ChanBeDu/relevant_section_length · Datasets at Hugging Face

23,299

150,583

15895

Discharge summary

report

Admission Date: [**2169-8-29**] Discharge Date: [**2169-9-4**] Date of Birth: [**2106-11-13**] Sex: M Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old white male with a past medical history significant for coronary artery disease, chronic obstructive pulmonary disease, and hypercholesterolemia. The patient originally presented with unstable angina at the end of [**2169-9-29**]. At that time, the patient experienced sudden onset of shortness of breath, dyspnea, and lightheadedness. He eventually presented to an outside hospital, which revealed possible inferior ST changes. A cardiac catheterization was performed, which revealed three vessel coronary artery disease. The patient was then transferred to [**Hospital1 346**] to be evaluated for a possible coronary artery bypass graft. On the day of admission, the patient was feeling well, denying any chest pain or shortness of breath. He came in on an intravenous heparin drip. PAST MEDICAL HISTORY: 1. Hypertension 2. Coronary artery disease 3. Chronic obstructive pulmonary disease 4. Anxiety 5. Obesity PAST SURGICAL HISTORY: No significant surgical history ALLERGIES: Penicillin OUTPATIENT MEDICATIONS: 1. Paxil 2. Effexor 3. Lipitor 4. Aspirin PHYSICAL EXAMINATION: The patient's temperature was 97.2, heart rate 72, blood pressure 128/77, oxygen saturation 94% on room air. He was in no apparent distress. His head, eyes, ears, nose and throat examination was within normal limits. There was no jugular venous distention. There were no bruits. He was clear to auscultation, although decreased breath sounds throughout. His abdomen was obese, nontender, nondistended, with no hernia or masses palpable. He had decreased bowel sounds. Extremities showed no edema, were warm and well perfused. He had palpable dorsalis pedis and posterior tibial pulses bilaterally. LABORATORY DATA: Hematocrit 41.1, white blood cell count 8.0, platelets 268. PT 12.8, PTT 43.7, INR 1.1. Glucose 79, BUN 15, creatinine 1.0, sodium 141, potassium 4.0. Chest x-ray obtained on [**2169-8-29**] showed no evidence of acute cardiopulmonary disease. HOSPITAL COURSE: The patient was admitted to Cardiac Surgery. At the time, given three vessel disease on cardiac catheterization, it was thought that a surgical solution would be the best approach. On [**2169-8-30**], the patient underwent coronary artery bypass graft x 3, with left internal mammary artery to the left anterior descending, reverse saphenous vein graft to the obtuse marginal, branch of the circumflex and reverse saphenous vein graft of the right coronary artery. The patient tolerated the procedure well. There were no complications. Please see the full operative report for details. The patient was transported to the Cardiac Intensive Care Unit postoperatively. The patient remained intubated. The Swan-Ganz catheter was in place. The patient had chest tubes in place. On the same day, the patient was extubated without incident. The patient was encouraged pulmonary toilet. On postoperative day one, the patient remained in the Intensive Care Unit. He was tolerating ice chips without complaints of nausea. He remained Neo-Synephrine dependent despite additional fluid, with systolic blood pressures in the 90 to 100 range. His BUN, creatinine and white cell count remained stable, as did his hematocrit. Physical Therapy was consulted and worked with the patient daily. The patient was consequently transferred to the regular Cardiac floor. He remained stable. His pacing wires were discontinued. His chest tubes were first put to water seal and then removed as well. He continued to be diuresed and beta blocked as per protocol. He was on aspirin. The patient continued to make significant progress with physical therapy. He was eventually cleared by Physical Therapy to go home. The patient remained in sinus rhythm. CONDITION ON DISCHARGE: Stable DISCHARGE DISPOSITION: Home DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass graft x 3 2. Coronary artery disease 3. Hypertension 4. Hypercholesterolemia 5. Obesity 6. Anxiety 7. Depression DISCHARGE MEDICATIONS: 1. Fenofibrate 160 mg by mouth once daily 2. Venlafaxine XR 150 mg by mouth three times a day 3. Albuterol nebulizers as needed 4. Celexa 40 mg once daily 5. Neurontin 800 mg by mouth twice a day 6. Colace 100 mg by mouth twice a day as needed 7. Milk of magnesia as needed 8. Percocet one to two tablets by mouth every four to six hours as needed 9. Ibuprofen 400 mg by mouth every six hours as needed 10. Enteric-coated aspirin 325 mg by mouth once daily 11. Ranitidine 150 mg by mouth twice a day 12. Potassium chloride 20 mEq by mouth twice a day for ten days 13. Lasix 20 mg by mouth twice a day for ten days 14. Lopressor 12.5 mg by mouth twice a day DISCHARGE INSTRUCTIONS: 1. The patient is to follow up with his surgeon, Dr. [**Last Name (STitle) **], within four weeks. 2. The patient is to follow up with Dr. [**Last Name (STitle) 45630**] [**Name (STitle) **], his primary care physician, [**Name10 (NameIs) 176**] the next week. 3. The patient was instructed to follow up with a cardiologist within the next three weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 45631**] MEDQUIST36 D: [**2169-9-4**] 22:17 T: [**2169-9-5**] 00:14 JOB#: [**Job Number 19739**]

[ "410.41", "272.0", "305.1", "300.00", "496", "414.01" ]

icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2173-12-14**] Discharge Date: [**2173-12-18**] Date of Birth: [**2099-1-10**] Sex: F Service: [**Hospital Unit Name 196**]/CCU HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old female who is transferred to [**Hospital1 18**] from [**Hospital3 23439**] Hospital where she was electively admitted the day prior to her admission here for a cardiac catheterization. The catheterization was scheduled, because of a positive ETT/Cardiolite, which showed anterior/apical ischemia. The ETT was performed, because of recurrent anginal symptoms both at rest and with exertion that have been occurring for the last several months. She has symptoms about once a week and take sublingual nitroglycerin with good relief. Her anginal equivalent is described as mid sternal chest pain radiating to the left arm with associated shortness of breath with nausea, vomiting or diaphoresis. Catheterization performed at States [**Hospital **] Hospital showed left anterior descending coronary artery in stent restenosis. Of note, in [**2173-4-18**] the patient underwent stents to the left anterior descending coronary artery as well as percutaneous transluminal coronary angioplasty to the left circumflex and obtuse marginal two. PAST MEDICAL HISTORY: Question of an myocardial infarction in the past as suggested by electrocardiogram, coronary artery disease status post left anterior descending coronary artery stent and left circumflex percutaneous transluminal coronary angioplasty in [**2173-4-18**]. Hypertension, hypercholesterolemia, status post colon cancer and status post skin cancer. Right eye cataract, question of history of reactive airway disease, carpal tunnel syndrome, remote history of Bells palsy, arthritis. PAST SURGICAL HISTORY: Status post bilateral knee replacement, status post appendectomy, status post cholecystectomy, status post TAH/BSO, status post colon resection for cancer. No radiation or chemotherapy. This was in [**2168**]. Status post excision of right eye "tumor" one to two years ago and status post excision of skin cancer apparently numerous procedures. ALLERGIES: No known drug allergies. No allergy known to contrast dye. MEDICATIONS ON ADMISSION: Aspirin 325 mg po q.d., Captopril 25 mg po b.i.d., Metoprolol 25 mg po b.i.d., Premarin 0.625 mg po q.d., Detrol, but the patient has not been taking recently secondary to cost. Lipitor 5 mg po q.d., Naprosyn 250 mg po prn. FAMILY HISTORY: Father, mother, sister and brother had cancer. Sister and brother have coronary artery disease beginning in their 40s and 50s. She has four grown children in good health. SOCIAL HISTORY: No tobacco use, occasional ethanol. She lives upstairs from her daughter in a two family home. The patient is very independent. She is widowed. She plans to travel to [**State 2690**] in the spring for a one month stay. REVIEW OF SYSTEMS: Notable for two pillow orthopnea. No melena. No BRBPR. No claudication or peripheral vascular disease. PHYSICAL EXAMINATION: Heart rate was in the 70s and blood pressure was 130s/70s. She was a well dressed, well nourished elderly female lying on the stretcher in no acute distress. Lungs were clear. Neck 1+ carotid pulses bilaterally without bruits. No JVD. Cardiovascular normal S1 and S2. No murmur. Abdomen soft, nontender, nondistended, normoactive bowel sounds. Obese. The right groin was notable for ecchymosis and a small hematoma at the site of the catheterization performed the day prior to admission. The left groin was unremarkable. There were no groin bruits. The feet were warm with no edema. The dorsalis pedis pulses and posterior tibial pulses were 1+ bilaterally. LABORATORY ON ADMISSION: CBC white blood cell count 6.4, hemoglobin 10.8, hematocrit 31.3, platelets 278. Chem 7 sodium 136, potassium 4.1, chloride 106, bicarb 26, BUN 13, creatinine 0.8, glucose 84. The INR was 1.0. Cholesterol was 142. HDL was 47, LDL 63, triglycerides 174. IMPRESSION: This is a 72 year-old female with left anterior descending coronary artery stent in [**2173-4-18**] who had been having increasing symptoms of angina and was noted to have instent restenosis of the left anterior descending coronary artery stent seen on diagnostic catheterization at the outside hospital. She is transferred for brachytherapy. HOSPITAL COURSE: The patient was brought to the catheterization laboratory. Left heart catheterization revealed osteal left anterior descending coronary artery lesion of 30% stenosis and an 80% instent restenosis of the left anterior descending coronary artery. There was also S1 osteal lesion of 80% as well as diffuse disease in the distal left anterior descending coronary artery. She had a cutting balloon of the mid left anterior descending coronary artery stent and a 30 mm catheter delivered beta brachytherapy for 2.58 seconds. Post beta catheter angiography showed a 50% hazy stenosis proximal to the stent with a grade B dissection. Given the flow limitation another 2.5 by 13 mm hepacote stent was deployed just proximal to and overlapping the prior stent, which jailed the S1. End result was 10 to 20% residual stenosis in the original stent with no angiographically apparent dissection. Following the procedure she returned to the cardiac flow where she did well until approximately 10:00 p.m. when she had her left groin sheath pulled. There was initially good hemostasis, but then she was later noted to be hypotensive with a systolic blood pressure in the 60s and bradycardia to the 40s. 0.5 mg of Atropine was given. Intravenous fluids were opened wide. Oxygen was applied and her blood pressure increased to 120/70. Physical examination revealed a large left groin hematoma. Manual pressure was applied to the groin for one hour. The patient was typed and crossed and received 2 units of blood. A bedside echocardiogram was performed that ruled out tamponade. She was transferred to the Coronary Care Unit overnight for monitoring and transfusion. Vascular Surgery was consulted. They recommended an ultrasound of the right groin, which revealed no pseudoaneurysm and no fistula. Therefore no vascular surgery was recommended. The patient did well and was hemodynamically stable overnight in the Coronary Care Unit and so was transferred back to the cardiac floor the following day. There she received another unit of blood, remained hemodynamically stable and was discharged on the first of [**2173-12-18**]. On her final night of admission she had a brief episode of asymptomatic nonsustained ventricular tachycardia lasting seven beats. Therefore it was recommended that her beta blocker be increased as an outpatient. DISCHARGE MEDICATIONS: Aspirin 325 mg po q.d., Plavix 75 mg po q.d. for one year, Capoten 25 mg po b.i.d., Lopressor 25 mg po b.i.d., Lipitor 5 mg po q.d., Premarin 0.625 mg po q.d., nitroglycerin sublingually prn. FOLLOW UP: She should follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33157**] in one to two weeks. DISCHARGE STATUS: She was discharged to home. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Instent restenosis treated with brachytherapy. 2. Restent of left anterior descending coronary artery. 3. Groin hematoma requiring transfusion. [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**] Dictated By:[**Name8 (MD) 2734**] MEDQUIST36 D: [**2174-3-11**] 16:36 T: [**2174-3-14**] 07:53 JOB#: [**Job Number **]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2136-12-15**] Discharge Date: [**2136-12-19**] Date of Birth: [**2057-4-9**] Sex: F Service: MEDICINE Allergies: A.C.E Inhibitors / Ciprofloxacin Attending:[**First Name3 (LF) 1070**] Chief Complaint: Altered mental status . Major Surgical or Invasive Procedure: None. . History of Present Illness: 79 F with multiple myeloma on no therapy, dementia oriented x1 at baseline, DM2, CHF, CAD s/p CABG, CKD, indwelling foley w/ recurrent ESBL Klebsiella UTIs who was brought in by daughter today from [**Name (NI) 1188**] house for concern of altered mental status. At baseline she is AxOx1 ( reportedly recognizes her children) but had acute change today. More lethargic. Less interactive. Pts daughter notes, has had a cough productive of clear sputum. She denies any recent fevers or diarrhea. She did have 2 episodes vomiting this week at nursing home. She has a chronic indwelling foley. No meds given today per daughter's request. At time of transfer from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **], T 97.5, BP 111/70, HR 100, RR 16. . In the ED, T 97.8, HR 57, BP 93/57-> recheck 116/68, RR 24, O2 97% 3LNC. She opened her eyes to voice but minimally followed commands. Received 1L IVF for presumed sepsis w/ HRs from 110s->80s. Lactate 4.1->4.9->4.3 although SBPs never below 100 after initial [**Location (un) 1131**]. ECG w/ AF and new TWI inferiorly. Troponin 0.1 but CKs negative and has baseline troponin elevation. Patient refused asa in ED. CXR showed mild CHF. BNP 33,800 but often that elevated in past and has been >70,000. Only 1 level on record <30,000. U/A c/w possible UTI and given vanco, ceftriaxone, and flagyl. WBC 7800 but typically <5000 and left shifted. Hct was at patient's baseline. Daughter refused guaiac in ED. Also treated for K of 5.4 w/ CaGluc, insulin, D50. Given elevated lactate, sepsis protocol pursued and RIJ CVL placed. Significant bleeding around line post-placement-> direct pressure, gelfoam, vit K 10 mg sc, 2 units FFP. Adequate placement confirmed with CXR. CVPs 18-20. Prior to transfer to ICU, patient received head CT. . Last admitted [**Date range (1) 94782**] for concern for potential hematemesis which was thought to be most likely epistaxis. Patient has a significant history of bleeding and epistaxis. Hospital course was complicated by CHF, volume overload, and CKD. She was diuresed and her creatinine remained elevated but at her baseline. . Upon arrival to the unit, patient is lethargic. Grones w/ positioning but not responsive to voice. Not following commands. . Past Medical History: Multiple Myeloma (IgG)- has consistently declined treatment Coronary artery disease with known 3-vessel disease, - s/p NSTEMI in [**2130-7-9**] - s/p 3V CABG [**8-8**] Congestive Heart Failure - EF 45% Atrial Fibrillation- declines anticoagulation Urinary retention with chronic Foley Chronic Kidney Disease (Stage III-IV Cr 1.3-2.0) Hyponatremia (Na 125-128) Type 2 Diabetes Mellitus on insulin Last A1c 6.3% Hypercholesterolemia Gastroesophageal reflux disease Hypertension Bilateral adrenal adenoma Iron deficiency anemia s/p cholecystectomy s/p TAH BSO . Social History: Most recently at [**Last Name (un) 2299**] house following recent hospital discharge. Used to live with daughter. She is widowed. Never smoked. Used to drink alcohol socially. No h/o IVDU. . Family History: Siblings with hypertension. Brother, father with CVA. Mother with MI and uterine cancer. . Physical Exam: T: 96.1 BP: 91/74 HR: 78 RR: 18 O2 95% 3LNC Gen: lethargic, groaning, breathing comfortably. HEENT: R pupil surgical. L pupil 3->2 mm. Dry MMs. NECK: Supple. No LAD. R IJ in place. + JVD. Cannot assess JVP CV: Irreg irreg. nl S1, S2. II-III/VI holosys murmur LUNGS: diffuse rhonchi likely referred upper airway noises. End expiratory wheezes diffusly. Bibasilar crackles, L>R ABD: Decreased BS. Soft, NT, ND. No HSM EXT: WWP. 2+ RUE edema. [**2-11**]+ LE edema bilat. SKIN: stage 2 ulcers on buttocks. NEURO: lethargic. Unresponsive to voice. Groans to nailbed pressure x 4 extremities. Moves LUE to nailbed pressure but does not withdraw and does not move other extremities. R pupil post surgical. L pupil reactive. Plantar responses upgoing bilaterally. . Pertinent Results: Pertinent labs: [**2136-12-15**] GLUCOSE-130* UREA N-69* CREAT-1.9* SODIUM-126* POTASSIUM-6.5* CHLORIDE-97 TOTAL CO2-18 [**2136-12-15**] WBC-7.8 HGB-8.3* HCT-25.7 PLT COUNT-130 NEUTS-85* BANDS-0 LYMPHS-10* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2136-12-15**] ALT(SGPT)-13 AST(SGOT)-32 LD(LDH)-186 ALK PHOS-116 TOT BILI-1.2 [**2136-12-15**] LACTATE-4.1* [**2136-12-15**] proBNP-[**Numeric Identifier **]* [**2136-12-15**] 01:30PM cTropnT-0.10 CK(CPK)-73 [**2136-12-15**] 06:17PM cTropnT-0.32 CK(CPK)-79 . [**2136-12-15**] URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015 BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD RBC-[**11-27**] WBC-[**11-27**] BACTERIA-MANY YEAST-NONE EPI-0-2 [**2135-12-16**] Urine culture: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION [**2136-12-17**] Urine culture: no growth . [**2136-12-15**] Blood culture: no growth to date [**2136-12-16**] Blood culture: no growth to date . . Studies: [**12-15**] CXR: Again noted is marked central pulmonary vascular congestion slightly diminished from the prior exam. Mild interstitial edema is again evident with interlobular septal thickening and cephalization of flow. No definite consolidation is evident. Slight improvement in the aeration of the left lower lobe is noted. No definite pleural effusion is seen. There is no pneumothorax. Evidence of prior CABG is again noted. There is cardiomegaly with left atrial prominence. The bones are diffusely osteopenic. IMPRESSION: Slight improvement in volume status with mild residual interstitial edema likely from cardiogenic etiology noted. . [**12-15**] CT Head: Age-appropriate atrophy with chronic microvascular disease as noted previously. Lytic lesions in skull consistent with known multiple myeloma. No interval change. . [**12-17**] TTE: The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with infero-lateral hypokinesis. EF 45%. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated. There is mild global right ventricular free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-10**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension (PASP = 37). The main pulmonary artery is dilated. Compared with the prior study (images reviewed) of [**2136-10-4**], no major change (aortic valve area underestimated on prior study). LVEF is similar. . Brief Hospital Course: Hospital course by problem: . # Altered mental status: She has dementia and at baseline her mental status is alert and oriented to name. On the day of admission, she was noted to be significantly more lethargic than usual and not interactive. She has had multiple episodes of altered mental status associated with infection in the past, notably with urinary tract infections. Thus it was felt that her altered mental status was most likely secondary to a UTI (see below). Her mental status improved significantly after treatment with antibiotics. By the day prior to discharge, she was back to her baseline, per daughter. . # UTI: She has a history of recurrent resistant Klebsiella UTIs. The E. coli was sensitive to gentamycin, meropenem, imipenem, and bactrim on most recent culture. Her admission urinalysis was borderline positive but was treated as altered mental status is her usual presentation for UTI. Urine culture was contaminated. She was treated with meropenem (based on previous culture data) and vancomycin for broad coverage. A repeat urinaylysis after antibiotic initiation was slightly positive. Repeat urine culture at that time was negative. Vancomycin was discontinued on hospital day 4. She was discharged with the plan to complete a 7 day course of meropenem. . # Anemia: Her anemia is likely secondary to MM. Last iron studies [**8-14**] suggested anemia of chronic disease. Folate and B12 normal. Hemolysis labs mostly unremarkable. Current labs on this admission suggest macrocytic anemia, which can be seen with MM. Baseline Hct 26-29. Hct dropped from 25.7-->21.8 on [**12-15**] --> 25 on [**12-16**]. She received a total of 4 units RBC transfusion and her hematocrit was stable at 32-34 afterwards. She did have a minimal amount of bright red blood in her stool on the day prior to discharge. Hematocrit was stable. This was most likely secondary to her coagulopathy. No further workup was pursued. . # Elevated lactate: Initially there was concern urosepsis as she met SIRS criteria on presentation to the ED. She was not acidemic. Elevated lactate can also be seen with MM, though not commonly. It could also have been secondary to decreased liver clearance. THough she has no known history of liver disease and LFTs were within normal limits, her INR were elevated and her albumin was low, suggesting decreased hepatic function. Resolved by hospital day 3. . # Congestive Heart Failure: EF 45% on recent ECHO w/ HK of LV, dilated RV w/ mod to severe TR, and mild to Mod MR. Evidence of CHF on CXR and exam. BNP elevated but not significantly above prior values. SBP has been stable with good O2 sat. Some concern for cardiac ischemia which could contribute to systolic and diastolic dysfunction although CKs negative. TTE showed no major change from prior. Once her blood pressure was stable, she was restarted on her lasix, metolazone, and beta blocker. . # CAD: She is s/p CABG in [**2130**]. Had new TWIs on ECG. Troponin peaked at 0.49. CKs negative. This was felt most likely to reflect demand-mediated ischemia in the setting of initial tachycardia with decreased clearance of troponin given CKD. She is not on spirin as an outpatient and her daughter refused in the [**Name (NI) **] given the patient's bleeding history. She was continued on her beta blocker once tolerating POs. She is also not on a statin as an outpatient for unclear reasons. . # Afib: She has a history of atrial fibrillation and has declined anticoagulation as an outpatient given her history of bleeding and coagulopathy. She is rate-controlled with toprol XL. This was held initially given infection, hypotension, and altered mental status making her unsafe to take POs. After transfer out of the MICU when she was tolerating POs safely, she was restarted on metoprolol. Her heart rate was maintained within normal limits during this admission, though she remained in atrial fibrillation. . # Coagulopathy: She has a chronic coagulopathy, likely secondary to MM, with baseline INR 1.6-2.1. Has a history of bleeding in her gums and nares. Her INR was at baseline during this admission. Currently at baseline. Received vitamin K and FFP in the ED. She did have a minimal amount of bright red blood in her stool on the day prior to discharge. Hematocrit was stable. This was most likely secondary to her coagulopathy. No further workup was pursued. . # Chronic Kidney Disease: She has Stage IV chronic kidney disease secondary to MM. Her baseline Cr is 2.0-2.8. Her creatinine remained at baseline during this admission. Her medications were renally dosed. . # Type 2 Diabetes Mellitus: Her DM is well-controlled with her last HbA1C 6.3. She was continued on an insulin sliding scale and diabetic diet. . # RUE swelling: She had right upper extremity swelling on admission. This is a recurrent problem, per daughter. Unclear cause. Had ultrasound of RUE in [**9-13**] which showed no DVT. This resolved over the course of the admission. . # Multiple Myeloma (IgG)- The patient/family has consistently declined treatment for this. . # Gastroesophageal reflux disease: She was continued on a PPI per her outpatient regimen. . # Nutrition: Once her mental status improved to baseline, she was evaluated by speech and swallow. Her recommended diet was ground solids with thin liquids and sugar-free supplement shakes. Pills should be administered in puree when possible. . # CODE: FULL, confirmed with HCP. Several conversations were held with family members regarding the patient's code status and the possibility of making her DNR/DNI. The family was not ready to make a change during this admission. . Medications on Admission: (per list provided in ED): lasix 120 mg QOD zaroxolyn 5 mg Qday levothyroxine 50 mcg Qday Toprol XL 25 mg once a day omeprazole 20 mg [**Hospital1 **] Insulin Sliding Scale Sodium Chloride 0.65 % Aerosol, [**1-10**] Sprays Nasal QID epogen 8000 units sc Tues/Fri duonebs QID tylenol . ALLERGIES: ace inhibitors, cipro . Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q12H (every 12 hours) for 3 days: last dose on [**12-21**]. 3. Metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): subcutaneous injection. 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. Insulin SC per sliding scale 8. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO every other day. 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-10**] sprays Nasal four times a day: nasal. 10. Epogen 4,000 unit/mL Solution Sig: Two (2) mL Injection Tuesday/Friday: subcutaneous. 11. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation four times a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) **] house Discharge Diagnosis: Primary: Urinary tract infection Secondary: 1) Multiple myeloma 2) Coronary artery disease s/p CABG and NSTEMI 3) Chronic systolic congestive heart failure 4) Atrial fibrillation 5) Chronic kidney disease 6) Type 2 Diabetes Mellitus 7) Hypertension 8) Anemia 9) Gastroesophageal reflux disease . Discharge Condition: Vital signs stable, afebrile. Mental status returned to baseline. . Discharge Instructions: You were admitted to the hospital with altered mental status and a urinary tract infection. You were treated with antibiotics and your mental status came back to your normal baseline. . If you develop change in mental status again, persistent fever > 101, chest pain, or shortness of breath, please return to the emergency room. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet . Followup Instructions: Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within the next 1-2 weeks. .

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

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8414

Discharge summary

report

Admission Date: [**2194-9-1**] Discharge Date: [**2194-9-12**] Date of Birth: [**2108-10-18**] Sex: F Service: SURGERY Allergies: Lisinopril / Metformin Attending:[**First Name3 (LF) 1390**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: [**8-20**] ex lap, extended right colectomy, end ileostomy [**9-2**] redo ex lap, subtotal colectomy, mucous fistula History of Present Illness: 85F well known to the ACS service, transferred from [**Hospital 100**] rehab, 12 days s/p ex-lap, right colectomy, and end ileostomy for lower GI bleeding localized to the cecum. By report from the facility, Ms. [**Known lastname 3647**] developed increasing abdominal pain associated with minimal ileostomy output, one episode of vomiting, and fever to 100.8 earlier today. She had been NPO secondary to nausea, but had a stable hematocrit and normal WBC during her 5 day rehab stay. Past Medical History: Diabetes Dyslipidemia Hypertension Atrial fibrillation Hypothyroidism Osteoarthritis, s/p bilateral knee replacements in [**2182**] Depression Asthma, diagnosed in [**2184**] C-sections in past Social History: Husband died many years ago. Patient lives with her granddaughter who is her proxy. Smoked 36 years x 1 ppd, quit in [**2181**], remote social ETOH. Family History: Family history of CVA/CAD. Physical Exam: Vitals: 99.6 127 118/76 26 100% GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: Irregular, mildly tachycardic 110-120 PULM: Diminished bilaterally ABD: Soft, mildly distended, +peristomal TTP in the RLQ, no rebound or guarding, no palpable masses. RLQ end ileostomy flush with abdominal skin, pink, small amount of watery brown effluent, no flatus in bag. Tender with digitalization. Midline laparotomy incision with VAC in place, no erythema, induration, drainage, or hernia. Left sided mucous fistula with scant mucous output. Ext: No LE edema, LE warm and well perfused Pertinent Results: Admission 8.0 > 29.5 < 486 N:65 Band:15 L:12 M:8 E:0 Bas:0 133 97 34 < 161 AGap=13 ------------ 4.3 27 1.5 Ca: 6.9 Mg: 1.8 P: 3.2 ALT: 23 AP: 125 Tbili: 0.5 Alb: 3.2 AST: 26 Lip: 26 Lactate:1.9 Admission CTAP CT A/P: 1. SBO w/ transition pt at ileostomy exit site; cause appears to be mass effect from herniated mesenteric fat adjacent to the ileostomy. 2. s/p R colectomy w/ tiny locules of gas adjacent to colonic staple line - may be post-operative although leak cannot be excluded. 3. small amt of complex free fluid in abdomen/pelvis - ddx includes [**Year (4 digits) **] or bowel leak contents - correlate w/ exam and hct. Discharge: [**2194-9-8**] 6:33 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2194-9-11**]** GRAM STAIN (Final [**2194-9-8**]): <10 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2194-9-11**]): RARE GROWTH Commensal Respiratory Flora. CULTURE WORKUP REQUESTED BY DR. [**First Name (STitle) **] [**Numeric Identifier 29695**]. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. MODERATE GROWTH. KLEBSIELLA PNEUMONIAE. SPARSE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- <=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- <=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] WBC-11.5* RBC-2.76* Hgb-8.2* Hct-25.6* MCV-93 MCH-29.8 MCHC-32.0 RDW-16.3* Plt Ct-458* [**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] PT-13.6* PTT-28.2 INR(PT)-1.3* [**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] Glucose-131* UreaN-19 Creat-1.0 Na-131* K-4.6 Cl-93* HCO3-29 AnGap-14 [**2194-9-12**] 02:08AM [**Month/Day/Year 3143**] Calcium-8.0* Phos-4.2 Mg-2.0 Brief Hospital Course: Neuro: On arrival, the patient was awake, but minimally alert and seemed to be unaware of her surroundings. Over the course of her stay, she was maintained on the minimum amount of pain medication necessary to adequately control her pain. As a stay progress, she became more alert and interactive, and after extubation, was alert, oriented, and very interactive. At the time of discharge, the patient was alert, oriented times three, and had a nonfocal neurologic exam. She was moving all four extremities, and complained only of tenderness of the abdomen. Still sluggish with decreased interactiveness but appropriate. CV: Initially, the patient was tachycardic ranging up to 140. She initially required a diltiazem drip to control her tachycardia, but as her stay progressed, the diltiazem drip was weaned, and she was restarted on her home rate control medications. She also initially required some low doses of Neo-Synephrine. This was weaned to fully off finally on hospital day seven, and she did not require any more pressors. She is now controlled well on an oral diltiazema and metoprolol regimen. She has not yet restarted her isosorbide, diovan, or pradaxa. Those are currently on hold. The patient has atrial fibrillation at baseline and fluctuates from sinus tachycardia into afib with rate control 90-115 and stable [**Month/Day/Year **] pressures. R: After her surgery, the patient was vent dependent for several days. On post operative day two, she was weaned to pressure support. She remained on these settings until postoperative day nine, after which she was extubated. From that point on, she tolerated minimal oxygen, and Room air. After extubation, the decision was made by the family, after a long family meeting, to make the patient DNR/DNI. She is getting albuterol and ipratropium inhalers as needed. GI: On postoperative day two, she began to have stool from her ostomy. Her tube feeds restarted on postoperative day four and she continued to tolerate these throughout her stay. On postoperative day 11, she failed a speech and swallow test, after extubation, and had a dobhoff feeding tube placed, as she had initially had an OGT while intubated. On postoperative day one, the patient had a wound VAC placed over the midline laparotomy incision. Last change [**9-11**]. End ileostomy with stool output, scant mucous output from mucous fistula. Two Jp drains from OR removed prior to discharge. Famotidine prophylaxis ongoing. GU: The patient made adequate urine throughout her stay, which was monitored with the catheter. On postoperative day six, she began to have signs consistent with pulmonary edema. She was started on a Lasix drip , But was only slightly negative for the first several days. On postoperative day nine, she began to diurese quite effectively, with no compromise of her hemodynamic stability. On postoperative day 11, Lasix drip as stopped and she was continued on intermittent Lasix. She continued to have excellent output after this. She should continue to have close monitoring of I's and O's and urine output. Heme: In total, the patient received two units of packed red [**Month/Year (2) **] cells. Her hematocrit was monitored frequently. After her surgery, her hematocrit remained stable throughout her stay. Pradaxa is being held at this time because it cannot be crushed via the dophoff tube. The patient's PCP should determine the patient's risk for stroke in setting of afib. For now no anticoagulation. Heparin prophylaxis should continue 5000 units sc TID. ID: During the perioperative period, the patient was initially placed on vancomycin and Zosyn. The vancomycin was stopped shortly after surgery. A culture from the wound on [**9-2**] grew back pan sensitive E. coli, and the patient antibiotics were changed to Bactrim. She had two sputum, and two urine cultures which grew back only bacteria sensitive to Bactrim. She was discharged on a two-week course of Bactrim. Her white [**Month (only) **] cell count was monitored throughout her stay. Medications on Admission: albuterol HFA 90 q4-6h PRN, cardiazem LA 240', diovan 160', loratadine 10 PRN, pradaxa 150'', allopurinol 200', Vit D3 1000', lasix 40', glyburide 2.5', isosorbide mononitrate ER 30', levothyroxine 112', metoprolol ER 100', oxybutynin 5', pravastatin 40' Discharge Medications: 1. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 2. Diltiazem 60 mg PO QID 3. Famotidine 20 mg PO Q12H 4. Furosemide 20 mg PO BID 5. Heparin 5000 UNIT SC TID 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 7. Metoprolol Tartrate 25 mg PO BID Hold for HR< 60 8. Ondansetron 4 mg IV Q8H:PRN nausea 9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 10. Sulfameth/Trimethoprim DS 3 TAB PO TID 12-15mg/kg/day trimethoprim component for tx Stenotrophomonas, per pharmacy recs 11. 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. 12. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN pain 13. Levothyroxine Sodium 112 mcg PO/NG DAILY 14. Glargine 10 Units Q24H Insulin SC Sliding Scale using REG Insulin 15. Ipratropium Bromide MDI 2 PUFF IH Q8H:PRN wheeze / dyspnea 16. Valsartan 160 mg PO/NG DAILY (not yet restarted) 17. Albuterol Inhaler [**12-16**] PUFF IH Q4H:PRN wheeze 18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY (not yet restarted) 19. Oxybutynin 5 mg PO DAILY (not yet restarted) 20. Vitamin D 800 UNIT PO DAILY (not yet restarted) 21. Pravastatin 40 mg PO DAILY (not yet restarted) 22. Allopurinol 200 mg PO DAILY (not yet restarted) 23. GlyBURIDE 2.5 mg PO DAILY (not yet restarted) 24. Medication Alert PLEASE NOTE MED REC -> MEDICATIONS THAT HAD NOT BEEN RESTARTED AS OF DISCHARGE FROM [**Hospital1 18**] ON [**9-12**] WERE NOTED. RESTART THESE MEDICATIONS AS APPROPRIATE IN CONVERSATION WITH DR. [**First Name (STitle) **] PCP AND REHAB PHYSICIAN. THE MEDICATIONS THAT THE PATIENT WAS GETTING DURING HER STAY INCLUDE PO DILTIAZEM, PO METOPROLOL, PO LASIX, PO BACTRIM, SYNTHROID, INSULIN SLIDING SCALE AND GLARGINE AS WRITTEN, ELECTROLYTE REPLETION, HEPARIN PROPHYLAXIS. DILAUDID AND TYLENOL AS NEEDED FOR PAIN AND ZOFRAN FOR NAUSEA. THE OTHER LISTED MEDICATIONS THAT THE PATIENT WAS TAKING AT HOME PRIOR TO ADMISSION WERE NOT RESTARTED. THANK YOU. 25. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain 26. Dabigatran Etexilate 150 mg PO BID (not yet restarted) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: anastamotic leak, colon necrosis Discharge Condition: good Discharge Instructions: Continue VAC dressing changes every 3 days and close wound monitoring. Call the Acute Care Surgery Clinic if there are any concerns about the wound appearance. Last VAC change was [**9-11**] at [**Hospital1 18**]. The patient did have two JP drains which were removed during her stay at [**Hospital1 18**]. Monitor those skin sites and use dry dressings as needed. Please continue ostomy teaching and management. The patient has an end ileostomy and mucous fistula in place. Please call Acute Care Clinic if concern with appearance or amount of ostomy output, monitor for dehydration, bloody or melenic output. Patient is on an antibiotic course with bactrim to cover for klebsiella and stenotrophomonas in her sputum cultures. She will complete a two week total course of antibiotics. Her last positive culture was on [**9-8**]. She will continue the bactrim through [**9-21**]. The patient is taking diltiazem and metoprolol via the dophoff tube to rate control her atrial fibrillation. Her pradaxa is currently on hold. She should get prophylactic heparin 5000 units three times daily. Discussion should be had with Dr. [**First Name (STitle) **], Ms. [**Known lastname **] primary care provider [**Last Name (NamePattern4) **]: anticoagulation. Patient had been on coumadin in the past and one year ago was transitioned to pradaxa. She is not on aspirin. Her initial presentation in early [**Month (only) **] was with GI bleeding while on pradaxa. Please discuss risks and benefits of anticoagulating again once the patient passes speech and swallow. For now she will remain with her dophoff tube, tube feeds, and oral medications as possible. Pradaxa will be held. No coumadin or aspirin to be started at this point. Discuss this issue with Dr. [**First Name (STitle) **] in determining how to move forward with anticoagulating. The patient did not pass her speech and swallow on [**9-11**] so a dophoff tube was placed and tube feeds and medications have been given through there. The dophoff should be flushed with 30cc q6 as well as additional flush as needed with crushed pills to prevent clogging. The patient is also being diruesed. Had been on a lasix drip for over a week and was transitioned to lasix via the dophoff tube on [**9-12**]. She is being discharged on 20mg lasix [**Hospital1 **] via dophoff, please closely monitor electrolytes and BUN/Cr and back off on diuresis as needed. Continue other home medications as able to give via dophoff. Continue reassessing speech and swallow ability to transition to oral feeding and medications. Call [**Hospital 2536**] clinic with concerns about ostomy output, inability to tolerate tube feeds, increasing abdominal pain, or other concerns. Followup Instructions: Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 600**] Date/Time:[**2194-9-18**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2010**] Date/Time:[**2194-10-20**] 10:50 Completed by:[**2194-9-12**]

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26774

Discharge summary

report

Admission Date: [**2196-2-21**] Discharge Date: [**2196-3-2**] Date of Birth: [**2124-11-14**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 759**] Chief Complaint: Confusion/weakness Major Surgical or Invasive Procedure: Extubation History of Present Illness: 71 year old with a hx. of COPD, HTN, who was taken by her sons to [**Hospital3 **] today after having two days of confusion, weakness, diminished PO intake, weakness, dyspnea at home. At [**Hospital1 **], reportedly found to have a chest XR revealing bilateral PNA, was using accessory muscles to breathe, and was in respiratory distress, unable to speak in full sentences. She had significant wheezing on exam. She was given a dose of levaquin and solumedrol IV. While there, she progressively became more obtunded, and had ABG revealing hypercarbic respiratory failure with 7.2/95/66/37. She was intubated, and started on Neosynephrine for sbp of 73/47. An ECG there revealed ST elevations in the inferior leads (II, III, F). She was transferred to the [**Hospital1 **] for further management. On arrival here, she was found to have a sbp of 48. A central line was placed in the Rt. subclavian vein. Cardiology was consulted, and they felt that the ECG was not especially convincing for an IMI, given the ECG here did not show the degree of ST changes as those of the OSH, and that there were no enzyme or marker elevations, and no reciprocal changes. A cxr here did not reveal any infiltrates. UA was negative. Blood cultures were sent. She was given 4 mg IV ativan for sedation and her Neo was up to 60 ucg per minute. Her sbp was in the 90's, and she was transferred to the CCU (MICU team). On arrival there, she was transitioned to Levophed, and an a line was placed. Fentanyl and Versed were started for sedation. Past Medical History: COPD: baseline O2 2L NC Hypertension Osteoporosis Social History: Lives in [**Location 686**] with sons. 40 pk yr tob, quit 15 yrs ago. No EtOH Family History: non-contributory Physical Exam: Tc 97.7, tm 99, pc 86, pr 80s, bpc 109/44, bpr 90s-110s/40s-50s, resp 26, 92% 4L NC 18h I/O [**Telephone/Fax (1) 65933**] Gen: elderly female, alert, oriented to person, "hospital", [**Month (only) 956**] (not date). breathing comfortably, NAD HEENT: anicteric, nl conjunctiva, OMMM, OP clear, neck supple, unable to assess JVP 2/2 body habitus, neck supple, no cervical LAD. Cardiac: RRR, no M/R/G appreciated Pulm: diffuse expiratory wheezing, decreased LS at left base Abd: obese, soft NT/ND, no masses Ext: trace LE edema at ankles bilaterally Neuro: CN II-XII grossly intact and symmetric bilaterally. Moves all 4 extremities equally. 1+ DTR throughout. Pertinent Results: EKG:NSR@90, nl axis/int, no st/t changes, U waves . CXR: slightly increased bibasilar atelectasis. right SC line in SVC. No evidence of CHF or PTX . ECHO [**2196-2-22**]: Conclusions: Poor image quality. The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue velocity imaging demonstrates an E/e' <8 suggesting a normal left ventricular filling pressure. The right ventricular cavity is mildly dilated. Free wall motion is good. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be estimated. There is an anterior space which most likely represents a fat pad. . IMPRESSION: Mild right ventricular cavity enlargement with good free wall motion. Preserved global left ventricular systolic function. . [**2-21**]: LENI: LOWER EXTREMITY VENOUS ULTRASOUND (BILATERAL): Grayscale, color, and Doppler images of the right and left common femoral, superficial femoral, and popliteal veins were obtained. Normal flow, compressibility, augmentation, and waveforms are demonstrated. No intraluminal thrombus is identified. IMPRESSION: No deep venous thrombosis in right or left common femoral, superficial femoral, or popliteal veins. . [**2-21**]: CXR: Endotracheal tube is 3 cm above carina. Right jugular CV line is in proximal SVC. No pneumothorax. NG-tube is difficult to localize on this film, but appears to extend below the diaphragm. No pneumothorax. There is slight elevation of the left hemidiaphragm and blunting of the left costophrenic angle. Small area of ill-defined opacity consistent with atelectasis is present at the right lung base. . [**2-22**]: CXR: IMPRESSION: Bilateral lower lobe opacities, right greater than left with associated bronchial wall thickening. Aspiration or evolving aspiration pneumonia should be considered. . [**2196-2-25**]:AP CHEST RADIOGRAPH: The previously seen bibasilar atelectasis is slightly more prominent on today's exam. There is a right subclavian line with its tip in the upper SVC. There is no pneumothorax. No CHF. The cardiac, mediastinal, and hilar contours are stable. IMPRESSION: Slightly worsened bibasilar atelectasis. . [**2-27**] CXR: HISTORY: 71-year-old woman with hypotension, possible fluid overload or focal infiltrates. Patient with worsening respiratory distress. FINDINGS: Compared to previous study from [**2196-2-25**]. The cardiac silhouette and mediastinum is within normal limits and unchanged. There remains some streaky density at the bases most consistent with subsegmental atelectasis, right side is slightly worse in the interval. There are no signs of focal consolidation or pulmonary edema. . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2196-3-2**] 06:35AM 7.7 3.43* 10.2* 32.3* 94 29.7 31.6 14.7 265 [**2196-3-1**] 06:15AM 7.1 3.58* 10.6* 33.2* 93 29.6 31.9 14.9 290 [**2196-2-29**] 06:05AM 7.9 3.26* 9.7* 29.2* 90 29.8 33.2 14.8 306 [**2196-2-28**] 06:25AM 8.1 3.46* 10.7* 31.9* 92 31.0 33.6 14.9 284 [**2196-2-27**] 06:40AM 7.7 3.43* 10.5* 31.6* 92 30.7 33.3 14.7 276 [**2196-2-26**] 10:24AM 8.4 3.62* 10.7* 33.2* 92 29.6 32.3 14.8 243 [**2196-2-25**] 12:02PM 9.2 3.54* 10.7* 32.0* 90 30.1 33.4 15.0 226 [**2196-2-24**] 02:23AM 10.4 3.46* 10.4* 31.5* 91 30.1 33.1 15.0 177 [**2196-2-23**] 02:54AM 8.8 3.28* 9.9* 29.3* 90 30.3 33.8 15.0 163 [**2196-2-22**] 03:21PM 11.0 3.72* 11.4* 33.2* 89 30.6 34.2 14.9 170 [**2196-2-22**] 04:30AM 9.9# 3.97* 12.3 34.9* 88 30.9 35.2* 14.8 165 [**2196-2-21**] 03:21PM 6.4 4.12* 12.6 36.5 89 30.5 34.4 14.9 158 [**2196-2-21**] 06:27AM 5.8 4.18* 12.7 37.7 90 30.4 33.8 14.8 162 [**2196-2-21**] 12:50AM 6.5 4.16* 12.8 37.0 89 30.8 34.6 14.5 161 HEMOLYTIC WORKUP Ret Aut [**2196-2-25**] 12:02PM 2.2 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2196-3-2**] 06:35AM 80 23* 0.8 147*1 3.8 102 44*2 5* ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2196-2-25**] 12:02PM 631* OTHER ENZYMES & BILIRUBINS Lipase [**2196-2-21**] 06:27AM 33 CPK ISOENZYMES CK-MB MB Indx cTropnT [**2196-2-25**] 12:02PM 2 <0.011 1 <0.01 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2196-3-2**] 06:35AM 8.6 4.2# 2.0 HEMATOLOGIC calTIBC VitB12 Folate Ferritn TRF [**2196-2-25**] 12:02PM [**Telephone/Fax (1) 65934**]* GREATER TH1 555* 200 PITUITARY TSH [**2196-2-25**] 12:02PM 1.7 CARDIAC/PULMONARY Theophy [**2196-2-21**] 03:21PM 4.5* Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calHCO3 Base XS AADO2 REQ O2 Intubat Vent Comment [**2196-2-27**] 10:07AM ART 92 4 64* 68*1 7.42 46*2 15 544 88 Brief Hospital Course: Following transfer to [**Hospital1 **], pt was transitioned from neo to levophed (d/c'd [**2-22**]), and central line was placed. Cardiology was consulted, who felt the patient was unlikely to have had MI given inconsistent EKG and negative cardiac markers. She continued steroids for COPD/possible adrenal insufficiency and levo/flagyl (subsequently flagyl d/c given low suspicion of aspiration) for pneumonia. Her respiratory status, the decline of which was attributed to COPD exacerbation and possible pneumonia, gradually improved and she was extubated [**2-23**]. MICU course also notable for runs of SVT (possible MAT), and ARF (Cr 1.5 on admit, which resolved during course of stay). . After being called out of the MICU, the pt was on the floor for <24 hours. She was not given any nebulizer treatments overnight. Was written for standing inhalers, which she doesn't use with good technique. In the morning, pt was noted to have worsening SOB. Given one nebulizer treatment for poor air movement. Pt was sat'ing 94-90% on 4L, increased to 70% FM w/O2 sats in low 90s. CXR showed slighly increased bibasilar atelectasis, no CHF. Pt was given Lasix 10 and 20 IV x once each, with UO of ~200-500cc, and no improvement in breathing. ABG 7.43/60/52. Stat labs and cardiac enzymes were sent. Currently, pt states that she feels like she's "suffocating". Denies CP, palpitations, nausea, vomiting, any other symptoms. She was transferred back to the MICU. . In the MICU, patient responded well to nebulizers and was maintained on albuterol/atrovent Q6 hrs. She was also continued on her prednisone - this will be tapered over a 2 week course. . On retransfer to floor on [**2196-2-26**], she remained stable on 4L NC. She remained stable on 4L NC with goal O2 sats 88-92%, although this dropped on minimal exertion. Her prednisone taper and around-the-clock neb treatments were continued and she completed a 10-day course of Levaquin. Her mental status improved to baseline. On [**2-28**] her lisinopril was restarted at a low dose (5mg). Patient on the floor completed the levoquin and her respiratory function was close to her baseline with her O2 sats in low to upper 90s on 4L NC. Patient's cough has also improved. She hasn't been febrile and no WBC while on the floor. . # anemia: unknown baseline @ low 30s c/w anemia of chronic disease, as patient has no iron deficiency and nl B12/Fe studies. Retic ct of 2.5% with guiac negative stools. . # hypernatremia - appear to be consistent with poor po intake. Patient corrects intermittently with encourage PO free water intake. continue to monitor. . F/U - patient is being transfered to [**Hospital3 **] associated acute rehab/care unit. Patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] will follow the patient. Patient should be set up with an outpatient pulmonologist as well. Medications on Admission: Combivent inhaler Fosamax Prednisone 15 mg daily Lisinopril 40 Hctz 25 Vitamin D Theophylline Clonazapam Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO once a day: please reduce by by 10 mg/q week. 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-4**] Puffs Inhalation q4-6:prn. 5. Albuterol Sulfate 0.083 % Solution Sig: [**1-4**] puff Inhalation Q2H (every 2 hours) as needed. 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-10 units Subcutaneous ASDIR (AS DIRECTED): per insulin sliding scale. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 **] TCU Discharge Diagnosis: Primary: 1) Pneumonia - community acquired - bilateral Lower Lobe 2) COPD flare, on 2L Home O2 at baseline, Prednisone dependent 3) Respiratory failure requiring intubation, hypoxemia Secondary: 4) Delirium - resolved 5) Supraventricular tachycardia, ? multifocal atrial tachycardia 6) Acute Renal failure 7) Hypotension - resolved 8) Anemia - NOS 9) Hypernatremia, resolved 10) Chronic Hypertension 11) Prednisone dependent x 3 yrs, on 15 mg prednisone prior to admission, Cushingnoid appearance 12) Probable osteoporosis Discharge Condition: Improved, on 4L O2 via nasal cannula with oxygen saturation around 95% (uses 2L O2 at home at baseline). Discharge Instructions: You have been hospitalized, as you know, with a bad flare of your COPD with a pneumonia that has now been treated. Please call your doctor or return to the emergency room if you have increasing shortness of breath, fevers, chest pain, or anything else concerning to you. We have added a few new medications as follows: You should take a baby aspirin (81 mg) daily to help prevent heart problems. We have started a new inhaler called fluticasone (Flovent) which delivers steroids directly to the lung and may help you get off oral steroids eventually. Lastly, we have started a medication called pantoprazole (Protonix) which you should continue taking once daily for as long as you are on oral steroids (prednisone). . Please have your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], also arrange you with a pulmonologist appointment around the area where you live. Followup Instructions: Follow-Up: 1) Follow up with a new pulmonologist that your PCP should help you set up in your area. Follow-up Chest X-ray in 6 weeks to ensure resolution of bilateral lower lobe infiltrates 2) Consider outpatient stress test which your primary care doctor should set you up with. 3) Please consider having a colonoscopy if you have not had one in the recent past to further evaluate your anemia. Sometimes, anemia can be caused by colon cancer. A colonoscopy can help detect this early when it is more easily treated. Completed by:[**2196-3-15**]

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icd9cm

[ [ [] ] ]

[ "93.90", "96.6", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

12017, 12064

7776, 10643

290, 303

12632, 12739

2767, 7753

13672, 14224

2054, 2072

10798, 11994

12085, 12611

10669, 10775

12763, 13649

2087, 2748

232, 252

331, 1870

1892, 1943

1959, 2038

4,609

167,750

48464

Discharge summary

report

Admission Date: [**2181-5-15**] Discharge Date: [**2181-5-18**] Date of Birth: [**2125-1-18**] Sex: F Service: [**Hospital Unit Name 196**] CHIEF COMPLAINT: Post catheterization. HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname 10063**] is a 56 year old female with a past medical history of coronary artery disease, hypercholesterolemia, hypertension, and type 2 diabetes mellitus who presents after cardiac catheterization from outside hospital. The patient was in her usual state of health until over the past few weeks she has had worsening of anginal symptoms, left arm and shoulder pain. The patient then underwent a thallium stress test showing interior apical ischemia. The patient then underwent a catheterization at outside hospital showing in-stent restenosis of a mid right coronary artery stent, also with 40% proximal right coronary artery and 40% mid left anterior descending lesions. The patient was transferred to [**Hospital1 69**] for possible brachy therapy. At presentation to [**Hospital1 69**], the patient was without symptoms. Denied any chest pain, shortness of breath, no nausea, vomiting, diarrhea, constipation, melena, bright red blood per rectum, no urinary symptoms, no fever or chills. PAST MEDICAL HISTORY: 1. Coronary artery disease with recent stress with apical ischemia, status post stent to the right coronary artery in [**2179-12-1**]. 2. Hypercholesterolemia. 3. Hypertension. 4. Type 2 diabetes mellitus. 5. Status post bladder suspension. 6. Obesity. ALLERGIES: Sulfa, Plavix and codeine. MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Monopril 20 mg p.o. q. day. 3. Celexa 20 mg p.o. q. day. 4. Premarin 0.625 mg p.o. q. day. 5. Glucotrol XL 10 mg p.o. twice a day. 6. Glucophage 1000 mg p.o. twice a day. 7. Pravachol 20 mg p.o. q. day. 8. Covera HS 240 mg p.o. q. day. 9. Humulin 22 units subcutaneously q. h.s. 10. Ambien p.r.n. 11. Multivitamin p.r.n. 12. Xanax p.r.n. 13. Lomotil p.r.n. 14. Nitroglycerin p.r.n. 15. Diflucan p.r.n. SOCIAL HISTORY: The patient lives at home with husband; is an artist. Habits, 20 pack year history, quit ten years ago. Rare alcohol. FAMILY HISTORY: Father with coronary artery disease. PHYSICAL EXAMINATION: On admission, vital signs were blood pressure 144/65; pulse 78; pulse oximetry 96% on room air. Generally, pleasant in no acute distress. HEENT: Anicteric, oropharynx clear. Cardiovascular: Regular rate and rhythm, S1, S2. II/VI systolic murmur. Pulmonary clear anteriorly and laterally. Abdomen soft, nontender, nondistended, with positive bowel sounds. Extremities showed trace edema bilaterally. Sheath in the right groin intact. Neurologic: Alert and oriented times three, mentating well. LABORATORY: On admission, white blood cell count 9.4, hematocrit of 33.5, platelets of 259, INR 1.1, PTT 22.4, PT 12.4, glucose 150, BUN 10, creatinine 0.4. Sodium 139, potassium 4.2, chloride 102, CO2 25, CK 86, alkaline phosphatase 73, total bilirubin 0.2, AST 27, ALT 17, magnesium 1.6, phosphorus 4.0, calcium 9.3, albumin 3.6. HOSPITAL COURSE: 1. Cardiovascular: The patient had a catheterization at an outside hospital on [**2181-5-15**] showing in-stent restenosis of the right coronary artery. The patient referred to [**Hospital1 1444**]. The patient had a cardiac catheterization on [**5-16**], showing left middle cerebral artery okay, left anterior descending okay, left circumflex okay. Right coronary artery with 70% in-stent restenosis. The patient had this percutaneous transluminal coronary angioplasty with acute thrombus after percutaneous transluminal coronary angioplasty with ST elevation; an emergent repeat percutaneous transluminal coronary angioplasty showed no dissection. The patient was transferred to the Cardiac Care Unit for observation overnight on [**2181-5-16**]. On [**5-17**], the patient had a re-catheterization showing TIMI-III flow through the right coronary artery. No intervention was done at this time and the patient was transferred to the Floor and discharged the following day on [**5-18**], with no further episodes of chest pain or shortness of breath. The patient was continued on her outpatient cardiac regimen. The patient was originally started on Ticlid but developed a rash on her buttock area similar to her rash to Plavix and this was discontinued. The patient should follow-up with her primary Cardiologist in one to two weeks. 2. Endocrine: The patient with a diagnosis of type 2 diabetes mellitus. The patient was kept on NPH at night and oral hyperglycemic medications were held while she was NPO. These were restarted at discharge and the patient had good blood sugar control while an inpatient. 3. Hematological: The patient with mild hematocrit drop to 27.8 from admission. The patient was transfused one unit of packed red blood cells with response to 29. This should be followed up in one to two weeks as an outpatient for repeat hematocrit draw. 4. Psychiatric: The patient was continued on Celexa, her outpatient regimen. CONDITION AT DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Monopril 20 mg p.o. q. day. 3. Celexa 20 mg p.o. q. day. 4. Premarin 0.625 mg p.o. q. day. 5. Glucotrol XL 10 mg p.o. twice a day. 6. Glucophage 1000 mg p.o. twice a day. 7. Pravachol 20 mg p.o. q. day. 8. Covera HS 240 mg p.o. q. day. 9. Humulin 22 units subcutaneously q. h.s. 10. Ambien p.r.n. 11. Multivitamin p.r.n. 12. Xanax p.r.n. 13. Lomotil p.r.n. 14. Nitroglycerin p.r.n. 15. Diflucan p.r.n. DISCHARGE STATUS: To home. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with primary Cardiologist, Dr. [**Last Name (STitle) 14522**], in one week. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Type 2 diabetes mellitus. 3. Anemia. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**] Dictated By:[**Last Name (NamePattern1) 1324**] MEDQUIST36 D: [**2181-5-19**] 11:19 T: [**2181-5-21**] 11:50 JOB#: [**Job Number 102031**]

[ "285.9", "V45.82", "996.72", "250.00", "401.9", "414.01", "998.2", "272.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2212, 2250

5781, 6093

5152, 5626

3129, 5104

5650, 5760

2273, 3112

5120, 5129

175, 198

227, 1277

1299, 2058

2075, 2195

846

195,564

4464

Discharge summary

report

Admission Date: [**2101-1-28**] Discharge Date: [**2101-2-3**] Date of Birth: [**2036-10-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transferred from outside hospital for coronary and carotid cath Major Surgical or Invasive Procedure: carotid cath coronary cath History of Present Illness: 64 yr old hypertensive, diabetic male with CAD s/p CABG '[**93**] and b/l carotid disease transferred from OSH after an episode of chest pain and aphasia. He was in his USOH until [**2101-1-27**] when at noon he developed substernal chest "burning" while sitting at his office. He noticed that his speech was slurred and "the words wouldn't come out." When his wife called him she noted that his words "made no sense" "he was saying nonsense." She thought he might have been hypoglycemia and gave him some coke, after which his symptoms improved. They called EMS and were taken to [**Hospital **] Hospital. A Head CT was (-) for bleed and Trop-I+ 0.87. Ck 200. He received 2 doses of 1 mg/kg lovenox and was transferred to [**Hospital1 18**]. He had LAD stent in [**Hospital1 18**]. A few days later, he has RCA stented and has myoclonic jerk, NOT seizure in the cath lab per neurology attending ROS: (-) SOB/Palp/Edema/N/V/Weakness/numbness/HA. Past Medical History: ##CAD s/p CABG in [**2093**] with EF 50% by LVG. He has chest pain with lifting boxes. LIMA>>LAD, SVG>>Diag -[**9-28**] ETT Thal for 2 minutes with HR 130, 2 mm horizontal lateral ST depressions. ##non-insulin dependent diabetes mellitus x 10 years. ##hypertension ##hypercholesterolemia ##Stroke/TIA with no residual defects. Carotid U/S in [**8-30**] with right ICA occlusion and left 80-99% stenosis. Followed by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] (cardiology) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19141**] (vasc [**Doctor First Name **]). ## B/L Claudication Social History: Quit smoking 25 years ago. No EtOH. Works as a mechanic. Lives with wife. 2 adopted children. Family History: Mother MI at 60 Physical Exam: Temp: afebrile BP:120/82 HR:60 RR:12 O2:99 RA Gen: NAD, A/O x 3 HEENT: PEARLA. EOMI. OP w/o lesions. CV: RR. Soft II/VI systolic murmur at LLSB. JVD flat. Sternotomy incision c/d/i. Pulm: CTA B/L ABD: S/NT/ND Ext: no edema. s/p vein graft incision c/d/i. 1+DP/PT Neuro: Motor [**3-31**] at all flexors/extensors. Sensation: GI to light touch and pinprick. [**Doctor First Name **] intact. FTN intact. CNII-XII: GI Pertinent Results: AT OSH: Na:138, K:4.3, BUN:20, Cr:1.4, INR:0.9, WBC:10.1 Hgb:14.6, Plt:171 ECG: NSR at 56. Qs in III, F. J-pt elevation in V1, V2, II, F. Lateral TWI (dynamic). Nl Axis/intervals. CXR: No CP processes [**2101-1-27**]: Chronic Right Occipital Cortical Infarct, chronic deep white matter infarction due to small vessel disease, small lacunar infarct in left thalamus. cath [**2-2**]: 1. Significant native coronary artery disease. 2. Severe bilateral internal carotid artery disease. 3. Arterial disease in the left subclavian and bilateral vertebrals 4. Successful placement of self-expanding stent in left ICA. 5. Successful employment of AccuNet distal embolic protection. 6. Self-limited, brief myotoclonus event. COMMENTS: 1. Limited coronary angiography demonstrated a right dominant system with left main and severe native vessel disease. The LMCA had an ostial 60% lesion. The proximal and midvessel LAD had diffuse calcific disease. The distal LAD filled via a LIMA which was not selectively engaged. The D1 branch was totally occluded. The LCx had mild diffuse disease. The RCA and bypass grafts were not successfully engaged. 2. Limited resting hemodynamics revealed a central blood pressure of 132/57 mmHg and a left CFA pressure of 101/67 mmHg. The mean gradient was 3 mmHg. 3. Retrograde access of the left common femoral artery was obtained for selective carotid, vertebral, and coronary angiography. The thoracic aorta had a Type I arch. The bilateral subclavian arteries had mild proximal disease. The left subclavian artery had a 50% lesion in the origin with a peak to peak gradient of 20 mmHg. 4. The right vertebral artery was small and diminutive with a total occlusion at the base of the skull before entering the brain. The left vertebral artery was large and was noted to have a 60% origin lesion and filled the basilar and the cerebellar arteries. The contralateral PCA filled from the vertebral but the ipsilateral (left) PCA was not seen. 5. The right common carotid artery was without disease but the ICA was totally occluded. The left common carotid artery was without disease but the ICA had diffuse tubular 80% disease. The left ICA filled the ipsilateral ACA and MCA as well as the contralateral ACA and MCA via a large ACOM. 6. Successful placement of a [**5-4**] x 40 mm Acculink stent in the left ICA postdilated with a 4.5 mm balloon. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 7. Transient, self-limited myoclonic event during postdilation which was though not likely to represent seizure activity. 8. Successful Perclose of the left femoral arteriotomy site at the conclusion of the procedure without complications. Cath at OSH [**8-30**]: "multiple tight stenoses of the proximal LAD and proximal D1. Proximal D2 occluded. RCA proximally occluded. LIMA to LAD patent, svg to diag could not be visualized and was presumed occluded. Left carotid patent, right carotid occluded." cardiac cath [**2101-1-31**] 1. Three vessel coronary artery disease. 2. Rotation atheterectomy of the proximal LAD. 3. Unsuccessful attempt at PTCA/stenting of the D1. COMMENTS: 1. Selective coronary angiography revealed a right dominant system. The RCA was not injected. The SVgs and the LIMA were not injected. The LMCA had a 60% ostial stenosis. The proximal LAD [**Last Name (un) **] 80% calcific stenosis. The distal LAD was filling via a LIMA (there was competitive flow). The D1 had a 80% calcific stenosis at the origin. The LCX had mild diffuise disease. 2. Unsuccessful attempt at PTCA/stenting of the D1 due to inability to cross despite using multiple wires. Rotational atherectomy was performed in the LAD in an attempt to modify the LAD lesion and allow crossing inro the D1 (See PTCA comments). carotid series [**2101-1-31**]: REASON: Known carotid atherosclerosis, pre-op for stenting. FINDINGS: Duplex evaluation was performed of both carotid arteries. Significant plaque was identified on the right. There is no flow in internal carotid artery including power Doppler technique. Of note there is no study for comparison. On the left, significant mostly soft appearing homogeneous plaque is identified in the internal carotid artery. Of note it appears to extend fairly distally in the cervical internal carotid artery. On the right, peak systolic velocities are 52, 72 in the CCA, ECA respectively. On the left, in the internal carotid artery the peak systolic over diastolic velocity is 361/123. In the remainder of the vessel the peak systolic velocities are 54, 584 in the CCA, ECA respectively. The ICA-CCA ratio is 6. This is consistent with an 80-99% stenosis. [**2101-1-28**] 05:48PM GLUCOSE-97 UREA N-18 CREAT-1.2 SODIUM-143 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-28 ANION GAP-14 [**2101-1-28**] 05:48PM ALT(SGPT)-32 AST(SGOT)-29 CK(CPK)-168 [**2101-1-28**] 05:48PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.8 [**2101-1-28**] 05:48PM WBC-7.5 RBC-4.46* HGB-14.0 HCT-40.8# MCV-92 MCH-31.4 MCHC-34.3 RDW-13.0 [**2101-1-28**] 05:48PM PLT COUNT-195# [**2101-1-28**] 05:48PM PT-13.2 PTT-32.6 INR(PT)-1.1 Brief Hospital Course: 64 y.o. male with CAD status post CABG, history of TIA with bilateral carotid stenosis presents s/p episode of chest pain and aphasia with borderline elevation in TN-I and non-specific ant/lateral ST-T wave changes. He was admitted for coronary and carotid cath.Patient had cardiac catheterization on [**2101-2-2**] and was discovered to have severe bilateral internal carotid artery disease and also arterial disease in the left subclavian and bilateral vertebrals. Successful placement of self-expanding stent in left ICA and successful employment of AccuNet distal embolic protection. Patient was admitted briefly to CCU for observation overnight. He did well and has no neurological events. His blood pressure was kept between 120-140. He did well and was discharged the following day Medications on Admission: Glipizide XL 5, Fish Oil 1000mg, Ca 600 [**Hospital1 **], MVI, Garlic Pill 1250, Loratadine, ASA 325, Atenolol 50, Metformin 1000mg, Nexium 40 daily, Lisinopril 5 tid, Lipitor 20, Zetia 10, Doxazosin 4. Coumadin was D/C'd 3 months ago Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 5. Omega-3 Fatty Acids 120-180-1.8 mg-mg-unit Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO DAILY (Daily). Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2* 8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*9* 9. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: coronary artery disease carotid artery stenosis Discharge Condition: stable Discharge Instructions: Please return to the hospital or call your doctor if you have chest pain/shortness of breath/dizziness/blur vision or if there are any concerns at all PLease take all your prescribed medication Followup Instructions: Please call Dr. [**First Name (STitle) **], [**First Name3 (LF) 487**] TOMORROW to schedule an appointment Completed by:[**2101-2-22**]

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icd9cm

[ [ [] ] ]

[ "00.61", "88.55", "36.01", "37.22", "00.63" ]

icd9pcs

[ [ [] ] ]

9992, 9998

7841, 8632

378, 407

10090, 10098

2666, 7818

10341, 10479

2185, 2202

8917, 9969

10019, 10069

8658, 8894

10122, 10318

2217, 2647

275, 340

435, 1394

1416, 2055

2071, 2169

46,961

156,874

49547

Discharge summary

report

Admission Date: [**2155-5-20**] Discharge Date: [**2155-5-23**] Date of Birth: [**2078-5-14**] Sex: F Service: MEDICINE Allergies: erythromycin (bulk) Attending:[**First Name3 (LF) 4891**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: 77F with h/o mild asthma p/w increasing sob, productive breath, and fever x 4 days. She had worsening sob today, so saw her PCP . In clinic she was noted to be 88% RA and reportedly was confused in setting of hypoxia. She was sent to the ED for further evaluation. She was in [**State 15946**] last week on a family vacation. Had two sick contacts of her grandchildren. Her symptoms started Saturday and notably had a fever to 101.8. She saw her PCP [**Name9 (PRE) 766**] and was given the opportunity to be treated in the hospital vs. home and patient requested to be home. Her daughter took her back to Dr. [**Last Name (STitle) 410**] the following day as she was not improving and she was found to be hypoxic to high 80s and was sent to the ED. Notably, her asthma is mild in nature. Never been intubated or hospitalized. She has never been on steroids. PFTs have been normal in [**2147**] . In the ED, initial vs were: 98.9 115 103/47 20-24 88% RA. Placed on NRB -> 100% and titrated down to 10 liters on face mask. She received two rounds of duonebs and attempted to place on nasal cannula. She could not tolerate this and was placed back on face mask at 5 liters. CXR showed LLL PNA. Labs notable for lactate of 2.9. Wbc of 14.8 with 7% bands. EKG showed NSR at rate of 87 with TWI in III and aVF. Troponin flat x 1. She was given levofloxacin and 2 liters of NS. She notably has an erythromcyin allergy. Last vitals: 99.1 HR: 94 BP: 111/45 RR: 24-28. . Upon arrival to the MICU, patient was feeling well with out pain. She was placed on nasal cannula with sats in the low to mid 90s. Past Medical History: Asthma Osteopenia Hypertension Allergies Low Back pain Hypothyroidism Social History: - Tobacco: None/Never - Alcohol: Rarely - Illicits: Denies Family History: Diabetes: son Physical Exam: ADMISSION: Vitals: T:98.2 BP: 103/39 P:86 R: 18 O2: 92% on 4 Liters General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles at bases L >R, clear otherwise, no wheezes or rhonhi 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, 1+ pulses, no clubbing, cyanosis or edema . DISCHARGE: O2 sats low 90s with ambulation and mid 90s at rest. BP 120s/60s Pertinent Results: ADMISSION LABS: [**2155-5-20**] 07:00PM BLOOD WBC-14.8*# RBC-3.43* Hgb-11.3* Hct-33.9* MCV-99* MCH-32.9* MCHC-33.3 RDW-12.6 Plt Ct-394 [**2155-5-20**] 07:00PM BLOOD Neuts-69 Bands-7* Lymphs-13* Monos-9 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2155-5-20**] 07:00PM BLOOD Glucose-138* UreaN-21* Creat-1.1 Na-135 K-3.8 Cl-96 HCO3-28 AnGap-15 [**2155-5-20**] 07:00PM BLOOD Iron-15* [**2155-5-20**] 07:00PM BLOOD calTIBC-260 VitB12-1150* Folate-GREATER TH Ferritn-462* TRF-200 [**2155-5-20**] 07:00PM BLOOD Lactate-2.9* DISCHARGE LABS: [**2155-5-21**] 07:06AM BLOOD Lactate-0.9 [**2155-5-23**] 06:08AM BLOOD Glucose-107* UreaN-12 Creat-0.7 Na-145 K-4.2 Cl-108 HCO3-27 AnGap-14 [**2155-5-23**] 06:08AM BLOOD WBC-12.3* RBC-3.06* Hgb-10.2* Hct-30.2* MCV-99* MCH-33.4* MCHC-33.8 RDW-12.8 Plt Ct-435 . MICRO: Legionella Urinary Antigen (Final [**2155-5-21**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . BLOOD CX [**5-20**]: NGTD . [**2155-5-21**] 8:10 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal swab. Respiratory Viral Culture (Preliminary): Respiratory Viral Antigen Screen (Final [**2155-5-21**]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. . SPutum cx: GRAM STAIN (Final [**2155-5-22**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2155-5-24**]): RARE GROWTH Commensal Respiratory Flora. YEAST. SPARSE GROWTH. FUNGAL CULTURE (Preliminary): YEAST. Coccidioides Ab negative C diff negative . STUDIES: CXR [**2155-5-21**]: FINDINGS: As compared to the previous radiograph, the lung volumes have increased, likely to reflect improved ventilation. As a consequence, the pre-existing atelectatic opacities at the left lung base have decreased in extent and severity. Unchanged mild cardiomegaly without evidence of pulmonary edema. No evidence of pleural effusions. Unchanged severe scoliosis with subsequent asymmetry of the rib cage. Brief Hospital Course: 77 yo F h/o asthma admitted with productive cough, fever, hypoxia, and infiltrate on CXR consistent with CAP Active Issues # Community Acquired Pneumonia: Patient presenting with symptoms above consistent with CAP. She had brief MICU stay with overall improved hypoxia and downtrending lactate and leukocytosis with resolution of bandemia. She was initially started on Ceftriaxone and Levofloxacin for double coverage of strep pneumo but was transitioned to levofloxacin alone to complete 10 day course. Coccidioides Ab, urine legionella, and respiratory viral screen were negative and sputum cx only positive for yeast. Given persistent wheezing and bronchospasm on day of discharge, she was given a prescription for an albuterol inhaler for rescue use. On day of discharge she was satting low to mid 90s at rest and with ambulation. # Asthma: Continued on Advair and prescribed albuterol as above. #. Diarrhea: Patient developed loose stools on HD#2. She did not have any fever or leukocytosis that suggested a new infection such as C diff so this was felt to be most likely related to antibiotic use. C diff was negative x 1. We suggested the use of probiotics, and noted that although the evidence is limited, this has been successful for some patients in limiting the diarrheal symptom. # Anemia: Markedly decreased from prior in [**2150**] (40.3). No signs of active bleeding and iron studies only remarkable for an elevated ferritin. B12 and folate were normal. This should be followed up as an outpatient. # Hypertension: Patient was normotensive with some borderline low BPs during stay. Her antihypertensives were initially held in MICU but then amlodipine, atenolol, and losartan were all restarted. HCTZ was held as patient still seemed slightly hypovolemic due to decreased PO intake overall and diarrhea so we continued to hold her hctz until she is seen in follow up for repeat BP check. Inactive Issues # Hypothyroidism: Continued on home dose of Levoxyl per home dosing. . # Osteoporosis: Continue Fosamax as outpatient. Medications on Admission: - Levoxyl 75mcg daily - Advair 100-50mcg daily - Nasonex 50mcg 2 puffs each nostril qday - Norvasc 5mg 1 po daily - Atenolol 25mg po daily - Fosamax [**Last Name (un) 80630**] D 70-2800 q po qweek - Ultram 50mg 1-2po q4-6hrs prn - Tums 500 1 tid - Vitamin D cholecalciferol 1000 IU daily - Trazodone 100mg qhs - Ativan 0.5mg qhs prn - Metronidazole gel apply to face daily - Losartan 100mg daily - HCTZ 25mg qday - Neurontin 300mg cap [**Hospital1 **] Discharge Medications: 1. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 2. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Fosamax Plus D 70-2,800 mg-unit Tablet Sig: One (1) Tablet PO once a week. 9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 11. metronidazole-skin cleanser 1 % Combo Pack Sig: One (1) application Topical once a day. 12. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 15. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-26**] Sprays Nasal [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Pneumonia, Community Acquired Secondary Diagnosis: Asthma, Hypertension, Hypothyroidism 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 pneumonia. You were initially in the ICU because your oxygen levels were low but your oxygen levels improved and you were transferred to the regular hospital floor. We treated you with antibiotics which you will continue for 6 more days. We made the following changes to your medications 1. We added levofloxacin for 6 additional days 2. We added saline nasal spray 3. We stopped ativan since you were no longer taking this medication and it made you confused when you were in the hospital 4. We held your hydrochlorothiazide. Please hold this until you see Dr. [**Last Name (STitle) 410**] in follow-up. He will determine when you should restart this medication for your blood pressure 5. We added albuterol for you to use as needed for SOB or wheezing Followup Instructions: Please follow up with your PCP as listed: Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: PERSONAL [**Hospital **] HEALTH CARE, P.C. Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 1408**] Appt: [**5-29**] at 1:30pm

[ "E930.5", "724.2", "401.9", "799.02", "244.9", "787.91", "493.90", "482.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8969, 9027

4952, 6999

284, 291

9179, 9179

2771, 2771

10148, 10483

2104, 2119

7503, 8946

9048, 9048

7025, 7480

9330, 10125

3303, 4400

2134, 2752

4436, 4929

241, 246

319, 1917

9119, 9158

2787, 3287

9067, 9098

9194, 9306

1939, 2011

2027, 2088

23,380

128,834

9179

Discharge summary

report

Admission Date: [**2138-9-4**] Discharge Date: [**2138-9-12**] Date of Birth: [**2074-5-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: Neutropenic fever, atrial fibrillation with rapid ventricular response, low blood pressure, dehydration Major Surgical or Invasive Procedure: Barium swallow study History of Present Illness: HPI: 64 year old male with esophageal cancer on treatment presenting with abdominal, chest and back pain for 4-6 weeks. He has been evaluated for this pain previously by his PCP and oncologist and was put on a Fentanyl patch, with escalating doses. The pain started in his chest and then spread to his abdomen and back. The abdominal pain is diffuse and has no relationship to food. The back pain is also diffuse, but he denies bowel or bladder incontinence or lower extremity weakness or paresthesias. He denies nausea, but did have one episode of vomiting. No diarrhea, constipation, blood per rectum. He continues to lose weight despite the addition of Megace to his regimen. He is failing at home and came in for a [**First Name3 (LF) 1988**] appointment today. He was seen by his oncologist today and was given 1 liter NS, 8 mg Zofran and 4 mg Morphine in the clinic and was referred to the ED for admission. . In the ED, his vitals were: 97, 100/78, 82, 95% RA . He was found to be neutropenic and developed a fever to 101.3 in the ED and was started on Cefepime. He had a noncontrast CT abdomen which did not reveal a cause of his pain. Initial ECG demonstrated AF with RVR. He was started on a diltiazem gtt with good HR response to the 80s-90s. After 5 hours on a diltiazem gtt he developed relative hypotension with SBP in 80s and the drip was stopped. Over the course of the clinic and ED he received a total 4 liters normal saline. IV pain medication given with some relief, but with discomfort at the IV site. He was transferred to the MICU for monitoring. BP at transfer 89/41. (Of note, last BP at outpatient onc clinic 97-100/55-72). Past Medical History: 1. Esophageal cancer: presented wtih severe indigestion which progressed to difficulty swallowing. Barium swallow [**5-21**] demonstrated esophageal lesion--8 cm infiltrating carcionma of distal esophagus. Biopsy demonstrated atpyical glandular proliferation. He started neoadjuvant 5FU and cisplatin and XRT from [**2137-5-23**]. [**8-21**] demonstrated total esophagogastretcomy. PET [**7-22**] showed multi-focal FDG avid left pleural nodular thickening and right medial upper pleural nodular thickening worrisome for metastatic disease. Left lung base nodule and right upper lobe nodule both FDG avid. Started Cisplatin, Irinotecan [**2138-8-14**]. Currently on day 22 Cis/irinotecan cycle. 2. History of diabetes but currently off insulin given significant weight loss. 3. Hypercholesterolemia which has resolved at this time. 4. Herniated disk. 5. DJD. . Past Surgical History 1. Operation for cholesteatoma at [**Hospital 31406**] 2. Multiple orthopaedics operations 3. Laparoscopy, laparoscopic jejunostomy and port placement under fluorscopic guidance Social History: SH: He lives in [**Location 3786**] with his sister, [**Name (NI) **], who came with him to his visit today. He was also accompanied by his brother [**Name (NI) **]. [**Name2 (NI) **] does not smoke or drink. He used to smoke a couple of packs a day for 40 years. He is currently on disability. He used to work for the City of [**Hospital1 8**] in their Sanitation Department. Family History: Father died of lung cancer Mother is [**Age over 90 **] [**Name2 (NI) **] and living in nursing home No other family history of malignancy Physical Exam: On admission: vitals: 97.5, 98/50, 71, 17, 97% RA General: cachectic, ill-appearing male, no distress, complains of severe pain, needs assistance to change position HEENT: PERRL, OP clear Neck: neck veins flat Car: RRR no murmur Resp: CTAB-ant/lat, could not sit up for posterior exam Abd: soft, diffuse mild ttp, no guarding, no rebound, + BS Ext: no edema Neuro: CN II-XII intact, UE/LE strength preserved. on discharge, vitals are stable, patient is afebrile. exam is largely unchanged except the patient has increased strength and is easily able to sit up for examination. Pertinent Results: [**2138-9-4**] 09:00AM GLUCOSE-248* UREA N-54* CREAT-1.9* SODIUM-134 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-21* ANION GAP-22* [**2138-9-4**] 09:00AM ALT(SGPT)-22 AST(SGOT)-9 CK(CPK)-25* ALK PHOS-131* [**2138-9-4**] 09:00AM CK-MB-2 cTropnT-<0.01 [**2138-9-4**] 09:00AM ALBUMIN-4.1 CALCIUM-9.9 . [**2138-9-4**] 09:00AM WBC-1.1*# RBC-4.30* HGB-12.5* HCT-36.0* MCV-84 MCH-29.2 MCHC-34.9 RDW-14.6 [**2138-9-4**] 09:00AM NEUTS-36* BANDS-16* LYMPHS-36 MONOS-4 EOS-4 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 [**2138-9-4**] 09:00AM PLT SMR-LOW PLT COUNT-132* . Studies: 1. pCXR: No change from the prior study of [**2138-7-31**], with pleural and parenchymal opacity in the left base. 2. Abd CT: Pleural and parenchymal abnormalities in the lung bases whose overall appearance is similar compared to the prior study. Certain opacities in the left lower lobe do appear more prominent, although whether these are atelectatic in nature, or neoplastic is difficult to discern. No evidence of acute abdominal or pelvic pathology given the limitations of a non-contrast study. Stable left adrenal nodule. High density within a nondistended gallbladder suggestive of sludge. . ECG: AF with RVR rate 167 bpm-->NSR with normal axis, normal intervals, TWI I, aVL, II, aVF, V5, V6, <1 mm STD V4-V6-->NSR, NA/NI, TWF I, aVL, no ST changes. . Barium Swallow: No evidence of stricture or obstruction within the gastric pull-through. . Bone Scan: No osseous metastasis seen. . Gallbladder US: Cholelithiasis and gallbladder sludge but no cholecystitis identified. . ECHO: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular ejection fraction is normal (LVEF 50-60%); however, the inferolateral (posterior) wall appears hypokinetic. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. 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. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: 64 year old male with esophageal cancer on chemotherapy presenting with uncontrolled chest, abdomen and back pain, failure to thrive, now with neutropenic fever and PAF. . 1. Neutropenic fever: Pt was started on cefepime and flagyl for neutropenic fever. Blood cultures were drawn and found to be negative. Urine culture demonstrated <10,000 organisms/ml, which was considered possibly [**1-17**] contamination. Fecal cultures were negative and he was CDiff negative. Vancomycin was not added as patient did not have a permanent line. CXR demonstrated no infiltrate. No infectious etiology to abdominal pain seen on CT scan. Cefepime and flagyl were discontinued [**9-7**]. The neutropenia resolved and the patient was transferred to the floor, where he has been afebrile. . 2. Atrial fibrillation: Pt spontaneously converted from Afib to normal sinus rhythm in the ED stayed in sinus throughout his hospital course. Pt ruled out for MI after cardiac enzymes were drawn given ST/T wave changes on ECG. ECHO on [**9-5**] demonstrated inferolateral wall hypokinesis but normal EF. Afib was considered likely [**1-17**] extreme hypovolemia from poor PO intake and stress from recurrent malignancy. TSH was normal at 0.91. . 3. Hypotension: Pt had significant recent weight loss and baseline low BP. Diltiazem was held and pt received 4 liters NS. Patient was alert and oriented with clear sensorium during this admission, and was net more than 3L positive. On the floor, his blood pressures remained stable. He required no further fluid resuscitation. . 4. Pain: Pt's chronic, multifocal pain was considered to stem from known malignancy and ongoing chemotherapy as per pt, pain arose concurrently with recurrence of disease. Pt was continued on fentanyl patch 75 mcg, Percocet for breakthrough pain, and morphine 2mg IV Q4H PRN. . 5. ARF: Cr 1.9=>1.1 from baseline 1.0. ARF likely prerenal, from poor PO intake. Pt net more than 3L positive during MICU stay, after aggressive hydration. Renal function returned to baseline and remained there throughout his course. . 6. FEN: Electrolyte disturbances likely from chemotherapy; pt repleted with good response. He continued to require repletion after transfer out of the unit, with appropriate bumps in his electrolyte levels. Patient has improved appetite, he is eating while in the hospital. He will continue to require electrolyte repletion while at skilled nursing. . 7. Esophageal cancer: patient will continue his oncology care as an outpatient with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. He had both a negative barium swallow as well as a negative bone scan while in the hospital. Medications on Admission: Fentanyl 75 mcg/72h (stopped taking all other medications) Discharge Medications: 1. Outpatient Lab Work Please draw chemistry 10 every Monday, Wednesday, and Friday, and fax to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], fax [**Telephone/Fax (1) 13345**], tel. [**Telephone/Fax (1) 6568**]. 2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Transdermal Q72H (every 72 hours) as needed for pain. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Megestrol 40 mg/mL Suspension Sig: 400 mg PO BID (2 times a day). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea, agitation. 8. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain: please hold for sedation or rr less than 8. 9. Morphine Sulfate 2 mg IV Q4H:PRN breakthrough pain 10. Metoclopramide 10 mg IV Q6H PRN nausea 11. Prochlorperazine 10 mg IV Q6H:PRN nausea 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily). 1. Outpatient Lab Work Please draw chemistry 10 every Monday, Wednesday, and Friday, and fax to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], fax [**Telephone/Fax (1) 13345**], tel. [**Telephone/Fax (1) 6568**]. 2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Transdermal Q72H (every 72 hours) as needed for pain. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Megestrol 40 mg/mL Suspension Sig: 400 mg PO BID (2 times a day). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea, agitation. 9. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain: please hold for sedation or rr less than 8. 10. Morphine Sulfate 2 mg IV Q4H:PRN breakthrough pain 11. Metoclopramide 10 mg IV Q6H nausea 12. Prochlorperazine 10 mg IV Q6H:PRN 13. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: On [**Location (un) **] - [**Location (un) **] Discharge Diagnosis: Atrial fibrillation, dehydration, esophageal cancer Discharge Condition: Stable Discharge Instructions: You were admitted for atrial fibrillation that we thought was related to dehydration and stress from your cancer. While you were here, we gave you antibiotics. You were transferred to the floor, where we repleted your electrolytes, advanced your diet and started ambulation. . Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. . Please take your medications as prescribed. . Please inform your care providers if you feel ill, develop chest pain, shortness of breath or any other symptoms that concern you. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-9-18**] 9:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2138-9-25**] 9:00

[ "275.2", "288.00", "338.3", "276.51", "458.29", "783.21", "715.90", "584.9", "780.6", "783.7", "272.0", "250.00", "276.2", "150.9", "787.91", "427.31", "276.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12099, 12172

6882, 9565

419, 442

12268, 12277

4403, 6859

12877, 13176

3648, 3789

9674, 12076

12193, 12247

9591, 9651

12301, 12854

3804, 3804

275, 381

470, 2135

3818, 4384

2157, 3232

3248, 3632

5,411

121,245

52145

Discharge summary

report

Admission Date: [**2131-8-12**] Discharge Date: [**2131-8-16**] Date of Birth: [**2053-7-5**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8747**] Chief Complaint: Headache (R occipital ICH) Major Surgical or Invasive Procedure: CT History of Present Illness: Pt is a 78 yo woman with hx multiple cerebral lobar hemorrhages secondary to amyloid angiopathy, who p/w HA since last night. HA began as "achy" pain over right eyebrow, with no associated sx; she did not think it was worse with valsalva. Pain woke her in the middle of the night, having spread to L eyebrow (across forehead), with slightly worsened severity, but still achy quality. She got up to use BR and found that her vision was poor; she looked at the clock and could not read the time, because she was "not seeing the whole picture" and the "hands were not in place." She looked in the mirror, but at this point she was crying and things looked blurry because of tears. The noticed no weakness, numbness, tingling, trouble with the ears/hearing, trouble speaking, understanding or swallowing, falls, head/neck trauma. She has had no recent illnesses, and does not believe she has made any medication changes. She c/o no n/v, no f/c/cp/uri sx/gi/gu sx. She was admitted to the neurology service in [**5-17**] with R occipital lobar hemorrhage - 8 cc - that had presented with headache and visual changes; she appeared to have a mild [**Doctor Last Name 4116**] syndrome at the time, with simultanagnosia on exam. Memory is chronically poor, and she becomes very upset when discussing issues of memory. Though placement was recommended at the time at rehab, her family was more comfortable having her live with her daughter for the short-term, with PT and OT. She improved at home, and eventually went back to living alone. She was seen in the ER again in [**6-16**] when she had presented with headache and no other neurological sx; head CT was negative for new bleed, and she returned home. Past Medical History: -History of multiple prior intracerebral hemorrhages. The first, of which have record, was in [**2120**], in the L occipital lobe. Follow up MRI/MRA after the hemorrhage showed no vascular malformation. Per daughter, patient had another hemorrhage in [**2122**] and then a third in [**2126**]. Daughter says that the [**2126**] hemorrhage left her with a period of severe word finding difficulties and a decline in her memory that improved a bit with time. Likely this one was R frontal. Most recent hemorrhage was in [**5-17**], right occipital. -She is being followed by a neurologist at [**Hospital1 336**] for dementia, recently started on aricept. -s/p cholecystectomy Social History: Lives independently, drives on her own, volunteers in an afterschool program working with 10 year olds. Although able to take care of her ADL's, her cognitive functioning has been declining significantly in the past 5-6 years. Formerly smoked. Family History: noncontributory Physical Exam: PE: T 98.4 BP 160/77 HR 90 RR 20 SAT 98% General appearance: well appearing older woman, NAD; tearful at parts of the exam. HEENT: moist mucus membranes, clear oropharynx Neck: supple, no bruits Heart: regular rate and rhythm, no murmurs Lungs: clear to auscultation bilaterally Abdomen: soft, nontender +bs Extremities: warm, well-perfused Skull & Spine: Neck movements are full and not painful to palpation in the paraspinal soft tissues Mental Status: The patient is alert and can provide history since yesterday; however, on formal testing of DOW bkwds or counting down (other than 10->1 by 1's), she is unable to perform these tasks; she can add 3+2 but has difficulty with other calculations given, and becomes very tearful at times during exam (ie, [**Location (un) 1131**]), saying "I can't, I can't." She registered [**4-13**] objects at 30 seconds, but could recall 0/3 at 3 minutes. She was not sure of the date, but knew which hospital she had come to. Language is intact with no errors, though naming for low-frequency objects is abnormal. There is no apraxia or agnosia. She cannot identify number of people in cookie picture - identifies woman, and cannot find other people. She can correctly identify colors. She is able to write a sentence "I want to go home," but then says "I can't see what I am writing." Cranial Nerves: The visual field testing initially reveals ?hemianopsia, but with confabulation of parts of the exam (ie, "seeing" finger when it is actually behind the head). With examiner standing behind her, she is able to locate finger movements bilat periph vision with accuracy, but she never is able to tell how many fingers. She has difficulty identifying objects, particularly number of objects, in any visual field. Eye mvmts with some saccadic intrusion but o/w nl, no nystag. Pupils react equally to light, both directly and consensually. Sensation on the face is intact to light touch, pin prick. Facial movements are normal and symmetrical. Hearing is intact to finger rub. The palate elevates in the midline. The tongue protrudes in the midline and is of normal appearance. Motor System: There is mildly increased tone in the left leg compared to the right. There is mild weakness on left - 5-/5 at triceps, wrist and finger extensors, and L IP is 5-/5, with 4+/5 at hamstrings. Right ham very mildly weak 5-/5. EHLs and EDBs are bilaterally mildly weak. There is very mild atrophy of intrinsic hand mms. Elsewhere, the appearance, tone, and power are normal in the limbs. There is no tremor, drift, or abnormal movements. Reflexes: The tendon reflexes are present, symmetric and normal. The toes are upgoing bilaterally. Sensory: Sensation is intact to pin prick, light touch in all extremities and trunk. very mild loss of vibration sense and position sense at the toes. No extinction to DSS. Coordination: There is no ataxia. The finger/nose test and finger and foot tapping are performed normally, as are rapid alternating hand movements. Gait: deferred Pertinent Results: [**2131-8-12**] 11:24AM WBC-7.8 RBC-4.45 HGB-14.1 HCT-39.0 MCV-88 MCH-31.7 MCHC-36.1* RDW-13.7 [**2131-8-12**] 11:24AM NEUTS-73.0* LYMPHS-20.3 MONOS-4.7 EOS-1.6 BASOS-0.4 [**2131-8-12**] 11:24AM PLT COUNT-262 [**2131-8-12**] 11:24AM PT-11.8 PTT-22.0 INR(PT)-1.0 [**2131-8-12**] 02:41PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2131-8-12**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2131-8-15**] 11:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2131-8-15**] 11:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2131-8-16**] 05:45AM BLOOD Glucose-92 UreaN-8 Creat-0.4 Na-142 K-3.5 Cl-106 HCO3-26 AnGap-14 [**2131-8-13**] 04:12AM BLOOD ALT-7 AST-15 LD(LDH)-150 CK(CPK)-99 AlkPhos-81 TotBili-0.9 [**2131-8-13**] 04:12AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2131-8-16**] 05:45AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 NCHCT: [**8-12**]: FINDINGS: There is a 4.7 x 3.4 cm intraparenchymal hemorrhage posterior to the right lateral ventricle. This is a small amount of surrounding edema. There is mass effect with compression of the posterior [**Doctor Last Name 534**] of the right lateral ventricle and posterior body of right lateral ventricle. There is no evidence of hydrocephalus. There is no significant amount of midline shift. The basilar cisterns are patent. Again seen are hypodense areas in the right frontal, left parietal and left occipital lobes which are stable compared to [**6-28**] consistent with chronic infarction. Of note, the patient had a prior right occipital hemorrhage in [**2131-5-21**]. The bony structures are unremarkable. The visualized portions of the paranasal sinuses and the mastoid air cells are well aerated. The surrounding soft tissue structures appear unremarkable. NCHCT [**8-13**]: IMPRESSION: No significant change since [**2131-7-13**]. There is stable right occipital intraparenchymal hematoma. CXR: CHEST: PA and lateral views. The heart, mediastinum, and pulmonary vessels are within normal limits. The lungs are clear. There is no pleural effusion or other pleural abnormality. Mild degenerative changes are noted in the thoracic spine. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the Neuro ICU overnight on labetolol drip for BP control. She did well and was transferred to the floor quickly. Neurosurg was consulted and no intervention was deemed necessary. Coags were WNL and repeat head CT showed a stable 54cc right occipital hemorrhage, no hydrocephalus, no midline shift. Clinically she improved. She initially complained of vision changes. Her exam is complicated given her underlying dementia, mild perseveration, and the fact she has had an old left occipital hemorrhage and now a right occipital hemorrhage. Her visual acuity is at least counting fingers (was not able to read snellin card). She has alexia and agraphia and simultagnosia (recognizing only pieces of a picture of her grandchild like the hair or eyebrow, not the whole face). She does not fully have Balints syndrome in that she is very upset by her vision loss, insight intact. She does not clearly have ocular dysmetria or apraxia, she performs finger to nose well. Visual fields were difficult to interpret, at times she seemed to confabulate seeing my fingers. However, it appeared she had at least a left lower quadrantanopsia. She is otherwise strong with sensation intact, gait normal. Her other complaint was that of headache, improved on percocet and now at a "tolerable" level. She was febrile after transfer to the floor to 101.1, UA neg, CXR neg. No further spikes in temperature. BP well controlled on ACEI. She should f/u with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] at [**Hospital1 2025**], specialist in amyloid angiopathy. She may benefit from a clinical trial. We attempted to make an appt for her, but she must register herself before an appt can be made. Phone numbers given to patient and daughter. Daughter was updated on a daily basis. Medications on Admission: Medications - confirmed doses with [**Doctor First Name **] pharmacy/[**Location (un) **] -keppra 1000 mg po bid -enalapril 2.5 mg po daily (old notes: 20mg; per pharmacy, no changes in this dose past year) -zoloft 25 mg po daily -zocor 5 mg qd -Aricept last filled [**6-3**], has not been taking Discharge Medications: 1. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for for headache. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: amyloid angiopathy and intracerebral hemorrhage dementia Discharge Condition: Stable - has simultagnosia, alexia, agraphia, visual acuity - counts fingers. Otherwise is strong, walks well. Discharge Instructions: Please take all medications. Please return to the ED if you experience much worsening of your headache or change in headache, new neurologic problems such as new troubles seeing, weakness, numbness, language dysfunction. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2131-8-20**] 11:30 Please followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40282**] clinic: please call [**Telephone/Fax (1) 66939**] to register, then [**Telephone/Fax (1) 107891**] to make the appointment with the hemorrhage prevention clinic.

[ "401.9", "285.9", "459.9", "277.3", "294.8", "431", "780.6", "368.46" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11279, 11351

8447, 10296

342, 347

11452, 11566

6142, 8424

11836, 12251

3065, 3083

10644, 11256

11372, 11431

10322, 10621

11590, 11813

3098, 3541

276, 304

375, 2086

4448, 6123

3556, 4432

2108, 2787

2803, 3049

79,275

166,330

35729+58029

Discharge summary

report+addendum

Admission Date: [**2123-2-17**] Discharge Date: [**2123-2-28**] Date of Birth: [**2040-2-25**] Sex: M Service: ORTHOPAEDICS Allergies: Penicillins Attending:[**Doctor Last Name 1350**] Chief Complaint: Low back pain Major Surgical or Invasive Procedure: [**2-18**]: L2 corpectomy, L1-3 AIF, L1-3 lamis, T12-L4 PSIF History of Present Illness: 82yoM who initially presented to [**Hospital1 18**] with onset of back pain and difficulty ambulating in mid-[**2122-12-27**]. His pain dated back to a fall in [**2122-10-26**]. No other h/o trauma. Pain became worse over the several days prior to his admission at that time prompting his presentation to the hospital. Imaging at that time revealed an L2 compression fracture with probably associated lytic changes. He was admitted for malignancy work-up including a CT-guided biopsy of the L2 vertebral body that was negative. He was fitted with a TLSO for support and discharged to rehab for a short period. He is readmitted at this time for his definitive surgical procedure for L2 open biopsy and spinal stabilization. His pain is unchanged and radiates toward bilateral groin. No bowel/bladder symptoms. Denies BLE numbness, tingling or weakness. No fevers, chills, or weight loss. No history of cancer. Past Medical History: 1. Type II heart block with pacemaker 2. HTN 3. BPH 4. Factor v Leiden 5. H/o DVT 6. Hypothyroid 7. B TKA 8. Partial thyroidectomy 9. Appendectomy Social History: Son is a PA who works at [**Hospital3 **] in [**Hospital1 1474**]. Mr [**Known lastname 41684**] is a nonsmoker, no ETOH, no Drug use Family History: N/C Physical Exam: His mental status is normal, he is fully alert and oreinted and responds appropriately to all questions. His bilateral upper and lower extremities are warm and well perfused. BUE [**3-30**] [**Doctor First Name **]/Bic/Tri/WE/WF/FF/IO SILT BUE C5-T1 dermatomal distributions BLE WWP, [**3-30**] IP/HS/Qu/[**Last Name (un) 938**]/FHL/TA/GS SILT BLE L1-S1 dermatomal distributions No clonus, toes down-going Pertinent Results: HEMATOLOGY: [**2123-2-25**] 10:15AM BLOOD Hct-28.4* [**2123-2-24**] 05:04AM BLOOD WBC-8.3 Hct-27.0* Plt Ct-193 [**2123-2-23**] 05:02AM BLOOD WBC-8.1 Hct-26.2* Plt Ct-165 [**2123-2-22**] 02:36AM BLOOD WBC-12.1* Hct-26.6* Plt Ct-155 [**2123-2-21**] 02:16AM BLOOD WBC-14.7* Hct-26.4* Plt Ct-116* [**2123-2-20**] 02:26AM BLOOD WBC-16.8* Hct-27.4* Plt Ct-107* [**2123-2-19**] 05:30PM BLOOD Hct-29.3* [**2123-2-19**] 10:41AM BLOOD Hct-31.5* [**2123-2-19**] 02:00AM BLOOD WBC-19.7* Hct-33.5* Plt Ct-148* [**2123-2-18**] 10:41PM BLOOD Hct-35.5* [**2123-2-18**] 08:05PM BLOOD WBC-17.0*# Hct-32.8* Plt Ct-175 [**2123-2-17**] 06:00PM BLOOD WBC-5.6 Hct-39.5* Plt Ct-153 COAGULATION: [**2123-2-28**] 11:20AM BLOOD INR(PT)-2.3* [**2123-2-27**] 07:40AM BLOOD INR(PT)-2.6* [**2123-2-26**] 06:20AM BLOOD INR(PT)-2.3* [**2123-2-25**] 05:50AM BLOOD INR(PT)-1.4* [**2123-2-24**] 05:04AM BLOOD INR(PT)-1.4* [**2123-2-23**] 05:02AM BLOOD INR(PT)-1.3* [**2123-2-22**] 02:36AM BLOOD INR(PT)-1.3* [**2123-2-19**] 02:00AM BLOOD INR(PT)-1.5* [**2123-2-18**] 10:42PM BLOOD INR(PT)-1.6* [**2123-2-18**] 02:12PM BLOOD INR(PT)-1.6* [**2123-2-18**] 03:20AM BLOOD INR(PT)-1.9* [**2123-2-17**] 06:00PM BLOOD INR(PT)-2.1* CHEMISTRY: [**2123-2-28**] 12:38AM BLOOD UreaN-16 Creat-0.6 Na-136 K-4.0 Cl-100 HCO3-26 [**2123-2-25**] 05:50AM BLOOD UreaN-23* Creat-0.7 Na-144 K-3.3 Cl-108 HCO3-26 [**2123-2-24**] 03:10PM BLOOD UreaN-26* Creat-0.7 Na-141 K-3.6 Cl-107 HCO3-24 [**2123-2-24**] 05:04AM BLOOD UreaN-24* Creat-0.6 Na-145 K-3.3 Cl-108 HCO3-31 [**2123-2-23**] 03:57PM BLOOD UreaN-23* Creat-0.7 Na-145 K-3.4 Cl-107 HCO3-31 [**2123-2-23**] 05:02AM BLOOD UreaN-23* Creat-0.8 Na-142 K-3.2* Cl-107 HCO3-32 [**2123-2-22**] 07:45PM BLOOD UreaN-21* Creat-0.7 Na-144 K-3.2* Cl-106 HCO3-31 [**2123-2-22**] 02:36AM BLOOD UreaN-19 Creat-0.7 Na-143 K-3.3 Cl-106 HCO3-32 [**2123-2-21**] 08:53PM BLOOD UreaN-18 Creat-0.7 Na-143 K-3.1* Cl-106 HCO3-30 [**2123-2-21**] 10:06AM BLOOD UreaN-17 Creat-0.7 Na-140 K-3.1* Cl-106 HCO3-28 [**2123-2-21**] 02:16AM BLOOD UreaN-16 Creat-0.8 Na-141 K-2.8* Cl-106 HCO3-28 [**2123-2-20**] 02:26AM BLOOD UreaN-15 Creat-0.6 Na-138 K-3.6 Cl-109* HCO3-22 [**2123-2-19**] 02:00AM BLOOD UreaN-12 Creat-0.6 Na-138 K-3.9 Cl-107 HCO3-21* [**2123-2-18**] 08:05PM BLOOD UreaN-11 Creat-0.5 Na-139 K-3.8 Cl-108 HCO3-24 [**2123-2-17**] 06:00PM BLOOD UreaN-13 Creat-0.8 Na-139 K-4.1 Cl-104 HCO3-29 Brief Hospital Course: Mr. [**Known lastname 41684**] was admitted pre-operatively to the [**Hospital1 18**] Orthopedic Spine Surgery Service on [**2123-2-17**] under the attending Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] for coumadin reversal. His INR on admission was 2.1 and his coumadin was held. He received vitamin K 10mg x 1 and 2U FFP prior to surgery. He was taken to the Operating Room on [**2123-2-18**] for the above procedure performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]. Please refer to the dictated operative note for further details. He received 2U FFP and 3U RBC intra-operatively. The procedure was without complication however due to long duration of surgery & EBL 1000cc he was taken intubated to the SICU postoperatively for monitoring. Postop HCT was 33.5. After the procedure his pacemaker interogated by cardiology. Pnemoboots and SC heparin were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with IV dilaudid. He was extubated the following day without incident. He had significant total body peripheral edema following surgery and was aggressively diuresed in the ICU for the first four days postoperatively with a goal of 1.5-2.0L negative each day. He tolerated the diuresis well. Electrolytes were checked twice daily during this period and repleted as needed. He did not have any signs of pulmonary edema and his respiratory status was stable on room air by POD#2. He did have significant serous ooze from his surgical wounds for several days postop. There was no purulance or erythema and this resolved gradually as his peripheral edema improved on diuresis. His home coumadin dosing was restarted on POD#3 and followed with daily INRs. His SC heparin was discontinued when INR>2.0. His INR goal was make 2.0-2.5 to minimize his risk of postop bleed and his home coumadin dose was decreased slightly. He was noted to have some difficulty swallowing and a speech and swallow consult was obtained on POD#4 after he was transferred to the regular orthopaedic floor. He was found to have coughing with all PO intake and it was felt that he was not safe to take food, liquid or oral medications. An NGT was placed for delivery of medications and tube feeds. Placement was confirmed on Xray and nutrition was consulted to tube feeding recommendations. Tube feeds were tolerated well. Speech and swallow re-evaluated him on POD#6 and recommended that he be restarted on an oral diet of ground solids and nectar thick liquids. He tolerated oral diet well and the NGT was removed the following day. On repeat S+S evaluation he was advaced to ground solids and thin liquids under supervision. Physical therapy was consulted for mobilization OOB to ambulate. On POD#8 he was slightly orthostatic while OOB with PT. His blood pressures normalized immediately when he was back in bed and his lasix was discontinued. HCT was checked and was found to be 28.4. On POD#9 his urine output was borderline. His HCTZ was held and BUN/Cre were checked and were normal. HCT was checked and was stable. He recieved a 500cc NS bolus with improvement in urine output. Foley catheter remained in place until POD#10 for strict monitoring of I+Os. A U/A was checked at the time of foley removal. Hospital course was otherwise unremarkable. Upright Xrays of the spine were performed prior to discharge. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet of ground solids and thin liquids with aspiration precuations. Medications on Admission: 1. Hydrochlorothiazide 12.5 mg QD 2. Finasteride 5 mg QD 3. Levothyroxine 150 mcg QD 4. Ezetimibe 5mg QD 5. Coumadin 7.5 mg 2days/week, 5mg 5day/week Discharge Medications: 1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ezetimibe 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: [**4-4**] MILLILITERS PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Titrate dose to daily INR, goal INR 2-2.5. 10. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day: Hold for SBP<100. Discharge Disposition: Extended Care Facility: [**Hospital **] rehab - [**Location (un) **] Discharge Diagnosis: L2 lesion & compression fracture Discharge Condition: Stable Discharge Instructions: You have undergone the following operation: L2 corpectomy with anterior interbody fusion & T12-L4 posterior intrumented fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Ground dysphagia diet, thin liquids, take pills whole in applesauce. Aspiration Precautions, patient must be supervised for ALL PO intake. - Brace: You do not need a brace but you may wear the brace you have for comfort when out of bed. - Wound Care: If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is COMPLETELY dry you may get the area wet. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Minimize time lying on your back to relieve pressure on the wound. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Physical Therapy: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Brace: You do not need a brace but you may wear the brace you have for comfort when out of bed. Treatments Frequency: Wound Care: If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is COMPLETELY dry you may get the area wet. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Minimize time lying on your back to relieve pressure on the wound. Followup Instructions: - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. [**Telephone/Fax (1) 3736**]. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Completed by:[**2123-2-28**] Name: [**Known lastname 13034**],[**Known firstname **] Unit No: [**Numeric Identifier 13035**] Admission Date: [**2123-2-17**] Discharge Date: [**2123-2-28**] Date of Birth: [**2040-2-25**] Sex: M Service: ORTHOPAEDICS Allergies: Penicillins Attending:[**Doctor Last Name 147**] Addendum: NOTE: A 10 day course of oral clindamycin was started prior to discharge for infection prophylaxis given slight wound erythema. Discharge Disposition: Extended Care Facility: [**Hospital **] rehab - [**Location (un) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**] Completed by:[**2123-2-28**]

[ "V45.01", "336.9", "426.13", "276.6", "289.81", "401.9", "788.5", "600.00", "244.0", "V12.51", "V58.61", "V43.65", "787.20", "733.13" ]

icd9cm

[ [ [] ] ]

[ "03.53", "81.06", "80.99", "96.6", "84.51", "81.05", "81.63", "77.79" ]

icd9pcs

[ [ [] ] ]

13082, 13308

4473, 8140

290, 353

9325, 9333

2080, 4450

12121, 12123

1633, 1638

8341, 9154

9269, 9304

8166, 8318

9357, 9485

1653, 2061

11381, 11639

11661, 11661

12135, 13059

9518, 9727

237, 252

11673, 12098

381, 1294

1316, 1464

1480, 1617

75,899

153,632

44604+58734+58735

Discharge summary

report+addendum+addendum

Admission Date: [**2128-3-11**] Discharge Date: [**2128-3-17**] Date of Birth: [**2068-5-1**] Sex: F Service: ORTHOPAEDICS Allergies: Morphine / Codeine / Red Dye / Vioxx / ibuprofen / Bactrim DS / Glucophage / simvastatin / Crestor / Allopurinol Attending:[**First Name3 (LF) 64**] Chief Complaint: Left Knee Pain s/p infection Major Surgical or Invasive Procedure: Left Total Hip Conversion Arthroplasty History of Present Illness: 59 yo female who in [**2127-2-8**] dev left hip pain and was dx'ed with OA. In [**2127-9-8**], she has sig worsening of pain in left hip and sought care at [**Hospital1 **] ED on [**2127-9-20**]. Had IR guided arthrocentesis c/w septic joint. Taken to OR for washout on [**2127-9-21**] and cx's showed strep anginosus. Blood cx's taken after initiation of abx were neg. TTE neg then and she had repeat washout on [**2127-9-24**]. She had imaging c/w osteo. She was seen by ID and she was treated initially with vanco alone, then ceftriaxone added and when her strep was [**Last Name (un) 36**] to pen-G, she was switched to Pen G to complete 6 wks of abx therapy. On [**2127-10-21**], she was dc'ed to home. She represented 3 days later with n/v and CP. She was switched from pen G to ceftriaxone given poss of nause due to pen G. She was dc'ed on [**2127-10-27**]. She was seen as outpt in [**Hospital **] clinic by Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] on [**2127-11-5**] and she was nauseated and c/o loose stools. She had completed 6 wks of abx and her inflamm markers were still elevated and she was still having mobility probs. ID decided to cont treating her with ceftriaxone 2G iv q 24. On [**2127-11-21**], she was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from ortho and he proposed surgery given concern she was failing abx therapy. on [**2127-12-2**], her ceftriaxone was stopped to max opportunity for positive cx at time of surgery. On [**2127-12-16**], she had resection arthroplasty, deep tissue synovectomy and removal of necrotic tissue with insertion of vanco/tobra spacer. Post op, she developed hypotension which led to admission to [**Hospital Unit Name 153**]. She received 5L of LR and 250cc 5% albumin in PACU. ICU course - her hct has drifted down to 23. Her blood pressure has improved but does occasionally drop down which the ICU team believes is related to her bolus doses of dilaudid. Past Medical History: CAD [**10-11**]: C. cath performed for exertional dyspnea and chest heaviness with occasional symptoms at rest as well. ETT at [**Hospital 882**] Hospital was abnormal by report, and echocardiogram [**2119-9-26**] showed moderate global hypokinesis. She is referred for right and left heart catheterization for evauation of filling pressures and coronary anatomy. [**6-/2127**]: TEE/DCCV cardioversion due to atrial fibrillation. [**2127-8-5**]: Cavo-tricuspid and coronary sinus RFA for atrial flutter on [**2127-8-5**] * DMII * bilateral knee replacements * h/o acute renal failure in setting of knee surgery * osteoarthritis * Idiopathic Cardiomyopathy diagnosed [**2119**] * depression * anemia * obesity s/p LAGB ([**2126**]) Social History: SOCIAL HISTORY: Lives in [**Hospital1 6930**] with daughter. Had a difficult separation from her husband of 30 [**Name2 (NI) 1686**] about a year ago. Worked as a mammographer at the [**Hospital1 882**]; recently laid off. Two adult children. -Tobacco history: never -ETOH: very rare -Illicit drugs: none Family History: Father died of MI at age 65. Mother had major CVA at 72. Three sisters with breast cancer, one who recently suffered bilateral PEs. Mother and 2 sisters with DM. Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm Pertinent Results: [**2128-3-12**] 11:15AM BLOOD WBC-7.9 RBC-3.35* Hgb-9.2* Hct-28.0* MCV-84 MCH-27.4 MCHC-32.8 RDW-15.7* Plt Ct-141* [**2128-3-12**] 06:02AM BLOOD Glucose-144* UreaN-15 Creat-0.8 Na-139 K-4.2 Cl-107 HCO3-24 AnGap-12 [**2128-3-12**] 06:12AM BLOOD Type-ART Temp-36.8 PEEP-5 FiO2-40 pO2-178* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 Intubat-INTUBATED [**2128-3-11**] 08:02PM BLOOD Glucose-108* Lactate-1.1 Na-142 K-1.5* Cl-132* [**2128-3-11**] CXR Left subclavian PICC line extends to the lower portion of the SVC. Endotracheal tube tip is approximately 4.5 cm above the carina. As on the study of [**2127-12-17**], there are low lung volumes that may be accentuating the prominence of the cardiac silhouette. No definite vascular congestion or pleural effusion. [**2128-3-11**] ABD XRAY There is a left total hip arthroplasty with a proximal cerclage wire and non-cemented femoral stem. Heterotopic ossification less likely residual methyl methacrylate is ntoed within the joint. There is no evidence of hardware failure or periprosthetic fracture. [**2128-3-11**] 5:00 pm TISSUE Site: HIP LEFT HIP #3 Leaking specimen. GRAM STAIN (Final [**2128-3-11**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2128-3-15**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**10/4201**] [**2128-3-14**] 2PM. STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: Transfer to the ICU overnight for BP monitoring and 1 L blood loss. She was extubated and transferred to the floor on POD1. Excellent work w/ PT [**Name (NI) **] pain control Stable Hct Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#4 and the patient had difficulty voiding thereafter requiring several straight catheterizations before she was able to void on her own. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. One culture grew Streptococcus Viridans. ID saw and evaluated her and at this point it was deemed likely a contaminant. She will return to the IR suite in 2 weeks for repeat Left Hip Aspiration. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms [**Known lastname **] is discharged to home rehab in stable condition. Medications on Admission: Colace Senna Amiodarone 200 mg qd Sertraline 100 mg qhs Dilaudid 2 mg q3 prn Oxycodone 20 mg q12 APREPITANT 40 mg Capsule take within 3 hours of surgery Lunesta 1 mg qhs Lasix 40 mg INSULIN ASPART sliding scale INSULIN DETEMIR [LEVEMIR] 18 units qhs Lisinopril 10 mg qd Metoprolol Succinate 100 mg qd Zolpidem qhs Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for Pain. Disp:*120 Tablet(s)* Refills:*0* 2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 3 weeks. Disp:*21 syringe* Refills:*0* 4. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. oxycodone 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks: to begin once Lovenox has stopped. Disp:*42 Tablet(s)* Refills:*0* 13. Levemir 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous at bedtime. 14. insulin regular human 100 unit/mL Solution Sig: sliding scale units Injection qac qhs. 15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Left hip infection s/p resection now w/ replantation. 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse (VNA) or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four (4) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three (3) weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two (2) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, and staple removal at two weeks after surgery. 12. ACTIVITY: 50% Weight bearing as tolerated on the operative extremity. Anterior and Posterior precautions. Knee immobilizer on at all times. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently Physical Therapy: Activity: Activity: Activity as tolerated Left lower extremity: Partial weight bearing Knee immobilizer: At all times 50% weight bearing. Abductor pillow to be removed once Pt extubated and stable and replaced with Knee immobilizer. Treatments Frequency: Wound care: Site: Incision Type: Surgical Dressing: Gauze - dry Comment: on AM of POD 2 by HO, then daily by RN; please overwrap any dressing bleedthrough with ABDs and ACE Followup Instructions: Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2128-4-9**] 12:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-7-19**] 2:00 Name: [**Known lastname 15130**],[**Known firstname 3410**] C Unit No: [**Numeric Identifier 15131**] Admission Date: [**2128-3-11**] Discharge Date: [**2128-3-17**] Date of Birth: [**2068-5-1**] Sex: F Service: ORTHOPAEDICS Allergies: Morphine / Codeine / Red Dye / Vioxx / ibuprofen / Bactrim DS / Glucophage / simvastatin / Crestor / Allopurinol Attending:[**First Name3 (LF) 370**] Addendum: Anticoagulation: Lovenox 40mg DAILY x 4 weeks Page 1 updated Discharge Disposition: Extended Care Facility: [**Location (un) 1132**] - [**Location (un) 407**] Discharge Instructions: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out at your follow-up visit in [**3-12**] weeks. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up visit. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, and wound checks. 12. ACTIVITY: PARTIAL (50%) weight bearing on the operative extremity. Anterior and Posterior precautions. Knee immobilizer on at all times. [**Month (only) 412**] remove immobilizer when in bed IF wedge pillow in place and for supervised physical therapy ONLY. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: LLE PWB (50%) at all times Knee immobilizer at all timed - [**Month (only) 412**] remove if in bed and wedge pillow in place - [**Month (only) 412**] remove for supervised physical therapy ONLY Anterior/posterior hip precautions Mobilize frequently Treatments Frequency: Dry sterile dressing daily as needed for drainage Wound checks Ice TEDs PICC line management per facility protocol [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 372**] MD [**MD Number(2) 373**] Completed by:[**2128-3-17**] Name: [**Known lastname 15130**],[**Known firstname 3410**] C Unit No: [**Numeric Identifier 15131**] Admission Date: [**2128-3-11**] Discharge Date: [**2128-3-17**] Date of Birth: [**2068-5-1**] Sex: F Service: ORTHOPAEDICS Allergies: Morphine / Codeine / Red Dye / Vioxx / ibuprofen / Bactrim DS / Glucophage / simvastatin / Crestor / Allopurinol Attending:[**First Name3 (LF) 370**] Addendum: Cultures from the OR [**2128-3-11**] grew the following (not Strep Viridans as noted previously). STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Left Total Hip Conversion Arthroplasty Past Medical History: CAD [**10-11**]: C. cath performed for exertional dyspnea and chest heaviness with occasional symptoms at rest as well. ETT at [**Hospital 5763**] Hospital was abnormal by report, and echocardiogram [**2119-9-26**] showed moderate global hypokinesis. She is referred for right and left heart catheterization for evauation of filling pressures and coronary anatomy. [**6-/2127**]: TEE/DCCV cardioversion due to atrial fibrillation. [**2127-8-5**]: Cavo-tricuspid and coronary sinus RFA for atrial flutter on [**2127-8-5**] * DMII * bilateral knee replacements * h/o acute renal failure in setting of knee surgery * osteoarthritis * Idiopathic Cardiomyopathy diagnosed [**2119**] * depression * anemia * obesity s/p LAGB ([**2126**]) Social History: SOCIAL HISTORY: Lives in [**Hospital1 **] with daughter. Had a difficult separation from her husband of 30 [**Name2 (NI) 15132**] about a year ago. Worked as a mammographer at the [**Hospital1 5763**]; recently laid off. Two adult children. -Tobacco history: never -ETOH: very rare -Illicit drugs: none Family History: Father died of MI at age 65. Mother had major CVA at 72. Three sisters with breast cancer, one who recently suffered bilateral PEs. Mother and 2 sisters with DM. Discharge Disposition: Extended Care Facility: [**Location (un) 1132**] - [**Location (un) 407**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 372**] MD [**MD Number(2) 373**] Completed by:[**2128-3-18**]

[ "272.4", "425.4", "V88.21", "715.35", "788.20", "V43.65", "285.1", "V58.61", "412", "250.00", "V54.82", "427.31", "414.01", "311", "V45.86", "278.01", "V85.41" ]

icd9cm

[ [ [] ] ]

[ "00.70", "84.57" ]

icd9pcs

[ [ [] ] ]

19897, 20129

5869, 7728

18577, 18618

9720, 9720

4214, 5785

13388, 14256

19711, 19874

8093, 9522

9643, 9699

7754, 8070

14380, 16399

3739, 4195

17300, 17552

17574, 18507

18524, 18539

16411, 17282

472, 2467

5821, 5846

9735, 9879

18641, 19374

19406, 19695

631

100,660

14066

Discharge summary

report

Admission Date: [**2124-1-23**] Discharge Date: [**2124-1-28**] Date of Birth: [**2049-2-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: hypoxia (transfer from outside hospital) Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: 74 y/o male with hx of CAD, HTN, s/p PM for sick sinus syndrome, CRI s/p nephrectomy who was recently discharged from [**Hospital1 18**] [**2124-1-18**] now returns from OSH after being intubated for CHF, initially hypotensive after lasix given then became hypertensive and also found to have + blood from NGT. . During previous admission patient admitted for abdominal pain underwent EGD and c-scope and found to have multiple diverticulae and gastritis. Shortly after EGD patient had respiratory failure was intubated thought to be [**1-14**] CHF, extubated the next day. Patient also thought to have NSTEMI which was medically managed and patient eventually discharged [**2124-1-18**]. . Patient presented to OSH with presumed CHF after being hypertensive and was intubated. Per daughter patient missed his blood pressure medications the day of admission. Patient denies any fever,chills, coughs or gradual SOB prior to event. He recieved lasix at home and then en route however still SOB in ED so was put on Bipap and then intubated. During his admission at OSH his BP has been labile with hypertension SBP 190s. Patient started on nitro gtt for BP control and got lopressor 5mg x3. At OSH CXR showed initially diffuse infiltrates c/w pulmonary edema vs PNA; repeat CXR the following day showed improved infiltrates. Patient's peak TropI was 1.8 and CK 68 at OSH. EKG done at OSH showed pattern c/w LVH and more pronounced ST depression in lateral leads. Repeat EKG done on arrival to [**Hospital1 18**] was similar to old EKGs. Upon arrival to [**Hospital1 18**] patient on minimal vent support with well controlled BP on nitro gtt. Past Medical History: CAD; NSTEMI [**10-17**] and [**1-19**] Anemia CRI (baseline Cre 3.1) s/p nephrectomy Gastritis Diverticulosis Hiatal Hernia Aortic Stenosis SSS s/p pacemaker Social History: Lives with daughter since recent d/c from hospital + tobacco 1 cig per day; formerly 1ppd no etoh use Family History: Reported family hisotry of CAD Physical Exam: T 98.6 BP 118/62 P 60 AC RR 16 TV 500 FiO2 0.4 100% Gen: NAD, intubated, awake Heent: PERRL, EOMI, OG tube in place Neck: no obvious JVD, RIJ in place Lungs: Clear ant/lat Cardiac: RRR S1/S2 grade III/VI SEM at RUSB Abd: soft non-tender Ext: no edema, DP and PT +1 Pertinent Results: [**2124-1-23**] 12:56PM WBC-7.9 RBC-3.17* HGB-9.7* HCT-29.5* MCV-93 MCH-30.6 MCHC-32.9 RDW-14.3 [**2124-1-23**] 12:56PM GLUCOSE-94 UREA N-46* CREAT-3.0* SODIUM-141 POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-25 ANION GAP-9 [**2124-1-23**] 12:56PM CK-MB-NotDone cTropnT-0.42* proBNP-[**Numeric Identifier 41959**]* . P-MIBI ([**2124-1-27**]): No anginal symptoms with an uninterpretable ECG for ischemia. There is a mild fixed perfusion defect involving the inferior and inferolateral walls. The left ventricle is moderately dilated at stress and rest and there is global hypokinesis with a calculated LVEF of 35%. . TTE ([**2124-1-24**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 0.8-1.19cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) eccentric mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. . Renal ultrasound (with Dopplers) [**2124-1-24**]: 2.0 cm cyst of the right renal lower pole. Otherwise, normal appearance of the right kidney with patent vasculature and no son[**Name (NI) 493**] evidence of renal artery stenosis. Surgically absent left kidney. Brief Hospital Course: Mr. [**Known lastname 41957**] was transferred to the [**Hospital1 18**] CCU intubated. Upon arrival, he had a favorable ABG and wsa quickly extubated without difficulty. His BP was intially controlled with a nitroglycerin drip which was slowly weaned off over the first night of his hospitalization. On the morning of hospital day #2, he became acutely short of breath with acute development of pulmonary edema at the same time that his blood pressure suddenly rose to 220-240/100-120. He was given IV Lasix and metoprolol and his nitroglycerin drip was quickly titrated back up. He was put on BiPAP with improvement in his oxygenation. Over the course of the day, he was weaned easily off BiPAP. The focus at this point became controlling his hypertension which was done with a high dose of Toprol XL, increasing his dose of Imdur, and starting him on amlodipine. He was temporarily controlled on PO hydralazine but this was titrated off due to his history of poor medication compliance. His history of a nephrectomy precluded the use of an ACEi or [**Last Name (un) **]. As far as working up the etiology of his refractory hypertension, a renal ultrasound showed no evidence of renal artery stenosis and a random cortisol level was within normal limits; a 24-hour urine collecion had normal levels of VMA and metanephrines. For his presumed coronary artery disease, he underwent a pharmacologic stress test which showed only a mild fixed defect in the inferior/inferolateral walls along with an LVEF of 35%. He was discharged home to stay with his daughter with plans to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] of cardiology. Medications on Admission: Meds at home: Lipitor 80mg qhs Mirtazapine 15mg qhs Buspirone 5mg [**Hospital1 **] Trazadone 25mg Sucralfate 1g qid ASA 325mg Protonix 80mg [**Hospital1 **] Atrovent Imdur 60mg Toprol XL 300mg . Meds on transfer: Nitro gtt SQ heparin ASA 325mg carafate lopressor 25mg q6 lasix 70mg IV plavix 75mg Humulog sliding scale Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*QS Disk with Device(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily): total dose 180mg. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO at bedtime: total dose 300mg. Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Hypertensive crisis with pulmonary edema . Secondary diagnoses: Aortic stenosis, hypertension, diastolic dysfunction, Chronic kidney disease Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your primary care doctor, Dr. [**First Name (STitle) 13277**] [**Name (STitle) **] ([**Telephone/Fax (1) 2636**] or return to the Emergency department if you experience shortness of breath, chest pain or pressure, dizziness, abdominal pain, nausea or vomitting or any symptoms that concern you. Followup Instructions: Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 13277**] [**Name (STitle) **] within 1-2 weeks of discharge ([**Telephone/Fax (1) 2636**]. . You will be seeing Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] from the department of cardiology for follow up. His office will get in contact with you within the next 1-2 days to tell you when and where to attend the appointment. If you have not heard anything within the next 2 days, you should call his office at [**Telephone/Fax (1) 10012**].

[ "403.91", "593.2", "518.81", "414.01", "V45.01", "562.10", "585.6", "553.3", "410.82", "428.30", "428.0", "799.02", "416.8", "424.1" ]

icd9cm

[ [ [] ] ]

[ "88.72", "93.90" ]

icd9pcs

[ [ [] ] ]

7868, 7926

4303, 5978

354, 362

8130, 8140

2696, 4280

8580, 9146

2362, 2395

6347, 7845

7947, 7947

6004, 6199

8164, 8557

2410, 2677

8030, 8109

274, 316

390, 2044

7966, 8009

2066, 2226

2242, 2346

6217, 6324

20,828

100,249

19988

Discharge summary

report

Admission Date: [**2139-12-20**] Discharge Date: [**2139-12-24**] Date of Birth: [**2066-3-22**] Sex: F Service: [**Location (un) 259**] MEDICINE HISTORY OF PRESENT ILLNESS: Patient is a 73 year-old female with past medical history significant for hypertension, breast cancer, history of alcohol abuse who was transferred to the Medical Service with diagnosis of colonic ischemic. Patient originally presented to [**Hospital3 628**] with lower abdominal cramping followed by severe low back pain. She ten was found to have palpable abdominal mass and had later bowel movements with bright red blood mixed with liquid stool. Because of the concern for aortic enteric fistula she was emergently transferred to [**Hospital1 188**] for further evaluation. At [**Hospital1 190**] emergent body CT scan was performed and showed no fistula. However, it was positive for 4.5 cm abdominal aneurysm with a large intramural thrombus. Push enteroscopy was negative. The patient was found to be in DIC and was given two units of fresh frozen plasma and one unit of blood. This was followed by sigmoidoscopy which showed changes consistent with ischemic colitis as well as sigmoid diverticulosis. The patient was transferred back to the Surgical Intensive Care Unit and remained stable overnight. She was then transferred to medical service for further management of colonic ischemia. PAST MEDICAL HISTORY: Hypertension, breast cancer, constipation, status post left mastectomy, status post hysterectomy, status post appendectomy. MEDICATIONS ON ADMISSION: Cardura XT 40 mg once a day, Ameredex 1 tablet once a day, Lipitor and nasal spray. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She is married, smokes one pack a day, drinks one to two glasses of whisky every day. PHYSICAL EXAMINATION: Temperature 97.1, blood pressure 128/70, pulse 76, respirations 18, oxygen saturation 97 percent on room air. General: in no acute distress, alert, oriented times two. Head, eyes, ears, nose and throat: Extraocular movements intact. Pupils equal, round and reactive to light and accomodation bilaterally. Oropharynx clear. Neck supple. Cardiovascular: regular rhythm and rate, no murmurs, rubs or gallops. Pulmonary: clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, positive bowel sounds. Extremities no edema, 2+ dorsal pedal pulses bilaterally. PERTINENT LABORATORIES: White cell cont 12.6, hematocrit 33.5, PT 12.9, PTT 25.4, INR 1.1. Sodium 145, potassium 3.3, chloride 108, bicarb 28, BUN 19, creatinine 0.7, glucose 149. HOSPITAL COURSE: The patient was kept in the hospital for three days for observation. She was started on prophylactic antibiotics, Levofloxacin or Flagyl for a four day course. Her hematocrit remained stable. Her gastrointestinal series resolved after receiving two units of fresh frozen plasma and one unit of packed red blood cells. She had a brief episode of post procedure delirium which resolved the next day. She remained oriented times three with no mental statu changes for the duration of the hospital stay. She was discharged to hoe on [**12-24**] in good condition. DISCHARGE DIAGNOSIS: Ischemic colitis. Transient delirium. DISCHARGE MEDICATIONS: Flagyl 500 mg p.o. 3 times a day for two days. Levofloxacin 500 mg p.o. once a day for two days, Lopressor 25 mg p.o. twice a day, lactulose p.r.n. FOLLOW UP: The patient will follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital 53879**] Medical Center. She is also informed that she needs repeat colonoscopy in eight to twelve weeks. Patient was given a choice between having colonoscopy at [**Hospital 53879**] Medical or calling [**Hospital1 346**] and scheduling an appointment with the gastroenterology department here. With regards to her abdominal aortic aneurysm vascular surgery was consulted and felt the patient did warrant consideration for elective surgical resection given the size and extent of the aneurysm (5cm infrarenal. A follow up appt with vascular surgery should be arrange approx 6 weeks after discharge DISCHARGE DIET: The patient is instructed to continue a low residue diet for another week and then start high fiber diet, activity as tolerated. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**] Dictated By:[**Name8 (MD) 2509**] MEDQUIST36 D: [**2139-12-24**] 12:26 T: [**2139-12-24**] 14:12 JOB#: [**Job Number 53880**]

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53897

Discharge summary

report

Admission Date: [**2105-7-8**] Discharge Date: [**2105-7-17**] Date of Birth: [**2048-2-11**] Sex: F Service: NEUROLOGY Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 20506**] Chief Complaint: pseudomeningocele, worsening HA, fevers Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 57-year-old R handed woman with a history of SLE on chronic prednisone, recent prolonged hospitalization from [**Date range (1) 110560**] for epidural abscess (Nocardia) s/p drainage and L2-S1 laminectomy complicated by L2-3 pseudomeningocele, and seizures thought to be related to PRES, who now presents with worsening headaches, low back pain, and fevers. She saw [**Date range (1) **]. [**Last Name (STitle) 1206**] and [**Name5 (PTitle) **] in neurology clinic on [**6-29**], at which point she was complaining of near daily headaches which worsened when sitting or standing and improved with lying down. Concern was raised for symptomatic pseudomeningocele with CSF leak. Her neurologic exam at that point was notable only for mild [**5-13**]+/5 weakness of IP's bilaterally and decreased vibration sensation at the great toes with a mildly positive Romberg. She had a follow up appointment in spine clinic on [**7-1**], at which point the pseudomeningocele was felt to be stable. The possibility of surgery was discussed if her symptoms worsened, with involvement of neurosurgery at that point if surgery was felt to be indicated. A repeat MRI of her brain was performed on [**7-3**] which showed interval increase in the left subdural CSF collection causing increased mass effect on the left lateral ventricle and slight midline shift. Her headaches have continued to worsen over the last week, with some incomplete relief with Fioricet and lying supine. In addition she has also developed worsening low back pain. She denies any fevers at home but does report chills. Has been on Bactrim and Moxifloxacin since her discharge and taking this as prescribed. Given the worsening headaches and MRI findings, she was referred to the ED by Dr. [**First Name (STitle) **] for evaluation for continued continuous CSF leakage and symptomatic pseudomeningocele. Upon arrival she was febrile to 101.4 and tachycardic to 110. Labs were significant for WBC 7.9, CRP 22.7, ESR 32, normal chem panel, and negative UA. CXR was also negative. She was treated with Vanc/Zosyn and the spine service was consulted. An MRI C/T/L spine was performed at their recommendation which showed a stable large R posterior paraspinal fluid collection with extension into R psoas, neural foramen, and posterior spinal canal. There was no significant enhancement to suggest re-infection although there was evidence of arachnoiditis. Given the unchanged appearance of the fluid collection no acute surgical intervention was felt to be warranted. Neurology was then consulted for further recommendations. History is currently somewhat difficult to obtain from patient as she has just received dilaudid and ativan for her MRI scan. She reports a severe holocephalic headache and low back pain. She denies any changes in vision, weakness, numbness/tingling, difficulty walking. Reports chills but no known fevers. No reports of any seizure activity since her discharge. Past Medical History: Lupus - diagnosed in [**2078**], on chronic prednisone Right lumbosacral radiculopathy s/p steroid injections Epidural abscess with extension into the psoas muscle - cultures grew Nocardia, s/p L2-S1 laminectomy on [**2105-5-4**] complicated by L2-3 pseudomeningocele Total teeth extraction Social History: Married, lives at home with husband. Previously smoked 1ppd until her admission in [**Month (only) 958**]. Does not drink alcohol or use any illicit drugs. Family History: Mother age 83 with [**Name (NI) 2481**] Father died at 70 from cancer Sister age 58 also with cancer (unknown what type) No known family history of seizures or other neurologic disorders. Physical Exam: At admission: Vitals: 101.3 ??????F (38.5 ??????C), Pulse: 100, RR: 17, O2Sat: 96% RA General: Lethargic but arousable, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no nuchal rigidity Pulmonary: Lungs CTA bilaterally, scattered rhonchi Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND Back: well-healed incision over lumbar spine, palpable 3cm fluid collection with some extension rostrally Extremities: No C/C/E bilaterally Neurologic: -Mental Status: Lethargic but arousable, requires frequent stimulation to maintain attention. Oriented to self, [**Hospital1 18**], day of week and year. Cannot remember president. Inattentive and frequently falls back to sleep. Speech fluent with very mild dysarthria. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to voice bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] L 5 5 5 5 5 5 4+ 5 4+ 5 5 5 R 5 5 5 5 5 5 4 5 4+ 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 0 R 2 2 2 0 0 Plantar response was flexor on right, extensor on left. -Coordination: Reaches well b/l, did not cooperate with FNF -Gait: Deferred given lethargy Pertinent Results: [**2105-7-7**] 06:15PM BLOOD WBC-8.5# RBC-3.42* Hgb-10.8* Hct-32.0* MCV-94# MCH-31.5 MCHC-33.6# RDW-14.6 Plt Ct-432 [**2105-7-7**] 06:15PM BLOOD PT-9.4 PTT-31.0 INR(PT)-0.9 [**2105-7-7**] 10:25PM BLOOD ESR-32* [**2105-7-7**] 06:15PM BLOOD Glucose-103* UreaN-12 Creat-0.7 Na-137 K-4.3 Cl-98 HCO3-26 AnGap-17 [**2105-7-8**] 10:45AM BLOOD ALT-11 AST-10 LD(LDH)-115 AlkPhos-88 TotBili-0.2 [**2105-7-8**] 10:45AM BLOOD Albumin-3.4* Calcium-7.8* Phos-3.7 Mg-1.6 [**2105-7-7**] 10:25PM BLOOD CRP-22.7* [**2105-7-7**] 06:20PM BLOOD Lactate-1.7 [**2105-7-7**] 11:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2105-7-7**] 11:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2105-7-7**] 11:15PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-1 [**2105-7-7**] 11:15PM URINE CastHy-5* [**2105-7-9**] 01:38PM CEREBROSPINAL FLUID (CSF) WBC-440 RBC-75* Polys-93 Lymphs-0 Monos-7 [**2105-7-9**] 01:38PM CEREBROSPINAL FLUID (CSF) WBC-485 RBC-415* Polys-94 Lymphs-2 Monos-4 [**2105-7-9**] 01:38PM CEREBROSPINAL FLUID (CSF) TotProt-65* Glucose-63 [**2105-7-9**] 01:38PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-PND [**2105-7-9**] 1:38 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final [**2105-7-9**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2105-7-12**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. VIRAL CULTURE (Preliminary): [**2105-7-9**] 1:38 pm CSF;SPINAL FLUID Source: LP. **FINAL REPORT [**2105-7-9**]** CRYPTOCOCCAL ANTIGEN (Final [**2105-7-9**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. [**2105-7-9**] 2:55 am SEROLOGY/BLOOD Source: Venipuncture. **FINAL REPORT [**2105-7-9**]** CRYPTOCOCCAL ANTIGEN (Final [**2105-7-9**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. A negative serum does not rule out localized or disseminated cryptococcal infection. Appropriate specimens should be sent for culture. BCx - all NGTD thus far MRI C-T-L- spine: IMPRESSION: 1. Interval increase in size of fluid collection in the posterior paraspinal soft tissues, communicating with the epidural space and the right psoas muscle. Stable thickening of the nerve roots of the cauda equina suggesting an element of arachnoiditis. Close follow up is recommended. 2. Fluid collection in the posterior extramedullary intradural space through the thoracic spine with mild mass effect over the posterior aspect of the spinal cord likely representing arachnoiditis, likely reactive in nature. No evidence of thick enhancement to suggest a pyogenic abscess. NCHCT: IMPRESSION: 1. Slight decrease in overall size of left frontal subdural fluid collection. 2. No pathologic enhancement. 2. Patent dural venous sinuses. MRI L-Spine [**2105-7-17**] IMPRESSION: 1. Interval decrease in posterior paraspinal and right psoas fluid collections. There has been interval resolution of indentation on the thecal sac by the fluid collection . 2. Stable thickening and enhancement of the nerve roots of cauda equina which might represent arachnoiditis. Continued attention on followup imaging is recommended. Brief Hospital Course: 57-year-old R handed woman with a history of SLE on chronic prednisone, recent prolonged hospitalization from [**Date range (1) 110560**] for epidural abscess (Nocardia) s/p drainage and L2-S1 laminectomy complicated by L2-3 pseudomeningocele, and seizures thought to be related to PRES, who now presents with worsening headaches, low back pain, and fevers. Her headaches sound consistent with intracranial hypotension given their positional nature and suggest continued CSF leak and symptomatic pseudomeningocele. This is also supported by the interval worsening of the left subdural CSF collection on her recent MRI brain. Her fevers, low back pain, and elevated inflammatory markers are very concerning for superinfection of the fluid collection, although no enhancement was seen on MRI. The ortho spine service declined acute surgical intervention but noted that surgery may be required if her pseudomeningocele remains symptomatic. . Neurosurgery and Infectious DIseases were consulted for assistance with her care. Neurosurgery planned for a repair of the pseudomeningocele with assistance from Plastic Surgery, but after following her clinically and repeating NCHCT and L-Spine MR imaging, her imaging characteristics and clinical status were improving and reassuring to them, prompting the decision to plan for surgery after one month when her treatment for meningitis is complete. The ID service helped guide antibiotic therapy during the inpatient hospitalization which initially was accomplished with several agents which were subsequently tapered down to Moxifloxacin and TMP-SMX for presumed Nocardia infection (her prior infection). The ID service recommended continuation of PO antibiotics as an outpatient until her next followup. . Her pain regimen was titrated to include a low dose of long-acting Oxycodone SR (10 mg [**Hospital1 **]) and PRN Oxycodone and Acetaminophen for breakthrough pain. . PENDING STUDIES: Cultures (CSF, Blood) . TRANSITIONAL CARE ISSUES: [ ] Meningitis - The Infectious Diseases service at [**Hospital1 18**] requires the following labs to be drawn weekly and faxed to their office at [**Telephone/Fax (1) 1419**]: CBC with differential, Complete Metabolic Panel (with liver function tests, calcium, magnesium, phosphorous), ESR, and CRP. [ ] ID/Antibiotics - Please determine when she can complete her antibiotics. [ ] Neurosurgery - Please followup the repeat MRI L-spine and prepare for her pseudomeningocele repair. [ ] Neurology - Please advance her Neurology f/u appt if possible. Medications on Admission: 1. Moxifloxacin 400 mg Tab 1 Tablet(s) by mouth once daily 2. Levetiracetam 500 mg Tab 2 Tablet(s) by mouth twice daily 3. Butalbital-acetaminophen-caffeine 50 mg-325 mg-40 mg Tab 1 Tablet(s) by mouth every 6 hrs as needed as needed for for headache 4. Bactrim DS 800 mg-160 mg Tab 1 Tablet(s) by mouth every 8 hrs 5. Tylenol 325 mg Tab (dose uncertain) 6. Omeprazole 20 mg Cap, delayed release 1 Capsule(s) by mouth once daily 7. Prednisone 10 mg Tab 1 Tablet(s) by mouth once daily Discharge Medications: 1. moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day: for treatment of infection. Continue until the Infectious Disease doctors [**First Name (Titles) **] [**Last Name (Titles) 74510**]. Disp:*30 Tablet(s)* Refills:*1* 2. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO three times a day: for treatment of infection. Continue until the Infectious Disease doctors [**First Name (Titles) **] [**Last Name (Titles) 74510**]. Disp:*90 Tablet(s)* Refills:*1* 3. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 4. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours): for control of pain. Do not take if sleepy. Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for breakthrough pain. Disp:*60 Tablet(s)* Refills:*0* 6. prednisone 10 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. Disp:*120 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Meningitis (likely Nocardia), Pseudomeningocele SECONDARY DIAGNOSIS: Systemic lupus erythematosus, Headache Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Neurologic: Full strength in her legs. Discharge Instructions: Dear Mrs. [**Known lastname **], You were hospitalized due to symptoms of HEADACHE and PAIN resulting from MENINGITIS, an infection of the covering of the spinal cord and brain. This was thought to be related to your prior Nocardia infection for which you are being continued on antibiotics. The Neurosurgery service plans to repair the PSEUDOMENINGOCELE that has developed after your prior surgery, but to be safe they would like to do this surgery at a later time. They will reevaluate you in one month with repeat imaging of the lower back and spine and then plan for surgery at that time. In the mean time, you will have weekly lab draws that the Infectious Disease doctors [**Name5 (PTitle) **] follow to help guide antibiotic therapy. Please continue taking: - MOXIFLOXACIN 400 mg once daily for your infection. - BACTRIM DS 1 tablet three times daily for your infection. - OXYCONTIN (Oxycodone Sustained Release) 10 mg once in the morning and once in the evening for long-term control of your pain. Please do not take this medication if you are drowsy. - OXYCODONE (Immediate Release) 5 mg up to every 6 hours in addition to the Oxycontin as needed for breakthrough pain. Please do not take this medication if you are drowsy. You can alternate doses with ACETAMINOPHEN 325-650 mg if needed. - Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. Please call Dr.[**Name (NI) 65626**] office as listed below if you have questions. If you experience any of the symptoms below, please seek medical attention. It was a pleasure providing you with care during this hospitalization. Followup Instructions: NEUROLOGY Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] HAERENTS Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2105-10-1**] 4:00pm, [**Hospital1 69**] ([**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) 858**]), [**Location (un) 830**], [**Location (un) 86**], MA Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2105-7-30**] 1:30 INFECTIOUS DISEASES Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 32437**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2105-8-20**] 11:00am, [**Hospital1 771**], [**Location (un) 86**], MA NEUROSURGERY Provider: [**Name10 (NameIs) 110561**] [**Name11 (NameIs) 739**], MD ([**Telephone/Fax (1) 18865**]. Dr.[**Name (NI) 4674**] office will call you with a followup appointment which should take place about 4-5 weeks after discharge from the hospital. As part of your Neurosurgical evaluation, you will have a repeat MRI of the Lumbar Spine which the Neurosurgery service requested prior to your clinic appointment. An order has been placed for this study. Please call ([**Telephone/Fax (1) 88581**] to scheduled this study just prior to your Neurosurgery appointment (this MRI should be done in about 4 weeks).

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Discharge summary

report

Admission Date: [**2151-3-16**] Discharge Date: [**2151-3-22**] Date of Birth: [**2120-4-17**] Sex: F Service: MEDICINE Allergies: Zosyn Attending:[**First Name3 (LF) 3556**] Chief Complaint: Transfer from [**Hospital **] Hospital MICU for neurologic compromise, at request of family for second opinion. Major Surgical or Invasive Procedure: None History of Present Illness: 30-year-old woman with metastatic squamous cell carcinoma of unknown primary. At [**State 792**]Womens', about [**3-1**], she developed pseudomonal urosepsis and vaginal bleeding from tumor extension/anti-coagulation. She was transfered to [**State 40074**]Hospital after an arrest. Her course was complicated by post-hypotensive coma as well as subarachnoid hemorrhages and intraparenchymal bleeds. Neurologists at RIH felt she had a poor prognosis, but communication between the medical team and family was strained and transfer was arranged to [**Hospital1 18**] for a second opinion. Her outside course in more detail: Patient transferred from Women and [**Hospital 60658**] Hospital to [**Hospital **] Hospital [**2151-3-1**] with weaknes, vag bleeding x several days, fever 102.5, hypotension, hypoxic 84% on 4L NC, tachypnic to 30, with labs significant for lactate 6.3, wbc <1.0, plt 9, hgb 8.9, and INR greater than lab threshold. Intubated for airway protection (ABG 7.39/26.5/73.6) and placed on levophed. . Placed on [**Last Name (un) 2830**]/vanc/fluc/gentamicin for neutropenic fever and thrush initially. IVC filter placed [**3-2**]. CT abdomen consistent with large necrotic pelvic mass - not sampled [**12-18**] coagulopathy. [**3-3**] results from Blood Cx from W+I: [**2-28**] PICC Bld Cx: pseudomonas [**Last Name (un) 36**] to zosyn, cipro, cefepime, [**Last Name (un) 2830**] -- staph epi- [**Last Name (un) 36**] to vanc [**2-28**] Peripheral Bld Cx: pseudomonas as above [**2-28**] Urine Cx: pseudomonas as above Abx changed to vanc, zosyn, cipro, fluc, azith. Pressors weaned off by [**3-3**]. Completed 7 days of vanc/fluc, 13/14 days of cipro/zosyn. Continued to have recurrent fevers. . Seen by Urology who did not change stents given severe coagulopathy and worsening renal function. Found to be in DIC and supported with daily blood products. Seen by heme and GCSF started. Despite aggressive blood product repletion patient poorly responsive [**12-18**] alloimmunization. Plt count 1 on [**2151-3-5**]. Supported on TPN for nutrition then switched to tube feeds. Developed renal failure with Cr peak of 2.9. Seen by renal who felt was c/w ATN. . Head CT done [**3-10**] with bilateral SAH and L temporal parenchymal hematoma. Also with multiple masses consistent with metastasis. Placed on Dilantin. Neurosurgery consulted. Felt secondary to low platelets with no surgical intervention indicated. . Mult family meetings given poor prognosis. Initially decided not to escilate care and make DNR [**3-11**]. Then progressed to withdrawal of care [**3-12**] with plan to extubate [**3-13**]. However there was dissent among neurologists about patient's ability to recover from the SAH while awaiting family members and the patient was changed to full code. Given 48 hours off sedation with out change in mental status (last morphine was [**2151-3-13**]). Transferred to [**Hospital1 18**] for further work up. . On arrival to the [**Hospital Unit Name 153**] the patient was intubated and non-sedated. Past Medical History: - Retroperitoneal Squamous Cell Carcinoma of unknown primary, dx [**10-21**], s/p XRT (last tx [**2150-2-23**]), s/p cisplatin (last dose 3/22) - L hydroureter obstruction, s/p R ureteral stent [**2151-1-28**] - h/o LLE DVT on coumadin - laser conization of cervix [**2147**] Social History: Lives with husband and 4 y.o. son. Family History: Non-contributory Physical Exam: VS - Tm 101.7 Tc 99.7 P 123 BP 137/75 Resp - PCV Pinsp 26 R 16 FiO2 50% Rate 8, breathing 20, Sat 100% Gen - lying in bed unresponsive HEENT - OP clear, PERRL Neck - supple Cor - RRR Chest - diffuse ronchi Abd - Mass in LLQ, nephrostomy with yellow clear output Ext - diffuse anasarca x 4 ext Neuro - PERRL, corneal reflex, gag reflex, Dolls eyes, spont mvt of head with out purpose side to side Pertinent Results: [**2151-3-16**] 11:02PM PT-14.6* PTT-29.1 INR(PT)-1.3* [**2151-3-16**] 11:02PM PLT SMR-LOW PLT COUNT-86* [**2151-3-16**] 11:02PM WBC-3.7* RBC-2.78* HGB-8.6* HCT-25.8* MCV-93 MCH-31.1 MCHC-33.5 RDW-14.9 [**2151-3-16**] 11:02PM CALCIUM-7.1* PHOSPHATE-5.1* MAGNESIUM-1.7 [**2151-3-16**] 11:02PM ALT(SGPT)-23 AST(SGOT)-19 ALK PHOS-101 [**2151-3-16**] 11:02PM estGFR-Using this [**2151-3-16**] 11:02PM GLUCOSE-96 UREA N-113* CREAT-2.3* SODIUM-150* POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-28 ANION GAP-16 [**2151-3-21**] 06:02AM BLOOD WBC-9.5 RBC-2.78* Hgb-8.8* Hct-25.7* MCV-93 MCH-31.7 MCHC-34.2 RDW-14.6 Plt Ct-26* [**2151-3-17**] 04:30AM BLOOD Neuts-80.4* Bands-9.3* Lymphs-4.1* Monos-3.1 Eos-1.0 Baso-0 Atyps-1.0* Metas-1.0* [**2151-3-21**] 06:02AM BLOOD Fibrino-406* [**2151-3-21**] 06:02AM BLOOD Glucose-120* UreaN-79* Creat-1.8* Na-144 K-3.6 Cl-110* HCO3-23 AnGap-15 [**2151-3-17**] 04:30AM BLOOD ALT-19 AST-18 LD(LDH)-313* AlkPhos-104 Amylase-37 TotBili-0.8 [**2151-3-21**] 06:02AM BLOOD Calcium-7.4* Phos-3.6 Mg-2.2 [**2151-3-17**] 04:30AM BLOOD Albumin-2.3 [**2151-3-19**] 08:32AM BLOOD Type-ART Temp-38.2 Tidal V-500 PEEP-5 FiO2-40 pO2-104 pCO2-50* pH-7.36 calTCO2-29 Base XS-1 -ASSIST/CON Intubat-INTUBATED [**2151-3-17**] 02:08AM BLOOD Lactate-1.6 . [**2151-3-17**] MRI head: FINDINGS: The sagittal T1 images demonstrate several areas of high signal along the sulci bilaterally which could be secondary to subarachnoid hemorrhages. There are several areas of hyperintensities at the convexity which could be intraaxial and could be related to hemorrhage within the metastatic lesions but in absence of gradient echo images, this could not be further confirmed. A CT would help for further assessment if indicated. There is increased signal seen in both basal ganglia region as well as along the rolandic region bilaterally which is suggestive of global hypoxic injury to the brain. There are several areas of brain edema identified in the left frontal and parietal lobe and both temporal lobes, which are suspicious for areas of metastatic disease with surrounding edema. There is no hydrocephalus or midline shift seen. No herniation is identified. Images through the skull base demonstrate soft tissue changes in the sphenoid sinus which could be due to retained secretions from intubation. There is increased signal seen along the sulci on FLAIR images at the convexity which could be secondary to subarachnoid hemorrhage. A CT would help for further assessment and exclude proteinaceous material within the sulci. Gadolinium-enhanced MRI would also help for further assessment. . pCXR [**2151-3-17**] 5:01am: FINDINGS: No prior comparisons. Tip of the ETT projects roughly 5 cm above the carina. A right IJ central venous line is at the level of the mid SVC. Tip of the NGT is below the edge of the image. IVC filter and probable NU stent catheter on the left also noted. Heart and mediastinum are unremarkable allowing for technique, no sizeable pneumothorax. There is a somewhat wedge-shaped opacity at the right lung base which could represent aspiration or pneumonia. No other confluent infiltrates are appreciated . pCXR [**2151-3-17**]. 1:46pm: 1. Mild pulmonary edema. 2. Vague right lower lobe opacity most likely represents pulmonary edema though if opacity persistent after diuresis, aspiration and pneumonia will become considerations. 3. ETT 4 cm above the carina with NG tube advancement into the stomach. . EEG [**2151-3-18**]: Abnormal portable EEG due to the slow and disorganized background and bursts of generalized slowing. These findings indicate a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. Subarachnoid hemorrhage is another possible explanation. There were no areas of prominent focal slowing, and there were no epileptiform features . Trans-thoracic echocardiogram [**2151-3-18**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) 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 pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No pericardial effusion. . pCXR [**2151-3-19**]: Mild left lower perihilar opacification has improved, probably resolving edema. There is more rightward mediastinal shift, suggesting new atelectasis in the right lung. Enlargement of the right hilus could represent adenopathy. Whether to pursue this would depend upon clinical circumstances. Heart size normal. ET tube in standard placement. Nasogastric tube passes below the diaphragm and out of view. No appreciable pneumothorax or pleural effusions . pCXR [**2151-3-20**]: Increasing opacification of the lungs could be due to mild pulmonary edema and multiple micrometastases, worsened slightly since [**3-19**] at 10:57 p.m. Heart size is normal. There is no pleural effusion. The ET tube and right PICC line in standard placements. Nasogastric tube passes below the diaphragm and out of view. No pneumothorax. . Microbiology: [**3-17**]- Blood cultures: no growth to date on [**12-18**] bottles [**3-18**]- Blood cultures: no growth to date on [**4-21**] bottles [**3-20**]- Blood cultures: no growth to date on [**2-17**] bottles . [**3-17**]- Urine culture: no growth (final) [**3-18**]- Urine culture: no growth (final) [**3-20**]- Urine culture: no growth to date . [**3-17**]- Stool: negative for Cdiff toxin [**3-18**]- Stool: negative for Cdiff toxin . [**3-18**]- Swab from Nephrostomy: GRAM STAIN (Final [**2151-3-18**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | . [**3-18**]- Sputum: Source: Endotracheal. GRAM STAIN (Final [**2151-3-18**]): [**9-9**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2151-3-20**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. . [**3-20**]- Sputum: Source Endotracheal. GRAM STAIN (Final [**2151-3-20**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): YEAST(S). . [**3-20**]- Catheter tip (IV): WOUND CULTURE (Final [**2151-3-21**]): No significant growth Brief Hospital Course: 30 yo F with metastatic squamous cell carcinoma of unknown primary who presented to OSH [**3-1**] with pseudomonal urosepsis, vaginal bleeding from tumor extension/anti-coagulation. Course complicated by sub arachnoid hemorrhages and intraparenchymal bleeds as well as potential hypotensive brain injury with poor prognosis per neurology. Transferred here for second opinion on poor prognosis. . # Neurologic - The patient was seen by the Neurology consult service and underwent MRI head which revealed lesions suspicious for metastases, possible hemorrhages, and findings consistent with hypoxic brain injury. EEG was performed and revealed encephalopathy. The patient's neurologic exam (performed after sedation removed >48 hours) revealed intact brainstem function without evidence of higher cortical activity. She had some metabolic abnormalities which were corrected (hypernatremia, hyperphosphatemia), but neurologic exam was unchanged. A family meeting on [**2151-3-19**] was held and these findings communicated with the patient's family. Final neurologic assessment was that the patient was unlikely to regain meaningful neurologic functioning. At the request of her family, she will be transferred closer to her home in [**Doctor Last Name **], to Women and [**Hospital 60658**] hospital. . # Respiratory Failure - Pt arrived on pressure support ventilation, which was changed to Assist control to make patient more comfortable. She was originally intubated for airway protection, and it is felt she could likely be weaned from the ventilator although she would be extremely high risk for aspiration. Due to family request to move patient to a hospital closer to home, she will remain intubated until transfer, with plan to extubate upon arrival to Women and [**Hospital 60658**] hospital with initiation of full palliative care and compliance of DNI status. . # Fevers/Infection - Per outside hospital records, the patient grew pseudomonas from blood and urine. At OSH, she was treated with 7 days of vancomycin, as well as 13 days (of 14-day planned course) of Ciprofloxacin and Zosyn. She was intially continued on Cipro/Zosyn. CXR [**3-17**] revealed ? pneumonia vs atelectasis at the R lung base. Continues to spike fever. Could have still seeding of nephrostomy tube. Urology at OSH against pulling tube because coagulopathy and may not be able to replace. Fevers also may be from head bleed, cancer, or drug. She was continued on zosyn and vancomycin to complete a >14 day course. She continued to have fevers. Antibiotics were discontinued on [**3-21**]. No further infectious course was identified and the fevers may have been due to underlying malignant process. . # Squamous Cell Cancer - unknown primary. The patient was seen by the oncology consult service who contact[**Name (NI) **] her outside hematologist Dr. [**Last Name (STitle) 73107**]. Upon discussion with him it was noted that the patient had progression of her disease after systemic therapy with topotecan and cisplatin. She then proceed to XRT with cisplatin which she was unable to tolerate this secondary to thrombocytopenia (40-50K). Given this we were unable to offer her additional therapy. Hematology/Oncology service at [**Hospital1 18**] confirmed her grim prognosis and expective survival in terms of weeks to months with no further available treatment. . # h/o DVT - patient with head bleed which is contraindication to anti-coagulation. IVC filter in place. Patient was on pneumoboots while in hospital. . # Hypernatremia - Improved from OSH. Total body volume overloaded. Water Deficit 2.5 L. She was continued on free H20 boluses and D5 1/2 NS and corrected. . # Acute Renal Failure - stable, likely [**12-18**] hypotension leading to ATN that is slowly improving. . # Access - R IJ changed sterilly over wire [**3-7**] . # FEN - tube feeds are held in route in anticipation of extubation. . . # Code Status: After multiple discussion with family and the doctor accepting the patient at Women and [**Hospital 60658**] Hospital( Dr. [**Last Name (STitle) 73107**] at RI. She was made DNR/DNI and the plan is that she will be transferred to WIH and extubated there upon arrival with initiation of full palliative care. The family understood this; all questions were answered and they wished to proceed. They understand that there is no ICU at WIH and no further advanced pulmonary support can be offered. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**4-23**] Puffs Inhalation Q2-4H (every 2 to 4 hours) as needed. 3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 25-100 mcg Injection Q2H (every 2 hours) as needed for comfort. 5. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 units Injection ASDIR (AS DIRECTED): per sliding scale for blood sugars > 150mg/dl. 6. Midazolam 1 mg/mL Solution Sig: 1-2 mg Injection Q2H (every 2 hours) as needed for comfort. 7. Phenytoin Sodium 50 mg/mL Solution Sig: One [**Age over 90 1230**]y (150) mg Intravenous Q8H (every 8 hours). 8. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg PO DAILY (Daily). 9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-17**] Drops Ophthalmic QID (4 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: 1. Hypoxic brain injury 2. Cranial hemorrages (sub arachnoid and parenchemal) 3. Pseudomonal sepsis, completed antibiotic course 4. Metastatic Squamous cell carcinoma of unknown primary. 5. Thrombocytopenia 6. Blood loss anemia Discharge Condition: Intubated, stable Discharge Instructions: You are being transferred to another hospital, intubated, with the plan to extubate upon arrival to Women's and Infants hosptial and initiation of palliative care. . Your antibiotics were stopped [**2151-3-21**] (Vancomycin 1000mg q24 and Aztreonam 1000mg q8) as your micorbiology data has been negative and your course for pseudomonal sepsis has been completed. If you continue to have fevers, blood cultures should be repeated. Followup Instructions: As directed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "286.6", "197.6", "198.3", "584.8", "348.1", "995.92", "785.52", "V12.51", "199.1", "431", "458.9", "276.0", "284.1", "038.43", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.22", "99.04", "96.72" ]

icd9pcs

[ [ [] ] ]

17200, 17215

11726, 16157

378, 384

17487, 17507

4286, 10294

17986, 18131

3836, 3854

16180, 17177

17236, 17466

17531, 17963

3869, 4267

11229, 11703

227, 340

10329, 11196

412, 3469

3491, 3768

3784, 3820

10,734

172,481

11295

Discharge summary

report

Admission Date: [**2154-12-18**] Discharge Date: [**2154-12-26**] Date of Birth: [**2106-4-28**] Sex: F Service: SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 48 year-old female who was admitted to the hospital for a Whipple procedure. The patient presented with recurrent fevers and jaundice. On [**11-11**] workup revealed an increased bilirubin of 10.7. She had an endoscopic retrograde cholangiopancreatography done with sphincterotomy, which showed a dilated common bile duct. The CT scan was done, which also showed a dilated duct with decreased filling of the common bile duct on [**7-7**]. The patient also had symptoms of dark urine, light stools and pruritus. She had no abdominal pain,nausea or vomiting and biopsy from endoscopic retrograde cholangiopancreatography revealed periampularry adenocarcinoma in situ. PAST MEDICAL HISTORY: Significant for hypertension during pregnancy, but none since. She had a TCA and lymph node biopsy in [**2152**], which showed reactive lymph nodes and a rebiopsy on [**2154-7-7**] of her axilla and inguinal nodes, which also showed reactive lymph nodes. ALLERGIES: No known drug allergies. MEDICATIONS: She does not take any medications. SOCIAL HISTORY: Occasional alcohol use. She does not smoke tobacco. FAMILY HISTORY: Significant for lung cancer. REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: She was found to be an obese woman in no acute distress. Her vital signs were all stable and within normal limits. Her head and neck, chest, cardiac and abdominal examination were all within normal limits and her extremities were also within normal limits. Given her endoscopic retrograde cholangiopancreatography and CT findings she was given the diagnosis of pancreatic carcinoma and scheduled for a Whipple procedure for which she was admitted to the hospital. ADMISSION LABORATORIES: White count 4.7, 41 hematocrit. She had a sodium of 136, potassium 4.3, chloride 96, bicarb 24, BUN 11, creatinine .7 and glucose of 105. HOSPITAL COURSE: The patient did well postoperatively. Her vital signs remained stable throughout the course of her hospital stay. Her hematocrit dropped significantly from a preoperative level of 41 to a low of 22.4 on postoperative day #3, however, her hematocrit stabilized and continued to increase from that point on and was expected to be partially due to hemodilution due to fluid resuscitation secondary to third spacing, no fluids. The patient spent the first evening in the Intensive Care Unit for observation and monitoring of her fluid status. She was transferred to the floor on postoperative day number one. The patient was started on a clear liquid diet on postoperative day number five, however, had difficulty tolerating sips and she was kept on sips and clear liquids until postoperative day number seven when she was started on regular solids. She was tolerating clear liquids well. She also tolerated her regular solids quite well. She had breakfast and lunch, however, at dinner she got nauseous and had 600 cc of emesis. However, on postoperative day number eight the patient was tolerating a regular solid food. Her vital signs continued to remain stable as they had throughout the course of her stay. A JP amylase was sent prior to discharge, which was 36 indicating that there was no evidence o a pancreatic fistula. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSIS: Pancreatic adenocarcinoma. MEDICATIONS ON DISCHARGE: Iron sulfate 324 mg po b.i.d., Reglan 10 mg one tab po q.i.d. and Percocet 5/325 one to two tabs po q 4 to 6 hours prn pain. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern1) 36253**] MEDQUIST36 D: [**2154-12-26**] 10:14 T: [**2154-12-30**] 07:42 JOB#: [**Job Number 36254**]

[ "575.6", "427.89", "157.0" ]

icd9cm

[ [ [] ] ]

[ "51.22", "52.7" ]

icd9pcs

[ [ [] ] ]

3414, 3423

1313, 1343

3444, 3472

3499, 3891

2055, 3392

1404, 2037

1363, 1381

167, 857

880, 1225

1242, 1296

30,600

170,933

48326

Discharge summary

report

Admission Date: [**2155-5-1**] [**Year/Month/Day **] Date: [**2155-5-6**] Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p Fall from standing Major Surgical or Invasive Procedure: None History of Present Illness: 89 yo female s/p fall while ambulating to bathroom. She was taken to an area hospital found to have small subdural hematoma, radial fracture and pelvic fracture. She was then transferred to [**Hospital1 18**] for further care. Past Medical History: Thyroid nodules Dementia GERD Osteoporosis Family History: Noncontirbutory Physical Exam: Upon admission: T: 98.6 BP: 167/75 HR:83 R16 O2Sats 100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 2.0-1.5 EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: slight edema in legs pain with movement on right side Right arm in splint Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, date "[**2153-3-24**]" (Baseline per son) Recall: 0/3 objects at 5 minutes. (Baseline per son) Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,2.0 to 1.5 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-28**] throughout. No pronator drift Sensation: Intact to light touch, Reflexes: B T Br Pa Ac Right 2+ 2+ Left 2+ 2+ Toes downgoing bilaterally Coordination: normal on finger-nose-finger Pertinent Results: Upon admission: [**2155-5-1**] 05:55PM GLUCOSE-107* UREA N-24* CREAT-1.0 SODIUM-143 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-22 ANION GAP-18 [**2155-5-1**] 05:55PM CK(CPK)-98 [**2155-5-1**] 05:55PM CK-MB-NotDone cTropnT-<0.01 [**2155-5-1**] 05:55PM CALCIUM-9.7 PHOSPHATE-3.0 MAGNESIUM-2.3 [**2155-5-1**] 05:55PM WBC-8.97 RBC-3.30* HGB-10.5* HCT-30.4* MCV-92 MCH-31.8 MCHC-34.6 RDW-15.9* [**2155-5-1**] 05:55PM PLT SMR-LOW PLT COUNT-107* LPLT-2+ [**2155-5-1**] 05:55PM PT-13.0 PTT-28.8 INR(PT)-1.1 CT HEAD W/O CONTRAST [**2155-5-3**] 2:59 PM CT HEAD WITHOUT IV CONTRAST: There is little change to the extra-axial, predominantly hyperdense right frontotemporal collection which extends through the vertex and measures 4 mm in maximal axial thickness. The remainder of the exam is also unchanged, without evidence of shift of midline structures, hydrocephalus, large vascular territory infarction, or new intracranial hemorrhage. The basal cisterns are preserved. The nasal septum is deviated towards the left with [**Doctor Last Name 13856**] bullosa greater on the right. Again diffuse mucosal thickening is seen in the ethmoid air cells and also within the sphenoid sinuses. The visualized maxillary and frontal sinuses as well as the mastoid air cells are well aerated. The patient is status post lens replacement on the left. IMPRESSION: Stable right frontotemporal subdural hematoma, again without mass effect or shift of midline structures. CHEST (PA & LAT) [**2155-5-1**] 6:25 PM FINDINGS: There is no consolidation or edema. A tortuous aorta is again identified. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is evident. No displaced fractures are evident. Degenerative changes are noted throughout the thoracic spine. IMPRESSION: No acute pulmonary process. No radiographic evidence for traumatic injury to the chest. PELVIS (AP ONLY) [**2155-5-1**] 7:52 PM FINDINGS: There is a cortical disruption at the right parasymphyseal regions, suspicious for fracture. No further pelvic fracture is identified. Bilateral femoral heads are appropriately located. The sacrum and sacroiliac joints are unremarkable. Degenerative changes are noted in the included lower lumbar spine. IMPRESSION: Right parasymphyseal pelvic fracture. Brief Hospital Course: She was admitted to the Trauma Service. Neurosurgery and Orthopedics were consulted. Her injuries were all nonoperative. Serial head CT scans were followed and were stable; she was loaded with Dilantin and will need to continue on this for another 10 days after [**Year/Month/Day **]. Her Dilantin levels will need to be followed; on [**5-1**] last level was 8.2. Her orthopedic injuries were treated conservatively; a short arm cast was applied and she was made non weight bearing on that extremity; she will follow up with Dr. [**Last Name (STitle) 1005**] in 4 weeks. She may weight bear as tolerated on her bilateral lower extremities. She is receiving Tylenol prn for pain. Physical and Occupational therapy were consulted and have recommended rehab stay after acute hospitalization. Case management initiated screening process and she is being discharged to rehab facility today. Medications on Admission: Omeprazole 20mg'' [**Last Name (STitle) **] Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 10 days. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Last Name (STitle) **] Disposition: Extended Care Facility: Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**]) [**Location (un) **] Diagnosis: s/p Fall Right subdural hematoma Right wrist fracture Right pelvic fracture (non operative) [**Location (un) **] Condition: Good [**Location (un) **] Instructions: Continue with the Dilantin for 10 more days after hospital [**Location (un) **]. DO NOT bear weight on your right arm because of your fracture. Followup Instructions: Follow up in 4 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2155-5-6**]

[ "244.9", "852.26", "294.8", "808.8", "V45.89", "E888.9", "530.81", "733.00", "813.42" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4371, 5260

251, 257

2055, 2057

6382, 6773

596, 613

5286, 6015

628, 630

6047, 6140

189, 213

6172, 6178

6213, 6359

285, 514

1269, 2036

2072, 4348

946, 1253

536, 580

13,033

124,112

43038

Discharge summary

report

Admission Date: [**2187-1-8**] Discharge Date: [**2187-1-17**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1042**] Chief Complaint: SOB Major Surgical or Invasive Procedure: Placement of PICC line. Removal of PICC line. History of Present Illness: 38yM with numerous hospital admissions well known to the medicine service with history of Type 1 DM, ESRD on HD, recent anterior STEMI s/p bare metal stent, episodes of hypoxia [**3-17**] pulmonary edema now being called out of MICU. . Briefly, he was recently admitted in [**12/2184**] for anterior STEMI. He subsequently developed severe pulmonary edema and hypoxia requiring MICU stay. He was aggressively diuresed with HD and oxygenation improved. He was discharged last week, but then 2 days ago developed SOB again, was hypertensive and tachycardic, and was readmitted to ICU service. He responded well to CPAP and BP improved with nitro gtt. He underwent HD with 3.5 kg fluid removal and sats improved to 90's on RA. Cardiology was consulted for lateral ST elevations and concern for another STEMI, but they did not think this was likely at this time. . Upon arrival to floor, he has no complaints and states that his breathing is significantly improved. He denies any dietary indiscretion while out of the hospital. He denies any CP, SOB, palpitations, N/V/abdominal pain or any other of his usual symptoms. he denies any fevers, chills, but does note frequent sweats. Past Medical History: 1. Diabetes mellitus type I - c/b gastroparesis requiring multiple hospitalizations. 2. End-stage renal disease on hemodialysis started [**2-/2184**] TuThSa 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, and orthostatic hypotension 5. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear 6. Coronary artery disease s/p BMS to LAD in [**12/2186**] 7. History of foot ulcer - 2 months, healing slowly 8. History of clot in AV fistula clot on coumadin - [**Month (only) 958**]/[**Month (only) 205**] of [**2185**] s/p multiple attempts to remove clot 9. CVA [**89**]. History of coagulase negative Staphylococcus bacteremia 11. Recent admission and discharge AMA for klebsiella/enterobacteremia 12. History of MRSA from sputum in [**2185**]. Social History: Denies alcohol or tobacco use or marijuana. Family History: His father 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: T99.3, BP 130/70, RR 16, Sat 93% RA GEN: Pleasant, comfortable, no acute distress HEENT: PERRL, EOMI, anicteric, mmm, OP without lesions NECK: no supraclavicular or cervical lymphadenopathy, no JVD RESP: Crackles at the bases bilaterally L>R, poor air movement CV: RR, S1 and S2 wnl, systolic murmur ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, 2+ pulses; trace edema bilaterally SKIN: no rashes/no jaundice NEURO: Alert and oriented, conversational Fem line C/D/I Pertinent Results: [**2187-1-8**] BCx, HD line: CN-SA (vanco [**Last Name (un) 36**], MIC's <1, 2) [**2187-1-9**] UCx: <10K organisms [**2187-1-10**] BCx, fem line: CN-SA (vanco [**Last Name (un) 36**], MIC 2) [**2187-1-10**] Cath tip Cx: CN-SA (vanco [**Last Name (un) 36**], MIC 2) [**2187-1-10**] BCx, PICC: CN-SA (vanco sense, MIC 2) [**2187-1-11**] BCx, PICC: No growth x2 [**2187-1-13**] BCx, PICC and HD line: No growth\ [**2187-1-14**] BCx, PICC: No growth x2 [**2187-1-16**] BCx, PICC: No growth x2 . CXR [**2187-1-9**]: AP chest compared to [**1-1**] and 26 shows subsequent improvement in diffuse infiltrative pulmonary abnormality which had worsened between [**1-1**] and [**1-8**]. The progression is consistent with improvement in pulmonary edema although mild cardiomegaly is stable throughout and there is no particular mediastinal vascular engorgement. Other diagnoses to consider include pulmonary hemorrhage. Small bilateral pleural effusions are unchanged since [**12-27**]. A dual-channel right supraclavicular dialysis catheter ends in the mid and low SVC. No pneumothorax. . ECHO [**2187-1-9**]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %) with mid to apical anteroseptal and anterior akinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. 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. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2186-12-28**], left ventricular wall motion is similar. . IR PICC placement [**2187-1-10**]: Successful placement of 36-cm total length single-lumen PICC via right basilic vein access with tip in the SVC. The line is ready for use. Venograms demonstrating extensive fibrin sheath around the right IJ tunneled dialysis catheter at the level of the right brachiocephalic vein and SVC. . ECG [**2187-1-13**]: Technically difficult study. Sinus rhythm. Inferior infarct, age indeterminate - consider acute. Anteroseptal infarct - age undetermined. Lateral ST-T changes offer additional evidence of ischemia Since previous tracing of [**2187-1-9**], anterior ST segment elevation and T wave inversion less prominent. Brief Hospital Course: # Respiratory Distress: Two days prior to admission, the patient was discharged s/p anterior STEMI complicated by severe pulmonary edema and hypoxia, treated in the MICU with aggressive hemodialysis which improved oxygenation. The patient then presented again with shortness of breath. He was found to be hypertensive and tachycardic, so was readmitted to the ICU. He responded well to CPAP, nitro GTT and hemodialysis. After transfer from MICU, the patient was free of respiratory distress and was satting in the 90's on room air. His SOB was thought to be secondary to fluid overload, although underlying etiology unclear as multiple echocardiograms have not shown dramatic change in cardiac function. There was initially some concern for diffuse alveolar hemorrhage; however HCT was stable and he responds so acutely to hemodialysis an and fluid removal. . # Hypertension: The patient is hypertensive at baseline, and blood pressures can be very labile. In the ICU, nitro GTT was used to provide aggressive BP control. Of note, blood pressures increased to 190's systolic or higher during episodes of gastroparesis. HTN during these episodes responded well to pain control and, if necessary, nitropaste. In addition, blood pressures drop to the 110's systolic after hemodialysis; the patient's antihypertensive regimen was held as needed post dialysis. Once stabilized in the MICU, the patient's BP med requirement decreased compared to his pre-admission regimen. This was thought to be related dietary indiscretion as an outpatient in the setting of ESRD requiring HD. . # STEMI: cards evaluated pt in MICU and felt that patient did not have a new STEMI; persistent STE at this time were thought to be residual. The patient's troponins trended down from their peak. He was maintained on ASA, [**Date Range 4532**], ACEI and statin, as well as aggressive BP control . # Gastroparesis: The patient suffers severe gastroparesis as a result of his diabetes. It is thought that the severe pain precipitates a hypertensive crisis which, if untreated, might contribute to shortness of breath and flash pulmonary edema. The patient was maintained on PRN ativan/dilaudid for pain control. When gastroparesis episodes were refractory, the frequency of his PRN's were increased and blood pressure was monitored and controlled. He was also made NPO except meds with his diet advanced as tolerated. Of note, the patient may still have severe nausea/vomiting when NPO or clears. . # Bacteremia: The patient developed leukocytosis. The patient has a long history of developing bactermia after completion of an extended course of antibiotic therapy for bacteremia. The patient was therefore started on empiric vacomycin. Blood culture drawn from HD catheter on [**1-8**] grew out vancomycin sensitive coagulase-negative staphylococcus. Femoral line cultures from [**1-10**], femoral line time (removed [**1-10**]) and PICC line cultures (placed [**1-10**]) all grew out CN-SA. Subsequent surveillance blood cultures from HD and PICC were NGTD until discharge, though final reports were pending. The patient was continued on vancomycin with HD dosing and goal level 15-20 until discharge. Of note, on review of MIC data from prior CN-SA infections in the past year, there is a possible trend towards higher vancomycin MIC's, though the organism causing this bacteremia did not continue this trend. If future MIC's are elevated, vancomycin dosing may been to be adjusted. The patient was assumed to have isolated bacteremia. However, the patient does have a longstanding systolic murmur as well as repeated bacteremias with a variety of organisms. While bacterial endocarditis is theoreticaly possible, bacterial endocarditis was not thought to be the cause of his bacteremia because CN-SA rarely causes endocarditis, the patient's bacteremias are caused by different organisms (Strep, Staph, Klebsiella, etc.), and the patient has had multiple TTE (last on [**2187-1-9**]) and TEE (last on [**2186-4-27**]) studies without vegetations. . # End-stage renal disease: The patient was maintained on his outpatient HD regiman with additional sessions to control fluid overload. The patient makes very little urine at baseline. . # Diabetes: the patient was maintained on lantus and sliding scale insulin for blood sugar control with most FSG < 200. . # Anemia: Anemia studies were suggestive of borderline iron deficiency anemia, with a marginally elevated ferritin. The patient was given EPO during HD per renal. . # F/E/N: The paitient was not given IVF on the floor. Electrolytes were repleted and adjusted per renal at HD. The patient ate a cardiac diabetic salt restricted diet when able to tolerate PO's. . # PPx: The patient was maintained on a bowel regimen supplemented with metoclopramide and erythromycin ethysuccinate. Pantoprazole for gastric PPX. Subcutaneous heparin for DVT prophylaxis. . # Access: Hemodialysis catheter. Femoral line d/c [**1-10**]. PICC placed [**1-10**], d/c prior to discharge. . # Dispo: Home with CHF VNA. . # Code Status: Full code . # Communication: With patient Medications on Admission: ASA 325mg daily Clopidogrel 75mg daily Docusate liquid [**Hospital1 **] B-complex with vitamin C Atorvastatin 80mg daily Lisinopril 5mg daily Labetalol 400mg TID Erythromycin Ethylsuccinate 200mg/5mL susp PO Q8H Lidocaine patch daily Metoclopramide 10mg QIDACHS Lanthanum 1000mg TID with meals Vancomycin 1000mg at HD per protocol Ceftazidime 1g QHD for five days Senna Glargine 5 units at bedtime Lispro sliding scale Discharge Medications: 1. Insulin Resume your pre-admission insulin regimen. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 cap* Refills:*2* 5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 8. Erythromycin Ethylsuccinate 200 mg/5 mL Suspension for Reconstitution Sig: Two Hundred (200) ML PO Q8H (every 8 hours). Disp:*450 ml* Refills:*2* 9. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 10. Lanthanum 500 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*270 Tablet, Chewable(s)* Refills:*2* 11. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. 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* 13. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty (30) ML PO TID (3 times a day) for 3 days. Disp:*45 ml* Refills:*0* 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol): given at dialysis. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Pulmonary edema . Secondary diagnosis: End stage renal disease requiring hemodialysis Diabetes mellitus Hypertension with autonomic dysfunction Gastroparesis Acute on chronic systolic congestive heart failure Myocardial infarction Discharge Condition: Stable, statting will on room air, eating a clear liquid diet. Discharge Instructions: You were admitted to the hospital because you were severely short of breath and pulmonary edema, likely the result of multiple factors including fluid overload. You were treated with emergent dialysis and stabilized in the medical intensive care unit. You were found to have a bacterial infection in your blood cause by the organism staphylococcus. You were treated with vancomycin and removed your femoral ("groin") intravenous line. The source of the infection is not known. We placed a PICC line for intravenous access until you are discharged. During your hospitalization, you were also treated for your other medical conditions including renal failure, hypertension, diabetes, acute on chronic systolic congestive heart failure, history of heart attack, and severe abdominal pain. Your electrocardiogram showed abnormalities that were thought to be related to your recent heart attack and not a new heart attack. You received hemodialysis during your hospitalization. We also helped coordinate social services for you after discharge. The nutritionist also visited with you to review diet instructions and follow-up appointment instructions. . You should follow up with your care providers. The appointments and contact information are listed below. You should advance your diet as tolerated. You should follow your diet guidelines including low-sodium, diabetic and cardiac diet. . You should return to the hospital if you have a recurrence of your symptoms, shortness of breath, chest pain, severe abdominal pain, swelling, high blood pressure, fever, chills, lightheadedness or any other concerning symptoms. Followup Instructions: You have an appointment to see your cardiologist [**Name6 (MD) 2053**] [**Name8 (MD) 27907**], MD (Phone:[**Telephone/Fax (1) 5003**]) on [**2187-1-29**] at 3:20pm. . You will see Dr. [**Last Name (STitle) 1366**] at dialysis on Thursday.

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Discharge summary

report

Admission Date: [**2173-7-27**] Discharge Date: [**2173-8-6**] Date of Birth: [**2105-8-12**] Sex: M Service: MEDICINE Allergies: Ephedrine / Penicillins / Plavix / Cipro Cystitis / aspirin Attending:[**Last Name (un) 11974**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: -Superior and inferior mesenteric arteriography -Colonoscopy History of Present Illness: 67M with history of recent a-fib s/p cardioversion x 2 with second one successful 6 weeks ago at [**Hospital3 **], on Pradaxa until he stopped taking 6 days ago with onset of symptoms. 6 days ago he had severe [**11-10**] LLQ abdominal pain worsened with movement, bending over, going over bumps in the car and palpation but that has since resolved. He has had intermittent BRBPR over the past week, mostly very light, but since earlier today with three episodes of large bright red blood. He had a sigmoidoscopy performed on Friday without cause for bleeding seen, and is scheduled for colonoscopy tomorrow. He drank Mg Citrate at 7pm and is scheduled for another dose at 3am and then NPO past 5 am for the colonoscopy at 9 am. He does not report LH, CP, SOB, fevers or chills. He is currently pain free. He did have nausea today associated with drinking the Mg Citrate very quickly but that has since resolved. He has a history of many prior polypectomies in the past with prior colonoscopies Upon arrival to the floor, the patient continued to have BRBPR and developed LH with standing. He does not report CP. Pt trigered for this. In ER: (Triage Vitals:2 97.6 72 161/107 16 100% ra ) Meds Given: none Fluids given: none Radiology Studies:none consults called: GI Past Medical History: -Afib - dx'd two months ago, started pradaxa at that time. Underwent cardioversion two weeks ago. -Renal Artery Stenosis S/P R Renal Bypass [**2135**] -Diverticulitis -Diverticulosis - has not had a problem in >10yrs since initiating daily wheat bran -[**Year (4 digits) **] adenoma -IR intervention on the mesenteric vasculature after 21u pRBC transfusion in the [**2131**] -Transient Ischemic Attack -Gout -CAD: [**10-6**] Cath - 90% LAD lesion (s/p DES). 60% RCA lesion. ETT [**2-5**] neg for ischemia. Followed by Dr. [**First Name (STitle) **] at [**Hospital 2586**]. -S/P Radiofrequency ablation of right greater saphenous vein (VNUS closure). [**6-/2170**] -S/P Right leg stab avulsions greater than 20 incisions (micro phlebectomy)for painful varicose varicosities [**7-/2171**] -Multiple knee surgeries -Sinus surgery for sinusitis/polyps -h/o SCC and BCC removal Social History: He lives with his wife of 40 years. He is a retired teacher. He has never smoked. He drinks socially and has never drank heavily. He has 2 grand children. He is physically very active and this weekend he was painting climbing on very tall ladders. He is independent of IADLs and ADLS. Family History: Cousins with [**Name2 (NI) 499**] cancer. His father died of cirrhosis from ETOH at age 74. His mother died of a brain tumor at age 72. Physical Exam: Admission: VS T = 97.7 P = 70 BP = 146/87 RR = 20 O2Sat on _98% on RA___ General: Alert, oriented, no acute distress. Supine on bedpan with R leg in brace, intermittently producing bloody diarrhea. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL. Conjunctivae pale. Neck: supple, no LAD. JVP <5cm H20. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: soft, non-distended, hyperactive BS. no organomegaly, no tenderness to palpation, no rebound or guarding. Healed transverse scar (renal bypass [**Doctor First Name **]) GU: no foley Ext: Hands/feet pale and warm without palpable pulses. No clubbing/cyanosis/edema. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 1+ reflexes in upper extremities, lower extremity reflexes and gait deferred. Discharge: VS: 97.5 112/66 73 16 96% RA GEN: Alert. Cooperative. In no apparent distress. Appears comfortable HEENT: PERRLA. EOMI. MMM. No icterus or pallor LUNGS: Clear to auscultation B/L. No wheezes or crackles. CV: S1, S2 Regular rhythm. No murmurs/gallops/rubs. Pulses 2+ throughout. No JVD. ABDOMEN: BS present. Soft. Nontender. Nondistended. No organomegaly noted. SKIN: No rashes or skin changes noted. No jaundice EXTREMITIES: No gross deformities, clubbing, peripheral edema, or cyanosis. Pertinent Results: Admission Labs: ====================== [**2173-7-27**] 10:27PM PT-11.3 PTT-30.2 INR(PT)-1.0 [**2173-7-27**] 10:10PM GLUCOSE-111* UREA N-21* CREAT-0.9 SODIUM-139 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-27 ANION GAP-19 [**2173-7-27**] 10:10PM estGFR-Using this [**2173-7-27**] 10:10PM WBC-10.0 RBC-4.82 HGB-15.2 HCT-44.2 MCV-92 MCH-31.5 MCHC-34.4 RDW-13.2 [**2173-7-27**] 10:10PM NEUTS-59.0 LYMPHS-26.9 MONOS-9.5 EOS-3.8 BASOS-0.8 [**2173-7-27**] 10:10PM PLT COUNT-269 . Discharge Labs: ======================== [**2173-8-5**] 09:15AM BLOOD WBC-7.3 RBC-3.79* Hgb-12.0* Hct-35.5* MCV-94 MCH-31.7 MCHC-33.8 RDW-14.7 Plt Ct-226 [**2173-8-5**] 09:15AM BLOOD Glucose-115* UreaN-5* Creat-0.6 Na-141 K-3.8 Cl-103 HCO3-27 AnGap-15 . Imaging ========== CTA Abd [**2173-7-28**] 1. Acute uncomplicated descending colonic diverticulitis with acute active extravasation supplied by the first left colic branch of the inferior mesenteric artery (3A:84). 2. Sigmoid and descending colonic diverticulosis. 3. Small hiatal hernia. . Colonoscopies: ===================== Colonoscopy [**2173-7-30**] Diverticulosis only in the sigmoid [**Month/Day/Year 499**]. No active bleeding was noted. Otherwise normal sigmoidoscopy to cecum ------------------- Colonoscopy [**2168**] Diverticulosis of the sigmoid [**Year (4 digits) 499**] Otherwise normal colonoscopy to cecum Recommendations: High fiber diet Follow-up with Dr. [**First Name (STitle) **] as needed Colonoscopy in [**5-6**] years Additional notes: The efficiency of colonoscopy in detecting lesions was discussed with the patient and it was pointed out that a small percentage of polyps and other lesions can be missed with the test. Degree of difficulty = 2 (5 most difficult) ------- Colonoscopy [**2163**]: Polyp at distal sigmoid ------- Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: ==================================== Mr. [**Known lastname **] is a 67 y/o M with a hx of CAD (s/p DES to LAD in [**2166**]), atrial fibrillation, diverticulosis, and massive GIB in the [**2131**], who was admitted with lower GI bleed 2 months after starting Pradaxa for AFib; likely Diverticular Bleeding ACTIVE ISSUES: ======================= # Lower GI bleed: Most likely diverticular bleed in setting of new dabigatran use. The patient was initially admitted to the medical floor but was transferred to the ICU because of brisk GI bleed. A CTA was performed while bleeding on [**7-28**] which showed descending colonic diverticulitis with active extravasation from a branch of the inferior mesenteric artery. However, by the time the patient was taken to the IR suite, bleeding had ceased. He had no further events but Hct trended down from baseline 44 to 26.4 at lowest and he required transfusion of 5 units of packed red cells. A colonoscopy was performed on [**2173-7-30**] which showed only diverticulosis with no source of bleed. After that point he stabilized without further evidence of bleeding and his HCT trended up to 35 prior to discharge. Aspirin was held on admission and was resumed at 325mg daily 2 days prior to discharge without any evidence of re-bleed. Patient had already stopped Dabigatran several days prior to admission and it was not continued. - Patient will follow-up with his gastroenterologist ~1week after discharge for a possible repeat colonoscopy. If there is no evidence of further bleeding then patient may be started on anticoagulation at follow-up with his cardiologist. He likely should be on coumadin instead of dabigatran so that his anticoagulation can be reversed rapidly if he has further GI bleeding. # Atrial Fibrillation: The patient had patient had been diagnosed ~2 months prior to admission and had successful cardioversion. He had been on sotalol for maintenance of sinus rhythm. During the admission he went into afib with rapid ventricular response. He wasn't able to be converted back into sinus rhythm despite increased doses of sotalol and therefore he was switched to dofetilide. He converted to sinus rhythm after a single dose. He was monitored for 3 days and his Qtc never exceeded 500. - The patient may be restarted on anticoagulation at follow-up with cardiology as discussed above pending a careful risk/benefit discussion. - Patient discharged on Dofetilide 500mg [**Hospital1 **] - Patient was counseled extensively on risks of QT prolongation and to avoid any medications or herbal supplements that could increase risk of torsade. # Diverticulitis: Patient had abdominal pain on admission and CTA showed diverticulitis. Unclear if this is related to bleed or incidental finding. The patient completed a 7 day course of Aztreonam/Flagyl - Patient will follow-up with GI as above - High fiber diet # Gout: patient had podagra during admission that improved with 1.8mg of colchicine (1.2mg followed by 0.6mg 1 hour later). - He will continue colchicine 0.6mg daily after dicharge CHRONIC ISSUES: ======================= # CAD (s/p DES to LAD in [**2166**]): no signs of ischemia during this admission. Aspirin was held initially because of bleed. Due to aspirin allergy patient had to be de-sensitized again - discharged on ASA 325mg daily. If he goes back on anticoagulation then can switch back to ASA 81mg daily - continued Atorvastatin 40mg TRANSITIONAL ISSUES: ============================= # Patient will follow-up with his gastroenterologist ~1week after discharge for a possible repeat colonoscopy. If there is no evidence of further bleeding then patient may be re-started on anticoagulation if benefits are deemed to exceed the risks. He likely should be on coumadin instead of dabigatran so that his anticoagulation can be reversed rapidly if he has further GI bleeding. # If patient goes back on anticoagulation then can switch back to ASA 81mg daily # Code Status: Confirmed Full Code Medications on Admission: Confirmed with pt on admission atorvastatin 80 mg Tablet 0.5 (One half) Tablet(s) by mouth once a day (Dose colchicine 0.6 mg Tablet 1 (One) Tablet(s) by mouth once a day [**2172-1-23**] lisinopril 5 mg Tablet 1 (One) Tablet(s) by mouth once a day [**2173-2-23**] soltatlol 80 mg [**Hospital1 **] aspirin 325 mg Tablet 1 Tablet(s) by mouth once a day - he was on 81 mg daily when he was started on pradaxa but with d/c of that 6 days prior to admission he started taking 325 mg ASA daily pradaxa - [**Hospital1 **] but self d/c'ed 6 days ago Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Colchicine 0.6 mg PO DAILY 4. Lisinopril 5 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Dofetilide 500 mcg PO Q12H check ecg 2 hours after each dose 7. Fish Oil (Omega 3) 1000 mg PO DAILY 8. saw [**Location (un) 6485**] *NF* 160 mg Oral daily 9. Vitamin B Complex 1 CAP PO DAILY 10. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: Primary: - Lower GI bleed - Diverticulosis - Diverticulitis - Atrial Fibrillation with Rapid Ventricular Response - Aspirin Allergy Secondary - Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], it was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted to the hospital because of rectal bleeding. You lost a large amount of blood and required 5 blood transfusions. Eventually your bleeding stopped on its own and your blood counts started to recover. You had no further bleeding for several days prior to discharge. During the admission your heart went into an abnormal rhythm called atrial fibrillation. You were put on a new medication called Dofetilide to help keep in you in normal (sinus) rhythm. It is VERY important that you let all your providers know that you are taking Dofetilide. There is risk of life-threatening arrythmias if dofetilide is combined with certain other medications. Please see the list of medications provided. You will follow-up with Dr. [**Last Name (STitle) **] in about 3 weeks as detailed below. After discharge you will follow-up with your gastroenterologist. If there is no evidence of further bleeding then you may discuss with your cardiologist about going back on a different blood thinner to help prevent stroke. Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] When: THURSDAY [**2173-8-12**] at 9:50 AM With: Dr [**Last Name (STitle) 19701**] [**Name (STitle) 1520**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage NOTE: This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: GASTROENTEROLOGY When: FRIDAY [**2173-8-20**] at 12:00 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 Department: CARDIAC SERVICES When: FRIDAY [**2173-8-27**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]

[ "401.9", "427.31", "V45.82", "272.4", "V14.8", "V07.1", "562.13", "285.1", "274.9" ]

icd9cm

[ [ [] ] ]

[ "88.47", "45.23" ]

icd9pcs

[ [ [] ] ]

11391, 11397

6290, 6633

324, 387

11609, 11609

4476, 4476

12896, 14246

2907, 3046

10895, 11368

11418, 11588

10327, 10872

11759, 12873

4969, 6267

3061, 4457

9767, 10301

279, 286

6648, 9380

415, 1689

4492, 4953

11624, 11735

9396, 9746

1711, 2587

2603, 2891

61,871

124,231

41994

Discharge summary

report

Admission Date: [**2196-8-23**] Discharge Date: [**2196-9-15**] Date of Birth: [**2132-5-3**] Sex: M Service: MEDICINE Allergies: Flagyl Attending:[**First Name3 (LF) 4095**] Chief Complaint: Diarrhea, weight loss, malnutrition Major Surgical or Invasive Procedure: CVL placement EGD PICC placement History of Present Illness: 64M HTN who presents with anorexia,weight loss, diarrhea and malaise x 8 months (since [**2196-1-9**]). He was treated with Xiafaxin and asacol in [**Month (only) 956**] for bacterial overgrowth without improvement. He was then hospitalized in [**State 108**] for approximately 2 weeks at the end of [**Month (only) 956**] with hypotension, dehydration, acute renal failure and electrolyte imbalances. He was discharged on enterocort 9 mg qd from the hospital in [**State 108**] in [**2196-3-8**] and with that he had had an improvement down to 5-6 BMs so he was able to return to his home in NY. Unfortunately his improvement did not last and he then presented to his local hospital in [**Month (only) 547**] in NY with diarrhea ([**12-21**] BM/daily) in [**2196-4-8**]. He was H pylori positive, prev pack given in [**Month (only) 547**]. He was then treated wtih neomycin for bacterial overgrowth. He was started on omeprazole for GERD. He was weaned off enterocort and then re-developed sx of diarrhea, chills, weakness, hypokalemia, and hypotension. Cdiff negative many times. Diagnosed with "refractory sprue at the end of [**Month (only) **]." His HLA pattern is DQ2 negative, DQ8 positive. At the end of [**Month (only) **] he was started on high dose prednisone 60 mg with good effect but it resulted in abdominal cramps, and acid reflux/burning. He then had an octreotide/abdominal CT/capsule study/eteroscopy. During this time he was on a gluten-free diet for three weeks without any effect and thus resumed a regular diet in the middle of [**Month (only) **]. He then started back on the gluten free diet at the end of [**Month (only) **]. At this time ulcers were found in the small bowel and he was thought to have IBD. These ulcers were biopsied and were negative for amyloid, Crohns. On the high dose steroids he felt very well for two weeks and he had a formed stool. He then declined again despite continuing on the 60 mg prednisone until he was readmitted [**2196-8-22**] with epigastric pain, electrolyte abnormalities, hypotension, and diarrhea - he thinks it increased to 10 BMS per day despite taking the entercort 9 mg po qd which was recently increased to entercort 6 mg [**Hospital1 **] on [**2196-8-18**] without effect. RUQ ultrasound yesterday did not show evidence of choledocholithiasis. Of note when his sx first began he had minimal RLQ pain but since starting on the different medications his RLQ pain has worsened with all of the medications he is taking. This cramping can occasionally precede a BM. His pain is also worsened with eating. He also has pain and diarrhea which awakens him from sleeping. Per his wife he developed petechiae on his feet which improved. No nausea or emesis. No recent foreign travel. No outdoor activity. No pets. Transferred her for evaluation by GI service/Dr. [**First Name8 (NamePattern2) 6665**] [**Name (STitle) 1356**]. . . PAIN SCALE: [**6-17**] LLQ ________________________________________________________________ REVIEW OF SYSTEMS: CONSTITUTIONAL: [] All Normal [- ] Fever [ ] Chills [ -] Sweats [ +] Fatigue [ +] Malaise [- ]Anorexia [- ]Night sweats [+ ] __50___ lbs. weight loss/ over _8____ months HEENT: [X] All Normal [ ] Blurred vision [ ] Blindness [ ] Photophobia [ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums [ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus [ ] Decreased hearing [ ]Tinnitus [ ] Other: RESPIRATORY: [X] All Normal [ ] SOB [ ] DOE [ ] Can't walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic pain [ ] Other: CARDIAC: [] All Normal [-] Angina [ ] Palpitations [+] Edema:b/l lower extremities x 2 months [ ] PND [ ] Orthopnea [ ] Chest Pain [ ] Other: GI: [] All Normal [ -] Blood in stool [ ] Hematemesis [ ] Odynophagia [ ] Dysphagia: [ ] Solids [ ] Liquids [ ] Anorexia [] Nausea [] Vomiting [ ] Reflux [+ ] Diarrhea - pea green [ ] Constipation [] Abd pain [ ] Other: GU: [X] All Normal [ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge []Menorrhagia SKIN: [] All Normal [ ] Rash [ ] Pruritus [+] petechiae which have resolved MS: [x] All Normal [ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain NEURO: [X] All Normal [ ] Headache [ ] Visual changes [ ] Sensory change [ ]Confusion [ ]Numbness of extremities [ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo [ ] Headache ENDOCRINE: [] All Normal [ ] Skin changes [ ] Hair changes [ ] Temp subjectivity HEME/LYMPH: [X] All Normal [ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy PSYCH: [X] All Normal [ ] Mood change []Suicidal Ideation [ ] Other: [x]all other systems negative except as noted above Past Medical History: Past Medical Hx: -Diverticulosis -Polyps -Hemorrhoids -HTN -Hypercholesterolemia -Kidney stones . Past Surgical Hx: - Knee surgery - appendectomy - CCY - Kidney stone extraction Social History: He smoked occasionally and quit entirely 40 years. No heavy alcohol abuse. Drank socially previously but now he has stopped altogether. Currently not working due to illness but previously he worked as a sales' manager of a carpet sales company. He lives with his wife of 39 years. He has two daughters who are in good health. Prior to this illness he was highly functional. Family History: Mother died of eye cancer which metastasized to the liver at age 72. She also had DM. His father died from ischemic cardiomyopathy s/p CABG x 5 vessels along with PAD at age 77. No family h/o intestinal/stomach problems. Sister with cushings and addison's dz with pituitary tumor s/p resection. She is currently being treated with breast cancer. Sister with non-malignant tumor of the parathyroid gland when she presented with fatigue. Another sister with melanoma. Physical Exam: Admission Exam: PAIN SCORE [**6-17**] VS: T = 97 P = 88 BP 110/60 RR 16 O2Sat 96% on RA GENERAL: Thin tired appearing gentleman who appears older than his stated age. Nourishment:OK Grooming:OK Mentation: alert, he is a very good historian. Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: dry MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Genitourinary: Skin: no rashes or lesions noted. No pressure ulcer Extremities: 2+ pitting edema b/l 2+ radial, 1 DP pulses b/l. Lymphatics/Heme/Immun: No cervical lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. - He is able to walk to the BR independently. Psychiatric: He has a limited affect and appears exhausted. . Discharge Exam: AVSS Mentation: A0x3 Eyes:NC/AT, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: dry MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. PICC Line without erythema or tenderness Extr: 1+ edema to knees bilaterally. Pertinent Results: Full Lab Report printed out and given to patient to present to PCP and Gastroenterologist. Other LABS: see below Imaging: PRIOR OTHER DIAGNOSTICS: RUQ US:[**2196-8-22**] Somehwat limited study with pancreas abdominal aorta not optimally visualized. Patient appears to have fatty changes in the liver during interval. . [**2196-7-4**] L LE US: No evidence of acute DVT in L L extremity . [**2196-4-13**] Abdominal US: No acute abnormalities noted in the abdomen or retroperitoneum. . CT scan of the abdomen Spleen is enlarged. S/p CCY 2mm low dense area in the medial segment of the L lobe of the liver suggests a cyst. . Capsule endoscopy [**2196-6-8**] Blunted villi, nicking, stacking folds. Multiple aptha noted in a scattered fashion throughout the small bowel. A few small agioectasias noted 50% and 51% of SBTT. One healed erosion noted at 68% of SBTT. Some segments with significant erosive enteritis. No actively bleeding sites appreciated. Moderately severe erosive enteritis. Findings are consistent wtih Celiac's vs Crohn's. Healed ulcerated patterns suggest some chronicity. Recommended trial of budesonide if patient is already on a gluten free diet. .............. Small bowel enteroscopy [**2196-6-8**] Non-specific duodenitis with parital flattening of the small bowel folds. ................ [**2196-6-8**] Jejunal bx Chronic enteritis with marked blunting of the villi nad crypts with focal chronic mucosal injury-type pattern. No active cryptitis or granulomas are seen. . [**Doctor Last Name **] of his biopsies demonstrated chronic enteritis/cryptitis with blunting of villi and increased epithelial lymphocytes. Special stains were negative for amyloid. Immunostaining was negative for T-cell lymphoma. Negative stool w/u and negative evaluation for carcinoid tumor including negative Octreoscan, negative chromogranin-A testing and negative pancreatic endocrine markers including negative gastrin VIP levels. EGD here at [**Hospital1 18**]: [**2196-8-25**] Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Mucosa: Diffuse continuous Diffuse scalloping and denuded mucosa of the mucosa with no bleeding were noted in the duodenal bulb, first part of the duodenum, second part of the duodenum and third part of the duodenum. Cold forceps biopsies were performed for histology at the second part of the duodenum. Impression: Diffuse scalloping and denuded mucosa in the duodenal bulb, first part of the duodenum, second part of the duodenum and third part of the duodenum (biopsy) Otherwise normal EGD to second part of the duodenum MR enterography IMPRESSION: 1. Diffuse mucosal hyperemia and hypomotility involving the small bowel without significant extramucosal and mesenteric inflammation. No enlarged nodes, which would be unusual for celiac sprue or infection. Roughly 10 cm ofterminal ileum with mucosal inflammation and chronic wall thickening does not distend and could have moderate stricturing, however the whole small bowel demonstrates minimal peristalsis and this is likely because of that and active mucosal disease. No small-bowel obstruction. 2. 7-mm cyst in the liver. 3. 1 cm common bile duct with mild intrahepatic duct dilation. CBD tapers smoothly to the papilla and this is likely because of cholecystectomy , though papillary stenosis is possible. Please correlate with symptoms and labs. . CXR [**8-30**]: FINDINGS: Semi-upright portable frontal view of the chest demonstrates increasing atelectasis bilaterally compared to prior. Again seen are dilated loops of bowel consistent with known enteritis. No pneumothorax or pleural effusion. No focal consolidation. Heart size is normal and unchanged. There is a right upper extremity PICC whose wire terminates in the lower SVC. Clips overlying the expected area of the gallbladder again seen. IMPRESSION: Worsening bibasilar atelectasis. . LENIs [**8-30**]: IMPRESSION: No evidence of bilateral lower extremity deep venous thrombus. Right peroneal veins not well visualized. . CT chest/abdomen/pelvis w/ and w/o contrast [**8-31**]: IMPRESSION: 1. No evidence of pulmonary embolism. 2. Patchy and coalescent consolidations involving all lobes of the lung, compatible with multifocal pneumonia. 3. Small amount of intra-abdominal fluid and prominent fluid filled small bowel loops, raising question of enteritis with a component of ileus. 4. Subcentimeter liver hypodensity within segment IIa, too small to fully characterize. 5. Marked anasarca. . TTE [**8-31**]: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. There are no echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen but is probably normal. No significant valvular abnormality. Unable to assess pulmonary artery systolic pressure. Trivial pericardial effusion without evidence of tamponade. . CXR [**9-2**]: IMPRESSION: Tip of endotracheal tube terminates 4.2 cm above the carina. The right internal jugular line ends in the lower SVC. Orogastric ends in the stomach and is appropriate. Both lung volumes remain low. Since [**2196-8-31**] the left perihilar and left lower lobe opacity has minimally decreased. Few other opacities in the right lung are also less conspicuous. The atelectasis in the right lung base has improved whereas on left side is unchanged. After concurrently reviewing chest CT dated [**2196-8-31**], multiple lung opacities are concerning for multifocal pneumonia, alternatively septic emboli is another possibility. . CTA chest [**9-3**]: IMPRESSION: 1. Diffuse multifocal pneumonia with more dense consolidation and marked volume loss in the bilateral lower lobes. Comparison to prior radiographs is difficult given the differences in modality. 2. Small bilateral pleural effusions. 3. Mild-to-moderate ascites. 4. Splenomegaly. . CXR [**9-4**]- There are persistent low lung volumes. Cardiomediastinal silhouette is unchanged with cardiac size top normal. Right PICC tip is in the SVC. There is no pneumothorax. Right lower lobe collapse is new. Left lower lobe consolidation has minimally improved. Small bilateral pleural effusions, larger on the right side, are probably unchanged. Smaller peribronchial opacities in the upper lobes bilaterally are better seen in prior CT from [**9-3**]. . IMPRESSION: No evidence of DVT . [**2196-9-3**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-9-3**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-9-3**] URINE URINE CULTURE-PENDING INPATIENT [**2196-9-3**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-9-1**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-8-31**] BRONCHOALVEOLAR LAVAGE POTASSIUM HYDROXIDE PREPARATION-FINAL; LEGIONELLA CULTURE-PRELIMINARY; Immunoflourescent test for Pneumocystis jirovecii (carinii)-FINAL INPATIENT NEGATIVE. [**2196-8-31**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {KLEBSIELLA PNEUMONIAE, YEAST} INPATIENT [**2196-8-31**] BRONCHIAL WASHINGS GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {KLEBSIELLA PNEUMONIAE, YEAST} INPATIENT [**2196-8-31**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-8-30**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2196-8-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2196-8-25**] STOOL OVA + PARASITES-FINAL INPATIENT [**2196-8-24**] STOOL NOT PROCESSED INPATIENT [**2196-8-24**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL; OVA + PARASITES-FINAL; FECAL CULTURE - R/O VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL; Cryptosporidium/Giardia (DFA)-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2196-8-24**] URINE URINE CULTURE-FINAL . . RESPIRATORY CULTURE (Final [**2196-9-2**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2196-9-9**] 1:37 am STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT [**2196-9-9**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2196-9-9**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . Pathology- DIAGNOSIS: Duodenal mucosal biopsies: Chronic, focally active duodenitis with diffuse foveolar hyperplasia, crypt regeneration and focal epithelial apoptosis and atrophy, and patchy villous shortening; no definite intraepithelial lymphocytosis or increase in subepithelial collagen thickness are seen; see note. . Immunostain for cytomegalovirus and special stains (GMS and Gram/Brown and Brenn) for microorganisms are pending and will be reported in an addendum. . Note: The findings are those of a chronic inflammatory process with very focal activity that is not typical of celiac disease or other malabsorption syndromes with a similar histologic picture. Ongoing chronic injury from an atypical infection, immune-mediated injury, or involvement of the upper gastrointestinal tract by inflammatory bowel disease remain in the differential diagnosis. Preliminary findings are discussed and reviewed with Drs. [**First Name8 (NamePattern2) 6665**] [**Name (STitle) 1356**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7017**] on [**2196-8-26**]. ADDENDUM: Special stains (GMS and Brown and Brenn Gram stain) are negative for microorganisms and immunostain for cytomegalovirus is negative with satisfactory controls. Brief Hospital Course: The patient is a 64 year old male with 8 months of watery diarrhea, abdominal pain, weight loss, hypoalbuminemia, severe malnutrition and failure to thrive. . #Enteropathy/enteritis unclear etiology, despite extensive workup at several outside institutions #Diarrhea #Weight loss #Failure to thrive #Malaise #Severe malnutrition #Hypoalbuminemia #LE edema secondary to hypoalbuminemia This patient has had ongoing diarrhea, anorexia, malaise, weight loss for many months, with workup at several institutions, though exact diagnosis is not yet clear. He reportedly had an OSH biopsy which was suggestive of collagenous sprue. He has also been given a prior diagnosis of refractory sprue but his serologies have not confirmed a diagnosis of celiac disease. With assistance of our GI specialists, our initial differential included collagenous sprue, celiac dz/refractory sprue (although all Ab tests negative), autoimmune enteritis, common variable immune deficiency, and inflammatory bowel disease (Crohn's, UC though prior workup reportedly negative) Interestingly, workup here showed an EGD with denuded duodenum and pathology suggestive of Crohn's. MR [**Name13 (STitle) 22553**] showed diffuse small bowel hyperemia and inflammation 10 cm of the terminal ileum. Pathology showed a focally active duodenitis, not typical of celiac or other malabsorption. Viral stains were negative. Despite treatment with IV methylprednisolone here, his symptoms had not abated. Started treatment with Entocort. Received first dose of Remicade on [**2196-8-29**] (hepatitis serologies and PPD were negative) and a second dose on [**2196-9-9**]. His symptoms significantly improved with the remicade and the addition of tincture of opium to control for loose stools. His symptoms were also likely attributed to significant gut edema (from significant iv fluids and marked hypoalbuminemia [from protein losing enteropathy)]. Over time, the frequency of loose stools lessened and the oral ulcers were notable reduced too. By the time of discharge, he was able to tolerate PO to a limited extent and tolerate solids. TPN was initiated on [**2196-8-27**] for which he will continue at home. Pain control with iv morphine, switched to iv Dilaudid on [**2196-8-30**]. At the time of discharge the patient was not requiring pain medications. Urinary retention: possibly related to narcotic use; high PVRs, but able to void some. Started Flomax on [**2196-8-27**] (no documented history of BPH). FOley dc'd [**9-8**] without difficulty. HCP is wife [**Name (NI) **] [**Telephone/Fax (1) 91182**] ICU [**Date range (1) 91183**] Patient was transferred to ICU in the setting of respiratory distress. SUMMARY OF ACTIVE INPATIENT ISSUES: #) Enteritis/Diarrhea: Likely autoimmune enteritiy, potentially Crohns per GI, based on MR enterography and pathology review. He was started on stress dosed steriods in the ICU as he had been on high dose steriods for a prolonged period of time prior to admission. This was eventually tapered to off. GI and pt wanted to DC steroids. Pt was started on bactrim PPX during admission. This can be dc'd if pt is discharged off of steroids. If steroids become long term he will need calcium and vitamin D supplementation. CT abdomen did not show abscess or sites of perforation/possible infection. Pt was started on remicade [**8-29**] as he was not steroid responsive. However, on [**8-30**] he was transferred to the ICU in septic shock from PNA (See above). Original plan had been to perform induction phase of remicade and give 2 weeks after 1st dose. However, given the above PNA course, ID was consulted to comment on safety of continuing remicade as well as timing. From, ID perspective, as long as pt was clinically improving, there was no need to delay therapy as he had anasarca and significant GI illness. Original plan was to give remicade on [**2196-9-12**]. Fortunately, pt's pneumonia rapidly improved on the medical floor and he was weaned to room air on [**9-7**]. ID was consulted to comment on use of remicade in setting of pneumonia and found no contraindication as long as he was clinically improving. 2nd dose, 400mg IV remicade was given on [**2196-9-9**], prior to transfer to rehab as stool outpt was beginning to pick up >4L daily. Pt did have negative hepatitis serologies and a PPD performed (off steroids) that was negative prior to starting remicade infusion. Plan going forward will be to continue follow up with primary GI in NY as well as Dr. [**First Name8 (NamePattern2) 6665**] [**Name (STitle) 1356**] at [**Hospital1 18**]. Plan is to continue remicade and titrate steroids to off. Continue to advance diet as tolerated with TID Boost supplements. Pt was started on TPN see above and will continue this in the outpatient setting until GI symptoms improve and pt starts to absorb from his GI tract. C.diff negative. Pt did not require pain medications for 4 days prior to discharge. . #) hypoxic respiratory failure/Hospital acquired pneumonia and acute diastolic heart failure- The patient becamse acutely short breath while on the floor. Differential included multifocal pneumonia (based on imaging), volume overnload (given at least 3L of IVF and continuous TPN), possibly a PE (given his large A-a gradient, tachycardia and possible hypercoaguable state , considered fungal/PCP (based on imaging characteristics and given his chronic steroid use for his IBD), or septic emboli (but later thought to be unlikely due to TTE with no evidence of vegetations). He was given albumin and lasix to diurese in the ICU. He was empirically started on a heparin gtt for PE as he was too unstable from a respiratory standpoint to undergo CTA, but LENIs were negative for DVT, and several days later, CTA was negative for PE, so heparin gtt was discontinued. He was also started on vanc/zosyn for HCAP, and a [**Hospital1 **] was performed and sent for gram stain, cell count and diff, legionella, fungal smear, and PCP. [**Name10 (NameIs) **] grew pan-sensitive Klebsiella, so his abx was narrowed to Ceftriaxone. CT chest repeated on day of transfer to floor continued to show multifocal pneumonia. He was originally intubated for hypoxic respiratory distress, but was extubated after 2 days. Pt was stable on the floor until [**9-4**] when he developed acute hypoxia requiring 6L NC as well as low grade fever. At that time, pt was started on lasix therapy, and antibiotics were rebroadened to Vanco/zosyn ([**9-4**]) to start an 8 day course, ending on [**9-12**] (later moved to [**9-15**]). Pt was also given intermittent doses of lasix on the floor. He was weaned to room air on [**2196-9-7**]. Given the significant improvements in symptoms and the clear [**Date Range **] positivity for pansensitive klebsiella and the need for minimal iv abx (for transfer to rehab), the abx regimen was switched to cipro. On this regimen, his breathing did well and was discharged without any O2 requirements. The patient completed a course of antibiotics on [**2196-9-15**] (Levaquin 750mg). . # Sepsis: Patient presented with diffuse anasarca, hypotension, in the setting of leukocytosis and respiratory distress. CT shows no clear sign of abdominal infection, but was later found to have have klebsiella pneumonia. Patient was originally put on stress dose steroids hydrocort 50 q6h, and then tapered to Solumedrol 24g IV q24 and budesonide 6mg PO bid. This was titrated to of by the time of discharge. He was treated for klebsiella PNA as above, and was not given antifungal coverage given that he improved clinically and [**Date Range **] did not show fungal organisms. Stool, blood, beta glucan, [**Date Range **] legionella, PCP [**Name9 (PRE) 91184**] were negative. B-glucan was somewhat elevated. However, this can be seen when pt are on zosyn therapy. Repeat was decreased compared to prior. PT was started on Bactrim PPX while on steroids. . #) Atrial Fibrillation with RVR: new onset per records, unclear if his worsening volume status caused the AF or if he became tachycardic and then flashed worsening his respiratory status or [**2-10**] PE. Cardiac enzymes and EKG did not ischemia. Started metoprolol PRN for rate control, converting in and out of afib for the first two ICU nights. Normal thyroid function. TTE showed no significant valvular abnormality. Unable to assess pulmonary artery systolic pressure. Trivial pericardial effusion without evidence of tamponade. Patient converted back to sinus spontaneously by ICU day 2. Nodal agents were discontinued. Pt can discuss need for aspirin/coumadin therapy in the outpatient setting. . #) Anasarca-likely due to hypoalbuminemia, recent sepsis, IV fluid resuscitation. PT consulted. Pt was given prn lasix dosing on the floor with good diuretic effect as well as a few doses of albumin and blood. Pt experienced large volume diuresis with these interventions and marked anasarca improved. Pt was given TPN and his diet was slowly advanced and supplemented with BOOST tid. . #)other protein/calorie malnutrition-Pt was followed by nutrition and placed on TPN. TPN was continued as his diet was advanced to regular, low residue, lactose free. He was given BOOST TID with meals which he tolerated. Plan is to continue TPN until he is able to take in enough PO and absorption improves. #)normocytic anemia- Significant drop in Hct on admission. Concern for diffuse alveolar hemorrhage, GI bleeding given colitis. No sign of bleeding on CT. LDH, T bili normal, so not suspicious of hemolysis. A transfusion goal was set for hct <21, but patient's hct stabilized initially, however continued to trend down while on the medical floor. Stool was guaiac positive, but watery diarrhea. Pt was given 1 unit PRBCs on [**9-9**]. Hct on discharge was 24.5 #) HTN: patient hypertensive to the SBP to 160s. At home, patient is on anti hypertensives, but these were held in the setting of sepsis. He was given lasix to diurese some volume, showing some improvement in his bp. Tamsulosin was the only BP med on his list at discharge, (being used for his previous difficulty urinating) . #) Oral ulcers: [**Month (only) 116**] be [**2-10**] to Crohn??????s. Does not resemble thrush. He was given lidocaine swish and swallow and magic mouth wash for pain relief. This resolved at time of discharge. . #FEN-Continue TPN, BOOST TID, regular, lactose free, low residue diet. . #PPX-heparin in TPN, pneumoboots . #code-full Medications on Admission: Medications on transfer - enterocort- 9 mg po qd - calcium carbonate 500 mg tid - vitamin D 50,000 twice a week, M and Friday - Alprazolam 0.25 mg q 8 hrs prn - Maalox prn - Lovenox 40 mg qd - Loperamide 2 mg [**Hospital1 **] - Magnesium oxide T qd - Zofran 4 mg IV prn - Pantoprazole 40 mg IV daily - Potassium chloride 20 mg tid - Prednisone 20 mg po daily - Prednisone 10 qhs .............. Discharge Medications: 1. budesonide 3 mg Capsule, Delayed & Ext.Release Sig: Two (2) Capsule, Delayed & Ext.Release PO BID (2 times a day). Disp:*30 Capsule, Delayed & Ext.Release(s)* Refills:*2* 2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 3. opium tincture 10 mg/mL Tincture Sig: Five (5) Drop PO Q6H (every 6 hours) as needed for diarrhea. Disp:*1 bottle* Refills:*0* 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Inhalation four times a day. Disp:*1 inhaler* Refills:*2* 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Robitussin-DM 10-100 mg/5 mL Syrup Sig: One (1) PO three times a day as needed for cough. 8. Menthol Cough Drops Lozenge Sig: One (1) Mucous membrane every four (4) hours as needed for cough. Discharge Disposition: Home With Service Facility: [**Hospital3 2005**] Home Care Discharge Diagnosis: Primary Diagnosis: - Autoimmune enteropathy - Severe malnutrition - Hypoalbuminemia - Multifocal pneumonia - Sepsis 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 for further work up of your abdominal pain, diarrhea and malnutrition. You were evaluated by the gastrointestinal team. You underwent an endoscopy with biopsy as well as MR enterography that was suggestive of an autoimmune enteritis, and/or potentially crohns disease. For this, you were started on immunosuppressive therapy (steroids and remicade). While here, you developed a pneumonia and were transferred to the ICU and were intubated. Your symptoms improved on antibiotic therapy. You were given 2 doses of Remicade during your admission. You will need to be sure to continue working with your gastroenterologist on treatment for your diagnosis as well as maintaining and promoting nutrition. You will be discharged on TPN. Please continue to advance your diet and take as much by mouth as possible. . Please take all of your medications as prescribed and follow up with the appointments below. Followup Instructions: Pt to follow-up with El-[**Last Name (un) 91185**] on [**Last Name (LF) 766**], [**2196-9-19**]. Please follow-up with Dr. [**Last Name (STitle) 60676**] from Gastroenterology [**9-20**], 11am.

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icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "96.71", "33.24", "96.04", "45.16" ]

icd9pcs

[ [ [] ] ]

30721, 30782

18772, 29225

302, 337

30942, 30942

7911, 8003

32068, 32266

5846, 6314

29669, 30698

30803, 30803

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3381, 5235

227, 264

365, 3362

30822, 30921

30957, 31101

5257, 5436

5452, 5830

8015, 18749

18,254

166,747

47967

Discharge summary

report

Admission Date: [**2196-10-4**] Discharge Date: [**2196-10-5**] Date of Birth: [**2134-9-9**] Sex: F Service: MEDICINE Allergies: Dilantin Attending:[**First Name3 (LF) 2297**] Chief Complaint: hyperkalemia Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: This is a 62 year old woman with pmh significant for ESRD secondary to IgA nephropathy, on HD, awoke this morning feeling shortness of breath, palpitations, nausea, and reported feeling crackles in her chest. She reports these symptoms are consistent with her being hyperkalemic, as she has experienced these in the past. She called EMS, on arrival her HR was in the 20's. EKG had peaked T waves. She was given 1 amp of calcium chloride by EMS. On arrival to [**Hospital1 18**] ED her HR was 36. Initial potassium was 9.9 on a hemolyzed sample. She was given an amp of sodium bicarbonate, dextrose, albuterol, and insulin. Her HR increased to 80's. Renal saw the patient and wanted admission to the ICU for urgent HD. . In the ICU, she reports feeling rather diaphoretic and not well. Notably, on FSBG check her BS is 60. She reports last HD session was [**10-1**]. She did have some non-bloody emesis this am which is new and has had some URI symptoms recently, though no myalgias, fevers, chills or sweats. She denies any consumption of foods high in potassium other than potatoes over the weekend. She has been taking all medications as directed. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Atrial fibrillation/flutter: first diagnosed in [**Month (only) **] [**2195**]. She has not been on Coumadin until very recently due to history of upper GI bleeding. On [**Month (only) 404**] of this year, she was admitted to [**Hospital1 18**] with chest pain and shortness of breath in the setting of atrial flutter with rapid ventricular response and hyperkalemia. She was treated for hyperkalemia and subsequently her atrial flutter was converted to sinus rhythm. Myocardial infarction was [**Hospital1 20003**] out based EKG and biomarkers. Thereafter, she underwent right-sided isthmus ablation of clockwise atrial flutter, and was started on quinidine and Coumadin. 2. End-stage renal disease on hemodialysis secondary to IgA nephropathy. She underwent cadaveric kidney transplant in [**2173**] which has eventually failed, and started on hemodialysis in [**2193**]. 3. History of upper GI bleeding on [**2195-2-20**] with evidence of esophagitis, gastric ulcer, and bleeding duodenal vessel. She was treated by clipping, cauterization and PPI. Repeated endoscopy in [**2195-4-21**] revealed mild inflammation and healing ulcer. She has not had any recurrent episodes of GI bleeding since then. 4. Diastolic heart failure supported by an echocardiography from [**2195-12-21**]. Clinically, she is stable and fairly asymptomatic on her current medical regimen. 5. History of malignant hypertension, which was complicated by seizure on [**2193-5-20**]. Not on antiepileptic meds. Denies h/o CVA. 6. Depression. 7. Rheumatic fever in childhood . Social History: She is single, lives by herself in [**Location (un) 686**], and has no children. She quit smoking 25 years ago (10-pack-years). She rarely drinks alcohol, and denies illicit drug use. She used to work part-time in a coffee shop, but currently does not work. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Her father died at the age of 80. Her mother died at the age of 64 from lung CA. She has a sister with breast CA. MI in uncle in his 60s Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2,SEM [**2-26**] in LUSB with radiation to carotids, also continuous murmer in apex Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CN II-XII grossly intact, 5/5 strength in all 4 ext Pertinent Results: on admission: 133 | 93 | 96 --------------144 7.7 | 17 |11.7 ca12.8 mg 3.3 phos 4.7 11.4 > 40.5 < 244 trop 0.5 CK 85 Brief Hospital Course: Assessment and Plan: This is a 62 yo female with history of ESRD on HD who presents with hyperkalemia of unclear etiology with ECG changes but otherwise hemodynamically stable admitted to MICU for urgent HD. . # Hyperkalemia: Potassium of 7.7 on presentation to ED. Unclear etiology given recent HD, no dietary indiscretions, normal acid base status and no other metabolic abnormalities. Pt was urgently dialyzed in the MICU. Recheck potassium 4 hours after HD was 4.0. She was sent home with a prescription for kayexelate. . # Hypoglycemia: Pt found to be hypoglycemic upon admission to the ICU. This was felt to likely be related to insulin she received in ED for her hyperkalemia, [**1-22**] amp D50 given c good result. . # HTN: BP currently stable. Continued outpateint regimen of lopressor (switched to tartrate while hospitalized) and lisinopril. Captopril held overnight, however, pt was more hypertensive overnight. Pt discharged on home dose of amlodipine. . #Afib: continued on amniodarone . # GERD: continued pantoprazole . # Depression: continued citalopram . # FEN: No IVF, HD for electrolyte balance, Renal Diet . # Prophylaxis: Subcutaneous heparin, PPI . # Access: peripherals . # Code: DNR/DNI per discussion with patient Medications on Admission: CALCIUM ACETATE - 667 mg Capsule - 3 Capsule(s) by mouth three times a day CAPTOPRIL - 12.5 mg Tablet - 1 Tablet(s) by mouth at bedtime CINACALCET [SENSIPAR] - 60 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily) CITALOPRAM - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth qam LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) pt holds on dialysis days METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth DAILY (Daily) PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 3 Tablet(s) by mouth three times a day WARFARIN - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]/c from [**Hospital1 18**]) - 2 mg Tablet - 2 Tablet(s) by mouth once a day Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 3. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 7. Cinacalcet Oral 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Kayexalate Powder Sig: Fifteen (15) grams PO once a day. Disp:*30 qs* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: hyperkalemia secondary diagnosis: chronic kidney disease, hypertension Discharge Condition: stable Discharge Instructions: You were admitted with a high potassium level. It is not clear what resulted in this potassium elevation. High potassium can cause arrythmias so you were admitted to the hospital for emergency dialysis. After dialysis your potassium was just a little bit above normal. When you go home, please eat a low potassium diet. We are providing you with some information about how to eat a low potassium diet. This is very important. Please continue with your regular hemodialysis. Please continue all of your current medicines. Followup Instructions: Please call Dr [**Last Name (STitle) **] and make an appointment to see him within the next week. Please tell him that you were recently hospitalized for elevated potassium levels.

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icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

7760, 7766

4693, 5934

282, 296

7900, 7909

4548, 4548

8481, 8665

3691, 3946

6811, 7737

7787, 7787

5960, 6788

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230, 244

324, 1478

7840, 7879

7806, 7819

4563, 4670

1837, 3398

3414, 3675

63,058

109,330

3880

Discharge summary

report

Admission Date: [**2167-10-27**] Discharge Date: [**2167-11-10**] Date of Birth: [**2101-2-24**] Sex: M Service: SURGERY Allergies: Chromium Attending:[**First Name3 (LF) 2777**] Chief Complaint: AAA Major Surgical or Invasive Procedure: [**10-27**]: OPERATION PERFORMED: Open repair of abdominal aortic aneurysm and bilateral common iliac artery aneurysms with a Dacron 20 x 10 bifurcated graft as well as a bypass to the left renal artery. [**10-29**]: Operation Performed: Flexible colonoscopy to 60 cm. History of Present Illness: This is a 66-year-old gentleman who has a known large abdominal aortic aneurysm. It has now grown to 8 cm in size. He has multiple comorbidities; however, he has been cleared for surgery by cardiology after cardiac catheterization. He has a suprarenal abdominal aortic aneurysm which is notamenable to endovascular repair. he has a single kidney (left) with a stent in the origin which comes off the aneurysm and will require bypass. In addition, he has bilateral common iliac artery aneurysms with a very large (5cm) right common iliac aneurysm which will require extension of the graft into the iliac bifurcation. Given his risk for rupture, the patient was consented for an open aneurysm repair Past Medical History: PAST MEDICAL HISTORY: 1. CAD RISK FACTORS: DM2, HTN, dyslipidemia, CAD, smoking 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - 50+ pack year history of smoking - CRI - RAS s/p L stenting 07, right kidney atretic - severe COPD - obesity - back surgery - abdominal aneurysm - CT angiogram performed in [**2167-9-20**] showed the size to be 8 cm. His descending thoracic aort is also enlarged (less than 5 cm), and the right common iliac artery was aneurysmal (5 cm) with left common iliac smaller (3 cm) aneurysm. Of note, the abdominal aortic aneurysm is pararenal and extends to the left renal artery (which had been stented in [**2165-2-17**]). Social History: The patient in married and lives with his wife. [**Name (NI) **] is retired. Smokes 1 ppd and has done so for over 50 years. He denies alcohol or recreational drugs. He does not exercise and has no dietary restrictions. Family History: significant for heart disease. Negative for stroke and diabetes Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Obese, Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2167-11-8**] 04:07AM BLOOD WBC-9.6 RBC-3.48* Hgb-10.1* Hct-29.3* MCV-84 MCH-29.1 MCHC-34.6 RDW-14.5 Plt Ct-388 [**2167-11-6**] 05:42AM BLOOD PT-14.5* PTT-26.2 INR(PT)-1.3* [**2167-11-10**] 06:05AM BLOOD Glucose-95 UreaN-42* Creat-2.1* Na-139 K-3.3 Cl-101 HCO3-24 AnGap-17 [**2167-11-10**] 06:05AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.7 [**2167-10-30**] 12:47PM URINE Hours-RANDOM UreaN-340 Creat-47 Na-89 URINE Hours-RANDOM URINE Osmolal-380 URINE Uhold-HOLD RENAL US: FINDINGS: The right kidney is noted to be atrophic measuring only 8.0 cm. No vascular flow is identified in the right kidney and color Doppler imaging. The left kidney measures 15.2 cm. There is no hydronephrosis. No cyst or stone or solid mass is seen in the left kidney. DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images were obtained from the left kidney only. Note is made that this is a limited Doppler study due to the portable technique and the patient's body habitus. Arterial flow is documented within the left main renal artery, but cannot be further assessed. Venous flow is seen in the main renal vein. Resistive indices are mildly elevated measuring 80, 79, and 73. IMPRESSION: 1. Arterial and venous flow identified within the left kidney with mildly elevated resistive indices in the intraparenchymal arteries. No further assessment can be made at the main renal artery due to the limited nature of this portable technique and the patient's body habitus. 2. Atrophic right kidney. Brief Hospital Course: Mr. [**Known lastname 17353**],[**Known firstname **] was admitted on [**10-27**] with AAA. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preparations were made. It was decided that she would undergo a: Open repair of abdominal aortic aneurysm and bilateral common iliac artery aneurysms with a Dacron 20 x 10 bifurcated graft as well as a bypass to the left renal artery. He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. He was transferred to the CVICU for further care. He had a prolong intubation. [**2167-10-27**] - [**2167-11-5**]. He received mo niter care and pressure support. During this time frame pt had ATN. His nephrotoxic drugs were held. He received PRBC for hypotension and volume support. His baseline creatinine was 1.6, High 4.6, now 2.1. All his home meds were restarted. He always maintained good urine output. Pr also had Bowel movements in the immediate post operative period. transplant was called. Had mucosal sloughing. His lactate was normal. This is assumed resolved. Pt had hypernatremia to 147. This resolved with fluids. After he was extubated he was then transferred to the VICU for further recovery. While in the VICU he received monitored care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabilized from the acute setting of post operative care, he was transferred to floor status On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged to a rehabilitation facility in stable condition. To note his staples were removed on DC. Steri strips are in place. PT HAS RUL OPACITY ON CXR. HE NEEDS TO HAVE THIS WORKED UP. HE NEEDS A CT SCAN OF CHEST. THIS SHOULD BE DONE BY HIS PCP. Medications on Admission: ATENOLOL 25', FUROSEMIDE 20', LISINOPRIL 10', LORAZEPAM 1', METFORMIN 850", PAROXETINE 20', CRESTOR 20', ASPIRIN 81' Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Rosuvastatin 20 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 Q12H (every 12 hours). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Metformin 850 mg Tablet Sig: Two (2) Tablet PO twice a day. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 9. Potassium Chloride 20 mEq Packet Sig: One (1) PO DAILY (Daily): please hold for k greater then 4.5. 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: prn. 11. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Insulin Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: AAA Acute Renal failure secondary to blood loss and hypotension Mucosal sloughing, flex sig RUL mass, Needs outpt CT scan from PCP hypotension from blood loss requiring PRBC Hypernatremia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home or Rehab: 1. It is normal to feel weak and tired, this will last for [**4-27**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**12-23**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2167-11-25**] 2:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2168-7-28**] 4:00 PCP: [**Name10 (NameIs) 17354**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17355**]. You should mnake an appointment with her ASAP. You need a ct scan of your chest to follow-up on a lung mass. This was a incidental finding. Completed by:[**2167-11-10**]

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icd9cm

[ [ [] ] ]

[ "96.6", "38.44", "96.72", "39.24", "99.15", "38.46", "33.24", "45.23" ]

icd9pcs

[ [ [] ] ]

8181, 8228

4372, 6478

274, 548

8460, 8460

2853, 4349

11332, 11896

2285, 2350

6645, 8158

8249, 8439

6504, 6622

8605, 10879

10905, 11309

2365, 2834

1404, 1477

231, 236

577, 1282

8474, 8581

1508, 2031

1326, 1384

2047, 2269

55,992

141,696

2811

Discharge summary

report

Admission Date: [**2154-4-14**] Discharge Date: [**2154-4-18**] Date of Birth: [**2074-11-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: weakness, anemia Major Surgical or Invasive Procedure: none History of Present Illness: 79 yo F with GI stromal tumor most recently on Sutent with recent CT scan showing progression of disease now on sorafenib, past admissions for intraperitoneal bleed [**2-14**] omental metastasis while on coumadin (now off), DM, hypothyroidism, atrial fibrillation, dCHF who presented to the ED yesterday ([**2154-4-14**]) with fatigue, weakness and sob for three days. Patient was found to have a hematocrit of 16 (baseline 28-30). She was hemodynamically stable and transfused 2 units of pRBCs. Patient was guaiac negative. She had a CT of the abdomen with contrast which showed hemoperitoneum with the origin of hemorrhage likely near known soft tissue mass. Surgery was contact[**Name (NI) **] and said that she was not an operative candidate. IR was consulted, reviewed the CT, did not see any evidence of active extravasation and felt that there was no indication for intervention at this time. Patient was admitted to the [**Hospital Unit Name 153**] for further monitoring. Patient was transfused a third unit of packed cells early this am and kept NPO. During transfusion of third unit of packed cells patient developed a red pruritic rash thought to be a transfusion reaction, given iv benadryl. She had a new 2L oxygen requirement which was thought to be due to increased cardiac demand due to severe acute anemia. She was found to have new TWI on ECG for which cardiac biomarkers were checked and negative x 3. Patient's sorafenib was held and per discussion with oncology fellow, patient to restart at home after discharge. Patient had mild [**Last Name (un) **] thought to be prerenal that improved with transfusions. Patient started on clears today, hematocrit continued to increase to 26.9 then 30.7 this evening. . Of note, patient had a recent admission [**12-24**] for acute on chronic diastolic heart failure which improved with diuresis. Also with multiple admissions in [**2153**] for intraperitoneal bleed due to omental metastasis in the setting of coumadin use for atrial fibrillation. Patient also has a right medial thigh wound that has been persistently open after cellulitis in [**2153**]. . Currently patient denies any abdominal pain. SOB and fatigue have improved. Her oxygen has been weaned to off. Patient does have constipation with last BM 2 days ago. Also continues to have pruritis and red rash, managed with sarna lotion and one dose of po benadryl today. . ROS as per HPI, 10 pt ROS otherwise negative Past Medical History: - RIGHT MEDIAL THIGH WOUND: Developed after developing severe cellulitis in late [**2153**] and underwent a biopsy of the area [**2153-11-22**]. Did not heal due to DM and chemo, as was on sudent. Was on sunitinib and this was put on hold to allow further healing, but has since restarted low dose. Measurement of wound was 8 x 0.5cm. The first 4 cm on the right was still open with hypergranulation tissue present on [**12-26**]. - GIST: Diagnosed in [**2143**], treated with surgery and multiple intermittant courses of gleevac, complicated by side effects. She had partial gastrectomy and GIST resection in [**2143**], and a GIST omental metastasis resection in 03/[**2153**]. Noted to have GIB in [**Month (only) 205**] and [**2153-8-13**] due to enlarging GIST lesions. Started on Sutent since [**2153-10-1**]. Currently on low dose Sutent following poor wound healing as above. - ANEMIA, iron deficiency - Paroxysmal ATRIAL FIBRILLATION, not on AC due to multiple RP bleeds - CONGESTIVE HEART FAILURE, Diastolic, ef >70%. - DIABETES MELLITUS - Chronic DYSPNEA, exertional - HYPERTENSION - HYPOTHYROIDISM - CVA in [**2136**], Residual R hemiparesis and intermittent aphasia, - TIA in [**2148**] - Status post knee surgery in [**2137**]. Social History: Lives alone. Has 2 daughters. Moved from [**Country **] in [**2137**]. Has grandchildren who visit her. -Tobacco history: negative -ETOH: negative -Illicit drugs: negative Family History: No family history of cancer, lung disease or heart disease. + for DM. Physical Exam: VS: 98.5 130/78 97P 18 100%RA Appearance: alert, NAD, obese Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mmm, no JVD, neck supple Cv: +s1, s2 -m/r/g, tr peripheral edema, 1+ dp/pt bilaterally Pulm: clear bilaterally, diminished at bases Abd: soft, nt, nd, +bs Msk: 5/5 strength throughout Neuro: cn 2-12 grossly intact, no focal deficits Skin: diffuse blanching confluent erythematous rash involving back, upper arms and upper chest Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] Pertinent Results: [**2154-4-17**] 06:10PM BLOOD Hct-26.8* [**2154-4-17**] 07:05AM BLOOD WBC-2.9* RBC-2.62* Hgb-8.2* Hct-26.6* MCV-102* MCH-31.4 MCHC-30.9* RDW-20.0* Plt Ct-230 [**2154-4-16**] 10:15PM BLOOD Hct-25.8* [**2154-4-16**] 02:35PM BLOOD Hct-27.9* [**2154-4-16**] 07:08AM BLOOD WBC-3.3* RBC-2.96* Hgb-9.4* Hct-29.6* MCV-100* MCH-31.9 MCHC-31.9 RDW-20.2* Plt Ct-211 [**2154-4-15**] 04:28PM BLOOD Hct-30.7* [**2154-4-15**] 11:57AM BLOOD Hct-28.2* [**2154-4-15**] 05:30AM BLOOD WBC-2.5* RBC-2.73* Hgb-8.9*# Hct-26.9* MCV-99* MCH-32.7* MCHC-33.2 RDW-20.1* Plt Ct-185 [**2154-4-14**] 10:00PM BLOOD WBC-3.1* RBC-2.24*# Hgb-7.1*# Hct-22.4*# MCV-100*# MCH-31.8 MCHC-31.8# RDW-20.8* Plt Ct-198 [**2154-4-14**] 02:00PM BLOOD WBC-3.7* RBC-1.54*# Hgb-4.7*# Hct-16.7*# MCV-108* MCH-30.2 MCHC-27.9* RDW-20.9* Plt Ct-230 [**2154-4-14**] 10:00PM BLOOD WBC-3.1* RBC-2.24*# Hgb-7.1*# Hct-22.4*# MCV-100*# MCH-31.8 MCHC-31.8# RDW-20.8* Plt Ct-198 [**2154-4-14**] 02:00PM BLOOD WBC-3.7* RBC-1.54*# Hgb-4.7*# Hct-16.7*# MCV-108* MCH-30.2 MCHC-27.9* RDW-20.9* Plt Ct-230 [**2154-4-17**] 07:05AM BLOOD Neuts-70.4* Lymphs-13.6* Monos-4.2 Eos-11.7* Baso-0.1 [**2154-4-14**] 02:00PM BLOOD Neuts-79.8* Lymphs-14.8* Monos-4.8 Eos-0.2 Baso-0.3 [**2154-4-17**] 07:05AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-1+ Target-2+ Schisto-1+ Burr-OCCASIONAL Stipple-1+ Acantho-1+ [**2154-4-14**] 10:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+ Burr-OCCASIONAL Stipple-1+ [**2154-4-14**] 02:00PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Target-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2154-4-16**] 07:08AM BLOOD PT-11.4 PTT-25.9 INR(PT)-1.1 [**2154-4-14**] 05:56PM BLOOD PT-12.4 PTT-29.8 INR(PT)-1.1 [**2154-4-17**] 07:05AM BLOOD Glucose-104* UreaN-26* Creat-1.3* Na-139 K-4.2 Cl-104 HCO3-26 AnGap-13 [**2154-4-16**] 07:08AM BLOOD Glucose-116* UreaN-25* Creat-1.3* Na-140 K-4.1 Cl-103 HCO3-27 AnGap-14 [**2154-4-15**] 05:30AM BLOOD Glucose-112* UreaN-30* Creat-1.3* Na-140 K-4.0 Cl-104 HCO3-24 AnGap-16 [**2154-4-14**] 10:00PM BLOOD Glucose-102* [**2154-4-14**] 02:00PM BLOOD Glucose-131* UreaN-37* Creat-1.5* Na-136 K-4.3 Cl-102 HCO3-25 AnGap-13 [**2154-4-16**] 07:08AM BLOOD ALT-9 AST-15 AlkPhos-57 TotBili-1.4 [**2154-4-14**] 02:00PM BLOOD LD(LDH)-319* CK(CPK)-79 TotBili-0.8 [**2154-4-15**] 05:30AM BLOOD CK-MB-2 cTropnT-<0.01 [**2154-4-14**] 10:00PM BLOOD CK-MB-2 cTropnT-<0.01 [**2154-4-14**] 02:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-2632* [**2154-4-17**] 07:05AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.3 [**2154-4-16**] 07:08AM BLOOD Phos-2.7 Mg-2.3 [**2154-4-15**] 05:30AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3 [**2154-4-14**] 02:00PM BLOOD Hapto-111 . EKG:Atrial fibrillation. Poor R wave progression. Non-specific T wave inverions in leads V4-V6. Compared to the previous tracing of [**2154-1-4**] atrial fibrillation remains present but now is slightly slower. Otherwise, no interval change. . CXR: IMPRESSION: Mild pulmonary vascular congestion. Cardiomegaly. Pulmonary nodules documented on CT from [**2154-3-29**] are better appreciated on that study . CT abdomen/pelvis: IMPRESSION: 1. Interval increase in heterogeneous intra-abdominal fluid, consistent with hemoperitoneum. The higher density material is present along the lesser sac and along the gallbladder fossa, likely indicating the region of origin of hemorrhage near known soft tissue mass. 2. Multilobulated soft tissue masses consistent with known GIST recurrence with increased omental nodularity. Stable liver lesions. Brief Hospital Course: 79 y/o F PMH significant for metastatic intra-abdominal GIST tumor, anemia, dCHF (last EF 55% 12/11) presents with lethargy, SOB and weakness x3 days found with HCT of 16.7. . #ACUTE ON CHRONIC ANEMIA/acute blood loss - presented with H/H 4.7/16.7. More recent baseline values were HCT of 28-30 as recently as [**2154-4-5**] suggesting acute change. MCV was chronically >100. Anemia w/u including b12/folate/fe studies checked in [**Month (only) **] [**2153**] wnl. Hemoperitoneum noted on abd CT presumably from metastatic GIST. Stool was guiaic negative so unlikely intra-intestinal bleeding. Pt with Afib but not on coumadin, INR wnl on presentation. Her hemolysis labs were negative. IR and surgery evaluated the pt and noted no acute intervention needed to be taken. She was transfused a total of 3U PRBCs with good effect. She was restarted on aspirin therapy. Oncology team's plan is to stop sutent and start pt on sorefenib as an outpatient. . #SHORTNESS OF BREATH - pt reported 3 days of increasing DOE on admission with oxygen saturation in the high 90s on 2L NC. This was felt to be due to acute severe anemia. Her SOB improved after blood transfusions. Her EKG was significant for new TWI on ECG and slightly deeper 1mm ST dep in lateral leads which was felt to be due to demand ischemia in the setting of her acute anemia. Her cardiac enzymes were negative times three. . # GIST: Patient with hx of GIST s/p incomplete resection in [**2143**] and omental resections in 3/[**2153**]. Intermittently treated with gleevac now on low dose sutent. The sutent was initially held on admission. Heme/onc was consulted for further recommendations an decided to stop sutent and start pt on sorafenib after discharge. # ARF: Cr at 1.5 on admission above b/l 1.1-1.2. Improved after PRBC transfusions back to her baseline. . #Pruritic rash: initially thought to be due to transfusion reaction from [**4-15**], unusual that it was initially persistent. No hives seen, rash was generalized erythema. No new medications. ? Malignancy related. ?chemo related. Bilirubin was normal. Pt was given benedryl and sarna lotion prn with good effect. This resolved. . CHRONIC/INACTIVE ISSUES: # Paroxysmal AFib: Given h/o bleeding, pt is no longer on warfarin, on ASA only. We continued ASA but held Diltiazem in the setting of acute bleed. Diltiazem was restarted on the medical floor. Need to address whether the benefits of ASA outweight the risks in this patient. . #HTN: Stable. Takes 180mg diltiazem ER at home. Thus far normotensive. Diltiazem was held in setting of actue bleed but restarted on the floor. . #Hypothyroidism: Continued home synthyroid. . #DM: placed on insulin sliding scale. Pt can resume Januvia upon discharge. Medications on Admission: diltiazem 180mg ER daily Am furosemide 60mg daily levothyroxine 200mcg daily oxycodone - unclear if currently taking - rx is for 5mg q4-6hrs for pain prn sitagliptin 100mg tab daily sunitinib 25mg daily timolol 0.5% drops right eye [**Hospital1 **] zolpidem 10mg qhs prn insomnia asa 81mg daily docusate senna Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic Left eye qhs (). 7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 8. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 9. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Family Care Extended Discharge Diagnosis: acute blood loss anemia due to intraperitoneal bleeding GI stromal tumor with metastasis atrial fibrillation DM type II hypothyroidism chronic diastolic heart failure hypertension 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 with weakness and found to have anemia. You had a CT scan of your abdomen that showed recurrence of bleeding from your cancer. For this, you were initially evaluated in the ICU and given blood transfusions. Your anemia improved and your aspirin was restarted. . Medication changes: lasix and Januvia were stopped but you can restart them at home tomorrow. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: [**Hospital3 249**] With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD When: MONDAY [**2154-4-22**] at 3:40 PM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in the next week. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call [**Telephone/Fax (1) 11133**] Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2154-5-1**] at 3:00 PM With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2154-5-8**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2154-5-29**] at 2:35 PM With: [**Name6 (MD) 13757**] [**Name8 (MD) 13758**], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2154-4-18**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12501, 12552

8540, 10706

321, 328

12776, 12776

4893, 8517

13448, 15355

4272, 4343

11630, 12478

12573, 12755

11295, 11607

12959, 13239

4358, 4874

13259, 13425

265, 283

356, 2799

10723, 11269

12791, 12935

2821, 4064

4080, 4256

30,713

169,358

33041

Discharge summary

report

Admission Date: [**2129-2-23**] Discharge Date: [**2129-3-7**] Date of Birth: [**2094-12-18**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: increasing back pain and leg numbness Major Surgical or Invasive Procedure: Thoracic fusion with posterior instrumentation and anterior reconstruction with Harms cage History of Present Illness: HPI:34yo M known to our service followed for Pott's disease of the thoracic spine. He had CT guided bx showing AFB growing in culture. He has been treated with TLSO brace and multiple antibxs per ID. He fevers have been gone for several days but he has had increasing back pain and left anterior thigh numbness and now right anterior thigh numbness. Denies weakness or bowel/bladder dysfxn. (Last BM 2 days ago). Dr [**Last Name (STitle) 548**] had planned elective two staged anterior/posterior stabilization with instrumented fusion but due to his progression of symptoms and worsening pain will be admitted for pain management and surgery. Past Medical History: PMHx: none Social History: Social Hx: no smoking, chews tobacco [**12-29**] can per day, occasional EtOH, no illegal drug use Family History: Family Hx: no history of heart disease, no history of cancers Physical Exam: PHYSICAL EXAM: O: T:afrb BP:100/60 HR: 96 R12 Gen: WD/WN, obvious discomfort with any motion, wearing TLSO. appears thinner than last visit Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G Sensation: Decreased to light touch anterior thigh bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 3 2 Left 2 2 2 3 2 No clonus bilaterally Pertinent Results: [**2129-2-23**] Thoracic CT: continued progression of compression of T11 vertebral body. [**2129-2-23**] 04:50PM GLUCOSE-130* UREA N-7 CREAT-0.6 SODIUM-136 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16 [**2129-2-23**] 04:50PM ALT(SGPT)-66* AST(SGOT)-64* LD(LDH)-131 ALK PHOS-233* TOT BILI-1.2 [**2129-2-23**] 04:50PM ALBUMIN-3.9 CALCIUM-9.3 PHOSPHATE-3.8 MAGNESIUM-2.1 [**2129-2-23**] 04:50PM WBC-8.8 RBC-4.29* HGB-11.2* HCT-34.0* MCV-79* MCH-26.0* MCHC-32.8 RDW-14.9 [**2129-2-23**] 04:50PM PLT COUNT-408 [**2129-2-23**] 04:50PM PT-15.2* PTT-33.5 INR(PT)-1.3* Brief Hospital Course: Pt was seen in clinic and admitted for worsening pain and numbness bilat thighs. CT done showed progressive compression of vertebral body. Pt was admitted, pain medication was increased and ID was consulted. He was readied for the OR and on [**2129-2-28**] brought to OR where under general anesthesia he underwent thoracic fusion with posterior instrumentation and anterior reconstruction with Harms cage. He tolerated this procedure well with intraop transfusions and placement of JP drain. He was remained intubated and transferred to ICU. Post op he was able to move lower extremities. He failed extubation initially but by POD#2 was able to be extubated. His mental status was decreased from pre-op, head CT done was wnl. By POD3 his mental status was at baseline. His drain was removed post op day #2. His hematocrit was followed and stable. PTT was elevated and SQ heparin was held. He was transferred to floor POD#4, diet and activity were advanced. Incision was CDI. Xrays standing were done and showed good alignment and hardware position. PT/OT were consulted and cleared him to be safe at home. On the day of discharge (POD#8) the patient was afebrile, vital signs stable and able to ambulate, pain was controlled. Medications on Admission: INH 300 mg daily Rifampin 600 mg daily Ethambutol 1200 mg daily Pyrazinamide 1500 mg daily Vit B6 50 mg daily oxycontin 20mg [**Hospital1 **] oxycodone for breakthrough Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take while on pain medication. Disp:*60 Tablet(s)* Refills:*1* 2. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pyrazinamide 500 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Ethambutol 400 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). 7. Oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as needed for pain: do not drive, do not drink alcohol, take a stool softener. Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0* 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed: This is for breakthrough pain. do not drink alcohol, do not drive, take a stool softener while taking this. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pott's disease thoracic spine Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ daily showers ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: PLEASE RETURN TO THE OFFICE IN 3 DAYS FOR REMOVAL OF YOUR STAPLES/SUTURES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT BE SURE TO tell the office that.

[ "305.1", "336.9", "015.04", "730.88", "013.54", "730.08", "737.43" ]

icd9cm

[ [ [] ] ]

[ "03.4", "80.51", "77.79", "77.69", "84.51", "81.05", "81.63" ]

icd9pcs

[ [ [] ] ]

5077, 5083

2628, 3872

357, 450

5156, 5180

2024, 2605

6558, 6837

1292, 1356

4098, 5054

5104, 5135

3899, 4075

5204, 6535

1386, 1638

280, 319

478, 1124

1653, 2005

1146, 1159

1175, 1276

27,676

197,898

48805+59116

Discharge summary

report+addendum

Admission Date: [**2155-8-24**] Discharge Date: [**2155-9-4**] Date of Birth: [**2091-4-9**] Sex: M Service: SURGERY Allergies: Penicillin G / Codeine Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP x 2 Cholecystectomy History of Present Illness: 64 yo M arrived via EMS for nausea, vomiting, diarrhea, chills and diffuse abdominal pain since 9 pm. Past Medical History: intraductal papillary mucinous tumor(based on MRI) cirrhosis(based on MRI) HTN arthitits s/p appy a/p c3-6 laminectomy Social History: single, employed, non-smoker, no EToH Family History: non contributory Physical Exam: PE at admission: Temp: 98.1 HR 96 BP 63.30 RR 18 O2 95% RA GEN: AOx3 HEENT: anictoric, neck supple Resp: CTAB CV s1/s2, no murmer GI + BS, ND, diffuse epigastric, RUQ > LUQ painful to palpation ext: no edema, mottled skin: clear but exts. mottled Neuro: nl speech psych: appropriate PE at discharge: Temp: 98.7, HR 60 BP 130/7 RR 16 O2 97% on RA Gen: AOx3 HEENT: PERRLA CV: RRR Pulm: CTAB AB: + BS, slightly distended, slightly tender, obese abdomen. Infraunbilical and RUQ incisions closed with staples - no erythema or drainage EXT: DP pulses 2+, no edema Skin: no rash, no jaundice Neuro: nl speech psych: appropriate Pertinent Results: [**7-25**] Liver US 1. Cholelithiasis without ultrasound criteria for acute cholecystitis. No intrahepatic duct dilatation. 2. Limited examination of the pancreatic head appears unremarkable [**7-25**] CT ab pelvis 1. Mesenteric fat stranding around the pancreatic head with associated thickening of the wall of the second portion of the duodenum. These findings may be consistent with acute pancreatitis. Evaluation is limited to the absence of intravenous contrast. No pseudocyst formation or peripancreatic fluid 2. Numerous pancreatic calcifications consistent with chronic pancreatitis. 3. Bilateral renal cortical hypodensities better assessed on the prior study that was performed with the IV contrast, too small to characterize but most likely representing cysts. 4. Small pericardial effusion. 6. Fat-containing inguinal hernias bilaterally. 7. Cirrhotic liver. [**7-25**] ab fluoro FINDINGS: Five fluoroscopic images were obtained by the clinical service, without a radiologist present. These images demonstrate opacification of the biliary tree, which is normal in caliber and contour, without definite filling defect. Final images demonstrate passage of a balloon catheter. Please refer to the clinical notes to determine whether any stones or sludge were extracted. [**7-27**] ERCP Small filling defect noted in the middle CBD suggestive of stone/sludge, which was extracted during ERCP [**2155-8-24**] 12:58PM ALT(SGPT)-157* AST(SGOT)-179* ALK PHOS-126* AMYLASE-1653* TOT BILI-4.0* [**2155-8-24**] 12:58PM LIPASE-2786* [**2155-8-24**] 12:58PM WBC-20.9* RBC-3.18* HGB-10.8* HCT-30.0* MCV-94 MCH-33.8* MCHC-35.8* RDW-14.5 8/48/07 ALT: 37 AST: 54 AP 92 T bili 1.4 Brief Hospital Course: In ER, pt was hypotensive and believe to be septic, so central line was placed, and abx were started - levofloxacin, vancomycin and flagyl. Pt admited to SICU where he was felt to have ascending cholangitis. He was intubated for airway control peri-procedurally and because he was felt likely to deteriorate rapidly. The GI/ERCP service was consulted and a request made for emergent ERCP with drainage. GI: ERCP on [**8-25**] showed a single stone in the mid/distal CBD, and a biliary stent was placed. LFT's, amylase, lipase, and bilirubin, which were rising upon admission, plateaued. A second ERCP was done on [**8-27**] which removed the stent as well as a small stone and sludge. A sphincterotomy was also performed. The LFT's thereafter fell steadily throughout hospital course. Pt continuted to improve and began regular diet on [**8-28**]. On [**9-1**] Cholecystecomty was begun as laproscopic procedure but converted to open due to difficulty removing the fundus of the gallbladder from the cirrhotic liver bed. Intra-operatively, the liver showed extensive macronodular cirrhosis, and the gallbladder was packed with faceted stones. Post-op, the patient was again advanced to regular diet. Phenergan and zofran were given for mild nausea, without emesis. Pt currently passing flatus. Resp: Pt initially intubated secondary to sepsis and emergent ERCP, and was extubated [**8-26**] with no complications. Used occasional albuteral nebulizer treatments for 2 days after extubation, then had no further respiratory issues. CV: Initially hypotensive likely due to sepsis. Quickly recovered, with no further cardiac issues. GU: Foley placed initially and removed without event. pt urinating appropriately MS: Pt with increased generalized weakness, but making substanstial improvement with PT and OT treatment. Walked several yards today, and will be discharged home with home pt services to continue to improve strength. Will need to go home with ambulance and walker. ID: pt placed on 10 day course of levo and flagyl for cholecycstitis, ending on [**9-4**]. Currently afebrile Medications on Admission: HCT 25', lisinopril 10, prilosec 20'', fluoxetine 20', V b12' Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Tablet(s) 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Ondansetron 4 mg IV Q8H:PRN nausea 10. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for cough. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Ascending cholangitis Septic shock Cholecystitis Cholelithiasis Pancreititis intraductal papillary mucinous tumor Cholecystitis Cholelithiasis Pancreititis intraductal papillary mucinous tumor Cholecystitis Cholelithiasis Pancreititis intraductal papillary mucinous tumor Cholecystitis Cholelithiasis Pancreititis intraductal papillary mucinous tumor Cholecystitis Cholelithiasis Pancreititis intraductal papillary mucinous tumor Discharge Condition: Stable Discharge Instructions: Please return to the hospital if you experience fevers greater then 101.4, chills, or other signs of infection. Also return to the hospital if you experience chest pain, shortness of breath, redness, swelling, or purulent discharge from the incision site. Return if you experience worsening pain or any other concerning symptoms. Certain pain medications may have side effects such as drowsiness. Do not operate heavy machinery while on these medications. Certain pain medications such as percocet or codeine can cause constipation. If needed you can take a stool softner such as Colace (one capsule) or gentle laxative (such as Milk of Magnesia) once per day. Restart taking all your regular medications once you arrive at home. Please follow-up as directed. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 10 days. Call to make an appointment: [**Telephone/Fax (1) 6429**] Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] as needed for results of liver biopsy. [**Telephone/Fax (1) 68666**] Name: [**Known lastname 16555**],[**Known firstname **] Unit No: [**Numeric Identifier 16556**] Admission Date: [**2155-8-24**] Discharge Date: [**2155-9-4**] Date of Birth: [**2091-4-9**] Sex: M Service: SURGERY Allergies: Penicillin G / Codeine Attending:[**First Name3 (LF) 9036**] Addendum: Spoke with pt's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16557**]. Will emphasize to patient to return to his home medicines. Also, instructed pt to return in 2 weeks for repeat chem 7 and cbc - to be followed up by Dr. [**Last Name (STitle) 16557**]. Dr. [**Last Name (STitle) 16557**] also will follow up the liver biospy and facilitate futher eval and treatment for his cirrhosis. Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA [**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**] Completed by:[**2155-9-4**]

[ "995.92", "V64.41", "571.5", "576.1", "785.52", "401.9", "038.9", "577.0", "574.60" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "51.22", "51.87", "51.85", "51.88", "50.12", "97.55" ]

icd9pcs

[ [ [] ] ]

8636, 8853

3065, 5166

295, 322

6757, 6766

1349, 3042

7577, 8613

668, 686

5278, 6199

6300, 6736

5192, 5255

6790, 7554

701, 993

1007, 1330

241, 257

350, 453

475, 596

612, 652

79,976

193,620

36235

Discharge summary

report

Admission Date: [**2178-6-4**] Discharge Date: [**2178-6-18**] Date of Birth: [**2121-9-7**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7729**] Chief Complaint: PREOPERATIVE DIAGNOSIS: 1. Squamous cell carcinoma right anterior oral tongue with extension into the floor of mouth, T3N2CM0. 2. Bilateral metastatic squamous cell carcinoma to the neck. Major Surgical or Invasive Procedure: [**2178-6-4**] 1. Laryngoscopy. 2. Rigid esophagoscopy. 3. Bilateral modified radical neck dissection. 4. Subtotal glossectomy. 5. Tracheostomy. 6. Right anterior lateral thigh free flap to the oral cavity and the floor of mouth and tongue defect. 7. Split-thickness skin graft measuring 10 cm x 6 cm to the right anterior thigh from the left thigh region. 8. Reconstruction of oral cavity. [**2178-6-5**] 1. Flap exploration. 2. Pectoralis flap reconstruction of oral cavity. [**2178-6-7**] Bronchoscopy [**2178-6-8**] Bronchoscopy [**2178-6-15**] 1. PEG tube placemeny by IR History of Present Illness: Mr. [**Known firstname 47104**] [**Known lastname 82152**] is a 56-year-old man with squamous cell carcinoma of the tongue with neck metastasis. He was seen by Dr. [**Last Name (STitle) 1837**] regarding the management of his disease. PREOPERATIVE DIAGNOSIS: 1. Squamous cell carcinoma right anterior oral tongue with extension into the floor of mouth, T3N2CM0. 2. Bilateral metastatic squamous cell carcinoma to the neck. Past Medical History: No other medical issues. CURRENT MEDICATION: Morphine 15 mg tablet. One tablet by mouth every 4-6 hours as needed for pain. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient works as a butcher and is accompanied by his sister. [**Name (NI) **] has been smoking half pack per day since age 12. He does drink alcohol. FAMILY HISTORY: No known family history of cancer. Social History: SOCIAL HISTORY: The patient works as a butcher and is accompanied by his sister. [**Name (NI) **] has been smoking half pack per day since age 12. He does drink alcohol. Family History: FAMILY HISTORY: No known family history of cancer. Physical Exam: Vitals: T- 96.8 100/50 62 16 100% RA General: A thin appearing gentleman, NAD, awake and alert HEENT: Face symmetric. Extraocular movements intact. On oropharynx examination, patient with viable flap. Neck incision Clean, dry and intact. Right neck drain in place. Lungs: Clear to auscultation bilaterally. Incision on right pectoral region. Abdomen: Soft, NT, ND, g tube in place left region. Cardiovascular: Regular rate and rhythm. S1 and S2, no murmurs. Extremities: Warm and symmetric pulses, equal strength bl, no weakness, Right thigh incision CDI Neurologic: Normal gait, CNII-XII intact. Pertinent Results: [**2178-6-14**] Hct-30.7* [**2178-6-8**] 12:34PM BLOOD Hct-23.8* [**2178-6-8**] 03:15AM BLOOD Hct-19.9* [**2178-6-7**] 03:10AM BLOOD Hct-26.2* [**2178-6-5**] 02:21AM Hct-34.2* Brief Hospital Course: Patient is a 56 y/o Portuguese speaking male with right floor of the mouth and tongue ca who underwent a radical neck dissection with partial glossectomy, trach and ALT free flap reconstruction on [**2178-6-5**]. Patient tolerated the procedure well and was admitted to the SICU for )@ monitoring and flap checks overnight. On post op day 2, patient was taken back to the OR for a failing flap on [**2178-6-6**]. Patient underwent a pectoralis rotational flap reconstruction. Patient once again tolerated the procedure well and was returned to the SICU for observation. The remainder of the summary will be in systems: Neurologic: Patient sedated 24 hrs post-op as per plastics. Patient on Midazolam and fent gtt. Patient weaned off of sedation begining [**2178-6-8**]. Patient finally off of sedation on [**2178-6-11**]. Patient given dialuded PCA for pain, and ativan prn for anxiety. Patient weaned off of Dilauded pca and placed on po pain meds [**2178-6-13**]. Cardiovascular: Patients with no cardiac issues Pulmonary: Patient with trach placed perioperatively. Patient placed on vent post operatively and monitored in the ICU. Collapse R lung was diagnosed with mucous plugging, resolved with bedside bronch. Patient underwent [**Last Name (un) 1066**] on [**6-7**] and [**6-8**]. Patient weaned off of vent and placed on trach mask on [**2178-6-11**]. Patient's trach down sized on [**2178-6-15**] and decannulated on [**2178-6-16**]. Gastrointestinal: Patient placed on pepcid. Dobhoff placed post operatively for feeding perioperatively. On [**2178-6-15**] patient underwent PEG placement by interventional radiology. Dobhoff removed and tube feeds started on [**2178-6-16**]. Nutrition: Patient on tube feeds and IVF while in ICU. Patient started on 5 cans of Replete with fiber once g tube placed. Nutrition was consulted and patient given 5 cans (1200 calories) per day. Speach and swallow was consulted and patient underwent video swallow. Patient allowed to have puree solids and nectar thick liquids. Patient advised to have po meds crushed. Hematology: Patient with HCT of 34.2 post operatively in the ICU. HCT levels trended down during his ICU stay and came down to 25.6. Patient given 2 units of PRBC and HCT came back to 27.4. Patient leave the hospital with last HCT of 30.7 on [**2178-6-14**]. Infectious Disease: Patient placed on Unasyn for prophylaxis while drain were in place. Patient discharged home on Duricef for two weeks with drain X1 in place. Musculoskeletal: Patient seen and evaluated by physical therapy. Patient with several sessions with physical therapy. Physical therapy cleared patient for discharge to home with family and services. Medications on Admission: None Discharge Medications: 1. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day for 14 days: Please take one tablet twice a day for two weeks or until follow up appointment. Disp:*28 Capsule(s)* Refills:*0* 2. Roxicet 5-325 mg/5 mL Solution Sig: One (1) teaspoon PO every four (4) hours as needed for pain for 5 days: Please take one teaspoon of Roxicet every four hours as needed for pain. Disp:*300 ml* Refills:*0* Discharge Disposition: Home With Service Facility: CareGroup VNA Discharge Diagnosis: 1. Squamous cell carcinoma right anterior oral tongue with extension into the floor of mouth, T3N2CM0. 2. Bilateral metastatic squamous cell carcinoma to the neck. Discharge Condition: Stable Discharge Instructions: Please refrain from strenous activity and heavy lefting. Please avoid any excessive pressure strain on right neck area. Patient should keep incisons clean and dry. Trach site should have dressing changed on a daily basis. Gtube site should be monitored and have daily tube site care. Please follow up with Dr. [**Last Name (STitle) 1837**] in clinic for post operative follow up. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1837**] On Friday [**6-26**]. Patient is to call the clinic to confirm appointment.([**Telephone/Fax (1) 21740**] Please follow up with Dr. [**First Name (STitle) **] (plastic surgery)within two weeks. Please call the plastic surgery clinic to make an appointment. ([**Telephone/Fax (1) 9144**] Please follow up with a nutritionist in four to six weeks to start weaning tube feeds. Please cal ([**Telephone/Fax (1) 7026**]

[ "196.0", "305.1", "599.70", "141.4", "998.11", "E878.6", "996.79", "458.29", "997.39", "144.9", "518.0", "525.50", "285.1", "525.10" ]

icd9cm

[ [ [] ] ]

[ "86.09", "96.6", "25.59", "27.59", "25.2", "34.04", "43.11", "31.42", "99.04", "42.23", "27.57", "86.69", "87.61", "40.42", "33.21", "96.72", "31.1", "27.56" ]

icd9pcs

[ [ [] ] ]

6285, 6329

3093, 5806

516, 1106

6545, 6554

2889, 3070

6987, 7465

2208, 2245

5861, 6262

6350, 6524

5832, 5838

6578, 6964

2260, 2870

280, 478

1134, 1569

1591, 1756

2017, 2175

8,784

176,179

28277

Discharge summary

report

Admission Date: [**2155-9-21**] Discharge Date: [**2155-9-27**] Date of Birth: [**2121-12-20**] Sex: F Service: MEDICINE Allergies: Cefaclor / Morphine Sulfate / Cephalosporins / Penicillins / Carbapenem Attending:[**First Name3 (LF) 943**] Chief Complaint: 1. Transfer from OSH with acute hepatitis. 2. Presentation to OSH with nausea, vomiting, abdominal pain, and malaise. Major Surgical or Invasive Procedure: 1. Left Internal Jugular Central Line Placement. 2. Endoscopic Gastroduodenoscopy. History of Present Illness: 33F s/p [**2137**] renal transplant [**2-13**] HSP, [**2146**] R nephrectomy for renal CA, chronic immunosuppression, recurrent pancreatitis, gallstone disease, pancreas divisum, and hypertension, who is transferred from MICU following admission for acute hepatic failure. Ms. [**Known lastname **] initially presented to an OSH on [**2155-9-19**] with nausea, vomiting, abdominal pain, and malaise. Symptoms began with sore throat and malaise and progressed to RUQ pain associated with nausea and vomiting. Noted to have transaminitis with AST 1478 and ALT 350 (83 and 31 on [**9-8**]). The following day AST was [**Numeric Identifier **] with ALT 2470. INR was elevated to 6.4. Laboratories also noted for metabolic acidosis (non AG, bicarb 17) and elevated creatinine (2.1, baseline 1.3) The patient was fluid resuscitated and given vitamin K for reversal of coagulopathy. Imaging of abdomen consistent with necrotic changes concerning for liver failure (report unavailable). Pt had been on trazodone and effexor which was held out of concern for liver toxicity. . The patient reports she has taken Tylenol almost every day for 10 years because of headaches. She says she has been taking less of this lately. She also denies recent alcohol use but says she previously used to drink quite a bit of alcohol a few months ago. She denies any sick contacts. Had never been tested for HIV, not currently sexually active. Denies any kind of mushroom ingestion. Main complaints were RUQ pain. No fevers, denies abd swelling, pruritus, no increased confusion. Past Medical History: 1) S/p Cadaveric renal transplant in [**2137**] for renal failure secondary to Henoch-Schonlein Purpura. Had R nephrectomy after developing renal cancer in [**2146**], L nephrectomy in [**2149**] prophylactically. Baseline Cr 1.2-1.3, on Imuran, Cyclosporine, and Prednisone since [**2146**]. 2) Recurrent pancreatitis, last attack in [**7-/2155**], common bile duct stone seen at that time, not confirmed by ERCP. Attack resolved with fluids and pain control. 3) Pancreas divisum 4) Hypertension 5) Headaches, has taken Tylenol 6) Depression 7) Anxiety Medications Social History: Used to drink heavily a few months ago, pt could not quantify). Denies tobacco and illicit drug use. Single, works as secretary. Not currently in relationship, not sexually active. Family History: Notable for diabetes in both sides of family. No known renal, liver, or autoimmune disease. Physical Exam: T: 97.7 P: 77 BP: 124/79 RR: 18 O2: 94% 2L NC Gen: WD, obese female Caucasian, anxious but NAD HEENT: Scleral and sublingual icterus, PERRL, EOMI, dry MM, no lesions Neck: No LAD appreciated. No TM, trachea midline. Chest: Lungs with decreased breath sounds at bases, otherwise CTAB. Heart: RR, S1S2, no murmur, rub or gallop Abd: Obese, tender in RUQ, epigastric region, periumbilical region. No rebound or guarding. Graft site without tenderness or erythema. Liver edge palpable 2cm below costal margin Ext: No edema, 1+ distal pulses Neuro: A&Ox3, no asterixis Pertinent Results: EGD [**2155-9-25**] Impression: Erythema and congestion in the antrum (biopsy) Otherwise normal EGD to second part of the duodenum. . CT abdomen with contrast [**2155-9-24**]: IMPRESSION: 1) Likely focal fat within the peripheral aspect of segment [**Doctor First Name **]/B of the liver; if warranted it cvould be definitively characterized by MRI. No other focal hepatic abnormalities or CT findings to explain the patient's acute hepatic failure. 2) Bibasilar atelectasis. 3) Normal appearing right lower quadrant transplant kidney. . . Cardiac ECHO [**2155-9-23**]: Conclusions: 1. The left atrium is mildly dilated. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. LABS: [**2155-9-21**] 02:37PM BLOOD WBC-8.4 RBC-3.10* Hgb-10.5* Hct-30.5* MCV-98 MCH-34.0* MCHC-34.5 RDW-13.9 Plt Ct-148* [**2155-9-27**] 07:40AM BLOOD WBC-5.5 RBC-2.96* Hgb-10.1* Hct-30.2* MCV-102* MCH-34.2* MCHC-33.6 RDW-15.0 Plt Ct-234 . [**2155-9-21**] 02:37PM BLOOD PT-20.6* PTT-22.2 INR(PT)-2.0* [**2155-9-27**] 07:40AM BLOOD PT-13.3* PTT-22.0 INR(PT)-1.2* . [**2155-9-21**] 02:37PM BLOOD Glucose-214* UreaN-18 Creat-1.3* Na-139 K-2.9* Cl-101 HCO3-24 AnGap-17 [**2155-9-27**] 07:40AM BLOOD Glucose-93 UreaN-19 Creat-1.2* Na-139 K-3.7 Cl-107 HCO3-24 AnGap-12 . [**2155-9-21**] 02:37PM BLOOD ALT-[**2085**]* AST-3942* LD(LDH)-824* AlkPhos-105 Amylase-79 TotBili-5.2* [**2155-9-27**] 07:40AM BLOOD ALT-214* AST-58* AlkPhos-111 Amylase-94 TotBili-2.3* . [**2155-9-21**] 02:37PM BLOOD Lipase-198* [**2155-9-27**] 07:40AM BLOOD Lipase-103* Brief Hospital Course: In the MICU, Ms. [**Known lastname **] was supported medically. IV fentanyl and anzemet were given for pain and nausea management, respectively. She was started on prophylactic Levofloxacin and given lactulose to prevent hepatic encephalopathy. RUQ U/S was done, which confirmed increased liver echogeneity, but saw no focal lesions, and found normal flow patterns. Viral hepatitis panel was negative for HCV Ab, HBSAg, and HBCAb. EBV was IgG positive, IgM negative. HIV Ab test drawn, pending at time of transfer. Neuro exam and FS were frequently monitored. She was followed by transplant surgery and liver team. Imuran was d/c'ed due to possible hepatotoxic effects. During MICU stay, LFTs and INR consistently trended down. She did experience some ARF on CRI, with creatinine peak 2.1 from baseline 1.3. back to 1.4 at time of transfer. She was transferred to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for further management. . While on the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service the patient continued to have biochemical resolution of her hepatitis, renal insufficiency and a brief elevation of pancreatic enzymes. The patient did continue to to have abdominal pain for which a diagnositc evaluation was performed, consisting of a CT-scan and an EGD. Neither of these tests revealed a definitive etiology. The patient's symptoms spontaneously resolved and she was discharged with follow up with her gastorenterologist in [**Location (un) **]. Medications on Admission: Cyclosporine 175 twice daily Imuran 100 mg daily Prednisone 50 mg every other day Procardia XL 60 daily Effexor XR 225 daily Trazodone 50 mg qHS Ativan 0.5 mg [**Hospital1 **] prn anxiety prn Tylenol Pancrease Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as directed Injection ASDIR (AS DIRECTED): as directed. 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule, Delayed Release(E.C.) Sig: ASDIR Cap PO QIDWMHS (4 times a day (with meals and at bedtime)): Please take this medication as originally prescribed. . 5. Cyclosporine 100 mg Capsule Sig: 1.75 Capsules PO Q12H (every 12 hours) as needed for Renal transplant. 6. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*10 Tablet(s)* Refills:*0* 7. Prednisone 20 mg Tablet Sig: 2.5 Tablets PO EVERY OTHER DAY (Every Other Day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Please note that this is a narcotic and addiction is a risk of this medication. Try to limit use. . Disp:*30 Tablet(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: Please discuss the utility of this medication with your gastroenterologist. . Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Three (3) Capsule, Sust. Release 24HR PO DAILY (Daily). 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Please take for stool softening while on percocet for pain management, as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 14. Cyclosporine 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) as needed for Renal transplant: Please take with 25mg capsule to total 125mg twice daily. Disp:*10 Capsule(s)* Refills:*0* 15. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours: Please take with 100mg capsule to total 125mg twice daily. Disp:*10 Capsule(s)* Refills:*0* 16. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:*12 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hepatititis of indeterminant etiology. . Secondary Diagnosis: 2. S/P Kidney Transplant. 3. Pancreas Divisum 4. Hypertension 5. Headaches 6. Depression. 7. Anxiety. Discharge Condition: Stable. Pain well controlled on percocet. Hepatic transaminases are trending down, nearly normalized. Ambulating without difficulty. Discharge Instructions: Please return to the hospital if you have nausea, vomiting, especially if there is blood in your vomit, fevers, chills, abdominal pain, diarrhea, especially if there is blood in your stool or if your stool is black and tarry. Also please return if you notice that the white's of your eyes are turning yellow. Please take your medications as prescribed. Please note that your blood pressure was stabilized while in the hospital on a medication that was different than what you were taking before you came in. We would like you to continue on the Amlodipine and to discontinue the Procardia (nifedipine). Please note that we will be sending you home with narcotics (Percocet - oxycodone/acetaminophen)to treat your pain. There is a risk of addiction to this medication so please to try to limit the use as much as possible. Followup Instructions: Please follow up with your gastroenterologist, Dr [**Last Name (STitle) 12262**] in [**Location (un) **]. Please call on monday morning ([**2155-9-29**]) to schedule an appointment to see him within the next week. Please inform him of the decrease in dose of your Imuran to 50mg daily. Completed by:[**2155-9-28**]

[ "996.81", "285.21", "584.9", "401.9", "V10.52", "300.4", "570", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "45.16", "38.93" ]

icd9pcs

[ [ [] ] ]

9295, 9301

5248, 6751

452, 537

9531, 9669

3619, 5225

10549, 10868

2926, 3019

7012, 9272

9322, 9322

6777, 6989

9693, 10526

3034, 3600

293, 414

565, 2121

9406, 9510

9341, 9385

2143, 2711

2727, 2910

46,820

148,749

42598

Discharge summary

report

Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-17**] Date of Birth: [**2046-10-9**] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 2297**] Chief Complaint: altered mental status, hypoxemic respiratory distress Major Surgical or Invasive Procedure: [**2109-11-13**] left sided thoracentesis [**2109-11-13**] endotracheal intubation [**2109-11-13**] trauma central line placed History of Present Illness: Ms. [**Known lastname **] is a 63 F with history Etoh cirrhosis who was initially transferred from [**Hospital3 **] Hospital with altered mental status. At the OSH, labs notable for WBC of 5.8, Tbil of 14.8. A CT torso without IV contrast was performed and showed a large left pleural effusion with white out of the left lung, ascites and diffuse wall thickening of the terminal ileum and right colon and was tranferred to [**Hospital1 18**] for further care. . Initially in the ED, VS: 101.0 103 103/51 16 95% 2L Nasal Cannula. A diagnostic para revealed 9000 WBC with 67% polys. UA was mildly positive. She was given 1gram of ceftriaxone for SBP and to cover for a UTI. Also got 3L NS. CXR showing white out of the left lung with shift of mediastinal structures to the right. Blood, urine, and peritoneal cultures were sent. The patient was seen by transplant surgery and was thought that she had SBP vs. secondary bacterial peritonitis. Was continued on Ceftriaxone. . Overnight, the patient pulled out one of her IVs and started bleeding out of her IV lines. She then started having respiratory distress during this episode. She was placed on right side, at which point she desatted to undetectable on 3LNC with 67% on NRB for approximately 3 min. Code Blue was called for emergent intubation which was done with etomidate and succinycholine without any complications. She was subsequently transferred to CCU under MICU [**Location (un) 2452**] team for further evaluation and management. . On arrival to the unit, the patient was intubated and sedated. Past Medical History: EtOH cirrhosis c/b esophageal varices EtOH abuse HLD HTN Depression Axiety Social History: Per report from OSH patient denies drinking since last [**Month (only) 956**]. Family History: nc Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL - Confused, somnolent but arousable and able to follow conmmands HEENT - NC/AT, PERRLA, EOMI, Icteric sclera, dry mucous membranse NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - Patient is poorly cooperative with exam. Right sides breath sounds intact with fine crackles at the bases. Left sided breath sounds diminished throughout. LHEART - RRR S1S2. 3/6 SEM loudeset at RUSB with radiation at the base. No radiation to axilla. ABDOMEN - Distended non-tender to deep palpation. No spider angiomata. No Caput madusa. EXTREMITIES - WWP, 2+ Pitting edema to the knees SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, AAOx 1 (name only) + Astrixes . DISCHARGE PHYSICAL EXAM expired Pertinent Results: ADMISSION LABS: [**2109-11-13**] 02:10AM BLOOD WBC-6.2 RBC-2.15* Hgb-8.2* Hct-23.4* MCV-109* MCH-37.9* MCHC-34.9 RDW-20.9* Plt Ct-73* [**2109-11-13**] 02:10AM BLOOD Neuts-85.3* Bands-0 Lymphs-8.8* Monos-5.3 Eos-0.4 Baso-0.2 [**2109-11-13**] 02:10AM BLOOD PT-25.6* PTT-40.8* INR(PT)-2.5* [**2109-11-14**] 06:20AM BLOOD Fibrino-110* [**2109-11-13**] 02:10AM BLOOD Glucose-87 UreaN-29* Creat-1.1 Na-129* K-5.0 Cl-96 HCO3-23 AnGap-15 [**2109-11-13**] 02:10AM BLOOD ALT-30 AST-125* AlkPhos-95 TotBili-14.7* [**2109-11-13**] 02:10AM BLOOD Lipase-40 [**2109-11-13**] 02:10AM BLOOD Albumin-2.6* [**2109-11-13**] 09:20AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8 [**2109-11-13**] 09:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2109-11-13**] 02:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2109-11-13**] 09:20AM BLOOD HCV Ab-NEGATIVE [**2109-11-13**] 02:13AM BLOOD Glucose-80 Na-129* K-4.0 Cl-98 calHCO3-23 [**2109-11-13**] 05:20AM BLOOD Lactate-1.9 [**2109-11-14**] 09:54AM BLOOD freeCa-1.10* . ICU LABS: [**2109-11-14**] 06:20AM BLOOD WBC-8.6# RBC-1.48*# Hgb-5.7*# Hct-16.7*# MCV-113* MCH-38.7* MCHC-34.3 RDW-20.7* Plt Ct-62* [**2109-11-16**] 04:09AM BLOOD PT-22.8* PTT-56.7* INR(PT)-2.2* [**2109-11-14**] 02:55PM BLOOD Fibrino-115* [**2109-11-15**] 03:57AM BLOOD Fibrino-157* [**2109-11-15**] 03:57AM BLOOD FDP-10-40* [**2109-11-16**] 04:09AM BLOOD Fibrino-144* [**2109-11-15**] 12:33PM BLOOD Glucose-120* UreaN-33* Creat-1.7* Na-133 K-3.8 Cl-103 HCO3-22 AnGap-12 [**2109-11-15**] 03:57AM BLOOD ALT-17 AST-51* LD(LDH)-353* AlkPhos-74 TotBili-16.6* DirBili-7.0* IndBili-9.6 [**2109-11-14**] 02:55PM BLOOD D-Dimer-[**Numeric Identifier **]* [**2109-11-16**] 01:13PM BLOOD Type-ART Temp-36.4 Rates-28/0 Tidal V-330 PEEP-8 FiO2-40 pO2-104 pCO2-33* pH-7.42 calTCO2-22 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [**2109-11-14**] 07:56AM PLEURAL WBC-3300* RBC-0 Hct,Fl-2.0* Polys-92* Lymphs-3* Monos-4* Macro-1* [**2109-11-14**] 07:56AM PLEURAL TotProt-1.4 Glucose-97 LD(LDH)-91 Amylase-16 Albumin-LESS THAN [**2109-11-13**] 02:30AM ASCITES WBC-9250* RBC-5200* Polys-67* Lymphs-0 Monos-31* Macroph-2* [**2109-11-13**] 02:30AM ASCITES LD(LDH)-90 Albumin-LESS THAN . MICRO: [**11-13**], [**11-14**] BLOOD CULTURES NO GROWTH TO DATE [**11-13**] PERITONEAL FLUID CULTURE AND GRAM STAIN NEGATIVE [**11-14**] PLEURAL FLUID CULTURE NO GROWTH TO DATE . IMAGING: [**11-14**] ECHO LEFT ATRIUM: Normal LA and RA cavity sizes. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. The IVC was not visualized. The RA pressure could not be estimated. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV cavity size. Normal regional LV systolic function. Hyperdynamic LVEF >75%. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Normal RV free wall thickness. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal descending aorta diameter. AORTIC VALVE: ?# aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild AS (area 1.2-1.9cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Suboptimal image quality - ventilator. Resting tachycardia (HR>100bpm). Ascites. Conclusions The left atrium and right atrium are normal in cavity size. The left ventricular cavity size is normal. Normal global and regional left ventricular systolic function. Right ventricular chamber size and free wall motion are normal. The right ventricular free wall thickness is normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular caivty size with mildly thickened inferolateral wall and preserved global and regional biventricular systolic function. Mild aortic stenosis, although in the setting of vigorous left ventricular systolic function its severity may be somewhat overestimated. At least moderate pulmonary artery systolic hypertension. . [**11-13**] CXR HISTORY: Feeding tube placement. FINDINGS: In comparison with the earlier study of this date, there has been placement of a feeding tube that extends to the distal stomach. Complete opacification of the left hemithorax is again seen, consistent with a large pleural effusion and collapse of the underlying left lung. Large opacification in the right upper abdomen most likely represents a laminated gallstone. . [**11-14**] CXR 3 AM INDICATION: Hypoxic respiratory failure, orogastric tube placement. FINDINGS: As compared to the previous radiograph, there is a massive change. The patient has been intubated. The tip of the endotracheal tube is located 2.5 cm above the carina. An additional nasogastric tube has been inserted. The course of the tube is unremarkable, the tip of the tube is not visualized on the image. There is unchanged complete opacification of the left hemithorax. However, massive alveolar opacities in the entire right hemithorax have newly appeared. These opacities could reflect bleeding, pneumonia, or acute pulmonary edema. There is mild-to-moderate volume loss of the right hemithorax. . [**11-14**] CXR 6 PM HISTORY: New OG tube placed. IMPRESSION: AP chest compared to [**11-13**] through [**11-14**], 8:28 a.m.: Nasogastric tube passes into the upper stomach and out of view. With the chin down, the ET tube ending no less than 2.5 cm from the carina is standard placement. Right jugular introducer ends in the upper SVC. Nasogastric tube ends in the region of the pylorus. Severe bilateral pulmonary consolidation, worse in the right lung, has not improved. The lung volumes are slightly better. At least small bilateral pleural effusions are present, increased on the left since the earlier examination. Heart size is normal. Mediastinal veins are dilated. I would have urged an upright chest radiograph to exclude the possibility of an anteriorly collected pneumothorax in the supine patient, but chest radiograph performed [**11-15**], 2:24 a.m., available at the time of this review, was performed with the patient in semi-erect and showed left pneumothorax is unlikely. . [**11-16**] CXR REASON FOR EXAMINATION: Followup of the patient with diffuse axonal hemorrhage. AP radiograph of the chest was compared to prior study obtained the same day earlier as well as several prior studies dating back to [**11-12**], [**2108**]. The left lung is grossly unremarkable within the limitations of the study technique although several pulmonary nodules are suspected and should be further evaluated with dedicated cross-sectional imaging since on the prior CT torso from [**2109-11-12**], the entire left lung was collapsed due to large amount of pleural effusion. On the right, there is slight improvement since yesterday of the extensive consolidation, but with still present multifocal nodular opacities, although overall the extent of the consolidation appears to be gradually improving. The ET tube tip is 2 cm above the carina. The NG tube tip is in the stomach. The right internal jugular line tip is at the level of superior SVC. Continued surveillance with radiographs is recommended. Brief Hospital Course: Ms. [**Known lastname **] is a 63 year old female with alcoholic cirrhosis initially presenting with altered mental status, then developed respiratory failure and found to have hepatic hydrothorax on imaging and abdominal sepsis as paracentesis with evidence of spontaneous bacterial peritonitis (SBP). . HOSPITAL COURSE BY PROBLEM: # Hypoxemic respiratory failure: On the floor, the patient was found to have large left sided pleural effusion, likely hepatic hydrothorax given her underlying cirrhosis. During the hospital stay, the patient had an acute desaturation that did not respond to nonrebreather therapy and ultimately required intubation. The etiology of this acute hypoxia is unclear, but her [**Name (NI) 65426**] were suggestive of pleural effusion but also an alveolar process. This alveolar process cleared up within a few hours, making diffuse alveolar hemorrhage or transfusion related lung injury a more likely cause of her acute hypoxemia, versus ARDS or an aspiration PNA. The patient was initially on 100% FiO2 and 16-20 of PEEP in order to maintain her oxygenation. She also underwent a left sided thoracentesis with removal of 3 L of fluid and an additional 1 L over the next two days to a drainage bag. The pleural fluid was transudative and had negative cytology. However, did not wean off the ventilator completely and her family decided to make her CMO and terminally extubate her as per her living will. . # Sepsis due to SBP: The patient had a diagnostic paracentesis done in the ED, consistent with SBP. Her CT abdomen showed edema of the bowel wall which could be ischemia or infection. However, this bowel wall edema in the setting of an elevated lactate, secondary peritonitis was also on the differential and the patient was being followed by transplant surgery. Before she decompensated, she was getting ceftriaxone 1 gram daily. After decompensation, she was broadly covered with vancomycin/pip/tazo/metronidazole, and this was continued until she was made CMO. The patient's living will stated that she would not want antibiotics. . # Decreased hematocrit: The day the patient was intubated, she also was found to have a crit drop from 23 to 16.7. A trauma line was placed and the patient was volume resucitated. Once stabilized, an EGD was done that showed no bleeding into the GI tract. It was thought that the crit drop may have gone into diffuse alveolar hemorrhage (as discussed above). . # Disseminate intravascular coagulopathy (DIC): Her sepsis developed into DIC with a low fibrinogen and continually rising Tbili and INR. She was treated with FFP for the thoracentesis and cryoglobulin to keep fibrinogen > 100. Her platelets stayed above 50 without transfusion. . # Altered mental status (AMS): Patient initially presented with AMS. This was thought opssibly related to hepatic encephalopathy vs. sepsis. Her toxicology screens were negative. The patient was initially on ceftriaxone for SBP treatment, and once she decompensated, her antibiotic coverage was broadened as above. She was also continued on lactulose/rifaxamin while in the hospital, titrating to [**2-1**] BMs daily. She was given albumin on the first and third day of SBP treatment. . # Acute kidney injury: Her creatinine increased and her urine output decreased to near anuria during the first day after hypoxemic respiratory failure. Her creatinine was slowly improving when she was made CMO. . # Alcoholic cirrhosis: The patient was continued on lactulose/rifaxamin for encephalopathy and SBP treatment as discussed above. Hepatology team was following with her and her hepatitis serologies were negative. She had reportedly been sober since the [**2109-1-1**]. . # Hyponatremia: Likley hypervolemic hyponatremia in the setting of cirrhosis. Urine Na <1, FeNa <1. Medications on Admission: Lasix Omeprazole Metoprolol Quinalapril Triamterene Spironolactone Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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icd9cm

[ [ [] ] ]

[ "34.91", "96.71", "54.91", "96.6", "38.97", "45.13", "96.04" ]

icd9pcs

[ [ [] ] ]

14834, 14843

10870, 11175

342, 470

14894, 14903

3088, 3088

14959, 14969

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12,978

188,496

28765

Discharge summary

report

Admission Date: [**2153-9-20**] Discharge Date: [**2153-9-29**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain, Dyspnea on Exertion Major Surgical or Invasive Procedure: [**2153-9-20**] Coronary Artery Bypass Graft x 4 (LIMA->LAD, SVG->OM, Diag, PDA), Atrial Septal Defect Closure History of Present Illness: 84 yoM with abnormal ETT, cath with 3VD. Past Medical History: Complete Heart Block s/p PPM [**2152**], ?SVT, Gout, s/p left Total Hip Replacement, s/p hernia repair, s/p l cataract surgery Social History: retired lives with wife no [**Name2 (NI) **] +etoh, stopped about 1 month ago Family History: NC Physical Exam: pleasant, NAD HR 71, BP 138/76 RR 18 Skin unremarkable HEENT unremarkable Neck supple, FROM, -JVD Lungs CTAB Heart RRR no M/R/G Abd Soft NT/ND +BS Extrem cool, 2+ edema, 2+femoral and radila pulses, 1+ DP&PT, no carotid bruits Pertinent Results: Echo [**9-20**]: Pre Bypass The left atrium is markedly dilated. There is a bidirectional shunt across the interatrial septum at rest. A small secundum atrial septal defect is present. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include mild to moderate hypokinesia of the basal, mid and apical portions of the inferior and inferolateral walls. The aortic root is mildly dilated. There are simple atheroma in the aortic root. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta and descending thoracic aorta. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Mild to moderate ([**2-12**]+)mitral regurgitation is seen. Post Bypass: Biventricular systolic function is unchanged. Mild Mitral regurgitation persists. Trivial left to right flow across the interatrial septum. CXR [**9-28**]: [**2153-9-20**] 12:50PM BLOOD WBC-11.4*# RBC-2.93* Hgb-9.2* Hct-26.3* MCV-90 MCH-31.4 MCHC-35.0 RDW-14.3 Plt Ct-138* [**2153-9-26**] 07:25AM BLOOD WBC-8.2 RBC-2.74* Hgb-8.6* Hct-25.2* MCV-92 MCH-31.5 MCHC-34.3 RDW-14.3 Plt Ct-348# [**2153-9-20**] 12:50PM BLOOD PT-17.0* PTT-38.4* INR(PT)-1.6* [**2153-9-21**] 03:08AM BLOOD PT-13.0 PTT-27.7 INR(PT)-1.1 [**2153-9-20**] 01:53PM BLOOD UreaN-13 Creat-0.7 Cl-110* HCO3-23 [**2153-9-26**] 07:25AM BLOOD Glucose-103 UreaN-16 Creat-1.1 Na-139 K-4.1 Cl-100 HCO3-31 AnGap-12 Brief Hospital Course: Mr. [**Known lastname **] was taken to the operating room on [**2153-9-20**] where he underwent a CABG x 4. Please see operative report for surgical details. He was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. He was transfused 2 units PRBCs for low HCT. On post-op day two he was seen by EP and his pacemaker was interrogated. EP continued to followe Mr. [**Known lastname **] during hospital course. His vasoactive drips were weaned off on post-op day two and he was tansferred to the SDU on post-op day three. Chest tubes were removed on post-op day two. Beta blockers and diuretics were intiated and he was gently diuresed towards his pre-op weight. Epicardial pacing wires were removed on post-op day four. Physical therapy followed patient during entire post-op period for strength and mobility. He continued to recover well and was discharged home in good condition with VNA services and the appropriate follow-up appointments. Medications on Admission: lasix, colchicine, asa 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 14 days. Disp:*60 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day for 2 weeks. Disp:*56 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease, Atrial Seotal Defect s/p Coronary Artery Bypass Graft x 4, ASD closure PMH: Complete Heart Block s/p PPM [**2152**], ?SVT, Gout, s/p left Total Hip Replacement, s/p hernia repair, s/p l cataract surgery Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No heavy lifting or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) **] (PCP/cardiologist) 2 weeks

[ "585.9", "427.31", "413.9", "414.01", "305.00", "996.01", "794.39", "274.9", "745.5" ]

icd9cm

[ [ [] ] ]

[ "99.05", "89.45", "88.72", "99.04", "99.07", "37.76", "36.13", "36.15", "39.61", "35.71" ]

icd9pcs

[ [ [] ] ]

4706, 4761

2461, 3509

300, 412

5032, 5038

1009, 2438

5323, 5421

743, 747

3582, 4683

4782, 5011

3535, 3559

5062, 5300

762, 990

229, 262

440, 482

504, 632

648, 727

20,805

134,226

7415

Discharge summary

report

Admission Date: [**2164-9-12**] Discharge Date: [**2164-10-6**] HISTORY OF PRESENT ILLNESS: This is an 85-year-old male with an extensive cardiac history significant for aortic valve replacement, coronary artery bypass graft, peripheral vascular disease (status post femoral-popliteal bypass), required removal of the pacemaker in [**2158**], and type 2 diabetes mellitus who was transferred to [**Hospital1 346**] from an outside hospital for placement of a new pacemaker for intermittent bradycardia consistent with Mobitz type 2. The patient was admitted to the outside hospital on [**Month (only) 359**] The patient also has a history of pancreatitis, and his amylase and lipase were increased on admission. The patient was reported to have made a rapid recovery, and his diet was advanced on [**9-12**]; and he reportedly tolerated a soft die [**Doctor First Name **] [**9-13**]. Cardiology was consulted and recommended further intervention for heart block. On admission, the patient experienced [**3-30**] to [**6-30**] left chest pressure. It was different from his previous anginal and pancreatic pain. He denied radiation to the back or extremities. There was no improvement with sublingual nitroglycerin times three. He was given morphine which resulted in nausea and vomiting. A nitroglycerin drip was started by the nurse [**First Name (Titles) 151**] [**Last Name (Titles) **] improvement. Electrocardiogram remained unchanged without ST changes, Q waves, or inversions. His blood pressures in the bilateral upper extremities were equal. Cardiac enzymes were negative. A chest x-ray was unchanged from his previous study. His amylase and lipase were still noted to be evaluated. Otherwise, the patient stated that his gastrointestinal discomfort was improved. He was tolerating solids and had regular bowel movements. He denied shortness of breath, fevers, and chills. PAST MEDICAL HISTORY: 1. Aortic stenosis; status post aortic valve replacement (a Bjork-Shiley valve) in [**2146**]. 2. Coronary artery disease; status post coronary artery bypass graft in [**2158**]; pacemaker for syncope in [**2156**] with endocarditis in [**2158**] with resultant pacemaker removal. 3. Peripheral vascular disease; status post right below-knee amputation; status post left femoral bypass in [**2161**] with revision; status post left great toe amputation. 4. Status post cholecystectomy. 5. Status post cerebrovascular accident with right facial droop and right hemiparesis. 6. Idiopathic pancreatitis. 7. History of partial small-bowel obstruction. 8. History of aspiration pneumonia. 9. Hiatal hernia. 10. Upper gastrointestinal bleed. 11. Hypertension. 12. Insulin-dependent diabetes mellitus (which was adult-onset). MEDICATIONS ON ADMISSION: 1. Persantine 25 mg p.o. b.i.d. 2. Norvasc 2.5 mg p.o. b.i.d. 3. Accupril 10 mg p.o. b.i.d. 4. Bextra 10 mg p.o. q.d. 5. Enteric-coated aspirin 325 mg p.o. q.d. 6. Multivitamin one tablet p.o. q.d. 7. Colace 100 mg p.o. b.i.d. 8. Celexa 20 mg p.o. q.d. 9. A regular insulin sliding-scale. 10. NPH 4 units subcutaneously q.a.m. and 1 unit subcutaneously q.p.m. ALLERGIES: An allergy to ZOCOR (which increases his liver function tests). DIGOXIN (causes nausea and vomiting). PEPCID (gives him mental status changes). SOCIAL HISTORY: Social history is negative for ethanol and tobacco. He was a professional ballerina and lives with his wife who is an astrophysicist. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 99.1, blood pressure was 176/68, heart rate was 66, oxygen saturation was 98% on room air. Blood sugar was 194. He was alert and oriented times three, in mild discomfort. Head, eyes, ears, nose, and throat revealed normocephalic and atraumatic head. A right-sided facial droop was noted. Bilateral bibasilar crackles on lung examination. No wheezes, rhonchi, or rales. He had a regular rate with intermittent dropped beats. He had a 3/6 systolic ejection murmur. His abdomen was soft and diffusely tender. Extremities were notable for a right below-knee amputation and left bypass scar. No edema with normal perfusion. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories revealed white blood cell count was 9.6, hematocrit was 35.3, and platelets were 209. Differential with 58% neutrophils. Sodium was 142, potassium was 3.8, chloride was 107, bicarbonate was 25, blood urea nitrogen was 22, creatinine was 1.2, and blood glucose was 111. Calcium was 8.8, magnesium was 1.7, phosphorous was 2.5. AST was 25, ALT was 14, alkaline phosphatase was 86, total bilirubin was 0.2, amylase was 203, and lipase was 369. Creatine kinase was 124. CK/MB was 3. Troponin I was less than 0.3. RADIOLOGY/IMAGING: Electrocardiogram with a heart rate in the 60s, prolonged P-R interval, poor R wave progression. No ST changes. A chest x-ray anterior/posterior film with appropriate mediastinal shadow compared with previous study. HOSPITAL COURSE: The patient was initially treated for rule out myocardial infarction due to significant coronary artery history. Initial cardiac enzymes were negative, and the electrocardiogram was without acute changes. He was continued on his ACE inhibitor, Norvasc, and nitroglycerin drip for blood pressure control. He was also continued on aspirin. According to an echocardiogram in [**2164-8-21**] revealed he did have an ejection fraction of greater than 55%, but he was noted to have intermittent bradycardia to the 30s on telemetry while sleeping. He was planned for a possible pacemaker placement the following morning. In light of his recent episode of pancreatitis with still elevated amylase and lipase, the patient was again made nothing by mouth due to his abdominal pain. In addition, he was started with gentle hydration. Overnight, the patient continued to have increased abdominal pain which was similar to his previous pancreatitis. He also had nausea and vomiting with greenish/yellowish output. It was determined by Electrophysiology not to place a pacemaker at this time in light of the previous history of endocarditis that required pacemaker removal. Since the patient was not going to receive a pacemaker at this time, and in light of his continued nausea and vomiting (consistent with pancreatitis), the patient was transferred from the Cardiology Medicine Service to the general Medicine [**Doctor Last Name **] Service. On the Medicine Service, he was continued as nothing by mouth with intravenous hydration and intravenous Dilaudid as needed for pain. Electrophysiology continued to follow the patient in light of his history of atrioventricular block and likely pacemaker placement once acute pancreatitis resolved and Infectious Disease cleared him. He was managed supportively for pancreatitis. To evaluate his risk for pacemaker, they recommended following routine blood cultures. An endoscopic retrograde cholangiopancreatography was offered to evaluate for stone causing pancreatitis, which the patient refused. Thus, he was continued with just supportive management. On [**9-14**], his diet was slightly advanced to ice chips and sips of fluids. Overnight, he started vomiting and had increased nausea. On the morning of [**9-15**], he had increased shortness of breath and respiratory distress. His temperature was 99.7 axillary, blood pressure was 233/80, respiratory rate was approximately 25, heart rate was 90 on electrocardiogram. Concerning for a possible gastric volvulus or obstruction. Of note, his bicarbonate was noted to have dropped to 9. Thus, he was managed with a nasogastric tube with several hundred cc of bilious fluid out. He was also given bicarbonate and transferred to the Unit. In a discussion on this day, the patient stated that he was full code. Planned to get an abdominal computed tomography. In addition, he was put on levofloxacin and Flagyl, per Infectious Disease Service recommendations in this setting. The patient was fluid resuscitated, received frequent arterial blood gases and Chemistry-7 panels to assess for improvement of his acidosis. An nasogastric tube was sufficient in addition to the fluids to decompress his stomach with resolution of his symptoms. The abdominal computed tomography showed an atrophic pancreas without necrosis of fat stranding, and the vasculature to the gut was with preserved flow. Some diverticula were noted. The contrast passed minimally through the gut. There were stones and no ductal dilatation of the gallbladder. A follow-up chest x-ray demonstrated right middle lobe and right lower lobe opacity; possibly an aspiration pneumonia. He was continued on levofloxacin and Flagyl. He remained afebrile. While in the Unit on [**9-17**], the patient was noted to be ruling in for a non-Q-wave myocardial infarction; although, he did not have any chest pain. He was started on a heparin drip, and his creatine kinases were monitored for a peak and trough. He was also continued on levofloxacin and Flagyl for his aspiration pneumonia. Due to his baseline atrioventricular block, no beta blocker was initiated. Over time, the metabolic acidosis resolved with intravenous fluids and stomach decompression only. His diet was slowly advanced to clears while in the Unit. On [**9-18**], he was determined to be stable with a non-Q-wave myocardial infarction on aspirin and intravenous heparin. He was scheduled for an echocardiogram. For the aspiration pneumonia, he was continued on levofloxacin and Flagyl. At this point, for this pancreatitis, the enzymes had normalized, and a swallow study was recommended to determine whether it was safe to advance his diet as tolerated or tube feeds in light of his aspiration pneumonia. He had a peripherally inserted central catheter line ordered to be placed by Radiology, and he was stable to be discharged to the floor on [**9-18**]. On [**9-20**], a modified barium swallow study was obtained which demonstrated that the patient had moderate oral, severe pharyngeal, dysphagia characterized by reducible formation; anterior/posterior, transit and pharyngeal, residue, as well as pharyngeal delay and swallowing initiation which resulted in gross aspiration with poor sensory awareness, with all consistencies assessed. A chin tuck maneuver effectively eliminated aspiration with only nectar-thick liquids and pureed solids with a limited bolus size. A chin tuck was not effective at limiting aspiration with thin liquids. In addition, laryngeal penetration occurred with nectar-thick and purees while using the chin tuck. Thus, the patient had clinical evidence of gross and intermittently silent aspiration and remained at high risk for aspiration which was moderately lessened with strict strategy use. The recommendations were nectar-thick liquids, pureed solids, and pills crushed and pureed, bolt upright with one-to-one supervision at all meals, and chin tuck to chest for all sips. All liquids were to be given via teaspoon with no cups or straws. He was to swallow twice for every bite and sip. Due to the continued risk for high aspiration, it was determined he would probably need placement for long-term nutrition and hydration such as a percutaneous endoscopic gastrostomy tube to meet his nutritional needs. The patient stated he wanted to continue taking oral foods. The patient continued to be managed for his acute issues while awaiting potential pacemaker placement. He continued to have atrioventricular block, bigeminy, as well as trigeminy on telemetry, and he also continued to have issues with elevated systolic blood pressures; occasionally in the 200s, for which he was titrated up on hydralazine q.6h. as needed in addition to a nitroglycerin paste sliding-scale. No beta blocker were used due to his underlying disease. He was continued on the levofloxacin and Flagyl. Of note, on [**9-21**], his hematocrit was noted to be 28.5. In light of his cardiac history, he was transfused 2 units of packed red blood cells with an appropriate response. He continued to be monitored symptomatically in preparation for his possible pacemaker placement. On [**9-22**], the patient had a follow-up chest x-ray in light of his aspiration pneumonia. On follow-up, he was noted to have a right-sided pneumothorax; probably secondary to several attempts for venous access via right internal jugular and right subclavian without success. Thus, Thoracic Surgery was consulted for chest tube placement. They placed a pigtail catheter. Repeat chest x-rays serially demonstrated continued improvement in the size of the pneumothorax. The patient remained asymptomatic with this pneumothorax. Of note, the chest tube was noted to be draining greater than 1300 cc of fluid in the first 16 hours. It was sent for analysis and culture. The chest tube continued to have decreased drainage over the next few days. He continued to remain afebrile with a normal white blood cell count during this time. Mr. [**Known lastname 12735**] continued to have occasional episodes of nausea and vomiting which precluded appropriate oral intake. Thus, he was initiated on total parenteral nutrition on [**9-27**]. On [**9-26**], it was noted that it was possible that the chest tube may have been moved out of the pleural space. Since Cardiothoracic Surgery would not be able to reposition it, it was determined to just remove it since there was almost complete resolution of the pneumothorax and significantly decreased fluid drainage. The chest tube was removed on [**9-27**]. The patient continued to be afebrile and felt better. The patient was continued on levofloxacin and Flagyl intravenously for his aspiration pneumonia until [**9-29**]; for a total of a 14-day course. On [**9-28**], a percutaneous endoscopic gastrostomy tube was placed by Gastroenterology for improved nutrition. Feeds were started without complications on [**9-29**]. Due to his continued hypertension, hydralazine continued to be titrated up for appropriate control. In preparation for pacemaker placement tentatively scheduled for [**10-2**], it was determined that the peripherally inserted central catheter line would need to be removed in order to decrease the infection risk. The peripherally inserted central catheter needed to be removed greater than 24 hours prior to pacemaker placement. The peripherally inserted central catheter line was removed on [**9-30**]. The peripherally inserted central catheter tip was sent for culture. The patient was made nothing by mouth for a planned pacemaker placement for [**10-2**]. Of note, the peripherally inserted central catheter tip culture came back with greater than 15 colonies of coagulase-negative Staphylococcus. Thus, the patient's pacemaker placement was deferred. Surveillance blood cultures were sent today. Based on his previous infection risk, it was determined to monitor the surveillance blood cultures sent that day, and if they remained negative for 48 hours, and the patient remained clinically stable, it could be placed (at the earliest) on [**10-4**]. Thus, the pacemaker placement was cancelled on [**10-2**]. The patient continued to remain stable without any active issues; off levofloxacin and Flagyl for the aspiration pneumonia after a 14-day course. The patient continued to tolerate tube feeds without complications. The cultures remained negative times 48 hours, and the patient had a pacemaker placement performed on [**10-5**]. The patient tolerated the procedure without complications. He was given vancomycin for prophylaxis prior to the procedure. The patient received a dual-chamber and rate-responsive pacemaker (serial number [**Serial Number 27223**]). Thus, he received a dual-mode, dual-pacing, dual-sensing pacemaker without complications. The pacemaker was made by [**Company 1543**]. DISCHARGE DISPOSITION: The patient was discharged home on [**10-6**] since he was stable status post procedure. He was discharged home with home health services. In addition, he was sent home with continued tube feeds in order to insure adequate nutrition. MEDICATIONS ON DISCHARGE: 1. Heparin subcutaneous 5000 units q.12h. 2. Prochlorperazine 10 mg p.o. q.4-6h. as needed. 3. Protonix 40 mg p.o. q.d. 4. Docusate liquid 100 mg p.o. b.i.d. as needed. 5. Citalopram 20 mg p.o. q.d. 6. NPH insulin 4 units subcutaneously q.a.m. and 2 units subcutaneously q.p.m. 7. A regular insulin sliding-scale. 8. Aspirin 325 mg p.r. q.d. 9. Furosemide 400 mg p.o. q.d. 10. Isosorbide mononitrate 20 mg p.o. t.i.d. 11. Bisacodyl 10 mg p.r. q.d. as needed. 12. Lorazepam 0.25 mg p.o. q.4-6h. as needed. 13. Sublingual nitroglycerin 0.3 mg as needed. 14. Persantine 25 mg p.o. b.i.d. 15. Accupril 5 mg p.o. b.i.d. 16. Multivitamin one tablet p.o. q.d. 17. Keflex 500 mg p.o. (times six doses). DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with his primary care physician (Dr. [**First Name (STitle) **] [**Name (STitle) **]) and with his cardiologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**]) as determined by both of these physicians. 2. In addition, the patient was instructed to follow up with his primary care physician in his [**Name9 (PRE) 27224**]. CONDITION AT DISCHARGE: Condition on discharge was improved status post pacemaker placement. DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**], Physical Therapy, Occupational Therapy, Speech Therapy, and tube feeds. DISCHARGE DIAGNOSES: 1. Atrioventricular block. 2. Status post pacemaker placement. 3. Status post a non-Q-wave myocardial infarction. 4. Aspiration pneumonia. 5. Pneumothorax. 6. Metabolic acidosis; likely secondary to partial small-bowel obstruction. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 21723**] Dictated By:[**Name8 (MD) 17134**] MEDQUIST36 D: [**2164-11-6**] 18:28 T: [**2164-11-10**] 04:50 JOB#: [**Job Number 27225**]

[ "276.2", "276.5", "577.0", "428.0", "507.0", "512.1", "584.9", "410.71", "426.12" ]

icd9cm

[ [ [] ] ]

[ "37.72", "45.13", "37.83", "96.6", "34.04", "38.93", "43.11" ]

icd9pcs

[ [ [] ] ]

15943, 16180

17620, 18096

16207, 16928

2798, 3335

5047, 15919

16961, 17366

17381, 17599

102, 1908

1931, 2771

3352, 5029

15,641

178,894

13237

Discharge summary

report

Admission Date: [**2174-2-19**] Discharge Date: [**2174-3-4**] Date of Birth: [**2101-11-8**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Ciprofloxacin / Clindamycin / Quinidine / Niacin / Persantine Attending:[**First Name3 (LF) 165**] Chief Complaint: angina, DOE, recent fatigue Major Surgical or Invasive Procedure: redo cabg off pump x 4 [**2174-2-24**] (LIMA to LAD, SVG to RCA with "y" graft to SVG to OM, SVG to OM graft has "y" graft to SVG to DIAG) History of Present Illness: Developed angina 13 days PTA with current SOB. Transferred in from OSH after echo showed multiple WMAs. Ruled out for MI by enzymes. Also had acute on chronic renal failure. Sent here for further management and cardiac cath. Past Medical History: CAD with prior CABG ([**2149**])/PTCA RCA [**2161**] Renal Failure Diabetes Melitus anemia gout HTN pituitary adenoma neuropathy IBS GERD arthritis frequent HAs PSH: cabg with RFA thrombosis and angioplasty [**2149**] right LE fasciotomies appy parotidectomy tumor ovarian cystectomy TAH-BSO cerv. repair cholecystectomy AAA repair [**2165**] Social History: remote tobacco abuse no ETOH abuse Family History: father died of CAD at 59 Physical Exam: HR 60 RR 16 right 156/54 left 140/49 66" 144 # NAD, well-nourished generalized rash back, thighs, arms, abd healed surgical scars left calf, right groin, mid-line sternal, midline abd, left neck, midline posterior [**Last Name (un) **] upper dentures PERRLA 2mm, EOMI neck supple, full ROM, no lymphadenopathy CTAB RRR 2/6 systolic murmur + BS, no palpable masses warm, well-perfused, no peripheral edema, no varicosities MAE, , right> left strengths, gait steady dopplerable right fem, 2+ left 1+ bil. DP/PT 2+ bil. radials Pertinent Results: [**2174-3-1**] 06:08AM BLOOD WBC-9.0 RBC-3.14* Hgb-9.8* Hct-28.6* MCV-91 MCH-31.0 MCHC-34.1 RDW-17.0* Plt Ct-188# [**2174-3-1**] 06:08AM BLOOD PT-12.9 INR(PT)-1.1 [**2174-3-1**] 06:08AM BLOOD Plt Ct-188# [**2174-3-1**] 06:08AM BLOOD Glucose-103 UreaN-34* Creat-1.6* Na-133 K-4.0 Cl-102 HCO3-25 AnGap-10 [**2174-2-22**] 06:25AM BLOOD proBNP-2514* Cardiology Report ECHO Study Date of [**2174-2-24**] PATIENT/TEST INFORMATION: Indication: Coronary artery disease. H/O cardiac surgery. Hypertension. Left ventricular function. Intraoperative TEE for off-pump CABG. Height: (in) 66 Weight (lb): 144 BSA (m2): 1.74 m2 BP (mm Hg): 138/46 HR (bpm): 80 Status: Inpatient Date/Time: [**2174-2-24**] at 11:33 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW000-0:0 Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 30% (nl >=55%) Aorta - Ascending: 2.9 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: *2.8 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec) Aortic Valve - LVOT Diam: 2.1 cm Aortic Valve - Valve Area: *2.2 cm2 (nl >= 3.0 cm2) Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A Ratio: 1.14 Mitral Valve - E Wave Deceleration Time: 296 msec INTERPRETATION: Findings: LEFT ATRIUM: Dilated LA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Severe regional LV systolic dysfunction. Moderate global LV hypokinesis. Moderately depressed LVEF. Severely depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Focal calcifications in ascending aorta. Complex (mobile) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. Suboptimal image quality. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions: No atrial septal defect is seen by 2D or color Doppler. There is moderate global left ventricular hypokinesis. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis/ akinesis of the apex with severe hypokinesis of the of all distal LV segments. Estimated EF 30%. 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 appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. There is mild TR. There is severe athersclerotic disease of the thoracic aorta including a large mobile plaque in the distal aortic arch. After completion of coronary grafting, and with epinephrine infusion, the LV displayed worse global and segmental function with extension of the severe hypokinesis towards the mid LV segments. Overall EF is approximately 20-25%. RV systolic function is preserved. No other changes. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD on [**2174-2-24**] 15:32. [**Location (un) **] PHYSICIAN: ([**Numeric Identifier 40349**]) Brief Hospital Course: Admitted [**2-19**] to cardiology. Echo at OSH showed EF 30% with mutiple wall motion abnormalities and [**11-23**]+ MR. [**First Name (Titles) 40350**] [**Last Name (Titles) **] test positive. Cath revealed: LAD calcified prox with distal aneurysm and bifurcating 80-90% distal Diag 1; CX distal 60%, RCA prox. 100%, SVG to RCA 50%, to 90% PDA, SVG to LAD 100%. Workup completed and bil. carotid dz. revealed as well as a calcified aorta.Underwent redo cabg x4 off pump with Dr. [**First Name (STitle) **] on [**2-24**]. Transferred to the CSRU in stable condition on epinephrine, insulin, phenylephrine, and propofol drips. Extubated the next morning and neurology consulted for eval. of pituitary adenoma. Developed RUE swelling with partial occlusion of a vein diagnosed and coumadin started.Transferred to the floor on POD #4. Dermatology consult requested by pt. due to faint rash that existed pre-op, but this is to be done as an outpt.Gentle diuresis continued and coumadin stopped per Dr. [**First Name (STitle) **]. Cleared for discharge to home with VNA services on POD #8. Pt. to make all follow-up appts. as per discharge instructions. Medications on Admission: diovan 8 mg QHS Iron 325 mg QHS aldactone 12.5 mg [**Hospital1 **] carvedilol 12.5 mg [**Hospital1 **] digoxin 0.125 mg q M,T, TH, F,SUN omeprazole 20 mg daily folate 1 mg daily ASA 81 mg daily allopurinol 150 mg QHS colchicine 0.6 mg PRN amaryl 6 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. 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* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 6. Glimepiride 2 mg Tablet Sig: Three (3) Tablet PO daily (). Disp:*90 Tablet(s)* Refills:*1* 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*45 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Patrners Home Care Discharge Diagnosis: s/p redo OPCABG x4 CAD with prior CABG ([**2149**])/PTCA RCA [**2161**] Renal Failure Diabetes Melitus anemia gout HTN pituitary adenoma neuropathy IBS GERD arthritis frequent HAs PSH: cabg with RFA thrombosis and angioplasty [**2149**] right LE fasciotomies appy parotidectomy tumor ovarian cystectomy TAH-BSO cerv. repair cholecystectomy AAA repair [**2165**] Discharge Condition: stable Discharge Instructions: A 7-mm ground-glass opacity with slightly irregular margins was seen within the right upper lobe of your lung on CT scan. Close followup evaluation in three months' time should be obtained to assess for interval change. no lotions, creams, or powders on any incision no driving for one month may shower over incisions and pat dry call for fever greater than 100.5, redness, or drainage NO lifting greater than 10 pounds for 10 weeks Followup Instructions: see Dr. [**Last Name (STitle) 174**] in [**11-23**] weeks see Dr. [**Last Name (STitle) 40351**] in [**12-25**] weeks see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2174-3-4**]

[ "250.00", "440.22", "V45.82", "356.9", "414.01", "564.1", "584.9", "458.29", "V58.67", "530.81", "414.02", "453.8", "440.0", "227.3", "285.9", "433.10", "403.91", "276.2", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "88.72", "88.57", "36.15", "37.22", "99.04", "88.56", "36.13" ]

icd9pcs

[ [ [] ] ]

8705, 8754

5728, 6879

368, 510

9161, 9170

1790, 2193

9652, 9967

1200, 1226

7186, 8682

8775, 9140

6905, 7163

9194, 9629

2219, 5632

1241, 1771

301, 330

538, 764

5667, 5705

786, 1131

1147, 1184

21,686

189,422

43947

Discharge summary

report

Admission Date: [**2110-1-11**] Discharge Date: [**2110-1-18**] Date of Birth: [**2033-7-30**] Sex: M Service: SURGERY Allergies: Percocet Attending:[**First Name3 (LF) 371**] Chief Complaint: Splenic hematoma Major Surgical or Invasive Procedure: Exploratory laparotomy and splenectomy. History of Present Illness: The patient is a 76 y/o male who recently had a laparoscopic left nephrectomy and distal ureterectomy with resection of the bladder cuff for a ureteral tumor 4 days ago and was discharged with an uncomplicated post-operative course who presents to the [**Hospital1 18**] ED with left shoulder pain, hypotension with SBP in the 70s, and lightheadedness. The patient's Hct was 28 at presentation and was transfused 2 units of packed RBCs and received crystalloid boluses in the ED. The patient denies chest pain, shortness of breath, abdominal pain, or nausea/vomiting. A CT scan revealed a large hematoma in the LUQ with predominantly intraperitoneal but also retroperitoneal components, consistent with a large perisplenic hematoma, with extension into the paracolic gutters bilaterally, and around the liver. There is also a smaller component in the left nephrectomy bed. Past Medical History: He has an extensive past medical history with history of diabetes, hypertension, COPD, emphysema, and coronary artery disease. He has had angioplasties for his coronary artery disease. Social History: He is a retired salesman. He smokes 1 pack of cigarettes per day for the past 50 years and he drinks three caffeinated products per day. He does not consume any alcoholic beverages. Family History: There is no family history of prostate cancer Physical Exam: T 98.4 P 78 BP 106/64 R 18 SaO2 98%5L NC Gen - fatigued, uncomfortable Heart - Regular rate and rhythm Lungs - diffuse wheezes abd - soft, tender in LUQ, no rigidity or guarding, no flank tenderness extrem - 2+ lower extremity edema Pertinent Results: [**2110-1-11**] 02:55PM BLOOD WBC-10.6 RBC-3.28* Hgb-10.1* Hct-28.4* MCV-87 MCH-30.9 MCHC-35.7* RDW-13.5 Plt Ct-295 [**2110-1-11**] 02:55PM BLOOD PT-13.0 PTT-23.6 INR(PT)-1.1 [**2110-1-11**] 02:55PM BLOOD Glucose-176* UreaN-26* Creat-1.5* Na-132* K-3.9 Cl-102 HCO3-23 AnGap-11 [**2110-1-11**] 06:15PM BLOOD CK(CPK)-112 [**2110-1-11**] 06:15PM BLOOD CK-MB-6 cTropnT-<0.01 [**2110-1-11**] 06:15PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.023 [**2110-1-11**] 06:15PM URINE Blood-LG Nitrite-POS Protein-100 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-6.5 Leuks-MOD [**2110-1-11**] 06:15PM URINE RBC->50 WBC->50 Bacteri-MOD Yeast-NONE Epi-0 [**2110-1-11**] 6:15 pm URINE CATHETER. **FINAL REPORT [**2110-1-13**]** URINE CULTURE (Final [**2110-1-13**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 8 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2110-1-11**] CT scan 1. Large hematoma in the left upper quadrant. Findings are consistent with a large perisplenic hematoma, with extension into the intraperitoneal cavity, with blood in the paracolic gutters and around the liver. Additionally, there is a smaller component within the left nephrectomy bed. Post-surgical changes from recent surgery are again seen in the abdominal wall. 2. Cholelithiasis. Brief Hospital Course: The patient was stabilized hemodynamically and transferred to the ICU. The patient had an a-line and a central line placed for hemodynamic monitoring. However, after a few hours of observation he was noted to become progressively more hypotensive and requiring more blood. The decision was made to take him to the operating room for an exploration. The patient underwent an exploratory laparotomy and splenectomy which he tolerated well and was transferred to the ICU intubated and in stable condition. Because the patient had a splenectomy, he received a Haemophilus, pneumococcal, and a meningococcal vaccine. The patient was able to be extubated on post-op day 1. The patient was started on a low dose furosemide drip to assist with his diuresis and was transitioned over to intermittent doses of furosemide. He will continue to receive furosemide for 4 days after discharge. Due to his foley catheter which had been in place since his previous surgery, the patient developed an E. coli urinary tract infection and was treated with Cipro for this. A CT cystogram was obtained on [**2110-1-16**] which showed no bladder leak. The patient's Hct remained stable for the duration of his hospital stay and had a Hct of 26.7 on discharge. During his admission, the patient had complaints of some mild shortness of breath with rhonchorous breath sounds and tachypnea. He was give Albuterol/Ipratropium duonebs to which he responded well to. He had a CT angiogram to rule out PE. On discharge, the patient was oxygenating well on room air and was not complaining of shortness of breath. The patient's previous symptoms were likely due to his COPD, atelectasis, and fluid overload for which he was receiving Lasix. Because he only has one kidney, his Cr was monitored daily and was 1.1 on discharge. The patient was able to tolerate a regular diet and was able to ambulate with some assistance at discharge. Medications on Admission: 1. atenolol 50 qd 2. albuterol prn 3. asa 4. topiramate 25mg qd 5. atrovent [**Hospital1 **] 6. flomax 7. lisinopril 10 qd 8. flunisolide [**Hospital1 **] Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebule Inhalation every six (6) hours. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebule Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 5. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection [**Hospital1 **] (2 times a day) for 4 days. 6. Oxybutynin Chloride 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 9. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 11. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Lacerated spleen Discharge Condition: Stable Discharge Instructions: Call your doctor or seek immediate medical attention if you experience fever, chills, lightheadedness, dizziness, chest pain, shortness of breath, palpitations, severe abdominal pain, nausea/vomiting, or increased drainage, bleeding, or redness from surgical incisions. You may resume all your home medications with the exception of lisinopril. No driving while taking pain medications. No strenous activity for 2 weeks. No tub baths. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 10941**] Date/Time:[**2110-1-21**] 9:15 Please also follow up with Dr. [**Last Name (STitle) **] in [**1-21**] weeks. Call [**Telephone/Fax (1) 1864**] for appointment.

[ "250.00", "996.64", "401.9", "998.12", "599.0", "E878.6", "414.01", "998.2", "492.8", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "99.04", "41.5" ]

icd9pcs

[ [ [] ] ]

7475, 7541

4183, 6101

284, 325

7602, 7611

1980, 4160

8095, 8398

1661, 1708

6307, 7452

7562, 7581

6127, 6284

7635, 8072

1723, 1961

228, 246

353, 1233

1255, 1443

1459, 1645

28,132

175,253

13821

Discharge summary

report

Admission Date: [**2127-5-23**] Discharge Date: [**2127-6-5**] Date of Birth: [**2069-3-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: HCV cirrhosis/HCC Major Surgical or Invasive Procedure: [**2127-5-23**] liver transplant [**2127-5-30**] ercp with stent History of Present Illness: 58 y.o. M with HCV Cirrhosis, HCC s/p RFA [**3-11**] with recent CT-scan showing no evidence of recurrent disease. Has been feeling well. Had 2 teeth extracted a few weeks ago. Did not fill script for prophylactic antibiotics, but has not had any sx of infection. Denies recent illness/colds, recent ill contacts. Denies f/c/HA/LAD/cp/sob/abd pain/dysuria/back or joint pain/rashes/melena. Does have some problems with constipation Had CT scan today at [**Hospital3 2358**] as part of live donor liver transplant w/u. Ate egg whites/ice tea a few hours ago, otherwise npo since yesterday for the CT. Past Medical History: HCV cirrhosis [**1-4**] IVD, h/o rx with interferon, HCC s/p RFA [**3-11**], Barrett's esophagus, PSH: hernia repair as child, 2 teeth extracted recently Social History: Social History: Married. No children. Not currently working due to illness. Worked in the catering business. Habits: Smoked as "a kid". none since. No ETOH for 25 years. In AA. Does not do intravenous drugs any more. Did this as a teenager. Family History: FH: Mother died from ETOH. Father died of liver cancer. Physical Exam: PE:97.6 65 125/70 18 96%RA Wt: 94kg A&O, a little tense, Wife and friends present [**Name (NI) **]: pupils equal, reactive, anicteric sclerae, no thrush, L upper & L lower tooth extraction sites appear to be healing well. Pharynx wnl Neck: 2+ carotids, no bruits, no LAD, No TM Lungs: clear Cor: RRR, no murmurs Abd: soft, + BS, NT/ND, No bruits, no HSM Ext: no cce, 2+ DPs bilat Neuro: A&O, no asterixis Pertinent Results: On Admission: [**2127-5-23**] WBC-6.0 RBC-4.73 Hgb-14.4 Hct-41.7 MCV-88 MCH-30.4 MCHC-34.5 RDW-13.7 Plt Ct-150 PT-13.2 PTT-27.7 INR(PT)-1.1 Glucose-83 UreaN-15 Creat-1.0 Na-141 K-3.9 Cl-105 HCO3-25 AnGap-15 On Discharge [**2127-6-5**] WBC-7.2 RBC-3.84* Hgb-12.2* Hct-35.9* MCV-93 MCH-31.7 MCHC-33.9 RDW-14.1 Plt Ct-197 ALT-822* AST-132* AlkPhos-216* TotBili-0.6 Albumin-3.1* AFP-2.5 tacroFK-17.2 Brief Hospital Course: On [**2127-5-24**] he underwent Orthotopic deceased donor liver transplant. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative note for complete details. Per the operative report, "the donor liver had a markedly enlarged right lobe relative to the space. It fit well but there was some angulation to the portal vein from the recipient to the donor as a result of the large size of the right lobe". Also, " shortly after reperfusion the patient developed hypotension to the 60s and 70s associated with atrial fibrillation. Blood pressure returned relatively quickly, but he did remain in atrial fibrillation for approximately 20 minutes. He then converted spontaneously to normal sinus rhythm. He remained hemodynamically stable". Two [**Location (un) 1661**]-[**Location (un) 1662**] drains were placed. Postop, he was transferred to the SICU intubated for management. On pod 1, he was extubated. U/S obtained on POD 1 was normal with normal vasculature. He continued to proceed along the pathway until POD 5, when bilious drainage was noted in the Lateral drain. (14) An ERCP was done on [**5-30**] which demonstrated a bile leak. Extravasation in the biliary tree was treated with sphincterotomy and stent placement (10 Fr stent) Normal pancreatic duct was noted. Post ERCP the AST and ALT were noted to increase (228 and 903 respectively) Over the next 3 days, labs were monitored, and it was decided since they were again trending down that a biopsy would be deferred. Both Dr [**Last Name (STitle) 497**] and Dr [**Last Name (STitle) 816**] were discussing this plan. The patient was ambulating freely and tolerating diet. He was started on insulin, scripts for supplies were given. He demonstrated understanding of blood sugars, insulin administration and immunosuppression regimen with the self med program. He is discharged with one drain Medications on Admission: [**Last Name (un) 1724**]:Prilosec 40 prn, Aspirin 81 prn (has taken randomly in last few weeks "maybe 3-4 times in last few weeks for heart protection" Discharge Medications: 1. One Touch Ultra 2 Kit Sig: One (1) kit Miscellaneous four times a day. Disp:*1 kit* Refills:*0* 2. One Touch II Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] four times a day. Disp:*1 bottle* Refills:*2* 3. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:*1 box* Refills:*2* 4. syringes Sig: One (1) four times a day: low dose 1/2 cc (u 50), 30 gauze needle. Disp:*1 box* Refills:*2* 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 6. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily): Taper per transplant clinic recomendations. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed: Do not exceed 4 tablets daily. Disp:*28 Tablet(s)* Refills:*0* 11. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection four times a day. Disp:*2 bottles* Refills:*2* 16. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO ONCE (Once) for 1 doses. 17. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day: Starting morning of [**2127-6-6**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: HCV cirrhosis HCC glucose intolerance while on steroids s/p liver transplant [**2127-5-24**] Discharge Condition: good Discharge Instructions: Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have fever (101 or greater), chills, nausea, vomiting, inability to take any of your medications, jaundice, increased abdominal pain, incision redness/bleeding/drainage Labs every Monday and Thursday [**Month (only) 116**] shower, pat incision dry. No tub baths or swimming until directed otherwise Empty and record drain output daily and as needed. Bring copy of output record with you to your clinic visit No heavy lifting No driving while taking pain medication Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2127-6-12**] 9:00 [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2127-6-12**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2127-6-18**] 9:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2127-6-5**]

[ "571.2", "427.31", "V45.89", "530.85", "458.29", "V16.0", "155.0", "997.4", "070.54", "V15.82", "E878.0", "576.8" ]

icd9cm

[ [ [] ] ]

[ "50.59", "00.93", "38.93", "51.87" ]

icd9pcs

[ [ [] ] ]

6302, 6360

2405, 4345

329, 396

6497, 6504

1985, 1985

7086, 7651

1481, 1539

4550, 6279

6381, 6476

4371, 4527

6528, 7063

1554, 1966

272, 291

424, 1026

1999, 2382

1048, 1205

1237, 1465

31,126

103,408

29191

Discharge summary

report

Admission Date: [**2145-3-9**] Discharge Date: [**2145-3-13**] Date of Birth: [**2070-8-6**] Sex: M Service: CARDIOTHORACIC Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 1283**] Chief Complaint: Exertional chest pain and shortness of breath Major Surgical or Invasive Procedure: [**2145-3-9**] Aortic Valve Replacement(21 St. [**Male First Name (un) 923**] Epic Porcine Valve) and Single Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to LAD. History of Present Illness: Mr. [**Known lastname 70228**] is a 74 year old male with history of known aortic stenosis and coronary artery disease. Serial echocardiograms have shown progression of aortic valve gradients. Most recent ECHO from [**2144-10-29**] revealed EF 70% with mean aortic gradient of 50mmHg. Over the last several months, he admits to worsening exertional chest discomfort and dyspnea on exertion. He has no history of syncope. Recent cardiac catheterization from [**2145-1-29**] showed a right dominant system and three vessel coronary artery disease. He underwent routine preoperative evaluation and was eventually cleared for surgery. Past Medical History: Coronary Artery Disease Aortic Valve Stenosis Hypertension Elevated Cholesterol Chronic Renal Insufficiency Type II Diabetes Mellitus History of Gout History of Kidney Stones - prior Lithotripsy Polypectomy Tonsillectomy Hemrrhoidectomy Social History: Quit tobacco over 50 years ago. Admits to occasional ETOH. He is married. He is a retired construction worker. Family History: Brother died of MI in his early 50's. Physical Exam: Vitals: 120/64, 68, 16 General: WDWN male in no acute distress HEENT: Oropharynx benign, EOMI. + rhinophyma Neck: Supple, no JVD. Some soft tissue fullness in supraclavicular area Lungs: CTA bilaterally Heart: Regular rate and rhythm. 3/6 systolic ejectiom murmur Abdomen: Soft, nontender with normoactive bowel sounds Ext: Warm, no edema Pulses: 2+ distally. Transmitted murmur in carotid region. Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2145-3-9**] Intraop TEE: PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the ascending aorta. There are focal calcifications in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([**12-30**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no pericardial effusion. POST-BYPASS: Preserved biventricular systolic function and it is normal. Preserved ascending aortic contour. Mild to Moderate mitral regurgitation. A bioprosthesis is seen in the native aortic valve position, stable and functioning well with a mean gradient of 10mm of Hg. CHEST (PA & LAT) [**2145-3-13**] There is slightly better aeration of the lungs since the prior study. There is a small left pleural effusion and there is very minimal left lower lobe atelectasis. The right lung is clear. Cardiomediastinal silhouette is unremarkable. Status post median sternotomy. IMPRESSION: Improved aeration of the left lung. Small left pleural effusion, minimal left lower lobe atelectasis. [**2145-3-9**] WBC-12.0* RBC-3.02*# Hgb-9.7*# Hct-27.6*# Plt Ct-143* [**2145-3-12**] WBC-14.5* RBC-3.81* Hgb-12.2* Hct-35.4* Plt Ct-129* [**2145-3-9**] UreaN-25* Creat-1.1 Cl-114* HCO3-25 [**2145-3-12**] Glucose-117* UreaN-19 Creat-1.1 Na-136 K-4.1 Cl-100 HCO3-31 Brief Hospital Course: Mr. [**Known lastname 70228**] was admitted and underwent aortic valve replacement and coronary artery bypass grafting surgery. For surgical details, please see separate 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. He maintained stable hemodynamics. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, he was transferred to the step down unit for monitoring. Mr. [**Known lastname **] was gently diuresed towards his preoperative weight. He was restarted on his preoperative medications. Tolerated a regular diet and had good pain control with PO pain medications. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He continued to make steady progress and was discharged to home on POD #4. He will follow-up with Dr. [**Last Name (Prefixes) **] as an outpatient. Medications on Admission: Allopurinol 100 [**Hospital1 **], Norvasc 5 qd, Lipitor 80 qd, Zetia 10 qd, Tricor 145 qd, Lasix 20 qd, Gabapentin 300 qd, Glipizide 2.5 am/1.25 pm, Imdur 60 qd, Lopressor 50 [**Hospital1 **], KCL, Diovan 160 qd, ASpirin 325 qd Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*50 Tablet(s)* Refills:*0* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: then 20 mg daily previous home dose. Disp:*5 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day for 5 days. Disp:*5 Tablet Sustained Release(s)* Refills:*0* 11. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO Qam: 0.5 mg QPM. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 701**] VNA Discharge Diagnosis: Coronary Artery Disease, Aortic Valve Stenosis - s/p AVR/CABG Hypertension Elevated Cholesterol Chronic Renal Insufficiency Type II Diabetes Mellitus Lung Nodule 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: 1)Dr. [**Last Name (STitle) 1290**] in [**4-3**] weeks, call for appt 2)Dr. [**Last Name (STitle) 7047**] in [**1-31**] weeks, call for appt 3)CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-3-3**] 11:30 AM [**Hospital Ward Name 23**] [**Location (un) **]. Nothing to eat or drink for 3 hours prior to scan. Arrive by 11:00 AM. For lung nodule follow up. Completed by:[**2145-3-13**]

[ "250.00", "414.01", "440.0", "272.0", "585.9", "V70.7", "518.89", "424.1", "274.9", "403.90" ]

icd9cm

[ [ [] ] ]

[ "39.63", "88.72", "36.15", "38.91", "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

6796, 6854

3983, 5007

336, 537

7060, 7067

2150, 3960

7403, 7802

1602, 1641

5285, 6773

6875, 7039

5033, 5262

7091, 7380

1656, 2131

251, 298

565, 1197

1219, 1458

1474, 1586

63,048

175,372

34090

Discharge summary

report

Admission Date: [**2170-6-22**] Discharge Date: [**2170-7-2**] Date of Birth: [**2092-6-12**] Sex: M Service: SURGERY Allergies: Cipro / Morphine Attending:[**First Name3 (LF) 3376**] Chief Complaint: Local recurrence of [**First Name3 (LF) 499**] cancer and new metastatic disease to the liver. Major Surgical or Invasive Procedure: 1. Placement of right ureteral stent by Dr. [**Last Name (STitle) **]. 2. Laparotomy and lysis of adhesions. 3. Resection of previous colorectal anastomosis. 4. Primary coloproctostomy, stapled number 31. 5. Small bowel resection en bloc with local recurrence specimen. 6. Diverting end ileostomy with local mucous fistula. 7. Segmental resection of three liver lesions by Dr. [**Last Name (STitle) **]. Past Medical History: HTN CAD [**Last Name (STitle) 499**] cancer BPH Past surgical: L ureteral stent, colectomy x 2, coronary atherectomy + angioplaty Social History: The patient works as an optometrist in [**Doctor Last Name 26532**]. He is married. He used to smoke 1 pack a day for 30 years, but quit in [**2149**]. He occasionally has a glass of beer, does not use any other drugs. Family History: He had a paternal uncle with [**Name2 (NI) 499**] cancer. Father with [**Name2 (NI) 499**] cancer at age 57 and CAD. He died at 72 from coronary artery disease. Mother had pancreatic cancer. Sister is healthy and two sons that are healthy. Physical Exam: Vitals: 98.4, 52, 158/60, 20, 96% on 2L, 82-84% on RA GEN: NAD, A/Ox3 CV: RRR, no m/r/g RESP: CTAB, no W/R/R ABD: soft, ND, slightly TTP, +BS Incison: midline abdominal OTA with staples Ostomy: stoma pink & viable, liquid brown effluence Extrem: no c/c/e Pertinent Results: [**2170-6-30**] 08:25AM BLOOD WBC-7.0 RBC-3.19* Hgb-8.9* Hct-28.3* MCV-89 MCH-28.0 MCHC-31.6 RDW-15.8* Plt Ct-287 [**2170-6-29**] 02:49AM BLOOD WBC-4.9 RBC-2.96* Hgb-8.5* Hct-26.6* MCV-90 MCH-28.7 MCHC-31.9 RDW-15.1 Plt Ct-237 [**2170-6-28**] 02:13AM BLOOD WBC-5.4 RBC-2.97* Hgb-8.7* Hct-26.7* MCV-90 MCH-29.2 MCHC-32.5 RDW-15.0 Plt Ct-200 [**2170-6-22**] 03:12PM BLOOD WBC-11.2*# RBC-4.21* Hgb-12.4* Hct-37.6* MCV-89 MCH-29.4 MCHC-32.9 RDW-15.6* Plt Ct-223 [**2170-6-30**] 08:25AM BLOOD Glucose-110* UreaN-32* Creat-1.6* Na-144 K-3.7 Cl-111* HCO3-24 AnGap-13 [**2170-6-29**] 02:49AM BLOOD Glucose-114* UreaN-29* Creat-1.8* Na-145 K-3.7 Cl-115* HCO3-19* AnGap-15 [**2170-6-30**] 08:25AM BLOOD ALT-94* AST-33 AlkPhos-104 TotBili-1.0 [**2170-6-28**] 02:13AM BLOOD ALT-176* AST-68* AlkPhos-75 TotBili-1.8* [**2170-6-24**] 01:30AM BLOOD CK-MB-11* MB Indx-0.5 cTropnT-0.02* [**2170-6-23**] 04:19PM BLOOD CK-MB-15* MB Indx-0.6 cTropnT-<0.01 [**2170-6-22**] 03:12PM BLOOD CK-MB-4 cTropnT-<0.01 [**2170-6-30**] 08:25AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.0 Mg-2.7* Brief Hospital Course: Mr. [**Known lastname 78636**]' operative course was complicated by increased blood pressure and difficult extubation. Surgical procedure was otherwise unremarkable. Patient transferred to ICU for closer monitoring on ventilator. Secretions sent for culture, positive for Klebsiella. Treated accordingly with antibiotics. Patient also required hemodynamic support due to elevated blood pressure while in ICU. . Once hemodynamically stable, transferred to Stone 5 for routine post-op care. Ileostomy teaching provided. Diet advanced once ostomy began to put out stool & gas. Tolerated regular diet. Medications switched to oral. Blood pressure remained elevated on home dose of Norvasc. Clonidine 0.2mg daily added to regimen with some effect. SBP's in 140-150 range. Pain well controlled with Tylenol. Activity progressed to baseline. Physical Therapy consulted. No PT needs at home. . Continued to require supplemental oxygen to maintain sats over 95%. Has H/O emphysema and sleep apnea. Sats on RA after walking between 82-84%. Supplemental Oxygen arranged for home. VNA arranged for continued teaching/management of ostomy care, respiratory and cardiovascular assessment. . Attempted to contact patient's PCP, [**Last Name (NamePattern4) **].[**First Name (STitle) **], unable to reach because office closed. Clonidine discontinued at discharge. Patient instructed to follow-up with PCP [**Last Name (NamePattern4) **] 1 week to re-assess blood pressure and respiratory status. In addition, he will follow-up with Dr. [**Last Name (STitle) 1120**] in a few weeks for staple removal. He agreed with this plan. Medications on Admission: amlodipine 7.5mg [**Hospital1 **], lipitor 10mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 325mg QD Discharge Medications: 1. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO twice a day. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 4. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for pain for 2 weeks: Do not exceed 4000mg in 24hrs. 5. Home Oxygen Therapy Home oxygen 1-2 liters via nasal cannula Titrate oxygen for saturations >88% Discharge Disposition: Home With Service Facility: Visiting Nurse Service of Greater [**Doctor Last Name **] Discharge Diagnosis: Local recurrence of [**Doctor Last Name 499**] cancer and new metastatic disease to the liver. post-op respiratory distress-difficult extubation post-op respiratory infection-cultures positive for Klebsiella post-op hypertension-treated with Clonidine & Norvasc Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Requiring oxygen during day (room air oxygen saturation after ambulation between 82-84%), CPAP at night ambulating with assistance Discharge Instructions: Please call your doctor or return to the ER for any of the following: * New or worsening cough or wheezing/shortness of breath. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples will be removed at your follow up appointment. -Steri-strips will be applied and will fall off on their own. Please remove any remaining strips 7-10 days after application. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . 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 (contact Dr. [**Last Name (STitle) 1120**], take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. Followup Instructions: Scheduled Appointments : ***Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 78637**] in 1 week to re-assess you lungs, oxygen saturation, and blood pressure. 1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2170-7-31**] 1:00 2. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**] Date/Time:[**2170-8-2**] 11:00 3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 15105**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2170-8-2**] 11:00 Completed by:[**2170-7-2**]

[ "401.9", "197.7", "519.8", "518.84", "153.9", "414.00", "600.00", "401.1", "514", "568.0", "276.7", "276.2", "041.3" ]

icd9cm

[ [ [] ] ]

[ "54.59", "96.72", "38.91", "96.04", "57.32", "38.93", "93.90", "45.62", "33.23", "46.20", "59.8", "50.29" ]

icd9pcs

[ [ [] ] ]

5027, 5115

2812, 4425

371, 781

5421, 5631

1728, 2789

7634, 8386

1192, 1437

4582, 5004

5136, 5400

4451, 4559

5655, 6750

6765, 7611

1452, 1709

236, 333

803, 935

951, 1175

27,242

130,558

17634

Discharge summary

report

Admission Date: [**2150-11-19**] Discharge Date: [**2150-11-22**] Date of Birth: [**2128-3-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: none History of Present Illness: 22 yr old obese male presented to his PCP for annual check up. BP noted to 210/110. Pt asymptomatic. Pt denied ingestion of cocaine or other elicit drugs. Denied alcohol use. Denied chest pain, back pain, shortness of breath, LE edema, hx of renal disease, hematuria, flushing, seizures or visual disturbances. Pt reported PE [**2147**] wnl, mildly high blood pressure he thinks. sinus infection. BP at that time 200/142. No intervention. Reports no exercise, and high salt diet. Mother with hypertension at age 34. Father expired from renal disease on dialysis at the age of 31. . In ED initial BP noted to be at peak 243/136. Asymptomatic. Lopressor 25 mg PO x1, hydralazine 50 mg PO x1 given. Bp still to 190 systolic. EKG NSR no criteria for LVH. Of note lytes with BUN/Cr 54/5.5. UA with blood, [**7-19**] RBC, [**7-19**] WBC, protein 500. Pt admitted to ICU given persistent elevated BP. Past Medical History: Hypertension No past surgical history Social History: Completed some college. Works at [**Hospital1 2177**] health plan. No exercise. Heavy eater. Smoked marijuana last month. No drug use. No cigarrette use. Rare alcohol use Family History: Mother HTN [**Name (NI) 12238**] Renal failure, expired on dialysis age 31, hx unknown Physical Exam: Vitals: 208/131, 88, 99% RA, 18 General: Obese male awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus or injection. MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated, difficult to assess secondary to girth Pulmonary: Lungs CTA bilaterally Cardiac: RRR, II/VI SEM RUSB nl. S1S2 Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. No abdominal bruits heard. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Trace pretibial edema Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact. Ubable to perform fundoscopic exam. -motor: normal bulk, strength and tone throughout. Pertinent Results: Renal u/s- [**2150-11-19**] Evaluation of the right flank demonstrates no evidence of a right kidney. The left kidney is atrophic measuring 8 cm, and demonstrates minimal color flow. There is no evidence of hydronephrosis, masses, or stones of the left kidney. The urinary bladder is partially distended. There is no evidence of a pelvic kidney. IMPRESSION: Atrophic left kidney measuring 8 cm with minimal flow. No evidence of hydronephrosis. Absent right kidney. . HEAD CT [**11-20**]: FINDINGS: There is no acute intracranial hemorrhage, mass effect, edema, shift of normally midline structures or hydrocephalus. The density values of the brain parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Imaged paranasal sinuses and mastoid air cells are well aerated. . CT ABDOMEN/PELVIS [**11-20**]:The lung bases are clear, with no nodules or masses identified. There is no pleural or pericardial effusion. On this non-contrast scan, the liver, gallbladder, spleen, adrenal glands, and left kidney are unremarkable. In greatest dimension, left kidney measures 12.5 cm. There is an ectopic and malrotated right kidney, with the hilum facing anteriorly. The right kidney starts superiorly at the level of the aortic bifurcation and extends to approximately S1. Renal parenchymal enhancement and ureteral opacification are not able to be evaluated due to lack of IV contrast. Intra-abdominal small and large bowel loops are normal. Scattered retroperitoneal lymph nodes are seen, none of which meet CT criteria for pathologic enlargement. The sigmoid colon, rectum, and bladder are normal. No pelvic free fluid or lymphadenopathy. Scattered inguinal lymph nodes are seen, with one prominent left inguinal lymph node that is rounded and measures 1.7 cm in short axis. IMPRESSION: Ectopic right kidney, located in the pelvis. Renal enhancement and ureteral insertion cannot be evaluated due to lack of IV contrast. . EKG: NSR 88. J point elevation. No ST segment changes . LABS ON ADMISSION: [**2150-11-19**] 10:01PM BLOOD WBC-13.9*# RBC-4.32* Hgb-12.6*# Hct-36.8*# MCV-85 MCH-29.1 MCHC-34.2 RDW-13.6 Plt Ct-331 [**2150-11-19**] 10:01PM BLOOD Neuts-72.4* Lymphs-21.2 Monos-3.7 Eos-2.2 Baso-0.5 [**2150-11-21**] 06:23AM BLOOD PT-13.4* PTT-31.6 INR(PT)-1.2* [**2150-11-19**] 05:55PM BLOOD Glucose-85 UreaN-54* Creat-5.5*# Na-142 K-4.0 Cl-107 HCO3-22 AnGap-17 [**2150-11-20**] 12:44AM BLOOD CK(CPK)-399* [**2150-11-20**] 12:44AM BLOOD CK-MB-6 cTropnT-<0.01 [**2150-11-20**] 06:00AM BLOOD calTIBC-243* Ferritn-333 TRF-187* [**2150-11-20**] 12:44AM BLOOD %HbA1c-5.3 [**2150-11-19**] 05:55PM BLOOD Triglyc-170* HDL-40 CHOL/HD-7.2 LDLcalc-215* LDLmeas-216* [**2150-11-21**] 06:23AM BLOOD PTH-283* [**2150-11-20**] 11:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . URINE LABS [**2150-11-19**] 05:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2150-11-19**] 05:40PM URINE Blood-MOD Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2150-11-19**] 05:40PM URINE RBC-[**7-19**]* WBC-[**7-19**]* Bacteri-FEW Yeast-NONE Epi-0-2 [**2150-11-19**] 05:40PM URINE CastGr-0-2 CastHy-0-2 [**2150-11-19**] 06:45PM URINE Hours-RANDOM Creat-124 TotProt-808 Prot/Cr-6.5* [**2150-11-21**] 02:24PM URINE pH-5 Hours-24 Volume-1225 Creat-117 TotProt-579 Prot/Cr-4.9* [**2150-11-21**] 02:24PM URINE 24Creat-1433 24Prot-7093 [**2150-11-20**] 08:07PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG. . PENDING W/U: [**2150-11-21**] 06:23AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND Brief Hospital Course: 22 yo male with no PMH who presented with hypertensive urgency and newly diagnosed renal failure. #)Hypertensive urgency- Felt to be due to either idiopathic hypertension and/or chronic kidney disease. No chest pain, shortness of breath, back pain, hx of cocaine use. No seizures or other visual disturbances. No EKG changes concerning for ischemia. Patient was started on a labetolol drip and pressures were slowly decreased from systolics of 220 to 160s over 2 days. Patient was transitioned to oral labetolol. Renal was consulted and followed. Pt discharged on labetalol 600 mg po tid. If pt's HTN not well-controlled on labetalol as outpt, would consider addition of calicium channel blocker. . #)Renal failure) No past creatinine to compare. Pt had creatine in the 5 range during admission, without any significant improvement or worsening. Renal U/S and CT abd/pelvis results as above. Note that pt's left kidney was normal size on CT scan. The pt had nephrotic range proteinuria (not nephrotic syndrome). Unclear etiology. A possible etiology is very progressive hypertensive nephropathy secondary to underlying malignant hypertension. Pt refused HIV test. Pt to f/u in renal clinic this week with repeat electrolytes. If no improvement, pt will likely require renal biopsy. SPEP, UPEP and vitamin D levels sent on day of discharge and are pending. Medications on Admission: None Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 2. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Renal Failure Discharge Condition: Vital Signs Stable Discharge Instructions: PT TO SCHEDULE IMMEDIATE RENAL F/U APPT IN [**Hospital **] CLINIC ([**Telephone/Fax (1) 60**]) WITH DR. [**First Name (STitle) **] TAM OR DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **] THIS WEEK. PT TO HAVE REPEAT electrolyte check at that visit. Followup Instructions: Pt to arrange f/u in renal clinic this week. Very important.

[ "276.2", "278.00", "285.9", "V45.73", "585.9", "753.3", "403.00", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7765, 7771

6071, 7448

337, 343

7849, 7869

2406, 4441

8191, 8255

1533, 1622

7503, 7742

7792, 7828

7474, 7480

7893, 8168

2283, 2387

1637, 2187

277, 299

371, 1267

4455, 6048

2202, 2266

1289, 1329

1345, 1517

30,795

162,156

31951

Discharge summary

report

Admission Date: [**2179-10-6**] Discharge Date: [**2179-11-25**] Date of Birth: [**2135-7-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Mr. [**Known lastname 74900**] is a 44-year-old gentleman who presents from an outside hospital after admission for acute pancreatitis and suffering a cardiac arrest. The patient was admitted to the hepatobiliary service on [**2179-10-6**]. Major Surgical or Invasive Procedure: [**2179-10-6**] Central line placed [**2179-10-7**] Exploratory laparotomy. Pancreatic debridement. [**2179-10-9**] Exploratory lap debridement of necrotic pancreas and packing change. [**2179-10-12**] Exploratory laparotomy, dressing and packing removal, abdominal washout and Vicryl mesh abdominal closure. [**2179-10-27**] CT Guided drainage Abdomen [**2179-11-4**] Dobbhoff and PICC placed History of Present Illness: 44 year old man hx idiopathic pancreatitis, HTN, DM, admitted to [**Hospital3 **] Hospital on [**10-4**] for pancreatitis, developed cardiac arrest and was rescusitated, then transferred to [**Hospital1 18**] on [**10-6**]. On [**10-4**] he had the acute onset of epigastric pain, [**9-29**] severity, non-radiating, associated with nausea and vomiting. He had no fever, chills, diarrhea. Patient was admitted to Cap Code Hospital for treatment of pancreatitis. He was given hydration and Zosyn. On [**10-6**] patient had tachypneic and respiratory acidosis. Patient was intubated. During the intubation the ETT was temporarily too far advanced and the left lung was not aerated. The ETT was pulled back and aeration of left lung was restored. Patient developed sinus tachycardia, then wide complex bradycardia. Cardiac arrest code was called. He received calcium chloride, insulin, D50, epinephrine, atropine. He then had ventricular fibrillation for fifteen minutes. Chest compressions were performed throughout the code. Patient received two shocks of 360 joules. His heart rate returned to [**Location 213**] sinus. His blood pressure was low necessitating Levophen and Vasopressin. At the time of transfer to [**Hospital1 18**], his BP was 95/52 with MAP of 67. Pulse was 124. Past Medical History: Acute pancreatitis Asthma Diabetes Hypertension Right knee surgery Social History: The patient is single, works as a salon manager. There is no history of excessive EtOH use, no tobacco or illicit drugs. Family History: Mother had DM and heart disease Father is alive. Physical Exam: VS: Tm 102.4 Tc 101.3 BP 115-174/50-66 P 121-134 R [**9-14**] 02 99% AC 50%/PEEP 12/TV 600/ R 20 Gen: WD/WN Heent: supple neck, no carotid bruits, no lymphadenopathy Chest: lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi Heart: regular rate and rhythm, no murmurs, Abd: soft, s/p exploratory laparatomy Ext: no cyanosis, clubbing, or edema Skin: no erythema Neuro: MS: does not open eyes to noxious, does not follow commands, CN: pupils 5 to 4 mm, + oculocephalics, weak gag, positive corneals bilaterally Motor: does not spontaneously move ext. flaccid tone of all four ext. Sensory: does not withdraw ext to pain Reflex: 0 for biceps, triceps, BR, knees, ankles toes mute Pertinent Results: [**2179-10-6**] 10:52 PM CT CHEST W/CONTRAST; CT ABD W&W/O C TECHNIQUE: Helical 5 mm axial MDCT sections were obtained through the abdomen and pelvis, with a small amount of oral and prior to intravenous contrast administration; helical 5 mm sections were then obtained from the thoracic inlet through the pubic symphysis during dynamic intravenous contrast administration. Coronal and sagittal reformations were prepared, and all images are reviewed in lung, soft tissue and bone window settings on the work station. FINDINGS: The study is quite limited by the patient's body habitus, and there are no comparisons on record. There is a low-lying endotracheal tube with its tip only 1.5 cm proximal to the carina and no endogastric tube is identified in the moderately gas- distended stomach. A right internal jugular central venous catheter reaches the distal SVC. There is extensive abnormality involving both lungs with dense consolidations with extensive air bronchograms involving the dependent portions of the lung bases, associated with layering pleural effusions. There are also dense consolidations involving the right middle lobe more than lingula. There are also widely-distributed multifocal ground-glass opacities, which are highly nonspecific. These are on the background of diffuse ground- glass opacity associated with smooth septal thickening likely related to fluid overload. There is no discrete pericardial effusion, with relatively mild left ventricular enlargement. No mediastinal adenopathy is seen. There is no pneumothorax and central airways are patent. There is a large amount of ascites, both around the liver and extending caudally in both paracolic gutters to reach the pelvis. This is associated with extensive inflammatory fat- stranding (and/or passive congestion) of the mesentery throughout the abdomen and pelvis. This process appears centered on a very abnormal pancreas which is diffusely and grossly enlarged and heterogeneous in both intrinsic attenuation and enhancement, with extensive peripancreatic edema and fat-stranding. The pancreatic head, itself, is markedly and focally enlarged, and measures, on average [**12-22**] [**Doctor Last Name **], pre-, enhancing to only 15, [**Doctor Last Name **], post- contrast, in comparison to the remainder of the gland, which enhances to roughly 52 [**Doctor Last Name **]. This finding, in context, is highly concerning for pancreatic necrosis. There is no gas within this process or elsewhere about the pancreas and there is no free intraperitoneal gas. There is no discrete rim-enhancing or other fluid collection. Evaluation of the pancreatic vessels is limited, and the proximal portion of the splenic vein, from the splenic hilum, is not definitely visualized. However, there is no evidence of thrombosis of the more distal splenic vein to the splenic- SMV confluence, and the portal vein and its branches appear patent by opacification. There is only limited evaluation of the celiac axis and the SMA and their branches, but there is no finding to specifically suggest pseudoaneurysm. IMPRESSION: 1) Severe acute pancreatitis, particularly involving the pancreatic head with non-enhancement suggestive of pancreatic necrosis; there is no definite evidence of pancreatic abscess formation. 2) Extensive ascites, likely related to #1, above, with no discrete fluid collection to suggest early pseudocyst formation. 3) No specific evidence of vascular complication, though the evaluation is somewhat limited, as above. 4) Extensive pulmonary abnormalities, as described, including bibasilar consolidations with pleural effusions, as well as diffuse but multifocal peripheral ground-glass opacities which have a wide differential diagnosis. In particular, there is evidence of volume overload, which may explain some of these findings, though ARDS related to "necrotizing" pancreatitis is also a consideration. 5) Relatively low-lying endotracheal tube, which should be partially withdrawn. CT HEAD W/O CONTRAST [**2179-10-8**] 10:58 AM FINDINGS: There has been no significant interval change. There is no intra- or extra-axial hemorrhage. There is no mass effect or shift of normally midline structures, and the ventricles, cisterns, and sulci maintain in a normal configuration with the exception of my incidental note of a prominent posterior CSF space. [**Doctor Last Name **]-white matter differentiation is always difficult to evaluate on non-contrast CT, but no gross abnormalities are identified. There is mild mucosal thickening of the sphenoid, ethmoid, and maxillary sinuses. The right mastoid air cells are opacified, and there is partial opacification of the left mastoid air cells, unchanged. The patient is intubated. IMPRESSION: Evaluation for diffuse hypoxic injury may be difficult by non- contrast head CT but there is no evidence for global abnormality of the [**Doctor Last Name 352**]- white matter differentiation. MR with diffusion-weighted imaging is recommended for a more sensitive evaluation. Neurophysiology Report EEG Study Date of [**2179-10-8**] FINDINGS: ABNORMALITY #1: Throughout the recording the patient's background was low voltage, disorganized, and slow, up to 5 Hz maximum. It was poorly reactive. No clearly epileptiform features were noted. ABNORMALITY #2: Several bursts of generalized delta frequency slowing were noted. At times, these had a bifrontal predominance. BACKGROUND: As above. HYPERVENTILATION: Could not be performed as this was portable study. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular but tachycardic rhythm. IMPRESSION: This is an abnormal portable EEG due to the slow, poorly organized, and poorly reactive background with admixed bursts of generalized delta frequency slowing, consistent with a moderate to marked global encephalopathy. This suggests bilateral subcortical or deep midline dysfunction. Medications, metabolic disturbances, infection, and anoxia are among the common causes of encephalopathy. There were no focal or epileptiform features, although encephalopathic patterns may obscure focal EEG abnormalities. No electrographic seizures were noted. INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B. Neurophysiology Report EEG Study Date of [**2179-10-13**] FINDINGS: ABNORMALITY #1: Throughout the record the background rhythm remained of very low voltage and with a uniform distribution of voltage and frequencies. There was no clear reactivity of the background to external stimuli. There was some low voltage evidence of cerebral activity, but much of the tracing was contaminated by cardiac and muscle artifact. There were no areas of prominent focal slowing, and there were no clearly epileptiform features. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular tachycardia with a rate of approximately 105. IMPRESSION: Markedly abnormal portable EEG due to the very low voltage, uniformly distributed background without clear reactivity to external stimuli. This finding indicates a severe and widespread encephalopathy. Such tracings can be due to sedating medications such as Propofol, but it was reported that the medication had been discontinued 30 minutes earlier. In the absence of medication effect, anoxia is a more common explanation. INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] W. Neurophysiology Report EP Study Date of [**2179-10-21**] FINDINGS: MEDIAN NERVE SOMATOSENSORY EVOKED POTENTIAL (07-149): After stimulation of either median nerve there were no discernible evoked potential peaks at Erb's point or at the P/N13 and N19 waveform positions. It is very unusual to not obtain a peak at Erb's point. This can be due to a severe peripheral neuropathy, technical factors, or body habitus (particularly at the neck or shoulders). In the absence of a peak at Erb's point it is not possible to comment on subsequent (intracranial, cerebral) conduction. INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] W. CT GUIDANCE DRAINAGE [**2179-10-27**] 3:43 PM COMPARISONS: CT of the abdomen and pelvis dated [**2179-10-23**]. PROCEDURE: After explaining potential risks, benefits and alternatives of the procedure to the [**Hospital 228**] healthcare proxy, written informed consent was obtained. All questions were answered. Patient identity was confirmed using name and date of birth. The patient's intensive care unit nurse was present to appropriately sedate and monitor the patient. Limited CT images from the lower chest through the proximal femora were obtained for localization purposes, without intravenous or oral contrast. Images revealed the tip of a central venous catheter in the distal superior vena cava and a nasogastric tube was seen to terminate in the stomach. Small bilateral pleural effusions with adjacent moderate atelectasis (left greater than right) appeared similar. A right lower lobe calcified granuloma was incidentally noted. The patient's largest peripancreatic fluid collection demonstrated significant interval decrease in size, with redemonstration of a small collection adjacent to the tail and a moderate-sized collection inferior to the head, measuring 6.3 x 10.6 cm. The remaining pancreatic parenchyma status post necrosectomy was surrounded by severe inflammatory change. The liver, adrenal glands and kidneys appeared grossly unremarkable. Splenomegaly was again noted. A small amount of fluid was tracking along both pericolic gutters. A large open anterior abdominal wound remained. The patient's fluid collection adjacent to the pancreatic head was localized with CT, and the right lateral abdomen was marked, prepared and draped in the usual sterile fashion. 1% lidocaine was injected into the overlying skin and subcutaneous tissues for local anesthesia. Thereafter, utilizing CT guidance and a trocar technique, a 12 French catheter was placed directly into the fluid collection. Approximately 200 cc of opaque beige-colored fluid was aspirated, and a portion was sent to the laboratory for Gram stain and culture . The catheter was then secured and adequate hemostasis was achieved. The patient tolerated the procedure, without immediate complication. Dr. [**First Name (STitle) **] was an essential participant in the procedure. Limited post- procedure scanning revealed significant interval decrease in the size of the fluid collection, with only a small amount of residual fluid remaining. IMPRESSION: 1. Patient status post CT-guided placement of a 12 French catheter into a fluid collection adjacent to the pancreatic head, without immediate complication. Neurophysiology Report EEG Study Date of [**2179-10-27**] OBJECT: ASSESS AFTER BRAIN INJURY. FINDINGS: ABNORMALITY #1: Throughout the record the background was of such low voltage that no clear electrical activity of cortical origin could be discerned. There was regular cardiac artifact on the EEG, and there was also muscle artifact in the forehead leads. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Markedly abnormal portable EEG due to the absence of discernible electrical activity of cortical origin. This implies an extremely severe encephalopathy. There was no evidence of epileptic seizure. There was no change from the previous recording. INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] W. Brief Hospital Course: On [**10-4**] he had the acute onset of epigastric pain, [**9-29**] severity, non-radiating, associated with nausea and vomiting. He had no fever, chills, diarrhea. Patient was admitted to Cap Code Hospital for treatment of pancreatitis. He was given hydration and Zosyn. On [**10-6**] patient had tachypneic and respiratory acidosis. Patient was intubated. During the intubation the ETT was temporarily too far advanced and the left lung was not aerated. The ETT was pulled back and aeration of left lung was restored. Patient developed sinus tachycardia, then wide complex bradycardia. Cardiac arrest code was called. He received calcium chloride, insulin, D50, epinephrine, atropine. He then had ventricular fibrillation for fifteen minutes. Chest compressions were performed throughout the code. Patient received two shocks of 360 joules. His heart rate returned to [**Location 213**] sinus. His blood pressure was low necessitating Levophen and Vasopressin. At the time of transfer to [**Hospital1 18**], his BP was 95/52 with MAP of 67. Pulse was 124. At [**Hospital1 18**] he was given vancomycin and meropenem. Levophed and Pitressin were given also. On [**10-7**], he underwent exploratory laparatomy. No pancreatic abscess found. There is inflammation of the pancreas body and tail. After his surgery he was taken off pressors. [**2179-10-7**] The patient was brought to the OR for and exploratory laparotomy and pancreatic debridement. The patient was unresponsive with limited non-purposefull movement. The patient was treated with vancomycin and meropenum. [**10-9**] The patient was brought back to the operating room for exploratory lapartomy and debridement of necrotic pancreas and packing change. The patient continues to be intubated and on ventilation. [**10-12**] The patient returned to the operating room for and exploratory laparotomy, dressing and packing removal, abdominal washout and Vicryl mesh abdominal closure. While the patient had + corneal, gag and cough reflexes at this time, he was not following commands and not moving any extremities to pain or spontaneously. [**10-13**] TPN nutrition was ordered [**10-16**] Foley changed due to presence of yeast. [**10-19**] Tube feeds started [**10-25**] Antibiotics changed to IV linezolid. [**10-29**] Bedside percutaneous trach placement. [**11-4**] Dobbhoff and PICC line placed, CVL removed. The patient remained intubated with variable neurological exams ranging from no movement at all to non-purposeful movement. The patient was extubated and placed on a trach collar [**11-5**]. On [**11-9**] the patient was transferred to the floor for continued monitoring. Antibiotics and tube feeding were continued. The VAC dressing was changed every 3-4 days and the wound was healing well with granulation tissue present. The Dobbhoff feeding tube was removed on [**11-18**] due to aspiration of feeds. There was a family meeting on [**11-19**] with a consensus made by the famlily and partner to make the patient comfort measures only. As a result, tube feeding and all unnecessary medications and treatments were stopped. The patient received morphine SL around the clock and as needed along with ativan, levsin, acetaminophen, and oxygen therapy. The patient expired on [**2179-11-25**]. Medications on Admission: metformin 1,000mg [**Hospital1 **] glyburide 5mg [**Hospital1 **] Lisinopril 20 qam [**Doctor First Name **] Flonase Duoneb Combivent Aspirin 325mg daily prilosec Multivitamin Vitamin B12 [**Hospital1 **] Vit C Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: CMO Pancreatitis Sepsis Discharge Condition: Expired Discharge Instructions: None Followup Instructions: none

[ "250.00", "427.41", "584.9", "401.9", "577.0", "348.1", "V46.11", "285.9", "995.92", "038.9" ]

icd9cm

[ [ [] ] ]

[ "00.14", "38.91", "38.93", "96.6", "54.72", "99.15", "31.1", "52.22", "96.72" ]

icd9pcs

[ [ [] ] ]

18684, 18693

15101, 18393

555, 950

18761, 18771

3316, 15078

18824, 18831

2507, 2558

18655, 18661

18714, 18740

18419, 18632

18795, 18801

2573, 3297

275, 517

978, 2263

2285, 2353

2369, 2491

17,703

190,726

50235

Discharge summary

report

Admission Date: [**2166-10-8**] Discharge Date: [**2166-10-14**] Date of Birth: [**2107-8-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: End stage liver disease secondary to Hep-c and EtOH cirrhosis Major Surgical or Invasive Procedure: liver transplant [**2166-10-9**] History of Present Illness: 59M presents to [**Hospital1 18**] on [**2166-10-8**] as pre-op for OLT. On review of systems pt has no specific complaints at this time. Pt denies fever, chills, N/V, CP but does have minimal amount of diarrhea. Past Medical History: - Liver disease - cirrhosis secondary to EtOH and hepatitis C complicated by ascites, mild encephalopathy, and upper GI bleeds - had first episode of GI bleed in [**2166-1-2**] with multiple subsequent episodes, all treated with banding. Prior to TIPs had undergone repeat currently receiving transplant work-up Social History: retired carpenter divorced x 30 years 3 adult children and supportive family denies EtOH - quit [**2165-1-2**] and active in AA denies drug use - prior history of smoking and snorting cocaine denies current tobacco use - quit 1.5 week ago, was smoking 1 pack/3 days prior to that Family History: non-contributory Physical Exam: NAD + Scleral Icterus CV: reg, +s1/s2, no m/r/g pulm: cta b/l abd: soft, NT/ND, +bs ext: good distal pulses, extremities warm and well perfused Pertinent Results: [**2166-10-14**] 04:30AM BLOOD WBC-4.0 RBC-3.23* Hgb-10.3* Hct-29.1* MCV-90 MCH-31.8 MCHC-35.4* RDW-16.8* Plt Ct-87* [**2166-10-13**] 04:30AM BLOOD WBC-4.5 RBC-3.23* Hgb-10.2* Hct-29.2* MCV-91 MCH-31.5 MCHC-34.8 RDW-17.1* Plt Ct-73* [**2166-10-9**] 08:18AM BLOOD WBC-8.2 RBC-2.74* Hgb-8.8* Hct-24.8* MCV-91# MCH-32.2* MCHC-35.5* RDW-17.2* Plt Ct-89* [**2166-10-8**] 09:59PM BLOOD WBC-7.5# RBC-3.03* Hgb-10.4* Hct-30.6* MCV-101* MCH-34.3* MCHC-33.9 RDW-17.2* Plt Ct-161 [**2166-10-14**] 04:30AM BLOOD Plt Ct-87* [**2166-10-13**] 04:30AM BLOOD Plt Ct-73* [**2166-10-9**] 02:35AM BLOOD PT-22.5* PTT-54.6* INR(PT)-2.2* [**2166-10-8**] 09:59PM BLOOD PT-19.3* PTT-49.5* INR(PT)-1.8* [**2166-10-11**] 09:02PM BLOOD Fibrino-371 [**2166-10-10**] 05:50AM BLOOD Fibrino-409* [**2166-10-9**] 02:35AM BLOOD Fibrino-102* [**2166-10-8**] 09:59PM BLOOD Fibrino-107* [**2166-10-14**] 04:30AM BLOOD Glucose-108* UreaN-40* Creat-1.2 Na-133 K-4.4 Cl-100 HCO3-27 AnGap-10 [**2166-10-13**] 04:30AM BLOOD Glucose-139* UreaN-40* Creat-1.1 Na-135 K-4.5 Cl-100 HCO3-28 AnGap-12 [**2166-10-9**] 08:18AM BLOOD Glucose-181* UreaN-21* Creat-0.9 Na-135 K-5.1 Cl-99 HCO3-27 AnGap-14 [**2166-10-8**] 09:59PM BLOOD Glucose-82 UreaN-23* Creat-1.1 Na-130* K-5.0 Cl-97 HCO3-27 AnGap-11 [**2166-10-14**] 04:30AM BLOOD ALT-237* AST-81* AlkPhos-232* TotBili-1.2 [**2166-10-13**] 04:30AM BLOOD ALT-272* AST-98* AlkPhos-284* Amylase-46 TotBili-1.2 [**2166-10-12**] 06:00AM BLOOD ALT-320* AST-122* AlkPhos-332* Amylase-51 TotBili-1.4 [**2166-10-9**] 08:18AM BLOOD ALT-634* AST-1518* AlkPhos-182* Amylase-81 TotBili-4.9* DirBili-3.7* IndBili-1.2 [**2166-10-8**] 09:59PM BLOOD ALT-57* AST-116* AlkPhos-228* TotBili-5.1* [**2166-10-9**] 03:19PM BLOOD ALT-518* AST-1231* AlkPhos-157* TotBili-3.9* DirBili-2.9* IndBili-1.0 [**2166-10-14**] 04:30AM BLOOD Albumin-2.6* Calcium-8.8 Phos-2.3* Mg-1.6 [**2166-10-13**] 04:30AM BLOOD Albumin-2.7* Calcium-8.9 Phos-2.7 Mg-1.8 [**2166-10-10**] 05:50AM BLOOD Albumin-2.6* Calcium-8.6 Phos-4.8* Mg-2.1 [**2166-10-9**] 08:18AM BLOOD Calcium-9.1 Phos-5.4*# Mg-2.1 [**2166-10-14**] 05:38AM BLOOD FK506-6.5 [**2166-10-11**] 07:13AM BLOOD FK506-3.4* [**2166-10-9**] 07:30PM BLOOD Type-ART pO2-158* pCO2-41 pH-7.44 calTCO2-29 Base XS-4 [**2166-10-9**] 03:43PM BLOOD Type-ART pO2-194* pCO2-38 pH-7.46* calTCO2-28 Base XS-3 [**2166-10-9**] 02:45AM BLOOD Type-ART pO2-228* pCO2-43 pH-7.38 calTCO2-26 Base XS-0 [**2166-10-9**] 12:24AM BLOOD Type-ART pO2-309* pCO2-43 pH-7.41 calTCO2-28 Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [**2166-10-9**] 07:05AM BLOOD Glucose-186* Lactate-3.2* Na-134* K-4.9 Cl-99* [**2166-10-9**] 06:34AM BLOOD Glucose-179* Lactate-2.9* Na-134* K-4.7 Cl-101 Brief Hospital Course: [**2166-10-8**] pt admitted for pre-op for OLT (Orthoptic liver transplant) [**2166-10-9**]: OLT surgery. The patient tolerated the procedure well, there were no complications. Pt transfered to SICU intubated after procedure. [**2166-10-10**]: POD#1 Pt extubated overnight. Alert and oriented doing well. DUPLEX DOPP ABD/PEL : Patent hepatic vessels. Absent late diastolic arterial flow, of uncertain significance. Recommend followup study to reevaluate hepatic arteries. [**2166-10-11**]: POD#2 [**Name (NI) 20851**] pt doing well and stable. Abd soft. DUPLEX DOPP ABD/PEL: [**2166-10-11**] The main, left, and right portal veins are widely patent, with normal hepatopetal flow. Middle, right, and left hepatic veins are also patent. Hepatic arteries are also patent with good arterial waveforms. Again seen is lack of flow in the late diastolic phase, which is of uncertain significance. A small fluid collection is seen in the gallbladder fossa measuring 4.1 x 1.9 x 2.4 cm. [**2166-10-12**]: POD#3 pt transfered from unit overnight. [**Month/Day/Year 20851**] No complaints. Tolerating PO diet. [**2166-10-13**]: POD#4 [**Name (NI) 20851**] pt continues to improve. Pt able to ambulate without difficulties. [**2166-10-14**]: POD#5 D/C JP drain overnight. [**Month/Day/Year 20851**]. Pt feels great. D/C home with services. Medications on Admission: Protonix 40' Spironolactone 200 qd asa 325' plavix 75' Lactulose 10g/15ml TID(45ml) clotrimazole 10' Furosemide 80 mg QD Rifaxamin 400 mg TID Discharge Medications: 1. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days: then follow taper. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:*1 * Refills:*2* 12. syringes insulin syringes, 1box refill:1 Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: HCV cirrhosis/etoh cirrhosis Discharge Condition: good Discharge Instructions: Call [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability to take meds, jaundice, worsening abdominal pain, fluid retention, incision redness/bleedin/drainage or any questions. labs every Monday and Thursday for cbc, chem10, ast, alt, alk phos, tbili, albumin and trough prograf level. fax to [**Telephone/Fax (1) 697**] [**First Name9 (NamePattern2) 5035**] [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-10-16**] 8:20 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2166-10-16**] 10:00 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-10-23**] 9:00 Completed by:[**2166-10-14**]

[ "070.70", "303.93", "571.2", "572.3", "570" ]

icd9cm

[ [ [] ] ]

[ "00.93", "38.93", "50.59" ]

icd9pcs

[ [ [] ] ]

6847, 6918

4193, 5538

377, 412

6991, 6998

1504, 4170

7501, 7956

1307, 1325

5733, 6824

6939, 6970

5564, 5710

7022, 7478

1340, 1485

276, 339

440, 657

679, 993

1009, 1291

49,322

172,472

40635

Discharge summary

report

Admission Date: [**2103-3-21**] Discharge Date: [**2103-4-4**] Date of Birth: [**2020-1-23**] Sex: M Service: CARDIOTHORACIC Allergies: lisinopril / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5790**] Chief Complaint: FDG avid right upper lobe cavitary lung nodule. Major Surgical or Invasive Procedure: [**2103-3-31**] bronchoscopy with interventional pulmonology [**2103-3-30**] IR drainage of right pleural effusion [**2103-3-29**] bronchoscopy with interventional pulmonology [**2103-3-26**] bronchoscopy with interventional pulmonology [**2103-3-25**] bronchoscopy with mucus plug removal [**2103-3-23**] bronchoscopy with interventional pulmonology [**2103-3-21**] VATS right upper lung lobe History of Present Illness: 83 y.o. Italian speaking male being followed for a 3.5 cm RUL cavitary nodule, suspcious for TB or cavitary tumor, returns for eval. He preferred observation rather than biopsy at his last visit. Currently, the pt reports only occas dry cough and some shortness of breath after climbing two flights of stairs, which does not require him to sit down. RUL transbronchial biopsy done in [**2102-7-31**] was negative for malignancy. Currently the patient has had a repeat CT scan which demonstrated FDG avidity in the region of the lung nodule and some uptake in T11. He does come today with an X-ray report of the thoracic and lumbar spine which demonstrated no abnormality in that region. . ROS: otherwise negative Past Medical History: COPD Hypertension Inguinal hernia Renal insufficiency BPH Social History: Cigarettes: quit: 17 yrs ago, 40 pk yr hx ETOH: [x ] Yes drinks/day: 1 cogniac/day Drugs: none Exposure: [ x] No Occupation: retired welder Marital Status: [x ] Married Lives: [x] w/ wife & 2 girls Travel history: From [**Country 2559**], last travel a year ago to [**Country 2559**]. USA x 45 years Family History: Mother- colon CA, rheumatic heart disease Father- CVA, HTN Siblings- one sister w/ lymphoma still alive, HTN Physical Exam: ON ADMISSION: ------------ BP: 134/60. Heart Rate: 75. Temperature: 96.7. Resp. Rate: 12. Pain 0. O2 Saturation%: 87% RA. Gen: AOx3 NAD Cor: RRR without MRG Res: Nl WOB, CTAB Abd: Soft, nt/nd without organomegaly Ext: w/w/p, no c/c/e, moves all . ON DISCHARGE: ------------- BP: 150/80. Heart Rate: 82. Temperature: 98.0. Resp. Rate: 18. Pain 0. O2 Saturation%: 87-92% on 2-4L NC. Gen: AOx3 NAD Cor: RRR without MRG Res: Nl WOB, decreased BS on right, expiratory wheezes b/l Abd: Soft, nt/nd without organomegaly Ext: w/w/p, no c/c/e, moves all Pertinent Results: LABS ON ADMISSION: ------------------ [**2103-3-22**] 07:10AM BLOOD WBC-10.3 RBC-3.63* Hgb-11.6* Hct-35.8* MCV-99* MCH-31.9 MCHC-32.3 RDW-13.3 Plt Ct-308 [**2103-3-21**] 07:07PM BLOOD Glucose-166* UreaN-31* Creat-1.4* Na-139 K-4.0 Cl-105 HCO3-25 AnGap-13 [**2103-3-21**] 07:07PM BLOOD Calcium-9.3 Phos-4.0 Mg-2.2 [**2103-3-21**] 02:52PM -ART pO2-195* pCO2-34* pH-7.41 calTCO2-22 Base XS--1 [**2103-3-21**] 02:52PM BLOOD Glucose-97 Lactate-0.9 Na-138 K-2.5* Cl-114* [**2103-3-21**] 02:52PM BLOOD Hgb-8.8* calcHCT-26 [**2103-3-21**] 02:52PM BLOOD freeCa-1.00* . LABS ON DISCHARGE: ------------------ [**2103-4-4**] 06:55AM BLOOD WBC-12.3* RBC-3.43* Hgb-10.7* Hct-33.8* MCV-99* MCH-31.1 MCHC-31.6 RDW-13.6 Plt Ct-588* [**2103-4-4**] 06:55AM Glu-107 BUN-21 Cr-1.1 Na-137 K-4.3 Cl-100 HCO3-27 AG-14 [**2103-4-4**] 06:55AM BLOOD Calcium-9.5 Phos-3.6 Mg-2.1 . IMAGING & STUDIES: ------------------ [**2103-3-21**] CXR: There is right chest tube in place. Opacities in the right perihilar region and right mid lung are postoperative findings. Cardiomegaly is stable. There is no large pneumothorax or pleural effusions. There is right subcutaneous emphysema. . [**2103-3-24**] CT CHEST NON-CONTRAST: IMPRESSION: 1. Status post right upper lobectomy, with a small air-fluid level seen in the resection bed. No evidence of hemorrhage. A small loculated pneumothorax and small simple effusion in the right basal pleural space. 2. Partial aeration of the superior segment of the right lower lobe, with near complete collapse of the right middle and lower lobes. Large amount of secretions obstructing the right main and bronchus intermedius. 3. Large amount of right chest wall emphysema relates to the recent procedure. . [**2103-3-30**] CT CHEST NON-CONTRAST: IMPRESSION: 1. Enlarged large right hydrothorax at the right upper lobectomy bed. 2. Interval complete collapse of the right middle and lower lobes, with slightly increased rightward mediastinal shift. 3. Unchanged right lower 4.8 x 4.3 cm extrapulmonary gas-fluid collection. 4. Large amount of secretions within the bronchus intermedius and distal branches. 5. Clear left lung. . [**2103-3-30**] BRONCHIAL WASHINGS: PLEURAL FLUID. GRAM STAIN (Final [**2103-3-30**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2103-4-2**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . [**2103-4-4**] CXR: FINDINGS: As compared to the previous radiograph, the right pigtail catheter has been removed. The extrathoracic air collection with multiple air-fluid levels is unchanged in size and appearance. The extent of the right pleural effusion has minimally increased. As a consequence, the amount of ventilated lung parenchyma at the lung base has decreased. Unchanged appearance of the left lung. Brief Hospital Course: Mr. [**Known lastname 88903**] is an 83yM who initially presented to the thoracic surgery clinic in [**2101**] for an incidentally discovered RUL mass on routine preoperative CXR. He underwent PET scanning as well as EBUS which were negative for malignancy. He was followed with surveillance CT scans as he desired conservative management as opposed to VATS biopsy. The nodule continued to grow on f/u CT scan [**1-/2103**] and recommendation was made for resection. He was admitted to [**Hospital1 18**] [**2103-3-21**] at which time he underwent VATS right upper lobectomy with mediastinal lymphadenectomy. He was admitted to the surgical floor postoperatively. He did well on POD1 with good pain control and oxygen requirement of 2-4L by nasal cannula. On POD2, his chest xray demonstrated progressive collapse as well as a sizeable pneumothorax. He underwent placement of an anterior pigtail for evacuation of the pneumothorax and was taken to the OR on [**3-23**] for bronchoscopy for evacuation of mucous plug likely causing lung collapse. He was admitted to the ICU for aggressive pulmonary toilet and continued observation. On [**3-25**], his CXR demonstrated continued atalectasis and he returned to the OR for a repeat therapeutic bronchoscopy. He remained in the ICU receiving 3% normal saline nebulizers as well as Acapella valve therapy and night-time BiPAP as tolerated. His CXRs continued to demonstrated atalectasis with nearly complete right sided collapse and Interventional Pulmonology performed two further bedside bronchoscopies for pulmonary toilet on [**3-27**] and 3.29. A CT chest was obtained [**3-29**] and demonstrated an apical pleural effusion which was drained with a pigtail by Interventional pulmonology. His last bronchoscopy was [**3-30**] with IP and resulted in significant improvement in his CXR with greater aeration. He was transferred from the ICU to the surgical floor and began working with physical therapy. On his first session, he was noted to desaturate with ambulation to 75% while on 2L NC. He continued to work with physical therapy and his ambulatory saturations improved. His pigtail drainage decreased significantly and was insignificant on [**2103-4-3**] at which time it was removed. Physical therapy recommended that he be discharged home with home PT and home oxygen. On [**4-3**], his pain was well controlled, he was tolerating a regular diet and his CXR following pigtail removal was stable. He was deemed to be stable for discharge with PT recommendations in place. Medications on Admission: pravastatin 40' symbicort 2 puffs [**Hospital1 **] losartan 100' hctz 25' latanoprost eye gtts 1 ou hs diltiazem 300' alendronate 70 mg wk spiriva 1 inh daily albut HRA prn miralax vit D multivit asa 81' calcium w/ D Discharge Medications: 1. nasal cannula oxygen Patient requires supplemental nasal cannula oxygen at home. 2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. diltiazem HCl 300 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 6. guaifenesin 600 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) as needed for cough/congestion. Disp:*60 Tablet Extended Release(s)* Refills:*0* 7. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Symbicort 80-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 9. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at bedtime: 1 drop to each eye once daily. 10. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day. 12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) packet PO once a day. 14. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO once a day: Take as prior to admission. 15. multivitamin Tablet Sig: One (1) Tablet PO once a day. 16. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a day. 17. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO twice a day: Take as prior to admission. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: FDG avid right upper lobe cavitary lung nodule. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity: ambulatory w/ assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 88903**], * You were admitted to the hospital for lung surgery, and you've recovered well. You are now ready for discharge to home. * Continue to use incentive spirometer 10 times an hour during day. * Check your incisions daily and report any increased redness or drainage. Cover the area with a gauze pad if it is draining. * Your chest tube dressing may be removed 48 hours after discharge from the hospital. If it starts to drain, cover the site with a clean dry dressing and change it as needed to keep clean and dry. * You will likely continue to need pain medication once you are home, but you can wean off of the Tramadol over a few weeks as the discomfort resolves. You may begin to take only Tylenol or ibuprofen for pain whenever you feel that this is reasonable instead of the Tramadol. Make sure that you have regular bowel movements while on pain medications as they are constipating which can cause more medical problems. Use an over the counter stool softener or gentle laxative to stay regular. * No driving while taking narcotic pain medication (Tramadol). * Tylenol 650 mg (as mentioned above) is OK to take every 6 hours in between your Tramadol doses, but do not take more than 4000mg in 24 hours. * Continue to stay well hydrated and eat well to heal. * Shower daily. Wash incision with mild soap & water, rinse, & dry. * No tub bathing, swimming, or hot tubs until OK given by Dr. [**Last Name (STitle) **]. * No lotions or creams to incision site. * Walk 4-5 times a day and increase activity as you can tolerate. . Call Dr.[**Name (NI) 2347**] office @ [**Telephone/Fax (1) 3020**] if you experience: -Fevers > 101 or chills -Shortness of breath, chest pain, or other concerning symptoms. Followup Instructions: Please call Dr.[**Name (NI) 88904**] office at [**Telephone/Fax (1) 3020**] to schedule a follow-up appointment within 1-2 weeks of discharge from the hospital. . Tentative appt: [**2103-4-17**] Completed by:[**2103-4-6**]

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icd9cm

[ [ [] ] ]

[ "32.41", "96.05", "40.3", "33.24", "34.04" ]

icd9pcs

[ [ [] ] ]

9928, 9979

5422, 7971

359, 755

10071, 10071

2604, 2609

12004, 12229

1913, 2024

8238, 9905

10000, 10050

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783, 1497

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10086, 10215

1519, 1578

1594, 1897

2,786

109,559

8606

Discharge summary

report

Admission Date: [**2118-11-18**] Discharge Date: [**2118-11-21**] Service: MEDICINE Allergies: Haldol / Benadryl Attending:[**First Name3 (LF) 2159**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 87 yo F with HTN, CAD s/p MI with LAD/RCA stents in [**2112**], DM2 on insulin, PVD, CKD (baseline Cr 5.5), and dementia (?nonverbal at baseline) admitted from ED with SOB and worsening mental status x3 weeks. The patient was originally hospitalized at [**Location (un) **] from [**2118-9-26**] to [**2118-10-14**] with left purulent foot ulcer s/p debridement. She was then transferred from the rehab facility with SOB and tachypnea back to [**Location (un) **] and from there to [**Hospital1 18**] ED for further management. At [**Location (un) **] she received Lasix 80 mg IV x1 and placed on CPAP with improvement in her respiratory status. Initial vitals at [**Location (un) **] were HR 86, RR 28, 100% on Neb, BP 137/72. ABG 7.27/40/68/18. WBC 21.4, HCt 31.6, K 6.3, Bicarb 19, BUN 108, Creat 5.1. BNP 1332. She was transferred to [**Hospital1 18**] for further management. On arrival to our ED, she was transitioned from CPAP with O2 sat of 90% to a NRB with O2 sat 94-98%. T 99.8, BP 187/63, HR 98, RR 30. She received 500 cc NS bolus, levoflox, anzemet, hydral, and isordil. Her WBC count was noted to be 23 with no bands, lactate of 1.6. UA with >50 WBC's and few bacteria. BNP [**Numeric Identifier **]. CXR/Chest CT revealed moderate congestive heart failure. A Right IJ was placed. Cr noted to be 5.3 (at baseline). ECG revealed slight ST depression in V4-V6, Trop of 0.31 (in the setting of Cr of 5.3) with a negative MB. She was transferred to [**Hospital Unit Name 153**] for diuresis. Recently admitted to [**Location (un) **] on [**2118-9-26**] until [**2118-10-14**] with left foot ulcer draining puss s/p debridement. On [**11-13**] Na 136, K 3.3, Cl 110. Bicarb 18, BUN 99, Creat 5.5; reported to be baseline. Baseline Hct 37. Echo with well preserved EF, no valvular abnormality. Pt is currently nonverbal and is unable to give any further history. Past Medical History: - CAD s/p anterior MI [**2112**], s/p stent in LAD and RCA in [**Country **] [**Country **]. Repeat cardiac catheterization [**2112**] at [**Hospital1 18**] revealed 1. Two vessel coronary artery disease. 2. Normal ventricular function. 3. Patent stents in the LAD and RCA - DM 2: on Insulin, c/b neuropathy - CKD (baseline Cr of 5.3) - Peripheral vascular disease with ulcerations - Anemia (baseline HCT ~30 from [**2113**]) - Hypertension - Hypothyroidism - h/o MRSA of right foot s/p partial amputation - h/o C-diff [**12/2112**] - paroxysmal Afib on dig (now in sinus), ?coumadin - h/o GI Bleed Social History: The patient is a Spanish-speaking female who lived at [**Location (un) 931**] House Nursing Home, before going to rehab. Denies Tob, EtOH, or illicit drug use. Her son is a physician at [**Name (NI) **] Hospital. Family History: + DM Physical Exam: Tm 99.8 ax BP 161/55 HR 103 RR 25 Sat 97% 2 L NC Gen: Elderly female in NAD. Groaning but nonverbal. Resting in bed. HENNT: NC AT. Dry mucous membranes. CV: RRR. S1S2. No M/R/G. Lungs: CTA anteriorly and laterally. Abd: Soft. ND. Does not appear tender. Positive bowel sounds. Guaiac negative as per ED note. PEG site clean. Ext: No c/c/e. S/P right great toe amputation. Extensive ulceration and necrosis of left foot to level of the bone. Most of heal area has been completely debrided. Neuro: Nonverbal. Not following commands. Pertinent Results: [**2118-11-18**] 01:15AM BLOOD WBC-23.0*# RBC-3.53* Hgb-9.6* Hct-29.8* MCV-85 MCH-27.1 MCHC-32.1 RDW-18.2* Plt Ct-355 [**2118-11-18**] 01:15AM BLOOD Neuts-88.7* Bands-0 Lymphs-7.7* Monos-3.5 Eos-0 Baso-0.1 [**2118-11-18**] 01:15AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ Ovalocy-OCCASIONAL [**2118-11-18**] 01:15AM BLOOD Plt Smr-NORMAL Plt Ct-355 [**2118-11-18**] 01:15AM BLOOD PT-13.1 PTT-25.9 INR(PT)-1.2 [**2118-11-18**] 01:15AM BLOOD Glucose-137* UreaN-116* Creat-5.3*# Na-144 K-5.9* Cl-109* HCO3-16* AnGap-25 [**2118-11-18**] 04:33PM BLOOD ALT-16 AST-12 LD(LDH)-348* CK(CPK)-59 AlkPhos-199* TotBili-0.3 [**2118-11-18**] 01:15AM BLOOD cTropnT-0.31* proBNP-[**Numeric Identifier 30174**]* [**2118-11-18**] 04:33PM BLOOD CK-MB-5 cTropnT-0.26* [**2118-11-18**] 11:00PM BLOOD CK-MB-4 cTropnT-0.28* [**2118-11-18**] 01:15AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.5 [**2118-11-20**] 06:15AM BLOOD WBC-15.0* RBC-3.51* Hgb-9.3* Hct-29.6* MCV-84 MCH-26.6* MCHC-31.6 RDW-20.0* Plt Ct-337 [**2118-11-21**] 03:57AM BLOOD WBC-14.5* RBC-3.29* Hgb-8.7* Hct-27.6* MCV-84 MCH-26.4* MCHC-31.4 RDW-18.2* Plt Ct-298 [**2118-11-19**] 03:45AM BLOOD Neuts-86.3* Bands-0 Lymphs-10.2* Monos-3.0 Eos-0.2 Baso-0.3 [**2118-11-20**] 06:15AM BLOOD PT-13.3 PTT-26.7 INR(PT)-1.2 [**2118-11-21**] 03:57AM BLOOD Glucose-221* UreaN-110* Creat-5.1* Na-147* K-3.4 Cl-109* HCO3-25 AnGap-16 [**2118-11-20**] 08:00PM BLOOD Na-150* [**2118-11-18**] 04:33PM BLOOD ALT-16 AST-12 LD(LDH)-348* CK(CPK)-59 AlkPhos-199* TotBili-0.3 [**2118-11-18**] 11:00PM BLOOD CK(CPK)-55 [**2118-11-21**] 03:57AM BLOOD Vanco-14.6* [**2118-11-20**] 06:15AM BLOOD Vanco-17.5* . CXR [**11-18**]: Interval placement of a right internal jugular central venous catheter. Unchanged congestive heart failure with bilateral pleural effusions. . CT Chest [**11-18**]: 1. Findings consistent with moderate congestive heart failure. 2. Right internal jugular central venous catheter terminating in the right atrium. 3. Atherosclerotic calcifications seen throughout the aorta and its branches, as well as coronary arteries. . CT Head [**11-18**]: No evidence for hemorrhage or cortical territorial infarction. . ECG: NSR, rate 96, LAD, nl intervals, new 0.[**Street Address(2) 1755**] depression in V4-V6. . CXR [**11-19**]: : 1.Mild congestive heart failure. 2. Improvement in the left perihilar infiltrate. . Art Duplex of LE [**11-18**]: prelim read by vasc surgery - R graft occluded, L metatarsal PVR 12 mm . blood cx [**11-18**]: P foot cx [**11-18**]: GPC 2 types urine cx [**11-19**]: P . UA: 15 RBCs 9 WBCs few bact 500 prote 100 gluc sm bld tr leuks . Brief Hospital Course: 87 yo F with HTN, CAD s/p MI with LAD/RCA stents in [**2112**], DM2 on insulin, PVD, and dementia (?nonverbal at baseline) transferred from [**Hospital **] Hospital with SOB from fluid overload and L foot ulcer. . * SOB: The patient's SOB was thought likely to be due to fluid overload; Chest X-Ray and Chest CT revealed moderate CHF; BNP [**Numeric Identifier 30174**]. This was most probably from diastolic dysfunction as she had a normal EF on previous echos. There was no evidence of infiltrate on CXR or CT. It was unlikely to be a PE as she was on standing SC heparin. While in house, strict I/Os were monitored with gentle diuresis with PRN lasix for goal 500cc - 1 L negative per day. Oxygen was given as needed to maintain saturation of 93% or above. Patient was satting better than 95% on room air on discharge. . *Foot Ulcer: Her left foot ulcer was assessed by vascular surgery out of the primary team's concern for osteomyelitis. The wound was debrided by vascular surgery on [**11-18**] and wound culture was sent. She was placed on vancomycin for empiric coverage, dosed by levels. Arterial duplex studies were done. The surgical team recommended amputation before the patient became septic. No other revascularization was recommended. Her son felt that amputation was against his mother's wishes, and opted for conservative management. Her wound was cleaned with Dakin's solution and dressed with wet to dry dressings [**Hospital1 **]. She was to complete a six week course of vancomycin (her first dose here was on [**2118-11-19**]) for her presumed osteomyelitis, although amputation was considered the best treatment. . *UTI: The patient had a UA suspicious of UTI, but epithelial cells were present. Repeat UA also showed signs of infection. A urine cx was sent. The patient was continued on levofloxacin (dosed Q48 hours). She was to complete a 10 day course of antibiotics and her regimen should end on [**2118-11-28**]. . *Elevated WBC: The patient had a chronic elevation of her WBC count (in OMR from yr [**2112**]). There were no signs of sepsis -- the patient remained afebrile, hypertensive, with a normal lactate. The most probable source of her leukocytosis is osteo of the left foot with the extensive ulceration and exposed bone. UTI was also considered as source of infection. Her decreased mental status was thought to be a combination of infection and uremia. . *CRF: The patient presented with Chronic Renal Failure, with her creatinine at baseline of 5.3. She continued to make urine. Her Cr was followed daily; medications were all renally dosed. She was also continued on epogen. The patient's gap acidosis of 20 was thought to be due to uremia. Bicitra was continued. It is recommmended that the patient follow-up with the PCP regarding possible initiation of dialysis. . *Hypernatremia: The patient was hypernatremic on presentation. After her diuresis in the ICU, she was given 1L D5W on the floor to help correct this. Her free water defecit was calculated to be 2.6 liters. Her free water flushes via her PEG tube was increased to 50cc Q2 hours. This may be reduced to 50 cc q 4hours when her hypernatremia resolves. . *HTN: The remained hypertensive and tachycardic while hospitalized. Since there were no signs of sepsis, she was continued on metoprolol and norvasc. Her metoprolol dosing was increased to 50 TID for better control. . * CAD- s/p MI and stenting in [**2112**]. ECG changes were nondiagnostic but patient had 0.[**Street Address(2) 1755**] depressions in V4-V6 that were most likely demand-related in the setting of hypertension. Cycled cardiac enzymes and were flat. She was started on ASA prior to her d/c. Had been noted to be guiac negative during admission before this was started. . *Type 2 DM- She was continued on NPH at reduced doses (16/8) and cover with RISS. QID FS. Sugars were elevated in the last few days of admission, but this was attributed to giving the patient D5W for her hypernatremia and juice flushes for clogged PEG tube. . *Paroxysmal A.Fib - Patient was in sinus rhythm but on dig. Digoxin level was supratherapeutic during admission, so dc'd. She was on Metoprolol TID for rate control. Would recommmend follow-up with her PCP regarding initiation of anti-coagulation. . * FEN: Patient received TF's per G-tube. She had agressive electrolye replacement. Potassium was followed closely, given her renal failure. Bicitra was given for low bicarb. PEG had a history of clogging at [**Location (un) **] and clogged several times her. Was flushed with cranberry juice, carbonated beverages to unclog. GI recommmended bicarb to help unclog the tube as well. . *PPX: SC heparin, PPI, bowel regimen, aggressive mouth care. Contact precautions for h/o C.Diff and MRSA. . *Communication: Communication was with her son, Dr [**Name (NI) 1692**] [**Name (NI) 30175**]. . * Code status: She was maintained as FULL CODE. . *Dispo- She was transferred to [**Hospital **] Hospital per her son's request, since he was on staff there. Medications on Admission: - Accuzyme ointment - Nitro ointment 2% 2inches q 6 hrs - Epo 20,000 3x/week - levoxyl 0.125 daily - phoslo 667 tid - dig 0.125 QOD - Hep SC BID - Metop 25 [**Hospital1 **] - Pantroprazole 40 IV daily - Norvasc 5 mg daily - Vit B12 IM q 15 days - ISS - KCL 20 [**Hospital1 **] - NPH 24 Units qam, 12 qpm Discharge Medications: 1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for SBP <100. 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Sodium Hypochlorite 0.5 % Liquid Sig: One (1) Appl Miscell. ASDIR (AS DIRECTED). 7. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Fifteen (15) ML PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours). 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 7 days. 10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 11. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous Qam. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous Qpm. 15. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day as needed: per Insulin Sliding Scale. 16. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Im injection Injection Q 15 DAYS (). 17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 18. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous see instructions: Please dose by level to complete a six week course. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis 1. Fluid Overload 2. Left necrotic foot ulcer 3. UTI 4. Hypernatremia .... Secondary Diagnosis: CAD DM 2 CRF Peripheral vascular disease with ulcerations Anemia Hypertension Hypothyroidism Discharge Condition: Stable, satting better than 95% on room air. Afebrile. Responds to her son. Discharge Instructions: Please return to the hospital if you wish to undergo amputation or initiate dialysis. Also return if you experience worsening shortness of breath, redness of left foot, fever >101.5, or any other worrisome symptoms. . Please take all medications as directed. You have been started on two antibiotics for infections in your foot and urine. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 30176**] within 1-2 weeks at [**Telephone/Fax (1) 30177**]. . If you would like to pursue amputation, please follow-up with Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) **].

[ "V45.82", "414.00", "403.91", "440.23", "428.0", "427.31", "730.27", "250.40", "585.5", "428.30", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "86.28" ]

icd9pcs

[ [ [] ] ]

13439, 13454

6265, 11303

247, 253

13705, 13784

3618, 6242

14173, 14406

3031, 3037

11657, 13416

13475, 13568

11329, 11634

13808, 14150

3052, 3599

188, 209

281, 2163

13589, 13684

2185, 2785

2801, 3015

4,803

159,789

1869

Discharge summary

report

Admission Date: [**2172-7-9**] Discharge Date: [**2172-7-15**] Service: HISTORY OF PRESENT ILLNESS: This is an 89-year-old male with history of CAD status post CABG, CVA, hypertension plus metastatic carcinoma, not currently undergoing treatment with acute onset of unresponsiveness at rehab facility. The patient had unwitnessed fall the day prior with no apparent injuries. This morning was doing well before this event, no history of complaint of chest pain, shortness of breath. REVIEW OF SYSTEMS: Positive only for fatigue and weakness. Patient noted to have decreased O2 sats during the event. In the Emergency Room the patient was afebrile with O2 sat 70% on room air, unresponsive. The patient was intubated to secure airway. Chest x-ray showed right lung mass. EKG with ischemic precordial changes. Head CT was negative. C spine CT negative. PAST MEDICAL HISTORY: Coronary artery disease, status post CABG, metastatic bladder carcinoma, osteoporosis, hypertension, diabetes mellitus, history of CVA two years ago. ALLERGIES: No known drug allergies. MEDICATIONS: Lasix 20 mg po q d, Ritalin 5 mg [**Hospital1 **], Zoloft 50 mg po q h.s., Colace, Milk of Magnesia, Atenolol 25 mg po q day, Megace 40 mg, Aspirin 325 mg po q day, Plavix 75 mg po q day, Nephrocaps. SOCIAL HISTORY: Positive tobacco, quit in [**2154**], no alcohol or drug use. PHYSICAL EXAMINATION: On admission, general, intubated and sedated. HEENT: Bilaterally surgical pupils, no JVD. Pulmonary, rhonchi bilaterally. Cardiovascular, regular rate and rhythm, no murmurs. Abdomen, nontender, non distended, positive bowel sounds but hypoactive. Extremities, no cyanosis, erythema or edema. LABORATORY DATA: On admission, white blood cell count 10.4, hematocrit 32.3, platelet count 340,000, sodium 139, potassium 4.7, CO2 27, chloride 99, BUN 62, creatinine 2.1, glucose 245. HOSPITAL COURSE: Given patient's hypoxemic respiratory distress, differential diagnosis including pneumonia vs pneumothorax vs ARDS, he was supported with mechanical ventilation. He was covered empirically with Ceftazidime and Vancomycin. Due to hemodynamic instability, he was started on Dopamine. Additionally, his acute renal failure was thought to be secondary to ATN and he was hydrated with IV fluids. The patient failed several attempts to extubate him. After extensive discussions with the family, it was decided to withdraw life support and pursue comfort measures only. On [**7-15**] the patient was extubated at 7:40 p.m. per family's wishes for comfort measures only and he was put on a Morphine drip. The patient expired at 7:45 p.m. CAUSE OF DEATH: Respiratory failure, likely secondary to ARDS. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**] Dictated By:[**Name8 (MD) 5753**] MEDQUIST36 D: [**2172-11-4**] 11:15 T: [**2172-11-4**] 11:13 JOB#: [**Job Number 10445**]

[ "707.0", "401.9", "584.5", "486", "V10.51", "250.00", "197.0", "518.81", "414.01" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

1909, 2973

1404, 1891

518, 874

112, 498

897, 1301

1318, 1381

50,141

182,345

5016

Discharge summary

report

Admission Date: [**2161-10-1**] Discharge Date: [**2161-10-9**] Date of Birth: [**2118-7-30**] Sex: M Service: MEDICINE Allergies: Codeine / Dilaudid / Ciprofloxacin Attending:[**First Name3 (LF) 2901**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Pericardiocentesis and drain History of Present Illness: Pt is 43 yo M with PMHx sig. ESRD s/p failed transplant and subsequent nephrectomy in [**8-7**] who p/w abdominal pain. He was recently hospitalized from [**Date range (3) 20750**] for worsening dyspnea and abdominal pain. He was admitted to the MICU for urgent HD as he missed his previous HD session. He also developed chest pain attributed to new onset systolic CHF (?SIRS related to graft rejection and recent nephrectomy, ischemia, or high output failure form AV fistula) and pericarditis [**1-31**] uremia. The abdominal pain was felt to be localized over the nephrectomy site, and serial exams did not show a surgical abdomen. He was noted to have new isolated elevated AST; an abdominal US did not show gallbladder pathology. It did show 4.7 x 2.2 x 2.9 cm thick-walled fluid collection in RLQ, decreased in size from [**2161-8-21**]. Pt was treated with acetaminophen and low dose IV morphine. His course with comblicated by gram-positive bacteremia, likely from HD line. He was treated with vancomycin for 2 week course. . He returns today with worsening abdominal pain, now for past 3 weeks, and poor appetite. . In the ED, initial vital signs were: . He had an abdominal CT scan that showed no infectious processes. The CT scan did show new ascites and pericardial effusion, which was not seen on cardiac MRI on [**2161-9-21**]. Cardiology performed a bedside ECHO that showed large effusion but NO cardiac tamponade physiology. His P stable. Pulsus is 6. The plan is to have cardiology take him to the cath lab tomorrow. Renal has been notified of his arrival and will likely need to dialysis him post-cath. Of note, his CT scan was complicated by infiltration of his IV. About 70 cc of contrast was run into his arm. Per protocol, plastic surgery was consulted to eval for compartment syndrome. Plastics felt exam was benign and recommended warm compresses. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope Past Medical History: * ESRD secondary to FSGS s/p cadaveric transplant in [**2156**], failed in [**2160**] now s/p nephrectomy of transplanted kidney in [**8-7**] * hepatitis C virus * congenital single kidney * hypertension * depression * status post MVA in [**2157-6-30**] with a right facial fracture and orbital zygomatic fracture * REM behavior disorder Social History: Lives with his wife, 2 step-sons, and 2 grandchildren. No pets. No current alcohol, tobacoo, or drug use. Previously worked as a janitor. Family History: Reports brother had end-stage renal disease. Physical Exam: VS: T 97.9, BP 164/106, P 87, RR 16, 100% on NRB Gen: alert, oriented, appropriately responsive Heent: PERRL bilaterally, EOMI, sclerae anicteric, MMM, OP clear, neck supple with prominent external jugular veins Chest: left tunnelled IJ HD catheter in place, site nontender Pulm: crackles up 1/2 posterior lung fields with dullness to percussion at bases, decreased breath sounds at bases, no wheezing or rhonchi CV: RRR, 3/6 systolic murmur at LUSB Abd: normoactive bowel sounds, nontender without guarding or rebound throughout, incision at nephrectomy site well-healed with one area of point tenderness overlying apparent retained suture, no erythema or oozing from site Ext: right AV fistula with clean incision Skin: no rash Neuro: alert, oriented, CN II-XII intact, moving all extremities without difficulty, sensation intact to light touch in all four extremities, toes downgoing bilaterally Pertinent Results: [**2161-10-1**] 03:00PM BLOOD WBC-6.6# RBC-3.31* Hgb-9.0* Hct-27.8* MCV-84 MCH-27.1 MCHC-32.3 RDW-18.8* Plt Ct-499*# [**2161-10-9**] 06:50AM BLOOD WBC-6.0 RBC-3.37* Hgb-9.1* Hct-28.5* MCV-85 MCH-26.9* MCHC-31.7 RDW-17.9* Plt Ct-367 [**2161-10-1**] 03:00PM BLOOD Neuts-68.4 Lymphs-19.8 Monos-9.1 Eos-1.7 Baso-1.0 [**2161-10-2**] 02:24AM BLOOD Neuts-76.0* Lymphs-15.6* Monos-6.4 Eos-1.5 Baso-0.5 [**2161-10-7**] 05:25PM BLOOD PT-17.3* INR(PT)-1.6* [**2161-10-1**] 03:40PM BLOOD Glucose-124* UreaN-59* Creat-11.0*# Na-138 K-5.6* Cl-96 HCO3-28 AnGap-20 [**2161-10-9**] 06:50AM BLOOD Glucose-86 UreaN-21* Creat-6.2* Na-137 K-4.9 Cl-100 HCO3-27 AnGap-15 [**2161-10-3**] 06:05AM BLOOD ALT-118* AST-67* AlkPhos-76 TotBili-0.4 [**2161-10-6**] 06:40AM BLOOD ALT-68* AST-31 AlkPhos-77 [**2161-10-3**] 06:31PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2161-10-4**] 01:45AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2161-10-9**] 06:50AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1 [**2161-10-5**] 02:53AM BLOOD calTIBC-189* Ferritn-305 TRF-145* [**2161-10-2**] 02:24AM BLOOD TSH-1.6 [**2161-10-2**] 02:24AM BLOOD T4-8.2 ========================================= EKG Prolonged Q-T interval. Low voltage in the standard leads. Left ventricular hypertrophy. Non-specific ST-T wave changes in leads I, aVL and V2-V6. Compared to the previous tracing of [**2161-10-7**] no significant change. The non-specific T wave changes are similar. The QTc interval is somewhat shorter. ========================================= CT chest/abdomen/pelvis 1. No retroperitoneal bleed. 2. Interval decrease in size of the pericardial effusion, now small. 3. Interval increase in bilateral pleural effusions, moderate on the right and small on the left, with associated atectasis at the lung bases. ========================================== [**Last Name (un) **] study Flow study demonstrates no fibrin sheath or significant thrombus of existing left-sided tunneled hemodialysis catheter. ========================================== PA LATERAL Small bilateral pleural effusions have decreased, moderate enlargement of the cardiac silhouette due to cardiomegaly and/or pericardial effusion is diminished, interstitial edema is cleared and bibasilar opacification has improved. Overall findings are consistent with resolved pulmonary edema. Cystic structure at the right lung apex now contains fluid, probably edema fluid in a bulla, not concerning for infection. Dual-channel supraclavicular left-sided central venous catheter projects over the upper right atrium. No complications. =========================================== TTE [**10-5**]: The left atrium is moderately dilated. The right atrium is markedly dilated. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size is mildly increased with normal free wall motion. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion. There are no echocardiographic signs of tamponade. ============================================= CATH [**10-1**]: 1. Limited resting hemodynamics revealed elevation and near-equalization of diastolic filling pressures with a mean RA of 25mmHg, PADP of 28mmHg, and mean PCWP 30mmHg. The pericardial pressure was also measured at 25mmHg. The initial cardiac index was 2.9l/min/m2. 2. After removal of 1200cc of pericardial fluid, the mean RA fell to 8mmHg, the pericardial pressure normalized at 0 to -3mmHg, and the cardiac index increased to 4.2l/min/m2. FINAL DIAGNOSIS: 1. Successful drainage of 1200cc of pericardial fluid with resolution of tamponade physiology. 2. A drainage catheter was successfully placed into the pericardial space over a wire and sutured in place to the skin. Brief Hospital Course: 43 yo M with PMHx sig. ESRD s/p failed transplant and subsequent nephrectomy in [**8-7**] who p/w abdominal pain, found to have pericardial effusion without tamponade physiology. Pericardiocentesis performed and 1200cc fluid removed; drain placed and later removed. Hospital course complicated by thrombus on tip of tunnel cath seen during echo, but subsequently not present on dedicated catheter study. Hospital course also c/b episode of hemoptysis in setting of heparin drip (PTT>150) for suspected [**Last Name (un) **] thrombus. . # Hemoptysis: This has occured to pt during previous hospitalization. Isolated incident. No findings on CT of the chest. Pulmonary was consulted and felt that suspicion for TB was very low. Etiology most likely related to to supratherapeutic PTT>150 from heparin drip. Pt was sceduled with outpt follow-up in the pulmonary clinic. . # Pericardial effusion: DDx includes uremia VS malignant effusion VS idiopatic. Patient's cultures and acid fast/TB negative. No evidence of malignancy on CT chest/abdomen/pelvis. Cytology of pericardial fluid negative for malignant cells. Repeat echo x2 showing minimal effusion, much decreased s/p drainage. Pericardial drain removed without complications. Pt has appt for f/u ECHO as outpt, and has f/u scheduled with cardiology. . # HD Catheter Thrombus: noted on ECHO [**2161-10-3**]. Subsequent dedicated catheter flow study did not detect thrombus. In the interim, pt was anticoagulated, but no indication to anticoagulate at the time of discharge. . # Rhythm - patient had several short runs of NSVT on [**2161-10-3**] which were attributed to electrolyte changes post-dialysis. This again occured on [**10-6**] post-dialysis. Dialysis bath was altered to include more K and NSVT did not recur. . # Hct drop (28-->20): CT of abdomen showed no evidence of bleed. Guiaic negative. IV iron therapy to be started at dialysis. Source of Hct drop not found. Hemolysis labs negative. Pt received total of 3 units of blood and Hct responded appropriately. Hct was 28.5 at time of discharge. . # Ascites/ Hepatitis: LFTs with mild elevation. This transaminitis may be fleeting and secondary to recent pericardial effusion presentation vs. worsening Hep C. Given increased INR and low albumin, may represent worsening cirrhosis--Pt will f/u in hepatology clinic where he is followed for his Hep C. . # ESRD s/p failed transplant and subsequent nephrectomy in [**8-7**]: - HD: pt will resume usual Tues/Thurs/Sat routine - renal team following the maturation of the pt's fistula with plan to remove the tunneled cath when ready; during this hospitalization fistula was accessed, but reanl team would prefer to use fistula several more times before being comfortable with remoal of line. . # HTN: continue lisinopril and carvedilol (previously on metoprolol). Medications on Admission: Atorvastatin 10 mg PO DAILY Citalopram 20 mg PO DAILY Clonazepam 1 mg PO QHS as needed for insomnia. Imipramine HCl 25 mg PO HS Lisinopril 40 mg PO DAILY Metoprolol Tartrate 25 mg 1.5 Tablets PO BID Nephrocaps Pantoprazole 40 mg PO Q24H Oxycodone 5 mg PO Q6H (every 6 hours) as needed for pain. Sevelamer HCl 800 mg (3) Tablet PO TID W/MEALS Calcium Carbonate 1000 mg PO TID W/MEALS Ferrous Sulfate 325 mg PO DAILY Nitroglycerin 0.3 mg Sublingual PRN Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Vancomycin HD PROTOCOL Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 3. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Do not drive while taking this medicine. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes for three doses as needed for chest pain. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Nut.Tx.Impaired Renal Fxn,Soy Liquid Sig: One (1) can PO three times a day. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] units Injection PRN (as needed) as needed for line flush: dwell in line, use as needed for dialysis. 14. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Pericardial Effusion Bacteremia Non sustained Ventricular Tachycardia Chronic Diastolic Congestive Heart Failure End Stage Renal Disease Hypertension Iron Deficiency Anemia/Anemia of Chronic Disease Transaminitis Discharge Condition: medically stable for d/c hct: 27.3 Creat: 7.2 Discharge Instructions: You had pericardial effusion and a temporary tube was placed to drain the fluid. You will need to get an echocardiogram in 2 weeks to see if the fluid has returned. . You also had fluid collections in your abdomen and lungs. We gave you extra dialysis treatments to remove this fluid. . You developed a severe anemia that required blood and iron transfusions. It is likely that frequent blood draws contributed to this. . You also had some irregular heart beats that are probably bacause of electrolyte shifts after dialysis. We have given you extra phosphate and potassium to treat this. . New medicines: 1. Carvedilol: this replaces your metoprolol 2. You will get iron trasfusions with your hemodialysis Please stop taking the following medicines: 1. Clonazepam 2. Citolopram 3. Imipramine Followup Instructions: Psychiatry: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1682**] Date/Time:Please call to reschedule missed appointment Gastroenterology: Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2161-10-16**] at 10:00 am. [**Last Name (NamePattern1) 439**] [**Location (un) 436**] Hematology/Oncology: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2161-10-22**] 10:45 Nephrology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD . Primary Care: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13983**], MD Phone: [**Telephone/Fax (1) 13987**] Date/Time: Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**2161-11-2**] at 4pm. . Echocardiogram: [**10-26**] at 11 am. SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] . Pulmonology: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2161-10-14**] 2:30 . Nephrology Transplant: [**Last Name (LF) **],[**Name8 (MD) **], MD (TRANSPLANT)Date/Time: [**2161-10-23**] 02:20p [**Hospital Unit Name **], [**Location (un) 436**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2161-12-3**]

[ "789.59", "427.1", "070.54", "285.9", "428.32", "790.7", "423.9", "280.9", "428.0", "585.6", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95", "37.21", "37.0" ]

icd9pcs

[ [ [] ] ]

13578, 13584

8707, 11541

310, 341

13841, 13889

4294, 8450

14732, 16322

3311, 3357

12153, 13555

13605, 13820

11567, 12130

8467, 8684

13913, 14709

3372, 4275

256, 272

369, 2777

2799, 3139

3155, 3295

296

159,503

13402+13403

Discharge summary

report+report

Admission Date: [**2191-3-1**] Discharge Date: [**2191-3-5**] Date of Birth: [**2117-5-15**] Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 73 year old previously healthy male who, on the day of admission, presented to an outside hospital complaining of substernal chest pain with radiation to the left arm. The patient says that in the weeks prior to admission, he had symptoms consistent with indigestion, which was not being resolved with Tums. On the day of admission, he was working on his boat and developed the chest pain. After 20 minutes, during which the pain did not resolve, he called 911. On the scene, there were ST elevations noted on the electrocardiogram. The patient was treated with aspirin and nitroglycerin and the nitroglycerin relieved the pain. He continued to have left arm discomfort. He denied any shortness of breath, nausea, vomiting or diaphoresis. He also denied any fevers, chills or sweats. The patient was taken to the outside hospital and underwent a workup for a myocardial infarction. He remained hemodynamically stable. His hematocrit was 40. There, he underwent cardiac catheterization which was significant for a left anterior descending artery with an ostial 60% stenosis followed by serial 90% stenosis. It also showed the left circumflex with 80% stenosis, an obtuse marginal two which was totally occluded, and an obtuse marginal three which was 90% stenotic. The right coronary artery was totally occluded. The patient tolerated the procedure well and was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] to Dr.[**Name (NI) 27686**] service for emergent coronary artery bypass grafting. The patient arrived at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] in stable condition. PAST MEDICAL HISTORY: Negative; the patient denies diabetes mellitus, hypertension or hypercholesterolemia. PAST SURGICAL HISTORY: Negative. MEDICATIONS ON ADMISSION: Tums p.r.n. indigestion; the patient arrived from the outside hospital on aspirin, Plavix, heparin drip and nitroglycerin. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient denies any alcohol or tobacco use. PHYSICAL EXAMINATION: On physical examination, the patient was an elderly gentleman in no acute distress, currently without angina. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, no murmur, rub or gallop. Abdomen: Soft, nontender, no masses. Extremities: Warm, no edema. Neurologic: Intact. LABORATORY DATA: Admission white blood cell count was 7.5, hematocrit 40.1, platelet count 334,000, sodium 139, potassium 3.9, chloride 98, bicarbonate 32, BUN 16, creatinine 0.7, glucose 149, and calcium 9.9. Electrocardiogram show normal sinus rhythm at a rate of 69 beats per minute, borderline first degree A-V block, and diffuse ST elevations. HOSPITAL COURSE: The patient was transferred from an outside hospital in stable condition. He arrived at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] and, after evaluation by cardiothoracic surgery, the patient was taken to the Operating Room, where he underwent coronary artery bypass grafting times three. The grafts were left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal one and saphenous vein graft to obtuse marginal two, performed by the team under Dr. [**Last Name (STitle) 70**]. The patient tolerated the procedure well. An EVH was performed on the right side with hypertechnique of the right graft. Postoperatively, the patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition. The patient was extubated without any incident. He was slowly weaned off of oxygen. The patient's cardiovascular status remained stable. Initially, cardiac output was 1.9. The patient received one unit of packed red blood cells and a bolus of lactated Ringer's. Output slowly improved to 2.39. He continued to remain hemodynamically stable. The patient remained alert and oriented times three. On postoperative day number one, the patient was transferred to the floor in stable condition. On postoperative day number one at 11:00 p.m., the patient's monitor recorded wide complex ventricular tachycardia. The patient's blood pressure remained in the 110s. The patient was asymptomatic. The longest continuous run included a 12 beat run. Otherwise, the patient's rhythm remained alternating between sinus rhythm intermixed with wide QRS complexes, often two to three beats at a time. The patient's blood pressure continued to remain stable. The patient's electrolytes were repleted and the patient spontaneously converted to a normal sinus rhythm. The patient was evaluated by the electrophysiology service and it was determined that the patient likely had reperfusion ventricular tachycardia. The patient has since remained in sinus rhythm and hemodynamically stable. The patient otherwise has remained afebrile. His chest tubes were discontinued on postoperative day number two without incident. Pacing wires were discontinued on postoperative day number three without incident. The patient is ambulating at a level 5. Early in postoperative day number two, there was a question of patient's mental status. Though the patient remained alert and oriented times three, the patient continually requested to be driving home. He was placed on close observation. The patient's mental status has improved and he is at baseline. On postoperative day number three, the patient's hematocrit had moved from 24 to 20.8. The patient was transfused two units of packed red blood cells and his hematocrit remained stable. The patient is now stable and ready for discharge to home. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass grafting times three. DISCHARGE MEDICATIONS: Lasix 20 mg p.o.b.i.d. times seven days. Potassium chloride 20 mEq p.o.b.i.d. times seven days. Colace 100 mg p.o.b.i.d. Enteric coated aspirin 325 mg p.o.q.d. Lopressor 50 mg p.o.b.i.d. Niferex 150 mg p.o.q.d. Tylenol 650 mg p.o.q.4h.p.r.n. Advil 400 mg p.o.q.6h.p.r.n. CONDITION ON DISCHARGE: Stable. FOLLOW-UP: The patient was instructed to follow up with Dr. [**Last Name (STitle) 70**] in six weeks. The patient is to follow up with Dr. [**Last Name (STitle) **], his primary care physician, [**Name10 (NameIs) **] two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2191-3-4**] 10:22 T: [**2191-3-5**] 11:04 JOB#: [**Job Number 26048**] Admission Date: [**2191-3-1**] Discharge Date: [**2191-3-9**] Date of Birth: [**2117-5-15**] Sex: M Service: ADDENDUM: The patient was initialy supposed to be discharge on [**2191-3-5**], however, he continued to have confusion. A psychiatric consult was obtained and Haldol was recommended. It was felt that he had postoperative agitation, confusion and delirium. It is not felt that this is secondary to an infection or metabolic causes. Over the course of the weekend on the 14th and 15th he became more agitated and confused. He does not remember that he is in the hospital or that he has had surgery. He had electrocardiograms while getting Haldol 5 mg po q 4 hours, which have not so far shown a prolongation of his QTC interval. His QTC on the 16th was .4 of 4. Additionally, the patient's sugars have been elevated since his surgery and he has required insulin for management. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained and he is to be started on Glyburide 5 mg po q.a.m. He will need follow up for his newly diagnosed type 2 diabetes mellitus. MEDICATIONS ON DISCHARGE: 1. Lopressor 75 mg po b.i.d. 2. Lasix 20 mg po b.i.d. to be continued for one week after discharge and then to be reevaluated by the patient's primary care physician. 3. K-Ciel 20 milliequivalents po q.d. also to be discontinued in one week. 4. Colace 100 mg po b.i.d. 5. ECASA 325 mg po q.d. 6. Niferex 150 mg po q.d. 7. Haldol 5 mg po q 4 hours hold for sedation. The patient will need daily electrocardiograms while taking the Haldol. 8. Tylenol 650 mg po q 4 hours prn for pain. 9. Regular insulin sliding scale blood sugars 150 to 200 3 units, 201 to 250 6 units, 251 to 300 9 units, greater then 300 12 units plus [**Name8 (MD) 138**] MD. 10. Glyburide 5 mg po q.a.m. The patient is being discharged to [**Hospital3 672**] Medical Psychiatric Unit. He has had a CT of his head that his negative for infarct. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 25727**] MEDQUIST36 D: [**2191-3-9**] 08:53 T: [**2191-3-9**] 09:11 JOB#: [**Job Number 40685**]

[ "414.01", "293.9", "427.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6170, 6442

6064, 6147

8161, 9299

2162, 2340

3111, 6043

2124, 2135

2428, 3093

166, 179

208, 1990

2013, 2100

2357, 2405

6467, 8134

10,272

176,310

54032

Discharge summary

report

Admission Date: [**2115-9-18**] Discharge Date: [**2115-9-28**] Date of Birth: [**2056-8-4**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 59 year old female with past medical history significant for insulin dependent diabetes mellitus, end-stage renal disease on peritoneal dialysis, Methicillin resistant Staphylococcus aureus bacteremia diagnosed in [**2115-3-12**], hypertension, status post left hip fracture with left hip osteomyelitis in [**2115-3-12**], Stage III decubitus ulcer, delirium, transfusion dependent anemia and hypothyroidism. She is admitted for low systolic blood pressure of 260/40. Her baseline systolic blood pressure is around 80s to 90s. In the Emergency Department, the patient was given normal saline which has increased her blood pressure to her baseline. One unit of packed red blood cells were transfused. Nasogastric lavage revealed coffee ground aspirate and guaiac positive stool. The patient was admitted to the Medical Intensive Care Unit and then the patient was transferred to the Floor on [**9-20**], after being stabilized. PAST MEDICAL HISTORY: 1. Type 1 diabetes mellitus. 2. End-stage renal disease on peritoneal dialysis. 3. Methicillin resistant Staphylococcus aureus bacteremia in [**2115-3-12**]. 4. Hypothyroidism. 5. Status post left hip fracture in [**2114-6-11**]. 6. Left hip osteomyelitis. 7. Stage III decubitus ulcer. 8. Urinary retention. 9. History of pneumonia. 10. History of delirium. 11. Transfusion dependent anemia. 12. Hypotension. ALLERGIES: To tetracycline, from which patient developed rash. SOCIAL HISTORY: The patient has chronic smoking history but had quit and has not been smoking. The patient denied any alcohol use. The patient has recently been widowed; her husband passed away in [**Name (NI) 547**] of this year and she has been living in the rehabilitation facility for the past three months. PHYSICAL EXAMINATION: On admission, vital signs were that the patient was afebrile; heart rate is 115; blood pressure is 79/47; 100% on room air. In general, the patient is chronically ill appearing, cachectic, lying in bed in no apparent distress. HEENT: Right eye is surgical; pale conjunctivae. Mucous membranes were moist. Heart tachycardic with a holosystolic murmur at the apex. Lungs: Decreased breath sounds at the bases bilaterally. Abdomen soft, nontender, nondistended. Positive bowel sounds. No organomegaly detected. Extremities positive for muscle wasting. No edema, no clubbing. Notable for obvious sacral decubitus ulcer that is covered by dressing. LABORATORY: On admission, the patient's white blood cell count is 9.1, hematocrit is 30.9, with baseline 32.9, platelets 256. Chem-10 is significant for creatinine of 2.9, and glucose of 469. HOSPITAL COURSE: 1. MENTAL STATUS CHANGE: The patient's mental status has been waxing and [**Doctor Last Name 688**]. It appeared to be delirium at times and clear at others. The patient had a CT scan done during her hospital stay that showed a new area of encephalomalacia involving the right frontal parietal region and the right occipital region consistent with areas of infarction; those are new since [**2115-3-12**]. An area of high attenuation within the infarcted area might represent residual brain parenchyma versus hemorrhaging to the infarction. Neurology was consulted and they recommended several tests as well, including lumbar puncture and other exams. The patient's family felt that they did not want to have invasive procedures for the patient, so a lumbar puncture was not done. 2. RIGHT FACIAL DROOP: Neurological was consulted and per their recommendations, it is likely to be felt as peripheral cranial nerve VII nerve palsy. Acyclovir was recommended, started on [**9-22**] and will continue for a 14 day course. 3. HYPOTENSION: At baseline, the patient's blood pressure is 80/60. The patient's blood pressure waxed and waned, but has been stabilized in the last few days and with rehydration and encouraging of p.o. intake, we will just keep on monitoring her and rehydrate her if necessary. The patient is on peritoneal dialysis and the fluid level has to be carefully monitored. 4. QUESTION OF INFECTION: The patient was started in Medical Intensive Care Unit on ....... and Ceftriaxone intravenously for potential sepsis. All cultures have been negative so far and her white blood cell count has been normal in the past few days and the patient remained afebrile. Will just continue monitoring the patient for any signs of infection given that she has open Grade III decubitus ulcer. 5. DECUBITUS ULCER: There was a question of osteomyelitis. Plastics was consulted and recommended dressing change from wet-to-dry three times a day. A CT scan of the pelvis revealed that there is no free air and no signs of osteomyelitis although there is a significant amount of fluid collection around the left hip joint. Orthopedics was consulted and they do not recommend drainage at this point. 6. PLEURAL EFFUSION SEEN ON CT SCAN: A chest CT scan was done and that showed a significant amount of pleural effusion on both sides. The patient is not symptomatic. The plan is to drain the fluid if patient becomes short of breath or desaturates. 7. ANOREXIA/DIFFICULTY SWALLOWING: Speech and Swallow was consulted and they stated that there are no signs of aspiration upon bedside swallow evaluation. They recommended a Gastrointestinal consultation. Dr. [**First Name (STitle) 679**] performed endoscopy on the patient on [**9-25**], and had the following findings: 1) He saw a grade 3 esophagitis in the gastroesophageal junction and lower third of the esophagus. Biopsy was done; 2) Ulcer in the stomach body greater curve as well as ulcer in the distal part. He also did a biopsy as well in the stomach antrum. Otherwise, it shows normal esophagogastroduodenoscopy to the second part of the duodenum. No stricture was seen. The patient's dose of Protonix as well as add Zantac to her daily treatment. The patient's difficulty to swallow might partly be attributed by the fact that she does not have teeth and she only had an upper denture which was not even with her during her hospital stay. The patient might need a new denture set as an outpatient. DISCHARGE DIAGNOSES: 1. Auto-immune disease, not elsewhere classified. DISCHARGE MEDICATIONS: 1. Timolol eye drop 0.25% drops, one drop in each eye twice a day. 2. Miconazole nitrate powder, apply three times a day as needed to affect the area. 3. Quetiapine fumarate 25 mg p.o. q. h.s. 4. Mirtazapine 15 mg q. h.s. 5. Docusate 100 mg p.o. twice a day. 6. Folic acid 1 mg p.o. q. day. 7. Clopidogrel 75 mg p.o. q. day. 8. Metoclopramide 10 mg p.o. four times a day before meals and at bedtime. 9. Levothyroxine 25 micrograms, 1.5 tablet p.o. q. day. 10. Polyphenol alcohol, 1.4% drop, two drops Ophthalmic four times a day. 11. Lanolin/mineral oil/petrolatum ointment: Apply to the right eye four times a day. 12. Folic acid, B vitamin complex, 1 mg p.o. q. day. 13. Nystatin 5 ml p.o. q. day swish and swallow. 14. Pantoprazole 40 mg p.o. twice a day. Take one before breakfast and take another one before dinner. 15. Acyclovir 150 mg intravenously q. day. The patient needs to take Acyclovir until [**10-6**]. 16. NPH insulin subcutaneously, 3 units twice a day. 17. Zantac 150 mg, take before bedtime once a day. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17144**] Dictated By:[**Name8 (MD) 18513**] MEDQUIST36 D: [**2115-9-27**] 16:20 T: [**2115-9-27**] 17:54 JOB#: [**Job Number 110763**]

[ "428.0", "261", "279.4", "403.91", "578.9", "530.10", "707.0", "285.9", "531.90" ]

icd9cm

[ [ [] ] ]

[ "38.93", "54.98", "45.16" ]

icd9pcs

[ [ [] ] ]

6348, 6400

6423, 7457

2831, 6327

1962, 2814

170, 1114

1136, 1622

1640, 1939

7483, 7799

19,966

132,782

9877

Discharge summary

report

Admission Date: [**2117-5-10**] Discharge Date: [**2117-5-14**] Date of Birth: [**2060-10-26**] Sex: M Service: CHIEF COMPLAINT: Coronary artery disease. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 56 year-old man who presents for coronary artery bypass graft. He has had symptoms of coronary artery disease for about the last seven years. He had an left anterior descending coronary artery stenting back in [**2109**]. He did well until [**2116-1-23**] when he had a positive exercise treadmill test. He subsequently had angiography with percutaneous transluminal coronary angioplasty, roto rooting and stenting of the proximal circumflex and percutaneous transluminal coronary angioplasty roto rooting of both poles of the obtuse marginal one. In [**Month (only) **] he subsequently had another positive stress test and at that time was found to have restenosis of the circumflex. It then appears that he had further percutaneous transluminal coronary angioplasty and brachytherapy. Now he presents with symptoms of fatigue and more recently the feeling of complete exhaustion. He never experienced any chest pain or shortness of breath with this and now denies claudication, orthopnea, edema or paroxysmal nocturnal dyspnea. In his prior cardiac workup his catheterizations have occurred, because of routine stress testing. In [**Month (only) 116**] of this year he had a stress test that demonstrated 2 to 3 mm ST segment depressions in the inferior and lateral leads and he had a small mild reversible inferolateral defect with an ejection fraction of 59%. PAST MEDICAL HISTORY: 1. High cholesterol. 2. Tobacco use. 3. Coronary artery disease. 4. Anxiety and depression. PAST SURGICAL HISTORY: 1. Status post appendectomy. 2. Status post tonsillectomy. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Lipitor 40 mg po q day. 3. Mavic 2 mg po q day. 4. Paxil 20 mg po q day. 5. Atenolol 25 mg po q day. FAMILY HISTORY: He has a positive family history with four half brothers that all died prematurely of coronary artery disease. LABORATORY STUDIES: In early [**Month (only) **] revealed a white count of 7.3, and a BUN and creatinine of 14 and 1.1. HOSPITAL COURSE: Outpatient cardiac catheterization revealed a right dominant system with two vessel and left main coronary disease. His left main was short with a 60 to 70% diffuse stenosis. His left circumflex had an 80% tubular stenosis and the right coronary had a 70% eccentric stenosis. For this reason he was referred for coronary artery bypass grafting. On [**2117-5-10**] the patient was admitted to the hospital and taken to the Operating Room. There he had coronary artery bypass grafts times three. His grafts are left internal mammary coronary artery to left anterior descending coronary artery and left internal mammary coronary artery to left radial to obtuse marginal and [**Female First Name (un) **] to right coronary artery. The procedure itself was unremarkable. Postoperatively, he was taken intubated to the Cardiac Surgery Intensive Care Unit on nitroglycerin and propofol drips. He was extubated early in the morning of his first postoperative day. He remained on an nitroglycerin drip that was subsequently weaned off throughout the course of that day. On the second postoperative day he developed rapid atrial fibrillation to a rate of 150 or 160. This was treated with intravenous Lopressor with marginal results in controlling his rate. He was then loaded with intravenous Amiodarone and had prompt conversion of his rhythm to a normal sinus rhythm. He was loaded with oral Amiodarone and his Lopressor dose was increased. After this time he had no further episodes of arrhythmia. The remainder of the [**Hospital 228**] hospital course was unremarkable. Throughout the following hospital days he continued to be diuresed. In addition, he was weaned from his oxygen and ambulated the hallways with physical therapy. By his fourth postoperative day he was eating, ambulating and voiding without any problems. The physical therapist cleared him to be safe to be discharged to home. Several medications were initiated during his hospitalization. He is on Plavix 75 mg po q day times three months for poor distal targets. In addition, he is on Imdur 60 mg po q day times three months, because of his left radial artery graft. In addition, he will be on Amiodarone and Lopressor in the immediately postoperative period, but if he continues to remain free of arrhythmia these can likely be weaned and discontinued. Th[**Last Name (STitle) 1050**] is discharged home on [**2117-5-14**] in stable condition in the care of his family. He is to follow up with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33153**] in approximately two weeks. In addition he is to follow up with his cardiologist who is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] in two to three weeks and he is to see Dr. [**Last Name (Prefixes) **] in four weeks. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg po q day. 2. Lopresor 25 mg po b.i.d. 3. Enteric coated aspirin 325 mg po q day. 4. Imdur 60 mg po q.d. times three months. 5. Plavix 75 mg po q.d. times three months. 6. Paxil 20 mg po q day. 7. Lipitor 40 mg po q.d. 8. Lasix 20 mg b.i.d. times seven days. 9. Potassium chloride 20 milliequivalents b.i.d. times seven days. 10. Colace 100 mg po b.i.d. times fifteen days. 11. Percocet 5/325 one to two po q 4 to 6 hours prn. DISCHARGE DIAGNOSES: 1. Coronary artery disease now status post coronary artery bypass graft times three. 2. Hypercholesterolemia. 3. Anxiety and depression. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 9638**] MEDQUIST36 D: [**2117-5-14**] 13:13 T: [**2117-5-17**] 14:14 JOB#: [**Job Number 33154**] cc:[**Last Name (NamePattern4) 33155**]

[ "V45.82", "411.1", "300.00", "414.01", "997.1", "272.0", "311", "427.31", "305.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2025, 2259

5615, 6061

5127, 5594

2277, 5103

1753, 2008

146, 172

201, 1606

1629, 1729

7,758

102,646

47392

Discharge summary

report

Admission Date: [**2114-10-29**] Discharge Date: [**2114-11-5**] Date of Birth: [**2058-5-23**] Sex: M Service: [**Hospital1 212**] HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with a history of diabetes type 2, hepatocellular carcinoma, colon cancer with lung metastases and esophageal varices who presents with an upper gastrointestinal bleed. The patient was in his usual state of health until one day prior to admission when he began experiencing coffee ground emesis followed by melena. The patient went to an outside hospital where his hematocrit was 32 with a baseline hematocrit of 35-40. He was transfused with one unit of packed red blood cells, Vitamin K and transferred to [**Hospital6 649**]. Upon arrival his hematocrit was found to be 28 and nasogastric lavage was done which showed mostly coffee grounds. The patient did not complain of any abdominal pain. Denied fevers, chills, nausea, vomiting prior to the day before admission. He also denied chest pain and shortness of breath. PAST MEDICAL HISTORY: 1. Diabetes type 2. 2. Hepatocellular carcinoma diagnosed in [**2113-12-13**]. 3. Colon cancer diagnosed in [**2105**] with metastatic disease of the lung and to the liver. 4. Esophageal varices, status post wide resection of right lung nodule in [**2106**]. 5. Cirrhosis, status post sigmoid colectomy. MEDICATIONS ON ADMISSION: 1. Regular insulin sliding scale. 2. Citalopram 20 mg daily. 3. Percocet prn. 4. Duragesic 50 mcg patch q. 72 hours. 5. Ativan prn. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives at home with his family and his wife. [**Name (NI) **] does not smoke. Patient is a former alcoholic and quit drinking four years ago. FAMILY HISTORY: The patient's father died of prostate cancer. PHYSICAL EXAMINATION: Temperature 99.9. Heart rate 106. Blood pressure 172/66. Respiratory rate 20. Oxygen saturation 97% on room air. In general, pleasant in no acute distress. Head, eyes, ears, nose and throat: Anicteric sclera, clear oropharynx, moist mucous membranes. Supple neck. Cardiovascular: Tachycardic, regular with no murmurs, rubs or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended, slightly obese. Extremities: No cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. Neurological exam: Alert and oriented times three. Cranial nerves II through XII are intact. LABORATORY DATA: White blood cell count 7.3, hematocrit 28.4, platelet count 132,000, INR 1.4, PTT 26.5, potassium 4.3, BUN 28, creatinine 0.7, ALT 85, AST 119, alkaline phosphatase 197, T bilirubin 1.1. Recent alpha-fetoprotein 27,054. Chest x-ray initially showed small right pleural effusion. No consolidation. HOSPITAL COURSE: 1. Upper gastrointestinal bleed: Because of his active upper gastrointestinal bleed, the patient was admitted to the Medical Intensive Care Unit where adequate intravenous access was obtained. Patient was hemodynamically stable and underwent an upper endoscopy. The upper endoscopy showed Grade 2 varices in the lower third of the esophagus and portal hypertensive gastropathy with blood in the duodenum. However, initially, the patient was not cooperative with the procedure and gastroenterologists' were unable to pass the banding scope. The patient was started on an octreotide drip and was intubated for protection of his airway and for an attempt at variceal banding. The second upper endoscopy was performed, however, again, the gastroenterologists' were unable to pass the banding scope, therefore, the patient was continued on his octreotide drip. His PPI and serial hematocrits were followed. Patient's hematocrit remained stable. He was extubated less than 24 hours and was transferred out to the General Medicine Wards, and a third repeat endoscopy was performed after five days of an octreotide drip. Repeat endoscopy showed, again, Grade 2 varices at the lower third of the esophagus, erythema, congestion and abnormal vascularity in the fundus and body of the stomach compatible with portal gastropathy. At this time the banding scope again was unable to be passed. As the patient's hematocrit was stable and he was no longer having any gastrointestinal bleeding, the patient was started on nadolol and he was discharged on Protonix and nadolol with a follow-up endoscopy scheduled for [**2114-11-14**]. At this time, the gastroenterologists' will attempt scleral therapy for his varices. 2. Aspiration pneumonia: 24-48 hours after extubation, the patient developed fever, productive cough, crackles and decreased bowel sounds at the left base of his lung despite no radiographic findings. The patient was felt to have an aspiration pneumonia versus pneumonitis. He was started on a seven day course of Levaquin and clindamycin. After starting antibiotics, the patient quickly defervesced and clinically improved. 3. Ascites: The patient was found to have moderate ascites on physical exam. He underwent a right upper quadrant ultrasound with Doppler flow which showed liver nodules consistent with metastatic disease and partial flow in the main portal vein consistent with nonocclusive thrombus. >........<left portal vein with normal right portal vein flow. A small amount of ascites was also visualized in the left lower quadrant. The patient was stable without any spironolactone or additional diuretics, however, he will need close follow-up and may need to be started on diuretics as an outpatient. 4. Gastrointestinal malignancies: The patient has a history of hepatocellular carcinoma, colon cancer with metastatic disease of the lung and liver. He will follow-up as an outpatient with his primary care physician, [**Name10 (NameIs) 3**] well as the liver specialists at the Liver Clinic. This appointment will be arranged at the time of his repeat endoscopy on [**2114-11-14**]. 5. Depression: The patient was continued on his Citalopram. 6. Diabetes: The patient was continued on a regular insulin sliding scale during this hospitalization. In addition he was started on glargine for his inpatient stay. He was discharged on his home regimen of regular insulin sliding scale. He will follow-up with his primary care physician for adjustment for his home insulin regimen. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: To home with follow-up for repeat endoscopy on [**2114-11-14**]. PATIENT DISCHARGE INSTRUCTIONS: Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 36098**], in one to two weeks. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] for your repeat endoscopy on [**2114-11-14**]. Your appointment is at 8:30 at [**Hospital Ward Name 121**] 8. Please arrive at 7:30 a.m. and do not eat or drink anything after midnight the night before. If you have any questions, please call the Endoscopy Suite at [**Telephone/Fax (1) 100287**]. At this time, an outpatient follow-up appointment will be arranged for a liver specialists. DISCHARGE DIAGNOSES: 1. Esophageal varices. 2. Upper gastrointestinal bleed. 3. Portal hypertensive gastropathy. 4. Hepatocellular carcinoma. 5. Colon cancer with metastatic disease to the liver and lung. 6. Diabetes mellitus type 2. 7. Hyponatremia. 8. Ascites. 9. Aspiration pneumonia. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2114-11-6**] 05:11 T: [**2114-11-7**] 21:50 JOB#: [**Job Number 100288**]

[ "507.0", "452", "572.2", "571.5", "456.20", "197.7", "197.0", "155.0", "789.5" ]

icd9cm

[ [ [] ] ]

[ "45.13", "42.33" ]

icd9pcs

[ [ [] ] ]

1758, 1805

7153, 7700

1392, 1568

2790, 6337

6479, 7132

1828, 2358

6352, 6454

2378, 2772

178, 1034

1056, 1366

1585, 1741

8,344

163,427

45891

Discharge summary

report

Admission Date: [**2130-7-6**] Discharge Date: [**2130-7-11**] Service: HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old male recently discharged from [**Hospital1 188**] for bright red blood per rectum after polypectomy on [**2130-6-22**] who presents with an episode of bright red blood per rectum. The patient's initial hematocrit in the Emergency Department was 30. The patient became hypotensive with a systolic blood pressure in the 70s while moving to commode. A repeat hematocrit was 15 after four hours. An Emergency Department nasogastric tube lavage was negative. The patient was admitted to the Medical Intensive Care Unit, and a Gastroenterology consultation was called. PAST MEDICAL HISTORY: 1. Colon cancer; status post resection. 2. History of prostate cancer; status post transurethral resection of prostate in [**2114**] and [**2129**]. 3. Coronary artery disease. 4. Hypertrophic obstructive cardiomyopathy. 5. Peripheral vascular disease. 6. Dyslipidemia; low high-density lipoprotein. 7. Hypertension. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Lipitor 10 mg p.o. once per day. 2. Synthroid 50 mcg p.o. once per day. 3. Lopressor 50/25/50. 4. Avapro 75 mg p.o. once per day. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed heart rate was 65, blood pressure was 78/40 (shortly thereafter 119/65). In general, the patient was pleasant and in no acute distress. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Neck examination revealed jugular venous pulsation was flat. The lungs were clear to auscultation. Heart revealed a regular rhythm. Normal first heart sounds and second heart sounds. A 3/6 systolic murmur. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremity examination revealed no edema. HOSPITAL COURSE BY ISSUE/SYSTEM: GASTROINTESTINAL BLEED ISSUES: The patient was kept nothing by mouth, transfused with 4 units of packed red blood cells, and given intravenous fluids. He was prepared for a colonoscopy. The patient went to Interventional Radiology for a red blood cell scan. Significant tracer accumulation was found in the area of the cecum. The patient's hematocrit continued to fall. He was transfused an additional unit, platelets, and a unit of fresh frozen plasma. The patient was taken to Interventional Radiology where a selective right colic arteriogram demonstrated extravasation of contrast from the distal branch of the right colic artery. The bleeding stopped after the infusion of vasopressin. The patient developed no pain or complaints, and the bleeding stopped. After the hematocrit stabilized, the patient was started on oral intake. He developed a low-grade fever, a white blood cell count, and a possible consolidation x-ray. He was started on a 7-day course of levofloxacin. He was continued on proton pump inhibitors and called out to the floor where he remained stable without evidence of further bleeding. He was evaluated by Physical Therapy who cleared the patient for discharge home with family. The patient was to follow up in two weeks with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. He was to continue on his outpatient medication regimen. MEDICATIONS ON DISCHARGE: 1. Lipitor 10 mg p.o. once per day. 2. Synthroid 50 mcg p.o. once per day. 3. Lopressor 50/25/50. 4. Avapro 75 mg p.o. once per day. [**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**] Dictated By:[**Last Name (NamePattern1) 11873**] MEDQUIST36 D: [**2130-7-20**] 15:17 T: [**2130-7-24**] 07:06 JOB#: [**Job Number **]

[ "486", "424.0", "285.1", "287.5", "425.1", "V10.46", "E878.8", "998.11", "397.0" ]

icd9cm

[ [ [] ] ]

[ "99.29" ]

icd9pcs

[ [ [] ] ]

3394, 3789

1120, 1948

1983, 3368

110, 709

731, 1094

7,275

178,772

43679

Discharge summary

report

Admission Date: [**2137-11-20**] Discharge Date: [**2137-11-24**] Date of Birth: [**2078-11-11**] Sex: M Service: MEDICINE Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine / Xanax / Oxycodone Attending:[**First Name3 (LF) 6029**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: intubation paracentesis hemodialysis History of Present Illness: Pt admitted to the MICU 2 days ago and now being transferred from the MICU. Please see original admission note for full H&P, PMH, home meds, SH, and FH. Briefly, this is a 59yo male with a past medical history of ESRD, ESLD, and epilepsy who was admitted from the ED with altered mental status and s/p seizure. He was found confused and lethargic at his [**Hospital3 **] facility and trasferred to [**Hospital1 18**] where he had a witnessed seizure. He reports that he was recently started on dilantin at his last hospitalization, which his neurologist was currently weening. He was hypersensive upon admission, and he was intubated for hypoxia and airway protection. He was given a head CT which was unremarkable, received kayexalate for hyperkalemia to 5.8, 2mg ativan x 2, ceftriaxone IV, and lopressor IV. He has multiple admissions for confusion, SOB, HTN, and falls in the past year. In the MICU, he was rapidly extubated and his blood pressure normalized. He was called out after stabilization and extubation. He had no further seizure activity. . When I saw him upon transfer, he was comfortable and only complained of itchiness of his left arm. He does not remember the seizure. He denies headache, dizziness, CP, abdominal pain. He was scheduled for an outpatient paracentesis this morning, which he missed because he was in the hospital. Past Medical History: -Seizure disorder -ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2 failed renal transplants -labile hypertension -hypothyroidism -peripheral [**Hospital1 1106**] disease -hypoparathyroidism -hepatitis C -CHF-systolic w/ EF 45% and diastolic dysfunction (echo [**12/2135**]) -SVT/AVNRT s/p ablation -multiple fistulas -H/O MRSA line infection -Recent admission [**2136-2-29**] for infected L upper arm AV fistula. -h/o mechanical falls admitted [**1-16**] -h/o VRE, MRSA Social History: Lives at [**Hospital3 **] facility on Mission [**Doctor Last Name **] called [**Hospital1 **] at [**Hospital1 1426**], on disability, has two sons. smokes 1ppd x 40 yrs, no etoh, drugs. Family History: Mother with breast CA; father alive with CAD & CHF; sons healthy. Physical Exam: PHYSICAL EXAM: T 38.0 / HR 87 / BP 109/83 / RR 13 / 100% room air / 24hr I/O +530, +2243 for entire length of stay. Gen: pleasant, NAD HEENT: NCAT, eomi grossly, MMM CV: RRF, NL S1, S2. No m/r/g LUNGS: bibasilar crackles and decreased bs diffusely, no w/r ABD: Soft, mildly tender in epigastric region, mildly distended but not tense, no obvious fluid wave, no hsm, no masses EXT: No c/c/e SKIN: No rash NEURO: AOx4, cn 2-12 intact grossly, strenth [**6-15**] throughout, no asterixis Pertinent Results: Admission Labs: [**2137-11-20**] 11:50PM GLUCOSE-92 UREA N-25* CREAT-4.3*# SODIUM-139 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-29 ANION GAP-16 [**2137-11-20**] 11:50PM CALCIUM-7.8* PHOSPHATE-6.1*# MAGNESIUM-2.0 [**2137-11-20**] 11:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2137-11-20**] 11:50PM WBC-4.4 RBC-3.32* HGB-9.3* HCT-27.6* MCV-83 MCH-28.0 MCHC-33.8 RDW-19.5* [**2137-11-20**] 11:50PM NEUTS-63.1 BANDS-0 LYMPHS-23.8 MONOS-12.3* EOS-0.4 BASOS-0.4 [**2137-11-20**] 11:50PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-NORMAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL [**2137-11-20**] 11:50PM PLT SMR-NORMAL PLT COUNT-273 [**2137-11-20**] 11:50PM PT-12.9 PTT-81.9* INR(PT)-1.1 [**2137-11-20**] 03:46PM AMMONIA-35 [**2137-11-20**] 03:38PM GLUCOSE-92 UREA N-40* CREAT-6.0*# SODIUM-137 POTASSIUM-5.8* CHLORIDE-96 TOTAL CO2-23 ANION GAP-24 [**2137-11-20**] 03:38PM ALT(SGPT)-13 AST(SGOT)-30 ALK PHOS-213* AMYLASE-55 TOT BILI-0.3 [**2137-11-20**] 03:38PM LIPASE-24 [**2137-11-20**] 03:38PM CK-MB-5 cTropnT-0.08* [**2137-11-20**] 03:38PM ALBUMIN-3.6 CALCIUM-7.7* PHOSPHATE-8.2*# MAGNESIUM-2.1 [**2137-11-20**] 03:38PM LACTATE-1.1 [**2137-11-20**] 03:38PM WBC-6.7 RBC-3.71* HGB-10.5* HCT-31.8* MCV-86 MCH-28.2 MCHC-32.9 RDW-19.5* [**2137-11-20**] 03:38PM NEUTS-63.9 BANDS-0 LYMPHS-26.3 MONOS-9.1 EOS-0.3 BASOS-0.4 [**2137-11-20**] 03:38PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-2+ [**2137-11-20**] 03:38PM PLT SMR-NORMAL PLT COUNT-307 [**2137-11-20**] 03:38PM PT-14.3* PTT->150* INR(PT)-1.3* . Discharge labs: [**2137-11-24**] 07:05AM BLOOD WBC-6.3 RBC-3.49* Hgb-9.8* Hct-29.2* MCV-84 MCH-28.2 MCHC-33.7 RDW-19.1* Plt Ct-345 [**2137-11-24**] 07:05AM BLOOD PT-11.9 INR(PT)-1.0 [**2137-11-24**] 07:05AM BLOOD Glucose-101 UreaN-27* Creat-4.3*# Na-138 K-5.1 Cl-96 HCO3-28 AnGap-19 [**2137-11-22**] 03:22AM BLOOD ALT-12 AST-26 LD(LDH)-208 AlkPhos-197* Amylase-41 TotBili-0.4 [**2137-11-22**] 03:22AM BLOOD Lipase-14 [**2137-11-24**] 07:05AM BLOOD Calcium-8.3* Phos-7.3*# Mg-2.3 [**2137-11-24**] 07:05AM BLOOD Phenyto-12.2 Phenyfr-LESS THAN . Micro: WOUND CULTURE (Final [**2137-11-25**]): STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S . STUDIES: CXR - [**2137-11-20**] - 1. Satisfactory positioning of the endotracheal tube. 2. Enlarged cardiac silhouette likely due to stable cardiomegaly with low lung volumes. 3. Retrocardiac opacity either representing infiltrate or atelectasis. . Echo [**2137-8-22**] - moderately dilated LA; no ASD; symmetric LVH; EF 40-50%; elevated LV filling pressure; RV free wall hypertrophy; trace AR; 1+ MR; moderate PA systolic hypertension . CT HEAD W/O CONTRAST Study Date of [**2137-11-20**] 3:40 PM IMPRESSION: Motion limited. No evidence of intracranial hemorrhage. Stable exam. . ECG Study Date of [**2137-11-20**] 5:06:34 PM Sinus rhythm with atrial premature depolarizations. Left axis deviation. Possible left anterior fascicular block. Left ventricular hypertrophy by voltage criteria in precordial leads. Delayed anterior precordial R wave progression with non-diagnostic repolarization abnormalities consistent with left ventricular strain pattern. Compared to previous tracing of [**2137-9-25**] multiple abnormalities as previously noted persist without major change. . PARACENTESIS DIAG. OR THERAPEUTIC [**2137-11-22**] 3:07 PM IMPRESSION: Ultrasound-guided paracentesis, removal of 3 liters of fluid. Brief Hospital Course: 59 yo male with past medical history of ESRD on HD, ESLD, and seizure disorder was admitted with altered mental status and seizures. . 1. Seizure/altered mental status He had a seizure at home and another witnessed seizure in the ED. Patient with multiple admissions previously. Differential included hypertensive encephalopathy, hepatic encephalopathy, post-ictal state, electrolyte imbalances in the setting of missing HD, poorly controlled seizure disorder in the setting of medication noncompliance, and infection. Infection appeared less less likely given that patient was afebrile, normal WBC, and no localizing symptoms. He was briefly intubated for airway protection and then extubated. Now patient is stable without further seizure for past two days. Mostly likely explanation is probably low dilantin level vs electrolyte imbalance. He had no further seizure activity. In addition to continuing his home regimen, he was reloaded with dilantin. During his stay his catheter site was cultured and grew out coag negative staph which was sensitive to everything but penicillin. The results came back after he left so this was communicated by email to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] of hepatology, who is the next provider to see him. He was afebrile during the last few days of his stay. He received Vancomycin during his stay per HD protocol. . 2. ESRD Followed closely by Dr. [**Last Name (STitle) 1366**] and dialyzed at [**Location (un) **] [**Location (un) **]. He was dialyzed in the MICU and then returned to his regular HD schedule. Renal was consulted. He was continued on his home regimen and also given cinacalcet. . 4. Hypertension Patient was significantly hypertensive on admission, which came undercontrol during his stay. His clonidine was stopped. His dose of metoprolol was changed to 150mg daily. His nifedipine was changed to nifedipine sustained release 180mg daily. On day of discharge, his lisinopril was also restarted at his home dose. His regimen should be titrated as needed and his clonidine should be restarted as well if his BP tolerates. . 5. Cirrhosis He was given rifaximin and lactulose as well as an elective paracentesis as he had already had one scheduled. . 6. Peripheral [**Location (un) **] Disease. Stable His plavix 75mg PO qdaily and aspirin 81mg PO daily were continued. . 7. Depression: His nortriptyline was continued. . 8. Hypertensive Cardiomyopathy His beta blocker was continued and his HTN control was maximized. . 9. CODE: DNR, confirmed with son [**Name (NI) **] [**Name (NI) 93850**] on [**2137-11-20**] over the phone . 10. COMM: [**Name (NI) **]; Health Care Proxy [**First Name8 (NamePattern2) **] [**Known lastname 93850**] [**Telephone/Fax (1) 93897**]; Health Care Proxy [**First Name8 (NamePattern2) 3640**] [**Known lastname 93850**] [**Telephone/Fax (1) 93898**] Medications on Admission: nifedipine ER 60 mg every eight hours lisinopril 20 mg daily metoprolol 50 mg t.i.d. Lamictal 250 mg b.i.d. Keppra 375 mg b.i.d. Dilantin 300 mg once daily Plavix 75 mg once daily Ecotrin 81 mg once daily Prevacid 30 mg once daily, nortriptyline 10 mg once daily Sensipar 30 mg daily. Discharge Medications: 1. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO every twenty-four(24) hours. 3. LaMOTrigine 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 4. Lamictal 25 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO twice a day. 5. Famotidine 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q24H (every 24 hours). 6. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Telephone/Fax (1) **]: One (1) Cap PO DAILY (Daily). 8. Lactulose 10 gram/15 mL Syrup [**Telephone/Fax (1) **]: Thirty (30) ML PO TID (3 times a day). 9. Aspirin 81 mg Tablet, Chewable [**Telephone/Fax (1) **]: One (1) Tablet, Chewable PO DAILY (Daily). 10. Rifaximin 200 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID (3 times a day). 11. Levetiracetam 250 mg Tablet [**Telephone/Fax (1) **]: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 12. Phenytoin Sodium Extended 100 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr [**Telephone/Fax (1) **]: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Nifedipine 90 mg Tablet Sustained Release [**Telephone/Fax (1) **]: Two (2) Tablet Sustained Release PO DAILY (Daily). 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Telephone/Fax (1) **]: One (1) Intravenous HD PROTOCOL (HD Protochol). 16. Cinacalcet 30 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 17. Lisinopril 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: epilepsy . Secondary: ESRD on HD (M,W,F) due to idiopathic glomerulonephritis, s/p 2 failed renal transplants Labile hypertension Hypothyroidism Peripheral [**Telephone/Fax (1) 1106**] disease Hypoparathyroidism Hepatitis C CHF-systolic w/ EF 45% and diastolic dysfunction (echo [**12/2135**]) SVT/AVNRT s/p ablation Multiple fistulas H/O MRSA line infection Recent admission [**2136-2-29**] for infected L upper arm AV fistula. h/o mechanical falls admitted [**1-16**] h/o VRE, MRSA Discharge Condition: Good Discharge Instructions: You were seen at [**Hospital1 18**] for seizure. You were transferred to the MICU where your were briefly intubated. You were stabilized, your BP was controlled, you were extubated, and you were sent out of the MICU to the regular medicine floor. You received hemodialysis while you were in the hospital as well as a therapeutic paracentesis (3 liters were taken off). Neurology was consulted and you can continue your dilantin 300mg daily as you were taking before you came in to the hospital. You should discuss with your neurologist about your dose of dilantin in the future. You should resume your outpatient hemodialysis as recommended by your kidney doctor. . Your dose of metoprolol was changed to 150mg daily. Your nifedipine was changed to nifedipine sustained release 180mg daily. On day of discharge, your lisinopril was also restarted at your home dose. Your PCP should titrate doses as needed and should restart your clonidin as well if your BP tolerates. . You were started on other medications called cinacalcet, rifaximin, lactulose, vitamin B/vitamin C/folic acid, senna, and colace. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. . Call your primary care physician or return to the ED if you experience worsening SOB, fever greater than 101.4 degrees F, seizures, worsening abdominal distension or discomfort, confusion, or any symptoms that concern you. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-11-28**] 10:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2137-11-28**] 10:40 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2137-12-5**] 1:45 . Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) 1216**] [**Initial (NamePattern1) **] [**Hospital6 29**], [**Location (un) **] NEUROLOGY UNIT CC8 (SB) [**2137-12-20**] 10:30a . You should call to make an appointment to follow up with your primary care physician [**Last Name (NamePattern4) **] 1 week from now ([**Last Name (LF) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 608**]). He should adjust your blood pressure medications as needed. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 6035**]

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Discharge summary

report

Admission Date: [**2171-3-29**] Discharge Date: [**2171-4-3**] Date of Birth: [**2091-5-22**] Sex: F Service: SURGERY Allergies: Bactrim / Tylenol Attending:[**First Name3 (LF) 6346**] Chief Complaint: Right lower quadrant bulge with abdominal bloating and crampy pain Major Surgical or Invasive Procedure: Spigelian hernia repair with mesh History of Present Illness: 79F with h/o right abdominal bulge x years who presents for herniorrhaphy Past Medical History: 1. Emphysema and ILD, with DlCO 33%, PFTs consistent with RLD. 2. Status post aortic arch repair for type I dissection ([**2169-4-7**]), status post graft repair [**2169-7-3**]. On home oxygen. 3. DVT/PE post-op, status post IVC filter placement. 4. Hypertension 5. H/o C.difficile colitis 6. Atrial fibrillation on coumadin 7. S/P ventral hernia repair 8. S/P CCY 9. Osteoarthritis Social History: She lives with one daughter and one son, has 6 children, no EtOH, 20 pk-year history of smoking, no IVDU. She has the equipment for home oxygen, but has not been using it regularly. She does not use her portable oxygen when she ambulates. Family History: Non-contributory. Physical Exam: Discharge Exam Afebrile VSS, SAT 100% on 4liters nasal cannula HEENT: nonicteric sclera CHEST: distant breath sounds with scattered rhonchi CV: irreg ABD: soft, incision c/d/i without erythema, mild incision tenderness EXT: warm Pertinent Results: Inpatient Labs ---------------- [**2171-3-30**] 11:50AM BLOOD WBC-9.0 RBC-4.41 Hgb-13.6 Hct-40.0 MCV-91 MCH-30.7 MCHC-33.9 RDW-14.9 Plt Ct-168 [**2171-3-31**] 04:59AM BLOOD WBC-9.4 RBC-4.55 Hgb-13.6 Hct-41.2 MCV-91 MCH-29.9 MCHC-33.1 RDW-15.0 Plt Ct-155 [**2171-3-29**] 09:37AM BLOOD PT-17.7* INR(PT)-1.7* [**2171-3-31**] 04:59AM BLOOD PT-17.1* PTT-33.3 INR(PT)-1.6* [**2171-3-30**] 11:50AM BLOOD Glucose-213* UreaN-15 Creat-1.0 Na-134 K-3.3 Cl-100 HCO3-23 AnGap-14 [**2171-3-31**] 04:59AM BLOOD Glucose-122* UreaN-13 Creat-0.8 Na-137 K-4.1 Cl-105 HCO3-22 AnGap-14 [**2171-3-30**] 11:50AM BLOOD ALT-14 AST-31 LD(LDH)-311* CK(CPK)-67 AlkPhos-101 Amylase-22 TotBili-2.2* [**2171-3-30**] 11:50AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2171-3-30**] 11:00PM BLOOD CK-MB-NotDone cTropnT-0.15* [**2171-3-31**] 04:59AM BLOOD CK-MB-NotDone cTropnT-0.16* [**2171-3-31**] 12:32PM BLOOD CK-MB-5 cTropnT-0.10* [**2171-3-30**] 11:50AM BLOOD Albumin-3.7 Calcium-8.6 Phos-3.5# Mg-1.9 UricAcd-6.3* [**2171-3-31**] 04:59AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 [**2171-3-30**] 11:29AM BLOOD Type-ART pO2-83* pCO2-40 pH-7.35 calTCO2-23 Base XS--3 Operative Note ------------------- PREOPERATIVE DIAGNOSIS: Right spigelian hernia. POSTOPERATIVE DIAGNOSIS: Right spigelian hernia. PROCEDURE: Right spigelian hernia repair with polypropylene mesh. ANESTHESIA: General endotracheal anesthesia and 30 cc of 0.5% Marcaine. IV FLUIDS: 700 cc. ESTIMATED BLOOD LOSS: Minimal. URINE OUTPUT: No Foley was placed in the case. INDICATIONS: [**Known firstname 1743**] is very pleasant, 79-year-old female with a history of a right lower quadrant bulge. She had an outpatient CT by her primary care doctor that showed a ventral hernia in the spigelian position with terminal ileum and cecum within the hernia. She had had abdominal cramping and obstructive symptoms and was sent for a surgical consultation. Despite her multiple medical issues, she was offered repair to prevent strangulation. The risks and benefits of the surgery were discussed, and she signed a consent. PREPARATION: The patient was given intravenous antibiotics and subcutaneous heparin, taken to the operating room, and placed in the supine position. Venodyne boots were placed and activated. The patient was then endotracheally intubated in the normal fashion. The patient was shaved and sterilely prepped and draped in the normal fashion. PROCEDURE IN DETAIL: Local anesthesia was infused overlying the palpable mass. An approximately 10-cm incision was made over the mass with a 10-blade scalpel. Dissection through the subcutaneous tissue was performed with electrocautery. The hernia sac was encountered and circumscribed with electrocautery dissection. The external oblique fascia had been eroded by this large hernia. Flaps of the external oblique fascia were created around the hernia defect. The hernia defect was reduced first by opening the hernia sac and reducing the bowel within the defect and then by dissecting the hernia sac in all quadrants. The sac was then closed and reduced back in the abdominal cavity. The internal oblique muscle and fascia were reapproximated with a running 0 PDS suture. A 7.5 x 15-cm mesh was then chosen. It was sutured to the lateral aspect of the pubic tubercle, the inferior aspect, and along the shelving edge of the inguinal ligament inferolaterally. These were done with 2-0 Prolene interrupted sutures. The mesh was sutured medially to the anterior abdominal wall and superolaterally to the anterior abdominal wall. There was good overlap of mesh on the defect. There was no further palpable defect. The subcutaneous tissues were irrigated with sterile saline. Bleeding was controlled with electrocautery. The external oblique fascia was reapproximated with a running 0 PDS suture. The wound was irrigated. Additional local was infused. The Scarpa layer and Camper layer were closed with a running 3-0 Vicryl suture. The skin was reapproximated with 4-0 Monocryl subcuticular suture. Steri-Strips and sterile occlusive dressing was placed over the wound. The patient was extubated in the operating room and transferred to the post anesthesia care unit. COUNTS: Correct x2 prior to closure. COMPLICATIONS: None were apparent. IMPLANTS: A 15 x 7.5-cm polypropylene mesh. STUDY: CTA chest with and without contrast and recons. INDICATION: A 76-year-old female with hypoxic episode. Evaluate for PE. COMPARISON: [**2171-1-31**]. FINDINGS: The major airways are patent down to the subsegmental level. There is a new, small left pleural effusion and trace right effusion. Diffuse emphysematous change is again noted in the lungs, especially in the upper lung fields. Also noted are interstitial changes and fibrosis in a predominantly peripheral and basilar distribution, most consistent with usual interstitial pneumonitis (UIP). These changes are not significantly changed since previous study, [**2170-1-10**]. No suspicious nodules or masses are identified within the lung parenchyma. Vascular calcifications are again noted within the coronary arteries. The main pulmonary artery measures 2.7cm and right main 2.3cm and left main 2.9cm. Large hiatal hernia is again noted and unchanged. CT Pulmonary Angiogram: Respiratory motion limited evaluation of the distal branches in both lower lobes. No pulmonary embolism is identified. No secondray signs of PE are present. Please note that given principal concern for pulmonary embolism, bolus timing was optimized for pulmonary arterial enhancement, not for aortic enhancement. Patient again noted to be post aortic dissection repair with stent graft in stable position extending from the proximal ascending aorta through the descending aorta terminating just proximal to the aortic hiatus. No gross evidence of leak or graft failure noted. The region of short segment dissection of the right common carotid artery is again noted and stable when compared to previous studies (3:11) although not optimally evaluated on this study. Limited views of the abdomen demonstrate no obvious abnormalities within the liver or spleen. IMPRESSION: 1. No evidence of pulmonary embolism. Limited evaluation as above. 2. Stable appearance to thoracic aortic stent graft. No evidence of aortic dissection although bolus timing is not optimal for evaluation for dissection as per given clinical history. No periaortic thrombus identified. 3. Stable emphysema and fibrotic changes. 4. Stable large hiatal hernia. 5. Pulmonary arterial hypertension. ECHO ---------- MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.1 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.3 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 3.6 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.1 cm Left Ventricle - Fractional Shortening: 0.42 (nl >= 0.29) Left Ventricle - Ejection Fraction: 60% to 70% (nl >=55%) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 2.9 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 1.3 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A Ratio: 2.60 Mitral Valve - E Wave Deceleration Time: 145 msec TR Gradient (+ RA = PASP): *42 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [**2169-5-18**]. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter with <50% decrease during respiration (estimated RAP 11-15mmHg). LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] No resting LVOT gradient. RIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall hypokinesis. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. Moderate to severe (3+) MR. Eccentric MR jet. LV inflow pattern c/w restrictive filling abnormality, with elevated LA pressure. LV inflow uninterpretable due to tachycardia and/or fusion of spectral Doppler E and A waves TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Significant PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Right ventricular dilation with mild hypokinesis. Preserved left ventricular systolic function. Moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary artery hypertension. Restrictive filling pattern consistent with elevated left atrial pressures. Compared with the prior study (images reviewed) of [**2169-5-18**], the severity of mitral regurgitation has increased. Brief Hospital Course: [**Known firstname 1743**] [**Known lastname **] was admitted to the surgery service under the care of Dr. [**First Name (STitle) 2819**] on [**2171-3-29**]. She was taken to the operating room where she underwent a right spigelian hernia repair with mesh. She tolerated the procedure well and was taken the floor after recovery in the PACU. At POD 1 the urinary catheter was replaced for urinary retention. She was tolerating a regular diet. On this day she was assisted to the side of the bed to ambulate and it was reported that she became cyanotic and unresponsive. A NRB was placed with recovery of breathing and O2 saturation. She remained with palpable pulses. EKG showed sinus rhythm. She was transferred the to ICU for further monitoring. CXR was negative for acute process. Cycled cardiac enzymes were slightly elevated at 0.15; 0.16 with trend to normal at 0.10. On arrival to the ICU she was in NAD and hemodynamically stable. She had no neurological deficits and denied CP/SOB. At POD 2 she remained stable, and was transferred back to the floor. At POD 3 she was afebrile and in good condition. She was tolerating a regular diet. A CTA was performed to evaluate for possible PE due to past history of such event. This was negative. On POD 4 an ECHO was done which showed LVEF> 55%; right ventricular dilation with mild hypokinesis; moderate to severe mitral regurgitation; moderate tricuspid regurgitation; and moderate pulmonary artery hypertension. At POD 5 she was doing well, afebrile, tolerating a regular diet. Incision was clean, dry and without erythema. Cardiology cleared her for discharge. She was sent home in good condition. She was instructed to use her oxygen at all times. She was to follow up with her primary care physician [**Name Initial (PRE) 176**] [**12-11**] weeks for reevaluation and INR check. Medications on Admission: ASA 81mg Colace 100mg PRN Coumadin HCTZ 12.5mg PRN Lipitor 10mg HS Toprol XL 25mg [**Hospital1 **] Prilosec 20mg PRN Iron MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Spigelian hernia Hypoxic event requiring ICU admission Troponin leak Discharge Condition: Good Discharge Instructions: Please resume your regular medications. Take all new medications as directed. Please resume your regular activities. Avoid heavy lifting for 6 weeks. You may resume your regular diet. You may shower, just allow water to run over the wound. No swimming or baths for 2 weeks. Continue to wear the abdominal binder until your follow up appointment. Please call or return to the ER if you experience: - Fever (> 101 F) - Worsening redness or drainage from the wound - Increased pain - Nausea, vomiting, or inability to drink - Other symptoms concerning to you Followup Instructions: Please follow up with Dr. [**First Name (STitle) 2819**] in [**12-11**] weeks. Call his office, ([**Telephone/Fax (1) 6347**], to arrange the appointment. Please follow up with your primary care doctor in [**12-11**] weeks for reevaluation and to check your INR/coumadin level. Completed by:[**2171-4-3**]

[ "515", "492.8", "401.9", "274.9", "427.31", "799.02", "788.20", "997.5", "715.90", "V12.51", "410.91", "553.29" ]

icd9cm

[ [ [] ] ]

[ "53.69", "57.94" ]

icd9pcs

[ [ [] ] ]

13893, 13899

11607, 13458

343, 379

14012, 14019

1445, 11584

14630, 14940

1161, 1180

13634, 13870

13920, 13991

13484, 13611

14043, 14607

1195, 1426

237, 305

407, 482

504, 888

904, 1145

29,683

133,538

2154

Discharge summary

report

Admission Date: [**2124-9-25**] Discharge Date: [**2124-9-28**] Date of Birth: [**2049-9-2**] Sex: F Service: MEDICINE Allergies: Keflex / Percocet Attending:[**First Name3 (LF) 898**] Chief Complaint: lower extremity weakness Major Surgical or Invasive Procedure: none History of Present Illness: 75 yo W PMH recent diagnosis of necrotic RUL mass concerning for malignancy, CRI (Cr 3.7), lumbar stenosis s/p partial R laminectomy, h/o b/l DVTs and PVD who was transferred from OSH with bilateral LE weakness since Saturday x3 days. Patient reports last walking on Saturday morning going about her usual am routine and then sat down in a chair. She was unable to get up after that and required use of a wheelchair since then. VNA saw her today and noted that she was unable to bear weight and recommended emergent evaluation. She was initially taken to an OSH where she was evaluated by a neurologist there who recommended transfer to [**Hospital1 18**]. At baseline, walks with a walker especially at home and uses a wheelchair when she goes outside." Images from OSH L-spine MRI and CT-chest obtained. In total CTL-Spine MRI all unrevealing. Exam fluctuates. Was dramatically improved on the morning of [**2124-9-26**] with 4-5/5 strength in the lower extremities. When rounding with the attending in the afternoon of the same day she was able to move the legs, but was weaker with left worse than right. It is not clear at this time what might cause such a rapidly fluctuating physical exam. EMG Fellow - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] - has been curbsided regarding the possibility of this being [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Location (un) **] Myasthenic syndrome. She is discussing the utility of EMG/NCS with her colleagues. An MRI of the pelvis was ordered to look for ancillary mass compressing the lumbosacral plexus. CT-chest at OSH and X-ray show large cavitary lesion in the right chest. Per the patient's PCP the CT was read as worrysome for bronchogenic carcinoma. A BAL was negative for AFB and was culture negative. It was also negative for malignant cytology. T/SICU team is helping by consulting thoracic surgery. Past Medical History: # bronchoscopy & biopsy of necrotic lung mass in RUL [**2124-9-12**] (?)dx of lung ca. Scheduled for outpt PET scan in am and CT needle biopsy [**9-28**]. # uterine ca s/p resection c/b chronic urine/stool incontinence # s/p partial right L4 laminectomy # chronic renal insufficency (patient reports congenital small kidney) # osteoarthritis/osteoporosis # h/o bilateral deep vein thrombosis # pernicious anemia # h/o c difficile # gastroesophageal reflux disease # h/o peripheral vascular disease Social History: Former smoker (40 yrs ago). No current tobacco or ETOH. Lives in nursing home. Family History: NC Physical Exam: VS: 97.4 94/50 86 20 94%RA Gen: Alter, oriented, loquacious HEENT: NCAT, no LAD NECK: No JVP noted CV: RRR s1, s2, no M/G/R noted LUNGS: CTA b/l ABD: soft, NT/ND, no masses EXT: dark discoloratoins bilaterally, trace edema NEURO: decreased strength of lower extremities, L >> R. Able to lift right leg [**4-13**] against gravity and wekanly against my hand. Left unable to lift against gravity. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2124-9-26**] 04:34AM BLOOD WBC-7.8# RBC-3.10* Hgb-7.9* Hct-24.8* MCV-80*# MCH-25.4*# MCHC-31.8 RDW-19.4* Plt Ct-267 [**2124-9-27**] 02:05AM BLOOD Neuts-86* Bands-2 Lymphs-7* Monos-2 Eos-0 Baso-0 Atyps-2* Metas-1* Myelos-0 NRBC-2* [**2124-9-27**] 02:05AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-1+ Microcy-2+ Polychr-1+ Ovalocy-1+ Target-1+ Burr-1+ [**2124-9-26**] 04:34AM BLOOD PT-14.2* PTT-27.7 INR(PT)-1.3* [**2124-9-26**] 04:34AM BLOOD Glucose-140* UreaN-53* Creat-3.5*# Na-138 K-4.4 Cl-103 HCO3-21* AnGap-18 [**2124-9-28**] 01:00AM BLOOD Calcium-8.3* Phos-1.8* Mg-1.8 [**2124-9-27**] 02:05PM BLOOD COPPER (SERUM)-PND [**2124-9-26**] 04:34AM BLOOD VitB12-GREATER TH Folate-GREATER TH . Blood cx pending . Urine cx: URINE CULTURE (Final [**2124-9-28**]): ESCHERICHIA COLI. PRESUMPTIVE IDENTIFICATION. >100,000 ORGANISMS/ML.. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S 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 . Studies: . Renal U/S: Evaluation of the kidneys is limited due to difficult beam penetration. The left kideny measures 9.2 cm. The right kidney is small measuring 6.8 cm. No hydronephrosis, stone, or renal masses identified. IMPRESSION: Asymmetrically small right kidney which is consistent with provided history of congenitally small kidney. No hydronephrosis. . EKG: Sinus rhythm. Low voltage. Since tracing of [**2122-12-28**] the voltage has decreased. . CXR: Cardiac and mediastinal contours appear grossly unremarkable. Large likely cavitary lesion seen in the right lung, measuring upwards of 12 cm in greatest dimension. No focal consolidations or definite pleural effusions. Surgical clips are seen overlying the abdomen. IMPRESSION: Large cavitary lesion within the right lung, concerning for neoplasm. CT would be helpful for further evaluation. . MRI Spine: CERVICAL SPINE: Normal cervical lordosis is preserved. The alignment of the vertebral bodies is normal. There is no abnormal signal in the vertebral bodies, spinal cord, or dural space. The limited assessment of posterior fossa is unremarkable. Cervicomedullary junction is normal. At C3-4 level, there is a posterior osteophyte disc bulge, leading to right neural foramen narrowing. There is no significant central canal narrowing. At C4-5, there is a posterior central disc bulge, leading to anterior thecal sac deformity, as well as bilateral neural foraminal narrowing. There is no significant central canal stenosis at this level. At C5-6 level, there is a posterior disc bulge as well as osteophytes, leading to left greater than right neural foramen narrowing. There is no significant spinal canal stenosis. At C6-7 level, there is mild spondylosis, without evidence of neural foraminal or central canal narrowing. THORACIC SPINE: Axial images of T1 through T8 presented. There is accentuation of thoracic kyphosis. There are no signal intensity abnormalities in the vertebral bodies, spinal cord or within the dural space. At T5-6 level, there is a posterior disc bulge, without significant neural foraminal narrowing or central canal stenosis. At T7-8 level, there is a central disc protrusion, leading to anterior thecal sac deformity without significant central canal stenosis. At T10-11 level, there is minimal posterior disc bulge, without significant neural foraminal narrowing or central canal stenosis. No significant abnormalities are reviewed atT11-L2 levels. Note made of a large cavitary right lung mass. IMPRESSION: 1. Multilevel spondylosis, without evidence of central canal stenosis or spinal cord compression. 2. Large cavitary lung lesion. Differential diagnosis is broad. If not already obtained, dedicated chest CT is recommended for further evaluation of this finding. Brief Hospital Course: The patient was initially admitted to the Neuro-ICU and evaluated by neurology. CTL-Spine MRI was performed and found to be unrevealing. Her physical exam seemed to fluctuate widely day to day, but her lower extremitiy exam was dramatically improved on the morning of [**2124-9-26**] with 4-5/5 strength in the lower extremities. She was weaker on the left side, especially with hip flexion but states that she has had that problem for 5 years. Upon discharge her exam was similar with good strength in her upper extremities and R lower extremity and mild defects in the left as described above. The neuromuscular team was consulted and had discussed the possibility of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]/[**Location (un) **] myasthenia in the setting of a possible pulomary malignancy. An MRI of the pelvis was ordered to look for ancillary mass compressing the lumbosacral plexus. She was evaluated by physical therapy on the day of discharge, but exam was limited by patient cooperation, however she was able to stand and shuffle a short distance with a walker. In regards to her lung lesion, CT-chest at OSH and X-ray show large cavitary lesion in the right chest. Per the patient's PCP the CT was read as worrysome for bronchogenic carcinoma. A BAL was negative for AFB and was culture negative. It was also negative for malignant cytology. Thoracic surgery was consulted at [**Hospital1 18**], but at that point the patient wished to pursue her care at [**Hospital3 4107**] and with her outpatient pulmonologist. The patient was also found to be in acute on chronic renal failure upon admission with a creatinine of 3.5. The renal team saw her and felt this might have been due to hypotension/hypovolemia. Her renal function improved with gentle hydration. Renal U/S showed no cause for acute renal failure, no hydronephrosis. She was also found to have a urinary tract infection (E.coli) for which she was started on ciprofloxacin on [**9-27**]. Medications on Admission: MEDICATIONS ON TRANSFER FROM OSH: Acetaminophen 325-650 mg PO Q6H:PRN pain or fever >101.4 Paricalcitol 1 mcg IV DAILY Nephrocaps 1 CAP PO DAILY Sodium Bicarbonate 650 mg PO BID Potassium Chloride 20 mEq PO DAILY Ferrous Sulfate 325 mg PO TID Pantoprazole 40 mg PO Q24H Docusate Sodium 100 mg PO BID:PRN constipation Furosemide 20 mg PO DAILY Loperamide 2 mg PO DAILY:PRN Epoetin Alfa 8000 UNIT SC QMOWEFR Lovenox 40mg SC QD . Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever >101.4. 2. Sodium Bicarbonate 650 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day): as instructed. 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection [**Hospital1 **] (2 times a day). 6. Epoetin Alfa 20,000 unit/2 mL Solution Sig: One (1) injection Injection once a week: Monday. 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a day as needed. 9. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection Injection once a month. 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 12. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) units Subcutaneous every twelve (12) hours. 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection subQ Injection four times a day as needed: Please follow insulin sliding scale, starting at blood glucose 151 give 4units, then per increase 50 in BG advance insulin dose by 2 units. 14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 15. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 17. Zemplar 1 mcg Capsule Sig: One (1) Capsule PO once a day. 18. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hosp Discharge Diagnosis: Primary: 1.) Lower extremity weakness 2.) Right lung mass 3.) Urinary tract infection Secondary: 3.) Chronic renal failure Discharge Condition: good Discharge Instructions: You were transferred to [**Hospital1 18**] because of lower extremity weakness. You were evaluated by the neurology servive and underwent imaging studies of your spine which showed no abnormalities. You were scheduled for an MRI of the pelvis which may be done at [**Hospital3 4107**]. . You should continue to take all medications as instructed and keep all health care appointments when you are discharged. . If you have worsening leg weakness, shortness of breath, chest pain, numbness, trouble speaking, or if your condition worsens in any way contact your physician or seek medical attention. Followup Instructions: Please follow-up as instructed by Dr. [**Last Name (STitle) 11510**] or the physician at [**Hospital3 **].

[ "V10.42", "724.02", "285.29", "530.81", "585.9", "584.5", "729.89", "162.3", "707.03", "276.52", "599.0", "041.4", "733.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12093, 12140

7891, 9877

301, 308

12307, 12314

3385, 7868

12961, 13071

2884, 2888

10355, 12070

12161, 12286

9903, 10332

12338, 12938

2903, 3366

237, 263

336, 2248

2270, 2771

2787, 2868

23,161

132,008

17791

Discharge summary

report

Admission Date: [**2132-4-1**] Discharge Date: [**2132-4-11**] Date of Birth: [**2055-3-1**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with a recent diagnosis of coronary artery disease at [**Hospital3 **] in [**2132-2-6**] with a stent times two to the right coronary artery, stent to the left anterior descending and an ejection fraction noted to be 40%, who presented with the acute onset of shortness of breath. The patient was his usual state of health until the afternoon on admission around 4:30 p.m. The patient was noted by his wife that he was having difficulty breathing. The patient was getting ready to ride a bus to a friend's house when the symptoms occurred. There was no associated chest pain, diaphoresis, light-headedness or palpitations. The patient was noted then to have nausea and vomiting times one that was nonbloody. EMS was called who found him down and unresponsive with a blood pressure of 170/70, heart rate 130, an electrocardiogram with left bundle branch block which is old. The patient was transferred to [**Hospital6 2018**] where a chest x-ray showed pulmonary edema where he was intubated. In the Emergency Room, his blood pressure was noted to be 230/110, heart rate 133, respirations 36, and an oxygen saturation of 89%. He was intubated and was noted to be foaming at the mouth. He received sublingual Nitroglycerin times one, followed by Nitroglycerin drip, Heparin, Aspirin, Lasix 80 mg IV, then 40 mg IV, .................. and .................. for initiation and intubation. His electrocardiogram was significant for left bundle branch block. PAST MEDICAL HISTORY: 1. Coronary artery disease status post stent in [**2132-2-6**]. 2. Hypercholesterolemia. 3. Insulin-dependent diabetes mellitus times two months. 4. Chronic renal insufficiency. 5. Hypertension. 6. Peripheral vascular disease. MEDICATIONS: Tento, Glyburide 10 b.i.d., Precose 50 t.i.d., Aspirin 81 q.d., NPH 14 q.a.m., Prevacid 30 q.d., regular Insulin sliding scale, Lasix 20 b.i.d., Zestril 20 q.d., Atenolol, Plavix 75 q.d., Lipitor 10 q.d., Lopressor 25 b.i.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: Tobacco history of 80-100 pack-year history; He quit seven years ago. Occasional alcohol use. The patient denied drugs. The patient is married without children. Primary care physician is [**Last Name (NamePattern4) **]. [**First Name (STitle) **] at [**Hospital3 **]. PHYSICAL EXAMINATION: General: The patient was intubated. HEENT: Pupils equal, round and reactive to light. Pulmonary: Rhonchi heard throughout. Cardiovascular: Regular, rate and rhythm. No murmurs, rubs, or gallops. Abdomen: Nontender and nondistended. Normoactive bowel sounds. No hepatosplenomegaly. Extremities: Positive 1+ pitting edema at the ankles. No calf tenderness or cords. LABORATORY DATA: White count 16.7, hematocrit 47.7, platelet count 383; INR 1.4; bicarb 18, BUN 26, creatinine 1.3, anion gap 24, sodium 144, chloride 102, CK #1 114, troponin less than 0.3, MB 2; ABG 7.15, 66, 83 on assist control 700 x 12, PEEP 8, 100%. Chest x-ray showed pulmonary edema, question of left lower lobe pneumonia. TTE from [**2132-2-6**] showed mild global hypokinesis, inferior hypokinesis, ejection fraction of 40%. Catheterization results from [**2132-2-6**], is status post right coronary artery stent times two and an left anterior descending stent times one. The left main artery was nonobstructed. The right coronary artery was dominant with severe proximal and mid 90%, 40% mid-distal stenosis. The left anterior descending artery showed diffuse disease with 80% midstenosis after diagonal #2 with a focal 80% mid and 50% distal, diagonal #1 with a medium 70% ostial stenosis and a 70% mid. Diagonal #2 showed a medium 50% ostial stenosis. The left circumflex artery showed diffuse disease. Obtuse marginal #1 and #2 were small with moderate diffuse disease, and the left main artery was nonobstructed. The patient had a two-vessel stenting with stents to the right coronary artery and left anterior descending artery. ASSESSMENT: This is a 77-year-old male with a newly diagnosed coronary artery disease, diabetes, and congestive heart failure status post hypoxic respiratory arrest and pulmonary edema. HOSPITAL COURSE: The patient was admitted to the CCU intubated for his acute episode of pulmonary edema. It was thought that it was multi-factorial, including possible acute myocardial infarction (stent closure from in-stent restenosis), diastolic dysfunction versus noncardiogenic edema which was doubtful. He was continued on a Nitroglycerin drip, given intravenous Lasix and continued on mechanical ventilation. The patient's first set of cardiac enzymes were negative. A stat bedside echocardiogram was with essentially old findings but revealed moderate to severe regional left ventricular systolic dysfunction. Resting regional wall motion abnormalities, included an inferolateral and apical akinesis with hypokinesis elsewhere. The ejection fraction was estimated to be around 30%. The left bundle branch block on his electrocardiogram was old, as he was noted to have this in [**Month (only) 404**] as well. He was started on a Dopamine drip for his hypotension and continued on Aspirin and Heparin drip, as well as Lopressor if his blood pressure could tolerate it. Also on admission, he spiked a temperature to 102.4??????, and there was a new disappearance of his left hemidiaphragm with a question of a left lower lobe pneumonia on chest x-ray. His labile blood pressure was thought perhaps to be due to sepsis. He was therefore pancultured and started on Ceftriaxone and Azythromax. Also on admission, he was started on Mucomyst in anticipation for cardiac catheterization the next morning in order to evaluate if this is a restenosis. For his diabetes, it was noted that he did have an elevated glucose on admission; however, acetone was negative, and there was evidence of DKA, although he did have a mild anion gap acidosis which was likely partially due to dehydration. He was continued on a regular Insulin sliding scale. His Glyburide was continued, but his NPH was held initially on admission. Famotidine was initiated for GI prophylaxis. He underwent placement of a left subclavian, as well as left a arterial line on admission. On the next morning, he underwent cardiac catheterization which revealed an left anterior descending with a 90% restenosis just proximal to the stent margin with moderate diffuse in-stent restenosis, then 50% stenosis after the first diagonal branch, and an ostial 60% stenosis at the second diagonal branch. Left ventriculography was not performed. He underwent successful PTCA, cutting balloon, as well as beta-brachy therapy of the moderate in-stent restenosis within the mid left anterior descending. Finally angiography demonstrated minimal residual stenosis, no dissection, and TIMI-3 flow. He also had a moderately severe elevation of his pulmonary wedge pressure and moderate pulmonary hypertension secondary to left ventricular disease. After his catheterization, he was continued on Plavix, Aspirin, Lipitor and Metoprolol. The Heparin was held because he had experienced some upper GI bleeding which did end up resolving. For his pump, he was continued on intravenous Lasix. He continued to experience very labile blood pressures, and it was a question of whether this was because of early sepsis from his left lower lobe pneumonia. He was continued on Ceftriaxone, and Azithromycin was changed to Levaquin. His cultures were followed closely. Eventually the Metoprolol was discontinued secondary to his hypotension, and it was still unclear whether this was mostly secondary to cardiogenic etiology or because of sepsis, as he was experiencing very high temperature spikes up to 103??????. His sugars also began to become very high, and he was started on an Insulin drip by [**4-3**] in order to better control his sugars. Because he continued to spike temperatures, the Ceftriaxone was discontinued and replaced with Vancomycin, and he was continued on Vancomycin and Levofloxacin on [**4-3**]. On [**4-4**], he actually seemed to improve, and extubation was attempted; however, he failed this and needed to be reintubated, as he went into flash pulmonary edema. Anesthesia was called to the bedside, and they underwent a rapid sequence, and intubation that was not complicated. Because he likely went into flash pulmonary edema because he was fluid overloaded on the attempt for the extubation, as well as also receiving some units of blood for low hematocrits, it was decided to attempt some diuresis with a goal of [**2-6**]?????? L negative per day with intravenous Lasix. He continued to be intubated, and the plan was to attempt an extubation tomorrow or the next day after adequate diuresis. His coffee-ground emesis from the NG tube did seem to resolve by this point, and his hematocrit bumped with the packed red blood cells. He was also noted to have an elevated creatinine on admission. This was thought to be acute on chronic renal failure, and his creatinine was followed closely. It did eventually decrease down to 1.2 by the time of discharge. The highest it went up to was 1.9 on [**4-2**]. He was undergoing diuresis, and ACE inhibitor was started on [**4-5**], in order to initiate afterload reduction. He was successfully extubated on [**4-6**] after significant diuresis and was much improved. On [**4-7**], the Vancomycin was decreased on day #5, as he remained afebrile, and it was decided to continue Levofloxacin for at least a [**8-14**] day course. His creatinine by [**4-5**] had come down to 1.2, and by [**4-8**], he was discharged to the floor in stable condition. His Captopril was converted to a long-acting Lisinopril. His Nitroglycerin drip was titrated down to off, and his beta-blocker was continued; it had been restarted once his hypotension had resolved, and he was also continued on his Plavix, Aspirin and Lipitor. He was continued on Levaquin for his left lower lobe pneumonia. He had some agitation status post extubation and had received some Haldol for this; however, this was only briefly. He was evaluated by the Speech and Swallow Team, as he was having some coughing and a question of aspiration. Their bedside evaluation revealed overt signs and symptoms of aspiration only when challenged with consecutive cup/straw drinking with liquids. This may be because of poor airway protection impacted by recent intubations, especially given his mild hoarse voice quality. They recommended that he undergo video swallow study and be maintained on aspiration precautions. The video swallow study revealed aspiration of the nectar and thin liquid consistencies. When used with honey-thick liquid, aspiration was prevented, and overall risk was reduced. It was recommended that he initiate a diet of honey-thick liquids and soft solids, remain bold upright for meals, as well as to consider a future ENT consult. Isordil was started for some hypertension close to the time of discharge and was titrated up. He was evaluated by Physical Therapy and felt to be stable to go home with VNA on [**4-11**], after he was recovered from his pneumonia and his upper GI bleed had resolved. His initial cardiogenic shock/pulmonary edema was also resolved, and his hypertension was under much better control. He completed a 10-day course of Levaquin. DISCHARGE STATUS: He was discharged home with VNA Services. He is to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on [**4-16**]. He is to follow-up with his [**Last Name (un) **] physician as well on [**4-16**], and will be following up with his cardiologist, Dr. [**Last Name (STitle) 49406**], in [**8-14**] days. He has another video speech and swallow study scheduled for [**4-24**] at 10 a.m. CONDITION ON DISCHARGE: Improved. MAJOR INTERVENTIONS: Cardiac catheterization, intubation, transfusion of packed red blood cells. DISCHARGE DIAGNOSIS: 1. Left anterior descending in-stent restenosis. 2. Acute myocardial infarction. 3. Pneumonia. DISCHARGE MEDICATIONS: Lipitor 10 q.d., Plavix 75 q.d., Aspirin 325 q.d., Metoprolol 25 b.i.d., Polyvinyl alcohol eyedrops p.r.n., Pantoprazole 40 mg q.d., Levaquin 250 mg 1 tab q.d. for another 4 days, Lisinopril 40 mg q.d., Lasix 20 mg b.i.d., Glyburide 10 mg b.i.d., Tylenol p.r.n., Isosorbide Mononitrate 120 mg q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Last Name (NamePattern1) 36974**] MEDQUIST36 D: [**2132-6-2**] 18:24 T: [**2132-6-2**] 19:53 JOB#: [**Job Number 49407**]

[ "518.81", "038.9", "507.0", "996.72", "410.71", "E878.2", "785.59", "428.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56", "38.91", "89.62", "96.33", "36.01", "96.07", "96.72", "96.04", "92.27" ]

icd9pcs

[ [ [] ] ]

12262, 12839

12139, 12238

4344, 11983

2507, 4326

163, 1656

1679, 2194

2211, 2484

12008, 12118

27,172

140,642

49079

Discharge summary

report

Admission Date: [**2109-8-5**] Discharge Date: [**2109-9-25**] Date of Birth: [**2055-11-20**] Sex: M Service: SURGERY Allergies: Penicillins / Aspirin / Ibuprofen / Ciprofloxacin Attending:[**First Name3 (LF) 668**] Chief Complaint: nausea, vomiting, abdominal pain, mental status changes and sepsis. Major Surgical or Invasive Procedure: [**2109-8-5**] Exploratory laparotomy, Lysis of adhesions ,Temporary abdominal closure with a [**State 19827**] patch [**2109-8-12**] Exploratory laparotomy; closure of abdomen with component separation and debridement of skin, subcutaneous tissue, and muscle; abdominal wound closure. [**2109-8-23**] Tracheostomy and bronchoscopy History of Present Illness: Per Dr.[**Name (NI) 670**] operative note, Mr. [**Known lastname 102989**] presented approximately 13 hours to the surgery service, transferred from a long-term skilled nursing facility with mental status changes and profound hypotension. In the emergency room, he was noted to have a blood pressure of 60/40. He received multiple fluid boluses and started on pressors. He was transferred to the surgical intensive care unit where he underwent placement of invasive lines and was started on Levophed and Neo. Ultimately, Pitressin was added. He received several units of packed cells and large volume resuscitation. Over the course of the day, his blood pressure slightly improved but not substantially. Eventually, he was able to undergo CT scan which demonstrated what appeared to be bilateral pulmonary consolidation and while there was no evidence of free air, there was some thickened small bowel in the proximal intestine and some findings that could be consistent with pneumatosis. These were not obvious on the CT scanner. Based upon his overall clinical status, we elected to proceed with exploratory laparotomy. Past Medical History: alcoholic cirrhosis, s/p Liver [**Known lastname **] [**2109-6-6**] [**2109-6-23**] exploration for hematoma and fluid collection - prior ascites - prior hepatorenal syndrome requiring several sessions of hemodialysis - known grade II esophageal varices and portal gastropathy by EGD [**2109-4-9**] - history of candidal and bacterial (SBP) peritonitis - colorectal cancer (stage unknown) s/p colectomy in [**11/2108**] - cervical stenosis - hyperlipidemia - hypertension - history of C Diff colitis - anemia with baseline Hct 27-30 - history of Torsades while on ciprofloxacin - depression - history of positive PF4 antibody - BPH -[**2109-8-5**] Exploratory laparotomy, Lysis of adhesions ,Temporary abdominal closure with a [**State 19827**] patch -[**2109-8-12**] Exploratory laparotomy; closure of abdomen with component separation and debridement of skin, subcutaneous tissue, and muscle; abdominal wound closure. -[**2109-8-23**] Tracheostomy and bronchoscopy Social History: Home: Lived with wife and daughter in [**Name2 (NI) **] prior to hospitalization in [**Month (only) 958**]. They have moved to a new home since his hospitalizations. Has since been at [**Hospital1 100**]/[**Hospital 8218**] rehab Occupation: used to work as construction worker. EtOH: denies ETOH for past 5 years, extensive in the past Drugs: denies h/o IVDA Tobacco: Tobacco: [**Date range (1) 61126**] PPD x 30 years; quit in 2/[**2108**]. Family History: Denies fhx of early MI, stroke, cancer. Pertinent Results: [**2109-9-23**] 08:00AM BLOOD WBC-5.9 RBC-3.07* Hgb-9.6* Hct-28.0* MCV-91 MCH-31.1 MCHC-34.2 RDW-18.9* Plt Ct-102* [**2109-9-24**] 04:46AM BLOOD WBC-5.4 RBC-2.92* Hgb-9.5* Hct-26.2* MCV-90 MCH-32.6* MCHC-36.2* RDW-18.2* Plt Ct-117* [**2109-9-22**] 05:30AM BLOOD Glucose-133* UreaN-73* Creat-1.4* Na-139 K-4.9 Cl-104 HCO3-27 AnGap-13 [**2109-9-23**] 08:00AM BLOOD Glucose-111* UreaN-73* Creat-1.5* Na-136 K-5.3* Cl-103 HCO3-26 AnGap-12 [**2109-9-24**] 04:46AM BLOOD Glucose-115* UreaN-70* Creat-1.5* Na-137 K-5.8* Cl-104 HCO3-25 AnGap-14 [**9-24**] K+ ________ [**2109-9-24**] 04:46AM BLOOD ALT-10 AST-16 AlkPhos-87 TotBili-0.3 [**2109-9-23**] 08:00AM BLOOD Albumin-3.3* Calcium-8.7 Phos-2.8 Mg-1.5* [**2109-9-24**] 04:46AM BLOOD tacroFK-7.2 Brief Hospital Course: Mr. [**Name14 (STitle) 102995**] had a complicated, prolonged hospital course with most of this time in the SICU. Per Dr.[**Name (NI) 670**] operative note, Mr. [**Known lastname 102989**] presented to the ED from a long-term skilled nursing facility with mental status changes and profound hypotension. In the emergency room, he was noted to have a blood pressure of 60/40. He received multiple fluid boluses and started on pressors. He was transferred to the surgical intensive care unit where he underwent placement of invasive lines and was started on Levophed and Neo. Ultimately, Pitressin was added. He received several units of packed cells and large volume resuscitation. Over the course of the day, his blood pressure slightly improved but not substantially. Eventually, he was able to undergo CT scan which demonstrated what appeared to be bilateral pulmonary consolidation and while there was no evidence of free air, there was some thickened small bowel in the proximal intestine and some findings that could be consistent with pneumatosis. These were not obvious on the CT scanner. Based upon his overall clinical status, he proceeded to the OR ([**2109-8-5**]) for exploratory laparotomy, Lysis of adhesions and temporary abdominal closure with a [**State 19827**] patch for sepsis and abnormal CT scan suggestive of proximal small bowel pneumatosis. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. No abnormalities were noted intra-abdominally. Please see operative note for further details. Due to the massive distention of the small bowel the abdomen was unable to be closed therefore a Silastic patch was sutured to the anterior abdominal wall. A JP was placed. On [**8-6**], he failed extubation trial and a bronch was done with sputum sent which grew pseudomonas and enterobacter cloacae. Meropenum was started for pseudomonas. Inhalation tobramycin was added for pseudomonas in sputum. IV flagyl was given for anaerobic coverage and PO vanco for presumed c.diff colitis. He was also on IV caspo for emperic coverage for fungemia. Stools came back negative for c.diff. ID was consulted and followed recommending discontinuation of IV caspo, po vanco and iv flagyl. Recommendations included a 14 dAy course of Meropenum, discontinuation of linezolid on day 8 and switching Caspo to fluconazole. ID signed off on [**7-31**]. He was treated with fentanyl for abdominal pain. Due to NPO status TPN was given. A lasix drip was administered for anasarca. This was discontinued on [**8-14**]. The Kentuck patch was periodically tightened and on [**8-12**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] performed exploratory laparotomy; closure of abdomen with component separation and debridement of skin, subcutaneous tissue, and muscle; abdominal wound closure. He was extubated on [**8-13**] and was maintained on a 50% Face Mask. On [**8-14**], a speech and swallow eval found that he did not have signs/sx of aspiration and recommended slow initiation of ground solids and thin liquids. Clear diet was started on [**8-15**] as well as a tube feeding with TPN weaned off. He experienced loose frequent stools. Several stool specs were sent for c.diff with all being negative. On [**8-15**], he had an episode of hypoxia with a sat of 85% and self limiting run of bradycardia with rate of 30's. O2 sats improved on 100% face tent. TTE did not show evidence of heart strain or PE. Cardiac enzymes were negative. Troponin was 0.12 with a creatinine of 1.6. He required re-intubation. A chest CTA was negative for a PE. This showed persistent but improving LLL pneumonia, with new RUL pneumonia. He did receive IV bicarb for renal protection. He produced copious amounts of sputum which continued to grow pseudomonas. WBC increased to 16.4 and Linezolid was started. He was extubated on [**8-17**], but was required reintubated for desaturation on a NRB. ID was reconsulted on [**8-20**] for persistent growth of pseudomonas noted on BAL on [**8-20**] with WBC increased from 3 to 10.2. Pseudomonas was noted to have more resistance with sensitivity to Amikacin. IV Amikacin and Cefepime were started. On [**2109-8-23**] due to prolonged mechanical ventilation and multiple attempts to extubate, a tracheostomy and bronchoscopy was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Cardiology was consulted for intermittent episodes of bradycardia. Temporary pacing was not felt to be indicated. Avoidance of nodal agents was recommended. He became bradycardia when on right side receiving CPT. HR was 44 and O2 sat dropped low 90s on 70% FM. He had hemoptysis and was reintubated on [**8-19**]. CXR was done to eval for aspiration. This was negative for foreign body. He had recurrent episodes of bradycardia and brief period of asystole. Temporary pacing was done for a few days then stopped. Caspo was discontinued on [**8-25**]. On [**8-26**], repeat BAL with culture again grew pseudomonas. Amikacin continued. CXR appeared slightly better. He was weaned to a trache collar, but did not tolerate this for long due to agitation/tachypnea requiring the ventilation. He had several unsuccessful attempts off the vent. He was re-bronch'd on [**8-26**] and [**8-30**]. He continued to receive aggressive pulmonary toilet. Mental status waxed and waned with notable confusion and dystonia (odd head movements) on [**9-1**]. There was concern that he might have experienced serotonin syndrome given that he was on zoloft and Linezolid due to some high BPs (SBP in 170s and confusion. A sertraline level was sent. Zoloft and Linezolid were stopped and Dapto was resumed. Head CT and MRI ([**9-1**]) was unreavling with no acute intracranial pathology. UA and Urine culture were sent with +UTI noted (>100,000 VRE) on [**8-30**] and [**9-1**]. Dapto was started, but due to worsening renal function (creat increased to 1.8) around [**9-3**], Dapto was discontinued and Linezolid was resumed. Mental status did improve. Given concern for renal side effects, Prograf dosing was adjusted periodically based on trough levels. A lower goal level was set due to severity of infection. Cellcept was held. Prednisone was continued at 10mg qd. LFTs remained stable. He was transferred out of the SICU on [**9-17**] to the Medical-Surgical Unit. He continued to improve with increase po intake. Speech and Swallow re-evaluated and recommended a regular diet. Kcal intake increased meeting at least 50% of his kcal needs. Tube feedings were then cycled using Nutren Renal at 90cc/hour x 6 hours from 10pm to 4am. He did exerienced hyperkalemia. K+ 6.3 [**9-24**] treated with lasix 10mg and kayexalate. K+ decreased to 5.3. Florinef was started for hyperkalemia with K+ decreasing to 5.1 on [**9-25**]. He should continue to have close f/u of potassium levels at rehab. On [**9-23**], he experienced some urinary incontinence. Bladder scan noted a residual of 800cc. A foley catheter was placed and he was started on flomax. Urology consult recommended a voiding trial in 1 week and then follow up in the outpatient [**Hospital 159**] clinic. At time of discharge, he was alert and oriented. Speaking with Passy Muir valve in place on 35%humidified trache collar. Abdomen was ND/NT with well healed abdominal incision. Foley was draining yellow, clear urine and he was OOB with assist of 2 with rolling walker. Discharged to [**Hospital 100**] Rehab Hospital. Medications on Admission: bactrim ss 1 qd, cellcept 1 gram [**Hospital1 **], colace 1 [**Hospital1 **], fluconazole 400mg qd, insulin regular sliding scale qid prn, kayexalate prn, lansoprazole 30mg qd, linezolid 600mg [**Hospital1 **], mag oxide 400mg [**Hospital1 **], metoprolol 12.5mg [**Hospital1 **], oxycodone 10mg prn q 6 hours, prednisone 10mg qd, tacrolimus 2.5mg [**Hospital1 **], tamsulosin 0.4mg qhs, valcyte 450mg qod Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day) as needed for thrush. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 4. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Hospital1 **]: Ten (10) ML PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff Inhalation Q4H (every 4 hours). 7. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution [**Hospital1 **]: 2.5 ml PO BID (2 times a day). 8. Sodium Bicarbonate 650 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 9. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed. 10. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours). 11. Clonidine 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 12. Pregabalin 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO tid (): for neuropathy. 13. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed for chronic pain: for neuropathy pain. 14. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr [**Hospital1 **]: One (1) Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily). 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Tacrolimus 1 mg Capsule [**Hospital1 **]: Four (4) Capsule PO Q12H (every 12 hours). 17. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: follow sliding scale Injection four times a day: see printed scale. 18. Fludrocortisone 0.1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 19. No Beta Blockers Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: hematoma malnutrition pseudomonas pneumonia ARF hyperkalemia failure to wean from vent urinary retention Discharge Condition: good Discharge Instructions: Please call the [**Hospital6 1326**] Office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take any of your medications, abdominal pain, jaundice or malfunction of the post pyloric feeding tube Continue cycled tube feeds as ordered Physical therapy Labs every Monday and Thursday with results fax'd to [**Telephone/Fax (1) 697**] Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-10-3**] 2:10 Please schedule follow up urology appointment in clinic [**Telephone/Fax (1) 164**] Completed by:[**2109-9-25**]

[ "276.7", "V10.06", "038.9", "482.1", "458.9", "788.39", "995.92", "401.9", "600.00", "V42.7", "599.0", "584.9", "272.4", "041.04", "518.81", "263.9", "427.89", "560.81" ]

icd9cm

[ [ [] ] ]

[ "54.3", "96.72", "99.15", "33.24", "96.04", "54.11", "96.71", "54.59", "31.1", "33.22", "54.62" ]

icd9pcs

[ [ [] ] ]

14042, 14108

4161, 11637

377, 712

14257, 14264

3395, 4138

14672, 14938

3335, 3376

12093, 14019

14129, 14236

11663, 12070

14288, 14649

269, 339

740, 1864

1887, 2858

2874, 3319

28,507

134,458

33742

Discharge summary

report

Admission Date: [**2170-3-30**] Discharge Date: [**2170-4-6**] Date of Birth: [**2099-1-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: [**2170-4-2**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to OM, SVG to PDA) History of Present Illness: 71 y/o male with increasing chest discomfort and b/l arm pain with activity. He underwent a cardiac cath which revealed severe three vessel coronary artery disease. Then referred for bypass surgery. Past Medical History: Coronary Artery Disease and Myocardial Infarction s/p PTCA to RCA [**2157**], Hypertension, Hypercholesterolemia, Obesity, Diabetes Mellitus PSH: Left eye surgery, Parotid Cyst surgery Social History: Quit smoking [**2156**] after 1ppd x 45 yrs. Drinks 1 beer/day. Lives with spouse Family History: NC Physical Exam: V: 68 18 126/83 5'8" 195lbs Gen: WDWN male in NAD Skin: Unremarkable Neck: Supple, FROM, -JVD, -carotid bruits Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, +varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [**2170-4-6**] 05:25AM BLOOD WBC-9.2 RBC-3.52* Hgb-10.7* Hct-31.3* MCV-89 MCH-30.3 MCHC-34.1 RDW-13.6 Plt Ct-196 [**2170-3-30**] 08:49PM BLOOD WBC-6.9 RBC-4.89 Hgb-15.1 Hct-41.9 MCV-86 MCH-31.0 MCHC-36.1* RDW-12.9 Plt Ct-156 [**2170-4-6**] 05:25AM BLOOD Plt Ct-196 [**2170-3-30**] 08:49PM BLOOD PT-12.5 PTT-25.0 INR(PT)-1.1 [**2170-4-6**] 05:25AM BLOOD Glucose-101 UreaN-16 Creat-0.8 Na-141 K-4.3 Cl-104 HCO3-28 AnGap-13 [**2170-3-30**] 08:49PM BLOOD Glucose-178* UreaN-14 Creat-1.0 Na-141 K-3.9 Cl-105 HCO3-26 AnGap-14 [**2170-3-30**] 08:49PM BLOOD ALT-23 AST-18 LD(LDH)-176 AlkPhos-60 Amylase-82 TotBili-0.7 [**2170-3-30**] 08:49PM BLOOD Lipase-41 [**2170-4-6**] 05:25AM BLOOD Mg-2.4 [**2170-3-30**] 08:49PM BLOOD %HbA1c-6.7* CHEST (PORTABLE AP) [**2170-4-4**] 5:05 PM CHEST (PORTABLE AP) Reason: eval for effusions [**Hospital 93**] MEDICAL CONDITION: 71 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for effusions CHEST RADIOGRAPH INDICATION: Followup. COMPARISON: [**2170-4-3**]. FINDINGS: As compared to the previous radiograph, there is no major change. Status post CABG. Unchanged cardiomegaly with no obvious signs of hyperhydration or cardiac failure. The minimal pleural effusion left has slightly increased in extent and causes moderate retrocardiac atelectasis. Otherwise, no focal parenchymal opacities. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: FRI [**2170-4-6**] 12:18 AM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 78059**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 78060**] (Complete) Done [**2170-4-2**] at 12:28:47 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2099-1-26**] Age (years): 71 M Hgt (in): 68 BP (mm Hg): 123/67 Wgt (lb): 196 HR (bpm): 72 BSA (m2): 2.03 m2 Indication: Intraoperative TEE for CABG procedure ICD-9 Codes: 786.05, 786.51, 440.0, 424.0 Test Information Date/Time: [**2170-4-2**] at 12:28 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW3-: Machine: AW3 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Peak Pulm Vein S: 0.6 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.1 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 5.2 cm Left Ventricle - Fractional Shortening: *0.15 >= 0.29 Left Ventricle - Ejection Fraction: 40% >= 55% Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 9 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 5 mm Hg Mitral Valve - E Wave: 0.5 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 0.71 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Moderately dilated LV cavity. Mild-moderate regional LV systolic dysfunction. Mildly depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. 3. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the anterior septum and anterior wall. Mid portion of the inferior wall is also hypokinetic. . Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 4.Right ventricular chamber size and free wall motion are normal. 5.There are simple atheroma in the descending thoracic aorta. 6.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 8.There is a trivial/physiologic pericardial effusion. 9.Dr. [**Last Name (STitle) **] was notified in person of the results on [**2170-4-2**] during the operative procedure. POST CPB Normal right ventricular systolic function. Left ventricle with continued apical, distal anterior, and anteroseptal hypokinesis. Overall left ventricular ejection fraction is slightly improved from pre-CPB study, now 45-50%. Mild mitral regurgitation remains. No other significant change from pre-CPB study. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2170-4-2**] 15:35 Brief Hospital Course: Mr. [**Known lastname **] was transferred from outside hospital following his cardiac catherization which showed severe three vessel coronary artery disease. Upon admission he underwent pre-operative work-up which included a cardiac echocardiogram. On [**4-2**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one his chest tubes were removed and he was transferred to the telemetry floor for further care. Beta blockers and diuretics were started and he was gently diuresed towards his pre-op weight. Late on post-op day one his heart rhythm went into rapid atrial fibrillation and he was started on amiodarone. He converted back to normal sinus rhythm with beta blockers and amiodarone. Physical therapy worked with him for strength and mobility. He continued to progress and was ready for discharge home POD 4 with VNA services. Medications on Admission: Aspirin 325mg qd, Lopressor 75mg [**Hospital1 **], Zocor 80mg qd, Lisinopril 10mg qd, Metformin 500mg qd 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 7 doses. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health and Hospice Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 Post-operative Atrial Fibrillation PMH: Myocardial Infarction s/p PTCA to RCA [**2157**], Hypertension, Hypercholesterolemia, Obesity, Diabetes Mellitus PSH: Left eye surgery, Parotid Cyst surgery 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 Dr. [**Last Name (STitle) 70025**] in [**1-28**] weeks Dr. [**First Name (STitle) **] in [**12-27**] weeks Completed by:[**2170-4-6**]

[ "997.1", "414.01", "272.0", "401.9", "250.00", "276.6", "413.9", "E878.2", "412", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10079, 10133

7600, 8708

337, 423

10434, 10440

1263, 2086

10952, 11129

974, 978

8863, 10056

2123, 2148

10154, 10413

8734, 8840

10464, 10929

5923, 7577

993, 1244

281, 299

2177, 5874

451, 651

673, 859

875, 958

16,856

147,865

51508

Discharge summary

report

Admission Date: [**2179-8-11**] Discharge Date: [**2179-8-22**] Date of Birth: [**2111-6-10**] Sex: M Service: MEDICINE Allergies: Penicillins / Heparin Agents Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: weight gain, shortness of breath, volume overload Major Surgical or Invasive Procedure: Right sided CVL CVVH via femoral line History of Present Illness: Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy EF < 20%, s/p CABG x2, s/p BIV ICD recently discharged on [**8-2**] for CHF admitted with another acute on chronic CHF exacerbation. During his recent last hospitalization, we were able to remove several liters of volume but diuresis was limited by advancing azotemia and low blood pressure. He was discharged from the hospital after a minimal diuresis. However, he claims to have felt less bloated and less dyspneic after his treatment. He states that he was doing well after discharge until the last 48-72 hours when he started gaining weight again and having increased shortness of breath. He reports gaining 6 pounds over the last 2 days and reports an increase in abdominal girth/firmness. His weight is 224 pounds currently with a dry weight on discharge [**8-2**] of 216 pounds. He did not take any extra doses of Lasix at home for this weight gain. His shortness of breath at rest also increased over this same time period. He feels increased dyspnea on exertion as well and as a result feels too weak to walk. He has been making a great effort to reduce the caloric and sodium content in his diet and has come up with an elaborate chart to document his intake. His goal intake is 1200 mg or less of sodium and fewer calories per day. He continues to use his BiPAP mask at night. Otherwise he denies fevers, chills, chest pain, nausea, vomiting, abdominal pain, diarrhea, constipation, hematochezia, melena. He does report recent onset of unsteady gait. . He was a direct admit from home and thus not seen in the ED. Past Medical History: # CAD -s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR4/17/07 -anatomy: LIMA to distal LAD, SVBG jump to LADD1 and D3, SVBG to OM3 -[**2177-4-8**] Redo coronary artery bypass graft x2 (Saphenous vein graft > right coronary artery, Saphenous vein graft > interposition to Saphenous vein graft> obtuse marginal graft) # CHF -severe systolic dysfunction EF 25% # h/o VT -dx in [**2164**] -> had asx VT on tele while hospitalize for urologic tx -single lead ICD was placed -had 2-3 episodes of appropriate ICD firing -> new lead placed [**2167**] -continued to have shocks -> tried betapace w/o relief -started on amiodarone btw [**2167**]-[**2169**] w/ no further shocks -had BiV ICD placed in [**2172**] -attempted VT ablation in [**2174**] w/ reload of amiodarone -last shocked: -ICD last interrogated: [**4-/2177**] # S/P Mitral Valve replacement (31mm [**Company 1543**] Mosaic Porcine valve) [**3-/2177**] # 3+ TR # HTN # CKD - baseline mid 2's # DM -insulin dependent # Hypothyroidism # Hyperparathyroidism # Hypercalcemia # Osteopenia # Hypercholesterolemia # Dyspepsia # Sleep apnea # Obesity # LFT abnormalities attributed to NASH, possibly amio # HIT Social History: Reports 20 year smoking history of about 1 PPD, quit 30 years ago. Very rare EtOH use. He is trained as an attorney but works in purchasing companies, predominantly telecommunications and sports teams. Married. Has 2 adopted boys, aged 18 and 20. Family History: Mother died of SCD in her 40s, though the patient notes that she also suffered from a severe depression at the time and "had lost the will to live". His father died of an MI in his mid 60s. He also has 2 older brothers who have CAD and are post-MIs. + HTN, but no stroke/TIA, no cancer and no DM. Physical Exam: VS: afebrile BP= 115/75 HR= 70 RR= 22 O2 sat= 96% on 2l o2. GENERAL: Resting comfortably, mild respiratory distress but able to speak in full sentences. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL left pupil slighty larger than right, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, no LAD, +JVD below the angle of the mandible sitting at 45 degrees. CARDIAC: RRR, distal heart sounds, [**1-29**] holosystolic murmur most notable in the sternal borders. No thrills, lifts. LUNGS: well healed midline sternal scar. Resp were unlabored, no accessory muscle use. Distant breath sounds, crackles at lung bases, no wheezes. ABDOMEN: Obese, distended, nontender, No HSM. Normoactive bowel sounds. EXTREMITIES: venous stasis dermatitis bilaterally; cool, dusky extremities which are no different than his baseline. Pertinent Results: Renal US [**2179-8-12**]: IMPRESSION: No hydronephrosis. Bilateral simple renal cysts. No obstructing renal stones identified. . IR guided CVL placement [**2179-8-12**]: IMPRESSION: Placement of temporary hemodialysis catheter via the right common femoral vein access with the tip of the catheter at the lower IVC and the catheter is ready to use. . Unilat upper extremity vein [**2179-8-14**]: IMPRESSION: No evidence for left upper extremity DVT. . Labs on discharge: [**2179-8-22**] 05:45AM BLOOD WBC-8.3 RBC-4.22* Hgb-12.8* Hct-39.1* MCV-93 MCH-30.4 MCHC-32.8 RDW-17.3* Plt Ct-175 [**2179-8-22**] 05:45AM BLOOD Glucose-112* UreaN-77* Creat-2.5* Na-138 K-4.2 Cl-97 HCO3-31 AnGap-14 . Labs on admission: [**2179-8-11**] 05:35PM BLOOD WBC-10.3 RBC-4.94 Hgb-14.9 Hct-46.3 MCV-94 MCH-30.3 MCHC-32.3 RDW-16.2* Plt Ct-111* [**2179-8-11**] 05:35PM BLOOD Glucose-205* UreaN-125* Creat-4.4* Na-130* K-6.1* Cl-93* HCO3-25 AnGap-18 Brief Hospital Course: Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy, EF 20%, s/p CABG x 2, s/p BIV ICD recently discharged on [**8-2**] for CHF, directly admitted from home with an acute on chronic CHF exacerbation for aggressive diuresis. . # PUMP: Patient has history of acute on chronic systolic heart failure [**1-25**] ischemic cardiomyopathy, EF 20%. He is s/p mitral valve repair in [**2176**] with improvement in cardiac function since. Now coming in approximately [**10-7**] kg above his dry weight. In the CCU, patient was continued on lasix bolus and gtt, along with milrinone bolus and gtt. He was continued on metolazone 5 mg [**Hospital1 **]. CVVH was started via R femoral line and continued for several days until it clotted off. Through this time, patient was continued on low dose neosynephrine as needed to support blood pressure with goal MAP of 55. When CVVH line clotted off ([**2179-8-17**]), patient was re-initiated on lasix gtt and metolazone with good UOP of 100-200 cc/hr. Patient was net -15 L fluid removal on discharge. Patient was continued on BB to prevent ectopy. EP was contact[**Name (NI) **] about the possibility of LV pacing, as patient has severe LV/RV dysynchrony on echo. It was felt that given his NYHA class IV status as well as prior use of LV pacing which was not very successful, the risks outweighed the benefits. However, patient's pacemaker HR was increased to 90 to improve forward flow. Patient approached new dry weight of 110kg (came in at 121 kg). His K+ goal was kept near 5-5.5 with aggressive supplementation. On discharge, patient told to stop his lasix (160 mg [**Hospital1 **]) and carvedilol (25 mg [**Hospital1 **]). Instead, he will take torsemide (80 mg [**Hospital1 **]) and metoprolol succinate (50 mg daily in AM). He was also discharged on potassium supplements 40 meq tid. Patient was informed to check his weights on a daily basis, nutrition care was discussed with patient as well. If patient starts gaining weight (i.e. [**1-26**] lbs), he is to take metolazone 5 mg tablet and call [**Hospital 1902**] clinic. He has f/u with [**Doctor First Name **] on [**2179-9-1**] in [**Hospital 1902**] clinic. . # CORONARIES: Extensive history of CAD s/p CABG x 2, last cath in [**2176**] with LIMA widely patent, SVG to OM with proximal 30% stenosis, SVG jump graft to D1 and distal diag patent. No acute issues. Patient was continued on asa 81, lipitor 20. No ACEi given acute on chronic renal failure. . # RHYTHM: Currently in NSR on admission, has BIV PPM/ICD. Does have h/o VT with ICD firing provoked by K <4.8. Monitored on telemetry without events, continued on BB to prevent ectopy, and continued on amiodarone. BiV ICD rate was increased to 90 to increase forward flow, as noted above. . # Acute on chronic renal failure - likely [**1-25**] combination of chronic systolic heart failure and poorly controlled DM, baseline creatinine 2.4-2.9. On discharge, Cr was 2.5. As above, pt was continued on CVVH for diuresis via R femoral line. Renal US showed no obstructive cause for elevated Cr. Lisinopril and aldactone were held in setting of ARF on CKD. . # Hypokalemia - Potassium 6.1 on admission, but for most of admission potassium level was repleted with approximately 100-150 meq per day, given aggressive diuresis. His goal K+ was between 5 and 5.5. On discharge, patient to take 40 meq potassium tid. . # Type II DM - HbA1C 3/09=7.5, 8/09=9.2; followed by Dr. [**Last Name (STitle) **] of the [**Last Name (un) **] but not recently. Patient was continued on outpatient regimen of 75/25 45 units qam, 50 units qpm with NPH 45 units at bedtime, with good control. . # Hypothyroidism - continued on home dose levothyroxine . # OSA - patient kept on his CPAP at night. His settings were adjusted and he transitioned to a full face CPAP, as per respiratory therapy. . # Anxiety - continued home dose ativan prn and ambien for sleep. . # Left hand swelling - one episode of left hand swelling, resolved the next day. LUE US was negative for DVT. Medications on Admission: Allopurinol 100 mg Tablet 1 (One) Tablet(s) by mouth once a day Amiodarone 200 mg Tablet 1 Tablet(s) by mouth daily Atorvastatin [Lipitor] 20 mg Tablet 1 Tablet(s) by mouth daily Carvedilol [Coreg] 12.5 mg Tablet 1 Tablet(s) by mouth twice daily Cinacalcet [Sensipar] 30 mg Tablet 1 (One) Tablet(s) by mouth daily Digoxin 125 mcg Tablet one Tablet(s) by mouth every other day on hold as of [**2179-8-9**] Folic Acid 1 mg Tablet one Tablet(s) by mouth daily Furosemide [Lasix] 80 mg Tablet two Tablet(s) by mouth twice a day on hold asof8/18/09 Gabapentin 300 mg Capsule 1 Capsule(s) by mouth daily Insulin Lispro Protam & Lispro [Humalog Mix 75-25] Dosage uncertain Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr 1 Tablet(s) by mouth once a day Levothyroxine [Levoxyl] 175 mcg Tablet 1 Tablet(s) by mouth once a day Lorazepam [Ativan] 0.5 mg Tablet 1 Tablet(s) by mouth Q6 as needed for anxiety Metolazone 5 mg Tablet 1 Tablet(s) by mouth three times per week on hold as of [**2179-8-10**] Nitroglycerin 0.4 mg Tablet, Sublingual 1 to 2 Tablet(s) sublingually as needed Oxycodone-Acetaminophen 5 mg-325 mg Tablet one or two Tablet(s) by mouth every 6 hours as needed for pain Pantoprazole [Protonix] 40 mg Tablet, Delayed Release (E.C.) 1 (One) Tablet(s) by mouth once a day Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal 4 Tab(s) by mouth three times a day for severe low K+ on hold as of [**2179-8-10**] Sertraline [Zoloft] 100 mg Tablet 1 Tablet(s) by mouth once a day Spironolactone 25 mg Tablet 1 Tablet(s) by mouth twice a day Zolpidem [Ambien] 10 mg Tablet one Tablet(s) by mouth hs Aspirin [Enteric Coated Aspirin] 81 mg Tablet, Delayed Release (E.C.) one Tablet(s) by mouth daily Cholecalciferol (Vitamin D3) [Vitamin D-3] 400 unit Capsule 2 Capsule(s) by mouth once a day Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for sleep. Disp:*30 Tablet(s)* Refills:*0* 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day as medication. Disp:*30 Tablet(s)* Refills:*0* 18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 19. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension Sig: 45 units at breakfast, 50 units at dinner units Subcutaneous once a day. 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 25 units at bedtime units Subcutaneous once a day. 21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO three times a day: please take 40 meq potassium supplements three times a day. 22. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO twice a day. Disp:*240 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: acute on chronic congestive heart failure Discharge Condition: Stable, ambulatory Discharge Instructions: You were admitted to the [**Hospital1 **] Hospital for fluid overload due to your known congestive heart failure. You underwent aggressive diuresis in the CCU and were able to put out a total of 15 liters of fluid. Diuresis was stopped when you reached your new dry weight of 110 kg. Please weigh yourself every morning and call your doctor if your weight increases by more than 3 lbs. Adhere to a 2 gm sodium diet and try to restrict your fluids. . MEDICATION CHANGES: 1. Take potassium supplements 40 mEQ three times a day 2. STOP carvedilol (coreg) 3. STOP lasix 4. START metoprolol succinate 50 mg daily 5. START torsemide 80 mg twice a day 6. Take metolazone 5 mg if your weight starts to increase (for example, if your weight goes up by [**1-26**] lbs, take 5 mg metolazone and call the [**Hospital 1902**] clinic). . Please seek medical attention for increasing shortness of breath, chest pain, abdominal pain, increasing weight (as noted above), or any other concerns. Followup Instructions: Please follow-up with the appointments listed below: . Provider [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2179-9-1**] 10:30 . Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2179-11-9**] 12:10 Completed by:[**2179-8-22**]

[ "250.00", "272.0", "585.9", "V45.81", "V42.2", "300.00", "403.90", "244.9", "327.23", "V58.67", "414.8", "V45.02", "276.8", "428.23", "428.0", "584.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

13803, 13809

5676, 9719

347, 386

13895, 13916

4728, 5179

14944, 15317

3500, 3799

11584, 13780

13830, 13874

9745, 11561

13940, 14393

3814, 4709

14413, 14921

258, 309

5198, 5420

414, 2020

5434, 5653

2042, 3220

3236, 3484

40,976

119,256

35267

Discharge summary

report

Admission Date: [**2177-11-8**] Discharge Date: [**2177-11-17**] Date of Birth: [**2150-11-11**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 5547**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: [**11-8**] - open cholecystectomy [**11-9**] - emergent c section, Exploratory laparotomy, hematoma evacuation with irrigation and washout History of Present Illness: The patient is a 26-year-old female, gravid at 33 weeks, who began having severe abdominal pain for [**1-15**] day, and presented to [**Hospital6 204**]. She became hypotensive and tachycardic, and was transferred to [**Hospital1 18**] ED after receiving 7 liters of crystalloid. On arrival, she was tachycardic, hypotensive to SBP of 70s, on norepinephrine drip. Sepsis protocol was initiated. The patient was found to have acute cholecystitis. She is a crack and heroine user, last used [**11-7**] in the am. Past Medical History: Hep C Heroine and Crack user Social History: Homeless. Uses crack and heroine Family History: Non-contributory Physical Exam: On admission: 99.2 113 91/63 24 ?sat NRB Gen: elderly female, appears younger than stated age, NAD, no icterus HEENT: NC/AT, EOMI, PERRLA bilat., dry MM, without cervical LAD on my exam Cor: RRR without m/g/r, no JVD, no bruits Lungs: CTA bilat. [**Last Name (un) **]: +BS, soft, ND, NT, no masses Ext: warm feet, no edema On discharge: Afebrile, VSS Gen: no distress, alert and oriented x 3 HEENT: NC/AT, PERLA, EOMi, MMM Neck: supple, no LAD Chest: RRR, no murmurs, lungs clear Abd: soft, nontender, nondistended, healing incision clean and dry, no erythema Ext: warm, palpalble pulses, no edema Pertinent Results: On Admission: [**2177-11-8**] 04:45AM BLOOD WBC-17.8* RBC-2.88* Hgb-7.7* Hct-24.0* MCV-83 MCH-26.7* MCHC-32.1 RDW-16.7* Plt Ct-61* [**2177-11-8**] 04:45AM BLOOD Neuts-77* Bands-21* Lymphs-1* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1* [**2177-11-8**] 11:19AM BLOOD Glucose-88 UreaN-17 Creat-0.9 Na-139 K-3.2* Cl-111* HCO3-17* AnGap-14 [**2177-11-8**] 04:45AM BLOOD ALT-31 AST-51* LD(LDH)-246 AlkPhos-89 TotBili-2.6* DirBili-2.4* IndBili-0.2 [**2177-11-8**] 04:45AM BLOOD Lipase-22 [**2177-11-8**] 11:19AM BLOOD Albumin-2.5* Calcium-6.1* Phos-2.7 Mg-1.3* [**2177-11-15**] 12:55PM BLOOD HIV Ab-NEGATIVE [**2177-11-11**] 12:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2177-11-9**] 03:57AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2177-11-11**] 12:15PM BLOOD HCV Ab-POSITIVE On Discharge: [**2177-11-16**] 04:57AM BLOOD WBC-4.5 RBC-3.51* Hgb-9.4* Hct-28.4* MCV-81* MCH-26.9* MCHC-33.3 RDW-17.0* Plt Ct-291 Brief Hospital Course: The patient was admitted to the surgical service from an outside hospital. She underwent an emergent open cholecystectomy followed by an emergent Ceasarian section delivery of her baby. She was transferred to the [**Hospital Ward Name 332**] ICU post-operatively and required vasopressor and ventilatory support. She was weaned off the vasopressor but remained intubated due to her high sedative requirement. Once her hemodynamics were stable, she was aggressively diuresed as she had received a large amount of intravenous fluid resuscitation. Her sedatives were changed from continuous to intermittent and on POD6 she self-extubated and did well afterwards. On POD7 she was transferred to the floor. She passed a bedside swallow exam and her diet was advanced. Social work and Psychiatry were both consulted now that she was extubated and could communicate. Psychiatry's final assessment was that she was a polysubstance abuser and not a danger to herself or others so she could not be kept involuntarily. She was provided with information on outpatient centers for substance abuse. On POD9 she was discharged per her request. She was given a cab voucher to help her reach her destination. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Acute cholecystitis Sepsis Discharge Condition: Good, tolerating a regular diet, good pain control. Psychiatry has cleared the patient for discharge. 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. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Incision Care: *You may shower. Pat incision dry. *Avoid swimming and baths until further instruction at your followup appointment. *Leave the steri-strips on. They will fall off on their own, or be removed during your followup. *Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) 1924**] to arrange a follow up appointment in [**2-16**] weeks at [**Telephone/Fax (1) 7508**]

[ "648.41", "518.5", "648.21", "647.61", "647.81", "304.01", "568.81", "286.6", "648.31", "300.4", "V02.62", "V27.0", "305.50", "E878.8", "998.12", "646.81", "038.9", "644.21", "285.9", "287.4", "995.92", "785.52", "575.0" ]

icd9cm

[ [ [] ] ]

[ "74.1", "51.22", "96.71", "99.05", "54.12", "38.93", "99.07", "99.04" ]

icd9pcs

[ [ [] ] ]

3990, 3996

2702, 3906

280, 421

4067, 4171

1736, 1736

5387, 5537

1083, 1101

3961, 3967

4017, 4046

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Discharge summary

report+addendum

Admission Date: [**2188-1-8**] Discharge Date: [**2188-1-11**] Date of Birth: [**2137-2-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7934**] Chief Complaint: Shirtness of breath Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Pt is a 50 y/o M who presents from home with c/o SOB after missing his [**First Name3 (LF) 2286**] session the day prior (Monday). By report pt "didn't feel well" x 24 hours with 1 day of SOB. He intially denied subjective fevers/chills or CP in ED, but later states he noted subjective fevers/chills since last night with myalgias. Also with a new nonproductive cough, althought he noted minimal blood-tinged sputum. . In the ED a nd noted to have a K+ of 8.1 (hemolyzed), and was given 10U insulin, 1 amp D50, and 1 amp calium gluconate. His O2 sat was 88% on RA, and his CXR was noted to have areas of frank consolidation with air bronchograms. By report this was most c/w pulmonary edema and superimposed aspiration or other infection. He was also noted to be very hypertensive with a BP of 220/136 and was placed on a NTG drip and sent urgently to [**First Name3 (LF) 2286**]. . At [**First Name3 (LF) 2286**] 3.3L of fluid was removed, and pt was continued on a NTG drip up to 60mcg for BP control. Pt denied c/o chest pain. He was then transferred to ICU for further evaluation. Past Medical History: 1. Alport's Syndrome: c/b ESRD on HD and deafness 2. ESRD: s/p failed renal transplant x 2 ([**2152**] and [**2168**]), now on HD M/W/F 3. Malignant hypertension 4. h/o CHF w/ dilated cardiomyopathy: now w/ recovered fxn, ECHO [**3-21**] w/ EF>55%, 1+ MR 5. SVT s/p ablation [**3-21**] 6. h/o seizures: likely metabolic etiology per notes 7. Restless legs syndrome 8. Anemia of chronic disease 9. h/o respiratory failure secondary to pulmonary edema 10. Pruritis: treated w/ prednisone, mirapex Social History: Divorced w/2 children, and he lives with his son and daughter. 3 pack yr hx. Occ EtOH. hx marijuana and cocaine, none x 2 yrs. No IVDU. Family History: mother with alport's syndrome, father with CAD and CABG at age 60, brother died at 16 yrs old from ESRD Pertinent Results: CXR: There is a diffuse parenchymal abnormality in the lungs. On the left, this has a micronodule or interstitial quality. On the right, there is greater radiodensity including many small nodules ranging up to 7 or 10 mm in diameter and areas of frank consolidation with air bronchograms. Findings are most consistent with pulmonary edema and superimposed aspiration or other cause of infection. Moderate enlargement of the cardiac silhouette is longstanding and could be due in part to pericardial effusion. There is no appreciable pleural effusion. [**2188-1-8**] 12:59PM TYPE-ART PO2-62* PCO2-36 PH-7.52* TOTAL CO2-30 BASE XS-5 INTUBATED-NOT INTUBA [**2188-1-8**] 06:30AM GLUCOSE-69* UREA N-111* CREAT-18.1*# SODIUM-135 POTASSIUM-8.1* CHLORIDE-89* TOTAL CO2-15* ANION GAP-39* [**2188-1-8**] 06:30AM CALCIUM-8.3* PHOSPHATE-7.2* MAGNESIUM-2.3 [**2188-1-8**] 06:30AM WBC-9.5 RBC-3.88*# HGB-12.2* HCT-37.2* MCV-96 MCH-31.5 MCHC-32.8 RDW-20.6* [**2188-1-8**] 06:30AM NEUTS-73.5* LYMPHS-21.1 MONOS-4.3 EOS-0.1 BASOS-1.1 Brief Hospital Course: HYPOXIA/FEVERS: pt with a clinical history which appears to correlate with CHF after missing HD session. His CXR, however, appears to have findings to suggest PNA +/- CHF. He underwent HD the day of admission but still had an O2 requirement and was febrile. He was initially placed on CTX and Azithro for CAP, and placed on flu precautions. f/u DFA was positive for influenza A, and given the acute nature of his symptoms he was given renally dosed Tamiflu. After several HD sessions pt resumed his M/W/F HD schedule, and no longer had an O2 requirement. he was changed to Levofloxacin to complete a 10 days course. . RENAL: Pt missed his outpt HD session b/o influenza/PNA, but later resumed his M/W/F HD schedule. He was scheduled as an elective oupt for IR procedure on [**1-10**], but b/o misunderstanding pt was not able to have this done while in the hospital. He should f/u with Dr [**Last Name (STitle) 28609**] and Dr [**Last Name (STitle) **] for rescheduling of this procedure. His AV fistula was functional during his hospitalization. . HTN: pt has long h/o malignant hypertension, which in the past has improved after HD sessions. He initially was placed on a NTG drip, which was weaned off. He did require several doses of IV hydralazine, but then was stabilized on short acting ACEi and BB. This was then transitioned to Lisinopril 40mg QD and Toprol 100 QD which he tolerated well the day of discharge. His blood pressure at discharge was systolic 160. . CARDIAC: he had subtle EKG findings and troponin leak in the setting of malignant HTN and ESRD. He had previously been scheduled for stress test wheich he couldn't tolerate secondary to claustrophobia. Given his h/o recurrent flash pulm edema and troponin leak, he may benefit from elective cath vs stress. As this episode is likely demand ischemia in the setting of influenza/PNA, he was continued on an ASA and will see his outpt Cardiologist which was previously scheduled in 3 weeks' time. His prior cholesterol panels have been well within normal limits, so no statin appears to be indicated at this time. . FOLLOW-UP: He was given an appointment to see his PCP, [**Name10 (NameIs) **] [**Last Name (STitle) **], less than one week after discharge. Medications on Admission: Lisinopril 20mg QD Pramipexole 0.125 mg HS Hydroxyzine HCl 25 mg prn Sevelamer 800 mg TID Pantoprazole 40 mg QD ASA 325 QD Quinine Sulfate 260 mg Tablet HS Toprol 50mg QD Nephrocap 1 QD Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prednisone 5 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. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oseltamivir Phosphate 75 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 2 days. Disp:*2 Capsule(s)* Refills:*0* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 4 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: pneumonia, hypertensive urgency, influenza, CHF Secondary: ESRD secondary to Alport's, SVT s/p ablation [**3-21**], h/o seizures, anemia of chronic disease, pruritis Discharge Condition: Good Discharge Instructions: Please continue previous medications as prscribed including your Toprol dose (100mg) and increase your Lisinopril to 40 mg once a day. You will also complete a course of Tamiflu and Levofloxacin for the flu and pneumonia. Try not to miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] session as worsens your blood pressure and shortness of breath. Be sure to check your blood pressure at home, and discuss a cardiac work up with Dr [**Last Name (STitle) **] next week. -Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs, and adhere to 2 gm sodium diet -If you develop an episodes of chest pain/pressure, lightheadedness, nausea/vomiting, fevers/chills, or any other new or concerning symptoms please seek further medical attention. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2188-1-17**] 10:00 Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Date/Time:[**2188-1-17**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2188-1-17**] 3:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2188-1-28**] 10:30 Please be sure to make a follow-up appointment with Dr [**Last Name (STitle) **] from nephrology, as well as with Dr [**Last Name (STitle) **] for evaluation of your fistula. Name: [**Known lastname 16616**],[**Known firstname 16617**] Unit No: [**Numeric Identifier 16618**] Admission Date: [**2188-1-8**] Discharge Date: [**2188-1-11**] Date of Birth: [**2137-2-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10603**] Addendum: at discharge, the patient's blood pressure was at his baseline following dialysis. Physical Exam: at discharge, patient's T 98.3, BP 160/80, HR 84, rr 11, satting 100% on RA Gen: awake, alert, poor hygiene, thin NAD HEENT: dry MMM chest: crackles bilaterally at bases Cor: RRR Abd: soft, NT ND, midline horizontal well healed surgical incision Ext: AV fistula with good thrill in Left upper extremity, WWP, no edema Neuro: CN II-XII grossly intact, except VIII as he has alport's and is hard of hearing Discharge Disposition: Home [**Name6 (MD) 3359**] [**Last Name (NamePattern4) 3360**] MD [**MD Number(1) 3361**] Completed by:[**2188-1-19**]

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73,884

159,494

30497

Discharge summary

report

Admission Date: [**2178-1-20**] Discharge Date: [**2178-2-1**] Date of Birth: [**2140-4-25**] Sex: F Service: MEDICINE Allergies: Aspirin / ivp dye / Iodine Attending:[**First Name3 (LF) 2782**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 37 year old female with refractory celiac disease, intermittent partial SBO, lypmphocytic colitis, hypothyroidism and dysautonomia who presents with severe mid-abdominal pain since last Friday. She endorses sharp mid abdominal pain with nausea and vomiting as well as diarrhea. The symptoms subsided somewhat over the weekend and then recurred Monday afternoon. In particular, she has complaints of severe mid abdominal pain, which she says feels similar to the pain she had when she was diagnosed with a partial small-bowel obstruction. Of note, the patient has known intermittent jejunal intussusception on recent MRE. The patient has also noted [**Known lastname **] in her stool, which is new for her, though she reported that she does have hemorrhoids. At baseline pt has chronic RUQ abdominal pain and watery diarrhea, and has frequent dietary indescretions documented in her GI notes for her Celiac Disease. She was seen at [**Hospital3 3583**] [**2178-1-19**] where she was given 500 cc of fluid for tachycardia and discharged home. She was subsequently seen in the [**Hospital **] clinic today where she was noted to be orthostatic and was sent to the ED for further evaluation. . In the ED, initial VS were: T 98.7 HR 134 BP 122/73 RR 20 O2 Sat 100% RA She had a CT abd/pelvis with PO contrast that showed dilated loops of small bowel with potentially thickened small bowel wall distally, likely from partial SBO versus distension from underlying celiac disease. Surgery was consulted and felt there was no indicaiton for surgical intervention. She received 1.5L NS in the ED with improvement in her tachycardia. She was given Dilaudid 4mg IV, Morphine 8mg IV and Zofran 4mg IV. There were no laboratory abnormalties. . On arrival to the MICU, initial VS were: T 98 BP 120/80 HR 100-120s RR 18 O2 Sat 100% RA (intermittent destats) She endorsed L sided chest pressure which is non exertional, lasts hours and resolves spontaneously. Denies assocaited SOB, lightheadedness or palpitations. States she is able to walk several flights of stairs, denies DOE or exertional CP. Otherwise, states abd pain is improved with Morphine. Past Medical History: Celiac disease Lypmphocytic colitis SBO Hypothyroidism Paroxysmal Sinus Tachycardia Autonomic dysautonomia Social History: Two children (7 and 11); currently with new partner. Adopted. [**Name2 (NI) 1139**]: Denies EtOH: Social Drugs: Denies Family History: Father with gastric ca. Rest unknown (pt adopted) Physical Exam: Admission Exam: Vitals: T 98 BP 120/80 HR 100-120s RR 18 O2 Sat 100% RA (intermittent destats) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, no LAD CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non tender, normoactive bowel sounds, no rebound or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, CN II-XII intact, non focal Discharge Exam: Vitals: 98.8, BP 92/52 , HR- 68, RR-18, SaO2- 97% on RA General: Alert, interactive HEENT: Sclera anicteric, mucous membranes moist, oropharynx clear Neck: supple CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, distended. Very tender to touch at RUQ> RLQ > LUQ. pos [**Doctor Last Name **] sign, no organomegaly appreciated, BS present, no rebound/guarding Ext: warm, well perfused, no edema Neuro: CNII-XII grossly intact. No gross focal deficits. Psych: affect: fair Pertinent Results: [**2178-1-20**] 11:50AM tTG-IgA-87* [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] WBC-10.6 RBC-4.46 Hgb-14.2# Hct-39.0 MCV-88# MCH-31.7# MCHC-36.3*# RDW-12.2 Plt Ct-364 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] Neuts-80.0* Lymphs-14.4* Monos-3.7 Eos-0.2 Baso-1.6 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] Plt Ct-364 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] ESR-20 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] Glucose-100 UreaN-5* Creat-0.6 Na-139 K-3.8 Cl-103 HCO3-24 AnGap-16 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] ALT-29 AST-29 AlkPhos-90 TotBili-0.5 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] Lipase-54 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] Albumin-4.2 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] TSH-21* [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] Free T4-1.1 [**2178-1-20**] 11:50AM [**Year/Month/Day 3143**] CRP-3.7 [**2178-1-20**] 12:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2178-1-20**] 12:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.007 [**2178-1-20**] 12:00PM URINE [**Year/Month/Day 3143**]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2178-1-23**] 06:00AM [**Year/Month/Day 3143**] C3-122 C4-30 [**2178-1-21**] 03:40AM [**Year/Month/Day 3143**] ASA-NEG Ethanol-NEG Acetmnp-9* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2178-2-1**] 05:22AM [**Month/Day/Year 3143**] Plt Ct-342 [**2178-1-29**] 07:00AM [**Month/Day/Year 3143**] Lupus-NEG [**2178-2-1**] 05:22AM [**Month/Day/Year 3143**] Glucose-325* UreaN-7 Creat-0.7 Na-141 K-3.9 Cl-102 HCO3-31 AnGap-12 [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] ALT-37 AST-34 LD(LDH)-162 AlkPhos-82 TotBili-0.3 [**2178-1-30**] 05:45AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.5 Mg-2.2 [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] Cryoglb-NO CRYOGLO [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] ANCA-NEGATIVE B [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] dsDNA-NEGATIVE [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] RheuFac-8 [**2178-1-23**] 06:00AM [**Year/Month/Day 3143**] [**Doctor First Name **]-POSITIVE * Titer-1:1280 [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **] NEG [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] SM ANTIBODY-Test NEG [**2178-1-28**] 05:17AM [**Month/Day/Year 3143**] RNP ANTIBODY-Test NEG FECAL CULTURE (Final [**2178-1-29**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2178-1-28**]): NO CAMPYLOBACTER FOUND. CT A/P ([**2178-1-20**]): Mildly dilated loops of small bowel with potentially thickened small bowel loops, both findings potentialy due to patients underlying celiac disease, less likely from partial SBO however clinical correlation suggested. No current intussuception. KUB [**2178-1-22**] There is no free gas or pneumatosis. A moderate amount of barium is present throughout the colon, from previous CT study. There is no evidence of bowel obstruction. Scattered phleboliths are present bilaterally in the pelvis. There is linear subsegmental atelectasis in the left lung base. KUB [**2178-1-25**] No evidence of bowel obstruction. MRE [**2178-1-23**] 1. Mild nonspecific dilated loops of small bowel which could be secondary to celiac disease. No MR [**Name13 (STitle) 72443**] features to definitively suggest celiac disease. 2. Mildly prominent mesenteric lymph nodes, nonspecific. CXR [**2178-1-21**] No acute intrathoracic process Brief Hospital Course: 37F with past medical history notable for celiac disease, lymphocytic colitis, intermittent partial SBO, hypothyroidism and paroxysmal sinus tachycardia with a question of dysautonomia presenting with severe epigastric pain, hematochezia, nausesa, vomiting, dirreah, orthostatic hypotension, and sinus tachycardia. # ABDOMINAL PAIN Patient has a complex GI history notable for refractory celiac disease, lymphocytic colitis, intermittent partial SBO, and asymptomatic jejunal intussusception. Patient had a waxing and [**Doctor Last Name 688**] course of abdominal pain throughout her stay. Her initial presentation was notable for the epigastric pain that she thought was similar to her prior SBO symptoms. General surgery was consulted, and there was no evidence of acute obstructive process. Repeat KUBs were negative for obstruction. Gastroenterology was involved throughout her entire stay. Her pain has gradually evolve to be worst at the RLQ and eventually at RUQ. Her LFTs and amylase/lipase were WNL. She tolerated regular gluten free diet and continued to have flatus. A trial of elemental diet was aborted due to poor tolerance. Her constipation was treated as below. Her pain was attributed to celiac (Her tTG level was elevated upon admission) and constipation. Patient's pain was controlled with tylenol standing plus oxycodone PRN. MRE was notable for nonspecific dilated small bowel. There was no definitive evidence suggestive of ulcerative jejunititis. Patient was given three day course of high dose IV steriod. Her overall abdominal symptoms improved. Patient still had her baseline RUQ pain by the time of discharge. Rheumatology was involved given her [**Doctor First Name **] positivity. The rest of serology, including ANCA, RF, Ro, La, dsDNA, SM, RNP were negative and they did not think that a rheumatologic disorder was contributing. Patient was discharged with the plan to taper steroid intake until her outpatient GI follow up. . # CONSTIPATION She was constipated despite multiple bowel regimens (Colace, senna, miralex lactulose, Magnesium citrate, bisacodyl pr, enema). Patient ambulated and was encouraged to increase fluid intake. She was having 1 small bowel movement every other day by the time she was discharged and was given erythromycin orally for the last 2 days of her hospitalizations. . # HEMOATOCHEZIA Patient presented after one episode of bright red bleed per rectum and subsequently had two additional episodes involving small amount (reported by patient) here. Patient has a known history of hematochezia, and patient reported this was similar to her prior hemorrhoidal bleed. Guaic stool however was negative. Patient's Hct remained stable. . # SINUS TACHYCARDIA/ORTHOSTASIS In the MICU, her HR ranged 110-130s but otherwise remained hemodynamically stable. Outside cardiologist was [**Name (NI) 653**], who said this has been a chronic issue for her related to multiple factors, including her anxiety and pain. Albuterol was held. Her HR was controlled < 100 with fluid resuscitation and maintaining euvolemic state, metoprolol succinate 25 started [**1-22**] (which patient had tried outpatient setting in the past), and klonipin PRN. SBP remained stable at 100-120s. She had only several additional episodes of non-sustained sinus tachycardia on the floor, in the setting of what patient thought to be anxiety attack. Patient was advised to follow up with her outpatient cardiologist on this issue. # Question of multiple sclerosis with history of recurrent paralysis Her neuro exams upon transfer to the medicine floor was only notable for mild left lower extremity weakness and upper motor signs with upgoing toes on the left. This remained unchanged throughout the remaining hospital course. Patient had no other additional deficits. . # Hypthyroidsm: TSH upon admission was high. Patient was maintained on her home levothyroxine regimen. She remained asymptomatic. # Transitional issues: - Steroid taper to be continued by gastroenterologist - patient will follow-up with outpatient gastroenterologist - Continue strict gluten free diet - Cardiology f/u regarding long term management of sinus tachyrcardia - Neurology f/u regarding the question of multiple sclerosis - Retest TSH once acute issues resolve - Patient remained Full code during her hospitalization Medications on Admission: AMITRIPTYLINE - (Prescribed by Other Provider) - Dosage uncertain CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - Dosage uncertain DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) - 60 mg Capsule, Delayed Release(E.C.) - Capsule(s) by mouth once a day HYOSCYAMINE SULFATE - 0.125 mg Tablet, Rapid Dissolve - 2 Tablet(s) by mouth once a day as needed for as needed for pain IRON INFUSIONS - (Prescribed by Other Provider) - Dosage uncertain LEVOTHYROXINE - (Prescribed by Other Provider) - 88 mcg Tablet - Tablet(s) by mouth once a day LISDEXAMFETAMINE [VYVANSE] - (Prescribed by Other Provider) - 50 mg Capsule - Capsule(s) by mouth once a day MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10 mg Tablet - Tablet(s) by mouth once a day MORPHINE - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC BIOTIN - (Prescribed by Other Provider) - 5 mg Capsule - Capsule(s) by mouth CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO once a day: 2 tablets every night. 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for anxiety. 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. iron infusion Sig: One (1) . 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: do not use this medication while driving or operating heavy machinery. do not use while drinking alcohol. Disp:*20 Tablet(s)* Refills:*0* 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO three times a day: do not take more than 3g a day. 9. biotin 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation for 10 doses. Disp:*10 Suppository(s)* Refills:*0* 13. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): on [**3-19**]. Disp:*6 Tablet(s)* Refills:*0* 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Celiac disease Lymphocytic colitis Paroxysmal sinus tachycardia Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to [**Hospital1 18**] on [**2178-1-20**] for abdominal pain, diarrhea, nausea, vomiting, rapid heart rate, and lightheadness when standing-up. You had one day stay in the intensive care unit to monitor your rapid heart rate. You were transferred to the regular medicine service the next day. Your heart rate remained intermittently high in the 100-130s, but slowly came down to the normal range of 60-100s before your discharge from the hospital. The improvement in your heart rate came after we gave you IV fluids and started you on a medication called metoprolol. You should continue to take this medication after you leave the hospital. Your [**Date Range **] pressure remained stable. Your lightheadedness resolved. You were able to walk around without difficulty by the time you were discharged. We did not see anything abnormal on your electrocardiogram (EKG) to suggest any problems with [**Name2 (NI) **] supply to your heart. Your abdominal pain unfortunately continued to be an ongoing issue throughout your stay. Your liver and pancreas tests were normal. The test for your celiac disease showed evidence of active inflammation. Imaging showed some small bowel abnormality, likely due to your celiac disease. Your bloating and constipation were treated with colace, senna, miralax, bisacodyl and simethicone, milk of magnesia, enemas, and lactulose. You were also followed by the GI doctors, who recommened intravenous steroids for 3 days and starting erythromycin all of which seemed to help your symptoms. You were transitioned to oral steroids and tolerated those well. It is important that you continue to maintain a gluten free diet and continue to take metoprolol and your other medications. We also recommend that you try to switch to the generic brands that do not contain gluten, as we have listed for you below: - Amitriptyline: [**Location (un) 20872**], Qualtest, [**Last Name (un) **] - Levothyroxine: Lannett, [**Last Name (un) **] - Metoprolol: Apothecon, NovaPharm, Watran (uses potato starch) - Oxycodone: Mallindnat These medications are gluten free: - Duloxetine - Montelukast We have made the following changes to your medication list: - DISCONTINUED morphine - ADDED metoprolol succinate (for heart rate control) - ADDED acetaminophen (Tylenol) - ADDED oxycodone (as needed for pain) - ADDED prednisone 60mg daily x 2 days and then decrease it to 40mg daily until you follow-up with Dr. [**Last Name (STitle) **]. Please continue to take your other medications as you have been doing. Please call Dr.[**Name (NI) 72444**] office on [**2-2**] to set up an appointment within the next 7 days. See below for your upcoming appointments. Followup Instructions: Please schedule a follow-up with your PCP within [**Name Initial (PRE) **] week from discharge. The clinic number is [**Telephone/Fax (1) 36604**]. Please call Dr.[**Name (NI) 72444**] office for an appointment on Monday as well. Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2178-3-17**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7167**] [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

[ "276.51", "729.89", "337.9", "789.01", "564.00", "338.19", "785.0", "455.2", "300.00", "244.9", "558.9", "338.29", "280.9", "340", "455.5", "578.1", "579.0", "789.06", "458.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14702, 14708

7616, 11545

301, 307

14846, 14846

4019, 7593

17749, 18340

2787, 2839

13018, 14679

14729, 14825

11970, 12995

14997, 17726

2854, 3428

3444, 4000

247, 263

335, 2503

14861, 14973

11568, 11944

2525, 2634

2650, 2771

48,165

159,521

36022

Discharge summary

report

Admission Date: [**2110-1-2**] Discharge Date: [**2110-1-10**] Date of Birth: [**2048-1-2**] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins Attending:[**First Name3 (LF) 3645**] Chief Complaint: Low back pain s/p MVA Major Surgical or Invasive Procedure: L3 Corpectomy History of Present Illness: Mrs. [**Known lastname 81757**] was involved in a high speed motor vehicle accident with loss of consciousness. She was transported to [**Hospital1 18**] and was noted to have an L3 burst fracture on CT scan. Conservative operations were attempted. She was placed in a brace, but unable tolerating ambulation. She had person leg pain. After informed choice, she wished to proceed with surgical stabilization and decompression were spinal elements. Past Medical History: Anxiety Social History: N/A Family History: N/A Physical Exam: A+Ox3 NAD Cardiac: RRR, No M/R/G Lungs: CTA/B Abd: soft, non-tender Right LE: 5/5 strength, SILT left LE: 4+/5 iliopsoas, [**4-29**] all others, decreased senstaion L2 dermatome, all others intact. distal pulses intact. Pertinent Results: [**2110-1-3**] 06:48PM BLOOD WBC-8.4 RBC-4.00* Hgb-11.3* Hct-32.0* MCV-80* MCH-28.2 MCHC-35.2* RDW-13.7 Plt Ct-184 [**2110-1-4**] 02:02AM BLOOD WBC-7.7 RBC-3.67* Hgb-10.4* Hct-29.6* MCV-81* MCH-28.4 MCHC-35.3* RDW-14.0 Plt Ct-199 [**2110-1-5**] 03:46AM BLOOD WBC-6.2 RBC-3.56* Hgb-9.9* Hct-28.7* MCV-81* MCH-27.9 MCHC-34.6 RDW-13.8 Plt Ct-221 [**2110-1-7**] 07:53PM BLOOD WBC-7.7 RBC-4.65# Hgb-13.5# Hct-38.2# MCV-82 MCH-29.0 MCHC-35.3* RDW-14.1 Plt Ct-286 [**2110-1-8**] 09:18AM BLOOD WBC-8.8 RBC-4.53 Hgb-12.5 Hct-36.4 MCV-80* MCH-27.5 MCHC-34.2 RDW-14.3 Plt Ct-367 [**2110-1-9**] 05:30AM BLOOD WBC-8.5 RBC-4.48 Hgb-12.6 Hct-37.3 MCV-83 MCH-28.0 MCHC-33.7 RDW-14.6 Plt Ct-122*# [**2110-1-5**] 03:46AM BLOOD Glucose-103 UreaN-9 Creat-0.6 Na-136 K-3.6 Cl-101 HCO3-26 AnGap-13 [**2110-1-7**] 07:53PM BLOOD Glucose-166* UreaN-6 Creat-0.6 Na-137 K-4.8 Cl-103 HCO3-27 AnGap-12 [**2110-1-8**] 09:18AM BLOOD Glucose-169* UreaN-7 Creat-0.6 Na-135 K-4.5 Cl-101 HCO3-27 AnGap-12 [**2110-1-9**] 05:30AM BLOOD Glucose-128* UreaN-8 Creat-0.7 Na-135 K-5.0 Cl-99 HCO3-26 AnGap-15 Brief Hospital Course: Mrs. [**Known lastname 81757**] was involved in an motor vehicle accident with loss of consciousness. On CT scan she was noted to have an L3 burst fracture with significant retropulsion. She was neurologically intact. Conservative operations were attempted. She was placed in a brace, but unable tolerating ambulation. She had person leg pain. After informed choice, she wished to proceed with surgical stabilization and decompression were spinal elements. She tolerated the procedure well. After her procedure, she was brought to the PACU and then to the general floor. On the general floor, she had an episode of hypoxia. Medicine was consulted and she was brought to the MICU overnight for workup and observation. It was determined that her hypoxia was secondary to oversedation with narcotic and aspiration. Her symptomology resolved. Mrs. [**Known lastname 81757**] worked with physical therapy who recommended rehab. The rest of her course was unremarkable. # Hypoxia: Likely from aspiration pneumonitis in the setting of sedation/ nausea from opioids. CTA w/o PE. Is now breathing more comfortably s/p suctioning. Trauma surgery does not believe she has pulmonary contusions as she does not have rib fractures and that her CT scan shows aspiration + atelectasis. - Incentive spirometry - will hold on antibiotics as likely a pneumonitis but if hypoxia worsens again would add levofloxacin and flagyl for aspiration PNA - titrate O2 to O2 sat > 93% - minimize sedation . # Fever: Likely from aspiration pneumonitis in the setting of aspiration vs inflammatory response post-trauma. Blood and urine cx pending. UA w/o obvious UTI. - treat aspiration PNA as above - f/u blood and urine cx . # Tachycardia: Sinus tachycardia. Likely from pain + adrenergic tone from trauma along with fever. Does not appear to be from bleeding as hct stable. - trend for now - IVF given fever . UTI-GNR on Cx. will start Bactrim DS given Tizanidine interaction with cipro. . # L-3 Burst fracture: - L3 corpectomy with stabilization . # Microcytic anemia: Unclear baseline. - trend for now - guiac stools . # FEN: IVF prn if continues to be febrile, replete electrolytes, regular diet . # Prophylaxis: Subcutaneous heparin, already on PPI . # Access: peripherals X 2 . # Code: presumed full . # Communication: Patient Medications on Admission: Prilosec Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 4. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for spasm. 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 10. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: L3 burst fracture Discharge Condition: Stable Discharge Instructions: Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at [**Telephone/Fax (1) **]. Please resume all home mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **] have been given additional medication to control pain. Please allow 72 hours for refills of this medication. Please plan accordingly. You can either have this prescription mailed to your home or you may pick this up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for narcotics to the pharmacy. If you have questions concerning activity, please refer to the activity sheet. Followup Instructions: Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3648**] PA-C. You have an appointment scheduled on [**2110-1-28**] at 2.00pm. If you have any questions, please call [**Telephone/Fax (1) **] Completed by:[**2110-1-9**]

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icd9cm

[ [ [] ] ]

[ "99.04", "77.79", "80.99", "81.06", "81.62", "84.51" ]

icd9pcs

[ [ [] ] ]

5636, 5738

2209, 4532

296, 312

5800, 5809

1119, 2186

6697, 6955

859, 864

4591, 5613

5759, 5779

4558, 4568

5833, 6674

879, 1100

235, 258

340, 791

813, 822

838, 843

13,432

124,788

47682

Discharge summary

report

Admission Date: [**2142-3-28**] Discharge Date: [**2142-4-1**] Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 2356**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Colonoscopy EGD Blood transfusion History of Present Illness: Ms. [**Known lastname 100720**] is an 89 yo F w/history of CAD s/p NSTEMI and CABG '[**28**] (LIMA to LAD, SVG to OM and SVG to RCA), TIA/CVA s/p R CEA, HTN, AF on coumadin anticoagulation. Presents to ED with chest pain radiating to her left arm similar to anginal pain in past. She was recently admitted from [**2142-3-2**] - [**2142-3-8**] for AF with RVR. She had a biomarker leak with ischemic ECG changes, but refused catheterization. That admission was also significant for finding of iron-deficiency anemia for which she received 3 U pRBCs. Plan was make for an outpatient GI work-up. . She reports acute onset of mid-sternal chest pressure at ~midnight. Ranked as 10 on scale of 10. Assoc with dyspnea, nausea, and diaphoresis, similar to symptoms prior to her NSTEMI and CABG in [**2128**]. Called 911 and was brought to [**Hospital1 18**] ED. Received ASA 325 & SLNTG. Subsequent workup revealed anemia with Hct 20.1. Of note, INR 5.5. Rectal showed dark brown stool that was strongly guaiac positive. Anticoagulation reversed with 2 units FFP and 5 mg SQ vitamin K. Received 1 U pRBCs. On arrival to ICU, free of chest pain. EKG with ST depression V3-V6. Patient notes stool has been darker than usual, but not black and no visible blood. No abd pain. Past Medical History: - Aortic stenosis (gradient 30 mmHg by cath) - TIA [**2128**] and [**2141-12-11**] following cardiac catheterization - hypertrophic cardiomyopathy - CAD status post non-ST elevation MI followed by complicated catheterization and emergent CABG [**2128**] - Hypercholesterolemia - Status post right carotid endartectomy [**2128**] - Hypertension - GERD - Status post right cataract surgery - iron deficiency anemia Social History: Widowed 4 years ago. Lives in an apartment in [**Location (un) **]. Independent in all ADLs. Still works as a travel [**Doctor Last Name 360**]. No tobacco, drug use. Social EtOH. Currently supporting son financially. Family History: Mother suffered from HTN and CAD. Physical Exam: Vitals - 100.3F HR 74(60-85) 186/52(118-186/35-92) 23 98/5Ln.c. Gen - alert, comfortable, interactive, speaking in full sentences, NAD HEENT - R periorbital swelling, but without erythema or discharge, PERRL, EOMI, OP clear, MM sl dry, no LAD, no JVD CV - RRR, [**2-13**] harsh systolic murmur at LUSB, sternotomy scar well healed Chest - faint right basilar crackles Abd - NABS, soft, NT/ND, no rebound or guarding Ext - no edema, WWP Pertinent Results: ECG (02:58 [**2142-3-28**]): NSR @ 89, LVH, 1st degree AV delay, 2-3 mm STD v4-v6, new compared to prior on [**2142-3-6**] and at 01:55 on same day . CXR [**2142-3-28**]: Comparison with [**2142-3-2**]. Cardiomegaly again noted. Aortic mural calcifications seen. Perihilar fullness and indistinctness of pulmonary vasculature. Changes of CABG seen. Loss of portion of right hemidiaphragm may be due to atelectasis. No focal consolidations. IMPRESSION: Mild CHF. . COLONOSCOPY [**2142-3-30**]: Impression: Grade 2 internal hemorrhoids. Diverticulosis of the sigmoid colon and distal descending colon. Otherwise normal colonoscopy to cecum. Recommendations: Bleeding likely from small bowel AVMS. would keep on iron . EGD [**2142-3-30**]: Impression: Angioectasias in the second part of the duodenum, third part of the duodenum and fourth part of the duodenum Angioectasias in the stomach body. Otherwise normal EGD to second part of the duodenum. Recommendations: AVMs nonbleeding may be cause of iron def anemia Brief Hospital Course: 89 year old female with CAD s/p CABG, recent NSTEMI, AFib on anticoagulation, iron deficiency anemia, admitted with angina in setting of anemia likely secondary to GI bleed . 1) GI Bleed - Hematocrit was 20 on arrival to the ED, down from 33.7 on [**3-8**]. She was initially admitted to the MICU where she she received 2 units pRBCs with Hct increase to 24. She was transfused 2 additional units with hematocrit up to 33 on recheck. She was started on a pantoprazole drip. The GI consult service evaluated patient and felt this to be a non-brisk bleed which likely occurred in the setting of supratherapeutic INR. She has never had a colonoscopy. She was transferred to the floor with a plan for diagnostic colonoscopy and EGD. INR was allowed to trend down following discontinuation of heparin with goal INR<1.5 at time of procedure. She was transfused 1 unit FFP on the morning of the procedure. Colonoscopy revealed multiple non-bleeding arterio-venous malformations and severe diverticulosis. Her hematocrit remained stable for the duration of the hospitalization wih no evidence of further bleeding once coumadin was discontinued. . 2) Cardiac: (a) CAD - known CAD s/p CABG with prior MIs, no evidence of ACS; angina likely reflects decrease in O2 delivery [**1-12**] anemia rather than progression of plaque. Troponins were initially upward trending peaking and 1.04 (0.06, 0.25, 0.58, 1.04, 0.89, 0.83) but CK's flat; likely this represents demand in the setting of severe anemia. ASA and Plavix were held in the setting of active bleeding. She was continued on a statin and isosorbide dinitrate. ASA 81 mg was restarted prior to discharge. . (b) Pump - preserved EF by TTE in [**Month (only) 404**]; clinically euvolemic. . (c) Rhythm - Patient reported to have a history of atrial fibrillation, recently started on coumadin. She has previously been maintained on Verapamil for rate control. Anticoagulation was reversed in the setting of GIB and coumadin was permanently discontinued. Telemetry during this hospitalization revealed paroxysmal AVNRT, with which she was symptomatic with palpitations which awakened her from sleep. Episodes of sinus bradycardia were also documented on teletry, most likely consistent with sick sinus sydrome. EP was consulted and recommended amiodarone 100 mg daily as anti-arrhythmic therapy vs. ablation vs. calcium-channel blockade for the AVNRT. However, amiodarone was somewhat contraindicated in the setting of her sinus nodal dysfunction. It was decided to continue with Verapamil at the current dose, as ablation was considered to be too invasive by the patient. . 3) Iron deficiency anemia: presumed [**1-12**] GI loss. She was transfused a total of 4 units PRBC's. . 4) HTN - h/o HTN, though concern for hypotension given presentation with GIB; However, she remained hemodynamically stable to this point with some lability of blood pressures. She was continued on Verapamil, and amlodipine was restarted prior to discharge. . 5) Pre-septal right eye cellulitis - Infection with unclear source. Opthalmology was consulted and recommended Bacitracin opthalmic ointment TID plus IV unasyn. She was discharged on Augmentin with plan to complete a 7-day course of antibiotics. . 6) Restless legs: PRN tylenol, then ativan (per her home regimen) Medications on Admission: ASA 325mg po qday Plavix 75mg po qday lisinopril 5mg po qday (recently stopped [**1-12**] cough) verapamil 40mg po q12hrs simvastatin 40mg po qday ranitidine 150mg po bid isosorbide mononitrate 120mg po qday ativan prn restless legs coumadin (recently started) amlodipine 2.5mg po bid (recently increased) Discharge Medications: 1. Verapamil 40 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Protonix 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* 4. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* 5. Isosorbide Dinitrate 40 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: GI bleed Coronary artery disease AVNRT Hypertension Discharge Condition: Hemodynamically stable, with intermittent runs of AVNRT Discharge Instructions: You have undergone evaluation for a GI bleed. You were found to have several arterio-venous malformations and diverticuli in your colon. Your coumadin therapy has been discontinued due to the risk of bleeding. . Your Plavix has been discontinued also. You should follow-up with Dr. [**Last Name (STitle) 1270**] this week about whether he wants you to resume this medication. . You are being discharged with an antibiotic called Augmentin for the infection in your right eye. You have an additional 3 days course to complete your antibiotic course. . You should return to the emergency room if you experience blood in your stools, black tarry stools, dizziness, chest pain, shortness of breath, or persistent palpitations. Followup Instructions: You should follow-up with your Cardiologist Dr. [**Last Name (STitle) 1270**] in the next 7 days. Please call [**0-0-**] to schedule your appointment. . Please follow-up with your Ophthalmologist, Dr. [**Last Name (STitle) **] in [**12-12**] weeks. Please call [**Telephone/Fax (1) 253**] to schedule this appointment. [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]

[ "530.81", "413.9", "V45.81", "272.0", "427.31", "562.10", "537.83", "401.9", "682.0", "424.1", "427.89", "280.0" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04", "99.07", "45.23" ]

icd9pcs

[ [ [] ] ]

8225, 8283

3802, 7117

231, 267

8379, 8437

2757, 3779

9212, 9662

2250, 2285

7473, 8202

8304, 8358

7143, 7450

8461, 9189

2300, 2738

181, 193

295, 1561

1583, 1997

2013, 2234

44,452

199,372

40156+58350

Discharge summary

report+addendum

Admission Date: [**2139-12-21**] Discharge Date: [**2139-12-29**] Date of Birth: [**2059-9-20**] Sex: F Service: SURGERY Allergies: Bacitracin Attending:[**First Name3 (LF) 4748**] Chief Complaint: Abdominal pain; Abdominal Aortic Aneurysm Major Surgical or Invasive Procedure: [**2139-12-21**]: Repair of infrarenal abdominal aortic aneurysm with an 18-mm Dacron tube graft. History of Present Illness: History obtained from chart as patient unable to provide secondary to dementia. Patient is an 80F w/ severe Alzheimer's dementia with known AAA, last seen by Dr. [**Last Name (STitle) 1391**] in [**2-24**] for a 5.5 cm aneurysm treated non-operatively. Patient was reportedly found unresponsive [**2139-12-21**] AM at [**Hospital3 12272**] facility. Upon arrival of EMS patient arose to slight sternal rub and was taken to [**Hospital3 7571**]Hospital. CT scan there showed enlargement of aneurysm to 7.0 cm. Patient currently reports no abdominal pain however is confused and is unaware of where she is. Past Medical History: PMH: AAA, hypertension, hyperlipidemia, depression, Alzheimer's dementia . PSH: none known . [**Last Name (un) 1724**]: amlodipine 5', Wellbutrin SR 100'', fluoxetine 20', fluticasone IH, Razadyne ER 24', memantine 10'', metoprolol 25'', tylenol prn, cholecalciferol 1,000', glucosamine 500', melatonin-pyridoxine [**3-17**]' Social History: Lives at [**Hospital3 **]. Family History: Non-contributory. Physical Exam: P/E at Discharge: VS: 99.2 98.0 86 149/72 18 96%RA GEN: obese elderly F in NAD HEENT: NC/AT; sclerae anicteric CV: RRR PULM: No respiratory distress ABD: S/minimally tender in peri-incisional area/non-distended; midline laparotomy wound with peri-incisional ecchymosis; incision C/D/I with staples in place EXT: lower extremities warm, well perfused B/L; pulses 2+ at DP B/L NEURO: A&Ox2; no focal deficits Pertinent Results: LABORATORIES: [**2139-12-21**] 01:45PM BLOOD WBC-5.6 RBC-5.40 Hgb-15.7 Hct-46.6 MCV-86 MCH-29.1 MCHC-33.8 RDW-13.8 Plt Ct-187 [**2139-12-25**] 07:55AM BLOOD WBC-6.9 RBC-3.52* Hgb-10.3* Hct-30.3* MCV-86 MCH-29.3 MCHC-34.1 RDW-14.9 Plt Ct-179 [**2139-12-21**] 01:45PM BLOOD PT-13.3 PTT-24.9 INR(PT)-1.1 [**2139-12-21**] 01:45PM BLOOD Glucose-85 UreaN-12 Creat-0.7 Na-138 K-4.2 Cl-102 HCO3-27 AnGap-13 [**2139-12-27**] 07:20AM BLOOD Glucose-90 UreaN-11 Creat-0.5 Na-137 K-3.8 Cl-103 HCO3-27 AnGap-11 [**2139-12-21**] 06:36PM BLOOD Calcium-8.7 Phos-4.0 [**2139-12-27**] 07:20AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7 MICROBIOLOGY: Urine Cx [**2139-12-22**]: No growth - FINAL Brief Hospital Course: The patient was admitted to the vascular surgery service on [**2139-12-21**] and had an urgent open repair of an infrarenal abdominal aortic aneurysm. The patient tolerated the procedure well and was admitted to the CVICU postoperatively and to the VICU on POD1. Geriatrics and physical therapy consults were placed for assistance in management. Neuro: Post-operatively, the patient received Morphine IV/PCA however, patient's mental status was not compatible with PCA use. Patient was switched to intermittent IV morphine and standing acetaminophen po on POD1 with good effect and adequate pain control. When tolerating oral intake on POD2, the patient was transitioned to oral pain medications. Patient was intermittently delirious postoperatively requiring restraints/mittens and per recommendation of geriatrics was given low dose seroquel prn with good effect. Patient's dementia medications were restarted immediately postoperatively and continued throughout admission. CV: The patient was started on a nitroglycerin gtt for blood pressure control postoperatively. This was weaned on POD1. Patient was also started on IV metoprolol postoperatively and was transitioned to po home dose when tolerating po. Patient was transfused 1 unit pRBCs on POD#3. A-line was removed on POD3; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Advanced to sips on POD#1 then was made NPO for increasing abdominal distention and no bowel activity. Patient took clears on POD#4 and advanced to regular diet on POD#5 which was tolerated well. Patient had a mild postoperative ileus that resolved with BM on POD#4. She was also started on a bowel regimen to encourage bowel movement. Bolused x2 on POD1 for low urine output. Foley was removed on POD#4. Intake and output were closely monitored. ID: Patient was given appropriate preoperative antibiotics. The patient's temperature was closely watched for signs of infection. 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#7, 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: [**Last Name (un) 1724**]: amlodipine 5', Wellbutrin SR 100'', fluoxetine 20', fluticasone IH, Razadyne ER 24', memantine 10'', metoprolol 25'', tylenol prn, cholecalciferol 1,000', glucosamine 500', melatonin-pyridoxine [**3-17**]' Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. quetiapine 25 mg Tablet Sig: 0.25 Tablet PO Q6H (every 6 hours) as needed for delirium. 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. galantamine 4 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day) as needed for dementia. 8. memantine 5 mg Tablet Sig: Two (2) Tablet PO daily () as needed for dementia. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) for 7 days. 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 12. bupropion HCl 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: Abdominal Aortic Aneurysm Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the Vascular Surgery service for repair of an abdominal aortic aneurysm. What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**6-23**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**2-18**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] within two to three weeks. Call ([**Telephone/Fax (1) 4852**] for an appointment. Completed by:[**2139-12-28**] Name: [**Known lastname 13972**],[**Known firstname 1966**] Unit No: [**Numeric Identifier 13973**] Admission Date: [**2139-12-21**] Discharge Date: [**2139-12-29**] Date of Birth: [**2059-9-20**] Sex: F Service: SURGERY Allergies: Bacitracin Attending:[**First Name3 (LF) 231**] Addendum: Patient prepared for discharge on POD7 but disposition to rehab still in process. Patient remained stable for discharge to rehab on POD8. Discharge Disposition: Extended Care Facility: [**Hospital3 1620**] - [**Location (un) 1621**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2139-12-29**]

[ "293.0", "518.0", "441.4", "311", "294.10", "331.0", "272.4", "997.4", "401.9", "285.9", "560.1" ]

icd9cm

[ [ [] ] ]

[ "38.44" ]

icd9pcs

[ [ [] ] ]

10145, 10377

2627, 5064

314, 414

6571, 6571

1934, 2604

9424, 10122

1463, 1482

5347, 6407

6522, 6550

5090, 5324

6724, 8972

8998, 9401

1497, 1501

1515, 1915

233, 276

442, 1054

6586, 6700

1076, 1403

1419, 1447

7,826

147,838

10525

Discharge summary

report

Admission Date: [**2166-12-30**] Discharge Date: [**2167-1-2**] Date of Birth: [**2106-3-20**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Penicillins / Ivp Dye, Iodine Containing / Erythromycin Base / Iron / Demerol / Codeine Attending:[**First Name3 (LF) 106**] Chief Complaint: transfer from OSH with Chest Pain Major Surgical or Invasive Procedure: Cardiac catheterization [**12-30**], [**1-2**], flexible and rigid bronchoscopy [**1-2**], open throacic surgical procedure to attempt right lung hemostatsis [**1-2**] History of Present Illness: 60 yo female with DM II, HTN, hyperlipidemia, and PVD s/p bilateral bypass in [**2160**] who presented to [**Hospital6 33**] with chest pain at rest. Pain started last night prior to going to bed. Pain is constant, substernal, radiating to the back, associated with nausea and vomiting. Denies radiation to jaw/neck/arm or diaphoresis. Pain not significantly worse with inspiration. She reports intermittent chest pain for several months, which her PCP attributed to GERD; she was recently started on protonix. She denies PND or orthopnea, but she has been sleeping upright [**12-26**] to CP. No change in exerciese tolerance, no leg swelling, or symptoms of claudication. No recent travel or periods of immobility. No known hx of MI. No stress tests in the past. . At OSH patient had EKG w/ new ST seg dep in II, V4-V6, and TWI in I and AVL. She was given SL NTG several times with some relief, asa 161 mg x 2, and plavix 300 mg po x 1. She received solumedrol 60 mg IV x 1, mucomyst 600 mg iv x 1, benadryl 50 mg iv x 1, zantac 50 mg iv x 1, and D5W with sodium bicarb for a contrast allergy in anticipation of cath. She also received ativan 1 mg iv x 1. She was started on an integrilin and heparin gtt with a bolus prior to transfer. . On arrival to the ED, patient noted to be increasingly dyspneic with continued chest pain. Placed on a NRB with O2 sats in the mid 90's. Past Medical History: DM II x 13 yrs - on oral agents peripheral neuropathy HTN hyperlipidemia PVD - s/p b/l bypass grafts [**2160**] bilat cataracts GERD depression Social History: Lives with her husband who has Parkinsons. Daughter lives nearby. Works in the kitchen at a local school. Smoked 1 PPD x 20 yrs, quit 21 yrs ago. No Etoh. Family History: brothers - CABG, MI father - MI @ 48 mother - renal failure 80s Physical Exam: Tc 99.4, HR 106, BP 160/107, RR 30, O2 99% NRB Gen: tachypneic, breathing labored, able to communicate in full sentences HEENT: dried blood on teeth NECK: no JVD appreciated CV: regular, tachy, No murmurs LUNGS: Crackles at bases, no E->a changes ABD: obese, soft, NT/ND EXT: no edema, strong DP/PT pulses b/l, Pertinent Results: Admssion Labs: 130 96 46 ------------<529 4.8 20 2.0 . Hemoglobin A1C: 8.7% . CK: 210 MB: 14 MBI: 6.7 Trop: 2.71 . 11.2 13.5>--<497 33.0 N:92.7 Band:0 L:6.6 M:0.4 E:0.1 Bas:0.1 Hypochr: OCCASIONAL Anisocy: OCCASIONAL Microcy: 1+ . PT: 13.0 PTT: 79.8 INR: 1.1 . UA: Color Straw Appear Clear SpecGr 1.018 pH 5.0 Urobil Neg Bili Neg Leuk Neg Bld Sm Nitr Neg Prot 30 Glu 1000 Ket Neg RBC [**1-26**] WBC 0-2 Bact None Yeast None Epi 0 . ABG: pH 7.43 pCO2 32 pO2 181 HCO3 22 BaseXS -1 . EKG: NSR, Rate 103, prolonged PR interval, new TWI in I and AVL, ST depressions resolved. . CXR [**2166-12-30**]: Chronic CHF of moderate degree with interstitial edema and at least some mild blunting of the right pleural sinus. . ECHO [**2166-12-30**]: Overall left ventricular systolic function is mod to severely depressed (EF 30%) secondary to severe hypokinesis of the anterior septum and anterior free wall; there is extensive apical akinesis. Mild (1+) mitral regurgitation. . Cardiac cath [**2166-12-30**]: 1. Coronary angiography in this left dominant system demonstrated a 10% stenosis of the LMCA. The LAD had an 80% proximal lesion and 50-60% distal stenoses. The LCX system had extensive disease with 70% proximal and distal lesions as well as a ramus intermedius with 70% stenosis. The RCA was non-dominant and totally occluded. 2. Limited resting hemodynamics revealed normal systemic arterial pressures. LV filling pressure was elevated at 30 mmHg. 3. Patient referred for CABG. . Carciac cath [**2167-1-2**]: 1. Three vessel coronary artery disease. 2. Moderate systolic ventricular dysfunction. 3. Acute/subacute clousure of the CX 4. Cardiac arrest necessitating intubation and vetilation 5. 30 cc IABP placement 6. Successful stenting of the CX (Drug eluting and barematal) 7. Successful stenting of the LAD (Drug eluting) 8. Severe bleeding in the ET tube Brief Hospital Course: A/P: 60 yo F with DMII, HTN, PVD presents with NSTEMI with 3V CAD initially thought not amenable to PCI but also not able to have CABG so to cath for PCI. . CAD: She was stabilized and readily weaned of nitro and fentenyl, and chest pain free by [**1-1**], 3 VD on cath initially thought not amenable to PCI, but not able to have CABG so went again for high risk PCI, with premedication for dye allergy and renal failure, after medically stabilized with CE's trending down on aspirin, metoprolol (titrate up as tolerated), plavix. She was taken to cath and found to 100% occlusion at ostium of left circumflex and subsequesntly had asystolic arrest and was successfully resuscitated with PCI of left circumflex and LAD. During this she developed frank bleeding from her ETT so was taken to the OR for rigid bronchoscopy. Hemostatic control was not able to be achieved despite operative efforts, aggressive transfussions and pressors. She expired. Medications on Admission: Meds at home per pharmacy-[**Telephone/Fax (1) 34685**]: pantoprazole 40mg po qd ASA 81mg po qd quinapril 40mg po qd indapamide 2.5mg po qd diltiazem xr 240mg po qd celexa 40mg po qd glipizide er 10mg po bid betimol 0.5% 1 gtt od qam advair 250/50 prn . Allergies: PCN sulfa e-mycin demerol codeine contrast dye high dose iron supplement Discharge Disposition: Expired Discharge Diagnosis: Coronary artery disease, pulmonary hemorrhage. Discharge Condition: Expired.

[ "998.11", "250.00", "786.3", "427.5", "278.00", "401.9", "272.4", "410.71", "585.9", "785.51", "998.2", "414.01" ]

icd9cm

[ [ [] ] ]

[ "00.47", "99.60", "88.56", "37.61", "33.23", "33.92", "96.04", "36.06", "37.91", "37.78", "00.41", "33.22", "37.22", "36.07", "99.20", "96.71", "89.64", "00.66" ]

icd9pcs

[ [ [] ] ]

6004, 6013

4667, 5615

404, 573

6103, 6114

2749, 4644

2336, 2402

6034, 6082

5641, 5981

2417, 2730

331, 366

601, 1980

2002, 2148

2164, 2320

2,124

195,034

16524

Discharge summary

report

Admission Date: [**2146-6-17**] Discharge Date: [**2146-6-22**] Date of Birth: [**2066-9-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6169**] Chief Complaint: seizure Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. [**Known lastname **] is a 79-year-old woman with hx of CVA, HTN, hypothyroidism newly diagnosed Diffuse large B-Cell Non-Hodgkins Lymphoma discharged yesterday from [**Hospital1 18**] with a diagnosis of urosepsis thought to be secondary to ureteral obstruction from an abdominal mass who presents today after a seizure at her nursing home. . She was discharged from [**Hospital1 18**] to rehab the day prior to presenation after an 11 day hospitalization stay after she presented with urosepsis which was thought to be secondary to hydronephrosis from obstruction secondary to her tumor. She underwent ureteral stent revision with good effect. Her urine and blood cultures grew pan-sensitive E. Coli which was treated with ceftriaxone. The patient began chemotherapy on [**2146-6-7**]. She received cytoxan, prednisone, vincristine, and intrathecal methotrexate. She tolerated the chemo well. She developed tumor lysis syndrome which was treated with high rates of IVF and diuresis to keep her urine output up. She did not develop complications, and tumor lysis resolved. She was given intrathecal MTX on [**2146-6-13**]. Port cath placed on [**2146-6-13**]. . The patient had a witnessed grand mal seizure at her nursing home. On EMS arrival she was minimally responsive vitals at the time 99.3 60 160/100 36-40 95% RA. In the ED, temp to 101.8 106 134/68 16 99% on NRB. She was witnessed to seizure again in the ED. Out of concern for altered mental status and inability to protect airway, the patient was intubated. She received propofol, vecuronium and ativan for sedation. The patient received vanc 1gm, ceftriaxone 2gm, dexamethasone 10mg and dilantin 1500mg. After sedating and paralyzing medications, the patient developed hypotension to 88/54 (and sbp to ?60's) and was started on a levophed drip for hypotension. She was placed on sepsis protocol with sepsis catheter placed via right IJ. The patient received approximately 5.5L of NS with good blood pressure response to 140's/50's. The patient was seen in the ED by oncology and per their recommendations, she received a dose of filgrastim. Past Medical History: High grade B-cell NHL- presented with three to four months of appetite loss, nausea, and back pain. CT scan performed on [**2146-5-6**] revealed extensive ascites and peritoneal masses concerning for ovarian cancer. Also, noted were bilateral ureteral irregularities close to obstruction, both on the left and the right. CVA- no residual deficit R carotid artery occlusion Melanoma- (~[**2140**]) Left eye localized involvement, s/p proton beam tx without evidence of recurrence hypertension hypercholesterolemia hypothyroidism gout . Psurg: Appendectomy Social History: married, lived with her husband in [**Name (NI) 1268**] until her most recent hospitalization. No current tobacco, or illicits. Drinks 2 glasses of wine per week. smoking 20+ years ago. Not currently working. She has 6 children who live in the area and daughter in law who is a nurse. Family History: She has one cousin with history of breast cancer and daughter had renal cell cancer. Physical Exam: per admitting resident 98.6 89 141/78 Vent: AC Vt set 550 obs 600 RR 14/0=14 PEEP 5 PIP 28 Plateau 18 Gen:NAD, A and Ox3 HEENT:PERRL, MMdry, upper full dentures lower bridge, no elev JVP NEck:supple CV:RRR, nS1S2 no MRG PULM: scant wheezes througout lung fields. Abd:nabs Extrem:2+ rad and dp pulses, 2+ LE edema worse on left Neuro:CNII-XII intact, [**6-11**] UE and LE strength except for [**5-12**] in hip flexers bilat, distal sensation intact Pertinent Results: [**2146-6-17**] 11:53PM TYPE-ART PO2-300* PCO2-28* PH-7.56* TOTAL CO2-26 BASE XS-4 [**2146-6-17**] 07:29PM CEREBROSPINAL FLUID (CSF) PROTEIN-59* GLUCOSE-104 [**2146-6-17**] 07:29PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-475* POLYS-0 LYMPHS-60 MONOS-40 [**2146-6-17**] 07:29PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-4222* POLYS-6 LYMPHS-81 MONOS-13 [**2146-6-17**] 01:42PM LACTATE-1.6 [**2146-6-17**] 01:30PM GLUCOSE-182* UREA N-9 CREAT-0.6 SODIUM-137 POTASSIUM-2.7* CHLORIDE-110* TOTAL CO2-23 ANION GAP-7* [**2146-6-17**] 01:30PM ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-73 AMYLASE-151* TOT BILI-0.5 [**2146-6-17**] 01:30PM LIPASE-15 [**2146-6-17**] 01:30PM ALBUMIN-2.0* [**2146-6-17**] 01:30PM WBC-0.1* RBC-2.79* HGB-8.6* HCT-24.5* MCV-88 MCH-30.9 MCHC-35.2* RDW-14.3 [**2146-6-17**] 01:30PM PLT COUNT-58* [**2146-6-17**] 01:30PM GRAN CT-50* [**2146-6-17**] 11:18AM TYPE-ART PH-7.30* [**2146-6-17**] 11:18AM GLUCOSE-186* LACTATE-5.8* NA+-131* K+-3.5 CL--95* TCO2-27 [**2146-6-17**] 11:18AM HGB-11.5* calcHCT-35 [**2146-6-17**] 11:18AM freeCa-1.08* [**2146-6-17**] 11:00AM GLUCOSE-205* UREA N-13 CREAT-1.0 SODIUM-132* POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16 [**2146-6-17**] 11:00AM CK(CPK)-36 [**2146-6-17**] 11:00AM CK-MB-NotDone cTropnT-0.02* [**2146-6-17**] 11:00AM CALCIUM-8.2* PHOSPHATE-3.1 MAGNESIUM-1.7 [**2146-6-17**] 11:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2146-6-17**] 11:00AM WBC-0.2* RBC-3.54* HGB-10.9* HCT-31.8* MCV-90 MCH-30.8 MCHC-34.3 RDW-14.4 [**2146-6-17**] 11:00AM NEUTS-16* BANDS-0 LYMPHS-80* MONOS-0 EOS-0 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 [**2146-6-17**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2146-6-17**] 11:00AM PLT SMR-LOW PLT COUNT-97* [**2146-6-17**] 10:57AM URINE HOURS-RANDOM [**2146-6-17**] 10:57AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2146-6-17**] 10:57AM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.009 [**2146-6-17**] 10:57AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2146-6-17**] 10:57AM URINE RBC->50 WBC-[**4-11**] BACTERIA-FEW YEAST-NONE EPI-0-2 [**2146-6-17**] 10:50AM GLUCOSE-164* LACTATE-5.2* NA+-133* K+-4.1 CL--96* TCO2-28 [**2146-6-17**] 10:45AM UREA N-13 CREAT-1.1 [**2146-6-17**] 10:45AM CK(CPK)-59 AMYLASE-109* [**2146-6-17**] 10:45AM CK-MB-NotDone cTropnT-0.01 [**2146-6-17**] 10:45AM CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.8 [**2146-6-17**] 10:45AM WBC-0.4* RBC-3.74* HGB-11.5* HCT-33.1* MCV-89 MCH-30.8 MCHC-34.8 RDW-14.3 [**2146-6-17**] 10:45AM PT-13.5* PTT-29.8 INR(PT)-1.2* [**2146-6-17**] 10:45AM PLT SMR-LOW PLT COUNT-99* [**2146-6-17**] 10:45AM FIBRINOGE-428* . CXR IMPRESSION: 1. Appropriate placement of a new right-sided internal jugular central venous catheter with no evidence of pneumothorax. 2. Unchanged small bilateral pleural effusions and lower lobe atelectasis (left greater than right) along with a persistent mild-to-moderate interstitial edema. . CT head No evidence of acute intracranial process. . CT abdomen 1. New moderate bilateral pleural effusion with compressive atelectasis. 2. Small fluid accumulation around the liver and in the pelvis suggesting the presence of ascites. 3. Status post bilateral double J catheter of both kidneys. There has been interval dcrease in the size of soft tissue infiltrate surrounding the course of both ureters into the pelvis. 4. No retroperitoneal or pelvic hematoma is seen. 5. Unchanged appearance of calcified splenic artery aneurysm measuring 16 mm. 6. Interval significant decrease in size of massively enlarged mesenteric lymph nodes. The previously described soft tissue mass within the upper pelvis is less prominent and can not be well characterized since no oral or IV contrast has been used. . EEG This is a normal portable EEG in the awake and drowsy states. No focal or epileptiform features were seen. Brief Hospital Course: 1) Seizure: Etiology of seizure remains unclear, most likely in setting of IT MTX. Head CT negative, EEG normal, LP not consistent with CNS disease/meningitis. On keppra 1000 [**Hospital1 **]. Stable. No further workup at this point. . 2) Repiratory distress: RESOLVED. Was probably secondary to depressed CNS drive in the setting of seizure. Now satting well on room air. . 3) ID: needs to finish 14-day course for fluconazole for thrush. . 4) NHL: On CVP (Day 1 [**2146-6-7**]). Scheduled for rituxan as outpatient on [**2146-6-24**]. Medications on Admission: Bisacodyl 10 mg DAILY PRN Miconazole Nitrate 2 % Cream 2 times a day Acetaminophen 325-650 mg PO Q4-6H: PRN Alprazolam 0.25 mg PO once a day at bedtime Allopurinol 200 mg DAILY Fluconazole 200 mg Q24H Trimethoprim-Sulfamethoxazole 160-800 mg 3X/WEEK (MO,WE,FR) Alprazolam 0.25 mg 3 times a day: PRN Docusate Sodium 100 mg 2 times a day Senna 8.6 mg 1-2 Tablets 2 times a day Saliva Substitution Combo as needed for mouth sores Filgrastim 480 mcg Q24H Trazodone 25 mg at bedtime PRN Metoprolol Tartrate 50 mg, 2 times a day Morphine Sulfate 2 mg IV Q4H:PRN Ceftriaxone 1 g once a day Ondansetron 4-8 mg IV Q8H:PRN Menthol-Cetylpyridinium Cl 2 mg Lozenge PRN Discharge Medications: 1. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 5. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) as needed for qday. 8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO every twelve (12) hours. 9. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care Discharge Diagnosis: Primary - seizures - shock - respiratory distress Secondary - NHL Discharge Condition: good Discharge Instructions: Admitted for seizures in setting of intrathecal chemotherapy. Now asymptomatic, EEG normal. On Keppra for prophylaxis. Please take all medication as prescribed. Please go to follow up appointments. Next outpatient treatment is on Friday [**2146-6-24**]. Followup Instructions: Provider: [**Name Initial (NameIs) 455**] 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2146-6-24**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2146-6-27**] 11:15 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 6317**] Date/Time:[**2146-9-20**] 8:30 Completed by:[**2146-6-22**]

[ "785.50", "401.9", "V12.59", "518.82", "V10.82", "244.9", "274.9", "E933.1", "345.90", "200.20", "V15.82", "E937.8" ]

icd9cm

[ [ [] ] ]

[ "96.04" ]

icd9pcs

[ [ [] ] ]

10076, 10189

8023, 8562

323, 336

10299, 10306

3949, 8000

10608, 11048

3378, 3464

9270, 10053

10210, 10278

8588, 9247

10330, 10585

3479, 3930

276, 285

364, 2475

2497, 3055

3071, 3362

83,061

153,483

53154

Discharge summary

report

Admission Date: [**2116-5-22**] Discharge Date: [**2116-6-1**] Date of Birth: [**2039-6-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: CHIEF COMPLAINT: ACTH-dependent [**Location (un) 3484**] Syndrome Major Surgical or Invasive Procedure: Bilateral adrenalectomy History of Present Illness: 76 y/o wf with PMH with breast cancer [**2091**] Rx mastectomy, metastatic to lung (bx proven, f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 19**]) but stable over time on TAM (tamoxifen). Also [**2112**] dx of endometrial cancer s/p TAH/BSO and XRT with no recurrences, and actually put back on TAM afterwards to prevent breast cancer spread. She is a direct admit from [**Hospital 1800**] clinic for pituitary MRI and adrenalectomy by Dr. [**Last Name (STitle) 3748**] early next week. She was recently diagnosed with ACTH-dependent [**Location (un) 3484**] syndrome. Of note, pt fell on her way to clinic last week. She went to the ED and had sutures placed on her left forehead. She reports recent worsening dizziness, fatigue, and swelling in her lower extremities. On arrival to the medical floor, patient continued to be dizzy and fatigued. Upon questioning, patient is able to answer questions, but gets confused and forgets easily. Past Medical History: metastatic breast ca to lungs endometrial ca-s/p tah bso and xrt myeloproliferative disorder htn hyperlandipidemia anxiety basal cell ca face Social History: She is extremely active, currently does some sculpting and goes to classes in [**University/College **]. Lives with her husband, [**Name (NI) **]. Had some previous cigarette smoking, but has quit many years ago. Occasional alcohol once a month. Denies any IV or other drug use. She has a friend who recently died and is currently practicing to play at her funeral. Family History: An uncle who was diabetic, an aunt who had breast cancer, and a fraternal twin who had lung cancer. She also has another sister with myasthenia [**Last Name (un) 2902**]. Physical Exam: PHYSICAL EXAM GENERAL: elderly woman, in NAD HEENT: round, red cushingoid face, steri-strips covering sutures on left side of forehead - c/d/i, bruising under left eye, telengiectasias on both cheeks, hair growth on upper cheeks, mouth clear with dry mucous membranes CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops. LUNGS: CTAB, good air movement biaterally. no wheezing/crackles. ABDOMEN: +BS. Soft, NT, ND. No striae. No HSM, masses. EXTREMITIES: 3+ pitting edema symmetric and [**1-29**] of the way up to the knee with blistering at the ankles/feet SKIN: dark pigmentation. NEURO: CN 2-12 grossly intact. prox strength 5/5 deltoids, but 3+/5 for iliopsoas muscles Mental Status: Can be irritable and easily distracted, pressured speech Pertinent Results: ADMISSION LABS ([**2116-5-22**]): WBC-14.0* RBC-4.28 Hgb-12.9 Hct-38.5 MCV-90 MCH-30.1 MCHC-33.6 RDW-16.0* Plt Ct-239# UreaN-51* Creat-1.8* Na-143 K-4.7 Cl-102 HCO3-28 AnGap-18 Cortsol-39.8* PERTINENT LABS: Serial Hct: [**5-22**] 38.5 [**5-23**] 32.9 / 33.1 [**5-24**] 31.8 (Retic 2.4) [**5-24**] 35.2 [**5-25**] 32.9 [**5-26**] 33.4 [**5-27**] 29 Cr: [**5-22**] 1.8 [**5-23**] 1.8 [**5-24**] 1.8 [**5-25**] 2.0 [**5-26**] 1.9 [**5-27**] 1.4 [**5-28**] 1.3 [**5-29**] 1.0 7/4-6 0.9 K: [**5-22**] 4.7 [**5-23**] 4.3 [**5-24**] 5.1 [**5-25**] 4.7, 6.1 [**5-26**] 5.0, 5.2, 5.1 [**5-27**] 3.6 Cortisol: [**5-22**] 39.8 [**5-25**] 23.9 STUDIES: MRI pituitary - no evidence of micro- or macroadenoma PATH: Adrenal glands - Part 1 is additionally labeled "left adrenal gland." It consists of a fragment of yellow-tan fibroadipose tissue containing an adrenal gland measuring overall 11.5 x 5.0 x 2.4 cm. The outer surface is inked in blue. The specimen is sectioned to reveal a tan-brown adrenal gland measuring 6.5 x 2.2 x 1.5 cm and weighing 28 grams after the excess fat is trimmed. The head measures 6.0 cm in length x 0.4 cm in diameter, the body measures 6.8 cm in length x 0.5 cm in diameter, and the tail measures 6.4 cm in length x 0.8 cm in diameter. The cortex measures up to 0.1 cm and is [**Location (un) 2452**]. On cut sections, no masses or lesions are identified in the cortex or medulla. The specimen is represented as follows: A-B = head, C-D = body, E = tail. Part 2 is additionally labeled "right adrenal gland." It consists of a fragment of fibroadipose tissue containing an adrenal gland measuring overall 7.8 x 4.5 x 1.5 cm. The outer surface is inked in black. The specimen is sectioned to reveal a tan-brown adrenal gland measuring 4.5 x 1.8 x 1.2 cm and weighing 16 grams after the access fat is trimmed. The head measures 3.5 cm in length x 0.3 cm in diameter, the body measures 4.5 cm in length x 0.5 cm in diameter, and the tail measures 3.5 cm in length x 1.1 cm in diameter. The cortex measures up to 0.1 cm and is [**Location (un) 2452**]. On cut sections, no masses or lesions are identified in the cortex or medulla. The specimen is represented as follows: F-G = head, H-I = body, J = tail. DISCHARGE LABS ([**2116-6-1**]): WBC-11.7* RBC-2.97* Hgb-9.0* Hct-26.7* MCV-90 MCH-30.3 MCHC-33.7 RDW-16.3* Plt Ct-396 Glucose-73 UreaN-22* Creat-0.9 Na-143 K-3.3 Cl-109* HCO3-27 AnGap-10 Calcium-8.2* Phos-2.5* Mg-1.9 Brief Hospital Course: Mrs. [**Known lastname **] is a 76F with severe ACTH-dependent [**Location (un) **] syndome affecting multiple systems. Localization of ectopic sources of ACTH unsuccessful, so she was admitted for pituitary MRI, followed by adrenalectomy by Dr. [**Last Name (STitle) 3748**]. Final [**Location (un) 1131**] of MRI reports no micro- or macroadenoma of the pituitary. # [**Location (un) **] SYNDROME: The patient's dizziness and fatigue improved over the course of her stay. LE edema also improved greatly during the last several days. Pt was followed closely by Endocrine. Pt was on Ketoconazole to control her symptoms. This was discontinued after her adrenalectomy on Wednesday [**5-27**]. Pt was started on hydrocortisone 100mg IV q8h just prior to surgery and weaned down after surgery to a maintenance dose of 20mg qAM and 10mg qPM. She tolerated the surgery well, and her symptoms improved. # HYPERKALEMIA: The patient's K level increased to 6.2, likely secondary to medications. She was given 2 doses of kayexalate, and repeat K was 5. Spironolactone and amiloride were discontinued. Subsequent K levels ranged between 3.3-4.5. # ANEMIA: Pt's HCT fluctuated between 29-33 in the first several days of hospitalization. Retic count 2.4. Pt reports minimal rectal bleeding from known hemorrhoids. Pt has recent MRI head with no evidence of bleed. Pt did not have any symptoms of acute bleed during these episodes - no shortness of breath and no lightheadedness. HCT remained stable after surgery, and there was no evidence of bleeding. # DIABETES MELLITUS: Pt was manic [**12-30**] to her disease prior to surgery, and was unable to manage her blood glucose level at home. She was placed on an insulin sliding scaled while in the hospital. Glucose levels dropped after surgery. She was discharged on metformin 500mg daily. # HEMORRHOIDS: Pt had painful hemorrhoids, with minimal bleeding. She was treated with Tucks hemorrhoid cream. # ACUTE RENAL FAILURE: Pt has a baseline Cr 1.1, but was admitted with Cr 1.8, which was as high as 2.0. This was likely secondary to medication regimen. Lisinopril was discontinued on admission, and spironolactone and amiloride were subsequently d/c'd as well. As medications were discontinued, pt's Cr dropped to normal levels. Cr level was 0.9 on discharge. # VOLUME OVERLOAD: Edema in b/l lower extremities improved greatly. Pt received several days of Lasix IV, which was held when her BP dropped. She was autodiuresing on discharge. # HYPOTENSION: The patient's blood pressure, which was initially high prior to adrenalectomy, ran low at 90s-low 100s/50s during her hospitalization. Lisinopril, spironolactone, and amiloride were discontinued. Metoprolol was decreased to 25mg PO BID. The patient's blood pressure was stable on this regimen, so she was discharged on metoprolol 25mg [**Hospital1 **]. Medications on Admission: AMILORIDE - 5 mg Tablet - 2 Tablet(s) by mouth daily ATORVASTATIN [LIPITOR] - 10 mg Tablet - [**11-29**] Tablet(s) by mouth every other day BRIMONIDINE [ALPHAGAN P] - (Prescribed by Other Provider) - 0.1 % Drops - 1 OU three times a day FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth twice a day KETOCONAZOLE - 200 mg Tablet - 1.5 Tablet(s) by mouth three times a day LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN - 500 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) METOPROLOL TARTRATE - 50 mg Tablet - 2 Tablet(s) by mouth two times a day SPIRONOLACTONE - 100 mg Tablet - 2 Tablet(s) by mouth twice a day TAMOXIFEN - 10 mg Tablet - 1 Tablet(s) by mouth twice a day TIMOLOL MALEATE - 0.25 % Drops - 1 OU twice a day Medications - OTC ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal Q6H (every 6 hours) as needed for pain. 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO Q48H (every 48 hours). 4. Tamoxifen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): for constipation. Disp:*60 Capsule(s)* Refills:*2* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Hydrocortisone 10 mg Tablet Sig: 1-2 Tablets PO twice a day: Please take 4 tablets in the morning and 2 tablets at night on [**2116-6-1**] and [**2116-6-2**]. Then take 2 tablets in the morning and 1 tablet at night. Disp:*100 Tablet(s)* Refills:*2* 14. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis [**Location (un) 3484**] Syndrome Secondary Diagnoses Diabetes Mellitus Acute Renal Failure Hypertension Discharge Condition: Stable, improved Discharge Instructions: You were treated in the hospital for worsening symptoms due to [**Location (un) 3484**] syndrome. You had both adrenal glands removed while you were here. The surgery went well, and you are recovering nicely. As your Endocrine doctors have told [**Name5 (PTitle) **], you will be on chronic steroids. Right now, we are decreasing your dose of Hydrocortisone slowly. You will be discharged on Hydrocortisone 40mg in the morning and 20mg at night for Monday [**6-1**] and Tuesday [**6-2**]. Then starting Wednesday [**6-3**], you will continue on your maintenance dose of 20mg in the morning and 10 mg at night. You have an appointment with Dr. [**Last Name (STitle) 574**], who will give you further instructions regarding your steroid dose. In the future, they will likely add Florinef, which is another kind of steroid, to your medication regimen. The following changes have been made to your medications: 1. Ketoconazole has been discontinued since your surgery 2. You are currently only taking Metoprolol 25mg twice a day for your blood pressure. Amiloride, Lasix, Lisinopril, and Spironolactone have been stopped since your blood pressure is lower now. Please see your primary care physician to monitor your blood pressure and add medications as necessary. 3. You will be taking Metformin 500mg once a day to control your blood sugars. 4. You are now taking Hydrocortisone for your steroid replacement. You will take 40mg in the morning and 20mg at night on Monday [**6-1**] and Tuesday [**6-2**]. Starting Wednesday [**6-3**], you will take 20mg in the morning and 10mg at night. If you have a minor illness, such as a cold or fever, you will need to double or triple your Hydrocortisone dose (40mg in the morning and 20mg at night, or 60mg in the morning and 30mg at night). You will do this for 3 days, and then return to your regular dose if you feel better. You will need a DexaPen, which is an injection of the hydrocortison for when you cannot tolerated medication by mouth. Please follow-up with your Endocrine doctor to find out how to get it at the pharmacy. If you are not able to tolerate the medication by mouth before you get the injection, please go to the emergency department. If you don't get better or if you have a severe illness, call your doctor right away. It is very important that you get a Med Alert Bracelet that you will need to wear at all times. You can buy them at drug stores, or online ([**URL 109461**]). If you experience fevers, chills, worsening abdominal pain, bleeding, lightheaded, shortness of breath, or any other concerning symptoms, please call your primary care physician or return to the emergency department. It was a pleasure meeting you and participating in your care. Followup Instructions: Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4390**]: Monday [**2116-6-8**] @ 10:15am Location: [**Street Address(2) **]. [**Location (un) 620**], MA Phone number: [**Telephone/Fax (1) 3070**] Please follow-up with Dr. [**Last Name (STitle) 574**], [**First Name3 (LF) **] Endocrinologist [**6-24**] @ 1pm Phone number: [**Telephone/Fax (1) 6468**] Please call Dr. [**Last Name (STitle) 3748**], your urologist, for a follow-up appointment within the next 2 weeks. ([**Telephone/Fax (1) 8791**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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54063

Discharge summary

report

Admission Date: [**2132-12-10**] Discharge Date: [**2133-1-11**] Date of Birth: [**2070-11-29**] Sex: F Service: MEDICINE Allergies: Percocet / Percodan Attending:[**First Name3 (LF) 465**] Chief Complaint: Alcohol intoxication Major Surgical or Invasive Procedure: Central line placement History of Present Illness: Patient is a 62 yo lady with history of alcohol abuse, C.diff colitis, also s/p colectomy in [**4-8**] with small pelvic abscess, admitted on [**2132-12-10**] for placement after being found intoxicated in her apartment, found lying in her feces, unable to care for herself per family. On admission patient was found to have low blood pressures 80/40s in the ED, given NS ~3L with little improvement. Alcohol level 299 on admission. On remained hypotensive with BP raning 80-110s/40-60s but responded to fluid boluses. Patient was essentially admitted for detox/placement. Patient was a very poor historian, reported drinking vodka at home which she ordered by telephone to her apartment. Patient has a brother and sister who live far away but concerned for her well being. Patient denies any complaints on admission, no shortness of breath, chest discomfort, fevers. Patient c/o ongoing diarrhea which was unchanged from prior. Unclear wether patient was compliant with medications at home given intoxication. Past Medical History: - EtOH Abuse with admissions for EtOH W/D at [**Hospital1 112**] - questionable colon mass - s/p Sigmoid Colectomy (~16 cm) by path report at [**Hospital1 112**] in [**5-8**] with subsequent diarrhea - s/p L oophorectomy and hysterectomy in [**2132**] for mature cystic teratoma - s/p ovarian cystectomy in [**2097**] with prophylactic appendectomy - s/p ORIF of toe in 4/99 - s/p Left knee surgery - Rosacea - Hand fracture - s/p normal pMIBI in [**5-8**] at [**Hospital1 112**] - Macrocytic Anemia due to EtOH use with normal B12 levels - Hypoalbuminemia due to EtOH use - C. Diff + at [**Hospital1 112**] in [**5-8**] - Fatty Liver by U/S at [**Hospital1 112**] in [**9-8**] without ascites - Chronic Lacunar infarcts on Head CT Social History: Drinks 2 drinks (vodka) daily - history of alcohol use since teenager per family Smokes 80 pack-years Lives alone Retired travel [**Doctor Last Name 360**], but wanted to become a postal worker. Divorced with no children. Has close contact with a brother in and sister who live out of state. Family History: Father died of lung cancer secondary to liver mets Mother died in her 60's of emphysema, CHF No CAD/DM/CVA Physical Exam: VS: 98.5 92/52 90 21 91% RA Gen: NAD, oriented, flat affect HEENT: red mildly swollen tongue, MMM, OP clear, sclerae anicteric Neck: JVP flat Chest: enlarged AP diameter CV: tachycardic, regular, nl S1/S2, no murmurs Pulm: clear bilaterally, decreased breath sounds but symmetric Abd: soft, mildly distended, hypoactive bowel sounds, no tenderness even to deep palpation Ext: [**1-5**]+ pitting edema bilaterally, room temperature, normal pulses Neuro: 5/5 strength in upper extremities, does not lift legs off bed, CN II-XII intact Skin: no jaundice Pertinent Results: On Admission: [**2132-12-10**] 12:10PM GLUCOSE-87 UREA N-7 CREAT-0.5 SODIUM-130* POTASSIUM-3.6 CHLORIDE-90* TOTAL CO2-29 ANION GAP-15 [**2132-12-10**] 12:10PM ALT(SGPT)-123* AST(SGOT)-210* ALK PHOS-203* AMYLASE-20 TOT BILI-1.5 [**2132-12-10**] 12:10PM ALBUMIN-2.5* [**2132-12-10**] 12:10PM ETHANOL-299* [**2132-12-10**] 12:10PM WBC-9.7 RBC-3.17*# HGB-12.1 HCT-33.9*# MCV-107*# MCH-38.0*# MCHC-35.6* RDW-13.4 [**2132-12-10**] 12:10PM NEUTS-68.1 LYMPHS-27.3 MONOS-3.7 EOS-0.4 BASOS-0.5 [**2132-12-10**] 12:10PM MACROCYT-3+ [**2132-12-10**] 12:10PM PLT COUNT-212 . Micro Data: [**2132-12-11**] 12:07 pm URINE **FINAL REPORT [**2132-12-13**]** URINE CULTURE (Final [**2132-12-13**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2132-12-11**] 8:29 pm STOOL CONSISTENCY: FORMED Source: Stool. **FINAL REPORT [**2132-12-12**]** OVA + PARASITES (Final [**2132-12-12**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. Cryptosporidium/Giardia (DFA) (Final [**2132-12-12**]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2132-12-12**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. . RPR - non reactive Legionella antigen - negative Repeat Stool cultures (multiple) - negative for C.diff toxin A . *****CLOSTRIDIUM DIFFICILE TOXIN B ASSAY Test Result Reference Range/Units CLOSTRIDIUM TOXIN B SCRN DETECTED NONE DETECTED SPECIMEN SOURCE: FECAL TEST PERFORMED AT: [**Company **] [**Doctor Last Name **] INSTITUTE [**Numeric Identifier **] [**Doctor Last Name 42068**] HWY. [**Location (un) **] CAPISTRANO, [**Numeric Identifier **] Comment: Source: Stool . Blood Cx [**12-24**]; [**12-26**]; [**12-29**] - no growth . Catheter tip culture [**12-30**] - no growth . [**2132-12-30**] 11:38 am PLEURAL FLUID PLEURAL RECEIVED AT 4:07PM. **FINAL REPORT [**2133-1-4**]** GRAM STAIN (Final [**2132-12-30**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2133-1-2**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2133-1-4**]): NO GROWTH. . Urine Cx [**12-30**], [**1-5**] - +yeast . Imaging: CXR [**12-10**]: No evidence of acute cardiopulmonary process . Echo [**12-11**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . LE doppler [**12-11**]: Negative for proximal deep venous thrombosis bilateral lower extremities. . EKG [**12-11**]:Probable ectopic atrial rhythm Borderline right axis deviation Low limb lead QRS voltages Poor R wave progression with late precordial QRS transition Finding are nonspecific but clinical correlation is suggested for possible chronic pulmonary disease Since previous tracing of [**2132-12-10**], ST-T wave changes decreased . XR Pelvis [**2132-12-12**]: There are old fractures identified of bilateral sacral ala, right medial acetabulum, right superior and inferior pubic rami. No new fractures are identified. . CT Abd/Pelvis [**12-13**]: 1. No evidence of psoas abscess, or process related to the patient's leg weakness. 2. Anasarca, with new small pleural effusions, small amount of fluid within the abdomen inferior to the liver, small amount in the pelvis, and subcutaneous edema. 3. Diffuse low attenuation of the liver has worsened since the prior exam, consistent with fatty infiltration. More advanced forms of liver disease are not excluded. 4. Air within the bladder. Please correlate with urinalysis. . MRI L-spine [**2132-12-15**]: Redemonstration of T12 compression deformity. Mottled appearance of the sacrum and iliac bones consistent with osteopenia. No acute abnormalities of the lumbar spine identified, including no sign of discitis or spinal stenosis. Questionable bladder dilatation. . EMG [**2132-12-17**]: Complex, abnormal study. There is electrophysiologic evidence for a moderate, generalized, sensorimotor, polyneuropathy with predominantly axonal features. There is also evidence for a mild generalized myopathic process without clear denervating features. The findings of polyneuropathy and myopathy preclude an accurate diagnosis of a superimposed right lumbosacral radiculopathy or plexopathy. In addition, a central process as a cause of the right leg weakness also cannot be excluded. . Echo [**2132-12-19**]: Compared with the findings of the prior report (images unavailable for review) of [**2132-12-11**], no change other than trivial AI now seen. . CXR lateral/decubitus [**2132-12-24**]: Bilateral layering effusions. . [**2132-11-25**] CT Abd/Pelvis/Chest: IMPRESSION: 1. Marked increase of bilateral pleural effusions with atelectasis and edema, as well as increased ascites. No evidence of abscess. 2. Increased subcutaneous edema throughout chest, abdomen, and pelvis. 3. Healing fractures and wedge-shaped compression fracture. 4. No specific wall thickening of the ascending colon, probably due to increased ascites; however, colitis such as C. difficile colitis cannot be totally excluded. Please correlate with the clinical findings and C. diff titer. . MRI C-spine [**2133-1-2**]: No evidence of extrinsic cord compression or intrinsic cord signal abnormalities. Cervical spondylosis as described above. . PICC Placement [**2133-1-2**]: Successful placement of a 44 cm, double lumen PICC line through left basilic vein with the tip in the superior vena cava. The line is ready to use. . EKG [**2133-1-6**]: Sinus rhythm. Low limb lead QRS voltage is non-specific. Diffuse T wave abnormalities with prolonged QTc interval - clinical correlation is suggested for possible metabolic/electrolyte/drug effect, possible ischemia or possible CNS event. Since the previous tracing of [**2133-1-4**] no significant change. . CT head [**2133-1-10**]: IMPRESSION: No significant interval change, or evidence of intracranial hemorrhage. . Upon Discharge: WBC 9.8, Hct 30, Plts 303 BUN/Cr 4/0.3 Na 141 K 3.8 Cl 103 HCO3 29 Brief Hospital Course: In summary, patient is a 62 y/o lady with h/o alcohol abuse, C.diff colitis, also s/p colectomy in [**4-8**] with small pelvic abscess, admitted on [**2132-12-10**] for placement after being found intoxicated in her apartment, found lying in her feces, unable to care for herself per family. On admission patient was found to have low blood pressures 80/40s in the ED, given NS ~3L with little improvement. On the floor the patient remained hypotensive with BP ranging 80-110s/40-60s. She triggered twice for hypotension but responded to fluid boluses. Patient remained asymptomatic throughout. Patient was also being worked up for proximal right leg weakness and the w/up was negative including pelvic CT scan and EMG. Patient also found to have a pansensitive Klebisella UTI and completed a course of Cipro x 7 days.Patient was also being evaluated by GI for chronic diarrhea. She was admitted on PO vanco for recurrent C.diff but was C.diff negative x 3 during this admission. As such, vanco was discontinued. GI was intending to do colonsocopy but this was deferred due to episodes of tachycardia and one episode of NSVT. EKGs showed low voltage but no other significant changes. Patient also had two echos done which showed normal EF, no pericardial effusions. In terms of her hypotension, she had a random cortisol level and stim that were wnl and therefore was not started on steroids. . On [**2132-12-20**] patient again became hypotensive to 80s/doppler which again responded to fluids. Patient later spiked a temperature of 102.4 and later desaturated to 83% on RA. INR was up to 3.4 and was previously normal. She was treated empirically with vanco, levo, and flagyl and transferred to MICU. . In MICU, patient was initially treated with Vanco, Zosyn, and Flagyl. CXR showed b/l pleural effusion. Patient remained stable w/out a clear source of infection. Zosyn was stopped on [**12-22**]. She is now transferred to the floor on po vanco/flagyl for presumed C.diff infection. . Upon transfer to the floor: Patient was transferred on 5 NC sating >95%. Patient later desated to low 80s and O2 increased to 6L, patient later weaned on 4L, now sating 97%. Patient also had 2 episodes of frankly blood stool. Hct dropped from 34->28. VSS. Patient treated with Zosyn and po vanco for presumed pneumonia and c.diff. Patient initially doing well, alert, no complaints. Later that evening patient went into what was thought to be V-tach with HR to 190s, patient continued to mentate, BP dropped to 70-80s/doppler. Loaded with IV Amiodarone with conversion to SR (HR 90s) and transferred to the MICU again. Cards/EP evaluation felt that this was V-tach as well but subsequently felt that this was SVT with aberrancy. Amio was d/ced and patient was put on beta blocker with good HR control. Patient was called out from ICU [**2132-12-23**]. [**12-23**] evening, patient had GIB w/crit drop from 34 to 28, spont increased AM [**12-25**] to 30 in AM and 32.5 at noon. The same evening, the patient was found to be SOB by RN then quickly converted to vtach @ 194 w/pressure 89/50 not substantially changed from floor baseline. Pt's mental status was good throughout episode. Pt spontaneously converted to sinus and was transferred to MICU briefly. Patient was treated empirically with steroids for oingoing low blood pressure. Thoracentesis was also perforemed which showed a transudative effusion. Patient was then diuresed with Lasix. Patient continued to be followed by cardiology, continued on beta blocker with good HR control. Patient continued treatment for C. difficile colitis with flagyl/vancomycin. Patient has remained stable over the last week maintaining good blood pressure, mentating well, diarrhea decreasing although still loose, afebrile, HR under good control. Her nutritional status is also improved and she is consuming a PO diet with supplementation. Her magnesium level remains low however she is receiving [**Month/Year (2) **] repletion. Would recommend long acting magnesium if able to get at the nursing home (this was not available through the hospital pharmacy). EKGs have been showing a prolonged QT interval. Patient was evaluated by Cardiology again who could not find an exact mechanisms. Flagyl was discontinued given a few reported cases of prolonged QT syndrome with this medication. All other medications do not produce prolonged QT. The best explanation is her persistently low magnesium which must be continuously repleted and improvement in her nutritional status. CT head was performed to r/out bleed. This was negative. Other testing was performed including anti-Ro/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 32545**] which are pending at the time of discharge. Patient was refusing all other testing at the time of discharged and requested to leave the hospital and go to the nursing home without further intervention. She will need close PCP follow up and possibly cardiology follow up as an outpatient. Patient's Hct is also slightly low however she is not GI bleeding and she is scheduled for GI follow up. Patient likely requires a colonoscopy in the near future. Her lab studies are consistent with anemia of chronic disease. Patient was guiac negative on discharge. Hct stable at 30. . In terms of her individual problems: . # Sepsis. Likely secondary to chronic C.diff, found to be positive for toxin B on [**12-20**], diarrhea improving, still on po vanco and flagyl to continue until GI follow up. WBC down to wnl. Afebrile. . # SVT with Aberrancy/Prolonged QT on EKG. On Metoprolol 37.5mg [**Hospital1 **]. No further episodes. HR well controlled. Continue beta blocker at current dose. Likely will need cardiology follow up in future to be arranged by PCP. [**Name10 (NameIs) **] electrolyte repletion required for prolonged QT. . # Chronic diarrhea. Secondary to C.diff, toxin B positive. On antibiotic treatment as above. Continue PPI. . # Hypotension: Secondary to intravascular volume depletion [**2-5**] to diarrhea, poor po intake, hypoalbuminemia. Currently stable with ongoing treatment of underlying infection. Patient received a tapering dose of steroids completed on [**2133-1-11**]. . # Anasarca: unclear etiology, likely in part due to very poor nutritional status, long hx of etoh abuse, hypoalbuminemia. Tolerating diuresis with stable BP. Upon discharge her LE edema was completely resolved, lung clear to auscultation which was significantly improved. She is discharged on 20 mg of lasix daily. Continue lasix as blood pressure tolerates along with daily weights. Patient scheduled for PCP follow up, chemistries should be repeated in two days and results sent to PCP or physician at rehab. Continue fluid restriction 1500ml. . # Anemia: Macrocytic anemia [**2-5**] etoh as well as anemia of chronic disease based on iron studies, elevated B12, nl folate; hemolysis labs negative; patient received total 5 units since admission. Also with 2 x blood diarrhea, now resolved, Hct low but stable. Repeat CBC in two days. GI follow scheduled. . # ETOH abuse. No evidence of withdrawal, did not require benzodiazepines by CIWA while in hospital. Cont thiamine, MVI, magnesium supplementation. Needs intensive rehabilitation. . # Leg weakness - peripheral neuropathy, most likely alcohol induced. MRI c-spine also performed given hyperreflexia - showing cervical spondylosis, no cord involvement. Extensive w/up has been negative to date. Requires intensive rehab, possibly neurology follow up in future. . # Nutrition. Very poor po intake, nutrition followed while in house, currently on regular diet with boost. Patient had NG tube temporarily, now taking good POs. BUN slightly improved from admission. Please encourage po intake, frequent meals, boost as tolerated. Continue vitamin supplementation. . # Communication - brother [**Name (NI) **] [**Name (NI) 56378**] [**Telephone/Fax (1) 110824**]; sister [**Name (NI) 9485**] [**Name (NI) 110825**] . Code: Full Medications on Admission: Medication on Admission: vancomycin po Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 2. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO QID (4 times a day): Ongoing until patient follows up with Gastroenterology. 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): Hold for SBP <100, HR <55. 9. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 10. Therapeutic Multivitamin Liquid Sig: One (1) PO qd (). 11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO three times a day: If available please give long acting magnesium SR or magnesium lactate for prolonged effect. Tablet(s) 14. Outpatient Lab Work Please check CBC and Chem 13 including Magnesium level on [**2132-1-14**] and provide results to physician on staff or alternatively fax to Dr. [**Last Name (STitle) **] at [**Hospital6 733**] Te: ([**Telephone/Fax (1) 1300**] Fax: ([**Telephone/Fax (1) 8137**] 15. General Care Please do daily weights and provide results along with above laboratory data 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1. C.difficile colitis 2. Alcohol abuse 3. Supraventricular Tachycardia with Rapid Ventricular Rate 4. Lower extremity polyneuropathy/myopathy of unclear etiology Discharge Condition: Good - diarrhea significantly improved, blood pressure stable, afebrile, no evidence of alcohol withdrawl Discharge Instructions: Please take all of your medications as directed Please follow up as listed below Please contact your physician or return to the hospital if you have any fever, worsening diarrhea, headache/dizziness, chest discomfort, or any other complaints Followup Instructions: 1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11183**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2133-1-21**] 1:30 . 2. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2133-1-27**] 1:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2133-1-11**]

[ "995.92", "794.31", "285.29", "427.89", "458.9", "359.9", "578.9", "038.9", "038.3", "355.8", "486", "255.4", "788.5", "008.45", "511.9", "782.3", "263.9", "599.0", "303.01" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.6", "34.91", "38.93", "94.62", "99.07" ]

icd9pcs

[ [ [] ] ]

20795, 20865

11003, 18953

302, 327

21072, 21180

3152, 3152

21472, 21946

2451, 2559

19042, 20772

20886, 21051

18979, 18990

21204, 21449

2574, 3133

242, 264

10911, 10980

355, 1368

19004, 19019

1390, 2124

2140, 2435

47,654

129,382

42161

Discharge summary

report

Admission Date: [**2134-3-17**] Discharge Date: [**2134-3-21**] Date of Birth: [**2047-3-10**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Lipitor / Bee Pollen Attending:[**First Name3 (LF) 922**] Chief Complaint: worsening SOB with activity Major Surgical or Invasive Procedure: -Redo sternotomy. -First-time aortic valve replacement with a 27 mm [**Company 1543**] Mosaic Ultra aortic valve bioprosthesis. Valve data is the following: model number 305, serial number [**Serial Number 91436**]. History of Present Illness: Patient is an 86 yo male with h/o CAD s/p CABGx3, diabetes, obstructive sleep apnea, parkinsons and known aortic stenosis who presented with c/o's of worsening dypsnea on exertion, fatigue and a presyncopal episode. He was evaluated for options at [**Hospital1 2025**], was found to be of high surgical risk, and aortic annulus too large for TAVI options available there. He underwent BAV ([**2133-9-23**]) with some improvement and was referred for further aortic valve treatment options. He was evaluated including a neurology consult to examine his Parkinson's disease severity which was determined not to be prohibitive for surgical AVR. He enrolled in the Corevalve TAVI study and was excluded due to large annular size. Since that time, a larger Corevalve device (31mm) has been introduced. Past Medical History: Severe aortic stenosis - s/p BAV ([**2133-9-23**]) CAD s/p CABG x 3 ([**2127**]) hypertension hyperlipidemia diabetes mellitus obstructive sleep apnea (CPAP) Parkinson's disease with [**Last Name (un) 309**] body dementia PPM secondary to SSS - [**Company **] model#P1501DR diabetic retinopathy (s/p laser treatment) peripheral neuropathy - feet bladder and kidney stones bilateral cataract surgery lumbar spine surgery s/p fall hematuria depression gout erectile dysfunction BPH bilateral cataract surgery right abdomen lipoma removal tonsillectomy Social History: Retired clinical psychologist ([**Hospital1 1474**] school system). Four stairs to enter ranch style house. Family History: father and brothers, mother deceased age 39, cancer. Lives with wife. [**Name (NI) **] 4 adult children. Physical Exam: Height: 67 inches Weight: 170 lbs General: Quiet pleasant male sitting in chair in NAD. Skin: Turgor fair, well healed surgical scars chest and legs, color pale tan, no lesions noted. HEENT: normocephalic, anicteric, good dentition, oropharynx moist. Neck: neck supple, trachea midline, bilat bruits vs. murmer Chest: well healed sternal incision, mild kyphosis Heart: murmer throughout Abdomen: soft, nontender, nondistended, (+)BS Extremities: no edema, no obvious deformities. Neuro: Flat affect, unsteady gait, slight shuffling, gross FROM Pulses: palpable distal pulses Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 91437**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91438**] (Congenital) Done [**2134-3-17**] at 11:11:41 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2047-3-10**] Age (years): 87 M Hgt (in): 67 BP (mm Hg): 132/61 Wgt (lb): 172 HR (bpm): 60 BSA (m2): 1.90 m2 Indication: Aortic valve disease. Coronary artery disease. H/O cardiac surgery. Left ventricular function. Preoperative assessment. Shortness of breath. ICD-9 Codes: 424.1, 424.0, 746.9 Test Information Date/Time: [**2134-3-17**] at 11:11 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD Test Type: TEE (Congenital) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW-1: Machine: p2 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.8 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Left Ventricle - Stroke Volume: 52 ml/beat Left Ventricle - Cardiac Output: 3.12 L/min Left Ventricle - Cardiac Index: *1.64 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 8 < 15 Aorta - Annulus: 3.0 cm <= 3.0 cm Aorta - Sinus Level: 3.6 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm Aorta - Ascending: *3.6 cm <= 3.4 cm Aorta - Arch: 2.9 cm <= 3.0 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Aortic Valve - Peak Velocity: *3.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *52 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 31 mm Hg Aortic Valve - LVOT pk vel: 0.60 m/sec Aortic Valve - LVOT VTI: 15 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A ratio: 1.17 Findings LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Normal regional LV systolic function. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Mild PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Written informed consent was obtained from the patient. The patient was under general anesthesia throughout the procedure. No TEE related complications. The rhythm appears to be A-V paced. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data Conclusions PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at time of surgery. POST-CPB:: The patient is AV paced. The patient is on epinephrine, norepinephrine, and vasopressin infusions. Biventricular function is unchanged. There is a well-seated, well-positioned bioprosthetic valve in the aortic position. Trace central AI is seen. There is a mean gradient of 11 mmHg at a cardiac output of 3.7 L/min. Mitral regurgitation is unchanged. The aorta is intact post-decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2134-3-17**] 16:45 [**2134-3-20**] 04:15AM BLOOD WBC-8.0 RBC-3.12* Hgb-9.9* Hct-28.6* MCV-92 MCH-31.7 MCHC-34.6 RDW-14.7 Plt Ct-103* [**2134-3-20**] 04:15AM BLOOD Glucose-89 UreaN-34* Creat-1.5* Na-141 K-3.8 Cl-104 HCO3-30 AnGap-11 Brief Hospital Course: Mr. [**Known lastname **] is an 87 year old male with a complex past medical history including balloon aortic valvuloplasty in [**2133-9-14**], coronary artery bypass grafting times three in [**2127**] who presented with worsening dyspnea on exertion, fatigue and a presyncopal episode. On [**2134-3-17**] he was brought to the operating room where he underwent aortic valve replacement with #27mm tissue valve. Please see the operative note for further details. He arrived from the operating room in stable condition, vented on Vaso/Epi/Levo. He was seen by the electrophysiology service to reprogram his internal pacer (placed for sick sinus syndrome). He extubated without difficulty and pressors were weaned off. Immediately post-operatively he was hypotensive and required blood and pacing, to which he responded. He was initially very sleepy, but he has a history of parkinsons with [**Last Name (un) 309**] body dementia. He continued to progress and was transferred to the step down floor on POD#2. Pacing wires and chest tubes were removed without difficulty. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post-operative day four the patient was ambulating with assistance. His sternal wound was healing and pain was controlled with oral analgesics. The patient was discharged to Presidential Oaks in [**Location (un) 1514**] [**Location (un) 3844**] in good condition with appropriate follow up instructions. Medications on Admission: Active Medication list as of [**2134-3-7**]: Medications - Prescription ALLOPURINOL - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth once a day ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth twice a day CARBIDOPA-LEVODOPA-ENTACAPONE [STALEVO 150] - (Prescribed by Other Provider) - 37.5 mg-150 mg-200 mg Tablet - 1 Tablet(s) by mouth four times a day CLINDAMYCIN HCL - (Prescribed by Other Provider) - 150 mg Capsule - 4 Capsule(s) by mouth 1 hr prior to dental ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 5 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day GLIPIZIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth 2x/day OLOPATADINE [PATADAY] - (Prescribed by Other Provider) - 0.2 % Drops - 1 gtt in each eye as needed for prn RIVASTIGMINE [EXELON] - (Prescribed by Other Provider) - 4.6 mg/24 hour Patch 24 hr - 1 patch once a day SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day TAMSULOSIN [FLOMAX] - (Prescribed by Other Provider) - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2* 5. rivastigmine 4.6 mg/24 hour Patch 24 hr Sig: One (1) Transdermal daily (). Disp:*30 * Refills:*2* 6. entacapone 200 mg Tablet Sig: One (1) Tablet PO qid (). Disp:*120 Tablet(s)* Refills:*2* 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. carbidopa-levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). Disp:*240 Tablet(s)* Refills:*2* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 11. insulin lispro 100 unit/mL Solution Sig: sliding scale units Subcutaneous ASDIR (AS DIRECTED). Disp:*qs * Refills:*2* 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. olopatadine 0.2 % Drops Sig: One (1) gtt Ophthalmic twice a day as needed for dry eyes. Disp:*qs * Refills:*0* 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*2* 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Tablet Extended Release(s)* Refills:*2* 16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 17. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: 1. Severe critical aortic stenosis. 2. Coronary artery disease status post previous coronary artery bypass grafting. Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics 1+ lower extremity 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: RECOMMENDED FOLLOW-UP: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] [**2134-4-19**] at 2:30pm [**Hospital Ward Name **], [**Hospital Unit Name **] Primary Care Dr.[**Last Name (STitle) 91439**] [**Name (STitle) 91440**], MD ([**Location (un) 1514**] NH)in [**2-15**] weeks Cardiologist Dr.[**Last Name (STitle) **] in [**2-15**] weeks Please call cardiac surgery if need arises for evaluation or readmission to hospital [**Telephone/Fax (1) 170**] Completed by:[**2134-3-21**]

[ "331.82", "424.1", "600.00", "362.01", "294.10", "274.9", "V45.01", "327.23", "356.9", "458.29", "285.1", "250.50", "414.00", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "89.45", "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

13641, 13671

8606, 10206

328, 558

13836, 13960

2817, 8583

14584, 15125

2100, 2206

11647, 13618

13692, 13815

10232, 11624

13984, 14561

2221, 2798

261, 290

586, 1384

1406, 1958

1974, 2084

1,586

192,146

54267+59591

Discharge summary

report+addendum

Admission Date: [**2184-7-5**] Discharge Date: [**2184-7-14**] Date of Birth: [**2109-11-1**] Sex: M Service: [**Hospital1 212**] PRESENTING ILLNESS: Left hip subcapital fracture. PHYSICAL EXAMINATION: Vital signs: Temperature 97.7, blood pressure 130/70, pulse 63, respirations 20, and 97% on room air. General: Awake, alert, lucid, and conversational. HEENT: Oropharynx clear. Sclerae are clear. Extraocular movements are intact. Cardiovascular: Regular, rate, and rhythm, however, heart sounds distant due to body habitus. Jugular venous distention hard to ascertain due to body habitus. Positive capillary refill less than two seconds bilaterally in the upper extremities. Strong pedal pulses bilateral. Respiratory: Clear to auscultation bilaterally. Abdomen: Bowel sounds positive, soft, and nontender to palpation. Extremities: Trace edema bilaterally. Left knee appeared mildly erythematous, warmth, but nontender to palpation. Left hip: Dressing in place, no acute discharge. Areas of ecchymosis surround the surgical site. LABORATORIES: White blood cells 11.6, H&H 10.6/32.2, platelets 196. Sodium 137, potassium 3.8, chloride 101, bicarb 26, BUN 26, creatinine 0.9, glucose 138, calcium 9.0, magnesium 1.8, phosphorus 3.0. IMAGING: Echocardiogram done on [**2184-7-6**] which showed ejection fraction of less than 25%, mild mitral regurgitation and dilation of left atrium, left ventricle, and aortic root. CULTURES: Sputum culture showed rare gram-negative rods and rate Staphylococcus aureus. Sensitivities were not done. CHEST X-RAY: Negative for pneumonia or any other acute changes. HOSPITAL COURSE: Patient with past medical history significant for coronary artery disease with CABG x5 vessels in [**2168**], hypertension, and intracardiac defibrillator placed in [**2183-9-16**] presented to outside hospital status post mechanical fall on [**2184-7-1**]. X-rays show left subcapital fracture. Review of systems is otherwise negative. Patient was transferred to the [**Hospital3 55759**] Center per family's wishes after cardiac etiology for fall, was ruled out on [**2184-7-5**]. Patient underwent surgical resection and left hip hemiarthroplasty on [**7-7**]. Postoperative the patient remained intubated in consideration of numerous comorbidities and was admitted to the CCU. In the CCU, the patient required pressors for blood pressure support on postoperative day #1, that was subsequently weaned off on postoperative day #2. The patient was also started on levofloxacin IV for likely aspiration pneumonia. A more thorough course of Intensive Care Unit course will be dictated by the Intensive Care Unit team. Patient quickly weaned of pressors, extubated on [**2184-7-10**]. Patient saturated well on 2 liters nasal cannula, and was quickly weaned to room air. At time of transfer, the patient denied chest pain, shortness of breath, nausea, vomiting, dizziness, fevers, chills, but complained of pain at the left knee and left hip surgical site. Patient was transferred to Medicine in stable condition. Patient's course on Medicine was unremarkable. Patient is awaiting placement on discharge. Discharged to rehab center in stable condition. DISCHARGE MEDICATIONS: 1. Simvastatin 40 mg po q day. 2. Lovenox 30 mg subQ q12h. 3. Albuterol prn. 4. Aspirin 325 mg q day. 5. Levofloxacin 500 mg tablets po q day. 6. Hydrochlorothiazide 50 mg po bid. 7. Lisinopril 10 mg q day. 8. Toprol XL 100 mg tablets q day. FOLLOW-UP PLANS: With primary care physician as well as Dr. [**First Name (STitle) 1022**], patient's orthopedic surgeon to be scheduled by patient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 21646**] MEDQUIST36 D: [**2184-7-13**] 09:10 T: [**2184-7-13**] 09:09 JOB#: [**Job Number 111185**] Name: [**Known lastname 3205**], [**Known firstname 389**] Unit No: [**Numeric Identifier 18248**] Admission Date: [**2157-2-14**] Discharge Date: [**2157-2-14**] Date of Birth: Sex: M Service: ADDENDUM: The patient's discharge weight is 256.9 pounds. The patient's weight and I and O should be strictly monitored. The patient should have an initial output positive by 500 cc. The patient is discharged in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**] Dictated By:[**Last Name (NamePattern1) 6818**] MEDQUIST36 D: [**2184-7-14**] 09:46 T: [**2184-7-14**] 13:43 JOB#: [**Job Number 18249**]

[ "401.9", "820.8", "414.01", "E880.1", "276.5", "250.01", "V45.81", "272.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "81.52" ]

icd9pcs

[ [ [] ] ]

3260, 3503

1670, 3237

226, 1652

3521, 4691

55,867

195,689

43161

Discharge summary

report

Admission Date: [**2105-7-14**] Discharge Date: [**2105-7-21**] Date of Birth: [**2041-2-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 783**] Chief Complaint: Weakness, slurred speech, increased frequency of urination Major Surgical or Invasive Procedure: Foley catheter placed History of Present Illness: Pt is a 64 y/o African American gentleman who has a past medical history significant for DMII (most recent HbA1c:11.8 on [**2105-3-28**]), HTN, and BPH who initially presented with dysarthria, weakness and change in bladder habits. Pt was in his normal state of health until about a week ago when he began to notice an increase in the number of times he had to urinate. Although he has nocturia at baseline (usually wakes 3-4 times per week to use the bathroom at night), he began to use the bathroom during the day with increasing frequency, every 15-20 minutes. He found that he was urinating only a very small amount, "several drops" each time and felt like he had not completely emptied his bladder. Then, on [**2105-7-14**], the patient woke up and felt generally weak. He noticed his speech was slurred and his legs felt unsteady when getting up from bed. The weakness came on all of a sudden and he felt a cramping fatigue worst in his calves. He had no trouble understanding others or finding words, but noticed his pronunciation of words was impaired. In addition, he also felt intermittently very cold and then very hot. When his partner arrived home, she too immediately noticed the changes in his speech and brought him to the ED at [**Hospital3 **]. At [**Hospital1 **] initial VS were: 98.2 72 156/82 14 98% on RA. He was observed to have altered mental status, raising suspicion for possible TIA or stroke. Head CT was normal. Lab work was notable for Cr 10.4, K 8.4. He received 2 grams Ca-gluconate, 10 units of insulin and D50, sodium bicarbonate, and 15 mg PO Kayakelate. He was found to be in acute renal failure with hyperkalemia, with EKG changes notable for peaked T waves. Suspecting the need for emergent dialysis he was transferred to [**Hospital1 18**]. Pt arrived to the MICU at [**Hospital1 18**] where he was alert and oriented x3 At [**Hospital1 18**], he presented with SBPS to 190. Electrolyte abnormalities not improved. EKG with persistently peaked t waves. He was transfered to the MICU and treated medically without need for hemodialysis. Foley was placed with over 500cc relieved. DRE showed prostate enlargement, symmetric in nature. In the MICU serial ekg's normalized. He proceeded to have brisk urine output. Potassium normalized and Cr trending downward. He has had chronic knee pain for which he takes acetaminophen; he also takes a nightly ibuprofen-containing sleep aid for insomnia. Past Medical History: -Hyperlipidemia -Hypertension: Stress ECHO ([**2105-7-1**]) with normal LV wall [**Last Name (LF) 93024**], [**First Name3 (LF) **]=60%, no LVH, normal stress response -Non-insulin dependent DM II: HbA1c=11.8 ([**2105-3-28**]) Social History: Pt is a bus driver for children with special needs. He lives alone, but has a partner with whom he is very close. He has three grown children and three grandchildren. He denies a history of tobacco or cigarette use. He drinks socially, [**3-22**] times per week; 6 shots of vodka/week. He denies any history of illicit drug use. Family History: Father: killed in [**Country 10181**] Mother: died of kidney failure in her early 60s Children in good health Physical Exam: ADMISSION PHYSICAL EXAM: VITAL SIGNS: 98.3 159/84 66 100%RA FS 134 GEN: Pt is an African American gentleman, who is alert and orientedx3 with fluent and linear thinking. He does not appear to be in any immediate distress or discomfort HEENT: Neck is supple with full ROM, no evidence of lymphadenopathy, sclera are anicteric, MMM, OP clear, no observed JVP PULM: Lungs are clear to auscultation bilaterally CV: II/VI midsystolic blowing murmur loudest at the heart base, rate was at times regular and during shorter periods entered episdoes of an irregularly irregular rhythm, no rubs or gallops appreciated, PMI was not displaced ABD: obese, soft, hypoactive bowel sounds, nontender to palpation, no masses palpated, no heptosplenomegaly GU: foley catheter in place, draining without obstruction EXT: distal pulses intact, warm and well perfused, 1+ pitting edema of lower legs bilaterally that per patient report has been there for the past 6 months SKIN: no ulcers or lesions appreciated, legs are slightly lighter in color than thigh with less hair growth NEURO: CN 2-12 grossly intact, sensation intact throughout, strength 5/5 throughout DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 98.0 154/98 (Systolic range: 165-136) 62 18 99%RA FS 136; Max FS of 189 @1200 I/Os: I: No IV fluids, O: 3520 (24 hr total) GEN: alert and orientedx3 with fluent and linear thinking. Not in any immediate distress or discomfort HEENT: Neck is supple with full ROM, no evidence of lymphadenopathy, sclera are anicteric, MMM, OP clear, no observed JVP PULM: Lungs are clear to auscultation bilaterally CV: Frequent premature beats, II/VI systolic blowing murmur loudest at the heart base without radiation, no rubs or gallops appreciated, PMI was not displaced ABD: obese, soft, hypoactive bowel sounds, nontender to palpation, no masses palpated, no heptosplenomegaly GU: foley catheter in place, draining without obstruction, urine is clear, light yellow in color EXT: distal pulses intact, warm and well perfused, trace pitting edema of lower legs bilaterally that is improved from 2 days prior. Right forearm is less swollen and nontender to palpation. SKIN: no ulcers or lesions appreciated, legs are slightly lighter in color than thigh with less hair growth NEURO: CN 2-12 grossly intact, sensation intact throughout, strength 5/5 throughout Pertinent Results: ADMISSION LABS: [**2105-7-14**] 10:49PM GLUCOSE-69* NA+-135 K+-7.9* CL--105 [**2105-7-14**] 10:40PM GLUCOSE-75 UREA N-78* CREAT-10.2* SODIUM-133 POTASSIUM-8.0* CHLORIDE-103 TOTAL CO2-19* ANION GAP-19 [**2105-7-14**] 10:40PM estGFR-Using this [**2105-7-14**] 10:40PM CK(CPK)-73 [**2105-7-14**] 10:40PM CALCIUM-9.8 PHOSPHATE-4.9* MAGNESIUM-2.6 [**2105-7-14**] 10:40PM WBC-9.2 RBC-3.97* HGB-13.0* HCT-39.4* MCV-99* MCH-32.7* MCHC-33.0 RDW-13.7 [**2105-7-14**] 10:40PM NEUTS-67.2 LYMPHS-19.0 MONOS-9.6 EOS-3.8 BASOS-0.4 [**2105-7-14**] 10:40PM PLT COUNT-494* [**Hospital3 984**]: [**2105-7-18**] 06:30AM BLOOD C3-157 C4-40 [**2105-7-18**] 06:30AM BLOOD HIV Ab-NEGATIVE DISCHARGE LABS: [**2105-7-21**] 06:00AM BLOOD WBC-4.8 RBC-3.31* Hgb-11.1* Hct-32.7* MCV-99* MCH-33.5* MCHC-33.9 RDW-13.2 Plt Ct-307 [**2105-7-21**] 06:00AM BLOOD Glucose-127* UreaN-69* Creat-5.7* Na-137 K-4.6 Cl-104 HCO3-21* AnGap-17 [**2105-7-21**] 06:00AM BLOOD Calcium-9.5 Phos-5.2* Mg-2.0 URINE: [**2105-7-15**] 01:17AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2105-7-15**] 01:17AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2105-7-15**] 01:17AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 [**2105-7-17**] 05:36AM URINE Eos-NEGATIVE [**2105-7-17**] 03:56PM URINE U-PEP-NEGATIVE EKGS: [**Hospital1 **] ECG sinus 68 PR 212, QRS 102 Qtc 402, +peaked Ts [**Hospital1 18**] ECG sinus @ 68, with peaked T waves. [**2105-7-14**] 10:36:10 PM Sinus rhythm. Within normal limits. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 68 148 94 376/390 25 -3 7 EKG: [**2105-7-16**] 6:21:52 PM Sinus rhythm. Atrial and ventricular ectopy. Compared to the previous tracing of the same date, there is no significant change. Rate PR QRS QT/QTc P QRS T 70 148 84 398/415 13 -2 3 Imaging Studies Renal Ultrasound ([**2105-7-15**]) 1. No hydronephrosis. Bilateral tiny simple renal cysts noted. 2. Incidentally noted, the liver is diffusely echogenic, consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. Brief Hospital Course: 64 y/o African American male with a PMH of DMII and HTN who presented with generalized weakness, altered mental status, slurred speech and increased frequency of small amounts of urination. He was found to be in acute renal failure at an OSH and transferred here to [**Hospital1 18**] for possible hemodialysis. He was stabilized medically in the ICU until [**7-16**] when his care was transitioned to the general medicine service. **ACUTE ISSUES** # Acute Renal Failure: He presented in acute renal failure with creatinine of 10.4 (baseline 0.9), hyperkalemia, and EKG changes. His ARF was largely attributed to obstruction as he was retaining over 500cc urine and found to have large symmetric prostate on DRE. However, no hydronephrosis seen on ultrasound. Additionally, he was also on a number of potentially nephrotoxigenic medications causing ATN, including lisinopril, NSAIDs, and potassium citrate. He was initially medically managed in the ICU IVF, lasix, bicarb with good effect. Renal function gradually improved over several days following catheter placement, fluid support, and discontinuation of nephrotoxigenic drugs. He was discharged with a Cr of 5.7, and not restarted on his nephrotoxic meds. He will be followed by renal as an outpatient. Furthermore, he was started on Tamsulosin for his BPH. His foley remained in place to allow [**5-26**] day bladder rest before urology will try voiding trial as an outpatient in the next few days. #Hyperkalemia: He was found to have an elevated K 8 with associated peaked T waves. Potassium levels dropped with administration of kayexalate, insulin, and bicarbonate. Serial EKGS also showed resolution of peaked T waves. #DM II: Prior to this admission, he was only taking oral hypoglycemics. However, these were discontinued in light of his ARF. His blood sugars were managed on sliding scale insulin. Since he required Humalog 5-7 units for the last 3 days of hospitalization, he was sent home on Lantus 2units QHS with lispro sliding scale coverage. He will be followed by his PCP in the next 2-3 days for follow-up of this new diabetes regimen. He was also provided with an educational counseling session regarding home insulin. His oral hypoglycemics were held, with the goal of transitioning back to agents after renal approval and Cr normalization. #BPH: As above, his BPH contributed to urinary obstruction and ARF. DRE revealed symmetric enlargement of prostate. Previous biopsy was benign. Was started on Tamsulosin this admission. Urology will follow in clinic for void trial. **CHRONIC ISSUES** # Hypertension: He was found to be hypertensive to SBP 180s during the admission as his ACE-I was held in light of his ARF. After transfer to the floor, he was continued on his Amlodipine 5mg and Metoprolol succinate 100 daily. Quinapril discontinued indefinitely. Tamsulosin added for BPH. # Hyperlipidemia: Stable, continued his home statin. **TRANSITIONAL ISSUES** -Urology outpatient follow up: The patient will be called by urology for an appointment this week. Until then, foley will remain in place and he will be visited by VNA for foley-related care. -Renal outpatient follow up to readdress kidney function and possibility of restoring prior home meds: quinapril, metformin, glipizide -PCP follow up in the next couple days to follow up glucose control on newly started insulin regimen and antihypertensive regimen, and side effects to newly started Tamsulosin. Also should repeat chem 7 to follow up K and Cr. -Following meds should not be restarted until clearance from renal: quinipril, metformin, glipizide, NSAIDS, KCL -Full Code Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Aspirin 162 mg PO DAILY 2. Metoprolol Succinate XL 100 mg PO DAILY 3. Ezetimibe 10 mg PO DAILY 4. Quinapril 20 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID 6. potassium citrate *NF* 2 tablets Oral Daily 7. Rosuvastatin Calcium 20 mg PO DAILY 8. GlipiZIDE XL 10 mg PO BID 9. Amlodipine 5 mg PO DAILY Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Rosuvastatin Calcium 20 mg PO DAILY 3. Aspirin 162 mg PO DAILY 4. Metoprolol Succinate XL 100 mg PO DAILY 5. Tamsulosin 0.4 mg PO HS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*1 6. Acetaminophen 325-650 mg PO Q6H:PRN pain RX *acetaminophen 500 mg 1 tablet(s) by mouth q6 hour Disp #*40 Tablet Refills:*0 7. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 8. Ezetimibe 10 mg PO DAILY 9. HumaLOG KwikPen *NF* (insulin lispro) 100 unit/mL Subcutaneous qam ac RX *insulin lispro [Humalog KwikPen] 100 unit/mL Inject 0-9 units per sliding scale before meals Disp #*2 Unit Refills:*1 10. Glargine 2 units SQ qhs Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Acute Renal Failure Hyperkalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Dr. [**Known lastname 174**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 69**]. You were hospitalized because of changes in mental status, decreased urine output, generalized weakness, and decreased functioning of your kidney. Your kidney injury was most likely caused by an obstruction of the bladder as a result of your large prostate. You were treated with IV fluid resuscitation, that you tolerated well. A foley catheter was also placed to bypass the bladder obstruction caused by the enlarged prostate. The catheter will remain in place until you follow up with the urology doctors. You will receive more information about the details of this appointment in the next couple of days. At the time of the appointment they will provide you with further instructions concerning the catheter and management of your large prostate. You were also started on Tamsulosin, a medication that will help to reduce the size of your prostate. Overall, your kidney function improved greatly with these interventions. Over the next several weeks it is very important that you stay well hydrated and drink lots of fluids. If you notice an increase in pain around the catheter, pain with urination, change in urine color, or fever please contact your PCP or return to the Emergency Room. We have arranged several follow-up appointments for you regarding your kidney function and enlarged prostate. These are listed below. We have made changes to your medications which are described below. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: MONDAY [**2105-7-27**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] W. Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] Appt: [**7-28**] at 1:15pm Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2105-8-5**] at 1:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2105-7-21**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13075, 13133

8201, 11184

362, 386

13210, 13210

5947, 5947

14908, 16026

3471, 3583

12303, 13052

13154, 13189

11871, 12280

13361, 14885

6646, 8178

3623, 4743

11195, 11845

264, 324

414, 2857

5963, 6630

13225, 13337

2879, 3108

3124, 3455

4768, 5928

16,846

134,500

10813

Discharge summary

report

Admission Date: [**2188-10-6**] Discharge Date: [**2188-10-24**] Date of Birth: [**2134-9-11**] Sex: M CHIEF COMPLAINT: Subarachnoid hemorrhage. HISTORY OF PRESENT ILLNESS: 54-year-old male transferred from [**Hospital6 8283**] with subarachnoid hemorrhage, headache was of sudden onset above the right eye, beginning last night. He had never had a headache like this before. There was no history of vomiting, no fevers or chills, no history of trauma or falls. The blood pressure was 220/100 and he received 20 mg of Labetalol, 1 gm of Dilantin and was started on a sodium Nitroprusside infusion for blood pressure control. The patient gave no history of loss of PAST MEDICAL HISTORY: Nephritis at the age of 18, hypertension, alcoholic. According to wife, takes 7 drinks per day. The patient is a smoker. ALLERGIES: No known drug allergies. MEDICATIONS: Takes Enalapril and Toprol at home. PHYSICAL EXAMINATION: Patient is alert and oriented times three. Heart rate 83, blood pressure 168/96, respirations 24, oxygen saturation on room air 95. Pupils equal and reactive to light, extraocular movements intact. Chest clear to auscultation bilaterally. Cardiac, S1 and S2 normal, regular rate and rhythm. Abdomen soft, nontender, non distended, bowel sounds present. Extremities warm, no edema. Neuro examination, cranial nerves II through XII intact, motor left upper extremity [**6-14**], left lower extremity [**5-15**] throughout. Right upper extremity [**6-14**], right lower extremity [**6-14**] throughout. Babinski bilaterally downgoing. LABORATORY DATA: White blood cells 9.0, hemoglobin 15.1, hematocrit 44, platelet count 232,000, sodium 139, potassium 4.3, chloride 102, CO2 23, BUN 16, creatinine 0.8, blood sugar 115. PT 12.2, PTT 29.6, INR 1.03, calcium 9.7. EKG, normal sinus rhythm at 70, normal axis, [**5-16**] ST downgoing, biphasic T waves in V5 and V6. CT of the head showed large hematoma in the region of the corpus callosum with subarachnoid blood in the anterior hemispheric fissure and adjacent sulci. AVM of the right posterior frontal region with communication to the right lateral ventricle and deep venous system. Aneurysm of the anterior communicating artery. Subparietal hematoma with flattening of the corpus callosum and lateral ventricles. HOSPITAL COURSE: The patient was admitted to the hospital on [**2188-10-6**]. Blood pressure was controlled with sodium Nitroprusside drip. The patient underwent coiling of the aneurysm on [**2188-10-6**] without any complication. The patient was then transferred to the SICU with a goal to maintain systolic blood pressures between 150-180 with large volumes of IV fluids, albumin and vasopressors. Repeated transcranial dopplers were done to ascertain the intracranial blood flow and to check for vasospasm. The postoperative period remained uneventful and the patient was transferred to the floor after stay of 15 days in the ICU. The patient was neurologically stable and doing well. DISCHARGE DIAGNOSIS: 1. Subarachnoid hemorrhage secondary to ACOM aneurysm treated with endovascular coiling and untreated incidental posterior frontal AVM. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Doctor Last Name 35285**] MEDQUIST36 D: [**2188-10-24**] 10:58 T: [**2188-10-24**] 12:13 JOB#: [**Job Number 35286**]

[ "305.1", "430", "401.9", "782.1", "342.92", "303.91", "535.30", "998.12" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.29", "88.41", "38.93" ]

icd9pcs

[ [ [] ] ]

3044, 3182

2345, 3023

949, 2327

140, 166

195, 690

713, 926

3207, 3510

10,049

197,815

6477+55760

Discharge summary

report+addendum

Admission Date: [**2160-2-6**] Discharge Date: [**2160-2-16**] Date of Birth: [**2097-5-25**] Sex: M Service: MEDICINE Allergies: Crestor Attending:[**First Name3 (LF) 458**] Chief Complaint: exertional chest pain Major Surgical or Invasive Procedure: Cardiac catheterization twice intra-aortic balloon bump History of Present Illness: Pt is a 62 yo man w/ PMH CRI, CAD s/p CABG and multiple PCIs, who p/w exertional CP, equivalent to his anginal sxs, + stress ECHO. At OSH, pt underwent cardiac catheterization [**2160-2-6**] where during injection of dye into native vessels, experienced [**9-5**] CP and severe HTN, relieved with nitro and IV lopressor. Demonstrated SVG to OM with 80% stenosis. ISR and an 80% distal stenosis along with 2 other lesions w/in the graft, patent LIMA, occluded SVG to [**Month/Year (2) **], patent SVG to PDA w/ moderate disease. He reports recent increase in his anginal symptoms including DOE and chest pressure (mostly with activity, but occasionally at rest). Denies SOB, orthopnea, edema, palpitations, n/v. He was sent to [**Hospital1 18**] for PCI. Cath showed all the grafts occluded except LVG to RCA. SVG to OM had minimal flow. Attempted intervention c/b perferation with embolization. A coated stent was placed but the vessel was thrombosed. He was then transferred to the CCU with an acute lateral MI. IABP was placed for support. Currently, patient describes 2/10 chest pain, no SOB, no palpitations, no n/v or fevers, chills or diaphoresis. Past Medical History: htn hypercholesterolemia gerd cad- s/p cabg, stents, 3 vessel disease chronic renal insufficiency s/p appy s/p inguinal repair 100% carotid stenosis left (by pt report) s/p cea right carotid Social History: +tobacco- has tried numerous times to quit but never successful. Whole family smokes. currently [**1-29**] ppd (used to be more) for 40years. Has tried patches, gum, hypnosis. Drinks 3 oz of wine per night. Lives with wife and two cats. Family History: cad Physical Exam: Physical exam: Vitals - T 95.9, BP 156/86, HR 62, RR 17, O2 sat 100% on RA, IABP 1:1 General - A&O x3, pleasant male in NAD HEENT - PERRL, MMM, anicteric sclera, non-injected conjunctiva, no cervical LAD or supraclavicular LAD, no carotid bruits heard CVS - balloon pump heard Lungs - CTAB without w/r/r Abd - +BS, soft, NTND Ext - no e/c/c. R groin c/d/i, no hematoma. L groin small oozing, no hematoma. R foot cool but palpable pulses DP and PT. L foot pulses palpable DP and PT. Pertinent Results: Admission Labs [**2160-2-6**] 10:03PM: GLUCOSE-127* UREA N-16 CREAT-1.4* SODIUM-136 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-12 . WBC-13.8*# RBC-3.57* HGB-12.1* HCT-33.9* MCV-95 MCH-33.9* MCHC-35.7* RDW-12.5 PLT COUNT-255# . [**2160-2-6**] 10:03PM CK(CPK)-476* CK-MB-36* MB INDX-7.6* cTropnT-0.63* . [**2160-2-13**] pleural effusion cytology: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, macrophages and neutrophils. . [**2-6**] Cardiac cath: COMMENTS: 1. Selective limited vein graft angiography of sapehenous vein graft to an obtuse marginal branch of the left circumflex coronary artery revealed a degenerated, thrombotic lesion of 80% in the mid graft and a proximal 60-70% stenosis partially within a stented segment in the proximal portion of the graft. 2. Unsuccessful PTCA and stenting in the SVG-->OM with 3.5 Cypher DES complicated by no-reflow phenomenon that failed to resolve despite thrombectomy and intracoronary vasodilators, and peforation treated with a 3.5 covered stent in the proximal segment of the graft. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Unsuccessful PCI of SVG to OM. 3. Unresolved no-reflow phenomenon. 4. Vein graft peforation treated with covered stent. 5. Intr-aortic balloon pump support. . [**2-9**] TTE (echo): 1. The left atrium is elongated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6.There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. . [**2160-2-12**] CXR PA/Lat: FINDINGS: There is no focal consolidation or superimposed edema. The mediastinum again demonstrates evidence of prior median sternotomy and CABG with indwelling coronary stents. The cardiac size is stable in size and morphology. There is a moderate to large sized left pleural effusion. Very small right pleural effusion is also evident. There is no pneumothorax. The visualized osseous structures are unremarkable. IMPRESSION: Bilateral pleural effusions, left much greater than right. Extensive prior interventions in the heart as noted above [**2160-2-12**] left lat decub CXR: New small bilateral pleural effusion, left greater than right, is freely mobile on the left, partially mobile on the right. . [**2-14**] CTA: No Pulmonary Embolism, no masses, R hilar lymph node 1.4cm, coronary calcifications, bilateral ground glass opacities likely infection or infiltrate, but could be bronchoalveolar carcinoma. Needs f/u in [**7-4**] weeks to reevaluate. . Brief Hospital Course: # Cardiac: A. CAD with AMI: Pt w/ h/o CAD s/p CABG (LIMA to LAD, SVG to [**Last Name (LF) **], [**First Name3 (LF) **], and RCA) in [**2148**] and multiple PCI who p/w exertional angina, + stress test for cardiac cathetherization. Cath showed all the grafts occluded except LVG to RCA. SVG to OM had minimal flow. Attempted intervention complicated by perferation with embolization. A coated stent was placed but the vessel was thrombosed. He was then transferred to the CCU with an acute lateral MI. Peak CK of 2781, mb of 187, TropT 7.0. IABP was placed for support and d/c'd on [**2160-2-8**] and heparin gtt turned off. EF overall preserved with relatively small area of damage. Patient had persistant chest pain similar to his anginal pain. He had repeat cardiac catheterization on [**2-15**] which was unchanged and no intervention was done. His CAD was medically managed with aspirin, Plavix (for at least one year), metoprolol, lisinopril, simvastatin. His anginal pain was medically optimized with imdur 120, metoprolol to 100 tid, and lisinopril 2.5mg. . B. Pump: Had IABP placed during cath (but for coronary art perfusion, not afterload reduction). Echo on [**2-9**] showed overall improvement of EF at 55% and improved motion. Had episodes of hypotension on [**2-9**] in setting of incresed medications which were decreased. Blood pressure was well controlled on discharge medications. . C. Rhythm: Pt in NSR throughout and monitored on telemetry . # Pleural effusion: Initially seen on PA/Lat film taken for persistent left sided shoulder pain distinct from his typical angina. It was tapped on [**2-13**] and was exudative with PMN predominance. Cytology was negative for malignant cells. It is unclear what the eitiology was. Cultures pending at discharge. . # anemia: Stable throughout. . # CRI: Pt w/ h/o CRI, baseline Cr 1.3-1.4. Bumped to 1.6 and at discharge it was down to baseline at 1.3-1.4. He was pretreated with Mucomyst for all contrast exposures. . # H/o PUD: protonix and maalox. . # Tobacco abuse: Counsel on smoking cessation ----------------- PCP to follow up: 1) pleural effusion cultures 2) repeat CT scan in [**7-4**] weeks for resolution of opacities, monitor lymph notde. 3) lytes within 7-10 days Medications on Admission: ASA 325mg daily Plavix 75mg daily Diovan 80mg daily atenolol 75mg daily simvastatin 40mg daily tricor 145mg daily protonix 40mg daily isosorbide MN 60mg daily avodart 0.5mg daily fish oil 1000mg vitamin C 1000mg Discharge Medications: fish oil 1000mg vitamin C 1000mg 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*QS Tablet Sustained Release 24HR(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Fenofibrate Nanocrystallized 145 mg Tablet Sig: One (1) Tablet PO once a day. 10. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: CAD s/p cath NSTEMI Chronic kidney disease Tobacco use Pleural effusion Discharge Condition: Stable. Vital signs stable. Patient still with residual chest pain without obvious gross anatomical cause. Discharge Instructions: You had a cardiac catheterization. It was complicated by a vein graft thrombosis and subsequent heart damage. You also had a pleural effusion (fluid around your lung. This was tapped and there are results pending. Please have your PCP follow up on these. You had a CT which showed some opacities and a lymph node. You should have this followed up by your PCP as well. . We have changed some of your medications. We increased your nitrate (imdur) to try to manage your angina. . Please see your cardiologist, Dr. [**Last Name (STitle) 2912**] and your PCP. . It is very important that you go to cardiac rehab. . Followup Instructions: Follow up with your PCP in the next 7-10 days. Please have Dr. [**Last Name (STitle) 24873**] follow up with the CT scan results and the pleural effusion cultures. . Follow up with Dr. [**Last Name (STitle) 2912**] in the next 2-3 weeks. Name: [**Known lastname 4233**],[**Known firstname 448**] Unit No: [**Numeric Identifier 4234**] Admission Date: [**2160-2-6**] Discharge Date: [**2160-2-16**] Date of Birth: [**2097-5-25**] Sex: M Service: MEDICINE Allergies: Crestor Attending:[**First Name3 (LF) 4235**] Addendum: To clarify, the patient presented with unstable angina. He had a PCI which was complicated by a vein graft perforation, stent placement and thrombosis with subsequent MI. During his hospital course he also had minor ARF secondary to contrast which had resolved by time of discharge. Discharge Disposition: Home [**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 4236**] MD [**MD Number(2) 4237**] Completed by:[**2160-2-27**]

[ "E849.9", "996.72", "401.9", "E879.0", "997.1", "997.3", "411.1", "E849.7", "414.02", "414.01", "E947.8", "511.8", "997.91", "E878.2", "272.0", "997.5", "996.03", "584.9", "410.11", "996.74" ]

icd9cm

[ [ [] ] ]

[ "99.20", "36.07", "00.41", "37.22", "37.21", "97.44", "37.61", "88.56", "00.66", "00.46" ]

icd9pcs

[ [ [] ] ]

10875, 11040

5452, 7538

288, 346

9211, 9320

2540, 3584

9986, 10852

2016, 2021

7956, 9057

9107, 9190

7719, 7933

3601, 5429

9344, 9963

2051, 2521

7549, 7693

227, 250

375, 1531

1553, 1745

1761, 2000

81,592

106,177

36590

Discharge summary

report

Admission Date: [**2198-8-9**] Discharge Date: [**2198-8-10**] Date of Birth: [**2137-9-5**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2297**] Chief Complaint: complicated pancreatitis, pseudocyst Major Surgical or Invasive Procedure: ERCP History of Present Illness: please see discharge note from [**Hospital1 **]Hospital for full details of complicated hospital course Ms. [**Known lastname **] is a 68-year-old female who is being transferred from [**Hospital 8**] Hospital ICU for urgent ERCP management/intervention in the setting of recent gallstone pancreatitis (initial admission [**2198-6-8**])complicated by pseudocyst, multiple intra-abdominal infections, PNA, ARDS and persistent fevers. To date, she has failed 3 ERCP ampulla cannulations at OSH. She is now being transferred for additional ERCP attempt to cannulate duct and for placement of possible stent. Per patient, she had been very healthy with no significant prior medical conditions before this recent hospital admission. . Per OSH, her last WBC count was 10.8 / LFTs last done 10 days ago and were WNL. She has been having chronic low grade temperatures in the 99-100F range and has been afebrile x 2 days per OSH notes. She developed respiratory distress which was originally attributed to PNA and she was given course of Moxifloxacin. Respiratory failure followed which was felt to be from ARDS and she needed eventual intubation on [**2198-6-11**] followed by a long course on the mechanical ventilator followed by tracheostomy on [**2198-7-12**] and she was weaned off of the ventilator completely on [**2198-7-24**]. She is now stable on a tracheostomy collar at FiO2 28%. She also has Dobhoff tube in place for nutrition and is on tube feeds with Promote to 80-100cc/hr. She continues to have a very low prealbumin. She had been on vancomycin for empiric coverage for C.difficile (culture/toxins negative to date) but this was discontinued. She is on no additional antibiotics at present time. . While at OSH she also developed several episodes of bradycardia with intermittent tachycardia and she was seen by cardiology and diagnosed with tachy-brady syndrome and a transvenous pacemaker was placed on [**7-25**] which is set at rate of 50bpm. Goal is for eventual permanent PCM once she is stabilized at later date. . On arrival to the [**Hospital Unit Name 153**], her vital signs were temp 100F, BP 105/63, HR 102, O2 Sat was 99% on 10L at 35% FiO2 on trach collar. She was in no apparent distress and was fully alert and oriented. No abdominal pain complaints, denied nausea/emesis. She is having [**2-2**] loose stools daily. Past Medical History: -Prior left foot surgery for a heel spur -no other PMH prior to gallstone pancreatitis -as above: ARDS, PNA, gallstones, pancreatitis, pseudocyst, tachy-brady syndrome Social History: Patient lives in [**Hospital1 8**] and has a partner/boyfriend, has 3 grown children. Tobacco history: smoked 1PPD x 10 years and quit in early [**2159**], stopped drinking ETOH 30 years ago, no illicit drug use. Family History: Noncontributory Physical Exam: VS: vital signs were temp 100F, BP 105/63, HR 102, O2 Sat was 99% on 10L at 35% FiO2 on trach collar. GENERAL: No acute distress. Oriented to person, place and time, affect appropriate. HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Thrush noted over tongue NECK: Supple with JVP of 7-8cm. No lymphadenopathy noted, trach site clean/dry/in tact, nonerythematous, minimal clear secretions CARDIAC: RRR, S1/S2 appreciated, no murmurs/rubs/gallops. LUNGS: Respirations unlabored, no accessory muscle use. Diffuse rhonchi noted over upper lung fields and decreased lung sounds at bases (R>L). No wheezes noted. ABDOMEN: Soft, nondistended. No HSM . Mild tenderness with moderate palpation over LLQ, LUQ and epigastric region. No external bruising noted, no guarding, no rebound. Small drain at LLQ and LUQ draining yellowish fluid ( 50-75cc) EXTREMITIES: No edema, 2+ pedal pulses bilaterally SKIN: No rashes, +dermatitis on left and right buttocks, no other ulcers or lesions NEURO: CNs [**3-15**] grossly intact, no focal sensory or motor deficits, gait assessment deferred Pertinent Results: [**2198-8-9**] 09:30PM PT-13.4 PTT-21.9* INR(PT)-1.1 [**2198-8-9**] 09:30PM PLT COUNT-655* [**2198-8-9**] 09:30PM WBC-12.4* RBC-2.42* HGB-7.1* HCT-22.9* MCV-95 MCH-29.2 MCHC-30.8* RDW-20.1* [**2198-8-9**] 09:30PM CALCIUM-8.8 PHOSPHATE-3.8 MAGNESIUM-2.1 [**2198-8-9**] 09:30PM ALT(SGPT)-18 AST(SGOT)-41* ALK PHOS-120* TOT BILI-0.2 [**2198-8-9**] 09:30PM estGFR-Using this [**2198-8-9**] 09:30PM GLUCOSE-88 UREA N-18 CREAT-0.5 SODIUM-141 POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-35* ANION GAP-10 Brief Hospital Course: Patient was transferred from [**Location (un) **]Hospital to [**Hospital1 18**] ICU without incident. Patient remained clinically stable overnight and was continued on prior management. During ERCP in am, ability to visualize the sphincter of oddi but unable to pass the wire through the pancreatic duct. ERCP attending discussed case with surgical attending at [**Location (un) 25991**]Hospital and agreed on plan to transfer patient back to [**Hospital1 **]Hospital. Upon transfer, the patient was clinically stable. BP 97/45 P101 RR 20 on 35% FiO2 T 97.6 Medications on Admission: -Albuterol/Ipratropium -4 puffs TID -Ferrous Sulfate 325mg daily -Lovenox 40mg SC daily -Guaifenesin 200mg q4hrs PRN -Tylenol 650mg q6hrs PRN -Albuterol INH, 4 puffs qhour PRN -Lactobacillus Acidophilis/lactinex -1 tablet daily -Miconazole 2% ointment PRN -Octreotide acetate 100 mcg SC TID -olanzapine 10mg PO qhs -Protonix 40mg IV BID -Vitamin A&D external cream PRN -Zinc oxide ointment PRN Discharge Medications: -Albuterol/Ipratropium -4 puffs TID -Ferrous Sulfate 325mg daily -Lovenox 40mg SC daily same medications on transfer: -Guaifenesin 200mg q4hrs PRN -Tylenol 650mg q6hrs PRN -Albuterol INH, 4 puffs qhour PRN -Lactobacillus Acidophilis/lactinex -1 tablet daily -Miconazole 2% ointment PRN -Octreotide acetate 100 mcg SC TID -olanzapine 10mg PO qhs -Protonix 40mg IV BID -Vitamin A&D external cream PRN -Zinc oxide ointment PRN Discharge Disposition: Extended Care Facility: [**Location (un) **]Hospital Discharge Diagnosis: complicated pancreatitis, pseudocyst Discharge Condition: stable Discharge Instructions: continue management as dictated by [**Hospital1 **]Hospital Followup Instructions: cont. current management

[ "576.8", "577.0", "577.2", "576.2" ]

icd9cm

[ [ [] ] ]

[ "51.10" ]

icd9pcs

[ [ [] ] ]

6318, 6373

4856, 5426

303, 309

6453, 6461

4328, 4833

6569, 6596

3124, 3141

5870, 5963

6394, 6432

5452, 5847

6485, 6546

3156, 4309

227, 265

337, 2686

5988, 6295

2708, 2878

2894, 3108

9,841

130,933

18706+18707

Discharge summary

report+report

Admission Date: [**2119-7-9**] Discharge Date: [**2119-7-12**] Service: ADDENDUM: This is a continuation of the Discharge Summary for this patient. PHYSICAL EXAMINATION: On admission, the vital signs were temperature of 98.9 F.; blood pressure 130/55; heart rate of 93; respiratory rate of 20; 98% on room air. The patient is lying in bed in no acute distress. HEENT: The pupils are icteric. The mucous membranes are dry. Cardiac examination is regular rate and rhythm, S1, S2, with no rubs, murmurs or gallops. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, with normoactive bowel sounds; no hepatosplenomegaly. Extremities are without cyanosis, clubbing or edema. Two plus dorsalis pedis pulses bilaterally. Neurological is alert and oriented times three without any asterixis. Skin: The patient is jaundiced without palmar erythema or spider veins on the abdomen. LABORATORY: The patient's white blood cell count is 8.1, hematocrit is 24.3, down from a discharge hematocrit of 37.1 on the [**8-3**]. The sodium is 141, potassium 3.5, chloride is 106, bicarbonate is 22. The BUN is 30. The creatinine is 0.9. The glucose is 152. The ALT is 914, the AST is 989. Alkaline phosphatase is 117; amylase 21, lipase 16; and total bilirubin is 24.7. An EKG shows normal sinus rate at 94; normal axis, and intervals with T wave inversions in lead III compared to [**2119-7-3**]. HOSPITAL COURSE: 1. GASTROINTESTINAL BLEED: The patient was volume resuscitated in the Emergency Department and nasogastric tube lavage was performed which was negative for blood. The patient was admitted to the Surgical Intensive Care Unit and transfused with three units of packed red blood cells and two units of fresh frozen plasma. The patient underwent an esophagogastroduodenoscopy which revealed clot at the site of the previous sphincterotomy. The clot was then washed off; some oozing was seen. The site was injected with epinephrine and cauterized with electrocautery. Hemostasis was achieved. No other abnormalities were found. Following this procedure and transfusions, the patient's hematocrit appropriately responded and was increased to 28.6 on the second hospital day. The patient had no further episodes of gastrointestinal bleeding throughout her stay and hematocrit on discharge was 33.8. The patient was transferred out of the Surgical Intensive Care Unit to the 4 Campus. She was placed on Protonix 40 mg intravenously twice a day. She was slowly transitioned from n.p.o. to a full diet which she tolerated well. At that time, her Protonix was switched to 40 mg p.o. q. day. She did well throughout her hospital stay with no further episodes of drops in hematocrit or gastrointestinal bleeding. 2. INTRAHEPATIC CHOLESTASIS: The patient's initial liver function tests were decreased from the time of her discharge from her previous hospitalization, however, remain markedly elevated. Throughout the hospital stay, the ALT and AST steadily decreased to a discharge ALT and AST of 449 and 406 respectively. The alkaline phosphatase remained relatively constant at 130 and the total bilirubin initially decreased to 24.8, but then rebounded to 26.7 at the time of discharge. Previous serologies for hepatitis A, B and C, all returned negative. Serologies were sent for Herpes Simplex virus 1 and 2, [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus, and cytomegaly. A serulo-plasmin came back not elevated. The patient was started on 600 mg twice a day of Ursodiol and AMSA was sent and remains pending at this time. [**Doctor First Name **] was sent and returned positive with a titer still pending. There were elevated levels of IgG and IgA, however, SPEP remains pending at this time. The patient continued to be icteric throughout her hospital stay, however, as she was feeling well, she was discharged home to follow-up as an outpatient with Dr. [**Last Name (STitle) 497**]. 3. FLUIDS, ELECTROLYTES AND NUTRITION: The patient transitioned a full diet without any difficulty. Of note, she had persistently low potassiums that required daily replenishment with oral p.o. potassium chloride. She was discharged with instructions to eat two bananas per day. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: Full code. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Intrahepatic cholestasis. 3. Hypokalemia. DISCHARGE MEDICATIONS: 1. Ursadial 600 mg p.o. q. day. 2. Protonix 40 mg p.o. q. day. 3. Eat two bananas or kiwi per day. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [**First Name (STitle) **] at the [**Hospital6 18075**] who will become her primary care physician. 2. She will follow-up with Dr. [**Last Name (STitle) 497**] here at the Liver Service for further work-up of her intrahepatic cholestasis. [**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**] Dictated By:[**Last Name (NamePattern1) 51288**] MEDQUIST36 D: [**2119-7-14**] 15:17 T: [**2119-7-14**] 15:54 JOB#: [**Job Number 51289**] Admission Date: [**2119-7-9**] Discharge Date: [**2119-7-12**] Service: [**Location (un) 259**] HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a past medical history of intrahepatic cholestasis, who presented to the Emergency Department five days after a previous discharge with progressive weakness, fatigue, and difficulty breathing. The patient states that she was feeling well after her discharge from the [**Hospital1 **] Hospital on [**7-4**]. She returned home and was able to eat a normal diet. Over the next 2-3 days, she developed progressive fatigue with difficulty getting around. She complains of being weak all over. As this continued, she eventually was able to perform limited minimal exertion and became short of breath, and had difficulty breathing. She notes the passage of numerous black-tarry stools consistent with melena. She denies any bright red blood per rectum. On the day of admission, she became anorexia. She denies fevers, chills, nausea, vomiting, chest pain or abdominal pain. She denies any changes in bladder function. She does not complain of any edema. PAST MEDICAL HISTORY: 1. Episode of painless jaundice that was first noticed by a co-worker somewhere around [**Date range (1) 51290**]/[**2118**]. She presented to [**Hospital6 1597**] at that time, where a CT scan showed minimally dilated biliary tree. She was transferred to [**Hospital1 1444**], where she underwent an ERCP and sphincterotomy. Sludge and a few stones were drained from the gallbladder, however, no significant dilatation of the biliary tree was noted and there were no obstructing stones seen. She tolerated the procedure well and recovered to be discharged home the following day. 2. Left eye cataract. 3. Traumatic blindness in the right eye. Of note, the patient has not seen a primary care physician in the past 75 years prior to these events. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: None. PHYSICAL EXAMINATION: DICTATION ENDED. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**] Dictated By:[**Doctor Last Name 51291**] MEDQUIST36 D: [**2119-7-14**] 13:31 T: [**2119-7-25**] 14:54 JOB#: [**Job Number 51292**]

[ "576.8", "276.8", "E878.8", "285.1", "998.11" ]

icd9cm

[ [ [] ] ]

[ "45.13", "51.64" ]

icd9pcs

[ [ [] ] ]

4350, 4426

4449, 4552

7133, 7140

1462, 4264

4576, 5254

7164, 7452

5283, 6277

6299, 7106

4290, 4329

10,580

140,886

50187

Discharge summary

report

Admission Date: [**2184-3-1**] Discharge Date: [**2184-3-12**] Date of Birth: [**2132-4-20**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 7141**] Chief Complaint: Recurrent Stage IV ovarian cancer Major Surgical or Invasive Procedure: Examination under anesthesia Exploratory laparotomy Drainage of ascites Small bowel resection with ileal ascending colon anastomosis. Transverse loop colostomy Tumor debulking Bilateral ureteral catheterization History of Present Illness: 51 yo woman who presents w/recurrent and progressive stage IV ovarian CA. She c/o poor appetite, depression, abdominal discomfort, constipation, fatigue, and insomnia. She denies rectal bleeding, vaginal bleeding, discharge, CP, fever, chills, SOB, nausea, and leg swelling. Her most recent CA-125 was 3276 on [**2184-2-13**]. Past Medical History: 1) [**10/2179**] optimal debulking serous ovarian carcinoma w/removal of omental caking and drainage of ascitic fluid (2.5 L) 2) [**10/2179**] pleural effusion 3) s/p 1 cycle Taxol/Carboplatin w/mild response and 2 cycles Docagem (Docataxel, Carboplatin, Gemcitabine) w/excellent response (CA-125 nadir 7.5) 4) [**12/2180**] Recurrence, s/p 3 cycles Taxol/Carboplatin, followed by complete remission (6 months between remission). Ca-125 nadir 4.6. 5) [**4-/2181**] Recurrence, tx'd w/Arimidex 4 mg qd 6) s/p 4 cycles Tellik/Carboplatin c/b marrow suppression, 2 cycles Xeloda and 2 cycles Topotecan w/disease progression (received only [**12-25**] treatments secondary to thrombocytopenia) Social History: Lives with children, no EtOH, no Tob Family History: Breast cancer Physical Exam: Wt 224 lb 113/71 HR 102 Sat 97% RA Gen: Chronically fatigued Skin: anicteric HEENT: Sclerae anicteric No LAD Lungs: CTA B Abdomen: palpable mass in lower abdomen to R of incision Pelvic: Nl vulva and vagina. Large mass in rectovaginal septum measuring at least 5 cm, impinging on vaginal apex and rectum. Vaginal mucosa smooth. Brief Hospital Course: The patient underwent EUA, ELAP, drainage of ascites, small bowel resection with ileal ascending colon anastomosis, transverse loop colostomy, tumor debulking, and bilateral ureteral catheterization on [**2184-3-1**]. Please see operative report for full details of procedure. 1) CV: The patient went to the [**Hospital Unit Name 153**] for hemodynamic monitoring secondary to hypotension during the procedure and extensive fluid shifts. Her blood pressure was initially maintained on a neosynephrine drip, which was d/c'd on POD1. She also received albumin 25% 25g IV x 2 doses to maintain oncotic pressure, as well as multiple NS boluses. She was then hemodynamically stable and transferred to the floor on POD#3. On POD#7 the pt was noted to be tachycardic to the 110s. An EKG was obtained and was notable for possible anterior Q waves as well as poor R wave progression. An Echocardiogram was notable for mild left atrial dilation. Lower extremity dopplers were normal. Her D-Dimer was elevated at 3279. A chest x-ray on POD#8 revealed LL lobe effusion/atelectasis. A V/Q scan demonstrated intermediate probability of PE. A pulmonary consult was obtained on POD#9. The recommendation was to continue Lovenox at her current dose of 30 mg [**Hospital1 **]. 2) Renal: The patient's urine output was initially decreased but improved with IV lasix. The output from the right ureteral catheter remained low and she was evaluated by urology on POD 2. A renal ultrasound was obtained and revealed no hydronephrosis. Her creatinine decreased from 1.7 preop to 1.0. Her urine output improved. Her catheters were removed on [**2184-3-8**] and stents placed. 3) Heme: The pt received a total of 5U PRBCs to maintain her HCT above 30. Her INR increased to 1.9. It improved to 1.3 with Vitamin K but her PT remained elevated in the 14-15 range. She then tested positive for lupus anticoagulant. Hematology was consulted and she was started on Lovenox 30 mg SQ [**Hospital1 **] for prophylaxis. 4) ID: The pt was maintained on levofloxacin/flagyl until POD 6. Her wound culture and blood cultures were negative. Her LIJ catheter was removed on POD 4 secondary to purulent drainage and erythema. The culture of the tip was negative. Her WBC decreased from 30 to 12, but increased to 20 on POD 7. Her levofloxacin/flagyl were then restarted. 5) GI: The pt was advanced to a regular diet on postoperative day 4. 6) Pain: The pt's pain was initially well-controlled on a fentanyl PCA. This was changed to PO pain meds on POD#5. 7) Endocrine: The pt's TSH was checked as part of her tachycardia workup and was elevated at 7.7. Her T3 was low. The remainder of her thyroid function labs were normal. Endocrine was curbsided and felt that the labs were consistent with "post-ICU" hypothyroidism and recommended outpatient follow-up in [**2-25**] weeks with her PCP. On the day of discharge, the pt was ambulating and tolerating PO's with pain well-controlled on PO medications and stable vital signs. Medications on Admission: Ambien 5 mg hs Colace Atenolol 50 mg/day Zoloft 50 mg/day Senna 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:*2* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*2* 3. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*2* 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Metastatic ovarian cancer Blood loss anemia Discharge Condition: Good Discharge Instructions: - No driving for 2 weeks - No heavy lifting, nothing in vagina for 6 weeks - Call if you have temperature >100.4, worsening pain, nausea/vomiting, or other concerns/questions Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 104699**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-3-19**] 9:00 Provider: [**Name10 (NameIs) 17515**] CHAIR 1A Date/Time:[**2184-3-19**] 9:00 Provider: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-3-19**] 9:00 Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 5777**] Call to schedule appointment

[ "197.5", "280.0", "183.0", "197.4", "197.6", "593.4", "401.9", "276.5", "591" ]

icd9cm

[ [ [] ] ]

[ "45.62", "45.93", "96.72", "45.74", "87.74", "59.8", "99.04", "96.04", "54.3", "46.03" ]

icd9pcs

[ [ [] ] ]

5935, 5993

2067, 5065

333, 545

6081, 6087

6310, 6909

1684, 1699

5179, 5912

6014, 6060

5091, 5156

6111, 6287

1714, 2044

259, 295

573, 901

923, 1614

1630, 1668

10,159

109,556

6238

Discharge summary

report

Admission Date: [**2118-12-16**] Discharge Date: [**2118-12-17**] Service: MEDICINE Allergies: Codeine / Percocet / Ambien Attending:[**First Name3 (LF) 3556**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation History of Present Illness: Mr. [**Known lastname **] is an 84 year old male with history of CAD and CHF with multiple recent admits ([**Date range (1) 24293**], [**Date range (1) 24294**], [**Date range (1) 24295**]) for MRSA pneumonia who presents with dyspnea. Per records, he had increasing sob and lower extremity edema over the past two days. He also c/o CP after moving bowels. . Patient initially presented to [**Hospital1 18**] on [**11-10**] with complaints of SOB. He was diagnosed with a MRSA pneumonia and treated with Vancomycin and Levaquin for a total of 14 and 10 days each. During that admission, he had a left mainstem bronchus plugging with left lung collapse requiring bronchoscopy [**11-14**] (cx grew MRSA). Large left pleural effusion tapped [**11-17**] (1.4L, transudate, cx negative). Most recent admission from [**Date range (1) 24295**]) when patient admitted with dyspnea. Treated with Vanc/zosyn for PNA, and diuresed. . In the ED, 98.4, HR 1020 BP 110/70 95%RA. c/o sob and placed on CPAP and nitro gtt and transferred to the ICU. He received 325 ASA, Lasix 40 X 2, Morphine 2mg and albuterol/ipratrop nebs. . On arrival to the ICU, he is on bipap. he states breathing is improved. Denies any chest pain. denies recent fevers, chills, n,v. Past Medical History: - CAD s/p (LIMA to LAD, SVG to OM2, SVG to RCA), repeat CABG [**2105**] after LIMA found to be occluded (Y-graft SVG to first acute marginal and LAD) - HTN - dyslipidemia - SSS s/p pacemaker [**7-27**] - CHF - EF 40% 10/06 - Gout - OA - h/o GIB - s/p knee replacements - s/p CCY - s/p prostate surgery - ?atrophic kidney Social History: Had lived with his wife. Denies [**Name2 (NI) **]/tob/drugs. Came from [**Hospital1 1501**] after recent admission Family History: NC Physical Exam: VITALS: 96.2, HR 99, BP 121/76 RR 26 O2 100% Gen: Elderly male with FM on in nad. HEENT: MMM, OP clear Neck: supple, no carotid bruits, difficult to assess JVP. Lungs: Bilateral wheezing. CV: RRR, nl S1S2, no m/r/g Abd: Soft, obese Ext: 2+ edema upto thighs, acebandage below the knees. Neuro: AAOx3, no focal deficits Brief Hospital Course: Impression and plan: 84 yom with h/o CAD, CHF and MRSA PNA admitted with dyspnea. Unclear precipitant but patient with worsening volume overload over the past two days including dyspnea and lower extremity edema. . # Respiratory distress - Likely multifactorial given h/o MRSA PNA and CHF. CHF likely contributing to the majority of dyspnea especially given wt gain over the past few days and CXR with worsening Pulmonary edema. Pt was initially intubated because the family felt it might ease his suffering. The pt self-extubated but was reintubated by anaesthesia. Hypotension- During his initial hours in the ICU, the pt's systolic blood pressure decreased to the low 70's. He was started on phenylepherine to raise his blood pressure. We discussed his course and previously stated wishes with his family, who asked that the patient be made comfort measures only. His family asked that no additional changes to the patient's medication regimen. The patient's blood pressure fell in the evening and his hear rate did not respond. The patient was pronounced at 931pm Medications on Admission: Ipratropium Bromide q6h. Calcium Carbonate 500 mg Tablet, tid Cholecalciferol (Vitamin D3) 400 unit [**Unit Number **] tab [**Hospital1 **] Ferrous Sulfate 325 (65) mg Tablet Oncea day Atorvastatin 20 mg Tablet once a day. Aspirin 325 mg Tablet, once a day Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) mL Injection QMOWEFR (Monday -Wednesday-Friday). Dolasetron 12.5 mg q8 prn Docusate Sodium 100 mg po bid Metoprolol Tartrate 12.5 po bid. Hydralazine 10 mg po q6h. Simethicone 80 mg Tablet po qid prn. Aluminum-Magnesium Hydroxide qid prn. Furosemide 40 mg Tablet PO BID Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment [**Hospital1 **] prn for pain. Isosorbide Dinitrate 10 mg TID Bismuth Subg-Balsam-ZnOx-Resor Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q48H (every 48 hours) until [**12-21**] Unasyn 1.5gm tid until [**12-21**] Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: heart failure, systolic exacerbation hypotension pneumonia, Staphylococcal Discharge Condition: deceased Discharge Instructions: none Followup Instructions: none [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "V45.01", "585.9", "428.0", "403.90", "272.4", "427.31", "482.41", "518.81", "274.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

4417, 4426

2400, 3477

257, 269

4544, 4554

4607, 4743

2037, 2041

4388, 4394

4447, 4523

3503, 4365

4578, 4584

2056, 2377

198, 219

297, 1542

1564, 1887

1903, 2021

29,493

170,406

31922

Discharge summary

report

Admission Date: [**2169-11-15**] Discharge Date: [**2169-11-21**] Date of Birth: [**2107-10-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 1402**] Chief Complaint: Syncope, CHB then asystolic arrest Major Surgical or Invasive Procedure: placement of St. [**Male First Name (un) 923**] Accent DR [**Last Name (STitle) **] 2210: DDD 50 BPM minimum Temporary pacer wire placement and removal Pulmonary intubation History of Present Illness: 62M with h/o chronic pancreatitis from gallstones c/b DM, and no cardiac PMH who presented with syncope then found to be in CHB then asystole now transvenous paced. . Mr [**Known lastname **] was at an outpatient appointment on the [**Hospital Ward Name **] when he had a witnessed syncopal event where he fell struck his head and had incontinence and LOC. He recovered and then came to the ED. There his vitals were 98.6 42 131/63 18 97% 4L Nasal Cannula. He was also noted to be in CHB but he was talking and responsive. Hed then went into asystole. At that point a code was called and he was intubated. He was trasncutaneously paced then taken to the cath lab for transvenous pacemaker placement. . He is now intubated and sedated though variably responing to commands in the CCU. . Pt unable to provide futher details or ROS Past Medical History: Diabetes, non-insulin dependent Hypertension Lumbar disk bulge (L4) Gallstone pancreatitis Necrotizing pancreatitis with infected pseudocyst s/p necrosectomy ventral hernia cholangitis . PSH: [**Hospital Ward Name **]/papillotomy/stent [**10-1**] c/b pancreatic necrosis & pseudocyst p/w hyperglycemia and infected pancreatic necrosis; s/p pancreatic necrosectomy (1 L of purulent fluid), cholecystostomy tube, g tube, j tube, [**Doctor Last Name 406**] X 4 (#1-gallbladder area, #2-pancreatic head, #3-body, #4-tail); s/p ex-lap, modified [**Location (un) 5701**] bag placement; s/p washout; decannulated [**11-13**] . Social History: He does not smoke. He does not drink. He works as a photographer. Family History: Non-contributory Physical Exam: Admission PE: GENERAL: Intubated and sedated. Responds to commands HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Intubated. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Multiple surgical scars EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: 2+ DP 2+ PT 2+ Left: DP 2+ PT 2+ . Discharge Exam: PHYSICAL EXAMINATION: VS: Tc 97.8 Tm 97.8 BP 126-161/82-101, HR 62-66 with v paced beats and first degree AV conduction delay, RR 18, O2 sat 98% GENERAL: Feeling well. NAD. HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVD unable to appreciate CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Right pacer site with very mild swelling, no redness or discharge. No bruising. Mild tenderness to palpation. LUNGS: [**Month (only) **] BS left base. ABDOMEN: Soft, obese, NTND. No HSM or tenderness. Multiple surgical scars EXTREMITIES: No edema. SKIN: No open areas. LUE TTP but no evidence of swelling or redness in bilat UE. Has dry skin on knuckles bilat. PULSES: trace bilat. Feet and hands warm. Pertinent Results: Admission labs: [**2169-11-15**] 09:48AM BLOOD WBC-6.5 RBC-5.69 Hgb-14.1 Hct-43.3 MCV-76* MCH-24.8* MCHC-32.6 RDW-16.0* Plt Ct-224 [**2169-11-15**] 12:20PM BLOOD Neuts-88.8* Lymphs-5.0* Monos-5.2 Eos-0.4 Baso-0.4 [**2169-11-15**] 09:48AM BLOOD Glucose-506* UreaN-18 Creat-1.6* Na-128* K-7.2* Cl-99 HCO3-23 AnGap-13 [**2169-11-15**] 08:22PM BLOOD CK(CPK)-153 [**2169-11-15**] 12:20PM BLOOD CK(CPK)-238 [**2169-11-15**] 08:22PM BLOOD CK-MB-7 cTropnT-<0.01 [**2169-11-15**] 12:20PM BLOOD CK-MB-9 cTropnT-<0.01 [**2169-11-15**] 09:48AM BLOOD cTropnT-<0.01 [**2169-11-15**] 12:20PM BLOOD Calcium-9.5 Phos-4.1 Mg-2.4 [**2169-11-15**] 12:20PM BLOOD Osmolal-323* [**2169-11-15**] 01:30PM BLOOD Type-ART Temp-36.6 FiO2-100 pO2-419* pCO2-45 pH-7.29* calTCO2-23 Base XS--4 AADO2-256 REQ O2-49 Intubat-INTUBATED . ECHO [**11-16**]: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. 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. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. IMPRESSION: No structural cardiac cause of syncope identified. Preserved global and regional biventricular systolic function. No resting LVOT obstruction. . Discharge labs: [**2169-11-21**] 06:25AM BLOOD WBC-7.3 RBC-5.38 Hgb-13.3* Hct-40.0 MCV-74* MCH-24.7* MCHC-33.2 RDW-15.9* Plt Ct-196 [**2169-11-21**] 06:25AM BLOOD Glucose-136* UreaN-26* Creat-1.2 Na-135 K-4.6 Cl-100 HCO3-26 AnGap-14 Brief Hospital Course: #Asystolic arrest: Baseline CHB degenerated to asystole. Unclear etiology of CHB. Did not appear to have had an ischemic event (no ischemia on EKG from ED, CEs neg). No iatrogenic procedure or medications to block AV node. EP study revealed that purkinje system was involved. Initially transvenously paced, then pacer was placed on [**2169-11-20**]. No complications with procedure. . #Hyperosmotic non-ketotic hyperglycemia: Pt had not taken his insulin in the morning and blood sugar > 500 on admission. Insulin drip was started and transitioned to Lantus and humalog. [**Last Name (un) **] diabetes team saw pt during hospital stay and adjusted insulin dosing. He will follow up with the [**Hospital **] clinic after discharge. . # S/P intubation: Intubated during code, then extubated the following day. CXR with no acute changes. . #Acute kidney injury: Thought secondary to hypovolemia possibly from hyperglycemia or poor perfusion in setting of complete heart block for unclear time period. Creatinine normalized after fluids and correction of rhythm. . #Hyperkalemia: K 7.2 on admission. Responded well to calcium gluconate, insulin gtt and Lasix IV. Normal at discharge. . #Chronic pancreatitis: Stable. Restarted Creon when eating . Transitional issues: 1. [**Hospital **] clinic f/u appt 2. EP and General cardiology follow up appts at [**Hospital1 18**] Medications on Admission: HOME MEDICATIONS: per OMR -Lantus 46 u QAM -Novolog SS -Creon [Creon 10] 249 mg (10,000 unit-[**Unit Number **],500 unit-[**Unit Number **],200 unit) -Omeprazole 20 mg daily -Paroxetine 5 mg daily every other day -Lisinopril 20mg daily Discharge Medications: 1. oxycodone 5 mg Tablet [**Unit Number **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. Disp:*10 Tablet(s)* Refills:*0* 2. cephalexin 500 mg Capsule [**Unit Number **]: One (1) Capsule PO four times a day for 2 days. Disp:*8 Capsule(s)* Refills:*0* 3. acetaminophen 500 mg Tablet [**Unit Number **]: Two (2) Tablet PO three times a day as needed for pain for 5 days. 4. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) [**Unit Number **]: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Unit Number **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. paroxetine HCl 10 mg Tablet [**Unit Number **]: 0.5 Tablet PO every other day. 7. lisinopril 20 mg Tablet [**Unit Number **]: One (1) Tablet PO once a day. 8. aspirin 81 mg Tablet, Chewable [**Unit Number **]: One (1) Tablet, Chewable PO once a day. 9. Lantus 100 unit/mL Solution [**Unit Number **]: Forty Six (46) units Subcutaneous once a day: 16 units at bedtime. 10. Humalog 100 unit/mL Solution [**Unit Number **]: 10-31 units Subcutaneous four times a day: per sliding scale. Discharge Disposition: Home Discharge Diagnosis: Complete heart block Hyperosmolar hyperglycemic ketoacidosis Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart conduction problem called complete heart block that made your heart rate very slow, then eventually stop. You received a pacing wire and then a permanant pacer to prevent your heart rate from being so slow again. No lifting more than 10 pounds with your right hand or lifting your right hand over your head for 6 weeks. You can take the dressing off after 3 days but dont take the tape strips off. You can then shower and wash your hair. You will come back in 1 week to have the wound and the pacer checked. You also had very high blood sugars and too much acid in your blood and required an insulin drip and adjustment of your home insulin regimen. You will see [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] doctor after your leave for further monitoring and adjustment. . We made the following changes in your medicines: 1. Take cephalexin for 2 days to prevent an infection at the pacer site 2. Take oxycodone as needed for pain at the pacer site, take tylenol 1000mg (2 extra strength) every 8 hours for the next few days for the pain as well. You should not need oxycodone or tylenol after 5 days. 3. Increase the glargine and humalog insulin as [**First Name8 (NamePattern2) **] [**Last Name (un) **] instructions to better control your blood sugar. 4. Start a baby aspirin every day Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2169-11-27**] at 3:00 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Apartment Address(1) 20557**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2490**] Appointment: [**Telephone/Fax (1) **] [**12-20**] AT 4PM **Please call to register at the number above before your appointment. You will also receive a conformation call before the appointment date.** Name: [**Last Name (LF) **],[**First Name3 (LF) **] F Location: [**Location (un) 4499**] INTERNAL MEDICINE Address: [**Apartment Address(1) 4500**], [**Location (un) 4499**],[**Numeric Identifier 4501**] Phone: [**0-0-**] **We are working on a follow up appointment with Dr. [**First Name (STitle) **] within 1 week. 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: CARDIAC SERVICES When: Monday [**1-15**] at 2:20pm With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "574.20", "250.22", "780.2", "451.82", "682.3", "276.52", "577.1", "427.5", "997.2", "276.7", "V58.67", "584.9", "276.2", "E879.8", "426.0" ]

icd9cm

[ [ [] ] ]

[ "37.26", "99.69", "37.83", "96.71", "37.78", "37.72", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

8093, 8099

5260, 6504

343, 518

8224, 8224

3457, 3457

9722, 11306

2122, 2140

6915, 8070

8120, 8203

6654, 6654

8375, 9699

5019, 5237

2155, 2664

6672, 6892

2680, 2680

2702, 3438

6525, 6628

269, 305

546, 1377

3474, 5002

8239, 8351

1399, 2020

2036, 2106

4,392

111,402

54380

Discharge summary

report

Admission Date: [**2115-4-30**] Discharge Date: [**2115-5-6**] Date of Birth: [**2064-10-4**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2186**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: -Bedside left foot wound debridement by Podiatry -Operating room left foot wound debridement by Podiatry History of Present Illness: Mr. [**Known lastname 100110**] is a morbidly obese 50 y.o. Male with a history of line infections, ESRD on HD, OSA, GERD, h.o. C Diff who presents from HD for initially hypoxia, fever from dialysis. Admitted to the ICU for concern for septic shock. . Per pt on Sunday he noted the onset of low grade fevers to 99, diarrhea 2-3 times, brown, liquidy with no abdominal pain. He also noted nausea and was vomiting "spit". He did not feel hungry and had decreased PO intake, on Monday he felt the same had the same episodes of low grade fever, diarrhea with same pattern/consistency, vomiting with spit only. He again did not feel like eating, he also noted some pain in his left foot since Monday. Per him his rt foot has been banadaged since his dermagraft placement and was not supposed to be evaluated until tomorrow with podiatry. The VNA looked at his left foot and said it looked good. . ROS: Denies night sweats, cough, rhinorrhea, sore throat, SOB, chest pain, abdominal pain. . Per ED signout pt was in dialysis this morning and was noted to be febrile to 100, diaphoretic with a reported O2 sat of 100%. As he was not feeling well he was referred to the ED. . In the ED his initial VS were noted to be HR 101, BP 118/59, RR 19, Sat 100% on RA. Per ED they have had a hard time obtaining BP 40 minutes into his ED visit, after having a temp of 103.3 his BP dropped to 74-86/50s per vitals sheet. Per ED signout his systolic BPs were in the 40s though he was noted to be mentating well and conversing with the ED team. They checked a CXR which was limited [**12-26**] technique but showed no infiltrates. His labwork was notable for profound electrolyte abnmlties, K 8.4, Na 127, HCO3 17, Cl 87, BUN/Cr 84/13.8. He was noted to have peaked Twaves in lateral leads. He was given 10units IV Insulin and Amp D50, 1 Amp Calcium Gluconate. Repeat lytes showed a K of 5.4. Renal were notifed by the ED and are aware of admission. With regards to the hypotension, ED were concerned about sepsis given presence of fevers. Suspected sources were foot ulcer (pt has chronic foot ulcers followed by vascular) vs HD line infection, he was given Zosyn/Vanc for borad coverage. He was also given 1gm Acetaminophen and Zofran 2mg for nausea. Though ED suspected some of the hypotension was [**12-26**] cuff size given level of mentation, he was given 4L of NS with BPs now in the 90s. They attempted a central line placement, decided L IJ given pt's HD line in the right. They were able to get drawback but had a difficult time threading the line. Groin line was thought to be difficult to place given obesity. . Prior to transfer to the ICU his VS were noted to be HR 76, RR 25, 96/40, 100.7, Sat 98% on 2L. . Of note his last hospitalization was [**2115-3-2**], he was hospitalized for a day for a HD R IJ line placement, his pressures were noted to be markedly elevated in the 140s-170s. He was recently seen by podiatry on [**2115-4-24**] for follow-up of rt lateral TMA ulceration, wound was noted to be 3.8 x 2.7 cm with dermagraft placed. Per note the wound has shown granulating tissue with no signs of infection. He was also seen in vascular clinic who recommended ABI studies. Past Medical History: - Non-insulin dependent diabetes mellitus - History of line infections - Peripheral neuropathy and peripheral vascular disease - Leukocytoclastic Vasculitis - Hypertension - Obstructive sleep apnea - Obesity - GERD - Anemia in setting of ESRD - Secondary hyperparathyroidism in setting of ESRD - Low-attenuation lesions in kidneys detected by CT in [**12/2111**] - C. difficile infection in [**2110**] and [**2111**] - S/p open cholecystectomy in [**2099**] Social History: The patient is unemployed and receives income via social security. Formerly, he worked as an electrician but he has been unemployed for many years. He lives in the [**Location (un) 4398**] in a facility owned by the city of [**Location (un) 86**] for elderly and disabled people. The patient does not use tobacco products. The patient does not drink alcohol. The patient does not use intravenous or other recreational drugs. Family History: NIDDM in both parents and two siblings. Mother with additional high. Hyperlipidemia, hypercholesterolemia, hypertension, and Alzheimer's. Physical Exam: GEN: Morbidly obese African American Male sitting up in NARD HEENT: PERRL, EOMI, anicteric, Mucous membranes dry RESP: Distant but CTA b/l CV: Distant S1 and S2, RRR ABD: 1 abdominal hernia, umbilical hernia noted, easily reducible, NT, ND, +BS x 4 [**Location (un) **]: Rt foot shows healing ulceration, pink granulating tissue, palpable DP, PT b/l.Left foot ulcer is dry, with ?eschar NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. . Discharge Exam: Unchanged except [**Location (un) **]: Right and left feet with c/d/i dressings Pertinent Results: Admission Labs: [**2115-4-30**] 06:40AM PLT COUNT-230 [**2115-4-30**] 06:40AM NEUTS-84.3* LYMPHS-7.9* MONOS-5.9 EOS-0.9 BASOS-1.0 [**2115-4-30**] 06:40AM WBC-10.2 RBC-3.70* HGB-10.8* HCT-31.9* MCV-86 MCH-29.1 MCHC-33.8 RDW-17.7* [**2115-4-30**] 06:40AM estGFR-Using this [**2115-4-30**] 06:40AM GLUCOSE-200* UREA N-84* CREAT-13.8* SODIUM-127* POTASSIUM-8.4* CHLORIDE-87* TOTAL CO2-17* ANION GAP-31* [**2115-4-30**] 06:45AM LACTATE-1.3 K+-6.7* [**2115-4-30**] 06:45AM COMMENTS-GREEN TOP, [**2115-4-30**] 09:00AM CALCIUM-8.1* PHOSPHATE-2.8# MAGNESIUM-2.0 [**2115-4-30**] 09:00AM UREA N-79* CREAT-13.7* TOTAL CO2-17* [**2115-4-30**] 09:15AM GLUCOSE-225* LACTATE-1.2 NA+-129* K+-5.4* CL--99* [**2115-4-30**] 09:33AM VoidSpec-NOTIFIED T [**2115-4-30**] 09:33AM COMMENTS-GREEN TOP [**2115-4-30**] 12:16PM PLT COUNT-205 [**2115-4-30**] 12:16PM WBC-8.6 RBC-3.46* HGB-9.9* HCT-30.0* MCV-87 MCH-28.7 MCHC-33.1 RDW-17.5* [**2115-4-30**] 12:16PM CALCIUM-8.5 PHOSPHATE-3.7 MAGNESIUM-2.2 [**2115-4-30**] 12:16PM GLUCOSE-97 UREA N-82* CREAT-14.0* SODIUM-133 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-20* ANION GAP-22* [**2115-4-30**] 03:03PM SED RATE-93* [**2115-4-30**] 03:03PM CRP-GREATER TH [**2115-4-30**] 05:25PM UREA N-24* [**4-30**] Chest Imaging: IMPRESSION: No acute cardiothoracic process. Very limited study. [**4-30**] Right Foot IMPRESSION: Multiple amputations and changes of neuropathic osteoarthropathy. Interval appearance or increase in left lateral soft tissue ulceration & equivocal bone destruction (is this area of concern/). [**5-1**] Art Rest IMPRESSION: Bilateral tibial arterial disease and possible inflow disease. [**5-1**] Left Foot THREE VIEWS OF THE LEFT FOOT: There are amputations of the fourth and fifth digits. Chronic fracture at the base of the third proximal phalanx is unchanged. There is a large soft tissue defect that appears to extend to the surface of the bone. The underlying bone is sclerotic with interval development of cortical irregularity. The findings raise concern for osteomyelitis. [**5-1**] Path Soft tissue, left foot, debridement (A): Squamous epithelium with subcutaneous fibrous tissue with acute and chronic inflammation and focal necrosis consistent with ulcer bed. Discharge Labs: [**2115-5-6**] 08:00AM BLOOD WBC-7.8 RBC-3.37* Hgb-10.1* Hct-30.2* MCV-90 MCH-29.9 MCHC-33.3 RDW-18.0* Plt Ct-253 [**2115-5-6**] 08:00AM BLOOD Neuts-68.2 Lymphs-23.2 Monos-3.4 Eos-4.0 Baso-1.3 [**2115-5-6**] 08:00AM BLOOD Glucose-192* UreaN-52* Creat-9.1*# Na-136 K-4.4 Cl-88* HCO3-32 AnGap-20 [**2115-5-6**] 08:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.4 Brief Hospital Course: 50 yo M with hx of long-standing Type II diabetes, line infections, ESRD on HD, OSA, obesity, GERD, hx of C Diff who was referred to [**Hospital1 18**] ED from HD on [**4-30**] for fever, admitted to the ICU with SIRS likely attributed to osteomyelitis of left foot called out to floor in stable condition but with possible bacteremia. ACTIVE ISSUES . # Artifactual Hypotension: The patient presented with hypotension, prompting concern for SIRS/Sepsis, but this was subsequently attributed to artifact, with even the largest cough only fitting on his forearm and requiring exquisite positioning for an accurate pressure. . # Osteomyelitis: The patient underwent a bedside evaluation of his left foot by podiatry demonstrating probing to bone; he was then taken to the OR for debridement. Cultures grew MRSA. The patient was treated with vancomycin HD protocol and discharged for a total course of 6 weeks. He was discharged with a vac dressing in place and appropriate ancillary services. . # Bacteremia: Culture from the ED grew S.Epi and a 2nd culture grew anaerobic GPCs attributed to contaminant. Since the patient had a history of difficult access, a collective decision was made between the patient's primary nephrologist, the IV access nurse ([**Doctor First Name 8817**]) and the primary medicine team to discharge the patient with plans for a wire changeover as an outpatient. . # Diarrhea: C.dif negative. Work-up unrevealing. Supporive care was given. . # DM2: Well controlled as an inpatient. Discharged on home dose scale. . # ESRD: Continued HD as an inpatient. Renal medications were unchanged on discharge. . INACTIVE ISSUES: # OSA: Remained on CPAP. . TRANSITIONAL ISSUES: # Tunneled dialysis catheter: To be changed over a wire after discharge. # Osteomyelitis: Patient will continue Vancomycin to complete prescribed course and follow-up with podiatry. Medications on Admission: Sensipar 90mg daily PhosLo 667 with meals Renagel 800mg with meals ISS NPH 22u qAM, 18u qPM Lisinopril 5mg daily Nifedipine ER 60mg daily ASA 325mg daily Nexium 40mg daily Discharge Medications: 1. Sensipar 90 mg Tablet Sig: One (1) Tablet PO once a day. 2. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day. 3. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a day. 4. insulin lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: per sliding scale. 5. NPH insulin human recomb 100 unit/mL Suspension Sig: 22 qAM, 18 qPM units Subcutaneous twice a day. 6. nifedipine 60 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Non-weight bearing status Non-weight bearing status on both left and right feet; OK to transfer 10. Right foot Wet to dry dressing daily. 11. Left foot Wound vac changes q3 days black sponge. Pressure continuous at 125. 12. vancomycin 1,000 mg Recon Soln Sig: One (1) Administration Intravenous every other day for 6 weeks: Per HD protocol. 13. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY: -Osteomyelitis -Bacteremia . SECONDARY: -Diabetes type 2 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It has been a privilege to take care of you at [**Hospital1 18**]. . You were hospitalized for a bone infection of the foot called osteomyelitis. You are being treated with antibiotics, which you will continue to receive with dialysis after discharge. . Your blood was found to be growing bacteria when you were first admitted to the emergency department; you are being treated for this with the same antibiotics for osteomyelitis. Your HD line will be exchanged over a wire this Wednesday at Advanced Vascular Care. **Do not put weight on either foot until you follow-up with Podiatry, who will oversee the management of your feet.** There was initially some concern about your blood pressure being low, but the low pressure was likely due to artificat due to blood pressure cuff size and placement. Your blood pressure has remained stable since admission. . No changes were made to your medications other than as detailed below. START -Vancomycin antibiotics administered with dialysis Followup Instructions: Advanced Vascular Care [**Street Address(2) 111327**], Briton MA [**Telephone/Fax (1) 5537**] 9:30AM . Department: PODIATRY When: WEDNESDAY [**2115-5-8**] at 2:40 PM With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Name: [**Last Name (LF) 5533**],[**First Name3 (LF) **] M. Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**] Phone: [**Telephone/Fax (1) 3581**] When: Tuesday, [**5-14**], 2:30PM

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icd9cm

[ [ [] ] ]

[ "83.39", "77.60", "39.95" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2200-7-20**] Discharge Date: [**2200-7-24**] Date of Birth: [**2135-10-25**] Sex: F Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Iodine-Iodine Containing Attending:[**First Name3 (LF) 5018**] Chief Complaint: two day history of falls and dysarthria Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 32675**] is a 64 year-old right-handed woman with a past medical history including hepatitis C, pulmonary hypertension, and chornic thrombocytopenia who initially presented to [**Hospital1 **] with a two day history of falls and dysarthria and was transferred to the [**Hospital1 18**] when she was found to have a right basal ganglia hemorrhage in the setting of a platelet count of 43. . The patient explains that she last felt well on Friday, two days prior to admission. One day prior to admission she started falling; she thinks that she generally fell toward the left. Although there was no loss of consciousness, she did strike her head during at least one of the spills. She also started to drop items from her left hand. On the evening prior to admission, she reportedly sent her friend a non-sensical email with letters strung together in non- English words. On the day of admission, the patient's friend called her to see how she was faring and discovered the patient's speech was slurred. Accordingly, the friend called 911. The patient was initially taken to [**Hospital1 **]. After a non-contrast CT of the head demonstrated right basal ganglia hemorrhage, she was transferred to the [**Hospital1 18**] for further evaluation and care. Past Medical History: - hepatitis C (contracted from "tainted needle" used in setting of miscarriage) - pulmonary HTN - [**First Name4 (NamePattern1) 329**] [**Last Name (NamePattern1) **] Tear - "stomach bleeds" - lyme disease - anemia - chronic thrombocytopenia - due to IFN tx per daughter - hypothyroidism - IBS - hiatal hernia - fibromyalgia - GERD - osteoporosis Social History: - lives independently - has two children - enjoys symphony and theater Family History: - positive for stroke (mother at age 62 years) - negative for other known neurological conditions Physical Exam: General: Awake, cooperative, NAD. HEENT: Normocepahlic, atraumatic, no scleral icterus noted. Mucus membranes dry, no lesions noted in oropharynx Neck: Supple. Cardiac: Regular rate, III/VI systolic murmur Pulmonary: Lungs clear to auscultation bilaterally anteriorly. Abdomen: round. Normoactive bowel sounds. Soft. Non-tender, non-distended. Extremities: Warm, well-perfused. Skin: no rashes or concerning lesions noted. NEUROLOGIC EXAMINATION: Mental Status: * Degree of Alertness: Alert. Able to relate history. * Orientation: Oriented to person, place, day, month, year, situation * Attention: Attentive. Able to name the days of the week backwards without difficulty. * Memory: Pt able to repeat 3 words immediately and recall [**2-26**] unassisted at 30-seconds and 5-minutes. * Language: Language is fluent without evidence of paraphasic errors. Repetition is intact. Comprehension appears intact; pt able to correctly follow midline and appendicular commands. Prosody is normal. Pt able to name high (knuckles) and low frequency objects (knuckles) without difficulty. [**Location (un) **] and writing abilities intact. * Calculation: Pt able to calculate number of quarters in $1.50 * Neglect: No evidence of neglect. * Praxis: No evidence of apraxia (mimes salute and tooth brushing). Cranial Nerves: * I: Olfaction not evaluated. * II: PERRL 3 to 2 mm. Visual fields full to confrontation (eyes tested individually with red pin). Fundi not well-visualized. * III, IV, VI: EOMI without nystagmus, some saccadic intrusions. * V: Facial sensation decreased on left relative to right to light touch in the V1, V2, V3 distributions. * VII: left facial droop. * VIII: Hearing intact to voice bilaterally. * IX, X: Palate elevates symmetrically. * [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally. * XII: Tongue protrudes in midline. Motor: * Tone: slight increase in tone with subtle spasticity of left upper extremity * Drift: left drift Strength: * Left Upper Extremity: 4 Delt, 4+ Biceps, 4 Triceps, 5 Wrist Ext, 5 Wrist Flex, 4+ Finger Ext, 5 Finger Flex * Right Upper Extremity: 5 throughout Delt, Biceps, Triceps, Wrist Ext, Wrist Flex, Finger Ext, Finger Flex * Left Lower Extremity: 4 Iliopsoas, 5 Quad, 4 Ham, 5 throughout Tib Ant, Gastroc, Ext Hollucis Longis * Right Lower Extremity: 5 Iliopsoas, 5 Quad, 4+ Ham, 5 throughout Tib Ant, Gastroc, Ext Hollucis Longis Reflexes: * Left: brisk throughout Biceps, Triceps, Bracheoradialis, 1+ Patella * Right: brisk throughout Biceps, Triceps, Bracheoradialis, 1+ Patella * Babinski: left extensor, right flexor Sensation: * Light Touch: decreased in left hemibody, intact in right lower extremities, upper extremities, trunk, face * Pinprick: decreased in left hemibody, intact in right lower extremities, upper extremities, trunk, face * Temperature: intact to cold sensation in a * Vibration: intact bilaterally at level of the great toe * Proprioception: intact bilaterally at level of great toe * Extinction: No extinction to double simultaneous stimulation Coordination * Finger-to-nose: intact bilaterally with some degree of dysmetria on left Gait: * Description: Good initiation. Seems to favor left lower extremity with exaggerated weight placed on right lower extremity Pertinent Results: MR head [**2200-7-21**] . Large acute-subacute intraparenchymal hematoma in the right basal ganglia with surrounding edema and mild leftward shift of the midline structures and mass effect on the right lateral ventricle, not significantly changed compared to the recent CT study. Small focus of subarachnoid hemorrhage in the left parietal lobe, corresponding to the previously noted hemorrhage on the CT. 2. 5 x 5 mm saccular, lobulated aneurysm in the region of the confluence of the A1 and A2 segment sof the right anterior cerebral artery and the anterior communicating artery. However, it is unclear if this has ruptured given the farther location of the hematoma. hence, any other aneurysms or vascular lesions cannot be completely excluded. Consider CT angiogram of the head for better assessment of this aneurysm and any other anuerysms/vascular lesions elsewhere and in the hematoma. Rec. INR consult. Post-contrast MR images can be considered after resolution of the hemorrhage to exclude an underlying mass lesion. Findings informed to [**Doctor Last Name **] by Dr.[**Last Name (STitle) **] on [**2200-7-22**]. 3. Diffuse mucosal thickening/fluid in the left mastoid air cells. I7/26/10 US abd. MPRESSION: 1. Chronic appearing nonocclusive thrombus involving the distal splenic vein/SMV confluence with regions of presumed chronic occlusion involving portions of the main portal vein which is diminutive in size. Some intrahepatic right portal flow is noted which may relate to arterial portal shunting or portal collateral vessel formation. Hepatic veins and arteries remain patent. 2. Mild splenomegaly. Coarsened heterogeneous liver parenchyma is presumably secondary to hepatitis C. TTE [**2200-7-21**] The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 10-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Ms. [**Known lastname 32675**] is a 64 year-old right-handed woman with a past medical history including hepatitis C, pulmonary hypertension, and chronic thrombocytopenia who initially presented to [**Hospital1 **] with a two day history of falls and dysarthria and was transferred to the [**Hospital1 18**] when she was found to have a right basal ganglia hemorrhage in the setting of a platelet count of 43. You were admitted to the ICU where you had an uncomplicated course while further workup was made to understand the etiology of your bleed. You had platlet infusion while in the the ICU. You had an MRI, TTE, CT head, CXR. You were observed in the ICU and you had a stable course only requiring frequent close observation. Your major deficits were imbalance, left hand/arm numbness and weakness, and dysarthria/dysphagia with a left facial droop. You were transferred to the floor for further observation. You had a brief episode of hypotension which responded to fluid. And we held your anti-hypertensive medications because of this. Your SBP ranged from the mid 90's to the 110's. You were evaluated by PT /OT who thought it was safe for your to return home with home PT/OT and home health aid which was requested. A call was made to your daughter [**Name (NI) 402**] to arrange for some supervision while the above home health aid could be arranged. You and [**Doctor Last Name 402**] stated that it would be best if the appointments requested were to be made by [**Doctor Last Name 402**] since she would be the one responsible for transportation. The etiology of your hemorrhagic stroke is unknown but thought not to be from hypertension but possibly from platlet dysfunction Vs amyloid angiopathy. Medications on Admission: - neupogen twice weekly - Tues, Sat (dose unknown) - procrit twice weekly - Tues, Sat (dose unknown) - ventavis neb 6 x daily (20mcg ampules) - viagra 50 tab po tid - lasix 120 mg po daily - aldactone 50 mg po daily - levoxyl 150 mcg po daily - pervacid 20 mg po daily - doxycycline 100 mg po bid - lotemax 1 gtt ou tid - tylenol 5/325 mg po q4 hr prn pain - clonazepam 1mg po bid - albuterol 108 mcg 2 puff qidp sob Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as needed for GERD. 2. Sildenafil 20 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day) as needed for pulm htn. 3. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) as needed for lyme. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 6. Iloprost 20 mcg/mL Solution for Nebulization Sig: One (1) ML Inhalation q4hrs (). Discharge Disposition: Home With Service Facility: [**Hospital3 **] HOME CARE Discharge Diagnosis: - Right basal ganglion hemorrhage - hepatitis C (contracted from "tainted needle" used in setting of miscarriage) - pulmonary HTN - [**First Name4 (NamePattern1) 329**] [**Last Name (NamePattern1) **] Tear - "stomach bleeds" - lyme disease - anemia - chronic thrombocytopenia - due to IFN tx per daughter - hypothyroidism - IBS - hiatal hernia - fibromyalgia - GERD - osteoporosis 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 for having a right basal ganglion bleed that was discovered at an outside hospital. You had thrombocytopenia and because of the bleed were given platlet infusion. You had an troponin bump that was thought to be from cardiac stress but given bleeding episode along with previous chronic intercranial pathology consistent with a previous bleed you were not anticoagulated or placed on aspirin. You have multiple serious comorbidiites and we contact[**Name (NI) **] your outpatient specialist. You were borderline hypotensive in the 90-110's systolic. Because of this we held your aldactone and lasix and while metoprolol 12.5 mg was tried this was stopped because this had an adverse effect on your blood pressure. We have asked you to stop these anti-hypertensive medications until you are seen by your [**Name (NI) 3390**]. Followup Instructions: I spoke with you and your daughter [**Name (NI) 402**] who preferred to make your own appointments. Please make an appointment to see; [**Last Name (LF) 32676**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name (Titles) **] [**Last Name (Titles) 3390**] (within 1 week) [**Telephone/Fax (1) 18377**] Dr [**Last Name (STitle) 656**] hepatologist ( in [**12-28**] months)#[**Telephone/Fax (1) 32677**] Dr [**First Name (STitle) **] pulmonology ( in [**12-28**] wks) #[**Telephone/Fax (1) 32678**] Dr [**Last Name (STitle) 32679**] [**Name (STitle) 32680**] (1 month) #[**Telephone/Fax (1) 32681**] Dr [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] ( 2 months) # ([**Telephone/Fax (1) 7394**] [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2200-7-24**]

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icd9cm

[ [ [] ] ]

[ "99.05" ]

icd9pcs

[ [ [] ] ]

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1698, 2046

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21,975

168,143

8744+8745

Discharge summary

report+report

Admission Date: [**2103-10-15**] Discharge Date: Date of Birth: [**2036-8-7**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old male with diabetes, history of PVD, left CVA in [**2098**] and bilateral calf claudication. The patient reported no discomfort or shortness of breath on admission. On [**2103-8-28**] the patient underwent ETT which showed a moderate inferior defect and reversible anterior wall defect. Ejection fraction at the time was 34%. PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, insulin dependent diabetes, PVD, diabetes retinopathy, chronic renal insufficiency, benign prostatic hypertrophy, chronic bronchiectasis, lower extremity claudication, carotid disease status post CEA, left colon polypectomy. MEDICATIONS: Included Aspirin 81 mg po q d, Lasix 40 mg po q d, Folic Acid, Lozar 100 mg po q d, Tandamine 75 mg po q d, Claritin 10 mg po q d, Lipitor 10 mg po q d, Cardura 80 mg po q d, NPH 42 units q a.m. and 10 units q p.m. subcu, Vitamin E, Vitamin C, Multivitamins and Rocaltrol .25 mg po q d. HOSPITAL COURSE: The patient was taken to the operating room by Dr. [**Last Name (STitle) 70**] where he underwent CABG times three on [**2103-10-15**]. He had LIMA to LAD, right saphenous vein to OM and ramus. Postoperatively the patient did well, was extubated and weaned of all drips in the Intensive Care Unit without any incidents. The patient was transferred to the floor on postoperative day #2. However, after transfer onto the floor the patient went into atrial fibrillation. Rate was controlled using beta blocker, Lopressor and patient was IV loaded with Amiodarone and started off on po Amiodarone subsequently. Since then patient has recovered well and was able to work with PT, was able to ambulate more than 500 feet and climbed a flight of stairs before discharge home. Upon discharge the patient's vital signs were stable, condition was afebrile, chest was clear, regular rate and rhythm, normal sinus, sternum was stable, incision was clean, dry and intact. The patient will be discharged home and told to follow-up with Dr. [**Last Name (STitle) 70**] in [**2-25**] weeks. Patient had chronic renal insufficiency with baseline creatinine of 2.4. Upon discharge creatinine was 2.3 and patient's creatinine postoperatively was stable at around 2.3 to 2.5. Upon discharge electrolytes were within normal limits and patient's condition was stable, afebrile. The patient was told to follow-up with Dr. [**Last Name (STitle) 70**] in [**2-25**] weeks. DISCHARGE MEDICATIONS: Lopressor 75 mg po bid, Lasix 40 mg po q d times 7 days, Aspirin 81 mg po q d, NPH 42 units q a.m. subcu and 10 units q p.m. subcu, Amiodarone 400 mg po tid times one day, then 400 mg po bid times one week, then 400 mg po q d, Percocet 1-2 tablets po q 4-6 hours prn, Colace 200 mg po q d. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2103-10-19**] 18:23 T: [**2103-10-19**] 21:41 JOB#: [**Job Number **] Admission Date: [**2103-10-15**] Discharge Date: [**2103-10-23**] Date of Birth: [**2036-8-7**] Sex: M Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: This 67 year-old diabetic patient with significant history of peripheral vascular disease with no history of chest discomfort or shortness of breath. In [**2103-8-25**] he underwent an exercise treadmill thallium test, which was positive. The patient was referred for cardiac catheterization. Cardiac catheterization showed moderate pulmonary hypertension, three vessel disease. Exercise treadmill thallium test showing an ejection fraction of 34%. The patient was referred to cardiac surgery for operative procedure. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Peripheral vascular disease. 3. Hypertension. 4. Hypercholesterolemia. 5. Insulin dependent diabetes mellitus. 6. Diabetic retinopathy status post bilateral laser ablation. 7. Chronic renal insufficiency. 8. Benign prostatic hypertrophy. 9. Chronic bronchiectasis. 10. History of lower extremity claudication. 11. Status post left CEA [**2098**]. 12. Status post excision of right facial skin cancer. 13. Status post resection of colonic polyps. 14. Status post resection of nasal polyps. ALLERGIES: 1. Sulfa. 2. Calcium channel blockers. PREOPERATIVE MEDICATIONS: 1. Aspirin 18 mg po q day. 2. Lasix 40 mg po q day. 3. Folic acid 1 mg po q day. 4. Cozaar 100 mg po q day. 5. Tenormin 75 mg po q day. 6. Claritin 10 mg po q day. 7. Lipitor 10 mg po q day. 8. Cardura 8 mg po q day. 9. NPH insulin 42 units subQ q.a.m., 10 units subQ q.p.m. 10. Humalog insulin sliding scale before meals. 11. Rocaltrol 0.25 mg q day. INITIAL PHYSICAL EXAMINATION: Temperature 97.6. Pulse 64 sinus rhythm. Blood pressure 128/70. Cardiovascular S1 and S2. S4 present. Lungs bibasilar crackles. Abdomen soft, positive bowel sounds. Extremities no carotid bruits. Positive left femoral bruit. Trace distal pulses bilaterally. LABORATORY DATA: CBC white blood cell count 7.3, hematocrit 34.5, platelet count 161, sodium 141, potassium 5.0, chloride 103, bicarb 26, BUN 54, creatinine 5.4, blood sugar 279. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2103-10-15**] by Dr. [**Last Name (STitle) 70**] for a coronary artery bypass graft times three, left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to obtuse marginal to ramus. Please see operative note for further details. The patient was transferred to the Intensive Care Unit in stable condition on Levophed to maintain blood pressure. The patient was weaned and extubated from mechanical ventilation on his first postoperative night. The patient required neosinephrine and insulin drip on postoperative day one. The patient was weaned from these medications and started on regular insulin sliding scale as well as NPH and transferred to the floor. Chest tubes were removed on postoperative day one and on postoperative day number two the patient went into atrial fibrillation with rapid ventricular response. The patient was treated with intravenous Lopressor, intravenous and oral Amiodarone. The patient remained hemodynamically stable throughout. The patient converted into sinus rhythm the night of postoperative day number two. The patient had multiple episodes of paroxysmal atrial fibrillation, which responded to intravenous Lopressor converted to sinus rhythm. The patient experienced hyperkalemia on postoperative day number six. His potassium was 5.6. The patient was given a dose of Kayexalate and subsequent potassium were less then 5. The patient's creatinine rose to 2.7 on postoperative day number 7, but returned down to the low baseline on postoperative day number eight to 2.3. The patient ambulating with the help of physical therapy. The patient experiencing oxygen desaturation with ambulation. On postoperative day number seven it was noted that the patient's left lower extremity saphenectomy site at the knee medial portion to be erythematous, warm to touch and painful. The patient was started on Dicloxacillin po times ten days due to his history of diabetes. On postoperative day number eight the patient was cleared for discharge for a rehabilitation facility. CONDITION AT DISCHARGE: Temperature max 98.9. Pulse 63 sinus rhythm. The patient has been in sinus rhythm for over 24 hours. Blood pressure 136/60. Room air oxygen saturation 94%. Weight 83.7 kilograms. Preoperative weight 77 kilograms. Neurologically the patient is awake, alert and intact. Cardiovascular regular rate and rhythm. No murmurs or rubs. Extremities are warm and well profuse. Respiratory breath sounds are clear bilaterally, decreased posteriorly at the bases. Gastrointestinal, positive bowel sounds. Abdomen is softly distended, nontender. The patient has been complaining of mild constipation. Positive flatus. Sternal incision is clean, dry and intact. No erythema or drainage. Sternum is stable. Left lower extremity saphenectomy at the knee, has minimal to moderate erythema edema, warm to touch. Steri-Strips are intact. No drainage is noted. CBC white blood cell count 8.6, hematocrit 29.0, platelet count 271, sodium 140, potassium 4.0, chloride 100, bicarb 31, BUN 59, creatinine 2.3. PT 13.1, INR 1.2. The patient is on Coumadin and Lovenox for atrial fibrillation. DISCHARGE STATUS: The patient is to be discharged to a rehabilitation facility in stable condition. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft. 2. Postoperative atrial fibrillation. 3. Postoperative left lower extremity saphenectomy wound infection. 4. Hypertension. 5. Hypercholesterolemia. 6. Peripheral vascular disease. 7. Diabetic retinopathy. 8. Insulin dependent diabetes mellitus. 9. Chronic renal insufficiency. 10. Benign prostatic hypertrophy. 11. Chronic bronchiectasis. 12. Lower extremity claudication. 13. Status post left CEA. 14. Status post excision of right facial skin cancer. 15. Status post resection of colon polyps. 16. Status post resection of nasal polyps. MEDICATIONS ON DISCHARGE: 1. Lopressor 100 mg po b.i.d. 2. Lasix 40 mg po q day. 3. Amiodarone 400 mg po t.i.d. times two days and then 400 mg po b.i.d. times seven days and then 400 mg po q day. 4. Lovenox 70 mg subQ b.i.d., discontinue when INR greater then 2.0. 5. Coumadin 2 mg po on [**10-23**] and then check PT/INR [**10-24**] and adjust Coumadin for INR 2.0 to 2.5. 6. Dicloxacillin 500 mg po q.i.d. times ten days. 7. Colace 100 mg po b.i.d. 8. Lipitor 10 mg po q.h.s. 9. Aspirin 81 mg po q day. 10. NPH insulin 42 units subQ q.a.m., 10 units subQ q.p.m. 11. Dulcolax 1 po pr q day prn. 12. Percocet 5/325 one to two tabs po q 4 to 6 hours prn. 13. Regular insulin sliding scale for blood sugar 150 to 200 give 3 units subQ, blood sugar 201 to 250 give 6 units subQ, blood sugar 251 to 300 give 9 units subQ, blood sugar 301 to 350 give 12 units subQ. The patient is to have Coumadin adjusted by the rehab facility for a PT/INR 2.0 to 2.5. Upon discharge from the rehab facility the patient's primary care physician is to dose his Coumadin. The patient is to be placed on an 1800 [**Doctor First Name **] renal low fat diet. The patient is to have his blood sugars checked before meals and at bedtime. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 3870**] MEDQUIST36 D: [**2103-10-23**] 11:14 T: [**2103-10-23**] 11:57 JOB#: [**Job Number 30600**]

[ "414.01", "593.9", "427.31", "250.51", "682.6", "276.7", "362.01", "998.59", "997.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8738, 9339

2590, 3317

9366, 10886

5384, 7509

4517, 4895

4918, 5366

7524, 8717

3346, 3869

3892, 4490

294

152,578

23278

Discharge summary

report

Admission Date: [**2118-1-17**] Discharge Date: [**2118-2-2**] Date of Birth: [**2039-5-21**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2704**] Chief Complaint: Transfer from outside hospital for PVD/left foot ischemia and NSTEMI Major Surgical or Invasive Procedure: -cardiac catheterization, stenting of LAD -left common femoral artery - DP bypass History of Present Illness: 78yo man with 30year history of HTN, 15 year history of DM, PMR on steroids, and inferior wall MI in [**2108**] who was admitted to [**Hospital3 **] on [**1-14**] with an ischemic left foot. Angiography showed SFA occluded and occluded popliteal above the knee. PTA was done of the mid popliteal with dissection of the politeal below the knee, which was stented. Post procedure, he ruled in for NSTEMI and suffered cardiogenic shock. He was on pressors, natrecor, and intubated. Subsequently, the leg worsened, becoming cool and cyanotic. He was then referred to [**Hospital1 18**] for further management. At [**Hospital1 18**], he underwent cardiac catheterization with stenting of the LAD. He also had angio/thrombectomy/tpa infusion of left SFA on [**1-17**]. He then underwent left CFA to DP bypass on [**1-20**]. Of note, creatinine was 1.7 on admission, which trended upward to 5.7 on [**1-22**]. Past Medical History: Hypertension DM II CAD with inferior wall MI in [**2108**] (no catheterization) PMR on steroids peripheral [**Year (4 digits) 1106**] disease h/o duodenal ulcer CRI CHF BPH dementia Social History: lives with wife no etoh or drug use previous history of tobacco use Family History: No family history of CAD Physical Exam: Physical exam on admission: P 75, BP 160/76, R 24, 100% sat exam significant for - resp: occasional scattered rhonchi - cv: RRR, S1 and S2 - extr: left extremity cool to the touch, motteld and necrotic digit Pertinent Results: [**2118-1-17**] 11:25PM GLUCOSE-552* UREA N-44* CREAT-2.0* SODIUM-137 POTASSIUM-3.0* CHLORIDE-89* TOTAL CO2-40* ANION GAP-11 [**2118-1-17**] 11:25PM CK(CPK)-297* [**2118-1-17**] 11:25PM CK-MB-4 [**2118-1-17**] 11:25PM CALCIUM-7.2* PHOSPHATE-3.4 MAGNESIUM-1.6 [**2118-1-17**] 11:25PM WBC-7.5 RBC-2.83* HGB-9.1* HCT-27.1* MCV-96 MCH-32.4* MCHC-33.8 RDW-13.7 [**2118-1-17**] 11:25PM PLT COUNT-156 [**2118-1-17**] 11:25PM PT-13.7* PTT-100.2* INR(PT)-1.2 [**2118-1-17**] 05:25PM INR(PT)-1.6 Brief Hospital Course: 1) CAD: Suffered NSTEMI at outside hospital, c/b cardiogenic shock. He underwent cardiac catheterization with placement of stent of LAD here. Cardiac catheterization revealed the following: -left dominant coronary anatomy -LMCA: distal taper of 40% -LAD: origin 80% lesion with serial 80% lesion in proximal LAD with moderate diffuse disease in the LAD -LCX: dominant vesel with moderate diffuse disease -RCA: non-dominant vessel with moderate diffuse disease -LSFA: diffuse disease from the FA to the stent; stents are occluded without reconstitution distally; there are mild geniculated collaterals to the infrapopliteal arteries without named vessels below. He was medically managed with ASA, plavix, beta blocker, and statin, ace inhibitor. He remained stable. Please continue medications on discharge. 2) Pump: He was felt to be euvolemic. There were no signs/symptoms of CHF despite receiving free water to correct his hyponatremia. He had an echo performed on [**1-18**], which demonstrated the following: -mild dilation of the left atrium -mild symmetric left ventricular hypertrophy with normal LV cavity size -overall LVEF preserved = 55% -noted basal inferior hypokinesis -Mitral valve leaflets mildly thickened -trivial mitral regurgitation 3) Acute/chronic renal insufficiency: Acute exacerbation of chronic renal insufficiency; felt to be secondary to contrast nephropathy following multiple procedures. Creatinine peaked at 5.7, and trended down to 1.5, which may be his new baseline level. 4)Hypernatremia: Resolved with Free water deficit replaced. Encouraging PO free h2o. 4) DM2: He was monitored with finger sticks glucose checks and covered with sliding scale insulin. BG levels not well controlled and remained b/w 250-300. He was not on outpt oral medications but started on glipizide 2.5mg [**Hospital1 **] on [**2118-2-1**] which improved BG control. 5) [**Date Range **]: He has a significant history of peripheral [**Date Range 1106**] disease, and is now s/p intervention followed by left CFA-DP bypass for this. As [**Date Range 1106**] surgery was concerned for infection of hematoma on his left calf,he was started on antibiotic coverage including vanc/levo/flagyl. Culture sent and revealed no growth. No microorganisms seen. His antibiotics were changed to keflex and levofloxacin on [**2118-2-2**] for empiric coverage. These should be continued for 1 week (last dose on [**2118-2-9**]). ACE on calf at all times. He will need toe amputation as an outpatient. He is to follow up with Dr. [**Last Name (STitle) **] from podiatry on [**2-9**] regarding 4th toe amputation and Dr. [**Last Name (STitle) 57956**] on [**2-9**] for r/u after surgery. At that time, he will have staples removed and discuss whether or not to continue antibiotics. [**1-18**]: concern for RUE edema and infiltration of IV site. Plastic surgery was consulted. No compartment syndrome. He has been keeping R arm elevated, as per recs. Also continue [**Hospital1 **] dressing changes with xeroform over blisters until resolve. Much improvement. Swelling/ecchymosis cont to decrease. 6) Mental Status: Baseline level of dementia/cognitive impairment, complicated by acute delirium. Neurology was involved; head CT was negative for bleed. Attempts at lumbar puncture failed. Altered mental status was felt to be secondary to sedative medications. As these meds were held, his mental status progressively improved back toward baseline. Still has some short-term memory deficits which will likely improve with time, but if they don't will require further neurologic evaluation. Medications on Admission: prednisone 5mg qD lisinopril 20mg qD plavix 75mg qD lipitor 80mg qD MVI lopressor 50mg [**Hospital1 **] protonix 40mg qD Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 300 days. 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Insulin Regular Human 100 unit/mL Solution Sig: please see sliding scale Injection ASDIR (AS DIRECTED). 4. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 14. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 19. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 20. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 weeks. 21. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for 1 weeks. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary diagnosis: NSTEMI - s/p cardiac catheterization Secondary diagnosis: Peripheral [**Location (un) 1106**] disease with popliteal artery thrombosis s/p fem-DP bypass Diabetes mellitus, type 2 Medication induced delerium Acute on chronic renal failure secondary to contrast nephropathy. Hypertension Discharge Condition: stable Discharge Instructions: Patient is to be discharged to [**Hospital3 **] Center. Please return to ED if you develop chest pain, shortness of breath, opening of left leg incision, or other worrisome symptom. Please follow up with podiatry and [**Hospital3 1106**] surgery as scheduled. Followup Instructions: You should call Dr [**First Name (STitle) **] to schedule a follow-up appointment for 1 week from your discharge for evaluation. Also, please follow up with Dr [**Last Name (STitle) **] from podiatry to evaluate your left toes on [**2118-2-9**] at 11:20am. LOCATION: [**Street Address(2) 59787**]. Far building. [**Location (un) 470**]. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **] SURGERY Date/Time:[**2118-2-9**] 9:45

[ "E937.9", "V58.65", "584.5", "440.24", "250.00", "410.71", "996.74", "276.0", "725", "999.9", "998.12", "292.81" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.10", "88.56", "88.48", "99.04", "36.01", "36.07", "39.50", "37.22", "39.29" ]

icd9pcs

[ [ [] ] ]

8134, 8219

2472, 5592

340, 424

8569, 8577

1946, 2449

8885, 9440

1672, 1698

6257, 8111

8240, 8240

6112, 6234

8601, 8862

1713, 1727

232, 302

452, 1365

8318, 8548

8259, 8297

1742, 1927

5608, 6086

1387, 1571

1587, 1656

71,943

186,900

47184

Discharge summary

report

Admission Date: [**2143-3-9**] Discharge Date: [**2143-3-12**] Date of Birth: [**2058-2-4**] Sex: M Service: MEDICINE Allergies: Levaquin / Quinolones / Polysorbates Attending:[**First Name3 (LF) 2009**] Chief Complaint: Left upper quadrant abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 85 yo M with CAD, COPD on 2L home O2, Parkinson's, Alzheimer's, HTN, multiple back surgeries who presents with severe upper abdominal pain LUQ>RUQ. Per the patient's report, coroborated by his wife his pain started Thursday at dinner and was sharp and stabbing in nature, it was worsened by movement and inspiration, and increased up to [**9-9**] over the last few days. He states it was in the same place that he was punched in the stomach a month ago by an aid at his nursing home. . Patient reports no associated fevers, chills, nausea, vomiting, diarrhea, change in stool, blood in stool, or dark/tarry stool. He denies cough or change in chronic SOB, but reported pain with deep breaths in the ED which he denies on the floor. . In the ED, initial vs [**9-9**] pain 97.8 81 118/64 16 97% 4L NC. In the ED he desatted to the high 80s off of O2 and was found to have wheezes in all lung fields, JVP up to the jaw, and 3+ pitting edema bilaterally. His abdomen was noted to be tense and tender diffusely, worst in the LUQ. The patient was given Morphine 4 mg IV x 2 for pain, albuterol nebs, and Solumdedrol 125mg IV. CXR showed low lung volumes and linear atelectasis, CT chest that showed possible aspiration, low lung volumes, atelectasis, poor bolus timing, no central or lobar PE. CT abd/pelvis showed no acute process. EKG showed SR at 80 bpm, RBBB, inferior Q waves, unchanged from prior. . On the floor, he is in no respiratory disress, says his breathing is at his baseline. He is c/o LUQ pain worsened by leaning to his side. He states that it occasionally radiates around to the back. He does not think anything releives it including passing gas. He states his last bowel movement was yesterday, and it was normal and formed. Careful review of his [**Hospital1 1501**] notes reveal oxygen sats of 88-96 % on 2L, with baseline wheezes and crackles. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: had "minor heart attack" 30-35 years ago prostate CA parkinson's alzheimer's dementia HTN h/o back operations - last 5 years ago, has been wheelchair bound, can't stand, legs are very weak, not able lift up own legs angina throat polyps (cancerous) removed 5-6 years h/o UTI's lumbar stenosis, diagnosed [**2129**] s/p laminectomy/discetomy [**2117**] at [**Location 1268**] VA s/p back surgery [**2130**] s/p appendectomy s/p tonsillectomy/adenoidectomy Social History: He currently lives in [**Hospital **] [**Hospital **] Nursing Home. His wife lives in an assisted care facility nearby. tobacco: former smoker, quit [**2117**], started at age 11 EtOH: rare Drugs: denies Family History: Father died in MVC. Mother had [**Name (NI) 2481**]. Brother with heart failure. Physical Exam: VS: Tm 98.2 Tc 97.2 BP 130/75 HR 74 RR 15 O2sat 89-93% (2L) GA: AOx3, in NAD HEENT: PERRLA. MMM. no LAD. no JVD. Cards: Difficult to ausculate due to loud breath sounds. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: Upper airway sounds throught the lung. Anterior exam notable for good air movement to the bases. Abd: + bs, soft, distended, tympanic. no g/rt. Extremities: wwp, 2+ edema to ankles bilaterally. DPs, PTs 2+. GU: Foley and Flexiseal in, draining urine and stool, respectively Skin: slight mottling on soles Neuro/Psych: CNs II-XII intact. Alert and oriented. Pertinent Results: 1. Labs on admission: [**2143-3-9**] 10:35AM BLOOD WBC-10.2 RBC-3.50* Hgb-12.0* Hct-35.0* MCV-100*# MCH-34.2*# MCHC-34.2 RDW-14.5 Plt Ct-226 [**2143-3-9**] 10:35AM BLOOD Glucose-148* UreaN-21* Creat-1.4* Na-135 K-7.4* Cl-95* HCO3-31 AnGap-16 [**2143-3-9**] 10:35AM BLOOD ALT-10 AST-53* AlkPhos-48 TotBili-0.5 [**2143-3-9**] 10:35AM BLOOD proBNP-496 [**2143-3-9**] 10:35AM BLOOD cTropnT-0.07* [**2143-3-10**] 02:14AM BLOOD CK-MB-3 cTropnT-0.03* [**2143-3-9**] 10:35AM BLOOD Lipase-26 [**2143-3-9**] 10:35AM BLOOD Albumin-3.7 [**2143-3-10**] 02:14AM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.9 Mg-2.0 [**2143-3-10**] 02:14AM BLOOD VitB12-326 Folate-GREATER TH . 2. Labs on discharge: [**2143-3-12**] 05:40AM BLOOD WBC-7.8 RBC-3.36* Hgb-11.4* Hct-33.4* MCV-99* MCH-34.0* MCHC-34.2 RDW-14.5 Plt Ct-243 [**2143-3-11**] 05:50AM BLOOD Glucose-94 UreaN-20 Creat-1.1 Na-141 K-3.9 Cl-100 HCO3-31 AnGap-14 [**2143-3-10**] 02:14AM BLOOD ALT-8 AST-15 LD(LDH)-226 CK(CPK)-73 AlkPhos-53 TotBili-0.4 [**2143-3-11**] 05:50AM BLOOD Calcium-9.3 Phos-2.3*# Mg-2.1. . Urine culture ([**2143-3-9**]): No growth . 3. Imaging/diagnostics: - CXR ([**2143-3-9**]): Lung volumes are low and there is associated linear subsegmental atelectasis at both lung bases. Mild central pulmonary vascular congestoin is likely present. Cardiac, mediastinal, and hilar contours are unchanged. There is no pleural effusion, pneumothorax. Lumbar spinal fixation hardware is partially imaged. IMPRESSION: Mild congestion. . - CTA chest ([**2143-3-9**]) & CT abdomen ([**2143-3-9**]): 1. No acute aortic syndrome. 2. Suboptimal opacification of the pulmonary arterial tree, permitting only confident exclusion of central and lobar pulmonary embolus. Segmental and subsegmental evaluation is limited. 3. Secretions in the left main stem bronchus, with dependent opacity in the left base, suggesting possible aspiration. Evolving infectious consolidation cannot be excluded. 4. Low lung volumes, with diffuse dependent atelectasis. 5. Bowing of the posterior tracheal wall, suggesting tracheomalacia. 6. No acute intra-abdominal process or explanation for left upper quadrant pain. 7. Innumerable renal hypodensities, incompletely characterized on this study, though grossly stable from prior examination in [**2142-3-31**]. 8. Extensive aortic and coronary atherosclerosis. 9. Healed sternal fracture, T6 compression fracture, status post kyphoplasty, multiple rib fractures. Extensive posterior fusion from T10 through L5 is also unchanged. There is a chronically dislocated right femoral prosthesis. . - Abdominal plain film ([**2143-3-12**]): **** prelim read **** Dilater loops of bowel consistent with ileus. . Pending labs on discharge (to be followed by outpatient PCP) - Blood culture ([**2143-3-9**]) Brief Hospital Course: 85 yo M with CAD, COPD on 2L home O2, tracheomalacia, Parkinson's and Alzheimer's dementia, HTN, multiple back surgeries, and hx of left stomach trauma, admitted to MICU severe upper abdominal pain, now transferred to floor. . # LUQ Pain: Etiology most likely a combination of increased abdominal distention from constipation (on chronic oxycodone) and gas superimposed on known rib fractures. CT abdomen was reassuring in that there is no evidence of splenic infarct, bowel stranding to indicate AMI, gall stones, or pancreatitis. Labs are reassuring for the lack of cholestasis, lipase elevation or LFT elevation. Old rib fractures again seen. Troponin peaked at 0.07 -> 0.03 without any signs to suggest ACS. No PE or PNA on CTA. Abdominal plain film showed dilated loops of bowel without signs of free air. Patient treated with aggressive bowel regimen with passing of flatus and stool throughout. Pain treated with tylenol and restarted on home oxycodone dose prior to discharge. . # Hypoxia: Chronic issue with COPD and tracheomalacia. On 2L of oxygen at home and saturation here ranged from 89-95%, similar to baseline. Ruled out PE and pneumonia on CTA. Continued on home nebs and PRN guaefenesin. . # Acute renal failure: On admission Cr elevated at 1.4 which resolved after hydration. Most likely prerenal from decreased po intake. . # Macrocytic Anemia: Slight Hct drop from 35 -> 32.9 but then stable and comparable to baseline. No signs of abdominal bleed on CT abdomen. B12 and folate level appropriate. Continued on iron and folate supplementation. . # CAD: Ruled out for MI. Continue ASA 81, 12.5mg [**Hospital1 **] metoprolol. . # Alzheimers: Continued on Celexa 40 mg PO once a day and Donepezil 10mg QHS. . # Parkinsons disorder: Continued on Comtan 200 mg PO TID and Carbidopa-Levodopa 25-100 mg TID. . # h/o Seizure disorder: Continued on Divalproex 250 mg once a day . # Dry eyes: Continued on refresh eye drops OU QID . # Osteoporosis: Continued on Multivitamin, vitamin D, Calcium . # h/o Prostate cancer: Patient continued on home bicaluamide dose. Lupron was not given as next injection due [**2143-3-30**]. . # GERD: Continued on Omeprazole 40 mg Capsule PO BID . # Gout: Continued on allopurinol 100mg daily. . Pending labs on discharge (to be followed by outpatient PCP) - Blood culture ([**2143-3-9**]) Medications on Admission: * Aspirin 81 mg Tablet PO once a day. * Oxycodone 5 mg Tablet Sig: [**12-2**] (one-half) q8 PO PRN pain * Celexa 40 mg PO once a day. * Divalproex 250 mg Tablet, Delayed Release (E.C.) PO once a day * Gabapentin 400 mg PO TID * Donepezil 10mg QHS * Comtan 200 mg PO TID * Combivent 18-103 mcg/Actuation TID * Carbidopa-Levodopa 25-100 mg TID * Refresh eye drops OU QID * Aricept 10 mg PO QHs * Guaifenesin 10ml PO q4h prn cough * Multivitamin PO DAILY * Vitamin D 800 daily * Bicalutamide 50mg daily * Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Daily * Calcium Carbonate 500 mg Tablet [**Hospital1 **] * Docusate Sodium 100 mg PO BID * Metoprolol Tartrate 12.5 mg PO BID * Spironolactone 25mg [**Hospital1 **] * Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS * Omeprazole 40 mg Capsule, PO BID * Lupron Depot (3 Month) 22.5 mg Syringe Sig: One (1) Injection Intramuscular q 3 mo. * Allopurinol 100 mg PO DAILY * Iron 325 mg (65 mg Iron)PO once daily * Folic Acid 1 mg PO DAILY * Lasix 60 mg PO once a day. * Terazosin 5 mg PO at bedtime. * Erythromycin Eye drops OU TID Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: Please hold for constipation. 3. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. gabapentin 400 mg Capsule Sig: One (1) Capsule PO three times a day. 6. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. entacapone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) Inhalation three times a day. 9. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Refresh Tears 0.5 % Drops Sig: One (1) drop Ophthalmic four times a day. 11. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO every four (4) hours as needed for cough. 13. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 17. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 20. spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a day. 21. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 22. leuprolide (3 month) 22.5 mg Syringe Sig: One (1) injection Intramuscular Q3MO (every 3 months). 23. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 25. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) application to each eye Ophthalmic three times a day. 27. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 28. Lasix 40 mg Tablet Sig: 1.5 Tablets PO once a day. 29. simethicone 125 mg Capsule Sig: One (1) Capsule PO four times a day as needed for bowel gas. 30. lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO three times a day. 31. Miralax 17 gram/dose Powder Sig: One (1) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: PRIMARY DIAGNOSIS: Abdominal pain Acute renal failure Constipation . SECONADRY DIAGNOSES: Hypoxia COPD Tracheomalacia Anemia GERD Gout Dementia Seizure disorder Prostate cancer Rib fractures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. [**Known lastname **], you were admitted to the [**Hospital1 827**] because you had abdominal pain. We did a CT scans of your chest and your abdomen, which were all reassuring. You had a lot of gas and stool in your bowels, which can explain your pain. We gave you medication to help with that. You also have old rib fractures which can contribute to your pain. You will be returning to your nursing home. . up more than 3 lbs. . Medications: ADDED: - simethicone 125 mg Capsule by mouth four times a day as needed for bowel gas. - Lactulose 30 mL by mouth three times a day - Polyethylene Glycol 17 g by mouth daily CHANGED: none REMOVED: - Senna 1 TAB by mouth twice a day - Followup Instructions: Please ask your nursing home to make a follow-up appointment with your primary care doctor within the next 7-14 days. Completed by:[**2143-3-12**]

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Discharge summary

report

Admission Date: [**2149-10-11**] Discharge Date: [**2149-10-28**] Date of Birth: [**2083-8-6**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 65686**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: - Endotracheal tube intubation [**2149-10-12**] - Left IJ central venous line [**2149-10-13**] - Left radial arterial line [**2149-10-13**] - Endotracheal tube extubation [**2149-10-14**] - Removal of Left IJ CVL [**2149-10-15**] - Removal of Left radial arterial line [**2149-10-15**] History of Present Illness: 66 YO M with neuroendocrine small cell carcinoma (Merckel's) s/p L craniotomy for tumor resection of L parietal/temporal mass on [**2149-8-14**] s/p WBI, recent h/o Serratia meningoencephalitis (completed a 2 week course of Ceftriaxone from [**Date range (1) 79614**]), c diff colitis p/w admitted for altered mental status from [**Hospital1 **], found to have recurrent meningities in ED, and seizure on the floor requiring ativan now being transferred to [**Hospital Unit Name 153**] for further management. Of note pt underwent tumor resection ([**8-14**]), readmitted ([**Date range (1) 79615**]) for pansensitive Serratia Marcescens meningitis (tx w/ ceftriaxone [**Date range (1) 79614**]), c diff colitis, and LE DVT (tx w/ lovenox). Per wife, had an episode of ?seizure on that admission, though no documentation in OMR. Pt readmitted for ICH in the region of his prior tumor resection, lovenox stopped and repeat LENIs negative for clot. Since then pt has been at [**Hospital3 **], being treated w/ po vanc for recurrent c diff. Morning of admission, pt w/ emesis, h/a, neck stiffness, and unresponsive brought to ED. In the ED, VS 98.6 (rectal temp 102) 111 127/80 20 97% 102. Pt unresponsive, w/ episode of agitation. Labs: lactate of 3.1, K 3.4, Mg 1.8, Hct 36, ABG 7.56/24/120. Head ct showed reduced area of ICH. LP revealed yellow, cloudy fluid w 6350 WBCs and 13 RBCs (93% polys), glu. He was given cefriaxone, vanc, acyclovir, ampicillin, 1L NS. Neurosurgery evaluated pt, nothing to do. On arrival to the floor, pt tachy to low 100s, SBP 120, rectal temp 103.1. He was unresponsive. He had episode of upper body shaking, and disconjugate gaze, thought to be seizure w/ improvement of ativan 2mg x2. Neuro consulted recommended keppra loading (20mg/kg) x1. Currently, patient is non-responsive. Past Medical History: # Neuroendocrine small cell cancer likely [**Location (un) 5668**] cell: - diagnosed in [**7-/2147**] after patient incidentally found a left axillary lymph node. FNA was positive for malignant cells, positive for cytokeratin (AE1/3/CAM 5.2), CK20, synaptophysin, and chromogranin, negative for CD45, CK7, TTF-1, and S-100. The immunophenotype suggested a neuroendocrine carcinoma. Imaging studies showed FDG-avid enlarged left axillary lymph node without other concerning nodes or masses. - [**8-/2147**]/[**2146**]: 4 cycles of cisplatin and etoposide - [**11/2147**]/[**2147**]: received radiation - [**4-/2148**]: imaging study showed no evidence of recurrence of - [**8-/2149**]: several weeks of AMS --> large L temporo/parietal/occipital lesion s/p craniotomy by Dr. [**Last Name (STitle) **], biopsy consistent with [**Location (un) 5668**] cell cancer #. [**2149-8-14**]: s/p Left parietal-occipital craniotomy for mass resection. Pathology report was consistent with a neuroendocrine tumor. #. Treated for recent UTI and epididymitis as an outpatient prior to [**2149-8-12**] admission #. Basal cell carcinoma #. Left hip pain #. H/o shooting pain to the left lower extremity after a fall in college #. pan-sensitive SERRATIA MARCESCENS meningitis [**2149-8-24**] treated with ceftriaxone #. C. diff #. VRE ? rectal swab Social History: (From OMR) Married. Works as a dentist, likes to be called "Doc". No smoking history. Family History: Unable to obtain. (From OMR) His father did have melanoma and developed brain metastases. He mother had thyroid disease and congestive heart failure. He has two sisters, all healthy. History of malignant melanoma in his maternal aunt. Physical Exam: Physical Exam on Admission to [**Hospital Unit Name 153**] Tcurrent: 39.3??????C, HR: 110 bpm, BP: 128/59 mmHg, RR: 24 insp/min, SpO2: 96% General: Unresponsive, laying in bed, no current seizure activity Neuro: Unresponsive, Horizontal nystagmus preferntially to the left, Pt grimaces, normal muscle bulk/tone, equivical babinski, no clonus HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Coarse anterior breath sounds CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: cool extremities, palpable peripheral pulses, no clubbing, cyanosis or edema Pertinent Results: Labs upon admission: [**2149-10-11**] 12:25PM BLOOD WBC-9.9 RBC-4.13* Hgb-13.2* Hct-36.0* MCV-87 MCH-31.8 MCHC-36.5* RDW-18.0* Plt Ct-252 [**2149-10-11**] 12:25PM BLOOD Neuts-94.6* Lymphs-3.7* Monos-1.2* Eos-0.2 Baso-0.4 [**2149-10-14**] 03:04AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-1+ Polychr-NORMAL Spheroc-1+ Ovalocy-1+ Burr-1+ Tear Dr[**Last Name (STitle) 833**] [**2149-10-11**] 12:25PM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1 [**2149-10-14**] 11:51AM BLOOD Fibrino-839* [**2149-10-11**] 12:25PM BLOOD Glucose-133* UreaN-13 Creat-0.5 Na-136 K-3.4 Cl-100 HCO3-21* AnGap-18 [**2149-10-11**] 10:37PM BLOOD ALT-28 AST-15 CK(CPK)-23* AlkPhos-49 TotBili-0.6 [**2149-10-11**] 12:25PM BLOOD Calcium-8.5 Phos-3.3 Mg-1.8 [**2149-10-14**] 03:04AM BLOOD calTIBC-113* VitB12-254 Folate-11.7 Hapto-268* Ferritn-[**2088**]* TRF-87* [**2149-10-13**] 03:00AM BLOOD Genta-1.1* [**2149-10-13**] 01:39AM BLOOD Osmolal-275 [**2149-10-11**] 12:31PM BLOOD Type-ART Temp-37.0 Rates-/26 pO2-120* pCO2-24* pH-7.56* calTCO2-22 Base XS-1 Intubat-NOT INTUBA Comment-GREEN TOP [**2149-10-11**] 12:31PM BLOOD Glucose-127* Lactate-3.1* Na-135 K-3.2* Cl-100 [**2149-10-12**] 01:14AM BLOOD freeCa-1.08* Microbiology: CSF: [**2149-10-11**] SERRATIA MARCESCENS - rare growth | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Crypotcoccal antigen: negative Fungal culture: negative Blood cultures: [**2149-10-11**]: no growth C.diff [**2149-10-12**]: negative Urine [**2149-10-12**]: no growth Sputum [**2149-10-14**]: yeast CSF: [**2149-10-14**]: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. Imaging: CT head [**2149-10-11**]: 1. Progressive decreased size of left occipitoparietal intracranial hemorrhage with surrounding edema. No new definite areas of hemorrhage. 2. Evaluation for possible intracranial infection is limited on this study and if there is clinical concern for an infection, MRI with contrast should be performed. 3. Stable configuration of the ventricles with enlargement of the left temporal [**Doctor Last Name 534**]. MRI/MRV head [**2149-10-12**]: 1. Dramatic interval change, characterized by new confluent foci of slow diffusion with extensive leptomeningeal enhancement in both frontal lobes with pachymeningeal enhancement in the left temporal pole in keeping with meningoencephalitis and early cerebritis, consistent with clinical course and recent CSF results. 2. Large left temporoparieto-occipital surgical cavity with nodular margins appears slightly more prominent since the recent studies. The presence of blood products in the cavity makes it difficult to exclude superinfection with abscess formation at this site. However, the overall appearance is not much changed, with no increase in associatd FLAIR-signal abnormality indicative of further edema, as might be expected with pyogenic infection. 3. Ependymal enhancement in the occipital [**Doctor Last Name 534**] of left lateral ventricle, unchanged and likely related to persistent tumor at this site, with no finding to suggest ventriculitis, elsewhere. 4. No evidence of cerebral venous thrombosis. MRI spine [**2149-10-12**]: 1. No evidence of infection or tumor dissemination in the entire spine. 2. Extensive abnormal but amorphous STIR-hyperintensity in the deep dorsal and the interspinous and supraspinous soft tissues from L2 to L4-L5 level, likely related to multiple recent attempts at lumbar puncture; correlate clinically. 3. Small disc-spondylotic ridges at C5-C6 and C6-C7 levels, without canal compromise. CXR [**2149-10-15**]: Right PICC has been withdrawn. Now the tip is in the distal SVC. Right lower lobe atelectasis has improved. Left lower lobe opacities consistent with atelectasis are unchanged. If any there are small bilateral pleural effusions. Cardiomediastinal silhouette is unchanged. Right perihilar opacities have resolved. EEG [**2149-10-14**]: This is an abnormal video EEG telemetry due to generalized slowing with a maximum 4 Hz posterior predominant rhythm as well as bursts of generalized delta slowing, left more than right. This represents a severe encephalopathy such as can be seen with diffuse ischemia, toxic/ metabolic changes, infections, or medication effects. There were no clear epileptiform discharges or electrographic seizures noted. Brief Hospital Course: 66 y/o M with Merckel's cell carcinoma s/p L craniotomy ([**8-14**]) c/b post-op Serratia meningitis tx w/ 2wk course of ceftriaxone ([**Date range (1) 79616**]) and IPH now p/w AMS. # Recurrent Serratia Meningoencephalitis: Complicated by associated seizure activity, altered mental status (comatose initially) and history of recent craniotomy and intracranial bleed. Head CT showed interval improvement in IPH and lack of abscess. He had a very high fever of 104 that was very difficult to control with antipyretics and cooling measures. He was intubated for airway protection in anticipation of MRI/MRV and risk for aspiration when laying flat for a prolonged period. MRI/MRV showed meningoencephalitis, slightly more prominent margins of his surgical cavity where an abscess/infection could not be ruled out, and no cavernous sinus thrombi. He was started on antibiotics gentamicin and meropenem with vancomycin po for C. diff prophylaxis on [**10-12**]. Meropenem was chosen because of good BBB penetration and does not lower seizure threshold as much as imipenem, and gentamicin is useful in combination therapy for fastidious Gram negatives. LP was repeated on [**2149-10-14**] and showed significant decrease in WBC count indicating positive antibiotic effect. His mental status improved gradually throughout his stay in the ICU, although not yet back to baseline per his family. He was followed by the neurooncology team and infectious disease while in the ICU. He was transferred to OMED. His first CSF culture grew out pan sensitive Serratia whereas repeat CSF culture (performed after he was started on antibiotics) had no growth. The gentamicin was stopped [**10-22**]. He will be continued on meropenem until [**2149-11-10**]. Blood cx negative x 3. MRI showed evidence of progressive leptomeningeal disease and stable surgical cavity. EEG showed evidence of moderate to severe encephalopathy with no evidence of seizure activity. # Seizure. He had a seizure while on the medical floor likely due to underlying Serratia meningoencephalitis that was responsive to Ativan. He was given Keppra maintenance dose 750 mg q12 with dexamethasone 4 mg q12 and kept on seizure precautions per neuro-onc. Continuous EEG monitoring in the ICU showed no seizure activity. Dexamethasone was tapered down and keppra was continued. He had no further episodes of seizure activity during his hospital course. He will be dsicharged on keppra and dexamethasone. # Resp alkalosis: ABG was also notable for hypocapnea and respiratory alkalosis very likely centrally mediated in the setting of meningoencephalitis. Patient also presented with elevated lactate and AG of 14 likely secondary to his infection. Treatment with antibiotics and fluids improved his respiratory status. No respiratory complaints. Normal oxygen saturation on room air. # History of C. diff. He had a history of Cdiff while at [**Hospital1 **]. Cdiff was negative during this admission. He was placed on C. diff prophylaxis using vancomycin PO per ID recommendations. The plan is to continue prophylaxis 8 days after completion of antibiotics for Serratia. #Transient hypotension: Shortly after MRI, he had transient hypotension requiring intermittent pressor support and placement of an a-line and LIJ CVL. Most likely this was secondary to sedation boluses of versed and fentanyl that he received during the imaging study, but sepsis secondary to meningoencephalitis was considered. Pressors were weaned within 8 hours of onset of hypotension and there were no signs of end-organ ischemia. BP stable for rest of hospital course # Neuroendocrine small cell carcinoma: Patient is s/p tumor recention, c/b meningitis and recent rebleed. Has completed WBI. He was continued on dexamethasone throughout his stay. He was started on bactrim for PCP prophylaxis while on steroids. Further treatment for his cancer will be deferred until resolution of meningoencephalitis. # Anemia: His hematocrit has steadily declined, but remained stable in the low to mid 30s. B12 and folate were normal. Iron studies revealed anemia of chronic inflammation. His stool was guaiac + on the medical wards. This may be explained by hemmorrhoids or diverticulosis that were seen on previous colonoscopy. He did not require blood transfusions during his hospital stay. He was given an IV PPI for ulcer prophylaxis. He was started on oxycontin 10 mg [**Hospital1 **] for pain control. The patient was full code for this admission. He was evaluated by speech and swallow and nutrition services and is taking adequate POs of soft diet upon discharge. Medications on Admission: Medication on transfer to [**Hospital Unit Name 153**]: MVI aquaphor colace decadron 2mg PO BID desonide fragmin 5000u daily keppra 500mg po bid miralax MOM prilosec 20 [**Hospital1 **] questram 4g PO BID roxicodone 2.5 q4 prn pain APAP prn vancomycin 125 mg PO q6h ([**Date range (1) 79617**]) regular insulin sliding scale Discharge Medications: 1. meropenem 1 gram Recon Soln Sig: Two (2) g Intravenous Q8H (every 8 hours) for 13 days. Disp:*78 g* Refills:*0* 2. multivitamin Oral 3. Aquaphor Topical 4. Colace Oral 5. decadron Sig: Two (2) mg twice a day. 6. desonide Topical 7. Fragmin 5,000 unit/0.2 mL Syringe Sig: One (1) syringe Subcutaneous once a day. 8. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Miralax Oral 10. Milk of Magnesia Oral 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. questram Sig: Four (4) mg twice a day. 13. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every twelve (12) hours. Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2* 14. Tylenol Oral 15. insulin regular human Subcutaneous 16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 17. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 21 days. Disp:*84 Capsule(s)* Refills:*0* 18. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Serratia meningitis Neuroendocrine small cell carcinoma s/p resection history of c diff anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to [**Hospital1 69**] for altered mental status. You were found to have meningitis and you were treated with antibiotics. You were admitted to the ICU after a seizure where you were put on a breathing machine, you were disconnected from the breathing machine and did not have any evidence of further seizures. Please make the following changes to your medications: START Meropenem [**2138**] mg intravenous every 8 hours until [**2149-11-10**] for meningitis. START Vancomycin Oral Liquid 125 mg every 6 hours until [**2149-11-18**] for C.diff prophylaxis START Sulfameth/Trimethoprim DS 1 TAB DAILY for pneumonia prophylaxis START Oxycontin 10 mg twice a day for pain STOP roxicodone for pain Please continue your other home medications. Followup Instructions: The following appointments have been made for you. Please also see your primary care physician and your oncologist as needed. Department: INFECTIOUS DISEASE When: THURSDAY [**2149-11-6**] at 3:10 PM With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: FRIDAY [**2149-12-12**] at 11:00 AM With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "99.15", "96.04", "89.19", "96.6", "96.71", "03.31", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

15793, 15863

9583, 14222

340, 627

16003, 16003

4958, 4965

16964, 17725

3953, 4189

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655, 2476

4980, 6820

16018, 16155

2498, 3834

3850, 3937

6852, 9560

11,850

152,968

10789

Discharge summary

report

Admission Date: [**2193-8-27**] Discharge Date: Date of Birth: [**2142-2-10**] Sex: M HISTORY OF PRESENT ILLNESS: This is a 52-year-old man with a history of paroxysmal atrial fibrillation, cerebrovascular accident leading to sense left hemiparesis, methicillin-resistant Staphylococcus aureus pneumonia, fractures who present progressive shortness of breath and cough productive of rust-colored sputum. This is a gentleman whose complicated medical course dates back to [**2189**] when he suffered a cerebrovascular accident secondary to atrial fibrillation leading to left hemiparesis. He currently lives at [**Hospital3 2558**] and has had problems in the past year including endocarditis and recurrent urinary tract In [**2193-7-21**], he was dropped in the process of being lifted from his bed leading to fracture of his left femur and was hospitalized here. During that hospital course he bled into his leg leading in a drop of his hematocrit to about 23 and a transfusion, which put him into congestive heart failure, was diuresed, and then went into atrial fibrillation. He was cardioverted times two at that time and started on amiodarone. He also spiked fevers during that admission secondary to pneumonia with consolidation of his left lung. This was methicillin-resistant Staphylococcus aureus pneumonia and bacteremia, and there was also vegetations on his echocardiogram during that admission. He was sent out on six weeks of vancomycin due to a history of endocarditis and methicillin-resistant Staphylococcus aureus positive blood cultures; however, on admission, he was subtherapeutic taking only 1 g of vancomycin intravenously q.d. For the last few days prior to admission he had been experiencing increased shortness of breath and cough productive of rust-colored sputum. He was seen at [**Hospital6 6613**] on the morning of admission and found to be short of breath with oxygen saturation in the middle 80s. He was transferred to the Emergency Department where he received 2 g of intravenous ceftazidime, and his saturations were increased to the 90s on 4 liters of oxygen. REVIEW OF SYSTEMS: Review of systems was negative for chest pain, palpitations or nausea. However, he did complain of dysuria, hematuria, and urinary frequency. PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation, on amiodarone and therapeutic on Coumadin. 2. Cerebrovascular accident secondary to atrial fibrillation leading to left hemiparesis. 3. Hypertension. 4. Non-insulin-dependent diabetes mellitus. 5. Status post left hip hemi-repair, status post fall leading to new fracture of his left femur and unrepaired fracture of his right hip. 6. Endocarditis. 7. Methicillin-resistant Staphylococcus aureus pneumonia. 8. Urinary tract infections. MEDICATIONS ON ADMISSION: Lopressor 25 mg p.o. b.i.d., Zoloft 200 mg p.o. q.d. BuSpar 5 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d., Coumadin 1 p.o. q.d., valproic acid 500 mg p.o. every noon and 75 mg p.o. q.a.m. and q.h.s., Oramorph 15 mg p.o. b.i.d., Roxicodone 5 mg p.o. q.4h. p.r.n. for pain, amiodarone 200 mg p.o. q.d., Colace 100 mg p.o. b.i.d., Dulcolax 10 mg p.o. q.d. p.r.n. for constipation, Senokot, aspirin 325 mg p.o. q.d., multivitamin 1 p.o. q.d., zinc 220 mg p.o. q.d., vitamin C 500 mg p.o. q.d., Serax 10 mg p.o. q.h.s. p.r.n., Atrovent nebulizers q.4h. p.r.n., and vancomycin 1 g intravenously q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He lives in [**Hospital3 2558**]. His mother and brother live in [**Name (NI) 86**]. No alcohol or tobacco use. PHYSICAL EXAMINATION ON ADMISSION: Temperature of 95.4 axillary, temperature of 96.8 rectally, blood pressure 181/83, with a pulse of 56, respiratory rate of 18, satting 95% on 4 liters. The patient looked older than his stated age and uncomfortable. He was normocephalic and atraumatic. His pupils were constricted by round and reactive to light, and there was a 1.5-cm node in the right anterior cervical chain. He had jugular venous distention to 9 cm. On cardiac examination, he was bradycardic to the 40s, but with a regular rhythm, and a [**3-26**] holosystolic murmur loudest at the apex. On lung examination, he had diffuse rales anteriorly. On abdominal examination, he had right lower quadrant tenderness without rebound. He was not distended and had positive bowel sounds. The patient refused guaiac examination. On extremity examination, he had 2+ pulse on the right, 1+ on the left, and evidence of chronic venous disease bilaterally. On neurologic examination, he had 0/5 strength in the left upper and lower extremities, but 5/5 strength in right upper and lower extremity. His mental status was alert and oriented times three. He was able to name the months backwards and remembered [**2-23**] objects after five minutes. LABORATORY DATA ON ADMISSION: Significant laboratories included a hematocrit of 29.8, white blood cell count of 4.8, platelets of 106. The differential for his white blood cell count was 70 neutrophils, 0 bands. His baseline hematocrit was 34 from previous admissions. He had a PT of 18.9, a PTT of 35.6, and an INR of 2.4. His electrolytes were remarkable only for a potassium of 3.3 and a calcium of 7.7. His initial creatine kinase was 19 with a troponin I of 0.3. On urinalysis, he had greater than 50 red blood cells, greater than 50 white blood cells, and many bacteria. RADIOLOGY/IMAGING: On chest x-ray there was evidence of congestive heart failure with indistinct pulmonary vasculature in a prehilar distribution. There were small bilateral pleural effusions and linear band-like opacity in the left middle lung zone which was likely atelectasis. There was a left PICC line appropriately placed. On electrocardiogram he had downgoing T waves in leads V2 and V6; of which only the T wave in V2 was new from previous examination. ASSESSMENT: This was felt to be a man with congestive heart failure and possibly also with some residual pneumonia given his therapeutic vancomycin treatment. The other problems of concern at that time included a probable urinary tract infection and bradycardia. HOSPITAL COURSE: 1. CARDIOVASCULAR: He was ruled out for a myocardial infarction by enzymes and repeat electrocardiogram. He received 20 mg of intravenous Lasix immediately and then the next day with a goal of diuresis for resolution of his congestive heart failure, and an echocardiogram was planned to evaluate his systolic function and endocarditis. His hypertension was controlled by Lopressor with strict hold parameters. His amiodarone was continued at 200 mg for his atrial fibrillation, as was his Coumadin for that indication. 2. PULMONARY: He was placed on oxygen at a sufficient level to maintain saturations of greater than 93%. He was ordered for a chest x-ray. He was started on vancomycin as well as gentamicin for coverage of possible agents for his pneumonia. A sputum culture was taken, and he received p.r.n. albuterol nebulizers. 3. GASTROINTESTINAL: He was placed on an aggressive bowel regimen and all stools were guaiaced. 4. GENITOURINARY: His urine was sent for culture, and he had Foley catheter placed. The gentamicin was added also to treat his urinary tract infection. 5. RENAL: His creatinine was 0.5, which was baseline. 6. HEMATOLOGY: His hematocrit of 29 was just below his baseline in the 30s. He refused rectal examination, but all stools were guaiaced. 7. INFECTIOUS DISEASE: He was started on vancomycin and gentamicin intravenously and had cultures were sent of his sputum, blood, and urine. 8. FLUIDS/ELECTROLYTES/NUTRITION: His electrolytes were repleted and followed with daily laboratories. He had a left PICC line in place. On the afternoon of [**8-28**], he was found in his room obtunded and barely responsive to sternal rub with bradycardia down to the 30s and 40s. A blood gas showed that he was acidotic with a CO2 of 56, an O2 of 123 on 100% FIO2. He was transferred to the Cardiac Intensive Care Unit and Electrophysiology was consulted. Their impression was that his decline in mental status was secondary to poor cardiac output secondary to bradycardia, and a temporary wire was placed to increase cardiac output. He remained in the Coronary Care Unit until [**8-31**]. During his stay there, he had a Swann-Ganz catheter placed into his internal jugular which demonstrated elevated pulmonary capillary wedge pressure, and he was found to have poor cardiac output with high systemic vascular resistance of 1200s. He was started on captopril to decrease his systemic vascular resistance, and this improved his cardiac output dramatically with some improvement of his mental status. Blood cultures came back as positive only in [**1-24**] bottles, and that was with coagulase-negative Staphylococcus which was a presumed contaminant. He was transferred to [**Hospital Ward Name 121**] 7 on [**8-31**] in stable condition with improving mental status. On [**9-1**], he was found to have good mental status but in rapid atrial fibrillation to the 120s and 130s. He was given 12.5 mg of p.o. Lopressor as well as 50 mg intravenous Lopressor, and 10 mg of diltiazem which improved his heart rate to the 100s. Electrophysiology was reconsulted, and they recommended resumption of his amiodarone which had been discontinued in an effort to keep a more rapid heart rate. On [**9-2**], he was back in sinus rhythm with a heart rate in the 60s and 70s, and good mentation. An ultrasound demonstrated no significant residual pleural fluid in his right lung, and a 3-cm fluid in his left lung. Given his dramatic medical improvement, it was deemed unnecessary to have a diagnostic tap. On [**8-28**], in the morning, he received an echocardiogram which demonstrated increased mitral regurgitation of 2+ and decreased systolic function of approximately 30%. CONDITION AT DISCHARGE: He was afebrile with stable vital signs including a blood pressure in the 130s, and a pulse in the 60s, satting 99% on room air. He was in no apparent distress with cardiac examination in regular rhythm, and still with a [**2-26**] holosystolic murmur at the left sternal border. His examination was otherwise remarkable for a stable hematoma in his right upper thigh. His mental status had returned to baseline as he was alert and oriented times three with good cognitive function. DISCHARGE STATUS: He was to be discharged to [**Hospital3 2558**] (his place of residence). MEDICATIONS ON DISCHARGE: 1. Vancomycin 1 g intravenously q.12h. 2. Captopril 75 mg p.o. t.i.d. 3. Aspirin 325 mg p.o. q.d. 4. Colace 100 mg p.o. b.i.d. 5. Zoloft 200 mg p.o. q.d. 6. BuSpar 5 mg p.o. b.i.d. 7. Zantac 150 mg p.o. b.i.d. 8. Depakote 500 mg p.o. q.a.m. and q.h.s. and 750 mg p.o. every noon. 9. Percocet 5/325 q.6h. p.r.n. for pain. DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus pneumonia. 2. Congestive heart failure. 3. Paroxysmal atrial fibrillation. 4. Status post right cerebrovascular accident. 5. Hypertension. 6. Diet controlled non-insulin-dependent diabetes mellitus. 7. Bilateral hip fractures, unrepaired. 8. Endocarditis. 9. Urinary tract infection. DISCHARGE FOLLOWUP: He was to follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**] Dictated By:[**Last Name (NamePattern1) 35238**] MEDQUIST36 D: [**2193-9-3**] 10:25 T: [**2193-9-3**] 11:10 JOB#: [**Job Number 35239**]

[ "V09.0", "790.7", "250.00", "599.0", "428.0", "427.31", "421.0", "401.9", "482.41" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10886, 11232

10534, 10865

2822, 3453

6173, 9911

9926, 10508

2148, 2293

11253, 11683

134, 2128

4869, 6155

2315, 2795

3470, 3606

5,339

193,578

25491

Discharge summary

report

Admission Date: [**2199-8-29**] Discharge Date: [**2199-9-18**] Date of Birth: [**2150-12-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: Repair of aortic tear with interposition graft ORIF, left medial malleolar fracture ORIF, right tibial plateau fracture History of Present Illness: This is a 48 year-old male who the unrestrained driver in a high-speed single-vehicle MVC (versus tree). He was intoxciated at the time with an unclear LOC and was stable on transfer by [**Location (un) 7622**]. Past Medical History: HTN Diabetes pancreatitis high cholesterol Social History: +EtOH Family History: Noncontributory Physical Exam: On discharge: VS T97.9 BP108/62 P79 R18 94%RA Gen: Awake and alert Chest: Clear to auscultation bilaterally CV: Regular rate and rhytm Abd: Soft, nontender, nondistended Ext: Right knee brace in place. Incision clean dry and intact. Left lower extremity cast in place; good toe perfusion and movement. Pertinent Results: Radiology results of note: CT abd ([**8-29**]): 1. Pseudoaneurysm of the descending thoracic aorta consistent with acute injury with associated mediastinal hemorrhage. 2. Multiple bilateral rib fractures with small right-sided pneumothorax. 3. Bilateral lung consolidations/atelectasis that may represent contusion. 4. Large complex liver laceration that likely extends through the capsule with perihepatic hemorrhage. 5. Small inferiorly located splenic laceration. 6. Free intraabdominal fluid. Mesenteric or traumatic bowel injury cannot be excluded. LE x-rays: 1. Depressed medial plateau fracture with joint effusion. 2. Right medial malleolar fracture without adjacent soft tissue swelling of unknown acuity. Clinical correlation advised. 3. Acute left medial malleolar fracture. Brief Hospital Course: The patient was stabilized in the ED and the initial evaluation revelead a tear in the descending aorta. The patient was taken to the OR by vascular surgery for repair with an interposition graft. Please see the operative note for details. Post-operatively he did relatively well in the ICU, with a consult by the Infectious Disease service for fevers and positive blood cultures felt to be secondary to a thrombophlebitis; he was maintained on antibiotics for 10 days and had no return of fevers. During his hospital stay he was discovered to also have bilateral lower extremity fractures, which were treated by Orthopedic Surgery with open reduction-internal fixation. Please see the operative notes for details. He was seen by social work, physical therapy and occupational therapy. Given his non-weightbearing status, he was discharged to a rehabilitation center on lovenox (40mg SC QD). He was also seen by the [**Last Name (un) **] Service for management of his diabetes. During his stay he had one episode of dark, guiac-positive stool with no change in hematocrit. His initial abdominal CT had showed some diverticuli. The episode and findings were discussed with a representative from the office of the patient's primary care physician (Dr. [**Last Name (STitle) **] and a copy of the summary was faxed to the office for follow-up. He did not have a reoccurrance of GI bleeding while hospitalized and was discharged in good condition to a rehabilitation center given his inability to bear weight. Medications on Admission: fluoxetine ranitidine lisinopril alprazolam metformin pantoprazole labetaolol Discharge Medications: 1. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 4 weeks. Disp:*QS syringe* Refills:*0* 2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*0* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Thiamine HCl 100 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 BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 14. Quetiapine Fumarate 200 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*0* 15. Insulin Syringes (Disposable) Syringe Sig: One (1) Miscell. three times a day. Disp:*50 syringes* Refills:*1* 16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous QAM for 1 months. Disp:*QS units* Refills:*0* 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous at bedtime for 1 months. Disp:*QS units* Refills:*0* 18. Insulin Regular Human 100 unit/mL Solution Sig: as per sliding scale units SC Injection four times a day for 1 months: For FS 0-60mg/dL, give [**1-20**] amp D50 For FS 61-120mg/dL, give 0 Units For FS 121-160mg/dL, give 4 Units For FS 161-200mg/dL give 6 Units For FS 201-240mg/dL give 8 Units For FS241-280mg/dL give 10 Units For FS 281-320mg/dL give 12 Units For FS 321-360mg/dL give 14 Units For FS 361-400mg/dL give 16 Units For FS> 400mg/dL Notify M.D. Disp:*QS units* Refills:*0* 19. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed: do not apply over incision sites!. Disp:*1 container* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital **] rehab Discharge Diagnosis: Aortic tear, repaired Liver laceration Splenic laceration Diverticulosis Right tibial plateau fracture with joint effusion, repaired Right medial malleolar fracture Left medial malleolar fracture, repaired Guiac-positive stool Discharge Condition: Good Discharge Instructions: You should call a physician or come to ER if you have worsening pains, fevers, chills, nausea, vomiting, shortness of breath, chest pain, redness or drainage about the wounds, or if you have any questions or concerns. It is important you take medications as directed. You should not drive or operate heavy machinery while on any narcotic pain medication such as percocet as it can be sedating. You may take colace to soften the stool as needed for constipation, which can be cause by narcotic pain medication. You should keep your dressing intact and dry until seen at follow-up visit. You need to remain non-weight-bearing on both legs for [**6-26**] weeks. You should wear the knee brace at all times but can leave it unlocked and move the knee as tolerated. Followup Instructions: Call your primary care physician (Dr. [**Last Name (STitle) **] for a follow-up appointment in [**1-20**] weeks. You had some blood in your stools while hospitalized; this will need evaluated further. Call for a follow-up appointment with Orthopedic Surgery ([**Telephone/Fax (1) 4845**]) in 2 weeks. Call for a follow-up appointment with Dr. [**Last Name (STitle) 1290**] ([**Telephone/Fax (1) 170**]) in 4 weeks.

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icd9cm

[ [ [] ] ]

[ "38.45", "79.36", "38.93", "39.61", "39.57", "34.04", "99.15" ]

icd9pcs

[ [ [] ] ]

6296, 6344

1957, 3468

323, 445

6615, 6622

1145, 1934

7435, 7855

791, 808

3597, 6273

6365, 6594

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6646, 7412

823, 823

837, 1126

276, 285

473, 686

708, 752

768, 775

61,113

156,645

40806

Discharge summary

report

Admission Date: [**2151-7-19**] Discharge Date: [**2151-8-1**] Service: MEDICINE Allergies: Toprol XL Attending:[**First Name3 (LF) 896**] Chief Complaint: Bright red blood per rectum. Major Surgical or Invasive Procedure: - Mesenteric angiograhphy with embolization ([**2151-7-19**]) - Capsule endoscopy History of Present Illness: The patient is an 88 y/o female with a history o AVR on coumadin, atrial fibrillation who was recently hospitalization ([**Date range (1) 89158**]) for melena & subsequently found to have colonic adenomas and diverticula but no obvious source of bleeding, who now returns with BRBPR, anemia, & hypotension. On [**7-1**], Ms. [**Known lastname **] was admitted by her PCP after she experienced 7 days of melena and had a positive hemoccult test in office. During that admission, EGD was negative, and colonoscopy revealed multiple polyps and diverticula, but no active source of bleeding. Pathology of the polyps was consistent with adenoma. Hct dropped from 32.3 to 24.2 during that admission, but remained stable thereafter; the patient was hemodynamically stable. Her coumadin was initialy held; she was eventually restarted on coumadin with a heparin bridge. Ms. [**Known lastname **] had been doing well since discharge, until the day of admission when she had 3 episodes of BRBPR. She saw her PCP for [**Name9 (PRE) 1944**] [**Name9 (PRE) 702**] on [**7-15**], at which time her H/H was 8.9/26.5 and Cr 1.08. In the ED, initial vs were: T 96.8 BP 70/33 R 17. Patient was asymptomatic with no CP, SOB, N/V, or dizziness. She had a bowel movement in the ED which was brow mixed with bright red blood. Labs were significant for Hct 24.1, INR 3.1, BUN 32 and Cr 1.3. She was started on a pantoprazole drip and given vitamin K 10mg IV. GI was consulted and recommended reversal of anticoagulation and CTA vs colonoscopy in AM. Surgery consulted as well in case of urgent need to control of bleeding, but the patient declined potential surgical interventions. Past Medical History: - [**Hospital3 9642**] Mechanical Aortic Valve Replaced [**1-20**] Aortic stenosis - Mitral valve repair - CAD s/p CABG - Diastolic HF - HTN - HLD - Atrial Fibrillation - Squamous cell skin cancer Social History: - Lives in a 3 family home (family members live upstairs and downstairs) - Smoking: Never Smoker - Smokeless Tobacco: Never Used - Alcohol: 0.0 oz alcohol/week Family History: - Brother: [**Name (NI) 3495**] disorder - Daughter: Cancer; [**Name (NI) **]-intestinal disorder - Father: [**Name (NI) 3495**] disorder - Mother: [**Name (NI) 3730**] Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:97.8 BP:79/32 P:76 RR:20 SpO2:99%on2L. 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 EXAM: Afebrile. BP: 100s/60s GEN: Well-appearing female resting in bed in NAD. HEENT: MMM. PEERL NECK: Supple. Nml JVD. COR: + S1S2 regular. Loud S2 with parasternal heave. PULM: CTAB, no c/w/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: Soft, NTND to deep palpation. EXT: Warm, well-perfused. 1+ pitting edema of bilateral lower extremities. NEURO: Aware, alert. Pertinent Results: ADMISSION LABS: [**2151-7-19**] 02:45AM GLUCOSE-144* UREA N-32* CREAT-1.3* SODIUM-139 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13 [**2151-7-19**] 02:45AM CK(CPK)-38 [**2151-7-19**] 02:45AM cTropnT-<0.01 [**2151-7-19**] 02:45AM CK-MB-2 [**2151-7-19**] 02:45AM WBC-7.3# RBC-2.74* HGB-8.0* HCT-24.1* MCV-88 MCH-29.4 MCHC-33.4 RDW-16.5* [**2151-7-19**] 02:45AM NEUTS-68.7 LYMPHS-22.9 MONOS-4.7 EOS-3.0 BASOS-0.6 [**2151-7-19**] 02:45AM PT-31.7* PTT-30.1 INR(PT)-3.1* [**2151-7-19**] 03:07AM LACTATE-1.4 Imaging: CXR ([**7-19**]): AP UPRIGHT VIEW OF THE CHEST: There is severe cardiomegaly. There is no overt edema. There is no pleural effusion or pneumothorax. There is no focal consolidation. There has been prior median sternotomy and CABG. The uppermost sternal wire is discontinuous. IMPRESSION: Severe cardiomegaly without overt edema. CT abdomen and pelvis ([**7-19**]): IMPRESSION: 1. Lower GI bleed in the ascending colon with active arterial extravasation and intraluminal accumulation of intravenous contrast. 2. Diffuse atherosclerotic disease. There is approximately 50% narrowing of the origin and proximal celiac artery with post-stenotic dilation. The celiac axis, SMA, bilateral single renal arteries and [**Female First Name (un) 899**] are patent. 3. Peripheral branches of the portal vein are thrombosed in segments V and II. Imaging findings are suggestive of chronic thrombus. 4. Subcentimeter hypodense lesions in the right hepatic lobe are too small to accurately characterize. Mesenteric angiography ([**7-19**]): FINDINGS: 1. SMA angiogram demonstrated contrast extravasation in the region of the cecum and proximal ascending colon. Subsequent subselective ileocolic and third-order branch angiograms confirmed the above finding. Visualization of likely early filling of venous structures in the region of contrast extravasation. 2. Successful coil embolization for bleeding from the right colon, which was likely as a result of angiodysplasia in the cecum/proximal ascending colon related to third- order branch of superior mesenteric artery. IMPRESSION: Successful coil embolization of extravasation in the cecum/proximal ascending colon. CXR ([**7-21**]): ONE VIEW OF THE CHEST: The lungs are well expanded and show mild interstitial opacities. The cardiac silhouette is enlarged. The mediastinal silhouette and hilar contours are normal. There may be a small left pleural effusion. IMPRESSION: Cardiomegaly with mild edema. CXR ([**7-21**]): FINDINGS: Tip of the left PICC line is seen in the SVC. Post CABG with intact sternotomy sutures. The cardiomegaly is unchanged. There is mild pulmonary vascular congestion, slightly worse since prior radiograph. Otherwise there are no other relevant interval changes. DISCHARGE LABS: [**2151-7-31**] 11:08AM BLOOD WBC-4.9 RBC-3.19* Hgb-9.5* Hct-28.7* MCV-90 MCH-29.8 MCHC-33.1 RDW-16.0* Plt Ct-229 [**2151-7-29**] 07:15AM BLOOD Glucose-97 UreaN-17 Creat-0.9 Na-139 K-4.3 Cl-104 HCO3-28 AnGap-11 [**2151-7-31**] 06:15AM BLOOD PT-27.2* PTT-66.2* INR(PT)-2.6* Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: 88 y/o female with mechanical AVR on coumadin, atrial fibrillation, & recent hospitalization ([**Date range (1) 89158**]) for melena presents with bright red blood per rectum and hypotension. . ACUTE DIAGNOSES: # Bright Red Blood Per Rectum: Ms. [**Known lastname **] had a significant lower GI bleed, complicated by prior anticoaguliation, requiring a total of 11 units pRBCs transfusion. CT angiogram showed a clear bleeding source in the right colon and she was sent to IR for embolization of this vessel. Due to the appearance of this vessel, it was felt that this was most likely an angiodysplastic lesion, which is consistent with the association of aortic stenosis and angiodysplasia. The surgical service felt that a right hemicolectomy may be beneficial to her to eliminate this site of a potential re-bleed, but the patient ultimately declined surgery, after deciding the risks of the surgery itself given her comorbidities as well as the possibility of other angioplastic lesions elsewhere in the colon that could bleed also outweighed the potential benefits of removing the culprit lesion. In order to rule out any other source of bleeding, the GI service elected to pursue a capsule endoscopy when the patient stabilized which showed a non-bleeding jejunal erosion. She was monitored in the ICU while she was restarted on a heparin drip, in anticipation of a bridge back to outpatient anticoagulation. Given her stability with Hct >30, she was transferred to the general medical floor for further management. She had one episode of guaiac positive brown stool on the floor, but this was not associated with a change in her blood count and was thought to be due to old blood. It was decided that her new INR goal would be 2.0-2.5; she successfully completed a bridge to coumadin with plans to follow-up her INR on the first day after discharge. # Acute Kidney Injury: The patient's creatinine increased to 1.3 from a baseline 0.8-1.1. This was thought to be due to pre-renal injury in the setting of GI bleed and BUN/Cr ratio > 20. Her ceatinine returned to baseline after rehydration. # Mechanical AVR: Ms. [**Known lastname **] has a history of an mechanical AVR for aortic stenosis. Given her active GI bleed on admission, coumadin was held & her INR reversed until her HCT was stable & she was no longer bleeding. Her St. Jude's valve places her at higher risk of stroke, especially in light of her concomitant atrial fibrillation & CHADS score of 3. Given her high risk of stroke, a heparin drip was started on hospital day 4 with a PTT goal of 60-80 given her recent GI bleed. She was bridged to coumadin with an INR goal of [**1-20**].5. Upon discharge, her last INR was 2.6 and she was given instructions to have it rechecked on the first day post-discharge. CHRONIC DIAGNOSES: # Chronic Diastolic Congestive Heart Failure: Ms. [**Known lastname 27210**] lasix was held in the setting of low blood pressures and GI bleeding. She was monitored while receiving pRBCs for hypervolemia and flash pulmonary edema. On the morning of hospital day 4, she had mild bibasilar crackles and was given 20 IV lasix to diurese for pulmonary edema. It was difficult to reinitiate her lasix on the floor because she would have a strong diuretic response to even small doses of lasix with systolic BPs in the 90s-100s. As such, she was discharged on 20 mg PO lasix each day with plans to follow up with her primary doctor in the outpatient setting. On discharge she had stable 1+ lower extremity edema (which she said is her baseline) and no crackles to auscultation of her lung fields. # Atrial Fibrillation: Anticoagulation was managed as above for AVR (patient has CHADS2 score of 3). # Hypertension: The patient's antihypertensives were held in the setting of a hemodynamically significant GI bleed. On the floor her BPs were in the 130s range at their highest; we were unable to reinitiate her amlodipine or enalapril without compromising her blood pressure. She was ultimately started on enalapril 10 mg [**Hospital1 **] (compared to 30 mg [**Hospital1 **]) and instructed to follow-up with her primary doctor regarding the reinitiation of her anti-hypertensive medications. # Hyperlipidemia: Ms. [**Known lastname **] was continued on her home statin. # CAD s/p CABG: The patent denied having chest pain during hospitalization. Her aspirin was held in the setting of GI bleeding; this medication was also held on discharge as it was not felt that it reduced her risk of CVA or MI given that she is on warfarin. # Depression: Ms. [**Known lastname **] was continued on her home regimen of paroxetine. TRANSITIONAL ISSUES: # Follow-Up: The patient has plans to follow-up with her primary care doctor on the first day post-discharge. She will also have an INR drawn on that day as well. She will need to follow-up with gastroenterology to discuss the final results of her capsule endoscopy. # Risk of Readmission: Ms. [**Known lastname **] is at risk of readmission for a recurrent GI bleed. Unfortunately, she likely has angiodysplasias within her GI tract which are prone to bleed in the setting of anticoagulation. Due to her risk of thromboembolic disease, she needs to continue coumadin. Hopefully, the lower INR goal of [**1-20**].5 & close follow up will reduce the likelihood of another hemodynamically significant GI bleed. # Code Status: Full Code. Medications on Admission: 1. multivitamin 1 Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. paroxetine HCl 10 mg Tablet Sig: 1.5 Tablets PO DAILY 3. furosemide 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day 4. furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. enalapril maleate 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. PreserVision 7,160-113-100 unit-mg-unit Tablet Sig: Two (2) Tablet PO once a day. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Omeprazole 20mg [**Hospital1 **] 11. Ferrous sulfate 325mg TID 12. Calcium with Vitamin D 600-400mg daily Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. paroxetine HCl 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 5. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM. Disp:*30 Tablet(s)* Refills:*0* 7. enalapril maleate 2.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: PRIMARY DIAGNOSIS: - Bleeding arteriovenous malformation SECONDARY DIAGNOSIS: - Mechanical aortic valve replacement requiring anticoagulation - Jejunal erosion - Atrial fibrillation requiring anticoagulation - Diastolic congestive heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], it was a pleasure to participate in your care while you were at the hospital. You came to the hospital because you had several episodes of bright red blood in your stool. You were admitted to the intensive care unit because your blood pressure was very low. You were given a total of 11 units of blood. You underwent several tests and ultimately had one of the vessels in your abdomen embolized(blocked) so it would no longer cause bleeding in your gastrointestinal tract. After leaving the ICU, your blood counts were all stable indicating that the bleeding had stopped. You did not have any further episodes of bright red blood in your stool. Since you have a mechanical heart valve & atrial fibrillation, you are taking a medication called coumadin to thin your blood so you do not develop dangerous clots. This medication can result in prolonged bleeding. Due to your risk of clots, we are unable to completely stop your coumadin, but from this point forward it will be more closely monitored to ensure it has a lower level of activity in your blood (your INR should now be between 2 - 2.5 instead of [**1-21**]). You should have close follow-up to make sure you do not have any further GI bleeding. MEDICATION CHANGES: - Medications ADDED: None. - Medications STOPPED: Amlodipine (this medication was stopped because your blood pressure was adequately controlled without it, but you should talk to your primary doctor about this change). - Medications CHANGED: ----> Your enalapril dose was decreased from 30 mg twice a day to 2.5 mg twice a day (you should continue to take it at this dose until you are seen by your primary care doctor) ----> Your lasix doses have changed to 20 mg per day (from 80 mg in the morning & 40 mg in the afternoon). You may need more lasix when you go home, but his will be determined with your primary care doctor. Followup Instructions: Department: Primary Care Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43785**] When: Monday [**2151-8-2**] Notes: Please have your blood drawn in the morning of [**2151-8-2**] for your INR level and hematocrit. This lab value will help your PCP make changes to your Coumadin (your blood thinner) and will help your PCP keep track of your blood counts. Location: [**Location (un) 2274**]-[**Location (un) **] Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**] Phone: [**Telephone/Fax (1) 31019**] Please call ([**Telephone/Fax (1) 2233**] to make an follow-up appointment in the [**Hospital **] clinic (within 2-3 weeks).

[ "569.85", "414.00", "401.9", "427.31", "272.4", "V45.81", "584.9", "428.0", "V58.61", "311", "562.10", "V43.3", "285.1", "428.32" ]

icd9cm

[ [ [] ] ]

[ "38.97", "39.79", "88.49", "45.19" ]

icd9pcs

[ [ [] ] ]

13495, 13552

6669, 11346

245, 328

13842, 13842

3588, 3588

15904, 16603

2447, 2620

12944, 13472

13573, 13573

12136, 12921

13993, 15233

6372, 6646

2660, 3176

3192, 3569

11367, 12110

15253, 15881

176, 207

356, 2032

13652, 13821

3604, 6356

13592, 13631

13857, 13969

2054, 2253

2269, 2431

80,497

170,376

7060

Discharge summary

report

Admission Date: [**2105-9-6**] Discharge Date: [**2105-9-16**] Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 2356**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: This is a [**Age over 90 **] y/o M with h/o HTN, HLD, DM, who presented to [**Hospital1 18**] with worsening shortness of breath. History was mainly obtained from daughter. [**Name (NI) **] was in usual state of health until [**12-24**] days ago when daughter noticed that patient began coughing (non-productive) and appeared more tired. She stated that she noticed he was wheezing but denied any fevers/chills, sick contacts, or recent travel history. This evening, the daughter noticed that the patient had increased respiratory noices after the patient went to sleep. The daughter was concerned and called 911. . When EMS arrived, the patient was noted to have an O2sat of 74%. With supplemental oxygen, O2sat's normalized. Patient was then taken to the ED. In the ED, initial VS were: T 97.5 BP 127/68 HR 64 RR 10 SpO2 95% NRB. Patient was given nebulizer treatments. Laryngoscopy was completed for inspiratory wheezing and visualized normal vocal cords. CXR was concerning for pulmonary edema v. consolidation and the patient was started given ceftriaxone and levaquin for CAP coverage. . Of note, CBC in ED indicated Hct of 25 (down from baseline in mid 30s). Stools were maroon appearing and were Guaiac positive. Patient was started a protonix gtt and was crossed for 2 units of blood prior to transferring to the ICU. Additionally, lactate on admission was 4.0. . On encounter, the patient was feeling better. He endorsed some SOB and nausea but denied any CP, dizziness, LH, vomiting, or diarrhea. Patient was immediately given 20mg IV lasix and was started on the pRBC infusion. Past Medical History: 1. HTN 2. Hypercholesterolemia 3. Borderline DM 4. hx of prostate cancer - receives hormone or chemotherapy every 3 months 5. Legally blind - macular degeneration 6. GERD 7. Hearing difficulty Question of COPD Social History: Lives at home with 2 daughters, [**Name (NI) 11894**] and [**Name (NI) 17**]. Also has 2 sons, [**Name (NI) **] lives in [**Location 1411**], MA and other son lives in [**Name (NI) 4565**]. Pt has a significant tobacco hx: started smoking as a teenager, smoked at least 1PPD, quit smoking over 25 years ago. Denies EtOH use. Used to be men's clothing buyer. Pt does not currently have a HCP as he has not had any mental status issues and remains cognitively intact. Family History: Pt denies any hx of malignancies in his family members Physical Exam: Vitals: T: 95.2 (axillary) BP: 112/37 P: 75 R: 18 O2: 90% 2L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry mucuous membranes, left pupil larger than right pupil, oropharynx clear Neck: supple, JVP elevated to angle of mandible, no LAD Lungs: diffuse rhonchi and wheezes, no wheezes, rales, ronchi CV: Regular rate and rhythm, difficult to assess heart sounds given lung exam Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: cool feet, warm hands, +2 DP and radial pulses b/l, trace to +1 edema in lower extremities b/l Pertinent Results: [**2105-9-6**] 10:03PM WBC-13.8* RBC-3.18* HGB-9.4* HCT-27.5* MCV-87 MCH-29.6 MCHC-34.1 RDW-16.0* [**2105-9-6**] 10:03PM PLT COUNT-259 [**2105-9-6**] 11:26AM TYPE-[**Last Name (un) **] PH-7.43 [**2105-9-6**] 11:26AM LACTATE-2.7* [**2105-9-6**] 11:26AM freeCa-1.09* [**2105-9-6**] 11:05AM VoidSpec-CLOTTED [**2105-9-6**] 10:47AM WBC-14.4* RBC-3.30* HGB-9.6* HCT-28.2* MCV-85 MCH-29.2 MCHC-34.2 RDW-15.8* [**2105-9-6**] 10:47AM PLT COUNT-258 [**2105-9-6**] 06:42AM TYPE-[**Last Name (un) **] PO2-37* PCO2-31* PH-7.39 TOTAL CO2-19* BASE XS--4 [**2105-9-6**] 06:42AM LACTATE-4.5* [**2105-9-6**] 06:42AM freeCa-1.07* [**2105-9-6**] 06:07AM GLUCOSE-153* UREA N-42* CREAT-1.9* SODIUM-140 POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-18* ANION GAP-15 [**2105-9-6**] 06:07AM CALCIUM-7.5* PHOSPHATE-2.8 MAGNESIUM-2.6 [**2105-9-6**] 06:07AM WBC-14.9* RBC-2.73* HGB-7.9* HCT-24.1* MCV-88 MCH-29.0 MCHC-32.8 RDW-15.8* [**2105-9-6**] 06:07AM PLT COUNT-277 [**2105-9-6**] 06:07AM PT-13.8* PTT-24.6 INR(PT)-1.2* [**2105-9-6**] 04:12AM URINE HOURS-RANDOM UREA N-248 CREAT-36 SODIUM-96 POTASSIUM-26 CHLORIDE-111 [**2105-9-6**] 04:12AM URINE OSMOLAL-348 [**2105-9-6**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2105-9-6**] 12:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG [**2105-9-6**] 12:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2105-9-5**] 11:52PM COMMENTS-GREEN TOP [**2105-9-5**] 11:52PM GLUCOSE-241* LACTATE-4.0* NA+-138 K+-4.6 CL--105 TCO2-18* [**2105-9-5**] 11:45PM GLUCOSE-251* UREA N-44* CREAT-1.9* SODIUM-138 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-20* ANION GAP-16 [**2105-9-5**] 11:45PM estGFR-Using this [**2105-9-5**] 11:45PM CK(CPK)-45* [**2105-9-5**] 11:45PM cTropnT-LESS THAN [**2105-9-5**] 11:45PM CK-MB-2 [**2105-9-5**] 11:45PM CALCIUM-8.3* PHOSPHATE-4.3 MAGNESIUM-2.5 [**2105-9-5**] 11:45PM WBC-20.7*# RBC-2.88*# HGB-8.1*# HCT-25.0*# MCV-87 MCH-28.2 MCHC-32.5 RDW-16.2* [**2105-9-5**] 11:45PM NEUTS-84* BANDS-6* LYMPHS-7* MONOS-2 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2105-9-5**] 11:45PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-OCCASIONAL TEARDROP-OCCASIONAL [**2105-9-5**] 11:45PM PLT SMR-NORMAL PLT COUNT-371# [**2105-9-7**] echo The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and global systolic function are 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 valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild to moderate ([**11-22**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. [**2105-9-11**] Chest xray: Cardiomediastinal silhouette is unchanged. The patient was extubated. There is significant interval improvement in widespread parenchymal opacities consistent with interval improvement of pulmonary edema. Still significant abnormalities within the parenchyma are seen, widespread. The right PICC line tip is at the cavoatrial junction Brief Hospital Course: Mr. [**Known lastname 17437**] is a [**Age over 90 **]y/o M with prostate CA, borderline DM, CKD, who presented with dyspnea likely [**12-23**] pulmonary edema v. PNA, also found to be anemic likely [**12-23**] GI bleed. #) Hypoxemic Respiratory Failure: Pt was initially admitted with shortness of breath. He was intubated on hospital day 2 for increased work of breathing. Pt improved with diuresis on Lasix gtt. He was also treated for possible PNA with Levquin/Ceftriaxone. Pt likely had cardiac event at home prior to admission, resulting in worsening diastolic dysfunction and mitral regurgitation, leading to pulmonary edema. Pt was extubated on [**2105-9-10**] without complication and was satting well on NC at the time of transfer out of the MICU. LOS negative 5L at the time of transfer on [**9-11**]. On the floor pt continued to be clinically euvolemic though required 2.5L NC. Home dose of metoprolol was restarted. In anticipation for discharge pt attempted ambulation trial on [**9-14**] though had desaturation down to 83% with recovery to mid 90's at rest (off of oxygen). Pt continued to have mild leukocytosis and a CXR on [**9-15**] showed residual pulmonary edema though improved as well as some concern of bony lesions possibly related to his rostate CA. On [**9-16**] pt continued to improve from a respiratory standpoint. Pt was discharged with services (PT and VNA), on home oxygen. #) Hypotension: Pt was hypotensive initially, which improved with diuresis. No evidence of septic physiology. He was also started on Amlodipine for afterload reduction. #) Acute on Chronic Renal Insufficiency: Cr 1.9 on admission, up from baseline around 1.5. Likely [**12-23**] to poor forward flow, as Cr improved with diuresis. Cr 1.7 on transfer from the MICU. Cr continued to improve until [**9-13**] when it started to climb up to 1.8 by [**9-15**]. At this point lasix was stopped and pt was bolused with NS. On [**9-16**] Cr improved to 1.6. #) Anemia: Pt with HCT 24.1 on admission, down from baseline in mid30s. He was transfused 2units pRBCs on admission. Likely source was GI bleed, as patient had melanotic, guaiac+ stools initially. HCT has improved to 30, and the patient has remained hemodynamically stable. Discussed with patient and family regarding EGD/colonoscopy for evaluation of GIB, but they deferred given his age and other medical conditions. #) Prostate CA: Currently on ketoconazole, hydrocortisone, and leuprolide as an outpatient. Last PSA 114.1. Restarted on Ketoconazole and Hydrocortisone when taking PO after extubation. #) Diabetes: diet-controlled as outpatient. ISS while hospitalized. #) Code status: DNR/DNI Medications on Admission: Leuprolide 22.5mg SC Q 3 months Imdur 120mg (2 60mg tabs) PO QAM Metoprolol 50mg PO BID ASA 325mg PO daily Norvasc 5mg PO daily Zantac PRN heartburn Tylenol PM 1 tab PO QHS for insomnia Hydrocortisone 20mg QAM and 10mg QAfternoon Ketoconazole 400mg PO BID Discharge Medications: 1. ketoconazole 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 4. hydrocortisone 5 mg Tablet Sig: Four (4) Tablet PO QAM (once a day (in the morning)). 5. hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Imdur 120 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO qAM. 8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Tablet, Delayed Release (E.C.)(s) 9. oxygen 2L continuous pulse dose for portability. Pulmonary edema and pneumonia. 10. Ocean Nasal 0.65 % Aerosol, Spray Sig: One (1) spray each nostril Nasal three times a day as needed. Disp:*2 bottles* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Pneumonia, anemia 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 18**] and spent time in the ICU as well as the medical floor. You were treated for pneumonia which caused you to have shortness of breath. You also had a likely episode of bleeding from your gastrointestinal tract and you received 2 units of blood. Per your wishes, you did not have any scope or further work-up of your bleed. Your symptoms improved and your antibiotics were switched to oral antibiotics. A medication called lasix was added to your regimen as your lungs had fluid in them. We also prescribed a nasal spray to help with dryness caused by your oxygen tube. Please note that we decreased your aspirin dose to 81mg daily (from 325mg). Otherwise please continue all your home medications. A chest xray showed abnormalities in the bones of your chest which may be related to your prostate cancer. Please follow up with your primary care docotr regarding these findings. Followup Instructions: Please see your Primary care physician [**Name Initial (PRE) 176**] 2-4 days. In addition please see: Name: [**Last Name (LF) 1270**], [**Name8 (MD) **] MD Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **] Address: [**Street Address(2) 26362**] [**Location (un) 4628**], [**Numeric Identifier **] Phone: [**0-0-**] Appointment: Tuesday [**2105-9-22**] 11:30am Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2105-9-24**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD,PHD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**] Completed by:[**2105-9-16**]

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icd9cm

[ [ [] ] ]

[ "38.97", "96.04", "96.71", "31.42" ]

icd9pcs

[ [ [] ] ]

10666, 10737

6770, 9434

234, 247

10799, 10799

3331, 6747

11924, 12768

2599, 2655

9740, 10643

10758, 10778

9460, 9717

10982, 11901

2670, 3312

175, 196

275, 1866

10814, 10958

1888, 2099

2115, 2583

5,844

181,669

10133

Discharge summary

report

[** **] Date: [**2118-8-25**] Discharge Date: [**2118-8-26**] Date of Birth: [**2038-11-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Central venous catheter placement, [**2118-8-25**] History of Present Illness: Pt is a 79yoM with chronic back pain, CHF, CAD, who presented to ED with worsening back pain and was tranferred from the floor for sepsis. Five days prior to [**Month/Day/Year **] patient received an injection for worsening chronic back pain no longer responsive to tylenol #4 at [**Location (un) 86**] Pain Clinic. Since then pain has progressively worsened, especially on the left, and he felt warm according to family. History was obtained via chart and family as patient with depressed MS [**First Name (Titles) **] [**Last Name (Titles) **] to [**Hospital Unit Name 153**]. They state that he complained of HA in ED, but prior to that was asymptomatic. No photophobia, neck stiffness, bowel or bladder incontinence, sensory loss or muscle weakness. He ambulates on his own at baseline. + constipation for 3 days, but no complaints of abdominal pain, melena, hematochezia. Patient was brought to ED by family for worsening back pain. . In ED they felt he had a cellulitis over lower spine and MRI with contrast was obtained and there was no evidence of OM, epidural abscess, or discitis. Pt was started on oxacillin out of concern for cellulitis and received morphine for pain control. Overnight the patient recieved a dose of unasyn for further concern of cellulitis. This morning the patient was felt to have an altered MS, HA, ?neck stiffness, and he was started on vancomycin, cefepime, acyclovir, and ampicillin for presumed meningitis. Blood cultures were obtained (not obtained in ED). He was taken down for head CT, at which time his lactate came back at 8. He was tachpnic and febrile to 101, and tranferred emergently from radiology to [**Hospital Unit Name 153**] for sepsis. . Upon arrival to [**Hospital Unit Name 153**], vitals were 101.9, 157/70, 109, 40, 96% on 2L NC. Patient was minimally communicative, saying 'help' often, and grimicing in pain on palpation of abdomen and turning. Family was present and history as above obtained. KUB demonstrated dilated stomach but no dilated loops of bowel or air fluid levels. ABG was 7.25/40/98. Left subclavian line was placed and sepsis protocol initiated. Past Medical History: CHF chronic back pain CAD, CABG [**2113**] hyperlipidemia DM Social History: The patient does not use alcohol and does not have a smoking history. He lives with his daughter and his wife. [**Name (NI) **] used to work in maintenance. He is originally from the [**Last Name (un) 33854**] Republic. Recently came to US in [**Month (only) 547**] to live/visit family. No other recent travel. Family History: His brothers died of myocardial infarctions at ages 63 and 66. He has a sister who had a coronary artery bypass graft at age 73. Physical Exam: T 101.9, 109, 157/70, 40, 96% 2L NC Agitated, moaning in pain, unable to verbally communicate d/t depressed MS. [**Name14 (STitle) 4459**]: PERRL, anicteric sclera, OM clear, no exudate, no LAD Cardiac: RRR, NL S1 and S2, II/VI SEM at LUSB, no JVD appreciated Lungs: Mod wheezes bilaterally Abd: Distended, not tense, TTP throughout with patient grimicing and yelling out when palpated, low hypoactive BS. Rectal with nl tone per ED resident. Skin: No evidence of erythema or warmth along lumbar spine. +bullae, 1cm, left of lumbar spine. Could not appreciate paraspinal tenderness. + sacral edema. Skin color changes, but no overt evidence of cellulitis. Pertinent Results: 134 | 99 | 41 227 --------------/ 5.0 | 21 | 1.7 Comments: Hemolysis Falsely Increases This Result \ 11.5 / 5.2 D ------ 139 D / 34.1 \ N:55 Band:14 L:20 M:7 E:0 Bas:0 Atyps: 1 Metas: 3 Nrbc: 1 Poiklo: 1+ Ellipto: 1+ SED-Rate: 34 Plt-Est: Low Urinalysis: Color Yellow Appear Clear SpecGr 1.017 pH 5.0 Urobil Neg Bili Neg Leuk Neg Bld Lg Nitr Neg Prot Neg Glu Neg Ket Neg RBC 0-2 WBC 0 Bact None Yeast None Epi <1 Urine: UreaN:918 Creat:118 Na:27 CK: 1270 MB: 18 MBI: 1.4 Trop-*T*: 0.09 ALT: 40 AP: 52 Tbili: 2.1 AST: 94 [**Doctor First Name **]: 30 Lip: 13 Hapto: 253 PT: 14.8 PTT: 28.5 INR: 1.3 Fibrinogen: 682 Lactate:8.6->9.2->9.7-> ABG: 7.25/40/98/18-8/24/06-1249 . Imaging: [**2118-8-23**] MR without contrast: Disc degeneration of L3-L4, L4-L5, L5-S1.Central disc bulge at L5-S1. L5 facet joint DJD. Mod-severe central spinal stenosis at L4-L5, L3-L4. No conus compression or lesion. Abnormal T2 singal in left erector spinae muscle (infectious, traumatic, neoplastic). . [**2118-8-25**] MRI (unsigned): IMPRESSION: 1. Enlargement of the left spinal rectus muscle which demonstrates abnormal increased T2 signal and enhancement. As the fat planes are preserved, this is not consistent with an abscess. These findings may be suggestive of myositis of the patient has a prior history of trauma to this region, or post-inflammatory process. Comparison with the patient's previous MRI is recommended. 2. Degenerative disc disease as described above with most severe spinal stenosis at L4-5. 3. No evidence of osteomyelitis or epidural abscess. . [**2118-8-25**]: CT HEAD: No evidence of acute intracranial pathology including no evidence of acute intracranial hemorrhage. . EKG: NSR, 0.5mm ST elevation in V1 and V2 with Jpoint elevation in V3. No Q waves. . Brief Hospital Course: A/P: 79yoM with acute on chronic back pain, CAD, CHF, who was tranferred to [**Hospital Unit Name 153**] for concern of sepsis. . 1. Sepsis: Patient with severe sepsis, developing multisystem organ failure with severe lactic acidosis and evidence of DIC (elevated FDP), required intubation for respiratory failure (ARDS vs. pneumonia vs. edema-less likely given patchy distribution). No evidence of abscess on MRI of lower spine. Only source of infection is blood cultures from [**8-25**] with 2/4 coag + staph. Abdominal source also possible given acute abdomen, though this could also represent ischemic damage in the setting of sepsis. UA negative. He was aggressively volume resuscitated as well as treated with maximum dose levophed and vasopressin to elevate blood pressure and elevate SVO2 per sepsis protocol to maintain CVP 12-15 and MAP >60. He was placed on a HCO3 gtt with additional HCO3 pushes in an effort to elevate his pH, which continuted to fall as lactate continued to rise during his hospital course. He was also started on Xigris based on his APACHE score. Despite these measures his blood pressure did not respond well as his pH fell to 7.27 then 7.03, regardless of HCO3. His lactate continued to rise to 12.2. He was treated empirically with ceftriaxone, vancomycin, ampicillin, flagyl and acyclovir. He was designated CPR not indicated on the evening of [**2118-8-25**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 217**]. The following day at 1355 he was noted to be increasingly bradycardic with many missed or dropped beats and rapidly became asystolic. He was assessed at 1400 and found to lack have no heart sounds, breath sounds, corneal blink reflex, oculocephalic reflex, withdrawl to pain in any extremity or grimace to sternal rub, therefore he was pronounced deceased. His family was at the bedside and they consented for an autopsy. . 2 Abdominal Pain - KUB with dilated stomach but no overt evidence of SBO, lavage with frank blood so pantoprazole was started for ulcer protection. NG tube was left in place to decompress the stomach but further imaging was not possible prior to death. . 3 H/O CAD - Patient with elevated CK and mildly elevated troponin but normal CK-MB and MBI. Troponin trended up during hospital course from 0.09 to 0.3 to 0.6 but in the setting of severe sepsis with multisystem organ failure and DIC. He was maintained on Aspirin and lipitor during this time but betablockers and nitro were held in the setting of sever hypotension refractory to vasopressors. . 4 Elevated CK - Initially thought to be c/w trauma from left paraspinal injection but CK continued to rise in the setting of severe sepsis up to 3680. . 5 ARF: Unclear baseline renal function but creatinine cont. to rise in the setting of severe sepsis with refractory hypotension likely prerenal. ACEi and lasix were held. . 6 Anion gap metabolic acidosis - ABG 7.25/40/98. Metabolic acidosis likely d/t elevated lactate. Unable to appropriately blow off CO2 perhaps d/t pulmonary process (wheezes). This continued to worsen despite HCO3 gtt and pushes. . 7 DM - Patient continued on avandia with blood glucose 163-227. Medications on [**Last Name (NamePattern1) **]: His medications are currently Lipitor 40 mg per day, Avandia 4 mg a day, isosorbide 20 mg t.i.d., aspirin 325 mg a day, Lopressor 75 mg b.i.d., doxazosin 2 mg a day, lisinopril 40 mg a day, Lasix 40 mg a day and vitamin E and C supplements Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Deceased. Discharge Condition: Deceased.

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9107, 9116

5592, 9054

321, 373

9169, 9181

3778, 5372

2955, 3086

9077, 9084

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3101, 3759

275, 283

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5381, 5569

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2626, 2939

48,656

199,229

3884

Discharge summary

report

Admission Date: [**2176-8-10**] Discharge Date: [**2176-8-19**] Date of Birth: [**2107-6-27**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2176-8-13**] Coronary Artery Bypass Graft x4 (Left Internal Mammary Artery to Left anterior descending, Saphenous Vein Graft to Diagonal, Saphenous Vein Graft to Posterior descending artery sequence to posterolateral ventricular branch) [**2176-8-12**] Cardiac Cath History of Present Illness: 69-year-old Cantonese speaking male with a history of coronary artery disease including right coronary artery and posterolateral branch stenting([**10/2162**]), old inferior MI with an ejection fraction of 40% to 45%. Patient presented to emergency room with chest pain. Patient took some little nitroglycerin with some relief. Chest pain w/negative markers, no EKG changes. Admitted and brought to cath lab- found to have 3VD. Referred for surgery. Past Medical History: Coronary artery disease-right coronary artery and posterolateral branch stenting([**10/2162**]), inferior myocardial infarction Hypertension Hypercholesterolemia Chronic renal insufficiency (Cr 1.1) Diabetes mellitus mild Aortic stenosis ([**Location (un) 109**] 1.2cm2/gradient 13/23) Past Surgical History: Kidney stone removal- bilat incision lateral abd Social History: Lives in [**Hospital1 17359**] with his family. Contact: [**Name2 (NI) 17360**] Phone #[**Telephone/Fax (1) 17361**] Occupation: He is not currently working. Cigarettes: Smoked-yes [x]1.5ppd x35yrs/quit smoking 8 years ago Other Tobacco use:no ETOH: He does not drink alcohol. Illicit drug use: denies Family History: Father died at the age of 75 due to coronary artery disease. His mother died at the age of 84 from lung cancer. There is no history of early coronary artery disease or sudden cardiac death in his family. Physical Exam: T 98.4 Pulse: 58 Resp: 20 O2 sat: 97%-RA B/P Right: 126/72 Height 168 cm (5'6'') Weight 95.30 kg (210 lbs) BSA 2.05 m2 Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] no M/R/G Abdomen: obese, Soft[x] non-distended[x] non-tender[x] +BS [x] well healed scars lateral abdm wall bilaterally Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: non focal exam/Grossly intact [x] Pulses: Femoral Right: bandage Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: cath Left: 2+ Carotid Bruit - none Pertinent Results: [**2176-8-13**] PRE-CPB: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. The number of aortic valve leaflets cannot be determined. The valve behaves as a functional bicuspid. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. 8. Trivial mitral regurgitation is seen. POST-CPB: On infusion of phenylephrine, AV pacing, sinus rhythm with long PR interval, preserved biventricular systolic function, no new regional wall motion abnormalities, trace AR, mild MR, aortic contour remains normal post decanulation. [**2176-8-15**] Echo: The left ventricular cavity is small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is small. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. The aortic valve is not well seen. Significant aortic stenosis is present (not quantified). The epicardial surface of the heart is poorly visualized. A consolidated pericardial effusion (? thrombus) cannot be excluded on the basis of this study. Both ventricles appear small, but this study cannot distinguish between extrinsic compression and underfilling. [**2176-8-15**] Abd x-ray: Multiple air-filled non-distended loops of small bowel with a small quantity of air in the colon is most consistent with a post-operative ileus. [**2176-8-18**] KUB:Gas-filled loops of large and small bowel are present with multiple air-fluid levels, consistent with an ileus pattern. Note is made of a left effusion. [**2176-8-19**] 05:40AM BLOOD WBC-10.8 RBC-3.33* Hgb-10.6* Hct-32.2* MCV-97 MCH-31.9 MCHC-33.0 RDW-14.3 Plt Ct-361 [**2176-8-19**] 05:40AM BLOOD Glucose-106* UreaN-19 Creat-1.3* Na-138 K-4.1 Cl-105 HCO3-24 AnGap-13 [**2176-8-18**] 05:55AM BLOOD Glucose-76 UreaN-22* Creat-1.3* Na-139 K-3.8 Cl-106 HCO3-23 AnGap-14 [**2176-8-17**] 04:50AM BLOOD WBC-13.1* RBC-3.09* Hgb-10.2* Hct-29.5* MCV-95 MCH-32.9* MCHC-34.5 RDW-13.7 Plt Ct-260# [**2176-8-19**] 05:40AM BLOOD ALT-43* AST-43* LD(LDH)-362* AlkPhos-56 Amylase-56 TotBili-0.6 [**2176-8-18**] 05:55AM BLOOD ALT-41* AST-48* LD(LDH)-357* AlkPhos-54 Amylase-51 TotBili-0.7 [**2176-8-15**] 05:28AM BLOOD ALT-26 AST-68* LD(LDH)-353* AlkPhos-42 TotBili-1.0 Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**8-10**] with chest pain. He received medical management and had negative cardiac enzymes and no EKG changes. Underwent a cardiac cath on [**8-12**] which showed severe coronary artery disease. Underwent usual pre-operative work-up and was brought to the operating room with Dr. [**Last Name (STitle) **] on [**8-13**]. Please see operative report for surgical details. Following surgery he was transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Later that evening 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. Later this day he was transferred to the step-down floor and began increasing his activity level. Chest tubes and epicardial pacing wires removed per protocol. On post-op day two he developed nausea and vomiting. An nasogastric tube was placed and KUB done. X-ray showed multiple air-filled non-distended loops of small bowel with a small quantity of air in the colon, consistent with a post-operative ileus. Aggressive bowel regimen was instated and he was made NPO. With time he moved his bowels and his radiographs improved. His nasogastric tube was removed and trialed on clears, which he tolerated without incident. His diet was advanced as his radiographs and symptoms improved. He was having multiple loose bowel movements at the time of discharge and he was tolerating a full oral diet. Finger sticks were 80-153 and he was advised to follow up with PCP for blood sugar management given his elevated A1C after discharge from rehab. By post-operative day 6 he was ready for discharge to [**Hospital 392**] Rehab. Medications on Admission: ISOSORBIDE DINITRATE - 10 mg Three times a day LOSARTAN 50 mg daily METOPROLOL 12.5 mg [**Hospital1 **] OMEPRAZOLE dosage uncertain daily Crestor 20 Daily ASPIRIN 325 mg daily NTG infusion- Heparin infusion Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO every twenty-four(24) hours for 7 days. 4. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 10 days. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every eight (8) hours as needed for constipation. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Regular insulin sliding scale - Finger sticks QID Discharge Disposition: Extended Care Facility: [**Hospital 392**] Rehabilitation & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Graft x4 Postop ileus Past medical history s/p right coronary artery and posterolateral branch stenting [**10/2162**]), Inferior myocardial infarction Hypertension Hypercholesterolemia Chronic renal insufficiency (Cr 1.1) Diabetes mellitus mild Aortic stenosis ([**Location (un) 109**] 1.2cm2/gradient 13/23) Past Surgical History: Kidney stone removal- bilat incision lateral abdm Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] on [**9-4**] at 1:45pm in the [**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **] Cardiologist: Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 62**] on [**9-12**] at 11:20am Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) 17362**] [**Name (STitle) **] in [**5-21**] 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:[**2176-8-19**]

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icd9cm

[ [ [] ] ]

[ "88.56", "39.61", "37.21", "36.13", "36.15" ]

icd9pcs

[ [ [] ] ]

9116, 9215

5806, 7558

317, 588

9691, 9914

2707, 5783

10837, 11502

1790, 1995

7815, 9093

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9619, 9670

2010, 2688

271, 279

616, 1067

1089, 1375

1465, 1774

67,239

194,379

41881

Discharge summary

report

Admission Date: [**2165-9-6**] Discharge Date: [**2165-10-10**] Date of Birth: [**2131-12-24**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5569**] Chief Complaint: liver [**First Name3 (LF) **] evaluation Major Surgical or Invasive Procedure: Liver [**First Name3 (LF) **] [**2165-9-12**] EGD paracentesis [**10-4**] and [**10-9**] History of Present Illness: 33 y/o M with PMH of primary sclerosing cholangitis, autoimmune hepatitis transferred from OSH for liver [**Month/Year (2) **] evaluation. . Briefly, patient was diagnosed with AIH overlapped with PSC in [**2158**] and since that time has had numerous admissions for obstructive jaundice and possible cholangitis. During an admission in [**3-/2165**] he was found to have CA [**72**]-9 markedly elevated at 325, AFP at 6.7 with MRCP showing no evidence of cholangiocarcinoma. He has been maintained on imuran and prednisone although there is some question whether the patient has been fully compliant with his regimen. . He initially presented to an OSH with fatigue and was found to have decompensated cirrhosis with jaundice, ascites and acute renal failure (creatinine 1.5 from baseline of 0.7- 1.0). On [**2165-9-3**] he underwent diagnostic paracentesis and was found to have SBP [**1-30**] to alpha-hemolytic strep, treated with 2gm IV CTX (currently D4/5) with supplemental albumin on D1 and D3. Given concern for possible cholangitis, he underwent ERCP w/ sphincterectomy on [**2165-9-5**] which showed stable, known constrictions without acute pathology. Of note, prior to ERCP he received 4U FFP for INR of 2.4 . Enroute to the hospital, he noted diffuse abdominal pain. Described as a throbbing or burning. Past Medical History: -- cirrhosis [**1-30**] autoimmune hepatitis, PSC, ETOH -- s/p ERCP in [**5-/2165**], [**8-/2165**] with sphincterectomy -- hx of ETOH abuse -- Liver [**Year (4 digits) **] [**2165-9-12**] Social History: works in the Navy, lives in [**Location 7188**] with a roommate. Currently in monogamous relationship with female partner. - EtOH: heavy up until [**2162**], no alcohol in 2 years - Drugs: none - Smoking: none Family History: mother with diabetes, died at 37. father with HTN & CAD s/p CABG no history of liver disease. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.9 106/60 73 20 99% General: well-appearing, mild abdominal pain HEENT: icteric, PERRL, MMM Neck: no lymphadenopathy, supple Heart: RRR no m/r/g Lungs: Left basilar crackles and dullness to percussion Abdomen: soft, NT, distended with ascites Extremities: 1+ edema bilaterally Neurological: A+Ox3, no gross motor deficits, no asterixis Rectal: guaiac negative Pertinent Results: OSH labs: [**9-6**] Na 137, K 3.8, Cl 106, CO2 22, BUN 18, Cr 1.5 WBC 8.2, Hct 27.9, Plt 195 PT 23.8, INR 2.2, PTT 43.9 ALT 31, AST 104, TBili 20.4, AP 140 [**9-5**] Amylase 114, Lipase 131 [**9-4**] Urine Na 15, Cr 1.53 ADMISSION LABS [**2165-9-6**] 06:46PM BLOOD WBC-9.8 RBC-3.84* Hgb-11.9* Hct-31.6* MCV-82 MCH-31.0 MCHC-37.8* RDW-16.6* Plt Ct-243 [**2165-9-6**] 06:46PM BLOOD Glucose-78 UreaN-19 Creat-1.8* Na-138 K-3.8 Cl-105 HCO3-21* AnGap-16 [**2165-9-6**] 06:46PM BLOOD ALT-43* AST-132* LD(LDH)-234 AlkPhos-159* TotBili-22.5* [**2165-9-6**] 06:46PM BLOOD Albumin-3.1* Calcium-8.6 Phos-2.7 Mg-2.7* Iron-71 CXR [**2165-9-6**]: The lung volumes are low, there is evidence of elevation of the right hemidiaphragm. Subsequently, a small area of atelectasis is seen at the right lung bases. On the left, a large plate-like atelectasis is present. Borderline size of the cardiac silhouette. No pleural effusions. No pulmonary edema. No evidence of pneumonia. CT ABDOMEN [**2165-9-7**]: 1. Markedly cirrhotic liver with diffuse nodularity and heterogeneity, but no mass visualized. Intrahepatic biliary dilatation is also noted. 2. No evidence of portal venous thrombosis. However, the left portal vein drains into a markedly enlarged umbilical vein while the right portal vein is significantly attenuated in size. 3. Common origin of the celiac and SMA. The remaining hepatic arterial anatomy is conventional. 4. Multiple tiny gallstones. 5. Moderate ascites. ECHO [**2165-9-9**]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Left ventricular wall thicknesses are normal. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. 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. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Ascites is noted. IMPRESSION: Borderline pulmonary artery hypertension. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. EGD [**2165-9-17**]: Varices at the lower third of the esophagus. Erythema and petechiae in the stomach body compatible with gastropathy. Blood in the whole stomach. Varices at the fundus. Blood in the jejunum. Otherwise normal EGD to third part of the duodenum. CT chest/abdomen/pelvis [**2165-9-18**]: 1. Status post liver [**Year (4 digits) **] with expected postoperative periportal fluid. No evidence of postoperative complication. 2. No intraabdominal fluid collection or free air. 3. Dilated ascending and transverse colon, likely colonic ileus. 4. Anasarca. 5. Small right-sided pleural effusion with associated overlying atelectasis. Tube cholangiogram [**2165-9-18**]: Gravity cholangiogram demonstrating contrast within a small bowel loop without evidence of contrast within bile ducts. CT chest/abdomen/pelvis [**2165-9-23**]: 1. Findings concerning for early/partial small-bowel obstruction; possible etiologies include adhesion versus mass effect from the catheter positioned within the pelvis. 2. Small bilateral pleural effusions with atelectasis. BLE US [**2165-9-23**]: 1. No deep vein thrombosis in either lower extremity. 2. Likely right [**Hospital Ward Name 4675**] cyst, measuring up to 4.4 cm. Nuclear lung scan [**2165-9-23**]: Matched ventilation and perfusion defects. Low likelihood of pulmonary embolism. Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2165-10-10**] 06:20 13.5* 2.99* 8.8* 26.5* 89 29.4 33.2 16.5* 388 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2165-10-10**] 06:20 881 52* 1.9* 135 4.7 99 25 16 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili [**2165-10-10**] 06:20 26 17 130 0.7 Brief Hospital Course: 33 y/o M with PMH of primary sclerosing cholangitis, autoimmune hepatitis who was transferred from [**Hospital1 2025**] for liver [**Hospital1 **] evaluation. He had experienced a large increase in his ascites with worsening LFTs. Ceftriaxone was continued for SBP diagnosed at [**Hospital1 2025**] x5 days and albumin. Therapeutic tap was done on [**9-7**] which showed resolution of SBP. Diuretics were held as creatinine was up to 1.5 from baseline of 0.9. Cr increased to 3.5 on 2nd hospital day. This was treated with octreotide and midodrine, as well as daily albumin, with resolution of Cr closer to baseline. He was febrile on [**9-7**], with an elevated WBC. No source was isolated from cultures. Assumed to be due to cholangitis from ERCP performed on [**9-5**] at [**Hospital1 2025**]. Started on vanc/zosyn on [**9-7**]. Paracentesis showed no SBP. Remained afebrile with WBC stable around 12. Vanc/zosyn continued for 7 days. . On [**2165-9-12**], the patient underwent liver transplantation. Two JP drains were placed. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Post-operatively, he was admitted to the SICU for management. LFTs initially increased, but trended down on subsequent days. Liver duplex showed patent vasculature, no ductal dilatation or perihepatic collections. He had a persistent leukocytosis to 59K for many days without fever or other sign of infection. He was continued on vancomycin and zosyn for recent SBP. On [**2165-9-13**], he was transferred to the floor. On [**2165-9-15**], he passed flatus and diet was advanced to regular food. On [**2165-9-16**], he vomited coffee grounds, and NGT placement continued to drain similar fluid. On [**2165-9-17**], he was acutely anemic with orthostasis and hematocrit of 15.7. He was transferred to the SICU. PRBC were transfused, and coagulopathy was corrected with FFP and cryoprecipitate. Pantoprazole was started as well as Octreotide. EGD demonstrated esophageal varices, but these were not banded. Blood was noted in the stomach and jejunum. The J-J anastomosis was not reached. There was no clear site of bleeding in the jejunum and no active anastomotic bleed. Around this time, he developed acute renal failure from tacrolimus toxicity and hypoperfusion. He was persistently orthostatic due to hypovolemia due to high JP ascites output which required IV fluid/albumin. Broad-spectrum empiric antibiotics were started. On [**2165-9-18**], WBC increased to 60K. In conjunction with hematology and hepatology, this was attributed to a steroid-induced leukemoid reaction. Vancomycin and meropenem were started empirically. Blood and urine cultures were negative. CT chest showed no pneumonia. He was extubated without difficulty. On [**9-18**], a Roux tube gravity cholangiogram was performed to assess the roux anastomosis. This failed to demonstrated the bile anastomosis. The tube was noted in the bowel. Roux tube was capped. On [**2165-9-19**] TPN was started for nutrition, as the patient developed ileus requiring NGT. Hematocrit stabilized and there was no further evidence of bleeding. On [**2165-9-21**], he was transferred out of the SICU. On [**2165-9-22**], he was transferred back to the SICU for tachypnea. Vancomycin was changed to linezolid for VRE growing from bile sampled from his Roux tube. CXR found little interval change, and nuclear lung scan showed low likelihood of PE. Tachypnea resolved spontaneously and on [**2165-9-24**], he was transferred to the floor. TPN had been continued daily since initiation, as the patient could not advance to a significant oral diet due to ileus. On [**2165-9-26**], NGT was clamped which he tolerated. Residuals were minimal and the NG was removed. Appetite continued to remain poor. TPN continued. Orthostasis continued to be a problem impairing his ability to ambulate. IV fluid boluses were given and a unit of PRBC were administered on [**9-28**] for HCT of 25.2. JP outputs continued to be high 3500cc per day (ascitic). JPs were finally removed on [**9-29**] and [**10-1**]. On [**9-30**], a post pyloric feeding tube was placed. Tube feeds were started and rate was increased as tolerated. Creatinine increased to 6.5 on [**10-1**] due to creatinine increase to 2.4 from 1.7. This was due to Prograf level that increased to 22.5. Hyperkalemia ensued due to Prograf toxicity. Hyperkalemia was treated with IV meds and po Kayexalate. Potassium came down, but the patient vomited the feeding tube. The tube was left out per patient request as he felt that he could drink [**4-2**] supplements per day. Prograf was held for 4 doses then resumed at lower dose. Creatinine increased further to 2.6, but then trended down daily with lower Prograf doses. He began to feel better and was able to drink 4 Nutren supplements (2300 kcals) plus some food to reach Kcal goal of 2400. Of note, he was found to have an elevated TSH 8.5 and low T3/T4 on [**9-17**]. Levothyroxine was started on [**9-17**]. Given repeated orthostatic episodes, anasarca, flat affect and lack of appetite, a repeat TSH was checked on [**9-27**] and found to be 12. Levothyroxine was increased to 100mcg per day. Endocrinology was consulted and recommended increasing to 125mcg per day with repeat TSH/T3/T4 in 1 month. This was done on [**10-1**]. Patient's energy level increased as well as appetite. Lasix was started for edema as well as for ascites that had accumulated after abdominal JPs were removed. A 6 liter paracentesis was performed on [**10-4**]. Albumin was administered. PD fluid was sent for gram stain and culture. Cell count was indicative of peritonitis with 1350 WBC with 88 polys. IV Ceftriaxone was started and continued for 5 days. Repeat paracentesis was done on [**10-9**] for approximately 4 liters. Albumin was given post para. Cell count had 268 WBCs and 59 polys. 3+pmns and no microorganisms were noted. Culture was pending. Ceftriaxone was switched to Ciprofloxacin on [**10-10**] for SBP prophylaxis indefinitely ([**Hospital1 18**] [**Hospital1 1326**] MD to re-assess in outpatient f/u). He felt better, vital signs were stable. He was ambulating several times per day with supervision. HCT was noted to have dropped from 27 to 23 on [**10-7**]. Repeat HCT on [**10-8**] was 23. Two units of PRBC were administered on [**10-8**]. HCT remained at 25. Prograf level increased again to 17 on [**10-9**]. Prograf was held and dose decreased to 1mg [**Hospital1 **]. Trough level was pending. The plan was for him to go to [**Hospital3 **] in [**Hospital1 8**], MA. PT recommended rehab (see notes). A bed became available on [**10-10**] and he was transferred there. Medications on Admission: home meds (which were d/c'ed in [**Month (only) **]): lasix 40mg daily spironolactone 100mg daily ursodiol 600mg [**Hospital1 **] omeprazole 40mg [**Hospital1 **] azathioprine 50mg daily prednisone tape ciprofloxacin 500mg [**Hospital1 **] flagyl 500mg TID . meds on transfer: nadolol 20mg daily bisacodyl docusate omeprazole 40mg daily heparin 5000 TID CTX 2g IV q24 octreotide 200 SC TID (one dose prior to DC midodrine 10mg TID (one dose prior to DC) Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): Until mobile. 3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): Decrease to 15 mg daily on [**10-12**]. Decrease per [**Month/Year (2) **] clinic taper. 10. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): Check TSH first week of [**11-8**]. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day: SBP prophylaxis duration -indefinate. 13. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day. 14. insulin lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 15. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day: check trough level daily with results fax'd to [**Hospital1 18**] [**Hospital1 **] [**Telephone/Fax (1) 697**]. 16. Outpatient Lab Work Daily thru [**10-14**] then every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, tbili and trough prograf level with results fax'd to [**Hospital1 18**] [**Hospital1 1326**] [**Telephone/Fax (1) 697**] weekdays. call [**Telephone/Fax (1) 673**] on weekends 17. Outpatient Lab Work TSH [**11-4**] fax results to [**Telephone/Fax (1) 697**] [**Hospital1 18**] [**Hospital1 1326**] Office Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: PSC/autoimmune hepatitis GI bleed Anemia malnutrition Afib Hypothyroidism VRE in Bile Ileus Orthstasis/hypovolemia Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). (supervision) Discharge Instructions: You will be transferring to [**Hospital 69348**] Rehab in [**Hospital1 8**], MA Blood will be drawn every Monday and Thursday for lab monitoring Please call the [**Hospital1 18**] [**Hospital1 1326**] Office [**Telephone/Fax (1) 673**] if you have any of the following: fever (temperature of 101), shaking chills, nausea, vomiting, inability to take any of you medications, increased abdominal distension, abdominal pain, incision redness/bleeding/drainage, increased leg edema or any concerns Your RN coordinator is [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 10575**] Followup Instructions: Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-10-10**] 3:00 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-10-17**] 1:50 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2165-10-24**] 1:30 Completed by:[**2165-10-10**]

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icd9cm

[ [ [] ] ]

[ "45.13", "00.14", "87.54", "54.91", "99.15", "96.6", "38.93", "00.93", "50.59", "51.37" ]

icd9pcs

[ [ [] ] ]

16052, 16123

6900, 13587

346, 437

16302, 16302

2778, 6877

17145, 17598

2245, 2341

14092, 16029

16144, 16281

13613, 13872

16499, 17122

2381, 2759

265, 308

465, 1789

16317, 16475

1811, 2001

2017, 2229

13890, 14069

42,385

135,792

37238

Discharge summary

report

Admission Date: [**2182-11-29**] Discharge Date: [**2182-12-10**] Date of Birth: [**2111-2-21**] Sex: F Service: MEDICINE Allergies: Glyburide / Shellfish Derived / Influenza Virus Vaccine / Pneumovax 23 Attending:[**First Name3 (LF) 1145**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: Central line placement Replacement of tunneled dialysis catheter Cardiac catheterization History of Present Illness: 71 yo F with h/o ERSD on HD, CAD s/p 2 prior stents, HTN, PVD, AAA 6.5 cm and COPD who was found unresponsive around 2am this morning and was taken to an OSH. She was found to have hypercarbic respiratory failure with a respiratory and metabolic acidosis(ABG 7.08/80/290), BNP 5000, WBC 20, and lateral ST depressions in EKG. She was placed on BiPAP, blood cultures were stent and she was started on Zosyn and received hemodialysis with 2.5L removed with UF. When her troponin I was elevated at 1.75, a femoral CVL was placed and IV heparin started. . Prior to transfer, VS HR 80s in SR, BP 140/70s, on BIPAP 12/6 3L ABG 7.33/43/129. She was reported to be alert but lethargic, moving all extremities having had 2 bowel movements. She had left leg pain from placement of intraosseous IV in the field. She had dopplerable LE pulses but mottled skin with 2+ edema. . Per family, the patient had been experiencing a dry cough over the past few weeks and had been treated for PNA requiring 10 days of hospitalization in early [**Month (only) 359**]. She was scheduled for an elective AAA repair on the morning of presentation because it had recently been increasing in size. . On review of systems, reports recent dry cough with occassional sputum production but denies. she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She uses a wheelchair at baseline. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: unknown -PERCUTANEOUS CORONARY INTERVENTIONS: unknown -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: COPD Tobacco Abuse HTN PVD CAD, h/o MI s/p 2 stents AAA, infarenal 6.5cm planning surgical repair ESRD on HD VRE in Urine in past Clotted AV fistula in LUE - clotted off 3 weeks DM Social History: Lives with daughter. Recently admitted approx 6 weeks ago for PNA, staying 10 days at Lakes General. -Tobacco history: Currently smoking 1.5PPd, has smoked since age 12 -ETOH:Social use -Illicit drugs: None Family History: non-contributory Physical Exam: VS: T=98.8 BP= 133/68 HR=80 RR=30 O2 sat=99% on 2L NC GENERAL: cachetic, chronically ill appearing female in NAD. Oriented x3, became progressively more drowsy during the evaluation. Mood aggitated, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MMM. No xanthalesma. NECK: Supple with JVP of 12 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: + kyphosis. Resp were rapid and shallow, but speaking in full sentences. Distant BS diffusely, no crackles, few scattered wheezes in upper airway. ABDOMEN: Soft, mildly distended NT. No HSM. No tenderness. Abd aorta pulsital by palpation. No stigmata of chronic liver disease. Guiac positive, brown stool mixed with blood tinged mucous. EXTREMITIES: distal cyanosis of toes b/l. pitting edema to mid-calf r>L. Right femoral CVL, left knee w/ intraosseous line removed. No asterxis. SKIN: Dusky toes b/l, 2x0.5cm stage II sacral decub without drainage PULSES: Right: Carotid 1+ Femoral 1+ DP daint on doppler PT faint on doppler Left: Carotid 1+ Femoral 1+ DP doppler PT doppler Neuro: Following all commands, PERRLA, EOMI, CN II-XII without focal deficit, moving all extremities, strength 4+/5 throughout Pertinent Results: [**2182-11-29**] 07:48PM BLOOD WBC-22.4* RBC-3.38* Hgb-10.9* Hct-34.4* MCV-102* MCH-32.3* MCHC-31.8 RDW-19.0* Plt Ct-178 [**2182-11-29**] 07:48PM BLOOD Neuts-93.9* Lymphs-4.5* Monos-1.3* Eos-0.1 Baso-0.1 [**2182-11-29**] 07:48PM BLOOD PT-21.9* PTT-59.6* INR(PT)-2.1* [**2182-11-29**] 07:48PM BLOOD Glucose-81 UreaN-28* Creat-3.7* Na-136 K-3.9 Cl-95* HCO3-25 AnGap-20 [**2182-11-29**] 07:48PM BLOOD ALT-2070* AST-5547* LD(LDH)-5810* CK(CPK)-93 AlkPhos-182* Amylase-95 TotBili-1.0 [**2182-11-29**] 07:48PM BLOOD Lipase-48 GGT-65* [**2182-11-29**] 07:48PM BLOOD CK-MB-NotDone cTropnT-2.31* [**2182-11-30**] 04:29AM BLOOD ALT-1418* AST-2907* LD(LDH)-1431* CK(CPK)-49 AlkPhos-147* TotBili-0.9 [**2182-11-30**] 04:29AM BLOOD CK-MB-NotDone cTropnT-2.19* [**2182-11-30**] 11:56AM BLOOD CK(CPK)-37 [**2182-11-30**] 11:56AM BLOOD CK-MB-NotDone cTropnT-2.66* [**2182-12-7**] 06:10AM BLOOD ALT-151* AST-30 AlkPhos-140* TotBili-0.6 [**2182-12-2**] 05:42AM BLOOD %HbA1c-5.5 [**2182-11-29**] 07:48PM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [**2182-11-29**] 07:48PM BLOOD HCV Ab-NEGATIVE [**2182-11-29**] 07:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG RUQ U/S [**11-29**]: 1. Branching echogenic pattern in the liver, concerning for possible tubular gas. The configuration is most consistent with hepatic venous gas (conceivably from central venous line), although considerations include pneumobilia and portal venous gas. Correlation to history, physical examination and lactate value is recommended. This finding might be further evaluated with a CT. 2. 6cm abdominal aortic aneurysm. 3. No Budd-Chiari syndrome and limited evaluation of the hepatic artery, secondary to poor patient tolerance. 4. Cholelithiasis. . CT A/P [**11-30**] IMPRESSION: 1. No portal venous gas or pneumobilia. 2. Extensive atherosclerotic disease with an infrarenal abdominal aortic aneurysm, measuring 60 x 56 mm. 3. Cholelithiasis. . TTE [**11-30**] The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis with more severe hypokinesis of the basal half of the inferior and inferolateral walls (LVEF = 30%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-11**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Moderate global left ventricular hypokinesis with some regionality suggestive of multivessel CAD or other diffuse process. Right ventricular cavity enlargement with free wall hypokinesis. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. . Cardiac Cath [**12-4**] COMMENTS: 1. Selective coronary angiography of this right dominant system revealed three vessel coronary artery disease. The LMCA had no angiographically apparent disease. The previous LAD stent was patent and the LAD had diffuse calcification with distal 50-60% stenosis. The Lcx was calcified and occluded. The distal Lcx filled via collaterals from the diagonal. The RCA had diffuse disease with serial 90% stenosis and distally filled via collaterals from the LAD. 2. Limited resting hemodynamics revealed an elevated left sided filling pressure with an LVEDP of 35 mmHg. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Moderate left ventricular diastolic dysfunction. . Art Ext Studies: pending . DISCHARGE LABS Brief Hospital Course: 71 yo F w/ h/o ESRD on HD, CAD s/p 2 stents, PVD, HTN, AAA and COPD presents as OSH transfer with hypercarbic respiratory failure, isolated elevated troponin, and new hepatic dysfunction # CAD - The patient has a h/o 2 prior stents. Positive troponin in setting of flat CKs and h/o ?arrest/unresponsiveness likely [**2-11**] initial hypotensive episode causing demand ischemia. TTE this admission showed newly depressed EF compared to two years ago. LHC showed diffuse 3VD. The patient and her family were unwilling to pursue CABG at this time. The patient was treated medically with ASA, BB, ACEi. Statin was held in the setting of acute liver injury. The patient was also provided with materials regarding tobacco cessation. # Chronic systolic congestive Heart Failure: TTE shows EF of 30%. No sx of heart failure on exam, no oxygen requirement or crackles on exam. The patient was continued on ASA, BB, ACEi, as above. # AAA - 6.5cm with plan at OSH for elective repair. Given severe CAD, felt that percutaneous repair could not be done. Per VSurg, obtained ABI/venous mapping and will be followed up by Vascular Surgery as an outpatient in 2 wks. # RHYTHM: Sinus Rhythm with no history of atrial or ventricular arrhythmias. # Hypercarbic Respiratory Failure: Has history of COPD, continues to smoke with recent dry cough raising suspicion for COPD exacerbation. S/p BiPAP at the OSH with improvement in PCO2. Currently appears comfortable on RA. Discussed smoking with pt and offered nicotine replacement systems, she has refused and wants to quit on her own. Of note, daughter is a current smoker and is the only venue for pt to obtain cigarettes. Will focus information about quitting to her. The patient was treated with ipratropium/albuterol nebs while hospitalized. # Hepatic Failure: Most likely etiology is shock liver (ischemic hepatitis) given history and significantly elevated LDH, although no clear documentation of hypotension at OSH and has not been observed here, vascular obstructive disease, acute viral/toxic injury, infiltrate process. AST/ALT decreased quickly. CT abd/pelvis showed no acute change, pos cholelethiasis. Hepatitis serologies negative. Statin was held [**2-11**] to increase in LFTs. # GI Bleed: Guaiac positive stools with maroon mucous tinged on heparin gtt as transfer. No prior history per family. HCt 40 at OSH, down trending to 33 on admission and 29 here. Stable during the rest of the hospitalization. The patient was treated with PPI. # Altered Mental Status - Waxing and [**Doctor Last Name 688**] in setting of normal PCO2, dramatic LFT abnormality. She is more confused at night per daughter and tends to wake frequently. MS improved during hospitalization, although the patient continued to be confused at times. She was started on low dose Seroquel at hs. # ESRD on HD: On regular M/W/F schedule. The patient's line clotted on [**12-6**]. Instillation of tPA failed to open line, and patient was sent for tunneled cath placement on [**12-9**]. # Unilateral Peripheral Edema: resolved. # PVD - Mottled LE at baseline, but improved during hospitalization. No open areas were noted. The patient had vein studies, as per Vsurg and will f/u as an outpatient. Medications on Admission: On transfer:per discharge summary heparin aspirin IV lopressor IV ACEI . At home: omprazole 20 mg po daily valium 1mg po BID zocor 5mg po daily lopressor 25mg TID synthroid 25mcg daily renal caps 600mg po daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day. 5. EMLA 2.5-2.5 % Cream Sig: One (1) application Topical as directed. 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. 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* 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4,000-11,000 units Injection PRN (as needed) as needed for line flush. 11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 13. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 min for total of 3 doses as needed for chest pain. Disp:*1 bottle* Refills:*0* Discharge Disposition: Home With Service Facility: Community Home Health and Hospice Discharge Diagnosis: Non St elevation Myocardial Infarction Chronic Obstructive Pulmonary Disease Exacerbation Acute on chronic congestive heart Failure Exacerbation End Stage Renal Disease Coronary Artery Disease Aortic Aneurysm Discharge Condition: Activity Status:Out of Bed with assistance to chair or wheelchair Level of Consciousness:Alert and interactive Mental Status:Confused - sometimes Discharge Instructions: You had an acute exacerbation of congestive heart failure. Your heart had some damage around that time (a heart attack) and the pumping function of your heart has worsened. A cardiac catheterization showed severe blockages in your arteries that we were unable to fix. In addition, we could not fix your aneurysm. You were seen by a vascular surgeon here who may be able to help your legs, you have an appt to see him again in 2 weeks. Your dialysis catheter was replaced on [**12-9**] and you should resume your regular dialysis schedule. . . Medication changes: 1. Start Aspirin 325 mg daily (can be coated) 2. Start Lisinopril, an ACE inhibitor that helps your heart pump better. 3. Stop taking Metoprolol Tartrate, Start taking a long acting Metoprolol Succinate. 4. Start taking Seroquel to sleep at night. 5. Start taking Calcium Acetate to control your phosphate level. 6. Start taking Nitroglycerin if you have chest pain or pressure. Take 5 minutes apart for a total of 3 doses. Call Dr. [**Last Name (STitle) 11250**] if you use this medicine. 7. Stop taking Ambien at night 8. Talk to your nephrologist at dialysis about continuing Sensipar. 9. Increase your Simvastatin to 20 mg daily at night. . You will be weighed in dialysis and will have your treatment adjusted to keep your weight steady. If you notice any swelling or trouble breathing between dialysis treatments, please call Dr. [**Last Name (STitle) 11250**]. Followup Instructions: Cardiology: [**Last Name (LF) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] S. Phone: [**Telephone/Fax (1) 11254**] Date/time: [**12-23**] at 3:30pm . Please follow up with your Vascular Surgeon, Dr. [**Last Name (STitle) **], in 2 weeks. Phone: [**Telephone/Fax (1) 20413**]. Date/Time: [**12-25**] at 1:15pm. [**Hospital Unit Name **] on the [**Hospital Ward Name 517**] of [**Hospital1 18**].

[ "440.22", "V12.04", "414.01", "570", "428.0", "518.81", "585.6", "578.9", "349.82", "276.7", "V45.11", "441.4", "403.91", "707.22", "491.21", "V45.82", "428.23", "V17.3", "410.71", "707.03", "V18.0", "305.1", "412", "250.70", "276.4", "443.81" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22", "39.95", "38.95", "38.93" ]

icd9pcs

[ [ [] ] ]

13197, 13261

8203, 11428

353, 444

13514, 13625

4232, 8025

15142, 15553

2856, 2874

11689, 13174

13282, 13493

11454, 11666

8042, 8180

13686, 14229

2889, 4213

2323, 2403

14249, 15119

294, 315

472, 2219

13639, 13662

2434, 2616

2241, 2303

2632, 2840

11,818

125,952

23833

Discharge summary

report

Admission Date: [**2180-4-14**] Discharge Date: [**2180-4-28**] Date of Birth: [**2143-1-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: fall Major Surgical or Invasive Procedure: ORIF of right femur History of Present Illness: 37 y/o male who fell off ladder approximately 15-20 feet onto back. No LOC. GCS 15 at scene and on arrival to ED. Complaining of severe back pain in trauma bay. Past Medical History: prior left hip injury Social History: lives in group home Family History: non-contributory Physical Exam: on arrival in the trauma bay: Vitals Temp 99.8 HR 80 BP 138/85 RR 16 sats 100% on NRB, GCS 15 GEN: well-nourished male, moderate to severe distress [**1-5**] pain, alert and oriented x 4 HEENT: PERRL, EOMI, right TM intact, left unable to be visualized, OP clear, trachea midline PULM: CTA bilaterally CV: RRR ABD: soft, non-distended Pelvis: TTP over right hip RECTAL: normal tone, guiac negative BACK: no step-offs EXT: RLE externally rotated and shortened, DP pulses intact bilaterally NEURO: CNII-XII intact, no focal motor or sensory deficits. Pertinent Results: [**2180-4-14**] 09:15AM BLOOD WBC-4.4 RBC-2.55* Hgb-7.9* Hct-23.5* MCV-92 MCH-30.9 MCHC-33.5 RDW-12.8 Plt Ct-158 [**2180-4-18**] 03:50AM BLOOD WBC-7.4 RBC-2.86* Hgb-8.9* Hct-25.5* MCV-89 MCH-31.2 MCHC-35.0 RDW-12.8 Plt Ct-198 [**2180-4-14**] 09:15AM BLOOD PT-14.7* PTT-34.0 INR(PT)-1.4 [**2180-4-14**] 09:15AM BLOOD UreaN-14 Creat-0.3* [**2180-4-18**] 03:50AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-137 K-3.6 Cl-102 HCO3-24 AnGap-15 [**2180-4-15**] 02:58AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.5* [**2180-4-18**] 03:50AM BLOOD Calcium-8.3* Phos-3.5# Mg-1.5* [**2180-4-14**] 09:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG FEMUR (AP & LAT) RIGHT [**2180-4-14**] 10:18 AM Four views of the right femur again show a comminuted displaced right intertrochanteric fracture with varus deformity. The remainder of this femur is intact. Tricompartmental degenerative changes in the right knee with medial joint space narrowing. (suboptimally assessed with knee radiographs not obtained, but no fracture in this area). CT RECONSTRUCTION [**2180-4-14**] 9:38 AM IMPRESSION: Comminuted intratrochanteric fracture of the right proximal femur. The lesser trochanter is a separate fragment. Severe degenerative changes opposite left hip, without evidence for underlying etiology (LCPerthes or SCFE). Associated muscular atrophy of all pelvic and proximal leg muscles on the left. Lucency previously described in right ilium represents a normal nutrient foramen. No other pelvic fracture is seen. Vascular calcification are abnormal in this age group. CT RECONSTRUCTION [**2180-4-14**] 9:10 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST IMPRESSION: 1) Hemoperitoneum, with a pocket of high attenuation fluid consistent with blood within the small bowel mesentery, concerning for mesenteric vascular injury. Small amount of blood surrounding the liver, without evidence of hepatic injury. 2) No evidence of other intra-abdominal/pelvic major organ injury or aortic injury. No evidence of extravasation of arterial contrast or collecting system contrast. 3) Small right-sided pneumothorax. 4) Burst fracture of the L1 vertebral body (there are six lumbar vertebrae), with extension into the right-sided posterior elements and involving the facet joint. Approximately 50% retropulsion of several vertebral body fragments into the spinal canal, impinging and compressing the spinal cord at this level. Correlate with clinical symptoms. 5) Comminuted, displaced right intratrochanteric fracture. 6) Probable subtle nondisplaced 4th right, posterior rib fracture. 7) Subtle linear lucency at the lateral aspect of the right iliac crest, which may represent a small nondisplaced fracture versus a nutrient foramen. Slight assymetric enlargement of the iliacus muscle at this level, suggesting a possible small intramuscular hematoma. See dedicated CT pelvis bone algorithm CT under separate clip number. 8) Cortical fragment anterior to the superior endplate of L5 which appears more likely to represent a degenerative osteophyte than an acute fracture. Again see dedicated CT pelvis under separate clip number. 9) Decompressed bladder with Foley, without evidence of bladder injury, though a CT cystogram would be much more sensative to assess for this if there is clinical suspicion. CT C-SPINE W/O CONTRAST [**2180-4-14**] 9:09 AM IMPRESSION: No cervical spine fracture. Right apical pneumothorax. CT HEAD W/O CONTRAST [**2180-4-14**] 9:09 AM IMPRESSION: No intracranial hemorrhage MR L SPINE SCAN [**2180-4-14**] 12:31 PM IMPRESSION: L1 vertebral body burst fracture with retropulsion of the fracture fragments and compression of the conus medullaris. Subdural hematoma centering at this level. MR THORACIC SPINE [**2180-4-14**] 12:30 PM FINDINGS: In agreement with the lumbar spine MRI, there is a fracture of the L1 vertebral body with retropulsion of fracture fragments posteriorly and compression of the conus medullaris. There is a right disk protrusion at T9-10, but no cord compression at this level. The remainder of the vertebral bodies within the thoracic spine have normal signal intensity and alignment. IMPRESSION: As described in detail on the lumbar spine MRI, there is a L1 vertebral body fracture with retropulsion of the fracture fragments and compression of the conus medullaris. Brief Hospital Course: TSICU [**2180-4-14**] to [**2180-4-18**]: After initial exam, survey, and stabilization in the trauma bay, the patient was taken for CT scan and x-ray evaluation of his injuries. His head and cspine CT were negative for hemorrhage or fracture. The patient's chest/abd/pelvis CT revealed hemoperitoneum surrounding the small bowel mesentery, a small right-sided pneumothorax, burst fracture of the L1 vertebral body with extension into the right-sided posterior elements and involving the facet joint and approximately 50% retropulsion of several vertebral body fragments into the spinal canal, impinging and compressing the spinal cord at this level, a comminuted, displaced right intratrochanteric fracture, subtle nondisplaced 4th right, posterior rib fracture. The patient was taken to the OR where he had an expolartory laparotomy with resection of his small bowel as well as placement of a right chest tube. On [**4-15**] the patient was taken by orthopaedics to the OR for an ORIF of his right femur. In the OR a retrievible IVC filter was placed. small R ptx pelvis: R comminuted femur fracture CT head: neg CT c-spine: neg CT chest/ab/pelvis: small R ptx, free fluid, L1 fracture MRI spine: L1 burst fracture, retropulsion of fracture fragments, compression of the conus medullaris. Subdural hematoma centering at this level. Injuries: R femur fracture, L1 fracture w/ compression and hematoma, mesenteric/small bowel injury OR: Plan: ortho, RLE traction, pain control, plan for ORIF [**4-15**], ICU, neuro checks, ordered TLSO brace, CT to suction Medications on Admission: ultram Discharge Medications: 1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 5. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). COntinue for 3 more weeks 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Continue for 2 more days. 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Lactulose 10 g/15 mL Syrup Sig: Sixty (60) ML PO BID (2 times a day). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 11. Oxycodone HCl 40 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q8H (every 8 hours). 12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for spasm, anxiety. 13. Tizanidine HCl 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for back spasms. 14. Tizanidine HCl 4 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: L1 compression fracture Right femur fracture Right pneumothorax Small bowel mesenteric tear Discharge Condition: Stable Discharge Instructions: 1.Complete remaining 2 days of oral anitbiotic course for your pneumonia 2. Continue Lovenox injections for another 3 weeks Followup Instructions: 1. Follow up with Orthopedics Dr. [**Last Name (STitle) 1005**] in [**1-6**] weeks, call [**Telephone/Fax (1) 1228**] for an appointment 2. Folllow up with Ortho Spine, Dr. [**Last Name (STitle) 363**] in 2- weeks, [**Telephone/Fax (1) 3573**], call for appoinment 3. Follow up with Trauma Clinic, [**Telephone/Fax (1) 6439**] in [**1-6**] weeks, call for an appoinment. Completed by:[**2180-4-28**]

[ "E849.3", "868.03", "807.01", "860.0", "E884.9", "922.31", "863.89", "780.39", "820.21", "806.4", "790.92", "304.23", "486" ]

icd9cm

[ [ [] ] ]

[ "38.7", "39.99", "81.63", "79.15", "81.07", "77.79", "84.52", "34.04", "45.62", "99.04", "84.51", "03.90" ]

icd9pcs

[ [ [] ] ]

8708, 8805

5579, 6683

318, 339

8941, 8949

1230, 5556

9121, 9523

627, 645

7200, 8685

8826, 8920

7169, 7177

8973, 9098

660, 1211

274, 280

367, 529

6692, 7143

551, 574

590, 611

26,989

133,696

29375

Discharge summary

report

Admission Date: [**2135-9-15**] Discharge Date: [**2135-9-21**] Date of Birth: [**2107-8-21**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: altered mental status, acute renal failure, pyelonephritis Major Surgical or Invasive Procedure: none History of Present Illness: 28 yo female with pmhx of recent TAH 2 weeks ago at OSH was brought in by her family to [**Hospital3 **] yesterday with acute mental status changes and chills. At [**Hospital3 **], patient was found to have a white count of 7.9 and temperature of 103 and was given tylenol, ceftriaxone and vancomycin IV. In addition, she was also found to have elevated cks at 4100 with ckmb 52 at osh. They treated her for rhabdo and gave her 2.5 liters of IVF. She was also noted to be in acute renal failure with initial creatinine 2.3 at osh and to 1.7 today. Given her recent surgery, she had a CT abdomen which showed right pyelonephritis, left-sided non-obstructing renal stones and ? free air in abd wound. She was transferred to [**Hospital1 18**] ED for tertiary level of care. CT scan was repeated at [**Hospital1 18**] and showed right-sided pyelonephritits and no free air. Surgery saw pt in the ED and did not feel that patient had free air or acute abdomen. She was given 2.5 liters IVF at OSH and 2 liters IVF in the ED. She did not receive any additional abx at [**Hospital1 18**] as she had just received them at OSH. Pt did get tylenol. In addition, patient per notes, patient has been acting strangely at home. Sitting alone in the house with all the stove burners on or dropping burning cigarettes on the ground. Mother was worried she was a danger to herself. . Vitals in the ED on initial presentation were HR 100, BP 129/96, R 16, O2 sat 100% on 2 liters. . On admission to the ICU, initial vitals were 114/63, HR 84, R 17, O2 sat 100% on 2 L. Patient was very lethargic. She knew she was at [**Hospital1 18**], her name and that it was [**Month (only) 359**] but she thought it was [**2135**]. Patient denied dizziness, headache, chest pain, sob, abd pain, nausea, vomiting, dysuria, frequency or hematuria. Patient answered almot every question no and was inappropriate in her responses, so history is very limited. Social History: lives w/ mother and son, 1.5ppd smoker- although pt denies, denies etoh or drug use. Per notes, mother reports history of drug abuse and episode of overdose. Family History: Non-contributory. Physical Exam: PE VS T 99 P 84 BP 114/63 R 17 O2 sat 100 % on 2 liters Gen- lethargic, arousable to stimuli HEENT- NCAT, anicteric, no injections, left pupil slightly larger than right, both equal and reactive to light, OP dry MMM Neck- no JVD or LAD Cor- RRR S1S2, 2/6 systolic murmur at LUSB Pulm- CTA b/l Abd- +bs, soft, nt, nd, no masses or hsm, lower horizontal excision s/p TAH with staples in place, surrounding erythema around staples but no drainage or tenderness Extrem- no cce Neuro- CN 2-12 intact, moves all extrem, strength 5/5 throughout, sensation grossly intact, slow finger to nose and has difficulty following commands, DTRs 1+ symmetrical throughout. Pertinent Results: [**2135-9-15**] 03:00AM BLOOD WBC-6.4 RBC-3.32* Hgb-9.5* Hct-27.3* MCV-82 MCH-28.5 MCHC-34.7 RDW-17.6* Plt Ct-147* [**2135-9-15**] 03:00AM BLOOD Neuts-84.7* Bands-0 Lymphs-11.8* Monos-3.2 Eos-0.2 Baso-0.1 [**2135-9-15**] 03:00AM BLOOD PT-13.4* PTT-40.2* INR(PT)-1.2* [**2135-9-15**] 03:00AM BLOOD Glucose-110* UreaN-52* Creat-1.7* Na-145 K-3.6 Cl-112* HCO3-21* AnGap-16 [**2135-9-15**] 06:30AM BLOOD ALT-61* AST-78* LD(LDH)-395* CK(CPK)-3752* AlkPhos-153* TotBili-0.3 [**2135-9-15**] 03:00AM BLOOD CK-MB-34* cTropnT-0.02* [**2135-9-16**] 01:00AM BLOOD Lipase-241* [**2135-9-15**] 03:00AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.4 [**2135-9-16**] 01:00AM BLOOD TSH-1.3 [**2135-9-15**] 03:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2135-9-15**] 03:43AM BLOOD Lactate-0.8 Brief Hospital Course: 1)Pyelonephritis: CT showed pyelonephritis and urine cx at OSH showed e coli sensitive to Bactrim. Pt improved clinically with antibiotics. Continue Bactrim until [**2135-9-27**]. 2)Rhabdomyolysis: Likely due to sedation, pt had marked rhabdomyolysis with elevated CK, transaminases. These trended down with IV hydration. 3)Depression/Anxiety: Pt told multiple providers that she had overdosed on pills as suicide attempt. Please see psychiatry note for details. She was continued on clonazepam 0.5 mg po tid. 4) s/p TAH: Wound well healed staples removed, no signs of infection by CT abd/pelvis. OB-GYN is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 5)Elevated amylase/lipase: These trended down though remain elevated. No abd pain or CT scan evidence of pancreatitis. No implication of medications. Will need f/u amylase/lipase on [**2135-9-27**] (one week). 6)ARF: Resolved completely in less than 24 hours with IV fluid hydration. 7)Tachycardia: Pt with mild tachycardia to 110 at times, sinus. Encouraged increased hydration and decrease caffeine intake. Medications on Admission: ibuprofen 500 mg tripetal 600 mg seroquel 100 mg aterol 50 mg oxycodone, percocet, vicodin tramadol citalporam 20 mg enjuvia 0.625 mg klonopin Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: last dose [**2135-9-27**]. 3. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 15986**], [**Hospital1 14211**],MA Discharge Diagnosis: pyelonephritis depression/anxiety with possible suicide attempt Discharge Condition: stable Discharge Instructions: Please continue the Bactrim antibiotic until [**2135-9-27**]. Please return to the ER with fevers, chills, abdominal pain, yellowing of skin, or other concnerning symptoms. Followup Instructions: please follow up care plans with the providers of the inpatient facility [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2135-9-21**]

[ "300.4", "728.88", "041.4", "590.10", "584.9", "E950.4", "966.3", "276.0", "304.01" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5688, 5762

4070, 5177

374, 381

5870, 5879

3245, 4047

6101, 6327

2535, 2554

5370, 5665

5783, 5849

5203, 5347

5903, 6078

2569, 3226

276, 336

409, 2343

2359, 2519

10,145

135,661

1045

Discharge summary

report

Admission Date: [**2112-1-18**] Discharge Date: [**2112-1-30**] Date of Birth: Sex: Service: [**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: This is an 86 year-old woman from [**Hospital3 **] Center where she was found minimally responsive, cyanotic, diaphoretic and tachypneic with an O2 sat between 34 and 54% on 6 liter per minute oxygen mask. She was brought to the Emergency Department where she was initially verbal and complained of some upper back pain and some shortness of breath. Her vital signs in the Emergency Department were a blood pressure of 162/77, heart rate 70, respirations 40 and her O2 sat was 93% on a nonrebreather mask. It was 100% on norebreather mask. She was initially given 40 mg of intravenous Lasix times one in the Emergency Department, but then became hypotensive with a blood pressure of 79/47. She required a Dopamine drip. The Dopamine was weaned off and then restarted later as the blood pressure fell yet again. Dopamine was later stopped and a neo drip was started, which was later weaned off. The patient was admitted to the [**Doctor Last Name **] firm on the [**2112-1-18**]. She was treated with Levofloxacin and Flagyl for a urinary tract infection as well as possible aspiration pneumonia. She had a swallow study on the [**2112-1-19**], which she described as a borderline dysphagia and was made NPO, but later the patient was inadvertently fed ice cream by a patient. The patient was later found to have a drop in O2 sats down to 70% and required intubation transfer to the Medical Intensive Care Unit. Suctioning at that time was positive for melted ice cream. The patient was extubated on the [**1-21**], but then felt distressed believed to be mechanical restrictive lung disease. The patient has noted kyphosis scoliosis as well as congestive heart failure and pneumonia and required BiPAP at night and face mask during the day. On the [**1-27**] the patient's nephew decided to change the patient's status to DNR/DNI and comfort measures only and the patient was transferred back to the [**Doctor Last Name **] firm on the [**2112-1-28**]. PAST MEDICAL HISTORY: Congestive heart failure, acute renal failure, atrial fibrillation, coronary artery disease, hypertension and a history of scoliosis and kyphosis. ALLERGIES: Intolerant of ace inhibitors. MEDICATIONS ON TRANSFER: 1. Metoprolol 25 b.i.d. 2. Losartan 75 mg daily. 3. Multivitamin. 4. _____________ 20 mg daily. 5. Iron 150 mg daily. 6. Miconazole powder topical b.i.d. 7. Docusate. 8. Senna. 9. Subq heparin 5000 b.i.d. 10. Vitamin D 325 mg po daily. 11. Aspirin. 12. Bisacodyl. 13. Calcitonin. 14. Fentanyl drip. 15. Ativan. 16. Albuterol prn. 17. Vancomycin 1 gram intravenous daily. 18. Famotidine 20 mg intravenous daily as well as a morphine drip. Upon transfer back to the [**Doctor Last Name **] firm the patient was response to voice or touch only with mumbling. General appearance was an elderly woman lying in bed in no acute distress. No sudden hand grasp motion with object placed in palm. Lung examination no wheezes. Cardiovascular examination was regular rate and rhythm. Abdomen soft and apparently nontender. Extremities were warm with distal pulses 1+ and dorsalis pedis pulses palpable. Over the course of the next two days the patient became more and more unresponsive to both voice and touch and was found on the 31st to have minimal pupillary reflexes at that time. She was provided pain relief with sublingual morphine at that point and oxygen via nasal cannula. The patient expired on the [**2112-1-30**] at 1:42 a.m. Pronouncement of death was done by Dr. [**Last Name (STitle) 6836**] [**Name (STitle) 6837**]. The family was notified as well as the attending. Autopsy was declined. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Last Name (NamePattern1) 6838**] MEDQUIST36 D: [**2112-5-12**] 12:13 T: [**2112-5-12**] 12:14 JOB#: [**Job Number 6839**]

[ "599.0", "737.30", "427.31", "507.0", "428.0", "733.00", "518.89", "482.41", "518.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

181, 2150

2389, 4095

2173, 2364

11,818

104,730

23838

Discharge summary

report

Admission Date: [**2184-11-1**] Discharge Date: [**2184-11-12**] Date of Birth: [**2143-1-25**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**Last Name (NamePattern1) 1136**] Chief Complaint: Right arm pain Major Surgical or Invasive Procedure: Drainage of Right Arm Abscess by Plastic Surgery History of Present Illness: 41 year-old male with history significant for paroxysmal atrial fibrillation, active IV drug use, recurrent bacteremia, s/p spinal fusion surgery and total hip replacement, who is transferred to general medicine floor from the SICU s/p right arm debridement for an abscess, also with MRSA bacteremia and lower back pain. The patient had a complicated medical course following a fall in [**2179**], including T10-L3 fusion, iliac crest bone graft, ORIF right femur, and left total hip replacement complicated by MRSA septic hip requiring further surgical intervention. Patient also has had recurrent bacteremia, including uncomplicated enterococcal PICC-associated bacteremia in [**9-10**]. He was admitted to SICU under the plastics service [**2184-11-1**] for sepsis and right arm abscess, initially suspected to be necrotizing fasciitis. Past Medical History: 1) L THR [**2184-5-20**] (due to traumatic osteoarthritis [**2179**] - fell off ladder), L hip MRSA prosthetic joint infection with bacteremia, s/p explant [**6-9**], multiple washouts, spacer placement, 2) ex-lap with resection of his small bowel, 3) ORIF R femur, 4) T10-L3 fusion, transpedicular decompression, at T12, multiple laminotomies, 5) right Iliac Crest Bone Graft, 6) h/o polysubstance abuse, etoh, cocaine 7) depression, s/p multiple suicide attempts: cocaine binge, radial artery laceration/percocet overdose 8) SVT after washouts, responded to dilt 9) h/o GI bleed in the setting of thrombocytopenia from Vancomycin, improved with stopping Vanco, refused colonoscopy Social History: Mom died while pt hospitalized for initial fall. h/o incarceration Disability. Tobacco 1.5 ppd, continues to smoke. ETOH, crack cocaine, opiate use in past. Active IVDU. Family History: NC Physical Exam: After transfer from SICU to medical floor: VS: 99.4 132/80 84 16 98% on RA GEN: alert, lying supine, visibly distressed and moaning from pain, shouting at medical staff HEENT: moist mucus membranes CV: regular rhythm, rate 80s, no murmurs appreciated RESP: diffuse anterior and lateral wheezing and soft rhonchi; posterior exam limited due to position BACK: difficult to assess due to supine position ABD: soft, nontender, nondistended EXT: right dorsomedial forearm with open debridement, mostly wrapped with gauze ; no lower extremity edema NEURO: limited due to pain Pertinent Results: ADMISSION LABS: [**2184-11-1**] WBC 18.5 / hct 25.5 / Plt 412 Serum tox - negative for aspirin, EtOH, tylenol, BDPs, barbiturates, and TCAs Na 130 / K 3.8 / Cl 97 / CO2 19 / BUN 40 / Cr 2.3 / BG 132 Lactate 1.2 DISCHARGE LABS: [**2184-11-12**] WBC 7.9 / Hct 26.8 / Plt 577 Na 140 / K 3.6 / Cl 100 / CO2 29 / BUN 9 / Cr 1.2 / BG 94 MICROBIOLOGY: [**2184-11-1**] Blood Cx = [**3-6**] MRSA [**2184-11-1**] Urine Cx negative [**2184-11-1**] Wound Swab - MRSA, Prevotella 12/2,3,4,5,[**6-10**] Blood Cx negative [**2184-11-5**] Right Hip Aspirate Cx negative STUDIES: UNILAT UP EXT VEINS US RIGHT [**2184-11-1**] 1. No evidence of right upper extremity DVT. 2. Complex fluid and swelling along the right forearm underlying area of redness and swelling. Known deep tissue air is better visualized on recent radiograph. FOREARM (AP & LAT) RIGHT [**2184-11-1**] IMPRESSION: Large amount of subcutaneous and deep soft tissue air. These findings are concerning for necrotizing fasciitis. CHEST (SINGLE VIEW) [**2184-11-1**] IMPRESSION: Low lung volumes. Mild right pleural thickening vs trace right effusion. TTE (Complete)[**2184-11-2**] Suboptimal image quality. No echocardiographic evidence of endocarditis but study limited technically. Normal global biventricular systolic function. Aortic root dilation. CT T / L Spine [**2184-11-5**] 1. Prevertebral soft tissue density at L3-4 of uncertain chronicity as there is no prior postoperative cross-sectional imaging for comparison. Infection cannot be excluded. 2. Limited evaluation of the spinal canal due to streak artifact from spinal fusion hardware. CT does not provide intrathecal detail comparable to MRI. 3. Unchanged L1 vertebral body fracture. 4. Layering right pleural effusion. TEE [**2184-11-9**] No echocardiographic evidence of endocarditis. MR T and L Spine [**2184-11-9**] 1. Fluid collection identified at the L2/L3 intervertebral disc space, posteriorly, causing anterior thecal sac deformity, likely consistent with an epidural phlegmon, measuring approximately 7 x 28 mm in size. Associated inflammatory changes noted at the intervertebral disc space and vertebral bodies at L2/L3, which are worrisome for early changes possibly related with discitis/osteomyelitis, please correlate clinically. Multilevel disc degenerative changes throughout the lumbar and thoracic spine as described above, more significant at T6/T7, T7/T8, and T8/T9. 2. Compression fracture at T12 vertebral body is again identified, apparently unchanged since the most recent CT, dated [**2184-11-5**] with mild posterior retropulsion. 3. Lumbar disc degenerative changes noted at L3/L4 and L4/L5 levels with narrowing of intervertebral disc spaces, articular joint facet hypertrophy, causing bilateral neural foraminal narrowing at L4/L5 level. 4. Status post posterior fixation of the thoracic spine with laminectomies from T11 through L1 level. 5. Right pleural effusion and possible left lung basal consolidation as described above. Brief Hospital Course: 41 year old male with recurrent MRSA bacteremia, active IV drug use, paroxysmal atrial fibrillation, history of spinal fusion surgery T10-L3 and Left total hip replacement, who presented with with right arm abscess, MRSA bacteremia and lower back pain. After the patient was found to have fluid collections surrounding his spinal hardware that would require Ortho Spine surgery, he left Against Medical Advice but was accepted by the Rehab facility on a prolonged antibiotic regimen, with the understanding that he would return for surgery in a few weeks when ready. 1. Right Arm Abscess Patient presented with Right arm pain and swelling s/p injection drug use. Ultrasound of arm showed no DVT but complex fluid and swelling along the right forearm. Xray showed large amount of subcutaneous and deep soft tissue air, concerning for necrotizing fasciitis. The patient was taken emergently to surgery by Plastics who noted that there was no necrotizing fasciitis but drained the abscess. Wound cultures initially grew MRSA and gram negative rods, so the patient was started in intravenous daptomycin, clindamycin, and zosyn, per Infectious Disease team recommendations. The clindamycin was used for a synergistic effect against MRSA for its ability to reduce the production of exotoxins by staphylococci. Per ID recommendations, the clindamycin and the zosyn were discontinued after a few days. Metronidazole was started on the evening of [**2183-11-11**] per oral for a total of seven days with prevotella was found growing from the wound in addition to MRSA. For control of his Right arm wound post surgically, the Plastics Surgery team continued to follow the patient. The wound was dressed with wet to dry dressings and Dakins; the patient should be started on a wound vac, but he refused this treatment option. He should be continued on [**Hospital1 **] wet to dry dressing changes and follow up in [**Hospital 3595**] clinic in [**2184-12-3**]. 2. MRSA bacteremia The patient has a history of recurrent MRSA bacteremia in the setting of active IV drug use. A transthoracic echo showed no evidence of vegetations, though the image quality was suboptimal. The patient initially refused TEE, but eventually agreed to it; TEE showed no evidence of vegetations as well. He does have a fluid collection in his left hip, as seen on imaging, where he has recently had hardware from a hip replacement and now has an antibiotic spacer. Patient was initially unable to tolerate imaging of his spine due to extreme pain with movement, particularly transfers; initial MRI and CT of lower spine were of poor quality. Patient was ultimately placed under general anesthesia for an MRI of his thoracic and lumbar spine, which showed large infected fluid collections surrounding spinal hardware. The patient requires surgical removal of his spinal hardware in two surgeries, one to work on the anterior and one for the posterior sides of the spine. The patient refused to have surgery at this time. He prefers to wait until after [**Holiday **] and the New Year and will have surgery after that time. He knows and respects Dr. [**Last Name (STitle) 363**], the Ortho Spine surgeon, well; he would only stay to have the surgery during this admission if Dr. [**Last Name (STitle) 363**] insisted that this was the only option. Dr. [**Last Name (STitle) 363**] felt that the patient should have the surgery sooner than later, optimally during this admission, but agreed to do the surgery at a later time if the patient preferred and to send the patient back to Rehab on IV antibiotics in the meantime; he will follow up with the patient in his clinic next week. The patient refused to have a CT-guided drainage of the fluid collection at this time as well; he preferred to just wait "until the New Year" to have the surgery by Dr. [**Last Name (STitle) 363**]. The patient has been afebrile for multiple days, so a PICC line was placed, and the patient will continue on IV daptomycin daily indefinitely until he has the surgery; the daptomycin should continue for 6 weeks at minimum. The patient will also continue on oral metronidazole for five more days to treat the prevotella in the arm wound. The Rehabilitation facility from which he came will take him back under strict monitoring for drug abuse. He will follow up in clinic with Dr. [**Last Name (STitle) 363**] next week and in Infectious Disease clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] next Friday [**11-19**]. He will need to have his BUN/Creatinine, CBC with diff, and CK checked weekly and faxed to Dr.[**Name (NI) 60811**] office. 3. Back Pain Patient has chronic back pain and is s/p spinal fusion T10-L3; the pain is likely worsened by the infectious fluid collections surrounding his spinal hardware. The patient was placed on a ketamine drip, with the help of the chronic pain team, while on the surgical service to help manage for pain control in addition to per oral and intravenous dilaudid, fentanyl patch, gabapentin, and diazepam. Once the patient was transferred to the general medical service, the chronic pain team was officially consulted to help with pain management. The ketamine drip was weaned slowly, and the dilaudid dose was increased to 8mg every four hours as needed, as the patient stated he was taking prior to admission. His gabapentin dose was increased slowly to his apparent home dose of 300mg TID, which can further be increased slowly to 600mg TID if needed, per chronic pain team. The diazepam is a home medication, which the patient only uses once every couple of days for back spasms. 4. Psychiatric Issues Patient with a reported history of bipolar disorder and suicidal attempts in the past. Similar to previous hospitalizations, he was verbally abusive to nursing staff and exhibiting bizarre behavior, including chewing through his central venous line. Psychiatry was consulted and recommended clear limits with pain medicines, avoiding benzodiazepines which could have a paradoxical effect, and starting seroquel 25 mg TID as needed for agitation as well as prozac 20 mg daily. The seroquel did work very well to keep the patient calm but appeared to make him more sleepy than usual. After patient was told that he had infected fluid collections around the hardware in his spine and would need definite surgical removal of the hardware, he refused surgery. He was initially upset and agitated, threatening to leave Against Medical Advice without any explanation as to why he did not want surgery. The risks of no surgery or delayed surgery were explained to him, including possible paralysis and possible death. The patient appeared to understand these risks. Psychiatry was called again to assess the patient and felt that he had capacity to make his own decisions; patient was completely oriented and showed no signs of delirium-- he understood his options and the possible consequences of his decision. He expressed again to the medical team that he "just wanted a break." He was allowed to leave Against Medical Advice after a PICC line was placed and a plan for IV antibiotics and close followup was made. The patient does have a history of active IV drug use and will need to be monitored very carefully with a PICC line in place while at the Rehab facility long term. 5. Paraphimosis After transfer to the general medical service, patient was noted to have some edema of his foreskin which was pulled back tightly around his penis. The patient did complain of some pain, but the head of the penis was still pink. The medical team and the patient were unable to reduce the paraphimosis. The paraphimosis was ultimately reduced by Urology. 6. Paroxysmal Atrial Fibrillation Patient was intermittently treated with IV diltiazem for atrial tachycardia, likely atrial fibrillation, and responded well to it. He was started on per oral diltiazem in SICU per cardiology recommendations and continued on it for the rest of his hospitalization. Given that his CHADS-2 score was 0, he was recommended to consider starting aspirin for anticoagulation once his surgical plan was confirmed. 7. Acute Renal Failure Patient's baseline renal function was about 0.8-1.0. He was noted to have an elevated creatinine to 2.0-2.9 on previous admission for MRSA bacteremia, and he had presented to the surgical service with an elevated creatinine of 2.3 on this admission. Acute renal failure was of [**Last Name (un) 5487**] etiology, but creatinine trended down to 1.2 by the time of discharge. 8. Rash Patient did have patches of blanching erythematous macular rash on bilateral lower extremities, asymmetric, while on the floor. He denied pruritis and pain with the rash, but it slowly darkened and resolved with a few days. The rash appeared to be a contact dermatitis. 9. Loose Stool Patient did have some episodes of loose stools, despite high narcotic regimen, likely antibiotic associated diarrhea. He did not have a leukocytosis and has been afebrile, but a C difficile toxin test was checked and was negative. Medications on Admission: Fentanyl patch 50mcg/hr 1 patch Q72H Valium 5mg QHS and q6-8h prn Dilaudid 8mg Q4H Iron 325QD Gapapentin 300mg TID Dilt 30mg PO QID Omeprazole 40mg QD Lasix 20mg Qd Colace 100mg QD Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml 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. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. 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. 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Daptomycin 500 mg Recon Soln Sig: Seven Hundred (700) mg Intravenous Q24H (every 24 hours). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation / insomnia. 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days. 10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for For back spasms only (use seroquel for agitation. 11. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. Hydromorphone 4 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): please hold for diarrhea. 15. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fe [**Last Name (un) **]. Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Primary Diagnosis: MRSA Bacteremia Infected Spinal Hardware Right Arm Abscess Secondary Diagnoses: Chronic Pain Paroxysmal Atrial Fibrillation Depression Discharge Condition: alert, oriented x3 pain controlled Discharge Instructions: Mr. [**Known lastname **], You were admitted to the hospital because you had a bad infection in your right arm which had gone also to your bloodstream. You were started on antibiotic treatment for this infection. You were found to have infected fluid collections in the hardware in your spine; this hardware needs to be surgically removed as soon as possible. You did not wish to have this surgery at this time, so you decided to sign out of the hospital Against Medical Advice. As you are aware, delaying surgery could increase your risk for worsened infection in your spine; if the fluid collections get larger, you could become paralyzed. There is also the risk that the infection could again spread to your bloodstream and infect other parts of your body, including your heart; there is the risk that you may die before coming back for surgery. Prior to discharge, you understood these risks and signed the paper to leave Against Medical Advice, as the medical team strongly felt that you should not leave the hospital at this time. It is very important for you to continue on the intravenous antibiotics prescribed to you by the medical and infectious disease teams in the hospital until you are able to have the surgery. You should return for followup in Ortho Spine clinic next week. Please do not inject any more IV drugs because this puts you at risk for another infection. You will be continued on IV antibiotics through a PICC line at Rehab. The following important changes have been made to your medications: - You are STARTING the antibiotic Daptomycin intravenously daily indefinitely, which should be continued at least until you have the surgery to remove the infected hardware in your spine - You were STARTED on fluoxetine, which is an antidepressant which will take a few weeks to start to help - You were STARTED on metronidazole antibiotic for your Right arm wound to be continued for five more days - You were also STARTED on diltiazem per oral 30mg four times per day to control your heart rate. This medication can later be changed to a once daily medication by your primary care doctor Please seek immediate medical attention if you begin to experience fevers/chills, if you become incontinent of urine or stool, if your legs become weaker, or if you experience any other symptoms concerning to you. Followup Instructions: It is extremely important that you keep all of your followup appointments because you have a very bad infection around your spine. Please be sure to follow up in Ortho Spine clinic next week with Dr. [**Last Name (STitle) **] [**2184-11-17**] at 4pm [**Hospital Ward Name 23**] Building, [**Location (un) **] [**Telephone/Fax (1) 3573**] Please also follow up in Infectious Disease Clinic. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2184-11-19**] 11:30 Please follow up in Plastic Surgery clinic in [**2184-12-3**]; you should call the following number to make the appointment. [**Telephone/Fax (1) 3009**]

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icd9cm

[ [ [] ] ]

[ "88.72", "93.59", "38.93", "99.04", "86.04", "86.28" ]

icd9pcs

[ [ [] ] ]

17050, 17086

5750, 14833

295, 345

17285, 17322

2744, 2744

19703, 20405

2127, 2131

15065, 17027

17107, 17107

14859, 15042

17346, 19680

2972, 5727

2146, 2725

17207, 17264

241, 257

373, 1216

2760, 2956

17126, 17186

1238, 1923

1939, 2111

8,471

108,550

10512

Discharge summary

report

Admission Date: [**2114-2-23**] Discharge Date: [**2114-3-13**] Date of Birth: [**2082-3-28**] Sex: F Service: MICU CHIEF COMPLAINT: Transfer for hypercapneic respiratory failure. HISTORY OF PRESENT ILLNESS: The patient is a morbidly obese 31 year old female with a history of asthma (recent admission to outside hospital, no history of intubations), who was in her usual state of health until approximately two weeks prior to admission when she began experiencing increasing shortness of breath at home, not improving with her outpatient asthma medications. She began using her father's home oxygen. She was admitted to [**Hospital3 1443**] Hospital on [**2114-2-8**]. Arterial blood gases on admission revealed pH 7.19, pCO2 of 108 and pO2 of 119. Her bicarbonate level at that time was 37. She was treated with BIPAP, [**Last Name (un) **]-Dur, Solu-Medrol which was switched to Prednisone. Chest x-ray reportedly was unremarkable at that time. She improved with treatment and was transferred to [**Hospital1 34648**]. Admitted to [**Hospital1 34648**] on [**2114-2-14**], with arterial blood gases of pH of 7.41, pCO2 of 86 and pO2 of 84 on 40% FIO2 face mask. She was aggressively diuresed and plan was for rehabilitation with subsequent follow-up at [**Hospital 34649**] Clinic. She began to do poorly, however, with increasing shortness of breath and occasional nonproductive cough. Arterial blood gases showed pH of 7.31, pCO2 of 131 and pO2 of 63 on 90%. She was placed on BIPAP and unable to be weaned off. Over that time, she denied fever, chills, chest pain, light-headedness, confusion, calf pain. She was treated with Enoxaparin prophylactically. She did describe some nasal stuffiness. She was started on Augmentin for suspected sinusitis and Levaquin was added on [**2114-2-23**], for possible pneumonia when her chest x-ray showed white out of the right lung. She was transferred to [**Hospital1 188**] at that time for likely tracheostomy. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Asthma. 3. Anxiety/depression. 4. Question history of thyroid nodule. 5. Echocardiogram in 05/00, shows left atrial enlargement with an ejection fraction of 60%. MEDICATIONS ON TRANSFER: 1. Levaquin 500 milligrams intravenously q.d. 2. Augmentin 875 milligrams p.o. q.d. 3. Flonase b.i.d. 4. Afrin b.i.d. 5. Multivitamin. 6. Sertraline 50 milligrams p.o. q.h.s. 7. Combivent inhaler q.i.d. 8. Theophylline 300 milligrams p.o. q.d. 9. Guaifenesin 10 milligrams p.r.n. 10. Enoxaparin 40 milligrams subcutaneously q12hours. 11. Singulair. 12. K-Dur. ALLERGIES: Vicodin and Percocet. SOCIAL HISTORY: She lives with her parents. No history of tobacco or alcohol use. PHYSICAL EXAMINATION: On admission, in general, morbidly obese female with marked respiratory distress speaking in complete sentences and mentally alert. Head, eyes, ears, nose and throat anicteric sclera. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. No sinus tenderness. Mucous membranes are moist with no oral lesions. The heart is regular rate and rhythm, normal S1 and S2, with a II/VI systolic ejection murmur at the left upper sternal border radiating to the carotids. Lungs - bilateral crackles two thirds of the way up on the right, half way up on the left. The abdomen is morbidly obese, soft, nontender, positive bowel sounds. Extremities are warm, 2+ distal pulses bilaterally, no cyanosis, clubbing or edema. LABORATORY DATA: Arterial blood gases revealed a pH of 7.33, pCO2 116, pO2 70 on 90% FIO2. Chest x-ray showed white out of the right hemithorax and one half of the way up on the left. White count 5.8, hematocrit 33.9, platelets 259,000, Sodium 139, potassium 4.1, chloride 84, bicarbonate 53, blood urea nitrogen 10, creatinine 0.4, glucose 93. Prothrombin time 13.4, partial thromboplastin time 26.5, INR 1.2. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit and initially she was alternated between 100% nonrebreather and BIPAP at 18/8. She was continued on Albuterol and Atrovent nebulizers, Flovent meter dose inhaler and Levofloxacin for a seven day course of empiric treatment for pneumonia. Over the next two days, her breathing did not improve significantly despite the above measures and in the a.m. of [**2114-2-26**], her pCO2 had climbed to 132, and she was less mentally responsive. She was then intubated and over the next few hours, she was unable to wean down from 100% FIO2 and was changed to pressure control ventilation for better oxygenation. She was subsequently weaned down to 50% FIO2. Bronchoscopy on [**2114-2-26**], revealed edematous airways that were collapsible on expiration, however, there was no visible plugging or secretions. She was evaluated for tracheostomy at the bedside by Doctor [**Last Name (Titles) **], but was felt to be a poor candidate for the bedside procedure secondary to her obesity and high PEEP. [**First Name8 (NamePattern2) **] [**Last Name (un) 20042**] was contact[**Name (NI) **] and she was scheduled for tracheostomy to be performed in the operating room. In the meantime, she made gradual improvement in her respiratory function with lower driving pressure requirements on pressure control ventilation. She was changed back to assist control on the morning of [**2114-2-28**]. The patient was unable to be transported to the operating room due to her size. The tracheostomy was changed to a bedside procedure performed by CT Surgery which was done on [**2114-3-6**]. Complication was only moderate amount of blood loss. She tolerated the procedure well. She was taken off all sedatives and began to wake up at that time. She was then turned to pressure support ventilation and continued at a PEEP of 20. The PEEP was unable to be weaned down secondary to her overall size and relative supine position. The second issue is her infectious disease issue. She had intermittent temperature spikes to 101. She completed an initial course of Levofloxacin for presumed pneumonia which had been started on admission to the [**Hospital1 190**]. Blood cultures drawn on [**2114-3-2**], began to grow gram positive cocci that was later identified as staphylococcus epidermidis. She had subsequent positive blood cultures with the same organism from her central line. Her left IJ line was switched to a right IJ which also began to grow gram positive cocci. Eventually all central lines were removed and peripheral access was obtained. She was continued on Vancomycin. Given the multiple positive blood cultures and high grade bacteremia, a Transesophageal Echocardiogram was performed that showed no evidence of valvular vegetation and a normal ejection fraction. It was planned that she would complete a four week course of Vancomycin for her high grade bacteremia and possible endovascular source. She continued to spike fever despite treatment with Vancomycin and a subsequent respiratory culture began to grow pseudomonas. She was started on Levofloxacin and Ceftazidime for treatment to complete a ten day course of these. Her white count has trended down and she has been afebrile since started on these antibiotics and is stable from an infectious disease standpoint. Fluids, Electrolytes and Nutrition - She was started on tube feeds via nasogastric tube. The plan is for her to take p.o. intake at a later time. Her goal for her tube feeds is 80 cc per hour with replete with fiber. She has required occasional fluid boluses for decreased urine output at times. Prophylaxis - She has been treated with subcutaneous Heparin t.i.d. as well as p.o. Zantac. Access - The patient is to be evaluated for a PICC line prior to transfer to [**Hospital1 34648**]. DISPOSITION: The patient will be transferred to [**Hospital1 34648**] when a bed is available. She is a full code. Her family is very supportive and have been present regularly throughout her hospitalization. DISCHARGE DIAGNOSES: 1. Morbid obesity with obesity hypoventilation syndrome. 2. Asthma. 3. Anxiety/depression. MEDICATIONS: 1. Ceftazidime one gram intravenously q8hours to complete ten day course. 2. Vancomycin one gram intravenously q12hours to complete four week course. 3. Levofloxacin 500 milligrams p.o. q.d. to complete ten day course. 4. Iron Sulfate 325 milligrams p.o. t.i.d. 5. Heparin 8000 units subcutaneous t.i.d. 6. Flonase nasal spray two puffs nasally b.i.d. 7. Multivitamin 5 cc p.o. q.d. 8. Colace Elixir 100 milligrams per nasogastric tube t.i.d. 9. Zoloft 100 milligrams p.o. q.d. 10. Zantac 150 milligrams per nasogastric tube b.i.d. 11. Nystatin swish and swallow q6hours. 12. Miconazole powder applied t.i.d. and p.r.n. 13. Flovent 110 mcg MDI four puffs b.i.d. 14. Duragesic patch 25 mcg transdermally q72hours. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**] Dictated By:[**Last Name (NamePattern1) 9422**] MEDQUIST36 D: [**2114-3-12**] 17:29 T: [**2114-3-12**] 17:45 JOB#: [**Job Number **]

[ "041.19", "780.57", "518.81", "300.00", "482.1", "278.01", "493.90", "996.62", "790.7" ]

icd9cm

[ [ [] ] ]

[ "31.1", "42.23", "96.72", "88.72", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

8026, 9137

3948, 8005

2748, 3931

151, 199

228, 1994

2235, 2640

2016, 2210

2657, 2725

26,395

159,009

54224

Discharge summary

report

Admission Date: [**2193-6-4**] Discharge Date: [**2193-6-7**] Service: MEDICINE Allergies: Aleve / Ace Inhibitors / Florinef Attending:[**First Name3 (LF) 613**] Chief Complaint: Fall Major Surgical or Invasive Procedure: Central line placement History of Present Illness: [**Age over 90 **]M with history of lymphocytic lymphoma and recent hospitalization two weeks ago for pneumonia and multiple admissions for orthostatic hypotension presents from home after falling twice in the same day in the setting of going from sitting to standing. He denies loss of conscious but does endorse feeling lightheaded more than usual this week. He is not on any anticoagulation and denies any vasoactive or changes in medications. During his first fall this morning, he declined further evaluation despite head strike. He then experienced a second tumble onto his wife with again no LOC after getting dizzy. He does endorse poor PO intake, feeling lightheaded more this week than usual in addition to R hip pain where he had previous surgery. He otherwise denies headache, blurry vision, numbness/tingling, weakness, neck pain. In the ED, initial VS were 5 97.7 91 94/59 16 93% RA FSGLC 190 Exam significant for skin tears to L arm and slight R hip, frontal hemotoma, bruising on the extremities. Rectal was guiaic negative. Orthostatics were positive. He was given 1 L NS without much change in [**Age over 90 **] pressure for which a CVL was placed with CXR confirming placement. Labs were significant for Hgb 5.9 (Baseline 7.4-9.3) with repeat of 5.9, Plt 29 (near baseline), K 5.5, BUN 42, Cr 1.9 (Baseline 1.3-1.4). Coag within normal limits. EKG showed NSR with LAD and poor R-wave transitions similar to prior. Head CT showed small focus of subarachnoid hemorrhage in the right lateral sulcus just posterior to the right insula and sylvian fissure. C-spine film was negative. Neurosurgery was consulted for SAH and recommended repeat CT in AM with no AED needed at this time in addition to neuro checks. OMED was also notified of the admission. He was given 1 bag of platelets and pRBCs were ordered before being sent to the MICU. VS on transfer: 98.8 91 100/44 22 100 RA with GCS 15, AAOx3, non-focal neuro exam. On the floor, patient without any compliants or concerns. Past Medical History: Past Oncologic History: # Year/Age of diagnosis: [**2191**]/ [**Age over 90 **]yo Dx: MDS with 20q deletion and history of lymphoplasmacytic lymphoma versus CLL with plasma cell differentiation. # [**5-/2192**]: present with e.coli bacteremia secondary to neutropenia. # [**2192-6-5**]: bone marrow biopsy consistent with lymphoplasmacytic lymphoma or small lymphocytic lymphoma (total lymphocyte count <4,000), with plasma cell differentiation. # [**2192-6-21**]: Started on RITUXIMAB (received 4 doses of cycle one and 2 doses during cycle 2). He received several doses of neupogen and started on neulasta q2 weeks. # [**2192-10-18**]: started on aranesp 30mg (0.45mcg/kg) q 2weeks # [**11/2192**]: repeat bone marrow biopsy consistent with MDS with 20q deletion in 13 out of 20 metaphases and no signs of lymphoplasmacytic lymphoma. Supportive care with Aranesp dose for MDS 300mcg every 2 weeks increased to 600mg and Neulasta 6mg every 2 weeks. # Required hospitalization with [**Year (4 digits) **] transfusion ([**12/2192**] and 03/[**2192**]). Other Past Medical History: - recurrent malignant melanoma (including local recurrences), last [**2191**] that was pT1b - [**Doctor Last Name **] 3+3 prostate adenocarcinoma (diagnosed [**2183**]) followed by surveillance with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 79**] - benign prostatic hypertrophy - cholecystectomy - chronic intestinal pneumatosis - Type 2 DM - HTN - asthma - hyperlipidemia - GERD Social History: Smoked 6-7 years as a young adult, none since. Lifelong nondrinker. Retired 11 years ago after working as a travel [**Doctor Last Name 360**] for 50+ years; also worked conducting a band. Lives at home with his 78yo wife. Family History: not contributory to current admission Physical Exam: ON ADMISSION: Vitals: BP 113/56 HR 101 RR 23 pOx 98 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, small hematoma located on posterior scalp. Neck: supple, JVP not elevated, no LAD, + LIJ CVC 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, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, upper extremity skin impairments from fall, right ankle with deformity. Neuro: CN III-XII grossly intact, motor/sensory intact, cerebellar exam (point-to-point testing, [**Doctor First Name **]) intact. Pertinent Results: [**2193-6-4**] 10:15PM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2193-6-4**] 09:05PM WBC-5.7 RBC-1.81* HGB-5.9* HCT-17.2* MCV-95 MCH-32.6* MCHC-34.2 RDW-18.1* [**2193-6-4**] 07:30PM LD(LDH)-156 CK(CPK)-40* TOT BILI-0.4 [**2193-6-4**] 07:30PM cTropnT-0.02* [**2193-6-4**] 07:30PM HAPTOGLOB-100 [**2193-6-4**] 07:30PM WBC-5.0 RBC-1.82*# HGB-5.9*# HCT-17.4*# MCV-96 MCH-32.5* MCHC-34.0 RDW-18.1* [**2193-6-4**] 07:30PM PT-12.3 PTT-22.6 INR(PT)-1.0 CXR ([**2193-6-4**]): Prelim - LIJ CVC extending to superior vena cava. Low lung volumes limit evaluation, likely right basiliar atelectasis. C-spine ([**2193-6-4**]): Severe multi-level degenerative disease without acute fracture or dislocation CT Head ([**2193-6-4**]): Small focus of subarachnoid hemorrhage in the right lateral sulculs just posterior to the right insula. Hemorrhage also seen in the sylvian fissure. Small amount of intra-ventricular [**Month/Day/Year **] layering in the posterior horns. Small para-falcine subdural hematoma. . CT head ([**2193-6-5**]) Redistribution of subarachnoid [**Month/Day/Year **] with a slight increase in intraventricular hemorrhage located dependently in the occipital horns of the lateral ventricles, bilaterally. No new hemorrhage in any other compartment. . CT ABD ([**2193-6-6**]) IMPRESSION: 1. No evidence of retroperitoneal bleed or other acute intra-abdominal process. 2. Air in the bladder could reflect recent catheterization, and correlation is suggested. 3. Unchanged pulmonary nodules and pleural plaque, stable since at least [**2187**]. Brief Hospital Course: Mr [**Known lastname **] is a [**Age over 90 **]M with history of lymphocytic lymphoma and recent hospitalization two weeks ago for pneumonia and multiple admissions for orthostatic hypotension presents from home with fall resulting in SAH with other issues including ARF from poor PO intake, relative hypotension, and worsening anemia. # Subarachnoid hemorrhage Patient presented from home with a fall after getting dizzy, resulting in skin tears on left arm and R hip pain. NCHCT in the ED showed Small focus of subarachnoid hemorrhage in the right lateral sulculs just posterior to the right insula. Hemorrhage also seen in the sylvian fissure. Small amount of intra-ventricular [**Age over 90 **] layering in the posterior horns. Small para-falcine subdural hematoma. Patient had known thrombocytopenia prior to fall. Neurosurgery was consulted and did not see need for surgical intervention. Repeat NCHCT was stable and no interventions were necessary, and no anti-epileptics were warranted. They did, however, recommend that ASA be held for one week and that he f/u in [**Age over 90 **] with repeat head CT in 4 weeks. # Fall Patient reported falls in setting of dizziness, and were likely the result of orthostatic hypotension. Patient was placed on telemetry which revealed sinus rythm, and an EKG did not show ischemic changes. On presentation, he was initially orthostatic and was transfused 2 units PRBCs, fluid resusitated and his orthostatics improved. In addition, the patient was evaluated by physical therapy who found no significant strength or balance deficits to explain his fall, but did find him to be still severely orthostatic despite being euvolemic. # Relative hypotension [**Name2 (NI) **] usually SBP 140-160 supine to 105 with standing. He denies any recent medication changes. No obvious source of infection with clear CXR and urinalysis although leukocytosis relative to baseline (WBC ~ 3 --> 5). EKG without ischemia. While anemia was concerning for possible GI bleed, FOBT was negative. Patient does appear dry on exam and likely hypovolemic. It is reassuring that he has responded to fluids on the floor (SBP 100 --> 113). Given his long h/o orthostatic hypotension and failed trials of medical therapy in the past, we felt it was best that he be evaluated by a specialist in the field. Arrangements were made for him to be seen by neurology/ autonomic [**Name2 (NI) **]. # Anemia Patient presented with a drop in Hgb 8.8-9.3 a week prior to admission to 5.9. There was no evidence of GI bleed, hemolysis labs were negavtive and SAH would not have explained the degree of [**Name2 (NI) **] loss. Reteroperitoneal bleed was ruled out with abdominal CT and no other sources of active bleeding were identified. The patient received 2 units of pRBCs in the ICU, and 2U PRBCs on the medicine service. Hematology was consulted regarding whether this is progression of his MDS, and they provided reassurance that the patient was stable for discharge with a HCT of 24 with outpatient f/u for aranesp and neupogen administration within 3 days. # Thrombocytopenia: had known thrombocytopenia from underlying malignancy likely contributed to development of SAH. He received one unit of platelets in the MICU and remained relatively stable therafter. # Acute on chronic kidney disease: BUN and Cr were elevated from baseline in the setting of poor po intake. Creatinine began to correct with fluid resusitation and returned to a baseline of 1.6. # DM2 without complications: was maintained on home dose NPH 10 U qAM (70 % of basal while NPO) with humalog SSI (when eating). #Glaucoma: coNtinued home dose of timolol. #BPH: Finesteride was held due to orthostatic hypotension. . TRANSITION OF CARE: -f/u in neurosurgery [**Name2 (NI) **] with repeat head CT -f/u with hematology for neupogen and procrit -f/u with neurology for orthostatic hypotension w/u Medications on Admission: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. magnesium oxide 140 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*4 Tablet(s)* Refills:*0* 5. Lumigan 0.01 % Drops Sig: One (1) Ophthalmic once a day. 6. insulin NPH & regular human 100 unit/mL (70-30) 7. Aranesp 600mcg every 2 weeks 8. Neulasta 6mg every 2 weeks Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic daily (). 4. magnesium oxide 140mg Sig: Two (2) twice a day. 5. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lumigan 0.01% Eye Drop Sig: One (1) once a day. 7. Insulin NPH 70/30 Sig: 15 units qAM. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Subarachnoid Hemorrhage Orthostatic Hypotension Anemia attributed to MDS Thrombocytopenia Acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname **], You were admitted to the hospital because you had a very bad fall. This was probably because your [**Known lastname **] pressure falls too much when you stand up. A CT scan of your head showed that there was a small amount of [**Known lastname **] around your brain, but it did not cause you any problems. The neurosurgeons would like to make sure that this resolves, so they would like you to get a head CT in one month and go see them for a check-up. You were also found to have low [**Known lastname **] counts, so while you were here you received [**Known lastname **] and platelets. You still have orthostatic hypotension. Your florinef medication was stopped earlier this year since it was causing many side effects. Please make sure to follow up in the [**Hospital 31176**] [**Hospital **] where they specialize in orthostatic hypotension. Doctors in that [**Name5 (PTitle) **] will assess your orthostatic hypotension and figure out what medications might help you. For now, please walk VERY carefully, stand very carefully. If you feel dizzy, immediately sit down. Medication changes STOP aspirin until [**6-13**], then you may resume on [**6-14**] Please make sure to see the [**Month/Year (2) **] doctors [**First Name (Titles) **] [**Last Name (Titles) 3816**]. This is VERY important. They will give you the injection for your [**Last Name (Titles) **] counts. Followup Instructions: NOTE: We are working on a follow up appt for you in the Autonomic Disorders Dept with Dr [**First Name8 (NamePattern2) **] [**Telephone/Fax (1) 111115**]. The office is aware you need an appt and will call you at home when one becomes available. Please discuss this as well with Dr [**Last Name (STitle) **] during your follow up appt on [**6-13**]. Department: HEMATOLOGY/ONCOLOGY When: [**Month (only) **] [**2193-6-11**] at 1:30 PM With: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital **] MEDICAL GROUP When: THURSDAY [**2193-6-13**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 95431**], MD [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2193-6-20**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: THURSDAY [**2193-7-4**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2193-7-4**] at 11:15 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 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11569, 11627

6541, 10448

243, 268

11781, 11781

4863, 6518

13490, 15439

4048, 4087

11060, 11546

11648, 11760

10474, 11037

12058, 13467

4102, 4102

199, 205

296, 2297

4116, 4844

11922, 12034

3400, 3792

3808, 4032

29,365

177,450

9188

Discharge summary

report

Admission Date: [**2120-1-9**] Discharge Date: [**2120-1-14**] Date of Birth: [**2076-8-4**] Sex: F Service: Plastic Surgery PRIMARY DIAGNOSIS: Breast cancer. COURSE IN HOSPITAL: Patient is a pleasant 43-year-old woman, who was admitted to the hospital on [**1-9**] for recurrent left breast cancer. She was admitted the same day for wide resection of the recurrent left breast cancer and a skin graft over the region. She was taken to the operating room by Dr. [**Last Name (STitle) **] on the General Surgery service for the excision of the recurrent carcinoma. Subsequently, Dr. [**First Name (STitle) **] performed a split thickness skin graft from her left thigh to cover the region on her left breast. She tolerated the procedure well with no complications. She was extubated the same day. Postoperatively, she remained afebrile with stable vital signs. She did well postoperatively. A VAC was placed over the split thickness skin graft and kept in place for five days. The bandage on the donor site was removed on postoperative day one, and blow dried t.i.d. for 15 minutes. She continued to do well and tolerated p.o. intake. Her course in the hospital has remained uneventful otherwise, and she was discharged home on postoperative day five after the VAC was removed. PAST MEDICAL HISTORY: Only significant for breast cancer. PAST SURGICAL HISTORY: She had a TRAM flap of the left breast on [**2118-11-29**] as well as C section and cholecystectomy as well as a lumpectomy. ALLERGIES: She has no known drug allergies. The patient has always been well. She is currently stable for discharge home to followup with Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. DISCHARGE MEDICATION: Vicodin 5/500 1-2 tablets p.o. q.4h. prn. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 31577**] MEDQUIST36 D: [**2120-1-13**] 13:33 T: [**2120-1-17**] 09:04 JOB#: [**Job Number 31578**]

[ "174.8" ]

icd9cm

[ [ [] ] ]

[ "85.82", "85.22" ]

icd9pcs

[ [ [] ] ]

1392, 2070

162, 1308

1331, 1368

23,707

159,015

5337

Discharge summary

report

Admission Date: [**2151-9-9**] Discharge Date: [**2151-9-14**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Sulfonamides / Gadolinium-Containing Agents / Demerol / Morphine Attending:[**First Name3 (LF) 21731**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: intubated in the MICU History of Present Illness: 59 y/o woman with mast cell degranulation syndrome with several recent admissions for flares of this syndrome presents with one day of worsened nausea and vomiting and re-onset of dyspnea. Symptoms began this morning with worsened abd pain in epigastric area associated with nausea, pt could not keep food down and vomited once. Shortly thereafter she noted her breathing became more difficult with sensation of chest tightness. Per pt, these symptoms were consistent with her previous flare ups of mast cell degranulation. She gave herself a shot of epinephrine and went to the ED. In the [**Name (NI) **] pt slightly tachypneic and with diffuse wheezes. Placed on 100% non rebreather. Given solumedrol, epinephrine, albuterol with little resolution in symptoms. CXR negative for infiltrates or edema. LFTs within normal limits with normal amylase and lipase. Pt admitted to MICU for monitoring further work up. Past Medical History: - Mast cell activation syndrome: Followed by [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **] who is an allergist at [**Hospital1 112**], #[**Telephone/Fax (1) 21735**]. Also followed here by Dr. [**Last Name (STitle) 79**] in GI. Has been intubated twice. - Depression/anxiety/bipolar d/o, hx of SI - MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi - HTN - erosive osteoarthritis - GERD, gastritis and esophagitis on recent EGD [**2151-1-8**]. also had shortening of villi. - Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy - Anemia, iron studies c/w AOCD - Hemorrhoids - pt reports recent EGD demonstrated vegetable bezoar (?[**12-7**]). - Status post hysterectomy and oophorectomy - h/o MRSA infection (porthacath associated) - portacath placed [**3-8**] - d/c'd [**2-4**] MRSA infection - portacath placed [**2151-6-9**] Social History: recently divorced. son and daughter in AZ & OH. No tobacco or EtOH. Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: VS- P=109 BP= 120/74 R=16 O2sat=98% on NRB Gen- anxious appearing female, speaks in full sentences no accessory muscle use Eyes: Anicteric Mouth: MMM, no edema Neck: trachea midline, no stridor***please see below***, no JVD CV- RR, no m/r/g Pulm- poor air movement, scattered exp wheezes Abd: Mild diffuse tenderness greater in epigastric region. Minimal bowel sounds, no rebound or guarding. Ext- No LE edema, 1+ DP pulses Skin: Patchy erythema on arms bilaterally. Bruise on R arm, no swelling or exudate Pertinent Results: Admission labs: 142 106 12 ------------< 132 3.5 26 1.1 . Ca: 9.9 Mg: 1.9 P: 2.1 ALT: 16 AP: 81 Tbili: 0.3 Alb: AST: 19 LDH: Dbili: TProt: [**Doctor First Name **]: 43 Lip: 26 . 13.5 4.9 >----< 265 38.8 . N:68 Band:0 L:23 M:7 E:2 Bas:0 . [**2151-9-9**] 06:00PM BLOOD WBC-4.9 RBC-4.67# Hgb-13.5# Hct-38.8# Plt Ct-265 [**2151-9-14**] 05:37AM BLOOD WBC-6.8 RBC-3.79* Hgb-11.6* Hct-32.8* Plt Ct-188 [**2151-9-9**] 06:00PM BLOOD Glucose-132* UreaN-12 Creat-1.1 Na-142 K-3.5 Cl-106 HCO3-26 AnGap-14 [**2151-9-14**] 05:37AM BLOOD Glucose-88 UreaN-17 Creat-0.8 Na-143 K-3.4 Cl-106 HCO3-31 AnGap-9 [**2151-9-10**] 12:25AM BLOOD Type-ART pO2-262* pCO2-50* pH-7.24* calTCO2-22 Base XS--6 [**2151-9-10**] 02:45PM BLOOD Type-ART Temp-36.7 Rates-16/ Tidal V-550 PEEP-5 FiO2-40 pO2-167* pCO2-40 pH-7.38 calTCO2-25 Base XS-0 Intubat-INTUBATED [**2151-9-10**] 12:25AM BLOOD Lactate-5.7* [**2151-9-10**] 02:45PM BLOOD Lactate-1.4 Brief Hospital Course: HOSPITAL COURSE BY PROBLEM: . 1) Respiratory distress/Mast cell degranulation. The patient had a flare up of her mast cell degranulation. Despite taking a shot of the epinephrine, she continued to feel tachypneic and had diffuse wheezing. She was placed on a non-rebreather mask and given solumedrol, epi, albuterol and had little resolution of her symptoms. Her CXR was negative for infiltrates and she was admitted to the MICU for further workup. She became more tachypneic and required intubation. Her ABG at that time was 7.24/50/262 with a lactate of 5.1. She was extubated on [**2151-9-12**] with improvement in her ABG and normalization of her lactate level. She was sent to the floor the following day and monitored closely. Her wheezes had almost completely resolved and we continued her home medications. We also sent the patient home on a steroid taper since she was pulsed with up to 125mg of solumedrol. . 2) Abdominal pain: Pancreatitis is associated with this syndrome and she does have symptomatology c/w this; however abd exam fairly benign and she had normal LFTs and normal amylase/lipase. We continued her on a PPI and her home medications and used dilaudid for pain. Her abdominal pain resolved to baseline prior to discharge. with normal LFTs and amylase and lipase . . 3) UTI: the patient had urine cultures which grew out enterobacter aerogenes. We treated her with levaquin and continued this upon discharge. He elevated WBC was likely partially from the UTI but also [**2-4**] steroid use. . 4) HTN: We continued her home medications and her blood pressure was stable . 5) Erosive osteoarthritis - followed by Dr. [**Name (NI) 21736**]. Continued plaquenil. . 6) Depression/anxiety: We continued the patient on her home medications of seroquel and ativan. She did not experience any worsening of her symptoms. Medications on Admission: gastrocrom 2amps QID cadizem CD 120 mg qd estrogen patch 0.05 twice weekly diphenhydramine 50mg qhs zantac 300mg [**Hospital1 **] seroquel 450mg qhs ambien 10mg qhs cymbalta 60mg qhs plaquenil 400mg qd adderal 10mg qd zofran 8mg po prn dilaudid 2mg prn percocet prn klonopin prn epipen prn Discharge Medications: 1. Cardizem CD 120 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 2. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Seroquel 400 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Protonix 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* 5. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO once a day. 8. estrogen Sig: 0.05 patch twice weekly. 9. Gastrocrom 100 mg/5 mL Solution Sig: Two (2) PO four times a day. 10. Diphenhydramine HCl 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for wheezing. 11. Zantac 300 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Adderall 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 14. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 15. EpiPen 0.3 mg/0.3 mL Syringe Sig: One (1) Intramuscular once a day as needed for allergy symptoms. 16. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day. 17. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 18. Prednisone 10 mg Tablet Sig: variable Tablet PO once a day for 6 days: take 4 tabs per day x 2 days, take 2 tabs per day x 2 days, then take 1 tab per day x2 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - mast cell activation syndrome - depression/anxiety - hypertension - respiratory distress - abdominal pain Secondary: - status post myocardial infarction - erosive osteoarthritis - Gastroesophageal reflux disease, gastritis, esophagitis - status post bezoar - hemorrhoids - anemia of chronic inflammation - status post hysterectomy Discharge Condition: stable Discharge Instructions: You were admitted with an exacerbation of mast cell degranulation syndrome. You required a brief stay in the intensive care unit and intubation. We treated you with steroids and your home medications with improvement in your respiratory status. You also developed a UTI and required antibiotic therapy for this. . Please contact your allergist or gastroenterologist if you have worsening shortness of [**Hospital1 1440**], chest pain, or abdominal pain. Please return to the ED if you experience signifcant worsening pain or breathing. . Please take your medications as directed. Please take your prednisone taper as directed. It is important for you to complete this course of medication. We also think it would be therapeutic for you to restart both the protonix and [**Doctor First Name 130**]. We have given you a prescription for protonix. Please contact your allergist to discuss with her the need for [**Doctor First Name 130**]. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2151-10-5**] 1:20 Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2151-9-24**] 12:30 Please contact your allergist, Dr. [**Last Name (STitle) **], at [**Telephone/Fax (1) **] to make a close followup appointment.

[ "041.85", "786.09", "577.1", "715.35", "285.29", "786.1", "599.0", "279.8", "401.9", "276.2", "530.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7789, 7795

3936, 3936

358, 381

8181, 8190

2984, 2984

9182, 9581

2364, 2439

6128, 7766

7816, 8160

5814, 6105

8214, 9159

2454, 2965

311, 320

3964, 5788

409, 1324

3000, 3913

1346, 2262

2278, 2348

13,790

185,203

51171

Discharge summary

report

Admission Date: [**2129-4-24**] Discharge Date: [**2129-5-2**] Service: MEDICINE Allergies: Amiodarone Attending:[**First Name3 (LF) 898**] Chief Complaint: MS Change Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] year old male with chief complaint of altered mental status, delerium, CRF on HD. He has been disoriented since Friday. He has 24 hour home health care and concierge physician. [**Name10 (NameIs) **] fever today to 100.6 and wife brought him in to the [**Name (NI) **] where he was noted to have multilobar pneumonia. In the ED he was satting 92-94% on NC. He recieved levofloxacin for pneumonia, zyprexa and haldol for agitation. Past Medical History: 1)CORONARY ARTERY DISEASE- P MIBI on [**2126-7-3**] showed a mild reversible defect in the inferior wall 2)CHF [**1-5**] Diastolic dysfunction 3)ATRIAL FIBRILLATION: seen by EP at [**Hospital1 18**] 4)DIABETES W/RENAL MANIFESTATIONS, TYPE II 5)ISCHEMIC OPTIC NEUROPATHY 6)HYPERTENSION 7)HYPERCHOLESTEROLEMIA 8)RENAL FAILURE, CHRONIC : on HD since [**11-6**]. Mon/thurs. 9)ANEMIA 10)Hx of GASTRITIS W/O HEMORRHAGE 11)SPINAL STENOSIS, LUMBAR 12)MONOCLONAL GAMMOPATHY UNCERTAIN SIGNIFICANCE 13)PROSTATIC HYPERTROPHY S/P REMOVAL OF PROSTATE (TURP) 14)Hx of COLONIC POLYPS 15)Hereditary sensory motor neuropathy with ataxia. 16)KIDNEY STONE 17)BASAL CELL CANCER, FACE (L PREAURICULAR) 18)PAPILLARY TRANSITIONAL CELL BLADDER CANCER (LOW-GRADE) 19)MODERATE MITRAL REGURGITATION 20)History of temporal artery biopsy which was negative for GCA 21)Question of pulmonary fibrosis secondary to Amiodarone. 22)GERD 23)S/p CCY 24)History of Meniere's disease. Social History: Patient lives at home with his wife. [**Name (NI) **] has been bed bound for some time. He has a 24 caretaker at home as well as a homemaker. He has been going to [**Hospital1 18**] for >40 years and has been a donor for much of that time. Family History: Coronary artery disease in multiple first-degree relatives Physical Exam: on admission: GEN: deeply somnolent, agitated with sternal rub, does not answer questions or open eyes HEENT: sclerae anicteric. COR: irreg irreg, nl s1s2, no murmur heard LUNGS: upper fields with few crackles and rhonchi, no wheezes, bronchial sounds on R laterally. ABD: thin, soft, nondistended. active bowel sounds EXT: thin, no edema, feet cool, 1+ dp pulses bilat. NEURO: not arousable except to sternal rub, but agitated, pulling at lines. received 2.5 mg sublingual zyprexa and 1 mg haldol in EW. significant muscle twitching LUE and LLE. moves all extrem but twitching on L side >>> R. SKIN: warm/dry Pertinent Results: [**2129-4-24**] 11:32AM LACTATE-3.1* [**2129-4-24**] 10:53AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2129-4-24**] 10:53AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2129-4-24**] 10:53AM URINE RBC-[**5-13**]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2129-4-24**] 09:10AM K+-5.0 [**2129-4-24**] 08:35AM LACTATE-4.5* K+-6.2* [**2129-4-24**] 08:20AM GLUCOSE-211* UREA N-55* CREAT-3.8* SODIUM-137 POTASSIUM-5.7* CHLORIDE-97 TOTAL CO2-22 ANION GAP-24* [**2129-4-24**] 08:20AM AMYLASE-43 [**2129-4-24**] 08:20AM CALCIUM-9.2 PHOSPHATE-4.8* MAGNESIUM-1.7 [**2129-4-24**] 08:20AM WBC-9.9 RBC-3.61* HGB-11.5* HCT-35.6* MCV-99* MCH-31.9 MCHC-32.4 RDW-17.9* [**2129-4-24**] 08:20AM NEUTS-84.5* LYMPHS-10.2* MONOS-5.1 EOS-0.1 BASOS-0.1 [**2129-4-24**] 08:20AM HYPOCHROM-1+ ANISOCYT-1+ MACROCYT-2+ [**2129-4-24**] 08:20AM PLT COUNT-352 [**2129-4-24**] 08:20AM PT-15.4* PTT-25.7 INR(PT)-1.6 Brief Hospital Course: [**Age over 90 **] yo M h/o ?CAD, diastolic CHF, chronic A.F., ESRD on HD who developed mental status changes after dialysis on Friday and was admitted with a multilobar, possibly bilateral pneumonia. 1. Pneumonia - Originally diagnosed based on fever, elevated wbc, and chest x ray findings. Although final read of the cxr was more consistent with chf, the pulmonologists felt it was more consistent with PNA. He recieved 500mg IV levaquin in the ED, and then had vancomycin added to broaden his covereage. He was admitted to the MICU, but did not require intubation or BiPap. He did well and was called out in less than 48 hours. No sputum or blood cultures returned positive. The patient continued to have some respiratory difficulties on the floor and had vancomycin restarted. He was dialyzed for volume overload. He continued to have an oxygen requirement and worsening delirium. Given his overall worsening status, his multiple cormorbidities, and his poor quality of life at home, the decision was made to make the patient comfort measures. This decision was reached by Dr. [**Last Name (STitle) 1407**], Dr. [**Last Name (STitle) 1911**], the patient's wife and family. Mr. [**Known lastname **] passed away on [**2129-5-2**] at 6:15 am. 2. Delirium- patient was agitated in the setting of hypoxia and illness. He initially required sedation with haldol until his clinical condition improved. These medications were tapered off, but he became increasing more agitated and restless. They were reinstituted. A source of delirium was done with UA, cxr, telemetry, cardiac enzymes, electrolytes, Head CT. These were all remarkable. No source was clearly found and it was thought to be multifactorial. 3. ESRD - Patient was seen by renal. He underwent hemodialysis. Following the patient's worsening clinical and mental status, the decision was made to stop dialysis and make the patient comfort care. 4. Vision problems: patient had long history of difficulty with his vision. He had known cataracts and ischemic optic neuropathy. During his hospitalization, he noted lack of vision in his right eye. This occurrred in the setting of delirium. The true nature of his symptoms could not be determined. Opthalmology was consulted and did not find any new lesions or ischemic changes in the eye. Medications on Admission: 1) Metoprolol Succinate 50 mg PO DAILY 2) Lisinopril 10 mg PO DAILY 3) Furosemide 40 mg PO DAILY 4) Atorvastatin Calcium 10 mg PO DAILY 5) Glimepiride 2 mg PO bid 6) Prilosec 20 mg PO once a day. 7) Cyanocobalamin 1000 mcg PO DAILY 8) Folic Acid 1 mg PO DAILY 9) Warfarin Sodium 2 mg PO HS 10) Pioglitazone HCl 45 mg PO DAILY 11) B Complex-Vitamin C-Folic Acid 1 mg PO DAILY 12) Quinine Sulfate 260 mg PO HS Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pneumonia Congestive Heart Failure End stage renal disease delirium Discharge Condition: expired Discharge Instructions: - Followup Instructions: -

[ "294.8", "530.81", "427.31", "515", "293.0", "486", "403.91", "724.02", "272.0", "250.40", "276.2", "428.32", "414.01", "V10.51", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

6444, 6502

3681, 5984

226, 233

6614, 6623

2661, 3658

6673, 6677

1956, 2016

6523, 6593

6010, 6421

6647, 6650

2031, 2031

177, 188

261, 712

2045, 2642

734, 1682

1698, 1940

13,033

161,891

42979

Discharge summary

report

Admission Date: [**2186-2-8**] Discharge Date: [**2186-2-15**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: gastroparesis associated with hypertensive urgency in setting of not having taking his anti-HTN meds Major Surgical or Invasive Procedure: HD History of Present Illness: This is a 37 y/o male patient with PMH Type I DM, HTN, Gastroparesis, ESRD on HD (last in [**2-7**] per patient )who presents to the with hypertensive urgency in the setting of inability to take po anti-HTN meds [**3-17**] n/v. . Patient is admitted to hospital at 3 times every month for similar complaints. Last admission [**2186-1-22**] . At that time BP was attributed to missing dialysis session. BP returned back to baseline after dialysis He was also found to have [**Month/Day/Year **] neg staph bacteremia and Renal recommended Vancomycin for 3 weeks without removing the dialysis line. I unable to obtain a good H&P since patient has received Ativan and Dilaudid and is somnolent now. He denies chills and sweats at home. He denies hematemesis, melena, BRBPR. . ED course: SBP's 240's-260's upon arrival. He was given the usual protocol : Dilaudid 2 mg x 3 , Ativan 2 mg x 2 and Labetalol IV 10 -20 . BP on arrival to floor was 180/70. . ROS - He denies HA, blurry vision. . He denies CP, palpitations, shortness of breath. He denies cough. He denies hematochezia, hematuria. 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 in [**7-/2181**]), normal stress [**11/2182**] 6. hx of Foot Ulcer 7. h/o clot in AV graft x2 ([**Month (only) 958**] and [**2185-8-13**]) Social History: Denies any alcohol, tobacco, or drug use. He has his own room but lives with his [**Hospital1 **] mother who is a good match for kidney transplant. has 3 children in early teens. 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: Vitals: T 97 .4 HR 102 180-195/90-[**Numeric Identifier 22419**] 99% RA FS 308 General: falling asleep during interview. HEENT: PERRL, EOMI, sclera anicteric, MMM, No OP lesions Neck: Supple, no JVD or carotid bruits CV: RRR, nl S1, S2, 2/6 systolic murmur at LUSB as well as [**4-18**] systolic murmur radiating to apex Chest : L subclavian without tenderness or eryhtma. CTAB, no crackles, rhonchi Abd: Soft, ND, diffusely tender, + BS, no guarding, no rebound, multiple well healed scars. Ext: no c/c/e; Left arm with fistula with good thrill Skin: no rashes Access: Port - accessed, NT, no erythema Pertinent Results: ADMISSION LABS: [**2186-2-8**] 04:20PM GLUCOSE-269* UREA N-41* CREAT-6.4*# SODIUM-138 POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-33* ANION GAP-16 [**2186-2-8**] 04:20PM WBC-7.1 RBC-4.92 HGB-13.0* HCT-40.2 MCV-82 MCH-26.4* MCHC-32.4 RDW-20.0* [**2186-2-8**] 04:20PM NEUTS-61.8 LYMPHS-27.1 MONOS-5.1 EOS-5.4* BASOS-0.6 [**2186-2-8**] 04:20PM PLT COUNT-159 . IMAGING: [**2186-2-10**]: CT head: 1. Minimal small vessel disease. 2. New air-fluid levels of the sphenoid sinuses bilaterally . DISCHARGE LABS: [**2186-2-15**] 05:47AM BLOOD WBC-6.2 RBC-3.94* Hgb-10.6* Hct-33.0* MCV-84 MCH-26.9* MCHC-32.2 RDW-20.3* Plt Ct-209 [**2186-2-8**] 04:20PM BLOOD Neuts-61.8 Lymphs-27.1 Monos-5.1 Eos-5.4* Baso-0.6 [**2186-2-8**] 04:20PM BLOOD Hypochr-2+ Anisocy-2+ Microcy-2+ [**2186-2-15**] 05:47AM BLOOD PT-13.2* PTT-62.8* INR(PT)-1.2* [**2186-2-15**] 05:47AM BLOOD Glucose-199* UreaN-42* Creat-6.7*# Na-137 K-5.3* Cl-98 HCO3-28 AnGap-16 [**2186-2-9**] 11:43AM BLOOD ALT-9 AST-13 LD(LDH)-191 AlkPhos-74 Amylase-101* TotBili-0.2 [**2186-2-11**] 03:20AM BLOOD Lipase-36 [**2186-2-15**] 05:47AM BLOOD Calcium-9.8 Phos-6.0* Mg-2.2 [**2186-2-9**] 01:12AM BLOOD Vanco-2.2* [**2186-2-11**] 11:17AM BLOOD freeCa-1.04* Brief Hospital Course: 37 y/o male with Type I DM complicated by ESRD on HD, gastroparesis, and autonomic dysfunction w/ HTN who presented with one day of nausea, vomiting, abdominal pain and hypertensive urgency and tranferred to MICU for hypertensive urgency then transferred to medicine floor once hemodynamically stable. . # Hypertensive Urgency: Hypertension likely d/t pain, autonomic dysfunction, and occasional HD non-adherence. The patient has presented with numerous episode of hypertension over the past year. He was initially managed with his combination of pain control, and anti-hypertensives. He did require MICU transfer briefly for further blood pressure management. There was no evidence of end-organ damage from his markedly elevated blood pressure. He was gradually converted to his outpatient oral regimen of anti-hypertensives. His blood pressure often is triggered by his abdominal pain so this was aggressively treated as below. - cont outpatient regimen including BB, CCB, clonidine - maintain pain control to limit triggers to hypertension . # Nausea/Vomiting/Abdominal Pain: The patient has a a long history of these symptoms consistent with gastroparesis. He has had J tubes in the past for enteral feeding but these were complicated by tube infections requiring removal. These were much improved with ativan, dilaudid, reglan and [**Month/Day/Year 8337**] advancement in diet today. He was given a generous bowel regimen to maintain as much forward GI flow as possible to limit his abdominal pain. By time of discharge his pain was controlled on oral medications. - Continue usual regimen of reglan, anzemet and ativan for nausea - Dilaudid as needed for abdominal pain - Reglan for gastroparesis - bisacodyl pr . # DM I: The patient has had type 1 diabetes mellitus for ~15 years during which time he has developed nephropathy, neuropathy, and gastroparesis. His hospital stay was complicated by quite labile blood sugars from 9-400. The [**Last Name (un) **] service followed him closely during the stay. As he has had numerous severe hypoglycemic episodes, he should target his blood sugars to 150-200. His home regimen included NPH 5 units twice daily with humalog sliding scale. As his diet was advanced, his insulin regimen was adjusted accordingly [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. - NPH 4 units [**Hospital1 **] - humalog sliding scale to be given after meals . # CAD No evidence for ischemia. - Continue asa/BB . # ESRD: The patient has been on hemodialysis for nearly 2 years. His renal failure is from a combination of hypertension and diabetic nephropathy. His calcium-phosphate product was managed per renal recommendations. He has a matched unrelated living kidney donor available but has not been able to arrange the transplant due to concerns for the donor's willingness to donate, financial concerns, and having outstanding dental work. - HD via Left AVF on Tue/[**Last Name (un) **]/Sat - Calcium Acetate 667 mg, two capsules three times a day - needs to complete required dental work prior to pursuing kidney transplant . # HD Access: The patient has a history of thromboses in AV grafts on 2 occassions ([**Month (only) 958**] and [**2185-8-13**]) which required surgical thrombectomy. As he is currently dialyzed via AV graft he needs to remain anti-coagulated to protect his HD access. Although it is noted that his markedly elevated blood pressure makes the risk of anti-coagulation high, he could not be without access to allow for adequate HD. While in the hospital, he was bridged to therapeutic [**Year (4 digits) **] with heparin gtt. Renal recommended discontinuing heparin gtt prior to INR being therapeutic. INR was 1.2 on day patient eloped. He was to take 2.5mg [**Year (4 digits) **] for two days, then to resume outpatient dose of 1.5mg thereafter and have INR checked at dialysis. . # FEN: ADAT very slowly . # Prophylaxis: PPI, heparin gtt transitioning to [**Year (4 digits) **] . # Dispo: SW consult to help arrange meal services at home. See addendum below for discharge situation. . # Code: Full code . Patient eloped: FSBG checked prior to discharge. It returned critically high. RN gave patient 3 units of humalog and advised him to wait 1 hour, and his blood sugar would be rechecked. She explained he could not be discharged until after his blood sugar was rechecked. He protested, saying that he had bills to pay but the RN explained that his FSBG was critically high and we needed to check it before he left. [**Name8 (MD) **] RN, patient agreed and she left to care for her other patients. When she returned, patient had eloped, without having his blood sugar rechecked and without his discharge paperwork, including medication prescriptions. . Dr. [**First Name8 (NamePattern2) 2894**] [**Last Name (NamePattern1) **] called both his cell phone ([**Telephone/Fax (1) 92671**]) and his home number ([**Telephone/Fax (1) 92670**]) and left messages urging him to return to the hospital to have his blood sugar rechecked. Further advised him that if he were unable to return immediately, that he should check his blood sugar at home and if it were high, to return to the ED immediately. Situation was discussed with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. Medications on Admission: B Complex-Vitamin C-Folic Acid 1 mg daily Metoclopramide 5 mg/5 mL q6h prn Metoprolol Tartrate 50 mg PO BID Calcium Acetate 1340 mg tid with meals Ondansetron HCl 4 mg/5 mL - q8h prn Ativan 2 mg PO every 4-6 hours as needed for nausea. Insulin NPH 6 units Subcutaneous twice a day. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QTHUR Clonidine 0.4 mg PO TID Prochlorperazine 10 mg q 6 h Reglan 10 mg tid. [**Last Name (NamePattern1) 197**]. Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 13. Prochlorperazine 10 mg IV Q6H:PRN 14. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1) Injection Sliding Scale. 15. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO at bedtime: Start in 2 days. Disp:*45 Tablet(s)* Refills:*2* 16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 17. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Two (2) units Subcutaneous AM and PM. Disp:*1 cartridge* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Diabetes Mellitus type 1 - complicated Gastroparesis . Secondary: history of AV graft thromboses Discharge Condition: Stable, without nausea/vomiting, abdominal discomfort, BP stable. Discharge Instructions: You have been evaluated and treated for high blood pressure, nausea/abdominal pain, and blood sugar control. Your blood pressure was controlled initially with IV medications and then transitioned to oral agents. . Your INR was supratherapeutic and your [**Last Name (NamePattern1) **] was held briefly. You were given treatment to decrease the level and placed on heparin until your INR returned to therapeutic range with [**Last Name (NamePattern1) **]. You should continue to take a higher dose of [**Last Name (NamePattern1) **] for 2 more days and then have your level checked outpatient. You will then resume taking your home dose of 1.5mg [**Last Name (NamePattern1) **]. . You are advised to receive dental treatment as soon as possible so you may be considered for your kidney transplant. . Please call your PCP or return to the ED if you experience headaches, visual changes, chest pain, abdominal pain, nausea, emesis. Please check your blood pressure regularly and seek medical treatment if elevated from your baseline. . Please take all your medications as prescribed, especially your diabetic and BP medications. You should continue your routine scheduled hemodialysis. Followup Instructions: Please followup with Dr. [**Last Name (STitle) 1366**], your kidney specialist, in 2 weeks for further medical management: [**First Name4 (NamePattern1) 1877**] [**Last Name (NamePattern1) **] at [**Hospital1 18**] PHONE: ([**Telephone/Fax (1) 773**] . Please have INR checked at next dialysis. . You will establish a PCP [**Name Initial (PRE) 151**]: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2186-3-20**] 1:30pm

[ "250.61", "250.81", "337.1", "414.01", "536.3", "250.41", "585.6", "276.51", "403.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11539, 11545

4240, 9541

415, 419

11716, 11784

3018, 3018

13016, 13518

2208, 2379

10035, 11516

11566, 11695

9567, 10012

11808, 12993

3522, 4217

2394, 2999

275, 377

447, 1536

3411, 3506

3034, 3402

1558, 1995

2011, 2192

75,305

104,995

30471+30109+57698

Discharge summary

report+report+addendum

Admission Date: [**2150-8-10**] Discharge Date: [**2150-8-21**] Date of Birth: [**2095-9-11**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Optiray 350 Attending:[**First Name3 (LF) 5141**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: None History of Present Illness: 54F with metastatic melanoma presenting with fatigue. Pt reports she was seeing her [**First Name3 (LF) 3390**] yesterday and felt extremely fatigue and generally unwell. Pt referred to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for IVF. In [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], stool guiac positive. Hct found to be 25. Pt transferred to [**Hospital1 18**] for further mgmt. Pt denies pain. Recently admitted [**Date range (1) 62150**] with pleuritic chest pain and also had issues with n/v during that admission. Pt discharged on regimen of PO reglan and zofran. She reports nausea pretty well controlled. Reports last emesis >1wk ago. Reports relatively poor PO intake with liquids > solid foods. Denies CP, SOB, lightheadedness. Denies urinary symptoms. Reports baseline constipation, last BM 3 days ago which was loose. Pt denies evidence of blood in stool or with BMs. This morning, pt reports feeling relatively better. Denies pain. Past Medical History: PAST MEDICAL HISTORY: Metastatic melanoma with known lung metastases Hypopituitarism secondary to ipilimumab tx Diabetes Mellitus Type 2 Hypertension Atrial fibrillation s/p ablation [**2149-2-5**] h/o DVT &PE s/p IVC filter [**2144**] h/o catheter-associated IJ thrombus [**2150-2-11**] s/p Cholecystectomy s/p tonsillectomy s/p C-section Thyroid nodule Osteoporosis Vitamin D deficiency PAST ONCOLOGIC HISTORY: - [**2140**]: diagnosed with right shoulder melanoma - [**2145-3-21**]: presented with hemoptysis, bilateral DVT, PE, lung mass biopsy revealed metastatic melanomam. IVC filter placement. - [**2145-5-21**]: underwent chemotherapy. Disease progression noted. - [**2145-9-20**]: enrolled in MDX-010/ipilimumab study - [**2146-5-22**]: CT evidence of disease progression with enlarging right paratracheal and retrocaval nodes - [**2146-6-21**]: restarted MDX-010, completing 3 cycles of therapy. Follow-up CTs showed minimal interval progression - [**2147-9-21**]: began ipilimumab on compassionate access trial, found to have autoimmune hypophysitis [**1-22**] ipilimumab and protocol was subsequently discontinued. She was found not to have the specific BRAF mutation. - [**2148-3-21**]: started phase 1 RAF265 clinical trial with dose reduction x2 for nausea, vomiting and neuropathy. - [**2149-2-5**]: therapy held due to atrial flutter unrelated to study drug, requiring cardiac ablation on [**2149-2-11**]. Drug could not be restarted. She was taken off study on [**2149-2-19**]. - [**2149-3-12**]: started trial of sorafenib and bortezomib. Completed 6 cycles of therapy. - [**2149-12-1**]: CT showed disease progression with peritracheal pleural-based and retroperitoneal metastatic foci with several new right pleural and diaphragmatic foci. Treatment options were discussed and high-dose IL-2 was chosen given the small chance of a durable complete response. She passed eligibility testing with PFTs notable for FEV-1 1.66 or 71% predicted. - [**0-0-0**]: Admitted for first cycle of IL-2. She received [**8-4**] doses on week 1, complicated by tachycardia and pulmonary edema. - [**2150-2-11**] - [**2150-2-14**]: Admitted with left neck pain, found to have catheter-associated IJ thrombus, treated with Lovenox Social History: Married, lives in [**Hospital1 392**]. She has 3 adult children. She used to do clerical work but has not recently been employed. Remote smoking history. No history of EtOH abuse, no drug use. Family History: Mother had breast cancer and died of PE at age 62. Father died of an MI at 61. One brother with a dx of melanoma, which was completely excised. Physical Exam: Admission PE: Vitals: 98.1, 100-110s, 120s/50-60s, 18, 95-99% RA GENERAL: pleasant obese woman, lying in bed, in NAD HEENT: PERRLA, anicteric sclera, dry membranes CARDIAC: regular rhythm, tachycardic to 100s LUNG: bibasilar inspiratory rales, otherwise CTAB, no wheezes or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: obese, soft, nondistended, +BS, nontender EXTREMITIES: moving all extremities well, no LE edema, no obvious deformities NEURO: grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Discharge PE: Physical Exam: Vitals: Tmax 98.3, 102/70, P101 96% RA BS 117-190 GENERAL: pleasant obese woman, lying in bed, in NAD CARDIAC: regular rhythm, tachycardic to 117s LUNG: Good air movement bilaterally, no wheezes or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: obese, soft, nondistended, +BS, mild RUQ tenderness. RLQ superficial firmness that is tender. normoactive BS. EXTREMITIES: moving all extremities well, trace symmetric LE edema, no obvious deformities NEURO: grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission Labs: [**2150-8-10**] 06:40PM WBC-9.9 RBC-3.28* HGB-9.3* HCT-29.2* MCV-89 MCH-28.2 MCHC-31.7 RDW-14.4 [**2150-8-10**] 06:40PM NEUTS-74.5* LYMPHS-19.9 MONOS-4.5 EOS-0.8 BASOS-0.4 [**2150-8-10**] 06:40PM PLT COUNT-477* [**2150-8-10**] 06:40PM PT-12.3 PTT-33.7 INR(PT)-1.1 ENDOCRINE [**2150-8-18**] 07:00AM BLOOD TSH-1.3 [**2150-8-18**] 07:00AM BLOOD Free T4-1.3 [**2150-8-18**] 07:00AM BLOOD Cortsol-7.2 Discharge Labs: [**2150-8-18**] 07:00AM BLOOD WBC-8.8 RBC-3.03* Hgb-8.5* Hct-26.3* MCV-87 MCH-28.1 MCHC-32.3 RDW-15.3 Plt Ct-311 [**2150-8-18**] 07:00AM BLOOD Glucose-60* UreaN-11 Creat-0.8 Na-137 K-4.3 Cl-96 HCO3-26 AnGap-19 IMAGING: MRI Head [**2150-8-18**]: No findings to suggest metastatic disease to the brain. CT Abd/Pelv [**2150-8-19**]: 1. Overall, worsening disease burden with increase in right lower lung pleural lesion with multiple new mesenteric nodules as well as metastatic lesions within the ascending colon and small bowel. No evidence of bowel obstruction. 2. Right paraaortic lesion is stable. 3. Soft tissue nodules in the anterior abdominal wall appear smaller. Brief Hospital Course: HOSPITAL COURSE 54F with metastatic melanoma s/p treatment with ipilimumab with complicating hypophysitis presenting with fatigue, nausea, abdominal pain. Initially thought due likely secondary to combination of anemia and dehydration from poor PO intake. Pt recieved IVF and 1unit PRBC, but to minimal relief of symptoms of nausea and fatigue. Patient also had intermittent low grade fevers around 100.5 during admission initially thought to be from atelectasis. Given hx of hypophysitis [**1-22**] previous treatment with ipilimumab, AM Cortisol was drawn. It was found to be low-normal. After consultation with outpatient endocrinology it was agreed that cortisol response was inadequate. Patient's prednisone was increased from 5mg to 10mg to improvement of fatigue and nausea. During admission patient was noted to have LLE DVT and started on subQ Lovenox. Anti-Xa level was drawn after 3rd dose and found to be within range for dosing. Patient was discharged on day 12 of hospitalization with followup with Heme-Onc ([**2150-8-26**]), Endocrine ([**2150-8-25**]) and GI ([**2150-8-26**]). ACTIVE ISSUES: # FATIGUE/NAUSEA: Initially thought to be from combination of dehydration and anemia. Did not improve markedly after IVF and PRBC. MRI negative for brain metastases. Nausea was treated with Zofran and Reglan. Patient has hypophysitis [**1-22**] previous treatment with ipilimumab for metastatic melanoma. AM Cortisol was drawn and found to be low normal. After consultation with outpatient endocrinology it was agreed that cortisol response was inadequate. Patient's prednisone was increased from 5mg to 10mg to improvement of fatigue and nausea. # ABDOMINAL PAIN: Likely combination of progression of disease and adrenal insufficiency. CT Abd/Pelv demonstrated multiple new mesenteric nodules as well as metastatic lesions within the ascending colon and small bowel with no evidence of bowel obstruction. At discharge, patient's pain was controlled on morphine. # LOW GRADE FEVERS: Initially thought to be be related to atelectasis; Had been unlikely that pt had PNA in setting of no leukocytosis and no coughing. Pt was at high risk for PE, but recent scans had been negative. No source of infection had ever been found. After increase in prednisone dosage, intermittent fevers resolved. # LLE DVT: Found on LENI due to leg swelling. Initially treated with Heparin gtt and then transitioned to Lovenox. Due to patient obesity, Anti-Xa level was sent after third dose of Lovenox and found to be within acceptable limits. Patient sent out on twice daily Lovenox SubQ. # DM: Patient came in on Levemir, which was changed over to Lantus. However, BS were noted to be persistently low likely due to decreased PO intake so Lantus was titrated downwards. After resolution of nausea and lethargy, patient began to take POs again and Lantus was again titrated. Patient was discharged with followup with [**Hospital **] Clinic on [**2150-8-25**]. # SINUS TACH: Chronic baseline in 100-110s, with bursts to 140s with minimal exertion during admission. Pt with h/o aflutter s/p ablation seen by cardiology with persistent sinus tach on diltiazem. Unclear origin but chronic tachy in 100-110s documented >6months. Not much improvement after 1u pRBC transfusion [**8-13**], so does not seem to be related to anemia. EKG sinus without change from prior. No evidence of DVT and holding off on CTA to r/o PE as pt had CTA a little over a week ago negative for PE. Converted Diltiazem to PO metop tartrate with somewhat better HR control, which was then transitioned to succinate. Pt continued with HR in 100-110s on metop succinate 100mg QD. # HYPOTENSION: One episode of SBPs down to 80s on [**8-13**], improved to SBPs 90s-120s with better HR control and s/p small IVF boluses. # R PLEURAL EFFUSION: on CXR, likely in some part related to known melanoma mets to the R lung. Seems most likely to have atelectasis as well and seems less likely underlying infiltrate. Pt was intermittently with small O2 requirements (up to 2L NC), but easily weaned to RA with sats in mid to high 90s. # CONSTIPATION: Despite bowel regimen of docusate, senna, and miralax, patient was intermittently constipated throughout admission. Patient sent home with prescriptions for docusate, senna, miralax and lactulose. # ANEMIA: Pt with new anemia since 6/[**2149**]. Prior Hb 10-12 range without any evidence of anemia prior to 1/[**2149**]. Pt with Hb of 12 in [**5-/2150**], now with Hb stable in [**7-30**] range. Pt with guiac positive stool per OSH report. Pt without hematochezia or melena. Recent iron studies [**2150-7-28**] more c/w anemia of chronic disease: iron mildly low with normal ferritin and low TIBC. Unclear that this normocytic normochromic anemia would be from blood loss via GI tract. Hemolysis labs unremarkable. Retic count not elevated and seems more c/w anemia of inflammation. Spoke with GI regarding scope for workup of possible melanomatous mets to bowel as cause of guiac + stool and they said that in setting of hemodynamic stability and stable H/H, will set up with OP f/u with GI first in clinic and then to get scope. S/p 1u pRBCs [**8-13**]. H/H stable after transfusion. INACTIVE ISSUES: # Metastatic melanoma: no current treatment. Communicated with OP onc team and discharged with followup with Heme/Onc on [**2150-8-26**]. # Neuropathy: chronic likely [**1-22**] chemotherapy, continued neurontin # GERD: continued ranitidine TRANSITIONAL ISSUES: # [**Month/Day (2) 269**] to visit patient for Lovenox teaching # f/u with GI for clinic evaluation in order to set up scope to evaluate of intestinal mets from melanoma as cause of guiac + stool ([**2150-8-26**]). # f/u with OP oncologist, Dr. [**Last Name (STitle) **] ([**2150-8-26**]) # f/u with endocrine re: hypophysitis with adrenal insufficiency ([**2150-8-25**]) # f/u with [**Last Name (un) **] re: insulin dosage. # Pt's iron supplementation discontinued on discharge as it was contributing to significant constipation and pt's anemia workup seems most c/w anemia of chronic disease so iron supplementation unlikely to help. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain 2. Calcium Carbonate 500 mg PO DAILY 3. Diltiazem 60 mg PO TID plesae hold for HR<60 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 900 mg PO TID 6. Metoclopramide 10 mg PO QAC/HS PRN nausea 7. Mirtazapine 45 mg PO HS 8. Multivitamins W/minerals 1 TAB PO DAILY 9. PredniSONE 5 mg PO DAILY 10. Pyridoxine 50 mg PO DAILY 11. Ranitidine 150 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Senna 1 TAB PO BID constipation hold if has loose bowel movement 14. Polyethylene Glycol 17 g PO DAILY hold if has loose bowel movement 15. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting 16. Morphine SR (MS Contin) 15 mg PO Q12H for pain not taking 17. Morphine Sulfate IR 7.5-15 mg PO Q6H:PRN breakthrough pain not taking, but has 18. Ferrous Sulfate 325 mg PO DAILY 19. detemir 34 Units Bedtime Discharge Medications: 1. Calcium Carbonate 500 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 900 mg PO TID 4. Metoclopramide 10 mg PO QAC/HS PRN nausea 5. Mirtazapine 45 mg PO HS 6. Polyethylene Glycol 17 g PO DAILY hold if has loose bowel movement 7. Pyridoxine 50 mg PO DAILY 8. Ranitidine 150 mg PO BID 9. Senna 1 TAB PO BID constipation hold if has loose bowel movement 10. Vitamin D 1000 UNIT PO DAILY 11. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting 14. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Enoxaparin Sodium 120 mg SC Q12H RX *enoxaparin 120 mg/0.8 mL Inject one syringe subcutaneous every twelve (12) hours Disp #*60 Syringe Refills:*2 16. detemir 20 Units Bedtime 17. Lactulose 30 mL PO BID:PRN constipation RX *lactulose 10 gram/15 mL 30 mL by mouth [**Hospital1 **]:PRN Disp #*30 Container Refills:*0 18. Morphine Sulfate IR 7.5-15 mg PO Q6H:PRN breakthrough pain RX *morphine 15 mg 0.5-1 tablet(s) by mouth q6h:PRN Disp #*60 Tablet Refills:*0 19. PredniSONE 10 mg PO DAILY RX *prednisone 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Adrenal insufficiency Secondary diagnosis: Metastatic melanoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 4886**], It was a pleasure taking care of you in the hospital. You were admitted with fatigue. Initially, we had thought this was partially from dehydration and in part from your anemia. We gave you one unit of blood and fluids. You had issues with a fast heart rate during your hospital stay, although this seems to be a chronic issue. We changed your diltiazem to metoprolol to better control this. Despite these treatments, you continued to feel vague symptoms of nausea, abdominal pain and fatigue. We did a test to measure a hormone called cortisol and found it to be relatively low. When we increased your prednisone (which acts in a similar way to cortisol), your symptoms seemed to dramatically improve. During your stay, you also developed a blood clot in your left leg. We are treating this with the blood thinner Lovenox, which is the injection you are receiving in your abdomen. Your blood sugars were running low while you were here, so we decreased your Levemir dosing to 20u at night (instead of 34u). Please check your blood sugars three times a day and bring these numbers to your [**Last Name (un) **] provider at your [**Name9 (PRE) 702**] appointment. If your sugars are >200 but <300, you can increase your levemir to 24u, if they're >300 but <400 you can increase to 28u, and if they're >400 you should return to 34u. If your sugars are lower than 80 you should decrease your dose to 18. With improvement of your fatigue, abdominal pain and nausea, we discharged you on day 12 of your hospital stay. Please follow-up at the appointments listed below. You should see your endocrinologist ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) to adjust your prednisone as needed. We would like you to see the GI doctors to possibly get a colonoscopy because of the positive test for blood in your stool. Please see the attached list for any changes to your home medications. Followup Instructions: Department: Endocrinology, [**Last Name (un) **] Diabetes Center Name: Dr. [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) **] When: Tuesday [**2150-8-25**] at 3:30 PM Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3402**] Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2150-8-26**] at 9:00 AM With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2150-9-4**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2150-8-26**] at 2:30 PM With: [**Year (4 digits) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2150-8-26**] at 2:30 PM With: [**Name6 (MD) **] [**Name8 (MD) 7880**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Cardiology Appt: [**2150-8-31**] 11:20a With: [**Doctor Last Name **] Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] Completed by:[**2150-8-21**] Admission Date: [**2150-8-25**] Discharge Date: [**2150-8-30**] Date of Birth: [**2095-9-11**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Optiray 350 Attending:[**First Name3 (LF) 5141**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Colonoscopy [**2150-8-28**] History of Present Illness: 54 y/o F with history of melanoma with mets to lung, diaphragm, retroperitoneum, small bowel and colon not currently on chemotherapy, recent LLE DVT diagnosed [**8-18**] now on lovenox, presenting with 2 day history of bright red blood per rectum. She was recent admitted to [**Hospital1 18**] with fatigue, found to have anemia thought secondary to disease of chronic inflammation. She had been transferred to [**Hospital1 **] from OSH where had had gauic positive stool although non noted at [**Hospital1 18**]. Her fatigue was thought to be secondary to hypophysitis and her prednisone was increased to 10mg and she was discharged. She notes that her fatigue has improved somewhat, she continues to have intermittent right lower abdominal pain likely secondary to metastatic disease, controlled with p.o morphine. Over the last two days she has noticed worsening in her right lower quadrant pain. Yesterday she had 3 episodes of loose stools, on the third one she noted some blood clots. Today, she noted watery black stool with bright red blood and clots. She denies feeling light headed, having abdominal pain at the time. Came to ED where initial vitals were BP110/73 HR 100 t97.9 RR 18 100% RA. In anticipation of potential IR intervention,solumedrol 125mg IV, benadryl 50 was given as well as morphine 5IV for RLQ pain, zofran 2mg for nausea. On arrival to the MICU, pt found to be normotensive, comfortable on room air with mild RLQ pain. No further episodes GI bleeding Past Medical History: PAST MEDICAL HISTORY: Metastatic melanoma with known lung metastases Hypopituitarism secondary to ipilimumab tx Diabetes Mellitus Type 2 Hypertension Atrial fibrillation s/p ablation [**2149-2-5**] h/o DVT &PE s/p IVC filter [**2144**] h/o catheter-associated IJ thrombus [**2150-2-11**] s/p Cholecystectomy s/p tonsillectomy s/p C-section Thyroid nodule Osteoporosis Vitamin D deficiency PAST ONCOLOGIC HISTORY: - [**2140**]: diagnosed with right shoulder melanoma - [**2145-3-21**]: presented with hemoptysis, bilateral DVT, PE, lung mass biopsy revealed metastatic melanomam. IVC filter placement. - [**2145-5-21**]: underwent chemotherapy. Disease progression noted. - [**2145-9-20**]: enrolled in MDX-010/ipilimumab study - [**2146-5-22**]: CT evidence of disease progression with enlarging right paratracheal and retrocaval nodes - [**2146-6-21**]: restarted MDX-010, completing 3 cycles of therapy. Follow-up CTs showed minimal interval progression - [**2147-9-21**]: began ipilimumab on compassionate access trial, found to have autoimmune hypophysitis [**1-22**] ipilimumab and protocol was subsequently discontinued. She was found not to have the specific BRAF mutation. - [**2148-3-21**]: started phase 1 RAF265 clinical trial with dose reduction x2 for nausea, vomiting and neuropathy. - [**2149-2-5**]: therapy held due to atrial flutter unrelated to study drug, requiring cardiac ablation on [**2149-2-11**]. Drug could not be restarted. She was taken off study on [**2149-2-19**]. - [**2149-3-12**]: started trial of sorafenib and bortezomib. Completed 6 cycles of therapy. - [**2149-12-1**]: CT showed disease progression with peritracheal pleural-based and retroperitoneal metastatic foci with several new right pleural and diaphragmatic foci. Treatment options were discussed and high-dose IL-2 was chosen given the small chance of a durable complete response. She passed eligibility testing with PFTs notable for FEV-1 1.66 or 71% predicted. - [**0-0-0**]: Admitted for first cycle of IL-2. She received [**8-4**] doses on week 1, complicated by tachycardia and pulmonary edema. - [**2150-2-11**] - [**2150-2-14**]: Admitted with left neck pain, found to have catheter-associated IJ thrombus, treated with Lovenox Social History: Married, lives in [**Hospital1 392**]. She has 3 adult children. She used to do clerical work but has not recently been employed. Remote smoking history. No history of EtOH abuse, no drug use. Family History: Mother had breast cancer and died of PE at age 62. Father died of an MI at 61. One brother with a dx of melanoma, which was completely excised. Physical Exam: Admission exam T 98.3 BP:120/74 HR: 105 02: 94% GENERAL: pleasant obese woman, lying in bed, in NAD HEENT: PERRLA, anicteric sclera, dry membranes CARDIAC: regular rhythm, tachycardic to 100s LUNG: CTAB, no wheezes or rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: obese, soft, nondistended, +BS, moderately TTP in RLQ EXTREMITIES: moving all extremities well, no LE edema, no obvious deformities NEURO: grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM Vitals - T:98.6 BP:130/80 HR:106 RR:20 93% RA GENERAL: NAD today HEENT: oropharynx clear, anicteric, JVP difficult to assess CARDIAC: S1/S2,reg rhythm, increased rate, no murmers, gallops LUNG: no wheezing this AM, decreased BS right base. No crackles. ABDOMEN: nondistended, +BS, nontender, no rebound/guarding EXTREMITIES: no cyanosis, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: face symmetric, tongue midline, moves all extremities without gross deficit, sensory exam grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Labs on admission: [**2150-8-25**] 03:19PM BLOOD WBC-8.6 RBC-3.17* Hgb-8.7* Hct-27.6* MCV-87 MCH-27.5 MCHC-31.5 RDW-15.7* Plt Ct-519*# [**2150-8-25**] 03:19PM BLOOD Neuts-85.0* Lymphs-11.4* Monos-2.9 Eos-0.5 Baso-0.3 [**2150-8-25**] 02:40PM BLOOD PT-13.0* PTT-40.0* INR(PT)-1.2* [**2150-8-25**] 02:40PM BLOOD Glucose-86 UreaN-15 Creat-0.9 Na-138 K-3.9 Cl-100 HCO3-29 AnGap-13 [**2150-8-25**] 02:40PM BLOOD ALT-15 AST-23 AlkPhos-80 TotBili-0.4 [**2150-8-25**] 02:40PM BLOOD Albumin-3.5 Calcium-9.7 Phos-2.2*# Mg-1.7 [**2150-8-25**] 02:48PM BLOOD Lactate-1.4 Hematocrit trend [**2150-8-25**] 03:19PM BLOOD WBC-8.6 RBC-3.17* Hgb-8.7* Hct-27.6* MCV-87 MCH-27.5 MCHC-31.5 RDW-15.7* Plt Ct-519*# [**2150-8-26**] 04:16AM BLOOD WBC-6.6 RBC-3.18* Hgb-8.6* Hct-27.0* MCV-85 MCH-27.2 MCHC-32.0 RDW-15.9* Plt Ct-448* [**2150-8-26**] 12:43PM BLOOD Hct-26.6* Brief Hospital Course: HOSPITAL COURSE Ms. [**Known lastname 4886**] is a 54 year old woman with widely metastatic melanoma to lung and retroperitoneum treated with ipilimumab c/b autoimmune hypophysitis, history of DVT/PE (on lovenox + s/p IVC filter in [**2144**]), now with acute onset of BRBPR. She was recently admited for vague symptoms of nausea/vomiting and abdominal pain. She was found to have inappropriate cortisol response and her home prednisone was uptitrated with resolution of symptoms. During that admission it was found that she had a LLE DVT and was started on Lovenox. Throughout this admission she had been constipated so she was sent home on a strong bowel regimen. She returned to the ED after one bowel movement with dark clots and one with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Lovenox was held. CTA was performed and did not show active extravasation and that the IVC filter was still in proper position. She was admitted to the ICU and then the floors after her hematocrit and vitals were stable. A colonscopy showed a non-bleeding mass in the ascending colon, likely metastasis. Given that pt had an IVC filter and that she was perhaps to start on a biologic therapy trial (for which she cannot be on anticoagulation for inclusion) it was decided to hold anticoagulation. ACTIVE ISSUES # GI bleed: Lower GI bleed more likely given [**Last Name (NamePattern1) **], brisk UGI bleed less likely. Bowel ischemia unlikely given lactate 1.4. Hematocrit did not show any significant drop from prior baseline levels. CTA was performed to look for active bleeding and showed no active extravasation and an IVC filter in proper position. Lovenox started on previous admission for LLE DVT was held. She was initially admitted to the ICU for monitoring and her hematocrits were stable throughout her stay. While in the unit, she was seen by the GI team who recommended preparation for colonoscopy to look for diverticular disease, AVMs, or any intervenable lesions. Subsequent colonoscopy revealed a non-bleeding mass in the ascending colon. # Thromboembolic disease: Given her history of recurrent DVT/PE and recent catheter-associated IJ thrombus, she has been on enoxaparin prior to this admission. She has an IVC filter that was placed in [**2144**]. Management of the balance of her bleeding and thromboembolic diease was discussed with pt and her family and it was decided that given her IVC filter and possible enrollment in a biologics trial for melanoma that did not accept patients on anticoagulation that she would go home without restarting Lovenox. # Metastatic melanoma: No active therapy at this time. Struggling with fatigue felt to be secondary to hypophysitis from ipilimimab therapy, anemia, and her malignancy. Increased doses of prednisone have been helpful for this. Currently being considered for study with Dr. [**Last Name (STitle) **]. INACTIVE ISSUES # Diabetes mellitus: On levemir and ISS at home. In house, she was continued on Lantus and ISS. TRANSITIONAL ISSUES # FULL CODE Medications on Admission: 1. Calcium Carbonate 500 mg PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Gabapentin 900 mg PO TID 4. Metoclopramide 10 mg PO QAC/HS PRN nausea 5. Mirtazapine 45 mg PO HS 6. Polyethylene Glycol 17 g PO DAILY 7. Pyridoxine 50 mg PO DAILY 8. Ranitidine 150 mg PO BID 9. Senna 1 TAB PO BID constipation 10. Vitamin D 1000 UNIT PO DAILY 11. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain 12. Multivitamins W/minerals 1 TAB PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting 14. Metoprolol Succinate XL 100 mg PO DAILY 15. Enoxaparin Sodium 120 mg SC Q12H 16. detemir 20 Units Bedtime 17. Lactulose 30 mL PO BID:PRN constipation 18. Morphine Sulfate IR 7.5-15 mg PO Q6H:PRN breakthrough pain 19. PredniSONE 10 mg PO DAILY Discharge Medications: 1. Metoprolol Succinate XL 100 mg PO DAILY 2. Calcium Carbonate 500 mg PO DAILY 3. Lactulose 30 mL PO BID:PRN constipation 4. Morphine Sulfate (Concentrated Oral Soln) 7.5-15 mg PO Q6H:PRN pain 5. Multivitamins 1 TAB PO DAILY 6. Ondansetron 4 mg PO Q8H:PRN nausea 7. Polyethylene Glycol 17 g PO DAILY 8. Mirtazapine 45 mg PO HS 9. PredniSONE 10 mg PO DAILY 10. Pyridoxine 50 mg PO DAILY 11. Ranitidine 150 mg PO BID 12. Senna 1 TAB PO BID:PRN constipation 13. Vitamin D 1000 UNIT PO DAILY 14. Metoclopramide 10 mg PO QIDACHS Nausea 15. Gabapentin 900 mg PO TID 16. Other 20 Units Bedtime 17. Docusate Sodium 100 mg PO BID 18. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN pain Discharge Disposition: Home Discharge Diagnosis: Non bleeding colonic mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to care for you. . You were brought to the hospital after a bloody bowel movement. You received a colonoscopy which revealed a colonic mass. We had a extensive conversation regarding the risks and benefits of anticoagulation with Lovenox and you decided to stop it for now. . We made the following changes to your home medication list: STOP LOVENOX . Please continue to take the rest of your home medications as you were before coming to the hospital. . Please follow up with the outpatient appointments below: Followup Instructions: . We have emailed Dr.[**Name (NI) **] office to schedule a follow up appointment,please call his office if you do not hear from them in 2 days. Office Phone: ([**Telephone/Fax (1) 16668**] . Department: CARDIAC SERVICES When: MONDAY [**2150-8-31**] at 11:20 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: FRIDAY [**2150-9-4**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2151-1-18**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2150-8-31**] Name: [**Known lastname 2601**],[**Known firstname **] E Unit No: [**Numeric Identifier 12076**] Admission Date: [**2150-8-25**] Discharge Date: [**2150-8-30**] Date of Birth: [**2095-9-11**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Optiray 350 Attending:[**First Name3 (LF) 12077**] Addendum: The patient's GI bleed was likely due to the metastatic melanoma to the ascending colon. It was not bleeding when visualized by GI during colonoscopy, but was the most likely source. The LLE DVT was subacute during this admission. Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 12078**] MD [**MD Number(2) 12079**] Completed by:[**2150-10-8**]

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icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

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19138, 19168

29967, 29967

24471, 24476

30672, 32529

23182, 23327

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23342, 24452

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4568, 4568

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14784, 14806

11515, 11757

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14740, 14763

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29982, 30094

20722, 22953

22969, 23166