ChanBeDu/relevant_section_length · Datasets at Hugging Face

16,985

138,680

7120

Discharge summary

report

Admission Date: [**2158-5-15**] Discharge Date: [**2158-5-18**] Date of Birth: [**2116-4-17**] Sex: F Service: MEDICINE Allergies: Sulfamethoxazole / Dapsone / Nevirapine Attending:[**First Name3 (LF) 2297**] Chief Complaint: respiratory distress, abdominal distention, facial swelling Major Surgical or Invasive Procedure: thrombolysis History of Present Illness: HPI: 42 year old woman with AIDS (By CD4 criteria, CD4 of 42), and a high-grade AIDS-related lymphoma (plasmablastic lymphoma with the initial site of disease in the left maxillary sinus). She was recently hospitalized here for progressive odynophagia and possible "pill esophagitis" and/or acid reflux. by EGD (biopsy results pending), and comes back to the ED with dyspnea, pain in the extremities (legs > arms), swelling of the right jaw, and abdominal distension. Per PCP note patient describes symptoms prior to arriving to Ed and after recent discharge as: "she started to notice swelling of the right lower jaw that, after being recumbent for a while (such as over night) extends up the right side of her face to close the right eye. The swelling tends to go down if she is upright for a while, but she still has painful swelling over the right side of the mandible. About 48 hours ago, she started to have swelling of the abdomen, with a feeling of being "bloated" and this is making it difficult to eat much. She has had increasing dyspnea over the past 24 hours, and she is not sure if this is because of the abdominal distension making it difficult to expand her lungs. However, with short walks, even across a room, she feels very dyspneic and "weak" and has to sit down to rest." She also reports having increasing pain in the extremities, more the legs (thighs and knees) and the upper extremities. This discomfort is "achy" and does not seem to worsen or get better with movement or rest. . When patient arrived to the ED was found to have temp of 101.2, have a distended abdomen that was diffusely tender. She also was hypotensive with SBP 80-90s and tachycardic with HR 120s. She then went into SVT that terminated with vagal maneuvers. She got a dose of dilaudid and her SBP dropped to 70s however patient mentating normally. She was given vanc/levo/flagyl in the ED for concern of infection although no clear source identified. Patient then underwent CT torso which revealed multiple pulmonary emboli including left main artery, right atrium extending into SVC, cannot exclude extension into IVC, focal clot within pulmonary veins as well; abdominal and pelvic ascites, moderate large right pleural effusion. She was then started on heparin gtt in the ED. Radiology felt that patient may benefit from cardiac MRI to differentiate between mass vs clot. Cardiac surgery evaluated patient who recommended patient get echo to assess for RV collapse, which will be done in am. Vascular also consulted in ED and recommend LENI to rule out DVT and possible IVC filter placement. Patient hypoxic with O2Sat 90% on RA, put on NRB with O2Sat 97%. ABG on NRB was 7.48/29/81; in the ED also tachycardic to 120-140s, appears to be sinus tachy. Patient also getting boluses of IVF in the ED. . Past Medical History: 1. AIDS (CD4 63 and VL 7,290 in [**1-15**])- multiple antiretroviral meds. Adherance has never been an issue. Hx of highly resistant viral strains. Thought to have gotten HIV from blood transfusion in the [**2131**]'s. 2. high-grade AIDS-related lymphoma diagnosed in [**4-14**](plasmablastic lymphoma with the initial site of disease in the left maxillary sinus s/p chemotherapy in [**8-14**] infusional with a regimen of [**Hospital1 **], complicated by a severe pneumonia in the left lung requiring intubation, and then a left-sided empyema requiring several weeks of a chest tube. She had a recurrence of the lymphoma in the sinus, and has had radiation therapy to the tumor. She has areas in several bones that are hypermetabolic on PET scan 3. Thrombocytopenia- responded [**Doctor Last Name **]-[**Doctor Last Name **] (antiD-globulin) 4. Lung nodules - 1.5 cm cavitary nodule in the left upper lung in 9/[**2156**]. She had a CT scan of the chest in [**3-/2157**] that revealed a 13-mm cavitary lesion in the left upper lobe that had remained stable, and stable nodule in the other lung fields: 3-4 mm noncalcified nodules in the right upper lobe, lingula and right middle lobe remain stable. Social History: SHx: Notable for having been born in [**Country 2560**] and she came to the US at the age of 17. She had the surgery of her mandible the following year and received blood transfusion. She lives in [**State 3914**] on a farm with her husband and 2 sons (8 and 6 years old), and they own a restaurant. Family History: FMHx: Notable for her mother who is in her 70's and has hypertension. Her father died 2 years ago, at the age of 69 of lymphoma. She has 3 sisters, one of whom had problems with ethanol abuse. No other disorders that she is aware of run in her family. Physical Exam: PE: T 97.9 HR 107 BP 98/59, 76-99/50-62 RR 26 O2Sat 94-98 on 100% NRB Gen: comfortable, + resp effort, tachypneic Heent: PERRL, EOMI, OP clear, MMM; palpable mass on right mandible Neck: no LAD Chest: Decreased BS on R side, + exp wheezes Cardiac: Tachy, no murmurs appreciated Abd: soft, distended, + shifting dullness; no hepatomagaly appreciated, + BS Ext: no edema, skin abrasion on L knee Neuro: AAOx3 Pertinent Results: [**2158-5-15**] 01:07PM K+-3.8 [**2158-5-15**] 01:00PM GLUCOSE-121* UREA N-14 CREAT-0.8 SODIUM-137 POTASSIUM-6.7* CHLORIDE-102 TOTAL CO2-20* ANION GAP-22* [**2158-5-15**] 01:00PM ALT(SGPT)-52* AST(SGOT)-143* CK(CPK)-112 ALK PHOS-69 TOT BILI-1.1 [**2158-5-15**] 01:00PM CK-MB-2 cTropnT-0.03* [**2158-5-15**] 01:00PM ALBUMIN-3.4 [**2158-5-15**] 01:00PM WBC-12.5*# RBC-4.39# HGB-12.4# HCT-38.8# MCV-88 MCH-28.3 MCHC-32.0 RDW-19.1* [**2158-5-15**] 01:00PM NEUTS-81.7* LYMPHS-12.6* MONOS-5.4 EOS-0.1 BASOS-0.1 [**2158-5-15**] 01:00PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ [**2158-5-15**] 01:00PM PLT COUNT-369 [**2158-5-15**] 01:00PM PT-14.1* PTT-24.7 INR(PT)-1.3* . ct abdomen: IMPRESSION: 1. Multiple filling defects that could be consistent with either primary cardiac tumor versus tumor thrombus versus de [**Last Name (un) 11083**] bland embolus located within the left pulmonary artery, the right atrium extending into the superior vena cava, possibly within the inferior vena cava, and within the left atrium. The differential includes a possible primary cardiac tumor centered in the left atrium and further assessment could be performed by cardiac MRI. No pulmonary emboli is present within the right lung. . 2. Moderate-to-large right pleural effusion. Smaller left pleural effusion. 3. Incompletely imaged left groin hematoma versus enhancing mass measuring 5.4 x 2.5 cm. Recommend CT of the left lower extremity for further assessment. 4. Left upper lobe lesion as described above. 5. Abdominal and pelvic ascites. 6. Thickening of the bladder wall which could be consistent with cystitis. Clinical correlation is recommended. . Lenis: IMPRESSION: Non-occlusive thrombus within the proximal right superficial femoral vein that does not extend either superiorly or inferiorly. . echo [**5-16**]: Conclusions: The left atrium is normal in size. A large (at least 2 cm x 2 cm) mass is seen in the right atrium, prolapsing into the right ventricle during diastole. Its attachment is not well-defined, but it appears to originate in the inferior vena cava, or near its insertion into the right atrium. The mass is partially obstructing the RV inflow, creating severe functional tricuspid stenosis. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is mildly dilated. Right ventricular systolic function is 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. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. IMPRESSION: Large right atrial mass with partial right ventricular inflow obstruction. Severe functional tricuspid stenosis. Preserved global and regional biventricular systolic function. Small pericardial effusion without tamponade. Brief Hospital Course: 1) R heart/pulm lymphoma vs clot: Chest CT in ED showed extensive obstruction of IVC/SVC, RA/RV by tumor or clot. On admission to MICU, she was started on Heparin IV, and thrombolytics were not immediately given until her respiratory distress increased. TEE revealed 2x2 cm mass in RA prolapsing into the RV during diastole, creating severe functional TS. LVEF>55%. LENIs showed non-occlusive clot/mass in R superior femoral vein. IVC filter not placed given the respiratory distress and unstable hemodynamics. Twelve hours after admission to the ICU, she received thrombolytics (Alteplase 100 mg) but dyspnea did not improve and SBP continued to hover in the 90s, which supports the malignant nature of the mass rather than thrombosis. PET at [**Hospital **] [**Hospital3 26522**] center showed light up in long bones, R heart area, and L groin area. Flow cytometry on this admission was nondiagnostic. She received Decadron 10mg Q6H for the likely lymphoma. . After a family discussion that no other medical/surgical interventions would be effective, comfort measures only were deployed starting on [**5-17**]. She received a morphine drip, titrated to minimize her pain and discomfort. . Deceased: Patient expired from heart failure in the early morning hours of [**5-18**]. . 2) Respiratory Distress: Given the R heart outflow obstruction, she had poor pulmonary perfusion. She was tachypneic throughout her admission, but Oxygen sats remained above 90% on 100% NRB. . 3)Tachycardia - Patient appears to be sinus tachy from R heart outflow obstruction (tumor vs clot). She was not rate controlled since this is normal compensation and she did not experience chest pain or palpitations. . 4) Oliguria: She received continuous IV fluids (3amps HCO3 in D5W) to maintain max effective arterial volume in setting of preload dependence and organ hypoperfusion, . She had received 8 liters by the time she left the ICU, but her urine output remained low, 0-30 cc/hr. Her Cr rose to 1.6 from a baseline of 0.9, likely prerenal with iscehmic ATN. . 5)Anion gap acidosis: Due to hypoperfusion, her lactate increased from 3.4 on admission to 4.9 on HD 2, and she had an AG of 18. She received more than 8L of 3amps HCO3 in D5W. . 6) LE Mass/Hematoma - Patient found to have hematoma/? mass of left groin on CT torso. This was felt to be either tumor or clot and further eval was not undertaken on this admission. 7) Fever/Leukocytosis - Low grade temp on arrival with mild leukocytosis, but shortly defervesed. Question of dental abscess from dental work that had been drained once by her dentist. No other obvious source of infection based on history/phys, and exam. Leukocytosis most likely from stress and recent steroid taper. She did not receive antibiotics. . 8) HIV - Patient was on salvage therapy, has been off HAART for weeks now given trouble taking PO meds (recent esophagitis). Per patient was to restart HAART as outpatient. Her last CD4 count was 47 on [**2158-5-9**], and viral load 7290 ([**2158-1-9**]. She did not start HAART during admission, but did receive Mepron for PCP/Tox prophylaxis and Azithromycin for MAC prophylaxis given her low CD4 count. . 9) Abdominal discomfort: Abdomen did not show any acute process, but diffuse abd discomfort, likely from ascites. She was not tapped given low suspicion for SBP and high risk of bleeding on heparin. Medications on Admission: 1. Atovaquone Suspension 750 mg PO BID 2. Hydromorphone 2 mg q3-4h as needed 3. Nystatin 100,000 units 4x/day 4. Pantoprazole 40 mg daily 5. Sucralfate 1 gram 4x/day Discharge Disposition: Home with Service Discharge Diagnosis: Deceased from heart failure induced by R heart/pulmonary tumor from AIDS related lymphoma. Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

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Discharge summary

report

Admission Date: [**2191-6-18**] Discharge Date: [**2191-7-7**] Date of Birth: [**2121-8-17**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old female who presented on [**6-17**] with generalized abdominal pain of two weeks duration. The pain was localized to the left lower quadrant and left upper quadrant. The patient also had nausea and vomiting times one prior to admission, increased abdominal girth with increased shortness of breath. The patient denied any fevers or any chills, any change in bowel movement. The patient was initially seen and diagnosed with a diverticulitis. A CT revealed possible perforation with abscess. The patient was admitted to surgery initially and placed on NPO and antibiotic therapy. The patient initially started on Ceftriaxone, Flagyl but when an IV was unable to be obtained the patient was switched to po antibiotics, this time on Levofloxacin and Flagyl. These antibiotics were started on [**6-23**]. The patient subsequently developed worsening urine output and was transferred to the SICU for better fluid management. A Swan Ganz catheter was floated in the SICU and patient received aggressive diuresis and aggressive fluid monitoring. The patient recovered from symptoms of sepsis and a repeat abdominal CT revealed a decrease in the size of the abscess and a small fluid collection that was not deemed drainable. The patient improved while in the SICU and was transferred out and then transferred to the Acove Medicine Service for further medical management and placement issues. PAST MEDICAL HISTORY: Degenerative joint disease, status post left total knee replacement in [**2185**], hypertension, status post childhood head injury with residual cognitive deficits and right side weakness. Chronic renal insufficiency. Anemia. GERD. Congestive heart failure. Hypothyroid. Status post appendectomy. MEDICATIONS ON TRANSFER: Tylenol prn, Hydralazine 10 mg po qid, Lopressor 50 mg po bid, Flagyl 500 mg po tid, Levofloxacin 500 mg po q day, Morphine 2 mg subcutaneously q 4 hours prn, Ampicillin 2 gm IV q 6 hours. ALLERGIES: Biaxin. SOCIAL HISTORY: The patient lives in a residence for elderly, homeless women. The patient has a good resident contact, [**Name (NI) 6480**] [**Name (NI) 11907**] [**Telephone/Fax (1) 11908**] who knows the patient very well. The patient denies any smoking or alcohol use. PHYSICAL EXAMINATION: On transfer, temperature 97.5, pulse 84, respirations 24, blood pressure 140/90, O2 sat 92% on room air, 99% on two liters. Generally the patient is alert and oriented, resting, mild shortness of breath, in no apparent distress. Pupils equal, round and reactive to light. Extraocular movements intact. Normocephalic, atraumatic. Mucus membranes moist. Oropharynx clear, no evidence of thrush. Neck supple with 2+ carotids without any bruits, no JVD, no lymphadenopathy, no thyromegaly. Chest was significant for bibasilar crackles and decreased breath sounds throughout. Cardiac was regular, normal S1 and S2 without any murmurs, rubs or gallops. Abdomen was soft with normal bowel sounds, non distended. Patient has had mild tenderness in the left lower quadrant without any rebound or guarding. Extremities without any clubbing or cyanosis. The patient had 1+ lower extremity edema bilaterally and 1+ non pitting edema of the right wrist. Neuro exam, patient was alert and oriented, cranial nerves II through XII intact, strength 4/5 and symmetric, reflexes [**12-25**]+ at the biceps and brachioradialis and symmetric. Lower extremity reflexes were not tested given presence of compression boots. Patient's sensation was grossly intact. HOSPITAL COURSE: 1. History of diverticulitis, status post transfer from surgery. The patient was diagnosed with diverticulitis via CT on admission. The patient was treated medically with antibiotics, Levofloxacin, Flagyl, Ampicillin. The patient will likely need a full four week course of antibiotics for prevention of worsening diverticulitis. The patient has subsequently improved symptomatically and will likely not need surgical intervention. The patient was initially npo but has since been advanced to a full diet. At time of discharge the patient is tolerating full diet. The patient was also placed on Colace and Senna for possible question of ileus vs constipation. The patient has been having regular bowel movements since bowel regimen was added. 2. The patient has a history of congestive heart failure. During the course of the hospital stay the patient was continued on Lopressor 50 mg po bid. Hydralazine was discontinued and the patient was initially started on Captopril at 6.25 mg po tid. The patient's blood pressure and pulse has been tolerating and Captopril has been titrated up and is currently at 25 mg po tid with a target max of 50 mg po tid. 3. History of chronic renal insufficiency. The patient has a baseline creatinine of 1.7 and 1.9. The patient's creatinine while hospitalized was significantly below that at 1.1 to 1.4. With the recent addition of the ACE inhibitor and increasing of the dosages it is important to continue to monitor the creatinine on an outpatient basis. 4. History of anemia. The patient is guaiac negative. The patient's hematocrit was stable throughout the hospital stay and stable at the time of discharge. 5. Physical therapy. The patient received a physical therapy consult who found the patient to be extremely weak and necessitated max assist to chair. Weakness likely secondary to deconditioning since patient has been in the hospital for 18 days. The patient was recommended to go to a subacute rehab facility prior to returning to home. CONDITION ON DISCHARGE: The patient is stable at time of discharge. DISCHARGE STATUS: The patient will be discharged to a subacute rehab facility for further rehab work-up secondary to deconditioning while in the hospital. The patient will eventually likely be able to return back to her resident facility. DISCHARGE DIAGNOSIS: 1. Diverticulitis with possible perforation. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4236**] Dictated By:[**First Name (STitle) 11909**] MEDQUIST36 D: [**2191-7-6**] 15:53 T: [**2191-7-6**] 18:32 JOB#: [**Job Number 11910**]

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Discharge summary

report

Admission Date: [**2147-12-8**] Discharge Date: [**2147-12-27**] Date of Birth: [**2093-8-14**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: R IPH, LOC Major Surgical or Invasive Procedure: [**2147-12-8**]: Right Craniectomy, embolization of AVM, and evacuation of right IPH History of Present Illness: This is a 54 year old female who was in her usual state of health until she was found by upstairs neighbors after they heard a loud noise. The patient reported that she had run into the door, which caused her left eye ecchymosis the day prior. EMS transported patient from home to [**Hospital1 18**] ER. Upon arrival she was quite somnolent and was intubated post-CT scan. Past Medical History: HTN, AVM(known hx), XRT for cervical CA, OP, s/p MVA 2yrs ago. Social History: Possible history of domestic abuse, lives alone, works at funeral home, has two daughters ages 30 and 21 Family History: family history of aneurysms Physical Exam: On admssion: O: T: 97.0 BP: 105/89 HR: 74 R 18 O2Sats 100% Gen: Somnolent; cervical hard collar in place HEENT: Normocephalic. Ecchymosis to left eye Neck: Hard cervical collar in place Extrem: Warm and well-perfused. Neuro: Mental status: Awake and somnolent, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus, left sided neglect. V, VII: Right facial droop VIII: Hearing intact to voice. IX, X: not tested [**Doctor First Name 81**]: not tested XII: Tongue midline without fasciculations. Motor: RUE and RLE [**3-27**]. LUE and LLE was antigravity but no initiation of movement on that side- apparent left sided neglect. On discharge: **** Pertinent Results: CT Head [**2147-12-13**]: Stable size and appearance of intraparenchymal and interventricular hemorrhage, pneumocephalus, post-surgical changes and frontal hematoma. Midline shift measures 12 mm today vs 10 mm today likely due to inter-scan variability given stable size of intracranial hemorrhage and edema. CT Head [**2147-12-11**]: 1. Postoperative changes of the right frontoparietal lobe as described. Increase in the amount of hypodensity within the surgical bed, concerning for evolving infarct with edema. 2. Unchanged 8-9mm leftward shift of midline structures, mass effect on the right lateral ventricle and adjacent sturctures including thalami, subthalamic regions and upper midbrain. 3. Slight interval enlargement of the lateral and third ventricles concerning for developing hydrocephalus. Unchanged intraventricular hemorrhage. MR [**Name13 (STitle) **] [**2147-12-9**]: 1. Straightening and reversal of the cervical lordosis. 2. There is no evidence of focal or diffuse lesions within the cervical spinal cord. 3. Multilevel disc degenerative changes throughout the cervical spine as described in detail above, more significant from C4/C5 through C6/C7 levels. No diffusion abnormalities are detected to suggest acute ischemic changes. MRA of Brain [**2147-12-9**]: There is no evidence of significant flow stenotic lesions, mild deviation of the vessels on the right, likely consistent with mass effect from the previously drained parenchymal hematoma. MRA of Neck [**2147-12-9**]: Patency of the carotid arteries and vertebral arteries with mild decreased signal at the origin of the left common carotid artery, possibly artifactual in nature. CT Head [**2147-12-9**]: 1. Expected postoperative changes in the right frontoparietal lobe as described above. Persistent shift of normally midline structures towards the left by approximately 10 mm, unchanged. 2. No significant change in intraventricular hemorrhage as described above. Small amount of hemorrhagic products again identified within the surgical bed, similar in appearance. CT Head [**2147-12-8**]: 5 cm right intraparenchymal hemorrhage in right temporal and parietal lobe with extension into right lateral ventricle. Midline shift of 14 mm, slight effacement of basal cisterns suggest early or impending central herniation. CT C-spine [**2147-12-8**]: Linear lucency through the right C4 transverse foramen. This would be unusual for an isolated injury; however, a non-displaced fx cannot be excluded. A CTA is recommended for assessment of [**Month/Day/Year 1106**] injury. CTA Head and Neck [**2147-12-8**]: 1. Arteriovenous malformation in the posterior right temporal lobe, supplied by branches of the distal right MCA and draining into the cortical veins and eventually into the superior sagittal sinus. 2. Similar size and appearance of large parenchymal hematoma and intraventricular hemorrhage as estimated on the contrast-enhanced study, and similar degree of mass effect, midline shift and central herniation. Brief Hospital Course: Ms. [**Known lastname 101911**] was admitted to the Neurosurgery service on [**2147-12-8**]. She was started on Dilantin. Following an acute decompensation and posturing in the ED, she was emergently taken to the OR on [**2147-12-8**] initially for a right craniectomy, followed by cerebral angiography and onyx embolization of rt parietal AVM. Immediately after, she was taken back to the OR where blood products and AVM nidus were resected-followed by cranioplasty. She was transferred to the ICU from the OR. While in the ICU she was closely monitored with q1hour neuro checks. On [**2147-12-9**], she had a NCHCT which showed expected post-operative changes, with persistent 10mm of midline shift. She also had an MRI/MRA of the head and neck [**2147-12-9**]. On [**2147-12-11**], she was noted to have a fixed and dilated right pupil. She was treated with mannitol bolus and hyperventilation to PCO2 to 35. She improved with this intervention. With this event, she underwent a Head CT which showed Slight interval enlargement of the lateral and third ventricles but was otherwise unchanged from previous studies. On [**2147-12-12**] her exam improved with her eyes opening to voice, following commands in the Right Upper and Right Lower extremities as well as the Left Upper extremity. She had brisk withdrawal on the Left Lower Extremity. Her pupils were equal round and reactive to light with hippus. On [**2147-12-13**] her mannitol dosing was decreased from 50mg q4hours to 50mg q6hours, and her exam remained stable, however she appeared to be more interactive. In the late am, she had a bronchospastic event(thought to be caused by carinal irritation), requiring Propofol for additional sedation, albuterol and racemic epinephrine. Her neuro exam remained stable despite this. She was further weaned of her ventilator requirements for goals of extubation. On [**2147-12-14**] she developed a fever to 104 overnight and was subsequently pancultured. On exam she was found to be less interactive, with eye opening to voice with light stimulation, but was not following commands otherwise, and withdrew to noxious stimuli in all 4 extremities. A STAT Head CT was obtained which was stable when compared to the prior study done on [**2147-12-13**]. Her mannitol was then decreased to 25g q6 hours with the intent to wean. On [**2147-12-15**] the patient's HCT was 21 and she received 1 unit of RBCs. Her exam was improved and she was following commands with the right side. Her mannitol was decreased to 12.5 Q6 hours. On [**2147-12-16**] her sputum culture grew coag + staph aureus so she was changed to Cipro. The patient's mannitol was decreased again and her exam remained stable. Her steroids were also weaned down. On [**2147-12-17**] the patient was noted to have bilateral vesicular lesions in the sacral region so antivirals were started empirically. ID was consulted for assistance in managing the pneumonia and the skin infection. Eventual cultures were negative for HSV but positive serum HSV for which she was treated for 7 days with Acyclovir. Mannitol was weaned to off. Her hematocrit was trended during her hospital course. No source of bleed was found for her initial drop in hct, however at that time the patient was receiving multiple amounts of IV fluids and it was thought to be dilutional. On discharge her hct was 24.8. She is being treated for a VAP pneumonia (dx [**12-16**]) a bronch showed Coag + staph for which she is being treated with IV Naficillin until [**1-8**] for a RLL pneumoia. Follow up CXR showed on [**12-25**] showed much improved pneumonia. All blood have been negative to date. She was treated for a UTI on [**12-8**]. She has been afebrile since [**12-23**] and had a PICC line placed for IV Naficilin on [**12-25**]. Social work has been involved due to question of abuse. A family member has brought this concern to a detective in the [**Location (un) 86**] Police Department. On [**2147-12-19**] she was transferred to the Step Down Unit. HSV culture was finalized on [**2147-12-20**] which was positive for HSV, negative shingles; Acyclovir for 7 days for treatment. She remained febrile and on [**12-21**] LENIS was done to rule a thrombus in the tibial vein, [**Month/Year (2) 1106**] surgery was consulted regarding question of treatment and need for IVC filter. Follow up ultrasound on [**12-25**] did not show any progression of the clot. They recommended following up in 2 weeks that appointment has been made. On [**12-25**] she had a transient increase in LFTs for which her Naficllin was changed to Vancomycin and a ultrasound of her liver showed a grossly normal son[**Name (NI) 493**] assessment of the abdomen with incidental note of hepatic cyst. Her LFTs returned to normal on [**12-26**]. Her hepatitis panel was negative. On discharge she was awake, alert and orientated X3 with no cranial nerve findings. She has some minimal left sided weakness noted. She was tolerating a regular diet and voiding without difficulty, final ua was negative. Medications on Admission: Unknown HTN, Unknown OP 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 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/SOB. 9. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheeze. 11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 13. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for SBP>160. 14. 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. 15. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 16. Vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns Intravenous Q 12H (Every 12 Hours) for 12 days: End [**1-8**]. Discharge Disposition: Extended Care Discharge Diagnosis: Right intraparenchymal hemorrhage Right AVM Respiratory Failure Hypertension Staph aureus pneumonia Urinary Tract Infection Bronchospasm Left lower extremity deep vein thrombus (posterior tibial vein) small pericardial effusion Left hemi neglect Left visual field cut HSV + Discharge Condition: Neurologically Stable Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair as normal as your staples are removed ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain YOU WILL NEED TO SEE YOUR PRIMARY CARE PHYSICIAN WITHIN TWO WEEKS OF YOUR DISCHARGE PLEASE CALL [**Telephone/Fax (1) **] FOR AN APPOINTMENT TO SEE DR. [**Last Name (STitle) **] / [**Hospital **] CLINIC / FOR FURTHER TREATMENT AND WORK UP OF YOUR DEEP VEIN THROMBOSIS (CLOT)....AN APPOINTMENT HAS BEEN MADE FOR YOU Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2148-1-5**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2148-1-5**] 10:45 YOU WILL NOT NEED TO FOLLOW UP IN THE INFECTIOUS DISEASE CLINIC. Completed by:[**2147-12-27**]

[ "519.11", "041.11", "V10.41", "348.5", "733.00", "518.81", "E849.7", "E912", "V10.3", "041.4", "453.42", "599.0", "997.31", "054.9", "401.9", "430", "933.1" ]

icd9cm

[ [ [] ] ]

[ "01.39", "01.24", "88.41", "38.93", "96.04", "02.12", "01.59", "96.6", "96.72", "39.72" ]

icd9pcs

[ [ [] ] ]

11805, 11820

5055, 10091

329, 416

12138, 12160

2018, 5032

13983, 14866

1043, 1072

10165, 11782

11841, 12117

10117, 10142

12337, 13960

1087, 1318

1992, 1999

279, 291

444, 819

1507, 1978

12174, 12313

841, 905

921, 1027

6,365

141,958

10659

Discharge summary

report

Admission Date: [**2200-4-29**] Discharge Date: [**2200-10-20**] Date of Birth: [**2129-2-20**] Sex: M Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: Gallstone pancreatitis Ventilator related pneumonia Pancreatic pseudocyst Major Surgical or Invasive Procedure: [**2200-5-6**] - exploratory laparotomy, cyst gastrostomy, G-tube placement, J-tube placement, Tube cholecystostomy [**2200-7-23**] - exploratory laparotomy, abdominal washout, cholecystectomy,, gastric tube replacement, liver biopsy, L chest tube thoracostomy, Cholecystostomy tube repositioning (IR) [**6-4**], [**6-23**] Tracheostomy ERCP [**7-2**], [**7-15**] EGD [**8-27**] Bronchoscopy and BAL picc line placement History of Present Illness: 71 y.o.M with history of HTN, aortic valve replacement, presented to [**Hospital 487**] hospital on [**3-23**] with complains of new onset of epigastric pain, radiating to the R side accompanied by Nausea and vomiting. At that time he had epigastirc and RUQ tenderness to palpation. His laboratory data showed increase in transaminases as well as in amylase and lipase. He underwent abdominal ultrasound which revelaed gallstones, normal CBD. Patient was addmittted for conservative mgt. on HD4 patient developed worsening of symptoms and some respiratory distress (CO2 retention). His CT scan revelaed some inflamation around the pancreas as well as pseudocyst. Patient status continued to detirorate requiring prolong ICU course with extubation and and reintubvation, nutritional support with TPN, attempt for pseudocyst drainage by IR (failed), tracheostomy. F/U CT of the abdomen revelaed huge pseudocyst and patient was transferred to [**Hospital1 18**] for further mgt Past Medical History: HTN CAD, s/p angioplasty s/p AVR [**7-6**] Respiratory failure tracheostomy Failure to thrive s/p R knee surgery ventilator associated pneumonia pancreatic pseudocyst Atrial fibrilation galstone pancreatitis picc line placement cholelithiasis COPD CHF sepsis Social History: lives with his wife former tobacco use Physical Exam: awake, following comands temp 99.1, hr 110, bp 147/71, 97% IMV HEENT: MM moist, no [**Last Name (LF) 34964**], [**First Name3 (LF) 13775**] EOMI, no lymphadenopathy Card: iregular heart rate, tachy, 2/5 SEM Resp: trach in place, bilateral ronchi and [**Doctor Last Name 34965**], occasional weezing Abd: soft, midly distended, non-tender to palpation, no bowel sounds rectal: no masses, guac negative Extr: warm, 2 plus edema both arms and legs Skin: no jaundice Pertinent Results: [**2200-4-29**] 09:38PM WBC-11.1* RBC-3.49* HGB-10.0* HCT-31.4* MCV-90 MCH-28.6 MCHC-31.8 RDW-14.6 [**2200-4-29**] 09:38PM PLT COUNT-292# [**2200-4-29**] 09:38PM PT-13.4* PTT-25.4 INR(PT)-1.2 [**2200-4-29**] 09:38PM DIGOXIN-0.6* [**2200-4-29**] 09:38PM ALBUMIN-2.5* CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-2.1 [**2200-4-29**] 09:38PM LIPASE-26 [**2200-4-29**] 09:38PM ALT(SGPT)-41* AST(SGOT)-48* LD(LDH)-180 ALK PHOS-364* AMYLASE-24 TOT BILI-1.1 [**2200-4-29**] 09:38PM GLUCOSE-116* UREA N-30* CREAT-0.3* SODIUM-137 POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-41* ANION GAP-7* [**2200-4-29**] 10:56PM freeCa-1.25 [**2200-4-29**] 10:56PM GLUCOSE-122* LACTATE-0.9 [**2200-4-29**] 10:56PM TYPE-ART PO2-95 PCO2-59* PH-7.44 TOTAL CO2-41* BASE XS-12 [**2200-4-29**] 11:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [**2200-4-29**] 11:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024 Brief Hospital Course: Neuro: Patient has received some sedation with Ativan and propofol during perioperative periods. Once recovered from that, he is alert, oriented to self and place. he can mouth words and maintain simple conversation. He showed some signs of depression and was started (and maintained) on Paxil his pain through the admission was controlled with morphine, fentanyl, Percocet Patient develop tremors in his arms and head, for which neurology consult was obtained and felt that it is an essential tremor, which does not need any treatment at this time Now: patient is alert, oriented to self and place, does not have pain, does not require any sedation, still has tremor Cardiovascular: through out patient admission he remained in atrial fibrillation, with heart rate 80-100, controlled with Lopressor, blood pressure stable, His repeated echocardiogram showed stable EF of 55%, mild CHF and mild left ventricular outflow obstruction. cardiology consult was obtained. [**6-22**] - patient developed LUE DVT associated with catheter, catheter was removed Respiratory: patient had BiPAP requiring sleep apnea at the base line. By the time of transfer to [**Hospital1 18**] he had prolong intubation course, with a few attempts for extubation which failed, eventually requiring tracheostomy (performed at the OSH). He had persistent pleural effusion left more then right, requiring tube thoracostomy, pleurocentesis, thoracic surgery consult. As patient condition improved, although he still has small bilateral pleural effusions, they are stable and do not require other interventions. His lungs show evidence of bilateral atelectasis, mild bibasilar collapse, evidence of edema. He has multiple attempts to wean him of the vent, however we are only able to wean him to CPAP with peep of 8 and PS of 14. he is receiving a few recruitment breaths every 6 hours. Had a few bouts of ventilator associated and aspiration pneumonia with proteus, klebsiella, Xanthomonas, yeast which are now controlled (please see ID section), had a number of bronchoscopy for evaluation and diagnosis. Patient has been evaluated by speech and swallow service a few times, however failed attempts to Passy-Mur valve placement Now: patient is stable on CPAP, bilateral rhonchi and wheezing. Tracheostomy tube has positional leak (not influencing his resp condition). receiving recruitment breaths q6hours. growing GNR from sputum culture, treated with meropenem Gastrointestinal: after admission patient underwent exploratory laparotomy with cyst gastrostomy, G, J and cholecystostomy tube placement, please see operative note for details. Patient tolerated procedure well, with prompt return of bowel function. His tube feedings were started through jejunostomy tube. His cholecystostomy tube was repositioned by OR. On [**7-14**], Mr [**Known lastname **] was noted to have an rising WBC to 16.8, continued low-grade fevers, rigors, and tachycardic into 140s in atrial fibrillation with systolic BP dropping as low as 70. Blood, peritoneal, central line, and sputum cultures were drawn. Because the cholecystostomy tube had not drained throughout the day, a T-tube study was performed to evaluate the position of the cholecystostomy tube. This study showed contrast extravasation from the indwelling cholecystostomy tube near its insertion. Mr [**Known lastname **] was taking into the OR for peritonitis, question of leaking cholecystostomy tube. where a cholecystectomy, abdominal washout, replacement of the G-tube, left tube thoracostomy, and liver biopsy were all performed. He was transferred to the N-SICU postoperatively. On [**7-15**], given his rising Tbili to 4.9, an ERCP was performed and a biliary stent was successfully placed in the common bile duct. follow up ERCP and EGD showed satisfactory position of the biliary drain [**2207-9-14**] patient again developed increase of the G-tube output with feculent looking material, evidence of aspiration with succus from the ET tube suctioned,respiratory distress, septic physiology. patient had G-tube study which showed that G-tube eroded into the transverse colon. Patient g-tube was pulled back to the area of the cyst, which seem to control patient's output. [**10-9**] - patient developed increased G tube output, he underwent g-tube study which showed well formed tract between colon and stomach(former area of pancreatic cyst, now almost completely obliterated) and g-tube advance too far into the colon. the tube was pulled back which mildly decrease its output. J tube in place. Now: patient's abdomen is soft, non-tender, j tube in place, tolerating tube feeds, G-tube in place output [**Telephone/Fax (1) 34966**] cc/day intermittently guac positive, no drainage around the tube. Bowel sounds present, normal BM on bowel regiment Liver: patient's liver showed evidence of steatosis for which hepatology and biliary surgery service consult and biopsy was obtained. There was a suspicion of portal hypertension, causing persistent ascites (s/p paracentesis x3), however portal vein pressure studies showed normal pressures. The conclusions of the team were that it was due partially due to supplemental nutrition, partially due to patient's severe medical problems. his liver enzymes normalized, patient is stable and does not require further interventions Renal/Urology: through out patient admission, patient renal function remained stable, Patient required multiple doses of Lasix and Diamox to help with perioperative diuresis and heart failure. He responds to diuretics well. He does remain very sensitive to dehydration with prompt decrease in urine output as well and increase in BUN. He had problems with phimosis requiring urology consult for Foley placement. Endocrine: patient has been maintained on NPH insulin in addition to regular insulin sliding scale. His blood glucose remains in 100-140 range. He developed hypothyroidism for which he has been on Levoxyl. No active concerns or issues Hematology: patient has anemia of chronic disease, as well as procedure associated anemia, requiring multiple blood transfusions. He is maintained on epoetin, iron and folate supplements. His hematocrit remains low but stable. No evidence of coagulopathy ID: Patient had a few episodes of septic etiology, associated with pneumonia as well as an episode of cholecystostomy tube dislodgement. through out his admission he developed vent associated pneumonia, aspiration pneumonia (grew klebsiella, proteus, Xanthomonas, yeast). his peritoneal washings grew yeast, Enterobacter. His antibiotic regiment was tailored to sensitivities, and he was on different occasion has been treated with vancomycin, Zosyn, Flagyl, Unasyn, Bactrim, fluconazole, meropenem, Kefzol. Infectious disease service followed patient for some time Now: G and J tubes are clean, with no evidence of erythema or cellulitis, his he has some secretions requiring ET suctioning, the most recent culture ([**10-12**]) is growing Xanthomonas. awaiting sensitivities Nutrition/FEN: patient arrived here on TPN, was switched to Tube feedings through feeding jejunostomy. His nutritional profile showed signs of malnutrition with albumin in 2.4-2.6 range. He has been tried on impact with fiber, Nepro, Respalor. He also had multiple electrolyte abnormalities including hyperkalemia, hyponatremia, hyperchloremia which normalized with switching to Respalor. As mentioned before, he is very sensitive to dehydration with prompt BUN increase. he does respond to free water boluses though J-tube Now: patient is on Respalor 2/3 strength @110 cc/hr, receiving 124 of protein and 2600 kcal per day. His electrolytes are in good control Activity: patient has been actively working with physical and occupational therapy services, with slow but steady improvement. He is moving bed to chair with assistance Medications on Admission: digoxin 0.25daily lovenox 40daily combivent 4 puffs daily lopressor 100bid protonix 40daily albuterol neb prn anzimet 12.5g [**Hospital1 **] haldol 1mg q 6 hours atrovent neb prn colace 100mg [**Hospital1 **] Discharge Medications: Meropenem 1000 mg IV Q8H (started [**10-12**]) Metoprolol 25 mg NG TID, HOLD MAP<65, HR<60, if hold call HO. Dolasetron Mesylate 12.5 mg IV Q8H:PRN Folic Acid 1 mg PO DAILY via J tube Ferrous Sulfate 300 mg PO DAILY via J tube Digoxin 0.25 mg PO QOD alternate with other dose Metronidazole 500 mg PO TID per jtube Digoxin 0.125 mg PO QOD alternate with 0.25 dose Insulin SC (per Insulin Flowsheet) Allopurinol 300 mg PO QD down J tube Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN Levothyroxine Sodium 300 mcg PO QD Metoprolol 5 mg IV Q 6 PRN Glycerin Supps 1 SUPP PR PRN Lansoprazole Oral Suspension 30 mg NG QD Epoetin Alfa 10,000 UNIT SC 3X/WEEK (MO,WE,SA) Multivitamins 5 ml PO QD Zinc Sulfate 220 mg PO QD Heparin Flush CVL (100 units/ml) 1 ml IV QD:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift Heparin 5000 UNIT SC TID Liothyronine Sodium 25 mcg PO QD Anusol-HC Suppository 1 SUPP PR [**Hospital1 **]:PRN rectal pain Bismuth Subsalicylate 30 ml PO TID Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO Q3H:PRN guaiac pos G tube Miconazole Powder 2% 1 Appl TP TID:PRN Albuterol-Ipratropium [**12-6**] PUFF IH Q6H:PRN Paroxetine HCl 40 mg PO QD crush with tf's Acetaminophen 325-650 mg PO/NG Q4-6H:PRN Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Gallstone pancreatitis Ventilator related pneumonia Pancreatic pseudocyst [**2200-5-6**] - exploratory laparotomy, cyst gastrostomy, G-tube placement, J-tube placement, Tube cholecystostomy [**2200-7-23**] - exploratory laparotomy, abdominal washout, cholecystectomy,, gastric tube replacement, liver biopsy, L chest tube thoracostomy, Cholecystostomy tube repositioning (IR) [**6-4**], [**6-23**] ERCP [**7-2**], [**7-15**] EGD [**8-27**] Bronchoscopy and BAL picc line placement HTN CAD, s/p angioplasty s/p AVR [**7-6**] Respiratory failure Failure to thrive s/p R knee surgery ventilator associated pneumonia pancreatic pseudocyst cholelithiasis COPD CHF sepsis aspiration pneumonia LUE DVT essential tremor anemia of chronic disease surgery associated anemia dehydration phimosis UTI hyperkalemia hyponatremia hypomagnesimis hypercalcemia [**Last Name (un) **]-gastro-pancreatic fistular depression hypothyrodism gerd pleural effusions R knee effuion - benign hyperglacemia Discharge Condition: stable Discharge Instructions: Wean off ventilator slowly as tolerated [**1-7**] recrutment breaths every 6 hours G-tube to gravity, please record output daily, dry dressing J-tube - for tube feedings, dry dressings Tracheostomy- expectant care hematocrit check q2-3 days BMP check q 2 days activity- bed to chair as tolerated, PT/OT eval and treatment Blood glucose checks qid, RISS Followup Instructions: f/u with Dr. [**Last Name (STitle) 957**] next week please call/come back if develop fevers, nausea, vomiting, abdominal pain, respiratory distress

[ "518.81", "276.3", "783.7", "998.59", "276.2", "276.1", "453.8", "275.2", "605", "789.5", "537.4", "427.31", "V46.11", "997.4", "244.9", "276.9", "790.6", "682.2", "719.06", "995.92", "311", "577.0", "486", "401.9", "414.01", "996.74", "599.0", "567.8", "536.42", "577.2", "276.7", "285.1", "275.42", "038.9", "574.11", "V55.0", "507.0", "496", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.09", "99.15", "45.13", "97.23", "51.22", "54.91", "43.19", "00.13", "99.04", "96.72", "51.03", "33.21", "51.10", "34.91", "50.11", "38.93", "97.02", "38.91", "46.39" ]

icd9pcs

[ [ [] ] ]

13064, 13138

3671, 11501

409, 831

14161, 14169

2671, 3648

14571, 14721

11760, 13041

13159, 14140

11527, 11737

14193, 14548

2188, 2652

296, 371

859, 1835

1857, 2117

2133, 2173

20,062

159,643

16189

Discharge summary

report

Admission Date: [**2141-3-13**] Discharge Date: [**2141-3-24**] Date of Birth: [**2080-6-12**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 60 year old white male has a known murmur since childhood. He is status post inferior myocardial infarction and anteroseptal myocardial infarction in [**2130**] and status post angioplasty at that time. Since [**2140-9-23**] he has had increased dyspnea on exertion and an echocardiogram in [**2140-12-24**], revealed an aortic stenosis with an 80 mm gradient and ejection fraction of 40% with apical akinesis. He had a cardiac catheterization in [**2140-12-24**] which revealed an ejection fraction of 40%, 1+ mitral regurgitation with moderate MAC, left anterior descending is 90% mid 90% lesion, diagonal 1 70% lesion and the right coronary artery had a mid occlusion. He is now admitted for aortic valve replacement and coronary artery bypass graft. PAST MEDICAL HISTORY: Significant for history of skin cancer of the left shoulder, history of hypothyroidism, history of hypercholesterolemia and history of hypertension and history of coronary artery disease, status post angioplasty in [**2130**], status post inferior myocardial infarction and anteroseptal myocardial infarction in [**2130**]. MEDICATIONS ON ADMISSION: Prozac 20 mg p.o. q. day; Synthroid .125 mEq; Pravachol 80 mg p.o. q. day; Toprol XL 100 mg p.o. q. day; Altace 5 mg p.o. q. day; Aspirin 325 mg p.o. q. day. ALLERGIES: No known drug allergies. FAMILY HISTORY: Significant for coronary artery disease. SOCIAL HISTORY: He smokes cigars occasionally and drinks alcohol occasionally. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: He is a well developed, well nourished male in no apparent distress. Vital signs are stable, afebrile. Head, eyes, ears, nose and throat examination, normocephalic, atraumatic, extraocular movements intact. Oropharynx was benign. Neck supple, full range of motion, no lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs, clear to auscultation and percussion. Cardiovascular examination, regular rate and rhythm, III/VI blowing murmur. Abdomen was soft, nontender, with positive bowel sounds, no masses or hepatosplenomegaly. Extremities were without cyanosis, clubbing or edema. Neurological examination was nonfocal. Pulses were 2+ and equal bilaterally throughout. HOSPITAL COURSE: He was admitted to the unit for heart failure workup. He was in stable condition on the unit and on [**2141-3-15**] he underwent aortic valve replacement, 24 mm [**Last Name (un) 3843**]-[**Doctor Last Name **], and coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, reverse saphenous vein graft to obtuse marginal 1 and diagonal. Crossclamp time was 93 minutes, total bypass time 131 minutes. He was transferred to the Cardiothoracic Surgery Recovery Unit in stable condition. He was extubated. He was started on an ACE inhibitor. Chest tubes were discontinued on postoperative day #2. He was transferred to the floor on postoperative day #2. He continued to have a stable postoperative course. He went into rapid atrial fibrillation and had to be anticoagulated and converted back to sinus rhythm. Electrophysiology was following him and wanted him to be seen in follow up on [**4-18**] at 2 PM, Tuesday with Dr. [**Last Name (STitle) **]. He was on Amiodarone and he had an increased TSH to 46 with a decrease T3 and free T4, so he was discontinued from the Amiodarone and his Levoxyl was increased to .150 mg. He needs his pulmonary function tests checked in two to three weeks. So, he was discharged to home on postoperative day #9 in stable condition. His laboratory data on discharge revealed hematocrit 33.1, white count 8,700, platelets 164. Sodium 135, potassium 4.2, chloride 98, carbon dioxide 27, BUN 16, creatinine 0.6 and blood sugar 104. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. b.i.d. 2. Percocet 1 to 2 p.o. q. 4-6 hours prn pain 3. Ecotrin 81 mg p.o. q. day 4. Coumadin 5 mg p.o. q.h.s. 5. Prozac 20 mg p.o. q. day 6. Levoxyl 150 mcg p.o. q. day 7. Atenolol 25 mg p.o. q. day 8. Altace 5 mg p.o. q. day 9. Lipitor 10 mg p.o. q. day FO[**Last Name (STitle) 996**]P: He will be followed by Dr. [**Last Name (STitle) 46214**] in one to two weeks and Dr. [**Last Name (Prefixes) **] in four weeks and Dr. [**Last Name (STitle) **] on [**4-18**]. Also the visiting nurses will check his coagulation screens on Monday, Wednesday and Friday and call them to Dr. [**Last Name (STitle) 46214**] and he is aware of that. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2141-3-24**] 16:04 T: [**2141-3-24**] 17:02 JOB#: [**Job Number 46215**]

[ "412", "424.1", "V45.82", "414.01", "276.7", "276.5", "997.1", "427.32", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.61", "35.21", "36.12", "36.15" ]

icd9pcs

[ [ [] ] ]

1513, 1555

3976, 4910

1299, 1496

2424, 3950

1694, 2406

1656, 1671

160, 924

947, 1272

1572, 1636

1,180

131,713

23028

Discharge summary

report

Admission Date: [**2130-3-12**] Discharge Date: [**2130-3-20**] Date of Birth: [**2047-9-1**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1674**] Chief Complaint: management of acute renal failure, metabolic acidosis and delirium Major Surgical or Invasive Procedure: right internal jugular central venous catheter left upper extremity PICC line (Peripherally inserted central catheter) History of Present Illness: This is an 82 year-old female with history of CRI not on HD who was transferred to our ED for hyperkalemia and acidosis, transferred to the ICU for management of acidosis and acute mental status changes. She fell at her NH yesterday, and was discharged back to her NH after a reportedly negative work up at [**Hospital3 7569**]. Today her son saw her at the [**Name (NI) **] and felt that her MS [**First Name (Titles) **] [**Last Name (Titles) 28495**]. At the OSH ED, labs showed K 6.7, Na 126, bicarb 7, and pH 7.11. They treated her hyperkalemia with Insulin/glucose, bicarbonate, and kayexelate. Ceftriaxone 1 g was given for a suspected UTI. She had a R TLC placed supraclavicularly, which had to be pulled back. In the ED vitals were HR 89 BP 127/48 RR 15 SpO2 95% RA CVP 9. CT Head showed no bleed. Haldol 2.5 mg IV was given for agitation. Renal was called and suggested possible HD. She was admitted to the ICU for AMS and acidemia. Her TLC had oozing around the sutures site and a pressure dressing was placed. On review of systems, the patient's son reports that she has increased facial swelling and leg edema over the last several days. +increased breathing x 1 day. +Poor energy; +poor appetite. In addition, she has been having episodes of muffled speech x 1 month, increasing in frequency. [**Name (NI) 1094**] son does not feel that her speech is slurred but rather that her mouth is dry. She sometimes gets confused, but usually knows her son. She does c/o dyspnea, +thirsty. Past Medical History: *chronic kidney disease Stage IV-V, not on HD [s/p RUE fistula placement [**8-14**]; Nephrologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 59393**] @ [**Hospital1 4494**]] *coronary artery disease *hypertension *GERD *Pulmonary fibrosis *rheumatoid arthritis: on MTX and prednisone *h/o PCP [**Name Initial (PRE) 11091**] [**2127**] *hypothroidism *depression and anxiety *breast cancer s/p L mastectomy *osteoarthritis *s/p bilateral total knee replacements *chronic pain syndrome *macular degeneration Social History: Lives at [**Hospital6 **] home. Lifetime non-smoker. Rare ETOH. Son [**Name (NI) **] very supportive & involved in her care, is her HCP/POA. Family History: +breast CA in daughter. Had a son who died in his 50s of appendiceal carcinoid. Physical Exam: VS: 99.8 132/93 101 15 98% RA General: Elderly woman, trembling and mumbling incoherently. Moaning in pain with any movement. HEENT: Mucous membranes dry, OP clear. Neck: Supple Chest: Moving air well b/l CV: S1, S2, RRR, +II/VI systolic murmur, no rub. Abd: Normoactive BS, NT, slightly distended. No masses or organomegaly. MS: dressing over skin tear on left forearm; winces with pain with movement of legs, arms b/l. No focal point tenderness. Ext: +palpable thrill on Right forearm over AV fistula. No cyanosis, no clubbing, trace pedal edema with 2+ dorsalis pedis pulses bilaterally. Marked deviation of all toes on both feet. Neuro: Oriented to "hospital." PERRL, follows commands but unable to maintain focus for conversation, closes eyes while talking and starts mumbling. +tremor of hands. Unable to test for asterixis b/c patient not cooperating. No clonus. Pertinent Results: OSH labs: Na 127, K 6.3 Cl 108, CO2 7 BUN 61, Cr 4.2 Glucose 110 Ca 9.2, Alb 3.8 WBC 12.7 Hct 31.1 Plt 389 ABG: 7.11/21/97 on room air UA: Cloudy with large leuks, neg nitrites, 3+ bact. OSH EKG: NSR, peaked T waves. CT Head: No hemorrhage. CXR: 1. No focal consolidation detected or evidence of pulmonary edema. However, the right lung base is limited given the overlying density. 2. Suggestion of biapical traction bronchiectasis. 3. Right humeral head deformity. 4. Clips in left axilla suggesting nodal dissection. . [**2130-3-12**] 9:15 pm URINE Site: CATHETER **FINAL REPORT [**2130-3-14**]** URINE CULTURE (Final [**2130-3-14**]): ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R PIPERACILLIN---------- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 82yo woman with complex PMH as above, with no known dementia, transferred from OSH with altered mental status, acute renal failure, hyperkalemia, and acidosis in the setting of UTI and hypovolemia. # Altered Mental Status: Multifactorial etiology, including uremia, severe metabolic acidosis, hypovolemia and UTI. Resolved during ICU course as underlying causes were addressed: acidosis was corrected with bicarbonate infusion, volume repleted, diuretics held, UTI treated. Head CT that was negative for bleed or hydrocephalus. TSH was WNL. # Acute on Chronic Renal Failure: presented at Cr 4.2, per outside nephrologist and renal team here, Cr at baseline is 2.5-3.0. Acute worsening was most likely due to volume depletion in the setting of high doses of diuretics and UTI. In ICU, treated acidosis, hyperkalemia, and hypovolemia as discussed, held diuretics. Note patient was on a 1200ml fluid restriction at the nursing home, which we did not continue here as her sodium level was within normal limits. Epogen increased. Renal consult team followed closely until creatinine returned to baseline around [**3-15**]. Patient has AV fistula as she may require dialysis in the future, though unclear if mature yet. Lasix was finally restarted on [**3-17**], at a decreased dose of 80mg [**Hospital1 **]. Spironolactone restarted at prior outpatient dose. Creatinine remained stable at 2.7 on these diuretic doses. Pt should have electrolytes and creatinine checked at least every three days and hold diuretics if any increase in creatinine. # s/p fall: Most likely secondary to volume depletion/orthostasis but also possible that worsening mental status contributed. Plastic Surgery and Wound Care teams followed closely for superficial skin tears on left forearm and right leg. Healing well. Please see wound care recommendations of plastic surgery in the page 1 and page 2 of dc plan. # UTI: Enterobacter resistant to cipro. Started on cefepime with ID approval on [**3-14**], completed 7 day course via PICC line. PICC line in left arm was removed on day of discharge. # Macrocytic Anemia: Checked Iron studies, B12 and Folate, within normal limits though B12 was low-normal. Iron supplementation was therefore discontinued. Methylmalonic acid was elevated suggesting that pt may in fact be vitamin b12 deficient. She should have a homocysteine level checked as outpatient, and if elevated, consider vitamin b12 and folate repletion. Pt had drop in Hct shortly after admission, received rbc transfusion, no source of bleeding found, stool guaiac negative. # CAD: Continued plavix and beta blocker, isosorbide. Unclear why not on [**Month/Day (1) **] or statin. # HTN: continued antihypertensives but held diuretics until [**3-17**]; see above # Rheumatoid Arthritis: continued home meds, including low dose prednisone # Depression and Anxiety: continued paxil, trazodone, clonazepam PRN # Hypothyroidism: Continued levothyroxine, TSH WNL # GERD: continued PPI # FEN: renal, cardiac diet # PPx: heparin SubQ # FULL CODE but would not want sustained intubation # Communication: regularly with son [**Name (NI) **] [**Name (NI) 30207**] (HCP) [**Telephone/Fax (1) 59394**] # Physical therapy: Physical therapists saw patient required max assist to get out of bed to chair. Pt should be getting out of bed with max assist to chair on daily basis. Medications on Admission: Medications at Home (per nursing home med sheets): - Fluid restriction 1200ml - Levothyroxine 50 mcg PO DAILY - Guaifenesin 400mg PO TID - Hydralazine 50mg Q8H - Isosorbide Dinitrate 10 mg PO TID - Metoprolol Succinate 25mg QPM - Prilosec 20 mg PO daily - Calcium Carbonate 500 mg PO TID W/MEALS - Cholecalciferol (Vitamin D3) 800 unit PO DAILY - Multivitamin PO DAILY - Fentanyl 50 mcg/hr Patch 72HR -- placed [**3-11**] - Senna 8.6 mg Tablet PO BID - Prednisone 5 mg PO daily - Trazodone 50 mg PO HS prn - Brimonidine Tartrate 0.2 % Drops [**Hospital1 **] - Epogen 4,000 units SubQ MF Every other week - Iron 325 daily - Potassium 20mEq daily - Nortryptiline 10mg QAM - Albuterol PRN - Macrobid 100mg PO BID x 10 days (Day 1 = [**3-5**]) - Clonazepam 0.5mg QHS PRN - Renagel 800mg TID with meals - Combivent 2 puffs [**Hospital1 **] - Nystatin swish and swallow - Saline nasal spray five times a day - Paxil 30mg daily - Plavix 75mg daily - Singulair 10mg daily - Spironolactone 50mg daily - Lasix 100mg daily - Nasocort [**Hospital1 **] - Lactulose 15ml [**Hospital1 **] - Vitamin C 1000mg [**Hospital1 **] Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 11. CefePIME 500 mg IV Q24H 12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 15. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-8**] Sprays Nasal QID (4 times a day) as needed for nasal dryness/congestion. 19. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 20. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 21. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: 1. delirium of multifactorial etiology, resolved 2. acute on chronic renal failure 3. severe metabolic acidosis 4. hypovolemia 5. urinary tract infection with Enterobacter 6. anemia of chronic disease 7. traumatic ulcers of the left arm and right leg Secondary Diagnoses: *chronic kidney disease Stage IV-V, not on HD [s/p RUE fistula placement [**8-14**]; Nephrologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 59393**] @ [**Hospital1 4494**]] *coronary artery disease *hypertension *GERD *Pulmonary fibrosis *rheumatoid arthritis: on MTX and prednisone *h/o PCP [**Name Initial (PRE) 11091**] [**2127**] hypothroidism depression and anxiety breast cancer s/p L mastectomy osteoarthritis s/p bilateral total knee replacements chronic pain syndrome macular degeneration Discharge Condition: Hemodynamically stable with good urine output, mental status at baseline, tolerating regular diet. Discharge Instructions: You were originally admitted to the Intensive Care Unit with altered mental status attributed to acute renal failure, severe acidosis, dehydration, and urinary tract infection. In addition, you had traumatic ulcerations of your left arm and right leg after you fell in your nursing home. You were stabilized on IV fluids, bicarbonate infusion, and antibiotics, and you were transferred to the Hospital Medicine Service on [**3-14**]. Your mental status and renal function returned to baseline, and you were maintained on antibiotics for your urinary tract infection. The Plastic Surgery team assisted in the care of your traumatic ulcers, which are healing well. Followup Instructions: PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1159**]: Nephrologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59393**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2130-3-20**]

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Discharge summary

report

Admission Date: [**2112-10-24**] Discharge Date: [**2112-11-2**] Date of Birth: [**2083-11-27**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 783**] Chief Complaint: Scrotal abscess Major Surgical or Invasive Procedure: Incision and drainage of peroneal abscess Trans-esophageal echocardiogram History of Present Illness: 28 year-old male previously healthy male with history of IVDU, who initially presented with a peroneal abscess and concern for peroneal necrotizing fasciitis, and multiple sepitc lung emboli. The abscess was first noted as a small pimple 5 days prior to presentation ([**10-19**]) and has progressively enlarged and become more painful. He had severals days of fevers and chills and started experiencing pleuritic chest pain, worse with inspiration. He also complained of cough prior to presentation. The day he presented, he noted an area of induration and erythema on left shin. . Patient underwent I&D of abscess on [**2112-10-24**]. An idurated, purulent area in the scrotal raphe and an area on the left buttock were opened. Pustular sinus tracts with necrotizing soft tissue wre found and debrided. Following procedure, patient was admitted to the SICU for close monitoring given concern for SIRS/sepsis. Patient initially treated with clindamycin, piperacillin-Tazobactam, gentamicin, and vancomycin. Patient grew GPC in [**5-30**] bottles. Pt had CXR which showed hypodensities, concerning for septic emboli. On CT chest he was found to have numerous bilateral pulmonary nodules, all concerning for septic embolic, infarcts, and disseminated infection felt secondary to abscess. TTE was negative for vegatations. . ID was consulted and felt that the source of the bacteremia and septic emboli was likely his scrotal abscess. The recommended continuing broad spectrum antibiotics because of polymicrobial nature of scrotal abscesses, including clindamycin to cover for necrotizing fasciitis. The gentamycin was discontinued. . Overnight, on [**10-26**], oxygen saturation decreased to mid to high 80s on 4L NC. Patient was noted to have increased work of breathing. He was transitioned to NRB and oxygen saturation improved to low 90s, but patient continued to have increased WOB. He was transitioned to BIPAP mask and his breathing symptoms improved. Given worsening respiratory status and persistent tachycardia, patient underwent CTA to assess for PE, which showed no PE, but does show worsening right sided non-hemorrhagic pleural effusion. . On transfer to the MICU, patient is comfortable and feels like his breathing is more comfortable on BIPAP. Scrotal pain is well controlled with current regimen. Patient reports having fevers and chills overnight. . Review of systems: (+) Per HPI. Constipation, has not moved bowels since admission. (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies wheezing. Denies chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: Left shoulder surgery [**2099**] No history of skin infections Social History: - Tobacco: 1 ppd x 16 years - Alcohol: None currently - Illicits: History of IV heroin use, last injected 5 months ago. Currently incarcerated for the past 4 months. Family History: Noncontributory Physical Exam: Physical Exam on Admission: Vitals: Tm: 101.1, Tc: 99.3, BP: 138/73 P: 89 R: 21 O2: 98% on BIPAP General: On BIPAP, appears comfortable HEENT: Sclera anicteric, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachy, regular rhythm, no murmurs/rubs/gallops Lungs: Dull at bases b/l R > L, coarse breath sounds b/l, no wheezes Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place, scrotal wound packed with wet to dry dressings, no drainage or surrounding erythema Ext: warm, well perfused, 2+ pulses, 3 cm x 3cm area of induration noted on left anterior shin, non-fluctuant Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Physial Exam on Discharge: Vitals: T98.7, BP:144/84, HR:101, RR:20, O2st: 94%RA General: breathing comfortably on room air CV: RRR, no M/R/G LUNGS: rales in right lung base and right middle lobe GU: foley removed, scrotal wound packed Ext: Anterior shin wound packed with wick Exam otherwise unchanged from admission Pertinent Results: Lab Results on Admission: [**2112-10-24**] 08:30PM BLOOD WBC-22.4* RBC-4.55* Hgb-14.6 Hct-42.1 MCV-93 MCH-32.1* MCHC-34.8 RDW-11.3 Plt Ct-248 [**2112-10-24**] 08:30PM BLOOD Neuts-81* Bands-1 Lymphs-13* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2112-10-24**] 08:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2112-10-24**] 08:30PM BLOOD Glucose-127* UreaN-10 Creat-0.7 Na-137 K-4.1 Cl-103 HCO3-23 AnGap-15 [**2112-10-25**] 06:10PM BLOOD HIV Ab-NEGATIVE [**2112-10-26**] 02:42AM BLOOD Type-ART pO2-62* pCO2-44 pH-7.39 calTCO2-28 Base XS-0 [**2112-10-24**] 08:38PM BLOOD Lactate-1.4 Studies: [**10-24**] Skin Biopsy: DIAGNOSIS: 1. Skin and soft tissue, scrotal raphe; debridement (A-C): 1.Cutaneous acute inflammation with abscess formation, tissue necrosis, and surface bacterial organisms. 2.Special stains for microorganisms in process, to be reported in an addendum. 2. Skin, left buttock; debridement (D-E): 1.Cutaneous acute inflammation and abscess formation with tissue necrosis. 2.Special stains for microorganisms in process, to be reported in an addendum. [**10-24**] ECG: Sinus tachycardia. Left axis deviation. No previous tracing available for comparison. [**10-24**] CXR: IMPRESSION: Ill-defined nodular opacities primarily within the lung bases. Findings are concerning for infectious process such as septic emboli, and a CT can be obtained for further evaluation. [**10-25**] transthoracic Echo: The left atrium is dilated. The right atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is a mild resting left ventricular outflow tract obstruction. 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. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. No vegetation seen (cannot definitively exclude). [**10-26**] CTPA: IMPRESSION: 1. No pulmonary embolism within the limitations of the study. 2. Numerous pulmonary nodules compatible with septic emboli. Bilateral lower lobe peripheral heterogenous opacities are now largely obscured by atelectasis are indeterminate but could also be due to septic emboli with possible infarction. 3. Small-to-moderate bilateral pleural effusions, increased from the study one day prior. 4. Regions of low attenuation within bilateral atelectasis, concerning for pneumonia. [**10-26**] LLE U/S: IMPRESSION: Serpiginous-appearing hypoechoic structure left anterior shin, possibly representing a fluid collection or alternatively superficial thrombophlebitis of a markedly distended venous structure. Clinical correlation is recommended. [**10-30**] CXR: IMPRESSION: 1. Lung volumes remain low. There is more focal patchy nodular opacity at the left apex as well as in the right upper to mid lung which appears somewhat cavitary and may reflect known septic emboli which are now radiographically visible. More focal patchy opacity at the right lung base is also present and could represent a combination of compressive atelectasis, pneumonia and/or evolving septic embolic areas. The more rounded appearance to the right costophrenic angle is slightly less apparent on the current examination but still could represent loculated pleural fluid. The heart remains enlarged but unchanged which may reflect cardiomegaly or pericardial effusion. Interval improvement in aeration at the left lung base with no definite left pleural effusion identified on the current examination. Stable mediastinal contours. No evidence of pulmonary edema. . [**10-31**] TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 45 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: No valvular pathology or pathologic flow identified. [**11-2**] CXR: IMPRESSION: 1. New left PICC with the tip at least at the estimated location of the cavoatrial junction but possibly 1-2 cm beyond this. No evidence of procedural complication. 2. Possible persistent right loculated pleural effusion. Followup with conventional PA and lateral radiograph is recommended when clinically feasible. Lab results on Discharge: [**2112-11-2**] 06:30AM BLOOD WBC-14.3* RBC-3.88* Hgb-12.1* Hct-36.7* MCV-95 MCH-31.2 MCHC-33.0 RDW-12.1 Plt Ct-511* [**2112-11-1**] 06:20AM BLOOD UreaN-9 Creat-0.6 [**2112-10-29**] 03:14AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.2 [**2112-10-31**] 04:40PM BLOOD Vanco-18.0 [**2112-10-27**] 04:37AM BLOOD Type-ART pO2-81* pCO2-52* pH-7.43 calTCO2-36* Base XS-8 Brief Hospital Course: Primary Reason for Hospitalization: Patient is a 28 year-old, previously healthy, incarcarated male with history of IVDU, who initially presented with a peroneal abscess and concern for perineal necrotizing fasciitis, and multiple septic lung emboli. The perineal wound was drained and showed no necrotizing fasciitis. Cultures from the wound and blood grew MRSA and patient began treatment with vancomycin. A wound on patient's anterior left shin was incised and drained as well. He required a brief ICU stay for respiratory distress but was never intubated. His fever and shortness of breath resolved and patient went to teh floor. TEE showed no vegetations and patient was discharged to complete a 6-week course of vancomycin. . ACUTE CARE: . 1. MRSA bacteremia: Patient had a perineal and buttock wound that grew MRSA in culture and blood cultures that grew MRSA as well. He was found to have radiographic evidence of septic emboli and was febrile with shortness of breath as well. He was started on a course of IV vancomycin. Patient received a TEE which showed no vegetations. He was discharged to complete a 6-week course of vancomycin. . 2. Perineal wound and other buttock and shin wound: Patient's initial complaint was a tender, erythemetous wound involving the scrotum and perineum. It started off as a pimple-sized lesion and grew to involve a large area. Surgery evaluated and debrided the wound because of concern for necrotizing fasciitis, which was not present. The wound grew MRSA and patient recieved vancomycin and wet-to-dry dressing changes. The additional wounds on the left anterior shin and left buttock were incised and drained and had daily dressing changes as well. He was dishcarged with instructions for antibiotics and dressing changes to continue. . 3. Lung Septic Emboli: Patient had septic emboli to the lung as evidenced by chest CT. He showed no neurologic signs suggesting brain lesions. Because of the lung lesions, patient had a period of respiratory distress requiring Bipap in the unit. This and patient's fever resolved with antibiotics and he did not require intubation. He was weaned to room air and previous pain experienced with respiration was greatly decreased. IP evaluated patient for a small loculated pleural effusion associated with the involved lung, and it was found to be too small to drain. CTPA showed no PE on this admission as well . CHRONIC CARE: . 1. IVDU history: Patient was informed about the possibility of infection with IVDU and he was made aware that the current damage to his veins from this history interferes with vascular access. . TRANSITIONS IN CARE: 1. FOLLOW UP: Patient will follow up with the medical system within the department of corrections. He should receive follow up with infectious disease upon finishing the 6-week course of vancomycin. 2. CARE TRANSITION: Per request of the DOC, patient will be transferred to [**Hospital1 **] to complete his inpatient care. he should be continued on heparin SC for DVT ppx. 3. VACULAR ACCESS: Patient has a PICC line placed. It was initially placed 2 cm too far in as seen on CXR, but was retracted 2cm and is OK to use for IV abx now that it is properly positioned. 4. CODE STATUS: presumed full Medications on Admission: none Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. 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. 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. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: hold for sedation or RR<10. 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for dyspnea. 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain: do not administer more than 4g per day. 9. vancomycin 1,000 mg Recon Soln Sig: [**2100**] ([**2100**]) mg Intravenous three times a day for 6 weeks: 6 weeks of therapy to be completed with last day [**2112-12-7**]. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary: MRSA bacteremia Secondary: Septic emboli to the lungs Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 82864**], You were admitted to the hospital because you developed a large abscess on your scrotum. We also found wounds on your left shin and left buttock and areas of infection in the lungs as well. The cultures from the wound grew a bacteria called MRSA, and you were found to have this growing in your blood stream as well. The bacteria spread from one the above-mentioned skin wounds to the blood and went to the lungs and other wounds from there. We did an ultrasound of your heart that showed no infection in the heart itself. MRSA is a bacteria that is very resistant to most antibiotic treatment, which is why you are being given vancomycin intravenously, which does work agaist this bacteria. You will need to continue this antibiotic for a total of 6 weeks. Please start the following medications: 1. START Vancomycin 2g IV q8hr (to be completed [**2112-12-7**]) 2. START Dilaudid 2mg 1-2 tablets by mouth every 6 hours as needed for pain ** This medication can cause sedation and drowsiness 3. START Docusate 100mg by mouth twice daily for constipation 4. START Heparin 5000 units subcutaneously three times daily if you are not ambulating 5. START Ipratropium nebulizer as needed for shortness of breath or wheezing 6. START Ranitidine 150mg by mouth twice daily for heartburn 7. START Tylenol as needed for pain (do not exceed 4g in one day) Followup Instructions: Please follow-up with the doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "608.4", "415.12", "682.6", "276.1", "511.9", "038.12", "682.2", "682.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "83.39", "88.72" ]

icd9pcs

[ [ [] ] ]

14748, 14821

10365, 12994

322, 398

14928, 14928

4661, 4673

16488, 16716

3513, 3531

13644, 14725

14842, 14907

13615, 13621

15079, 16465

3546, 3560

13005, 13589

9987, 10342

2824, 3223

266, 284

426, 2805

4351, 4642

4688, 9972

14943, 15055

3245, 3310

3326, 3497

49,582

111,923

6818

Discharge summary

report

Admission Date: [**2139-6-3**] Discharge Date: [**2139-6-13**] Date of Birth: [**2075-1-8**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 11291**] Chief Complaint: seizures, concern for status epilepticus Major Surgical or Invasive Procedure: Intubation and subsequent extubation History of Present Illness: HPI: Ms [**Known lastname **] is a 64 year old right handed woman with a history of seizures, leukodystrophy, dementia, feeding tube, presenting as a transfer from [**Hospital6 **] for status epilepticus. This history was taken over the phone from her Daughter; [**First Name5 (NamePattern1) 402**] [**Last Name (NamePattern1) 25807**] [**Telephone/Fax (1) 25808**]. She lives at home with her and the patients husband who are her primary care givers. She is bedbound at baseline with quadraparesis with prominent rightsided weakness. This morning she was scheduled to see IR today to have G tube replace at 3 pm. This morning she had a questionable small seizure with non responsiveness and quivering of her lips but it was short lived. Daughter; felt she had a low grade temp and a mild cough, but no overt illness. On the way to [**Hospital3 9717**] she went into a generalized tonic clonic seizure at 2:30 pm with was refractory to 5 mg of ativan, she was intubated at 3:30 for airway protection and was given a paralytic so it was unclear if she was still seizing. They got a head ct and transferred her to [**Hospital1 **] for further management. lidocaine 70 mg IV x 1 Fentanyl 120 mcg IV x 1 Rocuronium 36 mg IV x 1 Propofol gtt 10 mg / kg/ min Zosyn 3.375 g IV x 1 sq As far as her seizure history, they have been fairly well controlled on Dilantin, with her lat seizure being months ago. They are often generalized and recover her to come to the emergency room. Seizure began around the beginning of her mental decline and discovery of her leukodystrophy back in 99, she did have one seizure requiring intubation at that time. Regarding her Leukodystrophy, she had genetic testing at [**Hospital1 2025**] and [**Last Name (un) 18355**] School, she was tested for common for leukodystrophies and "they all came up negative." But cognitive decline started in 99 with slurred speech and weakness on one side, and wasn't sure if it was MS [**First Name (Titles) **] [**Last Name (Titles) 25809**] and then had as seizure, has continued to decline and has been bedbound for about 6 years. Currently, her neurologic baseline is that she has some movement of limbs, weaker on right side; does move a little bit, but not much, she fidgets a lot with her hands, rips blankets off and tips. Her Primary Contacts: Lives Daughter: [**First Name5 (NamePattern1) 402**] [**Last Name (NamePattern1) 25807**] [**Telephone/Fax (1) 25808**] Husband: [**Name (NI) **] [**Name (NI) 25810**] [**Telephone/Fax (1) 25811**] Past Medical History: 1. Cerebral leukodystrophy described above 2. Seizure disorder. 3. COPD, history of CO2 retention. 4. Depression. 5. Status post NCR. 6. Recurrent UTIs. 7. Chronic dysphagia and history of aspiration pneumonias PSH: Status post right hip fracture and status post ORIF, ORIF for right ankle fracture. Social History: SOCIAL HISTORY: Lives at home with family, no home Health Aide, former smoking quit in [**Month (only) **] of 99, former drinker, but quit in 99. No former drug use. Family History: She is adopted, no family history is available Physical Exam: Physical Exam on Admission: Vitals: T: 98.1 P:72 R:12 BP:126/72 SaO2:100% General: intubated HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, Pulmonary: Lungs CTA Cardiac: RRR Abdomen: soft, NT/ND, Extremities:cold feet bilaterally Skin: no rashes or lesions noted. . Neurologic: -Mental Status: obtunded grimaces to noxious no eye opening. -Cranial Nerves: PERRL 3 to 2mm and brisk, + brisk corneals bilaterally, + gag, face symmetric -Motor: withdraws left side to noxious, intermittent rhytmic shaking of the left arm. -DTRs:[**Name2 (NI) 20772**] throughout Physical Exam on Transfer: General: awake and alert, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA Cardiac: RRR Abdomen: soft, NT/ND Extremities: no edema Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Awake and alert, able to state name and answer a few simple questions, follows basic commands. -Cranial Nerves: PERRL, EOMI with limited rightward gaze, ?partial INO, VFF, R facial droop. -Motor: Quadriparetic, weaker on R. Able to lift b/l arms anti-gravity and wiggles toes b/l. -DTRs: [**Name2 (NI) **] throughout. L toe down, R toe up. Physical Exam on Discharge: ???????????? Pertinent Results: [**2139-6-3**] 06:45PM WBC-17.7* RBC-4.18* HGB-14.0 HCT-41.5 MCV-99* MCH-33.5* MCHC-33.7 RDW-12.3 [**2139-6-3**] 06:45PM NEUTS-91.6* LYMPHS-5.0* MONOS-3.0 EOS-0.2 BASOS-0.2 [**2139-6-3**] 06:45PM PLT COUNT-229 [**2139-6-3**] 06:45PM GLUCOSE-126* UREA N-17 CREAT-0.4 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17 [**2139-6-3**] 06:45PM estGFR-Using this [**2139-6-3**] 07:00PM LACTATE-2.7* [**2139-6-3**] 07:48PM O2 SAT-98 [**2139-6-3**] 07:48PM LACTATE-1.6 [**2139-6-3**] 07:48PM TYPE-ART RATES-16/ TIDAL VOL-450 PEEP-5 O2-100 O2 FLOW-7 PO2-366* PCO2-35 PH-7.50* TOTAL CO2-28 BASE XS-4 AADO2-314 REQ O2-58 -ASSIST/CON INTUBATED-INTUBATED [**2139-6-3**] 11:04PM URINE MUCOUS-RARE [**2139-6-3**] 11:04PM URINE RBC-103* WBC-7* BACTERIA-NONE YEAST-NONE EPI-1 [**2139-6-3**] 11:04PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [**2139-6-3**] 11:04PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023 CT head [**2139-6-3**]: IMPRESSION: No acute intracranial process. Severe chronic small vessel disease and atrophy. CXR [**2139-6-3**]: FINDINGS: AP portable supine chest radiograph obtained. The endotracheal tube is seen with its tip residing approximately 3.4 cm above the carina. The NG tube courses into the left upper abdomen. Contrast is seen within large bowel loops in the right upper quadrant. Linear areas of plate-like atelectasis in the right and left lower lungs are noted. There is no large consolidation or signs of CHF. No definite pneumothorax is present. The heart and mediastinal contours appear grossly unremarkable aside from atherosclerotic calcifications of the aortic knob. No definite displaced rib fractures are seen. IMPRESSION: Appropriately positioned endotracheal and nasogastric tubes. CXR [**2139-6-4**]: FINDINGS: As compared to the previous radiograph, the endotracheal tube and the nasogastric tube are in unchanged position. There is unchanged mild elevation of the right hemidiaphragm. The pre-existing right basal atelectasis is improved. Retrocardiac atelectasis is unchanged. Unchanged size of the cardiac silhouette. No newly appeared focal parenchymal opacities. Brief Hospital Course: 64-year-old right handed woman with a history of seizures, leukodystrophy, dementia, and G tube placement who presented as a transfer from [**Hospital6 **] for status epilepticus. She had a GTC yesterday afternoon which was refractory to 5mg of ativan and was subsequently intubated and paralyzed. Head CT showed severe chronic small vessel disease and atrophy but no acute intracranial process. Upon transfer she was continuing to have some intermittent rhythmic movements of the left hand. She was admitted to the neuro ICU for close monitoring. ICU and Hospital course: #Neuro: She was continued on her home Dilantin as well as a propofol drip overnight and had no further evidence of seizure activity. She was maintained on continuous EEG monitoring which showed L sided slowing with polymorphic delta compared with R sided theta but no epileptiform activity. She was extubated in the am of [**6-4**] and quickly returned to her baseline, able to answer simple questions appropriately and follow basic commands. Dilantin level was 15.4. She received an extra 200mg dilantin on [**6-4**] and her home dose was increased to 100mgQAM/200QPM 5x/wk rather than 4x/wk, with 100mg [**Hospital1 **] 2x/wk. Etiology of her seizure is somewhat unclear at this point. Infectious w/u has been negative thus far; it is possible she could have had an underlying low grade viral URI given her recent hx of cough. Labs unremarkable except for leukocytosis which is now downtrending. The patient was transferred to the floor in good condition. The patient was extubated the day after admission and did well over the weekend, however on [**6-8**] the patient spiked a temp and was found to have a white count of 19 (see below). She began having more seizures that responded acutely to ativan. She was frequently somnolent following the seizures - which had a unique semiology, including rather purposeful picking at covers and items real and imagined on her bed, waving her hand in the air as if being attacked by flies, and looking off into the corner of the room, often up and to the left. She received several boluses of Dilantin and her dose was increased to 300 mg total daily. A steady level was difficult to obtain and she was switched to infatabs that could be crushed and administered via g-tube. The patient tolerated this transition well with improved level. Her medications and seizures were discussed with her daughter and husband who care for her, as well as her primary doctor who has been managing her dilantin. Plan was made to continue at 300 mg total daily with plans to recheck the level in the week following discharge. The patient did generally well through the rest of her hospitalization with a single seizure the day prior to discharge for which she received an extra dose of dilantin with a level up to 14.4 on discharge. # Infectious disease: She initially had some low grade fevers with a Tmax of 100.3. UA and CXR were unremarkable. Blood cultures were negative. She was continued on her home Bactrim for chronic UTI. On transfer to the floor she became more somnolent related in part to being post-ictal and also due to a new fever up to 103, as well as an elevated WBC count and inflammatory markers. A CXR revealed bilateral aspiration pneumonias, likely related to her seizures. These were treated with empiric antibiotics with significant clinical improvement withing 36 hours. A PICC line was placed and Cefepime and Vanco were coursed conitnued for 4 more days following discharge (~ 10 day course). # FEN/GI: She was maintained NPO as at baseline does not take anything by mouth. She received her medications and tube feeds via her PEG. Her temporary PEG tube was replaced by IR aas it had fallen out the week prior and was due to be replaced as an outpatient. A foley had been placed there temporarily. The patient tolerated the new tube well. # Cardiovascular: She was maintained on telemetry monitoring. She was continued on her home antihypertensives. # Pulmonary: She was successfully extubated on [**6-4**] and remained stable from a respiratory standpoint. CXR was clear. Subsequent aspiration PNA as above. #CODE: full confirmed with family Contact: Lives w/ Daughter: [**First Name5 (NamePattern1) 402**] [**Last Name (NamePattern1) 25807**] [**Telephone/Fax (1) 25808**] Husband: [**Name (NI) **] [**Name (NI) 25810**] [**Telephone/Fax (1) 25811**] The patient was discharged home in improved condition with VNA and a plan to complete her antibiotic course, continue on dilantin and follow-up with her primary doctor. Medications on Admission: 1. metoprolol 25 mg twice daily 2. vitamin B12 tablet 1000 mcg daily 3. alendronate 70 mg every Friday 4. doxepin 25 mg q.p.m. 5. Advair Diskus one inhalation twice daily 6. Methenamine hippurate 500 mg twice daily 7. Paroxetine 10 mg every morning 8. Dilantin liquid 100 mg q am and MWF takes 100 mg in the evening, T,TH, F, Sat,Sun 200 in the evening. 9. Ranitidine 300 mg at bedtime 10. Spiriva one inhalation daily. levocarnitine, Discharge Medications: 1. Alendronate Sodium 70 mg PO QFRI 2. CefePIME 1 g IV Q12H RX *cefepime 1 gram twice a day Disp #*8 Each Refills:*0 3. Phenytoin Infatab 100 mg PO QAM Start now, Crushed tabs. RX *Dilantin Infatabs 50 mg twice a day Disp #*180 Each Refills:*4 4. Tiotropium Bromide 1 CAP IH DAILY 5. Vancomycin 1000 mg IV Q 12H Duration: 5 Days RX *vancomycin 1 gram twice a day Disp #*8 Each Refills:*0 6. Docusate Sodium 100 mg PO BID 7. Doxepin HCl 25 mg PO HS 8. Paroxetine 10 mg PO DAILY 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 10. Cyanocobalamin 1000 mcg PO DAILY 11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 12. Metoprolol Tartrate 25 mg PO BID hold for SBP < 100, HR < 60 13. Outpatient Lab Work Please draw Dilantin level prior to one of her scheduled doses to get a trough level (prior to pulling PICC line). Send results to PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 25812**] [**Last Name (NamePattern1) 25813**], [**Telephone/Fax (1) 25814**], fax [**Telephone/Fax (1) 25815**]. 14. Lorazepam 1-2 mg PO Q4H:PRN seizures RX *lorazepam 1 mg q1 hr as needed Disp #*12 Each Refills:*1 15. Phenytoin Infatab 200 mg PO QPM Crushed tabs via G-tube Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: 1. Status epilepticus, 2. Leukodystrophy Discharge Condition: Mental Status: Confused. Level of Consciousness: Alert and interactive, perseverative, intermittently follows commands. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: Mental status as above, intermixed appropriate and inappropriate responses to questions, pseudobulbar. CNs intact. Strength is at least antigravity and against some resistance in all extremities, left greater than right. Discharge Instructions: Ms. [**Known lastname **] was admitted to [**Hospital1 69**] on [**2139-6-3**] after a prolonged seizure. She was initially admitted to the ICU,, requiring a mechanical respirations while her seizures came under control. She was transferred to the floor and had another seizure and subsequently developed bilateral aspiration pneumonias. She was treated with IV antibiotics and her Dilantin was increased. A large IV was placed for her to get medicine at home and her G-tube was replaced. Because we had trouble maintaining an accurate level with her Dilantin we switched to the infatabs and increased her dose to 100 mg in the morning and 200 mg in the evening every day. Her level the morning of discharge was 11.2 and she was given an extra 200 mg, which should bring her level up above 15. Next week she should follow up with her primary doctor and get a level drawn. The Visiting nurses who will remove her PICC line may be able to do this for you. Followup Instructions: With PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 25812**] [**Last Name (NamePattern1) 25813**], [**Telephone/Fax (1) 25814**], fax [**Telephone/Fax (1) 25815**].

[ "311", "345.50", "344.00", "496", "294.20", "V15.82", "V55.1", "V15.51", "V58.62", "995.29", "401.9", "330.0", "728.87", "E936.1", "303.93", "787.22", "507.0", "345.70" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "97.02", "96.6", "89.19" ]

icd9pcs

[ [ [] ] ]

13359, 13404

7089, 7646

345, 383

13488, 13488

4830, 7066

14910, 15098

3467, 3515

12139, 13336

13425, 13467

11680, 12116

7664, 11654

13929, 14887

4539, 4768

3530, 3544

4796, 4811

265, 307

411, 2935

3558, 3854

13503, 13905

2957, 3266

3298, 3451

9,718

123,341

20843+57202

Discharge summary

report+addendum

Admission Date: [**2106-2-26**] Discharge Date: [**2106-3-3**] Date of Birth: [**2027-3-26**] Sex: F Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 78**] Chief Complaint: unsteadiness for two years, urinary incontinence for approximately a year, and memory difficulties for about 6 months Major Surgical or Invasive Procedure: Laparoscopic ventriculoperitoneal shunt placement History of Present Illness: 78 year old female with unsteadiness for two years, urinary incontinence for approximately a year, and memory difficulties for about 6 months. She had significant difficulty with her gait, and she has severe kyphosis. She was ambulating with the help of a wheelchair. Past Medical History: osteoporosis, severe COPD, kyphoplasty, hysterectomy, mitral valve repair, status post tonsillectomy, MI in [**2103**], and seizure disorder Social History: She does not work, and she continues to smoke and has a heavy history of smoking in the past. daughter [**Name (NI) **] cell [**Telephone/Fax (1) 55511**]. Family History: non contributory Physical Exam: afebrile, VSS NAD, AAO x3 RRR, S1 and S2 CTAB abd: soft, mild tenderness RUQ/epigastric and over incisions, incisions clean, dry and intact. EOMI, PERRL, follows all commands face symmetric, tongue midline no drift strength and sensation intact Pertinent Results: [**2106-2-27**] 08:40AM BLOOD WBC-6.1 RBC-3.28* Hgb-11.0* Hct-33.2* MCV-101* MCH-33.7* MCHC-33.3 RDW-13.2 Plt Ct-139* [**2106-2-27**] 08:40AM BLOOD PT-11.9 PTT-25.7 INR(PT)-1.0 [**2106-2-27**] 08:40AM BLOOD Glucose-97 UreaN-12 Creat-0.7 Na-141 K-4.5 Cl-107 HCO3-31 AnGap-8 Brief Hospital Course: Ms. [**Known lastname **] was admitted to the neurosurgical service following placement of a VP shunt on [**2106-2-26**]. She tolerated the procedure well and a post op CT showed no hemorrhage and good placement of the shunt. She was transferred to the PACU and later to the floor. She did well post operatively and continued to work with physical therapy during her hospitalization. She did have some post operative abdominal pain which she noted was worse with movement. She was evaluated by the general surgery team who felt that it was post operative pain with an exam within normal limits. She continued to tolerate a regular diet. She was cleared by physical therapy for discharge home with home PT services. She was discharged home in stable condition on [**3-11**]. She will follow up with Dr. [**First Name (STitle) **] in [**5-16**] wks with repeat NCHCT. Medications on Admission: aspirin, Prozac, Lasix, Tegretol, calcium, lovastatin, verapamil, potassium chloride, Diovan, [**Doctor First Name **], Flovent, Spiriva, albuterol, Fosamax, Ditropan, Miacalcin, Colace, and Plavix. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 1 weeks. Disp:*50 Tablet(s)* Refills:*0* 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 10. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation for 1 months. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: normal pressure hydrocephalus Discharge Condition: neurologically stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT TO HAVE YOUR STAPLES REMOVED ON THURSDAY JANYARY 31st AND TO SEE DR.[**First Name (STitle) **] IN FOLLOW-UP IN CLINIC IN [**5-16**] WEEKS (YOU WILL NEED A REPEAT HEAD CT WITHOUT CONTRAST THAT DAY). Completed by:[**2106-3-1**] Name: [**Known lastname **],[**Known firstname 460**] Unit No: [**Numeric Identifier 10391**] Admission Date: [**2106-2-26**] Discharge Date: [**2106-3-3**] Date of Birth: [**2027-3-26**] Sex: F Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 40**] Addendum: Upon reevaluation, PT recommended rehab so she will be discharged to rehab rather than home with PT as per previously planned. Patient is alert and oriented x 3, neurological exam is non-focal, she is still incontinent of urine; however, she does have sensation, and is able ask for help with voiding. She is tolerating diet without difficulties. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 2075**] [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**] Completed by:[**2106-3-3**]

[ "493.20", "345.90", "331.5", "737.10", "412", "401.9", "733.00", "788.30" ]

icd9cm

[ [ [] ] ]

[ "02.34" ]

icd9pcs

[ [ [] ] ]

6350, 6550

1690, 2567

388, 440

4223, 4247

1393, 1667

5345, 6327

1094, 1112

2817, 4059

4170, 4202

2593, 2794

4271, 5322

1127, 1374

231, 350

468, 740

762, 904

920, 1078

59,261

159,122

42396

Discharge summary

report

Admission Date: [**2156-4-16**] Discharge Date: [**2156-4-19**] Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 3705**] Chief Complaint: Fall, SAH/SDH Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [**Age over 90 **]yo female with history of hypertension and arthritis who was recently admitted on [**4-16**] after a fall felt to be mechanical in nature. The patient had been recently admitted to medicine on [**4-10**] after a fall and diagnosis of SDH in the left temporal region and a left occipital subarachnoid hemorrhage. These were conservatively managed, and was discharged from the medicine service to home with services due to her daughter's wish to avoid rehab. . Yesterday, she was being transferred from the commode back to her leather chair when she became weak. The daughter could not support her weight and she slipped to the floor. Her head brushed the leather couch but there was no significant impact. There was no syncope, chest pain, shortness of breath. She presented to the ED where a CT was done showing essentially stable sizes of her SDH and SAH without neurologic deficit. She was admitted to the neuro ICU overnight and received q1hr neuro checks. This morning, she was felt to be stable from a neurologic perpective and was transferred to medicine. . She was seen in the room with her two daughters with whom she resides at home. She has had a waxing and [**Doctor Last Name 688**] mental status- yesterday she had slurring of speech and confusion, though she is answering questions appropriately now. Her daughters are upset at the realization that they cannot care for her at home, and very reluctantly agree that rehab is appropriate. . On review of systems, she complains of bilateral knee pain which has been ongoing for many years. She denies headache, shortness of breath, nausea, vomiting, diarrhea. Past Medical History: -Hypertension -Arthritis -NSTEMI [**2153**] s/p stenting at [**Hospital1 336**] -CHF ([**First Name8 (NamePattern2) **] [**Hospital1 **] records) - last EF unknown -Surgery for endometriosis and exploratory laparatomy of unknown time and reason -traumatic left SDH and left occipital SAH [**4-/2156**], conservatively managed Social History: She lives alone at home with daughters. She has been growing progressively weaker in recent [**Last Name (un) 26512**], relying fully on daughters for all transfers in and out of bed, as well as feedings. CAnnot manipulate stairs but there is a chair lift. She is occasionally confused. She does not drink or smoke cigarettes. Family History: not contributory Physical Exam: Admission Exam: Vitals: T:98.9 BP:135/75 P:77 R: 14 O2: 99RA General: Alert, oriented to person, hospital, [**Month (only) 958**]. Thought it was [**2056**]. HEENT: MMM, 3-4cm lac over right brow, bruising around the brow and zygoma Neck: supple, no LAD Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes, rales, ronchi CV: Regular rate and rhythm, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Pain on palpation of the knees R>L. 5x6cm hematoma on the right hip. Neuro: CNII-XII intact. Strength 5/5 in the UE, [**5-13**] in the lower extremities but symmetric. Normal sesnation throughout. Pertinent Results: Admission Labs: [**2156-4-16**] 11:09PM GLUCOSE-115* UREA N-16 CREAT-1.0 SODIUM-135 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15 [**2156-4-16**] 11:09PM estGFR-Using this [**2156-4-16**] 11:09PM PHENYTOIN-1.9* [**2156-4-16**] 11:09PM WBC-10.4 RBC-3.76* HGB-12.4 HCT-34.9* MCV-93 MCH-33.0* MCHC-35.5* RDW-12.5 [**2156-4-16**] 11:09PM NEUTS-78.5* LYMPHS-15.9* MONOS-3.6 EOS-1.2 BASOS-0.8 [**2156-4-16**] 11:09PM PLT COUNT-271# [**2156-4-16**] 11:09PM PT-10.0 PTT-25.5 INR(PT)-0.9 Discharge Labs: [**2156-4-19**] 05:40a 137/106/14 -----------< 99 AGap=14 4.2/21/ 0.8 Mg: 3.0 ALT: 25 AP: 80 Tbili: 0.4 AST: 29 6.3> 10.7/ 30.5< 277 MCV 94 [**2156-4-18**] 08:40a 137/106/ 15 -------------< 104 4.2/ 22/ 0.8 Ca: 8.3 Mg: 2.2 P: 3.0 Phenytoin: 3.3 92 8.4> 11.1/ 31.5< 258 PT: 10.8 PTT: 23.8 INR: 1.0 IMAGING CT HEAD NON-CON [**2156-4-16**]: The subdural hemorrhage layering along the entire left cerebral convexity is similar in size and appearance compared to prior with a posterior hyperdense component and a fluid-fluid layer with relatively higher density material layering posteriorly. There is 6-mm rightward shift of normally midline structures, which is unchanged. The basal cisterns appear patent. Left temporal subarachnoid hemorrhage appears similar compared to most recent prior exam and decreased compared to [**2156-4-10**]. Right frontal and midline posterior falcine meningiomas are again noted. There is no evidence for new hemorrhage. Right frontal scalp soft tissue swelling appears similar compared to most recent prior exam. The visualized portions of the paranasal sinuses and mastoid air cells appear well aerated. There are stable meningiomas along the flax and right frontal lobe. IMPRESSION: Stable left subdural hematoma and left temporal subarachnoid hemorrhage. LEFT HIP, PLAIN FILMS: [**2156-4-17**]: An AP view of the pelvis and two additional views of the right hip are submitted. Positioning for the cross-table lateral view is suboptimal. However, on the other submitted images, bones are markedly osteopenic. There are degenerative changes of both hips with no evidence of a displaced fracture or dislocation. If a hip fracture, however, remains of clinical concern, further imaging with MRI could be undertaken. RIGHT KNEE XRAY ON [**2156-4-18**]; IMPRESSION: 1. Severe tricompartmental osteoarthritic changes with large loose body or Preliminary Reportdetached osteophyte in the right suprapatellar joint. 2. No definite acute fracture or dislocation. If there is continued clinical Preliminary Report concern for acute radiographically occult fracture, consider correlation with MRI. Brief Hospital Course: This is a [**Age over 90 **]yoF with a history of recent traumatic SDH/SAH here s/p repeat fall with stable head bleeds per CT-scan. ACTIVE PROBLEMS: 1. RECURRENT FALLS: This fall appeared mechanical, she was being transferred from the commode to a chair when she felt weak and slid to the floor. No major trauma. Her daughter [**Name (NI) 4134**] activated EMS. She realized that she could not care for her aging mother at her current weakened state just a few days since her last discharge. There was no change in the size or shift from the SAH/SDH found during the last hospitalization on repeat CT. She was admitted to the neuro SICU on the night of admission for neuro checks, and then was transferred to medicine for further management. She worked with PT, and decision was made with family to pursue short term rehab. She is also has difficulty with ambulation due to severe osteoarthritis in her knees leading to pain. 2. SUBDURAL/SUBARACHNOID HEMORRHAGE: Appear radiographically similar on CT. Will finish 2 more days of seizure prophylaxis with dilantin since dilatin level was low and keep on Keppra until she sees neurosurgery on [**5-11**] or for max of 30 days. Will f/u with Dr. [**Last Name (STitle) **] in 3 weeks with a repeat head CT. No neurologic deficits on exam 3. ACUTE DELIRIUM: She had a waxing and [**Doctor Last Name 688**] level of attention, which the daughters felt was stable from her last hospitalization. She could be easily re-directed. She was conversing this morning and oriented to place and person. 4. OSTEOARTHRITIS: She had severe pain of the right knee from arthritis which limited PT. Plain films revealed severe arthritic changes with large loose body or detached osteophyte in the right suprapatellar joint, but no fracture were noted. If there is continued clinical concern for acute radiographically occult fracture, consider correlation with MRI. She was started on Tylenol 1000mg Q 8hours and tramadol Q 6 hours with good effect for her pain. Would consider changing Tylenol back to PRN once pain is better controlled. She will need to cont to work with PT. INACTIVE ISSUES: 1. HYPERTENSION: normotensive, continue lisinopril, metoprolol, lasix 2. CAD s/p NSTEMI: patient on minimal cardiac regimen- NTG patch and metoprolol. 3 sCHF: will continue lasix per home regimen, oxygen saturations are reassuring. 4. CODE STATUS: is DNR DNI TRANSITIONAL CARE: - needs repeat CT in 3 weeks prior to appt with Dr. [**Last Name (STitle) **] on [**5-11**] - Stop Dilantin in 2 days given that levels were low and there was concern for AMS with this, so she was switched to Keppra 1000mg [**Hospital1 **]- Please change dose if pt has change in her renal function Patient going to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Nursing Home. Medications on Admission: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for pain. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 7. Outpatient Lab Work phenytoin level (started phenytoin in hospital for seizure ppx) and Chem 7 (started lisinopril while in house) to be drawn on [**2156-4-15**], and faxed to PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 11321**] 8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0 10. methyl salicylate-menthol One (1) Appl Topical TID (3 times a day) Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO every six (6) hours as needed for pain. 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 6. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal Q24H (every 24 hours). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. phenytoin sodium extended 200 mg Capsule Sig: One (1) Capsule PO twice a day for 2 days: Should stop in the evening of [**2156-4-21**]. 9. methyl salicylate-menthol Topical 10. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day for 30 days: Or until you were told by neurosurgeon to stop. . Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Continuing Care Center - [**Hospital1 392**] Discharge Diagnosis: Mechanical fall subdural hematoma, subarachnoid hemorrhage, stable arthritis, knee pain delirium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted to the hospital after having fallen again. A CAT scan of your head showed no significant worsening of your known bleeds, which were diagnosed during your last hospitalization. After working with physical therapy, it was determined that you should go to rehab to get stronger before going home. The following changes were made to your meds: 1. CONTINUE DILANTIN 200mg twice a day for another 2 days 2. Start on Keppra 1000mg twice daily for a total of 30 days or until when you see neurosurgeon tells you when to stop 3. START ACETAMINOPHEN 1000mg three times daily for knee pain 4. START TRAMADOL 25mg every 6 hours as needed for knee pain No other changes were made to your medications, please continue all other previously prescribed medications It was a pleasure working with you, I wish you the best. Followup Instructions: Department: RADIOLOGY When: TUESDAY [**2156-5-11**] at 1 PM 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: TUESDAY [**2156-5-11**] at 1:45 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You will also need to schedule an appointment with your primary care doctor once you leave the rehabilitation facility.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10823, 10964

6174, 8297

239, 246

11105, 11105

3481, 3481

12168, 12795

2648, 2666

9952, 10800

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2302, 2632

3,133

154,403

15611

Discharge summary

report

Admission Date: [**2173-9-14**] Discharge Date: [**2173-12-3**] Date of Birth: [**2131-2-13**] Sex: M Service:TRANSPLANT SURGERY SERVICE HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 174**] is a 42-year-old gentleman who underwent a cadaveric liver transplant on [**2173-7-7**] for hepatitis C related cirrhosis. He was hospitalized from [**7-5**] through [**8-11**]. The patient was seen in follow-up and had normalization of his LFTs. The patient also has a history of depression and bipolar disease. He is treated with lithium. He has a history of gastroesophageal reflux disease. The patient was treated with immunosuppressants including CellCept 1 gm [**Hospital1 **], Neoral and prednisone. The patient was doing well until we received a phone call from the patient's sister on the 19 reporting that the patient had a fever of 100.7 and generalized malaise. The patient was admitted directly to Far-6. PAST MEDICAL HISTORY: 1. Orthotopic liver transplant on [**2173-7-7**]. 2. Hepatitis C and alcohol cirrhosis. 3. GERD. 4. Bipolar disease. 5. Diabetes. MEDICATIONS ON ADMISSION: 1. Flucortisone. 2. Pepcid. 3. Fluconazole. 4. Metoprolol. 5. Bactrim. 6. Risperidone. 7. Valcyte. 8. Lasix. 9. Lithium. HOSPITAL COURSE: The patient was admitted to the surgical service on Far-6. The patient had blood cultures, urine cultures, sputum cultures, CMV viral load sent on the [**9-13**]. The patient was begun on broad spectrum antibiotics. The patient underwent an ultrasound on the 20 which demonstrated no flow in his hepatic artery. The patient underwent a CAT scan that demonstrated a 4 x 5 x 4.7 cm collection consistent with a large biloma. The patient had an MRCP that showed that his left duct communicated with a large biloma at the confluence. This was consistent with hepatic artery thrombosis and bile duct necrosis. The patient was covered with broad spectrum antibiotics, as stated, including vancomycin, Levofloxacin and Zosyn. On the 25, the patient was admitted, had some depression of his mental status and was admitted to the ICU for monitoring. He remained in the ICU for 5 days and then was transferred to the floor. As stated, he was continued on broad spectrum antibiotics. We followed him serial CAT scans on the 25 and again on the 31. They showed a large biloma with question of infarction of the liver, and small pleural effusions. The patient's biliary cultures grew out gram-negative Staph. On the [**9-30**], the patient underwent CT-guided drainage of his biloma. Of note, his LFTs on admission revealed an AST and ALT of 47 and 55, and an alk phos of 228, and a total bilirubin 1.0, that slowly increased up to a bilirubin of 4.3 on [**10-4**], with transaminases of 39 and 48, and alk phos increased to 377. The patient was relisted for liver transplant patient with a diagnosis of hepatic artery thrombosis. The patient had significant lower extremity swelling, and had an IVC gram that showed a stenosis that was angioplastied on the [**10-8**]. The patient's vanc levels remained in a therapeutic range. On [**10-10**], the patient received an offer for a cadaveric liver, and on [**10-10**] the patient underwent cadaveric renal transplantation. This transplant was done in an orthotopic fashion. It was an end-to-end anastomosis between the recipient splenic artery and the donor hepatic artery. The portal vein was end-to-end and the duct was duct-to-duct with a T-tube placed. The donor was CMV positive and O+. The recipient was CMV negative and O+. The patient received Simulect at the time of retransplantation and again on day 4. The patient was given 500 mg of steroid of Solu-Medrol on day 0 and day 1, and started on a steroid taper. The patient was also continued on mycophenolate and Prograf. Postoperative course was significant for delayed graft function/primary cholestasis. His bilirubin slowly increased postoperatively to a high of 22.6 on [**10-30**], which was postop day #19. The patient had full investigations including tube cholangiograms which were normal, CT scanning with IV contrast which demonstrated a small wasting of the portal vein with good flow through the portal vein, and a small residual stenosis of IVC with good flow in the IVC. The patient underwent a portal cavagram on the [**10-22**] which demonstrated a small wasting of the portal vein again with no gradient as well. The patient had an IVC gram that showed no gradient across the IVC stenosis. This is status post previous angioplasty. The patient had a mesenteric A gram that demonstrated the hepatic-splenic artery anastomosis to be intact with good flow and perfusion of the left and right hepatic arteries without evidence of stenosis. The patient had a liver biopsy that was consistent with some ischemic changes of preservation injury, without evidence of rejection. With his increasing bilirubin, the patient required reintubation for decreased mental status and inability to clear his respiratory secretions. The patient had a repeat CT scan done on the [**9-27**] which showed a small collection in the lesser sac for which he had a percutaneous drain placed. This percutaneous drain fluid was consistent with a small pancreatic fistula. His postop course after the [**10-30**] was consistent with slow resolution of most of his symptoms. His hepatic graft and function returned, and he slowly increased his synthetic function, and over the ensuing weeks his bilirubin decreased from a maximum of 22.6 down to 3.5. As his bilirubin decreased, his mental status improved, and the patient began to participate in his care. The patient's nutrition was supplemented by originally TPN and then by enteral tube feeds to meet his goal rate. All of the patient's cultures were negative, and all of his antibiotics were completed. The patient also had some mild abdominal pain. The patient was seen and evaluated by urology for left-sided abdominal pain. The patient was known to have nephrolithiasis on the right side, and no nephrolithiasis on the left side. By [**Month (only) **], the patient had improved. The patient was ambulatory with physical therapy. Although the patient was weak, he would ambulate with a walker and with assistance. The patient was off all antibiotics. The patient's bilirubin, as stated, decreased and was meeting all of his goal nutrition with tube feeds and was tolerating a PO diet. The patient's pigtail catheter was putting out approximately 100-120 cc a day of a small pancreatic fluid collection. The patient had a repeat CT scan done on the [**11-30**] which demonstrated nephrolithiasis on the right, and no kidney stones on the left, a decrease in ascites, a small collection associated with the pigtail catheter, and a small pancreatic pseudocyst. The patient's other issue was his platelet count. The patient had a large hepatosplenomegaly and was felt to have secondary platelet destruction. The platelet count was stable at 40,000 at the time of discharge. By the time of discharge on [**2173-12-3**], the patient was on hospital day #53, and the patient was afebrile with a temperature of 98.8. Blood pressure was stable. The patient had good I's and O's and had 130 cc out from his drain. His labs as of the [**12-2**] revealed a creatinine which was stable at 1.2, AST and ALT 40 and 55, alk phos 286, and a bilirubin of 3.4. The patient was maintained on Insulin sliding scale, bactrim single-strength 1 qd, labetalol 100 po bid, clonidine 0.4 tid, hydralazine 75 qid, Epogen 10,000 U subcu q Monday, nystatin 5 cc qid, Actigall 300 mg po qid, Prevacid 30 mg po qd, colace 100 mg po bid, lithium 300 mg po qid, fluconazole 400 mg qd. DISCHARGE DIAGNOSES: 1. Liver retransplantation. 2. Right-sided nephrolithiasis. He will transfer to rehabilitation for further physical therapy and occupational therapy. The patient has a pigtail catheter in place which we left to bag drainage and have daily recording of drain output. The patient has a biliary T-tube in place that is capped. The patient will have [**Hospital1 **]-weekly laboratory examinations for CBC including platelets to follow platelet count, a chem-10 or a renal to follow his creatinine and his blood chemistries, LFTs, and [**Hospital1 **]-weekly Prograf levels. DISCHARGE MEDICATIONS: Immunosuppressants include: 1. CellCept [**Pager number **] mg po bid. 2. Prednisone 10 mg po qd. 3. Prograf 1 mg po bid. 4. Bactrim single-strength tablets 1 tablet po qd. 5. Labetalol 100 mg po bid. 6. Clonidine 0.4 mg po tid. 7. Hydralazine 75 mg po qid. 8. Epogen 10,000 U subcu q week. 9. Nystatin 5 cc qid. 10.Actigall 300 mg po tid. 11.Prevacid 30 mg po qd. 12.Colace 100 mg po bid. 13.Lithium 300 mg po qd. 14.Fluconazole 400 mg po qd. FOLLOW-UP: At the [**Hospital 6752**] Medical Bldg., [**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **], 7th Fl., Transplant Center, next Monday. The patient will have labs, as stated, [**Hospital1 **]-weekly labs for CBC, a chem-10, LFTs and a Prograf level. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**MD Number(1) 45113**] MEDQUIST36 D: [**2173-12-3**] 10:29 T: [**2173-12-3**] 10:35 JOB#: [**Job Number 45114**]

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icd9cm

[ [ [] ] ]

[ "87.54", "88.51", "50.11", "88.47", "38.93", "96.04", "99.15", "38.91", "54.91", "50.59", "96.72" ]

icd9pcs

[ [ [] ] ]

7723, 8299

8322, 9318

1117, 1239

1257, 7702

182, 938

960, 1091

42,757

167,098

38775

Discharge summary

report

Admission Date: [**2154-10-6**] Discharge Date: [**2154-10-28**] Date of Birth: [**2094-12-2**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chief Complaint: muscle weakness, hypotension, renal failure. Reason for ICU Admission: hypotension with pressor requirement Major Surgical or Invasive Procedure: [**2154-10-6**] Lumbar puncture [**2154-10-17**]: Median sternotomy, open removal of old automated implantable cardioverter defibrillator leads and removal of automated implantable cardioverter defibrillator. [**2154-10-21**]: Right Basilic Vaxcel PICC line 50 cm History of Present Illness: The patient is a 59-year-old man with history of arrhythmogenic right ventricular dysplasia s/p ICD placement, complicated by ICD pocket infection (MSSA) s/p removal and reimplantation in [**Month (only) 547**] of this year, who is admitted to the ICU for hypotension. Per patient, he was in his usual state of health until six days prior to admission, when he developed sore throat, subjective fever, muscle weakness, and headache. He went to see his primary care physician who diagnosed him with likely flu-like illness. Patient then began to feel better for 1 to 2 days. However, three days prior to admission, he awoke feeling profoundly weak in both his arms and his legs, hardly able to get out of bed. He also endores muscle pain at this time, and he noticed that his urine was darker. He may have had some mild dysuria at this time. Thinking that the symptoms were part of the flu-like illness, he remained at home for two days before presenting to [**Hospital3 **] Hospital, one day prior to admission. At [**Hospital3 **] Hospital, he was found to be hypotensive with blood pressure of 70/40 with lactate of 3.4 and new acute renal failure. He was fluid resuscitated, a right IJ was placed, and he was started on Levophed. Labs showed a positive urinalysis, so he receieved one dose of Zosyn and then was transferred to [**Hospital1 18**] for further management. At [**Hospital1 18**] ED, initial vitals were T 98, HR 66, BP 100/57, RR 18, sat 96% on 2L nasal cannula. Exam was notable for hyporeflexia at the patellar and achilles reflexes, with significant upper and lower extremity motor weakness. Sensation was intact. Patient with no other focal complaints for infection. His labs were notable for lactate of 3.2 and creatinine of 5.4 (up from baseline 1.0), ALT and AST of 47 and 55, with TBili of 6.7 (predominantly direct hyperbilirubinemia), albumin of 2.7 and INR of 1.2. His platelets were 63 and hematocrit was 37.9 (hematocrit was at baseline, platelets were down from ~200 previously). Differential revealed occasional schistocytes. Notably, CK was normal. There was concern of GBS as well as TTP-HUS, and both neurology and hematology were contact[**Name (NI) **]. Neurology has preliminarily recommended lumbar puncture for diagnosis of progressive peripheral neuropathy. Hematology will take a look at the peripheral smear, although they felt that TTP-HUS was unliklely given the normal LDH. Patient then underwent RUQ ultrasound that showed no acute right upper quadrant process, and CXR with no acute infiltrate. He was continued on norepinephrine drip and was admitted to the ICU for further treatment. Review of systems: currently, patient endorses muscle weakness in his legs and his arms; the weakness does not spare his distal muscle groups. He denies respiratory complaints. He denies gastrointestinal complaints. His headache has resolved. He denies nausea or vomiting. With respect to infectious risk factors, he lives on [**Hospital3 **], plays golf and is frequently outdoors, although he denies known tic bites. There is recent travel history to [**Country 6607**] and no sick contacts at home. Past Medical History: -Arrhythmogenic Right Ventricular Dysplasia c/b sustained monomorphic ventricular tachycardia, s/p single chamber ICD in [**2139**] -ICD Hx: [**2139**]: Initial single chamber device placement at [**Hospital 71571**] Hospital in [**State 18250**] in [**2139**]. The following month his lead dislodged resulting in inappropriate ICD therapy. The lead was removed with a new ventricular lead. [**2145**]: Generator change for depleted ICD battery. Developed insulator breech on this lead in [**2146**], necessitating lead revision. Old lead was capped and abandoned at that time. Percutaneous coronary intervention, in [**2139**]: Diagnostic. Per patient, coronary arteries were clean. -Hypertension Social History: Patient lives in [**Hospital3 **] with his wife. [**Name (NI) **] is a consultant for mid-sized companies. He has two children. Remote history of smoking, quit in [**2116**]. Drinks two glasses of wine/night. Denies illicit drugs Family History: Sister: ARVD as well and has an ICD in place. Father also has disorder, never had ICD in place. He died at 82 d/t CHF. There is no family history of premature coronary artery disease or sudden death. Physical Exam: Vitals: T: afebrile, BP: 113/69, P: 61, R: 24 O2: 97% 2L General: well-appearing man, no acute distress Neurological: patient able to lift arms and legs against gravity but not against force; hand grip and intrinsic finger muscles are weak in proporation to proximal muscle weakness; reflexes are absent at the patella and HEENT: subtle sclear icterus, pupils equal and reactive Neck: supple, RIJ in place without evidence of infection Lungs: clear bilaterally anterior fields Cardiovascular: RRR, normal s1/s2, no murmurs; area over right chest over ICD is intact, non-erythematous, not tender and not warm Abdomen: soft, non-tender Genitourinary: foley catheter in place, draining dark urine Extremities: without rashes, warm, well perfused, non-edematous Pertinent Results: Labs at Admission: [**2154-10-6**] 03:28AM BLOOD WBC-10.2 RBC-4.38* Hgb-13.4* Hct-37.9* MCV-86 MCH-30.6 MCHC-35.4* RDW-14.1 Plt Ct-63*# [**2154-10-6**] 03:28AM BLOOD Neuts-73* Bands-13* Lymphs-9* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2154-10-6**] 03:28AM BLOOD Neuts-73* Bands-13* Lymphs-9* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2154-10-6**] 03:28AM BLOOD PT-14.3* PTT-26.1 INR(PT)-1.2* [**2154-10-6**] 03:28AM BLOOD Ret Aut-1.1* [**2154-10-6**] 09:12AM BLOOD Parst S-NEGATIVE [**2154-10-6**] 03:28AM BLOOD Glucose-106* UreaN-77* Creat-5.4*# Na-132* K-3.7 Cl-96 HCO3-19* AnGap-21* [**2154-10-6**] 03:28AM BLOOD ALT-47* AST-55* LD(LDH)-245 CK(CPK)-155 AlkPhos-261* Amylase-23 TotBili-6.7* DirBili-6.1* IndBili-0.6 [**2154-10-6**] 09:13AM BLOOD Lipase-14 [**2154-10-6**] 03:28AM BLOOD CK-MB-9 cTropnT-0.03* [**2154-10-6**] 03:28AM BLOOD Albumin-2.7* Calcium-8.2* Phos-2.7 Mg-1.7 CSF Data: [**2154-10-6**] 09:01PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-88 Lymphs-5 Monos-7 [**2154-10-6**] 09:01PM CEREBROSPINAL FLUID (CSF) TotProt-69* Glucose-64 Imaging Data: Liver/gallbladder ultrasound ([**10-6**]): No acute right upper quadrant process detected. Small gallbladder polyp. The study and the report were reviewed by the staff radiologist. Abdominal ultrasound ([**10-6**]): 1. Splenomegaly (17 cm). 2. No evidence of hydronephrosis or stones bilaterally. 3. 2.1 cm hypoechoic lesion at the left kidney, likely representing a cyst. Transthoracic echocardiogram ([**10-7**]): The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild aortic and mitral leaflet thickening, but no focal vegetations or pathologic valvular regurgitation. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2154-2-7**], the findings are similar. CLINICAL IMPLICATIONS: Based on [**2150**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CT Torso ([**10-8**]): (Preliminary read: multiple scattered nodules, some of which are cavitated, within the lungs, consistent with septic emboli.) [**2154-10-18**] Flouro Procedure: Uncomplicated ultrasound and fluoroscopically guided 5 French double-lumen PICC line placement via the right basilic venous approach. Final internal length is 50 cm, with the tip positioned in the distal SVC. Brief Hospital Course: In summary this is a 59-year-old man with history of arrythmogenic RVD s/p ICD placement who presents with severe muscle weakness, hypotension, thrombocytopenia, coagulopathy, and acute renal failure in setting of recent flu-like illness, found to have MSSA bacteremia, and right sided ICD lead vegetations. Cardiac Surgery: On [**2154-10-17**] he was taken to the operating room for Median sternotomy, open removal of old automated implantable cardioverter defibrillator leads and removal of automated implantable cardioverter defibrillator. For additional surgical details, please see 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. His CVICU course was otherwise uneventful, and he transferred to the SDU on postoperative day one. Chest tubes and pacing wires were removed without complication. On On [**2154-10-23**] he was re-admitted to the CVICU for frequent prolonged sinus pauses. EP changed Sotalol to Dofetilide 250 mg [**Hospital1 **] and monitored closely. He transferred back to the floor on [**2154-10-24**]. # Methicillin sensitive staphylococcal bacteremia: Patient was treated with nafcillin, renally dosed, throughout this hospital admission. Imaging studies revealed multiple lesions, some cavitating, in the pulmonary parenchyma, which were felt to be consistent with septic emboli. Patient underwent a transesophageal echocardiogram which showed ICD lead vegetations. Electrophysiology and the cardiac surgery team were involved in his care and it was decided to take him to expedited surgery to remove his fractured lead as well as his right sided ICD after the patient had a short-lived acute event of rigors, fevers to 102, tachycardia to 140s, and desaturation to 70s on room air after receiving 9 days of IV nafcillin likely consistent with a septic pulmonary embolus. # Infectious disease continued to follow and on [**2154-10-21**] he was transitioned from nafcillin to Vancomycin for suspected CONS seeded new AICD leads. Surveillence blood cultures were drawn with no growth to date. Goal Vancomycin trough 15-20 for a 6 week course. # Upper GI Bleed: The patient developed melena and a Hct drop from a baseline of high 30s to a nadir of 22 shortly after being started on a heparin gtt for a left upper extremity PICC related DVT with extension to the left IJ. The patient describes 2 dark, tarry stools on [**10-15**] and his heparin drip was stopped. He was transfused 3 unit of pRBCs with a resulting stable Hct around 24. GI was consulted for an EGD which was performed under general anesthesia which showed several duodenal ulcers, erosions, and gastritis, but no signs of active bleeding. He was given pantoprazole 40 mg IV BID and his hematocrit was trended closely. H pylori serology was negative. #. Left Upper Extremity DVT: Patient had known clot in LUE and had an event of tachycardia to 140s with desaturation to 70s on room air which was at first concerning . CTA could not be obtained given that the patient does not have peripheral UE access due to his clots. Given that his heparin gtt stopped today # Hypotension, likely systemic infection: given recent fevers (reported to 101 several days PTA), rising white count and bandemia, and positive urinalysis, suspect infection. CXR without evidence of pneumonia. Patient with no focal symptoms apart from muscle weakness, pain, and ?dysuria. Apart from urinary tract infection, tick-borne diseases should also be considered given his possible exposure history (consider babesiosis or Lyme disease). Other considerations include autonomic dysfunction causing neurogenic hypotension, less likely cardiogenic (slight troponin elevation in ED in setting of acute kidney injury; CK and MB were flat; EKG at [**Hospital3 **] Hospital was without ischemic changes). Patient was started empirically on antibiotics for above possible infections with Zosyn, vancomycin, and doxycycline. On the first hospital day, his blood cultures came back positive for MSSA, and his antibiotic coverage was narrowed to just nafcillin. Infectious disease service was consulted and helped to manage his antimicrobial therapy. With respect to the hypotension, his pressor (norepinephrine) was weaned and stopped by the end of the first hospital day. # Acute kidney injury. The patient had ATN secondary to hypotension/sepsis. Renal ultrasound on the first hospital day showed no evidence of hydronephrosis. The renal service was consulted and looked at his urine sediment, which showed muddy brown casts consistent with ATN, presumably the result of hypotensive insult prior to admission. He was managed conservatively, and his renal function gradually improved to baseline. Post surgery he was gentley diuresed with good urine output. His renal function remained at his basline. His electrolytes were repleted to maintain K > 4.0 and Mg > 2.0. # Transaminitis, hyperbilirubinemia: Right upper quadrant ultrasound was without evidence of hepatobiliary pathology; no right upper quadrant tenderness and negative [**Doctor Last Name 515**] on exam. Hyperbilirubinemia is predominantly direct, making hemolytic process less likely. Most likely is systemic infection causing hepatic injury. His liver enzymes were trended and improved. # Muscle weakness: Likely due to underlying infectious process. Guillain-[**Location (un) **] is certainly a consideration given the time shortly after a flu-like illness and the absence of distal reflexes. Lumbar puncture on the first hospital day was normal. The patient's muscle weakness improved with treatment of his systemic infection. # Arrythmogenic RVD s/p ICD placement, removal [**2154-10-17**]. He was followed by EP. Metoprolol was titrated once stable he was transitioned and restarted on his Sotolol. On [**2154-10-23**] he was re-admitted to the CVICU for prolonged sinus pauses. EP changed Sotalol to Dofetilide 250 mg [**Hospital1 **] and monitored closely with daily ECG's to monitor QTc for prolongation. 0n [**2154-10-26**] EP recommended continuing Dofetilide 250 mg twice daily. # Anticoagulation: Coumadin for LUE DVT. Coumadin Follow-up with Dr. [**Last Name (STitle) **] Fax [**Telephone/Fax (1) 86099**]. Goal INR 2.0 - 3.0. # Nutrition: was followed by nutrition. Supplementals and meals were encouraged. # IV Access: [**2154-10-21**]: Right Basilic Vaxcel PICC line 50 cm terminates in the SVC. # Pain: IV pain medications converted to PO with good control. # Disposition: he was followed by Physical therapy who deemed him safe for home. He will follow-up with Infectious disease, Cardiology, Vascular as an outpatient. Upon discharge he will continue to wear LIFE vest until replacement of AICD once bacteremia fully treated. Medications on Admission: --sotalol 160 mg [**Hospital1 **] --lisinopril 2.5 mg [**Hospital1 **] --multivitamin --baby aspirin --vitamin E Discharge Medications: 1. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous every twelve (12) hours for 6 weeks: 750 mg every 12 hours - to be evaluated in [**Hospital **] clinic prior to completion . Disp:*qs qs* Refills:*0* 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 5. dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): being managed by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] . Disp:*60 Capsule(s)* Refills:*0* 6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. 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* 8. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. Zaroxolyn 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Outpatient [**Name (NI) **] Work Pt/INR for coumadin dosing 13. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 14. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 15. warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day for 1 days: Goal INR [**1-16**] for DVT - dose to be adjusted by Dr [**Last Name (STitle) **] - please take 7.5mg on [**10-29**] and labs to be drawn [**10-30**] and further dosing as per Dr [**Last Name (STitle) **] . Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA [**Hospital3 **] Discharge Diagnosis: MSSA bacteremia/endocarditis Septic Pulmonary Emboli Thrombus left internal jugular and left subclavian veins GI Bleed Arrhythmogenic right ventricular dysplasia Hypertension Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Edema +2 pitting edema bilateral LE and Left upper arm +3 at DVT site Discharge Instructions: Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Answering service will contact on call person during off hours** -Shower daily washing incisions with mild soap, rinse, pat dry. -No tub bathing, swimming or hot tubs until incision healed -Daily weights: keep a log. Call you with 3-4 pound weight gain for further instructions. -No driving until after follow up with Dr [**Last Name (STitle) 914**] [**Name (STitle) **] lifting anything greater than 10 pounds for 10 weeks -LIFE Vest at all times Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time:[**2154-11-19**] 2:00 Vascular: Dr [**Last Name (STitle) 3407**] [**Telephone/Fax (1) 1237**] [**2154-11-19**] 4:00pm with ultrasound [**11-19**] at 3pm in vascular surgery office prior to seeing Dr [**Last Name (STitle) 3407**] Infectious disease Dr [**First Name (STitle) **] [**Telephone/Fax (1) 457**] [**2154-11-13**] 9:30 Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **] in 2 weeks Cardiologist Dr [**Last Name (STitle) 3315**] in [**2-14**] 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** Labs: PT/INR for Coumadin ?????? indication Left arm DVT Goal INR 2.0-3.0 First draw Wednesday [**10-30**] Results to Dr [**Last Name (STitle) **] fax [**Telephone/Fax (1) 86099**] Please draw potassium and magnesium [**10-30**] and call results to cardiac surgery office [**Telephone/Fax (1) 170**] ID weekly labs qwednesday: CBC w/diff, BUN, CR, Potassium, Magnesium, CRP, ESR, Vanco Trough to ID RN [**Telephone/Fax (1) 1419**] Completed by:[**2154-10-28**]

[ "287.5", "599.0", "584.5", "995.92", "427.89", "996.61", "E934.2", "415.12", "276.2", "578.9", "726.33", "785.52", "453.85", "421.0", "276.1", "518.81", "038.11", "453.86", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.77", "37.79", "88.55", "37.22", "45.13", "03.31", "88.72", "38.97" ]

icd9pcs

[ [ [] ] ]

18166, 18234

9088, 15915

446, 712

18453, 18681

5859, 8411

19252, 20505

4865, 5066

16078, 18143

18255, 18432

15941, 16055

18705, 19229

5081, 5840

8434, 9065

3396, 3880

299, 408

740, 3377

3902, 4602

4618, 4849

20,274

181,005

21798+21799

Discharge summary

report+report

Admission Date: [**2167-9-30**] Discharge Date: [**2167-10-5**] Date of Birth: [**2116-4-7**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 51 year old female had an episode of decompression hit while scuba diving in [**Month (only) 205**], with acute hearing loss in her right ear and subsequent problems with her hearing. She had a work-up which, in the process, revealed a patent foramen ovale. PAST MEDICAL HISTORY: 1. Hypertension. 2. Heart murmur. 3. PFO. 4. Remote history of [**Doctor First Name 533**] measles as a child. MEDICATIONS PRIOR TO ADMISSION: When she was seen on [**9-4**], medications were as follows: 1. Misoprostol 200 mcg p.o. twice a day. 2. Calcium carbonate 1000 mg p.o. once daily. 3. Fosamax 70 mg p.o. once weekly. 4. Vitamin D 400 units p.o. daily. 5. Multi-vitamin, one p.o. daily. 6. Vitamin B-12 250 mg p.o. daily. 7. Lisinopril 10 mg p.o. daily. 8. Low-agesterol, her birth control medication, p.o. daily. ALLERGIES: Penicillin, which cases a rash; tape, which causes blisters. SOCIAL HISTORY: She is a full time engineer with no use of tobacco and rare use of alcohol. Echocardiogram in [**2167-6-28**] showed trace mitral regurgitation with an ejection fraction of 60 percent and a patent foramen ovale. PHYSICAL EXAMINATION: She was 5' 11" tall; 212 pounds. Heart rate of 102. Saturating 100 percent on room air. Blood pressure 151/76. She was a well appearing and talkative, neurologically intact, alert, oriented and appropriate. Her skin was warm, dry and intact. HEAD, EYES, EARS, NOSE AND THROAT: Unremarkable. She had no jugular venous distention or bruits. Her lungs were clear bilaterally. Hear tones were S1 and S2, normal, regular rate and rhythm, with no murmurs, rubs or gallops. Her abdomen was soft and round, nontender, nondistended, with positive bowel sounds. Extremities were warm and well perfused with no edema. She had no obvious varicosities. Neurologically, she also appeared to be somewhat anxious and non focused. She had 2 plus bilateral pulses; dorsalis pedis, posterior tibial and radial, and no obvious carotid bruits. Preoperative chest x-ray showed that the heart was normal in size. Lungs were clear with no acute cardiopulmonary process. Preoperative electrocardiogram showed sinus rhythm at 94. Please refer to the final report dated [**2167-9-4**]. LABORATORY DATA: White count 6.7; hematocrit of 38.1; platelet count 280,000; PT 12.1; PTT 22.4; INR 0.9. Urinalysis was negative on dipstick with the presence of bacteria and white blood cell count on microscopic examination. Glucose 87; BUN 10; creatinine 1.0; sodium of 139; potassium of 3.7; chloride 104; bicarbonate of 25; anion gap of 14; ALT 17; AST 25; alkaline phosphatase 70; total bilirubin 0.5; total protein 7.7; albumin 4.5; globulin 3.2. HBA1C was 5.5 percent. Th[**Last Name (STitle) 1050**] was readmitted on [**2167-9-30**] as same day admit for same day surgery with Dr. [**Last Name (Prefixes) **], for closure of her atrial septal defect through a minimally invasive approach. On [**2167-9-30**], the patient underwent minimally invasive atrial septal defect repair, PSO closure with Dr. [**Last Name (Prefixes) 411**]. She was transferred to the cardiothoracic Intensive Care Unit in stable condition. That evening, the patient had an episode of bradycardia and hypotension. She was alert and responsive. Her heart rate dropped to the 40's and the systolic blood pressure dropped into the 70's. She had a Dopamine drip started and Neo-Synephrine drip increased. Her insulin drop was off at that time. At the time of examination, her blood pressure was 79/44 with a heart rate of 49. She was saturating 100 percent. Electrophysiology service from cardiology was also called to see the patient and recommended titrating her Dopamine and discontinuing her Neo-Synephrine. The patient was still intubated at that time. Overnight, she had a junctional rhythm. She ran on Dopamine and received some low dose Atropine. Postoperative laboratory studies were as follows: White count 15.8; hematocrit of 27.7; platelet count 208,000. Sodium 138; potassium of 4.0; chloride 108; bicarbonate 22; BUN 10; creatinine 0.8 with a blood sugar of 101. The patient was extubated. We continued to follow the patient every day. She continued with some junctional rhythm, to determine whether or not EP could place a temporary pacing lead, which they decided to do. It was done on the [**10-1**]. On postoperative day number two, the patient had received her temporary pacing lead. She continued on Lasix diuresis. Her white count came down to 12.2. Her hematocrit remained stable at 27.5 with a potassium of 4.0 and a creatinine of 1.0. It should be noted that Dopamine drip at 7.5 mg/kg per minute was given, with a blood pressure of 151/92 and heart rate of 61. She was also screened by the nutritionist for her nutrition risks. On postoperative day number three, her chest tubes were removed. She was started on some subcutaneous heparin. Her Dopamine was weaned to off. She had a junctional rhythm at 48 with a blood pressure of 105/49. White count dropped to 7.4. Creatinine remained stable at 0.8. She remained in the CSRU until her rhythm issues could be sorted out. She was transfused one unit of packed red blood cells for a hematocrit of 22.5. Her epicardial pacing wires were removed. On the 6th, the sheath and wire were also discontinued from her left groin by the EP service. She had episodes of occasional junctional escape beats and had some bradycardia which was asymptomatic and she was hemodynamically stable. EP determined that there was no indication for pacing at this time. On postoperative day number four, her pacing wires had been removed. She continued on Lasix diuresis and was receiving heparin subcutaneously as well as aspirin therapy. Her hematocrit rose slightly to 25.2 after the transfusion of one unit of packed red blood cells. Later that afternoon, she was transferred out of the CSRU for 402. She was allowed to advance her activity level. On postoperative day number five, the day of discharge, the patient had been transferred from the CSRU in the morning. She had no further episodes of symptomatic bradycardia. Her heart rate was in sinus rhythm in the 50 range. Most recent laboratory studies were as follows: White count of 5.4; hematocrit of 28.0; platelet count 249,000; sodium of 143; potassium of 4.7; chloride 109; bicarbonate of 28; BUN 13; creatinine 0.8 with a blood sugar of 108. The patient was evaluated by physical therapy. She did a level V and was cleared for discharge to home with VNA services. EP service was consulted again. They determined there was no need for home monitoring as the patient had no further symptomatic episodes. DISCHARGE DIAGNOSES: Status post minimally invasive arteriosclerotic disease repair and PFO closure. Hypertension. Remote history of [**Doctor First Name 533**] measles as a child. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. once daily for two days. 2. Potassium Chloride 20 meq p.o. once daily for two days. 3. Percocet 5/325 one to two tablets p.o. prn q. Four hours for pain. 4. Tylenol 650 mg p.o. prn q. Four hours as needed for temperature above 38. 5. Colace 100 mg p.o. twice a day. 6. Ibuprofen 600 mg p.o. every six hours as needed. 7. Calcium carbonate 1000 mg p.o. once daily in the morning. 8. Vitamin C 500 mg p.o. twice daily. 9. Enteric coated ferrous sulfate 325 mg tablet p.o. once daily. 10. Multi-vitamin, one tablet p.o. once daily. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was given discharge instructions to follow-up with Dr. [**First Name (STitle) 6164**], her primary care physician, [**Name10 (NameIs) **] two weeks; Dr. [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in approximately 2 to 4 weeks. This is her cardiologist. There is a question of scheduling an ETT prior to cardiac rehabilitation. Follow-up with Dr. [**Last Name (Prefixes) **] in four weeks, her cardiac surgeon, for a postoperative visit. DISPOSITION: The patient was discharged to home in stable condition with VNA services on [**2167-10-5**]. DISCHARGE DIAGNOSES: [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2167-10-5**] 15:26:52 T: [**2167-10-5**] 16:11:42 Job#: [**Job Number 57221**] Admission Date: [**2167-9-30**] Discharge Date: [**2167-10-5**] Date of Birth: [**2116-4-7**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This is a 51-year-old female who had a sudden right ear hearing loss with loud noises in [**2167-5-31**]. She was driving in [**2167-5-28**], when she had a decompression episode and heard a loud noise in her right ear with subsequent hearing loss. A workup for her hearing loss revealed a patent foramen ovale PFO. Echo TE done on [**2167-7-21**] showed a trace MR; ejection fraction was 60 percent and a PFO. PAST MEDICAL HISTORY: 1. Hypertension. 2. Murmur. 3. PFO. 4. [**Doctor First Name 533**] measles as a child. ALLERGIES: SHE IS ALLERGIC TO PENICILLIN WHICH CAUSE A RASH AND TAPE WHICH CAUSE BLISTERS. SOCIAL HISTORY: She is a full-time engineer, does not smoke and rarely drinks. MEDICATIONS: Medications prior to admission when she was seen on [**2167-9-4**] are as follows: 1. Misoprostol 200 mcg p.o. b.i.d. 2. Calcium carbonate 1000 mg p.o. once daily. 3. Fosamax 70 mg p.o. once weekly. 4. Vitamin D 400 mg international units p.o. daily. 5. Multivitamin p.o. once daily. 6. Vitamin B12 250 p.o. daily. 7. Lisinopril 10 mg p.o. daily. 8. Zestril p.o. once daily. PHYSICAL EXAMINATION: Her current height and weight on exam 5 feet 11 inches and 212 pounds. Dictation Ended At This Point [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2167-10-5**] 12:08:45 T: [**2167-10-6**] 01:13:26 Job#: [**Job Number 57222**]

[ "401.9", "458.29", "427.89", "745.5", "V12.02", "389.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.78", "35.71", "88.72", "00.17" ]

icd9pcs

[ [ [] ] ]

8293, 8655

7045, 8245

605, 1060

9798, 10153

8684, 9099

9121, 9303

9320, 9775

3,263

194,644

10163+56114

Discharge summary

report+addendum

Admission Date: [**2161-4-6**] Discharge Date: [**2161-5-1**] Date of Birth: [**2090-12-24**] Sex: M Service: MEDICINE Allergies: Univasc Attending:[**First Name3 (LF) 613**] Chief Complaint: atrial flutter for scheduled ablation Major Surgical or Invasive Procedure: Electrophysiology study with ablation. Tunnelled right internal jugular hemodialysis catheter placement. Hemodialysis EGD History of Present Illness: 70 M with DM, HTN, hyperlipid, DM2, CRF, stroke x 3 s/p R CEA, SAH s/p LMCA aneurysm clip, CAD, LV dysfxn who had p/w CHF, atrial flutter and found on TEE 6 weeks ago to have left atrial appendage thrombus since rate controlled with metoprolol and anticoagulated with warfarin, now returning for flutter ablation. . The atrial flutter was diagnosed when the patient reported palpitations to his visiting nurse. [**First Name (Titles) **] [**Last Name (Titles) 28085**], EKG documented atrial flutter and TEE documented clot in a left atrium appendage. . The patient was recently hospitalized for TIA and had non-invasive carotid studies showing 40% stenosis of [**Country **] and significant plaque in the distal [**Doctor First Name 3098**]. He has reported some persistent numbness in the thighs, incidentally. . He has had primary symptoms of fatigue and dyspnea. He was started on replacement therapy for iron-deficiency anemia. He was diuresed with lasix for lower extremity edema and has had improved symptoms but a rising creatinine, such that on [**2161-3-30**], his was 5.3 (baseline ~mid-3's). He was instructed to hold his lasix, permitting his weight to go increase, and then resume lasix at 60 mg daily. Off lasix3 days later, however, his BP increased to approx 180/110, HR was about 110 and weight up to 180 lbs by remote monitoring, although he denied SOB or CP. He did respond well to lasix 60 mg daily with BP down to 170/74, HR 108, improved symptoms with residual bibasilar crackles. . On presentation, the patient denies dyspnea or chest pain and notes that his exercise capacity is limited more by claudication symptoms in the quadriceps than by DOE. Denies orthopnea or PND. Occasional palpitations but no lightheadedness, dizziness, or vertigo. +Constipation without n/v. +Insomnia only partially explained per patient by nocturia. No pruritis, sleep-wake reversal. Past Medical History: 1. Stroke in [**2145**], ? new stroke in [**5-25**] with decreased word finding ability, Repeat CT stable, EEG nl. [**8-25**] carotid U/S-->80-99% rt carotid stenosis, 50% on left. [**10-25**] right CEA. 2. Subarachnoid hemorrhage in [**2137**] status post middle cerebral artery aneurysm clipping with residual large area of infarct and encephalomalacia 3. Coronary artery disease -[**2130**] MI.[**2143**] CABG at [**Hospital1 2025**], details unavailable followed by [**Name (NI) **] PTCA. [**2149**] cath-->occlusion of all grafts. Repeat CABG NEDH, SVG-->OM1, SVG-->D1, SVG-->RCA. [**2-20**] rest pain, cath-->occluded native RCA and LAD, grafts patent. [**Month/Year (2) 8714**] stented. [**9-25**] routine ETT/[**Doctor Last Name **]--LAD and PDA distribution ischemia on [**Doctor Last Name **]. Cath-->stent of SVG to PDA. -[**1-24**] TTE with EF 30-40% (see below) 4. Hypercholesterolemia 5. Type 2. Diabetes mellitus - no neurologic/opthalmalogic complications. 6. Chronic renal insufficiency - [**4-22**] incr creat 2.4. D/c Univasc, repeat labs-->creat 2.6. Renal U/S nl. [**6-22**] eval Dr. [**Last Name (STitle) 1366**] felt c/w microvascular disease +/- atheroembolic complications post cath. SPEP, UPEP nl. Began Diovan. [**12-27**] incr creat 3.2 persists post cath despite d/c Diovan. 7. Gastroesophageal reflux disease 8. Status post bilateral cataract surgery 9. Hearing loss 10. Peripheral vascular disease with claudication 11. Carpal tunnel syndrome Social History: Married, lives with wife. Former accountant, retired in [**2145**]. Former tobacco smoker, quit in [**2144**]. Social alcohol use. Denies drug use. Family History: Father with strokes. Brother with coronary artery disease. Physical Exam: T: 96.7F, BP: R-168/90 L-148/90, P: 68, R: 20, SaO2:96%,RA NAD, nondiaphoretic Edentulous, no OP lesions, no scleral/sublingual icterus. No LAD, Carotids 2+ without bruits, JVP 8cm H20 Chest with rales confined to bases. Heart with irregularly irregular rate. No S3,S4 heard consistently. No M/R. +BS, quite distended but nontender. No HSM by percussion or palpation. 2+ left femoral and dp. 1+ right femoral and dp. Trace left and 1+ right leg edema. 1-second capillary refill. Neuro A/Ox3 with word-finding difficulties, occasionally stuttering, motor with 5/5 throughout except 4+/5 RLE and [**3-26**] LLE. (+)R Babinski sign. (-)L Babinski sign. Pertinent Results: . LABS [**3-16**]: WBC 7.4, HCT 26.0-->28.5, PLT 323 [**3-19**]: PT 23.0, INR 3.3 [**3-27**]: NA 135, K 4.4, CL 92, CO2 29, BUN 87, CR 5.3 (baseline ~3.3), GAP=14 [**3-15**]: CK 28, TrT 0.09 [**3-16**]: Fe 29, TIBC 307, [**Last Name (un) **] 118, TRF 236 [**3-15**]: Chol 71, TG 126, HDL 25, [**3-14**]: HbA1c 8.1 [**3-14**]: Dig 0.7 . [**2161-4-6**] 05:08PM WBC-9.1 HCT-27.7* MCV-81* PLT COUNT-144*# [**2161-4-6**] 05:08PM PT-17.3* PTT-33.4 INR(PT)-2.0 [**2161-4-6**] 05:08PM SODIUM-140 POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-28 UREA N-99* CREAT-6.2* GLUCOSE-146* ANION GAP-17* ALBUMIN-3.9 MAGNESIUM-3.0* . [**2161-4-6**] 08:16PM URINE UREA N-536 CREAT-53 SODIUM-49 CHLORIDE-42 TOT PROT-117 PROT/CREA-2.2* . . . TTE, [**2161-1-22**] The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (ejection fraction 30-40 percent) with global hypokinesis that may be somewhat worse in the inferior and posterior walls. 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 ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. . TEE, [**2161-2-13**] 1. The left atrium is dilated. A definite thrombus is seen in the left atrial appendage. It seem well organised and has a small stalk to which it is attached. 2. A patent foramen ovale is present. 3. The left ventricular cavity size is normal. LV systolic function appears depressed. 4. There are complex (>4mm and/or mobile) atheroma in the ascending aorta, aortic arch, and in the descending thoracic aorta. 5. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. . CARDIAC CATHETERIZATION, [**2160-11-3**]: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal ventricular function. 3. Systolic hypertension 4. Successful stenting of the retrograde limb of the PDA via the SVG to the PDA with two overlapping Drug Eluting Stents. COMMENTS: 1. Coronary arteriography revealed a right dominant system with severe native three vessel disease. The LMCA was diffusely diseased. The LAD was totally occluded after a small D1 branch. The distal vessel filled well via a patent LIMA. The SVG to D2 graft was not visualized (aortography was performed) and is presumed to be occluded. The [**Month/Day/Year **] was totally occluded after the first OM, which was small. A large branching OM2 was well filled by a patent SVG. The RCA was totally occluded in its mid segment. The SVG to PDA was widely patent however the retrograde limb of the PDA had a 90% stenosis and the antegrade limb had a 50% stenosis. 2. Limited hemodynamics revealed systolic hypertension. 3. Left ventriculography was not performed due to concerns about the patient's renal function. Ascending aortography was performed to assess location of the bypass grafts. 4. Successful stenting of the retrograde limb of the PDA via the SVG to the PDA with two overlapping DES, a distal 3.0x23mm Cypher DES and a more proximal 3.5x13mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.5mm at the mid/proximal segment. Brief Hospital Course: A/P: 70 M with type II diabetes mellitus, hypertension, hyperlipidemia, chronic renal insufficiency, stroke x 3 s/p R CEA, SAH s/p LMCA aneurysm clip, coronary artery disease with LV dysfunction who had been admitted with decompensated heart failure, atrial flutter and found on TEE 6 weeks ago to have left atrial appendage thrombus. Since that time he has been rate controlled with metoprolol and anticoagulated with warfarin. He was admitted for flutter ablation. Hospital course was complicated. During his hospitalization the following problems were addressed: 1. Atrial flutter: Patient was treated with heparin gtt and underwent aflutter ablation [**2161-4-7**]. Coumadin was subsequently restarted. His INR became supratherapeutic, and he developed bilateral retroperitoneal bleeds. All anticoagulation was held, and he was transfused PRBC to maintain Hct. As the RP bleeds did not improve in size, FFP was administered. The patient developed a transfusion reaction to the FFP that was treated with solumedrol and benadryl. He was admitted overnight to the CCU for close monitoring. Symptoms resolved, and he was transferred back to the floor. Subsequent plans to restart anticoagulation were postponed as his Hct continued to drift down, requiring further PRBC transfusions. A GI consult was obtained and he had an EGD which revealed gastritis, which was cauterized. His hematocrit was stable thereafter. He remained in sinus rhythm. He was restarted on anticoagulation given his [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7388**] (and needed for 6 weeks post ablation in any case) and his goal INR is 2.0-2.5. Please be very careful in preventing overcoagulation. 2. CHF: Patient has congestive heart failure with some degree of brittle volume status. He was treated initially with nitrates, beta-blockade, and hydralazine for afterload reduction, and diuresed with lasix as needed. Eventually, the hydralazine was discontinued, and ACE-inhibitor restarted after initiation of hemodialysis and no further concern for renal disease. Volume status stabilized, and he was continued on metoprolol and ACE-I for secondary prevention. 3. CAD: Continued isordil, metoprolol, aspirin and ACEI for secondary prevention. There were no acute issues. 4.Chronic kidney disease: Patient has a history of diabetic and hypertensive nephropathy with volume-dependent kidney function and baseline creatinine in mid-3 range with creatinine clearnace of ~30 at optimum. On presentation, creatinine was >6 with increased anion gap. Nephrology service was consulted, and he was started on hemodialysis. A tunnelled dialysis line was placed by IR, and he was started on Mon/Wed/Fri dialysis. He eventually had an AF graft placed which was used for his next HD session without problems. The Renal team recommended keeping the tunnelled line in place until the AV graft has been consistently functional. 5. Type II diabetes mellitus: Oral hypoglycemics were held, and he was treated with a sliding insulin scale. Recent HgbA1c was 8.1. 6. TRALI: Pt recieved FFP during when he had his RP bleed and developed fevers, SOB and infiltrates. Found to have TRALI and treated with IV steroids X 1 day. Did not require intubation. 7. L femoral compressive neuropathy: developed as a complication of his retroperitoneal bleeding, causing significant LE pain and weakness. He slowly improved with PT and analgesics; he will continue aggressive PT at rehab. Medications on Admission: MEDS AT HOME: AMARYL 2MG--2 qam, one every evening AMBIEN 5MG--One by mouth at bedtime as needed ASPIRIN 325MG--One every day EPOETIN ALFA 2,000 unit/mL--1 cc ([**2155**] u) sc three times weekly HYDRALAZINE HCL 25 mg--1 tablet(s) by mouth three times a day ISOSORBIDE DINITRATE 30 mg--1 three times a day LASIX 40 mg--2 tablet(s) by mouth once a day LIPITOR 10MG--One by mouth every day NIFEREX 60 mg--1 capsule(s) by mouth once a day METROPOLOL 100mg TID WARFARIN SODIUM 3 mg--as directed (held 3 days prior to admission) WARFARIN SODIUM 5 mg--as directed (held 3 days prior to admission) Milk of magnesium Colace Senna Discharge Medications: 1. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for prn insomnia. Disp:*10 Tablet(s)* Refills:*0* 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. 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* 10. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 11. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): until INR >2.0 . Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Atrial Flutter Congestive heart failure Acute renal failure Trali Retroperitoneal Bleed GI Bleed left femoral compressive neuropathy Discharge Condition: stable and improved Discharge Instructions: Please call your physician with any new, worsening, or different shortness of breath, chest pain, lightheadedness, fatigue, nausea, vomiting, or confusion. Please continue your current medications as previously directed. Please follow up in dialysis as per the recommendations of the nephrology social worker, [**Name (NI) **] [**Name (NI) 17926**]. Followup Instructions: Please note the following previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2161-5-28**] 2:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**] [**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2161-10-7**] 9:30 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] VASCULAR [**Name12 (NameIs) 3628**] Where: VASCULAR [**Name12 (NameIs) 3628**] Date/Time:[**2162-3-29**] 10:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2161-5-1**] Name: [**Known lastname **],[**Known firstname **] P Unit No: [**Numeric Identifier 5953**] Admission Date: [**2161-4-6**] Discharge Date: [**2161-5-1**] Date of Birth: [**2090-12-24**] Sex: M Service: MEDICINE Allergies: Univasc Attending:[**First Name3 (LF) 1472**] Addendum: Pt was found to have a small thrombophlebitis on left forearm at site of old IV. Will be discharged with keflex 500mg q6H X 72 hours. Please eval at that time for resolution of infection and prolong antibiotics if indicated. Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**] Completed by:[**2161-5-1**]

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icd9cm

[ [ [] ] ]

[ "37.26", "99.04", "99.07", "42.33", "39.95", "39.27", "37.34", "38.95" ]

icd9pcs

[ [ [] ] ]

16344, 16589

8626, 12112

305, 429

14524, 14545

4776, 7198

14946, 16321

4031, 4091

12784, 14228

14369, 14503

12138, 12761

7215, 8603

14569, 14923

4106, 4757

227, 267

457, 2351

2373, 3849

3865, 4015

59,134

149,047

33886

Discharge summary

report

Admission Date: [**2181-12-15**] Discharge Date: [**2181-12-17**] Date of Birth: [**2114-5-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: S/p Seizure secondary to Celexa overdose Major Surgical or Invasive Procedure: None History of Present Illness: 67 yo M with past medical history of depression with a suicide attempt in the [**2153**]'s, diabetes, hypertension who reports having taken celexa 40 mg x15 pills (600mg total) on day of admission in an effort to kill himself. He reports that after taking the pills, he decided he did not want to die and he called 911. In the ED, he had a 30 second generalized clonic-tonic seizure and was given 2mg iv ativan with cessation of seizure activity. Psychiatry consult was placed in the ED but they were unable assess as he was post-ictal. Review of systems was negative in the ED for chest pain, shortness of breath , headache. nausea, vomiting or diarrhea. Past Medical History: Diabetes Type II complicated by retinopathy, neuropathy CKD baseline 1.5-1.7 HTN Depression with suicide attempt in the [**2153**]'s Social History: Lives alone; previously worked as a cab driver but had to quit given worsening vision. No alcohol since [**2147**]; no tobacco. Family History: No diabetes or CAD. Father with pancreatic cancer. Physical Exam: VS: 97.1 117/51 62 16 98% RA GEN: NAD HEENT: dry mmm, EOMI, PERRL NECK: supple CV: regular rate, no mrg, no elevation in JVP PULM: CTAB ABD: +bs, soft, NTND EXT: No edema 2+ distal pulses NEURO: CN 2-12 intact, 5/5 strength UE/LE Bilaterally PSYCH: flat affect, depressed mood, poor eye contact, denies [**Name2 (NI) **] . Labs: See attached Pertinent Results: DISCHARGE LABS: -[**2181-12-17**] WBC-7.3 Hgb-9.9* Hct-28.2* Plt Ct-192 -[**2181-12-17**] Glucose-82 UreaN-28* Creat-1.8* Na-143 K-4.1 Cl-109* HCO3-28 AnGap-10 -[**2181-12-17**] ALT-12 AST-16 AlkPhos-37* TotBili-0.4 -[**2181-12-17**] Calcium-8.3* Phos-3.0 Mg-1.7 -[**2181-12-15**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 67 yo M admitted s/p celexa overdose (600mg total) who had a generlized tonic-clonic seizure in emergency room lasting 30 seconds. Seizure treated with ativan with cessation of activity. Psychiatry consult was placed who recommended likely in-patient psychiatry admission after medically stable. Admitted to ICU for monitoring and transfered to floor after being stable and seizure-free for 24 hours. Patient's QTc was monitored, patient on a 1:1 sitter on transfer. Denied suicidal ideation on transfer to floor. Patient was monitored on floor and was discharged to in=patient psychiatry in stable condition. # Celexa Overdose: Total dose was 600mg known to cause seizure, serotonin syndrome, QTc prolongation, QRS widening, hypokalemia. Patient seized in ED for 30 second as above which abated with one dose of iv ativan, had no other seizures and has had no signs or symptoms of serotonin syndrome. QTc has been stable. Electrolytes all within normal limits. Renal function at baseline. Celexa held given overdose. # Depression/Suicide Attempt: Per patient was suicidal at time of ingestion of medication but changed his mind. Denied SI after admission. Has long psychiatric history (obtained by psychiatric consult). Per psych notes, has history of depression with possible remote history of psychosis, EtOh abuse now in remission. Regarding this suicide attempt, patient reports significant concern for his vision which has been decreasing likely [**2-24**] to his diabetes, is s/p bilateraly vitrectomy over the summer. Patient continues to deny active suicidality though reports feeling unsure that he wants to live. Has no suicidal plan. Given psych history and suicide attempt, patient was placed on section 12, 1:1 sitter continued. Psychiatry recommended in-patient hospitalization. Celexa held as above. # Diabetes: Last A1c 5.9% [**5-/2181**], on glypizide at home which was held on admission. Treated with sliding scale. Restarted glyipzide on discharge. # Hypertension: Normotensive through hospitalization off of anti-HTN medications which were held in light over overdose. Will continue to hold after discharge. Patient should see primary care physician for restarting of these medications # Chronic Kidney Disease Stage III: Baseline 1.5-1.7, creatinine 1.9 likely [**2-24**] to poor po intake. Improved after small fluid bolus. Of note, celexa is not renally cleared. # Communication: With patient and half-sister [**Name (NI) **] [**Name (NI) 1661**] [**Telephone/Fax (1) 78310**] Medications on Admission: Celexa Glipizide Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for diarrhea. 2. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: Primary: Celexa overdose Depression Secondary: Diabetes Hypertension Discharge Condition: Good, vital stable. Discharge Instructions: You were admitted after overdosing on your anti-depressant Celexa. You had a seizure in the emergency room and you were treated with medication to stop the seizure which it did. Because of the overdose, none of your home medications were given as celexa can cause low blood pressure. Your diabetes medication was also held which you can start taking when you leave. You should not take your blood pressure medications as your blood pressure has been fine while in the hospital. You were seen by psychiatry here who recommended in-patient psychiatric hospitalization given your prior history and this drug overdose. You will be discharged to a psychiatric hospital and will be followed there. If you have chest pain, shortness of breath, fever higher than 100.5, severe abdominal pain, dizziness or lightheadedness or any other concerning symptom, please seek medical care immediately. Additionally, if you are feeling suicidal please go to the emergency room immediately or call 911. It was nice to meet you and participate in your care. Followup Instructions: Please follow up with your primary care doctor and your out patient psychatrist when you are discharged from the psychiatric hospital.

[ "250.50", "969.0", "362.01", "403.90", "585.3", "E950.3", "780.39", "250.60", "311", "357.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5126, 5171

2170, 4703

357, 363

5285, 5306

1797, 1797

6399, 6537

1368, 1420

4770, 5103

5192, 5264

4729, 4747

5330, 6376

1813, 2147

1435, 1778

277, 319

391, 1050

1072, 1206

1222, 1352

1,712

182,577

11623+56261

Discharge summary

report+addendum

Admission Date: [**2166-11-8**] Discharge Date: [**2166-12-9**] Date of Birth: [**2114-10-28**] Sex: M Service: TRAUMA HISTORY OF PRESENT ILLNESS: The patient is a 52 year old white male who presented as a trauma alert, status post fall from a flight of stairs. The patient was intubated at the scene and came in with a GCS of 3. The patient underwent CAT scan of his head as well as cervical spine, abdomen and pelvis. CAT scan of the head remarkably was negative. Cervical spine showed a C2 dense fracture that was displaced. The patient's CAT scan of his abdomen and pelvis on arrival was also negative. Chest x-ray was also within normal limits. His pelvis x-ray was also within normal limits. The patient was subsequently admitted to the Surgical Intensive Care Unit for further management. HOSPITAL COURSE: On [**2166-11-14**], the patient underwent anterior fixation of his C2 dense fracture. Postoperatively, the patient did well and on [**2166-11-15**], the patient was extubated. His residual neurologic function includes movement in his right upper extremity as well as right lower extremity, however, his left extremity, upper as well as lower, had absolutely no function neurologically. His Intensive Care Unit course was a complicated one. The patient required reintubation on [**2166-11-17**], for respiratory distress. At that time, sputum cultures as well as blood cultures and urine cultures were sent for temperature of up to 101. Those cultures came back positive for Methicillin resistant Staphylococcus aureus in his sputum for which the patient was placed on Vancomycin. Moreover on [**2166-11-21**], the patient's mother who at that time believed to have health care for this patient made the patient "Do Not Resuscitate". In early [**Month (only) 1096**], the patient was mentating well and was able to nod to simple questions and interact to a minimal degree. On [**2166-11-28**], the family agreed to a tracheostomy after which the patient's mentation improved even more where he was able to interact with nursing staff, able to ask for things as well as answering more complex questions. On [**2166-12-3**], the patient received a gastrostomy tube per interventional radiology. Tube feed was then restarted two days later for which the patient tolerated without any difficulty. Also rescan of the patient's neck noted that his initial repair of his C2 fracture required revision. Dr. [**Last Name (STitle) 363**] of orthopedics took the patient back to the operating room on [**2166-12-4**], and the patient underwent a revision of his C2 fracture fixation. Postoperatively, the patient did well. It was noted, however, that the wound had some serous drainage. Dr. [**Last Name (STitle) 363**] evaluated the wound and determined that the drainage was not cerebrospinal fluid and that the patient should be able to recover nicely without further intervention. On discharge, the patient is in stable condition. The patient's wound is healing well. His serous drainage is minimal and the patient received a full fourteen days of Vancomycin for his Methicillin resistant Staphylococcus aureus. He has remained afebrile for the last week. By systems, neurologically, the patient is stable. His wound is healing well as mentioned and neurologically, he is able to interact, however, he is unable to talk secondary to his tracheostomy. Cardiovascularly, he is hemodynamically stable. He is on Lopressor. Respiratory wise, currently he is on a weaning protocol. He has been off the ventilator for as much as six hours without any problems, resting only at night. We will try keeping the patient off the ventilator for 24 hours to see how he does. Gastrointestinal - The patient is tolerating tube feeds which is ProMod with fiber at 80 cc per hour which is his goal. He has gastrostomy tube without any problems. Genitourinary - The patient is making good urine output with a stable creatinine. Infectious disease - The patient is receiving fourteen days of Vancomycin for his Methicillin resistant Staphylococcus aureus in the sputum and prophylactically, the patient is receiving Lovenox for deep vein thrombosis prophylaxis as well as Venodyne boots. MEDICATIONS ON DISCHARGE: 1. Lotrimin 1% cream b.i.d. applied to feet. 2. Zoloft 50 mg per gastrostomy tube q.d. 3. Lopressor 50 mg per gastrostomy tube b.i.d. 4. Vancomycin one gram intravenous q12hours. He requires two more days for completion of his fourteen day course. 5. Ferrous Sulfate 325 mg per gastrostomy tube t.i.d. 6. Lovenox 30 mg subcutaneous b.i.d. 7. Diamox discontinued. 8. Prevacid 30 mg per gastrostomy tube q.d. 9. Dulcolax one tablet PR p.r.n. 10. Combivent two to four puffs q.i.d. p.r.n. 11. Miconazole Powder to affected areas. In summary, the patient is a 52 year old status post fall from stairs with C2 dense fracture, status post repair and fixation and revision of that fixation, now getting discharged in stable condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Name8 (MD) 20292**] MEDQUIST36 D: [**2166-12-8**] 17:56 T: [**2166-12-8**] 17:59 JOB#: [**Job Number 11121**] Name: [**Known lastname **], [**Known firstname 133**] R/JR. Unit [**Name2 (NI) **]: [**Numeric Identifier 6589**] Admission Date: [**2166-11-8**] Discharge Date: Date of Birth: [**2114-10-28**] Sex: M Service: STAT ADDENDUM: Change discharge date to [**2166-12-11**]. Due to rehab availability the patient was kept in the hospital for an extra two days. There is now a bed available at [**Hospital6 6590**] and he will likely be discharged on today, Thursday [**2166-12-11**], in the same condition as previously described. [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**], M.D. [**MD Number(1) 3712**] Dictated By:[**Name8 (MD) 6298**] MEDQUIST36 D: [**2166-12-11**] 09:24 T: [**2166-12-11**] 10:25 JOB#: [**Job Number 6591**]

[ "996.62", "E880.9", "V10.11", "342.92", "482.41", "518.81", "806.04", "305.00", "705.1" ]

icd9cm

[ [ [] ] ]

[ "38.7", "96.72", "03.53", "81.01", "43.11", "77.79", "96.6", "02.95", "31.1" ]

icd9pcs

[ [ [] ] ]

4261, 6095

843, 4235

169, 825

80,239

193,855

36096

Discharge summary

report

Admission Date: [**2160-3-26**] Discharge Date: [**2160-4-1**] Service: MEDICINE Allergies: Acetylcysteine Attending:[**Doctor First Name 2080**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: None History of Present Illness: The patinet is an 86 year old male with a history of advanced dementia, CAD w/ prior PCI, CHF, CKI (baseline cratinine ~1.3) COPD, CAF (not on coumadin due to GI bleed), bipolar disorder who presented to [**Hospital3 **] on [**3-21**] with abnormal lab results. He was found to have a hematocrit of 17, WBC of 23. He was admitted to their ICU for further care. . He recieved a total of 9 units of pRBC, but if he had elements of hemodynamic instaiblity. On the day of transfer hehis hct was 29.8. The patient underwent an EGD which showed a a "huge deep ulcer" in the distal duodenal bulb with evidence of recent bleding, but no active bleed. It was injected with 2ml of epinephrine, but the patient continued to have a falling hct. General surgy was consulted, who fent that given the patients multiple comorbidities, embolization for the GDA would be most appropriate. . Other significant elements of his hospitalization include ongoing chronic AF with a bradicardic response for which cardiology was consulted. His BB was decreased and his digoxin was discontinued in the setting of ARF on presentation to 1.9 (now down to baseline of 1.3) with IVF. Additionally, the patinet was treated empirically for c.diff with PO vancomycin, despite having 2 stool cultures which were negative. His WBC fell to 11.4 during his hospitalization. He is now transfered to [**Hospital1 18**] for further manegment. . The patient is currently AAOx1. He denies any abdominal pain, nausea/vomtiing, fevers/chills, and endorses being hundry. No complaints of chest pain, shortness of breath, lightheadedness. Past Medical History: CAD w/ prior stent. HTN Chronic AF not on coumadin [**1-15**] to GI Bleed COPD Dementia CVA CKI (baseline Cr of 1.3) Chronic Anenia Hyperlipidemia C.diff CHF Social History: The patient lives at [**Location 2203**] [**Hospital1 1501**] after recent d/c from Radius. He is a former smoker and has a formal history of alcohol use. Family History: NO history of GI issues Physical Exam: afebrile HR 73 BP 157/57 97% RA appears well- pleasantly confused, talkative MMM- no oropharyngeal lesions, anicteric lungs with faint bibasilar ronchi irregular, soft SM at LSB abdomen soft, nontender, no organomegaly rectal with small/mod amount of borderline melena (vs. dark stool) in vault extremities- no c/c/e Pertinent Results: [**2160-3-26**] 06:19PM GLUCOSE-84 UREA N-31* CREAT-1.2 SODIUM-144 POTASSIUM-3.7 CHLORIDE-115* TOTAL CO2-20* ANION GAP-13 [**2160-3-26**] 06:19PM estGFR-Using this [**2160-3-26**] 06:19PM AMYLASE-107* [**2160-3-26**] 06:19PM LIPASE-60 [**2160-3-26**] 06:19PM CALCIUM-8.0* PHOSPHATE-3.6 MAGNESIUM-1.7 [**2160-3-26**] 06:19PM WBC-13.8* RBC-3.70* HGB-11.3* HCT-33.2* MCV-90 MCH-30.5 MCHC-34.1 RDW-16.5* [**2160-3-26**] 06:19PM PLT COUNT-197 [**2160-3-26**] 06:19PM PT-12.3 PTT-25.8 INR(PT)-1.0 . Time Taken Not Noted Log-In Date/Time: [**2160-3-27**] 5:08 pm SEROLOGY/BLOOD CHEM# 3333B. **FINAL REPORT [**2160-3-28**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2160-3-28**]): NEGATIVE BY EIA. (Reference Range-Negative). Time Taken Not Noted Log-In Date/Time: [**2160-3-27**] 7:47 am URINE Site: NOT SPECIFIED HEM # 0094B [**3-27**]. **FINAL REPORT [**2160-3-29**]** URINE CULTURE (Final [**2160-3-29**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**2160-3-26**] 6:19 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2160-3-28**]** MRSA SCREEN (Final [**2160-3-28**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. CHEST, AP: The lungs are slightly hyperexpanded. Mild vascular congestion, interstitial edema, and small bilateral pleural effusions, left greater than right, are slightly improved. Mild bibasilar atelectasis persists. The cardiac silhouette is normal. No free intraperitoneal air is visualized, although portable radiograph is not in full upright position. IMPRESSION: Slightly improved edema. . Discharge Labs: [**2160-4-1**] 05:35AM BLOOD WBC-9.2 RBC-3.21* Hgb-9.7* Hct-29.9* MCV-93 MCH-30.3 MCHC-32.5 RDW-15.6* Plt Ct-251 [**2160-3-31**] 05:25AM BLOOD Glucose-100 UreaN-24* Creat-1.2 Na-138 K-3.6 Cl-110* HCO3-20* AnGap-12 [**2160-3-31**] 05:25AM BLOOD Valproa-33* Brief Hospital Course: Acute blood loss anemia/duodenal ulcer bleed: The cause of his GI bleed was found to be a deep duodenal ulcer, discovered at [**Hospital3 **]. Upon transfer to [**Hospital1 18**] his HCT was stable in the low-mid 20s. GI, surgery, and IR were consulted. It was felt that endoscopy would not be helpful in terms of intervention. Surgery did not feel he was a good candidate for surgery given his multiple comorbidities. IR felt that embolization could be pursued if his bleeding resumed. He was maintained on [**Hospital1 **] PPI with good effect and improvement in his Hct. No further interventions were performed. H. pylori was negative. His ASA/Plavix were held in house. - should continue [**Hospital1 **] PPI indefinitely. - will need GI follow up - baseline Hct at discharge 27-28 - still had guaiac positive stool at discharge . CAD, native: Per report he had underwent stenting many years ago. His ASA/plavix were held prior to transfer here. These were held in house, his metoprolol and statin were continued. Going forward, may consider restarting aspirin after resolution of his ulcer and outpatient assessment. - aspirin/plavix held. can consider restarting if duodenal ulcer heals and is cleard by GI. risk/benefits should be discussed with sister. . HTN, benign: His metoprolol was continued at lower dose. Amlodipine was continued. - metoprolol decreased to 12.5mg [**Hospital1 **] am/pm, 25mg in the afternoon . Atrial Fibrillation: Stable in house with episodes of bradycardia to 40-50s. His digoxin had been held at [**Hospital1 **]. His metoprolol was decreased in house. Further titration will be necessary. He is not an anticoagulation candidate. - digoxin held, metoprolol adjusted per below . Encephalopathy: Likely delirium from GI bleed and UTI. Supportive care was provided. His depakote was continued and increased to 250mg [**Hospital1 **] . UTI: E. coli in urine with encephalopathy. He was treated with ceftriaxone x3 days, and discharged on cefpodoxime to complete 5 day course through [**2160-4-3**] . CKD: Stable during admission. . COPD: started on flovent, spiriva, albuterol prn . Baseline was pleasant, lucid/awake, and talkative. Only occasionally oriented to place, person. no focal neurologic deficits. has mild cough. . DNR/DNI during admission, discussed with sister who is his primary contact. [**Name (NI) 3608**]: [**Telephone/Fax (1) 81880**] SISTER [**Name (NI) 81881**] HOME PHONE Medications on Admission: Home Medications: MVI Amlodipine 10mg daily Plavix 75mg daily Flvoent Trazadone Simvastatin 80mg daily Colace Ultram Tylenol Duoneb Lopressor 100mg TID Depakote Digoxin 0.125mg daily Fe Calcitrol Allopurinol Allergies: . ---- MEDICATIONS AT TIME OF TRANSFER---- . mvi AMLODIPNE 10MG DAILY FLUTICOSONE 110 MCG ih [**Hospital1 **] TRAZADONE 50MG Qhs SIMVASTATIN 80MG DAILY COLACE 200MG DAILY TRAMADOL 25MG q8h PRN TYLENOL 650MG prn Metoprolol 50mg TID Depakote 125mg [**Hospital1 **] Sucralfate 1gm TID Lactobacillus 1tab daily Ferrous sulfate 325mg daily Calcitrol 0.25mcg daily Allopurinol 100mg daily pantoprazole 40mg [**Hospital1 **] IV Amlodipine 10mg daily Vancomycin PO 125mg q6h Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 8. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule, Sprinkle PO BID (2 times a day). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): in the morning and evening. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): in the afternoon. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 14. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 2 days: through [**2160-4-3**] for UTI. 15. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital 1514**] Health Care Discharge Diagnosis: Acute blood loss anemia/duoenal ulcer GI bleed Encephalopathy Dementia CAD, native CKD HTN, benign COPD Atrial fibrillation Encephalopathy UTI Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Patient was admitted from [**Hospital3 **] with acute blood loss anemia and GI bleed from a deep duodenal ulcer. He did not require blood transfusion while admitted at [**Hospital1 18**]. He was evaluted by GI, surgery, and interventional radiology services. They felt that only surgery or artery embolization would succeed. However, definitive treatment was deferred given that his bleeding resolved spontaneously. He was transitioned successfully to a [**Hospital1 **] PPI. His aspirin and plavix were held due to his bleeding risk. His digoxin was held due to bradycardia, and his metoprolol was continued at a decreased dose. His depakote was increased slightly . He was also mildly delirious while in patient. He was found to have a likely E. coli . Medication changes: 1. aspirin/plavix held until ulcer healed 2. digoxin held due to bradycardia 3. metoprolol decreased to 12.5 [**Hospital1 **] am/pm, 25mg afternoon 4. protonix 40mg [**Hospital1 **] added 5. depakote increased to 250mg [**Hospital1 **] Followup Instructions: Please follow up with your PCP as soon as possible after discharge: PCP: [**Name10 (NameIs) 81882**],[**Name11 (NameIs) 306**] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 81883**] . Patient will require GI follow up requiring his duodenal ulcer.

[ "285.1", "V45.82", "296.80", "285.21", "294.8", "599.0", "041.4", "403.10", "414.01", "585.9", "348.30", "427.31", "496", "532.40" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9958, 10016

5222, 7673

229, 236

10203, 10203

2607, 4926

11431, 11686

2229, 2254

8410, 9935

10037, 10182

7699, 7699

10388, 11151

4942, 5199

2269, 2588

7717, 8387

11171, 11408

183, 191

264, 1859

10218, 10364

1881, 2041

2057, 2213

30,201

156,919

34130

Discharge summary

report

Admission Date: [**2118-5-15**] Discharge Date: [**2118-5-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Gastrointestinal bleeding. Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: Mr. [**Known lastname **] is an 87yo male with PMH significant for HTN, aortic aneurysms, and hip fracture s/p repair on [**5-4**] who is being transferred from OSH for major GI bleed. The patient underwent recent hip surgery and was then discharged to [**Hospital 29158**] Rehab facility. He had been started on Fragmin after his surgery. On the day of admission to OSH he had a large bowel movement with blood. He was then brought to the ED for evaluation and his Hct was 18.1 (down from 38 six days prior) and he passed approximately one liter of blood and clots. Per records from OSH, he did not have any upper GI symptoms. He was transferred to the CCU for closer management. He underwent two endoscopies and two colonoscopies. The most recent endoscopy showed bleeding from the duodenal wall proximal to ampulla but due to technical difficulties was unable to be clipped, cauterized, etc. Per OSH records, surgery was consulted for possible angiogram. This could not be done since his aorta is occluded. It appears that he also underwent a bleeding scan which localized the bleed to the transverse colon. He received a total of 12 units pRBCs, 6 units platelets, 4 units FFPs during his length of stay at the OSH. He is now being transferred to [**Hospital1 18**] for management of his acute bleed. His Hct on transfer is 29.6. Past Medical History: 1)Hypertension 2)Aortic aneurysm (occluded) 3)Right hip fracture s/p ORIF on [**5-4**] 4)Congenital single kidney 5)? prostate cancer 6)Dementia Social History: Retired marine mechanic. No history of alcohol, tobacco, or IVDA. He is a widower. He has one daughter and two sons. Family History: NC Physical Exam: vitals T 99.4 BP 159/65 AR 82 RR 21 O2 sat 95% on 2L Gen: Awake and alert, no acute distress HEENT: MMM Heart: RRR, no audible m,r,g Lungs: CTAB, scattered crackles posteriorly Abdomen: Soft, NT/ND, +BS Extremities: No LE edema, 1+ DP/PT pulses bilaterally Pertinent Results: ADMISSION LABS: =============== 11.3 12.5 >-------< 240 31.9 Neuts 81.9 Lymphs 12.5 Monos 1.6 Eos 3.7 Basos 0.3 PT 13.3 PTT 26.6 INR 1.1 148 112 31 -----|-----|-----< 133 3.9 30 1.3 ALT 20 AST 20 LDH 233 Alk Phos 63 Total Bili 2.0 Alb 3.1 Ca 8.2 Phosphate 2.5 Mg 2.0 [**2118-5-15**] 07:06PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0* LEUK-MOD [**2118-5-15**] 07:06PM URINE RBC-[**5-24**]* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-0-2 PERTINENT LABS DURING HOSPITALIZATION: ======================================= Hct trend: 31.9 - 29.1 - 28 - 31.9 - 30.7 - 32.6 - 31.4 - 34.1 - 34.1 - 34.9 MICROBIOLOGY: ============= [**2118-5-15**] 7:06 pm URINE Source: Catheter. URINE CULTURE (Preliminary): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. 2ND ISOLATE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2118-5-16**] H. pylori: pending STUDIES: ======== [**5-15**]: Endoscopy: Esophagus: Mucosa: Grade 2 esophagitis with no bleeding was seen in the lower third of the esophagus and middle third of the esophagus. Stomach: Excavated Lesions A single cratered non-bleeding 5mm ulcer was found in the antrum. Duodenum: Excavated Lesions A single cratered 2 cm ulcer was found in the duodenal bulb. There were 2 visible vessels seen, but no evidence of active bleeding. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis. A duodenoscope was used to visualize the periampullary area. A single cratered non-bleeding 6mm ulcer was found in the second part of the duodenum, above the level of the major papilla. A visible vessel was identified, but it was not actively bleeding. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis. Impression: Ulcer in the antrum Ulcer in the duodenal bulb (thermal therapy) Ulcer in the second part of the duodenum (thermal therapy) Grade 2 esophagitis in the lower third of the esophagus and middle third of the esophagus . Relevant Imaging: 1)Upper endoscopy ([**5-13**]): The endoscope was inserted into esophagus, stomach, down into duodenum well passed the ampulla including a retroflexed view of the fundus. The distal esophagus revealed ulceration. There was no bleeding from this area. There was coffee grounds in the stomach. On entering hte duodenal bulb there was a superficial ulceration about 2cm in size. Had a slightly necrotic base. There was no visible vessel. This ulceration was not bleeding at the time. . 2)Colonoscopy ([**5-13**]): Tubular structure in the rectum which appears to be vascular. There is no bleeding from this lesion. . 3)Endoscopy ([**5-14**]): Examination of the esophagus and stomach were both normal, except for coffee grounds in the stomach. Examination of the duodenum revealed a duodenal ulcer in the bulb without overlying clot or visible vessel. The endoscopy was then advanced into the second portion of the duodenum where almost immediately adjacent to the ampulla or slightly proximal to it there was fresh blood and an apparent clot. It was very difficult to visualize this, as it was on the medial wall at an area where there is a sharp angulation. Using ERCP cannula, easily able to lift the clot off the duodenal wall proximal to ampulla. Gentle irrigation was used and the clot was not able to be dislodged. Clip was attempted but unsuccessful. . 4)Colonoscopy ([**5-14**]): Small to moderate amount of blood in the colon. There was no stool. The blood was easily irrigated. There was fresh blood in the cecum. There are no obvious lesions or bleeding sites. . 5)Bleeding scan ([**5-11**]): GI bleeding originating in the region of the mid transverse colon. . 6)EGD ([**5-15**]): EGD on [**2118-5-15**] that showed grade 2 esophagitis, single non-bleeding ulcer in antrum, single non bleeding ulcer in duodenal bulb with 2 visible vessels without active bleeding that were cauterized, and single non-bleeding ulcer in the 2nd part of the duodenum with non-bleeding vessel that was cauterized. . CHEST (PORTABLE AP) [**2118-5-16**] IMPRESSION: Mild cardiomegaly. No acute cardiopulmonary process. . HIP UNILAT MIN 2 VIEWS RIGHT [**2118-5-17**] FINDINGS: No previous images. There is a metallic fixation device about a previous fracture of the proximal femur. No fracture line is appreciated at this time and there is no evidence of hardware-related abnormality. Extensive vascular calcification is seen in the lower pelvis. Of incidental note are severe degenerative changes involving the visualized portion of the lower lumbar spine. Brief Hospital Course: Mr. [**Known lastname **] is an 87yo m with PMH as listed above on Fragmin since recent hip fracture repair who presents with major GI bleed. 1)GI bleed: Patient transferred from OSH to the MICU with major GI bleed. Endoscopy from OSH showed bleeding from duodenal wall lateral to ampulla. Due to technical constraints no intervention could be done. Endoscopy here showed multiple ulcers, one of which was located at the site of suspected bleeding. BiCAP was done here which will hopefully prevent any further bleeding. Most likely NSAID induced since he had been on Motrin and ASA. Hct on admission here is 31.9. He received 12 units pRBCs at OSH and 1 additional unit here at [**Hospital1 18**]. Hcts remained stable post endoscopy, and he was transferred from the MICU to the medical floor. His aspirin, nsaids, and fragmin were discontinued. He was discharged on Protonix 40 mg po BID. H. pylori pending. 2)Atrial fibrillation: EKG on admission suggested atrial fibrillation. No prior history based on OSH records. Converted to NSR spontaneously. Patient is not a candidated for anticoagulation due to massive GI bleed. 3)Hypernatremia: Patient was hypernatremic at OSH and Na, on admission, was 148. Likely due to decreased access to free water since his PO intake has been poor since his admission to the OSH. It corrected after IVFs/ 4)Chronic renal insufficiency: Baseline is not known but is indicated on his problem list from OSH. Possible prerenal component as well. All medications were renally dosed and creatinine monitored. 5)Hypertension: Patient is on Norvasc, Diovan, and Metoprolol as an outpatient. He was continued on some of these medications at the OSH despite having a major GI bleed. After his GI bleed stabilized, he was started on metoprolol 12.5 mg TID and norvasc. Diovan was held in setting of slightly elevated Cr. 6)R hip fracture s/p ORIF: Patient had been started on Fragmin after his surgery and continued until day of admission when it was stopped at OSH. Fragmin was discontinued. Orthopedics took staples out, and an X-ray was normal post-surgery. He will need follow up with his orthopedic surgeons at OSH in 4 weeks. PT followed patient and recommended rehab. 7)Aortic aneurysm: Per records from OSH, patient has occluded aortic aneurysm. No further information is known at this time. 8)Dementia: One episode of dementia/delirium while in hospital. Had 1:1 sitter and prn haldol started, but then discontinued as patient's son stated it makes him worse. 9) UTI: UCx with Proteus >100K, sensitive to ciprofloxacin. Continue ciprofloxacin for 7 day course. 10)Communication: [**Doctor First Name **] (daughter): [**Telephone/Fax (1) 78686**] 11) FULL CODE 12) Dipso: Rehab Medications on Admission: Aspirin 325mg PO daily Norvasc 10mg PO daily Diovan 160mg PO daily Fragmin 5000 units daily Motrin 800mg PO Q8H PRN Discharge Medications: 1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO three times a day. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital 78687**] Care Center Discharge Diagnosis: Primary Diagnosis: 1. Gastrointestinal Bleed 2. Atrial fibrillation 3. Urinary tract infection Secondary Diagnosis: 1. Chronic renal insufficiency 2. Hypertension 3. s/p ORIF of R hip 4. Delirium Discharge Condition: Stable. Hematocrit stable. Discharge Instructions: You were admitted for a large gastrointestinal bleed. During your hospitalization, you were given 1 blood transfusion. The gastroenterologists saw you, and you had an endoscopy that showed the sources of your bleeding, including stomach ulcers and several blood vessels that were very friable. These blood vessels were clipped to stop the bleeding. Your blood counts were monitored closely, and they remained stable after the endoscopy. Because you had a large GI bleed, you were not deemed a candidate for anticoagulation. Your staples were removed from your hip by orthopedics, and you had an X-ray that showed healing of your hip. You were also seen by physical therapy. Also, your heart went into an irregular rhythm called atrial fibrillation, but then converted to normal rhythm spontaneously. Also, you were found to have a urinary tract infection while in the hospital, and you were treated with an antibiotic. You should continue your medications as prescribed. The following changes were made: 1. Please stop taking your Aspirin. 2. Please stop taking Fragmin. 3. Please stop taking Motrin. 4. Start taking ciprofloxacin 500 mg every 12 hours for 5 more days. This is for a urinary tract infection. 5. Please take metoprolol 12.5 mg by mouth three times a day. 6. Please take pantoprazole 40 mg twice a day for your GI issues. 7. We have held your diovan while your Cr is slightly elevated. Please keep all your medical appointments. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of breath, lightheadedness/dizziness, abdominal pain, black stools, bright red blood in the toilet bowel, red colored stools, or any other concerning symptoms. Followup Instructions: Primary Care: Please call Dr. [**Last Name (STitle) 10062**] at [**Telephone/Fax (1) 10070**] to schedule a follow up appointment in [**1-16**] weeks. Orthopedics: Please call [**Hospital 6136**] Hospital Group (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78688**]) for an appointment in 4 weeks and follow up Xray of your hip. 1-[**Telephone/Fax (1) 78689**]. Completed by:[**2118-5-18**]

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icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

11039, 11118

7504, 10237

288, 305

11359, 11389

2284, 2284

13178, 13594

1987, 1991

10404, 11016

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11256, 11338

2300, 3062

11158, 11235

1690, 1837

1853, 1971

83,057

116,398

1457

Discharge summary

report

Admission Date: [**2135-6-6**] Discharge Date: [**2135-6-14**] Date of Birth: [**2072-3-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: 63 YO F with Parkinson's and dementia (recent baseline oriented times 1) p/w hypotension, hypoxia and AMS from her NH. Conflicting reports about what happened at NH per the ED but as per EMT notes the patient became pale and diaphoretic then unresponsive with episodes of apnea. Her VS when EMTs arrived where 97.1 90/40 98 14 and 88% on RA. She was placed on a NRB with sat of 91%. She remained intermittently responsive with moaning. . Upon arrival to the ED, VS were: 95 102/62 14 95% on unclear amount of oxygen. Paitent was triggered with a BP of 90. Per report her SBP did decrease to the 80s but was responsive to fluids. A bedside u/s showed dilated RV with strain. She was started on a heparin gtt due to c/f PE. Prior to heparin gtt, rectal exam revealed brown guiac positive stool. Given hypotension and recent surgery the ED was also concerned for sepsis so the patient was given cefepime, vanc and levoflox. A foley was placed with cloudy urine and u/a had >50 WBCs. Blood and urine cultures were drawn. Exam was also notable for purulent drainage and staples from his surgery on [**5-19**] so [**Month/Day (4) **] spine was called. Per report, the ED was unable to express any pus but did obtain a CT neck with contrast which did not show a fluid collection. . Given c/f PE and unclear series of events, a CTA along with CT A/P with contrast were completed and was notable for extensive bilateral pulmonary emboli spanning from the distal main pulm art to the distal segmental and subsegmental arteries along with a LLL wedge-shaped lesion c/w an infarct. Past Medical History: Parkinson's for 15 years. Dementia worse for the last 1 year. Obesity. No history of CVA, cancer, MI or other chronic illnesses. Usually blood pressure is low. She has a history of multiple falls. Social History: Lives at home with husband. Usually walks and plays piano but sometimes dependent on cane also. She is a retired school teacher. No smoking, alcohol or drugs. Family History: Parkinsons - Dad, brother Physical Exam: General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL, Conjunctiva pale, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: S1, S2 regular rhythm, normal rate Respiratory / Chest: CTA bilaterally, unlabored respirations Abdominal: Soft, Non-tender, Obese Extremities: Right lower extremity edema: Trace, Left lower extremity edema: 1+, left second toe purple Skin: Not assessed Neurologic: Responds to voice, MAE antigravity, Pertinent Results: LOWER EXTREMITY U/S: FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**] evaluation of the bilateral common femoral, superficial femoral, and popliteal veins was performed. There is extensive occlusive thrombus in the left superficial femoral vein extending to the popliteal vein. Right-sided veins are patent with normal compressibility, flow, and augmentation. Calf veins were not visualized due to patient's body habitus. IMPRESSION: DVT throughout the entire left superficial femoral vein extending through the popliteal vein. . CT CHEST: CT OF THE CHEST WITH CONTRAST: There are extensive bilateral pulmonary emboli extending from the bilateral distal main pulmonary arteries into the lobar, segmental and subsegmental branches. There is an area of hypoenhancing wedge-shaped opacity at the left lung base which is most consistent with pulmonary infarct. Small amount of atelectasis is also noted at the left lung base. There is mild bowing of the interventricular septum, concerning for right heart strain. The main pulmonary artery is also mildly enlarged. There is also a trace pericardial effusion. There is no mediastinal, hilar or axillary lymphadenopathy. The airways are patent. CT OF THE ABDOMEN WITH IV CONTRAST: Please note that there is significant artifact from the patient's overlying arms limiting evaluation. The spleen, adrenal glands, pancreas, stomach, and intra-abdominal loops of bowel are within normal limits. Multiple tiny hypodensities are noted in the kidneys bilaterally, too small to characterize. A small cyst is noted within the interpolar region of the left kidney. Gallbladder is distended but otherwise normal in appearance. There is no retroperitoneal or mesenteric lymphadenopathy. No free air or free fluid is present. CT OF THE PELVIS WITH IV CONTRAST: There is a large amount of stool within the rectum. A Foley catheter is noted within a decompressed bladder. Small amount of air within the bladder is likely due to recent instrumentation. There is no free fluid. No pelvic or inguinal lymphadenopathy is present. BONE WINDOWS: No concerning osseous lesions are identified. IMPRESSION: 1. Extensive bilateral pulmonary emboli, spanning from the distal main pulmonary arteries into the lobar, segmental and subsegmental branches. Area of pulmonary infarct in the left lower lobe. Mildly enlarged main pulmonary artery suggests component of pulmonary hypertension. In addition, bowing of the interventricular septum raises concern for right heart strain. Recommend echocardiogram for further evaluation of cardiac function. 2. No acute intra-abdominal or intrapelvic process. 3. Subcutaneous air noted in the right arm, incompletely assessed. . Brief Hospital Course: 63 YO F with Parkinson's and progressive dementia s/p recent hospitalization for fall with 2 c-spine operations now presenting with altered mental status, hypoxia and hypotension found to have submassive pulmonary emboli on imaging. . # Pulmonary embolism: She was found to have extensive bilateral pulmonary emboli on chest CT with evidence of right heart strain and slightly elevated troponin. She was started on a heparin drip for systemic anticoagulation. She remained hemodynamically stable in the ICU and was transferred to the floor. On [**6-8**], pt was started on Warfarin, and her INR was trended. . # LLE DVT: LENI's done on [**2135-6-7**] demonstrated DVT throughout the entire left superficial femoral vein extending through the popliteal vein. There was concern that due to her high clot burden in her lungs, pt would not tolerate another PE. Heme/onc was consulted. Through review of the literature it appeared that IVC filters had their greatest benefit in the first few days of DVT (up to 12 days). However, given concern that there would be difficulty in retrieving the filter, we opted to first repeat LENI's to assess for clot progression since it was found on [**2135-6-6**]. It showed extension into the femoral artery, and the study was unable to visualize extension into the pelvis. Given concern for clot progression, and IVC filter was placed on [**2135-6-10**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Dr. [**Last Name (STitle) **] indicated the filter could be retrieved in approx 4 weeks time. Please call to schedule an appointment for this by calling Dr.[**Name (NI) 8664**] assistant: [**First Name5 (NamePattern1) 8665**] [**Last Name (NamePattern1) 8666**] Cardiac Cath Lab Scheduling [**Hospital1 69**] [**Street Address(2) 8667**] [**Location (un) 86**] [**Numeric Identifier **] Phone: ([**Telephone/Fax (1) 8668**] . # Altered mental status: On the morning of [**2135-6-10**], pt was found to be unresponsive even to sternal rub around 0800. She had been seen earlier that morning around 0630 and had been sleeping, but awakened to voice and was trying to speak. Pt found to have O2 sats 96% on RA; an ABG was done which showed mild respiratory alkolosis but PO2 was normal. Pt had stat head CT without which showed no acute intracranial abnormality. Neuro was consulted, who suggested that some of her mental status changes could be attributed to her severe [**Last Name (un) 309**] Body dementia. However, seizure was also on the DDx. An EEG was ordered, but there was an equipment failure and it was never performed. In discussing the case with Neurology, they felt seizure was very low on the DDx so it was not pursued further. . # ?Urinary tract infection/Urinary Retention: Pt was found to have a grossly positive UA on admission. She was started empirically on Levofloxacin as well as broad spectrum antibiotics (cefepime and vancomycin) transiently. UCx came back as contaminated. Her levofloxacin was stopped on [**2135-6-11**]. On [**6-14**], a repeat U/A (straight cath sample) was sent that showed moderate bacteria, no WBC. Urine culture is pending at the time of discharge. She clinically appears well with no leukocytosis. Her only urinary complaint is new urinary retention. She had had incontinence with frequent bed wetting (? overflow incontinence) till Saturday, [**6-11**]. Then, on [**6-12**], she was noted to have diminished/absent urinary output. She was found to have significant urinary retention since and has required intermittent straight catheterization. Dr. [**Last Name (STitle) **] discussed this with Neurology who felt that it was unlikely due to her Neurologic or Psychiatric medications as she has been on these medications for some time. Dr. [**Last Name (STitle) **] discussed the situation with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] who felt that the urinary retention may be related to her initial cervical spine injury but that there was not much to be done at this time about it. . # C-spine surgery, Surgical site: Orthopedics spine was consulted and felt that the surgical wound was healing appropriately without evidence of surgical site infection. Her staples were removed on [**2135-6-13**] and the wound was described by Surgery as looking good. She has follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in [**Month (only) 216**] as outlined. . # Parkinson's disease: She was continued on carvidopa, levodopa. Neurology was consulted given pt's agitation and questions regarding her sinemet. They recommended decreasing her Sinemet to q3hrs and using Seroquel titrating up as needed prn agitation. . FOR FOLLOW UP: 1) INR on [**2135-6-15**] with warfarin dosing to achieve an INR goal [**12-22**] Last INR's have been as below: [**2135-6-14**] 9:20 AM 6.5 [**2135-6-14**] 5:45 AM 6.9 @ [**2135-6-13**] 7:30 PM 6.2 [**2135-6-13**] 6:05 AM 5.2 [**2135-6-12**] 6:48 AM 2.6 [**2135-6-11**] 6:05 AM 2.6 [**2135-6-10**] 5:40 AM 1.8 [**2135-6-9**] 10:00 PM 1.6 [**2135-6-9**] 4:54 PM 1.5 [**2135-6-9**] 7:15 AM 1.5 [**2135-6-8**] 3:53 AM 1.4 [**2135-6-7**] 4:26 AM 1.4 [**2135-6-6**] 8:30 PM 1.1 [**2135-6-6**] 6:45 PM 2.9 [**2135-5-20**] 7:15 AM 1.2 [**2135-5-17**] 11:39 PM 1.2 ===================== warfarin dosing: [**6-13**] - no warfarin given [**6-12**] - 2.5 mg warfarin given [**6-11**] -2.5 mg wafarin given [**6-10**] - 5 mg wafarin given [**6-9**] - 5 mg warfarin given [**6-8**] - 3 mg warfarin given ================================ 2) Please straight cath q8 hours, monitor Post-Void residuals for ongoing need 3) Monitor urine culture results ***SHOULD BE BACK on [**6-15**] or [**6-16**]. PLEASE ASK DR. [**Last Name (STitle) **] TO CHECK ON THESE in the [**Hospital1 18**] system****** 4) Please call to have IVC filter removal appointment scheduled for 3-4 weeks from now (information as listed above) Medications on Admission: 1. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS 2. Zonisamide 25 mg Capsule Sig: Two (2) Capsule PO QHS 3. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO eight times daily (): Give with each dose of sinemet except with the last dose while awake. 4. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO EVERY 2 HOURS (): Hold during evening hours while patient sleeping. Resume at 8 AM . 5. Lodosyn 25 mg Tablet Sig: One (1) Tablet PO ASDIR (AS DIRECTED): Take with each dose of sinemet. 6. Paxil 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day: with dinner. 8. Namenda 5 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day: with food. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day: Hold for loose stools. 11. Ativan 2 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week for 12 weeks. Discharge Medications: 1. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Zonisamide 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. Disp:*30 Tablet(s)* Refills:*0* 5. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. Disp:*60 Tablet(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 9. Lodosyn 25 mg Tablet Sig: One (1) Tablet PO 1 tablet with each dose of sinemet (). 10. Carbidopa-Levodopa 25-100 mg Tablet Sig: 1.5 Tablets PO Q3H EXCEPT WHILE SLEEPING (). Disp:*270 Tablet(s)* Refills:*2* 11. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO with each dose of sinemet except for last dose of sinemet (). 12. Miralax 17 gram/dose Powder Sig: One (1) PO once a day: Hold for loose stool. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO qhs prn as needed for Constipation: Hold for loose stool. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 15. Warfarin 1 mg Tablet Sig: 1-2 Tablets PO once a day as needed for Please give as per Dr.[**Name (NI) 8669**] order. INR today [**2135-6-14**] was 6.5 (down from 6.9 on [**6-13**]). Do not give warfarin tonight ([**6-14**]). Check INR on [**6-15**] and dose warfarin accordingly with goal INR [**12-22**]. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: ## extensive bilateral pulmonary emboli, pulmonary infarction: hemodynamically stable, therapeutic on heparin, on room air, s/p IVC filter placement [**6-10**] seconddary to extensive occlusive LLE DVT ## Encephalopathy - likely mulitfactorial ## Parkinson's disease with reported dementia ## moderate pulmonary hypertension ## cervical spine rim-enhancing fluid collection: seroma vs abscess # s/p anterior cervical discectomy & fusion at C3-C4 on [**2135-5-20**] # s/p C2-C4 decompression and fusion at C2-C5 with grafts on [**2135-5-21**] # Urinary retention - ? secondary to cervical cord injury # possible UTI - culture pending Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during this admission. You were admitted with shortness of breath and found to have clots in your lungs. You were in the ICU where they started Heparin to prevent the clots in the lungs from spreading. You did well, and were transferred to the medicine floors. You were continued on Heparin and Warfarin was started as well. You had a large clot in your left leg. You had a filter (IVC filter) placed to prevent the clot in your leg from breaking off and going to your lung. During the stay your shortness of breath improved. You were also seen by the Spine team, who helped to monitor your wound, which looked clean. Neurology also saw you and helped to adjust your medications for Parkinson's disease. . The following changes were made to your medications during this hospitalization: STOP Lorazepam 1 mg by mouth three times daily STOP Carbidopa-Levodopa 25-100 mg Tablet 1.5 tablets every 2hrs except while asleep STOP Quetiapine 200mg by mouth at night . START Lorazepam 1 mg Tablet by mouth every 8 hours as needed for agitation. START Quetiapine 50 mg Tablet once by mouth at bedtime START Quetiapine 50 mg tablet once by mouth three times daily as needed for agitation START Acetaminophen 325mg 2 tablets by mouth every 6 hours as needed for pain START Carbidopa-Levodopa 25-100 mg Tablet 1.5 tablets every 3 hrs except while asleep START Docusate Sodium 50mg/5ml liquid 10 ml by mouth twice daily as needed for constipation . Please continue all other medications you were on prior to this admission. Followup Instructions: Please follow-up with the following appointments below: Department: ORTHOPEDICS When: WEDNESDAY [**2135-7-13**] at 1:10 PM With: [**Year (4 digits) **] XRAY (SCC 2) [**Telephone/Fax (1) 1228**] . Please call to schedule IVC filter removal. She should have the filter removed in [**1-20**] weeks from the time of discharge. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will remove it. To schedule the removal, please call the person below: [**First Name5 (NamePattern1) 8665**] [**Last Name (NamePattern1) 8666**] Cardiac Cath Lab Scheduling [**Hospital1 69**] [**Street Address(2) 8667**] [**Location (un) 86**] [**Numeric Identifier **] Phone: ([**Telephone/Fax (1) 8668**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: SPINE CENTER When: WEDNESDAY [**2135-7-13**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3736**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.7" ]

icd9pcs

[ [ [] ] ]

14591, 14681

5655, 7554

330, 336

15358, 15358

2907, 5632

17153, 18329

2350, 2377

12829, 14568

14702, 15337

11797, 12806

15545, 17130

2392, 2888

10379, 11771

274, 292

365, 1937

15373, 15521

1959, 2158

2174, 2334

14,313

152,033

1959

Discharge summary

report

Admission Date: [**2141-3-16**] Discharge Date: [**2141-3-30**] Date of Birth: [**2072-6-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: R femoral TLC History of Present Illness: Pt is a 68 yo M with ESRD on HD s/p failed renal transplant (access through L IJ non-tunneled catheter placed [**2141-2-9**]) admitted from ED after being snet in from dialysis. Prior to starting dialysis today, noted to have BP 60/40s, asymptomatic. In ED received 1.5 L NS with increase BP to 80s-100s. He also received 1 gm vanco for empiric coverage of possible line sources of infection. Denies any recent CP/SOB/Abd pain/ Fever/chills/cough/melena. There was a question of some recent cocaine use but patient denies. . Seen by Renal in ED, no urgent need for HD on day of admission. Past Medical History: #status post failed cadaver renal transplant in [**2134**] with explantation in [**12-19**] (path acute and chronic rejection). Complicated by wound infection with ENTEROCOCCUS and BACTEROIDES FRAGILIS . #hypertension #diastolic dysfunction #congestive heart failure (Echo [**3-19**] EF 60%, 2+MR, 2+TR, moderate pulmonary artery hypertension) #diabetes type 2 #hepatitis C virus #chronic anemia #status post mitral valve replacement in [**2131**] #history of IV drug abuse with recent cocaine and heroin #h/o PTX #h/o depression #positive PPD s/p INH #s/p L eye loss after accident #cervical radiculitis #Reports HIV negative. Social History: Retired water meter reader, now disabled +ETOH/tobacco IVDA, cocaine lives alone On methadone maintenance program, but still using cocaine and IV heroin. Family History: Father -- CVA (50's),Mother -- CAD,Sister -- SLE (deceased @ 60 due to renal/cardiac complications) Physical Exam: VS - T 100.7, BP 92/56, HR 100, RR 20, O2 sat 96% RA gen - somnolent, but responsive HEENT - OP clr, MMM, L IJ site c/d/i CV - irreg irreg, tachy, [**2-20**] syst mur at apex chest - CTAB anteriorly abd - NABS, soft, NT ext - no edema, 2+ distal pulses R groin - open ~1 cm wound, no exudate or surrounding erythema Pertinent Results: [**2141-3-16**] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2141-3-16**] 04:40PM LACTATE-1.6 [**2141-3-16**] 04:15PM POTASSIUM-5.1 [**2141-3-16**] 12:45PM GLUCOSE-189* UREA N-57* CREAT-9.9*# SODIUM-142 POTASSIUM-5.8* CHLORIDE-100 TOTAL CO2-25 ANION GAP-23* [**2141-3-16**] 12:45PM CK(CPK)-24* [**2141-3-16**] 12:45PM CK-MB-NotDone cTropnT-0.15* [**2141-3-16**] 12:45PM WBC-5.1 RBC-3.67* HGB-11.1* HCT-34.3*# MCV-93# MCH-30.2 MCHC-32.4# RDW-17.0* [**2141-3-16**] 12:45PM NEUTS-65.0 LYMPHS-23.5 MONOS-8.8 EOS-2.2 BASOS-0.6 [**2141-3-16**] 12:45PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-1+ [**2141-3-16**] 12:45PM PLT COUNT-221# [**2141-3-16**] 12:45PM PT-13.0 PTT-27.3 INR(PT)-1.1. . CHEST - PORTABLE AP ([**2141-3-16**]): Comparison is made to [**2-6**], [**2141**]. The patient is status post sternotomy. The tip of the central venous line terminates at the cavoatrial junction in a similar location. Cardiac and mediastinal contours are unchanged. The lungs are clear. However, there is evidence of a small right subpulmonic effusion, new since the prior study. There is also similar fullness of the pulmonary vessels bilaterally, consistent with pulmonary venous hypertension. . ECG: Atrial fibrillation with somewhat rapid ventricular response. Since the previous tracing of [**2141-2-13**] atrial fibrillation is a new rhythm. The rate is somewhat faster. Otherwise, no significant change. . FEMORAL VASCULAR US RIGHT PORT ([**2141-3-17**]): [**Doctor Last Name **] scale, color, and pulse Doppler examination of the right femoral vessels was performed. Markedly turbulent, increased flow is seen in the right femoral vein with arterialization of the venous waveform demonstrated on pulse Doppler examination. There is a large groin hematoma measuring at least 18.5 x 7.9 x 8.3 cm. . FEMORAL VASCULAR US RIGHT ([**2141-3-18**]): Grayscale, color, and Doppler son[**Name (NI) 1417**] of the right common femoral artery and vein were performed. Again demonstrated is pulsatility of the right common femoral venous waveform with markedly elevated velocities of 180 cm/s consistent with an arteriovenous fistula. Redemonstrated within the right medial groin is a heterogeneous collection measuring at least 8.9 x 6.0 x 3.0 cm. These findings are consistent with a hematoma which appears more organized than on prior exam. Brief Hospital Course: The patient was admitted to the MICU service for close observation. At the time of admission to the ICU, the patient's SBP was stable ~100. There was concern for sepsis, [**2-16**] to an indwelling dialysis line, and the patient was covered with Vancomycin. He had a h/o of GIB in the past but his Hct remained stable and no evidence of active bleeding on exam. His BP responded to a 500cc bolus and remained stable. He was noted to be in an atrial fibrillation/flutter with RVR, requiring max diltiazem gtt and IV lopressor at one time. He was transitioned over to diltiazem and lopressor PO. With improvement in his rate, his blood pressure remained stable. The patient was noted to have a R groin hematoma, thought to be [**2-16**] to line attempts on admission. U/S revealed an AV fistula. Vascular Surgery was consulted and recommended holding pressure and repeating ultrasound. Repeat u/s following day showed no flow. . He remained hemodynamically stable and was called out to a monitored telemetry bed on the medical floor. There, a history of preceding diarrhea was elicited. Stool samples were sent for C Diff toxin assay, which returned positive on [**2141-3-22**]. The remainder of his workup remained negative, including blood cultures, chest X-ray, and [**Last Name (un) 104**] stim test. His presenting hypotension was presumed secondary to hypovolemia from C Diff associated diarrhea. He was started on PO Flagyl, with good symptomatic response. He was discharged with plans to complete a 2 week course. . He continued to be followed by the renal dialysis team and received dialysis on a MWF schedule. He was continued on Nephrocaps and received Epogen at dialysis. A temporary left internal jugular dialysis catheter was placed on [**2141-3-22**]. This was changed to a permanent tunnelled line on [**2141-3-28**]. . He was continued on a proton pump inhibitor twice daily for a recent history of gastrointestinal bleed. For this reason, he was not anticoagulated for atrial fibrillation. He received subcutaneous heparin three times daily for DVT prophylaxis. Medications on Admission: -epo -zemplar -tums -diltiazem 120 qd -thiamine 100 qd -lopressor 100 tid -protonix 40 [**Hospital1 **] -seroquel 25 tid Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Disp:*120 Tablet, Chewable(s)* Refills:*2* 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Capsule* Refills:*2* 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: C Diff colitis Dehydration Atrial fibrillation with rapid ventricular response . Diabetes End Stage Renal Disease on Hemodialysis History of recent gastrointestinal bleed Discharge Condition: Stable, discharged to home of Mr [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 10794**] (health care proxy) Discharge Instructions: 1) Continue your medications as prescribed. - You were started on an antibiotic called Flagyl (metronidazole) for your diarrhea. Take this medication until you run out (last dose [**4-6**]). - Your lopressor was changed to a once daily formulation. - Please continue taking Protonix for your stomach. 2) Weigh yourself daily. Call your doctor if your weight changes by more than 3 lbs. Please adhere to a 2 gm sodium diet, and 2 L fluid restriction. 3) Follow up as directed below. 4) Call if you have chest pain, shortness of breath, palpitations, lightheadedness, nausea, fevers, or any other concerns. Followup Instructions: Continue with outpatient dialysis as scheduled Follow up with Dr [**Last Name (STitle) **] on Friday, [**2141-4-14**] at 11:40 am - If you have any questions, or need to reschedule, you may contact his office at [**Telephone/Fax (1) 250**]. Completed by:[**2141-4-29**]

[ "427.31", "996.62", "285.29", "998.12", "428.30", "293.0", "403.91", "276.52", "458.9", "998.32", "729.5", "585.6", "008.45", "070.70" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

8059, 8108

4657, 6738

326, 341

8323, 8452

2253, 4634

9108, 9380

1800, 1902

6909, 8036

8129, 8302

6764, 6886

8476, 9085

1917, 2234

275, 288

369, 961

983, 1613

1629, 1784

28,429

163,585

29657

Discharge summary

report

Admission Date: [**2142-12-22**] Discharge Date: [**2142-12-28**] Date of Birth: [**2083-11-28**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p fall, back pain Major Surgical or Invasive Procedure: 1. Anterior reduction of fracture dislocation, C5/C6. 2. Anterior cervical diskectomy C5/C6. 3. Fusion C5/C6. 4. Anterior instrumentation. 5. Structural allograft. 6. Halo traction placement 7. Posterior fusion C5-C6. 8. Interspinous wiring C5-C6 . 9. Structural autograft. 10. Inferior vena cava filter. 11. Fluoroscopic control for inferior vena cava filter placement. 12. Incision and drainage of thrombosed hemorrhoids History of Present Illness: Pt is a 59 y/o F s/p fall down 12 stairs last night. On admission she was unable to move lower extremities and her upper extremities were weak. She had decreased rectal tone as well. She was initially hypotensive to the 80s requiring levophed. Past Medical History: hypertension, hypercholesterolemia Social History: lives with husband Family History: noncontributory Pertinent Results: [**2142-12-26**] 01:03AM BLOOD WBC-8.6 RBC-3.06* Hgb-9.7* Hct-27.6* MCV-90 MCH-31.7 MCHC-35.1* RDW-13.5 Plt Ct-235 [**2142-12-21**] 11:30PM BLOOD PT-11.0 PTT-22.3 INR(PT)-0.9 CT c-spine: Acute 3-4 mm anterolisthesis at the C5-6 level and accompanying left-sided locked facet. Likely disruption of the posterior longitudinal ligament. MRI recommended. d/w trauma and neurosurg. CT head: No acute intracranial hemorrhage. MRI: severe fx dislocation of c5 on c6 with ant sublux of c5 and retropulsion of disc/and or bony fragment impinging thecal sac and cord c/w severe stenosis; abnormal signal in cord c/w cord contusion CT torso: 1. No acute intrathoracic, abdominal, or pelvic injuries. 2. Mild anterior wedging of the T11 vertebral body, likely consistent with a compression fracture of indeterminate age. In the setting of trauma, clinical correlation is recommended. No associated pondylolisthesis. 3. Low-attenuation focus in the left lobe of the thyroid. Dedicated ultrasound examination of the thyroid could be performed if clinically indicated. 4. 2-mm right upper lobe pulmonary nodule. In the absence of a history of smoking or malignancy, no further followup is necessary. Otherwise, a followup in [**7-3**] months to confirm stability is recommended. Brief Hospital Course: The patient was brought to the [**Hospital1 18**] ED, evaluated and stabilized for imaging. Ortho-spine was consulted for evaluation of spinal cord and vertebral injury. Imaging revealed C5/6 anterolithesis with disruption of posterior longitudinal ligament requiring emergent ACDF with allograft and open reduction. Subsequent [**Location (un) 1131**] of neck MRI revealed occlusion of left vertebral artery for which vascular surgery was consulted. Post-operatively, the patient was brought to the trauma ICU for recovery. For details, please see operative note; the patient recovered in the PACU initially intubated. Neuro: While intubated, the patient was on propofol and fentanyl for pain control. When appropriate, her pain medications were adjusted to IV/PO format for pain control, which was a priority during her stay. Her neurologic exams were closely monitored, and improved throughout her stay. CV: The patient had some hemodynamic instability and lability during her stay, and was thought to be in neurogenic shock on arrival. SHe was put on levophed to maintain pressures. The patient was weaned off levophed, and put on metoprolol and lisinopril when the patient required it. Pulm: The patient was initially intubated and on a ventilator; when it became possible she was extubated, and had good pulmonary toilet subsequently. GI: The patient was evaluated by speech and swallow, and her diet was adjusted appropriately, which she tolerated well. She was put on strict aspiration requirements. The patient's stay was complicated by several episodes of diarrhea, as well as rectal pain. The patient was noted to have two thrombosed hemorrhoids, and her diarrhea was thought due fecal impaction and diarrhea oround this. The impaction was due to exquisite pain from her hemorrhoids. These were excised under local anesthetic at the bedside on [**12-28**]. The patient was also disimpacted. Subsequently she felt much better and was able to have normal bowel movements. GU: The patient's urinary output was closely monitored throughout her stay. When fluid overloaded, the patient was diuresed. Heme: The patient's hematocrit was closely monitored, and she was transfused when necessary. ID: The patient was on Kefsol perioperatively, and was monitored for signs of infection. Endo: The patient was put on decadron for 24 hours postoperatively, and her blood sugars were tightly controlled with insulin. Proph: The patient received GI and DVT prophylaxis; anb IVC filter was placed and the patient was put on SQH when appropriate. Throughout her stay, the patient was evaluated and treated by social work, physical and occupational therapy. Medications on Admission: HCTZ, Lisinopril, Effexor, Oxycodone, Hydrocodone Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 10. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal PRN (as needed). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p fall (C5-C6 bilateral facet fracture-dislocation and paraplegia) Discharge Condition: stable Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -You should take [**Last Name (un) **] baths as tolerated, especially after bowel movements, to keep your peri-anal area clean. -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. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Please follow up in 10 days with ortho-spine; call [**Telephone/Fax (1) 11061**] for appointment. You must continue to wear your hard collar until that time when out of bed. Please follow up with Dr. [**Last Name (STitle) **] on the trauma surgery service as needed; call [**Numeric Identifier 71078**] if you need an appointment. A pulmonary nodule was noted on one of your CT scans; please have repeat CT in [**7-3**] months, and follow up with your PCP regarding this matter.

[ "272.0", "806.09", "455.4", "E880.9", "839.05", "958.4", "401.9", "433.20" ]

icd9cm

[ [ [] ] ]

[ "81.02", "49.47", "93.41", "81.62", "03.53", "99.04", "81.03", "38.93", "38.7", "02.94", "80.51" ]

icd9pcs

[ [ [] ] ]

6120, 6190

2457, 5137

303, 732

6303, 6312

1154, 1533

7781, 8266

1118, 1135

5238, 6097

6211, 6282

5163, 5215

6336, 6336

6352, 7758

244, 265

760, 1008

1542, 2434

1030, 1066

1082, 1102

26,368

194,903

5261

Discharge summary

report

Admission Date: [**2109-11-11**] Discharge Date: [**2109-11-22**] Date of Birth: [**2050-1-9**] Sex: M Service: MEDICINE Allergies: Ampicillin / Amoxicillin Attending:[**Doctor First Name 1402**] Chief Complaint: ST-elevation myocardial infarction, transferred from OSH Major Surgical or Invasive Procedure: cardiac catheterization x2 ([**2109-11-12**], [**2109-11-15**]) History of Present Illness: A 59yoM with DM, HTN, ESRD on HD presnted to OSH with subacute altered mental status. Per family, patient has had trouble walking, intermittently slurred speech, non-sensical speech, decreased memory and lethargy over the past 3-6 weeks. Of note, he may have been taking Vicodin at home for his ankle pain. In the ED, neurology evaluated the patient and thought he had a mild encehpolpathy of unknown etiology. He was alert and oriented x3, able to follow commands. In the ED, CT head negative. They told him he was unsafe to leave and needed admitted. He refused and then psych was called who found him to be unalbe to make decisions. He then became very agitated and was given 0.5 ativan and 2mg haldol. He then became more agitatied and was given benedryl 50mg for agitation. Then he became HTN (SBP>200), and hypoxic (85%) and felt to have pulmonary edema. He was given 80 lasix IV and nitropaste and 10mg Zyprexa. He was then subsequently intubated for pulmonary edema and agitation and admitted to the MICU. There he was hypertensive to the 230's. In dialysis, he dropped his pressure to the 70's and then his BP meds were stopped. Tox screen was + for benzos (had ativan), neg for opiates. ESR 22B12 476, folic acid 3.7, TSH 1.2. On [**11-11**] @338AM - his EKG showed SR@92, 1-2mm STE in II, III (nl/small Q waves) and 4mm STD in V2, V3 with lateral TWI. On [**11-11**] @ 810AM - SR@66 with inferior Qs and hyperacute Ts 4am Trop: 0.85 CK: 299 MB: 14 12pm Trop: 30.0 CK: 779 MB: 57 5pm Trop: 33.0 CK: 673 MB: 44 Echo showed severe inferior wall hypokinesis/akinesis, EF ~45% with 3+ MR; no pericardial effusion. WBC ct: 11; HCt: 36.5; Ca: 10.6; TSH 1.2 CXR: On admission showed CHF In AM of [**11-11**], dialysis was stopped because of hypotension (500cc taken off). He received heparin, ASA. Past Medical History: DM HTN [**Date Range 18048**] ESRD - on HD (MWF) - last dialysis [**11-8**]; [**11-11**] Thrombectomy L arm fistula [**12-22**] Hypercholesterolemia GIB [**10-20**] in prepyloric area by EGD (? [**12-19**] NSAIDS) Gastritis [**12-22**] (EGD) Anemia Hip surgery [**6-21**] - on coumadin Prostate adenocarcinoma Chronic low back pain Social History: Occasional EtOH, No tobacco, No drugs Family History: Mother: [**Name (NI) 18048**] Physical Exam: VS: T bp hr rr % on gen: NAD, restless. HEENT: no LAD, no JVD, PERRL, EOM intact. CV: RRR, nl S1S2, no murmurs. chest: CTA b/l, no crackles or wheezes abd: soft, non-tender, non-distended, +bs, no organomegaly extr: no cyanosis, clubbing, or edema. 2+ distal pulses bilaterally neuro: a&ox1, somewhat disorganized and tangential thought process. Pertinent Results: SPEP = negative; PTH = 357; TSH = 1.4; B12 = 361, folate = 7.1; PSA = 1.0 . ECG [**2109-11-17**]: There is new first degree A-V block. Anterior wall ST segment depressions persist and are unchanged. . CXR [**2109-11-16**]: Comparison with [**2109-11-14**], the right IJ central venous catheter, and nasogastric tubes remain in position. Since the prior exam, there has been improvement in the underlying pulmonary vascular congestion throughout both lungs. There is however persistent interstitial pulmonary edema most notable in the perihilar distribution. No alveolar pulmonary edema is identified. There is mild blunting of the left costophrenic angle, which likely represents a small effusion. No focal infiltrate is identified. Cardiomediastinal silhouette is stable. There is degenerative change of the thoracolumbar spine. . ECG [**2109-11-15**]: Inferior ST segment elevation and anterior ST segment depression have improved. . Cath [**2109-11-15**]: 1. Selective coronary angiography of this right dominant system revealed significant obstructive coronary artery disease. The left main coronary artery was without angiographic evidence of significant obstructive coronary artery disease. The left anterior descending had a 30% ostial stenosis. There was no significant obstructive coronary artery disease in the mid or distal LAD. The left circumflex was proximally occluded. The ramus branch was a large vessel with an subtotal occlusion at the ostium. The right coronary artery was without angiographic evidence of significant obstructive coronary artery disease in the proximal or mid segment. There was a total occlusion in the distal RCA (unchanged from three days prior). 2. Successful PCI of the proximal ramus with a 3.5 x 18 mm Cypher [**Month/Day/Year **] (see PTCA comments). 3. Left femoral arteriotomy site was closed with an 8 French Angioseal closure device. FINAL DIAGNOSIS: 1. Significant obstructive coronary artery disease. 2. Successful PCI of the ramus intermedius. . EEG [**2109-11-14**]: Largely normal portable EEG for sleep. Drowsiness and sleep dominated the record. There were no areas of focal slowing although sleep can obscure such findings. There were no epileptiform features. . Head MRI/MRA 12/29/05:1. Mild brain atrophy. 2. Left scalp lipoma. 3. Unremarkable circle of [**Location (un) 431**] MRA. . Echo [**2109-11-12**]: LVEF>55%. The left atrium is markedly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is a trivial/physiologic pericardial effusion. . Cath [**2109-11-12**]: 1. Selective coronary angiography in this right dominant patient revealed two vessel (three counting Ramus) coronary artery disease. The LMCA was heavily calcifeid with diffuse plaquing to 20%. The LAD was heavily calcified with septal collaterals to rPDA and origin 20-30% lesion. The LCX was moderately calcified with stump occlusion of AV groove CX with delayed filling via both antegrade and ramus collaterals. The Ramus intermedius had an ostial 95% stenosis and supplied collaterals to rPDA. The RCA was heavily calcified with proximal 30%, mid 40%, and distal 50% lesions. The origins to both rPDA and RPL were occluded. 2. Resting hemodynamics revealed mild elevation of left and right sided filling pressures with RA of 11mmHG and PCWP of 15mmHG. There was mild pulmonary hypertension with mean PA of 26mmHG. The cardiac index was preserved at 3.3 (pt was on ventilator at time of cath). There was no gradient on aortic valve pullback. 3. Known systolic dysfunction with EF45% with inferior akinesis. Due to anatomy, EF and diabetes patient referred for CABG. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease of LCX, RCA and Ramus 2. Moderate LV diastolic and known LV systolic (echo with EF 45%) heart failure with preserved cardiac index. . CXR [**2109-11-12**]: Mild congestive heart failure. . Brief Hospital Course: 59 yo man with multiple cardiac risk factors w/ ESRD presents with STEMI and mental status change x 6 weeks. . ##Cardiac: #ISCHEMIA: Peak CK 779. Cath [**11-12**] w/2VD, considered CABG, however, CT surgery wanted mental status changes worked up first. No h/o angina. Likely had chronic total occlusions and demand ischemia in setting of acute stress and anxiety at OSH. Pt had sub-sternal chest pain on [**11-15**] with ECG changes and went to cath where [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] to ramus was performed. It was felt that plaque migration was responsible for the increase in LAD occlusion on the second catheterization. Given successful revascularization with stent, it was not felt that there was a need for CABG at this time. The Pt. will follow up as outpatient with Dr. [**Last Name (STitle) **] (cardiac surgery). Pt. was continued on ASA, statin, beta blocker, lisinopril, plavix. Pt. continued on amlodipine for HTN. #PUMP: Echo on [**11-12**] showed >55% EF with LVH and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**]; impaired relaxation of LV - trivial MR by [**Location (un) 1131**] here. Pt. remained euvolemic during hospitalization with no signs of worsening heart failure. #RHYTHM: normal sinus throughout, monitored on telemetry with no significant events. . #Renal: Pt with ESRD on HD. Pt. will continue with HD on mondays, wednesdays, fridays. Pt. continued on renagel. Pt. received tube feeds with low-phos until tolerating po's on [**2109-11-18**] (s/p d/c NG tube). . #MS changes: Likely acute toxic-metabolic process + subacute encephalopathy. Mental status continues to improve. MRI without etiology for subacute encephalopathy. EEG within normal limits. Unclear etiology, ?due to medications (vicodin) Pt. had been taking prior to admission. Per family, Pt.'s mental status improved at time of discharge. Pt. had 1:1 sitter until his mental status seemed to clear on [**11-18**]. 1:1 sitter was d/c'ed on [**2109-11-19**]. Pt. seen by psychiatry and neurology. Neurology's impression was a toxic-metabolic process + subacute encephalopathy, that resolved during the hospitalization. They recommended starting thiamine. Psychiatry recommended avoid ativan and other anti-cholinergics that could worsen mental status. . #Resp: Pt. intubated due to concern for pulmonary edema, and extubated on [**11-13**]. Weaned to 4L NC, then to RA. Sputum with Staph. aureus, treated with vancomycin for 10-day total course. Pt. seen by pulmonary who did not recommend CPAP at this time, since there was no evidence of OSA as a source of altered mental status. . #ID: Sputum x 2 growing Coag + Staph. aureus, [**12-23**] blood cultures with Coag Neg staph. Pt's central line d/c'd, with no positive cultures since. Pt. received vancomycin while in house, and vanco levels were monitored; Pt. received 10-day total course. C.Diff toxin negative. +U/A with U Cx that showed mixed genital flora. will complete 3-day course of Cipro. . #FEN: Pt. was on tube feeds until [**2109-11-18**], at which time the patient's mental status started to clear and he tolerated PO's without evidence of aspiration. . #Dispo: Pt. seen by physical therapy who recommended rehab, given several falls during hospital stay without LOC or other injury. Medications on Admission: Zoloft 100 qd Zestril 40 [**Hospital1 **] Atenolol 100 qd Lipitor Norvasc 10 qd Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day): hold for loose stools. 3. Humalog insulin sliding scale 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Sevelamer 800 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 14. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 15. Cipro 250 mg Tablet Sig: One (1) Tablet PO twice a day for 2 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Myocardial infarction end stage renal disease urinary tract infection encephalopathy Discharge Condition: Fair, stable. Discharge Instructions: Please continue to take all your medications exactly as prescribed. If you experience chest pain, weakness, shortness of breath, abdominal pain, nausea, or increasing confusion, please return to the hospital. Followup Instructions: Please continue to follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) 177**] [**Telephone/Fax (1) 21517**] as you have been doing. . Please call to arrange an appointment with Dr. [**Last Name (STitle) **] in Cardiac Surgery. [**Telephone/Fax (1) 170**]. . Please call to arrange an appointment wioth Dr. [**First Name (STitle) **] Yank (at [**Hospital1 **]) in Cardiology, within the next 1-2 weeks. . Please call to arrange a followup appointment with neurology at ([**Telephone/Fax (1) 2528**] Completed by:[**2109-11-23**]

[ "482.41", "401.9", "250.00", "585.6", "410.71", "428.40", "V09.0", "753.12", "414.01", "V10.46", "349.82", "599.0", "790.7", "428.0", "285.9" ]

icd9cm

[ [ [] ] ]

[ "37.23", "96.6", "36.07", "00.45", "00.66", "37.22", "88.56", "39.95", "38.93", "96.71", "99.04", "00.40" ]

icd9pcs

[ [ [] ] ]

12330, 12389

7461, 10810

344, 409

12518, 12534

3088, 7438

12792, 13328

2666, 2697

10940, 12307

12410, 12497

10836, 10917

12558, 12769

2712, 3069

248, 306

437, 2240

2262, 2595

2611, 2650

27,811

157,821

34697

Discharge summary

report

Admission Date: [**2147-10-6**] Discharge Date: [**2147-10-18**] Date of Birth: [**2094-3-16**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: SOB Major Surgical or Invasive Procedure: OPCABG x1 (LIMA to LAD)/endoscopic LIMA takedown [**2147-10-12**] History of Present Illness: 58 yo male who presented to [**Hospital3 13313**] on [**10-2**] with SOB/cough/dependent edema. Transferred to [**Hospital1 **] for cath which revealed total occlusion of the LAD. Transferred to [**Hospital1 18**] for surgical evaluation. Past Medical History: NIDDM CAD MI CRI ( baseline 1.5) CHF obesity MR [**Last Name (Titles) **]. lipids mild hyponatremia asthma HTN MRSA ( [**First Name8 (NamePattern2) **] [**Hospital 10478**] hosp. notes) Social History: lives alone works in a gas station denies ETOH use denies tobacco use Family History: non-contrib. Physical Exam: 5'[**50**]" 180# HR 73 RR 18 136/73 mutiple scars on lower legs secondary to shrapnel injury HEENT unremarkable neck supple , full ROM, no carotid bruits CTAB RRR , no murmur soft, NT, ND, + BS extrems warm, well-perfused, no edema or varicosities noted 1+ bil. fems/ DP/ PTs Pertinent Results: [**2147-10-13**] 02:01AM BLOOD WBC-11.0 RBC-3.10* Hgb-9.4* Hct-26.7* MCV-86 MCH-30.5 MCHC-35.3* RDW-13.8 Plt Ct-235 [**2147-10-13**] 02:01AM BLOOD Plt Ct-235 [**2147-10-13**] 02:01AM BLOOD Glucose-72 UreaN-21* Creat-0.9 Na-137 K-3.8 Cl-109* HCO3-23 AnGap-9 [**2147-10-6**] 07:33PM BLOOD ALT-27 AST-28 LD(LDH)-199 AlkPhos-64 Amylase-22 TotBili-0.4 [**2147-10-6**] 07:33PM BLOOD %HbA1c-11.0* Pre Bypass Graft 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. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is dilated. There is moderate regional left ventricular systolic dysfunction with a global mild hypokinesis of LV and focalities in apical regions with mid anteroseptal and anterior regions.. Overall left ventricular systolic function is moderately depressed (LVEF= 30 to 35 %). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. Post grafting: Normal RV systolic function. Overall LVEF 35%. The wall motion abnormalities are similar to pre grafting. Intact thoracic aorta. Mild MR. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**First Name (STitle) **] was notified in person of the results on Mr. [**Known lastname 79547**] at 9AM.. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2147-10-12**] 16:09 ?????? [**2142**] CareGroup IS. All rights reserved. Brief Hospital Course: Admitted [**10-6**] and pre-op w/u completed.Dental consult also done for possible MVR. He will require multiple extractions after surgery.Social work also consulted . Diuresis continued pre-op as well as better glucose management. Thoracic consult and CT scan also done to evaluate pulm. nodules. IV heparin also started. Seen by pulmonology also.Completed 5 day course of abx for PNA. Underwent OPCABG x1 with Dr. [**First Name (STitle) **] on [**10-12**]. Transferred to the CVICU in stable condition on a phenylephrine drip. Extubated overnight and transferred to the floor on POD #1. Chest tubes also removed that morning. The remainder of his postoperative course was essentially uneventful. He did, however, fail a voiding trial twice, had a foley catheter reinserted and Urology was consulted. Per their reccommendations, foley will remain for 1 week, flomax will be continued, and the patient will f/u in [**Hospital **] clinic in one week. By the time of discharge on POD 6, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Pt complained of dizziness and blurry vision after he was told he was being discharged.. Neuro exam was non-focal. Dr [**First Name (STitle) **] felt there was nothing occurring medically and that he was to be discharged home with services. Medications on Admission: glipizide 5 mg daily lisinopril 20 mg daily zocor 40 mg daily lasix 40 mg daily ASA 81 mg daily coreg 6.25 mg [**Hospital1 **] avelox 400 mg daily for 7 days azithromycin/ levofloxacin for PNA albuterol 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:*0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:*90 Tablet(s)* Refills:*0* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Packet PO twice a day for 7 days. Disp:*14 Packet(s)* Refills:*0* 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*qs 1 month* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: CAD s/p OPCABG x1 NIDDM CRI obesity MR [**Last Name (Titles) **]. lipids CHF asthma HTN MI MRSA mild hyponatremia Discharge Condition: good Discharge Instructions: no lotions, creams or pwders on any incision SHOWER dialy and pat incisions dry call for fever greater than 100.5, redness or drainage no driving for 2 weeks or until off all narcotics no lifting greater than 10 pounds for 4 weeks Followup Instructions: 1) see Dr. [**Last Name (STitle) **] in [**2-15**] weeks 2) get a referral from Dr. [**Last Name (STitle) **] for a cardiologist to follow you and make appt. for 2-3 weeks after discharge 3) see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] 4) Follow up with the [**Hospital 159**] Clinic (Dr [**Last Name (STitle) 261**] in one week to discontinue the Foley catheter. ([**Telephone/Fax (1) 4276**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2147-10-18**]

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icd9cm

[ [ [] ] ]

[ "36.15" ]

icd9pcs

[ [ [] ] ]

6655, 6714

3349, 4683

282, 350

6872, 6879

1259, 3326

7158, 7705

930, 944

4936, 6632

6735, 6851

4709, 4913

6903, 7135

959, 1240

239, 244

378, 618

640, 827

843, 914

54,689

116,806

48761

Discharge summary

report

Admission Date: [**2114-4-11**] Discharge Date: [**2114-4-15**] Date of Birth: [**2037-1-13**] Sex: M Service: MEDICINE Allergies: Penicillins / Iodine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Dr. [**Known lastname 102490**] is a 77yo physician w/hx of alcoholic cirrhosis, HCC s/p ablation, CHF (EF 55-60%), chronic afib not on coumadin, portal vein thrombus, who was transferred from [**Hospital 3278**] Medical Center for SOB. He initially presented to to his PCP [**Name Initial (PRE) 151**] 1 month of SOB and fatigue as well as syncope and was found to have a HR of 25. He reports syncope on [**2114-4-1**] and struck his head but did not seek medical attension. He was sent to the [**Hospital **] Hospital ED [**4-4**] and was found to have afib with HR in the 30s and SBPs in the 130s. An echo showed nl EF, 2+MR, mild AS, severe TR, septal HK, RV dysfunction. He was transferred to [**Hospital1 3278**] for a pacemaker insertion which was placed on [**4-6**] with single chamber pacemaker (VVI). He received no contrast with the PPM placement. His creatinine rose to 4.0 after the procedure and his urine output dropped. Renal was consulted and thought that this was HRS vs. ATN vs. pre-renal. Renal U/S was normal. His T bili rose to 7.0. RUQ U/S showed portal vein thrombus and ascites with no clear fluid pocket for paracentesis. Potassium was 5.8 prior to transfer, he got kayexalate yesterday. ABG 7.36/34/98 on 3L prior to transfer. INR 1.7. He was started on Vanc and Meropenem for possible sepsis as a cause for his decompensation. . He was to be transferred to the [**Hospital1 3278**] MICU today and family requested transfer to [**Hospital1 18**]. . On the floor, his primary complaint is SOB. He denies chest pain, palpitations, abdominal pain, nausea, vomiting, fevers, chills, night sweats. He has been having diarrhea after getting lactulose at [**Hospital1 3278**] Past Medical History: # alcoholic cirrhosis complicated by ascites (1x) # hepatocellular carcinoma s/p radiofrequency ablation in [**4-5**]. Recurrence in [**6-5**] with second radiofrequency ablation in [**8-5**]. # atrial fibrillation # partial portal vein thrombosis s/p short course of coumadin Social History: Patient is former heavy drinker consuming [**12-30**] pint of whiskey per day and approximately 2 bottles of wine per day. Has not drank in 15 years. Patient has never smoked cigarretes. Denies any illicit drug use. Patient is retired physician living alone in [**Location (un) 2624**]. Daugther lives nearby in [**Location (un) 538**]. Family History: Extensive family history of alcoholism on father's side. Brother died of bladder cancer. Sister died of unknown cause, but suffered from alcoholism. Father died of complications from a ruptured appendix in the Phillipines, also suffered from alcoholism. Mother died at age [**Age over 90 **] from old age. Physical Exam: Exam on admission: General: Alert, oriented, increased work of breathing HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated to jaw, no LAD Lungs: Bilateral crackles throughout CV: Regular rate and rhythm, [**3-3**] holosystolic murmur at apex Abdomen: soft, non-tender, distended with appreciable ascites on exam, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + foley with minimal yellow urine Ext: warm, well perfused, 2+ pulses, 2+ peripheral edema to thighs bilaterally . Pertinent Results: CXR ([**2114-4-11**]): Silhouette is markedly enlarged, and is accompanied by pulmonary vascular engorgement, perihilar haziness, and mild interstitial edema. Chronic blunting of right costophrenic sulcus could reflect small pleural effusion and/or pleural thickening. Permanent pacemaker lead terminates in right ventricle. . [**2114-4-11**] 09:46PM BLOOD WBC-12.7*# RBC-3.55* Hgb-9.9* Hct-30.2* MCV-85 MCH-27.9 MCHC-32.8 RDW-19.2* Plt Ct-75* [**2114-4-11**] 09:46PM BLOOD Glucose-114* UreaN-115* Creat-4.2*# Na-125* K-5.2* Cl-88* HCO3-20* AnGap-22* [**2114-4-11**] 09:46PM BLOOD ALT-115* AST-110* LD(LDH)-374* AlkPhos-104 TotBili-7.0* [**2114-4-11**] 09:46PM BLOOD Calcium-8.7 Phos-7.7*# Mg-2.8* Brief Hospital Course: Mr. [**Known lastname 102490**] is a 77M with a history of alcoholic cirrhosis, HCC s/p ablation, CHF, presents as a transfer from [**Hospital1 3278**] with worsening liver failure, oliguric acute on chronic renal failure, volume overload and respiratory distress. The acute renal failure may be due to hepatorenal syndrome or possibly ATN but given his minimal urine output and significant volume overload and electrolyte abnormalities the corrective option would be dialysis, which would likely be a longterm need. A discussion took place between the medicine ICU team, the daughter [**Name (NI) **] [**Name (NI) 102490**] (HCP) and the patient regariding dialysis, intubation, and resuscitation. The decision was made to focus on patient comfort and to not pursue dialysis, which was thought to be reasonable. He was placed on supplemental oxygen, given morphine or dilaudid as needed for dyspnea, and started on a scopolamine patch. The palliative care service was consulted and coordinated this care plan with the primary team. He was transitioned to the regular floor from the ICU where he received comfort care and eventually died on [**2114-4-14**] from acute renal failure, which was a consequence of his alcoholic cirrhosis and liver failure, also with underlying hepatocellular carcinoma. Medications on Admission: Home Medications: Lasix 40mg PO qday Lactulose 30ml PO BID - not taking Spironolactone 200mg PO qday Rifaximin 400mg PO TID - not taking due to cost Testosterone 1% gel apply to skin once a day . Medications on Transfer: Pantoprazole 40mg PO qday Lactulose 800mg PO TID Lasix 40mg IV x 1 [**2114-4-11**] Lasix 80mg IV x 1 [**2114-4-11**] Kayexalate 30gm PO x 1 [**2114-4-11**] Ipratropium/Albuterol q4H Vancomycin 1gm IV x 1 Meropenem 500mg IV q12H Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Acute on chronic renal failure . Secondary alcoholic cirrhosis complicated by ascites - atrial fibrillation - COPD Discharge Condition: comfort measures only Discharge Instructions: (pt died in-house) Followup Instructions: none [**Name6 (MD) **] [**Name8 (MD) **] [**Known lastname **] [**MD Number(2) 2158**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6154, 6163

4320, 5624

301, 307

6330, 6354

3596, 4297

6421, 6540

2723, 3030

6124, 6131

6184, 6309

5650, 5650

6378, 6398

3045, 3050

5668, 5846

242, 263

335, 2049

3064, 3577

5871, 6101

2071, 2352

2368, 2707

69,811

142,089

880

Discharge summary

report

Admission Date: [**2170-7-18**] Discharge Date: [**2170-9-1**] Date of Birth: [**2109-1-7**] Sex: M Service: MEDICINE Allergies: Pollen/Hayfever Attending:[**First Name3 (LF) 6021**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: HPI: Patient is a 61 y/o male with cutaneous squamous cell carcinoma metastatic to regional lymph nodes currently receiving XRT with Cisplatin who p/w malaise and febrile neutrophenia. Pt noted malaise for the last couple of days prior to admission, with temp elevated to 101.5 at home. Sx included sore throat, "tickle cough," and chronic rhinorrhea, unchanged from baseline. No N/V/D or dysuria. Most recent ANC on [**2170-7-16**] was 486. Upon arrival to floor, pt did not want to discuss his symptoms at length with examiner and wanted to sleep. He did say that he has been able to eat and drink adequately although his taste/appetite are decreased. On arrival to the ED, his temperature was measured at 102.4, and other vital signs were HR 90 BP 112/75 RR 18 98%RA. He was given vancomycin and tylenol and cefepime prior to transport to [**Hospital Ward Name 5074**]. Past Medical History: PMH: left temporal SCC: s/p Mohs procedure [**2169**] left malar SCC: with firm preauricular and submandibular adenopathy noted ([**2170-4-18**]), with FNA positive for SCC CLL (dx [**2166**]) managed with low dose weekly cisplatin 20mg/m2 with concurrent xrt x 4 weeks. Held on [**2170-7-16**] [**1-20**] to neutropenia. Last dose was [**2170-7-2**]. HTN Atrial flutter s/p ablation Social History: Married with one child. He is an oral pathologist at [**University/College 6022**]. He does not smoke tobacco; however, he drinks three to four glasses of wine nightly and has done this for many years without impairment, none currently. Family History: Significant for prominent coronary artery disease. No one has had lymphomas or leukemias or any other malignancies. Physical Exam: T 100.2 HR 82 BP 93/54 RR 18 96%RA General: Tired-appearing 61 y/o male in NAD, asking to be left alone so he could sleep. HEENT: NC/AT. PERRLA. EOMI. Erythema, dry skin, and flaking skin with some crusting over left face where he is currently receiving radiation. Also evidence of some mucositis on upper left inner buccal region without fungus. MMM. CV: Normal S1, S2 without any m/r/g. Pulm: CTAB without any wheezes or crackles. Abd: Soft, NT/ND with normoactive BS. Ext: No c/c/e. Neuro: A/O x 3. CNs II-XII grossly intact. Sensation intact. Nonfocal. Skin: As above on face. No other rashes Pertinent Results: CBC [**2170-7-25**] 05:18AM BLOOD WBC-0.3* RBC-2.53* Hgb-8.5* Hct-25.1* MCV-99* MCH-33.7* MCHC-34.0 RDW-16.3* Plt Ct-48* [**2170-7-18**] 06:30PM BLOOD WBC-1.6* RBC-2.39* Hgb-8.5* Hct-24.0* MCV-101* MCH-35.4* MCHC-35.2* RDW-15.1 Plt Ct-82* Diff: [**2170-7-18**] 06:30PM BLOOD Neuts-17* Bands-0 Lymphs-83* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Chem7 [**2170-7-25**] 05:18AM BLOOD Albumin-2.6* Calcium-7.3* Phos-1.8* Mg-1.8 ABGs [**2170-7-24**] 07:57AM BLOOD Type-ART pO2-91 pCO2-32* pH-7.53* calTCO2-28 Base XS-4 [**2170-7-21**] 10:28PM BLOOD Type-ART Temp-37.0 pO2-143* pCO2-36 pH-7.45 calTCO2-26 Base XS-2 Lactate: [**2170-7-21**] 10:28PM BLOOD Lactate-0.6 Na-132* Cl-101 [**2170-7-18**] 06:35PM BLOOD Lactate-1.1 CT chest/abdomen/pelvis [**8-6**] 1. No evidence of acute hemorrhage. 2. Stable bilateral lower lobe pneumonia and pleural effusions. 3. Small amount of non-hemorrhagic fluid in the pelvis. CT head [**8-6**]: negative for hemorrhage or edema [**8-8**] Pleural fluid: negative for malignant cells [**8-4**], [**8-5**], [**8-6**], [**8-7**] Blood cultures negative [**8-6**] Urine culture negative [**8-7**] Sputum cultures x3 poor samples [**8-10**] CMV PCR negative [**8-7**] Pleural fluid cultures: negative [**8-11**], [**8-12**] C diff x2 negative [**8-11**] ALT 107, AST 81, LDH 232, Alk Phos 228, tbili 0.8 [**8-13**] ALT 142, AST 58, LDH 191, Alk Phos 202, tbili 0.9 [**8-14**] ALT 616, AST 550, LDH 360, Alk Phos 313, tbili 0.9 Brief Hospital Course: A/P: 61 y/o male with cutaneous squamous cell carcinoma metastatic to regional lymph nodes currently receiving XRT with Cisplatin presented with neutropenic fever, hypoxia. # Neuropenic fevers: Pt presented with neutropenic fever on work up was found to have a large RLL pneumonia with RUL extension. Pt was started on a course of cefepime/vanc/flagyl which changed to meropenem/vanc/voriconazole/acyclovir per ID recommendations. Pt was also noted to have a PICC line that was erythematous and discontinued. Pt was also inititated on Neupogen whicb was discontinued prior to discharge as Neutropenia resolved. As pt's oxygenation improved antibiotic coverage was changed to meropenem, caspofungin were continued. Pt underwent bronchoscopy with a BAL showing no nocardia, or PCP. [**Name10 (NameIs) **] on this result pt was started on Levofloxacin and Flagyl. Prior to discharge pt was afebrile and was discharged on a course of Levofloxacin and Flagyl per ID recommendations and will need to continue this regimen until his chest x-ray is radiographically normal. Discussed plan via e-mail with Dr. [**Last Name (STitle) **]. #Hypoxia: [**Hospital 1094**] hospital course was complicated with several bouts of hypoxia requiring 2 ICU stays. Most likely due to a combination of mucous plug, RUL/RLL PNA and bilateral effusions. During his work up for hypoxia pt underwent a CTA which showed no PE. Prior to discharge pt was saturating well on room air. # CLL: Bone marrow bx showed infiltration. Rituxan/Vincristine was initiated on [**7-21**], and he received the vincristine, but only [**12-23**] rituxan prior to onset of rigors/fevers/desaturations, and rituxan was restarted on [**7-24**]. IVIG was attempted twice and discontinued the first time [**1-20**] concern for allergic reaction given intra procedure tachypnea and hypoxia, rigors, and fevers to 104-105. # Nutrition. Pt's nutrition was noted to be poor during hospitalization. Pt stated his appetite was decreased. Pt initially had a Dobhoff placed and was started on Droberinol. Pt's poor PO intake contunied leading to PEG tube placement. Prior to discharge pt was able to tolerate his home goal rate in house, pt and pt's wife were also educated no how to use the Kangaroo pumps as well as basic PEG care. Pt was also started on Omeprazole as part of his PEG regimen. # Depression: Pt was noted be extremely depressed during hospital course. Pt was started on Fluoxetine, prior to discharge pt's mood and affect appeared to improve. # Pain: Pt experienced a lot of back and pleuritic pain. Pt was started and discharged on PRN Oxyocodone and bowel regimen. Medications on Admission: Lipitor 10 mg PO daily Dyazide 37.5/25 mg PO daily MVI Thiamine 100 mg PO daily Verapamil 240 mg PO QAM and 120 mg PO QPM Compazine PRN Tretinoin 0.025% cream Chlor-Trimeton 4 mg PO PRN Discharge Medications: 1. Tretinoin 0.025 % Cream Sig: One (1) Appl Topical QHS (once a day (at bedtime)). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 5. 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* 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 7. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). Disp:*60 60* Refills:*2* 8. 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* 9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 20 days. Disp:*20 Tablet(s)* Refills:*0* 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 20 days. Disp:*60 Tablet(s)* Refills:*0* 12. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Outpatient Lab Work Please get your blood drawn to check your complete blood count, (Electrolytes) Sodium, Potassium, Chloride, Carbon Dioxide, BUN, Creatinine, Magnesium, Phosphorous, Calcium every Monday and Thursday. Please have results faced to Dr. [**Last Name (STitle) **] office ([**Telephone/Fax (1) 6023**] Discharge Disposition: Home With Service Facility: [**Location (un) **] home therapies Discharge Diagnosis: Malnutrition Pneumonia Progresson of CLL Squamous cell carcinoma of the neck Depression Discharge Condition: Fair, afebrile. Discharge Instructions: You were admitted with fever and decreasing white blood cell counts. you required transfer to the intensive care unit as you developed respiratory distress. You were also found to have progression of you CLL which required administration of chemotherapy. You were also found to have a lesion in your lungs that was consistent with a pneumonia. We gave you antibiotics to help fight this process and you showed clinical improvement. Your white blood cell count also improved.You were also given a PEG tube to help with your nutrition. A VNA nurse will help you with your tube feedings. We have started you on seven new medications. You are on two antibiotics which you will continue to take until your chest xray shows that you have no pneumonia and Dr. [**Last Name (STitle) **] says it OK for you to stop. You will need to take Levofloxacin 500 mg once a day and Metronidazole 500 mg three times a day. You have also been started on Fluoxetine (antidepressant). Pantoprazole (stomach pill), Oxycodone (for pain) and Docusate Sodium, Senna (both are to prevent any constipation when you are taking the Oxycodone). You will also need to get your blood drawn every Monday and Thursday. You will also need to get a chest xray the morning of [**2170-9-6**] before you see Dr. [**Last Name (STitle) **]. We stopped the following medications. Please do not take 1) Dyazide 37.5/25 mg PO daily 2) Verapamil 240 mg PO QAM and 120 mg PO QPM 3) Chlor-Trimeton 4 mg PO PRN Please return to the ED if you experience fever, chills, shortness of breath, chest pain, abdominal pain or any other symptom that concerns you. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2170-9-6**] 2:30 **Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] for a follow up appointment to see you within the next two weeks**

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icd9cm

[ [ [] ] ]

[ "41.31", "99.25", "99.14", "34.91", "99.05", "96.07", "99.28", "45.23", "43.11", "33.24", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

8576, 8642

4118, 6752

280, 295

8774, 8792

2624, 4095

10452, 10797

1875, 1992

6988, 8553

8663, 8753

6778, 6965

8816, 10429

2007, 2605

235, 242

323, 1197

1219, 1605

1621, 1859

14,935

179,689

15445+15446

Discharge summary

report+report

Admission Date: [**2109-9-6**] Discharge Date: [**2109-9-10**] Service: Medicine, [**Location (un) **] Firm CHIEF COMPLAINT: Gastrointestinal bleed. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old woman with cryptogenic cirrhosis, known portal hypertension, history of hepatic coma, and coronary artery disease who presented to [**Hospital 26200**] Hospital on [**2109-9-6**] with a 2-day to 3- day history of melena. She was found to be guaiac-positive by examination, but since she was hemodynamically stable at the time, she was discharged home from the Emergency Department. She had a light dinner that evening, and shortly afterwards became diaphoretic, nauseous, and had one episode of hematemesis. She was brought back to the Emergency Department at [**Hospital1 **] [**Hospital 4068**] Hospital approximately three hours after she was initially discharged. At this time, she was found to be hypotensive, diaphoretic, and with a hematocrit drop to 26. An nasogastric lavage was performed in the Emergency Department and did not clear with 2 liters of normal saline. An emergent esophagogastroduodenoscopy was done which showed very large 10-cm varices crossing the gastroesophageal junction. Sclerotherapy was used but unable to stop the bleeding. She was intubated and then sent to [**Hospital1 69**]. PAST MEDICAL HISTORY: 1. Cryptogenic cirrhosis diagnosed one year ago. 2. Diverticulosis. 3. Coronary artery disease. 4. History of ulcerative colitis. 5. Hypertension. 6. Portal hypertension. 7. Question of diabetes mellitus. 8. Gastroesophageal reflux disease. 9. Status post cholecystectomy. 10. Status post hysterectomy. 11. Status post appendectomy. 12. Cataracts. SOCIAL HISTORY: The patient is married. She lives with her husband who is very supportive. She denies any history of alcohol, tobacco, or intravenous drug use. FAMILY HISTORY: Family medical history was noncontributory. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Isordil 30 mg p.o. q.d. 2. Nadolol 40 mg p.o. q.d. 3. Asacol 800 mg p.o. t.i.d. 4. Captopril 25 mg p.o. t.i.d. 5. Lactulose 20 g p.o. q.i.d. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on admission revealed temperature was 98.1, blood pressure was 118/56, heart rate was 64, oxygen saturation was 100% (intubated), respiratory rate was 10 to 14. Physical examination in general revealed the patient was intubated and sedated. Her pupils were equal, round, and reactive. Her neck was supple with no lymphadenopathy appreciated. Her sclerae were anicteric. Her mucous membranes were moist. Her chest was clear to auscultation bilaterally. Her heart had a regular rate. Normal first heart sound and second heart sound. A [**1-9**] soft early peaking systolic murmur at the left upper sternal border. No third heart sound or fourth heart sound were appreciated. Her abdomen was markedly distended with normal active bowel sounds. It was soft and nontender. No fluid wave was appreciated. Three well-healed surgical scars were noted. The liver and spleen could not be palpated secondary to ascites. She had no cyanosis, clubbing, or edema. Her lower extremities were in Pneumo boots with 2+ dorsalis pedis and posterior tibialis pulses bilaterally. On skin examination, she had no rashes, palmar erythema, or prominent spider hemangiomas. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory values on admission revealed white blood cell count was 4, hemoglobin was 10, hematocrit was 29.1, platelets were 81. PT was 15.3, PTT was 27.2, INR was 1.6. Chemistry panel revealed sodium was 139, potassium was 4.4, chloride was 112, bicarbonate was 17, blood urea nitrogen was 12, creatinine was 0.5, and blood glucose was 183. Calcium was 6.1, magnesium was 1.4, phosphorous was 3.4. ALT was 12, AST was 18, LDH was 188, alkaline phosphatase was 52, total bilirubin was 0.7. PERTINENT STUDIES DURING HOSPITALIZATION: 1. Cardiac enzymes were cycled times three with a peak creatine kinase of 385, CK/MB was 11, and troponin was less than 0.3. 2. A chest x-ray on [**2109-9-7**] showed an opacity in the left lower lobe with minimal left pleural effusion. 3. A right upper quadrant ultrasound on [**2109-9-7**] showed a heterogenous liver consistent with cirrhosis, no intrahepatic or extrahepatic ductal dilatation. Positive splenomegaly. Positive small amount of ascites noted in perihepatic, perisplenic, and pelvic areas. 4. Esophagogastroduodenoscopy done on [**2109-9-7**] revealed grade III varices starting in the lower one-third of the esophagus with a stigmata of recent bleed and oozing from multiple areas. Six and six injections sclerotherapy were performed with appropriate hemostasis. Clotted blood was seen throughout the whole stomach. A large adherent clot was present in the fundus which prevented complete visualization. IMPRESSION: This is an 80-year-old with cryptogenic cirrhosis and portal hypertension presenting with a gastrointestinal bleed secondary to a esophageal varices. HOSPITAL COURSE: 1. GASTROINTESTINAL: Upon admission, the patient was directly transferred to the Medical Intensive Care Unit where an nasogastric lavage was performed which did not clear after 5 liters of normal saline. An emergent esophagogastroduodenoscopy was performed which showed grade III varices which were successfully sclerosed. No other sites of bleeding were noted. The patient was then started on Octreotide on which she was continued for 72 hours without complications. A right upper quadrant ultrasound was performed which showed a small amount of ascites; however, the patient was started on ciprofloxacin for spontaneous bacterial peritonitis prophylaxis in the setting of a variceal bleed. The patient's cause for cirrhosis has been evaluated extensively; and per records from [**Hospital 26200**] Hospital, she is hepatitis negative and rapid plasma reagin nonreactive. She has a history of hepatic coma one year prior to this admission, at which time her cirrhosis was initially diagnosed. Fortunately, alpha- fetoprotein has been negative over the past year. In addition to Octreotide, the patient was restarted on her outpatient dose of nadolol 40 mg p.o. q.d. The patient's primary gastroenterologist, Dr. [**Last Name (STitle) **] at [**Hospital 26200**] Hospital was contact[**Name (NI) **] through Dr. [**Last Name (STitle) 22494**] who performed the esophagogastroduodenoscopy at [**Hospital1 346**]. 2. HEMATOLOGY: The patient with a baseline hematocrit of around 34. On presentation, hematocrit was 26 at the outside hospital and 29 on admission to [**Hospital1 188**]. She received a total of 2 units of packed red blood cells with an appropriate hematocrit bump in the Intensive Care Unit. After transfusion and sclerotherapy, the patient's hematocrit remained stable for greater than 48 hours prior to discharge. On admission, the patient's INR was elevated to 2.5 secondary to liver disease. She was given three doses of vitamin K with INR normalizing at 1.3. She was also noted to have thrombocytopenia which was thought secondary to her splenomegaly. 3. CARDIOVASCULAR: The patient with a history of hypertension and coronary artery disease. Given anemia, she was at high risk for demand ischemia; and therefore she was ruled out for myocardial infarction by cardiac enzymes. On admission, she was hypotensive; and therefore blood pressure medications were held on hospital day one. As her blood pressure normalized, her ACE inhibitor and beta blocker were titrated up with no complications. She was to restart her long-acting nitrate upon discharge. 4. PULMONARY: On admission, the patient was intubated and sent directly to the Medical Intensive Care Unit. After an emergent esophagogastroduodenoscopy, she was weaned off the ventilator and extubated the following morning without any difficulties. Her oxygen saturation remained high for the remainder of her hospital course. 5. INFECTIOUS DISEASE: The patient was afebrile with a normal to slightly elevated white blood cell count throughout her hospitalization. Given her portal hypertension and small amount of ascites, there was some concern for spontaneous bacterial peritonitis, and she was started on ciprofloxacin for prophylaxis. She was discharged with instructions to complete a 7-day course of ciprofloxacin. 6. ENDOCRINE: On presentation, the patient with a questionable history of diabetes mellitus; however, she was not on any outpatient medications for this diagnosis. Her fingerstick glucose throughout this admission was consistently less than 200 and most in the 100 to 150 range. She was monitored on q.i.d. fingersticks and covered on a regular insulin sliding-scale. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Grade III esophageal varices; status post sclerotherapy. 3. Portal hypertension. 4. Cryptogenic cirrhosis. 5. Hypertension. 6. Gastroesophageal reflux disease. MEDICATIONS ON DISCHARGE: 1. Nadolol 40 mg p.o. q.d. 2. Asacol 800 mg p.o. t.i.d. 3. Isordil 30 mg p.o. q.d. 4. Captopril 25 mg p.o. t.i.d. 5. Lactulose 20 g p.o. q.i.d. 6. Ciprofloxacin 500 mg p.o. b.i.d. (times five days; to complete a 7-day course). DISCHARGE INSTRUCTIONS: 1. The patient was to follow up with her primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**]) in approximately two to four weeks. 2. The patient was to follow up with her primary gastroenterologist (Dr. [**Last Name (STitle) **] at [**Hospital 26200**] Hospital for follow-up esophagogastroduodenoscopy with possible variceal banding. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 6240**] MEDQUIST36 D: [**2109-9-10**] 18:11 T: [**2109-9-14**] 02:59 JOB#: [**Job Number 44815**] Admission Date: [**2109-9-6**] Discharge Date: [**2109-9-10**] Service: Medicine, [**Location (un) **] Firm CHIEF COMPLAINT: Gastrointestinal bleed. HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old woman with cryptogenic cirrhosis, known portal hypertension, history of hepatic coma, and coronary artery disease, who presented to [**Hospital 26200**] Hospital on [**2109-9-6**] with a 2 to 3-day history of melena. She was found to be guaiac-positive by examination, but since she was hemodynamically stable at the time she was discharged home from the Emergency Department. She had a light dinner that evening, and shortly afterwards became diaphoretic, nauseous, and had one episode of massive hematemesis. She was brought back to the Emergency Department at [**Hospital 26200**] Hospital approximately three hours after she was initially discharged. At this time, she was found to be hypotensive, diaphoretic, and with a hematocrit drop to 26. A nasogastric lavage was performed in the Emergency Department which did not clear with 2 liters of normal saline. An emergent esophagogastroduodenoscopy was done which showed very large 10-cm varices crossing the gastroesophageal junction. Sclerotherapy was used but unable to stop the bleeding. She was intubated and then sent to [**Hospital1 69**]. PAST MEDICAL HISTORY: 1. Cryptogenic cirrhosis diagnosed one year ago. 2. Diverticulosis. 3. Coronary artery disease. 4. History of ulcerative colitis. 5. Hypertension. 6. Portal hypertension. 7. Question of diabetes mellitus. 8. Gastroesophageal reflux disease. 9. Status post cholecystectomy. 10. Status post hysterectomy. 11. Status post appendectomy. 12. Cataracts. SOCIAL HISTORY: The patient is married. She lives with her husband who is very supportive. She denies any history of alcohol, tobacco, or intravenous drug use. FAMILY HISTORY: Family medical history was noncontributory. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: (Outpatient medications included ) 1. ............. 30 mg p.o. q.d. 2. Nadolol 40 mg p.o. q.d. 3. Asacol 800 mg p.o. t.i.d. 4. Captopril 25 mg p.o. t.i.d. 5. Lactulose 20 g p.o. q.i.d. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on admission revealed temperature was 98.1, blood pressure was 118/56, heart rate was 64, oxygen saturation was 100% (intubated), respiratory rate was 10 to 14. Physical examination in general revealed the patient was intubated and sedated. Her pupils were equal, round, and reactive. Her neck was supple with no lymphadenopathy appreciated. Her sclerae were anicteric. Her mucous membranes were moist. Her chest was clear to auscultation bilaterally. Her heart had a regular rate. Normal first heart sound and second heart sound. A [**1-9**] soft early peaking systolic murmur at the left upper sternal border. No third heart sound or fourth heart sound were appreciated. Her abdomen was markedly distended with normal active bowel sounds. It was soft and nontender. No fluid wave was appreciated. Three well-healed surgical scars were noted. The liver and spleen could not be palpated secondary to ascites. She had no cyanosis, clubbing, or edema. Her lower extremities were in Pneumo boots with 2+ dorsalis pedis and posterior tibialis pulses bilaterally. On skin examination, she had no rashes, palmar erythema, or prominent spider hemangiomas. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory values on admission revealed white blood cell count was 4, hemoglobin was 10, hematocrit was 29.1, platelets were 81. PT was 15.3, PTT was 27.2, INR was 1.6. Chemistry panel revealed sodium was 139, potassium was 4.4, chloride was 112, bicarbonate was 17, blood urea nitrogen was 12, creatinine was 0.5, and blood glucose was 183. Calcium was 6.1, magnesium was 1.4, phosphorous was 3.4. ALT was 12, AST was 18, LDH was 188, alkaline phosphatase was 52, total bilirubin was 0.7. PERTINENT STUDIES DURING HOSPITALIZATION: 1. Cardiac enzymes were cycled times three with a peak creatine kinase of 385, CK/MB was 11, and troponin was less than 0.3. 2. A chest x-ray on [**2109-9-7**] showed an opacity in the left lower lobe with minimal left pleural effusion. 3. A right upper quadrant ultrasound on [**2109-9-7**] showed a heterogenous liver consistent with cirrhosis, no intrahepatic or extrahepatic ductal dilatation. Positive splenomegaly. Positive small amount of ascites noted in perihepatic, perisplenic, and pelvic areas. 4. Esophagogastroduodenoscopy done on [**2109-9-7**] revealed grade III varices starting in the lower one-third of the esophagus with a stigmata of recent bleed and oozing from multiple areas. Six and six injections sclerotherapy were performed with appropriate hemostasis. Clotted blood was seen throughout the whole stomach. A large adherent clot was present in the fundus which prevented complete visualization. IMPRESSION: This is an 80-year-old with cryptogenic cirrhosis and portal hypertension presenting with a gastrointestinal bleed secondary to a esophageal varices. HOSPITAL COURSE: 1. GASTROINTESTINAL: Upon admission, the patient was directly transferred to the Medical Intensive Care Unit where an nasogastric lavage was performed which did not clear after 5 liters of normal saline. An emergent esophagogastroduodenoscopy was performed which showed grade III varices which were successfully sclerosed. No other sites of bleeding were noted. The patient was then started on octreotide on which she was continued for 72 hours without complications. A right upper quadrant ultrasound was performed which showed a small amount of ascites; however, the patient was started on ciprofloxacin for spontaneous bacterial peritonitis prophylaxis in the setting of a variceal bleed. The patient's cause for cirrhosis has been evaluated extensively; and per records from [**Hospital 26200**] Hospital, she is hepatitis negative and rapid plasma reagin nonreactive. She has a history of hepatic coma one year prior to this admission, at which time her cirrhosis was initially diagnosed. Fortunately, alpha-fetoprotein has been negative over the past year. In addition to octreotide, the patient was restarted on her outpatient dose of nadolol 40 mg p.o. q.d. The patient's primary gastroenterologist, Dr. [**Last Name (STitle) **] at [**Hospital 26200**] Hospital was contact[**Name (NI) **] through Dr. [**Last Name (STitle) **], who performed the esophagogastroduodenoscopy at [**Hospital1 69**]. 2. HEMATOLOGY: The patient with a baseline hematocrit of around 34. On presentation, hematocrit was 26 at the outside hospital and 29 on admission to [**Hospital1 188**]. She received a total of 2 units of packed red blood cells with an appropriate hematocrit bump in the Intensive Care Unit. After transfusion and sclerotherapy, the patient's hematocrit remained stable for greater than 48 hours prior to discharge. On admission, the patient's INR was elevated to 2.5 secondary to liver disease. She was given three doses of vitamin K with INR normalizing at 1.3. She was also noted to have thrombocytopenia which was thought secondary to her splenomegaly. 3. CARDIOVASCULAR: The patient with a history of hypertension and coronary artery disease. Given anemia, she was at high risk for demand ischemia; and, therefore, she was ruled out for myocardial infarction by cardiac enzymes. On admission, she was hypotensive; and, therefore, blood pressure medications were held on hospital day one. As her blood pressure normalized, her ACE inhibitor and beta blocker were titrated up with no complications. She was to restart her long-acting nitrate upon discharge. 4. PULMONARY: On admission, the patient was intubated and sent directly to the Medical Intensive Care Unit. After an emergent esophagogastroduodenoscopy, she was weaned off the ventilator and extubated the following morning without any difficulties. Her oxygen saturation remained high for the remainder of her hospital course. 5. INFECTIOUS DISEASE: The patient was afebrile with a normal to slightly elevated white blood cell count throughout her hospitalization. Given her portal hypertension and small amount of ascites, there was some concern for spontaneous bacterial peritonitis, and she was started on ciprofloxacin for prophylaxis. She was discharged with instructions to complete a 7-day course of ciprofloxacin. 6. ENDOCRINE: On presentation, the patient with a questionable history of diabetes mellitus; however, she was not on any outpatient medications for this diagnosis. Her fingerstick glucose throughout this admission was consistently less than 200, and most in the 100 to 150 range. She was monitored on q.i.d. fingersticks and covered on a regular insulin sliding-scale; although, it was unclear whether the patient actually had the diagnosis of diabetes. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Grade III esophageal varices; status post sclerotherapy. 3. Portal hypertension. 4. Cryptogenic cirrhosis. 5. Hypertension. 6. Gastroesophageal reflux disease. MEDICATIONS ON DISCHARGE: 1. Nadolol 40 mg p.o. q.d. 2. Asacol 800 mg p.o. t.i.d. 3. .................... 30 mg p.o. q.d. 4. Captopril 25 mg p.o. t.i.d. 5. Lactulose 20 g p.o. q.i.d. 6. Ciprofloxacin 500 mg p.o. b.i.d. (times five days; to complete a 7-day course). DISCHARGE INSTRUCTIONS: 1. The patient was to follow up with her primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**]) in approximately two to four weeks. 2. The patient was to follow up with her primary gastroenterologist (Dr. [**Last Name (STitle) **] at [**Hospital 26200**] Hospital for follow-up esophagogastroduodenoscopy with possible variceal banding. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 6240**] MEDQUIST36 D: [**2109-9-10**] 18:11 T: [**2109-9-14**] 02:59 JOB#: [**Job Number 44815**]

[ "456.20", "530.81", "287.5", "571.5", "285.1", "789.5", "572.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "42.33", "96.71" ]

icd9pcs

[ [ [] ] ]

11896, 11979

18991, 19194

19220, 19467

12006, 15091

15109, 18906

19491, 20118

18921, 18970

10130, 10155

10184, 11323

11346, 11715

11732, 11879

4,741

146,293

11993

Discharge summary

report

Admission Date: [**2129-8-3**] Discharge Date: [**2129-8-15**] Date of Birth: [**2082-1-24**] Sex: M Service: [**Doctor First Name 147**] Allergies: Heparinoids Attending:[**First Name3 (LF) 148**] Chief Complaint: Hypotension and fever Major Surgical or Invasive Procedure: 1. Percutaneous drainage of hepatic abscesses 2. ERCP and stent placement in the common hepatic duct History of Present Illness: 47 yo male with a history of metastatic gallblader cancer presents to the ED with the acute onset of shortness of breath following a prodrome of several weeks of nocturnal rigors and chills. One week prior to presenting to the ED, the patient was evaluated at an outside clinic and was started on ciprofloxacin due to suspected cholangitis. Past Medical History: 1. Laparoscopic cholecystectomy 2. Metastatic gallbladder cancer 3. Palliation with gastrojejunostomy and placement of a biliary stent via previous PTC tube. 4. HCV 5. CBD stricture s/p stent 6. GERD 7. Asthma Social History: Noncontributory Family History: Noncontributory Physical Exam: T102 HR126 BP75/27 RR22 SaO297% on 4L NC; (while on Levophed 0.3) Gen: Awake alert, flushed, diaphoretic Pulm: BS clear Cor: RRR, tachycardic Abd: Distended, firm liver edge palpable 6cm below costal margin Soft, no tenderness or guarding; rare bowel sounds. Ext: warm Pertinent Results: [**2129-8-3**] 08:35AM BLOOD WBC-13.9* RBC-3.80* Hgb-10.0* Hct-30.2* MCV-80* MCH-26.2* MCHC-32.9 RDW-13.6 Plt Ct-171 [**2129-8-3**] 04:30PM BLOOD WBC-59.0*# RBC-3.36* Hgb-8.8* Hct-28.1* MCV-84 MCH-26.0* MCHC-31.1 RDW-14.1 Plt Ct-263# [**2129-8-3**] 08:27PM BLOOD WBC-68.6* RBC-3.65* Hgb-9.7* Hct-30.5* MCV-84 MCH-26.5* MCHC-31.7 RDW-14.4 Plt Ct-247 [**2129-8-4**] 02:29AM BLOOD WBC-61.1* RBC-3.62* Hgb-9.8* Hct-29.9* MCV-83 MCH-27.0 MCHC-32.6 RDW-14.4 Plt Ct-208 [**2129-8-5**] 02:13AM BLOOD WBC-24.7*# RBC-3.38* Hgb-9.1* Hct-26.9* MCV-80* MCH-27.0 MCHC-33.9 RDW-14.5 Plt Ct-67*# [**2129-8-5**] 03:23PM BLOOD WBC-32.2* RBC-4.10* Hgb-11.1* Hct-33.4* MCV-82 MCH-27.1 MCHC-33.2 RDW-14.7 Plt Ct-114*# [**2129-8-8**] 02:07AM BLOOD WBC-24.2* RBC-4.62 Hgb-12.4* Hct-38.0* MCV-82 MCH-26.9* MCHC-32.7 RDW-15.0 Plt Ct-113* [**2129-8-9**] 03:51AM BLOOD WBC-17.8* RBC-4.39* Hgb-11.9* Hct-35.8* MCV-82 MCH-27.2 MCHC-33.3 RDW-15.3 Plt Ct-118* [**2129-8-10**] 02:13AM BLOOD WBC-13.4* RBC-4.07* Hgb-10.8* Hct-33.5* MCV-82 MCH-26.7* MCHC-32.4 RDW-15.4 Plt Ct-114* [**2129-8-3**] 08:35AM BLOOD PT-16.1* PTT-42.2* INR(PT)-1.7 [**2129-8-3**] 08:27PM BLOOD PT-18.3* PTT-45.1* INR(PT)-2.2 [**2129-8-6**] 02:48AM BLOOD PT-14.7* PTT-29.4 INR(PT)-1.4 [**2129-8-10**] 02:13AM BLOOD PT-13.8* PTT-31.4 INR(PT)-1.3 [**2129-8-3**] 08:27PM BLOOD Fibrino-236 [**2129-8-4**] 02:29AM BLOOD Fibrino-286 [**2129-8-3**] 08:35AM BLOOD Glucose-77 UreaN-10 Creat-0.9 Na-135 K-3.2* Cl-95* HCO3-19* AnGap-24* [**2129-8-3**] 04:30PM BLOOD Glucose-62* UreaN-10 Creat-0.8 Na-141 K-3.1* Cl-109* HCO3-12* AnGap-23* [**2129-8-3**] 05:50PM BLOOD Glucose-81 UreaN-11 Creat-0.7 Na-141 K-3.2* Cl-110* HCO3-13* AnGap-21* [**2129-8-4**] 02:29AM BLOOD Glucose-127* UreaN-11 Creat-0.7 Na-145 K-3.4 Cl-109* HCO3-17* AnGap-22* [**2129-8-5**] 02:13AM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-143 K-4.2 Cl-111* HCO3-23 AnGap-13 [**2129-8-5**] 03:23PM BLOOD Glucose-105 UreaN-15 Creat-0.6 Na-142 K-3.6 Cl-109* HCO3-24 AnGap-13 [**2129-8-6**] 02:48AM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-141 K-5.3* Cl-105 HCO3-25 AnGap-16 [**2129-8-6**] 02:12PM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-142 K-3.3 Cl-103 HCO3-27 AnGap-15 [**2129-8-9**] 03:51AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-134 K-3.8 Cl-100 HCO3-23 AnGap-15 [**2129-8-10**] 02:13AM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-137 K-3.4 Cl-101 HCO3-25 AnGap-14 [**2129-8-3**] 08:35AM BLOOD ALT-30 AST-33 AlkPhos-575* Amylase-65 TotBili-2.3* [**2129-8-3**] 12:30PM BLOOD ALT-26 AST-45* AlkPhos-431* TotBili-2.8* [**2129-8-3**] 08:27PM BLOOD ALT-63* AST-287* AlkPhos-409* Amylase-41 TotBili-3.3* [**2129-8-6**] 02:48AM BLOOD ALT-106* AST-138* AlkPhos-275* TotBili-3.2* [**2129-8-8**] 02:07AM BLOOD ALT-48* AST-32 AlkPhos-345* TotBili-3.8* [**2129-8-9**] 03:51AM BLOOD ALT-40 AST-30 LD(LDH)-189 AlkPhos-441* Amylase-217* TotBili-4.0* [**2129-8-10**] 02:13AM BLOOD ALT-32 AST-25 AlkPhos-327* Amylase-159* TotBili-2.6* [**2129-8-3**] 08:27PM BLOOD Lipase-103* [**2129-8-9**] 03:51AM BLOOD Lipase-946* [**2129-8-10**] 02:13AM BLOOD Lipase-723* [**2129-8-3**] 08:35AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.6 [**2129-8-3**] 12:30PM BLOOD Albumin-2.0* Calcium-6.2* Phos-2.3* Mg-1.3* [**2129-8-4**] 02:29AM BLOOD Albumin-2.6* Calcium-7.3* Phos-3.7 Mg-2.2 [**2129-8-6**] 02:48AM BLOOD Albumin-2.3* Calcium-8.8 Phos-2.6* Mg-1.8 [**2129-8-10**] 02:13AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.1 Mg-1.9 [**2129-8-3**] 12:30PM BLOOD Cortsol-49.1* [**2129-8-3**] 12:43PM BLOOD Type-MIX pO2-48* pCO2-34* pH-7.26* calHCO3-16* Base XS--10 Intubat-NOT INTUBA [**2129-8-3**] 02:42PM BLOOD Type-[**Last Name (un) **] pO2-93 pCO2-30* pH-7.26* calHCO3-14* Base XS--12 Comment-GREEN TOP [**2129-8-3**] 03:55PM BLOOD Type-ART pO2-111* pCO2-38 pH-7.16* calHCO3-14* Base XS--14 Intubat-INTUBATED [**2129-8-3**] 09:07PM BLOOD Type-ART Temp-34.9 Rates-[**12-16**] Tidal V-700 PEEP-5 O2-100 pO2-66* pCO2-38 pH-7.25* calHCO3-17* Base XS--9 AADO2-624 REQ O2-99 Intubat-INTUBATED Vent-CONTROLLED [**2129-8-4**] 02:55AM BLOOD Type-ART Temp-36.2 Rates-[**12-20**] Tidal V-700 PEEP-10 O2-80 pO2-128* pCO2-33* pH-7.38 calHCO3-20* Base XS--4 AADO2-421 REQ O2-72 Intubat-INTUBATED Vent-CONTROLLED [**2129-8-4**] 12:01PM BLOOD Type-ART Temp-36.7 Rates-/25 Tidal V-420 PEEP-5 O2-50 pO2-109* pCO2-33* pH-7.42 calHCO3-22 Base XS--1 Intubat-INTUBATED Vent-SPONTANEOU [**2129-8-4**] 06:19PM BLOOD Type-ART Temp-37.2 Rates-/27 Tidal V-470 PEEP-5 O2-50 pO2-101 pCO2-34* pH-7.46* calHCO3-25 Base XS-0 Vent-SPONTANEOU [**2129-8-6**] 01:20PM BLOOD Type-ART Temp-36.9 O2-70 pO2-70* pCO2-35 pH-7.51* calHCO3-29 Base XS-4 Intubat-NOT INTUBA [**2129-8-7**] 01:58AM BLOOD Type-ART Temp-36.7 Rates-/28 O2-100 pO2-81* pCO2-40 pH-7.48* calHCO3-31* Base XS-5 AADO2-614 REQ O2-97 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-FACE TENT [**2129-8-7**] 03:58PM BLOOD Type-ART Temp-36.9 pO2-83* pCO2-40 pH-7.42 calHCO3-27 Base XS-0 Intubat-NOT INTUBA [**2129-8-7**] 09:55PM BLOOD Type-ART Temp-36.4 Rates-/26 O2 Flow-4 pO2-79* pCO2-36 pH-7.41 calHCO3-24 Base XS-0 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**] [**2129-8-8**] 02:30AM BLOOD Type-ART O2-100 pO2-101 pCO2-40 pH-7.40 calHCO3-26 Base XS-0 AADO2-593 REQ O2-94 [**2129-8-3**] 10:47AM BLOOD Lactate-9.1* [**2129-8-3**] 12:43PM BLOOD Lactate-8.8* [**2129-8-3**] 06:08PM BLOOD Glucose-82 Lactate-5.0* Na-139 K-3.1* Cl-110 [**2129-8-3**] 06:43PM BLOOD Glucose-90 Lactate-5.0* Na-139 K-3.0* Cl-110 [**2129-8-4**] 02:55AM BLOOD Lactate-6.1* [**2129-8-4**] 07:42AM BLOOD Glucose-131* Lactate-4.6* K-3.9 [**2129-8-4**] 06:19PM BLOOD Lactate-2.6* K-3.9 [**2129-8-7**] 09:55PM BLOOD K-3.7 [**2129-8-8**] 02:30AM BLOOD Glucose-107* K-4.1 [**2129-8-8**] 12:34PM BLOOD HEPARIN DEPENDENT ANTIBODIES- Brief Hospital Course: Since his arrival in the ED, he has displayed evidence of septic shock including hypotension refractory to 9 liters of normal saline. Despite efforts to aggressivley resuscitate the patient in the ED he continued to appear critically ill. A general surgery consult was obtained by the ED staff. Given the patients past history of cancer involving his biliary tree, and given his clinical picture, and available data, the working diagnosis of cholangitic septic shock was adopted. The patient was taken to interventional radiology to achieve drainage of his biliary tree. In the angio suite, a large, foul-smelling, hepatic abscess was drained percutaneously. The patient was then transferred to the ICU in critical condition on the HPB Surgery service. Broad spectrum antibiotics, mechanical ventilation, maintenance of his biliary drainage, and aggressive fluid resuscitation were the key components of his subsequent management. Clostridium Perfringens was isolated from the hepatic abscesses and antibiotic coverage was appropriately tailored. Following the initial inflammatory phase of the patient's illness, he began making progress daily. The remainder of his hospital stay was characterized by stability. There were no untoward events attendant on his recovery and the patient was discharged in good condition to a rehab facility. Appropriate follow-up was arranged with Dr. [**Last Name (STitle) **]. Medications on Admission: MS contin Discharge Medications: 1. Metronidazole 500 mg IV Q6H 2. Zosyn 4-0.5 g Recon Soln Sig: One (1) Intravenous every eight (8) hours. Disp:*qs 4/0.5* Refills:*2* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a day) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 4. 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* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Septic shock from hepatic abscesses Clostridium perfringens bacteremia Discharge Condition: Good Discharge Instructions: Take the Antibiotics as prescribed Followup Instructions: 1. Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2129-8-16**] 11:30 2. follow up with Dr. [**Last Name (STitle) **] on the 20th afternoon -- you should have a ct scan of your abdomen done the same day as your appointment

[ "996.59", "576.1", "287.4", "197.7", "196.2", "785.52", "572.0", "070.51", "038.3" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "96.6", "38.93", "99.04", "50.91", "51.84", "99.07", "51.87", "89.64" ]

icd9pcs

[ [ [] ] ]

9042, 9100

7119, 8544

311, 414

9215, 9221

1400, 7096

9305, 9663

1074, 1091

8604, 9019

9121, 9194

8570, 8581

9245, 9282

1106, 1381

250, 273

442, 785

807, 1025

1041, 1058

26,424

100,511

17696

Discharge summary

report

Admission Date: [**2171-3-26**] Discharge Date: [**2171-3-29**] Date of Birth: Sex: F Service: GYN/ONCOLOGY HISTORY OF PRESENT ILLNESS: The patient is a 58 year-old P3 who presented to Dr. [**First Name (STitle) 1022**] with a large pelvic mass. She had a history of undergoing exploratory laparotomy for appendicitis in [**2170-5-28**]. At that time a necrotic right fallopian tube was excised and the patient was noted to have a pelvic mass. No further follow up until recently when she presented to [**Hospital6 1597**] with severe anemia and a gastrointestinal bleed. She had a transfusion with 7 units of whole blood. She had a CT during her hospitalization, which revealed a large abdominal and pelvic mass. She had a full gastrointestinal evaluation, which included an upper endoscopy, colonoscopy and small bowel follow through all of which were negative. The patient states that during colonoscopy the right side of the colon could not be visualized due to the presence of the mass. The patient complains of nausea and increased abdominal girth. She has chronic constipation and there is nothing new. There is no other change in bowel or urinary habits. She denies any vaginal bleeding and any weight loss. PAST MEDICAL HISTORY: 1. Hypertension. 2. Psoriasis. 3. Chronic pain syndrome. PAST SURGICAL HISTORY: Uterine embolization [**2169-11-28**]. Tubal ligation in [**2143**]. Decompression and fusion [**2169**]. Appendectomy [**2169**]. Multiple breast adenoma excisions. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Tylenol. 2. Lasix. 3. Ativan. 4. OxyContin. 5. Celexa. 6. Atarax. 7. Neurontin. OB HISTORY: Vaginal delivery times three. GYN HISTORY: Last pap smear several years ago normal. Last mammogram [**2171-1-26**] normal. FAMILY HISTORY: Significant for mother with breast cancer. Sister with anal cancer and a brother with skin cancer. SOCIAL HISTORY: The patient does not smoke or drink. She is a retired nurse. REVIEW OF SYSTEMS: As above and otherwise noncontributory. PHYSICAL EXAMINATION: General appearance, well developed, well nourished, thin. HEENT lymph node survey was negative. Lungs were clear to auscultation. Heart was regular rate and rhythm without murmurs. Breasts were without masses. Abdomen was soft and moderately distended. There was a large palpable mass in both the upper and lower abdomen. There was no evidence of ascites. Extremities were without edema. On bimanual examination vulva and vagina were normal. The cervix was normal. Bimanual rectovaginal examination revealed a large pelvic mass, which was somewhat ill-defined. There was no cul-de-sac nodularity and the rectum was intrinsically normal. It was explained to the patient that this mass could be benign or malignant and it was recommended to undergo surgical excision including exploratory laparotomy, TAH/BSO and resection of the mass. The risks and benefits were discussed. Surgical consent was signed. HOSPITAL COURSE: The patient underwent an examination under anesthesia, exploratory laparotomy, TAH/BSO and resection of a pelvic mass on [**2171-3-26**]. Intraoperative findings include an enlarged uterus with a subserosal fibroid and evidence of tumor extending to the right lateral rectoperitoneum as well as centrally and left into the sigmoid and small bowel mesentery up to the splenic flexure of the colon. The anatomic survey was otherwise unremarkable. There was subcentimeter periaortic lymph nodes and normal ovaries bilaterally with 2 liters of bloody ascites in the abdomen. Estimated blood loss 3 liters. Secondary to the patient's blood loss, large amount of ascites and extensive surgery, the patient was admitted to the Intensive Care Unit for critical care. On postoperative day zero her vital signs were stable. Her abdomen was nondistended with only a small amount of drainage from the inferior aspect of the incision. The patient's hematocrit was 27.2, INR 1.2, PTT 28.3, electrolytes were within normal limits. The patient at this time had been transferred to the unit for further monitoring. She had been given 7 units of packed red blood cells. She was in stable condition. Postoperative day one the patient's vital signs continued to be stable with adequate urine output overnight. Her examination was appropriate postoperatively. On postoperative day one hemodynamically yesterday's hematocrit was 27, which improved to 34 after 2 more units of packed red blood cells. There is no evidence of ongoing intraabdominal bleeding. Fluids, electrolytes and nutrition: the patient had adequate urine output with no evidence of fluid overload. Pain, the patient was on a Dilaudid PCA. On postoperative day two the patient was extubated. Her pain was controlled. She was tolerating clears. No nausea or vomiting. No chest pain or shortness of breath. She was afebrile. Her vital signs were stable. She had adequate urine output. Her most recent hematocrit was 34.5. Her electrolytes were within normal limits. Her abdomen was appropriately tender and nondistended. Renal: her urine output was normal. Her Foley catheter was discontinued. Her creatinine was 0.6. The patient was encouraged to ambulate. Her diet was advanced. Hematology: patient had 9 units of packed red blood cells, 4 units of fresh frozen platelets. Her blood pressure was stable. Her hematocrit was 34.5. Coumadinization was started on postoperative day two. Pulmonary, the patient's supplemental oxygen was weaned for oxygenation of greater then 93%. On postoperative day three the patient was without complaints. She was tolerating clears. The pain was adequately controlled on 40 mg of OxyContin t.i.d. and Percocet for breakthrough pain. Cardiovascularly the patient has a history of hypertension, which was controlled with Lasix 40 mg q day. The patient was deemed stable enough for discharge to home. DISCHARGE DIAGNOSES: 1. Pelvic mass status post exploratory laparotomy, pelvic washings, TAH/BSO, pelvic mass resection. 2. Blood loss anemia requiring blood transfusion. 3. Hypertension. 4. Chronic pain syndrome. DISCHARGE CONDITION: Good. DISCHARGE STATUS: The patient was discharged to home without services. She will follow up with Dr. [**First Name (STitle) 1022**] as an outpatient in approximately two weeks for postoperative visit. DISCHARGE MEDICATIONS: 1. Percocet. 2. Motrin. 3. Celexa. 4. Lasix. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 16-314 Dictated By:[**Last Name (NamePattern1) 6763**] MEDQUIST36 D: [**2171-9-30**] 02:41 T: [**2171-10-1**] 08:23 JOB#: [**Job Number 49231**]

[ "198.89", "182.0", "285.1", "593.89", "198.82", "401.9", "197.6", "307.9", "E935.2" ]

icd9cm

[ [ [] ] ]

[ "54.4", "65.61", "54.59", "54.3", "59.02", "68.4" ]

icd9pcs

[ [ [] ] ]

6187, 6396

1832, 1932

5967, 6165

6419, 6705

3029, 5946

1364, 1815

2096, 3011

2032, 2073

165, 1257

1279, 1340

1949, 2012

10,417

165,133

24634+57407

Discharge summary

report+addendum

Admission Date: [**2145-6-17**] Discharge Date: [**2145-7-29**] Date of Birth: [**2077-5-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: Transferred for hypoxia and bronchoscopy Major Surgical or Invasive Procedure: intubation pulmonary artery catheter placement History of Present Illness: 68 y/o male with a history of angioimmunoblastic T cell Lymphoma s/p 6 cycles of CHOP chemotherapy diagnosed in [**2144-9-23**] on [**6-9**] with increasing hypoxia (90% on RA), orthopnea, decreasing appetite, increasing weakness and increasing abdominal girth. He was thought to be in decompensated CHF with pulmonary edema and ascites and underwent aggressive diuresis with no improvement in his symptoms. On admission he was started on azithromycin and ceftriaxone for community acquired pneumonia. Per report he was not febrile thru out his hospital stay. He was evaluated by infectious disease given his lack of improvment who recommended vancomycin for MRSA infection, bactrim for PCP pna, cefepime for GN coverage, and gatifloxacin for atypical pna. HIs WBC trended downward however his oxygen requirment continued to increase. He underwent CT chest/abdomen/pelvis which demonstrated extensive hilar, mediastinal, retroperitoneal, iliac and inguinal adenopathy. A 2.5 cm left perihilar mass and and 8 mm nodule in left lung near the descending aorta. Right sided pleural effusion. Small bilateral renal calculi with no obstructive changes. He underwent CT neck which revealed stable LN dz in neck, and LN enlargement in mediastinum He underwent echo with normal EF and was evaluated by cardiology who felt his symptoms were consistent with CHF. His hospital course was complicated by the development of acute renal failure with a Cr of 4.6 and agitation requiring haldol. And supratherapeutic INR. Worsening of his rapid afib with RVR to the 140s for which he was started on diltiazem. There were also rate related ST depressions reported. He underwent diagnostic paracentesis which revealed atypical cells on cytology and WBC 14,030, RBC 38,000, with 41% Neutropil concerning for SBP. He was transferred to [**Hospital1 18**] for bronch. Past Medical History: 1. Angioimmunoblastic T cell lymphoma s/p 6 cycles of chop diagnosed in late [**2144-9-23**] due to symptoms of night sweats, weight loss and bulky adenopathy in the neck. 2 COPD with FEV1/FVC 124% predicted, FEV1 42%, FVC 34%, TLC 76 % predicted 3 atrial fibrillation 4. coronary artery disease 5. diabetes mellitus 6. CRI 7. Nephrolithiasis 8. CHF (EF variable reported 35-60%) Social History: retired and lives with his wife. previously smoked 1 ppd, no etoh or ivda. Originally from [**Country 6257**] Family History: mother died of trauma, father died of old age Physical Exam: PE: 96.8 // 111 /62, 95% on 100% NRB FM, HR 111 (afib) gen- alert, agitated. chronically ill appearing male heent- EOMI. sclera non-icteric. neck- JVP at 7cm at 45 degrees. neg HJR pulm- diffuse ronchi b/l L >R. no wheezes cv- irreg irreg. variable s1. no murmurs abd- distended, not tense; no pain- except mild pain at L-sided paracentesis site (no erythema or pus at this area). + fluid wave. no caput. no spider angiomas. no HSM. ext- trace b/l LE edema to ankles. neuro- able to respond to yes/no questions, and follow simple commands, but speech is mostly incoherent; pt is mildly agitated, pulling at lines. currently in soft UE restraints. *primary language is portugese, but able to communicate in english at baseline- per son's report Pertinent Results: LAB Trends at OSH: ----------------- WBC: 17.2 <-- 18.2 <-- 24.8 <-- 23.2 <--22 <--19.5 <--18.2 <--19.1 . Cr: 4.6 <-- 4.8 <-- 4.2 <-- 2.3<--1.5 <-- 1.4 <-- 1.3 . Micro data: cdiff negative, blood cx ngtd, UA wnl . EKG: atrial fibrillation at 100 . Admission Labs: --------------- FIBRINOGE-101* PT-15.0* PTT-27.0 INR(PT)-1.5 PLT COUNT-153 WBC-16.7* RBC-3.17* HGB-10.4* HCT-29.7* MCV-94 DIGOXIN-1.1 VANCO-14.4* CORTISOL-100.8* TSH-8.8* calTIBC-270 HAPTOGLOB-94 FERRITIN-326 TRF-208 ALBUMIN-3.6 CALCIUM-7.3* PHOSPHATE-6.4* MAGNESIUM-2.2 URIC ACID-17.2* IRON-78 LIPASE-33 ALT(SGPT)-10 AST(SGOT)-17 LD(LDH)-548* ALK PHOS-134* AMYLASE-54 TOT BILI-0.4 GLUCOSE-317* UREA N-95* CREAT-4.0* SODIUM-130* POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-22 ANION GAP-19 freeCa-1.04* LACTATE-2.3* . Radiologic Studies: ------------------ CXR [**6-17**]: There are diffuse bilateral opacities and this is a cardiomegaly, consistent with CHF. However, a multifocal pneumonia cannot be excluded. . Micro Data: ----------- [**2145-6-18**] BAL- GRAM STAIN (Final [**2145-6-18**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2145-6-20**]): ~1000/ML OROPHARYNGEAL FLORA. YEAST. 10,000-100,000 ORGANISMS/ML.. STAPH AUREUS COAG +. ~5000/ML. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final [**2145-6-18**]): PNEUMOCYSTIS CARINII NOT SEEN. ACID FAST SMEAR (Preliminary): NO AFB SEEN ON DIRECT SMEAR. Brief Hospital Course: 68 y/o male with progressive pulmonary decline unresponsive to diuresis and broad spectrum antibiotics and new onset of ascites concerning for rapidly progressive metastatic lymphoma and new acute renal failure. Intubated emergently for refractory hypoxemia on [**6-17**] w/prolonged ICU stay c/b vent-assoc MRSA PNA, periods of rapid Afib, drug rash, and diffuculty weaning off ventilator. . # Hypoxemic Respiratory Failure/SIRS: Emergently intubated on admission to the ICU for refractory hypoxemia. The cause of his respiratory failure was unclear. However, infectious etiology was felt to be high given his immunosuppressed state from his T-cell lymphoma. He was covered broadly with ceftriaxone, azithromycin, bactrim, vancomycin, and voriconazole. Was on Vanco/CTX/Azithro/Vori x 14 days([**Date range (1) 62192**]), on Zosyn for increased fever and secretions, 7 day course ([**7-1**]- [**7-8**]). Bronchoscopy/BAL was performed and was negative for AFB, PCP or bacterial microorganisms. Induced sputum was also negative. He was continued empirically on antibiotics given his clinical decline with sepsis physiology. Tumor burden with lymphangitic spread was also considered as a potential etiology of his respiratory distress, but was felt less likely given the stable appearance of his tumor on imaging studies. CTA was negative for PE as a potential source. He had a tracheotomy tube placed on [**7-14**] and was slowly weaned off the ventilator. Weaning was complicated by large amount of bleeding from tracheostomy while on heparin and by large amounts of secretions leading to mucous plugging. Heparin was d/ced [**2-24**] to bleeding from tracheostomy. Course was further complicated by MRSA tracheobronchitis treated with Vancomycin ([**7-20**]-expected [**7-29**] to complete 10 day course). He improved greatly with decreased secretions with Vancomycin. Recent speech consult for passey muir valve, patient was able to tolerate for short periods of time (approximately 30 seconds [**2-24**] secretions) - currently able to tolerate longer periods of time. Currently patient with O2 sats @ 100% on 60% face mask. Current respiratory treatments include Vancomycin 1gm q12hr (day [**9-1**]), Albuterol q 6hr. It is hoped that in the next week or so he will have the trach removed and return to breathing from his oral airway. . # Hypotension: Hypotension felt to be septic in etiology given its distributive nature. SVR was found to be low, in 500's, by pulmonary artery cath, with normal cardiac output. He was treated with broad-spectrum antibiotics as outlined above. In addition he was started on pressors with neosynephrine. However, he remained persistently hypotensive, with decreasing SVR's. Therefore vasopressin was added to his regimen. Subsequently his MAP's increased >60 with steady UOP >30 cc/hr. He was also noted to have initial evidence of low-grade DIC with increasing PT/PTT, and decreasing fibrinogen and platelets. Therefore he was started on activated protein C. His fibrinogen levels subsequently improved with stable coags and platelets. He did not require cryoprecipitate or FFP transfusions. In addition he had no noted bleeding complications w/ APC. Currently he is normotensive with BP 130's-150's/50's-80's without use of pressors - given improvement of hypotension with antibiotic treatment, likely etiology was sepsis. . # Ascites: Cytology from outside hospital consistent with lymphoma and SBP. Started on ceftriaxone for sbp. Repeat ultrasound showed loculated abdominal ascites, not felt to be ammenable to paracentesis. Therefore he was monitored clinically, without further intervention. Repeat ultrasound [**7-13**] showed small amount of ascites. Unable to place PEG given ascites. He is currently with slightly distended, non-firm, non-tender abdomen, on Ciprofloxacin 400mg 1x/wk for SBP prophylaxis. . # Mental Status: Patient with episodes of delirium since admission to ICU - most commonly in morning then becomes more lucid later in day. Possibly [**2-24**] to lack of sleep, infection, medications, or combination. Haldol initially tried, but d/ced [**2-24**] to increased QTc. Zyprexa and Versed were also tried but were found to be ineffective in treating his delirium. Ativan 2mg was effective in assisting the patient to sleep, and patient has not had delirium since this time. He is currently awake and alert, oriented to being in [**Location (un) 86**], but remains slightly confused when asked if he knows what type of building he is in. He is portugeuse speaking, and therefore interviewed with help of an interpreter. . # Lymphoma: initially presented with hypocalcemia, hyperphosphatemia and acute renal failure, concern for suspected tumor lysis. Treated with IVF, allopurinol and close monitoring of electrolytes. He was felt to be too sick for chemotherapy during his stay. Pt??????s outpt onc will follow him once discharged. Cont acyclovir for prophylaxis. . # Acute renal failure -?????? Initially, pt had elevation of BUN, Cr, which resolved with fluid resuscitation. Cr stabilized at 0.8 . # Afib -- Loaded with Digoxin, and continued on 0.125 mg daily. Initially on heparin, but discontinued because of large amount of bleeding from trach site. Restarted with TPN (5000units). Good rate control with 0.125mg Digoxin QD, Metoprolol 7.5mg q4hr. Attempted anticoagulation with heparin drip and coumadin. However, had extensive bloody secretions and anticoagulation was subsequently stopped. Plan for Coumadin once start PO. As pt was not able to take po medications, metoprolol was d/c'd prior to discharge to rehab. Once he is able to take po's this medication may be restarted should he have rapid ventricular rates. . # Pulmonary Hypertension -- an echo on [**7-2**] showed severe pulmonary HTN associated with 2+ mitral regurgitation. It was unclear whether this could be due to the MR [**First Name (Titles) **] [**Last Name (Titles) **] pulmonary emboli. He was initially started on heparin, but this was discontinued given large amounts of bleeding from the trach site. Furthermore, MR was felt to be more likely the cause of the pulmonary hypertension. . # FEN ?????? Pt had post-pyloric feeding tube inserted twice, both of which he pulled out while in episodes of confusion/delirium. He failed a bedside swallowing study, and we were unable to place a PEG [**2-24**] ascites. As a result, he was started on TPN for nutrition. It is expected that pt will only require the trach mask for approx one more week, at which time the trach will be removed and hopefully he will be able to eat again. . # Rash and eosinophilia ?????? rash started after starting multiple antibiotics, biopsy performed, felt to be drug rash associated with antibiotics most likely ceftriaxone, improved on steroids. . # CAD ?????? Pt was treated with beta-blocker and ASA. Hydralazine for afterload reduction was initiated at low doses but d/c'd before discharge since pt could not take po medications and IV hydral could not be dosed at rehab. Pt should be started on an ACE-I once he can tolerate po's again. . # Anemia ?????? stable hct - pt previously with bleeding from trach when on heparin, now stopped. No evidence of bleeding. (Anticoag was primarily for afib) -Continue to monitor hct. # DM1 - ISS, Humalin (dose calculated out and based on carbs in tube feeds) and glargine (calculated based on basal metabolic rate). Currently pt is receiving insulin in TPN. Once this is stopped and he is able to eat he should be restarted on glargine approximately 18 units. . # [**Female First Name (un) 564**] in urine - Changed foley, but repeat culture has yeast. -No antifungal treatment for now. Latest UA with occ yeast and 0 WBCs . # ppx - heparin stopped because of bloody secretions - restarted in TPN. . # Access ?????? pt pulled out TLC and A-line. Currently has PIV and PICC for access. . # full code . Communication: [**Telephone/Fax (1) 62193**] wife/son [**Telephone/Fax (1) 62194**] PCP [**Name9 (PRE) 62195**], ONC [**Name9 (PRE) 17881**] ([**Hospital 42317**] Medical) Medications on Admission: allopurinol 100 qd dilt 120 [**Hospital1 **] colace lasix 40 [**Hospital1 **] gatafloxacin 200 qd insulin 70/30 ss solumedrol 60 q6 hours metoprolol 50 tid bactrim 18 ml IV q 6 hours 18 IV q 12 hours albuterol/atrovent prn morphine prn . Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 6. Senna 8.8 mg/5 mL Syrup Sig: One (1) PO BID (2 times a day). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-24**] Puffs Inhalation Q6H (every 6 hours). 8. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 9. Digoxin 250 mcg/mL Solution Sig: One (1) 0.125mg Injection DAILY (Daily). 10. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) 1g Intravenous Q 12H (Every 12 Hours) for 10 days: (total 10 days - through [**7-29**]). 12. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) 400mg Intravenous 1X/WEEK (SA): (Please give on Saturdays). 13. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 14. Lorazepam 2 mg/mL Syringe Sig: One (1) 2mg Injection HS (at bedtime) as needed. 15. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed for neck sore. 16. Insulin Regular Human 100 unit/mL Solution Sig: As directed units Injection qachs: For FSBS 0-159, 0 units For FSBS 160-199, 2 units For FSBS 200-239, 4 units For FSBS 240-279, 6 units For FSBS 280-319, 8 units For FSBS 320-359, 10 units For FSBS 360-399, 12 units For FSBS >400, notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital **] REHAB Discharge Diagnosis: 1.) Community Aquired Pneumonia/Sepsis requiring long intubation 2.) Tracheobronchitis 3.) SBP 4.) s/p ARF with Cr increase to 4.6, resolved with fluid rescusitation 5.) AFib - currently well controlled with Digoxin, Metoprolol 6.) Angioimmunoblastic T cell lymphoma s/p 6x cycles CHOP (dx in [**9-26**]) 7.) Ascites - [**2-24**] lymphoma. 8.) DM1 9.) CAD 10.) Anemia 11.) COPD Discharge Condition: Patient in fair/good condition on discharge. Main issues include tracheostomy, on trach mask to achieve good ventilation, TPN for nutrition, ascites [**2-24**] lymphoma. Discharge Instructions: 1.) Come to hospital if fever >100.4, increased respiratory distress, any other concerns. Followup Instructions: 1.) Follow up with Oncologist Dr. [**Last Name (STitle) 17881**] @ [**Hospital 42317**] Medical center 2.) Follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 62195**] Name: [**Known lastname 11186**],[**Known firstname **] H Unit No: [**Numeric Identifier 11187**] Admission Date: [**2145-6-17**] Discharge Date: [**2145-7-29**] Date of Birth: [**2077-5-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10790**] Addendum: Please check digoxin level in 3 days, target level 0.9-1.5. Please relay level to nursing home MD on call to adjust digoxin level as necessary and recheck digoxin accordingly. Discharge Disposition: Extended Care Facility: [**Hospital **] REHAB [**Doctor First Name 3354**] [**First Name8 (NamePattern2) **] [**Name8 (MD) 3353**] MD [**MD Number(2) 10791**] Completed by:[**2145-7-29**]

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icd9cm

[ [ [] ] ]

[ "00.11", "96.6", "33.24", "86.11", "96.04", "99.15", "89.64", "31.1", "96.72" ]

icd9pcs

[ [ [] ] ]

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354, 402

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136,599

37313

Discharge summary

report

Admission Date: [**2156-5-21**] Discharge Date: [**2156-5-23**] Date of Birth: [**2098-10-1**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: Increased Confusion Major Surgical or Invasive Procedure: laproscopic repositioning of distal peritoneal catheter History of Present Illness: HPI: Patient is a 57F presenting with increased confusion and visual blurriness, and "wobbly" gait per her husband. [**Name (NI) **] PMH is significant for VPS placement 13yrs ago(unclear reason why) and subsequent revision 7yrs ago(this even precipitated by MS changes quickly progressing to "coma"; requiring "emergent" surgery). In the setting of her visual changes and being "off" recently, her husband took her to her PCP who did an CT scan of the head, revealing significant hydrocephalus consistent with shunt failure. She was then transferred to [**Hospital1 18**] for definitive intervention. Past Medical History: PMHx: 1. Hydrocephalus(unclear etiology) s/p VPS and revision (13yrs, 7yrs ago)-done in [**State 108**] 2. Headache, Migraine 3. GERD 4. Depression 5. Osteoporosis 6. ADD Social History: Social Hx: resides at home with husband and adult child. Family History: unkown Physical Exam: O: T:97.8 BP: 109/50 HR:64 RR:18 O2Sats:100%ra Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic, Atraumatic. VPS valve is easily depressible, and recoils Pupils: PERRL EOMs: with left lateral gaze palsy and bilateral upgaze palsy Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, hospital, and season and year. Language: Speech fluent with fair comprehension. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4mm to 3mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements with left lateral gaze palsy and bilateral upgaze palsy 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. on discharge - non focal - eom's intact / with full upgaze/ no drift / incision CDI Pertinent Results: CT HEAD W/O CONTRAST Study Date of [**2156-5-21**] 8:30 PM FINDINGS: A non-contrast CT of the head was obtained. The patient is status post right transfrontal VP shunt placement with the shunt catheter terminating in the region of the right foramen of [**Location (un) 9700**]. Immediately surrounding the shunt tract is focal low-attenuation, also unchanged, which may represent gliosis. There is stable enlargement of the third and bilateral lateral ventricles compared to the prior study. Also noted is stable periventricular white matter hypodensities adjacent to the lateral ventricles, not significantly changed from the prior study and most likely representing transependymal flow of CSF. Also noted are focal hypodensity within the right genu of the corpus callosum and a more punctate hypodensity within the that sublenticular region, likely representing chronic lacune, dilated perivascular space or sublenticular (neuroglial) cyst. There is no intraparenchymal hemorrhage, mass, mass effect, or shift of midline structures. The extra-axial spaces are normal in appearance. No calvarial fractures are identified. The visualized paranasal sinuses are clear. IMPRESSION: Hydrocephalus and confluent periventricular hypodensity, most likely representing transependymal flow of CSF, unchanged from the [**Hospital1 **]-N study of one day earlier. CT ABDOMEN W/CONTRAST Study Date of [**2156-5-21**] 8:31 PM FINDINGS: CT ABDOMEN: There is bibasilar atelectasis noted at the lung bases. The heart is normal in size. Bilateral breast implants are identified. There is shunt catheter tubing within the abdomen, representing a ventriculoperitoneal shunt, which courses down the superficial soft tissues of the anterior chest wall and enters the peritoneum at the level of the mid abdomen, coursing over the dome of the liver. The catheter terminates within the right aspect of the liver dome, where there is an adjacent well-circumscribed loculated fluid collection measuring 5.4 x 1.7 cm. This fluid collection exerts mass effect on the right hepatic lobe and is most consistent with a CSF pseudocyst. The liver is otherwise normal in appearance with no focal liver masses, or intra- or extra-hepatic biliary dilatation. There is a 1.3-cm low-density lesion within the interpolar region of the right kidney, which is too small to characterize but most likely represents a small renal cyst. The left kidney, adrenal glands, spleen, pancreas, gallbladder, and small bowel are normal in appearance. There is a large amount of stool noted throughout the colon. No free air or free fluid is identified within the abdomen. There is mild atherosclerotic disease of the descending aorta. CT PELVIS: There are no pelvic masses or lymphadenopathy. The bladder, rectum, and uterus are normal in appearance. No free fluid is noted in the pelvis. CT BONE WINDOWS: Mild degenerative change is noted within the thoracic and lumbar spine. No focal lytic or sclerotic lesions are identified. IMPRESSION: 5.7-cm loculated fluid collection located between the right hemidiaphragm and right hepatic lobe adjacent to the VP shunt catheter tip, the appearance of which is consistent with a CSF pseudocyst. Brief Hospital Course: The pt was admitted to the ICU for close observation for HCP and possible shunt failure. Imaging revealed that the distal peritoneal catheter was encassed in a cyst. General surgery was contact[**Name (NI) **] for repositioning of catheter. She underwent the procedure without difficulty and her exam improved significantly postoperatively. Her images were stable and she was deemed safe for d/c to home. She agrees with this plan. She will follow up in our office in one month with CT of the brain. Medications on Admission: AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth three times a day BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet Sustained Release - 2 Tablet(s) by mouth daily DIVALPROEX - (Prescribed by Other Provider) - 250 mg Tablet Sustained Release 24 hr - 3 Tablet(s) by mouth HS FLUOXETINE - (Prescribed by Other Provider) - 40 mg Capsule - 1 Capsule(s) by mouth daily SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth HS TRAZODONE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth hs DESMOPRESSIN(UNKNOWN DOSE/REASON FOR USE) -PRN Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule, Sprinkle PO TID (3 times a day). 4. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep . 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: hydrocephalus distal peritoneal catheter obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. MEDICATIONS ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: o Narcotic pain medication such as Dilaudid (hydromorphone). o An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ACTIVITY The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**7-3**] days (from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2156-5-23**]

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icd9cm

[ [ [] ] ]

[ "54.95", "54.21" ]

icd9pcs

[ [ [] ] ]

7626, 7632

5807, 6314

340, 398

7729, 7729

2580, 5784

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1318, 1327

7029, 7603

7653, 7708

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10518, 12326

280, 302

426, 1032

1831, 2561

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1243, 1302

68,059

108,112

12059

Discharge summary

report

Admission Date: [**2175-7-17**] Discharge Date: [**2175-7-25**] Date of Birth: [**2102-6-19**] Sex: F Service: MEDICINE Allergies: Lactose / Levofloxacin Attending:[**Last Name (NamePattern1) 9662**] Chief Complaint: shortness of breath, chest pain Major Surgical or Invasive Procedure: L PICC Line Insertion for TPN History of Present Illness: 73 year old woman with h/o medullary and papillary thyroid CA s/p radiation c/b esophageal strictures requiring monthly dilations and h/o aspiration pneumonias who p/w SOB and CP. She has been feeling more SOB with increased productive cough for several days. Has felt warm but no objective fevers. This morning felt a "heavy feeling" in her chest which lasted all day so she came to the ED. She gets esophageal dilations approx every 6 weeks and was due for one tomorrow. Has been having increased dysphagia and subsequent poor PO intake. . In the ED initial VS were 99.0, 111, 139/76, 28, 80% on RA. Sats increased to 90% on 6L, high 90s on 40% venti mask. EKG with questionable lateral ST depressions. Labs notable for nml WBC (but 90% PMNs), neg trop, neg lactate. VBG 7.45/41/65/29. CXR with RLL infiltrate so patient given ceftriaxone and azithromycin. Also ASA 325mg. Also given 1L NS at 75/hr. Patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] had goals of care converstion with patient in the ED. Patient has had feeding tubes in the past and is unsure whether she would want another one. She is amenable to temporary noninvasive ventilatory support but would not want to be intubated or resuscitated. VS prior to transfer were 99.7, 95, 107/68, 25, 93% on 40% venti mask. . On arrival to the MICU, patient is wearing venti mask. Has noticeable productive cough but states that her breathing is slightly improved. Past Medical History: - Medullary and papillary thyroid CA s/p thyroidectomy and XRT in [**1-26**] with elevated calcitonin treated with monthly octreotide - Esophageal strictures secondary to radiation s/p esophageal balloon dilatations approx one a month - H/o PEG tubes - Recurrent aspiration pneumonia - Radiation-associated cervical myelopathy and foot drop - Hypertension - Lactose intolerance - IBS - S/p TAH - Basal cell carcinoma face/arms - Varicose veins s/p stripping - Eye surgery for strabismus as a child - Osteopenia Social History: Married. Has 8 kids. Worked as a receptionist/housewife Smoking: denies EtOH: denies Drugs: denies Family History: Her father died from gastric cancer. Mom died from leukemia. Brother had skin cancer, other brother with DM, and daughter also had papillary thyroid cancer. Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: VS- 98.2 BP 123/77 P87 R18 O298 RA Gen- Thin, frail elderly lady, cachetic. 1L O2. HEENT- trismus present, MM dry Lungs- Course inspiratory and fine expiratory wheezes. CV- S1S2, holosystolic murmur, no g/c/r. Abd- Soft, nt/nd, no hepatosplenomegaly. Ext- No c/c/e. Neuro- A&Ox 3, no focal deficits Pertinent Results: ADMISSION LABS: [**2175-7-17**] 05:45PM BLOOD WBC-9.3 RBC-4.56 Hgb-13.4 Hct-40.6 MCV-89 MCH-29.3 MCHC-32.9 RDW-13.0 Plt Ct-291 [**2175-7-17**] 05:45PM BLOOD Neuts-89.8* Lymphs-5.1* Monos-4.2 Eos-0.2 Baso-0.7 [**2175-7-17**] 05:45PM BLOOD PT-11.9 PTT-28.5 INR(PT)-1.1 [**2175-7-17**] 05:45PM BLOOD Glucose-118* UreaN-20 Creat-0.6 Na-141 K-4.3 Cl-100 HCO3-27 AnGap-18 [**2175-7-17**] 05:45PM BLOOD cTropnT-<0.01 [**2175-7-17**] 05:45PM BLOOD Calcium-8.5 Phos-2.5*# Mg-1.8 [**2175-7-17**] 05:50PM BLOOD Lactate-1.9 [**2175-7-17**] 05:50PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-41 pH-7.45 calTCO2-29 Base XS-3 Comment-GREEN TOP MICRO: Sputum Cx Negative Blood Cx Pending Negative MRSA screen IMAGING: CXR [**7-17**] IMPRESSION: Bibasilar opacities compatible with pneumonia in the proper clinical setting. Alternatively these could be related to aspiration given distribution. Clinical correlation is suggested. Repeat exam after treatment is recommended to document resolution. CXR [**7-21**] IMPRESSION: 1. Increasing multifocal airspace opacities, concerning for pneumonia. 2. New mild pulmonary edema. 3. New left upper extremity PICC, the tip of which is in the lower SVC. DISCHARGE LABS: [**2175-7-25**] 06:20AM BLOOD WBC-6.2 RBC-3.57* Hgb-10.5* Hct-32.4* MCV-91 MCH-29.4 MCHC-32.5 RDW-12.8 Plt Ct-244 [**2175-7-24**] 06:03AM BLOOD Glucose-96 UreaN-24* Creat-0.6 Na-140 K-4.6 Cl-102 HCO3-34* AnGap-9 [**2175-7-24**] 06:03AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0 Brief Hospital Course: 73F with h/o medullary and papillary thyroid CA s/p radiation c/b esophageal strictures requiring monthly dilations and h/o aspiration pneumonias who p/w SOB, found to have RLL pneumonia. # SOB: CXR c/w RLL pneumonia. Patient with h/o esophageal strictures and aspiration, so likely aspiration pneumonia. Continued ceftriaxone and azithromycin and sent sputum culture which were negatve. Pt was stabilized in the MICU and discharged to medicine floor a day later. Her O2 status while on the floor improved and we gradually weaned her off oxygen, no fevers, no WBC elevation. Respiratory was consulted to help with clearing airway secretions. Pulmonary was consulted on the option of suppression antibiotics, f/u appt [**Month/Day/Year 1988**]. # Chest pain: Likely in the setting of cough and pneumonia, and has since resolved. Unlikely ACS given that it lasted all day, two troponins negative, and no ischemic ekg changes. Given hypoxia, PE is a possibility, though lower liklihood given pneumonia on CXR. Pneumonia treatment as discussed above. No CP while on the medicine floor. # Dysphagia: Secondary to known esophageal strictures from radation tx for thyrood CA. Overdue for dilation which she has every 6 weeks. NPO for a few days while we determined what were her options for nutrition. Unable to do dilation while in the hospital (current condition, O2 req) so we decided to place L PICC and begin TPN [**7-21**]. TPN would be a bridge until her medical condition improved and she would be able to tolerate the dilation. Palliative care was consulted to discuss nutrition options and end-of-life issues. # Medullary/Papillary thyroid CA: S/p radiation c/b esophageal strictures. Thyroid scan on [**7-11**] showed new areas of recurrence in the left thyroid bed. Patient is followed by Dr. [**Last Name (STitle) **] from oncology. # Hypertension: Started Clonidine patch since pt will be unable to take PO pills while she waits for dilation. #Hypothyroidism - Stable, pt to stop levothyroxine (cannot take it PO) until after dilation per endocrinology recs. If she does not go for dilation in 2 weeks, she may need to start IV levothyroxine at home. Transitional Issues- Please follow up with your PCP and endocrinologist regarding your levothyroxine dose. Per endocrinology, she will not receive levothyroxine until dilation when she can take it PO. No pending labs. Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**1-23**] HFA(s) inhaled every 4-6 hours as needed for shortness of breath or wheezing ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth daily at bedtime may be crushed LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 (One) Tablet(s) by mouth once a day No substitution. - No Substitution LORAZEPAM - 0.5 mg Tablet - 1-1.5 Tablet(s) by mouth nightly as needed 90 day supply OCTREOTIDE ACETATE [SANDOSTATIN LAR DEPOT] - 20 mg Kit - 1 injection IM monthly SALMETEROL [SEREVENT DISKUS] - 50 mcg Disk with Device - 1 puff inhaled once or twice daily CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider) - 500 mg (1,250 mg)-200 unit Tablet - 1 (One) Tablet(s) by mouth once a day with mag CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Tablet - 1 (One) Tablet(s) by mouth daily IBUPROFEN [MOTRIN] - (Prescribed by Other Provider) - 100 mg Tablet - 1 (One) Tablet(s) by mouth once a day IMMODIUM - (OTC) - Dosage uncertain LACTOSE-FREE FOOD WITH FIBER [ISOSOURCE 1.5 CAL] - Liquid - one can by mouth four times a day Give three cases MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth once a day Discharge Medications: 1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QFRI 2. Lorazepam 0.5 mg PO HS:PRN insomnia Please place tablet under the tongue and let dissolve. DO NOT SWALLOW TABLET. Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: Primary- Aspiration Pneumonia, Esophogeal Stricture Secondary- H/o Thyroid CA (Medullary, Papillary), HTN, Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear [**Known firstname **] [**Known lastname **], It was a pleasure taking care of you during your stay at [**Hospital1 18**]. You were admitted for shortness of breath and chest pain. X-ray of your chest showed that you had a pneumonia. We treated you with antibiotics. We decided to start nutrition feeds through the vein in order to allow you to recover from the pneumonia so that you can tolerate the esophogeal dilation. You did well recovering from pneumonia, and did not require any additonal oxygen. Your condition improved and were discharged home. Please keep the doctor [**First Name (Titles) 4314**] [**Last Name (Titles) 1988**] and there is an updated medication list attached. Followup Instructions: Dr. [**Last Name (STitle) **], Gastroenterology [**2175-8-8**] Completed by:[**2175-7-25**]

[ "909.2", "401.9", "V10.83", "733.90", "309.9", "V49.86", "193", "336.8", "V16.0", "780.52", "787.20", "V16.8", "786.50", "530.3", "507.0", "V88.01", "244.9", "736.79", "263.0", "E879.2", "V15.3", "V16.6", "494.0", "564.1", "799.02" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.97" ]

icd9pcs

[ [ [] ] ]

8909, 8983

5120, 7507

324, 355

9150, 9150

3616, 3616

10021, 10115

2497, 2655

8719, 8886

9004, 9129

7533, 8696

9301, 9998

4826, 5097

2670, 3281

3297, 3597

252, 286

383, 1830

3632, 4809

9165, 9277

1852, 2364

2380, 2481

61,619

136,328

40360

Discharge summary

report

Admission Date: [**2121-11-28**] Discharge Date: [**2121-12-15**] Date of Birth: [**2065-10-25**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 922**] Chief Complaint: Cardiac arrest Major Surgical or Invasive Procedure: [**2121-12-9**] - Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to the second diagonal coronary artery; reverse saphenous vein single graft from aorta to the posterior descending coronary artery. Endoscopic left greater saphenous vein harvesting. Reconstruction of the pericardium with Core Matrix. [**2121-12-3**] - Cardiac Catheterization History of Present Illness: 57 F admitted for cardiac arrest. Pt was at bar earlier today and suddently collapsed. Two EMT's were at the bar and immediately started CPR. Pt was pulseless. Pt found to be in VT, V fib, and polymorphic VT (as documented in strips, unclear of the order of these rhythms) and was intubated and shocked seven times, given epi and atropine in the field. Arrived at OSH and EKGs revealed Vtach with rate at 108 as well as sinus tachy at 104 with 1mm ST elevation in V1, and 2mm ST depression in V4-V6, TWI in III. Pt given amiodarone 900mg bolus and drip, sodium bicarb, zosyn 4.5 g, vecuronium 20mg, and heparin drip, dopamine drip, dobutamine drip. Vitals at OSH shortly after arrival: BP 116/89, HR 107, T 97.8. Prior to transfer she was started on cooling protocol (via ice packs). Drug tox negative for cocaine, amphetamines, alcohol. Per report, pt had some posturing while on [**Location (un) **]. . Pt was transfered to this hospital for arctic cooling protocol. Upon transfer, vitals were T=30.4C, HR 105, BP 93/58 (on dopamine), 100% on CMV mode 40%, 450, f16, PEEP 5. Past Medical History: Asthma Social History: Bartender, long tobacco history, 2 beers of ETOH/day Family History: Mother died at 49- sudden cardiac death. Aunt died suddenly as well. Physical Exam: Admission physical exam: VS: T=30.4C, HR 105, BP 93/58 (on dopamine), 100% on CMV mode 40%, 450, f16, PEEP 5 GENERAL: sedated, comfortable. CARDIAC: RRR, no m/r/g LUNGS: bilateral breath sounds, no c/r/r ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES:no pedam edema, warm extremities SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Left: Carotid 2+ Femoral 2+ Pertinent Results: Admission labs: [**2121-11-28**] 10:25PM WBC-36.3* RBC-4.65 HGB-14.7 HCT-44.2 MCV-95 MCH-31.6 MCHC-33.2 RDW-14.1 [**2121-11-28**] 10:25PM NEUTS-67.9 LYMPHS-28.6 MONOS-2.6 EOS-0.3 BASOS-0.5 [**2121-11-28**] 10:25PM PT-15.4* PTT-150* INR(PT)-1.4* [**2121-11-28**] 10:25PM ALBUMIN-2.1* CALCIUM-8.2* PHOSPHATE-1.2* MAGNESIUM-1.7 [**2121-11-28**] 10:25PM CK-MB-245* MB INDX-3.5 cTropnT-0.74* [**2121-11-28**] 10:25PM ALT(SGPT)-257* AST(SGOT)-450* CK(CPK)-6974* TOT BILI-0.7 [**2121-11-28**] 10:25PM GLUCOSE-333* UREA N-13 CREAT-0.8 SODIUM-140 POTASSIUM-2.6* CHLORIDE-111* TOTAL CO2-18* ANION GAP-14 [**2121-11-28**] 10:32PM TYPE-ART PO2-112* PCO2-34* PH-7.34* TOTAL CO2-19* BASE XS--6 Discharge Labs: [**2121-12-15**] 06:29AM BLOOD WBC-11.1* RBC-3.16* Hgb-10.0* Hct-30.8* MCV-98 MCH-31.7 MCHC-32.5 RDW-15.7* Plt Ct-469* [**2121-12-15**] 06:29AM BLOOD Plt Ct-469* [**2121-12-9**] 12:46PM BLOOD PT-13.9* PTT-41.7* INR(PT)-1.2* [**2121-12-15**] 06:29AM BLOOD Glucose-125* UreaN-10 Creat-0.7 Na-141 K-4.4 Cl-106 HCO3-29 AnGap-10 . Cardiac Catheterization [**2121-12-3**] 1. Coronary artery disease in this right dominant system revealed two vessel coronary artery disease. The LMCA had no significant disease. The LAD had a 99% lesion in the proximal portion involving the D1 origin, with a 70% mid-LAD after the D2 origin, and diffuse disease distally. The LCX had minimal luminal irregularities. The RCA was totally occluded proximally, with a distal vessel filling via left-to-right collaterals. 2. Resting hemodynamics revealed mild systemic hypertension, with SBP of 158 mmHg. . ECHO [**2121-12-9**] Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is moderately depressed (LVEF= 30 - 35 %), with inferior, septal and antero-septal HK. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-11**]+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is in SR on no inotropes. Improved LV systolic fxn. EF now 40 - 45%. Preserved RV systolic fxn. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. . CT Scan ABD/PELVIS [**2121-12-2**] 1. Bilateral pleural effusions with mild pulmonary edema. 2. Markedly thickened gallbladder wall without secondary signs of acute cholecystitis likely from acute hepatic dysfunction. Small gall stones noted . Carotid Duplex Ultrasound [**2121-12-5**] Impression: Right ICA <40% stenosis. Left ICA 40-59% stenosis. Post-op ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 2.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm Right Atrium - Four Chamber Length: 4.5 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.8 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Left Ventricle - Stroke Volume: 43 ml/beat Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 11 < 15 Aorta - Sinus Level: 2.7 cm <= 3.6 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 17 Aortic Valve - LVOT diam: 1.8 cm Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.29 Mitral Valve - E Wave deceleration time: 150 ms 140-250 ms TR Gradient (+ RA = PASP): *35 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 0.9 m/sec <= 1.5 m/sec Findings This study was compared to the prior study of [**2121-12-1**]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Mild regional LV systolic dysfunction. No resting LVOT gradient. LV WALL MOTION: Regional left ventricular wall motion findings as shown below; remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Physiologic MR (within normal limits). Normal LV inflow pattern for age. TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Left pleural effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal to mid inferior wall and inferior septum. The remaining left ventricular segments contract normally. 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. Physiologic mitral regurgitation is seen (within normal limits). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild focal LV systolic dysfunction consistent with inferior ischemia/infarction. No pathologica valvular abnormality seen. Compared with the prior study (images reviewed) of [**2121-12-1**], the function of the inferior septum and inferior wall are similar. The function of the anterior wall has improved. Overall ejection fraction is slightly higher. Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2121-12-15**] 14:18 . Radiology Report CHEST (PA & LAT) Study Date of [**2121-12-13**] 4:28 PM [**Hospital 93**] MEDICAL CONDITION: 56 year old woman s/p CABG x 3 with elevated WBC count, please evaluate for infiltrate Final Report In comparison with study of [**12-12**], there is again a large left pleural effusion with apparent compressive atelectasis at the base. Extensive opacification suggests that there is marked volume loss in the left lower lobe. The right lung is essentially clear with a small pleural effusion. DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Brief Hospital Course: Mrs. [**Known lastname 67870**] was admitted to the [**Hospital1 18**] on [**2121-11-28**] for management after her cardiac arrest. The patient underwent arctic cooling protocol. During her hypothermia therapy, she required pressor support (dopamine and levophed). She was started on atorvastatin therapy for presumed coronary artery disease and a heparin drip. Per protocol, EEG was initiated with montioring by Neurology department. The patient was also enrolled in a study in which she either received placebo or stress-dose steroids. She was then rewarmed. Amiodarone was started for atrial fibrillation which converted her to a normal sinus rhythm. By [**2121-12-1**], the patient was extubated and conscious. Echocardiogram showed mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the septum and anterior walls and apex, LVEF 35-40%. Cardiac catheterization on [**12-3**] showed a patent left circumflex, subtotally occluded LAD in the proximal region with two sizable diagonal branches coming off this lesion. There was some mid LAD disease as well. The RCA was chronically occluded with evidence of left to right collaterals as well. Decision was made to proceed to CABG after cardiac surgery was consulted. Mrs. [**Known lastname 67870**] was worked-up in the usual preoperative manner. On [**2121-12-9**], Mrs. [**Known lastname 67870**] was taken to the operating room where she underwent coronary artery bypass grafting to three vessels. Please see operative note for details. In summary she had: 1. Coronary artery bypass grafting x3 with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to the second diagonal coronary artery; reverse saphenous vein single graft from aorta to the posterior descending coronary artery. 2. Endoscopic left greater saphenous vein harvesting. 3. Reconstruction of the pericardium with Core Matrix. Her BYPASS TIME was 64 minutes, with a CROSSCLAMP TIME of 52 minutes. She tolerated the operation well and post operatively was transferred to the cardiac surgery ICU in stable condition. She woke, neurologically intact and was extubated on the day of surgery. All tubes lines and drains were removed per cardiac surgery protocol. On POD2 she was transferred to the stepdown floor for further post-operative care and recovery. The remainder of her hospital course was uneventful. She progressed well with her activity and was discharged home on POD 6. she is to follow up with Dr [**Last Name (STitle) **] in 3 weeks. Postoperatively she was taken to the intensive care unit for monitoring. Medications on Admission: No regular medications. Occasional NSAID for knee pain. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 6. potassium chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: VF arrest Anoxic brain injury Coronary artery disease s/p CABG Hypertension Asthma Discharge Condition: Alert and oriented x3 nonfocal exam Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema- none 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: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2122-1-6**] 1:15 Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] in one month Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 17663**] in [**4-14**] 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** Please follow with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- neurologist who specializes in cognitive neurology in cardiac arrest patients. Completed by:[**2121-12-15**]

[ "493.90", "578.1", "276.7", "427.5", "410.91", "348.1", "276.1", "V17.41", "570", "276.2", "786.51", "427.41", "401.9", "427.31", "427.1", "414.01", "V70.7", "780.01" ]

icd9cm

[ [ [] ] ]

[ "96.71", "37.22", "88.56", "36.12", "37.49", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

13496, 13555

9575, 12214

315, 765

13682, 13913

2565, 2565

14837, 15649

1987, 2057

12320, 13473

9045, 9552

13576, 13661

12240, 12297

13937, 14814

3277, 7558

7600, 9008

2097, 2546

261, 277

793, 1871

2581, 3261

1893, 1901

1917, 1971

6,365

105,903

10661

Discharge summary

report

Admission Date: [**2201-1-5**] Discharge Date: [**2201-1-8**] Date of Birth: [**2129-2-20**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: 71M with complex hstory of pancreatic pseudocst and vent dependence presenting with acute onset lower GI bleeding. Per nursing at the rehab facility,he was passing small blood clots per rectum on [**2201-1-4**]. No other symptoms or precipitating events noted. Major Surgical or Invasive Procedure: None History of Present Illness: This patient is well known to the surgical service, with a complex history of pancreatic pseudocyst, ventilator dependence, and multiple septic episodes. He was most recently dischargded to [**Hospital 1319**] rehab on [**10-9**] after a prolonged hospital course, which included management of a cystgastrostomy, G-tube, J-tube placement, ultimately complicated by pneumonia and chest tube placement. He re-presented to [**Hospital1 18**] on [**12-4**] with a presumed LLL pneumonia, increased secretions. Subsequent cultures confirmed MRSa/GNR. Initially patient needed full ventilator support, but was weaned to just night support by the time of his discharge on [**2200-12-24**]. Past Medical History: HTN CAD, s/p angioplasty s/p AVR [**7-6**] Respiratory failure tracheostomy Failure to thrive s/p R knee surgery ventilator associated pneumonia pancreatic pseudocyst Atrial fibrilation galstone pancreatitis picc line placement cholelithiasis COPD CHF sepsis Social History: lives with his wifeformer tobacco use Physical Exam: 99.3 79 149/65 22 SaO2 100% on 60% TM Alert & Oriented x3. No Acute Distress. Currently on ventilator support via tracheostomy. CN II-XII intact. Slow amplitude facial tremor noted (old). Pupils equal bilaterally. Scalarae on non-icteric. Oral mucosa is dry. Trachesotomy well secured with cuff up. Neck is supple. Cardiac is irregular, no murmors or rubs nited. There are course breath sounds bilaterally. Abdomen is soft, non-tender. Good bowel sounds. J-tube secured in place. Lower extremities are warm, well perfused, 1+ edema noted bilaterally. Pertinent Results: [**2201-1-5**] 11:38PM HCT-27.3* [**2201-1-5**] 01:30PM GLUCOSE-95 UREA N-24* CREAT-0.5 SODIUM-144 POTASSIUM-3.5 CHLORIDE-107 TOTAL CO2-34* ANION GAP-7* [**2201-1-5**] 01:30PM ALT(SGPT)-15 AST(SGOT)-27 ALK PHOS-658* AMYLASE-12 TOT BILI-0.2 [**2201-1-5**] 01:30PM LIPASE-21 [**2201-1-5**] 01:30PM ALBUMIN-2.5* [**2201-1-5**] 01:30PM DIGOXIN-1.0 [**2201-1-5**] 01:30PM WBC-9.1 RBC-2.70* HGB-8.2* HCT-26.1* MCV-97 MCH-30.6 MCHC-31.6 RDW-16.2* [**2201-1-5**] 01:30PM NEUTS-77.0* BANDS-0 LYMPHS-15.2* MONOS-4.2 EOS-3.4 BASOS-0.2 [**2201-1-5**] 01:30PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL [**2201-1-5**] 01:30PM PLT COUNT-240 [**2201-1-5**] 01:30PM PT-12.2 PTT-25.9 INR(PT)-0.9 Brief Hospital Course: On hospital day one, patient was evaluated by Dr. [**Last Name (STitle) 957**] and his surgical team. At that time his hematocrit was noted to be 26.1, down slightly from 28 on [**12-24**]. He was transfused 2 units of packed red blood celss with an appropriate increase in hematocrit to 28. While stool was noted to be guiac positive, subsequent NG levage cleared easily, and there was no evidence of further bleeding. Over the next 2 days of observation, patients vital signs remained stable, and there was no change in hematocrit. After a final evaluation by Dr. [**Last Name (STitle) 957**], it wa fealt that the patoent was appropriate for discharge back to rehab. Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: [**12-7**] Caps Inhalation DAILY (Daily). 3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO TID (3 times a day). 9. Chlorhexidine Gluconate 0.12 % Liquid Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Levothyroxine Sodium 137 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 13. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 17. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days. 18. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K+< 4.0. 19. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN (as needed) as needed for mg +< 2.0. 20. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: transient upper GI bleed Resolving GI bleed Hyppertension Coronary Artery Disease, s/p angioplasty s/p Aortic Valve Repair [**7-6**] Respiratory failure Failure to thrive s/p R knee surgery h/o ventilator associated pneumonia pancreatic pseudocyst Atrial fibrilation galstone pancreatitis cholelithiasis COPD CHF sepsis Discharge Condition: stable, tolerating daytime trach mask Discharge Instructions: Resume all pre-hospitalization treatments and plans. Continue daytime vent wean as tolerated. Followup Instructions: Resume [**Hospital 34968**] rehab. plan Completed by:[**2201-1-8**]

[ "V44.4", "244.9", "486", "792.1", "V45.82", "414.01", "496", "401.9", "790.01", "V46.11", "V44.0", "578.1", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "99.04", "96.6", "96.34" ]

icd9pcs

[ [ [] ] ]

5492, 5562

3016, 3692

575, 581

5926, 5966

2223, 2993

6108, 6177

3715, 5469

5583, 5905

5990, 6085

1648, 2204

273, 537

609, 1296

1318, 1578

1594, 1633

76,134

160,956

10987

Discharge summary

report

Admission Date: [**2203-2-20**] Discharge Date: [**2203-2-27**] Date of Birth: [**2163-9-18**] Sex: M Service: MEDICINE Allergies: Keflex / ORENCIA / Remicade Attending:[**Doctor First Name 2080**] Chief Complaint: hypotension, presyncope Major Surgical or Invasive Procedure: none History of Present Illness: 39 YO M with psoriatic arthritis thought to have secondary adrenal insuff on chronic dexamethasone who presented to the ED with weakness and hypotension. The patient has been maintain on steroids for approximately the past 2 years. He was on prednisone but was switched to dexamethasone with plan to wean dose given significant Cushingoid appearance. The patient's dose was decreased from 4mg to 2mg on [**2-15**] and, since that time he was monitoring his BPs [**Month/Year (2) **]. On the morning of [**2-20**], upon return from church, he felt weak and so began taking his BP q30 minutes. He started w a BP of 120 but eventually found a value in the 70s for which he presented to the ED. . In the ED, initial vs were: 96.4 77 110/64 --> 69/50 16 98%. Exam was notable for diaphoretic, ill appearing male. Labs were notable for K 3.0, creatinine 1.9 (from baseline 1.0). EKG showed bigemeny. CXR was unremarkable. Patient was given zofran, dexamethasone 4mg and 1.5L NS. VS prior to transfer were: 95/33 22 98% on 3L. . Upon arrival to the ICU, the patient complains of multiple problems. [**Name (NI) **] reports ~70lb weight gain over the past 6 months. He has noted increased LE swelling and ~5 lb weight gain per day since mid-[**Month (only) 956**]. He was admitted for this from [**1-20**] to [**1-27**] during which time he had an extensive cardiac work up including tte, stress testing and cardiac MRI with no evidence of cardiac etiology. He then underwent PFTs which showed a restrictive ventilatory defect thought [**12-29**] his obesity. Despite his normal work up he has been maintained on torsemide and was taking twice his regular dose (40mg) for the past 3 days. He continues to complain of sob, pleuritic chest pain, and dry mouth. Past Medical History: # Psoriatic arthritis c/b steroid dependence with exogenous steroid-associated [**Location (un) **] syndrome, adrenal insufficiency # vitamin D deficiency # abnormal thyroid function tests. # Left gastrocnemius abscess and bacteremia growing MSSA ([**Month (only) 958**] [**2201**]). # History of MRSA infection status post eradication in [**2195**]. # Morbid obesity. # Obstructive sleep apnea, autoset CPAP 14-18cmH20 with CFlex 2 # Irritable bowel syndrome. # Hypertension. # Diabetes mellitus type 2. # Hyperlipidemia. # Peripheral neuropathy. # Nonalcoholic fatty liver disease secondary to previous methotrexate treatment. # Keratoconus status post bilateral corneal transplant ([**2186**], [**2190**]). # Status post four anal fistulotomies. # Status post tonsillectomy x2 and adenoidectomy. # Degenerative joint disease, status post L4/L5 discectomy. # Patellofemoral syndrome, status post arthroscopic surgery for both knees x3 each. Social History: Patient lives with his wife and children. He is currently on disability, previously teacher for autistic children. Tobacco: never ETOH: occasional Family History: Mother: Ulcerative colitis, hypertension, hypercholesterolemia, and bipolar disorder. Father: Non smoking-induced COPD and hypertension. Brother: Dermatologic psoriasis and ulcerative colitis. Sister: Hypertension, hypercholesterolemia. Paternal aunt: Crohn disease and sarcoidosis. Physical Exam: ADMISSION EXAM: Vitals: 98.4 161/100 --> 93/52 75 17 96% RA General: Alert, oriented, no acute distress; morbidly obese/Cushingoid HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, prominent dorsocervical fat pad Lungs: diminished breath sounds throughout CV: distant heart sounds Abdomen: obese, erythema more prominent on the right side, with some pitting body wall edema, couple of small ? abscesses GU: no foley Ext: warm, well perfused, 2+ pulses, 2+ pitting edema . Discharge exam: Vitals: 97.3 HR 104 BP 148/89 RR 20 O2 100% on RA . I/O: 1304/3950 in 24 hrs . General: Alert, oriented, no acute distress; morbidly obese, severely Cushingoid appearance HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, prominent dorsocervical fat pad Lungs: diminished breath sounds throughout CV: distant heart sounds Abdomen: obese, +BS, non tender, with some pitting body wall edema Ext: edema of the RLE worse than LLE, warm, well perfused, 2+ pulses, small linear vesicle on the anterior aspect of the right foot, 2+ pitting edema to the thigh. Pertinent Results: ADMISSION LABS: [**2203-2-20**] 04:35PM BLOOD WBC-10.0 RBC-4.45* Hgb-14.1 Hct-38.8* MCV-87 MCH-31.7 MCHC-36.4* RDW-15.1 Plt Ct-313 [**2203-2-20**] 04:35PM BLOOD Neuts-77.8* Lymphs-16.2* Monos-5.2 Eos-0.1 Baso-0.8 [**2203-2-20**] 10:23PM BLOOD PT-13.3 PTT-18.1* INR(PT)-1.1 [**2203-2-20**] 04:35PM BLOOD Glucose-74 UreaN-48* Creat-1.9* Na-140 K-3.0* Cl-96 HCO3-32 AnGap-15 [**2203-2-20**] 04:35PM BLOOD ALT-55* AST-28 CK(CPK)-139 AlkPhos-41 TotBili-0.5 [**2203-2-20**] 10:23PM BLOOD proBNP-584* [**2203-2-20**] 04:35PM BLOOD cTropnT-<0.01 [**2203-2-20**] 04:35PM BLOOD Albumin-4.4 Calcium-9.4 Phos-5.7*# Mg-2.3 [**2203-2-20**] 06:42PM BLOOD Type-ART Temp-36.1 pO2-86 pCO2-47* pH-7.45 calTCO2-34* Base XS-7 Intubat-NOT INTUBA . DISCHARGE LABS: [**2203-2-27**] 07:30AM BLOOD WBC-6.2 RBC-3.89* Hgb-12.3* Hct-35.0* MCV-90 MCH-31.5 MCHC-35.0 RDW-15.2 Plt Ct-245 [**2203-2-27**] 07:30AM BLOOD Glucose-143* UreaN-24* Creat-0.9 Na-143 K-4.1 Cl-103 HCO3-31 AnGap-13 [**2203-2-27**] 07:30AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.3 . MICROBIOLOGY: none . IMAGING: [**2203-2-20**] CXR: pending Brief Hospital Course: 39 yo male with morbid obesity, IDDM, HLD, HTN initially admitted to the MICU for hypotension found to be dehydrated with [**Last Name (un) **]. . # Hypotension: The patient was found to have increased torsemide to [**Hospital1 **] dosing over the days prior to admission and [**Last Name (un) **] which likely contributed to the patient's hypotension. All anti-hypertensives were stopped in the MICU. Endocrine was consulted given chronic steroids and determined not to be adrenally insufficient. Ultimately, he was restarted on some anti-hypertensives including torsemide, spironolactone and carvedilol instead of HCTZ and metoprolol. He was instructed to uptitrate carvedilol from 6.25mg [**Hospital1 **] as needed for BPs over 140/90. Blood pressure on discharge normal to hypertensive. . # Weight gain/LE edema: The patient has had extensive workup for right sided heart failure including cardiac MRI, echo and thought to not be present. Edema thought to be related to excess fluid intake in the setting of steroid therapy. Endocrine recommended decreasing dexamethasone to 1mg daily. He was placed on fluid restriction of 2L with tight i/os. He was diuresed with good output with torsemide 20mg daily and spironolactone 50mg daily. He complained of right sided foot pain and found to have asymmetric swelling. LENI was negative for clot. He was instructed to monitor i/os as outpatient and if more negative than 3L he may need to decrease diuretic therapy. . # Heel pain: Likely from compression stockings and possible plantar fasciitis. Resolved with tylenol and tramadol. . # [**Last Name (un) **]: On arrival Crn up to 2.2, resolved with IVFs. Trended down to baseline and did not increase with stable diuresis. Instructed to have labs checked this week and have the results sent to PCP. . # IDDM. Adjusting sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] . # HTN. Changed metoprolol to carvedilol, slowly increasing dose started at 3.25mg [**Hospital1 **], discharged on 6.25mg and will likely need to continue to increase. Increased spironolactone. Continued torsemide daily. Discontinued HCTZ . # Psoriatic Arthritis. Stable. Continued dexamethasone 1mg after quick taper. Continued ppx bactrim. Continued azathioprine . Medications on Admission: albuterol inhaler 2 puffs QID alendronate 35mg q sunday lipitor 80mg daily azathioprine 100mg [**Hospital1 **] dexamethasone 2mg daily vitamin D 50K every other week gabapentin 800mg [**Hospital1 **] HCTZ 25mg daily insulin aspart insulin detemir lidoderm patch to ankle/knee metoprolol succinate 200mg daily nortryptyline 25mg qhs donnatal 16.2mg 1-2 tabs QID KCL pregabalin 50mg qhs bactrim DS MWF tizanidine 8mg qhs torsemide dose 20-40mg daily ustekinumab SQ aspirin 81mg daily iron 325mg daily Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO every other week . 7. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily): DECREASED TO DAILY . 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for to ankle/knee. 9. pregabalin 75 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 11. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)) as needed for pain. 12. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 16. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 17. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain : over the counter. 18. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation: over the counter. 20. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation: over the counter. 21. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). 22. Outpatient Lab Work Please have your Chem 7 checked and sent to Dr.[**Doctor Last Name 35622**] office at Phone: [**Telephone/Fax (1) 35614**] Fax: [**Telephone/Fax (1) 35625**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypotension secondary to hypovolemia . Secondary Diagnoses: Psoriatic arthritis Morbid obesity. Obstructive sleep apnea Hypertension. Diabetes mellitus type 2. Hyperlipidemia. Peripheral neuropathy. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] for evaluation of low blood pressure. You were found to be taking too much torsemide. You were found to have no other reason for your low blood pressure. Your medications were changed as stated below. . You should monitor your fluid intake and attempt to drink only 2L of fluids a day. If you have been negative more than 3L in one day you should discuss with your primary care doctor about cutting back the torsemide. You should have your labs checked on Wednesday of next week and have the results sent to Dr. [**Name (NI) 35621**]. . You should check your pulse and blood pressure daily. If starting to trend up (HR > 100, BP > 140/90), increase carvedilol dose to 12.5mg twice a day. . MEDICATION CHANGES: STOP Hydrochlorothiazide STOP Potassium supplementation DECREASE Torsemide to 20mg daily START Spironolactone 50mg daily STOP Metoprolol START Carvedilol 6.25mg twice a day DECREASE Gabapentin to 800mg daily INCREASE Lyrica to 75mg daily DECREASE Dexamethasone to 1mg daily . Change insulin regimen to the below sliding scale Breakfast Glargine 12 Units Bedtime Glargine 15 Units . Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog 71-100 0 Units 0 Units 0 Units 0 Units 101-120 0 Units 0 Units 0 Units 0 Units 121-140 2 Units 2 Units 2 Units 0 Units 141-160 4 Units 4 Units 4 Units 0 Units 161-180 6 Units 6 Units 6 Units 2 Units 181-200 8 Units 8 Units 8 Units 4 Units 201-220 10 Units 10 Units 10 Units 6 Units 221-240 12 Units 12 Units 12 Units 8 Units 241-260 14 Units 14 Units 14 Units 10 Units 261-280 16 Units 16 Units 16 Units 12 Units 281-300 18 Units 18 Units 18 Units 14 Units 301-320 20 Units 20 Units 20 Units 16 Units 321-340 22 Units 22 Units 22 Units 18 Units 341-360 24 Units 24 Units 24 Units 20 Units Followup Instructions: Name: [**Last Name (LF) 3240**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: Family Medicine Address: [**Location (un) 35619**], [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 23661**] Phone: [**Telephone/Fax (1) 35614**] **Please contact your PCP office at the number above to schedule a follow up appointment from your stay at the hospital. Your appointment needs to be 1-2 weeks from your discharge** Department: DIV OF GI AND ENDOCRINE When: FRIDAY [**2203-3-11**] at 4:40 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Name: [**Last Name (LF) 32920**], [**First Name3 (LF) 35623**] A. MD Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Appointment: Wednesday [**3-2**] at 10AM Department: PFT When: THURSDAY [**2203-3-10**] at 8:30 AM Department: PULMONARY FUNCTION LAB When: THURSDAY [**2203-3-10**] at 8:30 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2203-3-10**] at 9:30 AM With: [**Name6 (MD) **] [**Name8 (MD) 611**], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2203-2-27**]

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35733+58025

Discharge summary

report+addendum

Admission Date: [**2148-3-9**] Discharge Date: [**2148-3-20**] Date of Birth: [**2099-1-1**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6088**] Chief Complaint: Abdominal pain w/ eating Major Surgical or Invasive Procedure: [**2148-3-13**] IVC filter [**2148-3-14**] Aortic Thrombectomy and Hysterectomy History of Present Illness: 49F with abd pain x1day. Describes as severe, cramping, unrelenting, not associated with eating. Located LLQ primarily, non-radiating. Pain currently absent after pain medications. Presented to OSH where CT revealed femoral vein thrombosis and large pelvic mass. Was transferred to [**Hospital1 18**] ED for further evaluation and management after heparin gtt was started. Past Medical History: HTN metrorrhagia 2 spont abortions in past Social History: Lives alone. H/o smoking but quit 15 years ago. Drinks socially. No other drug use. Family History: mother died breast Ca Physical Exam: VS: T99.2 HR 75 BP 148/83 RR 18 O2 sat 98% Gen: AAOx3, NAD card: RRR, no M/R/G lungs: CTA B/L Abd: soft, NT, ND, positive bowel sounds, incision dry and intact Ext: well perfused, warm b/l Pertinent Results: [**2148-3-19**] 05:20AM BLOOD WBC-7.5 RBC-3.87* Hgb-8.0* Hct-29.1* MCV-75* MCH-20.5* MCHC-27.3* RDW-27.1* Plt Ct-233 [**2148-3-18**] 05:20AM BLOOD WBC-7.5 RBC-3.74* Hgb-7.7* Hct-27.9* MCV-75* MCH-20.5* MCHC-27.5* RDW-27.5* Plt Ct-313 [**2148-3-17**] 03:51AM BLOOD WBC-12.1* RBC-3.70* Hgb-7.6* Hct-27.2* MCV-74* MCH-20.6* MCHC-28.0* RDW-27.7* Plt Ct-310 [**2148-3-16**] 01:50AM BLOOD WBC-14.4*# RBC-3.63* Hgb-7.4* Hct-26.2* MCV-72* MCH-20.2* MCHC-28.0* RDW-27.6* Plt Ct-329 [**2148-3-15**] 02:49AM BLOOD WBC-9.1 RBC-3.50* Hgb-7.2* Hct-24.9* MCV-71* MCH-20.4* MCHC-28.7* RDW-26.3* Plt Ct-416 [**2148-3-14**] 03:50PM BLOOD WBC-11.3* RBC-3.99* Hgb-8.1*# Hct-27.7* MCV-69* MCH-20.3*# MCHC-29.3*# RDW-26.6* Plt Ct-542* [**2148-3-13**] 03:50AM BLOOD Hct-24.6* [**2148-3-12**] 06:15AM BLOOD WBC-10.0 RBC-3.46* Hgb-6.0* Hct-22.9* MCV-66* MCH-17.4* MCHC-26.2* RDW-25.1* Plt Ct-579* [**2148-3-11**] 06:20AM BLOOD WBC-15.6* RBC-3.42* Hgb-6.1* Hct-22.3* MCV-65* MCH-17.9* MCHC-27.4* RDW-25.5* Plt Ct-634* [**2148-3-20**] 05:40AM BLOOD PT-25.1* PTT-116.8* INR(PT)-2.5* [**2148-3-19**] 05:20AM BLOOD PT-17.8* PTT-83.3* INR(PT)-1.6* [**2148-3-19**] 05:20AM BLOOD Glucose-86 UreaN-6 Creat-0.8 Na-139 K-3.9 Cl-100 HCO3-32 AnGap-11 [**2148-3-18**] 05:20AM BLOOD Glucose-106* UreaN-7 Creat-0.8 Na-139 K-3.8 Cl-102 HCO3-29 AnGap-12 CT PELVIS W/CONTRAST Study Date of [**2148-3-9**] 4:24 AM IMPRESSION: 1. Large pelvic mass with rounded components within it certainly could represent a fibroid uterus although the differential includes malignant etiologies such as uterine sarcoma or spindle cell lesion. 2. Left common femoral deep vein thrombosis. 3. Filling defect within the aorta extending into the celiac trunk, which may represent thrombus, proximal to the left renal vein. 4. Left renal infarcts (less likley pyelonephritis) Portable TTE (Complete) Done [**2148-3-11**] at 3:00:55 PM FINAL Conclusions The left atrium is mildly dilated. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The right atrial pressure is indeterminate. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. ECG Study Date of [**2148-3-12**] 9:04:52 PM Sinus rhythm. No previous tracing available for comparison. CT PELVIS W&W/O C Study Date of [**2148-3-12**] 10:20 AM IMPRESSION: 1. Large pelvic mass with rounded components likely representing a fibroid uterus, although the differential includes malignant etiology such as uterine sarcoma as well, unchanged. 2. Clot identified within the descending aorta at the level of the renal arteries, slightly smaller in appearance. 3. Multiple bilateral renal infarcts, worse when compared to prior exam. 4. Sludge within the gallbladder. 5. Multiple pulmonary emboli as described above. ECG Study Date of [**2148-3-13**] 4:51:38 PM Normal sinus rhythm. Within normal limits. Compared to the previous tracing of [**2148-3-12**] no diagnostic interval change except for slowing of the rate. Pathology Examination Procedure date Tissue received Report Date [**2148-3-14**] [**2148-3-14**] [**2148-3-19**] Gross: The specimen is received fresh in two parts, labeled with the patient's name "[**Known lastname 81273**], [**Known firstname 81274**]" and the medical record number. Part 1 is additionally labeled "aortic mass". It was received fresh in the operating room and consists of a piece of tan-yellow tissue measuring 1.5 x 0.8 x 0.4 cm. One half of the specimen was frozen. The frozen section diagnosis by Dr. [**Last Name (STitle) **]. [**Doctor Last Name 9885**] reads as follows: "Fibrin admixed with inflammatory cells, and degenerative cellular debris and cluster of atypical epithelioid cells. Defer further characterization to permanent sections". The frozen section is submitted in A. The remainder of the specimen is submitted in B. Part 2 is additionally labeled "uterus". The specimen is received fresh from the operating room. It consists of a uterus with detached cervix and without attached adnexae. The uterus is grossly distorted by leiomyomas and measures 22 cm anterior to posterior, 17 cm fundus to cervical neck, 11 cm from cornu to cornu. Cannot differentiate from posterior and anterior surfaces due to marked distortion. The serosa is smooth, except for subserosal leiomyoma and adnexal resection margins. The cervix measures 2.6 x 2.2 cm and the ectocervix measures 0.6 cm with a slit-like os. The uterus is bivalved to reveal an unremarkable endometrial surface with two small 1.2 and 1 cm submucosal leiomyomas. No other masses or lesions are seen in the endometrium. The myometrium is sectioned to reveal multiple leiomyomas, measuring up to 10 cm in greatest dimension. The largest leiomyoma is sectioned to reveal whorled cut surfaces without hemorrhage or necrosis. Gross diagnosis by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] reads as follows: "Endometrium with two submucosal leiomyomas, myometrium with numerous leiomyomas without gross hemorrhage or necrosis, final diagnosis pending permanent sections". The specimen is represented as follows: C = cervix with transition zone, D = endometrium with myometrium, E-I = representative sections of leiomyomas. PERITONEAL WASHINGS Procedure Date of [**2148-3-14**] DIAGNOSIS: Peritoneal Washing: NEGATIVE FOR MALIGNANT CELLS. Predominantly blood. DIAGNOSED BY: [**First Name9 (NamePattern2) 32952**] [**Last Name (un) 11503**], CT(ASCP) [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 60222**], M.D. TEE (Complete) Done [**2148-3-14**] at 10:25:44 AM FINAL Conclusions 1. No atrial septal defect is seen by 2D or color Doppler. 2. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. 5. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial pericardial effusion. 6. There appears to by a moble hypoechoic mass attached to the lumen of the descending thoracic aorta at the level of the kidneys which could represent a clot or tumor. 7. There are small bilateral pleural effusions. Brief Hospital Course: 3/14/09/Admitted w/ Lt CFV DVT and likely aortic thrombus in the setting of large pelvic mass. Continued on Heparin drip. CT pelvis/abd- large pelvic mass, L CFV thrombosis, L renal infarcts. Hematology consult for hypercoagulable evaluation- lab work-up sent. Gyn consult and following for recommendations regarding mass. Routine labs. [**2148-3-10**] T max 101.8- pan (blood, urine) cultured, CXR.Continued on Heparin drip. Hematology following. Dilaudid for pain. 3/16-17/09 Continued to be febrile overnight. Portable TTE done-no thrombus seen. LVEF 55%. Continued on Heparin drip. Repeated CT pelvis w/&w/o con- same large pelvic mass, clot identified in the descending aorta, multiple pulmonar emboli, multiple renal infarcts. Hct low 22.3, Hemonc following- no transfusion if not symptomatic-recs Iron supplement. Pre-op for IVC filter placement. Prte-op ECG done-NSR. [**2148-3-13**] Hct remains low 22.3-transfused w/ 2 units PRBCs. Taken to angio suite for IVC filter placement. Recovered in the PACU, resumed Heparin drip, transferred to [**Hospital Ward Name 121**] 5 VICU/telemetry. Kept NPO and pre-oped for Aortic thrombectomy/endarterectomy and hysterectomy [**3-14**]. Social work consult for coping. [**2148-3-14**] No overnight events. Taken to OR for dual Vascular and Gyn surgery (Aortic thrombectomy/endarterectomy and hysterectomy). Patient tolerated procedure, cell savers given intra-op, invasive monitoring devices placed (A-line, CL, foley), recovered in the PACU then transferred to CVICU. IV Kefzol and Flagyl per Gyn post-op. Placed on Nitro drip for BP control, given Fentanyl for pain control. Heparin drip resumed. TEE done-no thrombus found. 3/20-21/09 POD1-2 Remains in the CVICU, still on Nitro drip for BP control, recieving Fentanyl boluses for pain control. Continued w/ Flagyl and Ancef per GYN. Continued on Heparin drip. No bowel sounds yet. Pain better controlled w/ PCA Dilaudid. Diuresed w/ Lasix. Blood cultures from [**3-10**]- NG. Started Metoprolol IV, Nitro weaned off. [**2148-3-17**] POD3 Remains in CVICU. Continued on Heparin drip, good pain control w/ Dilaudid PCA, Metoprolol IV. Out of bed. A-line, foley D/C'd. Transferred to [**Wardname 10876**] floor. [**2148-3-18**] POD4 No acute events. Remains in VICU. Remains on Heparin drip and PCA Dilaudid d/c'd switched to oral Dilaudid. Started clears and progressed to full diet.Started Coumadin 10 mg. Hemonc and GYN following. Out of bed as tolerated. [**2148-3-19**] POD5 No acute events. Good pain control on PO Dilaudid. Remains on Heparin drip transitioning to Coumadin. Central line d/c'd. Hemonc and GYN following, will follow outpatient. Continued w/ out of bed activity. [**2148-3-20**] POD5 No acute events. Good pain control on PO Dilaudid. INR finally therapeutic. Heparin drip D/C'd. Discharged to home in good condition. Ambulating, taking adequate PO's, moving bowels and voiding well. Will FU w/ [**Hospital **] clinic in 1 week for staples/suture removal, FU w/ Heme and GYN as scheduled, will also FU w/ PCP to have her INR monitored and Coumadin dose titrated. She can walk in to have a blood draw. Medications on Admission: atenelol 50 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): GILEK-[**Doctor Last Name **],KATARZYNA J. [**Telephone/Fax (1) 81275**] for refills. Disp:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): GILEK-[**Doctor Last Name **],KATARZYNA J. [**Telephone/Fax (1) 81275**] for refills. Disp:*30 Tablet(s)* Refills:*2* 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): GILEK-[**Doctor Last Name **],KATARZYNA J. [**Telephone/Fax (1) 81275**]. Disp:*30 Tablet(s)* Refills:*2* 8. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Dose to be titrated by Dr. [**Last Name (STitle) **],KATARZYNA J. [**Telephone/Fax (1) 81275**] for refills. . Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: fibroid uterus aortic thrombis Anemia-requiring blood transfusion PMH: Hypertension Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Aortic Thrombectomy Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**6-3**] 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 [**1-30**] 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: [**Name6 (MD) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 8246**] Date/Time:[**2148-4-22**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2148-4-30**] 9:00 Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2148-5-8**] 4:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10107**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1237**] Date/Time:[**2148-3-27**] 11:00 Completed by:[**2148-3-20**] Name: [**Known lastname 13022**],[**Known firstname 13023**] Unit No: [**Numeric Identifier 13024**] Admission Date: [**2148-3-9**] Discharge Date: [**2148-3-20**] Date of Birth: [**2099-1-1**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5118**] Addendum: [**2148-3-19**] Per Hemonc recs patient was given a test dose of Iron Dextran 25 mg IV after premedication then given full dose of 1000 mg IV x 1. Discharge Disposition: Home [**Name6 (MD) 116**] [**Last Name (NamePattern4) 2878**] MD [**MD Number(2) 5119**] Completed by:[**2148-3-20**]

[ "280.9", "626.2", "444.1", "V02.54", "415.19", "401.1", "593.81", "453.41", "218.9", "338.19", "620.2" ]

icd9cm

[ [ [] ] ]

[ "00.40", "38.91", "38.14", "38.7", "68.49", "99.04" ]

icd9pcs

[ [ [] ] ]

16712, 16860

8361, 11496

337, 419

12796, 12805

1260, 8338

15532, 16689

1012, 1036

11558, 12639

12689, 12775

11522, 11535

12829, 15079

15105, 15509

1051, 1241

273, 299

447, 825

847, 892

908, 996

1,006

147,743

4628

Discharge summary

report

Admission Date: [**2158-10-16**] Discharge Date: [**2158-11-8**] Date of Birth: [**2085-8-27**] Sex: M Service: TSURG Allergies: Sulfonamides Attending:[**First Name3 (LF) 4272**] Chief Complaint: Adenocarcinoma of the right main bronchus Major Surgical or Invasive Procedure: Right pneumonectomy with serratus muscle flap Bronchoscopy Mediastinal lymph node dissection Exploratory laparotomy with lysis of adhesions Foley catheter placement Chest tube placement Peripherally inserted central catheter Nasogastric tube placement Endotracheal tube placement Epidural catheter placement History of Present Illness: This is a 73 year old Russian gentleman who presented to the Clinic with a diagnosis biopsy proven of adenocarcinoma of the right main stem. Per his report he had been diagnosed and treated in the Soviet [**Hospital1 1281**] for a right lung cancer 25 years ago. He has received a significant amount of radiation therapy and chemotherapy. Patient also has had a known partial collapse and consolidation of the right lung for the past several years and increasing shortness of breath for the past six months. He has scoliotic spine and a significantly reduced right lung capacity. He is a very active gentleman. He is able to walk for one to two hours every day. Past Medical History: PAST MEDICAL HISTORY: 1. Symptomatic cholelithiasis. 2. Right-sided lung cancer, status post chemotherapy and radiotherapy. 3. COPD/bronchiectasis 4. Hypertension. 5. Benign prostatic hypertrophy. 6. Status post pacemaker. 7. History of depression. 8. Status post partial colectomy in [**2126**]. 9. History of positive PPD in [**2146**]-no prophylaxis/active disease adenosine deaminase in 9/99 ~9.7, suggestive of possible TB pleural disease 10. History of exertional angina, which is currently asymptomatic. Social History: He is a former smoker who has quit 25 years ago. He is retired and lives in an apartment for the elderly. He has been quite active until recently. Pt with remote (20 pack year; quit 25 years ago) tobacco history. Pt denies use of alcohol or ivda. He lives with his wife. His son and daughter speak english and are able to translate. Family History: Non-contributory Physical Exam: Patient's physical exam on admission is as follows: Vitals: T=97.8, BP=159/59, P=97, R=16, SpO2=98%RA Gen: NAD, AAOx3 HEENT: PERRL, EOMI, no LAD CVS: RRR, no MRG Pulm: CTA bilaterally, no CRW Abd: soft, NT/ND, +BS Ext: no CCE, warm/dry with good cap refill Neuro: no focal deficits, CN 2-12 grossly intact Pertinent Results: [**2158-10-16**] 04:47PM WBC-22.4*# RBC-3.82* HGB-10.4* HCT-31.2* MCV-82# MCH-27.3# MCHC-33.4 RDW-16.9* [**2158-10-16**] 04:47PM GLUCOSE-140* UREA N-22* CREAT-1.3* SODIUM-141 POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12 [**2158-10-16**] 04:47PM PT-17.3* PTT-34.2 INR(PT)-1.9 [**2158-10-16**] 04:47PM PLT COUNT-238 [**2158-10-16**] 04:47PM BLOOD Glucose-140* UreaN-22* Creat-1.3* Na-141 K-5.0 Cl-109* HCO3-25 AnGap-12 Pathology Examination #[**-4/3312**] [**2158-10-16**] DIAGNOSIS: 1. Mediastinal pleura (AA): Lung parenchyma with chronic inflammation and fibrosis. No malignancy identified. 2. "Part of thymus and anterior mediastinum" (A-E): Adipose tissue with focal collection of macrophages, many ladened with carbon pigment. 3. Endobronchial tumor (F): Non-small cell carcinoma (see synopsis). 4. 4R, node (G-H): One lymph node, no malignancy identified. 5. Right lung, pneumonectomy (I-P): Non-small cell carcinoma (see synoptic report). Vascular and bronchial margins are free. Uninvolved lung shows collapse with hemorrhage and chronic inflammation. 6. Ribs (Q-R): Bone and marrow with trilineage hematopoiesis. CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST [**2158-10-24**] 7:15 PM 1. Evidence of viscus perforation with free air seen in the right lower quadrant. Fat stranding and a small amount of free fluid are also seen in the right lower quadrant. There is possible pneumatosis of the cecum. Findings are consistent with a perforated cecum likely due to ischemia. 2. Scattered diverticula seen throughout the remainder of the colon without frank diverticulitis. 3. Marked distention of the cecum measuring up to 10 cm. There is also distention of the ascending and transverse colons. There is no evidence of obstruction. UNILAT UP EXT VEINS US RIGHT [**2158-10-24**] 5:06 PM Right subclavian vein thrombosis. Limited examination, as above. The findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the time of the exam. Cardiology Report ECHO Study Date of [**2158-10-24**] 1. The left atrium is mildly dilated. 2. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function cannot be reliably assessed. 3. The right ventricular cavity is mildly dilated. 4. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6. There is mild pulmonary artery systolic hypertension. 7.There is a small pericardial effusion. 8. Compared with the findings of the prior study (tape reviewed) of [**2158-9-15**], there has been no significant change. CHEST (PORTABLE AP) [**2158-11-6**] 8:03 AM 1. Slight increase in the size of the left pleural effusion. 2. No evidence of pulmonary edema. Brief Hospital Course: Mr. [**Known lastname 19641**] was admitted to Thoracic Surgery on [**2158-10-16**] for an intrapleural, intrapericardial pneumonectomy with serratus muscle flap bronchoscopy and mediastinal lymph node dissection. For details of the procedure, please see the operative report. Upon completion of the operation, the patient was sent to the MICU as a border for hypotension. His course in the MICU was significant for afib/flutter which was controlled with verapamil and quinidine. Of note, the patient was extubated in the OR but which subsequently failed requiring re-intubation. He was then extubated the following day without issue thereafter. In the MICU, EPS interrogated his AICD after noting rare PVCs. Then on POD#3 he was found to be stable enough and was then transferred to the floor. On POD#4, patient was seen by EPS for an occurrence of A-flutter; was refractory to metoprolol and was then treated with digoxin and diltiazem which converted patient's rhythm to sinus. The digoxin and diltiazem was then subsequently discontinued with no need to start any antiarrhythmics at that time. However, on POD#7, patient was noted to have A-fib and was started on quinidine 324mg (1.5 tabs PO Q8hrs), a heparin drip and coumadin for anticoagulation. Furthermore, on POD#7, patient began having changes in mental status, complaining of abdominal pain and distention and had need of increased fluids. Despite having a completely benign exam and a white blood cell count within normal, he did have an elevated creatinine and lowered systolic blood pressure. The patient was then moved to the ICU, a cardiac echo was done, a general surgery consult was obtained and the patient was made NPO and had a nasogastric tube and arterial line placed. An abdominal CT showed free air within the right upper quadrant with significant inflammation/stranding about the cecum/appendix and questionable distention of the right colon. His abdominal exam also worsened at that point and general surgery was concerned about possible a perforated appendix, colonic ischemia secondary to the A-fib, or a perforation secondary to [**Last Name (un) 3696**] syndrome; an exploratory laparotomy was suggested and discussed with the family who agreed and wished to proceed. On [**2158-10-25**] patient underwent the exploratory laparotomy but was found to have no gross evidence of perforation. It is believed that the patient suffered a microperforation resulting in free air but which had subsequently healed. He was then taken to the SICU. On [**2158-10-26**] was restarted on a heparin drip, amiodarone and also extubated. On [**2158-10-28**], patient was assessed for nutritional requirements and found to need TPN which was started that day. On [**2158-10-30**] a post-pyloric Dobhoff feeding tube was placed by Int. Radiology for concerns of aspiration while attending to the patient's nutritional requirements; TPN was discontinued on [**2158-10-31**] and patient was moved to the floor. His pulmonary exam improved and begin to clear secretions much better throughout the remainder of his hospital course. On [**2158-11-6**], a bedside swallowing study was performed for concerns of regurgitation possibly leading to aspiration; the study was within normal. The feeding tube was then discontinued and patient's diet was advanced to ground solids with boost supplementation. On [**2158-11-8**], patient had 3 occurrence's of his AICD firing during the QRS complex. This was discussed with EPS who recommended that the patient be switched to amiodarone 400mg PO QD and be seen at his Rehab facility this week by Cardiology for possible AICD interrogation and further management. Patient was then discharged on the same day to [**Hospital3 105**] in good condition, ambulating and tolerating a ground diet. His INR was therapeutic and he was placed on 4mg of coumadin PO QHS; the INR is to be checked twice a week on Thursdays and Mondays and the coumadin dosage adjusted accordingly. Furtermore, he is to be discharged with a 7 day course of levofloxacin 500mg PO QD. He is asked to follow-up with Dr. [**Last Name (STitle) 175**] in 1 week, Dr. [**Last Name (STitle) 6633**] in general surgery in [**3-30**] weeks. It is also requested that he be seen by Cardiology at [**Hospital1 **] as mentioned above. Medications on Admission: Verapamil 240mg PO Q8hrs Protonix 40mg PO QD MDI-flovent Minoxidil Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*QS 1* Refills:*0* 2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*QS 1* Refills:*2* 3. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: [**1-27**] Disk with Devices Inhalation Q12H (every 12 hours). Disp:*QS Disk with Device(s)* Refills:*2* 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:*QS 1* Refills:*2* 5. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Warfarin Sodium 4 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Right lung carcinoma Hypertension Chronic obstructive pulmonary disease Depression Benign prostatic hypertrophy Diabetes Atrial fibrillation Constipation Hypovolemia Discharge Condition: Good Discharge Instructions: You may restart any medications taken prior to hospital admission. You may have a regular diet. You may shower. Please refrain from any strenuous lifting or activity for at least 1-2 months. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 175**] (Thoracic Surgery) in clinic in [**1-27**] weeks. Please call [**Telephone/Fax (1) 2348**] for an appointment. Also, please follow-up with Dr. [**Last Name (STitle) 6633**] (General Surgery) in [**3-30**] weeks. Please call [**Telephone/Fax (1) 2998**] for an appointment. Also, you have been scheduled for the following appointments. Please try to keep these appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2159-1-18**] 2:00 Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2159-1-18**] 2:30

[ "427.31", "276.5", "560.89", "V53.32", "584.9", "789.5", "458.29", "511.0", "428.0", "496", "162.2" ]

icd9cm

[ [ [] ] ]

[ "96.6", "34.04", "99.04", "38.91", "54.11", "99.15", "96.05", "33.22", "32.6", "38.93" ]

icd9pcs

[ [ [] ] ]

10970, 11041

5558, 9881

313, 622

11250, 11256

2615, 5535

11495, 12255

2255, 2273

9998, 10947

11062, 11229

9907, 9975

11280, 11472

2288, 2596

232, 275

650, 1320

1364, 1889

1905, 2239

13,579

168,554

10198

Discharge summary

report

Admission Date: [**2152-1-27**] Discharge Date: [**2152-2-3**] Date of Birth: [**2067-11-17**] Sex: M Service: MEDICINE Allergies: Amiodarone Hcl / Lisinopril / Latex Attending:[**First Name3 (LF) 4095**] Chief Complaint: [**Known lastname **] stools Major Surgical or Invasive Procedure: Endoscopy Enteroscopy Colonscopy History of Present Illness: 84 yo M with rectal cancer s/p chemoradiation and surgical resection complicated by radiation proctitis, atrial fibrillation, diastolic CHF, and CAD s/p CABG presenting to the ED after 3 days of dark [**Known lastname **] stool. He is completely incontinent to stools and notes that all of his stools have been [**Known lastname **] and sticky. He also noted chest pressure earlier today while walking to his car, associated with diaphoresis and palpitations. . In the ED, initial vitals were 97.2 68 95/27 20 100%. Hct was 16, down from 30 recently. Trop 0.02. Started on IV protonix drip and transfusion of PRBCs begun. Transferred to the [**Hospital Unit Name 153**]. . On transfer, vitals pulse: 60, RR: 19, BP: 111/50, O2Sat: 100% on RA. On arrival to the ICU, he feels well and has no complaints. Past Medical History: - rectal cancer s/p chemoradiation and surgical resection complicated by radiation proctitis ([**2145**]) - chronic incontinuence [**1-6**] radiation proctitis - radiation ileitis s/p ileumectomy - diastolic CHF with preserved EF (60% [**9-/2151**]) - CABG [**2140**] - Atrial fib - in NSR s/p cardioversion, maintained on dofetilide - severe aortic stenosis - h/o C. diff - h/o cellulitis in R leg Social History: Lives with his wife. Retired professor [**First Name (Titles) **] [**Last Name (Titles) 34011**] History at [**Last Name (un) **], still working part time. - Tobacco: quit in [**2101**] - Alcohol: glass wine/day - Illicits: None Family History: The patient's mother had breast cancer, [**Name (NI) 9876**] with stomach cancer, father had DM. Physical Exam: ADMISSION EXAM Vitals: 97.0 62 130*62 12 100% on RA General: Alert, oriented, no acute distress, pale HEENT: Sclera pale, dry membranes, oropharynx clear Neck: supple, JVP elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, severe aortic stenosis murmur Abdomen: diffuse surgical scars with a midline reducible hernia, 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: Vitals stable Abdomen benign Pertinent Results: Admission Labs: [**2152-1-27**] 09:45AM WBC-4.4 RBC-1.94*# HGB-5.4*# HCT-16.9*# MCV-87 MCH-27.7 MCHC-31.9 RDW-17.4* [**2152-1-27**] 09:45AM NEUTS-79.4* LYMPHS-14.7* MONOS-4.4 EOS-1.0 BASOS-0.6 [**2152-1-27**] 09:45AM PLT COUNT-194 [**2152-1-27**] 09:45AM cTropnT-0.02* [**2152-1-27**] 09:45AM GLUCOSE-164* UREA N-60* CREAT-1.3* SODIUM-139 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12 . Discharge Labs: [**2152-2-3**] 06:40AM BLOOD WBC-4.3 RBC-2.92* Hgb-8.4* Hct-24.9* MCV-85 MCH-28.7 MCHC-33.6 RDW-16.5* Plt Ct-236 [**2152-2-3**] 06:40AM BLOOD Plt Ct-236 [**2152-2-1**] 06:35AM BLOOD Glucose-98 UreaN-25* Creat-0.9 Na-149* K-3.1* Cl-116* HCO3-24 AnGap-12 [**2152-2-3**] 06:40AM BLOOD Glucose-72 UreaN-14 Creat-0.9 Na-146* K-3.0* Cl-112* HCO3-26 AnGap-11 [**2152-2-1**] 06:35AM BLOOD Mg-1.9 [**2152-1-28**] 02:44PM BLOOD Type-[**Last Name (un) **] pH-7.38 . CTA INDICATION: 84-year-old man with rectal cancer, status post surgical resection and chemoradiation [**2145**], complicated by radiation proctitis, now with lower GI bleeding and dropping hematocrit from 30 to 16 status post 7 units transfusion. COMPARISON: MR enterography [**2149-9-24**] and a CT torso with contrast [**2148-9-11**]. TECHNIQUE: MDCT helical images were acquired through the abdomen and pelvis before and after administration of 150 mL of Omnipaque intravenous contrast using the mesenteric CTA protocol. Sagittal and coronal reformats were generated and reviewed. FINDINGS: Moderate-sized bilateral simple pleural effusions with compressive atelectasis of the lung bases are seen. The imaged portion of the heart demonstrates moderate coronary arterial calcification. There is no pericardial effusion. CTA: The abdominal aorta has moderate atherosclerotic calcifications, without evidence of aneurysmal dilation. Minimal calcifications are seen at the origin of the celiac, SMA and renal arteries, with normal opacification of the vessels distally. The inferior mesenteric artery is patent. Incidental note is made of a replaced right hepatic artery. There is no evidence of active hemorrhage within the small/large bowel loops. Prominent vessels are seen along the wall of the cecum and proximal ascending colon, without evidence of active bleed. No significant retroperitoneal or mesenteric lymphadenopathy is seen. Multiple hypodense lesions are seen in both kidneys, consistent with simple renal cysts, with the largest in the lower pole of the right kidney measuring 3.9 cm and the largest exophytic cyst in the lower pole of the left kidney measuring 5.4 cm. Both kidneys enhance and excrete contrast symmetrically. Mild right hydroureteronephrosis has progressed since the prior study and ureter is dilated up to the level of the pelvic inlet and likely relates to post-radiation changes. The spleen and pancreas are normal. The right adrenal gland is normal. Nodular thickening of the left adrenal gland, is stable since the earlier study of [**2148-9-11**]. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: Multiple stones seen along the dependent aspect of the urinary bladder, likely relate to chronic outlet obstruction. Diffuse thickening of the rectal wall with perirectal fat stranding, likely represent post-radiation changes. Evidence of prior surgical anastomosis is seen in the the rectum. Small bilateral lymph nodes seen along the external iliac chain do not meet CT criteria for significant adenopathy and are stable since the prior study. There is no pelvic free fluid. BONES AND SOFT TISSUES: No bone lesions suspicious for infection or malignancy are detected. Moderate degenerative changes are seen in the lumbar spine, worse at L2-L3 level, with near complete reduction of disc space and mild retrolisthesis of L2 on L3 . IMPRESSION: 1. No evidence of active gastro-intestinal bleeding. 2. Bilateral moderate simple pleural effusions with compressive atelectasis of the lung bases. 3. Atherosclerotic disease of the abdominal aorta, without aneurysmal dilation. 4. Bilateral simple renal cortical cysts. Mild right hydroureteronephrosis, possibly secondary to radiation. 5. Post-radiation changes in the pelvis. Multiple bladder stones. . EGD: Esophagus: Lumen: A sliding small size hiatal hernia was seen. Stomach: Mucosa: Localized congestion and nodularity of the mucosa were noted in the stomach body. Protruding Lesions A single 5 mm polyp of benign appearance was found in the fundus. Duodenum: Mucosa: Normal mucosa was noted. Impression: Small hiatal hernia Congestion and nodularity in the stomach body Polyp in the fundus Normal mucosa in the duodenum Otherwise normal EGD to proximal jejunum. . Enteroscopy: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. jejunum: Flat Lesions Two small localized lymphangiectasia were seen in the mid jejunum and distal jejunum. ileum: Not examined. Other findings: A few pills were seen in the mid jejunum. There was no stenosis or sticture noted in the jejumum distal to the pills. No angioectasia or active bleeding was seen in the examined small bowel. Impression: Lymphangiectasia in the mid jejunum and distal jejunum A few pills were seen in the mid jejunum. There was no stenosis or sticture noted in the jejumum distal to the pills. No angioectasia or active bleeding was seen in the examined small bowel. Otherwise normal single balloon small bowel enteroscopy to distal jejunum Recommendations: please follow with in-patient GI consult team. please look for other sources of GI bleeding. . Colonoscopy: Findings: Mucosa: Ulceration and friability with contact bleeding were noted in the rectum. These findings are compatible with Radiation proctitis. The opening out of the rectum was tight. It was off to the side of the rectal channel. It was found by using the Pedi gastroscope first. Once this lumen was intubated, I changed to the gastroscope. With this scope, got to the hepatic flexure. I then changed scopes to the Pedi colonoscope and was able to enter the lumen and go to the cecum. The presence of the large ventral hernia made passage difficult. Except for the rectum, the rest of colon is normal. There was no fresh blood or melena above. No ischemia, angioectasia, polyps or tumor. Other The ileum was not intubated. Impression: Ulceration and friability in the rectum compatible with Radiation proctitis Otherwise normal colonoscopy to cecum Brief Hospital Course: 84 yo M with rectal cancer s/p chemoradiation and resection, chronic incontinence, afib, CAD s/p CABG, dCHF and severe AS, presenting with 3 days of melena and a Hct of 16 from 30. . # GI Bleed: Pt presented with large amount of melena, and incontinent due to surgery. Thought to be an upper GI bleed due to presence of melena. Started on IV PPI and made NPO. Had an EGD performed while in the [**Hospital Unit Name 153**] showing no evidence of bleeding down to the jejunum. Received a total of 7 units PRBCs and 2 units of platelets. Hct remained stable post-EGD and patient was called out to the floor. While on the floor had continued melena and underwent an enteroscopy that was unrevealing. The patient was then prepped for 2 days and underwent a colonscopy that revealed radiation changes to the rectum but no source for brisk bleed. The pt received 1pRBC prior to discharge. (His Hct was mid 24's prior to the pRBC transfusion). The patient was discharged with plans for a Hct check the day following discharge and to follow-up with [**First Name4 (NamePattern1) 1939**] [**Last Name (NamePattern1) 1940**] (GI) for a potential outpatient capsule endoscopy. . # Atrial fib: Pt currently in NSR on dofetilide and PRN metoprolol at home. Dofetilide continued. Metop held due to GI Bleed. Pt instructed to restart on discharge after discussion with his PCP. . # CAD: Initially held metoprolol and aspirin. Pt instructed not to restart ASA until instructed to do so. . # Hypokalemia: Pt noted to be hypokalemic to low 3s for 3 days prior to discharge. This was repleted daily. The patient was instructed to get his electrolytes checked the day after discharge and have them repleted as needed. Etiology was likely secondary to loose stools/diarrhea while in house. TRANSITIONAL: - Direct verbal signout was given to PCP ([**Doctor Last Name 131**]) and GI ([**Doctor Last Name 1940**]) prior to d/c. - He will see Dr. [**Last Name (STitle) 131**] in clinic this Tuesday and have his results faxed to Dr.[**Name (NI) 33376**] office. Medications on Admission: Vitamin B12 1000mcg/ml IM monthly Dofetilide 250mcg [**Hospital1 **] Metoprolol succinate 25mg PRN SBP>110 Quinapril 2.5mg daily PRN SBP>110 Alpha lipoic acid Aspirin 81mg daily Co Q Digestive enzymes Lactobacillus MVI Omega 3 Discharge Medications: 1. dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. quinapril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Outpatient Lab Work Please have a CBC and Chem-7 checked and faxed to Dr. [**Last Name (STitle) 131**] at [**Telephone/Fax (1) 445**]. 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Outpatient Lab Work Outpatient Lab Work Please have a CBC and Chem-7 checked and faxed to Dr. [**Last Name (STitle) 131**] at [**Telephone/Fax (1) 445**]. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Acute Blood Loss Anemia secondary to GI Bleed . Secondary Diagnosis - Atrial Fibrillation - HTN - Coronary Artery Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with low blood levels. You received several blood transfusions and underwent endoscopies that unfortunately did not pinpoint the site of bleeding. . Please continue to take your medications and note the changes that we have made to your regimen. We have started you on a medication called Omeprazole 40mg that you should take twice a day until instructed to decrease or stop by Dr. [**Last Name (STitle) 1940**]. . Please do not take aspirin until instructed to do so by your doctors. Followup Instructions: Please have your blood checked tomorrow and have the results fax: [**Telephone/Fax (1) 445**]. Tuesday 9:15am Dr. [**Last Name (STitle) 131**] Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2152-2-11**] at 7:30 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 18**] PODIATRY When: MONDAY [**2152-2-21**] at 3:10 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 34012**] Building: None [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2152-2-25**] at 9:00 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 15108**], 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

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icd9cm

[ [ [] ] ]

[ "45.13", "45.23" ]

icd9pcs

[ [ [] ] ]

12077, 12083

9062, 11103

325, 360

12269, 12269

2647, 2647

12995, 14034

1880, 1979

11380, 12054

12104, 12248

11129, 11357

12452, 12972

3067, 9039

1994, 2581

2597, 2628

257, 287

388, 1193

2663, 3051

12284, 12428

1215, 1615

1631, 1864

3,728

194,638

1250

Discharge summary

report

Admission Date: [**2105-4-21**] Discharge Date: [**2105-5-15**] Date of Birth: [**2042-12-9**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 905**] Chief Complaint: Worsening Dyspnea with exertion. Major Surgical or Invasive Procedure: Cardiac Stress test Cardiac Catheterization Hickman removal [**2105-5-1**] with PICC placement Hickman replacement [**2105-5-12**] History of Present Illness: 62 y/o M with pulmonary HTN on Flolan, CAD w/ mult stents, presents with 2-3 days of worsened SOB/DOE. He relates baseline abulation of around 50-60 yards, but now can barely walk several yards, and is unable to get around at home. On review of systems he also notes increased cough and phlegm production for the past week with brown/yellow sputum. He relates chronic [**3-6**] pillow orthopnea and PND, unchanged from prior. Denies new chest pain, but does relate some mild nausea. . He notes that he has been on steroids for ~year, and was tapered off last week from 5mg. In the ED he recieved prednisone and ASA, as well as IV Lasix. Past Medical History: CAD - multiple ptca's, stents, last cath [**10/2102**] with 1VD -DIASTOLIC DYSFUNCTION -GOUT -HYPERCHOLESTEROLEMIA -TYPE 2 DIABETES MELLITUS -PULMONARY HYPERTENSION on Flolan; his pulmonary HTN is followed by Dr [**Last Name (STitle) 7796**] at [**Hospital1 2177**], phone number ([**Telephone/Fax (1) 7797**] -CHRONIC LOW BACK PAIN -HYPERTENSION -H/O NEPHROLITHIASIS -ASTHMA -H/O FLOLAN INDUCED THROMBOCYTOPENIA -DIFFUSE INTERSTITIAL PULMONARY FIBROSIS ([**1-/2103**]) -COLONIC POLYPS ([**2104-6-20**]) -H/O SHINGLES -GASTRITIS Social History: Tob > 100 py ETOH: none IVDA: none divorced Health care proxy is daughter [**Name (NI) 7798**] [**Last Name (NamePattern1) **] 2 sons and 4 grandchildren Family History: No CAD Physical Exam: 98.1, 140/69, 100, 18, 90 on 4LNC Gen: A+O x 3, tachypneic HEENT: PERRL, OP clear, JVP 8 cm CV: RRR no m Lungs: bibasilar crackles Abd: soft, NTND +BS Ext: 1+pitting edema to shins Skin: erythmetous rash over chest, back and groin Pertinent Results: [**2105-4-21**] 02:30PM WBC-9.5 RBC-4.71 HGB-10.8* HCT-32.4* MCV-69* MCH-23.0* MCHC-33.4 RDW-15.7* [**2105-4-21**] 02:30PM calTIBC-242* FERRITIN-200 TRF-186* [**2105-4-21**] 02:30PM cTropnT-<0.01 proBNP-972* [**2105-4-21**] 02:30PM GLUCOSE-116* UREA N-21* CREAT-1.3* SODIUM-137 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 CTA chest and Abd: 1) No evidence of PE. 2) Diffuse lung changes consistent with emphysema and congestive heart failure. 3) Moderate bilateral pleural effusion with atelectasis, and a component of consolidation, aspiration, or pneumonia cannot be ruled out. 4) Bulk lymphadenopathy mainly of the mediastinum and hila. 5) Mild intrahepatic biliary dilatation, of uncertain significance. There is no good contrast enhancement of the abdomen and pelvis, which were done as an addition after PE study, and if clinically warranted, further evaluation can be done by multiphasic CT Cardiac Cath: 1. Selective coronary angiography of this right-dominant system revealed no evidence of flow-limiting coronary disease. The LMCA was free of flow-limiting stenoses. The LAD had mild luminal irregularities. The previously placed stent in the D1 branch was widely patent. The LCX had mild luminal irregularities. The ostial RCA had a 40% lesion. The previously placed stents in the PDA were patent. 2. Hemodynamic evaluation on entry revealed mildly elevated right-sided pressures (mean RA was 10 and RVEDP was 14 mmHg), mildly elevated left-sided pressures (mean PCW was 17 mmHg and LVEDP was 19 mmHg), and severely elevated pulmonary pressures (PA was 70/29/49 mmHg). The central aortic pressure was 105/55/71 mmHg. The cardiac index was normal at 3.7 L/min/m2 (using an assumed oxygen consumption). The pulmonary vascular resistance (PVR) was elevated at 305 dynes-sec/cm5. There was a 5 mmHg gradient across the aortic valve on pullback of the angled pigtail catheter from the left ventricle to the ascending aorta. 3. Hemodynamic evaluation after 15 minutes of 100% inhaled oxygen revealed severely elevated pulmonary pressures of 71/30/50 mmHg. The mean PCW was 15 mmHg. The cardiac index was normal at 3.8 L/min/m2 (using an assumed oxygen consumption). The PVR was elevated at 326 dynes-sec/cm5. 4. Hemodynamic evaluation after 15 minutes of inhaled nitric oxide revealed severely elevated pulmonary pressures of 65/29/42 mmHg. The mean PCW was 16 mmHg. The cardiac index was normal at 3.6 L/min/m2 (using an assumed oxygen consumption). The PVR was elevated at 248 dynes-sec/cm5. CXR: Slightly increased CHF. Right-sided PICC with its tip in the mid SVC. TTE: 1. The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 3. The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. 4. The aortic valve leaflets (3) are mildly thickened. 5. The mitral valve leaflets are mildly thickened. 6. There is severe pulmonary artery systolic hypertension. 7. Compared with the findings of the prior study of [**2105-4-24**], there has been no significant change. Hi Res CT: 1. CHF with bilateral atelectasis and small bilateral pleural effusions. 2. Mild pulmonary artery hypertension. 3. Mild emphysema. 4. Multiple focal calcified granulomas within both lungs. Appearances are most consistent with chronic changes due to prior histoplasmosis or varicella pneumonia. 5. We cannot define or clearly evaluate for diffuse lung disease in the presence of these acute abnormalities. PMIBI: Partially reversible, moderate defect in tracer uptake involving the apex, inferior wall and inferiolateral wall. Brief Hospital Course: Hypoxia- The patient was admitted on 4LNC. During the first week of his hospital course, he became profoundly hypoxic requiring 100% NRB and 8L NC. Etiology is likely multifactorial in origin from pulmonary HTN, possible DIP, and noncardiogenic edema. He is usually on 3L NC at home at baseline with sats 88-90%. He had several episodes of desaturations into the 60s on floor improved with ativan, morphine, and lasix. Pulmonary service was consulted. CT chest showed pulmonary edema and effusions, LENIS negative for DVT, and TTE with bubble negative for shunt. CTA was negative for PE. Increased flolan from 58 to 60. Coumadin was not started given anticoagulant effects of flolan and plavix. Attempt of aggressive diuresis did not improve saturations. After his catheterization, his baseline sats were lower in the 80s. He was tranferred to the MICU overnight for closer monitoring. He felt improved the next morning and transferred back to the floor. Restarted Prednisone 100 mg po QD and Bactrim PPX on [**2105-5-9**]. PPD negative. The patient's oxygenation improved and his oxygen was weaned to 4LNC. His saturations were 94% at rest and then decreased to low 80s with ambulation. He was able to walk 30-40 yards before feeling very short of breath, better than his baseline. Lung biopsy slides from [**2103-5-25**] were obtained from [**Hospital1 2177**] and are under review here currently. He will f/u with Dr. [**Last Name (STitle) **] to wean steroids. CARDIAC - On admit, patient noted increased NTG use for atypical chest pressure. He ruled out for MI by enzymes with unchanged EKG. Obtained stress MIBI which showed moderate reversible inferior defect. Continued ASA, BB, statin, plavix. BNP 600s. Cath without sig CAD [**5-5**], no interventions performed. Possible diastolic CHF - Increased pulmonary edema by CXR and CT scan. Repeat TTE in house w/ preserved systolic function, but increased pulm HTN. Increased lasix to 120 mg IV BID as well as added zaroxylyn. Cath [**5-6**] without evidence of diastolic or systolic failure. Wedge was 15. Cardiolgy was consulted and after review of cath and TTE, thought that there was no evidence for heart failure. Decreased Lasix from 160 po QD to 80 po QD secondary to his ARF. ID- Fever to 103 [**4-27**]. Blood cx from [**4-28**] grew 1/2 bottles with micrococcus. Cultures from [**4-29**] from line and peripheral also with G+cocci as well as tip of hickman. Was started on Linezolid given h/o vanc allergy for line infection. ID consulted. Abx changed to Ceftriaxone [**5-1**] x 2 weeks (last dose 5/12). PICC was placed and hickman d/c'd by Dr. [**Last Name (STitle) **] from the surgery service [**5-1**]. Hickman replaced [**5-12**]. He had oozing from his Hickman site with multiple pressure dressings applied. On discharge, he had clot formation with minimal bleeding. Surgery evaluated on day of discharge and felt no further sutures were needed. DM - Glucophage was d/c'd secondary to renal insufficiency. He was started on low dose Glipizide. . HTN - Continue Cartia XT and Toprol. . ANEMIA - Patient was guiac negative. He required a total of 3 units of PRBCs for anemia. No Retroperitoneal bleed on CT scan. Iron labs c/w ACD. B12 and folate were normal. His HCT remained stable. Abdominal pain - Patient had several days of abdominal pain. KUB was negative, LFTs wnl. CT abdomen with IV contrast unremarkable. He was placed on an aggressive bowel regimen and sxs resolved after several BMs. . LBP - Percocet prn Renal - Cr up to 2.3 likely secondary to overdiuresis vs cath dye load. Urine lytes c/w prerenal etiology likely to diuresis. Improving to 1.7 on discharge. GI - Four months of anorexia and early satiety. Followed by GI as outpatient. EGD and colonoscopy negative. ERCP with ampulla inflammation, needs repeat biopsy in [**4-8**] months. Gastric emptying study normal. On PPI. Appetite improved after reastarted steroids. F/u as outpatient. Rash - Chest rash secondary to flolan. Groin rash thought to be fungal in origen. Started clotrimazole cream with improvement. . Disposition: Patient was seen by PT and cleared to return home. Medications on Admission: -ASA 325mg QD -PLavix 75 QD -Cardia XT 160mg QD -Atenolol 100 QD -Lipitor 10mg QD -Glucophage 850 [**Hospital1 **] -Lasix 160mg QD -Pulmicort 2 [**Hospital1 **] -Prilosec OTC -Percocet prn -Flolan (been on for 8 years) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 11. Prednisone 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 30 days. Disp:*60 Tablet(s)* Refills:*0* 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Disp:*90 Tablet, Chewable(s)* Refills:*2* 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 15. home oxygen Continuous 4L O2 at rest and 5L on ambulation 16. Cartia XT 180 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 17. Pulmicort Turbuhaler 200 mcg/Inhalation Aerosol Powdr Breath Activated Sig: Two (2) INH Inhalation twice a day. 18. Epoprostenol Sodium 0.5 mg Recon Soln Sig: Sixty (60) ng/kg/min Intravenous continuous infusion. 19. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*3* 20. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: Five (5) Tablet, Delayed Release (E.C.) PO once a day. Disp:*150 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 21. Glipizide 5 mg Tab, Sust Release Osmotic Push Sig: One (1) Tab, Sust Release Osmotic Push PO once a day. Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Visiting Nurses Assoc. Discharge Diagnosis: Dyspnea CAD Diastolic CHF Elevated Cholesterol Diabetes Mellitus Pulmonary Hypertension Hypertension Pulmonary Fibrosis Discharge Condition: Stable Discharge Instructions: Please take your medications as prescribed. Please continue daily weights, as well as a low-sodium diet. If you develop any further episodes of chest/pressure, worsening shortness or breath, increasing cough, or have any other concerning symptoms whatsoever please seek immediate medical attention. Stop taking your glucophage and start glipizide, check your sugars at least twice per day and report abnormal numbers to Dr. [**Last Name (STitle) 7790**]. Stop Atenolol and in its place, start Toprol XL. Take one-half your dose of lasix 80mg per day until Dr. [**Last Name (STitle) 7790**] tells you to change it. Take all of your other home medications as before. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 1144**] Call to schedule appointment Provider: [**Name10 (NameIs) **], Hap [**Telephone/Fax (1) 7799**] Call to schedule appointment [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2105-5-15**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "88.56", "00.17", "00.12", "37.23" ]

icd9pcs

[ [ [] ] ]

12780, 12854

5967, 10097

303, 435

13018, 13026

2114, 5944

13740, 14080

1840, 1848

10367, 12757

12875, 12997

10123, 10344

13050, 13717

1863, 2095

231, 265

463, 1101

1123, 1653

1669, 1824

66,280

144,700

42672

Discharge summary

report

Admission Date: [**2130-2-2**] Discharge Date: [**2130-2-4**] Date of Birth: [**2100-12-13**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: Liver Failure Major Surgical or Invasive Procedure: none. History of Present Illness: Ms. [**Known lastname **] is a 29 F with hx of Migraines, chronic pancreatitis & pancreatic divisum, s/p a "partial Whipple" in [**2127**] at [**Hospital 2025**] transferred from [**Hospital3 4107**] today for management of liver failure. . Over the last 6 weeks she has been taking 5 Tylenol pm (325 mg) a day almost every day except for some days that she used melatonin for treatment of insomnia. On the day of admission she presented to her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] pressure check. Her [**Last Name (Titles) **] pressure at that time was found to be elevated and patient noted headache so was sent to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation. In the [**Hospital3 4107**] ER patient had a negative head CT, received dilaudid, admitted for observation, on labs was found to have ALT [**Numeric Identifier 961**], AST 25,000. T-Bili 1.6, INR 3.4. Her APAP level was less than 10. She was not encephalopathic. She was started on NAC at [**Hospital3 4107**]. . She denies taking any other OTC, herbals, NSAIDS, etoh, IV drugs. She has not had a recent transfusion, sick contact, tick bite, recent travel, needle stick. She is sexually active with only her husband. . In the SICU the patient was aggressively fluid hydrated and was continued on NAC. Her LFTS, INR, Bilirubin have all trended down with this therapy. Her MS has been normal. . On the Floor, patient continues to note migraine which developed last night and has been persistent. Today she has recieved iv pain medications with little improvement. She notes visual aura but no changes in her vision, weakness, parasthesias. No neck stiffness or fevers. Headache is similar to her prior headaches. . Review of Systems: Notes months of tingling in fingers since starting medication for nausea. Past Medical History: Past Medical History: -Recurrent pancreatitis -Pancreatic divisum -s/p partial Whipple in [**2127**], continues to be on narcotics -Migraine headaches . Past Surgical History: -[**2127**] whipple/CCY -mult ERCP sphincterotomy -L knee arthroscopy Social History: Married. Lives with husband in [**Name (NI) 2498**]. No kids, has 4 sibilings, her parents and 1 sister are present today. No smoking, no IVDU, no regular etoh use, she is an attorney who is recently back to work Family History: Father: HTN, DM2 Mother: Epilepsy Paternal History: Pancreatic Cancer Physical Exam: Admission Physical Exam: Vitals: 113/61, 88, 96%, 18, afebrile General: NAD, Pleasant, AOx3 HEENT: EOMI, sclera anicteric Neck: Supple, Right IJ Heart: Regular, Tachycardic, No M/R/G Lungs: CTA B Abdomen: Midline abdominal scar, soft, NABS, diffusely tender Extremities: No lower extremity edema Neurological: CN II-XII Intact, Strength 5/5 in upper and lower extremities, Normal sensation to light touch . Discharge PE: Vitals: Tm 98.6 Tc 96.0 106/51 (106-123/51-68) 78-104 18 98RA General: NAD, Pleasant, AOx3 HEENT: EOMI, sclera anicteric Neck: Supple, Right IJ Heart: Regular, Tachycardic, No M/R/G Lungs: CTA b/l Abdomen: Midline abdominal scar, soft, NABS, diffusely tender, most tender on R side Extremities: No lower extremity edema Pertinent Results: Labs on Admission: [**2130-2-2**] 07:37PM GLUCOSE-89 UREA N-9 CREAT-0.4 SODIUM-141 POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-22 ANION GAP-12 [**2130-2-2**] 07:37PM ALT(SGPT)-3335* AST(SGOT)-5829* LD(LDH)-2100* ALK PHOS-152* AMYLASE-37 TOT BILI-1.7* [**2130-2-2**] 07:37PM LIPASE-31 [**2130-2-2**] 07:37PM ALBUMIN-2.9* CALCIUM-7.8* PHOSPHATE-1.2* MAGNESIUM-1.8 [**2130-2-2**] 07:37PM WBC-4.1 RBC-3.19* HGB-10.0* HCT-27.9* MCV-87 MCH-31.2 MCHC-35.7* RDW-13.0 [**2130-2-2**] 07:37PM PLT COUNT-185 [**2130-2-2**] 07:37PM PT-22.0* PTT-27.1 INR(PT)-2.1* [**2130-2-2**] 07:37PM FIBRINOGE-198 [**2130-2-2**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2130-2-2**] 04:00PM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2130-2-2**] 02:37PM TYPE-ART PO2-98 PCO2-31* PH-7.46* TOTAL CO2-23 BASE XS-0 [**2130-2-2**] 02:37PM LACTATE-1.3 [**2130-2-2**] 01:59PM GLUCOSE-124* UREA N-14 CREAT-0.6 SODIUM-136 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-22 ANION GAP-15 [**2130-2-2**] 01:59PM estGFR-Using this [**2130-2-2**] 01:59PM ALT(SGPT)-4008* AST(SGOT)-8361* ALK PHOS-157* AMYLASE-51 TOT BILI-1.4 [**2130-2-2**] 01:59PM LIPASE-47 [**2130-2-2**] 01:59PM ALBUMIN-3.1* CALCIUM-7.6* PHOSPHATE-1.1* MAGNESIUM-1.9 IRON-114 [**2130-2-2**] 01:59PM calTIBC-296 FERRITIN-4302* TRF-228 [**2130-2-2**] 01:59PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2130-2-2**] 01:59PM HCG-<5 [**2130-2-2**] 01:59PM AMA-NEGATIVE Smooth-NEGATIVE [**2130-2-2**] 01:59PM [**Doctor First Name **]-NEGATIVE [**2130-2-2**] 01:59PM CEA-3.3 AFP-4.9 [**2130-2-2**] 01:59PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2130-2-2**] 01:59PM HCV Ab-NEGATIVE [**2130-2-2**] 01:59PM WBC-4.7 RBC-3.46* HGB-10.5* HCT-31.1* MCV-90 MCH-30.3 MCHC-33.6 RDW-13.1 [**2130-2-2**] 01:59PM PLT COUNT-190 [**2130-2-2**] 01:59PM PT-26.3* PTT-26.5 INR(PT)-2.5* [**2130-2-2**] 01:59PM FIBRINOGE-203 Discharge labs: [**2130-2-3**] 02:12PM [**Month/Day/Year 3143**] WBC-4.7 RBC-3.43* Hgb-10.2* Hct-30.4* MCV-89 MCH-29.7 MCHC-33.5 RDW-13.3 Plt Ct-222 [**2130-2-4**] 05:00AM [**Month/Day/Year 3143**] WBC-4.4 RBC-3.22* Hgb-9.8* Hct-28.9* MCV-90 MCH-30.4 MCHC-33.9 RDW-13.5 Plt Ct-220 [**2130-2-3**] 02:12PM [**Month/Day/Year 3143**] PT-15.5* PTT-33.5 INR(PT)-1.5* [**2130-2-3**] 10:15PM [**Month/Day/Year 3143**] PT-15.1* INR(PT)-1.4* [**2130-2-4**] 05:00AM [**Month/Day/Year 3143**] PT-13.7* INR(PT)-1.3* [**2130-2-3**] 07:43AM [**Month/Day/Year 3143**] Fibrino-194 [**2130-2-3**] 02:12PM [**Month/Day/Year 3143**] Glucose-91 UreaN-6 Creat-0.4 Na-140 K-3.8 Cl-107 HCO3-23 AnGap-14 [**2130-2-4**] 05:00AM [**Month/Day/Year 3143**] Glucose-96 UreaN-4* Creat-0.4 Na-141 K-3.1* Cl-110* HCO3-26 AnGap-8 [**2130-2-3**] 02:12PM [**Month/Day/Year 3143**] ALT-2557* AST-2459* AlkPhos-152* TotBili-1.7* [**2130-2-3**] 10:15PM [**Month/Day/Year 3143**] ALT-[**2120**]* AST-1280* AlkPhos-134* TotBili-1.1 [**2130-2-4**] 05:00AM [**Month/Day/Year 3143**] ALT-1755* AST-854* AlkPhos-130* TotBili-1.4 [**2130-2-3**] 02:12PM [**Month/Day/Year 3143**] Calcium-7.8* Phos-2.3* Mg-1.7 [**2130-2-3**] 10:15PM [**Month/Day/Year 3143**] Albumin-2.8* [**2130-2-4**] 05:00AM [**Month/Day/Year 3143**] Albumin-2.8* Calcium-8.1* Phos-1.7* Mg-1.9 . Abdominal Ultrasound: 1. Patent hepatic vasculature. 2. Splenomegaly. 3. Small amount of free fluid in [**Location (un) 6813**] pouch. Brief Hospital Course: 29 F with hx of Migraines, chronic pancreatitis & pancreatic divisum, s/p a "partial Whipple" in [**2127**] at [**Hospital 2025**] transferred from [**Hospital3 4107**] today for management of liver failure secondary to subacute tylenol overdose. . #. Acute Liver Failure: Likely secondary to subacute tylenol overdose over the last 6 weeks. Viral Hep serologies negative. Liver doppler without evidence of thrombosis. The patient was initially admitted to the surgical ICU, where she was started on NAC. Her LFTs and INR were trended while in the SICU, and on transfer to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service, the patient's INR was trending down. She was kept on the NAC drip initially while on the floor, but once her INR was stable at 1.5 it was discontinued. Upon discharge, the patient's INR was down to 1.3 and her transaminitis also continued trending down. Tbilis and alk phosph were also trending down. Neuro checks were done every 6 hours and no neurological deficits were ever appreciated. Upon discharge, the patient was also counseled re: NOT using tylenol for pain control. . #. Migraine: Symptoms classic for migraine and patient with history. No red flags at the moment to warrant further imaging and recent CT head negative. No symptoms warranting LP. The patient reported having some headaches while on the floor that responded well to Sumitriptan. . #. Chronic Abdominal Pain: Secondary to chronic pancreatitis, abdominal surgeries. The patient was continued on her home pain regimen, including Fentanyl, Oxycodone, Sucralafate, Omeprazole, as well as her home Gabapentin. . #. Normocytic Anemia: Likely anemia of chronic inflammation. Stable while on the floor, the patient's crits were monitored daily. . Transitional Issues: - The patient was instructed to follow up with her PCP. [**Name10 (NameIs) **] should be reemphasized that she should limit Tylenol use. Medications on Admission: Metoclopramide 10 QID, Sucralfate 1 Gram QID, Omeprazole 20mg [**Hospital1 **], Fentanyl 12mcq 72h, Neurontin 900 TID, Oxycodone 5mg PRN (up to 8 daily), vitD3, CalCitrate 1000 prn, Ascorbic acid prn, Ondansetron 8mg [**Hospital1 **], Ocella 3/0.03, MVT Discharge Medications: 1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day. 5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO q6h:PRN: please do not drive or operate any heavy machinery. 7. Vitamin D-3 Oral 8. Calcitrate Oral 9. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day. 10. multivitamin Capsule Sig: One (1) Capsule PO once a day. 11. ascorbic acid Oral 12. Ocella 3-0.03 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: acute liver failure secondary to tylenol toxicity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital because you were found to have liver failure in the setting of using too much tylenol over the past few weeks. You were initially admitted to the surgical intensive care unit where you were given a lot of fluids through your IV, and started on a medication that reduces the toxic effects that tylenol has on your liver. We monitored your liver function enzymes very closely, and they were nicely trending down. Because your liver function enzymes were improving, you were called out to the liver floor. While on the floor, we continued to monitor your liver function enzymes, and as they got better, we stopped the medication we were given you. . We strongly recommend that you STOP using tylenol, given this recent incident. Please take alternative medications for your headaches. It is also very important that you follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) **], within one week as well. . NO changes were made to your home medications. Please continue to take them as directed. Followup Instructions: Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 4320**] [**Last Name (NamePattern1) **], within the next one week. Please call ([**Telephone/Fax (1) 92265**] to schedule a follow up appointment. Completed by:[**2130-2-5**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10170, 10176

7123, 8888

315, 322

10270, 10270

3563, 3568

11657, 11917

2711, 2782

9351, 10147

10197, 10249

9073, 9328

10421, 11634

5660, 7100

2394, 2465

2822, 3204

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3218, 3544

262, 277

350, 2102

3582, 5643

10285, 10397

2240, 2371

2481, 2695

3,539

143,539

12693

Discharge summary

report

Admission Date: [**2160-12-18**] Discharge Date: [**2160-12-26**] Service: ACOVE HISTORY OF THE PRESENT ILLNESS: The patient is an 86-year-old female with coronary artery disease, diabetes mellitus type 2, hypertension, and tongue cancer status post 35 cycles of XRT, recently admitted to [**Hospital1 18**] with hyponatremia and loose stools who returned two days after discharge with nausea, vomiting, and continuing loose stools. The patient's grandson was feeding the patient her tube feeds this morning and the patient vomited times one. The patient does not remember the circumstances and cannot elaborate further on the history. She describes the vomit as her tube feeds without blood. She also complains of abdominal discomfort describes as a "funny feeling". She denied any gas or abdominal pain. She reports continuing loose stools with the sensation of tenesmus. The stool is described as watery, light-colored, without blood or mucus. She denied any rectal pain, bright red blood per rectum or melena. She also denied fevers, chills, night sweats, shortness of breath, chest pain, palpitations, cough. The patient states that she has not taken any food by mouth. She also reports no recent change in her tube feeds. She has been taking all of her medications per NG tube including her hydrochlorothiazide which was recently discontinued during her last admission for hyponatremia. PAST MEDICAL HISTORY: 1. Tongue cancer diagnosed in [**2160-6-22**], status post XRT times 35, status post PEG. 2. Coronary artery disease, status post MI in [**2154**]. 3. Diabetes mellitus type 2. 4. Hypertension. 5. Colon cancer, status post resection without chemotherapy. 6. Status post cholecystectomy. 7. Hyponatremia. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Amlodipine 7.5 mg p.o. q.d. 3. Propanolol 30 mg p.o. t.i.d. 4. Loperamide 2 q.i.d. p.r.n. 5. Glyburide 5 q.d. 6. Lisinopril 5 mg p.o. q.d. 7. Robitussin with codeine. SOCIAL HISTORY: The patient lives in [**Hospital1 3494**] with her grandson. She denied any tobacco, alcohol, or drug use. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.9, BP 112/60, pulse 97, respirations 20, 98% on room air. General: Well appearing, in no acute distress, no respiratory distress. HEENT: Pupils were equal, round, and reactive to light. Extraocular movements were intact. White exudate in mouth. Evidence of some minimal breakdown of the tongue mucosa. The patient has an edematous lower lip with blistering. There is hyperpigmentation of her lower face. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, normal S1, S2. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended. The patient's liver is palpated 2 cm below her right costal margin. Extremities: No clubbing or cyanosis. There was 1+ pitting edema in the bilateral lower extremities. LABORATORY/RADIOLOGIC DATA: White blood cell count 11.5, hematocrit 36.4, platelets 263,000, (neutrophils 84.4, lymphocytes 6.7). Sodium 126, potassium 4.3, chloride 88, bicarbonate 28, BUN 19, creatinine 0.6, glucose 153, CK 29, ALT 50, AST 50, total bilirubin 0.5, alkaline phosphatase 73, LDH 180, albumin 3.8, amylase 47, lipase 57. The U/A revealed negative nitrates, negative leukocytes. HOSPITAL COURSE: 1. PULMONARY: The patient was completely stable from a respiratory standpoint on admission; however, on hospital day number three, had respiratory arrest with an ABG of 7.15/82/33 and chest x-ray significant for asymmetric pulmonary edema with question of aspiration pneumonia. The patient was intubated and transferred to the [**Hospital Unit Name 153**]. The patient improved rather rapidly from a respiratory standpoint and was extubated on the following day. She was started on levofloxacin and vancomycin for aspiration pneumonia and when her sputum culture grew MSSA pneumonia, her vancomycin was stopped and she was continued on levofloxacin for a full course. The etiology of the patient's respiratory failure is likely multifactorial. It is considered likely that it was triggered initially by aspiration pneumonia with hypertensive urgency and subsequent flash pulmonary edema. The patient remained afebrile throughout her hospitalization with a normal white blood cell count and was maintained on levofloxacin for aspiration pneumonia. Her pulmonary edema occurred in the setting of hypertension and resolved on the second day of her stay in the [**Hospital Unit Name 153**]. It is likely that the patient has an element of diastolic dysfunction with this hypertensive crisis and she was diuresed with Lasix while in the ICU. There was also a question of possible mucus plugging given the patient's thick secretions after XRT. She was maintained on humidified oxygen for mobilization of this thick sputum. Given slight wheezing on examination on transfer back to the floor, the patient was started on Albuterol for likely post pneumonia inflammation of her airways. She maintained good oxygen saturations on room air once transferred to the floor and was completely stable from a respiratory standpoint. 2. GASTROINTESTINAL: The patient was admitted with abdominal discomfort with her tube feeds as well as loose stools and elevated transaminase levels. She had an abdominal CT on the day following her admission which was significant for a dilated common bile duct and was evaluated by the ERCP fellow who consented the patient for ERCP. However, on the following hospital day, the patient suffered a respiratory arrest and was taken to the [**Hospital Unit Name 153**]. Throughout the remainder of her hospital course, the patient's transaminitis resolved and she did not complain of any further "funny feeling" in her abdomen. It was, therefore, decided to hold off on the ERCP and readdress this issue at some time in the future if the patient becomes symptomatic once again. 3. CARDIOVASCULAR: The patient was noted during her respiratory arrest and brief stay in the [**Hospital Unit Name 153**] to have troponins peak to 0.36 with flat CKs and an uninterpretable EKG secondary to left bundle branch block. Given that she experienced a troponin leak in the context of her hypertensive crisis, it is likely that it represents demand ischemia. The patient was continued on her aspirin, beta blocker, and ACE inhibitor. There was a question of congestive heart failure. The patient was transferred to the [**Hospital Unit Name 153**] given pulmonary edema and her respiratory arrest. She had an echocardiogram which was significant for normal left ventricular systolic function with an ejection fraction of 55-70%. It is likely that the patient has an element of diastolic dysfunction and received several daily doses of Lasix while in the ICU. Her beta blocker and ACE inhibitor were continued, as described above, and she was given several doses of Lasix on the floor in order to maintain an even to negative fluid balance. The patient was admitted on an antihypertensive regimen of propanolol, lisinopril, and Amlodipine. This was changed to metoprolol and lisinopril with doses titrated to control her blood pressure. 4. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was admitted with difficulty tolerating her tube feeds. Her tube feed regimen was changed from boluses to continuous concentrated tube feed which the patient tolerated. The patient will be discharged on continuous tube feeds at night which will allow her to have increased mobility during the day in the hopes that the continuous tube feeds will avoid any abdominal discomfort. The patient was also admitted with hyponatremia in the context of restarting her hydrochlorothiazide at home. Her hydrochlorothiazide was held on admission and the patient received normal saline with eventual resolution of her hyponatremia. It is likely that the patient's hyponatremia was secondary to hydrochlorothiazide with an element of dehydration contributing. On transfer back to the floor, the patient had a video swallow study which was significant for poor tongue movement with premature spillover of fluids as well as an edematous epiglottis that does not deflect which contributes to aspiration. The patient's visualized aspiration, however, appeared to be related to her complaints of pain and discomfort with material being swallowed and she was able to swallow water multiple times without difficulty. It was also noted that when aspiration occurs she has an effective cough to clear it. The Speech and Swallow Team, therefore, recommended initiation of a p.o. diet for secondary means only consisting of pureed and thin liquids with the avoidance of any asitic, citrus or spicy foods. 5. ENDOCRINE: The patient was admitted with a history of diabetes mellitus type 2 on Glyburide. Her Glyburide was held on her transfer to the [**Hospital Unit Name 153**] and when she returned to the floor she was noted to have poor control of her sugars. The patient was started on Metformin 500 mg b.i.d. with her fingerstick glucoses monitored and noted to be under improved control. It is unclear if the patient's sulfonylurea caused cholestatic hepatitis which resulted in the patient's mild elevation in transaminase levels and abdominal discomfort but for this concern the patient was switched over to Metformin. 6. PSYCHIATRY: The patient was noted to have a somewhat depressed affect throughout her hospitalization as noted by physician and nursing staff. She had many vague complaints and appeared to be moderately depressed. For this reason, the patient was started on an antidepressant, Paxil, 20 mg p.o. q.d. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient was discharged to home with VNA services. She was encouraged to continue all medications as prescribed as well as her tube feeding regimen which will be continuous over 12 hours at night. DISCHARGE DIAGNOSIS: 1. Aspiration pneumonia, MSSA. 2. Flash pulmonary edema. 3. Hyponatremia. 4. Tongue cancer, status post XRT. 5. Diabetes mellitus type 2. 6. Coronary artery disease. 7. Hypertension. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Lisinopril 5 mg p.o. q.d. 3. Loperamide 2 mg p.o. q.i.d. p.r.n. diarrhea. 4. Clorhexadine 0.12% liquid 15 milliliters mucous membranes b.i.d. as needed. 5. Promethazine 25 mg p.o. q. six hours p.r.n. nausea. 6. Clotrimazole 10 mg troches one troche mucous membranes q.i.d. 7. Metformin 500 mg p.o. b.i.d. 8. Metoprolol 37.5 mg p.o. b.i.d. 9. Levofloxacin 500 mg p.o. q.d. times ten days. 10. Albuterol one to two puffs inhaled q. six hours p.r.n. Shortness of breath or wheezing. 11. Paroxetine 20 mg p.o. q.d. 12. Lidocaine 2% solution 20 milliliters to the mucous membranes t.i.d. p.r.n. mouth discomfort. FOLLOW-UP: The patient has a follow-up appointment with her primary care physician on [**2161-1-1**] at 9:30 a.m. She will be followed by VNA nursing for assistance with her medications and her cycled home tube feedings. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern4) 12799**] MEDQUIST36 D: [**2160-12-26**] 02:55 T: [**2160-12-26**] 17:08 JOB#: [**Job Number 39195**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10229, 11347

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1830, 2035

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9766, 9994

40,304

174,997

26838

Discharge summary

report

Admission Date: [**2163-11-21**] Discharge Date: [**2163-12-1**] Date of Birth: [**2086-12-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: CHF, ARF, Mediastinal lymphadenopathy Major Surgical or Invasive Procedure: Bronchoscopy x 2 Mediastinoscopy with lymph node biopsy History of Present Illness: 76M initially went to [**Hospital 1562**] hospital with L flank and sent home with narcs. Represented with DOE, weight gain and L flank pain. He reports that he has had intermittent DOE for year but notice a sharp increase in his weight over a period of 10 days. He gained 8-10lbs with associated LE swelling, but without medication noncompliance, dietary changes, chest pain, orthopnea, PND. This happened at the beginning of [**Month (only) 359**] and his Lasix was increased from 40 to 60 daily. He also had a holter revealing afib (rate 40-100), nuclear stress ([**2163-11-1**])without ischemia and normal ECHO on [**2163-11-3**] (mild AS, mild MR). Upon arrival to the ED he was found to be hypotensive with hyperkalemia and ARF (Cr ~4 from basline of 1.2) He was sent to the floor, diuresed and then sent to the ICU after he was hypotensive requiring dopamine and vasopressin. He had a Swan-Ganz catheter placed on [**11-19**] and had renally dosed dopamine. He was thought to be fluid overloaded and had a transudative thoracentesis (amount removed unknown). He was aggressively diuresed with Lasix and renally dosed Dopamine. His renal function improved prior to transfer. Swan numbers: RA: 25 RV: 55/20/10 PA: 55/25 PCW: 26 His L flank pain was evaluated with a CT Abdomen and he was found to have L nephrolithiasis and an exophytic cyst on the lower pole of the L kidney. His pain has been controlled with narcotics. He had also been recieving Zyvox for presumed pneumonia and solumedrol 60 mg q6h for presumed COPD. He was transferred for evaluation of his mediatinal LAD. This has been watched for seveal years and he has two non-FDG avid PET CTs, most recently in [**2163-6-26**]. He denies any B symptoms. He does have decreased appetite, but has been active with outside hobbies including golf and curling. The thoracics service was contact[**Name (NI) **] for this evaluation and it was suggested that the patient be admitted to the MICU given his underlying medical problems. Past Medical History: PAST MEDICAL HISTORY: ==================== AF, on coumadin at home CRI Cr:1.6 Chronic Anemia CHF EF Bladder CIS s/p BCG washout in [**10/2163**] Colonic dysplastic lesions on bx OSA- unable to tolerate CPAP low grade NHL with diffuse stable LAD AS R popliteal artery endarterectomy uretral stent Gout PVD L CEA [**2159**] UGIB [**2161**] LLL lobectomy in [**2135**] Nephrolithiasis Social History: EtOH: 2 martinis daily Tobacco: quit 1ppd 25 yrs ago outside hobbies included golf and curling Family History: no history of malignancy Physical Exam: Tmax: 35.9 ??????C (96.6 ??????F) Tcurrent: 35.9 ??????C (96.6 ??????F) HR: 74 (67 - 75) bpm BP: 113/46(60) {112/46(60) - 113/57(71)} mmHg RR: 20 (20 - 24) insp/min SpO2: 96% Heart rhythm: AF (Atrial Fibrillation) Physical Examination General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, MMM Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t) Cervical adenopathy Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), III/VI holosystolic murmur @ apex, III/VI holosystolic murmur at base Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bilateral bases) Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present, Distended, No(t) Tender: , No(t) Obese, hypoactive bowel sounds Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t) Clubbing Skin: Not assessed Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2163-11-22**] Echo: The left atrium is elongated. The right atrium is markedly dilated. The right atrial pressure is indeterminate. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild to moderate aortic valve stenosis (area 1.2 cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. [**2163-11-23**] Pathology report 1. Lymph nodes, 4L, biopsy (A-C): Metastatic neuroendocrine neoplasm, most consistent with carcinoid tumor, in two of ten lymph nodes/lymph node fragments. 2. Lymph nodes, 7, biopsy (D): Metastatic neuroendocrine neoplasm, most consistent with carcinoid tumor, in three of four lymph nodes/lymph node fragments. See note. 3. Lymph nodes, level 7, biopsy (E): Metastatic neuroendocrine neoplasm, most consistent with carcinoid tumor, in one of two lymph nodes/lymph node fragments. Note: Immunohistochemical stains show the tumor cells are diffusely positive for synaptophysin and chromogranin and are negative for CK 7 and TTF-1. Rare tumor cells are positive for CK20. Despite the negative TTF-1, the tumor is compatible with a lung primary. Clinical correlation recommended. FLOW CYTOMETRY [**11-23**]: FLOW CYTOMETRY IMMUNOPHENOTYPING: The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda and CD antigens: 2,3,5,7,19,20,23, and 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells comprise 34% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens. T cells comprise 50% of lymphoid gated events, and express mature lineage antigens. INTERPRETATION: Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see S08-[**Numeric Identifier 66053**]) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. [**11-23**] Bronchial Washings: Bronchial washing, left upper lobe: NEGATIVE FOR MALIGNANT CELLS. Reactive bronchial epithelial cells and alveolar macrophages. ADDENDUM: Hematology slide 0559R of bronchoalveolar lavage (BAL) was reviewed and shows alveolar macrophages. No evidence of malignancy. [**11-23**] CXR: FINDINGS: No pneumothorax. There is complete opacification of the left lung, which is indicating collapse in the left upper lung, likely due to mucus plug. There is overlapping opacification, which was seen on the previous film, in the left lower lung which might be postoperative, inflammatory, or malignant and further evaluation is needed. There is a small right pleural effusion, unchanged. There is no consolidation in the right lung. The right jugular line was removed. [**2163-11-23**] CXR Post-Bronch: FINDINGS: As compared to the previous examination, the left lung is slightly better aerated. There is no evidence of left-sided pneumothorax. In the right lung, in the middle lobe, some subtle areas of atelectasis are seen. No evidence of larger pleural effusions. [**2163-11-24**] CXR: PORTABLE CHEST RADIOGRAPH: Compared to recent studies of [**2163-11-23**], there is improved aeration of the left upper lung, without evidence of new pneumothorax. There persists opacification of the left perihilar and left lower lung, likely representing combination of pleural effusion and atelectasis, although underlying consolidation cannot be excluded. There is also improved aeration of the right lung although small right pleural effusion persists. [**2163-11-25**] CXR: REASON FOR EXAM: Status post mediastinoscopy and bronchoscopy. Since yesterday, diffuse opacification of the left lung is overall unchanged, mostly in the perihilar and left lower lung region, likely a combination of left pleural effusion and atelectasis, possibly consolidation. Small right pleural effusion is unchanged. The right lung is otherwise normal. There is no other change. [**2163-11-25**] CT Scan Chest: IMPRESSIONS: 1. Subcutaneous gas consistent with recent mediastinoscopy. A small left lower paratracheal collection containing fluid and gas could represent post- procedural changes. Correlation with recent procedure and clinical symptoms recommended. Multiple mediastinal lymph nodes are noted. Larger soft tissue density in the subcarinal region could represent lymphadenopathy or in the right clinical context could also represent a hematoma. Comparison with prior study if available could help differentiate between the two. 2. Status post left lower lobectomy with fibrotic changes and atelectasis noted in the left lung. Fluid collection with thick enhancing rind in the left posterior sulcus is chronic and organized. 3. Nodule in the anterior left lung could represent rounded atelectasis, though in atypical location. Recurrent tumor cannot be excluded. 4. Moderate right dependent pleural effusion with associated dependent atelectasis of the left lower lobe. 5. Left adrenal mass. Dedicated imaging of the adrenal glands recommended for further evaluation. There is also suggestion of lymphadenopathy in the retroperitoneum that is incompletely imaged. Small ascites noted along the dome of the liver. EKG [**2163-11-27**]: Normal sinus rhythm. Poor R wave progression, possibly related to lead placement. No other abnormality. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 72 0 88 [**Telephone/Fax (2) 66054**]1 OCTREOTIDE SCAN (SOMATOSTATIN) Study Date of [**2163-11-29**] Reason: NHL AND LUNG CA BX SHOWED MALIGNANT NEUROENDOCRINE NEOPLASM Prelim findings c/w metastatic carcinoid, full report pending. [**2163-11-21**] 07:32PM GLUCOSE-130* UREA N-119* CREAT-2.2* SODIUM-141 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16 [**2163-11-21**] 07:32PM estGFR-Using this [**2163-11-21**] 07:32PM CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.4 [**2163-11-21**] 07:32PM URINE HOURS-RANDOM UREA N-828 CREAT-45 SODIUM-LESS THAN [**2163-11-21**] 07:32PM URINE OSMOLAL-427 [**2163-11-21**] 07:32PM WBC-11.5* RBC-4.11* HGB-11.7* HCT-36.4* MCV-88 MCH-28.4 MCHC-32.1 RDW-15.1 [**2163-11-21**] 07:32PM NEUTS-96* BANDS-0 LYMPHS-2.0* MONOS-2 EOS-0 BASOS-0 [**2163-11-21**] 07:32PM PLT COUNT-389 [**2163-11-21**] 07:32PM PT-33.9* PTT-43.6* INR(PT)-3.6* [**2163-11-21**] 07:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2163-11-21**] 07:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR Other labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2163-12-1**] 05:45AM 5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6 288 [**2163-11-30**] 08:05AM 5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7 277 [**2163-11-29**] 06:45AM 5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1 280 [**2163-11-28**] 07:00AM 6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4 242 [**2163-11-27**] 07:25AM 9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5 247 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2163-12-1**] 05:45AM 96 18 1.0 147* 4.0 105 37* 9 [**2163-11-30**] 08:05AM 81 20 0.9 145 4.0 108 34* 7* [**2163-11-29**] 06:45AM 77 22* 0.9 1441 4.0 106 36* 6* [**2163-11-28**] 07:00AM 79 27* 1.0 144 4.1 105 32 11 [**2163-11-27**] 07:25AM 95 30* 1.0 143 4.0 106 33* 8 [**2163-11-26**] 07:00AM 103 37* 0.9 143 4.2 107 33* 7* [**2163-11-25**] 03:37PM 104 43* 1.0 147* 4.4 110* 33* 8 [**2163-11-25**] 02:07AM 168* 60* 1.0 146* 4.3 110* 31 9 [**2163-11-24**] 04:25AM 92 87* 1.2 150* 4.2 113* 31 10 [**2163-11-23**] 07:05AM 97 115* 1.7* 147* 4.5 108 31 13 [**2163-11-22**] 02:52PM 126* 2.0* [**2163-11-22**] 05:34AM 122* 125* 2.1* 143 4.5 104 28 16 DIG ADDED 9:08AM [**2163-11-21**] 07:32PM 130* 119* 2.2* 141 3.8 100 29 16 [**2163-11-27**] 07:25AM BNP 7554*1 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2163-12-1**] 05:45AM 8.9 3.2 2.2 [**2163-11-30**] 08:05AM 9.0 3.4 2.3 [**2163-11-29**] 06:45AM 9.0 2.8 2.3 [**2163-11-28**] 07:00AM 8.6 2.7 2.2 HEMATOLOGIC calTIBC Ferritn TRF [**2163-11-22**] 05:34AM 153* 270 118* DIG ADDED 9:08AM PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE [**2163-11-22**] 05:34AM NO SPECIFI1 1[**Telephone/Fax (3) 66055**] NO MONOCLO2 DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks [**2163-11-22**] 01:50PM NEG NEG NEG NEG NEG NEG NEG 5.0 NEG Source: Catheter MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE RenalEp [**2163-11-22**] 01:50PM 3* 2 FEW NONE <1 <1 Source: Catheter URINE CASTS CastHy [**2163-11-22**] 01:50PM 9* Source: Catheter OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro Other [**2163-11-24**] 08:13AM 01 01 71* 8* 6* 15* 02 BRONCHIAL LAVAGE [**2163-11-25**] 3:37 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2163-11-27**]** GRAM STAIN (Final [**2163-11-27**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. [**2163-11-24**] 8:13 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. **FINAL REPORT [**2163-11-26**]** GRAM STAIN (Final [**2163-11-24**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2163-11-26**]): NO GROWTH, <1000 CFU/ml. [**2163-11-23**] 7:10 pm TISSUE Site: LYMPH NODE GRAM STAIN (Final [**2163-11-23**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2163-11-26**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2163-11-29**]): NO GROWTH. ACID FAST SMEAR (Final [**2163-11-24**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2163-11-24**]): NO FUNGAL ELEMENTS SEEN. LEGIONELLA CULTURE (Final [**2163-11-30**]): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2163-11-24**]): NEGATIVE for Pneumocystis jirovecii (carinii).. Brief Hospital Course: 76M initially admitted to [**Hospital 1562**] hospital for CHF exacerbation, and then transferred ICU-to-ICU for workup of chronic mediastinal LAD. Thoracic Surgery had been contact[**Name (NI) **] and was interested in seeing the patient and deemed that he would be most appropriate for MICU given his ongoing ARF. While in the ICU his renal function improved with gentle intravascular hydration. Echo was performed which revealed severe diastolic dysfunction with ejection fraction of >70%. His digoxin was therefore discontinued. He was discharged to the floor after ~24 hours of observation. While on the medical service, the patient was brought to the OR on [**2163-11-23**] for Flexible bronchoscopy with bronchoalveolar lavage of the left upper lobe, cervical mediastinoscopy and bronchoscopy. On post-op CXR there was noticeable whiteout of the left lung field and the patient was kept in the PACU for observation. He was treated with Chest PT, IS and suctioning for the thought of possible mucus plugging. As per documentation, the patient was doing well until the morning when he had increasing oxygen requirements and more labored breathing. At 8am on [**2163-11-24**] the patient underwent unremarkable bronchoscopy by IP. Patient continued to have a significant oxygen requirement, satting 93% on 40% facemask, thus was transferred to the ICU for monitoring. In ICU on [**11-25**], patient underwent upper airway suctioning, along with albuterol, ipratropium, and mucinex treatment. He utilized incentive spirometry as well. Serial chest x-rays showed eventual clearing of his left lung. His oxygen saturation improved to 100% on 4L. He underwent a chest CT which showed a large right pleural effusion and left airspace disease possibly consistent with pneumonia. he continued to produce increasing amounts of airway mucous. Though he did not spike a fever or develop a leukocytosis, he was started on empiric coverage for hospital acquired pneumonia with vancomycin and zosyn. This was continued for a total of 4 days, and then discontinued. His respiratory status continued to improve, and he was weaned down to 2L NC O2, and often maintained O2 sats > 94% on room air at rest. He was transferred from the ICU to the medicine floor on [**11-25**], where the below issues were addressed: Hypoxia: Thought to be due to mucus plugging in setting of procedure. Given the acuity of both the change and the reversal it is likely that he experienced lung collapse and then reaeration of expectorating mucus. Received 4 days of vanc/zosyn for presumed HAP coverage in setting of hypoxia and increased sputum production, this was d/c'd [**11-28**] with no additional fevers and decreasing sputum. He was continued on ipratropium nebs, mucomyst nebs, guaifenesin, incentive spirometry. During his stay, his oxygen requirement was weaned, now requiring 2L NC only intermittently. Will continue albuterol and ipratropium nebs on a prn basis. . Hypernatremia: Na as high as 150, did decrease with IVF but still mildly elevated on transfer to floor. Improved to 147 with D5W. IV hydration stopped at this time and POs encouraged given risk of CHF. Free water deficit estimated at 2.3L on transfer to floor. Na remained stable in range of 143-147 when taking more PO fluid. Recommend continued intermittent monitoring. LAD: s/p mediastinoscopy. His mediastinal lymph node biopsy results were consistent with carcinoid. The hematology/oncology service was consulted, and they recommended getting an octreotide scan, the preliminary read showed metastatic carcinoid. These results were discussed with the patient and his outpatient oncologist. The patient requested to be followed by his oncologist in [**Hospital1 1562**]. . diastolic Congestive Heart Failure: ECHO with EF of 75%, has severe dCHF. Cards consulted while in ICU. Digoxin was discontinued in setting of diastolic CHF. Cardiology recommended using either BB or verapamil to control HR, goal to have <80. HR was well controlled without meds on transfer from ICU. Added Metoprolol 12.5 mg [**Hospital1 **] on [**11-26**], though this was d/c'd [**11-27**] for episodes of bradycardia to 30s. Added 12.5 Metoprolol SR [**11-28**], which he has tolerated well. Also added Candesartan at low-dose (4mg, home dose 16 mg) given h/o diastolic CHF and goal of reducing afterload. This can be titrated up as his blood pressure allows. He did have some increased edema during his stay on the medical floor, and was given TEDs stockings and encouraged to ambulate. He also received 40 mg IV lasix x 1 [**2163-11-28**], and an additional dose of 40 mg po on [**11-30**] and 40mg IV on [**12-1**]. The long-term goal remains to minimize diuretics, but use extreme caution with fluids as pt is exquisitely volume sensitive due to severity of dCHF. Discharged with instructions to continue home lasix (40 mg) for 3 days with monitoring of daily weights and chemistries, this may need to be reassessed and monitored. . RHYTHM: He has chronic afib. His heparin was held after surgery. He was restarted on coumadin 1.25 mg daily on [**11-26**]. His INR rose to the therapeutic range, and was 2.5 on discharge. Recommend intermittent monitoring to tritrate necessary dosing regimen. . ARF: Improved with hydration. Renal signed off prior to transfer to floor. Diuresis minimized on the floor, received 40 mg IV lasix and 40mg PO lasix on two occasions with good diuresis, pt maintained blood pressures. The goal continues to be to minimize diuresis to prevent excessive preload reduction. . CAD: He was continued on his statin, held ASA due to h/o GI bleed Medications on Admission: PPI Lipitor 10 Atacand 16 (confirmed with spouse) Digoxin 0.125 mg qd Aldactone 25 qd Lasix 40 qd Allopurinol 100 mg qd Verapamil 180 qd Coumadin 2.5 (MWF); 1.25 (TTSS) Flomax 0.5 Discharge Medications: 1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Warfarin 1 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Candesartan 4 mg Tablet Sig: One (1) Tablet PO daily (). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Discharge Disposition: Extended Care Facility: [**Hospital3 2857**] - [**Location (un) 9188**] Discharge Diagnosis: Primary: Mediastinal Lymphadenopathy Metastatic Carcinoid Acute renal failure Secondary: chronic diastolic congestive heart failure anemia atrial fibrillation chronic renal insufficiency Discharge Condition: fair, tolerating PO, afebrile, VS wnl, O2 95-100% on supplemental O2 2L [**Hospital **] transfer to chair with assist Discharge Instructions: You were admitted to the hospital with mediastinal lymphadenopathy. You had a mediastinoscopy and bronchcoscopy. The pathology reports showed this was consistent with carcinoid. You were seen by the oncologists, who recommended an Octreotide scan; you indicated you would like to follow up with your outpatient oncologist. You were also noted to have an exacerbation of your heart failure. You were seen by the cardiologists, who recommended you stop your digoxin. You were given diuretics to remove fluid. You also had acute renal failure, which resolved during your stay. . A CT scan showed a mass on your left adrenal gland, this should be worked up as an outpatient, you should talk with your primary care doctor about further evaluation. . The following changes were made to your medications: Your digoxin, verapamil and aldactone were stopped Your atacand dose was decreased to 4 mg You were started on metoprolol You were started on docusate, senna, and bisacodyl as needed for constipation and albuterol and ipratropium nebs as needed for SOB/wheezing Your allopurinol and flomax were held, these can be restarted during your rehab stay Your coumadin was decreased to 1.25 mg daily, this can be adjusted based on your INR . Please call your doctor or return to the ED for: - fevers/chills - shortness or breath or chest pain - increasing sputum production - weight gain > 3 lbs - any other new or concerning symptoms Followup Instructions: Follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25237**] ([**Telephone/Fax (1) 66056**], within 1 week of leaving rehab. On a CT scan, you were noted to have a mass on your left adrenal gland, and they recommended dedicated CT or MRI for better characterization. Dr. [**Last Name (STitle) 25237**] should help you this setting this up. Follow up with your cardiologist Dr. [**Last Name (STitle) 41632**] [**Name (STitle) **] [**Telephone/Fax (1) 19666**], fax [**Telephone/Fax (1) 66057**] within the next 2-3 weeks for reevaluation and adjustment of heart failure meds as needed. Oncology Dr. [**Last Name (STitle) 27009**] [**Telephone/Fax (1) 66058**]. You have an appointment on [**12-13**] at 1:20 PM, call if you need to reschedule or be seen sooner.

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Discharge summary

report

Admission Date: [**2192-3-30**] Discharge Date: [**2192-4-13**] Date of Birth: [**2106-12-31**] Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 7651**] Chief Complaint: CHIEF COMPLAINT: shortness of breath REASON FOR CCU ADMISSION: transfer for severe AS, CHF, resp. failure Major Surgical or Invasive Procedure: endotracheal intubation cardiac catheterization with no intervention History of Present Illness: Ms. [**Known lastname 1968**] is an 85y/o lady with HTN, diastolic HF (EF 70%), severe AS (valve area 0.8cm2), CVA, and anemia who was admitted to [**Hospital6 17032**] two days ago for shortness of breath and is transferred to the [**Hospital1 18**] CCU due to CHF with respiratory failure. Of note, she was admitted to the OSH twice last month due to CHF exacerbations. She had been doing fine at rehab until [**2192-3-28**] when she went for a doctor's appointment and got acutely short of breath - by the time she arrived at the OSH ED she had decreased level of consciousness and was intubated. She had pulmonary edema as well as ?RLL infiltrate. During her OSH stay, she was ruled out for acute MI, diuresed, and treated for CAP with Ceftriaxone and Azithromycin. Leukocytosis reportedly decreased from 15 on admission to 5 on the day of transfer. Left subclavian CVL was subsequently placed and CVP was [**2-23**], with decrease inurine output. Given her prior aggressive diuresis, she was given 500cc IVF followed by maintenance IVF and 1u pRBC with improvement in her urine output. Creatinine is at baseline. Also, her hospital stay has been notable for anemia. Her baseline Hct is 24. Upon OSH admission her Hct was 28, but today was 20 in the setting of the fluid boluses and she is reportedly guaiac negative. She is a very difficult cross-match; did receive one unit pRBCs with repeat Hct prior to transfer of 23.7. On arrival to the CCU, she is intubated and sedated. Opens eyes to command, appears comfortable. Per discussion with son [**Name (NI) **], she has never had any interventions for her AS. Has not been complaining of chest pain. She did have syncope in the past (incl. syncope and a fall 1.5 years ago). Does get short of breath with ambulation, which has been her biggest complaint. REVIEW OF SYSTEMS: Patient is intubated and unable to respond. Past Medical History: severe aortic stenosis ([**Location (un) 109**] 0.8) HTN CVA depression diverticulitis hypothyroidism Social History: - Home: Widowed since [**2185**]. Was in rehab at [**Location (un) 25576**] prior to presenting to the OSH. - Tobacco history: None - ETOH: None - Illicit drugs: None Family History: no significant cardiac history Physical Exam: ADMISSION PHYSICAL EXAMINATION: Tcurrent: 37.8 ??????C (100.1 ??????F) HR: 88 (88 - 115) bpm BP: 97/45(58) {94/45(57) - 119/60(71)} mmHg RR: 27 (19 - 32) insp/min SpO2: 97% FiO2 30%, PEEP 5, TV 450, RR 10 GENERAL: Elderly lady, intubated and sedated. Appears comfortable. HEENT: NCAT. Sclera anicteric. PERRL. NECK: JVP 15cm. CARDIAC: S1 and S2; crescendo-decrescendo systolic murmur heard best at RUSB; murmur radiates to carotids; murmur is late-peaking with no audible A2 LUNGS: coarse breath sounds bilaterally ABDOMEN: (+) bowel sounds; obese but nondistended; soft with no masses EXTREMITIES: 1+ edema to shins bilaterally SKIN: No stasis dermatitis NEURO: Opens eyes to voice, follows commands. PERRL. Moves extremities spontaneously. Withdraws extremities to pain. Toes downgoing bilaterally. PULSES: Carotid 2+ DP 2+ PT 2+ bilaterally DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: Vitals - Tm/Tc: 98.5/98 HR: 89-93 BP: 106-115/51-54 RR:22 02 sat: 93% RA In/Out: Last 24H: 1040/1775 ++ Last 8H: Weight: 75.6 kg( 75.6) Tele: SR/ST. FS: none GENERAL: 85 yo F in no acute distress HEENT: no lymphadenopathy, JVD at 14 cm CHEST: Crackles 1/3 up bilat, no rhonchi or wheezes CV: S1 S2 Normal in quality and intensity RRR, 3/6 systolic murmur at LUSB. ABD: soft, distended, BS normoactive. no rebound/guarding. EXT: bilat ankle edema, pneumoboots in place, feet warm with trace palp pulses. NEURO: 3/5 strength in U/L extremities. speech clearer. Memory impaired but trying hard to gather full picture. SKIN: no rash, stage 2 on coccyx, covered with drsg. PSYCH: calm, alert. Pertinent Results: ADMISSION LABS: [**2192-3-30**] 05:48PM BLOOD WBC-12.6* RBC-3.41* Hgb-9.1* Hct-31.7* MCV-93 MCH-26.7* MCHC-28.7* RDW-15.3 Plt Ct-272 [**2192-3-30**] 05:48PM BLOOD Neuts-87.3* Lymphs-7.3* Monos-1.7* Eos-3.3 Baso-0.3 [**2192-3-30**] 05:48PM BLOOD PT-12.0 PTT-32.2 INR(PT)-1.1 [**2192-3-30**] 05:48PM BLOOD Glucose-115* UreaN-18 Creat-0.6 Na-140 K-4.2 Cl-104 HCO3-27 AnGap-13 [**2192-3-30**] 05:48PM BLOOD ALT-14 AST-22 AlkPhos-78 TotBili-0.7 [**2192-3-30**] 05:48PM BLOOD Albumin-3.4* Calcium-8.9 Phos-5.0* Mg-1.8 [**2192-3-30**] 09:04PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.026 [**2192-3-30**] 09:04PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [**2192-3-30**] 09:04PM URINE RBC-139* WBC-5 Bacteri-FEW Yeast-NONE Epi-0 Micro: blood cultures ([**3-30**] and [**4-1**]): no growth urine cultures ([**3-30**] and [**4-1**] and [**4-9**]): no growth legionella urinary antigen ([**2192-3-30**]): negative sputum ([**3-31**]) no growth catheter tip from central line ([**4-1**]): no growth STUDIES: CXR ([**2192-3-31**]): An ET tube is present. The tip is partially obscured but appears to lie approximately 3.2 cm above the carina. An NG tube is present, tip extending beneath the diaphragm overlying the gastric fundus. A left subclavian line overlies the distal SVC, unchanged. No pneumothorax detected. There is cardiomegaly. Enlarged tapered pulmonary hilum raises the question of pulmonary hypertension. There is upper zone redistribution and diffuse vascular blurring, consistent with CHF. There is increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. Probable small bilateral effusions. Compared with [**2192-3-30**] at 18:29 p.m., there has been slight interval clearing at the right lung base and in the left mid zone, but, overall, findings are otherwise similar. ECHO ([**2192-3-31**]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size is normal. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 1.0cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Severe aortic valve stenosis. Mild mitral regurgitation. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Pulmonary artery hypertension. Pathology Crossmatch ([**2192-3-30**]): Ms [**Known lastname 1968**] has a new diagnosis of anti-E antibody. E antigen is a member of the Rh blood group system. Anti-E antibody is clinically significant and capable of causing hemolytic transfusion reactions. In the future, Ms [**Known lastname 1968**] should receive E antigen negative products for all red cell transfusions. Approximately 70% of ABO-compatible blood will be E antigen negative. Limited carotid ultrasound ([**2192-4-2**]) 1. Unable to scan the right carotid artery due to presence of central venous line. 2. 40-59% stenosis of the left internal carotid artery. Cardiac Catheterization ([**2192-4-4**]): FINAL DIAGNOSIS: 1. One vessel coronary artery disease of proximal LAD. 2. Moderate aortic stenosis. 3. Moderately elevated left sided filling pressure. 4. Medical rx for CAD. 5. Return to CCU. Brief Hospital Course: Ms. [**Known lastname 1968**] is an 85y/o lady with HTN, diastolic HF (EF 70%), severe AS (valve area 0.8cm2), CVA, and anemia who was admitted to [**Hospital6 17032**] two days ago for shortness of breath and is transferred to the [**Hospital1 18**] CCU due to respiratory failure in the setting of CHF and PNA. # Respiratory Failure: multifactorial. thought to be [**12-22**] aortic stenosis as well as PNA. Pt had been started on CAP coverage at OSH, but she has been hospitalized twice in the past month so more appropriate to cover for HCAP. Precipitant of CHF is unclear (was ruled out for MI, not able to answer history questions about med/dietary compliance), but she has had multiple hospitalizations recently for CHF. Started on vanc/cefepime/azithro on arrival to [**Hospital1 18**] to cover for HCAP and this was continued for 8 day course (last dose [**2192-4-7**], and azithro for only 5d). Blood cultures neg on admission and neg from OSH. Sputum culture had no growth. For management of CHF, diuresed pt with lasix drip with acetazolamide as well and removed several liters of fluid. HR consistently on 90s, so placed pt on metoprolol rather than atenolol to get targeted HR control and uptitrated as needed to achieve goal rate of 60-70s. A right central line was placed in the IJ for medication administration. Obtained echo which showed AoVA of 1.0cm^2 with mean gradient of 30mmHg. Pt was extubated on [**2192-4-5**]. Due to aggressive diuresis, she developed a contraction alkalosis that inhibited her respiratory drive, so lasix drip was stopped. Clinically and based on CXR, she was euvolemic at this point. By day before discharge, the patient's oxygen was weaned, no longer requiring any supplementation. . # CHF: As above. Responded well to diuresis. Switched from atenolol to metoprolol succinate 100mg. Also, started lisinopril and uptitrated to 5mg on d/c. Patient is on 40mg of torsemide per day. The patient should have at daily weights and ins and outs taken at the rehab facility. Renal function and volume status should be closely monitored. . # HCAP: as above, pt thought to have PNA on transfer to [**Hospital1 18**]. treated pt for HCAP due to multiple recent hospitalizations with vanc/cefepime for 8 days and azithromycin for 5d. She became afebrile and her WBC count normalized. She continued to have excessive secretions. Treated with chest PT, nebulizers, guaifenison. # severe AS: pt has normal EF on echo but severe AS, mild LVH, and pulm artery HTN. likely severe AS has caused her recent multiple hosp admissions for acute CHF. managed volume status as above in resp failure. managed HR with uptitration of metoprolol succinate to 100mg qd. Spoke with outpatient cardiologist Dr. [**Last Name (STitle) **] [**Name (STitle) 13469**] re: AS work up. Pt had never had significant work up for AS because she had never been symptomatic other than mild chest pressure on exertion. Valve area=0.9, peak=33, mean=20 in [**2190**]. He thought was good percutaneous candidate due to underlying history of lung disease. Consulted c-[**Doctor First Name **] to eval for op candidacy and obtained testing as requesting: carotid US (result: Unable to scan the right carotid artery due to presence of central venous line. 40-59% stenosis of the left internal carotid artery), MSSA swab (positive), and cardiac cath (result: AS moderate, wedge 14-15, CI 2.3, 60-70% proximal LAD lesion). Given AS only moderate, is not currently a surgical candidate. # Altered mental status: At baseline, per family, patient is functional, conversational and able to perform ADLs. After extubation, patient was confused, not speaking, inconsistently following commands. This was thought to be secondary to electrolyte disturbances (hyperNa and hyperCa). She was treated with free water boluses as well as calcitonin salmon for hyperCa. Her mental status improved significantly by the time of discharge, to approximately 85% of baseline, per son. # Nutrition: Patient failed speech and swallow evaluation initially. Thus, NG tube was placed and tube feeds were initiated. The tube feed and NG tube was removed on [**4-12**], and the patient was able to take PO meds and food by time of discharge. Repeat speech and swallow evaluation was as follows recommendations: 1. Continue PO diet of thin liquids and puree. 2. Pills crushed with puree. Small pills may be whole with puree. 3. 1:1 assist for all POs. # HTN: BP was stable off home meds. Held lisinopril and nifedipine in setting of normotension. continued BB but switched home atenolol to metoprolol for better rate control. # Anemia, acute on chronic: Pt has a h/o anemia (Hct 28) and was stable on arrival to the OSH, but had a precipitous drop the day of transfer to Hct 20. Hct bumped appropriately with 1u pRBCs to Hct 23 at OSH. Etiology thought to be most likely hemodilution in the setting of IVF's initially. No evidence of bleeding. Hemolysis labs neg. Stool guaiac neg. DIC labs neg. iron studies c/w anemia of chronic disease. This was likely [**12-22**] acute PNA and worsening of CHF. INACTIVE ISSUES # h/o CVA: no obvious deficit. continued ASA and statin # HLD: stable. continued Simvastatin #. Hypothyroidism: stable. continued Levothyroxine #. Depression: stable. continued Sertraline TRANSITIONAL ISSUES: - f/u with PCP s/p discharge from rehab - f/u with cardiologist in [**11-21**] weeks - f/u daily weights and track volume status, adjust torsemide as needed Medications on Admission: HOME MEDICATIONS: [per transfer summary] ASA 81mg daily Atenolol 50mg [**Hospital1 **] Nifedipine ER 90mg daily Lisinopril 5mg daily Lasix 40mg [**Hospital1 **] Simvastatin 40mg daily Albuterol neb Q4H PRN Ca Carbonate 500mg [**Hospital1 **] Calcitonin nasal spray: 1 spray daily Maalox 30mL Q4H PRN Sertraline 50mg daily Lorazepam 0.25mg PO BID PRN Tylenol 1000mg [**Hospital1 **] Ascorbic acid 500mg [**Hospital1 **] MTV daily Omeprazole 20mg daily Ferrous sulfate 325mg [**Hospital1 **] Vitamin D 50000U weekly Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 2. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB/wheeze. 7. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol Sig: One (1) spray Nasal once a day. 8. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO twice a day. 10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): give at same time as iron. 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 14. Vitamin D3 5,000 unit Tablet Sig: One (1) Tablet PO once a week. 15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for fungal rashincluding under breasts. 16. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Acute on chronic diastolic congestive heart failure Pneumonia Moderate Aortic Stenosis Hypertension Anemia Left pleural effusion Hypernatremia Delerium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mrs. [**Known lastname 1968**], It was a pleasure taking care of you. You were admitted to the [**Hospital1 69**] for an exacerbation of your heart failure and pneumonia. . Weigh yourself every morning before breakfast, call Dr. [**Last Name (STitle) 11493**] if weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. We made the following changes to your medicines: 1. Discontinue Atenolol, furosemide, nifedipine, Maalox, lorazepam and omeprazole 2. Start taking metoprolol xl to lower your heart rate 3. START taking torsemide to get rid of extra fluid 4. Start using miconazole for the rash under your breasts. Followup Instructions: Name:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] [**Name8 (MD) 11493**], MD Specialty: Cardiology Address: [**Apartment Address(1) 28703**], [**Location (un) **],[**Numeric Identifier 28704**] Phone: [**Telephone/Fax (1) 11650**] When: [**Last Name (LF) 2974**], [**4-27**] at 2:00pm

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icd9cm

[ [ [] ] ]

[ "96.6", "88.53", "37.23", "96.72", "88.56" ]

icd9pcs

[ [ [] ] ]

15514, 15600

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398, 469

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62,860

132,663

324

Discharge summary

report

Admission Date: [**2138-8-25**] Discharge Date: [**2138-10-3**] Service: MEDICINE Allergies: Sulfonamides / Macrodantin / Codeine / Norvasc / Hydralazine / Heparin Agents Attending:[**First Name3 (LF) 2195**] Chief Complaint: anemia and acute renal failure Major Surgical or Invasive Procedure: Renal biopsy [**9-1**] Placement of pheresis catheter [**9-3**] Plasma exchange [**9-3**], [**9-5**], [**9-8**] Hemodialysis Bronchoscopy [**2138-9-12**] Central line placement [**2138-9-12**] History of Present Illness: [**Age over 90 **] year-old female with hypertension admitted [**2138-8-25**] with acute renal failure secondary to hydralazine-induced glomerulonephritis (p-ANCA positive). Patient was initially nonresponsive to steroids, plasma exchange, and was started on hemodialysis on [**2138-9-9**]. She received her second HD treatment on [**2138-9-11**]. During both treatments L IVF was removed. Both renal and rheumatology have followed patient to date. Cyclophosphamide was considered, but not started given concern for toxicity due to age. . Overnight, patient developed oxygen requirement, initially hypoxic to 90% on room air at rest, 85% with ambulation. Oxygen delivery was increased progressively from 3L to 6L nasal cannula. She appeared volume overloaded on exam and CXR. She was given Lasix 40mg IV x2 with minimal urine output. Nebulizers were tried with minimal relief. Renal was called re: urgent dialysis, which was not possible. Additionally, given rapid progression of hypoxia, renal suspected etiology other than volume overload alone. Of note, patient also with hemoptysis this morning on multiple occasions - largest approximately 1 teaspoon bright red blood. Given progressive hypoxia and increased work of breathing, patient is transferred to [**Hospital Unit Name 153**] for further management. . Hospital course also complicated by lower GI bleed, anemia, coagulopathy, UTI. On [**2138-9-10**], patient developed LGIB in context of constipation and straining for bowel movement. GI was consulted. Based on recent colonoscopy, transient diverticular bleed was suspected. Ischemic colitis was also considered given underlying vasculitis. Patient also with chronic anemia. She has required 2 pRBC transfusions during this hospital course. Patient also with uncomplicated UTI treated with ciprofloxacin PO x3 days on admission. . On arrival to [**Hospital Unit Name 153**], was with O2 saturation 100% on 100% O2 shovel mask. She complained of shortness of breath, fatigue. She was urgently intubated given respiratory distress. Past Medical History: Hepatitis B secondary to transfusion ([**2078**]) Hypercholestremia Hypertension Carotid stenosis s/p endartarectomy Arthritis, s/p right THR ([**2130**]) Gastritis Prolapsed bladder s/p bladder suspension Breast cyst Social History: Lives in apartment above daughter's home. Well-supported by family. Active prior to admission - capable in all ADLs. Per daughter, no tobacco, alcohol, or illicit drug use. Formerly worked at [**Company 3004**]. Family History: unknown Physical Exam: On admission [**2138-8-26**]: Pt is at baseline per daughter who is with pt Pt is awake and responds appropriately. Able to tell me it is [**2138**] but unable to correctly tell me month or date or identify name of president. 97.8 197/77 78 14 99%RA CV-RRR lungs - CTA bilat abd - soft, nt, nD, no guarding ext - no c/c/e . On admission to [**Hospital Unit Name 153**] (prior to intubation) [**2138-9-12**]: 96.8, 95, 169/112, 20, 91% shovel mask 100% General: Labored respirations with use of accessory muscles HEENT: Sclera anicteric, dry blood at mucous membranes and in mouth, no site of active bleeding Neck: Supple, JVP difficult to assess given accessory muscle use Lungs: Rhoncherous throughout with crackles to midlung fields bilaterally; no wheezes; decreased breath sounds at bases bilaterally CV: Heart sounds hindered by rhonchi; regular, no murmurs appreciated Abdomen: Distended; hypoactive bowel sounds; nontender GU: No Foley Ext: Warm, well-perfused; 2+ radial and DP pulses; 1+ lower extremity edema to knees bilaterally Pertinent Results: [**2138-8-25**] Na 134 / K 4.5 / Cl 102 / CO2 19 / BUN 60 / Cr 3.6 / BG 134 ALT 16 / AST 33 / Alk Phos 58 / TB .4 Lipase 73 Ca 9.4 / Mg 2.6 / phos 4.3 INR 1.3 / PTT 64 [**2138-8-25**] CXR No acute cardiopulmonary process. Unchanged large hiatal hernia as noted. [**2138-8-26**] Renal US - No evidence of hydronephrosis. Normal-appearing kidneys. [**2138-8-28**] Renal US with dopplers - Normal arterial and venous flow to the bilateral kidneys. [**2138-9-1**] Renal biopsy: Pauci-immune crescentic glomerulonephritis in the setting of ANCA positivity. [**2138-8-30**] RLE ultrasound: No right lower extremity DVT. [**2138-9-1**] CXR: In comparison with study of [**8-25**], there has been substantial enlargement of the cardiac silhouette with pulmonary vascular congestion and bilateral pleural effusions. [**2138-9-12**] CXR: IMPRESSION: Worsening hydrostatic pulmonary edema. Early followup is recommended. [**2138-9-12**] CXR: IMPRESSION: Improved pulmonary edema which is now moderate, stable bibasilar pleural effusions with satisfactory position of the ET tube and right central venous line. Brief Hospital Course: [**Age over 90 **]yo female with history of hypertension was admitted with acute renal failure, coagulopathy, and microscopic hematuria of unclear etiology. 1. Acute renal failure Initially, the etiology of her acute renal failure was unclear. Initial evaluation with urine electrolytes, renal ultrasound, and renal ultrasound with doppler evaluation made pre-renal etiology or post-renal etiology less likely. Urine sediment was generally unremarkable. Renal biopsy was pursued and demonstrated crescentic glomerulonephritis in the setting of ANCA positivity. Etiology of her renal failure was found to be hydralazine-related pauci-immune glomerulonephritis. Shortly after admission, she was started on hemodialysis and did not demonstrate any signs of renal recovery. The decision was made not to continue dialysis. 2. Coagulopathy. Her INR was slightly elevated to 1.3 on admission and had minimal improvement with Vitamin K administration. PTT remained markedly elevated. Mixing study and lupus anticoagulant testing was performed and were both positive. However, the diagnosis of lupus anticoagulant was not deemed relevant to the above diagnosis. 3. Anemia: Patient was found to have anemia related most likely to anemia of chronic disease and chronic kidney disease. 4. Hypertension. Patient was initially continued on her home regimen for hypertension with the exception of her [**Last Name (un) **] which was held due to renal failure. However, when ANCA came back as positive, her hydralazine was discontinued given the known association between pauciimmune ANCA positive glomerulonephritis and hydralazine usage. She was then placed on labetalol with improvement in her blood pressure. 5. Diffuse Alveolar Hemorrhage During this admission, she developed an oxygen requirement and hemoptysis, concerning for diffuse alveolar hemorrhage. She was started on high dose steroids and cytoxan with remarkable improvement in her respiratory status from intubation to being on room air. 6. GI Bleding Patient had an episode of GI bleeding during this admission thought likely related to hemorrhoids, diverticuli, or ischemia in the setting of vasculitis. These symptoms did not recur during her hospitalization. 7. Thrombocytopenia Platelet count declined and patient was found to be HIT positive. Her platelet count remained between 80-150. 8. Goals of Care Prior to admission, patient was living independently with some help from her daughter. Over the course of her admission, she became remarkably weak and dependent for her activities of daily living, in addition to being dialysis dependent. After extensive discussion with her family, she was transitioned to comfort care and the plan was for her to be sent home with hospice. Prior to discharge, she was noted to be in more respiratory distress, with shallow respirations. Removal of her central line was required before discharge, and in discussion with the family about the risks of taking the patient off the floor for the procedure, it was determined that the goal of getting the patient home was worth the risk. While in the IR suite, the patient expired. Medications on Admission: Medications at home: (taken from admission H&P) Valsartan 320mg PO daily ASA 81mg PO daily Hydralazine 100mg PO TID HCTZ 25mg PO daily Simvastatin 20mg PO daily Metoprolol 25mg PO BID Citalopram 10mg PO daily (started [**2138-8-25**]) ferrous sulfate 325mg (65mg iron) tab just d/c'ed recently by pcp Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice Discharge Diagnosis: 1. Hydralazine related pauci-immune glomerulonephritis 2. Acute Renal Failure requiring hemodialysis 3. GI bleeding 4. Diffuse Alveolar Hemorrhage 5. Heparin induced thrombocytopenia 6. Dysphagia Discharge Condition: Expired Discharge Instructions:

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icd9cm

[ [ [] ] ]

[ "39.95", "96.72", "99.71", "86.05", "33.23", "96.04", "38.95", "55.23", "99.28" ]

icd9pcs

[ [ [] ] ]

8779, 8837

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49639

Discharge summary

report

Admission Date: [**2115-12-31**] Discharge Date: [**2116-1-10**] Date of Birth: [**2068-7-20**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Left frontal craniotomy History of Present Illness: 47 year old male presented to [**Hospital6 1597**] after having a new headache that was unlike any headaches he's had in the past. He has no dizziness, no N/V, no visual changes,gait changes or any other symptoms. The patient had a head CT at the OSH which showed a 6 cm left frontal mass. He was sent to [**Hospital1 18**] for a neurosurgical evaluation. Past Medical History: HTN thought to be related to pain that resolved with no medication Social History: The patient is Armenian. He is an investment consultant and lives with his wife, 2 children, and his father. [**Name (NI) **] smoked 1 ppd x 15 years. No ETOH. Family History: non-contributory Physical Exam: T:99.4 BP:178/124 HR:96 RR:14 O2Sats:97% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs-intact 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. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-4**] throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Pertinent Results: [**2115-12-31**] 05:51AM GLUCOSE-182* UREA N-18 SODIUM-142 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-25 ANION GAP-13 [**2115-12-31**] 05:51AM PHENYTOIN-14.4 [**2115-12-31**] 05:51AM WBC-9.7 RBC-4.73 HGB-14.5 HCT-42.0 MCV-89 MCH-30.6 MCHC-34.5 RDW-13.6 [**2115-12-31**] 05:51AM PT-12.5 PTT-25.9 INR(PT)-1.1 [**2115-12-31**] 01:30AM GLUCOSE-129* UREA N-16 CREAT-1.1 SODIUM-143 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-26 ANION GAP-14 [**2115-12-31**] 01:30AM WBC-10.0 RBC-4.70 HGB-14.5 HCT-40.1 MCV-85 MCH-30.9 MCHC-36.2* RDW-13.4 [**2115-12-31**] 01:30AM NEUTS-69.9 LYMPHS-24.1 MONOS-3.3 EOS-2.0 BASOS-0.8 [**2115-12-31**] 01:30AM PT-12.2 PTT-25.6 INR(PT)-1.0 MRI [**2115-12-31**]: Left frontal extra-axial mass most likely a meningioma. CT HEAD W/O CONTRAST [**2116-1-3**] 9:20 AM IMPRESSION: Expected postoperative changes without acute hemorrhage, edema or infarction. EEG Study Date of [**2116-1-6**] IMPRESSION: This is a normal portable EEG in the waking and drowsy states. There were no areas of prominent focal slowing. There were no epileptiform features. No electrographic seizures were recorded. Of note, the faster beta frequency rhythms are likely related to medication effects from benzodiazepine administration. Brief Hospital Course: Pt started initially on decadron with surrounding edema around mass. Mass resected via Left sided frontotemporal craniotomy on [**2116-1-1**], which patient tolerated well. However, on POD1, pt noted to be significantly agitated/striking at staff. As a result, pt was sedated and intubated. He continued to be significantly agitated/not responsive to commands on POD2-3. On POD3, he was noted to have PNA, likely aspiration related, for which he was started on vancomycin/zosyn for coverage. Psychiatry was consulted as well and recommended haldol PRN, which he started with improvement in agitation. He was able to follow simple commands with decreased agitation. however, on POD5, he was noted to have 5 second episode of R eye turn/head turn with bilateral UE shaking. Dilantin level 10.1 (corrected) at that time. Neurology consulted and recommend goal level 15-20. pt was given 500 mg x 1. EEG demonstrated normal results. Pt was extubated on POD 5 which the patient tolerated well. with seizure activity, psychiatry was contact[**Name (NI) **] with haldol's lowering of seizure threshold. Psychiatry recommended change to Ativan. In addition his Dilantin was changed to Keppra. On [**2116-1-7**] he was transfered to stepdown unit, and speech therapy was ordered, and recommended treatment between 5 - 7 weeks. On [**2116-1-8**] and [**2116-1-9**] his speech has greatly improved, he did not have any word finding difficulties, and his speech was fluent without dysarthria. Pt discharged on [**2115-1-10**] to home with 24 hours supervision per PT recommendations. Medications on Admission: none Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): take while on steroid. Disp:*14 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while on narcotic. Disp:*60 Capsule(s)* Refills:*0* 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 9. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] and Hospice Discharge Diagnosis: Left frontal meningioma Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 58980**]. Pt will need repeat CT head with visit. Have staples removed next week. please call above number to schedule appointment. Completed by:[**2116-1-10**]

[ "997.3", "486", "225.2", "401.9", "293.9" ]

icd9cm

[ [ [] ] ]

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icd9pcs

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22418

Discharge summary

report

Admission Date: [**2132-6-13**] Discharge Date: [**2132-6-15**] Date of Birth: [**2105-5-5**] Sex: F Service: MEDICINE Allergies: Morphine / Prochlorperazine / Tramadol Attending:[**First Name3 (LF) 7299**] Chief Complaint: Nausea and vomiting, one episode of coffee ground emesis Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: History of Present Illness: Ms. [**Known lastname **] is a 27yo F with history of DM type 1, known grade 1 esophageal varices, status post exploratory laparoscopy from trauma presenting with frequent emesis with episode of coffee grounds and abdominal pain. . In the ER, initial vitals were 141, 133/96, 16, 99% 3L. Patient was profusing vomiting and R femoral CVL was placed for access. She had a very tender abdomen on exam and CT showed signs of pneumobilia. Surgery was consulted who recommended admission to medicine with serial abdominal exams. GI and liver were also consulted. She was started on PPI and octreotide drips, and also received dilaudid, zofran, insulin (home dose), zosyn, metoclopramide and metoprolol. Her initial labs showed an anion gap which later closed and small amount of ketones. Hct was stable since prior on [**5-29**]. NG lavage cleared after 20 cc flush and guaiac was negative. Vitals on transfer were 98.0 85 125/88 12 100% RA. FSBS 132. . In the MICU, patient is initially coughing/retching up clear liquid. Soon after receiving IV dilaudid and reglan, she appears comfortable and is fixing her hair. She reports being in her usual state of health yesterday but awoke with a FSBS in the 60s and has been vomiting throughout the day. The vomitus looked like coffee grounds at one point so she came to the ER. Her abdominal pain resolved in the ER but she continued to have n/v. She has been unable to eat today. Past Medical History: - Diabetes mellitus type I: diagnosed age 16 in [**2120**] after her first pregnancy. - Severe anxiety/panic attacks - Previous admissions for nausea/vomiting with h/o esophagitis and with concern for diabetic gastroparesis on metoclopramide - Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**] - Stage I diabetic nephropathy - Grade I esophageal varices seen on scope in [**2132-1-1**], negative liver ultrasound, normal LFTs, hep panel negative - Anxiety/panic attacks - Depression - Hyperlipidemia - S/P MVA [**5-3**] - lower back pain since then. - S/P MVA [**2130**], ex-lap - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [**2122**], not menstruating secondary to being on Depo-Provera - Genital Herpes - H pylori, s/p 2-week triple therapy on [**2132-1-24**] Social History: She was born and raised in [**Location (un) 669**] but currently lives in her own apartment with her son. She is currently unemployed and received disability. Her mother and sisters live nearby. She had to drop out of school for becoming a medical assistant due to her multiple hospitalizations. She does not smoke and reports rare alcohol use on holidays. She denies drug use. Family History: Grandmother with type 1 diabetes, no history of CAD, hypertension, celiac disease, IBD. Physical Exam: ADMISSION PHYSICAL EXAM: General: Alert, oriented, initially retching but later NAD and comfortable appearing [**Location (un) 4459**]: NC/AT, sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, midline well healed scar, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISCHARGE PHYSICAL EXAM: Physical exam: General: pt appears comfortable, A&Ox3 [**Location (un) 4459**]: PERRL, moist MMM CV: Tachycardic, no m/r/g Resp: CTAB Abd: soft/NT/mildly distended, midline abdominal scar s/p ex-lap Extr: no edema, cyanosis or clubbing, femoral line on right side appears clean and non-erythematous Pertinent Results: Admission: [**2132-6-12**] 06:10PM BLOOD WBC-7.7 RBC-3.54* Hgb-10.2* Hct-31.0* MCV-88 MCH-28.9 MCHC-32.9 RDW-14.1 Plt Ct-282# [**2132-6-12**] 06:10PM BLOOD Neuts-81.6* Lymphs-16.5* Monos-1.1* Eos-0.1 Baso-0.6 [**2132-6-12**] 06:10PM BLOOD Plt Ct-282# [**2132-6-12**] 06:10PM BLOOD Glucose-355* UreaN-18 Creat-1.1 Na-138 K-3.7 Cl-99 HCO3-22 AnGap-21* [**2132-6-12**] 08:30PM BLOOD Glucose-236* UreaN-14 Creat-0.9 Na-141 K-3.7 Cl-105 HCO3-24 AnGap-16 [**2132-6-12**] 06:10PM BLOOD ALT-20 AST-30 AlkPhos-76 TotBili-0.4 [**2132-6-12**] 06:10PM BLOOD Lipase-32 [**2132-6-12**] 06:10PM BLOOD Calcium-9.9 Phos-2.0* Mg-1.7 [**2132-6-12**] 10:54PM BLOOD Lactate-2.0 Discharge: [**2132-6-15**] 12:00PM BLOOD WBC-5.8 RBC-3.13* Hgb-9.1* Hct-27.6* MCV-88 MCH-29.2 MCHC-33.2 RDW-14.0 Plt Ct-229 [**2132-6-15**] 12:00PM BLOOD Plt Ct-229 [**2132-6-15**] 12:00PM BLOOD Glucose-289* UreaN-6 Creat-1.0 Na-134 K-4.2 Cl-101 HCO3-27 AnGap-10 [**2132-6-15**] 04:52AM BLOOD ALT-13 AST-15 AlkPhos-59 Amylase-95 TotBili-0.4 [**2132-6-15**] 12:00PM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9 EGD ([**2132-6-13**]): Erosion in the fundus compatible with NG tube trauma/suction Erosion in the gastroesophageal junction compatible with retching CXR ([**2132-6-12**]): The lungs are clear without consolidation or edema. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. The osseous structures are unremarkable. CT abdomen/pelvis ([**2132-6-12**]): 1. Esophageal wall thickening could reflect esophagitis or reactive changes from emesis. 2. Focus of pneumobilia, correlate with history for ERCP or sphincterotomy. 3. No additional acute abdominal process to explain the patient's pain and her symptomatology. Brief Hospital Course: 27F with T1DM c/b gastroparesis and anxiety who presented to the ED with nausea, vomiting and one episode of coffee ground emesis. #Nausea/vomiting and coffee ground emesis - Had an EGD which showed no source of active bleeding. No note of esophageal varices as previously reported on last EGD, some erosion of gastroesophageal junction which was thought to be [**1-2**] retching. Coffee ground emesis thought to be caused by [**Doctor First Name **]-[**Doctor Last Name **] tear from vomiting. Received Zofran and Ativan for nausea with improvement. Pt was continued on PPI 40mg daily on discharge. #T1DM - While in MICU, Lantus dose was held on night of [**2132-6-13**] because pt was not taking PO. Was then given 8 units of lantus during the afternoon of [**2132-6-14**] in the MICU. She received an additional 12 units of Lantus on the evening of [**2132-6-14**] to equal her normal nightly dose of Lantus 20 units. She was additionally covered with Humalog per her home sliding scale. She did not have any episodes of significant hyper- or hypoglycemia despite the changes in her insulin regimen. At discharge, she will be continued on her home doses of Lantus 20 units at night and Humalog pre-meal and sliding scale after meals. #Anxiety/Tachycardia - Prior to transfer from MICU, she was noted to be tachycardic to the 140s and hypertensive to the 160s systolic. When left alone, she calmed down and her HR and BP returned to [**Location 213**]. The anxiety improved after transfer to the floor, she was significantly less anxious at the time of discharge. #Electrolytes - Required repletion of potassium and phosphorus on multiple occasions. At discharge, both are back to normal levels. #Access - A peripheral line was unable to be placed and she received a femoral line in the MICU. This was removed prior to discharge and hemostasis was ensured with 5 minutes of pressure to the groin. No erythema or welling noted around the catheter site. #Transitional issues: -Will need monitoring of glucose control after discharge given disruption to her insulin dosing schedule -Will need monitoring of electrolytes given low potassium and phosphorus during admission Medications on Admission: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 3. Lantus 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous at bedtime. 4. Humalog 100 unit/mL Solution Sig: 1-10 units Subcutaneous with meals: as directed by your sliding scale. 5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): may increase slowly up to 2 Capsules twice daily if tolerated. Disp:*100 Capsule(s)* Refills:*2* 7. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous three times a day: per sliding scale. Discharge Medications: 1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lantus 100 unit/mL Solution Sig: Seventeen (17) units Subcutaneous at bedtime. 3. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous with meals. 4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO with meals and before bed. 5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Vomiting with coffee ground emesis, likely small [**Doctor First Name **]-[**Doctor Last Name **] tear Secondary diagnoses: Type 1 diabetes Gastroparesis Anxiety 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 the hospital with nausea and vomiting with one episode of coffee ground appearing vomit. You were in the intensive care unit for one day and had an upper endoscopy which did not show any active bleeding. It is thought that the coffee ground vomit was caused by your repeated vomitng. Please continue to take Zofran at home as needed for nausea. For your diabetes, we continued you on insulin. Your doses were temporarily decreased while you weren't eating. However, at home you should continue to take your normal doses of insulin as printed on your medication sheet. This includes Lantus 20 units tonight as well as your normal pre-meal and sliding scale humalog insulin. Followup Instructions: Please make a follow-up appointment with your primary care physician for next week, we have contact[**Name (NI) **] your [**Name (NI) 6435**] office so that you can be seen this week. Department: REHABILITATION SERVICES When: FRIDAY [**2132-6-20**] at 11:10 AM With: [**Name (NI) 29835**] [**Name (NI) 29836**], PT [**Telephone/Fax (1) 2484**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

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355, 373

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22363

Discharge summary

report

Admission Date: [**2131-8-31**] Discharge Date: [**2131-9-4**] Date of Birth: [**2075-1-3**] Sex: F Service: Trauma HISTORY: This was a 57-year-old woman who entered via the Emergency Room after a fall. She was transferred from an outside hospital where she was found to have a subarachnoid hemorrhage on CT scan. Upon admission to [**Hospital1 346**] she was found to have on repeat CT a right temporal contusion and bifrontal subarachnoid hemorrhages. She complained of back pain although plain films of the spine were negative. The remainder of her trauma work-up was unremarkable. She remained stable throughout her admission and was ultimately discharged with plans for follow-up by Behavioral Neurology and Neurosurgery. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern4) 17555**] MEDQUIST36 D: [**2132-1-13**] 15:11:09 T: [**2132-1-13**] 15:51:06 Job#: [**Job Number 58208**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2189-5-21**] Discharge Date: [**2189-5-29**] Date of Birth: [**2169-5-22**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: headache, increased confusion Major Surgical or Invasive Procedure: [**2189-5-21**]: Right Occipital Craniotomy for Abcess History of Present Illness: Patient is a 19M who was seen in our ED on [**2189-4-9**] for worsening headaches and URI symptoms, at that time he had a negative head CT and fever work up and was discharged home. On the early morning of [**5-21**], his roommates found the patient in the bathroom with the water running confused, they called EMS who brought him to [**Hospital1 **]. CT scan performed at arrival was revealing a large right parietal/occipital hyperlucency. Past Medical History: None Social History: college student at Berklee, no tobacco. Resides with roommates Family History: Non-contributory Physical Exam: On Admission: PHYSICAL EXAM: T:100.4 BP: 130/88 HR:80 R: 18 O2Sats: 100 Gen: Awake, restless, agitated, c/o headache HEENT: Pupils: Left 6mm, Right 5mm Brisk EOMs: intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake, agitated, confused and restless Orientation: Oriented to self, home address in [**State 3908**], student status at [**Location (un) **] Language: Speech fluent with good comprehension . Cranial Nerves: I: Not tested II: Pupils as above 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**]: UA XII: Tongue midline without fasciculations. Motor: Moving all four extremities spontaneously EXAM ON DISCHARGE: Alert and Oriented x 3 Ambulating independently in halls Dense left sided field cut Pertinent Results: Labs on Admission: [**2189-5-21**] 05:40AM BLOOD WBC-15.2* RBC-4.64 Hgb-13.8* Hct-38.8* MCV-84 MCH-29.6 MCHC-35.5* RDW-13.6 Plt Ct-283 [**2189-5-21**] 05:40AM BLOOD Neuts-92.5* Lymphs-4.6* Monos-2.3 Eos-0.1 Baso-0.5 [**2189-5-21**] 05:40AM BLOOD ESR-10 [**2189-5-21**] 05:40AM BLOOD Glucose-182* UreaN-15 Creat-0.9 Na-138 K-3.7 Cl-98 HCO3-28 AnGap-16 [**2189-5-21**] 05:40AM BLOOD ALT-80* AST-41* AlkPhos-78 TotBili-0.7 [**2189-5-21**] 06:52PM BLOOD CK(CPK)-234 [**2189-5-21**] 06:52PM BLOOD CK-MB-2 cTropnT-<0.01 [**2189-5-21**] 05:40AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.8 [**2189-5-21**] 05:40AM BLOOD CRP-10.2* [**2189-5-21**] 05:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ---------------- IMAGING: --------------- HEAD CT [**5-21**]: IMPRESSION: Right parieto-occipital intraparenchymal bleed with surrounding edema and 1 cm of midline shift. Questionable minimal subarachnoid bleed. Differential diagnosis is broad and includes AVM, underlying mass, venous thrombosis. Correlation with MRI/MRA/MRV is recommended. CT TORSO [**5-21**]: Enlarged calcified and non-calcified mediastinal and hillar and axillary lymph nodes. ddx includes treated lymphoma, sarcoidosis, prior granulomatous dz. Please clinically correlat. periportal edema and pericholecystic fluid. MRA/V HEAD [**5-21**]: PFI: 1. About 2 cm measuring intensely enhancing mass in the posterior right occipital lobe with associated 3-cm hematoma anterior to the mass causing vasogenic edema and 6-mm shift of normally midline structures to the left. Two additional enhancing, hemorrhagic lesions in the right frontal lobe. Differential diagnosis is broad and includes metastatic disease from unknown primary, multifocal primary glial neoplasm, or hemorrhagic tumefactive demyelinating disease. Infectious etiology is very unlikely. 2. No evidence of vascular abnormalities including no evidence of vascular malformation or intracranial venous thrombosis. CT HEAD(POST-OP) [**5-21**]: 1. Expected post-surgical changes with small amount of blood products surrounding the surgical cavity, pneumocephalus in the surgical cavity and in the subdural space adjacent to the parieto-occipital craniotomy. 2. Compared to the pre-surgical CT, unchanged vasogenic edema in the right parietal lobe. The midline shift to the left is decreased from pre-surgical 10 mm to post-surgical 5 mm. 3. No evidence of significant intracranial hemorrhage or infarction. Brief Hospital Course: Patient is a 19M who was origionally evaluated by our ED approximatley 6 weeks prior to URI and dental pain, returns on [**5-20**] with increased confusion. He was taken to the ER by his friends, when CT of the head was done, revealing a right occipital hyperlucency with significant mass effect and midline shift. He was therefore taken emergently for decompression. He tolerated the procedure well; the intraoperative pathology report was consistent with abscess. He spend the weekend in the ICu, and he slowly had an improvement in his exam. once extubated, he was following commands and was non focal. His post op head CTs demonstrated no acute hemorrhage. He was started on Mannitol for vasogenic edema, which was taperd down over the weekend. On [**5-24**] he was transferred out of the ICU to the SDU. [**5-25**], he was seen and evaluated by PT and OT, and foley catheter was discontinued. On [**5-26**], PICC line was placed in preparation for longer term IV antibiotics. Intraop cultures returned ANAEROBIC GNR#2/FUSOBACTERIUM [**Last Name (LF) 86380**], [**First Name3 (LF) **] the ID team recommended 8 weeks of IV antibiotics and a PICC line was placed. Decadron was tapered down. Dental x-rays showed no dental abcesses. On [**5-29**] the patient was discharged home with services for IV home antibiotics. Medications on Admission: NONE; however recent empty Rx bottle of azithromycin Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 6. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) 500mg dose Intravenous Q8H (every 8 hours) for 8 weeks. Disp:*qs 500mg dose* Refills:*0* 7. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: One (1) 2gm dose Intravenous Q12H (every 12 hours) for 8 weeks. Disp:*qs 2gm dose* Refills:*0* 8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Disp:*qs ML(s)* Refills:*0* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 10. Outpatient Lab Work LFTs, Chem 7, CBC Every week please fax results to ([**Telephone/Fax (1) 10739**] 11. Outpatient Lab Work Every 2 weeks you will also need ESR CRP please fax to ([**Telephone/Fax (1) 10739**] Discharge Disposition: Home With Service Facility: Home Solutions Discharge Diagnosis: Right Occipital Lobe Abcess Discharge Condition: Neurologically Stable Discharge Instructions: GENERAL INSTRUCTIONS WOUND CARE ?????? You or a family member should inspect your wound every day and report any of the following problems to your physician. ?????? Keep your incision clean and dry. ?????? You may wash your hair with a mild shampoo 24 hours after your sutures are removed. ?????? Do NOT apply any lotions, ointments or other products to your incision. ?????? DO NOT DRIVE until you are seen at the first follow up appointment. ?????? Do not lift objects over 10 pounds until approved by your physician. DIET Usually no special diet is prescribed after a craniotomy. A normal well balanced diet is recommended for recovery, and you should resume any specially prescribed diet you were eating before your surgery. MEDICATIONS ?????? Take all of your medications as ordered. You do not have to take pain medication unless it is needed. It is important that you are able to cough, breathe deeply, and is comfortable enough to walk. ?????? Do not use alcohol while taking pain medication. ?????? Medications that may be prescribed include: o Narcotic pain medication such as Dilaudid (hydromorphone). o An over the counter stool softener for constipation (Colace or Docusate). If you become constipated, try products such as Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or Fleets enema if needed). Often times, pain medication and anesthesia can cause constipation. ?????? You have been prescribed Keppra (Levetiracetam), for antiseizure prevention, you will not require blood work monitoring. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc, as this can increase your chances of bleeding. ACTIVITY The first few weeks after you are discharged you may feel tired or fatigued. This is normal. You should become a little stronger every day. Activity is the most important measure you can take to prevent complications and to begin to feel like yourself again. In general: ?????? Follow the activity instructions given to you by your doctor and therapist. ?????? Increase your activity slowly; do not do too much because you are feeling good. ?????? You may resume sexual activity as your tolerance allows. ?????? If you feel light headed or fatigued after increasing activity, rest, decrease the amount of activity that you do, and begin building your tolerance to activity more slowly. ?????? DO NOT DRIVE until you speak with your physician. ?????? Do not lift objects over 10 pounds until approved by your physician. ?????? Avoid any activity that causes you to hold your breath and push, for example weight lifting, lifting or moving heavy objects, or straining at stool. ?????? Do your breathing exercises every two hours. ?????? Use your incentive spirometer 10 times every hour, that you are awake. WHEN TO CALL YOUR SURGEON: With any surgery there are risks of complications. Although your surgery is over, there is the possibility of some of these complications developing. These complications include: infection, blood clots, or neurological changes. Call your Physician Immediately if you Experience: ?????? Confusion, fainting, blacking out, extreme fatigue, memory loss, or difficulty speaking. ?????? Double, or blurred vision. Loss of vision, either partial or total. ?????? Hallucinations ?????? Numbness, tingling, or weakness in your extremities or face. ?????? Stiff neck, and/or a fever of 101.5F or more. ?????? Severe sensitivity to light. (Photophobia) ?????? Severe headache or change in headache. ?????? Seizure ?????? Problems controlling your bowels or bladder. ?????? Productive cough with yellow or green sputum. ?????? Swelling, redness, or tenderness in your calf or thigh. Call 911 or go to the Nearest Emergency Room if you Experience: ?????? Sudden difficulty in breathing. ?????? New onset of seizure or change in seizure, or seizure from which you wake up confused. ?????? A seizure that lasts more than 5 minutes. Important Instructions Regarding Emergencies and After-Hour Calls ?????? If you have what you feel is a true emergency at any time, please present immediately to your local emergency room, where a doctor there will evaluate you and contact us if needed. Due to the complexity of neurosurgical procedures and treatment of neurosurgical problems, effective advice regarding emergency situations cannot be given over the telephone. ?????? Should you have a situation which is not life-threatening, but you feel needs addressing before normal office hours or on the weekend, please present to the local emergency room, where the physician there will evaluate you and contact us if needed. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**11-19**] days (from your date of surgery) for removal of your sutures and a wound check.This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain with & without contrast. INFECTIOUS DISEASE FOLLOW UP: All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] - You need an MRI with gadolinium in 8 weeks, this can be arranged thru our office, please call Dr.[**Name (NI) 9034**] office, refer to the number above. Completed by:[**2189-5-29**]

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icd9cm

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Discharge summary

report+addendum

Admission Date: [**2188-2-11**] Discharge Date: [**2188-2-13**] Date of Birth: [**2104-1-17**] Sex: F Service: MEDICINE Allergies: Penicillins / Ditropan XL / Norvasc Attending:[**First Name3 (LF) 4327**] Chief Complaint: Atrial fibrillation with rapid ventricular response Major Surgical or Invasive Procedure: None History of Present Illness: 84 year old female with chronic afib, HTN, HLD, CAD, stage IV CKD (HD MWF), COPD, dCHF (EF >55%) with multiple admissions for CHF exacerbations, and with recent thrombosis of her left upper extremity AV [**First Name3 (LF) **] treated with thrombectomy on [**2187-12-21**], who c/o dyspnea and was noted to be in RAPID AFIB at HD. . Today, 1.5 hrs into HD, the pt became tachycardic w/ HRs in the 170s, so HD was stopped with 15 min left, after having gotten 2L IVF off. She was mentating okay per EMS and had no sx. EMS gave 2.5 mg cardizem. Pt has been noted to be fluid responsive on previous admissions. . In the ED, she was given 500 cc and another 500 cc, w/ hr going down to 130, and bp in the 100s. She got 10+5mg of dilt IV w/ pressures dropping to the 70s, with some change in mentation, so dilt was held. 2nd bolus of 500cc + 500cc was given and since she had labile bp, it was decided to trasnfer her to CCU. She got 25 mg po metoprolol and 5 mg metoprolol IV. . Vitals on transfer were hr 86, bp 85/45, rr 20, 100% RA. Rhythm was reported to be still in afib. . 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: PAST MEDICAL HISTORY: 1.) Stage 4-5 CKD c/b anemia and secondary hyperparathyroidism; on HD since [**2187-5-9**], does make some urine 2.) Hypertension 3.) Hyperlipidemia 4.) CAD: per patient, no records at [**Hospital1 18**] 5.) dCHF 6.) R carotid stenosis 7.) Depression 8.) Asthma 9.) Osteoporosis 10.) Osteoarthritis 11.) Thyroid disease- h/o both hypo and hyperthyroidism 12.) Vitamin D deficiency - 25 OH 19 in [**2-/2186**] 13.) Benign adnexal cyst: followed [**8-/2186**] and planned again for imaging [**8-/2187**] 14.) Chronic Aspiration: based on video swallow eval [**8-/2186**] 15.) Chronic labyrinthitis 16.) h/o L pneumothorax . PAST SURGICAL HISTORY: 1.) [**4-/2187**] LUE AV [**Year (4 digits) **] (Dr. [**First Name (STitle) **] 2.) hx bilat cataract surgery 3.) R hip fx s/p ORIF 4.) [**10/2187**] LUE AV [**Year (4 digits) **] thrombectomy and stent placement Social History: Patient is widowed, and she lives with her son, [**Name (NI) **] [**Name (NI) 96427**], and his fiance, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1169**], with [**Last Name (NamePattern1) 269**] assistance and private home care services. Denies any current or past smoking, current or past alcohol, or current or past drug use. Has care at the [**Location (un) 3137**] Center. Dialysis in [**Location (un) 1468**]. Family History: Son with heart surgery for unknown reason in [**2187**]. No family history of kidney disease. Physical Exam: ADMISSION EXAM: 95.2 126/59 60 100% CMV assist control 400/14 FIO2 40%, PEEP 5 GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of not visualised. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**2-12**] holosystolic mumur in apex LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Some inspiratory crackles in the bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Purpura on shins bilaterally. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE EXAM: 98.9 126/46 70 19 99%2LNC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of not visualised. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**2-12**] holosystolic mumur in apex LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Some inspiratory crackles in the bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Purpura on shins bilaterally. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: LABS ON ADMISSION: [**2188-2-11**] 10:15PM BLOOD WBC-10.8 RBC-3.29*# Hgb-9.7* Hct-28.9* MCV-88# MCH-29.6 MCHC-33.6 RDW-15.6* Plt Ct-300 [**2188-2-11**] 10:15PM BLOOD Neuts-87.3* Lymphs-8.1* Monos-2.7 Eos-1.4 Baso-0.5 [**2188-2-11**] 10:15PM BLOOD PT-22.7* PTT-35.1 INR(PT)-2.2* [**2188-2-11**] 10:15PM BLOOD Glucose-95 UreaN-13 Creat-2.0*# Na-141 K-3.9 Cl-100 HCO3-32 AnGap-13 [**2188-2-11**] 10:15PM BLOOD cTropnT-0.02* [**2188-2-11**] 10:15PM BLOOD Calcium-7.8* Phos-2.3* Mg-2.0 . LABS ON DISCHARGE: [**2188-2-13**] 05:12AM BLOOD Hct-27.0* [**2188-2-12**] 05:08AM BLOOD WBC-7.0 RBC-3.04* Hgb-9.1* Hct-27.2* MCV-89 MCH-29.9 MCHC-33.5 RDW-16.1* Plt Ct-250 [**2188-2-13**] 05:12AM BLOOD PT-16.6* PTT-34.9 INR(PT)-1.6* [**2188-2-13**] 05:12AM BLOOD Glucose-93 UreaN-36* Creat-3.6* Na-140 K-4.5 Cl-100 HCO3-30 AnGap-15 [**2188-2-13**] 05:12AM BLOOD Calcium-8.8 Phos-4.2# Mg-2.2 . [**2188-2-11**] pCXR FINDINGS: Single supine AP portable view of the chest was obtained. Again seen, there are increased diffuse interstitial opacities bilaterally, may be due to pulmonary edema, although appears less severe than on the prior study. Slight blunting of the bilateral costophrenic angles may be due to small bilateral pleural effusions. Cardiac and mediastinal silhouettes are stable. Left subclavian stent is again seen. Brief Hospital Course: 84 year old female with chronic afib, HTN, HLD, CAD, stage IV CKD (HD MWF), COPD, dCHF (EF >55%) who presented w/ AFIB w/ RVR and labile BPs after undergoing HD. . # AFIB w/ RVR: Pt has a hx of chronic AFIB and presented today with RVR, likely in the setting of being over diuresed. Per prior cardiology consult note, "It is most likely that the patient has baseline low blood pressures from poor autonomic tone and other factors, and her blood pressures are further reduced during tachycardic episodes in the setting of her diastolic dysfunction and left ventricular hypertrophy. Midrodrine should help the poor autonomic tone. She cannot augment her cardiac output enough when she is hemodynamically challenged (such as during fluid removal). It is also possible that because of her hyperdynamic LV function and LVOT gradient, she develops severe LVOT obstruction when her stroke volume is reduced and when she is tachycardic - similar to a patient with hypertrophic cardiomyopathy. We would also recommend reducing the rate of fluid removal during HD." Pt was placed on amiodarone and metoprolol, and converted to sinus rhythm. Of note, she did not have, but needs to be, continued on the above nodal blocking agents on discharge. She was continued on warfarin. Discharge INR is 1.6 and this should be checked daily with goal INR [**1-11**]. CXR, TSH and LFTs were checked upon initiation of amio. CXR was negative for evidence of fibrosis, TSH was wnl, LFTs were normal except for an alk phos of 116, which is stable from prior vales. These can be trended by her new cardiologist. . # Hypotension: Pt had labile blood pressures in the ED and on transfer to the CCU. However, urine output was good and pt was mentating well so displayed no signs of end-organ ischemia. Pt has had previous episodes of becoming hypotensive after HD, also in the setting of possible worsening of baseline LVOT obstruction. Hypotension improved with rate control and with conversion to normal sinus rhythm. Patient will also continue midodrine with HD, as before. . # DHF: pt has known DHF w/ hyperdynamic LV and gradient across LVOT. Likely exacerbated by aggressive diuresis per HD. Favor slow rate of removal of IVF during HD. Patient tolerated Wednesday HD session and -1L fluid was removed without complication. . # CKD: Pt HD dependant since [**2187-5-9**] MWF. Underwent HD w/ likely resultant hypovolemia. Continuing midodrine with HD, and plan as above. Patient's renagel pills were too big to swallow. Per renal, these can be stopped for now given low phosphate. . # HLD: stable. Pt continued on atorvastatin 40 mg daily. . # CAD: pt has previous hx of CAD, but no record in BDIMC and last MIBI normal, recent echo showed no WMAs. Continued on aspirin 81 mg daily. . # Constipation: continued senna, colase, polyethylene glycol prn . # Nutrition: continued multivitamin, folic acid . # Depression: continued home venlaflaxine Medications on Admission: 1) Coumadin 5mg PO daily 2) Renegel 800mg PO TID 3) 1200 cc fluid restriction 4) Effexor 75mg PO daily 5) Vit B complex 1 tab PO daily 6) Colace 100mg PO BID 7) Lactulose 22.5mL 15gm PO BID 8) Lipitor 40mg PO QHS 9) Aspirin 650mg PO TID 10) Bumex 1mg tab PO 4x weekly on non-HD days 11) Midodrine 2.5mg PO daily on MWF before HD 12) Protonix 40mg PO daily before meals 13) Iron 325mg PO daily 14) Folic acid 1mg PO daily 15) Nephrocaps 1mg PO daily 16) Ipratroprium and Albuterol PRN but never given 17) Zofran 4mg Q8H PRN nausea/vomitting but nothing given recently 18) Bisacodyl 1 tab PR PRN constipation Discharge Medications: 1. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 2. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a day. 3. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 4. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. lactulose 10 gram/15 mL (15 mL) Solution Sig: One (1) PO twice a day as needed for constipation. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. midodrine 5 mg Tablet Sig: 0.5 Tablet PO MWF (Monday-Wednesday-Friday): take with HD. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1) PO DAILY (Daily). 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. ipratropium bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed for SOB. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO TID (3 times a day) as needed for pain. 17. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 3137**] Care Center - [**Location (un) 1468**] Discharge Diagnosis: PRIMARY: 1. atrial fibrillation with rapid ventricular rate 2. end stage renal disease, on hemodialysis 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: Dear Ms. [**Known lastname 96427**], . You were admitted to the hospital for atrial fibrillation with fast heart rate during your dialysis session. The cause was likely aggressive fluid removal during dialysis, and your heart which can only tolerate gentle fluid removal. . Your heart rate was controlled with two medications, amiodarone and metoprolol. Please continue these medications as prescribed. You tolerated hemodialysis here, with one liter of fluid removed, without complication, on your date of discharge. . MEDICATION CHANGES: - START amiodarone 200 mg daily - START metoprolol tartrate 12.5 mg twice a day . Please seek medical attention for any concerns. Please attend your follow-up appointments below. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2188-3-11**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2188-2-13**] Name: [**Known lastname 15306**],[**Known firstname **] Unit No: [**Numeric Identifier 15307**] Admission Date: [**2188-2-11**] Discharge Date: [**2188-2-13**] Date of Birth: [**2104-1-17**] Sex: F Service: MEDICINE Allergies: Penicillins / Ditropan XL / Norvasc Attending:[**First Name3 (LF) 3373**] Addendum: She was also noted to have a skin tear on the right forearm. This appeared not to be infected, wound care nursing recommended xeroform dressing changes daily, recs were communicated to [**Hospital1 **] nurses. Discharge Disposition: Extended Care Facility: [**Hospital 549**] Care Center - [**Location (un) 130**] [**First Name11 (Name Pattern1) 947**] [**Last Name (NamePattern4) 3374**] MD [**MD Number(2) 3375**] Completed by:[**2188-2-13**]

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icd9cm

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Discharge summary

report+addendum

Admission Date: [**2158-6-7**] Discharge Date: [**2158-6-14**] Service: CME CHIEF COMPLAINT: Dyspnea and painful right foot. HISTORY OF PRESENT ILLNESS: This is a 79-year old female admitted to [**Hospital6 10353**] on [**5-26**] with a chief complaint of dyspnea. The patient also complained of a painful right foot. The patient stated that she had a one week history of increased dyspnea. At the outside hospital, she had a BNP of 1700. The patient was felt to be in congestive heart failure. She was ruled out for a myocardial infarction and was diuresed. The patient was started on antibiotics for cellulitis. Her foot was debrided and grew out Staphylococcus aureus as well as a group B Streptococcus. The patient was treated with vancomycin and then a cephalosporin. The patient was also maintained on Coreg and lisinopril as well as intermittent Lasix. An echocardiogram was performed which revealed LVH, akinesis of the inferior and posterior walls, anterolateral wall hypokinesis, with an ejection fraction of 30 percent, and severe mitral regurgitation. The left atrium was moderately dilated. The aortic valve was calcified with restricted movement, peak and mean gradients of 80 and 40; respectively. There was a valve area of 0.6 percent; felt to be consistent with severe aortic stenosis. The patient also had evidence of mild aortic insufficiency and moderate-to- severe tricuspid regurgitation. The patient's pulmonary artery systolic pressure was 63. The patient was transferred to the Transitional Care Unit at which time she developed oliguria with an increased creatinine to 4.5. The patient was transferred to the hospital again. She was found to be hypotensive as well as in renal failure. An echocardiogram was repeated, and the findings were similar to prior echocardiogram. The patient was placed on dopamine and intravenous fluids. Her blood pressure increased, and she also had increased urine output with her creatinine decreasing from 4.5 to 1.3. The patient was then transferred here for possible aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for type 2 diabetes complicated by peripheral neuropathy. Coronary artery disease. Ventricular aneurysm in [**2150**]; status post surgical repair. History of inferior posterior myocardial infarction 10 years ago complicated by LV free wall rupture and pseudoanuerysm repaired at [**Hospital1 18**]. History of hypertension. History of myeloproliferative disorder. History of anemia. History of gout. History of degenerative joint disease. History of chronic renal insufficiency (with a baseline creatinine of 1.3 to 1.7). History of peripheral vascular disease. Ischemia right medial hallux. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Hydrea. 2. Regular insulin sliding scale. 3. Lisinopril. 4. One-half normal saline with 40 of potassium chloride. 5. Vancomycin REVIEW OF SYSTEMS: The patient's constitutional, ophthalmologic, ear/nose/throat, gastrointestinal, endocrine, hematologic, genitourinary, and musculoskeletal systems were all within normal limits. On review of systems, the patient had no chest pain. She did have dyspnea on exertion with increasing lower extremity edema. No paroxysmal nocturnal dyspnea. No orthopnea. Increased shortness of breath with exertion. No palpitations, syncope, or presyncope. SOCIAL HISTORY: The patient lives by herself in [**Hospital1 42377**]. She has a very supportive and close family and a son that is very involved in her care. No tobacco. No ethanol. No illicit substances. PERTINENT LABORATORY VALUES ON PRESENTATION: Her temperature was 97.5, her blood pressure was 119/70, her heart rate was 90, and the patient was saturating at 97 percent on 2 liters by nasal cannula. Generally, the patient appeared her stated age. She was sitting in bed. She appeared in no acute distress. Head, eyes, ears, nose, and throat examination was significant for normocephalic and atraumatic. The extraocular movements were intact bilaterally. The sclerae were anicteric. The oropharynx was clear with moist mucous membranes. There was no evidence of thyromegaly on examination. Heart was regular in rate and rhythm with a 3/6 systolic murmur at the left and right upper sternal borders as well as the left lower sternal border with radiation to the axilla. Jugular venous pressure was noted to be 9 cm. The lungs were clear to auscultation with crackles at the bases. No wheezes or rales were noted. The abdomen was soft, nontender, and nondistended with normal active bowel sounds. No evidence of hepatosplenomegaly. No masses were palpated. Extremities were significant for no clubbing or cyanosis but trace edema that was nonpitting. On the patient's right foot there is an open wound adjacent to the first big toe with no active drainage, no erythema, and no edema. There was also a stage 1 decubitus ulceration on the patient's coccyx. On neurologic examination, cranial nerves II through XII were intact. Strength was [**5-31**] and symmetric. The toes were downgoing. Pulses were dopplerable; that is, both dorsalis pedis and posterior tibialis pulses bilaterally. The patient's femoral pulses were palpable bilaterally. PERTINENT RADIOLOGY-IMAGING: On electrocardiogram, the patient had evidence a right bundle branch block, a normal sinus rhythm at a rate of 87. No acute ST changes. The patient had T wave inversions in V1 through V4 as well as in II and III. On telemetry, the patient had evidence of a normal sinus rhythm with no ectopy. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 26.2, her hematocrit was 34.8, and her platelet count was 510. Differential with neutrophils of 90 percent, bands of 4 percent, lymphocytes of 4 percent, and monocytes of 2 percent. Her prothrombin time was 19, her partial thromboplastin time was 33.9, and her INR was 2.4. Her fibrinogen was 343. D-dimer was 1040. Erythrocyte sedimentation rate was 13. Sodium was 146, potassium was 4.3, chloride was 110, bicarbonate was 24, blood urea nitrogen was 49, creatinine was 1.3, and her blood glucose was 125. Her calcium was 8.6, her magnesium was 1.9, and her phosphate was 2.7. Thyroid stimulating hormone was 2. High- density lipoprotein was 23, her low-density lipoprotein was 58, and her triglycerides were 182. Her C-reactive protein was 2.47. Urine culture was consistent with yeast. Urinalysis was negative. Further data throughout her admission revealed Gram stain of wound culture obtained on [**2158-6-12**] revealed there were no microorganisms with only 2 plus polymorphonuclear neutrophils. Tissue no growth. Aerobic culture was no growth. Wound culture from [**6-12**]; again, Gram stain was significant 1 plus polymorphonuclear neutrophils and no microorganisms. Wound culture with no growth. Aerobic culture with no growth. Blood cultures from [**2158-6-10**] were no growth. Blood cultures from [**6-7**] were no growth. The patient's peak creatine kinase was 54, and her troponin was 0.43. SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS: CONGESTIVE HEART FAILURE ISSUES: The patient had a Swan-Ganz catheter placed, and her central venous pressure transduced at 20 with a pulmonary artery pressure of 66/32. The decision was made that the patient should not initially be diuresed given that she was preload dependent. Additionally, the patient was stable on minimal oxygen to stable on room air. The patient was maintained on her Coreg and lisinopril. Throughout her hospitalization, the patient received as needed Lasix intermittently. She had a good response to intravenous Lasix, but diuresis was kept to a minimum given the patient's aortic stenosis. The patient had a transthoracic echocardiogram on [**2158-6-8**] which revealed long axis dimension at 5.9, a four chamber length of 6.4, ejection fraction of 20 percent, a TR gradient of 38 to 42, E:A ratio of 1.3, left atrium that was moderately dilated, right atrium that was moderately dilated, and moderate symmetric LVH. The left ventricular cavity was mildly dilated. Overall left systolic ejection fraction was severely depressed. The right ventricular cavity was dilated. There was severe global right ventricular free wall hypokinesis. The aortic root was normal in diameter. The aortic valve leaflets were 3 and mildly thickened. There was moderate aortic valve stenosis. There was 1 plus atrial regurgitation was seen. The mitral valve leaflets were thickened. Mild 1 plus mitral regurgitation was seen. The mitral regurgitation is eccentric. The tricuspid valve leaflets were normal. Moderate-to-severe 3 plus tricuspid regurgitation was seen. Moderate pulmonary artery systolic hypertension was seen. Physiologic pulmonary regurgitation was seen. No pericardial effusion. The patient underwent cardiac catheterization on [**2158-6-9**] which revealed the following. Coronary angiography of a right-dominant system revealed moderate two vessel disease. The left main coronary artery was not obstructed. The left anterior descending artery and its major branches had no significant disease. The left circumflex had minimal distal vessel 70 percent stenosis. The right coronary artery had moderate luminal irregularities distally, up to 40 percent stenosed. Resting hemodynamic measurements demonstrated elevated right heart filling pressures. Right right atrial mean was 29 mmHg. The right ventricular end-diastolic pressure was 19 mmHg. Pulmonary arterial hypertension was noted with pulmonary artery pressure of 16/14 mmHg with a calculated peripheral vascular distance of 363 dynes seconds per cm5, and mildly elevated left heart filling pressures, with a mean capillary wedge pressure of 15 mmHg, and a left ventricular end-diastolic pressure of 14 mmHg. There was approximately 43 mmHg peak, and 36 mm mean gradient across the aortic valve, and mildly diminished cardiac output, an index of 3.9 liters per minute, and 2.4 liters per minute m2; respectively, for a calculated valve area of approximately 0.6 cm2. Left ventriculography revealed severe regional systolic ventricular dysfunction. There was severe anterior and apical hypokinesis and dyskinesis of the inferior wall with prominent aneurysm of the inferior basal segment. There was moderate 1 plus to 2 plus mitral regurgitation. Final diagnoses included noncritical two vessel coronary artery disease, severe aortic stenosis, moderate mitral regurgitation, and severe regional systolic ventricular dysfunction. It was felt that given these findings that the patient would be a candidate for aortic valve replacement. The case was discussed with Cardiothoracic Surgery, and it was felt that given the patient's active infection in the right foot that aortic valve replacement should be deferred until a later time after the patient has been on antibiotics for an adequate amount of time. CORONARY ARTERY DISEASE ISSUES: The patient was maintained on aspirin. INFECTIOUS DISEASE ISSUES: The patient was initially maintained on vancomycin for a presumed right foot osteomyelitis. The patient underwent x-rays of her right foot which revealed no fracture, evidence of bony destruction involving the head of the right first metatarsal consistent with osteitis. There has been an amputation through the base of the proximal phalanx of the second digit. No radiopaque foreign bodies were seen. The left foot views revealed that there was a hallux valgus deformity. There was resumption involving the head of the second metatarsal with metatarsal phalangeal subluxation at this location, and there could be bony resorption of the head and the base of the proximal phalanx of the second digit. No fracture. No radiopaque foreign bodies noted. Infectious Disease was consulted and they recommended oxacillin intravenously for osteomyelitis. The length of antibiotics was discussed with Infectious Disease, and it was recommended that the patient would need at the very minimum six weeks of intravenous antibiotics following right foot debridement, and up to eight week total of intravenous oxacillin depending upon how the patient's right foot looked at follow-up appointments with both Podiatry and Infectious Disease. Infectious Disease also stated that should an aortic valve replacement be necessitated prior to six weeks of intravenous antibiotics, at least two weeks of intravenous antibiotics are recommended and that the ptient should have surveillance blood cultures after this date, and if the patient's blood cultures are negative that the patient could then proceed with aortic valve replacement should it be necessitated before six weeks of antibiotics could be completed. Podiatry was also consulted, and they debrided the patient's wounds. As stated above, the patient's wound cultures were negative with no growth final. PERIPHERAL VASCULAR DISEASE ISSUES: The patient also underwent magnetic resonance imaging/magnetic resonance angiography of her lower extremities to assess for peripheral vascular disease and to see if she could possibly be a candidate for stenting. She had a magnetic resonance imaging/magnetic resonance angiography performed on [**2158-6-9**] which revealed the following. Mild atherosclerotic changes were present in the infrarenal abdominal aorta without evidence of aneurysm or dilatation. The assessment of the first station was limited due to technical factors and venous contamination; however, the iliac vessels appeared grossly normal to the level of the femoral arteries with no hemodynamically significant stenosis. The superficial femoral artery on the right leg had minimal atherosclerotic changes at the adductor canal. The right superficial femoral artery was of normal caliber and provided adequate flow to the lower right leg. The right profunda femoral appear appeared normal. The anterior tibial artery appeared normal throughout its course and as it enters the dorsalis pedis artery there was mild narrowing at the tibiofemoral trunk. The posterior tibial artery appeared normal at it enters the posterior foot. There was mild proximal narrowing. The plantar arch appeared normal. In the left leg, there was a surgical clip in the proximal superficial femoral artery which obscured evaluation of a very focal region of this area. The superficial femoral artery appeared normal. The profunda artery was diffusely diseased. The popliteal artery appeared normal. The anterior tibial artery had mild narrowing in its distal third but remains normal in caliber as it enters a normal-appearing dorsalis pedis. The tibiofemoral trunk appeared normal. The posterior tibial artery becomes diffusely atherosclerotic distally and was not identified at the ankle. The proximal peroneal artery appeared normal with diffuse disease distally. The plantar arch was not well visualized. The final impression was no significant aortoiliac disease, mild narrowing at the right tibioperoneal trunk, and of the distal peroneal artery, and diffuse disease of the left profunda femoral artery, mild narrowing of the mid segment of the anterior tibial artery, and diffuse disease of the distal posterior tibial and peroneal arteries with apparent occlusion of the these two vessels at the ankle. Given that the patient had good distal arterial flow, it was felt that the patient would not need stenting at this time. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's creatinine remained at her baseline. Her urine was sent, and urine culture was negative. Additionally, the patient had no evidence of urine eosinophils. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was maintained on a 2-gram cardiac diet as well as a diabetic diet. Her electrolytes were followed and repleted as needed. PROPHYLAXIS ISSUES: The patient was maintained on subcutaneous heparin and a bowel regimen. COMMUNICATION ISSUES: Communication was with her son throughout. Additionally, the patient's primary care physician was [**Name (NI) 653**] prior to the patient's discharge. CODE STATUS ISSUES: The patient remained a full code. MYELOPROLIFERATIVE DISORDER ISSUES: The patient was maintained on her outpatient dose of Hydrea with a good response. The patient did have elevated platelet counts in the range of 500s; however, there was no evidence of thrombo occlusive events. Prior to discharge, the patient had a peripherally inserted central catheter line placed for the purpose of extended intravenous antibiotics. This occurred without event. DISCHARGE INSTRUCTIONS: The patient was to take all medications as prescribed. The patient was to be weighed daily, and if greater than a 3- pound weight gain, as needed Lasix was to be considered. The patient also needs every 2-week liver function tests given that she was on oxacillin. Her liver function tests at the [**Hospital1 69**] were within normal limits except a mildly elevated alkaline phosphatase at 130. It was requested that the outside facility follow her liver function tests while the patient was on oxacillin for right osteomyelitis. FINAL DISCHARGE DIAGNOSES: Severe aortic stenosis. Congestive heart failure. Chronic renal insufficiency. Myeloproliferative disorder. Diabetes. Degenerative joint disease. Peripheral vascular disease. Hypertension. DISCHARGE FOLLOW UP: [**Hospital **] Clinic on [**Last Name (LF) 2974**], [**2158-6-23**] at 3 p.m. with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Infectious Disease by Dr. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 3640**] at the [**Last Name (un) 2577**] Building (telephone number [**Telephone/Fax (1) 457**]) on [**2158-7-17**] at 10:30 a.m. Cardiothoracic Surgery with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] on [**2158-7-6**]. MAJOR SURGICAL-INVASIVE PROCEDURES PERFORMED: Status post pulmonary catheter placement. Status post cardiac catheterization. Status post right foot debridement [**2158-6-11**]. CONDITION ON DISCHARGE: Stable. She was stable on room air. She was mentating appropriately. Had no ectopy on telemetry. No chest pain. She was not in congestive heart failure. DISCHARGE STATUS: She was to be discharged to [**Hospital1 392**] Transitional Care Unit. MEDICATIONS ON DISCHARGE: 1. Regular insulin sliding scale. 2. Hydroxyurea. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 15194**] Dictated By:[**Last Name (NamePattern1) 18827**] MEDQUIST36 D: [**2158-7-4**] 16:41:36 T: [**2158-7-4**] 18:58:31 Job#: [**Job Number 42378**] Name: [**Known lastname 3205**], [**Known firstname **] Unit No: [**Numeric Identifier 7646**] Admission Date: [**2158-6-7**] Discharge Date: [**2158-6-14**] Date of Birth: [**2078-12-9**] Sex: F Service: CME ADDENDUM: 1. Continue with Hydroxyurea 500 mg one p.o. twice a day. 2. Docusate 100 mg one p.o. twice a day. 3. Aspirin 325 mg one p.o. once daily. 4. Atorvastatin 40 mg one p.o. once daily. 5. Calcium Carbonate 500 mg tablets, one p.o. twice a day. 6. Ascorbic Acid 500 mg one p.o. twice a day. 7. Multivitamin one p.o. once daily. 8. Trazodone 50 mg tablets, 0.5 to one tablet p.o. q.h.s. as needed for insomnia. 9. Nystatin Ointment to be applied topically four times a day as needed. 10. Carvedilol 3.125 mg, take one tablet p.o. twice a day. 11. Captopril 6.25 mg one p.o. three times a day. 12. Oxacillin two grams intravenously q8hours for a minimum of six weeks per infectious disease and again up to eight weeks depending upon how the patient's foot looks at infectious disease follow-up. Additionally, infectious disease recommended a minimum of two weeks should AVR need to be expedited given the patient's symptoms but that the patient should have negative surveillance cultures post two weeks of antibiotics. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 7647**] Dictated By:[**Last Name (NamePattern1) 7648**] MEDQUIST36 D: [**2158-7-4**] 16:43:27 T: [**2158-7-4**] 18:31:19 Job#: [**Job Number 7649**]

[ "357.2", "707.15", "238.7", "398.91", "396.8", "707.0", "250.60", "682.7", "397.0" ]

icd9cm

[ [ [] ] ]

[ "89.64", "38.93", "88.53", "88.56", "99.04", "37.23", "77.88" ]

icd9pcs

[ [ [] ] ]

18434, 20407

2872, 3004

16686, 17220

17467, 18134

3024, 3468

106, 139

17248, 17455

168, 2152

2175, 2846

3485, 16661

18159, 18408

8,810

145,248

3282

Discharge summary

report

Admission Date: [**2192-2-19**] Discharge Date: [**2192-2-28**] Date of Birth: [**2114-10-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 77 y/o male with htn, glucose intolerance, cad (MI [**2168**], 5v cabg [**2183**], mibi in [**2188**] with no perfusion defects and ef 67%), cri who presents with stable doe that is new over the past 6 months. Pt states had some doe while walking to get water over night last night and felt uncomfortable being home alone. He also has a cough which began about the same time (neither cough nor dyspnea have been increasing or changing since onset). Cough is occasionally productive of whitish sputum. He states that he has not had any chest pain at rest or with exertion, no orthopnea, no palpitations, no light-headedness, no dizziness, and no feelings of passing out. He also denies fevers or chills. Denies URI symptoms, denies sick contacts. [**Name (NI) **] by EMS to be tachypneic in 30's. On arrival to the ED his blood pressure was 220/110, decreasing to 140's when I examined him. Of note, in ED had pocket full of condoms, and made sexual advances towards nurses. . In ED, got neb, rr down into 20's, satting 100%; no jvd, no rales; CXR without obvious infiltrate/chf; ecg with flipped t's v1-v4 (?new), rbbb (old, per dr.[**Doctor Last Name **] note from [**5-12**]); tn .18 (no prior values), ck 99, mb 8. Lactate 3.8. Past Medical History: PMHx: 1. Coronary artery disease s/p CABG x 5 v in [**2183**]. Stressed in [**2188**] with images - negative - see pertinent results 2. Angina. 3. Depression. 4. Schizophrenia. 5. Erectile dyfunction s/p penile implant 6. H/o delerium while inpatient Social History: lives alone, separated and estranged from wife and two daughters, admits to occasional EtOH, + smoking of [**12-11**] ppd x 10 years, quit previously about 45 yrs ago Family History: will not discuss Physical Exam: PE: 99.0, 102, 145/68, 17, 99% 2L Gen: NAD, mild tachypnea HEENT: sclera anicteric, mmm, o/p clear CV: rrr, nl S1 and S2, no m/r/g Pulm: CTAB, bronchial sounding Abd: protruberant, obese, s, nt, nd, nabs Extr: no c/c/e, 1+ dp bilaterally Neuro: AAOx3, CN II - XII grossly intact Pertinent Results: [**2192-2-19**] 06:40PM CK(CPK)-105 [**2192-2-19**] 06:40PM CK-MB-6 [**2192-2-19**] 03:00PM CK(CPK)-182* [**2192-2-19**] 03:00PM CK-MB-6 cTropnT-0.11* [**2192-2-19**] 02:33PM %HbA1c-6.7* [**2192-2-19**] 09:00AM GLUCOSE-251* UREA N-41* CREAT-2.2* SODIUM-137 POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-20* ANION GAP-23* [**2192-2-19**] 09:00AM CK(CPK)-99 AMYLASE-60 [**2192-2-19**] 09:00AM CALCIUM-9.6 PHOSPHATE-4.8* MAGNESIUM-2.0 [**2192-2-19**] 09:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2192-2-19**] 09:00AM GLUCOSE-244* LACTATE-3.8* NA+-141 K+-4.6 CL--100 TCO2-21 [**2192-2-19**] 09:00AM WBC-14.7*# RBC-5.75 HGB-17.3 HCT-50.5 MCV-88 MCH-30.1 MCHC-34.2 RDW-13.3 [**2192-2-19**] 09:00AM PLT COUNT-246 [**2192-2-19**] 09:00AM PT-14.3* PTT-26.1 INR(PT)-1.3 CXR: UPRIGHT AP CHEST: The patient is post-median sternotomy. The heart is probably enlarged. The aorta is tortuous. There is a double contour in the region of the right atrium, which may reflect left atrial enlargement. No definite consolidation is present. No evidence of CHF. No pleural effusion or pneumothorax detected. The osseous structures are unremarkable. IMPRESSION: No definite consolidation or CHF. LATERAL VIEW OF THE CHEST: The patient is post median sternotomy. There are no definite consolidations seen on the lateral view. No pleural effusions. When viewed in conjunction with the prior AP radiograph, there is prominence of the right hilum. This may represent early congestion. There is no evidence of overt failure, however. Degenerative changes of the spine are noted. . EKG: Sinus rhythm, inferior Q waves consistent with prior inferior infarction. Right bundle branch block (old). T wave inversion V1-4. ? old. . STRESS TEST [**2188**]: EKG stress: exercised for 6 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and asked the test be stopped for fatigue. No arm, neck, back or chest discomfort was reported by the patient throughout the study. The ST segments are uninterpretable for ischemia in the setting of the baseline inverted T waves. The rhythm was sinus with several isolated vpbs. Appropriate sytolic BP response to exercise. IMPRESSION: No anginal type symptoms or interpretable EKG changes. Nuclear report sent separately. MIBI images: Neither resting nor stress images reveal any myocardial wall perfusion abnormalities. Ejection fraction calculated from gated wall motion images obtained after exercise shows a left ventricular ejection fraction of approximately 67%. Regional wall motion appears grossly normal. IMPRESSION: No evidence of myocardial wall perfusion abnormalities at the level of exercise achieved. Brief Hospital Course: 1. Dyspnea : Etiology initially unclear, but he reported chronic dyspnea that acutely worsened. He ruled out for MI by enzymes and EKG-- (trop leak but has ARF on CRI; CKs flat). Had a persantine mibi which showed normal EF and perfusion, no symptoms. A chest xray was w/o infiltrate or effusion. Echo was performed which showed EF 70% and essentially normal study w/o wall motion abnormalities or valvular regurgitaton/stenosis. Despite these normal studies, patient continued to have dyspnea at rest, often with resp rates in the 40's, but with normal oxgyen saturations. He was extremely anxious, agitated at times, often not allowing his housestaff examine him and speak with him. He was a very difficult historian. A chest CT was performed to further evaluate the lung parenchyma which showed bilateral peripheral ground glass opacities in the absence of pleural effusions or septal thickening. Given the elevated white blood cell count and clinical picture, a multifocal pneumonia was thought most likely. He was treated with ceftriaxone and azithromycin, but he refused these treatments for approximately 24 hours. He was extremely anxious that we were trying to hurt him and that we didn't understand what was wrong with him. He would repeatedly say "nothing is wrong with me." After multiple conversations with the Russian interpreter and a psychiatry consultation, patient agreed to receive his antibiotics. He clinically improved over the first few days, but then acutely decompensated with an episode hypotension and tachypnea overnight. He was transferred to the ICU. Heparin drip was started for fear of MI and/or PE and was aggressively hydrated with good BP response. He ruled out for MI and a V/Q scan was attempted but patient didn't tolerate/complete the study. A CTA was not possible, given his renal insufficiency. Antibtics were contined as well and he was transferred back to the floor after an approximately 48 hour ICU course. Upon arrival to the floor, patient continued to have episodes of tachypnea and was placed on a non-rebreather. He had normal oxygen saturations during that time. ABG 7.39/29/223 on NRB. He would not allow his resident physician to examine him, thus an emergent psychiatry consultation was obtained. He continued to refuse to be seen by his resident physician, [**Name10 (NameIs) **] multiple efforts. He believed his resident was the daughter of people who hated him and, in turn, he hated her. It was decided he would be transferred to another medical service. Despite this, the patient had symptomatic relief with some ativan and morphine, breathing slowed, and he appeared improved. It was thought this tachypnea was secondary to a multifocal pneumonia (rather than a PE), as well as severe agitation and hyperventilation. His heparin was stopped at this time and he continued to improve over the next few days until his acute decompensation on the evening of his death. Autopsy revealed multiple pulmonary emboli. . 4. Elevated blood glucose: Has diagnosis of DM per his PCP, [**Name10 (NameIs) **] he is non compliant w/ DM strategies as outpatient per PCP. [**Name10 (NameIs) **] on sliding scale here but refused teaching on DM care. . 5. Hyperlipidemia: Had fasting lipid profile w/ severe dyslipidemia. Started lipitor on [**2-20**]. . 6. schizophrenia: documented in OMR. Not on meds. Has paranoid features and is hypersexual, inappapropriate at times. Started seroquel prn qhs. Haldol needed on [**2-19**] for agitation. Psychiatry consultation obtained multiple times as stated above for occasional refusal of care and splitting behaviors. * Medications on Admission: 1. lopressor 50 mg [**Hospital1 **] 2. monopril 10 mg daily 3. allopurinol 4. pepcid 5. asa Discharge Medications: Patient passed away Discharge Disposition: Expired Discharge Diagnosis: Schizophenia Pulmonary Emboli Community Acquired Pneumonia Discharge Condition: Pt passed away in hospital

[ "584.9", "487.0", "403.91", "415.19", "V45.81", "276.7", "428.31", "427.5", "295.90", "250.00", "518.84", "V15.81" ]

icd9cm

[ [ [] ] ]

[ "34.04", "96.04", "38.93", "99.60", "96.71" ]

icd9pcs

[ [ [] ] ]

8935, 8944

5137, 8748

323, 329

9046, 9075

2403, 5114

2071, 2089

8891, 8912

8965, 9025

8774, 8868

2104, 2384

276, 285

357, 1596

1618, 1871

1887, 2055

5,336

114,433

49418

Discharge summary

report

Admission Date: [**2157-9-28**] Discharge Date: [**2157-9-30**] Date of Birth: [**2102-11-12**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: Incarcerated hernia Major Surgical or Invasive Procedure: [**2157-9-28**] Left Inguinal hernia repair w/ mesh History of Present Illness: Pt is a 54 M w/ h/o L inguinal hernia repair by Dr. [**Last Name (STitle) **] in [**2151**]. He noticed a bulge in his left groin approximately 5 days, and has been having worsening nausea/vomiting for the last ~24 hrs, with approximately 11 episodes of emesis yesterday. His pain has been stable. He did have a subjective fever last night. Past Medical History: CAD s/p 3V CABG to LAD, OM1, PDA. HTN, controlled on meds Dyslipidemia Social History: No tobacco hx, very rare EtOH use, no IVDU. Pt is a MSM, lives with a steady male partner, currently sexually active, does not use protection, no hx of STDs in himself or partner. Employed in clothing design firm. Family History: Extensive family hx of CAD. F died of MI [**92**], Uncle died of MI [**83**]. GF died of MI. Physical Exam: Physical Exam upon admission: Vitals: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft. Minimally distended. Nontender. No guarding/Rebound. Palpable L inguinal Hernia Ext: No LE edema, LE warm and well perfused Physical Exam upon discharge: VS: 98.2, 119/57, 78, 16, 99/RA GEN: Resting in chair, NAD HEENT:No scleral icterus, mucus membranes moist CARDIAC: Normal S1, S2. RRR. No MRG PULM: Lungs CTAB ABDOMEN: obese, soft/nontender/mildly distended EXT: + pedal pulses. No CCE. NEURO: AAOx4 Skin: Left groin incision OTA, steri strips intact. Pertinent Results: Imaging: [**2157-9-28**] Radiology CT ABD & PELVIS WITH CO Left inguinal hernia containing sigmoid colon and causing large bowel obstruction. Minimal surrounding inflammation. No bowel wall enhancement abnormalities to suggest ischemia, though trace fluid is identified within the abdomen. No free air. [**2157-9-29**] 08:25AM BLOOD WBC-9.1 RBC-4.72 Hgb-14.9# Hct-41.3# MCV-88 MCH-31.5 MCHC-36.0* RDW-13.0 Plt Ct-173 [**2157-9-28**] 12:50PM BLOOD WBC-10.9# RBC-6.02 Hgb-18.7* Hct-51.8 MCV-86 MCH-31.1 MCHC-36.1* RDW-13.2 Plt Ct-245# [**2157-9-28**] 12:50PM BLOOD Neuts-82.9* Lymphs-11.5* Monos-5.1 Eos-0.1 Baso-0.3 [**2157-9-29**] 08:25AM BLOOD Glucose-103* UreaN-18 Creat-0.9 Na-136 K-3.9 Cl-103 HCO3-25 AnGap-12 [**2157-9-28**] 12:50PM BLOOD Glucose-118* UreaN-19 Creat-1.1 Na-132* K-3.6 Cl-95* HCO3-24 AnGap-17 [**2157-9-28**] 12:50PM BLOOD ALT-49* AST-31 AlkPhos-54 TotBili-1.3 [**2157-9-29**] 08:25AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.0 [**2157-9-28**] 12:50PM BLOOD Albumin-5.3* [**2157-9-28**] 12:58PM BLOOD Lactate-2.5* Brief Hospital Course: The patient is with h/o L inguinal hernia repair by Dr. [**Last Name (STitle) **] in [**2151**]. He noticed a bulge in his left groin approximately 5 days, and has been having worsening nausea/vomiting for the last several hours. He was admitted to the Acute Care Service after a CT Scan revealed "Left inguinal hernia containing sigmoid colon and causing large bowel obstruction. Minimal surrounding inflammation." On [**2157-9-28**], the patient was taken to the operating room for repair of his incarcerated recurrent left inguinal hernia with mesh. Please see operative report for details of this procedure. He tolerated the procedure well and was extubated upon completion. He was subsequently taken to the PACU for recovery. He was transferred to the surgical floor hemodynamically stable. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. He was initially given IV fluids postoperatively, which were discontinued when he was tolerating PO's. His diet was advanced on the morning of [**2157-9-29**] to regular, which he tolerated without abdominal pain, nausea, or vomiting. He was voiding adequate amounts of urine without difficulty. He was encouraged to mobilize out of bed and ambulate as tolerated, which he was able to do independently. His pain level was routinely assessed and well controlled at discharge with an oral regimen as needed. His left groin incision was open to air with steri strips that were clean/dry/intact. On [**2157-9-30**], he was discharged home with scheduled follow up in [**Hospital 2536**] clinic. Medications on Admission: Metoprolol Tartrate 25 mg PO BID Lisinopril 5 mg PO DAILY Atorvastatin 20 mg PO DAILY Discharge Medications: 1. Metoprolol Tartrate 25 mg PO BID 2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 3. Lisinopril 5 mg PO DAILY 4. Atorvastatin 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Incarcerated Inguinal Hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital complaining of nausea and abdominal pain. A CT scan revealed an left inguinal incracerated hernia . You were taken to the operating room for hernia repair. Your bowel function has returned and you have resumed a regular diet. Please follow up in [**Hospital 2536**] clinic at the appointment scheduled for you below. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your [**Hospital 5059**] at your next visit. Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU [**Month (only) **] FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: Your incision may be slightly red around the staples. This is normal. You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [**Month (only) 5059**]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 5059**]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. You will receive a prescription from your [**Name2 (NI) 5059**] for pain medicine to take by mouth. It is important to take this medicine as directied. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [**Name2 (NI) 5059**] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [**Name2 (NI) 5059**] has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your [**Name2 (NI) 5059**]: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. In some cases you will have a prescription for antibiotics or other medication. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. DANGER SIGNS: Please call your [**Name2 (NI) 5059**] if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] D. Location: [**Hospital1 **] [**Location (un) **] Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**] Phone: [**Telephone/Fax (1) 5723**] Appt: [**10-5**] at 12:20pm Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2157-10-13**] at 3:00 PM With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2157-9-30**]

[ "550.11", "401.9", "414.00", "V45.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "53.05" ]

icd9pcs

[ [ [] ] ]

4900, 4906

2912, 4496

323, 376

4979, 4979

1855, 2889

9968, 10578

1091, 1186

4636, 4877

4927, 4958

4523, 4613

5130, 9945

1201, 1217

264, 285

1533, 1836

404, 748

1231, 1503

4994, 5106

770, 843

859, 1075

15,923

116,118

11464+11494

Discharge summary

report+report

Admission Date: [**2165-3-1**] Discharge Date: [**2138-3-10**] Date of Birth: [**2101-5-12**] Sex: M Service: Internal Medicine [**Doctor Last Name **] Firm HISTORY OF PRESENT ILLNESS: This is a 63-year-old man with a history of hypertension, benign prostatic hypertrophy, and a recent history of upper respiratory infection type symptoms x1 week, who presents to the Emergency Department complaining of increased ear pain and drainage x1 week. He was found by his daughter this afternoon unresponsive and brought to the Emergency Department for workup of mental status changes. They have been seen by his primary care physician earlier in the week, and was started on ear drops for otitis externa. He had been working at his job as late as the Wednesday before admission. History was received all via the family. PAST MEDICAL HISTORY: 1. Hypertension. 2. Benign prostatic hypertrophy. 3. Sinusitis. SOCIAL HISTORY: Wife died from colon cancer one year ago. Lives with son. Former [**Name2 (NI) 1818**]. MEDICATIONS: 1. Claritin. 2. Ear drops. 3. Flonase. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Vital signs: Temperature 104, heart rate 120, blood pressure 190/100, oxygen saturation 96% on room air. The patient's physical examination in the Emergency Department was significant for a stuporous unresponsive state for which he required intubation. There were no other pertinent findings on physical examination. The patient had bilateral external auditory canal purulent drainage with blood behind the right tympanic membrane. PERTINENT LABORATORIES AND DIAGNOSTIC TESTS ON ADMISSION: The laboratories revealed a white count of 14.2 with 83% neutrophils, and 5% bands. The rest of his complete blood count, LFTs, and chemistries were normal. The patient's coagulation profile was normal. The patient had a lumbar puncture which drained purulent CSF and had an opening pressure greater than 55 mm of water. The patient had an electrocardiogram which revealed sinus tachycardia with a Q wave in III, normal axis, and no ST-T wave changes. The patient had a chest x-ray which was negative. Patient had a head CT scan which revealed a left maxillary sinusitis. ASSESSMENT: This 63-year-old man with bacterial meningitis. HOSPITAL COURSE: The patient was treated initially with ceftriaxone, Vancomycin, ampicillin, and dexamethasone for his presumed bacterial meningitis. The differential diagnosis included Strep pneumonia, hemophilus influenza B and Neisseria. CSF studies revealed a white count of 7,230, protein of 325, glucose of 1, and red blood cells of [**Pager number **]. CSF cultures revealed gram-positive cocci in pairs. Blood cultures x4 were positive for Streptococcus pneumoniae with sensitivity testing revealing pan-sensitivity including to penicillin. Urine culture was negative. After the sensitivities were obtained, the patient was switched on IV therapy to penicillin-G, with no further need for ceftriaxone, Vancomycin, or ampicillin. The dexamethasone was continued for three days. Although he required intubation for airway protection given his altered mental status, the patient was extubated shortly after admission. He was then able to tolerate dietary support and po intake. His electrolytes remained normal throughout his hospital stay requiring very little repletion. The patient's white count reached the maximum of 21.2, but decreased gradually throughout his hospital stay. He was continued on his outpatient medications. The patient's mental status continued to improve throughout his hospital stay. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE CONDITION: Good. DISCHARGE MEDICATIONS: 1. The patient is to continue all of his outpatient medications. 2. The patient will continue to receive penicillin-G 4 grams IV q4h for a total of two weeks. For this reason, a PICC line will be inserted into the patient prior to discharge, and will be removed when the full antibiotic course is completed. FOLLOWUP: The patient is to followup with his primary care physician as needed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 1595**] MEDQUIST36 D: [**2165-3-5**] 21:52 T: [**2165-3-6**] 08:24 JOB#: [**Job Number 36615**] Admission Date: [**2165-3-1**] Discharge Date:[**2165-3-7**] Date of Birth: [**2101-5-12**] Sex: M Service: ADDENDUM: Two days prior to discharge the patient developed an oral lesion consistent with erythema multiforme likely related to a penicillin reaction. As a result, the patient's penicillin was discontinued. He was switched to intravenous vancomycin one gram intravenous q. 12 hours. He tolerated this without any problems. His oral lesions did not progress, ruling out the possibility of [**Doctor Last Name **]-[**Location (un) **] syndrome development. The patient remained comfortable throughout the rest of his hospital stay. He had no further problems. DISCHARGE INSTRUCTIONS: 1. Continue vancomycin for a total of two weeks with an end date of [**2165-3-19**]. 2. Continue all outpatient medications. 3. Use viscous lidocaine and Vaseline to oral lesions as needed. 4. Follow up with primary care physician on [**3-10**] to assess progress and make sure arrangements are made to have PICC line discontinued. 5. Follow up with neurology on [**2165-4-9**] at 1 PM with Dr. [**Last Name (STitle) 1004**] in the [**Hospital Ward Name 23**] Building. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Last Name (NamePattern1) 1595**] MEDQUIST36 D: [**2165-3-7**] 12:57 T: [**2165-3-7**] 13:07 JOB#: [**Job Number 36674**]

[ "780.09", "320.9", "518.0", "401.9", "695.1", "473.0", "600.0", "380.10", "038.2" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "96.71", "03.31" ]

icd9pcs

[ [ [] ] ]

3677, 3684

3707, 5069

2296, 3655

5093, 5841

1143, 1623

203, 835

1637, 2278

857, 922

939, 1120

13,179

152,164

14154

Discharge summary

report

Admission Date: [**2119-3-17**] Discharge Date: [**2119-3-29**] Date of Birth: [**2067-8-18**] Sex: M Service: CARDIOTHORACIC Allergies: Zestril Attending:[**First Name3 (LF) 1283**] Chief Complaint: Generalized malaise, increased fatigue, adn chest discomfort on [**3-12**]. On [**3-16**] severe chest pain prompting presentation to ED. Major Surgical or Invasive Procedure: sternal wound debridement and bilateral pectoralis major muscle advancement/flaps History of Present Illness: Mr. [**Known lastname 11270**] is a 52 yo male patinet s/p AVR on [**2119-2-20**] with Dr. [**Last Name (STitle) **]. He was discharged home on [**2119-3-1**] after a post-op course complicated by atrial fibrillation. He notes that at hoemon [**3-12**] he noticed increased fatigue, maliase, and sternal pain. On [**3-16**] he awoke with extreme chest pain and was brought to an OSH via ambulance. Workup for PE via chest CT was negative but revealed mediastinal fibrosis and left pleural effusion. Later that day he began draining large amounts of purulent drainage from his sternal icision. He was startedon vancomycin and was transferred to the [**Hospital1 18**] for further management and treatment. Past Medical History: aortic stenosis Type 2 DM HTN s/p L fem bypass [**2095**] s/p MVA with multiple orthopedic injuries nephrolitihiasis Hyperlipidimia Social History: ETOH: socially. Tob: quit 4 years ago. Physical Exam: On presentation: General: male patient in siginificant pain. Neuro: Grossly intact. Pulm: CTAB. Decreased bilateral bases with left greater tahn right. CV: RRR. Abd: soft, non-tender. Extremities: warm. Sternal incision: reddened areas at upper aspect. Small open area draining copious amounts of purulent drainage. Pertinent Results: [**2119-3-23**] 12:15PM BLOOD WBC-10.4 RBC-3.75* Hgb-10.3* Hct-31.9* MCV-85 MCH-27.4 MCHC-32.2 RDW-15.5 Plt Ct-406 [**2119-3-17**] 04:37PM BLOOD Neuts-80.4* Lymphs-9.7* Monos-2.4 Eos-7.2* Baso-0.2 [**2119-3-27**] 05:25AM BLOOD PT-17.2* PTT-28.2 INR(PT)-1.9 [**2119-3-23**] 12:15PM BLOOD Glucose-133* UreaN-8 Creat-0.6 Na-134 K-4.3 Cl-100 HCO3-29 AnGap-9 [**2119-3-24**] 06:38AM BLOOD ALT-31 AST-35 LD(LDH)-292* AlkPhos-105 TotBili-0.4 [**2119-3-22**] 04:01AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.5* Brief Hospital Course: Mr. [**Known lastname 11270**] was transferred in from an OSH facility on [**2119-3-17**]. He was noted to have copious amounts of sternal drainage. A palstic surgery consult was obtained for probable sternal wound debridement adn flap. On [**2119-3-19**] he proceede to teh OR and underwent a sternal wound irrigation and debridement with bilateral pectoral major advancement flaps. Please see op note for full details. He was successfully weened and extubated on the evening of his operative day. On POD two a PICC was placed for long-term abx administration. On POD five he was transferred to the telemetry floor for further management/recovery. He remained on a heparin drip with PO coumadin through POD 6 when his INR reached 2.0 and his heparin was discontinued. PODs six through ten he continued to have one remaining JP drain in place, monitored by plastics. Last JP removed on POD 10. Dr. [**Last Name (STitle) **] to follow anti-coagulation regimen. Medications on Admission: Serax. Vicodin Vancomycin 1 gram IV BID. Ceftazidine 1 gm IV q8h. Glipizide 5 daily. Colace 100 [**Hospital1 **]. Crestor 10 daily. Lopressor 25 [**Hospital1 **]. Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. 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* 7. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 1 months. Disp:*30 Capsule(s)* Refills:*0* 10. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed. Disp:*50 Tablet(s)* Refills:*0* 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 12. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) grams Injection Q4H (every 4 hours) for 6 weeks: LD [**4-29**]. Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: mediastinitis s/p sternal debridement s/p bilateral pectoralis major advancement/flaps s/p AVR(mechanical) [**2119-2-20**] Discharge Condition: good Discharge Instructions: keep your incision clean and dry do not apply creams, lotions, powders, or ointments to your incisions. Wash incisions daily with soap and water. No heavy lifting greater than 10 pounds. No swimming or tub bathing. No driving. Followup Instructions: follow up in plastic surgery clinic in follow up with Dr. [**Last Name (STitle) **] in [**3-3**] weeks follow up with Dr. [**Last Name (STitle) **] in [**3-3**] weeks

[ "272.4", "427.31", "998.59", "401.9", "V43.3", "519.2", "E878.2", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.93", "77.61", "93.59", "99.04", "99.07", "83.82" ]

icd9pcs

[ [ [] ] ]

5060, 5121

2317, 3283

412, 496

5288, 5294

1798, 2294

5570, 5740

3496, 5037

5142, 5267

3309, 3473

5318, 5547

1460, 1779

235, 374

524, 1234

1256, 1389

1405, 1445

62,946

191,485

39315

Discharge summary

report

Admission Date: [**2171-7-17**] Discharge Date: [**2171-7-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: Admitted forcardiac catheterisation Major Surgical or Invasive Procedure: Cardiac catheterization with with Drug eluting stent to the Left Main coronary artery. History of Present Illness: 89 year old female with PMH hyperlipidemia, s/p DES 3.0X 23 mm in distal left main with impella, ostial 80% occluded successfully PTCA and PTCA RCA (90% occluded), who presented from cath lab due to impaired hemostasis at left femoral entry after perclose device deployment. . Following the closure she continued to bleed from her left groin and direct pressure was applied for 45 minutes continuously; after 45 minutes pressure was released and vigorous bleeding continued; pressure was again applied for 1 hour, however bleeding continued after pressure was released. Patient has remained hemodynamically stable with no significant change in her hematocrit. . Prior to this catherization and initially presented with the following symptoms at a total knee placment pre surgical workup. She c/o tightness in her chest and shortness of breath at times which had been going on constantly for approximately 2 months, not better or worse with anything inparticular, including exercise. She states that the pressure sometimes comes on worse in the middle of the night. It radiates to the L shoulder, is not associated with N/V/D. . Upon reaching the floor, patient was comfortable without any acute complaints. C-clamp in place at her left femoral access site. Past Medical History: DJD "Bladder problems", tx'd with pesserie Hypothyroidism Denies heart or lung pbs Hx Scarlet fever as a child . Cardiac Risk Factors: -Diabetes, +Dyslipidemia, -Hypertension . No hx CABG, PCI, Pacemaker/ICD Social History: Pt lives with her daughter. Denies EtOH, tob, drugs. Family History: There is no family history of premature coronary artery disease or sudden death. Both parents and siblings have lived to old age Physical Exam: VS - 98.3 160/70 75 18 98% RA Gen: WDWN middle aged woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits left hematoma where left femoral entry site was. Right femoral entry site intact. Skin: No stasis dermatitis, ulcers, scars, or xanthomas Neuro: CNs [**2-15**] intact, motor funx grossly intact . Pulses: Right: 2+ DP 2+ PT 2+ Left: 2+ DP 2+ PT 2+ Pertinent Results: [**2171-7-22**] 07:15AM BLOOD WBC-5.9 RBC-3.35* Hgb-10.5* Hct-30.4* MCV-91 MCH-31.3 MCHC-34.5 RDW-14.8 Plt Ct-213 [**2171-7-18**] 01:00AM BLOOD WBC-7.9 RBC-3.87* Hgb-12.0 Hct-35.1* MCV-91 MCH-30.9 MCHC-34.1 RDW-13.3 Plt Ct-258 [**2171-7-22**] 07:15AM BLOOD PT-13.2 PTT-43.8* INR(PT)-1.1 [**2171-7-18**] 05:50AM BLOOD PT-13.0 PTT-26.9 INR(PT)-1.1 [**2171-7-22**] 07:15AM BLOOD Glucose-86 UreaN-14 Creat-0.6 Na-136 K-4.4 Cl-104 HCO3-28 AnGap-8 [**2171-7-18**] 01:00AM BLOOD Glucose-99 UreaN-20 Creat-0.8 Na-135 K-4.5 Cl-102 HCO3-26 AnGap-12 [**2171-7-18**] 01:00AM BLOOD CK-MB-5 cTropnT-<0.01 [**2171-7-22**] 07:15AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1 [**2171-7-18**] 01:00AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0 Micro: [**2171-7-19**] 3:33 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2171-7-21**]** MRSA SCREEN (Final [**2171-7-21**]): No MRSA isolated. Radiology: Radiology Report FEMORAL VASCULAR US LEFT PORT Study Date of [**2171-7-20**] 2:31 PM FINDINGS: [**Doctor Last Name **]-scale and Doppler images of the left common femoral vein and artery were obtained. There is normal wall-to-wall flow in the visible vein and artery. A small hypoechoic region anterior to the common femoral artery likely represents the area of the thrombosed pseudoaneurysm. No recurrence is noted. IMPRESSION: No recurrence of left common femoral pseudoaneurysm. ECG [**Last Name (LF) 86936**],[**Known firstname **] E [**Medical Record Number 86937**] F 89 [**2082-1-6**] Cardiology Report ECG Study Date of [**2171-7-20**] 8:45:58 AM Sinus rhythm with baseline artifact. Compared to the previous tracing of [**2171-7-19**] both abnormalities are as previously reported without overall diagnostic change. TRACING #4 Radiology Report UNILAT LOWER EXT VEINS LEFT Study Date of [**2171-7-19**] 10:52 AM FINDINGS: There is an approximately 2 cm left common femoral artery pseudoaneurysm. After discussion with the patient and description of the risks and benefits, the left inguinal area was prepped and draped in a sterile fashion. Under ultrasound guidance, a 20-gauge spinal needle was advanced into the periphery of this patient's pseudoaneurysm after which approximately 500 units of topical thrombin were injected. There was complete thrombosis of the pseudoaneurysm and persistent patency of the underlying common femoral artery and vein. The patient's peripheral exam on the left did not change after thrombin injection. Assessment for lower extremity deep venous thrombosis was also requested. Duplex and color Doppler demonstrated normal augmentation, compressibility and flow involving the common femoral, superficial femoral, popliteal and proximal tibial veins on the left. IMPRESSION: 1. Left common femoral artery pseudoaneurysm successfully treated with 500 units of topical thrombin without complication. 2. No evidence of left lower extremity DVT. Cardiac cath: [**Known lastname 86938**],[**Known firstname **] E [**Medical Record Number 86937**] F 89 [**2082-1-6**] Cardiology Report Cardiac Cath Study Date of [**2171-7-18**] *** Not Signed Out *** BRIEF HISTORY: 89 year old female with prior cardiac work-up in preparation for TKR. Underwent diagnostic cath at [**Hospital1 86939**] revealing 90% distal Lmain disease. Given history of chest discomfort at rest, and comorbidities is forward on for PCI with Impella support. INDICATIONS FOR CATHETERIZATION: Known left main coronary disease. Triple vessel coronary disease. PROCEDURE: Bilateral femoral access was obtained in preparation for percutaneous coronary intervention with Impella device. With assistance of Micropuncture technique, 6F right femoral arterial access, and 8F venous access were obtained. A 5Fr pigtail catheter was inserted through the right femoral arterial access and was positioned in the distal aorta. Power injection aortogram revealed no significant disease of the distal aorta or iliofemoral system on either side. Left femoral access was obtained via micropuncture. It was then preclosed with 2 6Fr perclose devices, and the sheath was upsized to the 13Fr Impella sheath. Access to the left ventricle was obtained via pigtail catheter and J wire. This was then exchanged for the Impella wire. The Impella was prepped and inserted into the LV under fluoroscopic guidance. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 3 hours 35 minutes. Arterial time = 3 hours 15 minutes. Fluoro time = 23 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 165 mls - Midazolam 0.5 mg IV Fentanyl 75 mcg IV Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin ANGIOMAX units IV Other medication: ASA Bivalirudin 163 Complications: Hematoma Cardiac Cath Supplies Used: - [**Doctor Last Name **], PROWATER 300CM - [**Company **], CHOICE PT EXTRA SUPPORT 300CM - [**Company **], CHOICE PT [**Name (NI) **] INTERMEDIATE 300CM 2.5MM [**Company **], MAVERICK 20MM 3.0MM [**Company **], MAVERICK 20MM 6FR CORDIS, XBLAD 3.5 6FR CORDIS, JR 4 SH - [**Doctor Last Name **], PERCLOSE PROGLIDE - ALLEGIANCE, CUSTOM STERILE PACK - MERIT, LEFT HEART KIT - [**Doctor Last Name **], PRIORITY PACK 20/30 3.0MM [**Company **], PROMUS OTW 23MM - ABIOMED, IMPELLA 2.5 [**Hospital1 18**] ATTENDING OF RECORD: [**Last Name (LF) **],[**First Name3 (LF) **] J. REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] S. INVASIVE ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Last Name (LF) **],[**First Name3 (LF) **] S. Brief Hospital Course: This 89-year-old female presented for PCI with DES 3.0X 23 mm in distal left main with impella, ostial 80% occluded successfully PTCA and PTCA RCA (90% occluded). Post-procedure, she was started on aspirin and clopidogrel. Following her successful procedure, she had impaired hemostasis at left femoral entry after perclose device deployment. After the closure she continued to bleed from her left groin and direct pressure was applied for 45 minutes continuously; after 45 minutes pressure was released and vigorous bleeding continued; pressure was again applied for 1 hour, however bleeding continued after pressure was released. By [**7-18**], she dropped her hematocrit from 35.1 on admission to 27.2 and received 1 unit of PRBC. Post procedure there was evidence of a small left hematoma of the left femoral entry site and a left groin ultrasound was ordered to assess for pseudoaneurysm. Ultrasound identified a left common femoral pseudoaneurysm and this was then successfully treated with 500 units of topical thrombin without complication by IR. She then developed delirium which was noticeable mostly at night and at atimes was agitated and required only very rare sedation with very low dose haloperidol. By the morning of [**7-20**] she had pulled out her urinary catheter and was then incontinent but became more oriented. There was no evidence of UTi or other organic cause found for her delirium. She was more oriented by the morning of [**7-20**] and following her blood transfusion, her hematocrit remained stable. Metoprolol was started and tolerated well. A repeat femoral vascular US prior to discharge revealed no re-occurrence of the L femoral artery pseudoaneurysm. She was transferred to the cardiology [**Hospital1 **] on [**7-21**] and her confusion settled. By discharge, she was oriented. Brief hospital course by problem: # Bleeding and pseudoaneurysm at femoral site access: Following successful PTCA, Mrs [**Known lastname **] had prolonged bleeding from her left groin site but which eventually settled following direct pressure. Her HCt dropped from 35.1 on admission to 27.2 and received 1 unit of PRBC and after this her Hb and HCt remained stable. A vascular U/S demonstrated a pseudoaneurysm and this was successfully injected with thrombin by IR. There was no furtehrbleeding and repeat femoral vascular US revealed no re-occurrence of the L femoral artery pseudoaneurysm. Her HCt was stable prior to discharge. . #. CAD: Diagnostic cardiac catheterisation with impella was performed on [**2171-7-16**] demonstrated significant 3-vessel disease with a moderate 60% RCA lesion, tight 99% lesion in RCA, left main with 90% lesion at the bifurcation of L circ and LAD and an 80% lesion in LAD after ostium. She had PCI with DES to LMCA and BMS of LCx. She was continued on aspirin 325mg qd and clopidogrel. Her statin was also changed to Atorvastatin 80mg at night. There were no abnormalities in cardiac markers and she had no chest pain whilst an inpatient. . # Delirium: She developed delirium which was noticeable at night (during the day she was generally lucid). There was no cause found for her confusion and cultures and WBC were unremarkable. Her confusion settled and she was lucid by time of discharge. . # Hypertension: Due initially to low BPs, her amlodipine was held and metoprolol was started. By discharge her BP had settled and he was sent home on metoprolol succinate 50mg qd and amlodipine. . # Hypothyroidism: Levothyroxine was continued. Medications on Admission: 1. Levothyroxine 88 mcg daily 2. Amlodipine 5 mg daily 3. MVI 4. vit B, E 5. vit c 500 mcg 6. vit d 800 units 7. Glucosamine, unknown dose Discharge Medications: 1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. 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* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*3* 8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Glucosamine Oral 11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*3* 12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*3* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Coronary Artery disease Left femoral psuedoaneurysm s/p injection Hypertension Hypothyroidism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a cardiac catheterization with a Impella ventricular assist device and a drug eluting stent was placed in your left main coronary artery. You also had blockages in your right coronary artery and Left anterior descending artery that was opened with a balloon procedure but no stents were placed. After the procedure you had a bleed in your right groin that needed to be injected to stop bleeding. You needed one unit of blood. Now your blood counts are stable. You will need to watch your right groin closely and call Dr. [**Last Name (STitle) 11679**] right away if you have increased bleeding, pain or swelling in this area. No driving for 3 days, no working in your garden until after you see Dr [**Last Name (STitle) 13517**]. . We made the following changes in your medications: 1. Start Plavix 75 mg daily. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr. [**Last Name (STitle) 11679**] tells you to. This is very important to prevent the stent from clotting off and causing a major heart attack. 2. Increase aspirin to 325 mg daily 3. Stop taking vitamin E 4. Start taking Atorvastatin (Lipitor) to prevent further blockages in your arteries. 5. Increase Vitamin D to 1000mg daily 6. Start Metoprolol to prevent a heart attack and slow your heart rate. Followup Instructions: PCP [**Name Initial (PRE) **]:Thursday, [**7-25**] at 10:15am Wilt: [**Name6 (MD) 75760**] [**Last Name (NamePattern4) 86940**],MD Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Apartment Address(1) 86941**], [**Location (un) **],[**Numeric Identifier 32948**] Phone: [**Telephone/Fax (1) 75761**] Cardiology Appointment: [**Last Name (LF) 766**], [**8-5**] at 12:30 Name: [**Doctor Last Name 21976**] A.[**Name8 (MD) 11679**], MD Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**] Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**] Phone: [**Telephone/Fax (1) 26860**]

[ "411.1", "998.11", "401.9", "285.1", "442.3", "428.23", "244.9", "715.96", "293.0", "414.01", "997.2", "272.4", "E879.0" ]

icd9cm

[ [ [] ] ]

[ "36.07", "37.22", "00.41", "88.56", "00.45", "99.29", "00.66", "37.68" ]

icd9pcs

[ [ [] ] ]

13828, 13899

9019, 10843

298, 387

14037, 14037

3062, 6467

15537, 16191

1991, 2121

12708, 13805

13920, 14016

12544, 12685

14190, 15514

2136, 3043

7527, 8996

6500, 7508

223, 260

10872, 12518

415, 1674

14052, 14166

1696, 1905

1921, 1975

42,357

113,129

52401

Discharge summary

report

Admission Date: [**2100-7-14**] Discharge Date: [**2100-7-18**] Date of Birth: [**2055-7-18**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5606**] Chief Complaint: RUQ pain Major Surgical or Invasive Procedure: Central line placement ERCP History of Present Illness: 44yo F w/ PMHx significant for EtOH abuse, pancreatitis, known cholethiasis presented to the ED with 3 days of RUQ pain. This RUQ pain was not relieved with tylenol and motrin. The pain starts in the RUQ and radiates to the midaxillary line or to her back. The pain has been so severe that she has not had an appetite and has not been able to sleep well. When she does eat, she has noticed that there are times when her abdominal pain is worse. She reports nausea and vomitting. She also reports weakness and chills, but denies fevers. She reports diarrhea over the past couple of days as well as dark stools but not melena. She denies hematochezia. She reports defuse itching that started today. . In the ED, initial VS were: T 97.0 P 98 BP 94/58 R 15 O2 sat 100% RA. The patient was started on Unasyn 3mg IV times 1 and given morphine 2mg IV x3, and zofran 4mg IV. Surgery also saw the patient while she was in the ED recommended that the patient have urgent ERCP to relieve CBD obstruction and to have a cholecystectomy once her cholangitis resolves during this hospitalization. Because of persisently low BPs, the patient was bolused for a total of 5L of NS. Despite volume resuscitation, the patient's SBP remained in the 80s. A LIJ was placed in the ED and placement confirmed with CXR. The patient was subsequently started on Levophed at 0.03mcg/kg/min. Of note, vancomycin was also started in the ED and prior to transfer she recieved 1mg IV Dilaudid. . When the patient arrived to the unit, VS were: T 96.5 HR 119 BP 99/65 RR 19 O2 Sat 97% RA. The patient is conversant and able to provide her history. Levophed was set at 0.3mcg/kg/hr. . 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 constipation, . Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Past Medical History: -asthma -h/o seizures Past Surgical History: -Cesarian sectionx2 -s/p tonsillectomy Social History: - Tobacco: 4 Cigarettes/day - Alcohol: Denies use for 2-3 years - Illicits: Denies. Family History: No family history of biliary disease. Mother with HTN, asthma, and arthritis. Physical Exam: ADMITTING PHYSICAL EXAM: General: Alert, oriented, no acute distress HEENT: Sclera icteric. MMM. Oropharynx without erythema or exudate. Neck: Supple. JVP not elevated. no LAD. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardia +. Normal S1 + S2. No murmurs, rubs, gallops. Abdomen: Normal, active BS+. Soft, non-distended. No tenderness to palpation over RUQ. No rebound tenderness or guarding. No organomegaly. No [**Last Name (un) 108289**] sign. GU: Foley in place. Skin: Jaundiced appearance. Ext: WWP. 2+ DPs. No clubbing, cyanosis or pitting edema. Pertinent Results: ADMISSION LABS: [**2100-7-13**] 11:05PM PT-15.6* PTT-27.5 INR(PT)-1.4* [**2100-7-13**] 11:05PM PLT COUNT-309 [**2100-7-13**] 11:05PM NEUTS-89.5* LYMPHS-8.4* MONOS-1.3* EOS-0.5 BASOS-0.3 [**2100-7-13**] 11:05PM WBC-10.6 RBC-3.23* HGB-9.8* HCT-27.9* MCV-86 MCH-30.3 MCHC-35.1* RDW-19.3* [**2100-7-13**] 11:05PM ASA-NEG ACETMNPHN-12 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2100-7-13**] 11:05PM ALBUMIN-3.9 [**2100-7-13**] 11:05PM LIPASE-153* [**2100-7-13**] 11:05PM ALT(SGPT)-462* AST(SGOT)-1703* ALK PHOS-1489* TOT BILI-3.6* [**2100-7-13**] 11:05PM estGFR-Using this [**2100-7-13**] 11:05PM GLUCOSE-151* UREA N-23* CREAT-1.5* SODIUM-134 POTASSIUM-2.5* CHLORIDE-97 TOTAL CO2-18* ANION GAP-22* [**2100-7-13**] 11:12PM LACTATE-2.1* [**2100-7-14**] 01:54AM URINE MUCOUS-RARE [**2100-7-14**] 01:54AM URINE GRANULAR-1* HYALINE-5* CELL-0 [**2100-7-14**] 01:54AM URINE RBC-0 WBC-23* BACTERIA-FEW YEAST-NONE EPI-1 [**2100-7-14**] 01:54AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR [**2100-7-14**] 01:54AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 Urine cultures negative x 2. [**2100-7-14**] CTA Abd W and W/o contrast: IMPRESSION: Decompressed biliary tree following placement of plastic stent. Persistent pancreatic duct dilatation. Ill-defined hypoenhancing area in the pancreatic head is nonspecific and may relate to an area of focal pancreatitis; however, a focal mass lesion cannot be excluded. There are a number of peripancreatic lymph nodes which are enlarged as described above. Normal appearance of the kidneys and adrenal glands. Correlation with outside imaging would be of benefit to evaluate for interval change. A low-attenuation predominantly cystic lesion in the pancreatic tail likely represents a small pseudocyst. The lesion appears to indent the stomach. [**2100-7-16**]: US ABD: IMPRESSION: 1. Heterogeneous liver parenchyma in keeping with fatty infiltration. 2. Patent hepatic vasculature. 3. Satisfactory position of the CBD stent with air in the CBD and left-sided biliary duct system. 4. There is persitent irregular eccentric gall bladder wall thickening measuring 1.4 cm maximally. 5. Pancreatic duct dilatation as described. [**7-16**] CXR: mild lower lobe atelectasis. ERCP Impression: A stricture was seen at the distal common bile duct. A sphincterotomy was performed. Balloon sweep was peformed without extraction of stones or sludge. A 7cm by 10FR Plastic stent biliary stent was placed successfully. A single 2 cm stricture was seen in the distal pancreatic duct CBD and PD stricture most likely secondary to pancreatic mass vs. chronic pancreatitis. Brief Hospital Course: MICU COURSE:44yo F w/ PMHx significant for EtOH abuse, pancreatitis, known cholethiasis presented to the ED with 3 days of RUQ pain and hypotension. #Hypotension: Pressures unresponsive to saline boluses in ED. She had a central line placed in the ED and was started on Levophed in the ED with normotensive pressures in the unit. The patient's hypotension was thought to be multifactorial in etiology in part due to sepsis with her biliary tree being a likely source of infection and poor oral intake in the days prior to admission. On admission, patient had a lactate of 2. She was weaned from pressors as tolerated, with a goal of keeping MAPs >65 and bolusing with NS PRN to maintain CVPs between 8 and 12. Antibiotics were started in the ED and continued through the patient's in the [**Hospital Unit Name 153**]. Since being off pressors, the patient's BPs were maintained without fluid boluses. . #RUQ Pain: RUQ U/S showing dilated pancreatic duct and a heterogeneous pancreas as well as cholelithasis and elevated LFTs were suggestive of an obstructing process. The differential for the patient's RUQ pain upon admission included Pancreatits versus cholecystitis versus ascending cholangitis. She was seen by surgery in the ED who recommended ERCP and cholecystectomy later during the hospitalization. ERCP was performed and showed pancreatic/CBD strictures c/w malignancy vs chronic pancreatitis. The patient also had a biliary stent placed. Given the concern for malignancy, the patient had an abdominal CT done, which showed 2.4x2.0 cm (3a:38) cystic structure arising from the panc tail could reflect pancreatic pseudocyst (given h/o EtOH pancreatitis) vs. cystic pancreatic neoplasm. No definite pancreatic head mass though artifact from CBD stent limits assessment. Panc duct is dilated as on recent ERCP. Irregularity also seen in pancreatic tail (3a:46) of uncertain significance. Fatty liver. Heterogeneous perfusion in the liver is noted with multiple, non mass like sites of early arterial enhancement. Enlarged celiac and portocaval nodes. Gastrosplenic varicies noted. General surgery and pancreaticobiliary surgery service were aware of the patient wanted the patient to be kept NPO and antibiotics continued. They suspected the CBD stricture might be due to chronic pancreatitis, which is more probable due to past and possibly current EtOH intake and pancreatic cyst on CTA. The patient will need repeat ERCP in 6 weeks for stent exchange. . #Transaminitis: AST:ALT ratio >2:1, suggestive of alcholism. Elevated ALP suggests a biliary blockage which is consistent with findings on RUQ U/S. LFTs were trended through her stay in the [**Hospital Unit Name 153**]. ALP and total bilirubin improved after ERCP, but the patient's AST and ALT continued to rise. There was concern that the acutely elevated AST and ALT represented some other hepatic insult beyond those caused by the biliary tree obstruction. Hepatitis serologies and HIV were sent. The results of these studies are pending upon discharge from [**Hospital Unit Name 153**]. . #[**Last Name (un) **]: On admission, patient's sCr 1.5, baseline unknown. [**Last Name (un) **] thought to be most likely prerenal, secondary to sepsis and poor po intake given patient's 3-day h/o abdominal pain. With IVFs the patient's sCr improved to <1.0. . #Anion-gap Metabolic acidosis: Patient initially presented with an anion gap of 19, with elevated lactate 2.1. Patient's hypotension may have led to organ ischemia is suggestive by elevated sCr. Elevated lactate may be due in part to patient's underlying h/o EtOH abuse [**1-27**] impaired hepatic gluconeogensis. Anion gap was followed and resolved. Lactate normalized in the [**Hospital Unit Name 153**]. . #UTI: On admission, there was concern for UTI given the results of UA. Urine culture was drawn and was pending when patient left the [**Hospital Unit Name 153**]. Patient was on Unasyn, s/p 1 dose vancomycin in ED. . #Anemia: Microcytic w/ MCV 86, suggestive of fe deficiency anemia versus anemia of chronic disease. . #Asthma: Home albuterol and fluticasone were continued through her admission in the [**Hospital Unit Name 153**]. . #Alcohol history: Patient with a known history of EtOH abuse. No level drawn in ED and there were no signs of intoxication when the patient was admitted during her stay in the [**Hospital Unit Name 153**]. Patient was monitored for signs of withdrawal. She did not need to be placed on CIWA scale while in the [**Hospital Unit Name 153**]. Floor course: The patient was trasnferred to the floor on [**7-16**]. Her abdominal pain improved and her transaminitis improved. IV narcotics were discontinued and her pain was treated with oxycodone. Her diet was advanced. A liver consult was obtained for her transaminitis. They recommended checking [**First Name8 (NamePattern2) **] [**Doctor First Name **], [**Last Name (un) 15412**] antibody ceruloplasmin and immunoglobulins for other causes of acute heptatitis which are pending. Hepatitis serologies for Hep A, B, and C were negative. HIV was also negative. Repeat US showed satisfactory position of the CBD stent as well as patent hepatic vasculature. She was counseled extensively by me as well as gastroenterology about the need to follow up for repeat imaging for further eval of a pancreatic mass vs chronic pancreatitis. She understands that she should also follow up in the liver clinic. She will follow up with her PCP and will also need further evaluation of cholecystectomy as an outpatient. (Dr. [**First Name (STitle) **] from surgery saw her during her hospital course.) She was transitioned from Unasyn to Augmentin at discharge to complete a week of antibiotic coverage. Blood and urine cultures all showed no growth. She was discharged in stable condition with follow up. Medications on Admission: Albuterol inhaler Flovent 2 puffs inh [**Hospital1 **] Discharge Medications: 1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. oxycodone 5 mg Capsule Sig: [**12-27**] Capsules PO every four (4) hours as needed for pain. Disp:*30 Capsule(s)* Refills:*0* 3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*5 Tablet(s)* Refills:*0* 4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-27**] Inhalation every four (4) hours as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: cholangitis Discharge Condition: stable, tolerating regular diet, normal mental status, ambulating Discharge Instructions: You were treated for cholangitis. You underwent ERCP. We are concerned that you may have a pancreatic mass vs chronic pancreatitis causing strictures. You must follow up with Dr. [**Last Name (STitle) **] for stent replacement and for further imaging. You should also follow up in the liver clinic as you had evidence of significant liver injury. You should also follow up with your PCP this week as well. You should also take the antibiotics as prescribed. Followup Instructions: You should call your PCP to schedule an appointment this week. You should also call the liver clinic tomorrow morning (MONDAY, [**7-19**]) to schedule an appointment. Their phone number is [**Telephone/Fax (1) 2422**]. The following appointments were already scheduled for you. Department: GASTROENTEROLOGY When: WEDNESDAY [**2100-8-4**] at 10:00 AM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], 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: ENDO SUITES When: THURSDAY [**2100-9-2**] at 9:00 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2100-9-2**] at 9:00 AM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "51.87", "51.85", "38.93" ]

icd9pcs

[ [ [] ] ]

12526, 12532

6097, 11910

313, 342

12587, 12655

3371, 3371

13166, 14256

2667, 2746

12015, 12503

12553, 12566

11936, 11992

12679, 13143

2505, 2546

2786, 3352

2037, 2415

265, 275

370, 2018

3388, 6074

2459, 2482

2562, 2651

6,368

109,726

11653

Discharge summary

report

Admission Date: [**2175-5-4**] Discharge Date: [**2175-5-9**] Date of Birth: [**2114-11-30**] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who had non-Q-wave myocardial infarction on [**2174-8-7**] treated with PTCA stent to MLAD, DLAD, and PRCA and MRCA. The patient underwent a follow-up study in [**2175-1-7**] which showed apical and septal ischemia. Cardiac catheterization showed ISR treated by PTCA/brachy therapy of mid and distal left anterior descending stents, PRCA stent and PTCA stent to PRCA. The patient presented with recurrent exertional chest tightness for the past three weeks. PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia. Anxiety disorder. Coronary artery disease. Status post multiple PTCA and stent placement. MEDICATIONS ON ADMISSION: Altace 10 mg p.o. q.d., Lopressor 12.5 p.o. b.i.d., Klonopin 1 q.d., Lipitor 20 q.d., .................., Aspirin, fish oil, Prozac 40 mg p.o. q.d., Trazodone 1 tab p.o. q.h.s., Plavix 75 mg p.o. q.d., Imdur 30 mg p.o. q.d. ALLERGIES: NO KNOWN DRUG ALLERGIES. PHYSICAL EXAMINATION: General: The patient was a well-developed, well-nourished male in no apparent distress. HEENT: Cranial nerves II-XII intact. No evidence of scleral icterus. Moist mucous membranes. No evidence of oral ulcers. Chest: Clear to auscultation bilaterally. Sternal incision site with no evidence of erythema, with good healing. Cardiovascular: Regular, rate and rhythm. No1 murmurs. Abdomen: Soft, nontender, nondistended. No evidence of guarding or rebound. LABORATORY DATA: CBC on [**2175-5-8**], was with a white count of 7.2, hematocrit 27, platelet count 257. HOSPITAL COURSE: The patient is a 59-year-old male status post non-Q-wave myocardial infarction in [**2174-8-7**] with history of multiple PTCA and stents presenting with recurrence of exertional chest tightness times three weeks. The patient underwent an uncomplicated coronary artery bypass grafting times four (LIMA to left anterior descending, saphenous vein graft to distal right coronary artery, saphenous vein graft to posterolateral OM, sequential). Postoperatively the patient was taken to the CSRU for close observation. After being extubated, the patient maintained good oxygenation on 2 L nasal cannula which was ultimately weaned off. By postoperative day #3, chest tube, Foley and pacing wires were all removed. At this time, the patient was transferred to the floor at which point the patient was tolerating a regular diet, making good urine output, and maintaining good pressure with good oxygen saturation. Because the patient achieved level 5 Physical Therapy goal which involves being able to climb stairs, the decision was made to discharge the patient on postoperative day #5 in good condition. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Status post coronary artery bypass grafting times four. DISCHARGE MEDICATIONS: Prozac 40 mg p.o. q.d., Trazodone 25 mg p.o. q.h.s. p.r.n. insomnia, Clopidogrel 75 mg p.o. q.d., Oxazepam 15-30 mg p.o. q.h.s. p.r.n. insomnia, Milk of Magnesia 30 cc p.o. q.h.s. p.r.n. constipation, Percocet [**12-8**] tab p.o. q.4 hours p.r.n. pain, Aspirin 325 mg p.o. q.d., Ranitidine 150 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., Furosemide 40 mg p.o. b.i.d., Potassium 20 mEq p.o. b.i.d., Metoprolol 25 mg p.o. b.i.d. FOLLOW-UP: The patient was instructed to follow-up with Dr. [**Last Name (STitle) 1537**] in [**9-19**] days. The patient was also instructed to follow-up with Dr. [**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) **] in [**9-19**] days. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Name6 (MD) 36940**] MEDQUIST36 D: [**2175-5-8**] 11:05 T: [**2175-5-8**] 11:07 JOB#: [**Job Number 36941**]

[ "412", "401.9", "411.1", "414.01", "272.0", "300.00", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "88.42", "88.72", "36.13", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

3008, 3957

2927, 2984

859, 1122

1738, 2844

1145, 1720

183, 679

702, 832

2869, 2905

51,761

116,252

49612

Discharge summary

report

Admission Date: [**2163-8-18**] Discharge Date: [**2163-8-23**] Date of Birth: [**2085-4-19**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / hayfever Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dypnea on exertion Major Surgical or Invasive Procedure: [**2163-8-18**] Aortic valve replacement, Coronary artery bypass graft x 1 (saphenous vein graft to posterior descending artery) History of Present Illness: 78 year old male who has been followed with serial echocardiograms for aortic stenosis for several years. He continues to work full-time and walks several miles several days per week. In addition he continues to lift weights, do push-up and pull-ups, and play softball three time per week. However he has noticed more shortness of breath this year than past, particulary early in exercise. He underwent a echocardiogram in [**Month (only) 116**] which revealed worsening aortic stenosis, now severe ([**Location (un) 109**] 0.9cm2, pk/mn 81/53), and he was referred for surgical evaluation. Past Medical History: Aortic Stenosis Hypertension Heart murmur Duodenal ulcer 50 years ago Anemia in the distant past RBBB Past Surgical History s/p Appendectomy approximately 65 years ago s/p Tonsillectomy s/p Bilateral Cataract surgery Social History: Race: Caucasian Last Dental Exam: Less than 6 months ago Lives alone Occupation: Lawyer Cigarettes: Smoked no [] yes [X] no cigarette hx Other Tobacco use: Pipes/Cigars ETOH: < 1 drink/week [X] [**1-17**] drinks/week [] >8 drinks/week [] Illicit drug use: denies Family History: non-contributory Physical Exam: Pulse:70 Resp:16 O2 sat:99/RA B/P Right:173/84 Left:169/76 Height: 5'[**61**]" Weight: 200 lbs General: Well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur [X] grade 3/6 systolic Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema/Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: Transmitted murmur Pertinent Results: [**2163-8-22**] 06:05AM BLOOD WBC-13.7* RBC-3.27* Hgb-9.6* Hct-25.8* MCV-79* MCH-29.4 MCHC-37.4* RDW-15.2 Plt Ct-107* [**2163-8-18**] 12:47PM BLOOD PT-15.7* PTT-36.3* INR(PT)-1.4* [**2163-8-21**] 04:40AM BLOOD Glucose-110* UreaN-23* Creat-0.9 Na-134 K-3.6 Cl-101 [**2163-8-18**] 12:47PM BLOOD UreaN-19 Creat-1.0 Na-140 K-4.3 Cl-113* HCO3-21* AnGap-10 [**2163-8-23**] 06:10AM BLOOD WBC-13.2* RBC-3.37* Hgb-10.2* Hct-26.9* MCV-80* MCH-30.2 MCHC-37.8* RDW-15.0 Plt Ct-154 [**2163-8-22**] 06:05AM BLOOD WBC-13.7* RBC-3.27* Hgb-9.6* Hct-25.8* MCV-79* MCH-29.4 MCHC-37.4* RDW-15.2 Plt Ct-107* [**2163-8-23**] 06:10AM BLOOD Glucose-107* UreaN-16 Creat-0.9 Na-136 K-4.0 Cl-100 HCO3-26 AnGap-14 [**2163-8-22**] 10:44AM BLOOD Na-135 K-3.7 Cl-101 [**2163-8-21**] 04:40AM BLOOD Glucose-110* UreaN-23* Creat-0.9 Na-134 K-3.6 Cl-101 [**2163-8-23**] 06:10AM BLOOD PT-15.2* PTT-25.3 INR(PT)-1.3* [**2163-8-22**] 10:44AM BLOOD PT-14.3* INR(PT)-1.2* Brief Hospital Course: Mr. [**Known lastname **] was a same day admit and underwent an aortic valve replacement and coronary artery bypass graft x 1 (#23mm St.[**Male First Name (un) 923**] porcine valve/ Saphenous vein grafted to distal RCA). Cardiopulmonary Bypass Grafting= 94 minutes, Cross Clamp time=74 minutes. Please see operative report for surgical details. Following surgery he was transferred to the CVICU intubated and sedated in critical but stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated without incident. He weaned off pressors and was started on beta-blocker/statin/aspirin and diuresis. Later this day he was transferred to the step-down floor for further recovery. Chest tubes and epicardial pacing wires were removed per protocol. Physical Therapy was consulted for evaluation of strength and mobility. Postoperatively his rhythm was sinus tachycardia that responded minimally to increased beta-blockers. He was placed on Diltiazem for increased rate control. POD#2 his rhythm went into rate controlled Atrial Fibrillation. Medication dosages were increased. Amiodarone was added, Lopressor was titrated up, Diltiazem was discontinued and an ACE-I was added and titrated up for better rate and blood pressure control. For the remainder of his hospital course he had paroxysmal AFib. Anticoagulation was initiated and he was given Coumadin 2.5 mg on [**8-22**] and [**8-23**]. On POD 5 night he had an episode of acute confusion after receiving Ativan for insomnia. He cleared from a mental status stand point the following day and all narcotics and benzodiazepine medications were discontinued. He continued to progress and was cleared for discharge to brother's house with visiting nurse services on POD 5. His Coumadin will initially be followed by the cardiac surgery service and then subsequently by [**Hospital6 733**] Anticoagulation Management Services - referral form faxed. All follow up appointments were advised. Medications on Admission: Lisinopril 20mg daily Norvasc 5mg daily Simvastatin 10mg daily Aspirin 81mg daily Levitra 10mg prn Coenzyme q10 [**Hospital1 **] Omega 3 Fish oil daily Ativan prn Multivitamin daily Vitamin D daily Calcium supplement 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. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:140 Tablet(s)* Refills:*0* 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): x 1 week then 200 mg [**Hospital1 **] x 1 week then 200 mg daily x 1 month then as directed by cardiologist. Disp:*75 Tablet(s)* Refills:*0* 7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Take 2.5 mg on [**8-23**] then as directed for INR goal 2.0-3.0. Disp:*60 Tablet(s)* Refills:*0* 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed 4 gm/ day. 9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: tbd Discharge Diagnosis: Aortic stenosis/coronary artery bypass graft x 1 s/p aortic valve replacement and coronary artery bypass graft x 1 Past medical history: Hypertension Heart murmur Duodenal ulcer 50 years ago Anemia in the distant past RBBB s/p Appendectomy approximately 65 years ago s/p Tonsillectomy s/p Bilateral Cataract surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema 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) **] #[**Telephone/Fax (1) 170**] on [**9-21**] at 1:15pm Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] - office to call you with future appointment Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-15**] 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** Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2.0-3.0 First draw [**2163-8-24**] Results to [**Telephone/Fax (1) 170**] cardiac surgery service to follow until patient set up with [**Hospital6 733**] Anticoagulation Management Services - referral form faxed Completed by:[**2163-8-23**]

[ "287.5", "E939.4", "424.1", "780.52", "285.9", "300.00", "414.01", "292.81", "427.31", "786.8", "401.9", "458.29", "427.32" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6750, 6780

3303, 5286

308, 439

7140, 7366

2347, 3280

8289, 9189

1595, 1613

5553, 6727

6801, 6917

5312, 5530

7390, 8266

1628, 2328

250, 270

467, 1059

6939, 7119

1315, 1579

13,329

107,862

51446

Discharge summary

report

Admission Date: [**2188-1-30**] Discharge Date: [**2188-2-13**] Date of Birth: [**2112-8-23**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Neurontin Attending:[**First Name3 (LF) 5037**] Chief Complaint: Ventral hernia, incisional hernia Major Surgical or Invasive Procedure: [**2188-1-30**] Laparoscopic Ventral hernia repair History of Present Illness: Ms [**Known lastname 106665**] is a 75 year-old female with ESRD s/p LRRT in [**2180**], dCHF, and incisional hernia s/p previous repairs with recurrence. She continues to have pain at the hernia site with pressure or movement. She has also had some RLQ pain which radiates to her groin. Otherwise she has been doing well with just an occasional cough. Kidney function has been stable Past Medical History: ESRD s/p transplant ([**2180**]) CAD Diastolic CHF HTN COPD Chronic aortic dissection GERD moderate pulm HTN PSH: s/p TAH/BSO s/p appy s/p ventral hernia repair [**3-30**] Social History: Lives at home alone, but occasionally after hospitalizations has stayed with her daughter/granddauthger. Currently has VNA s/p recent hospitalization. Previously worked as a nurses aid. -Tobacco history: +smokes [**2-29**] cigarettes a day -ETOH: Endorses minimal EtoH use -Illicit drugs: Denies Family History: monther with MI at 68, father with MI at 70 Physical Exam: Gen: Elderly femle, minimal resp distress Vitals: 150-160/70-80, RR 16-18, afebrile, 100% on face tent HEENT: pallor present, no icterus NEck: Supple, no LAD Chest: Rales b/l bases CVS: S1S2 rrr, no r/m/g Abd: S, obese, mild to moderate tenderness with palpation, abd banding present Ext: 1 plus edema b/l LE Pertinent Results: Admission Labs: [**2188-1-30**] 04:43PM BLOOD WBC-11.0 RBC-3.34* Hgb-10.1* Hct-30.3* MCV-91 MCH-30.2 MCHC-33.3 RDW-16.9* Plt Ct-226 [**2188-1-30**] 04:43PM BLOOD Glucose-101* UreaN-54* Creat-2.3* Na-133 K-5.6* Cl-101 HCO3-22 AnGap-16 [**2188-1-30**] 04:43PM BLOOD Calcium-9.1 Phos-4.9* Mg-1.5* Discharge Labs: [**2188-2-11**] 05:20AM BLOOD WBC-12.5* RBC-3.51* Hgb-11.5* Hct-32.4* MCV-92 MCH-32.7*# MCHC-35.4*# RDW-16.2* Plt Ct-385 [**2188-2-11**] 05:20AM BLOOD Glucose-127* UreaN-64* Creat-2.3* Na-132* K-5.4* Cl-98 HCO3-25 AnGap-14 [**2188-2-11**] 05:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8 URINE STUDIES: [**2188-2-8**] 07:55PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011 [**2188-2-8**] 07:55PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2188-2-8**] 07:55PM URINE RBC-3* WBC->182* Bacteri-MANY Yeast-NONE Epi-3 RenalEp-<1 [**2188-2-8**] 07:55PM URINE WBC Clm-FEW Mucous-RARE [**2188-2-8**] 07:55PM URINE Eos-POSITIVE MICRO: [**2188-2-4**] 2:06 am STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2188-2-4**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2188-2-4**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2188-2-4**] 11:25AM. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). [**2188-2-8**] 7:55 pm URINE Source: CVS. **FINAL REPORT [**2188-2-10**]** URINE CULTURE (Final [**2188-2-10**]): SERRATIA MARCESCENS. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 128 R TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S IMAGING: CT ABDOMEN/PELVIS [**2188-2-2**]: The included portions of the lung bases demonstrate small bilateral pleural effusions, left greater than right with associated atelectasis. There are dense calcifications of the aorta extending throughout the intra-abdominal aorta to the iliac arteries. Within the abdomen and pelvis, the patient is status post repair of an anterior abdominal wall hernia. There is post-operative subcutaneous emphysema and fat stranding. A more focal 5.4 x 3.7 cm collection with air-fluid level is present in the anterior left lower subcutaneous tissues (2:40). No focal liver lesion is seen. There may be some intrahepatic biliary dilation, though evaluation is limited on this non-contrast examination. Additionally, the CBD appears prominent measuring approximately 9 mm in diameter. The gallbladder appears unremarkable. The spleen appears unchanged with coarse calcification. The native kidneys are atrophic with hypodensities consistent with cysts. Loops of small and large bowel are normal in size and caliber. A trace amount of free fluid is present within the pelvis; however, no large collection to explain hematocrit drop is seen. No hematoma is identified. There is a transplant kidney in the left lower quadrant. The bladder contains a Foley catheter. Multiple foci of subcutaneous emphysema are seen. A locule of air along the anterior abdominal wall (2:51), could be within the abdomen, though would not be unexpected given the recent surgery. There is diffuse anasarca. No concerning osseous lesion is seen. IMPRESSION: 1. Postoperative changes (mesh placement) with subcutaneous emphysema and edema within the subcutaneous tissues of the anterior abdominal wall, bilaterally. A focal subcutaneous fluid collection with air fluid level measuring 5.4 x 3.7 cm may represent a postoperative seroma; however, the presence of infection cannot be excluded by CT. 2. No evidence of hematoma or collection to explain hematocrit drop. 3. Mild intrahepatic biliary dilation. Mildly dilated CBD, though not significantly changed from prior examinations. If there is clinical concern, a right upper quadrant ultrasound may be performed. 4. Small bilateral pleural effusions, left greater than right. 5. Atrophy native kidneys with cysts; transplant kidney in left iliac fossa. TRANSPLANTED KIDNEY U/S [**2188-2-8**]: The renal transplant is located in the left lower quadrant and measures 10.7 cm. No hydronephrosis, stones, or masses are observed. No perinephric fluid collection is seen. The urinary bladder appearance is normal. COLOR DOPPLER AND SPECTRAL WAVEFORM ANALYSIS: The MRV is patent showing the normal flow direction. The MRA is patent with normal peak systolic velocity. The upper, mid, and lower pole of the renal arteries are patent, showing RIs in the range of 0.78 to 0.83 that are minimally higher in comparison to prior examination ( RI's in the range of 0.75-0.8). IMPRESSION: 1. No evidence of hydronephrosis or perinephric fluid collection in the transplanted kidney. 2. Patent kidney vasculture. 3. Minimal interval increase in the RIs of the intrarenal arteries. Brief Hospital Course: Primary Reason for Hospitalization: 75yoF admitted for elective laparoscopic ventral hernia repair with mesh Active Issues: # Ventral Hernia Repair c/b acute on chronic diastolic heart failure, c diff infection: Pt had laparoscopic ventral hernia repair on [**2188-1-30**] by Dr. [**First Name (STitle) **]. She tolerated the procedure well and was transferred to the PACU in stable condition. She has had some abdominal pain since the procedure in the area of her hernia repair. She had a repeat CT abdomen which showed no evidence of abscess or other post-surgical complications. The surgical service felt her pain did not warrant further surgical intervention, and her pain was controlled with PO oxycodone. If her pain is not well controlled on oxycodone at rehab hospital would favor trial of PO dilaudid. # Acute on chronic diastolic heart failure: She did well until [**2-1**] when her urine output decreased to 10-15cc/hr. She received IV fluids (total 3L NS), and the following morning was noted to be in respiratory distress requiring O2 via NRB and hypertensive to 200/100. CXR showed pulmonary edema, and ABG showed metabolic and resp acidosis. She was transferred to TSICU for respiratory support, was never intubated. She was diuresed with IV lasix and started on nitro gtt for BP control, and she was weaned to room air. TTE was consistent with moderate diastolic dysfunction. She was called out to the floor on [**2-4**], breathing comfortably on room air. # Acute on chronic kidney disease: On POD#10 her creat increased to 2.7 (baseline 2.2-2.4). She was transferred to the medical service (transplant nephrology) for further evaluation. This was felt most likely [**12-27**] diuresis since her urine output decrease and urine lytes were consistent with pre-renal etiology. Diuresis was held for a day and then resumed at her home dose lasix 40mg PO daily. Her creat downtrended and was 2.0 on discharge. She was noted to have persistent mild elevation in potassium (5.0-6.0), and was started on Kayexalate 15gm qMon and Thurs. She should have repeat potassium level checked 2 days after discharge. # Acute on chronic anemia: Pt sustained acute decrease in Hct from 28.9 on [**2-1**] to 22.9 on [**2-2**]. CT abdomen/pelvis showed no evidence of bleed. She received 2 units pRBCs and her Hct responded appropriately and was stable for the remainder of her hospitalization. Most likely the acute decrease was dilutional in setting of receiving 3L fluid the previous night. # C diff infection: Her course was complicated by c diff infection, was initially treated with PO flagyl but this caused nausea/vomiting and she was switched to PO vancomycin. She should continue PO vancomycin until [**2188-3-3**] (2 weeks after her course of cefpodoxime is completed). # Serratia UTI: Pt developed dysuria and urine cultures from [**2-8**] grew Serratia Marcescens which was sensitive to cephalosporins. She was started on PO cefpodoxime, and she should complete 10 day course (will be completed on [**2-18**]). # HTN: Pt had hypertensive urgency on day of transfer to TSICU with BP 200/100. Her BP improved on nitro gtt but remained elevated after her home meds were resumed. Her labetolol was increased to 200mg PO daily, and her amlodipine was switched to Nifedipine CR 30mg daily. She was continued on her home Imdur 30mg daily. Her BP was well controlled on this regimen at time of discharge. Chronic Issues # CAD: Continued home ASA. # GERD: Continued home omeprazole. Transitional Issues: -Medication changes: STARTED cefpodoxime for UTI, PO vancomycin for c diff infection, tylenol and oxycodone for pain, kayexolate for high potassium, sodium bicarb tablets, CHANGED labetolol to 200mg PO BID, switched amlodipine to nifedipine CR. -If abdominal pain not well controlled by oxycodone would recommend trial of PO dilaudid for better pain control. -She has f/u appts scheduled in transplant surgery and renal transplant clinics. -She should have repeat potassium level checked on [**2188-2-15**], and repeat creatinine level checked within the next week. -She maintained full code status throughout hospitalization. Medications on Admission: Albuterol alendronate 35 mg qweek amlodipine 2.5 mg po daily azathioprine 50 mg po daily calcitriol 0.25 mcg po daily Sensipar 30 mg po daily citalopram 10 mg po daily Aranesp monthly injection Lasix 40 mg po daily Isordil 30 mg po daily labetalol 100 mg po bid nitroglycerin SL prn omeprazole 20 mg po daily Prograf 5 mg po bid aspirin 81 mg po daily multivitamins iron Discharge Medications: 1. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. azathioprine 50 mg Tablet Sig: One (1) Tablet PO once a day. 7. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 10. 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. 11. alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 12. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Aranesp (polysorbate) 150 mcg/0.3 mL Syringe Sig: One (1) injection Injection once a month. 14. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day. 15. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 16. Kayexalate Powder Sig: Fifteen (15) gm PO On Monday and Thursday. 17. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 18. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 19. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 20. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 19 days: Last day [**2188-3-3**]. 21. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 22. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: Take until [**2-18**]. 23. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 24. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual q5min as needed for chest pain: Use q5min for 3 doses prn chest pain. 26. multivitamin Tablet Sig: One (1) Tablet PO once a day. 27. ferrous gluconate 324 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Roscommon on the Parkway - [**Location 1268**] Discharge Diagnosis: Ventral Hernia repair C.diff infection Acute on chronic diastolic heart failure Urinary tract infection S/p renal transplant Acute on chronic kidney failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 106665**], You were admitted to [**Hospital1 18**] for elective hernia repair. While here, you developed difficulty breathing due to fluid in your lungs and required observation in the ICU for a short period of time. You improved with IV lasix. You also developed an infection in your colon and a urinary tract infection which are being treated with antibiotics. Please note the following changes to your medications: -START cefpodoxime to treat urinary tract infection -START oral vancomycin to treat the infection in your colon -START nifedipine for blood pressure and STOP amlodipine -START tylenol and oxycodone for pain -START kayexalate for high potassium -START sodium bicarb tablets -INCREASE labetolol to 200mg twice daily We made no other changes to your medications while you were in the hospital. Please continue taking the rest of your medications as prescribed by your outpatient providers. Please call the transplant office [**Telephone/Fax (1) 673**] if you develop any of the following: temperature of 101 or greater, chills, nausea, vomiting, Increased abdominal pain, abdominal distension, incision redness/bleeding/ drainage or worsening diarrhea. Please see below for your currently scheduled appointments at [**Hospital1 18**]. It has been a pleasure taking care of you and we wish you a speedy recovery. Followup Instructions: You are scheduled for the following appointments at [**Hospital1 18**]: Department: TRANSPLANT CENTER When: MONDAY [**2188-2-25**] at 8:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: FRIDAY [**2188-2-29**] at 8:40 AM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**2188-3-31**] 10:00a BRAIN,[**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] [**Name8 (MD) 191**] [**Hospital **] CLINIC [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

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icd9cm

[ [ [] ] ]

[ "53.62", "38.91" ]

icd9pcs

[ [ [] ] ]

14768, 14841

7678, 7788

321, 374

15042, 15042

1710, 1710

16596, 17572

1319, 1365

12268, 14745

14862, 15021

11873, 12245

15208, 15629

2021, 7655

1380, 1691

11219, 11220

15658, 16573

11240, 11847

248, 283

7804, 11198

402, 791

1726, 2005

15057, 15184

813, 988

1004, 1303

17,260

136,587

1738

Discharge summary

report

Admission Date: [**2111-7-21**] Discharge Date: [**2111-7-26**] Service: MEDICINE Allergies: Penicillins / Plavix Attending:[**First Name3 (LF) 898**] Chief Complaint: fever, fatigue Major Surgical or Invasive Procedure: none History of Present Illness: 81yo man with CAD, CRI, DM, hyperlipidemia and h/o NSVT s/p AICD placement initially presented on [**2111-7-21**] with four days of non-specific weakness, chills, fatigue without any localizing symptoms. He specifically denied any fever, headache, meningeal symptoms, dyspnea or cough. He denied any chest pain. He has no new abdominal complaints. He had no dysuria. He denies any new skin rashes or lesions. . He was found to have a RML infiltrate on AP chest film, and was started in the ED on ceftriaxone, azithromycin, and vancomycin. As the suspicion for MRSA was low, and he has a history of penicillin allergy, this regimen was tapered down to monotherapy with levaquin. He initially was in no distress and saturating well on 2l nasal canula, but then decompensated on the floor: He developed acute onset of cough, dyspnea, and desaturated down to the 70's% and only returned to low 90's% on 100% non-rebreather. His ABG showed 7.32/44/66. He was treated with lasix 20mg IV, morphine 2mg IV, NTG, as well as albuterol nebulizer treatments. Stat EKG was unchanged, and stat chest film demonstrated again this infiltrate. . He was admitted to the MICU for hypoxic respiratory failure and for consideration of non-invasive mask ventilation. He is DNR/DNI, but was willing to try non-invasive. . During his MICU course, he was continued on levaquin for empiric CAP coverage. Vancomycin was not started. His supplemental oxygen was weaned down to 2L nc. He had no further events. He had a swallowing study with no evidence of aspiration. He was cleared by PT to go home with VNA services. Urine Legionella Ag negative. Blood cultures pending. Past Medical History: PMH: 1)CAD s/p MIx2, s/p RCA stent '[**04**], CHF - EF unknown 2)h/o NSVT s/p ICD/pacer [**10-22**] 3)s/p TIAs 4)DM 5)hypercholesterolemia 6)chronic renal insufficiency (baseline Cr 1.9) 7)spinal stenosis and radiculopathy 8)hypothyroid 9)irritable bowel syndrome 10)prostate CA s/p TURP '[**85**] and radiation proctitis 11)s/p cataract surgery R eye 12)BPH 13)B12 deficiency 14)diverticulosis 15)hemorrhoids . Social History: Lives in [**Hospital3 **] with wife, retired businessman, former cigar smoker > 10y ago, occasional EtOH Family History: +CAD Physical Exam: 97.8, 66, 103/44, 23, 97% on 2L nc . I/O (24h 1220/1375) gen a/o, mildly acute distress heent + oral thrush, no erythema/exudates neck no cervical lymphadenopathy cv RRR, no m/r/g resp coarse breath sounds/rhonchi throughout; no focal findings abd obese, soft, NT, NABS extr trace bilateral peripheral edema; mild stasis changes. Ecchymoses at left toes (traumatic) Pertinent Results: [**2111-7-21**] 09:04PM TYPE-ART PO2-66* PCO2-42 PH-7.32* TOTAL CO2-23 BASE XS--4 [**2111-7-21**] 01:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2111-7-21**] 01:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2111-7-21**] 01:35PM URINE RBC-[**1-24**]* WBC-[**1-24**] BACTERIA-MANY YEAST-NONE EPI-[**5-1**] [**2111-7-21**] 01:35PM URINE GRANULAR-[**5-1**] COARSE GRANULAR CASTS* [**2111-7-21**] 01:35PM URINE AMORPH-MOD [**2111-7-21**] 11:30AM GLUCOSE-111* UREA N-40* CREAT-1.9* SODIUM-138 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-21* ANION GAP-20 [**2111-7-21**] 11:30AM CK(CPK)-1041* [**2111-7-21**] 11:30AM CK-MB-7 cTropnT-0.03* [**2111-7-21**] 11:20AM ALT(SGPT)-38 AST(SGOT)-63* ALK PHOS-50 AMYLASE-95 TOT BILI-0.7 [**2111-7-21**] 11:20AM WBC-12.3*# RBC-3.74* HGB-11.7* HCT-34.9* MCV-93 MCH-31.4 MCHC-33.6 RDW-14.3 [**2111-7-21**] 11:20AM NEUTS-85.5* BANDS-0 LYMPHS-9.3* MONOS-4.3 EOS-0.8 BASOS-0.1 [**2111-7-21**] 11:20AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2111-7-21**] 11:20AM PLT SMR-NORMAL PLT COUNT-186 [**2111-7-21**] 11:20AM PT-13.2 PTT-24.1 INR(PT)-1.2 Brief Hospital Course: 81yo man with multiple medical issues presented from his ALF with non-specific complaints and was found to have a R sided pneumonia. 1. Pneumonia Initially started on ceftriaxone, azithromycin, and vancomycin. Then changed to levaquin. He initially did well, but on night of admission had acute hypoxic respiratory failure. He went to the MICU for consideration of non-invasive mask ventilation. He did not require this, adn was eventually weaned to 2L nc. He continued on levaquin and remained afebrile and clinically stable. He will complete a 10 day course of levaquin for his pneumonia. By time of d/c, he was saturating 95% on room air. He will not require home oxygen. . He was cleared by PT to go to home with VNA, services. He will f/u with his PCP. Medications on Admission: Admission medications: 1. Aspirin 81 mg 2. Gabapentin 300 mg [**Hospital1 **] 3. Rosiglitazone Maleate 8 mg qD 4. Folic Acid 1 mg 5. Carvedilol 6.25mg [**Hospital1 **] 6. Dipyridamole-Aspirin 200-25 mg [**Hospital1 **] 7. Multivitamin qD 8. Pantoprazole Sodium 40 mg 9. Ezetimibe 10 mg 10. Simvastatin 80mg qD 11. Levothyroxine Sodium 125 mcg 12. Citalopram Hydrobromide 10mg qD Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Rosiglitazone Maleate 4 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO BID (2 times a day). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1. Pneumonia Discharge Condition: stable Discharge Instructions: 1. Continue to take your usual medications 2. Finish your course of antibiotics 3. Call your doctor to set up an appointment within the next few days 4. Call your doctor for any fever, chills, worsening cough or any other concerns Followup Instructions: 3. Call your doctor to set up an appointment within the next few days

[ "486", "272.4", "250.00", "414.01", "V10.46", "412", "V45.82", "244.9", "518.81", "428.0", "V45.02" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6469, 6526

4178, 4940

242, 249

6583, 6592

2908, 4155

6871, 6944

2500, 2506

5369, 6446

6547, 6562

4966, 4966

6616, 6848

4989, 5346

2521, 2889

188, 204

277, 1926

1948, 2361

2377, 2484

26,052

109,303

51078+59308

Discharge summary

report+addendum

Admission Date: [**2187-8-3**] Discharge Date: [**2187-8-8**] Date of Birth: [**2108-5-19**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Iodine / Ibuprofen Attending:[**First Name3 (LF) 898**] Chief Complaint: "Feeling unwell" Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [**Known lastname **] is a pleasant 79 year old female with history TIA's, hypertension, and hyperlipidemia who presented to the ED feeling unwell. . She reports she was in her usual state of health, active all day including completing her water aerobics, and then developed some shortness of breath and pain across her chest. EMS was called and she received four 81 mg of aspirin en route. . In the ED, initial vital signs were: temperature of 101.0, blood pressure of 184/92, heart rate 94, respiratory rate 32-36, and oxygen saturation of 94% on non-rebreather (84% on room air). She received a sub-lingal nitroglycerin and 4 mg of zofran, 1 gram of ceftriaxone, and 500 mg of PO azithromycin. Systolic blood pressure trend was initially 184->173->136->98->95. Once her blood pressure trended down, she was initiated on IV fluids, and received about 1000 mL. She was eventually weaned from non-rebreather to 4 liters nasal cannula. She did not require CPAP. Denied any difficulties breathing, chest pain or nausea. Past Medical History: - Hypertension - Hyperlipidemia - History of pancreatitis - Lumbar radiculopathy status-post laminectomy - Status-post bilateral hip replacements - History of aspiration pneumonias - History of TIA - Impaired fasting glucose, insulin resistance--noted elsewhere in chart that she has had post-prandial hypoglycemia - Parathyroidectomy/thyroid nodule resection - Cervical radiculopathy - Status-post: tonsillectomy, cholecystectomy, hysterectomy ** Denies any history of cardiac disease including CHF or CAD.** Social History: Independent for ADL's, ambulates with cane. Lives above family in two-family house. No alcohol, tobacco, or drugs. Retired nurse. Family History: Non-contributory. Physical Exam: VS: Tm 98.3 / BP 123/67 (123-142/60-70) / HR 76 (76-80) / RR 19 (16-19) / SpO2 96%2L (90-96%RA) GEN: NAD HEENT: NCAT, EOMI, PEERL, MMM, oropharynx clear CV: RRR, no M/R/G Resp: minimal bibasilar crackles, no wheezes or rhonchi Abd: soft, obese, NT/ND, normoactive BS, no HSM Ext: no c/c, LLE 2+ pitting edema w/ decreased sensation compared to right leg. LLE 4/5 strength, RLE 5/5 strength. b/l upper extremities equal strength and sensation. Pertinent Results: Labs on discharge: [**2187-8-8**] 06:30AM BLOOD WBC-6.7 RBC-3.93* Hgb-12.3 Hct-36.4 MCV-93 MCH-31.2 MCHC-33.7 RDW-14.0 Plt Ct-134* [**2187-8-8**] 06:30AM BLOOD Glucose-101* UreaN-11 Creat-0.9 Na-146* K-3.8 Cl-111* HCO3-27 AnGap-12 [**2187-8-7**] 06:50AM BLOOD CK(CPK)-126 [**2187-8-8**] 06:30AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9 Troponins remained negative. Chest xray showed mild congestive heart failure and underlying consolidation. Brief Hospital Course: # Hypoxic respiratory distress: Patient arrived in respiratory distress. Initially felt to be CHF by ED staff, and given sub-lingual nitroglycerin, especially given chest pain, hypertension, and CXR findings. Had elevated CK to 500s; normalized during hospital course. Cardiac fractions were never elevated. Negative troponins, no EKG changes noted. Given fever in ED and CXR appearance, ICU staff felt the patient more had community-acquired pneumonia and she was started on ceftrixone and azithromycin. Patient improved on antibx treatment (improved leukocystosis, afebrile). . # Hypotension: Differential includes medication-related secondary to nitroglycerin versus sepsis from pulmonary process. Developed pressure as low as 87/50 on the unit and her home anti-hypertensive medications were held. Lactate also trended down (4.0->2.5). Patient responded well to IVF hydration alone. UOP, which had dipped down to 10cc/hr, improved with hydration. . # Chest pain: Patient complained of chest pain in the ED. At the time, differential included coronary artery disease (no known history, though has known vascular disease including CVA in past) and pneumonia, among other causes. Troponins were consistently negative. No EKG changes suggestive of ischemia. CK was elevated but normalized; MB fraction was not elevated. Daily ASA was started and continued. . # History of hyperlipidemia/TIA: Continued statin and aggrenox. Medications on Admission: - Avapro 300 mg - Aggrenox [**Hospital1 **] - Lipitor 80 mg daily - Metoprolol 50 mg [**Hospital1 **] - Ecotrin 325 mg - Multivitamin daily - Chlorthalidone 12.5 mg 3-5 times a week - Amlodipine 2.5 mg daily Discharge Medications: 1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*4 Tablet(s)* Refills:*0* 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*8 Tablet(s)* Refills:*0* 6. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day. 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Community Acquired Pneumonia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted with shortness of breath. A chest x-ray revealed evidence of pneumonia. You were treated with antibiotics and supplemental oxygen. You will require several more days of antibiotics once you leave the hospital. Please note the following changes in your medications: - Please START azithromycin 250mg, take one daily for 4 days - Please START cefpodoxime 200mg, take one tablet twice daily for 4 days. - Please STOP taking chlorthalidone and amlodipine until seeing Dr. [**Last Name (STitle) 172**] Followup Instructions: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 14973**] (one of Dr.[**Name (NI) 8156**] group) [**Street Address(2) **]. [**Location (un) **], MA [**Telephone/Fax (1) 133**] [**8-15**] at 1:00 pm Department: NEUROLOGY When: MONDAY [**2187-11-12**] at 1 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], M.D. [**Telephone/Fax (1) 541**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2187-8-9**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 17271**] Admission Date: [**2187-8-3**] Discharge Date: [**2187-8-8**] Date of Birth: [**2108-5-19**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Iodine / Ibuprofen Attending:[**First Name3 (LF) 211**] Addendum: Please see Brief Hospital Course. Brief Hospital Course: [**Last Name (un) **]: Patient's baseline creatinine 0.9, which peaked at 1.8 and was back down to 0.9 upon discharge. At one point patient's urine output was approx 10cc/hr likely secondary to hypotension. She responded appropriately to IVF. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare Discharge Diagnosis: Secondary diagnosis: Acute Kidney Injury [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**] Completed by:[**2187-9-13**]

[ "276.2", "458.9", "584.9", "729.2", "401.9", "799.02", "V12.54", "V43.64", "486", "786.59", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7386, 7444

7119, 7363

308, 315

5445, 5445

2566, 2566

6136, 7096

2068, 2087

4719, 5291

7465, 7465

4487, 4696

5593, 6113

2102, 2547

252, 270

2585, 3005

343, 1367

7486, 7662

5460, 5569

1389, 1902

1918, 2052

3,771

159,920

3579

Discharge summary

report

Admission Date: [**2190-8-3**] Discharge Date: [**2190-8-11**] Service: MEDICINE Allergies: Sulfonamides / Iodine; Iodine Containing / Procainamide / Amiodarone Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: L hip fracture Major Surgical or Invasive Procedure: Left hip ORIF. History of Present Illness: [**Age over 90 **] year-old woman with history of CAD, status post MI, tachy-brady, status post pacemaker, CHF, diabetes type II, and depression who presents from rehab status post a fall. The patient was coming out of bathroom with her walker when she had an altercation with people in the room and subsequently fell on her left hip. She had no head injury or loss of consciousness. She was found to have a left hip fracture in the ED. She was recently discharged from [**Hospital1 18**] with diagnosis of failure to thrive and was admitted to [**Hospital3 537**] on [**2190-7-20**]. She recently completed a course of Ciprofloxacin UTI and is currently on a course of Macrobid to be stopped on [**2190-8-4**]. She denies any new numbness or tingling or bowel or bladder changes. She says that she has numbness in her feet which is bilateral and of long duration. She denied nausea, vomiting, new abdominal pain, chest pain, shortness of breath, headache or vision changes. Past Medical History: 1. CAD s/p MI in [**2144**], [**2185**]. Negative ETT MIBI in [**1187-7-26**] 2. S/P pacemaker placement for sick sinus 3. HTN 4.AFIB s/p DC cardiversion 5.Sleep apnea 6.Anemia of chronic disease 7.spinal stenosis 8.Gastroesophageal reflux 9.osteoporosis 10. ?primary pulmonary hypertension Social History: Patient usually lives at home with her daughter, who is her primary caregiver [**First Name (Titles) **] [**Last Name (Titles) **] power of attorney. Patient also has son who lives in [**Location **]. Negative tobacco, EToH. Family History: NC Physical Exam: VS: 97.5 130/79 80 18 99% RA gen- elderly woman lying in bed, in moderate distress heent- AT, PERRLA, EOMI, neck supple, OP clear, mucous membranes dry and pale pulm- CTAB but poor respirtory effort CV- loud [**3-31**] murmur, regular ABD- soft, nontender to palpation, + BS, no HSM EXT- UE venous stasis changes on palms and fingers, 3+ LE pitting edema bilaterally, left LE shortened and externally rotated Neuro- alert, CN II- XII, UE motor grossly intact Pertinent Results: 8.7>33.6<222 N:83.0 L:10.0 M:4.6 E:2.2 Bas:0.3 . [**Age over 90 **]|93|16 /182 5.4|29|0.9\ . PT:14.7 PTT:32.1 INR:1.4 . UA:Clear yellow, SG:1.014 pH:5.0 dipstick negative. . Left hip x-ray: Comminuted left intertrochanteric fracture . CXR: Cardiomegaly without evidence of an acute cardiopulmonary process. Stable prominence of the right paratracheal stripe, likely related to normal vasculature. . Brief Hospital Course: A/P: [**Age over 90 **] year old woman with history of CAD, status post MI, tachy-brady, status post pacemaker, CHF, diabetes type II, and depression who sustained a left hip fracture after a fall at rehab. 1. Left hip fracture: Upon medical clearance (unchanged EKG, negative CXR, negative UA, normal PT/PTT, and correction of mild hyponatremia and hyperkalemia), she underwent ORIF of her left hip. She was started on a 7 day course of prophylactic antibiotics cefazolin and levofloxacin. She was started on a 6 week course of enoxaparin 40 mg SC for DVT prophylaxis post-operatively. She should follow-up with orthopedics in 2 weeks upon discharge. 2. Hypotension: She had post-operative hypotension that was attributed to hypovolemia given her peri-operative blood loss resulting in a 6 point hematocrit drop. She responded to fluid bolus. She remained hypotensive and required pressors. A cortisol stimulation test was borderline and she was started on stress-dose steroids. She required fluid boluses to maintain her CVP and pressors to maintain her blood pressor. On ICU day 3, she weaned off of the pressors. Her stress dose steroids were stopped after a 3 day course since her pressures were stabilized and since she had a borderline cortisol stimulation test. 3) Pain control: She was started on tramadol and acetaminophen post-operatively for pain control. She became somnolent and unresponsive after 100 mg dose of tramadol. She became responsive after a 1 mg dose of naloxone. Her tramadol dose was adjusted to 25 mg [**Hospital1 **], which she tolerated well. Her outpatient gabapentin was also continued throughout the admission for control of neuropathy in her feet. 3) Delirium: She had a exacerbation of delirium post-operatively, which was most likely related to the peri-operative Morphine and Fentanyl administration. Her neurological exam was grossly non-focal and a repeat head CT was negative for acute event. * 4) CAD/Afib/AS: Pre-operatively, her aspirin and isosorbide were held. Her Atacand was continued throughout the admission. Her sotalol was initially continued for rate control. Her sotalol was held post-operatively given her hypotension. He Aspirin was restarted on post-operative day 1. Her sotalol was restarted on ICU day 4 once her blood pressure was stable. She had a echocardiogram that showed left and right ventricular hypertrophy with an EF greater than 55%, moderate aortic stenosis, 1+ tricuspid regurgitation and 2+ mitral regurgitation. She is not on Coumadin for anticoagulation since she has a risk for fall. * 5) Anemia: She had a 6 point drop in hematocrit that required 2 units of pRBCs. Her hematocrit remained stable throughout the admission otherwise. * 6) Depression: Her sertraline was continued throughout the admission. 7) Diabetes: She was on Glyburide at rehab, but it was discontinued on admission. She was maintained on an insulin sliding scale. This scale needed to be increased once she was started on the stress-dose steroids. She was restarted on Glyburide 2.5 mg QD prior to discharge. 7) FEN: She passed a speech and swallow evaluation and was recommended to have honey thick liquids and pureed solids. Her electrolytes were repleted as needed. She received numerous fluid boluses to maintain her CVP during the first few days of her ICU admission. * 8) Prophylaxis: Enoxaparin for post-operative DVT prophylaxis. She was maintained on a PPI and bowel regimen. 9) Access: a right IJ catheter was placed given her hypotension. * 10) Code: Full. Her power of attorney is her daughter who recently was in the ICU and unable to make decisions. Her son [**Name (NI) **] [**Name (NI) 16343**] was also involved in her care and consented for surgery and care during this admission. Medications on Admission: Acetominophen 1000mg PO Q8hr PRN pain Atacand NF 8mg PO QD Bisacodyl 10mg PR daily PRN constipation Calcium carbonate 500mg PO BID PRN Docusate Sodium 100mg PO BID Gabapentin 100mg PO HS Isosorbide Mononitrate (XR) 30mg PO [**Name (NI) 244**] MOM MVI [**Name (NI) 16345**]+folate Nitrofurantoin 100mg PO BID Pantoprazole 40mg PO QD Viscous lidocaine gargle 15ml TID Senna 1 tab PO QD Sertraline HCL 75mg PO QD Sotalol Hcl 40mg PO BID Zolpidem Tartrate 5mg QHS PRN difficulty sleeping Tramadol 100mg PO BID ASA EC 325mg PO QD Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO QOD (). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Candesartan Cilexetil 4 mg Tablet Sig: Two (2) Tablet PO QD (). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 4 weeks: [**Month (only) 116**] continue longer if she continues to have pain with her hip fracture. 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 13. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous DAILY (Daily) for 5 weeks. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 18. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 19. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous Q8H (every 8 hours) for 2 days. 20. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior [**Hospital1 **] - [**Location (un) 1887**] Discharge Diagnosis: left hip fracture Discharge Condition: Stable. Hypotension resolved. Discharge Instructions: Please take all medications as prescribed and keep all follow-up appointments. Followup Instructions: You have the following appointment to follow-up on your hip fracture surgery with Dr. [**Last Name (STitle) 2719**]. Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 5499**] Date/Time:[**2190-8-18**] 2:40 . You also have the following cardiology appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2190-8-11**] 3:30 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2190-8-11**] 4:00 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2190-8-11**]

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icd9cm

[ [ [] ] ]

[ "99.04", "79.35", "38.93" ]

icd9pcs

[ [ [] ] ]

8956, 9050

2823, 6606

297, 314

9111, 9144

2398, 2800

9271, 10063

1899, 1903

7181, 8933

9071, 9090

6632, 7158

9168, 9248

1918, 2379

243, 259

342, 1324

1346, 1639

1655, 1883

44,459

101,062

22338

Discharge summary

report

Admission Date: [**2171-1-30**] Discharge Date: [**2171-2-21**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: fall Major Surgical or Invasive Procedure: [**2171-2-2**] EVD placement in OR [**2171-2-8**] Floroscopic placement of Dobhoff Tube PICC placement/replacement History of Present Illness: [**Age over 90 **] year-old female with PAF on coumadin, diastolic dysfunction, multiple valvular abnormalities (TR, MR, AR) admitted to neurosurgical service [**2171-1-30**] for ICH, and transferred to MICU [**2171-2-9**] for lethargy, hypoxia, and hypotension. . She was transferred [**2171-1-30**] from OSH after presenting with fall backwards onto her occiput from 2 stair height without reported LOC. She was on coumadin at that time. On presentation to OSH GCS 15 and head CT showed significant SAH. She was transferred to [**Hospital1 18**] for further care. . She was admitted to TICU [**2171-1-30**] for neurologic monitoring. INR was reversed with FFP and Vitamin K. While in the TICU, the patient became increasingly lethargic and was only intermittently oriented A&Ox3. She was found to have hydrocephalus and underwent external ventricular drain placement [**2171-2-2**]. She underwent Dobhoff placement under fluoro [**2171-2-8**]. . During her hospitalization, chest radiograph with pulmonary edema, basilar crackles and patient was diuresed with Lasix. She became hypoxic with decrease in blood pressures from baseline, and she went to the SICU [**2-3**] for a Lasix drip. Subsequently, she was called out [**2-5**] and her standing home Lasix dose was increased. On [**2-8**], she was noted to have increased respiratory effort with a "wet" cough, with PO2 88-96% and tachycardia. LENIs were negative. She received 300cc free water boluses for tachycardia and subsequently for hypotension in the 80's. Medicine was called and on review of the imaging studies and given the patient's hypoxia and hypotension, recommended initiating Vanc/Cefepime/Flagyl for possible aspiration pneumonia as well as a 250cc bolus x2 for SBP 70's-80's. A discussion of possible intubation was held with the son and the patient was made DNR/DNI. Lasix was d/c'ed. Cultures were drawn, and ABG showed 7.51/40/105/33 with a lactate of 2.7. . Of note, during the hospital course, the patient had loose stool [**2-6**] and had C. diff x3 which were negative. Her standing bowel regimen was d/c'ed. Of note, she was started on tube feeds on [**2-4**]. . This morning, [**2171-2-9**], the patient was found to have BP 70/30s and somnolent, minimally responsive to noxious stimuli. MERIT was called for further management and potential transfer to medicine service. On evaluation, the patient somnolent and a hct drop from 36 -> 31 was noted. She was written for 1 unit PRBC and 250cc bolus NS was initiated in the interim. Oxygen saturation fluctuated between high 80's-100% on high flow face mask. Of note, per neurosurgery, external ventricular drain at 10 open. . On evaluation in the MICU, she is nonverbal. She moans to sternal rub and does hold her son's hand. Past Medical History: - PAfib on Coumadin - Diastolic dysfunction, preserved EF, 3+MR, 2+TR, 2+AI - CAD - HTN - GERD Social History: Lives with her daughter. Requires assistance with all ADLs. No alcohol, tobacco, or illicit drug use. Family History: non-contributory Physical Exam: ADMISSION EXAM: 98 55 118/70 18 93% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: reactive bilateally EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-7**] objects at 5 minutes. 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, to 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 finger rub bilaterally. 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 [**4-11**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: ADMISSION LABS: [**2171-1-29**] 22:30 WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 14.5* 4.42 13.1 39.7 90 29.6 33.0 16.2* 195 Glucose UreaN Creat Na K Cl HCO3 AnGap 171*1 18 1.1 144 3.5 105 25 18 . DISCHARGE LABS: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 9.6 3.65* 10.8* 33.4* 92 29.5 32.2 17.2* 312 Glucose UreaN Creat Na K Cl HCO3 AnGap 83 17 0.8 152*2 4.0 114* 24 18 . MICROBIOLOGY: [**2-6**] Stool Cx: C. diff negative 3/5 Blood Cx: negative [**2-9**] Urine Cx: negative [**2-9**] Fungal Blood Cx: negative [**2-9**] CSF: negative [**2-9**] Stool Cx: C. diff negative [**2-10**] Sputum Cx: coag + Staph aureus CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S . IMAGING: [**1-29**] Head CT: 1. Multicompartmental hemorrhage with bifrontal intraparenchymal hemorrhage, extensive subarachnoid hemorrhage layering along the basilar cisterns, and a small amount of intraventricular hemorrhage layering along the occipital horns. 2. Left occipital fracture. Note that the reference CT was made available after initial review, and the bifrontal areas of intraparenchymal hemorrhage are new since the reference CT. In addition, the intraventricular hemorrhage is new since reference CT and the layering subarachnoid hemorrhage has increased. . [**1-30**] Head CT: IMPRESSION: 1. Increased size and surrounding edema of the right frontal lobe intraparenchymal hemorrhage. 2. Increased intraventricular hemorrhage in the right frontal [**Doctor Last Name 534**] and bilateral occipital horns. 3. Unchanged inferior left frontal lobe intraparenchymal hemorrhage, right frontal lobe subarachnoid hemorrhage, and basal cistern subarachnoid hemorrhage. 4. Left occipital fracture, better visualized on CT from [**2171-1-29**]. . [**1-31**] Head CT: 1. Unchanged size of right frontal lobe intraparenchymal hemorrhage and surrounding edema. 2. Increased hemorrhage in the bilateral occipital horns of the lateral ventricles compared to [**2171-1-30**]. 3. Unchanged inferior left frontal lobe intraparenchymal hemorrhage, right frontal lobe subarachnoid hemorrhage, bilateral superior parietal subarachnoid hemorrhage, and basal cistern subarachnoid hemorrhage. 4. Left occipital fracture, better visualized on CT from [**2171-1-29**]. . [**2-2**] Head CT: 1. Increased ventricular size indicating hydrocephalus since [revopis study. 2. No new hemorrhage. 3. Allowing for differences in technique, little change in known large right frontal intraparenchymal hemorrhage with surrounding edema and associated slight subfalcine herniation. 4. Unchanged diffuse subarachnoid hemorrhage and intraventricular hemorrhage. . [**2-4**] ECHO: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate-severe mitral regurgitation. Moderate pulmonary hypertension. Moderate aortic regurgitation. Moderate tricuspid regurgitation. Mild aortic valve stenosis. . [**2-7**] CT Head: 1. Slight decrease in the degree of hydrocephalus compared to [**2171-2-2**]. 2. Unchanged size of the right frontal lobe intraparenchymal hemorrhage, surrounding edema, and degree of mild leftward subfalcine herniation. 3. Unchanged right superior frontal lobe and left frontal/parietal subarachnoid hemorrhage. Further workup for underlyign cause after clinical correlation, as clinically indicated. . [**2-8**] CT Head: 1. Unchanged size of the right frontal lobe intraparenchymal hemorrhage, surrounding edema, and extent of leftward shift of normally midline structures. 2. No significant change in ventricular enlargement. . [**2-8**] LENI: No DVT. . [**2-13**] CT Head: 1. No significant change in the size of the right frontal lobe parenchymal hemorrhage, surrounding edema, or associated mass effect, including the slight leftward shift of normally-midline structures. 2. Near-complete interval resorption or drainage of intraventricular hemorrhage. Ventricular size is not significantly changed. . [**2-14**] CT Head: 1. Moderate right frontal intraparenchymal hematoma with surrounding vasogenic edema and effacement of the cerebral sulci and mild leftward shift of midline structures in the frontal region as before. No new acute intracranial hemorrhage noted. Intraventricular hemorrhage in the occipital horns unchanged. Continued close follow up as clinically indicated. While this may relate to trauma, underlying vascular/ neoplastic cause can be excluded after appropriate workup as felt necessary. 2. Persistent moderate dilation of the lateral ventricles, which has mildly increased from the prior study. Accurate assessment and comparison is limited due to the differences in position between the two studies and motion-related artifacts on the present study. Continued close follow up as clinically indicated. 3. Moderate mucosal thickening in the ethmoid and the sphenoid sinuses with small amount of fluid. . [**2-15**] CT Head: 1. Unchanged right frontal intraparenchymal hematoma with surrounding vasogenic edema, resulting in effacement of neighboring sulci and mild leftward shift of midline structures. 2. No new hemorrhage or large vascular territorial infarction seen. 3. Unchanged trace hemorrhage within the left occipital [**Doctor Last Name 534**]. 4. Unchanged mild ethmoid and sphenoid sinus disease. . CXR [**2-19**] IMPRESSION: Similar moderate-to-extensive bilateral hazy opacities, with persistent bibasilar opacities, likely combination of pneumonia and pulmonary edema. Mild cardiomegaly stable. Brief Hospital Course: Brief hospital course: . # Intracranial hemorrhage: Patient was admitted post fall as a transfer from OSH with large frontal IPH. Patient's coagulopathy was reversed with Por 9, Vit K and FFP. She was admitted to the ICU for Q1 hour neurochecks, systolic blood pressure control less than 140 and ICU care. Her occipital scalp laceration was stapled and she was started on Ancef IV in setting of open occipital fracture. She was loaded and started on Dilantin for seizure prophylaxis. Repeat Head CT on [**1-30**] showed mild increase in the size of hemorrhage with extension into the ventricular system. Repeat head CT on [**1-31**] was stable, she was started on SC heparin TID, restarted on her home Lasix dose of 40mg TID and she was transferred to the step down unit. On [**2-1**] she remained neurologically stable. On [**2-1**] she remained neurologically stable.On [**2-2**] she was lethargic and only arousable to sternal rub. A head CT showed hydrocephalus and an EVD was emergently placed in the OR. Her EVD was found to not be draining and it was drawn back 1cm with good results. On [**2-8**] Head CT demonstrated slight enlargement of ventricles an so EVD was opened at 10cm above the tragus. Drain clamped [**2171-2-13**], and CT head following day demonstrated stable findings. Drain removed [**2171-2-14**]. . # Respiratory failure: On [**1-31**], patient developed respiratory distress and desaturations to the upper 80's. She was given lasix x1 and a CXR was obtained. This revealed bilateral pleural effusions and vascular congestion. On [**2-2**] she was lethargic and only arousable to sternal rub. A head CT showed hydrocephalus and an EVD was emergently placed in the OR. She was also noted to have pulmonary edema and was given lasix. On [**2-3**] she was transferred to the ICU for diuresis. She was transfered back to the step down unit the following day. On [**2-8**], oxygen requirement increased again to 6L with a CXR consistent with pulmonary edema. Her lasix was increased to TID. She was started on and Cefipime/Vancomycin/Flagyl for presumed pneumonia. On [**2-9**], her care was transitioned to the MICU team. Hypoxia was felt to be due to aspiration and pulmonary edema. She was continued on broad-spectrum antibiotics initiated [**2171-2-9**] - vancomycin, cefepime, metronidazole. Metronidazole d/c'd [**2171-2-10**]. Sputum culture positive for MRSA. Patient steadily improved on antibiotic therapy, with decreased dyspnea. Plan was for 14 day total course of treatment, and all antibiotics were stopped on [**2-19**]. O2 weaned to 4-5L NC. . # Hypotension: Was felt to be secondary to intravascular volume depletion in the setting of diuresis, as evidenced by metabolic alkalosis (contraction alkalosis). Concern for peri-sepsis component given patient needed multiple boluses to maintain BP in 80's-90's, initially 100's-130's on transfer to [**Hospital1 18**]. Patient continued on 250cc boluses to maintain SBP >90, and diuretics, beta blockers held. She was on broad spectrum antibitics as above, and pan-cultured to look for etiology of infection. As above, sputum positive for MRSA PNA. Hypotension resolved with continued antibiotic treatment. . # Goals of care / Altered mental status: Patient was called out to the floor on [**2-14**], but she became progressive lethargic and was sent back to the ICU on [**2-17**]. [**Month (only) 116**] have been related to infection, hypernatremia (mild), delirium from complicated medical course. Mental status improved with antibiotic course, free water flushes, and reorientation. CSF fluid was sent for analysis, but was not concerning for infectious process. Mental status did not improve, and a family meeting was held on [**2-19**] with the decision to pursue comfort measures only care. As such, she is being transferred to hospice care. Palliative care consult was initiated on [**2-20**] and advised Zydis 5mg Q 12 hrs on as needed basis to decrease agitation (as opposed to scheduled dosing-- he'd rather she not be overly sedated if possible, does want to treatsymptoms), and discussed using MS 2.5-5 mg SL (5mg/ml concentration) Q 3 hrs as needed to ease respiratory distress. Would consider scopolamine patch 1.5 mg patch Q 3 days if secretions increase (recognizing that this may contribute to sedation as well). Medications on Admission: 1. Metoprolol 25mg [**Hospital1 **] 2. Diovan 20mg Daily 3. Furosemide 40mg TID 4. Ranitidine 150mg daily Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for sob, wheeze. 2. timolol maleate 0.25 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 3. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing, sob. 6. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 2.5-5 mg PO Q3H (every 3 hours) as needed for dyspnea. 7. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 8. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day): please hold for SBP <100, HR <60. 9. ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 10. acetaminophen 650 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Traumatic Intraparenchymal Hemorrhage Occipital skull fracture Exacerbation of CHF ARDS Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital after a fall, and were found to have a hemorrhage inside of your head. You required a drain to be temporarily placed in your head to relieve the pressure from this bleed. Your course was complicated by pneumonia and fluid in your lungs. Your family decided to focus your goals on comfort, and as such you are being transferred to a hospice facility. Followup Instructions: Please follow up with your primary care doctor on an as needed basis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2171-2-21**]

[ "428.0", "507.0", "285.9", "518.81", "V58.61", "801.71", "331.4", "276.3", "428.33", "293.0", "458.8", "276.0", "873.0", "414.01", "584.9", "427.31", "V49.86", "E880.9", "038.9", "482.42", "780.97", "995.92" ]

icd9cm

[ [ [] ] ]

[ "86.59", "96.6", "02.39", "38.97", "03.31", "96.08" ]

icd9pcs

[ [ [] ] ]

16436, 16522

10616, 13825

263, 380

16654, 16732

4895, 4895

17164, 17401

3443, 3461

15080, 16413

16543, 16633

14949, 15057

16756, 17141

5105, 5805

3476, 3718

219, 225

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4009, 4876

9982, 10570

7366, 8020

4911, 5089

13840, 14923

3210, 3307

3323, 3427

10,315

102,896

14679

Discharge summary

report

Admission Date: [**2166-9-5**] Discharge Date: [**2166-9-15**] Date of Birth: [**2096-7-26**] Sex: M Service: THORACIC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male who was first noted to have bilateral lung masses on a chest x-ray in preparation for possible sinus surgery. A follow-up CAT scan of the chest in [**2166-3-26**] originally had shown a 6.5 cm left upper lobe mass and a 3.5 cm lobulated right upper lobe mass. He consequently underwent fluoroscopic biopsy of the right-sided mass which showed adenocarcinoma. Bronchial biopsy of the left upper lobe showed poorly differentiated large cell carcinoma with squamous differentiation. Metastatic work-up of the head, bone, and abdomen was negative. His laboratory studies remained relatively normal. He was seen by the Oncology Service and started on chemotherapy. The follow-up imaging showed marked regression of his tumor. He was consequently referred to Thoracic Surgery for a possible surgical intervention. The patient has not lost significant weight and has not had any fevers, headaches, or chest pain. He has had good appetite PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Nasal polyps. 4. Bilateral lung carcinoma. 5. Chronic maxillary and ethmoid sinusitis. 6. Peptic ulcer disease. PAST SURGICAL HISTORY: None. MEDICATIONS: Hydrochlorothiazide 25 mg q.d., Lipitor 10 mg q.d., Atrovent, Vanceril, antihistamines for allergies. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: Likely asbestos exposure. History of smoking (60 pack years). PHYSICAL EXAMINATION: General: Well-developed, in no apparent distress. HEENT: Anicteric. No lymphadenopathy palpated. Lungs: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm without murmurs. Abdomen: Soft, nontender, nondistended. Extremities: Pulses present bilaterally. Warm and well perfused. LABORATORY DATA: White blood cell count 7.0, hematocrit 38, platelet count 351; BUN 17, creatinine 0.8, sodium 141, potassium 3.9, chloride 100, carbon dioxide 28; liver function tests within normal limits; FEV1 was 44% of the predicted value. HOSPITAL COURSE: Given the diagnosis of bilateral lung cancer, Thoracic Surgery was consulted. On [**2166-9-5**], the patient underwent median sternotomy, left upper lobectomy, bronchoscopy, pedicled pericardial flap, right upper wedge resection, and decortication of the left lung. The patient tolerated the procedure well, and there were no immediate complications. Please see the full operative report for details. The patient was transferred to the Intensive Care Unit in fair condition. He had to be reintubated and maintained on pressure support. He was transfused with 2 U of packed red blood cells for a hematocrit of 23.6. Chest x-ray obtained at that time, showed left lower lobe collapse/consolidation but appeared relatively unchanged. The patient underwent a series of therapeutic bronchoscopies during his stay in the Intensive Care Unit. It showed mucous plugging and thick secretions. He had an increased need of Neo requirement. The patient was weaned of sedation. His chest x-ray showed some interval improvement. He continued to have low-grade fevers. He was placed on Ceftriaxone and Kefzol. His hematocrit remained stable. There was some difficulty weaning him off of pressure support. In addition, his tube feeding was initiated. He continued to have thick oral secretions. He remained in sinus rhythm but had an eight-beat run of ventricular tachycardia was noted. The patient was started on Amiodarone drip. He was transfused again with one unit of red blood cells. The patient was successfully extubated on postoperative day #4. He was transferred to the red floor on postoperative day #5 in stable condition. He continued to produce good urine. He remained in sinus rhythm. He continued to be afebrile with stable blood pressure and heart rate. Physical Therapy was consulted which recommended rehabilitation facility upon discharge. The chest tubes were removed. The patient was discharged to the rehabilitation facility on [**2166-9-16**]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Bilateral lung carcinoma status post medial sternotomy, left upper lobectomy, bronchoscopy, pedicled pericardial flap, right upper wedge resection, and decortication of the left lung. 2. Hypertension. 3. Hypercholesterolemia. DISCHARGE MEDICATIONS: Amiodarone 400 mg q.d. x 1 month, Ambien 5 mg p.o. h.s., Atenolol 12.5 mg p.o. b.i.d., Fluticasone Propionate 110 mcg 2 puffs b.i.d., Keflex 500 mg q.6 hours p.o. x 7 days, Heparin subcue 5000 U b.i.d. until sufficiently mobile, Albuterol Ipratropium 1-2 puffs inhalers q.6 hours p.r.n., Hydrochlorothiazide 25/25 one tab q.d., Lipitor 10 mg p.o. q.d., Vanceril. DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with his surgeon Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] in approximately 1-2 weeks. 2. The patient is to follow-up with his primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**] in approximately 1-2 weeks. 3. The patient is to follow-up with his oncologist as scheduled (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**]). [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 1741**] MEDQUIST36 D: [**2166-9-15**] 18:13 T: [**2166-9-15**] 19:35 JOB#: [**Job Number 43211**]

[ "196.1", "518.0", "427.1", "997.3", "162.3", "401.9", "518.5", "276.2", "272.0" ]

icd9cm

[ [ [] ] ]

[ "32.4", "33.24", "96.71", "32.29", "96.04" ]

icd9pcs

[ [ [] ] ]

4237, 4263

4541, 4905

4284, 4517

2203, 4181

4930, 5693

1367, 1529

1633, 2185

177, 1153

1176, 1343

1546, 1610

4206, 4213

27,068

142,482

32757

Discharge summary

report

Admission Date: [**2177-2-15**] Discharge Date: [**2177-2-18**] Date of Birth: [**2106-3-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: Cardiac catheterization and bare metal stent placement to right coronary artery. History of Present Illness: 70M h/o DM2, hyperlipid, traumatic brain injury, c/b mental retardation, asthma, hypothyroidism, doing well until just before [**Holiday 944**], when noted to have increased non-productive cough, progressively worse until [**1-30**], when pt was started on 9d course of prednisone(60x3d, 40x3d, 20x3d) for presumed asthma flare. He was doing well until [**2177-2-12**] when sister notes markedly increased fatigue ("in bed all day") and decreased appetite. One episode of ?vomit vs cough on [**2-12**]. Pt denied cp/sob/palp/diaphrosis. On [**2-15**] sister was concerned about persistent fatigue, and noted worsening SOB when pt climbed flight of [**Last Name (LF) 5927**], [**First Name3 (LF) **] pt was brought to OSH ([**Hospital1 **]). While in car pt complained of SOB. . On arrival to [**Hospital3 **] 13:45PM [**2177-2-15**], VS=97.5 138/76 61bpm 99%2L, pt noted to be in junctional rythym in 60s, with STE in II, III, aVF. given 1L NS, asa 325, plavix 600, ativan 0.5mg iv, heparin gtt + bolus, integrellin + bolus, lipitor 80. lopressor held [**3-8**] bradycardia. pt transferred to [**Hospital1 18**] for urgent LHC. . LHC at [**Hospital1 18**] revealed 80% prox OM1, 100% pRCA. Pt underwent attempted clot removal, then succesfully recieved 2 BMS to RCA with residual clot which cleared with balloon dilation. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . 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: NIDDM x 11y hyperlipidemia - no meds [**3-8**] "muscle aches" after lipitor 10 qd asthma gerd hiatal hernia traumatic brain injury @ birth [**3-8**] forceps delivery, c/b epilepsy x 10yrs, none since age 10, c/b mental retardation. epididymitis - s/p right testicle removal. ?hematuria - attributed to UTIs. ?schizophrenia - on psych meds for "hallucinations" - denies h/o HTN, DVT/PE, CVA, CKD, CAD. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. mother with MI age 73, ovarian ca, father with [**Name2 (NI) 499**] cancer in his 70s. Physical Exam: VS: AF 150/67 62 100% on 2L NC. Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x1. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 8cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. +S4, no S3. [**4-10**] HSM @ LSB. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Extremities cool with ecchymoses on 2nd right toe Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; [**2-5**]+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; [**2-5**]+ DP Pertinent Results: [**2177-2-15**] 05:48PM CK-MB-22* MB INDX-5.6 cTropnT-2.62* [**2177-2-15**] 05:48PM ALT(SGPT)-70* AST(SGOT)-97* CK(CPK)-391* ALK PHOS-47 TOT BILI-0.6 [**2177-2-15**] 05:48PM GLUCOSE-198* UREA N-16 CREAT-0.7 SODIUM-130* POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-21* ANION GAP-15 [**2177-2-15**] 07:54PM PLT COUNT-180 [**2177-2-15**] 07:54PM WBC-10.6 RBC-3.31* HGB-10.3* HCT-29.2* MCV-88 MCH-31.0 MCHC-35.1* RDW-13.1 . Cardiac cath: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed two vessel coronary artery disease. The LMCA had no angiographically apparent flow-limiting stenoses. The LAD had no angiographically apparent epicardial lesions. The LCX had an 80% distal lesion in OM1. The RCA was totally occluded proximally with heavy clot burden. 2. Limited resting hemodynamics revealed moderate systemic arterial hypertension of 165/76 mm Hg. 3. Left ventriculography was deferred. 4. Successful thrombectomy and stentinf of the RCA with 3.0 X 23 mm and 2.5 X 12 mm Vision bare metal stents in an overlapping fashion without residual stenosis (see PTCA comments for detail). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Acute myocardial infarction with proximal RCA thrombus. 3. Moderate systemic arterial hypertension. 4. Successful stenting of the RCA with bare metal stents. . ECHO [**2177-2-17**] The left atrium is mildly dilated. The interatrial septum is aneurysmal. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior and inferolateral segments. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are myxomatous. There is moderate/severe mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Myxomatous mitral valve leaflets. Mild prolapse of the anterior mitral leaflet, moderate to severe prolapse of the posterior mitral valve leaflet. Moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **] LV systolic dysfunction. Dilated and hypokinetic right ventricle. Brief Hospital Course: . . ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN MULTIDISCIPLINARY ROUNDS: . 70 M h/o DM, hyperlipid, traumatic brain injury, asthma, transferred from OSH after 3d fatigue, decreased appetite, with new inferior STE, junctional rythym, found to have TO pRCA at cath, s/p BMS x 2 to RCA. . # CAD/Ischemia: Presented with inferior MI s/p 2 BMS to RCA. Also noted to have 80% occlusions of proximal OM1. Initially treated with heparin gtt and integrilin (18hours post cath). Started on high dose aspirin, plavix, and ace inhibitor. Treated for short period of time with high dose statin as history of myositis. Bblocker held initially in setting of bradycardia and prolonged PR interval. Patient will need follow up stress testing vs cardiac catheterization to evaluate lesion in OM1. Beta blocker not started as patient's blood pressure was borderline low. . # Pump: Echo completed which revealed EF of 50-55% with a dilated and hypokinetic right ventrilcle mild [**Last Name (Titles) **] LV systolic dysfunction. Started on an ACE for afterload reduction. Did not require preload reduction with lasix as there was no evidence of heart failure, either acute or chronic. . # Rhythm: Initially noted to be in junctional rhythm prior to stent placement. Following revascularization, patient converted back to sinus rhythm with borderline prolonged PR interval. Beta blocker held initially as he was bradycardic. However it was not started as blood pressure was borderline and would not tolerate addition of another [**Doctor Last Name 360**]. . # Valves: Noted to have myxomatous mitral valve leaflets, mild prolapse of the anterior mitral leaflet, moderate to severe prolapse of the posterior mitral valve leaflet. Moderate MR. Should be monitored with serial echos as outpatient. . # HTN: Treated with single [**Doctor Last Name 360**] ace inhibitor. . # DM: 11 yr history of DM Type II. Restarted on home regimen of glyburide. . # Dyslipidemia: Treated with short duration of high dose statin. Discontinued prior to discharge. . # Cough/Asthma: hx of nonproductive cough for several weeks; afebrile, slightly elevated WBC count at OSH; no smoking history with recent steroid taper for presumed asthma exacerbation. Also with no exposures or travel history. Continued on accolate, pulmicort, atrovent nebs prn, fexofenadine. Remained afebrile with normal white count. . # GERD: continued PPI . # Hypothyroid: continued synthroid . # Hyponatremia: Minimal PO intake in the last several days prior to admission. Likely hypovolemic hyponatremia, improved with IV fluids. . . # Code: DNR/DNI, confirmed with sister (health care proxy) . # Communication: Sister [**Name (NI) **] [**Name (NI) 7594**] ([**Telephone/Fax (1) 76303**] cell: [**Telephone/Fax (1) 76304**]; husband [**Name (NI) 892**] cell ([**Telephone/Fax (1) 76305**] Medications on Admission: accolate 20mg po qdaily claritin 10 mg po qdaily glyburide 3mg po bid levothyroxine 50mg po qdaily lexapro 10mg po qdaily perphenazine 2mg qdaily protonix 40mg po qdaily pulmicort 1mg/2ml qdaily xopenex 1.25mg/3ml [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Perphenazine 2 mg Tablet Sig: One (1) Tablet PO QDAILY (). 6. Zafirlukast 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: Inferior myocardial infarction Secondary: Type II Diabetes mellitus Discharge Condition: Good, chest pain free, vital signs stable. Discharge Instructions: You were admitted to the hospital because you had a heart attack. This was due to a blockage in your coronary artery and a stent was placed to open the artery. . You were started on new medications which you should continue unless otherwise directed by your cardiologist. These include: Aspirin 325mg daily Plavix 75mg daily Lisinopril 10mg daily . We discontinued your glyburide, a medication for your diabetes as your blood sugars were difficult to control. You should follow up with your primary doctor to manage your diabetes. Do not take your glyburide unless directed to do so by your primary doctor. . Please contact your doctor or return to the emergency room if you develop worrisome symptoms such as chest pain, shortness of breath, weakness, lightheadedness, palpitations (fluttering in your chest), etc. Followup Instructions: [**Last Name (LF) 1637**], [**First Name3 (LF) **]: Tuesday [**2177-2-25**] at 2pm. [**Telephone/Fax (1) 14655**]

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icd9cm

[ [ [] ] ]

[ "00.66", "37.22", "00.46", "99.20", "88.56", "00.40", "36.06" ]

icd9pcs

[ [ [] ] ]

10422, 10428

6563, 9399

322, 405

10549, 10594

3936, 5061

11458, 11575

2847, 3016

9681, 10399

10449, 10528

9425, 9658

5078, 6540

10618, 11435

3031, 3917

275, 284

433, 2280

2302, 2706

2722, 2831

16,646

195,287

18221

Discharge summary

report

Admission Date: [**2146-8-8**] Discharge Date: [**2146-8-12**] Date of Birth: [**2068-2-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: EGD History of Present Illness: 78M s/p CABG in [**2143**] s/p cypher stent [**2146-7-8**], ESRD on HD, CHF EF 45%, now presents with CP and GI bleeding to [**Hospital1 **]. The pt was in his USOH until this AM, he awoke with vomiting of coffee grounds emesis, several episodes. He describes a subsequent episode of dark black stool. There was also L sided chest pressure without radiation which persisted for 30 minutes, as well as SOB. The pt denies any light-headedness, syncope. The priest where this pt works as a saxon called for an ambulance. On OSH admission, was noted to have Hct 23.7, down from 35.8 when he was discharged from [**Hospital1 18**] in [**Month (only) **]. ECGs were concerning for deep ST depressions V2-6, with ST elevation in aVR. The pt was at the time assessed as having a primary cardiac issue and was transferred to [**Hospital1 18**] for cardiac cath. He had received aspirin, Lopressor 15mg IV in divided doses, Protonix, heparin bolus 2200 given but no drip started as Hct was found to be 23 after the fact, Plavix 600mg in addition to being on Plavix at home, Ativan 1mg, nitro at 10mcg/min, morphine. At [**Hospital1 18**], ECGs showed decreased althouth still significant lateral ST depressions. Pt was taken to cath lab, although hct was noted to be 21.2, after 1U pRBCs and cath was postponed in setting of active GI bleed. Past Medical History: CAD - CABG in [**2138**] (LIMA to diagnonal, RSVG to LAD, PDA w/ PDA endarderectomy), s/p high risk Cypher stenting of LM into Cx and LAD [**2146-7-8**] Anemia PVD CRI - baseline Cr. 3.7 per OSH records ESRD on HD [**2-24**] nephrosclerosis Hypertension Lung CA s/p RUL wedge resection [**5-27**] Gout Social History: church custodian, lives alone Family History: unremarkable Physical Exam: 96.8 134/55 97 26 99% RA Gen: elderly white male HEENT: mmm, no LAD Lungs: pt. w/ ant. crackles CV: RRR, normal S1, S2, no murmurs, rubs, or gallops. Abd: soft, NTND, + BS, no masses, no HSM Ext: had 1+ bilateral pitting edema. Pertinent Results: [**2146-8-8**] 02:25PM WBC-11.9 Hct-21.2 Plt Ct-159 [**2146-8-8**] 06:25PM WBC-11.1 Hct-23.0 Plt Ct-178 [**2146-8-9**] 05:08AM WBC-11.5 Hct-35.9 Plt Ct-153 [**2146-8-12**] 07:25AM WBC-5.5 Hct-32.2 Plt Ct-177 . [**2146-8-8**] 06:25PM Glucose-128 UreaN-111 Creat-7.7 Na-138 K-5.7 Cl-97 HCO3-19 [**2146-8-9**] 05:08AM Glucose-107 UreaN-57 Creat-5.3 Na-140 K-5.6 Cl-105 HCO3-24 [**2146-8-12**] 07:25AM Glucose-111 UreaN-37 Creat-4.9 Na-141 K-4.1 Cl-102 HCO3-29 . [**2146-8-8**] 06:25PM CK-624 CK-MB-69 MB Indx-11.1 cTropnT-1.48 [**2146-8-9**] 05:08AM CK-684 CK-MB-76 MB Indx-11.1 cTropnT-2.85 . EGD: Duodenal ulcer with overlying clot. cauterized and injected with 3 cc epinephrine. Brief Hospital Course: 78M s/p CABG in [**2143**] s/p cypher stent [**2146-7-8**], ESRD on HD, CHF EF 45%, now presents with likely demand ischemia in setting of GI bleeding. Duodenal ulcer cauterized, Hct stabilized. . ## GI bleed: Hct trend 33.2-->31.6-->30.5-->28.7-->32.0. GI noted duodenal ulcer, was cauterized and 3 cc epinephrine injected. Not biopsied. No melena or coffee-ground emesis since. An H. pylori titre was sent, but has not come back yet. Has f/u appointment with Dr. [**Last Name (STitle) 50328**] in [**Location (un) 47**] for repeat EGD. Hct should be checked with dialysis tomorrow. . ## Cardiac - Ischemia: Likely demand ischemia in setting of severe acute bleed and significant CAD. Big enzyme leak. We continued ASA 325 PO qd, clopidogrel 75 mg PO qd, metoprolol 50 mg PO bid, simvastatin 40 mg PO qd. No need for cardiac cath at this time. - Pump: Known EF 45%. Euvolemic during hospitalization. Dialyzed on schedule . ## Respiratory: Pt was intubated for EGD and extubated without difficulty. . ## ESRD: renal following, dialyzed per routine and once for hyperkalemia. Continued his sevalamer and nephrocaps. . ##ID: Spiked temp after EGD while intubated. No source of inxn was found, but he has been afebrile without antibx. Blood Cxs were sent but are not back eyt. Medications on Admission: Clopidogrel 75 mg PO qd Simvastatin 40 mg PO qd Clonidine 0.2 mg PO bid Metoprolol Tartrate 50 mg PO bid Aspirin 325 mg PO qd Latanoprost 0.005 % Drops OU qhs Hydralazine 100 mg PO q12hrs Imdur 30 mg PO qd Sevelamer 800 mg PO tid Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).* Tablet(s)* Refills:*2* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 12. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Duodenal ulcer Discharge Condition: Stable Discharge Instructions: Please return to the hospital if you experience chest pain, shortness of breath, palpitations or fever. Please also return if you vomit blood, have a bloody bowel movement, vomit black material or have a tarry, sticky bowel mevement. Followup Instructions: We have made an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. You are scheduled to see him at 1 p.m. on [**8-19**]. . We have made an appointment for you to see a gastroenterologist, Dr. [**Last Name (STitle) 50328**]. You are scheduled to see her at 3:15 p.mn. on [**9-6**]. Her office is located at [**Last Name (NamePattern1) 50329**]. Completed by:[**2146-8-12**]

[ "274.9", "443.9", "403.91", "V45.81", "276.7", "280.0", "416.8", "428.0", "532.40", "250.40", "V45.82", "585.6", "V10.11" ]

icd9cm

[ [ [] ] ]

[ "96.04", "45.13", "99.04", "96.71", "39.95", "44.43" ]

icd9pcs

[ [ [] ] ]

5780, 5786

3075, 4351

324, 330

5845, 5854

2371, 3052

6136, 6547

2085, 2099

4631, 5757

5807, 5824

4377, 4608

5878, 6113

2114, 2352

274, 286

358, 1695

1717, 2021

2037, 2069

57,578

158,315

25

Discharge summary

report

Admission Date: [**2119-5-12**] Discharge Date: [**2119-5-18**] Date of Birth: [**2079-3-9**] Sex: M Service: SURGERY Allergies: Percocet / Lisinopril Attending:[**First Name3 (LF) 301**] Chief Complaint: substernal chest pain Major Surgical or Invasive Procedure: 1. Closure of perforated ulcer. 2. Partial gastrectomy. 3. Cholecystectomy. 4. Omental patch of ulcer. History of Present Illness: 40 M who is 2 years s/p laparoscopic RNY gastric bypass presents to ED after transfer from [**Hospital6 302**] with a CT scan showing pneumoperitoneum. Mr. [**Known lastname 303**] reports sudden onset of substernal chest pain at 5 am. Pain was severe, and his first thought was that he was having an MI. Pain unrelieved with attempt at bowel movement. He denies fevers, chills, nausea, vomiting, or any other symptoms. No radiation of the pain. Cardiac work-up at OSH was negative, however abdominal CT showed pneumoperitoneum. Pain was relieved with dilaudid 4 hrs ago. He currently denies abdominal pain and feels much better. Past Medical History: HTN hypothyroidism back pain w/sciatica plantar fasciitis Social History: He denied tobacco or recreational drug usage, has alcoholic beverages on rare occasions, drinks iced coffee and diet soda several times per week. He is employed as a laboratory technologist in the chemistry lab at [**Hospital1 18**]. He is married living with his wife age 38 and they have one son age 6 months. Family History: His family history is noted for father living age 75 with thyroid disease; mother living age 73 with heart disease, cancer and obesity; sister living age 42 with thyroid disease and two sisters ages 48 and 53 living with diabetes and obesity. Physical Exam: 98.8 75 121/70 18 100% RA A&O x 3, NAD, comfortably sitting in bed RRR CTAB Abdomen obese, soft, nondistended, very mild tenderness in epigastrium just to the left of midline, no rebound, no guarding LE warm, no edema Pertinent Results: [**2119-5-12**] 03:00PM WBC-16.7*# RBC-4.53* HGB-14.2 HCT-41.4 MCV-91 MCH-31.3 MCHC-34.3 RDW-12.7 [**2119-5-12**] 03:00PM PLT COUNT-211 [**2119-5-12**] 03:00PM PT-12.8 PTT-26.9 INR(PT)-1.1 [**2119-5-12**] 03:00PM GLUCOSE-133* UREA N-16 CREAT-0.7 SODIUM-140 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12 [**2119-5-12**] 11:04PM WBC-14.6* RBC-4.21* HGB-13.1* HCT-39.1* MCV-93 MCH-31.0 MCHC-33.4 RDW-13.1 [**2119-5-12**] 11:04PM GLUCOSE-179* UREA N-14 CREAT-0.7 SODIUM-140 POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13 [**2119-5-16**] Upper GI : In this patient status post gastric bypass and partial gastrectomy with repair of marginal ulcer, there is free flow of contrast through the gastric pouch and the gastrojejunostomy. No leak or holdup of contrast identified in this study. Brief Hospital Course: Mr. [**Known lastname 303**] was admitted to the hospital and examined by the Bariatric service. He had no abdominal pain but had Dilaudid prior to his transfer. His cardiac work up was negative and due to the finding of pneumoperitoneum on abd CT he was taken to the Operating Room for an exploratory laparotomy. He had a perforated marginal ulcer and underwent a partial gastrectomy, omental patch to ulcer and a cholecystectomy. He tolerated the procedure well and returned to the ICU in stable condition. His pain was controlled with a Dilaudid PCA and he remained hemodynamically stable. He was subsequently transferred to the Surgical floor for further management. Due to his recent surgery and length of time prior to taking fluids he had a PICC line placed for TPN which began on [**2119-5-14**] through a right AC PICC line. This was continued until [**2119-5-18**]. In the interim he had an upper GI on [**2119-5-16**] which showed no anastomotic leak and he gradually began a stage 1 diet. This was slowly advanced over the next 24 hours to stage 3 and he had no trouble with nausea or fullness. His abdominal wound was healing well and he was up and walking independently. He remained free of any pulmonary complications post op by using his incentive spirometer. Roxicet was effective in treating his incisional pain and he was generally improving every day. After an uncomplicated course he was discharged to home on [**2119-5-18**] and will follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Medications on Admission: synthroid 137', cyclobenzaprine 5 Q12 prn, Ca, Vit B12 Discharge Medications: 1. Levothyroxine 137 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:*500 ML(s)* Refills:*0* 3. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 4. Colace 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO twice a day. Disp:*250 ml* Refills:*2* 5. Multivitamins Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO once a day. 6. Vitamin D-3 1,000 unit Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Home Discharge Diagnosis: Gastric perforation from marginal ulcer. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * 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. Activity: No heavy lifting of items [**9-29**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Wear your abdominal binder for 6 weeks. Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 305**] Date/Time:[**2119-5-31**] 4:45 Provider: [**Name10 (NameIs) 306**] [**Name Initial (MD) 307**] [**Name8 (MD) 308**], M.D. Date/Time:[**2119-10-20**] 9:00 Completed by:[**2119-5-18**]

[ "568.89", "401.9", "534.50", "V45.86", "244.9", "567.9" ]

icd9cm

[ [ [] ] ]

[ "51.22", "44.41", "43.89", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

5260, 5266

2830, 4352

301, 406

5351, 5351

1997, 2807

7110, 7414

1496, 1740

4458, 5237

5287, 5330

4378, 4435

5502, 6701

1755, 1978

240, 263

6713, 7087

434, 1067

5366, 5478

1089, 1148

1164, 1480

29,328

151,375

29891

Discharge summary

report

Admission Date: [**2159-7-4**] Discharge Date: [**2159-8-31**] Date of Birth: [**2126-6-30**] Sex: M Service: ORTHOPAEDICS Allergies: Cefazolin Attending:[**First Name3 (LF) 16613**] Chief Complaint: Right calcaneonavicular coalition Major Surgical or Invasive Procedure: [**2159-7-4**]: Right foot triple arthrodesis [**2159-7-5**]: Right thigh fasciotomies for compartment syndrome [**2159-7-6**]: Right thigh I&D with VAC placement [**2159-7-8**]: Right thigh I&D with VAC change [**2159-7-10**]: Right thigh I&D with medial incision closure and VAC change to lateral wound [**2159-7-13**]: Right thigh I&D with bilateral VAC placements [**2159-7-16**]: Right thigh I&D with bilateral VAC changes [**2159-7-19**]: Right thigh I&D with bilateral VAC changes [**2159-7-20**]: Right thigh I&D with Lateral VAC changes/ Medial wound packing [**2159-7-21**]: Right thigh I&D with Lateral VAC changes/ Medial wound packing [**2159-7-22**]: Right thigh I&D with Lateral VAC changes/ Medial wound packing [**2159-7-23**]: Right thigh I&D with Lateral VAC changes/ Medial wound packing [**2159-7-24**]: Right thigh I&D with Lateral VAC changes/ Medial wound packing [**2159-7-25**]: Right thigh I&D with Lateral and Medial VAC placements [**2159-7-27**]: Right thigh I&D with VAC changes [**2159-7-30**]: Right thigh I&D with VAC changes [**2159-8-1**]: VAC change at bedside [**2159-8-5**]: VAC change at bedside [**2159-8-8**]: Right thigh I&D partial closure lateral wound and VAC change to medial wound [**2159-8-12**]: Right thigh I&D closure lateral wound and VAC change to medial wound [**2159-8-16**]: Right thigh medial wound skin graft with partial closure [**2159-8-23**]: Removal of right thigh medial VAC [**2159-8-31**]: PICC line removal History of Present Illness: Mr. [**Known lastname 17811**] is a 33 year old man who presented to the [**Hospital1 18**] on [**2159-7-4**] for an elective triple arthrodesis on his right foot due to calcaneonavicular coalition. Past Medical History: Hypertension Depression Right shoulder fracture as a child w/ multiple surgeries Rotator Cuff Tear s/p repair [**11-20**] c/b infection, I&D [**12-21**] Chronic Foot pain followed at Pain Clinic Social History: Patient denies tobacco or illicit drug use. He reports tobacco use, at most .5 ppd, decreased to [**4-17**] cigarettes/day recently. He lives with his girlfriend and daughters. Family History: mom suffered MI at age 42, aunt MI in her 40's, no early or sudden deaths Physical Exam: Upon discharge Alert and oriented, NAD VSS Pulse regular R thigh lateral wound sutures in place proximally, steri strips in place distally, no surrounding edema/erythema medial thigh wound JP in place, xeroform covering wound, no surrounding edema/erythema L thigh graft open, tissue red no surrounding erythema/edema R leg cast in place, able to wiggle toes b/l L no c/c/e Pertinent Results: [**2159-8-29**] 04:31AM BLOOD WBC-11.2* RBC-3.57* Hgb-10.5* Hct-32.1* MCV-90 MCH-29.4 MCHC-32.7 RDW-13.1 Plt Ct-421 [**2159-7-5**] 12:23PM BLOOD WBC-16.7*# RBC-3.41* Hgb-10.9* Hct-32.2* MCV-94 MCH-32.1* MCHC-34.0 RDW-12.2 Plt Ct-179 [**2159-8-10**] 04:04AM BLOOD Neuts-61.2 Lymphs-25.6 Monos-6.7 Eos-6.0* Baso-0.5 [**2159-8-29**] 04:31AM BLOOD Plt Ct-421 [**2159-8-30**] 03:24AM BLOOD Glucose-114* UreaN-19 Creat-1.3* Na-140 K-4.5 Cl-99 HCO3-32 AnGap-14 [**2159-7-5**] 11:24AM BLOOD UreaN-16 Creat-1.6* Na-132* K-4.5 Cl-99 HCO3-22 AnGap-16 [**2159-8-30**] 03:24AM BLOOD ALT-15 AST-18 [**2159-7-5**] 11:24AM BLOOD CK(CPK)-[**Numeric Identifier 43203**]* [**2159-8-1**] 08:35AM BLOOD ALT-11 AST-22 LD(LDH)-267* CK(CPK)-238* AlkPhos-116 Amylase-66 TotBili-0.3 [**2159-7-5**] 02:35PM BLOOD Calcium-7.0* Phos-4.2 Mg-1.6 [**2159-8-30**] 03:24AM BLOOD Albumin-3.6 Calcium-9.7 Phos-5.5*# Mg-1.9 [**2159-8-16**] 03:59AM BLOOD calTIBC-183* Ferritn-257 TRF-141* Pertinent XR data: 1. [**7-4**]: Post-surgical changes of the right hindfoot are noted, status post triple fusion. No immediate hardware complication is noted. There is a cast in place that obscures fine bony detail. Skin clips are seen related to recent surgery. Soft tissues are otherwise unremarkable. 2. [**7-5**]: Findings compatible with compartment syndrome involving the right thigh. No hematoma is identified. The superficial and deep femoral veins on the right are not visualized and likely are markedly compressed secondary to adjacent mass effect. There are multiple collateral veins in the thigh. 3. [**7-5**]: No DVT in both lower extremities. 4. [**7-26**]: No bony abnormalities of the knee or ankle. Appropriate postoperative appearance of triple arthrodesis of the right hindfoot. 5. [**8-10**]: 1. Status post supraspinatus tendon repair. The repair appears intact. Stable postsurgical changes about the distal clavicle and acromion. New finding of mild tendinopathy of the long head of the biceps tendon. 6. [**8-29**]: No evidence of thrombus in the left IJ, subclavian, axillary, brachial and basilic veins. Cephalic vein was not visualized. A persistent cephalic vein thrombosis cannot be excluded. Pathology data: [**7-25**]: Muscle, right leg, biopsy: Skeletal muscle with focal myocyte necrosis, acute and chronic inflammation and hemorrhage. Brief Hospital Course: Consults during admission: Infectious Disease Plastic Surgery Nephrology Psychiatry 1. Triple Arthrodesis: Mr. [**Known lastname 17811**] presented to the [**Hospital1 18**] on [**2159-7-4**] for an elective triple arthrodesis. Prior to surgery he was prepped and consented. He was taken to the operating room and underwent a triple arthrodesis. He also had a popliteal nerve block. He was taken to the recovery room and then to the floor. 2: Compartment syndrome with acute renal failure and wound infection: On the floor he had continued right leg pain noted more at his thigh. On [**2159-7-5**] he underwent a CT of his leg which was positive for a probable compartment syndrome. He was taken to the operating room emergently and underwent right thigh fasciectomies. He remained intubated and was transferred to the ICU. He was noted to be in acute renal failure with a creatinine of [**2-19**] and a CPK of [**Numeric Identifier 71451**]. He was seen by the renal service, was given fluid with sodium bicarbonate for renal protection, and his creatinine returned to 1.1 on [**7-8**]. The patient was started on vancomycin. He had a fever to 101.9 on [**7-9**]; his sputum grew out H flu and E coli, and so he completed a 5-day course of ciprofloxacin. On [**2159-7-6**] he returned to the operating room and underwent another I&D with VAC placements to both open wounds. He returned to the ICU and was weaned and extubated. His CPK continued to decrease after surgery and renal function slowly returned to [**Location 213**] limits. On [**2159-7-8**] he again returned to the operating room for another I&D with VAC change. On [**2159-7-9**] he was transfused with 1 unit of PRBC due to acute blood loss anemia and again on [**7-11**] for H/H 7.6/22.8 with 2 units; his Hct rose to 27.0. On [**2159-7-10**] he returned to the operating room and underwent an I&D with medial wound closure and VAC change to lateral wound. Plastic surgery was consulted to help with wound closure and possible flap. On [**2159-7-10**] the chronic pain service was consulted to help with pain management. On [**2159-7-13**] he returned to the operating room and underwent an I&D of his right thigh with VAC changes. The medial wound was left open as there was concern for infection; the patient was continued on vancomycin and On [**2159-7-16**] he was again taken to the operating room and underwent another I&D of bilateral thigh wounds with VAC changes. His vancomycin was also decreased to 750mg Q12hrs for an elevated trough. On [**2159-7-17**] a short leg cast was placed on his right foot. On [**2159-7-19**] he returned to the operating room and underwent an I&D of his thigh wounds with VAC changes. Infectious disease was consulted, and the patient was started on zosyn in addition to the vancomycin, as tissue culture on [**7-19**] revealed Klebsiella pneumoniae, Staph coag negative, and Prevotella species. On [**2159-7-21**] he began daily I&D with dressing changes in the operating room which ended on [**2159-7-25**] when both wounds were dressed with VAC dressings. Repeat tissue cultures on [**7-21**] and [**7-23**] again revealed Klebsiella pneumoniae. On [**7-23**] and [**7-25**] his tissue cultures also grew out [**Female First Name (un) 564**] albicans, and so the patient was placed on fluconazole. On [**2159-7-26**] he was again transfused with 2 units of packed red blood cells due to acute blood loss anemia. On [**2159-7-27**] and [**2159-7-30**] he again returned to the operating room for an I&D of the right thigh with VAC changes. On [**2159-8-1**] he tolerated a VAC change at the bedside. On [**2159-8-3**] the Zosyn was stopped with the thought of a drug fever, and Cipro and Flagyl was started. On [**2159-8-5**] he underwent another VAC change at the bedside. On [**2159-8-8**] he underwent a right leg I&D with lateral wound partial closure and VAC change to the medial side. On [**2159-8-12**] he again returned to the operating room and underwent a right leg I&D with lateral wound closure and a VAC change to the medial wound. On [**2159-8-16**] he was taken to the operating room with plastic surgery and underwent a partial closure of the medial wound with a skin graft. A VAC was placed over the medial wound. On [**2159-8-23**] the VAC was removed, JP's remained in place and he was started on daily Xeroform dressing changes. On [**8-30**] his vancomycin, flagyl, and fluconazole were discontinued as per infectious disease, and on [**2159-8-31**] his PICC line was removed. Of note, all blood cultures taken were negative. A portion of the sutures on his lateral wound were removed on [**8-30**] (over 14 days beyond wound closure), but the skin had not completely epitheliazed, and so the remainder of the sutures were kept in place. Plastic surgery requested that the patient be maintained on ciprofloxacin as the JP drain remains in place. 3. Hypertension: On [**2159-8-25**] atenolol was started in addition to his previous lisinopril for hypertension. On [**2159-8-27**] his lisinopril was increased due to hypertension. On [**2159-8-29**] his lisinopril was stopped due to rising creatine and his atenolol was increased. 4. History of DVT: The patient had been on coumadin for a DVT in [**2158-12-14**]. This was discontinued on admission as the patient was placed on enoxaparin. On [**2159-8-30**] he had a left upper extremity ultrasound for evaluation of his known DVT, which revealed no thrombus in any of the veins with the excpetion of the cephalic vein, which could not be visualized. In communication with his Primary Care Provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **] he was not placed back on coumadin. 5. Depression: The patient has a history of depression, and had previously been on prozac. For this reason psychiatry was consulted on [**8-9**], and they recommended that the patient be placed on citalopram. His dose was titrated up and he responded well. 6. DVT Prophylaxis: The patient was maintained on enoxaparin throughout his hospital stay. 7. Physical therapy: The patient was seen by physical therapy to improve his stength. On [**2159-8-31**] he was ready for discharge home with daily dressing changes and JP care from the VNA. He has follow up appointments already arranged for orthopaedics, plastic surgery, and his primary care provider. [**Name10 (NameIs) **] was given prescriptions for all his medication. He is being discharged today in stable condition. Of note, I was directly involved in the care of the patient only from [**8-7**] - [**8-31**]. Medications on Admission: Coumadin held several days prior to surgery Lisinopril 10 Neurontin percocet Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 weeks: While drains are inplace. Disp:*56 Tablet(s)* Refills:*0* 2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal Q72H (every 72 hours). Disp:*10 patch* Refills:*0* 3. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours) as needed for pain. Disp:*270 Capsule(s)* Refills:*0* 4. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*5* 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*5* 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours). Disp:*60 Tablet(s)* Refills:*5* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*5* 10. Wheelchair Device Sig: One (1) Miscellaneous as needed: As needed for mobilization. Disp:*1 1* Refills:*0* 11. kerlex Sig: One (1) once a day: Wrap around wound once daily. Disp:*10 * Refills:*5* 12. Xeroform Petrolatum Dressing 5 X 9 Bandage Sig: One (1) Topical once a day: Apply to medial thigh wound once daily. Disp:*10 * Refills:*5* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right calcaneonavicular coalition Right thigh compartment syndrome Acute blood loss anemia Acute renal failure PMx diagnoses: Hypertension Depression R shoulder frx as a child w/ multiple surgeries Rotator Cuff Tear s/p repair [**11-20**] c/b infection, I&D [**12-21**] Chronic Foot pain followed at Pain Clinic, s/p b/l operations for tarsal coalitions, LUE DVT [**12-21**] Discharge Condition: Stable Discharge Instructions: Continue to be non-weight bearing on your right leg Keep cast clean and dry, do not put anything down your cast Please take your antibiotics until JP drains are out and you check with Plastic Surgery If you have any increased redness, drainage, or swelling, concerns about your wounds, or if you have a temperature greater than 101.5 please call the office or come to the emergency department. Physical Therapy: Activity: Activity as tolerated Right lower extremity: Non weight bearing Left lower extremity: Full weight bearing Treatment Frequency: Daily xeroform dressing over graft with kerlex dressing JP care and recording output daily Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 7376**] in next Thursday [**2159-9-6**], please call [**Telephone/Fax (1) 1228**] to schedule that appointment. Please follow up with Dr. [**First Name (STitle) **] [**2159-9-4**], 6:15pm in Plastic Surgery. His office is in the [**Hospital Unit Name **] [**Hospital Unit Name 71452**]. The phone to the office is [**Telephone/Fax (1) 6742**]. Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], PA at Dr.[**Name (NI) 71453**] office on [**9-5**] at 1130. The phone number to the office is [**Telephone/Fax (1) 4475**]. It is important to go to this appointment as your blood pressure medication has changed. [**Name6 (MD) 13978**] [**Name8 (MD) **] MD [**MD Number(2) 16614**] Completed by:[**2159-8-31**]

[ "998.59", "285.1", "729.5", "755.67", "716.97", "584.9", "401.9", "E878.8", "958.8", "V12.51", "282.5", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "83.45", "86.59", "83.14", "81.12", "83.19", "38.93", "86.69", "77.79", "83.21", "96.6", "81.91" ]

icd9pcs

[ [ [] ] ]

13460, 13518

5306, 11400

308, 1808

13938, 13946

2950, 5283

14644, 15473

2465, 2540

12051, 13437

13539, 13917

11949, 12028

13970, 14367

2555, 2931

14385, 14507

235, 270

1836, 2036

14528, 14621

2058, 2254

2270, 2449

40,600

197,261

36797

Discharge summary

report

Admission Date: [**2174-9-25**] Discharge Date: [**2174-10-4**] Service: MEDICINE Allergies: Lisinopril / Zoloft Attending:[**First Name3 (LF) 1515**] Chief Complaint: Unresponsiveness. Major Surgical or Invasive Procedure: Right lower extremity laser angioplasty on [**9-29**]/9. History of Present Illness: Mr. [**Known lastname 931**] is a [**Age over 90 **] year old gentleman wiht a PMH significant for CAD, COPD on 2L nc at night, PE on coumadin, mild AS, and DM 2 transferred to the CCU for unresponsiveness. The patient was initially admitted to an OSH for unresponsiveness and slurred speech that spontaneously resolved. At that time, he denied any chest pain, but does endorse dyspnea with exertion and occasional exertional chest pain when walking from his bed to the bathroom. At the OSH, the patient had a CTH that was negative and carotid dopplers that demonstrated severe bilateral carotid stenosis. He was also noted to have a right foot ulcer for which he received amp/sulbactam and was transfused 1 unit pRBCs on the morning of [**2174-9-25**] for a hemoglobin of 10.0. Of note, the patient was scheduled for an outpatient revascularization procedure of the RLE on [**2174-9-27**] prior to this admission. . On initial arrival, the patient was noted to be mildly fluid overloaded and noted that he had increased lower extremity edema for the past 2 weeks. A CXR demonstrated mild pulmonary edema and increased pulmonary vascular congestion with a BNP of 2200. This morning, the patient was found to be unresponsive. On initial exam, he was noted to have convulsions, which were not tonic-clonic in nature. ABG on 2L nc 7.40/62/91 and the patient received 40 mg IV lasix. He regained consciousness within minutes, although remained confused and unable to follow commands for several minutes without any stool incontinence (FC in place). . Currently, he is resting comfortably without complaints. Denies CP/SOB, f/c/s, n/v/d, abd pain, HA, palpitations, diaphoresis, or pain radiating to jaw or arm. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: Coronary Artery Disease s/p cath [**6-23**] with occlusion of LAD and collaterals, medically managed Aortic stenosis - mild on cath ([**6-23**]), mean peak to peak gradient of 28 mmHg. PE ([**4-23**]) COPD - 2L supplemental oxygen at night Restrictive lung disease (per report) Diabetes Mellitus Obesity arthritis Paralysed left hemi-diaphragm Appendectomy prior knee surgery Social History: He is a widower who lives with his daughter in [**Name (NI) 83153**]. Tobacco history: history of 1 ppd x 2 years, quit in 60s Family History: Mother had a stroke, [**Name (NI) **] CHF, Daughter with leukemia, Son died of "cancer". Physical Exam: VS: 97 67 [**10/2119**] 89%1L nc GENERAL: Age appropriate male in NAD HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without lesions, exudate, or erythema. CV: Nl S1+S2, II/VI systolic murmur throughout precordium loudest at the base. Unable to ascertain JVP. Pulm: Decreased breathsounds at left base. No wheezes. Abd: S/NT/ND +bs Ext: 1+ edema bilaterally. Unable to palpate dp/pt pulses Neuro: Oriented to person and time. CN II-XII intact. Skin: RLE bandaged. 2x2 cm ulcuer with eschar. No surrounding erythema. Pertinent Results: ECG: Sinus with 1:1 conduction. LBBB. NI. TWI in V1-V3 new compared to [**2174-7-11**]. . CXR ([**2174-9-25**]): Mild cardiomegaly is stable. The left hemidiaphragm is elevated as before, but small bilateral pleural effusions with adjacent basal atelectasis are new. There is mild vascular congestion. There is no pneumothorax. . CXR ([**2174-9-26**]): New LLL/lingula collapse. . Carotid Artery U/S 10/2/9 from OSH: FINDINGS: On the right, the common carotid artery peak systolic velocity is 36, diastolic velocity 5, internal carotid artery peak systolic velocity 143, diastolic velocity 15, external carotid artery peak systolic velocity 216. The vertebral artery is visualized with antegrade flow. The peak systolic velocity ratio is 0, diastolic velocity ratio 3.0. B-mode imaging is suboptimal, and not adequate to assess plaque morphology or degree of occlusion; however, based on the velocities obtained, the occlusion could range anywhere from 60-99%. . On the left, the common carotid artery peak systolic velocity is 75, diastolic velocity 12. Internal carotid artery peak systolic velocity 168, diastolic velocity 61, external carotid artery peak systolic elocity 220. The vertebral artery is visualized with antegrade flow. The peak systolic velocity ratio is 2.2, diastolic velocity ratio 5.1. Again, B- mode imaging is suboptimal due to patient habitus and cooperation, and is not adequate to assess the degree of occlusion or morphology of the plaque. Velocity criteria would suggest occlusion in the range of 60-99%. . Admission labs on [**9-25**]/9: WBC-9.9 RBC-3.22* Hgb-9.8*# Hct-30.8* MCV-96 MCH-30.3 MCHC-31.6 RDW-15.1 Plt Ct-338# PT-25.2* PTT-33.2 INR(PT)-2.4* Glucose-188* UreaN-17 Creat-0.7 Na-144 K-4.0 Cl-105 HCO3-33* AnGap-10 Calcium-8.2* Phos-2.2* Mg-2.0 Iron-17* calTIBC-217* VitB12-349 Folate-6.7 Ferritn-110 TRF-167* . CXR [**9-28**]: CHEST, AP UPRIGHT: There is similar moderate elevation of the left hemidiaphragm with confluent opacification of the left lower chest, likely reflecting extensive atelectasis of both the left lower lobe and lingula. Considerable leftward mediastinal shift is associated with volume loss, similar to slightly increased. Given confluent opacification, it is difficult to exclude an associated pleural effusion. However, unaffected portions of the lungs are essentially within normal limits without evidence for pulmonary edema. The right lung remains clear. There is no evidence of pneumothorax. IMPRESSION: Persistent collapse of the left lower lobe and lingula with volume loss, including elevation of the left hemidiaphragm and leftward mediastinal shift, perhaps slightly increased. . CTA head/neck: 1. Approximately 80% stenoses of the distal common carotid and proximal internal carotid arteries bilaterally. 2. Mild plaque slightly narrowing the right vertebral artery origin. 3. Mild narrowing of the cavernous and supraclinoid internal carotid arteries due to atherosclerosis. 4. No evidence of acute intracranial abnormalities. Areas of supratentorial white matter hypodensity are nonspecific, but likely represent sequela of chronic microangiopathy, given the patient's age. 5. Bilateral pleural effusions, left greater than right, with associated dependent atelectasis. Possible left upper lobe pneumonitis. These findings are new since [**2174-7-5**]. 5. Subluxation of the right temporomandibular joint. . Discharge labs [**10-4**]: Glucose 81 UreaN 23 Creat 0.8 Na 143 K 4.0 Cl 94 HCO3 46 AnGap WBC 10.6 RBC 2.79* Hgb 8.4* Hct 26.3* Plt 289 PMN 88.7* Bands 7.1* Lymphs 4.1 Monos 0 Eos 0.1 PT 19.0* PTT 63.0* INR 1.7* . EEG results: This is a mildly abnormal routine EEG due to mild slowing and disorganization of the background rhythm. These findings suggest a mild encephalopathy involving cortical and subcortical structures. Medication, toxic/metabolic disturbances, and infection are among the most common causes. There were no areas of prominent focal slowing although encephalopathies can obscure focal findings. There were no epileptiform discharges or electrographic seizures. . Cardiac cath [**9-29**] COMMENTS: 1. Peripheral angiography of the right lower extremity demonstrated patent Iliac arteries bilaterally. The right common femoral had no hemodynamic angiographically apparent disease. The right SFA had a serial calcified 90% stenosis in the mid to distal vessel that involved the above knee popliteal. There was single vessel runoff via the right AT. The left lower extremity was not injected. 2. Successful PTA and Laser of the right mid to distal SFA and above knee popliteal with a 5.0 x 120mm Submarine balloon. Final angiography revealed a 20% residual stenosis, no angiographically apparent dissection or perforation, and excellent flow distally via the AT. (see PTA comments for details) FINAL DIAGNOSIS: 1. 90% serial calcified stenosis of the right SFA and [**Doctor Last Name **]. 2. Successful PTA and Laser of the right SFA and [**Doctor Last Name **]. Brief Hospital Course: Mr. [**Known lastname 931**] is a [**Age over 90 **] year old gentleman with a PMH significant for CAD, COPD on 2L nc at night, PE on coumadin, mild AS, and DM 2 transferred to [**Hospital1 18**] and then subsequently to the CCU for unresponsiveness. Called out to the floor after a few days (following no further unresponsiveness episodes, and following laser angioplasty to right lower extremity). . # Unresponsiveness: Most likely etioloigy at this time is LLL collapse leading to transient hypoxia in setting of bilateral carotid occlusive disease with supple/demand mismatch. This may have also represented a TIA from embolic source, although less likely. Could also have been hyperventilation from anxiety as patient did not receive his regular daily ativan in the morning. From an obstructive lung disease standpoint, he appears to be at baseline with minimal wheezing and an ABG on 2L nc with appropriate pH and compensatory metabolic compensation in setting of chronic CO2 retention. Additionally, this may represent new seizure activity, although patient does not have a history of seizure activity. Neurology was consulted. Based upon the history, physical exam, imaging studies of the carotids, a decision between neuro and cardiology was made to not intervene on the carotid arteries during this admission. Patient did not have further episodes of unresponsiveness in-house. . # Femoral Artery Stenosis: Patient had a planned revascularization at OSH which the patient was unable to have, as he was in-house on the day of the planned procedure. In-house, he underwent catheterization which showed serial calcified 90% stenosis in the mid to distal vessel extending to the above knee popliteal artery. Patient underwent balloon and laser angioplasty of right SFA with restoration of excellent flow to RLE. . # Carotid stenosis: Patient transferred for carotid intervention. Based upon recommendations from neuro, the patient's mental status, and the imaging studies (CTA head/neck and reconstructions), a decision was made to not intervene on his carotid arteries. . # Respiratory: Patient with known COPD on supplemental overnight O2 at home. Based on physical exam, admission CXR, and elevated BNP, he likely also had an element of volume overload secondary to cardiogenic pulmonary edema. In addition, he was noted to have elevated filling pressures on cardiac catheterization in [**6-23**]. Patient was diuresed, given mucolytics, chest PT, nebulizers. For potential COPD flare (wheezes on exam), patient treated with Azithromycin and a prednisone burst which was then transitioned to a taper, as the patient was on long-term prednisone at home for hyper-IgE syndrome and eosinophil count was downtrending. Patient had episode of desaturation while lying flat during vascular procedure, but then responded to upright position and Lasix and by the next morning he was satting well on 1-2L NC; goal SpO2 in low 90's secondary to COPD history. Pulmonary was consulted and recommended nocturnal BIPAP which the patient refused. Pulmonary team also recommended draining pt's pleural effusion only if it fails to improve with antibiotics and BIPAP, in hopes of avoiding invasive procedures if possible. Patient's shortness of breath and PO2 improved with Lasix, and PO2 is lower at night due to patient refusing BIPAP at night. . # CAD: Patient continued on metoprolol, ASA, statin, imdur. Patient has daily morning chest pressure that he reports is typical for him. One night, he had chest pressure, during which nitro, morphine, lasix, oxygen, and ativan were given for the chest pressure and the SOB. This resolved. ECG had ST depressions in V1, V2, and TWI, low suspicion for ACS, more consistent with pulmonary edema and anxiety. After that episode, no further episodes. On telemetry for monitoring, and will be discharged on telemetry for continued monitoring. . # Pump: Patient with preserved LVEF on last echo, although with signs of volume overload initially. Patient was diuresed with Lasix, and breathing improved. . # Rhythmn: Sinus with 1:1 conduction. No events on telemetry. . # Anemia: Unclear baseline, although patient received 1 unit PRBC at OSH prior to transfer for hemoglobin 10. Patient with iron studies consistent with iron deficiency anemia. Patient's Hct stable while at [**Hospital1 18**]. No further transfusions. Would like patient to have outpatient work-up for anemia, ie: colonoscopy if appropriate, etc - recommend PCP [**Name9 (PRE) 702**] for this issue. . # Pulmonary embolism: Patient with history of PE in [**4-23**] on coumadin. Unclear based on review of records if there was an inciting event and need for continued anticoagulation. Plan to anticoagulate at least 6 months nonetheless until [**2174-10-16**]. Patient on heparin gtt while inpatient as preparation for potential procedure. Post-procedure, restarted coumadin at home dose, with heparin bridge. . # DM: Held home glipizide. Continued HISS and accuchecks. Patient hyperglycemia, beleived due to steroid course, so treated with insulin sliding scale. Will have this monitored at rehab, given the patient is having his steroids tapered. . # Heel ulcer: Patient with non-healing ulcer in setting of PVD and diabetes. On [**9-29**]/9 had right lower extremity laser angioplasty, to increase vascular flow to this leg, in the hopes to help decrease pain and help ulcer heel. . # Positive blood culture at outside hospital, 1 bottle of [**Last Name (LF) 83154**], [**First Name3 (LF) **] treated with 7 day antibiotic course (first unasyn IV, then augmentin PO). Medications on Admission: Lipitor 80mg PO qday Metoprolol 25mg PO BID Ranitidine 150mg PO BID Lorazepam .5mg PO qHS Coumadin 5mg four days per week (per d/c summary, was M/T/W/F) Coumadin 7.5mg 3 days per week (per d/c summary, was Sat/Sun/[**Last Name (un) **]) Glipizide 10mg PO BID Gabapentin 100mg PO TID Isosorbide 60mg PO qday Lasix 40mg PO qday Atenolol 25mg PO qday Insulin 20 units SC qday (type not specified) Prednisone 10 [**Hospital1 **] (for hyper-eosinophilia) 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. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK ([**Doctor First Name **],TH,SA). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK (MO,TU,WE,FR). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for Wheezing. 11. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily): Hold SBP<90. 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 14. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO daily () for 1 days: Last day [**10-5**]. 15. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO once a day for 3 days: last day [**10-8**]. 16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 3 days: Last day [**10-11**]. 17. Prednisone 2.5 mg Tablet Sig: 0.5 Tablet PO daily () for 3 days: Last day [**10-14**], then d/c. 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 21. Heparin (Porcine) in NS (PF) Intravenous 22. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: per sliding scale and PTT results units Intravenous continuous: D/c once INR > 2.0. 23. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: lakes regional hospital Discharge Diagnosis: Hypoventilation syndrome Anemia Peripheral Artery Disease Diabetes Mellitus type 2 Acute on chronic Diastolic congestive Heart Failure Bilateral Carotid Stenosis Discharge Condition: stable Na:143 CL=94 K=4.0 HCO3=46 Ca: 8.8 Mg: 2.4 P: 3.9 hct=26.3 PT: 19.0 PTT: Pnd INR: 1.7 Discharge Instructions: You had a procedure to open the arteries in your right leg. We hope this will help your ulcer on your right foot to heal. You also had a exacerbation of your lung disease and was treated with antibiotics, nebulizers and prednisone. Medication changes: 1. Stop Atenolol 2. Start Metoprolol Succinate to keep your heart rate low 3. START ATrovent to help with your breathing 4. Start a prednisone taper to help with your breathing 5. Restart Lasix to treat your fluid retention. . Followup Instructions: Primary Care: [**Last Name (LF) 83155**],[**First Name3 (LF) 2515**] W Phone: [**Telephone/Fax (1) 77350**] Please make an appt to see once you are out of rehab Cardiology: [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] Phone: ([**Telephone/Fax (1) 83156**] Date/time: Please make an appt to see her in [**1-18**] weeks.

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icd9cm

[ [ [] ] ]

[ "00.41", "88.48", "39.50" ]

icd9pcs

[ [ [] ] ]

16646, 16696

8385, 13968

245, 303

16902, 17002

3395, 8190

17530, 17912

2747, 2837

14468, 16623

16717, 16881

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17026, 17258

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331, 2187

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2602, 2731

79,987

150,729

36030

Discharge summary

report

Admission Date: [**2162-2-5**] Discharge Date: [**2162-2-12**] Date of Birth: [**2102-5-2**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Percocet / Iodine; Iodine Containing Attending:[**First Name3 (LF) 3948**] Chief Complaint: Shortness of breath, coughing, leaking from G-tube Major Surgical or Invasive Procedure: [**2162-2-11**]: Doboff feeding tube [**2162-2-9**]: Flexible bronchoscopy with therapeutic aspiration. [**2162-2-6**]: Flexible bronchoscopy with therapeutic aspiration [**2162-2-5**]: Rigid bronchoscopy with black Dumon bronchoscope. Therapeutic aspiration of secretions. Balloon dilatation right middle lobe. BAL. Tumor debridement (blood clot). [**2162-2-5**]: Flexible bronchoscopy with therapeutic aspiration. History of Present Illness: Patient is a 59-year-old female with h/o NSCLC, malignant pleural effusion s/p pleurodesis, and nonmalignant pericardial effusion, now presenting with increasing shortness of breath and worsening cough for the past 10 days. Her cough was minimally productive at first, but increased in production with slightly blood-tinged sputum after starting Mucinex on her recent OSH hospitalization. She also had some pleuritic chest pain with persistent coughing, rated [**8-13**]. She otherwise denies fever, chills, chest pain or palpitations. Additionally, she recently had a G-tube placement about 3 weeks ago at [**Hospital 931**] Hospital. Patient notes that it started leaking about 1 week ago. She returned to the hospital, at which point the position of the G-tube was confirmed by her surgeons. But it still continued to leak. Of note, patient has also been having vaginal bleeding for the past 2 weeks, worse in the beginning, but more recently improved with only some spotting now. Previous CT abdomen/pelvis (done about 5 weeks ago) had revealed a uterine fibroid, suspected as a possible cause for her menorrhagia. Her oncologist also suspects metastasis and wants a biopsy done. She was then admitted to [**Hospital2 **] [**Hospital3 6783**] hospital on [**2162-2-3**] to the Internal Medicine service. After obtaining a pulmonology consult by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], CT chest was done which revealed occlusion of the right mainstem bronchus with associated collapse and consolidation of the right lobe with additional adjacent loculated pleural effusion, stable pericardial effusion, and bilateral renal masses. She was started on azithromycin and ceftriaxone. She was also evaluated by GI (Dr. [**First Name (STitle) **], who increased the tightness of the G-tube bumper to 4 cm and recommended less water to be flushed after meds are given and to palce the patient on her right side during the day to encourage tube feeds to go from stomach to duodenum. Regarding her vaginal bleeding, OB/Gyn consult was initiated. Given her pulmonary status, patient is now being transferred here for further workup with bronchoscopy and possible stenting of the bronchus. ROS: Positive for shortness of breath, cough, dyspnea on exertion, abdominal pain, nausea, vaginal bleeding, bilateral lower extremity edema, back pain and occasional constipation. Negative for fever, chills, headache, vomiting, tingling, numbness, seizures, loss of consciousness, chest pain, palpitations or diarrhea Past Medical History: -Stage IV non-small-cell lung cancer, s/p radiation and 3 lines of chemotherapy -H/o malignant pleural effusion, s/p pleurodesis -Nonmalignant pericardial effusion, s/p pericardial window ([**11/2161**]) -Radiation-induced esophagitis -Type 2 diabetes mellitus -Hypertension -Depression -s/p G-tube placement 3 weeks ago -Hyperlipidemia Social History: Lives at home with her family. Ex-smoker, [**2-5**] ppd x35 yrs (35-70 pk-yrs), quit 1 year ago. Denies alcohol use. Previously smoked marijuana. Family History: non-contributory Physical Exam: VS: T: 98.4 HR: 111 ST BP: 122/56 Sats: 100% 2L General: sitting up in chair no apparent distress HEENT: mucus membranes dry, doboff feeding tube right nostril Card: RRR Resp: scattered rhonchi throughout GI: obese, bowel sounds positive Extr: warm Neuro: non-focal Pertinent Results: [**2162-2-8**] 06:24AM BLOOD WBC-9.3 RBC-3.26* Hgb-9.4* Hct-29.6* MCV-91 MCH-28.8 MCHC-31.8 RDW-13.9 Plt Ct-709* [**2162-2-7**] WBC-9.3 RBC-3.21* Hgb-9.1* Hct-28.9* Plt Ct-592* [**2162-2-5**] WBC-11.3* RBC-3.10* Hgb-9.1* Hct-27.7* Plt Ct-643* [**2162-2-11**] PT-15.6* INR(PT)-1.4* [**2162-2-10**] PT-16.2* PTT-25.8 INR(PT)-1.5* [**2162-2-9**] Glucose-122* UreaN-9 Creat-0.4 Na-139 K-3.7 Cl-93* HCO3-43* [**2162-2-8**] Glucose-103 UreaN-11 Creat-0.5 Na-138 K-3.7 Cl-92* HCO3-44* [**2162-2-5**] ALT-22 AST-20 LD(LDH)-192 CK(CPK)-19* AlkPhos-108 TotBili-0.5 [**2162-2-7**]: CTA airway, No evidence of pulmonary embolus. Occlusion of the right main stem bronchus as well as complete collapse of the right lung. An underlying obstructive mass cannot be excluded and further evaluation with bronchoscopy may be helpful. Bilateral pleural effusions and a small pericardial effusion. Enlarged bilateral adrenal glands as well as an L4 lytic lesion, both concerning for metastasis. NG tube malpositioned outside of the stomach body. [**2162-2-8**]: CXR: In comparison to study of [**2-7**], there are decreased lung volumes and some increasing prominence of interstitial markings, suggesting overhydration. Complete opacification of the right hemithorax persists, consistent with the CT demonstration of complete occlusion of the right mainstem bronchus and complete collapse of the right lung. [**2162-2-11**]: Abdominal film: NG tube tip coiled in the fundus of the stomach, [**2162-2-10**]: Barium Esophagus: Markedly limited study, shows aspiration as well as free passage contrast through the esophagus into the stomach, without evidence of frank stricture. Brief Hospital Course: Mrs. [**Known lastname 41033**] was admitted on [**2162-2-5**] for further evaluation of her Stage IV NSCLC s/p chemo/XRT therapy now with malignant airway obstruction. On [**2161-2-4**] she was taken to the operating room for Rigid bronchoscopy, balloon dilation, tumor debridement and therapeutic aspiration. She was extubated in the OR monitor in the PACU were she was re-intubated for hypoxia, bronch with removal of a small blood clot partially obstructing the RUL. She transferred to the SICU for further management. On [**2162-2-6**] she had bronchoscopy with aspiration for the RMS & RUL. She given a fluid bolus for hypotension. LENIS were negative for DVT. She was sucessfully extubated and diuresed with lasix. On [**2161-2-6**] the CT airway revealed No evidence of pulmonary embolus. Occlusion of the right main stem bronchus as well as complete collapse of the right lung.Bilateral pleural effusions and a small pericardial effusion. Enlarged bilateral adrenal glands as well as an L4 lytic lesion, both concerning for metastasis. NG tube malpositioned outside of the stomach body. The G-tube was removed secondary to placement in fascia. She transferred to the floor and remained stable. She remained NPO and was maintained on IV fluids. She was evaluated by GI for possible esophageal stricture and feeding tube placement. Pallative Care was consulted and assisted with her pain control and transition to hospice. On [**2161-2-9**] her INR was 1.5 she was given SL Vit k. On [**2162-2-11**] she underwent EGD which showed severe gastritis and absence of GI motility. A Doboff feeding tube was placed and tube feeds were started per nutrition recommendations. Over the course of her hospitalization she had multiple bronchoscopy for muscus pluggings. On [**2162-2-12**] she was discharged to home with family and hospice. Medications on Admission: -Lactulose 10 mg/mL [**2-5**] spoons TID -Bupropion 150 mg [**Hospital1 **] -Lasix 40 mg daily -Morphine sulfate 20 mg q1-3h prn pain -Magonate 27 mg [**Hospital1 **] -Reglan 5 mg TID -Metoprolol 12.5 mg [**Hospital1 **] -Polyethylene glycol 17g in 8oz of water daily -Ranitidine 150 mg [**Hospital1 **] -Mucinex 400 mg q6h -Temazepam 15 mg qhs prn -Glucerna 237 mL, 6 cans daily at rate of 50-60 mL per hour -Fentanyl transdermal patch 75 mcg per hour q3d -Xalatan 0.005% eye drops 1 drop in each eye qhs -Alphagan 0.2% eye drops 1 drop in each eye [**Hospital1 **] -Miracle mouthwash, swish and spit 5 mL TID -Ondansetron 8 mg q8h prn -Albuterol inhaler prn -Ibuprofen (only for couple weeks for menstrual cramps) Discharge Medications: 1. Replete with Fiber Goal 65 ml/hr. 2. Morphine Concentrate 20 mg/mL Solution Sig: 20-30 ML PO every 1-4 hours as needed for dyspnea or pain. Disp:*60 ML* Refills:*0* 3. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for anxiety: [**Month (only) 116**] crush and give SL with small amount of H20. Disp:*30 Tablet(s)* Refills:*0* 4. Hyoscyamine Sulfate 0.125 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for secretions. Disp:*30 Tablet(s)* Refills:*0* 5. Yankau Suction Suction set for home 6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 8. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Nebulizer Machine Acetylcysteine 10% 3-5 mL NEBs and Albuterol 0.083% Neb Soln 3 ml: Q 4-6 hours as needed for wheezes Discharge Disposition: Home With Service Facility: [**Company **] of hospice Discharge Diagnosis: Lung cancer Discharge Condition: stable Discharge Instructions: Follow-up with VNA Care/Hospice and Dr. [**Last Name (STitle) 26237**] with questions and concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 26237**] [**Telephone/Fax (1) 26268**] Completed by:[**2162-2-12**]

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icd9cm

[ [ [] ] ]

[ "96.05", "38.93", "32.28", "33.91", "96.04", "33.23", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

9477, 9533

5922, 7767

387, 805

9589, 9598

4237, 5899

9747, 9858

3912, 3930

8534, 9454

9554, 9568

7793, 8511

9622, 9724

3945, 4218

296, 349

833, 3371

3393, 3732

3748, 3896

29,688

121,230

18567

Discharge summary

report

Admission Date: [**2143-9-30**] Discharge Date: [**2143-10-16**] Date of Birth: [**2074-2-5**] Sex: M Service: MEDICINE Allergies: Lopid / Lipitor / Zocor Attending:[**First Name3 (LF) 2962**] Chief Complaint: Chest pressure. Major Surgical or Invasive Procedure: Cardiac catherization. IVC filter placement. EGD. Colonoscopy. History of Present Illness: Mr. [**Known lastname 1274**] is a 69 year old male with HTN, DM, Hyperlipidemia, and recent PE [**3-2**] s/p 6 months of anticoagulation completed 1 month ago, presents with shortness of breath and chest pressure on exertion for three days. Patient reports that the chest pain is a "dull" pain that does not radiate. It is associated with dizziness and diaphoresis. He denies cough, hemoptysis, fevers, chills, orthopnea, PND. He denies any similar episode in the past. He reports that at baseline is able to walk 50 yards and now is unable to walk more than a few steps. He reports that the episodes last 20 to 30 minutes and are relieved with rest. He reports that these symptoms are differnt from his presentation for PE in that that presentation was associated only with chest pressure and no shortness of breath. . In ED, vital signs were 98.8, 140/91, 16, 95% RA initially, to 88% RA at one point. He was placed on 2L NC. CXR was found to be normal. He was initially given a NS bolus, then stopped after giving 350 cc for unclear reasons. Although there was concern for PE, a CTA was not performed due to Cr of 2.0. He was started on heparin drip, and then given lipitor, lopressor, mucomyst, and aspirin. Past Medical History: 1)Hypertension 2)Hyperlipidemia 3)Diabetes 4)Chronic low back pain secondary to L4 arthritis 5)Anemia 6)L ear tympanoplasty 7)s/p R shoulder surgery, partial clavicular resection 8)Cervical spine operation [**2132**] 9)R lung biopsy in [**2132**]- benign 10)s/p appendectomy in [**2107**] 11)s/p vasectomy Social History: Social history is significant for the absence of current tobacco use though he smoked 4 PPD for 35 years, but quit 12 years ago. There is a history of alcohol abuse, but currently drinks 2 drinks/ week. There is no family history of premature coronary artery disease or sudden death. Family History: No history of hematological malignancies/PE/DVT. No family history of premature coronary artery disease or sudden death. Physical Exam: VS - BP 140/59, HR 81, RR 22, 02 sat 94% on 5L Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Unable to appreciate JVD. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: bilateral 2+ pitting edema. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: ADMISSION LABS: ================= 10.2 7.8 >------< 269 31.9 . MCV 78 . Neuts 84 Lymphs 8.9 Monos 5.0 Eos 1.4 Basos 0.7 . PT 12.3 PTT 22.2 INR 1.1 . 138 101 35 ----|-----|-----< 187 4.6 23 2.0 . CK 173 MB 5 Trop 0.02 BNP 1090 . PERTINENT LABS DURING HOSPITALIZATION: ====================================== D-DIMER 2956 - 2527 Hct 30-32 --> 35 s/p 1 pRBC Cr 1.6 to 2.0 CK trend: 173 - 158 - 152 - 140 - 158 MB trend: 5 - 5 - 4 - 5 - 5 Troponin trend: 0.02 - 0.03 - 0.04 - 0.03 - 0.04 . TIBC 430 ferritin 14 TRF 331 Iron 26 HgbA1C 7.2 TG 210 HDL 39 LDL 92 Total Cholesterol 173 . CEA 8.6 CA125 14 . INR on Discharge [**2143-10-16**]: 2.1 . STUDIES: ======== CHEST (PORTABLE AP) [**2143-9-30**] IMPRESSION: No evidence of acute cardiopulmonary process. Stable appearance of thorax. . EKG [**2143-9-30**] Sinus rhythm. Since tracing of [**2143-5-2**] there is no significant change. TRACING #1 . LUNG SCAN [**2143-10-1**] IMPRESSION: Low likelihood ratio of acute pulmonary embolus. . TTE (Complete) Done [**2143-10-1**] The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly to moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2143-3-18**], estimated pulmonary artery systolic pressure is now higher. . CARDIAC CATH [**2143-10-2**] COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated single vessel coronary artery disease. The LMCA was patent. The LAD had 50% stenosis in its mid portion. The LCX and RCA were without significant disease. 2. Resting hemodynamics were performed. The left sided filling pressures were elevated (mean RA pressure was 15mmHg and RVEDP was 19mmHg). The pulmonary arterial pressures were significantly elevated measuring 76/31mmHg. The left sided filling pressures were moderately elevated (mean PCW pressure was 24mmHg and LVEDP was 18mmHg). The systemic arterial pressures were elevated measuring 153/74mmHg. There was no significant gradient acorss the aortic valve upon pull back of the catheter from the left ventricle into the ascending aorta. The cardiac index was measured at 2.6 l/min/m2 using an assumed cardiac consumption rate. FINAL DIAGNOSIS: 1. Single vessel coronary artery disease. 2. Elevated left and right sided filling pressures. 3. Elevated pulmonary artery pressure. . CHEST (PORTABLE AP) [**2143-10-3**] FINDINGS: In comparison with the study of [**9-30**], there is little overall change in the appearance of the heart and lungs. Specifically, there is no convincing evidence of pneumothorax. . BILAT LOWER EXT VEINS PORT [**2143-10-3**] IMPRESSION: No evidence of DVT in the lower extremities. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2143-10-3**] IMPRESSION: 1. New multiple bilateral segmental and subsegmental pulmonary emboli. Compared to the most recent chest CT dated [**2143-5-1**] all of these pulmonary emboli are new. 2. Multiple pulmonary opacities are also noted. Given that some of these have a nodular appearance, a followup scan when the patient's symptoms resolve in approximately 3-6 months is recommended to ensure resolution and to exclude underlying pulmonary lesions. . CT ABD&PELVIS W/O C COLON TECHNIQUE [**2143-10-8**] IMPRESSION: 1. 2.7-cm hemi-circumferential sigmoid colonic mass highly suspicious for malignancy. 2. No CT evidence for lymphadenopathy or metastatic foci. 3. Additional 6 mm and 5 mm ascending colonic polyps and possible tiny rectal polyp. 4. Two 9-mm hypodense left adrenal lesions probably represent adenomas. 5. Bilateral pulmonary emboli again demonstrated. . IVC GRAM/FILTER [**2143-10-9**] IMPRESSION: 1. Successful placement of G2 IVC filter below the renal veins within a single IVC. DIAGNOSIS: Colon, sigmoid mass, biopsy: Adenocarcinoma, see note. Note: Invasion cannot be evaluated due to the superficial nature of the specimen . COLONSCOPY [**2143-10-11**] Polyps in the ascending colon Diverticulosis of the sigmoid colon Mass in the sigmoid colon at 35cm (biopsy, injection) Stool in the solid stool in right colon Otherwise normal colonoscopy to cecum . EGD [**2143-10-11**] Mucosa suggestive of short segment Barrett's esophagus Erosions in the antrum Erythema and congestion in the antrum compatible with gastritis Erythema and congestion in the first part of the duodenum compatible with duodenitis Otherwise normal EGD to second part of the duodenum Brief Hospital Course: In summary, Mr. [**Known lastname 1274**] is a 69 yo male with HTN, DM, Hyperlipidemia, former smoker, and history of recent PE who recently stopped anticoagulation admitted with chest pain and shortness of breath on exertion. Initial presentation was concerning for PE versus unstable angina, however, patient was found to have new bilateral pulmonary embolisms. After further workup of her iron deficiency anemia, he was found to have a sigmoid mass that was adenocarcinoma. . Pulmonary Embolism. Patient has a history of being heterozygous for Factor 5 Leiden and had a pulmonary embolism 7 months prior to admission and stopped anticoagulation 1 month prior to admission. Patient presented with shortness of breath and chest pain on exertion. He was hypoxic to 70s on ambulation. Initial presentation was concerning for unstable angina versus PE. He was started on a heparin drip in the ED. He initially underwent V/Q scan (because of elevated Cr) which was low probability for PE. His echo showed evidence of right heart strain and pulmonary hypertension. On hospital day 2, given the low probability V/Q scan, he underwent cardiac cath which showed single vessel disease, but did not explain his symptoms. On hospital day 3, he had a CTA which showed multiple bilateral PEs. He developed worsening respiratory distress and hypoxia so he was sent to the ICU for closer monitoring. During his ICU stay, no invasive interventions were needed. The patient's respiratory status improved, and he was was transferred back to the [**Hospital Unit Name 196**] service. He remained on heparin gtt for treatment of his PEs except for during his colonoscopy. He also was started on coumadin 5 mg daily for a goal INR of 2.0-3.0 per Heme-Onc. The patient was offered lovenox or a lovenox bridge, but he declined and stated that he would rather be on coumadin. His INR will be followed up by his primary care physician. . CAD. Patient reported chest pain and chest pressure with minimal exertion. He denied ever having chest pain with exertion in past. Patient has cardiac risk factors of HTN, DM, HL, and former smoker. He had an exercise MIBI in [**2143-1-31**] showed a mild, reversible defect of the inferior wall, new compared to [**2139-10-2**]. Chest pain/pressure was relieved with sublingual nitroglycerin. His EKG showed dynamic changes with variable TWI in V1-V3. Patient was started on heparin drip in the ED and was started on Integrillin drip on hospital day 2 due to dynamic EKG changes. Cardiac cath showed [**10-2**] showed 50 % mid LAD lesion that was not intervened upon. Cardiac enzymes were negative. He was continued on aspirin, statin, beta-blocker, ACEI, imdur during hospitalization. His lipid panel showed LDL 92, HDL 39, TG 210. His HgA1C was 7.2. He was started on pravastatin. . Fe deficiency anemia [**12-28**] colorectal cancer. Patient was found to have guaiac positive stool before starting heparin drip. Anemia studies were consistent with iron deficiency anemia. Patient denied recent colonoscopy. However, due to his guiaic positive stool and his persistent iron deficiency anemia, a GI consult was obtained. Due to the patient's acute treatment of PEs, it was felt that it would not be safe to stop his heparin gtt. A virtual colonography was completed that showed an ulcerative 3 cm lesion in the sigmoid. Surgery was consulted for surgical management. Surgery felt that the patient must have a colonoscopy/EGD for tattooing of the lesion as well as a biopsy. Prior to this procedure, he had an IVC filter placed. After this, he was taken to colonoscopy/EGD after turning off his heparin for 6 hours. Colonoscopy showed the ulcerative mass and biopsies were taken that later were identified as adenocarcinoma. He returned after his procedure and re-started on his anticoagulation. Heme-Onc was consulted for input about his anticoagulation. His goal INR was deemed to be [**12-29**], and he was offered Lovenox by Heme-Onc. He declined this and wanted to continue coumadin. He was discharged with his INR at 2.1. He is to follow up with surgery in [**Month (only) 1096**] for scheduling his laporascopic colectomy in [**Month (only) **]-[**2143-12-27**]. Four weeks after surgery, he will follow up with Heme-Onc. . Acute on Chronic renal failure. Patient has history of CRI, likely due to HTN and DM. During hospitalization, his creatinine peaked at 2.0 after contrast dye loads but decreased to his baseline of 1.7 on discharge. He continued to have good urine output. His outpatient furosemide dose was held while his Cr was elevated. Medications were dosed renally. . Pulmonary Hypertension. He will be scheduled with sleep study for possible evaluation of CPAP or BiPAP use in hopes of improving his pulmonary hypertension for his impending surgery for colorectal cancer. He is to be scheduled for an outpatient echo in [**3-1**] weeks to reevaluate the extent of his pulmonary hypertension. . HTN. Patient was continued on amlodipine, lisinopril, and metoprolol. Imdur was started due to chest pain with exertion. His Imdur was held for a short time for his renal failure but was restarted on discharge. His ACE-I was restarted and titrated during his hospitalization. . DM. Patient takes NPH, glipizide and metformin at home. He was given NPH plus ISS while in hospital. His NPH was increased from his home dosing to 64 units in the morning and 37 units in the evening. . Pulmonary nodules. Pt had h/o wedge resection of RUL. Per pt, not malignant. CTA showed multiple nodules. To stage colon cancer, it would be ideal to get CT lungs with contrast as outpatient. A CT chest was not performed with contrast as inpatient due to acute on chronic renal failure. It should be scheduled as an outpatient. . # PPx. The patient was kept on a heparin drip for treatment of his pulmonary embolism and this was bridged to coumadin at discharge. . # CODE. full Medications on Admission: MEDICATIONS ON ADMISSION: Fenofibrate micronized 145 mg po daily Metformin 850 mg TID Isosorbide mononitrate 30 mg po daily Gabapentin 600 mg TID Atneolol 100 mg daily Aspirin 325 mg daily Amlodipine 10 mg daily Atorvastatin 40 mg daily Lasix 20 mg daily Lidoderm patch prn Lisinopril 40 mg [**Hospital1 **] NPH insulin 45 mg qAM and 25 qPM . CURRENT MEDICATIONS: Obtained from medical records, will confirm with family members in AM Fenofibrate Micronized 145 mg daily Glipizide 10 mg Tablet PO BID Metformin 850 mg TID Isosorbide Mononitrate 30 Gabapentin 600 mg TID Atenolol 100 mg once a day. Aspirin 325 mg daily Amlodipine 10 mg DAILY Atorvastatin 40 Lasix 20 daily Lidoderm patch as needed Lisinopril 40 [**Hospital1 **] NPH insulin 45 q am, 25 qpm . . Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. 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* 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1) Subcutaneous twice a day: take 64 units in the morning. take 37 units at night. 12. Outpatient Lab Work Please draw Chem 7, PT, PTT, and INR by Friday, [**2143-10-18**] and fax attn: to Dr. [**Last Name (STitle) 7790**] at [**Telephone/Fax (1) 11038**]. 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. 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* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: 1. Pulmonary emboli 2. Colon cancer 3. Angina . Secondary Diagnosis: 1. Iron deficiency anemia 2. Coronary artery disease 3. Pulmonary hypertension 4. Acute on chronic renal failure 5. Hypertension 6. Diabetes Discharge Condition: Stable. Ambulating. Discharge Instructions: You were admitted for chest pain and shortness of breath. You had a cardiac catherization where no intervention was done. You also had a CT of the lungs which showed that you had multiple clots called pulmonary emboli. You were placed on anticoagulation medication to break up these clots. You had a brief stay in the intensive care unit as you were not breathing very well. You improved on your own, and then you were transferred back to the floor. You were then found to have bleeding from your colon. You had a virtual colography which showed a colon mass. An IVC filter was placed. You had a colonoscopy where the colon mass was biopsied. The pathology showed colon cancer. After these procedures, you were placed back on the anticoagulation to get your INR to your goal of 2.0-3.0. . Additionally, one of your lab tests showed that you had H.pylori, a bacteria that causes gastritis. You should be treated with triple therapy as an outpatient once your anticoagulation is achieved. Please talk to Dr. [**Last Name (STitle) **] about this. . You should make all your medical appointments. You should take all your medications as prescribed with the following changes: . New medications: 1. Iron sulfate 325 mg daily 2. Folic acid 1 mg daily 3. Pantoprazole 40 mg [**Hospital1 **] 4. Toprol XL 150 mg daily 5. Pravastatin 40 daily 6. Warfarin 5 mg daily 7. Folic acid 1 mg daily 8. Colace 100 mg twice a day . Changes of doses of the following medications: 1. Gabapentin 400 mg three times a day 2. Lisinopril 10 mg daily 3. NPH 64 units in the morning, NPH 37 units in the evening . Stop atorvastatin, atenolol, metformin, lasix, fenofibrate while you have kidney dysfuntion. Dr. [**Last Name (STitle) **] will let you know if you can restart them. . It is very important that you take your coumadin and that you get frequent lab draws to make sure your INR is within goal. A nurse will come to your home and draw your blood level on Friday [**2143-10-18**]. Dr.[**Name (NI) 10822**] office will be contacting you regarding your INR and your coumadin dosing Friday afternoon. . You will need to get an outpatient sleep study to optimize your outcomes for surgery in the next 1-2 months. You will also need a repeat echo in 6 weeks before your visit with the surgeons. This has been ordered for you. . If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of breath, abdominal pain, bright red blood per rectum, black stools or any other concerning symptoms. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD (Cardiology) Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2143-10-21**] 1:40 PM . Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (Primary Care) Phone:[**Telephone/Fax (1) 1579**] Date/Time: [**2143-10-24**] 9:50 AM . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD (Orthopedics) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2143-12-2**] 9:10 . Surgery appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 8792**] at 8:30 AM on [**1237-11-3**] West in [**Location (un) **]. . Hematology/Oncology appointment: Four weeks after your surgery, you will need to make an appointment with hematology-oncology for follow up. They have given you their phone number. . You will also be contact[**Name (NI) **] for a sleep study. The phone number is [**Telephone/Fax (1) 16716**]. . Also, you will need to have another echo in 6 weeks. This has been ordered for you. You should remind Dr. [**Last Name (STitle) **] that you need this for preoperative evaluation as the surgeons requested it. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**]

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Discharge summary

report

Admission Date: [**2132-10-15**] Discharge Date: [**2132-10-22**] Date of Birth: [**2088-2-15**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 12174**] Chief Complaint: Expidited pre-transplant workup for decompensated cirrhosis; Maroon blood in colostomy bag Major Surgical or Invasive Procedure: Right Heart Catheterization Upper Endoscopy Ileoscopy History of Present Illness: Ms. [**Known lastname 91442**] is a pleasant 44 year old woman with a history of UC s/p total colectomy, PSC diagnosed in [**2111**], cirrhosis diagnosed in [**2129**], and CML on gleevac (since [**2127**]) who presents for expidited pre-transplant workup from clinic. The patient states that she first experienced clinical manifestations of her liver disease in [**2129**] following her total colectomy. A biopsy performed at that time revealed cirrhosis with extensive canalicular cholestasis. Liver disease was well controlled until after her colectomy in [**2129**], when her bilirubin began to rise. In the last two months, she has become more symptomatic with jaundice and volume overload. On [**2132-9-8**], the patient was admitted to [**Hospital 794**] hospital with worsening ascites, anasarca, and acute kidney injury. Following her discharge, she has experienced episodes of severe fatigue and mild dyspnea on exertion. . Today, she presented to liver clinic for transplantation evaluation and complained of non-productive cough x 5 days, SOB, ongoing fatigue. She has not had any history of prior GI bleed and denies any hematochezia, melena, hematemesis, diarrhea, nausea or vomiting. She was admitted directly from liver clinic for hypotension to the 70s and need for expedited transplant work up. Labs on arrival were notable for WBC of 21.6. A small amount of ascites was seen on US, therefore she was sent for IR guided paracentesis, which was unusucessful. Vanc/ceftriaxone was started for coverage of SBP and PNA given recent respiratory symptoms. She was also given albumin for SBP treatment. While on the floor, maroon stool was noted in her colostomy bag and hematocrit was found to be 17.9, therefore transfusion was started and she was transferred to the ICU for urgent EGD. Pressures on transfer were in the 90s, HR in the 80s. Past Medical History: -UC s/p total colectomy in [**2129**] -PSC diagnosed in [**2111**] -cirrhosis diagnosed in [**2129**] (c/b jaundice and ascites) -CML on gleevac (since [**2127**]) -foot fracture s/p surgery -deaf in R Social History: Ms. [**Known lastname 91442**] is independent with her ADLs. She is a stay at home mom that is fully functioning and active with her two teenage children, a 13 year old son and a 15 year old daughter. She and her husband recently relocated to RI from PA for her husband's job. Pt denies any substance use or abuse history, including: smoking, alcohol, marijuana, or any other illicit drugs. Ms. [**Known lastname 91442**] has a degree in business from CAL State and worked as an account manager for an HMO prior to having children. Family History: Father (and likely son) - ulcerative colitis; grandmother died of CHF; DM II in all 4 grandparents, mother with htn, mom, brother, daughter with asthma Physical Exam: On admission: Vitals: BP:123/50 P:97 R:22 O2:100% General: Alert, oriented, no acute distress, jaundice HEENT: Sclera icteric, MMM, oropharynx clear Neck: supple, JVP at angle of jaw, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, mild TTP throughout, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Stoma without evidence of active bleeding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly intact in all extremities Skin: spider angiomas on chest . On discharge: VS: T:99.1 BP:98/44 P:80 RR:18 O2:100%RA Gen: Sitting comfortably in bed in NAD HEENT: Scleral icterus; MMM, no JVP or lymphadenopathy Card: Normal S1, S2, no murmurs, rubs or gallops Lungs: clear to auscultation bilaterally; no wheezes, rales, or rhonchi Abdomen: Soft, non-tender, RLQ ostomy draining brown stool; no evidence of bleed Ext: Trace edema to mid-calf; warm, well-perfused; 2+ DP pulses Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly intact in all extremities Skin: Jaundiced, with spider angiomas on chest Pertinent Results: Labs on admission: [**2132-10-17**] 05:49AM BLOOD WBC-4.3 RBC-3.05* Hgb-9.9* Hct-26.8* MCV-88 MCH-32.5* MCHC-36.9* RDW-18.2* Plt Ct-82* [**2132-10-17**] 05:49AM BLOOD PT-17.9* PTT-34.2 INR(PT)-1.6* [**2132-10-17**] 05:49AM BLOOD Glucose-84 UreaN-31* Creat-1.4* Na-133 K-3.7 Cl-105 HCO3-16* AnGap-16 [**2132-10-17**] 05:49AM BLOOD ALT-94* AST-132* LD(LDH)-287* AlkPhos-115* TotBili-33.1* [**2132-10-17**] 05:49AM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.3 Mg-1.8 . Other pertinent labs: [**2132-10-15**] 03:15PM BLOOD AMA-NEGATIVE [**2132-10-15**] 03:15PM BLOOD [**Doctor First Name **]-NEGATIVE [**2132-10-15**] 03:15PM BLOOD IgG-592* IgA-69* IgM-LESS THAN [**2132-10-15**] 10:12PM BLOOD Lactate-1.2 [**2132-10-16**] 09:38AM BLOOD Fibrino-305 [**2132-10-18**] 03:29PM BLOOD PEP-NO SPECIFI . Discharge labs: [**2132-10-22**] 05:20AM BLOOD WBC-1.4* RBC-2.59* Hgb-8.1* Hct-23.9* MCV-92 MCH-31.4 MCHC-34.0 RDW-18.2* Plt Ct-41* [**2132-10-22**] 05:20AM BLOOD Glucose-97 UreaN-31* Creat-1.4* Na-139 K-3.5 Cl-110* HCO3-18* AnGap-15 [**2132-10-22**] 05:20AM BLOOD ALT-60* AST-87* AlkPhos-73 TotBili-32.5* [**2132-10-22**] 05:20AM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.2 Mg-2.0 . Micro: [**2132-10-15**]: STOOL CULTURE: NO SALMONELLA, SHIGELLA, CAMPYLOBACTER FOUND. [**2132-10-15**]: Urine cultures negative [**2132-10-16**]: Blood cultures: Strep viridans POSITIVE in [**12-9**] bottles [**2132-10-16**]: Feces negative for C.difficile toxin A & B by EIA. [**2132-10-16**]: Blood culture x 2 negative . Imaging: . LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL [**2132-10-15**] 1. Patent hepatic vasculature. 2. Small scarred and distorted liver, which makes it difficult to assess for small focal lesions. Consider alternative forms of imaging such as CT or MRI to further characterize the hepatic architecture. 3. Scant trace of ascites, however, the amount is insufficient to safely tap. 4. Splenomegaly. 5. Small gallbladder polyp. . CXR [**2132-10-15**]: IMPRESSION: Mild-to-moderate pulmonary edema, likely of noncardiogenic origin given the lack of cardiomegaly. No evidence of pneumonia. . ECHO [**2132-10-16**]: The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 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. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic biventricular systolic function. No significant valvular abnormality seen. Mildly elevated pulmonary artery pressures that likely reflect increased flow rather than intrinsic lung disease. . MRCP [**2132-10-17**]: 1. Markedly cirrhotic / fibrotic liver with segmental atrophy of the entire left lobe and segment VIII of the liver. No suspicious focal liver lesion identifed. There is peripheral segmental intra-hepatic biliary dilatation in keeping with primary sclerosing cholangitis. 2. While the middle and left hepatic vein are diminutive owing to the extensive fibrosis centrally and within the left lobe of the liver, all the visualised hepatic and portal veins are patent. Note is made of the left hepatic artery arising from the left gastric artery, with conventional origin of the right hepatic artery. 3. Sequela of portal hypertension including splenomegaly, para-esophageal and left upper quadrant varices, recanalisation of the para-umbilical vein, and trace of perihepatic ascites. . RUQ ultrasound [**2132-10-19**]: 1. Loculated ascites in the right lower quadrant. 2. Multiple vessels in this region noted some of which may represent varices. . Pulmonary Function Tests [**2132-10-21**]: SPIROMETRY 7:47 AM Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 2.60 3.23 81 FEV1 1.95 2.48 78 MMF 1.48 2.95 50 FEV1/FVC 75 77 97 . LUNG VOLUMES 7:47 AM Pre drug Post drug Actual Pred %Pred Actual %Pred TLC 4.48 4.76 94 FRC 2.59 2.54 102 RV 1.62 1.54 106 VC 2.90 3.23 90 IC 1.89 2.23 85 ERV 0.96 1.00 96 RV/TLC 36 32 113 He Mix Time 0.00 . DLCO 7:47 AM Actual Pred %Pred DSB 15.18 20.18 75 VA(sb) 4.09 4.76 86 HB 8.20 DSB(HB) 19.15 20.18 95 DL/VA 4.68 4.24 110 . Right Heart Cardiac Catheterization [**2132-10-21**]: 1. Resting hemodynamics revealed elevated right side and left sided filling pressures with an RVEDP 17 mm Hg and mean PCW 23 mm Hg. Cardiac output was elevated with an index of 5.30 L/min/m2. Mild pulmonary hypertension with a PASP 42mm Hg and mean PA pressure of 30 mm Hg. FINAL DIAGNOSIS: 1. Mild pulmonary hypertension. 2. Elevated pulmonary wedge pressure. . Bilateral Screening Mammogram [**2132-10-22**]: No evidence for malignancy. Annual mammogram is recommended. Results discussed with the patient . Teeth Panorex [**2132-10-22**]: Lower right 2nd molar s/p root canal with continued surrounding radiolucency. Likely normal post-root canal changes; however, must correlate clinically. Brief Hospital Course: Ms. [**Known lastname 91442**] is a pleasant 44 yo F with hx UC s/p colectomy, and cirrhosis [**1-9**] PSC, admitted from liver clinic due to recent decompensation and need for expedited transplant workup; admission complicated by bleed and leukocytosis. . #. GIB: On admission, the patient was found to be hypotensive to SBP in the 70's with a hematocrit of 17.9. She was found to have maroon stool in colostomy bag. She was transferred to the ICU out of concern for variceal bleed given history of liver disease. EGD/Ileostomy in the ICU were remarkable for absence of varices and a non-bleeding ulcer at the GE junction with old blood in the stomach. She did have significant peristomal bleeding in the ICU, which was thought to be the primary source of the bleed. She underwent ultrasound that showed peristomal varices. She was transfused a total of 6 units of PRBCs, 2 units of FFP. She was started on a PPI and octreotide for GE junction ulcer and peristomal varices. Peristomal bleeding was stopped by transplant surgery with Surgicel. With stabilization of her hematocrit, the patient was transferred back to the medical floor. She continued to have minor oozing from around her stoma without hemodynamic significance. Per transplant surgery recommendations, the patient was discharged with silver nitrate for peristomal bleeding. She was also discharged on a PPI for ulcer prophylaxis. . #. Leukocytosis: On admission, the patient was found to have a leukocytosis to 21 in the setting of hypotension to the 70's. Leukocytosis was initially concerning for SBP given ascitic fluid, however she was unable to undergo paracentesis under IR due to scant amount of fluid present. Chest X-ray was normal and urine cultures showed no growth. Stool cultures were negative. The patient was started on ceftriaxone, vancomycin, and albumin for presumed SBP. On day 2 of hospitalization, blood cultures grew strep viridans so ceftriaxone was continued. Her WBC count returned to [**Location 213**]. The patient then became leukopenic, likely secondary to Gleevac. She was discharged on ciprofloxacin daily prophylaxis for SBP. . #. Hypotension: The patient was admitted with hypotension to the 70's, most likely due to GIB. Hypotension improved following a total of 6 units PRBCs and stabilization of bleed. The patient did not spike fevers or have a localizing source of infection on admission to support sepsis as a cause of hypotension. Pressures improved to the 90s-100s, and remained stable for the remainder of admission. . # Cirrhosis [**1-9**] PSC: Complicated by jaundice, ascites, and possible hepatic encephalopathy. Recent decompensation without clear etiology. Patient admitted for expedited transplant workup which included MRCP, PFTs, ECHO, CXR, screening mammogram, pap smear, right heart catheterization, and Panorex (given history of strep viridans). The patient also underwent all routine pre-transplant laboratory testing. Hematology was consulted for recommendations on management of CML in a transplant patient. They continued the patient on gleevac, and commented that CML with gleevac use should have no effect on peri-transplant management or post-transplant prognosis. The patient will follow up with her transplant hepatologist as an outpatient. She will need a bone mineral density test as an outpatient. . # [**Last Name (un) **]: The patient was admitted with a creatinine of 1.4 (baseline 0.6-0.8 last month). Urine electrolytes consistent with prerenal azotemia. The patient was repleted with both crystalloid and colloid for volume resuscitation. Creatinine did not improve at discharge. . # Metabolic acidosis: The patient was admitted with both an anion gap and non-gap metabolic acidosis. Anion gap metabolic acidosis likely due to renal failure. Etiology of non-gap acidosis unclear, as patient was without diarrhea, evidence of fistula or medication which could be contributing. Concern for renal tubular acidosis. Acidosis improved during the admission with IV fluids. . # Hyponatremia: The patient was admitted with hyponatremia to 117. Hyponatremia likely hypovolemic, as it normalized with fluid resuscitation. . # Ulcerative colitis s/p total colectomy with end ileostomy: Chronic. Patient without further GI symptoms following total colectomy. Routine ostomy care was maintained throughout admission. . # CML: Diagnosed in [**2127**]. Patient stable on Gleevac which was continued in house at the recommendation of the hematology service. During admission, gleevac was decreased to 200 mg daily, as the patient became increasingly pancytopenic (WBC count nadir 1.4, baseline 3.0). As part of the patient's pretransplant workup, the hematology/oncology team noted that CML with gleevac use should have no effect on peri-transplant management or post-transplant prognosis. . # Code: Full code Medications on Admission: Lactulose 1tbsp [**Hospital1 **] Potassium 1tbsp daily Urosiol 250 mg Gleevac 400 mg Discharge Medications: 1. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3 times a day). 2. ursodiol 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. silver nitrate applicators Misc Sig: [**12-9**] Miscs Topical PRN (as needed) as needed for stomal bleeding. Disp:*30 sticks* Refills:*0* 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 6. imatinib 400 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: PSC cirrhosis (decompensated with jaundice, ascites); peri-stomal variceal bleed Secondary diagnoses: Spontaneous bacterial peritonitis, Chronic myeloid leukemia, Ulcerative colitis s/p total colectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 18**] for an expedited pre-transplant workup. On admission, you were found to have an elevated white blood cell count and a very low red blood cell count (anemia). . For your anemia, you were transferred to the ICU, where you underwent upper endoscopy and ileoscopy. You were found to have old blood in your stomach, but no evidence of active bleed. You were found to have significant bleeding from around your stoma. The bleeding was stopped by our surgical colleagues with surgicel and you were transfused 6 units of packed red blood cells. You underwent ultrasound that showed varices around your stoma. You were treated with a medication called octreotide to decrease the pressure in your varices. . Because of your elevated white blood cell count, we were concerned that you had infection of your ascites. You went to interventional radiology, but did not have enough ascites in your abdomen to adequately sample. You were treated with antibiotics for presumed "spontaneous bacterial peritonitis", or infection of ascites. You underwent blood cultures that were positive for a bacterium - streptococcus viridans. You did not have any fevers throughout admission. With antibiotics, your white blood cell count improved. Upon discharge, you will start ciprofloxacin 250 mg daily to prevent against future episodes of spontaneous bacterial peritonitis. . You were followed by oncology for your CML throughout your admission. They feel that your CML and use of gleevac will not be affected by a liver transplant in the future. All of your blood cell counts decreased during admission, likely due to use of Gleevac. On discharge, you should decrease your gleevac dose to 200 mg daily. . While in the hospital, you underwent a near-complete pretransplant workup. You underwent EKG, chest X-ray, MRCP, pulmonary function tests, pap smear, mammogram, right heart catheterization, and dental panorex. You had many screening labs for infectious and immunologic processes. At this point, none of your tests preclude you from transplant. . Medications changed this admission: DECREASE gleevac to 200 mg daily START ciprofloxacin 250 mg daily for spontaneous bacterial peritonitis prophylaxis START protonix 40 mg daily for GI bleeding prophylaxis APPLY silver nitrate around ostomy as needed for bleed HOLD potassium until you have undergone follow up lab testing with your PCP Followup Instructions: Name: [**Last Name (LF) 91443**],[**First Name3 (LF) **] Specialty: FAMILY MEDICINE Location: PRIMARY CARE OF [**Location (un) **] Address: [**Street Address(2) 91444**], UNIT#A1 [**Location (un) **], [**Numeric Identifier 91445**] Phone: [**Telephone/Fax (1) 91446**] **We are working on a follow up appointment with Dr. [**Last 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: TRANSPLANT When: WEDNESDAY [**2132-10-29**] at 9:20 AM With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "37.21", "45.12", "45.13" ]

icd9pcs

[ [ [] ] ]

15706, 15712

10002, 14872

398, 454

15979, 15979

4578, 4583

18575, 19363

3128, 3281

15008, 15683

15733, 15834

14898, 14985

9570, 9979

16130, 18552

5383, 9553

3296, 3296

15856, 15958

4010, 4559

268, 360

482, 2337

5062, 5367

4597, 5040

15994, 16106

2359, 2563

2579, 3112

76,912

168,313

35705+58026

Discharge summary

report+addendum

Admission Date: [**2198-3-11**] Discharge Date: [**2198-3-15**] Service: MEDICINE Allergies: Penicillins / Aspirin / Metformin Attending:[**First Name3 (LF) 8104**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: None History of Present Illness: This is a 87 year-old female with a history of dementia, DM2, chronic UTIs, recently discharged from [**Hospital1 882**] with a UTI and PNA who presents with coffee ground emesis at her NH. Patient had emesis over a week ago, for which she was taken to [**Hospital1 882**] and a UTI and a pneumonia per the daughter. She states the patient was treated with levofloxacin. She was then discharged back to the [**Hospital3 **]. Prior to admission to [**Hospital1 18**], she had coffee ground emesis, vitals stable. She has had a cough, though unchanged from discharge. No documented fevers at NH. In the ED, vitals were t 100, hr 86, bp 183/64, rr 18, sa 02 96% 2L. peg lavage was done, cleared after 500 cc. CXR c/w PNA, and patient was given azithro/ceftriaxone and also given a dose of vancomycin. She was also started on pantoprazole. ECG was NSR without ischemic changes. She was guaiac positive as well. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: DM2 Dementia Chronic UTIs HTN CHF (? EF) CAD (unknown status) Parenchymal hemorrhage ([**12-16**]) Breast ca s/p mastectomy ([**5-12**]) -unknown status s/p PEG tube placement Social History: Lives in [**Hospital3 **]. Has most of her care at the [**Hospital 882**] hospital. Quit smoking in [**2158**]. 2 pks/week. Family History: Non-contributory Physical Exam: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2198-3-11**] 05:25AM GLUCOSE-209* UREA N-28* CREAT-0.7 SODIUM-142 POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-15 [**2198-3-11**] 05:25AM ALT(SGPT)-11 AST(SGOT)-19 CK(CPK)-26 ALK PHOS-82 TOT BILI-0.3 [**2198-3-11**] 05:25AM LIPASE-13 [**2198-3-11**] 05:25AM cTropnT-0.01 [**2198-3-11**] 05:25AM CK-MB-NotDone [**2198-3-11**] 05:25AM ALBUMIN-3.2* [**2198-3-11**] 05:25AM WBC-16.7* RBC-3.41* HGB-10.2* HCT-29.4* MCV-86 MCH-30.0 MCHC-34.7 RDW-14.5 [**2198-3-11**] 05:25AM NEUTS-91.6* LYMPHS-5.0* MONOS-2.2 EOS-0.8 BASOS-0.4 [**2198-3-11**] 05:25AM PLT COUNT-517* [**2198-3-11**] 05:25AM PT-12.7 PTT-32.9 INR(PT)-1.1 [**2198-3-11**] 05:20AM WBC-16.9* RBC-3.46* HGB-10.4* HCT-29.9* MCV-86 MCH-30.0 MCHC-34.7 RDW-14.7 [**2198-3-11**] 05:20AM NEUTS-91.6* LYMPHS-5.0* MONOS-2.0 EOS-1.1 BASOS-0.3 [**2198-3-11**] 05:20AM PLT COUNT-522* [**2198-3-11**] 05:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2198-3-11**] 05:55AM URINE RBC-2 WBC-13* BACTERIA-FEW YEAST-NONE EPI-<1 TRANS EPI-1 [**2198-3-11**] 09:16AM WBC-24.9* RBC-3.41* HGB-10.1* HCT-29.4* MCV-86 MCH-29.7 MCHC-34.4 RDW-14.5 [**2198-3-11**] 02:53PM HCT-30.3* ECG: Sinus rhythm, leftward axis, no signifcant ST segment changes Imaging: CXR: IMPRESSION: Right middle lobe air space opacity worrisome for aspiration or pneumonia. Brief Hospital Course: 87 year-old female with a history of dementia, CVA, DM2, CHF, chronic UTIs who presents with hematemesis and likely aspiration PNA # Hematemesis: In the ED PEG lavage showed coffee ground material which cleared after 500 cc and her Hct was 29.9. Likely UGIB- source gastritis vs duodenol vs gastric ulcer vs esophageal ([**Doctor First Name 329**] [**Doctor Last Name **], varices). No known liver cirrhosis. She was placed on an IV PPI [**Hospital1 **]. GI evaluated her and felt that as her Hct has been stable, she did not need an emergent scope. On the evening of [**3-11**] her Hct fell to 23 so she received a unit of pRBC's. Her hematocrit initially increased appropriately but then fell again to the 23 range. She received a second unit of pRBC's on the evening of [**2198-3-12**] at which time her hematocrit increased to 28 and remained stable at 29 the next morning. She had no guiac positive stools in the [**Hospital Unit Name 153**] and no hematemesis. She remained hemodynamically stable. Endoscopy was ultimately not performed as the benefits outweighed the indicated this chronically ill, severely demented woman. Plan is to continue PPI [**Hospital1 **]. H pylori remains pending at time of discharge. # PNA: Her ED CXR showed a RML infiltrate; left hemidiaphragm also obscured- likely HAP vs aspiration given hematemsis. She was treated with vanc, cefepime, and flagyl as she was admitted from a nursing home and there was concern for aspiration. Sputum and blood cultures were sent and remained negative as of the time of discharge. PICC was placed for a 10 day course of antibiotics for HAP. # Chronic UTIs: She was recently treated at [**Hospital1 **] for UTI; UA currently not very consistent with active infection (LE negative- WBC 13). Her foley was pulled. Urine culture was negative for growth. # DM: She was continued on her outpatient insulin glargine and RISS. Her tube feeds were briefly stopped for concern of GI bleed and during that time despite her glargine dose being halved she had some asymptomatic hypoglycemia for which she received 2 amps of dextrose. At that point her tube feeds were restarted and she was placed on half her usual glargine dose. Her gluxose was high and her glardine dose was increased. This will likely need continued adjustment in the outpatient setting. # Dementia: The patient is quite demented at baseline and unable to regularly answer questions appropriately. This is her baseline. No further management was initiated. At time of discharge she was still unable to state name or follow basic commands. # Chronic heart failure: Unclear if systolic or diastolic; no ECHO here. The patient appeared mildly fluid overloaded on the morning of [**2198-3-12**] and received 20 mg of furosemide IV. Her CXR improved with decreased hilar markings but as she still had an O2 requirement she received another dose of IV furosemide on [**2198-3-13**]. Her home CV meds ( captopril and metoprolol) were switched to once a day formulations. Her isosorbide was held as these pills were not able to be crushed and placed in PEG. She does not tolerate ASA (allergy). Further titration of cardiac medications is recommended in the outpatient setting. # FEN: She was started on tube feeds on [**3-10**] as her third Hct returned stable. This was then held on [**2198-3-11**] as her hematocrit was decreasing. These were restarted on [**2198-3-13**] after Hct was once again stable. She was evaluated by the speech and swallwing service. At that time, patient was not accepting pos and recommended if patient taking/accepting pos would continue trials of nectar thick liquids. She did swallow very small amounts of nectar thick liquid from the cup with maximum cues without overt s/sx of aspiration .Primary nutrition, hydration, and medications should be via PEG tube. # Code: FULL CODE: This was confirmed by the patient's daughter who appeared to have very poor insight into her mother's debiliated state and chance for meaningful recovery from multiple chronic conditions and acute medical issues. Medications on Admission: Calcium Carbonate 1250 mg [**Hospital1 **] Captopril 50 mg TID Colace 100 mg [**Hospital1 **] Lovenox 40 mg sc daily Ergocalciferol 50,000 units SC weekly Insulin Glargine 34 units QHS plus RISS Isosorbide Dinitrate 20 mg TID Maalox 30 mg q6H PRN Metoprolol tartrate 75 mg [**Hospital1 **] Omeprazole 40 mg daily Polyethylene glycol 17 gm [**Hospital1 **] Simvastatin 80 mg daily Multivitamlin 5 ml daily Tylenol PRN DIET: Pureed, nectar liquid, no egg Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): VIA PEG. 8. Insulin Glargine 100 unit/mL Solution Sig: Nineteen (19) units Subcutaneous at bedtime: **WILL LIKELY NEED FURTHER ADJUSTMENT**. 9. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q24H (every 24 hours) for 10 days. 10. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: 1) Upper GI Bleed-NOS 2) Hospital aquired pneumonia 3) Dementia 4) Diabetes 5) Chronic heart failure Discharge Condition: Stable Discharge Instructions: You were admitted for an upper GI bleed and have a hospital aquired pneumonia. You should return to the hospital should you develop worsening fevers, chills, have vomiting with blood or any other concerning symptoms. Followup Instructions: Please follow-up with your primary care doctor within the next 3-4 weeks Name: [**Known lastname **],[**Known firstname 13025**] Unit No: [**Numeric Identifier 13026**] Admission Date: [**2198-3-11**] Discharge Date: [**2198-3-15**] Date of Birth: [**2110-10-14**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Metformin Attending:[**First Name3 (LF) 5698**] Addendum: Nutrition: During this hospitalization patient was reinitiated onFibersource HN Full strength; Starting rate: 20 ml/hr; Advance rate by 20 ml q6h Goal rate: 50 ml/hr Residual Check: q4h Hold feeding for residual >= : 150 ml Flush w/ 150 ml water q6h Discharge Disposition: Extended Care Facility: [**Hospital3 901**] - [**Location (un) 382**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5700**] MD [**MD Number(2) 5701**] Completed by:[**2198-3-15**]

[ "578.9", "V45.71", "V10.3", "V44.2", "788.30", "250.00", "507.0", "414.01", "294.8", "486", "787.6", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10818, 11047

4060, 8143

253, 260

9827, 9836

2647, 4037

10102, 10795

1902, 1921

8646, 9589

9703, 9806

8169, 8623

9860, 10079

1936, 2628

202, 215

288, 1542

1564, 1742

1758, 1886

7,192

163,445

24532

Discharge summary

report

Admission Date: [**2154-1-30**] Discharge Date: [**2154-2-12**] Date of Birth: [**2075-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Abdominal pain & distention Major Surgical or Invasive Procedure: Paracentesis x 4 History of Present Illness: 78M h/o CAD s/p CABG, CHF (EF 35%), chronic GI bleed s/p Portacath placement [**2153**] for delivery of blood products, CKD, cardiac cirrhosis, presented to the ED with abdominal pain and distention, vomiting x1, as well as poor PO intake, x3 days after leaving AMA from nursing home and stopping his typical regimen of paracentesis every ~14 days. Noted to have N/V and increased protrusion of umbilical hernia. . In the ED, T 97, HR 62, BP 95/43, RR 16, O2sat 100% 2L. SBP 90-110s. Exam notable for ascites, positive guaiac, hct 18.8, Cr 3.3 (baseline 1.7), lactact 2.4. Received 4mg IV morphine, 40mg IV protonix, 20mg IV furosemide, 2units PRBC. Paracentesis with 3L removed, negative for SBp. CXR demonstrated incompletely evaluated opactiy in LL base, but considered atelectasis and effusion. CT abdomen/pelvis limited with no IV contrast and nearly no oral contrast, nondiagnostic for diverticulitis or "infection"; no discrete transition point or prox SB dilatation. Massive ascites on CT despite 3L paracentesis prior to study. Admitted to ICU for anemia, massive ascites, and acute renal failure. . ROS difficult to complete given limited verbal communication. Denied current f/c, n/v, dysuria/hematuria, increased melena/BRBPR, lightheadedness/dizziness. C/o itchiness. Past Medical History: # HTN # CAD: Reports CABG x3, first age 22(?), CABG [**2140**], cath [**2151**] with patent lima-lad, occluded svg-om, near occluded svg-rca # CHF: TTE [**7-6**] with EF 35%, mild LVH and LV-HK, 2+MR, 4+TR; cardiac cath [**3-7**] to determine volume status with elevated biventricular filling pressures, moderate pulmonary hypertension, ventricularization of RA pressure consistent with severe tricuspid regurgitation. # Afib: previously on coumadin but no longer secondary to GIB in past # Cardiac cirrhosis: Requiring repeat sx paracenteses # Chronic GIB [**3-2**] AVMs # Colon polyps # HBV # CRI: cr 1.5-1.8 # Hypothyroidism # OA Social History: Originally from [**Country 3397**]. Living with wife in [**Name (NI) 3146**] but states has difficulty getting around and she has difficulty moving him, recently in rehab. Previously stated quit smoking 15 years ago, smoked 1 ppd x 40 years. No EtOH. Retired, but used to work as a machinist. Unable to walk. Needs wheelchair/walker to get around his house. Family History: Reported previously: Mother- HTN, ?died of MI; Father-83 yo and died of "old age" but unable to verify this tonight, states "I don't remember." Physical Exam: Vitals: 96.6, 124/56, 70, 20, 97% RA HEENT: NCAT, PERRL, neck supple Cardiac: RRR, nl S1 and S2, no MRGs Lungs: CTAB anteriorly, too agitated and restless to listen post Abd: protruburant abd/umbilicus, +dullness to persussion, caput medusa, +BS Ext: in waffle boots, legs wrapped in gauze Skin: ecchymosis throughout Neuro: Alert but not able to assess orientation. MAE, uncooperative with further exam Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2154-2-12**] 05:09AM 6.4 3.37* 9.3* 29.7* 88 27.6 31.3 18.3* 151 [**2154-2-11**] 06:26AM 5.9 3.26* 9.0* 29.0* 89 27.6 31.0 18.0* 125* [**2154-2-10**] 05:37AM 7.1 3.29* 9.1* 29.3* 89 27.6 31.0 18.0* 127* . [**2154-2-4**] 06:07AM 7.3 3.52* 9.9* 30.0* 85 28.2 33.1 18.9* 112* [**2154-2-3**] 02:20AM 6.2 3.46* 9.9* 29.0* 84 28.7 34.2 17.0* 125* [**2154-2-2**] 03:22AM 5.5 2.91* 8.0* 24.6* 84 27.5 32.7 18.4* 127* [**2154-2-1**] 02:50AM 5.6 2.89* 7.8* 24.3* 84 26.9* 32.0 16.8* 110* [**2154-1-31**] 04:07AM 7.6 2.94* 7.9* 24.7* 84 26.8* 31.8 16.5* 163 [**2154-1-30**] 02:25AM 5.0 2.29* 5.7* 18.8*1 82 24.9* 30.4* 19.1* 291 . BASIC COAGULATION PT PTT INR(PT) [**2154-2-12**] 05:09AM 14.1* 54.2* 1.2* [**2154-2-11**] 06:26AM 14.2* 57.4* 1.2* . [**2154-1-30**] 02:25AM 16.8* 51.3* 1.5* . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2154-2-12**] 05:09AM 93 52* 1.0 138 4.2 103 28 [**2154-2-11**] 06:26AM 77 55* 1.1 141 4.1 103 27 [**2154-2-10**] 05:37AM 107* 58* 1.2 145 4.8 109* 26 . [**2154-2-5**] 05:10AM 151* 121* 1.6* 143 3.3 103 29 [**2154-2-4**] 06:07AM 141* 141* 2.0* 141 3.3 98 28 [**2154-2-3**] 02:20AM 93 161* 2.7* 133 3.6 90* 22 . [**2154-1-31**] 04:07AM 76 169 3.2* 125* 4.4 86* 24 [**2154-1-30**] 08:11PM 80 171 3.1* 126* 4.6 85* 24 [**2154-1-30**] 02:25AM 82 179* 3.3* 125* 4.9 85* 21* . CPK ISOENZYMES CK-MB MB Indx cTropnT [**2154-1-31**] 04:07AM 23* 13.0* 0.60* [**2154-1-30**] 03:44PM 25 16.0* 0.57* [**2154-1-30**] 08:00AM 0.53* [**2154-1-30**] 02:25AM 20* 17.9* . LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc [**2154-2-5**] 05:10AM 92 781 37 2.5 39 . PITUITARY TSH [**2154-1-30**] 08:00AM 13* . THYROID Free T4 [**2154-1-31**] 04:07AM 1.1 . OTHER ENDOCRINE Cortsol [**2154-1-30**] 08:00AM 26.3 . CARDIAC/PULMONARY Digoxin [**2154-2-12**] 05:09AM 1.0 [**2154-1-30**] 08:00AM 3.2* . . CT Abdomen/pelvis [**2154-1-30**] 1. Severely limited examination. Given the lack of intravenous contrast and near absence of oral contrast, the study is nondiagnostic for infection or diverticulitis as requested. 2. There is a large umbilical hernia which should be apparent on clinical exam (though not provided in the given history). A gas- distended loop of small bowel appears to enter and exit the hernia sac without definite transition point. No proximal small bowel dilatation, to CT criteria, is noted. . CXR [**2154-2-4**] In comparison with the study of [**1-31**], there is again substantial left pleural effusion. It is difficult to compare this upright film with the previous semi-upright study, in which the effusion layers out along the posterior chest wall. Enlargement of the cardiac silhouette persists. The degree of pulmonary vascularity is essentially unchanged Brief Hospital Course: ASSESSEMENT/PLAN: 78 yo M with h/o CAD, CHF (EF 35-40%), cardiac cirrhosis, CRI, chronic GIB and anemia who presented with abdominal pain, found to have acute on chronic renal failure and worsened anemia thus admitted initially to the ICU then transferred to the floor after stabilization. . # Acute on chronic renal failure: Baseline creatinine 1.3-1.8, 3.3 on admission. Further investigation revealed that pt had pre-renal failure due to dehydration and not hepatorenal syndrome. Fluid rehydration with IVF as well [**Date Range 61990**] was done with improvement in creatinine levels daily. Renal failure resolved prior to discharge. . # Hypotension: Pt was noromotensive on admission, however developed hypotension after aggressive diuresis in the intensive care unit. Hepatology and renal were consulted for the potential of hepatorenal syndrome. However, pt was found to be mostly dehydrated and IVF resusitation and [**Date Range 61990**] was aggressively engaged. Pt did not have hepatorenal syndrome, hence midodrine and octreotide that was initially started was stopped. His BP improved and IVF, [**Date Range 61990**] was eventally discontinued. Pt has remained normotensive since transfer from the unit. . # Anemia: Chronic anemia with baseline hematocrit ~20-30's. Per daughter, pt requires frequent blood transfusions ~q2weeks in the setting of chronic GIB r/t AVM's. Pt received 5units PRBC during this admission. . # CAD/NSTEMI: Pt developed NSTEMI during ICU stay in the setting of renal failure, pt with known hx of CAD. There were no changes on EKG. Pt not on aspirin due to h/o GIB, not started during this admission. Lipids were at goal, hence statin was not initiated. . # Atrial Fibrillation: Rate controlled on digoxin. Dig level 3.2 on admission, however held dose and redosed for dig levels < 1. Pt's dig level 1.0 at discharge. . # CHF: LVEF 35-40% and massive ascites [**3-2**] cardiac cirrhosis. Although with L pleural effusion, did not have evidence of fluid overload on admission. During ICU stay developed new crackles on examination, with evidence on CXR, however was post blood transfusion and thought to be TRALI. We dosed digoxin as above, rehydrated pt with IVF & [**Month/Day (2) 61990**] for renal failure. . # Abdominal pain: Had been a presenting complaint, however improved after paracentesis. LFTs, amylase normal, lipase only mildly elevated and unlikely etiology of previous symptoms. There was no evidence of infectious etiology per physical examination, labs or imaging. CT abdomen/pelvis unrevealing for SBO, but study lacked oral contrast thus limited. Has large umbilical hernia filled mainly with ascites on exam, however hernia is reducible and nontender. Abdominal pain resolved during hospitalization and has been attributed to abdominal distention. . # Hypoxia: Developed hypoxia in the intensive care unit where he was somnolent but with a low resp rate; however had only received minimal narcotics in the ED. Received narcan in the unit with some improvement. Evidence of atelectasis vs. L infiltrate, also with progresive crackles worrisome for a pneumonia, hence he received levofloxacin & ceftriaxone initially, however did not worsen hence the levaquin was discontinued. There was also ? of TRALI as pt had received 2U PRBC in the ED, this could not be completely ruled out. Pt was continued on ceftriaxone for a 7 day course to treat his UTI. . # Thrombocytopenia: Developed during admission, no clear etiology thus ?sequestration. +cardiac cirrhosis, negative HIT antibodies, no evidence of schitocytes on smear and negative DIC labs. Did not require transfusion and improved prior to discharge . # Hypernatremia: Initially hyponatremic during admission with intravascular depletion, this resolved. However developed hypernatremia after one episode of paracentesis, resolved with D5W bolus and encouraging pt to drink. No seizure activity or mental status changes. Max sodium level was 151. . # Cardiac cirrhosis: Known hx of frequent paracentesis for diuretic refractory acites. Liver function appears stable currently, however mild thrombocytopenia. s/p paracentesis [**2154-2-5**], received paracentesis on day of discharge with removal of ~5L ascitic fluid. Pt is scheduled for paracentesis at [**Hospital1 18**] on [**2153-2-26**] at 930am. We discontinued his Metolazone & furosemide daily as pt did not appear to be fluid overloaded, would recommend diuresis with evidence of overload while closely monitoring renal function. . # Complicated UTI: +UA noted on admission, urine culture with pansensitive P. mirabilis. Completed 7 day course of Ceftriaxone [**2154-2-7**] . # Senile Purpura/ecchymosis: [**Doctor Last Name 61997**] purpura [**3-2**] thin skin, trauma & coagulopathy. Applied mitts to prevent pt from scratching. Did not worsen during admission. . # Coagulopathy: INR 1.5 on admission, remained close to that baseline. Known cardiac cirrhosis, received vitamin K po x 3 days in ICU. . # ?COPD: Reportedly on 2L at home, however daughter was unsure if he had actually been using it. Remote tobacco use; had not need for oxygen after transfer to the floor. We provided albuterol, atrovent MDI's prn. . # Hypothyroidism: TSH on admission elevated to 13. Continued pt on levothyroxine 175mg po daily. . # Encephalopathy: Resolved during admission. Thought to be due to cardiac cirrhosis and also uremia with pt.renal failure. Pt was somewhat agitated, calling out at baseline. We avoided sedating meds and benzos. Pt refused lactulose during admission. . Pt had reached maximal hospital benefit and was transferred to a rehab facility. Medications on Admission: Meds per [**2153-11-27**] OMR Albuterol MDI QID PRN Albuterol nebs PRN Mylanta PRN Ca carbonate 500mg PO TID Digoxin 125mcg QOD Ferrous sulfate 325mg Po daily Ipratropium MDI QID PRN Lactulose 15ml [**Hospital1 **] Levoxyl 150mcg daily Ativan 0.25mg TID PRn Metolazone 5mg daily Mirtazapine 15mg HS MVI Oxycodone-acetaminophen 5-325mg Q4H PRN KCl 20mEq daily . Meds [**First Name8 (NamePattern2) **] [**Location (un) 1468**] [**Location (un) 269**] ([**2154-1-9**]) Tylenol PRN Digoxin 125mcg QOD Senekot [**Hospital1 **] Ativan 0.5mg PO TID Colace 100mg [**Hospital1 **] Lasix 120mg [**Hospital1 **] Potassium 10mEq daily Levothyroxine 175mcg daily metolazone 5mg daily Mirtazapine 15mg daily MVI Ferrous sulfate 325mg daily Lactulose 15ml [**Hospital1 **] PRN Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for Anxiety/insomnia. 6. Atrovent HFA 17 mcg/Actuation Aerosol Sig: [**1-30**] puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Mylanta 200-200-20 mg/5 mL Suspension Sig: Five (5) ml PO every eight (8) hours as needed for indigestion. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 2857**] - [**Location (un) 1121**] - [**Location (un) 4310**] Discharge Diagnosis: Acute on chronic renal failure Anemia Cardiac cirrhosis [**3-2**] CHF Hypothyroidism Atrial fibrillation Discharge Condition: Stable, Cr.1.0 Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L . We have held your Metolazone & furosemide for now. Please continue to take your other medications as prescribed. Followup Instructions: Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2154-2-26**] 11:00 - If with worsening abdominal pain and distension prior to [**2154-2-26**], please call to schedule the patient for a sooner appointment. . Please make an appointment to follow up with your PCP [**Name Initial (PRE) 151**] 1-2weeks of discharge or when your leave rehab. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1144**]

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Discharge summary

report

Admission Date: [**2197-12-15**] Discharge Date: [**2197-12-28**] Date of Birth: [**2131-1-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: AMS, s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [**Known lastname 55623**] is a 66 yo female with hx of stage IV NSCLC dx in [**2-26**] with known liver mets who presents to ED with AMS s/p fall at home. Ms. [**Known lastname 55623**] completed 3 cycles of chemotherapy with Carboplatinum and Taxol for metastatic non small cell lung cancer, with both objective and subjective response. Her right upper quadrant pain and fullness from her liver metastases disappeared, her CEA dropped significantly and a CAT scan confirmed shrinkage of tumor. She was initially on a standard regimen, but had significant hematologic toxicity requiring blood transfusions in [**2197-5-25**], and was switched from the every 3 week full dose regimen of Carboplatinum and Taxol to the weekly low dose schedule. She found this much more tolerable, and her CBC was also better on this regimen. However, more recently she developed extreme fatigue presumably from this regimen, and was switched over to Navelbine, we she started on [**2197-11-30**]. Of note, the patient was also started on Ritalin at this time. . The patient was tolerating the new regimen well until 1d PTA, when she began "feeling well over," with nausea, vomiting four times since yesterday, weakness and occasional dizziness. She denies any diarrhea, She was intending to come into clinic for hydration, but fell at home and was taken to the ER. . In the ED, it was noted that Mrs. [**Known lastname 55623**] had hyponatremia, a high anion gap, leukopenia, and low normal platelets. She had a CT scan of her head performed, which showed a rounded focus in the high left parietal lobe which was concerning for a metastatic lesion. The patient was scheduled for an MRI and admitted for further management. Past Medical History: 1. NSCLC - dx [**2-26**] with known liver mets 2. HTN 3. Osteoperosis 4. MIgraines 5. s/p cholecystectomy 6. Anxiety Social History: Lives with her paternal aunt age [**Age over 90 **], she is able to carry out all ADLs, cooks for them both; stopped smoking with dx of lung cancer in [**4-28**]. 40 pack year hx; occassional etOH. Family History: Mother:Died at age 29 in [**2132**] of pneumonia Father:Died of AMI age 78 Siblings: 1 Brother died of multiple myeloma age 48; 2 half brothers are alive and well Others:Paternal 1st Cousin had pancreatic cancer Physical Exam: Vitals: 98.4 112 143/76 12 97% on RA Gen: pleasant elderly caucasian female lying in bed, comforable, NAD Skin: dry, poor turgur, no rashes HEENT: PERRL, EOMI, sclerae anicteric, OP clear, partial upper dentures, full lower dentures, no cervical LAD Chest: scant bibasilar crackles, CTA otherwise Cardiac: RRR, nl s1s2, [**12-31**] syst murmur at apex with no radiations, JVP flat Abd: thin; old well-healed subcostal scar on right c/w prior open chole; soft, nt/nd, +BS, palpable liver edge 1-2cm below CM in midclav line, not tender Ext: thin extremities, no c/c/e, no LE edema, 2cm soft nt mobile mass in left popliteal fossa Neuro: CN II-XII intact; [**3-29**] biceps, triceps, plantar, dorsi strength; sensation to LT intact in UE and LE b/l; finger-to-nose slow but intact b/l; no dysdiadokokinesia; reflexes and gait deferred Psych: A+Ox3, ("[**Month (only) 404**], Friday, [**Hospital1 18**], President [**Last Name (un) 2450**]"), constricted affect, pleasant, linear TP Pertinent Results: [**2197-12-15**] Noncontrast head CT FINDINGS: There is no acute intracranial hemorrhage. Areas of low attenuation in the periventricular white matter are consistent with chronic microvascular infarcts. A more rounded focus in the high left parietal lobe may also represent a small infarct, however, in a patient with known metastatic disease, a metastatic lesion cannot be excluded. In the right cerebellar lobe, there are scattered areas of calcification of uncertain etiology. There is no associated mass effect. The ventricles are normal in appearance. There is no shift of normally midline structures. [**Doctor Last Name **]-white matter differentiation is preserved. Osseous and soft tissue structures are unremarkable. IMPRESSION: 1. No acute intracranial hemorrhage. 2. Low attenuation foci which likely represent chronic microvascular infarcts, however, metastatic lesions cannot be excluded. Gadolinium enhanced MRI can be performed for evaluation for metastatic disease. 3. Right cerebellar calcifications without associated mass effect of uncertain etiology. Labs on Admission: [**2197-12-15**] 10:35PM GLUCOSE-104 UREA N-13 CREAT-0.6 SODIUM-121* POTASSIUM-3.2* CHLORIDE-88* TOTAL CO2-25 ANION GAP-11 [**2197-12-15**] 10:35PM CALCIUM-7.7* PHOSPHATE-1.2* MAGNESIUM-1.2* [**2197-12-15**] 02:15PM URINE HOURS-RANDOM CREAT-55 SODIUM-121 POTASSIUM-44 CHLORIDE-110 [**2197-12-15**] 02:15PM URINE OSMOLAL-490 [**2197-12-15**] 12:30PM GLUCOSE-141* UREA N-17 CREAT-0.8 SODIUM-119* POTASSIUM-2.9* CHLORIDE-82* TOTAL CO2-24 ANION GAP-16 [**2197-12-15**] 12:30PM WBC-2.2*# RBC-3.16* HGB-11.6* HCT-31.9* MCV-101*# MCH-36.7* MCHC-36.4* RDW-16.2* [**2197-12-15**] 12:30PM PLT COUNT-134* [**2197-12-15**] 12:30PM PT-13.5 PTT-22.6 INR(PT)-1.2 Brief Hospital Course: A/P: 66yo woman with hx of stage IV NSCLC dx in [**2-26**] with known liver mets, s/p recent change in chemo regimen and initiation of Ritalin on [**2197-11-30**], who presents to ED with AMS s/p fall at home, found to have hyponatremia to 119, possible new brain mets on CT, high Anion gap, leukopenia, macrocytic anemia. 1. AMS: hyponatremia vs. new brain mets. She was hyponatremic on admission (?[**12-27**] SIADH), and this was corrected with fluid restriction and was stable upon discharge. MRI of the brain showed bilateral occipital changes consistent with reversible encephalopathy of unclear etiology with no evidence of brain metastases. Neurology was consulted and felt that she did not necessarily have this encephalopathy and required no further imaging or treatment. Her Mental status continued to improve as her sodium was corrected. She was at her baseline at discharge, alert and oriented x 3, with a stable sodium. She was discharged to continue with her fluid restriction. 2. E. coli Urosepsis: Although initially afebrile and hemodynamically stable, she became febrile, hypotensive, and was found to have [**2-26**] blood cultures growing E. Coli on [**2196-12-20**] (presumed urinary source). She was in the [**Hospital Unit Name 153**] briefly, started on Levofloxacin and gentamicin (to double cover for gram negatives; E. coli was sensitive to these antibiotics), and she defervesced, became hemodynamically stable. She returned to the floor, and only the Levofloxacin was continued (to complete a 10 day course). On [**12-25**], she spiked on antibiotics, and vancomycin was added (? of a superficial thrombophlebitis on her right forearm). She remained afebrile and stable after the addition of this antibiotic, and she will complete a 10-day course of both the levofloxacin and vancomycin. Her foley was taken out prior to discharge. She was bolused as necessary (with good response) for symptomatic hypotension. 3. Thrombocytopenia: Her platelets trended down in-house (never any signs of bleeding; nadir was 25,000). HIT antibody was checked and was negative. At time of discharge, platelets were trending up (she never required any platelet transfusion). The cause of this was thought to be secondary to infection/sepsis. These should be monitored as an outpatient to ensure that they remain stable. 4. Fall: witnessed at home with minor head trauma, no LOC. Neuro exam was followed in-house and was stable. She was on fall precautions. Physical therapy worked with her prior to discharge, and she will continue with this at rehabilitation. 5. Macrocytic anemia: likely from chemo; folate and b12 were within normal limits, transfusion threshold was 28 (given her history of CAD). She required 1 U PRBC on [**12-22**] with good response. Hematocrit was stable at time of discharge. 6. Nutrition: she had poor PO intake while in-house and was followed by nutrition. She was started on 40 mg Prednisone which improved her appetite. She was discharged on 20 mg Prednisone (to be tapered as an outpatient by Dr. [**Last Name (STitle) **] and Megace to improve her appetite. 7. PPx: colace, senna, PO diet, OOB as tolerated, SQ heparin given risk from NSCLCA; the SQ heparin should be continued at rehabilitation. Bowel regimen was used as necessary; her stools were loose at time of discharge (therefore bowel medications held). 8. Code: DNR/DNI per conversation with patient, HCP/son; corroborated with Dr. [**First Name (STitle) **] at 830pm on [**2197-12-15**] 9. Dispo: She was discharged to [**Hospital6 **] where she will continue with PT and complete her antibiotic course. After she leaves [**Hospital1 **], she should follow up with Dr. [**Last Name (STitle) **] (within 1 week of leaving [**Hospital1 **]). Medications on Admission: 1. Verapamil HCl 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 2. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO twice a day. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO QD (once a day). 6. Anzemet 7. Compazine 8. Colace 9. Senna 10. Ritalin, started [**2197-12-7**] Discharge Medications: 1. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*qs Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Continue until [**2197-12-30**]. Disp:*2 Tablet(s)* Refills:*0* 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day: Continue until follow up with Dr. [**Last Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*0* 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Continue while at rehabilitation only. 13. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 14. Lorazepam 0.5 mg IV Q4-6H:PRN anxiety or nausea/vomiting 15. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day: Continue until you follow up with Dr. [**Last Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*0* 16. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous twice a day for 6 days: 1 gm twice daily until [**2198-1-3**]. Disp:*qs * Refills:*0* 17. Megestrol Acetate 40 mg/mL Suspension Sig: One (1) PO DAILY (Daily): Please take 10 ml daily. Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: 1. E. coli Urosepsis 2. Hyponatremia/SIADH 3. Change in Mental status 4. Thrombocytopenia Secondary Diagnoses: 1. Stage IV NSCLC 2. Macrocytic anemia 3. Hypertension Discharge Condition: Good Discharge Instructions: 1. Please take all your medications as prescribed and described in this discharge paperwork. We made the following changes to your medication regimen: - We added 2 antibiotics; Levofloxacin 250 mg daily should be continued until [**2197-12-30**] (10-day course). Vancomycin 1 gm IV twice daily should be continued until [**2198-1-3**] (10-day course) - We are holding your Verapamil, a medication for blood pressure. You were previously on 240 mg daily; this should be restarted at the discretion of your PCP or Dr. [**Last Name (STitle) **]. - We are holding your Ritalin for now; Dr. [**Last Name (STitle) **] may want to restart this in the future - We started Prednisone (20 mg twice daily) on [**12-25**] to help with your appetite. You should take 20 mg daily upon discharge, and Dr. [**Last Name (STitle) **] will taper this medication when he sees you in follow-up - We started Megace, 400 mg daily, to help with your appetite. - We changed your Oxazepam to Ativan; you should take 1 mg twice daily of Ativan - We added Lansoprazole, a medication that should be continued while you are on the prednisone. - We added magnesium supplementation (400 mg daily); please continue this until you follow up with Dr. [**Last Name (STitle) **]. 2. Please follow up with your PCP and Oncologist (Dr. [**Last Name (STitle) **] as described below. 3. Please call your PCP if you are experiencing chest pain, shortness of breath, abdominal pain, fever, or with any other concerns. Followup Instructions: 1. Please call Dr.[**Name (NI) 8949**] office once you are discharged from [**Hospital1 **] and schedule an appointment for within 1 week of discharge ([**Telephone/Fax (1) 5562**]). You have an appointment scheduled for [**2198-1-4**] which you should attend if you are discharged from [**Hospital1 **] by this time. If not, you will have to reschedule 2. Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[**2198-1-4**] 10:00 3. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3281**], RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2198-1-4**] 10:30 4. Provider: [**Name Initial (NameIs) 4426**] 12 Date/Time:[**2198-1-4**] 10:30

[ "300.00", "599.0", "E933.1", "276.5", "197.7", "V12.59", "401.9", "287.5", "995.91", "253.6", "285.9", "733.00", "162.9", "346.90", "038.42" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

11763, 11842

5466, 9252

331, 338

12078, 12084

3688, 4766

13616, 14438

2451, 2665

9836, 11740

11863, 11863

9278, 9813

12108, 13593

2680, 3669

11997, 12057

278, 293

366, 2080

11882, 11976

4780, 5443

2102, 2220

2236, 2435

43,700

114,421

27646

Discharge summary

report

Admission Date: [**2170-1-15**] Discharge Date: [**2170-1-19**] Date of Birth: [**2091-10-23**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2170-1-15**] Coronary artery bypass graft x 4 (left internal mammary artery to left anterior descending, saphenous vein graft to diagonal, saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) History of Present Illness: This 78 year old Spanish speaking male has a cardiac history that includes RCA stent, inferior STEMI with in-stent restenosis of RCA, s/p BMS pRCA. He reports right sided back pain that radiates to his chest which occurs with walking short distances. The pain resolves with rest and does not occur unrelated to activity. He reports he has been taking Oxycodone three times daily for this chest pain. He states this is the only medication that helps him. He was recently seen by Dr. [**Last Name (STitle) 171**] and referred for a stress test which was positive and was referred for cardiac catheterization. He was found to have multivessel disease upon cardiac catetherization and is now being referred to cardiac surgery for revascularization. Past Medical History: s/p inferior Myocardial infarction restenosis of the RCA s/p bare metal stent of pRCA [**2160**] RCA stent Hypertension Hyperlipidemia Chronic Chest Pain Hypothyroidism noninsulin dependent diabetes mellitus h/o Prostate cancer- s/p radiation treatment [**2164**] Social History: Race:Hispanic Last Dental Exam:2 months agp Lives with:Alone, children live out of state Contact:[**Name (NI) **] [**Name (NI) 67533**] (friend) Phone #[**Telephone/Fax (1) 67534**] Occupation:Retired Cigarettes: Smoked no [] yes [x] Hx: [**11-20**] ppd x 15 years quit >40 years ago Other Tobacco use:denies ETOH: < 1 drink/week [x] [**12-26**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- Son had open heart surgery recently in [**State 108**]; age 54 Physical Exam: Pulse:58 Resp:12 O2 sat:100/RA B/P Right:169/77 Left:169/73 Height:5'6" Weight:150 lbs General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] No Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral 2 Right: 2 Left: DP 2 Right: 2 Left: PT 2 Right: 2 Left: Radial 2 Right: 2 Left: Carotid Bruit Yes Right: No Left: Pertinent Results: [**2170-1-15**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at time of surgery. POST-BYPASS: The patient is in sinus rhythm. Biventricular function is unchanged. Mitral regurgitation is unchanged. The aorta is intact post-decannulation. . [**2170-1-17**] 04:55AM BLOOD WBC-11.5* RBC-3.03* Hgb-10.2* Hct-28.1* MCV-93 MCH-33.6* MCHC-36.1* RDW-13.3 Plt Ct-113* [**2170-1-17**] 04:55AM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-129* K-4.2 Cl-94* HCO3-27 AnGap-12 [**2170-1-15**] 02:01PM BLOOD UreaN-14 Creat-0.9 Na-138 K-4.0 Cl-109* HCO3-20* AnGap-13 [**2170-1-19**] 06:10AM BLOOD WBC-7.2 RBC-3.21* Hgb-10.5* Hct-30.4* MCV-95 MCH-32.6* MCHC-34.5 RDW-12.7 Plt Ct-179# [**2170-1-19**] 06:10AM BLOOD Glucose-108* UreaN-17 Na-133 K-4.2 Cl-96 HCO3-32 AnGap-9 Brief Hospital Course: Mr. [**Known lastname **] was a same day admit and on [**1-15**] was brought directly to the Operating Room where he underwent coronary artery bypass grafts x 4. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta-blockers and diuretics and gently diuresed towards his pre-op weight. Later on this day he was transferred to the step-down floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. H edid experience some postoperative nausea and vomiting at POD 3. however, after moving his bowels this resolved and he felt well. Physical Therapy worked with him for strength and mobility. He was ready for transfer to a rehabilitation facility for further recovery prior to return home. He was discharged to [**First Name4 (NamePattern1) 730**] [**Last Name (NamePattern1) 731**] Rehab on [**1-19**]., Medications on Admission: Simvastatin 20mg (was instructed to stop and start Lipitor [**10-30**]- he is still currently taking simvasatin and no Lipitor) ATORVASTATIN (Not Taking as Prescribed) 80 mg Daily PLAVIX 75 mg Daily pt reports he does not take this consistently LISINOPRIL 40 mg daily METOPROLOL SUCCINATE 25 mg Daily OXYCODONE-ACETAMINOPHEN 5 mg/325 mg Tablet- takes 1 tablet 3 x day for chest pain RANITIDINE HCL 150 mg daily SIMVASTATIN 20 mg daily ASPIRIN 325 mg Daily MILK OF MAGNESIA Dosage uncertain Discharge Medications: Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location 8391**] Discharge Diagnosis: Coronary artery disease s/p Corornary artery bypass graft x 4 s/p inferior Myocardial infarction s/p bare metal stent of pRCA [**2160**] RCA stent Hypertension Hyperlipidemia Chronic Chest Pain Hypothyroidism noninsulin dependent diabetes mellitus h/o Prostate cancer (s/p radiation treatment [**2164**]) Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema- trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2170-2-14**] at 1:45pm Cardiologist: Dr. [**Last Name (STitle) 171**] on [**2170-2-7**] at 10am Please call to schedule appointments with: Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 14918**]) in [**2-22**] 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:[**2170-1-19**]

[ "V15.3", "V70.7", "272.4", "414.01", "412", "413.9", "V45.82", "V10.46", "401.9", "244.9", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6101, 6218

4472, 5535

322, 559

6567, 6811

2823, 4449

7651, 8242

2058, 2157

6078, 6078

6239, 6546

5561, 6052

6835, 7628

2172, 2804

272, 284

587, 1333

1355, 1620

1636, 2042

71,107

159,518

47749

Discharge summary

report

Admission Date: [**2183-5-29**] Discharge Date: [**2183-6-10**] Date of Birth: [**2103-7-12**] Sex: M Service: MEDICINE Allergies: Penicillins / Sulfonamides / Diltiazem / Codeine / Iodine-Iodine Containing / Ativan Attending:[**First Name3 (LF) 689**] Chief Complaint: increased cough, chills Major Surgical or Invasive Procedure: BiPAP History of Present Illness: 79-year-old man with history of COPD, hypercholesterolemia, hypertension, DMII who presents from home with a 1-day history of increasing cough and one episode of chills at home on the night of admission. . In the ED, initial vitals T 98.8, HR 74, BP 159/69, RR 18, sat 96%RA. Patient was complaining of increasing cough, thought it was [**1-28**] allergies. In the ED he was notably NOT hypoxic. Chest sounded rhonchorous, but cleared after coughing. CXR notable for retrocardiac opacity. Labs showed white count of 9.3 with normal differential (no bands), hct 39.5 (at baseline), with normal plts. BMP showed K of 5.3 with creatinine of 1.7 (at baseline). UA was negative. Lactate was 1.3. Patient was given 750 of levofloxacin and admitted, given his other medical comorbidities. Prior to admission, he received his home insulin dose (9u glargine, substituted for Levemir which was not available). At time of admit, vitals were T 98.8, HR 70, BP 95/42, RR 16, sat 94% on RA. . Initially, the patient awas admitted to the regular medical floor. He was started on nebulizers and antibiotics. Initial antibiotics were Levofloxacin. He was then Triggered for hypotension on [**2183-5-29**] and responded to fluid boluses. He then triggered during the day for Afib with RVR, which resolved with Metoprolol 5mg IV once. His antibiotics at that time were quickly broadened to Vancomycin / Meropenum / Clindamycin for possible aspiration pneumonia. He was also given IVF during that time period which worsened his dyspnea. He was then given Lasix IV with some urine output but not marked improvement in his respiratory status. Given concern for worsened respiratory fatigue, he was transferred to the ICU for closer monitoring. Upon initial floor evaluation, patient is speaking in [**12-28**] word sentences and with over wheezing from [**1-29**] feet away. Past Medical History: 1. Hypertension. 2. Type 2 diabetes mellitus- on metformine and glyburide, last a1c 6.5. 3. Hypercholesterolemia. 4. Ulcerative colitis- controlled on asacol alone 5. Cervical spinal stenosis 6. Status post total left hip replacement on [**2176-9-10**], postoperative atrial fibrillation/flutter with eleven second pauses. 7. Macular degeneration. 8. Schatzki's ring. 9. COPD 9. Left knee arthroscopy in [**2176-4-25**]. 10. Normal stress MIBI In [**10-28**], with an ejection fraction of 59%. 11. Atrial fibrillation with RVR Social History: The patient is a retired internal medicine doctor in the community, is married, quit tobacco fifteen years ago, has three to four drinks per week, and smokes a pipe (doesn't inhale, but reports a chronic "smokers cough"). Family History: His father died of myocardial infarction at age 70. Mother died of myocardial infarction at age 80. Sister died of complications of surgery at age 60. Physical Exam: Vitals: T 98.7, 76, 104/76, 18 and 99/RA Gen: Alert, oriented and in mild respiratory distress HEENT: PERRL, MMM Neck: Supple, JVD at 10cm CV: RR, no appreciable murmur over loud respiratory sounds Pulm: Diffuse ronchi and wheezing throughout both lungs and over trachea Abdomen: Notable movement with breathing, active bowel sounds, mildly distended and nontender Ex: WWP with palpable pulses Pertinent Results: LABS: CBC: [**2183-5-28**] 10:35PM BLOOD WBC-9.3 RBC-4.04* Hgb-13.1* Hct-39.5* MCV-98 MCH-32.5* MCHC-33.2 RDW-15.6* Plt Ct-196 [**2183-5-29**] 06:05AM BLOOD WBC-12.6* RBC-3.79* Hgb-11.6* Hct-36.8* MCV-97 MCH-30.7 MCHC-31.6 RDW-15.3 Plt Ct-215 [**2183-5-30**] 06:10AM BLOOD WBC-12.2* RBC-3.36* Hgb-10.6* Hct-32.9* MCV-98 MCH-31.6 MCHC-32.3 RDW-15.4 Plt Ct-182 [**2183-5-31**] 04:55AM BLOOD WBC-13.1* RBC-3.49* Hgb-11.1* Hct-35.3* MCV-101* MCH-31.9 MCHC-31.5 RDW-15.9* Plt Ct-188 [**2183-6-1**] 05:55AM BLOOD WBC-18.8* RBC-3.60* Hgb-11.4* Hct-37.1* MCV-103* MCH-31.7 MCHC-30.8* RDW-16.0* Plt Ct-258 [**2183-6-1**] 05:55AM BLOOD PT-12.1 PTT-24.5 INR(PT)-1.0 . CHEM: [**2183-5-28**] 10:35PM BLOOD Glucose-210* UreaN-60* Creat-1.7* Na-136 K-5.3* Cl-100 HCO3-24 AnGap-17 [**2183-5-29**] 06:05AM BLOOD Glucose-266* UreaN-67* Creat-2.1* Na-136 K-5.5* Cl-101 HCO3-23 AnGap-18 [**2183-5-29**] 03:45PM BLOOD UreaN-71* Creat-2.5* Na-136 K-4.7 Cl-102 HCO3-22 AnGap-17 [**2183-5-30**] 06:10AM BLOOD Glucose-206* UreaN-78* Creat-2.6* Na-132* K-4.6 Cl-100 HCO3-22 AnGap-15 [**2183-5-31**] 04:55AM BLOOD Glucose-396* UreaN-81* Creat-2.8* Na-132* K-5.0 Cl-100 HCO3-19* AnGap-18 [**2183-6-1**] 05:55AM BLOOD Glucose-336* UreaN-80* Creat-2.3* Na-138 K-5.6* Cl-106 HCO3-22 AnGap-16 . CE's: [**2183-5-28**] 10:35PM BLOOD CK(CPK)-69 [**2183-5-28**] 10:35PM BLOOD CK-MB-2 cTropnT-0.01 [**2183-5-29**] 06:05AM BLOOD CK(CPK)-62 [**2183-5-29**] 06:05AM BLOOD CK-MB-2 cTropnT-0.03* [**2183-5-29**] 03:45PM BLOOD CK(CPK)-134 [**2183-5-29**] 03:45PM BLOOD CK-MB-3 cTropnT-0.02* [**2183-5-30**] 10:15AM BLOOD CK(CPK)-196 [**2183-5-30**] 10:15AM BLOOD CK-MB-3 cTropnT-0.03* . [**2183-6-1**] 05:55AM BLOOD proBNP-[**Numeric Identifier **]* . ANEMIA: [**2183-6-1**] 05:55AM BLOOD VitB12-768 Folate-GREATER TH . ADRENAL: [**2183-5-29**] 06:05AM BLOOD Cortsol-35.6* MICRO: [**5-28**] - [**5-30**] BCx: No growth [**5-31**] Urine legionella: Negative [**5-31**] Rapid respiratory virus screen: Negative [**6-1**] SPUTUM: contaminated [**6-2**] Urine culture: No growth [**6-8**] Urine culture: < 10K organisms [**6-9**] Blood cultures x 2 sets: PENDING AT THE TIME OF DISCHARGE IMAGING: [**5-28**] CXR: IMPRESSION: 1. Left lower lobe pneumonia, abscess, or mass. 2. Smaller, possible right pneumonia. [**5-31**] CXR: Mild pulmonary edema has minimally improved. Aeration of the left lower lobe has improved, although left lower lobe retrocardiac consolidation persist. Cardiomediastinal contours are unchanged. Left transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. There is no pneumothorax. There are no new lung abnormalities. [**6-2**] Echocardiogram: The left atrium is mildly dilated. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. 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 regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2181-12-10**], the right ventricular cavity is now mildly dilated with mild free wall hypokinesis. The estimated PA systolic pressure is similar. [**6-3**] Head CT without contrast: IMPRESSION: 1. Limited study due to motion artifact. In case of clinical concern for acute cerebral infarction, an MRI can be obtained, if feasible. 2. No definite intracranial hemorrhage or mass effect. 3. Moderate cortical atrophy and moderately severe sequelae of chronic microvascular ischemic disease, as before. [**6-6**] CXR: IMPRESSION: AP chest compared to [**6-4**] and 10: Previous pulmonary edema has substantially cleared. Residual areas of consolidation in the perihilar left lung and both lower lobes medially could be due to pneumonia and should be followed. Pleural effusions are presumed, but small, and the heart is normal size. No pneumothorax. Transvenous right atrial and right ventricular pacer leads are in standard positions, unchanged. Brief Hospital Course: 79-year-old man with history of moderate COPD who presents with cough, chills at home admitted with concern for pneumonia with course complicated by hypotension, Afib with RVR and tachypnea and progressive respiratory distress prompting MICU transfer. # Respiratory distress: Likely multifactoral. At baseline has moderate obstructive pulmonary disease with moderate diffusion defect. There was also concern for PNA given chills and cough and ? infiltrate so he was treated with levofloxacin. Antibiotics had been broadened but were narrowed to levoflox alone when less concernf or resistantorganisms and sputum cx negative. Given most improvement with diuresis, most likely seocndary to heart failure and pulmonary edema. PE was considered but given improvement with diuresis and abs was felt to be less likely. Urine legionella, sputum cx all negative. treated with steroid taper transitioned from methylpred to prednison, course to finish [**6-9**]. At the time of discharge, patient had O2 sats in mid-90s on 3L of O2 by nasal canula. # Chronic obstructive pulmonary disease: FEV1 40% suggestive of moderate obstructive pulmonary disease. Home regimen consists of Advair with Combivent for breakthough symptoms. In hospital, was treated with Ipratroprium / Albuterol / IV steroids / Antibiotics as above. Prednisone taper was completed prior to discharge. # Acute kidney injury on chronic renal insufficiency: Unclear etiology but noted on arrival and most likely secondary to decreased renal perfusion from volume overload given improvement with creatinine with diuresis on lasix drip. Prior to transfer from ICU, patient was net negative greater than 8 L. After volume rescusitation and treatment for his pneumonia, creatinine returned to 1.2 which was improved to better than recent baseline. # Hypertension: Well controlled. Held enalapril and HCTZ given renal failure; these were restarted once renal function stabilized. Uptitrated beta blocker as below. # Hypotension: The patient's first episode of hypotension to SBP in 80s occurred shortly after admission on day #2 of antibiotic treatment. Subjectively, he felt somewhat tired but was otherwise asymptomatic. He responded to fluid rescusitation. This event was attributed to possible dehydration or undertreatment of his infection (? manifestation of sepsis). The second episode occurred with attempt to correct his A-fib with RVR with IV metoprolol, resulting in SBPs down to 70s. He was feeling poorly at this time and diaphoretic, but no specific lightheadedness or dizziness. He was transferred to the ICU for further management shortly after that event. He developed a third episode one day prior to discharge to SBP in 80s that occurred shortly after receiving both his metoprolol and verapamil. He was asymptomatic at this time. Blood pressure normalized with fluids. He has otherwise been quite stable on this regimen of metoprolol/verapamil with respect to both heart rate and blood pressure, so no changes were made to medication regimen. # Hypernatremia: Patient's Na was elevated to 147-150 for 3 days after discharge from the ICU. He had excellent urine output during this time (2+ liters daily) and moderate PO intake of [**12-28**] liters. This was felt most likely secondary to significantly elevated BUN correcting to normal (urine osmoles were appropriately elevated at close to 600), with possible contribution from patient somnolence and not drinking fully in response to thirst. His Na self-corrected to 142 prior to discharge. # Altered mental status: believed to be toxic metabolic encephalopathy secondary to steroids and infection. Oriented x [**1-29**] in MICU and awake and alert. On floor, patient was oriented x3 but was noted to be somnolent periodically and to close eyes/rest during conversations with providers. On the day of discharge, patient was more alert and able to converse normally, though still reported some fatigue. # Paroxysmal atrial fibrillation. Patient had recurrent episodes of AF with RVR requiring an esmolol drip in MICU. He was continued on his home amio and metoprolol uptitrated to 75mg Po q6 as he came off esmolol. Not anticoagulated due to PCP secondary to frequent falls. His rate was generally well controlled on discharge regimen of verapmil and metoprolol, with only a few short episodes of RVR to 130s-140s that responded administration of these PO medications. # Type II diabetes mellitus: Hyperglycemic once steroids started but his outpatient [**Last Name (un) **] provider recommended NPH in am given similar half life to prednisone. He shoudl continue on NPH while on prednisone but should d/c once off steroids. t starting systemic steroids. Held glyburide given renal failure and continued home januvia and glargine. # Hypercholesterolemia: Continued atorvastatin. # Hypothyroid: Last TSH 2.[**5-1**]/[**2182**]. Continued home levothyroxine. # Ulcerative colitis: No active issues. States well controlled recently. Continued home mesalamine. Medications on Admission: Home Medications: CARDIOVASCULAR - amiodorone 200mg qday - atorvastatin 10mg qday - enalapril 10mg [**Hospital1 **] - hydrochlorothiazie 12.5mg qday - metoprolol 100mg qday - asprin 325mg qday DIABETES - glyburide 5mg [**Hospital1 **] - insulin - 9u Levemir qhs - Januvia 100mg qday THYROID - levothyroxine 100mcg qday GASTRO - mesalamine 1200mg tid - pantoprazole 40mg [**Hospital1 **] PULMONARY - Advair 250-50 [**Hospital1 **] - Combivent inh 1-2puff q6h prn URO - vesicare 10mg qday - terazosin 6mg qday MISC - folate 1mg qday - primidone 150mg qhs (**unclear why he is taking; need to confirm**) - sertraline 50mg qday - Tramadol 100mg tid prn - Tylenol 1000mg tid - calcium-vitamin D dose uncertain - docusate prn - glucosamine 1500mg qday - guafenisen 600mg [**Hospital1 **] - magnesium 250mg qday - multivitamins-minerals-lutein Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: 5.5 Tablets PO TID (3 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Sitagliptin 100 mg Tablet Sig: One (1) Tablet PO daily (). 8. Levemir 100 unit/mL Solution Sig: Nine (9) units Subcutaneous at bedtime. 9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 14. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q4 hours PRN () as needed for dyspnea. 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Primidone 50 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime). 17. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever / pain. 19. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 20. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Oral 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 22. Glucosamine 500 mg Tablet Sig: Three (3) Tablet PO once a day. 23. Multivitamins-Minerals-Lutein Tablet Sig: One (1) Tablet PO once a day. 24. Magnesium 250 mg Tablet Sig: One (1) Tablet PO once a day. 25. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 26. Terazosin 2 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 27. Solifenacin 5 mg Tablet Sig: Two (2) Tablet PO at bedtime. 28. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 29. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 30. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: - Pneumonia - Acute-on-chronic renal failure - Atrial fibrillation with rapid ventricular rate Secondary: - Diabetes - Hypertension - Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 69**] with symptoms of pneumonia. Your infection progressed rapidly and led to instability of your heart rate and blood pressure as well as impaired kidney function. You also developed symptoms of fluid overload. You were transferred to the ICU where you were treated with IV antibiotics and steroids. Your breathing improved, as did your kidney function, and you were transferred back to the general medicine wards. We have made the following changes to your medication regimen: - STOP TAKING hydrochlorothiazide unless/until directed to resume by your physician [**Name Initial (PRE) **] [**Name10 (NameIs) **] DOSE of metoprolol to 137.5 mg by mouth three times daily - CHANGE MEDICATION from Combivent inhaler to ipratropium and albuterol nebs until directed to resume inhaler use - BEGIN TAKING verapamil 40 mg by mouth three times daily - BEGIN TAKING Montelukast 10 mg by mouth daily - TAKE AS NEEDED senna 1 tablet twice daily for constipation - TAKE AS NEEDED Dextromethorphan-Guaifenesin (cough syrup) every six hours Followup Instructions: Please call your primary care physician to schedule an appointment to discuss this admission once you are out of rehab: Department: [**State **] SQ (Primary Care) When: WEDNESDAY [**2183-6-25**] at 4:20 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Other follow up: Department: PULMONARY FUNCTION LAB When: TUESDAY [**2183-7-29**] at 11:00 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: TUESDAY [**2183-7-29**] at 11:00 AM Department: MEDICAL SPECIALTIES When: TUESDAY [**2183-7-29**] at 11:30 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2183-6-10**]

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Discharge summary

report

Admission Date: [**2195-8-4**] Discharge Date: [**2195-8-10**] Date of Birth: [**2120-3-18**] Sex: M Service: MEDICINE Allergies: Omeprazole Attending:[**First Name3 (LF) 1185**] Chief Complaint: Shortness of breath and increased cough with white sputum, continuous home O2 requirement overnight Major Surgical or Invasive Procedure: None History of Present Illness: 75 yo M with h/o severe COPD (FEV1 <30) on home O2, systolic CHF with LVEF 30%, cardiomyopathy, and recent ARF and hyponatremia (off Lasix, [**Last Name (un) **]) who presents with worsening shortness of breath acutely O/N, requiring constant O2 at his usual rate and increased SOB and fatigue for [**1-25**] wks. At home he uses O2 intermittently at a rate of [**2-25**].5 Lt/min. He reports increasing cough, productive of white phlegm and difficulty keeping medications down in past week or so, with desire to throw up after taking his pills that is relieved by taking sips of water. He also reports transient mild traveling pain from his R and L chest down to the R abdomen, as well as pain in his neck and back. The patient denied worsening chest pain accompanying his SOB, denied orthopnea, pleuritic chest pain, fevers, night sweats, dysuria, pain on urination, hematuria, hematochezia; eats a low salt diet, no dietary changes although decreased appetite in past weeks. Denies recent falls. Cardiologist evaluated on [**7-9**] with plan to stop dofetilide and start amiodarone due to ectopy. Dofetilide was stopped and pt has not been able to tolerate amiodarone due to nausea and emesis after ingesting the pill. In the ED, initial VS were 96.9 32 116/76 26 97% 2L Nasal Cannula. Labs were notable for Na 123, neg TnT. proBNP 1668. CXR consistent with COPD exacerbation. Pt was given Albuterol and Ipratropium nebs, 500mg Azithro and 125mg Solumedrol. Pt was then admitted for further evaluation and treatment. On transfer, VS were 116/66, 84, 97% 2 L, 20, 97.1. On the floor, he complaints of SOB despite 2.5 L O2 by NC, fatigue, he is alert and oriented, reported some back pain in neck and lumbar spine, not reproduced on palpation. Past Medical History: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (on [**2-25**].5L O2 by NC at home) ATRIAL FIBRILLATION CONGESTIVE HEART FAILURE (EF 30%), class 3 HEADACHE TINNITUS HYPERCHOLESTEROLEMIA ESOPHAGITIS, REFLUX IMPOTENCE, ORGANIC ORIGIN [**2182-10-3**] CARDIOMYOPATHY [**2184-10-18**]. Non-infarct related cardiomyopathy, status post dual-chamber ICD in [**2187**] VENTRICULAR ECTOPY BACK PAIN GOUT Social History: Lives in [**Location (un) **] with wife. Denies alcohol intake and tobacco in the past 10 years. 50py history. Has sons who live nearby and are involved in his care. Family History: Denies FH of heart disease, cancer, diabetes. Physical Exam: On admission: VS: 95.4, 110/60, 90, 22, 98% on 2 Lt nc GENERAL: thin man breathing with some effort on 2.5 Lt nc HEENT: sclera anicteric, PERRLA, EOMI, oropharynx with scant petechiae and no exudate, poor dentition NECK: no lymphadenopathy, no carotid bruits, JVP elevated. CV: regular rate, distant heart sounds, nl s1, s2, no r/m/g. Defibrillator in [**Doctor Last Name **] chest. RESP: breathing symmetrically with some difficulty, using accessory muscles of respiration, most noticeably sternocleidomastoids. Very distant lung sounds on exam, no crackles or wheezing. ABD: normoactive bowel sounds, soft and nontender, no organomegaly. EXT: Pitting edema 2+ at ankles bilaterally and nonpiting in both feet, 1+ edema in shins bilaterally. Hair lacking in distal legs anteriorly. Distal pulses difficult to palpate due to edema. SKIN: ecchymosis in L antecubitus, scant petechiae in anterior shins bilaterally. NEURO: A&O X3, attentive. CN 2-12 intact. Strength 5/5 in all extremities, intact light touch sensation, unable to elicit reflexes in upper or lower extremities bilaterally. Coordination and gait not tested. . On discharge: Unchanged except for the following: VS 95.8, 120/60 89 16 95% 2Lt GENERAL: thin man breathing with some effort on 2 Lt nc NECK: JVP not elevated. RESP: breathing symmetrically with some difficulty, using accessory muscles of respiration. Very distant lung sounds on exam, minimal bibasilar crackles, no wheezes. NEURO: A&O X2, uncooperative with attention testing. PSYCH: perseverant on leaving the hospital, some evidence of delirium and lack of competency for decision making at present. Pertinent Results: Admission Labs [**2195-8-4**] 10:23AM BLOOD WBC-7.1 RBC-4.64 Hgb-13.4* Hct-39.3* MCV-85 MCH-28.9 MCHC-34.2 RDW-14.6 Plt Ct-174 [**2195-8-4**] 10:23AM BLOOD Neuts-37* Bands-0 Lymphs-26 Monos-7 Eos-29* Baso-0 Atyps-1* Metas-0 Myelos-0 [**2195-8-4**] 10:23AM BLOOD PT-13.9* PTT-31.1 INR(PT)-1.2* [**2195-8-4**] 10:23AM BLOOD Glucose-84 UreaN-16 Creat-1.0# Na-123* K-4.5 Cl-84* HCO3-30 AnGap-14 [**2195-8-4**] 10:23AM BLOOD proBNP-1668* [**2195-8-5**] 05:06PM BLOOD Lactate-2.7* [**2195-8-5**] 09:36PM BLOOD Lactate-2.1* [**2195-8-5**] 10:25PM BLOOD Lactate-2.3* [**2195-8-7**] 12:27PM BLOOD Lactate-1.3 [**2195-8-7**] 12:13PM BLOOD Cortsol-2.2 [**2195-8-7**] 12:58PM BLOOD Cortsol-9.0 [**2195-8-7**] 01:24PM BLOOD Cortsol-12.7 [**2195-8-4**] 10:23AM BLOOD Digoxin-1.2 [**2195-8-6**] 04:45AM BLOOD Digoxin-1.2 [**2195-8-6**] 06:00AM BLOOD Digoxin-1.2 [**2195-8-7**] 02:26AM BLOOD Digoxin-1.4 [**2195-8-8**] 05:22AM BLOOD Digoxin-0.9 [**2195-8-4**] 10:23AM BLOOD cTropnT-<0.01 [**2195-8-4**] 07:25PM BLOOD cTropnT-0.02* [**2195-8-5**] 04:30PM BLOOD CK(CPK)-183 [**2195-8-5**] 04:30PM BLOOD CK-MB-7 cTropnT-0.06* [**2195-8-5**] 10:12PM BLOOD CK(CPK)-219 [**2195-8-5**] 10:12PM BLOOD CK-MB-8 cTropnT-0.09* [**2195-8-7**] 02:26AM BLOOD cTropnT-0.02* Discharge Labs [**2195-8-10**] 11:10AM BLOOD WBC-7.3 RBC-4.50* Hgb-13.0* Hct-38.7* MCV-86 MCH-28.9 MCHC-33.6 RDW-15.6* Plt Ct-272 [**2195-8-10**] 11:10AM BLOOD PT-39.4* PTT-37.8* INR(PT)-4.0* [**2195-8-10**] 11:10AM BLOOD Glucose-92 UreaN-19 Creat-0.9 Na-143 K-3.8 Cl-103 HCO3-32 AnGap-12 [**2195-8-10**] 11:10AM BLOOD Calcium-9.1 Phos-1.9*# Mg-2.0 Microbiology [**2195-8-9**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2195-8-9**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2195-8-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST - Negative [**2195-8-5**] URINE Legionella Urinary Antigen - Negative [**2195-8-5**] URINE URINE CULTURE - No growth. [**8-4**] CXR AP and lat: FINDINGS: In comparison with the study of earlier in this date, there is no interval change. The pacemaker remains in place and there is again evidence of hyperexpansion of the lungs consistent with chronic pulmonary disease and mild enlargement of the cardiac silhouette. No acute focal pneumonia or vascular congestion. . [**2195-8-5**] CTA CHEST W&W/O C&RECONS, NON-CORONARY IMPRESSION: No evidence of central or segmental pulmonary embolism. Enlarged pulmonary artery suggestive of pulmonary artery hypertension. Emphysema and multiple small solid lung nodules in left lung which are indeterminate. Mildly dilated ascending aorta. RECOMMENDATION: Followup CT is recommended at six months. . [**2195-8-5**] CT Head non-contrast: FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or acute territorial infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved, throughout. The ventricles and sulci are normal in size and configuration. There is a stable hypodensity demonstrated within the right corona radiata compatible with the a remote lacunar infarction. The visualized osseous structures are unremarkable, with no evidence of fracture. The visualized paranasal sinuses and mastoid air cells are well-aerated. Incidental note is made of a prominent right [**Doctor Last Name 13856**] bullosa with leftward deviation of the bony nasal septum. IMPRESSION: No acute intracranial process. CT has limited sensitivity for the evaluation of acute infarction and MRI can be obtained, as clinically indicated. . [**2195-8-9**] CXR: FINDINGS: In comparison with the study of [**8-5**], there are increasing opacifications at the left base silhouetting the medial aspect of the hemidiaphragm. In view of the clinical symptoms, this is suggestive of developing pneumonia. Otherwise little change. IMPRESSION: Probable development of left retrocardiac pneumonia. Brief Hospital Course: 75 yo M with severe COPD on [**2-25**].5 L O2 at home, CHF with LVEF of 30%, cardiomyopathy who presented with worsening SOB at rest, acutely increased oxygen requirement O/N and increasing cough productive of white sputum. Recently stopped diuretic, [**Last Name (un) **] and warfarin due to hyponatremia, rising creatinine and supratherapeutic INR. Admitted for COPD and CHF exacerbation. ACUTE ISSUES: # Dyspnea: The patient presented with acutely worsened SOB and increased O2 requirement O/N, increasing cough and sputum production without a clear change in sputum quality. However, without other symptoms or signs of infection (afebrile, no focal findings on lung exam). He met 2 criteria for acute COPD exacerbation and was empirically treated at the ED with B agonist/anticholinergic, steroids and antibiotics, on admission to the medicine floor he was continued on albuterol/ipratropium nebs q4hr standing and started on prednisone 40mg for [**8-2**] day planned course (d1 steroid [**8-4**]). Azithromycin was discontinued and he was started on levofloxacin 750mg q daily. CHF exacerbation was also considered a possible cause, in the context of recently stopped diuretics and signs of fluid overload on admission examination. He received 20mg IV furosemide at ED and a home po dose on [**2195-8-5**] with good urine output. He was ruled out for MI. On day 2 of admission he had worsening of SOB on 4Lt NC with sustained sinus tachycardia in 120-130s, he was ruled out for PE with a chest CTA. On HD #2, the patient was transfered to the MICU for hypoxemia with sats in the 70's. He was put on NRB mask, ABG showed 7.43 44 146 and sats came up to 100%, quickly weaned to 4L NC. Acute desat thought to be from COPD exacerbation versus PNA, PE or ACS. Patient later found to be coughing while eating and developed RLL infiltrate concerning for a HCAP vs aspiration pneumonitis patient was treated with vanc/cefepime. He was transfered back to the medicine floor on HD 6 in stable condition, afebrile, with O2 sats in low-mid 90s on 2Lt O2 by NC, he was continued on IV antibiotics for HCAP, standing levalbuterol/ipratropium and inhaled steroids. O/N the patient pulled out his IV and was refusing all care and stating he wanted to go home. Despite multiple discussions between his care providers and the patient, his son and wife, explaining the risks of leaving the hospital with a partially treated pneumonia and without IV antibiotics, the pt and his family left against medical advice on [**2195-8-10**] (see below for details). He was discharge on a 8-day course of cefpodoxime for oral HCAP coverage. # Hypotension: patient's baseline BP was in the 120s, but was persistently in the 70s-80s systolic while in the MICU. Was responsive to fluid boluses, but without great duration. Cortisol was checked and cosyn stimulation test was performed on [**8-7**] that showed a baseline cortisol level of 2.2, then 9.0 (30 minutes) and 12.7 (One hour), revealing mild adrenal insufficiency. Endocrine team was consulted and assessed impaired adrenal function most likely [**2-25**] long term inhaled steroids. Given acute stress, it was felt that he may benefit from stress-dose steroids. Started on stress dose hydrocortisone on [**2195-8-8**] per endocrinology recs. BPs stabilized to the 120s without further fluid boluses. As above, pt ultimately pulled out his IV, preventing him from getting his IV steroids. He left AMA and was discharged on a PO hydrocortisone taper. # Lung Nodules: Seen on chest CT. F/u chest CT recommended in 6 months. # Discharge AGAINST MEDICAL ADVICE: Overnight on HD 6, the patient pulled his IV, refusing po meds and vitals and stating he wanted to go home. The primary medical team assessed the patient and felt that he lacked the capacity to make decisions at that time. However, the team met with the patient's wife and son, who also wanted to take the patient home. A PICC line was considered; however, the patient was unable to undergo this procedure because of his elevated INR. The severity of the patient's illness was discussed with him and his wife and son. It was explained to them that there were significant risks (including death) if he were to leave against medical advice. It was explained that the likelihood of a bad outcome if he left AMA was quite high. The patient's family understood these risks and still wanted to take him home against medical advice. The patient also stated that he understood these risks and wanted to leave against medical advice. As above, he was discharged on PO defpodoxime for HCAP coverage and a PO hydrocortisone taper. # Hyponatremia: To 125 on admission, initially asymptomatic. Initially thought to be hypervolemic hyponatremia, and managed with gentle diuresis. Na was trended and did not require repletion. He was maintained of a 1L fluid restriction. # Mental status change: On day 2 of hospitalization, the pt was noted to be confused and agitated, he was unable to comply with attention testing. Multiple etiologies were thought to be contributing including hospitalization, steroids, hypoxia, hypercarbia. CT head was negative. Prednisone was held in the MICU with improvement in symptoms. Patient's aggitation redeveloped when started on stress dose hydrocortisone for hypotension. On HD 7 he showed limited capacity to make decisions regarding his medical care based on repeated inconsistencies on attention testing and goals of care. # Tachycardia: 100-110s at baseline with intermittent HR in 120-130s on hospital day 2. Received Zyprexa 2.5-5mg for agitation. Tn up to 0.06 likely demand [**2-25**] tachycardia. Ruled out for MI and PE. In the MICU, cardiology was consulted. Beta blocker was avoided given lung disease; pt was amiodarone loaded. He was discharged with plans to continue amiodarone load and then transition to maintenance dose. # Systolic CHF: Acute on chronic, LVEF 30%. Elevated pro-BNP on admission. No crackles on lung exam. Treated with gentle diuresis X2 initially. Digoxin level was therapeutic. [**Last Name (un) **] was initially held [**2-25**] renal insufficiency. Ultimately, [**Last Name (un) **] and lasix were held [**2-25**] hypotension (as above). Should be restarted when appropriate as an outpt. Pt was continued on home digoxin regimen. # NSVT / PAF: Recently discontinued dofetilide. Outpatient cardiologist had started amiodarone but pt has been unable to tolerate. Warfarin was held for supratherapeutic INR, starting [**2195-8-6**], likely related to poor nutrition and concurrent abx. He left the hospital on amiodarone load, holding warfarin. INR should be rechecked and coumadin restarted when INR levels in therapeutic range. # ARF: Thought to be pre-renal due to hypovolemia as it responded to stopping furosemide. Urine lytes consistent with pre-renal etiology. Cr 1.0 on admission ->peak 1.4 ->0.9 on departure. CHRONIC ISSUES: # GERD: was continued on home PPI # Gout: was continued on colchicine PRN TRANSITIONS OF CARE: -The patient was instructed to restart daily digoxin at 125mcg once daily, last digoxin level prior to departure was 0.9 on [**8-8**], he had been on every other day dosing during his MICU stay. Frequency of digoxin dosing should be addressed by PCP [**Name10 (NameIs) 13857**] to hold furosemide, valsartan and coumadin. PCP should address when to restart these medications. -On CTA-Chest from [**2195-8-5**] patient noted to have Emphysema and multiple small solid lung nodules in left lung which are indeterminate. Radiology recommends follow up CT in 6 months. Medications on Admission: -Atorvastatin 20 mg once a day -Colchicine 0.6 mg every 1 hour until diarrhea, then twice a day as needed for gout -Digoxin 125 mcg once a day -Fluticasone-salmeterol [Advair Diskus] 250-50 mcg/Dose 1 whiffs inhaled twice a day -Ipratropium-albuterol [Combivent] 18 mcg-103 mcg (90 mcg)/Actuation Aerosol 2 puffs(s) inhaled four times daily and prn -Nitroglycerin 0.3 mg sublingually as needed for chest pain -Pantoprazole 40 mg once a day -Spiriva with HandiHaler 18 mcg Capsule once a day -Aspirin 81 mg daily -Guaifenesin 600 mg twice a day -valsartan 160 mg once a day (currently held) -Warfarin 7.5 mg daily (currently held) -Furosemide 20 mg once a day (currently held) Discharge Medications: 1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO As directed: Take 2 tabs twice a day for 10 days (until [**8-20**]), then start taking 1 tab once a day until you follow-up with your cardiologist. Disp:*45 Tablet(s)* Refills:*0* 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 9. guaifenesin 600 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 10. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 11. colchicine 0.6 mg Tablet Sig: As directed Tablet PO As directed: As directed by your PCP when having [**Name Initial (PRE) **] gout flare. 12. hydrocortisone 5 mg Tablet Sig: 1-4 Tablets PO Follow taper as directed.: On [**8-10**], take 4 tabs in PM. On [**8-11**], take 4 tabs in AM and 2 tabs in PM. On [**8-12**], take 2 tabs in AM and 1 tab in PM. On [**8-13**], stop taking medication. Disp:*13 Tablet(s)* Refills:*0* 13. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days: Take for a total of 8 days, ending on [**2195-8-17**]. Disp:*32 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNa Discharge Diagnosis: COPD exacerbation Hospital acquired pneumonia Mild adrenal insufficiency secondary to chronic inhaled steroids Delirium Atrial fibrillation Hyponatremia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance. PATIENT LEFT THE HOSPITAL AGAINST MEDICAL ADVICE. Discharge Instructions: You were admitted with shortness of breath, increased cough and sputum after needing more home oxygen than usual. You were treated for an exacerbation of your severe lung disease, COPD. You were transferred to the intensive care unit (ICU) when your breathing worsened, you became agitated, and you needed more oxygen urgently. In the ICU you were also treated for low blood pressure, pneumonia and found to have mild adrenal insufficiency, meaning you need steroid medications to help maintain your body in balance, particularly when ill. You were restarted on amiodarone for your heart, as discussed with your cardiologist. We discussed the severity of your illnesses with you, and we recommended that you stay in the hospital for several more days for IV antibiotics. However, you decided to leave the hospital AGAINST MEDICAL ADVICE. INSTRUCTIONS: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. MEDICATION CHANGES: 1) START Hydrocortisone (steroid) taper: -today, [**8-10**], take 20 mg in evening -on [**8-11**], take 20 mg in am and 10 mg in pm -[**8-12**], take 10 mg in am and 5 mg in pm -[**8-13**] stop taking hydrocortisone 2) START Amiodarone -take 400 mg twice daily from [**8-10**] until [**8-20**], then STOP this dosage -on [**8-20**] start taking 200mg daily only 3) START Cefpodoxime (antibiotic). You will continue this for 8 days total (ending on [**2195-8-17**]). 4) Continue to hold your valsartan, furosemide, and warfarin. It is very important that you keep your follow-up appointments with your PCP. [**Name10 (NameIs) **] will determine when you should restart these medications. Continue all of your other medications as you were previously taking them. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] D. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 3329**] When: TUESDAY [**2195-8-11**] at 3:30 PM Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-8-21**] 12:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-10-20**] 10:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

18424, 18481

8341, 15229

370, 376

18678, 18678

4475, 8318

20644, 21315

2765, 2812

16635, 18401

18502, 18657

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15245, 15320

2180, 2566

2582, 2749

3,225

103,277

53747

Discharge summary

report

Admission Date: [**2133-3-6**] Discharge Date: [**2133-3-12**] Date of Birth: [**2084-3-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Transferred to ICU for monitoring of alcohol withdrawal Major Surgical or Invasive Procedure: Endotracheal intubation. Subclavian central venous line insertion. History of Present Illness: 48 y/o male with history of alcohol abuse presents after having two episodes which he describes as seizures. Unable to get report from his girlfriend, who was the only witness to theses episodes. Unclear if he lost consciousness or had a postictal period. He reports that he drank a case of beer and 3 half pint bottles of vodka yesterday, his last drink was at around 10 PM on the night of [**2133-3-5**]. In the [**Hospital1 18**] ED, he complained of nausea, vomiting, dizziness, shaking, fever/chills, chest pain, and visual hallucinations which he reports as seeing spots. He denies auditory hallucinations. He received Thiamine, Folate, 4 mg Ativan, and 40 mEq potassium repletion for a potassium of 2.8. Past Medical History: ? CAD with reported MI [**35**] years ago Thrombocytopenia, thought secondary to alcohol use Lower leg pain ETOH abuse h/o hypercholesterolemia per prior d/c summary h/o prior IVDU though he denies this to me, girlfriend similarly denies. + distant nasal cocaine use Social History: Patient currently lives with his girlfriend in [**Name (NI) 86**], MA although he has previously engaged in sexual intercourse with men as well. He and his girlfriend report they were recently HIV negative. ETOH: 1-1.5 pints of liquor each day. This has been going on since age 14. He has attempted to quit in the past but has relapsed each time. He lives with his girlfriend. His girlfriend and her daughter are involved in his care. Tobacco: Smokes 1-1.5 packs of cigarettes per day (50+ pack year history). IVDU: Denies Family History: Positive for lung cancer in his mother & father. His brother had HIV from sexual contact. Physical Exam: T 98.3 BP 162/100 HR 96 RR 14 SAT 99% 2L HEENT: Head Atraumatic. Pupils 3mm and reactive to light. Sclera anicteric. Throat clear. NECK: No LAD. Normal carotid pulses. CHEST: Large lungs fields. Lungs with poor air movement. No wheezes. HEART: Regular rhythm. No murmurs, gallops, rubs. ABD: NABS, Soft, NT, ND, no organomegaly. EXT: Thin legs. No edema. Good peripheral pulses. NEURO: Mental status- oriented to person and place, but not time (year [**2102**]). Cranial nerves- significant jerky eye movements with no localizing directionally. Tongue midline. Motor strength intact in upper and lower extremities. Toes upgoing bilaterally. Pertinent Results: [**2133-3-6**] 07:40PM PLT SMR-LOW PLT COUNT-84*# [**2133-3-6**] 07:40PM NEUTS-83.3* LYMPHS-10.3* MONOS-5.3 EOS-0.4 BASOS-0.7 [**2133-3-6**] 07:40PM WBC-8.8 RBC-4.03* HGB-12.8* HCT-36.9* MCV-92 MCH-31.7 MCHC-34.6 RDW-13.8 [**2133-3-6**] 07:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2133-3-6**] 07:40PM CALCIUM-9.3 PHOSPHATE-2.3*# MAGNESIUM-1.3* [**2133-3-6**] 07:40PM estGFR-Using this [**2133-3-6**] 07:40PM GLUCOSE-164* UREA N-8 CREAT-0.6 SODIUM-136 POTASSIUM-2.8* CHLORIDE-95* TOTAL CO2-27 ANION GAP-17 AT DISCHARGE Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2133-3-12**] 03:56AM 7.8 3.45* 11.0* 31.7* 92 32.0 34.8 13.8 179 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas [**2133-3-6**] 07:40PM 83.3* 10.3* 5.3 0.4 0.7 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2133-3-12**] 03:56AM 179 HEMOLYTIC WORKUP Ret Aut [**2133-3-7**] 03:26AM 1.1* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2133-3-12**] 03:56AM 92 7 0.5 138 3.6 100 29 13 CT HEAD W/O CONTRAST [**2133-3-10**] 11:58 AM CT HEAD W/O CONTRAST Reason: please rule out bleed [**Hospital 93**] MEDICAL CONDITION: 48 year old man with ETOH withdrawal with persistent altered mental status. REASON FOR THIS EXAMINATION: please rule out bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 48-year-old man with alcoholic withdrawal with persistent altered mental status. Rule out bleed. COMPARISON: [**2132-11-27**]. TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT CONTRAST: There is motion artifact, which degrades the quality of the study. Soft tissues and partial posterior skull are excluded, which represents a technical positioning error. FINDINGS: No intracranial mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct is apparent. The density values of the brain parenchyma are within normal limits. The visualized osseous structures demonstrate no evidence of fracture. Minimal maxillary mucosal sinus thickening, bilaterally. IMPRESSION: No acute intracranial pathology, including no sign of intracranial hemorrhage. Technically suboptimal study, as noted above. Brief Hospital Course: A/P: 48 y/o alcoholic male presenting with nausea, vomiting, dizziness, shaking, fever/chills, and chest pain, likely due to alcohol withdrawal. . # Alcohol Abuse/Withdrawal: the last drink was 10 PM on [**2133-3-5**]. He has a history of Delirium Tremens and Seizures as well as a history of heavy benzodiazepine requirements in the past to the point of intubation. The patient required>300 mg Valium the first 48 hours, as well as 8-10 mg Ativan. He had to be placed on soft restraints due to severe agitation. He developed hallucinosis but no DTs or seizures. Initially, CIWAs>30, but steadily decreased and 24 hours prior to discharge the patient required no benzos, haldol or restraints. Thiamine was repleted in ED and subsequently the patient received one liter banana bag daily IV with thiamine, folate, multivitamin. LFTs and coags remained stable. . # Nausea/Vomiting: Resolved within the first 24 hours. The patient did not take POs until 24 hours prior to discharge, first because of severe agitation and stupor, and 48 hours prior to discharge because of sedation. He was kept well hydrated and is discharged tolerating a regular diet. . # Respiratory Distress: On [**3-10**], the patient desatted to low 80s, possibly due to aspiration in the setting of severe agitation. He was instubated to protect his airway. He remained afebrile, CXR indeterminate not specific for pneumonia or pneumonitis, and was successfully extubated 24 hours later. On Levofloxacin for which he needs to continue 10 more days. . # Shaking: There was no evidence of seizures. Shaking stoppd as withdrawal resolved. He had CK>1000 that rapidly trended down as his shaking resolved. . # Reported Fever/Chills: Differential includes alcohol withdrawal and infection. The patient remained afebrile with no leukocytosis. . # Hypokalemia: Differential includes vomiting, diarrhea, poor nutritional intake. Potassium was repleted prn. . # Hypomagnesemia: Differential includes poor nutrition intake. Mg was repleted. . # Hypophosphatemia: Differential includes poor nutritional intake. Phos was repleted. . # Anemia: Differential includes impaired RBC production from B12, folate, iron deficiency or bone marrow suppression, infiltration vs. RBC destruction vs. blood loss. Iron, folate and B12 were checked and were normal. Active T and S was kept, but the patient required no transfusions and his Hct remained stable. His anemia is probably due to etoh induced bone marrow suppression. Retic was 1.1 . # Thrombocytopenia: He has a history of thrombocytopenia in the past. Differential includes decreased platelet production from marrow suppression or infiltration vs. platelet destruction vs. consumption vs sequestration. Spleen tip not palpable. . Prophylaxis: SQ heparin. Pantoprazole. Nicotine patch for smoking history. . Diet: Regular but patient unable to take POs except occasionally due to agitation. 24 hours prior to discharge, he was able to tolerate a regular diet and ensure supplements. . Code: Full. . Contact: [**Name (NI) 6480**] [**Name (NI) 110320**] [**Telephone/Fax (1) 110321**] Medications on Admission: None Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 4. Ensure Shakes Disp # 30 day supply Sig: Take 1 shake with meals for 30 days. 5. Nicotine 22 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. Disp:*10 patch* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Alcohol Withdrawal. Respiratory failure Discharge Condition: Good. Eating and drinking, no signs of active withdrawal. Discharge Instructions: You were admitted for alcohol withdrawal. You required a brief period of time on a ventilator for respiratory distress. You should never drink any alcohol ever again. We strongly recommend checking into an inpatient alcohol abuse treatment program directly after leaving the hospital. Please take your medications only as prescribed. Followup Instructions: Inpatient alcohol treatment program.

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8765, 8771

5102, 8197

370, 439

8856, 8916

2797, 4015

9301, 9341

2027, 2119

8252, 8742

4052, 4128

8792, 8835

8223, 8229

8940, 9278

2134, 2778

275, 332

4157, 5079

467, 1180

1202, 1470

1486, 2011

20,479

157,812

49376

Discharge summary

report

Admission Date: [**2153-8-24**] Discharge Date: [**2153-8-28**] Date of Birth: [**2079-5-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2704**] Chief Complaint: s/p right carotid stent, altered mental status Major Surgical or Invasive Procedure: Right side carotid stent Endotracheal intubation Left Femoral/left subclavian central line placement History of Present Illness: 74yo russian speaking male w/ PMH DM, HTN, CAD, s/p CABG w/ MVR [**2151**] now s/p [**Country **] stent placement [**12-21**] recent episodes of right hemiparesis and speech difficulties, referred for carotid angiography and possible revascularization. He [**Month/Day (2) 1834**] successful stenting but then had acute alteration in mental status with severe agitation. He was disoriented and could not be calmed after numerous attempts by staff and family. Patient was hypertensive w/ SBP 200s, sats stable. He was placed on NTG drip, became normotensive, but still remained very agitated. There was a concern for head bleed given altered mental status and elevated BP. However, pt was not cooperative for a head CT and needed to be sedated and intubated. A central line was placed to provide pressor for regulation of BP as pt was on fentanyl, versed drips. Pt was paralyzed w/ atracuronium and sent for head CT which was normal. Past Medical History: CHF - 3+ MR, EF 55% Carotid Disease - s/p stenting of [**Doctor First Name 3098**] HTN DM2 LBP elevated cholesterol hyperparathyroidism RCC s/p L partial nephrectomy, no chemo AAA BPH s/p turp s/p ccy kidney stones Social History: Married, Russian only speaking and lives with his wife who works at [**Hospital3 328**] and translates for him. Has one daughter and two granddaughters. His daughter will drive them to and from the hospital. Family History: Noncontributory - no premature CAD Physical Exam: VS T38.2 rectal BP 125/60 HR 74 RR 14-24 Sats 96% Gen: agitated, flailing extremities, speaking in russian, shouting HEENT: No icterus. NECK: Supple, no LAD, no JVD. No thyromegaly, no carotid bruits CV: nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: CTAB, no w/r/r ABD: Soft, ND. hypoactive BS. No HSM EXT: palpable pulses BL, no edema in LE SKIN: No rashes/lesions, ecchymoses NEURO: pt not alert or oriented x 3 Pertinent Results: [**2153-8-24**] 10:40PM TYPE-ART PO2-457* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-1 [**2153-8-24**] 10:40PM O2 SAT-99 [**2153-8-24**] 10:02PM GLUCOSE-141* UREA N-24* CREAT-1.3* SODIUM-141 POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12 [**2153-8-24**] 10:02PM CALCIUM-9.2 PHOSPHATE-2.0* MAGNESIUM-1.3* [**2153-8-24**] 10:02PM WBC-8.9 RBC-3.43* HGB-10.4* HCT-28.7* MCV-84 MCH-30.3 MCHC-36.3* RDW-15.4 [**2153-8-24**] 10:02PM PLT COUNT-156 [**2153-8-24**] 10:02PM PT-12.6 PTT-24.3 INR(PT)-1.1 [**2153-8-24**] 07:53PM TYPE-[**Last Name (un) **] RATES-14/2 TIDAL VOL-600 PEEP-5 O2-50 PO2-37* PCO2-52* PH-7.33* TOTAL CO2-29 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED . Imaging Studies: CT HEAD W/O CONTRAST [**2153-8-24**] 8:36 PM No intra- or extra-axial hemorrhage is identified. There is no mass effect or shift of normally midline structures. Again seen are lacunar infarcts in the right basal ganglia as well as a region of hypodensity in the white matter in the right Insula, unchanged. [**Doctor Last Name **]-white differentiation appears well preserved. . The paranasal sinuses demonstrate mucosal thickening of ethmoid air cells and the left maxillary sinus. No soft tissue abnormalities are seen. . IMPRESSION: No evidence of intracranial hemorrhage or mass effect. If concern for acute ischemia of the brain persists, diffusion-weighted imaging is recommended. . CHEST (PORTABLE AP) [**2153-8-24**] 6:57 PM Compared with [**2152-11-27**], an ET tube has been placed. The tip lies in satisfactory position approximately 5.8 cm above the carina. The patient is status post MVR with sternotomy wires. There is mild-to-moderate cardiomegaly, with unfolding and calcification of the aorta. There is mild pulmonary vascular plethora, suggesting very mild CHF. No gross effusion. Left costophrenic angle excluded from the film. . MR HEAD W/O CONTRAST [**2153-8-25**] 4:10 PM There are small areas of hyperintense signal seen in the right cerebral hemisphere involving the right posterior temporal, right occipital and right posterior frontal regions without corresponding abnormalities on FLAIR images and suggestive of small acute infarcts. There is no mass effect or midline shift seen. Minimal changes of small vessel disease are seen in the periventricular white matter. Mucosal thickening is seen in both maxillary sinuses and fluid is seen in the nasopharynx, which could be secondary to intubation. A small focus of susceptibility seen in the right posterior temporal region indicative of microhemorrhage which could be due to previous ischemia or could be due to amyloid angiopathy. IMPRESSION: Small foci of high signal on the diffusion images in the right temporal, occipital and posterior frontal regions suggestive of small acute infarcts. Minimal changes of small vessel disease. . CHEST (PORTABLE AP) [**2153-8-25**] 2:12 PM Tip of the ETT appears a bit higher than prior at 7.1 cm above the carina. This could be advanced at least 3 cm. There is a left CVL seen with the tip in the SVC and no PTX. The NGT remains in place. There is no PTX and the lungs remain clear. . CHEST (PORTABLE AP) [**2153-8-25**] 12:00 AM NG tube is present, extending into the stomach, with the tip curled in the stomach. The tip of the endotracheal tube remains 5.5 cm above the carina. Sternotomy sutures are present as well as mitral valve annulus, as seen previously. . Cardiac and mediastinal silhouettes are probably within normal limits allowing for the technique. There are no focal pulmonary opacities, pleural effusions, or pneumothorax. . IMPRESSION: NG tube extends into the stomach, with the tip curled in the stomach. . CHEST (PORTABLE AP) [**2153-8-26**] 7:03 AM Lines and tubes remain in place, although, I cannot clearly identify the distal aspect of the NGT. There is no new consolidation and some blunting ofthe left CP angle is unchanged. Pulmonary vascular markings are within normal limits and the heart size is mildly enlarged. There is no pneumothorax. . IMPRESSION: No significant interval change versus prior. No radiographic explanation for the patient's fever. Brief Hospital Course: 74yo russian speaking male with CAD s/p CABG, MVR, s/p L carotid stent and now s/p right carotid stent complicated by acute mental status changes. MRI required intubation, sedation, phenylephrine for BP support, revealed three small microinfarcts likely unrelated to encephalopathic picture. . NEURO # Mental status changes Patient was transferred to the cardiac care unit for hemodynamic monitoring after having a right internal carotid artery stent. Patient was noted to have acute alteration in mental status immediately after teh procedure with agitation, combativeness, disorientation, and confusion. Patient was not cooperative and was shouting profane words in Russian, while pulling at lines and foley. According to family, patient's mental status was normal before the procedure, without symptoms of psychosis or dementia. Patient was also hypertensive with SBP in 200s. There was obvious concern for an embolic stroke secondary to carotid stenting or hemorrhagic event due to high BP. He required sedation and intubation for urgent head CT and MRI scan to evaluate for CVA. . Head CT was negative for bleed or infarcts. MRI of head showed small foci of high signal on the diffusion images in the right temporal, occipital and posterior frontal regions suggestive of small acute infarcts. Given very small foci of bright signal on DWI, likely diagnosis was toxic/metabolic/infectious causes of confusional state or dye contrast-induced encephalopathy. MRI abnormalities were likely caused by small emboli from carotid manipulation but they are insufficient to explain encephalopathic state. . Patient was extubated after brain imaging and was given haldol as needed for agitation. He was given folate, thiamine, and multivitamin for possible wernicke's encephalopathy. He did not require a CIWA protocol. His mental status improved over the course of following two days and was no longer combative or disoriented. He was conversant, had intact comprehension, memory, and speech. Cranial nerves were intact and there were no focal neurological deficits in strength, sensation, or reflexes. Patient was found to have a UTI and treated with levoquin antibiotic treatment. . # Tremor Patient was noted to have a mild hand tremor. It was consistent with myoclonus, low suspicion for seizure. Improved with decreased fentanyl dose. Also considered chills with fever spike as possible etiology. Shaking was resolved upon discharge. . ID # Fevers Patient w/ persistent temp spikes. U/A positive, started on levofloxacin on [**8-26**]. Blood, urine cultures were negative. Sputum cx w/ gram+ cocci in pairs found to be moraxella. CXR negative for pneumonoia. Femoral line placement done under less than optimum conditions and it was removed on [**8-25**] with subsequent left subclavian line placement. Flagyl was given briefly for two days given concerns for aspiration pneumonia and stopped becase patient became afebrile, no elevation in WBC count, and clear CXR, without productive cough. . CARDIOVASCULAR Hx of CABG and MVR. s/p carotid stent to [**Country **] on [**8-24**], now off phenylephrine after extubation. After brain imaging revealed no bleed, patient was resumed on aspirin, and plavix. Since patient required sedation for intubation, BP was closely monitored and central line was placed for phenylephrine pressor to maintain SBP 100-140. Outpatient medications of lopressor, HCTZ, ACEi were held. Patient remained hemodynamically stable during intubation and pressor was discontinued once extubated as he was off versed and fentanyl which can cause hypotension. Patient did not have any complaints of chest pain, shortness of breath, lightheadedness, or dizziness. . Patient developed left groin pseudoaneurysm secondary to central line placement. Thrombin therapy was not administered due to small size of aneurysm and patient was asymptomatic. He will followup outpatient for re-evaluation and treatment. . PULMONARY Patient was intubated and placed on pressure support for brain imaging. Once extubated, he had mild productive coughing without blood. CXR was negative pneumonia and oxygen sats remained adequate and stable on room air after extubation. . RENAL Patient was had acute onset of renal insufficiency with Cr 1.3-1.7. The timing was consistent with contrast nephropathy. Patient received 150cc dye load during carotid stenting. While intubated, patient was on phenylephrine, which can decrease renal perfusion. FeNa was <1 consistent with pre-renal etiology of hypoperfusion. Urine output was adequate and creatnine level improved after patient was off pressor. . GI On protonix PPI IV, was NPO [**12-21**] intubation, w/ NGT. LFTs were within normal limits. Placed on regular diet once extubated without difficulties tolerating PO. . HEME Stable hct, no leukocytosis. . ENDOCRINE Pt w/ DM, held metformin as NPO while intubation and placed on RISS once resuming normal diet. TSH slightly elevated w/ normal free T4, no need for supplemental thyroxine therapy. . DISPO Patient out of bed ambulating prior to discharge, cleared by physical therapy. He will followup with PCP and Dr. [**First Name (STitle) **]. Mental status changes resolved and back to baseline cognition, not requiring further neurological assessments. . Code: Full Medications on Admission: Lipitor 40mg daily every evening Aspirin 81mg daily every morning Plavix 75mg daily every afternoon Lisinopril 20mg daily every morning HCTZ 12.5mg daily every morning Metformin 1000mg twice a day (hold the morning of the procedure) Metoprolol 25mg twice a day Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 6 days. Disp:*6 Tablet(s)* Refills:*0* 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: right internal carotid artery stent placement on [**2153-8-24**] Delirium secondary to contrast dye reaction Urinary tract infection Acute renal failure Acute micro-infarcts in right posterior frontal, temporal, occipital brain regions right groin pseudoaneurysm . Other diagnoses: Hypertension Hyperlipidemia Diabetes Carotid artery disease, s/p left carotid stenting [**2151**] CAD, mitral regurgitation CHF [**10-23**]: CABG/mitral valve replacement AAA [**2152-6-23**] gross hematuria/bladder and kidney stones, s/p bilateral lithotripsy [**2148**] BPH s/p TURP Anemia Lower back pain Hyperparathyroidism [**2149-10-13**] Renal cell carcinoma, s/p left partial nephrectomy Lipomas of posterior neck Osteopenia Remote shingles Cataracts Discharge Condition: Stable Discharge Instructions: You had a right side carotid stent placed for stenosis and were admitted to the cardiac care unit after the procedure for altered mental status with agitation, combativeness, and disorientation. It may have been secondary to contrast dye reaction that you received during during stenting. Given the agitation, you were intubated for a CT and MRI of head that did not show any bleeding, but did note a few small areas of embolic disease in a pattern unrelated to your stenting procedure. You were temporarily given a medicine to maintain your blood pressures. Neurology evaluation was done and ischemic stroke was ruled out. You had acute worsening of your kidney function which improved with rehydration and was likely due to the contrast dye load received during stenting. You had a fever due to a UTI and were started on levofloxacin antibiotic that you will continue for 6 more days. . You should return to the emergency room if you experience chest pain, shortness of breath, lightheadedness, dizziness, confusion, disorientation, pain in your left or right groin, or swelling or oozing from the groin sites. Please limit your activities for the next 4-6 weeks by avoiding strenuous physical activities such as running and heavy lifting. . You should continue a low salt, cardiac healthy diet. Please take all medications as prescribed. Followup Instructions: You have an appointment for an ultrasound of your left groin next Tuesday [**9-4**], at 9:30am at [**Hospital1 **] [**Hospital Ward Name 517**] [**Location (un) 470**] radiology suite (in the clinical center building). After the ultrasound please go to the [**Location (un) **] of the [**Hospital Unit Name **] also on the [**Hospital Ward Name **] (the heart catheterization lab reception desk). Where you will be seen by a cardiology fellow for follow up of the ultrasound result. . Please follow up with Dr. [**First Name (STitle) **] [**10-5**], and before that please meet with his nurse [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 496**] on [**2157-9-21**]:30am on the [**Hospital Ward Name 23**] [**Location (un) 436**] clinic. Call with any questions [**Telephone/Fax (1) 920**] . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3039**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2153-8-31**] 11:15 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2153-9-14**] 1:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 23733**], M.D. Date/Time:[**2153-9-28**] 11:10

[ "584.9", "349.82", "414.00", "292.81", "440.20", "V45.81", "272.0", "442.3", "252.00", "434.11", "V42.2", "265.1", "E947.8", "250.00", "733.00", "996.74", "V45.73", "V10.52", "997.02", "433.10", "997.2", "428.0", "599.0", "E879.9", "401.9", "285.9" ]

icd9cm

[ [ [] ] ]

[ "88.48", "96.71", "00.40", "00.61", "00.63", "96.04", "00.45", "88.41", "38.93" ]

icd9pcs

[ [ [] ] ]

12780, 12786

6540, 11807

362, 465

13589, 13598

2411, 3092

14987, 16229

1908, 1944

12120, 12757

12807, 13568

11833, 12097

13622, 14964

1959, 2392

276, 324

493, 1427

1449, 1666

1682, 1892

3109, 6517

13,071

174,077

20119

Discharge summary

report

Admission Date: [**2155-12-7**] Discharge Date: [**2155-12-10**] Service: Medicine CHIEF COMPLAINT: Gastrointestinal bleed and melena. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old Russian-speaking gentleman with terminal metastatic prostate cancer, atrial fibrillation (on Coumadin), and inferior vena cava syndrome who presented with one day of melanotic stool at [**Hospital **] Rehabilitation facility and a blood pressure of 68/40. According to the patient's daughter, he has been in his usual state of health over the past several days without any nausea, vomiting, hematemesis, abdominal pain, or bright red blood per rectum. The patient has had approximately two weeks of constipation and has had weight loss over the past several months. He denies chest pain, shortness of breath, and lightheadedness. He denies a history of gastrointestinal bleed. He does not drink alcohol. He does not take aspirin or nonsteroidal antiinflammatory drugs. The patient and the patient's daughter did not know his Coumadin dose and did not know if there had been any recent changes. In the Emergency Department, the patient's INR was found to be 14. His hematocrit was 20. A nasogastric lavage was negative for blood or coffee-grounds material. PAST MEDICAL HISTORY: 1. Terminal metastatic prostate cancer with metastases to the liver and bone and extensive pelvic and inguinal lymphadenopathy. Status post chemotherapy in [**2155-7-8**]. 2. Atrial fibrillation (on Coumadin). 3. Inferior vena cava syndrome. 4. History of congestive heart failure. MEDICATIONS ON ADMISSION: 1. Coumadin. 2. Iron. 3. Prednisone 20 mg once per day 4. Fentanyl 150-mcg patch q.72h. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was transferred from [**Hospital **] Rehabilitation. No alcohol. No tobacco. He is a retired chemist. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's temperature was 95.3 degrees Fahrenheit, his blood pressure was 113/59, his heart rate was 85, his respiratory rate was 17, and his oxygen saturation was 98% on room air. In general, the patient was a pale Russian-speaking gentleman. Alert and oriented times three. In no acute distress. Smelled melanotic. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. The sclerae were anicteric. The oropharynx was clear. The mucous membranes were slightly dry. The neck was supple. Cardiovascular examination revealed a regular rate and rhythm. The lungs were clear to auscultation bilaterally but decreased inspiratory effort. The abdomen revealed bilateral small masses in the lower quadrants. No tenderness on palpation. No distention. Rectal examination revealed guaiac-positive black stool. Skin examination revealed a maculopapular erythematous rash in the inguinal and pelvic regions. Extremity examination revealed 2 to 3+ bilateral lower extremity pitting edema. Neurologic examination revealed the patient was alert and oriented. Able to move all four extremities; however, weak throughout slightly greater in the lower extremities. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data revealed the patient's white blood cell count was 7.2, his hematocrit was 20, and his platelets were 245. INR was 13.9. Sodium was 137, potassium was 4.9, blood urea nitrogen was 51, and his creatinine was 1.4. Urinalysis was cloudy with moderate leukocyte esterase, large blood, positive nitrites, and greater than 50 white blood cells. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at a rate of 85, with left axis deviation, and nonspecific lateral T wave changes. A chest x-ray showed low lung volumes. No definite congestive heart failure. Small bilateral pleural effusions with atelectasis at the lung bases. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. UPPER GASTROINTESTINAL BLEED ISSUES: In the Emergency Department, the patient received 3 units of packed red blood cells and 4 units of fresh frozen plasma. With the rapid volume resuscitation, the patient's blood pressure improved to 110/60. He was also given 10 units of vitamin K subcutaneously, and his Coumadin was discontinued. The patient's bleeding quickly receded, and his hematocrit remained stable after correction of his INR. The patient was transferred to the Medical Intensive Care Unit for volume resuscitation and management of his upper gastrointestinal bleed. The patient was seen by the Gastroenterology Service and underwent an urgent upper endoscopy which revealed esophagitis and diffuse ulcerative gastritis which was felt to be the likely cause of the patient's gastrointestinal bleed in the setting of a supratherapeutic INR. The patient was placed on a twice per day proton pump inhibitor and was started on sucralfate for treatment of his gastric ulcerations. The patient was transferred out of the Medical Intensive Care Unit on [**12-8**] after his hematocrit had been stable for over 24 hours. On transfer to the floor, the patient's hematocrit was monitored twice per day and continued to remain stable. The patient was to be discharged on twice per day proton pump inhibitor. In addition, his prednisone will be decreased to 15 mg to see if he tolerates it froma pain standpoint/symptomatic relief for his prostate ca. If he does tolerate it then we can cont to taper very slowly over several weeks as this may contribute to an increased risk of gastrointestinal bleeding. If he does have increased symptoms it shoudl be continued. The patient's Coumadin should not be restarted as he has had a very high risk of recurrent bleeding. 2. HYPOTENSION ISSUES: The patient was initially extremely hypotensive with a blood pressure of 68/40. The patient received rapid volume resuscitation. His blood pressure responded well throughout his hospital stay. He had low normal systolic and diastolic blood pressures without any symptoms. On the day of discharge, his blood pressure was in the 90s systolic/40s diastolic. 3. ATRIAL FIBRILLATION ISSUES: The patient was admitted on Coumadin. His Coumadin was discontinued due to his gastrointestinal bleed and increased risk for recurrent bleeding. His Coumadin should not be restarted as an outpatient. 4. URINARY TRACT INFECTION ISSUES: The patient has terminal metastatic prostate cancer. He was most recently admitted to [**First Name8 (NamePattern2) 1495**] [**Hospital **] Medical Center where he was found to have mild hydronephrosis and a creatinine in the low 2 range. His urologist (Dr. [**Last Name (STitle) 54118**] knows the patient well and felt that ureteral stents were not indicated in this patient until he has complete obstruction or becomes septic. During the last 24 hours of his hospital stay, the patient was producing approximately 40 cc to 50 cc of urine per hour. On the day of discharge, his creatinine was 1.3. The patient also developed a urinary tract infection with Pseudomonas which was resistant to fluoroquinolones and aminoglycosides. The patient was started on intravenous Zosyn and was to complete a 14-day course of Zosyn therapy. In addition, the patient had a peripherally inserted central catheter placed for intravenous antibiotics. 5. METASTATIC PROSTATE CANCER ISSUES: After a discussion with the patient's primary urologist (Dr. [**Last Name (STitle) 54118**], it was discovered that the patient was in the terminal stage of the prostate cancer. There were no further treatments for his prostate cancer. The patient was placed on 20 mg of prednisone daily by Dr. [**Last Name (STitle) 54118**] for symptomatic relief in end-stage prostate cancer. If the patient tolerates it,the dose will be tapered as it was felt the patient's risk of gastrointestinal bleed is increased by his continued use of steroids. The patient was to follow up with Dr. [**Last Name (STitle) 54118**] as an outpatient in one to two weeks. 6. ORAL THRUSH ISSUES: The patient was found to have oral thrush and was started on Nystatin swish-and-swallow. 7. GROIN RASH ISSUES: The patient was felt to have a candidal intertriginous infection on the groin and was started on miconazole and Nystatin powders. 8. INFERIOR VENA CAVA SYNDROME: The patient had a significant amount of bilateral lower extremity and scrotal edema which was felt to be due to his inferior vena cava syndrome. The patient's legs should be elevated when possible. 9. CODE STATUS ISSUES: The patient's code status was addressed with his daughter ([**Name (NI) 54119**]) who is his health care proxy. She has had discussions with her father, and he knows that he has prostate cancer. She felt that he would not fully understand a code discussion, but clearly noted that he would not want any heroic measures taken should his heart stop beating or should he stop breathing. At this time, he was made do not resuscitate/do not intubate. It was determined that pressors would not be used as well. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To [**Hospital **] Rehabilitation. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to complete his prednisone taper very slowly - to start with a drop to 15mg and reassess symptoms. 2. The patient was instructed to follow up with his outpatient primary care physician (Dr. [**Last Name (STitle) **] in one to two weeks. 3. The patient was instructed to follow up with his outpatient urologist (Dr. [**Last Name (STitle) 54118**] in one to two weeks. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Ulcerative gastritis. 3. Acute anemia requiring blood transfusion. 4. Hypovolemic shock. 5. Elevation INR to 14. 6. Metastatic prostate cancer to the liver and bone. 7. Inferior vena cava syndrome. 8. Atrial fibrillation. 9. Pseudomonas urinary tract infection. MEDICATIONS ON DISCHARGE: 1. Dilaudid 2 mg by mouth q.4h. as needed. 2. Fentanyl 150-mcg patch q.72h. 3. Nystatin swish-and-swallow. 4. Miconazole powder. 5. Sucralfate 1 gram by mouth four times per day (for 14 days). 6. Prednisone 15 mg for seven days; and then reassess for further taper per sx. 7. Zosyn 2.25 grams q.6h. (for 14 days). 8. Protonix 40 mg by mouth twice per day. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**] Dictated By:[**Last Name (NamePattern1) 54120**] MEDQUIST36 D: [**2155-12-10**] 13:04 T: [**2155-12-10**] 13:05 JOB#: [**Job Number 54121**]

[ "427.31", "535.41", "285.1", "428.0", "197.7", "112.0", "599.0", "785.59", "198.5" ]

icd9cm

[ [ [] ] ]

[ "96.07" ]

icd9pcs

[ [ [] ] ]

9619, 9927

9953, 10590

1611, 1742

9197, 9598

3934, 9058

9073, 9164

113, 149

178, 1275

1297, 1585

1759, 3900

55,246

155,079

295

Discharge summary

report

[** **] Date: [**2123-1-12**] Discharge Date: [**2123-1-19**] Date of Birth: [**2048-3-13**] Sex: F Service: MEDICINE Allergies: Penicillins / Desmopressin Attending:[**First Name3 (LF) 2291**] Chief Complaint: hyponatremia Major Surgical or Invasive Procedure: endoscopy - EGD with EUS, [**First Name3 (LF) 2792**] History of Present Illness: 74F the patient w/ hx of PE, hyponatremia, breast CA, HTN states that she was sent in by her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]. The patient has a colonscopy on Wednesday (today) to evaluate for a possible cause of the patient's stool incontinence. Otherwise the patient does state that she has been drinking a bit more fluids for upcoming [**Last Name (Titles) 2792**] (but stopped after PCP coverage told her to come into the hospital, and has not taken the bowel prep yet). Otherwise the patient is not having any chest pain or shortness of breath. The patient is not having any symptoms that are new or acute. Pt has persistent stool incontinence. The patient notes that she has had 6 BMs in the past 24 hrs, and usually has a number of loose BMs per day. No CP, SOB, palpitations, cramps, joint pain. No headaches. . In the ED inital vitals were, 96.7 76 128/58 20 94% No symptoms. Nothing remarkable on exam. Patient's Na decreased from 119 --> 115 despite fluid restriction. CT head unremarkable. Peaked T's on EKG --> 1g calcium, insulin and dextrose. K+ 6.0 to 5.2. Ativan was given for anxiety. Cr 1.2 from 0.7 ([**12-17**]). WBC 5.5, Hct 32.4, Plt 205 Na 119 --> 115 K+ 6.0 --> 5.2 Cl 81; Bicarb 23; BUN 20; Cr 1.2 Ca 8.6, P 3.6, Mg 1.7 Access: 18 in R AC Fluids: no fluids . On arrival to the ICU, patient vitals are afebrile 63 132/63 18 100%ra. Patient was drowsy, likely secondary to ativan that was given before transport in ED. 1L NS bolus initiated. Repeat EKG showed a rate of 64 in sinus rhythm, J-point elevation V2-V6, QTc 477, peaked T waves V2, V3, II. . 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, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Denies headache. Past Medical History: - history of PE (last in [**2122-9-5**] at [**Hospital3 **]) - cystocele followed by Dr. [**Last Name (STitle) **] - L breast DCIS in [**2104**] s/p breast conserving surgery followed by recurrence in [**2117**] requiring mastectomy with immediate reconstruction. No re-occurance since. - R breast reduction performed in [**2117**] - Hypertension - GERD/Barrett's esophagus - Gout - Asthma - OA of knees - L popliteal DVT s/p anticoagulation - IBS w/fecal incontinence - Spinal stenosis - History of [**Year (4 digits) 499**] adenomas - Charcot's arthropathy of R ankle - History of endometrial cancer in [**2102**] s/p TAH-BSO - History of diverticulitis - Cholecystectomy - Hernia repair at CCY site Social History: Originally from [**Country 2784**], lives with husband. Denies tobacco or illicits. She drinks wine occasionally. Her daughter is a med/peds resident at [**Location 2785**]. She is disabled by chronic ankle and foot pain. Family History: Father - lung cancer Mother - pulmonary embolism, heart problems Sister - melanoma Sister - [**Name (NI) **] cancer Physical Exam: [**Name (NI) **] Physical Exam: afebrile 63 132/63 18 100%ra General: no acute distressed, drowsy, arousable to voice HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, obese, bowel sounds present, no rebound tenderness or guarding, no organomegaly Skin: bruises on pannus Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis; charcot feet; pedal edema Neuro: PERRL, no focal abnl on cranial nerve exam . Discharge Physical Exam: Pertinent Results: [**Name (NI) **] Labs: [**2123-1-12**] 10:35PM BLOOD WBC-5.5 RBC-3.43* Hgb-11.4* Hct-32.4* MCV-95 MCH-33.2* MCHC-35.1* RDW-14.2 Plt Ct-205 [**2123-1-12**] 10:35PM BLOOD Neuts-71.0* Lymphs-17.0* Monos-10.7 Eos-1.0 Baso-0.3 [**2123-1-13**] 03:09AM BLOOD WBC-4.7 RBC-3.46* Hgb-11.3* Hct-32.7* MCV-95 MCH-32.8* MCHC-34.7 RDW-14.2 Plt Ct-181 [**2123-1-13**] 03:09AM BLOOD Neuts-79.0* Lymphs-9.1* Monos-10.5 Eos-0.7 Baso-0.7 [**2123-1-13**] 03:09AM BLOOD PT-11.2 PTT-41.4* INR(PT)-1.0 [**2123-1-13**] 03:09AM BLOOD Glucose-70 UreaN-19 Creat-0.9 Na-119* K-4.3 Cl-89* HCO3-21* AnGap-13 [**2123-1-12**] 10:35PM BLOOD Glucose-74 UreaN-20 Creat-1.2* Na-115* K-5.2* Cl-81* HCO3-23 AnGap-16 [**2123-1-12**] 03:20PM BLOOD UreaN-22* Creat-1.2* Na-119* K-6.0* Cl-81* HCO3-25 AnGap-19 [**2123-1-13**] 03:09AM BLOOD ALT-27 AST-40 LD(LDH)-149 AlkPhos-88 TotBili-0.7 [**2123-1-13**] 03:09AM BLOOD Albumin-3.5 Calcium-9.0 Phos-3.7 Mg-1.8 [**2123-1-12**] 10:35PM BLOOD Osmolal-283 [**2123-1-13**] 02:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 [**2123-1-13**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2123-1-13**] 02:30AM URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-0 [**2123-1-13**] 02:30AM URINE Hours-RANDOM UreaN-203 Creat-28 [**2123-1-12**] 03:14PM URINE Hours-RANDOM Na-18 K-47 Cl-22 [**2123-1-12**] 03:14PM URINE Osmolal-276 IMAGING: EKG: [**1-12**] Sinus arrhythmia. P-R interval prolongation. Since the previous tracing of [**2122-12-17**] the rate is slower. The P-R interval is longer. Repolarization pattern is unchanged. . [**1-12**] Head CT: IMPRESSION: 1. No evidence of cerebral edema. If there is concern for central pontine myelinolysis, MRI is recommended for increased sensitivity. 2. Stable sequelae of chronic small vessel ischemic disease and global atrophy. 3. No mass effect or evidence of herniation. NOTE ADDED IN ATTENDING REVIEW: Osmotic demyelination syndrome ("central and extra-pontine myelinolysis") generally occurs as complication of the treatment, with too-rapid correction, of patients with profound, life-threatening hyponatremia, rather than the hyponatremia, per se . [**1-13**] EKG: Sinus rhythm. Borderline P-R interval prolongation. Q-T interval prolongation. Early R wave progression. J point and ST segment elevation are more apparent in limb and precordial leads. The QRS width is also wider. Consider metabolic derangements. Clinical correlation is suggested . CXR [**1-13**]: IMPRESSION: AP chest compared to [**12-16**]: Antilordotic positioning probably explains mild enlargement of both hila. Lateral aspect right hemithorax is excluded from the examination. Remainder of the imaged lungs and pleural surfaces are normal aside from mild bibasilar atelectasis. Heart is not enlarged. . [**1-14**] Knee xray: FINDINGS: There are severe degenerative changes involving the patellofemoral compartment with bone-on-bone contact to the patella with the trochlea at the lateral aspect. Bony irregularity and erosion is seen. There is also faint chondrocalcinosis. These overall findings can be seen in the setting of CPPD arthropathy. There is a knee joint effusion. . [**2123-1-14**] 06:30AM BLOOD WBC-5.0 RBC-3.26* Hgb-10.8* Hct-31.0* MCV-95 MCH-33.1* MCHC-34.8 RDW-14.2 Plt Ct-175 [**2123-1-13**] 03:09AM BLOOD WBC-4.7 RBC-3.46* Hgb-11.3* Hct-32.7* MCV-95 MCH-32.8* MCHC-34.7 RDW-14.2 Plt Ct-181 [**2123-1-12**] 10:35PM BLOOD WBC-5.5 RBC-3.43* Hgb-11.4* Hct-32.4* MCV-95 MCH-33.2* MCHC-35.1* RDW-14.2 Plt Ct-205 [**2123-1-13**] 03:09AM BLOOD Neuts-79.0* Lymphs-9.1* Monos-10.5 Eos-0.7 Baso-0.7 [**2123-1-12**] 10:35PM BLOOD Neuts-71.0* Lymphs-17.0* Monos-10.7 Eos-1.0 Baso-0.3 [**2123-1-13**] 03:09AM BLOOD PT-11.2 PTT-41.4* INR(PT)-1.0 [**2123-1-13**] 03:09AM BLOOD Eos Ct-60 [**2123-1-14**] 01:03PM BLOOD Glucose-128* UreaN-17 Creat-0.9 Na-124* K-4.4 Cl-89* HCO3-26 AnGap-13 [**2123-1-14**] 06:30AM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-123* K-4.6 Cl-91* HCO3-26 AnGap-11 [**2123-1-14**] 02:45AM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-120* K-4.5 Cl-91* HCO3-24 AnGap-10 [**2123-1-13**] 09:15PM BLOOD Glucose-137* UreaN-18 Creat-0.9 Na-125* K-4.5 Cl-91* HCO3-24 AnGap-15 [**2123-1-13**] 04:10PM BLOOD Glucose-110* UreaN-16 Creat-0.9 Na-125* K-4.4 Cl-90* HCO3-26 AnGap-13 [**2123-1-13**] 09:52AM BLOOD Glucose-168* UreaN-17 Creat-0.9 Na-120* K-4.6 Cl-91* HCO3-23 AnGap-11 [**2123-1-13**] 03:09AM BLOOD Glucose-70 UreaN-19 Creat-0.9 Na-119* K-4.3 Cl-89* HCO3-21* AnGap-13 [**2123-1-12**] 10:35PM BLOOD Glucose-74 UreaN-20 Creat-1.2* Na-115* K-5.2* Cl-81* HCO3-23 AnGap-16 [**2123-1-12**] 03:20PM BLOOD UreaN-22* Creat-1.2* Na-119* K-6.0* Cl-81* HCO3-25 AnGap-19 [**2123-1-14**] 06:30AM BLOOD ALT-26 AST-31 AlkPhos-80 TotBili-0.9 [**2123-1-13**] 03:09AM BLOOD ALT-27 AST-40 LD(LDH)-149 CK(CPK)-85 AlkPhos-88 TotBili-0.7 [**2123-1-13**] 09:52AM BLOOD CK-MB-2 cTropnT-<0.01 [**2123-1-13**] 03:09AM BLOOD CK-MB-3 cTropnT-<0.01 [**2123-1-14**] 01:03PM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8 [**2123-1-14**] 06:30AM BLOOD UricAcd-3.0 [**2123-1-14**] 02:45AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8 [**2123-1-13**] 09:52AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.1 [**2123-1-13**] 03:09AM BLOOD Albumin-3.5 Calcium-9.0 Phos-3.7 Mg-1.8 [**2123-1-12**] 10:35PM BLOOD Calcium-8.6 Phos-3.6 Mg-1.7 [**2123-1-13**] 09:52AM BLOOD Triglyc-29 [**2123-1-14**] 06:30AM BLOOD Osmolal-256* [**2123-1-12**] 10:35PM BLOOD Osmolal-283 [**2123-1-14**] 06:30AM BLOOD Osmolal-256* [**2123-1-14**] 06:30AM BLOOD Osmolal-256* [**2123-1-13**] 09:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2123-1-13**] 03:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2123-1-13**] 02:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 [**2123-1-13**] 03:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [**2123-1-13**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2123-1-13**] 03:25PM URINE RBC-2 WBC-13* Bacteri-FEW Yeast-NONE Epi-1 [**2123-1-13**] 02:30AM URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-0 [**2123-1-13**] 03:25PM URINE Hours-RANDOM UreaN-454 Creat-52 Na-67 K-54 Cl-90 [**2123-1-13**] 03:25PM URINE Hours-RANDOM [**2123-1-13**] 02:30AM URINE Hours-RANDOM UreaN-203 Creat-28 [**2123-1-12**] 03:14PM URINE Hours-RANDOM Na-18 K-47 Cl-22 [**2123-1-14**] 05:28AM URINE Osmolal-185 [**2123-1-13**] 03:25PM URINE Osmolal-435 [**2123-1-12**] 03:14PM URINE Osmolal-276 [**2123-1-13**] 02:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2123-1-15**] 07:25AM BLOOD Glucose-105* UreaN-17 Creat-0.8 Na-128* K-4.3 Cl-94* HCO3-28 AnGap-10 . [**2123-1-19**] 05:30AM BLOOD WBC-4.4 RBC-2.87* Hgb-9.2* Hct-27.7* MCV-96 MCH-32.1* MCHC-33.3 RDW-13.9 Plt Ct-298 [**2123-1-19**] 05:30AM BLOOD WBC-4.4 RBC-2.87* Hgb-9.2* Hct-27.7* MCV-96 MCH-32.1* MCHC-33.3 RDW-13.9 Plt Ct-298 [**2123-1-18**] 05:26AM BLOOD WBC-6.9 RBC-3.09* Hgb-10.0* Hct-29.6* MCV-96 MCH-32.4* MCHC-33.8 RDW-13.9 Plt Ct-279 [**2123-1-18**] 05:26AM BLOOD WBC-6.9 RBC-3.09* Hgb-10.0* Hct-29.6* MCV-96 MCH-32.4* MCHC-33.8 RDW-13.9 Plt Ct-279 [**2123-1-19**] 05:30AM BLOOD Glucose-92 UreaN-18 Creat-0.7 Na-133 K-3.6 Cl-98 HCO3-29 AnGap-10 [**2123-1-18**] 07:20PM BLOOD Glucose-196* UreaN-21* Creat-0.8 Na-133 K-3.5 Cl-97 HCO3-25 AnGap-15 [**2123-1-18**] 05:26AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-133 K-3.8 Cl-94* HCO3-29 AnGap-14 [**2123-1-18**] 05:26AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-133 K-3.8 Cl-94* HCO3-29 AnGap-14 [**2123-1-17**] 06:10AM BLOOD Glucose-86 UreaN-23* Creat-0.9 Na-128* K-4.1 Cl-93* HCO3-27 AnGap-12 [**2123-1-19**] 05:30AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.6 [**2123-1-17**] 06:16PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2123-1-18**] 07:13PM URINE Osmolal-643 [**2123-1-15**] 06:05AM URINE Osmolal-465 . MRSA screen ([**1-13**]): MRSA positive C. diff ([**1-17**]): negative for C. diff toxin. Urine Culture ([**1-17**]): URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . . Endoscopy ([**1-18**]): colonscopy Findings: Mucosa: Mild and patchy erythema at sigmoid [**Month/Year (2) 499**] and rectum were noted. Cold forceps biopsies were performed for histology. Protruding Lesions: A single sessile 4 mm polyp of benign appearance was found in the hepatic flexure. A single-piece polypectomy was performed using a cold forceps. The polyp was completely removed. Excavated Lesions: Multiple diverticula were seen in the sigmoid [**Month/Year (2) 499**]. Diverticulosis appeared to be of moderate severity. Other: The exam of terminal ileum was normal. Otherwise the exam of the rest of [**Month/Year (2) 499**] was normal. Cold forceps biopsies were performed to rule out microscopic colitis. Impression: The exam of terminal ileum was normal. -A 4 mm polyp in the hepatic flexure (polypectomy) -Mild patchy erythema at sigmoid [**Month/Year (2) 499**] and rectum in the [**Month/Year (2) 499**] (biopsy) -Moderate diverticulosis of the sigmoid [**Month/Year (2) 499**]. -Otherwise the exam of the rest of [**Month/Year (2) 499**] was normal. Cold forceps biopsies were performed to rule out microscopic colitis. -Otherwise normal [**Month/Year (2) 2792**] to cecum and terminal ileum. . EGD/EUS Findings: Esophagus: Z line was regular. A 1 cm sliding hiatal hernia was seen. otherwise the exam of the esophagus was normal. Stomach: The exam of the stomach was normal. Cold forceps biopsies were performed for histology. Duodenum: The mucosa at the proximal bulb of duodenum appeared mildly nodular. Cold forceps biopsies were performed for histology. The exam of the second part of the duodenum was normal. Cold forceps biopsies were performed for histology. Other findings: EUS was performed using a linear echoendoscope at 7.5 MHz frequency. The head and uncinate pancreas were imaged from the duodenal bulb and the second / third duodenum. The body and tail [partially] were imaged from the gastric body and fundus. A 0.8 cm X 0.6 cm discrete anechoic lesion, consistent with a cyst was noted in the uncinate process of the pancreas. The walls of the cysts were thin and well-defined. No intrinsic mass, septations or debris were noted within the cyst. The cyst did not appear to communicate with the main pancreatic duct. FNA was not performed because of the use of anticoagulant and no ''alarm features''. Pancreas parenchyma: there were mild lobularity and hyperechoic strands throughout. But there was no other chronic pancreatitis changes. Pancreas duct: The pancreas duct measured 1.8-2 mm in maximum diameter in the head and neck of the pancreas and 1.5 mm in maximum diameter in the body of the pancreas. The walls of the duct were hyperchoic. No stone or dilated side branch was seen. The exam of CBD was normal. It measured 4 mm. The celiac take-off was normal. The portal confluence was normal. The left lobe of liver was normal. . Impression: -Hiatal hernia -EGD exam revealed a normal stomach and D2 (biopsy) and slightly nodular duodenal bulb (biopsy) The -Linear EUS evaluation was then performed -A 0.8 cm X 0.6 cm discrete anechoic lesion, consistent with a cyst was noted in the uncinate process of the pancreas. The walls of the cysts were thin and well-defined. No intrinsic mass, septations or debris were noted within the cyst. The cyst did not appear to communicate with the main pancreatic duct. FNA was not performed because of the patient's anticoagulated status. -Pancreas parenchyma: there was mild lobularity and hyperechoic strands throughout. But there were no other findings of chronic pancreatitis. These findings are compatible with, but not diagnostic of, early chronic pancreatitis. -Pancreas duct: The pancreas duct measured 1.8-2 mm in maximum diameter in the head and neck of the pancreas and 1.5 mm in maximum diameter in the body of the pancreas. The walls of the duct were hyperchoic. No stone or dilated side branch was seen. -The exam of CBD was normal. It measured 6 mm, compatible with post-cholecystectomy dilation -The celiac take-off was normal. The portal confluence was normal. The left lobe of liver was normal. . Brief Hospital Course: 74 yo woman with history of breast ca, HTN, cystocele and hyponatremia, presented with recurrent hyponatremia and ARF, found to have ETOH withdrawal. . ACTIVE ISSUES: # Hyponatremia: Patient has had previous admissions for hyponatremia (and chronic hyponatremia with Na in mid-120s), which was thought to be SIADH in setting of vasopressin administration. Current presentation most likely a multifactorial process, from low solute intake, possible excess free water at home, diarrhea, as well as beer ingestion. Per report, patient had some somnolence in the ICU but was easily arousable to voice, which was thought to be most likely secondary to the IV ativan she received prior to transport up to the ICU. CXR negative for acute process and head CT was also negative. Nephrology was consulted to help with management of hyponatremia. Nephrology felt that presentation was consistent with a combination of low solute intake, SIADH and perhaps excess free water at home. In addition, pt also presented with an osmolar gap suggestive of ETOH ingestion. Recent TSH was normal, am cortisol 7 prior to [**Month/Year (2) **], not suggestive of adrenal insufficiency. Repeat AM cortisol was 11.7. Her sodium levels were followed closely as well as her blood and urine osmolarity. Pt was encouarged to have a liberal salt diet, 1200ml fluid restriction, Ensure TID and was started on salt tabs 1gm [**Hospital1 **] on [**1-14**]. Pt's sodium was monitored closely to ensure that she did not correct too quickly. Sodium level on day of discharge was 133. She will have her lytes repeated in approximately 10 days time, on [**1-28**]. A prescription for a lab check was provided to the patient and the results will be forwarded to her PCP. [**Name10 (NameIs) **] will also see her nephrologist in follow-up in [**Hospital 2793**] Clinic. . # L.knee pain-DDX included severe osteoarthritis vs. pseudogout vs. gout. Pt did have a mechanical fall preceding [**Hospital **] but did not have any previous knee pain. No new apparent trauma. No new erythema or induration or warmth to suggestion infection or septic joint. Xray confirmed severe arthritis with evidence to suggest CPPD. Pt was given tylenol and a lidocaine patch for pain. Uric acid was 3. . # Hyperkalemia: Peaked T's on initial EKG. She was given 1g calcium, insulin and dextrose in ED. K+ 6.0 to 5.2. Baseline is around 5.0. Was given kayexylate in ICU. Likely due to volume contraction in the setting of ACE-i use. Potassium levels were monitored and remained normal. . #ARF: Presented with a creatinine of 1.2 from 0.7, although pt stated she was drinking a lot of water at home, presentation was still likely c/w pre-renal, given recent diarrhea. FENA initially was 0.8%, FENA 0.9% 2/8. ACE-i and Celebrex were held and can re-started in the outpatient setting after repeat Cr check. Creatinine on discharge was 0.7. . # Diarrhea/fecal incontinence/abdominal pain-pt with h/o IBS- was recently supposed to have [**Hospital 2792**], endoscopy, and EUS to further evaluate these complaints. Per report lipase elevated in the past and that is why EUS was scheduled. The GI team was contact[**Name (NI) **] during [**Name (NI) **] as it was felt that the patient would certainly need inpatient prep given profound hyponatremia and risk for recurrent profound hyponatremia. The pt was prepped and underwent a C-scope, EGD/EUS on [**1-18**], and tolerated the procedure well. C-scope showed a 4mm poly (removed via polypectomy), patchy erythema (biopsied), moderate diverticulosis, and random biopsies of [**Month/Year (2) 499**] were also taken to rule out microscopic colitis. All the biopsies are currently pending. The EGD/EUS revealed a hiatal hernia, nodular duodenal bulb (biopsied), pancreatic changes consistent with chronic pancreatitis, and also a discrete lesion in the pancreas measuring less than 1 x 1cm in size, consistent with cyst. Pt will need to have her biopsy results followed-up on, and per GI recommendations, she will need a MRCP in 3 months time to evaluate her pancreas again. Given recent EtOH use, would recommend waiting 3 months, but sooner if she develops weight loss. The cyst could not be biopsied as the patient is on anticoagulation for her PE with fondaparanaux. . # Hx PE / DVT: Pt was continued on 7.5 fondaparanaux sc qd. She remained on room air. . #ETOH use/abuse-Pt's daugther raised concern of drinking at home. No reports of prior withdrawals. Pt appeared upset when asked to give specifics on her intake. She was tangential on answering the questions as well. Pt developed signs of ETOH withdrawal upon transfer out of ICU to the medical floor was was placed on a CIWA scale and given PRN valium. She was given MVI, thiamine and folate and SW was consulted. . UTI - pt complained of dysuria. Urine culture grew Cipro-sensitive E. coli. Pt to complete a course of Cipro. However, Urine culture also still growing 2nd organism, although at lower colony count, only 10 - 10,000 CFU of GPC. Will f/u final culture data/results and will contact pt if antibiotic regimen will need adjustment. . CHRONIC ISSUES: #normocytic anemia-baseline appears to be between 21-40. Presented at 32. . #GERD-continued [**Hospital1 **] PPI . #asthma-no sign of acute flare, continued fluticasone . #h.o breast ca-outpt f/u and monitoring. . #HTN, benign-did not appear to be on any meds at baseline . #gout-allopurinol . TRANSITIONAL ISSUES: . GI - will need outpatient MRCP in 3 months or sooner if weight loss occurs. Pt is already has order placed by ERCP but will need to call to schedule actual MRCP appointment. GI will need to follow-up biopsy results. Renal - pt will have to continue on fluid restriction, salt tabs, and will need her lytes checked in 10 days, with results to be faxed to and followed by PCP. [**Name10 (NameIs) **] see Renal in follow-up as well. Should continue to hold her Celebrex and lisinopril given recent [**Last Name (un) **] until follow-up with PCP or Renal. EtOH use/withdrawl - should continue on MVI/thiamine/folate. Can follow-up with PCP to discuss treatment options. . UTI - currently growing Cipro sensitive E. Coli. Patient to complete course of ciprofloxacin. However, 2nd bacteria also growing, albeit only at 10 - 10,000 CFU of GPC. Will f/u result and call pt if she needs additional or changed antibiotic. . Medications on [**Last Name (un) **]: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Celebrex 200 mg Capsule Sig: One (1) Capsule PO 1-2 per day. 4. conjugated estrogens 0.625 mg/gram Cream Sig: One (1) gram Vaginal Twice per week: Intravaginal. 5. fondaparinux 7.5 mg/0.6 mL Syringe Sig: 7.5 mg Subcutaneous DAILY (Daily). 6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 7. lorazepam 0.5 mg Tablet Sig: 0.5 - 2 Tablet PO twice a day as needed for anxeity or insomnia. 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. nystatin powder apply qd to affected areas 11. pantoprazole 40mg [**Hospital1 **] Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for cough, wheeze. 2. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for anxiety. 9. Premarin 0.625 mg/gram Cream Sig: One (1) gram Vaginal 2X/WEEK (2 times a week). 10. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 12. Outpatient Lab Work please obtain chemistry-10, including Na, K, Chloride, Bicarb, BUN/Cr, Glucose, Ca, Mg, Phos. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 2794**]. 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: hyponatremia acute renal failure alcohol withdrawal, anxiety knee pain-due to arthritis hyperkalemia urinary tract infection . Chronic diarrhea/IBS gout asthma HTN Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: You were admitted for evaluation and treatment of hyponatremia (low blood sodium), elevated potassium and impairment in your kidney function. You were initially monitored in the ICU and your symptoms improved. You were also followed by the kidney team to help with monitoring of your sodium levels. You will need to continue taking salt tabs and restricting your fluid intake. You will need repeat labs done in approximately 1 week (you can have them checked the day you see Dr. [**Last Name (STitle) **] on [**1-28**]). . You underwent an endoscopy, [**Month/Year (2) 2792**] and EUS (endoscopic ultrasound), which showed a polyp in your [**Month/Year (2) 499**], some areas of inflammation (biopsied), diverticulosis, a hiatal hernia, a nodular stomach (biopsied), possible chronic pancreatitis, and a pancreatic cyst. For your pancreatic cyst and possible changes c/w chronic pancreatitis, you will need follow-up imaging with a MRI in approximately 3 months. This has already been ordered by the GI doctors, and you will need to call after discharge to schedule the exact date. The contact number is listed below. Your polyp could not be removed, as you are on a blood thinner. This will need to be addressed by your PCP/GI doctors with repeat [**Name5 (PTitle) 2792**] when you are off your blood thinning medication. Please call Dr. [**First Name4 (NamePattern1) 2795**] [**Last Name (NamePattern1) 2796**] office to get the results of your biopsy. His office number is [**Telephone/Fax (1) 1983**]. . You were also noted to have a urinary tract infection with a urine culture growing E. Coli. We have started you on an antibiotic. We will notify you if that antibiotic will need to be changed. . You were also treated for alcohol withdrawal. . Medication changes: 1.STOP lisinopril 2.START salt tablets 3.START ciprofloxacin (complete a course for UTI) 4.STOP Celebrex . Please take all of your medications as prescribed below and follow up with the appointments below. Followup Instructions: . Department: [**Location (un) 2788**] INTERNAL MED. When: THURSDAY [**2123-1-28**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD [**Telephone/Fax (1) 2789**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site . Department: WEST [**Hospital 2002**] CLINIC/NEPHROLOGY When: THURSDAY [**2123-3-25**] at 11:00 AM With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage You have also been put on a waiting list to be seen sooner. . Department: URO/GYNECOLOGY When: WEDNESDAY [**2123-1-27**] at 2:45 PM With: [**Name6 (MD) 247**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2797**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . You will need a MRCP (imaging study to evluate your pancreas), please call [**Telephone/Fax (1) 327**] to schedule an appointment. This should be done in approximately 3 months time. Dr. [**First Name4 (NamePattern1) 2795**] [**Last Name (NamePattern1) 908**] will follow-up the results of this study. . If you have any GI symptoms, please call Dr.[**Name (NI) 2798**] office at [**Telephone/Fax (1) 2799**] to schedule an appointment to be seen as necessary. .

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19059

Discharge summary

report

Admission Date: [**2111-12-3**] Discharge Date: [**2111-12-16**] Date of Birth: [**2045-6-26**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2518**] Chief Complaint: headache, lethargy Major Surgical or Invasive Procedure: Right femoral pseudoaneurysm rupture with thigh hematoma. History of Present Illness: 66yo left-handed man with recent R MCA stroke and multiple vascular risk factors presents with difficulty seeing, change in personality, and lethargy. On Saturday prior to admission he did not seem himself to his wife; she felt he was quieter than usual and more lethargic. She asked him what was wrong and he complained of a headache on the right side of his head behind his ear. Throughout the next 5 days, he continued to complain of headache and did not seem his usual self. He was quiet, sleeping more than usual. He was not eating as much. He was having difficulty "seeing" - for example, he would have to feel around on the table for his fork. He dropped a spoon and potato and had difficulty finding them. His wife thought this was mostly a problem with things that were white or silver, but she was not sure. He had difficulty telling time, difficulty with the big and little hand - thought 20 of 5 was 20 past 8. She also felt he was emotionally labile, acting silly more than normal, acting angry, when usually he is eventempered. For example, he was walking up the ambulance ramp to the ED when she heard a car behind them, told him to move out of the way, and he stopped, shouted "leave me alone!" He has not had any change in his speech, gait, or weakness. He has had a recent stroke for which he presented to [**Hospital1 **] [**Location (un) 620**] with acute onset dysarthria and left facial droop, left hand weakness. He was diagnosed with a right MCA infarct. MRI/MRA and ECHO were performed (see reports below). He was newly diagnosed with diabetes. He was started on medications for hypertension, hyperlipidemia, and more recently for hyperglycemia. He was put on aggrenox, which he has been taking regularly. He has modified his diet, but BS continue to be 129-173, mostly in the 160s (fasting am). He has quit smoking. Past Medical History: R M1 segment MCA stroke [**7-/2111**] with residual left facial droop, left hand weakness/stiffness, mild dysarthria hyperlipidemia hypertension diabetes, diagnosed [**8-/2111**], initially diet controlled w/ FS 100s, last A1C 6.8, started on metformin h/o tobacco use, quit after stroke [**7-/2111**] s/p tonsillectomy Social History: tob 2.5ppd x 50yrs, h/o heavy EtOH use, "in recovery" 21yrs, no drug use, married Family History: mother died age 66, had HTN, stroke; father died age 87 Physical Exam: VS: T 97.8, HR 51, Bp 116/64, RR 16, SaO2 99%/RA Genl: NAD HEENT: NCAT, MMM, OP clear, left [**Doctor First Name 2281**] with brown in left upper quadrant, eyes otherwise blue Neck: supple, no bruits CV: RRR, nl S1, S2, no m/r/g Chest: CTAB Abd: soft, NTND, BS+ Ext: warm and dry Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place (hospital, ED, middle of [**Location (un) 86**]), and date. Mildly inattentive, says [**Doctor Last Name 1841**] backwards to [**Month (only) 958**], slowly. Speech is fluent with normal comprehension and repetition; naming intact. Mild dysarthria. Reads "speak on the radio last night" but can read full sentence when visually prompted to the beginning; reads "near the table the dining room." Writing intact (messy, but at baseline per wife). Registers [**2-1**], recalls [**1-3**] +1 from list in 5 minutes. No right-left confusion. No evidence of apraxia. Left visual neglect. Describes pictures on stroke cards initially correctly on right, but says "heart shape in circle" for key, and does not initially mention hammock, just tree. With additional time given, then names skeleton key and hammock. Describes cookie thief picture in parts, first notes the pitcher and plate, then the small cabinet, then sink, then "young fellow climbing on stepstool"; when asked how many people names the girl much later than the others. Can identify it as kitchen. Difficulty with drawing a house (draws roof, window on it, chimney with smoke, but nothing else). Cannot copy complex picture (draws left side of leftmost shape, with extensive spiral coming from it as squiggle, but nothing else to the right. Cranial Nerves: Fundoscopic examination reveals sharp disc margins. Pupils equally round and reactive to light, 4 to 2 mm bilaterally. No RAPD. Left inferior quadrantonopia. Extraocular movements intact bilaterally without nystagmus. Sensation intact V1-V3. Mild L facial droop. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk and increased tone bilaterally. No observed myoclonus, asterixis, or tremor. Left pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5- Sensation: Intact to light touch, pinprick, vibration and cold sensation throughout. Extinction on L to DSS in face, inconsistent in hands. Reflexes: 1 in R [**Hospital1 **], tri, br, 2 in L [**Hospital1 **], tri, br, 2 in R pat, ach, 2+ in L pat, ach, R toe down, L toe upgoing Coordination: finger-nose-finger, finger-to-nose slightly inaccurate b/l, fine finger movements and [**Doctor First Name **] slowed on left. Gait: Narrow based, steady. Some difficuly with tandem, ?if in proportion to age. Romberg negative. Pertinent Results: Labs: 139 103 14 ------------< 152 4.2 28 0.9 Comments: K: Hemolysis Falsely Elevates K 7.7 > 40.1 < 225 N:72.9 L:18.9 M:5.4 E:2.4 Bas:0.4 PT: 13.5 PTT: 28.7 INR: 1.2 TOX screens (urine and serum) negative ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . [**2111-12-4**] 02:15AM LIPID/CHOLESTEROL Cholest 177 Triglyc 149 HDL 38 CHOL/HD 4.7 LDLcalc 109 a1c 6.3 . [**2111-12-10**] TSH 1.8 Imaging: ECHO [**7-7**] from d/c summary: "This reveals normal EF of 65%. There is left ventricular hypertrophy. The echo is consistent with the presence of a patent foramen ovale." HCT [**2111-12-3**] shows subacute infarct of right parieto-temporal region, as well as more chronic infarct. Multiple chronic lacunes. CTA HEAD/NECK [**2111-12-3**] 1. Findings consistent with embolus completely occluding the proximal right MCA. 2. Substantial focal narrowing of the basilar artery, presumably due to atheromatous disease. 3. Substantial calcification of the internal carotid arteries bilaterally in the cavernous sinus, and at the bifurcation of the common carotid arteries bilaterally. 4. 60 percent stenosis of the right common carotid artery at the bifurcation. No stenosis seen on the left. . MRI/A BRAIN [**2111-12-4**]: MRI Head: Right middle cerebral artery inferior division infarction similar to the appearance on the recent CT examinations. No evidence of hemorrhage. Small bilateral occipital lobe infarctions suggesting basilar artery disease, likely embolic to the top of the basilar. MRA appears similar to the CTA with a severe stenosis of the M1 segment of the right middle cerebral artery as well as severe narrowing and irregularity of the basilar artery. CAROTID ANGIOGRAM [**2111-12-5**]: PROCEDURE: The patient was brought to the operating room. Anesthesia was induced in the supine position. Following this, both groins were prepped and draped in a sterile fashion. The right common femoral artery was accessed using a Seldinger technique and a 6 French vascular sheath was placed in the right groin. This was connected to a continuous saline flush. Through the sheath, we now advanced [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 2 catheter into the aortic arch from where the left vertebral artery, the right internal carotid artery and the right common carotid artery was catheterized and AP lateral filming done. Three- dimensional imaging was done where indicated. Following this, the patient was found to have a completely occluded right middle cerebral artery in the M1 region with very minimal stenosis of his right internal carotid artery. Therefore, we decided not to pursue any aggressive interventional strategies. The left common carotid artery was not catheterized as we felt that this was not necessary as the CT angiogram had supplied us with enough information. The vascular sheath was left in place since the patient was heparinized and removed later in the recovery room after the heparin was stopped for 2 hours. FINDINGS The left vertebral artery arteriogram demonstrates filling of the left vertebral artery with minimal stenosis at the origin. There is good reflux into the right vertebral artery. Both PICAs are seen. The AICA is seen on both sides as well as the superior cerebellar artery. There is a very significant basilar stenosis which is about 80% just distal to the vert confluence. This segment approximately measures about 0.7 cm in length. The right PCA is not well visualized as it is mainly fetal. The right common carotid artery arteriogram demonstrates 20% stenosis of the left internal carotid artery just distal to the bifurcation. The right external carotid artery has about 80% stenosis at the origin. Right internal carotid artery arteriogram demonstrates normal filling of the right internal carotid artery along the cervical, petrous, cavernous and supraclinoid portion. The right M1 seems to end abruptly. There is no antegrade flow. The distal M2 vessels seem to fill retrograde through pial collaterals. There is a large area of hypoperfusing area in the superior division of the middle cerebral artery. There is significant pial collateralization through the divisions of the anterior cerebral artery. There is also significant disease in the anterior cerebral artery with the proximal anterior cerebral arteries rather dilated, leading one to conclude that the MCA occlusion may be longstanding. The common femoral artery arteriogram demonstrates diffuse atherosclerotic disease with no significant stenosis seen. IMPRESSION: Mr. [**Known firstname **] [**Known lastname 23203**] underwent cerebral arteriography for possible right ICA and right middle cerebral artery stenting, however the right MCA was seen to be chronically occluded and the right ICA did not have significant stenosis. . Transthoracic ECHO: 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 normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is diffuse thickening of the left atrial anterior wall, abutting the posterior aortic root, and extending to the basal portion of the interatrial septum (? lipomatous hypertrophy); adherent thrombus cannot be excluded. If clinically indicated, a transesophageal echocardiographic examination is recommended. .. [**2111-12-7**]: CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The lung bases show mild dependent hypoventilatory change. There is an area of equivocal differential attenuation in the region of the origin of the right inferior pulomnary vein in the left atrium, for which adherent thrombus cannot be excluded. Within the limitations of a non- contrast exam, the liver, spleen, adrenal glands, pancreas, and kidneys are within normal limits. The intra- abdominal loops of large and small bowel maintain a normal caliber without evidence of obstruction. Scattered colonic diverticuli are present without evidence of diverticulitis. No free fluid, free air or lymphadenopathy is appreciated. Atherosclerotic calcification is seen involving the abdominal aorta and branch vessels. HIgh attenuation material is seen within the gallbladder likely representing vicarious excretion of contrast. CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The rectum, sigmoid colon, bladder, prostate, and seminal vesicles are unremarkable. No free fluid or lymphadenopathy is appreciated. There is a large right groin intramuscular hematoma extending down to the mid thigh and involving various compartments of the anterior thigh. No evidence of retroperitoneal extension of the hematoma. BONE WINDOWS: No suspicious lytic or sclerotic lesion is identified. IMPRESSION: 1. Massive intramuscular hematoma extending from the right groin into the mid thigh and involving various compartments of the anterior thigh. 2. An equivocal area of differential attenuation is seen in the region of the origin of the right inferior pulmonary vein in the left atrium for which adherent thrombus cannot be excluded. Given history of CVA, does patient have recent echocardiography? The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**] DR. [**First Name11 (Name Pattern1) 8711**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: WED [**2111-12-9**] 4:59 PM . GROIN ULTRASOUND [**12-8**]: FINDINGS: Duplex evaluation was performed only of the right groin vessels. The common femoral artery is patent with a triphasic waveform. IMPRESSION: Right groin pseudoaneurysm measuring 2.9 cm. . EKG [**12-10**]: Baseline artifact. Probable irregular supraventricular rhythm with fairly organized atrial activity, probably atrial fibrillation with a single ventricular premature beat. There is borderline voltage for left ventricular hypertrophy in lead aVL. Precordial voltage is also increased but probably does not meet criteria for left ventricular hypertrophy. ST-T wave abnormalities. Compared to the previous tracing of [**2111-12-4**] sinus bradycardia is no longer present and QRS voltage is more prominent. Clinical correlation is suggested. Brief Hospital Course: This 66 year old gentleman with h/o HTN, hyperlipidemia, DM2 and recent right MCA stroke, was readmitted for right MCA stroke on [**12-3**]. During this admission, he was found on MRI/MRA to have severe stenosis of the M1 segment of the right middle cerebral artery with recurrent MCA stroke. He underwent angiography which showed total occlusion of right MCA with some collateral circulation and with stenosis of the basilar artery. He was started on a heparin gtt and coumadin post angio for stroke prevention, after which he developed a right groin hematoma. His hematoma has been progressively enlarging and heparin gtt was discontinued; he received 5mg PO vitamin K. Vascular surgery was consulted and right groin U/S revealed pseudoaneurysm. Since [**2111-12-9**], his hct has fallen from 40-->26.6 and he has received 2U prbcs on [**2111-12-8**]. He received only approximately 150cc prbcs on [**2111-12-9**] after which time transfusion was stopped due to fever (no rash, hives, etc). . On the evening of [**2111-12-9**], his HR was noted to be 150s and EKG revealed a.fib vs. a. flutter w/ 2:1 conduction. He received 10mg IV diltiazem x2, then 60mg PO diltiazem. His HR briefly responded to each IV diltiazem with rates improving to the low 100s, however HR then rose to 130s. He was written for 2units prbcs. His SBPs remained stable in the 130s range. He then received 5mg IV lopressor to which his HR responded-->80s-90s. He was then transferred to the ICU for 20 point hct drop from [**12-6**]-->[**12-9**] now with new a. fib with RVR initially difficult to control on the floor. He received 10 IV lopressor and started on oral diltiazem. He was given 3 units pRBC and the following morning underwent repair of R femoral pseudoaneurysm by vascular surgery. He received an additional 2 units of pRBC post-operatively. He had no further signs of bleeding and his blood pressure and hypertension remained under good control. He remained in the MICU for two more days, at one time requiring IV diltiazem to control an episode of AF with RVR. This, along with his hypertension, was further controlled with PO diltiazem and metoprolol . ROS: Endorses right groin and leg pain. Denies CP, SOB, palpitations. Denies dysuria/hematuria. No rashes. He underwent, now found to have expanding right groin hematoma and hct drop after initiating heparin gtt; also with new a. fib w/ RVR on the floor. . # New atrial fibrillation/flutter with RVR: Etiology not entirely clear, but differential broad. Despite continued hct drop/volume status, appears slightly hypovolemic->euvolemic; currently getting prbcs. Does not appear to have infection to suggest as underlying cause. Although less frequently ischemic arrhythmia, may be in his case given his anemia (last hct prior to tx 26.6). In review of imaging there is some ? of left atrial thrombus on CT which may be a reflection of prev. undocumented h/o a.fib vs. etiology of current a. fib if has know atrial dilatation and now w/ ? atrial thrombus. Echo suggested that atrial clot was less likely than lipomatous hypertrophy. His wife declined a [**Month/Day (4) **] to confirm. EKG with rate related ST depressions which improved with decreased rate. If a. fib persists beyond acute illness, CHADS2 score 4 w/ HTN, DM2, stroke and would warrant anticoagulation. He was monitored in the MICU and continued on oral diltiazem, using IV lopressor PRN. Rate stabilized and rapid a-fib did not recur except briefly on [**2110-12-15**] for several minutes on the floor (responded to IV lopressor 5mg). He was given PRBCs x 2 units and hematocrit increased. Transfusion reaction was explored and determined that he did have a mild reaction to the blood he received. This did not recur with further transfusion. TSH was checked and was normal. Echo [**12-10**] again showed "There is diffuse thickening of the left atrial anterior wall, abutting the posterior aortic root, and extending to the basal portion of the interatrial septum (? lipomatous hypertrophy); adherent thrombus cannot be excluded." Coumadin was felt to be indicated, and despite thigh hematoma, was restarted on [**12-16**], the day of discharge at a very low dose of 2.5mg/day after deemed safe by vascular. He needs to have his INR checked daily to aim for a level of [**1-3**]. The risks and benefits were discussed with his wife, who agreed to use of coumadin. He will need to be monitored for bleeding closely. . # Hct drop: No other clear source of bleed beyond known right groin pseudoaneurysm and marked hematoma extending from groin to distal anterior thigh. Vascular is on board. Had previously only received 2Units prbc prior to today, now s/p addtional 2units (total 4Units prbcs thus far). Once again, after several days in the ICU and 2 PRBC packs, hematocrit rose to a tolerable level and remained stable. Aspirin was restarted after several days. . # Right groin hematoma: Management as above (pseudoaneurysm repaired by vascular surgery). Hematocrit remained stable, and vascular surgery felt it was resafe to start low-dose coumadin with NO heparin on [**12-16**]. . # S/P recurrent Right MCA stroke: MRI/MRA to have severe stenosis of the M1 segment of the right middle cerebral artery as well as severe narrowing and irregularity of the basilar artery, right middle cerebral artery inferior division without evidence of hemorrhage, small bilateral occipital lobe infarctions suggesting basilar artery disease, likely embolic to the top of the basilar. As above, his infarcts were felt to be embolic, and considering the new diagnosis of afib, coumadin was felt to be strongly indicated. After several days of aspirin following repair of the pseudoaneurysm, coumadin was resumed at discharge - this should be followed closely considering his bleeding risk. . # ?Left atrial thrombus: Commented on in [**2111-12-7**] CT abd/pelvis; reportedly possible adherent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. Patient does not have previous echo in our system. Does not appear to have been further investigated with echo here. Reportedly has patent PFO from echo at during [**7-/2111**] admission. Echo was repeated [**12-10**] and as above, confirmed possible thrombus. This should be repeated after several months of coumadin therapy. Wife refused [**Name2 (NI) **]. . # Hyperlipidemia: Statin was continued. . # HTN: Home dose labetalol has been held in the setting of his significant hct drop. Blood pressure was stabilized and he was discharged on alternate antihypertensives that were short-acting, and had some rate control properties. . # DM: HgbA1c 6.3% on this admission. He should be continued on insulin SS at discharge. . # F/E/N: Receiving prbcs currently. Replete lytes PRN. NPO. . # PPx: Bowel regimen, famotidine given CVA, pneumoboots. . # Access: 2 20G PIVs, 1 18G PIV. . # Dispo: after a stay in the MICU, he was transferred back to the neuro service on [**12-15**], and remained stable in the stepdown unit for over 24 hours. He was transferred to floor status and worked with PT, and OT. Swallowing was evaluated and he was felt not to be aspirating. He was discharged on [**12-16**] to [**Hospital 38**] rehab. . # Code Status: DNI, chest compressions okay, wife thinking about whether shocks okay. Discussed with patient's wife that in code situations oftentimes these go together; will need to continue further discussion. . # Communication: Wife [**Telephone/Fax (1) 52032**] (h), [**Telephone/Fax (1) 52033**] (c) Medications on Admission: AGGRENOX 25 mg-200 mg [**Hospital1 **] Labetalol 300 mg tid SIMVASTATIN 80 mg daily Metformin 500mg daily All: NKDA Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-2**] Puffs Inhalation Q4H (every 4 hours) as needed. 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 12. Cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection Q8H (every 8 hours) for 7 days: 2 grams q8h IV - first day is [**2111-12-15**]. 13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Acute stroke - RMCA Chronic occlusion of the right MCA Atrial fibrillation Thigh hematoma and associated anemia Pseudoaneurysm of femoral artery s/p repair [**2111-12-10**] Transfusion reaction Discharge Condition: Fair - some thigh pain remains on R; nearly full strength in the left lower extremity, 4+/5 upper motor neuron pattern strength on left lower extremity, subtle neglect both visual and tactile on the left, very mild dysarthria, mild inattention but normal speech and language Discharge Instructions: Please return to ER if you have any new signs of bleeding, as coumadin is being started today, and he has had bleeding complications during the acute hospitalization. Please return to ER if you have any signs of new stroke, including new visual problems, problems speaking or swallowing, numbness, tingling, clumsiness, or new gait problems. Please [**Name8 (MD) 138**] MD immediately if you have a severe headache. You are being discharged with a foley catheter in place - this should be discontinued at [**Hospital 38**] Rehab, with a voiding trial to follow. You must have your INR checked DAILY until it is within therapeutic range ([**1-3**]). We are starting coumadin at a low dose, but this dose will be adjusted by the inpatient facility based on the INR. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23183**], MD Phone:[**Telephone/Fax (1) 9347**] Date/Time:[**2112-1-12**] 8:30 . Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2112-2-9**] 4:00 . [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**] Completed by:[**2111-12-16**]

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Discharge summary

report

Admission Date: [**2126-4-29**] Discharge Date: [**2126-5-3**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7223**] Chief Complaint: Chest pain, SOB Major Surgical or Invasive Procedure: None History of Present Illness: Pt is 88 yo m with CAD s/p CABG, anemia, ESRD (not on HD), h/o CHF, presents with episode of chest pain. Pt was doing work in his yard yesterday, and then experienced [**8-4**] sub-sternal, dull, chest pain associated with SOB and palpitations. It lasted about 20 minutes ago, he then rested, and the pain improved, although he said he still had low-level pain for several hours. No N/V. No F/C. Pt also said he has had PND and mild orthopnea over past 2 days. He had been on Lasix in the past, but this was stopped approx 1 week ago. Pt reports increasing LE swelling since stopping Lasix. Of note, pt says he had similar episode of chest pain 1 year ago, and was admitted to [**Hospital1 2025**] with CHF. . Pt reportedly received ASA today (although he now says this is making his stomach "burn"). Also per ED triage sheet had HR 40's with bigeminy in the field. He currently denies CP, but c/o LLE cramp (he says he chronically gets LE cramping). He also complains of nausea and "acid" taste in his throat from his GERD. Past Medical History: CAD s/p CABG [**2112-7-22**] (reversed SVG->PDA) after unsuccessful PTCA on [**7-21**] resulting in increased pain requiring placement of intra-aortic balloon pump [**7-22**] ESRD (not on HD, but has fistula x 3 months, last Cr reportedly 4.4 at [**Hospital1 2025**]) Hypertension Hypercholesterolemia Anemia (hct reportedly 30 last month at [**Hospital1 2025**]) h/o R CVA '[**99**] s/p bilateral CEA BPH PUD Hiatal Hernia Nephrolithiasis Social History: Former fireman. Lives at home with wife and grandson. Smoked 1ppd x 40 yrs, quit many years ago. Occasional EtOH. No drugs. Family History: Non-contributory Physical Exam: VS: 97.9 132/58 (120-132) 75 (70-75) 22 94% 5L Gen: WDWN elderly male, NAD, pleasant CV: RRR, [**2-28**] mid-peaking systolic murmur at LUSB. no thrill. No S3/S4. JVP approx 8 cm Lungs: few bibasilar crackles, otherwise clear Abd: soft, NT. normal BS Ext: LLE slightly larger than RLE; trace pedal edema. non-tender calves bilaterally. 1+ DP pulses bilaterally. LUE with fistula, palpable thrill. Neuro: A/O x 3; moves all 4 extremities though has difficulty with moving lower extremities [**1-26**] cramping Pertinent Results: LABS: [**2126-4-29**] 07:10PM BLOOD WBC-4.6 RBC-2.74* Hgb-8.9* Hct-25.3* MCV-93 MCH-32.5* MCHC-35.2* RDW-13.1 Plt Ct-112* [**2126-5-3**] 06:50AM BLOOD WBC-5.2 RBC-2.88* Hgb-9.1* Hct-26.1* MCV-91 MCH-31.8 MCHC-35.0 RDW-12.9 Plt Ct-145* [**2126-4-29**] 07:10PM BLOOD Neuts-72.9* Lymphs-16.8* Monos-3.5 Eos-6.6* Baso-0.2 [**2126-4-30**] 11:38PM BLOOD PTT-59.2* [**2126-5-2**] 07:00AM BLOOD PT-11.7 PTT-59.6* INR(PT)-1.0 [**2126-4-29**] 07:10PM BLOOD Glucose-146* UreaN-60* Creat-3.7* Na-142 K-4.6 Cl-113* HCO3-19* AnGap-15 [**2126-5-3**] 06:50AM BLOOD Glucose-93 UreaN-80* Creat-4.6* Na-140 K-4.8 Cl-104 HCO3-25 AnGap-16 [**2126-4-29**] 07:10PM BLOOD CK(CPK)-67 [**2126-4-30**] 05:50AM BLOOD CK(CPK)-58 [**2126-4-30**] 12:40PM BLOOD CK(CPK)-58 [**2126-4-30**] 06:40PM BLOOD CK(CPK)-56 [**2126-5-1**] 05:46AM BLOOD CK(CPK)-72 [**2126-5-1**] 07:20PM BLOOD CK(CPK)-71 [**2126-4-29**] 07:10PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]* [**2126-4-29**] 07:10PM BLOOD cTropnT-0.01 [**2126-4-30**] 05:50AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2126-4-30**] 12:40PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2126-4-30**] 06:40PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2126-5-1**] 05:46AM BLOOD CK-MB-NotDone cTropnT-0.18* proBNP-[**Numeric Identifier 78883**]* [**2126-5-1**] 07:20PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2126-4-29**] 07:10PM BLOOD Calcium-8.3* Phos-3.3 Mg-1.6 Iron-56 [**2126-5-3**] 06:50AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.2 [**2126-4-29**] 07:10PM BLOOD calTIBC-263 VitB12-568 Folate-8.4 Ferritn-151 TRF-202 [**2126-5-1**] 05:46AM BLOOD calTIBC-255* Ferritn-261 TRF-196* [**2126-4-29**] 07:10PM BLOOD Osmolal-306 [**2126-4-30**] 06:54PM BLOOD Type-ART pO2-60* pCO2-33* pH-7.36 calTCO2-19* Base XS--5 [**2126-4-29**] 10:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2126-4-29**] 10:30PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2126-4-29**] 10:30PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 . MICRO: Sputum Cx ([**5-3**]): contaminated . IMAGING: ECG ([**4-29**]): Sinus rhythm at a rate of 60. Borderline first degree A-V block. Downsloping lateral ST segments are non-specific. . CXR Portable ([**4-29**]): FINDINGS: Single bedside AP examination labeled "upright "with excessive lordotic positioning and no comparisons. The patient is status post median sternotomy and apparent CABG with six intact cerclage wires. Allowing for the factors above, there is borderline LV enlargement but no pulmonary vascular congestion or other definite evidence of CHF. There is rounded blunting of the left CP angle, which may represent chronic pleural thickening related to the surgery. No acute airspace process is seen. There are atherosclerotic changes involving the thoracic aorta. IMPRESSION: Limited study, status post CABG with no definite acute process. . CXR Portable ([**4-30**]): The opacification in the right lung has developed over 24 hours, accompanied by new mild pulmonary edema on the left. Findings suggest pulmonary hemorrhage or severe aspiration pneumonia on the right and may be accompanied by a small-to-moderate pleural effusion. Heart size top normal unchanged. . Left LENIs ([**4-30**]): IMPRESSION: No evidence of deep vein thrombosis in the left leg. . TTE ([**4-30**]): The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF 55-60%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild calcific aortic stenosis. Moderate mitral regurgitation. Moderate pulmonary hypertension. . ECG ([**4-30**]): Sinus rhythm with multifocal PVCs, Inferior/lateral ST-T changes suggest ischemia, Since previous tracing of the same date, ST segment depression more pronounced . ECG ([**4-30**]): Sinus rhythm with borderline first degree A-V block. Poor R wave progression. Inferolateral ST-T wave changes suggest myocardial ischemia. Compared to the previous tracing of [**2126-4-29**] there is slight ST segment elevation in lead III with a biphasic T wave. ST segment depression is more pronounced and the lateral T waves are now upright. . CXR Portable ([**5-1**]): Previously present widespread asymmetrical air space opacification affecting the right lung to a greater degree than the left has markedly improved with residual subtle hazy opacities remaining in the right lung and minimal patchy opacity in the left retrocardiac area. It is uncertain whether this represents resolving asymmetrical edema or if there was a secondary superimposed process in the right lung such as aspiration. Small pleural effusions were present bilaterally. Brief Hospital Course: # Shortness of Breath: The patient presented with SOB in the setting of chest pain during exertion, also with increased PND and orthopnea after his Lasix had been discontinued 1 week prior to admission. During his hospitalization, he developed acute onset SOB thought to be flash pulmonary edema requiring a brief MICU stay and NRB. CXR showed diffuse opacity on the right side which was likely congestion. proBNP was [**Numeric Identifier **] on admission, and trended up to [**Numeric Identifier 78883**] after the acute episode. He was treated with Lasix IV, with ressolution of his symptoms. There was initial concern for PE and he was briefly empirically on a heparin gtt, but his left LENIs were negative for DVT. He could not get a CTA Chest given his renal failure. He was restarted on his home dose of Lasix 20 mg PO daily at the time of discharge. . # Acute on Chronic Diastolic CHF: He presented with increased PND and orthopnea in the setting of holding his Lasix for the week prior to admission. His proBNP was [**Numeric Identifier **] on admission, and trended up to [**Numeric Identifier 78883**] after the acute episode as described above. TTE on this admission showed mild symmetric LVH and LVEF 55-60% and moderate (2+) MR. There is moderate pulmonary artery systolic hypertension. He was treated with Lasix IV, and restarted on his home dose of Lasix 20 mg daily at the time of discharge. His Atenolol was changed to Toprol XL 100 mg daily. An ACE-I and [**Last Name (un) **] are contraindicated given his renal failure. . # CAD: The patient has a history of CAD s/p CABG in [**2112-7-22**] (reversed SVG->PDA). A stress test at [**Hospital1 2025**] in [**6-1**] showed the ECG is negative for ischemia; myocardial perfusion scans show a small, reversible, inferolateral defect suggestive for a limited area of mild ischemia; and septal wall motion is dyskinetic c/w prior CABG. He presented with 8/10 sub-sternal, dull chest pain with exertion associated with SOB and palpitations. ECG showed inferolateral ST-T wave changes and slight ST segment elevation in lead III with a biphasic T wave. His TropT was 0.01 on admission, and trended up to 0.18 in the setting of ESRD, but his CKs remained flat. His TropT was 0.17 upon discharge. He was briefly on a heparin gtt, but this was discontinued as he was not thought to be having an MI (more likely demand ischemia). He was continued on ASA 325 daily and Atorvastatin 40 mg daily. His Atenolol was changed to Toprol XL 100 mg daily. . # Aortic Stenosis: TTE on this admission showed mild aortic valve stenosis (area 1.2-1.9cm2). . # ESRD: His Cr was 3.6 on admission and 4.6 on discharge, unclear baseline. He has a fistula, but this will require several more months to mature. Renal was consulted for possible initiation of dialysis given labile volume status in the setting of valvular disease, but there was no need for urgent HD. His presentation favored volume overload, and he was diuresed. He was continued on Calcitriol 0.25 mcg daily. . # Anemia: The patient's Hct was 25.3 on admission (reportedly 30 at [**Hospital1 2025**]). He was guaiac negative per the ED. Vitamin B12 and folate were normal. Iron studies showed: Iron 56, TIBC 263, ferritin 151. Repeat iron studies 2 days later showed: Iron 23, TIBC 255 (trans sat 9%). He was continued on his outpatient FeSO4 325 mg [**Hospital1 **] and supplemented with Ferrlicit 125 mg IV x1. He was continued on Cyanocobalamin 1000 mcg daily. He will likely need to start Procrit as an outpatient. . # Hypertension: His Terazosin was discontinued during this hospitalization. His Atenolol was changed to Toprol XL 100 mg daily. He was continued on Amlodipine 5 mg daily. . # Hyperlipidemia: He was continued on Atorvastatin 40 mg daily. . # GERD: He was started on Protonix 40 daily. Medications on Admission: -ASA 325 daily -Amlodipine 5mg PO daily -Atenolol 50 mg daily -Ferrous sulfate 325 mg PO bid -Lasix 20 mg daily (but held since cards visit on [**2126-4-24**]) -Atorvastatin 40 mg daily -Terazosin 2mg PO bid -Calcitrol 0.25mcg PO daily -Vitamin B12 1000 mcg PO daily . ALLERGIES: NKDA Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Greater [**Location (un) 1468**] VNA Discharge Diagnosis: PRIMARY: Acute on Chronic Diastolic Heart Failure ESRD . SECONDARY: CAD Hypertension Hyperlipidemia GERD Mitral Regurgitation Mild Aortic Stenosis Anemia Discharge Condition: Stable Discharge Instructions: You were admitted for heart failure with fluid overload. Your shortness of breath improved after restarting your diuretic medications. You had chest pain during this admission that was likely due to your fluid overload. . You should weigh yourself daily and if you gain or lose more than 3 pounds in a week, call Dr.[**Name (NI) 78884**] office. . Seek medical attention immediately if you experience shortness of breath, chest pain, fainting, weakness or other new concerning symptoms. . Your Lasix PO was restarted at 20 mg daily. Your Terazosin was discontinued during this admission. Your Atenolol was changed to Toprol XL 100 mg daily. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] in Cardiology ([**Telephone/Fax (1) 78885**]) on [**5-15**] at 12:30 pm at [**Hospital1 2025**]. . You have a follow up appointment with Dr. [**Last Name (STitle) **] in Nephrology ([**Telephone/Fax (1) 10574**]) on [**5-15**] at 3:20 pm at [**Hospital1 2025**] [**Doctor Last Name **] [**Doctor Last Name **] [**Apartment Address(1) 78886**]. . Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 78887**] to schedule a follow up appointment soon.

[ "287.5", "403.91", "585.6", "530.81", "410.71", "600.00", "424.1", "285.21", "V45.81", "428.0", "428.33" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12979, 13046

7925, 11737

277, 284

13244, 13253

2528, 7902

13943, 14470

1960, 1978

12072, 12956

13067, 13223

11763, 12049

13277, 13920

1993, 2509

222, 239

312, 1340

1362, 1803

1819, 1944

75,631

170,141

32230

Discharge summary

report

Admission Date: [**2186-2-9**] Discharge Date: [**2186-2-13**] Date of Birth: [**2145-11-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Cardiac tamponade Major Surgical or Invasive Procedure: Pericardial tap and drain placement History of Present Illness: The patient is a 40-year-old female with a PMH of metastatic triple negative left breast carcinoma now presenting with cardiac tamponade. The pt was diagnosed with PNA last week and was started on levaquin and decadron. She denied improvement with these interventions. She contact[**Name (NI) **] her oncologist on [**2-6**] with complaints of nausea and along with PCP input her [**Name9 (PRE) 1378**] was changed to azithromycin. The denied fever but +productive cough with white mucus. + N/V and decreased po intake. + intermittent SSCP over past week currently [**2-28**]. States pain radiates to her back. . In the ED, initial vitals were T:97.6 HR:136 BP:119/91 RR:20 O2Sat:99% RA. Patient received aspirin 325mg, ceftriaxone 1g and dexamethasone. 3L NS given. CXR demonstrated R pleural effusion. Bedside US showed large pericardial effusion with evidence of tamponade. The patient was taken emergently to the cath lab. In the cath lab the patient was intubated due to tachypnea, need for supine position during procedure. Initial pericardial pressure measured at 30mm. 510cc blood pericardial fluid was removed and sent for studies. Post procedure TTE showed near complete resolution of pericardial effusion. The patient was extubated prior to transfer to CCU. Past Medical History: Breast CA - triple negative left breast carcinoma, who has brain metastases. Completed whole brain cranial irradiation on [**2185-12-20**]. In [**1-29**] she palpated a mass in the left breast and underwent a breast biopsy that showed triple negative breast carcinoma. She received 6 cycles of neoadjuvant taxotere and cyclophosphamide, followed by a left mastectomy. She then received chest irradiation completed on [**2185-11-7**]. MRI [**2185-11-23**] that showed multiple brain metastases. . Hypercholesterolemia Social History: She worked at WGBH as a data entry personnel. She smoked less than 1 pack of cigarettes per day for 10 years; she stopped smoking in [**2172**]. She does not drink alcohol or use illicit drugs. Family History: Her father is healthy. Mother died of complications from pancreatitis. Her two sons are healthy. Physical Exam: Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of *** cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: ***LABS ON ADMISSION*** [**2186-2-9**] 07:15PM WBC-10.8 RBC-4.33 HGB-14.2 HCT-40.0 MCV-92 MCH-32.9* MCHC-35.6* RDW-16.9* [**2186-2-9**] 07:15PM NEUTS-81.6* LYMPHS-13.9* MONOS-4.2 EOS-0.1 BASOS-0.1 [**2186-2-9**] 07:15PM PLT COUNT-307# [**2186-2-9**] 07:15PM PT-14.5* PTT-26.4 INR(PT)-1.3* [**2186-2-9**] 07:15PM CK-MB-NotDone proBNP-20 [**2186-2-9**] 07:15PM CK(CPK)-48 [**2186-2-9**] 07:15PM GLUCOSE-147* UREA N-17 CREAT-1.0 SODIUM-119* POTASSIUM-4.9 CHLORIDE-85* TOTAL CO2-21* ANION GAP-18 [**2186-2-9**] 09:00PM OTHER BODY FLUID WBC-[**Numeric Identifier 6085**]* RBC-[**Numeric Identifier 75351**]* POLYS-2* LYMPHS-7* MONOS-1* MESOTHELI-21* MACROPHAG-9* OTHER-60* [**2186-2-9**] 09:00PM OTHER BODY FLUID TOT PROT-5.7 GLUCOSE-1 LD(LDH)-4000 AMYLASE-30 ALBUMIN-3.8 . [**2186-2-13**] 07:15AM BLOOD WBC-5.0 RBC-3.55* Hgb-11.8* Hct-34.3* MCV-97 MCH-33.3* MCHC-34.4 RDW-16.0* Plt Ct-265 [**2186-2-10**] 04:49AM BLOOD Neuts-90.9* Lymphs-4.0* Monos-4.5 Eos-0.4 Baso-0.1 [**2186-2-13**] 07:15AM BLOOD Plt Ct-265 [**2186-2-13**] 07:15AM BLOOD Glucose-128* UreaN-9 Creat-0.5 Na-139 K-4.6 Cl-104 HCO3-26 AnGap-14 [**2186-2-12**] 06:17AM BLOOD CK(CPK)-17* [**2186-2-9**] 10:31PM BLOOD ALT-111* AST-79* LD(LDH)-537* AlkPhos-214* TotBili-1.4 [**2186-2-12**] 06:17AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2186-2-9**] 07:15PM BLOOD CK-MB-NotDone proBNP-20 [**2186-2-13**] 07:15AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1 [**2186-2-13**] 07:15AM BLOOD CA27.29-PND . [**2186-2-10**] 04:49AM URINE Hours-RANDOM UreaN-180 Creat-17 Na-LESS THAN K-6 Cl-LESS THAN . [**2186-2-9**] 9:00 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [**2186-2-9**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2186-2-12**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST CULTURE (Preliminary): ACID FAST SMEAR (Final [**2186-2-10**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. . [**2-9**] Blood cx x 2: pending . [**2-9**] EKG Sinus tachycardia. The P-R interval is short without evidence of pre-excitation. Right axis deviation. Low voltag in the precordial leads. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 132 108 72 296/422 61 104 29 . [**2-9**] CATH COMMENTS: 1. Emergent pericardiocentesis performed via subxyphoid approach. 510 cc bloody pericardial fluid removed and sent for studies. The drainage tube was sutured in place. Post procedure echo showed nearly complate removal of pericardial effusion. 2. Hemodynamics demonstrated initial pericardial pressure 30 mm Hg. FINAL DIAGNOSIS: 1. Severe pericardial tamponade. . [**2-10**] ECHO GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Resting tachycardia (HR>100bpm). Conclusions The left atrium is normal in size. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. No vegetations seen (but study technically suboptimal). . ***IMAGING*** [**2-9**] CXR IMPRESSION: Right pleural effusion likely with a subpulmonic component resulting in adjacent atelectasis of the right lung base. A focal consolidation is difficult to exclude in this area. . [**2-10**] CXR Dense opacification of the lower right hemithorax has worsened consistent with lower lobe and middle lobe collapse, which is probably an underlying subpulmonic effusion. The upper right lung and left lung are well aerated. Enlarged cardiac silhouette is not well evaluated with the right hemithoracic opacification. . [**2-10**] CT CHEST IMPRESSION: 1. Small to moderate right pleural effusion with only minimal anterior loculation. Small dependent left pleural effusion and very small pericardial effusion are also new from the prior CT. 2. Collapse of right middle and right lower lobes without evidence of obstructing lesion. Associated marked elevation of right hemidiaphragm. 3. New fullness of renal collecting systems, right greater than left. Renal ultrasound may be considered for more complete assessment, as discussed by telephone with Dr. [**Last Name (STitle) **] on [**2186-2-10**]. 4. Evolving post-radiation changes in the left lung. 5. Persistent mediastinal lymphadenopathy with new nonspecific stranding of mediastinal fat. . [**2-11**] Renal U/S Redemonstration of right moderate and mild left hydronephrosis compared to [**2186-2-10**] is unchanged, but new since [**2185-11-21**]. Brief Hospital Course: Patient is a 40F with stage IIIB breast cancer with progression to brain mets who presented with dyspnea and a large pericardial effusion + tamponade physiology. She is now s/p pericardiocentesis with drainage of 500mL of a serosanguinous fluid and improvement of her symptoms. . #. Pericardial effusion: Given history of advanced breast cancer likely a malignant effusion. No evidence of polys on initial pleural fluid to suggest infection. Signs of pericardial tamponade were seen on initial echo with improvement of hemodynamics and no residual effusion after tap. Of note, she has not been exposed to anthracyclines or recent XRT to the chest wall. Drain was pulled on [**2-10**]. Echo done on [**2-10**] showed no pericardial effusion. Fluid chemistries consistent with a serosanguinous exudate. No evidence of recurrence of effusion/tamponade. Fluid cytology pending. CBC of fluid has 60% "other" cells that are non-lymphoid and likely represent malignant clones. Cell count is [**Numeric Identifier 6085**]/uL. Fluid Gram stain negative for microorgs. Cultures negative. Pt underwent repeat ECHO, which showed improvement in RV dilatation, and no pericardial effusion. . # Pneumonia: Pt with recent diagnosis of PNA at OSH based on persistent low grade fevers, SOB, cough, and LUL infiltrate on CXR. Completed 5 day course of azithromycin, remains afebrile. . # Pleural effusions: CT scan showed right sided pleural effusion with small anterior loculations, RML/RLL collapse. Blood culture no growth to date. Pt underwent discussion with primary oncologist while inpatient. Plan to follow-up further as outpatient, including re: managemenet of pleural effusion. . # Hydronephrosis - Renal US demonstrates moderate right and mild left hydronephrosis. No nephrolithiasis. CT scan of pelvis will be considered in near future pending decision re: goals of care with primary oncologist as outpatient. . #. Breast cancer: Stage IIIB, ER/PR/HER2 triple negative with progression to metastatic disease. Of note, tumor was large and approached the chest wall treated with neoadjuvant cyclophosphamide and taxotere, surgery, and XRT to the chest wall. Pt with brain mets without evidence of leptomeningeal carcinomatosis. She is s/p recent brain XRT and steroids for edema. Outpatient oncologist will follow-up with pt further re: additional therapeutic chemo vs. palliative care. . #. Tachycardia: Likely compensatory from tamponade physiology, toxic metabolic state, and volume depletion from recent poor PO intake. Patient remains tachycardic although improved however suspect now that clinically euvolemic, may be secondary to cancer. Repeat ECHO did not show pericardial effusion. . #. FEN: Normal diet. Replete electrolytes PR . #. Access: PIV . #. PPx: Heparin SQ, no need for GI PPx for now . #. Code: FULL . #. Dispo: d/c to home following discussion of goals of care with primary oncologist. Medications on Admission: None Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): Take until chest pain is gone, then discontinue. 2. Codeine-Guaifenesin Oral Discharge Disposition: Home Discharge Diagnosis: Malignant Pericardial Effusion Metastatic Breast Cancer Discharge Condition: stable. Discharge Instructions: You had a fluid collection around your heart that was caused by the cancer. The fluid was removed and the echocardiogram today showed that you had no fluid reaccumulation today. Your chest x-ray showed the pleural effusions were somewhat better. Your chest pain is because of the irritation of the lining around your heart after the fluid removal. You can take Motrin (Ibuprofen) every 8 hours as needed for this chest pain. You have a CT of your abdomen and pelvis ordered to better assess some fluid collection around your kidneys. This has not been scheduled yet. . New medicines: 1. Motrin: to take for chest pain. . Please call your doctor if your chest pain worsens, if you have symptoms that are similar to the symptoms that led you to come to the hospital, if you have trouble breathing or for any other concerning symptoms. Followup Instructions: Oncology: Please call Dr.[**Name (NI) 67735**] office tomorrow to check on CT of your abdomen and pelvis and to discuss timing of chemotherapy. You have an appt for chemotherapy on Wednesday [**2-15**] at 1pm. Please talk to Dr. [**Last Name (STitle) **] about this appt. Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2186-3-6**] 11:15 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2186-3-6**] 1:00 . Surgery: Provider: [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 17898**] Date/Time:[**2186-6-22**] 2:00 Completed by:[**2186-5-8**]

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icd9cm

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11695, 11701

8564, 11466

332, 370

11801, 11811

3377, 5190

12692, 13391

2439, 2537

11521, 11672

11722, 11780

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50822

Discharge summary

report

Admission Date: [**2170-6-26**] Discharge Date: [**2170-7-17**] Date of Birth: [**2088-5-12**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 2751**] Chief Complaint: Found Down x4 days Major Surgical or Invasive Procedure: Endotracheal Intubation PICC line placement, right brachial vein Blood transfusion - 1 unit PRBC Fresh frozen plasma - 2 units Colonoscopy EGD History of Present Illness: This is an 82 year old male who lives alone, last time normal was likely Thursday (4 days of newspapers stacked up outside of house). Found in house in bathtub per nephew may have been lying next to bathtub breathing shallowly. Has history of prostate ca, CVA x 2, NKDA. Burn on L shoulder. GCS at the scene was 4. He was intubated in the field and given 1400cc IVF. . In the ED, initial vs were: 98.8, 128, 100/palp, 100% intubated. Patient was given vanc/zosyn. C-collar placed. Patient had a temp to 101.8 and was given tylenol. He was started on propofol in the ED. Acute Care Surgery (ACS) evaled patient in the ED. A FAST scan was negative. Urine tox was negative and UA revealed large blood, 500 protein, trace ketones, [**11-10**] RBC and occasional bacteria. Sodium was found to be 159, Cl at 125, Bicarb at 17, initial lactate was 2.4 which trended down to 1.5. CK was 3363. WBC was 12.9, plts 82, INR was 1.3, Fibrinogen at 547. Cr was elevated to 2.6 (b/l 1.2-1.4), BUN 91. Pt had a CT head/spine/chest/ab/pelv which was significant for probably aspiration pneumonia at the right base. He recieved about 4L total. Blood and urine Cx were sent. At the time of transfer the vitals were 101, 109, 114/68, 17, 100% FiO2 100%. After CXR ET tube pulled back 3cm. . On the floor, patient intubated and unable to provide history. Past Medical History: stroke - MRI reveals subacute infarcts in the inferior division of the L MCA Prostate CA -'[**54**]; Tx with radiation seeds, casodex and lupron. Radiation proctitis Severe Depression: recently stopped all meds HTN Carotid stenosis s/p stenting [**10-26**] on L CEA in [**4-29**] Nephrolithiasis Echo in 98 with mod-severe MR, rheumatic deformity, mod pulm HTN GERD HLD Pagets Disease bone diagnosed in '[**57**] Dilated esophogus in 04 Barretts esophagus CRI Interstitial lung disease Question of subclinical seizures on Keppra autonomic neuropathy impaired glucose tolerance Social History: He lives alone in [**Location 1268**]. Widowed from his second marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**]. Nephew [**Name (NI) **] is HCP, lives in [**Name (NI) 2498**], sister Sabre, also HCP lives in [**State 15946**]. He is retired from a medical supplier shipping business. He has an 80-pack-year smoking history; he quit 18 years ago. He denies any ETOH or illicit drug use. Family History: Unkown Physical Exam: Discharge Physical Exam O: Tc: 98.1 BP: 158/71 HR: 109 RR: 20 O2: 94% RA General: Lying comfortably in bed, conversive HEENT: MMM, no scleral icterus Neck: no JVD CV: RRR, +S1, S2, no m/r/g Resp: expiratory wheezing bilaterally, bibasilar crackles Abd: soft, NT/ND, +bowel sounds, no HSM Ext: 2+ DP/PT pulses - unstageable sacral pressure ulcer ~4x10 cm, minimal surrounding induration with raised edges. Rim of granulation tissue with yellow base with an area of black eschar. Stage 2 on left shoulder and upper middle back, both healing well with granulation tissue and some pigmentation starting again. Neuro: AAOx3, able to lift legs off bed ~1 feet, can raise knees to same level, 4/5 strength upper extremities Pertinent Results: I. Labs A. Admission [**2170-6-25**] 11:45PM BLOOD WBC-12.9* RBC-6.82* Hgb-15.9 Hct-49.8 MCV-73* MCH-23.3* MCHC-31.9 RDW-16.7* Plt Ct-82* [**2170-6-25**] 11:45PM BLOOD Neuts-88.9* Lymphs-4.1* Monos-6.4 Eos-0.1 Baso-0.5 [**2170-6-25**] 11:45PM BLOOD PT-14.7* PTT-21.1* INR(PT)-1.3* [**2170-6-25**] 11:45PM BLOOD Plt Smr-LOW Plt Ct-82* [**2170-6-25**] 11:45PM BLOOD Fibrino-547* [**2170-6-25**] 11:45PM BLOOD UreaN-91* Creat-2.6* [**2170-6-25**] 11:45PM BLOOD ALT-28 AST-72* LD(LDH)-828* CK(CPK)-3363* AlkPhos-209* TotBili-0.5 [**2170-6-25**] 11:45PM BLOOD Lipase-24 [**2170-6-25**] 11:45PM BLOOD Albumin-2.9* [**2170-6-25**] 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2170-6-25**] 11:45PM BLOOD LtGrnHD-HOLD [**2170-6-25**] 11:51PM BLOOD Type-ART pH-7.34* [**2170-6-25**] 11:51PM BLOOD Glucose-135* Lactate-2.4* Na-159* K-4.7 Cl-125* calHCO3-17* [**2170-6-25**] 11:51PM BLOOD Hgb-17.1 calcHCT-51 O2 Sat-99 [**2170-6-25**] 11:51PM BLOOD freeCa-1.08* [**2170-6-25**] 11:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026 [**2170-6-25**] 11:50PM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG [**2170-6-25**] 11:50PM URINE RBC-[**11-10**]* WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [**2170-6-25**] 11:50PM URINE CastGr-[**2-23**]* CastHy-[**11-10**]* [**2170-6-25**] 11:50PM URINE Hours-RANDOM Creat-292 Na-11 Cl-25 [**2170-6-25**] 11:50PM URINE Osmolal-726 [**2170-6-25**] 11:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG II. Microbiology [**2170-6-25**] URINE CULTURE-FINAL {LACTOBACILLUS SPECIES} BCx x 2 ([**2170-6-25**]) Blood Culture, Routine (Final [**2170-6-29**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. THIRD MORPHOLOGY. FINAL SENSITIVITIES. 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 _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | STAPHYLOCOCCUS, COAGULASE N | | | CLINDAMYCIN-----------<=0.25 S <=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S LEVOFLOXACIN----------<=0.12 S 0.25 S <=0.12 S OXACILLIN-------------<=0.25 S <=0.25 S <=0.25 S TETRACYCLINE---------- <=1 S <=1 S <=1 S VANCOMYCIN------------ 1 S 1 S <=0.5 S Aerobic Bottle Gram Stain (Final [**2170-6-26**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [**Month/Day/Year **] [**Doctor First Name 105693**] @1050PM ON [**2170-6-26**]. Anaerobic Bottle Gram Stain (Final [**2170-6-26**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) 105693**] @1050PM ON [**2170-6-26**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. 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. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. FINAL SENSITIVITIES. 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 _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | CLINDAMYCIN----------- =>8 R <=0.25 S ERYTHROMYCIN----------<=0.25 S =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN----------<=0.12 S <=0.12 S OXACILLIN-------------<=0.25 S <=0.25 S TETRACYCLINE---------- <=1 S <=1 S VANCOMYCIN------------ 1 S 1 S **FINAL REPORT [**2170-6-26**]** Legionella Urinary Antigen (Final [**2170-6-26**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. MRSA SCREEN (Final [**2170-6-28**]): No MRSA isolated. [**2170-6-27**]: Bcx x 2 pending [**2170-6-30**]: Bcx x 1 pending III. Radiology MRI BRAIN: In the posterior left middle cerebral artery distribution, there are several foci of slow diffusion, indicating acute infarct. These are in the same [**Month/Day/Year 1106**] territory, but in different locations compared to the [**2169-4-15**] MRI. The pattern and distribution is again most suggestive of thromboembolic disease. There is no intracranial hemorrhage or edema. Periventricular and subcortical white matter T2 hyperintense foci have progressed since the [**2168**] study, again compatible with chronic small vessel ischemic change. There are no masses, mass effect or other area of infarct. Ventricles and sulci are normal in size and configuration. The major intracranial [**Year (4 digits) 1106**] flow voids are unremarkable. MRA BRAIN: TECHNIQUE: Three-dimensional time-of-flight MR arteriography was performed. FINDINGS: The intracranial vertebral and internal carotid arteries and their major branches demonstrate diffuse irregularity, although without overt occlusion or severe stenosis. This pattern is compatible with diffuse atherosclerotic disease. No aneurysm is identified. IMPRESSION: 1. Scattered foci of restricted diffusion in the left MCA [**Year (4 digits) 1106**] territory distribution most compatible with thromboembolic infarcts. These are in the same [**Year (4 digits) 1106**] distribution, but in different locations compared to the [**2168**] MRI. 2. Diffuse atherosclerotic disease, without occlusion or severe stenosis. 3. Chronic small vessel ischemic change, progressed since [**2168**]. Findings discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 12 p.m., [**2170-6-28**]. CT C-spine IMPRESSION: 1. No fracture or malalignment. 2. Multilevel degenerative changes. In the setting of trauma, cord injury may occur and if there is concern for cord injury, MRI would be recommended. 3. Apical emphysema. Carotid Series Impression: Right ICA stenosis 40-59%. Left ICA stenosis 40-59%. CT Chest IMPRESSION: 1. No evidence for traumatic injury in the chest, abdomen or pelvis. 2. Prostate brachytherapy seeds. 3. Left hemipelvis Paget disease. Sclerotic T10 vertebral body likely reflects earlier Paget disease, but metastatic disease cannot be excluded. 3. Ground-glass opacity in bilateral bases, concerning for aspiration pneumonia, more pronounced on the right where there is high density material that could be barium aspirtated in the past or calcification. 4. Extensive atherosclerotic disease including coronary calcifications. Distal aortic stent graft. Possible pulmonary hypertension. 5. ET tube 3.5 cm from the carina. CT Abdomen IMPRESSION: 1. No evidence for traumatic injury in the chest, abdomen or pelvis. 2. Prostate brachytherapy seeds. 3. Left hemipelvis Paget disease. Sclerotic T10 vertebral body likely reflects earlier Paget disease, but metastatic disease cannot be excluded. 3. Ground-glass opacity in bilateral bases, concerning for aspiration pneumonia, more pronounced on the right where there is high density material that could be barium aspirtated in the past or calcification. 4. Extensive atherosclerotic disease including coronary calcifications. Distal aortic stent graft. Possible pulmonary hypertension. 5. ET tube 3.5 cm from the carina. CT Head IMPRESSION: 1. No evidence for acute intracranial pathology. 2. Chronic microvascular infarcts and parenchymal atrophy. 3. Chronic-appearing deformity of the medial left orbital wall. IV. Cardiology A. ECHO The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is probably normal and free wall motion is probably preserved (views are suboptimal). There is probably right ventricular hypertrophy (views suboptimal). 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. There is moderate thickening of the mitral valve chordae. There is mild to moderate functional mitral stenosis (mean gradient 6 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. B. EKG Baseline artifact. Sinus tachycardia. Short P-R interval. Left atrial abnormality. T wave abnormalities. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 127 100 72 284/[**Telephone/Fax (2) 105694**] [**2170-7-16**]: Sinus tachycardia. Compared to the previous tracing of [**2170-7-1**] the rate has increased. CXR [**2170-7-1**]: REASON FOR EXAMINATION: Evaluation of the patient with new hypoxia and suspected aspiration. PORTABLE AP CHEST RADIOGRAPH COMPARISON: Chest radiograph from [**2170-6-29**]. The right PICC line is at the level of mid low SVC. There is slightly more pronounced cardiac silhouette, which may be attributed to relatively low lung volumes. The bibasal areas of pleural calcifications and minimal interstitial changes are stable. There are no new consolidations that might represent areas of aspiration. There is no pleural effusion or pneumothorax. Overall, no significant change since the prior study has been demonstrated. [**2170-7-13**]: HISTORY: Lower GI bleeding with acute onset of wheezing and shortness of breath. FINDINGS: In comparison with the study of [**7-1**], there is continued mild enlargement of the cardiac silhouette. However, there is an increase in the interstitial markings bilaterally, suggesting elevated pulmonary venous pressure. Blunting of the costophrenic angles is consistent with small pleural effusions. If the condition of the patient permits, lateral view would be most helpful. KUB [**2170-7-10**]: COMPARISON: Abdominal radiograph from [**2162-8-16**]. FINDINGS: Four abdominal radiographs, one supine and three left lateral decubitus, were acquired showing multiple loops of redundant, air-distended colon. Air fluid levels are seen on the left lateral decubitus films. There is no evidence of free air in the abdomen. The visualized osseous structures appear unremarkable. An intraaortic stent is noted just proximal to the origin of the iliac arteries. Multiple punctate opacifications over the pelvis are likely seeds from brachytherapy. IMPRESSION: Moderately distended colon likely secondary to ileus. Colonoscopy [**2170-7-16**]: Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. The efficiency of a colonoscopy in detecting lesions was discussed with the patient and it was pointed out that a small percentage of polyps and other lesions can be missed with the test. A physical exam was performed. The patient was administered moderate sedation. The physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position.The digital exam was normal. The colonoscope was introduced through the rectum and advanced under direct visualization until the cecum was reached. The cecal sling folds were seen. The appendiceal orifice and ileo-cecal valve were identified. Careful visualization of the colon was performed as the colonoscope was withdrawn. The procedure was not difficult. The quality of the preparation was fair. Visualization of the transverse colon and descending colon was poor. The patient tolerated the procedure well. There were no complications. Findings: Contents: Brownish or yellowish liquid stool was found in the ascending colon, transverse colon and descending colon. There was no red blood or melena. Flat Lesions A few medium localized angioectasias that were not bleeding were seen in the rectum. It is compatible with radiation proctitis. Other We did not find the source of bleeding Impression: Stool in the ascending colon, transverse colon and descending colon Angioectasias in the rectum Otherwise normal colonoscopy to cecum Recommendations: Please consider Capsule study EGD [**2170-7-16**]: Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered moderate sedation. A physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The vocal cords were visualized. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Mucosa: A salmon colored mucosa distributed in a segmental pattern, suggestive of Barrett's Esophagus was found. Two cold forceps biopsies were performed for histology at the gastro-esophageal junction. Stomach: Mucosa: Patchy erythema and congestion of the mucosa were noted in the whole stomach. These findings are compatible with gastritis. Localized A few erosions of the mucosa with no bleeding was noted in the stomach body. These findings are compatible with gastritis. Duodenum: Mucosa: Localized erythema and congestion of the mucosa with no bleeding were noted in the duodenal bulb compatible with duodenitis. Impression: Mucosa suggestive of Barrett's esophagus (biopsy) Erythema and congestion in the whole stomach compatible with gastritis A few erosions in the stomach body compatible with gastritis Erythema and congestion in the duodenal bulb compatible with duodenitis Otherwise normal EGD to third part of the duodenum Recommendations: follow-up biopsy results Please continue using PPI PO Pt needs surveillance EGD for his barrett's esophagus Antireflux regimen: Avoid chocolate, peppermint, alcohol, caffeine, onions, aspirin. Elevate the head of the bed 3 inches. Go to bed with an empty stomach. Discharge Labs: [**2170-7-10**] 02:02AM BLOOD WBC-12.0* RBC-4.32* Hgb-10.1* Hct-31.0* MCV-72* MCH-23.3* MCHC-32.4 RDW-17.7* Plt Ct-197 [**2170-7-10**] 06:32AM BLOOD WBC-11.6* RBC-4.18* Hgb-9.8* Hct-30.3* MCV-73* MCH-23.4* MCHC-32.3 RDW-18.1* Plt Ct-207 [**2170-7-10**] 01:57PM BLOOD Hct-29.6* [**2170-7-10**] 10:28PM BLOOD Hct-31.6* [**2170-7-11**] 09:54PM BLOOD Hct-28.1* [**2170-7-12**] 05:54AM BLOOD WBC-8.2 RBC-3.69* Hgb-8.6* Hct-26.6* MCV-72* MCH-23.2* MCHC-32.2 RDW-18.6* Plt Ct-238 [**2170-7-12**] 12:10PM BLOOD WBC-8.1 RBC-3.48* Hgb-8.0* Hct-25.1* MCV-72* MCH-23.0* MCHC-31.9 RDW-18.5* Plt Ct-197 [**2170-7-12**] 10:22PM BLOOD Hct-30.9* [**2170-7-13**] 05:16AM BLOOD WBC-12.1* RBC-4.30* Hgb-10.4*# Hct-31.5* MCV-73* MCH-24.1* MCHC-32.9 RDW-19.1* Plt Ct-276 [**2170-7-15**] 05:47AM BLOOD WBC-13.2* RBC-3.87* Hgb-9.3* Hct-28.1* MCV-73* MCH-24.2* MCHC-33.2 RDW-19.6* Plt Ct-273 [**2170-7-16**] 05:22AM BLOOD WBC-13.0* RBC-3.76* Hgb-9.1* Hct-27.9* MCV-74* MCH-24.1* MCHC-32.5 RDW-20.2* Plt Ct-287 [**2170-7-17**] 04:57AM BLOOD WBC-13.5* RBC-3.76* Hgb-8.9* Hct-28.0* MCV-74* MCH-23.7* MCHC-31.9 RDW-20.7* Plt Ct-334 [**2170-7-12**] 05:54AM BLOOD PT-20.3* PTT-30.5 INR(PT)-1.9* [**2170-7-12**] 03:00PM BLOOD PT-21.7* PTT-31.8 INR(PT)-2.0* [**2170-7-14**] 08:54AM BLOOD PT-15.2* PTT-30.3 INR(PT)-1.3* [**2170-7-15**] 05:47AM BLOOD PT-15.1* PTT-28.2 INR(PT)-1.3* [**2170-7-16**] 05:22AM BLOOD PT-16.3* PTT-27.7 INR(PT)-1.4* [**2170-7-9**] 06:53AM BLOOD Glucose-90 UreaN-22* Creat-2.0* Na-138 K-3.5 Cl-104 HCO3-27 AnGap-11 [**2170-7-10**] 06:32AM BLOOD Glucose-97 UreaN-22* Creat-1.7* Na-139 K-3.3 Cl-109* HCO3-21* AnGap-12 [**2170-7-11**] 05:24AM BLOOD Glucose-75 UreaN-19 Creat-1.6* Na-138 K-3.5 Cl-106 HCO3-22 AnGap-14 [**2170-7-12**] 05:54AM BLOOD Glucose-86 UreaN-17 Creat-1.8* Na-141 K-3.1* Cl-109* HCO3-24 AnGap-11 [**2170-7-13**] 05:16AM BLOOD Glucose-134* UreaN-12 Creat-1.6* Na-139 K-3.2* Cl-107 HCO3-22 AnGap-13 [**2170-7-15**] 05:47AM BLOOD Glucose-92 UreaN-11 Creat-1.7* Na-140 K-3.0* Cl-106 HCO3-23 AnGap-14 [**2170-7-16**] 05:22AM BLOOD Glucose-94 UreaN-13 Creat-1.6* Na-141 K-3.3 Cl-108 HCO3-23 AnGap-13 [**2170-7-17**] 04:57AM BLOOD Glucose-88 UreaN-16 Creat-1.5* Na-141 K-3.3 Cl-107 HCO3-23 AnGap-14 [**2170-7-13**] 05:16AM BLOOD ALT-13 AST-22 LD(LDH)-326* AlkPhos-116 TotBili-0.4 [**2170-7-12**] 05:54AM BLOOD ALT-12 AST-18 LD(LDH)-275* AlkPhos-95 TotBili-0.4 [**2170-7-1**] 04:42PM BLOOD CK-MB-2 cTropnT-0.05* [**2170-7-1**] 10:00PM BLOOD CK-MB-3 cTropnT-0.07* [**2170-7-2**] 05:57AM BLOOD CK-MB-2 cTropnT-0.05* [**2170-7-15**] 05:47AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8 [**2170-7-16**] 05:22AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.9 [**2170-7-12**] 05:54AM BLOOD Albumin-2.5* Calcium-8.3* Phos-3.1 Mg-2.0 [**2170-7-11**] 05:24AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9 Iron-47 [**2170-7-11**] 05:24AM BLOOD calTIBC-157* Hapto-186 Ferritn-350 TRF-121* [**2170-7-7**] 06:16AM BLOOD VitB12-903* Folate-6.3 [**2170-7-7**] 06:16AM BLOOD TSH-2.2 [**2170-6-26**] 03:02PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2170-7-17**] 04:57AM BLOOD IgA-462* [**2170-7-17**] 04:57AM BLOOD tTG-IgA-PND Brief Hospital Course: Brief MICU course: Patient arrived to the MICU intubated. He was extubated the next day. He was quickly weaned to room air. He had some word finding difficulties in the ICU. He did not remember more history. His blood cultures returned positive for 4/4 bottles with coag negative staph. An MRI was done which was consistent with thromboembolic lesions in the brain. He was called out to the floor for further work-up. Floor course: #Recurrent stroke: MRI revealed new stroke with scattered foci of restricted diffusion in the left MCA [**Month/Day/Year 1106**] territory most compatible with thromboembolic infarcts in the same [**Month/Day/Year 1106**] distribution but in different locations compared to the [**2168**] MRI. His PCP visited in the hospital and confirmed that his current mental status and neurological function is at baseline. Carotid series revealed [**Country **] and [**Doctor First Name 3098**] stenosis at 40-59 %. Stroke team recommended continuing ASA and converting to plavix once platelets stabilized continue lipitor, follow-up carotid doppler in 6 months, and lipid panel. The anti-coagulation meds were continued until the patient developed a GI bleed. The meds were held for 1 week before restarting after the patient had his colonoscopy/EGD. # GI bleed - The patient developed GI bleeding on [**7-10**] with maroon colored stools. His Hgb/Hct were serially monitored and were stable, with a slow downward trend. He remained hemodynamically stable the entire duration. GI was consulted and recommended an EGD and colonoscopy. After a family meeting, the patient agreed to undergo the procedures, however he did not drink enough of the prep to have the procedure. He did receive 1 unit PRBC as his Hct dropped to a low of 25.1. After transfusion, he increased to 31.5. He tried the prep again 2 days later and was cleaned out enough to undergo the scopes. GI performed the procedure on [**7-16**]. They found gastritis and duodenitis but no obvious source of bleeding. He was noted to have Barrett's esophagus on EGD, biopsies were taken, the results of which were pending on discharge. H. pylori was negative. GI recommended the patient be continued on pantoprazole and to have surveillance EGD of his Barretts. Please recheck a CBC in the next 1-2 days to ensure no change in anemia after restarting aspirin plavix on [**7-16**] # Elevated INR - The patient did develop an elevated INR to a high of 2.0. Hemolysis labs and liver synthetic function was checked and was normal. It was thought that the coagulopathy was due to nutritional deficiency as the patient was variously on clears and NPO for several days before his colonoscopy. He received vitamin K and responded quickly with reversal of his INR. # Hypertension - The patient was noted to be hypertensive during the last 2-3 days of his hospitalization. His metoprolol was doubled to 50mg PO BID from 25mg PO BID. If there is more control needed for his BP, we would recommend amlodipine, hydralazine, and HCTZ as medications to be used. # Coagulase-negative Staph Bacteremia: Pt had multiple blood cultures with coag negative Staph with different morphologies. This unlikely represents contamination with potential source of entry from skin penetration given prolonged period down with resultant pressure ulcers. He was initially started on vancomycin with PICC placement secondary to loss of access and subsequently switched to nafcillin given sensitivities. The patient does have a heart murmur, is afebrile, and has no vegetations on ECHO. A TEE was not done as the patient did not have signs/symptoms of endocarditis. Subsequent blood cultures were negative. The patient was instructed to take antibiotics for 6 more days to finish a 14 day course. He remained afebrile during his stay on the floor. # Acute on chronic Renal failure secondary to possible rhabdomyolysis: The patient likely had rhabdomyolysis on admission given his high CK measurement. His Cr trended down, then increased again. Urine eosinophils were checked twice, but were negative, making AIN unlikely. Renal was consulted, they were able to look at a urine sample however saw no muddy brown casts indicative of ATN, or WBC casts indicative of AIN. The patient's creatinine stabilized at 1.6-1.8. # Thrombocytopenia and Anemia: The patient was noted to have very low platelets in the 40-60s without evidence of superficial bleeding. HIT was unlikely given no previous heparin exposure in the past few months and low platelets on admission before heparin administration. TTP was a concern given thrombocytopenia, anemia, worsening renal function, and neurological issues. Medication side effect with plavix and aspirin was a secondary consideration. A smear revealed true thrombocytopenia with target cells and microcytosis. Per hematology consult, his thrombocytopenia likely represents ITP and is unlikely HIT. His anemia may be secondary to thalassemia based on the blood smear. He was monitored with daily CBC for occult blood loss. Once his platelet level returned to greater than 100, his plavix was restarted. The platelets continued to trend upwards and remained normal through discharge. An iron panel was obtained and was consistent with anemia of chronic disease. A TTG level was pending at the time of discharge as an alternate cause of his anemia. # Hypoxia - The patient was noted to be hypoxic at various times during his stay, however this was primarily due to the plethysmograph being placed on a finger. When the forehead monitor was used, his saturations were above 93%. # Shortness of breath - The patient had 2 sudden-onset episodes of shortness of breath. The first was ~2-3 hours after finishing his blood transfusion. A chest x-ray was obtained which showed increased right sided pulmonary edema. It was thought that he flashed, got lasix 40mg IV with rapid resolution of his symptoms. The second time, his SBP was 190/80, with audible expiratory wheezing. He received a duoneb treatment which again, rapidly resolved his symptoms. Both times, EKGs were obtained and were unchanged from prior. The patient remained asymptomatic during both episdoes and he did not experience any hypoxia. #) Pressure ulcers: The patient has several pressure ulcers presumed from his prolonged time down prior to admission from prolonged time down prior to admission. Wound care was immediately consulted to address this issue and their recommendations were: TO Wound care: Site: Left scapula Type: Pressure ulcer Cleansing [**Doctor Last Name 360**]: Saline Dressing: Wound Gel (DuoDerm Gel) Change dressing: qd Comment: apply large Sofsorb to area, change daily . TO Wound care: Site: right toes Type: Pressure ulcer Cleansing [**Doctor Last Name 360**]: Saline Dressing: Gauze - dry Change dressing: qd . TO Wound care: Site: sacrum (unstageable) Type: Pressure ulcer Cleansing [**Doctor Last Name 360**]: Saline Dressing: Wound Gel (DuoDerm Gel) and Mepilex Foam Change dressing: Other Comment: change every 3 days . TO Wound care: Site: Left shoulder Type: Pressure ulcer Cleansing [**Doctor Last Name 360**]: Saline Dressing: Gauze - dry Change dressing: qd . TO Wound care: Site: Right hip Type: Pressure ulcer Cleansing [**Doctor Last Name 360**]: Saline Dressing: Gauze - dry Change dressing: qd . . #) Depression: The patient did become combative and refusing to participate in his medical care around the time his GI bleed started. A family meeting was held with the patient's nephew and his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. They spoke to the patient and were able to convince him to participate in his own care. He was much more cooperative after this meeting. His citalopram was continued at his home dose. Psych was consulted and had no further medication input. He did sign a health care proxy naming his nephew, [**Name (NI) **] [**Name (NI) 26160**] ([**Telephone/Fax (1) 105695**]). . #) Seizure disorder: The patient had no seizures during his hospitalization. He was kept on Keppra. . #) Placement issues - The patient was discharged to [**Hospital1 **]. Medications on Admission: Unclear what meds patient has actually been taking; recent OMR note reporting that patient stopped all meds. ATORVASTATIN 80 mg Tablet daily CITALOPRAM 40 mg daily CLOPIDOGREL 75 mg Tablet daily FUROSEMIDE 20 mg Tablet daily LEVETIRACETAM 250 mg Tablet daily METOPROLOL TARTRATE 25 mg Tablet ASPIRIN 325 mg DOCUSATE SODIUM 100 mg Capsule [**Hospital1 **] Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID:PRN. 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN. 5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheeze. 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Primary: Stroke, dehydration, pressure ulcers, acute on chronic renal failure, thrombocytopenia, bacteremia Secondary: Depression, seizure disorder, hypoglycemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 105691**], It was a pleasure taking care of you during your hospitalization. You were admitted after being found lying in your bathtub for 4 days. It was determined that you had a stroke which led you to be unresponsive. You were treated in the Medical Intensive Care Unit for 2 days getting fluids, then were treated on the floor. Your blood had a bacteria in it that was treated with antibiotics. You were found to have pressure ulcers from lying down so long that were treated by the Wound Care nurses. It was also found that you had a low platelet level when you were admitted. This level was watched and it returned to a normal level. You developed bleeding from your gastrointestinal tract. This caused your blood levels to drop enough that you needed 1 unit of blood to raise your levels. The Gastroenterologists (stomach doctors) performed a colonoscopy and EGD where they used a small camera to look at your colon and your stomach. They found some inflammation in your stomach and first part of the small intestine, but found no active bleeding in your GI tract. They also found some changes in the first layer of the esophagus which will need to be followed in the future. You also had worsening of your kidney function. We did not figure out why this happened. We watched your kidney function and it stablilized. We provided you with a new medication list. Please take these medications unless told otherwise by a doctor. Followup Instructions: There will be a doctor at the rehab center you are going who will see you daily. When you are discharged from the rehab center, you should make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Her office number is [**Telephone/Fax (1) 250**]. Completed by:[**2170-7-17**]

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icd9cm

[ [ [] ] ]

[ "96.71", "99.04", "45.23", "38.93", "99.07", "45.16" ]

icd9pcs

[ [ [] ] ]

33017, 33060

23336, 29826

294, 439

33267, 33267

3663, 20190

34955, 35314

2901, 2909

31926, 32994

33081, 33246

31546, 31903

33452, 34932

20207, 23313

2924, 3644

236, 256

30545, 31520

467, 1802

33282, 33428

1824, 2403

2419, 2885

4,039

115,874

50410

Discharge summary

report

Admission Date: [**2174-7-8**] Discharge Date: [**2174-7-12**] Date of Birth: [**2108-9-11**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2698**] Chief Complaint: substernal chest pressure, shortness of breath Major Surgical or Invasive Procedure: ICD placement on [**2174-7-11**] History of Present Illness: Patient is a 65 year old male with a history of an inferior myocardial infarction in [**2154**], hyperlipidemia, 50 year smoking history and family history of heart disease who presented to the ER at an outside hospital via EMS after he had a syncopal episode that lasted for 30 seconds on [**2174-7-8**] associated with substernal chest pressure, shortness of breath, lightheadedness, no diaphoresis, no nausea or vomiting. The pain did not radiate. EMS found the patient to be in ventricular tachycardia and administered 100 joules which converted the patient into torsades de pointes. He was shocked again at 200 and he converted to sinus rhythm. He was placed on a lidocaine drip at which he maintained sinus rhythm and was then transferred to the [**Hospital1 69**] for possible cardiac catheterization and electrophysiologic evaluation. Past Medical History: Hyperlipidemia CAD s/p inferior MI in [**2154**] Social History: Patient is a smoker of 1 pack per day for 50 years. He drinks occasional alcohol. He works with Airborne Express and lifts heavy objects at work. He lives with his family. Family History: The patient's father died at the age of 44 with an MI. His mother passed away with cancer and an "enlarged heart". He has a brother who suffered an MI in his 40's and underwent CABG. Physical Exam: T 97.2 P = 84 BP = 139/74 RR=25 96% O2 on RA General - In no apparent distress, alert and oriented x 3 HEENT - Pupils equally responvie to light and accomodation, no JVD, =2 carotid pulses with no bruits bilaterally Heart - faint S1, S2, no murmurs, rubs or gallops Lungs - Bilateral wheezes at both bases Abdomen - soft, nontender, nodistended, with active bowel sounds Extremities - no cyanosis, clubbing or edema, +2 dorsalis pedis, posterior tibial and femoral pulses bilaterally Pertinent Results: [**2174-7-8**] 06:22PM POTASSIUM-3.8 [**2174-7-8**] 06:22PM CK(CPK)-1318* [**2174-7-8**] 06:22PM CK-MB-4 [**2174-7-8**] 06:22PM PLT COUNT-166 [**2174-7-8**] 05:00AM GLUCOSE-155* UREA N-18 CREAT-1.0 SODIUM-143 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-24 ANION GAP-13 [**2174-7-8**] 05:00AM CK(CPK)-616* [**2174-7-8**] 05:00AM CK-MB-4 [**2174-7-8**] 05:00AM CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.2 CHOLEST-112 [**2174-7-8**] 05:00AM TRIGLYCER-111 HDL CHOL-31 CHOL/HDL-3.6 LDL(CALC)-59 [**2174-7-8**] 05:00AM WBC-10.5 RBC-4.71 HGB-14.8 HCT-43.2 MCV-92 MCH-31.5 MCHC-34.3 RDW-13.2 [**2174-7-8**] 05:00AM PLT COUNT-175 [**2174-7-8**] 05:00AM PT-13.2 PTT-28.7 INR(PT)-1.2 [**2174-7-7**] 11:00PM GLUCOSE-164* UREA N-17 CREAT-1.0 SODIUM-142 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17 [**2174-7-7**] 11:00PM CK(CPK)-411* [**2174-7-7**] 11:00PM CK-MB-4 cTropnT-<0.01 [**2174-7-7**] 11:00PM MAGNESIUM-2.8* [**2174-7-7**] 11:00PM WBC-12.3* RBC-5.31 HGB-16.6 HCT-48.8 MCV-92 MCH-31.3 MCHC-34.0 RDW-13.1 [**2174-7-7**] 11:00PM NEUTS-78.3* LYMPHS-15.0* MONOS-4.4 EOS-1.7 BASOS-0.7 [**2174-7-7**] 11:00PM PLT COUNT-196 [**2174-7-7**] 11:00PM PT-12.8 PTT-27.4 INR(PT)-1.1 Brief Hospital Course: The patient was transferred to the ICU under the service of the CCU. 1. Cardiac - The patient was maintained on a lidocaine drip at 2 mg/kg/min which was discontinued on [**2174-7-9**]. He maintained sinus rhythm. His CPK maximized at 411, CK_MB at 4, and his troponins were negative. He underwent a cardiac catheterization on [**2174-7-8**] during which his right coronary artery was stented with a TAXUS stent. He was found on ventriculogram to have an EF of 35% with mild hypokinesis posterobasally, a left circumflex lesion of 30% proximal to the second obtuse marginal, a 90% lesion in the proximal and mid RCA. His posterolateral was seen to be receiving collaterals from the left. He was maintained on an aspirin, beta blocker, ACE inhibitor, a statin and Plavix. On [**2174-7-11**], an ICD was placed without complications. Afterwards, he maintained sinus rhythm with occasional runs of NSVT. If the patient decides to enroll in the SMASH VT trial, he will return in 1 month for ablation. 2. Pulmonary - The patient has a strong history of smoking and presents with wheezing on exam. As a result, Wellbutrin was started on [**2174-7-9**] to aid smoking cessation. The patient was discharged on [**2174-7-12**] in normal sinus rhythm and good condition status post ICD placement on [**2174-7-11**]. Medications on Admission: ASA, Lipitor Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 2. Atorvastatin Calcium 80 mg Tablet Sig: half tablet Tablet PO at bedtime. 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Metoprolol Tartrate 50 mg Tablet Sig: half tablet Tablet PO twice a day. 5. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Lisinopril 20 mg Tablet Sig: half tablet Tablet PO once a day. 7. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 6 doses. Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia secondary to old infarct Coronary Artery Disease with a TAXUS stent in the right coronary artery Hypertension Discharge Condition: Good Discharge Instructions: Please return to the ER or call your primary physician if you experience any chest pain, shortness of breath, lightheadedness, dizziness, or if you pass out. Followup Instructions: If you decide to enroll in the SMASH VT protocol, you will need to follow up with your electrophysiologist in 1 month for VT ablation. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2174-7-15**] 2:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2174-9-23**] 12:30 Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Where: GI ROOMS Date/Time:[**2174-9-23**] 12:30

[ "272.0", "305.1", "427.1", "782.1", "412", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.94", "36.07", "88.53", "37.22", "99.20", "36.01", "88.56" ]

icd9pcs

[ [ [] ] ]

5458, 5464

3501, 4812

381, 415

5642, 5648

2275, 3478

5854, 6472

1565, 1749

4875, 5435

5485, 5621

4838, 4852

5672, 5831

1764, 2256

295, 343

443, 1287

1309, 1360

1376, 1549

10,136

112,965

28368

Discharge summary

report

Admission Date: [**2197-10-4**] [**Month/Day/Year **] Date: [**2197-10-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13386**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo female s/p fall out of bed; + EtOH. She was taken to an area hospital; found to have a sustaining right subdural hematoma and was subsequently transferred to [**Hospital1 18**] for ongoing care. Past Medical History: Hypothyroid Osteoporosis Social History: +Etoh Resides in [**Hospital3 **] facility Family History: Noncontributory Physical Exam: VS T 99.8 P 80 BP 90/41 RR 16 Gen: A&Ox3, NAD Head: NC, AT, no abrasions HEENT: TMs clear, hares clear, PERRLA, EOMI, 2mm L periorbital abrasion Neck: supple, NT CV: RRR Pulm: CTAB ABD: +BS, NT, ND, soft Pelvis: stable Back: NT Rectal: guaiac neg UE: b/l elbow ecchymosis, NT, FROM, +sensation, [**4-14**] MS, R hand superficial laceration/abrasion LE: NT, FROM, [**4-14**] MS, +sensation Pertinent Results: [**2197-10-4**] 11:40PM GLUCOSE-116* UREA N-14 CREAT-0.5 SODIUM-145 POTASSIUM-3.9 CHLORIDE-114* TOTAL CO2-23 ANION GAP-12 [**2197-10-4**] 11:40PM CK-MB-7 cTropnT-<0.01 [**2197-10-4**] 11:40PM CALCIUM-7.5* PHOSPHATE-1.3* MAGNESIUM-3.0* [**2197-10-4**] 11:40PM PLT COUNT-142* [**2197-10-4**] 11:40PM WBC-10.5 RBC-3.64* HGB-11.3* HCT-34.0* MCV-93 MCH-31.1 MCHC-33.4 RDW-14.0 [**2197-10-4**] 11:53AM LACTATE-2.5* ECG: [**10-5**] Sinus bradycardia First degree A-V block Left atrial abnormality rSr'(V1) - probable normal variant Possible right ventricular hypertrophy Low QRS voltages in limb leads Since previous tracing of [**2197-10-4**], junctional rhythm has reverted to sinus rhythm and ST-T wave abnormalities are resolved Intervals Axes Rate PR QRS QT/QTc P QRS T 56 256 84 462/451.86 82 10 56 CT HEAD W/O CONTRAST Reason: SUDDEN MS CHANGES, EVAL FOR PROGRESSION OF SDH [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with sudden MS change REASON FOR THIS EXAMINATION: r/o out sdh progression CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: [**Age over 90 **]-year-old with sudden mental status changes, history of subdural hemorrhage. TECHNIQUE: CT of the brain without IV contrast. Comparison is made to non-contrast CT performed at 3:00 a.m. today at [**Hospital1 18**] [**Location (un) 620**]. FINDINGS: Again seen is a subdural hemorrhage extending along the right parietal and temporal lobe convexities and extending into the middle cranial fossa. This measures 6 mm in greatest dimension over the right parietal lobe and is unchanged from the prior examination. No new hemorrhages identified. There is no new hydrocephalus. There have been no other changes in the seven-hour interval. IMPRESSION: Stable appearance of right subdural hematoma. Findings were discussed at approximately 11:00 a.m. with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3271**]. Brief Hospital Course: She was admitted to the Trauma service. She initially required Dopamine in the Emergency room because of hypotension following administration of sedative for agitation. Once stabilized she was transferred to the Trauma ICU for close monitoring. Her Dopamine was weaned off the following day and her blood pressures have remained stable. Neurosurgery was consulted because of her right SDH; this injury was nonoperative. She was loaded with Dilantin which will need to continue for a total of 7 days. Serial head CT scans were performed and were stable. Her Dilantin dose was decreased from 100 mg po tid to 100 mg [**Hospital1 **] because felt may be contributing to confusion given level of 17; although therapeutic, in elderly patients this level may be toxic. She will follow up with Neurosurgery in 6 weeks for repeat head imaging. Cardiology was also consulted to rule out cardiac causes of her fall; her troponin level was flat; junctional rhythm on ECG felt may be secondary to CNS event. No clinical evidence of heart failure or tamponade noted. Serial ECG's were performed (see pertinent results); she remained on telemetry with no recorded events. Geriatrics was also consulted because of her age and mechanism of injury; several recommendations were made pertaining to her medications. It was recommended that she be placed on prn Ativan given her alcohol consumption (EtOH level 19 on admission) and Seroquel at hs prn. She did initially require a 1:1 sitter and this was eventually discontinued. Pt was alert although remained slightly confused but easily redirectable for the remainder of her hospitalization. Her labs were stable, she was tolerating a regular diet and had no acute events. Physical therapy was consulted and have recommended a short rehab stay. Case management initiated the screening process for rehab placement. Pt discharged to a rehab facility attached to her prior retirement community and the pt was looking forward to [**Hospital1 **]. She was to continue for a total of 10days of dilantin for sz prophylaxis, but then be discontinued for potential CNS toxicity in this elderly lady. She has follow up in 6wks with neurosurgery to assess the resolution of her SDH. She was instructed to follow up with her PCP after [**Hospital1 **]. Her TSH was high at 5.2 a few days prior to [**Hospital1 **] and rechecked the day of [**Hospital1 **] and was still pending at time of [**Hospital1 **]. She was discharged on 25mcg of levothyroxine and instructed to follow up with her PCP for any further adjustments of her thyroid medication. Medications on Admission: Syntrhoid Fosmax [**Hospital1 **] Medications: 1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Acetaminophen 650 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 3 days. Disp:*6 Capsule(s)* Refills:*0* 9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). Disp:*12 Tablet(s)* Refills:*2* [**Hospital1 **] Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **] [**Location (un) **] Diagnosis: s/p Fall Right subdural hematoma [**Location (un) **] Condition: Stable [**Location (un) **] Instructions: Retrun to the Emergency room if you develop any severe headaches, dizzines, visual disturbances, seizure activity, fevers; weakness in any of your extremties and/or any other symptoms that are concerning to you. You will need to continue with Dilnatin for a total of 7 days; you have 3 more days to complete this course of medication. Followup Instructions: Follow up with Neurosurgery in 6 weeks with Dr. [**Last Name (STitle) 739**], call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab, you will need to call for an appointment. Ask your PCP to follow your thyroid function and medication for you.

[ "E884.4", "458.29", "E939.4", "276.8", "852.21", "244.9", "276.2", "707.02", "733.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3072, 5651

284, 291

1108, 1999

7355, 7784

662, 679

2036, 2092

5677, 5695

694, 1089

6884, 6919

236, 246

2121, 3049

6951, 6960

6737, 6852

5725, 6707

6995, 7332

319, 538

560, 586

602, 646

28,901

118,604

20863

Discharge summary

report

Admission Date: [**2170-2-21**] Discharge Date: [**2170-2-26**] Date of Birth: [**2107-9-21**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: DOE/fatigue Major Surgical or Invasive Procedure: AVR([**Doctor Last Name **] Tissue #23) [**2-21**] History of Present Illness: 62 yo M with history of AS which has been followed by serial echo. Over the past 6 months his DOE has worsened and most recent echo showed severe AS with a dilated ascending aorta. He was referred for surgery. Past Medical History: CAD s/p '[**65**] stent, AS (bicuspid), ^lipid, htn, copd, gerd, childhood rheumatic fever Social History: retired 90 pack year smoking history Quit [**2169-11-21**] 1 etoh/week Family History: sister with MI at age 37 Physical Exam: HR 86 RR 14 BP 152/70 NAD Lungs CTAB Heart RRR 4/6 SEM Abdomen benign Extrem arm, no edema Mild anterior varicose veins carotids with transmitted bruits Pertinent Results: [**2170-2-26**] 05:15AM BLOOD WBC-8.3 RBC-2.90* Hgb-9.1* Hct-26.1* MCV-90 MCH-31.4 MCHC-34.9 RDW-13.3 Plt Ct-194 [**2170-2-24**] 07:15AM BLOOD PT-13.9* PTT-28.0 INR(PT)-1.2* [**2170-2-26**] 05:15AM BLOOD Glucose-107* UreaN-22* Creat-0.8 Na-140 K-4.2 Cl-102 HCO3-29 AnGap-13 CHEST (PA & LAT) [**2170-2-24**] 9:01 AM CHEST (PA & LAT) Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 62 year old man s/p AVR REASON FOR THIS EXAMINATION: eval for pleural effusions EXAMINATION: PA and lateral chest. INDICATION: Status post AVR. Pleural effusion. PA and lateral views of the chest are obtained [**2170-2-24**] at 0906 hours and are compared with the prior study performed on [**2170-2-22**] 1310 hours. Patient is status post AVR. Small bilateral pleural effusions are seen, more marked on the left side and increased slightly since prior examination. Patchy increase in density is seen in the right base, likely in the right lower lobe, which was not present on the prior examination and may represent some developing airspace disease. The examination is otherwise unchanged from the prior study. IMPRESSION: Slight increase in bilateral pleural effusions, more marked on the left side. Patchy airspace disease developing in the right base. Increased retrocardiac density are not significantly changed since prior examination and likely representing subsegmental atelectasis. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT O'[**Known lastname **], [**Known firstname 1955**] [**Hospital1 18**] [**Numeric Identifier 55540**] (Complete) Done [**2170-2-21**] at 11:19:40 AM 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: [**2107-9-21**] Age (years): 62 M Hgt (in): 67 BP (mm Hg): 150/70 Wgt (lb): 150 HR (bpm): 60 BSA (m2): 1.79 m2 Indication: Intraoperative TEE for AVR, ? Ascending aortic replacement ICD-9 Codes: 746.9, 786.05, 440.0, 424.1 Test Information Date/Time: [**2170-2-21**] at 11:19 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW2-: Machine: [**Pager number **] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 2.4 cm <= 3.0 cm Aorta - Sinus Level: *3.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.4 cm <= 3.0 cm Aorta - Ascending: *4.2 cm <= 3.4 cm Aorta - Descending Thoracic: *3.0 cm <= 2.5 cm Aortic Valve - Peak Velocity: *3.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *54 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 35 mm Hg Aortic Valve - LVOT pk vel: 0.80 m/sec Aortic Valve - LVOT diam: 2.3 cm Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Focal calcifications in aortic root. Moderately dilated ascending aorta. Simple atheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Bicuspid aortic valve. Moderately thickened aortic valve leaflets. Severe AS (AoVA <0.8cm2). Mild to moderate ([**11-22**]+) AR. AR may be underestimated. Eccentric AR jet directed toward the anterior mitral leaflet. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Resting bradycardia for the patient. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). At least mild to moderate aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. POST-BYPASS: During the post-bypass study, the patient was initially AV paced and, later, A paced. 1. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient =12 mmHg, peak gradient = 16mmHg with CO 5.1L/min). Trace valvular aortic regurgitation is seen. 2. Regional and global left ventricular systolic function is normal. 3. Right ventricular systolic function is normal. 4. Trace Mitral Regurgitation and other valves are as noted prebypass. 5. Aortic contours are intact post-decannulation. Brief Hospital Course: He was taken to the operating room on [**2170-2-21**] where he underwent an AVR. He was transferred to the ICU in stable condition. He was extubated later that same day. He was transferred to the floor on POD #1. He was seen by speech and swallow for preoperative dysphagia. Video swallow showed no aspiraton. He had atrial fibrillation and was started on amiodarone, his PR interval lengthened and the amio was dc'd. He did well postoperatively and he was ready for discharge home on POD #5. Medications on Admission: asa 325', carvedilol 6.25'', chantix .5'', lipitor 40', protonix 40'. 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:*0* 2. 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* 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA Discharge Diagnosis: AS/bicuspid AV s/p AVR CAD s/p '[**65**] stent, ^lipid, htn, copd, gerd, childhood rheumatic fever Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 3302**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Completed by:[**2170-2-26**]

[ "E878.1", "427.31", "496", "414.01", "746.4", "997.1", "272.4", "305.1", "530.81", "511.9", "401.9", "395.0" ]

icd9cm

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31468

Discharge summary

report

Admission Date: [**2134-9-17**] Discharge Date: [**2134-9-23**] Date of Birth: [**2059-7-3**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: intraparenchymal hemorrhage Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 75 year old with a history of temporal arteritis and a cardiac arrhythmia, on amiodarone, who presents with intracerebral hemorrhages. History is per OSH records as pt. is unable to provide a cohorent history and family is still en route. Per report pt was brought to OSH this evening for 1 day of confusion, malaise, nausea, and vomiting. This had started in the evening prior to presentation. Her family described that she was confused and was saying non-sensical things, was confusing dates, and was forgetful. Today she looked tired and lethargic. She denied headache. At OSH neurologic exam was recorded as: oriented to name and DOB and place, can't say month, PERRL 3 mm, sleepy but arousable, answering some questions appropriately, no facial droop, tongue midline, strength 4-5/5 and symmetric. Head CT was performed and showed L frontal and R parietooccipital hemorrhages with 5 mm of midline shift, so she was medflighted here for further management. Pt. currently has no complaints, is unaware of the hemorrhage, denies headache, nausea, vomiting, weakness, numbness, vision changes or vision loss, diplopia, blurry vision, lightheadedness, or bowel or bladder incontinence. Past Medical History: temporal arteritis arrhythmia R shoulder replacement ORIF R forearm and jaw s/p MVC Social History: no tobacco, no EtOH Family History: NC Physical Exam: T- 99.0 BP- 152/57 HR- 67 RR- 19 O2Sat- 99% on RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: opens eyes to voice, answers questions and follows commands, says she's in "a place where you come when you're sick" and in [**Location (un) 86**], thinks she's here "for my temporal arteritis" Guesses [**Month (only) **] for month, [**2034**] for year, gets age correct. Naming intact. Registers [**4-3**], recalls 0/3 at 5 min, [**2-3**] with prompting. Reads only the left side of a sentence. Speech fluent with no dysarthria. Cranial Nerves: Pupils equally round and reactive to light, L pupil 5.5 -> 3, L pupil 4 to 2 mm. L hemianopsia. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1- V3. Facial movement symmetric, no droop. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 4+ 5 4+ 5 5 5 5 5- 5- 5 5- 5 5 5 L 4+ 5 4+ 5 5 5 5 5- 5- 5 5- 5 5 5 Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. Occasional extinction to DSS on left. Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally Coordination: finger-nose-finger normal, RAMs normal. Gait: not assessed Pertinent Results: Labs: PT: 11.3 PTT: 24.7 INR: 1.0 133 94 18 ------------< 126 4.0 28 0.7 CK: 52 MB: Notdone Trop-T: Pnd Ca: 9.1 Mg: 2.4 P: 4.0 WBC 13.9 Hgb 12.9 Plt 306 Hct 37.2 MCV 86 N:88.0 L:9.0 M:2.8 E:0.1 Bas:0.2 OSH Labs: Na 136 K 4.1 Cl 100 HCO3 29 BUN 20 Cr 0.9 Glucose 146 WBC 15.1 Hct 39.1 Plt 321 Hgb 12.9 N [**Age over 90 **] M 2.7 L 7.2 AST 55 ALT 75 AP 161 Lipase 156 Imaging Head CT [**9-17**]: 1. Left frontal and right posterior parietal intraparenchymal hemorrhage. 2. 7 mm rightward midline shift caused by left frontal hemorrhage. 3. Small SAH in left frontal and right posterior parietal region. 4. No transtentorial herniation MRI Head [**9-18**]: 1. Two large left frontal intraparenchymal hematomas and large right occipital/parietal hematoma of differing ages. 2. Intraventricular blood, bilateral small subarachnoid hemorrhages, and a tiny left subdural hematoma. All of these findings are not significantly changed since the prior study. 3. Minimal amount left to right shift of the normally midline structures. The basal cisterns are patent. Head CT [**9-18**]: Overall, no significant change since the prior CT examination in left frontal and right parietal hemorrhages and surrounding edema. CT Angiogram [**9-19**]: Tiny focal irregularity at right A1-A2 junction of the anterior cerebral artery, likely representing artifact versus fenestration versus tiny fusiform dilatation, and unrelated to current intraparenchymal hemorrhages. No vascular source of hemorrhage is identified. Brief Hospital Course: Ms. [**Known lastname **] is a 75-year-old woman with a history of temporal arteritis and arrhythmia who presents with a day and a half of confusion, nausea, and vomiting, found to have a left anterior temporal and right parieto-occipital hemorrhage on Head CT. Her brief hospital course was as follows: 1. Neuro: Intraparenchymal hemorrhages. This was most likely due to amyloid angiopathy with a microtrauma. No obvious signs of trauma were found on external physical exam, but the location of the bleeds on imaging was felt to be consistent with coup-contrecoup hemorrhage. She was initially admitted to the Neuro ICU for close observation as she became progressively somnolent while in the ED. She was started on mannitol, which was continued and then tapered off over the last two days of her hospitalization. Neurosurgery was consulted but did not feel there was need for surgical intervention. She was started on dilantin for seizure prophylaxis, but discontinued after several days. Her MAP was maintained less than 130, and she was kept euthermic and euglycemic. The bleed was stable on repeat CT. Long-term blood pressure control was begun with lisinopril for long-term goal SBP < 140. 2. CV: history of arrhythmia. She was kept on telemetry and amiodarone without event. She had been on aspirin, but this was held and will be until she follows up with Dr. [**First Name (STitle) **] in Neurology. 3. ID: She had a leukocytosis that was presumed to be due to her steroids. It was falling at time of discharge (11,000). She was never febrile. C diff toxin assay was negative. 4. FEN/GI: She passed a swallowing evaluation and can take soft foods and thin liquids. 5. Rheum: She was continued on steroids for temporal arteritis. 6. Code: DNR/DNI, confirmed by her daughter. 7. Disposition: She was discharged to acute rehab. Medications on Admission: Prednisone 4 mg QOD Amiodarone 200 mg QD ASA 81 mg QD ALL: NKDA Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO QOD. Discharge Disposition: Extended Care Facility: [**Hospital 16844**] Hospital - [**Location (un) 1157**] Discharge Diagnosis: intracranial hemorrhage Discharge Condition: The patient is awake but very perseverative. Her speech is fluent and she can follow simple commands. She breaksdown with complex commands. The patient does not comply with formal strength testing but she is antigravity in all 4 exremities. She is able to ambulate. Discharge Instructions: Please follow up in the neurology clinic and with your primary care doctor [**First Name (Titles) 3**] [**Last Name (Titles) 9304**] below. We have stopped your aspirin since you had an intracranial hemorrhage. You should not continue this medication until you have been seen in the neurology clinic. You have also been started on a blood pressure medication called Lisinopril. Followup Instructions: Please make an appointment to see Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] ([**Telephone/Fax (1) 19129**] in the stroke clinic upon discharge from rehabilitation. Please make an appointment to see you primary care physician upon discharge from rehabilitation. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2134-9-23**]

[ "E932.0", "288.60", "430", "E849.8", "255.8", "277.39" ]

icd9cm

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Discharge summary

report

Admission Date: [**2177-9-6**] Discharge Date: [**2177-12-1**] Date of Birth: [**2147-8-13**] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine Attending:[**First Name3 (LF) 30**] Chief Complaint: fever and hypotension Major Surgical or Invasive Procedure: [**2177-9-23**]-RLE wound debridement and bone biopsy under general anesthesia [**2177-9-28**]-RLE wound debridement under general anesthesia [**2177-9-29**]-Fluoroscopic placement of PICC line [**2177-10-10**]-RLE removal of intramedullary nail, irrigation and debridement of RLE wound, application of external fixator [**2177-10-14**]-RLE wound debridement [**2177-10-21**]-RLE wound debridement and bone biopsy [**2177-10-28**]-RLE wound debridement [**2177-11-4**]-RLE wound debridement, attempted removal of wound vac, replacement of wound vac [**2177-11-11**]-RLE wound debridement [**2177-11-18**]-RLE debridement [**2177-11-21**]-[**Month/Day/Year 6024**] [**2177-11-21**]-[**Month/Day/Year 6024**] revision History of Present Illness: 30 yo F w/ESRD on HD, SLE, hypertension and recent tib/fib fracture with right tibial IMN(intramedullary nail) on [**6-24**] with subsequent hardware infection c/b bacteremia treated with linezolid and vancomycin. Patient states that she finished her course of linezolid, but continues on vancomycin. She denies any odor or drainage to her leg wound, and states that her VNA did not notice any changes. Two days prior to admission, she developed worsening of her right leg pain, described as sharp and intermittent, relieved by dilaudid, similar to when she had an infection in the past. She has also noticed swelling and erythema of her right leg over the course of the past few days. She also notes low grade fevers to 100.6 per her VNA at home. She denies any headache, sore throat, rhinorrhea, cough, SOB, CP, nauseas, vomiting, dysuria, hematuria, diarrhea. She has been constipated for several days, and states that she has some pain across her lower quadrants that she tends to develop with constipation. Patient presented to dialysis today, and was noted there to have hypotension and fever to 101.8. She was then brought to the ED. ED course: BP 70s/30s with HR 120s. Received 2L IVF with BPs 100/70s with HR 100s. Received linezolid, flagyl, ciprofloxacin. CXR showed question of pneumonia. [**Month (only) 1957**] consulted and recommended plastics consult for wound debridement. Past Medical History: PAST MEDICAL HISTORY: - SLE diagnosed [**2166**] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [**2166**]. In [**2173**], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [**8-/2175**] complicated by rejection and capsule rupture 11/[**2174**]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [**2177-6-24**] Social History: No smoking, occasional alcohol, no drug use. Originally from [**Country **], now lives in [**Location 2268**]. Used to work at [**Hospital1 18**]. Family History: Noncontributory Physical Exam: Physical Exam on Admission (ED): Vitals: 101.8 F HR 116 BP: 119/66 RR: 17 SaO2: 98% 2L General: young female in pain Head/eyes: sclera anicteric, pupils 4 mm--> 2 mm bilat Chest: crackles [**12-11**] way up bilaterally, no wheezes or rhonchi Cardiovascular: tachy, holosystolic III/VI murmur heard throughout Abdominal: multipole scars, soft, diffusely tender. No rebound or guardin, but patient not cooperable with exam. Liver palpable 3 fingerbreadths below RCM. Flank: no CVA tenderness Musculoskeletal: no spinal tenderness. DIffuse pain on palpation of muscles of R leg. Skin: multiple hyperpigmented discoid lesions over extremity (UE,LE bilat) Neuro: pt not able to comply with strength testing R LE due to pain. [**4-12**] dorsi/plantar flexio L, sensation to LT intact LE. Bilat. 2+ patellar reflex on R, could not obtain on L. Pt. refused to allow dressing change, unable to visualize wound. Dressing soaked with serosangunious drainage. Pertinent Results: Admission Labs: [**2177-9-6**] 02:26PM LACTATE-1.2 [**2177-9-6**] 02:15PM GLUCOSE-87 UREA N-11 CREAT-4.0*# SODIUM-138 POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-37* ANION GAP-10 [**2177-9-6**] 02:15PM estGFR-Using this [**2177-9-6**] 02:15PM ALT(SGPT)-42* AST(SGOT)-45* ALK PHOS-258* AMYLASE-86 TOT BILI-0.4 [**2177-9-6**] 02:15PM LIPASE-21 [**2177-9-6**] 02:15PM WBC-8.6 RBC-3.00* HGB-8.7* HCT-27.2* MCV-91 MCH-29.1 MCHC-32.0 RDW-20.1* [**2177-9-6**] 02:15PM NEUTS-67.6 LYMPHS-26.1 MONOS-5.1 EOS-0.7 BASOS-0.5 [**2177-9-6**] 02:15PM PLT COUNT-108* [**2177-9-6**] 02:15PM PT-13.3* PTT-28.8 INR(PT)-1.2* Discharge Labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2177-11-30**] 08:50AM 9.5 3.23* 9.3* 29.4* 91 28.8 31.7 18.4* 150 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2177-11-30**] 08:50AM 35* 6.9* 142 4.7 107 27 13 Reports: CXR [**2177-11-11**]: FINDINGS: In comparison with the study of [**11-9**], the patient has taken a much better inspiration. There is still substantial enlargement of the cardiac silhouette and evidence of vascular congestion in this patient who has intact midline sternal sutures. No evidence of acute pneumonia. Again, the left subclavian catheter lies within this vessel and does not reach the superior vena cava. . Tib/Fib [**2177-11-11**]: RIGHT TIBIA AND FIBULA, FOUR VIEWS TOTAL: Comparison is made to [**2177-9-15**]. An intramedullary rod and interlocking screws have been removed from the tibia. There is a new external fixation device with three screws passing through the proximal tibia with two calcaneal screws. Increased callus is noted at the site of a transverse fracture through the distal left fibula. An oblique fracture is also present in the distal tibial diaphysis. Although there may be increased demineralization about the site, it is difficult to assess the tibia for the degree of interval healing. The alignment, however, is unchanged.IMPRESSION: Status post removal of intramedullary rod from the tibia and placement of an external fixation device across known tibia and fibula fractures. . CXR [**2177-11-9**]: No appreciable change in patchy consolidation of both lungs, suspicious for pneumonia with possible superimposed failure. . CXR [**2177-11-4**]: New ET tube tip is 4.3 cm above the carina. There is no pneumothorax or sizeable pleural effusion. Moderate pulmonary edema has improved from [**10-10**]. Severe cardiomegaly and marked dilatation of the pulmonary artery are chronic findings. Patient is post median sternotomy. Left PICC tip remains in the left subclavian vein. . CXR [**11-3**]: FINDINGS: In comparison with the study of [**10-11**], there is little overall change. Again, there is evidence of pulmonary vascular congestion with more focal opacification at the left base and huge enlargement of the pulmonary arteries consistent with pulmonary hypertension. Stable enlargement of the cardiac silhouette persists. . Pathology [**2177-10-28**]: Right leg tissue: 1. Acute osteomyelitis. 2. Fragments of soft tissue with gangrenous necrosis. . Bone Marrow Scan [**2177-10-28**]: IMPRESSION: 1. Increased uptake of labeled white blood cells in the distal third of the right lower extremity consistent with continued active infection. Cut off of bone marrow activity at the site of white cell uptake suggests the white cell uptake is secondary to osteomyelitis involving the distal third ofthe right tibia. 2. Extension of the bone marrow to the distal lower extremities bilaterally compatible with prolonged stimulation. The findings are unchanged compared to the prior study. . Bone Marrow Scan [**2177-10-17**]: IMPRESSION: Increased uptake in the distal third of the right distal lower extremity consistent with continued active infection. No other sites of white blood cell uptake. Extension of the bone marrow to the distal lower extremities bilaterally compatible with prolonged stimulation. Cut off of bone marrow activity at the site of white cell uptake is suggestive of osteomyelitis involving the distal third of the right tibia. . White Blood Cell study [**2177-10-15**]: IMPRESSION: 1. Findings consistent with osteomyelitis of the distal right tibia. 2. Photopenic defect of the proximal [**12-11**] of the right tibia presumed due to overlying external fixator hardware. . CXR [**2177-10-11**] (MICU): Enlarged pulmonary arteries due to pulmonary hypertension are unchanged. Moderate pulmonary edema is stable from the day before and has worsened from [**10-6**]. Moderate cardiomegaly is stable. There is no pneumothorax. There are no sizable pleural effusions. Left PICC remains in place, terminating in the left subclavian vein; if possible, this should be respositioned or advanced. . CXR [**2177-10-10**] (MICU): IMPRESSION: Interval worsening of congestive heart failure/volume overload. . Tib/Fib in OR [**2177-10-10**]: FINDINGS: Some fluoroscopic images from the operating room demonstrate interval removal of the intramedullary rod with proximal and distal interlocking screws within the tibia. There remains a fracture of the distal tibia with a large bony defect. Fracture of the distal fibula with subacute callus is also seen. Please refer to the operative note for additional details. . CXR [**2177-10-6**]: A small component of pulmonary edema present on [**10-4**] has resolved. Diffuse ground-glass opacification and more severe peribronchial infiltration at both lung bases are chronic findings present since at least [**2177-4-8**] consistent with lupus pneumonitis. Severe cardiomegaly and marked dilatation of the pulmonary arteries are also chronic features. A central venous line, presumably a PIC, ends on the left clavicle, probably not intrathoracic. No pneumothorax or appreciable pleural effusion is present. . Pathology [**2177-10-4**]: Right tibial bone: Bony fragments with acute and chronic inflammation, fibrosis and focal necrosis consistent with acute and chronic osteomyelitis. . CXR [**2177-10-4**]: Slightly improved congestive changes compared to prior but overall not particularly different; certainly no worse than baseline. . CXR [**2177-9-29**]: Mild pulmonary edema has developed since [**9-6**] superimposed on chronic atelectasis at the lung bases, mild chronic interstitial abnormality, severe pulmonary hypertension and vascular engorgement and moderate cardiomegaly. Mild tracheal narrowing in the neck is due in part to mild thyroid enlargement, but probably also post-intubation stricture or mild focal tracheomalacia. Present since at least [**2176-5-9**]. . Fluoro Placement of PICC [**2177-9-29**]: IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single lumen 4-French PICC line placement via the brachial venous approach. Final internal length is 25-cm, with the tip positioned in mid-subclavian due to known central venous stenosis and per request from clinical team. The line is ready to use. . Pathology [**2177-9-23**]: DIAGNOSIS: Right foot tissue and bone (A):Acute osteomyelitis. . US guided FNA [**2177-9-19**] CONCLUSION: Fine needle aspiration of an inflamed area in the right lower extremity was performed with minimal yield. Specimen sent for Gram stain and culture. No discrete fluid pockets could be identified during scanning. . WBC Scan [**2177-9-17**]: Right anterior lower extremity soft tissue abscess and underlying osteomyelitis of the adjacent tibia. No uptake within nephrectomy beds . Tib/Fib x-ray [**2177-9-15**]: IMPRESSION: No significant change compared to prior study. . Unilateral Doppler US [**2177-9-12**]: FINDINGS: [**Doctor Last Name **] scale and color Doppler examination of the right common femoral, superficial femoral and popliteal veins were performed. These demonstrate normal flow, compressibility and augmentation. Several lymph nodes are seen in the right inguinal area, the largest measuring 3.6 cm. . CT RLE: IMPRESSION [**2177-9-8**]: 1. 8 cm x 2 cm low-density, peripherally enhancing phlegmon within the anterior compartment of the calf just deep to the patient's large soft tissue defect. This phlegmon extends to the anterior tibial cortex and distal interlocking screws. There is no definite evidence of osteomyelitis or hardware-related complication at this time. 2. Circumferential edema within the lower extremity soft tissues, worse in the area of skin ulceration as described above. 3. Increased sclerosis compatible with healing of the previously described calcaneal insufficiency fracture. . Unilateral Non-vasc US [**2177-9-8**]: IMPRESSION: No discrete fluid collection. The diffuse soft tissue edema, likely corresponding to phlegmon, as well as its relationship to hardware and bone, is better evaluated on the CT. . Unilateral Doppler US [**2177-9-7**]: IMPRESSION: 1. Allowing for limitations, no evidence of DVT. 2. Enlarged right inguinal lymph node as described. . CT without contrast [**2177-9-7**]: CONCLUSION: Extensive bilateral airspace infiltrates in both lungs without change from [**2177-7-1**]. Very tiny bilateral pleural effusions. Extensive mediastinal lymphadenopathy which is without change. Bilateral nephrectomies. In the right nephrectomy bed, there is a 5.1 x 2.6 cm fluid collection which has increased in size from [**Month (only) 205**]. Results were called by Dr. [**Last Name (STitle) **] to Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) 1445**] at 6 p.m. on [**2177-9-7**]. . CXR [**2177-9-6**]: IMPRESSION: Bibasilar opacity, most suggestive of atelectasis although pneumonia cannot be entirely excluded. Mild interstitial edema. . Tib/Fib x-ray [**2177-9-6**]: IMPRESSION: 1. Distal right tibial and fibular fractures status post ORIF of tibial fracture. No significant change compared to the prior examination. 2. Unchanged soft tissue defect anterior to the fracture site. . US RUQ [**2177-9-6**]: IMPRESSION: 1. No cholecystitis. 2. Right lower lobe consolidation versus pleural effusion. Brief Hospital Course: Ms. [**Known lastname 14323**] is a 30 yo F w/PMHx sx for ESRD on HD, SLE, HTN, and tib/fib fracture w/ hardware repair c/b bacteremia s/p course of antibiotics who presented with RLE pain, swelling, erythema, fever, and hypotension. Hardware infection: On [**9-8**], pt received a CT of her RLE demosntrating an 8 cm x 2 cm low-density, peripherally enhancing phlegmon within the anterior compartment of the calf just deep to the patient's large soft tissue defect. This phlegmon extended to the anterior tibial cortex and distal interlocking screws. There was, however, no definite evidence of osteomyelitis or hardware-related complication at that time. As part of continued workup of the patient, she recieved an IN-111 tagged white blood cell scan to help determine whether her hardware was, in fact, infected. Meanwhile, all of the patient's antibiotics were held awaiting the redeclaration of the patient's infectious nidus in her leg. The IN-111 scan showed that Ms. [**Known lastname 18918**] hardware was infected. At that time, [**Known lastname **] recommended amputation of Ms. [**Known lastname 18918**] leg. She was not amenable to this option. US guided biopsy of phlegmon was inadequate and patient was taken to OR for debridement, culture and bone biopsy on [**9-23**]. Results showed pseudomonas and enterococcus. Patient was restarted on antibiotics including cipro, daptomycin, aztreonam. She was followed closely by the ID service. After debridement, orthopedics had placed a vac dressing on the wound which then needed to be changed in the OR every week. Family meetings were held between SW, patient, Dr. [**Last Name (STitle) **] medical team, ID, [**Last Name (STitle) **] and family where plans were discussed. Patient still declined [**Last Name (STitle) 6024**] understanding risks. Dr. [**Last Name (STitle) **] apprehensive to remove hardware and apply ex-fix due to condition of tissue. Patient requesting second opinion. Vascular surgery briefly consulted and agreed with plan to [**Last Name (STitle) 6024**]. Dr. [**First Name (STitle) 4304**] [**Name (STitle) 284**] also evaluated patient for additional opinion and agreed with a plan to remove hardware, apply exfix and trial abx. On [**10-10**], the hardware was removed and an ex-fix was applied by orthopedics. Bactrim was added per ID for coverage of stenotrophomonas. On [**2177-10-17**] she had a bone marrow scan which showed increased uptake in the distal third of the right distal lower extremity consistent with continued active infection. The patient continued to have weekly vac changes in the operating room on Tuesdays, and cultures were taken on [**2177-10-21**]. A bone marrow scan was completed on [**2177-10-28**] to investigate progression of her infection compared with a scan on [**2177-10-17**], which was found to be unchanged. On [**11-1**] she was started on Meropenem in addition to bactrim. The patient continued to spike fevers, and she had blood cultures drawn for temps >100.4 F. On [**11-19**] pt had another wbc scan again unchanged from prior, further evidence that despite the antibiotics, the osteomyelitis had not resolved. Orthopedics changed the vac dressing to a pressure wet to dry dressing, and allowed the patient to see the wound on [**11-19**]. A family meeting was called on [**11-20**] which involved Ms. [**Known lastname 14323**], her husband, her friend/pastor's representation, orthopedics, the medicine team, case management and social work. At that meeting Ms. [**Known lastname 14323**] decided have the [**Known lastname 6024**] done, and she was taken to the OR on [**11-21**] for [**Month/Year (2) 6024**] with subsequent revision on [**11-23**]. Path margins were found to be clear, cultures negative and ID recomended to d/c her abx (daptomycin/bactrim/meropenem) x10d after the OR cultures had been sent (abx course ended [**12-1**]). Pt had a short MICU course surrounding the [**Month/Year (2) 6024**] due to hypotension likely [**1-10**] epidural and narcotics for pain control. . Tib/Fib Fracture: Tib-fib films without evidence of displacement. An x-fix was placed in the OR on [**2177-10-10**]. Per her orthopedic team on [**2177-10-23**], the patient is able to use crutches to move around; however, she is strictly non-weight bearing. [**11-21**], [**Month/Year (2) 6024**] performed. Pt will undergo extensive PT and eventually be fitted with a prosthesis. . Pain control LLE pain: Patient remained on PCA for pain relief and was followed by the chronic pain service. Settings for her PCA were recommended by the chronic pain service, and she was taken off her basal rate. She progressively began to use less of her PCA and was weaned to oral medications. She was continued on fentanyl patch, oral dilaudid, amitryptiline, and lyrica. Following her [**Name (NI) 6024**] pt received an epidural in the PACU as well as large doses of narcotics. Pt followed by chronic pain service and PCA dose converted to long acting narcotic (fentanyl patch at 125mcg/hr) with 4-8mg po dilaudid for breakthrough pain. Also started on topamax for neuropathic/phantom limb pain . Myoclonus: Patient has had on/off myoclonus, with apparent worsening prior to dialysis. Initally cause was thought to be due to high dose lyrica (75 [**Hospital1 **], which was decreased to 75 qd with improvement). Have discussed with pain managment who started patient on lyrica. At the time, patient was not having bad myoclonus and lyrica was continued. Lyrica was decreased to 50 mg qd and her symptoms were monitored. Lyrica subsequently d/ced as recommended by chronic pain. . ESRD on HD: The patient was followed by the renal service while in house for hemodialysis. Her schedule was changed to M/W/F to avoid conflict with her OR washouts, which occurred on Tuesdays. She will require hemodialysis three times a week. . Hypotension: On [**9-30**] s/p a wash out/vac change with orthopedics, Ms. [**Known lastname 14323**] required Neosynephrine in PACU for high narcotic requirement with hypotension. She stabilized and returned to the floor where she triggered for hypotension and low grade fever. Patient's fever and BP improved with daily dose of antibiotics. On [**10-4**] after yet another day of dialysis and going to the OR with orthopedics, Ms. [**Known lastname 14323**] returned to the floor in agonizing pain and was given a total of 3mg dilaudid IV in addition to PCA. She subsequently became somnolent with desaturations and hypotension for which she was transferred to the MICU. She improved there and pain consult again changed pain recs. On [**10-9**], patient was again transferred to MICU for fever with hypotension. She again improved in the MICU and was transferred back to the floor. On [**10-14**], she had dialysis and subsequently returned to the OR for vac change. Upon return to the floor, patient again triggered and was sent to the MICU for hypotension. She was started on pressors and stress dose steroids and a femoral line was placed. She again improved, was taken off pressors and stress dose steroids, femoral line removed and was transferred back to the floor on [**10-16**]. Her HD schedule was changed so that she would not have hemodialysis on the same day as the OR washout and vac change (from T/Th/Sat to M/W/F) schedule and she tolerated 2 weeks of vacuum changes without an episode of hypotension. On [**2177-11-4**], the patient went back to the operating room to remove the vacuum and to continue with wet-to-dry dressing changes. She was sent to the SICU for recurrent hypotension/hemorrhage after wound debridement and placement of VAC sponge. She received a large amount of fluid (3.5 L fluid, 4 units PRBCs, and was initially on pressors (Levo 0.08). She was weaned off of pressors, she was extubated, and returned to the floor. Pt again had a short micu course [**11-21**] to [**11-24**] for hypotension surrounding her [**Month/Year (2) 6024**] and subsequent revision. Hypotension was attributed to narcotics and epidural. Pt remained afebrile, and w/o significant bleeding/stable HCT post op. . Bloody sputum: Had new cough and bloody sputum on [**11-11**] (pill cup amount). Pt. with recent intubations, has had bloody sputum previously with intubations. Vital signs stable--no elevation HR, drop BP, or decrease O2 sat on RA. CXR performed, with no new changes, unlikely large bleed. This issue resolved in 1 day, without further incident. . Anemia: The patient received epoeitin at hemodialysis for her anemia. She remained stable with plans to transfuse with Hct <21. She was transfused several units for her low Hct during her hospital stay as well as perioperativel;y. . Endocrine: Patient was maintained on 5 mg PO prednisone (since [**10-19**]). She had been on 50 mg IV hydrocortisone q8hrs in MICU, but was returned to 5 mg PO prednisone on the floor. Blood glucose levels were monitored closely. A cosyntropin stim test on [**2177-10-23**] revealed a modest bump in cortisol, but not as expected. ESR, and CRP levels were monitored without major changes. Pt. discharged to [**Hospital1 **] for rehab with f/u with Dr. [**Last Name (STitle) **] in 3 weeks. Medications on Admission: Home Oxygen 2-3L NC Amitriptyline 100mg PO HS Aspirin 81 mg PO qd Calcium Acetate 667mg PO TID Docusate sodium 100mg PO BID Senna 8.6mg PO BID Sevelamer 800mg PO TID w/meals Pantoprazole 40mg tablet, delayed release PO q24 Prednisone 5mg PO qd Hydromorphone 2mg tablet sig: 1-3 tablets PO q4h prn Lactulose 10mg/15ml syrup sig: thirty ml PO daily Vancomycin IV (given at hemodialysis per HD protocol) Nephrocaps 1 daily Linezolid (finished course) Discharge Medications: 1. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 8. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 10. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO qhs (). 11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 16. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 17. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal Q72H (every 72 hours). 18. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours: please combine with 100mcg fentanyl patch for a total of 125mcg/hr q72h. 19. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. 20. Epoetin Alfa 10,000 unit/mL Solution Sig: as directed by your nephrologist Injection ASDIR (AS DIRECTED). 21. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 22. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 23. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal QID (4 times a day) as needed. 24. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 25. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for Itching. 26. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 27. Diazepam 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Tibial non-[**Hospital1 **], fracture, polymicrobial osteomyelitis Anemia of CKD and inflammation Secondary: SLE c/b nephritis, serositis and ascites [**2166**] S/P CRT [**2174**] c/b rejection, biopsy hematoma, capsule and nephrectomy S/P bilateral radical nephrectomies for renal masses NOS S/P Left oophorectomy secondary to intrauterine device infection. S/P Total abdominal hysterectomy, right salpingo-oophorectomy. S/P Congenital VSD repair S/P Intramedullary nail right tibia c/b infected nonunion, fracture, Numerous perioperative abdominal/retroperitoneal bleeds Idiopathic thrombocytopenic purpura Warm Autoimmune hemolytic anemia HIT antibody positive / SRA negative MSSA endocarditis. Sickle cell trait. Restrictive lung disease Mild pulmonary HTN Polymicrobial septic shock PEA arrest Left IJ and left subclavian vein thrombosis. Left pneumothorax requiring chest tube placement. Respiratory failure requiring tracheostomy. Discharge Condition: stable, improved, transferring in bed with assistance, tolerating pos, pain controlled on po regimen Discharge Instructions: You have been treated at [**Hospital1 69**] with a wound infection. You have been followed by the medicine, infectious disease, and orthopedics teams. You were treated for an infection of the hardware holding your leg bones together. You initially received IV antibiotics for your infection and showed marked improvement over the course of your hospitalization in terms of your blood pressure and in terms of your fevers. However, the infection was severe and a significant amount of infected fluid and tissue remained above your hardware. Considering that your blood vessels and body is sick from your lupus and that you are receiving standing steroids, the chance of meaningful healing of the wound was felt not to be good. Therefore, orthopedic surgery recommended amputation of the leg. At the time of discharge, your infection was not progressing. You have finished a course of antibiotics for the infection. Please return to the ED with fevers, chills, nausea, vomiting, diarrhea, chest pain, or shortness of breath. You are next scheduled for dialysis on wednesday at [**Hospital1 **]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Please continue with dialysis per your normal schedule. Please return to the emergency department or call your primary care physician if you have fever >101.4 F, worsening pain, any new symptoms which are concerning to you. Followup Instructions: Please follow up with Dr. [**MD Number(4) 9138**]. You have an appointment on [**2-12**] at 1120. If you need to change the appointment, please call [**Telephone/Fax (1) 250**]. Please continue your normal MWF dialysis schedule. Please follow up with Dr. [**Last Name (STitle) **]. You have an appointment scheduled on [**12-25**] at 230 for xrays prior to your appt. Please call if you need to change your appointment: [**Numeric Identifier 18919**]. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2177-12-25**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2177-12-25**] 2:50

[ "733.82", "403.91", "285.1", "707.09", "785.4", "730.17", "995.92", "998.11", "282.5", "996.67", "585.6", "710.0", "730.07", "038.9" ]

icd9cm

[ [ [] ] ]

[ "77.87", "84.15", "39.98", "84.3", "39.95", "00.14", "77.67", "38.93", "78.17", "78.67", "77.47" ]

icd9pcs

[ [ [] ] ]

26550, 26620

14411, 23614

362, 1079

27612, 27715

4431, 4431

29164, 29891

3427, 3444

24112, 26527

26641, 27591

23640, 24089

27739, 29141

5064, 14388

3459, 4412

301, 324

1107, 2501

4448, 5048

2545, 3245

3261, 3411

22,757

190,577

29312+57634

Discharge summary

report+addendum

Admission Date: [**2194-11-21**] Discharge Date: Date of Birth: [**2174-2-17**] Sex: M Service: TRA ADMISSION DIAGNOSIS: Motor vehicle collision versus tree. DISCHARGE DIAGNOSIS: Motor vehicle collision versus tree. HISTORY OF PRESENT ILLNESS: This is a 20-year-old male who ended up in a MVC versus tree as an unrestrained driver. He was noted to have a GCS of 3. He was intubated in the field. The patient had an unknown past medical history which is currently nothing. No surgical history. No medications at home. No allergies. The patient was afebrile and vital signs were stable upon presentation to the ED with a regular rate and rhythm. His heart rate was clear bilaterally. The patient had a normal rectal exam which was guaiac negative. He also had bilateral DP and PT pulses. A CT scan was performed while the patient was in the trauma bay. A trauma series was performed which was notable for severe multilobar pulmonary contusions and/or aspiration combinations. He was also noted to have a right scapular fracture with no gross fracture of the pelvis. A CT C-spine was then performed which showed no evidence of fracture dislocation of the cervical spine. A CT head was performed which showed a subtle high density along the right sulci of the right frontal lobe which is worrisome for a subarachnoid hemorrhage given the setting of extensive trauma. He was also noted to have air fluid levels within the bilateral maxillary sinuses and mucosal thickening in the paranasal sinuses. A CT of the abdomen and pelvis was also performed which was notable for an extensive grade IV liver laceration with hemorrhagic fluid in the abdomen and pelvis with high density material possibly representing clot. There was also noted to be a small splenic laceration with surrounding hemorrhage. There was an area of high density with fluid in the region of the right adrenal gland. There was hemorrhagic fluid in the deep pelvis. The patient was also noted to have extensive subcutaneous emphysema with pneumomediastinum, moderate left pneumothorax and a small right pneumothorax. He ended up having chest tubes placed bilaterally with the right coursing along the major fissure and traversing the lung parenchyma in the right upper lobe. The patient was admitted to the trauma service on [**2194-11-21**]. He was admitted to the trauma surgical intensive care unit for evaluation. The patient was immediately taken to the operating room for an exploration. His liver was packed to control the hemodynamically instability the patient was receiving. At the same time on [**2194-11-21**], a right frontal bolt was also placed by the neurosurgery service for a diagnosis of [**Doctor First Name **]. The patient tolerated these procedures well without any complications. He was also noted to have a right ankle fracture which was discovered on an x-ray on [**2194-11-21**]. The patient also underwent successive chest x-rays for monitoring of the pneumothorax of his lungs following placement of an additional chest tube. The patient received two chest tubes on the right side and one on the left. They were held to suction for several days and subsequently pulled after several days of holding his lung up on follow up chest x- rays. The patient was intubated and remained intubated for several days. He remained in the ICU from [**2194-11-21**] to [**2194-11-29**]. The patient also received neurosurgery consults for his subarachnoid hemorrhages. He was started on Dilantin. He is to follow up with Dr. [**Last Name (STitle) 548**] in 4 weeks for management of his Dilantin levels as well as follow up for his subarachnoid hemorrhage. The patient also subsequently went to the operating room on [**2194-11-29**], with orthopedics for ORIF of his ankle fractures. The patient tolerated the procedure well without any events. He was then transferred to the floor and remained in stable condition. A PT/OT consult was obtained for evaluation of the patient. Following his course from the orthopedic operation he was cleared from PT on [**2193-12-2**]. The patient is to be discharged home. He required 5 units of blood upon presentation to the ED, however, he did not receive any blood products subsequently. An echo was performed on the patient on [**2194-11-22**], which showed normal cavity sizes with low normal left ventricular systolic function with mild pulmonary artery systolic hypertension. A repeat CT of the head was obtained on [**2194-11-24**], which showed that the bolt was removed with an unchanged appearance of the brain with tiny foci of high density in the right frontal lobe. A portable abdomen was also obtained after a feeding tube was placed in the patient on [**2194-11-28**]. The patient was started on tube feeds at that time. He stayed on tube feeds for a total of three days. The Dobhoff tube was removed and the patient began tolerating p.o. The patient is being discharged. He is doing well. He is tolerating p.o. He is on crutches. His right leg is in a cast in which he is to remain nonweightbearing until he is seen by orthopedics and Dr. [**Last Name (STitle) **] to take place in 2 weeks. The patient is being discharged on Dilantin to continue for 4 weeks. He is also being discharged on Percocet for pain control. He is also discharged on Colace for a stool softener as well as milk of magnesia. The patient may continue his home medications as prescribed. DISCHARGE DIAGNOSIS: Status post trauma motor vehicle collision versus tree. DISCHARGE CONDITION: Good. The patient is ambulating, tolerating p.o., voiding and having bowel movements. DISCHARGE INSTRUCTIONS: The patient was instructed that he had a MCV versus tree. He was told to follow up with Dr. [**Last Name (STitle) **] in 2 weeks for postop follow up of his ankle fractures. He was also told to stay on Dilantin for 4 weeks and to present to Dr.[**Name (NI) 2845**] office in 4 weeks with a CT of the head. The patient was told that he is not to drive or operate heavy machinery while on pain medication. He was told also to call the orthopedic or neurosurgery clinics for the following: Temperature greater than 101.1, any nausea or vomiting he may experience, any seepage along the incisional sites, any alterations in mental status, any increased pain that he may experience. [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**] Dictated By:[**Last Name (NamePattern1) 29268**] MEDQUIST36 D: [**2194-12-2**] 16:03:05 T: [**2194-12-2**] 18:16:01 Job#: [**Job Number 30211**] Name: [**Known lastname 11925**],[**Known firstname **] Unit No: [**Numeric Identifier 11926**] Admission Date: [**2194-11-21**] Discharge Date: [**2194-12-3**] Date of Birth: [**2174-2-17**] Sex: M Service: SURGERY Allergies: Amoxicillin / Penicillins Attending:[**First Name3 (LF) 5964**] Addendum: Pt should follow up in the trauma clinic in [**12-2**] weeks for his post operative follow up. He should also follow up with Dr. [**Last Name (STitle) **] for his ankle fx repair. Pt. is currently afebrile with vitals signs stable CTAB RRR +S1/S2 Soft NT ND R leg casted. Pt cleared by PT and is ambulating. Discharge Disposition: Home [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**] Completed by:[**2194-12-3**]

[ "958.7", "E815.0", "824.4", "861.21", "865.00", "807.02", "860.0", "825.0", "864.05", "852.01" ]

icd9cm

[ [ [] ] ]

[ "54.11", "96.6", "34.04", "01.18", "38.93", "96.71", "79.36" ]

icd9pcs

[ [ [] ] ]

7277, 7445

5523, 5610

5444, 5501

5635, 7254

143, 181

270, 5422

42,199

178,513

33335

Discharge summary

report

Admission Date: [**2117-3-21**] Discharge Date: [**2117-3-31**] Date of Birth: [**2044-6-27**] Sex: F Service: NEUROLOGY Allergies: Amoxicillin / Detrol Attending:[**First Name3 (LF) 5018**] Chief Complaint: AMS, Code Stroke Major Surgical or Invasive Procedure: IA tPA and Merci clot retrieval. History of Present Illness: 72 yo woman with metastatic pancreatic CA (to liver, off chemo) s/p palliative Roux en Y and chemotherapy, DM, HTN, multiple TIAs in past - L sided weakness, h/o breast CA s/p lumpectomy and XRT, recent pulmonary embolus in [**2-5**] and NSTEMI 1.5 weeks ago on lovenox and ASA who presented on [**3-21**] with R sided back and chest pain and found to have troponin bump. she was otherwise well this AM - last seen well at 7:30 am. when nurse evaluated her at 8:30, she was noted to have unresponsive pupil on R with L sided weakness. As a result, code stroke was called at just before 9am. Upon initial evaluation, pt was arousable to sternal rub and able to maintain arousal initially only with tactile stimulation but after several minutes able to maintain arousal. pt states correct name and age, but thinks it's [**Month (only) **] in [**2068**], follows commands briskly. she is noted to have dilated, nonreactive pupil on R, oculomotor paresis except for ? of R eye abduction, no eyelid opening bilaterally, L sided weakness - antigravity strength but drift to bed in UE and LE. reflexes brisker on R. stroke scale 8 (LOC2, LOC questions 1, commands 1, best gaze 2, facial palsy 2, motor L 1 for both arm and leg. She was taken emergently for CT/CTA where CTA demonstrated top of basilar thrombosis with loss of flow in RPCA. pt also with loss of flow in L vertebral. ? hypodensity noted in midline pons. As a result, pt emergently taken to neurointerventional angiography suite for vascular intervention. Past Medical History: pancreatic CA. mets to liver and lung. palliative chemo and roux en y. has declined chemo since [**1-4**] PE in [**2-5**] - on lovenox NSTEMI: presently and 1.5 weeks ago. on ASA. stroke/TIAs: followed previously by neurologist in [**Location (un) 3786**]. pt with L frontal infarcts in [**1-4**] (although presented to L sided weakness). h/o previous TIAs with R facial droop/twitching. R frontal meningioma DM2 L total hip replacement GERD migraine - scotoma with throbbing unilateral HA HTN Social History: Lives with her husband in [**Name (NI) 3786**]. Does not smoke or drink alcohol. Pt. and her husband have 3 sons, one of whom lives in an apt beneath her. Indepedent of ADLs. Walks with cane and walker Family History: Sister with lung cancer- heavy smoker. Stroke and heart attacks run in the family (mother, father, brother). Physical Exam: VS: T 97.1 HR 81-89 BP 156/82 RR18 95-96% RA GENERAL: NAD, pleasant, appropriate and cooperative HEENT: NCAT. Sclera anicteric. CARDIAC: RRR LUNGS: clear bilaterally ABDOMEN: Soft, non-tender, non-distended. Normal bowel sounds. EXTREMITIES: No c/c/e. Neuro: MS: no spont eye opening, arousable initially only with continued sternal rub, but after several minutes able to maintain arousal with continued exam. pt with fluent speech, although trouble with repetition, and following commands without L/R confusion briskly. oriented to name, but thinks she's at home and thinks it's [**2068**]. CN: able to visualize fingers but without BTT. R pupil 7-8mm, nonreactive. L pupil 1.5 with minimal reactivity. minimal abduction of R eye, but otherwise with oculomotor plegia. L NLF flattening. tongue ml. palate ml. shoulder shrug, head turn full. Motor: nl tone, with full strength on R. on L, delt 3+, bic 5-, tric 5-, WE 1, FE 1, FF 5-. IP 5-, H 4+, DF 3, TE 3 Reflexes: 2+ on R, 1+ on L. toes down coord. does not cooperate. [**Last Name (un) **]: withdraws to tickle R>L. Pertinent Results: [**2117-3-29**] 06:22AM BLOOD WBC-22.7* RBC-2.87* Hgb-8.3* Hct-24.4* MCV-85 MCH-28.8 MCHC-33.8 RDW-18.2* Plt Ct-146* [**2117-3-28**] 03:20AM BLOOD WBC-20.1* RBC-2.93* Hgb-8.3* Hct-24.9* MCV-85 MCH-28.3 MCHC-33.4 RDW-17.3* Plt Ct-185 [**2117-3-27**] 11:44AM BLOOD WBC-15.8* RBC-2.87* Hgb-8.0* Hct-24.5* MCV-85 MCH-28.0 MCHC-32.8 RDW-16.8* Plt Ct-221 [**2117-3-27**] 03:44AM BLOOD WBC-17.6* RBC-2.90* Hgb-8.4* Hct-24.7* MCV-85 MCH-29.0 MCHC-34.0 RDW-17.1* Plt Ct-231 [**2117-3-26**] 02:45AM BLOOD WBC-16.9* RBC-2.75* Hgb-7.4* Hct-23.5* MCV-86 MCH-27.0 MCHC-31.5 RDW-16.7* Plt Ct-235 [**2117-3-25**] 03:12AM BLOOD WBC-26.6*# RBC-3.13* Hgb-8.6* Hct-26.4* MCV-85 MCH-27.4 MCHC-32.4 RDW-16.7* Plt Ct-286 [**2117-3-24**] 02:17AM BLOOD WBC-16.3* RBC-3.62* Hgb-10.0* Hct-30.0* MCV-83 MCH-27.7 MCHC-33.4 RDW-16.5* Plt Ct-285 [**2117-3-23**] 05:07AM BLOOD WBC-11.5* RBC-3.67*# Hgb-10.2*# Hct-30.2* MCV-82 MCH-27.8 MCHC-33.7 RDW-16.5* Plt Ct-283 [**2117-3-22**] 06:52AM BLOOD WBC-8.7 RBC-2.85* Hgb-7.5* Hct-23.6* MCV-83 MCH-26.3* MCHC-31.7 RDW-16.4* Plt Ct-302 [**2117-3-21**] 06:50AM BLOOD WBC-8.7 RBC-3.02* Hgb-7.9* Hct-25.2* MCV-84 MCH-26.2* MCHC-31.3 RDW-15.6* Plt Ct-376 [**2117-3-24**] 02:17AM BLOOD Neuts-90.4* Lymphs-5.0* Monos-3.8 Eos-0.6 Baso-0.3 [**2117-3-21**] 06:50AM BLOOD Neuts-87.2* Lymphs-7.9* Monos-3.5 Eos-1.0 Baso-0.3 [**2117-3-28**] 03:20AM BLOOD PTT-26.0 [**2117-3-27**] 11:44AM BLOOD PTT-59.9* [**2117-3-27**] 03:44AM BLOOD PT-13.1 PTT-54.3* INR(PT)-1.1 [**2117-3-26**] 09:22PM BLOOD PTT-54.4* [**2117-3-26**] 02:09PM BLOOD PTT-70.5* [**2117-3-26**] 02:45AM BLOOD PT-14.5* PTT-85.1* INR(PT)-1.3* [**2117-3-25**] 04:25PM BLOOD PTT-61.2* [**2117-3-25**] 08:59AM BLOOD PTT-48.5* [**2117-3-25**] 01:20AM BLOOD PTT-39.8* [**2117-3-24**] 04:50PM BLOOD PT-14.8* PTT-31.5 INR(PT)-1.3* [**2117-3-23**] 05:07AM BLOOD PT-14.3* PTT-26.3 INR(PT)-1.2* [**2117-3-22**] 06:52AM BLOOD PT-13.8* PTT-75.5* INR(PT)-1.2* [**2117-3-21**] 06:50AM BLOOD PT-13.9* PTT-29.5 INR(PT)-1.2* [**2117-3-22**] 06:52AM BLOOD Ret Aut-2.3 [**2117-3-29**] 06:22AM BLOOD Glucose-184* UreaN-15 Creat-0.4 Na-142 K-3.4 Cl-105 HCO3-28 AnGap-12 [**2117-3-28**] 03:20AM BLOOD Glucose-182* UreaN-18 Creat-0.4 Na-143 K-3.7 Cl-108 HCO3-27 AnGap-12 [**2117-3-27**] 03:44AM BLOOD Glucose-163* UreaN-19 Creat-0.5 Na-141 K-5.2* Cl-109* HCO3-23 AnGap-14 [**2117-3-26**] 02:45AM BLOOD Glucose-122* UreaN-22* Creat-0.5 Na-143 K-3.6 Cl-111* HCO3-20* AnGap-16 [**2117-3-25**] 03:12AM BLOOD Glucose-144* UreaN-19 Creat-0.6 Na-144 K-3.8 Cl-109* HCO3-22 AnGap-17 [**2117-3-24**] 02:17AM BLOOD Glucose-89 UreaN-9 Creat-0.4 Na-144 K-3.0* Cl-109* HCO3-27 AnGap-11 [**2117-3-23**] 05:07AM BLOOD Glucose-81 UreaN-9 Creat-0.4 Na-142 K-3.4 Cl-109* HCO3-27 AnGap-9 [**2117-3-22**] 06:52AM BLOOD Glucose-118* UreaN-13 Creat-0.5 Na-143 K-3.8 Cl-109* HCO3-26 AnGap-12 [**2117-3-21**] 06:50AM BLOOD Glucose-117* UreaN-13 Creat-0.4 Na-142 K-3.6 Cl-108 HCO3-23 AnGap-15 [**2117-3-25**] 03:12AM BLOOD CK(CPK)-82 [**2117-3-24**] 04:50PM BLOOD CK(CPK)-181* [**2117-3-24**] 11:26AM BLOOD CK(CPK)-216* [**2117-3-24**] 02:17AM BLOOD CK(CPK)-84 [**2117-3-23**] 07:23PM BLOOD CK(CPK)-56 [**2117-3-23**] 05:07AM BLOOD ALT-32 AST-30 LD(LDH)-248 CK(CPK)-36 AlkPhos-195* TotBili-0.7 [**2117-3-22**] 06:52AM BLOOD ALT-28 AST-29 LD(LDH)-200 CK(CPK)-47 AlkPhos-198* TotBili-0.2 [**2117-3-21**] 05:00PM BLOOD CK(CPK)-52 [**2117-3-21**] 06:50AM BLOOD CK(CPK)-30 [**2117-3-25**] 03:12AM BLOOD CK-MB-14* MB Indx-17.1* cTropnT-0.45* [**2117-3-24**] 04:50PM BLOOD CK-MB-31* MB Indx-17.1* cTropnT-0.83* [**2117-3-24**] 11:26AM BLOOD CK-MB-35* MB Indx-16.2* cTropnT-0.68* [**2117-3-24**] 02:17AM BLOOD CK-MB-NotDone cTropnT-0.28* [**2117-3-23**] 07:23PM BLOOD CK-MB-NotDone cTropnT-0.22* [**2117-3-23**] 05:07AM BLOOD CK-MB-NotDone cTropnT-0.14* [**2117-3-22**] 06:52AM BLOOD CK-MB-5 cTropnT-0.17* [**2117-3-21**] 05:00PM BLOOD CK-MB-6 cTropnT-0.13* [**2117-3-21**] 06:50AM BLOOD cTropnT-0.08* [**2117-3-29**] 06:22AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.0 [**2117-3-28**] 03:20AM BLOOD Calcium-8.0* Phos-1.7* Mg-1.9 [**2117-3-27**] 03:44AM BLOOD Calcium-8.1* Phos-2.5* Mg-1.8 [**2117-3-26**] 02:45AM BLOOD Calcium-8.3* Phos-2.9# Mg-2.0 [**2117-3-25**] 03:12AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.8 [**2117-3-24**] 02:17AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.7 Cholest-125 [**2117-3-23**] 05:07AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.3 Mg-2.0 [**2117-3-22**] 06:52AM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.5 Mg-2.0 Iron-16* [**2117-3-21**] 06:50AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9 [**2117-3-22**] 06:52AM BLOOD calTIBC-220* Ferritn-151* TRF-169* [**2117-3-24**] 02:17AM BLOOD %HbA1c-6.2* [**2117-3-24**] 02:17AM BLOOD Triglyc-88 HDL-27 CHOL/HD-4.6 LDLcalc-80 CXR [**2117-3-21**]: IMPRESSION: No acute cardiopulmonary process identified CTA chest [**2117-3-21**] IMPRESSION: 1. Interval decrease in the burden of the pulmonary embolus within the right lower lobe pulmonary artery. No other focus of pulmonary embolism is identified. 2. Multiple pulmonary nodules and multiple hypodense liver lesions which appear relatively unchanged compared to the prior study. Findings are compatible with the reported pancreatic metastatic disease CT/CT Perf/CTA head [**2117-3-23**]: IMPRESSION: 1. Small area of reversible ischemia in the left cerebellar hemisphere in the medial portion. 2. Please note that the accuracy of CTP in the detection of small acute infarcts in the posterior fossa. In addition, acute infarcts in this location are elsewhere in the brain, not imaged, cannot be excluded. MR of the head can be considered, if this information is necessary. 3. Lack of enhancement in the tip of the basilar artery, as well as the posterior cerebral arteries on both sides, P1 and P2 segments on the right side and P1 segment on the left side, consistent with thrombosis. This appearance is new compared to the MR angiogram done on [**2116-3-8**]. 4. The patient is apparently undergoing conventional angiogram for better assessment and possible intervention; please see the detailed report on the conventional angiogram study. 5. Degenerative changes noted in the cervical spine at C4-5 level, not completely assessed on the present study. MRI/MRA brain [**2117-3-24**]: IMPRESSION: 1. Multiple acute infarcts, in the bilateral MCA, PCA territories, likely related to embolic etiology. 2. Recanalization of the previously thrombosed tip of the basilar artery and the posterior cerebral arteries on both sides. Evaluation for any acute hemorrhage may be limited. Correlate with follow up CT study. CT Head [**2117-3-24**]: CONCLUSION: No new intracranial hemorrhage. Beginning visibility of multiple infarcts noted on a prior MR study of [**3-23**], as described in detail above. CXR [**2117-3-24**]: IMPRESSION: No acute cardiopulmonary process is identified\ Echo [**2117-3-25**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). 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 masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2117-3-9**], no major change is evident. IMPRESSION: no mass or vegetations seen CXR [**2117-3-26**]: FINDINGS: As compared to the previous radiograph, a Dobbhoff catheter has been placed. The course of the catheter is unremarkable, the tip of the catheter is not included on the radiograph. Unchanged position of left-sided Port-A-Cath. Mild pre-existing right suprabasilar atelectasis. No new lung opacities. CT Abd/Pelvis [**2117-3-27**]: IMPRESSION: 1. Right inguinal hematoma, cannot exclude active extravasation. 2. Innumerable liver and pulmonary metastases. Pancreatic head mass. 3. Bilateral small pleural effusions. Femoral U/S [**2117-3-27**]: IMPRESSION: Large inguinal hematoma, no evidence of pseudoaneurysm CT Head [**2117-3-28**]: IMPRESSION: 1. Evolving left MCA infarct involving the left frontal and parietal lobes with obliteration of the adjacent sulci and no hemorrhage. This appears larger than on the previous MR examination. 2. Unchanged right thalamic infarction. 3. Right cerebellar and right occipital infarctions, barely detectable on this CT. CXR [**2117-3-28**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. Right Port-A-Cath and Dobbhoff catheter in place. Unchanged size of the cardiac silhouette, unchanged tortuosity of the thoracic aorta. No signs of overhydration, no pleural effusions, no focal parenchymal opacities suggestive of pneumonia. Brief Hospital Course: This 72 F was admitted for chest pain and was being managed for NSTEMI. She experienced a tip of the basilar stroke as outlined in the HPI. She was taken to the angio suite and received IA tPA and Merci clot retrieval with subsequent recanalization of her PCA's bilaterally. Although post-catheterization she was noted to be speaking, her neuro exam deteriorated overnight and the next morning she was somnolent, nonverbal, but able to move all extermities against gravity. Her brain MRI overnight showed scattered infarcts in the cerebellum, midbrain, right thalamus, and cortex. A repeat head CT showed no evidence of bleeding post-tPA, and she was started on a heparin gtt. Post-catheterization, her troponins began increasing again and peaked at about 0.8. She was started on a beta-blocker and aspirin. Her WBC count increased over days, however an infectious workup returned negative. Over days, her hemoglobin was noted to be trending down, a CT Abd/pelivs was done and confirmed the presence of a femoral hematoma. The heparin gtt was DC'd. Subsequently, her neuro exam deteriorated more to the point where she was not moving her extremities as well as previously. A repeat NCHCT showed evolution of her prior left MCA territory infarct. She was otherwise stable from a caridopulmonary perspective and was transferred out of the ICU to the floor. Given her hx of metastatic pancreatic CA, Trousseau syndrome, and now scattered strokes, her family decided that hospice care would be most appropriate for her. Medications on Admission: -Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: Two (2) Tablet PO QID. -Atenolol 50 mg Tablet: One (1) Tablet PO DAILY. -Spironolactone 12.5 mg PO DAILY. -Enoxaparin Fifty (50) mg Subcutaneous [**Hospital1 **]. -Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr, 1 Tab PO daily. -Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H PRN. -Docusate Sodium 100 mg Capsule Sig: Two (2) PO BID. -Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY. -Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID PRN. Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q1H (every hour) as needed for pain. 2. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for resp distress, restlessness. 3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72HR (). 4. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual QID (4 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] - [**Location (un) 7658**] Discharge Diagnosis: End-stage Pancreatic Ca Trouso syndrome Myocardial infarction Cerebral embolism with multiple infarctions Bacteremia Discharge Condition: comfort care Discharge Instructions: You had multiple strokes due to increased clotting caused by pancreatic cancer Followup Instructions: Hospice care [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2117-3-30**]

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Discharge summary

report

Admission Date: [**2103-5-16**] Discharge Date: [**2103-5-21**] Date of Birth: [**2043-6-18**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: anemia Major Surgical or Invasive Procedure: Removal of G-tube History of Present Illness: 59 year old woman with HIV on HAART (last VL 9,224, CD4 count 147 in [**4-/2103**]), and history of CVA and arterial thrombi, currently on coumadin, who presented to [**Hospital3 **] earlier today with dizziness and abdominal pain. Stools were dark and guiac positive and labs notable for HCT 13 and INR 13.7. She was given 2U FFP, 2U PRBCs, vit K 10mg IV, protonix, zosyn, morphine, zofran, and 750cc NS. There was concern for an acute abdomen so she was transferred to [**Hospital1 18**] for further evaluation. . At [**Hospital1 18**] initial VS were 98.6, 87/55, 78, 17, 100%. Stool was brown but guiac positive. EKG: NSR @ 84, NA/NI, no STEMI, c/w prior. Labs notable for HCT 15.8, INR 1.4. CXR neg for free air or other acute process. CT abd/pelvis with ileitis, transverse/descending colitis, simple free fluid, patent vasculature. Type and cross was sent but prior to completion patient was briefly hypotensive to the 70s so was given 1 unit of un-crossmatched blood and then a second unit of crossmatched blood, as well as 3 more liters of NS (with 40 meq K). Repeat Hct was 30. She was given 1g vanc, fentanyl, morphine, and started on protonix gtt. Surgery evaluated her but felt no acute surgical issues. GI evaluated her and recommended supportive care with possible plan to scope in the AM. VS prior to transfer were 109/56, 65, 14, 97% RA. . On arrival to the MICU, patient reports [**7-13**] abdominal pain but doesn't appear to be in acute distress. Past Medical History: # HIV/AIDS: diagnosed in [**2102-11-2**] - last viral load 28,000, CD4 count 96 in [**12-14**]. - HAART initiated on [**2102-11-13**] (Ritonavir, Darunavir, Emtricitabine-Tenofovir), genotyping compatible with regimen - CMV viremia, treating empirically for CMV colitis given persistent diarrhea with IV ganciclovir x 21 days (day 1= [**11-11**]), then transition to maintenance valgancyclovir -[**Doctor First Name **] (pulmonary) responding to steroids - on PCP/toxo prophylaxis with bactrim 1DS daily - on [**Doctor First Name **] prophylaxis with azithromycin # HSV # Occipital stroke([**11/2102**]): likely embolic, no evidence of PFO on TTE # Ischemic left foot s/p thrombectomy and fasciotomy d/t acute arterial thrombus([**11/2102**]) # h/o pneumothorax ([**11/2102**]):complication of subclavian line placement # Depression # Anxiety # Malnutrition/ wasting Social History: From [**Location (un) 5028**], MA. She is not married, but has had one partner for the past 26 years who lives in the apartment above her. She lives with a friend. She has been at [**Hospital3 **] for the days in between discharge and this new admission. - Tobacco: h/o 1ppd x 30 years, quit in [**2102-7-3**] - Alcohol: denies - Illicits: denies Family History: No history of lung or heart disease, no history of clotting disorders Physical Exam: ADMISSION EXAM: General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, TTP throughout but no guarding or rebound, bowel sounds present, g-tube in place and site clean and w/o erythema GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left leg s/p BKA Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: General: Alert, oriented x3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, TTP throughout but no guarding or rebound, bowel sounds present, g-tube in place and site clean and w/o erythema GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left leg s/p BKA Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: ADMISSION LABS: [**2103-5-16**] 04:45PM BLOOD WBC-4.6 RBC-1.47*# Hgb-4.8*# Hct-15.8*# MCV-107* MCH-32.8* MCHC-30.5* RDW-21.2* Plt Ct-230 [**2103-5-16**] 04:45PM BLOOD Neuts-74.4* Lymphs-17.7* Monos-4.9 Eos-2.7 Baso-0.3 [**2103-5-16**] 05:15PM BLOOD PT-15.4* PTT-31.5 INR(PT)-1.4* [**2103-5-16**] 04:45PM BLOOD WBC-4.6 Lymph-18 Abs [**Last Name (un) **]-828 CD3%-69 Abs CD3-570* CD4%-17 Abs CD4-139* CD8%-50 Abs CD8-417 CD4/CD8-0.3* [**2103-5-16**] 04:45PM BLOOD Glucose-58* UreaN-18 Creat-1.3*# Na-142 K-2.8* Cl-120* HCO3-14* AnGap-11 [**2103-5-16**] 04:45PM BLOOD ALT-7 AST-12 LD(LDH)-217 AlkPhos-39 TotBili-0.5 [**2103-5-16**] 04:45PM BLOOD Lipase-13 [**2103-5-16**] 04:45PM BLOOD Albumin-2.2* [**2103-5-16**] 04:45PM BLOOD Hapto-6* [**2103-5-16**] 04:48PM BLOOD Lactate-0.8 . DISCHARGE LABS: [**2103-5-21**] 06:30AM BLOOD WBC-5.1 RBC-3.41* Hgb-10.8* Hct-31.9* MCV-93 MCH-31.8 MCHC-34.0 RDW-19.6* Plt Ct-328 [**2103-5-21**] 06:30AM BLOOD PT-14.4* PTT-78.5* INR(PT)-1.3* [**2103-5-21**] 06:30AM BLOOD Glucose-91 UreaN-13 Creat-1.7* Na-143 K-2.6* Cl-110* HCO3-24 AnGap-12 [**2103-5-21**] 06:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 . URINE STUDIES: [**2103-5-16**] 05:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2103-5-16**] 05:20PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [**2103-5-16**] 05:20PM URINE RBC-35* WBC-5 Bacteri-FEW Yeast-NONE Epi-0 [**2103-5-16**] 05:20PM URINE CastGr-1* CastHy-1* [**2103-5-18**] 05:57PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011 [**2103-5-18**] 05:57PM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [**2103-5-18**] 05:57PM URINE RBC-<1 WBC-7* Bacteri-FEW Yeast-NONE Epi-0 [**2103-5-18**] 05:57PM URINE CastGr-5* CastHy-3* [**2103-5-18**] 05:57PM URINE Hours-RANDOM UreaN-178 Creat-28 Na-111 K-20 Cl-112 . MICRO: [**2103-5-20**] STOOL OVA + PARASITES- NEGATIVE [**2103-5-19**] STOOL OVA + PARASITES- NEGATIVE [**2103-5-18**] STOOL C. difficile DNA amplification assay- NEGATIVE FECAL CULTURE-NEGATIVE; CAMPYLOBACTER CULTURE-NEGATIVE; OVA + PARASITES-NEGATIVE; FECAL CULTURE - R/O YERSINIA-NEGATIVE; MICROSPORIDIA STAIN-NEGATIVE; CYCLOSPORA STAIN-NEGATIVE; Cryptosporidium/Giardia (DFA)-NEGATIVE [**2103-5-17**] URINE URINE CULTURE-NEGATIVE [**2103-5-17**] MRSA SCREEN MRSA SCREEN-NEGATIVE [**2103-5-16**] BLOOD CULTURE Blood Culture, Routine-NEGATIVE [**2103-5-16**] BLOOD CULTURE Blood Culture, Routine-NEGATIVE . REPORTS: CXR [**2103-5-16**]: A left-sided PICC line has been removed. The cardiac, mediastinal, and hilar contours appear unchanged. Aside from streaky left basilar opacity suggesting minor atelectasis, the lungs appear clear. There is no pleural effusion or pneumothorax. No free air is demonstrated. A partly imaged catheter projects over the left upper quadrant of the abdomen, compatible with a gastrostomy tube. . CTA abdomen/pelvis [**2103-5-16**]: Moderate volume ascites with long segment small bowel (distal ileum) edema. Differential considerations include inflammatory, infectious causes, and less likely ischemic, and angioedema/allergic reaction. Ischemic enteritis is not a favored diagnosis given the reported normal serum lactate, and preservation of arterial and venous flow as well as normal mucosal enhancement. Findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the time of this dictation. . RUQ DUPLEX [**2103-5-17**]: 1. Patent hepatic vasculature with no portal venous clot identified. 2. Trace of ascites and small right pleural effusion. 3. Cholelithiasis. Brief Hospital Course: 59F with HIV on HAART (last VL 9,224, CD4 count 147 in [**4-/2103**]), and history of CVA and arterial thrombi, currently on Coumadin, who presented with dizziness and abdominal pain; found to have HCT drop and ileitis. . # Anemia, chronic blood loss: Patient presented to OSH with HCT 13 in the setting of INR 13.6. Hematocrit improved to 30 on transfer to [**Hospital1 18**] following 4 units PRBCs, 4 units FFP, and 10 mg IV vitamin K to reverse coagulopathy. Although stool was guaiac positive, she denied any melena or grossly bloody stools to explain such an acute drop. GI evaluated patient and felt EGD/[**Last Name (un) **] was not indicated at this time. She was started on [**Hospital1 **] PPI. She had no evidence of bleed throughout admission. Hemolysis labs did show some hemolysis, but not enough to account for hematocrit drop. The patient's hematocrit remained stable for the remainder of admission. The patient should follow up for outpatient HCT check with VNA on discharge. . # Abdominal pain/C. difficile colitis: The patient complained of epigastric and right lower quadrant pain on admission. She related epigastric pain to irritation from her chronic G-tube. RUQ ultrasound benign. For epigastric pain, the patient's G-tube was removed, as she was eating well and had not used it in months. She was also started on a PPI. Pain resolved. For her right lower quadrant pain, CT abdomen revealed ileitis. Considering history of HIV and CD4 count <200 there was concern for infectious processes including CMV colitis. GI was consulted, and recommended conservative management of symptoms. As the patient has a history of C. difficile, she was started on an empiric course of PO vancomycin for C. diff. She was first made NPO, then diet was slowly advanced. She tolerated it well. . # HIV: The patient was followed by infectious disease throughout admission. She was continued on Abacabir-lamivudine, Darunavir, and Ritonavir. Lamivudine renally dosed for acute on chronic renal failure. The patient was continued on dapsone for PCP [**Name Initial (PRE) 1102**]. She was discharged on lamivudine 100 mg daily (rather than home dose of 300mg) due to renal function. She should follow up with her PCP regarding her renal function for further adjustment of her HIV medication dosing. . # Acute on chronic kidney disease: Patient admitted with a creatinine of 1.3, up from her normal baseline a few months ago, but down from the recent peak at 2.5 secondary to Bactrim and Truvada (stopped prior to admission). During admission, creatinine increased to a peak of 2, with a FENa of 5%. Acute kidney injury was felt to be a combination of resolving AIN from her recently changed HAART regimen, as well as contrast induced nephropathy from her initial CT scan with IV contrast. At the time of discharge, creatinine was 1.7. The patient should have renal function checked on [**2103-5-23**]. Results to be sent to PCP for renal dosing of medications. . # H/o stroke, PVD, arterial emboli: On Coumadin at home with INR goal [**1-5**]. At the OSH, the patient was given 4 units FFP and 10 mg IV vitamin K for a supratherapeutic INR. At the time of admission to [**Hospital1 18**], INR 1.0. The patient was monitored for evidence of bleed. After 24 hours, she was resumed on home Coumadin with a heparin drip bridge. Heparin was changed to Lovenox with daily dosing at the time of discharge, as the patient's GFR became > 30. The patient will have renal function and INR checked on [**2103-5-23**]. Pending GFR, Lovenox should be increased to [**Hospital1 **] dosing. The patient should continue Lovenox until therapeutic on warfarin for 48 hours. She will follow up with heme/onc as an outpatient for hypercoaguable workup. . # Depression: Chronic. The patient was continued on home sertraline. . # Communication: partner [**Name (NI) **] ([**Telephone/Fax (1) 91035**] # Code: Full code ============================================== TRANSITIONAL ISSUES: # Patient to have INR and Chem 7 drawn on [**2103-5-23**]. Pending GFR, lamivudine and Lovenox dosing should be adjusted. # Patient should remain on Lovenox until therapeutic on warfarin for 48 hours. INR goal [**1-5**]. # Patient to complete 14 day course of PO vancomycin for empiric coverage of C. diff Medications on Admission: - Abacabir-lamivudine 600-300mg daily - Ariprazole 2mg daily - Clonazepam 0.5mg [**Hospital1 **] - Dapsone 100mg daily - Darunavir 800mg daily - Metronidazole 250mg QID - Omeprazole 40mg daily - Pramipexole 0.125mg QHS - Ritonavir 100mg daily - Sertraline 50mg daily - Valganciclovir 450mg [**Hospital1 **] - Warfarin 1mg daily - Aspirin 81mg daily - Docusate 100mg [**Hospital1 **] Discharge Medications: 1. Vancomycin Oral Liquid 125 mg PO Q6H RX *vancomycin 125 mg 1 Capsule(s) by mouth every 6 hours Disp #*40 Capsule Refills:*2 2. Enoxaparin Sodium 60 mg SC DAILY RX *enoxaparin 60 mg/0.6 mL 60 mg daily Disp #*14 Syringe Refills:*2 3. Abacavir Sulfate 600 mg PO DAILY RX *Ziagen 300 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Aripiprazole 2 mg PO DAILY 5. Dapsone 100 mg PO DAILY 6. LaMIVudine 100 mg PO DAILY RX *Epivir HBV 100 mg 1 Tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0 7. Darunavir 800 mg PO DAILY 8. Omeprazole 40 mg PO DAILY 9. pramipexole *NF* 0.125 mg Oral qHS 10. RiTONAvir 100 mg PO DAILY 11. Sertraline 50 mg PO DAILY 12. Warfarin MD to order daily dose PO DAILY16 take 5 mg daily for two days, then decrease to 2mg daily RX *Coumadin 1 mg AS DIRECTED Tablet(s) by mouth DAILY Disp #*66 Tablet Refills:*0 13. Aspirin 81 mg PO DAILY 14. Outpatient Lab Work Please check Chem 7 and INR on [**2103-5-23**]. Please report results to [**First Name8 (NamePattern2) **] [**Last Name (un) 14740**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]: Fax ([**Telephone/Fax (1) 1353**]. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Anemia, ileitis, C. difficile diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - transfers to wheelchair Discharge Instructions: Ms. [**Known lastname **], . You were admitted to the hospital with abdominal pain and low blood counts in the setting of an elevated INR. You were given medication to return your INR to normal, and your bleeding stopped. Your G-tube was pulled, and your abdominal pain improved. You were also found to have C. difficile diarrhea, for which you were started on vancomycin. . You experienced some temporary kidney injury during your admission that we believe was from contrast administration and possibly medication side effect. Your kidney function was improving at discharge. . You were resumed on your home coumadin and started on a heparin drip to thin your blood until your coumadin level becomes therapeutic. When your renal function improved, you were transitioned to lovenox. You will continue lovenox until your coumadin level becomes therapeutic. . You should have your Chem 7 and INR checked by VNA on Wednesday [**2103-5-23**]. . MEDICATIONS CHANGED THIS ADMISSION: START lovenox 60 mg sub-cutaneous daily START vancomycin 125 mg every 6 hours DECREASE lamivudine to 100 mg daily STOP valgancyclovir STOP metronidazole Followup Instructions: Department: PRIMARY CARE When: FRIDAY [**2103-5-25**] 3:00 PM With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) **] . Department: INFECTIOUS DISEASE When: TUESDAY [**2103-5-29**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: GASTROENTEROLOGY When: WEDNESDAY [**2103-5-30**] at 1:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage . Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2103-6-22**] at 10:30 AM With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 5056**], MD [**Telephone/Fax (1) 3062**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: INFECTIOUS DISEASE When: TUESDAY [**2103-6-12**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "300.00", "V58.61", "V12.51", "285.1", "V15.82", "008.45", "042", "280.0", "584.9", "311", "443.9", "585.9" ]

icd9cm

[ [ [] ] ]

[ "97.51" ]

icd9pcs

[ [ [] ] ]

14176, 14259

8261, 12247

312, 332

14342, 14342

4583, 4583

15664, 17088

3117, 3189

13010, 14153

14280, 14321

12603, 12987

14504, 15641

5379, 8238

3204, 3884

3900, 4564

12268, 12577

266, 274

360, 1829

4599, 5363

14357, 14480

1851, 2730

2746, 3101

22,979

196,612

52894

Discharge summary

report

Admission Date: [**2139-12-15**] Discharge Date: [**2139-12-24**] Service: ADMISSION DIAGNOSES: 1. Gastric adenocarcinoma. 2. Parkinson's. 3. Diabetes mellitus type 2. 4. Osteoarthritis. 5. Glaucoma. 6. Status post hysterectomy. 7. Status post goiter removal. 8. Status post spinal surgery for a bone spur. DISCHARGE DIAGNOSES: 1. Gastric adenocarcinoma - lienitis plastica type - status post total gastrectomy, J tube placement. 2. Atrial fibrillation - resolved. 3. Bilateral pleural effusions. 4. Urinary tract infection. 5. Parkinson's. 6. Diabetes mellitus type 2. 7. Osteoarthritis. 8. Glaucoma. 9. Status post hysterectomy. 10. Status post goiter removal. 11. Status post spinal surgery for bone spur. ADMISSION HISTORY AND PHYSICAL: The patient is an 80 year-old female who presented initially for surgical evaluation after having a workup for postprandial abdominal pain, which found a gastric mass on gastrointestinal series. CT subsequently revealed a large gastric mass with increased soft tissue density within the transverse colon. The patient subsequently had an esophagogastroduodenoscopy, which showed a submucosal infiltrative circumferential mass of malignant appearance in the antrum and stomach body pathology of which showed an adenocarcinoma of the signet ring cell type with chronic inactive gastritis. The patient therefore was evaluated for a subtotal versus total gastrectomy. On initial presentation her weight was 116 pounds. She was otherwise afebrile. HEENT was unremarkable. The neck was supple without mass, nodules or thyromegaly. The chest was clear to auscultation and percussion. The heart sounds were regular, but there was notably a grade 2 to 3 systolic ejection murmur heard best at the left sternal border that radiates up into the carotids with minor radiation to the axilla. The abdomen was soft with an upper abdominal mass, which was consistent with the distal stomach, which felt firm. There is a well healed lower midline scar. There were no other masses. There was no ascites and the extremities showed no clubbing, cyanosis or edema. There was mild to moderate tremor noted to be present. PREOPERATIVE LABORATORIES: Her preoperative hematocrit was 36.2. Preoperative platelet count was 466. HOSPITAL COURSE: The patient was admitted on [**2139-12-15**] and on that same day underwent a total gastrectomy with placement of a feeding jejunostomy without note of intraoperative complications. Intraoperatively it was noted that there was a large tumor of the stomach, which was of lienitis plastica type, which involved mostly the distal stomach, but notably the lesser curvature of the stomach was also involved without lymphatic - type invasion, which made a subtotal gastrectomy impossible. The celiac access was noted to be quite firm, but there were no obvious liver mets. The patient tolerated the procedure well and was extubated in the Operating Room and taken to the Post Anesthesia Care Unit in stable condition. Notably the patient is a Jehovah's witness. She refused any sort of transfusion of blood products, therefore there was a concern of any sort of bleeding that the patient might encounter. Postoperatively her hematocrit was 29, which the patient was tolerating well with satisfactory O2 saturation and no other evidence of tachycardia or hypoxia. In the initial postoperative phase she was mildly volume depleted for which she was hydrated resulting in good urine output. Blood draws were minimized in the postoperative period in order to avoid over phlebotomizing the patient. 1. Neurologically: Her pain was initially controlled with an epidural, which was subsequently discontinued and she was switched over to intravenous pain medications followed by po pain medications without any sort of difficulty. She did notably experience some mental status changes, which seemed to resolve after treatment for urinary tract infection she had postoperatively and also reduction in the patient's narcotics. 2. Respiratory: The patient had persistent O2 requirement several days after surgery. The chest x-ray revealed bilateral pleural effusions, but it was deemed that thoracentesis would not be indicated in her case. Therefore she was diuresed somewhat with the subsequent improvement in her respiratory function. At the time of discharge she did have moderate bilateral pleural effusions, but was satting in the mid 90% on room air. 3. Cardiac: The patient did develop some postoperative atrial fibrillation with rates as high in the 150s. She was ruled for myocardial infarction with the serial cardiac enzymes. Her postoperative atrial fibrillation initially did not respond to intravenous Lopressor and did require Cardizem drips for which the patient was placed in the Intensive Care Unit. These episodes had resolved two to three days prior to discharge at which time the patient remained in sinus rhythm and was placed on po Cardizem and Amiodarone. She did also require Amiodarone in the Intensive Care Unit. 4. Gastrointestinal: The patient actually did well. Her upper gastrointestinal study on postoperative day six evidenced no leak or stricture. 5. Nutrition: The patient was on her goal tube feeds of ProMod 3/4 strength at 80 an hour during the last several days prior to discharge. In addition to this she was being given post gastrectomy diet, which she was tolerating without any nausea or vomiting. She had received a vitamin B-12 shot and was receiving supplemental iron. 6. Renal function: Her BUN and creatinine were fairly stable and were 35 and 1.0. At the time of the patient's discharge she was making good urine. She was diuresed as needed with Lasix secondary to volume shifts from the postoperative fluid that she had received in order to avoid any sort of volume overload. 7. Hematology: In order to stimulate the patient's erythropoietin she was started on Epogen 40,000 units three times per week. This was discontinued prior to discharge. 8. Infectious disease: The patient's only postoperative complication was a urinary tract infection, which was treated with Levofloxacin and discontinuation of the Foley. By postoperative day nine the patient had been afebrile and had remained in sinus rhythm for several days and otherwise with good blood pressures and had been making excellent urine and tolerating a post gastrectomy diet without difficulty. Therefore it was determined that she would be appropriate for discharge to rehabilitation facility. Physical therapy had seen the patient and cleared her for this. When the patient was discharged she was to continue her tube feeds of Promote with fiber at 3/4 strength at 80 cc an hour to meet her caloric needs and this would be in addition to the post gastrectomy diet, which she could take. Otherwise the patient will need q monthly vitamin B-12 shots and also supplementation of iron. DISCHARGE MEDICATIONS: 1. Iron sulfate liquid. 2. Sinemet 25/100 take one tab po t.i.d. 3. _______________ 5 mg take one tablet po b.i.d. 4. Lescol 40 mg po q.d. 5. Avandamet 4/500 one tablet po q.d. 6. Amiodarone 400 mg po b.i.d. 7. Lopressor 50 mg po b.i.d. 8. Diltiazem 30 mg po q.i.d. DISCHARGE STATUS: The patient was discharged to rehab in good condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern1) 13262**] MEDQUIST36 D: [**2139-12-24**] 10:00 T: [**2139-12-24**] 10:09 JOB#: [**Job Number 109049**]

[ "276.5", "427.31", "997.5", "428.0", "599.0", "196.2", "151.8", "997.1", "197.6" ]

icd9cm

[ [ [] ] ]

[ "43.99", "96.6", "46.39" ]

icd9pcs

[ [ [] ] ]

348, 2291

6961, 7591

2309, 6938

107, 327

51,555

100,922

52352

Discharge summary

report

Admission Date: [**2189-9-13**] Discharge Date: [**2189-10-8**] Date of Birth: [**2144-11-9**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Zomig Attending:[**First Name3 (LF) 11040**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Arterial Line Mechanical Ventilation PICC placement History of Present Illness: 44yo autoimmune hepatitis and transplant presented for AMS at [**Hospital1 **] senior healthcare at [**Location (un) **]. Finger stick was 50 so got D50, was combative and screaming in ED so got 10mg haldol, tried NGT and desatted so decided to intubate for airway protection given degree of AMS. Then got lactulose by NGT, got CTX 2g, Vanc 1g. Nothing tapable on bedside U/S. CT abdomen no acute process, no significant ascites. Got head CT which was negative. Got limited portal doppler stud which was unchanged from prior w/ known portal vein thrombosis. No family present so far. . In the ED, initial vs were: T P 106 BP 90/54 R O2 sat 100% CMV TV 550, 14, PEEP 5 FiO2 100%. UOP 1400cc since foley placed which was around 9 hours ago. Past Medical History: - Autoimmune hepatitis, s/p orthotopic liver transplant in UAB in 2/98, known chronic rejection and now with recurrence, complicated by encephalopathy, portal vein thrombosis. - Chronic portal vein thrombosis - Chronic lymphedema, which developed after her liver transplant - Psorasis - Allergic rhinitis - Dysfunctional uterine bleeding s/p partial hysterectomy - s/p CCY - Depression - Adnexal masses noted on scan in [**12/2187**] - Antiphospholipid antibody - Staph epidermatis bactermia [**5-/2189**] Social History: - Lives with daughter and grandson - [**Name (NI) 1139**]: Denies - etOH: Rarely - Illicits: Denies Family History: - Several relatives with heart disease and DM - No history of auto-immune hepatitis or liver failure Physical Exam: General: Jaundiced woman, in restraints. Moves all extremities spontaneously but does not follow commands. Does not open eyes to command. HEENT: Scleral icterus, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, 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: foley present with dark urine Ext: 3+ total body anasarca Pertinent Results: Admission labs: [**2189-9-13**] 02:42PM TYPE-ART TEMP-37.8 TIDAL VOL-528 PEEP-5 O2-40 PO2-166* PCO2-29* PH-7.34* TOTAL CO2-16* BASE XS--8 INTUBATED-INTUBATED [**2189-9-13**] 02:42PM LACTATE-2.4* [**2189-9-13**] 02:42PM freeCa-1.09* [**2189-9-13**] 02:22PM URINE HOURS-RANDOM [**2189-9-13**] 09:55AM TYPE-ART TEMP-36.4 TIDAL VOL-610 PEEP-5 O2-40 PO2-136* PCO2-28* PH-7.33* TOTAL CO2-15* BASE XS--9 -ASSIST/CON INTUBATED-INTUBATED [**2189-9-13**] 09:55AM freeCa-1.09* [**2189-9-13**] 05:17AM freeCa-1.00* [**2189-9-13**] 03:52AM CALCIUM-7.1* PHOSPHATE-3.8 MAGNESIUM-1.5* [**2189-9-13**] 03:52AM WBC-12.7* RBC-3.11* HGB-10.4* HCT-32.0* MCV-103* MCH-33.5* MCHC-32.6 RDW-17.2* [**2189-9-12**] 05:33PM LACTATE-3.3* [**2189-9-12**] 04:33PM URINE BLOOD-SM NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2189-9-12**] 03:47PM LACTATE-5.5* [**2189-9-12**] 03:42PM ALT(SGPT)-44* AST(SGOT)-81* TOT BILI-6.3* [**2189-9-12**] 03:42PM AMMONIA-155* [**2189-9-12**] 03:42PM NEUTS-85.9* LYMPHS-7.4* MONOS-5.9 EOS-0.3 BASOS-0.6 [**2189-9-12**] 03:42PM PT-19.7* PTT-41.4* INR(PT)-1.8* MICRO (Many other studies other than those listed below were negative) -[**9-12**] UCx: ESCHERICHIA COLI. >100,000 ORGANISMS/ML. ESBL. SENSITIVE TO Tigecycline <=1MCG/ML. RESISTANT TO MEROPENEM <=1MCG/ML. RESISTANT TO IMIPENEM <=1MCG/ML. | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- R MEROPENEM------------- R NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- =>128 R TETRACYCLINE---------- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R -[**9-13**] UCx: GRAM NEGATIVE ROD(S). ~4000/ML -[**9-20**] Mycolytic BCx: BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. -[**9-28**] BAL: GRAM STAIN: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE: Commensal Respiratory Flora Absent. YEAST 100/ML. LEGIONELLA CULTURE (Final [**2189-10-5**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. OF TWO COLONIAL MORPHOLOGIES. ACID FAST SMEAR (Final [**2189-9-29**]): NO AFB SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. -[**9-28**] Rapid Viral Screen/Culture: No respiratory viruses isolated. No Cytomegalovirus (CMV) isolated. +HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY -[**9-30**] UCx: YEAST >100,000 ORGANISMS/ML -[**10-5**] BCx: GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. GRAM NEGATIVE ROD(S) | AMIKACIN-------------- S AMPICILLIN------------ R AMPICILLIN/SULBACTAM-- R CIPROFLOXACIN--------- R GENTAMICIN------------ R PIPERACILLIN/TAZO----- R TOBRAMYCIN------------ R -[**10-5**] BAL: GRAM STAIN (Final [**2189-10-5**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): BUDDING YEAST. MODIFIED ACID-FAST STAIN FOR NOCARDIA: Test cancelled by laboratory due to lack of branching gram positive rods in the gram stain. RESPIRATORY CULTURE (Preliminary): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. YEAST. ~ ~3000/ML. ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- PND CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM------------- PND TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2189-10-6**]): Test cancelled by laboratory. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2189-10-6**]): NO AFB SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NOCARDIA CULTURE (Preliminary): VIRAL CULTURE (Preliminary): No Virus isolated so far STUDIES: -[**9-12**] ECG: Baseline artifact. Sinus tachycardia. Early precordial R wave progression. Compared to the previous tracing of [**2189-8-27**] the sinus rate is much faster. The other findings are similar. -[**9-12**] CXR: No gross pulmonary process noted. If clinically feasible, consider repeat study once patient is able to tolerate the procedure. -[**9-12**] CT Abd/Pelvis: 1. No acute intra-abdominal or pelvic process to explain the patient's symptoms. 2. Status post orthotopic liver transplant with diffuse anasarca. Known portal vein thrombus is not well evaluated on the current study. 3. Trace pleural effusions and minimal atelectasis. 4. Unchanged 8 mm left renal stone. -[**9-12**] CT Head 1. Stable appearance of the brain without evidence of an acute intracranial abnormality. 2. The partially imaged orogastric tube appears to make a loop in the nasopharynx. -[**9-12**] Abdominal U/S: Limited study as above with persistent main portal vein thrombosis and no evidence of intrahepatic portal vein flow, similar to [**2189-8-27**]. -[**9-21**] Renal U/S: 8-mm left renal calculus within the lower pole, unchanged from CT scan of [**2189-9-12**]. No evidence of hydronephrosis or obstruction. -[**9-23**] CT Chest/Abd/Pelvis: 1. Bilateral, multifocal consolidative airspace opacities. These have progressed compared to recent chest radiographs, and are new compared to [**2189-9-12**] CT of the abdomen and pelvis (when the lung bases were imaged). This most likely represents multifocal pneumonia. Aspiration and a component of pulmonary edema could also be considered. Clinical correlation is advised. 2. Malpositioned left upper extremity PICC, with tip extending into the right ventricle. This should be withdrawn for optimal positioning. 3. Findings compatible with anemia. 4. Large pulmonary artery compatible with pulmonary hypertension. 5. Status post liver transplantation. There is small ascites and diffuse anasarca, a distended IVC, and mild cardiomegaly, all compatible with fluid overload. 6. 11-mm non-obstructing left renal stone. 7. No retroperitoneal hematoma or other source of blood loss, as questioned. -[**9-23**] CT Head: 1. Study limited by motion shows no large intracranial hemorrhage or other obvious acute intracranial abnormality. 2. Persistent catheter fragment seen to course from one side of nasal cavity to the other on prior CT of [**2189-9-12**]; clinical correlation recommended. -[**9-26**] RUQ U/S: Limited evaluation with the main portal vein again not visualized. However, flow appears present in the left hepatic vein and left hepatic artery. Abdominal ascites. -[**9-27**] Abd X-ray: No evidence for obstruction; NG tube in place. Brief Hospital Course: The patient was initially admitted to MICU [**Location (un) **] for severe encephalopathy requiring intubation in the ED for airway protection. She was treated for hepatic encephalopathy, with lactulose and rifaximin. Initial cultures revealed carbapenemase-resistant E.coli, for which she was initially treated with nitrofurantoin and amikacin. Nitrofurantoin was subsequently discontinued. Per ID recommendations, antibiotics were changed to colistin, then ultimately to tetracycline. She was weaned off of the ventilator and was transferred to the internal medicine service on [**9-16**]. Her lactulose dose was increased. Her renal function worsened, which was believed likely due to nephrotoxic medications. She was also started on octreotride, midodrine and albumin for hepatorenal syndrome. Se was transferred back to MICU Green on [**9-19**] for worsening encephalopathy and labs consistent with low-grade DIC, including a ten point hematocrit drop, thrombocytopenia, worsening coagulation studies, and indirect hyperbilirubinemia. Hematology was consulted and agreed with diagnosis of DIC. Over the subsequent days, the patient required large amounts of blood products, including red blood cells, platelets, cryoprecipitate, and fresh frozen plasma. Despite these measures, she still had large amounts of bloody output from her rectal tube; she was felt too unstable to undergo any GI procedures, and was treated with further blood transfusions. Her significant hypernatremia and hypercalcemia improved to some degree during her stay in the MICU. The patient's mental status did not improve, and she was reintubated for hypoxic respiratory failure, which was partially due to a new pneumonia. Her mental status was sufficiently poor that she only required intermittent sedation for her endotracheal tube. She had high residuals through her OG tube, and tube feeds frequently had to be held. She had frequent bloody secretions from her endotracheal tube; bronchoscopy revealed diffuse oozing of blood throughout her bronchi. Multiple family meetings were held, including a meeting with the patient's primary hepatologist, who confirmed that the patient was not a candidate for retransplantation. As the patient's liver disease was believed to be a central factor in her deteriorating condition, measures were transitioned towards making the patient comfortable and prolonging her life only long enough for her family members to be able to say goodbye. She passed away peacefully with her family at her side. Medications on Admission: Lactulose 30cc tid Atovaquone 750 mg/5 mL 10cc daily Citalopram 20 mg daily Montelukast 10 mg daily Mycophenolate Mofetil 500 mg [**Hospital1 **] Omeprazole 20 mg daily Rifaximin 550 mg [**Hospital1 **] Spironolactone 50mg daily Prednisone 10 mg daily Sucralfate 1 gram QID Tacrolimus 0.5 mg daily Torsemide 15 mg daily Calcium 600 with Vitamin D3 600 mg(1,500mg)-400 unit twice a day. Ursodiol 600 mg daily Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Primary: Disseminated intravascular coagulation Hepatic encephalopathy Fulminant hepatic failure Urinary tract infection Hypernatremia Hypercalcemia Secondary: Autoimmune hepatitis, s/p orthotopic liver transplant in [**2176**] Chronic portal vein thrombosis Chronic lymphedema, which developed after her liver transplant Psorasis Allergic rhinitis Dysfunctional uterine bleeding s/p partial hysterectomy s/p cholecystectomy Depression Adnexal masses noted on scan in [**12/2187**] Antiphospholipid antibody Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12839, 12848

9830, 12347

305, 358

13400, 13410

2469, 2469

13467, 13478

1793, 1895

12806, 12816

12869, 13379

12373, 12783

13434, 13444

1910, 2450

6997, 9265

6859, 6961

6073, 6826

244, 267

386, 1130

9274, 9807

2485, 4484

1152, 1659

1675, 1777

12,290

153,111

28914

Discharge summary

report

Admission Date: [**2186-9-4**] Discharge Date: [**2186-9-13**] Date of Birth: [**2159-3-2**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: [**2186-9-4**] IVC venography [**2186-9-4**] Bladder repair; diverting colostomy [**2186-9-6**] ORIF sacral fracture; IVC filter History of Present Illness: 27 yo female s/p fall from 4 stories; transported to [**Hospital1 18**]. +EtOH Initial GCS 3; responsive to painful stimuli only. FAST exam positive and hemodynamically unstable requiring PRBC's; she was taken to the operating room for exploratory laparotomy. Past Medical History: Unknown Social History: +EtOH Family History: Noncontibutory Pertinent Results: [**2186-9-9**] 05:15AM BLOOD Hct-27.8* [**2186-9-7**] 09:36PM BLOOD Hct-26.4* [**2186-9-7**] 06:07AM BLOOD WBC-8.9 RBC-2.63* Hgb-8.6* Hct-24.1* MCV-92 MCH-32.7* MCHC-35.6* RDW-13.3 Plt Ct-246 [**2186-9-7**] 06:07AM BLOOD Plt Ct-246 [**2186-9-5**] 01:09AM BLOOD Fibrino-374# [**2186-9-7**] 06:07AM BLOOD Glucose-107* UreaN-7 Creat-0.6 Na-137 K-3.7 Cl-101 HCO3-28 AnGap-12 [**2186-9-6**] 08:25PM BLOOD Glucose-145* UreaN-8 Creat-0.6 Na-136 K-4.1 Cl-100 HCO3-26 AnGap-14 [**2186-9-7**] 06:07AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0 [**2186-9-6**] 08:25PM BLOOD Calcium-8.7 Phos-2.5* Mg-2.1 [**2186-9-4**] 11:55AM BLOOD Type-ART Temp-37.0 Rates-14/6 Tidal V-560 PEEP-5 FiO2-40 pO2-199* pCO2-37 pH-7.33* calTCO2-20* Base XS--5 -ASSIST/CON Intubat-INTUBATED [**2186-9-4**] 08:05AM BLOOD Glucose-129* [**2186-9-4**] 06:04AM BLOOD Hgb-10.1* calcHCT-30 [**2186-9-4**] 08:05AM BLOOD freeCa-1.17 . . [**2186-9-11**] VOIDING CYSTOGRAM - No masses or contrast extravasation was noted within the bladder. The urethra was unable to be evaluated secondary to lack of voiding function. . [**2186-9-6**] ABDOMEN (SUPINE ONLY) - Three intraoperative frontal radiographs of the abdomen were obtained during placement of IVC filter. I am uncertain of the exact level of placement. . [**2186-9-5**] ECG - Sinus rhythm. Non-specific inferior T wave changes. No previous tracing available for comparison. . [**2186-9-5**] CT LOW EXT W&W/[**Initials (NamePattern5) **] [**Last Name (NamePattern5) **] - 1. Comminuted fracture of the left calcaneus with intraarticular involvement. 2. Largely nondisplaced fracture of the right calcaneus. 3. Comminuted nondisplaced intraarticular fracture at the base of the right fourth metatarsal bone. . [**2186-9-5**] MR CERVICAL SPINE - No evidence of fracture or bone marrow edema. Normal alignment. Prevertebral fluid is present from C2 through C4-5. There is soft tissue edema posterior to the spinous processes of C2 through C5. Clinical correlation is recommended as this could represent, at the very least, a ligamentous sprain. . [**2186-9-5**] BILAT LOWER EXT VEINS - No deep venous thrombus. . [**2186-9-4**] TIB/FIB (AP & LAT) [**Last Name (un) **] - 1. Comminuted fracture of the left calcaneus with extension into the subtalar joint and flattening of the calcaneal contour. 2. Right lateral malleolar soft tissue swelling with no evidence of fracture. 3. Right 4th metatarsal fracture is not well evaluated on the current study. Evaluation of the spine is recommended given the appearance of the calcaneal fracture. . [**2186-9-4**] CT PELVIS W/CONTRAST - 1. Pelvic fractures involving both sides of the sacrum, the anterior column of the left acetabulum and the left inferior pubic ramus. Slight asymmetry of the pubic symphysis. No definite foci of active contrast extravasation are identified. 2. Extraluminal air seen just superior to the bladder, just deep to the rectus abdominis muscles. A bladder injury could be considered. Alternatively, bowel/mesenteric injury cannot be entirely excluded. 3. Wedge/linear hypodensity of the right mid kidney, possibly indicating a laceration. 4. Free fluid throughout the abdomen and pelvisas described. 5. Shock bowel. 6. Right L5 transverse process fracture. . [**2186-9-4**] CT HEAD W/O CONTRAST - No evidence of acute intracranial hemorrhage. . [**2186-9-4**] CT C-SPINE W/O CONTRAST: No cervical spine fracture or malalignment. Brief Hospital Course: Patient admitted to the Trauma service. Her forehead laceration was closed. She was immediatley taken to the operating room because of her extensive pelvic injuries for exploratory laparotomy; repair of bladder perforation and a diverting loop colostomy was performed. Posteoperatively she did well. The Wound/Ostomy nurse has followed patient closely during her hospital stay. On HD# 8 she underwent a voiding cystogram, no extavasation was noted in the bladder. Her foley catheter was discontinued but she failed to void; subsequently the cathter was replaced. Another voiding trial should be attempted in 7 days. She was taken to the operating room on [**9-6**] by Orthopedics for repair of her pelvic and calcaneal fractures. An IVC filter was placed as well because of her extensive fractures and increased risk of thrombus. Psychiatry was consulted because of concerns regarding possible suicidal ideation surrounding her fall; there were concerns that the fall may have been intentional. Her evaluation revealed that she was not suicidal. Social work was also closely involved in patient's care. Her pain is being controlled with long acting narcotics. She is on a bowel regimen. Her ostomy output has been adequate. She is tolerating a regular diet. Physical and Occupational therapy were also consulted and have recommended short term rehab stay. Discharge Medications: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 2. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for breakthrough pain. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 5. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day as needed for constipation. 6. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to open left foot blisters. [**Month (only) 116**] discontinue when completely healed. 7. Milk of Magnesia 800 mg/5 mL Suspension Sig: Five (5) ML's PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: s/p Fall Pelvic fracture Bladder Injury Comminuted fractures of left calcaneous, right 4th metatarsal bone & base of left 4th metatarsal Discharge Condition: Stable Discharge Instructions: Do not bear any weight on either lower extremity. Continue with Lovenox injections until instructed otherwise by Orthopedics. Followup Instructions: Follow up with Orthopedics in 2 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up in Trauma Clinic with Dr. [**Last Name (STitle) **], in 2 weeks, call [**Telephone/Fax (1) 6429**] for an appointment. Inform the office that you will need a barium enema study; rectum to colostomy; on the same day prior to this appointment. Completed by:[**2186-9-13**]

[ "808.2", "805.6", "868.03", "808.0", "785.50", "825.0", "805.4", "873.42", "867.0", "E884.9" ]

icd9cm

[ [ [] ] ]

[ "46.03", "86.59", "79.07", "38.7", "96.04", "54.11", "96.71", "57.81", "03.53" ]

icd9pcs

[ [ [] ] ]

6516, 6586

4275, 5637

278, 409

6767, 6776

803, 4252

6951, 7328

768, 784

5660, 6493

6607, 6746

6800, 6928

230, 240

437, 698

720, 729

745, 752

32,127

153,242

33451

Discharge summary

report

Admission Date: [**2117-4-7**] Discharge Date: [**2117-4-11**] Date of Birth: [**2052-5-8**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: asymptomatic Major Surgical or Invasive Procedure: CABG X 3 (LIMA > LAD, SVG>Diag, SVG> OM) on [**2117-4-7**] History of Present Illness: + ETT, referred to cath which revealed 3vCAD, Ef 50% Past Medical History: DM CAD Nephrolithiasis GERD Vasculitis s/p femoral artery repair Social History: no tobacco rare ETOH married, lives w/wife retired engineer Family History: non-contributory Physical Exam: unremarkable pre-op Pertinent Results: [**2117-4-8**] 03:35AM BLOOD WBC-9.5 RBC-3.06* Hgb-9.6* Hct-28.0* MCV-92 MCH-31.5 MCHC-34.3 RDW-14.3 Plt Ct-84* [**2117-4-7**] 01:52PM BLOOD PT-17.3* PTT-42.3* INR(PT)-1.6* [**2117-4-8**] 03:35AM BLOOD Glucose-119* UreaN-10 Creat-0.7 Na-137 K-4.4 Cl-109* HCO3-24 AnGap-8 [**2117-4-7**] 09:43PM BLOOD Type-ART pO2-162* pCO2-31* pH-7.47* calTCO2-23 Base XS-0 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77592**] (Complete) Done [**2117-4-7**] at 10:18:14 AM 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: [**2052-5-8**] Age (years): 64 M Hgt (in): 70 BP (mm Hg): 156/74 Wgt (lb): 161 HR (bpm): 70 BSA (m2): 1.91 m2 Indication: intraop CABG evaluate valves, ventricles, aortic contours ICD-9 Codes: 440.0, 424.0 Test Information Date/Time: [**2117-4-7**] at 10:18 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) 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 #: 2008AW4-: Machine: aw 4 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.4 m/s Left Atrium - Peak Pulm Vein D: 0.3 m/s Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 4.3 cm Left Ventricle - Fractional Shortening: *0.17 >= 0.29 Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Left Ventricle - Peak Resting LVOT gradient: 1 mm Hg <= 10 mm Hg Aorta - Annulus: 2.4 cm <= 3.0 cm Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 0.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 2 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 1 mm Hg Aortic Valve - Valve Area: *2.9 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 0.4 m/sec Mitral Valve - Pressure Half Time: 54 ms Mitral Valve - MVA (P [**12-9**] T): 4.1 cm2 Mitral Valve - E Wave: 0.4 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A ratio: 1.33 Mitral Valve - E Wave deceleration time: 140 ms 140-250 ms Findings LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. 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. Normal ascending aorta diameter. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Mild to moderate ([**12-9**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Conclusions Pre Bypass: The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-9**]+) mitral regurgitation is seen. Post Bypass: Pt initially av paced, later a paced on no drips. Preserved biventricular function LVEF 55%. MR is now trace- mild. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2117-4-7**] 13:19 Brief Hospital Course: Admitted to [**Hospital1 18**] on [**2117-4-7**], taken to the OR, and underwent CABG X 3 (LIMA>LAD, SVG>Diag, SVG>OM). PLease see operative report for details of procedure. POD # 1 extubated. POD #2 CT and foley DC'd, transfered to the floor. POD # 3 Pacing wires DC'd. PT consult. POD # 4 home with PT. CXR on DC stable without acute process. Medications on Admission: [**Last Name (un) 1724**]: asa 325', norvasc 2.5', lisinopril 5', metoprolol 50qAM, 25qPM, lipitor 80', plavix 75', metformin 1000'', lantus 36qHS, humulin ss, arava 20', prednisone 5', flexeril 5''', gabapentin 100''', lidoderm patch 5%, prilosec 20', trazadone 50', centrum, fish oil Discharge Medications: 1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 12. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO daily (). Disp:*60 Tablet(s)* Refills:*2* 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 14. Insulin Glargine 100 unit/mL Solution Sig: Thirty Four (34) units Subcutaneous once a day. Disp:*3 vials* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: CAD DM-2 GERD vasculitis nephrolithiasis Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no driving for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks Followup Instructions: with Dr. [**First Name (STitle) **] in [**1-10**] weeks with Dr. [**Last Name (STitle) **] in [**3-13**] weeks with Dr. [**Last Name (STitle) 656**] Completed by:[**2117-4-11**]

[ "530.81", "V13.01", "414.01", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8188, 8247

5803, 6150

332, 393

8332, 8339

729, 5780

8535, 8715

656, 674

6486, 8165

8268, 8311

6176, 6463

8363, 8512

689, 710

280, 294

421, 475

497, 563

579, 640

3,954

157,532

29813

Discharge summary

report

Admission Date: [**2120-12-17**] Discharge Date: [**2120-12-28**] Date of Birth: [**2076-5-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Shortness of breath. Reason for transfer: Atrial fibrillation, cardiomyopathy. Major Surgical or Invasive Procedure: Cardioversion [**2120-12-27**], [**2120-12-22**], [**2120-12-19**] History of Present Illness: This is a 44 year old gentleman with no known medical history who presented on Monday to an OSH with onset of dyspnea. The patient reports that he had a symptoms of a cold characterized by congestion and cough for approximately a week and a half. He saw his PCP one week ago and was prescribed a course of oral steroids. His symptoms improved over the next few days. Last Saturday, [**12-14**] (3 days ago), the patient reported sudden onset of dyspnea. Simple tasks such as getting up from the chair or climbing up stairs resulted in him becoming short of breath. He notes no chest pain or palpitations. For the past week he has noticed waking up from sleep suddenly and requires 3 pillows to lie down comfortably. No wheezing, no recent fevers. . He went to the OSH as his dyspnea had persisted for three days. There, he was found to be in atrial fibrillation with RVR, HR from 140-165. BP 148/88, RR 26 O2 96 on 2L. The patient was admitted to the ICU unit and started on a diltiazem drip. Heparin gtt was also started. The patient underwent an [**Month/Year (2) 113**] which revealed severe, unexplained cardiomyopathy with an EF of 20-25% and 4+MR. The patient was started on lisinopril and underwent diuresis with 20 IV lasix, fluid balance -1350 over the hospital stay with improvement in dyspnea. . Pt also admitted to drinking 6 beers the day prior to admission, denied history of alcohol abuse. He was placed on a CIWA scale. . Rate control remained difficult despite diltiazem drip at 15 mg/hr and initiation of metoprolol. SBP remained stable as did respiratory function. He was transferred here for further management. . Past Medical History: 1) Status post cholecystectomy 2) Status post tonsillectomy Social History: Works in packaging. Married with two children. Drink -2 beers on occasion, denies that he drinks frequently. Did drink six beers while watching football game 2 d PTA. No tobacco or illicit drug use. Family History: Grandmother with heart problems. Uncle with CABG. No known history of CHF, arrhythmias or sudden death. Mother alive and well. Medical history of father unknown. Physical Exam: T 97.8 P 105-150 BP 106/70 RR 16 O2 96 on 2L Gen: WD/WN male Caucasian in NAD. Head: NCAT Mouth: MMM Neck: Obese, JVP to 4-5 cm Chest: CTA b/l Cor: Tachycardic irregular, no murmur Abd: Obese Rectal: Guaiac negative Ext: No edema, nl distal pulses. Pertinent Results: OSH laboratories on [**2119-12-18**]: Na 134, K 3.7, Cl 107, BUN 10, Cr 1.1 Gluc 134 . WBC 11.2, Hct 43.9, Plts, 244 PTT 109 . CK 315, MB 4.5 Trop 0.02 . TSH 1.02 T4 11.2 . see below for rest . CXR: "pulm congestion" per radiology read. . EKG: Atrial fibrillation with ventricular rate in 120's. No ischemic changes. . Echocardiogram: per discharge summary at OSH: "mildly dilated LV, severely decreased LV function with EF estimated at 20-25%, moderate dilation of L atrium. Mild RV and RA enlargement. Moderate to severe MR, mild to moderate TR. . TEE: Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%) INTERPRETATION: . Findings: LEFT ATRIUM: Mild LA enlargement. Mild spontaneous [**Date Range 113**] contrast in the body of the LA. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Mild spontaneous [**Last Name (Prefixes) 113**] contrast in the LAA. Depressed LAA emptying velocity (<0.2m/s) . RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No mass or thrombus in the RA or RAA. No ASD by 2D or color Doppler. . LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Moderately depressed LVEF. . RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis. . AORTA: No atheroma in aortic arch. No atheroma in descending aorta. . AORTIC VALVE: Normal aortic valve leaflets (3). No AR. . MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. . TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. . PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. . PERICARDIUM: No pericardial effusion. . [**2119-12-19**] TTE The rhythm is very irregular Afib. The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is probably mildly depressed (LVEF 40-45%) but difficult to [**Month/Day/Year 11197**] with very irregular AF. There is no ventricular septal defect. Right ventricular systolic function is normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [**2119-12-20**] TEE Conclusions: The left atrium is mildly dilated. Mild spontaneous [**Month/Day/Year 113**] contrast is seen in the body of the left atrium and left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed. Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No left atrial or left atrial appendage thrombus identified. . [**2120-12-21**] CXR: Lungs clear. . [**Month/Day/Year **] Study Date of [**2120-12-21**] (prelim): EF 35-40% with no significant change from prior [**Date Range 113**] except now in NSR. (n.b. the [**Date Range 113**] performed just after cardioversion) . EKG on discharge Sinus rhythm Left atrial abnormality Nonspecific T wave abnormalities Since previous tracing of [**2120-12-27**], no significant change . Coagulation studies on discharge PT-21.9* PTT-31.3 INR(PT)-2.1* Brief Hospital Course: This 44 year old gentleman with no significant past medical history was admitted to an OSH for dyspnea where he was found to be in atrial fibrillation with rapid ventricular response and to have severe cardiomyopathy with an EF of 25% of unclear cause. He was transferred for further management of his AF with RVR which was proving to be refractory to standard treatments. On admission, his rates remained in the 120 to 140 range despite aggressive attempts at rate control with diltiazem and metoprolol. His blood pressure were in the low normal (85-95)range through this time. Heparin was maintained for anticoagulation. . Also of note, the patient had some signs of volume overload (JVD, pulm congestion). He was not in respiratory distress and received a one time dose of lasix to which he had a good diuresis response. He remained essentially euvolemic thereafter. Lisinopril was maintained. . Given the lack of success in rate control of the AF with RVR, it was decided to attempt cardioversion on HD 3. A TEE performed before the cardioversion showed no evidence of intracardiac thrombus, it also confirmed the low EF. Cardioversion that day was not successful. On the advice of the Electrophysiology Service, amiodarone was added to his regimen of metoprolol and diltiazem. His rates were somewhat improved but still remained above 100. The amiodarone dose was therefore increased on HD 4. At this time the patient became hypotensive to the 70's and was transferred to the coronary intensive care unit. Cardioversion was attempted twice more on HD 5 while the patient was in the unit and his rhythm converted to sinus. He was transferred back to the step down unit. . On HD 7 the patient was found to have returned to AF with RVR. Digoxin was loaded and toprol and diltiazem were uptitrated with consultation of the EP service. His LFT's were noted to trend up necessitating discontinuation of amiodarone. Verapamil replaced diltiazem. Rate control improved somewhat with rates ranging from 80-120. Bridge to coumadin was begun His LFT's were noted to trend up necessitating discontinuation of amiodarone. It was decided to attempt cardioversion again on HD 11 with commencement of sotalol. Cardioversion successfully resulted in sinus rhythm; sotalol was started soon thereafter the patient remained in sinus with normal heart rate for the next 36 hours. No significant qT prolongation occurred. He was by this time therapeutic on coumadin. He was discharged on HD 12 with instructions to wear [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart monitor arrange for cardiac MR studies and repeat echocardiogram and to follow up with EP service within one month. . In summary, this is a 44 year old gentleman with no known medical history who presented with atrial fibrillation with RVR refractory to standard treatments and with cardiomyopathy with an EF of 25-40%. His atrial fibrillation proved difficult to rate control despite several attempts at electrial and chemical cardioversions and frequent adjustments in rate controlling agents. He finally converted to sinus on the fourth cardioversion attempt and by discharge remained in sinus rhythm on sotalol. He was hemodynamically stable and euvolemic on discharge on throughout most of his stay. His respiratory status remained stable throughout his stay . Issues and plan from this hospitalization: . 1) Atrial fibrillation with rapid ventricular response. . 1) Atrial fibrillation, rate poorly controlled, cardioversion unsuccessful -continuing metoprolol 100 TID, verapamil 80 three times a day--verapamil appeared to be superior to diltiazem for rate control -continuing sotalol -discharged with [**Doctor Last Name **] of hearts monitor to monitor for qT prolongation or relapse into -anticoagulated with warfarin, will need outpt follow up to monitor INR -cardiac MR [**First Name (Titles) **] [**Last Name (Titles) 11197**] for possible ablation procedure . 2) CHF. Remains idiopathic. EF 20-25% at OSH, 40-45% here (difficult to [**Last Name (Titles) 11197**] secondary to tachycardia). Differential remains tachycardia related, viral, or ischemia related. -will get repeat echocardiogram, if EF nl while in sinus, suggests depressed EF was secondary to tachycardia. -if EF depressed while in sinus, will need evaluation for other possible causes such as ischemic. Of note pt had no symptoms or signs of ischemic disease. -Resp status remained stable. Some signs of volume overload on admission and pt diuresed 2 L to 20 IV lasix on [**12-18**]--was euvolemic thereafter. -continuing on lisinopril . 3) Question alcohol abuse, there were no sign of d.t.'s at this point other than tachycardia. -PRN valium for CIWA greater than 10 was neer required . 4) Transaminitis, appears secondary to amiodarone. Hepatitis screen negative -will need follow up as outpt to check LFT's -needs reimmunization for hepatitis B . Prophylaxis consisted of heparin/warfarin. . Access maintained with peripheral IVs . FEN: Low sodium heart healthy diet . Code status remains full. Medications on Admission: Medications at home: None standing. . Medications on transfer: Lopressor 100 TID Esmolol gtt Heparin gtt/Coumadin 5 ASA 325 Protonix Diazepam for CIWA Thiamine Folate . NKDA Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*60 Tablet, Chewable(s)* Refills:*2* 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO twice a day. Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 6. Verapamil 80 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 7. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation with rapid ventricular response Congestive heart failure, EF 35-40% Elevated LFTs on amiodarone. Discharge Condition: Good. Heart rate now normal (70-79 bpm), rhythm is sinus. Blood pressure normal (systolic range 100-110. Breathing normally on room air. No signs of volume overload. Chest pain free. Discharge Instructions: Please return to the hospital if you develop shortness of breath, palpitations, lightheadedness or dizziness. . Please follow up for you cardiac MR [**Name13 (STitle) **] will need to have your INR checked on Monday with your primary care physician. [**Name10 (NameIs) 357**] also have your liver enzymes checked at this time. Followup Instructions: Please return for your follow up with Dr. [**Last Name (STitle) **] detailed below. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Pager number **] Date/Time:[**2121-2-5**] 3:40. You will need to have a cardiac MRI. The necessary paperwork provided to you prior to your cardiac MRI has been faxed to their facility. Please call [**Telephone/Fax (1) 327**] for an appointment. This can be arranged for any time in approximately two weeks. Please also arrange for an echocardiogram,prior to your appointment with Dr. [**Last Name (STitle) **] the appointment below has been made. You should call to see if an appointment around the time of your cardiac MR can be made. Provider: [**Name10 (NameIs) **] LAB TESTING Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2121-2-5**] 2:00

[ "359.89", "428.0", "570", "790.6", "427.31", "429.0", "280.0", "425.4" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.61" ]

icd9pcs

[ [ [] ] ]

12970, 12976

6775, 11863

399, 467

13136, 13324

2896, 6752

13700, 14521

2448, 2611

12088, 12947

12997, 13115

11889, 11889

13348, 13677

11910, 11927

2626, 2877

278, 361

495, 2132

11952, 12065

2154, 2216

2232, 2432

9,515

147,040

11247

Discharge summary

report

Admission Date: [**2183-8-22**] Discharge Date: [**2183-9-8**] Date of Birth: [**2137-5-2**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: This is a first [**Hospital1 346**] admission for this, otherwise, healthy 46-year-old white male with a history of having fallen from a ladder while pruning a tree earlier in the day. He fell approximately 15 feet. There was no loss of consciousness, headache, or blurred vision. He is unsure of the side he fell onto, but, he developed severe pain upon landing. He noted the pain primarily in the back and felt he could not get up. He denied pain or weakness at that time. He was taken to [**Hospital 1725**] Hospital, where x-ray and CT of the spine showed a burst fracture of L4 with encroachment of the spinal canal. He was given a bolus of methylprednisolone and started on infusion of methylprednisolone. He was then transferred to the [**Hospital1 69**] for further evaluation and management. PREVIOUS MEDICAL HISTORY: There was a history of bladder cancer status post two prior surgeries, the last being four months' prior to admission. ALLERGIES: The patient has no known allergies to medications. MEDICATIONS: He takes no current medications. PREVIOUS SURGICAL HISTORY: History included the two prior bladder surgeries, which were believed to be both cystoscopies, although the patient could not provide records of this. SOCIAL HISTORY: The patient drinks approximately twelve alcoholic beverages per week and smokes one pack per day times 32 years. PHYSICAL EXAMINATION: On physical examination the vital signs were as follows: Temperature 100.3 Blood pressure 124/63. Heart rate 98. Respiratory rate 18. Oxygen saturation 96%. When seen in the emergency room, the patient was slightly sedated from medication, but easily arousable. He was oriented times three. [**Location (un) 2611**] Coma Scale was 15/15. HEAD: Head was atraumatic, normocephalic. Pupils were 3-mm bilaterally and reactive to 2-mm to light and accommodation. Conjunctivae showed no pallor or icterus. Extraocular movements were intact. NECK: There was a cervical collar. CHEST: Chest was clear to auscultation. CARDIAC: Cardiac reveals S1 and S2 normal sinus rhythm. ABDOMEN: Abdomen was obese, nontender, bowel sounds present in all four quadrants. EXTREMITIES: Extremities: The left foot was bandaged due to pain. There were bilateral pulses present and no edema. NEUROLOGICAL: The pupils were 3-mm to 2-mm reactive. Extraocular movements full. Facial and sensory nerves were intact. The tongue was central with lateral movements normal. The uvula was not visualized secondary to collar. Trapezius muscle was normal strength. The upper extremity strength in all muscle groups was bilaterally equal. However, lower extremity strength showed mild weakness proximally with inconsistent examination due to severe pain in the distal lower extremities. Plantar response was downgoing bilaterally. Sensory examination was normal to prick bilaterally. Rectal tone was normal. Bulbocavernosus reflex was positive. There was no pronator drift. Review of the CT scan from the outside hospital confirmed a burst fracture of L1 with approximate 40-50% encroachment into the spinal canal in the area of L1. Due to the clinical findings, the patient was admitted to the hospital. Arrangements were made for further studies, including a CT dedicated to thoracolumbar junction of T11 through L3 with sagittal reconstructions and an MRI of the lumbar spine with axial through L1 and inversion recovery sequence. The patient was continued on Solu-Medrol for a full twenty-four hour protocol. He was maintained on flat bed rest with log rolling and maintained in a cervical collar until the neck was cleared and the cervical collar was subsequently removed on the [**4-23**]. The patient had a relatively benign hospitalization until on the [**4-1**], after all studies were assessed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1327**]. The patient was taken to the operating room on the [**4-1**], where under general endotracheal anesthetic the patient underwent a retroperitoneal approach to L1 with a resection of the fractures of the body of L1 and insertion of a titanium cage in place of L1 with a lateral mass fusion from T12 to L2. The patient tolerated the procedure well. The patient went to the recovery room stable. POSTOPERATIVE COURSE: The patient had a gradually decreasing hematocrit over the first two to three postoperative days. The patient subsequently received a transfusion of two units of packed red blood cells on the [**4-5**] for a hematocrit of 22, which returned to a hematocrit of 28 after the transfusions and remained stable and gradually increasing, thereafter. He also had an elevated white blood cell count with a fever and septic workup, essentially negative. He was seen in consultation by the Hematology Service for both of these. It was feeling of the Hematology Service, after consultation, that these primarily due to stress response from injury and surgery. The remainder of the patient's postoperative hospitalization was essentially unremarkable. He was followed throughout the postoperative hospitalization by the Physiotherapy Service. He was given a TLSO brace and was only allowed out of bed when the brace was on, but, he was noted to be ambulating and doing reasonably well. Postoperatively, he was subsequently discharged to the Acute Rehabilitation Facility for further aggressive physiotherapy on a postoperative basis. He was discharged on the [**2183-9-8**] to the [**Hospital3 12564**] Hospitalization. RECOMMENDATIONS: Recommendations were for the patient to have every-other-day CBC to evaluate the continuing correction of the white blood cell count and the hematocrit. He was discharged on Percocet 1-2 tablets p.o.q.4-6h.p.r.n.; Ativan 0.5 mg p.o.q.8h.p.r.n. for anxiety; Zantac 150 mg p.o. b.i.d.; and Colace 100 mg p.o.b.i.d. The patient was also instructed to call Dr.[**Name (NI) 1334**] office on the day following discharge to arrange for a follow-up appointment for a visit to Dr.[**Name (NI) 1334**] office in one week's time for staple removal and followup plain films of the thoracolumbar spine. He was also instructed to call the Hematology Department for a followup appointment in one week's time on the same day as when he sees Dr. [**Last Name (STitle) 1327**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) 1339**] J. 14-127 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2183-9-8**] 10:30 T: [**2183-9-8**] 11:25 JOB#: [**Job Number 36128**]

[ "560.1", "V10.51", "E884.9", "285.9", "782.1", "806.4", "305.1", "288.9" ]

icd9cm

[ [ [] ] ]

[ "03.53", "38.93", "96.6", "81.07" ]

icd9pcs

[ [ [] ] ]

1563, 6677

1426, 1540

11,788

183,396

26993

Discharge summary

report

Admission Date: [**2123-4-13**] Discharge Date: [**2123-4-22**] Date of Birth: [**2047-10-30**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 443**] Chief Complaint: Episodes of recurrent Ventricular tachycardia Major Surgical or Invasive Procedure: Electrophysiologic study and Ventricular tachycardia ablation. History of Present Illness: 75 y.o. male transferred from [**Hospital6 **] with V-Tach, BiV ICD firing several times per day. Loaded with amiodarone in the ED. Recently admitted in [**Month (only) 956**] for Left lead revision. . He reports a history of recurrent ICD firing since it was placed approximately 3 years ago but has not had an incident since [**Month (only) 956**] when his leads were revised. ~4am on [**4-12**] his ICD fired while he was sleeping. He was scheduled to have a colonoscopy today so went through a bowel prep throughout the day but did take his medications. His ICD fired again early this morning. He was instructed not to take his medications and remain NPO for his colonoscopy, but when his gastroenterologist found out that his ICD had fired again, he cancelled the procedure. The patient then took his usual morning medications at ~1pm. His ICD fired 2 more times, and as he was close to his cardiologist's office, he stopped in. His ICD was interrogated, verified that it did fire, and he was sent by ambulance to [**Hospital6 33**] ED. There, he was loaded with IV amio (15 mg/min for 150mg, then 1mg/min) and transferred to [**Hospital1 18**] for further care. The patient reports a fluttering-type of sensation and "funny feeling" before his ICD fired each time, similar to the past, but he never syncopized, had chest pain, or had shortness of breath. Currently he feels at his baseline with no complaints. . ROS: No orthopnea, PND, chest discomfort, lower-extremity swelling, N/V/D/C/abdominal pain, fevers, chills. Past Medical History: -Ischemic cardiomyopathy, EF documented as low as 15% -CHF -Prior MI -[**2102**] CABG at [**Hospital6 **] --Cath report from [**Hospital1 112**] [**2121-3-28**]: ---Right-dominant system ---50% LMCA ostial lesion ---50% tubular stenosis at bifurcation of LAD and LCx ---proximal LAD-> D1 stent placed on [**2-/2121**] patent ---LIMA->LAD patent, known occlusion of RCA. --- Pressures, Aortic - 127/65, RA 16-17, RV 64/8, PA 61/26, PCWP 27 -Ventricular tachycardia, s/p ablation -Prior ICD implant with upgrade to BiV ICD in [**6-22**] -Atrial flutter, s/p ablation -Chronic renal insufficiency (baseline creatinine 2.0) -Peripheral vascular disease -Facial melanoma -Bladder cancer Pacemaker/ICD, BiV ICD in [**6-22**], revised in [**2-24**]. Cardiac Risk Factors: Dyslipidemia, Hypertension. No diabetes. Social History: No EtOH or tobacco use. Family History: No family history of premature CAD or SCD. Physical Exam: Blood pressure was 117/56 while supine. Pulse was 63 beats/min and regular, respiratory rate was 14 breaths/min. GEN: well developed, well nourished and well groomed. Oriented to person, place and time. Mood and affect appropriate. HEENT: no xanthalesma, no conjunctiva pallor, mucous membranes moist NECK: supple with JVP of 10cm with +HJR. carotid pulses +1. There was no thyromegaly. left-sided carotid bruit PULM: No chest wall deformities, scoliosis or kyphosis. Respirations unlabored, no accessory muscle use. lungs CTAB, no W/R/R COR: PMI diffuse, laterally displaced to anterior axillary line. There were no thrills, lifts or palpable S3 or S4. Normal S1, loud P2. [**1-23**] early systolic murmur at LLSB radiating to apex. ABD: No pulsatile masses, no hepatosplenomegaly or tenderness, NT, ND, +BS. No abdominal or femoral bruits. EXT: No pallor, cyanosis, clubbing or edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 1+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Left: Carotid 1+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+ Pertinent Results: [**2123-4-22**] 06:55AM BLOOD WBC-9.7 RBC-4.09* Hgb-10.0* Hct-31.1* MCV-76* MCH-24.5* MCHC-32.2 RDW-18.6* Plt Ct-316 [**2123-4-22**] 09:45AM BLOOD PT-22.6* PTT-37.7* INR(PT)-2.2* [**2123-4-22**] 06:55AM BLOOD Glucose-95 UreaN-42* Creat-2.4* Na-137 K-3.8 Cl-101 HCO3-25 AnGap-15 [**2123-4-20**] 06:59PM BLOOD CK(CPK)-65 [**2123-4-22**] 06:55AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.6 Chest X-ray on [**2123-4-19**]: AP UPRIGHT VIEW OF THE CHEST: The mildly enlarged heart is unchanged. The mediastinal and hilar contours are normal. The lungs are clear. The ICD and pacemaker leads are in proper positions projecting over the right atrium, right ventricle, and left ventricle. Patient is status post CABG. IMPRESSION: 1. No acute cardiopulmonary process is noted. 2. Mildly enlarged heart is unchanged. Brief Hospital Course: #) CV - Rhythm: Patient on Mexiletine 200mg [**Hospital1 **] and amiodarone 200mg qday as outpatient but was started on amiodarone continuous infusion at OSH. Pacer interrogation demonstrated firing x4 as above. Given previous history of ischemic disease, this may be V-tach with permanent re-entrant substrate secondary to ischemia/infarction. Recent increasing frequency of events may be secondary to recent bowel preparations from colonoscopy, and decreased absorption of anti-arrhythmic agents secondary to this. Had recurrent episodes of V-tach with ICD firing on [**4-14**]. Now status-post VT ablation on [**2123-4-16**]. Per Electrophysiology service recommendations, restarted mexiletine and continued oral amiodarone 200mg qdaily. Started on anticoagulation with warfarin and heparin gtt after VT ablation procedure, which will need to continue for 2 months. . #) Ischemia - History of CABG in [**2102**]. Experienced few episodes of angina associated with V-tach during this admission, that resolved with sublingual nitroglycerin without and significant ECG changes. Continued with aspirin, clopidogrel, metoprolol, statin, but held lisinopril. . #) Pump - Per records, patient has EF ranging 15-25%. Although JVP is elevated, appears to be euvolemic otherwise, given absence of crackles on pulmonary exam and absence of peripheral oedema. Continued with furosemide 120mg qAM, 80mg qPM , Isosorbide mononitrate, and hydralazine, metoprolol. Held lisinopril, can consider discontinuing if already on Imdur/hydralazine. Discontinued digoxin due to arrhythmogenicity . #) Valves - no known issues. [**Month (only) 116**] have mitral regurgitation secondary to dilated cardiomyopathy. No symptoms. . #) Hypertension - Continued metoprolol, imdur/hydralazine, furosemide. . #) Chronic renal failure - Creatinine was slightly elevated from baseline of 2.0. Likely secondary to recent bowel preparation/dehydration. Electrolytes and volume status stable. Held Lisinopril. . #) COPD - Continued advair. . #) Iron deficiency anemia - Patient was undergoing colonoscopy for work-up of this. Continued with iron supplements. Guaiaced stools and monitor hematocrit. Medications on Admission: Aspirin 81 mg daily Digoxin .125 mg daily Lasix 120 qAM, 80 mg qPM Mexiletine 200 mg [**Hospital1 **] Hydralazine 10 mg three times a day Protonix 40 mg [**Hospital1 **] Lisinopril 2.5 mg qd Metoprolol 100 mg q AM, 50 mg qPM Folic acid 1 mg qd Niferex 150 mg daily colace 100 mg [**Hospital1 **] Plavix 75 mg daily Flomax 0.4 mg daily MVI 1 qd Lipitor 80 mg daily Amiodarone 200 mg daily Imdur 60 mg qd Advair 250/1 puff [**Hospital1 **] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO QAM (once a day (in the morning)). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QDay at 3:00 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 13. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 16. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 17. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 18. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime: Adjust dose as directed by primary care physician. [**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2* 19. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days: To complete 7-day course on [**2123-4-27**]. [**Date Range **]:*12 Tablet(s)* Refills:*0* 20. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 21. INR check Sig: PT and INR 2 times per week.: Please have INR checked 2 times per week in lab in Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office building and forward results to Dr. [**Last Name (STitle) 36589**]. [**Last Name (STitle) **]:*qs * Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia Urinary tract infection Secondary diagnoses: Ischemic cardiomyopathy Chronic renal insufficiency Coronary artery disease Discharge Condition: Vital signs stable. Discharge Instructions: You were admitted for evaluation of abnormal heart rhythm. You were evaluated by heart rhythm specialist and had an ablation procedure to help improve problems with heart rhythm. Your rhythm medications were adjusted. Also, you were started on blood thinners (Coumadin) which you should continue for at least 1 month. You were also started on antibiotic for urinary tract infection. Please complete the full course of antibiotic even if you no longer have any symptoms. Please call your physician or report to the emergency room if you notice worsening chest pain, shortness of breath, severe palpitations, receive a shock from your ICD device, or any other concerning symptoms. Followup Instructions: You should follow up for your blood-thinning levels (INR) in the laboratory at your primary care physician's office building. (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36589**]). You should have your next level checked on Friday [**2123-4-23**]. You have been given a prescription for this and the results will be automatically sent to your primary care physician. [**Name10 (NameIs) **] taking 2mg of Coumading until adjustment made by primary care. . You have been scheduled for follow-up in Dr.[**Name (NI) 66351**] office on Mondary [**4-26**] at noon. Please call [**0-0-**] for any questions or to change your appointment. Completed by:[**2123-4-25**]

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