocci pairs. Cxs oroflora. Pleural Tap from [**12-7**] with 2+PMNs but nor orgs and no growth Off ABX for 24 hrs and was afebrile with normal white count on d/c. - trach mask [**12-12**], tolerated well. Tolerating CPAP vs trach mask intermittently. Continues to retain CO2 and get acidodic when on trach mask for long periods. ID - Initially had sinusitis and completed ABX. So far has grown yeast and oral flora in sputum cultures. BALs G+ cocci pairs on GS and oroflora in cx. Pleural tap negative. Most recently completed 7 days cipro/vanc and afebrile for >5 days now. GI - On TF. On aggressive bowel regimen. Endo: on RISS Renal - BUN slightly increased as has had lasix drip and IV lately. Will need to watch BUN/Cr after transfer. No other renal issues. Heme: anticoag as above Line access: Needs Piccline placed at rehab, and then Central line needs to be pulled. Medications on Admission: Meds on transfer: Insulin SS Valsartan 160mg [**Hospital1 **] HCTZ 12.5mg [**Hospital1 **] Vytorin (Ezetimibe-Simvastatin) 1tab QD Solumeedrol 125mg IV QD Protonix 40mg IV QD Coumadin 1.25mg QMonday, 2.5mg QSuTuWeThFrSa Levoquin 500mg IV Enalapril 5mg IV Q3 Tylenol 650mg Q4 PRN Home meds: Vytorin 10/40 QD Diovan/HCTZ 160/12.5 [**Hospital1 **] Garlique Nexium 40mg QD Biaxin Azithromycin Flomax 0.4mg Mucinex Coumadin Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed. Disp:*1 1* Refills:*0* 2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. Disp:*1 1* Refills:*0* 3. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 150 mg/15 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). Disp:*30 1* Refills:*2* 5. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Cortisone 1 % Cream [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for psoriasis. Disp:*1 1* Refills:*0* 8. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 ML(s)* Refills:*0* 11. Lactulose 10 g/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*30 ML(s)* Refills:*0* 12. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: half tab Tablet PO BID (2 times a day) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 13. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 14. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID (4 times a day) as needed. Disp:*30 ML(s)* Refills:*0* 15. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 16. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection ASDIR (AS DIRECTED): per regular sliding sclae. Disp:*1 1* Refills:*0* 17. Warfarin 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO at bedtime: titrate for goal INR [**2-18**]. Disp:*30 Tablet(s)* Refills:*2* 18. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (3) **]: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 19. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (3) **]: Two (2) Puff Inhalation QID (4 times a day). 20. Acetazolamide 250 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO Q8H (every 8 hours) for 3 doses. 21. Furosemide 20 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Right lateral medullary syndrome secondary to hemorrhage of medullary cavernous angioma Needs Piccline placed and then central line removed after picc placed. Discharge Condition: Good. Discharge Instructions: Needs to have follow up arranged as below. Needs Piccline placed and central line should then be pulled. Followup Instructions: Please call to arrange follow up with Neurology: ([**Telephone/Fax (1) 15319**] for 2 months from now. Patient will need to f/u with PCP when [**Name9 (PRE) 42405**] from rehab.

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icd9cm

[ [ [] ] ]

[ "96.6", "99.62", "88.72", "38.93", "96.72", "43.11", "33.24", "96.04", "34.91", "31.1" ]

icd9pcs

[ [ [] ] ]

16383, 16464

7916, 13033

324, 440

16668, 16676

5401, 5401

16830, 17012

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3329, 3902

2435, 2678

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13077, 13480

18,229

122,153

9544

Discharge summary

report

Admission Date: [**2158-5-11**] Discharge Date: [**2158-5-22**] Date of Birth: [**2096-4-26**] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 62-year-old female has a past medical history significant for alcoholism and presented with a two month history of worsening shortness of breath, dyspnea on exertion, and PND. She first noticed a decreased exercise tolerance one year ago, and has had increased fatigue and dyspnea on exertion for one month, experiencing right sided chest pressure at rest with diaphoresis, shortness of breath, and nausea with pain. A day prior to admission, her chest pain worsened. She was sent to the Emergency Room by her PCP, [**Name10 (NameIs) **] received aspirin, nitroglycerin, Lopressor, and was started on a Heparin drip, and given IV Lasix and Ativan, and was admitted. PAST MEDICAL HISTORY: 1. History of alcoholism. 2. Status post TAH/BSO. 3. Status post basal cell carcinoma of the face. MEDICATIONS ON ADMISSION: 1. Zantac. 2. Doxycycline for recent bronchitis. ALLERGIES: She has no known allergies. SOCIAL HISTORY: She drinks 3-4 drinks a day and she smoked cigarettes. She has a 40-50 pack year smoking history, currently smokes a pack a day. FAMILY HISTORY: Significant for coronary artery disease. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION: On physical exam, she is an elderly white female in no apparent distress. Vital signs: Stable, afebrile. HEENT examination is normocephalic, atraumatic. Extraocular movements are intact. Oropharynx is benign. Neck is supple, full range of motion, no lymphadenopathy or thyromegaly, 6-8 cm jugular venous distention. Carotids 2+ and equal bilaterally without bruits. Lungs are coarse at the right base with no wheezes. Abdomen is soft and nontender with positive bowel sounds, no masses or hepatosplenomegaly. Extremities without clubbing, cyanosis, or edema. Neurologic examination is nonfocal. Pulses are 2+ and equal bilaterally throughout. She had an echocardiogram on admission which revealed an ejection fraction of 25-30% with anteroapical hypokinesis. Her electrocardiogram was normal sinus at 80 with a question of left ventricular hypertrophy, T-wave inversion in I, V4, and poor R-wave progression with left axis deviation. She was admitted and her alcohol was 167. She had a half a pint of alcohol the day before admission. She underwent cardiac catheterization on [**5-12**] which revealed the left ventricle had mitral regurgitation with an ejection fraction of 30%. She was right dominant. Her left main had a hazy subtotal occlusion. Left anterior descending artery was widely patent beyond the left main. Left circumflex was 90% stenosis at the origin of OM-1 and right coronary artery was 50% mid RCA stenosis. She had an intra-aortic balloon pump placed for severe left main disease, and Dr. [**Last Name (STitle) 1537**] was consulted. She underwent emergency coronary artery bypass graft x3 that same day [**5-12**] with LIMA to the left anterior descending artery, reverse saphenous vein graft to the right coronary artery and OM. Cross-clamp time was 31 minutes. Total bypass time is 61 minutes. She was transferred to the CSRU in stable condition. She was placed on an alcohol drip and she was on Levophed. She was extubated the following morning, and she had her balloon discontinued on postoperative day #1. She was still on some Levophed on postoperative day two, and her alcohol drip. Postoperative day three, her alcohol drip was weaned off, and her Levophed was also weaned and she was being diuresed. She also required aggressive respiratory therapy. She was transferred to the floor on postoperative day four. On postoperative day five, she had her chest tubes discontinued, and her wires discontinued. She was started on Lopressor and Captopril. She had difficulty tolerating these with her blood pressure, and her Lopressor was changed to atenolol 25 q day, and her captopril was decreased to 6.25 tid. She also required oxygen throughout the rest of her stay and was slow to ambulate with PT and required aggressive pulmonary therapy, .................... and was started on levofloxacin. She did have a contaminated urine culture, and so she was kept on the Levaquin, and on postoperative day #10 she was discharged. MEDICATIONS ON DISCHARGE: 1. Levofloxacin 500 mg po q day x7 days. 2. Lasix 20 mg po bid x7 days. 3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq po q day x7 days. 4. Colace 100 mg po bid. 5. Aspirin 325 mg po q day. 6. Percocet 1-2 tablets po q4-6h prn pain. 7. Lipitor 10 mg po q day. 8. Captopril 6.25 mg po tid. 9. Atenolol 25 mg po q day. 10. Home oxygen 2 liters prn. LABORATORIES ON DISCHARGE: Hematocrit 34.2, white count 8,300, platelets 318. Sodium 132, potassium 5.1, chloride 97, CO2 29, BUN 10, creatinine 0.6, blood sugar 85. FOLLOW-UP INSTRUCTIONS: She will be followed by Dr. [**Last Name (STitle) 1537**] in four weeks and Dr. [**Last Name (STitle) 32412**] in [**1-19**] weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 32413**] MEDQUIST36 D: [**2158-5-22**] 11:20 T: [**2158-5-22**] 11:51 JOB#: [**Job Number 32414**]

[ "411.1", "428.0", "414.01", "305.1", "300.00", "303.90", "291.81" ]

icd9cm

[ [ [] ] ]

[ "36.12", "88.56", "37.61", "36.15", "88.72", "37.23", "88.53", "39.61" ]

icd9pcs

[ [ [] ] ]

1263, 1305

4372, 4769

1007, 1098

1359, 4346

4784, 4925

1325, 1336

184, 859

4950, 5366

881, 981

1115, 1246

20,746

182,449

14281

Discharge summary

report

Admission Date: [**2145-11-25**] Discharge Date: [**2145-11-29**] Date of Birth: [**2110-3-16**] Sex: M Service: MEDICINE Allergies: Librium / Lithium / Morphine Sulfate Attending:[**First Name3 (LF) 613**] Chief Complaint: DKA Major Surgical or Invasive Procedure: None History of Present Illness: Pt is s 35 yo male with DM type I (+neuropathy), HCV and hx polysubstance abuse who presented to [**Hospital1 18**] ED [**11-25**] with nausea, vomiting and chest pain after not taking insulin X 2 days prior after getting in a fight with his girlfriend. [**Name (NI) **] stated that he wanted to kill himself by not taking insulin. CBG 434 with gap 19. Insulin gtt started in [**Name (NI) **], pt transferred to the MICU and patient's capillary blood glucose's and gap normalized overnight. His EKG revealed no dynamic changes during pt's chest pain when compared to prior and the patient was ruled out for AMI by negative CE's X 3. Pt did not develop alcohol withdrawl (CIWA's 0-2), but was agitated and was felt to be a continued risk to himself--therefore, psychiatry was consulted and felt the patient requires inpatient psyc admission for further safety/stabilization and for pt's polysubstance abuse. Currently, the pt feels anxious but denies SI/HI/hallucinations. No further nausea/vomiting/CP. Past Medical History: Diabetes mellitus: Diagnosed in [**2135**]. Checks sugars 0-2 times per day, mostly in morning. Takes 40 units NPH each am and 30 units NPH before dinner. Sugars range in 300-400, which he attribures to drinking alcohol. Also with neuropathy, no vision changes. His diabetes care is received from a nurse [**First Name (Titles) **] [**Last Name (Titles) **] where he lives (he has no primary care provider). Multiple DKA admissions, most recently [**2145-2-15**]. Depression/Suicidality: By the patient's report, he has attempted suicide three times: twice by overdose and once by standing on a train track. He has had multiple psychiatric hospitalization, the last being at [**Hospital 1680**] Hospital and at [**Hospital1 18**] in [**2145-2-15**]. He reports that he has a therapist at [**Hospital1 1680**] named "[**Female First Name (un) 42408**]", although he has not let other medical teams caring for him contact her. [**Name2 (NI) **] says that he sees her once a week, although, does not find that helpful. He reports he has tried Prozac and Zoloft, neither of which were beneficial to him. Hepatitis C recent liver function tests normal. Status post hemorrhoid surgery in [**2145-1-17**]. Status post gunshot wound to the abdomen with a partial small-bowel resection. Status post bilateral amputations of all fingers and toes due to frostbite in [**2128**]. Social History: Home and Support: The patient was born in [**Male First Name (un) 1056**] but adopted by a United States family when he was two years old. He is not in contact with his birth family or his adopted family, but he does report having has family in the [**Location (un) 86**] area. He has a GED level of education. He is currently homeless and unemployed and lives at [**Location **] St. [**Location **] as above on occasion. He reports that his ex-fiance is pregnant, and he was trying to salvage the relationship. Sexual history: Sexually active with girlfriend of last year. No protection, monogamous with her only. No hx of STD/s. Last HIV test in [**Month (only) 958**] was negative per him. Vaccinations: Has "had them all", per patient report. Animal Exposure: None TB: History of "plus/minus" PPD tests since [**60**] years old, but CXR consistently clear. Was "again plus/minus" 3 days ago at [**Year (2 digits) **] Travel: None Diet/Exercise: Not balanced. Obstacles to care: On [**Social Security Number 42409**]social security, homeless off and on since [**2136**]. No primary provider. [**Name10 (NameIs) **] patient has refused all follow-up options offered by his treatment teams at the [**Hospital1 18**] in the past. He does see his nurse practitioner ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42409**]) at the [**Location (un) 9904**] [**Location (un) 23536**]. She is available for him every Tuesday and Thursday morning between the hours of 8 a.m. and 12 p.m Tobacco/Drug Use: Smokes 2 packs per day. 30 pack-yr history. History of IV drug use, none current. Positive cocaine use, did crack the other day. Daily use of marijuana Alcohol: He drinks approximately a fifth, or a pint of vodka and up to a six pack of beer per day. He denies any history of withdrawal seizures, but he believes he may have experienced delirium tremens in the past. Positive blackout history. Family History: The patient reports that his birth mother was "nuts." NO FH of DM, CVA, or CAD. No history of cancer. Physical Exam: General: The patient is a well nourished, well developed male who looks his stated age, in no acute distress, lying down on the bed, in no distress HEENT: Normocephalic, atraumatic. Normal hearing on both sides. Mucosa of oropharynx is dry and pink. Normal dentition. Clear nasal mucosa. Clear sclera. Pink conjunctiva. No lid lag. No Facial swelling or tenderness. Neck: Supple. Thyroid is palpable and normal. Trachea midline. No bruits. Lymph nodes: No cervical, submandibular, supraclavicular or axillary nodes. Back: Spine midline. No masses or tenderness. No CVA tenderness Pulmonary: Symmetric expansion upon breathing. No use of accessory muscles. CTAB, with good air movement. No dullness to percussion. Equal fremitus on both sides. CV: PMI at mid-clavicular line. No RV heave. Regular rate and rhythm. Clear S1, S2 with physiologic split. No murmurs, rubs or gallops. Radial pulses symmetric and regular. Dorsalis pedis pulses, Carotid pulse 2+. No JVP seen with patient flat. Abdominal: Large midline scar with well-healed scar in RQ. NT, ND. Normoactive bowel sounds in all 4 quadrants. Soft. No organomegaly. No dullness to percussion. No masses. No HSM. Extremities: S/P Amputation of fingers/toes of all 4 extremities. No cyanosis. No palpable masses. Diffuse muscular pain along legs that is constant and not changed with palpation. Normal skin turgor. No edema. Pertinent Results: [**2145-11-29**] 05:29AM BLOOD WBC-3.9* RBC-4.43* Hgb-12.7* Hct-37.3* MCV-84 MCH-28.6 MCHC-33.9 RDW-17.1* Plt Ct-165 [**2145-11-25**] 08:00AM BLOOD Neuts-89.0* Bands-0 Lymphs-7.7* Monos-3.0 Eos-0.2 Baso-0.1 [**2145-11-29**] 05:29AM BLOOD Plt Ct-165 [**2145-11-29**] 05:29AM BLOOD Glucose-190* UreaN-14 Creat-0.8 Na-139 K-3.9 Cl-100 HCO3-29 AnGap-14 [**2145-11-25**] 12:03PM BLOOD Glucose-169* UreaN-13 Creat-0.8 Na-133 K-4.8 Cl-98 HCO3-16* AnGap-24* [**2145-11-25**] 03:17PM BLOOD ALT-24 AST-30 CK(CPK)-235* AlkPhos-100 Amylase-77 TotBili-0.7 [**2145-11-25**] 03:17PM BLOOD Lipase-23 [**2145-11-29**] 05:29AM BLOOD Calcium-9.3 Phos-4.2 Mg-1.7 [**2145-11-26**] 07:40AM BLOOD TSH-1.2 [**2145-11-25**] 08:00AM BLOOD ASA-NEG Ethanol-21* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 1. DKA: Pt developed DKA because he did not take his insulin (suicide attempt). CBG 434 with gap 19. Insulin gtt started in [**Name (NI) **], pt transferred to the MICU and patient's capillary blood glucose's and gap normalized overnight. Subsequent to this, the pt developed hypoglycemia on his usual dose of scheduled insulin (40U am and 30U pm), which was decreased to 15U AM and 10U PM. [**Last Name (un) **] consult obtained. Free AM cortisol ruled out adrenal insufficiency. 2. Suicide attempt: Pt tried to kill himself by not taking insulin (has history of numerous suicide attempts). Psychiatry eval felt inpatient psychiatry admission for safety and stabilization in setting of acute suicide attempt. 3. HCV: Pt with no transaminitis or signs of chronic liver failure (coagulopathy, encephelopathy, hypoalbuminemia). Pt will need liver biopsy as outpt to establish presence and/or extent of chronic liver disease. 4. Chest Pain: Pt copmlained of chest pain at presentation. Normal EKG and pt ruled out by serial cardiac enzymes. Discharge Medications: 1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Insulin NPH InnoLet 100 unit/mL Syringe Sig: One (1) syringe Subcutaneous once a day. Disp:*30 syringe* Refills:*2* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: DKA Suicide Attempt Discharge Condition: Stable Discharge Instructions: Please call your doctor if you have these problems: fever chills nausea/vomiting persistent low or high blood sugars Followup Instructions: Please follow up with medical physician either at [**Hospital1 18**] or your own physician [**Name Initial (PRE) 176**] 2 weeks. Pt needs ophthalmology appointment as outpatient. Pt needs outpatient cardiac risk stratificatin with pharmacologic stress test. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2145-11-29**]

[ "250.61", "250.11", "300.9", "070.54", "V60.0", "291.81", "V49.62", "285.9", "786.50", "401.9", "V49.72", "311", "357.2", "303.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8810, 8880

7015, 8072

302, 308

8943, 8951

6210, 6992

9117, 9528

4688, 4792

8095, 8787

8901, 8922

8975, 9094

4807, 6191

259, 264

336, 1346

1368, 2746

2762, 4672

42,715

146,156

38165

Discharge summary

report

Admission Date: [**2165-1-19**] Discharge Date: [**2165-2-6**] Date of Birth: [**2144-10-18**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7567**] Chief Complaint: Status Epilepticus Major Surgical or Invasive Procedure: LTM EEG monitoring VP shunt tap History of Present Illness: Mr. [**Known lastname 4882**] is a 20 year old man with severe traumatic brain injury in [**7-28**], now admitted for status epilepticus. Initial injury during roll-over MVA in [**7-28**], ejected from car, sustaining subdural hematoma, skull fracture, SAH, with midline shift requiring emergency hemicraniectomy for increased ICPs. Given severity of injury, he was on prophylactic levetiracetam, although no record of clinical seizures and continuous EEG monitoring for total of 6 days showed no electrographic seizures, but occasional right hemisphere and left frontal spikes. Discharged to rehab in [**2164-8-19**]. Had right cranioplasty and VP shunt in [**9-28**]. Was being tapered off Keppra because of sedation (to 250mg TID). Mother reported that at rehab he followed some commands, answered yes/no questions, spoke few word phrases, and had been able to sit, lift head, and stand with assistance. On [**1-19**] AM, was found to be unresponsive with posturing; given Ativan 4mg and taken to [**Location (un) 1121**], where he continued to have recurrent generalized seizures despite Ativan 10mg, Dilantin 1g, Keppra 2g. Transferred to [**Hospital1 18**] later on [**1-19**], where had continued right arm twitching, head deviation to right, eye twitching, which improved with propofol infusion and resolved with IV phenobarbital load. Past Medical History: Right subdural hematoma multiple brain contusions TBI s/p VP shunt L1 burst fracture s/p PEG, G-tube feeds only s/p Trach, now decanulated Social History: Has been at [**Hospital3 **] in [**Hospital1 3597**]. Family History: Noncontributory Physical Exam: Initial exam: Gen: Lying in bed, intubated/sedated CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS soft, nontender Ext: warm, well perfused, no edema Skin: G-tube site okay, old trach scars Mental status: Intubated, sedated, does not open eyes, does not follow commands. CN: head appeared initially deviated toward right with facial twitching and eye twitching vertically. With increased propofol, only eye twitching, head midline. PERRL 1.5mm not reactive. Motor exam: Initially with right hand twitching with stopped with increased propofol. Has decerebrate extensor posturing and rigidity in upper and lower extremities. Sensory: Withdraws/postures lower extremities bilaterally to noxious stimuli. Reflexes: Brisk and symmetric at patella bilaterally. Unable to elicit in UE due to tone/extensor posture. Plantar response mute bilaterally. Current exam: Mental status: No spontaneous eye opening or eye opening to command. NO eye movements to voice. Does not follow commands. Opens eyes partially to noxious stimuli. CN: pupils OD [**5-22**], OS [**6-22**], EOMI to doll's, corneals and gag present. Nearly continuous eyelid twitching. Unable to see palate secondary to increased tone in jaw. Motor: extensor posturing bilateral arms with contractures, increased extensor posturing to pain in UEs, triple flexion in LEs to pain. Reflexes absent in UEs, 3+ at knees. Triple flexion to plantar stimulation. Pertinent Results: Initial Labs: 10.4>11.8/34.2<346; 85 PMNs, 6 Bands, 5 Lymphs Na 140, K 4, CL 105, CO2 24, BUN 16, Cr 0.4, Gluc 128 ALT 31, AST 19, CK 357 Alk phos 144 T bili 0.8 Alb 3.6 Ca 8.6, Phos 3.7, Mg 1.6 PT 14.2, PTT 24.2, INR 1.2 Phenytoin 10.6 REPORTS: EEG ([**2165-1-20**]): EEG gives evidence for a severe diffuse encephalopathy with the presence of persistent epileptiform activity (PLEDs)over the left central-temporal region. EEG ([**2165-1-31**]): This is an abnormal video EEG due to the presence of left frontal delta slowing which represents focal cerebral pathology. It is also abnormal due to the appearance of very rare left frontal broad-based sharp waves which may represent epileptogenic cortex. There were two pushbutton activations, neither of which showed any clinical or electrical changes concerning for seizure. There were no electrographic seizures seen. IMAGING: LE Dopplers: Extensive deep venous thrombosis of the left lower extremity extending from common femoral to popliteal veins. CTA chest: Acute segmental pulmonary emboli involving the right upper lobe anterior and apical segments and segmental and subsegmental emboli involving the posterior basal right lower lobe pulmonary arteries; Bilateral lower lobe atelectasis with marked endobronchial secretions within the posterior basal segment of the left lower lobe, consistent with partial drowned lung. Additional foci of patchy airspace consolidation in the remainder of the right lower lobe is suspicious for superimposed aspiration or infection Brief Hospital Course: Mr. [**Known lastname 4882**] is a 20 year old man with severe traumatic brain injury in [**7-28**], now admitted for status epilepticus. 1) Status Epilepticus/Seizures: On [**1-19**] AM, was found to be unresponsive with posturing; given Ativan 4mg and taken to [**Location (un) 12914**], where he continued to have recurrent generalized seizures despite Ativan 10mg, Dilantin 1g, and Keppra 2g. Transferred to [**Hospital1 18**] Neuro ICU later on [**1-19**], where he had continued right arm twitching, head deviation to right, eye twitching, which improved with propofol infusion and resolved with IV phenobarbital load. While in the Neuro ICU, he was initially monitored on cEEG, which showed left central-temporal PLEDs. He was maintained on Dilantin, Keppra and Phenobarb. The doses of these medications were adjusted during hospital course. His continued unresponsive to commnads during hospitalization was thought to possibly be related to his [**Last Name (LF) 85127**], [**First Name3 (LF) **] the plan is to slowly taper this, while continuing his current doses of Keppra 1500 mg [**Hospital1 **] and Dilantin 200 mg q8h. With regards to his Dilantin dosing, we have had to go up on the standing dose as well as occasionally load him as his levels are frequently low and should be monitored to make sure they remain therapeutic. The Keppra dose was recently increased to 1500 mg [**Hospital1 **] to prevent breakthrough seizures given the difficulty in maintaining a therapeutic Dilantin level. His Phenobarb dose is currently at 60 mg [**Hospital1 **], with the plan to taper this to 45 mg [**Hospital1 **] next week and then to call Dr. [**First Name (STitle) **] the following week regarding further medication adjustments. Please contact Dr. [**First Name (STitle) **] regarding any adjustments of seizure medications. 2) Respiratory: Initially intubated for airway protection in setting of status epilepticus. Unable to be weaned off [**Last Name (LF) **], [**First Name3 (LF) **] tracheostomy was eventually performed and he is currently maintaining good O2 sats while on 40% trach mask. 3) ID: He was initially spiking fevers, which was believed to be due to his autonomic dysregulation, but cultures were sent and he did have blood cultures (both centrally and peripherally) positive for coag negative Staph. He was started on Vancomycin for this and his central line was pulled as a possible source of infection. After fevers were controlled, a PICC was placed for access. While in the ICU, he also had a BAL, which ended up growing Pseudomonas and coag + Staph. For the bacteremia, he was started on a 14 day course of Vancomycin and for the pneumonia he was started on a 14 day course of Ceftazadime. Repeat blood cx have been negative and a repeat sputum cx only showed sparse growth of Pseudomonas and Coag + Staph; this is likely colonization and as per ID, there is no need to continue antibiotics longer for this as long as there is no further fevers or respiratory distress. To ensure the bactermia was not related to a CSF infection given his VP shunt; Neurosurgery was asked to tap the VP shunt; there was no evidence of infection in the CSF. Wound cultures were also performed of his areas of folliculitis on his torso to ensure that this was not a portal of entry of his bacteremia; there were no microorganisms seen on the wound cultures. Will is currently afebrile. 4) Heme: Left lower extremity swelling was noted, so LE Dopplers were performed ands showed Extensive deep venous thrombosis of the left lower extremity extending from common femoral to popliteal veins. A CTA was subsequently performed and despite his IVC filter, there were acute segmental pulmonary emboli involving the right upper lobe anterior and apical segments and segmental and subsegmental emboli involving the posterior basal right lower lobe pulmonary arteries. For his DVT/PE, he was started on therapeutic Lovenox. The decision was made to not start Coumadin given its interaction with Dilantin; he will thus need to remain on therapeutic Lovenox for [**3-24**] months for his DVT/PE. 5) Tachycardia: He reportedly was tachycardic prior to admission and this was attirbuted to his autonomic instability from his injury. Other contributing factors could be pain induced tachycardia and now, from his PE as well. His Metoprolol was increased during hospitalization to 25 mg tid to help control his heart rate. He was continued on his home dose of Clonidine. Medications on Admission: tylenol 650 mg GT Q6h prn amantadine syrup 125 mg GT q24h baclofen 10 mg GT tid chlorhexidine oral rinse [**Hospital1 **] clonidine 0.1mg GT tid colace 100 mg GT [**Hospital1 **] senna 2 tabs GT [**Hospital1 **] dulcolax suppository prn fleets enema prn ferrous sulfate 300 mg GT qday neurontin 300 mg GT tid ibuprofen 800 mg GT q8h prn fever labetalol 800 mg GT [**Hospital1 **] keppra 250 mg GT [**Hospital1 **] metoprolol 50 mg GT Q6h prn HR>110, SBP>160 oxycodone 10 mg GT q4h prn pain Discharge Medications: 1. phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet, Chewable PO Q8H (every 8 hours). 3. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for spasticity. 6. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for HTN. 7. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for tachycardia. 9. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dryness. 11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. metoprolol tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous q4h prn as needed for tachycardia, HR > 110. 13. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 8H (Every 8 Hours) as needed for GPC in blood for 2 doses. 14. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 5 doses. 15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO q6h prn as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: status epilepticus DVT PE bacteremia pneumonia Discharge Condition: nonverbal and does not does not respond to commands currently bedbound Discharge Instructions: You were admitted to the hospital in status epilepticus. On [**1-19**] AM, you were found unresponsive with posturing; given Ativan 4mg and taken to [**Location (un) 1121**], where you continued to have recurrent generalized seizures despite Ativan 10mg, Dilantin 1g, and Keppra 2g. You were then transferred to [**Hospital1 18**], where you had continued right arm twitching, head deviation to right, and eye twitching, which improved with propofol infusion and resolved with IV phenobarbital load. EEG the next morning showed epileptic activity but no electrographic seizures. On the last day of EEG monitoring, there was still diffuse slowing indicating an encephalopathy, but there were only very rare sharp waves in the left frontal region; this was an improvement from the initial EEGs. Despite the overall improved EEG, there was still diffuse encephalopathy with no significant improval in your level of arousal. It is believed that the [**Hospital1 85127**] could be contributing to your mental status; the dose was slowly titrated down. For seizure control, you are currently on Keppra 1500 mg twice a day, Dilantin 200 mg three times a day and [**Hospital1 **] 60 mg twice a day. The plan is to decrease the [**Hospital1 **] to 45 mg twice a day in one week and then the following week, to call Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 35413**] regarding further instructions. For the status epilepticus, you were initially intubated. You then had another tracheostomy placed tp enable you to come off the ventilator. While in the hospital, you were spiking fevers and were found to have blood cultures positive for coag negative Staph and a bronchoalveolar lavage was performed while you were intubated and it grew Pseudomonas. For these infections, you were started on a 14 day course of Vancomycin and Ceftazadime respectively. Your left leg was also noted to be swollen, so an ultrasound was performed on your legs. This showed that you had a DVT in your left leg; you were subsequently noted to have a pulmonary embolus, which is a clot in your lung that probably dislodged from the clot in your leg. For this, you were started on a blood thinning medication called Lovenox, you will need to be on this for 3-6 months. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] when able to visit her in outpatient clinic. While at rehab, please call her at ([**Telephone/Fax (1) 32465**] regarding any questions with adjustment of seizure medications. Completed by:[**2165-2-6**]

[ "790.7", "704.8", "415.19", "348.30", "V15.52", "518.81", "041.12", "345.3", "453.41", "V45.2", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.97", "03.31", "31.1", "01.02", "96.6", "33.24" ]

icd9pcs

[ [ [] ] ]

11513, 11649

5069, 9547

325, 358

11740, 11813

3512, 5046

14119, 14377

1994, 2011

10088, 11490

11670, 11719

9573, 10065

11837, 14096

2026, 2266

266, 287

388, 1743

2952, 3493

1765, 1906

1922, 1978

3,181

170,805

14528

Discharge summary

report

Admission Date: [**2120-9-12**] Discharge Date: [**2120-9-18**] Service: MEDICAL ICU HISTORY OF PRESENT ILLNESS: This is a 79 year-old male with a history of coronary artery disease status post recent coronary artery bypass graft in early [**Month (only) **] with multiple complications including atrial fibrillation, aspiration pneumonia, multiple pulmonary emboli, and poor graft flow necessitating subsequent percutaneous coronary revascularization. He has a recent diagnosis of squamous cell cancer of the lip with nodal metastases. He was transferred to the [**Hospital1 69**] Medical Intensive Care Unit from [**Hospital3 3834**] for further management of severe C-difficile colitis and left lingular pneumonia. The patient had been undergoing rehabilitation and receiving his radiation treatment for his head and neck cancer while residing at [**Hospital6 25759**] Home. He had been noted to be lethargic over the course of his stay with poor appetite and occasional nausea and vomiting. He had recently been treated for a urinary tract infection with antibiotics. On [**9-5**], the patient noted increasing abdominal pain, distention, nausea and vomiting, accompanied by fever to 103 degrees Fahrenheit. He also became hypotensive and was subsequently transferred to [**Hospital3 3834**]. He had an extensive workup there, which ultimately revealed severe C-difficile colitis. He required fluid resuscitation as well as pressors to support his blood pressure. His creatinine was elevated to 3.6 from a baseline of 1.0. He also suffered some mild myocardial damage with a small troponin leak of .7 with precordial T wave inversions. Abdominal imaging revealed the presence of ascites, which was sampled and determined to be purulent with 4700 white blood cells and 98% neutrophils, though culture turned out to be negative. He had no evidence of perforation on his CT scan. The patient was also determined to have a pneumonia involving the lingula, with sputum proving positive for MRSA. The patient was covered broadly with antibiotics including Vancomycin and Flagyl for his C-difficile colitis. Over the course of his stay at [**Hospital3 3834**] he became afebrile and eventually weaned off of pressors. His creatinine had improved to 1.2. He was transferred to [**Hospital1 1444**] for further management of his C-difficile colitis and pneumonia. PAST MEDICAL HISTORY: Coronary artery disease status post coronary artery bypass graft in [**2120-7-13**] complicated by poor graft flow necessitating percutaneous coronary revascularization, postoperative atrial fibrillation and pneumonia. Pulmonary embolus in [**2120-7-13**]. Squamous cell cancer of the lip with metastasis to the submandibular nodes. He had been receiving radiation therapy. Hypothyroidism. Diabetes mellitus type 2. Abdominal aortic aneurysm, infrarenal, measuring 6.5 cm in diameter. MEDICATIONS ON TRANSFER: Protonix 40 mg intravenous q.d., Flagyl 500 mg intravenous t.i.d., Synthroid 25 micrograms intravenous q.d., Vancomycin 250 mg po q.i.d., Vancomycin enemas 250 mg per rectum q 6 hours, ceftazidime 2 grams intravenous q 8 hours, Lopresor 5 mg intravenous t.i.d., Tobramycin 600 mg q 36 hours, total parenteral nutrition, heparin drip 1000 units per hour. SOCIAL HISTORY: The patient is married. He has an adult daughter. [**Name (NI) **] is a former tobacco user. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: A chronically ill appearing elderly white male with labored respirations. Temperature was 19.8. Heart rate 86. Blood pressure 119/44. SPO2 was 99% on 3 liters nasal cannula. Skin was pale, warm and dry. HEENT sunken face, a large scab lesion was noted over his lower lip. His oropharynx appeared very dry. Neck was supple. He had a right subclavian line recently placed without signs of obvious infection. Lungs diffuse bilateral inspiratory and expiratory rhonchi, there was coarse crackling noted bilaterally throughout the lung fields. Heart regular rate and rhythm. 2 out of 6 systolic ejection murmur at the apex. Abdomen was markedly distended with absent bowel sounds. He was tender to palpation over the left lower and upper quadrants without guarding or rebound. His stool was OB positive by report with rectal tube in place. Extremities 2+ bilateral pitting edema. His saphenectomy scar appeared to be healing. LABORATORIES ON ADMISSION: White blood cell count 17.3, hematocrit 29.3, platelets 275, neutrophils 88, bands 3, lymphocytes 2, PT 12.3, INR 1.0, PTT 43.4. Sodium was 136, potassium 4.3, chloride 108, bicarb 21, BUN 26, creatinine 0.9, glucose 157, calcium 6.3, phosphate 4.3, albumin was 1.5. AST was 12, ALT 9, alkaline phosphatase 120, total bilirubin was 0.2. Venous blood gas showed pH of 7.31, PCO2 of 46. Chest x-ray showed left lingular infiltrate. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for further management of his C-difficile colitis and left sided pneumonia. He was treated with antibiotics, including oral Vancomycin and intravenous Flagyl for C-difficile as well as intravenous Vancomycin for treatment of his MRSA pneumonia. He was also placed on Zosyn for empiric converge in case of transmural injury of the bowel leading to translocation of enteric pathogens. He had a repeat CT scan of the abdomen performed, which showed a diffuse colitis, consistent with his history of C-difficile colitis. There was no evidence for bowel wall perforation. His stool culture was repeatedly positive for C-difficile infection. The patient was followed by the Gastroenterology and Surgical Consult Services. It was determined that there was no immediate indication for colectomy or surgical exploration. His ascites culture remained sterile. The patient had a tenuous respiratory status over the course of his hospitalization. He had abundant secretions with weak cough requiring intermittent suctioning and chest physical therapy. He was given nebulizer treatments as needed. He showed evidence for a worsening respiratory acidosis by arterial blood gas measurement. Extensive discussions with the patient and the patient's family were held throughout his hospitalization. The patient opted for DNR/DNI status and his wishes were honored accordingly so he continued to receive intermittent suctioning and nebulizer treatments as well as broad antibiotic coverage. The patient's respiratory status continued to decline. He was noted to have intermittent periods of apnea. He declined further and went into full respiratory arrest around midnight on [**2120-9-18**]. He was pronounced dead at 12:24 a.m. on [**9-18**]. His family was updated on his condition throughout the night and at the time of his death. Autopsy was declined. DISCHARGE DIAGNOSES: 1. Lingular pneumonia. 2. C-difficile colitis. 3. Diabetes mellitus type 2. 4. Coronary artery disease. 5. Pulmonary embolus. 6. Hypothyroidism. 7. Squamous cell carcinoma of the lip with metastasis. 8. Abdominal aortic aneurysm. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 23338**] MEDQUIST36 D: [**2120-9-18**] 19:15 T: [**2120-9-25**] 13:38 JOB#: [**Job Number 42904**]

[ "789.5", "567.2", "V45.81", "482.41", "518.81", "707.0", "250.00", "008.45", "244.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.91" ]

icd9pcs

[ [ [] ] ]

3413, 3431

6812, 7343

4872, 6791

3454, 4404

124, 2389

4419, 4854

2928, 3283

2412, 2902

3300, 3396

22,836

113,745

13610

Discharge summary

report

Admission Date: [**2174-8-1**] Discharge Date: [**2174-8-4**] Date of Birth: [**2116-11-12**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 943**] Chief Complaint: Direct admission for paracentesis and blood transfusion in anticipation of TIPS Major Surgical or Invasive Procedure: TIPS mechanical ventilation central line placement therapeutic paracentesis History of Present Illness: 57 year old man with alcoholic cirrhosis and resultant portal hypertension and ascites scheduled for TIPS this week who presented to Dr.[**Name (NI) 948**] clinic today with reaccumulated ascites. He has had multiple large volume paracenteses in the past month most recently 2 days ago in the ED when he had 6 liters tapped from his abdomen (he was given 50g albumin at that time). In addition, Hemoglobin was noted to be 8.4 (down from 10.2 on [**7-19**]). He was discharged home from the ED with planned TIPS scheduled for [**8-2**]. However, in clinic today, his fluid had reaccumulated and given his recent drop in Hemoglobin, per Dr. [**Last Name (STitle) 497**], he is being admitted today for paracentesis of reaccumulated fluid as seen in clinic today and a 2 unit blood transfusion in anticipation of TIPS planned for tomorrow. . His ascites has been recurrent since [**Month (only) 547**] and has been refractory to diuretics. Prior to that, his last episode of ascites was a few years ago. The differential of his worsening ascites was initially thought to include progression of liver disease, portal vein thrombosis, HCC, hepatic mets, peritoneal carcinomatosis. During an admission in [**Month (only) 116**], he had a RUQ US with normal vasculature and no liver lesions. AFP was within normal limits. Fluid from paracenteses has been negative for SBP and cultures have also been consistently negative. He has known esophageal varices that were visualized on 3 EGDs in [**Month (only) 116**] and were found to be nonbleeding. He had no evidence of encephalopathy and was maintained on prophylactic lactulose. The team was initially considering performing a TIPS procedure in [**Month (only) 116**], however, when he developed bacteremia, it was felt to be safer to administer 2 weeks of antibiotics and then plan for TIPS scheduled for this week. . He denies fever, chills, abdominal pain, N/V, constipation, BRBPR/melena, hematemesis, cough, SOB, LE edema, headache, neck stiffness, confusion, pruritus, change in BMs. He does report some daytime somnolence and mild nighttime insomnia. He reports he first developed ascites approximately 4y ago, for which he underwent paracentesis. He states he had no further ascites until last month. Past Medical History: 1. EtOH cirrhosis: decompensated with ascites and varices, on transplant list 2. Colonic adenoma: polypectomy in [**2171**] 3. Esophageal varices: grade 1 on last EGD in [**8-26**], s/p banding of grade II varices in [**10-25**], h/o hematemesis in the past 4. Cholelithiasis 5. Partial colectomy: at [**Hospital3 **] in [**2158**] [**2-24**] severe GI bleed after polypectomy 6. hernia repair Social History: [**Month/Day (2) **] Priest. [**Name (NI) **] children. No tobacco. Currently no EtOH. Formerly a heavy drinker (cannot quantify). Currently living with parents Family History: no fam hx of cirrhosis/liver disease; 6 siblings, all healthy. parents both alive and healthy Physical Exam: T 97.8 BP 98/62 HR 83 RR 20 Sat 100% ra Gen: thin man lying in bed in NAD HEENT: no scleral icterus; nasogastric feeding tube in place with small amount of dried blood Neck: no LAD, no JVP Pulm: cta bilaterally CV: reg rate, nl s1s2, no murmurs Abd: moderately distended; nontender; normoactive bowel sounds; (+)shifting dullness; no liver edge or spleen tip palpated Extr: 2+ PT pulses Skin: no jaundice; no rashes Neuro: alert, oriented, nonfocal Pertinent Results: REPORTS: . Procedure [**2174-8-2**]: 1. Ultrasound-guided paracentesis. 2. Transjugular intrahepatic portosystemic shunt placement (TIPS). 3. Single coronary vein varix ablation with absolute alcohol. 4. Quadruple lumen central venous line, right internal approach. PRESSURE MEASUREMENTS: Initial direct portal vein pressure = 22 mmHg. Initial free hepatic vein pressure = 4 mm. Post TIPS direct portal vein pressure = 17 mm. Post TIPS free hepatic vein pressure = 14 mm. Post TIPS inferior vena cava pressure = 8 mm. A single coronary vein was ablated with a bolus of 5 cc of absolute alcohol. IMPRESSION: 1. Status post paracentesis. 1500 cc of clear amber acetic fluid was collected. 2. Status post TIPS procedure with deployment of the 10 mm x 68 mm wall stent in the transparenchymal tract. Initial portosystemic gradient was 19 mm. Subsequent to stent creation, portosystemic gradient was 9 mm 3. Status post single coronary vein varix ablation with absolute alcohol. 4. Status post quadruple lumen central venous line placement. . DUPLEX DOPP ABD/PEL [**2174-8-3**] 2:05 PM IMPRESSION: Patent TIPS with flow rates from 122.1 to 226.6 cm/sec. The velocites are upper limits of normal and follow-up is recommended. Patent and appropriate direction of flow within the anterior right and left portal veins, hepatic veins, left and main hepatic artery. . LABS: . [**2174-8-4**] 01:57AM BLOOD WBC-7.4 RBC-3.06* Hgb-9.4* Hct-26.7* MCV-88 MCH-30.9 MCHC-35.3* RDW-16.8* Plt Ct-49* [**2174-8-3**] 08:02AM BLOOD Hct-27.6* [**2174-8-3**] 03:30AM BLOOD WBC-9.4 RBC-3.08* Hgb-9.5* Hct-26.9* MCV-87 MCH-30.7 MCHC-35.1* RDW-17.0* [**2174-8-2**] 11:50PM BLOOD WBC-7.8 RBC-3.15* Hgb-9.7* Hct-27.4* MCV-87 MCH-30.8 MCHC-35.5* RDW-17.0* [**2174-8-2**] 08:47PM BLOOD WBC-8.3 RBC-3.26* Hgb-9.9* Hct-28.2* MCV-87 MCH-30.5 MCHC-35.2* RDW-16.9* [**2174-8-2**] 04:55PM BLOOD WBC-8.4 RBC-3.15* Hgb-9.8* Hct-27.3* MCV-87 MCH-31.1 MCHC-35.8* RDW-17.0* Plt Ct-74* [**2174-8-2**] 02:24PM BLOOD WBC-7.5# RBC-3.33* Hgb-10.1* Hct-29.0* MCV-87 MCH-30.2 MCHC-34.7 RDW-17.4* Plt Ct-76* [**2174-8-2**] 04:25AM BLOOD WBC-4.9 RBC-2.72* Hgb-8.3* Hct-24.5* MCV-90 MCH-30.6 MCHC-34.0 RDW-16.5* Plt Ct-86* [**2174-8-2**] 12:00AM BLOOD Hct-22.9* [**2174-8-1**] 12:45PM BLOOD WBC-7.3 RBC-2.32* Hgb-7.3* Hct-21.5* MCV-92 MCH-31.5 MCHC-34.1 RDW-16.7* [**2174-8-4**] 01:57AM BLOOD Neuts-76.9* Lymphs-8.4* Monos-9.5 Eos-4.9* Baso-0.3 [**2174-8-2**] 04:55PM BLOOD Neuts-82.9* Lymphs-3.8* Monos-9.7 Eos-2.9 Baso-0.7 [**2174-8-1**] 12:45PM BLOOD Neuts-79.3* Lymphs-6.7* Monos-8.1 Eos-5.3* Baso-0.5 [**2174-8-4**] 01:57AM BLOOD Plt Smr-VERY LOW Plt Ct-49* [**2174-8-4**] 01:57AM BLOOD PT-16.7* PTT-36.1* INR(PT)-1.5* [**2174-8-3**] 08:02AM BLOOD Plt Smr-UNABLE TO [**2174-8-3**] 08:02AM BLOOD PT-15.9* PTT-36.1* INR(PT)-1.5* [**2174-8-3**] 03:30AM BLOOD Plt Smr-VERY LOW Plt Ct-69* [**2174-8-3**] 03:30AM BLOOD Plt Smr-UNABLE TO LPlt-1+ [**2174-8-3**] 03:30AM BLOOD PT-14.9* PTT-34.4 INR(PT)-1.3* [**2174-8-3**] 01:48AM BLOOD Plt Smr-LOW Plt Ct-81* [**2174-8-2**] 11:50PM BLOOD Plt Smr-UNABLE TO [**2174-8-2**] 11:50PM BLOOD PT-15.2* PTT-33.9 INR(PT)-1.4* [**2174-8-2**] 08:47PM BLOOD Plt Smr-VERY LOW Plt Ct-79* [**2174-8-2**] 08:47PM BLOOD Plt Smr-UNABLE TO [**2174-8-2**] 08:47PM BLOOD PT-15.5* PTT-35.9* INR(PT)-1.4* [**2174-8-2**] 04:55PM BLOOD PT-15.8* PTT-36.0* INR(PT)-1.4* [**2174-8-2**] 02:24PM BLOOD Plt Smr-VERY LOW Plt Ct-76* [**2174-8-2**] 02:24PM BLOOD PT-16.1* PTT-58.0* INR(PT)-1.5* [**2174-8-1**] 12:45PM BLOOD Plt Smr-UNABLE TO [**2174-8-1**] 12:45PM BLOOD PT-15.9* PTT-33.7 INR(PT)-1.5* [**2174-8-2**] 04:25AM BLOOD PT-16.0* PTT-36.8* INR(PT)-1.5* [**2174-8-3**] 03:30AM BLOOD Fibrino-254 [**2174-8-2**] 11:50PM BLOOD Fibrino-241 [**2174-8-2**] 08:47PM BLOOD Fibrino-236 [**2174-8-2**] 02:24PM BLOOD Fibrino-221 [**2174-8-2**] 02:24PM BLOOD Ret Aut-4.5* [**2174-8-4**] 01:57AM BLOOD Glucose-128* UreaN-30* Creat-1.1 Na-133 K-4.2 Cl-105 HCO3-21* AnGap-11 [**2174-8-3**] 03:30AM BLOOD Glucose-88 UreaN-39* Creat-1.1 Na-132* K-4.0 Cl-99 HCO3-22 AnGap-15 [**2174-8-2**] 11:50PM BLOOD Glucose-92 UreaN-40* Creat-1.1 Na-132* K-4.1 Cl-99 HCO3-22 AnGap-15 [**2174-8-2**] 04:55PM BLOOD Glucose-91 UreaN-42* Creat-1.1 Na-130* K-4.1 Cl-98 HCO3-22 AnGap-14 [**2174-8-2**] 02:24PM BLOOD Glucose-92 UreaN-43* Creat-1.1 Na-127* K-4.3 Cl-98 HCO3-19* AnGap-14 [**2174-8-2**] 04:25AM BLOOD Glucose-100 UreaN-52* Creat-1.3* Na-125* K-4.6 Cl-94* HCO3-21* AnGap-15 [**2174-8-2**] 12:00AM BLOOD K-4.9 [**2174-8-1**] 12:45PM BLOOD Glucose-102 UreaN-50* Creat-1.3* Na-125* K-5.3* Cl-94* HCO3-22 AnGap-14 [**2174-8-4**] 01:57AM BLOOD ALT-29 AST-39 AlkPhos-88 TotBili-1.9* [**2174-8-3**] 03:30AM BLOOD ALT-26 AST-37 LD(LDH)-153 AlkPhos-85 TotBili-3.0* [**2174-8-2**] 04:55PM BLOOD ALT-23 AST-35 LD(LDH)-145 AlkPhos-79 TotBili-3.5* [**2174-8-2**] 02:24PM BLOOD ALT-23 AST-37 LD(LDH)-151 AlkPhos-77 TotBili-3.7* [**2174-8-2**] 04:25AM BLOOD ALT-18 AST-26 LD(LDH)-136 AlkPhos-80 TotBili-2.3* [**2174-8-1**] 12:45PM BLOOD ALT-21 AST-30 LD(LDH)-154 AlkPhos-97 TotBili-1.4 [**2174-8-4**] 01:57AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0 [**2174-8-3**] 03:30AM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.0 Mg-2.1 [**2174-8-2**] 11:50PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1 [**2174-8-2**] 04:55PM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.8 Mg-2.1 [**2174-8-2**] 04:25AM BLOOD Albumin-3.7 Calcium-8.6 Phos-4.5 Mg-2.1 [**2174-8-1**] 12:45PM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.7 Mg-2.2 [**2174-8-2**] 02:24PM BLOOD Hapto-<20* [**2174-8-2**] 04:25AM BLOOD AFP-2.1 [**2174-8-3**] 05:39AM BLOOD Type-ART Temp-36.1 Rates-/16 PEEP-5 FiO2-50 pO2-150* pCO2-33* pH-7.46* calTCO2-24 Base XS-1 Intubat-INTUBATED [**2174-8-2**] 05:13PM BLOOD Type-ART Temp-37.2 Rates-/14 Tidal V-450 PEEP-5 FiO2-50 pO2-161* pCO2-36 pH-7.42 calTCO2-24 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU [**2174-8-2**] 02:35PM BLOOD Type-ART pO2-153* pCO2-32* pH-7.42 calTCO2-21 Base XS--2 [**2174-8-2**] 05:48PM BLOOD HEPARIN DEPENDENT ANTIBODIES: negative [**2174-8-1**] 04:38PM ASCITES TOT PROT-0.6 LD(LDH)-19 ALBUMIN-LESS THAN [**2174-8-1**] 12:30PM ASCITES WBC-105* RBC-1085* POLYS-11* LYMPHS-33* MONOS-47* EOS-7* MESOTHELI-2* . MICRO: . Time Taken Not Noted Log-In Date/Time: [**2174-8-1**] 4:38 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL. AEROBIC BOTTLE (Pending): ANAEROBIC BOTTLE (Pending): . Time Taken Not Noted Log-In Date/Time: [**2174-8-1**] 4:38 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL. BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Brief Hospital Course: On admission, pt was transfused 2 U PRBC's, with minimal bump in hct from 21.5 to 24.5. He also underwent therapeutic paracentesis, and 5L of fluid was removed. Pt was placed on Hep SC for DVT ppx. Pt then underwent TIPS procedure, which was successful. A therapeutic paracentesis of 1600cc was also performed during the TIPS. However, after the procedure, he was found to have blood pooling in his oropharynx, as well as oozing of blood from his nares and R IJ site. There was ? of coffee ground aspirated from NG tube. He was kept intubated for airway protection, and labs were sent. He was then given 2L NS, 1 U PRBC's, 2U FFP, and 1 bag of platelets. Pt had been on Neosynephrine briefly during the TIPS procedure, but did not require pressors after the procedure. He remained hemodynamically stable in the PACU, and was transferred to the MICU for further management. His hct remained stable s/p initial transfusion, and he remained hemodynamically stable throughout his stay in the MICU. He was given Vitamin K 10mg SC to treat an INR of 1.5. Pt's platelets dropped during the admission, and a HIT Ab test was negative. The platelet drop was of unclear etiology. The pt was started on protonix for GI ppx, but this was started after the platelet drop, and this med was subsequently d/c'd (although not thought to be cause of inital platelet decrease). Heparin products were held after his initial episode of bleeidng. He had fibrinogen levels >200, so DIC was thought unlikely. He had an episode of increased bleeding from his nasal passage overnight in the ICU, so he was given an additional 2 [**Location 16678**] and treated with Afrin. The bleeding then ceased, and the pt was successfully extubated on [**8-3**]. It was believed that the initial episode of bleeding s/p TIPS was due to epistaxis from possible NGT trauma, in the setting of dysfibrinoginemia and coagulopathy from liver disease. GI bleed or bleeding from his airway were thought much less likely. Pt's diuretics and lactulose were held during his MICU stay and on discharge. His hct remained stable s/p extubation, and he was discharged directly from the ICU in good condition. Medications on Admission: 1. omeprazole 30mg daily 2. Folic Acid 1mg daily 3. Multivitamin one tab daily 4. Bupropion SR 100mg qAM 5. Benzonatate 100mg TID 6. Hydroxyzine 25mg [**Hospital1 **] 7. Furosemide 60mg [**Hospital1 **] 8. Spironolactone 100mg [**Hospital1 **] 10. Lactulose 30 ML PO TID 11. Metoclopramide 10mg TID prn 12. Ferrous Sulfate 325mg daily Discharge Medications: 1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 6. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Lactulose (for Encephalopathy) 10 g/15 mL Solution Sig: Thirty (30) ml PO three times a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary diagnosis: cirrhosis requiring TIPS procedure Secondary diagnosis: epistaxis requiring intubation and ICU monitoring Discharge Condition: stable Discharge Instructions: please seek medical attention immediately if you experience bleeding, chest pain, shortness of breath, fevers, chills, nausea, vomiting, diarrhea, dizziness, or any other concerning symptoms. Please take all medications as prescribed. Please attend all follow-up appointments. Followup Instructions: You have the following appointment scheduled: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2174-8-10**] 8:20 Please follow-up with your PCP [**Last Name (NamePattern4) **] 1 week as well. Completed by:[**2174-8-5**]

[ "571.2", "572.3", "456.21", "V49.83", "263.9", "287.5", "784.7", "789.5" ]

icd9cm

[ [ [] ] ]

[ "39.1", "99.04", "99.05", "38.93", "54.91", "99.07" ]

icd9pcs

[ [ [] ] ]

13688, 13763

10527, 12690

347, 424

13933, 13942

3913, 10182

14269, 14546

3329, 3424

13076, 13665

13784, 13784

12716, 13053

13966, 14246

3439, 3894

10415, 10504

228, 309

10212, 10212

10241, 10382

452, 2718

13860, 13912

13803, 13839

2740, 3135

3151, 3313

31,135

181,651

9983

Discharge summary

report

Admission Date: [**2151-9-18**] Discharge Date: [**2151-9-23**] Date of Birth: [**2074-5-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: Transfer from [**Location (un) 47**] for cholangitis Major Surgical or Invasive Procedure: ERCP with stent placement Central line placement History of Present Illness: This is a 77 year-old male with a history of cholecysectomy in [**2143**] and subsequent ERCP in [**2143**] & [**2148**] for stones, AVR/MVR, CABG, AICD, hyperlipidemia,m COPD presented to [**Hospital1 **] with abdominal pain x2 days and transferred to [**Hospital1 18**] for cholangitis and ERCP. There was no discharge summary sent with the patient on transfer. The patient reports that he had complaints of abdominal pain after eating a pizza [**9-15**]. The pain was across the middle of of his abdomen [**2152-9-19**] pain. The patient presented to the [**Hospital1 **] and underwent CT-abd at the that showed 12mm dilation of the common bile duct and pneumobilia. The patient's bilirubin was 6 and was started on Zosyn. Additionally, the patient's labs were significant for plts of 87 (trending fown from 127), creatinine 2.0 (baseline 1.5-1.9), BUN 40. His vitals signs were temp 101, BP 90/60, and reportly tachycardic. The lactic acid 6.0 on [**9-17**]. He also reports 3 episodes of nausea and vomiting. On arrive the patient had continued complaints of abdominal pain across his abdomen. The patient was hypotensive with SBP 89/50 and HR 90's. He was afebrile. at 96.9. The patient denied fevers or chills. The patient was started on IVF 500cc bolus. ROS: (+) Per HPI. Baseline SOB, unchanged from prior The patient denies any weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Coronary artery disease s/p Coronary Artery Bypass Graft [**2127**] & [**2137**] (PTCA/stent to SVG to PDA graft [**2-18**]) with redo sternotomy x2 and coronary artery bypass graft x1 (SVG>PDA) in [**5-19**] Mitral valve repair [**5-19**] AVR (tissue valve) redo in [**5-19**] Atrial fibrillation (off anti-coagulation [**3-15**] GI bleed) Cardiomyopathy Hyperlipidemia Chronic Obstructive Pulmonary Disease Gastroesophageal Reflux Disease Hypertension GI bleed Renal insufficiency (baseline Cr 1.5-1.9) Past Surgical History: Cholecystectomy [**2143**] Back Surgery Nasal Surgery Eye Surgery Social History: Currently smokes 10 cigs/day and 1ppd since at 18yrs. Drinks 2 ETOH beverages/wk. No rec drug Family History: Father with valve problems died at age 54. Mother died at 48 from ?MI. Physical Exam: Vitals: T:96.9 BP:89/50 HR:91 RR:22 O2Sat:93% 3L NC GEN: Jaundiced, toxic appearing, no acute distress HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea, dry MM, OP Clear NECK: supple, no cervical lymphadenopathy, trachea midline COR: irregularly irregular, III/VI SEM, normal S1 S2, radial pulses +2 PULM: + end exp wheeze, otherwise CTA ABD: Soft, + diffuse tenderness more extensive in the RUQ and mid abdomen, +[**Doctor Last Name **] signs, +BS, EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. SKIN: jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: On admission to [**Hospital Unit Name 153**]: [**2151-9-19**] 04:32AM WBC-16.2*# RBC-3.56* Hgb-11.3* Hct-33.9* MCV-95 MCH-31.6 MCHC-33.2 RDW-14.1 Plt Ct-86* Glucose-130* UreaN-46* Creat-2.8* Na-139 K-5.1 Cl-107 HCO3-18* AnGap-19 ALT-132* AST-137* LD(LDH)-264* AlkPhos-125* TotBili-6.6* Lactate-2.9* [**9-19**] ERCP: Pus, sludge and one stone were released from the bile duct following cannulation - consistent with cholangitis (cannulation) Previous sphincterotomy at the major papilla Multiple filling defects in the CBD consistent with stones and sludge were seen A 5cm 10F double pigtail stent was successfully placed in the common hepatic duct for drainage (stent placement) Otherwise normal ercp to third part of the duodenum *repeat ERCP in 4 weeks for stent removal and stone extraction. . [**9-20**] CXR: 1. Bilateral interstitial opacities, which could lead to interstitial edema, but differential diagnoses includes atypical pneumonia and other interstitial abnormalities. Followup PA and lateral radiographs would be helpful for initial further evaluation. 2. Asbestos-related pleural plaques . Discharge Labs: [**2151-9-23**] 06:15AM BLOOD WBC-7.6 RBC-3.16* Hgb-9.9* Hct-30.1* MCV-95 MCH-31.2 MCHC-32.7 RDW-14.4 Plt Ct-120* [**2151-9-23**] 06:15AM BLOOD Glucose-99 UreaN-34* Creat-1.7* Na-143 K-3.7 Cl-110* HCO3-23 AnGap-14 [**2151-9-23**] 06:15AM BLOOD ALT-59* AST-50* AlkPhos-480* TotBili-3.5* Brief Hospital Course: #Cholangitis: Patient underwent ERCP which showed multiple filling defects c/w sludge/stones. Pus and sludge were noted to be draining from the bile duct during ERCP. A pig tail biliary stent was placed in the common hepatic duct. Patient was intubated for procedure, and was extubated the same day without difficulty. Zosyn was continued on transfer (started [**9-18**]) and converted to Ciprofloxacin 500mg po Q12H on [**9-22**]. Initial transaminitis and hyperbilirubinemia improved during hospital course (on discharge AST/ALT 44/62, TBili 3.5. Of note, patient's alkaline phosphatase continued to rise during hospitalization (in three days prior to admission 225, 438, and 480 on discharge). Elevation was thought to be [**3-15**] evolving hepatic injury vs. cholestasis/ductal obstruction. After discussion with the GI service, it was felt that the patient was safe to return home with close PCP f/u and re-check of alk phos within 5 days (appointment has been scheduled). Presence of declining bili, and alk phos trend was reassuring. The plan per discussion with ERCP/GI service is for total 2wk course of Ciprofloxacin. . #Hypotension: Initially noted to be hypotensive (BP 80/50). Home ACEI, Beta Blocker were held on admission. Required Vaso/Norepinephrine initially. Also required Dopamine post-ERCP. Dopamine was weaned on HD2 and Vaso/Norepinephrine weaned HD3. Patient subsequently remained normotensive, hemodynamically stable. . #AoCRF: Noted to be ARF on admission (Cr 2.7) which returned to baseline (baseline Cr 1.7-2) with aggressive IVF hydration, BP support. CKD likely [**3-15**] HTN vs. ischemic cardiomyopathy/CHF. . #Heme: Normocytic anemia likely [**3-15**] AOCD vs. CKD. There was no evidence of bleed or hemolysis. Anemia studies (Fe 51, TIBC 221, Ferritin 265) were c/w AOCD. Patient was also noted to be thrombocytopenic on admission (Platelets 75). Available data suggests thrombocytopenia is chronic (baseline 100-130s). There was no evidence of DIC, though admission thrombocytopenia below baseline was presumed [**3-15**] septic physiology. A blood smear was evaluated and was unrevealing. Of note, there are prior reports of prosthetic valve related thrombocytopenia (?auto-immune mechanism). No clear mechanism of marrow hypo-proliferation or destruction. Given known chronicity, and stability of thrombocytopenia during hospitalization, there was low concern for HIT. . #AF: Initial rate-control [**Doctor Last Name 360**] (Metoprolol) was held [**3-15**] hypotension on admission. Home dose metoprolol 25mg [**Hospital1 **] was re-started on HD4. There were no episodes of AF/RVR. Patient's ASA 325mg was continued and further anti-coagulation was deferred per home regimen given hx of significant GIB. . #CAD/Cardiomyopathy/CHF: No episodes CP during admission. Troponins were checked at the OSH and were negative. Home dose ACEI, statin were held initially. Patient's ACEI (Lisinopril 5mg po qd) was re-started on HD4. Patient's statin was held during hospitalization given transaminitis. Patient was discharged home with instructions to re-start statin. . #Hypoxemia: Thought to be [**3-15**] aggressive IVF (+TBB 8L in ICU) in the setting of poor underlying respiratory substrate ([**3-15**] COPD). Initially requiring 3L O2, weaned to 2L by HD2 and patient remained stably on RA for duration of admission. Day prior to discharge patient received Lasix 20mg IV with notable diuresis and subjective improvement of dyspnea. He also received Atrovent and Albuterol Q6H during hospitalization. Medications on Admission: Zetia 10mg daily ASA 325mg daily Vit B12 250mg daily Gemfibrzole 600mg [**Hospital1 **] Folic Acid 1mg QID Simvastatin 80mg daily Lisinopril 5mg daily Metoprolol 25mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*14 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing: Use inhaler every 4-6 hours for shortness of breath or wheezing. Disp:*1 unit* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*10 Tablet(s)* Refills:*0* 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for lower extremity swelling, shortness of breath. Disp:*15 Tablet(s)* Refills:*0* 8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Cholangitis Secondary Diagnosis Coronary Artery Disease Cardiomyopathy Hyperlipidemia Chronic Kidney Disease Chronic Obstructive Pulmonary Disease Hypertension Discharge Condition: Stable. Discharge Instructions: You were transferred to the [**Hospital 18**] hospital because of concern for an infection involving the bile ducts in your liver. Your blood pressure was also very low at this time. You were admitted to the hospital and were evaluated by the GI service. It was felt that you had cholangitis, or an infection of the bile duct. You underwent an ERCP with drainage of the infected material, and a plastic stent was placed in the bile duct to help clear and drain the infected material. You received antibiotics after the procedure and will continue them for a total of 14 days--last day is [**2151-10-2**]. . New medications started during your hospitalization: 1. Ciprofloxacin 500mg po Q12H . If you experience worsening abdominal pain, diarrhea, a change in your stool color (dark, bloody), worsening abdominal distention, shortness of breath, chest pain, dizziness, headache different from usual, or any symptoms that concern you please return to the hospital for further evaluation. Followup Instructions: Please follow-up with the GI service in 3 weeks for removal of the temporary stent placed in your bile duct. The GI team will call you to schedule an appointment. If you do not hear from the [**Hospital1 18**] GI service within 2 weeks please call [**Telephone/Fax (1) 33414**] to schedule an appointment. Please also follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4427**]. We have scheduled an appointment for you with Dr. [**Last Name (STitle) 4427**] on Monday [**9-27**] at 4PM.

[ "576.1", "530.81", "V43.3", "574.50", "496", "285.21", "428.22", "427.31", "V45.02", "305.1", "V45.81", "584.9", "403.90", "272.4", "428.0", "038.9", "995.92", "V45.79", "425.4", "V45.82", "585.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.87" ]

icd9pcs

[ [ [] ] ]

10024, 10030

5128, 8663

368, 418

10252, 10262

3695, 4802

11297, 11815

2831, 2904

8887, 10001

10051, 10231

8689, 8864

10286, 11274

4818, 5105

2636, 2703

2919, 3676

276, 330

446, 2085

2107, 2613

2719, 2815

2,743

112,709

1027

Discharge summary

report

Admission Date: [**2128-12-16**] Discharge Date: [**2129-3-17**] Date of Birth: [**2073-2-10**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / Motrin / Depakote / Reglan Attending:[**First Name3 (LF) 6780**] Chief Complaint: Fever, hypotension, altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 55 y/o F with neurosarcoidosis, panhypopituitarism, DM, HTN, presents to ED from home this am with fever, altered mental status and hypotension. Patient was recently hospitalized for similar symptoms secondary ot pseudomonas uti, discharged [**12-8**]. Patient fluid recusitation and given stress dose steroids with improvement in BP and mental status. Lactate 3.8 -> 1.8 with hydration. Patient denies recent illness, did skip prednisone on day of admission, no n/v/d/c, does c/o sore throat, no congestion, mild abdominal pain, no urinary symptoms. Past Medical History: 1. Neurosarcoidosis 2. Panhypopituitarism. 3. Status post right temporal craniotomy for brain biopsy. 4. Diabetes insipidus. 5. Diabetes mellitus type 2. 6. Questionable gastroparesis in the past. 7. Hypertension. 8. Hypercholesterolemia. 9. Migraines. 10. Gastroesophageal reflux disease. 11. History of upper gastrointestinal bleed. 12. Anemia. 13. Obesity. 14. History of subarachnoid hemorrhage 20 years ago. 15. Shingles. 16. L4 through L5 disc disease. 17. Stroke with left hemiparesis in [**2106**] Social History: The patient denies any tobacco, alcohol or intravenous drug use. She lives with a friend in [**Name (NI) 669**]. She is originally from [**Country **]. Family History: noncontributory Physical Exam: Unavailable Pertinent Results: [**2128-12-15**] 10:20PM GLUCOSE-164* UREA N-13 CREAT-1.6* SODIUM-143 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30* ANION GAP-17 [**2128-12-15**] 10:20PM WBC-15.2* RBC-4.34 HGB-13.6 HCT-40.2# MCV-93 MCH-31.3 MCHC-33.8 RDW-16.1* [**2128-12-15**] 10:20PM NEUTS-79.9* LYMPHS-13.2* MONOS-3.8 EOS-2.8 BASOS-0.3 [**2128-12-15**] 10:20PM ANISOCYT-1+ MACROCYT-1+ [**2128-12-15**] 10:20PM PLT COUNT-280 [**2128-12-15**] 10:40PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1 [**2128-12-15**] 10:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2128-12-15**] 10:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2128-12-15**] 10:45PM LACTATE-3.4* [**2128-12-16**] 03:38AM LACTATE-1.8 [**2128-12-16**] 05:00AM PT-14.8* PTT-30.2 INR(PT)-1.4 [**2128-12-16**] 05:00AM PHENYTOIN-1.2* [**2128-12-16**] 05:00AM TSH-0.045* [**2128-12-16**] 05:00AM CALCIUM-7.9* PHOSPHATE-1.9* MAGNESIUM-1.3* [**2128-12-16**] 05:00AM LIPASE-40 [**2128-12-16**] 02:00PM CK(CPK)-243* [**2128-12-16**] 02:00PM CK-MB-3 cTropnT-<0.01 [**2128-12-16**] 09:25AM TYPE-ART TEMP-36.2 O2 FLOW-4 PO2-70* PCO2-44 PH-7.31* TOTAL CO2-23 BASE XS--4 INTUBATED-NOT INTUBA [**2128-12-29**] 07:00AM BLOOD WBC-12.8* RBC-3.24* Hgb-10.5* Hct-29.9* MCV-92 MCH-32.4* MCHC-35.2* RDW-16.4* Plt Ct-274 [**2128-12-27**] 06:32AM BLOOD Glucose-103 UreaN-14 Creat-1.1 Na-132* K-3.9 Cl-93* HCO3-30* AnGap-13 [**2128-12-29**] 07:00AM BLOOD Glucose-86 UreaN-20 Creat-1.4* Na-133 K-4.1 Cl-92* HCO3-28 AnGap-17 --- See records for results of numerous studies while an inpatient. Brief Hospital Course: 1. ID: With concerns of a septic etiology of her fever and hypotension, the patient was empirically treated with vanc/zosyn on admission but was stopped after two days of treatment secondary to negative blood and urine cultures and afebrile stability. Blood and urine cultures were repeated on [**12-19**] off of the antibiotics- urine grew yeast (likely colonization, <10,000), and the blood remained negative. THe patient did have an inframammary fold rash which appeared fungal and improved on miconazole powder. She also had a skin lesion on her back, however the breakdown was not consistent with zoster or any other infectious cause; it improved with duoderm. On the third week, she began to have first low grade fevers, then spiking to 102 over 4 days. Serial cultures were primarily negative but then third set grew MRSA. Patient had already been started on empiric vancomycin for presumptive PICC line infection as source of fevers, which was then continued for eventual 14day course. Pt remained afebrile after second day of vancomycin, survellience cultures negative. She was noted to have a slight leukocytosis w/inc WBC [**Date range (1) 6782**]. U/A was dirty and ahe was started on cipro 500mg [**Hospital1 **]. UCx were again positive only for yeast. CXR neg. BCx were also negative. Pt was also noted to have ulcerative lesions on her tongue. These were initially thought to be [**Female First Name (un) **] (pt on chronic immunosuppressive steriods and has hx of candidal esophagitis) but ddx included herpes simplex (pt with hx of cold sores), CMV, and aphthous ulcers. Derm was consulted for DFA and cultures were sent, including: HSV (neg), bact (neg), viral, and candidal (neg for yeast and [**Doctor Last Name 6783**] organisms). CMV viral load was negative. Clotrimazole troches/magic mouthwash were prescribed. Viral cx's positive for herpes and pt received full course of acylovir with complete resolution of lesions. Pt had witnessed aspiration on [**1-21**] with acute desaturation and hypotension. Pt was treated with 7 days of Vanco, Levo and Flagyl. After this episode, she did well for several weeks but then began to develop daily fevers. Multiple sets of blood cultures were drawn and she grew GNRs in several sets. SHe was treated with vancomycin until these returned as coag neg staph. ~1 week later, she again began to have fevers and elevations in her chronically elevated WBC ct. FOund to have yeast in her urine and treated with fluconazole for 1 week with resolution. Continued to have fevers, and occ episodes of mild hypotension, so started on vancomycin and levaquin. Fevers resolved, but no source found. Again grew coag neg staph, but determined to be contaminant. Also, grew VRE in urine, but recheck was negative and per conversation with ID, believed to be contaminant. After ~5 days of abx, they were discontinued as she was stable and no source was found. She remained stable off the abx. * 2. AMS: the patient has a severely limited baseline, although the admission mental status was indeed a change. The differential diagnosis for cause of her AMS was originally infection, hypotension, hypercarbia, or somnolence due to OSA. The patient remained without s/s of an infection, and pt rebounded back to her baseline after stress dose steriods with taper and BIPAP at night. Pt MS changed with any infection or stress. On [**1-28**] pt complained of chest pain and found to have ECG changes with + troponins. After this stress, pt's MS continued to decline for unknown reasons. After Na normalized and pt receiving steroids she did not improve. Psychiatry consulted for ? depression. Felt that she had a form of akinetic mutism and suggested adding Bromocryptine. Neuro also consulted for possible CVA. MRI repeared on [**2-5**] with no changes from [**12-31**]. Neuro recommended decreasing dose of Dilantin and giving Ritalin. Due to her recent MI, decided not to use Ritalin. Neuro revisited situation and believe that ot is suffering from akinetic mutism. For this she was started on bromocriptine, with gradually escalating doses. Unclear whether it was due to medication or not, but pt appeared to wake up significantly over the month that I knew her. She still had moments of relative unresponsiveness, but the majority of the time she would talk to me, and by the end of the month, she was making jokes and coming up with spontaneous comments. Contineud her dilantin and saw no evidence of seizures. Of note, her limited baseline status from her neurosarcoid does not allow her to take care of herself at home, and there is no family or other support who can care for her appropriately. 3. HYPOTENSION: On admission, patient was hypotensive and febrile and was resuscitated in the ED and MICU for presumed sepsis although without ever a cultured source. Intermittently the patient still has occasional episodes of hypotension, that is responsive to NS boluses. Likely these episodes are [**2-16**] her disability of her thirst mechanism and her adrenal insufficiency. She was given maintenance fluids nearly every day as patient was unable to be properly encouraged to drink enough on her own. Attending spoke with family and decided that pt would not want MICU stay and no pressors. She had 1-2 episodes of asymptomatic hypotension over the month I took care of her, relieved by IVFs. Otherwise she was stable from this standpoint. 4. PANHYPOPITUITARISM/ SECONDARY ADRENAL INSUFFICIENCY: This patient needs exogenouspituitary replacmenet to survive- she has no thirst mechanism and cannot respond appropriately to stress. -Secondary Adrenal Insuffic: On admission, she recieved stress dose steriods and then was tapered over two weeks slowly back to prednisone 10mgQD (baseline dose). With continued hypotension episodes associated with nausea and vomiting, the suspicion of adrenal insufficiency arose and was verified by a cortisol level of 0.8. Likely secondary adrenal insufficiency from hypopituitarism, and therefore she was started on prednisone [**Hospital1 **] (10am and 5pm) for maintanence. However on MRSA bacteremia infection and high fevers, she was restarted on Hydrocortisone/ fludricortisone stress steriods on [**1-5**] and then retapered. - Fludrocort stopped as pt has central deficit. SHe was on solumedrol IV for the month I had her. SHe did well on this and was given stress doses for fevers, suspected infection. Typically ,would give extra 20 mg IV solumedrol for every degree her temp rose over 100.(ie. 100-101=20 mg extra, 101-102=40 mg extra, etc.). She did well with this regimen. The plan is to switch her to oral prednsione through the PEG tube to take her completely off IV medications. -Central Diabetes Insipidus: from her neurosarcoid- Endocrine consulted for regulation of Na. With pts poor MS she could not properly take nasal DDAVP and was therefore started on IV. Pt placed on standing dose of 0.4mcg with good results. Pt requring 2 liters of fluid per day. Alternating fluids between D5W and D51/2NS. She tolerated this well. After PEG tube placed, she was converted to oral ddavp and after some trial and error with her IVFs and free water boluses through her PEG, we found a steady state inher sodium levels. This was very sensitive, and her I/Os had to be watched closely daily along with her sodium in order to keep her in balance. She would start to drift up or down at times with no changes made for unclear reasons, but was stable by the time I left the wards. -Hypothyroidism: appropriately replaced as demonstrated by free T4 level. This was followed every 10 days when she was switched to oral levothyroxine, and she is currently stable at 175 mcg qday through her PEG. 5. NEUROSARCOID: Her neurosarcoid is followed by Dr [**First Name8 (NamePattern2) 1151**] [**Last Name (NamePattern1) **] Neuro-oncology [**Hospital1 18**] and has been treated with cytoxan every few months via portacath. However with progressive decline of her mental status over several months and no significant improvement on interval MRI, the cytoxan therapy was aborted per Dr [**Last Name (STitle) 724**]. progression of disease has left Ms [**Known lastname **] unable to care for herself / take meds/ feed herself / etc... according to NeuroOnc Cytoxan is only a prolonging measure, not a curative solution. She will die from this disease (likely from endocrine effects) but no time table can be reasonably named. She was continued on her seizure prophylaxis with dilantin/neurontin. 6: ACCESS: The patient's Left sided port-a-cath was removed during admission. Her first PICC line was eventually nidus for bacteremia episode and was removed; another was placed for IV antibiotics and hydration purposes after survellience cultures negative x 3days. This PICC clotted and a third was placed on [**2-1**]. The pt pulled this PICC line out, and a 4th was placed by IR that functioned well for >1 month. 7. DIABETES MELLITUS: the patient is on metformin at home, which she tolerated well here until she was on stress dose steriods. She then was maintained on glargine and ISS. Her blood glucose levels were initially high, and get higher when she gets higher doses of steroids for temps. She is currently stable with good levels on glargine 7 units and a customized sliding scale. 8. HYPERLIPIDEMIA: The patient was continued on lipitor. 9.DVT: Pt found to have RLE DVT despite pneumoboots. Staretd Lovenox as pt has extreme heparin sensitivity. Checked factor Xa levels and she is in the therapeutic range on Lovenox 60 mg/kg. Started coumadin after several days at dose of 2.5 initially due to history of sensitivity to anticoagulation. Wasn't effective, so increased dose to 5 mg qday and INR climbed to only 1.6. 10.Cardiology: Pt with chest pain on [**1-28**]. Found to have slightly elevated trop with deeper diffuse T wave inversions. + MB fraction on [**1-30**] so pt was started on heparin gtt for 48 hours. Extremely sensitive, and low doses only needed to get her therapeutic(ie SQ haprin doses) - Medically managed on Lopressor, Lisinopril and ASA 11.Shoulder pain:Pt started to c/o shoulder pain. Xray clear so MRI performed. Found to have 3 rotator cuff muscles with complete tears through the tendons. Also had bllod in joint capsule, which explained concurrent 6 point Hct drop. Unclear how this occured, but staff was using lift to get pt from bed to chair and suspect that she was injured in this process, alternatively, may have fallen and gotten up without anyone seeing her. Seen by ortho and felt no intervention unless joint became septic. Began to improve on its own and pt was able to use joint without pain eventually. No intervention performed. 12. Nutrition: Had long discussion with attending and team on [**2-1**] regarding nutrition. Pt not eating with altered MS. - PEG placed [**2-12**]. Tube feeds recommended by nutrtion and she tolerated them well. Currently getting 150 cc q8h water boluses to maintain stable sodium levels. This volume and frequency was manipulated often to get to this eventual steady state, and she responds well to changes in this if her levels begin to change. 13.On the day before death, pt was found by her intern in the morning to have right sided weakness and facial droop. She was sent for MRI which showed pontine hemorrhage. Unclear why she had this hemorrhage, but she has multiple reasons for such an insult. However she developed [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations in the MRI scanner and was taken back to the floor. Pt was found to have BP of 240/120 and bradycardia. O2 sat then dropped down into 60s. Pt was a DNR/DNI, but upon speaking with family, her son asked that this be reversed and that she be intubated/resuscitated. She was intubated and had central line placed. Transferred to the unit. Once there, team spoke with family about poor prognosis and decision was made to withdraw care. Pt was then sent for organ donation. Medications on Admission: Lipitor Prednsione (tapered to 10mg) Lisinopril Desmospressin Cipro (completed [**12-15**]) Metformin Humulin Protonix Sucralfate Levothyroxine Flovent Discharge Medications: None Discharge Disposition: Extended Care Facility: unknown Discharge Diagnosis: neurosarcoid, adrenal insufficiency Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

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icd9cm

[ [ [] ] ]

[ "43.11", "86.07", "93.90", "38.93", "96.04", "99.04", "86.05", "96.6" ]

icd9pcs

[ [ [] ] ]

15592, 15626

3367, 15361

349, 356

15705, 15715

1716, 3344

15768, 15775

1652, 1669

15563, 15569

15647, 15684

15387, 15540

15739, 15745

1684, 1697

268, 311

384, 936

958, 1466

1482, 1636

10,412

133,053

13941

Discharge summary

report

Admission Date: [**2110-9-2**] Discharge Date: [**2110-9-10**] Date of Birth: [**2065-8-21**] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Vancomycin Attending:[**First Name3 (LF) 2186**] Chief Complaint: Hypotension Fever Major Surgical or Invasive Procedure: Catheterization [**2110-9-5**] Hemodialysis every M/W/F History of Present Illness: On the morning of admission, he had chest pain and shortness of breath while on 2L of nasal canula at his rehabilitation center. He was given 1" nitropaste with improvement of both his chest pain and shortness of breath. He had an EKG at the time that showed ST elevations in V1-V3 and ST depressions in V4-V6. At the time, he was thought to be fluid overloaded. He subsequently went to his regular dialysis and had a greater amount of fluid removed (about 5 L). After dialysis, he no longer had chest pain or shortness of breath but had a decreased ability to "verbalize what he wants." His glucose at the time was 67. His speech did not improve with carbohydrates. He was also found to be hypotensive with a systolic pressure in the 70s and febrile to 102.2. He was transfered to the [**Hospital1 18**] emergency room for further evaluation and treatment. . In the emergency room, he complained of some mild chest pain that was less severe than that of earlier in the day. He states that it is left-sided, does not radiate, and is worse on inspiration. He denies current shortness of breath. He denies fevers, chills, sweats, dysuria (produces small amount of urine), diarrhea, headache. He does state that he feels tired. Past Medical History: Diabetes mellitus type 1 ESRD on hemodialysis Neuropathy Depression History of CVA and history of TIA Status post cervical laminectomy History of MRSA and VRE Social History: He lives at a rehabilitation facility. He has a significant other. He denies tobacco, alcohol, and IV drug use. Family History: Noncontributory Physical Exam: On admit PE: 98 90s/50s 100 20 100% RA Gen: appears comfortable, somewhat sleepy but easily arousable HEENT: MM dry, PERRL, EOMI, OP clear Chest: HD catheter without surrounding erythema or tenderness CV: RRR, nl S1/S2, 2/6 systolic murmur loudest at the base Pulm: CTAB, no wheezes or crackles Abd: soft, NT, mildly distended, +BS, no masses Groin: R femoral line in place Ext: contractures in R hand; 2+ distal pulses; 2+ edema Pertinent Results: LABS: On admit [**2110-9-1**]: 20.9>40.7<381 N:82.2 L:10.1 M:6.9 E:0.6 Bas:0.3 . [**Age over 90 **]|94|30 /59 6.0|28|3.8\ Ca:8.6 Mg:2.4 P:5.5 . ALT:17 AST:15 AP:66 Tbili:0.3 TProt:6.4 Alb:3.2 [**Doctor First Name **]:59 Lip:17 . PT:13.8 PTT:26.7 INR:1.3 . Cortisol:9.6 CRP:187.4 Lactate:2.2 D-dimer:593 . Acetone:negative . CK:41 MB:not done TropT:0.80 [**9-3**] tropT 1.05 [**9-6**] tropT 0.57 . On discharge [**2110-9-10**]: WBC 8.2, Hct 31.7, MCV 91, Plt Ct 422 Na 137, K 4.3, Cl 93, HCO3 29, BUN 31, Cr 5.5, Glu 117 ALT 12, AST 17, AlkPhos 70, Tbili 0.2 Calcium 9.4, Phos 4.6, Mg 2.2 . MICRO: [**9-2**] UA:Hazy SG:1.022 pH:7.0 Mod leuks, Mod Bld, 500 Prot, 1000 Glu, rest of dipstick negative. [**9-2**] Ucx: 10,000-100,000 yeast [**9-2**] Blood cx x2 negative [**9-3**] Blood cx x2 negative [**9-6**] Blood cx x2 no growth to date . RADS/IMAGING: Head CT at Outside Hospital: negative for acute bleed; chronic small vessel ischemic disease; age-related volume loss; focal encephalomalacia in left cerebral hemisphere and left external capsule likely from previous CVA. . [**2110-9-2**] Chest CTA, Abdomen/Pelvic CT with and without contrast: No evidence of pulmonary embolism or aortic dissection. Interstitial pulmonary edema. Bilateral pleural effusions. Small pericardial effusion. Heterogeneous hepatic perfusion, likely secondary to right heart failure. Diffuse mesenteric fat stranding, which may represent mild edema. Small amount of perihepatic free fluid. . ECHO [**2110-9-3**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>70%). Regional left ventricular wall motion is normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be estimated. There is an anterior space which most likely represents a fat pad. Compared with the report of the prior study (tape unavailable for review) of [**2109-10-9**], the findings are similar. . EKG: sinus tachycardia rate 119, normal axis and intervals, 1-1.5mm ST depressions in V5-V6, 1mm ST depression in I, TWI in I, V5-V6, no change from previous; LVH . CATH [**2110-9-5**]: 1. Selective coronary angiography in this right dominant system reveals no significant flow limiting coronary artery disease. The LMCA, LAD, LCX were all normal. The LCX gave off a very large OM1 and continued in the AV groove as a very small vessel. The RCA had a smooth 30% mid stenosis. 2. Hemodynamics revealed elevation of left and right filling pressures. The mean RA was 21mm HG and the mean wedge was 28mmHG (LVEDP 29mm HG). There was also moderate pulmonary hypertension with mean PA 37mmHG. There was no evidence of aortic gradient on LV pullback. The cardiac index was preserved at 2.7l/min/m2. FINAL DIAGNOSIS: 1. No significant coronary artery disease. 2. Elevated filling pressures with preserved cardiac output. . XR foot [**2110-9-7**]: Diffuse osteopenia limits the assessment. Irregularity at the dorsal surface at the junction of the navicular and cuboid bones will require clinical correlation for determining its significance. No definite evidence for toe osteomyelitis. . PVR [**2110-9-8**]: Artifactually high pressures in bilateral lower extremities, due to vessel non-compressibility. Otherwise, there is mild arterial obstructive disease in the bilateral dorsalis pedis arteries, and no evidence of significant obstruction more proximally. Brief Hospital Course: 45 year-old male with history of diabetes type I, end stage renal disease on hemodialysis, who was transfered from outside hospital for evaluation of hypotension, fever, altered speech, and chest pain. . 1. Hypotension - His initial hypotension resolved after fluid [**Last Name (LF) 41699**], [**First Name3 (LF) **] it was attributed to over-dialysis. Since he was febrile with a leukocytosis, there was an initial concern for sepsis; however, his blood pressure remained stable after the initial fluid boluses and his lactate was not considerably elevated. No source of infection was found, though he had been on antibiotics from the OSH prior to having cultures sent. His broad spectrum antibiotics were stopped and his BP remained stable (SBP 110s-140s) for the remainder of his hospital course. . 2. Fever - At the outside hospital, he had a temperature of 102.2 and received a dose of levofloxacin and flagyl. In the emergency room, he received empiric linezolid and aztreonam given his history of MRSA and vancomycin allergy. The initial infectious workup was negative. Chest x-ray didn't show an infiltrate and blood cultures were negative. After that, he had a positive urinalysis with pyuria and many bacteria and was started on 7 day course of cefpodoxime. He remained afebrile during his MICU course and was transferred to the floor. Cefpodoxime was discontinued after 5 days as he had been started on levofloxacin/clindamycin for the infection in his R great toe. . 3. Chest pain - He complained of pleuritic type chest pain on admission. A CTA was negative for PE in the emergency room. He had ST elevations in V1-3 and depressions in V4-6 on EKG that were stable from a prior EKG. He also had an elevated troponin that was difficult to interpret in the setting of his renal disease which caused a baseline elevated troponin. His intial chest pain was right sided and pleuritic; however, he developed substernal chest pain and diaphoresis during his hospital stay. He was maintained on a ACE-I, aspirin, beta-blocker, and high dose statin for optimal medical management of his ischemic chest pain. During this chest pain, his EKG remained stable. His troponins remained elevated so cardiology was consulted and he was scheduled for a diagnostic catherization on [**2110-9-5**]. Cath showed that the LMCA, LAD, LCX were all normal. The LCX gave off a very large OM1 and continued in the AV groove as a very small vessel. The RCA had a smooth 30% mid stenosis. He had elevated filling pressures with preserved cardiac output. His chest pain improved and he had no further episodes of angina while here. . 4. Toe ulcer - During his hospital course, the patient's wife bumped into his R great toe and he developed a black, necrotic ulcer at the medial side of the right nailbed. Podiatry was consulted and recommended empiric treatment with levaquin and clindamycin for his toe ulcer. PVRs were done which showed that he had adequate arterial flow to his feet and should be able to heal. Follow-up was recommended with podiatry in [**1-12**] weeks. . 5. End-stage renal disease - His regular hemodialysis was continued throughout the hospital course. Renal followed the patient and he was started on Phoslo for his elevated phosphate. . 6. DM1/hypoglycemia - He initially presented with hypoglycemia that resolved with IV dextrose. Once he was admitted, his glucose was elevated and he required an insulin drip to control his sugar. He was transitioned to his regular glargine and an insulin sliding scale on transfer to the floor, but he proved to be very sensitive and dropped his glucose to 16 and experienced mental status changes. He was given an amp of D50 and his glucose came up to the 50s. His PM dose of glargine was held for several nights and he was only given regular insulin based on his FS. On day prior to discharge, he was given 7u Lantus (half of his regular dose) prior to bedtime, and his FS in the AM were 67 and 84. He will be discharged on a RISS and a decreased dose of Lantus (5u QHS). . 7. FEN/GI - He was maintained on a renal diet. He was treated for initial hyperkalemia with kayexalate, but his K remained in normal range for the rest of the hospital course. He was treated for elevated phospate with phoslo and his magnesium was repleted as necessary. A portable XR of his abdomen was obtained the day of discharge as the patient was complaining of abdominal bloating and constipation (despite having 3 bowel movements yesterday). . 8. PPx - SC heparin, PPI, contact precautions for h/o MRSA/VRE . 9. Code - full . 10. Access - He had a right femoral line placed in the emergency room. He also has a left subclavian hemodialysis catheter. . Medications on Admission: dulcolax 10mg lactulose 30mL 4x/day lidoderm patch celexa 40mg po daily plavix 75mg po daily vitamin B12 flexeril 10mg po bid folate 1mg po daily neurontin 100mg po tid reglan 5mg before meals, qHS flagyl 250mg po 4x/day ambien 5mg levaquin 250mg po every other day anzemet 12.5mg po q6 procrit 12,000 units q HD heparin 45,000 units q HD Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 2. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 3. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 11 days. Disp:*44 Capsule(s)* Refills:*0* 4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 11 days. Disp:*6 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 14. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 20. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 21. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous at bedtime. 22. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection four times a day: per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: UTI Hypotension, likely from dehydration and not sepsis Ingrown great toe on R foot with superinfection Pleuritic chest pain, likely from pneumonia and not NSTEMI Discharge Condition: Stable. T 97.8, BP 112/80, HR 79, RR 20, sats 95% on RA. FS 67 and 84 this morning. Discharge Instructions: Please continue to cooperate with your healthcare team and to take all your medications as prescribed. Also, call your doctor if you develop any of the following symptoms: fever >101, chills/rigors, chest pain, shortness of breath, nausea, vomiting, constipation, or any other worrisome symptoms. Followup Instructions: Please follow up with Podiatry in [**1-12**] weeks to have your right toe re-examined. Call ([**Telephone/Fax (1) 21608**] to set up an appointment. You will need to have your insulin regimen adjusted as your sugars and insulin doses have been changed multiple times during this admission.

[ "995.91", "038.9", "250.61", "357.2", "280.9", "735.8", "403.91", "786.59", "250.81" ]

icd9cm

[ [ [] ] ]

[ "39.95", "00.14", "97.49", "37.21", "38.93", "88.56" ]

icd9pcs

[ [ [] ] ]

13393, 13465

6238, 10941

319, 376

13672, 13758

2465, 5551

14104, 14398

1975, 1992

11331, 13370

13486, 13651

10967, 11308

5568, 6215

13782, 14081

2007, 2446

262, 281

404, 1645

1667, 1828

1844, 1959

5,689

157,267

5739

Discharge summary

report

Admission Date: [**2124-9-18**] Discharge Date: [**2124-9-28**] Date of Birth: [**2048-7-14**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 689**] Chief Complaint: CC: Emesis, diarrhea, fever Major Surgical or Invasive Procedure: None History of Present Illness: HPI: Pt. is a 76 yo female with a history of ESRD on HD, CAD, atrial fibrillation, and DM2 who presents with a 1 day history of 3 episodes of nonbloody, nonbilious, clear emesis and 1 episode of nonbloody diarrhea. The patient woke up in her USOH this AM when she suddenly developed 3 episodes of emesis and 1 episode of diarrhea. She reports that she did not eat breakfast this morning, and has had no change in her diet. She has a sick contact: a next door neighbor in rehab had vomiting and diarrhea recently. She denies abdominal pain/cramping, chest pain, palpitations, SOB, dysphagia, cough, sore throat, HA, dysuria, neck stiffness. She does report passing gas. She has been tolerating PO food and fluid. Of note, she was discharged from [**Hospital1 18**] [**2124-9-8**] for an UGIB [**1-7**] PUD so has been off Coumadin. On the day of admission she finished treatment for H. pylori (Clarithromycin, Flagyl, and PPI), which she reports giving her a sour taste in her mouth. . In the ED, her vital signs were temp 100.1, HR 88, bp 160/71, RR 18, SaO2 100% on RA. The patient was given lunch in the ED. She had an EKG which showed NSR, [**Month/Day (2) **] in I, aVL, no ST changes. CT abdomen/pelvis, CXR, and abdominal films were negative for acute disease. WBC 12.1 -> 7.9. Troponin 0.32 -> 0.26, CK 61 -> 50, and the patient was admitted for further work-up and to r/o MI. . On the floor, the patient continued to have no symptoms and reported no pain. She remained febrile to 102.2 and tachycardic to 120. She was given IVF NS 500 cc bolus x1, and her SBP became 90. She then received IVF NS 500 cc bolus x2, but her SBP remained 85. No EKG changes. MICU was called for evaluation for transfer. Past Medical History: PMH: - ESRD on HD qTues, Thurs, Satuday. Baseline Cr 3.5-5.0. s/p failed transplant [**10-8**]. Left AV fistula. Patient does not make urine. - UGIB [**2124-9-8**], received 3 U PRBCs, EGD showed ulcers in the antrum, above pylorus, at 12 o'clock and 2 o'clock. 2nd ulcer had visible vessel, nonbleeding. (thermal therapy). - CAD s/p NSTEMI treated at [**Hospital1 112**] [**12-11**], ?NSTEMI/demand mediated ischemia with recent GIB. Patient has a baseline Troponin T of 0.08-0.16 ([**Hospital1 **] [**Location (un) 620**] records). - HTN - Hyperlipidemia - Atrial fibrillation currently off Coumadin [**1-7**] UGIB, s/p pacemaker placement - CHF: per cards note Echo [**4-9**]: s/p MVR, Mod-Severe TR, Atrial dilatation, LVEF 45%, followed mostly at [**Hospital1 112**] (last TTE here [**2120**]); report of eval at [**Hospital **] hospital [**2123-5-11**]: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] 55-60% with LVH and new wall motion abnormalities, severe pHTN (>65mmHg). - pulmonary hypertension as above - DM2, last HgA1c 6.7% on [**10-8**]. - Peptic ulcer disease, recently finished triple abx therapy (Clarithromycin 500 mg daily, Flagyl 500 mg PO bid, Protonix 40 mg [**Hospital1 **]) for H. pylori - Multiple pelvic fractures: CT pelvis ([**Hospital1 **] [**Location (un) 620**]) [**8-11**] showed MULTIPLE PELVIC FRACTURES INVOLVING SUPERIOR AND INFERIOR PUBIC RAMI BILATERALLY AS WELL AS THE RIGHT SIDE OF THE SACRUM. THE PATIENT IS S/P ORIF OF LEFT HIP FRACTURE. THIS IS WELL HEALED AND NO ACUTE HIP FRACTURES ARE SEEN. - GERD - Cirrhosis - Ascities - Inguinal Hernia - Lower Extrem Edema - Valvular Disease - stage II/III sacral decubitis ulcer - R sided sciatic pain Social History: Social Hx: Prior to recent admit with multiple pelvic fractures had been living at home, independent of ADL's. Since then she has been living in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (rehab). No tobacco, occ. alcohol, no illicit drug use. Supportive son. Family History: Family Hx: NC Physical Exam: Physical Exam: Vitals: temp 102.2, bp 94/34, HR 88, RR 20, SaO2 93% on RA General: Awake, alert, NAD. Alert to person, place, time. HEENT: NCAT, Dry mucous membranes. No pharyngeal erythema. No submandibular, supraclavicular, or anterior cervical lymphadenopathy. PERRL. EOMI. No nuchal rigidity. CV: Regular rate. Nl S1, S2, III/VI systolic murmur best heard at apex. Pulm: Decrease breath sounds. Bibasilar crackles. No wheezes/rhonchi. Abd: Positive bowel sounds. Soft, NTND abdomen. No masses. No guarding or rebound. Guaiac negative in the ED. Ext: 1+ pitting ankle edema bilaterally, 1+ DP pulses bilaterally. L AV fistula in place. Pertinent Results: Studies: CT Abdomen/Pelvis ([**9-18**]): IMPRESSION: 1. No evidence of obstruction or acute intra-abdominal pathology. 2. Right-sided renal lesion concerning for carcinoma and not completely characterized on this single phase of contrast study. MRI is recommend for further evaluation. 3. Bilateral healing pelvic fractures, one of which involves the left acetabulum. 4. 9 mm partially calcified splenic artery aneurysm. . CXR ([**9-18**]): IMPRESSION: Bilateral pleural effusions and associated atelectasis. No infiltrate or evidence of pulmonary edema. . Abdomen Films ([**9-18**]): IMPRESSION: Subacute fractures of right superior and inferior pubic rami; no evidence of obstruction or free air. . EKG: NSR, No [**Last Name (LF) **], [**First Name3 (LF) **] elevation in V2, ST depression in V6 (noncontiguous) . Renal U/S ([**9-21**]): IMPRESSION: Mixed solid and cystic right interpolar renal lesion as noted on CT examination. Findings are still concerning for neoplastic involvement and dedicated MRI examination is recommended. Brief Hospital Course: 76 yo female with a history of ESRD on HD, CAD, atrial fibrillation, and DM2 who presents with a 1 day history of vomiting and diarrhea. . # Fever. Patient presented with a 1 day history of emesis and diarrhea, with a temperature of 100.1. CT abd/pelvis was without evidence of acute intra-abdominal pathology, CXR was without evidence of infiltrate, and abdominal film was without free air. WBC was initially 12.1 with a left shift, and lactate 0.8. The patient was transferred to the MICU on the day of admission for fever up to 102.2 and hypotension; in the ICU the fever defervesced without antibiotics and she remained afebrile. She most likely had a viral gastroenteritis causing her symptoms. Patient was also tachycardic, which was likely a response to fever or dehydration, as patient denied any pain. Blood cultures taken at that time were with no growth. (UA/urine Cx not able to be done as patient makes minimal urine.) C. difficile toxin was negative x 3. Fecal culture negative for salmonella, shigella, and campylobacter. Diarrhea resolved spontaneously without intervention prior to discharge. . # Hypotension: On admission, she had fever and hypotension down to 88/40. She was given IVF NS 500 cc bolus x2 without initial improvement in her BP. She was transferred to the MICU, where her BP incrased up to 110s. She was transferred back from MICU with SBP up to 110s. The patient also developed hypotension down to SBP in the 70s during 3 HD sessions when given IV lopressor and IV diltiazem for treatment of a fib with RVR into 140s-170s (see below). . # Atrial fibrillation: Patient initially in NSR on admission. Patient has a [**Company 1543**] dual chamber ICD, followed by Dr. [**Last Name (STitle) 11679**] at [**Hospital1 112**]. Her Coumadin is being held for at least 1 month pending GI f/u s/p UGIB at the beginning of [**9-10**]. She was continued on ASA 81 daily. Beta blocker was initially held when patient was hypotensive. Outpatient Metoprolol dose was initially continued at 25 mg [**Hospital1 **] qMWF, 25 mg qhs qTuThSa. However, she was developing a fib with RVR into 140s-170s with HD, but this was increased to metoprolol 25 PO bid for better HR control. The patient developed afib with RVR at 3HD sessions, treated with IV Lopressor and Diltiazem. She becomes hypotensive during these episodes (usually down to 70/30) but responsive to IVF boluses. The patient once c/o chest pain, CE negative x 3 at this time. Digoxin was started on [**2124-9-23**] (renally dosed) with post-load digoxin level of 1.6 and no EKG changes consistent with digoxin toxicity. She was continued on a daily dose of digoxin at 0.125mg qd. F/u monitoring on [**9-27**] showed level of 1.1. (Digoxin levels should be monitored until they reach steady state.) . # Erratic pacemaker firing: Patient has a [**Company 1543**] dual chamber ICD, and is followed by Dr. [**Last Name (STitle) 11679**] at [**Hospital1 112**]. On telemetry, it was noticed that she had occasional pacemaker spikes on top of T waves. EP was consulted and interrogated her ICD. She was found to have a normal functioning ICD, and the spikes appeared to be [**1-7**] undersensing of a fib waves with inappropriate atrial pacing. This was not thought to be dangerous. The patient will need to follow up with her outpatient electrophysiologist (Dr. [**Last Name (STitle) 11679**] at [**Hospital1 112**]) upon discharge. . # Renal lesion: CT abdomen showed a right-sided renal lesion concerning for carcinoma. Renal U/S showed mixed solid and cystic right interpolar renal lesion as noted on CT examination concerning for neoplastic involvement. An MRI was unable to be completed as patient has ICD and rod in leg. The patient is unlikely a good surgical candidate. The patient is to follow-up with Urology (Dr. [**Last Name (STitle) 261**] for further evaluation and management of this. . # ESRD: Patient was continued on usual HD schedule: qTues, Thurs, Satuday. Baseline Cr 3.5-5.0. She developed a fib with RVR and hypotension during 3 HD sessions as above, and they had to be terminated early. The patient received UF to remove total of 3kg prior to discharge. The patient continued Nephrocaps and Calcium, and patient received epogen with HD sessions (Note: did not receive Epo on [**9-28**] - will need dose at next HD session.) She will need to reschedule her appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Last Name (NamePattern1) **] and Mineral as she missed her [**2124-9-20**] appointment while in the hospital. She will also eventually need an endocrinology appointment to evaluate [**Month/Day/Year 500**] disease. . # Elevated Troponins: Patient has a baseline elevated troponins per [**Hospital1 **] [**Location (un) 620**] records (0.08-0.16). Troponins here have been 0.32 -> 0.19 with flat CK-MB. EKG without any acute changes. Continued ASA 81 daily. . # Hyperlipidemia: Continued Simvastatin. . # DM: Continued NPH [**Hospital1 **], RISS, FSBG qachs. . # Chronic diastolic CHF: Stable . # Subacute Pelvic fracture: Found on [**Location (un) 620**] CT, seen again on Pelvic CT here. Patient given Tylenol prn and Oxycodone 2.5 mg PO Q6H prn while inhouse. . # Sacral decubitus ulcer: Daily Duoderm dressing changes with saline cleansing. . # PUD: Patient finished PUD treatment on the day of admission (Clarithromycin, Flagyl, PPI). Continued Protonix 40 mg [**Hospital1 **]. She has an appointment with Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) **] in gastroenterology on [**2124-10-30**]. . # On [**9-28**] the patient was discharged in stable condition, afebrile with VSS to rehab for further care. Medications on Admission: Medications (Per Recent d/c Summary): -Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. -Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. -Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). -Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) as needed for pain. -B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). -Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. -Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. -Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): On Tu/Th/Sa, hold for sbp<100 and hr<60. -Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): [**Hospital1 **] on M/W/F/Sunday Hold for SBP<100 or HR<60 . -Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). -Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. -Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 11 days. -Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). -Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). -NPH 16 qAM, 3 qPM and HISS . Allergies: Codeine Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheeze. 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): last dose 10/24. 15. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 16. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension Sig: One (1) vial Subcutaneous once a day: Please administer NPH 16u qam, 3u qpm, and HISS as follows: Gluc < 60 --> 4oz juice 61-150 --> 0u 151-200 --> 2u 201-250 --> 4u 251-300 --> 6u 301-350 --> 8u 351-400 --> 10u > 400 --> notify MD. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **] Discharge Diagnosis: PRIMARY: 1. Gastroenteritis 2. Hypotension 3. Atrial fibrillation 4. Right renal lesion SECONDARY: 1. ESRD 2. Diabetes Mellitus 2 3. Peptic Ulcer Disease 4. Chronic diastolic CHF 5. Subacute Pelvic Fractures 6. Sacral decubitus ulcer 7. Hyperlipidemia 8. Hypertension 9. GERD Discharge Condition: Stable, afebrile, VSS Discharge Instructions: You were admitted to the hospital with vomiting and diarrhea, most likely due to a viral illness. During the admission your irregular heart rhythm became difficult to control, and your metoprolol was increased to 25mg twice a day every day. We also added a new medicine, digoxin. You were found to have a mass in your kidney which Dr. [**Last Name (STitle) 261**] in Urology will follow. 1. Take all medications as prescribed 2. Please make all follow-up appointments 3. If you develop worsening fevers >101.5, chills, nausea, vomiting, diarrhea, chest pain, palpitations, shortness of breath, or any other concerning symptoms, contact your provider or report to the Emergency Department Followup Instructions: Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 3070**] . You have an appointment with Dr. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. on [**2124-10-3**] at 1:00pm, Phone:[**Telephone/Fax (1) 277**] for evaluation of a renal mass found on CT. . You need to make a follow up appointment with your outpatient elecrophysiologist, Dr. [**Last Name (STitle) 11679**], at [**Hospital6 13185**]. . You will need to reschedule your appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Last Name (NamePattern1) **] and Mineral in [**Hospital Ward Name **] CENTER, [**Location (un) **] (you missed your [**2124-9-20**] appointment because you were in the hospital). . You have an appointment with Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) **] in gastroenterology on [**2124-10-30**] at 11:00 in the [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] ENDOSCOPY SUITES, GI WEST,ROOM TWO

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2199-5-30**] Discharge Date: [**2199-6-3**] Date of Birth: [**2143-6-21**] Sex: F Service: MEDICINE Allergies: Morphine / Betadine / Iodine / Demerol / Lisinopril Attending:[**First Name3 (LF) 2186**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: This is a 55 year old Caucasian female with a PMH significant for tracheo-bronchomalacia, paradoxical vocal cord dysfunction, GERD, OSA, who presents with dyspnea. . Reports that she was in her usual state of good health until [**4-21**], when she developed acute angioedema and anaphylaxis that was thought to be secondary to lisinopril. Due to persistence of dyspnea, however, further workup by IP demonstrated tracheo-bronchomalacia. Patient received a Y stent and has had limited improvement from bronchodilators and steroids. Has had multiple hospital and ICU admissions (one intubation) during this past year, with prior bronchoscopy also demonstrating paradoxical vocal cord movement. She has been treated with maximal PPi therapy as well. . Patient was admitted to the hospital approximately 3 weeks ago with dyspnea. At that time, she had developed a persistent non-productive cough. Denies any sputum production. No fever, chills, nausea, vomiting, or diarrhea. Or pleuritic chest pain. During her hospitalization, she was evaluated by ENT and found no further evidence of paroxysmal vocal cord movements. IP performed a flexible bronchoscopy on [**5-10**] which demonstrated severe granulation tissue at the right distal end of the Y-stent. Y stent was removed by rigid bronchoscopy, as it was of little benefit and could have been making her symptoms worse. She felt better after discharge only for a few days. . Today, patient felt faint while walking, shortness of breath, and with the development of stridor. She was able to walk to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] ED (where she works). In the [**Hospital **] Hospital ED, was given racemic epi, nebulizers, ativan, IV 125 solumedrol. Patient was medlighted to [**Hospital1 18**] for further management, and stridor resolved en route. Was speaking full sentences with no stridor upon arrival to [**Hospital1 18**]. Initial vital signs were: HR 72, BP 124/80 RR 16, 93% 3L NC. Here, was given ativan 1mg IV X 1. CXR was without acute process. IP was consulted and recommended ICU admission for close airway monitoring and speech and swallow evaluation. . On arrival to the medical floor, patient reports that her breathing is back at baseline. . 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: 1. Tracheobronchomalacia s/p 2 stents,most recent placed [**2-20**] 2. Hypertension 3. Hyperlipidemia 4. Numerous right hand surgeries s/p R hand trauma 5. S/p cholecystectomy 6. S/p appendectomy 7. S/p Tonsillectomy 8. Back surgery (unclear procedure) 9. Hyperglycemia in setting of steroids 10. OSA, on home BIPAP 11. Obesity Social History: Lives with mother, father, and brother in [**Location (un) 15984**]. Works as patient coordinator at [**Hospital **] hospital and has strong support network at work. - Tobacco: Denies any history. - Alcohol: Denies. - Illicits: Denies. Family History: Mother and father with HTN, Mother with [**Name (NI) 10322**]. [**Name2 (NI) **] h/o lung diseases Physical Exam: Vitals: T: 98 BP: 101/69 P: 72 R: 16 O2: 93% 3L NC General: Alert, oriented, NAD HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Intermittent inspiratory stridor heard across neck. Bibasilar crackles but good air movement. No wheezes or rhonchi. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AOx3, 5/5 strength in all 4 ext Psych: stable mood, saddened affect Skin: no rashes Pertinent Results: On admission: [**2199-5-30**] 06:35PM BLOOD WBC-4.8# RBC-3.90* Hgb-12.0 Hct-36.1 MCV-93 MCH-30.8 MCHC-33.3 RDW-14.3 Plt Ct-179 [**2199-5-30**] 06:35PM BLOOD Neuts-74.8* Lymphs-20.3 Monos-1.9* Eos-2.7 Baso-0.3 [**2199-5-30**] 06:35PM BLOOD Plt Ct-179 [**2199-5-30**] 06:35PM BLOOD Glucose-125* UreaN-12 Creat-0.9 Na-138 K-4.3 Cl-100 HCO3-27 AnGap-15 [**2199-5-31**] 03:48AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.1 . On discharge: [**2199-6-3**] 06:48AM BLOOD WBC-4.8 RBC-4.12* Hgb-12.8 Hct-37.9 MCV-92 MCH-31.0 MCHC-33.8 RDW-14.2 Plt Ct-196 [**2199-6-1**] 06:45AM BLOOD Neuts-56.7 Lymphs-36.1 Monos-5.4 Eos-1.5 Baso-0.3 [**2199-6-3**] 06:48AM BLOOD Plt Ct-196 [**2199-6-3**] 06:48AM BLOOD Glucose-115* UreaN-14 Creat-0.8 Na-141 K-3.8 Cl-105 HCO3-25 AnGap-15 [**2199-5-30**] 06:35PM BLOOD CK(CPK)-77 [**2199-6-3**] 06:48AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0 . Brief Hospital Course: Pt [**Name (NI) **] is a 55 year old Caucasian female with a PMH significant for tracheo-bronchomalacia, paradoxical vocal cord dysfunction, GERD, OSA, who presented with dyspnea. She was admitted to the MICU on [**2199-5-30**] and transferred to the general medicine service on [**2199-5-31**]. Her brief hospital course was notable for: . MICU course: . # Dyspnea/Stridor: Unclear precipitant, but patient with known tracheo-bronchomalacia s/p recent removal of Y stent and paradoxical vocal cord dysfunction. Stridor suggests focal vocal cord issue. The patient also has a great deal of anxiety at baseline that likely exacerbated her symptoms. The patient's symptoms improved after nebulizers, steroids, recemic epinephrine and benzodiazepines. The patient was placed on standing nebulizers, benzonatate and guafenesin and her steroids were discontinued. She was continued on her home maximal PPI therapy of fexofenadine, omeprazole and zantac. By hospital day 2, the patient's symptoms had improved to the point where she was stable for transfer to the floor. Unlikely to benefit significantly from steroids. Symptoms improved s/p nebulizers, steroids, racemic epi, and benzos. [**Month (only) 116**] be further exacerbated by underlying GERD, stress/anxiety, borderline pulmonary hypertension. No leukocytosis, fever, or radiographic evidence of pneumonia. Now breathing comfortably on 3L on NC with good oxygen saturations. . # Hypertension: Given blood pressures in the 90s-100s on admission, home antihypertensive medications which may have contributed to lightheadedness were held. This included amlodipine, metoprolol, furosemide, clonidine. . # Hyperlipidemia: Stable, continue home simvastatin. . # OSA: CPAP at night. . # Depression: Patient reportedly with moderate difficulty in coping with prolonged course of her illness. She was continued on her home sertraline and lorazepam. . Medicine wards course: . # Stridor: The Pt was noted to have 1-3 episodes of stridor per day, most of which resolved spontaneously. Those episodes which did not resolve spontaneously, resolved after doses of guiafensein and/or ativan. The Pt was seen by the IP and ENT service. The IP service felt that the Pt's presentation of paroxysmal stridor was not likely related to trancheobronchomalacia. She underwent bronchoscopy on [**2199-6-3**] and tolerated the procedure well. During the procedure the IP team noted findings consistent with paroxysmal vocal cord dysfunction. The ENT team felt that her symptoms were most likely related to paroxysmal vocal cord dysfunction and that she would benefit from speech therapy and execises. At the time of discharge she was set up with an appointment to be seen at the [**Hospital1 2025**] vocal cord dysfunction clinic on Thursday [**2199-6-4**]. . #Hypotension: Pt was initially hypotensive from 90s-100s while in the hospital. In this setting her home BP meds were held. She gradually became normotensive. At the time time of discharge her home doses of clonidine, lasix, and amlodipine were still stopped. She was instructed to stop these medications until being told to restart them by her PCP. [**Name10 (NameIs) **] was scheduled with her PCP [**Name Initial (PRE) 176**] 10 days of discharge. . All other chronic medical issues for this patient were stable and no further changes were made to her outpatient medication regimen other than those described above. She was discharged to home on [**2199-6-3**] in good condition with appropriate outpatient follow-up scheduled. Medications on Admission: 1. Ipratropium Bromide 0.02 % Solution INH Q6H 2. Amlodipine 5 mg Tablet PO DAILY 3. Metoprolol Succinate 100 mg Tablet SR 24 hr once a day 4. Furosemide 20 mg Tablet 0.5 Tablet PO DAILY 5. Clonidine 0.2 mg Tablet PO BID 6. Benzonatate 100 mg Capsule PO TID 7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk Inhalation [**Hospital1 **] 8. Fexofenadine 60 mg Tablet PO BID 9. Omeprazole 20 mg Capsule, Delayed Release PO BID 10. Simvastatin 10 mg Tablet PO DAILY 11. Guaifenesin 600 mg Tablet Sustained Release PO BID 12. Zantac 300 mg Tablet PO at bedtime. 14. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Inhalation Q 8H 16. Lorazepam 1 mg Tablet PO every four hours as needed for cough, feeling of severe shortness of breath Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 3. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for cough, dyspnea. 11. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: paroxysmal vocal cord dysfunction Secondary: tracheobronchomalacia, anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. vital signs stable, breathing comfortably on room air Discharge Instructions: You were admitted to the [**Hospital1 69**] on [**2199-5-30**] after you experienced shortness of breath and stridor. Your condition has improved and on [**2199-6-3**] you are being discharged to home in good condition, ambulatory, and with stable vital signs. It has been a pleasure participating in your medical care. . We have made the following changes to your home outpatient medication regimen: . STOP taking Furosemide 20 mg qD STOP taking Clonidine 0.2 mg PO BID STOP taking Amlodipine 5 mg qD . You will likely be able to restart these medications in the near future, but should wait to restart them until you are instructed to do so by your primary care doctor. [**First Name (Titles) **] [**Last Name (Titles) 84741**] are for high blood pressure and we have held them since your blood pressure was low, and then normal while you were in the hospital. Followup Instructions: An appointment has been made for you to be seen in a specialty clinic for vocal cord dysfunction. Your appointment is tomorrow Tuesday [**6-4**] at 9:30 AM, with Dr.[**Last Name (STitle) **]. His office is at 1 [**Hospital1 **] Square, at the intersection of [**Hospital1 8**] and New [**Location (un) **] Streets. The office phone # is [**Telephone/Fax (1) 84742**], feel free to call with any questions or concerns. . We have made an appointment to see your primary care doctor, Dr. [**Last Name (STitle) **] on Weds [**6-2**] at 3pm. Please call his office if you cannot make this appointment or need to reschedule.

[ "327.23", "786.1", "374.43", "272.4", "519.19", "478.4", "786.05", "478.5", "300.00" ]

icd9cm

[ [ [] ] ]

[ "33.22" ]

icd9pcs

[ [ [] ] ]

10926, 10932

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26901

Discharge summary

report

Admission Date: [**2167-4-10**] Discharge Date: [**2167-4-15**] Date of Birth: [**2110-5-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: airway monitoring Major Surgical or Invasive Procedure: none History of Present Illness: 56 y/o M admitted to [**Hospital6 **] for respiratory distress. He noted the onset of respiratory sx's ~6 months ago and weight loss, which lead to a laryngeal biopsy noting laryngeal ca dx [**2-25**]. Arrangements had been made to start chemo and XRT on [**4-15**] at [**Hospital1 789**] VA. . Prior to presentation, the patient was brushing the snow from his car when he became SOB and presented to [**Hospital3 46817**] with stridor. He also noted mildly increased cough with phlegm production, as well as 3-4 days of subjective chills. There a CT scan noted a large enhancing L paraglottic mass w/ an airway lumen of 3x6 mm with multiple metastatic nodes and question of esophageal extention. Pt was given combivent nebs and solumedrol 125 in the ED. A trach was then placed percutaneously, and the pt was transferred to [**Hospital1 18**] as no beds were available at [**Hospital1 789**] VA. Past Medical History: -Lanyngeal ca dx on larygeal bx, w/o h/o radiation or node dissection -s/p G-tub -h/o R thumb amputation [**9-/2161**] -HTN -h/o Lyme dx and babesiosis treated this past summer Social History: worked as a carpenter, stopped smoking 2 weeks ago Family History: sister w/ DM Physical Exam: VS:T=98.2, BP=114/62-141/71,HR=66-95, RR=13-22, O2=98-100% on 40%trach GEN: Pt thin appearing but in NAD HEENT: nonicteric, mucosa slightly dry, trach in good position; oropharynx difficult to visualize but no erythema CHEST: transmitted upper airway sounds but no wheezes, whales CV: distant HS, RRR ABD: scaphoid, soft, NT, ND, G-tube EXT: no LE edema; +clubbing SKIN: facial telangectasias Pertinent Results: CXR: The patient is status post tracheostomy. The tracheostomy tube appears to be in good position. The heart, mediastinal and hilar contours appear to be within normal limits. The pulmonary vascularity is normal. There is no evidence of CHF. Lung fields are grossly clear without evidence for pneumonia. IMPRESSION: No evidence of pneumonia. Status post tracheostomy. [**2167-4-10**] 10:27PM GLUCOSE-144* UREA N-13 CREAT-0.6 SODIUM-136 POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-29 ANION GAP-15 [**2167-4-10**] 10:27PM CALCIUM-9.1 PHOSPHATE-4.3 MAGNESIUM-1.8 [**2167-4-10**] 10:27PM WBC-21.1* RBC-3.86* HGB-12.3* HCT-36.0* MCV-93 MCH-31.8 MCHC-34.1 RDW-12.6 [**2167-4-10**] 10:27PM NEUTS-95.1* BANDS-0 LYMPHS-4.5* MONOS-0.3* EOS-0.1 BASOS-0 [**2167-4-10**] 10:27PM PLT COUNT-616* [**2167-4-10**] 10:27PM PT-13.0 PTT-26.7 INR(PT)-1.1 [**2167-4-14**] 6:00AM WBC-23.3 HCT-32.2 PLT COUNT-593 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [**2167-4-14**] 03:59PM NEG NEG NEG NEG NEG NEG NEG 8.0 NEG OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION EVALUATION: An oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with Radiology. Thin liquid, Nectar-thick liquid, honey thick liquid and pureed consistency barium were administered. Results follow: ORAL PHASE: Bolus control was within normal limits. He could form a bolus with liquids, but no ground or solid consistencies were tested. Premature spillover was seen. Mild tongue weakness was noted with difficulty transporting material from the front to the back of his mouth. PHARYNGEAL PHASE: There was a mild to moderate delay in initiation of the pharyngeal swallow. Once started, palatal elevation was normal. Laryngeal elevation was moderately to severely reduced. Epiglottic deflection was absent. Upper esophageal sphincter relaxation was also reduced. After the swallow, a moderate amount of residue remained in his pharynx. This mixed with secretions pooling in his throat, and spilled into the airway leading to aspiration after the swallow. ANTERIOR TO POSTERIOR POSITION: Vocal cord movement was reduced on the Left side. Pharyngeal contraction was better on the Right, and food and liquid tended to go down the right side. More residue remained on the right side, as there was no space in the valleculae or pyriform sinuses on the left due to the presence of the mass. ASPIRATION/PENETRATION: Aspiration occurred with all consistencies; thin liquid, nectar thick liquid, honey thick liquid and pudding. Aspiration occurred before the swallow due to premature spillover and swallow initiation delay; during the swallow due to reduced vocal cord closure, and after the swallow due to spillage of residue mixed with secretions into the airway. No cough was produced upon aspiration. A cued cough was effective in reducing but not in eliminating the aspiration. TREATMENT TECHNIQUES: His most functional swallow with the least amount of aspiration occurred when he swallowed with a chin tuck, used the swallow-cough-swallow technique, and alternated between one bite and one sip. Aspiration was reduced but not eliminated. SUMMARY: Mr. [**Known lastname **] aspirates all consistencies due to his laryngeal mass and the excess secretions in his oropharynx. We were able to reduce but not to eliminate the aspiration when he swallowed with a chin tuck, used the swallow-cough-swallow technique and alternated between bites of puree and sips of Nectar-thick liquid. RECOMMENDATIONS: 1. Remain strictly NPO for now with PEG feeds for nutrition, hydration and medications 2. Suggest medically treating his secretions to reduce them with something like a Scopolamine patch 3. Repeat videoswallow once his secretions have decreased to see if he might be able to take small amounts of nectar-thick liquids and pureed foods PO for pleasure using a chin tuck, swallow-cough-swallow and alternating consistencies These recommendations were shared with the patient, the nurse and the medical team. [**2167-4-12**] 10:19 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2167-4-12**]): <10 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH OROPHARYNGEAL FLORA. STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH. BEING ISOLATED FOR SENSITIVITIES. Brief Hospital Course: 1) RESPIRATORY FAILURE - pt appears to have extensive involvement of his tumor and had stridor upon presentation to OSH. He is much improved after trach placement, and is now comfortable with normal sats. CXR's show no PNA. -cont frequent suctioning. . 2) LEUKOCYTOSIS: unclear etiology. Initially was ascribed to steroid treatment at OSH, but WBC count has remained elevated for several days. Pt denies diarrhea. Sputum culture shows Strep Pnuemo colonization vs. tracheitis/PNA. -will treat for suspected respirtory infection for 7 days with ceftriaxone. . 3) LARYNGEAL CARCINOMA: -pt is due to start chemo/radiation at [**Hospital1 789**] VA on Wed, [**4-15**]. -Pt has received a bed at [**Hospital1 789**] VA and will transfer the patient to start recieving treatment . 4) TACHYCARDIA: Likely [**3-12**] slight volume depletion and low grade fevers. Responds to IVF. . 5) HTN - continue Lisinopril, monitor BP. . 6) FEN - continue TF's. Failed S&S video study. . 7) PPx - placed on SQ heparin, bowel regimen, taking TF's . 8) Access - PIV. Medications on Admission: Ibuprofen prn, 2 tabs at night Lantus 55U QAM Humalog ISS Actos 15mg QD Zetroretic (? antihypertensive) Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for sBP<100. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-9**] Puffs Inhalation Q6H (every 6 hours) as needed. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y (150) mg PO BID (2 times a day). 9. Acetaminophen 160 mg/5 mL Solution Sig: 325-650 mg PO Q4-6H (every 4 to 6 hours) as needed. 10. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 11. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours). Disp:*QS for 7 days * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 789**] VA Discharge Diagnosis: laryngeal cancer Discharge Condition: stable Discharge Instructions: Please continue to instruct pt with suctioning trach often. Please follow fever curve and monitor tachycardia. Followup Instructions: Please followup with your cancer doctors as previously [**Name5 (PTitle) 1988**] and get your chemotherapy and XRT. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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Discharge summary

report

Admission Date: [**2115-4-2**] Discharge Date: [**2115-4-30**] Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 2159**] Chief Complaint: Throat swelling Major Surgical or Invasive Procedure: Endotracheal intubation Placement of central venous catheter Placement of triple-lumen foley catheter History of Present Illness: 85 y.o. M with hx of HTN, AFib, GERD p/w with 1 wk hx of neck swelling, dyspagia of solids and liquids, felt to have supraglottitis, started on high dose steroids. He initially was started on steroids, but developed delirium and agitation, requiring intubation for airway protection. Steroids were weaned off. The cause of his supraglottitis was thought to be angioedema [**1-24**] ACE-I, however pt states that he has been taking his medicines for a long time. Pt extubated, but had worsening stridor, hypoxemia and reintubated electively. He then self-extubated on [**4-9**], but on [**4-12**] was found to be unresponsive, hypercarbic and in PEA arrest, and reintubated. Given atropine, epi and on pressors for 1 day. Pt finally extubated on [**4-16**], no respiratory problems since then. Otherwise MICU course complicated by rapid AF requiring IV lopressor, large amount of secretion, and sputum cx's with e.coli and pseudomonas, started on Zosyn on [**4-15**] for sinusitis by head CT on [**4-14**]. In addition, pt has required NGT for nutrition given concern for aspiration, however pulled out earlier today. Video swallow study earlier today showed some evidence of aspiration and assymetrical neck swelling. On further hx pt admits to preceding subjective fever, denies chills. Also admits to lots of rhinorrhea, nasal congestion. + sick contacts with grandchildren. He denies chills, diarrhea, cough, shortness of breath, urinary sx's, rash, recent medication changes. He is followed at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**] VA. He was born in [**Male First Name (un) 1056**], moved to US in [**2060**], unclear status of vaccinations. Past Medical History: chronic AFib-anticoagulation on coumadin s/p DCCV in 12/99 HTN Borderline CAD - cath [**11/2109**]- 2. Selective coronary angiography reveals a right dominant system with two vessel disease. The left main tapers distally to a 40% stenosis. There is ostial disease of all vessels at the trifurcation: LAD 60%, ramus 40-50%, LCX 50%. The RCA is small, but dominant, without focal stenosis. ?CAD -s/p IMI diabetes mellitus COPD BPH/Increased PSA Hypercholesterol OA- knees -Possible Osggod Schlatter right knee Syncope [**4-/2107**] - neg w/u (tilt, EP, DSE) GI bleed [**10-24**] -EGD: [**10-24**] - Single non-bleeding ulcer at antrum, single non- bleeding superficial ulcer in duodenum -Colonoscopy [**10-24**] - polyps (HP x 2, TA x 1) [**8-/2114**]- ext hemorrhoids Social History: 110 pack year smoking hx, quit 3 years ago, occais etoh. Lives alone, independent in all adl's Family History: NC Physical Exam: T 98.9 P 83 BP 128/47 RR 18 O2 96% RA, wt 88 kg complains of mild sob when flat Gen: no respiratory distress, no noticable gurgling, minimal drooling HEENT: EOMI, PERRLA, +trismus, erythema, difficult to visulize tonsills, swelling R>L LN: +submandibular lymph nodes right>L Lungs: CTA x 2 Heart: s1 s2 no m/r/g Abd: soft nt/nd +bs Ext: no c/c/e CN II-XII intact AOx3 Pertinent Results: [**4-2**] Neck CT: FINDINGS: A moderate amount of soft tissue swelling is seen within the peritonsillar region with no definite focal low-attenuation lesion to suggest abscess. A preponderance of soft tissue swelling is seen within the supraglottic region. No pathologically enlarged nodes are identified. Of note, significant amount of ossification is seen within the anterior cervical spine consistent with DISH. This region of ossification is displacing soft tissue anteriorly. IMPRESSION: 1. Soft tissue density within predominantly supraglottic region with no definite evidence peritonsillar abscess. 2. No evidence of lymphadenopathy. 3. DISH causing anterior soft tissue displacement of the pharynx. . [**4-3**] Head CT: FINDINGS: There is no evidence of intracranial bleed, mass effect, shift of normally midline structures. Within the left cerebellum, there is a focal area of low density, likely representing volume averaging. No major vascular territorial infarct is seen. No evidence of hydrocephalus. Small air-fluid levels are seen within the sphenoid sinuses and mucosal thickening is present within the ethmoid sinuses. The maxillary sinuses and ethmoid air cells are clear. IMPRESSION: No evidence of intracranial hemorrhage. Sinusitis . [**4-14**] Sinus CT: NON-CONTRAST SINUS CT: Mucosal thickening is seen in the right maxillary sinus. Minor mucosal thickening is seen in the ethmoid air cells. Both sphenoid sinuses show air fluid levels and mucosal thickening. There is scattered opacification of the mastoid air cells. No bony destruction is seen. The patient has a smallbore nasogastric feeding tube. A tiny focus of air is seen between the dens and the anterior ring of C1; the atlantoaxial interval is still within normal limits. The right ostiomeatal unit is not patent, although the left is. The nasal septum deviates to the right of midline. Anterior clinoid processes are not pneumatized. The sphenoid sinus septum inserts roughly on the midline. IMPRESSION: Sinusitis, slightly worse compared to the CT scan of [**2115-4-7**]. . [**4-22**] Neck CT FINDINGS: The patient is status post extubation. Previously noted lobulated soft tissue swelling in the supraglottic region is not identified in the present scan. Oropharynx and hypopharynx are patent and symmetric. No significant lymphadenopathy. Note is made of cervical spondylosis, as noted previously. The visualized portions of the lung apices are clear. No suspicious lytic or blastic lesions. IMPRESSION: Previously noted supraglottic soft tissue swelling is not identified. Cervical spondylosis. . TTE: MEASUREMENTS: Left Atrium - Long Axis Dimension: *6.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *6.4 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *6.5 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: 4.8 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%) Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm) Aorta - Ascending: *3.6 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.4 m/sec Mitral Valve - E Wave Deceleration Time: 132 msec TR Gradient (+ RA = PASP): *40 mm Hg (nl <= 25 mm Hg) Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s) Conclusions: The left atrium is markedly dilated. The right atrium is moderately dilated. The inferior vena cava is dilated (>2.5 cm). There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular systolic function is normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-24**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. . [**2115-4-2**] 02:00AM BLOOD WBC-11.5* RBC-4.60 Hgb-13.4* Hct-39.9* MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 Plt Ct-223 [**2115-4-6**] 01:30AM BLOOD WBC-12.0* RBC-4.47* Hgb-12.8* Hct-38.7* MCV-87 MCH-28.6 MCHC-33.0 RDW-15.3 Plt Ct-196 [**2115-4-13**] 04:11AM BLOOD WBC-11.9* RBC-3.58* Hgb-10.5* Hct-31.5* MCV-88 MCH-29.4 MCHC-33.5 RDW-16.3* Plt Ct-240 [**2115-4-24**] 05:20AM BLOOD WBC-10.0 RBC-3.08* Hgb-9.4* Hct-28.4* MCV-92 MCH-30.4 MCHC-33.0 RDW-19.2* Plt Ct-381 [**2115-4-2**] 02:00AM BLOOD Neuts-87.1* Lymphs-8.1* Monos-4.4 Eos-0.3 Baso-0.1 [**2115-4-7**] 02:30AM BLOOD Neuts-87.3* Lymphs-7.7* Monos-4.0 Eos-0.5 Baso-0.4 [**2115-4-14**] 04:30AM BLOOD Neuts-87.9* Lymphs-8.3* Monos-3.1 Eos-0.5 Baso-0.1 [**2115-4-2**] 03:20AM BLOOD PT-34.4* PTT-31.9 INR(PT)-3.7* [**2115-4-4**] 01:35PM BLOOD PT-68.8* PTT-36.2* INR(PT)-8.8* [**2115-4-5**] 03:00AM BLOOD PT-24.8* PTT-29.2 INR(PT)-2.5* [**2115-4-24**] 05:20AM BLOOD PT-12.8 PTT-29.0 INR(PT)-1.1 [**2115-4-2**] 02:00AM BLOOD Glucose-154* UreaN-16 Creat-0.9 Na-137 K-3.5 Cl-100 HCO3-26 AnGap-15 [**2115-4-6**] 01:30AM BLOOD Glucose-148* UreaN-21* Creat-0.9 Na-143 K-3.4 Cl-108 HCO3-25 AnGap-13 [**2115-4-13**] 04:11AM BLOOD Glucose-161* UreaN-31* Creat-2.0* Na-150* K-3.6 Cl-116* HCO3-25 AnGap-13 [**2115-4-24**] 05:20AM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-143 K-4.2 Cl-109* HCO3-22 AnGap-16 [**2115-4-3**] 10:00PM BLOOD ALT-22 AST-57* CK(CPK)-3122* AlkPhos-69 Amylase-338* TotBili-0.7 [**2115-4-5**] 03:00AM BLOOD ALT-25 AST-48* CK(CPK)-1270* AlkPhos-65 Amylase-384* TotBili-0.7 [**2115-4-19**] 05:00AM BLOOD ALT-23 AST-28 AlkPhos-68 TotBili-1.4 [**2115-4-13**] 04:11AM BLOOD CK(CPK)-69 [**2115-4-3**] 03:06AM BLOOD Lipase-23 [**2115-4-5**] 03:00AM BLOOD Lipase-21 [**2115-4-2**] 02:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2115-4-3**] 10:00PM BLOOD CK-MB-13* MB Indx-0.4 cTropnT-0.04* [**2115-4-4**] 03:04AM BLOOD CK-MB-13* MB Indx-0.5 cTropnT-0.03* [**2115-4-12**] 01:25PM BLOOD CK-MB-6 cTropnT-0.01 [**2115-4-2**] 05:55AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.6 [**2115-4-19**] 05:00AM BLOOD calTIBC-192* TRF-148* [**2115-4-3**] 03:06AM BLOOD VitB12-337 Folate-7.9 [**2115-4-3**] 03:06AM BLOOD TSH-0.25* [**2115-4-4**] 03:04AM BLOOD Free T4-1.2 [**2115-4-5**] 03:00AM BLOOD C4-18 [**2115-4-24**] 05:20AM BLOOD C4-24 [**2115-4-2**] 02:00AM BLOOD Digoxin-0.5* [**2115-4-2**] 02:10AM BLOOD Lactate-1.7 Urine Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks LG NEG TR NEG TR NEG NEG 5.0 TR RBC WBC Bacteri Yeast Epi TransE RenalEp >50 [**6-1**]* FEW NONE 0-2 CYTOLOGY ATYPICAL. Rare atypical urothelial cells present singly and in loose clusters. Squamous cells, histiocytes, neutrophils and red blood cells. Micro: Blood cultures 4/11, [**4-11**], [**4-12**]: No growth. Blood culture [**4-14**]: Presumptive PROPIONIBACTERIUM ACNES [**12-26**] bottles [**4-2**]: Monospot negative [**4-2**] Throat Culture: Beta-hemolytic, non group-A strep, sparse growth [**4-2**]: Respiratory virus screen negative on nasopharyngeal aspirate [**4-3**] Urine culture negative [**4-7**] Sputum: No growth [**4-11**] Sputum: ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S 16 I CEFTAZIDIME----------- <=1 S =>64 R CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- 0.5 S =>4 R GENTAMICIN------------ <=1 S 4 S IMIPENEM-------------- <=1 S I LEVOFLOXACIN---------- 1 S MEROPENEM-------------<=0.25 S 8 I PIPERACILLIN---------- =>128 R =>128 R PIPERACILLIN/TAZO----- <=4 S 64 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R . [**4-11**] Stool: C. diff negative [**4-14**] RPR nonreactive [**4-14**] Sputum: E. Coli and P. aeruginosa . [**4-18**] Video Swallow: VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oral and pharyngeal video fluoroscopy swallowing study was performed in collaboration with the Speech and Language Pathology division. Various consistencies of barium including thin liquid, nectar-thickened liquid and puree consistencies were administered. A single spot fluoroscopic image again demonstrates ossification of the anterior longitudinal ligament of the cervical spine, which is unchanged from recent neck CTs on [**4-2**] and [**4-7**], [**2114**]. The oral phase of the study was notable for mild impairment of bolus formation and control without premature spillover. The pharyngeal phase was notable for moderate-to-severely impaired laryngeal elevation and valve closure. There was absent epiglottic deflection. Following swallow, mild residue remained in the pharynx and spilled into the airway after the swallow. In the AP position, bilateral vocal fold adduction was observed. Left pharyngeal swelling was noted with the left piriform sinus nearly completely effaced. There was penetration into the laryngeal vestibule with all consistencies before and after swallowing. There was aspiration of small amounts of all consistencies following the swallow due to spillage of material from the laryngeal vestibule and piriform sinuses. There was a spontaneous cough upon aspiration. IMPRESSION: Moderate pharyngeal dysphagia with aspiration of small amounts of all consistencies after the swallow. A combination of left pharyngeal swelling and chronic ossification of the anterior longitudinal spinal ligament contributes to the swallowing difficulty. . [**4-22**] Video Swallow: An oral and pharyngeal swallowing videofluoroscopy was performed today in collaboration with the speech and language pathology division. Various consistencies of barium including thin liquid, nectar-thickened liquid, puree, and ground cookies and pudding were administered. The oral phase was notable for mildly impaired bolus formation control and anterior to posterior tongue movement. There was premature spillover of thin and nectar-thickened liquids into the pharynx prior to initiation of the swallow. The pharyngeal phase was notable for mild delay in the pharyngeal swallow. There was moderate-to-severe impairment of laryngeal elevation and valve closure. Epiglottic deflection was not demonstrated. Mild-to-moderate amounts of puree and ground consistencies were retained in the valleculae to a greater extent than in the piriform sinuses. In the anterior to posterior position swelling of the left pharynx was again demonstrated, but improved compared to prior study last week. There was penetration of thin and nectar-thickened liquids into the laryngeal vestibule before and during the swallow. There was aspiration of thin and nectar-thickened liquids before and after the swallow. There was a spontaneous cough upon aspiration. IMPRESSION: Overall improved oropharyngeal swallowing function compared to [**2115-4-18**] but continued aspiration of thin and nectar-thickened liquids before and after the swallow. Improvement in left pharyngeal swelling. Brief Hospital Course: # s/p PEA arrest - unclear etiology. Likely secondary to hypoxia, hypercarbic respiratory acidosis, copious secretions. Became temporarily hypotensive on pressors with CEs negative. Pressors quickly weaned without difficulty. Treated with aggressive suctioning, albuterol/atrovent/flovent. . # Supraglottitis - Treated initially with Unasyn. Resolved over span of [**10-5**] days. Etiology remains unclear. Throat culture grew sparse B-hemolytic, non-Group-A strep. EBV, blood cultures, nasopharyngeal aspirate for respiratory viruses all negative. Possibly angioedema secondary to ACEI, which was immediately d/c'ed on admission. On [**4-3**], pt became acutely agitated, thought to be [**1-24**] steroid psychosis. Intubated for airway protection in setting of increased need for sedation. Patient extubated uneventfully on [**4-5**]. D/c'd Unasyn and Decadron on [**4-5**] as unclear that these interventions were adding any benefit. ENT re-eval on [**4-6**] without signs of edema. On [**4-6**], again became increasingly stridorous, acidotic, hypoxic after ativan/haldol for agitation and re-intubated. Self-extubated on [**4-9**]. Reintubated after PEA arrest, as above. Serial neck CTs demonstrated gradual resolution of soft tissue edema, but did demonstrate diffuse ossification of the anterior longitudinal ligament, which likely limits functional reserve, predisposing Mr. [**Known lastname 66593**] to respiratory distress with small amount of soft tissue swelling. Speech and swallow evaluation from [**4-7**] and [**4-18**] demonstrated evidence of aspiration, and Mr. [**Known lastname 66593**] was kept NPO with NGT in place. As mental status cleared, repeat S&S evaluation done on [**4-23**], which demonstrated improvement. Was placed back on carefully observed PO diet, with repeated teaching regarding safe PO intake. On [**4-23**], consulted Allergy, who thought it would be safe to restart low-dose [**Last Name (un) **], as a) possible infectious etiology, and b) relatively small cross-over effect in likelihood between ACEI and [**Last Name (un) **]. Experienced episode of relative hypotension to SBP 80 after two doses [**Last Name (un) **], and was d/c'ed prior to d/c. However, did not experience any resporatory compromise; therefore, should ACEI/[**Last Name (un) **] become important to Mr. [**Doctor Last Name 66594**] future medical management, it should be reasonably safe. . # Delirium/Psychosis: Probable ICU psychosis vs. steroid psychosis. Also with positive sputum cultures and leukocytosis, possible constributing infection component. Received high doses Haldol in ICU, QTc remained stable. Head CT neg [**4-3**], [**4-7**], [**4-14**]. Psychiatry followed and left recommendations regarding sedating meds for agitation. Mental status improved around [**4-22**], scheduled Haldol d/c'ed, with continued options for prn Haldol and Seroquel. . # CAD: H/o IMI. Cath [**2108**] with 2VD - LAD 60%, LCX 50%. PMIBI at VA [**11-26**] without ischemic changes. CE neative after PEA arrest. Maintained on ASA, titrated up BB, reinstituted [**Last Name (un) **] on [**4-23**], but d/c'ed after episode of hypotension to SBP 80. . # HTN- Home regimen includes fosinopril, atenolol, hctz, terazosin, nifedipine. Held antihypertensives given hypotension in ICU. Also experienced episode of relative hypotension to 80/palp on [**4-25**] after reintroduction of [**Last Name (un) **] to regimen of metoprolol, terazosin, and [**Last Name (un) **] d/c'ed. . # Afib- remains in chronic A fib. Held coumadin in setting of supratherapeutic INR, held lopressor/dilt/digoxin in acute setting. Achieved rate control once reintroducing metoprolol. Restarted coumadin [**4-26**]. Will need to have INR monitored and coumadin adjusted to goal INR [**1-25**]. . # Urinary retention/hematuria - Experienced gross hematuria, initially in setting of supratherapeutic INR. Experienced concommitant urinary retention, likely [**1-24**] to clots. Had 24 french 3 way catheter with continuous bladder irrigation in ICU, d/c'd [**4-12**] as urine cleared. Gross hematuria returned once called out to floor, with persistent clots despite flushing and changing foley. Reinstituted 3-way CBI, with urology consultation. Urine cytology demonstrated atypical cells. Will need close f/u by urology for outpatient cystoscopy for possible bladder CA. He will need to renew his application for Freecare before an outpatient appointment can be made. . # FEN - While NPO, fed via Dobhoff w/ TF's - Promote with fiber, free water flushes. After POs reinstituted, maintained on pureed solids, nectar-thick liquids, with closely observed feeding. Aspiration precautions instituted. #Code- Full Code Medications on Admission: 1) ALBUTEROL 90/IPRATROP 18MCG 200D PO INHL INHALE 2 ACTIVE PUFFS BY MOUTH FOUR TIMES A DAY 2) ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY 3) ATENOLOL 100MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE (S) 4) CAPSAICIN 0.075% CREAM APPLY THIN FILM TO SKIN TWICE ACTIVE A DAY FOR LOCALIZED PAIN 5) CODEINE 30MG/ACETAMINOPHEN300MG TAB TAKE 1 TABLET BY ACTIVE MOUTH THREE TIMES A DAY FOR PAIN 6) DIGOXIN (LANOXIN) 0.125MG TAB TAKE ONE TABLET BY ACTIVE MOUTH EVERY DAY 7) DOCUSATE NA 100MG CAP TAKE ONE CAPSULE BY MOUTH TWICE ACTIVE A DAY TO SOFTEN STOOL 8) FOSINOPRIL NA 20MG TAB TAKE TWO TABLETS BY MOUTH ACTIVE EVERY MORNING AND TAKE ONE TABLET EVERY EVENING INCREASE IN DOSE [**2113-6-27**] 9) HYDROCHLOROTHIAZIDE 25MG TAB TAKE ONE TABLET BY MOUTH ACTIVE EVERY DAY 10) MENTHOL 10%/METHYL SALICYLATE 15% CREAM APPLY ACTIVE MODERATE AMOUNT TO SKIN EVERY DAY AS NEEDED FOR KNEE ARTHRITIS 11) NIFEDIPINE (ADALAT CC) 30MG SA TAB TAKE (DO NOT ACTIVE CRUSH) ONE TABLET BY MOUTH EVERY DAY FOR HEART 12) OMEPRAZOLE 20MG SA CAP TAKE ONE CAPSULE BY MOUTH ACTIVE EVERY MORNING 30 MINUTES BEFORE BREAKFAST (REPLACES RABEPRAZOLE) 13) PSYLLIUM SF ORAL PWD TAKE 1 TABLESPOONFUL BY MOUTH ACTIVE EVERY DAY (DISSOLVE IN 8OZ WATER/JUICE BEFORE DRINKING) 14) SIMVASTATIN 80MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE BEDTIME FOR REDUCING CHOLESTEROL 15) TERAZOSIN HCL 5MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE BEDTIME 16) WARFARIN (COUMADIN) NA 2MG TAB TAKE ONE AND ONE-HALF ACTIVE TABLETS BY MOUTH EVERY EVENING EXCEPT TAKE TWO TABLETS EVERY MONDAY TO PREVENT BLOOD CLOTS(ANTICOAGULATION) Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. Disp:*30 Suppository(s)* Refills:*2* 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*2* 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime): Restarted coumadin [**4-26**] - will need INR checked [**5-2**]. Disp:*120 Tablet(s)* Refills:*2* 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation prn as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*2* 9. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. Disp:*1 inhaler* Refills:*2* 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO once a day. Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Supraglottitis Hematuria Discharge Condition: Stable Discharge Instructions: You were admitted with supraglottitis, and were intubated in the ICU. Your swelling has resolved. You were also treated for blood in your urine, and it is very important that you follow up with urology. . You also need to have your coumadin level checked on Thursday, [**5-2**]. Followup Instructions: It is important that you follow up at urology clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]. You will need to finalize your Freecare renewal before an appointment can be made, but when this is done, you should call [**Telephone/Fax (1) 5727**] for an appointment. . If you have trouble arranging urology follow-up with Dr. [**Last Name (STitle) 770**], you should try to arrange this through the [**Location 1268**] system.

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icd9cm

[ [ [] ] ]

[ "38.93", "96.49", "96.72", "96.6", "57.95", "96.07", "96.71", "57.94", "96.04", "31.42" ]

icd9pcs

[ [ [] ] ]

22958, 23016

14987, 19691

237, 341

23085, 23094

3387, 4106

23421, 23887

2979, 2983

21335, 22935

23037, 23064

19717, 21312

23118, 23398

2998, 3368

182, 199

369, 2059

4115, 14964

2081, 2850

2866, 2963

48,370

138,534

38223

Discharge summary

report

Admission Date: [**2118-5-12**] Discharge Date: [**2118-5-14**] Date of Birth: [**2045-2-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 2387**] Chief Complaint: s/p seizure Major Surgical or Invasive Procedure: [**5-13**]- balloon to [**Female First Name (un) 899**] History of Present Illness: This is a 73 y.o. with a history of ischemic bowel s/p limited R sided colonic resection [**2-9**] ([**Hospital6 5016**]) with a ileo transverse primary anastamosis, this course was complicated c/b UTI, sepsis, and C.diff initally RX with flagyl and changed to PO vancomycin secondary to possible bone marrow suppression. The patient was eventually discharged home from the hospital but then due to falls at home she was readmitted to [**Hospital3 19345**]. She was found to be anemic at LGH with a hct of 25, she was noted to not have a GI bleed and was transfused and hct stabilized, there was not a reason found for her anemia. She has since apparently been very weak with a poor appetite since her initial hospitalization. The patient was transferred from LGH to NEBH at her daughter's request. She was noted to have recurrent abdominal pain which was deemed to be related to a small bowel obstruction based on a CT scan. She also had some evidence of colitis on CT scan and was started on levo/flagyl. She underwent a colonoscopy without any evidence of C diff but did note evidence of chronic mesenteric ischemia based on a long stricture with a diameter of 8mm and multiple ischemia related ulcerations. The patient then underwernt an MRA of her abdomen which revealed [**Female First Name (un) 899**] occlusion / high grade stenosis. The plan was to have her undergo colonic resection but her albmuin was 1.5 and temporizing measures (colonic stenting and plan for [**Female First Name (un) 899**] stenting) were undertaken in order to allow her to improve her nutritional status and undergo surgery in [**3-3**] weeks. The patient was coming out of the elevator with EMS and while on the stretcher was noted to become unresponsive, her eyes rolled back and she had rhythmic face movements. She also became apenic and required bag mask ventilation for 3-5 minutes. A code Blue was called but she had a pulse (HR 70, SBP 100) throughout the event. She rec'd no medications. She then awoke and had some confusion lasting 30+ minutes. Currently the patient is AOx3 but very lethargic and seems slightly confused still. She is occasionally falling asleep while speaking. She denies any chest pain, abd pain, nausea, vomiting, SOB or any other symptoms. Past Medical History: Bilateral carotid disease with R CEA, hypertension left sublcavian stenosis malrotation of the small intestine hiatal hernia hyperlipidemia aortic insuffieceincey mitral regurgitation tricuspid regurgitation ischemic bowel s/p recection [**2-9**] UTI's. Social History: lives w/ partner x 21 years, smokes 1 cigarette daily and 2 glasses of wine per week. Daughter, [**Name (NI) **] involved in her care. Family History: NC Physical Exam: VS - T 96.8 HR 78 RR 18 BP 117/61 99% on 2L NC Gen: NAD, AOx3 (person, hospital (NEBH), [**2118-4-30**], spring) HEENT: MM dry, OP clear, JVP not elevated, conjunctiva pink, sclera anicteric CV: RRR, 2/6 SEM at the USB Chest: CTAB anteriorly Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. WWP. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: See below. OSH DATA:Labs: [**5-11**]/ mag 1.0 (400mg po x 1 and 2gm) recheck later on, WBC 5.7, HGB 12.4, HCT 36.2, PLT 192, INR - none, NA 139, K 4.0, CL 103, CO2 24, GLU 87, BUN 4, CR 0.6, CAL 7.4, MAG 1.0 Radiology Results: [**5-9**] Abdominal MRI: diffuse disease, renal artery stenosis, and high grade disease of mesenteric artery. EEG [**2118-5-12**]: FINDINGS: ABNORMALITY #1: There were several brief isolated sharp waves in the left temporal region, centering at about the T1 electrode. This did not include simple spike or sharp and slow wave complexes. There was a single similar sharp wave in the right anterior temporal region. BACKGROUND: Included a well-formed 9 Hz alpha frequency in posterior areas bilaterally during wakefulness. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Produced no activation of the record. SLEEP: The patient appeared to remain awake or minimally drowsy throughout the recording. No stage II sleep was obtained. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal portable EEG due to the focal sharp waves in the left anterior quadrant, particularly in the left anterior temporal region. There was also a single similar sharp wave on the right. Nevertheless, there were no spike or sharp and slow wave complexes. The finding indicates an area of cortical hypersynchrony and could be related to the clinical report of seizure. There was no prominent focal slowing in the same area or elsewhere. MRI [**2118-5-13**]: 1. Focal hyperintensity overlying the left parietal lobe may represent slow flow in a cortical vein, although a focal area of cortical vein thrombosis cannot be excluded. The adjacent brain parenchyma is normal in appearance, without evidence of a venous infarct. 2. There is no acute infarct, hemorrhage or mass lesion. 3. Extensive areas of white matter signal abnormality, as detailed above, which are a nonspecific finding, but likely represent the sequela of chronic microangiopathy given the patient's age. CARDIAC CATH [**2118-5-13**]: final report pending, had balloon to [**Female First Name (un) 899**] Brief Hospital Course: 73 yo female w/ PVD and ischemic colitis s/p colonic partial resection [**2-9**]- course complicated by C diff, uti, sepsis, with recurrent abdominal pain which was likely caused by mesenteric ischemia, sent from OSH for [**Female First Name (un) 899**] angioplasty, course complicated by seizure. 1. SEIZURE- Patient Most likely etiology of pt's seizure was severe metabolic derrangement from hypokalemia and hypomagnesemia. Her electrolytes were repleted and carefully monitored during her hospital course. She has no family or personal history of seizures in the past. She was evaluated by the Neurology service who recommended 20min EEG, which showed left anterior and right mid-temporal foci of activity. She also underwent MRI of her brain which revealed no acute infarct, hemorrhage or mass lesion. She had did have extensive areas of nonspecific white matter signal abnormality which could be the sequela of chronic microangiopathy given her age. She was loaded with 1000mg IV Keppra and then transitioned to a PO Keppra regimen. Her mental status improved on [**5-13**] and she became much more coherent and interactive. Neurology decided 24h EEG was not necessary. However, following her [**Female First Name (un) 899**] balloon angioplasty, she became more agitated and aggressive, refusing blood draws and becoming verbally abusive with the nursing staff. Unclear if this was secondary to benzodiazepenes administered during procedure vs. keppra, but keppra was continued on discharge. Could consider vitamin B6 supplementation and holding keppra for now vs. initiation of dilantin although this would require closer monitoring given pt's numerous vascular complications. 2. MESENTERIC [**Name (NI) **] pt was transferred from [**Hospital1 **] for restoration of blood flow through her inferior mesenteric artery with Dr. [**Last Name (STitle) **]. Pt tolerated the procedure without complication, high-dose aspirin was continued in house. Pt's IV levofloxacin and flagyl were discontinued per her outpt GI doctor, Dr. [**Last Name (STitle) **]. This could have also been contributing to her QT prolongation, which resolved by the time of discharge. Her plan was to be transferred to [**Hospital6 **] for further nutritional support prior to planned subtotal vs total colectomy. Medications on Admission: Colace [**Hospital1 **] Ecotrin 81mg daily IV levaquin 500mg daily Flagyl 500mg IV q 8 hours IV protonix 40mg daily Atenelol 50mg po daily. Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Discharge Disposition: Extended Care Discharge Diagnosis: PRIMARY: mesenteric ischemia, seizures Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital to have a blood vessel that supplies the major parts of your bowel opened up. You were having abdominal discomfort. You also had a seizure which was likely caused by having an imbalance of chemicals in your blood, such as low potassium and magnesium. We repleted these chemicals and also started you on anti-seizure medication. You were also seen by our neurology team and had some tests and imaging (MRI) which did not show any acute seizure or stroke. Your medications have CHANGED as follows: 1. INCREASED Aspirin 81mg to 325mg daily 2. ADDED Keppra- take 500mg twice per day for the next 2 days (end [**5-16**]). Then take 750mg twice per day for the next 3 days ([**Date range (1) 61876**]). After that, take 1000mg twice per day thereafter. Please follow-up with your outpatient neurologist to titrate this medication. It was started to help prevent seizures. 3. We DISCONTINUED your antibiotics (IV levofloxacin and IV flagyl) after speaking with your GI doctor, Dr. [**Last Name (STitle) **] Followup Instructions: Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 84113**] Follow up with your outpatient neurologist Follow up with Dr. [**Last Name (STitle) **] your gastroenterologist Follow up with Dr [**Last Name (STitle) **] your cardiologist You will be transferred to the NEBH.

[ "440.0", "440.1", "557.1", "780.39", "440.21" ]

icd9cm

[ [ [] ] ]

[ "39.50", "00.40" ]

icd9pcs

[ [ [] ] ]

8590, 8605

5743, 8040

323, 381

8688, 8688

3591, 5720

9934, 10247

3129, 3133

8230, 8567

8626, 8667

8066, 8207

8873, 9911

3148, 3572

272, 285

409, 2684

8703, 8849

2706, 2961

2977, 3113

29,625

189,154

946

Discharge summary

report

Admission Date: [**2137-8-1**] Discharge Date: [**2137-8-11**] Date of Birth: [**2063-4-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: Reccurent Rectal Cancer Major Surgical or Invasive Procedure: Abdominoperineal resection, cystectomy, Radical prostatectomy, ileal conduit, bilateral gracilis flaps. History of Present Illness: Mr. [**Known lastname 6314**] is a 74-year-old male with a history of T1 rectal cancer in [**2132**] s/p transanal resection without adjuvant chemoradiation at that time. He was followed with imaging and colonnoscopy and was diagnosed with recurrent rectal cancer in [**2-1**] upon work-up for change in bowel habits x 6-7 months with an increase in gas and rectal pain. On ultrasound [**1-1**], pt noted to have a 3 x 2.5 cm infiltrative mass in the left side of the rectal mucosa, extending from approximately 8 cm down towards the anal verge and breaching through the muscularis mucosa into the perirectal soft tissues. On PET there was FDG-avid asymmetric rectal thickening and perirectal soft tissue nodules. Cytology [**2137-2-21**] positive for malignant cells. Mr. [**Known lastname 6314**] [**Last Name (Titles) 1834**] concurrent chemoradiation [**Date range (1) 6315**] and now presents to the surgical team for resection. Past Medical History: Hypertension. High cholesterol controlled on medication Asthma, no longer needs medication frequently. GERD. not currently a problem TIA [**2132-11-24**]. On plavix except around biopsies Hernia repair. Nasal polypectomy. Hematuria. s/p urologic work-up about 1 month ago. Colonoscopies with polyps. Likely familial hypercholesterolemia syndrome Social History: Started smoking at age 9, quit in [**2127**]: 135-pack-year history. Hx of social alcohol use. Two sons in their 20s. Brother is a famous pediatrician. Lebanese origin. Born in the USA. Family History: Familial hypercholesterolemia syndrome Physical Exam: At Discharge: Vitals: T99.2 HR 88 Bp 120/52 RR18 97% on ra. GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB, no w/r/r ABD: +BS, soft, ND, appropriately TTP Incision: C/D/i incision at abdominal surgical site as well as b/l medial thighs.Jp drains in place at b/l thighs. Extrem: B/L pedal edema Pertinent Results: INTRA-OPERATIVE ULTRASOUND- no evidence of liver metastasis, mulitple cysts. . Pathology Report---[**2137-8-1**] DIAGNOSIS: I. Bladder, prostate gland, and rectosigmoid colon (A-Z): 1. Residual adenocarcinoma in three of eight regional lymph nodes ([**3-2**]); associated extensive fibrosis and calcification. 2. Marked fibrotic change with admixed single atypical gland, likely carcinoma (peritoneal nodule) 3. Chronic active colitis with ulceration, extensive submucosal fibrosis; no evidence of residual carcinoma; changes consistent with radiation effect. 4. Colonic proximal margin unremarkable. 5. Squamous mucosa of anal resection with fibrosis and chronic inflammation. 6. Bladder, prostate and seminal vesicles, no malignancy identified. II. Right pelvic sidewall implant (AA-AB): Fibroadipose tissue with foreign body giant cell reaction (likely suture); no carcinoma seen. III. Right pelvic brim implant (AC-AF): Fibrous and adipose tissue with foreign body giant cell reaction (likely suture); no carcinoma seen. Clinical: Rectal cancer. . [**2137-8-5**] 04:35AM BLOOD WBC-9.3 RBC-3.36* Hgb-10.3* Hct-30.2* MCV-90 MCH-30.7 MCHC-34.1 RDW-14.1 Plt Ct-189 [**2137-8-2**] 05:37AM BLOOD WBC-11.3* RBC-2.94*# Hgb-9.4* Hct-26.4* MCV-90 MCH-32.1* MCHC-35.7* RDW-13.7 Plt Ct-187 [**2137-8-1**] 08:02PM BLOOD WBC-13.3*# RBC-3.93* Hgb-12.1* Hct-35.6* MCV-91 MCH-30.8 MCHC-34.0 RDW-13.4 Plt Ct-237 [**2137-8-4**] 04:19AM BLOOD PT-13.9* PTT-30.0 INR(PT)-1.2* [**2137-8-3**] 05:41AM BLOOD PT-14.4* PTT-31.6 INR(PT)-1.3* [**2137-8-6**] 05:09AM BLOOD Glucose-118* UreaN-20 Creat-0.9 Na-140 K-3.2* Cl-106 HCO3-27 AnGap-10 [**2137-8-5**] 04:35AM BLOOD Glucose-73 UreaN-26* Creat-1.1 Na-142 K-3.8 Cl-108 HCO3-23 AnGap-15 [**2137-8-4**] 04:19AM BLOOD Glucose-83 UreaN-21* Creat-1.3* Na-138 K-4.0 Cl-107 HCO3-24 AnGap-11 [**2137-8-4**] 04:19AM BLOOD ALT-7 AST-24 LD(LDH)-180 AlkPhos-44 TotBili-0.6 [**2137-8-3**] 05:41AM BLOOD ALT-6 AST-23 LD(LDH)-169 AlkPhos-44 TotBili-0.9 [**2137-8-6**] 05:09AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.7 [**2137-8-5**] 04:35AM BLOOD Calcium-7.9* Phos-3.3 Mg-2.0 [**2137-8-3**] 05:41AM BLOOD Albumin-2.6* Calcium-7.9* Phos-2.4* Mg-2.5 [**2137-8-1**] 05:59PM BLOOD freeCa-1.10* [**2137-8-7**] 06:41AM BLOOD WBC-9.8 RBC-3.41* Hgb-10.5* Hct-30.7* MCV-90 MCH-30.7 MCHC-34.0 RDW-14.1 Plt Ct-301# [**2137-8-9**] 05:30AM BLOOD Glucose-114* UreaN-23* Creat-1.0 Na-142 K-3.7 Cl-111* HCO3-25 AnGap-10 [**2137-8-9**] 05:30AM BLOOD Calcium-7.5* Phos-2.8 Mg-2.0 Brief Hospital Course: [**8-1**] Pt [**Month/Day (4) 1834**] [**Month (only) **], cystectomy, RP, ileal conduit, bilateral gracilis flaps. Post operatively pt remained electivley intubated and was transferred to the ICU where he remianed NPO, IVF with PRN boluses.Neosynephrine was titrated to keep MAP >65. Epidural was placed in conjunction with PCA to aid in pain contol. NGT to LWS.Tight glycemic control, TID HCT. Famotidine was started for Gi porphylaxis. . [**8-2**] Neosynephrine weaned off. Pt hemodynamically stable. PT extubated . Toradol added to epidural for better pain relief. NGT dc'd. Pt allowed ice chips. Pt transfused 1 Unit PRBCfor HCt of 23.4. . [**8-3**]: Pt required increased FIO2 after fluid resuscitation. Lasix 20 mg started with good diueresis. PT consult placed. Pt transitioned from PCa to IV dilaudid. Epidural remianed in placed. Neosynephrine briefly restarted for SBP in the 80s after pain medication administration and then dcd again once pressures were >110/50s. . [**8-4**]: Pt had improved oxygenation with diueresis. Transferred to floor. Cxr showed mild pulmonary congestion. . [**8-5**]- [**8-6**]: Diet advanced to clear liquids for breakfast, tolerated well. Medications converted to all PO's. Restarted on most home medications. Epidural removed per Acute pain service. Pain well controlled with oral medication. Flatus and stool production noted in ostomy. Diet advanced to regular food for dinner. Tolerated well. Continued to work with Physical Therapy. Steady on feet, but deconditioned. Continues to benefit from [**Hospital 3058**] rehab. Awaiting bed availability. Plan to discharge to Rehab on [**2137-8-7**]. . [**8-7**]: Developed Nausea, vomiting, and abdominal distention. Ostomy continues to function, but decreased amount. NGT inserted with over 1 liter of thick, bilious output. IV fluid restarted, and made NPO. Medications converted back to IV. KUB revealed ileus. Urine output stable. . [**8-8**]: NGT removed. Started on clears. Tolerated well. Ostomy output increased. Abdominal distention decreased. Continued to ambulate with nursing & RW. Minimal assist. Otherwise stable. Repeat abd xray revealed resolving ileus. Diet advanced to regular food in evening. Tolerated well. . [**8-9**]: Tolerating regular food. Denies N/V. Adequate ostomy & urine output. Ambulating with minimal assist using walker. Re-screened per PT, cleared for discharge home with services. . [**8-10**]: Vitals stable. Abdominal incision, ostomy, ileal conduit, and gracilis flaps intact. Pain well controlled with oral medication. Hemodynamic status stable. [**8-11**] Ureteral stents removed. Pt discharged to home with [**Name (NI) 269**], PT/OT, & home health aide. Also with planned follow-up with Dr. [**Last Name (STitle) 1120**] in a few weeks, and with Dr. [**First Name (STitle) **], Plastic Service in 10 days for assessment of groind JP drain output, and readiness for removal. In addition, patient will see Dr. [**First Name (STitle) **], Urology in [**12-26**] weeks. Medications on Admission: Clopidogrel 75', Diltiazem SR 180', Fluticasone 50 ii", Ipratropium-Albuterol ii", Lisinopril 40', Montelukast 10', Rosuvastatin 40', Triamterene-Hydrochlorothiazid 37.5/25 qMWF, Aspirin 81', Famotidine 20" Discharge Medications: 1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB, wheeze. 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-26**] Puffs Inhalation Q6H (every 6 hours) as needed for difficulty breathing. 4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day) as needed for nasal congestion. 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) for 1 weeks: oral thrush-discontinue once symptoms resolve. Disp:*qs * Refills:*0* 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB/wheeze. 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain: Do not exceed 4gm/24hr. 11. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO once a day. 13. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain for 2 weeks: Take with food. Disp:*25 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: CareGroup [**Hospital1 269**] Discharge Diagnosis: Primary: Recurrent rectal cancer Post-op hypotension-managed with IV fluid boluses & neosynephrine in ICU Post-op hypervolemia-diuresis with IV Lasix Post-op pain-managed with Fentanyl & Bupivicaine epidural . Secondary: HTN, Familial HCHL, GERD, TIA, Colonic polylps, Asthma Discharge Condition: Vitals stable, tolerating cardiac diet, pain well controlled with PO pain meds. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . JP Drain Care: -Please look at the site every day for signs of infection (increased redness, swelling, odor, yellow or bloody discharge, fever). -Maintain the bulb deflated to provide adequate suction. -Note color, consistency, and amount of fluid in drain. Call doctor if amount increases significantly or changes in character. -Be sure to empty the drain frequently. -You may shower, wash area gently with warm, soapy water. -Maintain the site clean, dry, and intact. -Avoid swimming, baths, hot tubs-do not submerge yourself in water. -Keep drain attached safely to body to prevent pulling . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 1120**] office in [**1-27**] weeks [**Telephone/Fax (1) 6316**]. 2. Follow-up with your PCP, [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**] [**Telephone/Fax (1) 3329**] in 1 week and as needed. 3. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1429**] in 10 days for management of JP drains. 4. Follow-up with Urology, Dr.[**First Name (STitle) **] [**Telephone/Fax (1) 6317**] in [**12-26**] weeks. NEITHER DICTATED NOR READ BY ME Completed by:[**2137-8-11**]

[ "458.29", "518.5", "560.1", "530.81", "V12.54", "276.6", "154.8", "493.90", "196.6", "401.9", "997.4", "E878.8", "V12.72", "285.1", "272.0" ]

icd9cm

[ [ [] ] ]

[ "49.74", "40.3", "57.71", "38.93", "96.07", "56.51", "38.91", "99.04", "48.5", "03.90" ]

icd9pcs

[ [ [] ] ]

9833, 9893

4871, 7886

337, 443

10213, 10295

2367, 4848

12479, 13078

1999, 2039

8143, 9810

9914, 10192

7912, 8120

10319, 12456

2054, 2054

2068, 2348

274, 299

471, 1408

1430, 1778

1794, 1983

4,454

141,541

10300+56131

Discharge summary

report+addendum

Admission Date: [**2184-9-21**] Discharge Date: [**2184-9-24**] Date of Birth: [**2111-6-23**] Sex: M Service: MEDICAL IC HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] is a 73-year-old gentleman with a history of multi-infarct dementia and recurrent aspiration pneumonias, requiring admission to [**Hospital1 1444**]. The patient presented on the [**5-22**] to the [**Hospital1 188**] Emergency Room from the [**Hospital3 6560**] Center with tachycardia, hypoxia, and fever. Mr. [**Known lastname **] was in his usual state of health until the evening prior to admission, when he was noted to be diaphoretic, tachypneic, and tachycardia in his nursing home. He had a fever to greater than 104 degrees. He also had an increase in sputum production and he was coughing copious-green sections at that time. The patient was started on Levaquin and Flagyl, but failed to improve. He was subsequently sent to the [**Hospital1 1444**] for further evaluation and treatment. In the emergency room, the patient was found to have a fever of 103.4, sinus tachycardia of 144 beats per minute. He was also noted to be tachypneic with a respiratory rate of 40 and a hypoxic with oxygen saturations of the high 80s on room air. The patient was placed on 100% oxygen by face mask. He was given two liters of normal saline and he received a dose of Clindamycin. Blood cultures, urine cultures, and wound cultures of the decubitus ulcers were obtained. The patient was then found to be stable with blood pressures in the 120s/70s. Oxygen saturations were 100% on a nonrebreather face mask. He defervesced following the administration of Clindamycin and Tylenol. He was then admitted to the Medical Intensive Care Unit for observation and further treatment of the infection and the oxygen requirement. PHYSICAL EXAMINATION: Examination revealed the following: The patient was febrile to 101.2, heart rate 115 and irregular. Blood pressure was 134/82, respiratory rate 22, and oxygen saturation 99% on a nonrebreather face mask. He was a well-developed, well-nourished male, who was awake and opened his eyes to his name, but otherwise, he was nonresponsive. Pupils equal, round, and reactive. Oropharynx was dry. He had no jugulovenous distention. He was tachycardiac. Heart rate was regular and he had no murmurs, rubs, or gallops. He had course breath sounds bilaterally with decreased breath sounds in dependent areas, but no crackles. Abdomen was soft, nondistended and nontender with diminished bowel sounds; no masses and the PEJ site was clean, dry, and intact. The suprapubic catheter site was located in the intertriginous fold, beneath his pannus and it was moist without purulent exudate or erythema. He had an erythematous patch around the left elbow, but without edema or induration. He had no cyanosis or clubbing. Skin was warm and moist. The patient was diaphoretic and he had stage III to IV decubitus ulcer in his right buttock, which was 3 cm x 3 cm x 4 cm deep, but with good granulation tissue and on exudate or drainage and a left hip sacral decubitus ulcer also without drainage or erythema. LABORATORY DATA: Laboratory data revealed the following: Laboratory data on admission included CBC with a white blood cell count of 14.2 with hematocrit of 40.4, and platelet count of 236,000. The Chem 7 revealed sodium of 150, potassium 3.8, chloride of 119, bicarbonate 24, BUN 48, creatinine 1.2. The patient's baseline creatinine ran between 0.7 and 0.8. He also had a glucose of 496. Other laboratory included urinalysis, which showed small blood, nitrite negative, 30 protein, glucose of greater than 1000, no ketones or bilirubin, trace leukocyte esterase, 3 to 5 red blood cells, greater than 50 white cells and a few bacteria. The sputum Gram stain showed 4+ Gram-negative rods, 2+ yeast, and the arterial blood gas on admission showed a pH of 7.1, CO2 of 38, oxygen saturation 159 on 15 liters nonrebreather face mask 60%. Chest x-ray, compared to an AP of [**2184-6-21**], showed no cardiomegaly or effusions, lungs fields grossly clear, no cephalization, and a feeding tube in her abdomen. EKG demonstrated sinus tachycardia only. HOSPITAL COURSE: As mentioned previously, Mr. [**Known lastname **] was admitted to the Medical Intensive Care Unit. His issues during the hospital course are as follows: #1. PULMONARY: The patient was placed on supplemental oxygen and received Gentamicin, Vancomycin and Flagyl. The oxygen requirement decreased and by discharge the patient was requiring only two liters by nasal cavity and saturating well. Chest x-ray remained clear throughout the hospitalization with no evidence of aspiration pneumonia. In the patient's recurrent history of aspiration pneumonia, it was recommended that the patient received tracheostomy to allow suction of secretions and to prevent repeated admissions for aspiration pneumonia. Prior to discharge, the patient was discontinued on the Gentamicin, Vancomycin, and Flagyl and the patient was treated with Levofloxacin on which he was to be discontinued. Although the patient had Gram-negative rods on sputum Gram stain the cultures were negative at the time of discharge. The patient does have a history of MRSA and multiple aspiration pneumonias, however, it was deemed at the time of discharge that Levofloxacin would be adequate coverage for these potential infections. #2. INFECTIOUS DISEASE: The patient was admitted with high fevers and elevated white count. He was initially treated with Gentamicin, Flagyl and Vancomycin. These antibiotics were given for empiric coverage of his previous resistant organisms. During this admission, Gram stain of his decubitus ulcer showed 3+ polys, 3+ Gram-positive cocci and 1+ Gram-negative rods of multiple species. In addition, 1 out 4 bottles of blood cultures grew Gram-positive cocci, which was not yet speciated. Sputum Gram stain showed 4+ Gram-negative rods, 2+ yeasts and 4+ oral flora. Urine cultures grew multiple Gram-negative rods consistent with fecal contamination. This was somewhat puzzling considering the sample of the urine was drawn from the suprapubic catheter. These organisms were all deemed to be likely colonization given his repeated episodes of aspiration and UTIs and his nursing home residency. The 1 out of 4 bottles of Gram-positive cocci were treated with Vancomycin. At the time of discharge, speciation of this organism was pending. The patient was discharged only on Levofloxacin and the primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was to follow up on the speciation results and restart Vancomycin as necessary, if the organism was deemed to be real infection and not contamination of those blood cultures. During this stay, the patient's sacral decubitus ulcers were examined by the Plastic Surgery Service and the right ulcer was debrided. Plastic Surgery determined that these wounds both looked good and they were not infected at this time. #3. FLUIDS, ELECTROLYTES, AND NUTRITION: Upon admission, the patient was noted to be severely hypovolemic and hyponatremic with a free-water deficit of greater than four liters and an overall volume deficit likely approaching six liters. The patient was given free-water boluses to correct both the hypovolemia and the hyponatremia. The hypovolemia and hyponatremia was deemed likely to osmotic diuresis relating to his poorly-controlled diabetes mellitus and glucosuria. Upon discharge, the patient's sodium had corrected from greater than 156 to 142 with free-water boluses and he was clinically normovolemic. #4. GASTROINTESTINAL: The patient was admitted with a PEJ tube and on admission, he was restarted on his tube feeds, which he tolerated well without residuals and he was quickly brought to full goals of tube feeds, tolerating these well. #5. ENDOCRINE: The patient was admitted with blood sugar of close to 500 and urine sugars greater than 1000. He was initially started on an Insulin drip and he was quickly changed to a sliding scale with good controls of the blood sugars. Upon discharge, the patient was to restart his normal insulin NPH. #6. NEUROLOGICAL: The patient is demented at baseline secondary to multi-infarct dementia. He was at his neurological baseline throughout the hospital stay opening his eyes to name, but, otherwise, unresponsive. #7. HEMATOLOGIC: On the day of discharge, the patient was noted to have right upper extremity edema. This edema was worrisome for deep venous thrombosis and ultrasound of the right upper extremity was ordered. Results were not available at the time of discharge and the results were to be Emailed to Dr. ....................for further follow up at the nursing home as necessary. CODE STATUS: The patient was full code throughout his hospital stay. Numerous conversations were held with the patient's daughters who insisted on the patient being full code. DISPOSITION: The patient was to be discharged directly back to the [**Hospital3 6560**] Center, where he was to have follow up for the blood-culture results and the right upper quadrant ultrasound results under the direction of Dr. [**Last Name (STitle) **], primary care physician. CONDITION ON DISCHARGE: Mr. [**Known lastname **] was stable on discharge. DISCHARGE STATUS: The patient is to be discharged as aforementioned to the [**Hospital3 6560**] Home, where he is a resident. DISCHARGE DIAGNOSES: 1. Tracheobronchitis. 2. Colonization of sputum and urine with multiple Gram-negative organisms. 3. Insulin dependent diabetes mellitus. DISCHARGE MEDICATIONS: 1. Insulin NPH 10 units subcutaneously q.a.m. 2. Levaquin 500 mg PO q.d. 3. Pepcid 20 mg q.h.s. 4. Aspirin 81 mg PO q.d. 5. Zinc sulfate. 6. Vitamin C. 7. Colace. 8. Multivitamin one tablet PO q.d. 9. The patient was to restart Baclofen 10 mg PO q.d. FOLLOW-UP PLANS: The patient is to be followed up by Dr. [**Last Name (STitle) **] at the [**Hospital3 6560**] Home. The patient has two issues, which need to be followed up. Issue #1: Possible infection of his blood with Gram-positive cocci. The patient has speciation of 1 out of 4 positive cultures from [**Hospital1 69**] pending. Dr. [**Last Name (STitle) **] is to follow up on these culture results. Issue #2: Possible right upper quadrant deep venous thrombosis. Right upper extremity ultrasound is being performed on the day of discharge and the results will be Emailed to Dr. [**Last Name (STitle) **]. [**Name6 (MD) **] [**Name8 (MD) **], MD Dictated By:[**Last Name (STitle) 34257**] MEDQUIST36 D: [**2184-9-24**] 12:24 T: [**2184-9-24**] 12:31 JOB#: [**Job Number 34258**] Name: [**Known lastname 400**], [**Known firstname **] Unit No: [**Numeric Identifier 6020**] Admission Date: [**2184-9-21**] Discharge Date: [**2184-9-28**] Date of Birth: [**2111-6-23**] Sex: M Service: NOTE: This is a discharge summary addendum. HOSPITAL COURSE [**2184-9-25**] through [**2184-9-28**]: The patient was transferred to the Medical Intensive Care Unit on [**2184-9-25**] and stayed overnight with a low grade fever to 100.8?????? and tachycardia, but no change in white blood cell count. His Levaquin was discontinued, as the pseudomonas was found to be resistant to it. He was then switched to vancomycin and cefepime for antibiotic coverage. He spiked a temperature to 101.2?????? on [**9-27**] at 0400. Chest x-ray was done at that time which showed increased left lower lobe consolidation which was consistent with pneumonia and worsened from prior chest x-ray. Therefore, the patient's antibiotic course was changed to cover for pneumonia (hospital acquired versus aspiration) instead of previous treatment for tracheobronchitis. Antibiotic coverage was extended for a 14 day course of vancomycin cefepime. It was pathogen directed against Methicillin resistant Staphylococcus aureus, Proteus and Pseudomonas, all of which showed moderate growth on sputum culture from [**2184-9-21**]. A PICC line was placed under fluoroscopy due to need for long term antibiotics on [**2184-9-27**]. The 1 of 4 positive blood cultures from [**9-22**] was identified as gamma strep. No further speciation was made. Per microbiology lab, this was "very likely" to be a contaminant. On further testing, it was identified as not being Enterococcus and therefore assumed to be skin flora and susceptible to current antibiotic regimen. Since transfer to the floor on [**2184-9-25**], the patient's sputum production decreased dramatically. Respiratory therapy continued with prn albuterol/Atrovent nebulizers and aggressive suctioning, however very little secretions were suctioned. He was continued on his tube feeds at a goal of 85 cc an hour. He was non responsive for a majority of the time on the floor, however, he followed simple commands on one occasion. His hematocrit dropped slightly from 40 on admission to 30 on discharge which was thought to be secondary to dilution with intravenous fluids, especially given patient's hypovolemia on admission. No source of active bleeding was identified and his hematocrit was stable for the five days prior to discharge. Due to worsening edema in his right arm just prior to transfer from the Medical Intensive Care Unit, a Doppler study was performed on the right upper extremity which was negative for deep venous thrombosis. Dr. [**Last Name (STitle) **] discussed future plans with the patient's daughter and it was decided to consider tracheostomy in the future to avoid further aspiration events. DNR status was also discussed and the patient remains full code. DISCHARGE DIAGNOSES: 1. Multi-infarct dementia 2. Hypertension 3. Recurrent urinary tract infection 4. Pneumonia 5. Diabetes 6. Benign prostatic hypertrophy with chronic suprapubic catheter 7. Decubitus ulcer x2 - chronic (right hip and sacrum) DISCHARGE MEDICATIONS: 1. Lansoprazole 15 mg po qd 2. Colace 100 mg po qd 3. Scopolamine transdermal change q 72 hours 4. Albuterol/Atrovent nebulizers prn wheezing 5. Cefepime 1 gm q 12 hours, day 4 of 14, first dose included with patient on discharge. 6. Vancomycin 1 gm q 12 hours a day for 14, one dose included with patient at time of discharge. 7. Regular insulin sliding scale per flow sheet 8. Aspirin 81 mg qd 9. Multivitamin 1 tablet qd 10. ProMod with fiber at 85 cc an hour FOLLOW UP: Patient is to be discharged back to [**Hospital3 6024**] Home with follow up to be arranged per Dr. [**Last Name (STitle) **]. DISCHARGE CONDITION: Stable and improved. [**First Name11 (Name Pattern1) 1463**] [**Last Name (NamePattern4) 6021**], M.D. [**MD Number(1) 6022**] Dictated By:[**Last Name (NamePattern1) 6025**] MEDQUIST36 D: [**2184-9-28**] 16:25 T: [**2184-10-4**] 13:53 JOB#: [**Job Number 6026**]

[ "290.40", "507.0", "250.22", "401.9", "038.9", "276.5", "707.0", "276.0", "V44.59" ]

icd9cm

[ [ [] ] ]

[ "86.22", "38.93" ]

icd9pcs

[ [ [] ] ]

14650, 14953

13760, 13992

14015, 14488

4227, 9272

14500, 14628

1855, 4209

9941, 13739

9297, 9477

76,174

143,515

49590

Discharge summary

report

Admission Date: [**2118-5-19**] Discharge Date: [**2118-5-24**] Date of Birth: [**2037-8-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 30**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: EGD [**2118-5-19**] Colonoscopy [**2118-5-23**] Capsule endoscopy [**Date range (3) 103721**] History of Present Illness: 80yoM with CAD s/p DES to RCA and LCx [**2110**], likely instent thrombosis [**5-/2118**] in setting of stopping ASA/Plavix; also with HTN/HL/DM, PVD, CKD baseline Cr 1.4-1.7 who presented to ED after having BRBPR, dizziness, and SOB walking upstairs tonight at 5pm. EMS noted pt to have SBP 80, PIV was placed and pt given IVF's. . In the ED initial vitals: 99.6 88 100/38 18 100% 4LNC. Started having epigastric pain in the ED. Gross blood on rectal exam, no NGL done. Given Protonix bolus + gtt. Getting 2nd unit of PRBC's, and has received 1 IVF's in the ED and unclear amt by EMS. EKG with <1 mm in II; TWI in III, aVF. CXR: limited study but no gross edema or consolidation. . Of note pt was recently admitted [**5-12**] to [**5-13**] after having stopped Plavix and ASA for upcoming spinal stenosis surgery, had code STEMI inferolateral leads, Plavix 600 mg loaded, and was taken to cath lab which showed probable instent thrombosis of LCx stent that had resolved with antithrombotics. He was given Integrillin x12 hrs and restarted on daily ASA 325 and Plavix 75. Noted to have slow 4:1 Aflutter with CHADS2 of 3, but deferred Coumadin to outpt Cards given he was on dual antiplatelets already. . Vitals before tranfer: 99.5 p72 108/53 18 98%RA. . ROS as above otherwise pt was feeling well before this, without f/c, n/v, cough. Past Medical History: CAD s/p RCA and LCx PCI [**2110**] h/o exercise induced SVT CRI (baseline 1.7-2.3) PVD ([**2113-5-4**], revascularization of B/L iliacs) [**7-9**] 60% lesion REIA 70% lesion [**Female First Name (un) 7195**] s/p stents (5) LCIA s/p stent RCIA DJD GERD T2DM HTN Hyperlipidemia s/p excision of melanoma Gout Ulcerative Colitis (not active) Social History: Married, with children and is a CPA. Occasional EtOH use. No current tobacco use. No IVDU. Family History: Father had rheumatic fever. Physical Exam: ADMISSION EXAM: p84 124/41 14 99%RA Large, pleasant M in no distress, joking around, appears well, no distress. EOMI, no scleral icterus, mouth moist no apparent lesions Bilateral crackles noted, good air movement otherwise, no wheezes/rhonchi Very faint, almost inaudible S1/S2, no apparent m/g Abd obese and slightly distended but not tight, non tender, no palpable hepatomegaly No BLE edema, extrems are warm. No chronic venous stasis changes noted. CN 2-12 grossly intact, no focal neuro deficits, moving all extremities. Conversant, linear, lucent. DISCHARGE EXAM: VS: 97.5, 128/58, 73, 18, 95% RA GENERAL: awake, alert, resting comfortably, NAD HEENT: sclera anicteric, MMM, OP clear NECK: supple, JVP 7-8 cm CARDIAC: RRR, no r/m/g LUNGS: bibasilar crackles, no wheezing or rhonchi, good air movement bilaterally, respirations unlabored, no accessory muscle use ABDOMEN: bowel sounds present, soft, NT/ND, no guarding or rebound tenderness EXTREMITIES: warm, well-perfused, DP pulses 2+, no edema, right thigh slightly tender to palpation in lateral area just above knee, no appreciable erythema, edema, or ecchymosis Pertinent Results: ADMISSION LABS: [**2118-5-19**] 04:57PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-1+ [**2118-5-19**] 04:57PM NEUTS-85* BANDS-0 LYMPHS-5* MONOS-9 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* [**2118-5-19**] 04:57PM WBC-17.8*# RBC-3.26* HGB-9.0* HCT-29.7* MCV-91 MCH-27.6 MCHC-30.3* RDW-14.8 [**2118-5-19**] 04:57PM URIC ACID-8.8* [**2118-5-19**] 04:57PM UREA N-84* CREAT-2.7*# SODIUM-142 POTASSIUM-5.1 CHLORIDE-107 [**2118-5-19**] 04:57PM GLUCOSE-204* [**2118-5-19**] 07:40PM PT-13.4 PTT-24.1 INR(PT)-1.1 [**2118-5-19**] 07:40PM cTropnT-0.03* [**2118-5-19**] 11:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2118-5-19**] 11:39PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 OTHER PERTINENT LABS: [**2118-5-22**] 03:56AM BLOOD ALT-25 AST-16 AlkPhos-55 TotBili-0.2 [**2118-5-19**] 07:40PM BLOOD cTropnT-0.03* [**2118-5-19**] 11:43PM BLOOD CK-MB-3 cTropnT-0.03* [**2118-5-20**] 05:33AM BLOOD CK-MB-3 cTropnT-0.03* [**2118-5-20**] 12:41PM BLOOD CK-MB-3 cTropnT-0.02* [**2118-5-19**] 11:43PM BLOOD CK(CPK)-43* [**2118-5-20**] 05:33AM BLOOD CK(CPK)-32* [**2118-5-20**] 12:41PM BLOOD CK(CPK)-28* DISCHARGE LABS: [**2118-5-24**] 07:10AM BLOOD WBC-12.1* RBC-3.40* Hgb-9.6* Hct-29.5* MCV-87 MCH-28.2 MCHC-32.4 RDW-14.6 Plt Ct-272 [**2118-5-24**] 07:10AM BLOOD Neuts-86* Bands-0 Lymphs-3* Monos-7 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-2* [**2118-5-24**] 07:10AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2118-5-24**] 07:10AM BLOOD Glucose-217* UreaN-25* Creat-1.5* Na-141 K-4.2 Cl-106 HCO3-26 AnGap-13 [**2118-5-24**] 07:10AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.7 MICROBIOLOGY: Urine culture [**2118-5-19**]: <10,000 organisms/ml. Blood cultures [**2118-5-19**]: pending IMAGING: CXR [**2118-5-19**]: Limited study. No gross consolidation or edema is appreciated. If clinically feasible, consider PA and lateral views in the radiology suite for more sensitive and specific evaluation. LE US [**2118-5-20**]: No evidence of right lower extremity deep vein thrombosis EGD [**2118-5-19**]: Superficial ulcer in the stomach antrum. Mild antral gastritis. No old or fresh blood throughout. Short segment Barrett's esophagus. Otherwise normal EGD to third part of the duodenum. Colonoscopy [**2118-5-23**]: Mild diverticulosis throughout the whole colon. Normal mucosa in the whole colon and terminal ileum. No fresh or old blood throughout the whole colon and terminal ileum. Otherwise normal colonoscopy to cecum and terminal ileum. Capsule Endoscopy [**Date range (1) 103722**]: PATIENT DATA: Gastric Passage Time: 0h 14m. Small Bowel Passage Time: 3h 0m. PROCEDURE INFO & FINDINGS: 1. Residual fluid and secretions at the antrum. 2. Lymphangiectasias at the duodenum and jejunum. 3. Prominent venous markings at the distal jejunum (non-specific findings). 4. No active bleeding seen on this study. SUMMARY & RECOMMENDATIONS: Duodenal and jejunal lymphangietasias with a prominent venous pattern at the jejunum. No active bleeding seen on this study. Follow-up with PCP and GI. Brief Hospital Course: 80yoM with h/o DES to RCA and LCx in [**2110**] and recent ? instent thrombosis treated with antithrombotics and discharged on ASA/Plavix (no Coumadin), CKD, PVD, and DM/HTN/HL who presented with BRBPR, Hct drop, leukocytosis with bandemia, and [**Last Name (un) **]. #. Acute Blood Loss Anemia: Patient was started on PPI gtt and Octreotide gtt. Received 2 units pRBCs in ED. GI performed an EGD on initial presentation which showed a non-bleeding ulcer in the antrum. Diverticulosis seen on prior colonoscopy in [**2115**]; and initially was felt current GIB may be diverticular bleed exacerbated by daily ASA/Plavix. Plavix was held but ASA was continued after discussion with outpatient cardiologist, given high risk of in-stent thrombosis. Patient had additional 1 unit pRBCs transfused in the MICU to goal Hct 28-30, given recent in-stent thrombosis and CAD. Patient received total of 3u pRBCs. Colonoscopy on [**2118-5-23**] showed mild diverticulosis but was otherwise unremarkable, with no evidence of old or recent bleeding. Patient did not have any further bleeding in the MICU, Hct stabilized, and he remained hemodynamically stable. Was transferred to general floor on [**5-23**], and GI continued to follow. GI recommended capsule endoscopy, which was done overnight on [**5-28**]. Study showed duodenal and jejunal lymphangietasias with a prominent venous pattern at the jejunum, but no active bleeding seen on this study. Given stability, patient discharged to home with PCP, [**Name10 (NameIs) **], and cardiology follow-up. Per discussion with cardiology prior to discharge, patient's ASA dose decreased to 81mg daily and Plavix restarted for at least 2 additional weeks. Patient's home PPI dose increased to omeprazole 40mg [**Hospital1 **]. #. CAD/In-stent thrombosis: s/p RCA and LCx PCI [**2110**]. Patient recently admitted to CCU with STEMI in setting of holding ASA/Plavix prior to planned spinal fusion surgery, ? instent thrombosis of LCx stent. Patient had been discharged on lifelong ASA 325mg daily, and plavix for at least 4-6 weeks, though presented this admission with BRBPR as above. Plavix was held and ASA was continued in the setting of GIB after discussion with his outpatient cardiologist, as mentioned above. CE's neg x3 during current hospitalization without any acute ischemic changes on EKG. Home antihypertensives were held in setting of acute GIB, though restarted on discharge day as patient remained hemodynamically stable. Patient discharged on aspirin, plavix, statin, beta blocker, and ACE inhibitor. Will follow-up with cardiology. #. RLE pain/Gout: Patient with erythema and exquisite tenderness of right medial malleolus, no effusion appreciable and no pain with flexing the ankle, but exquisite tenderness to light touch. Has a history of gout, on Allopurinol and Colchicine in past at home. Held Allopurinol in the setting of ARF on initial presentation but pain improved in-house. Patient discharged back on Allopurinol given improvement in renal function. Of note, imaging this admission negative for RLE DVT. #. Leukocytosis: WBC elevated on admission with bandemia, but resolved. Patient afebrile, without any localizing signs or symptoms of infection. Urine culture negative, and blood cultures negative to date at time of discharge. CXR on admission showed no gross e/o PNA. #. [**Last Name (un) **]: Cr elevated to 2.5 on admission, up from baseline of 1.7-2.3. [**Last Name (un) **] was felt to be pre-renal in setting of acute blood loss, and resolved with IVF and blood product administration. Cr trended back to baseline and was stable at 1.5 on morning of discharge. #) DJD: Patient received acetaminophen prn pain. . #) GERD: Continued PPI, but at increased dose as above. . #) DM2: Held home glipidize while inpatient. Patient was on diabetic diet, FSBS monitored, and he was on insulin sliding scale. Glipizide resumed on discharge. . #) HTN: BP generally well controlled off anti-hypertensive meds, which were held in setting of recent GI bleeding. Given hemodynamic stability, lisinopril, atenolol, and amlodipine restarted on day of discharge. . #) Hyperlipidemia: Continued atorvastatin. LABS/STUDIES PENDING AT TIME OF DISCHARGE: Blood cultures [**2118-5-19**] ISSUES REQUIRING FOLLOW-UP: -Patient will follow-up with PCP, [**Name10 (NameIs) **], and cardiology -Patient was a FULL code during this admission -Should continue on aspirin 81 mg daily and plavix 75mg daily for now, and follow-up with cardiology -Should have repeat Hct check at PCP [**Last Name (NamePattern4) 702**] Medications on Admission: Aspirin 325mg daily Plavix 75mg daily Atorvastatin 80mg daily Omeprazole 20mg daily Lisinopril 10mg daily Atenolol 50mg daily Amlodipine 5mg daily Glipizide 5mg daily Allopurinol 100mg daily SL NTG PRN Multivitamin daily Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 5. amlodipine 10 mg Tablet Sig: 0.5 Tablet PO once a day. 6. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab Sublingual every 5 minutes, may take up to 3 times as needed for chest pain. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: GI bleeding Secondary: Coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus, gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 18134**], You were admitted to the hospital after passing bright red blood from your rectum. You received a blood transfusion, and your blood counts stabilized. You were seen by the Gastroenterology specialists and had an upper endoscopy and colonoscopy which did not show evidence of active bleeding. You then had a capsule endoscopy study, which also did not show any concerning areas for bleeding. Given the bleeding, your Aspirin and Plavix were initially held. The Aspirin was restarted, and per disucssion with the Gastroenterology and Cardiology, it was advised that you continue taking Aspirin for lifelong and Plavix for at least another 2 weeks. The Aspirin can be decreased to 81mg daily. We made the following changes to your medications: 1. INCREASED Omeprazole to 40mg twice daily 2. DECREASED Aspirin to 81mg daily We did not make any other changes to your medications. Please continue to take them as you have been doing, including Plavix and lower dose Aspirin. Please keep follow-up appointments as scheduled. Followup Instructions: Name: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14973**] Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 133**] Appointment: Monday [**2118-5-30**] 11:15am **This is a follow up appointment for your hospitalization. You will be reconnected to your primary care physician after this visit. Department: [**Hospital **] MEDICAL GROUP When: MONDAY [**2118-5-30**] at 11:15 AM Department: [**Last Name (un) 12214**] [**Doctor Last Name **] MED GRP When: TUESDAY [**2118-5-31**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], MD [**Telephone/Fax (1) 5068**] Building: [**Location (un) **] ([**Location (un) 86**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: GASTROENTEROLOGY When: MONDAY [**2118-6-27**] at 3:15 PM With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "45.13", "45.23", "45.19" ]

icd9pcs

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12527, 12533

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307, 403

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30,070

144,328

47181

Discharge summary

report

Admission Date: [**2151-8-23**] Discharge Date: [**2151-9-1**] Date of Birth: [**2081-11-18**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 165**] Chief Complaint: Hypotension, Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 69 year old male who recently underwent CABG and MV repair on [**2151-7-27**]. While at rehab, he experienced sudden onset of dizziness. He was found on his knees by nursing staff, unable to report any further specific symptoms or complaints. There were no signs of head trauma. Past Medical History: Coronary Artery Disease, Mitral Regurgitation, Hypertension, Hyperlipidemia, Prostate cancer - s/p brachytherapy [**2145**], Peripheral Vascular Disease, s/p Parathyroidectomy, GERD, Diverticulosis, Sleep disorder Social History: Social history is significant for previous smoking 2ppd x40 yrs quit 1 yr ago. No ETOH. Lives alone and is a retired worker for Xerox. Never married and has no children. Family History: Sister died age 60 of CA unknown type and brother died in his 60's of esophageal CA Physical Exam: General NAD well developed Neuro A/O x3 nonfocal Cardiac RRR no m/r/g Resp CTA bilat except decreased left base no rhonchi/wheezes Abd Soft, NT, ND +BS BM [**8-4**] Ext warm no edema pulses palpable Inc Left leg EVH no erythema/drainage steris intact Inc Sternal no erythema/drainage steris intact sternum stable Pertinent Results: [**2151-8-22**] 11:55PM PT-52.0* PTT-52.7* INR(PT)-6.2* [**2151-8-22**] 11:55PM WBC-9.6 RBC-3.47* HGB-10.2* HCT-29.6* MCV-85 MCH-29.5 MCHC-34.6 RDW-15.3 [**2151-8-22**] 11:55PM GLUCOSE-133* UREA N-61* CREAT-1.9* SODIUM-141 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17 [**2151-8-23**] 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2151-8-23**] Chest CTA: 1. No evidence of pulmonary embolism or aortic dissection. 2. Cardiomegaly with scattered parenchymal opacities likely reflective of ulmonary edema. 3. Left upper and lower lobe consolidation, may be due to aspiration pneumonia. 4. Fluid filled esophagus and stomach. NG tube is recommended for decompression. 5. Extensive coronary artery calcification. [**2151-8-23**] CT Head: No acute intracranial pathology including no intracranial hemorrhage. [**2151-8-23**] Echocardiogram: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (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 (3) are mildly thickened. Severe aortic stenosis is unlikely. Aortic regurgitation was not assessed. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. [**2151-8-30**] Chest X-ray: Marked improvement from prior similar study of [**8-26**]; essentially unchanged study from two days prior showing resolved left pleural effusion and significant improvement in airspace opacification with residual opacity in the right base. [**2151-8-31**] 06:25AM BLOOD WBC-11.0 RBC-5.49 Hgb-15.2 Hct-48.1 MCV-88 MCH-27.8 MCHC-31.6 RDW-15.8* Plt Ct-450* [**2151-8-24**] 07:35PM BLOOD PT-26.8* PTT-47.7* INR(PT)-2.8* [**2151-8-25**] 02:45AM BLOOD PT-18.0* PTT-38.6* INR(PT)-1.7* [**2151-8-26**] 01:58AM BLOOD PT-12.8 PTT-29.8 INR(PT)-1.1 [**2151-8-27**] 03:53AM BLOOD PT-11.2 PTT-26.0 INR(PT)-0.9 [**2151-8-28**] 05:29AM BLOOD Glucose-99 UreaN-24* Creat-1.0 Na-137 K-3.4 Cl-100 HCO3-26 AnGap-14 [**2151-8-29**] 06:00AM BLOOD Glucose-115* UreaN-30* Creat-1.2 Na-139 K-3.6 Cl-101 HCO3-26 AnGap-16 [**2151-8-31**] 06:25AM BLOOD Glucose-105 UreaN-32* Creat-1.2 Na-141 K-4.4 Cl-102 HCO3-29 AnGap-14 [**2151-8-28**] 05:29AM BLOOD ALT-32 AST-30 LD(LDH)-311* AlkPhos-77 TotBili-1.0 [**2151-8-31**] 06:25AM BLOOD ALT-111* AST-80* LD(LDH)-291* AlkPhos-85 Amylase-88 TotBili-0.6 [**2151-8-27**] 03:53AM BLOOD Lipase-96* [**2151-8-31**] 06:25AM BLOOD Lipase-123* Brief Hospital Course: Mr. [**Known lastname **] was readmitted to the CSRU with hypotension and hypoxia associated with gastric distention. There was no evidence of bowel obstruction on abdominal films but a nasogastric tube was placed for findings of fluid filled stomach and esophagus on CT scan. He was empirically started on antibiotics for findings of left upper and lower lobe consolidation on CT scan suspicious for aspiration pneumonia. The chest CTA was negative for pulmonary embolus and echocardiogram showed no evidence of tamponade. He was given fresh frozen plasma for a supratherapeutic prothrombin time. He did not require intubation but did require face mask for adequate oxygenation. Warfarin anticoagulation was not resumed as he remained in a normal sinus rhythm. His prothrombin quickly normalized. Over several days, his hemodynamics and oxygenation improved with medical therapy. The naasogastric tube was eventually removed, and he was started on an aggressive bowel regimen with good results. Given aspiration, he underwent video oropharyngeal swallow study on [**8-30**] which revealed mild oral dysphagia, with moderate pharyngeal dysphagia. There was evidence of penetration and aspiration, more with thin liquids than nectar thick. He was therefore placed on a modified diet of thick liquid and puree consistency solids. PO medications were crushed in puree. Patient tolerated diet without further evidence of aspiration. He continued to maintain stable hemodynamics and remained in a normal sinus rhythm. The remainder of his hospital course was otherwise unremarkable and he was eventually cleared for discharge to rehab on [**9-1**]. He will continue to require physical and speech therapy at discharge. Medications on Admission: Aspirin 81 qd, Lipitor 80 qd, Colace, Lopressor 100 tid, Protonix 40 qd, Lasix 40 [**Hospital1 **], Warfarin, Albuterol MDI Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-9**] Puffs Inhalation Q6H (every 6 hours) as needed. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Aspiration Pneumonia CAD, MR s/p CABG/MVR [**2151-7-27**] CRI GERD PVD History of Prostate Cancer Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], Appt on [**2151-9-8**] @ 1PM, [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 33059**] after rehab, please call for appt [**Telephone/Fax (1) 85509**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2151-9-1**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7374, 7444

4302, 6018

295, 302

7586, 7595

1517, 2330

8310, 8648

1083, 1168

6192, 7351

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6044, 6169

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1183, 1498

234, 257

330, 642

2339, 4279

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895, 1067

40,548

168,670

54672

Discharge summary

report

Admission Date: [**2156-6-29**] Discharge Date: [**2156-8-14**] Date of Birth: [**2082-6-29**] Sex: F Service: SURGERY Allergies: Ativan / Motrin / Altace / azithromycin / amiodarone Attending:[**First Name3 (LF) 2777**] Chief Complaint: Pulseless legs Major Surgical or Invasive Procedure: [**2156-6-29**] thrombectomy and relining of EVAR, repair left femoral aneurysm, bilateral fasciotomy [**2156-7-1**] left subclavian stent placment [**2156-7-1**] bedside debridement of fasciotomies and R calf and heel ulcer [**2156-7-6**] Debridement of right posterior calf and right heel in the operating [**2156-7-7**] Guillotine Right Above the Knee Amputation [**2156-7-15**] Debridement and Closure R AKA [**2156-7-23**] Mesenteric Angiogram, SMA stenting [**2156-7-29**] PEG placement [**2156-8-7**] Tracheostomy placement [**2156-8-9**] Exploratory laparotomy, closure gastrostomy, J-tube placement [**2156-8-13**] Neck exploration, replacement of tracheostomy, repair thyroid bleeding History of Present Illness: History Present Illness: Ms. [**Known lastname 91103**] is a 73F with a history of aortic thrombi s/p aortobifemoral stent placement, CHF (last EF <45%), PVD, HOLD, HTN, CKD, COPD, afib on coumadin, who comes in with bilateral pulseless lower extremities since 1pm on day of admission. She has decreased sensation and motor function R>L which has worsened from her baseline of decreased RLE motor function. She also has increased pain and mottling of the BLE R>L which is new. She has multiple open wounds on her legs and feet including a large R heel ulcer which reportedly developed while being in a walking boot or immobilizer. She has multiple skin tears which occur with minimal mechanical trauma. She reports that she was minimally ambulatory with assist but has been unable to ambulate for the past 1-2 days. She has a history of an aortobifemoral stent which was placed endovascularly in [**2156-5-23**] for aortic thrombus as well as bilateral femoral artery cutdowns with thrombectomy for clot at the same time. She denies any other vascular procedures but neither she nor the husband are positive and the records from the outside facility are incomplete. She is transferred emergently from [**Hospital 189**] Hospital for evaluation of the pulseless legs. VASCULAR ROS: Other: As HPI, multiple BLE ulcers and skin tears . Past Medical History: VASCULAR HISTORY: Endovascular Repair: Aortobifem for clot. PAST MEDICAL HISTORY: aortobifemoral stent placement, CHF (last EF <45%), PVD, HOLD, HTN, CKD, COPD, afib on coumadin, previous aortic clots PAST SURGICAL HISTORY: bilateral total hip replacement, bilateral total knee replacement, endovacular aortobifem stent, bilateral femoral artery cutdowns Social History: SOCIAL HISTORY: denies tob/etoh/illicits Family History: non contrib Pertinent Results: CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS Study Date of [**2156-6-29**] CT CHEST: The thyroid gland appears heterogeneous, possibly containing subcentimeter hypodense lesions inferiorly (2, 12), which could be assessed by ultrasound if not already performed. There is moderate-to-severe diffuse atherosclerotic calcification. The heart demonstrates severe biatrial enlargement and multivessel coronary arterial calcifications as well as mitral annular and aortic valve calcifications. A moderate-sized pericardial effusion is present inferior to the heart. A small epicardial lymph node is calcified. There is pretracheal and precarinal lymphadenopathy measuring up to 14 mm. There is no axillary lymphadenopathy. There are bilateral pleural effusions, moderate on the right and small on the left, with associated compressive atelectasis. Mild bronchiectasis is seen in the right lung base. Patchy peribronchovascular opacities in the right lower lobe, in combination with layering fluid in the upper esophagus, suggest aspiration. CT ABDOMEN: Note is made of reflux of contrast into the hepatic veins, compatible with right heart insufficiency. The liver demonstrates no focal lesion. The spleen and pancreas appear within normal limits. The adrenal glands appear thickened, without definite nodularity. The left kidney demonstrates delayed nephrogram and scattered areas of wedge-shaped transcortical hypoattenuation, consistent with renal infarction. The right kidney demonstrates relatively preserved nephrogram, however, contains a somewhat wedge-shaped hypodensity in the lower pole (3A, 140), possibly an additional area of infarct. Small and large bowel loops are normal in caliber. There is no free air or free fluid. Prominent retroperitoneal lymph nodes are noted. CT PELVIS: Assessment is highly limited due to streak artifact from bilateral hip arthroplasty. Allowing for such, the bladder and rectum appear within normal limits. CTA: There is moderate amount of thrombosis within the proximal left subclavian artery near the origin (3A, 1). Remainder of arch vessels are unremarkable. The aorta is normal in caliber without dissection or aneurysm. There is diffuse severe atherosclerotic disease. Although not tailored for assessment of pulmonary embolism, there are no large filling defects to suggest central pulmonary embolism. The celiac trunk is patent. The hepatic arterial anatomy is conventional. There is high-grade narrowing of SMA origin with patent distal vessel. The left renal arterial origin appears narrowed; however, distally, the left renal artery is opacified. The right renal artery appears patent. No inferior mesenteric artery is visualized. Patient is status post aortobiliac stent grafting. Distal to the renal arterial origins, there is complete thrombosis of the aorta, with thrombus extending to the level of distal common iliac arteries. Bilateral total knee arthroplasty generates considerable metal streak artifacts, limiting below assessment. Multiple soft tissue ulcers are seen along bilateral lower extremities. RIGHT LOWER EXTREMITY: On the right, there is reconstitution of flow in the distal right common iliac artery and external and internal iliac arteries via the inferior epigastric and circumflex iliac arteries. There is minimal trickle flow in the common femoral artery and proximal superficial femoral artery, which attenuates within the mid superficial femoral artery. From the mid superficial femoral artery distally, there is complete non-opacification of distal arterial branches including trifurcation of anterior and posterior tibial and peroneal arteries, which is likely related to slow flow, though high grade obstruction proximally is not excluded. LEFT LOWER EXTREMITY: On the left, there is similarly reconstitution of the distal common iliac artery and opacification of the internal and external iliac arteries by retrograde filling via inferior epigastric and circumflex iliac arteries. Trickle flow is seen in the common femoral and proximal superficial femoral arteries. From the level of mid superficial femoral artery distally, there is complete non-opacification of arterial branches, including trifurcation into the anterior and posterior tibial and peroneal arteries to the level of the ankle. This is likely related to slow flow, and less likely due to proximal occlusion. Clips are seen in the left groin. No underlying vascular stent or graft is noted. BONE WINDOW: There is diffuse osseous demineralization. There is high-grade L1 wedge compression deformity with greater than 60% loss of height. Severe discogenic osteoarthritis is present at L4-L5 with endplate sclerosis and vacuum phenomenon. A large expansile lytic lesion within the left ischial tuberosity is incompletely assessed and could be correlated with prior exam and clinical history. Patient is status post bilateral total hip arthroplasty and bilateral total knee arthroplasty with hardware grossly in expected locations. IMPRESSION: 1. Complete occlusion of the infrarenal aorta with non-opacification of proximal common iliac arteries. Bilateral distal common iliac arterial reconstitution via circumflex iliac and inferior epigastric arteries, opacifying proximal superficial femoral arteries. From the mid superficial femoral arteries on, there is complete non-opacification bilaterally, most likely due to slow flow though a high grade occlusion cannot be excluded. 2. Diffuse severe atherosclerotic disease, coronary arterial disease, biatrial enlargement. 3. Moderate right and small left pleural effusions with compressive atelectasis. Right lower lobe aspiration. 4. Hypoperfused left kidney with left renal infarcts, and possible right inferior pole renal infarct. 5. Severe biatrial cardiomegaly and diffuse severe atherosclerotic disease. 6. Heterogeneous thyroid gland with possible subcentimeter hypodensities, which could be assessed by ultrasound if not previously performed. 7. Left ischial expansile lytic lesion of unclear source with mediastinal adenopathy. Recommend correlation with prior imaging and clinical history. 8. Bilateral lower extremity ulcerations. [**2156-6-30**] arterial duplex IMPRESSION: Severely diminished flow in the left subclavian, axillary, brachial, radial and ulnar arteries suggesting proximal left subclavian stenosis. [**2156-7-22**] CTA 1. No pulmonary embolism. 2. Patent aortobiliac endograft. The distal end of the left external iliac stent and junction with the left common femoral graft is not adequately evaluated due to streak artifact from the adjacent hip prosthesis. High grade stenosis of the proximal right common femoral artery. Unchanged right internal iliac and left profunda femoris arterial occlusion. 3. Unchanged high-grade stenosis of the superior mesenteric artery with no evidence of bowel ischemia. 4. Right lower lobe ground-glass opacity with secretions at the right lower lobe bronchi, could represent a small amount of aspiration. Moderate left and small right pleural effusion with associated atelectasis. [**2156-8-9**] CT 1. Contrast leak to external body surface from previous PEG site. No intra-abdominal contrast leak to suggest visceral perforation. 2. Stable b/l pleural effusions with punctate old hemorrhage. 3. Rim enhancing fluid collection anterior to R iliacus reduced in size. 4. Improvement in intra-abdominal free air. Brief Hospital Course: Ms. [**Known lastname 91103**] was transferred to [**Hospital1 18**] on [**2156-6-29**] from an OSH for lower extremity pain where she was found to have b/l pulseless lower extremities. She was found to have an occlusive thrombus in her previously placed endovascular stent-graft. She was heparized and emergently taken to the OR for thrombectomy, [**Hospital1 **]-iliac stenting, resection of L CFA aneurysm with PTFE interposition grafts and b/l LE fasciotomies. she was initially transferred to the CVICU. On POD 1 she was noted to have a painful dusky left hand. Arterial duplex demonstrated a likely chronic subclavian stenosis. Nitropaste was applied without improvement, so on POD2 she underwent angioplasy and steting of her L subclavian artery with improvement in her blood flow. She was started on plavix in addition to her heparin gtt. She was continued on antibiotics and on POD6/4 she underwent debridement of her R leg and heel and was noted to have extensive necrotic/nonviable muscle. Lather that day she became hypotensive requiring pressors and was noted to have an altered mental status. A TTE was performed showing a large mobile right atrial thrombus and loculated pericardial effusion with tamponade. She underwent an emergent pericardial window on POD 7/5/1/. There was concern at this point for HITT so she was changed to bivalrudin, but her HITT antibody was negative and she was replaced on heparin. on POD 8/6/2/1 she underwent guillotine right AKA. She was weaned off pressors, eventually extubated and started on tube feeds by NG tube, and was transferred to the VICU with VAC placement over her R AKA site. On POD 15/13/9/8 she underwent closure of her R AKA site, however on POD 20/18/14/13/5 her R AKA site was noted to be dehisced and it was opened and a VAC replaced. During this time she underwent repeated speech and swallow evals without success, she was, however transitioned to coumadin and NG tube meds. On POD 22/20/16/15/7 she suffered PEA arrest x 2 with return of spontaneous circulation. She was reintubated and transferred to the CVICU. A CTA torso at this time showed no pulmonary embolism, but did show a high grade stenosis of her SMA. On POD 23/21/17/16/8 she underwent SMA stenting. On that same day she suffered from recurrent episodes of VTach, and was transiently placed on a lidocaine gtt after consult with electrophysiology. By POD 26/24/19/18/11 she was extubated. She appeared to be recovering well at this point and was readvanced to goal TF and worked with physical therapy. On POD 30/28/23/22/15 she underwent PEG placement by the ACS service. The following day she had her staples removed from her initial operation and her antibiotics were stopped. On POD 32/30/25/24/17/2 she had a respiratory arrest and became severely hypoxemic. She was reintubated and underwent bronchoscopy showing mucous plugging and very friable and hyperemic tracheal and bronchial mucosa. The following day she became hypotensive, transiently requiring pressors and a BAL was performed showing pseudomonas, and she was noted to have cellulitis of her LLE and she was restarted on antibiotics. She improved and was transiently weaned to PSV, however due to concern over her multiple cardiac and respiratory arrests and her multiple intubations, she underwent tracheostomy placement by ACS on POD 39/37/32/31/24/9. Two days later (POD 41/39/34/33/26/11/2) her PEG tube became dislodged and fell out. A CT abdomen was performed and she was noted to have continued free air, but no extravasation of contrast. However, since her PEG tract was not matured she returned to the operating room for exploratory laparotomy, closure gastrostomy, and placement of jejunal feeding tube. The following day she had a PICC line placed and had her last central line removed. She was doing well on trach mask until POD 45/43/38/37/30/15/6/4 when she spontaneously began to have brisk active bright red blood from trach and around her trach site. Due to concern for tracheo-innominate fistula, her trach was removed and she was reintubated and taken emergently to the OR by thoracic surgery for neck exploration, where she was found to have arterial bleeding from her thyroid. This was ligated and her trach was replaced. However, that evening, she suffered from a VFib arrest and was unable to be resuscitated. Medications on Admission: MEDICATIONS: alendronate 70 qweek, digoxin 150', flonase'', lasix 40'', metoprolol 100''', omeprazole 20', pravastatin 10', aldactone 25', albuterol, tiotropium 18mcg', apap, maalox, vit C, docusate, vit D, Ca, senna, docusate, ferrous sulfate, mucinex, magOH, MVI, pilocarpine ophthalmic 2% 2 drops'', prednisolone ophthalmic 1%'', florastore, zolpidem 5 prn Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Aortic Graft Thrombus Left subclavian artery stenosis decubitus ulcers / stage 4 on heel / stage 3 on right post calf / both present on admission Ischemic Right Leg s/p AKA SMA stenosis Pericardial effusion respiratory failure Discharge Condition: expired. Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2156-8-14**]

[ "427.5", "682.6", "707.07", "423.8", "410.71", "041.7", "707.24", "440.8", "444.81", "440.20", "442.3", "263.9", "998.30", "428.42", "E878.2", "707.23", "428.0", "427.31", "707.09", "447.1", "707.03", "285.1", "008.45", "444.89", "557.1", "996.74", "536.49", "519.09", "599.0", "423.3", "429.89", "348.30", "444.21", "518.84", "444.09", "707.25", "427.1" ]

icd9cm

[ [ [] ] ]

[ "37.31", "39.50", "29.11", "99.15", "84.17", "38.93", "06.93", "37.12", "38.08", "00.40", "31.1", "33.24", "88.47", "96.72", "86.59", "96.6", "86.22", "44.63", "00.45", "46.39", "88.49", "83.45", "39.49", "83.14", "39.90", "00.41", "88.42", "46.32", "38.97", "43.11" ]

icd9pcs

[ [ [] ] ]

15167, 15176

10358, 14724

327, 1023

15446, 15456

2884, 10335

15512, 15550

2852, 2865

15135, 15144

15197, 15425

14750, 15112

15480, 15489

2643, 2777

273, 289

1051, 2395

2500, 2620

2809, 2836

23,706

145,364

46534

Discharge summary

report

Admission Date: [**2200-4-27**] Discharge Date: [**2200-4-30**] Date of Birth: [**2134-1-20**] Sex: F Service: MEDICINE Allergies: Codeine / Bactrim / Sulfa (Sulfonamides) Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: arterial line placement/removal History of Present Illness: 66 yo female with h/o COPD on home O2, OSA, DM2, morbid obesity who presents with two days of dyspnea and diarrhea. She states that she has been feeling more SOB for the last 2 days, even without doing much activity. She has been wheezing and feeling lightheaded with this. She does have a non-productive cough, but thinks that this has been going on for a long time. She denies fevers, chills, sore throat or chest pain. She called an ambulance today because she felt as if she couldn't breath. In addition to these symptoms, she thinks that she has been having some diarrhea in the last 1-2 days. She has not looked at it, so does not know if it was watery or bloody. Has some mild abdominal pain with no N/V. . In the ER her initial sat was 77% on RA, with a RR of 40 and she was audibly wheezy. She was placed on a [**Last Name (NamePattern4) 597**] with improvement in sats to 97%. She was treated with combivent nebs x3, 125 mg IV solumedrol and azithromycin. Her sats went down to the upper 80s-low 90s on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 597**], [**First Name3 (LF) **] she was placed on a continuous nebulizer and sats improved. Additionally, her SBP was noted to be in the low 100s, she was treated with 500 cc of NS and her SBP improved to the 120s. . Upon arrival to the floor the pt was conversant and stated her breathing felt better. ABG was 7.28/74/36. Shortly after arrival she became more somnolent, she was placed on bipap and repeat ABG was 7.30/68/35. . ROS: Denies fevers, chills, ST, chest pain, dysuria, N/V, palpitations. Does have wheezing, increasing LE edema and diarrhea as described above. Past Medical History: Obstructive Sleep Apnea (on BiPAP at night) COPD (last [**First Name3 (LF) 1570**]'s [**12-21**] - FVC 0.77L (37%) FEV1 0.31L (21%) FEV1/FVC 57%. Last intubation [**8-20**]. Multiple ICU admissions for BiPAP. On [**3-17**].5 L by NC at home and BiPAP at night (14/10).) Possible diastolic HF DM2 HTN GERD Hyperlipidemia Morbid Obesity (BMI 51) Schizophrenia Depression s/p R ankle ORIF Social History: 40 pack-year history of smoking, quit 10 years ago, no alcohol, no drug use. Family History: non-contributory Physical Exam: VS: T: 98.5 HR: 96 Bp 131/55 RR: 21 O2 sat 99% on bipap Gen: obese, pale female with bipap on, appears tachypneic HEENT: anicteric sclera, left eye with yellow crusting Neck: obese, supple Cardio: RRR, nl S1 S2, 2/6 systolic murmur loudest at apex Pulm: diffuse expiratory wheezes b/l, crackles at LLL, not using accessory muscles Abd: soft, obese, epigastric tenderness, +BS Ext: 2+ DP pulses; 2+ edema b/l LE edema, slightly pitting Neuro: A&Ox2 (not oriented to date) Skin: no rashes, no jaundice Pertinent Results: [**2200-4-27**] WBC-17.3*# Hgb-10.3* Hct-35.5* MCV-76* RDW-15.9* Plt Ct-297 Neuts-89.6* Lymphs-6.3* Monos-3.1 Eos-0.5 Baso-0.6 PT-13.1 PTT-29.7 INR(PT)-1.1 Glucose-214* UreaN-26* Creat-0.9 Na-140 K-4.1 Cl-98 HCO3-33* AnGap-13 ALT-40 AST-26 LD(LDH)-261* CK(CPK)-38 AlkPhos-70 Amylase-15 TotBili-0.4 Lipase-19 CK-MB-4 proBNP-396* Calcium-9.0 Phos-5.4* Mg-2.2 cTropnT-<0.01 [**2200-4-28**] 12:48AM ABG pO2-201* pCO2-74* pH-7.28* calTCO2-36* . Echo [**6-21**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. The mitral valve appears structurally normal with trivial mitral regurgitation. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2199-4-20**], the findings are similar. . CXR [**4-27**]: Stable cardiomegaly. No acute cardiopulmonary disease. . EKG: NSR with rate of 91, nl axis, nl intervals, no ST elevations or depressions, TWF in II,AVl, V6 are old Brief Hospital Course: 66 yo female with h/o COPD, OSA, DM2, morbid obesity who presents with dyspnea, likely COPD exacerbation. . # Respiratory Distress: Pt with underlying COPD with h/o multiple admissions for bipap and intubations in the past. Wears 3-3.5L of NC O2 at baseline. Likely that symptoms are d/t a COPD exacerbation, as pt is diffusely wheezy on examination and responded to steroids and nebulizer treatments. ABGs c/w chronic compensated respiratory acidosis, with slight component of acute respiratory acidosis. Her WBC is elevated, but she does not have a new cough, fevers, chills or infiltrate on x-ray to suggest PNA. In the setting of recent diarrhea, could also have component of viral URI causing some respiratory distress. Pt does have questionable history of diastolic heart failure for which she is on lasix. She has noticed some increased LE edema, but exam, CXR and low BPs do not suggest volume overload. BNP somewhat elevated at 396. She was continued on bipap overnight and changed to nasal cannula during the day. Regular neb treatments continued. Started on IV steroids with transition to PO prednisone with taper. Azithromycin continued. Arterial line was placed for frequent ABGs (also concern of hypotension at first). She improved with these measures and was tolerating O2 by nasal cannula at home O2 flows. She will continue treatment at pulmonary rehab. . # Leukocytosis: WBC elevated at 17.6 with left shift. Pt denies fevers, chills, new cough or dysuria. Only source is slight abdominal pain and diarrhea. Could be d/t infectious diarrhea or viral syndrome. CXR with no definite infiltrate. Urinalysis and culture negative. Legionella urine antigen negative. Decreasing WBC counts at discharge. Pt afebrile. Azithromycin was given for COPD flare. . # Hypotension: Pt relatively hypotensive in the ER with SBPs in the upper 90s that improved with fluids. Upon arrival to the ICU her pressures were initially stable and then dropped to 78 systolic by noninvasive methods. Bolus was started and a-line was placed, SBP readings in the low 100s. Antihypertensives initially held but quickly restarted with blood pressures at goal. . # Anemia: Hct at recent baseline of 33-35. . # Schizophrenia: Continued outpt regimen of risperdone and fluoxetine. . # GERD: continued pantoprazole. . # Hyperlipidemia: Continued atorvastatin. Medications on Admission: 1. Albuterol Sulfate 0.083 % q4 hours prn 2. Albuterol 90 mcg aerosol, 1-2 puffs q4 hours prn 3. Tiotropium Bromide 18 mcg inhalation daily 4. Fluticasone-Salmeterol 250-50 mcg one puff [**Hospital1 **] 5. Furosemide 40 mg daily 6. Lisinopril 40 mg daily 7. Amlodipine 10 mg daily 8. Hydralazine 50 mg q8 hours 9. Atorvastatin 20 mg daily 10. Fluoxetine 80 mg daily 11. Risperidone 2 mg daily 12. Pantoprazole 40 mg daily 13. Docusate Sodium 100 mg [**Hospital1 **] 14. Bisacodyl 10 mg daily 15. Senna 8.6 mg [**Hospital1 **] 16. Acetaminophen 325 mg , 1-2 tabs q 4-6 hours prn pain 17. Regular insulin sliding scale Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluoxetine 40 mg Capsule Sig: Two (2) Capsule PO once a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 10. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Aricept 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 16. Insulin Regular Human 100 unit/mL Solution Sig: see attached Injection ASDIR (AS DIRECTED). 17. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 18. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 doses: on [**2200-5-1**]. 19. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 1 doses: on [**2200-5-2**]. 20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 doses: on [**2200-5-3**]. 21. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 doses: on [**2200-5-4**]. 22. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): hold for SBP <100. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: COPD exacerbation Secondary: Obstructive sleep apnea Type II Diabetes Mellitus GERD Hyperlipidemia Morbid obesity Schizophrenia/Depression Discharge Condition: Stable to pulmonary rehabilitation Discharge Instructions: You were admitted to the hospital with respiratory distress which resolved with treatment of your COPD. . Please continue to take your medications as prescribed. It was unclear if you were taking hydralazine at home; you should take this medication while at rehab. You will also need two more doses of azithromycin (an antibiotic) and a steroid taper as directed. . Please wear your BIPAP mask as directed by your doctor. . Please follow up with your primary care physician within two weeks of discharge from pulmonary rehabilitation. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within one to two weeks of discharge from the rehabilitation center. Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2200-5-28**] 2:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2200-6-2**] 2:40 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2200-6-2**] 3:00 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "285.9", "493.22", "428.30", "458.9", "530.81", "428.0", "V45.89", "276.2", "V15.82", "E947.9", "278.00", "311", "401.9", "272.4", "250.00", "327.23", "295.90", "787.91", "V85.4", "288.60" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.91" ]

icd9pcs

[ [ [] ] ]

9706, 9772

4675, 7029

316, 349

9964, 10001

3099, 4652

10586, 11366

2545, 2563

7697, 9683

9793, 9943

7055, 7674

10025, 10563

2578, 3080

269, 278

377, 2025

2047, 2434

2450, 2529

53,432

158,601

34866

Discharge summary

report

Admission Date: [**2112-5-19**] Discharge Date: [**2112-5-20**] Date of Birth: [**2058-2-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Vancomycin / Dilaudid Attending:[**First Name3 (LF) 2817**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname 79825**] is a 54 year old female with history of pancreatic cancer and portal vein thrombosis on warfarin admitted with recent GI bleed and Hct drop. . She reports feeling generalized fatigue in the last two weeks but noticed dark stool and "pink" urine about 4 days ago. She has been on coumadin since her diagnosis of portal vein thrombosis on [**3-9**]. She denies any recent NSAID, iron or pepto bismol use. Patient reports light-headedness and being unsteady on her feet at work recently. Also report dyspnea on exertion. CT A/P yesterday was overall unchanged- showed known portal vein occlusion and liver lesions . She was diagnosed with pancreatic cancer in [**2109**]- underwent Whipple in 12/[**2109**]. She has undergone chemotherapy with gemcitabine (completed in [**7-18**]) and CyberKnife therapy ([**2-16**]). She has known mets to her liver and lung but they have been stable per recent CT scan. She called her oncologist to report her recent symptoms and was asked to come to the ED for further evaluation. . In the ED, initial vs were: T- 97.8 P- 58 BP- 131/60 R- 20 O2 sat- 100% on RA. Labwork significant for Hct of 23.4 (down from 30.9 on [**2112-4-22**]). Also found to have mild transaminitis but it is actually down from levels check in [**2112-2-8**]. Lastly, her INR has been within 2 and 3 in the last 3 months (is 3.0 on admission). . She is being admitted to the MICU for close monitoring and GI scope to find source of bleed. . Review of systems: (+) Per HPI- nausea, vomiting, dyspnea on exertion, mild intermittent abdominal pain, dark stool, "pink" urine (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Pancreatic cancer, s/p Whipple, chemotherapy, CyberKnife. - Portal vein thrombosis - Psoriasis - Severe osteoporosis - Hip fracture after a fall in [**2109-3-10**]. - Breast surgery (removal of mass, negative cytology) [**2103**] - Tubal Ligation [**2091**] - ERCP - EUS Lap staging procedure [**9-16**] - GERD Social History: The patient lives in [**Location **], [**State 350**] with her husband. She has 1 son who lives in [**Name (NI) 8449**] and 1 daughter who lives in [**Name (NI) 8117**], [**Name (NI) 3844**]. She continues to work as a paralegal for a medical device company. She states that she eats a very healthy diet and mostly because after her surgery it is very difficult for her to tolerate foods that have a high-fat content. She states that she is used to exercising often by taking long walks; however, at this point she is trying not to because she needs to maintain her weight. She states that she has approximately [**12-12**] alcoholic beverages per week and has never used intravenous drugs, intranasal cocaine or marijuana. The patient does not smoke. Family History: Her family medical history is significant for the patient's mother who was diagnosed with rheumatoid arthritis and died last year of vascular dementia at the age of 82. Her father is 86 years old and has colon cancer with liver metastases and has suffered from cardiovascular disease. She has a sister who is 64 years old and only suffers from rheumatoid arthritis. Physical Exam: Vitals: T: 97.2 BP: 114/67 P: 56 R: 12 O2 100% on RA: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Mildly tender to deep palpation in epigastrim GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2112-5-18**] 08:40AM BLOOD WBC-3.9* RBC-2.61* Hgb-7.8* Hct-24.2* MCV-93 MCH-29.9 MCHC-32.2 RDW-14.2 Plt Ct-116* [**2112-5-19**] 11:45AM BLOOD WBC-5.1 RBC-2.63* Hgb-7.7* Hct-23.4* MCV-89 MCH-29.3 MCHC-32.9 RDW-14.6 Plt Ct-165 [**2112-5-19**] 05:57PM BLOOD WBC-3.5* RBC-2.48* Hgb-7.5* Hct-22.4* MCV-90 MCH-30.1 MCHC-33.3 RDW-14.7 Plt Ct-105* [**2112-5-20**] 02:36AM BLOOD WBC-3.1* RBC-3.26*# Hgb-9.8*# Hct-28.5*# MCV-88 MCH-30.1 MCHC-34.3 RDW-15.2 Plt Ct-102* [**2112-5-18**] 08:40AM BLOOD PT-28.3* INR(PT)-2.8* [**2112-5-19**] 12:58PM BLOOD PT-30.4* PTT-44.1* INR(PT)-3.0* [**2112-5-19**] 05:57PM BLOOD PT-22.1* PTT-29.1 INR(PT)-2.1* [**2112-5-19**] 05:57PM BLOOD Plt Ct-105* [**2112-5-20**] 02:36AM BLOOD PT-17.2* PTT-25.1 INR(PT)-1.5* [**2112-5-18**] 08:40AM BLOOD UreaN-22* Creat-0.7 Na-135 K-4.3 Cl-104 HCO3-25 AnGap-10 [**2112-5-19**] 11:45AM BLOOD Glucose-109* UreaN-19 Creat-0.6 Na-134 K-4.1 Cl-103 HCO3-27 AnGap-8 [**2112-5-19**] 05:57PM BLOOD Glucose-100 UreaN-14 Creat-0.5 Na-138 K-4.1 Cl-107 HCO3-24 AnGap-11 [**2112-5-20**] 02:36AM BLOOD Glucose-154* UreaN-17 Creat-0.6 Na-135 K-4.2 Cl-105 HCO3-24 AnGap-10 [**2112-5-18**] 08:40AM BLOOD ALT-93* AST-47* AlkPhos-154* TotBili-0.4 [**2112-5-19**] 11:45AM BLOOD ALT-101* AST-56* LD(LDH)-127 AlkPhos-159* TotBili-0.5 [**2112-5-20**] 02:36AM BLOOD ALT-84* AST-48* AlkPhos-152* TotBili-2.7* [**2112-5-18**] 08:40AM BLOOD Albumin-3.7 [**2112-5-20**] 02:36AM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.3 Mg-1.9 EGD- 1. Varices at the lower third of the esophagus and gastroesophageal junction (ligation) 2. Varices at the gastroesophageal junction and lower third of the esophagus 3. Erythema, congestion, abnormal vascularity and mosaic appearance in the whole stomach compatible with portal gastropathy Otherwise normal EGD to second part of the duodenum Brief Hospital Course: 1. GI Bleed- Patient reports dark stool for 4 days. Has no history of GI bleed. She was started on coumadin in recent months but her INR has been therapeutic since initiation of therapy. Found to have ~10 point Hct drop since [**4-22**] (31 to 23) and was symptomatic. She was admitted to the MICU and underwent a EGD which showed grade 1 and grade 2 esophageal and gastric varices. She underwent banding x 1 and was started on IV protonix [**Hospital1 **] and octreotide gtt. Octreotide was stopped at midnight. She received two units PRBCs and Hct bumped appropriately. Liver team would like her to be discharged from the ICU on carafate x 10 days, iron supplementation x 7 days, protonix 40mg PO daily. We are holding her coumadin in the setting of recent GI bleed. She has follow-up with Dr. [**Last Name (STitle) **] on [**5-25**] and scheduled an EGD for [**5-31**]. 2. Portal venous thrombosis- Started on coumadin in [**2-17**] (3mg per day except for Friday when she takes 2mg per day). Her INR has remained within therapeutic range while on anticoagulation. She had presented to clinic with increased fluid overload and was started on lasix, spironolactone and nadolol about 30 days ago. While here, we held her coumadin (in the setting of bleed) as well as her home lasix, spironolactone, and nadolol. Her pressures improved with blood products. Given recent bleed, we are only resuming home lasix and nadolol on discharge. She will re-evaluate spironolactone when she shes outpatient providers within 1 week of discharge. 3. Pancreatic cancer- Patient not currently on active therapy. Has not been on since 8/[**2110**]. Had CT on [**5-18**] with final read pending at the time of discharge. Medications on Admission: 1. Ativan 0.5 mg tablets 1-2 tablets by mouth every 4-6 hours as needed for nausea, insomnia or anxiety, 2. Warfarin 1 mg tablets 1 tablet by mouth 2-3 times daily, dosage varies 3. Acetaminophen as needed. 4. Vitamin E- 800 units daily 5. Nadolol 20mg- 1 tab daily 6. Furosemide- 20mg PO daily 7. Spironolactone- 50mg PO daily Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 9 days. Disp:*36 Tablet(s)* Refills:*0* 2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Vitamin E 800 unit Capsule Sig: One (1) Capsule PO once a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: GI bleed Secondary: Pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with a GI bleed. While here, you were monitored closely in the ICU and did well. You underwent a scope which showed an esophageal varix with no signs of active bleed. You received blood here and responded appropriately. Upon discharge, you were stable and comfortable. The following changes were made to your medications: 1. Please hold your coumadin in the setting of this GI bleed. 2. Please start taking carafate 1g four times a day for 9 more days 3. Please start taking iron supplementation for 7 total days 4. Please start taking pantoprazole 40mg by mouth daily 5. Please do not take your home spironolactone until you are seeing by your outpatient [**Provider Number 35338**]. You may resume your home dose of lasix and nadolol. Please contact your primary outpatient physician or go to the emergency department if you experience persistent/worsened GI bleed, dizziness, chest pain, shortness of breath or any other medically concerning symptom. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] on [**2112-5-25**] at 2:30pm to get your labs checked. You will be scheduled for a follow-up scope on [**5-31**] at 10:30am with Dr. [**Last Name (STitle) **].

[ "530.81", "571.8", "456.8", "V58.61", "790.01", "696.1", "578.1", "197.7", "V12.51", "197.0", "V10.09", "572.3", "456.1", "537.89", "733.00" ]

icd9cm

[ [ [] ] ]

[ "42.33", "99.04" ]

icd9pcs

[ [ [] ] ]

8989, 8995

6207, 7936

305, 311

9088, 9088

4368, 6184

10263, 10479

3407, 3776

8321, 8966

9016, 9067

7962, 8298

9239, 10240

3791, 4349

1847, 2280

257, 267

339, 1828

9103, 9215

2302, 2617

2633, 3391

10,003

144,039

52816

Discharge summary

report

Admission Date: [**2111-11-21**] Discharge Date: [**2111-12-2**] Date of Birth: [**2070-10-24**] Sex: M Service: MOST RESPONSIBLE DIAGNOSIS: Traumatic right hemothorax. OPERATIONS: [**2111-11-22**] - Dr. [**Last Name (STitle) 954**] - Right thoracotomy for retained hemothorax. HISTORY: This man was traumatized in [**Country 16573**]. He jumped out of a window to escape an assailant. He was hospitalized in [**Country 16573**]. He was treated for a hemothorax and a fractured foot. The hemothorax was treated conservatively. After a couple of weeks of treatment in [**Country 16573**], he flew here and presented himself to our hospital in late [**Month (only) 1096**]. PHYSICAL EXAMINATION: There was decreased air entry on the right side. He had a cast-like device on the right foot. He was hemodynamically stable. He was afebrile. HOSPITAL COURSE: Initially, we placed a chest tube to see if we could evacuate what we thought was a retained hemothorax. That did not prove to be successful. On [**11-21**], he underwent right thoracotomy and evacuation of the retained hemothorax. We cleaned the chest up nicely. Drains were placed. He had a vague history of some sort of bleeding disorder, and after surgery, he did manifest what we thought was abnormal bleeding. We could not identify a specific problems. Fortunately, it did not seem to be something we could not control. The chest tubes were removed after several days. Orthopedics saw him regarding his fractured foot. He then started to develop fevers. He ended up having malaria. Treatment was initiated by the Infectious Disease Service. He was discharged home in early [**Month (only) 404**] in good condition. At the time of this dictation, he has been seen in followup at Dr.[**Name (NI) 31850**] office, and the recent x-ray was satisfactory. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Last Name (NamePattern4) 108902**] MEDQUIST36 D: [**2112-2-17**] 13:44 T: [**2112-2-18**] 06:55 JOB#: [**Job Number 108903**]

[ "289.9", "825.23", "E879.8", "807.08", "860.2", "458.2", "825.25", "401.9", "998.11" ]

icd9cm

[ [ [] ] ]

[ "33.99", "34.09", "34.04", "38.93" ]

icd9pcs

[ [ [] ] ]

886, 2104

722, 868

1,163

137,602

50060

Discharge summary

report

Admission Date: [**2198-1-7**] [**Year/Month/Day **] Date: [**2198-1-11**] Date of Birth: [**2139-5-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 58 year old male with PMH significant for diastolic heart failure, pulmonary hypertension and stage III CKD who presented from an outside hospital with respiratory distress, chest pain, fever, chills and cough. He states he had been feeling ill for about one week with increasing difficulty breathing while at home. At the outside hospital, he was treated with both Lasix and a nitroglycerin drip. He was admitted to the intensive care unit at [**Hospital1 18**] for further management. Past Medical History: Stage III chronic kidney disease (baseline creatinine 2.1) Cystinuria with a history of heavy stone burden (on longstanding penicillamine until 3 yrs ago) Cutis laxa secondary to penicillamine [**Last Name (un) 4584**] [**Location (un) **] Syndrome (thought to be secondary to penicillamine) Restrictive cardiomyopathy (diastolic CHF) Pulmonary hypertension Atrial flutter s/p AV node ablation (with postprocedure complete heart block requiring pacemaker placement) Pancreatic low grade, benign mucinous cystic neoplasm (LGBMC) Large bilateral renal cysts Small AAA Popliteal aneurysm hyperuricosuria restless leg syndrome GERD Social History: Works as a software engineer. Is married with no children. Denies any smoking or drug history; uses rare alcohol. Family History: Several second-degree relatives with DM2. Physical Exam: Gen - awake, alert, NAD, no use of accessory muscles HEENT - OP clear Neck - Difficult to assess JVP given thickened neck; appears nml. CVS - RRR, no noted m/r/g Lungs - Decreased BS bilat w/ mild rales throughout lung fields Abd - soft, NT/ND. Ext - no LE edema b/l Pertinent Results: CXR - [**2198-1-7**]: There is a new airspace consolidation involving the left lung (mostly upper) consistent with pneumonia. The right lung is grossly unremarkable. A dual-lead pacemaker is seen with leads overlying the right atrium and right ventricle, unchanged since [**2197-10-25**]. There is no pneumothorax. CXR - [**2198-1-9**]: A new airspace opacity has developed in the right lower lobe since the prior day. However, there has been considerable improvement in left upper and medial left lower lobe opacities. There are no effusions or pneumothorax. The heart is normal in size. Mediastinal contours are unchanged. A dual-lead pacemaker/ICD device is again noted. RENAL ULTRASOUND: Multiple cysts are seen within bilateral kidneys, the largest of which is located on the right and measures greater than 16 cm. Note is made of fullness of the right renal collecting system, similar to CT from [**2197-5-26**]. The bladder is normal. Brief Hospital Course: Pt is a 58 yo man with PMH significant for a h/o HTN, diastolic CHF, pulm HTN who initially presented from [**Hospital3 3765**] in respiratory distress w/ evidence of pneumonia on CXR along w/ pulm edema. . # Resp distress/pneumonia: The patient was originally admitted to the intensive care unit given his level of respiratory distress. On admission, it was felt his shortness of breath was most likely due to pneumonia seen on CXR along w/ component of CHF especially given response to nitro gtt and Lasix while at [**Hospital3 **]. The patient also had AFib with RVR while in the intensive care unit, which was treated with IVF resuscitation. The patient was also treated with CTX/azithro for a community acquired pneumonia. He had a negative DFA for influenza. He did not require intubation for his breathing, but initially did need a non-rebreather while in the unit. He was maintained on nasal cannula while on the floor, with his oxygen requirement lessening each day, until he did not require oxygen while at rest. His ambulatory saturation did hover around 88-90% so he was sent home with portable oxygen until he is fully recovered from his pneumonia. He was discharged to complete a course of oral antibiotics to treat his community acquired pneumonia. . # Cardiac: A. Pump: The patient has a h/o diastolic CHF. He appeared to have component of failure contributing to resp status above given response to treatment of CHF which was likely contributed to by AFib w/ RVR. He was treated with Lasix and beta-blcokade as needed. He did require one additional dose of Lasix the morning after he was called out of the unit, but was then maintained on his home regimen without incident. His captopril was held throughout this admission given his acute on chronic renal failture. He was advised to restart his captopril at [**Hospital3 **]. . B. Rhythm: Pt w/ h/o paroxysmal AFib and is not on coumadin due to problems w/ epistaxis. The patient was originally maintained on telemetry after leaving the ICU. After remaining in sinus for >24 hours, telemetry was discontinued. He remained in NSR after IVF resuscitation and resolution of fever. . C. Cor: The patient has no h/o CAD. He did have a slight troponin leak which was felt to be consistent with demand ischemia. He was briefly on a heparin gtt, which was rapidly discontinued. He was discharged to resume his ACE-I. . # Acute on chronic renal failure: The patient had an elevated Cr to 3.4 from baseline 2.1 which was likely due to infection. The patient was given IVF in the ED & ICU. He appeared euvolemic with mild pulmonary edema. His creatinine improved to his baseline. The patient was continued on his sevelamer and calcitriol. . # HTN: The patient was continued on his outpt Lasix dose. He was advised to restart his captopril and eplerenone after [**Hospital3 **]. . # Hyperuricosuria: The patient was continued on his allopurinol. . # Restless leg: The patient was continued on his outpatient doses of Neurontin, Requip and oxycontin. . # Code: Full Medications on Admission: Furosemide 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Potassium Citrate 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q DAY AT 6PM (). Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO QPM PRN as needed. Magnesium Chloride 64 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Captopril 25 mg Tablet Sig: One (1) Tablet PO four times a day. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Ropinirole 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital3 **] Medications: 1. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Potassium Citrate 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day. 3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q DAY AT 6PM (). 6. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO QPM PRN as needed. 7. Magnesium Chloride 64 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Captopril 25 mg Tablet Sig: One (1) Tablet PO four times a day. 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 17. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 18. Oxygen Continuous oxygen at 2L NC to keep oxygen saturation levels greater than 92% 19. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 20. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital3 **] Disposition: Home [**Hospital3 **] Diagnosis: Primary: #Pneumonia #Diastolic CHF secondary to restrictive cardiomyopathy #ATN and ARF due to hypovolemia/hypotension . Secondary: #HTN #Chronic kidney disease #Cystinuria #Pulmonary hypertension #PAF #Hyperuricosuria #GERD #Restless leg syndrome [**Hospital3 **] Condition: Stable, resting O2 sat of 95%. [**Hospital3 **] Instructions: You were admitted to the hospital with pneumonia and heart failure. Whiel you were in the hospital we treated you with antibiotics. You required additional oxygen to help keep the levels of oxygen in your blood at adequate levels. You may need to use oxygen at home during the day when you are walking around or otherwise exerting yourself. Please complete your course of antibiotics. We did not change any of your other medicines. Please restart your captopril tomorrow. Please resume taking your other medications as prescribed by your outpatient physicians. Please follow up with your primary care doctor as well as your kidney doctors [**First Name (Titles) **] [**Last Name (Titles) **]. Followup Instructions: Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14069**] at [**Telephone/Fax (1) 37171**]. Please call to make a follow up appointment within one to two weeks of your [**Telephone/Fax (1) **] from the hospital. Please have Dr. [**Last Name (STitle) 14069**] check your creatinine level at your appointment. Please follow up at your other previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2198-2-14**] 11:00 . Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2198-4-6**] 10:30 . Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2198-5-14**] 11:15

[ "425.4", "428.0", "333.94", "403.90", "427.31", "585.3", "486", "276.52", "530.81", "428.32", "416.8", "584.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2986, 6028

344, 351

2017, 2963

10230, 11132

1671, 1714

6054, 10207

1729, 1998

285, 306

379, 871

893, 1522

1538, 1655

64,996

181,151

53972

Discharge summary

report

Admission Date: [**2135-4-13**] Discharge Date: [**2135-5-6**] Date of Birth: [**2062-4-18**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: expressive aphasia Major Surgical or Invasive Procedure: [**2135-4-14**]: cerebral angiogram with partial embolization of AVM [**2135-5-3**] Re-embolization of AVM [**2135-5-5**] Trachesotomy [**2135-5-5**] PEG placement History of Present Illness: 72 yo M hx CAD s/p AAA repair [**2133**] on ASA 325mg daily who presented with 3 days of HA and onset today of difficulty with word finding according to his wife. OSH CT demonstrated left IPH and the patient was transferred to [**Hospital1 18**] for further evaluation. Pt notes difficulty with his memory today and headache. He denies numbness, weakness tingling. Past Medical History: HTN, DM, hyperlipidemia, MI, PVD, Angina, AAA repair [**2133**], Back [**Doctor First Name **] [**2120**] with rods and plates, cardiac stent [**2120**] Social History: lives with wife Family History: non-contributory Physical Exam: O: BP: 107/70 HR: 88 R: 21 O2Sats: 95 % 2l NC Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, atraumatic Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech is halted with good comprehension and repetition. Naming intact however he frequently repeats an answer in the follow up question 3-4 times but eventually corrects himself. No dysarthria. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, left slightly larger than right. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Slight right facial droop. sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-23**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin PHYSICAL EXAM UPON DISCHARGE: Trach and Peg in place Patient on Vent support CPAP Sitting in chair, alert with eyes open and follow simple commands to come extremities. Plegic in right upper extremity. Pertinent Results: [**4-13**] CT Head- IMPRESSION: Left frontal intraparenchymal hematoma, with neighboring edema. Mild adjacent sulcal effacement. There is no shift of midline structures. Neighboring [**Name2 (NI) 110674**] hyperdense structures may represent vessels. These findings may represent a bleed from a vascular malformation. Alternatively, this could represent a hemorrhagic mass. Findings further evaluated with CTA or MRI. [**4-13**] CTA Head- IMPRESSION: 1. Left frontal arteriovenous malformation with enlarged hypertrophied arteries arising from the A2 segment of anterior cerebral artery on the left and enlarged draining veins with multiple high flow venous aneurysms, draining into the superior sagittal sinus. 2. Unchanged left frontal intraparenchymal hematoma with surrounding vasogenic edema and mild mass effect on the left lateral ventricle. [**4-14**] CT Head- In comparison to study obtained 14 hours prior, there is no significant change in size and distribution of the intraparenchymal hemorrhage centered in the left frontal lobe. No new area of intracranial hemorrhage is identified. [**4-15**] CT Head- FINDINGS: Evaluation of the left frontal region is limited by streak artifact from metallic coils after AVM coiling. Again seen is the large parenchymal hemorrhage inthe left frontal lobe measuring 3.2 x 2.1 cm, unchanged (3:18). Surrounding vasogenic edema is unchanged with mild mass effect on the left lateral ventricle. Again seen is a small focus of air just inferior to the coils, likely post-procedural (3:15). No new hemorrhage is identified. There is no shift of normally midline structures. Basal cisterns are patent.[**Doctor Last Name **]-white matter differentiation elsewhere is preserved. Mild mucosal thickening is seen in the ethmoid air cells. The mastoid air cells and middle ear cavities are clear. No acute osseous abnormality is identified. IMPRESSION: No change from [**2135-4-15**] at 5:25 a.m., rougly 12 hours earlier. Status post coiling of left frontal AVM with unchanged parenchymal hemorrhage and surrounding edema in the left frontal lobe. No new edema or hemorrhage. [**4-15**] CT Chest- FINDINGS: Endotracheal tube is in standard position, terminating at the level of the _ arch; a nasogastric tube loops in the lower esophagus and would need to be advanced 12 cm to move all the side ports into the stomach. Large areas of confluent consolidation with volume loss in both lower lobes, sparing only portions of the superior and anterior basal segments is atelectasis. There is no bronchiectasis in either lower lobe or any obstructing mass in the left hilus. On the right, the superior segmental bronchus and the basal trunk could be circumferentially narrowed by a hilar mass, 5:114-133, a determination difficult to make on a non contrast study. A small region of peribronchial infiltration in the anterior segment of the left upper lobe, 3:17-20 could be an early pneumonia, but the upper lungs are otherwise relatively clear. The interstitial abnormality in the lungs on the preceding conventional radiograph, three hours earlier, was due to transient pulmonary edema, accompanied by small left pleural effusion, all of which has resolved. Mediastinal lymph nodes are numerous but not pathologically enlarged. Atherosclerotic calcification is found in the left main, anterior descending and circumflex coronary arteries, and at the bifurcation of the innominate artery and in the left subclavian artery arch and descending portion of the thoracic aorta, but the heart is only minimally enlarged. There is no pleural or pericardial effusion. IMPRESSION: 1. Severe bibasilar atelectasis. No pneumonia or diffuse lung disease. No bronchial obstruction on the left. Right perihilar atelectasis and retained secretions cannot be distinguised from a hilar mass compromising lower lobe superior segment and basal trunk bronchi. Suggest continued followup, first with conventional radiographs--subsequent chest radiograph available at the time of this review already showed improvment in RLL atelectasis. 2. Resolved pulmonary edema. 3. Nasogastric tube needs to be advanced. [**4-17**] CT HEAD FINDINGS: Assessment of the vertex is limited by streak artifacts from embolization material. Again noted is a 3.1 cm focus intraparenchymal hemorrhage with surrounding edema adjacent to embolized AVM in the left frontal lobe, unchanged in size compared with a preprocedural CT. Otherwise, there are no new hemorrhagic foci, or areas of infarction. No shift of normally midline structures is noted. There is some sulci effacement of the left frontal lobe, but the remaining sulci are within normal limits. A lacune is noted in the posterior limb of the right internal capsule suggestinf chronic small vessel ischemic disease. There is preservation of [**Doctor Last Name 352**]-white differentiation in the non-affected parts of the brain. The basal cisterns appear patent. There is no evidence of fracture. There is concentric thickening of the maxillary, sigmoidal, sphenoidal and frontal sinuses, which appear new compared with [**2135-4-14**]. The mastoid air cells and middle ear cavities are clear. IMPRESSION: 1. Status post embolization of the left frontal AVM with unchanged focus of intraparenchymal hemorrhage and surrounding edema. 2. Interval increase in thickening of the mucosal lining of the sinuses suggests acute versus subacute sinusitis. BILAT LOWER EXT VEINS [**2135-4-19**] No DVT in the right or left lower extremity LENI's [**2135-4-28**]:IMPRESSION: No evidence of deep vein thrombosis in either leg. CT chest abd pelvis [**2135-4-29**] IMPRESSION: 1. Decompressed stomach, through which a nasointestinal tube traverses. Transverse colon passes anterior to the gastric body with the stomach in its presently decompressed state, limiting window for PEG placement. 2. Indeterminate 2.8-cm right adrenal nodule and possible 8 mm left adrenal nodule, which could be further evaluated with MRI or contrast enhanced CT washout protocol on a non-urgent basis. 3. Mild increase in bibasilar pulmonary densities consistent with atelectasis with increased superimposed consolidation. Pneumonia or aspiration cannot be excluded. 4. Stable-appearing bifurcated infrarenal abdominal aortic graft. 5. Distal sigmoid colonic narrowing is felt likely to represent peristaltic activity but correlation with screening colonoscopy results is recommended. [**2135-5-4**] CXR IMPRESSION: AP chest compared to [**4-29**] through [**5-3**]: Left PIC line, previously cannulating the azygos vein may still be in that location or may have passed into the SVC. ET tube in standard placement. Feeding tube passes into the stomach and out of view. Heterogeneous opacification at the lung bases has increased since [**4-29**] and there is a small irregular opacity in the right mid lung projecting over the medial aspect of the lower scapula which is more apparent today than previously. I wonder if this patient is aspirating. Heart size is normal. No appreciable pleural effusion or indication of pneumothorax. [**2135-5-4**] CT FINDINGS: Streak artifact from Onyx embolization material again limits the evaluation of the adjacent parenchyma. Allowing for this, there is continued evolution of the left frontal parenchymal hemorrhage with slight interval decrease in size of the hemorrhage and extent of surrounding vasogenic edema. No new hemorrhage is seen. There is no evidence of acute territorial infarction. The ventricles and sulci are unchanged in size. There is no shift of normally midline structures. There is moderate mucosal thickening in the sphenoid more than the ethmoidal air cells and left maxillary sinus. There is fluid-opacification of the mastoid air cells, bilaterally, progressive over the series of studies dating to [**2135-4-13**], which likely relates to prolonged intubation and supine positioning. No fracture is seen. IMPRESSION: Status post re-embolization of left frontal AVM with continued evolution of the left frontal parenchymal hemorrhage, and no new blood. [**2135-5-4**] LENS: negative for DVT bilaterally Brief Hospital Course: The patient was admitted to the Neuro ICU for Q1 hour neuro checks, SBP control less than 140. We requested 2 units of platelets for platelet dysfunction in the setting of full dose aspirin therapy - hematology only released 1 unit. Holding Aspirin. Keppra 500mg [**Hospital1 **] for seizure prophylaxis was initated. The patient remained NPO overnight with IVF and metformin and glipizide will be held. He underwent a CTA Head which revealed a left frontal arteriovenous malformation with enlarged hypertrophied arteries arising from the A2 segment of anterior cerebral artery on the left and enlarged draining veins with multiple high flow venous aneurysms, draining into the superior sagittal sinus. On [**4-14**] the patient underwent a cerebral angiogram to further evaluate the AVM. There was partial embolization of the AVM performed at that time. He tolerated the procedure and was extubated and returned to the SICU. It was noted post procedure that he had decreased movmement in the right UE/LE. Overnight he developed respiratory distress requiring reintubation. A CXR was performed which confirmed severe pulmonary edema bilaterally. Head CT was performed and stable. On [**4-15**] he remained intubated and weak on the right side. A ptt was checked and the femoral sheath was removed without complication. A repeat CT was peformed that evening that was unchanged. Triple abx coverage was started for presumed VAP PNA. He had fever to 102. and workup was initiated. Patient was febrile to 101.1, bronch was done. Head CT was stable and TF were started. He is currently being treated for a VAP and UTI. On [**4-19**] and [**4-20**], patient remained unchanged on exam. With treatment of cipro/vanc/cefipine, his fevers have decreased. On [**4-22**], The patient's neurological exam was improved. The patient's eye were open spontaneously and they were tracking. The patient was moving the left upper extremity spontaneously and purposfully, The patient moves the toes to command bilaterally. There continued to be no movement in the right upper extremity. The patient was diuresed with lasix in an attempt to improve the patient ventilatory status. On [**4-23**], The patient continued to follow commands in the lower extremities by moving the toes. The patient was diuresed and the ventilator was weaned. The patient continued to have a moderate amount of respiratory secretions. On [**4-24**], The patient was extubated at 1000. Chest PT and frequent suctioning and repositing of the patient occured to maximize his respiratory status. The patient had a weak cough and trouble independently raising secretions. The white blood count was slightly elevated at 13. On [**4-25**], The patient was out of bed to the chair via [**Doctor Last Name **] lift. The patient remained extubated on high flow o2 with a )2 saturation of 92-95%. The BUN was noted to be elevated at 43 and the White Blood Count was improved at 11.6. The patient was given lasix 40 mg IV to maximize diuresis in an attempt to improve respiratory status further. The patient continued on Cefeipime for Mssa pneumonia and UTI. On [**4-26**] he was OOB to chair and was off of face tent for 2 hours however he required the hgih flow O2 again for decreasing sats. Speech and swallow was scheduled to see him however given his respiratory status this was deferred. [**Last Name (un) **] has been involved for elevated blood sugars. On [**4-27**], patient became tachypnic and O2sats were dropping. He was re-intubated. On [**4-28**], his EO to voice and he was spontaneous with L side, but no movement on the R side, no commands. Trach and PEG will be discussed with family. On [**2135-4-29**] he was febrile to 101.5 and he was restarted on antibiotics. ACS eval was done for trach/peg planning. An incidental adreanl cyst was noted. He was prepped for angiogram with embolization and this occured on [**5-3**]. Follow up CT on [**5-4**] did not show and infacrt or acute changes. He had a trachesotomy and PEG on [**5-5**]. LENS were done and there was no evidence of DVT. [**5-6**] patient is stable in the ICU and alert, tube feeds will be started at noon, which is 24 hours post PEG Placement, if tolerated patient will advance to goal. Transfer to Vent weaning rehab pending. Medications on Admission: ASA 325mg daily, atenolol 25mg daily, metformin 500mg [**Hospital1 **], Glyburide 5mg [**Hospital1 **], simvastatin 40mg daily, fenofibrate 160mg daily, omeprazole 20 mg [**Hospital1 **], gabapentin 600mg TID, MVI Discharge Medications: 1. levetiracetam 100 mg/mL Solution [**Hospital1 **]: One (1) PO BID (2 times a day). 2. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 3. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2 times a day). 4. simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. gabapentin 300 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3 times a day). 6. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 7. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 8. Acetaminophen Extra Strength 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 9. metoprolol tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 10. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 12. modafinil 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO daily (). 13. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: Six (6) Puff Inhalation Q6H (every 6 hours). 14. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 15. nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day). 16. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 17. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 18. insulin regular hum U-500 conc Injection 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 20. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 21. magnesium sulfate 4 % Solution [**Last Name (STitle) **]: One (1) Injection PRN (as needed). 22. calcium gluconate in D5W 2 gram/100 mL Solution [**Last Name (STitle) **]: One (1) Intravenous ASDIR (AS DIRECTED). 23. potassium phosphate dibasic 3 millimole/mL Parenteral Solution [**Last Name (STitle) **]: One (1) Intravenous PRN (as needed). 24. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain/vent intolerance 25. CefTAZidime 2 g IV Q8H 26. potassium chloride 20 mEq/50 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous PRN (as needed). Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: arteriovenous malformation respiratory distress [**1-20**] pulmonary edema expressive aphasia intraparenchymal hemorrhage sinusitis vap urinary tract infection adrenal cyst protien/calorie malnutrition Electrolyte imbalance 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: Angiogram with Embolization of AVM Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No driving until you are no longer taking pain medications Followup Instructions: Please call Dr. [**First Name (STitle) **] office at [**Telephone/Fax (1) 1669**] for to arrange fo follow up in 6 months with an MRI/MRA Completed by:[**2135-5-6**]

[ "599.0", "401.9", "461.9", "E879.8", "518.52", "041.11", "V58.67", "263.9", "041.6", "272.4", "276.69", "443.9", "431", "348.5", "276.9", "997.31", "342.90", "412", "250.02", "276.0", "784.3", "V45.82", "781.94", "V45.4", "V49.87", "413.9" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.72", "88.41", "99.29", "31.1", "43.11", "88.48", "96.6" ]

icd9pcs

[ [ [] ] ]

17999, 18097

10798, 15075

324, 490

18365, 18365

2648, 10775

19160, 19328

1114, 1132

15340, 17976

18118, 18344

15101, 15317

18543, 19137

1147, 1313

266, 286

2455, 2629

518, 888

1655, 2425

18380, 18519

910, 1065

1081, 1098

80,956

130,695

6432

Discharge summary

report

Admission Date: [**2158-11-7**] Discharge Date: [**2158-11-13**] Date of Birth: [**2083-8-3**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Iodine; Iodine Containing Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2158-11-7**] Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] Porcine), Coronary Artery Bypass Graft x 4 (Left internal mammary artery to Left anterior descinding, Saphenous vein graft to Diagonal, Saphenous vein graft to Obtuse Marginal, Saphenous vein graft to Posterior descending artery) History of Present Illness: 75 y/o male who presented to OSH in [**10-14**] with severe shortness of breath and intially treated medically. He was then transferred to [**Hospital1 18**] for further care. During that admission he was ruled in for a myocardial infarction and underwent cardiac cath. Cath revealed severe three vessel coronary disease. Echo and also showed severe aortic stenosis. Referred for cardiac surgery. Past Medical History: Aortic Stenosis, Coronary Artery Disease s/p Myocardial Infarction [**10-14**], Hypertension, Hyperlipidemia, Rheumatic heart disease, Chronic renal insufficiency, Stroke x 2, Right Carotid stenosis, s/p Left Carotid stent [**2158-10-4**] Social History: Married, lives at home with his wife. Quit tobacco in [**2095**]. Denies alcohol or IVDU Family History: Non-contributory Physical Exam: Admission: HR: 72 Resp: 12 B/P: 117/74 Height: 5'[**59**]'' Weight: 195 lbs. Gen: NAD Skin: Unremarkable HEENT: Unremarkable Neck: Full ROM Chest: Lungs CTA bilaterally Heart: RRR 2/6 systolic murmur Abd: Soft, non-tender, non-distended. +BS x4 quadrants. Extremities: warm and well perfused. Varicosities: right lower extremity varicose veins. Neuro: Grossly non-focal. At Discharge: VS:Temp: 97, BP: 152/82, HR: 78 SR, RR: 20 O2 sat: 96% on RA. Gen: NAD Skin: Grossly in tact. Mid sternal incision clean/dry/intact, no redness, swelling or drainage. Left leg incision open to air with steri strips. No redness, swelling or drainage. HEENT: Conjunctiva pink, MMM. Neck: full ROM Chest: Lungs diminished at bases bilaterally. Heart: RRR, no murmurs, gallops or rubs. Abd: Soft, non-tender, slightly distended. Last BM [**11-12**]. Ext: +3 Lower extremity edema. Neuro: Grossly non-focal. Pertinent Results: [**11-7**] Echo: Prebypass: 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, mid and apical portions of the inferior wall.. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are three aortic valve leaflets. There is severe aortic valve stenosis (area <0.8cm2). Moderate (2+) aortic regurgitation is seen. 5. The mitral valve leaflets are moderately thickened. Moderate to severe (3+) mitral regurgitation is seen. Post Bypass: 1. Patient is being AV paced and receiving an infusion of epinephrine. 2. Biventricular systolic function is unchanged. 3. Bioprosthetic valve seen in the aortic position. The valve appears well seated and the leaflets move well. Trace central aortic insufficiency present. 4. Moderate mitral regurgitation present. 5. Aorta is intact post decannulation. [**2158-11-7**] 04:25PM UREA N-21* CREAT-1.0 CHLORIDE-114* TOTAL CO2-23 [**2158-11-7**] 04:25PM WBC-14.3* RBC-2.70* HGB-8.2* HCT-23.0* MCV-85 MCH-30.4 MCHC-35.8* RDW-15.2 [**2158-11-7**] 04:25PM PLT COUNT-155 [**2158-11-7**] 04:25PM PT-16.8* PTT-46.6* INR(PT)-1.5* [**2158-11-12**] 08:50AM BLOOD WBC-8.2 RBC-3.56* Hgb-10.6* Hct-31.0* MCV-87 MCH-29.7 MCHC-34.2 RDW-15.3 Plt Ct-150 [**2158-11-9**] 02:39AM BLOOD PT-15.2* PTT-36.9* INR(PT)-1.3* [**2158-11-12**] 08:50AM BLOOD Plt Ct-150 [**2158-11-12**] 08:50AM BLOOD Glucose-120* UreaN-31* Creat-1.2 Na-137 K-4.1 Cl-98 HCO3-28 AnGap-15 [**Known lastname **],[**Known firstname **] [**Medical Record Number 24761**] M 75 [**2083-8-3**] Radiology Report CHEST (PA & LAT) Study Date of [**2158-11-10**] 3:24 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2158-11-10**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 24762**] Reason: eval for pneumothorax s/p chest tube removal [**Hospital 93**] MEDICAL CONDITION: 75 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumothorax s/p chest tube removal Final Report HISTORY: Chest tube removal, to evaluate for pneumothorax. FINDINGS: In comparison with study of [**11-9**], the left chest tube has been removed. There is a small apical pneumothorax that was apparently present on the previous examination. Otherwise little change in the appearance of the heart and lungs. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: FRI [**2158-11-10**] 5:31 PM Imaging Lab Brief Hospital Course: Mr. [**Known lastname **] was a same day admit after undergoing pre-operative work-up during prior admission. On day of admission he was brought to the operating room where he underwent an aortic valve replacement and coronary artery bypass graft x 4. Please see operative report for surgical details. In summary he had an AVR (#23mm ST. [**Male First Name (un) 923**] pericardial) and CABG(LIMA-LAD, SVG-OM, SVG-Diag, SVG-PDA)with a bypass time of 112min and a cross clamp time of 92min. There were no OR complications. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He remained hemodynamically stable in the immediate post-op period. Sedation weaned and he was successfully extubated. He was transferred to the step down unit on POD#2. His activity was gradually inceased and medications where adjusted. Of note, he had intermittent atrial fibrillation treated with amiodarone and subsequently started on coumadin. On POD#6 he was ready for discharge to Life Care at [**Location (un) 1475**]. Medications on Admission: Aspirin 325mg qd, Atenolol-Chlorthalidone 100/25mg qd, Lisinopril 10mg qd, Allopurinol, Zocor 10mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): Target INR 1.5-2.0. [**11-13**] dose 5mg. 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for carotid stent. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily): hold if K+ is > 4.5. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 [**Hospital1 **] for one week, then 400 daily for one week, then 200 daily. 13. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection Q AC and HS. 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold if HR < 55 and SBP < 100. 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP <100. 16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day: 40mg [**Hospital1 **] for 2 weeks, then 40 mg daily. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Myocardial Infarction PMH: Myocardial Infarction [**10-14**], Hypertension, Hyperlipidemia, Rheumatic heart disease, Chronic renal insufficiency, Stroke x 2, Right Carotid stenosis, s/p Left Carotid stent [**2158-10-4**] Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) **] [**1-8**] wks after d/c rehab. [**Telephone/Fax (1) 3183**] Pt to call for appointment. Completed by:[**2158-11-13**]

[ "410.72", "458.29", "511.9", "424.1", "V12.54", "272.4", "427.31", "414.01", "585.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "34.04", "36.13", "36.15", "39.61", "38.91", "35.21" ]

icd9pcs

[ [ [] ] ]

7901, 7968

5015, 6067

326, 639

8338, 8344

2393, 4354

8855, 9074

1449, 1467

6219, 7878

4394, 4419

7989, 8317

6093, 6196

8368, 8832

1482, 1854

1868, 2374

267, 288

4451, 4992

667, 1065

1087, 1327

1343, 1433

62,622

117,047

27995

Discharge summary

report

Admission Date: [**2150-4-26**] Discharge Date: [**2150-5-1**] Date of Birth: [**2088-1-14**] Sex: M Service: MEDICINE Allergies: Carbamazepine Derivatives Attending:[**First Name3 (LF) 613**] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: Foley insertion [**2150-4-26**] Foley removal [**2150-4-29**] Foley re-insertion [**2150-4-30**] History of Present Illness: Mr. [**Known lastname 1007**] is a 62yo M with history of lung cancer s/p resection, DM and CAD who presents after not taking his medications for the past 3 weeks and being found at home incontinent of urine. He was brought in by EMS (and police escort he says) after his roommate called after finding him incontinent. . In the ED, initial vs were: T 98.6 P 50 BP 114/98 R 20 O2 sat 100% RA. He was found to have hyperglycemia, hyperkalemia without peaked T waves and in acute renal failure with creatinine of 8.8 from 1.6 in [**10-26**]. His urinalysis was significant for glucosuria without ketones. He had an anion gap of 24 and was started on an insulin drip at 10cc/hr. A foley was placed and 2.5L of urine returned. Patient was given 2 liters of IVF and admitted to the ICU for further management. Vitals on transfer were 93, 141/86, 22, 100% RA. . In the ICU, he reports three-four weeks of not taking his medications as it was too confusing. His roommate typically cooks for him but has been on an alchol binge recently, and he reports decreased PO intake for the past couple weeks. On admission to the ICU, he complained of some diffuse abdominal cramping but was otherwise asymptomatic. He endorsed some increased urinary frequency from diuretics in the past but none recently. Patient has been wearing diapers for the past two months as he has been intermittently incontinent. He has not noted any hematuria. In the ICU he was monitored and his Cr improved, his anion gap closed, his hyperglycemia improved and he was taken off his insulin drip, and his toe film returned not osteolyelitis. Therefore, he was sent to the floor. . Upon transfer to the floor, he was somewhat confused and continually asked where he was. He denied any pain anywhere and was eager to "just understand all of this." . . Review of systems: (+) Per HPI, bilateral hand and foot numbness x 10 years, intermittent fevers and chills for unknown period of time (-) Denies night sweats, recent weight loss or gain. Denies headache, congestion, cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: 1. HTN 2. CAD 3. DM 4. Hyperlipidemia 5. Strokes 6. Panic/anxiety disorder Social History: The patient started smoking cigarettes at age 16 and smoked up to 2-4 packs per day. He quit smoking at age 58. The patient is currently retired. He denies alcohol intake. He worked previously in labor and is a retired janitor. He lives with a roommate who typically helps cook meals for him. He does allude to that roomate being his "incarcerator" and when asked what that meant he said "well she made me come here", but when asked specifically if she abused him, he replied "people just don't understand" Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 95.6 BP: 131/71 P: 94 R: 18 O2: 98% RA General: Alert, oriented to person and year, not date or month, no acute distress HEENT: Sclera anicteric, MM dry, EOMI, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, initial wheezing which cleared with cough, No rales or rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place, no CVA tenderness Ext: Left large toe with erythema surrounding nail and severe onycholysis, warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema, strength 5/5 in all extremities DISCHARGE PHYSICAL EXAM: Tc+Tm 98.3, BP 116/63 (116-131/63-89), 53 (53-89), 18 (18-22), 98%RA (98-100%RA) FS: 284, 338, 376, 324 GENERAL - elderly-appearing man in NAD, comfortable, sleeping HEENT - EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ND, NT, no masses or HSM, EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs),dressing on L big toe. NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-21**] throughout, sensation grossly intact throughout Pertinent Results: ADMISSION LABS: [**2150-4-26**] 05:55PM SED RATE-95* [**2150-4-26**] 05:55PM PT-12.4 PTT-21.9* INR(PT)-1.0 [**2150-4-26**] 05:55PM PLT COUNT-203 [**2150-4-26**] 05:55PM WBC-10.9 RBC-5.16 HGB-15.0 HCT-43.9 MCV-85 MCH-29.0 MCHC-34.1 RDW-13.0 [**2150-4-26**] 11:08PM GLUCOSE-424* UREA N-128* CREAT-7.6*# SODIUM-139 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22* [**2150-4-26**] 11:15PM URINE HOURS-RANDOM CREAT-35 SODIUM-18 POTASSIUM-29 CHLORIDE-17 [**2150-4-26**] 08:43PM GLUCOSE-445* LACTATE-1.2 NA+-132* K+-5.3 CL--88* TCO2-20* DISCHARGE LABS: [**2150-5-1**] 05:35AM BLOOD WBC-6.4 RBC-3.87* Hgb-11.4* Hct-33.0* MCV-85 MCH-29.3 MCHC-34.4 RDW-13.0 Plt Ct-172 [**2150-5-1**] 05:35AM BLOOD Glucose-194* UreaN-35* Creat-2.6* Na-145 K-3.9 Cl-113* HCO3-24 AnGap-12 [**2150-5-1**] 05:35AM BLOOD Calcium-7.4* Phos-3.3 Mg-1.8 IMAGING: CXR [**2150-4-26**]: IMPRESSION: Bilateral low lung volumes with crowding of bronchovascular markings. No definite sign of pneumonia. RENAL U/S [**2150-4-27**]: FINDINGS: The right kidney measures 12.8 cm. The left kidney measures 12.8cm. No stones or masses are identified in either kidney. There is mild pelvocaliectasis, most marked in the lower poles, bilaterally, without evidence of frank hydronephrosis. The urinary bladder is contracted. IMPRESSION: Mild bilateral pelvocaliectasis, without evidence of frank hydronephrosis. No renal stones or masses identified. L FOOT XRAY [**2150-4-27**]:FINDINGS: Three views show no definite destructive change or gas within softtissues. Calcification in soft tissues is consistent with diabetes. CT CHEST [**2150-4-30**]: IMPRESSION: No evidence of new or recurrent intrathoracic malignancy following right upper lobectomy. Atherosclerotic coronary calcifications. HEAD CT: 4/15/11:1. No acute intracranial abnormality. 2. Slightly enlarged ventricles for the patient's age and relative to the sulci. No evidence of transependymal CSF flow. 3. Chronic small vessel ischemic change and old lacunes as previously Brief Hospital Course: Mr. [**Known lastname 1007**] is a 62yo M with history of lung cancer s/p resection, type 2 DM and CAD who presents with medication noncompliance and was found to be in acute renal failure with hyperglycemia consistent with HONK . # Acute renal failure: His creatinine on admission was elevated to 8.8 from recent value of 1.6 in [**10-26**]. His large amount of urine return after Foley placement in the ER is suggestive of possible post-obstructive etiology with possible overflow incontinence at home. This may be related to underlying BPH. Pre-renal cause is also likely given he appears dry on exam and patient's renal ultrasound did not show hydronephrosis. In addition, his Cr improved dramatically with fluids. Therefore this was likely pre-renal ARF with a component of BPH. We gave the patient IVF and tamsulosin with good effect. However on [**4-30**] patient became obstructed again and Cr bumped to 3.0, which improved to 2.6 with foley placement. Foley drained almost 2L of fluid when it was placed. Patient may therefore need a chronic indwelling foley catheter, and has a urology f/u appt to be evaluated for this. On dispo, patient taking in 2L per day of PO fluids, and therefore did not need further IVF to help with pre-renal component of ARF. # Hyperglycemia: He is a known diabetic and had not taken his medications for the past 3 weeks PTA which likely lead to his significant hyperglycemia. His elevated glucose in the setting of elevated anion gap was concerning for DKA but his lack of urinary ketones suggested this was more likely HONK. He was started on an insulin drip in the ER and transitioned to insulin sc [**4-27**]. Aggressive IVF repletion with NS/D5/0.45NS with K per protocol. His HgBA1C returned at 16.8. He will need insulin teaching at rehab as he is clearly not controlled on oral medications. We sent him to rehab on an insulin sliding scale and glargine at 16units QHS. This regimen was keeping his sugars in the high 200's and will likely need to be further titrated at rehab. We were hesitant as pt's renal failure was likely causing slower absorption of the glargine and we were concerned about the possibility of hypoglycemia. . # Toe wound: Concerning for underlying osteomyelitis in diabetic patient with peripheral neuropathy and poor hygiene and given elevated CRP and ESR was treated initially with unasyn and vancomycin for cellulitis. No evidence of osteo on xray. Vancomycin was stopped [**4-27**], and unasyn [**4-28**], after podiatry saw the patient and determined the wound was from trauma. We soaked the patient's foot in Domeboro soaks QD per podiatry recs. He has an outpatient podiatry appt for follow-up. # Altered mental status: His roomate and friend came to visit on [**4-28**] and felt he was more disoriented than at baseline. Apparently pt always has word finding difficulties (per them s/p "a few strokes"), but is usually AAOx3. Patient's MS improved with his renal failure and hyperglycemia until he was AAOx3 at dispo. Psychiatry saw the pt and felt that he did not show s/sx of a mental illness, but that his "oddness" was likely early dementia. We did a head CT to r/o NPH, which did show slightly englarge ventricles for pt's age, but no transepndymal CSF flow, and ventricle size essentially unchanged from CT head in [**2148**] but AMS and urinary incontinence were new sx. We did not believe that this therefore correlated with NPH, but were unable to rule it out completely. Therefore, pt will need outpatient neuro f/u as well as likely neuropsych testing and possible outpatient LP if neurology feels that this could be NPH. He will see neurology this month for further workup. In addition, we also ordered tests for reversible causes of dementia including vitamin B12, folate, TSH and RPR. We will follow these up and transmit this information to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] if any of them are positive. . # CAD: He has a history of CAD reportedly s/p MI. He was restarted on home medications after contacting his pharmacy. PENDING RESULTS: BCX [**2150-4-26**]: Pending BCX [**2150-4-27**]: Pending RPR [**2150-5-1**]: Pending Vitamin B12 [**2150-5-1**]: Pending Folate [**2150-5-1**]: Pending TSH [**2150-5-1**]: Pending TRANSITIONAL CARE ISSUES: Patient will need his insulin dose adjusted at rehab and will need diabetes teaching and insulin teaching when discharged home. PATIENT EXPECTED TO BE AT REHAB LESS THAN 30 DAYS. Medications on Admission: Lipitor 40mg daily Plavix 75mg daily Lorazepam 0.5mg qHS PRN Diazepam 5mg TID Prilosec 20mg daily Imdur 30mg daily SL Nitro PRN Metformin 1g [**Hospital1 **] Toprol XL 25mg daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 10. aluminum-calcium Packet Sig: One (1) Packet Topical QDaily as needed for fungal infection on toe: Do a soak of L big toe once a day. 11. Zyprexa 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: Hold for sedation. 12. insulin glargine 100 unit/mL Solution Sig: Sixteen (16) units Subcutaneous QHS. 13. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous QAHS. Discharge Disposition: Extended Care Facility: Rosscommon Discharge Diagnosis: Primary: Acute renal failure, BPH with obstruction, Hyperglycemia Secondary: Type II Diabetes Mellitus Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr [**Known lastname 1007**], You were seen in the hospital for acute renal failure and hyperglycemia. You were treated with a Foley catheter and intravenous fluids for your renal failure and with insulin for your hyperglycemia. While you were here, we did a test that checks your longterm blood glucose levels called a hemoglobin A1C, and this was elevated to 16.8, indicating your average blood sugars are in the 400s. This means that you will need insulin when you go home. You should be taught how to use this as at rehab. In addition, you may need to have a chronic foley catheter placed in the future. We made the following changes to your medications: 1) We STARTED you on a MULTIVITAMIN once a day by mouth. 2) We STARTED you on SENNA twice a day as needed for constipation. 3) We STARTED you on TYLENOL 325mg every 6 hours as needed for pain. 4) We STARTED you on DOCUSATE 100mg twice a day. 5) We STARTED you on TAMSULOSIN 0.4mg once a day. 6) We STARTED you on DOMEBORO soaks once a day to your L big toe. 7) We STARTED you on ZYPREXA 2.5mg at bedtime. 8) We STOPPED your DIAZEPAM. If you start to feel withdrawal symptoms please inform your doctor at your rehab facility. 9) We STOPPED your LORAZEPAM. 10) We STOPPED your GLIPIZIDE. 11) We STOPPED your METFORMIN. Please continue to take your other medications as prescribed. DO NOT DRIVE AGAIN UNTIL YOU HAVE COMPLETED A FORMAL DRIVING EVALUATION. Driving with your current medical illnesses could put your life and others lives at risk. If you experience any of the below listed Danger Signs, please call your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospital admission. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2150-5-7**] 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 Department: Podiatry Location: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 543**] We are working on a follow up appointment with Podiatry within 1-2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above. Department: NEUROLOGY When: TUESDAY [**2150-5-12**] at 2:30 PM With: [**First Name11 (Name Pattern1) 4092**] [**Last Name (NamePattern1) 4093**], MD [**Telephone/Fax (1) 2574**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **Please contact your Primary Care Physician for [**Name Initial (PRE) **] referral for this visit** Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2150-5-13**] at 8:00 AM With: UROLOGY UNIT [**Telephone/Fax (1) 164**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **Please contact your Primary Care Physician for [**Name Initial (PRE) **] referral for this visit. They can fax it to [**Telephone/Fax (1) 68166**], attention [**Doctor First Name **]** PLEASE NOTE: On [**2150-5-1**] at 1:30pm Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from [**Hospital1 18**] called pt's PCP referral [**Name9 (PRE) 68167**] service and requested a referral for the above neurology and urology appts. Please ensure that these referrals have been completed prior to sending pt to these appts. The PCP [**Name9 (PRE) 68167**] service stated that it takes 5 days for the referrals to go through. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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Discharge summary

report+report

Admission Date: [**2101-9-14**] Discharge Date: [**2074-2-5**] Date of Birth: [**2064-5-20**] Sex: F Service: MEDICAL ADMISSION DIAGNOSIS: Aspergillus for rigid bronchoscopy and/or flexible bronchoscopy. CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 37 year-old female without a prior medical history with a current complaint of worsening shortness of breath and cough. The patient first began feeling ill roughly one year ago with symptoms of shortness of breath, lethargy and decreased ability to talk. The shortness of breath tends to worsen at night and in the morning. Per the patient the shortness of breath was initially a 4 out of 10 during onset a year ago, continued to progress and peak at 8 out of 10 in severity during [**Month (only) **] before she was admitted to an outside hospital. She presented to several outside hospitals total in five admissions in the past year with multiple outside imaging studies. Of note the patient was in a coma per the patient's mother for two and a half weeks and intubated times two during last admission at an outside hospital, which lasted eight weeks. During the admission the patient was told her right lung collapsed and her left lung had decreased lung function. The patient is currently on 3 liters of O2 nasal cannula at home. The sputum production has decreased over time. The patient has an additional complaint of night sweats at rate of four times per week for the past several months, weight loss up to 25 pounds unintentional over the past year, fevers and chills about three times a week over the past week with fevers up to 103 for the past two days. Right sided focal chest pain that is located at the level of the tenth rib, which worsens with cough and is more severe on inspiration versus expiration. The right sided chest pain began two days ago during a severe bout of coughing when the patient heard a snap in the chest and "could not move for a short period of time." The patient denies any recent sick contacts or travel (went to the Bahamas three year ago), denies nausea, vomiting, constipation, diarrhea, hemoptysis, hematemesis, melena, hematochezia or dysuria. On further questioning the patient noted that she had a upper respiratory infection roughly a month before the onset of her current one year shortness of breath. PAST MEDICAL HISTORY: None. MEDICATIONS: 1. Fluconazole. 2. Guaifenesin. 3. Pantoprazole 40 mg b.i.d. 4. Iron 325 mg b.i.d. 5. Zoloft 100 mg q day. 6. Ciprofloxacin 750 mg b.i.d. 7. Combivent two puffs q 6 hours. 8. O2 via nasal cannula 3 liters. VACCINES: Nothing beyond childhood. ALLERGIES: Codeine, which gives hives. FAMILY HISTORY: Father died at 52 years from pancreatic cancer. Was also told (he had a poor immune system). Mother who is alive and healthy. The patient has five children, which are also healthy with no current respiratory problems. SOCIAL HISTORY: The patient is married and lives with her husband and five healthy children. She has been a housewife and a mother. The patient stopped smoking six months ago and has used cigarettes on and off for about ten years. She admits to the use of intranasal cocaine and smoked marijuana for about one year roughly 20 years ago and has never injected any drugs. She reports regular exercise until a few months ago when her condition started to decline. There is no known sexual risk for HIV as the patient has had only one partner, her husband, since [**15**] years of age. PHYSICAL EXAMINATION: In general, no acute distress. Vital signs temperature current 98.2. Temperature max 98.2. Blood pressure 118/87. Heart rate 91. Respiratory rate 20. 93% on room air with a second sat [**Location (un) 1131**] of 95% on room air. Head and neck examination normocephalic, atraumatic. Extraocular movements intact. Pupils are equal, round and reactive to light. No thyromegaly. Oropharynx is clear. JVD was flat. Pulmonary examination decreased air movement throughout. No rales. Positive wheeze, positive rhonchi, diaphragmatic contraction was even. Dull to percussion at the right apex. Cardiac examination S1 and S2 were normal. No murmurs, rubs or gallops. Regular rate and rhythm. Abdomen examination tender in the right upper quadrant at the level of the approximately the tenth rib in the midaxillary line, soft, nondistended, no organomegaly, normoactive bowel sounds. Positive flatus. Rebound was negative. No peritoneal signs. Extremities/vascular examination moves all extremities times four. Distal pulses are +2 bilaterally. No clubbing, cyanosis or edema. Neurological examination alert and oriented times three. Cranial nerves II through XII are intact. DATA: From an outside hospital on [**2101-8-29**], the CT of trachea without intravenous contrast was done, which showed that there were bilateral breast implants. There is thickening of bilateral maxillary sinuses. There is few small mediastinal lymph nodes. There is diffuse circumferential thickening of the entire tracheal wall extending from the subglottic area to the proximal bronchi. There is slight asymmetry of the thickening with nodularity and marked narrowing of the trachea throughout the course of the trachea. The diameter of the cervical trachea is 7 by 10 mm. The diameter of the intrathoracic portion of the trachea is 5 by 6 mm representing a high grade stenosis of this portion. The caliber of the main bronchi is preserved. The wall thickening is up to 7 mm at the level of the thoracic inlet. There is a component of trachea malacia with a tracheal volume that goes from 88 square mm in inspiration to 26 square mm during dynamic breathing. There is no evidence of bronchial malacia. There is a tiny area of calcification in the left wall of the cervical trachea at the level of the thyroid gland. There is a tiny calcification of the calcified granuloma in the right upper lobe. Multi [**Last Name (un) 50751**] and 3-D reformats again demonstrated marked narrowing of the trachea with circumferential thickening and nodularity. It [**Last Name (un) 7162**] demonstrated the severe trachea malacia. On [**2101-8-30**] spirometry was also performed, SVC was 59% predicted, FEV1 was 20% predicted, MMS 13% predicted, FEV1/FVC ratio was 34% of predicted, TLC was 103, FRC 142, RV 183, VC 69, IC 60, ERV 86 and RV/TLC ratio of 178. The results demonstrated the FVC was moderately reduced while the FEV1 and FEV1/FVC ratio were markedly reduced. There was blunted inspiratory and expiratory flow. The TLC was normal. FRC/RV/RV/TLC ratios were elevated. The DLC was mildly reduced. These results were consistent with marked obstructive ventilatory defect and a blunted flow volume contour consistent with airway obstruction. ADMISSION LABORATORIES: White blood cell count 6.3, hematocrit 39.5, MCV 91, platelets 279, PT 12.2, PTT 29.1, INR 1.0. Differential neutrophils 55.1%, bands 0%, lymphocytes 6.8%, monocytes 5.6%, eosinophils 1.2%, basophils 1.3%. Chem 7 was found have a sodium of 142, potassium 4.3, chloride 105, bicarb slightly elevated at 30, BUN 12, creatinine 0.6, glucose 91 with an anion gap of 11. HOSPITAL COURSE: The patient is a 37 year-old female without prior significant past medical history with a current complaint of worsening shortness of breath. Outside hospital endoscopy, mucosal biopsies demonstrated a positive Aspergillosis infection. The patient has per report failed Caspofungin and Itraconazole. The patient was recently put on Miconazole for which she has currently run out of the medication. Per report the last endoscopy performed at the outside hospital demonstrated no further indications of Aspergillosis. The patient was referred to the [**Hospital1 346**] to be worked up through interventional pulmonary. The primary concern was to address her worsening pulmonary status. The patient was started on intravenous fluids at 1:30 a.m. on [**2101-9-15**] and was made NPO overnight for procedure the following morning with interventional pulmonary and ENT. The patient was also put on 2 liters nasal cannula O2 to maintain saturations. The patient underwent surgery for potential stent placement in the bronchial airways, however, intraoperatively the patient was noted to have a fused larynx and ENT was consulted. ENT then placed a tracheostomy tube to address the acute airway tracheomalacia. The surgical plan at the time was changed to a three staged series of procedures, the first one being placement of the tracheostomy and to allow ventilation. Number two lysing of the anterior and posterior portions of the fused larynx via ENT and number three rigid bronchoscopy/flexible bronchoscopy via interventional pulmonary with possible stenting of the airways. Postoperatively, the patient was in the MICU for a 24 hour period to watch the newly placed tracheostomy tube. There were no other significant events during the MICU stay. The patient was then transferred to the floor the following day. A swallow was then consulted. The patient then failed a passing air valve test. The patient was put on NPO until clearance via speech and swallow studies. Intraoperative two punch biopsies of the four tracheal rings were obtained. Preliminary pathological results included no abnormal cartilage, no bacteria, no fungal elements, no Aspergillosis. Gram stain revealed no PMNs, no microorganisms and anaerobic culture was negative. Acid fast smear was negative and acid fast culture was pending at the time of dictation. The fungal culture was pending. Micro laboratories were sent with the tracheal biopsy, which demonstrated alpha strep, which grew from broncho only and rare Lactobacillus growth. Infectious disease was consulted and discontinued the Fluconazole and started Amphotericin B. Respiratory care was consulted and recommended continuing a cool mist on the tracheostomy site 40%. The patient was noted to have continued and worsened vocal cord dysfunction without voice production. The patient remained NPO. Social work was consulted to help with coping. A PICC was placed in the right arm and subsequent chest x-ray status post PICC placement demonstrated that the PICC was lined in good position. On [**2101-9-20**] an allergy consult was obtained. Nutrition was consulted as well regarding tube feeds versus total parenteral nutrition regarding the fact that the patient remained NPO secondary to aspiration risk. The patient underwent a bed side speech and swallow examination, which was failed and subsequently underwent a video swallowing study through radiology. The oropharyngeal fluoroscopic swallowing evaluation demonstrated aspiration with thin and nectar thickened consistencies likely due to delayed swallowing reflex inability to completely closed vocal cords. Chin tuck with nectar consistency prevented aspiration. Silent aspiration occurred during swallow with thin plus nectar thick liquids. There was no spontaneous cough reflex. On [**2101-9-21**] the Ciprofloxacin was discontinued secondary to lack of evidence of current empyema. The patient was started on thick liquid po and solid foods with chin tuck. Physical therapy was consulted for evaluation regarding home safety and risk of fall. Potassium was noted to be 3.1. The patient was given a one time bolus of 40 mg of potassium po. The morphine PCA was discontinued and the patient was started on Dilaudid 2 to 8 mg po q 4 hours prn for pain after a pain management consultant was obtained. ENT reexamined the patient at the bedside and confirmed that the trach position was okay and no infection was at the site. UCON records were obtained. HIV 1 and 2 were found to be negative, [**Doctor First Name **] was negative, ANCA was normal, CRP was slightly elevated at 2.5, CH 50 was slightly elevated at 216, ferritin was slightly elevated at 750, CD4 slightly elevated at 1288, total protein down to 5.4, C3 was slightly elevated at 173. An allergy and immunology consult was obtained with recommendations of potential diagnoses including a defect of T cell function and/or neutrophil chemotaxis. Infectious disease recommendations at the time were to discontinue the Ambazone and start Amphotericin D 1 mg per kilogram q 24 hours prehydrated with 500 ml of normal saline. Data came back with IGG levels at 843, IGA 201, IGM 63, all within normal limits. On [**2101-9-22**] a CT sinus was read as having one, mucosal thickening slightly polypoid in nature, left greater then right involving the left maxillary sinus. Two, middle and inferior turbinates that were not visualized well secondary to surgical resection versus erosion. Three, sphenoid sinuses and frontal sinuses are clear. Four, no air fluid levels and bony destruction. Five, no capitation in the ethmoid sinus. Six, no acute sinusitis. Seven, partial calcification of the right mastoid sinus, which was only partially visualized, which would suggest mastoiditis. The evaluation at the time suggested that the patient had a high likelihood of physical recovery, but recommended daily ambulation and discharge to home as soon as possible. On [**2101-9-23**] the patient's pain management was addressed and the Dilaudid was changed to 12 mg q 3 hours prn pain with Tylenol t.i.d. A rheumatological consult was obtained. Interventional pulmonology discussed the plan and decided that the phase of the three phases of surgery would begin the following week. A psychiatric consult was obtained secondary to the patient's depressed mood. The patient's depressed mood seemed more then and out of proportion given the current circumstances. The infectious disease consult called the UCON ID Department and obtained the mucosal biopsies for further review at [**Hospital1 69**]. The punch biopsies read at [**Hospital1 69**] from the intraoperative trach placement on [**2101-9-15**] were sent to [**Hospital1 2025**] for a second review as well. The rheumatological consult felt that diagnoses of the following Wegener's was unlikely given no hemoptysis, no renal involvement and negative ANCA. Sarcoid was possible, however, mediastinal lymph nodes were likely reactive secondary to pulmonary infection and pulmonary function tests are usually restricted in pattern. Amyloid is likely given normal liver and positive renal function. Relapsing polychondritis remained possible, can have frequent involvement, and the biopsy will rule this out. Septal perforations are probably secondary to past cocaine use. Recommendations included biopsies that should not be done during inflammatory. If strong clinical suspicion for relapsing polychondritis was felt. Tracheomalacia was likely secondary to persistent fungal infection or repeated intubations. IGE came back as 93.3 within normal limits. Sputum samples from the trachea site demonstrated gram positive cocci in pairs and clusters, gram stain greater then 25 PMNs, however, there were also greater then 10 epithelial cells per field consistent with contamination. Respiratory cultures preliminary were pending and fungal cultures were pending at the time of dictation. An OR of the sinuses done as well demonstrated dissection of the nasal turbinates and the nasal septum as per the CT. Nonspecific soft tissue thickening in the maxillary sinuses and to a lesser extent in the anterior ethmoid air cells with no evidence of bony destruction or soft tissue edema surrounding the sinuses. The sphenoid sinus and frontal sinuses were well aerated. There is opacification of the right mastoid air cells. Tympanic cavity appears well aerated. No edema in orbits or inferior to the skull base and/or brain parenchyma. CT of the chest was also read with worsening diffuse peritracheal and proximal bronchial circumferential wall thickening, scarring at bilateral lung bases, 5 mm subpleural ground glass opacity nodule in the left lower lobe, several small mediastinal lymph nodes without change and do not have or meet criteria for pathology. Given the findings on the MRI and CT sinus, CT chest and fourth tracheal ring biopsies, pathologies and micro, negative for Aspergillosis, the Amphotericin D was discontinued per ID's recommendations. ID pulmonology also removed the tracheal sutures not the stay sutures. This was done through lead tension at the tracheostomy site secondary to patient's continuous complaint of pain. Respiratory care continued to note copious amounts of white sputum production. CONDITION ON DISCHARGE: Pending. DISCHARGE STATUS: Pending. DISCHARGE DIAGNOSES: Pending. DISCHARGE MEDICATIONS: Pending. FOLLOW UP PLANS: Pending. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 50752**] MEDQUIST36 D: [**2101-9-25**] 11:12 T: [**2101-9-28**] 07:39 JOB#: [**Job Number 50753**] Admission Date: [**2101-9-14**] Discharge Date: [**2101-10-5**] Date of Birth: [**2064-5-20**] Sex: F Service: [**Hospital1 **] HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old female without a prior medical history who presents as a transfer from an outside hospital for evaluation of tracheal stenosis. The patient reports that over the past year she has had worsening shortness of breath. She began feeling ill approximately one year ago with shortness of breath, lethargy, and a decreased ability to talk clearly, with shortness of breath. Tends to worsen at night and in the morning. Shortness of breath was at its worst in [**Month (only) **] when she was admitted to Yocon. The patient reports that she has had over five admissions in the past year with shortness of breath with multiple outside imaging studies. Of note, the patient was in a coma for two and a half weeks and intubated twice during her last admission at the outside hospital which lasted a total of eight weeks. During the admission the patient was told that her right lung collapsed and her left lung had decreased function. She is currently on 3 liters of oxygen at home via nasal cannula. The patient does have a history of night sweats, a 25-pound unintentional weight loss over the past year, fevers and chills (of up to 103 degrees Fahrenheit), and right-sided chest pain that worsens with cough and is more severe on inspiration. The patient denies sick contacts or travel; although she did go to the Bahamas three years ago. She denies any nausea, vomiting, cough, diarrhea, hemoptysis, hematemesis, melena, hematochezia, or dysuria. PAST MEDICAL HISTORY: The patient has no past medical history. By history, she had a history of aspergillosis treated for an unknown duration of time with voriconazole. MEDICATIONS ON ADMISSION: 1. Voriconazole (the patient had run out if and was no longer taking it over the past few days). 2. Guaifenesin. 3. Protonix 40 mg by mouth twice per day. 4. Iron 325 mg by mouth twice per day. 5. Zoloft 100 mg by mouth once per day. 6. Ciprofloxacin 750 mg by mouth twice per day. 7. Combivent inhaler 2 puffs inhaled q.6h. ALLERGIES: The patient reports that CODEINE gives her hives. FAMILY HISTORY: The patient's father died at the age of 52 from pancreatic cancer. Her mother is alive and well. SOCIAL HISTORY: The patient had five children who are all healthy with no current respiratory problems. The patient is married and lives with her husband. She is a housewife and mother. She stopped smoking six months ago and has used cigarettes on and off for the past ten years. She admits to the use of intranasal cocaine and smoked marijuana for about one year; roughly 20 years ago. She has never used any intravenous drugs. She reports she had regularly exercised up until a few months ago. She has no known risk factors for human immunodeficiency virus and has had only one sexual partner since she was 18 years of age. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient was afebrile on admission, with a blood pressure of 118/87, her heart rate was 91, her respiratory rate was 20, and her oxygen saturation was 93% on room air. Head, eyes, ears, nose, and throat examination revealed the sclerae were anicteric. She had no thyromegaly. The oropharynx was clear. Jugular venous distention was flat. Cardiovascular examination revealed the patient had a normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. Pulmonary examination revealed decreased air movement. There were no rales. There was positive wheezes and rhonchi. There was dullness to percussion at the right apices. The abdomen was tender in the right upper quadrant around the tenth rib. The abdomen was soft and nondistended. There was no organomegaly. There were positive bowel sounds. Extremity examination revealed no edema. The extremities were warm. Radial and dorsalis pedis pulses were 2+ bilaterally and equal. Neurologic examination revealed cranial nerves II through XII were grossly intact. Light touch was intact. Her strength was [**4-11**] throughout. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data revealed from the outside hospital revealed that on [**2101-8-29**] she had a history of aspergillins and tracheal stenosis. PERTINENT RADIOLOGY/IMAGING: A computed tomography examination revealed circumferential thickening of the entire tracheal wall extending from the subglottic area to the proximal bronchi. There was slight asymmetry of the thickening with nodularity and marked narrowing of the trachea throughout the course of the trachea. The diameter of the cervical trachea was 7 mm X 10 mm. The diameter of the intrathoracic portion of the trachea was 5 mm X 6 mm; representing a high-grade stenosis in this portion. The caliber of the main bronchi was preserved. Wall thickening was up to 7 mm at the level of the thoracic inlet. There was a component of tracheal malacia with a tracheal volume but decreased on inspiration. There was no evidence of bronchial malacia. The differential diagnosis included Wegener granulomatosis given that she also had associated thickening of the maxillary sinuses as well as amyloidosis, sarcoidosis, infectious granulomatosis process. It was thought that involvement of the posterior wall makes relapsing polycarditis unlikely. Spirometry from [**2101-8-29**] revealed forced vital capacity moderately reduced while the FEV1 and FVC:FEV1 were markedly reduced. She had blunted inspiratory and expiratory flow. Her total lung capacity was normal. Functional residual capacity, RV, and RV:TLC ratio were elevated. Diffusing capacity of lungs for carbon monoxide was mildly reduced; revealing a marked obstructive ventilatory defect and blunted flow volume contours consistent with an airway obstruction. IMPRESSION: Our impression was that the patient was a 37-year-old female with a past medical history of shortness of breath worsening over the course of one year with multiple hospital admissions and intubations. The patient has a history of aspergillosis. It was unclear why an immunocompetent person would have an aspergillosis; although, it was noted that it was a limited infection and had not extended beyond the lung. CONCISE SUMMARY OF HOSPITAL COURSE: In order to evaluate this, the patient had multiple consultations called for assistance. The Infectious Disease Service consulted and found no indication that the patient was immunocompromised. She had been treated completely with antifungal medications. It was thought that there was no indication for further treatment at this time. Subsequent biopsies were negative for aspergillosis. An Allergy Service consultation was called as well as a Rheumatology consultation. They felt that the patient most likely did not have Wegener granulomatosis. She was found to be antineutrophil cytoplasmic antibody negative. They recommended an immunodeficiency workup for evaluating the titers for past exposures such as diphtheria IgG titer test, pneumococcus IgG titer, and aspergillosis IgG titer panel. As stated, antineutrophil cytoplasmic antibody was negative. Antinuclear antibody was negative. Serum protein electrophoresis revealed an IgG, IgA, and IgM levels all within the normal ranges. Human immunodeficiency virus antibody was negative. Rapid plasma reagin was nonreactive. Multiple sputum cultures revealed no fungus and no mycobacteria and only oropharyngeal flora. IgG subclass determination revealed subclasses 1 through 4 all within the normal range. Aspergillosis antibodies for different species were also found to be negative for Aspergillosis [**Country 11730**], Aspergillosis fumigatus, and Aspergillosis flavus. Tetanus toxic antibody was normal. Diphtheria antibody was normal. ACE level was normal. Immunoglobulin E level was normal. Upper bronchoscopy biopsy of the fourth tracheal ring and the superior nasoseptal of the right inferior turbinate was done. The fourth tracheal ring revealed chorionitis and squamous mucosa with underlying cartilage with fibrosis of the lamina propria consistent with a scar. The superior nasoseptal perforation revealed ulcerated squamous mucosa with acute and necrotic inflammation. The right inferior turbinate revealed an ulcerated sinusoidal mucosa with acute and predominantly chronic inflammation and fragments of fibrinous exudate with bacterial colonies. It was noted that in the right inferior turbinate biopsy there were necrotic vessels noted; however, there was no evidence of vasculitis or necrosis of the vessels away from the ulceration in any of the specimens. No granulomas or viral inclusions were seen, and all Gram stains were negative for bacterial organisms. The DMS stains were negative for fungal organisms. [**Country 7018**] red stains were negative for amyloid. A biopsy of the posterior oropharyngeal mucosa on [**2101-9-23**] revealed fragments of squamous mucosa with associated fibrinopurulent exudate with fungal septated hyphae branching at 45 degrees; consistent with Aspergillosis species. Carinii biopsy revealed fibropurulent exudate with fungal septated hyphae branching at 45 degrees; also consistent with Aspergillosis species. As stated, the patient has a history of Aspergillosis. Biopsies were positive for aspergillosis and history of airway and laryngeal narrowing. The patient was treated with multiple courses of antifungals. The patient subsequently developed fibrosis/fusion of the patient's vocal cords. The patient was transferred to [**Hospital1 188**] and received tracheostomy on [**9-14**] and was monitored in the Medical Intensive Care Unit for one day. 1. PULMONARY ISSUES: The patient with a history of aspergillosis. It was unclear why she would have this; although, she could have developed it after having a community-acquired pneumonia back in her history. It was treated with antifungals, and it was not determined during this admission that it needed further treatment. Cultures were negative. Her high oxygen requirements were thought to be secondary to the tracheostomy only portal entry for her oxygen. She continued to be weaned from the mask. She ambulated well on room air without desaturations but used a 40% mask at night to improve her oxygen saturations. A high-resolution chest computed tomography on admission was not consistent with any findings for reinfection with aspergillosis. She was afebrile throughout the admission. She had occasional shortness of breath that resolved with suctioning and nebulizer treatments. There was a concern that she had an aspiration event due to tracheostomy. She received a full course of clindamycin therapy. Interventional Pulmonology, after traching her two weeks later with assistance of Ear/Nose/Throat, did a dilation of her vocal cords. It was determined that she should follow up later with Dr. [**Last Name (STitle) **] for a rigid bronchoscopy and further evaluation. At the time of discharge, the patient was breathing well on room air with a trach in place. She was phonating quietly. Much improved from admission. She had pain at her surgical site and was still using a 40% trach mask occasionally at night. 2. EAR/NOSE/THROAT ISSUES: Tracheal biopsies revealed no evidence for polychondritis or amyloid. In the end, it was determined that the fusion of her vocal cords was most likely due to fibrosis after multiple intubations from past outside hospital admissions. 3. INFECTIOUS DISEASE ISSUES: The patient had no clear signs of immunodeficiency leading to an Aspergillosis infection. Titers revealed [**Male First Name (un) **] function to be normal. She received an influenza vaccine and pneumovax vaccine during this admission. She was treated with a full course of antibiotics for aspiration pneumonia. She remained afebrile and was breathing well until the day of discharge. 4. RHEUMATOLOGIC ISSUES: As stated, there was a concern for Wegener granulomatosis. In the end, after multiple consultations, this was thought not to be consistent with picture and the results of the biopsies. 5. HEMATOLOGIC ISSUES: The patient has chronic iron deficiency anemia. She was taking iron daily. She did have a hematocrit drop during this admission that was thought to be dilutional in the context of increased intravenous fluid hydration. A chest x-ray revealed no infiltrates, or evidence of pulmonary hemorrhage, or any concern for hemorrhage elsewhere or hemolysis. 6. PSYCHIATRIC ISSUES: The patient has had depression over the past year secondary to coping with her illness. During this admission, her Zoloft was increased to 200 mg by mouth every day. The patient was instructed to follow up with her psychiatrist as an outpatient. 7. PAIN ISSUES: The patient was status post surgery with high pain needs. There was great concern to find the best management for her. She was given a patient-controlled analgesia and then changed over to intravenous and then by mouth pain medications with Ativan as needed for extensive anxiety. Tylenol was used as an adjuvant therapy. The patient did not tolerate Toradol secondary to nausea. On the day of discharge, the patient was still requiring opioid analgesics, but it was thought that this need would decrease as the surgical site healed. 8. CARDIOVASCULAR ISSUES: The patient remained hemodynamically stable throughout this admission and had no issues. 9. GASTROINTESTINAL ISSUES: The patient was maintained on a general by mouth diet. She received H2 blocker prophylaxis. She had bowel movements daily and was maintained on a bowel regimen during the opioid use. Her electrolytes were monitored carefully. Her bicarbonate level was increased occasionally due to relative respiratory acidosis given her oxygen use. 10. RENAL ISSUES: The patient had no history of urinary tract infections. She had no blood in her urine, and her creatinine was normal throughout the entire admission. There was no evidence of renal insufficiency or any type of renal involvement due to a vasculitic process. 11. PROPHYLAXIS ISSUES: The patient was maintained on deep venous thrombosis prophylaxis by ambulating three times per day. She had a H2 blocker for gastrointestinal prophylaxis and a bowel regimen as stated. She was maintained on pain and anxiety regimens carefully. DISCHARGE DISPOSITION: On the day of discharge, the patient was ambulating well. She was breathing through her trach on room air and phonating quietly. She was eating and drinking and moving her bowel regularly. She occasionally required oxygen at nighttime for an oxygen saturation above 90%. DISCHARGE STATUS: The patient was discharged to home with home health services. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [**Last Name (STitle) **] for a rigid bronchoscopy. 2. The patient was also instructed to follow up with her primary care provider. DISCHARGE DIAGNOSES: 1. Tracheal Aspergillosis. 2. Tracheal stenosis. MEDICATIONS ON DISCHARGE: 1. Multivitamin by mouth every day. 2. Albuterol meter-dosed inhaler as needed. 3. Atrovent meter-dosed inhaler as needed. 4. Senna twice per day as needed (for constipation). 5. Docusate 100 mg by mouth twice per day. 6. Iron 325 mg by mouth every day. 7. Zoloft 200 mg by mouth once per day. 8. Trazodone 50 mg by mouth at hour of sleep. 9. Tylenol as needed. 10. Ativan 1 mg by mouth q.6-8h. as needed (for anxiety). 11. Protonix 40 mg by mouth once per day. 12. MS Contin 100 mg by mouth twice per day. 13. Morphine sulfate immediate release 15-mg tablets one tablet by mouth q.6-8h. as needed (for pain). [**Name6 (MD) **] [**Name8 (MD) **], M.D. Dictated By:[**Last Name (NamePattern1) 6374**] MEDQUIST36 D: [**2101-12-5**] 13:39 T: [**2101-12-8**] 17:59 JOB#: [**Job Number 50754**]

[ "117.3", "519.1", "478.1", "478.74", "285.29" ]

icd9cm

[ [ [] ] ]

[ "31.42", "22.60", "31.45", "31.1", "97.23", "30.09" ]

icd9pcs

[ [ [] ] ]

31409, 31766

19178, 19277

32007, 32059

16627, 17055

32086, 32937

18764, 19160

7224, 16507

31799, 31986

23292, 31385

3559, 7206

156, 222

240, 262

17084, 18565

18589, 18738

19294, 23263

16532, 16571

46,569

163,079

49204

Discharge summary

report

Admission Date: [**2145-8-31**] Discharge Date: [**2145-9-4**] Date of Birth: [**2078-1-1**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [**Known lastname 103181**] had been at rehab following her surgery, per patient progressing well. She states that she was at her sisters for a picnic yesterday and felt OK. Last evening her blood sugar dropped to 38 and she was minimally responsive to treatment. EMS was called, she was pale and diaphoretic, vomited during transport to OSH. At OSH, she continued to vomit, was hypoxic on RA, and tachypnic. Per rehab report, patient has been more tachypnic over last day, patient states her breathing has been OK and denies increased SOB or sputum production. She was also noted to have an area of erythema and separation of her sternal incision at the distal portion, which is about the same at discharge. Upon arrival to [**Hospital1 18**] pt temp was 102.9. Past Medical History: CAD s/p cabg x4 [**2145-8-17**] Diabetes mellitus type 2 Lower Extremity Neuropathy Hypertension Hyperlipidemia Obesity Osteoporosis Arthritis Hypothyroidism Hard of Hearing Social History: Occupation: Retired from BJ Wholesalers Lives with: daughter; pt is divorced and has 3 grown daughters [**Name (NI) 1139**]: quit [**11-30**], 1ppd x >30yrs ETOH: Rare Family History: Non-contributory Physical Exam: Pulse:84 Resp:28 O2 sat:97 on 3L NC B/P Right:137/76 Left: General: Skin: Dry [x] HEENT: PERRLA [x] Neck: Supple [x] Chest: decreased BS bilat, faint crackles at bases Heart: RRR [x] Abdomen: Soft [x] mildly distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema1-2+ Varicosities: None [x] Neuro: Grossly intact[x] Sternal incision w/distal portion separation of skin edges w/yellow fibrinous on edges, mild erythema between breasts, small amout of serous drainage expressed, sternum stable. Chest tube sites w/fibrinous exudate, no drainage. LLE vein harvest site minimal erythema, no drainage Pulses: DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left: 2+ Pertinent Results: [**2145-8-31**] 07:40PM WBC-14.6* RBC-3.12* HGB-7.7* HCT-24.8* MCV-80* MCH-24.6* MCHC-30.9* RDW-15.5 [**2145-8-31**] CTA 1. No pulmonary embolus. No aortic dissection. 2. Bibasilar atelectasis with small left pleural effusion. Pneumonia cannot be excluded especially in the context of enlarged mediastinal lymph nodes, which may be reactive in etiology. 3. Pulmonary nodules at the left base. Recommend dedicated chest CT after termination of antibiotic treatment, especially in the context of mediastinal lymphadenopathy. 4. Emphysema. 5. Hepatic granulomata. 6. Small renal hypodensities, too small to characterize, statistically likely to be benign cysts. 7. Vascular including, coronary artery calcifications in this status post CABG patient. 8. Small fluid collection in the anterior mediastinum is likely a postoperative seroma. 9. Cholelithiasis. [**2145-9-4**] 02:39AM BLOOD WBC-7.4 RBC-3.95* Hgb-9.9*# Hct-31.9* MCV-81* MCH-25.1* MCHC-31.2 RDW-15.1 Plt Ct-672* [**2145-9-4**] 02:39AM BLOOD Glucose-144* UreaN-10 Creat-0.6 Na-140 K-4.4 Cl-103 HCO3-29 AnGap-12 Brief Hospital Course: Mrs. [**Known lastname 103181**] was admitted to the [**Hospital1 18**] on [**2145-8-31**] for further management of her fever and shortness of breath. A chest CT showed a left lower lobe consolidation. She was thus placed on vancomycin, ciprofloxacin and cefepime. She was transferred to the step down unit on [**2145-9-1**] for further management. A PICC line was placed for intravenous access. She was brought back to the intensive care unit on [**9-2**] for blood sugar management with an insulin drip.[**Last Name (un) **] consult done. Hematology consult also done for thrombocytosis. Transferred back to the floor on [**9-3**] and PICC removed on [**9-4**]. Cleared for discharge on [**9-4**]. Pt. is to make all follow-up appts. as per discharge instructions. Medications on Admission: Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO daily Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): will evaluate lasix at wound check follow up 9/8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): call [**Month/Year (2) 5059**] for fevers, change in wound [**Telephone/Fax (1) 170**]. Lantus 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous twice a day. humalog sliding scale Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): take 2 pills (40mg) daily for one week, then decrease to 1 pill (20mg) daily. Disp:*30 Tablet(s)* Refills:*2* 3. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 10 days. Disp:*40 Capsule(s)* Refills:*2* 8. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous QAM. Disp:*qs * Refills:*2* 9. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime. Disp:*qs * Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Fever/Hypoglycemia/Dyspnea Pneumonia Past Medical History: Diabetes mellitus type 2 Lower Extremity Neuropathy Hypertension Hyperlipidemia Obesity Osteoporosis Arthritis Hypothyroidism Hard of Hearing Past Surgical History: s/p CABGx4 [**8-17**] s/p left knee replacement s/p Tonsillectomy s/p C-section x 3 s/p TAHBSO S/P bilateral shoulder surgery Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] (cardiac surgery) at 1 month postop. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 5314**] (PCP) in 2 weeks. ([**Telephone/Fax (1) 103182**] Please follow-up with Dr. [**Last Name (STitle) 5686**] (cardiology) in [**1-26**] weeks. Wound check on [**Hospital Ward Name 121**] 6 in 1 week. Completed by:[**2145-9-8**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6501, 6559

3464, 4233

339, 346

6953, 6960

2367, 3441

7759, 8162

1549, 1567

5153, 6478

6580, 6617

4259, 5130

6984, 7736

6804, 6932

1582, 2348

280, 301

374, 1150

6639, 6781

1363, 1533

66,424

185,977

44917

Discharge summary

report

Admission Date: [**2184-6-3**] Discharge Date: [**2184-6-18**] Date of Birth: [**2114-9-29**] Sex: M Service: SURGERY Allergies: Lisinopril Attending:[**First Name3 (LF) 1384**] Chief Complaint: ESRD Major Surgical or Invasive Procedure: renal transplant [**2184-6-4**] History of Present Illness: 69M with history of UC and ESRD [**2-11**] hypertensive nephrosclerosis admitted tonight for cadaveric renal transplant. He reports that he has been in his usual state of health since his last transplant clinic visit. He denies fevers, chills, nausea vomiting. He reports that his ileostomy output has been unchanged. He denies sick contacts. [**Name (NI) **] was last dialyzed today. He reports that he urinates ~3x a day and drinks a lot of water. He reports his appetite has been normal and denies weight loss. His pretransplant workup is complete. Tissue typing sent to [**Hospital1 112**]. He is blood type AB positive. Cardiac echo and stress echo were unremarkable. He is CMV negative, EBV positive. Hepatitis and HIV serologies are negative. He has low level anti-DR 51 and DR18 antibodies. ROS: (+) per HPI (-) Denies pain, fevers chills, unexplained weight loss, fatigue/malaise/lethargy, changes in appetite, trouble with sleep, pruritis, jaundice, rashes, bleeding, easy bruising, headache, dizziness, vertigo, syncope, weakness, paresthesias, nausea, vomiting, hematemesis, bloating, cramping, melena, hematochezia, dysphagia, chest pain, shortness of breath, cough, edema, urinary frequency, urgency Past Medical History: Ulcerative Colitis, ESRD [**2-11**] hypertensive nephrosclerosis, hypercholesterolemia, COPD, started HD summer [**2183**] Past Surgical History: AVF right arm by Dr.[**Last Name (STitle) 96070**], previous colostomy on right side, ileostomy s/p TAC [**2150**], exploratory laparoscopy for ?cyst Social History: Denies ETOH, IV drug use, or tobacco use. Lives with girlfriend Family History: Family History: is significant for hypertension in his mother. Father had metastatic cancer of the pancreas. He has two children who are alive and well and two brothers who are also healthy. Physical Exam: Vitals:99.2 113 129/79 20 97RA GEN: A&O, NAD, sunburned skin HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses, large midline incision, no hernias, ileostomy in right lower quadrant Ext: RUE AVF fistula, with palpable thrill, +radial pulse No LE edema, LE warm and well perfused. Pulse exam: palpable femoral, popliteal and DP bilaterally, PT not palpated Pertinent Results: [**2184-6-17**] 05:47AM BLOOD WBC-6.1 RBC-2.42* Hgb-8.3* Hct-23.7* MCV-98 MCH-34.3* MCHC-35.0 RDW-15.3 Plt Ct-210 [**2184-6-11**] 05:49AM BLOOD PT-15.3* PTT-26.6 INR(PT)-1.3* [**2184-6-17**] 05:47AM BLOOD Glucose-173* UreaN-54* Creat-2.0* Na-140 K-4.4 Cl-111* HCO3-18* AnGap-15 On Discharge: [**2184-6-18**] WBC-6.8 RBC-2.34* Hgb-7.8* Hct-22.9* MCV-98 MCH-33.5* MCHC-34.1 RDW-15.3 Plt Ct-193 Glucose-177* UreaN-46* Creat-1.9* Na-139 K-4.5 Cl-110* HCO3-19* AnGap-15 Calcium-8.2* Phos-3.1 Mg-1.6 tacroFK-11.2 Brief Hospital Course: On [**2184-7-4**], he underwent cadaveric renal transplant into left iliac fossa, lysis of adhesions, small bowel resection. A ureteral stent was placed. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please refer to operative notes for details. He was given induction immunosuppression consisting of ATG (x 4 doses total), Solumedrol with taper and Cellcept. Prograf was started on the evening of POD 1. Urine output was produced with increasing volume each day. Creatinine was slow to decrease. Peak value was 6.5 on POD 6, and was falling daily to 1.9 by discharge. He never received hemodiaysis post transplant. He received a total of 4 doses of ATG (100mg each), cellcept, solumedrol tapered to prednisone then off and prograf that was dosed per trough level. Levels ranged between 8.9 to 13. He experienced an ileus and required an NG tube which remained in place for many days. Stool output occurred via ostomy. However, abdomen was distended and NG output was high. An abd CT scan was done on [**6-12**] with findings consistent with partial SBO. The patient was started on TPN as he was unable to have oral intake, this was continued until discharge. Once abdomen was softer and patient having more gas in bag the NG Tube came out. He was very slowly advanced from sips to clears and then regular diet which he was tolerating. Ostomy output varied and was supplemented intermittently with IV fluids. He received one units RBCs for Hct 22.9, value had drifted down slowly during hospitalization and not associated with acute blood loss. The patient was ambulating without difficulty and was cleared by PT for home. He was tolerating regular diet, received medication teaching. Medications on Admission: omeprazole 20mg PO daily, fenofibrate 200mg PO daily, ropinirole 0.75 PO daily, hydrocodone 5/500 PO daily. Allergies: lisinopril and iodine Discharge Medications: 1. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ropinirole 0.25 mg Tablet Sig: Three (3) Tablet PO QPM (once a day (in the evening)). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain: no more than 4000mg per day. 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Bayada Nurses, Inc Discharge Diagnosis: ESRD PSBO ileus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience any of the following: fever (101 or greater), chills, nausea, vomiting, inability to take any of your medications, increased abdominal pain/distension, difficulty voiding, incision redness/bleeding/drainage, weight gain of 3 pounds in a day or any concerns. Drink enough fluids to keep urine light yellow in color and also to keep up with your ostomy output. No heavy lifting You may shower, pat incision dry and place gauze over incision as it is still having drainage. Please call if the drainage increases, develops a foul odor or if the incision becomes red, or pus develops. Your labwork is to be drawn every Monday and Thursday at the [**Hospital **] Medical Building [**Location (un) 448**] lab with results to the transplant clinic. Followup Instructions: Department: TRANSPLANT When: TUESDAY [**2184-6-22**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT SOCIAL WORK When: TUESDAY [**2184-6-22**] at 11:00 AM [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2184-6-24**] at 9:30 AM With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2184-6-18**]

[ "458.29", "568.0", "E878.0", "997.4", "560.1", "556.9", "998.2", "585.6", "496", "E870.0", "V44.2", "276.8", "403.91" ]

icd9cm

[ [ [] ] ]

[ "46.39", "54.59", "45.91", "38.91", "55.69", "99.15", "38.93", "45.62", "00.93" ]

icd9pcs

[ [ [] ] ]

6051, 6100

3262, 4991

274, 308

6160, 6160

2731, 3009

7156, 8025

1997, 2175

5183, 6028

6121, 6139

5017, 5160

6311, 7133

1731, 1883

2190, 2712

3023, 3239

230, 236

336, 1562

6175, 6287

1584, 1708

1899, 1965

12,567

188,892

3876

Discharge summary

report

Admission Date: [**2206-6-28**] Discharge Date: [**2206-7-4**] Date of Birth: [**2143-6-19**] Sex: F Service: MEDICINE Allergies: Tetracyclines / Adenosine Attending:[**First Name3 (LF) 15519**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: cardioversion History of Present Illness: 63 y/o F with hx of severe COPD requiring multiple intubations in recent months, IgA deficiency, CAD and HTN presents with worsening dyspnea over the past 2 weeks. Denies change in her infrequent cough, fever, chills. She does note that her sputum may be slightly more green than usual. No chest pain, no pedal edema. Her daughter said that she has not seemed confused, as she sometimes gets when her COPD flares. Since her condition has worsened, she no longer gets out of bed. If she stands up, she is very dizzy and feels the room spinning. She denies falls. Approximately one week ago, a taper of prednisone was stopped. . She does have chronic abdominal pain. It feels like "someone is punching her in the stomach" constantly. This makes her somewhat nausated and she has a very low appetite. Her pain now is [**5-7**], and at it's worst it is [**9-6**]. She occassionally vomits. No blood in her vomit or stool. She has had significant weight loss over the past year from 125 lbs to 85 lbs. Her fentanyl patch was replaced this morning. . In the ED, initial vs were: T 97.9, P 121, BP 182/120, R 32, O2 sat 96% on NRB. Patient was given several nebulizer treatments but continued to be tachypneic. She was then placed on nasal CPAP and felt better. She was still using accessory muscles. The ED was unable to get an ABG. . On the floor, patient still complained of shortness of breath, although feeling better than when she initally came in. She denies chest pain, leg pain, swelling, dizziness. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation or abdominal pain, although has hx of constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% predicted respectively); intubated several times in the past. on 2L home O2, most recently intubated in [**5-6**]. - IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**], no treatment with IVIG recently. - CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in [**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA and LCx. - Hypertension - Hyperlipidemia - Gastritis, on PPI - Osteoporosis, with history of multiple compression and rib fractures from coughing - History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy - Depression - Tremor Social History: patient was recently in rehab after her previous hospitalization in [**Month (only) 596**] (which included intubation and an ICU admission); she now lives in her apartment and has home nursing. Has difficulty getting around, but when she gets up uses a cane or walker. Has 30 pack yr smoking history but quit several years ago. No etoh/illicts. Family History: Mother with DM, father with pancreatic cancer. Physical Exam: Vitals: T:98.6, BP: 160/91, P: 120, R: 25, O2: 100% on 4L, desatted to 82% when placed on nasal CPAP 8/5 General: chronically ill appearing, alert, oriented x3, in acute respiratory distress and using accessory muscles HEENT: Sclera anicteric, dry mucous membranes, poor dentition, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decreased air movement in all lung fields, scant wheezes anteriorally, no crackles or rhonchi CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to diffuse palpation, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: cool extremities, thin, palp pulses, clubbing Pertinent Results: [**2206-6-28**] 03:23PM BLOOD WBC-15.1* RBC-4.33 Hgb-11.3* Hct-37.6 MCV-87 MCH-26.1* MCHC-30.1* RDW-15.2 Plt Ct-512* [**2206-6-29**] 04:38AM BLOOD WBC-6.4# RBC-3.72* Hgb-10.0* Hct-31.4* MCV-85 MCH-26.9* MCHC-31.8 RDW-16.2* Plt Ct-393 [**2206-6-30**] 03:47AM BLOOD WBC-17.8*# RBC-3.67* Hgb-9.5* Hct-31.3* MCV-85 MCH-26.0* MCHC-30.5* RDW-15.2 Plt Ct-419 [**2206-7-1**] 04:16AM BLOOD WBC-17.4* RBC-3.50* Hgb-9.3* Hct-29.5* MCV-84 MCH-26.7* MCHC-31.6 RDW-16.2* Plt Ct-409 [**2206-6-28**] 03:23PM BLOOD PT-11.7 PTT-25.2 INR(PT)-1.0 [**2206-6-28**] 03:23PM BLOOD Glucose-93 UreaN-26* Creat-0.6 Na-141 K-4.1 Cl-100 HCO3-30 AnGap-15 [**2206-6-29**] 04:38AM BLOOD Glucose-172* UreaN-30* Creat-0.7 Na-137 K-4.4 Cl-98 HCO3-30 AnGap-13 [**2206-6-30**] 03:47AM BLOOD Glucose-160* UreaN-30* Creat-0.8 Na-139 K-4.7 Cl-99 HCO3-31 AnGap-14 [**2206-6-30**] 05:13PM BLOOD Glucose-139* UreaN-28* Creat-0.7 Na-140 K-5.2* Cl-101 HCO3-32 AnGap-12 [**2206-7-1**] 04:16AM BLOOD Glucose-174* UreaN-32* Creat-0.7 Na-140 K-4.4 Cl-102 HCO3-31 AnGap-11 [**2206-6-30**] 03:47AM BLOOD ALT-10 AST-17 LD(LDH)-193 AlkPhos-55 TotBili-0.2 [**2206-6-28**] 03:23PM BLOOD CK-MB-5 cTropnT-0.02* [**2206-6-28**] 11:59PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2206-6-28**] 03:23PM BLOOD Calcium-9.9 Phos-4.3# Mg-1.7 [**2206-7-1**] 04:16AM BLOOD Calcium-9.0 Phos-2.3* Mg-2.1 [**2206-6-30**] 03:47AM BLOOD TSH-0.14* [**2206-6-30**] 05:13PM BLOOD Free T4-1.0 [**2206-6-28**] 08:45PM BLOOD Type-[**Last Name (un) **] Temp-36.2 pO2-27* pCO2-71* pH-7.30* calTCO2-36* Base XS-4 Intubat-NOT INTUBA [**2206-6-29**] 05:30AM BLOOD Type-[**Last Name (un) **] pO2-49* pCO2-64* pH-7.34* calTCO2-36* Base XS-5 Intubat-NOT INTUBA [**2206-6-28**] 03:18PM BLOOD Lactate-1.2 . Echo: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with akinesis of the basal inferior wall and hypokinesis of the mid-segment. The remaining segments contract normally (LVEF = 50 %). The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**11-29**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild regional left ventricular systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation most likely due to papillary muscle dysfunction. Compared with the report of the prior study (images unavailable for review) of [**2205-5-27**], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are now reduced. . CXR: The cardiomediastinal silhouette is stable. The lungs are essentially clear except for multiple rib fractures with healed and non-healed fracture seen bilaterally. There is no pleural effusion or pneumothorax. There is no evidence of failure or new consolidation worrisome for infectious process. Brief Hospital Course: 63 y/o F with hx of severe COPD, IgA immunedeficiency and CAD who presents with worsening dyspnea, consistent with a COPD flare. . # Dyspnea/COPD Flare: Pt.'s dyspnea was most likely secondary to COPD flare as she recently came off steroids. She was sent to the MICU and stabilized on nasal canula with frequent nebulizer treatments. She was also treated wtih IV solumedrol q8hrs for 4 days before being transitioned to PO Prednisone 60mg with 18 day taper. She completed a 5 day course of Azithromycin, but was afebrile without positive blood cultures or signs of infection during her hospitalization. An ECHO was performed to rule out worsening heart disease as the cause of her dypsnea that showed improvement since a previous echo. By hospital day 4, she returned to her home O2 requirement and was transferred to the general medicine floor for the remainder of her stay. . # Afib or SVT: Pt. had episode of 15 minutes of heart rate in the 180s that looked consistent with Afib with RVR, although SVT could not be ruled. Pt was initially given adenosine and started to go into acute respiratory distress, so she was sedated, bag mask ventilated and cardioverted into NSR. She responded well and was in NSR the rest of her admission. In the discussion of anticoagulation, we weighed her chronic medical conditions with her CHADS score of 2 and her PCP ultimately decided not to initiate Coumadin. She was not placed on aspirin, as she has a history of duodenal ulcer perforation. She was however, placed on Diltiazem 60mg QID and will continue this in long acting form as an outpatient. . # CAD: Pt. had an EKG with new ST depressions, but was asymptomatic, likely rate related. Cardiac enzymes were negative. We continued her medical management of CAD with statin and plavix. She was not on aspirin, as above. . # Tachycardia: initially presents wtih sinus tach, but this appeared to be chronic as she has been tachycardic in all prior discharge summaries. Likely, her tachycardia is multifactorial and secondary to respiratory distress, pain, and dehydration, so her albuterol was switched to Xopenex, but this was switched back on discharge as her rehab facility did not have the necessary medication. . # IgA Deficiency: Pt. has known immunedeficiency but did not appear infected. She completed a 5 day course of azithromycin. . # Cachexia: Pt. has chronic has weight loss in past year secondary to poor PO intake. Her outpatient malignancy workup has been negative, but this is being followed by her PCP. [**Name10 (NameIs) **] team encouraged high calorie food intake. . # Depression: Pt. had interval worsening of depression during this hospitalization as assessed by her PCP. [**Name10 (NameIs) **] was seen by social work and her home dose of Paroxetine was increased. She continue her outpatient dose of nortriptyline. . # Pain Control: Pt. has chronic pain from kyphotic fractures. She is on chronic opioids at home and has a narcotic contract with her PCP. [**Name10 (NameIs) **] was continued on her home regimen without incident. Medications on Admission: Plavix 75 mg daily Nortriptyline 25 mg qHS Simvastatin 20 mg daily Montelukast 10 mg daily Albuterol Nebulizer 1 treatment q4hr Ipratropium Nebulizer 1 treatment q4hr Docusate 100 mg [**Hospital1 **] Percocet 5/325 mg q6hr PRN Fentanyl Patch 50 mcg q72 hr Paroxetine 10 mg daily Ranitidine 150 mg daily Tiotropium 18 mcg 1 cap daily Salmeterol 59 mcg 1 disc [**Hospital1 **] MVI daily Insulin Lispro Sliding Scale Senna 8.6 mg [**Hospital1 **] PRN Discharge Medications: 1. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Nortriptyline 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at bedtime). 4. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: hold for sedation, rr<12. 6. Ranitidine HCl 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) 5000 Injection TID (3 times a day). 8. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1) amount per flowsheet Subcutaneous ASDIR (AS DIRECTED): please see insulin sliding scale included in paperwork. 9. Fentanyl 50 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 12. Docusate Sodium 100 mg Capsule [**Hospital1 **]: [**11-29**] Capsules PO BID (2 times a day). 13. Multivitamin Oral 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Month/Day (2) **]: One (1) cap Inhalation once a day. 15. Salmeterol 50 mcg/Dose Disk with Device [**Month/Day (2) **]: One (1) disc Inhalation twice a day. 16. Prednisone 10 mg Tablet [**Month/Day (2) **]: Five (5) Tablet PO once a day for 15 days: Please take 5 pills a day for 3 days. Then, take 4 pills a day for 3 days. Then take 3 pills a day for 3 days, 2 pills a day for 3 days, and 1 pill a day for 3 days. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Month/Day (2) **]: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing. 18. Diltiazem HCl 240 mg Capsule, Sust. Release 24 hr [**Month/Day (2) **]: One (1) Capsule, Sust. Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Primary: Chronic obstructive pulmonary disease exacerbation Secondary: Hypertension, Hyperlipidemia, Gastritis, Osteoporosis, Depression Discharge Condition: Improved. Stable. Discharge Instructions: You were admitted to the hospital due to an exacerbation of your COPD. While you were in the hospital, you were given IV steroids, nebulizer therapy and a course of antibiotics and your breathing improved. You did have an episode of an irregular heart rate, but your heart rate was converted to a normal rhythm using electrical conversion. As your symptoms improved, you were transitioned to oral steroids. Medications: The following changes were made to your medications, 1. Paroxetine - Your home dose of Paroxetine was increased from 10mg to 20mg a day. Please continue to take this increased dose. 2. Prednisone - You were placed on 60mg of oral Prednisone each day for your COPD exacerbation. This will be tapered down over time. Please continue to take this medication as prescribed. 3. Diltiazem - You were placed on 240mg of Diltiazem once a day to control your heart rate. Please continue to take this medication as prescribed. Followup Instructions: Please follow-up in your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office on [**7-18**] at 9:40AM with her nurse practitioner [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-[**Doctor Last Name **]. If you need to reschedule, please call [**Telephone/Fax (1) 250**].

[ "535.50", "428.22", "733.00", "311", "V13.51", "428.0", "304.01", "412", "401.9", "491.21", "276.51", "V45.82", "272.4", "427.31", "737.10", "424.0", "414.01", "279.01", "427.1" ]

icd9cm

[ [ [] ] ]

[ "99.62" ]

icd9pcs

[ [ [] ] ]

12934, 13031

7317, 10372

294, 309

13212, 13232

4168, 7294

14219, 14587

3384, 3432

10871, 12911

13052, 13191

10398, 10848

13256, 14196

3447, 4149

247, 256

1859, 2191

337, 1841

2213, 3006

3022, 3368

14,478

159,515

10164

Discharge summary

report

Admission Date: [**2144-3-16**] Discharge Date: [**2144-3-23**] Date of Birth: [**2084-8-25**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 59-year-old patient with a known history of coronary artery disease status post multiple interventional procedures presented with chest pain on the day of admission. Most recently had a PTCA with a restent of his distal left circ in [**Month (only) 404**] of this year. Past medical history is significant for known coronary artery disease status post multiple interventional procedures, noninsulin dependent diabetes mellitus, hypertension, hyperlipidemia, chronic low back pain, status post tonsillectomy, asthma, congestive obstructive pulmonary disease. The patient has a significant smoking history however, quit two years ago. MEDICATIONS: Albuterol, Atrovent metered-dose inhalers prn, aspirin 325 mg po q day, Darvocet 650 mg q8h, Flovent two puffs [**Hospital1 **], Glucovance 5/500 once a day, Imdur 90 once a day, Plavix 75 mg once a day, Serevent two puffs [**Hospital1 **] inhaler, Lopressor 100 mg [**Hospital1 **], Tussionex 5 cc [**Hospital1 **], Zestril 20 mg po q day. The patient states no known drug allergies. SOCIAL HISTORY: A 60 pack year smoking history, quit two years ago, occasional alcohol intake. Physical examination on admission reveals normal sinus rhythm with a rate of 61, a blood pressure of 126/68, respiratory rate 18, on room air oxygen saturation is 94%. In general examination, the patient was in no acute distress. HEENT were unremarkable. Cardiovascular examination was normal as was his pulmonary examination. His abdomen was nontender and nondistended, and his extremities were with trace bilateral edema and cool feet. He was neurologically alert and cranial nerves II through XII are grossly intact. Laboratory values upon admission to the hospital were unremarkable. Chest x-ray was normal. Patient on his admission, electrocardiogram revealed Q waves in his inferior leads with no acute ST changes or ischemia. The patient was admitted to the Medicine Service and was taken to the Cardiac Catheterization Laboratory on [**2144-3-17**]. This catheterization revealed total occlusion of OM-III which was old, a total occlusion of the PDA with no intervention at this time, however, the patient had continued chest pain. A Cardiothoracic Surgery consultation was obtained on [**2144-3-18**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]. Patient was ultimately taken to the operating room on [**2144-3-19**], where he underwent coronary artery bypass graft x1 by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]. Postoperatively, the patient was transported from the operating room to the Cardiac Surgery Recovery Unit in stable condition. Is on Neo-Synephrine IV drip, which was weaned off by late in the day on postoperative day one. The patient was ultimately transferred from the Intensive Care Unit to the Telemetry floor late in the day on postoperative day one. Physical therapy assessment was obtained the following day. The patient began to progress with rehabilitation and physical therapy. Patient has remained stable on postoperative day four. Is ready to be discharged. The patient's chest tubes and epicardial pacing wires have been removed. The patient's vital signs have remained stable. He has remained in normal sinus rhythm and he is ready to be discharged home today on postoperative day four. The patient's condition today is as follows: Temperature is 98.1 as pulse is 74 in normal sinus rhythm, respiratory rate is 18. Blood pressure is 128/64, on room air oxygen saturation is 95%. His weight today is 97.2 kg, which is slightly below his preoperative weight of 98 kg. Physical examination: The patient is neurologically alert and oriented without apparent neurologic deficits. His lungs are clear to auscultation bilaterally. His coronary examination is regular, rate, and rhythm. His abdomen is soft, nontender, nondistended. His sternal incision is clean, dry, and intact. The patient's extremities are warm and well perfused. DISCHARGE MEDICATIONS: Plavix 75 mg po q day, Lopressor 25 mg po bid, Serevent metered-dose inhaler two puffs [**Hospital1 **], Flovent metered-dose inhaler 110 mg two puffs [**Hospital1 **], Glucovance 5/500 one po q am, Combivent metered-dose inhaler two puffs q4h prn, ibuprofen 400 mg po q6h prn, enteric coated aspirin 325 mg po q day, Lasix 20 mg po bid x5 days, potassium chloride 20 mEq po bid x5 days. Patient is to be discharged home. He is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in six weeks. The patient is to followup with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**] in [**2-24**] weeks. Discharge diagnosis is coronary artery disease status post coronary artery bypass graft. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 964**] MEDQUIST36 D: [**2144-3-23**] 09:53 T: [**2144-3-23**] 10:19 JOB#: [**Job Number 33922**]

[ "250.00", "272.0", "414.01", "401.9", "410.11", "724.5" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "88.56", "88.72", "37.22" ]

icd9pcs

[ [ [] ] ]

4206, 5306

3837, 4182

184, 1227

1244, 3814

22,387

178,674

17534

Discharge summary

report

Admission Date: [**2114-4-6**] Discharge Date: [**2114-4-11**] Date of Birth: [**2045-8-10**] Sex: M Service: [**Location (un) 259**] HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old male with cirrhosis presumed due to alcohol use, diabetes type 2, coronary artery disease, and chronic renal insufficiency who was admitted to [**Hospital3 **] Hospital on [**2114-3-28**] due to worsening renal failure and increased weight gain. The patient's laboratory data is currently remarkable for a creatinine of 4.3 from a baseline of 2. The patient transferred to [**Hospital1 18**] on [**2114-4-6**] for evaluation of acute renal failure and for consideration of TIPS. Paracentesis was performed to rule out spontaneous bacterial peritonitis. Since admission, the patient was started on Levofloxacin for pneumonia. He was transfused 2 units of packed red blood cells. He underwent thoracentesis of right hemithorax fluid consistent with a transudate. He was treated with albumin and was started on midodrine and Octreotide. With the administration of albumin, packed red blood cells, and IV fluids, the patient became volume overloaded and experienced worsening respiratory distress. The patient was transferred to the MICU for further monitoring. HOSPITAL COURSE: In the MICU, the patient continued to be treated for pneumonia with levofloxacin and was noted to have worsening bilateral alveolar infiltrates and bilateral effusions, all consistent with pulmonary edema. His oxygenation remained adequate on 100% nonrebreather. Since aggressive diuresis would further worsen the patient's renal function, he was placed on noninvasive positive pressure ventilation. The patient had worsening delirium and worsening acidosis. A family meeting was held to determine the plan of care. The family decided to pursue comfort measures. The patient was started on a morphine drip and was transferred to the Medical Service. The patient passed away on the night of [**2114-4-11**]. DIAGNOSIS: 1. Chronic renal insufficiency with concomitant hepatorenal syndrome. 2. Cirrhosis secondary to alcohol use. 3. Type 2 diabetes mellitus with retinopathy. 4. Hypotension. 5. Peptic ulcer disease. 6. Osteoarthritis. 7. Spinal stenosis, status post laminectomy. 8. Pancreatitis. 9. History of myocardial infarction. 10. Cholelithiasis, status post cholecystectomy. As noted above, the patient was transferred to the Medical Service for comfort measures and was maintained on a morphine drip. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2114-4-11**] 02:09 T: [**2114-4-11**] 14:42 JOB#: [**Job Number 48926**]

[ "584.9", "789.5", "572.4", "511.9", "599.0", "486", "571.2", "518.81", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.91", "34.91", "96.71" ]

icd9pcs

[ [ [] ] ]

1300, 2789

26,648

131,481

24197

Discharge summary

report

Admission Date: [**2116-2-7**] Discharge Date: [**2116-2-25**] Date of Birth: [**2068-6-21**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Combined liver/kidney transplant Major Surgical or Invasive Procedure: [**2116-2-7**]: Combined deceased donor kidney transplant, Umbilical hernia repair, Redo piggyback liver transplant with portal envenectomy and aortic conduit. History of Present Illness: 47 y/o female s/p liver transplant in [**2105**] for fulminant liver failure from HAV. Since [**2112**] she has developed post transplant cirrhosis and also chronic renal insufficiency secondary to calcineurin induced nephrotoxicity. Most current labs show a MELD of 28. Creat 2.9. Patient currently immunosuppressed with Rapamycin and prednisone. Within the last two years she was diagnosed with chronic rejection, SBP, esophageal varices with bleeding and acute viral hepatic failure. Patient also currently has a portal vein thrombosis currently treated with daily warfarin. Was recently on 3 days of antibiotics for a salivary gland infection, now completed. Admitted for combined liver/kidney transplant Past Medical History: - s/p liver transplant in [**2105**] [**1-24**] fulminant hepatitis A c/b cirrhosis, portal HTN, resistant ascites (diuretic resistant and requiring intermittent paracenteses-last [**2115-6-22**] per patient), esophageal varices s/p bleed, and SBP (on list for repeat liver transplant) - relative lymphocytosis of unknown etiology on paracentesis fluid - CRI (on list for renal transplant) - Repair of Incarcerated Umbilical Hernia - managing with binder for now - Left Knee Ligament Surgery - Laminectomy for 2 Herniated Dics Social History: Smoker for 30 years- 1 ppd; currently 1 pack every 4 days, denies alcohol or IVDU. Lives with parents. Family History: Father, Sister with DM. Aunt with Lupus. No early MI, no stroke, no cancer. Physical Exam: VS: 99.0, 86, 111/64, 16, 99% RA, 62.6 kg Gen: Resting comfortably in bed, NAD, cigarette smell noted HEENT: soft supple, cachetic in appearance, sclera non-icteric, EOMI, PERRLA Neuro: A+Ox3, sensation grossly intact, CN II-XII grossly intact Lungs: CTA bilaterally Card: S1S2, III/VI systolic murmur heard throughout precordium Abd: Soft, NT, ND, several scars, large supraumbilical hernia that is reducible (5 cm in diameter) No gross hepatosplenomegaly Extr: + ecchymoses on bilateral forearms, wasted appearance, grade 4 clubbing Pertinent Results: On Admission: [**2116-2-7**] WBC-6.0 RBC-3.70* Hgb-9.8* Hct-29.0* MCV-79* MCH-26.5* MCHC-33.8 RDW-18.1* Plt Ct-78* PT-36.6* PTT-35.6* INR(PT)-4.0 Fibrinogen-417* Glucose-116* UreaN-60* Creat-2.9* Na-134 K-3.8 Cl-96 HCO3-25 AnGap-17 ALT-20 AST-20 AlkPhos-156* TotBili-0.5 Lipase-31 Albumin-4.3 Calcium-8.7 Phos-3.7 Mg-2.7* Brief Hospital Course: 47 y/o female s/p liver transplant in [**2105**] for fulminant liver failure from HAV. Since [**2112**] she has developed post transplant cirrhosis and also chronic renal insufficiency secondary to calcineurin induced nephrotoxicity. Admitted for combined liver and kidney transplant and hernia repair. Donor was from a 19-year-old intravenous drug abuser. The risks and benefits of this particular liver were explained extensively to Ms. [**Known lastname 61461**] who understood the risks of HIV and hepatitis C and wished to proceed. Liver transplant was performed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see the op report for details of the liver transplant surgery. There were significant adhesions from prior surgery and the remaining portal vein was found to have significant clot in it. A thrombectomy was attempted, and once the new liver was placed, it reperfused immediately. Of note, Dr [**Last Name (STitle) 816**] made note that this was a reoperation with significant adhesions and there was a pre-existing dissection of the celiac axis requiring the complete dissection of the infrarenal aorta and conduit placement. There was also a clot in the portal vein requiring envenectomy and thrombectomy. Dr [**First Name (STitle) **] [**Name (STitle) **] performed the hernia repair and kidney transplant. Once the liver was in, the large umbilical hernia repair was performed. In order to avoid the kidney incision, both liver JP drains were placed from the left side of the abdomen with the lateral-most drain into the bile duct, and the more medial drain being the one under the right lobe of the liver. The kidney transplant was then performed. This was a left kidney placed in the right iliac fossa. The organ reperfused evenly and well. The bladder was very thin and attenuated and recommendation was made to keep the Foley in for 7-10 days post-op. Patient tolerated all procedures well and was transferred to the ICU still intubated. Immunosuppression was per liver transplant protocol. Prograf was started on POD 1. Please note patient was on Rapamycin prior to transplant. Liver U/S performed on POD 1 showed Abnormal hepatic arterial waveform showing partial reversal of flow in diastole with elevated resistive indices as high as 0.98. The U/S of the transplant kidney done on the same day showed abnormally high resistive indices within the arterial flow to the transplant kidney measuring up to 0.9. No peritransplant collection or evidence for hydronephrosis was seen. Creatinine was variable, from 2.9 at transplant as low as 1.4 on POD 4. Liver U/S again performed on POD 3, showing persistently abnormal high resistance and hepatic arterial waveforms showing reversal of diastolic flow in the main and right hepatic artery. The left hepatic artery is not visualized on the [**2-10**] study. Patient seen by [**Last Name (un) **], insulin was adjusted. The expectation is that patient will D/C home with Insulin. Lateral JP drain d/c'd on POD 6. As well, Heparin was increased from 300 to 600, then 800 then 1000. Coumadin started on POD 8. Patient stable, liver and kidney function continued to improve. Waiting for PT to be therapeutic. On POD 11 in the AM, patient c/o groin pain, that then radiated to the left flank. CBC noted to have 10% drop in Hct from day prior, repeat went even lower. Patient transferred to the CSRU, received 3 u RBCs, heparin/coumadin was discontinued. CT w/o contrast was performed; Findings: 1.Multiple intraperitoneal hematomas as well as a large retroperitoneal hematoma measuring 12.0 x 9.9 cm in the left flank. 2. Small fluid collection adjacent to the medial aspect of the left lobe of the transplanted liver and ligamentum teres. Hypodensity around the portal vein consistent with periportal edema. 3. Patient is status post kidney transplant into the right lower quadrant with ureteral stent extending from the renal pelvis through the ureter terminating in the bladder. 4.2 x 3.9 cm hematoma just immediately inferior to the transplanted kidney. 4. Small fluid collection with tiny amount of gas in the subcutaneous tissue 5. Bilateral ground-glass opacities and linear area of atelectasis within the right lung base. After several days of watchful waiting, it was decided to take patient back to the OR. Pain had continued. Hct was stable only with continued Tranfusion support. On POD 14 ([**2116-2-21**]) the patient was taken back for Exploratory laparotomy, retroperitoneal exploration and liver biopsy. Please see the op note for operative details. The abdomen was opened using the old chevron incision.There was a fair amount of ascitic fluid and some blood in the abdomen. The arterial conduit appeared intact with an excellent pulse. There was hematoma in the mesentery which was evacuated. A liver biopsy was taken, the liver itself was reported to look fine. When the retroperitoneum was opened, the team immediately evacuated about 2 liters of bloody fluid. The clot was manually evacuated and then the area was washed out with 3 liters of saline and then amphotericin. At this point, all hemostasis appeared satisfactory. A drain was left in place. The patient tolerated the procedure well. The patient was transferred the following day to the surgical floor from SICU, where she continued to improve PO intake, pain management much better. Hct remained stable with last transfusion received 4 days prior. Liver enzymes are all WNL and creatinine baseline appears around 1.2 Patient to discharge home with VNA services for JP care and insulin sl scale management. Keflex was started on [**2-24**] for 5 days for c/o lateral incision soreness and minor erythema. She will be staying with her mother. [**Name (NI) **] family is close by. Medications on Admission: protonix 40', oxycodone prn, mvi, pamidronate 50 iv q3months, calcium/vit d, lasix 40', spironolactone 200', iron 325', tramadol 50''', pentamadine 30 qmonth, coumadin 1'/2', [**Last Name (un) **] 20', pred 7.5' Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day: Change per transplant clinic instruction. 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Continue as long as you are taking pain medications and as needed. Disp:*60 Capsule(s)* Refills:*2* 7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 3 days. Disp:*12 Capsule(s)* Refills:*0* 11. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection every six (6) hours. Disp:*1 * Refills:*2* 12. syringes low dose 1 box refill: 1 13. One Touch Ultra test strips 1 box refill:1 14. Lancets 1 box refill:1 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*1* 16. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: s/p liver transplant [**2105**] now with cirrhosis and chronic renal insufficiency. Received liver and kidney transplant [**2116-2-7**] [**2116-2-21**]: s/p Exploratory laparotomy, retroperitoneal exploration and liver biopsy for hematoma evacuation. Discharge Condition: Good Discharge Instructions: Call the transplant office at [**Telephone/Fax (1) 673**] if you experience any of the following symptoms: fever, chills, nausea, vomiting, diarrhea, inability to eat, inability to keep your medications down, pain over the incision site, kidney or liver, yellowing of the skin or eyes, an increase in abdominal girth. Monitor incision for redness, drainage or bleeding. Measure and record drain output daily, bring this record with you to your transplant clinic visit. Do not drive if you are taking narcotics. Take your medications exactly as directed. Have labs drawn every Monday and Thursday and have them faxed to [**Telephone/Fax (1) 697**] to the transplant office: CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili and trough Prograf Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-3-5**] 9:40 [**Doctor Last Name **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 61465**] Call to schedule appointment Completed by:[**2116-2-25**]

[ "403.90", "305.1", "552.1", "V58.65", "E878.0", "443.29", "998.12", "572.4", "568.0", "572.3", "571.5", "452", "E933.1", "599.0", "996.82", "585.9" ]

icd9cm

[ [ [] ] ]

[ "39.26", "55.69", "99.04", "00.93", "99.07", "50.59", "54.59", "54.12", "53.49", "50.12", "99.05" ]

icd9pcs

[ [ [] ] ]

10509, 10570

2927, 8689

345, 507

10865, 10872

2579, 2579

11663, 11987

1932, 2009

8952, 10486

10591, 10844

8716, 8929

10896, 11640

2024, 2560

273, 307

535, 1245

2593, 2904

1267, 1795

1811, 1916

78,515

196,984

54937

Discharge summary

report

Admission Date: [**2156-8-30**] Discharge Date: [**2156-9-8**] Date of Birth: [**2098-6-26**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 598**] Chief Complaint: Fall from ladder. Major Surgical or Invasive Procedure: [**9-1**] 1. Posterior approach for open reduction. 2. Realignment, instrumented fusion T9, T10, T11, T12, L1, L2, L3, L4 with bilateral pedicle screws, crosslinks, rods. 3. Autologous bone graft (left-sided iliac crest). 4. Allograft (morselized). 5. Implantation of two subfascial drains. [**9-2**] Attempted sacroiliac screw placement -- aborted due to inability to visualize secondary to excessive bowel gas. [**9-6**] Fixation with a sacroiliac screw, 7.3 mm, fully-threaded. History of Present Illness: Mr. [**Known lastname **] is a 58 year old male with no past medical history. He presented after a 25 foot fall to pavement from a ladder. He was working on a roof when the ladder slipped. The patient stated that he landed on his back. He was seen at the outside hospital, then transferred to [**Hospital1 18**] as a basic trauma. The patient complained of pain to his back and hips, denied numbness/tingling. He remembered the fall. He had no LOC and stated he did not think he struck his head. Past Medical History: PMH: denies PSH: prior hand surgery, "spine surgery" for herniated disc Family History: Non-contributory. Physical Exam: On admission: BP: 114/80 O(2)Sat: 92 Normal Constitutional: boarded, collared, oriented x 3, GCS 15 HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light Chest: crepitus right lateral low rib post axillary line Cardiovascular: Normal Abdominal: Normal Extr/Back: pelvis ttp R side, spine ttp low t spine and upper/mid L spine without palpable deformities Neuro: distal pulses 2+ bilaterally, motor [**4-17**] x 4 On discharge: 98.4, 68, 122/75, 16, 100% on room air. Pertinent Results: [**2156-8-30**] 08:34PM BLOOD WBC-14.6* RBC-3.98* Hgb-12.9* Hct-38.0* MCV-96 MCH-32.3* MCHC-33.8 RDW-11.9 Plt Ct-178 [**2156-8-31**] 03:13AM BLOOD WBC-9.6 RBC-3.58* Hgb-11.5* Hct-33.8* MCV-95 MCH-32.1* MCHC-33.9 RDW-12.3 Plt Ct-137* [**2156-9-7**] 04:20AM BLOOD WBC-6.8 RBC-2.93* Hgb-9.0* Hct-27.2* MCV-93 MCH-30.9 MCHC-33.3 RDW-13.5 Plt Ct-278# [**2156-8-30**] 08:34PM BLOOD PT-11.3 PTT-25.1 INR(PT)-1.0 [**2156-8-30**] 08:34PM BLOOD Plt Ct-178 [**2156-9-3**] 04:30AM BLOOD Plt Ct-119* [**2156-9-7**] 04:20AM BLOOD Plt Ct-278# [**2156-8-31**] 03:13AM BLOOD Glucose-395* UreaN-27* Creat-0.8 Na-135 K-5.0 Cl-107 HCO3-24 AnGap-9 [**2156-9-7**] 04:20AM BLOOD Glucose-94 UreaN-22* Creat-0.6 Na-136 K-4.1 Cl-103 HCO3-25 AnGap-12 [**2156-8-31**] 03:13AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.8 [**2156-9-7**] 04:20AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.0 [**2156-9-1**] 04:10PM BLOOD Type-ART pO2-169* pCO2-44 pH-7.40 calTCO2-28 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED IMAGING: CT scans uploaded from osh; neg head and c-spine, T11-L2 compression fractures, l2-l4 transverse process fractures, right sacral ala fracture, right superior and inferior pubic rami facture, right ischial tuberosity fracture, right 9th rib fracture [**9-2**] CT T spine w/o contrast 1. Status post T9-L4 posterior rod and screw fusion with bone graft with satisfactory hardware position and preserved vertebral body alignment in this patient with T11 and L2 fractures. 2. Incompletely assessed pelvic fractures including a right sacral body and [**Doctor First Name 362**] fracture extending into at least one of the right neural foramina. [**9-4**] KUB Two AP views of the abdomen demonstrate substantially dilated bowel loops, both colon and small bowel that most likely consistent with ileus but attention on the subsequent studies is required to exclude the possibility of obstruction. No definitive free air is seen. Brief Hospital Course: Mr. [**Known lastname **] is a 58M who presented after a 25 foot fall to pavement from a ladder. He was working on roof when ladder slipped, pt states that he landed on his back, had no LOC. Pt seen at OSH, then transferred to [**Hospital1 18**] as a trauma basic. On arrival, Mr. [**Known lastname **] complained of pain to his back and hips, but denied numbness/tingling. In the ED no intra-abd, intracranial, or intrathoracic injuries were identified; he was seen and evaluated by the ortho trauma and neuro-spine services. Injuries: T11, L2 fracture R sacral alar fracture Right superior/inferior pubic rami fracture R 9th rib fx [**8-30**]: Admitted to TSICU for Q2hr neuro checks, on log roll precautions without any neurologic deficits. Pain controlled with IV dilaudid. [**8-31**]: His C-spine was cleared and the collar removed. He was advanced to a regular diet. Mr. [**Known lastname **] continued on logroll precautions, awaiting operative fixation of L2 fracture with spine. RLE nonweightbearing. Evaluated by PT. He was found to be stable for transfer to the surgical floor, and was kept NPO after midnight in preparation for operative intervention [**9-1**] with spine. [**9-1**]: Went to the OR with spine surgery for posterior fusion of T9 through L4. Tolerated teh procedure well. Transfused 1U PRBC for itnra-op blood loss. Left intubated overnight for OR with ortho trauma on [**9-2**]. [**9-2**]: OR with ortho trauma for attempted SI fixation, but the procedure was aborted secondary to overlying bowel gas. He was extubated in the OR and recovered uneventfully in the PACU. He underwent CT of the thoracic and lumbar spines for hardware evaluation, and was then transferred to the surgical floor for further recovery. [**9-4**]: The patient went back to the OR with Ortho-Trauma for a successful SI fixation. He tolerated the procedure well, was extubated post-procedure and recovered in PACU. He was then transferred back to the surgical floor for further management. On the same day, the patient was complaining of nausea and vomiting. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube was inserted for gastric decompression. A KUB was obtained, showing dilated loops of bowel, likely due to an ileus. He was kept NPO and IV fluids were administered. [**9-6**]: Mr. [**Known lastname **] had removed his [**Last Name (un) **]-gastric tube, but his ileus seemed to have resolved. His diet was advanced slowly until he was taking a full diet. Since that time, Mr. [**Known lastname **] continued to recover well. His pain was initially managed with a dilaudid PCA and then transitioned to oral narcotic and non-narcotic analgesics once taking a full diet. Both physical and occupational therapy evaluated Mr. [**Known lastname **] and felt that he would benefit from intense rehabilitation at an appropriate facility. As his ambulation and mobilization increased over the subsequent days, pain management had been an issue. He is being discharged with standing acetaminophen and ultram with PRN dilaudid. In terms of his rehabiliation, Mr. [**Known lastname **] has been instructed to wear his TLSO brace at all times when out of bed. He is also touch-down weight bearing to his right lower extremity until his is re-evaluated by Orthopedics. Follow-up appointments have been made with both the Ortho-Trauma and Neurosurgery teams. At the time of discharge, Mr. [**Known lastname **] is hemodynamically stable and afebrile. His pain is well controlled on the current regimen. He has been moving his bowels and urinating without issue. He is being transferred to [**Hospital3 **] for further care. Medications on Admission: None. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Calcium Carbonate 500 mg PO QID:PRN heartburn 3. Docusate Sodium 100 mg PO BID 4. Sarna Lotion 1 Appl TP QID:PRN pruritis 5. Senna 1 TAB PO HS 6. TraMADOL (Ultram) 50 mg PO Q 8H Hold for sedation, RR<12 7. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: T11 compression fracture L2 fracture Superior/inferior pubic rami fractures Right sacral ala fracture Right 9th rib fracture 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**] on [**8-30**] after you fell off a ladder. Upon radiological evaluation, you were found to have the injuries as noted below under "Final Diagnosis". You were taken to the Operating Room on [**9-1**] with NeuroSurgery for fixation of your spine. You also had your pelvic fracture repaired with Orthopedics on [**9-6**]. You have recovered well from your operative procedures. Physical and occupational therapy has worked with you and feel you are ready to be discharged to a rehabilitation facility. Your discharge instructions are provided below: Please resume all regular home medications, unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. You are being discharged on narcotic pain medications (dilaudid and ultram). Take them as needed. It is also beneficial to take narcotics along with standing Tylenol during this acute period. As you progress over the next days to weeks, the goal is to take less narcotics and ease your pain with non-narcotic analgesics, such as Tylenol. Narcotic pain medications tend to cause constipation. You may take Colace and Senna to prevent this complication. If you beging to have regular or loose stools, you do not need these medications. You must wear your TLSO brace when out of bed at all times. You should apply it when you are laying in bed. Until you are re-evaluated by orthopedics, you should on apply touch-down weight to your right lower extremity. Follow-up appointments with Orthopedics and NeuroSurgery have been made for you. See below. Followup Instructions: Department: ORTHOPEDICS When: FRIDAY [**2156-9-17**] at 9:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: FRIDAY [**2156-9-17**] at 9:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: TUESDAY [**2156-11-2**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Please arrive at 9:45am for this scan. Department: RADIOLOGY When: TUESDAY [**2156-11-2**] at 10:15 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: TUESDAY [**2156-11-2**] at 11:15 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2156-9-8**]

[ "805.4", "807.01", "997.49", "808.2", "722.10", "805.2", "560.1", "805.6", "788.20", "E878.1", "E881.0" ]

icd9cm

[ [ [] ] ]

[ "77.79", "03.53", "81.05", "78.59", "81.63" ]

icd9pcs

[ [ [] ] ]

7966, 8036

3912, 7597

319, 804

8205, 8205

1990, 3889

10024, 11510

1444, 1463

7653, 7943

8057, 8184

7623, 7630

8388, 10001

1478, 1478

1930, 1971

262, 281

832, 1333

1493, 1915

8220, 8364

1355, 1428

24,076

163,966

14385

Discharge summary

report

Admission Date: [**2183-7-18**] Discharge Date: [**2183-7-25**] Date of Birth: [**2129-11-30**] Sex: M Service: ADMISSION DIAGNOSIS: DISCHARGE DIAGNOSES: 1. Intertrochanteric hip fracture. 2. Aspiration pneumonia. HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname **] is a 53-year-old with Alzheimer's dementia who lives in a group home. He was found to be ambulating with difficult yesterday with some pain in his right hip. His care takers noted that he was unable to bear weight on his right lower extremity and brought him to the Emergency [**Hospital1 **]. There was no documentation of a traumatic fall. PAST MEDICAL HISTORY: (Past medical history includes) 1. Down syndrome. 2. Alzheimer's. 3. Hypothyroidism. 4. Seborrhea. 5. Depression. PAST SURGICAL HISTORY: None. MEDICATIONS ON ADMISSION: Levoxyl 100 mg p.o. q.d., Paxil 25 mg p.o. q.d., vitamin B, vitamin C, and Ensure. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He lives in a group home. No alcohol. No tobacco. PHYSICAL EXAMINATION ON PRESENTATION: Temperature on admission was 94.9, heart rate was 81, blood pressure was 117/55, respiratory rate was 16. He had an oxygen saturation of 96% on room air. He was alert and cooperative, in no acute distress. He was following simple commands. His lungs were clear to auscultation. He had a regular rate and rhythm. His abdomen was soft, nontender, and nondistended. His left lower extremity demonstrated a 2+ dorsalis pedis. Light touch was intact in both lower extremities. His right lower extremity was flexed and externally rotated. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission included a white blood cell count of 16.8, with a hematocrit of 44. His had normal electrolytes with a potassium of 3.8 and a sodium of 141. RADIOLOGY/IMAGING: His electrocardiogram was normal. A chest x-ray was pending. Hip demonstrated a garden 4 femoral neck fracture. HOSPITAL COURSE: The patient was admitted on [**7-18**]. He was also seen and evaluated by his primary care physician (Dr. [**Last Name (STitle) 33301**]. He received medical clearance. On [**2183-7-18**] he underwent a bipolar hemiarthroplasty without incident. His postoperative course was remarkable for the development of respiratory distress noted on postoperative day two. The patient developed a respiratory rate of 40 with room air saturations in the 80s with an increase in pressure, with a temperature of 100.2. The patient was placed on a 100% nonrebreather with saturations of 97%. A chest x-ray at that time demonstrated evidence of a right lower lobe pneumonia. The patient was then placed on levofloxacin and Flagyl. He was admitted to the Medical Intensive Care Unit and followed by that team. On [**2183-7-21**], the patient improved and was weaned off the nonrebreather to cool nebulizers. He was febrile to 101.6; and once again was monitored by the Medical Intensive Care Unit team. He improved; however, he did have a hematocrit drop to 23. The patient was on Lovenox postoperatively. Because of this, he was transfused 2 units. He was guaiac-negative. The Lovenox was then discontinued. The patient did have lower extremity noninvasive tests performed on [**2183-7-22**]. These were negative, and because of this negative examination, the patient had his Lovenox and Coumadin stopped and was placed on an aspirin per day. DISCHARGE DISPOSITION/STATUS: The patient was then discharged back to his group home on [**2183-7-25**] with appropriate treatment. He was partial weightbearing on his right lower extremity at the time of discharge. He was afebrile with stable vital signs and a normal white count. His pneumonia was managed by the Medicine Service. The patient was discharged on levofloxacin. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE DIAGNOSES: 1. Subcapital femoral fracture. 2. Aspiration pneumonia. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Levofloxacin 500 mg p.o. q.d. (for seven days). 2. Percocet as needed. 3. Colace 100 mg p.o. b.i.d. 4. Levoxyl 100 mg p.o. q.d. 5. Vitamin B one tablet p.o. q.d. 6. Vitamin C one tablet p.o. q.d. 7. Ensure 8 ounces p.o. b.i.d. 8. Dexamethasone ointment. 9. Nizoral shampoo daily for his seborrhea. 10. Debrox 3 to 4 drops every week for a wax buildup. 11. Paxil 25 mg p.o. q.d. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**MD Number(1) 20990**] Dictated By:[**Last Name (NamePattern4) 34202**] MEDQUIST36 D: [**2183-10-20**] 23:09 T: [**2183-10-28**] 09:43 JOB#: [**Job Number 42634**]

[ "820.8", "331.0", "997.3", "427.89", "758.0", "244.9", "E887", "486", "311" ]

icd9cm

[ [ [] ] ]

[ "81.52" ]

icd9pcs

[ [ [] ] ]

3912, 3972

3999, 4719

860, 982

2003, 3840

826, 833

150, 150

3855, 3891

263, 658

681, 801

999, 1984

62,186

166,964

47876

Discharge summary

report

Admission Date: [**2158-11-29**] Discharge Date: [**2158-12-9**] Date of Birth: [**2097-8-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 922**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: [**2158-11-29**] Successful embolization of the left renal artery and one left lumbar artery just distal to the left renal artery using a combination of PVA particles and coils with good angiographic results. History of Present Illness: 59 year old Male with hx of endocarditis in setting of septic wrist in [**2156**] with subsequent 3+MR, 2+AR, persistent vegetation on mitral valve, moderate pulmonary hypertension with past admissions for abdominal pain, ascites secondary to (?) partial small bowel obstruction vs ileus and possible GIB - s/p Aortic valve replacement(21 mm ON-X, Mitral valve replacement 25/33 On-X Conform-X mechanical valve) presents to ED with acute abdominal pain. He reports feeling well until yesterday when he developed LLQ pain reported as dull in nature. He reports falling asleep and awakening with sharp LLQ pain described as "the worst pain I ever felt in my life". No associated SOB, CP, fever chills. Of note, most recent INR 6 at cardiologist on [**2158-11-27**]. Past Medical History: -endocarditis in setting of septic wrist in [**2156**] with subsequent 3+MR, 2+AR, persistent vegetation on mitral valve, moderate pulmonary hypertension, and signs of right ventricular pressure and volume overload on echo ([**3-/2158**]),on suppressive antibiotic therapy, -ESRD on hemodialysis, secondary to post-streptococcal glomerulonephritis. Renal transplant in [**2137**] failed after several years. s/p transplant nephrectomy in [**2143**]. Hyperparathyroidism due to ESRD -Atrial fibrillation- started on warfarin [**Date range (1) 101024**] -Coronary artery disease -Diastolic CHF with remote history of systolic CHF -MSSA Endocarditis with aortic and mitral valve involvement -Repeated episodes of pneumonia -pulmonary nodules -VRE septic arthritis -L wrist MSSA infective arthritis -Right femoral neck fracture s/p right hip hemiarthroplasty [**2157-1-11**] -Right Prosthetic hip infection s/p explantation [**2-18**] with subsequent Girdlestone procedure -History of Ischemic colitis/ileitis s/p subtotal colectomy and terminal ileal resection, followed by ileocolonic anastomosis with diverting loop ileostomy and gastrostomy tube placement [**2158-11-7**] Aortic valve replacement(21 mm ON-X, Mitral valve replacement 25/33 On-X Conform-X mechanical valve) [**2158-7-13**]: Fistulogram, 6-mm balloon angioplasty of juxta- anastomotic segment [**2157-6-16**]: Washout and drainage right hip wound infection, with deep bone biopsy of right proximal femur [**2157-6-14**]: Revision left radiocephalic arteriovenous fistula, endarterectomy radial artery [**2157-6-3**]: Arthrotomy right hip Girdlestone with debridement and evacuation of hematoma and infection. [**2157-2-22**]: Evacuation drainage of right hip deep hematoma-abscess. [**2157-2-18**]: Removal right hip hemiarthroplasty. [**2157-2-3**]: Irrigation, debridement and evacuation of hematoma of right septic hemiarthroplasty. [**2157-1-26**]: Right hip revision of hemi arthroplasty due to dislocation. [**2157-1-15**]: Exploratory laparotomy, gastrostomy tube, ileocolonic anastomosis and diverting loop ileostomy. [**2157-1-14**]: Exploratory laparoscopy, subtotal colectomy. [**2157-1-13**]: Exploratory laparotomy, Subtotal colectomy, Resection of terminal ileum, Temporary abdominal closure. [**2157-1-11**]: Right hip hemiarthroplasty. [**2156-12-10**]: Left wrist incision and drainage. [**2156-2-17**]: Right ring finger closed reduction percutaneous pinning for mallet finger.Left index and long ring finger PIP joint manipulation under anesthesia. [**2155-12-16**]: Left carpal tunnel release and left index, long and ring finger trigger releases. Social History: Owner of a clothing store in [**Location (un) 4398**]. Patient has been hospitalized/in rehab since [**2156-12-10**]. Prior to this, he lived in [**Location **] with his mother and brother. [**Name (NI) **] current tobacco and alcohol use but notes intermittent tobacco use in the past (~3 pack-years). Denies illicit drug use. HIV negative [**2156-12-27**] Family History: Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother). Father deceased. Brother has fibromyalgia. Daughter in good health Physical Exam: Pulse:AF 109 Resp:24 O2 sat: B/P Right: 65/49 Left: Height: Weight: General: AAO x 3 in NAD, mentating Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur II/VI SEM, + mech click Abdomen: Soft [x] non-distended [] non-tender [] no bowel sounds + mild LLQ TTP, Persistent fistula drainage seen at the left upper quadrant, ostomy site clean, dry, and intact, RLQ ostomy bag in place Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Discharge Physical Exam VS: T 98.0 HR: 90 Afib BP: 99/66 Sats: 100% RA General: NAD Card: irregular Resp: breath sounds clear GI: benign, ostomy functioning, Feeding tube capped Extr: warm no edema Incision: sternal clean, dry intact Vascular: AVFistula good bruit Neuro: awake, alert oriented Pertinent Results: [**2158-12-8**] 08:00AM BLOOD WBC-6.0 RBC-3.86* Hgb-11.0* Hct-34.1* MCV-89 MCH-28.5 MCHC-32.2 RDW-17.3* Plt Ct-183 [**2158-12-7**] 04:30AM BLOOD WBC-4.8 RBC-3.55* Hgb-10.2* Hct-32.4* MCV-91 MCH-28.7 MCHC-31.5 RDW-17.4* Plt Ct-141* [**2158-11-29**] 05:12AM BLOOD WBC-8.4# RBC-3.27* Hgb-9.6* Hct-29.6* MCV-91 MCH-29.3 MCHC-32.3 RDW-18.0* Plt Ct-223 [**2158-12-9**] 04:30AM BLOOD UreaN-16 Creat-3.3*# Na-137 K-3.7 Cl-94* [**2158-12-8**] 08:00AM BLOOD Glucose-125* UreaN-30* Creat-5.1*# Na-136 K-3.9 Cl-95* HCO3-30 AnGap-15 [**2158-11-29**] 05:12AM BLOOD Glucose-126* UreaN-24* Creat-5.5* Na-138 K-4.3 Cl-100 HCO3-25 AnGap-17 [**2158-12-8**] 08:00AM BLOOD ALT-12 AST-33 LD(LDH)-498* AlkPhos-146* Amylase-90 TotBili-3.1* [**2158-12-9**] 04:30AM BLOOD Mg-1.8 [**2158-12-9**] 04:30AM BLOOD PT-41.1* INR(PT)-4.3* [**2158-12-8**] 08:00AM BLOOD PT-49.1* INR(PT)-5.4* [**2158-12-7**] 04:30AM BLOOD PT-46.8* INR(PT)-5.1* [**2158-12-6**] 04:55AM BLOOD PT-42.9* INR(PT)-4.6* [**2158-12-5**] 11:19AM BLOOD PT-34.5* INR(PT)-3.5* [**2158-12-4**] 04:47AM BLOOD PT-29.1* PTT-39.9* INR(PT)-2.9* [**2158-12-1**] 07:32AM BLOOD PT-22.7* PTT-43.5* INR(PT)-2.1* [**2158-11-29**] 03:00PM BLOOD PT-19.9* PTT-33.8 INR(PT)-1.8* Micros: Blood cultures x 7 no growth to date [**2158-11-29**] BLOOD CULTURE Blood Culture, Routine (Final [**2158-12-5**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Brief Hospital Course: Following admission he underwent imaging that demonstrated a bleed into the nonfunctining transplanted kidney, and extravasation of contrast from a lumbar artery. The presumed mechanism was that of the expanding hematoma avulsing the artery. He was taken to the Interventional Radiology suite where coiling and embolization of the renal and lumbar bleeding diatheses was undertaken. He stabilized , was hemodynamically stable and weaned and extubated. He was subsequently transferred to the floor where he recovered. He continued hemodialysis and was seen by Physical Therapy for mobility. He was walking with his [**Month/Day/Year **] and ready for discharge on [**12-9**] home with Caregroup VNA. Arrangements were made for follow up and Coumadin management. His INR goal is 2-2.5. Medications on Admission: aspirin 81 mg Tablet PO DAILY acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every hours) as needed for fever or pain. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. B complex-vitamin C-folic acid 1 mg Capsule 1) Cap PO DAILY Daily as needed for CRF. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS) as needed for CRF. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal Daily as needed for constipation. Protonix 40 mg Tablet PO once a day. Coumadin 2 mg Tablet -told to stop 2 days ago with INR 6.0 by cardiologist Ciprofloxacin 500 mg/day Cinacalcet 30 mg daily Nephrocaps Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): suppressive therapy to continue indefinitely . 6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 1 mg Tablet Sig: 0.5 Tablet PO as directed: start when INR < 3.0. 10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Spontaneous left renal artery bleed with transection of lumbar artery MSSA Endocarditis ESRD on hemodialysis Renal transplant in [**2137**] failed s/p nephrectomy in [**2143**]. Hyperparathyroidism Atrial fibrillation Coronary artery disease Diastolic heart failure Pneumonia VRE septic arthritis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1194**] managed with dilaudid 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 No lifting more than 10 pounds for 6 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: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2159-1-16**] 10:00 Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2159-1-18**] 1:00 Provider: [**Known firstname 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2159-1-2**] 1:00 Blood draw [**2158-12-10**]: Please call [**Telephone/Fax (1) 170**] with INR result and for further warfarin dosing. INR [**2158-12-9**] 4.3 Check INR daily. Warfarin will restart when INR < 3.0 Completed by:[**2158-12-9**]

[ "V45.11", "593.81", "588.81", "428.0", "568.81", "416.8", "287.9", "427.31", "585.6", "V44.3", "414.01", "403.91", "V43.3", "286.9", "428.30", "560.1" ]

icd9cm

[ [ [] ] ]

[ "39.95", "88.42", "39.79", "88.45", "96.04", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

10044, 10102

7476, 8270

335, 547

10443, 10584

5651, 7453

11140, 11731

4397, 4535

9078, 10021

10123, 10422

8296, 9055

10608, 11117

4550, 5632

281, 297

575, 1342

1364, 4005

4021, 4381

3,240

192,798

46205

Discharge summary

report

Admission Date: [**2100-7-18**] Discharge Date: [**2100-7-22**] Service: ACOVE HISTORY OF PRESENT ILLNESS: In brief, this is a [**Age over 90 **]-year-old woman with a history of congestive heart failure, gastroesophageal reflux disease, anemia, silent myocardial infarction, AR/MR who presents on [**7-18**] with bilateral lower extremity weakness and hip pain. A hematocrit that was done clots. The patient was guaiac positive. The [**Hospital 228**] home health aides reported that the patient had melanotic stools over the weekend. The patient was transferred to the MICU and was transfused 4 units of packed red blood cells. Hospital course was complicated by 2 to 1 atrial flutter with heart rates in the 120s to 140s. The patient had a troponin peak of 6.4. The patient was to be cardioverted, but self q6h was started. The patient was evaluated by gastrointestinal who thought that the upper bleed was due to NSAID use. The patient was on Celebrex at home for arthritis and degenerative joint disease and recently had increased a dose from qd to [**Hospital1 **]. Gastroenterologists have decided not to scope the patient given her age and comorbidities, unless she becomes hemodynamically unstable in the future. The patient has been managed with q8h hematocrit checks and Protonix 40 mg. MICU course was also complicated by decreased oxygen saturations to the high 80s that was thought to be due to CSF exacerbation. The patient has been gently diuresed with Lasix and is now saturating in the 90s on room air. PAST MEDICAL HISTORY: 1. Status post cerebrovascular accident/transient ischemic attacks 2. Status post right hip replacement in 10/99 3. Hypothyroidism 4. Hypertension 5. Dementia 6. Hiatal hernia 7. Echocardiogram from [**11/2098**] revealed systolic function within normal limits, moderate aortic regurgitation, moderate to severe mitral regurgitation, positive tricuspid regurgitation, moderate PA hypertension 8. Status post total abdominal hysterectomy/bilateral salpingo-oophorectomy 9. Status post appendectomy 10. Status post cholecystectomy [**09**]. History of melanoma, status post resection 12. Non Q-wave myocardial infarction in [**2094**] 13. Congestive heart failure 14. Anemia 15. Gastroesophageal reflux disease 16. Degenerative joint disease 17. History of hypercalcemia secondary to hyperparathyroidism ADMISSION MEDICATIONS: 1. Ultram 50 mg po q day 2. Tums 3 tablets po q day 3. Tylenol prn 4. Epogen [**Numeric Identifier 961**] units. Of note, this was started in the MICU. 5. Celebrex 100 mg [**Hospital1 **] 6. Zaroxolyn 2.5 mg po q day 7. Calcium chloride 10 mg q day 8. Iron 325 mg q day 9. Lasix 100 mg q day 10. Captopril 50 mg tid 11. Prilosec 20 mg q day 12. Multivitamin 13. Enteric coated aspirin 325 mg q day 14. Peri-Colace 1 tablet q day 15. Levoxyl 112 mcg q day 16. Zoloft 25 mg q day ALLERGIES: PENICILLIN - THE PATIENT GETS A RASH. SOCIAL HISTORY: The patient lives at [**Location (un) 5481**] [**Hospital3 **] Environment with 24 hour home health aide care. LABORATORY DATA: White blood cell count 12.3, hematocrit 33.9; of note, hematocrit has remained stable during this entire admission after transfusions, platelets 211. PT 12.4, PTT 24, INR 1.1. Sodium 149, potassium 4.3, chloride 114, bicarbonate 22, BUN 75, creatinine 1, platelets 146, calcium 9.9, phosphate 1.7, magnesium 2.7. [**7-19**]: Troponin 3.8 IMAGING: Admission electrocardiogram revealed new ST segment depressions in inferior and lateral leads, 2, F, V4, V5, V6 at 117 beats per minute, variable P-wave morphology, notched P-waves. Chest x-ray revealed bilateral effusions, linear atelectasis at left mid lung zone. PHYSICAL EXAM: VITAL SIGNS: Heart rate 100, respiratory rate 20, blood pressure 132/64, oxygen saturation 99% on 40% face mask. HEAD, EARS, EYES, NOSE AND THROAT: No jugular venous distention, no murmur. Mucous membranes are moist. Extraocular muscles intact. LUNGS: Positive crackles at bases bilaterally, right greater than left. Decreased breath sounds at bases bilaterally. HEART: Positive S1, positive S2, positive APCs, positive holosystolic murmur heard best at apex. ABDOMEN: Soft, nontender, slightly decreased bowel sounds. EXTREMITIES: Trace edema bilaterally. HOSPITAL COURSE: In summary, this is a [**Age over 90 **]-year-old woman with a history of congestive heart failure, dementia, gastroesophageal reflux disease, degenerative joint disease and arthritis who presents with upper gastrointestinal bleed thought secondary to NSAID use who is now status post 4 units of packed red blood cell transfusions. MICU course is complicated by atrial flutter and a troponin of 6.4. The patient's hematocrit was checked q8h and then [**Hospital1 **] during this hospitalization. Hematocrit has remained stable. The patient was followed by gastrointestinal who felt that the patient did not need to be scoped at this time and should be followed up as an outpatient if she has any other symptoms of gastrointestinal bleeding. During this hospitalization, the [**Hospital 228**] hospital course was complicated by congestive heart failure exacerbation due to the 4 units of packed red blood cells. The patient was diuresed with Lasix. The patient is currently on room air and will resume her outpatient Lasix dose of 100 mg po q day. The patient's troponin has decreased while in house. Most likely, the patient had a non Q-wave myocardial infarction with atrial flutter. The patient is not a good candidate for aspirin because of her upper gastrointestinal bleed. Will continue Lopressor 12.5 mg [**Hospital1 **] and captopril 50 mg tid. In terms of the patient's anemia, the patient has normal renal function and will not be discharged with Epogen injections. The patient will get iron and vitamin C as an outpatient. The patient may need occasional hematocrit checks in the future. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed secondary to NSAID use 2. Congestive heart failure DISCHARGE CONDITION: Stable DISCHARGE STATUS: Return to [**Location (un) 5481**] with 24 hour home health aide care. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po qd 2. Lopressor 12.5 mg po bid 3. Levoxyl 112 mcg po q day 4. Captopril 50 mg po tid 5. Tums 3 tablets po q day 6. Ultram 50 mg po q day 7. Multivitamin 1 tablet po q day 8. Zoloft 25 mg po q day 9. Zaroxolyn 2.5 mg po q day 10. Lasix 100 mg po q day 11. Iron sulfate 325 mg po tid on an empty stomach 12. Vitamin C 250 mg tid with iron 13. Peri-Colace 1 tablet po q day 14. Potassium chloride 10 milliequivalents po q day [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], M.D. [**MD Number(1) 1590**] Dictated By:[**Last Name (NamePattern1) 218**] MEDQUIST36 D: [**2100-7-22**] 09:51 T: [**2100-7-22**] 10:55 JOB#: [**Job Number 98238**]

[ "416.0", "428.0", "396.3", "285.9", "410.71", "397.0", "427.32", "E935.9", "578.9" ]

icd9cm

[ [ [] ] ]

[ "96.33" ]

icd9pcs

[ [ [] ] ]

6053, 6152

5945, 6031

6175, 6908

4310, 5924

2403, 2943

3726, 4292

119, 1546

1568, 2380

2960, 3711

6,955

157,282

48119

Discharge summary

report

Admission Date: [**2133-5-25**] Discharge Date: [**2133-6-2**] Date of Birth: [**2061-5-19**] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: This is a 72-year-old female, a Jehovah's Witness, who was admitted on [**2133-5-25**] with sepsis of unknown origin. She was hypotensive and required pressors and her white count was 22.3. Possible sources included: Pulmonary: She had a left lower lobe consolidation on chest x-ray and her sputum cultures from [**2133-5-26**] grew MRSA and gram-negative rods. Urine: She had an indwelling Foley catheter at that time and her urine culture on [**2133-5-27**] grew greater than 100,000 gram- negative rods, which were not further speciated for possible fecal contamination. A hemodialysis line, which on admission was a tunneled right IJ catheter. The line was changed to a left IJ catheter on [**2133-5-27**]. Blood and line tip cultures were all negative. She complained of abdominal pain, which was noted from [**2133-5-26**]; on that day, she had a CT scan that was normal. Due to persistent complaints, a CT scan was later obtained on [**2133-5-29**] and that one was read as having a transition point to the right lower quadrant. There was contrast from the previous scan in the distal small bowel and colon. A delayed scan was obtained on [**2133-5-30**] and showed that new contrast still was not in the colon. The Surgical Service evaluated her at that point and in view of her benign exam, the fact that she had not deteriorated over the course of days, the CT findings of contrast from [**2133-5-27**] in the rectum, no significant dilatation of the proximal small bowel on the scan, and the fact that she was continuing to pass flatus, it was decided to follow her exam and treat her conservatively at that point. On [**2133-6-1**], the patient demonstrated deterioration in her clinical condition. She became more acidotic. Her lactate was persistently rising. There was still no obvious source of sepsis that was treated. It was, therefore, decided to take the patient to the operating room for an exploratory laparotomy. The patient was explored through a midline incision. The bowel seemed mildly distended, but viable throughout; and there was no point of obstruction. The bowels ran from the ligamentum of Treitz to the ileocecal valve and then the colon was inspected and looked normal throughout its course. The patient was brought back to the intensive care unit. At that point, the patient was requiring full support and had multiple organ failure. On the morning of [**2133-6-2**], the patient developed arrhythmias including ventricular fibrillation and asystole. She was initially coded with good response, but a discussion was carried with the family and due to her grave condition and unlikely recovery it was decided at that point to make her comfort measures only. The patient expired on [**2133-6-2**] at 08:33 a.m. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**] Dictated By:[**Last Name (NamePattern1) 28297**] MEDQUIST36 D: [**2133-6-2**] 08:40:34 T: [**2133-6-2**] 13:52:52 Job#: [**Job Number 101464**]

[ "585", "560.1", "995.92", "428.0", "518.83", "482.41", "996.73", "038.9", "V44.0" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "00.14", "93.90", "54.11", "96.6" ]

icd9pcs

[ [ [] ] ]

164, 3229

11,670

120,337

30214

Discharge summary

report

Admission Date: [**2185-3-15**] Discharge Date: [**2185-3-21**] Date of Birth: [**2127-7-13**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Betadine Attending:[**First Name3 (LF) 7141**] Chief Complaint: abdominal discomfort Major Surgical or Invasive Procedure: - Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, debulking, omentectomy and splenectomy - Transfusion of 1 unit packed red blood cells History of Present Illness: HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old G0 sent by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for consultation regarding a possible diagnosis of ovarian cancer. The patient states that she has had increasing abdominal distention and intermittent episodes of abdominal discomfort over the past six weeks. She was evaluated with a CT of the abdomen and pelvis at [**Hospital6 204**] on [**2185-3-1**]. She had presented with acute worsening of epigastric pain associated with nausea and vomiting. The CT demonstrated a moderate amount of ascites. There was infiltration of the omentum with tumor. There were bilateral mixed solid and cystic ovarian masses. There were peritoneal implants over the convexity of the liver and within the fissure of the falciform ligament. There was some adenopathy anterior to the inferior vena cava. There were several lesions within the liver measuring about 1 cm, suspicious for parenchymal metastases. The patient states that she is tolerating a regular diet, although she does describe some early satiety. She has had some undefined weight loss. She feels somewhat constipated. She is unable to fit into her usual clothes because of her abdominal distention. Past Medical History: PAST MEDICAL HISTORY: Negative. * PAST SURGICAL HISTORY: Dermoid cystectomy, tonsillectomy, and appendectomy. * ALLERGIES TO MEDICATIONS: Betadine. * CURRENT MEDICATIONS: Vicodin, Reglan, multivitamins, calcium, and Prilosec. * OB HISTORY: Negative. * GYN HISTORY: Last Pap smear and mammogram were both recently normal. * Social History: SOCIAL HISTORY: The patient does not smoke. She drinks occasionally. She is a nurse. Family History: FAMILY HISTORY: Significant for a paternal grandmother with probable colon cancer and a paternal aunt with possible ovarian cancer. Physical Exam: PHYSICAL EXAMINATION: GENERAL: Well developed, well nourished, and in no acute distress. HEENT: Sclerae anicteric. LYMPHATICS: Lymph node survey was negative. LUNGS: Clear to auscultation. HEART: Regular without murmurs. BREASTS: Without masses. ABDOMEN: Obviously distended with a palpable fluid wave. There were no palpable masses. EXTREMITIES: Without edema. PELVIC: The vulva and vagina were normal. The cervix was normal. Bimanual and rectovaginal examination revealed a large firm and somewhat fixed mass in the cul-de-sac. There was associated cul-de-sac nodularity. RECTAL: Intrinsically normal. Pertinent Results: [**2185-3-21**] 07:10AM BLOOD WBC-6.9 RBC-2.62* Hgb-7.7* Hct-23.0* MCV-88 MCH-29.5 MCHC-33.6 RDW-12.6 Plt Ct-809* [**2185-3-20**] 11:10AM BLOOD WBC-6.8 RBC-2.76* Hgb-8.0* Hct-25.5* MCV-92 MCH-28.9 MCHC-31.4 RDW-12.7 Plt Ct-879* [**2185-3-19**] 09:30AM BLOOD WBC-6.4 RBC-2.47* Hgb-7.2* Hct-22.9* MCV-93 MCH-28.9 MCHC-31.2 RDW-12.5 Plt Ct-751* [**2185-3-18**] 10:45AM BLOOD WBC-11.6* RBC-2.57* Hgb-7.4* Hct-24.1* MCV-94 MCH-29.0 MCHC-30.9* RDW-13.2 Plt Ct-750* [**2185-3-16**] 05:10PM BLOOD WBC-21.0* RBC-3.20* Hgb-9.5* Hct-28.2* MCV-88 MCH-29.7 MCHC-33.8 RDW-13.2 Plt Ct-768* [**2185-3-16**] 04:42AM BLOOD WBC-21.4* RBC-3.89* Hgb-11.4* Hct-36.3 MCV-93 MCH-29.4 MCHC-31.4 RDW-13.0 Plt Ct-900* [**2185-3-15**] 09:05PM BLOOD WBC-18.7*# RBC-3.71* Hgb-11.5* Hct-34.7* MCV-94 MCH-30.9 MCHC-33.1 RDW-13.1 * [**2185-3-16**] 04:42AM BLOOD Plt Ct-900* [**2185-3-21**] 07:10AM BLOOD Plt Ct-809* * CXR [**2185-3-18**] Small bilateral pleural effusions are stable. Lateral view shows irregular opacification one or both of the lower lobes, either of which could be a pneumonia or atelectasis. The upper lungs are clear and heart is normal size. * Brief Hospital Course: This patient is a 57 yo G0 woman who was admitted s/p exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, debulking, omentectomy and splenectomy for likely ovarian cancer. SHe was transfused one unit intra-operatively. Please see operative report for full details. * Following surgery, the patient was transferred to the ICU for hemodynamic monitoring. SHe was immediately extubated and was stable throughout her one day stay in the ICU. On post-op day #1, she was transferred to the floor. Her post-op course was uneventful. Her diet was slowly advanced over 5 days. Her pain was well controlled with a dilaudid PCA for the first 4 days and oral pain meds thereafter. On post-op day #3, her CBC was notable for blood loss anemia with a Hct of 24. This was rechecked the following day, at which time it was noted to be 23. The patient was recommended for blood transfusion but she declined. On the following day, her hematocrit measured at 25. * At the time of her discharge, she was ambulating, urinating without difficulty and tolerating her diet with pain well controlled. The results of the pathologic evaluation were still pending. The patient was given vaccinations against pneumococcus, H. influenzae, and meningococcus prior to discharge. Discharge Medications: 1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. Disp:*60 Capsule(s)* Refills:*2* 4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 5 days. Disp:*10 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Ovarian cancer Discharge Condition: Good Discharge Instructions: vomiting, difficulty with urinating, worsening abdominal pain, vaginal bleeding or any other worrisome symptom. * No driving while taking narcotics. * Avoid driving for the first 2 weeks * No heavy lifting for 4 weeks * Nothing in your vagina for 4 weeks (includes sex). Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Date/Time:[**2185-3-24**] at 9:15 AND [**2185-4-21**] 13:30 Completed by:[**2185-3-23**]

[ "560.1", "198.2", "197.8", "197.6", "183.0", "285.1", "E878.6", "998.59", "197.5", "198.82", "198.89", "518.5" ]

icd9cm

[ [ [] ] ]

[ "65.61", "99.04", "54.4", "68.39", "41.5" ]

icd9pcs

[ [ [] ] ]

6002, 6008

4182, 5466

303, 480

6067, 6074

3022, 4159

6394, 6562

2250, 2368

5489, 5979

6029, 6046

6098, 6371

1840, 1934

2383, 2383

2405, 3003

243, 265

1956, 2111

537, 1759

1804, 1816

2144, 2217

41,385

103,289

24980+57434

Discharge summary

report+addendum

Admission Date: [**2105-12-18**] Discharge Date: [**2105-12-22**] Date of Birth: [**2040-10-2**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Left lower lobe nodule. Major Surgical or Invasive Procedure: [**2105-12-17**] VATS left lower lobe wedge resection. History of Present Illness: Ms. [**Known lastname **] is a 65-year-old woman with an incidentally noted left lower lobe nodule. She presents for diagnosis and treatment. Because of her co- morbidities it was decided that a limited resection would be the extent of the treatment as opposed to anatomic resection. Past Medical History: COPD, allergic rhinitis, severe OSA Heavy ETOH use restless leg syndrome, GERD/hiatal hernia CAD CHF EF 55-60% Diabetes Mellitus Type 2 on insulin Hypertension CRI baseline 1.5 PVD Hyperlipidemia arthritis of hip. Social History: Lives with family. Tobacco 40 pack-year quit [**4-/2103**] ETOH drinks 5 Vodka's per day Family History: Mother CAD Father CAD Siblings 1 sister healthy Offspring 2 children (1 deceased) Other Physical Exam: VS: T 98.4 HR 56 BP: 116/54 Sats: 96% TM FS: 454-163 General: sitting up in chair no apparent distress HEENT: normocephalic Neck: trach in place: site no erythema Card: RRR Resp: decreased breath sounds bilateral no crackles GI: obese, benign Extr: warm no edema Incision: Left lower lobe VATs site clean dry intact Neuro: non-focal Pertinent Results: [**2105-12-21**] WBC-5.6 RBC-3.41* Hgb-9.9* Hct-30.9 Plt Ct-325 [**2105-12-19**] WBC-5.7 RBC-3.27* Hgb-9.7* Hct-29.2 Plt Ct-277 [**2105-12-21**] Glucose-320* UreaN-28* Creat-1.8* Na-133 K-4.6 Cl-95* HCO3-25 [**2105-12-19**] Glucose-133* UreaN-54* Creat-2.7* Na-141 K-4.2 Cl-103 HCO3-26 [**2105-12-21**] Calcium-8.7 Phos-2.4* Mg-1.9 Cultures: Urine, blood x 2 and pleural no growth Pleural tissue: no growth CXR: [**2105-12-22**] the degree of pulmonary vascular congestion has substantially reduced, and there is improved aeration in the left lung. The tube coiling over the upper neck has been removed. Ileostomy tube remains in place. [**2105-12-21**] Tracheostomy tube is at the midline with its tip 5 cm above the carina. A coiled tube is projecting over the oropharynx and it is unclear if it represents an internal or external device. It should be correlated with patient's supporting devices. Cardiomediastinal silhouette is stable. There is interval development of vascular engorgement/mild pulmonary edema since prior study obtained on [**2105-12-20**] increased opacification at both bases consistent with volume loss and infiltrate. There is a right greater than left pleural effusion. The left-sided chest tube remains in place. The tracheostomy tube is unchanged. Brief Hospital Course: Mrs. [**Known lastname **] was admitted on [**2105-12-18**] for VATS left lower lobe wedge resection. She was transferred to the PACU requiring CPAP [**10-15**] FIO2 60% and was later transfer to SICU for respiratory distress The FIO2 was increased to 70% for oxygen saturation 87-89% improved to 90-93%. Respiratory: POD2 she weaned to TM, 12L 02 sats 88-92% which is her baseline. She was gent ley diuresed. Her Trach was changed back to fenestrated, [**Location (un) **] #4 cuff less with oxygen saturations 90-92% on 50% Trach mask (her baseline). She was followed by serial Chest films which showed improving pulmonary vascular congestions with improved left lung aeration. Left [**Doctor Last Name 406**] drain was removed on POD 2. Cardiac: her home cardiac medications were restarted with stable HR and hemodynamics. Renal: CRI baseline 1.5-2.0. Peak CRE 2.7->.2.2. Foley was removed and she voided without difficulty Endocrine: Insulin sliding scale was started until taking PO's then her Home insulin dose was started. Nutrition: Tolerated a regular diet once able to eat. ETOH: she was maintained on Ativan prophylactic. ID: Temp 101 pan cultured with no growth Neuro: pain well controlled with Dilaudid discharged on Percocet. Disposition: home with VNA on POD4. Medications on Admission: Crestor 40mgdaily, lopressor 50 TID, tricor 145 mg daily, Norvasc 10 mg daily, protonix 40mg [**Hospital1 **], paxil 20 mg daily, ativan 2 mg prn, lasix 40 mg daily insulin humulin N 25 units [**Hospital1 **], humalog 5 units [**Hospital1 **], ASA 325 mg daily, advair inhaler 250/50 1 puffs [**Hospital1 **] daily, fluicasone 110 2 puffs [**Hospital1 **] Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 8. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day as needed. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Humalog 100 unit/mL Solution Sig: Five (5) units Subcutaneous twice a day. 14. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous twice a day. 15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Community Health and Hospice Discharge Diagnosis: Left lower lobe nodule. Discharge Condition: stable. Discharge Instructions: -You may shower, keep covered with bandaid. -Do not drive while taking narcotics. -resume home medications. -Trach care as per your home routine. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] [**1-5**] at 1:00pm on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]. Phone:[**0-0-**] Chest X-Ray 45 minutes before your appointment on the [**Location (un) 861**] Radiology Department Completed by:[**2105-12-22**] Name: [**Known lastname 11255**],[**Known firstname 540**] A. Unit No: [**Numeric Identifier 11256**] Admission Date: [**2105-12-18**] Discharge Date: [**2105-12-22**] Date of Birth: [**2040-10-2**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3454**] Addendum: Renal: episode of ARF with a peak CRE 2.7 and mild pulmonary edema. With diuresis her CRE improved to 1.8 with good urineout put. Discharge Disposition: Home With Service Facility: Community Health and Hospice [**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**] Completed by:[**2106-1-20**]

[ "250.40", "428.0", "V55.0", "333.94", "496", "511.9", "780.62", "327.23", "V45.81", "478.5", "276.6", "303.91", "584.9", "162.5", "278.00", "403.90", "291.0", "585.9", "478.74", "V44.2", "412" ]

icd9cm

[ [ [] ] ]

[ "97.23", "32.20", "96.71", "96.6", "33.21" ]

icd9pcs

[ [ [] ] ]

7057, 7255

2848, 4139

348, 405

5981, 5991

1543, 2825

6185, 7034

1079, 1169

4546, 5831

5934, 5960

4165, 4523

6015, 6162

1184, 1524

284, 310

433, 719

741, 957

973, 1063

43,118

179,948

53912

Discharge summary

report

Admission Date: [**2124-3-17**] Discharge Date: [**2124-4-15**] Date of Birth: [**2073-1-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5893**] Chief Complaint: Chief Complaint: tonsillar cancer Reason for MICU transfer: airway comprimise Major Surgical or Invasive Procedure: Endotracheal intubation Tracheostomy Bronchoscopy Bilateral chest tube placement Skin Biopsy (R dorsum of hand) Hemodialysis line placement G-tube placement History of Present Illness: 51yo male with stage IV tonsillar cancer who recently initiated chemotherapy with docetaxel/displatin/5-FU, admitted to an OSH with failure to thrive, transferred here because of potential for airway compromise. Presented for chemo [**2124-3-7**] with dehydration and dizziness, found to have acute renal failure (Cr 2.0). He had been unable to eat or drink due to throat pain. Hospital stay complicated by Afib with RVR managed with a dilt drip, and he was started on coumadin. He had pancytopenia, thought to be multifactorial. His thrombocytopenia may be from HIT, so he was switched to Arixtra (fondaparinox). He did not get blood transfusion prior to transfer. His renal failure worsened, to Cr 5.0, thought to be ATN. He began having hemoptysis and was seen by ENT, who felt he needed a tracheostomy, but did not feel comfortable doing it given his comorbidities. He was being for placement of a G-tube. He was evaluated by ENT [**2124-3-10**], who . [**2124-3-16**] he was found to have bilateral infiltrates on CXR, and was started on vanc/Zosyn. He also had positive blood cultures for gram positive cocci. He had a worsening respiratory status today requiring a non-rebreather, with which is O2 improved and he was thought stable. There was concern for his ability to protect his airway, so he was transferred here by [**Location (un) **]. On arrival to the MICU, patient was responsive, following commands and complained RUQ pain. His respiratory status worsened with development of stridor, so anesthesia was called. Labs notable for hyponatremia to 132, Cr 4.8 (per d/c summary peak 5.0), BUN 111, WBC 3.4 with N73 and 15% bands, Hct 24.0 and Plts 10. INR 2.1 (from 2.1), fibrinogen 738. Albumin 1.6, though gas reassuring 7.36/39/97. Patient transiently hypotensive with SBPs to 80. Intubated for airway protection. Patient unable to provide ROS. Per his brother, he drank heavily, roughly 12-pack of beer per day, up until about 3 weeks ago. He has not had signs of withdrawal. He was having a lot of trouble eating and would have prolonged coughing spells after trying to have even a milkshake. Past Medical History: - Stage IVb squamous cell carcinoma of the left tonsil, s/p first round of chemo with docetaxel/cisplatin/5-FU - DVT in [**2091**] s/p 3 months of anticoagulation - alcohol abuse - tobacco abuse - s/p right shoulder arthoscopy Social History: He smokes 1.5ppd since [**29**], quit 3 weeks ago. Heavy alcoholic (12-pack beer per day), but has not drunk x2-3 weeks. Single, lives alone, and is disabled. His brother has been identified as his HCP. Family History: Father died at 61 of CHF. Mother died at 73, but was apparently in good health. He has 3 brothers and two sons who are apparently healthy. No h/o tonsillar cancer. Physical Exam: Admission Physical Exam: Vitals: 98 109 111/60 (was down to 78/46) 30 99% on face mask General: Somnolent, obese, pale male in mild respiratory distress HEENT: Sclera anicteric, oropharynx full of fresh blood from mouth care, EOMI, PERRL Neck: obese, no clear JVP CV: Initially regular, then irregularly irregular and tachycardic Lungs: Rhonchorus with upper airway stridor Abdomen: Obese, points to RUQ being painful, soft, non-distended GU: no foley Ext: Warm, well perfused, diffuse anasarca Neuro: CNII-XII grossly intact, moving all 4 extremities . Discharge physical exam: T 98.4 HR 112 BP 115/68 O2 100% on pressure support 8, PEEP 5, 40%FiO2 General: awake and appears comfortable HEENT: small amt of dried blood at L angle of mouth Neck: tracheostomy CV: regular rhythm, nl S1,2, no rub or murmurs Abdomen: PEG tube in place, distended, soft, non-tender PULM: diffuse rhonchi in anterior lung fields, bilateral chest tubes in place EXT: [**11-22**]+ edema BLEs Skin: improved erythematous, plague like rash on LUE and chest. 1+ LE edema in hands and arms Neuro: Trying to communicate, appears appropriate. Pertinent Results: ADMISSION LABS: [**2124-3-17**] 03:33PM BLOOD WBC-3.4* RBC-2.58* Hgb-7.9* Hct-24.0* MCV-93 MCH-30.6 MCHC-32.9 RDW-14.1 Plt Ct-10* [**2124-3-17**] 03:33PM BLOOD Neuts-73* Bands-15* Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2124-3-17**] 03:33PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2124-3-17**] 03:33PM BLOOD PT-21.6* PTT-53.9* INR(PT)-2.1* [**2124-3-17**] 03:33PM BLOOD Fibrino-738* [**2124-3-17**] 03:33PM BLOOD Glucose-99 UreaN-111* Creat-4.8* Na-132* K-3.9 Cl-98 HCO3-21* AnGap-17 [**2124-3-17**] 03:33PM BLOOD ALT-22 AST-26 LD(LDH)-281* AlkPhos-39* TotBili-1.0 [**2124-3-17**] 03:33PM BLOOD Albumin-1.6* Calcium-7.0* Phos-6.3* Mg-2.4 [**2124-4-11**] 03:51AM BLOOD VitB12-1815* [**2124-3-22**] 06:01AM BLOOD Triglyc-202* [**2124-4-10**] 04:47AM BLOOD TSH-1.1 [**2124-3-25**] 03:52AM BLOOD Cortsol-29.2* [**2124-3-30**] 03:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2124-3-17**] 03:33PM BLOOD Vanco-14.6 [**2124-3-30**] 03:40AM BLOOD HCV Ab-NEGATIVE [**2124-3-17**] 04:05PM BLOOD Type-ART FiO2-60 pO2-97 pCO2-39 pH-7.36 calTCO2-23 Base XS--2 Vent-SPONTANEOU [**2124-3-17**] 05:35PM BLOOD freeCa-1.04* . DISCHARGE LABS: [**2124-4-15**] 02:31AM BLOOD WBC-17.3* RBC-2.39* Hgb-7.1* Hct-22.2* MCV-93 MCH-29.9 MCHC-32.1 RDW-15.2 Plt Ct-100* [**2124-4-14**] 03:56AM BLOOD Neuts-75* Bands-0 Lymphs-9* Monos-8 Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-5* [**2124-4-14**] 03:56AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Stipple-OCCASIONAL [**2124-4-15**] 02:31AM BLOOD PT-14.7* PTT-34.0 INR(PT)-1.4* [**2124-4-15**] 02:31AM BLOOD Glucose-93 UreaN-46* Creat-4.6*# Na-137 K-3.7 Cl-101 HCO3-26 AnGap-14 [**2124-4-13**] 03:06AM BLOOD ALT-10 AST-16 AlkPhos-114 TotBili-0.3 [**2124-4-15**] 02:31AM BLOOD Calcium-7.9* Phos-4.9* Mg-2.4 [**2124-4-15**] 01:56PM BLOOD Type-ART pO2-63* pCO2-43 pH-7.47* calTCO2-32* Base XS-6 [**2124-4-13**] 05:53PM BLOOD Lactate-0.9 [**2124-4-13**] 05:53PM BLOOD freeCa-1.16 [**2124-4-11**] 09:09PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.007 [**2124-4-11**] 09:09PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [**2124-4-11**] 09:09PM URINE RBC->182* WBC-47* Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 [**2124-3-21**] 11:51AM URINE Eos-NEGATIVE [**2124-3-23**] 01:39PM URINE Hours-RANDOM UreaN-341 Creat-18 Na-91 K-29 Cl-108 . IMAGING: -[**4-12**] CT chest: FINDINGS: Right thoracostomy tube and left pigtail catheter have been removed. Moderate bilateral pleural effusions persist, with several internal locules of air. Tracheostomy tube terminates in the proximal trachea, with surrounding retained secretions. There has been slight overall increase in multifocal ground-glass and consolidative opacities, demsontrating a peribronchovascular distribution. Lower lobe consolidation persists, with multiple areas of cavitation and varicoid bronchiectasis. Diffuse intrathoracic lymphadenopathy has slightly increased, measuring up to 2.6 x 1.9 cm in the mid right paratracheal region, previously 2.3 x 1.7 cm; 12 mm in the right hilum, previously 11 mm; and 9 mm in the paraaortic region, previously 8 mm. Left PICC again terminates in the high right atrium, and a left internal jugular dialysis catheter ends in the lower SVC. Mild-to-moderate cardiomegaly is unchanged. There is a small pericardial effusion. Incidental note is made of a bovine aortic arch. There are moderate calcifications in the thoracic aorta and coronary arteries. Relative hypoattenuation of the blood pool is compatible with anemia. Examination is not tailored for subdiaphragmatic evaluation, but reveals tiny stone in the gallbladder neck, as well as a percutaneous gastrojejunostomy tube. Multiple bilateral old healed rib fractures are present. There are multilevel degenerative changes in the thoracic spine. IMPRESSION: Slight worsening of multifocal necrotizing pneumonia. Persistent moderate pleural effusions. . [**2124-4-14**] KUB: FINDINGS: Multiple of the abdomen are provided. Due to the patient's large body habitus, the film is limited. A surgical drain is seen coursing into the mid abdomen. There is no evidence of free air. Bowel gas pattern appears unremarkable. Underlying bony structures appear normal. IMPRESSION: No evidence of obstruction or free air. . -[**2124-3-30**] EEG: IMPRESSION:This is an abnormal EEG due to moderate to severe diffuse background slowing. These findings are indicative of a moderate to severe diffuse encephalopathy, which is etiologically non specific. There were no focal asymmetries or epileptiform features. . -[**2124-4-14**] CXR: FINDINGS: As compared to the previous radiograph, there is no relevant change. Moderate-to-severe pulmonary edema, tracheostomy tube, double lumen hemodialysis catheter. Relatively extensive bilateral basal areas of atelectasis and moderate cardiomegaly. No pneumothorax. . MICROBIOLOGY . -[**2124-4-11**] 9:10 pm SPUTUM Source: Endotracheal 12 HRS OLD. GRAM STAIN (Final [**2124-4-12**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2124-4-15**]): RARE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110588**] ([**2124-4-6**]). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2124-4-13**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): . [**2124-4-14**] 10:55 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2124-4-15**]** C. difficile DNA amplification assay (Final [**2124-4-15**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). . [**2124-4-11**] 9:09 pm URINE Source: Catheter. **FINAL REPORT [**2124-4-12**]** Legionella Urinary Antigen (Final [**2124-4-12**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). . [**2124-4-6**] 3:05 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2124-4-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2124-4-9**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam , sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STENOTROPHOMONAS (XANTHOMONAS) MALTOPH | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 4 I PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S POTASSIUM HYDROXIDE PREPARATION (Final [**2124-4-6**]): Test cancelled by laboratory. PATIENT CREDITED. 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). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2124-4-7**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2124-4-6**]): TEST CANCELLED, PATIENT CREDITED. CANCELLATION PER DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] REQUEST @ 1623 ON [**4-6**] . ACID FAST CULTURE (Final [**2124-4-6**]): SEE ABOVE COMMENT. . [**2124-4-6**] 5:01 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2124-4-9**]** GRAM STAIN (Final [**2124-4-6**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2124-4-9**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. OF TWO COLONIAL MORPHOLOGIES. Piperacillin/Tazobactam , sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. HEAVY GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STENOTROPHOMONAS (XANTHOMONAS) MALTOPH | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 8 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2124-3-31**] 3:30 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2124-4-3**]** GRAM STAIN (Final [**2124-3-31**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. RESPIRATORY CULTURE (Final [**2124-4-3**]): SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110589**] FROM [**2124-3-31**]. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 110589**] [**3-31**]. . [**2124-3-31**] 10:04 am Mini-BAL ADD-ON DAS,ACU,MCU, KOH PER REQUEST [**2124-4-1**] @2240. GRAM STAIN (Final [**2124-3-31**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2124-4-3**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | STENOTROPHOMONAS (XANTHOMONAS) MALTOPH | | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 8 R PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ACID FAST SMEAR (Final [**2124-4-3**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Final [**2124-4-13**]): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2124-4-1**]): Test cancelled by laboratory. PATIENT CREDITED. 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). . [**2124-3-26**] 8:23 pm TISSUE Source: Skin biopsy. GRAM STAIN (Final [**2124-3-26**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2124-3-29**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2124-4-1**]): NO GROWTH. POTASSIUM HYDROXIDE PREPARATION (Final [**2124-3-27**]): NO FUNGAL ELEMENTS SEEN. FUNGAL CULTURE (Final [**2124-4-9**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2124-3-27**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . [**2124-3-26**] 12:45 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2124-3-29**]** GRAM STAIN (Final [**2124-3-26**]): THIS IS A CORRECTED REPORT ([**2124-3-27**]). [**9-14**] PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. . PREVIOUSLY REPORTED AS. <10 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. QUALITY OF SPECIMEN CANNOT BE ASSESSED ([**2124-3-26**]). RESPIRATORY CULTURE (Final [**2124-3-29**]): SPARSE GROWTH Commensal Respiratory Flora. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. HEAVY GROWTH. ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | ACINETOBACTER BAUMANNII COMPLEX | | AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- 8 S CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- <=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . [**2124-3-20**] 12:02 pm BLOOD CULTURE Source: Line-peripheral. **FINAL REPORT [**2124-3-26**]** Blood Culture, Routine (Final [**2124-3-26**]): ENTEROCOCCUS FAECIUM. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 345-7808L [**2124-3-19**]. Aerobic Bottle Gram Stain (Final [**2124-3-21**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. . [**2124-3-19**] 1:55 am BLOOD CULTURE Source: Line-L PIV. **FINAL REPORT [**2124-3-25**]** Blood Culture, Routine (Final [**2124-3-25**]): ENTEROCOCCUS FAECIUM. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 345-7808L [**2124-3-19**]. Aerobic Bottle Gram Stain (Final [**2124-3-20**]): GRAM POSITIVE COCCI IN PAIRS AND IN SHORT CHAINS. . Brief Hospital Course: Mr. [**Known lastname **] is a 51yo male with Stage IV squamous carcinoma of the tonsil, transferred to [**Hospital1 18**] with stridor, bacteremia, hypotension, and pancytopenia. His MICU course was complicated by ARDS, intubation and subsequent tracheostomy, volume overload, pneumonia, tachycardia and AMS. . #) Hypoxemic Respiratory Failure and Pneumonia: Multifactorial, likely due to PNA/lung abscesses and volume overload as well as ARDS. He was initially treated for MSSA PNA, however, Cx's also grew Acinetobacter/Stenotrophomonas on [**3-26**] sputum, as well as pseudomonas on mini BAL from [**3-31**]. He had completed a 14-day course of Zosyn for HCAP (MSSA and GNRs), last dose 5/11. He was then started on Bactrim for Acinetobacter/Stenotrophomonas as well as Cefepime for Pseudomonas in the miniBAL. He was requiring q1h suctioning of thick/copious/bloody or tan secretions, but his secretion production decreased significantly. His CT chest scan suggested b/l lung necrosis and cavitary lesions, w/ right hydropneumothorax and L pleural effusion. His respiratory status began improving due to fluid removal with HD and increased movement (getting into the chair). He had b/l chest tubes placed by IP, removed several days later once drainage ceased. He had a trach placed on [**3-27**]. We progressively weaned his vent settings, and on the day of d/c he was on 40% FiO2 and 8 of pressure support and 5 of PEEP. Pt was started on seroquel during intubation given agitation and delirium; can be weaned down as tolerated. Infectious disease was consulting along with the primary team, and agreed with the following Abx regimen to treat PNA attributed to pseudomonas/stenotrophomonas/possible invasive aspergillosis: Abx regimen and projected duration: - Sulfameth/Trimethoprim Suspension 120 mL PO/NG QHD - Cefepime 1gm IV q24h (give after HD on HD days) start date: [**2124-3-29**] stop date: [**2124-5-10**] - Voriconazole 200mg PO q12h start date: [**2124-4-12**] stop date: ongoing pending [**Hospital1 18**] ID f/u . #) [**Last Name (un) **]: Baseline Cr 0.7. Prerenal at OSH w/ Cr 2, but subsequently developed ATN. Although he was not oliguric, he was uremic with Cr ~4 for several weeks. He was initiated on HD [**3-30**] and had a HD-line placed. He was being dialyzed 3x/week on T,Th, Sat, but per the nephrology team, he can be transitioned to MWF if necessary. He may have had recurrent [**Last Name (un) **], and thus may still be able to recover kidney function. Thus, he needs to be monitored for signs of kidney recovery (including better UOP and improvement in pre-HD labs), as well as avoidance nephrotoxins and contrast. . #) Bacteremias: His OSH cultures were positive for MSSA on [**3-16**]. Therefore, his Port-a-cath was removed by surgery right after admission to [**Hospital1 18**]. Subsequently fhe developed VRE bacteremia, likely from GI translocation in setting of GIB peri-admission. He was briefly on Daptomycin, but was switched to a 2-week course of Linezolid day 1=[**3-30**] (out of concern that Daptomycin was only bacteriostatic at his MIC). TTE negative for vegetation, and TEE was not performed as there was no strong suspicion for endocarditis. RIJ CVL was removed [**2124-3-21**], placed a new LIJ CVL [**2124-3-21**], removed [**3-30**]. A-line was changed [**3-25**]. . #) Atrial flutter: Throughout admission, he has had a persistently elevated HR usually ranging in the 90-130 or 140s. After consultation with cardiology, he was briefly started on digoxin without effect, then was switched to amiodarone and metoprolol. His TSH and LFTs were WNL. He should be continued on Amiodarone 400 mg PO/NG TID for total 14 days (d1=[**4-11**]), thus until [**4-25**]. Then cont amio at 400mg [**Hospital1 **] for 1 week, then at 200mg daily thereafter. . #) Anemia: Patient with history of melena concerning for upper GI bleed. NG lavage upon admission was negative for any blood or coffee grounds. However, he may have had diffuse bleeding from multiple sites related to mucositis [**12-23**] chemotherapy. He required a total of 20 blood transfusions during this hospitalization (was being transfused for Hct <21). . #) Leukocytosis ?????? He had a WBC in the low- to mid 20's for several weeks, which slowly began to improve. It was likely secondary his multiple infectious sources and his pneumonia. . #) Lip lesion ?????? After trach, pt had some bleeding from the L angle of his mouth. This was unclear in etiology and difficult to stop; there was no cut or lesion visible, but rather the mucusa of the lip was friable. His uremic platelets may have exacerbated this; his coags and PLT counts remained nl however. The pt was also picking at the lip. The bleeding improved with PO Amicar. Multivitamins were given for empiric treatment of vitamin deficiency, which would have been less likely. . #) Thrombocytopenia: Pt required 15U of PLTs throughout hospitalization; no e/o active bleeding. Possibly [**12-23**] Abx effect. . #)Stage IVb squamous cell carcinoma of the left tonsil: s/p 1 cycle of docetaxel/cisplatin/5-FU, approximately on [**2124-3-2**]. OSH records are sparse, but appears to be stage IV in left tonsil and lymph nodes. Unclear if there are other areas of involvement. Presumed treatment according to notes are 3 cycles of Docetaxel/Cisplatin/5-FU followed by radiation. . #) Low grade NHL: Unclear diagnosis but unlikely to be contributing to active issues at this time. If pancytopenia continues or worsens, can consider a bone marrow biopsy for diagnosis. . TRANSITIONS OF CARE: . Abx regimen and projected duration: - Sulfameth/Trimethoprim Suspension 120 mL PO/NG QHD - Cefepime 1gm IV q24h (give after HD on HD days) start date: [**2124-3-29**] stop date: [**2124-5-10**] - Voriconazole 200mg PO q12h start date: [**2124-4-12**] stop date: ongoing pending [**Hospital1 18**] ID f/u . Laboratory monitoring required Frequency: Weekly - CBC - BMP - LFTs - Voriconazole trough levels All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. . -Pt should be continued on Amiodarone 400 mg PO/NG TID for total 14 days (d1=[**4-11**]), thus until [**4-25**]. Then cont amio at 400mg [**Hospital1 **] for 1 week, then at 200mg daily thereafter. . -Pt will need a voriconazole level drawn on Monday [**2124-4-17**] . -Pt will need cardiology follow-up for atrial flutter once his condition has stabilized. He will also need follow-up with his previous outpatient oncologist ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 110590**], md: [**Telephone/Fax (1) 110591**]) for his tonsillar SCC and low-grade non-hodgkins lymphoma. . -Pt's fentanyl patch was decreaed on [**4-15**] from 100mcg to 75mcg; can increase back if pt experiences pain (was originally started while trying to wean pt off of ventilator). Medications on Admission: Medications at home: - oxycontin 20mg [**Hospital1 **] - oxycontin 10mg Q6hrs PRN - lorazepam 1mg Q4hrs PRN - diltiazem 60mg TID - nicotine patch 14mg - arixtra 10mg SQ injections Discharge Medications: 1. white petrolatum-mineral oil 56.8-42.5 % Ointment [**Hospital1 **]: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 2. saliva substitution combo no.2 Solution [**Hospital1 **]: Thirty (30) ML Mucous membrane QID (4 times a day). 3. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed for groin rash. 4. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours). 5. fentanyl 75 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Transdermal every seventy-two (72) hours. 6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 7. acetaminophen 500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO QID PRN () as needed for fever/pain. 8. oral wound care products Gel in Packet [**Last Name (STitle) **]: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed for mucositis. 9. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection TID (3 times a day). 10. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day) for 9 days. 11. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours): hold for sbp < 100, HR < 60 . 12. nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 13. aminocaproic acid 25 % Solution [**Hospital1 **]: 1.25 grams PO Q4H (every 4 hours). 14. therapeutic multivitamin Liquid [**Hospital1 **]: Five (5) ML PO DAILY (Daily). 15. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: 4-6 Puffs Inhalation Q4H (every 4 hours): Ok to go to q6h overnight . 16. quetiapine 25 mg Tablet [**Hospital1 **]: Four (4) Tablet PO QHS (once a day (at bedtime)). 17. quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO QAM (once a day (in the morning)). 18. clonazepam 0.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia, agitation: hold for sedation, RR<12 . 19. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Hospital1 **]: One [**Age over 90 **]y (120) ML PO qHD: D1=[**3-29**]. To be given QHD. For 6 wk course, last dose should be on [**2124-5-10**] . 20. cefepime 1 gram Recon Soln [**Date Range **]: One (1) Recon Soln Injection Q24H (every 24 hours): D1=[**4-1**]. For 6 wk course, last dose should be on [**2124-5-10**]. . 21. amiodarone 400 mg Tablet [**Date Range **]: One (1) Tablet PO twice a day for 7 days: to be started after TID dosing. 22. amiodarone 200 mg Tablet [**Date Range **]: One (1) Tablet PO once a day: to be started after [**Hospital1 **] dosing. 23. voriconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours): d1=[**4-12**]. Should be given ongoing, pending ID f/u at [**Hospital1 18**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Primary diagnosis: Hypoxic respiratory failure Multifocal pneumonia Secondary diagnoses: VRE Bacteremia Atrial flutter Anemia Thrombocytopenia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you had trouble breathing, and had pneumonia for which you had to be intubated. Your breathing improved over time and you received treatment for the pneumonia. Your condition has improved and you can be discharged to your rehab facility. Followup Instructions: -Pt will need cardiology follow-up for atrial flutter once his condition has stabilized. He will also need follow-up with his previous outpatient oncologist ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 110590**], md: [**Telephone/Fax (1) 110591**]) for his tonsillar SCC and low-grade non-hodgkins lymphoma. . [**2124-5-5**]: Opat attending visit: [**Hospital **] clinic, [**Hospital Ward Name **] Bldg Basement, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Completed by:[**2124-4-15**]

[ "303.93", "528.01", "578.9", "263.9", "038.8", "995.92", "275.2", "484.6", "V12.51", "E879.8", "510.9", "288.04", "327.23", "513.0", "117.3", "511.89", "202.80", "427.31", "V15.82", "584.5", "041.7", "276.2", "276.1", "V49.86", "997.31", "280.0", "286.7", "427.32", "785.52", "276.0", "112.3", "196.0", "278.00", "276.8", "284.19", "695.89", "147.1", "999.32", "518.81" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.91", "38.97", "46.32", "86.11", "86.05", "38.95", "00.14", "96.6", "31.42", "31.1", "33.21", "39.95", "33.24", "96.72", "99.15" ]

icd9pcs

[ [ [] ] ]

30899, 30999

20731, 26289

384, 542

31187, 31187

4495, 4495

31768, 32325

3172, 3338

27927, 30876

31020, 31020

27723, 27723

31365, 31745

5710, 10690

27744, 27904

3378, 3910

31110, 31166

17981, 20708

13237, 16908

282, 346

570, 2685

4511, 5694

31039, 31089

31202, 31341

26310, 27697

2707, 2936

2952, 3156

3935, 4476

12,842

164,904

13883

Discharge summary

report

Admission Date: [**2185-4-16**] Discharge Date: [**2185-4-21**] Date of Birth: [**2104-1-26**] Sex: F Service: MEDICINE Allergies: Tramadol Attending:[**First Name3 (LF) 2704**] Chief Complaint: syncope Major Surgical or Invasive Procedure: Pacemaker placement Pericardial drain placement History of Present Illness: Pt is an 81 yo woman with PMH HTN, early alzheimer's, bradycardia, who presents w/ syncope. Per pt and pt's husband, pt was sitting at kitchen table eating lunch this afternoon when her husband noticed she suddenly looked pale and then passed out, falling off her chair and hitting her head on the floor. She had LOC for approximately 20 seconds and then awoke, no confusion/post-ictal state. Pt otherwise denies any pre-syncope including LH/dizziness, palpitations, diaphoresis, also denies any CP/pressure, SOB, f/c. With this event, pt's husband called EMS. Per report, on EMS arrival, pt was felt to be in junctional rythym at 40bpm (looking at strip, looks sinus w/ p waves before QRS, just wavy baseline) and pt was administered atropine 0.5mg IV x 1 and brought to [**Hospital 47**] Hospital. . At OSH, per report pt was bradycardic to 30's and 40's, BP stable, pt asymptomatic. Pt had head CT at OSH that per report showed "2 punctate hemorrhages, one frontal and one parietal" and was therefore transferred to [**Hospital1 18**] for neurosurg evaluation. . Upon arrival at [**Hospital1 18**], HR 40's-50's, BP stable, pt asymptomatic. Labs WNL except for elevated Ca at 10.5. CT head negative for bleed, and therefore neurosurg consult was cancelled. CT C spine negative for acute fracture. Pt admitted for syncope w/u. Currently pt feels well, denies any sxs. Past Medical History: -HTN -Bradycardia (per pt's husband, baseline HR in 40's) -early alzheimer's dementia (per husband, they call it the "[**Last Name **] problem". Pt does not know about diagnosis of alzheimers) -h/o arm and leg pain -> per pt, PCP attributes this to arthritis -s/p appy -s/p cholecystectomy Social History: Married, lives with husband. Past tobacco 20 pack year history, quit in [**2156**], rare EtOH, no drug use. Family History: NC Physical Exam: Vitals - T 97.3, BP 150/44, HR 48, RR 16, O2 97% RA Gen - awake, alert, lying in bed, NAD, pleasant HEENT - PERRL, EOMI, MMM Neck - L sided faint carotid bruit CVS - bradycardic, regular, grade II/VI SEM Lungs - CTA b/l Abd - soft, NT/ND Ext - no LE edema b/l Pertinent Results: [**2185-4-16**] 07:30PM PT-12.4 PTT-24.6 INR(PT)-1.1 [**2185-4-16**] 07:30PM PLT COUNT-177 [**2185-4-16**] 07:30PM NEUTS-65.5 LYMPHS-28.8 MONOS-4.4 EOS-0.5 BASOS-0.8 [**2185-4-16**] 07:30PM WBC-7.7 RBC-4.26 HGB-12.6 HCT-38.1 MCV-89 MCH-29.5 MCHC-33.0 RDW-13.3 [**2185-4-16**] 07:30PM CALCIUM-10.5* PHOSPHATE-2.8 MAGNESIUM-2.1 [**2185-4-16**] 07:30PM CK-MB-2 cTropnT-<0.01 [**2185-4-16**] 07:30PM CK(CPK)-51 [**2185-4-16**] 07:30PM estGFR-Using this [**2185-4-16**] 07:30PM GLUCOSE-101 UREA N-28* CREAT-0.7 SODIUM-140 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17 [**2185-4-16**] 11:43PM URINE GR HOLD-HOLD [**2185-4-16**] 11:43PM URINE HOURS-RANDOM [**2185-4-16**] 11:43PM URINE HOURS-RANDOM TOT PROT-40 . CT C-Spine [**2185-4-17**]: Degenerative changes with osteophyte formation on the left side of uncovertebral joint, with left neural foraminal narrowing at 3/4. Grade I anterolisthesis at C3/4. No fracture. . CT Head [**2185-4-17**]: FINDINGS: There is no acute intracranial hemorrhage. There is no mass effect. No shift of normally midline structure is noted. Ventricles are not dilated, and [**Doctor Last Name 352**]-white differentiations are preserved. Calcification along the choroid plexus, pineal gland and mid posterior fossa is noted. There is subcutaneous hematoma in the left frontal area. IMPRESSION: No acute intracranial hemorrhage. No mass effect. Left subcutaneous hematoma. . [**4-18**] ECHO Conclusions: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 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. Moderate (2+) 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 [[**3-12**]+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [**4-18**] ECHO Conclusions: Left ventricular systolic function is hyperdynamic (EF>75%). There is a large pericardial effusion. The effusion is echo dense, consistent with blood. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. Compared with the prior study (images reviewed) of [**2185-4-18**] at 10am, the pericardial effusion and tamponade are new. Images were obtained after pericardiocentesis with significant reduction of pericardial fluid (0.8 cm residual interiorly) and improved RV diastolic expansion. . [**4-20**] XR L-spine IMPRESSION: No compression fracture is seen. There is grade I spondylolisthesis at L4/5. Blunting of both costophrenic sulci is noted, also seen on a plain film of the chest performed on the same day. . [**4-19**] XR of bilat Hips IMPRESSION: No evidence of an acute bony injury. . [**4-19**] CXR FINDINGS: AP and lateral chest views obtained with the patient in sitting upright position are analyzed in direct comparison with preceding portable chest examinations obtained nine hours earlier during the same date and a first portable chest examination dated [**2185-4-18**]. The patient is now extubated, and there is no evidence of pneumothorax. The previously described permanent pacer remains in left anterior axillary position connected to two intracavitary electrodes. One of these terminates in a position compatible with the anterior superior wall of the right atrium possibly in the right atrial appendage. The second right ventricular lead terminates overlying the apical area of the right ventricle. There is no evidence of pulmonary vascular congestion or new acute parenchymal infiltrates, however, there exists mild blunting of the left lateral pleural sinus, continuing into the posterior sinus, as seen on the lateral view. Patient's inability to elevate the arms detracts from the image quality of the heart on the lateral view and thus conclusive findings concerning pleural effusion related displacement of the epicardial fat line cannot be made. Comparison with the next previous studies does not indicate a significant change in heart size as possible on portable examinations. Comparison of the right ventricular electrode position suggests that the termination point was slightly further advanced on the previous studies than it is now. IMPRESSION: Satisfactory followup findings following extubation and pericardial drain removal, status post tamponade. . [**4-19**] EcHO Conclusions: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2184-4-18**], the large pericardial effusion is no longer present. . [**4-20**] ECHO Conclusions: The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2185-4-19**], there is no significant change. Brief Hospital Course: 81 F w/ PMH HTN, bradycardia, p/w syncope, found to have sick sinus syndrome, s/p pacemaker placment c/b tamponade from RV perforation s/p pericardial drain and intubation for airway protection. . # RV perforation: s/p pericardial drain. The day after drain placement the patient's drain had minimal output and repeat echocardiogram showed trivial pericardial effusion. The drain was pulled prior to transfer. . # S/p Dual chamber ICD: for sick sinus syndrome - Cefazolin IV X 3 days, started [**2185-4-18**], will have 2 days of cephalexin as outpatient to complete a 5-day course - EP followed - will have an appt on Monday with Dr. [**Last Name (STitle) **] and for device clinic. . # Respiratory Failure: intubated for airway protection during drain placement. Extubated the day after intubation without difficulty. - satting in high 90s on RA on discharge . # Hip pain: Her husband was concerned that she was having L lower rib and hip pain from her fall. Multiple XRs did not sho hip/rib/spinal fractures. She did not have any pain on discharge . # Anemia: normocytic, ? ACD - iron studies/folate/B12 as outpatient . # Hypercalcemia: Resolved. Most likely secondary to dehydration +/- increased calcium intake. Other possibilities include hyperparathyroidism, multiple myeloma, paraneoplastic syndrome, sarcoid, all unlikely. - PTH, SPEP, and UPEP all wnl . # HTN: restarted metoprolol on discharge, may need addition of lisinopril as outpatient. . # Dementia: continue Aricept . Medications on Admission: -aricept 10mg qhs -hctz 25mg daily -caltrate + VitD 600mg daily -fosomax 70mg q friday -prilosec 20mg prior to fosamax dose -asa 81mg daily -genteel eye drops PRN -multivit daily Discharge Medications: 1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 4. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a day: every Friday. 5. Caltrate [**Telephone/Fax (3) 41616**]-25 mg-unit-mg Tablet Sig: One (1) Tablet PO twice a day. 6. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 30 days: 400 mg 2X/day through [**4-26**], then 400 mg 1X/day through [**5-3**] then 200 mg po daily through [**2185-5-17**] then stop. Disp:*100 Tablet(s)* Refills:*0* 10. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Sick sinus syndrome Hypertension Atrial fibrillation Discharge Condition: Hemodynamically stable. Ambulatory with assist. Discharge Instructions: You were admitted after an episode of syncope. You were found to have a slow heart rate and a pacemaker was placed. . Please keep your pacer site dry. . Please seek medical medical attention if you spike a fever > 101, or have chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] on [**2185-4-25**] at 9:40 am [**Hospital Ward Name 23**] [**Location (un) 436**]. Tel. ([**Telephone/Fax (1) 5862**]. You have an appointment in device clinic the same day ([**4-25**]) at 8:30 am. Tel. ([**Telephone/Fax (1) 30924**], also [**Hospital Ward Name 23**], [**Location (un) 436**]. . Please make a follow-up appointment with Dr. [**Last Name (STitle) 6051**] (your primary care doctor) within the next 2 weeks. - You will need pulmonary function testing and an eye exam as you have been started on amiodarone that can cause vision and lung problems. . Please make a follow-up appointment with Dr. [**First Name (STitle) 1075**] within the next 2-3 weeks.

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Discharge summary

report+addendum

Admission Date: [**2165-5-21**] Discharge Date: [**2165-6-6**] Date of Birth: [**2090-11-19**] Sex: M Service: SURGERY Allergies: Neurontin Attending:[**First Name3 (LF) 2597**] Chief Complaint: RLE Claudication Major Surgical or Invasive Procedure: [**2165-5-23**] Diagnostic aortic and pelvic arteriogram with left common and external iliac stents; ultrasound-guided imaging for [**Month/Day/Year 1106**] access; aortic catheterization. History of Present Illness: 74M with c/o R buttock and thigh claudication who is followed by Dr. [**Last Name (STitle) **]. He had a duplex study performed in [**Month (only) 404**] of this year that showed a patent aortoiliac system with heavily calcified and extensively diseased distal right common iliac artery, right external iliac artery, and right common femoral artery, as well as likely SFA occlusion. He has not had any tissue loss and denies rest pain. He also has some lower back issues, which he originally believed to be the source of his discomfort. He recently had a R L4, L5 and S1 transforaminal epidural and SI joint steroid injection. He denies recent fevers, chills, or chest pain. Baseline DOE/SOB due to his COPD and is on home O2. He does have CRI and L renal artery stenosis with an atrophied L kidney and is followed by Nephrology here at [**Hospital1 18**]. He also notes bruising and bleeding easily, despite only being on aspirin. Past Medical History: 1. CVA x 2 s/p left vertebral artery stent in [**2161**]; s/p right carotid endarterectomy and left carotid endarterectomy [**2161**] 2. CAD s/p 5 vessel CABG [**2152**] s/p cath in [**12/2161**] (preop) with stent to SVG-RCA 3. HTN 4. Prostate cancer last psa 8.2, treated with watchful waiting 5. Hep C VL zero in [**2155**] 6. hyperlipidemia 7. COPD/emphysema 8. right upper lobectomy for lung CA, adenocarcinoma [**2154**] 9. s/p hernia repair 10. thrombosed pseudoaneurysm dxed [**12/2161**], medically managed 11. CRI baseline creatinine 1.5-2.0 12. Cavitary RLL abscess/PNA in [**3-20**]- treated with 4 week course of levo/flagyl. Social History: Lives at home with wife. Retired salesman for Sears. Quit smoking in [**2160**]. 30 pack year history. No etoh use. Independent in all daily activities. Family History: Non-contributory Physical Exam: NAD. A&Ox3. Anicteric. MMM. No carotid bruits. B CEA scars. RRR. Fair aeration. Diminished bases. Scattered wheezes. Soft. NT. ND. No palpable pulsatile masses. Feet are warm. No ulcers or fissures. No peripheral edema. C R F P DP PT R 2+ 2+ 1+ dop dop dop L 2+ 2+ 2+ 1+ dop dop Pertinent Results: Labs: \11.0/ 9.2 ---- 266 /33.7\ PT: 11.8 PTT: 26.0 INR: 1.0 142 107 72 / ------------- 90 4.7 22 3.7 \ estGFR: 16/20 (click for details) Ca: 9.1 Mg: 2.3 P: 4.2 renal u/s 5/7/8 CONCLUSION: Atrophic left kidney with further shrinkage compared to a prior study in [**2163**]. Normal size right kidney with mildly elevated RI's but otherwise excellent flow. No hydronephrosis. Multiple simple cysts bilaterally. Brief Hospital Course: The patient was admitted to [**Year (4 digits) **] Surgery for angiogram. The patient's procedure was cancelled on [**5-22**] secondary to concern over his creatinine. Nephrology was consulted and renal ultrasound performed. With Nephrology's recommendations on optimizing the patient, the patient went for his angiogram on [**5-23**]. He underwent a diagnostic aortic and pelvic arteriogram with left common and external iliac stents, ultrasound-guided imaging for [**Month/Day (4) 1106**] access, and aortic catheterization. The patient tolerated the procedure well. For further detail of the procedure, please refer to the operative note. Post operatively, the patient developed hypertension to the 180's. He was transfered to the VICU for BP management. The patient's blood pressure normalized and Nephrology left recommendations on BP management. The patient is discharged home with the medication changes and with instruction to return on Wednesday for an endarterectomy. Upon discharge, the patient is afebrile with all vitals stable, with stable blood pressure, tolerating po feeds, ambulating, and with pain controlled on po pain medication. Medications on Admission: Albuterol 2 puffs q4-6h prn, Allopurinol 100 qod, DILTIAZEM SR 360', Advair 250/50 one puff", Lasix 40', Meclizine 25' prn, Lopressor 50", NTG SL prn, Percocet prn, PROTONIX EC 40', Simvastatin 40', Spiriva with HandiHaler 18mcg one puff', Ultram 50 q6h prn, Valsartan 160", ECOTRIN 325', FeSO4 325' Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 13. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Primary: R buttock & thigh claudication . Secondary: CAD, s/p CVA x 2, aortic arch aneurysm, HTN, prostate ca, lung ca, h/o hepatitis C, hyperlipidemia, COPD, stage IV CKD, chronic back pain, vitamin D deficiency, L renal artery stenosis, L kidney atrophy, prepatellar bursitis, h/o cavitary RLL abscess/PNA [**3-20**] Discharge Condition: Afebrile, vital signs stable, tolerating regular diet, ambulating, pain well controlled on PO medication. Discharge Instructions: Division of [**Month/Year (2) **] and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Please note the changes we made your medications and take them as prescribed in the sheet. We discontinued your diltiazem so please make a note of this. ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-17**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-19**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call [**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Please return on Wednesday [**5-29**] to the Surgery check-in for your angiogram. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2165-7-4**] 2:10 Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2165-7-11**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2165-10-29**] 10:30 Name: [**Known lastname 1929**],[**Known firstname **] M. Unit No: [**Numeric Identifier 1930**] Admission Date: [**2165-5-21**] Discharge Date: [**2165-6-6**] Date of Birth: [**2090-11-19**] Sex: M Service: SURGERY Allergies: Neurontin Attending:[**First Name3 (LF) 1546**] Addendum: The patient's discharge was delayed [**2-16**] rising creatinine and concerns over oxygenation status. The patient's creatinine rose to 2.9 from 2.4. While 2.9 is near his baseline, we wanted to ensure the trend did not exceed his baseline. In regards to his oxygenation, he desated to the low 80's on RA. He states he occasionally uses home O2. Chief Complaint: R buttock and thigh claudication Major Surgical or Invasive Procedure: [**2165-5-23**] Diagnostic aortic and pelvic arteriogram with left common and external iliac stents; ultrasound-guided imaging for vascular access; aortic catheterization. [**2165-5-29**] Right common femoral endarterectomy and Dacron patch angioplasty and right common and external iliac artery angioplasty and stenting and angiogram. History of Present Illness: 74M with c/o R buttock and thigh claudication who is followed by Dr. [**Last Name (STitle) **]. He had a duplex study performed in [**Month (only) **] of this year that showed a patent aortoiliac system with heavily calcified and extensively diseased distal right common iliac artery, right external iliac artery, and right common femoral artery, as well as likely SFA occlusion. He has not had any tissue loss and denies rest pain. He also has some lower back issues, which he originally believed to be the source of his discomfort. He recently had a R L4, L5 and S1 transforaminal epidural and SI joint steroid injection. He denies recent fevers, chills, or chest pain. Baseline DOE/SOB due to his COPD and is on home O2. He does have CRI and L renal artery stenosis with an atrophied L kidney and is followed by Nephrology here at [**Hospital1 8**]. He also notes bruising and bleeding easily, despite only being on aspirin. Past Medical History: 1. CVA x 2 s/p left vertebral artery stent in [**2161**]; s/p right carotid endarterectomy and left carotid endarterectomy [**2161**] 2. CAD s/p 5 vessel CABG [**2152**] s/p cath in [**12/2161**] (preop) with stent to SVG-RCA 3. HTN 4. Prostate cancer last psa 8.2, treated with watchful waiting 5. Hep C VL zero in [**2155**] 6. hyperlipidemia 7. COPD/emphysema 8. right upper lobectomy for lung CA, adenocarcinoma [**2154**] 9. s/p hernia repair 10. thrombosed pseudoaneurysm dxed [**12/2161**], medically managed 11. CRI baseline creatinine 1.5-2.0 12. Cavitary RLL abscess/PNA in [**3-20**]- treated with 4 week course of levo/flagyl. Social History: Lives at home with wife. Retired salesman for Sears. Quit smoking in [**2160**]. 30 pack year history. No etoh use. Independent in all daily activities. Family History: Non-contributory Physical Exam: General: NAD. A&Ox3. HENT: Anicteric. MMM. No carotid bruits. B/L CEA scars. Heart: RRR. Lungs: Fair aeration. Diminished bases. Scattered wheezes. Abdomen: Soft. NT. ND. No palpable pulsatile masses. Extremities: Feet are warm. No ulcers or fissures. No peripheral edema. Pulses: C R F P DP PT R 2+ 2+ 1+ palp palp palp L 2+ 2+ 2+ 1+ palp palp Pertinent Results: [**2165-6-3**] 07:25AM BLOOD WBC-7.2 RBC-3.42* Hgb-9.6* Hct-29.9* MCV-88 MCH-28.1 MCHC-32.1 RDW-13.8 Plt Ct-386 [**2165-6-2**] 06:50AM BLOOD WBC-6.8 RBC-3.18* Hgb-9.4* Hct-27.9* MCV-88 MCH-29.4 MCHC-33.6 RDW-14.1 Plt Ct-366 [**2165-6-1**] 03:40PM BLOOD WBC-7.1 RBC-3.18* Hgb-9.4* Hct-28.0* MCV-88 MCH-29.6 MCHC-33.6 RDW-14.2 Plt Ct-313 [**2165-6-1**] 07:45AM BLOOD WBC-6.9 RBC-3.35* Hgb-9.6* Hct-29.6* MCV-88 MCH-28.7 MCHC-32.4 RDW-14.2 Plt Ct-293 [**2165-5-31**] 01:12AM BLOOD WBC-8.0 RBC-3.34* Hgb-9.7* Hct-28.5* MCV-86 MCH-29.2 MCHC-34.1 RDW-14.5 Plt Ct-256 [**2165-5-30**] 01:20PM BLOOD WBC-10.6 RBC-3.50* Hgb-10.4* Hct-30.1* MCV-86 MCH-29.8 MCHC-34.7 RDW-14.4 Plt Ct-268 [**2165-5-30**] 04:08AM BLOOD WBC-8.3 RBC-3.42* Hgb-10.2*# Hct-29.2* MCV-85 MCH-29.9 MCHC-35.0 RDW-14.4 Plt Ct-256 [**2165-5-29**] 10:19PM BLOOD Hct-31.5*# [**2165-5-29**] 01:41PM BLOOD WBC-6.3 RBC-2.84* Hgb-8.1* Hct-24.4* MCV-86 MCH-28.5 MCHC-33.1 RDW-14.6 Plt Ct-271 [**2165-5-29**] 07:15AM BLOOD WBC-7.9 RBC-3.31* Hgb-9.6* Hct-29.3* MCV-88 MCH-29.0 MCHC-32.8 RDW-14.7 Plt Ct-316 [**2165-5-27**] 07:00AM BLOOD WBC-6.1 RBC-3.20* Hgb-9.0* Hct-27.9* MCV-87 MCH-28.0 MCHC-32.2 RDW-14.9 Plt Ct-261 [**2165-5-24**] 05:35AM BLOOD Hct-36.3* [**2165-5-22**] 05:40AM BLOOD WBC-8.7 RBC-3.68* Hgb-10.5* Hct-31.3* MCV-85 MCH-28.6 MCHC-33.7 RDW-15.8* Plt Ct-264 [**2165-5-21**] 09:35PM BLOOD WBC-9.2 RBC-3.83* Hgb-11.0* Hct-33.7* MCV-88 MCH-28.9 MCHC-32.8 RDW-15.3 Plt Ct-266 [**2165-6-3**] 07:25AM BLOOD Plt Ct-386 [**2165-6-2**] 06:50AM BLOOD Plt Ct-366 [**2165-6-1**] 03:40PM BLOOD Plt Ct-313 [**2165-6-1**] 07:45AM BLOOD Plt Ct-293 [**2165-5-31**] 01:12AM BLOOD Plt Ct-256 [**2165-5-31**] 01:12AM BLOOD PT-12.0 PTT-30.6 INR(PT)-1.0 [**2165-5-30**] 01:20PM BLOOD Plt Ct-268 [**2165-5-30**] 01:20PM BLOOD PT-11.5 PTT-28.7 INR(PT)-1.0 [**2165-5-30**] 04:08AM BLOOD Plt Ct-256 [**2165-5-29**] 01:41PM BLOOD Plt Ct-271 [**2165-5-29**] 07:15AM BLOOD Plt Ct-316 [**2165-5-29**] 07:15AM BLOOD PT-11.6 PTT-27.3 INR(PT)-1.0 [**2165-5-27**] 07:00AM BLOOD Plt Ct-261 [**2165-6-4**] 06:40AM BLOOD Glucose-125* UreaN-63* Creat-3.2* Na-140 K-4.2 Cl-104 HCO3-27 AnGap-13 [**2165-6-3**] 07:25AM BLOOD Glucose-87 UreaN-50* Creat-2.7* Na-140 K-4.2 Cl-103 HCO3-26 AnGap-15 [**2165-6-2**] 06:50AM BLOOD Glucose-100 UreaN-51* Creat-2.9* Na-139 K-4.3 Cl-104 HCO3-25 AnGap-14 [**2165-6-1**] 03:40PM BLOOD Glucose-118* UreaN-54* Creat-3.1* Na-138 K-4.1 Cl-102 HCO3-28 AnGap-12 [**2165-6-1**] 07:45AM BLOOD Glucose-92 UreaN-53* Creat-2.9* Na-138 K-4.0 Cl-102 HCO3-26 AnGap-14 [**2165-5-31**] 01:12AM BLOOD Glucose-100 UreaN-48* Creat-2.8* Na-138 K-4.0 Cl-101 HCO3-27 AnGap-14 [**2165-5-30**] 01:20PM BLOOD Glucose-113* UreaN-47* Creat-2.8* Na-139 K-4.1 Cl-101 HCO3-28 AnGap-14 [**2165-5-30**] 04:08AM BLOOD Glucose-98 UreaN-42* Creat-2.6* Na-141 K-4.0 Cl-102 HCO3-28 AnGap-15 [**2165-5-29**] 01:41PM BLOOD Glucose-107* UreaN-43* Creat-2.6* Na-140 K-3.5 Cl-102 HCO3-30 AnGap-12 [**2165-5-29**] 07:15AM BLOOD Glucose-109* UreaN-44* Creat-2.6* Na-140 K-3.5 Cl-100 HCO3-30 AnGap-14 [**2165-5-21**] 09:35PM BLOOD Glucose-90 UreaN-72* Creat-3.7* Na-142 K-4.7 Cl-107 HCO3-22 AnGap-18 [**2165-6-2**] 06:50AM BLOOD CK(CPK)-39 [**2165-6-1**] 08:50PM BLOOD CK(CPK)-70 [**2165-6-1**] 03:40PM BLOOD CK(CPK)-68 [**2165-5-31**] 09:57AM BLOOD CK(CPK)-224* [**2165-5-30**] 01:20PM BLOOD CK(CPK)-383* [**2165-5-30**] 04:08AM BLOOD CK(CPK)-98 [**2165-6-2**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2165-6-1**] 08:50PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2165-6-1**] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2165-5-31**] 09:57AM BLOOD CK-MB-4 cTropnT-0.07* [**2165-5-31**] 01:12AM BLOOD CK-MB-5 cTropnT-0.07* [**2165-5-30**] 01:20PM BLOOD CK-MB-4 cTropnT-0.09* [**2165-6-4**] 06:40AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2 [**2165-6-3**] 07:25AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0 [**2165-6-2**] 06:50AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0 [**2165-6-1**] 03:40PM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0 [**2165-6-1**] 07:45AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0 [**2165-5-31**] 01:12AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.9 [**2165-5-30**] 01:20PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.8 [**2165-5-30**] 04:08AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.6 UNILAT LOWER EXT VEINS RIGHT [**2165-6-3**] 8:22 AM COMPARISONS: Right lower extremity ultrasound dated [**2164-7-11**]. FINDINGS: The bilateral common femoral, right superficial femoral and right popliteal veins are patent and compressible, without filling defect. Waveforms demonstrate normal respiratory phasicity and appropriate response to Valsalva and distal augmentation. The posterior tibial and peroneal veins are also patent on the right. IMPRESSION: 1) No evidence of right lower extremity DVT. ECG Study Date of [**2165-6-1**] 3:03:54 PM Sinus rhythm. Atrial ectopy. The P-R interval is short without evidence of pre-excitation. Low voltage in the limb leads. Compared to the previous tracing atrial fibrillation has resolved. CHEST (PORTABLE AP) [**2165-6-1**] 4:36 PM Comparison with [**2165-5-30**]. The lungs are hyperexpanded, consistent with COPD, as before. Scattered parenchymal scarring as demonstrated previously. The costophrenic sulci remain blunted. The patient is status post median sternotomy as before. The heart is normal in size, and mediastinal structures appear stable. The bony thorax is grossly intact. There is no significant interval change. ECG Study Date of [**2165-5-31**] 5:28:04 AM Probable atrial fibrillation with rapid ventricular response, although some sinus beats appear present. Compared to the previous tracing of [**2165-5-30**] atrial fibrillation is present. ECG Study Date of [**2165-5-30**] 6:54:50 AM Sinus tachycardia Slight ST-T wave changes - are are nonspecific and may be within normal limits Since previous tracing of [**2165-5-24**], sinus tachycardia now present Portable TTE (Complete) Done [**2165-5-30**] at 12:33:20 PM Conclusions The left atrium is elongated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2164-11-29**], the findings are similar. Brief Hospital Course: The patient was admitted to Vascular Surgery for angiogram. HD1 [**2165-5-21**] Admitted to [**Hospital Ward Name **] 5/Vacular Surgery Dr. [**Last Name (STitle) **] [**Name (STitle) 1931**]. Routine nursing, IV access, pre-op Bicarb/Mucomyst, NPO after MN, Nephrology consult, EKG, CXR, UA, Labs, consent, home meds. The patient's procedure was cancelled on [**5-22**] secondary to concern over his creatinine. Nephrology was consulted and renal ultrasound performed. With Nephrology's recommendations on optimizing the patient, the patient went for his angiogram. On [**5-23**] he underwent a diagnostic aortic and pelvic arteriogram with left common and external iliac stents, ultrasound-guided imaging for vascular access, and aortic catheterization. The patient tolerated the procedure well. For further detail of the procedure, please refer to the operative note. Post operatively, the patient developed hypertension to the 180's. He was transfered to the VICU for BP management. The patient's blood pressure normalized and Nephrology left recommendations on BP management. [**2165-5-25**] it was planned to discharge the patient to home with the medication changes and with instruction to return on Wednesday for an endarterectomy. The patient's discharge was delayed [**2-16**] rising creatinine and concerns over oxygenation status. The patient's creatinine rose to 2.9 from 2.4. While 2.9 is near his baseline, we wanted to ensure the trend did not exceed his baseline. Foley was placed for failure to void and 800 cc in bladder by scan. Also transfered back to VICU for monitoring secondary to persistent HTN. Nitro drip, Norvasc and Diovan started per renal recs. In regards to his oxygenation, he desated to the low 80's on RA. He states he occasionally uses home O2. [**5-26**] Foley was d/c'd, still having trouble voiding, foley re-inserted. Unsteady on his feet when walking. Creatinine 2.9->2.4. [**5-27**] Foley d/c'd, voiding well. Still hypertensive, increasing beta blockers. Creatinine ->3.2, continue to monitor. Patient to floor status. [**5-28**] Creatinine ->2.9. Now patient c/o L ankle pain with swelling secondary to what seems to be Gout exacerbation, treated with Colcichine. Plan for OR in am for R fem endardarectomy and stenting. Pre-op, hydration, mucomyst/bicarb drip. [**5-29**] Patient c/o L ankle pain-thought to be Gout excacerbation-started on Colchichine. Taken to OR for L CIA stent, POD 8 s/p R CFA EA/PA into profunda, R CIA/EIA stent. Post-operatively did well, recovering in the PACU. Transfused 2 units PRBC for HCT 24.4-> 31.5 post transfusion.Post-op Bicarb drip for 3 hours. Stabilized and transferred to Far 5. [**5-30**] Transferred to ICU for tachycardia,low BP and desaturation. BP responded to fluid bolus for borderline low BP. Renal following. [**5-31**] On and off A-Fib- given IV Lopressor. Hypotensive-given fluid boluses. Cardiac Echo-normal EF. Diuresed with Lasix. Transferred back to [**Hospital Ward Name **] 5 VICU. [**6-1**] VICU status.VSS. Afbrile. Continues on beta blockers.Renal following- low does Colchichine [**Hospital1 **] for gout. [**6-2**] VICU status, still with on & off A-fib, with low grade T (TM 100.5). Started Diltiazem gtt started PO Dilt. Renal FU- Colchichine started, Lasix hold, fluid bolus per renal.PT consult, ambulate. [**6-3**] Patient c/o R knee pain, R hip edema with erythema/L forearm edema. Creatinine 3.1->2.9. Afberile. Rheumatology consult-start on PO steroids for Gout, ambulate, LE and UE US. Change status from VICU to floor. Started Prednisone taper [**6-4**] Floor status. UE & LE NIV. negative for DVT. Foley d/c'd. Cochichine changed to QD. . Started on Cipro for 2 wks. for KLEBSIELLA PNEUMONIAE growth in urine.VSS, afebrile. [**6-5**] [**Hospital 1932**] Rehab screen for dispo. Renal consult: stage IV CKD. Continue current medications (Lasix, [**Last Name (un) **] on hold) [**6-6**] VSS, no events. Cipro until [**6-10**]. If RT knee remains swollen after steroid taper- will need injections. Medications on Admission: Albuterol - 90 mcg Aerosol - 2 puffs inhalation every 4 - 6 hours as needed Allopurinol - 100 mg Tablet - 1 Tablet(s) by mouth every other day DILTIAZEM HCL - 360MG Capsule, Sust. Release 24 hr - ONE EVERY DAY Fluticasone [Flonase] - 50 mcg Spray, Suspension - [**1-16**] sprays in each nostril once a day as needed for congestion Fluticasone-Salmeterol [Advair Diskus] - 250 mcg-50 mcg/Dose Disk with Device - one puff inhaler twice a day Furosemide [Lasix] - 40 mg Tablet - 1 Tablet(s) by mouth daily Meclizine - 25 mg Tablet - 1 Tablet(s) by mouth qd prn Metoprolol Tartrate - 50 mg Tablet - 1 Tablet(s) by mouth twice a day NITROGLYCERIN - 400 MCG (1/150 GR) TABLET - [**1-16**] UNDER THE TONGUE AS NEEDED FOR CHEST PAIN Oxycodone-Acetaminophen [Percocet] - 5 mg-325 mg Tablet - one Tablet(s) by mouth three times a day as needed for pain PROTONIX - 40MG Tablet, Delayed Release (E.C.) - ONE EVERY DAY Simvastatin [Zocor] - 40 mg Tablet - 1 Tablet(s) by mouth once a day Tiotropium Bromide [Spiriva with HandiHaler] - 18 mcg Capsule, w/Inhalation Device - one puff inhaler once a day Tramadol [Ultram] - 50 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for pain - No Substitution Valsartan - 160 mg Tablet - 1 Tablet(s) by mouth twice a day ECOTRIN - 325MG Tablet, Delayed Release (E.C.) - ONE EVERY DAY Ferrous Sulfate [Iron (Ferrous Sulfate)] - 325 mg (65 mg) Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection twice a day: until fully ambulatory. 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 14. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 15. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): hold SBP <120 . 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for sbp< 120, HR< 60 . 17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours): last dose 5/26. 18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 2 days: Dose on [**6-6**] and [**6-7**]. 19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 2 days: Dose on [**6-8**] and [**6-9**]. Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] Discharge Diagnosis: Primary: R buttock & thigh claudication s/p RT leg intervention Hospital course complicated by increase Cr (Has Stage IV CKD), afib and gouty knee (steroid taper) Secondary: CAD, s/p CVA x 2, aortic arch aneurysm, HTN, prostate ca, lung ca, h/o hepatitis C, hyperlipidemia, COPD, stage IV CKD, chronic back pain, vitamin D deficiency, L renal artery stenosis, L kidney atrophy, prepatellar bursitis, h/o cavitary RLL abscess/PNA [**3-20**] Discharge Condition: VSS Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Please note the changes we made your medications and take them as prescribed in the sheet. We discontinued your diltiazem so please make a note of this. ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-17**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-19**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office [**Telephone/Fax (1) 283**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: . Provider: [**First Name8 (NamePattern2) 153**] [**Last Name (NamePattern1) 1934**], [**Name12 (NameIs) 1935**] Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2165-7-4**] 2:10 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1147**], M.D. Phone:[**Telephone/Fax (1) 1936**] Date/Time:[**2165-7-11**] 3:00 Provider: [**First Name11 (Name Pattern1) 1937**] [**Last Name (NamePattern1) 1938**], M.D. Date/Time:[**2165-10-29**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], MD Phone:[**Telephone/Fax (1) 283**] Date/Time:[**2165-6-24**] 4:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**] Completed by:[**2165-6-6**]

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icd9cm

[ [ [] ] ]

[ "00.44", "39.90", "38.18", "00.41", "39.57", "00.47", "39.50", "99.04", "00.45", "00.42", "88.42", "88.48" ]

icd9pcs

[ [ [] ] ]

27202, 27249

19825, 23865

10540, 10878

27733, 27739

13103, 19802

30350, 31114

12686, 12704

25335, 27179

27270, 27712

23891, 25312

27763, 29754

29780, 30327

12719, 13084

10468, 10502

10906, 11836

11858, 12499

12515, 12670

21,447

106,948

4669

Discharge summary

report

Admission Date: [**2201-5-31**] Discharge Date: [**2201-6-1**] Date of Birth: [**2158-11-18**] Sex: F Service: MICU Green HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 19730**] is a 43-year-old female with a longstanding history of type 1 diabetes mellitus, end-stage renal disease on peritoneal dialysis and hemodialysis, and atrial fibrillation. The patient was in her usual state of health until the morning of admission when she awoke and felt lightheaded. She took her blood pressure and it was roughly 76/40. At that time, she had her mother check her fingerstick which was critically high on her home glucose monitor. At that point, the patient came in to be evaluated at the [**Hospital1 69**]. She denied any fever or chills, nausea, vomiting, diarrhea, sore throat, cough, rhinorrhea, abdominal pain, back pain. No changes in her skin. Of note, the last hemodialysis one week prior to admission, and the patient had normal po intake on the days prior to admission. She denied missing any insulin or eating any concentrated sweets. She denied missing any of her midodrine. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus complicated by triopathy. 2. End-stage renal disease on peritoneal dialysis and hemodialysis. 3. Atrial fibrillation. 4. History of an atrial thrombus. 5. Barrett's esophagus. 6. Labile blood pressure. 7. Hypothyroidism. ALLERGIES: 1. Tetracycline. 2. Erythromycin. 3. Morphine. 4. Dilaudid. 5. ACE inhibitors. MEDICATIONS AT HOME: 1. Midodrine 10 mg po tid. 2. Reglan 10 mg po qid. 3. Levoxyl 75 mcg po q day. 4. Nephrocaps one cap q day. 5. Renagel 800 mg one tablet tid. 6. PhosLo 667 mg one tablet [**Hospital1 **] with lunch and dinner. 7. Amiodarone 200 mg po q day. 8. Neurontin 100 mg po tid. 9. Protonix 40 mg po q day. 10. Coumadin varying dose currently on 2.5 mg po q day. 11. Epogen 1200 units subQ [**Hospital1 **]-weekly. 12. Humalog insulin-sliding scale. 13. Lantus insulin 20 units every evening. 14. Compazine 10 mg prn. 15. Senokot two tablets at bedtime prn. 16. Colace one tablet at bedtime prn. 17. Lactulose one tablespoon at bedtime prn. 18. Lomotil as needed. 19. Vitamin D 50,000 units one time a week on Mondays. PHYSICAL EXAMINATION: The patient's vital signs are as follows: In the Emergency Department, her temperature is 97.9, blood pressure is 137/45, pulse is 74, breathing at 11, and sating 94% on room air. General: She is awake, alert in no acute distress. HEENT: Normocephalic, atraumatic. Oropharynx with moist mucous membranes. She has alopecia. Neck: No jugular venous distention. Cardiovascular: Regular, rate, and rhythm, II/VI systolic murmur at the right sternal border. No rubs or gallops. Lungs: There were bibasilar crackles right greater than left. Abdomen: Soft, nontender, nondistended, normal bowel sounds. There is a PD catheter, surrounding dry erythema and scab. Chest: There is a hemodialysis catheter also with the site clean, dry, and intact without signs of infection. Extremities: Trace edema bilaterally. Skin: Bilateral shin erythema with ulcers in various stages of healing. Neurological: Decreased sensory perception in both feet. LABORATORY DATA ON ADMISSION: The patient had the following laboratory data: She had a white blood cell count of 9.1, hematocrit of 35.4, and platelets of 349. MCV is 101. Her differential was 72% polys, 20% lymphocytes, and 5% monocytes, 2% eosinophils. Her Chem-7 was as follows sodium 141, potassium 5.4, chloride 98, total CO2 17, BUN 16, creatinine 9.3, and glucose 303. Calcium 9.9, magnesium 1.9, phosphorus 9.0. Patient had a negative chest x-ray. TSH of 9.4 at this time. The patient had an ALT of 29, AST of 38, alkaline phosphatase of 197, T bilirubin of 0.2, and lipase 56. She had blood cultures which were done, but not finalized at the time of her discharge. She was acetone negative. Electrocardiogram showed on admission: Sinus rhythm at 74 beats per minute with peaked T waves in V2, V3, and V4. Possible left axis deviation. HOSPITAL COURSE: 1. Endocrine: The patient was initially placed on insulin drip for a blood glucose greater than 500 and a small anion gap. Her gap rapidly closed, and the patient subsequently had a blood glucose as low as 40. She was administered an amp of D50 and sent to the Medical Intensive Care Unit for q1 hour glucose monitoring, where her glucose normalized overnight to 120 by the time of discharge. She required regular doses of subQ insulin per regular sliding scale. She was also administered her 20 units of Lantus during her stay. The patient was found to have an elevated TSH, but her Synthroid dose was not changed as we left it up to her primary care physician as an outpatient. The etiology of the patient's hyperglycemia is not known. There was no obvious infection found, and perhaps it is related to dietary indiscretion or change in her medication. 2. Cardiovascular: The patient had presented with hypotension at home and lightheadedness. She occasionally suffers from hypotension as she has extremely labile blood pressure and was placed on midodrine by her primary care physician to smooth out her hypotensive episodes. On arrival, the patient was normotensive and remained that way during the hospital stay with the exception of one brief episode of a drop to systolic blood pressure in the 60s in the Intensive Care Unit when she was asymptomatic. The patient has a history of atrial fibrillation. She had several episodes in the Medical Intensive Care Unit of atrial fibrillation with a rapid ventricular rate and a right bundle branch block. Patient was continued on her Coumadin and her amiodarone. The patient on the day of discharge had no further episodes of atrial fibrillation. 3. Renal: The patient is an end-stage renal disease patient on peritoneal dialysis and hemodialysis. She was seen by the Renal Consult Service and underwent peritoneal dialysis overnight in the Medical Intensive Care Unit, she was also found to be hyperkalemic, which she is slightly at baseline. She was given Kayexalate as she is in ARC and cannot use Lasix, and allowed minimal IV fluid resuscitation because she is in ARC. The patient was told to continue all her renal medications, and resume her peritoneal dialysis and hemodialysis schedule upon discharge. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Home. DISCHARGE DIAGNOSES: 1. Hyperglycemia of uncertain etiology. 2. Atrial fibrillation. 3. End-stage renal disease on PD and HD. 4. Hypothyroidism. 5. Labile blood pressure. DISCHARGE MEDICATIONS: 1. Midodrine 10 mg po tid. 2. Reglan 10 mg po qid. 3. Levoxyl 75 mcg po q day. 4. Nephrocaps one cap q day. 5. Renagel 800 mg one tablet tid. 6. PhosLo 667 mg one tablet [**Hospital1 **] with lunch and dinner. 7. Amiodarone 200 mg po q day. 8. Neurontin 100 mg po tid. 9. Protonix 40 mg po q day. 10. Coumadin varying dose currently on 2.5 mg po q day. 11. Epogen 1200 units subQ biw. 12. Humalog insulin-sliding scale. 13. Lantus insulin 20 units every evening. 14. Compazine 10 mg prn. 15. Senokot two tablets at bedtime prn. 16. Colace one tablet at bedtime prn. 17. Lactulose one tablespoon at bedtime prn. 18. Lomotil as needed. 19. Vitamin D 50,000 units one time a week on Mondays. FOLLOW-UP PLAN: The patient is to followup with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] within two weeks of discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2201-6-1**] 15:44 T: [**2201-6-3**] 13:34 JOB#: [**Job Number 19743**]

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2473

Discharge summary

report

Admission Date: [**2159-7-27**] Discharge Date: [**2159-8-2**] Date of Birth: [**2091-9-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 348**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right internal jugular central line placement History of Present Illness: 67M history of gout, CVA, DM, ? cardiac disease who has had one week of right hip pain. He presented to [**Hospital3 **] because of intense hip pain with inability to walk. He was found to be hypotensive with BP 80/50. At [**Hospital1 **], he also had RLQ pain. CT abd/pelvis was negative for acute pathology. He received 2L NS but was still hypotensive to SBP 70s, was started on levophed, and then received 2.5 L NS. Labs were significant for acute renal failure with Cr 4. He became fluid overloaded with difficulty breathing with resultant pOx in low 90s during IVF infusion. He was placed on BiPap, which helped with work of breathing. He was given zosyn for ? sepsis and transferred to [**Hospital1 18**]. [**Hospital1 **] labs were significant Trop-I < 0.06, Cr 4, HCO3 10 [**Hospital1 **] imaging showed CT Abd showing normal appendix with no free air, bowel obstruction, or gross intestinal inflammation. In the ED, initial VS were: 01:24 (unable) 98.6 90 98/56 24 99% 15L on NRB. He was audibly wheezing and working to breath. He was placed on BiPap which helped his work of breathing, and he calmed down. On physical exam, he had tenderness to palpation in RLQ, right hip, and groin/scrotum. There was concern for [**Last Name (un) 12653**] gangrene, so surgery consult was obtained. CT Pelvis was obtained that did not suggest the diagnosis. He was also noted to have a "slight pericardial effusion" on US, but no tamponade and pulsus only of 6. He received 1 L NS with placement of RIJ CVC. Levophed was started at 0.8 mcg/min with resultant BP 120/80, HR 95, RR 17, pOx 100 % on biPap. He received flagyl for anaerobic coverage and vancomycin in addition to zosyn given at [**Hospital1 **]. Labs were performed: - WBC 4.6 Hgb 10.5 Hct 31.8 Plt 89 Diff A 2 - Na 143 K 5.8 Cl 122 HCO3 10 BUN 79 Cr 3.7 Glc 107 - ALT 34 AST 25 ALP 88 Tbili 0.5 Albumin 2.9 - CRP 251.1 - Serial ABG 7.13/31/83/11 --> pH 7.17/27/61/10 - Lactate 0.8 --> 0.8 - UA was bland - Blood culture pending Diagnostic testing was performed: - CXR: Borderline cardiomegaly, widening of mediastium, increased interstitial edema with pulmonary overload pattern. - CT Pelvis: Comminuted fracture of the right femoral head with associated cortical breakthrough and step off of the right acetabulum. BiPap settings were stable throughout ER course (NIV FiO2:30 PS: 5 PEEP: 5) On arrival to the MICU, the patient remained stable on continuous dose of levophed. He was taken off biPap with adequate respiratory status. He was AAOx3. His son [**First Name8 (NamePattern2) **] [**Name (NI) **]) was at bedside and provided translation. Past Medical History: - gout - CVA - DM - prior stress test in [**2141**] consistent with inferolateral and posterior myocardial -Possible incomplete medical history, as unable to obtain records from his PCP Social History: He lives with his daughter. Remote smoking history, denies alcohol use. Denies illicits. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: General: on biPAP, responds to verbal stimuli, unable to assess full mental status HEENT: Sclera anicteric, MMM, EOMI, PERRL Neck: supple, unable to assess JVP, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly. GU: foley. Scrotum has thickened skin, redness. Rectal exam with no abscess, + gross blood 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 DISCHARGE PHYSICAL EXAM: VS 98.7; 70-76; 114-126/74-81; 18; 95RA General: NAD CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: breathing well on room air. Clear to auscultation bilaterally, mild wheezing, rales, ronchi Ext: warm, well perfused, 2+ pulses, bilateral 3rd digit PIP swelling Exam otherwise unchanged Pertinent Results: [**2159-7-27**] 02:25AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-<1 [**2159-7-27**] 02:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2159-7-27**] 02:35AM PT-12.1 PTT-33.9 INR(PT)-1.1 [**2159-7-27**] 02:35AM SED RATE-45* [**2159-7-27**] 02:35AM NEUTS-65 BANDS-3 LYMPHS-19 MONOS-7 EOS-3 BASOS-1 ATYPS-2* METAS-0 MYELOS-0 [**2159-7-27**] 02:35AM WBC-4.6 RBC-3.61*# HGB-10.5*# HCT-31.8*# MCV-88 MCH-29.0 MCHC-32.9 RDW-16.3* [**2159-7-27**] 02:35AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2159-7-27**] 02:35AM CRP-251.1* [**2159-7-27**] 02:35AM cTropnT-0.03* [**2159-7-27**] 02:35AM CK-MB-4 [**2159-7-27**] 02:35AM ALBUMIN-2.9* [**2159-7-27**] 02:35AM ALT(SGPT)-34 AST(SGOT)-25 CK(CPK)-77 ALK PHOS-88 TOT BILI-0.5 [**2159-7-27**] 10:01AM CK-MB-6 cTropnT-0.04* [**2159-7-27**] 10:01AM CK(CPK)-94 [**2159-7-27**] 10:20AM LACTATE-0.7 [**2159-7-27**] 05:00PM HCT-30.0* [**2159-7-27**] 05:00PM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2159-7-27**] 05:00PM GLUCOSE-131* UREA N-62* CREAT-2.6* SODIUM-142 POTASSIUM-5.3* CHLORIDE-124* TOTAL CO2-12* ANION GAP-11 [**2159-7-27**] 05:21PM TYPE-ART TEMP-38.6 RATES-/16 O2 FLOW-2 PO2-127* PCO2-26* PH-7.27* TOTAL CO2-12* BASE XS--13 INTUBATED-NOT INTUBA [**2159-7-27**] 11:10PM CALCIUM-8.1* PHOSPHATE-3.1 MAGNESIUM-1.6 [**2159-7-27**] 11:10PM GLUCOSE-82 UREA N-54* CREAT-2.2* SODIUM-144 POTASSIUM-4.8 CHLORIDE-125* TOTAL CO2-11* ANION GAP-13 IMAGING: ECG [**7-27**]: Sinus rhythm with slowing of the rate as compared to the previous tracing of [**2159-7-27**]. There is variation in the precordial lead placement. More precordial lead voltage is recorded. There is low limb lead voltage. Cannot exclude prior inferior wall myocardial infarction. Compared to the previous tracing of [**2159-7-27**] no diagnostic interim change. ECHO [**7-27**]: The left atrium is elongated. The right atrium is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. CT PELVIS W/O CONTRAST [**7-27**]: 1. Comminuted fracture of the right femoral head with associated cortical breakthrough and step off of the right acetabulum . 2. Minimal thickening of bilateral scrotal skin and skin along the medial thighs (corresponding to area of redness clinically; ? cellulitis) with no focal fluid collections or gas locules to sugggest fourniers/abscess. CHEST (PA & LAT) [**7-30**]: There is no significant lung nodule in this exam. MICRO: Blood culture, urine culture [**7-27**] no growth Discharge labs: [**2159-8-2**] 07:00AM BLOOD WBC-6.0 RBC-3.63* Hgb-10.4* Hct-30.7* MCV-85 MCH-28.7 MCHC-33.9 RDW-16.3* Plt Ct-149* [**2159-8-2**] 07:00AM BLOOD PT-40.8* PTT-44.8* INR(PT)-4.0* [**2159-8-1**] 05:55AM BLOOD PT-14.5* PTT-40.9* INR(PT)-1.4* [**2159-8-2**] 07:00AM BLOOD Glucose-60* UreaN-20 Creat-1.1 Na-136 K-3.9 Cl-105 HCO3-21* AnGap-14 [**2159-8-2**] 07:00AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.7 Brief Hospital Course: 67-year-old Vietnamese male history of gout, CVA, DM2, ? cardiac disease presenting with one week history of right hip pain and transferred to [**Hospital1 18**] for hypotension of uncertain etiology and right hip fracture. Initially admitted to MICU for stabilization due to his hypotension and hypoxemic respiratory failure requiring BiPAP, then transferred to the floor. ACUTE ISSUES # Shock, undifferentiated Patient presented with hip fracture and hypotension. Initially thought to be sepsis; however, no obvious source in scrotum, pelvis/abdomen, urine, chest or other source. Cardiogenic shock appears to be unlikely. Hypovolemic shock may be possibility although no clear history of dehydration, and BP did appear to respond to IVF (currently 5.5 L NS total received on admission) with CVP 15. Distributive shock from hip fracture or even fat emboli may also explain picture. Secondary causes of hypotension such as pericardial effusion or systemic condition such as adrenal insufficiency were investigated and ruled out. His blood pressures stabilized while in the MICU, he was taken off of pressors and transferred to the floor. There, his blood pressures remained stable throughout the remainder of his hospital course. # Acute hypoxemic respiratory failure Etiology is likely secondary to flash pulmonary edema during fluid resuscitation and also respiratory compensation for severe metabolic acidosis although did have superimposed respiratory acidosis from likely from tiring out before biPAP. Patient was placed on BiPAP in ED and for a period of time while in the MICU. His respiratory status stabilized and after being transferred to the floor he maintained good oxygen saturation levels while on room air for the remainder of his hospital course. # Acute renal failure Admission Cr 3.7 (from 4) with K 5.8 HCO3 10 consistent with primary non-gap metabolic acidosis with normal anion gap and superimposed respiratory acidosis. Baseline Cr [**2159-6-22**] was 1.79. Renal failure likely pre-renal +/- some element of intrinsic disease +/- drug side effect from numerous NSAIDs on medication list. No evidence of obstruction on CT Abd. Patient's Cr was monitored during admission and was noted to have down trend in Cr following IV hydration. The patients creatinine continued to improve after being transferred to the floor, 1.1 on discharge. # Right Hip Avascular Necrosis: Patient received CT Pelvis to evaluate for Fournier's gangrene in setting of scrotal skin changes, was negative for Fournier's, but concerning Right hip changes were noted. Final read per radiology showed "Right femoral head avascular necrosis with subchondral collapse and subchondral fracture. Cystic area within the anterior femoral head presumably secondary to subchondral cystic change." Ortho was consulted for further evaluation and management. They suggested that given his acute medical instability that the patient follow up as [**Known firstname **] outpatient for operative management. Until follow up with Ortho, patient is non-weight bearing on the RLE. #New Onset Atrial Fibrillation with Rapid Ventricular Response While in the MICU, the patient had two brief episodes of AFib with RVR; once requiring a dose of IV metoprolol, and once self-converting into sinus rhythm. During his hospital course on the floor, however, the patient again began to enter a rhythm consistent with AFib, often times with a ventricular rate into the 140s. His metoprolol was increased gradually, but because of persistent episodes of AFib the decision was made to convert the patient from short acting to Metop XL 100mg [**Hospital1 **]. On this regimen the patient remained in sinus rhythm for the remainder of his hospital course. Given his new diagnosis of AFib and his history of diabetes, CAD and prior CVA, the decision was made to initiate anticoagulation with coumadin. Given 5mg on [**7-31**], 5mg on [**8-1**], INR was 4.0 on [**8-2**], so coumadin stopped. Please check daily INR at rehab, and restart at 2mg daily once INR between [**1-5**]. # Gout - On the day prior to discharge, patient had swelling of his PIP joints in bilateral middle fingers. Restarted on indomethicin and stopped allopurinol in the acute setting. Plan to restart allopurinol once acute flare is treated. # Abdominal pain/scrotum issue Patient's scrotum appears to be without acute infection. There is no acute abdomen to explain abdominal pain on admission. At the time od discharge, his abdomen is pain free. # Normocytic, normocytic Anemia Unknown baseline Hgb. He had positive gross blood on rectal exam. There is no evidence of blood loss into hip fracture at this time with neurovascular structures intact. # Thrombocytopenia Patient has platelets of 89 on admission with normal coags. Likely from marrow suppresion given acute illness with no stigmata of chronic liver disease. CHRONIC ISSUES # Diabetes - The patient was maintained on [**Known firstname **] insulin sliding scale during his hospital course. TRANSITIONAL ISSUES The patient will need to follow up with our [**Hospital 9696**] Clinic in order to plan possible operative intervention for his right hip avascular necrosis once he is more medically stable. The patient will need close follow up to monitor his INR given the initiation of anticoagulation therapy during his hospital course. Will need to restart allopurinol after acute flare. Medications on Admission: Unable to obtain information regarding preadmission medication at this time. Information was obtained from [**Hospital1 **] records. 1. CeleBREX *NF* (celecoxib) 200 mg Oral daily:prn gout flare 2. Allopurinol 300 mg PO DAILY 3. Indomethacin 50 mg PO TID:PRN gout flare 4. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 5. Clopidogrel 75 mg PO DAILY 6. Niaspan Extended-Release *NF* (niacin) 500 mg Oral daily 7. lisinopril-hydrochlorothiazide *NF* 20-12.5 mg Oral daily 8. Colchicine 0.6 mg PO Q 12H gout flare 9. HydrOXYzine 25 mg PO DAILY 10. Vitamin D 400 UNIT PO DAILY 11. GlipiZIDE 10 mg PO BID 12. Omeprazole 20 mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Simvastatin 20 mg PO DAILY Discharge Medications: 1. Clopidogrel 75 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Indomethacin 50 mg PO TID:PRN gout flare 4. Simvastatin 20 mg PO DAILY 5. Acetaminophen 650 mg PO Q6H 6. Aspirin 81 mg PO DAILY 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB 8. Metoprolol Succinate XL 100 mg PO BID 9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain hold for sedation or RR<10 RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 10. Senna 1 TAB PO BID:PRN constipation hold for loose stool 11. Colchicine 0.6 mg PO Q 12H gout flare 12. GlipiZIDE 10 mg PO BID 13. Niaspan Extended-Release *NF* (niacin) 500 mg Oral daily 14. Omeprazole 20 mg PO DAILY 15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 16. Vitamin D 400 UNIT PO DAILY 17. Lisinopril 5 mg PO DAILY Discharge Disposition: Extended Care Facility: Tower [**Doctor Last Name **] Discharge Diagnosis: AVN of the Right femoral head Atrial fibrillation Acute kidney injury Hypotension Acute hypoxemic respiratory failure Anemia Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure to take care of you during your recent hospitalization at [**Hospital1 69**]. As you know, you were hospitalized with right hip pain that was complicated by low blood pressure and difficulty breathing. You were admitted to the ICU and given IV fluids which helped your blood pressure. Unfortunately this caused your lungs to build up fluid which made it difficult for you to breath. You were placed on BiPAP and your oxygen status improved. We then gave you medication to remove the fluid from your lungs, and your breathing improved even further. Your hip pain is the result of a type of fracture known as avascular necrosis. It is unclear at this time why you had such a fracture without any trauma. Our orthopaedic surgeons believe that you should follow up with them as [**Known firstname **] outpatient to plan possible operative fixation in the future once you are doing better from a medical standpoint. During your hospital stay you developed [**Known firstname **] irregular heart beat known as atrial fibrillation. We gave you medication in order to control your heart rate and keep it regular, and you should continue this medication as [**Known firstname **] outpatient. Because people who have atrial fibrillation are at a higher risk of developing strokes, we began treating you with a blood thinner known as coumadin, which can help decrease this risk. We have made the following changes to your medications: START Coumadin Metoprolol RESTARTED Indomethicin STOPPED allopurinol (during the acute gout flare. please restart after acute flare is done) DECREASED Lisinopril STOPPED Hydrochlorothiazide Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2159-8-16**] at 3:30 PM With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *Please call your primary care doctor to request [**Known firstname **] insurance referral for this visit. Dr. [**Last Name (STitle) 12654**] [**Name (STitle) **] number which you will need to give to you PCP office is [**Numeric Identifier 12655**].

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Discharge summary

report

Admission Date: [**2105-3-10**] Discharge Date: [**2105-3-20**] Date of Birth: [**2054-7-25**] Sex: F Service: Orthopedic HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 50-year-old female with a history of pathologic fracture of L1 and T3 secondary to metastatic breast cancer. She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] on [**2105-1-14**] in his office. At the time, the patient was disabled and had pain with coughing and twisting motions, bending, standing and prevented her from driving. She had pain while working, sleeping and performing house chores. The patient's pain subsequently increased. An MRI done on [**2105-2-12**] showed progressive severe collapse of the L1 vertebral body from the pathologic fracture with associated severe spinal stenosis with compression upon the conus. Metastatic disease had spread throughout the lumbar spine and upper sacrum. Several options were discussed with the patient. The patient decided that the best option for relief of her symptoms would be an operative procedure. The patient understood the risks and benefits of the procedure and gave her consent. She was admitted to [**Hospital1 69**] on [**2105-3-10**] for the operation. PAST MEDICAL HISTORY: Asthma. PAST SURGICAL HISTORY: 1. Lumpectomy with radiation and chemotherapy secondary to breast cancer. 2. Subtotal hysterectomy on [**2099-6-8**]. 3. Lumpectomy in 01/[**2102**]. 4. Bilateral oophorectomy on [**2103-8-15**]. ALLERGIES: The patient is allergic to animals. Codeine causes nausea and vomiting. Contrast dye causes hives. Tetracycline causes nausea and vomiting. MEDICATIONS ON ADMISSION: 1. Inhaler. 2. Effexor. 3. Singulair. 4. Uniphyl. 5. Volmax. 6. Beta carotene and other vitamins. FAMILY HISTORY: There is family history of cancer and arthritis. PHYSICAL EXAMINATION: On admission the patient was a well-developed, well-nourished white female in no distress. She walks gingerly to and from the examining table. She was clear to auscultation. Heart was regular rate and rhythm without murmur. Abdomen was soft and nontender. Motor examination of the lower extremities, in terms of hip flexion, abduction, adduction, knee extension, flexion, dorsiflexion and plantar-flexion were 4+/5 bilaterally. Deep tendon reflexes were 1+ at the knees and Achilles. The patient had sustained clonus on the right side with three beats on the left. Negative Babinski sign. The patient also complained of being incontinent of urine since a motor vehicle accident that occurred on [**2104-6-15**], which also caused a fracture dislocation of L1. HOSPITAL COURSE: The patient was admitted to the hospital and underwent a partial vertebrectomy of L1 and L2, osteotomy at L1 and L2, anterior fusion from T11 to L3, anterior interbody spacer placement at the L2-3 level and autograft placement on the day of admission, [**2105-3-10**]. Surgery was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. The patient tolerated the procedure well and was taken to the medical/surgical floor. Pain was controlled with a PCA. On [**2105-3-13**] the patient returned to the operating room for completion of stabilization of her spine. On that day the patient underwent fusion of T1 to L4, osteotomy of L1 and L2, multiple thoracic laminotomies, laminectomy of L1, L2 and L3, with instrumentation from T1 to L4 through a posterior approach. The epidural catheter was placed. During the surgery the patient had massive blood loss and for that reason was given eight liters of crystalloid, fresh frozen plasma and 10 units of packed red blood cells. She remained intubated and was admitted to the surgical intensive care unit. Acute pain service followed the patient throughout this admission. The patient remained intubated until [**2105-3-16**] when she was extubated successfully. The patient had a chest tube placed during the surgery. The patient underwent central line placement from a left subclavian vein without any complications. The Hemovac drain was removed on [**2105-3-17**]. The patient had Pneumoboots throughout this admission to prevent formation of deep venous thrombosis. The patient had a TLSO brace delivered and started mobilization. The patient is to wear her brace whenever she is out of bed. The Hemovac drain was discontinued on [**2105-3-17**]. The epidural was discontinued a day before that. The chest tube was also removed at that time. Throughout the remaining course of admission the patient did very well. She was able to ambulate with some assistance. There were no other complications. The patient was screened for rehabilitation and was expected to go on [**2105-3-20**]. Again, the patient is to wear her TLSO brace whenever she is out of bed. She will need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] in [**9-29**] days. The wound needs to be checked and a dry sterile dressing applied daily. DISCHARGE DIAGNOSES: 1. Status post anterior-posterior thoracolumbar fusion laminectomy with instrumentation at T1 through L3 on [**2105-3-10**] and [**2105-3-13**]. 2. History of breast cancer. Please refer to the full list of diagnoses at the beginning of this chart. DISCHARGE MEDICATIONS: 1. Morphine sulfate SR 30 mg p.o. q. 12 hours. 2. Percocet 5/325 mg one to two tablets p.o. q. 4-6 hours p.r.n. 3. Metoprolol 50 mg p.o. b.i.d. 4. Ipratropium bromide 2 puffs IH q.i.d. 5. Albuterol 1-2 puffs IH q. 4 hours. 6. Potassium chloride 20 mEq/50 mL SWIV p.r.n. if potassium less than 4.0. 7. Magnesium sulfate 2 grams/100 mL D5W IV p.r.n. if magnesium less than 2.0. 8. Morphine sulfate 2-4 mg IV q. 2 hours p.r.n. 9. Famotidine 20 mg IV q. 12 hours. 10. Diazepam 5 mg p.o. q. 6 hours p.r.n. 11. Cyclobenzaprine HCl 10 mg p.o. t.i.d. p.r.n. 12. Acetaminophen 325 1-2 tablets p.o. q. 4-6 hours p.r.n. 13. Venlafaxine 25 mg ?????? tablet p.o. b.i.d. 14. Femara nonformulary 2.5 mg p.o. q.h.s. 15. Volmax nonformulary 8 mg p.o. b.i.d. 16. Theophylline SR 600 mg p.o. b.i.d. 17. Advair Diskus nonformulary one puff inhaler b.i.d. 18. Montelukast sodium 10 mg p.o. q.d. 19. Docusate sodium 100 mg p.o. b.i.d. 20. Droperidol 0.625 mg IV q. 6 hours p.r.n. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**] Dictated By:[**Last Name (NamePattern1) 4307**] MEDQUIST36 D: [**2105-3-20**] 09:16 T: [**2105-3-20**] 09:29 JOB#: [**Job Number 46395**]

[ "737.30", "285.1", "E878.8", "998.11", "733.13", "V10.3", "198.5", "518.5", "733.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "81.04", "77.89", "96.04", "81.05", "77.79", "96.71" ]

icd9pcs

[ [ [] ] ]

1830, 1880

5068, 5318

5341, 6575

1709, 1813

2690, 5047

1327, 1682

1903, 2672

172, 1271

1294, 1303

61,588

161,200

20797

Discharge summary

report

Admission Date: [**2163-9-30**] Discharge Date: [**2163-10-7**] Date of Birth: [**2103-12-7**] Sex: F Service: CARDIOTHORACIC Allergies: lisinopril / Erythromycin Base Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2163-10-1**] 1. Urgent coronary artery bypass graft x3: Left internal mammary artery to left anterior ascending artery, and saphenous vein grafts to distal circumflex and posterior descending arteries. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: 59 year old female with PMH significant for hypertension, dyslipidemia, tobacco use that presented to outside hospital emergency department with chest pain on [**9-29**]. She had chest pain lasting about 1 hour the night before at home that resolved on its own and went to sleep. She felt okay in the morning and went to work were she had another episode and called her PCP. [**Name10 (NameIs) **] PCP referred her to the emergency room and en route she had nitroglycerin SL that resolved the pain. Additionally she had nausea, shortness of breath and sweating with the chest pain episodes. She was admitted to the outside hospital and underwent workup which cardiac enzymes were negative, nuclear stress indicated ischemic changes, so she was referred for cardiac catheterization. That revealed significant coronary artery disease and additionally she was hypertensive to the 200 systolic b/p that required intravenous medications of nitroglycerin and hydralazine. She was transferred in for surgical evaluation. Cardiac Catheterization: Date: [**9-30**] at [**Hospital1 **]. Right dominant LM 25% stenosis with eccentric calcification LAD proximal calcification 50-60% tubular mid stenosis,OM 1 sm diffusely diseased,OM 2 med no stenosis RCA 90% proximal, 65 % mid, 50-60% long distal PDA without significant stenosis. Right groin closure with Mynx. Cardiac Echocardiogram: 9/2/3011 [**Last Name (LF) **],[**First Name3 (LF) **] mild AI no AS, Mitral mild to mod MR, TV mild TR,LVEF 55%. Persantine [**2163-9-29**] - stress images revealed a small sized mild intensity distal anterolateral defect Past Medical History: Hypertension Hyperlipidemia Tobacco Abuse Abdominal Aortic aneurysm (incidental finding on CT scan [**8-/2163**] - with measured to 3cm) Hematuria Chronic diastolic dysfunction Osteopenia Pulmonary embolism (complication after hysterectomy) Migrane (has 1 a year) s/p OOpherectomy s/p Hysterectomy s/p Cholecystectomy s/p laminectomy s/p exploratory laparotomy for ecotpic pregnancy Social History: Lives with: Husband Contact: [**Name (NI) **] [**Known lastname **] Phone # [**Telephone/Fax (1) 55460**] Occupation: Insurance sales Cigarettes: Smoked no [] yes [x] last cigarette [**9-29**] Hx: 30 pack year history - quit for few years 20 years ago after smoking a pack a day but restarted smoking and currently smokes half a pack a day for last 20 years ETOH: 1 drink a month. Illicit drug use denies Family History: Father massive MI deceased at 62 Physical Exam: General: Pleasant, interactine, chest pain on arrival resolved with SL NTG x2 and restarting nitroglycerin gtt Skin: Dry [x] intact [x] right groin cath site HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Murmur [x] grade 1/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] Neuro: Alert and oriented x2 nonfocal Pulses: Femoral Right: mynx closure Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: + bruit Pertinent Results: [**2163-10-1**] Echo PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2163-10-1**] at 11:00 AM. POST-BYPASS: The patient is on no inotropes. Left ventricular function is low normal (LVEF 50%). Right ventricular function is unchanged. Mitral regurgitation is mild (1+). Trace aortic regurgitation is seen. The aorta is intact post decannulation. . [**2163-10-4**] Carotid Ultrasound: 1. A 60-69% stenosis in the right internal carotid and 70-79% stenosis in the left internal carotid artery with significant heterogeneous atherosclerotic plaques. 2. The assessment of the right system is limited due to presence of dressings and central line. . [**2163-10-6**] CXR: In the interim from the prior examination, a left-sided chest tube has been removed. Small [**Hospital1 **]-apical pneumothoraces are not significantly changed. There are, however, worsening bibasilar opacities, right greater than left, which could represent aspiration or developing pneumonia. Persistent perihilar opacities likely reflect atelectasis. No significant pleural effusion is seen. The cardiomediastinal silhouette is unchanged. Median sternotomy wires appear intact . [**2163-9-30**] 10:32PM BLOOD WBC-8.5 RBC-4.07* Hgb-12.3 Hct-34.8* MCV-86 MCH-30.3 MCHC-35.4* RDW-13.8 Plt Ct-159 [**2163-10-3**] 02:59AM BLOOD WBC-9.5 RBC-2.74* Hgb-8.6* Hct-23.5* MCV-86 MCH-31.2 MCHC-36.5* RDW-14.0 Plt Ct-92* [**2163-10-7**] 06:10AM BLOOD WBC-8.4 RBC-2.84* Hgb-8.8* Hct-24.6* MCV-87 MCH-31.1 MCHC-35.9* RDW-14.0 Plt Ct-238# [**2163-9-30**] 10:32PM BLOOD PT-12.8 PTT-25.1 INR(PT)-1.1 [**2163-10-4**] 02:31AM BLOOD PT-13.9* PTT-25.8 INR(PT)-1.2* [**2163-9-30**] 10:32PM BLOOD Glucose-119* UreaN-16 Creat-0.8 Na-140 K-3.7 Cl-106 HCO3-24 AnGap-14 [**2163-10-3**] 09:45PM BLOOD Glucose-102* UreaN-14 Creat-0.6 Na-139 K-5.2* Cl-108 HCO3-23 AnGap-13 [**2163-10-7**] 06:10AM BLOOD Glucose-101* UreaN-19 Creat-0.8 Na-137 K-4.2 Cl-101 HCO3-25 AnGap-15 [**2163-9-30**] 10:32PM BLOOD ALT-10 AST-17 LD(LDH)-149 CK(CPK)-76 AlkPhos-66 Amylase-37 TotBili-0.3 [**2163-10-4**] 02:31AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.7 Brief Hospital Course: Following admission he underwent pre-operative testing and was brought to the operating room on [**2163-10-1**] where the patient underwent urgent CABG x 3 with Dr. [**First Name (STitle) **]. Please see operative note for surgical details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Within 24 hours she was weaned from sedation, extubated, alert and oriented and breathing comfortably. She became agitated and confused on the evening of POD 1, requiring Haldol. There are inconsistent reports of the patient's alcohol consumption, and she was given benzodiazepines for possible alcohol withdrawal as well as vitamins. Carotid ultrasound was performed and revealed a 60-69% stenosis of the [**Country **] and a 70-79% stenosis of the [**Doctor First Name 3098**]. The patient is advised to follow up with vascular surgery as an outpatient. The PCP has recommended Dr. [**Last Name (STitle) 29316**] of [**Hospital1 **]. 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. Chest x-ray's post chest tube removal revealed bilateral apical pneumothoraces. All repeat x-ray's showed stable pneumothorax. Norvasc and Valsartan were added for hypertension. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital 3548**] [**Hospital 3549**] Rehab in [**Location (un) 1110**] in good condition with appropriate follow up instructions. Medications on Admission: Pravastatin 80 mg daily Labetolol 200 mg twice a day Vitamin D Discharge Medications: 1. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 16. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks. 17. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day. 18. ferrous sulfate 325 mg (65 mg iron) Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**] Discharge Diagnosis: Coronary Arery Disease s/p Coronary artery bypass graft x 3 PMH: Hypertension Hyperlipidemia Tobacco Abuse Abdominal Aortic aneurysm (incidental finding on CT scan [**8-/2163**] - with measured to 3cm) Hematuria Chronic diastolic dysfunction Osteopenia Pulmonary embolism (complication after hysterectomy) Migrane (has 1 a year) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: 1+ Alert and oriented x3 nonfocal Ambulating with assistance Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: Trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon Dr. [**Last Name (STitle) **] on [**11-14**] at 1:00pm [**Telephone/Fax (1) 170**] Please call to schedule the following: Cardiologist Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 6256**] in [**4-1**] weeks Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 3658**] in [**5-3**] weeks Vascular Surgery (regarding carotid stenosis): Dr. [**Last Name (STitle) 29316**] [**Telephone/Fax (1) 55461**] **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:[**2163-10-7**]

[ "429.9", "276.2", "291.81", "411.1", "305.1", "401.9", "783.1", "287.49", "303.90", "V12.51", "414.01", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10556, 10698

6890, 8729

307, 567

11070, 11409

3822, 6867

12280, 13081

3046, 3080

8842, 10533

10719, 11049

8755, 8819

11433, 12257

3095, 3803

257, 269

595, 2202

2224, 2608

2624, 3030

5,866

160,429

4477

Discharge summary

report

Admission Date: [**2142-8-18**] Discharge Date: [**2142-8-29**] Date of Birth: [**2077-11-16**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 4659**] Chief Complaint: ABDOMENAL PAIN Major Surgical or Invasive Procedure: SIGMOID COLECTOMY WITH PRIMARY ANASTOMOSIS ILEOCECTOMY WITH END ILEOSTOMY AND CECAL MUCOUS FISTULA History of Present Illness: 64 YEAR OLD FEMALE WITH ABDOMENAL PAIN OVER 5 DAYS. She is recently s/p bilateral knee replacements at an outside hospital and has been constipated on the narcotic pain medication. SHE PRESENTED WITH RIGHT LOWER QUADRANT PAIN--"SHARP, GRABBING PAIN" THAT IS [**11-19**] IN SEVERITY. SHE HAD BEEN CONSTIPATED AND HAD ABDOMENAL DISTENTION FOR SEVERAL DAYS BEFORE PRESENTATION. DENIES FEVERS. SOME NAUSEA, BUT NO VOMITING. Past Medical History: HYPOTHYROID HYPERCHOLESTEMIA GERD S/P BILATERAL KNEE REPLACEMENT Physical Exam: TEMP 98.5 PULSE 65 177/65 RESPIRATORY RATE 15 99% 3L GENERAL: MILD DISTRESS, ALERT AND ORIENTED HEART REGULAR RATE RHYTHM LUNGS CLEAR TO ASCULATION BILATERALLY ABDOMEN SOFT, very DISTENDED, marked focal RIGHT SIDED TENDERNESS, with isolated rebound. RECTAL MINIMAL STOOL IN VAULT, GUAIC NEGATIVE Pertinent Results: [**2142-8-18**] 02:45AM BLOOD Neuts-90.5* Lymphs-6.1* Monos-2.9 Eos-0.4 Baso-0.1 [**2142-8-18**] 02:45AM BLOOD WBC-16.4* RBC-3.54* Hgb-10.8* Hct-33.7* MCV-95 MCH-30.5 MCHC-32.1 RDW-16.1* Plt Ct-622* [**2142-8-18**] 12:17PM BLOOD WBC-9.4 RBC-3.97* Hgb-12.0 Hct-36.5 MCV-92 MCH-30.1 MCHC-32.8 RDW-16.9* Plt Ct-558* [**2142-8-18**] 05:00PM BLOOD WBC-15.9*# RBC-3.79* Hgb-11.7* Hct-34.5* MCV-91 MCH-30.9 MCHC-33.9 RDW-16.9* Plt Ct-575* [**2142-8-18**] 08:59PM BLOOD WBC-18.7* RBC-3.96* Hgb-12.0 Hct-37.2 MCV-94 MCH-30.3 MCHC-32.2 RDW-17.0* Plt Ct-558* [**2142-8-19**] 02:37AM BLOOD WBC-19.5* RBC-3.77* Hgb-11.3* Hct-35.0* MCV-93 MCH-30.1 MCHC-32.4 RDW-16.9* Plt Ct-513* [**2142-8-20**] 02:23AM BLOOD WBC-14.1* RBC-3.01* Hgb-9.4* Hct-28.1* MCV-93 MCH-31.2 MCHC-33.4 RDW-16.3* Plt Ct-319 [**2142-8-20**] 03:41AM BLOOD WBC-13.9* RBC-2.94* Hgb-9.1* Hct-27.5* MCV-94 MCH-30.9 MCHC-33.0 RDW-16.4* Plt Ct-337 [**2142-8-21**] 02:02AM BLOOD WBC-17.0* RBC-2.99* Hgb-9.3* Hct-28.1* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.2* Plt Ct-374 [**2142-8-22**] 01:54AM BLOOD WBC-11.8* RBC-3.08* Hgb-9.1* Hct-28.9* MCV-94 MCH-29.5 MCHC-31.4 RDW-16.1* Plt Ct-381 [**2142-8-23**] 03:05AM BLOOD WBC-10.7 RBC-3.26* Hgb-9.9* Hct-30.6* MCV-94 MCH-30.3 MCHC-32.2 RDW-16.2* Plt Ct-418 [**2142-8-18**] 12:17PM ALT(SGPT)-22 AST(SGOT)-24 ALK PHOS-53 AMYLASE-40 TOT BILI-0.5 ACUTE ABD SERIES ([**3-15**] VIEWS OF ABD & SGL CHEST VIEW) [**2142-8-18**] 3:14 AM IMPRESSION: Massive pneumoperitoneum, with severe dilation of the proximal colon to the level of the splenic flexure, after which no air is visualized, suggestive of perforated large bowel obstruction. Brief Hospital Course: UPON PRESENTATION TO THE HOSPITAL, SHE WAS IMMEDIATELY TAKEN TO THE OPERATING ROOM FOR AN EXPLORATORY LAPAROTOMY, SIGMOID COLECTOMY, ILEOCECTOMY. She had a necrotic segment of the anterior wall of her massively distended cecum (approximately 17cm in diameter) which had perforated and sealed against the abdominal wall. On exploration of her abdomen she had a hard mass in her distal sigmoid colon which was causing a partial obstruction. Pathology revealed this to be an old diverticular perforation with scaring and narrowing of the lumen. SHE TOLERATED THE SURGERY AND WAS ADMITTED TO THE INTENSIVE CARE UNIT. SHE SLOWLY IMPROVED AND WAS TRANSFERED TO THE SURGICAL FLOOR WHERE SHE CONTINUED TO MAKE PROGRESS. SHE HAS BEEN ON VANCOMYCIN, ZOSYN, AND FLUCONAZOLE. SHE IS BEGINING TO AMBULATE MORE. SHE HAS BEEN AFEBRILE WITH VITALS BEING STABLE AND WILL BE DISCHARGED TO A REHABILITATION CENTER IN FAIR CONDITION. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 9. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed. 10. Fluconazole in Normal Saline 400 mg/200 mL Piggyback Sig: One (1) 400 mg IV Intravenous Q24H (every 24 hours) for 3 days. Disp:*3 400 mg IV * Refills:*0* 11. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) 4.5 gm IV Intravenous Q8H (every 8 hours) for 3 days. Disp:*2 4.5 gm IV * Refills:*0* 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) 1000 mg IV Intravenous Q 12H (Every 12 Hours) for 3 days. Disp:*6 1000 mg IV * Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Center Discharge Diagnosis: CECAL ISCHEMIA AND BOWEL PERFORATION Diverticulosis with old perforation and sigmoid narrowing. Discharge Condition: FAIR Discharge Instructions: PLEASE TAKE ALL MEDICATIONS AS PRESCRIBED. IF SYMPTOMS OF INFECTIONS SUCH AS FEVERS/CHILLS, INCREASE PAIN, INCREASE IN PURULENT DISCHARGE FROM ABDOMENAL WOUND, PLEASE CALL OR GO TO AN EMERGENCY ROOM. Followup Instructions: PLEASE FOLLOW UP WITH DR. [**Last Name (STitle) **] IN 1 WEEK. CALL FOR AN APPOINTMENT([**Telephone/Fax (1) 15665**] ([**Telephone/Fax (1) 19177**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**] Completed by:[**2142-8-29**]

[ "244.9", "557.0", "530.81", "560.89", "272.0", "567.2", "998.59", "V43.65", "569.83" ]

icd9cm

[ [ [] ] ]

[ "45.72", "45.76", "46.23" ]

icd9pcs

[ [ [] ] ]

5120, 5181

2964, 3887

338, 439

5320, 5326

1318, 2941

5576, 5898

3910, 5097

5202, 5299

5350, 5553

994, 1299

284, 300

467, 891

913, 979

13,033

106,445

42978

Discharge summary

report

Admission Date: [**2185-12-23**] Discharge Date: [**2185-12-25**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: MICU admission for malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 37 y/o male with type I DM with known gastroparesis, ESRD on dialysis, and multiple prior admissions for nausea/vomiting and difficult to control hypertension who presented to the ED last PM with 1 day of N/V, and SBP in 250's. Pt had dialysis yesterday afternoon, and then experienced symptoms later that evening. Pt denies CP, SOB, F/C. Of note, pt has had multiple [**Hospital1 18**] admissions in the past for similar symptoms and was recently discharged on [**2185-12-10**]. . ED COURSE: He had N/V, and was found to have an elevated BP of 250's/140's. He was initially placed on Nipride gtt, but this was then d/c'd and he was given Labetolol 20mg IV x1 and hydral 10mg IV x 3. He also received dilaudid 2mg IV x 5, Ativan 2mg IV x 5, droperidol 2.5mg IM x 1, and Anzemet 12.5mg IV x 1. . Pt currently feels well, and denies N/V, CP, SOB. Past Medical History: 1. DM type I 2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension. 4. History of esophageal erosion, MW tear 5. CAD with 1-vessel disease (50% stenosis D1), normal stress [**11/2182**] 6. Foot Ulcer - 2 months, healing slowly 7. h/o clot in AV fistula clot on [**Year (4 digits) **] Social History: Denies any alcohol, tobacco, or drug use. He has his own room but lives with his son's mother. His son is 12 years old. Family History: His father recently died of ESRD and diabetes. His mother is in her 50s and has hypertension. He has two sisters, one with diabetes, and six brothers, one with diabetes. Physical Exam: VS- T 96 BP 197/96 --> 145/94, HR 86, RR 13, O2 97% 2L NC Gen: Pleasant male lying on bed in no acute distress HEENT: Sclerae muddy. MMM. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. CV: RRR. nl S1, S2. Has 2/6 systolic murmur at LUSB as well as [**4-18**] sysotlic murmur radiating to apex. L sided port in place. LUNGS: CTAB ABD: Soft, nt, nd, +BS. No rebound/guarding. EXT: WWP, NO CCE. 2+ DP pulses BL. Has a healing ulcer on the inferior R foot. No surrounding erythema or drainage. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2185-12-23**] 12:48AM BLOOD PT-34.3* PTT-40.7* INR(PT)-3.7* [**2185-12-24**] 04:20AM BLOOD PT-52.1* PTT-44.3* INR(PT)-6.2* [**2185-12-24**] 01:42PM BLOOD PT-48.7* PTT-39.5* INR(PT)-5.7* Brief Hospital Course: Mr. [**Known lastname **] is a 37 year old male with hypertension, ESRD on dialysis, and multiple prior admissions for hypertension with nausea & vomiting who presented with HTN and nausea/vomiting. . # Nausea/vomiting: The presentation appears to be consistent with his prior admissions for severe autonomic dysfunction with hypertensive emergency, and gastroparesis. - He was continued on his usual medications including ativan, dilaudid, and anzemet, as well as antihypertensive regimen with resolution of his nausea and vomiting. . # Hypertension: Upon admission, his SBP were up to 250's initially. His regular antihypertensive regimen was resumed including clonidine patch, PO clonidine, metoprolol, ativan, dilaudid and his BP improved. He was 132/87 upon discharge . # ESRD on dialysis: Mr. [**Known lastname **] usual dialysis schedule was T/Th/Saturday. He received Saturday dialysis during this admission and will resume his usual schedule upon discharge. He was followed by the renal team during this admission. . # Type I DM: Glucose upon admission was 300. He was continued on his home dose of NPH 6 units [**Hospital1 **] and an insulin sliding scale and glucose control was adequate. . # Elevated INR: Patient with INR elevated to 5.7 during this admission. The patient's [**Hospital1 197**] was held and he was instructed to stop his [**Hospital1 197**] upon discharge and to be seen in coagulation clinic on [**Hospital1 766**] to recheck his INR. The patient was not reversed as he had no signs of bleeding. . # Ulcer on right foot: Stable during this admission. There were no signs of infection. . # FEN: Patient was maintained on a renal, gastroparesis diet. . # PPx: ? HIT per renal, but HIT Ab negative during last admission. Will use pneumoboots for now. Platelets were stable at 184 upon discharge. . # CODE: Full . Medications on Admission: Metoprolol Tartrate 37.5 mg [**Hospital1 **] B Complex-Vitamin C-Folic Acid 1 mg qd Warfarin 3mg PO qhs Clonidine 0.4 mg PO tid Clonidine 0.3 mg/24 hr Patch QTHUR Calcium Acetate 1334 tid w/meals Metoclopramide 5 mg qid Insulin NPH 6U [**Hospital1 **] Ativan 2 mg q4-6hrs prn Ondansetron HCl 4 mg/5 mL PO q8h prn Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO every six (6) hours as needed for nausea. 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO three times a day: take with meals. 5. Ondansetron HCl 4 mg/5 mL Solution Sig: Five (5) mL PO every eight (8) hours as needed for nausea. 6. Ativan 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. 7. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: 6 units Subcutaneous twice a day. 8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 9. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Outpatient [**Hospital1 **] Work Please check INR at dialysis on Tuesday [**2185-12-27**] given supratherapeutic INR at discharge (INR 5.7). Discharge Disposition: Home Discharge Diagnosis: . Primary: Malignant hypertension, Gastroparesis . Secondary: 1. DM type I 2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension. 4. History of esophageal erosion, MW tear 5. CAD with 1-vessel disease (50% stenosis D1), normal stress [**2183**] 6. Foot Ulcer - 2 months, healing slowly 7. h/o clot in AV fistula (on [**Year (4 digits) **]) . Discharge Condition: Good: Taking POs well. No nausea/vomiting. BP well controlled. Discharge Instructions: . 1- Please take all medications as prescribed. Do not take your [**Year (4 digits) 197**] until you are seen at dialysis on Tuesday [**12-27**] for a check of your INR (your INR is currently elevated (5.7)). . 2- Please followup with your PCP [**Last Name (NamePattern4) **] 1 week. You will need an outpatient echo to evaluate your heart function given complaints of paroxysmal nocturnal dyspnea. . 3- Please seek medical attention for severe nausea/vomiting or for elevated blood pressure (sbp> 200) that does not resolve after taking your usual outpatient BP medication regimen. . Followup Instructions: . 1- Please hold your [**Last Name (NamePattern4) 197**] until you are seen at dialysis on Tuesday for a repeat INR. Your [**Last Name (NamePattern4) 197**] is currently supratherapeutic. . 2- Please followup with your outpatient doctor to have an echo of your heart scheduled to evaluate your symptom of paroxysmal noctural dyspnea. . [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2185-12-24**]

[ "250.61", "337.1", "585.6", "536.3", "414.01", "403.01", "707.14" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

6104, 6110

2918, 4771

367, 373

6637, 6704

2705, 2895

7339, 7844

1883, 2054

5135, 6081

6131, 6616

4797, 5112

6728, 7316

2069, 2686

285, 329

401, 1281

1303, 1729

1745, 1867

43,975

195,421

42532

Discharge summary

report

Admission Date: [**2196-12-12**] Discharge Date: [**2196-12-17**] Date of Birth: [**2125-1-9**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: coronary artery bypass grafts x3(LIMA-LAD,SVG-OM,SVG-PDA) [**2196-12-13**] left heart catheterization, coronary angiogram [**2196-12-12**] History of Present Illness: This 71 year old white male has known coronary disease, having undergone catheterization 10 years ago. medical management was recommended then. His angina has been stable and chronic. He over the last month has had several episodes of rest angina which has crescendoed. A stress test was positive and he underwent catheterization this admission which revealed 40% left main and severe triple vessel disease which has progressed. Surgical intervention was recommended. Past Medical History: Diabetes-diet controlled hypercholesterolemia coronary artetery disease Barrett's esophagus tonsillectomy at age 4 Social History: Psycho/Social: Lives with girlfriend. Retired. [**Name2 (NI) **] children. Contact for discharge: [**Doctor First Name 717**] cell # [**Telephone/Fax (1) 92043**] Tobacco: No: quit [**2155**]-smoked 1.5PPD x 10 y ETOH: 3 beers 4 times per week . Family History: noncontributory Physical Exam: Height: 6 feet Weight: 190 lbs General:A&Ox3, NAD HEENT:carotids 2(+)bilaterally-no bruits CVS: RRR, no murmur/rub/gallop Lungs:CTA Abd:benign Extr:No C/C/E, no varicosities. DP 2+(B) (R)groin cath site-soft/no drainage Pertinent Results: [**2196-12-16**] 05:49AM BLOOD WBC-10.6 RBC-2.97* Hgb-9.9* Hct-27.1* MCV-92 MCH-33.3* MCHC-36.4* RDW-13.7 Plt Ct-165 [**2196-12-12**] 01:10PM BLOOD WBC-7.9 RBC-4.48* Hgb-14.2 Hct-40.3 MCV-90 MCH-31.7 MCHC-35.2* RDW-13.4 Plt Ct-190 [**2196-12-16**] 05:49AM BLOOD Glucose-158* UreaN-17 Creat-1.1 Na-138 K-4.2 Cl-101 HCO3-28 AnGap-13 [**2196-12-12**] 01:10PM BLOOD Glucose-127* UreaN-12 Creat-1.0 Na-140 K-4.1 Cl-106 HCO3-25 AnGap-13 [**2196-12-12**] 05:45PM BLOOD ALT-29 AST-22 LD(LDH)-141 AlkPhos-61 Amylase-29 TotBili-0.6 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 92044**] (Complete) Done [**2196-12-13**] at 12:13:03 PM 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: [**2125-1-9**] Age (years): 71 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: CABG ICD-9 Codes: 786.05, 786.51, 424.0 Test Information Date/Time: [**2196-12-13**] at 12:13 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW1-: Machine: us6 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Complex (mobile) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Physiologic 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. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%) with apical hypokinesis. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on no inotropes. Preserved biventricular systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2196-12-15**] 14:09 ?????? [**2188**] CareGroup IS. All rights reserved. Brief Hospital Course: He remained stable after catheterization and surgical evaluation was undetaken. On [**12-13**] he went to the Operating Room where Coronary artery bypass times 3 (left internal thoracic artery to left anterior descending artery and reverse saphenous vein grafts to obtuse marginal branch and to the right posterior descending branch) with Dr.[**Last Name (STitle) **]. CARDIOPULMONARY BYPASS TIME: 70 minutes CROSS-CLAMP TIME: 61 minutes Please refer to operative report for further details. He tolerated the operation well and was transferred to the intensive care unit where he awoke, weaned and was extubated. His CTs were removed on POD 1 and beta blockade resumed. Pacing wires discontinued per protocol. Diuresis towards his preoperative weight was begun. Physical Therapy was consulted for evaluation of his strength and mobility. Postoperative rapid atrial fibrillation occurred transiently. It was treated with IV Lopressor and converted to normal sinus rhythm. No further arrythmias. He progressed well and was discharged on POD#4 with appropriate follow up appointments advised. Medications on Admission: Simvastatin 80mg daily Nexium 40mg daily Atenolol 50mg daily Aspirin 81mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 7. 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* 8. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 10. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day for 5 days. Disp:*5 Capsule, Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: coronary artery disease s/p coronary artery bypass grafts noninsulin dependent diabetes mellitus hypercholesterolemia Barrett's esophagus s/p tonsillectomy Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia 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**] **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 Cardiac surgery office [**Hospital **] medical Building [**Hospital Unit Name **] [**Telephone/Fax (1) 170**] Wound check: Thrusday [**12-22**] at 10:30 am Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2197-1-19**] at 1pm Cardiologist:Dr. [**First Name (STitle) **] [**Name (STitle) **] office will call you with appt Please call to schedule appointments with: Primary Care Dr. [**Last Name (STitle) 73983**] in [**4-5**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2196-12-17**]

[ "272.4", "E878.2", "997.1", "530.85", "414.01", "411.1", "401.9", "530.81", "427.31", "287.5", "250.00", "285.9", "V15.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7884, 7933

5339, 6439

327, 468

8133, 8359

1660, 5316

9199, 9902

1386, 1403

6570, 7861

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6465, 6547

8383, 9176

1418, 1641

272, 289

496, 966

988, 1105

1121, 1370

13,207

198,035

46394

Discharge summary

report

Admission Date: [**2140-11-7**] Discharge Date: [**2140-11-20**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4162**] Chief Complaint: Diarrhea. Major Surgical or Invasive Procedure: EGD on [**2140-11-11**]. Bronchoscopy on [**2140-11-11**]. hemodialysis [**2140-11-20**] History of Present Illness: The pt. is a 72 year-old male with a history of alcoholic cirrhosis complicated by chronic LE edema and cellulitis who presented with a 4 to 5 day history of diarrhea and decreased p.o. intake. The pt. stated that he was in his USOH until [**Month (only) **] of this year when he began to develop watery, non-bloody diarrhea after being treated with clindamycin for lower extremity cellulitis. At that time, he was empirically treated with flagyl for suspected c. difficile enterocolitis and his diarrhea abated. He subsequently experienced diarrhea again in [**Month (only) 359**] under the same circumstances which also improved with flagyl. The pt. reported that the same sequence of events occurred again beginning 4-5 days prior to admission. The pt. stated that his diarrhea is watery and brown and primarily occurred after meals. He has not noticed any blood in his stools. He had been unable to tolerate p.o. for the past [**12-29**] days and stated that any time the pt. would attempt to take p.o., he would experience copious diarrhea. The pt. admitted to a roughly 10 pound weight loss over this time period. The pt. denied fever or diaphoresis but did complain of chills during the past four days. He has also noticed increased redness and swelling of his lower extremities, more marked on the right. He had been unable to ambulate secondary to lower extremity pain. On ROS, the pt. complained of a mild headache but denied chest pain, shortness of breath, nausea, dysuria. In the ED, the pt. was a total of 2 liters of IV fluid, 60g of kayexelate for elevated serum potassium and IV oxacillin for lower extremity cellulitis. An ultrasound of the pt's. RLE was performed and was negative for DVT. He was admitted to the MICU for dehydration secondary to presumed c. difficile enterocolitis. Past Medical History: -cirrhosis [**12-28**] alcohol abuse c/b grade 1 esophageal varices, gastric varices and thrombocytopenia; has been abstinent since [**2121**] -chronic LE edema and cellulitis as a result of cirrhosis -HTN -normocytic anemia, thought to be [**12-28**] CRI, on aranesp injections -AAA, dx. in [**1-26**] and measured 3.5x3 by U/S (stable as of [**5-29**]) -chronic constipation -BPH, S/P TURP in [**2133**] -agoraphobia -chronic renal insufficiency with a baseline Cr. of 2 -lipomas -ED Social History: The pt. lives at home with his wife and son. [**Name (NI) **] has been abstinent from alcohol since [**2121**] after a history of alcohol abuse. He has a distant history of tobacco use (quit 30 years ago). Denied illicit drug use. Family History: Mother died of colon cancer in her 90's. Physical Exam: T: [**Age over 90 **]F P: 84 R: 18 BP: 110/32 SaO2: 100% RA General: awake, alert, NAD HEENT: PERRL, EOMI, MM dry, no lesions in OP Neck: supple, no JVD appreciated Pulmonary: lungs CTA bilaterally Cardiac: RRR, S1S2, no m/r/g appreciated Abdomen: soft, NT/ND, hyperactive bowel sounds, no masses or organomegaly appreciated Extremities: 2+ pitting edema of LLE with pretibial erythema and 2+ DP pulse; 4+ pitting edema of RLE with marked pretibial erythema and skin breakdown, 1+DP pulse Neurologic: Alert and oriented x 3. No asterixis noted. Skin: Skin changes over BLE as described above. Otherwise, hemangiomas noted over trunk. Pertinent Results: Labs on admission: [**2140-11-7**] 06:00AM WBC-17.3*# RBC-3.67* HGB-11.9* HCT-34.8* MCV-95 MCH-32.5* MCHC-34.3 RDW-16.5* [**2140-11-7**] 06:00AM PLT COUNT-61* [**2140-11-7**] 06:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-2+ BURR-1+ [**2140-11-7**] 06:00AM NEUTS-68 BANDS-24* LYMPHS-1* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2140-11-7**] 06:00AM CORTISOL-56.7* [**2140-11-7**] 06:00AM GLUCOSE-95 UREA N-83* CREAT-5.5*# SODIUM-127* POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-14* ANION GAP-21* [**2140-11-7**] 06:00AM ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-4.9*# MAGNESIUM-1.7 [**2140-11-7**] 06:00AM ALT(SGPT)-22 AST(SGOT)-43* LD(LDH)-239 ALK PHOS-65 AMYLASE-35 TOT BILI-2.6* DIR BILI-1.1* INDIR BIL-1.5 [**2140-11-7**] 06:00AM LIPASE-24 [**2140-11-7**] 06:00AM HAPTOGLOB-36 [**2140-11-7**] 07:40AM FIBRINOGE-227 [**2140-11-7**] 07:40AM PT-20.8* PTT-41.0* INR(PT)-2.7 [**2140-11-7**] 08:04AM LACTATE-4.7* [**2140-11-7**] 09:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2140-11-7**] 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2140-11-7**] 09:30AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 Brief Hospital Course: Mr. [**Known lastname **] was a 72 yo male with alcoholic cirrhosis, admitted to the [**Hospital Unit Name 153**] with C diff colitis, RLE cellulitis, acute on chronic renal failure, enterobacter bacteremia, and anion gap metabolic acidosis. He was stabalized in the [**Hospital Unit Name 153**], called out on [**11-15**], and progressively developed acute on chronic hepatic insufficiency. Hepatic failure thought to be due to chronic liver disease in setting of chronic infection. He developed a hepatorenal syndrome and underwent hemodialysis but became acutely hypotensive. He was transferred to the [**Hospital Unit Name 153**] [**2140-11-20**]. A family meeting was held, and the patient was made DNR/DNI with emphasis on confort measures. He expired [**2140-11-20**] at 20:48 with his family present. During his hospitalization the following problems were addressed: 1. Acute on Chronic renal failure and Hypovolemia: The pt presented with severe volume depletion secondary to the history of severe diarrhea. He was aggressively hydrated with IV fluids over the course of the first two hospital days. IV fluids were discontinued once the pt. was able to tolerate p.o. fluids. Pt presented with a serum creatinine that was elevated well above baseline on admission. This rapidly improved with the administration of IV fluids, suggesting a prerenal azotemia on admission. Pt's renal function worsened when he developed acute on chronic hepatic insufficiency, likely due to worsening prerenal azotemia. The renal team was following. Despite colloid (PRBC) and sodium bicarbonate, pt's renal function continued to decline on the floor with worsening uremia. On [**11-19**] pt was started on midodrine and octreotide. He was transferred to the [**Hospital Ward Name **] for hemodialysis. During hemodialysis he became acutely hypotensive. Dialysis was discontinued and he was transferred to the [**Hospital Unit Name 153**] for further care. 2. C. Difficile Colitis: The pt. was started on po metronidazole on admission. His diarrhea subsequently abated over the course of the first hospital day. Stool sent for c. difficle toxin assay confirmed the diagnosis. Pt was maintained on PO metronidazole with repeat stool sample negative for C. Dif on [**11-18**]. However, he continued to have diarrhea whenever he ate, possibly functional or related to Abx use. 3. Lower extremity cellulitis: The pt. presented with significant edema, erythema and tenderness of his right lower extremity. He was started on IV oxacillin which was continued for the first two hospital days. However, the pt's. cellulitis worsened on this regimen. Over concern for possible community-acquired MRSA cellulitis, IV vancomycin was begun on the third hospital day. As there continued to be no improvement, an MRI of the lower extremities was performed over concern for possible abscess or osteomyelitis. There was no evidence of abscess on MR, just non-specific edema. On the floor, in the setting of his worsening renal function, pt's IV vancomycin was continued and dosed daily by level. 4. Enterobacter bacteremia: The pt. was noted to have [**11-29**] bottles positive for Enterobacter. Accordingly, he was placed on ceftriaxone and levofloxacin. He remained afebrile for the duration of the MICU stay and he never developed signs or symptoms suggestive of sepsis or SBP. He was maintained on IV Levofloxacin and Cefepime on the floor, the latter to cover for ?Pseudomonas from his cellulitis. 5. Hypoxia: Pt was noted to have bilateral pleural effusions and mild fluid overloaded, likely due hepatic and renal failure. IVFs were stopped. Pt remained stable on 3L of oxygen by nasal canula on the floor, but desaturated on transfer to the [**Hospital Unit Name 153**]. 6. Hemoptysis: The pt. experienced an episode of hemoptysis on hospital day 5. The initial concern was for variceal bleeding and he was intubated for airway protection, started on octreotide, and given FFP and platelets. EGD showed nonbleeding varices. Bronchoscopy showed some blood but no bleeding source suggestive of aspiration. It was ultimately felt that he was suffering from epistaxis secondary to oxygen therapy via nasal cannula. He was extubated after 24 hours and did not experience any further episodes. 7. Acute on Chronic Hepatic Insufficiency: Pt has a history of alcoholic cirrhosis. The etiology of his acutely worsening liver function is unclear, but likely due to infection. The liver team followed, and advised that the pt's liver disease portended a poor prognosis. A paracentesis on [**11-17**] drained 500cc of fluid which had SAAG supporting portal hypertension, as suspected, and ruling out SBP. His total bili continued to rise in the setting of renal insufficiency. He was maintained on SQ vitamin K. On transfer to the [**Hospital Unit Name 153**] the patient was jaundiced with total bilirubin 17. Mental status quickly deteriorated over the afternoon. 8. AAA: Stable at 3.5cm. 9. Swallowing: A video swallow found a small amount of penetration identified with thin liquid and pill, otherwise no aspiration. 10. The patient was transferred to the [**Hospital Unit Name 153**] on [**2140-11-20**] after decompensating into end stage hepatic failure and renal failure on the floor, intolerant of hemodialysis. A family meeting was held, and the patient was made DNR/DNI with emphasis on comfort measures. He expired [**2140-11-20**] at 20:48 with his family present. Medications on Admission: -atenolol 25mg po daily -aranesp 50mcg sc qweek -lasix 40mg po daily, recently d/c'ed -moexipril 7.5mg po daily -spironolactone 100mg po daily, recently d/c'ed Discharge Medications: --- Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: ---- Followup Instructions: ----

[ "008.45", "786.3", "572.4", "458.21", "584.9", "041.85", "276.2", "518.82", "403.91", "286.7", "790.7", "787.91", "571.2", "784.7", "570", "287.5", "276.6", "682.6", "276.5" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.05", "39.95", "96.71", "38.93", "99.07", "99.04", "54.91", "96.04", "33.22" ]

icd9pcs

[ [ [] ] ]

10806, 10815

5067, 10568

326, 416

10867, 10877

3748, 3753

10930, 10937

3035, 3078

10778, 10783

10836, 10846

10594, 10755

10901, 10907

3093, 3729

277, 288

444, 2261

3768, 5044

2283, 2771

2787, 3019

14,514

199,646

3819

Discharge summary

report

Admission Date: [**2183-7-27**] Discharge Date: [**2183-8-30**] Service: MED Allergies: Penicillins / Sulfonamides / Keflex / Bactrim Attending:[**First Name3 (LF) 898**] Chief Complaint: Fevers and Chills Major Surgical or Invasive Procedure: None History of Present Illness: 86M w/ PMH sig for CAD s/p CABG, recurrent aspiration PNAs d/t decreased cough reflex who p/w fevers/chills since 4am on DOA. Per wife, his symptoms were reminiscent of aspiration episodes in the past. No change in cough, SOB, recent travel, or clear aspiration event. He was on a regular diet with thickened liquids at home. ROS notable only for constipation and decreased fluid intake over the past few days. In ED, he was noted to be febrile to 101.3 and hypoxic to 88% on RA. Although his CXR shows improvement in his RLL opacity, he was given levo/flagyl for a presumed recurrent aspiration pneumonia, as well as 1L NS. Past Medical History: 1. Dysphagia with solids with a speech and swallow showing aspiration on [**6-28**], with decreased cough reflex. 2. Coronary artery disease status post coronary artery bypass graft in [**2147**]; status post myocardial infarction in [**2175**]. Cardiac catheterization in [**2175**] showed a patent graft. 3. Atrial fibrillation and atrial flutter status post AV pacer in [**2176**]. 4. Congestive heart failure with ejection fraction greater than 40% in [**2178**]. 5. Hypertension. 6. Hyperthyroidism. 7. Status post bilateral cerebrovascular accidents. 8. Colon cancer status post right hemicolectomy. 9. Hypercholesterolemia. 10. Status post cervical spinal fusion. 11. Benign prostatic hypertrophy status post transurethral resection of prostate. 12. Peptic ulcer disease. 13. Gastroesophageal reflux disease. 14. Osteoarthritis. 15. Gout. 16. Cholelithiasis. 17. Watery diarrhea times seven months with negative stool cultures in [**2180**]. Social History: Lived in [**Location (un) 55**] with his wife. [**Name (NI) **] had a daughter in the [**Name (NI) 86**] area and a son in [**Name (NI) 108**]. No history of tobacco use or ethanol use. No other drug use. The patient was a retired maintenance worker. Ambulated w/ a cane at baseline. Family History: Brother died at age 54 from MI. Physical Exam: 98.2 (Tm 101.3) 92/48 60 16 88%RA -> 95% 2L Gen - elderly, thin [**Male First Name (un) 4746**], pleasant, A&O x 3, nontoxic appearing, speaking in full sentences w/o getting SOB Heent - anicteric, OP clear, MM sl dry Neck - no JVD, no TM, no LAD Lungs - +bibasilar crackles R>L CV - RRR, 2/6HSM at apex Abd - soft, NT/ND, no HSM, no masses Ext - no edema, no CT, warm, no rashes Neuro - nonfocal and symmetric, appropriate mentation & speech Pertinent Results: CXR: The patient is status-post median sternotomy and CABG. A left-sided dual chamber pacemaker is again noted with leads in stable and satisfactory position with leads overlying the right atrium and right ventricle. Cardiac and mediastinal contours remain stable. Pulmonary vascularity is within normal limits. There is pleural and parenchymal scarring present within the right lower lobe. Additionally, there are bibasilar patchy opacities present, suggestive of superimposed aspiration or pneumonia. There is flattening of the diaphragms bilaterally. The costophrenic angles are blunted on the lateral views posteriorly, consistent with small bilateral pleural effusions. No pneumothorax is identified. Degenerative changes are noted within the thoracic spine. [**2183-7-27**] 06:30AM BLOOD WBC-9.2 RBC-3.66* Hgb-11.9* Hct-34.1* MCV-93 MCH-32.5* MCHC-35.0 RDW-14.9 Plt Ct-163 [**2183-7-30**] 08:58AM BLOOD WBC-13.3*# RBC-3.18* Hgb-10.4* Hct-30.3* MCV-95 MCH-32.8* MCHC-34.5 RDW-15.1 Plt Ct-194 [**2183-8-3**] 04:44AM BLOOD WBC-11.4* RBC-3.03* Hgb-10.0* Hct-29.3* MCV-97 MCH-33.2* MCHC-34.3 RDW-15.3 Plt Ct-232 [**2183-8-9**] 04:24AM BLOOD WBC-12.2* RBC-3.55* Hgb-11.5* Hct-34.6* MCV-97 MCH-32.4* MCHC-33.3 RDW-17.0* Plt Ct-275 [**2183-8-14**] 04:48AM BLOOD WBC-8.9 RBC-3.49* Hgb-11.2* Hct-33.1* MCV-95 MCH-32.0 MCHC-33.7 RDW-16.7* Plt Ct-315 [**2183-8-20**] 04:56AM BLOOD WBC-7.6 RBC-3.71* Hgb-11.6* Hct-35.0* MCV-94 MCH-31.1 MCHC-33.0 RDW-15.7* Plt Ct-212 [**2183-8-30**] 02:08AM BLOOD WBC-7.8 RBC-3.12* Hgb-10.2* Hct-30.9* MCV-99* MCH-32.5* MCHC-32.9 RDW-16.0* Plt Ct-26* [**2183-7-27**] 06:30AM BLOOD Neuts-84.8* Lymphs-9.7* Monos-3.6 Eos-1.5 Baso-0.3 [**2183-7-31**] 08:14AM BLOOD Neuts-84.8* Lymphs-10.0* Monos-4.3 Eos-0.6 Baso-0.4 [**2183-8-14**] 04:48AM BLOOD Neuts-87.5* Bands-0 Lymphs-8.2* Monos-2.9 Eos-1.1 Baso-0.3 [**2183-7-29**] 05:47PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2183-7-27**] 06:30AM BLOOD PT-17.6* PTT-31.5 INR(PT)-2.1 [**2183-7-30**] 03:36AM BLOOD Plt Smr-NORMAL Plt Ct-165 [**2183-8-4**] 04:00PM BLOOD PT-28.4* PTT-40.9* INR(PT)-5.3 [**2183-8-8**] 04:27AM BLOOD Plt Ct-289 [**2183-8-15**] 05:37AM BLOOD PT-21.1* PTT-34.0 INR(PT)-2.8 [**2183-8-25**] 04:54AM BLOOD PT-18.8* PTT-32.9 INR(PT)-2.2 [**2183-8-30**] 02:08AM BLOOD Plt Ct-26* [**2183-7-27**] 06:30AM BLOOD Glucose-130* UreaN-40* Creat-2.1* Na-140 K-4.9 Cl-97 HCO3-28 AnGap-20 [**2183-8-5**] 01:32PM BLOOD Glucose-129* UreaN-84* Creat-2.0* Na-146* K-4.5 Cl-114* HCO3-22 AnGap-15 [**2183-8-15**] 05:37AM BLOOD Glucose-150* UreaN-56* Creat-1.5* Na-145 K-4.2 Cl-101 HCO3-36* AnGap-12 [**2183-8-28**] 03:50AM BLOOD Glucose-162* UreaN-108* Creat-2.6* Na-129* K-5.0 Cl-93* HCO3-24 AnGap-17 [**2183-8-30**] 02:08AM BLOOD Glucose-158* UreaN-116* Creat-2.8* Na-133 K-4.9 Cl-98 HCO3-19* AnGap-21* [**2183-7-29**] 08:20AM BLOOD CK(CPK)-22* [**2183-8-5**] 01:32PM BLOOD CK(CPK)-32* [**2183-8-6**] 02:48PM BLOOD CK(CPK)-113 [**2183-8-21**] 01:59PM BLOOD CK(CPK)-22* [**2183-7-29**] 08:20AM BLOOD CK-MB-1 cTropnT-<0.01 [**2183-8-5**] 06:46AM BLOOD CK-MB-1 cTropnT-1.96* [**2183-8-11**] 08:13PM BLOOD CK-MB-1 cTropnT-0.27* [**2183-8-18**] 04:05AM BLOOD CK-MB-1 cTropnT-0.06* [**2183-8-21**] 01:59PM BLOOD CK-MB-1 cTropnT-0.04* [**2183-7-27**] 06:30AM BLOOD Albumin-4.2 Calcium-10.0 Phos-3.9 Mg-2.1 [**2183-7-30**] 08:58AM BLOOD Albumin-3.5 Calcium-8.3* Phos-3.9 Mg-2.0 [**2183-8-5**] 06:46AM BLOOD Calcium-7.9* Phos-5.8*# Mg-2.8* [**2183-8-5**] 01:32PM BLOOD Calcium-7.3* Phos-4.7* Mg-2.7* [**2183-8-11**] 04:04AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.4 [**2183-8-16**] 04:33AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.3 [**2183-8-27**] 03:20PM BLOOD Mg-2.9* [**2183-8-28**] 03:50AM BLOOD Calcium-8.1* Phos-6.6*# Mg-2.7* [**2183-8-29**] 01:36AM BLOOD Calcium-7.9* Phos-4.7*# Mg-2.6 [**2183-8-30**] 02:08AM BLOOD Calcium-7.8* Phos-6.9*# Mg-2.7* [**2183-8-30**] 02:08AM BLOOD Triglyc-53 [**2183-8-12**] 04:12AM BLOOD Vanco-9.6* [**2183-7-27**] 06:30AM BLOOD Digoxin-0.8* [**2183-7-29**] 05:36AM BLOOD Type-ART pO2-55* pCO2-38 pH-7.42 calHCO3-25 Base XS-0 Intubat-NOT INTUBA [**2183-7-30**] 08:13PM BLOOD Type-ART pO2-154* pCO2-24* pH-7.47* calHCO3-18* Base XS--3 [**2183-8-9**] 07:03PM BLOOD Type-ART pO2-73* pCO2-37 pH-7.41 calHCO3-24 Base XS-0 Intubat-INTUBATED Vent-SPONTANEOU [**2183-8-11**] 03:57PM BLOOD Type-ART pO2-92 pCO2-40 pH-7.45 calHCO3-29 Base XS-3 [**2183-7-27**] 07:13AM BLOOD Lactate-3.0* [**2183-7-30**] 12:28AM BLOOD Glucose-148* Lactate-1.6 Na-132* K-4.3 Cl-103 [**2183-8-28**] 03:50AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Brief Hospital Course: Pt was admitted to GeriMed for for recurrent aspiration PNA. 1) Aspiration PNA. At the beginning his hospital course, the patient's respitory status declined and he was intubated and cared for in the ICU. He was initially treated with Levo/Flagyl. He was transitioned to Vanco and then Linezolid for MRSA positive sputum. He failed speech and swallow eval and was made NPO. After much discussion with the patient and his family, regarding the institution of comfort care only, the patient decided that he did not want a J-tube or to take any food by mouth. He was started on TPN towards the end of his course. Mr [**Known lastname 17136**] respitory status waxed and waned after he left the ICU. It was believed that chronic micro and macro aspiration causing respiratory failure, along with worsening hypotension, ultimately caused his death. 2) Thrombocytopenia. The pt developed low plts toward the end of his course. The etiolgoy was unclear but was deemed likely secondary to Linezolid which was D/Ced on [**2183-8-27**], after a near complete course. Of note his HIT-AB was negative. He never had any overt signs of bleeding, but his BUN steadily rose, which may have represented a subclinical UGIB. His plts were down to around 20 at the time of his death. 3) CAD: The patient suffered from int SSCP. His cardiac enzymes were elevated during the middle of his course. He was managed medically. 4) CHF (EF40%). The patient was repeatly hypervolemic on exam. He responded several times to diuresis. Diruresis, however, became increasingly problem[**Name (NI) 115**] in light of low blood pressures and increasing BUN. 5) Afib: The pt was normally on Coumadin. It was initially held for J-tube placement, which was later refused. However Coumadin was not restarted given his INR >2, which was likely secondary to nutr deficiency of Vitamin K. He was successfully rate controlled with standing Metoprolol IV and Diltiazem IV PRN. 6) Hypothyroidism: Continued on Levothyroxine Sodium 50 mcg PO QD. 7) Code: The patient was DNR/DNI, with the wishes of no pressors and only supplemental O2 and suctioning. This was discussed at length with the patient by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 17137**] [**Name8 (MD) **], MD, who represented the medicine team prior to the discharge medicine team. Medications on Admission: 1. Coumadin 2.5 mg p.o. q. p.m. 2. Aspirin 325 mg p.o. q. day. 3. Nitroglycerin spray p.r.n. 4. Altace 5 mg p.o. q. day. 5. Norvasc 5 mg p.o. q. day. 6. Lasix 80 mg p.o. q. day. 7. Imdur 60 mg p.o. q. day. 8. Lipitor 20 mg p.o. q. p.m. 9. Atenolol 50 mg p.o. twice a day. 10. Lanoxin 0.0625 mg p.o. q. day. 11. Folic acid 1 mg p.o. q. day. 12. Allopurinol 150 mg p.o. q. a.m. 13. Synthroid 0.05 mg p.o. q. day. 14. Indomethacin p.r.n. gout. 15. Zantac 150 mg p.o. q. day. 16. Lorazepam 0.5 mg p.o. q. day p.r.n. 17. Clindamycin before dental evaluation. 18. Trazadone 50mg qHS Discharge Medications: None Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Dx: Death, Respiratory Failure, Hypotension, Aspiration Pneumonia. Secondary Dx: Atrial Fibrillation, Congestive Heart Failure. Discharge Condition: Death. Discharge Instructions: None. Followup Instructions: None.

[ "276.0", "428.0", "585", "286.9", "584.9", "518.84", "287.5", "427.31", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "00.14", "96.07", "99.15", "96.6", "96.04", "99.04", "38.93", "99.07" ]

icd9pcs

[ [ [] ] ]

10365, 10423

7320, 9708

265, 271

10602, 10610

2736, 7297

10664, 10672

2220, 2253

10336, 10342

10444, 10581

9734, 10313

10634, 10641

2268, 2717

208, 227

299, 929

951, 1902

1918, 2204

74,851

104,465

42715

Discharge summary

report

Admission Date: [**2124-3-24**] Discharge Date: [**2124-3-31**] Date of Birth: [**2090-9-22**] Sex: F Service: MEDICINE Allergies: Cisatracurium / penicillin G / morphine Attending:[**First Name3 (LF) 30**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation, mechanical ventilation History of Present Illness: 33F w/muscular dystrophy, OSA on CPAP, Cushings s/p pituitary resection, DMII, hypothyroid p/w SOB. . Presented from home. Was in USOH until last night when she developed a sore throat and then URI symptoms with cough. This progressed to include nausea, vomitting and diarrhea. Per her husband, she took one dose of narcotic cough syrup (likely vicodin containing). . Presented to [**Doctor Last Name 1495**] Medical Center where came in with lethargy, SOB, AF with RVR. Appeared pale, cool, dusky, RR 12, sat 68% RA.Given Dilt f/b Dilt gtt, and autoconverted back to sinus rhythm. CPAP initiated. CT chest with contrast reportedly unremarkable, not sent over. Trop (X) 0.196 at OSH. ABG 7.21 / 77 /110 on NRB. +opiates on tox screen. Did have transient improvement of mental status and vomited with 2 mg Narcan at OSH. . Pt denied any complaints (including fevers, CP, SOB, palps, abd pain, N/V, HA), [**Last Name (un) **] arousable to voice, but quickly falls back asleep. Endorsed taking cough syrup last few days, unsure if contains codeine, o/w denied any drug use. EMS gave supplemental O2 but not PPV. In our ED: arousable to voice then falls back to sleep, pupils 4 mm, moving all extremities. Vomiting lethrgic on arrival afib co2 retention to 75- on CPAP- ? response to narcan? maybe [**Hospital1 **] gen? - Initial vitals: 97.4 90 129/77 30 96% 15L - EKG: SR@90 NA NI - diltiazem gtt d/c'd - Trop-T 0630 - 0.08 - BiPAP initiated - ABG a few min after started BiPap: resp acidosis, improved from prior at OSH (pH 7.28 pCO2 63 pO2 229 HCO3 31 BaseXS 1) - repeat ABG 0810 - 7.27 pCO2 64 pO2 88 HCO3 31 BaseXS 0 - cxr: Poor film, AP, large heart, crowded, looks fluid overload - head ct - - Additional Narcan 0.4 mg --> improved mental status - ED thinking - possible unifying diagnosis would be opiate overdose leading to respiratory depression leading to hypoxia leading to NSTEMI and AFib - 99, HR 80-90, BP 100/60, Sat 99% on 50%, [**11-10**] Past Medical History: Myotonic dystrophy type 1 - per husband no Cardiac structural abnormalities, high normal QRS and mild bradycardia. [**Month/Day (1) **] wants her to take mexiletine and modafinil. Cushings s/p pituitary resection OSA uses CPAP, tonsillectomy that did not change CPAP settings [**12-15**] - admitted for pneumonia and discharged on O2 (Multilobar PNA) [**2122-8-6**] - admitted for LUL pneumonia to Saints and discharged on O2. Continued shortness of breath attributed to hibiscus plant with fungal spores Gout Hypothyroidism last talked to PCP in [**Name9 (PRE) 216**] about hair loss Social History: She is [**Name8 (MD) **] RN with VNA of [**Location (un) 3307**]. Husband works in respiratory at [**Hospital1 18**]. - Tobacco: none - Alcohol: none - Illicits: none Family History: non-contributory Physical Exam: Admission Physical: Initial 97.4 90 129/77 30 96% 15L Vitals at 1000: 108/72, HR 80, 99% on 50% BIPAP General: Lethargic but arousable to voice, no acute distress HEENT: NCAT, Sclera anicteric, BIPAP Neck: supple, JVP not elevated, no LAD Lungs: Air movement to bases with crackles on left side to midlevel 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, 2+ pulses, no clubbing, cyanosis, 2+ edema to knees Discharge Physical: Pertinent Results: ADmission labs: Discharge labs: Micro: MRSA SCREEN (Final [**2124-3-26**]): No MRSA isolated. SPutum: GRAM STAIN (Final [**2124-3-24**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2124-3-26**]): RARE GROWTH Commensal Respiratory Flora. [**2124-3-24**] 8:24 pm Influenza A/B by DFA Source: Nasopharyngeal swab. **FINAL REPORT [**2124-3-27**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2124-3-25**]): 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 (NamePattern4) 92318**] [**2124-3-25**] 1125AM. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2124-3-25**]): 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. Respiratory Viral Culture (Final [**2124-3-27**]): 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. [**2124-3-24**] 9:35 pm BLOOD CULTURE Source: Line-central. Blood Culture, Routine (Pending): [**2124-3-25**] 5:54 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2124-3-27**]** GRAM STAIN (Final [**2124-3-25**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2124-3-27**]): NO GROWTH. Images: TTE [**2124-3-24**]: Conclusions 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. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is a borderline mild resting left ventricular outflow tract systolic gradient. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Tricuspid regurgitation is present but cannot be quantified. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. CT head w/o [**3-24**]: IMPRESSION: 1. Global loss of [**Doctor Last Name 352**]-white matter differentiation may be secondary to hypoxic injury. For further evaluation, could consider an MRI if not contraindicated. 2. No evidence of hemorrhage. CTA [**3-24**]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Scattered ground-glass and more consolidative opacities throughout the lungs, with a bilateral lower lobe predominance, thought to be infectious in etiology. Prominence of bilateral hilar lymph nodes is likely reactive. 3. Moderate bilateral lower lobe atelectasis. 4. Diffuse hepatic fat deposition. CXR [**2124-3-27**]: IMPRESSION: 1. The right subclavian PICC line now has its tip in the mid SVC in satisfactory position. The right internal jugular central line continues to have its tip in the right atrium. A nasogastric tube is seen coursing below the diaphragm with the tip not identified. Endotracheal tube continues to have its tip approximately 4 cm above the carina. 2. Relatively low lung volumes with crowding of the vasculature and likely residual perihilar edema. Left basilar airspace process appears slightly worsened and may reflect worsening lower lobe atelectasis. Pneumonia should also be considered. No large right effusion. No large pneumothorax on the supine film. Brief Hospital Course: Mrs. [**Known lastname 8529**] is a 33 F with Myotonic dystrophy type 1, remote history of multilobar pneumonia, and new rapid respiratory failure in the setting of URI symptoms and recent history of presents with lethargy and sob. She was admitted to the MICU and intubated for respiratory failure. # Hypercapneic Respiratory Failure: The patient was intubated in the ED, and transferred to the ICU. Etiology was thought to be due to her underlying neuromuscular disorder in combination with pneumonia and/or possible viral bronchitis and use of opioid-based cough suppressants. Her CXR showed opacities concerning for pneumonia, and she was treated with Ceftriaxone and Levofloxacin for a total of a 7 day course. Her respiratory viral screen was negative. CTA done on [**3-25**] and was negative for PE's, but did show ground glass opacities concerning for infection versus atelectasis. Her ventilation was weaned, and she was extubated on HD #4. The extubation was complicated by laryngeal edema treated with a steroid [**Doctor Last Name 2949**] and was nearly resolved by discharge. She was transferred to the medical floors on HD#5 and continued to improve and was discharge on HD# 7 after her last dose of antibiotics. She was instructed to follow up with her neuro muscular specialist and to avoid opioid-based cough suppressants. # Somnolence: Thought in part due to narcotics and hypercapnea in setting of respiratory failure. Thought that narcotics may have contributed to respiratory depression, leading to hypercarbia and worsening somnolence. The patient's mental status improved on HD#2 and she was following commands. Pt's mental status back to baseline by extubation. # R thigh pain: patient endorses burning R thigh pain, which has been unchanged for 2 weeks prior to presentation. Patient was told to follow up with her PCP for further evaluation and management. # Hypothyroid: continued on Levothyroxine. # Elevated liver enzymes: Nonspecific pattern potentially related to MD, likely NAFLD/NASH, given CT findings. Would recommend follow-up for further evaluation as an outpatient. # Elevated Troponin: Elevated on admission to 0.08, potentially related to initial afib, and down trended with flat CK-MB. # Afib: Single episode on arrival to ED, likely triggered by hypoxia, resolved in the ICU. Not started on anti-coagulation and the patient remained in sinus rhythm from HD#1 until discharge. # diarrhea- The patient developed watery non-bloody on HD#5, which was C.diff negative thought to be secondary to antibiotic use. She was able to maintain adequate hydration to replace the diarrheal losses. Medications on Admission: Levoxyl 127 HISTORICAL MEDS Allopurinol 100 Lasix 20 prn Albuterol Advair 250 Cal-D, vitamin, new cough syrup Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [**2-7**] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 2. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 3. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO once a day. 4. Home Oxygen Supplement Oxygen (1-3L) via nasal canula to titrate oxygen saturation to greater than 95% during the day time. Please exclusively use Bi-PAP with supplement Oxygen at night. Discharge Disposition: Home Discharge Diagnosis: hypercarbic respiratory failure pneumonia muscular dystrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 8529**], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for respiratory distress and required intubation. We believe you had respiratory distress due to both an underlying neuromuscular disorder and from pneumonia. You have been treated with antibiotics and have complete treatment for the pneumonia. You continue to require supplemental oxygen, which you should continue after you are discharge until no longer needed. Please continue to use the Bi-PAP as prescribed. Please also follow up with your primary care doctor and your [**Hospital1 850**]. While in the hospital, you developed diarrhea, we tested the stool for c. difficile which was negative. The diarrhea is likely related to recent antibiotic use and is unlikely to be infectious. Medication Changes: Please take albuterol [**2-7**] puff every 4-6 hours as needed for shortness of breath or wheezing Please continue to take levothyroxine as prescribed Please take imodium up to 4 times daily as needed for diarrhea Followup Instructions: Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 850**] within 2 weeks of discharge

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11837, 11843

8479, 11120

318, 354

11947, 11947

3832, 3832

13163, 13296

3173, 3191

11280, 11814

11864, 11926

11146, 11257

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12925, 13140

259, 280

382, 2361

3849, 3849

11962, 12073

2383, 2970

2986, 3157

3,874

198,184

52818

Discharge summary

report

Admission Date: [**2163-6-24**] Discharge Date: [**2163-7-13**] Date of Birth: [**2118-9-7**] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim Attending:[**First Name3 (LF) 165**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: redo sternotomy, Aortic valve replacement (St. [**Male First Name (un) 923**] 21 mm mechanical) [**2163-7-6**] Cardiac catherization [**2163-6-30**] History of Present Illness: 44 year old male on [**2163-1-21**] he was hospitalized at [**Hospital1 18**] following an episode of chest pain/pressure while walking to his car. He was completely rulled out for an MI and followed up with cardiology as an outpatient (cardiology believes reflux related). After discharge he was worked up: CTA showed no aortic pathology, EGD normal mucosa, coronary cath showed patent stent with to evidence of CAD, and PFTs showed obstructive defect. Additionally, he underwent an alcohol rehabilitation program at [**Hospital1 778**]. Since [**12-31**] hospitalization, he has had increasing shortness of breath on exertion. He used to only notice it while walking, now he get short of breath while giving presentations sitting down. When he gets short of breath it feels like a pressure on his chest and pain in the epigastric region. When he rests the symptoms resolve. He denies LE edema, has orthopnea (two pillows to sleep), notes abdominal distention/bloating over the previous 6 mo, denies any weight gain/loss, restless sleep, decreased appetite. He has never been jaundiced and received the HepB vaccination. Except for HIV, he has never had any other STI. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Over the past 3-4 weeks he has developed a productive cough with yellow sputum. He also notes he can hear expiratory wheezes at night. He denies sick contacts, fevers, or night sweats. Over the past few days, he has been feeling nausea after eating. He notes multiple episodes of dry heaves where he just spit up clear liquid. He vomited twice and denies any frank blood, coffee grounds or different colored material. Past Medical History: HIV - CD4:532 [**2163-4-6**]. On HAART Bicuspid aortic valve repair and ascending aortic graft - [**2155**] CAD s/p DES in LAD [**1-27**] HTN - treated. Normal pressure 125/80 Hyperlipidemia - treated on atorvastatin GERD - [**1-24**] hiatal hernia (surgery not needed as per Dr. [**Last Name (STitle) **] Depression/anxiety Alcohol abuse - drinks 1 large bottle of wine/day. rehab program at [**Hospital1 778**] early [**2162**]. Wants to quit. Never caused problems at work or with law enforcement Social History: works as lawyer married EtOH - peak 2 large bottles wine/night, currently [**2-23**] glasses wine/day Tobacco - never Illicits - nasal cocaine (never IV), no use +20 years Family History: Heart Attacks - maternal grandparents, maternal aunts x2, mother, brothers x2 (non-fatal MI [**02**] and 50yo). Psychiatric illness - father [**Name (NI) **] cancer - paternal grandfather dx50s MS - mother Physical Exam: Vitals: T:96.1 BP:95/69 P:101 R:32 O2:93ra General: Alert, oriented, no acute distress, sitting up in bed HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, EOMI Neck: supple, JVP not appreciated, no LAD Lungs: thorax expands symetrically, ressonant to percussion, bilateral crackles [**1-25**] lung fields, forced expiratory wheezes, CV: Regular rate and rhythm, normal S1 + S2, ?systolic murmur at base, no rubs or gallops Abdomen: +BS; soft, distended, tender to deep palpation, no rebound tenderness or guarding, no organomegaly. RUQ produces sharp pain in the epigastric region Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no lesions or rashes, no palmar erythema or telangectasias Neuro: a/ox3, CNs [**2-3**] intact, strength and sensation intact throughout, downgoing Babinski, no asterixis Pertinent Results: Admission Labs [**2163-6-24**] 03:30PM BLOOD WBC-6.8# RBC-3.96* Hgb-13.5* Hct-39.9* MCV-101*# MCH-33.9* MCHC-33.7 RDW-15.9* Plt Ct-213 [**2163-6-24**] 03:30PM BLOOD Neuts-68.4 Lymphs-23.2 Monos-6.5 Eos-1.2 Baso-0.7 [**2163-6-24**] 03:30PM BLOOD Glucose-136* UreaN-20 Creat-1.2 Na-132* K-4.6 Cl-96 HCO3-21* AnGap-20 [**2163-6-24**] 03:30PM BLOOD ALT-307* AST-601* CK(CPK)-181* AlkPhos-121* TotBili-1.3 [**2163-6-24**] 03:30PM BLOOD CK-MB-7 proBNP-[**Numeric Identifier **]* [**2163-6-25**] 06:10AM BLOOD Calcium-8.4 Phos-5.0* Mg-2.0 [**2163-6-26**] 05:15AM BLOOD Triglyc-74 HDL-40 CHOL/HD-2.0 LDLcalc-26 [**2163-6-24**] 03:30PM BLOOD VitB12-780 Folate-10.8 [**2163-6-25**] 06:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [**2163-6-25**] 12:40PM BLOOD HAV Ab-POSITIVE IgM HAV-NEGATIVE [**2163-6-26**] 05:15AM BLOOD HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2163-6-24**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2163-6-24**] 06:49PM BLOOD Lactate-2.8* [**2163-6-25**] 09:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2163-6-26**] 12:15PM PLEURAL WBC-145* RBC-1600* Polys-4* Lymphs-53* Monos-0 Meso-33* Macro-4* Other-6* [**2163-6-26**] 12:15PM PLEURAL TotProt-1.3 Glucose-137 LD(LDH)-104 Albumin-LESS THAN . Echocardiography [**2163-6-27**]: The left atrium is moderately dilated. The interatrial septum is aneurysmal. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild to moderate global left ventricular hypokinesis (LVEF = 35 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. A bioprosthetic aortic valve prosthesis is present with thickened leaflets and markedly increased gradient (peak 100mmHg) c/w severe aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2161-8-7**], the gradient across the aortic valve is markedly increased and c/w severe aortic valve stenosis. Aortic regurgitation and global left ventricular systolid dysfunction are now seen as well as moderate mitral regurgitation and moderate pulmonary artery systolic hypertension. . Coronary catheterization [**2163-6-30**]: 1. Coronary angiography of this right dominant system revealed no angiographically signicant CAD. 2. Severe prosthetic valve aortic stenosis with markedly elevated filling pressures and very low cardiac output. . Brief Hospital Course: Presented with six months of progressive dyspnea on exertion and 2-pillow orthopnea. He was given ASA 325mg, ceftriazone (to cover SBP), zofran and ativan in the ED. On the floor, he was given Azithromycin (to cover CAP), lasix 10mg (to diurese pulmonary edema and ascites), albuteral nebs (for wheezes) and multivitamin. He responded well to diuretics. On day 2 of hospitalization, a diagnostic thoracentesis was performed to clarify the cause of the pleural effusions. During the procedure, he became diaphoretic and syncopized. He then appeared to seize and was incontinent of urine and stool. A code blue was called but the patient was never asystole. Once he was stable he was transfered to the ICU where he seized again. Of note, the pleural chemistry was consistent with a transudate, as per Light's Criteria. As part of his work-up in the MICU, the patient got an echocardiogram. The echo showed that the patient's bioprosthetic aortic valve prosthesis was present with thickened leaflets and markedly increased gradient consistent with severe aortic valve stenosis. Cardiology and cardiac surgery were consulted so that a plan could be developed to replace the patient's sclerosed aortic valve. After his second day in the MICU, the patient was transferred to a step down unit where it was decided that he should undergo cardiac catheterization to rule out ischemia and better assess his aortic valve. Cath showed clean coronaries, critical aortic stenosis (valve area 0.3cm) and a cardiac output of 1.3. The patient was then transferred to the CCU for close monitoring of his hemodynamics. In the CCU he was diuresed with a heparin drip and diuril 500mg IV to a total -3.5L. This provided symptomatic improvement in his respiratory status and abdominal distention, and his LFTs continued to trend down. He was cleared by hepatology and ID for surgery and carotid ultrasounds were negative. lasix gtt was stopped on [**7-2**] [**1-24**] hypotension (SBP 80s), sinus tachycardia (Hr90s) and Creatinine bump to 1.4. Creatinine went back down to 1.2 that same day but lasix gtt continued to be held. He was otherwise stable while awaiting surgery. In addition, he had a rapidly increasing transaminitis. On admission his statin was held due to concerns of liver toxicity. A RUQ US showed heterogeneous architecture suggestive of fatty liver and small ascites. The 2nd day of admission his HIV medications and Buspar dose was reduced from 15mg to 10mg for toxicity concerns. Hepatitis serologies were not suggestive of an acute infection. Urine and serum tox screens were negative. Upon transfer to the ICU, more of the patient's medications were weaned, including buspirone and paroxetine. However, after the patient's echocardiogram revealed the significant sclerosis that had occured on his prosthetic aortic valve, it was believed that his transaminitis was most likely secondary to shock liver. After he was transferred out of the unit his LFTs slowly trended down with diuresis and improving hemodynamics. Pattern of injury most consistent with alcoholism and congestion. Also hyponatremia, likely in the setting of diuresis. Also possibly med effect (SSRIs). Could also be secondary to liver disease. Hyponatremia persisted throughout stay but improved slightly, Na 132 by [**2163-7-3**] prior to OR. ------------------- Cardiac Surgery: He was taken to cardiac surgery on for a re-do sternotomy for placement of mechanical AVR on [**2163-7-6**]. Refer to operative notes for details. He received vancomycin perioperative as he was in the hospital preoperatively. Post operatively, he was admitted to the cardiovascular ICU for intensive post-operative care. He was weaned and extubated without difficulty. His chest tubes and temporary pacing wires were removed per protocol. He was started on coumadin with IV heparin bridge. He was discharged to home on postoperative day seven when his INR was therapeutic. Target INR is 2.5-3.0 for mechanical aortic valve. Coumadin /INR will be followed by Dr. [**Last Name (STitle) 2392**]. First blood draw is [**2163-7-14**] with results called to Dr. [**Last Name (STitle) 2392**]. Medications on Admission: Abacavir-Lamivudine [Epzicom] 600 mg-300 mg Tablet daily Atorvastatin [Lipitor] 80 mg daily Buspirone 15 mg [**Hospital1 **] Efavirenz [Sustiva] 600 mg daily Ezetimibe [Zetia] 10 mg daily Lisinopril 20 mg daily Lorazepam 1 mg Tablet daily Omeprazole 20 mg tablets, 3 tablets daily Paroxetine HCl 40 mg [**Hospital1 **] Tenofovir Disoproxil Fumarate [Viread] 300 mg daily Zolpidem [Ambien] 10 mg daily PRN Aspirin 325 mg daily 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 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Buspirone 15 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 6. Sustiva 600 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO once a day: 40 mg in am and 20 mg in pm . Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 9. Paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 10. Viread 300 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. Warfarin 5 mg Tablet Sig: inr 2.5-3.0 Tablets PO once a day: dosing adjusted based on INR . Disp:*60 Tablet(s)* Refills:*0* 12. Warfarin 2 mg Tablet Sig: INR 2.5-3.0 Tablets PO once a day: dose adjusted based on INR . Disp:*60 Tablet(s)* Refills:*0* 13. Outpatient [**Name (NI) **] Work PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical Aortic valve first draw [**7-14**] with results to Dr [**Last Name (STitle) 2392**] [**Telephone/Fax (1) 5723**] for further dosing 14. coumadin You are receiving two different doses of coumadin 2mg and 5 mg tablets so that your dose can be adjusted - you are to have [**Telephone/Fax (1) **] drawn thrusday [**7-14**] and then dosing to be decided by Dr [**Last Name (STitle) 2392**] 15. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: continue until follow up with cardiologist in 2 weeks . Disp:*30 Tablet(s)* Refills:*0* 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: continue until follow up with cardiologist in 2 weeks . Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 18. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 19. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic Stenosis s/p AVR Acute on chronic systolic heart faiure Hyponatremia preoperatively Acute renal failure preoperatively Hepatitis Alcohol abuse Hypertension Hyperlipidemia Gastroesophageal reflux disease Coronary artery disease s/p stent [**2158**] s/p ascending aorta andaortic valve replacement [**2155**] Depression Anxiety Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 100.5 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, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 2392**] in 1 week ([**Telephone/Fax (1) 5723**]) Dr. [**Last Name (STitle) **] in [**1-25**] weeks *** PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical Aortic valve first draw [**7-14**] with results to Dr [**Last Name (STitle) 2392**] [**Telephone/Fax (1) 5723**] for further dosing Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2163-7-13**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "34.91", "37.23", "88.56", "39.61", "35.22" ]

icd9pcs

[ [ [] ] ]

14227, 14285

6985, 11152

292, 443

14662, 14669

3972, 6962

15210, 15839

2898, 3105

11628, 14204

14306, 14641

11178, 11605

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3120, 3953

233, 254

471, 2164

2186, 2693

2709, 2882

30,394

134,610

11981

Discharge summary

report

Admission Date: [**2173-10-20**] Discharge Date: [**2173-10-27**] Date of Birth: [**2092-5-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 922**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: [**2173-10-21**] Aortic Valve Replacement utlizing a 25mm [**Company 1543**] Mosaic Porcine Heart Valve History of Present Illness: Mr. [**Known lastname 37686**] is an 81 year old gentleman who presented to outside hospital with syncopal episode. He has a known history of aortic stenosis and has had one similar episode of syncope in the past. His cardiologist is Dr. [**Last Name (STitle) **]. A recent cardiac catheterization showed no significant coronary artery disease. He denied a history of chest pain, shortness of breath, and dyspnea on exertion. Patient also PMH notable for anemia and Waldenstroms Macroglobulinemia for which he has required blood transfusions in the past. Mr. [**Known lastname 37686**] was stabilized on medical therapy and transferred to the [**Hospital1 18**] for cardiac surgical intervention. Past Medical History: Aortic Stenosis Waldenstroms Macroglobulinemia Anemia Nephrolithiasis Glaucoma GERD Social History: Remote tobacco use, admits to 30 pack year history. Admits to social ETOH. He is married with three children. He is a retired project manager. Family History: Denies premature coronary artery disease. Physical Exam: Vitals: 98.8, 118/50, 95, 20, 95%RA General: WDWN elderly male in no acute distress HEENT: Oropharynx benign, EOMI Neck: Supple, no JVD Lungs: CTA bilaterally Heart: Regular rate and rhythm, harsh systolic murmur radiating to neck Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2173-10-20**] 09:04PM BLOOD WBC-3.8* RBC-3.11* Hgb-9.2* Hct-27.7* MCV-89 MCH-29.5 MCHC-33.1 RDW-17.6* Plt Ct-204 [**2173-10-20**] 09:04PM BLOOD PT-11.9 PTT-39.7* INR(PT)-1.0 [**2173-10-20**] 09:04PM BLOOD Glucose-115* UreaN-18 Creat-1.2 Na-135 K-4.2 Cl-100 HCO3-25 AnGap-14 [**2173-10-20**] 09:04PM BLOOD ALT-9 AST-23 LD(LDH)-180 AlkPhos-124* TotBili-0.4 [**2173-10-20**] 09:04PM BLOOD Albumin-2.7* Calcium-9.8 Phos-9.7* Mg-2.4 [**2173-10-20**] 09:04PM BLOOD %HbA1c-5.9 Brief Hospital Course: Mr. [**Known lastname 37686**] was admitted to cardiac surgery and underwent routine preoperative evaluation. Workup was unremarkable and he was cleared for surgery. On [**10-21**], Dr. [**Last Name (STitle) 914**] performed an aortic valve replacement. Operative course was notable for possible cold agglutination during hypothermia. For additional surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Given possible cold agglutination and hyperviscosity syndrome associated with Waldenstroms, hematology was consulted for further evaluation. SPEP and viscosity assays were obtained. He displayed no clinical signs on neurologic complications. He otherwise remained stable from a cardiac standpoint and transferred to the SDU on postoperative day one. Due to intermittent episodes of paroxysmal atrial fibrillation, Amiodarone was initiated and beta blockade was advanced as tolerated. He was also started on coumadin with a lovenox bridge. SPEP and serum viscosity continued to be followed closely along with his hematocrit. He will follow up with his outpatient oncologist within one week. He was ready for discharge to rehab on POD #6. Medications on Admission: Ranitidine, Alphagan eye gtts, Potassium Citrate Discharge Medications: 1. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day): until INR >=2.0. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Tablet(s) 7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400 [**Hospital1 **] x 4 days, then 400 daily x 1 week, then 200 daily ongoing until dc'd by cardiologist. 12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: Aortic Stenosis - s/p AVR Waldenstroms Macroglobulinemia Nephrolithiasis Glaucoma GERD Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) 914**] in [**4-29**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**2-27**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**2-27**] weeks, call for appt Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (hematologist) [**Telephone/Fax (1) 37687**] within one week Completed by:[**2173-10-27**]

[ "273.3", "365.9", "530.81", "E878.8", "200.80", "424.1", "991.6", "427.31" ]

icd9cm

[ [ [] ] ]

[ "35.21", "99.05", "39.61", "99.04" ]

icd9pcs

[ [ [] ] ]

5136, 5239

2421, 3734

328, 434

5370, 5377

1924, 2398

5713, 6074

1444, 1487

3833, 5113

5260, 5349

3760, 3810

5401, 5690

1502, 1905

281, 290

462, 1160

1182, 1268

1284, 1428

5,060

196,749

24305

Discharge summary

report

Admission Date: [**2182-1-4**] Discharge Date: [**2182-1-14**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: Monitoring and treatment of EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: This is a 37 year-old male with a history of alcoholism with many admissions for intoxication, Hep B+C, polysubstance abuse, and depression, who presents with intoxication. Pt reports that he drank 1 liter of listerine today as well as a fifth of vodka and then blackout. He was brought to the ED intoxicated but has no recollection of how he got to the hospital. He complains of pain at his left knee, but does not recall injuring it, and also complains of chronic abdominal tenderness (but only when someone presses on it). Denies nausea or vomiting. . In the ED, initial vitals were T 98.7, BP 123/87, HR 110, RR 16, 99% on RA. His BAL was 456. Serum tox was also positive for benzos. Urine tox was negative. The plan was initially to observe the patient overnight in the ED until he became sober. However, around 7:30pm, the attending found the patient tremulous, with HR in the 120-130s and complaining of withdrawal symptoms. He was also having visual hallucinations of mice running over his legs. Exam was only notable for some blood on his pants over his left knee and a bump on his L forehead. Neuro exam was non-focal. He remainted tachycardic with HR as high as 140s. He received a total of 15mg PO valium, 15mg IV valium, and 1mg IV ativan. Banana bag was started but PIV was not functioning well. Admitted to the ICU for further monitoring. . On arrival to the [**Hospital Unit Name 153**], the patient is very anxious. He is no longer experiencing visual hallucinations but reports that he is delirious and does not know what is going on. He is adamant that he is going to stop drinking this time and wants to go to a detox facility-- apparently his best friend died one week ago from drinking listerine. . ROS: He has been having frontal headaches for the past month since being hit by an SUV one month ago. Has also had R-sided chest pain at the site of impact from this MVC for the past month. Has broken his nose several times and has difficulty breathing from that. He also notes seeing spots in the periphery of his vision recently. He complains of gait instability when sober (less so when intoxicated) and also peripheral neuropathy in his arms and legs. The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, focal weakness, rash or skin changes. Past Medical History: polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Denies IVDU recently. Denies tobacco recently. Does have a history of both. Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: Vitals: T: 98.7 BP: 138/106 HR: 132 RR: 17 O2Sat: 97% RA GEN: Disheveled male, tremulous, anxious HEENT: EOMI, PERRL, sclera anicteric, no nystagmus, no epistaxis or rhinorrhea, MMM, OP Clear, poor dentition NECK: No JVD, lymphadenopathy, trachea midline COR: tachy, regular, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, diffusely tender to palpation, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords MUSCULOSKELETAL: L knee swollen with 2 small healing lacerations and echymossis over the patella, decreased range of motion (to 90 degrees), tender to palpation over the patella and medial joint line NEURO: A+O x 2 (person, year). CN II ?????? XII grossly intact. Strength 5/5 in upper and lower extremities. Decreased sensation grossly over lower extremities. Normal finger-to-nose. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: 143 104 12 83 AGap=14 4.2 29 0.7 ALT: 60 AP: 101 Tbili: 0.3 Alb: 4.6 AST: 95 LDH: Dbili: TProt: 7.9 [**Doctor First Name **]: Lip: 134 Serum EtOH 456 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative Comments: Positive Tricyclic Results Represent Potentially Toxic Levels;Therapeutic Tricyclic Levels Will Typically Have Negative Results Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative 86 5.8 12.3 313 36.3 N:40.2 L:53.0 M:3.8 E:1.6 Bas:1.4 . FINDINGS: Lungs are clear without evidence lung nodules or consolidations. No pleural effusion. Cardiomediastinal silhouette is unremarkable. Bone structures are grossly normal. IMPRESSION: Normal examination without evidence of active or inactive tuberculosis. PPD positive with >20mm reaction Brief Hospital Course: 37 year-old male with a history of alcoholism with multiple admissions for detox and history of DTs/withdrawal seizures who presents with intoxication followed by withdrawal. He received 30 mg Valium in the emergency room and was placed on a q1h CIWA in the ICU. This was transitioned to a standing valium order per his protocol on arrival to the floor. Social work was consulted. MVI/thiamine/folate were given. He was monitored on telemetry. . His lipase and transaminases were elevated during his admission, consistent with his chronic hepatitis C, in addition to alcoholic hepatitis. He had abdominal pain which was the same as on prior admissions and was likely related to alcoholic pancreatitis or gastritis, but was resolved on discharge. This improved and he was tolerating pos. . He noted knee pain as well, and an x-ray was performed which did not show a fracture. . He was started on Klonopin for anxiety, similar to previous outpatient dosing. He had a PPD placed, which was positive at >20 mm, and a CXR was performed which was negative. Unfortunately, on the day of anticipated discharge to [**Hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (AMA, although he left without risk/benefit). Medications on Admission: none chronically on klonopin, but it is frequently stolen on the street. Discharge Medications: none, AMA Discharge Disposition: Home Discharge Diagnosis: alcohol withdrawal/dependence anxiety Discharge Condition: ambulating, no longer in withdrawal Discharge Instructions: AMA Followup Instructions: AMA

[ "070.32", "719.46", "577.1", "795.5", "305.90", "291.0", "070.54", "V60.0", "571.1", "303.01", "300.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6379, 6385

4965, 6222

314, 320

6467, 6505

4156, 4942

6557, 6564

3163, 3224

6345, 6356

6406, 6446

6248, 6322

6529, 6534

3239, 4137

231, 276

348, 2820

2842, 3043

3059, 3147

32,062

115,347

24933

Discharge summary

report

Admission Date: [**2147-5-6**] Discharge Date: [**2147-5-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1828**] Chief Complaint: low HCT Major Surgical or Invasive Procedure: EGD with epinephrine and clipping, [**2147-5-8**] History of Present Illness: Pt is a 85 yo female with a Hx significant for A-fib on aspirin 325BID, who presented to OSH with a HCT of 16 and report per son that patient had experienced increased fatigue and unsteady gait yesterday. with two episodes of near syncope since than. NP saw pt and had discovered low BP and recommended transfer to ED given her low BP and weakness. No other complains or symptoms had been endorsed. She was taken to [**Hospital1 2025**] and was transfered without prior transfusion to [**Hospital1 18**] based on family request. . ROS: pt denies categorically any complain Past Medical History: [**Name (NI) 17584**], unclear why not on anticoagulation, no history of falls Dementia Incontinence Arthritis . Social History: lives with husband at assisted [**First Name9 (NamePattern2) 62680**] [**Location (un) **], walks with walker, no tobacco or alcohol abuse Physical Exam: T 99.4 BP: 108/33 HR 77 SPO2 100% 3L General: pale appearing female in NAD, AOx1, flat affect HEENT: pale conjunctiva, dry MM, no dentition Neck: supple, no LAD Lungs: CTA bilaterally Heart: RRR, no m/r/g Abdomen: obese, soft, epigastric tenderness Extremities: cool, without clubbing or edema Pertinent Results: [**2147-5-6**] 03:45PM WBC-17.5*# RBC-1.92*# HGB-5.9*# HCT-18.5*# MCV-96 MCH-30.7 MCHC-31.9 RDW-14.7 [**2147-5-6**] 03:45PM NEUTS-82.0* LYMPHS-14.7* MONOS-2.8 EOS-0.3 BASOS-0.3 [**2147-5-6**] 08:30PM GLUCOSE-113* UREA N-73* CREAT-1.2* SODIUM-140 POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-20* ANION GAP-13 . EGD ([**2147-5-8**]) Esophagus: Lumen: A complex, sliding, medium paraesophageal hernia was seen. Stomach: Normal stomach. Duodenum: Excavated Lesions. A single cratered ulcer was found in the duodenal bulb. A clot suggested recent bleeding. 4 cc.Epinephrine 1/[**Numeric Identifier 961**] hemostasis with success. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis successfully. A single superficial ulcer was found in the distal bulb. A visible vessel suggested recent bleeding. 4 cc.Epinephrine 1/[**Numeric Identifier 961**] hemostasis with success. A hemoclip was then applied to the visible vessel. Brief Hospital Course: MICU course: 2 large-bore IVs were placed. The pt's ASA, BB, ACEi and Lasix were held. She had no further BMs or melena. She remained HD stable with SBP in 110s and HR in 70s after initial 2L NS bolus. She was transiently on a PPI drip and was transfused a total of 4U with HCT coming up to 27 from 18. Her HCT remained stable after these initial 4 units. . GI did not feel that the pt was still actively bleeding, thus no urgent scope was performed in the MICU. She was switched to PPI IV bid and started on clears which she tolerated well. The pt was transferred to the medicine floor for further management. . Floor Course: # GI bleed: The pt required a total of 7 units pRBCs to maintain her HCT over her hospital course. She had an EGD performed by GI which demonstrated a single cratered ulcer in the duodenal bulb with stigmata of recent bleeding. This was injected with epinephrine and clipped; GI indicated that a risk of rebleeding remained. The pt was treated with a Protonix gtt for >48 hours and then transitioned to PO therapy [**Hospital1 **]. The pt's HCT was stable for the remainder of her [**Hospital 62681**] hospital stay at around 27 to 28. The pt's antihypertensives were held in this setting and her blood pressure was well-controlled with only diltiazem. The pt's home aspirin was held. . # A-fib/SVT: At the time of admission, the pt was taking ASA 325 [**Hospital1 **] for her prior history of PAF; this was stopped at the time of admission. In the setting of having her beta blocker held, the pt was noted to have several episodes of AF with RVR (HR to the 140s), as well as two episodes of SVT (HR again to 140s) that was thought to likely represent AVNRT. All of these episodes were asymptomatic for her and she remained HD stable. A TSH and CXR were checked and were unremarkable. Although the pt's HR responded well to re-initiation of her beta blocker, this did not suppress her SVT, and thus her beta blocker was transitioned to PO diltiazem. At the time of discharge, she had not had any SVT for 24 hours. We would suggest possible up-titration of her diltiazem as allowed by her HR and BP, and eventual conversion to the long-acting form of the medication. . # Diastolic dysfunction: The pt appeared euvolemic throughout her stay. A chest x-ray after several days without Lasix did not demonstrate any evidence of failure. A echo in [**2145**] demonstrated preserved EF and mild AR. As above, the pt's ACEi, beta blocker and lasix were held at admission; ***these may need to be restarted in the future.*** . # CAD: The pt had a negative stress-MIBI in [**2145**]. Her ASA was held throughout her hospital stay as described above. When her HR was elevated, the pt was noted to have fairly diffuse ST depressions which resolved with better HR control, thus continued aspirin therapy, likely at 325 mg daily, would be ideal. This was deferred at the time of discharge so that the pt's HCT could be followed for another 1-2 weeks. . # Dementia: The pt remained pleasantly and mildly demented throughout her hospital course. There was no evidence of delirium. Medications on Admission: Aspirin 325 [**Hospital1 **] Lasix 20 mg daily Metoprolol 25 [**Hospital1 **] Lisinopril 2.5 Citalopram 20mg QHS Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Location (un) **] [**Hospital1 **] [**Hospital1 1501**] Discharge Diagnosis: Primary: upper GI bleeding atrial fibrillation other SVT (suspected AVNRT) . Secondary: coronary artery disease diastolic dysfunction Discharge Condition: Improved. Vital signs and HCT stable. Pt moderately deconditioned. Discharge Instructions: -You were admitted with bleeding in your GI tract that was caused by an ulcer. We have treated you with blood transfusions, applied clips to the blood vessels in your ulcer and are giving you medications to help prevent a recurrence. You are being discharged to rehab before going home to help regain your strength. -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> Aspirin was held because of bleeding. Talk with your doctor about when or if to restart this. --> Your home metoprolol was changed to diltiazem. This is a similar medicine that we think will do a better job of controlling your heart rate. --> Your Lasix was stopped because your blood pressure was normal. Please talk with your doctor about when to restart this. --> Your lisinopril was stopped because your blood pressure was normal. Please talk with your doctor about when to restart this. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Dr. [**Last Name (STitle) 5351**] is aware that you have been discharged from the hospital. Her office will contact you to arrange follow-up in the next few days. Please call her office at [**Telephone/Fax (1) 608**] if you have not heard from them by then.

[ "428.32", "276.52", "285.1", "427.31", "276.2", "532.40", "427.89", "584.9", "E935.3", "428.0", "294.8" ]

icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

6039, 6124

2499, 5592

269, 321

6302, 6371

1548, 2476

7590, 7851

5755, 6016

6145, 6281

5618, 5732

6395, 7567

1233, 1529

222, 231

349, 924

946, 1061

1078, 1218

58,287

178,918

8928

Discharge summary

report

Admission Date: [**2156-12-10**] Discharge Date: [**2156-12-16**] Date of Birth: [**2086-9-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 70 y/o female with dilated cardiomyopathy (EF 20%), T2DM, HTN, and hypothyroidism who presented to [**Hospital1 **] [**Location (un) 620**] ED with 2 days of worsening dyspnea and chest pain. Pt also reported 2-3 days of intermitttent, diffuse back pain. Upon arrival to the ED, vitals were BP 164/77, HR 92, RR 34, 71% O2 sat on RA. She reported 1-2 days of worsening dyspnea and [**11-12**] SSCP, no radiation or associated symptoms. Sats improved to 100% on NRB. She was given 1 SL nitro, which decreased her CP to [**6-12**] but also dropped her BP to 83/42. EKG without any acute ST changes. There was AV pacing. She was given Lasix 40 mg IV x 1 with marked improvement in her symptoms and able to wean her oxygen to 4L NC, satting 98%. Foley was placed. CXR reportedly revealed pulmonary edema but report did not accompany patient. She was given another 40 mg of IV Lasix. She was also given ASA 325 mg. The decision was made to transfer to [**Hospital1 18**] CCU for further diuresis in the setting of hypotension. Upon arrival to the CCU, she was in NAD and hemodynmically stable. BP was 106/54 and HR 72, satting 100% on 4L NC, quickly weaned to 2L NC. She still complained of [**5-13**] chest pain. Upon further questioning, she explained that there were no recent changes in her medication regimen. She admits to using salt on her food but not a large amount. Followed by a cardiologist at [**Location (un) 745**]-[**Location (un) 3678**]. She had recently had a course of steroids for gout flare which was perhaps responsible for fluid retention. Denies F/C. Denies N/V/D/abdominal pain. Denies urinary symptoms. Denies palpitations or PND. Usually sleeps at an incline so difficult to know if orthopnea worsened. No recent travel. ROS otherwise N/C. Of note, pt is a poor historian. Past Medical History: Dilated cardiomyopathy, recent EF 20%, cath in 200 which revealed no CAD, mild MR, and EF of 35%, s/p pacer/ICD placement (unsure what kind of pacer/when placed/when was last interrogated T2DM HTN Hypothyroidism Social History: No prior history of smoking or alcohol use. Family History: Non-contributory Physical Exam: T 97.2 BP 106/54 HR 74 RR 20 98% 2L NC General: WD/WN 70 y/o female in NAD. HEENT: NC/AT. MMM. OP clear. Neck: +JVD CV: Normal S1, S2 without any m/r/g. Pulm: Bibasilar crackles, no wheezes. Abd: Soft, NT/ND with normoactive BS. Ext: No c/c/e. Skin: No rash. Neuro: A/O x 3. CNs II-XII grossly intact. Good ROM and strength in all 4 extremities. Sensation intact. No spinal tenderness. Mild lumbar paraspinal TTP. Pertinent Results: [**2156-12-16**] 05:35AM BLOOD WBC-4.2 RBC-3.01* Hgb-9.4* Hct-29.4* MCV-98 MCH-31.2 MCHC-31.9 RDW-16.6* Plt Ct-252 [**2156-12-10**] 06:09AM BLOOD Neuts-84.6* Lymphs-9.9* Monos-5.0 Eos-0.2 Baso-0.3 [**2156-12-13**] 05:45AM BLOOD PT-11.9 PTT-41.1* INR(PT)-1.0 [**2156-12-16**] 05:35AM BLOOD Glucose-88 UreaN-42* Creat-2.3* Na-138 K-5.3* Cl-102 HCO3-29 AnGap-12 [**2156-12-10**] 06:09AM BLOOD ALT-13 AST-15 CK(CPK)-31 AlkPhos-107 TotBili-0.3 [**2156-12-10**] 03:46PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2156-12-15**] 09:25AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.3 [**2156-12-12**] 06:03AM BLOOD TSH-8.9* [**2156-12-12**] 06:03AM BLOOD T4-5.7 T3-53* [**2156-12-14**] 07:06PM URINE Hours-RANDOM UreaN-188 Creat-58 Na-71 ECHO [**12-10**]: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 15-20%). Right ventricular chamber size is normal. with mild global free wall hypokinesis. 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. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is at least mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe global left ventricular systolic dysfunction with elevated LVEDP. Mild aortic regurgitation. Mild mitral regurgitation. At least mild pulmonary hypertension. CXR [**12-10**]: 1. Right basilar area of consolidation concerning for pneumonia or aspiration. Left basilar atelectasis. 2. Moderate cardiomegaly. 3. No sign of failure or effusion. Brief Hospital Course: [**Hospital1 18**] EKG: Mostly V-paced, occasional PVCs, no acute ST changes, 70 F with idiopathic cardiomyopathy (EF 20% in [**6-10**]), T2DM, HTN, and hypothyrodism who presents with worsening DOE and chest pain. # DYSPNEA - On transfer, in the setting of pt's history, exam (basilar crackles, JVD) and laboratory findings (OSH CXR with volume overload, and elevated BNP), etiology of pt's dyspnea was thought to be secondary to left sided CHF exacerbacion. Etiology of exacerbation was thought to be partly dietary indiscretion and more importantly a recent course of prednisone. Pt was diuresed aggresively with IV lasix drip. CXR confirmed fluid overload and ruled out infection. BP meds were held while diuresing and restarted once tolerated. Pt's oxygen supplementation was weaned as she was diuresed. # CHEST PAIN - Not thought to be ischemic based on EKG and cardiac enzymes. # Hypotension - Thought to be chronic due to low EF. Pt's beta-blocker and ace-inhibitor were initially held while aggresively diuresing and restarted slowly prior to discharge. # CHRONIC KIDNEY DISEASE - Pt's creatinine fluctuated around her baseline with diuresis. She was asked to have her renal function checked on follow up with PCP. # DIABETES type 2 - Pt's blood sugars were controlled with standing glarging and humalog sliding scale. # HYPOTHYROIDISM - Pt's TSH was elevated and repeated due to concern for contribution to CHF, but T3 and T4 were within appropriate range, thus suggesting sick euthyroid. She was continued on her outpt dose of levothyroxine. # ARRHYTHMIA - Pt initially had frequent ectopy with PVCs alternating with paced beats. Her PVCs were not perfusing and thus her effective pulse was 40s while being paced at 70s. Pt remained asymptomatic but EP was consulted and recommended increasing beta-blockade to suppress ectopy. On discharge pt's perfusing pulse was in the 70s on Toprol. Medications on Admission: ASA 81mg po daily Toprol XL 50mg po daily Amiodarone 200mg po daily Ramipril 5mg po daily Allopurinol 100mg po daily Lasix 80mg po QAM, 40mg QPM *Humalin 15/12 units SC AM/PM--Pt states recently she has been taking 10 AM, 15 PM (3am glucose 70s, 8am glucose 240s) *Levothyroxine 75mcg po daily + 2 tabs on saturday and tuesday *Vitamin B12 50mcg po qd *Prednisone 20mg po qd--Self DC'd Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous once a day. 7. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous twice a day. 8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO every morning. 12. Furosemide 80 mg Tablet Sig: 0.5 Tablet PO at 6 pm. 13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Outpatient Lab Work Please check BUN,Creatinine, Hct, K, Na when you see Dr. [**Known lastname **]. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Dilated Cardiomyopathy Daibetes Mellitus Type 2 Hypertension Acute on Chronic systolic Congestive Heart Failure. Bradycardia with Ventricular Ectopy Discharge Condition: bun=42 creat=2.3 hct=29.4 k=5.3 Discharge Instructions: You had a congestive heart failure exacerbation that may have been caused by a high sodium diet. it is important that you stay active and get as much activity as you can. We gave you intravenous furosemide to remove the fluid. Your kidney function declined temporarily because of the stress of the fluid removal. You should get your kidney function checked in the next week. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet, information regarding this was discussed with you and given to you on discharge. Fluid Restriction: 1.5 Liters, about 7 eight ounce cups per day. . Medication changes: Your Metoprolol was changed to 100mg daily (long acting medicine) Followup Instructions: Primary Care: [**Known lastname **],[**First Name3 (LF) **] M Phone: [**Telephone/Fax (1) 6163**] Date/Time: Monday [**12-20**] 12:00pm . Cardiology: [**Name6 (MD) 31011**] [**Name8 (MD) **], MD Phone: ([**Telephone/Fax (1) 31012**] Date/Time: [**12-22**] at 2:15pm. Completed by:[**2156-12-21**]

[ "707.05", "585.9", "425.4", "428.0", "244.9", "518.0", "707.21", "403.90", "584.9", "428.23", "V45.02" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8237, 8308

4723, 6632

325, 332

8501, 8535

2971, 4700

9327, 9626

2504, 2522

7068, 8214

8329, 8480

6658, 7045

8559, 9217

2537, 2952

9237, 9304

278, 287

360, 2192

2214, 2427

2443, 2488

4,094

139,737

21483

Discharge summary

report

Admission Date: [**2192-5-21**] Discharge Date: [**2192-5-30**] Date of Birth: [**2130-2-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x 6 (LIMA to LAD, Sequential SVG to OM1, OM2, and OM3, Sequential SVG to Acute Marginal and PDA) [**2192-5-23**] History of Present Illness: 61 y/o male with known coronary artery diease who has shortness of breath. Cardiac cath on [**2-20**] revealed severe three vessel disease. Echo showed an EF of 30%. Admitted prior to surgery to address CHF. Past Medical History: Coronary Artery Disease, Diabetes Mellitus, Hypertension, Hypercholesterolemia, Peripheral Vascular Disease (L Carotid, Bilat SFA & Iliac DZ), Chronic Obstructive Pulmonary Disease, Depressions, HOH, Cognitive Disorder Social History: pt is disabled, lives at Tower [**Doctor Last Name **] Rest Home. 45 pack/yr tob hx. Quit [**2189**]. Denies ETOH Family History: sister MI and CABG at 69yo, father deceased, MI/Valve at 63yo, mother deceased, MI at 77yo. Physical Exam: VS: 65.6 116/57 56 20 99%RA HEENT: EOMI, PERRL, OP benign Neck: Supple, FROM, R Carotid Bruit, Well healed small scar Lungs: CTAB -w/r/r CV: Hard to hear, -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, decreased PP, trace bilat edema Pertinent Results: Echo [**5-22**]: The left atrium is mildly dilated. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is moderately-to-severely depressed (ejection fraction 30 percent) secondary to extensive apical akinesis with focal dyskinesis. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. CXR [**5-26**]: Median sternotomy wires are seen. The distal portion of a vascular sheath in the internal jugular vein is again seen and high. Previously, there was a kink within the sheath; however, the portion of the kink has been excluded on this study, and it is unclear whether or not the catheter kink has been readjusted. There is marked cardiomegaly which is increased since the previous study. There are some linear densities seen at the base most consistent with subsegmental atelectasis. No focal consolidation is seen. There are no signs for overt congestive heart failure. [**2192-5-21**] 10:50AM BLOOD WBC-7.2 RBC-3.90* Hgb-11.8* Hct-34.2* MCV-88 MCH-30.3 MCHC-34.6 RDW-14.4 Plt Ct-241 [**2192-5-28**] 08:15AM BLOOD WBC-7.5 RBC-3.21* Hgb-9.8* Hct-28.1* MCV-87 MCH-30.4 MCHC-34.8 RDW-15.0 Plt Ct-209 [**2192-5-21**] 10:50AM BLOOD PT-12.8 PTT-24.0 INR(PT)-1.1 [**2192-5-28**] 08:15AM BLOOD PT-12.5 PTT-24.2 INR(PT)-1.1 [**2192-5-21**] 10:50AM BLOOD Glucose-191* UreaN-36* Creat-1.5* Na-138 K-4.7 Cl-101 HCO3-26 AnGap-16 [**2192-5-28**] 08:15AM BLOOD Glucose-134* UreaN-29* Creat-1.3* Na-137 K-4.0 Cl-100 HCO3-27 AnGap-14 [**2192-5-27**] 03:19AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.2 [**2192-5-21**] 10:50AM BLOOD %HbA1c-7.0* [Hgb]-DONE [A1c]-DONE [**2192-5-25**] 09:02PM URINE RBC->50 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 [**2192-5-25**] 09:02PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 34909**] was electively admitted prior to surgery and underwent usual pre-operative work-up. He also had a psychiatry and cardiology/EP consultation. Following consent and stable lab work, he was brought to the operating room on [**2192-5-23**] where he underwent a coronary artery bypass graft x 6. Please see operative report for surgical details. He tolerated the procedure well and was transferred to the CSRU for invasive monitoring in stable condition. He did require Amiodarone bolus and drip when coming off CPB secondary to VT. Very early on post-op day one he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed on post-op day two. Beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. He was transfused multiple times with PRBCs secondary to low HCT. At time of discharge HCT was 28.1. Throughout CSRU post-op course he had multiple episodes of VT/Atrial Fibrillation and remained on Amiodarone. Mr. [**Known lastname 34909**] remained in the CSRU until post-op day four when he was transferred to the cardiac surgery step down floor. Physical therapy worked with Mr. [**Known lastname 34909**] during entire post-op course for strength and mobility. Mr. [**Known lastname 34909**] continued to have episodes of atrial fibrillation and thus coumadin was started for anticoagulation. He remained stable and was discharged to his rest facility on post-op day seven with the appropriate follow-up appointments. He will take coumadin daily for a goal INR of 2.0-2.5. His last dose was today [**2192-5-30**] of 5mg and he will have his blood (PT/INR) checked tomorrow with results sent to Dr.[**Name (NI) 1912**] office for continued dosing. Amiodarone will be continued on a wean starting today ([**2192-5-30**]) which will be 400mg twice daily for 6 days, then 400mg once daily for 7 days, then 200mg once daily thereafter. Medications on Admission: Lipitor 40mg qd, Prozac 20mg qd, Aspirin 325mg qd, Lasix 20mg qd, KCl 20meq qd, Digoxin 0.25mg qd, Aldactone 25mg qd, NTG patch, Albuterol, Combivent, Lisinopril 5mg qd, Lopressor 25mg [**Hospital1 **], Glyburide 5mg qd, Avandia 4mg [**Hospital1 **], Nifedipine 90mg qd, Antacid Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 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. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO Starting [**2192-5-30**] - 400mg [**Hospital1 **] for 6 days, then 400mg once daily for 7 days, then 200mg once daily thereafter. . Disp:*30 Tablet(s)* Refills:*2* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*1* 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1* 13. Coumadin 2.5 mg Tablet Sig: As instructed by Dr. [**Last Name (STitle) 1911**] Tablet PO once a day: Goal INR is 2.0-2.5 for postoperative atrial fibrillation. Please take as instructed. Disp:*60 Tablet(s)* Refills:*1* 14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-19**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 MDI* Refills:*0* 15. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months: Take for 1 month. Disp:*30 Tablet(s)* Refills:*0* 16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months: take for 1 month. Disp:*60 Tablet(s)* Refills:*0* 17. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] manor residence home Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 6 PMH: Diabetes Mellitus, Hypertension, Hypercholesterolemia, Peripheral Vascular Disease (L Carotid, Bilat SFA & Iliac DZ), Chronic Obstructive Pulmonary Disease, Depressions, HOH, Cognitive Disorder NOS Discharge Condition: Good Discharge Instructions: 1) [**Month (only) 116**] take shower. Wash incisions with water and gentle soap. Gently pat dry. Do not take bath or swim until incision has healed. 2) Do not apply lotions, creams, ointments, or powders to incisions until they have healed. 3) Do not drive for 1 month. 4) Do not lift greater than 10 pounds for 10 weeks. 5) If you develop a fever or notice redness or drainage from incisions, please contact office immediately. 6) Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases 2 pounds in 24 hours or 5 pounds in 1 week. 7) Take coumadin as instructed by Dr. [**Last Name (STitle) 1911**]. Goal INR is 2.0-2.5 for atrial fibrillation. Visting nurse may draw blood and report results to Dr.[**Name (NI) 1912**] office. ([**Telephone/Fax (1) 56694**] or fax ([**Telephone/Fax (1) 19722**]. Otherwise, you must report to Dr. [**Name (NI) 36806**] lab for blood work or as instructed by his nurse [**Doctor First Name **]. You will be instructed on what dose to take on [**2192-5-31**] after the results of your blood work are done. 8) Amiodarone - Starting [**2192-5-30**] take 400mg [**Hospital1 **] for 6 days, then 400mg once daily for 7 days, then 200mg once daily thereafter until changed by Dr. [**Last Name (STitle) 1911**]. 9) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) 914**] (surgeon) in 4 weeks. ([**Telephone/Fax (1) 1504**] Dr. [**Last Name (STitle) 1911**] (Cardiologist) [**Telephone/Fax (1) 902**] in [**12-19**] weeks. Dr. [**First Name (STitle) **] (Primary care provider) in [**1-20**] weeks. ([**Telephone/Fax (1) 56695**] Completed by:[**2192-5-30**]

[ "272.0", "414.01", "401.9", "443.9", "250.00", "428.0", "428.22", "427.31", "411.1", "397.0", "427.1", "424.0", "496" ]

icd9cm

[ [ [] ] ]

[ "36.14", "36.15", "99.04", "39.61" ]

icd9pcs

[ [ [] ] ]

8263, 8334

3693, 5657

339, 482

8641, 8647

1464, 3670

9994, 10316

1108, 1201

5986, 8240

8355, 8620

5683, 5963

8671, 9971

1216, 1445

280, 301

510, 719

741, 961

977, 1092

24,198

157,166

49744+49745+49810

Discharge summary

report+report+report

Admission Date: [**2181-9-1**] Discharge Date: [**2181-9-8**] Service: MICU A [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 104005**] MEDQUIST36 D: [**2181-9-8**] 02:59 T: [**2181-9-8**] 03:59 JOB#: [**Job Number 104006**] Admission Date: [**2181-9-1**] Discharge Date: [**2181-9-8**] Service: MICU A HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old male with multiple medical problems, including congestive heart failure with an ejection fraction of 20%, end stage renal disease requiring hemodialysis, diabetes Type 2, coronary artery disease status post coronary artery bypass graft, and status post replacement of left hip. The patient presented to the Emergency Department on the [**2-1**] after being noted by his caretakers at [**Name (NI) 582**] Rehabilitation Home to have decreased mental status and lethargy per wife and per caregivers at the [**Name (NI) 582**] Rehabilitation facility. The patient was also desaturating on room air into the 70% range, and was brought into the Emergency Department for evaluation. In the Emergency Department, the patient was found on examination to have grossly melanotic stools, which were guaiac positive. A hematocrit drop was also noted in the Emergency Department from 37.7, the patient's baseline, to 19.3. Also of note, the patient had a supratherapeutic INR of 4.2. He was on deep venous thrombosis prophylaxis status post a left hip replacement. In the Emergency Department, the patient was transfused packed red blood cells, was given fresh frozen plasma, vitamin K, and DDAVP. He was transferred to the Medical Intensive Care Unit for further management. PHYSICAL EXAMINATION: In the Medical Intensive Care Unit, the patient was noted to have vital signs of a temperature of 96.8, blood pressure 110/47, pulse 110, respiratory rate 18, oxygen saturation 96% on 6 liters by nasal cannula. He was found to be an elderly gentleman, chronically ill-appearing, with a flat affect. Head, eyes, ears, nose and throat examination: Pupils equal, round and reactive to light and accommodation. There was no lymphadenopathy, and the neck was supple. On heart examination, he was noted to have a systolic ejection murmur, II/VI, at the right upper sternal border. Lung examination: Decreased breath sounds at the bases, with soft crackles. Abdomen: Soft, tender to deep palpation, with positive bowel sounds. Extremities: There was no cyanosis, clubbing or edema. On neurological examination, the patient was irritable, but was alert and oriented x 3. He was unable to follow commands. Rectal examination showed black stool that was guaiac positive. LABORATORY DATA: White count 8.3, hematocrit 19.3, platelets 459. Chemistries: Sodium 141, potassium 4.5, chloride 104, bicarbonate 24, BUN 65, creatinine 4.7, with a blood sugar of 166. The patient's first troponin came back elevated at 26. Electrocardiogram showed sinus tachycardia with a rate of 118, right axis, right bundle branch block, a Q wave in the inferior leads, and ST depressions in the anterior and lateral leads. A chest x-ray was done that showed a perihilar haziness and early signs of cardiac heart failure. ASSESSMENT: The patient had a gastrointestinal bleed and was experiencing cardiac demand ischemia secondary to hypotension and anemia. HOSPITAL COURSE: On the morning of the 28th, the patient required intubation for respiratory failure secondary to cardiac failure. 1. Cardiovascular: The patient required pressors to maintain adequate blood pressure from the 27th until the 30th. The patient was first placed on dopamine, but became tachycardiac, so was switched to Neo-Synephrine, which was then switched to Levophed. The patient did have active ischemia, however, after consulting with Cardiology and discussing treatment options, it was decided not to anticoagulate the patient as he had an active gastrointestinal bleed. The patient was placed on aspirin as part of a cardiac regimen, however, he was not started on a beta blocker or an ACE inhibitor with the issue of hypotension. As stated, the pressors were discontinued on the 30th, and the patient maintained adequate pressure with systolic pressures 100 and above, and was transferred to the floor with a stable cardiac status. His troponin level did continue to decline to a level of 12. It had risen to above 50. 2. Renal: The patient was started on CVVH dialysis as it was felt by Renal that he could not tolerate hemodialysis because of his hypotension and need for pressure support. He received CVVH on the 29th, and then he received hemodialysis on the 31st and again on the 2nd, prior to his discharge from the Medical Intensive Care Unit to the floor. He remained stable from a renal standpoint. 3. Pulmonary: The patient was intubated, as stated previously, on the morning of the 28th. He was weaned and extubated on the [**2-5**], did very well from a pulmonary standpoint, maintaining saturations of 97 to 100% on 2 liters nasal cannula status post extubation. 4. Gastrointestinal: The Gastroenterology fellow was very involved in the patient's care. It was decided not to scope the patient during this acute illness, as he was unstable clinically. Gastroenterology has already made plans to follow up with the patient on an outpatient basis. The patient's hematocrit remained stable throughout his stay in the Medical Intensive Care Unit. He still had guaiac positive stools, but was not actively bleeding. 5. Infectious Disease: The patient remained afebrile during his course. He never had an elevated white blood count. Blood cultures did come back with bacterium diphtheroids, which was felt to be a contaminant. Sputum cultures came back with methicillin resistant staphylococcus aureus, however, this was felt to be a colonization secondary to intubation, as the patient had no white count, again was afebrile, clinically showed no signs of pulmonary infection, and had no evidence of an infiltrate on chest x-ray. The patient was placed on methicillin resistant staphylococcus aureus precautions. 6. Neurology: The patient was noticed to have decreased attention and a flat affect on initial presentation to the Medical Intensive Care Unit. After being intubated, this obviously could not be assessed. Once the patient was extubated on the 31st, he had much improvement in his mental status. He was alert and oriented x 3, able to respond to commands appropriately, able to carry on abbreviated conversations. 7. Endocrine: The patient is a known diabetic. He takes oral Glyburide as an outpatient. While in the Unit, he was maintained on a regular insulin sliding scale and did well on this. 8. Nutrition: The patient was initially nothing by mouth. When the bleeding was stabilized, the patient was placed on tube feeds. After extubation, the patient tolerated oral intake very well, eating three meals a day before he was transferred to the floor. The patient was prophylaxed with Protonix intravenously, and then Prevacid per nasogastric tube. He was also given heparin subcutaneously. 9. Code status: Full. A discussion was held with the entire Medical Intensive Care Unit team, including the attending, myself, resident, and the patient's wife, regarding the patient's code status on the [**1-6**]. Also a social worker was present. The goal of this meeting was to make sure the wife understood the grave nature of the [**Hospital 228**] medical status and each medical issue was discussed in depth with the patient's wife so that she had a good understanding of his cardiovascular status, his renal status, his pulmonary status, etc. Code status was addressed as to what the patient's wife thought the patient would want. The patient's wife believed that the patient would wish to remain full code, however, the patient's wife will discuss code status again with the social worker and with the rest of her extended family, including nieces and nephews who are involved in the patient's care along with the wife. DISPOSITION: The patient was transferred to CC7, [**Apartment Address(1) 104007**], on the [**1-7**]. The patient is to be discharged on the [**1-8**] to [**Location (un) 582**] facility in [**Location (un) 620**], [**State 350**]. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSIS: 1. End stage renal disease requiring hemodialysis 2. Heart failure 3. Diabetes [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 104005**] MEDQUIST36 D: [**2181-9-8**] 03:44 T: [**2181-9-8**] 04:24 JOB#: [**Job Number **] Admission Date: [**2181-9-1**] Discharge Date: [**2181-9-8**] Service: MICU A HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old gentleman with multiple medical problems, including congestive heart failure, status post myocardial infarction, end stage renal disease requiring hemodialysis, status post recent hip fracture. The patient presented to the Emergency Department from [**Hospital 582**] Nursing Home on the [**1-2**], noticed to have mental status changes, increased lethargy. In the Emergency Room, the patient had a drop in hematocrit from baseline of 37.7 to 19.3, was found to have melanotic stool that was grossly guaiac positive. The patient was given four units of packed red blood cells and three units of fresh frozen plasma and DDAVP. The patient was transferred to the floor for further management. HOSPITAL COURSE: In the Medical Intensive Care Unit, the patient continued to have problems with respiration. He was requiring more oxygen to maintain his saturations. He ultimately was intubated on the morning of the 28th at 5 A.M. It was felt that the patient had gone into respiratory failure secondary to cardiac heart failure from demand ischemia related to hypotension and anemia. The patient was found to have a troponin leak of greater than 50, with electrocardiogram changes showing ST depressions in the anterior and lateral leads. Due to the patient's gastrointestinal bleed, no treatment with heparin was initiated. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**] Dictated By:[**Last Name (NamePattern1) 104005**] MEDQUIST36 D: [**2181-9-8**] 03:10 T: [**2181-9-8**] 04:19 JOB#: [**Job Number 104093**]

[ "410.91", "250.00", "518.81", "578.9", "412", "425.4", "585", "285.1", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95", "96.04", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

8460, 8903

9675, 10566

1812, 3456

8932, 9657

11,817

172,085

16328+16329+56750

Discharge summary

report+report+addendum

Admission Date: [**2129-12-7**] Discharge Date: [**2129-12-16**] Service: ACOVE DISCHARGE DIAGNOSES: 1. Sepsis. 2. Multidrug resistant urinary tract infection. 3. Methicillin resistant Staphylococcus aureus pneumonia. 4. Congestive heart failure. 5. Non ST elevation myocardial infarction. 6. Rapid atrial fibrillation. 7. Status post cerebrovascular accident. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old female with multiple medical problems who was admitted to the Intensive Care Unit on [**2129-12-7**], from a nursing home with signs of sepsis including fever of 101, room air saturation of 86%, and a lactate of 5.2, as well as delta MS. The patient had been previously well at the nursing home but had acutely decompensated. On arrival, she had electrocardiographic evidence of demand ischemia and was aggressively intravenous fluid resuscitated, as well as started on broad spectrum antibiotics. PAST MEDICAL HISTORY: 1. Left middle cerebral artery cerebrovascular accident [**5-21**], with resulting right hemiparesis and aphasia. 2. Percutaneous endoscopic gastrostomy placed [**5-21**]. 3. Status post tracheostomy in [**5-21**], which has been since reversed. 4. Coronary artery disease times two myocardial infarctions. 5. Atrial fibrillation, no history of anticoagulation. 6. Peripheral vascular disease. 7. Hypertension. 8. Diabetes mellitus type 2. 9. Hypercholesterolemia. 10. Multiple urinary tract infections in [**2129**]. 11. Methicillin resistant Staphylococcus aureus line sepsis [**7-21**]. 12. Basal cell carcinoma right cheek. 13. Congestive heart failure with an ejection fraction of 21% by transesophageal echocardiogram [**5-21**]. MEDICATIONS ON ADMISSION: 1. Lopressor 25 mg twice a day. 2. Aspirin 81 mg once daily. 3. Heparin 5000 units subcutaneous twice a day. 4. ProMod with Fiber via nasogastric tube. 5. Dulcolax 10 mg PR p.r.n. 6. Tylenol p.r.n. 7. Eucerin cream. 8. Regular insulin sliding scale. 9. NPH 4 units subcutaneous twice a day. 10. Ritalin 5 mg p.o. twice a day. 11. Lasix 20 mg p.o. once daily. 12. Lipitor 10 mg p.o. once daily. 13. Prevacid 30 mg p.o. once daily. 14. Albuterol MDI p.r.n. 15. Colace 100 mg p.o. twice a day. 16. Nystatin Powder. 17. Scopolamine Patch transdermal once daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is from Poland and moved to the United States in [**2088**]. She has been married for over fifty years. No ETOH, tobacco or drug history. Most recently, she has resided at [**Hospital **] Nursing Home. Minimal verbalization at baseline since cerebrovascular accident. Her daughter is very involved in her care. PHYSICAL EXAMINATION: On admission, temperature is 96.6, heart rate 96 and in atrial fibrillation, blood pressure 106/42 with a MAP of 63, CVP of 6, respiratory rate 18, oxygen saturation 100% on 50% face mask. Examination is notable for thin elderly woman looking acutely ill. Surgical pupil on the right. The pupil is reactive on the left. Sclera anicteric, mucous membranes are moist. Strong gag. No jugular venous distention or lymphadenopathy. The heart is irregular and rapid, no murmurs. Lungs revealed coarse breath sounds and diffuse rhonchi. The abdomen is soft, nondistended, nontender, gastrostomy tube in place. Extremities showed no edema, 2+ pulses. Neurologically, dense hemiparesis of the right side with upgoing toe on the right and downing toe on the left and moving left extremities without difficulty. LABORATORY DATA: On admission, white blood cell count was 14.8, hematocrit 44.0, platelet count 350,000. Chem7 was normal except for glucose of 149, CK 167, troponin 0.04. Urinalysis notable for many bacteria, [**12-8**] white blood cells, moderate leukocytes. Chest x-ray revealed retrocardiac density and bibasilar atelectasis. Electrocardiogram showed atrial fibrillation at 137 beats per minute, left axis deviation, 0.[**Street Address(2) 11725**] depressions V3 and V4, T wave inversion in leads I and aVL. HOSPITAL COURSE: 1. Infectious disease - The patient was initially started on broad spectrum antibiotics, Vancomycin, Levofloxacin and Flagyl in the setting of sepsis. Eventually, urine cultures grew resistant proteus and sputum cultures grew Methicillin resistant Staphylococcus aureus and E. coli. Her antibiotic coverage was eventually changed to Vancomycin and Ceftriaxone to which she responded well. She should complete a ten day course of each. 2. Cardiac - Pump - The patient was initially septic and dry on admission and was treated aggressively with multiple boluses of intravenous fluids. She subsequently developed evidence of pulmonary edema, not surprisingly since her ejection fraction is 20%. She was then started on Lasix for diuresis which eventually evoked hypotension and she was felt to be dry. Total length of stay she is positive eight liters in the Intensive Care Unit. At this point, her goal is even fluid balance. She will be restarted on her baseline Lasix. Rate - The patient was in rapid atrial fibrillation on admission, unclear of the duration of her atrial fibrillation, however, she has never been anticoagulated per primary care physician because of risk of falls. The patient had a left middle cerebral artery cerebrovascular accident in [**5-21**], thought to be embolic in nature. She has not been anticoagulated since that time due to concern for rebleed. Atrial fibrillation has been controlled initially with Diltiazem drip but she was then changed to p.o. beta blocker with good rate control with heart rate in the 80s. The patient was started on Lovenox 60 mg subcutaneous twice a day for anticoagulation. Ischemia - The patient had non ST elevation myocardial infarction in the setting of sepsis and rapid atrial fibrillation. Electrocardiographic changes resolved with heart rate control. The patient was continued on Aspirin, beta blocker and Lipitor. 2. Status post cerebrovascular accident - According to the family, the patient has been only minimally verbal since cerebrovascular accident. They do feel that they can communicate with her and understand what she is trying to communicate. There seems to have been little improvement in her function since [**Month (only) 116**]. 3. Access - The patient had a right IJ placed on admission which remained throughout her hospital course. She had no erythema or infection felt to be associated with the line. 4. Code Status - Code on admission, the patient was full code. She never did require intubation or CPR. Multiple discussions with the family were undertaken while the patient was in the Intensive Care Unit with the result that the patient was made DNR/DNI as documented on [**2129-12-10**], in the chart. DISCHARGE STATUS: The patient will be discharged to an extended care facility. DISCHARGE INSTRUCTIONS: The patient should continue Vancomycin intravenously until [**2129-12-17**]. She will continue Ceftriaxone or p.o. equivalent to end on [**2129-12-21**]. In addition, she should continue on Lovenox for anticoagulation and her beta blocker should be titrated for adequate heart rate control. Tube feeds to be continued and the patient will need physical therapy. In addition, her weight should be monitored closely for evidence of weight gain at which time her Lasix should be intermittently increased. The patient may also require chest physical therapy intermittently to help handle her secretions. MEDICATIONS ON DISCHARGE: 1. Bisacodyl 10 mg p.r.n. 2. Atorvastatin 10 mg once daily. 3. Tylenol 325 to 650 mg p.r.n. 4. Atrovent nebulizer p.r.n. 5. Insulin sliding scale. 6. Albuterol nebulizer p.r.n. 7. Metoprolol 25 mg p.o. twice a day. 8. Lansoprazole 30 mg p.o. once daily. 9. Miconazole Powder p.r.n. 10. Lasix 40 mg p.o. once daily. 11. Enoxaparin Sodium 60 mg subcutaneous q12hours. 12. Aspirin 325 mg once daily. 13. Antibiotics as outlined in page one. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 6765**] MEDQUIST36 D: [**2129-12-16**] 11:30 T: [**2129-12-16**] 12:06 JOB#: [**Job Number 46521**] Admission Date: Discharge Date: Date of Birth: Sex: Service: ADDENDUM: When the patient arives home to nursing facility, she will need physical therapy and occupational therapy services. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Doctor Last Name 46522**] MEDQUIST36 D: [**2129-12-16**] 06:01 T: [**2129-12-16**] 18:26 JOB#: [**Job Number 46523**] Name: [**Known lastname 8538**], [**Known firstname 8539**] Unit No: [**Numeric Identifier 8540**] Admission Date: [**2129-12-7**] Discharge Date: [**2129-12-19**] Date of Birth: [**2038-3-6**] Sex: F Service: ACOVE ADDENDUM: HOSPITAL COURSE: (Since previous dictation) The patient remained clinically stable throughout the remainder of her hospitalization since the previous dictation with treatment for her congestive heart failure, atrial fibrillation, and Methicillin resistant Staphylococcus aureus pneumonia. She finished her full ten day course of Vancomycin. She was noted to have a low grade fever to 99.9 two days prior to discharge with an elevated white blood cell count as well as diarrhea. She was started prophylactically on Flagyl for presumed Clostridium difficile infection. The following day the patient's stool was positive for Clostridium difficile toxin and she will therefore receive Flagyl for fourteen days. The patient was hemodynamically stable for the remainder of her hospital stay. She was maintained on Lasix once daily for her congestive heart failure and had a follow-up chest x-ray which was negative for congestive heart failure. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient is discharged to rehabilitation facility. DISCHARGE DIAGNOSES: 1. Sepsis. 2. Methicillin resistant Staphylococcus aureus and E. coli pneumonia. 3. Urinary tract infection. 4. Coronary artery disease. 5. Congestive heart failure. 6. Atrial fibrillation. MEDICATIONS ON DISCHARGE: 1. Bisacodyl 10 mg p.o. once daily p.r.n. constipation. 2. Atorvastatin 10 mg p.o. once daily. 3. Ipratropium Bromide 0.02% solution one nebulizer inhaled q6hours p.r.n. wheezing. 4. Albuterol Sulfate 0.083% one nebulizer inhaled q4hours p.r.n. shortness of breath or wheezing. 5. Metoprolol 25 mg p.o. twice a day. 6. Lasix 40 mg p.o. once daily. 7. Miconazole Powder p.r.n. 8. Aspirin 325 mg p.o. once daily. 9. Lovenox 60 mg subcutaneous q12hours. 10. Cefpodoxime 200 mg p.o. twice a day times one day. 11. Flagyl 500 mg p.o. three times a day times twelve days. 12. Lansoprazole 30 mg liquid per nasogastric tube once daily. FOLLOW-UP: The patient will be followed by the physicians at [**Location (un) **] Skilled Nursing facility. A follow-up appointment should be made with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 223**], once she is discharged from the facility. [**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**] Dictated By:[**Last Name (NamePattern1) 1288**] MEDQUIST36 D: [**2129-12-19**] 15:29 T: [**2129-12-19**] 19:02 JOB#: [**Job Number 8541**]

[ "008.45", "427.31", "482.82", "482.41", "428.0", "410.71", "038.9", "599.0", "276.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

10036, 10233

10259, 11474

1748, 2354

8980, 9909

6895, 7501

2723, 4050

408, 954

976, 1722

2371, 2700

9934, 10015

12,567

111,664

3873

Discharge summary

report

Admission Date: [**2206-3-15**] Discharge Date: [**2206-3-17**] Date of Birth: [**2143-6-19**] Sex: F Service: MEDICINE Allergies: Tetracyclines Attending:[**First Name3 (LF) 330**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 62 F COPD, prior intubations, increased dypnea, productive cough and increased phlegm over last 7 days, spoke with PCP 3 days ago and was placed on azithromycin and prednisone which she has taken the past 3 days. Her daughter was worried that her breathing was worse so told her to go to the ED. She denied any chest pain, dysuria, abdominal pain, diarrhea or any other symtpoms. . In the ER she was placed on BIPAP in ER for brief period of time. Vitals were 99.2, 120, 139/79, she was 96% on undocumented level of oxygen and then placed on nasal bipap for unclear reasons. Given solumedrol 125mg IV, azithromycin then levaquin, duonebs, IVF. 2 liters of oxygen at home. Wheezing on exam. And admiited to MICU, no ABG was checked. She was comfortable on arrival to the MICU, breathing 93% on 3L. She was monitored for a few hours, and called out to the floor. Past Medical History: - COPD, last PFTs [**8-4**] with FVC 1.72, FEV1 0.82, FEV1/FVC 66% (61% and 40% predicted respectively); intubated several times in the past. on 2L home O2. - IgA deficiency, was on IV gamma globulin with Dr. [**Last Name (STitle) 2148**]. - CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in [**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA and LCx. - Hypertension - Hyperlipidemia - Gastritis, on PPI - Osteoporosis, with history of multiple compression and rib fractures from coughing - History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy - Depression - Tremor Social History: She lives with her daughter, [**Name (NI) 6177**], son-in-law and 3 grand-children. She is a widow. She is an ex-smoker, with about a 30-pack-year smoking history, quit in [**2200**]. No EtOH. Uses a cane and walker to ambulate. Family History: Mother with DM, father with pancreatic cancer. Physical Exam: VS - BP 128/84, HR 114, R 22, O2-sat 93% 3L GENERAL - Cachectic female, mildly SOB w/ speaking but able to speak in full sentences. Mildly tachypneic. + productive cough. HEENT - MMM, OP clear LUNGS - Barrel chest, scattered wheezes bilaterally with good air movement HEART - very distant heart sounds, tachycardic ABDOMEN - scaphoid, soft, nt/nd/nabs EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions Pertinent Results: [**2206-3-15**] 03:30PM PLT COUNT-497* [**2206-3-15**] 03:30PM NEUTS-92.9* LYMPHS-5.1* MONOS-0.9* EOS-0.8 BASOS-0.4 [**2206-3-15**] 03:30PM WBC-16.8* RBC-5.09# HGB-13.9# HCT-44.7# MCV-88 MCH-27.4 MCHC-31.2 RDW-14.8 [**2206-3-15**] 03:30PM estGFR-Using this [**2206-3-15**] 03:30PM GLUCOSE-125* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-31 ANION GAP-17 [**2206-3-15**] 03:59PM LACTATE-2.7* . CXR: Relatively stable chest x-ray examination with no acute pulmonary process. Brief Hospital Course: # COPD exacerbation: The patients symptoms and exam consistent with a COPD exacerbation. She was initially admitted to the MICU, but as she was breathing comfortably on 3L (baseline 2L requirment,) she called out to the floor within a few hours. She had been initially started on solumedrol, and switched to prednisone 60mg, with a slower taper. She was continued on her home nebulizer treatments, and started on a course of levofloxacin. She breathing comfortably and felt closer to her baseline on time of discharge. . #. Gastritis- She has a history of prior ulcer, egd [**2206-2-5**] showed gastritis. She was srarted on a PPI while on steroids. . #. CAD- Continued statin and plavix. Medications on Admission: ALBUTERL SOLUTION - 0.83 MG/ML - USE EVERY 4-6 HOURS AS NEEDED WITH NEBULIZER MACHINE ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 (Two) puffs(s) by mouth every four (4) hours as needed for cough/wheezing ALENDRONATE SODIUM - (Not Taking as Prescribed) - 70MG Tablet - ONE BY MOUTH Q WEEK, FIRST THING IN THE MORNING WITH A FULL GLASS OF WATER; AVOID LYING DOWN OR TAKING OTHER MEDICINES OR FOOD FOR THE NEXT 30 MINUTES CLOPIDOGREL - 75 mg Tablet - 1 Tablet(s) by mouth once a day EQUIPMENT - - oxygen by nasal canula at 2 liters/min at nite and with exertion ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule - 1 Capsule(s) by mouth twice a week --take on Wed and Sunday FENTANYL - 25 mcg/hour Patch 72 hr - apply one patch q72 hours FLUTICASONE - 220 mcg Aerosol - 2 puffs twice a day - use with spacer; rinse mouth after use FLUTTER - Device - Use tid and as needed IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 (One) vial inhaled via nebulizaiton up to every four (4) hours along with albuterol solution as needed for shortness of breath or wheezing IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol - 2 inhalations four times a day MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day NORTRIPTYLINE - 25 mg Capsule - 1 Capsule(s) by mouth at bedtime OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day OXYCODONE-ACETAMINOPHEN [PERCOCET] - 10 mg-325 mg Tablet - 1 Tablet(s) by mouth up to qid as needed for pain PAROXETINE HCL - 10 mg Tablet - 1 Tablet(s) by mouth qam regularly, to treat anxiety SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 inhalation ih twice a day SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day in the morning Medications - OTC DOCUSATE SODIUM - 100 mg Capsule - 2 Capsule(s) by mouth two times a day with a big glass of water each time MULTIVITAMIN - (OTC) - Tablet - 1 Tablet(s) by mouth once a day NEBULIZER & COMPRESSOR FOR NEB - Device - Use EVERY 3 HOURS PRN as needed for wheezing not controlled by inhalers - please replace old machine which is no longer delivering adequate pressure Discharge Medications: 1. Prednisone 20 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY (Daily): take 60mg for 2 days, then take 40mg for for 3 days, then 20mg for 2 days, then 10mg for 2 days. Disp:*13 Tablet(s)* Refills:*0* 2. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours). 3. Clopidogrel 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 6. Salmeterol 50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation Q12H (every 12 hours). 7. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. Paroxetine HCl 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Levofloxacin 750 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times a day). 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: One (1) Inhalation every four (4) hours. 14. Vitamin D 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO qwed and sat. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation every four (4) hours. 16. Omeprazole 20 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Dx: COPD exacerbation Secondary Dx: HTN, Gastritis, CAD Discharge Condition: Stable Discharge Instructions: You were admitted for shortness of breath, which is seconary to a flare of your COPD. You are being started on steroids called prednisone, which you should taper per the instructions. Additionally, we are starting you on antibiotics. You should continue all other medications as previous. If you develop significant worsening of your shortness of breath, worsened oxygen requirement, diahrea, or any other concerning symptoms, please call your PCP or go to the emergency room. Followup Instructions: You have an appointment already scheduled with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (PRE) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2206-4-15**] 12:00. I would recommend calling tomorrow to see if you can get an earlier appointment for next week.

[ "272.4", "V45.82", "493.22", "535.50", "279.01", "401.9", "412", "733.00", "414.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7973, 8031

3266, 3962

293, 300

8139, 8148

2732, 3243

8676, 8994

2201, 2249

6171, 7950

8052, 8118

3988, 6148

8172, 8653

2264, 2713

234, 255

328, 1193

1215, 1935

1951, 2185

30,016

167,527

48538

Discharge summary

report

Admission Date: [**2122-12-8**] Discharge Date: [**2122-12-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1162**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 86 yo w/ pmh of h/o breast ca, htn, w/ increasing confusion over few days noted by neighbors. Also c/o abdominal pain. Brought by EMS to [**Hospital1 18**] ED. Initially alert but non-verbal and unable to answer questions in ED. Initial vitals in the ED: 93.8, 76, 110/68, 16, 98RA, lactate of 4.7. Code sepsis called and early goal directed therapy was intiated. A RIJ placed with CVP of 8 (per ED resident). Given 2L IVF. Due to elevated lactate and question of mesenteric ischemia with exam finding of a diffusely tender abdomen she was evaluated by surgery. They felt pt. did not have an acute abdomen and that there was no indication for abd CT. Repeat lactate improved to 2.4 then 2.0. Per [**Name (NI) **], pts. mental status improved with fluids. UA shows >50 WBC, mod leuks, many bacteria. Pt. started on cipro/flagyl. Notable labs: WBC of 17.5, bun/crt of 51/2.8, AP 884, lipase 151. Prior to arrival in the [**Name (NI) 153**], pt. had pulled her RIJ. Past Medical History: breast ca HTN hyperlypidemia ?depression/anxiety Social History: lives independently. does her own [**Name (NI) 5669**], son is next of [**Doctor First Name **]. Family History: nc Physical Exam: Admission exam: Vitals: 96.6, 100/68, 77, 20, 100RA gen: awake alert, but not oriented. NAD heent: very dry mucous membranes cvs: III/VI mid-peaking SEM at RUSB, III/VI SEM at LLSB pulm: expiratory wheezes anteriorly, decreased BS bilaterally at the bases, otherwise clear to auscultation. abd: diffusely mildly tender throughout, ? more tender RUQ. soft. normoactive bowel sounds. mildly distended. back: ? L CVA tenderness. GU: foley in place. ext: thin, non-adematous. neuro: AA0 x 0, moves all extremities. Pertinent Results: Admit labs [**2122-12-8**] 07:40PM BLOOD WBC-17.1*# RBC-4.96 Hgb-14.8 Hct-44.3 MCV-89 MCH-29.8 MCHC-33.4 RDW-13.7 Plt Ct-265# [**2122-12-8**] 07:40PM BLOOD PT-15.3* PTT-24.4 INR(PT)-1.4* [**2122-12-8**] 07:40PM BLOOD Glucose-186* UreaN-51* Creat-2.8*# Na-135 K-4.1 Cl-94* HCO3-22 AnGap-23* [**2122-12-8**] 07:40PM BLOOD ALT-9 AST-17 CK(CPK)-21* AlkPhos-884* Amylase-97 TotBili-0.6 [**2122-12-8**] 07:40PM BLOOD Lipase-151* [**2122-12-8**] 07:40PM BLOOD cTropnT-<0.01 [**2122-12-8**] 07:40PM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.9 Mg-2.1 [**2122-12-8**] 09:13PM BLOOD Lactate-4.7* CT OF THE HEAD WITHOUT CONTRAST [**2122-12-8**] TECHNIQUE: Non-contrast head CT. FINDINGS: Examination of the brain is somewhat limited by massively thickened calvarium. The visualized portions of the brain appear unremarkable. No acute hemorrhage is identified. The density values of the brain parenchyma appear maintained. There is no shift of normally midline structures or hydrocephalus. The entire cranial vault, skull base, and visualized facial bones are markedly thickened and irregular with areas of small lucency. Normal trabeculae are not identified. No destructive bony lesions are seen. The visualized portions of C1 and C2 vertebral bodies are unremarkable. The mastoid air cells are aerated. The right maxillary sinus is clear. The left maxillary sinus is partially opacified. Similarly, there is partial opacification of the ethmoid air cells. There is complete opacification and obliteration of the sphenoid sinus. IMPRESSION: 1. No definite acute intracranial hemorrhage. 2. Massive thickening of the skull. This likely represent Paget's disease. ECHO [**2122-12-10**] Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal images (no short axis images). Hyperdynamic LV function with mild resting LVOT gradient and mild aortic stenosis. Probable diastolic dysfunction. URINE CULTURE (Final [**2122-12-10**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 1. E. coli UTI/urosepsis -- Initially admitted to the [**Hospital Unit Name 153**], treated with ciprofloxacin and flagyl. She responded well and was transferred to the medical floor for further care. IV ciprofloxacin was continued secondary to poor po intake related to mental status changes. She will continue a 10 day course of cipro IV with the last dose to be given on [**2122-12-19**]. A repeat urine cx was obtained on the above antibiotic regimen which was negative. She had a foley placed during her initial ICU stay that was subsequently removed. She has remained afebrile without leukocytosis for the last 5 days of admission. 2. Altered mental status -- Independed of all ADLs prior to arrival. Very hard of hearing, thought to contribute to her difficulty communicating. She slowly improved during the course of the admission. On the day prior to discharge a family meeting was held and the patient's son felt that she was about back to her baseline. He remarked that communication with her is difficult and sometimes she needs to have things written down due to her poor hearing. It is unclear if the patient is stubborn and doesn't want to respond to the staff because when her son appeared she was responsive to his questions. 4. Paget's disease--patient was treated with tylenol for pain 5. HTN--patient's bp meds were initially held on admission and lopressor was added back at 25mg po bid for adequate control. The patient has been intermittently refusing meds and or cheeking them so it is important that the nurses monitor her swallowing the pills. 6. Breast ca--patient was continued on her tamoxifen. Medications on Admission: atenolol, lipitor, tamoxifen Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Tamoxifen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) Intravenous Q24H (every 24 hours) for 3 days. 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: urosepsis altered mental status breast cancer COPD Discharge Condition: stable Discharge Instructions: You were admitted with altered mental status and found to have urosepsis. You will be discharged to a rehab facility to complete your course of intravenous antibiotics. You will need to return to the ER if you develop fevers, chills, nausea or vomiting. Followup Instructions: You will need to follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**] at [**Telephone/Fax (1) 608**] within one week from discharge from your rehab. You will also need to have your PICC line removed upon completion of the antibiotics.

[ "389.9", "784.0", "584.9", "276.2", "276.51", "038.42", "496", "272.4", "401.9", "995.91", "789.00", "564.00", "174.9", "731.0", "272.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8023, 8096

5536, 7177

285, 291

8191, 8200

2038, 5513

8504, 8777

1487, 1491

7256, 8000

8117, 8170

7203, 7233

8224, 8481

1506, 2019

224, 247

319, 1283

1305, 1356

1372, 1471

77,527

100,919

30650

Discharge summary

report

Admission Date: [**2146-2-18**] Discharge Date: [**2146-2-22**] Date of Birth: [**2074-1-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: chest pain /STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization with Drug Eluting stent to Obtuse marginal Artery History of Present Illness: Mr. [**Known lastname 17922**] is a 72 year-old male with pmh of CAD s/p STEMI and stent to the proximal LAD in [**2141**], DM, htn, HL who was admitted from the ED to the cath lab with a STEMI s/p DES to OM1. He presented from home with substernal CP radiating to his left arm. The pain started at rest. Denied associated shortness of breath, nausea, or vomiting. Not currently on plavix. . In the ED initial VS: T 99 BP 128/63 P 83 RR 18 Sat 97%. He was given ASA 81 mg, nitro SL x3 without relief. EKG showed inferior ST elevations. He was started on a heparin gtt, nitro gtt, and was given 4 mg IV morphine and 5 mg IV metoprolol. No integrillin was given due to his chronic kidney disease/single kidney. Got 600 mg of plavix. . He was taken to the cath lab. His inital CK returned normal at 173 and trop was 0.02. Cardiac catheterization showed a patent proximal LAD stent with proximal edge 40% and 60-70% lesion distal to stent involving diagonal bifurcation. Left circ showed 80% large OM1. A DES was placed in the OM1. Anomalous RCA with significant disease (totally occluded), however chronic as the RV branches were open with good flow. He experienced pain in his left shoulder and arm [**2146-8-9**] which he states is chronic of many months duration. His post intervention EKG showed resolution of the ST elevations. . On presentation, he denied chest pain, shortness of breath, shoulder pain, or other symptoms. . On review of systems, he denied any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, black stools or red stools. He denied recent fevers, chills or rigors. He did admit to a chronic cough. He did have pain in his knees and left shoulder at baseline. All of the other review of systems were negative. . Cardiac review of systems was notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He stated his exercise ability was limited by knee pain. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: STEMI in [**2141**] s/p PTCA at [**Hospital1 2177**] -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: 1)CAD s/p STEMI and PTCA of LAD [**2141**] at [**Hospital1 2177**], presented with lower abd pain and SOB 2)Hypertension 3)dyslipidemia 4)BPH 5)Type 2 diabetes with peripheral neuropathy 6)s/p R nephrectomy 5 years ago - pathology benign per patient 7)early parkinsonism-followed by Neuro 8)Bells'palsy ([**2-1**] HTN) [**6-8**] s/p valtrex 9)CKD II baseline 1.1-1.2 10)Depression 11)Microcytic anemia-stable all his life-?thalassemia. neg, [**Last Name (un) **]-egd in past. 12)Elevated PSA 13)Urinary frequency and incomplete emptying on UDS 14)Knee arthritis Social History: Married, lives with wife. Currently retired. Denies tobbaco, alcohol, or IVDA. He and his wife take care of a 3 year old grandchild. Family History: Significant for a father with diabetes. No history of cancers or strokes. One child with DM Physical Exam: GENERAL: Elderly male lying in bed in NAD. Alert and appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: No JVD present. CARDIAC: RRR, 3/6 systolic murmur radiating to his carotids present. LUNGS: Patient is breathing comfortably. He has slight crackles at the sides of his bases bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No edema present. Right femoral area with dressing in place. No active bleeding present. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Femoral 2+ DP 2+ PT 2+ Left: Femoral 2+ DP 2+ PT 2+ Pertinent Results: [**2146-2-18**] 11:20PM BLOOD WBC-6.1 RBC-4.97 Hgb-9.9* Hct-32.8* MCV-66* MCH-19.9* MCHC-30.1* RDW-14.1 Plt Ct-197 [**2146-2-20**] 05:50AM BLOOD WBC-10.6# RBC-4.45* Hgb-9.4* Hct-29.6* MCV-67* MCH-21.1* MCHC-31.7 RDW-14.3 Plt Ct-184 [**2146-2-22**] 06:15AM BLOOD WBC-7.5 RBC-4.50* Hgb-9.5* Hct-30.0* MCV-67* MCH-21.0* MCHC-31.5 RDW-14.1 Plt Ct-198 [**2146-2-21**] 06:50AM BLOOD PT-12.0 PTT-32.6 INR(PT)-1.0 [**2146-2-18**] 11:20PM BLOOD Glucose-265* UreaN-21* Creat-1.2 Na-140 K-3.6 Cl-103 HCO3-29 AnGap-12 [**2146-2-22**] 06:15AM BLOOD Glucose-135* UreaN-18 Creat-1.2 Na-139 K-4.3 Cl-102 HCO3-30 AnGap-11 [**2146-2-18**] 11:20PM BLOOD CK(CPK)-173 [**2146-2-18**] 11:20PM BLOOD cTropnT-0.02* [**2146-2-19**] 05:27AM BLOOD CK-MB-9 cTropnT-0.13* [**2146-2-21**] 06:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0 [**2146-2-19**] 12:06AM BLOOD Type-ART FiO2-2 pO2-81* pCO2-45 pH-7.40 calTCO2-29 Base XS-1 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2146-2-19**] 12:06AM BLOOD Glucose-241* Lactate-1.0 Na-138 K-3.8 [**2146-2-19**] 12:06AM BLOOD Hgb-10.0* calcHCT-30 O2 Sat-94 Cardiac Cath Study Date of [**2146-2-18**] COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated 3 vessel CAD with likely culprit OM. The LMCA had no significant stenoses. The LAD had a patent stent with a 40% stenosis at the proximal edge and a 60-70% stenosis distal to the stent. The LCx was large and had an 80% stenosis at OM1. The RCA was small and had diffuse subtotal occlusion with TIMI 3 flow to the RV branches. 2. [**Name (NI) 18583**] PTCA and stenting of thr OM1 with a 2.5x18 mm Promus DES with excellent results (see PTCA Comments). 3. Successful closure of the RCF arteriotomy with a 6F angioseal. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease with likely culprit OM. 2. Stenting of the OM1 with a Promus DES 3. Closure of the R-CF arteriotomy with a 6F angioseal. 4. Severely diseased non-dominant RCA with patent RV branches 5. Anterior take off of the RCA that was difficult to selectively engage with AR2 diagnostic catheter 6. ASA 325 mg daily and Plavix 75 mg daily [**Hospital1 **] x 7 days then once daily x minimum of 12 months 7. High dose statin 8. Echo on Monday 9. ACE-inhibitor if renal parameters permit 10. beta blockers 11. Consider stress test in few weeks to evaluate the significance of the LAD (ostial and mid) lesions TTE (Complete) Done [**2146-2-19**] at 10:57:04 AM FINAL The left atrium is moderately 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 mild regional left ventricular systolic dysfunction with inferior hypokinesis. The remaining segmetns are hyperdynamic and the LVEF is therefore preserved.. 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 root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. There is atypical mitral annular calcification (MAC) that occurs mainly at the anterior annulus encroaching on the LVOT but without evidence for LVOT obstruction or sub (aortic) stenosis (LVOT diameter is 1.5 cm). Ther are small, bland-appearing, mobile elements associated with the MAC. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Mr. [**Known lastname 17922**] is a 72 year-old male with pmh of CAD s/p STEMI and stent to the proximal LAD in [**2141**], DM, htn, HL who was admitted from the ED to the cath lab with a question of STEMI s/p DES to OM1. # CORONARIES/STEMI s/p DES to OM1: Initial CK is normal at 173 and Trop of 0.02. STE in the inferior leads, however he was found to have a new occlusion in his Lt Cx OM1 now s/p DES. His STEs resolved after intervention. His peak CK was 173 and was downtrending afterwards. The patient was continued on aspirin, plavix, metoprolol and simvastatin. A TTE was done which showed EF 55%. He was discharged with close follow up with his cardiologist and primary care physician. # Hypertension: The patient had elevated blood pressure that was difficult to correct. He was started was eventually maintained on valsartan, metoprolol, hydrochlorothiazide and amlodipine. At discharge his blood pressure was controlled. If he needs further management he may do well with clonidine. He will follow up with his primary care physician in the near future. # Hyperlipidemia: The patient was started on simvastatin 80mg daily while an inpatient. Gemfibrozil was held. Further management was deferred to primary care physician and cardiologist. # Diabetes type II: The patient was continued on his home insulin regimen. # Chronic kidney disease: The patient had a history of nephrecomy. He was treated with n-acetylcysteine and fluids per cath protocl. His creatinine remained stable at 1.2. # Chronic anemia: The patient was at his baseline and has a chronic microcytic anemia. This will be followed by his primary care physician. # Arm pain: chronic in nature. Not related to heart. The patient will see orthopedics as an outpatient for further evaluation. # BPH: He was continued on his home terazosin and finasteride. # Code status: the patient was full code. Medications on Admission: Aspirin 81 mg po daily Pravastatin 20 mg po daily Terazosin 7mg po qhs Valsartan 80 mg po daily Gemfibrozil 600 mg po daily Finasteride 5 mg po daily Atenolol 50 mg po daily Omeprazole 20 mg Capsule, Delayed Release(E.C.) po daily Insulin NPH & Regular Human 100 unit/mL (70-30), 25 units SQ [**Hospital1 **] Hydrochlorothiazide 12.5 mg po daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Terazosin 2 mg Capsule Sig: 3.5 Capsules PO HS (at bedtime). 3. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day. 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Metoprolol Succinate 200 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* 8. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: Twenty Five (25) units Subcutaneous twice a day. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days. Disp:*8 Tablet(s)* Refills:*0* 11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST Elevation Myocardial Infarction Hypertention Diabetes mellitus Coronary Artery Disease Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You had a heart attack and a cardiac catheterization showed a blockage in one of your arteries that was opened with a stent. It is extremely important that you take Plavix and aspirin every day for at least one year. Don't stop taking Plavix unless Dr. [**Last Name (STitle) 911**] tells you to. If you stop taking Plavix, you could have another more serious heart attack. Your blood pressure was high and we made the following changes to your medicines: 1. Increase your aspirin to 325 mg 2. Increase your Pravastatin to 80 mg daily 3. Increase your Valsartan to 160 mg twice daily 4. Stop taking Atenolol 5. Start taking Metoprolol XL daily 6. Take Plavix twice daily for the next 4 days, then decrease to once daily for one year. Followup Instructions: Primary Care: [**Last Name (LF) 72667**],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 1260**] Date/time: Wednesday [**2-23**] at 2:45pm. . Cardiology: Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] Phone: [**Telephone/Fax (1) 62**] Date/Time: Thursday [**3-24**] at 3:00pm. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "250.60", "403.90", "410.71", "351.0", "585.2", "414.01", "412", "V45.82", "280.9", "600.01", "V45.73", "357.2", "332.0", "788.41" ]

icd9cm

[ [ [] ] ]

[ "00.66", "88.56", "36.07", "00.45", "37.22", "00.40" ]

icd9pcs

[ [ [] ] ]

11554, 11560

7936, 9820

332, 408

11717, 11717

4266, 5997

12622, 13067

3475, 3568

10217, 11531

11581, 11696

9846, 10194

6014, 7913

11865, 12599

3583, 4247

2588, 2712

275, 294

436, 2478

11732, 11841

2743, 3307

2500, 2568

3323, 3459

15,259

178,406

47141

Discharge summary

report

Admission Date: [**2112-4-5**] Discharge Date: [**2112-4-8**] Service: NEUROLOGY Allergies: Penicillin G Attending:[**First Name3 (LF) 5018**] Chief Complaint: Code Stroke Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a [**Age over 90 **] year old man with a history of CAD, high cholesterol, hypertension, now presenting as a code stroke. The patient is a poor historian and unfortunately has few notes to confirm his medical history. His son provides the details of the event. The patient awoke this morning at 4:30 am and went about his daily routine. He was talking and interacting with the son. Around 7 am, the patient began to wash the dishes and the son left to walk to the corner grocery store. When he returned around 7:30 am, his mother informed him that his father had fallen to the ground. He walked into the kitchen to discover the patient lying on the floor, not moving his left side and slurring his speech. He was following simple commands The son activated EMS and he was taken to an OSH. A head ct did not reveal any evidence of infarct or hemorrhage. There he was found to be in afib, they decided against iv-tpa and started him on heparin. He was transferred to [**Hospital1 18**] ED for further care. He arrived here at 1:56 pm, a code stroke was activated at 2:01 pm. I arrived at the bedside within 3 minutes. ROS: no recent fevers, chills, or urinary problems (according to the son who observes him on a daily basis) Past Medical History: -CAD s/p cabg -high cholesterol -high blood pressure -elevated PSA in past -COPD Social History: Lives with wife, primary caregiver for her. Family History: Unknown. Physical Exam: Physical Exam Vitals: 98.6 130 120/70 18 98% RA General: older man in no acute distress Neck: supple Lungs: clear to auscultation CV: irregular rhythm Abdomen: non-tender, non-distended, bowel sounds present Ext: warm, no edema Neurologic Examination: Mental Status: Awake but keeps eyes closed; looks primarily toward the right, intermittantly following simple commands; talking and will repeat but with phonemic errors and significant dysarthria; inattentive to left side Cranial Nerves: Blinks to threat on right, no blink on left; right pupil reacts 3 to 2 mm, left pupil more sluggish 3 to 2.5 mm; eyes move rightward, difficulty getting eyes to pass midline left, left facial droop Motor: Increased tone on right; more flaccid tone on left (arm more so than leg); right arm and leg full strength; left arm and leg 2/5 strength (not anti-gravity) No pronator drift on right Sensation was intact to noxious stimuli on left (and right as well) Reflexes: B T Br Pa Pl Right 2 2 2 2 1 Left 2 2 2 1 1 Toe up on the left side Coordination shows good fnf on right, unable to perform on left Gait exam deferred Pertinent Results: [**2112-4-5**] 02:20PM PT-13.1 PTT-27.7 INR(PT)-1.1 [**2112-4-5**] 02:20PM PLT COUNT-247 [**2112-4-5**] 02:20PM WBC-11.7* RBC-5.08 HGB-15.7 HCT-46.3 MCV-91 MCH-31.0 MCHC-34.0 RDW-14.7 [**2112-4-5**] 02:20PM TSH-2.2 [**2112-4-5**] 02:20PM TRIGLYCER-64 HDL CHOL-49 CHOL/HDL-3.8 LDL(CALC)-123 [**2112-4-5**] 02:20PM ALBUMIN-4.4 CHOLEST-185 [**2112-4-5**] 02:20PM CK-MB-17* MB INDX-6.3* cTropnT-0.47* [**2112-4-5**] 02:20PM LIPASE-16 [**2112-4-5**] 02:20PM ALT(SGPT)-27 AST(SGOT)-48* LD(LDH)-256* CK(CPK)-268* ALK PHOS-505* AMYLASE-45 TOT BILI-0.9 [**2112-4-5**] 02:20PM GLUCOSE-143* UREA N-34* CREAT-1.1 SODIUM-141 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2112-4-5**] 02:30PM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2112-4-5**] 02:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2112-4-5**] 02:30PM URINE COLOR-Pink APPEAR-Hazy SP [**Last Name (un) 155**]-1.007 [**2112-4-5**] 05:52PM LACTATE-2.2* [**2112-4-5**] 06:29PM %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE [**2112-4-5**] 11:01PM CK-MB-11* MB INDX-5.3 cTropnT-0.78* [**2112-4-5**] 11:01PM CK(CPK)-207* [**2112-4-5**] 11:13PM freeCa-1.12 [**2112-4-5**] 11:13PM O2 SAT-94 [**2112-4-5**] 11:13PM LACTATE-1.5 [**2112-4-5**] 11:13PM TYPE-ART PO2-144* PCO2-37 PH-7.42 TOTAL CO2-25 BASE XS-0 INTUBATED-NOT INTUBA NON-CONTRAST HEAD CT SCAN: There is hypodensity of the right caudate nucleus and right putamen, extending into the subinsular white matter on the right side. The right caudate nucleus is enlarged compared to the left side, and the contours of the hypodensity suggest edema consistent with recent infarction of this tissue. Furthermore, there are areas of relative [**Name (NI) 99906**] compared to the normal brain parenchyma within the hypodense infarct, raising the possibility of small areas of hemorrhage within the infarct. There is no evidence of extra-axial hemorrhage. There is no shift of the normally midline structures. The ventricles and sulci are prominent, consistent with involutional change. There is a small rounded hypodensity within the left cerebral peduncle, likely representing either a vascular space or an old lacunar infarction, and there is lacunar infarction in the inferior right cerebellum. The visualized paranasal sinuses and mastoid air cells are clear. There are dense vertebrobasilar and carotid calcifications. There are densities at the periphery of the left globe, probably indicating scleral banding. Soft tissues are otherwise unremarkable, as are osseous structures. IMPRESSION: 1. Recent infarction of the right caudate, putamen, extending into the subinsular white matter on the right side. Correlate with clinical history. 2. Isodense areas within the infarcted tissue, which may represent small areas of hemorrhage or spared brain parenchyma. The findings of acute infarction and possible hemorrhage within the infarcted tissue were discussed with Dr. [**Last Name (STitle) 14944**] at the immediate conclusion of the exam. [**Age over 90 **]-year-old man with dyspnea and hypoxia, CVA, AFib. Evaluate for edema or infiltrate. CHEST, PORTABLE: Prior studies obtained at an outside office are not available for comparison. The heart is enlarged. The mediastinal and hilar contours are unremarkable. There is haziness of the pulmonary vasculature with more patchy opacities throughout the left lung. Sternal wires are identified from prior cardiac surgery. There are no large pleural effusions. IMPRESSION: Cardiomegaly with CHF. The patchy opacities throughout the left lung likely represent asymmetric pulmonary edema. Differential diagnosis includes multifocal pneumonia superimposed on CHF and followup after treatment is recommended. MRI OF THE BRAIN: Diffusion-weighted images demonstrate a large area of restricted diffusion corresponding to the right middle cerebral artery territory, including the right basal ganglia, insular cortex and portions of the right frontal, parietal, and temporal lobes. The apparent infarcted tissue occupies a much larger region than seen on the head CT scan of the prior day. There is susceptibility effect noted within the right putamen and the infarcted tissues are slightly effaced. There is no shift of the normally midline structures. There is mild mass effect on the right lateral ventricle. There is a smaller rounded area of restricted diffusion at the left temporo- occipital junction region. There is elevated T2 and FLAIR signal at this locale, suggesting a more subacute small infarct. There are small foci of increased T2 and FLAIR signal within the cerebral periventricular white matter, consistent with chronic microvascular ischemia. MRA OF THE BRAIN: TECHNIQUE: 3-D time-of-flight imaging of the distal vertebral and internal carotid arteries were obtained, including the circle of [**Location (un) 431**]. 3-D reformatted images are provided. MRA OF THE BRAIN: As expected in this case of right middle cerebral artery infarction, no flow is seen within the right middle cerebral artery beyond the M1 segment. In addition, no flow is visualized within the distal left vertebral artery, nearly to the junction point with the basilar artery. A small amount of residual flow is seen within the superior-most left vertebral artery. Of note, there is no evidence of infarction of the territory supplied by the posterior circulation. There are no areas of aneurysmal dilation clearly appreciated. IMPRESSION: 1. Large acute right middle cerebral artery territory infarction, significantly increased in size compared to infarcted tissue seen on recent head CT of one day previous. 2. Evidence of hemorrhagic transformation within the right putamen. 3. MRA shows occlusion of the right middle cerebral artery beyond the most M1 segment. 4. No flow is visualized within the left vertebral artery, except at the immediate junction of the left vertebral artery with the basilar artery. Brief Hospital Course: [**Age over 90 **] yo man with hx htn, cad s/p cabg, COPD, who presented with sudden onset left hemiplegia, found to be in new afib; initial exam with inattention, lethargy, dysarthria, left arm and leg weakness, and head ct with new right subcortical stroke; also found to have demand NSTEMI with peak troponin 0.78, pneumonia versus asymmetric pulmolnary edema with high O2 requirement and tenuous sats, and low initial pressures requiring fluid boluses, worsened respiratory status. Brain MRI/A with Right M1 occlusion, large area of infarct +DWI including basal ganglia; hemorrhagic transformation R putamen. No flow in left vert. (NOTE: also lots of atrophy, big vents). The patient was admittd to the ICU and was diuresed; cardiology was consulted for aflutter vs afib at presentation and ?indication for anticoag vs antiplatelet. The patient's respiratory status remained tenuous throughout the admission thought secondary to CHF (versus pneumonia) and he showed no major improvement from the stroke. His heart rate remained high despite diltiazem drip; his pressure was often tenuous. He was made CMO on [**4-7**] via family discussion with Dr. [**Last Name (STitle) 26687**]/ICU attending. He passed away at 8:55 am on [**4-8**] - exam with no spont breath/heart sounds, pupils fixed and 5mm, no brainstem reflexes. The patient's son was at the bedside and declined autopsy. Medications on Admission: -asa 325 -imdur 30 qd -metoprolol 12.5 [**Hospital1 **] -triamterene/hctz -lipitor Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: expired immediate cause of death: resp arrest x hours, secondary: chf exacerbation x days, stroke x days Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2112-4-8**]

[ "401.9", "413.9", "427.31", "410.71", "V45.81", "496", "428.0", "272.0", "434.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10441, 10450

8884, 10278

232, 238

10598, 10607

2884, 8861

10663, 10815

1703, 1713

10412, 10418

10471, 10577

10304, 10389

10631, 10640

1728, 1963

180, 194

266, 1522

2226, 2865

2002, 2210

1987, 1987

1544, 1626

1642, 1687

21,942

144,950

30992

Discharge summary

report

Admission Date: [**2187-4-23**] Discharge Date: [**2187-4-30**] Date of Birth: [**2140-1-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**2187-4-24**] Aortic Valve Replacement(25mm [**Company 1543**] Mosaic)/Ascending Aorta and Hemi-Arch Replacement (26mm Gelweave graft)/Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) History of Present Illness: 47 y/o male firfighter with new exertional chest pain . Underwent cath at OSH which revealed severe coronary artery disease. Also had an echo which showed moderate AI with dilated aorta. He was then transferred to [**Hospital1 18**] for further care. Past Medical History: Hypertension, Dyslipidemia Social History: Denies tobacco, but admits to occ. ETOH. Family History: +CAD in mother/grandfather/grandmother Physical Exam: Gen: NAD Neuro: A&O x 3, MAE, non-focal HEENT: NC/AT, EOMI, PERRL Neck: Supple, FROM, -JVD Pulm: CTAB CV: RRR 4/6 SEM Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, 2+ pulses throughout, -varicosities Pertinent Results: [**2187-4-24**] Echo: PRE-BYPASS: 1.No atrial septal defect is seen by 2D or color Doppler. 2.There is mild symmetric left ventricular hypertrophy. 3. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed. 4.There are focal calcifications in the aortic arch. 5.The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. POST-BYPASS: 1. Patient is in sinus rhythm. 2. Biventricular systolic function is unchanged. 3. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 12 mmHg). Trace aortic regurgitation is seen. 4. Aorta intact post decannulation. [**4-29**] CXR: The patient is status post sternotomy, with mediastinal clips. There is marked prominence of the cardiomediastinal silhouette, compatible with recent surgery. Again seen is increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation, not significantly changed compared with one day earlier. There is minimal patchy atelectasis in the right cardiophrenic region and minimal blunting of the right costophrenic angle. A small left effusion may also be present. No CHF. ? small amount of residual mediastinal air, as seen on the lateral view. Otherwise, no evidence of pneuumotrax or mediastinal air. [**2187-4-23**] 09:04PM BLOOD WBC-9.7 RBC-5.54 Hgb-16.7 Hct-47.6 MCV-86 MCH-30.1 MCHC-35.0 RDW-13.6 Plt Ct-312 [**2187-4-26**] 06:20AM BLOOD WBC-12.6* RBC-3.22* Hgb-9.8* Hct-28.4* MCV-88 MCH-30.5 MCHC-34.6 RDW-14.3 Plt Ct-193 [**2187-4-23**] 09:04PM BLOOD PT-12.8 PTT-31.8 INR(PT)-1.1 [**2187-4-23**] 09:04PM BLOOD Glucose-151* UreaN-28* Creat-1.8* Na-136 K-4.0 Cl-97 HCO3-28 AnGap-15 [**2187-4-26**] 06:20AM BLOOD Glucose-146* UreaN-22* Creat-1.5* Na-137 K-4.5 Cl-98 HCO3-35* AnGap-9 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname 73249**] was transferred from OSH after cath and echo revealed CAD, AI, and dilated aorta. On [**4-24**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4, aortic valve replacement and a ascending aorta and hemi-arch replacement. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and diuresed towards his pre-op weight. On post-op day two he was transferred to the telemetry floor for further care. His chest tubes and epicardial pacing wires were removed per protocol. He required aggressive respiratory toilet and worked with physical therapy for strength and mobility. He was slow to wean from oxygen via nasal cannula d/t low O2 sat. Over the remainder of his hospital course his electrolytes were repleted and blood pressure meds adjusted for maximum hemodynamics. On post-operative day six he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Toprol XL 25mg qd, Simvastatin 40mg qd, Aspirin 325mg qd, Lisinopril/HCTZ 10/12.5mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Greater [**Hospital1 189**] Discharge Diagnosis: Aortic Insufficiency/Dilated Aorta/Coronary Artery Disease s/p Aortic Valve Replacement, Ascending Aorta and Hemi-Arch Replacement, Coronary Artery Bypass Graft x 4 PMH: Hypertension, Dyslipidemia Discharge Condition: good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. Followup Instructions: wound clinic in 2 weeks Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73250**] in [**1-21**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2187-4-30**]

[ "593.9", "746.4", "401.9", "441.2", "272.4", "414.01", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "36.15", "38.45", "39.61", "35.21", "89.60", "36.13" ]

icd9pcs

[ [ [] ] ]

5655, 5720

3317, 4514

331, 552

5960, 5966

1232, 3294

6680, 6868

956, 996

4651, 5632

5741, 5939

4540, 4628

5990, 6657

1011, 1213

281, 293

580, 832

854, 882

898, 940

13,881

164,487

25413

Discharge summary

report

Admission Date: [**2110-11-6**] Discharge Date: [**2110-11-23**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 5880**] Chief Complaint: Colon polyp Major Surgical or Invasive Procedure: Sigmoid colectomy Tracheostomy History of Present Illness: Patient is an 81 year old woman with a recent history of CVA x 3 ([**9-4**], [**9-16**], [**9-19**]), and lower GI bleeding. She presented for removal of her sigmoid colon for polyps. She had a colonoscopy on [**2110-9-2**] which found polyps in the ascending colon, polyps at distance of 30-35cm in mid-sigmoid colon, as well as transverse colon and descending colon in addition to diverticulosis of sigmoid and descending colon. Pathology from colonic biopsies showed adenomas and hyperplastic polyps. The patient had been well since last discharge with no CVA events or bleeding episodes. Past Medical History: PMH: Hypothyroidism; Temporal arteritis 2 years ago, with residual left eye blindness; HTN; h/o dizziness/vertigo; Polymyalgia rheumatica; h/o laryngeal CA [**25**] yrs, s/p XRTx41. PSH: Hysterectomy at age 25 for fibroids, per pt; Appendectomy [**2054**]; Breast lump excision, benign per pt; Right knee arthroscopy Social History: Pt is married and has 2 children. 35 pack year smoker, quit 20 years ago. Drinks 2-3 drinks/week. Family History: Father died of lung CA, sister and brother died of MI. Other brother had a stroke in his 80s, now 84. Physical Exam: Exam on admission: Temp 98.2, HR 90, BP 110/68, RR 18, SaO2 97% room air Alert and oriented, no distress. No scleral icterus, EOMI, no vision Left eye. RRR, no M/G/R. CTAB. Soft, NTND. No C/C/E. Motor strength 4+/5 in upper and lower extremities. CN II-XII grossly intact. Normal speech and language. No facial assymetry. Pertinent Results: [**2110-11-6**] 09:12PM PTT-49.0* [**2110-11-6**] 04:16PM GLUCOSE-106* UREA N-10 CREAT-0.7 SODIUM-144 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-28 ANION GAP-13 [**2110-11-6**] 04:16PM CALCIUM-9.6 PHOSPHATE-4.2 MAGNESIUM-2.1 [**2110-11-6**] 04:16PM WBC-9.2 RBC-3.93* HGB-11.4* HCT-33.8* MCV-86# MCH-29.0 MCHC-33.6 RDW-13.1 [**2110-11-6**] 04:16PM PLT COUNT-295 [**2110-11-6**] 04:16PM PT-13.4* PTT-22.1 INR(PT)-1.2 Brief Hospital Course: The patient was admitted and underwent resection of her sigmoid colon on [**2110-11-7**]. Postoperatively, she was anticoagulated for her history of CVAs on heparin. She subsequently developed a respiratory infection, sputum cultures grew out coag postive staph (resistant) and sparse yeast. On post op day 7, she had respiratory failure and was transferred to the ICU. She was intubated and underwent an open tracheostomy tube placement on [**2110-11-19**]. A PICC line was placed for IV antibiotics. She was deemed ready for discharge to an acute care rehabilitation facility on [**2110-11-23**]. Medications on Admission: Prednison 10 qd, Lisinopril 5 qd, Synthroid 100 qd, Alendronate 70 qMon, Meclizine 25 tid, Simvistatin 20 qd, Metoprolol 25 [**Hospital1 **], Coumadin Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed. 4. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO PRN (as needed). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 7. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as needed). 8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 10. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 11. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. 14. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. 16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): INR goal 2.0-2.5. 20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 21. Vancomycin 500 mg Recon Soln Sig: 750 mg Recon Solns Intravenous Q 12H (Every 12 Hours) for 4 days: 750mg Q12H, please stop [**11-26**]. 22. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours): Hold for SBP<120. 23. Heparin (Porcine) 2,500 unit/mL Solution Sig: 650ml/hr ml Intravenous drip: Please adjust for PTT 40-60 until therapeutic INR reached on Coumadin (INR goal 2.0-2.5). 24. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 25. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): please maintain glycemic control with sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Colon polyps CVA x 3 Discharge Condition: Stable Discharge Instructions: Please continue ventilatory support via trachestomy tube as necessary. Please continue tube feeds as directed. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **], general surgery, in 2 weeks, [**Telephone/Fax (1) 6439**]. Please follow up with your neurologist as directed. Completed by:[**2110-11-23**]

[ "V10.21", "427.31", "V15.3", "244.9", "997.02", "518.5", "997.1", "725", "153.3", "285.9", "008.45", "482.41", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.94", "33.24", "99.04", "45.76", "31.1", "96.04", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

5487, 5566

2263, 2863

231, 264

5631, 5640

1818, 2240

5799, 5995

1358, 1461

3064, 5464

5587, 5610

2889, 3041

5664, 5776

1476, 1481

180, 193

292, 885

1495, 1799

907, 1226

1242, 1342

58,389

117,815

35421

Discharge summary

report

Admission Date: [**2122-4-1**] Discharge Date: [**2122-4-10**] Date of Birth: [**2095-4-9**] Sex: F Service: MEDICINE Allergies: Xanax / Lamictal Attending:[**First Name3 (LF) 9415**] Chief Complaint: Suicide attempt by polypharmacy ingestion Major Surgical or Invasive Procedure: Endotracheal intubation Incision and drainage of left wrist phlebitis PICC placement History of Present Illness: 26 female with history of depression, previous suicide attempts and numerous psychiatric admission who was found down at home. Last seen a couple of days ago. Bowl of pills found near her containing acetaminophen-diphenhydramine, ibuprofen. Other meds she takes include quetiapine and duloxetine. FS in field 190. Brought to ED. Initial vitals 97.8 130 75/60 14 100%NRB. She presented obtunded, tachycardic, dilated pupils and has dry mucous membranes. Withdraws to noxious stimulus. Intubated for airway protection. Got fluids with improvement in blood pressure. Initial ECG reveal tachycardia, QRS 90, QTc 454. NG lavage did not reveal any pill fragments. Tylenol level positive at 178. Trycyclic positive on tox screen likely [**2-16**] diphenhydramine ingestion. Initial ABG 7.0/43/646/11. Started on NAC and bicarb gtt. Head CT and chest CT negative. Transferred to ICU. In ICU, intial vitals 97.0 114 136/91 21 100% on AC. Pt restless, jerking movements, eyes moving frenetically. Evidence of cutting on arms and abdomen. K 6.5 with EKG changes suggestive of hyperkalemia so gave 1 amp Ca and 10 units insulin plus an amp of D50. Past Medical History: 1) Depression with hx of previous ECT - [**2121**] x 6-8 months at [**Doctor First Name **] at one point 2) Suicide Attempts x4 involving Tylenol Overdose 3) Multiple Psychiatric Hospitalizations 4) Anorexia nervosa 5) Bulimia Social History: *per psych inpatient consult* Born and raised in [**Location (un) 686**]. FTT as a baby, not very social and cried a lot. At ten yo, started getting panic attacks. This was treated with therapy, no meds. Pt did well in school, but had social anxiety. No known history of abuse. No known history of romantic relationships. Youngest of 3 (one sister and one brother). Family History: No known or pertinent family medical history. FAMILY PSYCHIATRIC HISTORY: *per psych inpatient consult* Mat Grandfather committed suicide at [**Hospital1 **] in [**2074**], had been hospitalized for ECT. Maternal aunt with manic depression. Maternal aunt ?borderline - multiple hospitalizations. Brother - became very isolated, living on streets, [**Last Name (un) 68185**]. Now doing well. Physical Exam: Upon Discharge: VS: T 98.2, BP (105-140)/(70-90), HR (66-85), RR 18, O2sat 99% RA GEN: NAD HEENT: PERRL, EOMI, wears corrective lenses, oral mucosa moist NECK: Supple, no LAD, EJ IV site with minimal tenderness and without erythema CARD: RR, nl S1, nl S2, no M/R/G PULM: Minimal bibasilar decreased breath sounds and dullness to percussion, no crackles ABD: Muliple scars on lower abdomen with one healing superficial laceration of RLQ, BS+, soft, mildy tender RUQ, ND EXT: no C/C/E, left wrist with erythematous pustule and reduced swelling and no residual bleeding s/p I&D NEURO: Oriented x 3, non-focal, ambulatory without assistance PSYCH: Good range of affect Pertinent Results: ECG [**2122-4-1**]: Sinus tachycardia, rate 129. Vertical axis. Left atrial abnormality. No other diagnostic abnormality. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 129 114 90 334/454 73 95 71 CHEST (PORTABLE AP) [**2122-4-1**]: IMPRESSION: Appropriate position of ET tube. No acute intrathoracic process. CT HEAD W/O CONTRAST [**2122-4-1**]: IMPRESSION: No acute intracranial process. ECG [**2122-4-2**]: Sinus tachycardia. Non-specific T wave flattening throughout the tracing. These diffuse T wave changes may be related to electrolyte abnormalities. Clinical correlation is suggested. Rate PR QRS QT/QTc P QRS T 125 124 80 282/395 68 80 29 ECG [**2122-4-4**]: Sinus tachycardia. Diffuse non-specific T wave flattening. Compared to the previous tracing of [**2122-4-2**] there is no significant diagnostic change. Rate PR QRS QT/QTc P QRS T 125 134 70 278/391 56 47 37 CHEST (PA & LAT) [**2122-4-5**]: IMPRESSION: Probable multilobar aspiration pneumonia. TTE (Complete) [**2122-4-7**]: CONCLUSIONS: The left atrium is normal in size. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. No vegetations seen (cannot definitively exclude). HEMATOLOGY: [**2122-4-1**] 08:05PM BLOOD WBC-13.0* RBC-4.53 Hgb-13.3 Hct-41.8 MCV-92 MCH-29.3 MCHC-31.7 RDW-13.9 Plt Ct-395 [**2122-4-2**] 05:56AM BLOOD WBC-12.6* RBC-3.28*# Hgb-10.2*# Hct-29.8*# MCV-91 MCH-31.0 MCHC-34.1 RDW-14.2 Plt Ct-265 [**2122-4-3**] 08:31PM BLOOD Hct-24.7* [**2122-4-7**] 03:45PM BLOOD WBC-6.6# RBC-3.30* Hgb-9.8* Hct-29.4* MCV-89 MCH-29.8 MCHC-33.5 RDW-14.5 Plt Ct-244 COAGS: [**2122-4-1**] 08:05PM BLOOD PT-15.5* PTT-25.3 INR(PT)-1.4* [**2122-4-3**] 03:20AM BLOOD PT-17.4* PTT-32.5 INR(PT)-1.6* [**2122-4-7**] 03:45PM BLOOD PT-13.1 INR(PT)-1.1 CHEMISTRY: [**2122-4-1**] 08:05PM BLOOD Glucose-156* UreaN-28* Creat-2.8* Na-142 K-5.2* Cl-102 HCO3-11* AnGap-34* [**2122-4-1**] 08:05PM BLOOD TotProt-7.3 Albumin-4.4 Globuln-2.9 Calcium-9.4 Phos-9.5* Mg-2.1 [**2122-4-2**] 05:56AM BLOOD Glucose-243* UreaN-21* Creat-2.1* Na-146* K-3.8 Cl-110* HCO3-18* AnGap-22* [**2122-4-3**] 03:20AM BLOOD Glucose-95 UreaN-17 Creat-1.4* Na-142 K-3.8 Cl-113* HCO3-20* AnGap-13 [**2122-4-5**] 06:22AM BLOOD Glucose-97 UreaN-5* Creat-0.6 Na-140 K-3.4 Cl-113* HCO3-20* AnGap-10 [**2122-4-7**] 03:45PM BLOOD Glucose-110* UreaN-5* Creat-0.7 Na-142 K-4.3 Cl-105 HCO3-27 AnGap-14 [**2122-4-7**] 03:45PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.8 Mg-1.8 HEPATOLOGY: [**2122-4-1**] 08:05PM BLOOD ALT-36 AST-57* LD(LDH)-217 CK(CPK)-1056* AlkPhos-58 TotBili-0.2 [**2122-4-3**] 03:20AM BLOOD ALT-42* AST-80* CK(CPK)-2179* AlkPhos-38* TotBili-0.3 [**2122-4-6**] 05:05AM BLOOD ALT-47* AST-38 LD(LDH)-270* CK(CPK)-489* AlkPhos-62 TotBili-0.4 [**2122-4-7**] 03:45PM BLOOD ALT-38 AST-29 TotBili-0.2 IRON STUDIES: [**2122-4-3**] 08:31PM BLOOD calTIBC-274 Ferritn-32 TRF-211 [**2122-4-3**] 08:31PM BLOOD Iron-8* TOXICOLOGY: [**2122-4-1**] 08:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-178.9* Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2122-4-2**] 05:56AM BLOOD Acetmnp-92.9* [**2122-4-2**] 10:02AM BLOOD Acetmnp-73.6* [**2122-4-3**] 03:20AM BLOOD Acetmnp-16.4 [**2122-4-3**] 08:31PM BLOOD Acetmnp-NEG LACTATE TREND: [**2122-4-1**] 11:33PM BLOOD Lactate-4.9* [**2122-4-2**] 10:23AM BLOOD Lactate-2.2* [**2122-4-3**] 01:18PM BLOOD Lactate-0.9 MICROBIOLOGY: [**2122-4-7**] URINE URINE CULTURE-FINAL, NO GROWTH [**2122-4-6**] BLOOD CULTURE Blood Culture, Routine-PENDING NGTD [**2122-4-6**] BLOOD CULTURE Blood Culture, Routine-PENDING NGTD [**2122-4-5**] BLOOD CULTURE Blood Culture, Routine-PENDING NGTD [**2122-4-5**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {STAPH AUREUS COAG +} OXACILLIN SENSITIVE; Anaerobic Bottle Gram Stain-FINAL [**2122-4-5**] URINE URINE CULTURE-FINAL, CONTAMINATED [**2122-4-2**] MRSA SCREEN MRSA SCREEN-FINAL, NEGATIVE Brief Hospital Course: MICU COURSE: The patient was extubated successfully. Mental status improved. Per Toxicology recommendations, she was continued on NAC until her Tylenol level was undetectable and her mental status had improved. A Renal consult was obtained and felt that ARF likely multifactorial including ATN, rhabodomyolysis, APAP, Iburprofen. ARF resolved prior to transfer to medical floor and further Renal follow-up was not recommended. Psychiatry was also consulted and recommended minimal medications in her initial overdose and planned for psychiatric admission once medical issues were stable. Additionally, upon admission K was 6.5 on arrival with peaked T waves on EKG. She was given calcium, insulin, and glucose. Potassium stabilized with resolution of ARF. Patient noted to have small amount of bloody secretions on NGL, likely gastritis in setting of Motrin ingestion, GI evaluated and no need for urgent scope. HCT remained stable and this was not pursued further while in the ICU. The patient was transferred to the floor with a 1:1 sitter on night of [**2122-4-3**]. FLOOR COURSE: #. Fevers / Bacteremia / Pneumonia: Patient initially became febrile overnight on [**2122-4-4**]. On morning of [**2122-4-5**] CXR revealed a multilobar pneumonia. Patient was started on vancomycin and Unasyn on [**2122-4-5**] due to concern for HAP. Patient initially with bibasilar crackles, decreased breath sounds, and dullness to percussion. Plan at that time was to only cover pseudomonas if sputum cultures grew pseudomonas, if patient did not defervesce within two days, or if patient had acute worsening. Had minimal dry cough and never able to provide a sputum sample. On morning of [**4-6**], single blood culture from [**4-5**] returned positive for gram positive cocci and later speciated as an MSSA on [**4-8**]. Given MSSA bacteremia, Vancomycin discontinued on [**4-8**] and Unasyn planned to be continued for total of 14 days via PICC line placed on [**4-8**]. Last dose of antibiotics should be given on morning of [**2122-4-19**]. After that time, the PICC line should be discontinued. Patient's pulmonary exam normalized on [**2122-4-9**] with no residual abnormal findings. Patient's last fever spike was at 0600 on [**2122-4-6**]. Given this data, patient is medically stable for discharge to any extended care facility that can manage IV antibiotics via PICC. At time of discharge, a blood culture from [**4-5**] and two blood cultures from [**4-6**] were still pending and will need to be followed to finality. The number for the microbiology lab is [**Telephone/Fax (1) 4645**]. #. Left wrist phlebitis: At former IV site there was an indurated erythematous pustule. I&D on [**2122-4-7**] with minimal drainage. No culture of exudate was able to be obtained due to insufficient volume. At time of discharge the wound appeared to be resolving and needed no further medical care. #. Tylenol toxicity: Tylenol level returned as negative on [**2122-4-4**], the morning following transfer to the medical floor and patient's NAC infusion was discontinued. LFTs were trended daily until they completely normalized on [**2122-4-7**] and no more labs were felt to be needed. Hepatology team following upon transfer; however, signed off of the case once patient's LFTs were reliably trending down. Was felt that patient should have an acetaminophen restriction of < 2 grams daily for 2 weeks from [**2122-4-7**] as a precaution to prevent further liver injury. Patient is medically stable from this standpoint. #. Anemia: HCT at time of admission ([**2122-4-1**]) was 41.8 and this dropped precipitously to 29.8 on morning after admission. Patient had question of pinkish aspirate from NG tube prior to transfer to floor on [**2122-4-3**]; however, NG lavage was negative for UGI bleeding. HCT was measured daily through [**2122-4-7**] (nadir of 24.7 on [**2122-4-3**]) and found to be stable (and trending upward slightly) with final measured HCT of 29.4 on afternoon of [**2122-4-7**]. Iron of 8 and iron sat of 2.9% from [**2122-4-3**] indicated iron deficiency anemia. GI absorption of iron supplement likely to be reduced in setting of PPI twice daily, thus we decided to replete iron stores with ferric gluconate 125 mg IV daily for 5 total days. Patient will be on ferrous sulfate 325 mg [**Hospital1 **] for iron supplement upon discharge. She will need a daily stool softener to combat and constipation related to her iron supplements. She is medically stable from anemia standpoint and any further follow-up can be done as an outpatient. #. Sinus Tachycardia: On presentation from MICU, heart rate was ranging from 100 to 140s when patient ambulatory. Was given fluid boluses, which decreased rate slightly. Some consideration given to benzodiazepine withdrawal; however, heart rate not significantly responsive to low dose benzos. After fever spike on night of [**2122-4-4**], patient noted to have pneumonia and later bacteremia. Then team felt that tachycardia related to fevers and infectious state. Tachycardia resolved shortly following resolution of fevers and patient had no episodes of tachycardiac in her last 4 days of hospitalization. She is medically stable and ready for discharge from this standpoint. #. Depression/anxiety/suicide attempt: Patient was observed with 1:1 sitter and received safety trays with meals. Patient with good range of affect on daily examinations by medical team. Patient was followed by psychiatry team. Her inpatient psychiatric medications were seroquel 100 mg QHS as well as lorazepam 0.5 mg TID:PRN anxiety. Patient denied feeling anxiety and used only one PRN lorazepam dose. Medical team and psychiatry team agreed that patient should be in care of psychiatry inpatient unit upon discharge. She was deemed medically stable and was discharged with plans for 9 additional days of IV Unasyn via PICC ending on [**2122-4-19**]. The PICC should be discontinued once antibiotic course is complete on morning of [**2122-4-19**]. Medications on Admission: Seroquel 400mg QHS Cymbalta 120mg daily Ativan 0.5mg TID Prilosec 20mg daily Tetracycline 500mg daily Discharge Medications: 1. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 4. Ampicillin-Sulbactam 3 gram Recon Soln Sig: Three (3) grams of Recon Soln Injection Q6H (every 6 hours) for 9 days: Final dose on morning of [**2122-4-19**]. 5. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: Drug overdose Aspiration pneumonia Bacteremia Depression with suicide attempt and suicidal ideation Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted due to an overdose of medications. You briefly required a breathing tube, but were quickly able to breathe on your own. You also have gastritis, or irritated stomach lining, for which you were started on an acid blocker called pantoprazole. You developed a pneumonia, likely from vomiting while you were unconscious, which is being treated with antibiotics. You also developed a blood infection which is being treated with intravenous antibiotics through a special IV called a PICC. Please complete the entire course of your antibiotics. If you develop fevers, chest pain, shortness of breath or any other concerning symptoms please contact your primary care provider or return to the Emergency Department. You are being discharged to a psychiatric facility to help you with your depression. Followup Instructions: Please call your primary care provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32651**] [**Telephone/Fax (1) **] to schedule a hospital follow-up appointment after you complete your psychiatric treatment. Completed by:[**2122-4-10**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "96.04", "86.09", "96.34" ]

icd9pcs

[ [ [] ] ]

14651, 14666

7590, 13580

317, 404

14819, 14838

3331, 7567

15698, 15989

2237, 2631

13732, 14628

14687, 14798

13606, 13709

14862, 15675

2646, 2646

236, 279

2662, 3312

432, 1581

1603, 1832

1848, 2221