ChanBeDu/relevant_section_length · Datasets at Hugging Face

44,663

115,889

39379

Discharge summary

report

Admission Date: [**2136-9-12**] Discharge Date: [**2136-9-16**] Date of Birth: [**2063-1-29**] Sex: F Service: NEUROSURGERY Allergies: Cortisone + Cooling Relief / Latex Attending:[**First Name3 (LF) 3227**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: 73yo woman on [**First Name3 (LF) **] and [**First Name3 (LF) **] for CAD was walking in a parking lot today and had a mechanical fall. no LOC. Taken to [**Hospital **] Hospital where Head CT revealed left SDH. [**Location (un) 7622**] to [**Hospital1 18**]. no vision changes, no N/V. Neurosurgery consultation for evaluation and treatment. Past Medical History: GERD, HTN, HL, hysterectomy, CABG x5, PCI x2 stents Social History: Widowed, lives alone. Has 4 grown children and a close friend. no tobacco, rare etoh. ambulates without assistance. daughter [**Name (NI) **] [**Telephone/Fax (1) 87052**] is who she would like called if she can't make her own decisions. Family History: NC Physical Exam: PHYSICAL EXAM: BP: 132/64 HR:66 R 16 O2Sats 98%RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL 3mm EOMs intact Neck: hard collar Abd: Soft 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, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation limited by large temporal hematoma. 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 [**4-25**] throughout. No pronator drift Sensation: Intact to light touch, propioception Toes downgoing bilaterally Exam upon discharge: a nad o x3, motor full, no pronator drift. ecchymosis left eye Pertinent Results: [**2136-9-12**] 03:45PM PT-11.9 PTT-23.1 INR(PT)-1.0 [**2136-9-12**] 03:45PM PLT COUNT-235 [**2136-9-12**] 03:45PM NEUTS-68.1 LYMPHS-23.6 MONOS-4.3 EOS-2.5 BASOS-1.5 [**2136-9-12**] 03:45PM WBC-7.6 RBC-4.48 HGB-14.0 HCT-41.6 MCV-93 MCH-31.4 MCHC-33.8 RDW-13.7 [**2136-9-12**] 03:45PM GLUCOSE-126* UREA N-23* CREAT-1.1 SODIUM-142 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 CTH [**9-12**] CT Head: 4mm left frontal-parietal acute SDH. no mass effect or midline shift Repeat CT head [**9-12**] 1. Stable small 4-mm transverse diameter area of left subdural hemorrhage. No new foci of hemorrhage. 2. Stable extensive left scalp hematoma and hematoma surrounding the left orbit. CT cervical spine [**9-12**] No fracture or subluxation repeat Head CT [**2136-9-13**]: stable CT head [**9-13**] Stable exam, no change from previous CT scan. Brief Hospital Course: [**9-12**] Pt admitted to neurosurgery service and the ICU on [**9-12**] for strict blood pressure control less than 140 systolic and q1 neurochecks. Given her use of [**Month/Year (2) **] and [**Month/Year (2) 4532**] she did receive 1 unit of platelets. She did well overnight with no complaints or change in her neurological exam. She did have a repeat head CT 4 hours after admission that showed no change in her subdural hematoma. [**9-13**] Pt seen on A.M rounds and doing well. She did have some complaints of seeing things that were not there but she says this has been happening for some time and has seen multiple doctors as [**Name5 (PTitle) **] outpatient for workup. She says these episodes are self limited and there has been no change in their frequency since her fall. She will see cognitive neurologist Mark [**Doctor Last Name 8012**] as an outpatient for neurologic evaluation. She had a repeat CT head on this day that again showed no change in amount of subdural blood and she was transfered to the floor in stable condition. [**9-14**] Upon arrival to the floor she was seen by the physical therapy team and worked with them until cleared for discharge to home with home services. Medications on Admission: [**Last Name (LF) 4532**], [**First Name3 (LF) **], metoprolol, levothyroxine, ranitidine, lovastatin, Vit D Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 7 days. Disp:*21 Capsule(s)* Refills:*0* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for T>38.5, pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on pain med. Disp:*60 Capsule(s)* Refills:*0* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for h/a. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Left frontal subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc.until seen in follow up. ?????? You were on [**Hospital6 **] (clopidogrel) and Aspirin prior to your injury, you may not safely resume taking these medications until follow up with Dr. [**First Name (STitle) **] and repeat head ct in clinic in one month. Followup Instructions: ?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Please follow up with Dr. [**Last Name (STitle) 8012**] of cognitive neurology on [**9-21**] at 8:30 A.M. Please call [**Telephone/Fax (1) 50382**] if questions or you are unable to keep this appointment. Completed by:[**2136-9-16**]

[ "272.4", "V45.82", "414.01", "530.81", "V58.69", "852.21", "401.9", "E885.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5438, 5488

3168, 4374

304, 310

5562, 5562

2281, 2690

6480, 7006

1030, 1034

4534, 5415

5509, 5541

4400, 4511

5712, 6457

1064, 1246

260, 266

338, 682

1498, 2175

2699, 3145

5577, 5688

704, 758

774, 1014

2197, 2262

10,531

171,037

28024

Discharge summary

report

Admission Date: [**2140-6-20**] Discharge Date: [**2140-7-9**] Date of Birth: [**2078-7-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10293**] Chief Complaint: Hepatic Encephalopathy Major Surgical or Invasive Procedure: Colonoscopy Esophagogastroduodenoscopy Serial Paracenteses Thoracocentesis History of Present Illness: 61 yo M w/ hx etOH cirrhosis [**2-4**] EtOh, anemia, and hepato-renal syndrome presented to OSH for routine paracentesis and was found to have hyperkalemia. Patient is confused and unable to give any hx, all data is obtained from OSH records though no d/c summary is present. Per these records, patient get regular parcentesis the last prior to admission being [**6-3**]. On presentation to OSH on [**6-13**], he complained of abdominal pain, distension, SOB, anorexia, generalized weakness. He denied melena, diarrha, fevers or chills. He was found to be hyperkalemic to 6.5 and had a Cr of 4.3 and was transferred to ER. . At OSH, treated wtih kayexelate and potassium followed. Lasix given for diuresis and nephrology consulted. Continued on cipro for SBP prophylaxis. Patient was tranfused PRBCs for anemia. He was maintained on a low protein<45g/day diet. Became increasingly lethargic and confused and was transferred for transplant work up and eval. Past Medical History: Liver Cirrhosis followed at [**Hospital3 2358**] by the transplant team Anemia Hepato-renal syndrome Social History: Lives alone, was a drinkier until [**2-/2140**], non-smoker. States he is a retired teacher (AP chem and physics teacher). Healthcare Proxy: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 68214**] [**Telephone/Fax (1) 68215**]. Dr. [**Last Name (STitle) 3315**] is his PCP. [**Name10 (NameIs) **] doctor is Dr. [**Last Name (STitle) 57141**]. Family History: [**Name (NI) **] sister died of pancreatic cancer Physical Exam: 95.9 114/76 101 20 98% RA BG 217 180# Gen: confused, mumbling, states "no I haven't" to almost all questions. Not oriented to place or date. Jaundiced HEENT: slight scleral icterus, mmm, tounge fasiculations noted, prrl CV: rrr s1s2 no m/r/g noted Pulm: diminished left sided breath sounds, right side cta Abd: ascites present, soft, not tensly distended, non-tender, Ext: trace pedal edema Neuro: Oriented to self. Does not know dates, location, president of the US. ++Asterixis Pertinent Results: OSH labs- [**6-20**]: WBC 6.7 Hct 27.3 Plt 31 INR 1.6 PT 17.8 Na 129 K 5.2 Cl 101 CO2 21 BUN 782 Cr 4.0 Ca 8.5 [**6-19**]: AST 33 ALT 24 Alk Ph 92 [**Doctor First Name **] 45 LIp 68 HA1c: 6.0 . UA [**6-13**]: negative . [**6-14**] renal US: large ascites. no calculus or obstruction of either renal collecting system. . [**6-13**] cxr: large left pleural effusion / [**2140-6-28**]: PFTs: FEV1 45% FVC 41% FEV1/FVC 110 TLC 46% DL/VA 116% . [**2140-6-29**]: p-MIBI: no anginal symptoms or ischemic EKG changes. Calculated EF 78% with normal myocardial perfusion and wall size and motion. . [**2140-6-30**]: MRI/A of liver: could not resolve hepatic arterial architecture. no liver masses, patent portal vein, small liver cyst . Infectious Serologies: HSV1&2, HCV, RPR, toxo IgG/M, CMV IgG/M, HbsAg, HbcAb: negative EBV IgG+/IgM-, VZV IgG+, HbsAb - borderline . Tumor Markers: CA19-9: 37, CEA 5.7, PSA 0.4 Brief Hospital Course: 61 yo m with etoh cirrhosis on regular paracentesis at baseline, presented to OSH with presumed worsened Cr (unknown baseline), hyperkalemia and worsening mental status. Transferred to [**Hospital1 18**] for transplant evaluation and further work-up. In brief the patient arrived in hepatorenal syndrome, hepatic encephalopathy, and was later found to have strept viridans sbp and bacteremia. His acute presentation slowly resolved with octreotide/midodrine/albumin, lactulose/rifaximin, and antibiotics, respectively. In addition, he continued to have elevated blood sugars requiring insulin therapy. He was evaluated in collaboration between the hepatology team and the transplant surgery to determine his candidacy for transplant. His pre-transplant evaluation included multiple infectious disease serologies, non-invasive cardiac imaging, MRI/MRA of the liver, serial paracenteses, colonoscopy and EGD, tumor markers, and dental evaluation. At the time of discharge he was stable to go home with close follow-up. He was listed for liver transplant. . # Hepatic Encephalopathy: The patient has a history of cirrhosis secondary to EtOH. On presentation his INR was 1.7, Alb was 2.6, total bili was 4.2 and ammonia level was 282. His transaminases remained within normal limits. He was very confused and had displayed prominent asterixis on exam c/w hepatic encephalopathy. He was started on lactulose, and rifaximin and observed in the MICU. His confusional state cleared after several days of aggressive lactulose/rifaximin and antibiotics for the sbp. He was transferred to the medical floor for further management. His level of consciousness gradually improved as did his asterixis with continued therapy. By discharge he was conversant with content appropriate to questioning, attentive to interview and exams, and following directions appropriately to check blood sugars and administer insulin injections. . # Spontaneous Bacterial Peritonitis: The patient has a history of refractory ascites which had been managed with weekly paracenteses. During the evaluation for the trigger for the encephalopathy, a diagnostic paracentesis was performed on the second day of his [**Hospital1 18**] stay. It revealed WBC 387 RBC 1400 polys 48%. The patient had been taking levofloxacin as sbp prophylaxis at home so the <250 PMN count was still thought to represent sbp and thus merit treatment - initially with vancomycin/zosyn. The peritoneal fluid was later cultured revealing viridans streptococci which was sensitive to penicillins (and therefore cephalosporins) and the patient was switched to ceftriaxone on which he completed a 7 day course. Serial diagnostic/therapeutic paracenteses were performed to follow clearance of the infection which was ultimately confirmed on [**6-28**]. Each paracentesis was accompanied with appropriate colloid replacement. The last paracentesis performed during this hospitalization revealed:..... Following the therapeutic course of ceftriaxone, the patient will be maintained on Bactrim SS prophylaxis as the prior microbe was resistant to quinolones. He is still likely to need regular therapeutic paracenteses to manage his ascites. . # Bacteremia: Blood cultures drawn on admission also grew viridans streptococci. The patient had a TTE to evaluate for endocarditis which was negative. Repeat blood cultures from hospital day 2 and 4 have resulted as negative. A dental consult was obtained to evaluate for an oral source to the bacteremia/sbp. No oral abscess or infectious nidus was found, but 2 teeth were recommended to be removed (see "Teeth" section below). He did have a RIJ central venous catheter in place and the time the bacteremia was detected. Although the line was not thought to be the culprit source for the infection, the line was pulled when adequate access was obtained. Cath tip culture was negative. By the time he was stabilized and transferred to the medical floor he was afebrile and remained so for the duration of his hospital stay. . # Hyperkalemia: Upon arrival to [**Hospital1 18**] the patient had a K level of 5.2. An ECG was obtained. He was treated with Kayexalate, fluid and diuresis. The hyperkalemia was thought secondary to renal failure (see below). As the renal function improved his potassium level returned to [**Location 213**]. . # Renal Failure: The patient has a history of hepatorenal syndrome and although his baseline creatinine was unknown prior to admission, his dropping UOP, euvolemic status, and pre-renal ARF were consistent with hepatorenal syndrome. This diagnosis was further supported by low urinary protein/creatinine ratio, bland urine sediment, negative for hepatis serologies, negative cryoglobulin and no hydronephrosis by u/s. He was started on octreotide/albumin/midodrine. His creatinine was at a maximum of 4.3 on admission and slowly trended down with continued treatment. However, his creatinine showed some lability and concern persisted for the need for combined liver-kidney transplant. . # End-stage liver Disease: The patient was evaluated in collaboration by the hepatology, nephrology, and transplant surgery teams. The pre-transplant evaluation revealed no contra-indications to transplant, and the patient was placed on the transplant list. For results of the pre-op evaluation, please see "Pertinent Results." . # Hyperglycemia: The patient has no history of diabetes although he did have persistent elevated blood sugars. A glycosylated hemoglobin was normal at 6% and the hyperglycemia was managed with insulin. His blood sugar control improved with a twice daily dosing regimen of NPH with a sliding scale for coverage. He will continue to monitor his blood sugars and administer insulin at home with assistance of VNA and family members. [**Name (NI) **] received extensive teaching with nursing regarding insulin administration and blood glucose measurements. . # Anemia: The patient was found to be anemic with Hct of ~28% on admission this reached a nadir of 23.3% before recovering to >31% prior to discharge. There was no evidence of blood loss or hemolysis by smear examination. He had adequate iron, folate, and B12 stores. His anemia was largely attributed to his hypersplenism and underlying liver disease. He received Epogen to stimulate his marrow, and he was transfused 3 units of pRBCs during his stay. . # Thrombocytopenia: The patient has a baseline thrombocytopenia secondary to hypersplenism. He required 6 platelet transfusions to support him while he underwent various invasive procedures. There were no precipitous declines in the platelet count to suggest HIT, but heparin products were limited in their use nonetheless. . # Teeth: During the evaluation for the source of the bacteremia, a Panarex film was obtained and a dental consult was called. No infectious nidus to be indentified, however two teeth were noted to be diseased and meriting removal (Teeth #5 and #13 both upper bicuspids). The patient was referred to the outpatient oral surgery department at [**Hospital1 2025**] for these teeth to be extracted while awaiting a liver to become available. . # FENGI: The patient was gradually advanced to full regular diet as his condition improved. . # Prophy: PPI, pneumoboots while on bedrest. # Comm: sister [**Name (NI) **] [**Name (NI) 68214**] [**Telephone/Fax (1) 68216**] . # Code: full, does have living will in chart Medications on Admission: Protonix 40, Renagel 400mg TID, Lactulose tid, levaquin 250mg qd, SSI, Reglan prn, Docusate prn, Melatonin prn Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours). Disp:*2700 ml* Refills:*2* 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. Insulin - NPH Please check your blood sugar 4 times a day. Please take 10 units NPH in the morning and 8 units of NPH at night. 7. Octreotide Acetate 100 mcg/mL Solution Sig: Two (2) mL Injection Q8H (every 8 hours). 8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) mL Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*qs ml* Refills:*2* 9. Midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as directed units Subcutaneous once a day: Please take 10 units in the morning and 8 units at night. Disp:*qs ml* Refills:*2* 11. Insulin Syringe Syringe Sig: as needed syringe Miscell. four times a day as needed for low blood sugar: with needles. Disp:*120 syringes* Refills:*2* 12. One Touch Test Strip Sig: as needed Miscell. four times a day. Disp:*100 strips* Refills:*2* 13. One Touch UltraSoft Lancets Misc Sig: as needed Miscell. four times a day. Disp:*100 lancets* Refills:*2* 14. Insulin Regular Human 100 unit/mL Cartridge Sig: as directed units Injection four times a day as needed for high blood sugar: Per sliding scale. Disp:*qs ml* Refills:*2* 15. Syringe with Needle (Disp) 3 mL 20 x 1 Syringe Sig: as directed Miscell. QMOWEFR (Monday -Wednesday-Friday).: For Epogen. Disp:*30 syringes* Refills:*2* Discharge Disposition: Home With Service Facility: VNA CareNetwork Discharge Diagnosis: Primary: Liver Cirrhosis Hepatorenal syndrome Hepatic encephalopathy Hyperglycemia Spontaneous bacterial peritonitis Strep. viridans bacteremia Left sided pleural effusion Secondary: Refractory ascites Discharge Condition: fair - tolerating oral medications, tolerating food, ambulating well. Discharge Instructions: Please seek immediate medical assistance if you experience fevers, chills, increasing confusion, or noticeable decrease in your urination. Take your medications as prescribed. You were started on insulin while in the hospital. This will require you to take fingerstick glucose measurements and then adjust your insulin requirements according to the following schedule: . Wake up: 1) Check blood sugar, 2) give insulin - 10 units of NPH and regular insulin according to both the sliding scale and measured blood glucose, 3) eat 30 minutes after insulin. . 30 min before lunch: 1) check blood sugar, 2) give regular insulin according to sliding scale and blood glucose measurement, 3) eat 30 minutes after insulin. . 30 minutes before dinner: 1) check blood sugar, 2) give regular insulin according to both the sliding scale and blood glucose measurement, 3) eat 30 minutes after insulin. . Bedtime: 1) check blood sugar, 2) give 8 units of NPH and regular insulin depending on sliding scale and blood glucose measurement. . Please have visiting nurse fax your blood test results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13144**]. Her fax number is [**Telephone/Fax (1) **] and her phone number is [**Telephone/Fax (1) **]. Please call Ms. [**Name13 (STitle) 13144**] if you have any further questions about your home nursing. Followup Instructions: Provider: [**Name10 (NameIs) 454**],TEN DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2140-7-14**] 2:00 . Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] on Monday [**2140-7-11**] in the morning to schedule an appointment within one week of leaving the hospital. His numbers are the following: Liver Center Phone: [**Telephone/Fax (1) 2422**]; Liver Transplant Phone: [**Telephone/Fax (1) 673**]

[ "790.6", "211.3", "511.9", "789.5", "285.29", "287.4", "572.4", "276.7", "572.2", "571.2", "790.7", "567.23" ]

icd9cm

[ [ [] ] ]

[ "99.04", "54.91", "34.91", "45.25" ]

icd9pcs

[ [ [] ] ]

13024, 13070

3453, 10886

338, 415

13317, 13389

2512, 3430

14787, 15227

1932, 1983

11048, 13001

13091, 13296

10912, 11025

13413, 14764

1998, 2493

276, 300

443, 1411

1433, 1535

1551, 1916

19,533

139,341

29434

Discharge summary

report

Admission Date: [**2107-12-18**] Discharge Date: [**2108-2-7**] Date of Birth: [**2039-7-6**] Sex: F Service: SURGERY Allergies: Bactrim / Cogentin Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain Nausea/vomiting Anorexia Major Surgical or Invasive Procedure: [**12-18**] Right hemicolectomy with ileocolonic anastomosis [**2108-1-10**] Exploratory laparotomy with washout and diverting ileostomy [**2108-1-23**] PICC catheter placement History of Present Illness: 66 year old female with chief complaint of abd pain and decreased po intake. Pt is a poor historian because she is schizo-affective with some mental retardation, but states that her abdominal pain started 5 days PTA and was located all over. It prevented her from eating anything because it made the pain worse. She states that she started having diarrhea 2 days PTA,not bloody. She denies any chest pain, shortness of breath, dysuria, cough, sore throat. . On initial presentation, she was hypotensive with systolic blood pressure in the 80's with fever to 101.5. She received about 6L of NS and her pressure improved to 120/60 with HR in the 90s. She received broad spectrum antibiotics Vanc/cipro/flagyl. She then had an episode of emesis that appeared dark, gastroccult positive. An NG lavage appeared bilious and cleared after 900cc. Her rectal revealed guaiac pos brown stool. At this time, her SBP dropped into the 80s again and more fluids were given. She then had a right subclavian line placed and a CVP was measured at 7. She received a total of 10 liters of fluid in the ED and blood pressure stabilized in the 100s/60s. Past Medical History: * Schizoaffective d/o * Mild mental retardation * Hypothyroid * Diabetes insipidis * HTN * High cholesterol * Right hip fx s/p ORIF * hx of UTIs (MRSA UTI in [**8-30**]) * Tardive Dyskinesia * Psoriasis * hx of esophageal candidiasis * Renal insufficiency, baseline cr 1.5 (? due to lithium toxicity) * hx of c diff * hx of hyperkalemia Social History: Lives in group home x 25 years; ambulates 20ft with assist, uses wheelchair; wears depends but can use bathroom if needs to; smoked 1ppd x 40 years, quit at age 60; no etoh use Family History: - Father died at age 48 of MI - Mother died in [**2080**] Physical Exam: Upon admission: Temp 97.8, BP 109/79, HR 88, R 24, O2 96% on 3L; wt 185.3lbs GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MM mildly dry NECK: JVP flat RESP: crackles at bases with scattered exp wheezes CV: RRR, 2/6 systolic murmur at LUSB ABD: no BS heard, diffusely distended, nontender, no rebound, but 'doughy' EXT: no edema, 2+ DP SKIN: psoriasis across abdomen, legs NEURO: AO x 3 (name, [**Location (un) **], [**2107**]); moves all extremities, strength 4+/5 throughout; sensation intact, CN 2-12 intact RECTAL: guaiac pos brown stool Pertinent Results: [**2107-12-18**] 11:54PM LACTATE-1.2 [**2107-12-18**] 11:54PM HGB-12.0 calcHCT-36 [**2107-12-18**] 11:45PM GLUCOSE-97 UREA N-61* CREAT-3.0* SODIUM-136 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-15* ANION GAP-16 [**2107-12-18**] 11:45PM PHOSPHATE-4.3 MAGNESIUM-1.7 [**2107-12-18**] 11:45PM CORTISOL-39.3* [**2107-12-18**] 11:45PM LITHIUM-0.8 [**2107-12-18**] 11:45PM WBC-6.6 RBC-3.91* HGB-12.0 HCT-34.7* MCV-89 MCH-30.8 MCHC-34.7 RDW-13.6 [**2107-12-18**] 11:45PM PT-12.3 PTT-28.1 INR(PT)-1.1 [**2107-12-18**] 11:45PM PLT COUNT-332 [**2107-12-18**] 06:50PM AST(SGOT)-15 ALK PHOS-122* AMYLASE-19 TOT BILI-0.6 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2108-2-6**] 05:08PM 142* 35* 3.5* 135 5.0 99 23 18 [**2108-2-6**] 04:27AM 94 34* 3.4* 132* 5.7* 96 24 18 [**2108-2-5**] 05:08AM 83 33* 3.3* 129* 5.5* 97 24 14 [**2108-2-4**] 04:49AM 75 30* 2.7* 130* 5.3* 99 24 12 [**2108-2-3**] 04:13AM 86 33* 2.6* 134 5.4* 99 26 14 [**2108-2-2**] 05:29AM 88 27* 2.2* 133 5.7* 97 30 12 [**2108-2-1**] 05:45AM 95 27* 1.9* 135 5.3* 98 30 12 [**2108-1-31**] 05:02AM 88 25* 1.5* 141 5.2* 103 31 12 [**2108-1-30**] 03:39AM 80 30* 1.6* 140 5.6* 101 33* 12 [**2108-1-29**] 02:01PM 87 30* 1.5* 143 5.5* 103 34* 12 [**2108-1-29**] 04:28AM 85 31* 1.5* 144 5.4* 105 33* 11 [**2108-1-28**] 11:35PM 102 32* 1.6* 144 4.9 104 32 13 [**2108-1-28**] 07:15PM RENAL U.S. Reason: assess for any renal patholgy in setting of rising creatinin [**Hospital 93**] MEDICAL CONDITION: 66 year old woman with fever, UTI, leukocytosis with multiple hyperdense renal cysts seen on abd CT REASON FOR THIS EXAMINATION: assess for any renal patholgy in setting of rising creatinine. thank you. HISTORY: 68-year-old female with fever, urinary tract infection, leukocytosis, and hyperdense renal lesions seen on recent CT, now with rising creatinine. COMPARISON: CT torso [**2108-1-5**] and CT abdomen and pelvis [**2108-1-16**]. RENAL ULTRASOUND: This study is somewhat limited by large patient body habitus. The right kidney measures 9.3 cm and the left kidney 9.0 cm. Again demonstrated are bilateral hypodense foci of both kidneys similar to low attenuation lesions seen on recent CT and most compatible with cysts. The largest on the left measures 1.8 cm, the largest on the right is 1.0 cm. There is no evidence of hydronephrosis or solid renal mass. IMPRESSION: 1. Small somewhat atrophic appearing kidneys without hydronephrosis. 2. Bilateral renal cysts. CHEST (PORTABLE AP) Reason: interval change [**Hospital 93**] MEDICAL CONDITION: 66 year old woman s/p colectomy, anastamotic leak, diverting ileostomy, now with expiratory wheezes, decreased O2 sats REASON FOR THIS EXAMINATION: interval change INDICATION: Status post colectomy. PORTABLE AP CHEST COMPARISON: [**2108-1-25**]. The right-sided PICC line overlies the upper SVC. The NG tube is in the distal stomach. The heart size is normal. The aorta is unfolded. Lung volumes remain low. A small left pleural effusion persists. No CHF. Resolved right pleural effusion. Cardiology Report ECG Study Date of [**2108-1-25**] 5:58:14 PM Baseline artifact. Sinus rhythm. Since the previous tracing of [**2108-1-25**] probably no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 96 136 80 338/391.57 66 25 46 Pathology Examination DIAGNOSIS: Segment of bowel containing previous ileo-colonic anastomosis: 1. Partially disrupted previous anastomosis site with surrounding fat necrosis, acute and chronic inflammation, and granulation tissue. 2. Unremarkable mucosa at resection margins. 3. Four lymph nodes with no evidence of malignancy. Clinical: Resection of ileocolonic anastamosis. Gross: The specimen is received fresh labeled with "[**Known lastname 70667**], [**Known firstname 335**]"; the medical record number and "bowel" and consists of a segment of bowel consisting measuring 76.4 cm in length and 8.5 cm in greatest diameter. The serosal surface is pink tan. There are numerous adhesions and areas of apparent fat necrosis. The anastomosis site is partially disrupted. The specimen is opened along the anti-mesenteric region to reveal a mucosal surface that appears red at the area of anastomosis, and a normal appearing pink tan mucosal surface along the rest of the bowel. The specimen is serially sectioned at the site of anastomosis to reveal a large area of surrounding indurated fat measuring up to 10.5 x 7.3 x 6.5 cm. No other masses or lesions are identified. The specimen is represented as follows: A = ileal margin, B = colonic margin, C-E = adipose tissue near site of anastomosis, F-G = ileal and colonic tissue at site of anastomosis, respectively, H = normal appearing ileum, I-R = adipose tissue for lymph nodes. Brief Hospital Course: She was admitted to the Medicine and underwent abdominal CT which showed no acute pathology though exam was limited due to lack of contrast but did reveal an ileus. A suspicion was raised by radiology of an intusussception of the distal small bowel. She was treated with PPI. One episode coffee ground emesis noted in ED; her stool was guaiac positive; hematocrits were followed every 6 hours; the Hct did drop as low as 19.7; last value was 26.3 on [**2108-2-6**]. Vancomycin, Cipro and Flagyl were given in the ED. The patient however, had an clinical abdominal exam that was increasingly worrisome for peritonitis and a lactate elevation. She was taken to the operating room on [**12-18**]. A mass was found in the distal ileal and cecal area that was densely adherent to the retroperitoneum with neovasculature over the mass suggestive of a malignant tumor. In addition, there was frank perforation of the ascenting colon, which was non-obstructed. Because of the predicted problems with fluid management due to diabetes insipidus as well as the known durability of ileocolic anastomoses the patient was treated by right hemicolectomy with ileocolonic anastomosis. the patient initially did well and was on a regular diet by day 7, but nonetheless on [**1-6**] there was a fluid collection in her abdomen that was drained. The drainage was clear initially but later became feculent. She was again taken to the operating room on [**1-10**] for resection of ileocolic anastomosis with right upper quadrant phlegmon, drainage of intraperitoneal abscess and formation of ileostomy. Her ostomy output was initially high; she was later started on Loperamide to slow down output to allow for better absorption of her oral intake. She has required intermittent IV fluid replacement to replete the losses from her ostomy output. During her postoperative period she was placed on enteral tube feedings and later underwent a Speech and Swallow evaluation; she was assessed as an aspiration risk and was placed on nectar thickened liquids and pureed solids. Her oral intake at first,was poor; calorie counts were initiated. Her diet did eventually improve dramatically and she is meeting her caloric needs from solely oral intake. She does like supplements and receives these thickened at minimum three times/day with her meals. The wound ostomy nurse have been closely involved in her care. They have recommended the following: cleanse peri-stoma skin with wound cleanser,dried,loosely packed with aquacel Ag. Also inferior to stoma at 6 o'clock position, is small wound from old drain site, 0.5 cm with 1.5 cm depth(much less tunneling). Loosely packed with aquacel Ag strip. Applied stoma adhesive powder to denuded area, no sting 3M Cavilon barrier wipes applied. Placed new pouching system, and connected to bed side drainage. Patient has large abdominal incisional line with stay sutures, at the distal site is partial-thickness wound 0.5 cm, slightly raised from skin level, bed is pink, and edges attached. Cleanse incisional line with commercial wound cleanser. Placed aquacel Ag to wound site,DSD and mefix tape to secure. She was hyponatremic during her ICU stay and was felt due to volume depletion; she was given IV fluids and the problem was corrected. It should be mentioned that she has a history of diabetes insipidus likely secondary to Lithium. The Lithium levels during her hospital stay were consistently subtherapeutic. Her primary care team was consulted and conveyed that the history of her Lithium initiation was unclear given that her current primary care doctor had only recently taken her on as a new patient. The decision was subsequently made to stop her Lithium. Her creatinine began to slowly rise on [**2108-2-3**] 2.6 up to 3.4 on [**2-6**]. A renal consult was obtained. It was initially recommended to stop the Lithium, this was discontinued on [**2-3**] as this can cause nephrotoxicity. Intravenous fluids were increased as felt likely from hypovolemia related to her increased ostomy output. Also of note she was previously on Vancomycin and did have elevated levels; the Vanco was stopped; this along with the Lithium and high ostomy output all are felt to be contributing her acute renal failure. A renal ultrasound was also ordered; no hydronephrosis noted; bilateral renal cysts present. Her IV fluids were increased and will likely require further adjustment given her history of diabetes insipidus. She was placed on a renal diet. She will need to have a renal consult once transferred to the MACU @ [**Hospital1 100**] Senior Life. Physical therapy was consulted due to her deconditioned status and have recommended acute rehab post hospital stay. The plan after discharge from such a facility is to return to her group home. Medications on Admission: * Toprol XL 25mg * Protonix 40mg * Synthroid 125mcg * Lithium 150 [**Hospital1 **] * Haldol 5mg qhs * Lidex topically * Colace Discharge Medications: 1. Fluocinonide 0.05 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to affected areas. 2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ML Injection TID (3 times a day). 3. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) neb rx Inhalation Q3-4H (Every 3 to 4 Hours) as needed for shortness of breath or wheezing. 6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) rx Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day): hold for Hr <60; SBP <110. 9. Tylenol 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every 4-6 hours as needed for pain. 10. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 11. Psyllium 1.7 g Wafer [**Last Name (STitle) **]: One (1) Wafer PO DAILY (Daily). 12. Diphenoxylate-Atropine 2.5-0.025 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 13. Loperamide 2 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID (3 times a day). 14. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift 15. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) dose Injection four times a day as needed for per sliding scale. 16. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Small Bowel Obstruction Cecal Perforation Secondary Diagnosis: Acute renal failure Discharge Condition: Stable Followup Instructions: Follow up in 2 weeks with Dr. [**Last Name (STitle) **], call [**Telephone/Fax (1) 6429**] for an appointment. Follow up with your PCP ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] @ [**Hospital3 4262**] Group) after discharge from rehab. Completed by:[**2108-2-7**]

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icd9cm

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icd9pcs

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1680, 2018

2034, 2212

19,972

135,155

12680

Discharge summary

report

Admission Date: [**2115-4-14**] Discharge Date: [**2115-5-6**] Date of Birth: [**2044-9-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 465**] Chief Complaint: large IPH Major Surgical or Invasive Procedure: External ventricular drain placement and removal. G-tube placement History of Present Illness: The patient is a 70 year old man with a h/o prior stroke now presenting with a large IPH. The patient is unable to give a history so details are taken from his medical record. He was in his usual state of health until right after dinner, he arose from the table and then collapsed to the ground. He was "out of it" for about a minute. When he came to, he was agitated and confused. EMS was called and he was taken to Caritas [**Hospital 39167**]. A head CT there revealed a small amount of right parietal subarachnoid blood. During his stay there, he also vomited and was intubated for aspiration protection. He was transferred to [**Hospital1 18**] for further care. Past Medical History: -atrial fibrillation -CAD s/p CABG -h/o rectal polyps -h/o old left parietal stroke -h/o sleep apnea Social History: -lives with wife -no tobacco or alcohol use Family History: unknown Physical Exam: Vitals: 98.6 155/88 88 16 General: older man, intubated Upon admission: Neck: supple Lungs: clear to auscultation CV: irregular rhythm Abdomen: non-tender, non-distended, bowel sounds present Ext: warm, no edema Neurologic Examination: awake at times, eyes open, not following simple commands, pupils 3 to 2 mm and sluggish, +corneal reflex, +gag, +localizing to pain x4, spontaneous movement x4; dtrs depressed throughout at 1 but symmetric, toes mute . Upon transfer to medicine service: Vitals: T: 101.6 BP: 131/61 P: 73 R: 20 SaO2: 94% on 35% face tent General: Elderly man lying in bed, responds to voice minimally, A&Ox1 HEENT: Not cooperative with pupillary exam, healing incision across top of head, no scleral icterus, MM dry, no lesions noted in OP Neck: no significant JVD or carotid bruits appreciated Pulmonary: noncompliant with lung exam, CTA bilaterally, no wheezes, ronchi or rales Cardiac: tachycardic, sounds irregularly irregular, no appreciable murmurs, but difficult to assess given bowel sounds and mumbling Abdomen: soft, mildly distended, not obviously tender, normoactive bowel sounds, no masses or organomegaly noted Extremities: No edema, 2+ radial, DP pulses b/l Lymphatics: No cervical, supraclavicular lymphadenopathy noted Skin: alrge rash across abdoemn and lower chest, small erythematous maculopapular rash. Neurologic: Difficult to engage. Speaking only in mumbles. able to move all extremities. Pertinent Results: [**2115-4-13**] 11:00PM PT-11.7 PTT-21.9* INR(PT)-1.0 [**2115-4-13**] 11:00PM WBC-18.8* RBC-4.40* HGB-14.1 HCT-40.9 MCV-93 MCH-31.9 MCHC-34.4 RDW-13.9 [**2115-4-13**] 11:00PM PLT COUNT-230 [**2115-4-13**] 11:00PM NEUTS-81.1* BANDS-0 LYMPHS-12.8* MONOS-4.2 EOS-1.5 BASOS-0.4 [**2115-4-13**] 11:00PM CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-2.5 [**2115-4-13**] 11:00PM CK-MB-4 [**2115-4-13**] 11:00PM cTropnT-<0.01 [**2115-4-13**] 11:00PM CK(CPK)-135 [**2115-4-13**] 11:00PM GLUCOSE-166* UREA N-28* CREAT-1.4* SODIUM-142 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-19 [**2115-4-13**] 11:38PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2115-4-13**] 11:38PM URINE RBC->50 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2115-4-13**] 11:38PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2115-4-14**] 12:18AM LACTATE-1.8 . CT C-spine [**2115-4-13**]: 1. No evidence of cervical spine fracture. 2. Multilevel degenerative changes. There is intervertebral disc space narrowing at C6-7, and mild, probably degenerative, grade I anterolisthesis of C5 on C6. 3. Nasogastric tube is coiled within the supraglottic region. 4. Evidence of pulmonary edema at the lung apices. 5. Left subclavian vascular stent. . CT head w/o contrast [**2115-4-13**]: The epicenter of hemorrhage is probably posterior to the splenium of the corpus callosum, with extension of hemorrhage into the lateral ventricles, and right ambient cistern. Subarachnoid blood is seen within right parietal sulci and there is a potential subdural component between the cerebral hemispheres and along the tentorium. Though the epicenter of the hemorrhage is somewhat unusual, the differential diagnosis includes hypertensive hemorrhage, hemorrhage related to an AVM, neoplasm, amyloid angiopathy and idiopathic. . pCXR [**2115-4-13**]: A trauma board obscures detail. An endotracheal tube is in place, with the tip approximately 7.9 cm from the carina. Of note, a nasogastric tube is not visualized, and was seen coiled within the pharynx on the accompanying cervical spine CT. There are sternotomy wires and mediastinal clips consistent with prior CABG. The heart may be mildly enlarged. The aorta is calcified. There are increased interstitial markings within the lungs, suggesting some degree of pulmonary edema. A pacer pad over the right hilar region obscures some detail. No definite pleural effusion or pneumothorax. A stent in the left apical chest is seen . ECG [**2115-4-13**]: Atrial fibrillation. Inferior/lateral ST-T wave changes. Intraventricular conduction delay. Clinical correlation is suggested. No previous tracing available for comparison. . CT head w/o contrast [**2115-4-14**]: Again noted a rounded area of hemorrhage located within the midline posterior to the level of the lateral ventricles, measuring approximately 4.3 x 3.5 cm on today's study, compared to 4.5 x 3.4 cm previously, not significantly changed in axial dimensions. Again seen extension of the hemorrhage into occipital horns of the lateral ventricles bilaterally. Today it is also seen within right and left ambient cisterns. Subarachnoid and subdural components of the hemorrhage are not changed. There is no shift of normally midline structures. There has been interval placement of a right ventriculostomy tube. There is a small focus of air in the right frontal [**Doctor Last Name 534**] of the lateral ventricle, consistent with recent manipulation. An air-fluid level is seen in the maxillary sinus on the right and the left. The mastoid air cells are well aerated. . CT head w/o contrast [**2115-4-15**]: No significant interval change in unusual location and distribution of intracranial hemorrhage. Absent a history of trauma or anticoagulation, amyloid angiopathy should be considered, though the deep white matter location and intraventricular extension would be atypical. . pCXR [**2115-4-16**]: Comparison to prior film from earlier the same day demonstrates worsening of interstitial and alveolar opacities bilaterally likely representing edema. New retrocardiac density is likely also secondary to underlying edema, however, a focal infectious consolidation cannot be excluded. Small new pleural effusions may be present bilaterally. Cardiomegaly is again noted and the remainder of mediastinal contours are unchanged. Midline sternotomy wires and surgical mediastinal clips are seen. . CT head w/o contrast [**2115-4-17**]: No change from the prior examination with a large intraparenchymal hemorrhage centered about the splenium of the corpus callosum. Unchanged amounts of intraventricular and subarachnoid blood. Encephalomalacia in the region of the left parietal lobe. . pCXR [**2115-4-17**]: Cardiomediastinal silhouette remains enlarged. There are sternotomy wires and mediastinal clips in place. There has been an interval improvement of interstitial and alveolar opacities bilaterally, likely represented CHF. Previously noted retrocardiac density has improved as well. There is no sizable left pleural effusion. Right costophrenic angle is excluded on this study. The feeding tube is seen coiled in the esophagus. . CT head w/o contrast [**2115-4-18**]: No significant short interval change. The ventricles are unchanged in configuration compared to one day ago. . CXR Pa/L [**2115-4-20**]: There is a dense alveolar infiltrate in the right upper lung greater than left upper lung with pulmonary vascular redistribution and cardiomegaly. Given the rapid change in appearance of the infiltrates over the past few days, this likely represents pulmonary edema but an underlying infectious infiltrate cannot be totally excluded. There are small bilateral effusions. . CT head w/o contrast [**2115-4-21**]: No significant change in ventricular size and shape, when compared to the series of studies dating to [**2115-4-14**], when the ventriculostomy catheter was placed. The parenchymal, intraventricular and subarachnoid hemorrhage are, overall, unchanged in appearance. . CXR Pa/L [**2115-4-21**]: When compared with the prior examination, there appears to be a slight improvement in the appearance of the airspace disease in the right upper lobe. Mild pulmonary vascular congestion persists. The left lung is not optimally evaluated since the patient's arm is overlying it. No large pleural effusions are seen in this projection. Colon interposition is seen on the right side. . CT head w/o contrast [**2115-4-23**]: Since that examination, there has been no change. There is a large hemorrhage centered about the splenium of the corpus callosum. There is intraventricular and subarachnoid blood, similar in appearance to the prior examination. The right frontal ventriculostomy catheter remains unchanged in position. There is encephalomalacia in the left parietal lobe. . CT chest w/contrast [**2115-4-24**]: 1. Widespread alveolar consolidations, most likely representing widespread infection. The differential diagnosis should include alveolar hemorrhage, but clinical correlation is recommended. The pulmonary edema is less likely due to the patchy appearance in predominantly upper lobe distribution of these findings. Aspiration should also be considered although the upper lobe predominance with relative sparing of the lower lobes is unusual. No mass seen. 2. Mediastinal and hilar lymphadenopathy most likely reactive to the lung process, but followup is recommended, especially for the right paratracheal lymph node for documentation of its decrease in size. 3. Cardiomegaly, coronary calcifications, previous CABG, and aortic atherosclerosis. 4. Hypodense right kidney lesion most likely cortical cyst. Evaluation with ultrasound is recommended. 5. Probable mixing artifact causing apparent filling defect in upper SVC, as above. Depending on the patient's clinical exam and risks for SVC thombus, an MRV is a consideration for further evaluation if indicated. . Echo [**2115-4-24**]: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. There is no mass/thrombus in the right ventricle. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . EKG [**2115-4-24**]: Afib with RVR . CT head w/o contrast [**2115-4-25**]: 1) Status post right ventriculostomy catheter removal with a new moderately- sized hypodense subdural collection causing mass effect on the adjacent parenchyma. 2) Stable appearance of the hemorrhage centered on the splenium of the corpus callosum, layering within the ventricles, and scattered within the subarachnoid spaces. 3) Study is somewhat motion limited and, especially in evaluation of the left frontal distribution . EEG [**2115-4-25**]: This is a very abnormal portable routine EEG due to the low voltage, slow background with bursts of generalized slowing suggestive of diffuse encephalopathy was well as dysfunction of the subcortical and deep midline structures. Metabolic disturbance, infection, and medications are among the most common causes of encephalopathy. No epileptiform features were seen. This study was limited by muscle artifacts during a significant portion of the recording . CT head w/o contrast [**2115-4-26**]: No significant interval change in hemorrhage centered on the body of the corpus callosum and small right frontal extra-axial collection with intracranial air. The etiology of this hemorrhage is still unclear. . RUQ u/s [**2115-4-26**]: 1. No evidence of hepatic or biliary pathology. 2. Small right pleural effusion. 3. Septated right renal cyst . pCXR [**2115-4-29**]: Comparison is made with the prior chest x-ray of [**4-23**]. Dense opacification of the right upper lobe is present consistent with right upper lobe pneumonia. Patchy infiltrates are present also in the left upper lobe consistent with pneumonia in this area as well. Elsewhere, the lung fields appear clear. No failure is seen. . CT head [**2115-5-1**]: Comparison with the prior study reveals little change in the extent of the large hemorrhage which appears centered in the body of the corpus callosum. There is a probable tiny amount of blood layering in the right occipital [**Doctor Last Name 534**]. However, there is a suggestion that there may be very slight interval increase in the size of the supratentorial ventricular system. The left parietal lobe chronic infarct is again noted. The present study also suggests that there is a lacunar infarct in the right lentiform nucleus, which I cannot clearly identify on prior studies. This lesion is arcuate in configuration, measuring approximately 1 cm in length. The right frontal subdural fluid and gas collection has undergone essentially complete regression. At this time, there is moderate mucosal thickening within the left maxillary sinus along its lateral wall (the present study does not completely image the maxillary sinuses, however). . pCXR [**2115-5-5**]: One portable view. Comparison with [**2115-4-29**]. The lung volumes are quite low. Dense consolidation and the right upper lobe consistent with pneumonia persists. There is now increased density in the lower right lung, which may represent a new infiltrate. The left lung is grossly clear. The patient is status post median sternotomy and CABG as before. A feeding tube has been withdrawn. . pAbdomen x-ray [**2115-5-5**]: One view. Comparison with [**2115-4-17**]. A feeding tube has been withdrawn. A percutaneous gastrostomy tube has been placed with its balloon tip projected in the gastric bubble. There is increased gas in nondilated bowel. Gas is present in the colon to the level of the rectum. Soft tissues are unremarkable. There is scattered atherosclerotic calcification. Degenerative arthritic changes are again noted in the spine. Brief Hospital Course: 70 yo man with CAD s/p CABG and multiple stents (last in [**2112**]), paroxysmal atrial fibrillation and h/o stroke p/w ICH an subarachnoid hemorrhage s/p ventricular shunt now transferred to medicine service for persistent fevers. . ## Fevers: The fevers were felt likely due to pneumonia vs chemical meningitis (especially given recent surgery and blood in brain). He was treated with at least 10 days of IV antibiotics (vancomycin, aztreonam, and metronidazole), after he developed a rash to piperacillin/tazobactam. Pulmonary evaluated the patient and recommended a 10 day course of antibiotics. There was also concern for drug fever from anti-epileptics; he was initially on phenytoin for anti-seizure prophylaxis, which was changed to levetiracetam, then d/c'ed altogether. All blood and urine cultures were negative (final) C. diff was considered since the patient also had diarrhea, but Cdiff toxin was negative x5. Of note, Cdiff toxin B was sent off on three stool samples, but results are still pending and need to be followed up. Finally there was concern for a biliary tree source since the patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] RUQ U/S was performed and was negative. His liver enzymes normalized. All antibiotics were stopped on [**2115-5-2**], and the patient remained afebrile. On the day prior to discharge, there was concern that the patient had a new [**Last Name (LF) **], [**First Name3 (LF) **] a CXR was performed revealing a possible new RLL infiltrate. His coughing improved, he remained afebrile, and his WBC decreased, and this was more indicative of transient aspiration pneumonitis rather than pneumonia. No intervention was made. If he should spike another fever, aspiration pneumonia should be considered given his altered mental status and failure of swallowing evaluation. He is being fed by peg tube to avoid overt aspiration. He should follow up with his primary care physician. . ## s/p ICH and subarachnoid hemorrhage: The patient had a ventricular drain placed and later removed by neurosurg. He had multiple head CTs revealing stable fluid collections, as well as some dilatation of the ventricles. EEG revelaed evidence of encephalopathy, without evidence of seizure activity. He was initially on anti-seizure prophylaxis, but this was later stopped. His mental status remained altered, likely due to delirium from infection, but possibly due to defecit from the stroke. His mental status should be monitored for signs of improvement, and his goals of care re-assessed if he does not improve. The patient should follow up with Dr. [**Last Name (STitle) 548**] from neurosurgery in 4 weeks (call for an appointment), and have a repeat CT head at that time. . ## Delirium: This was felt likely secondary to fevers and infection although worrisome that the patient has permanent deficits given recent head bleed. EEG was done and revealed evidence suggestive of encephalopathy. Also his chemical meningitis from hemorrhage could be contributing, and his mental status may improve once the blood resorbs. . ## Paroxysmal atrial fibrillation: On the medicine floor, the patient was noted to be in Afib with RVR. He was given several doses of IV Metoprolol, and his dose of oral Metoprolol was increased to 100mg QID. Diltiazem 30mg QID was added for better HR and BP control. His rhythm spontaneously converted to Sinus. The diltiazem was discontinued when the patient had asymptomatic bradycardia in the 40s. Anti-coaggulation is contraindicated in this patient secondary to his intra-cranial hemorrhage. . ## L great toe erythema: The patient had some erythema of the L great toe, and there was concern for gout. NSAIDS were contraindicated due to his intracranial hemorrhage, and colchicine was not given as the patient was having loose stools. He was given tylenol, but did not seem to be experiencing pain at the toe. The erythema resolved by the time of discharge. . ## ARF: The patient's Cr improved back to baseline after he was given fluid boluses and started on tube feeds, making pre-renal the most likely etiology. If he needs further blood pressure control, an ACE inhibitor can be used. . ## HTN: His blood pressure was controlled with Metoprolol and Hydralazine. His ACE-inhibitor was held initially due to the renal failure, but can be restarted if needed. . ## Rash: The patient developed what appeared to be a drug rash, felt likely secondary to piperacillin-tazobactam. This antibiotic was stopped and his rash resolved. . ## CAD s/p CABG: While in Afib with RVR, there were mild ST depressions and new TWI in lateral leads, felt likely to be rate related. He was continued on Metoprolol, Simvastatin. Aspirin and Plavix were held due to his bleed. Aspirin may be able to be restarted in the future, and Neurosurgery should address this at the patient's follow up appointment. . ## [**Last Name (STitle) 5779**]: The patient was noted to have a mild [**Last Name (STitle) **]. RUQ U/S was performed and was unrevealing. Hep serologies were negative. His [**Last Name (STitle) **] resolved without intervention. . ## High INR: The patient received Vitamin K 5 mg PO x3, with normalization of his INR. . ## FEN/Lytes: Tube feeds, now at goal . ## Prophylaxis: No heparin given head bleed, PPI, pneumoboots . ## Code status: DNR/DNI (Decision was made in a family meeting with the patient's wife/HCP several days prior to discharge.) Medications on Admission: ASA Simvastatin Amiodarone 200 Clopidogrel 75 Furosemide Ramipril Discharge Medications: 1. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours). 2. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) nebulizer treatment Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. nebulizer treatment 3. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 5. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO twice a day. 6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QID (4 times a day): hold for sbp <100 or hr <60. 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed. 10. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 11. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Twelve (12) units Subcutaneous every twelve (12) hours. 12. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: as directed per sliding scale Subcutaneous four times a day. 13. Hydralazine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every six (6) hours: hold for systolic blood pressure less than 120. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: * Intracerebral hemorrhage with intraventricular extension * Hydrocephalus * Pneumonia * Altered Mental Status likely due to delirium combined with some permanent defecit from your stroke. * s/p G- tube placement Discharge Condition: Afebrile, with altered mental status. (awake, arousable, but does not follow commands; cannot take orals, G-tube feeds only) Discharge Instructions: You were admitted with a stoke caused by bleeding into your brain. You also had pneumonia, and you completed a full course of antibiotics. Since your mental status is still not clear, do not take any food or medicine by mouth; only tube feeds. You may take medications through your G-tube. . Take all medications as prescribed and keep all follow up appointments. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any change in mental status (currently you have altered 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 WITH DR.[**Last Name (STitle) **] FROM NEUROSURGERY, TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST at that time. . Call your primary care physician for an appointment in [**1-22**] weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Completed by:[**2115-5-6**]

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icd9cm

[ [ [] ] ]

[ "96.71", "43.11", "96.6", "93.90", "02.2" ]

icd9pcs

[ [ [] ] ]

22507, 22577

15216, 20703

325, 394

22834, 22961

2787, 15193

23984, 24420

1303, 1313

20822, 22484

22598, 22813

20729, 20797

22985, 23961

1328, 1390

275, 287

422, 1100

1404, 1546

1570, 2768

1122, 1225

1241, 1287

7,415

142,869

3856

Discharge summary

report

Admission Date: [**2189-1-16**] Discharge Date: [**2189-1-31**] Date of Birth: [**2158-6-22**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1974**] Chief Complaint: Diarrhea. Major Surgical or Invasive Procedure: Sternotomy and drainage pericardial effusion. Lymph node biopsy. History of Present Illness: 30F with hypothyroidism and anemia history initially presented to ED [**1-16**] w/ [**3-21**] day h/o fever and diarrhea. Patient was taking stool softeners daily with her iron pills and she attributed her watery diarrhea to overdose of the stool softener. She denied hematochezia. In the ED, found to be hypotensive, responsive initially to fluids, and febrile to 101. Patient was given empiric vanco/levo/flagyl. CXR showed cardiomegaly and an ECHO revealed a large pericardial effusion as well as intramural hematoma in aorta. Emergent CTA of the chest showed a likely type A aortic dissection. Of note, patient's initial INR was elevated at 1.8 and PTT was elevated at 45 which was of unclear etiology, thought potentially due to loss of bowel flora. She received no heparin prior to when these values were drawn. Pt was taken emergently to OR, revealing serous pericardial effusion, per surgical team. The aorta showed calcifications and inflammatory changes concerning for infectious process. Therefore, no intervention of the aorta was undertaken. Pericardium was stripped and left open. [**Name (NI) **], pt failed to be weaned off of epinephrine drip. Continued to spike temp to 102.2 on vancomycin started post-op. CXR showed L pleural effusion and loculated fluid in the L fissure. Levo added [**1-19**] for presumed pneumonia. In the ICU, patient had deteriorating mental status and 1 day of neck stiffness. Neuro was consulted but neck stiffness resolved. CT and LP were both negative. Mental status improved [**1-22**], extubated [**1-22**], now back to baseline. Mental status changes presumed to be due to either SLE cerebritis or hypoperfusion. WBC continued to be elevated and low grade fever persisted. ID was consulted. All blood and stool cultures have been negative. RPR was negative. ID determined that aortitis is unlikely of infectious etiology. Patient was found to have low complement levels and Rheum was consulted. Rheum suspected lupus/takayasu/giant cell as the etiology of pericardial effusion and aortitis. Patient was also found to have low cortisol in the setting of hypotension. Endocrine was consulted. MRIpit showed partially empty sella. Likely hypopituitary but not panhypopit b/c FSH/LH levels were normal. Patient was started on dexamethasone [**1-21**], switched to prednisone [**1-24**]. Upon arrival to the floor, she was found to have LUE edema. An U/S was ordered and found a thrombus occluding L IJ and a thrombus in the R cephalic vein. Patient describes feeling better with her arrival to the floor. She recalls none of the events that took place in the ICU. She says that her diarrhea went away with discontinuation of the stool softeners. She complains of fatigue, a mild cough, and shortness of breath. She denies hematochezia, hematemesis, abdominal pain, chest pain, wheezing, nausea, vomiting, headache, dizziness, fevers, chills, dysuria, vision changes, numbness and tingling in her extremities, joint pain, rashes, and claudication. [**Name (NI) **], pt failed to be weaned off of epinephrine drip (CVP 8, PAD 14, PA mean 19). Continued to be CVP10 PA27/17, thermodilution CI 1.8, SVO2 61. Continued to spike temp to 102.2 on vancomycin (given post-operatively), however, no additional antibiotics added. Past Medical History: 1. Iron deficiency anemia 2. Hypothyroidism - no current medications 3. Shortness of breath of unclear etiology (DOE) 4. History of leg cramps Social History: Married. Has one 3 year-old son. Noted to have failure to nurse after her son was [**Name2 (NI) **]. Also bled alot during delivery but did not require blood transfusions. Had 1 miscarriage in [**2181**] with 2 pregnancies total. Noted a history of irregular and heavy menstrual periods. Denies tobacco, rare EtOH, no drugs. Family History: Maternal aunt with PEs, died of stroke and MI at age 50 Maternal uncle with bilateral DVTs in legs Mother with HTN Aunt with uterine cancer Aunt with diabetes Physical Exam: VS 123 88/53 (MAP ranging 60-65), PSV 16/5 FiO2 0.32 100% GENERAL: Intubated, appears sedated HEENT: PERRL, intubated NECK: JVP not able to appreciate level. CARDIOVASCULAR: S1, S2, regular, tachy LUNGS: Clear by anterior exam ABDOMEN: Soft, NT, ND. EXTREMITIES: Warm, no CCE. NEURO: Moving all four to commands. Pertinent Results: [**Year (4 digits) **] DATA: CBC: [**2189-1-16**] WBC-10.8# RBC-4.72# Hgb-12.0# Hct-35.4*# MCV-75* MCH-25.5* MCHC-34.0 RDW-18.2* Plt Ct-284 COAGS: [**2189-1-16**] PT-18.6* PTT-45.0* INR(PT)-1.8* CHEMISTRIES: [**2189-1-16**] Glucose-51* UreaN-19 Creat-1.7* Na-132* K-4.1 Cl-101 HCO3-17* AnGap-18 LFTS: [**2189-1-16**] ALT-41* AST-150* AlkPhos-102 Amylase-79 TotBili-1.1 Lipase-82* Albumin-3.7 CARDIAC ENZYMES: [**2189-1-18**] CK-MB-24* MB Indx-0.9 cTropnT-<0.01 [**2189-1-18**] CK-MB-33* cTropnT-<0.01 [**2189-1-18**] CK-MB-28* MB Indx-1.0 cTropnT-<0.01 ENDOCRINE LABS: [**2189-1-22**] FSH-2.4 LH-2.2 Prolact-<1.0* TSH-2.2 [**2189-1-22**] T4-3.7* T3-37* calcTBG-1.05 TUptake-0.95 T4Index-3.5* Free T4-0.52* [**2189-1-16**] HCG-<5 RHEUM LABS: [**2189-1-19**] ANCA-NEGATIVE B [**2189-1-19**] RheuFac-<3 CRP-GREATER TH [**2189-1-19**] [**Doctor First Name **]-POSITIVE Titer-1:40 [**2189-1-27**] [**Doctor First Name **]-NEGATIVE [**2189-1-22**] Anti-Tg-LESS THAN [**2189-1-22**] dsDNA-NEGATIVE [**2189-1-26**] antiTPO-LESS THAN [**2189-1-20**] b2micro-2.3* [**2189-1-19**] 03:27AM BLOOD C3-0* C4-2* HEME LABS: Fact II-63 FactVII-40* FacVIII-247* Fact IX-77 Fact X-63 Lupus-POS AT III-67* ProtCAg-82 SEROLOGIES: [**2189-1-19**] HIV Ab-NEGATIVE [**2189-1-19**] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE CT CHEST/ADB ([**2189-1-16**]): 1. Findings consistent with ascending aorta circumferential large intramural hematoma. A focal outpouching along the anterior aorta just superior and to the right of the RCA origin appears unchanged from prior studies in [**2187**]. This could be a small pseudoaneurysm. 2. Large pericardial effusion with density greater than simple fluid raises suspicion for bleeding into a pericardial effusion. Right and left coronary arteries appear widely patent at their origins. 3. Small bilateral pleural effusions. 4. Right upper lobe 4 mm nodule again seen. New 3 mm nodule in the right upper lobe ([**4-29**]). One-year followup is recommended to document stability. 5. Replaced right subclavian artery. CT HEAD W/O CONTRAST ([**2189-1-16**]) No evidence of hemorrhage or mass, appearance unchanged from [**2186-7-18**]. CXR ([**2189-1-16**]): Enlargement of the cardiac silhouette compared to [**2187**] may represent cardiomegaly versus pericardial effusion. Prominence of pulmonary vascularity noted bilaterally suggests mild pulmonary edema. ECHO ([**2189-1-16**]): 1. The right atrium is markedly dilated. 2. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed. 3. The right ventricular cavity is markedly dilated. There is severe global right ventricular free wall hypokinesis. 3. The aortic root is mildly dilated. The anterior and posterior walls of the aortic root are homogenous thickened (1 cm) suggesting an intramural hematoma. 4. The mitral valve leaflets are mildly thickened. 5. Moderate [2+] tricuspid regurgitation is seen. Mild pulmonary hypertension is present. 6. There is a large, circumferential pericardial effusion with large amounts of fibrin/thrombus on the surface of the heart. No clear evidence of tamponade is seen, but this may be due to pulmonary hypertension. 7. Compared to the previous report of [**2187-8-24**], the pericardial effusion is much larger. MR PITUITARY W&W/O CONTRAST ([**2189-1-23**]) Ventricles to have normal in size which is unchanged from the previous CT examinations of [**2184-10-18**]. Empty sella without evidence of pituitary micro or macroadenoma. No enhancing lesions identified. MRA abdomen/chest ([**2189-1-27**]): 1. Arteritis involving predominantly wall thickening of the ascending aorta, although the entirety of the descending aorta is also involved to a much lesser extent. No significant luminal narrowing is present. Prominent wall thickening of the SMA is also appreciated. Given the patient demographics, findings may be consistent with Takayasu's arteritis. 2. There is no evidence of involvement of the carotid or subclavian arteries. 3. Right-sided pulmonary embolism, as shown on the subsequent CTA of the chest. 4. Left internal jugular vein thrombus. 5. Bilateral pleural effusions, mild to moderate in size, greater on the right than on the left. Brief Hospital Course: 1. Pericardial Effusion Patient initially presented to the ED with diarrhea and fever for 2-3 days. On CXR she was found to have large pericardial effusion, confirmed by echo. Patient had pericardial effusion drained in the OR, revealing serous pericardial fluid. After pericardial fluid drainage, patient's pericardial effusion appeared to remain stable, with continued pulsus paradoxus checks. Unclear etiology for patient's pericardial effusion. Most likely possibilites include rheumatologic diagnoses, including SLE. 2. Aortitis Patient was found on CTA to have intramural hematoma. Then in the OR, patient was found to have aortitis with the following findings noted in the operative report: "inflammatory pathology with the complete matting of the tissues around the aortic root extending onto the ascending aorta with heavily calcific on the aorta all the way from the root to the beginning of the arch." Differential diagnosis for patient's aortitis includes various vasculitides. Additionally, patient was found to be RPR negative. Rheumatology and infectious disease were both consulted to help in the evaluation of this finding. MRA showed thickening and inflammation of the ascending and descending aorta as well as SMA. Patient had 1 [**Doctor First Name **] that was mildly positive. SLE vs. Takayasu arteritis. Patient was treated with high dose steroids for 5 days followed by 3 days of half pulse solumedrol. She was discharged on prednisone and will follow up with rheumatology. 3. DVT Approximately one week into patient's hospitalization, she was found to have left arm swelling greater than the right and was found on upper extremity ultrasound to have an occlusive thrombus in her left IJ and R cephalic. She was also found with a PE and a L cephalic clot a few days later. She was started on heparin drip and had fluctuations of her PTT, so was switched to lovenox. She was then started on coumadin prior to discharge. Hypercoagulable w/u showed one positive lupus anticoagulant so pt may have antiphospholipid antibody syndrome. She was seen by [**Doctor First Name 1978**] who was felt further repeat Ab testing would need to be done as outpt to diagnose APS. 4. Anemia Patient was noted to have a history of anemia. Iron studies obtained prior to this admission suggested iron deficiency anemia with ferritin of 197. During this admission, patient received blood transfusions post-operatively, making any further iron studies difficult to interpret. Patient had a 3 week long menses which started 1 week prior to admission and finished 2 weeks into her hospital stay. However, her hct was stable while on the floor and she required no more blood transfusions. 5. Adrenal Insufficiency Patient was found to be profoundly adrenally insufficient with three failed cosyntropin stim tests. Empty sella found on MRI. Endocrine consult suggest hypophysitis possibly postpartum, followed by atrophy of the gland leaving her with empty sella. ACTH levels low, TSH normal but T4 low, PRL unmeasurable suggesting partial hypopituitary. Patient was covered with steroids for both her rheumatologic and adrenal problems. Discharged on prednisone. 6. Asthma Patient had nebs PRN throughout her stay. She was stable during her stay with no severe flares. 7. GERD Patient had numerous complaints of epigastric pain relieved by antacids. She was maintained on PPI, Maalox and Tums PRN. 8. Hypothyroid Patient was diagnosed with sick euthryoid. TSH normal, Free T4 low. Started on levothyroxine during her stay. Medications on Admission: Albuterol prn Docusate Iron sulfate Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 unit* Refills:*2* 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). Disp:*30 Tablet(s)* Refills:*2* 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Outpatient [**Name (NI) **] Work PT/PTT/INR Please have this checked on Monday. Have the results sent to: [**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 250**] 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 8. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 6 days. Disp:*12 * Refills:*0* 9. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day: Please take 6 pills a day until [**2-5**]; then take 5 pills a day until [**2-11**]; then take 4 pills a day [**2-19**]; then continue to take 3pills a day. Disp:*180 Tablet(s)* Refills:*1* 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: 1. Aortitis 2. Pulmonary embolus 3. Adrenal insufficiency, secondary 4. Pericardial effusion 5. Upper extremity thrombus Secondary: 1. Hypothyroidism, secondary 2. Asthma 3. GERD Discharge Condition: Vital signs stable, improved. Discharge Instructions: At the time of discharge, you have been begun on multiple new medications. It will be important for you to continue taking these, as prescribed. These include: 1. Prednisone: This is a steroid which helps to decrease inflammation. You should continue taking this medication, as prescribed, until you see the rheumatology doctors. 2. Coumadin: This medication will help to thin your blood - this is particularly important for you given that you have clots in some of your blood vessels. Blood levels need to be followed as an outpatient. Please be sure to have blood work drawn 2 days after discharge (a prescription is included) to determine if the dose of this medication needs to be changed. Please take this medication AT NIGHT. 3. Lovenox: It will take a few days for your coumadin to become effective. In the time before it works, you need to use this medication to ensure that your blood is thinned. You will continue hese injections twice a day until your coumadin level called INR is high enough. Your primary care doctor and the [**Hospital 197**] clinic nurses will manage this. 4. Levothyroxine: Given that you have low thyroid function, this medication will provide you with thyroid hormone replacement. It should be taken once daily. 5. Calcium/Vitamin D: These are vitamin supplements to help protect your bones. 6. Bactrim: This is an antibiotic that should be used to prevent infections - we prescribe it to patients with chronic steroid use, which you will require. It is to be taken every Monday, Wednesday and Friday. 7. Omeprazole: you should take this for protection against stomach ulcers while you are taking steroids. 8. Your should be started on the medication called Plaquenil at the dose 200 mg twice a day, but one of your [**Hospital **] tests is not back yet (G6PD), so we could not start this medication in the hospital. Please discuss this [**Last Name (STitle) 17290**] regarding starting this medication. Some of the [**Last Name (STitle) **] tests that we ordered during your hospitalization are still pending in the computer. Please follow up with your primary care physician (including repeat [**Doctor First Name **], CRP, protein C, protein S, anti-treponemal Abs, G6PD). Please follow up as listed below. In addition to the above, if you notice increased fatigue, chest pains, problems breathing, increased swelling or have any other questions or concerns, please be sure to call your primary care doctor or go to the emergency room. Followup Instructions: You have the following appointments scheduled: 1. [**Name8 (MD) 17291**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2189-2-4**] 4:00 This is on the [**Location (un) **] of the [**Hospital Ward Name 23**] building ([**Hospital Ward Name **]). 2. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2189-2-13**] 2:45 You have an appointment with the opthomologist to get your eyes checked. This is on the [**Location (un) 442**] of the [**Hospital Ward Name 23**] building. 3. [**Last Name (LF) 7801**],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9 Date/Time:[**2189-2-20**] 9:30. This is a follow-up appointment with the hematologist regarding your blood clots. This is in [**Hospital Ward Name 23**] buiding, [**Location (un) **]. 4. You have a follow-up appointment with the rheumatologist on [**2189-3-4**] at 10am. Please call ([**Telephone/Fax (1) 1668**] for directions to the office or if you need to reschedule. 5. You should call on Monday ([**Telephone/Fax (1) 1504**] to schedule a follow up appointment with Dr. [**Last Name (STitle) **], your cardiac surgeon, in about 2 weeks. 6. Please call on Monday ([**Telephone/Fax (1) 9072**] to schedule a follow up appointment with Endocrinology in about 2-3 weeks.

[ "276.51", "799.02", "486", "280.9", "584.9", "453.8", "244.9", "253.9", "420.91", "V58.65", "447.6", "493.90", "710.9" ]

icd9cm

[ [ [] ] ]

[ "03.31", "37.31", "38.93", "96.72", "99.04", "88.72", "00.17", "34.09", "89.64", "96.6", "40.11" ]

icd9pcs

[ [ [] ] ]

14081, 14138

8957, 12489

282, 349

14371, 14403

4685, 5084

16953, 18333

4175, 4336

12576, 14058

14159, 14350

12515, 12553

14427, 16930

4351, 4666

5101, 8934

233, 244

377, 3648

3670, 3814

3830, 4159

15,858

155,180

23591

Discharge summary

report

Admission Date: [**2112-3-9**] Discharge Date: [**2112-3-11**] Service: MICU The patient was admitted on [**2112-3-9**]. The patient expired on [**2112-3-11**]. HISTORY OF PRESENT ILLNESS: The patient was an 82-year-old female, with a history of smoking, who presented as a transfer from an outside hospital for bronchoscopy and stent placement. The patient was admitted to an outside hospital in [**2112-2-2**] complaining of [**2-5**] days of a nonproductive cough, as well as increasing dyspnea, mainly on exertion. The patient had an x-ray done which was suspicious for a right lower lobe infiltrate and was admitted to the hospital for treatment of pneumonia. A CT scan done during the hospitalization showed right lower lobe and middle lobe post obstructive consolidation. There was also a complete obliteration of the right bronchus intermedius and narrowing and constriction of the right pulmonary artery. There were multiple small nodules in the right upper lobe and several left sided ground glass nodules. It was thought that these findings were likely secondary to cancer, although other granulomatous disease was also possible. The patient was seen by a pulmonologist at the outside hospital, and it was felt that there was a probable endobronchial mass consistent with lung cancer with obstruction in the right lower lobe, as well as left mainstem bronchi compression and pulmonary artery compression. At that time, the plan was to proceed with outpatient bronchoscopy. The patient came in to [**Hospital1 18**] on [**2112-3-8**] for a flexible bronchoscopy. This bronchoscopy showed obstruction of the bronchus intermedius and lower lobe, with severe tumor involvement of the carina, as well as right and left sided involvement. Secondary to tumor involvement, there was narrowing of the left mainstem bronchus to 5 mm. The patient was then taken to the operating room for a rigid bronchoscopy. Balloon dilatation and stent placement were performed in the left mainstem bronchus. The patient remained intubated after the procedure due to the severity of the condition and a prolonged procedure and was transferred to the medical ICU. PAST MEDICAL HISTORY: 1. Pneumonia. 2. COPD. MEDICATIONS ON ADMISSION: 1. Combivent inhaler. 2. Calcium. 3. Vitamin D. 4. Multivitamins. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was a heavy smoker quitting 2 years ago. No history of alcohol or IV drug use. She lived alone and had 4 children. PHYSICAL EXAMINATION: On admission, the patient was afebrile, with a blood pressure of 91/56, heart rate of 84, respiratory rate of 18, and O2 sat of 98%. General: The patient was a frail elderly woman lying in bed intubated. HEENT exam: Normocephalic and atraumatic with pupils equally round and reactive. Sclerae anicteric and oropharynx clear, with the ET tube in place. Lungs: Crackles bilaterally and coarse breath sounds. Cardiovascular: Regular rate and rhythm, S1 and S2. Abdomen: Soft, nontender, nondistended, with normal active bowel sounds. Extremities showed no clubbing, cyanosis, or edema. Extremities were warm and well perfused. LABORATORY DATA: CBC showed a white count of 12.6, hematocrit of 44 and platelets of 344. Chem 7 was within normal limits. Initial ABG was pH 7.38, PCO2 of 41, and PAO2 of 68 on assist control with a tidal volume of 400, respiratory rate of 16, PEEP of 8 and FIO2 of 0.6. HOSPITAL COURSE: Respiratory failure: The patient's respiratory failure was secondary to extensive lung cancer and bronchial obstruction. During the bronchoscopy, she did have a stent placed in the left mainstem bronchus. Due to her extensive malignancy, it was felt that her prognosis would be very poor. It was also likely that she would be able to be extubated successfully. Family discussion was conducted and the patient's poor prognosis was relayed to the family. At this time, it was decided to make the patient Comfort Measures Only. Per the family's wishes, the patient was extubated and started on a morphine drip for comfort. This was done on the afternoon of [**2112-3-10**]. The patient died on [**2112-3-11**] at 5:20 a.m. At that time, she was unresponsive to voice or pain. Pupils were fixed and dilated. There were no breath or heart sounds. The patient was pronounced dead at 5:20 a.m. The patient's so was present at the time of death and the daughter was notified by the son. A post mortem examination was declined by the family. FINAL DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Lung cancer. DISCHARGE STATUS: The patient expired. [**Last Name (LF) **],[**First Name3 (LF) **] J. 12-[**Last Name (un) **] Dictated By:[**Doctor Last Name 7255**] MEDQUIST36 D: [**2112-8-10**] 16:21:27 T: [**2112-8-11**] 09:12:06 Job#: [**Job Number 60389**]

[ "519.1", "197.0", "493.20", "162.8" ]

icd9cm

[ [ [] ] ]

[ "33.91", "96.71", "32.01", "96.05", "33.23" ]

icd9pcs

[ [ [] ] ]

2238, 2347

3432, 4466

4483, 4827

2515, 3414

203, 2164

2186, 2212

2364, 2492

7,778

134,342

26359

Discharge summary

report

Admission Date: [**2160-10-17**] Discharge Date: [**2160-10-25**] Date of Birth: [**2083-11-21**] Sex: M Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 7299**] Chief Complaint: Fever and stomach pain Major Surgical or Invasive Procedure: ERCP with stent Endotracheal intubation History of Present Illness: Mr. [**Known lastname 57853**] is a 76yo male who presented to [**Hospital3 **] on [**10-11**] with complaints of SOB. He had a WCC of 11.2 w a CXR suggestive of COPD w/o signs of CHF or PNA. He was admitted for treatment of COPD exacerbation. On [**10-12**] he complained of RUQ pain, without fevers/N/V/D. An abdominal CT demonstrated cholelithiasis w gallbladder wall thickening and edema, raising concern for cholecystitis. However on [**10-13**] he underwent a HIDA scan with no signs of cystic obstruction or acute cholecystitis. For uncertain reasons patient underwent a lap chole for treatment of presumed cholecystitis. Procedure was completed w/o incident and patient was discharged. On POD#3, pt presented to [**Hospital1 **] with fevers, abdominal pain, and leukocytosis 14.4, concern for retained stone vs biliary leak. Pt possibly had a HIDA at this time, although no report has been found. Patient was then transferred to [**Hospital1 18**] for ERCP. At time of transfer patient's vitals were recorded as 97.6 113/61 67 93% 2LNC. . On arrival at ERCP patient's vitals were T98.6 HR71 BP156/58 RR24 O2sat 100% 2LNC. During pre-op preparation, patient went into respiratory distress on passing a BM, requiring bipap. He was then intubation for airway protection for the procedure. . ERCP was completed, finding a single 6mm round stone causing partial obstruction of the CBD; a single plastic stent was placed. . On transfer to the [**Hospital Unit Name 153**], initial VS were: T97.6 P89 BP98/44 R26 O2 sat 98% on CMV 100% Fi02, Tv550 RR16 PEEP5. Patient's SBP trended down to high 80s. Patient was bolused 500cc NS and his propofol was decreased then switched to fent/midaz. Pressures improved to MAPs >65. Past Medical History: # Aortic Stenosis s/p Aortic Valve Replacement [**2156-1-9**] - (#[**Street Address(2) 65216**]. [**Male First Name (un) 923**] # ESRD [**2-26**] htn on Hemodialysis T/Th/Sat thru L AVF # Hypertension # Hypercholesterolemia # s/p AAA repair in ?[**2150**] @ [**Hospital1 336**] # s/p right aortoiliac bypass # R knee surgery # R aorti iliac bypass # Peripheral Vascular Disease # Anxiety/depression # s/p R quad repair # Benign Prostatic Hypertrophy # s/p L lung biopsy . Social History: Lives in [**Location 38640**], MA with his wife. 2 children. Works as a security guard. Former 2 ppd smoker. ~ 96 pk/yr hx. Quit in [**2144**]. Drinks [**1-26**] glasses of wine/day. No h/o heavy EtOH use. Family History: Denies any family h/o early CAD or other heart problems. . Physical Exam: General: intubated NAD HEENT: Sclera anicteric, PERRL, MMM, OP clear Neck: JVP not elevated Lungs: coarse breath sounds, otherwise CTA b/l CV: RRR, nlS1/S2, no mrg Abdomen: scabs from lap chole c/d/i, soft, NT/ND, naBS, no rebound/guarding, GU: foley+ Ext: WWP, chronic vascular congestion changes, 2+ pulses, no edema Pertinent Results: Admission Labs: [**2160-10-17**] 10:05PM BLOOD WBC-18.5* RBC-4.46* Hgb-13.0* Hct-38.3* MCV-86 MCH-29.1 MCHC-33.9 RDW-15.3 Plt Ct-206 [**2160-10-17**] 10:05PM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2* [**2160-10-17**] 10:05PM BLOOD Glucose-137* UreaN-25* Creat-3.7* Na-138 K-4.0 Cl-106 HCO3-24 AnGap-12 [**2160-10-17**] 10:05PM BLOOD ALT-127* AST-108* LD(LDH)-176 AlkPhos-565* Amylase-41 TotBili-3.1* [**2160-10-17**] 10:05PM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.0 Mg-2.1 [**2160-10-17**] 06:33PM BLOOD Type-[**Last Name (un) **] pO2-22* pCO2-42 pH-7.43 calTCO2-29 Base XS-1 Intubat-NOT INTUBA Comment-O2 DELIVER . CXR [**10-17**]: IMPRESSION: Interstitial lung disease, scarring left upper lung zone, atelectasis at the right lung base. . CXR [**2160-10-18**]:Single portable chest radiograph is compared to multiple prior examinations. Endotracheal tube terminates at the thoracic inlet. Status post CABG. Diffuse interstitial edema with Kerley B lines. Mild atelectasis at both lung bases. Heart is top normal in size. Aorta is calcified and somewhat tortuous. Scarring is present in the left upper lobe periphery. . ERCP [**2160-10-17**]: A single periampullary diverticulum with large opening was found at the major papilla Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. A single 6 mm round stone that was causing partial obstruction was seen at the middle third of the common bile duct. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. The stone was extracted successfully using a 11.5 mm RX balloon. To ensure bile duct patency, a 5cm by 10mm single pigtail biliary stent was placed successfully. Otherwise normal ercp to third part of the duodenum . [**2160-10-25**] 08:30AM BLOOD WBC-8.0 RBC-4.40* Hgb-12.5* Hct-38.2* MCV-87 MCH-28.3 MCHC-32.6 RDW-14.7 Plt Ct-293 [**2160-10-25**] 08:30AM BLOOD Glucose-88 UreaN-28* Creat-3.3* Na-137 K-4.8 Cl-102 HCO3-26 AnGap-14 [**2160-10-20**] 07:30AM BLOOD ALT-51* AST-26 AlkPhos-306* TotBili-0.9 Brief Hospital Course: #. Choledocolithiasis: Pt had undergone cholecystectomy 3 days prior to returning with fevers and leukocytosis. Imaging/labs were concerning for retained CBD stone. Pt was transferred for ERCP and developped respiratory distress prior to procedure requiring BIPAP. He was electively intubated for ERCP which revealed 6mm CBD stone. Pt underwent sphincterotomy, stone extraction and stenting before being transferred back to the ICU intubation. Pt was treated empirically with Cipro/Flagyl and did not show signs of sepsis while in the ICU. He was extubated and weaned to home O2 of 2-3L within 48hrs of admission. LFTs trended down post procedure and will need to be followed up as an outpt. Pt was scheduled for follow up ERCP in [**Month (only) **] for re-evaluation and stent removal. After transfer to the floor, pt was continued on Cipro/Flagyl for 5 day course but was noted to have profuse diarrhea which returned positive for C.diff. Cipro was stopped and pt was continued on Flagyl 500mg TID with Vanc 250mg po q6hrs. Pt was treated with low dose oxycodone for abd cramping and remained with a normal WBC ct, tolerating a regular diet. He was discharged after HD on [**10-25**] with plan for surgical follow up on [**10-27**] and was given a prescription for 8 additional days of po Vancomycin. . #. Emphysema/COPD/Fibrosis: Pt developped acute respiratory distress pre-ERCP and required intubation. He was notably more hypoxic in the first few days post intubation possibly due to volume and bronchospasm. However, with HD and volume loss of diarrhea, his breathing returned to baseline with 2-3L O2 requirement at rest. He was seen by physical therapy who recommended home PT and he was continued on his home regimen of Advair, Spiriva and Levalbuterol. . #. CAD/PVD: Pt has significant vascular disease with CAD, aortic stenosis s/p AV replacement and significant PVD s/p AAA repair and bypass. Per ERCP team, aspirin was held for 5 days post procedure and he was restarted on [**10-22**] without complications. He was otherwise continued on his home regimen of Lisinopril and Atorvastatin. . #. ESRD on HD T/Th/Sat: Pt was followed by the renal team while in house and was dialyzed Tu/Th/Sa. He was continued on his home regimen of nephrocaps and sevelamer. . Medications on Admission: Sevelamer HCl 800mg w meals Pantoprazole 40mg daily Nephrocaps 1 cap daily Tamsulosin HCl 0.4mg daily Simvastatin 20mg PO daily Lisinopril 20mg daily Fluticasone250-Salmeterol 1puff [**Hospital1 **] Levalbuterol 1.25mg neb q4h Tiotropium Bromide 1 puff daily ASA 325mg daily Discharge Medications: 1. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three times a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 8. Levalbuterol HCl 1.25 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 11. Vancocin 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 8 days. Disp:*32 Capsule(s)* Refills:*0* 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Obstructive Cholangitis Severe Emphysema/COPD C. Diff diarrhea . Secondary: ESRD on HD CAD s/p stenting & AAA repair s/p AVR s/p CCY Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with abdominal pain after having your gall bladder removed and you were found to have a retained gallstone. You were taken for an ERCP with removal of the stone and stent placement. You were intubated for the procedure and taken to the ICU for monitoring overnight due to persistent hypoxia. Unfortunately, you have developped an antibiotic associated diarrhea called C. difficile colitis and we have been treating you with oral Vancomycin every 6hrs. You will need to continue this treatment for another 8 days. . Please note the following changes to your medication regimen: Start Vancomycin 250mg q6hr for another 8 days Start Oxycodone 5mg twice daily as needed for abd pain over the next 7 days, not to be used on a continuing basis. . Otherwise, you can continue taking your medications as you were prior to admission. Followup Instructions: Department: ENDO SUITES When: FRIDAY [**2160-12-12**] at 10:30 AM Department: DIGESTIVE DISEASE CENTER When: FRIDAY [**2160-12-12**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], 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 . You have a follow up appointment scheduled with Dr. [**Last Name (STitle) 43078**] on Monday [**10-27**] at 3:45pm. Please call his office if you are unable to keep this appointment. . Please call Dr.[**Name (NI) 34847**] office on monday to schedule a follow up appt this week. Name: [**Name (NI) **],[**Doctor Last Name **] Address: [**Street Address(2) 4472**], [**Apartment Address(1) 51742**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 31188**]

[ "530.81", "272.0", "V45.11", "515", "428.0", "300.4", "V45.82", "443.9", "577.8", "285.9", "403.91", "600.00", "585.6", "V15.82", "492.8", "008.45", "288.60", "414.01", "V43.3", "428.33", "576.1", "574.91" ]

icd9cm

[ [ [] ] ]

[ "51.87", "96.71", "51.85", "96.04", "51.88" ]

icd9pcs

[ [ [] ] ]

9210, 9261

5407, 7698

304, 346

9447, 9447

3250, 3250

10468, 11433

2834, 2895

8024, 9187

9282, 9426

7724, 8001

9598, 10445

2910, 3231

242, 266

374, 2098

3266, 5384

9462, 9574

2120, 2594

2610, 2818

82,920

181,937

12801

Discharge summary

report

Admission Date: [**2192-6-2**] Discharge Date: [**2192-6-6**] Date of Birth: [**2135-6-13**] Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 2195**] Chief Complaint: dyspnea/chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 56 year old male with past history of and recent hip replacement 2 weeks ago, transferred from [**Hospital6 33**] for bialteral PE's. He presented this morning with chest pain and syncope - fell forward on face. Found down, with pulse. EMS called and transfered to [**Hospital6 **]. At OSH, found to be tachycardic with hypotension (SBP 85). CTA showed large bilateral PE's. Troponin negative. CT Head with no evidence of acute infartion, acute hemorrhage or mass lesion. He was tranferred to [**Hospital1 18**] for further management. Patient arrived to [**Hospital1 18**] ED with hypoxia on 4L O2 satting 94% and requiring peripheral levophed for blood pressure support. Bedside echo showed RV strain, but no impingement on left ventricle. Continued to be tachypnic, oxygen requirement increased to 6L NC. Vitals prior to transfer 96.7 100/76 26 94% on 4L. On arrival, patient is comfortable. States has some shortness of breath. Chest pain, described as pressure on center chest has resolved. Stopped lovenox 2 days prior. Swelling in left leg, improved. Has been ambulatory since day after discharge from THR. ROS: + per HPI. + feeling cool. Denies fever, chills, nightsweats. No headache or vision change. No N/V/D. No cough. No hematachezia, melena, dysuria, hematuria. No weakness. No parasthesias Past Medical History: s/p Total Hip Replacement 2 weeks ago Hypertension Hyperlipidemia Social History: Married, wife RN at [**Hospital1 18**] [**Name (NI) **]. Works as structural engineer. 1 alcoholic beverage per day, no smoking history, no drug use. Family History: Strong family history of heart disease in mother and brother. [**Name (NI) **] clotting disorders. No diabetes. Physical Exam: ADMISSION VS: Temp: 96.2 BP: 126/76 HR: 111 RR: 24 O2sat 95% 4L NC GEN: pleasant, comfortable, lying in bed HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no jvd. laceration on right side of cheek. RESP: CTA b/l with good air movement throughout anteriorally CV: tachycardic, regualr rhythm. S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: dependent edema in left thigh, incision over left thigh appears well healed with no sign of drainage or infection. right leg without edema. no cyanosis. peripheral pulses palpable in bilateral radial position. SKIN: no rashes/no jaundice/no splinters noted NEURO: AAOx3. Cn II-XII intact grossly intact. no facial droop, speech fluent and appropritate. spontaneously moving all 4 extremities. DISCHARGE: VS: 96 136/70 95 19 95% RA GEN: pleasant, comfortable, lying in bed HEENT: PERRL, EOMI, anicteric, MMM, laceration on right side of cheek. NECK: No JVD RESP: Clear bilaterally CV: regular rhythm ABD: nd, +b/s, soft, nt EXT: dependent edema in left thigh, incision over left thigh appears very well healed with no sign of drainage or infection. right leg without edema or calf tenderness NEURO: AAOx3. Cn II-XII intact grossly intact. speech fluent and appropritate. spontaneously moving all 4 extremities. Pertinent Results: [**2192-6-2**] 01:00PM BLOOD WBC-13.3* RBC-4.30* Hgb-12.6* Hct-36.0* MCV-84 MCH-29.3 MCHC-34.9 RDW-13.4 Plt Ct-388 [**2192-6-3**] 06:00AM BLOOD WBC-8.2 RBC-3.92* Hgb-11.4* Hct-32.8* MCV-84 MCH-29.0 MCHC-34.6 RDW-13.4 Plt Ct-255 [**2192-6-2**] 01:00PM BLOOD Glucose-122* UreaN-17 Creat-0.5 Na-141 K-5.0 Cl-110* HCO3-19* AnGap-17 [**2192-6-3**] 06:00AM BLOOD Glucose-113* UreaN-18 Creat-0.7 Na-135 K-4.4 Cl-105 HCO3-19* AnGap-15 [**2192-6-2**] 01:00PM BLOOD cTropnT-0.28* [**2192-6-3**] 12:02AM BLOOD CK-MB-6 cTropnT-0.19* [**2192-6-2**] 12:33PM BLOOD Glucose-111* Lactate-4.0* Na-141 K-4.8 Cl-107 calHCO3-19* CTA Chest OSH: CTA showed large bilateral PE's. No evidence of acute infartion, acute hemorrhage or mass lesion. Bilateral LENI's [**2192-6-2**]: 1. Occlusive thrombus involving the right popliteal vein and possibly the right gastrocnemius veins. 2. No DVT in the left lower extremity. DISCHARGE LABS: - CBC: WBC-6.2 Hgb-12.3 Hct-34.0 Plt Ct-291 - COAGS: PT-16.3* PTT-28.2 INR(PT)-1.4* - CHEM 7: Glucose-113* UreaN-18 Creat-0.7 Na-135 K-4.4 Cl-105 HCO3-19* AnGap-15 Brief Hospital Course: 56 year old male with history of HTN/HLD, s/p hip replacement presented to OSH with syncope, hypotension found to have bilateral PEs and to [**Hospital1 18**]. TRANSITION OF CARE: 1. INR following: VNA to draw and fac to PCP, d/c lovenox [**Last Name (un) 4050**] INR threapeutic for 48 hours 2. Set up in [**Hospital 2786**] clinic 3. Consider restarting atenolol which was stopped as he was normotensive here 4. Restart ASA once off of coumadin. #. Large Bilateral PEs: Presented with dyspnea/chest pain with associated LOC, found to have large bilateral PE's on CTA. He briefly required pressors in ED but these were weaned evening of admission. Due to concern for head trauma with fall, decision made not to lyse with TPA. Treated with iv heparin and discharged on lovebox with bridge to coumadin. VNA to draw INR and fax to PCP. [**Name10 (NameIs) 39448**] with PCP's office who will set patient up in their [**Hospital 2786**] clinic. On room air and cleared by PT prior to discharge. #. Hypertension: Stopped atenolol as patient was normotensive. Consider restart as out patient. Also stopped aspirin 81 mg as on coumadin and aspirin was for primary prevention. Would restart once off coumadin. #. Hyperlipidemia: Continued lipitor 10 mg daily. # Code Status: FULL # Communication: patient, wife [**Name (NI) **] is HCP. Medications on Admission: Atenolol 25 mg qday Lipitor 10 mg daily ASA 81 mg daily Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Bilateral Pulmonary Embolus Deep Venous Thrombosis - Right popliteal vein, occlusive Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after you collapsed and it was found you had large clots in your lungs. This is likely from being immobile after your hip surgery. You were initially admitted to the intensive care unit because your blood pressure was dangerously low but this resolved with treatment. Your clots were treated with an iv blood thinner and you were transitioned to an oral medication called Coumadin to thin your blood and an injection called lovenox. You need to take the lovenox until your coumadin level is high enough (INR [**3-22**]) and this will take up to another week to get to. The coumadin requires monitoring on a frequent basis and Dr. [**First Name (STitle) **] will help you organize this. VNA will check your INR for the next week and send the results to Dr. [**First Name (STitle) **]. Dr. [**First Name (STitle) **] will have you set up in the [**Hospital 2025**] [**Hospital 2786**] clinic. Your atenolol was stopped beause your blood pressure was low. You should not take this medication when you go home, but Dr. [**First Name (STitle) **] may restart this when you see him. Finally, you should stop taking your aspirin as you will be on the coumadin. Dr. [**First Name (STitle) **] may restart this once you are off the coumadin. No other medication changes were made, you should continue all your home medications as previously directed. It was a pleasure meeting you and participating in your care. Followup Instructions: Please make an appointment with your PCP in the next 2 weeks, as we discussed your wife will do this.

[ "V43.64", "401.1", "415.11", "272.4", "453.41" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5923, 5994

4467, 5816

303, 310

6123, 6123

3365, 4262

7731, 7836

1918, 2031

6015, 6102

5842, 5900

6274, 7708

4278, 4444

2046, 3346

245, 265

338, 1645

6138, 6250

1667, 1735

1751, 1902

60,894

196,231

48297

Discharge summary

report

Admission Date: [**2192-9-2**] Discharge Date: [**2192-9-6**] Date of Birth: [**2116-2-25**] Sex: F Service: MEDICINE Allergies: Penicillins / Citalopram Attending:[**First Name3 (LF) 1845**] Chief Complaint: Left Lower Back and Buttock Pain Major Surgical or Invasive Procedure: None History of Present Illness: 76 yof who was seen in the ED on [**2192-8-31**] for atraumatic left buttock pain. The pain started just over one week ago as a tingling sensation in her left buttock/lower back. It progressively got worse and is now a constant ache in left lower back, worse with movement and ambulation. Denies any numbness/tingling/weakness. Was discharged from the ED on [**2192-8-31**] with a walker and home VNA. The patient did not take very much of the pain medication and returned due to uncontrolled pain. The pain worsened after an ice pack was applied to the area. She denies any fevers/chills, no headache, no nausea/vomiting/diarrhea. Denies any urinary or bowel incontinence. . In the ED, initial vs were: T: 98.6 HR: 92 BP: 199/113 RR: 20 O2: 98%. Patient was given vicodin and percocet with some relief. . On the floor, the patient continues to be in pain, difficulty with moving the leg, trouble standing up. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Past Medical History: COPD ([**Date Range 1570**]'s in [**2184**] with 38% predicted FEV1, 72%predicted FEV1/FEV) Hx of SBO Hypertension Headaches Duodenal and stomach ulcers (duodenal ulcer hemorrhage- was hospitalized for 7 mos, intubated, trached) s/p partial gastrectomy Aortic aneurysm AMI - possible history of some cardiac ischemia years ago, had stress MIBI in [**7-26**] that was negative Cataracts Pulmonary Nodule and Fibroid Uterus - per pt's PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] (discussed with him on [**2192-9-3**]) pt. has declined workup of these issues. Social History: Lives alone in senior housing, husband died at 31 yr of aneurysm, 2 sons, 9 grandchildren. Originally from NC. Smoked 1-1.5 ppd for most of her life, quit 7 yrs ago. No ETOH, no drugs Family History: DM, CAD, HTN, colon cancer (sister) Physical Exam: PHYSICAL EXAM ON ADMISSION TO THE FLOOR: Physical Exam: Vitals: T:98.4 BP:178/100 P:77 R:20 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation slightly decreased b/l, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, protuberant, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, rectal tone is wnl Ext: Warm, well perfused, 2+ pulses, TTP above left buttock, near sacroiliac joint. No radiation - sensation intact, plantar/dorsiflexion [**5-22**], has pain with hip flexion and extention Skin: warm, dry, intact Neuro: alert, oriented, CB II-XII grossly intact, strength 5/5 BUE, LLE limited due to pain, unable to ambulate currently due to pain. PHYSICAL EXAM ON DAY OF DISCHARGE: Vitals: T:97.9 BP:122/72 P:79 R:20 O2: 98% RA General: NAD HEENT: PERRL, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: BS decreased, occasional exp. wheeze, no crackles CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, protuberant, non-tender, non-distended, +BS Ext: Warm, well perfused, 2+ pulses, TTP above left buttock, near sacroiliac joint and extends to proximal thigh, no sensation defecit. Mild TTP over right medial epicondyle, pain on wrist flexion against resistance, improved from yesterday Skin: warm, dry, intact Neuro: A&Ox3, CN II-XII intact, no focal defecits, no sensory defecits Pertinent Results: Labs on [**2192-9-3**]: [**2192-9-3**] 04:13PM BLOOD WBC-4.4 RBC-4.54 Hgb-12.9 Hct-40.6 MCV-89 MCH-28.3 MCHC-31.7 RDW-13.6 Plt Ct-198 [**2192-9-3**] 06:15AM BLOOD Glucose-116* UreaN-18 Creat-0.7 Na-138 K-4.1 Cl-100 HCO3-28 AnGap-14 CT Abd/Pelvis on [**2192-9-2**]: IMPRESSION: 1. Abdominal aortic aneurysms, as detailed, which are larger in size from [**2191-4-21**]. Extensive atheromas throughout the aorta with ulcerated plaque at the level of the diaphragmatic hiatus, unchanged from prior study. 2. Multiple abdominal wall defects, including a small hernia containing non- obstructed small bowel and a small left upper abdominal [**Doctor Last Name 6261**] hernia containing a small portion of transverse colon. 3. Minimally prominent left intrahepatic biliary ducts and CBD. No obstructing lesion is identified. Recommend correlation with LFTs, although no significant change is noted. 4. Enlarged and bulky uterus with foci of calcifications, likely reflects a fibroid uterus, similar to before. 5. Degenerative changes in the lumbar spine with central canal narrowing at L4-L5. This can be further evaluated with an MRI if there is persistent clinical concern for a cause of back pain. PERTINENT RESULTS DURING EPISODE OF HYPOTENSION: [**2192-9-3**] 04:05PM BLOOD Type-ART pO2-71* pCO2-46* pH-7.40 calTCO2-30 Base XS-2 [**2192-9-3**] 04:13PM BLOOD CK(CPK)-226* [**2192-9-3**] 04:13PM BLOOD CK-MB-5 cTropnT-<0.01 [**2192-9-3**] 04:13PM BLOOD Glucose-117* UreaN-28* Creat-1.3* Na-133 K-7.3* Cl-99 HCO3-28 AnGap-13 HEAD ct: IMPRESSION: 1. No hemorrhage or edema. 2. No significant change since the prior study DISCHARGE LABS: [**2192-9-6**] 06:22AM BLOOD WBC-3.1* RBC-4.08* Hgb-11.6* Hct-36.5 MCV-90 MCH-28.5 MCHC-31.9 RDW-14.3 Plt Ct-198 [**2192-9-6**] 06:22AM BLOOD Glucose-129* UreaN-20 Creat-0.7 Na-139 K-4.8 Cl-103 HCO3-29 AnGap-12 [**2192-9-6**] 06:22AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.5 Brief Hospital Course: 76 yof with history of HTN, COPD, severe PUD (gastric and duodenal), recent admission in [**7-26**] for chest pain that had a negative work up who presents with one week of worsening left low back/buttock pain without radiation, no numbness, tingling. # Low Back/Buttock Pain: On initial exam, pain was very focused over left buttock and low back and she denied any radiation of her pain. The straight leg raise was difficult to assess as she was unable to lie on her back due to pain. She was started on a llidocaine patch, tylenol 650mg q6h, tramadol 50mg q6h prn, and morphine 0.5-1mg IV prn for breakthrough pain. She slept well overnight and on [**9-3**] a more thorough exam was illicted. She continued to have tenderness to palpation over left buttock with some radiation to upper thigh. Pain in that location was reproduced with SLR and crossed SLR, but the pain did not radiate below the upper thigh. She denied any numbness/tingling, and sensation was intact. Her rectal tone was normal. After touching base with her attending, the most likely diagnosis was considered to be sciatic pain. Due to hypotension and decreased mental status (see below) pt. was triggered and spent one night in the MICU. This was thought to be narcotic induced and received Narcan x 2. She improved and in discussion with attending, Dr. [**First Name (STitle) **] on the morning of [**2192-9-5**], Ultram was stopped and ibuprofen was started despite risk of bleeding due to the fact that the benefits outweighed the risk (her GI bleed was many years ago and because she has been on PPIs it was felt that she could tolerate NSAIDS). Her pain became tolerable. She was continued on Tylenol, Ibuprofen, Neurontin, and lidoderm patches. # Blood Pressure Changes: Pt. had poorly controlled HTN on last admission which was thought to be part of the cause for her chest pain at that time. Pressure was 178/100 when she was admitted to the floor, but she had not received any of her home medications. She had been recently discharged on Lisinopril, HCTZ, and Metoprolol which were continued. At 20:00 on [**2192-9-2**], it came down to 134/64. The patient was triggered at about 15:45 on [**2192-9-3**] for low blood pressure to 82/doppler. Differential at that time included narcotic side effects (thought to be most likely), bleed - has known AAA - but patient denied any abdominal pain at the time of exam, CVA, seizure. At the time her airway was patent, an ABG was sent that was not particularly abnormal (pH7.40, PCO2 46, PO2 71) and she was transferred to the MICU after receiving 0.4mg Narcan x 2. She was observed overnight and he blood pressure came up to SBP 90s-100s. Her home BP meds were not restarted. This was discussed with Dr. [**First Name (STitle) **]. As above, her hypotension was thought to be related to pain medication and all narcotics were stopped, including Ultram. Dr. [**First Name (STitle) **] will start her back on her BP meds at a later time. # Right Elbow Medial Epicondylitis: Pt. began to complain about some right elbow pain that was consistent with medial epicondylitis. She had been lying on her right side preferentially. There was no trauma, no tenderness over the olecranon, but did have pain with active wrist flexion against resistance. Pt. was kept on regimen for pain as above and this pain was improved on the day of discharge. # Headaches: Patient currently does not have any headaches, has been on nortriptyline qhs for control of her headaches which was maintained throughout her hospitalization. # COPD: Pt. has history of COPD with liekly poor compliance with home nebulizers. She did not complain of any SOB and her home regimen of nebulizers (albuterol and budesonide TID) was continued. She did have some occasional wheezing on exam which is her baseline per Dr. [**First Name (STitle) **]. # History of gastric/duodenal ulcers that required an ICU admission in the past, intubation, trach. Initially NSAIDS were avoided during this hospitalization, but due to the patient's poor response to narcotic pain meds (hypotension and AMS) and the remote history of her GI bleed, it ws decided that she could start NSAIDS. This was discussed with Dr. [**First Name (STitle) **] who felt that the benefits of NSAID use outweighed the risks. #Constipation: Pt. has a BM q2-3 days at baseline, however she has not had a BM in approximately 4 days - likely an effect of her pain medication and decreased mobility. Colace, senna, and Dulcolax were given with good effect and pt. had large BM overnight prior to discharge. # Code Status: On admission, the patient was unclear on whether or not she wanted to be DNR/DNI. Her family wanted her to be full code, however after talking with the patient and Dr. [**First Name (STitle) **] on the morning of [**2192-9-5**], she was very clear that she did not want to go through what she had been through in the past when she was intubated and in the ICU. She does not want to be intubated or rescuscitated. Medications on Admission: She was discharged from her last admission with the following medications: 1. Nortriptyline 25 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 2. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical QID (4 times a day). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation TID (3 times a day). 5. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One (1) neb Inhalation three times a day. 6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-20**] puff Inhalation four times a day as needed for shortness of breath or wheezing. 10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual under the tongue as needed for chest pain, every 5 minutes to max of 3 tablets. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Metoprolol Succinate 25 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* 13. Home oxygen Home oxygen at 2 Liters per minute as needed to maintain oxygen saturation above 90%. Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) ml Inhalation TID (3 times a day): with budesonide. 2. Budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: Two (2) ML Inhalation TID (3 times a day): with albuterol. 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation QID (4 times a day) as needed for wheezing. 4. Nortriptyline 25 mg Capsule Sig: Four (4) Capsule PO HS (at bedtime). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for irritation. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: apply 12 hours on and 12 hours off. 10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime): hold for oversedation or rr<12. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): if patient mobile, can consider discontinuation. 18. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual as needed for chest pain as needed for chest pain: You can take as needed for chest pain every 5 minutes for 3 doses. If persistent chest pain, call 911. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: 1. Low Back Pain - likely sciatica 2. Hypotension - may have been narcotic induced Secondary: Chronic Obstructive Pulmonary Disease Hypertension Abdominal Aortic Aneurysm Severe Peptic Ulcer Disease in '[**75**]-'[**76**] - s/p partial gastrectomy, prolonged ICU course Recent Hospitalization for chest pain - negative stress MIBI with EF 63% Discharge Condition: Vital signs stable, pt. in good condition. Discharge Instructions: You were admitted to the hospital due to your back pain which has worsened over the last week. You were seen in the emergency department and sent home with VNA services and physical therapy at home, but your pain continued to get worse. You were given pain medication for your back pain. We believe that this medication may have made you tired and less responsive and may have lowered your blood pressure. Due to this, you were transferred to the medical ICU for observation. Your blood pressure came up and your back pain improved enough to allow you to work with physical therapy. Medication Changes: Your blood pressure medications were stopped due to your low blood pressure and can be restarted by Dr. [**First Name (STitle) **] as needed. You were started on the following medications: 1. Ibuprofen 600mg every 8 hours as needed - this should be stopped once pain controlled or within one week 2. Ranitidine was added to protect your intestinal tract from any irritation from the ibbuprofen 3. Tylenol 1 gram every 6 hours for pain. 4. Neurontin was added 100mg at bedtime for pain control. You should call your doctor immediately or return to the hospital if you develop any fever, chills, headache, numbness/tingling, weakness, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or diarrhea. Followup Instructions: You were scheduled a follow up appointment with your PCP and the [**Name9 (PRE) 1194**] Clinic. If you cannot make these appointments, please call them to cancel/reschedule. Appointment #1: You have an appointment with Dr. [**First Name (STitle) **] on [**9-21**] at 1:30 pm. [**Telephone/Fax (1) 250**] Appointment #2 MD: [**Doctor First Name **] [**Doctor Last Name **] Specialty: Pain Management Date and time: [**Last Name (LF) 766**], [**9-17**] 1:30pm Location: [**Location (un) 8170**], [**Apartment Address(1) **], [**Location (un) **] MA (building is at the end [**Location (un) 71679**] at Rt 9) Phone number: [**Telephone/Fax (1) 1652**]

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Discharge summary

report

Admission Date: [**2172-7-27**] Discharge Date: [**2172-8-6**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: s/p Lap R Colectomy s/p exlap for postop hypotension & falling hct History of Present Illness: 84M Russian-speaking with h/o severe 3-vessel CAD unamenable to PCI s/p CABG x4 ([**2157**]) and MI x3, chronic angina, DM, CHF (EF 30-35%) presented from clinic with progressive dyspnea x 2 days. The patient developed SOB and worsening orthopnea at home. He was also having chest pain which is similar to his chronic angina. He denies fevers, chills, cough, or sick contacts and reports that he was taking his medications at home. At clinic, he was noted to have increased peripheral edema (increased over 1 wk per the patient) and was sent to the ED where his vitals were T 97.1 HR 76 BP 148/80 RR 25 SpO2 92%/RA. Bilateral crackles and elevated JVD were noted on examination. CXR revealed bilateral layering effusions and pulmonary edema. ECG was unchanged and cardiac enzymes were CK 137, MB 9, TnT 0.02. He received [**Year (4 digits) **], sl NTG x2, morphine 2mg IV, and lasix 40mg IV. He was admitted for diuresis and r/o MI. . Of note, he has had similar admissions in the past for anginal exacerbations and heart failure, including a recent NSTEMI in [**2-/2172**] (CK up to 1376) that required management in the CCU with an intraaortic balloon pump. He underwent cardiac cath at that admission that resulted in angioplasty of a significant 80% left main lesion, that subsequently restenosed. He subsequently underwent cardiac cath on [**2172-3-26**] that was unsuccessful at circumflex revascularization, resulting in dissection of that artery and contained perforation. Per recent cardiology note, there are no further options for revascularization and his medications are being optimized prior to surgery as he was also recently found to have an adenocarcinoma in his cecum with plans for future resection. He was admitted to the General Surgery service for excision of the colon mass Past Medical History: Hypertension Hypercholesterolemia CAD s/p MI ([**2154**], [**2170**], [**2-/2172**]) s/p CABG x4 ([**2157**]) DM2 (A1c 9.6 in [**2-/2172**]) Chronic renal insufficiency (baseline Cre 2.0) Peripheral Vascular Disease s/p R 4th toe amputation ([**2167**]) Diabetic Neuropathy Lumbar Spinal stenosis CHF (EF 30-35% in [**6-27**]) Gout Arthritis Right eye cataract repair Colon cancer (diagnosed [**2172-7-3**]) Iron-deficiency anemia Social History: The patient currently lives at home with services for assistance with ADLs. He was an accountant in [**Country 532**]. He denied smoking, alcohol or illicit drugs. He does not recall any family history of premature coronary artery disease of sudden death. Family History: He does not recall any family history of premature coronary artery disease of sudden death. Physical Exam: Vitals - T 95.5 BP 132/65 HR 78 RR 20 SpO2 98%/3L Generally the patient was elderly, well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. Mucous membranes were moist. The neck was supple with JVP of 12cm. The carotid waveform was normal. There was no thyromegaly. The were no chest wall deformities, scoliosis or kyphosis. The respirations were not labored and there were no use of accessory muscles. The lungs were with decreased breath sounds at the bases and rales 1/3rd of the lower lung fields bilaterally. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. There was a well-healed sternotomy scar. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender and nondistended. The extremities had no pallor, cyanosis, or clubbing. There was 2+ bilateral pitting lower extremity edema. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no xanthomas. . Pulses: . Right: DP dopp PT dopp Left: DP dopp PT dopp Pertinent Results: Admission labs: [**2172-7-27**] 01:35PM BLOOD WBC-7.4 RBC-3.89* Hgb-9.8* Hct-30.9* MCV-79* MCH-25.2* MCHC-31.7 RDW-19.5* Plt Ct-199 [**2172-7-27**] 01:35PM BLOOD Neuts-65.1 Lymphs-27.2 Monos-6.1 Eos-1.3 Baso-0.3 [**2172-7-27**] 01:35PM BLOOD PT-12.6 PTT-28.6 INR(PT)-1.1 [**2172-7-27**] 01:35PM BLOOD Glucose-83 UreaN-28* Creat-1.5* Na-141 K-4.5 Cl-110* HCO3-22 AnGap-14 [**2172-7-27**] 01:35PM BLOOD CK(CPK)-137 [**2172-7-27**] 09:45PM BLOOD CK(CPK)-152 [**2172-7-27**] 01:35PM BLOOD cTropnT-0.02* [**2172-7-27**] 09:45PM BLOOD CK-MB-10 MB Indx-6.6* cTropnT-0.04* . Discharge labs: . EKG demonstrated NSR, normal axis, IVCD, prolonged PR, <1mm ST depressions V4-6 with no significant change compared with prior dated [**2172-6-27**]. . 2D-ECHOCARDIOGRAM performed on [**2172-6-25**] demonstrated: EF 30-35%. The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2172-3-27**], left ventricular systolic function now appears more depressed and right ventricular systolic function is now depressed. . CARDIAC CATH performed on [**3-/2172**] demonstrated: 1. Three vessel and left main coronary artery disease. 2. Unsuccessful rotational atherectomy of the proximal circumflex complicated by mid vessel dissection with contained perforation. . CXR [**2172-7-27**] - 1. Increasing opacity at the lung bases, possibly reflecting evolving pneumonia and/or subsegmental atelectasis. 2. Nodular prominence of the right pulmonary hilum, unchanged from multiple previous studies. Findings may correlate with right hilar lymph node as was seen on recent CT from [**2172-7-22**]. . Brief Hospital Course: The patient was admitted to the [**Hospital Ward Name 121**] 6 cardiology service with a heart failure exacerbation. He was diuresed and responded well. He did have and acute exacerbation of his chronic renal failure, and at the time of this summary, was stable @ 2.2 from a baseline of 2. He has adenocarcinoma of the colon and was planned for a lab-partial colectomy. He was taken to surgery on [**2172-7-31**] after reaching medical and cardiac optimization. Pt was taken to the OR on [**7-31**] for lap colon resection. Post op he was noted to be hypotensive and was in the ICU for hemodynamic monitoring. Overnight, he required treatment with vasopressors and PRBC to keep his pressure stable. On POD#1 he was taken urgently to the OR because of concern for bleeding. A 900cc Intra-op clot was noted and removed in the abdomen, however no active bleeding was noted. He was taken back to the ICU and continued to improve, he was extubated, was weaned off pressor, had good UOP, and was hemodynamically stable. On POD #3 and 4 he was started on lasix to help diuresis which he tolerated. He was subsequently transferred to [**Wardname 7911**]. His post-operative course on the floor has been stable and uncomplicated. He was screened per physical therapy due to instability with transfers. He was recommended to have [**Hospital 3058**] Rehab for strenghtening and reconditioning since he lives alone. His sons are also in agreement with this plan. Medications on Admission: Ezetimibe 10mg daily Celexa 20mg daily Clobetasol ointment [**Hospital1 **] Betamethasone gel qSatSun Calcipotriene cream [**Hospital1 **] Ranolazine 500mg q12hr Plavix 75mg daily Lipitor 80mg daily Gabapentin 300mg daily NTG 0.3mg sl prn Iron 325mg daily [**Hospital1 **] 325mg daily Protonix 40mg [**Hospital1 **] Lasix 40mg daily Imdur 90mg daily Hydralazine 25mg tid Toprol XL 50mg daily NPH 28 units qAM, 15 units qPM Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for constipation. Disp:*30 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet(s)* Refills:*2* 4. Codeine Sulfate 30 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection QAC&HS: Please see sliding scale. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary: CHF exacerbation with chest pain cecal adenocarcinoma post-operative hypotension treated with Intravenous resuscitation. post-operative blood loss treated with ex/lap removal of blood clots, no source of bleed. Secondary: HTN, CHF, EF 30%, MI x3, s/p CABG [**2157**], CRI 2.0, DM, PVD Discharge Condition: Good Tolerating a regular diet Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please call Dr.[**Name (NI) 3377**] office at [**Telephone/Fax (1) 160**] for a follow-up appointment in [**1-25**] weeks. Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**] Date/Time:[**2172-9-7**] 9:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2172-9-23**] 3:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2172-11-16**] 10:40 Completed by:[**2172-8-6**]

[ "428.0", "724.02", "250.40", "403.90", "V45.61", "998.11", "V58.67", "357.2", "414.01", "272.0", "V45.81", "583.81", "285.1", "458.29", "412", "250.60", "998.12", "196.2", "584.9", "V45.82", "585.9", "285.22", "274.0", "153.4", "250.70", "440.20", "413.9" ]

icd9cm

[ [ [] ] ]

[ "54.21", "99.05", "99.07", "45.93", "99.04", "54.12", "89.64", "45.73", "99.77" ]

icd9pcs

[ [ [] ] ]

10140, 10220

6887, 8350

280, 349

10559, 10635

4531, 4531

11845, 12504

2920, 3013

8823, 10117

10241, 10538

8376, 8800

10659, 11822

5114, 6864

3028, 4512

221, 242

377, 2175

4547, 5098

2197, 2629

2645, 2904

15,085

117,166

16381

Discharge summary

report

Admission Date: [**2111-1-26**] Discharge Date: [**2111-1-29**] Service: CCU CHIEF COMPLAINT: Transferred from an outside hospital for persistent left arm pain. HISTORY OF PRESENT ILLNESS: An 85-year-old male with a history of coronary artery disease is status post myocardial infarction and percutaneous transluminal coronary angioplasty in [**2093**] at [**Hospital6 **] who presents with total body aching and malaise at outside hospital on [**1-25**]. He subsequently developed chest pain and left arm pain. EMTs were called and gave the patient nitroglycerin. The patient was started on nitroglycerin drip and became pain free, however over the course of the next day he developed left arm pain and rest that was not relieved with nitroglycerin drip, aspirin and Lovenox. He was then transferred to [**Hospital6 1760**] for emergent catheterization. En route, the patient was given Integrilin drip as well as fentanyl 50 mcg x2 with resolution of his pain. PAST MEDICAL HISTORY: 1. Transient ischemic attack 2. Coronary artery disease, status post myocardial infarction with angioplasty in [**2093**] 3. 4.2 cm abdominal aortic aneurysm being followed by Dr. [**Last Name (STitle) 1391**] 4. Leg cramps OUTPATIENT MEDICATIONS: 1. Atenolol 2. Echinacea multivitamin 3. Protonix 4. Pravachol 5. Doxazosin 6. Aspirin TRANSFER MEDICATIONS: 1. Nitroglycerin drip 2. Integrilin drip 3. Lovenox 4. Aspirin 5. Atenolol 50 mg po q day 6. Fentanyl prn ALLERGIES: No known drug allergies. SOCIAL HISTORY: Lives with his wife, former [**Name2 (NI) 1818**] and no alcohol use. FAMILY HISTORY: Father with coronary artery disease at unspecified age. PHYSICAL EXAM ON ADMISSION: VITAL SIGNS: Blood pressure 125/76, heart rate 71, O2 saturation 98% on 2 liters nasal cannula. GENERAL: Elderly male lying flat in no acute distress. HEAD, EARS, EYES, NOSE AND THROAT: Extraocular movements intact. Tongue midline, no jugular venous distention. CARDIOVASCULAR: Normal S1, S2, regular rate and rhythm, Q6 systolic murmur at right upper sternal border. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, obese, normoactive bowel sounds. EXTREMITIES: 2+ DP pulses bilaterally. No groin bruits. ADMISSION LABS: White blood count 9.5, hematocrit 36.4, platelets 154. INR 1.1, PTT 34.9. Sodium 141, potassium 3.9, chloride 101, bicarbonate 28, BUN 17, creatinine 0.9, glucose 109. CK 253 with an MB of 21, troponin of 17. IMAGING: Electrocardiogram normal sinus rhythm at 80 beats per minute. Q-wave in 2 and AVF, [**Street Address(2) 4793**] depression in V4 through V6. IMPRESSION: The patient is an 85-year-old male with non ST elevation myocardial infarction with recurrent pain despite Lovenox, aspirin and nitroglycerin drip. HOSPITAL COURSE: 1. Cardiovascular: The patient was taken to cardiac catheterization on the morning of [**2111-1-26**]. Catheter was found to have a diffusely diseased and totally occluded right coronary artery with collateralization suggesting chronic occlusion. There was a 70% LAD lesion and an OM1 lesion which was 90% stenosed. The OM1 lesion was felt to be the culprit given the electrocardiogram findings and this was percutaneous transluminal coronary angioplastied and stented with resulting 0% stenosis and TIMI-3 flow. The patient was started on captopril which was gradually titrated up from 6.25 mg [**Hospital1 **] to 37.5 mg po tid and was then changed over to lisinopril 10 mg po q day. The atenolol was increased to 75 mg po q day. He was started on Plavix 75 mg and continued on the aspirin. The patient was also started on Lipitor 20 mg po q day. Post catheter, the patient continued to complain of bilateral shoulder pain and it was unclear if this was due to muscular and skeletal pain versus possibility of aortic dissection. He underwent a CT angiogram on [**1-26**] which showed the abdominal aortic aneurysm unchanged in size with no evidence of dissection. There was also a small hematoma at the right groin site which was manually compressed and which stopped bleeding with stable hematocrit for two days with post catheter. The patient's CKs peaked at about 355 and MB 27. Troponin peaked at 20.1 and were trending down by [**1-28**]. The patient was seen by physical therapy who recommended cardiac rehabilitation and the patient is to follow up with his primary cardiologist, [**First Name8 (NamePattern2) **] [**Location (un) 4640**], at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital within the next week. DISCHARGE DIAGNOSES: 1. Acute myocardial infarction 2. Status post percutaneous transluminal coronary angioplasty and stent of OM1 lesion 3. Abdominal aortic aneurysm 4. Leg cramps DISCHARGE CONDITION: Good. The patient is feeling well, is ambulating without difficulty, eating and drinking without any problems and is to be discharged home with plans for cardiac rehabilitation and cardiac follow up. DISCHARGE MEDICATIONS: 1. Lisinopril 10 mg po q day 2. Atenolol 75 mg po q day 3. Lipitor 20 mg po q day 4. Aspirin 325 mg po q day 5. Plavix 75 mg po q day x1 year [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Dictated By:[**Doctor Last Name 46618**] MEDQUIST36 D: [**2111-1-29**] 11:00 T: [**2111-1-29**] 11:12 JOB#: [**Job Number 46619**]

[ "401.9", "412", "V45.82", "410.71", "441.4" ]

icd9cm

[ [ [] ] ]

[ "36.01", "36.06", "88.56", "88.53", "37.22" ]

icd9pcs

[ [ [] ] ]

4782, 4984

1629, 1700

4595, 4760

5007, 5382

2811, 4574

1257, 1351

107, 175

1373, 1524

204, 982

2266, 2794

1714, 2249

1004, 1233

1541, 1612

15,672

177,980

17673

Discharge summary

report

Admission Date: [**2138-10-31**] Discharge Date: [**2138-11-7**] Date of Birth: [**2078-11-12**] Sex: M Service: [**Last Name (un) **] The patient is a 59-year-old male with end-stage renal disease, atrophic right kidney, left nephrectomy for malignancy, status post cadaveric renal transplant [**2138-3-14**]. Received a kidney from extended donor 80 year-old kidney. DGF initially on hemodialysis presented on admission with mental status changes with poor compliance with medication. While at home the patient was ambulating and defecating in the refrigerator. The patient attempted assault on emergency room staff while the patient was in the emergency room on [**2138-10-31**]. The patient has been taking medications for the past 10 days according to girlfriend but prior to that was not compliant for one week. No reported fevers. PAST MEDICAL HISTORY: Atrophic right kidney, left nephrectomy for malignancy, cadaveric renal transplant [**2138-2-15**]. Deafness secondary to auto toxicity. Noncompliant, difficult patient. ALLERGIES: Heparin, beef. MEDICATIONS: 1. Rapamune 7 mg once daily 2. CellCept [**Pager number **] mg once daily 3. Iron 4. Multivitamin 5. Protonix SOCIAL HISTORY: Lives with girlfriend, positive marijuana use, positive tobacco, history of intravenous drug abuse. PHYSICAL EXAMINATION: Temperature 96.9, 87, 122/56, respirations 16, 100% on room air. The patient was asleep when resident from transplant saw patient. Lungs clear to auscultation bilaterally. CV: Regular rate and rhythm. Abdomen: Soft, nontender, nondistended. The patient does have a left AV thrill, no extremity edema. The extremities are well perfused, range of motion appears to be intact. Pulses are palpable at the dorsalis pedis and to a lesser extent PT level on both sides. There is no popliteal aneurysm. Femoral's are fully palpable and bounding. LABORATORY FINDINGS: White blood cell of 2.8, crit of 19.2, platelets 151, sodium 142, 4.3, 112, 10, BUN and creatinine 126 and 8.4. Glucose 144. Tox screen demonstrated ethanol was unremarkable. Tox screen was negative. The patient had a gas arterial blood gas which demonstrated a pH of 7.20, pO2 182, pCO2 25, bicarbonate 10. The patient was not intubated at that time. Rabomycin level on [**2138-10-31**] was 18.8. The patient was admitted to the SICU under transplant service. The patient had hemodialysis on [**2138-10-31**] later that afternoon renal service was consulted. Social work followed the patient while the patient was in the hospital. The patient remained afebrile, vital signs stable. The patient was on a bicarbonate drip, continued on Rabomycin MMF. The patient was transferred from intensive care unit to regular floor, continue with hemodialysis while patient was in in-house. The patient had intermittent acute anger episode while in house and on [**2138-11-4**] the patient was very upset and abusive to nursing staff when he realized that clothes and shoes were missing. Social Work continued to meet with patient. Psychiatry met with patient on [**2138-11-4**] who made threats towards his present girlfriend saying "I am going to kill her." The patient did get an ultrasound while he was an inpatient demonstrating interval increased amount of hydronephrosis of the left kidney with interval increase of resistive index within this kidney, mild increase in the index in the right kidney without hydronephrosis. No perinephric fluid collection. On [**2138-11-5**] the patient had an acute episode of right visual field loss which was episodic now and then on [**2138-11-6**] had completely resolved. The patient was unclear to exact duration of visual disturbance, he noted blurry vision and "double vision" on [**2138-11-5**]. The patient had a workup of his acute visual episodic visual loss which included ophthalmology who met with the patient and felt that it was possible to have retinitis pigmentosus of both eyes, had recommended getting an ultrasound of the carotids, MRI of the head and CT of the head. On [**2138-11-6**] carotids were performed demonstrating a right non- occlusive thrombus and IJ carotids demonstrated no stenosis otherwise within normal limits. CT of head demonstrated no bleed, no midline shift and the MRI that was performed demonstrated it was a very limited study but there was no evidence of acute infarction. Neurology specifically the stroke team was consulted as well and felt that they definitely would like to have an MRI of the head performed and MRA of the head and carotids, to start aspirin and check a sed rate. Since the patient had moved on [**2138-11-6**] the patient was scheduled for repeat MRI of the head and neck on [**2138-11-7**]. On [**2138-11-6**] the patient had syncopal episode at 10 PM, no head trauma. On [**2138-11-7**] the patient afebrile, vital signs stable. Normal visual fields, normal finger-to-nose coordination, strengths were [**6-19**] bilaterally. The patient was awaiting an MRI of the head on [**2138-11-7**] and then on [**2138-11-7**] the patient was scheduled for hemodialysis and had refused to go to hemodialysis today, that he was leaving against medical advice. He felt that the hemodialysis personnel did not care about and that they would not dialyze him even though they had stated that they would dialyze him. Dr. [**First Name (STitle) **] [**Name (STitle) **] discussed early the risks of leaving without having dialysis and he stated that he did understand and did not care. The patient appeared to understand and be competent to make his own decision. Dr. [**Last Name (STitle) 49187**] notified social services. The patient did sign the against medical advice form. Girlfriend notified transplant team of the patient's decision to leave. The patient's girlfriend did call to let staff know that he arrived safely to his home. Throughout the patient's hospitalization the patient had acute episodes of outbursts of anger and being noncompliant with staff so the patient abruptly left and actually has returned since then onto renal transplant team and is a patient on Far 10. It is uncertain whether or not the patient was discharged on his medications that he was on during his hospitalization but he was supposed to leave on an aspirin EC 81 mg once daily, ferrous sulfate 325 mg once daily, insulin sliding scale, MMF 500 mg twice a day, Protonix 40 mg q 24 hours, ______5 mg q day and Bactrim SS one tablet once daily but again since his abrupt leave against medical advice he is currently on nephrology service receiving hemodialysis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2138-11-7**] 20:41:47 T: [**2138-11-7**] 22:24:04 Job#: [**Job Number 49188**]

[ "780.2", "389.9", "362.74", "584.9", "591", "285.21", "996.81", "276.2", "759.89", "V10.52", "V15.81" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

1352, 6824

883, 1211

1228, 1329

55,616

166,062

41683

Discharge summary

report

Admission Date: [**2153-10-18**] Discharge Date: [**2153-10-25**] Date of Birth: [**2087-2-28**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest discomfort Major Surgical or Invasive Procedure: Coronary Artery Bypass Grafting x4 (Left internal mammary artery grafted left anterior descending artery/Saphenous vein grafted Diag/Obtuse Marginal/Posterior descending artery)-on [**2153-10-18**] History of Present Illness: 66 year old male with a [**4-13**] month history of mild exertional chest discomfort, usually after walking 200 yards, rarely associated with left arm discomfort. He reports very rare episodes occurring at rest, however last week he was awaken with chest discomfort and left arm pain, he took an Aspirin and the pain resolved. He reports his blood pressure at the time was elevated and his heart rate was 99 bpm. He reported his symptoms during pre-op hip surgery workup and was sent for a stress echo which revealed a new anterior and anteroseptal wall motion abnormality. He has had a chronic dry cough since his bilateral carotid endarterectomies in the fall of [**2152**]. He also report ongoing tightness under his chin, unrelated to exertion, following the surgeries last fall. He was referred for a cardiac catheterization and was found to have coronary artery disase and is now being referred to cardiac surgery for revascularization. In addition, he was originally scheduled to have f/u upper endoscopy today to monitor progress of treated esophagitis. This appt was cancelled given his cardiac cath. He reports food sticking or burning only occasionally now that he is on prilosec, and says this is much improved from a couple of months ago. Past Medical History: peripheral arterial disease Osteoarthritis Hypertension GERD Congenital Horse Shoe Kidney s/p Kidney Stones Dyslipidemia TIA x2 Melanoma x3 with removal recent esophagitis ( rx with prilosec and improved Social History: Lives with:wife, occasionally uses a cane or a walker when his hip is bothering him Occupation:retired Cigarettes: Smoked Hx:50 pack year history and quit in [**2151**] ETOH: [**3-19**] drinks/week [x] Illicit drug use:denies Family History: none Physical Exam: Pulse:72 Resp:18 O2 sat:95/RA B/P Right:122/51 Left:125/58 Height:6'2.5" Weight:252 lbs General:lying flat on bedrest Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM []no JVD noted; healed B scars Chest: Lungs clear bilaterally anterolaterally Heart: RRR [x] Irregular [] Murmur [x] grade _2/6 radiates to carotids_____ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]; no HSM, very obese Extremities: Warm [x], well-perfused [x] Edema [] _none____ Varicosities: None [x]examined while on bedrest Neuro: Grossly intact , nonfocal exam, MAE [**6-14**] strengths Pulses: Femoral Right: dressing in place Left:2+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit murmur radiates to carotids Pertinent Results: [**2153-10-21**] 05:51AM BLOOD WBC-15.9* RBC-3.23* Hgb-9.7* Hct-27.3* MCV-84 MCH-30.1 MCHC-35.7* RDW-13.4 Plt Ct-250 [**2153-10-18**] 05:16PM BLOOD WBC-23.5*# RBC-2.76*# Hgb-8.5*# Hct-23.8*# MCV-86 MCH-30.7 MCHC-35.5* RDW-13.3 Plt Ct-268 [**2153-10-18**] 06:31PM BLOOD PT-16.3* PTT-37.3* INR(PT)-1.4* [**2153-10-21**] 05:51AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-133 K-4.2 Cl-98 HCO3-30 AnGap-9 [**2153-10-18**] 06:28PM BLOOD Glucose-118* UreaN-15 Creat-1.0 Na-137 K-4.8 Cl-108 HCO3-24 AnGap-10 [**2153-10-24**] 08:55AM BLOOD WBC-14.3* RBC-3.44* Hgb-10.2* Hct-29.0* MCV-84 MCH-29.6 MCHC-35.2* RDW-13.9 Plt Ct-390 [**2153-10-23**] 06:05AM BLOOD WBC-17.0* RBC-3.19* Hgb-9.5* Hct-27.1* MCV-85 MCH-29.7 MCHC-35.0 RDW-13.7 Plt Ct-380 [**2153-10-24**] 08:55AM BLOOD Glucose-144* UreaN-26* Creat-1.1 Na-139 K-3.6 Cl-97 HCO3-33* AnGap-13 [**2153-10-23**] 06:05AM BLOOD Glucose-99 UreaN-21* Creat-0.9 Na-139 K-4.3 Cl-98 HCO3-32 AnGap-13 [**2153-10-21**] 05:51AM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-133 K-4.2 Cl-98 HCO3-30 AnGap-9 [**2153-10-25**] 06:00AM BLOOD WBC-16.8* RBC-3.32* Hgb-9.7* Hct-28.2* MCV-85 MCH-29.3 MCHC-34.4 RDW-13.4 Plt Ct-451* [**2153-10-25**] 06:00AM BLOOD Glucose-93 UreaN-32* Creat-1.2 Na-137 K-3.9 Cl-95* HCO3-31 AnGap-15 [**2153-10-25**] 06:00AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.4 CXR [**10-22**] The right internal jugular line has been removed in the interim. Post-sternotomy wires are unremarkable. Cardiomegaly is unchanged. Small bilateral pleural effusions are unchanged. There is no appreciable pneumothorax. No evidence of interstitial pulmonary edema noted. Note is made that the left pleural effusion is slightly bigger than the right, both small. Brief Hospital Course: He was admitted same day surgery and was brought to the operating room for coronary artery bypass graft surgery. See operative report for further details. He was transferred to the intensive care unit for post operative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. He was started on betablockers and diuretics. He did have atrial fibrillation that was treated with betablockers and amiodarone. He converted back to normal sinus rhythm. He remained in the intensive care unit for hemodynamic and respiratory monitoring. On post operative day two he was transferred to the floor for the remainder of his stay. Physical therapy worked with him on strength and mobility. He remained in sinus rhythm for the remainder of his hospital course. His CXR showed bilateral effusions and pulmonary edema, with ongoing oxygen requirements. His diuresis was increased and zaroxlyn added with good response. He was weaned off oxygen and ambulating without difficulty. He was ready for discharge home with services on post operative day seven. Medications on Admission: ATORVASTATIN [LIPITOR] 80 mg Tablet Daily CLOPIDOGREL [PLAVIX] 75 mg Tablet 1 (One) Tablet(s) by mouth loaded with 300mg at Dr. [**Last Name (STitle) **] on [**2153-10-10**] METOPROLOL SUCCINATE 25 mg Daily RAMIPRIL 5 mg Capsule HS ASPIRIN 81 mg Daily CHOLECALCIFEROL (VITAMIN D3)2,000 unit Daily MULTIVIT-MIN-FA-LYCOPEN-LUTEIN 500 mcg-300 mcg-250 mcg Daily FISH OIL Daily OMEPRAZOLE 20 mg Daily Discharge Medications: 1. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 2. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 14 days. Disp:*14 Packet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 5. 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* 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1* 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*qs qs* Refills:*0* 11. Outpatient Lab Work Please have drawn [**10-30**] at [**Hospital1 18**] lab in am Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease s/p CABG Post operative atrial fibrillation peripheral arterial disease Osteoarthritis Hypertension Gastroesophageal reflux disease Congenital Horse Shoe Kidney s/p Kidney Stones Dyslipidemia TIA x2 Melanoma x3 with removal esophagitis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet ncisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema +1 lower extremity 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 [**11-21**] at 1:30pm Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**11-14**] at 1:00pm Wound check appointment - tuesday [**10-30**] at 1015 am - cardiac surgery office in [**Hospital **] medical building [**Telephone/Fax (1) 170**] Please call to schedule appointments with your Primary Care:Dr. [**First Name4 (NamePattern1) 13291**] [**Last Name (NamePattern1) 32683**] in [**2-11**] 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:[**2153-10-25**]

[ "E878.2", "272.4", "414.01", "V12.54", "780.62", "401.9", "278.00", "427.31", "753.3", "V85.32", "285.9", "288.60", "411.1", "530.81", "V43.65", "V45.4", "997.1", "518.4", "443.9", "715.95" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7891, 7940

4914, 6051

318, 518

8244, 8476

3202, 4891

9316, 10069

2286, 2293

6498, 7868

7961, 8223

6077, 6475

8500, 9293

2308, 3183

261, 280

546, 1799

1821, 2026

2042, 2270

7,159

106,975

13772

Discharge summary

report

Admission Date: [**2103-5-31**] Discharge Date: [**2103-6-5**] Service: Medicine HISTORY OF PRESENT ILLNESS: The patient is a 79 year old male who came from an outside hospital status post three bloody stools. He was orthostatic with a hematocrit of 22.8. During his stay at the outside hospital, he was given a total of 20 units of packed red blood cells, 16 units of platelets and 10 mg of vitamin K and four bags of fresh frozen plasma to correct his INR. He was also on Coumadin. Nasogastric lavage did not have any coffee-grounds in it. He was scoped and had small polyps that were not bleeding. A red tag scan was negative and a repeat scan after melanotic stool showed uptake throughout his entire colon. He was scoped the next day, which showed a friable cecum without bleeding. He was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for angiography. PAST MEDICAL HISTORY: 1. Cerebrovascular accident in [**2102-5-11**] with left paralysis, since resolved. 2. Myelodysplastic syndrome with pancytopenia. 3. Gastric ulcers. 4. Chronic renal insufficiency. 5. Coronary artery disease, status post myocardial infarction in [**2098**], status post coronary artery bypass grafting in [**2097**]. 6. Hypertension. 7. Congestive heart failure. 8. Type 2 insulin dependent diabetes mellitus. 9. Questionable gastrointestinal bleed. 10. Peripheral vascular disease. 11. Alcohol abuse, last drink [**2074**]. 12. Malignant gastrointestinal polyp in [**2096**], subsequent scopes have been negative. 13. Transurethral resection of prostate. 14. Cataract surgery. 15. Helicobacter pylori in [**2103-2-8**]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: Zantac, NPH, Actose, Coumadin, Altace, Lasix, folate, pyridoxine, iron sulfate and multivitamins. PHYSICAL EXAMINATION: On physical examination on transfer to the medical team from the Medical Intensive Care Unit, the patient had a temperature of 97.8, pulse 81, blood pressure 135/56 and oxygen saturation 99% in room air. General: Pleasant male in no acute distress. Head, eyes, ears, nose and throat: Anicteric sclerae, oropharynx clear, moist mucous membranes. Neck: No jugular venous distention. Cardiovascular: Regular rate and rhythm, no murmurs. Lungs: clear to auscultation bilaterally. Abdomen: Soft, nontender, positive bowel sounds. Extremities: No peripheral edema. LABORATORY DATA: Upon transfer, white blood cell count was 2.1, hemoglobin 11.1, hematocrit 32.4, platelet count 72,000, sodium 136, potassium 4.2, chloride 111, bicarbonate 16, BUN 20, creatinine 1, platelet count 212,000, prothrombin time 14.6, partial thromboplastin time 35.5 and INR 1.4. HOSPITAL COURSE: 1. Gastrointestinal: The patient was transferred from the outside hospital for possible angiography. He was admitted to the Medical Intensive Care Unit for close observation. There was no evidence of further bleeding since his arrival here, with a stable hematocrit and no melena. Therefore, angiography was not performed. A repeat tagged red blood cell scan, to look for a fistula, was negative. The patient was transferred to the medicine service and, again, his hematocrit remained stable. He was able to tolerate oral intake and was discharged to follow up for a repeat colonoscopy in six to eight weeks. Coumadin, non-steroidal anti-inflammatory drugs and aspirin were discontinued and he was to await further instructions from his gastroenterology doctor as an outpatient concerning these medications. 2. Cardiovascular: The patient remained stable. 3. Fluids, electrolytes and nutrition: The patient was able to tolerate oral intake and his diet was eventually advanced to a diabetic diet without difficulty. DISCHARGE DIAGNOSIS: Gastrointestinal bleed of unknown source. DISCHARGE MEDICATIONS: Zantac. NPH. Actose. Altace. Lasix. Folate. Pyridoxine. Iron sulfate. Multivitamins. DISCHARGE INSTRUCTIONS: 1. Call to schedule a follow-up colonoscopy. 2. Avoid aspirin and aspirin-like products. 3. Do not take Coumadin. 4. [**Month (only) 116**] resume normal activities. 5. Call doctor [**First Name (Titles) 151**] [**Last Name (Titles) **] greater than 101, increased pain, weakness, nausea, vomiting and/or blood in stool. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4518**] Dictated By:[**Name8 (MD) 4385**] MEDQUIST36 D: [**2103-10-23**] 01:29 T: [**2103-10-23**] 14:37 JOB#: [**Job Number **]

[ "412", "250.00", "284.8", "578.1", "V45.81", "401.9", "569.82", "414.01", "428.0" ]

icd9cm

[ [ [] ] ]

[ "45.23", "45.43" ]

icd9pcs

[ [ [] ] ]

3943, 4029

3877, 3920

1819, 1918

2824, 3856

4054, 4646

1941, 2806

120, 968

991, 1792

69,483

103,926

51997

Discharge summary

report

Admission Date: [**2167-4-9**] Discharge Date: [**2167-4-20**] Service: MEDICINE Allergies: Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac catheterization, mechanical intubation, continuous [**Last Name (un) **]-venous hemofiltration History of Present Illness: 85 year old woman with hx of CAD s/p prior PTCA, pVD, DM2, htn, chol and anemia presented to NWH on [**2167-4-8**] with unstable angina. Her EKG was described as unchanged from prior. Her labs were notable for Trop0.06. BNP 234. creat 1.3 on arrival (baseline 1.2). Her evaluation there was notable for cardiac enzymes as above. She was felt to be in mild congestive heart failure after 1 unit of pRBCS which she received for a Hct of 26. She received 2 doses of lasix. She was started on a heparin gtt (not listed in discharge meds. She did have small amount of blood on her toilet tissue thought secondary to hemorrhoidal bleed. She did receive a 2nd unit of PRBCs. A TTE (prelim only) LAE, preserved LVEF, mild MR/TR. . She describes her baseline at chronic stable angina with chest pressure at similar level of exertion such as walking [**5-17**] block of level ground. However over the past month she noted a decreased threshhold for her discomfort now after only 1 flight of stairs. On the day prior to her admission she had the similar sensation of chest pressure while at rest. It lasted for ~2 hours and improved with nitroglycerin. She had recurrent event at 1:30pm on the 25th so she presented to the hospital. She states her weight has been stable. She has chronic venous stasis and has had new lower extremity swelling over the past few weeks. She has no orthopnea or PND. . On floor, patient was feeling short of breath with walking to the bathroom but otherwise feeling well. She has no current chest pain. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools. She has been having small amount of blood on the toilet tissue over the past few weeks. She denies recent fevers, chills or rigors. She has exertional leg pain at 4 blocks of walking. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: # s/p inferior wall NQWMI in [**2157**], s/p cardiac catheterization in [**2157**] with PTCA of RCA (RCA mid-vessel total occlusion -> PTCA with grade C dissection -> TIMI 3 flow, no stent); complicated by dissection and pseudoaneurysm #. Type 2 diabetes - HgA1C 7.3% [**2166-11-12**] - complicated by neuropathy #. Hypertension #. Hyperlipidemia #. Peripheral [**Year (4 digits) 1106**] disease #. Asthma #. Chronic kidney disease baseline 1.1-1.2 #. GERD #. Hyperparathyroidism #. Osteoarthritis #. B12 deficiency anemia #. Appendectomy #. Bladder suspension #. Right meniscectomy in [**2161-1-11**] #. Excision of benign breast mass times two Social History: The patient currently lives in [**Location 107641**] with her [**Age over 90 **] year old Husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she walks with a cane, she is otherwise independent in all ADl although looking to get an aid to help clean soon. Tobacco: None ETOH: None Illicits: None Family History: Non-Contributory Physical Exam: VS: 98.7 148/62 74 20 93%3L wt. 96kg GENERAL: obese elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**3-20**] MR murmur. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. crackles at left base greater than right. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. external hemorrhoids. red blood (heme+) in rectal vault. EXTREMITIES: No c/c/e. right femoral bruit. SKIN: +stasis dermatitis. no ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP trace PT trace Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP trace PT trace Neuro: -MS a,ox3. coherent response to interview. -CN II-XII intact (pupils reactive, EOMI, face symmetric, palate/tongue midline) -Motor moving all 4 extremities symmetrically -[**Last Name (un) **] light touch intact to face/hands/feet Pertinent Results: [**2167-4-9**] 10:40PM GLUCOSE-141* UREA N-65* CREAT-1.6* SODIUM-142 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-17 [**2167-4-9**] 10:40PM CK(CPK)-150* [**2167-4-9**] 10:40PM CK-MB-6 cTropnT-0.07* [**2167-4-9**] 10:40PM WBC-9.6# RBC-2.84* HGB-9.4* HCT-26.9* MCV-95 MCH-33.2* MCHC-35.1* RDW-14.6 [**2167-4-9**] 10:40PM PLT COUNT-220 [**2167-4-9**] 10:40PM PT-13.4 PTT-36.9* INR(PT)-1.1 . STUDIES OF RELEVANCE IN CHRONOLOGICAL ORDER: [**2167-4-9**] CXR: Lungs clear, mild pulmonary engorgement and top normal heart size suggest borderline cardiac decompensation, but there is no edema or appreciable pleural effusion. [**2167-4-10**] Card Cath: COMMENTS: 1. Coronary angiography in this right-dominant system revealed: --the LMCA had no angiographically apparent disease. --the LAD had a proximal <50% stenosis. --the LCX had no angiographically apparent disease. --the RCA had an ostial >90% stenosis. 2. Limited resting hemodynamics revealed severely elevated left-sided filling pressures, with LVEDP 30 mmHg. There was mild systemic arterial systolic hypertension with SBP 149 mmHg. There was no gradient across the aortic valve upon pullback of the angled pigtail catheter from LV to ascending aorta. 3. Successful PTCA and stenting of the ostial RCA with two overlapping bare metal stents - Minivision (2.5x15mm distally; 2.5x12mm proximally) postdilated with a 2.75mm balloon. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vesel (See PTCA comments). 4. Successful closure of the right femoral arteriotomy site with a 6F Angioseal closure device. FINAL DIAGNOSIS: 1. Significant one coronary artery disease. 2. Successful PTCA and stenting of the ostial RCA with two overlapping bare metal stents. 3. Successful clousre of the right femoral arteriotomy site with a 6F Angioseal closure device. [**2167-4-11**] ECHO: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with mild basal and mid-anterior septal hypokinesis, distal septal akinesis and probable apical hypokinesis. The remaining segments contract normally (LVEF = 40-45%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericar dial effusion. IMPRESSION: Normal right ventricular systolic function. Mild regional left ventricular systolic dysfunction, c/w CAD. Moderate mitral regurgitation. Mild pulmonary hypertension. [**2167-4-11**]: IMPRESSION: CT A and P 1. Multifocal consolidations may represent pneumonia, however pulmonary hemorrhage in the setting of hyperdense, and likely hemorrhagic, effusions should be considered. 2. Retained renal contrast with vicarious excretion via the gallbladder, all consistent with renal failure. 3. Fibroid uterus. [**2167-4-13**] CT Chest: Followup of a patient with bilateral pleural effusion, consolidations, and known pneumothorax. COMPARISON: CT abdomen from [**2167-4-11**] and multiple chest radiographs obtained in the interval between [**4-9**] and [**2167-4-13**]. TECHNIQUE: Unenhanced MDCT of the chest was obtained from thoracic inlet to upper abdomen with subsequent 1.25- and 5-mm collimation axial images reviewed in conjunction with coronal and sagittal reformats. FINDINGS: Extensive widespread consolidations involve mostly the right upper lobe, right middle lobe, and right lower lobe but also are seen in left lower lobe and left apex. The consolidations are relatively high in density (the left upper lobe consolidation is about 57 Hounsfield units in density), as are the right middle lobe and lower lobe consolidations (ranging up to 50 Hounsfield units). The comparison of the lung bases with a recent CT abdomen from [**2167-4-3**] demonstrates interval progression of the consolidations in the right middle and right lower lobe. The bilateral pleural effusion, although did not increase significantly in size, is still of high density (up to 46 Hounsfield units) in the lower portions of the lungs suggesting sedimentation effect. The mediastinal lymph nodes are enlarged ranging up to 16 mm in right lower paratracheal area and might be reactive. Extensive coronary calcifications are noted. The heart size is mildly enlarged. There is no significant pericardial effusion. Minimal left pneumothorax is demonstrated, 2A:31, seen in the anterior mediastinum giving the patient's supine position and might correspond to an apical pneumothorax demonstrated on the upright chest radiograph obtained the same day earlier at 09:09 a.m. Although the comparison between the chest CT and chest radiograph is difficult, the size of the pneumothorax is most likely unchanged and is small. The imaged portion of the upper abdomen demonstrates fat density left adrenal lesion, -19 Hounsfield units, consistent with lipoma. The rest is unremarkable within the limitations of this non-enhanced study. Again note is made of the presence of contrast enhancement of the kidneys consistent with known failure and retained excretion of contrast. Contrast is also demonstrated in the renal pelvis. The vicarious excretion of the distended gallbladder is again noted. The bladder is at least 5 cm in diameter, although no wall thickening or surrounding abnormalities are seen. There are no [**Year (4 digits) 500**] lesions worrisome for malignancy. Degenerative changes are seen. IMPRESSION: 1. Extensive bilateral consolidations, right more than left, of high density that might be consistent with multifocal hemorrhage. The differential diagnosis in the presence of renal failure might include vasculitis. Hemorrhagic pneumonia might be considered in appropriate clinical setup. 2. Small left apical pneumothorax, most likely unchanged compared to prior chest radiograph. 3. Bilateral grossly unchanged pleural effusions, high in density that might also contain an element of hemorrhage. 4. Extensive coronary calcifications. 5. Still present contrast enhancement of kidneys and vicarious excretion of contrast the gallbladder consistent with known renal failure. Brief Hospital Course: 85-year-old woman with a history of coronary artery disease s/p BMS x 2 in RCA on [**2167-4-10**], with post-cath course complicated by pulmonary edema, contrast-induced nephropathy requiring CCU stay with transition to cardiac service. 1) Unstable angina/CAD: Patient's typical anginal pain was occurring at rest and had ST depressions in V4-6. Given concern for ongoing bleeding cath was deferred until [**4-10**]. Cardiac catheterization demonstrated 90% occlusion of ostial RCA which was stented with two overlapping bare metal stents. Her chest pain occurred intermittently since the PCI with intermittent ST depressions in V4-V6. Nitro gtt was temporarily started for the pain, and she remained pain free after it was discontinued. Cardiac markers were mildly elevated, likely demand ischemia from anemia, and CK-MB was negative. She was treated with aspirin, statin, and plavix. Patient's metoprolol was restarted once she stabilized. 2) Acute on chronic diastolic heart failure: Felt to be secondary to RBC transfusions at OSH. She had an ongoing O2 requirement and desatted to 85% RA on am of [**4-11**], for which she was transferred to the CCU and lasix gtt was started. Fluid was initially removed via CVVH (as below), although once UOP improved, she was successfully diuresed with IV furosemide. 3) Acute on chronic CKD: FENa 6%, likely contrast nephropathy. Her [**Last Name (un) **] was held. Renal was consulted for poor UOP while on lasix drip and high dose diuril. Her creatinine rose and she was started on CVVH via L IJ line. After a few days, her UOP picked up and responded well to 40mg IV furosemide boluses, so the CVVH line was removed. 4) Anemia: Given concern for RP bleed related to cath, she had CT abd, which showed bilat ?hemothoraces, but no RP bleed. Other source could be GI bleed from external hemorrhoids. She received 1 unit of pRBCs and her hematocrit remained stable. 5) Pneumonia: Patient had frequent coughing associated with desaturations. CT chest was concerning for atypical pneumonia vs. alveolar hemorrhage, although pulm consult favored the former. ANCA and anti-GBM were negative. She received a 5 day course of azithromycin and a brief course of prednisone for possible diffuse alveolar hemorrhage (one day each at 60mg, 40mg, 20mg, 10mg). Her cough greatly improved. 6) Diabetes mellitus: Initially on glargine, although changed to insulin gtt in the CCU due to highly elevated (300s) sugars in the setting of steroids. She was transitioned back to glargine as the steroids were rapidly tapered. Medications on Admission: Home Meds: Amlodopine 5mg daily atorvastatin 20 mg daily furosemide 40mg [**Hospital1 **] glimepiride 4 mg daily humalog insulin sliding scale imdur 60 mg [**Hospital1 **] lidoderm patch [**Hospital1 **] nitroglycerin spray prn pentoxifylline SR 400 mg TID with meals diovan 320 mg daily aspirin 325 mg dialy calcium +D 600/200 units [**Hospital1 **] cyanocobalamin (unknown dose) multivitamin daily Omega 3 fatty acids 1000 mg daily . Meds on transfer: amaryl 4 mg daily calcium +d [**Hospital1 **] centrum daily diovan 160 mg daily aspirin 325 mg daily fish oil daily isodil 40 mg q8hours lasix 40 mg [**Hospital1 **] lipitor 20 mg daily lopressor 25 mg q6 nitrostat prn norvasc 10 mg [**Hospital1 **] protonix 40 mg IV daily tylenol prn vitamin b12 daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Lidoderm Topical 10. Nitroglycerin Sublingual 11. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day: with meals. 12. Calcium 600 with Vitamin D3 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 13. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 14. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease Angina Pulmonary Edema Contrast Induced Nephropathy Discharge Condition: Good Discharge Instructions: You were admitted for cardiac catheterization and stent placement in the setting of unstable angina. You required ICU level care for pulmonary edema and contrast-induced nephropathy. . Please take all your medications as prescribed. . Please follow-up with your providors as below. . Please return if you have any further chest pain or shortness of breath. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Followup Instructions: #You will need to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] (your PCP) ([**Telephone/Fax (1) 250**]) within one week of discharge. Please call to make this appointment. At that time, please bring-in your daily weights and ask your doctor to determine if he feels your Lasix needs to be restarted. You may note that we have just restarted your [**Last Name (un) **] (Valsartan). You are no longer on Isosorbide Dinitrate s/p your intervention. . #You will need to see Dr. [**Last Name (STitle) **] (your cardiologist) within two week of discharge. Please call to make this appointment. Ask him to review your blood pressure and medications. . #Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**] Date/Time:[**2167-4-27**] 9:00 . #Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-4-27**] 10:00 . #Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2167-5-4**] 9:30 Completed by:[**2167-5-18**]

[ "486", "E947.8", "250.40", "272.0", "250.60", "414.01", "428.0", "428.33", "403.90", "518.0", "411.1", "455.8", "584.9", "493.90", "585.9", "443.9", "530.81", "357.2" ]

icd9cm

[ [ [] ] ]

[ "36.06", "00.40", "00.46", "88.52", "88.55", "00.66", "38.93", "37.22", "99.20" ]

icd9pcs

[ [ [] ] ]

15781, 15830

11258, 13811

278, 382

15949, 15955

4753, 6411

16437, 17473

3519, 3537

14620, 15758

15851, 15928

13838, 14274

6428, 11235

15980, 16414

3552, 4734

228, 240

410, 2502

2524, 3172

3188, 3503

14292, 14597

15,717

116,404

24838

Discharge summary

report

Admission Date: [**2111-10-9**] Discharge Date: [**2111-10-30**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2186**] Chief Complaint: confusion, change in MS, hypoxia, humeral fracture Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 83 yo man w/ h/o CAD s/p CABG >25 yrs ago, s/p ICD, Afib not on coumadin, HTN who was admitted after mechanical fall with proximal left humeral fracture on [**2111-10-9**]. At time of initial admit, patient had rec'd 2 mg SC morphine, 2 percocets in the emergency room with subsequent dramatic change in mental status, but was noted to be clear and oriented prior to administration. He denied head trauma or LOC during fall. Has been having "almost" falls lately with some frequency. . Since admission, patient has been having waxing and [**Doctor Last Name 688**] mental status, worsened by narcotics and benzos, as above. Xray showed comminuted, displaced fracture of left proximal humerus. Seen by ortho, given sling, and told to be non-weight bearing. PT consult obtained. Had transient low bp on [**10-9**] to 80's/60's, thought to be due to wrong medication/antihypertensive doses (family unsure of doses/ meds). This improved with dose adjustments. Cr also elevated during admission, thought to be mostly chronic per notes (but no baseline), given hydration. . Past Medical History: information limited- no records here CAD s/p CABG [**31**] years ago CHF ICD early/mild dementia per medical record this admission CRI? baseline unclear Afib not on coumadin cataracts w/ ?left sided blindness Social History: visiting from berkshires; wife having surgery here; Family History: not elicited Physical Exam: T 101.1 BP 113/76 P 134 AF? Vpaced R 24 sat 93% 4L gen: elderly, dysarthric, garbled speaking man, agitated, calling out HEENT: MM dry; NC in place, left surgical pupil, right is 2 mm and reactive, EOMI intact but not to command, tongue midline NECK: JVP flat; supple CV: ICD palpated, midline scar; tachy, regular CHEST: poor effort/cooperation; decreased breath sounds at bases w/ some crackling; no wheeze ABD: soft, non tender, nabs EXTRM: thin; non edematous, left shoulder with severe ecchymoses; tender to palpation and any movement. In sling. NEURO: babbling, incoherent, responsive to voice/command/pain; CN exam limited [**2-25**] selective-command following but tongue midline, EOMI but not to command (spontaneous), slight left sided facial droop; down going toes bilaterally w/ withdrawal to pain, slightly rigid lower extremities- no clonus; hyper reflexive achilles, patellar, biceps (3+) bilaterally, squeezes hands and wiggles toes to command, moving all extrm spontaneously, speech is garbled with intact comprehension to some extent but unable to formulate meaningful sentences. Able to give one word answers. Pertinent Results: 2 views left shoulder: Comminuted, displaced fracture of the left proximal humerus. [**10-11**] CT head: There is no intraaxial hemorrhage. There is no shift of normally midline structures, acute fractures, loss of the [**Doctor Last Name 352**]-white matter differentiation, or major vascular territorial infarct. The ventricles and sulci are prominent consistent with mild brain atrophy. There is low attenuation of the centrum semi-ovale consistent with chronic microvascular ischemia. There is a low attenuation in the left basal ganglia consistent with an old lacunar infarct. This study is degraded secondary to patient motion and streak artifact. There are prominent low density extra-axial spaces over the right convexity and in the left parafalcine region, most likely representing subdural hygromas or chronic subdural collections. There is no evidence of an acute subdural hematoma. There is no mass effect. [**2111-10-12**] B/L LE dopplers:Negative bilateral lower extremity Doppler examination. . [**2111-10-12**] CT head: 1. No evidence of intracranial hemorrhage or edema. 2. Cerebral atrophy. 3. Widening of the right extra-axial space likely secondary to atrophy and/or a subdural hygroma. . [**2111-10-12**] CXR:Mild pulmonary edema has developed accompanied by numerous small right pleural effusion. Severe cardiomegaly is stable. Atrial biventricular pacer leads are in standard placements. No pneumothorax. . [**2111-10-12**]: EF 15-20% Mild pulmonary edema has developed accompanied by numerous small right pleural effusion. Severe cardiomegaly is stable. Atrial biventricular pacer leads are in standard placements. No pneumothorax. . [**2111-10-14**] CT OF THE LEFT SHOULDER WITHOUT CONTRAST: A reference is made to a prior radiograph dated [**2111-10-8**]. There is a complex, comminuted fracture through the surgical neck of the left humerus with anteromedial angulation of the humeral shaft. A small fracture involving the distalmost aspect of the clavicle is likely also present. The acromioclavicular joint is preserved. The humeral head is normally seated within the glenoid, without evidence of dislocation. An unusual dense ovoid bony "nodule" is present adjacent to the fracture site and is of unclear etiology. ? sclerotic focus within the bone (e.g. bone island which was "released" by the fracture or possibly a dense loose body in the joint space. There is surrounding soft tissue hematoma and effusion. Incidental note is made of a 3.3 x 1.7 cm lipoma along the lateral aspect of the proximal humeral shaft. IMPRESSION: Comminuted, displaced fracture through the surgical neck of the left humerus as above. Small distal clavicular fracture. Unusual ovoid density, as described. . [**2111-10-16**] RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler son[**Name (NI) 1417**] of the right internal jugular, right subclavian, right axillary, right brachial, right basilic, and right cephalic veins were performed. The most superiorly located brachial vein is noncompressible and does not demonstrate any wall to wall color or venous waveforms. These findings are suggestive of thrombosis involving the superior brachial vein. The remaining veins otherwise appeared normal with wall-to-wall color flow, normal waveforms, and normal compressibility. IMPRESSION: Noncompressibility of the superior right brachial vein, with lack of color flow and absent venous waveforms, findings consistent with venous thrombosis. . [**2111-10-16**] Renal ultrasound: Large left renal cyst with a thick septation with calcification falling in the Bosniak II F category. A four to six month followup is recommended. There is no evidence of hydronephrosis or renal stones. . [**2111-10-19**] RIGHT UPPER QUADRANT ULTRASOUND: This examination was extremely limited due to altered mental status. No ascites is seen. This study should be repeated when the patient is more able to cooperate with the exam . [**2111-10-19**]: ABDOMINAL ULTRASOUND WITH LIVER DOPPLER EXAMINATION: The gallbladder is not visualized. The common bile duct is not dilated at 3 mm. The liver parenchyma is normal in echo texture without focal nodules or masses. There is a moderate right-sided pleural effusion. The right kidney measures 11.4 cm. There is an exophytic 2.9 x 2.8 x 2.5 cm simple cyst off the lateral aspect of the right kidney. The left kidney measures 12.4 cm, with a 7.5 x 6.2 x 6.9 cm cyst, which a thin septation and mild calcifications. The spleen is not enlarged. The pancreas is poorly visualized secondary to overlying bowel gas. Doppler examination reveals normal flow and phasicity within the main and right portal veins, demonstrating hepatopetal flow. Normal flow and phasicity is seen within the main hepatic artery. All hepatic veins are patent, with appropriate flow. Increased phasicity is consistent with underlying right heart failure. IMPRESSION: 1. All hepatic vessels are patent with normal directional flow. Increased phasicity within the hepatic veins is consistent with underlying right heart failure. 2. Normal appearing liver parenchyma without focal nodules or masses identified. 3. No evidence of hydronephrosis bilaterally. Simple cyst in right kidney. Cyst with internal calcification and thin septation within left kidney. 4. Moderate right-sided pleural effusion. . [**2111-10-21**] CXR: 1. Mild congestive heart failure. 2. Increasing atelectasis or pneumonia in the left lower lobe. . [**2111-10-22**] CXR: Low lung volumes have worsened; there is more consolidation at both lung bases, worrisome for pneumonia. Moderate cardiomegaly is stable. Upper lungs show pulmonary vascular congestion but no edema. Tip of the right PIC catheter is in the SVC. Right atrial and left ventricular pacers and right ventricular pacer defibrillator leads are unchanged in their respective positions. No pneumothorax. . [**2111-10-28**] Successful placement of a 37-cm 4 French single-lumen PICC by way of the right brachial vein with tip at the superior vena cava-right atrial junction. The catheter may be used immediately. . [**10-15**] blood cx: [**1-25**] with gram positive cocci [**10-18**]: blood cultures: [**1-25**] with gram positive cocci R femoral line tip for culture: final - no growth [**10-20**]: Blood culture off PICC - no growth [**10-21**]: Blood culture off PICC - no growth [**10-22**]: Blood culture peripheral - no growth [**10-23**]: Blood cultures: no growth [**10-21**]: urine culture - no growth . EKG: most recent from 23:37 with AF rate 138 normal axis; intermittent V pacing spikes; S1 QIII TIII present. IVCD, no ischemic changes. [**2111-10-9**] 06:30PM CK(CPK)-94 [**2111-10-9**] 06:30PM CK-MB-3 cTropnT-0.03* [**2111-10-9**] 07:45AM GLUCOSE-121* UREA N-43* CREAT-1.8* SODIUM-143 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-26 ANION GAP-13 [**2111-10-9**] 07:45AM PLT COUNT-139* [**2111-10-9**] 07:45AM PT-14.0* PTT-27.3 INR(PT)-1.3 Brief Hospital Course: 83 M with multiple medical problems after mechanical fall with proximal humerus fracture complicated by delirium. . 1. Altered Mental status: Patient initially presented to medicine service with opiate induced delirium as he had been given 2 Percocet tablets and 4mg of Morphine for pain control before being seen by medicine service. His delirium, likely exacerbated by pain from recent fracture, hypoxia/infection from pneumonia, also may have some degree of uremia from rising creatinine and persistent renal failure. Fat emboli syndrome was also high on the differential given his elevated LFTs and worsening renal failure. PE was also on the differential, however this was felt to be less likely given the other reasons for hypoxia and delirium, and given his poor renal function, CTA was not done during admission. He was also ruled out for MI. Patient was intermittently agitated. He was hypotensive at 1 point and had limited IV access and was sent to the ICU, but did not require intubation. Opiates were avoided as much as possible. A pain consult was obtained hoping that pain control would help with his delirium. However, due to his multiple medical problems they felt that aggressive intervention would not be possible. They recommended Ultram and standing Tylenol. His delirium persisted and he became progressively more tachypneic and looked uncomfortable. Tiny doses of morphine were give (total of about 2 mg in 24 hours). He remained tachypneic and then became hypoxic and went into respiratory failure on [**10-22**]. He was intubated and sent back to the ICU. From a respiratory status he improved and it was felt that he could be extubated, however he remained heavily sedated after fentanyl and versed were discontinued. It was unclear if he would do well on extubation given his mental status, however he tolerated it well and sats were in high 90's in 4 L NC. He remained delirious only answering to what his name is, but otherwise was disoriented. A family meeting was held in the ICU, and it was decided that the patient would want to be DNR/DNI but medical management would be continued. Although they did not make him comfort measures only, the family stressed that he should be made as comfortable as possible. He occasionally became agitated and seemed somewhat uncomfortable when he returned to the floor. Ultram was restarted with hopes of controlling his pain without giving morphine and Zyprexa was ordered PRN. Geriatrics followed the patient throughout his hospital stay and they agreed that we should treat all of his medical issues and control his pain, given this was likely contributing to his delirium. Would continue scopolamine patch for secretions and suction PRN, continue aspiration precautions until mental status clears, ultram and tylenol for pain. . 2. ID: Patient developed pneumonia most likely secondary to aspiration given his altered mental status he was treated with 12 days of levofloxacin, 8 days of Flagyl and 10 days of vancomycin. His blood cultures from [**10-15**] and [**10-18**] grew coag negtaive staph sensitive to vancomycin. However, on [**10-22**] he spiked a fever to 104 and became hypoxic, chest x-ray looked like worsening pneumonia most likely to continued aspiration. He went into respiratory distress, was intubated, brought to the [**Hospital Unit Name 153**] where he was also on pressors and was started on Zosyn, He received a full 7 days of Zosyn, was afebrile with improving respiratory status, was extubated and began maintaining his sats at 98-100% on 4 L NC. At discharge, he was on no antibiotics and all cultures from [**10-20**] on were negative. . 3. Respiratory failure: It was thought that his respiratory failure was due to pulmonary edema along with pneumonia. It is likely that he was continuously aspirating. On serial CXR there was pulmonary edema and O2 sats did improve with diuresis. On [**10-22**] his respiratory status rapidly declined, blood gas showed a metabolic acidosis. CXR revealed worsening pneumonia and patient was tachypneic and hypoxic and eventually began having apneic episodes. He was intubated, sedated and taken to the ICU where he was started on pressors and Zosyn for pneumonia. It was thought that his rapid decline was secondary to worsening pneumonia and mucous plugging. He was extubated and was satting 98-100% on 4 L NC after treatment with 7 days of Zosyn. . 4. Access: Multiple attempts were made to get IV access including PIV in his foot, central lines and femoral lines. Lone placement was limited by his agitation, edema, pacemaker, right brachial artery thrombus, and fractured left arm. A femoral line was briefly placed as patient was in desperate need of hydration, but was discontinued after 2 days after which time a PICC line was place. However, patient was bacteremic and PICC was pulled and he was treated with antibiotics and then a PICC was replaced. At discharge he has a right PICC which was left in place given all of his issues with IV access. 5. Renal: Probably ARF on CRF. Patient had rising creatinine from PCP's office: Cr 1.7->2.2 (rising on 4 consecutive readings every 2-3 weeks) prior to admission. His creatinine peaked at 2.9, He did not receive any contrast, but has gotten some ibuprofen. No signs of active sediment with muddy brown casts consistent with ATN as well, good UOP and renal u/s showed no signs of obstruction. Urine lytes c/w prerenal etiology. Creatinine improved with hydration, but his fluid status was precarious given his low EF. He did have worsening pulmonary edema after hydration and responded well to 40 of IV Lasix. He was positive about 10 liters during admission but appears euvolemic on discharge. Also, patient was hypernatremic to 157 during the time it was difficult to gain IV access. A renal consult was obtained and agreed with our management of replete his free water. His free water deficit was estimated at 4-5 liters. He received 5 liters D5W and his sodium was within normal limits and remained normal for the rest of his hospital stay. His HCO3 remained about 18 throughout most of his hospital stay. The reason for this is unclear. It is possible that he has an RTA, but renal was not re consulted. Can consider further work up after resolution of his acute medical problems. . 6. Humerus fx/Pain control: Orthopedic consulted and had no plan for surgery and to follow as outpatient. They recommended continuing sling with swath for 6 weeks and non-weight bearing of left arm. His arm remained edematous and ecchymotic thorough out admission and the patient was reevaluated for possible compartment syndrome, but Ortho did not think this was likely. Pain control with Tylenol 1000 mg Q 6H and Ultram [**Hospital1 **]. He should follow up with orthopedics as an outpatient. 7. Cardiac: Patient has CAD and is s/p CABG and had an ICD placed for unknown reasons but likely due to low EF. Patient also has known ECHO in [**2109**] with EF of 30% (as per PMD)with ischemic changes including enlarged left ventricle and mitral and aortic regurgitation. On this admission ECHO was repeated and revealed EF 15-20%. He was ruled out for MI on admission as he complained of some mild substernal chest pain. Cardiac enzymes were negative and EKG revealed no ischemic changes. He had no further episodes throughout admission. His blood pressure medications were held for hypotension and renal failure. However, given his low EF and valvular disease would recommend titrating captopril as blood pressure tolerates. . 8. Heme: Patient's INR was 1.2 on admission and on HOD#3, INR peaked at 2.2; on HOD#[**5-3**] A hematology consult was obtained to evaluate for possible DIC/TTP picture given anemia and thrombocytopenia. However, there were no schistocytes on smear and these abnormalities began to normalize, therefore no further work up was pursued. it has been steady in the 1.8-2.0 range. . 9. Elevated LFTS: LFTS began to elevate on HOD#9. Abdominal ultrasound was negative and there was no other reason to explain this. He did become hypotension, but not to a significant extent and enzymes are not high enough to indicate shock liver. It was thought this may have been to an overall inflammatory response due to fat emboli syndrome. His LFTs continued to improve over the course of hospitalization. . 10. FEN: Patient was hypernatremic as mentioned above, but this has since resolved. Currently has NG in place with TF as 600 cc/hr and D5 1/2 NS at 50 cc/hr. Given his CHF and renal failure his fluid status had to be closely monitored. On discharge he appeared euvolemic. . 11. Code: DNR/DNI. Family would like complete medical management, but also think comfort is very important so would consider pain medications even if this worsened his mental status. Medications on Admission: levoflox 250 mg qd IV today day 1 metoprolol 12.5 qd changed to 5 mg IV q6 hr when made NPO isosorbide 40 mg po bid bisacodyl protonix 40 mg qd asa 162 po qd oxybutynin 5 mg tid lipitor 10 mg qd quinine 260 mg qod magnesium oxide 280 qd donepezil 10 mg qd heparin sc tid psyllium colace 100 mg [**Hospital1 **] doxepin 25 qd MVI tylenol 1 g q 4hr Discharge Medications: 1. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO QHS QOD (). 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO 2 CAPLETS DAILY (). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 14. Isosorbide Dinitrate Oral 15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 1. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Quinine Sulfate 260 mg Tablet Sig: One (1) Tablet PO QHS QOD (). 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO 2 CAPLETS DAILY (). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 14. Isosorbide Dinitrate Oral 15. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary 1. Humeral fracture 2. Delirium 3. Acute renal failure 4. CHF Secondary 1. A. fib 2. cataracts Discharge Condition: Delirium, oriented to self only, respiratory status stable, afebrile, NGT in place Discharge Instructions: Please take all of your medications as directed. You should follow up with orthopedics for your humeral fracture. Followup Instructions: Call the orthopedics clinic for a follow up visit 4-6 weeks.

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Discharge summary

report

Admission Date: [**2185-12-16**] Discharge Date: [**2185-12-17**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Ciprofloxacin Attending:[**First Name3 (LF) 492**] Chief Complaint: Transferred from [**Location (un) 62562**] Hospital for repeat bronchoscopy for possible tracheal stenosis. Major Surgical or Invasive Procedure: Rigid bronchoscopy with replacement of the tracheostomy tube History of Present Illness: 89yoF with h/o CHF, ?COPD, s/p aortic valve replacement in [**2181**], PAF, s/p trach for failure to wean on chronic ventilator support who presented to [**Location (un) 62562**] Hospital on [**2185-12-15**] with hypoxemia and high peak airway pressures. Per OSH admission history and physical, her ventilator started alarming on [**2185-12-14**] for "high pressure." Her daughter called the ventilator company who instructed her to attempt "some maneuvers" which apparently did not stop the vent from alarming. Thus, she presented to OSH thereafter. . In the ED at OSH, respiratory staff [**Date Range 4351**] had difficulty bagging her and initially suspected mucous plug, however they were unable to suction significant secretions and peak pressures remained high. She was admitted to the ICU there where she is apparently well known for multiple admissions. She underwent brochoscopy this am, however, they were unable to pass the bronchoscope beyond the trach (distal portion of trach with 1/3 occlusion) thought to be obstructed by either mucous plug or more likely granulation tissue. She is now being transferred for IP procedure. . Additionally of note, at OSH, WBC count was noted to be elevated to 20.7 and she was started on zosyn for unclear source, presumably respiratory. Per her daughter, she has been "in and out of the hospital" recently; she was discharged from [**Hospital **] rehab in [**2185-8-20**] on trach collar during the day and AC overnight. She was again admitted to [**University/College 23925**] [**Location (un) **] for 2 months (discharged [**2185-10-19**]) for CHF ?in the setting of a.fib with RVR at which time she was discharged to home on chronic AC mechanical ventilation. She was again admitted last week for chest pain at which time her daughter reports workup was negative. Also, her daughter notes that she has grown both MRSA and pseudomonas in her sputum and doctors have told [**Name5 (PTitle) **] this was [**1-21**] to colonization, not infection although her daughter apparently requested course of ciprofloxacin x 1 week (stopped 2 days early by daughter [**1-21**] "rash" on back). . Currently denies fevers/chills, no rigors. She does endorse perhaps some mild increase in secretions which she reports she is able to clear well on her own (daughter needs to suction infrequently and does not believe secretions are significantly increased), no hemoptysis, no shortness of breath. No chest pain, palpitations. . Further ROS: Denies HA, changes in vision. No changes in weight. No N/V/diarrhea. No blood in stool. No dysuria/hematuria. No rashes, joint pain. She reports chronic diffuse weakness and rigidity since her CVA and since being bedbound. Wears hearing aid. Past Medical History: Past Medical History: Respiratory failure requiring mechanical ventilator support Tracheal stenosis Chronic kidney disease on hemodialysis Diabetes mellitus (per OSH H+P, daughter denies) COPD (per OSH H+P, daughter denies) Hypertension, but now requires midodrine to maintain BPs s/p CVA (per OSH H+P, daughter denies) Aortic stenosis s/p aortic valve replacement in [**2181**] Hypothyroidism per OSH record however pt. recently on methimazole Paroxysmal atrial fibrillation CAD Dementia (given med list although daughter denies) Hyperlipidemia CHF Osteoarthritis . Past surgical history: CABG in [**2181**] w/ AVR; mosaic porcine valve AVR [**2181**] Hip surgery Hemodialysis catheter placement placed [**10/2184**] at [**Hospital 1281**] Hosp,[**Location (un) **], MA Social History: No smoking, no alcohol, no drug use. Lives with daughter, bed bound. Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: Temp: 97.4 BP: 157/51-->117/49 HR: 124-->105 RR: 14 O2sat: 97%; AC 420/12 PEEP 5.0, FiO2 0.30 GEN: nods/answers questions appropriately, appears comfortable HEENT: left pupil 2mm, right pupil 4mm; neither responsive to light (patient's daughter states chronically), [**Name (NI) 3899**], anicteric, MMM, OP without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: rhonchorus anteriorly and mildy laterally, no wheezes, no rales appreciated, unable to assess posterior lung fields CV: sinus tachy, harsh systolic murmur heard throughout precordium > at LUSB ABD: nd, +b/s, soft, nt, +umbilical hernia EXT: no c/c/e, warm, 2+ DP/PT pulses bilaterally; bilateral upper and lower extremities rigid with flexion with limited range of motion, no cogwheeling appreciated; moves all 4s spontaneously, reports sensation to soft touch intact throughout SKIN: Left anterior shin with large well healed scar, ? skin graft NEURO: Alert, unable to fully interpret, but pt. is oriented to place as hospital, me as MD (can't assess for date and exact hospital location). Diffusely weak LE and UE ([**2-21**] biceps, hip flexor and symmetric). No sensory deficits to light touch appreciated. Downgoing toes bilaterally. Pertinent Results: ADMISSION LABS: [**2185-12-16**] 08:56PM BLOOD WBC-8.7 RBC-5.30 Hgb-13.8 Hct-44.5 MCV-84 MCH-26.1* MCHC-31.1 RDW-18.1* Plt Ct-220 [**2185-12-16**] 08:56PM BLOOD Neuts-93.4* Bands-0 Lymphs-3.4* Monos-2.8 Eos-0.2 Baso-0.3 [**2185-12-16**] 08:56PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-1+ [**2185-12-16**] 08:56PM BLOOD Plt Smr-NORMAL Plt Ct-220 [**2185-12-16**] 08:56PM BLOOD PT-12.5 PTT-27.2 INR(PT)-1.1 [**2185-12-16**] 08:56PM BLOOD Glucose-168* UreaN-34* Creat-2.5* Na-141 K-4.3 Cl-97 HCO3-29 AnGap-19 [**2185-12-16**] 08:56PM BLOOD Calcium-9.7 Phos-4.5 Mg-2.0 [**2185-12-16**] 08:56PM BLOOD TSH-0.18* [**2185-12-16**] 11:32PM BLOOD Type-ART Rates-[**12-2**] Tidal V-420 FiO2-40 pO2-106* pCO2-47* pH-7.44 calTCO2-33* Base XS-6 -ASSIST/CON Urine Analysis [**2185-12-17**] 12:03AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.019 [**2185-12-17**] 12:03AM URINE Blood-LG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2185-12-17**] 12:03AM URINE RBC-95* WBC->1000* Bacteri-FEW Yeast-NONE Epi-0 [**2185-12-17**] 12:03AM URINE WBC Clm-MANY [**2185-12-17**]: UCx- NGTD; BCx- NGTD EKG: Sinus tachy to 114, normal axis, borderline 1st degree delay, QTc 452, LVH, <1mm ST depression V3-V6, o/w without significant ST/TW changes. [**2185-12-16**] CXR: 1. Possible mild CHF. 2. Small-to-moderate left effusion with underlying collapse and/or consolidation. [**2185-12-17**] Trachea/Chest CT: final report pending [**2185-12-17**] Rigid Bronchoscopy: see report Brief Hospital Course: # Chronic Ventillator-Dependent Respiratory Failure: Ms. [**Known lastname 4318**] is chronically on mechanical ventilation since [**2183**] and has failed mutliple attempts at weaning. The underlying etiology of her respiratory failure is not entirely clear; however, her daughter reports CHF and the patient's records give a history of COPD (although her daughter denies this history, and the patient has no history of smoking). Bronchoscopy the morning of [**2185-12-16**] at [**Doctor Last Name 62565**] Hospital showed an obstruction distal to the ET tube, thought to be either a mucous plug, granulation tissue or other mass. She was transiently hypoxic with O2 sats in the high 80s just after arrival to [**Hospital1 18**], but her oxygen saturations quickly increased to the mid to high 90s on assist-control mode at 40% FiO2. On [**2185-12-17**] at [**Hospital1 18**], she underwent a rigid bronchoscopy, which showed tracheomalacia just distal to the end of the tracheostomy tube (there was no evidence of granulation tissue). Her original tracheostomy tube was exchanged for a longer tube (size 7, advanced 9.5 cm) that ended distally to the tracheamalacia; no stent was placed. # Leukocytosis: Ms. [**Known lastname 4318**] [**Last Name (Titles) 4351**] had a WBC of 21,000 at [**Doctor Last Name 62565**] Hospital, although she was without a fever. The H&P from the OSH reported that she was to receive Zosyn, although she did not have a medicine administration record listing antibiotics and it is unclear whether she actually received this at the OSH. Supposedly, per her daughter, Ms. [**Known lastname 4318**] has a history of sputum cultures positive for MRSA and pseudomonas in past. Moreover, the source for the leukocytosis was unclear, as her cultures were negative and there was no evidence of pneumonia on CXR. WBC at [**Hospital1 18**] was normal throughout admission, and she remained afebrile and normotensive. She was not continued on antibiotics. Urine analysis on [**2185-12-17**] showed many WBC's and RBC's, although few bacteria and negative nitrites; antibiotics were deferred while urine cultures were pending. Blood cultures were drawn on [**2185-12-16**] and urine culture was sent on [**2185-12-17**]; all cultures have been no growth to date thus far. # Chronic Renal Failure requiring Hemodialysis: Ms. [**Known lastname 4318**] usually has dialysis Monday-Wednesday-Fridays, and her last session was on [**2185-12-16**] at the OSH prior to admission. Electrolytes and volume status were stable throughout the admission, and no dialysis was performed at [**Hospital1 18**]. # Diabetes: According to her daughter, Ms. [**Known lastname 4318**] has no formal diagnosis of diabetes; however, DM was listed on the medical record from the OSH and her blood glucose was 168 on admission to [**Hospital1 18**]. She was placed on sliding scale insulin. Medications on Admission: Medications on transfer (listed in H+P): DuoNeb Lipitor Aricept Folate Prevacid Nephrocaps Nystatin powder Rythmol 150mg via G tube q8h Namenda Midodrine 5mg PO tid . Home medications: Aspirin 81mg daily Folic acid 800mcg daily Prevacid 30mg daily Namenda 5mg [**Hospital1 **] Midodrine 5mg qid at 9am, noon, 5pm if SBPs <120, hs if SBPs <90 Rythmol 150mg [**Hospital1 **] Nephrocaps daily Lipitor 10mg daily Aricept 10mg daily Combivent 6puffs tid Tums tid with meals Nepron 2 cans daily Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 5. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Memantine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO bid (). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). 9. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation QID (4 times a day). 11. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 12. Midodrine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 13. Donepezil 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at bedtime). 14. Propafenone 150 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 15. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. insulin [**Last Name (STitle) **]: Sliding scale insulin Intramuscular four times a day. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnoses: Tracheomalacia Chronic ventillator-dependent respiratory failure Secondary Diagnoses: Diabetes mellitus Chronic renal failure requiring hemodialysis Discharge Condition: Stable-- peak ventillator pressure around 20; oxygen saturations in the upper 90's on 40% FiO2 with Assist Control ventillatory mode. Discharge Instructions: You are being transferred back to [**Location (un) 62562**] Hospital, where they will continue to care for you until you are able to go home. Followup Instructions: You will have continued care at [**Location (un) 62562**] Hospital. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]

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icd9cm

[ [ [] ] ]

[ "33.22", "97.23", "96.71" ]

icd9pcs

[ [ [] ] ]

12160, 12175

7028, 9926

353, 415

12388, 12524

5452, 5452

12714, 12897

4083, 4101

10466, 12137

12196, 12281

9952, 10119

12548, 12691

3796, 3979

4141, 5433

12302, 12367

10137, 10443

206, 315

443, 3184

5468, 7005

3228, 3773

3995, 4067

45,326

134,994

35582

Discharge summary

report

Admission Date: [**2101-3-4**] Discharge Date: [**2101-3-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: abdominal pain/hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: This 84 yo woman with a PMH of metastatic renal Cell Ca, dementia, HTN, developed a fever of 101 today at [**Last Name (un) 1188**] house, with hypoxia, cough and abdominal pain. She had poor appetitie today. VS were BP 109/66- HR 112- RR 32 with O2 sats of 91% on 2 l/min. Abdomen was generally tender. Stool was guaiac neg. She was uncomfortable and restless. Per HCP, patient has had URI symptoms over the past two weeks. She is DNR/DNI and was at home with hospice. She was recently transferred to [**Last Name (un) 1188**] house secondary to declining mental status, and was continuing with hospice care there as well. The patient wears 2L NC at home at baseline. . On presentation to the ED the patient was hypotensive with SBPs in 80-90s. Her O2 sat was 93% on 4L NC. Rectal temp was 103. WBC 32.0, lactate 5.7, Cr 2.7. CXR and CT torso showed multifocal pneumonia, without intrabdominal pathology. She was given vancomycin, zosyn, and 3L NS. Her BP increased to 104/49, with HR in 90's, RR 30 98% on NRB. The patient was more responsive prior to transfer. . On presentation to [**Hospital Unit Name 153**] the HCP decided that she believed the patient would not want to have aggressive care, including central line placement or pressors. She agreed to continuing with IVF resuscitation and antibiotics. Mot importantly, she wanted to keep the patient comfortable Past Medical History: renal cell cancer L nephrectomy [**2081**] Hypertension Hypothyroid constipation dyslipidemia angina depression Social History: No living family Family History: NC Physical Exam: Vitals 97.0 150/80 73 18 99%3Lnc Pain: still grimacing to palpation of abdomen (before BM) Access: PIV Gen: lying in bed, mild resp distress, awake but not oriented or communicating HEENT: mm dry CV: RRR, no m appreciated Resp: CTAB, anterior crackles b/l, no wheezing, no accessory muscle use Abd; mild distended, +mild tenderness to palpation diffusely, no guarding, +BS Ext; no edema Neuro: unable to fully assess, awake, not communicating GU: foley with dark urine . Pertinent Results: wbc 32.5->22.6 with 74%N and 12% bands H/H 11/36 chem panel: BUN 29->56, Creat 2.7->2.5 (?unknown baseline) Na 144->147 lactate 5.7 on admission BNP 15,312 . blood Cx [**3-4**] 2 sets with strep PNEUMONIA (changed from viridans) blood cx [**3-6**] pending UA 10wbc, few bacteria, UCx negative . Vanc [**3-5**] 12.8 . . . Imaging/results: CXR [**3-4**]: pulm edema, bibasilar opacification c/w PNA . CXR [**3-7**]: In comparison with the study of [**3-4**], there is persistent bibasilar opacifications. Although this could merely reflect atelectasis and effusion, the possibility of superimposed pneumonia should be seriously considered in view of the clinical symptoms . . CT c/a/p: b/l pulm nodules with med/hilar LAD c/w metastatic dz, bibasilar consolidations and effusions, gallbladder is markedly distended, but there is no pericholecystic fat stranding or cholelithiasis, R adrenal nodule susp for metastases, R inguinal fat containing hernia Brief Hospital Course: 85year old female with h/o metastatic RCC (lung mets), remote L nephrectomy, ?CKD, HTN, hypothyroid, who is currently enrolled in hospice and residing at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] prsented to ED on [**3-4**] with hypoxia/fever/cough/abdominal pain, found to be hypotensive with severe sepsis (temp 103, SBP 80, lactate 5.7, creat 2.7) with imaging revealing bibasilar PNA. Recieved vanc/zosyn, 3L IVFs and transfered to MICU. After discussion with HCP, it was decided not to escalate care with placement of central line or pressors, okay to continue supportive care with fluids, antibiotics and oxygen, and low threshold to shift goals of care to CMO. In ICU, got more IVFs, vanc/zosyn continued. She appeared to stabilize with improved BP and urine outpt and was transfered to Gen Med [**3-6**] for further management. Blood cultures eventually grew out strep pneumonia and [**Month/Day (4) **] changed to ceftriaxone 1g q24 (PICC placed) for plan 2week treatment given bacteremia. . see progress note for details: . . Severe Sepsis, strep PNA with bacteremia: WBC 30s, hypotension, hypoxic, lactic acidosis, ?ARF->severe sepsis, s/p approx 5L IVFs, now HDS. With Strep Pneumonia bibasilar PNA and bacteremia (2 sets on [**2-20**] blood cx pending). Has Abd pain but CT unremarkable. s/p Vanc/Zosyn X3days, changed to ceftriaxone 1g q24 with plan for total 14day coruse, PICC placed today. Currently on 3L O2. Goal per HCP is for supportive care with [**Name (NI) **] and fluids but no aggressive measures. If pt appears dyspneic, give morphine, liberalize O2, overall goal for comfort precedes treatment. . . Abdominal Pain/constipation: Abd tenderness on exam. CT w/o any acute abnormalities other than GB dilation w/o evidence of cholecysitis and fat containing inguinal hernia that doesnt appear incarcerated. Most likely [**1-31**] constipation and finally had BM today after enema. Cont aggressive bowel regimen with enema, laxatives, balance narcotics for pain control with worsening constipation . . Acute Renal failure +/- CKD IV: unsure baseline creatinine. s/p L nephrectomy [**2071**] so likely has some CKD. Creat 2.5-2.7 while here, no improvement despite IVFs. Rising BUN and hypernatremia suggests volume depletion but crackles on exam, on lasix as outpt, and BNP 15K, not sure if carries diagnosis of heart failure. Given very low PO intake and clinically appears dry, will give 500cc more IVFs and hold lasix for a couple days. Can resume at [**Hospital1 1501**] if pt requiring more O2 or more resp distress. . . Renal cell Carcinoma, metastatic: known lung nodules, ?adrenal nodule. Enrolled in hospice. On Morphine for pain symptoms, complicated by constipation despite aggressive bowel regimen Continue with pain regimen with morphine IR 15mg [**Hospital1 **], 5mg PO prn breakthrough and 1-2mg IV prn if not taking PO, bowel regimen with colace/senna/MOM/lactulose/enema. When awake, resume diet with aspiration precautions, megace . . Hypertension: Resume lisinopril and atenolol, hold lasix for a couple of days . . Pulm Edema: Unclear if has h/o heart failure (on lasix as outpt), CXR with pulm edema here and BNP 15K. Clinically appears dry and BUN rising/hypernatremia suggesting dehydration (unless this is decompensated heart failure with decreased forward will not repeat one here at this time. Resume lasix in a couple days or sooner if pt appears dyspneic or increased O2 requirements. . . Depression: resume celexa 20 . . Hypothyroidism: continue levothyroxine PO . . FEN/proph: HLIV, small fluid boluses prn hypotension, general diet when awake, TEDs, heparin, aggressive bowel regimen . . Dispo/Code: DNR/I. condition critical/guarded. Plan for 14days ceftriaxone via PICC. [**Hospital **] hospice care on discharge. On conversation with HCP, no further escalation of care and low threshold to shift goals of care to CMO Medications on Admission: Lasix 80 mg 1 tab(s) once a day atenolol 50 mg 1 tab(s) once a day lisinopril 7.5 mg 1.5 tab(s) once a day Robitussin 100 mg/5 mL 5 mL Q6 H prn morphine 20 mg/mL 5mg q4h prn MSIR 15 mg 1 tab(s) [**Hospital1 **] Milk of Magnesia 400 mg/15 mL 30 mL QD, PRN Dulcolax 10 mg 1 SUPP(s) QOD @ 6am fleet enema one enema PRN after suppos if no BM Colace sodium 100 mg 1 cap(s) [**Hospital1 **] senna 8.6 mg 2 tab(s) [**Hospital1 **] lactulose 10 g/15 mL 15 mL TID MiraLax - 17 g once a day Megace 40 mg/mL 10 mL [**Hospital1 **] Ensure oral TID Celexa 20 mg 1 tab(s) once a day Tylenol 325 mg 2 tab(s) qid levothyroxine 50 mcg (0.05 mg) 1 tab(s) once a day lidoderm 5% 1 patch daily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 6. Morphine 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Morphine 10 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain. 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 12 days. 11. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day. 12. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day: resume in 2days or earlier if resp distress and prior echo with low EF. . 13. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 14. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO once a day. 15. Ensure Powder Sig: One (1) PO three times a day. 16. Robitussin-DM 10-100 mg/5 mL Syrup Sig: One (1) PO three times a day. 17. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours for 10 days. 18. Megace Oral 400 mg/10 mL Suspension Sig: One (1) PO once a day. 19. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Strep pneumonia PNA with bactermia/sepsis Constipation/abdominal pain Discharge Condition: Guarded Discharge Instructions: Admitted with sepsis due to strep pneumonia PNA. On ceftriaxone X12 more days. Supportive care with fluids and oxygen. review prior Echo if available. If more resp distress and low EF, resume lasix. resume prior hospice services. Has PICC in place for [**Location (un) **]. Followup Instructions: Hospice Care at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] with physicians. f/u Dr. [**First Name (STitle) **] as needed

[ "244.9", "272.4", "189.0", "038.2", "294.8", "482.30", "584.9", "995.92", "311", "564.00", "197.0", "401.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9629, 9702

3365, 7274

283, 289

9815, 9824

2390, 3342

10146, 10296

1876, 1880

7999, 9606

9723, 9794

7300, 7976

9848, 10123

1895, 2371

221, 245

317, 1690

1712, 1826

1842, 1860

60,722

154,796

22087

Discharge summary

report

Admission Date: [**2114-1-26**] Discharge Date: [**2114-1-30**] Date of Birth: [**2053-5-21**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 60 yo male with daily ETOH use recently started on gabapentin 2 days ago for neuropathic pain as a result of frostbite to his feet ~5 years ago who became dizzy and reportedly fell. He is a poor historian, unclear if LOC, + head strike. Pain in posterior neck, throbbing/aching in quality. Denies any new numbness/tingling/weakness. He has hyperesthesisa in both feet at baseline and has difficulty moving his toes at baseline. Denies incontinence. Past Medical History: PMH: Hypthyroidism, Alcoholism, Frostbite 5 years ago, denies other medical problems, but is unsure if on meds for anything else Social History: SH: Homeless Activity Level: walks for a majority of the day Mobility Devices: none Occupation: currently unemployed Tobacco: 2 cigs/day EtOH: 1 pint vodka/day, denies other drug use Family History: non-contributory Physical Exam: ON ADMISSION: Vitals: 95.8 88 103/57 18 96% RA General: seems intoxicated, but arouses to voice and able to answer questions Mental Status: AOx2 Cranial nerves II-XII grossly intact. BUE [**3-29**], SILT C5-S1 1+ symmetric UE DTRs no pathologic reflexes BLE - [**3-29**], significant pain dysesthetic pain with ankle and toe motion. SILT all dermatomes. 2+ DTR @ quad, 1+ @ achilles No pathologic reflexes, no spasticity, no clonus Pertinent Results: IMAGING: CT head [**2114-1-26**] 1. No acute intracranial hemorrhage. 2. [**Location (un) 5621**] type fracture of the C1 vertebral body CT c-spine [**2114-1-26**] There is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5621**] type fracture through the anterior and posterior processes of the C1 vertebral body. The atlantoaxial interval is maintained. There are spinous process fractures of C4, C5, and C6. Spinal alignment is maintained, no other fracture is seen. Visualized soft tissues of the neck and lung apices are unremarkable. CT abd/pelvis [**2114-1-26**]: Healed L5-6th rib fx, subacute R10 rib fx. Hypodensity left kidney too small to characterize. No acute intrabdominal injuries XR facial bones [**2114-1-26**]: No displaced fractures or dislocations are seen. The paranasal sinuses are grossly intact. If there is high clinical concern, would recommend facial bones CTs. Orbital contours are preserved. MRI c-spine [**2114-1-26**]: Ligamentous injury status post fractures in the cervical spine. No evidence for cord contusion or epidural hematoma. No retropulsion of bone into the canal is seen. There is no compression fracture. Brief Hospital Course: He was admitted to the Acute Care Surgery Service. He was admitted to the Trauma ICU given his hypotension in the ED and was given a banana bag and placed on a CIWA scale given his history of alcohol abuse. He was evaluated by the orthopedics spine team. Their recommendations included C-spine precautions with cervical collar at all times and MRI C-spine to evaluate the craniocervical junction ligaments as well as soft tissue stabilizers of the subaxial spine. The findings revealed ligamentous injury with no evidence for cord contusion or epidural hematoma. No retropulsion of bone into the canal was seen and no compression fracture noted. He will follow up in the Spine center in [**5-2**] weeks for repeat imaging studies. In the meantime he may shower with the collar on and the pads changed while spine precautions maintained. He was transferred to the floor [**2114-1-27**]. Early in the day he requested to leave for [**Hospital3 **]. There were some concerns for his capacity and a Psychiatry consult was placed. It was felt that he did possess the capacity to make decisions. He ultimately did agree to stay. He was evaluated by Physical therapy for gait disturbance given his neuropathy and was issued a walker. He is being discharged to the [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] House with instructions for follow up. Medications on Admission: Synthroid, Gabapentin Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] [**Last Name (un) **] House Discharge Diagnosis: s/p ?Fall [**Location (un) 5621**] type fracture of C1 with accompanying spinous process fractures of C4, C5 and 6. Rib fractures - right 5th, 6th ribs Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 18**] after a probable fall where you sustained a fracture of the spine bones in your neck (cervical). You seen by the orthopedic Spine doctors who have recommended a hard collar which must be worn for at least the next 6-8 weeks when you will follow up in the Spine Center for xrays. You were also found to have rib fractures which can be painful and limit your ability to take deep breaths. it is important that you cough and deep breathe and use the incentive spiormeter 10 times every hour that you are awake. If you notice a cough with sputum production you should return to the Emergency room for evaluation. Please call your doctor or go to the emergency department if: *You experience new chest pain, pressure, squeezing or tightness. *You develop new or worsening cough, shortness of breath, or wheeze. *You are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *Your pain is not improving within 12 hours or is not under control within 24 hours. *Your pain worsens or changes location. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You should also AVOID alcohol and/or other illicit drugs. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Followup Instructions: Follow up in [**12-28**] weeks in Acute Care Surgery clinic for your rib fractures; call [**Telephone/Fax (1) 600**] for an appointment. You will need a standing end expiratory chest xray for this appointment. Follow up with Dr. [**Last Name (STitle) 1007**] in the Spine center in [**5-2**] weeks; call [**Telephone/Fax (1) 3736**] for an appointment. Completed by:[**2114-2-6**]

[ "807.03", "805.01", "780.09", "805.05", "805.04", "782.0", "805.06", "244.9", "E001.0", "303.01", "V60.0", "E976", "458.8", "780.39", "305.1" ]

icd9cm

[ [ [] ] ]

[ "93.52", "94.62" ]

icd9pcs

[ [ [] ] ]

4749, 4873

2846, 4216

311, 318

5068, 5068

1657, 2823

7623, 8007

1170, 1188

4288, 4726

4894, 5047

4242, 4265

5250, 6791

1203, 1203

6823, 7600

263, 273

346, 800

1217, 1328

5083, 5226

822, 953

969, 1154

2,364

195,555

9762

Discharge summary

report

Admission Date: [**2167-5-24**] Discharge Date: [**2167-6-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: 1. Altered mental status 2. Hypoxemic respiratory failure 3. Hypotension Major Surgical or Invasive Procedure: 1. Bronchoscopy 2. Endotracheal intubation 3. PEG placement History of Present Illness: [**Age over 90 **]-year-old Russian-speaking female with a history of HTN, CRI, chronic nephrolithiasis, who presents with hypoxemic respiratory failure. She was in her USOH at the [**Hospital3 2558**] nursing home when she was found with a RR of 8, unresponsive, SBP 70's, O2Sat 75%. She was intubated by EMS on the scene. No CPR was needed. In the ED found to have a right mainstem intubation so her ETT was drawn back. Large amount of thick sputum noted. In ED, BP 70/30, AC 400x16 100% PEEP 5 and 100%. Got Levo and flagyl empirically. Initial WBC 10K , Hct 29.9. U/A revealed many bacteria, w/ >50 WBC's. Past Medical History: 1. Hypertension 2. Chronic renal insufficiency 3. Type II diabetes mellitus 4. Chronic low back pain 5. Nephrolithiasis Social History: 1. Nursing home resident Family History: noncontributory Physical Exam: On admission: VS: T 100.5 HR 87 BP 97/56 RR 16 sat 99% intubated GEN: open eyes to command HEENT: PERLA, NCAT, neck supple, ETT in place CARDIO: S1S2, RRR, no m/r/g PULM: CTAB anteriorly [**Last Name (un) **]: soft, guarding EXTR: DPPBL NEURO: MAE Pertinent Results: [**2167-5-24**] 06:40PM WBC-10.0 RBC-3.56* HGB-9.8* HCT-29.9* MCV-84 MCH-27.4 MCHC-32.7 RDW-15.6* [**2167-5-24**] 06:40PM PT-13.7* PTT-23.7 INR(PT)-1.2 [**2167-5-24**] 06:40PM PLT COUNT-331 [**2167-5-24**] 06:53PM GLUCOSE-188* LACTATE-1.9 NA+-142 K+-5.9* CL--111 TCO2-22 [**2167-5-24**] 06:40PM UREA N-20 CREAT-2.4* [**2167-5-24**] 06:40PM CK(CPK)-236* AMYLASE-39 [**2167-5-24**] 06:40PM CK-MB-2 cTropnT-0.03* [**2167-5-24**] 06:40PM CALCIUM-8.4 PHOSPHATE-5.5*# MAGNESIUM-2.0 [**2167-5-24**] 07:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013 [**2167-5-24**] 07:00PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2167-5-24**] 07:00PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 ## CT [**Last Name (un) 103**]/pelvis [**5-24**]: 1) Limited study due to lack of oral and IV contrast. No obvious perinephric abscess is seen. There is no evidence of small bowel obstruction. 2) Right lower lobe opacity is most likely atelectasis, but pneumonia cannot be excluded. 3) Small pericardial effusion. 4) Severe vascular calcifications. 5) Compression of the L1 vertebral body of indeterminate age. ## CXR [**5-25**]: The tip of the endotracheal tube is identified 3 cm above the carina. A nasogastric tube terminates in the gastric body. There is continued patchy opacity in the right lower lobe indicating atelectasis and aspiration. The lungs are clear otherwise. The heart and mediastinum are within normal limits. No pneumothorax is identified. ## RADIOLOGY Final Report MRA BRAIN W/O CONTRAST [**2167-5-26**] 1:57 PM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: Tip of basilar stroke? [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with left PCA acute infarct on CT, unresponsive, intubated. Has flaccid right arm, moves the right leg less than the left. Cannot breath over the vent. REASON FOR THIS EXAMINATION: Tip of basilar stroke? CLINICAL INFORMATION: Left PCA stroke on CT. Unresponsive and intubated ____ right arm. MRI OF THE BRAIN. Exam is compared to the patient's noncontrast head CT of [**2167-5-24**] and also the MR study of [**2163-2-3**]. FINDINGS: There is abnormal diffusion in the inferior right cerebellar hemisphere as well as focally in the left cerebellar hemisphere. There is also abnormal signal in the left medial occipital lobe and medial temporal lobe, all consistent with infarction. In retrospect the right inferior cerebellar infarct was present on the CT scan of [**2167-5-24**]. There is no evidence of acute hemorrhage. On the susceptibility sequences compared to the prior study of [**1-27**], there appears to be a new abnormal focus in the medial left thalamus perhaps reflecting the intercurrent petechial hemorrhage in this location. The ventricles are unchanged in dimension. There is no evidence of a focal extra-axial lesion or fluid collection. There is confluent T2 high signal intensity signal in the periventricular white matter and centrum semiovale, which is nonspecific but could reflect microvascular angiopathy. There is a cystic lesion deep to the left rectus capitis muscle which was not present on the prior MR study of [**2163-2-3**]. This may be an unusual location of a Tornwaldt cyst or possibly an inclusion cysts. No specific evidence to suggest that this represents retroperitoneal abscess. IMPRESSION: Subacute infarcts involving the left cerebral hemisphere and the cerebellum as described. Fluid collection deep to the rectus capitis muscle see above discussion. MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES. FINDINGS: There is no evidence of aneurysm or flow abnormality. The basilar artery is patent. The right posterior cerebral artery is patent. The left posterior cerebral artery has diminished signal and to be occluded or stenotic. IMPRESSION: Reduced signal left posterior cerebral artery see above discussion. DR. [**First Name (STitle) 23303**] [**Doctor Last Name **] Approved: [**Doctor First Name **] [**2167-5-28**] 12:53 PM ## PATIENT/TEST INFORMATION: Indication: Source of embolism. Height: (in) 60 Weight (lb): 135 BSA (m2): 1.58 m2 BP (mm Hg): 134/70 HR (bpm): 72 Status: Inpatient Date/Time: [**2167-5-27**] at 15:50 Test: Portable TTE (Complete) Doppler: Full doppler and color doppler Contrast: None Tape Number: 2005W254-0:00 Test Location: West MICU Technical Quality: Adequate MRI OF THE BRAIN. Exam is compared to the patient's noncontrast head CT of [**2167-5-24**] and also the MR study of [**2163-2-3**]. FINDINGS: There is abnormal diffusion in the inferior right cerebellar hemisphere as well as focally in the left cerebellar hemisphere. There is also abnormal signal in the left medial occipital lobe and medial temporal lobe, all consistent with infarction. In retrospect the right inferior cerebellar infarct was present on the CT scan of [**2167-5-24**]. There is no evidence of acute hemorrhage. On the susceptibility sequences compared to the prior study of [**1-27**], there appears to be a new abnormal focus in the medial left thalamus perhaps reflecting the intercurrent petechial hemorrhage in this location. The ventricles are unchanged in dimension. There is no evidence of a focal extra-axial lesion or fluid collection. There is confluent T2 high signal intensity signal in the periventricular white matter and centrum semiovale, which is nonspecific but could reflect microvascular angiopathy. There is a cystic lesion deep to the left rectus capitis muscle which was not present on the prior MR study of [**2163-2-3**]. This may be an unusual location of a Tornwaldt cyst or possibly an inclusion cysts. No specific evidence to suggest that this represents retroperitoneal abscess. IMPRESSION: Subacute infarcts involving the left cerebral hemisphere and the cerebellum as described. Fluid collection deep to the rectus capitis muscle see above discussion. MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES. FINDINGS: There is no evidence of aneurysm or flow abnormality. The basilar artery is patent. The right posterior cerebral artery is patent. The left posterior cerebral artery has diminished signal and to be occluded or stenotic. IMPRESSION: Reduced signal left posterior cerebral artery see above discussion. REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Long Axis Dimension: *4.7 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 4.9 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: 4.6 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%) Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 1.4 m/sec Mitral Valve - E/A Ratio: 0.50 Mitral Valve - E Wave Deceleration Time: 310 msec TR Gradient (+ RA = PASP): 24 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Aneurysmal interatrial septum. LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Normal regional LV systolic function. Low normal LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Focal calcifications in aortic root. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: Based on [**2158**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Conclusions: The left atrium is mildly dilated. The interatrial septum is markedly aneurysmal. No atrial septal defect is identified on color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: Interatrial septal aneurysm. Low normal left ventricular systolic function. Mild mitral regurgitation. Aortic valve sclerosis. Based on [**2158**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a low risk (prophylaxis not recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD on [**2167-5-27**] 16:50. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **] J. ([**Numeric Identifier 32915**]) ## CHEST (PORTABLE AP) [**2167-5-30**] 1:17 PM CHEST (PORTABLE AP) Reason: r/o pna [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman intubated for hypoxic resp failure, new CVA, RLL PNA and new fevers REASON FOR THIS EXAMINATION: r/o pna INDICATION: Fever. A developing density at the left base is noted since [**2167-5-25**]. The NGT terminates in the mid stomach and heart is enlarged. Widening of the superior mediastinum on the right side remains stable. The right lung is clear. IMPRESSION: Developing density at the left base since [**2167-5-25**]. Otherwise, no change in the chest. Brief Hospital Course: 1) CVA - The patient presented after being found unresponsive. A CT head was performed and revealed an "acute / sub acute infarct in the left posterior cerebral artery distribution." It was presumed that the patient may have suffered a new stroke leading to a aspiration pneumonia. She remained intubated during her short ICU stay as she remained minimally responsive off sedation. The neurologists noted a left-sided weakness on their exam and recommended a MRI/MRA scan to assess for the new stroke which was confirmed acute and embolic. The MR revealed "subacute infarcts involving the left cerebral hemisphere and the cerebellum" and the MRA revealed "left posterior cerebral artery has diminished signal and to be occluded or stenotic." She was placed on ASA and coumadin. Given multiple areas of infarction suspicion was for an embolic source. A TTE was performed which revealed a aneurysm of thje right atrial septum. This was presumed to be the source of the embolic strokes. For this reason coumadin was recommended and she reached an INR of 2.5. However, ongoing hematuria limited coumadin therapy. Eventually she needed to have the coumadin stopped and was placed on ASA only. After further discussion with Neurology, she was placed on Aggrenox plus ASA 81mg daily. However, hematuria continued nonetheless, requiring another unit of blood to be transfused. Therefore, aggrenox was discontinued and she was maintained on aspirin alone for secondary prophylaxis. The possibility of an increased risk of stroke with less anticoagulation was conveyed to the daughter and HCP. She understood that the bleeding risk made more anticoaguation impossible. At time of discharge, her mental status had improved some, but she demonstrated no movement of her right side. 2) Respiratory failure - She presented with hypoxic respiratory failure requiring intubation. This was presumed to be due to aspiration pneumonia following the CVA. On day 2 of admission, the patient underwent a bronchoscopy revealing pus in the right lower lobe area. She was treated with levofloxacin and metronidazole. She was eventually weaned off the ventilator. She completed a 10 day course of Levo, Flagyl IV and was oxygenating well on room air at time of discharge. 3) Altered mental status: The patient's mental status was attributed to a combination of infectious processes and medications, and multiple strokes. Over her hospital course she showed slow improvement, eventually speaking a few words in Russian prior to discharge. 4) UTI - treated with Levoquin 5) Nutrition - Given her poor mental status following extubation, it was not safe to even attempt a speech and swallow evaluation. She was maintained on PPN for nutrition while the family decided whether to pursue a feeding tube. Ultimately they decided to consent to a PEG. She was started on tube feeds per nutrition recommendations. If her mental status improves she should have an outpatient swallow evaluation prior to taking any POs. 6) Hematuria - Patient has a history of bladder polyps that have required cauterization. Recently a large, fungating bladder mass was found at an OSH. Patient had persistent hematuria in house requiring continuous bladder irrigation. Coumadin was held for this reason. She required occassional blood transfusion to maintain her HCT. As mentioned above, the continued hematuria with clots necessitated the reduction of her anticoagulation to aspirin alone. Urology was following and stated that the patient will always have hematuria and that prior attempts have been unsuccessful in reducing it. They stated that hematuria could be tolerated as long as there were no large blood clots. Eventually, the bleeding slowed and the continuous irrigation was stopped. She continued to have bleeding, but no clots were observed and there was good UOP. The foley was therefore discontinued and the patient maintained good UOP and a stable HCT. Although unlikely to occur, if her urine output drops off then blood clot retention should be considered. 7) Abdominal pain - Following PEG placement, she complained intermittently of abdominal pain. There were no tube feed residuals and amylase and lipase were normal. It was presumed to be due to tube irritation. She was treated with prn morphine with good result. 8) Hyperglycemia - she had elevated blood sugars once tube feeds started. Initially treated with ISS, but Lantus started due to persistent hyperglycemia. [**Month (only) 116**] need titration of dose. 9) Thrush - 7 day course of fluconazole 10) HTN - lopressor 50 [**Hospital1 **] 11) Code - DNR/DNI Medications on Admission: 1. Amaryl 2. Cozaar 3. Imdur 4. Detrol 5. Cipro 6. Vioxx Discharge Medications: 1. Insulin Lantus 12 units QHS plus Regular Insulin sliding scale 2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection subcutaneously Injection three times a day. 7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-1**] hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: CVA PNA UTI Sepsis Hematuria Thrush Hyperglycemia Discharge Condition: stable Discharge Instructions: Please seek medical attention if you experience chest pain, shortness of breath, or other concerning symptoms. Followup Instructions: Please follow-up with PCP Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 5308**] in [**1-29**] weeks Please call the Neurology department at [**Telephone/Fax (1) 541**] at schedule a follow appointment with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please follow up with Dr [**Last Name (STitle) 17696**] of urology.

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icd9cm

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7,884

156,234

12870

Discharge summary

report

Admission Date: [**2161-1-16**] Discharge Date: [**2161-2-21**] Date of Birth: [**2100-10-31**] Sex: M Service: MEDICINE Allergies: Metoprolol / Ibuprofen Attending:[**First Name3 (LF) 2641**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: Bronchoscopy [**2161-1-17**] History of Present Illness: 60 year old man with metastatic NSCLC (R hilar mass) s/p chemotherapy (Navelbine) and completed course of radiation, also membranous nephropathy, CAD, schizophrenia, and COPD who is transferred from micu after presenting with hemoptosis from [**Hospital **] rehab. There he had been coughing up about 1 teaspoon of blood per day since [**2161-1-13**]. His Hct was stable. He denies SOB, CP, fever, or chills. In the MICU his hemoptysis resolved, hct remained stable, no transfussion required. He had a bronchoscopy [**1-18**] that showed his right hilar mass but no stigmata of bleeding. He was treated for COPD exacerbation with z-pak (started [**1-18**]) and prednisone taper. . Of note, He was recently admitted to [**Hospital1 18**] [**2160-11-27**]- [**2160-12-27**] with a pathologic fracture of his left femur which was treated with radiation. He was evaluated but surgery was felt medical management was best for his fracture. His course was complicated by hospital acquired pneumonia (sputum grew pseudomonas), treated with a 2 week course of Zosyn, followed by a two week course of Ceftaz which was started b/c he was hypotensive and repeat sputum culutres grew sparse GNRs and oropharyngeal flora. . Currently he has no complaints. He notes occaisional headaches but none currently and intermittent constipation though had BM on date of transfer. He denies visual changes, hearing changes, congestions, sore throat, chest pain, nausea, vomitting, abdominal pain, shortness of breath, dysuria, melena, BRBPR, leg pain other than left hip (which currently is not painful), back pain, tingling or numbness. flora. Past Medical History: Non-small-cell lung cancer, metastatic left femur fx, [**11/2160**], had lytic lesion and then fell on [**Hospital Ward Name 1826**] 7 Arterial embolic disease s/p right SFA stent in [**June 2159**] CAD s/p 2 vessel CABG at [**Hospital1 112**] in [**Month (only) 205**] 97 HTN COPD CHF; EF 35-40% Hypercholesterolemia Primary polydipsia BPH s/p TURP Schizophrenia, Paranoia Nephrotic Syndrome [**2-28**] membranous GN Social History: He did smoke for 30 years, but quit. He quit drinking alcohol significantly 12 years ago. He previously was in the real estate business with his brother. [**Name (NI) **] is Lebanese by heritage. He has two adult children, and he is married and lives [**Location (un) 6409**], [**Location (un) 86**]. Family History: Mother died at age 60 of cancer (unknown type) Physical Exam: VS: T 97.7, BP 126/77, HR 99, RR 18, 100% 2L Gen: comfortable, no apparent distress HEENT: perrl, eomi Neck: no JVD Lungs: b/l course rhonchi Heart: RRR nl S1S2 no M/R/G Abd: soft, ND/NT, no rebound or guarding Ext: LE muscle wasting, 2+ DP pulses. +TTP over left thigh/femur neuro: AAO x 3 Skin: soft tissue mass, mobile, non-tender right side of back, soft tissue mass left upper extremity Pertinent Results: CXR: port-a-cath in place in SVC. R. hilar mass again noted. clear lungs otherwise, w/o evidence pleural effusions Bronchoscopy - showed no evidence of intrinsic compression, no evidence of active or prior evidence of bleeding. Clear minimal secretions, patent airways. Hct stable - 23-28, upon d/c 26.1 WBC 6.9 upon d/c. [**2161-1-21**] 01:22AM BLOOD Glucose-130* UreaN-42* Creat-1.5* Na-135 K-4.3 Cl-102 HCO3-25 AnGap-12 Brief Hospital Course: 60 year old male with metastatic NSCLC, COPD, CAD, HTN, recent pathologic L femur fx, admitted from rehab with hemoptysis. . Hemoptysis: This was felt to be most likely secondary to NSCLC with R hilar mass. He had a bronch on [**2161-1-17**] that showed no stigmata of current or recent bleeding. He continued to have intermittent blood-tinged sputum during this hospitalization. His hct steadily declined until [**2161-2-6**], when his hct was 19.5, he was given 2 units of pRBC. His hct remained stable at ~29-30 throughout the remainder of the hospitalization. Of note on [**2161-2-20**], he had an increased amount of blood in his sputum. Interventional pulmonary was called and felt that a repeat broncoscopy would not be useful at this time, given no finding on previous broncoscopy. They recommended IR guided embolization if hemoptysis were to persist. Pt was monitored closely [**Date range (3) 39588**], hemoptysis resolved and hct remained stable. Of note, pt was continued on lovenox for DVT ppx in the setting of hip fracture. Pt should have his coags and renal function checked on the day of transfer to [**Hospital1 **] on [**2161-2-21**]. Baseline renal function is between 1.6 to 1.8. He should also have a hct check on [**2-22**]. . COPD Flare: The patient had a productive cough and was wheezing throughout his hospital course. He was given a course of z-pack. His prednisone was initally doubled to 40mg daily but because his symptoms did not improve and he was placed on 60mg daily on [**2161-1-18**]. This was tapered and he resumed his home regimen of prednisone of 20 mg daily. He was maintained on albuterol and ipratropium nebulizers. His oxygen saturations remained in the 90's on RA. . Dysuria: He had intermittent dysuria throughout this hospital course. His urine culture from [**2-16**] and [**2-19**] revealed coag negative staph, he was started on microbid for a total of 10 day course. A renal US on [**2-18**] was done to further evaluate for potential post-obstructive picture and was normal. Bladder scans were also done to rule out urinary retention as a potential cause of his dysuria. He was restarted on flomax. For symptomatic relief he was also started on pyridium as well. . Left femur fx: Medically managed throughout the hospital course, given that he is a poor surgical candidate. His pain was managed with oxycontin, lidocaine patch and oxycodone prn. On [**2161-2-13**], he reported having worsening left lower extremity pain and worsening swelling at the level of the hip. A CT scan of the hip revealed further dislocation of the femur and increased hematoma. Orthopedic surgery was reconsulted and continued medical management was recommended. He is able to bear weight on both legs as it is tolerated. He was also started on lovenox for DVT ppx. . Leukocytosis: WBC to 18 on [**2161-1-28**] of unclear etiology. His urinalysis, blood culture and cx-ray were unremarkable during this hospitalization. He did have urine cultures postive for coag negative staph and was started on macrobid. WBC normalized throughout the rest of his hospitalization. . NSCLC: followed by Dr. [**Last Name (STitle) **] here at [**Hospital1 18**], he had an appointment at [**Hospital3 328**] for a 2nd opinion on [**2161-1-29**]. Dr. [**Last Name (STitle) 39589**] also felt that he is not a candidate for further chemotherapy. . Chest pain: On [**2161-2-18**], began to report right sided chest pain near port. No evidence of infection. Cx-ray revealed proper placement of port and no evidence of rib fractures. His EKG was without acute ischemic changes. His pain was managed with oxycodone prn. . CKD: Pt has history of membranous nephropathy associated with malignancy. Baseline Cr 1.6-1.8. His creatinine remained near its baseline throughout this hospital course. . HTN: His blood pressure was labile early during his hospitalization with SBP ranging between 80 and 200. He was initially on lisinopril and diltiazem. However due to subsequent hypotensive episodes to the 80s resolving with hydration, his antihypertensives were discontinued. His BP remained stable in the 100-130s throughout the remainder of his hospital course . CAD s/p CABG: The patients aspirin was held in the setting of hemoptysis but was restarted prior to discharge. His statin was continued. . Hypothyroidism: continued levothyroxine at home dose Medications on Admission: Lidoderm patch qdaily Acetaminophen prn Fluticasone-Salmeterol 250-50 1 puff [**Hospital1 **] Ipratropium Bromide 1 puff QID Levothyroxine 25 mcg daily Pravastatin 20 mg daily Prednisone 20 mg daily Protonix 40mg daily Lisinopril 5mg daily Calcium Carbonate 500 mg PO QID Olanzapine 10 mg PO QAM, 20mg PO QPM Fluphenazine HCl 10 mg PO QAM, 15mg QPM Lorazepam 2 mg PO TID at 0900, 1400, 1800 Trazodone 50 mg QHS prn Xopenex neb QID Colace 100 mg PO BID Senna 8.6 mg PO BID prn Bisacodyl 10mg po prn Bactrim 160-800 mg Tablet, 1 tab PO 3X PER WEEK Insulin SS Oxycodone 5 mg Tablet PO Q4H prn pain Oxycontin 20mg PO Q12H Nitroglycerin SL prn Aspirin 81mg daily Xenaderm oint to sacral wound qShift Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 (). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO four times a day. 8. Olanzapine 5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 9. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 10. Fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 11. Fluphenazine HCl 10 mg Tablet Sig: 1.5 Tablets PO QPM (once a day (in the evening)). 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for sleep. 13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 17. Insulin Lispro 100 unit/mL Solution Sig: 1-15 units Subcutaneous ASDIR (AS DIRECTED): as directed by the sliding scale. 18. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed. 19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 20. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 21. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours). 22. Clindamycin Phosphate 1 % Solution Sig: One (1) Appl Topical DAILY (Daily) as needed for facial acne. 23. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1) ML Intravenous DAILY (Daily) as needed for PICC line care. 24. Benzoyl Peroxide 10 % Gel Sig: One (1) Appl Topical DAILY (Daily) as needed for lesions on face, back. 25. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 26. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 27. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for pain. 28. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 29. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 30. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours). 31. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 32. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 33. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 34. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO Every Mon, Tues, Wed for 3 days. 35. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 9 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Hemoptysis Chronic Obstructive Pulmonary Disease Non-small Cell Lung Cancer Coronary Artery Disease Discharge Condition: Improved; oxygenating well on RA. Discharge Instructions: You were admitted to the hospital because you were coughing up blood. You had a bronchoscopy to look into your lungs and they did not see any evidence of bleeding. Your blood counts remained at their baseline. You also had a cough and wheezing. Your prednisone was temporarily increased and is now back at your baseline dose. Please alert your medical provider if you have any further blood when you cough, lightheadedness or any symptoms that are new or of concern to you. You were advised of the potential risks of further bleeding due to your underlying malignancy, especially in the setting of blood thinner (to prevent blood clots) and kidney disease. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2161-2-4**] 11:20 Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2161-2-5**] 11:30 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2161-2-4**] 10:00 Completed by:[**2161-2-23**]

[ "295.90", "733.14", "276.51", "414.00", "401.9", "272.0", "788.20", "403.90", "285.9", "198.5", "585.3", "197.7", "491.21", "V45.81", "162.8", "786.3" ]

icd9cm

[ [ [] ] ]

[ "33.23" ]

icd9pcs

[ [ [] ] ]

12095, 12174

3687, 8092

295, 325

12318, 12354

3233, 3664

13065, 13500

2755, 2803

8839, 12072

12195, 12297

8118, 8816

12378, 13042

2818, 3214

245, 257

353, 1977

1999, 2418

2434, 2739

23,764

153,471

24128

Discharge summary

report

Admission Date: [**2154-4-22**] Discharge Date: [**2154-4-26**] Date of Birth: [**2110-2-25**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Congenital aortic stenosis, ascending aortic aneurysm, and ASD. Major Surgical or Invasive Procedure: 1. AVR (29mm [**Last Name (un) **] [**Doctor Last Name **] pericardial) 2. ASD repair 3. Ascending aorta replacement (26mm gelweave) History of Present Illness: 44M c known congenital AS, with symptoms of dyspnea on exertion. Known anomaly since birth c several screening cardiac caths which did not uncover significant findings. Asymptomatic except with strenuous exercise. Referred for definitive repair. Past Medical History: 1. Aortic stenosis 2. Ascending aortic aneurysm 3. BPH Social History: Quit smoking 2 years ago. 20 pack-years. 2 glasses wine/day. Family History: Noncontributory Physical Exam: Afebrile, VSS NAD, alert Neck: no JVD, no bruits Heart: RRR, 4/6 SEM at RUSE Lungs: CTAB Abd: soft, NT, ND Ext: no edema, palp pulses throughout Pertinent Results: [**2154-4-24**] 05:10AM BLOOD WBC-7.0 RBC-3.06* Hgb-9.3* Hct-26.0* MCV-85 MCH-30.6 MCHC-36.0* RDW-13.9 Plt Ct-107* [**2154-4-22**] 11:07PM BLOOD PT-13.7* PTT-29.5 INR(PT)-1.2 [**2154-4-24**] 05:10AM BLOOD Glucose-137* UreaN-12 Creat-0.8 Na-138 K-3.9 Cl-103 HCO3-33* AnGap-6* Brief Hospital Course: 44M c known congenital AS, with symptoms of dyspnea on exertion. Known anomaly since birth c several screening cardiac caths which did not uncover significant findings. Asymptomatic except with strenuous exercise. Referred for definitive repair. He was taken to the OR [**2154-4-22**] for AVR (29mm pericardial), ASD repair, and ascending Ao replacement (26mm gelweave). Post-op, he was taken to the CSRU where he was extubated on POD 0. He received 1 unit of pRBC for a Hct of 23.5 on POD 1. Transferred to the floor on POD 1. Chest tubes, pericardial wires were removed on POD 3. Discharged to home on POD 4. Medications on Admission: 1. ASA 81 mg PO QD 2. Ativan prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 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. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Packet(s)* Refills:*0* 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 weeks. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 8300**] VNA Discharge Diagnosis: 1. Bicuspid aortic valve 2. BPH 3. Ascending aortic aneurysm Discharge Condition: Good Discharge Instructions: 1. Resume medications as directed. 2. Call office or go to ER if fever/chills, drainage from incisions, chest pain, shortness of breath. Followup Instructions: PCP, 2 weeks, call for appointment. Cardiologist, 2 weeks, call for appointment. Dr[**Last Name (Prefixes) 4558**], 4 weeks, call for appointment.

[ "746.3", "423.8", "746.4", "441.2", "745.5" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "35.52", "99.04", "35.21", "37.31", "38.45" ]

icd9pcs

[ [ [] ] ]

3014, 3073

1425, 2046

342, 477

3178, 3184

1126, 1402

3369, 3521

929, 946

2129, 2991

3094, 3157

2072, 2106

3208, 3346

961, 1107

239, 304

505, 755

777, 833

849, 913

56,697

121,611

13048

Discharge summary

report

Admission Date: [**2164-8-15**] Discharge Date: [**2164-9-11**] Date of Birth: [**2084-7-28**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2164-8-17**]: 25 mm tissue AVR, Coronary Artery Bypass Graft x 3 with Left internal mammory artery-> Left anterior descending, reverse saphenous vein graft--> Obtuse marginal, posterior descending artery Permanent [**Company **] pacer [**2164-8-24**] History of Present Illness: 80 year old male who slowly developed worsening sypmtoms from aortic stenosis. He currently complains of dyspnea on exertion and chest discomfort. He recently underwent a cardiac echo which showed moderate to severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.01cm2. He was referred for surgical management and now found to have three vessel disease. He is referred for an aortic valve replacement and revascularization. Past Medical History: Diastolic heart failure Chronic atrial fibrillation Pulmonary hypertension Obstructive sleep apnea, not on CPAP History of falls, walks with a cane Obesity Hyperlipidemia Prostate cancer, s/p radiation and pellet implantation Diabetes Mellitus, diet controlled History of GIB from overdose of coumadin Arthritis Past Surgical History:gall bladder removal, achilles tendon repair, R shoulder replacement, bilateral cataracts, repair of R leg fracture Social History: Race:Caucasian Last Dental Exam:more than one year ago Lives with:alone, family lives nearby Occupation: retired Tobacco:never ETOH:1.5 rum/ginger beers/day Family History: father dies at age 45 of heart disease Physical Exam: Pulse:49 Resp: 16 O2 sat: 99% RA B/P Right:172/61 Left: 183/75 Height: 5'[**64**]" Weight: 283 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur II/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] RUQ incision Extremities: Warm [x], well-perfused [x] Edema [**1-15**]+LE Varicosities: Left leg Neuro: Grossly intact [x] Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right:- Left:- Pertinent Results: [**2164-8-19**] 01:49PM BLOOD WBC-12.7* RBC-3.04* Hgb-10.7* Hct-30.1* MCV-99* MCH-35.1* MCHC-35.5* RDW-16.5* Plt Ct-92* [**2164-8-19**] 12:09AM BLOOD Glucose-131* UreaN-22* Creat-1.2 Na-132* K-4.2 Cl-98 HCO3-25 AnGap-13 [**2164-8-16**] TTE: PRE-BYPASS: The left atrium is dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). 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 normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([**1-15**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results prior to surgical incision. POST-BYPASS: Biventricular systolic function remains preserved. There is a well seated, well functioning bioprosthesis in the aortic position. No aortic insufficiency is visualized. The MR remains mild to moderate. The remaining study is unchanged compared to prebypass ECHO [**2164-8-31**] The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with borderline normal free wall function. A bioprosthetic aortic valve prosthesis is present. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-15**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Well seated, normally functioning aortic valve bioprosthesis. Preserved global left ventricular systolic function. Mild-moderate mitral regurgitation. Pulmonary artery systolic hypertension. Compared with the prior study (images reviewed), the overall findings are similar (image quality is better on the current study, but remains suboptimal). Chest CT [**2164-9-5**] INDICATION: 80-year-old male status post aortic valve replacement and pacemaker placement. Followup evaluation of sternal dehiscence and left pleural effusion. TECHNIQUE: Multidetector helical CT scan of the chest was obtained without the administration of contrast. Axial reconstructions in standard and lung algorithm were performed. Coronal and sagittal reformations were prepared. COMPARISON: CT examinations dated [**2164-8-31**] and [**2164-8-25**]. Correlation with multiple prior radiographs, most recent dated [**2164-9-4**]. FINDINGS: The patient is status post median sternotomy, CABG, aortic valve replacement, and pacemaker placement. Again seen are seven sternal wires, the most inferior three no longer bridge the sternum, which is separated to a similar degree to the examination of [**2164-8-31**]. A fluid collection located at the level of the inferior sternum and inferior to the sternum measuring up to 4.5 x 2.6 cm (2:49), previously measured 4.5 x 2.8 cm, not significantly changed. The extent and size of a loculated left pleural effusion is unchanged from the prior examination. Associated atelectasis also appears similar. Previously seen trace right pleural effusion is essentially resolved with residual atelectasis at the right base. No pneumothorax is seen. There are secretions within the trachea and right mainstem bronchus. There is trace pericardial effusion. Cardiomegaly is stable. The pacemaker lead in the right ventricle, mediastinal clips and appearance of the aortic valve are unchanged. There are coronary calcifications. Multiple mediastinal lymph nodes are not pathologically enlarged. The osseous structures appear unchanged with dehiscence of the inferior portion of the sternum and a 5 mm gap in the superior portion of the sternum. Multilevel degenerative changes of the thoracic spine include marginal osteophyte formation and vertebral body endplate irregularities. Limited views of the upper abdomen show a hyperdensity in the right upper quadrant which is unchanged and may represent a surgical clip. IMPRESSION: 1. Similar appearance of sternal dehiscence and size of adjacent fluid collection. 2. Unchanged loculated left pleural effusion with associated atelectasis. 3. Essentially resolved small right pleural effusion with residual atelectasis at the right base. The study and the report were reviewed by the staff radiologist. Head CT [**2164-8-31**] FINDINGS: The patient is intubated. There is no acute intracranial hemorrhage, edema, mass effect, or major vascular territorial infarcts. The prominent ventricles and sulci are similar in appearance and compatible with age-related involutional changes. There is no shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is no acute fracture. The paranasal sinuses and mastoid air cells are clear. Moderate fluid pools in the posterior nasal passage, likely retained secretion back up from the cuff of the endotracheal tube. IMPRESSION: 1. No acute intracranial pathologic process. Of note, CT is not sensitive to detect subtle infectious/inflammatory changes. 2. Moderate secretion retained in the posterior nasal passage, likely secondary to intubation. Video swallow [**2164-9-5**] Oropharyngeal swallowing video fluoroscopy was performed in conjunction with the speech and swallow division. Multiple consistencies of barium were administered. FINDINGS: Barium passes freely through the oropharynx and esophagus without evidence of obstruction. There was no gross aspiration with any consistency of barium. There was penetration with thin and nectar-thick liquids. For details, please refer to speech and swallow division note in OMR. IMPRESSION: Penetration with thin and nectar-thick liquids, but no aspiration. Brief Hospital Course: On [**2164-8-16**] Mr.[**Known lastname **] was taken to the operating room and underwent Aortic Valve Replacement (#25mm Porcine)/Coronary artery bypass grafting x 3 (left internal mammary artery grafted to left anterior descending/Saphenous vein grafted to Obtuse Marginal/Posterior descending artery) with Dr.[**Last Name (STitle) 3067**]. Please refer to operative report for further surgical details. Cross clamp time=80 minutes, Cardiopulmonary Bypass Time=110 minutes. He tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition requiring pressor support. He awoke neurologically intact and was weaned from the ventilator and extubated. He continued to require inotropic support until POD#2. On POD#3 he was hemodynamically stable and was transferred to the stepdown unit for ongoing post-op care. On POD#4 he had a witnessed syncopal event, was intubate and rec'd CPR. He was transferred back to the CVICU. He was hemodynamically stable. He was extubated later that day. He was evaluated by EP for possible pacer placement. A trial of betablocker (2.5mg IV ) was trialed w/HR 40's. A perm pacer was placed on [**2164-8-24**] and after lead placement was confirmed and pacer was interrogated, he was transferred to the stepdown unit. Anticoagulation resumed for afib. On [**2164-8-25**] Mr. [**Known lastname **] suffered a PEA arrest and was successfully resusitated and transferred back to the CVICU. Pacer was checked and found to be functioning properly. He is V-paced at 60. On the next day he was weaned from pressors and weaned from the ventilator and extubated. He was confused and has been slow to clear neurologically. He became hypercarbic and was re-intubated on [**2164-8-30**]. A head CT was done which showed no acute process. He was again weaned and extubated on [**2164-9-3**]. He was thought to have a component of sleep apnea and intermittantly tolerates BiPAP at night. He is presently alert and oriented but remains intermittantly confused. A speech and swallow consult was done and he was cleared for po diet w/o signs of aspiration. He remained in the ICU until [**2164-9-11**] for ongoing post-op care. He was followed by physical therapy for chset PT and stength and conditioning and rehab was recommended for ongoing strength training and chest PT. He was screened and accepted by [**Hospital1 100**] Rehabiliation Center for the Aged MACU and was transferred there on [**2164-9-11**] via ambulance. All discharge intructions were advised. Medications on Admission: FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other Provider) - 250 mcg-50 mcg/Dose Disk with Device - 1 puff twice daily FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day IPRATROPIUM-ALBUTEROL [COMBIVENT] - (Prescribed by Other Provider) - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 1 puff as needed LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth twice a day OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth once a day ZOLPIDEM - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth once a day as needed for bedtime ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth as needed for pain ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever . 12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for sob/wheezing. 14. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic QID (4 times a day). 16. warfarin 1 mg Tablet Sig: dose per INR Tablet PO DAILY (Daily): Indication: afib Goal INR 2.0-2.5. 17. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous once a day. 18. chest PT Chest PT Q6hrs 19. humalog insulin Humalog insulin per sliding scale Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Aortic Stenosis Coronary Artery Disease s/p coronary artery bypass grafts,aortic valve replacement Diastolic heart failure Chronic atrial fibrillation Pulmonary hypertension Obstructive sleep apnea Obesity Hyperlipidemia Prostate cancer, s/p radiation and pellet implantation noninsulin dependent Diabetes Mellitus osteoarthritis bradycardic/PEA arrest x2 Permanent pacer [**2164-8-24**] Discharge Condition: Alert and oriented x3- nonfocal Ambulating with assist of one Incisional pain managed with Tylenol 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 [**2164-10-3**] at 1:00pm Cardiologist:Dr.[**First Name (STitle) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**2164-9-19**] at 11:00 am Please call to schedule appointments with: Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 16308**] ([**Telephone/Fax (1) 22245**]) in [**4-17**] weeks DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] **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:[**2164-9-11**]

[ "427.89", "996.03", "511.9", "427.31", "427.5", "V10.46", "416.8", "518.81", "414.01", "428.0", "E878.2", "250.00", "428.32", "518.0", "327.23", "424.1", "272.4" ]

icd9cm

[ [ [] ] ]

[ "96.71", "36.12", "35.21", "39.61", "37.71", "96.04", "96.6", "38.91", "37.81", "36.15" ]

icd9pcs

[ [ [] ] ]

14491, 14534

9038, 11574

331, 586

14966, 15189

2488, 9015

16029, 16733

1742, 1783

12756, 14468

14555, 14945

11600, 12733

15213, 16006

1433, 1551

1798, 2469

271, 293

614, 1077

1099, 1411

1567, 1726

31,881

143,414

32218

Discharge summary

report

Admission Date: [**2175-12-6**] Discharge Date: [**2175-12-9**] Date of Birth: [**2131-2-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4654**] Chief Complaint: Suicide attempt/ polysubstance overdose Major Surgical or Invasive Procedure: Intubation [**2175-12-6**], extubation [**2175-12-7**] History of Present Illness: HPI obtained through parents. Pt with extensive psychiatric HX (bipolar type 2), 3 past suicide attempts with psych meds, on current ECT treatment by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Pt had initially responded well on ECT treatment (started [**12/2174**]), but more recently felt depressed. Perhaps precipitated by recent minor ankle twist with subsequent fixation on to this injury. Pt had expressed thoughts about SI to his father over the weekend, but had no clear plan of doing so. He had seen his [**Year (4 digits) 2447**] yesterday, who started seroquel. Pt work place had called his friend today as he had not shown up for work, police was notified who discovered pt s/p overdose, unclear in what exact condition he was. Past Medical History: Bipolar disorder type II polysubstance abuse OCD, 3 prior suicide attempts by OD Social History: The patient lives alone in an apartment in [**Location (un) 86**]. He grew up in [**Location (un) 3844**] and has two younger sisters. [**Name (NI) **] graduated from [**Location (un) 75328**] College. He has worked as a waiter for the last 20 years and at the same restaurant for the last six years. His family is very supportive. He describes having few social contacts. [**Name (NI) **] came out to his family as gay in college and reports that they were supportive, but that he is not yet comfortable with his homosexuality. He reports that his last intimate relationship was with a male professor when he was in college. No children. He used marijuana x 20 years but quit 15 months ago. Also quit EtOH 2 yrs ago but has relapsed since then. Quit cigarettes. Family History: No family history of psychiatric disorders. Physical Exam: On admission Gen: intubated, Arousing slightly to verbal commands Pupils: PERRL CV: distant heart sounds but RRR, No M/R/G Pulm: Equal breath sounds bilat, No W/R/R Abd: soft, ND, BS + Extr: No edema, pulses 2+ symmetric Pertinent Results: On admission: [**2175-12-6**] 06:00PM BLOOD WBC-8.8 RBC-4.54* Hgb-14.7 Hct-42.4 MCV-93 MCH-32.4* MCHC-34.7 RDW-13.4 Plt Ct-285 [**2175-12-6**] 06:00PM BLOOD Neuts-79.6* Lymphs-15.0* Monos-3.6 Eos-1.5 Baso-0.2 [**2175-12-6**] 06:00PM BLOOD PT-13.3 PTT-31.0 INR(PT)-1.1 [**2175-12-6**] 06:00PM BLOOD Glucose-127* UreaN-19 Creat-1.1 Na-142 K-4.6 Cl-110* HCO3-22 AnGap-15 [**2175-12-6**] 06:00PM BLOOD ALT-15 AST-22 CK(CPK)-184* AlkPhos-74 TotBili-0.3 [**2175-12-6**] 06:00PM BLOOD cTropnT-<0.01 [**2175-12-6**] 06:00PM BLOOD Albumin-4.6 Calcium-9.7 Phos-4.5 Mg-2.4 [**2175-12-6**] 06:00PM BLOOD Lithium-0.3* [**2175-12-6**] 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2175-12-6**] Head CT : IMPRESSION: No acute intracranial hemorrhage. [**2175-12-6**] CXR: ET and NG tubes appear in appropriate positions. No acute intrathoracic injury. Brief Hospital Course: 44 yo male with no 4th suicide attempt by OD, bipolar with poor response to therapy. On admission, appears to have overdosed with Lithium, Topomax, Imipramine, Seroquel, Alprazolam, pt stating basically taking full pill bottles - resp failure - s/p intubation/admission to MICU - extub [**12-7**] without problems - tx to floor [**12-8**]. Pt [**12-9**] medically stable - though with persistant severe suicide ideation. Psych evaluated - tranfer to in-patient psych. # Polysubtance Overdose with Suiacide attempt: Patient??????s Li level normal on admission, but urine tox positive for benzos and methodone (seroquel can cross react with methadone in this assay). In ED, activated charcoal given. Initially in ICU, Golytely per toxicology but this was stopped [**12-8**]. IVF stopped as well on [**12-8**] when regular diet was being tolerated by the pt. Serial EKG checks all normal last in am [**12-8**] - stable. # Respiratory: Pt intubated in ED. Extubated successfully [**12-7**] without event. # Depression/Bipolar type 2: Patient s/p ECT now q 6wks (last 5 wks ago) and psychotropic medications including Lithium, Topamax, seroquel, alprazolam, and imipramine. Outpt [**Month/Day (4) 2447**], Dr. [**First Name (STitle) **] confirms he was on a Xanax taper at the time of overdose. Pt's parents think he was having an OCD "flare" in the last month or so having rheuminations on joint pains. Psych following and plan for admission to today. Instructions for transfer are in front of the chart- handwritten by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32355**] for CM. -overall pt not considered stable from a psychiatric standpoint with severe on-going suicide ideations -defer to psych team for further mgmt - medically cleared if deemed to need further ECT - not on medications that would require further recommendations at time of procedure - (has good METS - no cardiac history, no herbal meds, would note psych meds prior and defer to psych team prior if ECT needed). Insomnia: Patient requested benadryl 25 mg for sleep. Pt given one time dose without effect but I am hesitant to give more. Defer to psychiatry. Pt prior used 50mg trazodone, but wants 100mg - defer to psych tonight for preference of use on psych floor (will likely give trazodone 100mg if still on medical floor). Epigastric Abdominal Pain: Ab labs wnl. Likely [**3-4**] to gastric effects from overdosing - trial of calrafate per request. Can start protonix at rehab if persisting. - LFTs, amylase, lipase - patient initially requested carafate but agrees to try TUMS for now. Anemia, nos - mild - stable here, (noted one [**Location (un) 1131**] very low - but given course described by MICU - likely erroneous lab). Will recommend further H/H check by PCP once [**Name Initial (PRE) **]/c with further w/u as an outpt. Currently stable. Code: Presumed full, however psych status needs further stabilization prior re-discussion can take place. Medications on Admission: Unclear at this time. But per outpt [**Name Initial (PRE) 2447**]: Xanax 0.5 mg tid (90 tabs picked up 10/29)- pt on a taper Seroquel 50 mg qhs Topamax 100 mg qam and 200 mg qhs (90 100 mg tabs picked up [**11-23**]). Discharge Medications: 1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agigtation' tachycardia: can be changed by psych team. 2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO twice a day as needed for heartburn: can change to protonix 40mg qdaily by psych team while on psych floor. 3. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection DAILY (Daily) as needed for severe agitation. Discharge Disposition: Extended Care Facility: [**Hospital1 18**]-[**Hospital1 **] 4 Discharge Diagnosis: Primary Diagnosis: Suicide Attempt with psychiatric medication overdose Severe Depression/?Bipolar/OCD Secondary: Anemia epigastric pain(dyspepsia) Insomnia Discharge Condition: medically stable, psychiatrically unstable (tranfer to in-patient psych) Discharge Instructions: Please closely follow recommendations and plan as set forth by your psychiatric team. If you ever start developing the urges you had prior - contact your [**Hospital1 2447**] or come to the emergency room immediately. Followup Instructions: PCP f/u in [**3-5**] weeks following discharge from psychiatric facility. [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**] Completed by:[**2175-12-9**]

[ "789.06", "E950.4", "V62.84", "969.8", "969.3", "300.3", "E950.3", "V15.82", "966.3", "296.89", "285.9", "969.0", "780.52", "969.4", "780.01", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7068, 7132

3367, 6365

355, 411

7334, 7409

2461, 2461

7676, 7892

2154, 2199

6633, 7045

7153, 7153

6391, 6610

7433, 7653

2214, 2442

276, 317

439, 1240

7172, 7313

2476, 3344

1262, 1346

1362, 2138

5,125

123,320

495

Discharge summary

report

Admission Date: [**2163-7-19**] Discharge Date: [**2163-7-23**] Date of Birth: [**2091-3-10**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Penicillins Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2163-7-19**] - Ministernotomy with Primary ASD closure History of Present Illness: This is a 72-year-old female who has shortness of breath on exertion. Her work-up revealed an atrioseptal defect of the secundum type of left and right shunting and elevated right heart pressures. It was recommended that she have this repaired. The risks were explained to her and she agreed to proceed with operation to close her atrioseptal defect. Past Medical History: 1. HTN 2. Hypothyroidism 3. Atrial fibrillation s/p ablation [**3-23**] 4. ASD secundum type with left to right shunting on echo Echo [**12-3**] (TEE): nl LA size, no thrombus, mod dilated RA; LVEF 55%, mild global RV HK; mild to mod MR, mod to severe 3+TR, large ASD with 1.5 cm jet 5. Back pain 6. Anxiety 7. Mild obesity 8. Arthritis 9. s/p R knee arthroscopy [**2-1**] 10. [**2129**] vein ligation R leg Social History: lives with her husband. Does not work. Denies tob, EtOH, or IVDA. Family History: No family history of CAD, DM, CVA. Physical Exam: T 99.3 BP 135/77 P69 R15 Sat 100% RA Gen: well appearing female, lying comfortably, NAD HEENT: PERRL, EOMI, OP clear with MMM, conjunctiva slightly pale, sclera anicteric Neck: supple, NT, no JVD CV: RRR, +3/6 systolic murmur at R and L USB Pulm: CTA bilaterally Abd: soft, +bilateral ecchymoses on lower abdomen in area of lovenox shots with palpable hematomas and tender to moderate palpation; +superficial ecchymoses in right groin with no palpable hematoma; +small hematoma on L groin; +femoral pulses bilaterally equal and symmetric Rectal (per ED note): guiac negative Ext: no edema, no CT, +2 DP pulses bilaterally Pertinent Results: [**2163-7-22**] 02:50PM BLOOD WBC-10.8 Hct-26.1* [**2163-7-21**] 06:25AM BLOOD WBC-14.8* RBC-3.13* Hgb-9.2* Hct-27.0* MCV-87 MCH-29.3 MCHC-33.8 RDW-14.1 Plt Ct-103* [**2163-7-21**] 06:25AM BLOOD Plt Ct-103* [**2163-7-22**] 02:50PM BLOOD K-4.0 [**2163-7-21**] 06:25AM BLOOD Glucose-122* UreaN-17 Creat-1.0 Na-144 K-3.6 Cl-106 HCO3-30 AnGap-12 [**2163-7-20**] CXR 1. Stable bibasilar atelectasis. Improving congestive heart failure. 2. No pneumothorax. [**Last Name (NamePattern4) 4125**]ospital Course: Mrs. [**Known lastname 4126**] was admitted to the [**Hospital1 18**] on [**2163-7-19**] for elective surgical management of her atrial septal defect. She was taken directly to the operating room where she underwent a mini sternotomy with primary closure of her atrial septal defect. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, she was awake, extubated and neurologically intact. Her chest tube was removed per protocol. She was then transferred to the floor for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Aspirin as well as her preoperative medications were resumed. Mrs. [**Known lastname 4126**] continued to do very well and make steady progress and was discharged home on postoperative day four. She will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Atenolol 25 mg daily Detrol 1 mg daily Levoxyl 75 mcg daily Folic acid 1 mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 6. 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* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: ASD Afib s/p pulm vein isolation c/b retroperitoneal bleed ARF PNA septic shock from hematoma infection HTN hypothyroid basal cell skin ca RLE DVT [**2120**] obesity OA\nhemorrhoids s/p R knee arthroscopy s/p T&A s/p RLE vein stripping s/p BL eye muscle surgery Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision, or weight gain more than 2 pounds in one day or five in one week. No lifting more than 10 pounds or driving until follow up with surgeon. Shower, no baths, no lotions, creams or powders to incisions. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] 4 weeks Dr. [**Last Name (STitle) 4127**] 2 weeks Completed by:[**2163-8-4**]

[ "278.00", "274.9", "745.5", "401.9", "300.00", "427.31", "V10.83" ]

icd9cm

[ [ [] ] ]

[ "38.91", "88.72", "39.61", "35.71", "38.93" ]

icd9pcs

[ [ [] ] ]

4537, 4612

308, 368

4918, 4926

1976, 2430

1282, 1318

3648, 4514

4633, 4897

3540, 3625

4950, 5203

5254, 5366

1333, 1957

2481, 3514

249, 270

396, 749

771, 1181

1197, 1266

14,768

107,630

50248

Discharge summary

report

Admission Date: [**2150-2-21**] Discharge Date: [**2150-2-24**] Date of Birth: [**2080-5-6**] Sex: M Service: MEDICINE Allergies: Mevacor / Pravachol / Bactrim / Adhesive Tape Attending:[**First Name3 (LF) 1973**] Chief Complaint: left leg cellulitis Major Surgical or Invasive Procedure: LENI CT Head History of Present Illness: Mr. [**Known lastname **] is a 69 y/o M with PMH significant for ESRD s/p cadaveric renal transplant in [**2145**] with CKD, afib, and recurrent cellulitis who presented with cellulitis and hypotension. He was admitted [**Date range (1) **] for cellutis and had right great toe debridement and was discharged on ciprofloxacin and vancomycin to treat osteomyelitis. He presented to [**Hospital **] clinic on day PTA who felt his toe looked well post debridement. At home he noted poor glucose control and fever so presented to the ED. In the ED, he had a fever to 103.3 orally, HR 107, BP 153/69 with elevated lactate at 4.5. He received 1700 cc of NS and 650 mg of tylenol. Per ID recommendations he was given 2.25 g of Zosyn IV X 1 and vancomycin and had good urine output with UA and CXR clear. Due to elevated lactate and tachycardia decision was made to admit the patient to the ICU. While in the ICU he was continued on vancomycin and Zosyn per ID. Renal was consulted and decreased cellcept to 500 [**Hospital1 **], prednisone to 5, with plan to check Cyclosporin level in AM. LENIs were negative and [**Hospital1 **] was consulted. Past Medical History: 1. Atrial fibrillation- s/p cardioversion and initiation of amiodarone on [**1-7**]. 2. Atrial flutter s/p ablation in [**3-/2145**] with resultant atrial fibrillation 3. S/P cadaveric renal transplant in 07/[**2145**]. Complicated by delayed graft rejection. Pt's ESRD secondary to autoimmune glomerulonephritis. 4. [**Name (NI) **] Pt is s/p MI x2 and CABG in [**2138**]. No cath or stress results in our system. 5. [**Name (NI) 4964**] Pt's most recent echo was [**1-/2148**] with EF 40% and mild dilated LV and LV mild hypokinesis, post akinesis, 1+ MR. 6. H/O pulmonary nocardiosis in [**10/2144**] 7. H/O bladder cancer s/p surgery and BCG treatment in [**2136**] 8. S/P GI bleed while on heparin 9. H/O line related DVT 10. Stable right adrenal lesion 11. Type 2 diabetes mellitus complicated by neuropathy, on insulin, followed at [**Last Name (un) **] 12. BL leg cellulitis: RLE cellulitis began after a board fell on his leg in the beginning of [**Month (only) 1096**]. Swab MRSA +, treated with IV vancomycin and unasyn & d/c'd on linezolid and augmentin (14 day course). Re-presented one week later with fevers (felt to NOT be related to the cellulits), completed remainder of the 14 day course with vancomycin and unasyn. Next admission treated with cipro/linezolid. Developed diarrhea while on linezolid ([**Month (only) 404**]), so changed to doxycycline. 13. Chronic Kidney Disease 14. elevated triglycerides 15. Pseudogout Social History: Patient is married and lives with his wife. [**Name (NI) **] is a former illustrator. Denies drugs/alcohol. Smoked 1.5 ppd X 25 years. Quit 20 years ago. Has 2 daughters. Family History: Mother with diabetes Physical Exam: T: 98.9, 144/74, 84, 20, 96% Gen: Pleasant male in NAD. Lying in bed. HEENT: periocular left eye ecchymosis CV: irreg irreg, S1 S2 [**2-3**] HSM at RUSB LUNGS: CTA bilat ABD: soft, NT, mod distended, no HSM EXT: absent dp pulses [**Last Name (un) **], severe hyperpigmentation changes of RLE chronic venous stasis changes, 1+ pitting edema to knees bilat, markedly improved erythema of LLE now well inside demarcated line, markedly improved tenderness to palpation in posterior calf NEURO: CNII-XII intact, [**4-4**] UE and LE strength, distal sensation diminished in [**Month/Day (1) 104785**] distrubution bilat, A and Ox3 Pertinent Results: [**2150-2-24**] 09:15AM BLOOD WBC-7.0 RBC-4.04* Hgb-9.3* Hct-29.5* MCV-73* MCH-22.9* MCHC-31.3 RDW-19.6* Plt Ct-261 [**2150-2-21**] 09:45PM BLOOD WBC-16.7*# RBC-4.72 Hgb-11.1* Hct-34.6* MCV-73* MCH-23.5* MCHC-32.1 RDW-19.2* Plt Ct-313 [**2150-2-21**] 09:45PM BLOOD Neuts-80.1* Lymphs-15.8* Monos-3.4 Eos-0.4 Baso-0.2 [**2150-2-23**] 06:15AM BLOOD PT-20.1* PTT-37.1* INR(PT)-1.9* [**2150-2-24**] 09:15AM BLOOD Glucose-173* UreaN-58* Creat-3.2* Na-141 K-3.5 Cl-102 HCO3-28 AnGap-15 [**2150-2-20**] 12:30PM BLOOD UreaN-71* Creat-3.9* Na-141 K-4.7 Cl-105 HCO3-23 AnGap-18 [**2150-2-23**] 06:15AM BLOOD TotBili-1.6* [**2150-2-21**] 09:45PM BLOOD CK(CPK)-79 [**2150-2-21**] 09:45PM BLOOD CK-MB-NotDone cTropnT-0.08* [**2150-2-22**] 03:05AM BLOOD Acetone-NEGATIVE [**2150-2-23**] 06:15AM BLOOD Vanco-18.4 [**2150-2-22**] 06:52PM BLOOD Vanco-21.5* [**2150-2-22**] 06:24AM BLOOD Vanco-26.4* [**2150-2-20**] 12:30PM BLOOD Vanco-35.0* [**2150-2-24**] 09:15AM BLOOD Cyclspr-46* [**2150-2-21**] 11:58PM BLOOD Lactate-1.2 [**2150-2-21**] 09:44PM BLOOD Lactate-4.5* K-4.6 [**2150-2-21**] CT HEAD: No evidence of acute intracranial hemorrhage. . [**2150-2-21**] CXR: No evidence of pneumonia. . [**2150-2-21**] ECG: Sinus tachycardia. P-R interval is prolonged. Left axis deviation. Left anterior fascicular block. Right bundle-branch block with left anterior ascicular block/ Since the previous tracing the rate is increased. . [**2150-2-22**] UNLAT LE VEINS: No DVT in the left lower extremity. . Brief Hospital Course: A/P: Mr. [**Known lastname **] is a 69 y/o M with PMH significant for ESRD s/p renal transplant in [**2145**] with persistent CKD, afib, and recurrent cellulitis who presented with cellulitis and septicemia. . # LLE post-procedure Cellulitis with septicemia Markedly improved with zosyn and vancomycin ID Consultation - Continue vanc/zosyn total of 14 days - Re consult [**Year (4 digits) **] felt surgical wound clean, not osteomyelitis - ID consult to follow vanco levels as outpatient # CKD Stage 5 s/p Transplant: Patient's creatinine increased from previous discharge. Renal transplant consultation following - Continue usual doses of cyclosporine and decreased cellcept and prednisone per renal consult They will continue to follow this in the outpatient setting - Continue calcitriol, folplex vitamin. . # Gout: Continue allopurinol and prednisone at 10 mg daily. . # DM Type 2 uncontrolled with complications: Cont usual NPH regimen 20 U [**Hospital1 **] with sliding scale. - Continue neurontin for neuropathy . # Hypertension - benign: Continue toprol and [**Hospital1 **] . # CHF - Systolic: EF 35% Continue toprol and bumex . # yeast balanitis: clotrimazole cream . # Atrial fibrillation: Continue toprol, amiodarone for rate control coumadin for anticoagulation and monitor INR. . # Microcytic anemia of CKD: Hct slightly below baseline but likely dilutional. Baseline anemia due to CRI. [**Month (only) 116**] benefit from Epogen. Fe studies may suggest mild iron deficiency with neg colonoscopy [**2144**]. Medications on Admission: 1. Mycophenolate Mofetil 1000 mg [**Hospital1 **] 2. Amiodarone 100 mg daily 3. Warfarin 2 mg daily 4. Cyclosporine Modified 50 mg QAM, 25 mg QPM 5. Bumetanide 1 mg [**Hospital1 **] 6. Sarna lotion 7. Allopurinol 100 mg daily 8. Calcitriol 0.25 mcg daily 9. Docusate Sodium 100 mg [**Hospital1 **] 10. B Complex-Vitamin C-Folic Acid 1 cap daily 11. Atorvastatin 5 mg Q3 days 12. Prilosec 40 mg daily 13. Toprol XL 50 mg daily 14. NPH 20 U [**Hospital1 **] with sliding scale regular insulin 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 16. Nystatin ointment 17. Vancomycin 750 mg daily 18. Cipro 500 mg [**Hospital1 **] 19. Gabapentin 300 mg daily 20. Prednisone 10 mg daily Discharge Medications: 1. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 2. Cyclosporine Modified 25 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pyridoxine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO 3X/WEEK (MO,WE,FR). 11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 17. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 11 days. Disp:*33 Recon Soln(s)* Refills:*0* 18. Vancomycin 1,000 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous once a day for 11 days: Note: Not full dose!. Disp:*11 Doses* Refills:*0* 19. PICC CARE PICC Care per NEHT Protocol 20. Outpatient [**Age over 90 **] Work Please Draw Weekly (Every Wednesday) Vancomycin Level CBC Basic Metabolic Profile To be followed by Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**]. Tel: [**Telephone/Fax (1) 457**] Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Post-Procedure Cellulitis of the Leg Chronic Kidney DIsease s/p renal transplant Type 2 DM uncontrolled with complications CAD Systolic CHF Gout Atrial Fibrillation Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500ml If you are unable to walk, increasing pain in the calf, notable leg swelling, fever/chills, weight gain Note your cyclosporine level has been reduced and will be controlled by Dr. [**Last Name (STitle) 118**] You will be on a total of 2 weeks of IV Zosyn and Vancomycin, you will need to finish ALL doses. It may take up to a week to see the majority of the redness to disappear from your leg. Followup Instructions: 1. Provider: [**Name10 (NameIs) 1947**] CLINIC (SB) Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2150-3-6**] 10:30 2. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2150-3-23**] 10:30 3. Dr. [**First Name4 (NamePattern1) 4850**] [**Last Name (NamePattern1) **] has re-scheduled your follow-up appointment with her. It is now on [**2150-3-5**] at 9:30. Your vancomycin levels will be sent to Dr. [**First Name (STitle) **] to follow.

[ "V42.0", "582.89", "357.2", "414.00", "285.21", "255.8", "427.31", "998.59", "585.5", "V58.61", "401.9", "V58.67", "428.0", "038.9", "426.52", "250.62", "V12.51", "428.20", "427.89", "V45.81", "682.6", "112.2", "V10.51", "274.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9596, 9671

5370, 6895

325, 339

9879, 9885

3861, 4935

10456, 10996

3178, 3200

7682, 9573

9692, 9858

6921, 7659

9909, 10433

3215, 3842

266, 287

367, 1508

4944, 5347

1530, 2973

2989, 3162

28,765

195,415

44987

Discharge summary

report

Admission Date: [**2144-12-7**] Discharge Date: [**2144-12-24**] Date of Birth: [**2068-12-18**] Sex: F Service: MEDICINE Allergies: Keflex / Codeine / Diltiazem / A.C.E Inhibitors / Tetracycline / Aspirin Attending:[**First Name3 (LF) 603**] Chief Complaint: Hypotension and Hypoxia Major Surgical or Invasive Procedure: Central line placement, left hip reduction History of Present Illness: This is a 75 yo F with a PMH of asthma, HTN, AV nodal ablation with PCM placement, PVD, and other medical problems who presents with hypotension and hypoxia. The patient was feeling unwell for the past 2 weeks, with rhinorrhea, and cough productive of green sputum and streaked with blood. She has noted increasing shortness of breath over the past several days, but no increase in her lower extremity edema. She also denies PND or nocturia. She has been increasingly using her albuterol nebs several times a day for the past several days. She notes that her theophyline was discontinued in [**Month (only) 359**]. She has been taking her lasix as instructed, but notes some dietary indiscretion with the recent holidays. She also notes some increased wheezing, but denies any chest pain, palpitations, or fevers. Of note, pt also had a mechanical fall out of bed this AM, landed on her hips, and now complains of bilateral hip pain. In the ED, the pts vitals were: T 97.2 HR 70s BP 80-101/31-49, R 15-20, Sat 95% 5 LNC. She was noted to have a possible LUL infiltrate on CXR so she was given clindamycin 600 mg IV x 1 and levofloxacin 750 mg IVx1. She also was given Lasix 100 mg IV x1 for concern of pulmonary edema on exam. Due to her SBP of 80, a femoral CVL was inserted and she was started on dopamine at 10 mcg/kg/min. She was then transferred to the floor for further management. Past Medical History: 1. Asthma. 2. Hypertension. 3. Osteoarthritis. 4. Atrial fibrillation status post amio toxicity, status post ablation of the A-V node and pacemaker placement in [**2138-12-26**]. 5. PVD 6. Anticoagulated. 7. Hypothyroidism. 8. Lower extremity cellulitis with MRSA. 9. Venous stasis disease. 10. Left hip fracture in [**2129**] with multiple complications. 11. DVT. 12. Bell's palsy. 13. Left heel ulcer. 14. Left total knee replacement. Social History: She has never used any tobacco. Socially uses alcohol. She lives with her husband in [**Name (NI) 583**]. Feels safe at home. Family History: There is an aunt with asthma. [**Name (NI) 1094**] mother has HTN. Physical Exam: VS: T 96.8 BP 102/49 P 72 R 19 Sat 93% on 5 L NC with 15L high flow; ABG: 7.26/56/154 GEN: pleasant, laying at 60 degrees, NAD HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, JVP approximately 12, no carotid bruits, no thyromegaly or thyroid nodules RESP: diffuse ronchi and end expiratory wheezing CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: cool, mildly cyanotic, dopplerable L DP pulse but not dopplerable on the R, [**11-25**]+ pitting edema in BL legs up to the knee, 1+ bilateral radial pulses, pain with external rotation of both hips SKIN: cracking and eczema of hands and feet, erosion on R big toe NEURO: AAOx3. Cn II-XII intact. Pertinent Results: [**2144-12-7**] WBC-21.2*# Hgb-10.7* Hct-33.6* MCV-91 RDW-17.5* Plt Ct-247 Neuts-79* Bands-17* Lymphs-1* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 PT-40.5* PTT-51.7* INR(PT)-4.4* Fibrino-776* Glucose-70 UreaN-61* Creat-2.4*# Na-136 K-5.3* Cl-95* HCO3-22 AnGap-24* CK(CPK)-1584* CK-MB-48* MB Indx-3.0 proBNP-[**Numeric Identifier 27822**]* cTropnT-0.08* ABG pO2-154* pCO2-56* pH-7.26* calTCO2-26 Base XS--2 Lactate-7.1* [**2144-12-8**] 12:00AM BLOOD FDP-10-40 [**2144-12-7**] 05:08PM BLOOD Fibrino-776* [**2144-12-8**] 12:00AM BLOOD ALT-92* AST-174* CK(CPK)-[**2088**]* AlkPhos-103 TotBili-0.7 [**2144-12-7**] 06:37PM BLOOD Cortsol-57.2* [**2144-12-8**] 01:54PM BLOOD freeCa-1.10 [**2144-12-9**] 04:01AM BLOOD CK(CPK)-937* . Micro: [**12-7**] blood cultures: [**2-26**] with strep pneumo, sensitive to ceftriaxone, R to PCN. [**12-8**] blood NGTD (4 bottles). Legionella neg. . Imaging: CXR ([**12-7**]): PORTABLE UPRIGHT CHEST, ONE VIEW: Heart size is moderately enlarged. There is a focal airspace opacity in the left upper lung zone, which may represent an area of infectious infiltrate. There is no overt CHF. No definite pleural effusions are seen. Single lead pacer with tip terminating in the right ventricle is unchanged. Osseous structures are mildly demineralized, otherwise unremarkable. IMPRESSION: 1. Focal airspace opacity in the left upper lung may represent pneumonia. 2. Cardiomegaly. . EKG: V paced, no change from prior . ECHO [**2144-12-7**]: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild global left ventricular hypokinesis (LVEF = 40 %). The estimated cardiac index is depressed (<2.0L/min/m2). The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2144-6-24**], a pacing wire/catheter is now clearly seen in the RA/RV. There is no pericardial effusion. LV function and mitral regurgitation are similar. Estimated pulmonary artery systolic pressure is normal on the current study. . Discharge Labs: [**2144-12-24**] 06:07AM BLOOD WBC-9.3 RBC-2.82* Hgb-7.9* Hct-25.0* MCV-89 MCH-28.2 MCHC-31.7 RDW-14.8 Plt Ct-410 [**2144-12-24**] 06:07AM BLOOD PT-18.9* PTT-35.5* INR(PT)-1.7* [**2144-12-24**] 06:07AM BLOOD Glucose-95 UreaN-27* Creat-1.0 Na-137 K-4.6 Cl-100 HCO3-31 AnGap-11 [**2144-12-24**] 06:07AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.1 Brief Hospital Course: A/P: 75 yo F with a PMH of asthma, HTN, AV nodal ablation with PCM placement, PVD, and other medical problems who presents with hypotension and hypoxia, found to have LUL PNA on CXR and Strep pneumo septicemia. . # Strep pneumo pneumonia/septicemia: Admitted to MICU. Was hypotensive requiring fluids and pressors (initially on phenylephrine, norepi, dobutamine then weaned to dopa) initially in MICU. She was started on broad spectrum antibiotics. When culture data returned, antibiotics were trimmed down to ceftriaxone. With her hypotension, also evaluated for adrenal insufficiency and had [**Last Name (un) 104**] stim test, which was normal. Became afebrile and leukocytosis improved. Weaned off pressors and transferred to the floor. No further issues with hypotension. Completed a 14 day course of ceftriaxone. . # Hypoxemia/Respiratory distress: History of asthma; now with new pneumonia. With hypotension/shock required a lot of fluids. Resp status was likely a combination of underlying chronic lung disease/asthma with pneumonia and volume overload/CHF. On ABGs, has had mild to mod hypercarbia. [**12-12**] AM she triggered for hypoxemia to low 80's on 2.5 L NC. Received one day of steroids. Improved daily with nebs, diuresis. Weaned off O2 and remained stable on room air. . # CHF, systolic dysfunction, acute exacerbation: She received a lot of fluids as above due to shock. Echo done in the MICU was limited but with EF 40-45% (previous in [**2144-6-24**] was 45-50%). BNP was elevated even in the ED, prior to fluid resuscitation. Once hemodynamically stable, she was diuresed with improvement in volume status and respiratory status. Beta blocker, [**Last Name (un) **], and diuretics were continued when BP allowed. . # Finger pain and swelling: noted to be slightly red and swollen in setting of other fingers/hand being swollen with overall volume overload. However, this persisted despite diuresis and became painful. On [**12-17**] vancomycin was started given concern for possible cellulitis. Whole finger was involved, did not seem c/w gout or arthropathy. Improved with vancomycin and she will complete a 15d course of IV vanco for this, to be completed on [**2144-12-30**]. Xrays were negative for fracture or evidence of osteomyelitis. . # Acute renal failure: Initially prerenal with elevated BUN/Cr ratio, dry MM. Initial urine lytes prerenal [**12-7**]. Improved with treatment of sepsis. Chem 7 should be checked on [**2144-12-28**] as per discharge orders. . # h/o Afib/Anticoagulation: V paced s/p AV ablation. INR elevated at admission; warfarin held. Peak INR > 8. Plts stable. Coumadin restarted and adjusted as needed for goal INR [**12-27**]. INR should be followed as per discharge orders. . # NSTEMI/demand ischemia: Elevated CK with MB elevation, but max MB index 3%. Troponin also elevated to 0.3 range, but also in setting of renal failure. EKG shows no changes, but this is with a V paced rhythm. ASA ordered but patient repeatedly refused, as has history of worsening asthma when taking it in the past. Statin was increased to 80 mg daily. Beta blocker restarted when BP tolerated. . # Anemia: HCT was at or below recent baseline (upper 20s through 30) for most of her stay. On her last day, her HCT was 25. She was sent out with instructions to check daily HCT until stable for three draws. Further outpatient workup may be indicated. . # Left femur dislocation: [**12-26**] arthritis as well as s/p mechanical fall on [**12-7**]. AP pelvis with dislocation of prosthetic hip. Ortho consulted and recommended reduction when medically stable. Had successful reduction [**12-10**]. Denies hip pain. Continued percocet prn, PT. . # Hyperlipidemia: continued atorvastatin at increased dose as above. . # HTN: metoprolol, valsartan, diuretics continued when BP allowed. . # Hypothyroidism: Continued synthroid . # OA: continued home perocet. . # Code Status: Full Medications on Admission: Atrovent 2 puff inhlaation q 4 hr prn flovent 100 mcg/actuation, 2 puff twice a day salmeterol 1 puff every 12 hrs atorvastatin 10 mg daily colace levothyroxine 125 mcg daily valsartan 80 mg daily percocet 5-325 mg every 6 hrs as needed coumadin 4 mg on MWF and 3 mg on the other days lasix 120 mg daily omeprazole 40 mg daily Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP < 100. 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP <100. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) inhalation Inhalation every six (6) hours. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation every six (6) hours. 13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) inhalation Inhalation every four (4) hours as needed for shortness of breath or wheezing. 14. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): hold for SBP <100. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 7 days: Please continue through [**2144-12-30**]. 16. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Goal INR [**12-27**]. . 17. Outpatient Lab Work -INR daily until at least 3 consecutive draws within goal range of [**12-27**]. -HCT daily until stable for 3 consecutive draws. -Na, K, Cl, HCO3, BUN, Cr, Glu on [**2144-12-28**]. . Please fax results to Dr. [**Last Name (STitle) 5444**]. Fax: [**Telephone/Fax (1) 3382**], Phone: [**Telephone/Fax (1) 250**] Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Pneumococcal septicemia Pneumococcal pneumonia Sepsis Congestive heart failure, systolic dysfunction, acute exacerbation Asthma, acute exacerbation NSTEMI (due to demand ischemia) Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted with a serious pneumonia with infection in your blood as well. You initially required admission to the intensive care unit but you are improving. We are treating your with antibiotics for your pneumonia and an infection involving your thumb. . Please return to the hospital or call your doctor if you are having worsening breathing, recurrence of fever, chest pain, severe cough, or any new symptoms that you are concerned about. . Please take your medications as prescribed. The following medication changes have been made: a new antibiotic (vancomycin) has been started. We have temporarily changed some of your inhalers to nebulizer treatments. We have increased your atorvastatin to 80 mg daily. We have also decreased your coumadin. Followup Instructions: You also have the following upcoming appointments at [**Hospital1 18**]: . Provider: [**Name10 (NameIs) **] FERN, RNC (at Dr.[**Name (NI) 86986**] office) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2145-1-21**] 9:20 . DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2145-1-29**] 1:00 . [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2145-1-29**] 1:40 . Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2145-7-14**] 11:30

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icd9cm

[ [ [] ] ]

[ "38.93", "79.75", "38.91", "88.72" ]

icd9pcs

[ [ [] ] ]

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149,044

47163

Discharge summary

report

Admission Date: [**2107-5-12**] Discharge Date: [**2107-5-18**] Date of Birth: [**2029-7-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6114**] Chief Complaint: Fever, tachycardia, and hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 77 M with end-stage Parkinson's Disease, resident of [**Location 1036**] (Hospice), transferred from [**Hospital1 **]-[**Location (un) 620**] [**5-12**] with symptoms of tachycardia and tachypnea, febrile to 101.1, resp rate in the 30's, and HR 110-130s. Initially received 3L NS, levofloxacin for presumed UTI with positive UA, though cultures from the outside hospital were not performed. He was transferred to [**Hospital1 18**] into the MICU. In MICU, the patient was normotensive, continued on Levofloxacin, diuresed for increasing crackles on exam and being 5 liters positive. He was then called out to the floor without fever, stable hemodynamics, and with a decreasing white count. Past Medical History: 1.CAD: S/p 3V CABG '[**96**], PCI to RCA '[**02**], PCA instent stenois seen on cath [**8-8**], patent grafts 2. HTN 3. Hyperlipidemia 4. CHF EF 40%, [**2-6**]+ MR [**First Name (Titles) **] [**Last Name (Titles) 113**] [**8-8**] 5. PVD: S/p L aorto-fem bypass 6. Hx of TB with LLL resection in [**2062**] 7. Lymphoma s/p XRT 8. Parkinsons Disease 9. Vascular Dementia 10.Depression 11.Diverticulosis 12.BPH Social History: SH: [**Location (un) 1036**] NH resident. Divorced, estranged from children, sister is contact person. Family History: NC Physical Exam: 98.4, 149-163/59-74, 109-117, 32, 100% 2LNC I/O: 1280/2925 GEN: NAD, responsive, can answer question "yes, no" oriented x to person. Does not know year or place. HEENT: anicteric, OP MMM NECK: no JVD (difficult to assess) PULM: Decreased BS, L>R with crackles and faint exp wheezes ABD: soft, PEG in place, tympanic to percussion EXT: no CCE, cog-wheel rigidity NEURO: CN II-XII intact, unable to move legs for me, strength in UE [**5-10**]. Speech limited but coherent. Pertinent Results: [**2107-5-12**] 09:10PM BLOOD WBC-19.4*# RBC-3.18* Hgb-9.5* Hct-28.2* MCV-89 MCH-30.0 MCHC-33.8 RDW-15.6* Plt Ct-282 [**2107-5-17**] 06:10AM BLOOD WBC-7.7 RBC-3.72* Hgb-11.0* Hct-33.4* MCV-90 MCH-29.5 MCHC-32.8 RDW-15.0 Plt Ct-301 [**2107-5-12**] 09:10PM BLOOD Glucose-115* UreaN-30* Creat-1.0 Na-142 K-4.4 Cl-110* HCO3-25 AnGap-11 [**2107-5-14**] 05:05PM BLOOD Glucose-101 UreaN-20 Creat-0.9 Na-144 K-3.9 Cl-106 HCO3-26 AnGap-16 [**2107-5-17**] 06:10AM BLOOD Glucose-135* UreaN-24* Creat-0.8 Na-147* K-4.2 Cl-108 HCO3-28 AnGap-15 [**2107-5-17**] 06:10AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1 Brief Hospital Course: 77M with dementia, end-stage Parkinson's Disease, CAD, and CHF who was admitted to the MICU for UTI with sepsis. 1.)UTI with sepsis -- Initially quite ill appearing, with fevers, tachycardia, hypotension, and tachypnea, Mr. [**Known lastname 99933**] [**Last Name (Titles) 99934**]d well to fluids, was transiently on pressors, and levofloxacin. Within a day, the patient was off pressors, required no more fluid support, and demonstrated a dramatic decline in his WBC. From there, he was moved to the floor, where he continued to do well without any additional need for blood pressure support. His WBC remained low, and he remained afebrile. He was felt ready for discharge on an oral course of levofloxacin. Unfortunately, the patient did not have any cultures grow out despite grossly positive urinalyses, yet the brisk clinical response certainly points to a sensitive organism. 2.)CHF -- The patient has a known EF of 45% and became volume overloaded in the setting of aggressive volume resuscitation, a necessary component of the treatment for sepsis. He then was diuresed while in the MICU, and by the time he was called out to the floor, had an improved chest x-ray and was satting well, with a lung exam that, though limited by poor inspiratory effort, demonstrated decreasing rales. He was restarted on his metoprolol and lisinopril, without requirement for daily diuretics. 3.)Coronary artery disease -- The patient's disease remained quiescent throughout his hospital stay, with no evidence of ischemia. He remained on atorvastatin, clopidogrel, metoprolol, and lisinopril. 4.)Sinus tachycardia -- On the floor, the patient again became tachycardic, without fever, hypotension, or hypoxia. His Hct was unchanged, and the tachycardia did not respond to diuresis. At this point, the most likely etiology was felt to be beta-blocker withdrawal, as he was significantly off of his outpatient dose; slowly titrated back up to this level, he was subsequently found to be in the 70's. 5.)Anemia -- Although low, his hematocrit was at its baseline of 28-30. Guaiac positive early in the admission, he was subsequently negative and remained as such. Previous iron studies demonstrated an anemia of chronic disease, with a normal B12. 6.)Parkinsonism -- The patient was continued on his carbidopa/levodopa with no change in symptoms. Medications on Admission: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO HS 3. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO TID 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID 6. Lansoprazole 30 mg Capsule Sig: One (1) Capsule PO DAILY Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Neomycin-Polymyxin-Dexameth 3.5 mg-10,000-1 mg/g-unit/g-% Ointment Sig: One (1) Appl Ophthalmic HS (at bedtime). 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 6. Carbidopa-Levodopa 25-250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Urinary tract infection Sepsis Secondary: 1.)CAD s/p 3v CABG 2.)Endstage Parkinson's 3.)HTN 4.)Hyperlipidemia 5.)Dementia 6.)Diverticulosis 7.)CHF 8.)Peripheral vascular disease 9.)Tuberculosis s/p LLL resection Discharge Condition: Fair, afebrile with stable hemodynamics Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Return to ED for fevers, tachycardia, low blood pressure, or other concerning symptoms. Follow-up as below. Take medications as prescribed. Followup Instructions: Please be seen your primary care doctor within the next few weeks. His number is [**Telephone/Fax (1) 99935**]. Follow-up with your neurologist as previously scheduled.

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icd9cm

[ [ [] ] ]

[ "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

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350, 357

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49495

Discharge summary

report

Admission Date: [**2157-3-20**] Discharge Date: [**2157-3-25**] Date of Birth: [**2082-2-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Cephalosporins Attending:[**First Name3 (LF) 3984**] Chief Complaint: increased lethargy Major Surgical or Invasive Procedure: Intubation, central line placement, arterial line placement History of Present Illness: 74yo F with HTN, DM, CVA, CRI and hx of frequent falls s/p ORIF [**11-30**] who presents from [**Hospital3 2558**] unresponsive and O2 sat of 80%. She was last admitted from [**Date range (1) **] with acute on chronic renal failure and new CHF with new systolic and diastolic dysfunction and was started on diuretics. . On discussion with staff at the [**Hospital3 2558**], the pt. was in her USOH until this AM when she was noted to be more lethargic than usual and demonstrated oxygen saturation of 62% on 3L NC. She wears 3L O2 at baseline. She has been afebrile. No cough. Baseline, can answer questions and is on oxygen per nursing. Per [**Hospital3 **] RN, her lasix dose was decreased on [**3-14**] from 120 mg po qd to 80 mg po qd. . Per ED signout, she presented there initially hypoxic and with a right gaze preference, not initially moving her LUE, and a decreased gag reflex. She was intubated for airway protection secondary to her decreased gag and she had a head CT that showed no acute hemorrhage but an equivocal new hypodense focus in right parietal white matter. Urine tox screen was negative and labs showed worsening renal failure from 3.9-->4.6. She was given vancomycin/levofloxacin/clindamycin for a questionable PNA? She was also given narcan and lidocaine for unclear reasons. . She was transferred to the [**Hospital Unit Name 153**] for further evaluation. Here, she was intubated and sedated. No further history could be obtained. . Past Medical History: 1. Hypertension. 2. Diabetes mellitus. 3. Paranoid schizophrenia. 4. History of frequent falls. 5. Hypercholesterolemia. 6. Iron deficiency anemia. 7. Status post cerebrovascular accident in [**2149**]. 8. History of granulomatous hepatitis in [**2139**]. 9. Chronic renal insufficiency with a baseline creatinine of 1.2-1.6 but since surgery in [**Month (only) **] has been between [**1-15**]. 10. OA 11. Hx of amyloid angiopathy 12. L. ORIF [**11-15**] 13. Paranoid schizophrenia Social History: No ETOH or IVDA. No smoking. Family History: noncontributory Physical Exam: 97.1, 150/72, 89, 17, 100% on AC 450/16/5/100% GEN- lying in bed intubated and sedated HEENT- R. pupil larger than left, both reactive to light NECK- supple CV- RR, no M CHEST- bibasilar rales anteriorly ABD- soft, NT/ND, +BS EXT- + 2 pitting edema bilaterally to upper thighs NEURO- upgoing toes bilaterally, R>L patellar reflexes, could not assess CN exam, not withdrawing to pain stimuli while on propofol Pertinent Results: PRIOR ECHO: [**2157-2-1**]- EF 40-45%, symmetric LVH, Resting regional wall motion abnormalities include mid to distal anteroseptal and apical akinesis/hypokinesis. 1+ MR. . HEAD CT- No acute hemorrhage or shift of normally midline structures. Equivocal new hypodense focus in right parietal white matter. MRI with diffusion weighted images is more sensitive in evaluation of acute ischemia/infarct and for vascular detail. . CXR #1 - R. mainstem bronchus intubation, cardiomegaly, pulmonary congestion, diffuse opacity of left lung, NG tube in stomach . CXR #2 - CHF. Cannot clearly see an infiltrate on this CXR. Brief Hospital Course: A/P: 75 yo F with HTN, DM, CVA, CRI who presents from her NH with hypoxia and unresponsive and intubated in the ED for airway protection. . 1. Hypoxia- Most likely etiology of this hypoxia is CHF exacerbation given the CXR and BNP >70,000. Also considered in the differential was a pneumonia and she was covered with vanco/levaquin. However, she remained afebrile and with flat wbc count so these were eventually discontinued. She received diuretics that initially included a lasix gtt. Howerver, she failed to diurese well to this and it was expanded to include diuril. She responded with moderate diuresis to this regimen. A family meeting was held with the sister [**1-13**] her recent decline in functional capacity and the decision was made to extubate the patient and change her code status to DNR/DNI. She tolerated the extubation w/out event and was maintained on a high flow mask with SpO2 in the 90s. Her CHF regimen was maximized with hydralazine and imdur although an ACE-I was avoided [**1-13**] her ARF. . 2. AMS: The patient was unresponsive with decreased gag reflex and left UE paralysis initially. Neurology evaluated the patient and a CT scan showed a new hypodensity. Neurology felt that this could be responsible for her AMS but that it was likely not an acute event and had happened in the recent past. After extubation, her mental status continued to be depressed despite adequate treatment of her CHF and infectious processes. . 3. Acute on chronic renal failure - This was attributed to both her UTI and her increased lasix dose. Her FeUrea >30 which did not suggest a prerenal etiology. She was treated for her proteus UTI with ceftriaxone and continued to be diuresed as above. Her creatinine initially trended towards normal but rose again just prior to discharge likely due to more aggressive diuresis in the setting of her active CHF. . 4. UTI - Treated with with ciprofloxacin initially but this was changed to CTX once culture sensitivities became available. . 4. HTN - Her BP was treated w/ hydral/imdur as above. . 5. DM - She was followed with finger sticks and covered with an ISS. . 6. Code status - As mentioned previously, the patient was initially full code and was intubated for respiratory protection. Discussion with her sister (and HCP) led to her being extubated and her code status being changed to DNR/DNI. At the time of discharge, the current plan of care was to make her comfortable and continue to treat her underlying CHF/UTI with oral meds if the patient was able to take them. The HCP wished to avoid any procedures that would cause her pain such as central line placement, NGT placement, or the initiation of pressors. Medications on Admission: 1. Hydralazine 75 mg po q6h 2. Ferrous Sulfate 325 mg po qd 3. Pantoprazole 40 mg po qd 4. Isosorbide Mononitrate SR 90 mg po qd 5. Lovenox 30 mg SC q24 h 6. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY 7. Citalopram 10 mg po qd 8. Olanzapine 2.5 mg po qhs 9. Atorvastatin 10 mg po qd 10. Miconazole Nitrate 2 % Powder PRN 11. Metoprolol Tartrate 100 mg PO bid 12. Diltiazem SR 120 mg po qd 13. Epo Alfa 4000 units qM/W/F 14. Lasix 120 mg po qd-> 80 mg po qd 15. Metolazone 5 mg po bid Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 3. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 4. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID (3 times a day) as needed. 5. Benztropine 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 7. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q6H (every 6 hours). 8. Isosorbide Dinitrate 10 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 9. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Ferrous Sulfate 325 (65) mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 11. Lasix 80 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO twice a day. 12. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback [**Last Name (STitle) **]: One (1) g Intravenous Q24H (every 24 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Urinary tract infection Acute on chronic renal failure sub-acute CVA Discharge Condition: Stable, bedbound and not taking POs Discharge Instructions: please take your medications as directed by the facility Followup Instructions: Please arrange to see your PCP [**Name Initial (PRE) 176**] 2weeks of discharge [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2157-3-25**]

[ "401.9", "250.00", "599.0", "295.32", "428.43", "584.9", "428.0", "585.9", "518.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8070, 8140

3541, 6232

318, 380

8253, 8291

2901, 3518

8396, 8633

2440, 2457

6768, 8047

8161, 8232

6258, 6745

8315, 8373

2472, 2882

260, 280

408, 1872

1894, 2378

2394, 2424

57,836

140,124

36585

Discharge summary

report

Admission Date: [**2151-8-5**] Discharge Date: [**2151-8-9**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1257**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 89 yo male with history of type 2 diabetes mellitus and hypertension was admitted with RUQ pain and jaundice. . Patient initially presented to an OSH with one day of RUQ pain and several days of jaundice. At OSH, he was noted to have elevated LFTs, and dilation of common bile ducts but with no evidence of gallstones. He was transferred to [**Hospital1 18**] for further evaluation and management of cholangitis. . Upon transfer to [**Hospital1 18**], vital signs were temp (not done), HR 70, BP 106/60, RR 16, and pulse ox 96% on room air. Exam was notable for jaundice and RUQ tenderness. Surgery was consulted and discussed surgery. Given his age and comorbidities, he was thought to be a poor candidate for surgery and was instead evaluated for ERCP. . Past Medical History: HTN, diabetes, hypercholesterolemia, hernia repair in remote past Social History: SOCIAL HISTORY: Home: Occupation: EtOH: Drugs: Tobacco: Family History: No cancer Physical Exam: HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-29**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ERCP Biliary stricture compatible with probable pancreatic neoplasm Pancreatic duct was partially filled and was grossly dilated Cytology was taken from the biliary stricture A biliary stent was placed with good flow of bile thereafter Abnormal mucosa in the esophagus- cytology taken An EGD was perfomed prior to commencing the ERCP to ensure patency of the duodenum. Note was made of a grossly abnormal esophagus which was friable. The mucosa above the GE junction was very abnormal and suspicious for malignancy ( no mass was seen) Brushings were taken (biopsies were not possible due to INR 2.4) Brief Hospital Course: 89 year old man with h/o DM, HTN, hyperlipidemia, atrial fibrillation, and recent falls who was sent in from OSH with RUQ pain, jaundice, and leukocytosis concerning for cholecystis and pancreatic malignancy. . CT of abdomen was positive for common bile duct and pancreatic duct dilation. Total bilirubin was elevated to 11.2 range. Also he had marked transaminitis with 1345, ALT 871, ALP 2711. On ICU admission, he had features of looming sepsis. He was started on Levofloxacin, flagyl, and Vancomycin. On EGD, he was found to have grossy abnormal esophagous suspicious for malignancy and cytologic brushings were taken. On ERCP, there was a biliary stricture compatible with probable pancreatic neoplasm. A stent was placed and cytology sample was taken. He was also found to have a dilated stomach and possible outlet stenosis( from pancreatic head lesion?). Following the procedure, he was extubated without complication and remained stable in the ICU. He was then transferred to the floor on broad spectrum antibiotics. I met with the family who decided on hospice care and against further diagnostic tests or treatment. Hospice care was arranged at home. . #Hypotension - He has a known history of HTN. His BPs responded well to 2L-3L IVFs and returned to the 120s/60s range. As noted above, abx were started and fluid administered out of concern for early sepsis, however, blood were cxs negative to date. Bblocker was initially held but restarted when pressures stabilized. . #Atrial fibrillation- unclear if this is a new diagnosis. we decided against anticoagulation because of hospice care. He received rate control only. . #Anemia: Pt with normocytic anemia while in the ICU. No obvious source of bleed at this time, with non-bloody G tube drainage and no evidence of bloody stools. Suspect this is primarily dilutional as crit drop was preceeded by agressive rehydration. . #Recent PNA: Noted to have RLL infiltrate on recent hospitalization on [**7-27**] at [**Hospital6 33**]. He was on a course of Levaquin which was due to be completed on [**2151-8-6**]. Current CXR still showing infiltrate. Patient states his recent cough and sputum production improving but still has leukocytosis which is more likely related to cholangitis given recent labs and imaging but PNA still in differential in terms of contributing causes for his leukocytosis. While in the ICU, levaquin was continued and pt initially require high flow O2 by face mask, weaned to NC at transfer from ICU. On the floor, he was continued on Vancomycin, Meropenem, and Flagyl. He was then changed to oral flagyl and Ciprofloxacin as he was discharged to hospice care to finnish treatment for cholangitits and pneumonia . #Communication: - daughter, [**Name (NI) **] [**Name (NI) **] #[**0-0-**] . He was discharged home on hospice care. We adniced follow up with PCP and GI regarding his biliary stent if needed. Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: [**11-16**] ML PO Q6H (every 6 hours) as needed for fever, pain . 2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. Disp:*30 Tablet(s)* Refills:*0* 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 6. Oxycodone 5 mg/5 mL Solution Sig: Five (5) ML PO every [**5-3**] hours as needed for pain. Disp:*120 ML* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Obstructive jaundice with possible pancreatic head mass Esophageal abnormality that could be related to malignancy Gastric outlet narrowing Hospital pneumonia Cholangitis Discharge Condition: Hospice with poor short term prognosis. Discharge Instructions: you have obstructive jaundice which could be related to pancreatic cancer pending the pathology report. You and your family decided on hospice care and against further diagnostic tests. You also declined further treatment. Therefore, we arranged for hospice care at your home. Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) 2191**] A. [**Telephone/Fax (1) 64161**]

[ "272.4", "250.00", "427.31", "995.91", "038.9", "486", "560.1", "576.1", "285.9", "537.0", "576.2", "789.59", "585.9", "403.90", "157.0" ]

icd9cm

[ [ [] ] ]

[ "45.16", "51.14", "51.85", "51.87" ]

icd9pcs

[ [ [] ] ]

5914, 5965

2346, 5248

232, 239

6180, 6222

1719, 2323

6547, 6633

1206, 1217

5271, 5891

5986, 6159

6246, 6524

1232, 1700

178, 194

267, 1028

1050, 1117

1149, 1190

48,666

115,353

42537

Discharge summary

report

Admission Date: [**2153-2-7**] Discharge Date: [**2153-2-12**] Date of Birth: [**2069-11-11**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 83 y/o F with history of HTN presents s/p mechanical fall today. Per EMS patient was at a high school basketball game when she tripped and fell striking her head. She unconscious for 5 minutes per witnesses. She was taken to OSH where she was a GCS of 15. CT head revealed a traumatic SAH. Patient had some n/v and was intubated for airway protection. She was also given 2 units of FFP and transferred to [**Hospital1 18**] for further evaluation. On arrival, patient was sedated and intubated. SBP was elevated to 215. Past Medical History: HTN, colon CA s/p chemotherapy and radiation, cholecystectomy Social History: HTN, colon CA s/p chemo/radiation, cholecystecomy Family History: non-contributory Physical Exam: On admission: O: BP:138/69 HR: 56 R 17 O2Sats: 100% Gen:intubated and sedated HEENT: R eye periorbital ecchymosis and edema Pupils: 4-3mm L pupil, R ecchymotic and edematous L eye open to voice No commands Localize BUE to nox BLE w/d to nox On Discharge: awake, a+ox3 although she was confused/speaking inappropriately at times. PERRL,EOMI face symmetric, tongue midline facial ecchymosis no drift MAE's [**5-19**] Pertinent Results: CT head [**2-7**] IMPRESSION: Stable appearance of right frontal/supra-orbital scalp subgaleal hematoma, few right frontal punctate parenchymal hemorrhages, and subarachnoid hemorrhage in the quadrigeminal and left perimesencephalic cisterns. NOTE ADDED IN ATTENDING REVIEW: 1. The focal basal cisternal subarachnoid hemorrhage is in a non-aneurysmal distribution, and likely represents coup-contre-coup mechanism. 2. The superficial frontal punctate hemorrhagic foci lie in a linear array along the [**Doctor Last Name 352**]-white matter interface, and may represent underlying diffuse axonal ("shear") injury. 3. There is a minimally-displaced fracture of the right orbital floor, associated with a small "trapdoor" fragment (103b:19-22). This is associated with layering hemorrhagic fluid within the ipsilateral maxillary sinus (2:5). There is no evidence of significant herniation of intra-orbital contents or impalement of extra-ocular muscles; correlate with clinical evidence of "entrapment." No other facial fracture is seen. X-Ray left knee [**2-7**] Two views of the left knee were obtained. There is soft tissue swelling along the medial border of the distal femur. However, no fractures or dislocations. Mild medial degenerative changes are visualized with small osteophytes and probably similar changes patella (poorly assesss on cross table lateral image). No radiopaque foreign bodies. Can't assess presence of effusion X-Ray right shoulder [**2-7**] Three views right shoulder. There is marked superior and anterior subluxation of humeral head and related cartilage loss and subchondral erosions. These appearances are chronic and no acute fractures suggested. Can't exclude incidental bursal calcifications (difficult asssessment secondary to sclerosis. X-ray left hand [**2-7**] Extensive degenerative changes with joint space narrowing and osteophytes are visualized at the 3nd MCP joint and at the first CMC joint. Minor DJD at first IP joint. Equivocal widening of scapho-lunate joint. No acute fractures. Normal alignment is maintained. No soft tissue calcifications or radiopaque foreign bodies. CT head [**2-7**] 1. Stable subarachnoid hemorrhage involving the perimesencephalic and quadrigeminal plate cisterns. 2. Stable small subdural hematoma along the tentorium. 3. Small punctate hemorrhages at the bifrontal [**Doctor Last Name 352**]-white mattter junction, one of which appears new, likely reflects diffuse axonal injury. 4. Probable layering hemorrhage in the right maxillary sinus. 5. Right orbital floor fracture. 6. Stable right periorbital subgaleal hematoma. CTA Head/Neck [**2-7**] IMPRESSION: 1. No evidence of intracranial aneurysm larger than 2 mm in diameter. The stable small amount of subarachnoid hemorrhage in the left posterior fossa is likely post-traumatic. 2. Principal cervical and intracranial vessels are patent, with only scattered atherosclerotic disease but no flow-limiting stenosis. 3. Acute right facial traumatic injury, with minimally-displaced right orbital floor fracture. better assessed in the prior non-contrast head CT studies. [**2-8**] MRI Brain: IMPRESSION: 1. Blood products in the subarachnoid right frontal region, quadrigeminal plate cistern and 4th ventricle. No evidence of intraparenchymal hemorrhage. 2. Bilateral periventricular and subcortical T2 FLAIR hyperintensities likely related to microangiophatic chronic ischemic changes. [**2-9**] CT max/face: IMPRESSION: 1. Non-displaced subtle right orbital floor fracture. No evidence of herniation of orbital fat or extraocular muscles. 2. No other acute facial fractures identified. Brief Hospital Course: Patient was admitted to the ICu under the neurosurgery service after having a mechanical fall with subsequent findings of traumatic SAH and tentorial SDH. She was intubated prior to arrival at [**Hospital1 18**] and remained intubated during the day on [**2-7**]. She was following commands off sedation while intubated. She was extubated the evening of [**2-7**] without incident. Her CT scans were stable and a CTA of the head and neck was obtained which showed no signs of vascular abnormality. On AM rounds on [**2-8**] she was deemed fit for transfer to the Step Down unit. MRI Brain with and without constrast was performed on [**2-8**] and was negative for uderlying mass. Plastic surgery was consulted on [**2-9**] for orbital fracture and they recommended a dedicated CT facial bones. She was noted to have a heart rate in the 130-150's. She was asymptomatic and all other vital signs were stable. An EKG revealed Afib vs Aflutter. she was given IV lopressor and converted to SR. She was started on 12.5 of Metoprolol at this time. On [**2-10**] in the early AM she again was noted to have a heart rate in the 130-150's. She was asymptomatic and all other vital signs were stable. An EKG revealed Afib vs Aflutter. she was given IV lopressor and converted to SR. Her Metoprolol was increased to 25mg at this time. Medicine consultation was requested. CE's were cycled, a TSH and echo were ordered and metoprolol was increased to 37.5. She was otherwise neurologically stable. Plastic surgery final recommendation were no intervention was needed and she could follow up PRN. On [**2-11**] she was stable without any further episodes of tachycardia. TSH was WNL and CE's were negative x3. She was cleared for transfer to floor status and PT/OT were ordered. On [**2-12**] she was neurologically stable. She complained of some right shoulder pain which was noted to be bruised. An xray was performed on [**2-7**] and was negative for fracture. ROM was decreased and pain subsided with rest. The echocardiogram was performed and revealed mild mitral regurgitation, otherwise no major structural abnormality. She was seen and evaluated by PT/OT who felt that she could be discharged home with 24hr supervision. At this time she was cleared for discharge. This was discussed with the patient's daughter who was in agreement with this plan. Medications on Admission: lisinopril Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. potassium chloride 10 mEq Tablet Extended Release Sig: Four (4) Tablet Extended Release PO DAILY (Daily). Disp:*120 Tablet Extended Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 16426**] home health care Discharge Diagnosis: Subarachnoid Hemorrhage Tentorial Subdural Hemantoma Atrial Fibrillation vs Atrial Flutter Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 6 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ?????? You were diagnosed with a heart arrythmia (afib/aflutter)while you were inhouse. You were started on new medication to decrease your heart rate. It was determined that you do not need to start anti-coagulation. You need to follow up with your PCP [**Name Initial (PRE) 176**] 7-10 days to have your heart rate and blood pressure checked. You were also noted to have decreased potassium levels over many days so you were started on a potassium supplement. You should have your level checked with your PCP [**Name Initial (PRE) 151**] 7 days. ?????? You were evaluated by the Plastic Surgery service for your facial fractures. You do not require any surgery and it was recommended that you follow up with your PCP if any problems arise. Completed by:[**2153-2-12**]

[ "E029.1", "401.9", "V10.05", "E849.4", "427.31", "851.42", "E885.9", "427.32", "802.6" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

8044, 8112

5171, 7520

317, 324

8247, 8247

1522, 5148

9379, 10453

1043, 1061

7581, 8021

8133, 8226

7546, 7558

8432, 9356

1076, 1076

1342, 1503

269, 279

352, 874

1090, 1328

8262, 8408

896, 960

976, 1027

23,188

152,316

11432

Discharge summary

report

Admission Date: [**2125-10-11**] Discharge Date: [**2125-10-13**] Date of Birth: [**2087-4-22**] Sex: M Service: PRINCIPAL DIAGNOSIS: Alcohol intoxication. HISTORY OF PRESENT ILLNESS: In brief, the patient is a 38 year old male with a long history of alcohol abuse and mood disorders who was admitted via the Emergency Department on [**2125-10-11**], with acute alcohol intoxication. The patient was found by ambulance services in the street with a bottle of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] next to him. He smelled of alcohol and had a normal blood glucose level. He was markedly obtunded with a respiratory rate of 10 and no verbal responses to commands. He did respond with flexion to painful stimuli. He was brought to the [**Hospital1 69**] Emergency Department where he was found to have no gag reflex and marked decreased level of consciousness. He was electively intubated using rapid sequence induction and transferred for further care in the Intensive Care Unit. His alcohol level was subsequently found to be greater than 500 mg/deciliter. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Mood disorder. He had recently completed an outpatient treatment program at [**Hospital 1191**] Hospital. 3. Hypertension. MEDICATIONS: None. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: As above. REVIEW OF SYSTEMS: As detailed in house officer notes and above. PHYSICAL EXAMINATION: His examination showed a blood pressure of 122/80 with a heart rate of 114, respiratory rate initially 10 and subsequently mechanically ventilated. Lung examination showed bilateral symmetric diffuse wheezes. The heart was regular rate and rhythm with no murmurs, gallops or rubs. The abdomen was soft with normal bowel sounds. Symmetric lower extremities with no edema. Neurologic examination initially showed marked decreased level of consciousness with flexion to painful stimuli. Sensation was intact in all four extremities. LABORATORY DATA: Normal blood urea nitrogen and creatinine and normal electrolytes. Hematocrit was 44.8 and platelet count 155,000. Blood gas in the Emergency Department while intubated showed a pO2 of 242, pCO2 40, pH 7.37. Radiologic studies included a normal head and neck CT. Chest x-ray showed endotracheal tube in good position with grossly normal lung fields. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit and had slow improvement in his level of consciousness. He was extubated without incident on the first hospital day. Psychiatric consultation was obtained. Psychiatry felt strongly that he was at great risk to himself due to probable bipolar disorder along with severe alcohol dependence and adjustment disorder with mixed features. It was recommended that he be held on a section twelve for inpatient psychiatric treatment. He currently is medically stable with need for only p.r.n. bronchodilators. He should continue to abstain from alcohol. His reactive airways are likely secondary to his prior tobacco abuse. MEDICATIONS ON DISCHARGE: 1. Albuterol MDI one puff q6hours p.r.n. 2. Benzodiazepine for alcohol withdrawal as deemed appropriate by the psychiatric services. He will be transferred to the [**Hospital1 188**] [**Hospital Ward Name 517**] for inpatient substance abuse treatment as per the psychiatric consultative service. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**] Dictated By:[**Name8 (MD) 36540**] MEDQUIST36 D: [**2125-10-13**] 12:08 T: [**2125-10-13**] 12:16 JOB#: [**Job Number 36541**]

[ "518.81", "401.9", "303.02", "980.0", "780.09", "E980.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "94.62" ]

icd9pcs

[ [ [] ] ]

1364, 1382

3126, 3689

2426, 3100

1499, 2408

1429, 1476

207, 1118

1140, 1348

1398, 1409

8,312

174,196

1813+55321

Discharge summary

report+addendum

Admission Date: [**2188-6-3**] Discharge Date: [**2188-6-11**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1620**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation Thoracentesis History of Present Illness: This is an 81 year old female resident of the [**Hospital1 10151**] Center for Aged who has a history of a LLL nodule, R hilar fullness on CT in [**10-15**], and a transbronchial biopsy with lavage that initially showed initially squamous CA, but which was then reread as reactive only. At time patient also had endobronchial lesions concerning for ? aspiration but normal swallow eval. Pt declined intervention/aggressive care for possible CA and returned to [**Hospital1 5595**]. Pt continued to have chronic cough, and over last 4 days had increasing sputum production, increasing SOB, and progressive hypoxia. She had been started on Levo/Azithro at [**Hospital1 5595**] and steroids added on [**6-2**]. Pt was urgently transferred to [**Hospital1 **] on [**6-3**] due to hypoxia/tacypnea (ABG 7.39/46/81 on 100%NRB)...patient and daughter both agreed to reverse code status despite previous DNR/I. CXR notable for new large L pleural effusion. Intubated in ED, started on coverage for nosocomial PNA (levo/vanc) and a-line placed. No septic physiology Past Medical History: PMHx: 1)As above, 2)Gastritis, 3)UGI bleed, 4)Anemia (Fe deficiency), 5)CAD s/p CABG, 6)HTN, 7)Hypercholesterol, 8)s/pCCY and appy Social History: Pt is a retired teacher from Siberia. She denies EtOh intake. Physical Exam: T 97.7 BP 140/90 HR 94 RR 20 O2 sats 95% %L O2 General: Pt sitting in chair in NAD HEENT: PERRLA, EOMI, no JVD, no LAD CVS: RRR, no M/R/G Chest: L base with decreased air movement, bronchial breath sounds, dullness to percussion 2/3 up from base orf L lung field Abd: soft, nontender, nondistended, + bowel sounds Ext: 1+ pitting edema, no cyanosis or clubbing, good pedal pulses Neuro: CN II-XII grossly intact, strength 5/5 bilat UE/LE Pertinent Results: [**2188-6-3**] 08:28PM TYPE-ART TEMP-36.7 PO2-91 PCO2-42 PH-7.40 TOTAL CO2-27 BASE XS-0 [**2188-6-3**] 01:58PM URINE HOURS-RANDOM [**2188-6-3**] 01:58PM URINE GR HOLD-HOLD [**2188-6-3**] 01:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2188-6-3**] 01:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2188-6-3**] 01:58PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2188-6-3**] 01:58PM URINE MUCOUS-OCC [**2188-6-3**] 12:35PM TYPE-[**Last Name (un) **] PO2-81* PCO2-46* PH-7.39 TOTAL CO2-29 BASE XS-1 COMMENTS-NOT SPECIF [**2188-6-3**] 12:35PM LACTATE-1.8 [**2188-6-3**] 11:30AM GLUCOSE-131* UREA N-26* CREAT-1.2* SODIUM-140 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 [**2188-6-3**] 11:30AM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-71 AMYLASE-35 TOT BILI-0.4 [**2188-6-3**] 11:30AM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-4.4 MAGNESIUM-2.5 [**2188-6-3**] 11:30AM WBC-12.9*# RBC-4.52 HGB-12.3 HCT-38.5 MCV-85# MCH-27.3# MCHC-32.1 RDW-15.9* [**2188-6-3**] 11:30AM NEUTS-95* BANDS-0 LYMPHS-3* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2188-6-3**] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2188-6-3**] 11:30AM PLT SMR-NORMAL PLT COUNT-335 [**2188-6-3**] 11:30AM PT-13.4* PTT-29.1 INR(PT)-1.2 [**2188-6-11**] 06:35AM BLOOD WBC-6.4 RBC-3.81* Hgb-10.5* Hct-32.6* MCV-86 MCH-27.5 MCHC-32.1 RDW-15.9* Plt Ct-278 [**2188-6-10**] 06:30AM BLOOD WBC-6.4 RBC-3.81* Hgb-10.6* Hct-32.2* MCV-85 MCH-27.7 MCHC-32.8 RDW-16.0* Plt Ct-243 [**2188-6-9**] 06:25AM BLOOD WBC-7.3 RBC-3.80* Hgb-10.2* Hct-32.5* MCV-85 MCH-26.8* MCHC-31.3 RDW-15.7* Plt Ct-286 [**2188-6-8**] 03:47AM BLOOD WBC-8.4 RBC-3.99* Hgb-11.1* Hct-32.9* MCV-82 MCH-27.7 MCHC-33.7 RDW-15.4 Plt Ct-267 [**2188-6-7**] 03:30AM BLOOD WBC-8.6 RBC-4.03* Hgb-11.0* Hct-34.3* MCV-85 MCH-27.3 MCHC-32.1 RDW-15.5 Plt Ct-288 [**2188-6-6**] 04:04AM BLOOD WBC-7.0 RBC-3.75* Hgb-10.5* Hct-31.8* MCV-85 MCH-27.9 MCHC-32.9 RDW-16.2* Plt Ct-244 [**2188-6-5**] 04:55AM BLOOD WBC-8.5 RBC-3.93* Hgb-10.5* Hct-33.3* MCV-85 MCH-26.8* MCHC-31.6 RDW-16.0* Plt Ct-254 [**2188-6-4**] 06:00AM BLOOD WBC-7.4 RBC-3.77* Hgb-10.3* Hct-31.1* MCV-83 MCH-27.4 MCHC-33.2 RDW-16.0* Plt Ct-238 [**2188-6-4**] 04:00AM BLOOD WBC-8.3 RBC-3.83* Hgb-10.4* Hct-32.9* MCV-86 MCH-27.1 MCHC-31.5 RDW-15.9* Plt Ct-286 [**2188-6-3**] 11:30AM BLOOD WBC-12.9*# RBC-4.52 Hgb-12.3 Hct-38.5 MCV-85# MCH-27.3# MCHC-32.1 RDW-15.9* Plt Ct-335 [**2188-6-4**] 06:00AM BLOOD Neuts-86.7* Lymphs-8.4* Monos-4.6 Eos-0.2 Baso-0.1 [**2188-6-4**] 06:00AM BLOOD Hypochr-1+ Anisocy-1+ Microcy-1+ [**2188-6-11**] 06:35AM BLOOD Plt Ct-278 [**2188-6-10**] 06:30AM BLOOD Plt Ct-243 [**2188-6-9**] 06:25AM BLOOD Plt Ct-286 [**2188-6-6**] 04:04AM BLOOD PT-12.4 PTT-33.3 INR(PT)-1.0 [**2188-6-7**] 07:54AM BLOOD Type-ART Temp-36.2 Tidal V-380 O2-40 pO2-81* pCO2-57* pH-7.35 calHCO3-33* Base XS-3 Intubat-INTUBATED [**2188-6-3**] 12:35PM BLOOD Type-[**Last Name (un) **] pO2-81* pCO2-46* pH-7.39 calHCO3-29 Base XS-1 Comment-NOT SPECIF Brief Hospital Course: 1)Respiratory failure: Her respiratory failure was felt to be due to large LLL lesion, pleural effusion and ? underlying PNA. She was extubated on [**6-7**] to face tent, then weaned to 5L O2 NC and improved. Her lung exam continued to be consistent with a left sided effusion and she continued to have coarse breath sounds and secretions supporting a possible underlying PNA. She was started on levofloxacin 250 mg QD on [**6-4**] and is to continue for a 14 day course (to end [**6-17**]). The pleural effusion was tapped for diagnostic and therapeutic purposes. Cytology is pending at time of dicharge. Repeat CXR shows evidence of reacculmulation of fluid, but stable pulmonary status. She may require repeat thoracentesis if she becomes symptomatic. 2)LLL lesion: She has a persistent LLL lesion with possible post-obstructive pneumonia. Therapuetic/diagnostic thoracentesis on [**6-4**] removed 2L serosanguinous fluid; fluid cytology exudative by numbers, with lots of atypical cells present. Definitive cytology pending, lymphoma vs. adenoCA. At time of discharge, final cytology was pending; however, the preliminary report was poorly differentiated, and more stains were being done to determine type of CA. Mrs.[**Known lastname 10152**] failed to accept the possibility of having cancer and did not wish to pursue further therapeutic options. This may be a topic for discussion with her PCP who likely has a more longstanding relationship with her. At the very least, if the pleural effusion continues to worsen, she may need a repeat thoracentesis with a sclerosing [**Doctor Last Name 360**]. 3)Anemia: HCT dropped initially in setting of hydration, it climbed back to 32.6 and remained stable. It was 32.2 on the day of discharge. Stool guaiac was negative. 4)CAD/HTN: Pt was normotensive on started on Norvasc 5 mg PO QD. 5)Hyperlipidemia: Pt was on zocor for lipid control. Medications on Admission: Meds on transfer: albuterol, norvasc, ASA, dulcolax, HCTZ, Celexa, zoclor, imdur, detrol, prednisone, levo, azithro Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*2* 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 inhaler* Refills:*2* 3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*1 bottle* Refills:*2* 10. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) ampule Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: 5000 (5000) units Injection three times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: 1) Lung cancer 2) Post-obstructive PNA 3) L pleural effusion Discharge Condition: Stable. Discharge Instructions: Please return to hospital if worsening shortness of breath, temp > 101, or chest pain. Followup Instructions: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**] Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2188-7-17**] 2:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] Date/Time:[**2188-7-17**] 3:00 Name: [**Known lastname 1416**],[**Known firstname 1417**] Unit No: [**Numeric Identifier 1418**] Admission Date: [**2188-6-3**] Discharge Date: [**2188-6-11**] Date of Birth: [**2106-12-4**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 923**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Intubation Thoracentesis History of Present Illness: PLease see full report. Past Medical History: PMHx: 1)As above, 2)Gastritis, 3)UGI bleed, 4)Anemia (Fe deficiency), 5)CAD s/p CABG, 6)HTN, 7)Hypercholesterol, 8)s/pCCY and appy Social History: Pt is a retired teacher from Siberia. She denies EtOh intake. Family History: Please see full report. Physical Exam: PLease see full report. Pertinent Results: Please see full report. Brief Hospital Course: Uterine prolapse: Of note, pt was noted to have uterine prolapse affecting her ability to urinate. GYN was consulted and made the recommendation to f/u with Dr.[**Last Name (STitle) 1419**] at [**Hospital1 1420**] for further evaluation, but currently, they recommend: 1) optimizing her bowel regimen to avoid bearing down; 2) decreasing caffeine intake to minimize urinary incontinence and 3) optimizing pulmonary status to minimize pt coughing. Medications on Admission: Please see full report Discharge Medications: Plerase see full report. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - LTC Discharge Diagnosis: 1) Lung cancer 2) Post-obstructive PNA 3) L pleural effusion Discharge Condition: Stable. Discharge Instructions: Please return to hospital if worsening shortness of breath, temp > 101, or chest pain. Followup Instructions: Provider: [**Name10 (NameIs) 1421**] BREATHING TESTS Where: [**Hospital6 189**] Phone:[**Telephone/Fax (1) 1422**] Date/Time:[**2188-7-17**] 2:45 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 189**] Date/Time:[**2188-7-17**] 3:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 927**] MD [**MD Number(1) 928**] Completed by:[**2188-6-11**]

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icd9cm

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29602

Discharge summary

report

Admission Date: [**2196-5-18**] Discharge Date: [**2196-5-26**] Date of Birth: [**2135-2-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: 61 y.o. M currently resident at [**Hospital1 1501**], h/o HTN, R MCA stroke with L side hemiplegia, h/o chronic pain in all four extremities, CAD s/p CABG, CKD who was admitted to the hospital with presumtive PNA on [**5-18**]. Patient was subsequently transfered to ICU on [**5-21**] after being found to be hypertensive to 190s with HR of 120 and underlying Afib. Patient has been refusing his PO medication due to trouble swallowing. Patient was admited initially with a fever to 103.3 at [**Hospital1 1501**], CXR showed ? of retrocardiac opacity and he was given 3L of NS with vanco/cipro and flagyl for PNA. Head CT was unrearkable. Since his admission he underwent speech and swallow test which recommended modified diet of nectar thick liquids and puree consistency solids with 1:1 supervision. Pills can be crushed in puree. Patient however has been refusing his medication since [**5-19**] due to nausea. Thus he has not received most of his PO BP medications. Patient was thus trigered on [**5-20**] @ 5 am for HR of 145 and BP of 100/70 after receiving Lopressor 5 mg IV x 2. Patient also had decreased UO ~ 50 cc from 12 am to 4 am and IVF 125 cc/hr were started. Patient subsequently continued to be tachycardic and he received 10 mg IV Dilt x 3 with HR return to SR in 80s and hypertensive to SBP 190s. Patient was subsequently transfered to ICU for continued BP management. ROS On review of systems, the pt. denied recent fever or chills. No night sweats or recent weight loss or gain. Denied headache, sinus tenderness, rhinorrhea or congestion. He stated his cough is unchanged with continued greenish sputum production. He denied any shortness of breath. Denied chest pain or tightness, palpitations. He did admit to persistent nausea which is present at baseline x several months and is usually exacerbated by any PO including pills, liquids and solids. He denies any dysphagia. Denied vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Patient does have chronic pain that he identifies in his lower legs, around his knees - currently [**9-19**] with diffuse radiation in all directions. Past Medical History: - New onset atrial fibrillation - CAD s/p CABG - Right MCA stroke 5 years-ago with left-sided hemiplegia and contractures - Hypertension - Chronic pain [**2-12**] stroke - depression - likely CKD (last Creat 1.8) - dementia - cataracts - arthritis Social History: - Lives in extended care facility [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42905**] [**Telephone/Fax (1) 70967**] - daughter [**Name (NI) **] is [**Hospital1 18**] employee - Hx ETOH abuse - many pack-years of tobacco - past cocaine use Family History: NC Physical Exam: VS T 97.4 P 91 BP 178/110 RR 18 O2Sat 96% RA GENERAL: elder, contracted male, NAD, speaking in full sentences HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally without R/R/W but poor inspiratory effort, no splinting, exam limited by pain Cardiac: RRR, nl. S1S2, no M/R/G noted, physiologically split S2 Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. No tenderness, no rebound. Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: intact fine touch, mild L sided facial droop, tongue deviating to the R, nl gag -motor: exam limited to severe pain due to mild touch, [**4-14**] RUEs, hemipalegic on the L and the R leg. hard to elicit DTRs throughout. [**Name2 (NI) **] abnormal movements noted. -sensory: No deficits to light touch throughout - Fully intact. -cerebellar: No nystagmus, dysarthria, intention or action tremor, dysdiadochokinesia noted. Pertinent Results: [**2196-5-17**] 08:05PM WBC-13.0* RBC-4.46* HGB-13.3* HCT-39.8* MCV-89 MCH-29.7 MCHC-33.3 RDW-15.7* [**2196-5-17**] 08:05PM NEUTS-82* BANDS-10* LYMPHS-4* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2196-5-17**] 08:05PM CK-MB-4 cTropnT-0.16* [**2196-5-18**] 12:50PM CK-MB-5 cTropnT-0.14* [**2196-5-18**] 05:10PM CK-MB-4 cTropnT-0.12* [**2196-5-18**] 05:10PM CK(CPK)-364* [**2196-5-18**] 12:50PM GLUCOSE-106* UREA N-21* CREAT-0.7# SODIUM-141 POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14 [**2196-5-18**] 12:50PM CALCIUM-8.5 PHOSPHATE-1.5* MAGNESIUM-1.9 [**2196-5-18**] 11:33AM URINE BLOOD-SM NITRITE-NEG PROTEIN->300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.5 LEUK-NEG [**2196-5-17**] 08:07PM LACTATE-1.3 K+-3.8 . Micro: Urine culture ([**2196-5-18**] and [**2196-5-22**]): No growth Spurum ([**2196-5-19**]): Moderate growth MRSA ([**2196-5-22**]): No growth Blood ([**2196-5-19**]): No growth . Imaging: CT Head ([**2196-5-17**]): No evidence of intracranial hemorrhage or acute process. Chest xray PA and lateral ([**2196-5-18**]): Focal increased density behind the heart. Ankle x-ray ([**2196-5-19**]): No osteomyelitis. Echo ([**2196-5-23**]): The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate left ventricular systolic dysfunction with severe hypokinesis of the septum and basal inferior wall, and milder hypokinesis of the other LV segments (EF 30%). The right ventricular cavity is mildly dilated. There is mild global right ventricular 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. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction. Mild right ventricular systolic dysfunction. Moderate tricuspid regurgitation. Mild pulmonary hypertension. Renal U/S ([**2196-5-23**]): 1. Abnormal area of increased echogenicity in the anterior upper pole of the right kidney with ill-defined margins. Recommend MRI for further evaluation. 2. Slightly increased RIs on the left. Normal Doppler study on the right. Gastric emptying study ([**2196-5-24**]): Limited study although there is no evidence to indicate delayed gastric emptying. There is delayed esophageal clearance, which could reflect dysmotility. An esophogram and upper GI study may be helpful for further evaluation. Head CT ([**2196-5-24**]): No overt interval change in the appearance of the brain compared to the prior head CT scan. Obviously, it is possible that an acute area of brain ischemia could be present, and yet undetectable by the present CT examination. ADDENDUM: Redemonstrated is moderately extensive atherosclerotic calcification of the distal left vertebral artery and both cavernous internal carotid arteries. Brief Hospital Course: Mr. [**Known lastname 1661**] was admitted with fevers and left-shifted leukocytosis. Infectious work-up revealed a retrocardiac opacity on chest x-ray and sputum was found to grow MRSA. The patient received a 7 day total course of vancomycin. Other infectious work-up, including LFT's and ankle x-ray (to rule out osteomyelitis)were negative. . The [**Hospital 228**] hospital course was complicated by a fib with RVR requiring transfer to the ICU. The patient returned to NSR with IV lopressor and remained in NSR for the duration of his ICU course. The patient's bp meds were held in the setting of hemodynamically siginificant A. Fib with RVR. Upon re-institution of bp meds, the patient had markedly fluctuant BP's ranging from systolic 80-210. His bp meds were trimmed to low-dose beta blocker with improved ranges from 110-170. The patient was noted on echo (biventricular disease, EF 30%) and BNP (>40,000) to have finding consistent with heart failure. Attempts to provide afterload reduction (with low-dose nitropaste, hydralazine or CPAP) were unsuccessful as the patient had periods of hypotension with any escalation of his bp regimen. When hypotensive (sbp 90-100) the patient developed altered mental status and poor urine output. The patient was discharged on low dose beta blocker three times daily. His goal systolic blood pressure is 150-160 as lower pressures reveal signs of end-organ hypoperfusion. The reason for the patient's labile hypertension are not well understood. It is possible that the patient had prolonged washout of clonidine used as an outpatient and early in his hospital course. Autonomic dysfunction in this patient s/p CVA is also possible. A final explanation - though far less likely - is a pheochromocytoma. Of note, the patient was found to have an anterior right kidney pole echogenicity. The patient is likely unable to tolerate MRI for further evaluation of this mass. Instead plasma free metanephrins were sent and are pending at the time of discharge. The patient's PCP should [**Name9 (PRE) 702**] on the result of this test. . The patient also developed acute renal failure while in the hospital. This was likely secondary to episodes of hypotension and a pre-renal etiology. The patient's creatinine was trending down (1.8 at discharge down from a peak of 2.2 compared with 0.5 on admission). He underwent a renal ultrasound revealing no hydronephrosis or stones. Of note he was found to have a renal mass as described above. The patient is not likely to tolerate an MRI for further evaluation and plasma free metanephrins are pending for work-up of possible pheochromocytoma. . The patient had persistent nausea and emesis while in the hospital. This is likely as at the patient's baseline. He underwent a nuclear gastric motility study revealing no delay in gastric emptying but signs of delayed esophageal clearance. He was evaluated by the speech and swallow team and was felt to be able to tolerate a pureed diet with nectar thickened liquids. He should be monitored 1:1 when eating or drinking. The patient's PCP may choose to do further GI evaluation including esophogram and/or upper GI studies for further evaluation. . The patient suffers from chronic pain secondary to contractures as a result of prior CVA. The patient will continue on a fentanyl patch (the dosing of which was reduced inthe setting of renal failure and could be titrated back up after documented resolution of this renal impairment), gabapentin and baclofen. Lidocaine patches were added to the patient's focal complaints of knee pain with good effect. Medications on Admission: - Isosorbide Mononitrate 30 mg PO DAILY - Fentanyl 100 mcg/hr Patch Q72H - Clopidogrel 75 mg PO DAILY - Choline & Magnesium Salicylate 750 mg PO TID - Tizanidine 4 mg PO TID - Baclofen 10 mg PO TID - Citalopram 30 mg PO DAILY - Hexavitamin PO DAILY - Senna 8.6 mg PO BID - Gabapentin 300 mg PO three times a day. - Acetaminophen 1000 mg PO Q 8H - Docusate Sodium 100 PO BID - Calcium Carbonate 500 mg PO TID - Oxycodone 5 mg Sig: 1 Tablet PO Q4-6H as needed for pain. - Cholecalciferol (Vitamin D3) 800 unit PO DAILY - Trazodone 25 mg PO HS - Clonidine 0.1 mg po daily - Lactulose (30) ML PO BID - Lisinopril 5 mg PO DAILY - Atenolol 12.5 mg PO DAILY - Nitroglycerin 0.3 mg Tablet, Sublingual as needed for chest pain. - Rocephin 1 gm IM q am (day 1 [**2196-5-17**]) - oxycodone 5 mg tid - trazadone 25 mg q 8 hrs prn Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 50 mg/15 mL Syrup Sig: One Hundred (100) mg PO BID (2 times a day). 5. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 6. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to the knees for pain. Adhesive Patch, Medicated(s) 8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 12. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Pneumonia Atrial Fibrillation Labile hypertension Acute renal failure Discharge Condition: Stable Discharge Instructions: You were admitted with fevers due to pneumonia. You completed a course of antibiotics for this problem. . In addition you were found to have episodes of arrhythmia and widely fluctuant blood pressure. You must take metoprolol three times a day for this problem. Follow-up with Dr. [**Last Name (STitle) 53939**] for further evaluation of your fluctuant blood pressure. A blood test (plasma free metanephrins) is currently pending and must be followed up with Dr. [**Last Name (STitle) 53939**]. . Your kidney function declined likely due to episodes of low blood pressure but improved prior to discharge. You must follow-up with Dr. [**Last Name (STitle) 53939**] for monitoring of your kidney function. Have your blood drawn at your follow-up appointment with Dr. [**Last Name (STitle) 53939**] for monitoring of your kidney function. . Call your doctor or return to the hospital for any new or worsening dizziness, lightheadedness, chest pain or new weakness or altered sensation. Followup Instructions: Dr. [**Last Name (STitle) 53939**] ([**Telephone/Fax (1) **]) will call Roscommon to schedule a follow-up appointment. You must have your blood drawn at this follow-up appointment to monitor your kidney function. Please make sure that Dr. [**Last Name (STitle) 53939**] [**Name (STitle) 70968**] on a blood test (plasma free metanephrins) that is still pending for further evaluation of your fluctuant blood pressure.

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13375, 13411

7596, 11184

322, 329

13525, 13534

4411, 7573

14565, 14986

3104, 3108

12052, 13352

13432, 13504

11210, 12029

13558, 14542

3967, 4392

3123, 3871

276, 284

357, 2541

3886, 3950

2563, 2812

2828, 3088

15,316

111,000

16862

Discharge summary

report

Admission Date: [**2114-11-24**] Discharge Date: [**2114-12-1**] Service: [**Location (un) **] Medicine CHIEF COMPLAINT: Fatigue. HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] was transferred to the Medicine Service from the Medical Intensive Care Unit. An 84-year-old female admitted to [**Hospital1 190**] MICU [**2114-11-24**] after being found by VNA on [**2114-11-21**] being somnolent, fatigued, and lightheaded when standing. The patient denied any melena, bright red blood per rectum, hematemesis, hemoptysis, hematuria, abdominal pain. She was found to have an elevated BUN-creatinine ratio and hematocrit of 19 with her baseline of 30, and the patient was taken to [**Hospital6 27253**], where she had guaiac positive brown stool, and nasogastric lavage was negative. The patient was subsequently transferred to [**Hospital1 346**] for further management. Upon arrival to [**Hospital1 69**], she was hemodynamically stable, in-fact somewhat hypertensive. She was guaiac negative at [**Hospital1 69**]. In the MICU, she was transfused 2 units of packed red blood cells with an appropriate hematocrit increase to 24. She required 40 mg of intravenous Lasix between the units of blood for some mild congestive heart failure. Her resting heart rate was in the 40s, so her beta blocker was held, and hydralazine was titrated up for blood pressure control. Her Coumadin was held as well, and INR allowed to drift down. She remained hemodynamically stable for 24 hours, and was transferred to the Medical floor for further management. PAST MEDICAL HISTORY: 1. Stroke in [**2114-9-28**] with residual left sided weakness. 2. History of two transient ischemic attacks. 3. Coronary artery disease with nonST segment elevation myocardial infarction at [**Hospital 4415**] three years ago, no intervention. 4. History of congestive heart failure. 5. Non-insulin dependent-diabetes mellitus. 6. Anemia on Procrit, baseline hematocrit on 30. Has had esophagogastroduodenoscopy and colonoscopy showing Barrett's esophagus. 7. Chronic renal insufficiency, baseline creatinine of 2.0. 8. Hypothyroidism. 9. Hypertension. 10. PMR. 11. Atrial fibrillation. 12. History of ARDS. ALLERGIES: Penicillin and sulfa. OUTPATIENT MEDICATIONS: 1. Glipizide 5 mg q am, 2.5 q pm. 2. Cozaar 100 mg po q day. 3. Aspirin 81 mg po q day. 4. Isordil 10 sublingual qid. 5. Sublingual nitroglycerin prn. 6. Hydralazine 50 mg qid. 7. Protonix 40 mg po q day. 8. Levoxyl 100 mcg po q day. 9. Lipitor 10 mg po q day. 10. Nitropatch 0.6 mg transdermal on for 12 hours q day. 11. Cardura 4 mg po q day. 12. Atenolol 25 mg po q day. 13. Lasix 80 mg po q day. 14. Coumadin q day. MEDICATIONS UPON TRANSFER FROM THE MICU: 1. Cozaar 100 mg po q day. 2. Levoxyl 100 mg po q day. 3. Lipitor 10 mg po q day. 4. Doxazosin 4 mg po q day. 5. Protonix 40 mg po q day. 6. Lasix 80 mg po q day. 7. Hydralazine 75 mg po qid. 8. Regular insulin-sliding scale. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: No tobacco, no alcohol, recently widowed. Home with VNA. Health-care proxy is daughter, [**Name (NI) **], whose phone number is [**Telephone/Fax (1) 47514**]. EXAM ON TRANSFER: Vital signs: Temperature is 98.6, heart rate 51, blood pressure 160/21, and 99% on 2 liters oxygen. General: Elderly female in no acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation, normocephalic, atraumatic. Mucous membranes dry. Clear oropharynx. Neck is supple, no jugular venous distention, no lymphadenopathy, normal carotid upstrokes. Chest: Faint crackles on left, no wheezes. Heart regular rate, S1, S2 normal, no murmurs, rubs, or gallops. Abdomen is soft, nontender, nondistended, positive bowel sounds, no hepatosplenomegaly. Extremities: Multiple ecchymoses, no clubbing, cyanosis, or edema. Neurologic: Alert and oriented times three, 5/5 strength bilateral upper extremities and lower extremities. Cranial nerves II through XII intact. Nonfocal examination. LABORATORIES ON TRANSFER: White blood cell count 9.3, hematocrit 24.6 up from 19 after 2 units of blood, platelets 302. Sodium 132, potassium 4.0, chloride 103, bicarb 21, BUN 130, creatinine 1.7, platelets 175. ALT 13, AST 13, LDH 168, alkaline phosphatase 60, amylase 55, total bilirubin 0.4, lipase 42, albumin 2.5, calcium 8.3, magnesium 1.9, phosphorus 5.4, reticulocyte count 0.8. HOSPITAL COURSE: This is an 84-year-old female with multiple medical problems admitted with increased fatigue and found to have a hematocrit of 19 down from her baseline 30 with guaiac-positive stool and negative nasogastric lavage at an outside hospital. She was initially admitted to the MICU, and subsequently transferred to the floor. 1. Gastrointestinal bleed: Initially, there was a question of whether or not this patient had a GI bleed with a guaiac positive stool at an outside hospital, but no history of frank melena or hematemesis, and her most recent stool guaiac negative. The patient was transfused again when she got to the floor, two more units to have her hematocrit above 30 with her history of coronary artery disease, the next day it was noted that her hematocrit had dropped from 32 to 25, and that she did pass a large melanotic stool. At this time, she again was transfused above 30 and did maintain at this level throughout the rest of her hospitalization. She had an esophagogastroduodenoscopy done at that time which did not show any active bleeding from her stomach or proximal duodenum. It did show duodenal diverticulosis. The patient did have a past history of a Dieulafoy's lesion in the past as seen by her outside hospital medical records, this was not seen during her esophagogastroduodenoscopy during this visit. It was thought that most likely her bleed was from a diverticulum in the setting of patient having a high INR. Her INR on transfer to the floor from the MICU was 3.2 after having her Coumadin held. Coumadin was held for the next few days with no drop in her INR. In-fact, it increased to 3.9 over the next three days. This was thought secondary to poor nutritional status. In the setting of her hematocrit dropped and melanotic stools seen on the floor, her anticoagulation was reversed with vitamin K and 2 units of fresh-frozen plasma. Her hematocrit remained stable for the remainder of the hospitalization after reversal of her anticoagulation. 2. Cardiovascular: 1. Coronary artery disease: The patient does have a history of coronary artery disease with a nonST segment elevation myocardial infarction three years ago. She did not have any symptoms of angina during this hospitalization. She was maintained on her antihypertensives which were increased with her refractory hypertension. 2. Pump: An echocardiogram was obtained on Ms. [**Known lastname **] in order to evaluate her wide pulse pressures for the question of aortic insufficiency, although she did not have a murmur. This study showed a normal systolic function and normal valves with only 1+ aortic regurgitation and 1+ mitral regurgitation. There was a dilated left atrium and severe pulmonary hypertension. It was thought that this pulmonary hypertension might be secondary to the patient being in some congestive heart failure after receiving blood transfusions. 3. Rhythm: The patient has a history of atrial fibrillation and in the setting of her Lopressor being held for prolonged P-R and bradycardia to the 40s, she did develop one episode of rapid ventricular response, atrial fibrillation to the 120s. She was restarted on her Lopressor at this time, and had a controlled rate. She had no other episodes of rapid atrial fibrillation after this. 4. Hypertension: Ms. [**Known lastname **] continued to have severe hypertension with systolic blood pressures in the 190s-low 200s during her stay here. This was despite increase of her Hydralazine to 100 qid, restarting of the Lopressor. Continuation of her Cozaar 100 q day and starting the patient on amlodipine. Her nitropatch, which had been held on admission in the setting of bleed was also restarted and her blood pressure still remained in the high 180s to 190s. Ms. [**Known lastname **] did have abdominal bruits, and there is a question whether she may have renal artery stenosis by her examination in the hospital. I am unsure if she has had already a workup for secondary causes of hypertension. 3. Heme: Ms. [**Known lastname **] had been admitted while on anticoagulation for her atrial fibrillation and history of a recent stroke. In the setting of anticoagulation, she did have a gastrointestinal bleed, likely from diverticulosis. Her anticoagulation was reversed in this setting, and she was not discharged on Coumadin. I will defer to her primary care physician for question of restarting anticoagulation. She does have a baseline anemia of chronic disease. Iron studies showed an iron of 75 which is normal, a total iron binding capacity of 221 which is low. Vitamin B12 of 253, a folate of 8.6, ferritin of 124. Haptoglobin and other hemolysis laboratories are also normal. Question whether her anemia may be related to her chronic renal insufficiency. 4. ID: Ms. [**Known lastname **] did have an elevated white blood cell count during this hospitalization of 15,000. Urinalysis showed 20 white blood cells with no squamous, epi's, and no red blood cells, and she was thought to have a urinary tract infection in the setting of recent catheterization. She was given a course of Levaquin for this. 5. Endocrine: The patient has a history of diabetes mellitus and was maintained on Glipizide and insulin-sliding scale during this hospitalization. She was continued on Levoxyl for her hypothyroidism. 6. Renal: Her BUN which was very highly elevated in the setting of gastrointestinal bleed began to trend down after her hematocrit became stable. At the time of discharge, her BUN was 69 down from 131 on admission. Code: The patient was DNR/DNI status. DISPOSITION: Home with [**Hospital6 **]. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed likely diverticular. 2. Pulmonary hypertension. 3. Urinary tract infection. 4. Congestive heart failure. 5. Atrial fibrillation. 6. Diabetes mellitus. 7. Hypothyroidism. 8. Anemia. DISCHARGE MEDICATIONS: 1. Glipizide 5 mg q am, 2.5 mg po q pm. 2. Nitroglycerin patch 0.6 mg/hour q am on for six hours, off for six hours. 3. Amlodipine 10 mg po q hs. 4. Levofloxacin 250 mg po qod for seven days. 5. Magnesium oxide 400 mg po bid. 6. Metoprolol 25 mg po bid. 7. Hydralazine 100 mg po qid. 8. Pantoprazole 40 mg po q day. 9. Colace and Senokot. 10. Erythropoietin 3,000 units q week. 11. Influenza virus vaccine x1. 12. Multivitamin one po q day. 13. Losartan 100 mg po q day. 14. Aspirin 81 q day. 15. Levoxyl 100 mcg po q day. 16. Lipitor 10 mg po q day. Discharged to home with services. DISCHARGE CONDITION: Good. FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 47515**] at [**Hospital **] Medical. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8859**], M.D. [**MD Number(1) 4728**] Dictated By:[**Last Name (NamePattern1) 9352**] MEDQUIST36 D: [**2114-12-10**] 15:07 T: [**2114-12-13**] 10:14 JOB#: [**Job Number 47516**] cc:[**Numeric Identifier 47517**]

[ "562.12", "438.20", "416.8", "401.9", "281.9", "250.00", "427.31", "428.0", "593.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

10908, 10915

2967, 2985

10068, 10276

10299, 10886

4416, 10047

2261, 2950

132, 142

171, 1569

10940, 11377

1591, 2237

3002, 4398

56,307

103,947

50932

Discharge summary

report

Admission Date: [**2203-11-18**] Discharge Date: [**2203-12-3**] Date of Birth: [**2143-10-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1242**] Chief Complaint: 1. Hyperglycemia 2. Hypothermia Major Surgical or Invasive Procedure: Intubation Dialysis Endoscopy History of Present Illness: 60F w seizure hx and diabetes was found down today in fetal position and brought to ED by EMS. She was noted to be hypothermic and hyperglycemic. Unclear how long she was down. There was no evidence of trauma. In the ED, she was found to have blood in her mouth, she was intubated for airway protection and had a central line placed. She required phenylephrine briefly during intubation, but otherwise did not require any pressors. She was sedated with fent/midaz. Because of the blood in her mouth and OG was placed with return of coffee ground. She was started on a PPI gtt. Her initial serum glucose was 900 and she was started on an insulin drip. For her hypothermia she was given warm saline, warm air through the ED tube and a bear hugger. A CT scan was done which showed pancreatic stranding around the head and gallbladder sludge. AN ECG was note to have some QRS widening (120) comparred to prior (100) Upon review of previous notes in OMR, the patient intermitantly threatens noncompliance with her insulin therapy and has a length history of impulse control problems, for which she sees psychiatry. Seizure disorder history is unclear and unproven, but was prescribed Tegretol. Most recent HbA1c was 7.9. Her last note indicates that she did agree to taking all of her prescribed medications, including her Tegretol and insulin. She inappropriately and frequently calls her providers and it has been difficult in the past to get her to agree to medications that will control her chronic issues, with threatened section 12's to get her into the hospital for appropriate treatment. Past Medical History: - Mild mental retardation - DM, onset age 51 (poorly controlled, does not check FS; A1c [**10-18**] 9.7%) - neuropathy - dysphagia - hx of [**Doctor Last Name **] with spontaneous remission - PVD, angioplasty of R femoral in [**2198**] - Seizure disorder (per pt focal, partial) - Lower Back pain s/p fall, followed in chronic pain clinic - posterior mediastinal mass since [**2182**], stable (likely neurofibroma). - Hyperlipidemia - Urinary Incontinance - Pneumonia ([**2198**]) - ? gastroparesis- normal gastric emptying, no reflux in [**1-/2200**] Endoscopy with ? [**Last Name (un) **]; biopsy negative. . Surgical History - Angioplasty as above ([**2198**]) - Appendectomy . Psychiatric History: Patient reports growing up in state care. She has a history of an impulse control disorder. She reports that she is not currently not seeing any psychiatrists. She has discontinued her use of amitriptyline. Social History: The patient lives alone. She is disabled and on [**Social Security Number 105858**]social security. DMR caseworker [**Doctor First Name **] (Phone #[**Telephone/Fax (1) 105853**]) . Sister [**Name (NI) 717**] [**Telephone/Fax (1) 105854**]. Gets Home services from [**Location (un) 1465**] Elder Services through Case Worker [**Doctor First Name **] [**Telephone/Fax (1) 105855**] Tobacco: Smoker since the age of 3, 2 packs per day. Quit [**2198**] Etoh/Drugs: None Family History: Ovarian Cancer, Diabetes in mother and grandmother Physical Exam: On Admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: [**2203-11-19**] 04:00PM BLOOD WBC-11.7* RBC-4.07* Hgb-12.0 Hct-33.0* MCV-81* MCH-29.4 MCHC-36.3* RDW-14.0 Plt Ct-137* [**2203-11-19**] 03:58AM BLOOD WBC-9.9# RBC-4.51 Hgb-13.0 Hct-37.9 MCV-84 MCH-28.8 MCHC-34.4 RDW-13.4 Plt Ct-156 [**2203-11-18**] 09:15PM BLOOD WBC-26.6* RBC-4.61 Hgb-13.3 Hct-40.6 MCV-88 MCH-28.7 MCHC-32.7 RDW-13.1 Plt Ct-249 [**2203-11-18**] 12:44PM BLOOD WBC-30.0* RBC-4.88 Hgb-14.6 Hct-46.0 MCV-94 MCH-29.9 MCHC-31.7 RDW-12.6 Plt Ct-236 [**2203-11-18**] 09:15PM BLOOD Neuts-83* Bands-2 Lymphs-11* Monos-1* Eos-0 Baso-2 Atyps-0 Metas-1* Myelos-0 [**2203-11-19**] 04:00PM BLOOD Plt Ct-137* [**2203-11-19**] 03:58AM BLOOD Plt Ct-156 [**2203-11-19**] 03:58AM BLOOD PT-10.5 PTT-29.6 INR(PT)-1.0 [**2203-11-18**] 12:44PM BLOOD PT-10.1 PTT-30.8 INR(PT)-0.9 [**2203-11-19**] 03:58AM BLOOD Fibrino-158* [**2203-11-19**] 04:00PM BLOOD Glucose-124* UreaN-38* Creat-2.6* Na-142 K-4.0 Cl-111* HCO3-16* AnGap-19 [**2203-11-19**] 10:30AM BLOOD Glucose-316* UreaN-38* Creat-2.5* Na-141 K-3.5 Cl-113* HCO3-16* AnGap-16 [**2203-11-19**] 07:22AM BLOOD Glucose-274* UreaN-40* Creat-2.4* Na-141 K-4.1 Cl-116* HCO3-12* AnGap-17 [**2203-11-19**] 03:58AM BLOOD Glucose-249* UreaN-42* Creat-2.4* Na-142 K-3.6 Cl-117* HCO3-9* AnGap-20 [**2203-11-19**] 12:19AM BLOOD Glucose-357* UreaN-42* Creat-2.4* Na-143 K-4.0 Cl-115* HCO3-8* AnGap-24* [**2203-11-18**] 12:44PM BLOOD Glucose-900* UreaN-48* Creat-2.2* Na-133 K-5.3* Cl-93* HCO3-LESS THAN [**2203-11-19**] 10:30AM BLOOD ALT-29 AST-49* LD(LDH)-242 AlkPhos-80 TotBili-0.3 [**2203-11-19**] 03:58AM BLOOD ALT-30 AST-52* LD(LDH)-256* AlkPhos-109* TotBili-0.3 [**2203-11-19**] 12:19AM BLOOD LD(LDH)-253* CK(CPK)-378* [**2203-11-18**] 07:00PM BLOOD ALT-28 AST-58* LD(LDH)-299* CK(CPK)-461* AlkPhos-153* TotBili-0.4 [**2203-11-18**] 12:44PM BLOOD CK(CPK)-381* [**2203-11-19**] 04:00PM BLOOD Calcium-8.0* Phos-2.8# Mg-1.9 [**2203-11-19**] 10:30AM BLOOD Calcium-6.9* Phos-0.4* Mg-2.2 [**2203-11-19**] 07:22AM BLOOD Calcium-7.1* Phos-1.1* Mg-2.4 [**2203-11-19**] 12:19AM BLOOD Triglyc-272* [**2203-11-19**] 12:19AM BLOOD Osmolal-337* [**2203-11-19**] 12:19AM BLOOD TSH-1.6 [**2203-11-19**] 12:07PM BLOOD Cortsol-77.3* [**2203-11-19**] 11:35AM BLOOD Cortsol-79.7* [**2203-11-19**] 10:30AM BLOOD Cortsol-83.2* [**2203-11-19**] 03:58AM BLOOD Cortsol-91.7* [**2203-11-19**] 10:30AM BLOOD Carbamz-1.8* [**2203-11-18**] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2203-11-19**] 04:15PM BLOOD Type-ART Temp-38.8 Rates-26/6 Tidal V-500 PEEP-8 FiO2-50 pO2-74* pCO2-29* pH-7.36 calTCO2-17* Base XS--7 Intubat-INTUBATED Vent-CONTROLLED Studies: . [**11-18**] CT Spine - IMPRESSION: 1. No acute fracture or subluxation of the cervical spine. Moderate narrowing of the central canal at C5-6 is noted, and if there are myelopathic symptoms, these could be better evaluated with MRI. 2. Soft tissue within pharynx and hypopharynx consistent with history of hemorrhage. A mucosal or submucosal pharyngeal/hypopharyngeal mass is not excluded, which could be clarified by direct visualization. 3. Intubated patient, with the tip of endotracheal tube projecting 1 cm from the level of the carina, this should be withdrawn for appropriate positioning vs re-evaluated with chest radiograph. . [**11-18**] CT Head - IMPRESSION: 1. No acute intracranial injury. There is stable age-appropriate atrophy. 2. Air-fluid levels within multiple paranasal sinuses. . [**11-18**] CT Abdomen/Pelvis - IMPRESSION: 1. Stranding of the retroperitoneal fat in the region of the pancreatic head, second and third portions of the duodenum, extending to the region of the gallbladder fossa. Differential diagnosis includes gallbladder pathology, pancreatitis, and duodenitis, which might be clarified with laboratory analysis. 2. Bibasilar atelectasis. A well-circumscribed stable mass is seen in the left paraspinal location, benign. . [**11-19**] ECHO - IMPRESSION: Mild symmetric left ventricular hypertrophy with normal regional and global systolic function. Mild right ventricular cavity enlargement with low normal free wall motion. Increased PCWP. . [**12-1**] Endoscopy - Impression: (dilation, biopsy) Abnormal mucosa in the lower third of the esophagus (biopsy) Blood in the fundus Polyp in the fundus (polypectomy)Granularity and friability with shallow ulceration in the duodenal bulb (biopsy)Medium hiatal hernia Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 60F with lengthy psychiatric history with impulse control and difficult to control t2DM, now presenting with hypothermia, extreme hyperglycemia, and severe metabolic acidosis. . # Severe metabolic acidosis: The patient was found down prior to admission with markedly elevated serum glucose (900). pH on admission was 6.84 with a minimal osmolar gap. With mild ketones in the urine and an undetectable bicarbonate level in the serum, this appeared to be a combination of a hyperglycemic hyperosmolar state and a diabetic ketoacidosis. However, it was felt that even with both of these processes at play, they likely still could not explain the degree of acidosis. Initial thought was given to emergent dialysis, but the acidosis corrected with fluid boluses of D5-1/2NS + 3 amps of bicarbonate. She was also aggressively volume resuscitated for what was presumed to be extreme hypovolemia and kept on an insulin gtt, with refractory glucoses requiring a gtt to up to 40 units per hour. Toxicology screens and cultures were unrevealing in finding a cause for her extreme acidosis. # Respiratory failure: She was intubated in the setting of hypothermia and visible blood in the nares. Intubation was done mostly for airway protection. Due to persistent respiratory alkalosis, occasional difficulty with oxygenations, and volume overload after fluid resuscitation, she was slow to be extubated. She was covered broadly for pulmonary processes. Her dead space fraction was calculated at 68%. Sputum cultures grew out MRSA. To address the anxiety component of extubation and her home dosing of clonazepam TID, she was started on dexmedetomidine (Precedex) to help transition to her home benzodiazepines. Upon fluid mobilization s/p CVVH and anxiety control, she was extubated successfully after 1 week and continued to do quite well, with a slow improvement in her O2 dependence. # Septic shock: Complicated by hypothermia, hyperglycemia, and acidosis. Initially found to be hypothermic and covered broadly for sepsis with antibiotics and administered warm NS and Bair hugger, resulting in improving temperatures within days of admission. When her first course of antibiotics was nearly complete, her CXRs began to show suspicious findings for developing infiltrates, prompting a switch in her antibiotic course (Vanc/Zosyn --> Vanc/Cefepime). We also covered for ?C. difficile with Flagyl and PO Vancomycin, but toxins were negative and this course was stopped a few days later. Her pressor requirement was slowly weaned as her fluid was mobilized >1 week into her hospitalization. Her leukocytosis has waxed and waned, with peak on admission of 30 and a nadir of 5.5. # Acute kidney injury: The first few days of her admission saw an acute rise in her creatinine from baseline and oliguria to anuria. The Renal service was consulted and spun the urine, noting some muddy brown casts consistent with ATN. Given her poor urine output, minimally responsive to furosemide, and her continued respiratory requirements, a femoral dialysis line was placed (C-collar was still in place, preventing IJ placement) and she was started on CVVH. Volume was aggressively ultrafiltrated with the goal of extubation. She continued to have oliguria and was given a brief dialysis holiday while her femoral line was pulled. Though she continued to be responsive to furosemide and may have some residual kidney function, it is still too soon to predict if her renal function will return to her prior baseline. The patient was transferred to the floor where a temporary dialysis line was placed. She went for HD once with removal of fluid. The patient's Cr continued to rise on the subsequent days as did her UOP. Given rising UOP, further dialysis was held until Cr peaked on [**2203-12-1**]. The temporary dialysis line was removed on [**2203-12-2**] and the patient will follow-up with nephrology for further evaluation. # Glucose control: Inciting event leading to severe hyperglycemia unclear. After her initial insulin resistance with high-dose insulin drip, her blood glucose seemed to be better controlled with close monitoring. Prior to her discharge from the ICU, she had been started on an insulin regimen closely resembling her home regimen with resulting hypoglycemia with minimal symptoms. Her insulin regimen was adjusted such that she was placed on long acting with sliding scale only. This worked well until the patient began to eat normally on the medicine floor. At that time her insulin dose was steadily adjusted upwards towards her home dosing. She will be discharged on her pre-admission dose as she is eating well and her kidney function is improving. # Dysphagia - The patient has a long history of dysphagia. Prior to this admission, plan had been for EGD. While the patient was here and EGD was done. Expected strictures were not seen although there was abnormal mucosa in the lower third of the esophagus, blood in the fundus, polyp in the fundus and granularity and friability with shallow ulceration in the duodenal bulb. The patient was dilated. PPI uptitrated. Following this procedure the patient reported being able to eat very well. Diet returned to baseline. # ?unstable neck: [**Location (un) 2848**] J-collar was initially in place until the patient was extubated and able to verbalize her lack of pain was palpation of the C-spine. She was radiographically cleared within a day or two of admission, but the collar was finally removed after she was extubated >1 week later. # Coffee grounds from OG tube: Likely epistaxis or facial trauma given blood seen on nares. GI bleed was treated initially with IV PPI [**Hospital1 **], but this was felt to be less likely and hematocrit were trended and stable. She did not require any transfusion. # CT findings - Pancreatic stranding and gallbladder sludge: Non-specific finding with normal lipase. ?relation to dehydration and initial hyperglycemia. Unclear if other ingestions such as alcohol were related to the inciting event. # ?Seizure disorder: EEG negative. She was continued on her home AEDs (carbamazepine) with therapeutic levels on admission. # Goals of care / HCP proxy information: She has a confusing chain of important people in her life that help her with medical decision making. She is a FULL code and relies on her friend [**Name (NI) 11894**] [**Name (NI) 105858**] (cell # [**Telephone/Fax (1) 105859**] - former case worker, now good friend) and her sister for assistance. Both have been heavily involved in her care. Her health care is mostly coordinated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (NP) and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (MD), who follows her closely. # Transitional Issues: 1) Continue to actively encourage good glucose control 2) No need for HD. Will follow-up with renal 3) Follow-up on results of Bx from EGD Medications on Admission: CARBAMAZEPINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day CLONAZEPAM 0.5mg TID GABAPENTIN 200mg [**Hospital1 **] INSULIN ASPART [NOVOLOG FLEXPEN] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 100 unit/mL Insulin Pen - 12 units with meals three times a day INSULIN DETEMIR [LEVEMIR FLEXPEN] - 100 unit/mL (3 mL) Insulin Pen - 24 units sq qam - No Substitution LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - one patch qd 12 hours on and 12 hours off prn back pain LORATADINE - 10 mg daily MELOXICAM - 7.5 mg [**Hospital1 **] OMEPRAZOLE [PRILOSEC] - 20 mg daily SIMVASTATIN [ZOCOR] - 40 mg daily TRAZODONE - 50 mg qhs PRN insomnia Medications - OTC CARBAMIDE PEROXIDE - 6.5 % Drops - 4 drops left ear twice a day for ear wax blockage GLUCERNA - Liquid - 1 can by mouth twice a day Discharge Medications: 1. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**12-12**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO twice a day. 8. insulin aspart 100 unit/mL Solution Sig: Twelve (12) Units Subcutaneous With Meals. 9. insulin detemir 100 unit/mL Solution Sig: Twenty Four (24) Units Subcutaneous once a day. 10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day: Apply to back . 11. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. meloxicam 7.5 mg Tablet Sig: One (1) Tablet PO twice a day. 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 16. Carbamoxide Ear Drops 6.5 % Drops Sig: Four (4) Drops Otic twice a day as needed for ear blockage. 17. Glucerna Liquid Sig: One (1) Can PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] hospital for Continuing Medical Care Discharge Diagnosis: Diabetic coma, renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]! You initially came to this hospital severely ill in a diabetic coma. You were in the intensive care unit for over a week. In the hospital we have treated your diabetic coma and a number of associated complications. You are now ready for discharge to a rehabilitation facility See below for changes to your home medication regimen: 1) Please INCREASE Omeprazole dosing to 40mg twice daily Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2203-12-13**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105860**] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2203-12-20**] at 10:00 AM With: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], NP [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2203-12-27**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105860**] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Nephrology With: Dr. [**Last Name (STitle) 4090**] When: [**2203-1-5**] at 1:00pm

[ "443.9", "518.81", "300.00", "584.5", "991.6", "317", "211.1", "276.69", "287.5", "997.31", "345.50", "250.22", "482.42", "507.0", "V15.81", "276.3", "312.30", "995.92", "272.4", "250.12", "785.52", "787.20", "038.9", "348.31" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "38.93", "38.91", "42.92", "39.95", "96.72", "43.41", "38.95", "45.16" ]

icd9pcs

[ [ [] ] ]

17844, 17923

8578, 15338

338, 370

17995, 17995

4134, 8555

18652, 19726

3439, 3491

16370, 17821

17944, 17974

15527, 16347

18178, 18629

3506, 3506

267, 300

398, 2004

3520, 4115

18010, 18154

15361, 15501

2026, 2938

2954, 3423

16,636

154,814

43642

Discharge summary

report

Admission Date: [**2109-3-2**] Discharge Date: [**2109-3-12**] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female with a history of type 2 diabetes mellitus and hypertension who presented to [**Hospital6 2018**] on [**2109-2-9**] with unstable angina. She was found to have an acute myocardial infarction and underwent coronary artery bypass grafting x5. The patient was doing well postoperatively and was discharged to [**Hospital **] [**Hospital **] Hospital. During her rehabilitation course, she had a left pleural effusion and was tapped for serosanguinous fluid. The patient had a forceful cough on the day of admission which caused dehiscence of her lower sternotomy wound. The patient was transferred to [**Hospital6 1760**] for further management. PAST MEDICAL HISTORY: Type 2 diabetes mellitus, hypertension, degenerative joint disease and hearing impairment. PAST SURGICAL HISTORY: Bilateral total knee replacement, bilateral cataracts, melanoma resection of back, colon surgery for internal hernia and the cardiac surgery stated above. ALLERGIES: The patient has an allergy to Codeine. MEDICATIONS: Duragesic patch 50 mcg, Lasix 80 mg p.o. b.i.d., Lisinopril 5 mg p.o. q day, vitamin E 400 iu p.o. q day, calcium 1000 mg q day, Lopressor 25 mg b.i.d., Plavix 75 mg q day, Nortriptyline 10 mg q h.s., aspirin 325 mg q day, Metformin 1000 mg p.o. q day, Glynase 30 mg p.o. b.i.d., Dilaudid 2-6 mg p.o. q4 hours p.r.n., Percocet 1-2 tablets p.o. q4 hours p.r.n., Robitussin 2 tsp q3 hours p.r.n., Vancomycin 1 gram given prior to transfer to the hospital. PHYSICAL EXAMINATION: The patient was afebrile with stable vital signs. The distal 3 cm aspect of the sternotomy wound was dehisced with exposure of the pericardial fat. Lungs were clear to auscultation. Heart revealed normal S1 and S2. HOSPITAL COURSE: The patient underwent partial sternal debridement, sternal re-wiring and a pectoral flap on [**2109-3-3**]. The patient was noted to have a pleural effusion which was not resolving with two chest tubes, and Thoracic Surgery was then consulted. The patient underwent a VATS procedure with decortication. General Surgery was also consulted on postoperative day #1 for a question of bowel obstruction due to her distended abdomen. KUB showed a dilated colon. The decision was made to treat conservatively, and the situation resolved via physical examination. The patient underwent episodes of atrial fibrillation with periods of block. The patient was evaluated by EPS who suggested some medication changes and a need for [**Doctor Last Name **] of Hearts monitor on discharge with daily strips to be sent to Dr. [**Last Name (STitle) **] for two weeks after discharge with follow up with Dr. [**Last Name (STitle) **]. On postoperative day #8, the patient was felt to be ready for discharge to a rehabilitation facility as the patient was afebrile with vital signs stable. She was tolerating a regular diet, ambulating and passing flatus. DISCHARGE STATUS: Stable. DISPOSITION: To rehabilitation facility. DISCHARGE DIAGNOSIS: Status post sternal re-wiring, partial sternal debridement and pectoral flap. FO[**Last Name (STitle) 996**]P: With Dr. [**Last Name (Prefixes) **] and Dr. [**Last Name (STitle) **] as an outpatient. The patient will be going home on Amiodarone 400 mg p.o. b.i.d., Lasix 40 mg p.o. b.i.d., potassium chloride 20 mEq p.o. b.i.d., Percocet 1-2 tablets p.o. q4 hours p.r.n., Levofloxacin 250 mg p.o. q day x7 days, Ranitidine 150 mg p.o. q day, Plavix 75 mg p.o. q day, Captopril 12.5 mg p.o. t.i.d., Nortriptyline 10 mg p.o. q h.s., Tylenol 650 mg p.o. q4 hours p.r.n., milk of magnesia 30 ml p.o. q h.s. p.r.n. constipation, Colace 100 mg p.o. b.i.d., aspirin 325 mg p.o. q day, Metformin 1000 mg p.o. q day and Glynase 3 mg p.o. b.i.d. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 5915**] MEDQUIST36 D: [**2109-3-12**] 09:54 T: [**2109-3-12**] 10:00 JOB#: [**Job Number 93839**] cc:[**Last Name (NamePattern4) **]

[ "512.1", "V45.81", "427.31", "511.9", "997.3", "997.4", "998.31", "414.01", "560.1" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.51", "34.21", "96.04", "96.09", "34.79", "77.61", "96.71" ]

icd9pcs

[ [ [] ] ]

3138, 4165

1898, 3116

961, 1638

1661, 1880

136, 822

845, 937

57,321

171,040

24168

Discharge summary

report

Admission Date: [**2133-8-12**] Discharge Date: [**2133-9-2**] Date of Birth: [**2080-7-23**] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**First Name3 (LF) 2736**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**First Name3 (LF) 61403**] ECMO RIJ History of Present Illness: Mr [**Known lastname 61404**] is a 53 year old with a PMH significant for DM, HTN, a-fib with LV thrombus on coumadin, PHTN and non-ischemic cardiomyopathy and CHF with an EF of 15% from [**2133-6-26**], s/p cath in [**8-/2132**] that showed 80% occlusion in RCA who presented to clinic today with 2 days of chest pain to [**3-7**] with associated cough but no shortness of breath. His pain was not associated with exertion as he has been pretty sedentary at home because of his condition. He has no energy and is unable to do much over the last few months. At his PCPs office, he was feeling unwell, with constant non-radiating chest pain that was centrally located and persistent. He had not taken any medications at the time of the appointment. Dr. [**First Name (STitle) **] checked an EKG that showed a rate of 138, that was interpreted as sinus tachycardia with no signs of ischemia. He was given a nitroglycerin tab, which resolved his chest pain, as well as a chewable aspirin. He was supposed to get 25mg of lopressor in the office, but Dr. [**First Name (STitle) **] was unsure if he got it prior to transfer. . On transfer to the ED, EMS was concerned for STEMI with ST elevations in lead V4 on transport, however, the initial EKG in the ED showed tachycardia with ST depressions in V6. Initial vitals were HR 133, BP 101/71, RR 28, SaO2 100% RA, T 96.5. His rate was in the 130s and EKGs showed possible a-flutter. He had persistent chest pain with nausea and vomiting in the ED. He was given 1 tab of nitro and lopressor 5mg IV x2. His SBP dropped to the 60's and he became unresponsive and pulseless, in PEA arrest. CPR was initiated, he recieved 2 mg of epinephrine, 1mg of atropine, 1 of bicarb, and then a bicarb drip was started. He was coded for 7 minutes. He was intubated and placed on dopamine and levophed drips and transferred to the CCU. Vitals post arrest on transfer were HR 84, BP 109/70, O2 Sat 97% TV 500, PEEP 5, RR 14, and Fi02 100%. . His lactate was elevated to 8.5 prior to the code, so the ED ordered a head CT which was negative, and a CT torso to look for possible infection. He was started on vanc/levo/cefepime in the ED. . In the ED labs showed an metabolic acidosis with an elevated lactate. Labs were also notable for a HCT drop (35->31), a supratherapeutic INR (7.4) and end organ ischemia with elevated transaminases and elevated creatinine. . On the floor he was intubated and sedated, on dopamine and levophed drips. A triple lumen RIJ was placed at the bedside. He was started on dobutamine in addition to dopa and levophed with a goal of transitioning the dopa to dobutamine. At the time his BP was 85/40, HR of 86, and being ventilated on AC 500/5/18/100% FiO2. He was started on cooling protocol. After the procedure he was being turned, became bradycardic to the 40's and pulses were lost. Chest compressions were iniated, he was given epinephrine and bicarb. He had blood in his endotracheal tube as well as his OG tube. Pulses returned, and he was maintaining pressures in the 120s. He became bradycardic a 2nd time and pulse was lost. CPR was initiated and he was started on an epinephrine drip. His pulse and pressure returned, and he was sent to the cath lab for tandem heart placement. . Review of systems positive for CP, cough, increased lethargy and decreased activity over the past few months, nausea and vomiting in the ED. . Past Medical History: Cardiac History: . Cardiac Catheterizaton [**9-5**] without interventions: A right dominant system with single vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD and LCx had mild luminal irregularities. The RCA was diffusely diseased with serial 20% stenoses and an 80% stenosis in the mid-vessel. The LAD and RCA had moderate calcifications in the proximal to mid-vessel. . ICD: Single-chamber [**Company 2267**] Teligen 100 ICD was placed [**9-5**] for primary prevention of sudden cardiac death from VT/VF. . Other Past History: 1. Nonischemic cardiomyopathy, EF 15% ([**2133-6-26**]), with history of LV thrombus on Coumadin. Dry Weight: 164 pounds 2. Hypertension 3. Diabetes 4. HLD 5. Hepatitis B 6. Question of Paroxysmal Atrial Fibrillation on Coumadin with bursts of SVT on pacer interrogation. 7. LV wall thrombis, completed treatment but coumadin continued likely due to PAF. Social History: He moved from [**Country 16225**] to the US and lives in [**Hospital1 392**] with his wife and son. [**Name (NI) **] is retired from the shipping industry. He formerly smoked one pack per day x30 years and quit when he began feeling unwell. Prior [**4-2**] shots of vodka daily. No other drugs or IVDU. Family History: His parents and siblings have type 2 diabetes and brother had CAD diagnosed at age 53. Physical Exam: PHYSICAL EXAM on Admission: VS: T 95, BP 89/55, HR 76, RR 16 on AC 500/5/16/100% GENERAL: middle aged male, intubated and sedated, not responding to commands. Blood in the OG, ET tubes. HEENT: NCAT. Sclera anicteric. Pupils 4mm sluggish, minimally reactive to 3.5mm NECK: unable to asses JVP. CARDIAC: normal rate, regular rhythm. No m/r/g. LUNGS: Rhonchorus, ventilated breath sounds, equal and bilateral. ABDOMEN: Soft, NTND. No HSM. EXTREMITIES: No c/c/e. A-line in left femoral artery. SKIN: Cool dry PULSES: thready 1+ radial, carotid and right femoral, 2+ left femoral . PHYSICAL EXAM on Discharge: CV: Normal S1 and S2 with S3. Ventricular Heave. No JVP. Peripheral Edema 2+ Res: Basilar Crackles. Pertinent Results: Labs: [**2133-8-12**] 12:00PM BLOOD WBC-8.4 RBC-4.67 Hgb-9.5* Hct-35.3* MCV-76* MCH-20.4* MCHC-27.0* RDW-19.4* Plt Ct-334 [**2133-8-12**] 04:18PM BLOOD WBC-18.3*# RBC-4.04* Hgb-8.8* Hct-31.4* MCV-78* MCH-21.7* MCHC-27.9* RDW-19.1* Plt Ct-301 [**2133-8-12**] 09:05PM BLOOD WBC-17.6* RBC-4.04* Hgb-9.6* Hct-32.6* MCV-81* MCH-23.8* MCHC-29.5* RDW-19.9* Plt Ct-202 [**2133-8-12**] 09:51PM BLOOD WBC-19.3* RBC-4.40* Hgb-10.5* Hct-36.5* MCV-83 MCH-23.7* MCHC-28.6* RDW-20.0* Plt Ct-173 [**2133-8-13**] 05:44AM BLOOD WBC-18.3* RBC-3.44* Hgb-8.4* Hct-25.9*# MCV-75*# MCH-24.3* MCHC-32.4# RDW-19.8* Plt Ct-118* [**2133-8-13**] 09:41AM BLOOD WBC-19.1* RBC-3.82* Hgb-9.3* Hct-29.2* MCV-76* MCH-24.2* MCHC-31.7 RDW-20.1* Plt Ct-135* [**2133-8-13**] 04:03PM BLOOD WBC-18.8* RBC-3.98* Hgb-10.2* Hct-29.8* MCV-75* MCH-25.7* MCHC-34.3 RDW-20.3* Plt Ct-116* [**2133-8-14**] 04:04AM BLOOD WBC-15.9* RBC-4.21* Hgb-10.8* Hct-32.0* MCV-76* MCH-25.7* MCHC-33.8 RDW-19.7* Plt Ct-72* . [**2133-8-12**] 12:00PM BLOOD Neuts-72.0* Lymphs-19.6 Monos-6.7 Eos-0.6 Baso-1.1 [**2133-8-12**] 04:18PM BLOOD Neuts-78.9* Lymphs-13.8* Monos-6.2 Eos-0.2 Baso-0.9 [**2133-8-12**] 09:51PM BLOOD Neuts-81* Bands-11* Lymphs-4* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1* [**2133-8-12**] 12:00PM BLOOD Plt Ct-334 . [**2133-8-12**] 12:00PM BLOOD PT-64.4* PTT-40.1* INR(PT)-7.4* [**2133-8-12**] 04:18PM BLOOD PT-34.3* PTT-43.2* INR(PT)-3.5* [**2133-8-12**] 04:18PM BLOOD Plt Ct-301 [**2133-8-12**] 09:51PM BLOOD Plt Smr-NORMAL Plt Ct-173 [**2133-8-13**] 05:44AM BLOOD PT-49.0* PTT-92.4* INR(PT)-5.3* [**2133-8-14**] 04:04AM BLOOD Plt Ct-72* [**2133-8-14**] 08:00AM BLOOD PT-30.0* PTT-45.8* INR(PT)-3.0* . [**2133-8-12**] 12:00PM BLOOD Fibrino-382 . [**2133-8-12**] 12:00PM BLOOD Glucose-193* UreaN-52* Creat-1.7* Na-135 K-5.1 Cl-100 HCO3-13* AnGap-27* [**2133-8-12**] 04:18PM BLOOD Glucose-126* UreaN-50* Creat-1.6* Na-135 K-8.0* Cl-102 HCO3-10* AnGap-31* [**2133-8-12**] 09:05PM BLOOD Glucose-210* UreaN-48* Creat-1.7* Na-138 K-7.4* Cl-100 HCO3-8* AnGap-37* [**2133-8-12**] 09:51PM BLOOD Glucose-376* UreaN-50* Creat-1.7* Na-142 K-4.7 Cl-99 HCO3-11* AnGap-37* [**2133-8-13**] 01:33AM BLOOD Glucose-273* UreaN-53* Creat-1.9* Na-145 K-3.5 Cl-98 HCO3-15* AnGap-36* [**2133-8-13**] 05:44AM BLOOD Glucose-334* UreaN-55* Creat-2.0* Na-143 K-3.7 Cl-98 HCO3-23 AnGap-26* [**2133-8-13**] 04:03PM BLOOD Glucose-145* UreaN-51* Creat-2.0* Na-144 K-3.8 Cl-102 HCO3-31 AnGap-15 [**2133-8-14**] 04:04AM BLOOD Glucose-98 UreaN-46* Creat-2.0* Na-143 K-3.4 Cl-104 HCO3-30 AnGap-12 . [**2133-8-12**] 12:00PM BLOOD ALT-384* AST-240* AlkPhos-114 TotBili-1.8* [**2133-8-12**] 04:18PM BLOOD ALT-668* AST-595* CK(CPK)-216 AlkPhos-106 TotBili-2.0* [**2133-8-12**] 09:05PM BLOOD CK(CPK)-260 [**2133-8-12**] 09:51PM BLOOD ALT-420* AST-286* CK(CPK)-260 AlkPhos-106 [**2133-8-13**] 05:44AM BLOOD ALT-2905* AST-3765* LD(LDH)-5688* CK(CPK)-311 AlkPhos-88 TotBili-3.1* . [**2133-8-12**] 12:00PM BLOOD cTropnT-0.32* [**2133-8-12**] 12:00PM BLOOD CK-MB-10 [**2133-8-12**] 04:18PM BLOOD CK-MB-9 cTropnT-0.54* [**2133-8-12**] 09:05PM BLOOD cTropnT-0.91* [**2133-8-12**] 09:51PM BLOOD CK-MB-11* MB Indx-4.2 cTropnT-1.04* [**2133-8-13**] 05:44AM BLOOD CK-MB-14* MB Indx-4.5 cTropnT-1.17* . [**2133-8-12**] 04:18PM BLOOD Calcium-7.1* Phos-7.0*# Mg-2.0 [**2133-8-12**] 09:05PM BLOOD Calcium-6.2* Phos-7.9* Mg-1.9 [**2133-8-12**] 09:51PM BLOOD Calcium-9.7 Phos-8.7* Mg-3.0* [**2133-8-13**] 05:44AM BLOOD Calcium-7.7* Phos-4.3# Mg-1.9 [**2133-8-13**] 04:03PM BLOOD Calcium-7.9* Phos-4.6* Mg-1.9 [**2133-8-14**] 04:04AM BLOOD Calcium-7.4* Phos-3.9 Mg-1.7 . [**2133-8-12**] 12:00PM BLOOD Digoxin-0.5* . [**2133-8-12**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2133-8-12**] 01:37PM BLOOD Type-ART Rates-/18 Tidal V-500 PEEP-5 FiO2-100 pO2-117* pCO2-27* pH-7.14* calTCO2-10* Base XS--18 AADO2-585 REQ O2-94 Intubat-INTUBATED [**2133-8-12**] 02:54PM BLOOD Type-ART Rates-/16 Tidal V-500 FiO2-100 pO2-84* pCO2-34* pH-7.15* calTCO2-13* Base XS--16 AADO2-611 REQ O2-98 Intubat-INTUBATED [**2133-8-13**] 05:53AM BLOOD Type-ART pO2-459* pCO2-36 pH-7.43 calTCO2-25 Base XS-0 [**2133-8-13**] 10:19AM BLOOD Type-ART pO2-503* pCO2-50* pH-7.42 calTCO2-34* Base XS-7 Comment-(R) FEMORA [**2133-8-13**] 10:22AM BLOOD Type-ART pO2-404* pCO2-22* pH-7.66* calTCO2-26 Base XS-6 Comment-(R) RADIAL [**2133-8-13**] 12:51PM BLOOD Type-ART Temp-35.8 pO2-442* pCO2-41 pH-7.49* calTCO2-32* Base XS-8 Comment-FEMORAL A- [**2133-8-13**] 12:54PM BLOOD Type-ART Temp-35.8 Rates-16/ Tidal V-500 PEEP-8 FiO2-50 pO2-109* pCO2-24* pH-7.65* calTCO2-27 Base XS-7 Intubat-INTUBATED Vent-CONTROLLED [**2133-8-13**] 02:19PM BLOOD Type-ART pO2-75* pCO2-31* pH-7.54* calTCO2-27 Base XS-4 Comment-(R) RADIAL [**2133-8-13**] 04:09PM BLOOD Type-ART pO2-94 pCO2-34* pH-7.52* calTCO2-29 Base XS-4 Comment-RADIAL [**2133-8-13**] 04:11PM BLOOD Type-ART pO2-458* pCO2-41 pH-7.46* calTCO2-30 Base XS-5 Comment-FEMORAL [**2133-8-13**] 08:09PM BLOOD Type-ART pO2-112* pCO2-37 pH-7.56* calTCO2-34* Base XS-10 Comment-RADIAL [**2133-8-13**] 08:10PM BLOOD Type-ART pO2-461* pCO2-46* pH-7.48* calTCO2-35* Base XS-10 Comment-FEMORAL [**2133-8-13**] 09:35PM BLOOD Type-ART pO2-88 pCO2-41 pH-7.53* calTCO2-35* Base XS-10 Comment-RADIAL GAS [**2133-8-14**] 02:45AM BLOOD Type-ART pO2-117* pCO2-42 pH-7.50* calTCO2-34* Base XS-8 Comment-FEMORAL [**2133-8-14**] 08:10AM BLOOD Type-ART Temp-34.8 PEEP-8 FiO2-60 pO2-468* pCO2-53* pH-7.39 calTCO2-33* Base XS-6 -ASSIST/CON Intubat-INTUBATED Comment-FEMORAL -L [**2133-8-14**] 08:14AM BLOOD Type-ART Temp-34.8 Tidal V-450 PEEP-8 FiO2-60 pO2-203* pCO2-38 pH-7.47* calTCO2-28 Base XS-4 -ASSIST/CON Intubat-INTUBATED Comment-RADIAL -LI . [**2133-8-12**] 12:08PM BLOOD Lactate-8.5* [**2133-8-12**] 01:37PM BLOOD Glucose-160* Lactate-13.9* Na-137 K-4.5 Cl-109 [**2133-8-12**] 05:59PM BLOOD Glucose-123* Lactate-14.2* K-4.9 [**2133-8-12**] 09:27PM BLOOD Glucose-195* Lactate-14.0* Na-136 K-7.3* Cl-105 [**2133-8-12**] 09:35PM BLOOD Glucose-171* Lactate-15.2* Na-140 K-6.4* Cl-106 [**2133-8-12**] 09:59PM BLOOD Lactate-17.7* K-4.6 [**2133-8-12**] 10:38PM BLOOD Lactate-18.1* K-3.4* [**2133-8-13**] 12:13AM BLOOD Lactate-17.8* K-3.6 [**2133-8-13**] 01:03AM BLOOD Lactate-17.2* K-3.5 [**2133-8-13**] 03:11AM BLOOD Lactate-15.2* K-3.4* [**2133-8-14**] 02:43AM BLOOD Lactate-2.6* . [**2133-8-12**] 12:08PM BLOOD Hgb-9.8* calcHCT-29 [**2133-8-12**] 01:37PM BLOOD Hgb-8.4* calcHCT-25 [**2133-8-12**] 06:52PM BLOOD Hgb-8.7* calcHCT-26 O2 Sat-93 [**2133-8-12**] 09:27PM BLOOD Hgb-9.6* calcHCT-29 O2 Sat-85 . [**2133-8-14**] 08:14AM BLOOD O2 Sat-98 . [**2133-8-12**] 04:33PM BLOOD freeCa-0.7* [**2133-8-12**] 09:27PM BLOOD freeCa-0.7* [**2133-8-12**] 09:35PM BLOOD freeCa-1.03* [**2133-8-12**] 09:59PM BLOOD freeCa-1.14 [**2133-8-14**] 08:14AM BLOOD freeCa-0.91* . CHEST (PORTABLE AP) Study Date of [**2133-8-12**] FINDINGS: Single frontal AP upright portable view of the chest was obtained. A single-lead left-sided AICD is seen, with leads extending to the expected position of the right ventricle. Cardiomegaly is again seen, unchanged. Hilar prominence is without significant interval change and may be due to enlarged pulmonary arteries and/or pulmonary vascular engorgement. Calcifications of the aortic knob are noted. There is mild prominence at the AP window, unchanged since prior. No focal consolidation, pleural effusion, or evidence of pneumothorax is seen. IMPRESSION: No significant interval change. Stable cardiomegaly and enlarged pulmonary arteries. . CHEST (PORTABLE AP) Study Date of [**2133-8-12**] FINDINGS: Single supine AP portable view of the chest was obtained. There has been interval placement of an endotracheal tube, with tip approximately 5.2 cm above the carina. Per the clinical team, no NG tube has in place. The right costophrenic angle is excluded from the image. There has been interval development of slight hazy opacity over the right upper to mid lung, which may be asymmetric edema, interval aspiration versus artifact due to patient positioning. Cardiac silhouette remains enlarged. . CT HEAD W/O CONTRAST Study Date of [**2133-8-12**] FINDINGS: There is no hemorrhage or major vascular territory infarction. The ventricles and sulci are normal in size and configuration for patient's age. No mass effect or shift of normally midline structures are noted. There is mild opacification of the left frontal sinus. The remainder of the visualized paranasal sinuses and mastoid air cells are clear. No fractures are noted. IMPRESSION: No acute intracranial abnormality. . CTA TORSO W&W/O C & RECONS Study Date of [**2133-8-12**] FINDINGS: CHEST: Large area of opacification involving the right upper lobe, predominantly posteriorly, is seen. Given short-term development since chest radiograph performed on the same date at 11:48 a.m. (2 hrs prior), findings are concerning for aspiration with possible partial right upper lobe collapse(although no significant shift of midline structure), superimposed infection is not excluded. On coronal image 400B, image 33, narrowing of right upper lobe bronchus extending to the area of consolidation is seen, which could be due to mucus plugging. Plate-like areas of opacification in the anterior right upper to middle lobe (series 5, image 22), may represent atelectasis, although infection is not excluded. Additional areas of nodular opacity along the periphery of the right upper, middle, and lower lobes are seen. Additionally, on series 5, image 19, a subtle 4-5 mm ground-glass opacity is seen in the left upper lobe. While findings may relate to infectious and/or aspiration, follow-up to resolution is recommended to exclude underlying pulmomary lesion. Atelectasis along the dependent portion of the right greater than left lower lobes is also seen. Overall haziness of the lung fields with areas of septal thickening bilaterally suggest fluid overload. No pleural or pericardial effusion is seen. Extensive coronary artery calcifications are seen. AICD lead is seen extending into the right ventricle. There is cardiomegaly. Evidence of right heart failure is seen with reflux into the hepatic veins. The main pulmonary artery is enlarged, measuring up to 3.8 cm in diameter. The right main pulmonary artery is also enlarged, measuring 3.4 cm in diameter. No evidence of pulmonary embolism is seen, although evaluation of the subsegmental branches is slightly suboptimal due to patient motion. No evidence of acute aortic dissection is seen. There are aortic calcifications. A prominent right paratracheal lymph node measures 1.2 cm in short axis (series 5, image 17). No hilar or axillary lymphadenopathy is seen. The esophagus is patulous, but thin-walled. Endotracheal tube is seen, terminating just below the level of the clavicles. A left subclavian central venous catheter terminates at the cavoatrial junction. ABDOMEN: Evaluation of the viscera is suboptimal due to arterial phase of post-contrast image acquisition. Periportal edema is seen. The spleen, pancreas, adrenal glands, and kidneys are unremarkable. The gallbladder is relatively collapsed and full of stones. There is evidence of gallbladder wall edema. Mesenteric haziness is seen throughout, which may be due to fluid overload. Nonspecific bilateral perinephric stranding is seen. There is no hydronephrosis. There are severe atherosclerotic changes of the aorta and its branches. The origin of the celiac axis, SMA, and left renal artery are patent. Severe atherosclerotic changes are seen along the proximal SMA where there is mural thrombus causing significant narrowing (series 5, image 64) of the SMA, flow/contrast is seen distal to this. There are atherosclerotic changes along the right renal artery, with suggestion of narrowing at the origin. Atherosclerotic changes of the [**Female First Name (un) 899**] are also noted with the origin not optimally assessed, but appearing patent. PELVIS: The appendix is not identified in the right lower quadrant, but there are no inflammatory changes in the right lower quadrant to suggest acute appendicitis. Foley catheter is within a partially collapsed bladder. Air is seen in the nondependent portion of the bladder, likely due to instrumentation. There are severe atherosclerotic changes of bilateral iliac arteries with extensive mural thrombus, particularly along the right common iliac artery with focal areas of near complete occlusion along the distal right common iliac artery, (series 5, image 91) and proximal right external iliac artery (series 5, image 96), with reconstitution seen more distally. Very trace pelvic free fluid is seen. Mesenteric haziness is also noted in the pelvis, which may relate to fluid overload. There is no bowel obstruction. The prostate is mildly prominent. The seminal vesicles are symmetric. Scattered colonic diverticula are seen. There is apparent minimal thickening of the ascending [**Female First Name (un) 499**], although this may relate to underdistension. OSEOUS STRUCTURES: No evidence of acute fracture or dislocation is seen. Punctate sclerotic focus in the right femoral head and in the left iliac [**Doctor First Name 362**] may represent a bone island in the absence of known malignancy. IMPRESSION: 1. Large area of posterior right upper lobe opacification, developed in the interval since chest radiograph 2 hours previous, findings most likely due to aspiration/partial right upper lobe collapse, particularly given short term development. Superimposed infectious process is not excluded. Evidence of narrowing of a right upper lobe bronchus, which could be due to chronic inflammation or mucous plugging, other process not excluded. Additional areas of nodular opacity bilaterally, as above, infectious process not excluded. Recommend follow-up to resolution. 2. Evidence of fluid overload with diffuse pulmonary haziness, septal thickening, gallbladder wall edema, and mesenteric haziness. Cardiomegaly with findings concerning for right heart failure. 3. Enlarged main and right pulmonary artery suggesting pulmonary arterial hypertension. 4. Severe atherosclerosis of the coronary arteries, at the aorta and its main branches, with focal areas of near complete occlusion in the right common and right external iliac arteries (with distal reconstitution) and with significant narrowing of the proximal SMA. No evidence of acute aortic dissection. 5. Minimal apparent thickening of the ascending [**Last Name (LF) 499**], [**First Name3 (LF) **] relate to underdistention. . TTE (Focused views) Done [**2133-8-13**] Conclusions The left ventricular cavity is dilated. There is severe global left ventricular hypokinesis (LVEF = [**9-11**] %). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) are mildly thickened. The study is inadequate to exclude significant aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. IMPRESSION: Biventricular dilatation and severe hypokinesis. Mild mitral regurgitation. There is a wire/catheter passing through the right atrium into the right ventricle. Compared with the prior study (images reviewed) of [**2133-6-26**], number and quality of images are much more limited on the current study. The right ventricle is more dilated with evidence of pressure-volume overload. Consequently, the left ventricle is compressed and less dilated on the current study. Biventricular function is probably worse. The previously mentioned strands on the catheter are not visible on the current study. . CHEST (PORTABLE AP) Study Date of [**2133-8-13**] FINDINGS: As compared to the previous radiograph, the right IJ line appears to have been advanced. The tip of the line now projects over the basal parts of the right atrium, the line should be pulled back by approximately 6 to 7 cm. The other monitoring and support devices are in unchanged position. The pre-existing parenchymal opacities in the right lung are unchanged. The retrocardiac opacities have markedly increased, so that the major parts of the retrocardiac lung areas are now atelectatic. The overall size of the cardiac silhouette is unchanged. . CHEST (PORTABLE AP) Study Date of [**2133-8-14**] CHEST FLUORO [**2133-8-17**] Single fluoroscopic view was taken. Swan-Ganz catheter tip is in the distal right pulmonary artery or most likely in the interlobar artery and should be withdrawn for standard position. CARDIAC CATH [**2133-8-17**] FINAL DIAGNOSIS: Successful removal of [**Month/Day/Year **]/membrance oxugenator support cannula. EKG [**2133-8-18**] Sinus tachycardia and frequent atrial ectopy. Left atrial abnormality. Low limb lead voltage. Left ventricular hypertrophy. Compared to the previous tracing of [**2133-8-15**] the atrial rate has increased. Ventricular pacing is no longer recorded. LIVER/GB US [**2133-8-18**] IMPRESSIONS: 1. Engorged hepatic veins at confluence with IVC, consistent with CHF. No ascites. 2. Uncomplicated cholelithiasis redemonstrated. 3. Normal son[**Name (NI) 493**] exam of liver, with no focal liver lesion seen. CT-HEAD W/O CONRAST [**2133-8-18**] IMPRESSION: No new hemorrhage, edema, infarction, or masses. New onset sphenoid sinus mucosal thickening. LEFT GROIN US [**2133-8-18**] IMPRESSION: No evidence of left groin pseudoaneurysm, hematoma, or AV fistula. AP CXR [**2133-8-19**] Comparison is made with prior study performed the day earlier. ET tube tip is in standard position, 5.1 cm above the carina. Swan-Ganz catheter tip is in the right main pulmonary artery. NG tube tip is in the stomach. Left transvenous pacemaker lead terminates in the standard position in the right ventricle. Moderate cardiomegaly is stable. The pulmonary arteries are significantly dilated consistent with pulmonary hypertension. This is unchanged from prior studies. Diffuse lung opacities are unchanged from the day before but increased from [**8-16**], worrisome for aspiration given the clinical concern. The component of pulmonary edema has improved. There are no large pleural effusions. Left lower lobe retrocardiac opacity has minimally improved consistent with improved atelectasis. R UE US [**2133-8-23**] No evidence of DVT. AP CXR IJ [**2133-8-23**] Single chest radiograph is compared to multiple prior examinations. Swan-Ganz catheter has been removed. Right IJ catheter terminates at the superior vena cava. Left subclavian pacer AICD terminates in the right ventricle. Cardiomegaly, moderate congestive failure, left pleural effusion, left lower lobe consolidation persists. No pneumothorax identified. AP CXR PICC [**2133-8-25**] 1. Right-sided PICC at the low SVC. 2. Moderate pulmonary edema, slightly improved when compared to prior exam. 3. Worsening retrocardiac opacity likely representing atelectasis. AP CXR [**2133-8-30**] As compared to the previous radiograph, the pre-existing parenchymal opacities have decreased in extent and severity. However, they are still clearly visible in both the left and the right lung. Unchanged is the borderline size of the cardiac silhouette as well as the increased diameter of the hilar vascular structures. No evidence of larger pleural effusions. No evidence of pneumonia. TTE [**2133-8-27**] The left atrium is moderately dilated. The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF=[**9-11**] %). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe LV systolic function, mildly improved compared to prevous study. RV function mild depressed, markedly improved. Severe pulmonary hypertension. Compared to study performed on [**2133-8-13**], the RV is slightly smaller and its function slightly better. The LV is similar. Severe pulmonary hypertension and moderate TR have persisted. Discharge Labs: 134/ 102/ 45 / 123 -------------------- 4.4 / 26/ 1.7 Ca: 8.7 Mg: 2.1 P: 3.4 7.2/ 9.4 / 29.5/ 347 PT: 20.1 PTT: 32.9 INR: 1.8 Brief Hospital Course: 53 year old Male with PMH of HTN, DMII, HLD, non-ischemic CM EF of 15%, a-fib, and PHTN that presented after 2 month chronic decompensation and 2 days of [**3-7**] chest pain found to be tachycardic s/p multiple PEA arrests with resuscitation. . # PEA Arrest, Cardiogenic Shock, Biventricular Heart Failure: Dr. [**Name (NI) **] (pt's PCP) checked an EKG that showed a rate of 138, that was interpreted as sinus tachycardia with no signs of ischemia. He was given a nitroglycerin tab, which resolved his chest pain, as well as a chewable aspirin. He was supposed to get 25mg of lopressor in the office, but it was unclear if he got it prior to transfer. Pt was transferred to ED, where there was concern for STEMI with ST elevations in lead V4 on transport, however, the initial EKG in the ED showed tachycardia with ST depressions in V6. Initial vitals were HR 133, BP 101/71, RR 28, SaO2 100% RA, T 96.5, HR 130s. He had persistent chest pain with nausea and vomiting in the ED and there was a question of EKGs showeing possible a-flutter. Pt recieved 1 tab of nitro and lopressor 5mg IV x2; however, his SBP dropped to the 60's and he became unresponsive and pulseless, in PEA arrest. CPR was initiated, he recieved 2 mg of epinephrine, 1mg of atropine, 1 of bicarb, and then a bicarb drip was started. He was coded for 7 minutes. He was intubated and placed on dopamine and levophed drips and transferred to the CCU. Vitals post arrest on transfer were HR 84, BP 109/70, O2 Sat 97% TV 500, PEEP 5, RR 14, and Fi02 100%. . Pt was found to be in cardiogenic shock. Likely etiology was decompensated heart failure with poor forward flow and resultant end organ ischemia vs. myocardial infarction. He had documented stenosis of 80% in the RCA, and a last documented EF of 15%. On admission his lactate was 8.5 with a creatinine of 1.7 and transaminitis. His white count was normal on admission but then began to rise. However, given aspiration and findings on CT of apical right sided consolidation that was likely aspiration related, PNA could not be ruled out. He was given broad spectrum antibiotics to cover for potential sepsis which consisted of vanc/levo/cefepime in the ED and then was changed to vanc/zosyn/cefepime on the floor. . On the floor he was intubated, sedated, and on dopamine and levophed drips. A triple lumen RIJ was placed at the bedside. Dobutamine was added with a goal of transitioning the dopamine to dobutamine and was started on cooling protocol; however, the patient became bradycardic to the 40's and pulses were lost. Chest compressions were iniated, he was given epinephrine and bicarb. Pulses returned, and he was maintaining pressures in the 120s. He had blood in his endotracheal tube as well as his OG tube. He became bradycardic a 2nd time, pulses were lost and CPR was initiated again and pt was started on an epinephrine drip with return of pulse and pressure. At this point, pt was sent to the cath lab for tandem heart placement. . After placement of [**Name (NI) 61403**], pt was transeferred back to the CCU. On arrival he had 2.5LPM circulation off of pressors but circulation began to slow below 2LPM and MAPs began to drop to the 50s. He again became pulseless and CPR was initiated. He was given multiple rounds of epinephrine, atropine, bicarb, magnesium, and calcium and chest compressions. He was started back on dopamine, epinephrine, and levophed. A bedside echo showed compression of the LA and LV by a massively dilated RA and RV from [**Name (NI) 61403**] circulation. The cannula was withdrawn from the LA and positioned in the RA and it was hooked up to ECMO. Pt marginally improved after readjustment of [**Name (NI) 61403**] and initiation of ECMO. Milrinone was started while on ECMO and he was requiring 0.5mcg/kg/min and at first did not tolerate turning down the flow of the tandem heart, but over the course of a few days, the [**Name (NI) 61403**] and ECMO were able to be removed while maintaining the dose of milrinone. He was continuing to require milrinone for ionotropic support of his poor EF. Prior to extubation he was started on nitrous oxide in order to try and decrease his PA pressures. He showed some improvement, but not did not get his Wood's units for PVR less than 5. He was placed on sildenafil, and tolerated the medication well. After extubation, his mental status steadily improved, and his pressures improved as well. He was diuresesd with a lasix drip because he appeared fluid overloaded with pulmonary edema and a 10kg increase from his admission weight. On [**8-22**], he was extubated and mentally at baseline. In the interval between extubation and discharge, clinical management was directed at optimizing volume status and preparing the patient for discharge on a medication regimen amenable to his tenuous social situation in the absence of insurance. For social reasons, milrinone was titrated down; the patient tolerated this well. Sildenafil was continued and the patient was discharged on a dose of Sildenafil 40mg TID. IV Lasix was transitioned to Torsemide, which was titrated to 10 mg PO daily prior to discharge. The patient was also discharged on Lisinopril 5 mg, as well as Warfarin 2 mg PO daily and Aspirin 81 mg daily. His home dose of Digoxin 0.125mg daily was restarted the day of discharge. . # Coagulopathy: Pt had a supratherapeutic INR on coumadin at 7.4 on admission. He was ordered for FFP to correct his coagulopathy. He had blood in his OG and ET tubes, with a HCT drop. There was concern for alveolar hemmorrhage based on CT findings but pt had also aspirated. Over the course of his the first 24hrs he was given 2 units FFP and 2 units PRBC. HCT improved but did not bump appropriately. Given extracorporal blood volume in [**Month (only) 61403**] ECMO, possible continued bleeding due to high INR and pt's critical status, an additional 3 units of PRBCs were given over the next 24hrs. HCT improved to >30. Pt was switched to heparin gtt for continued anticoagulation needs given [**Month (only) 61403**] ECMO and immobility. Heparin was discontinued once his INR was therapeutic. . # Longterm anticoagulation (history of LV thrombus, depressed LVEF): Discharged with an INR of 1.8 and plans to follow-up 2 days after discharge with his primary cardiologist. . # Shock Liver: In the acute setting following the hemodynamic interventions discussed above, the patient's LFTs reflected shock liver. On admission ALT/AST/AP/TB were 384* 240* 114 1.8*, respectively. AST/ALT peaked [**8-14**] at 3041* 3843*, respectively. AP peaked [**8-24**] at 227. TB peaked [**8-22**] at 27.8 with a DBili peak of 22.5 from 5.4 on [**8-15**]. Prior to dicharge LFTS were all showing a normalizing trend, with ALT/AST/AP/TB 62* 53* 158* 11.1* 6.9* respectively on [**8-27**]. He was still moderately jaundiced on examination on discharge. . # Acute Kidney Injury: In the acute setting following the hemodynamic interventions discussed above, the patient's Cr and BUN elevated, reflecting [**Last Name (un) **] due to decreased effective circulatory volume. Cr peaked at 2.1 on [**8-16**] before normalizing to 0.9 on [**8-21**]. In the setting of aggressive diuresis, his Cr steadily rose to 2.8, at which point diuresis was held and the patient was allowed to re-equilibrate prior to starting him on his discharge regimen of Torsemide detailed above. . # Acid-Base Derangements: Anion Gap metabolic acidosis with a lactate of 8.5 on admission with increase on subsequent ABGs and persistent bicarb of [**9-8**]. Likely etiologies include end organ ischemia from cardiogenic shock and sepsis. Chest X-Ray on admission was clear but in ED patient vomited and possibly aspirated. CT chest showed right apical dense consolidation and infectious etiology could not be ruled out. As above, broad spectrum antibiotics, vanc, cefepime, levo were started in ED and then switched to vanc zosyn and levo on the floor for better anaerobe coverage. The patient was briefly on a bicarb drip and the acidosis improved. However, the patient then developed an alkalosis which was believed to be attributed to over ventilation and the bicarb drip. Bicarb drip was stopped, diamox was given and ventilation was marginally decreased. ABG's normalized. . # Hyperkalemia and Electrolytes Derangements: Potassium elevated to a peak of 8.0 and fluctuated between 3.4 and 8.0 before normalizing and stabilizing. He has recieved insulin and glucose as well as calcium gluconate as well as a bicarb drip. The patient's K improved to within normal ranges and he was repleted as needed. Other electrolytes were also monitored and repleted as needed. . # Dyslipidemia: Was on a statin on admission, but this was discontinued in the setting of the patient's shock liver. He was NOT discharged on a statin in the setting of his resolving shock liver. A statin should be started as an outpatient to optimize his risk profile. . # Thrombocytopenia: Etiology was thought to be due to invasive hemodynamic support; platelets nadired [**8-16**] at 28, after which he was transfused 1 unit of platelets and his count continued to recover to within normal limits upon discharge. . # Anemia: Etiology was thought to be due to macrovascular hemolysis in the setting of invasive hemodynamic support. Transfused a total of 8 units of pRBCs to maintain sufficient oxygen tissue delivery; 6 of these units were given in the acute setting of his hemodynamic instability. . # Leukocytosis: In the acute setting, leukocytosis was thought to be potentially due to systemic infection concerning for sepsis. Empiric broad spectrum antibiotics were started for coverage of gram negative, positive, and resistant organisms, then stopped once it was clear that the patient's shock was cardiogenic. The leukocytosis showed a trend toward normalization until circa [**8-17**], when multifocal infiltrates on CXR and uptrending leukocytosis raised concern for Pneumonia. The latter trend resolved with the antibiotic regimen detailed below for Pneumonia. . # Pneumonia: During his CCU course, was treated with an 8 day course of vancomycin, cefepime, and levofloxacin for suspected ventilator versus hospital acquired pneumonia. His pneumonia clinically resolved, with the patient remaining afebrile after the course's completion and with his leukocytosis showing a trend toward resolution as well. Initial respiratory cultures showed ASPERGILLUS FUMIGATUS 10,000-100,000 ORGANISMS/ML but subsequent beta glucan and beta glucaminase cultures were negative. All blood cultures were negative as well. . # DMII: Glucose was initially elevated in house. ISS was started and blood glucose was monitored Q6 finger sticks. He was discharged on glipizide 2.5mg ER daily upon discharge. . # Right arm edema: During his CCU course, was found to have right arm edema; an ultrasound study was negative for venous thrombosis. . # Left foot pain: In the period following his acute hemodynamic lability, the patient was found to have left foot pain on exam, most pronounced over the left greater toe. Colchicine was started empirically for 2 days but discontinued after uric acid was found to be wnl and a translator helped clarify that he was having tingling sensations rather than tenderness/pain. . # Loose stool: Had several episodes of loose stool in the interval immediately following him being started on colchicine. Stool normalized after stopping colchicine. C.Dif negative. . The patient was full code for this admission. Medications on Admission: (Home meds Per OMR). Carvedilol 6.25mg PO BID Digoxin 0.125mg PO daily Furosemide 60mg PO BID Lisinopril 10mg PO daily Asipirin 81mg PO daily Simvastatin 20mg PO daily Warfarin 2.5 mg (last dose in [**8-/2132**]) Glyburide 10mg PO BID Metformin 1000mg PO BID Vitamin B complex Calcium Carbonate 600-400mg PO BID Discharge Medications: 1. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for Pain. Disp:*30 Tablet(s)* Refills:*0* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. sildenafil 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. Vitamin B Complex Tablet Sig: One (1) Tablet PO once a day. 7. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO twice a day. 8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other day. Disp:*15 Tablet(s)* Refills:*2* 9. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2* 10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Cardiac Arrest Acute on Chronic biventricular Heart Failure: non Ischemic Diabetes Mellitus Type 2 Hypertension Atrial Fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Physical Exam: Gen: NAD HEENT: Sclera Anicteric Res: CTA-bilaterally CV: Normal S1, and S2 with thrill and hyperdynamic PMI Abd: Soft, NT, ND Ext: No cyanosis, erythema, or edema Neuro: As above. Discharge Instructions: You were admitted to the hospital because you had chest pain and your heart stopped multiple tiimes because you were so sick. You were in the CCU for a few weeks and needed medicines and machines to support your heart function. Your heart is now stronger and we have adjusted your medicines to help your heart work better. You were treated for a pneumonia and needed to be on a breathing machine. It is very important that you watch yourself very closely for fluid retention and take all of your medicines every day as prescribed. You can watch for fluid retention by monitoring the swelling in your legs, and noticing if your breathing is worse or if you are more tired than usual. If you notice any of these symptoms, please call Dr. [**Last Name (STitle) 171**]. You will be monitored closely by Dr. [**First Name (STitle) **] and [**Doctor Last Name 171**] after you go home. . Medication changes: 1. Stop taking Metformin, Carvedilol, Furosemide, Simvastatin and Glyburide. 2. Decrease Lisinopril to 5 mg daily 3. [**Last Name (un) **] Warfarin at 2.5 mg daily 4. Start Taking Sildenifil three times a day to decrease the pressure in your lung arteries 5. Start taking Tramadol as needed for pain 6. Start taking Glipizide 2.5 mg daily for your diabetes. 7. Start taking Torsemide instead of furosemide to prevent fluid buildup 8. Take Digoxin every other day instead of every day. . Weigh yourself every morning, call Dr. [**Last Name (STitle) 171**] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Wear your TEDS stockings every day, take off at night. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 10348**] Location: [**Hospital3 8233**] Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 61405**] Phone: [**Telephone/Fax (1) 10349**] Appointment: Friday [**2133-9-4**] 11:30am . Department: CARDIAC SERVICES When: Wednesday [**9-9**] at 3:00pm With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]: [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: [**2133-9-14**] 1:40 With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Phone: [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: WEDNESDAY [**2133-12-9**] at 8:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: CARDIAC SERVICES When: WEDNESDAY [**2133-12-9**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "707.05", "785.51", "416.8", "285.9", "427.5", "427.31", "274.9", "570", "584.5", "428.23", "276.7", "518.81", "V58.61", "428.0", "401.9", "427.89", "425.4", "250.00", "997.31", "276.2", "286.9", "707.22", "287.49", "507.0" ]

icd9cm

[ [ [] ] ]

[ "39.65", "89.64", "96.04", "38.93", "96.72", "99.60", "96.6", "37.68", "97.44" ]

icd9pcs

[ [ [] ] ]

39507, 39564

26573, 38069

316, 356

39740, 39740

5895, 22573

41690, 43142

5064, 5152

38431, 39484

39585, 39719

38095, 38408

22590, 26397

40088, 40970

26413, 26550

39881, 40064

5773, 5876

40990, 41667

266, 278

384, 3775

5195, 5745

39755, 39866

3797, 4727

4743, 5048

15,422

168,703

21601

Discharge summary

report

Admission Date: [**2118-1-6**] Discharge Date: [**2118-1-9**] Date of Birth: [**2062-6-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6180**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: 55yo woman with history of chronic hepatitis C and hepatocellular carcinoma s/p chemotherapy with gemcitabine and cisplatin presented with upper GIB. She states she was getting ready for work the day of admission and felt unwell. She did not fell nauseated but flet what she describes as a large burp. She went to the sink and spit out ~ 1 cup of blood with clot. Her base line HCT is 30-36 and was 18.5 upon presentation to the ED. Her INR was 2.2 secondary to coumadin for IVC clot. Coffee grounds were noted on NG lavage in the ED, which cleared after 300 cc. Pt was orthostatic with BP drop from 138/68 to 100/60. EGD showed varices at the lower third of the esophagus and gastroesophageal junction as well as prepyloric erosion and blood in the stomach. She reports that she recently had cyber knife radiation to her liver and has been taking ibuprofen 400 mg po every couple of days for RUQ pain. She was observed overnight in the [**Hospital Unit Name 153**]. She has recieved 4 units of pRBCs with an appropriate rise in HCT. She has had no further episodes of bleeding. She was started on a brief course of octratide which was quickly stopped. She was then startedon nadolol. . ROS (+)fatigue, RUQ pain (-) fever, chills, nausea, chest pain, SOB, Past Medical History: 1. chronic hepatitis C, s/p interferon, ribavirin 2. mild asthma 3. hepatocellular carcinoma: - had history of chronic hepatitis C (uncertain means of acquisition), in [**2112**] treated for one year with interferon/ribavirin - presented in [**2116**] with fever, abdominal pain - CT abd in [**9-19**] - malignancy in posterior right hepatic lobe; also with tumor thrombus extending into the portal vein and up to the R atrium - US-guided biopsy: well-differentiated HCC with focus of hemorrhage and necrosis. AFP at dx was 53,905 - treated with gemcitabine/cisplatin; started in [**10-19**] last chemotherapy in [**6-20**].Treatment complicated by thrombocytopenia. On break from chemo with stable disease. Recent gamma knife. 4. Bilateral tubal ligation 5. Guiac positive stool Social History: Lives in [**Location 1468**]. Single. No children. No etoh currently, "socially" in the past. No tobacco or drug abuse. Denied any IV drug abuse. She is a training coordinator for fidelity investments. She is engaged to be married and will be married in [**Location (un) 5354**] in 3 weeks. Family History: Her maternal grandmother died of the colon cancer in the 70s and paternal grandmother had lung cancer in her 40s. Her mom died of an MI and her father died of old age. Physical Exam: VITALS 110.1/99.2 120s/50s 67-100 currently 73 16 98% RA GEN Well groomed, bright affect, NAD SKIN Pink, warm, dry HEENT PERRL sclera white, mmm NECK Supple CV RRR nl S1-S2 no m/r/g LUNGS CTAB ABD Soft, non-tender, non-distended, BS+, No hepatomegaly noted EXT ppp no edema NEURO AOX3 Non-focal Pertinent Results: [**2118-1-6**] 09:40PM GLUCOSE-127* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15 [**2118-1-6**] 09:40PM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.8 [**2118-1-6**] 09:40PM WBC-2.8* RBC-2.63* HGB-7.6*# HCT-21.3* MCV-81* MCH-28.9# MCHC-35.6*# RDW-18.0* [**2118-1-6**] 09:40PM PLT SMR-VERY LOW PLT COUNT-65* [**2118-1-6**] 09:40PM PT-15.3* PTT-27.4 INR(PT)-1.6 [**2118-1-6**] 11:11AM GLUCOSE-131* K+-4.2 [**2118-1-6**] 11:00AM GLUCOSE-126* UREA N-31* CREAT-0.5 SODIUM-137 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-22 ANION GAP-13 [**2118-1-6**] 11:00AM ALT(SGPT)-24 AST(SGOT)-44* ALK PHOS-82 AMYLASE-75 TOT BILI-0.8 [**2118-1-6**] 11:00AM LIPASE-76* [**2118-1-6**] 11:00AM WBC-4.8 RBC-2.30*# HGB-5.8*# HCT-18.5*# MCV-81* MCH-25.1*# MCHC-31.1 RDW-18.5* [**2118-1-6**] 11:00AM PT-17.9* PTT-27.4 INR(PT)-2.2 _ _ _ _ _ _ _ ________________________________________________________________ EGD Report [**Hospital1 **] varices at the lower third of the esophagus and gastroesophageal junction second part of the duodenum prepyloric erosion stomach fundus Brief Hospital Course: #)Upper GI bleed - Gastric erosions likely related to NSAID use in the setting of anticoagulation. Initially admitted to [**Hospital Unit Name 153**] and transfused 4 units with approriate rise in HCT in first 24 hours of admission. Hct w/ adequate bump with each transfusion. Initially on IV PPI q12h, then PO protonix. Held off on restarting anticoagulation given continued guaiac positive stools during admission. Hct's were watched carefully over 48 hrs and remained stable at 29-31, so patient was discharged home. She will get repeat hct within one week's time. Pt was cautioned against further NSAID use. Re-initiation of anticoagulation held off for now. Will discuss in one week's time w/ Dr. [**First Name (STitle) **]. . #)Hepatocellular Carcinoma - s/p gammma knife. Further therapy to be determined. Will follow up with Dr. [**First Name (STitle) **] within one weeks time. . #)IVC clot - off anticoagulation until outpatient follow up this week. . #)FEN - regular diet . #)PPx - PPI . #)Code - full Fiance [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8494**], [**Telephone/Fax (1) 56886**] Discharged home. Medications on Admission: coumadin 4 mg po qd ibuprofen 400 mg po prn ativan prn Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 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* Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed secondary to gastric erosion non bleeding esophageal varices Hepatitis C Hepatocellular carcinoma Discharge Condition: stable Discharge Instructions: Continue to take protonix once daily. Please avoid use of motrin, aspirin. If need pain relief, please use tylenol. If you notice further bleeding, please call your doctor and/or go to the nearest emergency room. Followup Instructions: You will need a repeat blood count (hematocrit) within one week of discharge. Please call your doctor (Dr. [**First Name (STitle) **] or your primary care)to get this done. You will need to discuss your anticoagulation (coumadin) re-initiation at your next appointment with Dr. [**First Name (STitle) **]. Given that it is the weekend, please call ([**Telephone/Fax (1) 16336**] on Monday to schedule an appointment. Completed by:[**2118-1-9**]

[ "155.0", "456.21", "070.54", "285.1", "535.41", "E935.9", "493.90", "287.5" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

6122, 6128

4379, 5522

324, 341

6285, 6294

3256, 4356

6555, 7003

2755, 2924

5628, 6099

6149, 6264

5548, 5605

6318, 6532

2939, 3237

273, 286

369, 1627

1649, 2431

2447, 2739

57,231

191,887

600

Discharge summary

report

Admission Date: [**2105-9-8**] Discharge Date: [**2105-9-16**] Date of Birth: [**2053-8-14**] Sex: M Service: NEUROSURGERY Allergies: seasonal Attending:[**First Name3 (LF) 1271**] Chief Complaint: neck and bilateral arm pain Major Surgical or Invasive Procedure: [**2105-9-8**]: Anterior cervical, removal of hardware and loose screws [**2105-9-8**]: Neck exploration, Repair of pharynx, direct laryngoscopy History of Present Illness: Patient comes in today for discussion of surgery - revision of cervical fusion, that is scheduled for this week. Patient states he has pain in his neck to 2 inches below his elbow bilateral. He states that the pain in his neck is sharp, shooting in nature and the arms are a constant dull ache. Left side is worse and he feels his neck cracking. He was initially seen [**2105-5-21**]. He also notes difficulty swallowing CT reviewed at that visit. Per Dr.[**Name (NI) 4674**] note: Prior surgery with a plate lying anterior at the C4 through C6 levels. The screws at C5 are slightly inferior placed. There is probably nonunion at C4-C5. There are two completely extruded screws inferior to that plate probably coming from the C4 and C5 areas. They are in close contact with the esophagus and potentially causing the symptoms of dysphagia. The risks and benefits of undergoing surgical intervention were discussed with the patient. He now electively presents for ACDF revision. Past Medical History: 1. Recurrent syncope of unclear etiology with no arrhythmia identified on extended monitoring with a Reveal implanted monitor 2. Single, brief episode of atrial fibrillation 3. Hypertension 4. Hyperlipidemia 5. Obesity 6. COPD (PFT's [**2-/2105**]: moderately severe obstructive defect with significant improvement in bronchodilator, mild reduction in diffusing capacity) 7. Prior failed cervical fusion (C3-C5) with implanted hardware 8. History of heavy alcohol use 9. Chronic pain 10. benign prostatic hypertrophy 11. Anxiety/depression 12. Multiple prior infections (Reveal pocket, cystitis, multiple abscesses, prostatitis) 13. Dysphagia 14. Tobacco abuse Social History: smokes 1ppd ongoing 13 years, admits to 3 beers a night. He was a manager in retail now applying for disability Family History: non-contributory Physical Exam: From clinic [**8-12**] Gen: anxious uncomfortable gentleman in no acute distress. HR 100 and BP 146/100 HEENT: Pupils: PERRL EOMs intact 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. Language: Speech fluent with good comprehension and repetition. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 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 [**5-30**] throughout except in shoulders [**4-30**]. No pronator drift. Gait is slow Sensation: Intact to light touch Reflexes: 3 + symmetrical throughout Toes downgoing bilaterally Discharge: AVSS NAD Tolerating thick liquids upon swallow evaluation symmetric chest rise Full strength UE/UE. Incision c/d/i Drain removed. Dry No focal or diffuse neurologic deficits appreciated. Pertinent Results: [**9-9**] Cervical Xr - Interval removal of metallic hardware from anterior cervical spine. [**9-13**] LENI: No right lower extremity deep vein thrombosis. [**Hospital Ward Name 4675**] cyst in the right popliteal fossa with an area of irregularity possibly representing rupture. [**9-15**]: Video Swallow: 1. No large leak or collection of barium is visible, however, small leak along the left pharyngeal mucosa cannot be excluded. 2. Trace penetration with thin liquids. See also the note from the Speech Pathology division in the electronic medical records for further assessment and recommendations. Brief Hospital Course: Pt electively presented and underwent a revision of his previous ACDF. Surgery was without complication and he tolerated it well. Please see operative report for details, but of note there was a hypopharyngeal fenestration discovered during surgery likely caused by free floating hardware. Given the injury to his pharynx he remained intubated for 48 hours. on [**9-10**] the patient was safely extubated after being seen by ENT. During extubation his dobhoff was accidentally removed. ENT made two separate attempts to replace it fiberoptically was they were not successful. He had a temperature to 101 overnight. Chest xray showed no signs of pneumonia. He was started on Unasyn to continue until JP drain was removed. On [**9-12**] the patient was stable and was transfered out of the ICU. On [**9-13**], patient reported some discomfort overnight and anxiety. He was started on xanax. ENT to evaluate and remove JP drain. On [**9-14**] patient was complaining of right lower extremity pain and swelling, on exam we noted 1+ pitting edema and ordered a doppler ultrasound which showed a leaking [**Hospital Ward Name **] cyst and no DVT. On [**9-15**], patient underwent video swallow which showed no definitive leak. Full liquids were started and patient had no evidence of leak overnight. On [**9-16**], drain was removed, patient continued to have a nonfocal intact neurologic exam and was discharged home with instructions to follow up in one week for repeat swallow evaluation to advance diet. Medications on Admission: . Information was obtained from . 1. Albuterol Inhaler [**1-26**] PUFF IH Q6H:PRN sob/wheeze 2. Citalopram 20 mg PO DAILY 3. DiCYCLOmine 10 mg PO QID 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 5. Hydrochlorothiazide 25 mg PO DAILY 6. Losartan Potassium 50 mg PO BID 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 8. Aspirin 81 mg PO DAILY 9. Vitamin D 1000 UNIT PO BID Discharge Medications: 1. Albuterol Inhaler [**1-26**] PUFF IH Q6H:PRN sob/wheeze 2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 3. ALPRAZolam 0.5 mg PO TID:PRN anxiety can be crushed and placed sublingual RX *alprazolam 0.5 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Citalopram 20 mg PO DAILY 6. DiCYCLOmine 10 mg PO QID 7. Hydrochlorothiazide 25 mg PO DAILY 8. Losartan Potassium 50 mg PO BID 9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 10. Vitamin D 1000 UNIT PO BID 11. Amoxicillin-Clavulanic Acid 500 mg PO Q12H Duration: 10 Days RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet by mouth q12hr Disp #*20 Tablet Refills:*0 12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*60 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: failed cervical fusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Anterior Cervical Discectomy and Fusion Dr. [**First Name (STitle) **] [**Name (STitle) 739**] ?????? Your large dressing should be off 2 days after surgery. ?????? You have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? Do not smoke. ?????? No tub baths or pool swimming for two weeks from your date of surgery. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? You may shower briefly without the collar on if you are sitting and not as risk of falling in the tub or shower. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. This medication is as needed for pain, you do not need to take it if you have no pain. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc for 2 weeks. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. Followup Instructions: Follow Up Instructions/Appointments ??????Please call Paresa at ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr. [**Last Name (STitle) 739**] to be seen in 4 weeks. You will need AP and Lateral Cervical spine x-rays prior to your appointment. Please call [**Telephone/Fax (1) 3731**] upon discharge to schedule an evaluation with speech and swallow to re-evaluate in 1 week. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2105-10-7**] 11:30 Provider: [**Name10 (NameIs) 4677**] [**Name11 (NameIs) 4678**], MD Phone:[**Telephone/Fax (1) 3506**] Date/Time:[**2105-10-9**] 1:00 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2105-10-27**] 11:30 [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2105-9-29**]

[ "478.31", "727.51", "300.00", "458.9", "874.4", "996.49", "600.00", "V85.36", "787.20", "278.00", "750.8", "E878.1", "493.20", "338.29", "V45.4", "305.1", "311" ]

icd9cm

[ [ [] ] ]

[ "31.42", "96.71", "78.69", "96.6", "06.09", "29.51" ]

icd9pcs

[ [ [] ] ]

7097, 7103

4303, 5812

300, 447

7170, 7170

3666, 4280

8856, 9746

2289, 2307

6255, 7074

7124, 7149

5838, 6232

7321, 8833

2322, 2518

233, 262

475, 1456

2719, 3647

7185, 7297

1478, 2142

2158, 2273

43,061

191,878

42870

Discharge summary

report

Admission Date: [**2153-6-20**] Discharge Date: [**2153-6-26**] Date of Birth: [**2108-9-15**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5569**] Chief Complaint: ESRD Major Surgical or Invasive Procedure: living non-related renal transplant [**2153-6-20**] History of Present Illness: 44 year old woman who developed type 1 DM at age 27 (no family history of DM) and now has CKD stage 4, eGFR 16 ml/min. A kidney biopy on [**2153-1-9**] showed Advanced diabetic nephropathy with nodular glomerulosclerosis. She completed transplant evaluation and presented for living non-related renal transplant from her husband. Past Medical History: PMH: hypertension and hyperlipidemia. She denies any cardiac history of MI or arrhythmia. She has no history of pulmonary complaints. She denies any significant urinary tract infections, hematuria or kidney stones. PSH: IMN in the left tibia due to a combined tibia-fibula fracture seven years ago. Social History: Married Physical Exam: see preop note Pertinent Results: [**2153-6-20**] 04:45PM BLOOD WBC-6.3 RBC-3.02* Hgb-9.7* Hct-29.6* MCV-98 MCH-32.0 MCHC-32.7 RDW-13.9 Plt Ct-249 [**2153-6-26**] 06:40AM BLOOD WBC-14.7* RBC-3.45* Hgb-11.2* Hct-33.7* MCV-98 MCH-32.5* MCHC-33.3 RDW-14.2 Plt Ct-251 [**2153-6-25**] 05:42AM BLOOD PT-11.7 PTT-23.6* INR(PT)-1.1 [**2153-6-20**] 04:45PM BLOOD Glucose-154* UreaN-89* Creat-2.4* Na-140 K-3.7 Cl-110* HCO3-18* AnGap-16 [**2153-6-26**] 06:40AM BLOOD Glucose-161* UreaN-26* Creat-1.3* Na-137 K-3.5 Cl-106 HCO3-17* AnGap-18 [**2153-6-24**] 01:34AM BLOOD ALT-22 AST-25 AlkPhos-60 TotBili-0.5 [**2153-6-26**] 06:40AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.6 [**2153-6-20**] 09:10AM BLOOD HCG-<5 [**2153-6-26**] 06:40AM BLOOD tacroFK-10.3 Brief Hospital Course: On [**2153-6-20**], she underwent living non-related renal transplant from husband. A 6-[**Name2 (NI) 18252**] double J stent was inserted into the renal pelvis. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details. Urine output was excellent. IV fluid replacements were given. Induction immunosuppression was administered (ATG, Solumedrol and Cellcept). Creatinine decreased to 1.1 on postop day one. Urine output was 10 liters for the day. She experienced a lot of nausea. IV Zofran was given with only minimal relief. IV Phenergan was given. She received a 2nd dose of ATG (75mg). During this infusion she became febrile to 101.7. Blood and urine cultures were done. Temperature increased to 102.6. She was pan-cultured again and a portable CXR was unremarkable. Urine output decreased significantly. IV fluid boluses and albumin were given. Renal duplex was done and showed patent vessels. A small perinephric collection was noted.Foley was irrigated without increase in urine output. Given persistent decrease in urine output and development of tachycardia with low blood pressure, she was transferred to the SICU for management. Hct was stable. TTE was done and was normal. She continued to receive aggressive IV fluid replacement with response of increased urine. ATG (3rd dose)was held. Lopressor was given for tachycardia. On [**6-22**], repeat CXR demonstrated bibasilar opacities compatible with consolidation and/or atelectasis. Slight increase in pulmonary vascular congestion. Non-contrast abdominal CT was done On [**6-23**] after blood cultures were noted to be positive. Bilateral pneumonia, left worse than right, compatible with aspiration pneumonia, no collection or infectious process was noted within the abdomen and pelvis, or evidence of bowel injury. Once stable, she transferred out of the SICU. Urine output greater than a liter per day. Blood cultures from [**6-22**] isolated pseudomonas aeruginosa (pan-sensitive)on [**6-24**]. IV Vancomycin was started on [**6-24**]. WBC was up to 17 on [**6-25**]. Vancomycin was switched to Cefepime on [**6-25**] per ID. A 2 week course of Cefepime was recommended. A left arm Midline was placed on [**6-26**] for IV antibiotics. She remained afebrile. BP was elevated. Lopressor was continued. Weight was up to 74.7 kg from admission weight of 61 kg. Lasix was given with excellent diuresis. Weight decreased to 70 kg. Creatinine was done to 1.3. Urine output averaged 2700 with Lasix. Diet was advanced and tolerated. She passed stool. [**Last Name (un) **] was involved and adjusted insulin for hyperglycemia. Abdominal incision was intact with staples and no redness/drainage. She was ambulating independently on postop day 6. Immunosuppression consisted of CellCept which was well tolerated, and Prograf which was adjusted to 2mg [**Hospital1 **] per trough levels of 10.3. Steroid taper was complete. Of note, she was never given 3rd dose of ATG. She felt well enough to go home on [**6-26**] and was discharged on Lasix 20mg daily as weight was still up 10kg from baseline. Lopressor was switched to home dose of amlodipine. She will have labs on [**6-28**]. Medications on Admission: amlodipine, vitamin D2, furosemide, Lantus, Humalog, lisinopril, lorazepam, omeprazole and calcium carbonate. Discharge Medications: 1. Furosemide 20 mg PO QD RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 2. Acetaminophen 650 mg PO Q6H:PRN Pain/pre med atg 3. CefePIME 2 g IV Q12H RX *cefepime 2 gram give via PICC every twelve (12) hours Disp #*19 Not Specified Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Nystatin Oral Suspension 5 ml PO QID swish and swallow 6. Omeprazole 20 mg PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*40 Tablet Refills:*0 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Tacrolimus 2 mg PO Q12H 10. ValGANCIclovir 900 mg PO Q24H Start [**6-26**] 11. Atorvastatin 20 mg PO DAILY 12. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **]) 13. Mycophenolate Mofetil 1000 mg PO BID 14. Lorazepam 0.5 mg PO HS:PRN anxiety do not take at same time as oxycodone 15. Amlodipine 5 mg PO DAILY 16. Glargine 24 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: critical care systems Discharge Diagnosis: ESRD DM HTN pseudomonas bacteremia pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the Transplant Office at [**Telephone/Fax (1) 673**] if you have any of the following; temperature of 101 or greater, chills, nausea, vomiting, inability to take any of your medication, increased abdominal pain, incision redness/bleeding/drainage, decreased urine output, edema, dizziness/thirst or constipation/diarrhea -Keep picc line clean and dry -you may shower is you keep picc line dry. No swimming or tub baths -you will need to have blood drawn on Mondays and Thursday for lab monitoring -No driving while taking pain medication -weigh yourself every day Critical Care will supply antibiotic and IV/picc line supplies [**Company 1519**] will assist you with caring for the picc/cefepime administration Followup Instructions: Please schedule a follow up appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 65384**] Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2153-7-2**] 8:45 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Date/Time:[**2153-7-2**] 10:30 Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2153-7-10**] 11:00 Completed by:[**2153-6-26**]

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Discharge summary

report

Admission Date: [**2198-2-24**] Discharge Date: [**2198-3-7**] Date of Birth: [**2125-2-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3556**] Chief Complaint: T6 cord compression, NSTEMI Major Surgical or Invasive Procedure: T4-T7 Laminectomy History of Present Illness: 73 year old man with severe COPD on 3L home O2, HTN, HL, osteoporosis status post compression fractures and vertebrolplasty T11-L1 presented. To [**Hospital6 **] earlier today complaining of abdominal, back, chest pain starting this morning, very excruciating that he could not talk. CTA chest and CT of his abdomen was done which was negative for any aortic dissection, or any intra-abdominal pathology, and patient began complaining of severe leg weakness and numbness. Apparently this leg weakness began at 10 AM. He also complains of urinary retention and had no rectal tone. At this point, troponin returned at .[**Street Address(2) 42984**] depressions. Emergent MRI without contrast done at [**Hospital3 **] showed acute T6 fracture with likely retropulsion versus epidural hematoma compressing the cord at that level. ED Course (labs, imaging, interventions, consults): - Initial Vitals/Trigger: 97.7 68 150/81 18 96% 4L EKG: His ECGs revealed RBBB and inferior Q waves (old per prior reports no images available) and 2mm ST depressions V4-V6 (unclear if old or new). Given the ST changes and positive troponin, cards was consulted, recommended aspirin if cannot get heparin in the setting of epidural hematoma. Neurosurg: Looks like he may have mass compressing the spinal cord. Needs contrast MRI, patient is likely permanently paraplegic, they will review the stat images, but have explained to patient that his likelihood of benefiting from emergent surgery is minimal. Does NOT recommend heparin due to possibility of epidural hematoma. . Admission Vitals: 75 120/50 14 98% 2L NC, patient chest pain free at the time of admission. He is being admitted to the MICU for neuro checks and relative instability. . On arrival to the MICU, patient complaining of severe [**9-5**] back pain which diminished with 1 mg IV dilaudid. Past Medical History: Severe COPD with llongstanding steroid use & on home O2 3L NC asthma osteoporosis with compression Fx's & vertebroplasty (T11-L1) CAD with multivessel disease (last cath [**2194**] with non-intervenable three vessel disease and deemed not a surgical candidate [**12-28**] COPD) HTN hyperlipidemia eczema stroke with no residual deficit renal cyst OA R sided musculoskeletal back pain hyponatremia possibly d/t SIADH (chronic in nature) PAST SURGICAL HISTORY T11-L1 vertebroplasty, hernia repair x2 Social History: Lives at home with family, No home services, Primary Language - Speaks ENGLISH, Smoking - Current Nonsmoker, ETOH - hx not obtained, Rec. drugs - None, Family History: NC Physical Exam: ADMISSION EXAM 75 120/50 14 98% 2L NC 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 General: Awake, alert, NAD, breathing more comfortably HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate/rhythm, S1/S2 are difficult to hear well, no obvious murmur Lungs: Wheezes and coarse breath sounds throughout, but improved air movement Abdomen: soft, distended (likely body habitus), mildly tympanitic non-tender, movement with marked accessory muscle use, easily reducible umbilical hernia GU: + foley Ext: Warm, well perfused, 2+ DP pulses, mild peripheral edema of legs bilaterally (pneumoboots leaving indentations but limited further pitting), back incision well approximated, non-erythematous Neuro: Moves all extremities, A+Ox3 Pertinent Results: ADMISSION LABS [**2198-2-24**] 07:50PM URINE MUCOUS-RARE [**2198-2-24**] 07:50PM URINE RBC-0 WBC-6* BACTERIA-NONE YEAST-NONE EPI-0 [**2198-2-24**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2198-2-24**] 07:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.028 [**2198-2-24**] 07:50PM PT-10.5 PTT-25.1 INR(PT)-1.0 [**2198-2-24**] 07:50PM PLT COUNT-303 [**2198-2-24**] 07:50PM NEUTS-85.6* LYMPHS-5.9* MONOS-7.3 EOS-0.3 BASOS-0.8 [**2198-2-24**] 07:50PM WBC-10.4 RBC-3.31* HGB-11.1* HCT-33.2* MCV-100* MCH-33.6* MCHC-33.5 RDW-13.8 [**2198-2-24**] 07:50PM CK-MB-5 [**2198-2-24**] 07:50PM CK(CPK)-81 [**2198-2-24**] 07:50PM estGFR-Using this [**2198-2-24**] 07:50PM GLUCOSE-73 UREA N-26* CREAT-0.9 SODIUM-136 POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-32 ANION GAP-13 . _________________CKMB|Troponin [**2198-2-24**] 08:36 | 0.21* [**2198-3-2**] 16:15 4| 0.25*1 [**2198-3-2**] 02:52 3| 0.20*1 [**2198-3-1**] 16:29 4| 0.19*1 [**2198-3-1**] 09:49 5| 0.19*1 [**2198-3-1**] 02:35 5| 0.19*1 [**2198-2-28**] 19:45 6| 0.21*1 [**2198-2-28**] 14:30 5| 0.20*1 [**2198-2-28**] 05:10 5| 0.14*1 [**2198-2-25**] 17:58 6| 0.14*1 [**2198-2-25**] 03:40 4| 0.20*1 [**2198-2-24**] 20:36 0.21*2 . DISCHARGE LABS [**2198-3-6**] 03:00AM BLOOD WBC-7.5 RBC-3.03* Hgb-9.3* Hct-28.8* MCV-95 MCH-30.6 MCHC-32.2 RDW-14.1 Plt Ct-259 [**2198-3-6**] 03:00AM BLOOD Glucose-97 UreaN-26* Creat-1.1 Na-133 K-3.9 Cl-93* HCO3-34* AnGap-10 . MRI Spine Non contrast: 1. New T6 compression deformity with marrow edema probably extending into the pedicles although image quality is suboptimal due to patient motion. Apparent space occupying structure, possibly hemorrhage tracking from the T6 vertebral level to the T4 vertebral level and exerting posterior mass effect on the cord but preserved in some of the posterior epidural fat. Preliminary findings discussed with Dr. [**First Name (STitle) **]. 2. Acute to subacute mild compression deformities of the L2 and L3 vertebrae without central canal or neural foraminal compromise. New L4 compression deformity since [**2197-8-7**] but without evidence of marrow edema suggesting that this fracture is older. . MR [**Name13 (STitle) **] W &W/O CONTRAST Study Date of [**2198-2-25**] 9:53 AM 1. Compression fracture identified at T6 vertebral body with low signal intensity, no frank evidence of retropulsion is identified. This fracture is associated with an epidural collection, likely consistent with an epidural hematoma extending from T5 through T7 level, and impinging the spinal cord as described above. 2. Multiple chronic compression fractures are noted at T7, T9, T11, T12, and L1 levels as described above. Associated multilevel degenerative changes. . EKGs [**2-24**] EKG: NSR with RBBB, LAFB, interatrial conduction disease and 2mm STD V4-V6. QW III, AVF. No prior in our system for comparison but reports from prior at [**Hospital3 **] (images not available) have RBBB and inferior Q waves. . [**2-25**] Sinus rhythm with premature atrial contractions. First degree A-V block. Right bundle-branch block. Inferior myocardial infarction of indeterminate age and lateral-apical ST segment depressions are suggestive of myocardial ischemia. Compared to the previous tracing of [**2198-2-24**] premature atrial contractions are new and the lateral ST segment changes are new. . [**2-28**] Sinus rhythm. Prior inferolateral myocardial infarction. Right bundle-branch block. Ongoing ST segment elevation inferiorly with more prominent ST segment depression in leads I and aVL. There is variation in precordial lead placement in the lateral leads. The ST-T wave changes are consistent with ongoing ischemic process. Rule out myocardial infarction. Followup and clinical correlation are suggested. . [**3-1**] Sinus rhythm with slowing of the rate as compared with previous tracing of [**2198-2-28**]. There is continued evidence of active inferolateral ischemic process and continuing right bundle-branch block. Rule out myocardial infarction. Followup and clinical correlation are suggested. . [**3-1**] Sinus rhythm. Right bundle-branch block. Probable old inferior myocardial infarction. No change compared to earlier tracings of [**2198-3-1**] and [**2198-2-25**]. . ECHO [**2-28**] The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with 55%. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. . IMPRESSION: Suboptimal image quality. Preserved biventricular function. Regional wall motion abnormalities consistent with CAD (inferior ischemia). No significant valvular abnormality. . CXR [**2-25**] In comparison with the study of [**2-24**], there are continued low lung volumes. Areas of opacification at the bases are consistent with atelectasis and effusion. There may be minimal asymmetric elevation of pulmonary venous pressure, more prominent on the right. No pneumothorax is identified. . CXR [**3-1**] In comparison with the study of [**2-25**], there are continued low lung volumes that may account for much of the prominence of the transverse diameter of the heart. There is increasing opacification at both bases with silhouetting of the hemidiaphragms. This is consistent with pleural effusions and compressive atelectasis. However, in the appropriate clinical setting, supervening pneumonia could not be excluded. . CXR [**3-5**] FINDINGS: Since prior radiograph acquired over the last 24 hours, there has not been no significant changes in the lung. Bibasal mild atelectasis is similar. Upper lungs are clear, and there are no lung opacities concerning for pneumonia or aspiration or new areas of atelectasis. Heart size, mediastinal and hilar contours are normal. There is no pleural effusion. Brief Hospital Course: 73 year old man with severe COPD on 3L home O2, HTN, HL, osteoporosis status post compression fractures and vertebrolplasty T11-L1 now with new T4-T6 compression fracture causing impingment and loss of motor and sensation below that level now s/p laminectomy. . #T6 Vertebral fracture with spinal cord compression: Presented to an outside hospital with paralysis and back pain. An MRI showed concern for epidural hematoma versus T6 fracture with retropulsion vs tumor/mass in the Non-con MRI and he was transferred here. MRI with contrast here showed compression fracture identified at T6 vertebral body with low signal intensity though to be blood clot versus tumor compressing the spinal cord. He was started on steroids and neurosurgery then took the patient to the OR and performed a T4-T6 laminectomy. Post operatively he regained strength and sensastion in both lower extremities. Final pathology ruled out malignacy. His steroids were weaned down to his home dose. . #DEMAND CARDIAC ISCHEMIA: Patient has a history of CAD with multivessel disease (last cath [**2194**] with non-intervenable three vessel disease and deemed not a surgical candidate [**12-28**] COPD). He developed new ST depressions V4-V6 and elevated troponins. Cardiology was consulted who believed that his EKG changes and tropnonins were related to demand ischemia peri-procedurally. Given concern for epidural hematoma he was not started on plavix or heparin iniitally. We continued his home regimen of beta blocker and ace inhibitor. His atorvasattin was increased to 80mg daily. His aspirin was increased to 325 mg. Plavix was started on post operative day 10 ([**2198-3-7**]) per neurosurgery and cardiology recommendations. . #COPD/PNA/Obstructive sleep apnea: Patient has severe COPD on 3L NC at baseline. We continued his advair, Fluticasone, montelukast, albuterol, spiriva, and IV steroids were given for cord compression He was intubated for the surgery and was noted to be difficult to extubate. After extubation he repeatedly had episodes of of acute SOB and hypoxia requiring Bi-PAP. He was treated with nebulizers, diuresis, steroids, as well as vanc/zosyn/azithromycin for hospital aqcuired PNA (last day [**2198-3-8**]). He is also highly likely to have obstructive sleep apnea so his BiPAP/CPAP was used at nights. He will need a sleep study and CPAP as an outpatient. . #HYPERTENSION: We continued home lisinopril, metoprolol and Imdur. He was diuresed for his respiratory distress and his home furosemide 20 mg PO daily was restarted on discharge. His diltiazem was held for low blood pressures. . Transitional Issues: Needs Sleep study formally Needs CPAP at night for sleep apnea Needs follow up with his pulmonologist and cardiologist Medications on Admission: lisinopril (Prinivil) - 20mg - PO (By mouth) - DAILY, Fosamax - 70mg - PO (By mouth) - once a week, Calcitonin nasal spray - 200 units (1 spray each nostril) - NAS DAILY, Advair inhaler 500 - 1 puff - INH (Inhalation) - [**Hospital1 **], Flonase - INH (Inhalation) - QHS, Flovent inhaler 110 mcg - 2 puffs - INH (Inhalation) - [**Hospital1 **], Albuterol neb 2.5 mg - INH (Inhalation) - QID, Pro air inhaler 90 mcg - INH (Inhalation) - PRN, Singulair - 10mg - PO (By mouth) - DAILY, Spiriva inhaler 18 mcg - 1 capsule - INH (Inhalation) - DAILY, Diltiazem XR - 180mg - PO (By mouth) - DAILY, Metoprolol succinate ER - 150mg - PO (By mouth) - DAILY, Isosorbide mononitrate (Imdur) - 20mg - PO (By mouth) - DAILY, Plavix - 75mg - PO (By mouth) - DAILY, Ecotrin (ASA) - 81mg - PO (By mouth) - DAILY, gabapentin (Neurontin) - 100mg - PO (By mouth) - PRN, Hydromorphone - 4mg - PO (By mouth) - Q4H, ibuprofen (Advil) - 400mg - PO (By mouth) - Q4H (in between Hydromorphone), hydroxyzine (Atarax) - 50 mg - PO (By mouth) - PRN, Zyrtec - 10mg - PO (By mouth) - DAILY, Nasonex - 2 puffs - NAS (Nasal) - QHS, Atorvastatin (Lipitor) - 40mg - PO (By mouth) - QPM, Protopic ointment FUJ 0.1 - TOP (Topical) - BIDP, Econazole topical 1 - to feet - TOP (Topical) - DAILY, Mupirocin topical 2 - TOP (Topical) - [**Hospital1 **], Triamcinolone 0.1 - TOP (Topical), Clobetasol proprionate (Olux) foam 0.05 - TOP (Topical), Olux - to scalp - TOP (Topical), Colace - 100-200 mg - PO (By mouth) - DAILY, senna (Ex-lax) - 1-2 tabs - PO (By mouth) - DAILY, Calcium - 750mg/ 2tabs - PO (By mouth) - [**Hospital1 **] Multivitamin - 1tab - PO (By mouth) - DAILY, Fish oil - 1000mg/2 tabs - PO (By mouth) - [**Hospital1 **], Glucosamine/chondroitin - 1500mg/2 tabs - PO (By mouth) - [**Hospital1 **], Tylenol - 650mg - PO (By mouth) - PRN, Vitamin D - 400mg - PO (By mouth) - DAILY, Zantac - PO (By mouth) Prednisone taper - taper, until reaches 20 mg. Miralax - 17 gms - PO (By mouth) - DAILY, Oxygen - 2L during the day, 3L at night Discharge Medications: 1. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 2. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol Sig: One (1) inhalation Nasal DAILY (Daily). 3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal HS (at bedtime). 4. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. 6. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for loose stools. . 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation: Hold for loose stools. . 13. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Three (3) Tablet, Chewable PO BID (2 times a day): Total dose 1500 mg twice a day. . 14. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 16. omega-3 fatty acids Capsule Sig: Two (2) Capsule PO BID (2 times a day): Dose = [**2185**] mg twice a day. . 17. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) inhalation Inhalation once a day. 20. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 21. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 22. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 23. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 24. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulization Inhalation Q4H (every 4 hours). 25. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 26. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 27. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical twice a day as needed for rash. 28. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 29. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for anxiety. 30. econazole 1 % Cream Sig: One (1) application Topical once a day as needed for to feet. 31. Protopic 0.1 % Ointment Sig: One (1) application Topical twice a day. 32. 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. 33. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day. 34. clobetasol 0.05 % Foam Sig: One (1) application Topical once a day: As directed by your prescribing physician. 35. ipratropium bromide 0.02 % Solution Sig: One (1) nebulization Inhalation every four (4) hours as needed for shortness of breath or wheezing. 36. Xolair 150 mg Recon Soln Sig: One (1) injection Subcutaneous every two weeks: As directed by your prescribing physician. . 37. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 38. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 39. glucosamine-chondroitin Oral 40. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Do not take with other Acetaminophen-containing products. Do not drink alcohol while on this medication. . 41. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for back pain. 42. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Anxiety. 43. Nasonex 50 mcg/actuation Spray, Non-Aerosol Sig: Two (2) Nasal at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Primary Diagnoses: T6 vertebral body compression fracture T4-7 Laminectomy Demand Cardiac Ischemia Severe COPD Pneumonia . Secondary Diagnoses: COPD Coronoary artery disease Hypertension Osteoprosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair (working with PT following surgery). Discharge Instructions: Mr. [**Known lastname 16546**]: . You were admitted to [**Hospital1 69**] for concerns of spinal cord compression. We performed an MRI which showed you had a fracture in your thoracic vertebra and our neurosurgeons performed a laminectomy to correct the fracture. The pathology did not show any evidence of cancer. Following your surgery, you developed respiratory distress and were admitted to the medical intensive care unit. It was felt that your respiratory distress was due to problems with your lungs and your heart. Multiple medication changes were made to your lung and cardiac medications. It was also felt that you have a condition called sleep apnea and were started on CPAP/BiPAP at night to support your breathing. Although you were started on CPAP/BiPAP during this hospitalization, you will need to have a formal sleep study to begin this therapy at home. . **Your Plavix (Clopidogrel) was stopped around the time of your surgery. You resumed taking Plavix on [**2198-3-7**]. Resume taking 75 mg by mouth daily on [**2198-3-7**]. Please see below for additional medication changes. ** . The following changes were made to your medications: 1. The frequency of your Albuterol nebulizations was increased from every 6 hours (four times a day) to every 4 hours. 2. Your Aspirin dose was increased from 81 mg by mouth daily to 325 mg by mouth daily. 3. Your Metoprolol succinate 150 mg daily was changed to a short acting formulation called Metoprolol tartrate as we were attempting to optimize the dose of this medication. You are being discharged on Metoprolol tartrate 50 mg by mouth three times a day. Please follow up with your cardiologist regarding further management of this medication. 4. STOP taking Diltiazem XR 180 mg by mouth daily. Your blood pressure was slightly low throughout this hospitalization so Diltiazem was stopped. 5. Your Isosorbide mononitrate was increased from 20 mg by mouth daily to 30 mg by mouth daily. 6. Your Atorvastatin was increased from 40 mg by mouth daily to 80 mg by mouth daily. 7. Start using Ipratropium bromide 0.02% solultion for nebulization every four hours as needed for shortness of breath. 8. Start taking Sulfamethoxazole-Trimethoprim 800-160mg by mouth every Monday, Wednesday and Friday. This medication is to prevent a particular lung infection while you are on Prednisone. 9. Please follow instructions from your rehab facility at discharge regarding pain medications (at the time of discharge from [**Hospital1 18**], your home hydromorphone and ibuprofen were held and you were receiving 5-10 mg oxycodone every 3 hours as needed). 10. Please follow instructions from your rehab facility at discharge regarding supplemental oxygen use at home. Followup Instructions: Please call the office of Dr. [**Last Name (STitle) **] for an appointment to be seen in 6 weeks at [**Telephone/Fax (1) **] You will not need imaging at that time Pt needs formal sleep study Pt needs follow up appointments with his pulmonologist and cardiologist [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

[ "38.93", "03.09", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

19610, 19653

10606, 13200

331, 350

19896, 19896

4326, 10583

22859, 23258

2929, 2934

15401, 19587

19674, 19797

13367, 15378

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19818, 19875

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263, 293

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19911, 20084

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2759, 2913

29,685

169,340

16294

Discharge summary

report

Admission Date: [**2152-10-27**] Discharge Date: [**2152-11-4**] Date of Birth: [**2075-10-4**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: CAD, recent urosepsis with ureteral stent placement Major Surgical or Invasive Procedure: CABGx6(LIMA-LAD,SVG-D1-D2,SVG-Ramus-OM,SVG-PDA) History of Present Illness: This 77-year-old patient with recent cardiac symptoms was investigated and was found to have severe triple-vessel disease with diminished ejection fraction of about 35% and was transferred urgently for coronary artery bypass grafting. Also pt has the following history of nephrolithiasis s/p multiple shock wave lithotripsies and prostate cancer s/p brachytherapy who presented to [**Hospital **] Hospital on [**10-19**] with chills and fever to 104.4 after having undergone in office cystoscopy in [**Hospital1 1559**] the day before for urinary frequency and new left flank pain. The pt had received 1 periop dose of levaquin. During admission to the MW ED he was found to be uroseptic, hypotensive, have a creatinine of 2.0, WBC of 14, and a tropnin bump to 0.63 (later 29.9) with ST depressions in lateral leads c/w an NSTEMI. In the ED on [**10-19**] a CT was performed which showed an obstructing 1cm left distal ureteral stone with hydro. The pt was treaated with iv abx and transferred to the CCU. After the pt had been reasonably stabilized on [**10-23**], a ureteral stent was placed by Dr. [**First Name (STitle) **] to decompress the left kidney which was obstructed by a 1cm distal left ureteral stone. Per the MW chart, purulent material was drained from the kidney and the pt resopnded well clinically with a return of his creatinine to normal. After further recovery, on [**10-27**], the pt uderwent a cardiac cath which showed severe 3v dz and was transferred to [**Hospital1 18**] for CABG. The pt reports having had many stones in the past, requiring >10 shock wave lithotripsies. He is unsure, but thinks he has not had laser lithotripsies, and may have had a percutaneous nephrolitotomy on the left side in the past. He reports constant urinary frequency and urgency at baseline, urinating every 10 minutes or so. He currently denies fever, chills, nausea, vomitting, hematuria, dysuria, stent pain, flank pain, chest pain, or SOB. Past Medical History: PMH: CHF, high cholesterol, HTN, NSTEMI, prostate Ca s/p brachytherapy, BPH, nephrolithiasis s/p 12 lithotrpsies, recent urosepsis, uretel stent placement PSH: Lithos, Brachytherapy, cataract surgery Social History: Recently in rehab after fall, no tob or etoh NC Family History: NC Physical Exam: VS: 99.0/98.0 76 151/84 20 99RA NAD RRR CTAB Abd soft, NT, ND, no incisions or masses, no flank pain on either side Sternal INC C/D/I palp distal pulses Pertinent Results: [**2152-11-4**] 06:30AM BLOOD WBC-9.7 RBC-3.48* Hgb-10.8* Hct-31.6* MCV-91 MCH-31.1 MCHC-34.3 RDW-15.4 Plt Ct-583* [**2152-11-2**] 04:07AM BLOOD PT-15.7* PTT-33.4 INR(PT)-1.4* [**2152-11-4**] 06:30AM BLOOD Glucose-89 UreaN-12 Creat-1.0 Na-141 K-3.7 Cl-104 HCO3-23 AnGap-18 [**2152-11-2**] 04:07AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2 [**2152-11-1**] 09:39AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG URINE RBC->50 WBC-[**4-10**] Bacteri-OCC Yeast-NONE Epi-0 [**2152-11-1**] 9:39 am URINE Source: Catheter. CHEST (PORTABLE AP) [**2152-11-1**] 7:24 AM REASON FOR EXAM: S/P CABG. Followup pleural effusions. Comparison is made to prior study performed a day earlier. A small left pleural effusion and left lower atelectasis is persistent. Small right pleural effusion is unchanged. Left chest tube remains in place as is right IJ vein catheter. Cardiomediastinal silhouette is stable. There is no overt CHF. URINE CULTURE (Final [**2152-11-2**]): NO GROWTH. RADIOLOGY Final Report CT ABDOMEN W/O CONTRAST [**2152-10-28**] 3:42 PM Reason: please check stones / kidney abcess / hydro CT OF THE ABDOMEN WITHOUT IV CONTRAST: Small bibasilar pleural thickening/small effusions are identified. There is a small amount of atelectasis at the lung bases. Trace pericardial effusion is demonstrated. Liver, gallbladder, spleen, pancreas, adrenal glands, and visualized bowel loops are all within normal limits. A nephroureteral stent is identified within the left collecting system extending from the upper pole calix to the bladder. Air is identified within the left collecting system, and there appears to be probable mild hydronephrosis, however, the extent of hydronephrosis cannot be fully evaluated on this non- contrast examination. A left extrarenal pelvis is identified. The proximal and mid portions of the left ureter are dilated and distended with gas, and an apparent caliber change is identified within the distal ureter (series 2, image 60) because of an obstructing 8- mm calculus. There is periureteral stranding demonstrated proximal to this point of obstruction in the ureter. No other renal or ureteral calculi are demonstrated. There is mild bilateral perinephric stranding, left greater than right. No focal fluid collections to suggest an abscess are present. Bilateral simple cysts are also seen within both kidneys. The right kidney does not demonstrate any hydronephrosis. Visualized bowel loops are within normal limits. The abdominal aorta is normal in caliber but demonstrates a somewhat tortuous course. No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen. There is no free fluid within the abdomen. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Multiple fiducial seeds are seen within the prostate. The pelvic loops of bowel appear unremarkable. The bladder contains a small focus of air anteriorly, likely related to the patient's recent instrumentation. The distal right ureter appears unremarkable without evidence of stones. Some calcified phleboliths are seen within the pelvis. No pelvic or inguinal lymphadenopathy is identified. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are present. A small bone island is seen within the left proximal femur. Degenerative changes are seen involving the lumbosacral spine. IMPRESSION: 1. 8-mm obstructing calculus within the left distal ureter causing mild- moderate ureteral dilatation and probable mild hydronephrosis. Extent of hydronephrosis cannot be well characterized on this non- contrast study. Air within the left collecting system and ureter is consistent with recent instrumentation. Nephroureteral stent in place. No evidence for renal abscess. 2. Multiple simple bilateral renal cysts. Cardiology Report ECHO Study Date of [**2152-10-30**] MEASUREMENTS: Left Atrium - Long Axis Dimension: 4.0 cm (nl <= 4.0 cm) Left Atrium - Four Chamber Length: 3.7 cm (nl <= 5.2 cm) Left Ventricle - Inferolateral Thickness: *1.5 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 3.5 cm Left Ventricle - Fractional Shortening: *0.26 (nl >= 0.29) Left Ventricle - Ejection Fraction: 40% to 50% (nl >=55%) Left Ventricle - Peak Resting LVOT gradient: 2 mm Hg (nl <= 10 mm Hg) Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm) Aorta - Ascending: 3.4 cm (nl <= 3.4 cm) Aorta - Arch: 2.3 cm (nl <= 3.0 cm) Aorta - Descending Thoracic: 2.4 cm (nl <= 2.5 cm) Aortic Valve - Peak Velocity: *2.1 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 18 mm Hg Aortic Valve - Mean Gradient: 8 mm Hg Aortic Valve - Valve Area: *1.5 cm2 (nl >= 3.0 cm2) Mitral Valve - Peak Velocity: 0.8 m/sec Mitral Valve - Mean Gradient: 1 mm Hg Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.6 m/sec Mitral Valve - E/A Ratio: 1.33 Mitral Valve - E Wave Deceleration Time: 150 msec Pericardium - Effusion Size: 1.2 cm INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Moderate regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. Mild AS (AoVA 1.2-1.9cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. The MR vena contracta is <0.3cm. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: Small to moderate pericardial effusion. Conclusions: Pre bypas: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with moderate mid to apical anterior hypokinesis and mild mid to apical inferior hypokinesis. LVEF 40%. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is partial fusion of the right and left coronary cusps. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2) on multiple analyses, average [**Location (un) 109**] 1.5 cm2. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a small to moderate sized pericardial effusion. Post bypass: Patient is A paced, on phenylehperine and epinepherine infusions. LV funciton is mildly improved with LVEF 45%. RV function is unchanged. There may be slight improvement in mid anterior wall motion, (possibly due to ionotrope) but remaining wall motion is unchanged. Aortic stenosis is still mild. Aortic contours are intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. Brief Hospital Course: Admitted [**2152-10-27**], Pt transferd from outide hopital for CABG Pt pre-op'd in the usual fashion. To note pt had recent urosepsis with stent placement in the ureter. Because of this, this prompted a urology and a ID cosult. Pt started on Broad spectrum Antibiotic pre and post surgery. US of kidneys done, CT scan of pelvis done to assess for underlying abcess, ua done, cx of urine sent, blood cx's sent. All negative pt cleared for surgery. [**2152-10-30**] - Pt underewent a Coronary artery bypass graft x6, left internal mammary artery to left anterior descending artery, and saphenous vein graft sequential grafting to obtuse marginal and ramus branches, and saphenous vein graft sequential grafting to diagonal 1 and diagonal 2, and saphenous vein graft to posterior descending artery. POD # 1 Transfered to the CVICU. Required pressure support for hypotension post operative period. POD # 2 Extubated without problems, lopressor and statin started. Transfered to the floor. Chest tubes removed. POD # 3 Pacing wires removed without sequele, pt tachycardic lopressor increased, repeat ua with cx takes. IV antibiotics continued. Pt process begins PT process POD # 4 Foley [**Name (NI) 1788**] pt had some hematuria with voiding trial. Pt urine clear on DC. POD # 5 Urine Cx's X 2 negative. IV Antibiotics stopped. Pt switched to PO Cipro. Pt to continue this untill follow-up with Dr [**First Name (STitle) **] for ureatl stone removal. Lopressor increased for tachycardia. Pt stable for DC Medications on Admission: [**Last Name (un) 1724**]: Atenolol, Lovastatin 40 Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): hold for HR less then 60 SBP less then 90. 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): continue untill kidney stones are removed. 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: PRN for pain. 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital 1294**] Healthcare Center - [**Location (un) 1294**] Discharge Diagnosis: CAD CHF, high cholesterol, HTN, NSTEMI, BPH recent urosepsis, uretel stent placement prompting an ID and urology consult Discharge Condition: Stable Discharge Instructions: SHOWER DAILY and pat incisions dry no lotions, creams or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness, or drainage c/w po cipro untill you folow-up with an urologist and have the stones removed Followup Instructions: You should call your PCP and schedule an appointment for 2 weeks. [**Last Name (un) 46448**],BIPINCHANDRA [**Telephone/Fax (1) 46449**] [**Doctor First Name **] [**Doctor Last Name **] ([**Telephone/Fax (1) 1504**], two weeks this is your cardiologist. Please follow up with Dr [**First Name (STitle) **] the urologist who put your urethral stent in. He can be reached at [**Telephone/Fax (1) 46450**]. He should remove your other stones before you come of the antibiotics ciprofloxacin. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2152-11-4**]

[ "414.01", "285.9", "998.11", "998.0", "272.0", "458.29", "V10.46", "599.0", "401.9", "410.71" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

13188, 13279

10373, 11887

373, 423

13447, 13456

2915, 10350

13794, 14406

2716, 2721

11988, 13165

13300, 13426

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13480, 13771

2736, 2896

282, 335

451, 2410

2432, 2634

2650, 2700

56,287

190,062

9021+9022+9023

Discharge summary

report+report+report

Admission Date: [**2122-7-9**] Discharge Date: [**2122-7-18**] Date of Birth: [**2061-9-22**] Sex: F Service: SURGERY Allergies: Codeine / Rhogam Attending:[**First Name3 (LF) 5569**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2122-7-10**]: Exploratory laparotomy with lysis of adhesions, right colectomy, end ileostomy. [**2122-7-14**]: Paracentesis History of Present Illness: The pt is a 60-yo woman with h/o EtOH abuse and cirrhosis c/b ascites, who comes in today with RUQ pain, fevers, and hypotension. The pt started feeling ill approx 1 week ago with malaise. She also developed right-sided back pain, RUQ abd pain, fevers, and diffuse cramps over the last day. Today she also had chills and sweats, so she came in to the ED for evaluation. She endorses lightheadedness and nausea, but denies vomiting, diarrhea, change in bowel habits, hematemesis, melena, hematochezia, or worsening jaundice or abdominal distension. She describes her back pain as constant achey [**9-1**] pain at the back of the right ribcage below the scapula, while she describes the RUQ abd pain as intermittent, sharp, [**9-1**] pain. She describes them as two separate, different pains, without radiation or clear exacerbating factors. . In the ED, VS - Temp 102.2F, BP 117/78, HR 84, R 24, SaO2 100% RA. Her BPs subsequently decreased as low as the 60s systolic, so she was given IVF and started on pressors, although her mental status was never compromised. She received a total of 7L NS IVF in the ED, as well as being started on the Levophed and Dopamine gtts. She also received Zosyn 4.5mg IV x1 and Vancomycin 1g IV x1 for broad-spectrum Abx coverage, Tylenol, Zofran, Morphine, and Protonix IV. Labs revealed WBC 10.2 (90% PMNs) and lactate 3.8, but otherwise normal lytes, renal function, and LFTs, negative CEs, negative tox screen, and negative UA. RUQ U/S showed cirrhosis, and no evidence of portal vein thrombosis or acute gallbladder process. CT Abd/Plv showed cirhosis, mildly distended GB w/o stones or wall edema, bowel wall thickening nonspecific in setting of ascites, and normal appendix. CXR showed no acute pulmonary process. Surgery was consulted, who saw the pt once she was admitted to the MICU. She is admitted for further care. . In the MICU, repeat labs showed further elevation of her WBC to 25.2, increased INR to 1.8, increased Cr to 1.2, decreased HCO3 to 17, and no significant change in her lactate. SCVO2 was found to be 83%, and CVP 13-16. Past Medical History: - EtOH abuse: last drink [**2122-2-28**], drank "heavy" x15 years - Cirrhosis: c/b ascites, esophgeal varices w/o hemorrhage - Prior admission for ischemic colitis - Asthma - Gastric ulcers - Hypothyroidism - Chronic diarrhea - s/p gastric bypass 14 years ago - s/p multiple abdominal hernia operations - s/p hysterectomy for endometriosis and "abnormal looking cells" Social History: Quit smoking 25 years ago. Last drink ETOH [**2122-2-28**]. Denies drugs. Lives with husband who is s/p renal transplant from daughter. [**Name (NI) 4906**] works a lot so patient is often home alone without help to care for herself. Mentioned only 2 daughters, but other notes say four children, one of which is estranged. Has grandson 6 y/o who she helps to take care of. Currently unemployed. Has worked in billing and collections in past. Family History: Father, brother and uncle have [**Name (NI) 3729**]. +family history of Crohn's. Physical Exam: General Appearance: Well nourished, No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Wheezes : , No(t) Rhonchorous: ) Abdominal: Soft, Bowel sounds present, Tender: RUQ, + right CVA tenderness, Obese, mildly distended Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing Skin: Warm, Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal Pertinent Results: [**2122-7-9**] 09:08PM WBC-25.2*# RBC-3.51* HGB-10.1* HCT-30.8* MCV-88 MCH-28.6 MCHC-32.7 RDW-17.4* [**2122-7-9**] 09:36PM LACTATE-3.3* [**2122-7-9**] 09:08PM GLUCOSE-111* UREA N-17 CREAT-1.2* SODIUM-136 POTASSIUM-2.9* CHLORIDE-106 TOTAL CO2-17* ANION GAP-16 [**2122-7-17**] 09:50AM BLOOD WBC-12.4* RBC-3.69* Hgb-10.8* Hct-32.9* MCV-89 MCH-29.2 MCHC-32.7 RDW-18.8* Plt Ct-146* [**2122-7-16**] 07:10AM BLOOD PT-19.5* PTT-41.7* INR(PT)-1.8* [**2122-7-17**] 09:50AM BLOOD Glucose-105* UreaN-12 Creat-0.7 Na-134 K-4.5 Cl-104 HCO3-21* AnGap-14 Brief Hospital Course: 60-yo woman with EtOH cirrhosis, h/o ischemic colitis, presenting with right back and RUQ abd pain, fevers, and hypotension on [**2122-7-9**]. In the ED, VS - Temp 102.2F, BP 117/78, HR 84, R 24, SaO2 100% RA. Her BPs subsequently decreased as low as the 60s systolic, so she was given IVF and started on pressors, although her mental status was never compromised. She received a total of 7L NS IVF in the ED, as well as being started on the Levophed and Dopamine gtts. She also received Zosyn, Vancomycin for broad-spectrum Abx coverage, Tylenol, Zofran, Morphine, and Protonix IV. Labs revealed WBC 10.2 (90% PMNs) and lactate 3.8, but otherwise normal lytes, renal function, and LFTs, negative CEs, negative tox screen, and negative UA. RUQ U/S showed cirrhosis, and no evidence of portal vein thrombosis or acute gallbladder process. CT Abd/Plv showed cirrhosis, mildly distended GB w/o stones or wall edema, bowel wall thickening nonspecific in setting of ascites, and normal appendix. CXR showed no acute pulmonary process. Surgery was consulted, who saw the pt once she was admitted to the MICU. She is admitted for further care. Patient was initially transferred to the MICU for evaluation. She was kept on broad spectrum antibiotics of vancomycin, zosyn and flagyl. However, given increasing pressor requirement for hypotension, rising lactic acidosis, she was evaluated by surgery and transferred to their service for further care. Please see operative note for further details. Procedure performed was an exploratory laparotomy, lysis of adhesions, right colectomy, and end ileostomy ([**2122-7-10**]). Intraoperative findings concerning and consistent for a rather ischemic right colon. Her operation involved a right colectomy with end ileostomy. We encountered no complications to the procedure and transferred to the SICU for further management and care. She left the SICU in stable condition on [**2122-7-14**] and was transferred to the general surgical floor. Her post-operative course were as follows: POD1: Pressor requirement successfully weaned off. Extubated without issues. Antibiotics continued. Stoma appeared patent and intact. Pain was well controlled with dilaudid. Albumin for resuscitation colloid. POD2: Transfused blood (1 unit) for Hct 25. With resuscitation, urine production improved and resolved renal failure. NGT removed and antibiotics discontinued. Ostomy with flatus. POD3: Pain continued to be well controlled. Started on clear diet. Pressor requirement continued to be weaned. Stoma consult from nursing wound care. Ostomy continued to work without issues. POD4: Weaned off pressors. Diet advanced to regular food. She was transferred to general surgical floor. Reports worsening abdominal pain. Hepatology consulted since arrival performed diagnostic paracentesis and removed 1L of fluid. POD5: Restarted lasix and aldactone. Albumin discontinued. Social work and physical therapy consulted. Disposition plan initiated. Physical therapy cleared patient for discharge with home physical therapy. She is tolerating a regular diet and continues to ambulate with a walker. Vicodin providing pain control. She will be discharged on [**2122-7-18**] with VNA services. Medications on Admission: - Magnesium 64mg 2tabs PO TID - Levothyroxine 50mcg PO daily - Mirtazapine 15mg PO QHS - Nadolol 20mg PO daily - Omeprazole 40mg PO daily - Paroxetine 30mg PO daily - Spironolactone 200mg PO daily - Multivitamin 1tab PO daily - Docusate 100mg PO BID PRN constipation - Furosemide 80mg PO daily - KCl 20mEq PO TID Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for SOB, cough, wheeze. 2. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for SOB, cough, wheeze. 3. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: Two (2) Capsule PO twice a day: take when also taking narcotic. Disp:*120 Capsule(s)* Refills:*2* 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 12. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right colon ischemia Discharge Condition: Stable/fair A+Ox3 Ambulatory with walker, needs home PT Discharge Instructions: Please call Dr [**Last Name (STitle) 17116**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, inability to eat, take medications or keep up with fluids. Monitor the incision for redness drainage or bleeding Monitor the ostomy output, take care of the ostomy to assure it appears red, keep appliance on and empty as needed throughout day. No heavy lifting You may shower, pat abdomen dry and assure appliance in place. Follow social work recommendations regarding relapse prevention counseling and joining a support group for colostomy Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2122-7-30**] 2:20 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-7-23**] 1:20 Admission Date: [**2122-7-23**] Discharge Date: [**2122-7-31**] Date of Birth: [**2061-9-22**] Sex: F Service: SURGERY Allergies: Codeine / Rhogam / Morphine Attending:[**First Name3 (LF) 5569**] Chief Complaint: abdominal distension, incisional drainage, LE edema Major Surgical or Invasive Procedure: Post pyloric feeding tube History of Present Illness: 60 YOF with EtOH cirrhosis (Child's B) s/p colectomy/ileostomy for ischemic colitis on [**2122-7-10**] presented to f/u clinic appt today with increased abdominal distension, drainage from her incision, and LE edema. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] arranged for a direct admission to the Transplant Surgery service for further evaluation. Mrs. [**Known lastname 2643**] reports that since her hospital discharge on [**2122-7-18**], she has experienced slowly increasing abdominal distension and diffuse pain. She notes particular tenderness over her inferior abdomen bilaterally, as well as over her RUQ. On [**7-20**] she noticed serous fluid draining from the inferior aspect of her incision, which, in the following days, leaked enough fluid to necessitate changing her bed sheets/clothes. While she has been drinking several glasses of water per day, she admits that she has barely eaten anything. She does endorse that she has taken her meds as directed. She has noted a decrease in urine output as well. She reports difficulty ambulating due to fatigue and weakness. She additionally feels that her mood has declined significantly since her discharge. ROS: A 12 pt ROS was completed and was negative aside from that described in the HPI. Notably, she denies F/C, CP, SOB, N/V. She notes that she has continued to have loose stool per her ostomy since her discharge. Past Medical History: - EtOH abuse: last drink [**2122-2-28**], drank "heavy" x15 years - Cirrhosis: c/b ascites, esophgeal varices w/o hemorrhage - Prior admission for ischemic colitis - Asthma - Gastric ulcers - Hypothyroidism - Chronic diarrhea - s/p gastric bypass 14 years ago - s/p multiple abdominal hernia operations - s/p hysterectomy for endometriosis and "abnormal looking cells" Social History: Quit smoking 25 years ago. Last drink ETOH [**2122-2-28**]. Denies drugs. Lives with husband who is s/p renal transplant from daughter. [**Name (NI) 4906**] works a lot so patient is often home alone without help to care for herself. Mentioned only 2 daughters, but other notes say four children, one of which is estranged. Has grandson 6 y/o who she helps to take care of. Currently unemployed. Has worked in billing and collections in past. Family History: Father, brother and uncle have [**Name (NI) 3729**]. +family history of Crohn's. Physical Exam: V: T 96, P 69, BP 117/61, 20, 98% RA Gen: Alert, oriented. NAD. HEENT: PERRL. Moist mucous membranes. Neck: No lAD. No JVD appreciated. CV: RRR. 3/6 systolic murmur heard best at LUSB. Pulm: Bibasilar crackles. Abd: Normoactive BS. Soft, distended, diffusely tender. No tympany. No rebound or gaurding. Incision clean with staples in place. Incisional drainage noted just lateral to the umbilicus, as well as at the base of the incision. Ext: Warm. 2+ LE pitting edema. DP pulses 2+. Pertinent Results: On Admission: [**2122-7-23**] WBC-11.0 RBC-3.11* Hgb-9.5* Hct-28.2* MCV-91 MCH-30.5 MCHC-33.6 RDW-19.2* Plt Ct-273# PT-19.4* PTT-41.1* INR(PT)-1.8* Glucose-102* UreaN-13 Creat-0.8 Na-133 K-3.2* Cl-98 HCO3-21* AnGap-17 ALT-13 AST-30 AlkPhos-93 Amylase-25 TotBili-4.7* Calcium-8.3* Phos-3.2 Mg-1.2* On Discharge: [**2122-7-30**] WBC-11.5* RBC-2.71* Hgb-8.2* Hct-24.9* MCV-92 MCH-30.4 MCHC-33.1 RDW-19.2* Plt Ct-312 PT-20.6* PTT-44.6* INR(PT)-1.9* Glucose-132* UreaN-13 Creat-0.6 Na-132* K-4.2 Cl-101 HCO3-21* AnGap-14 ALT-8 AST-21 AlkPhos-108* TotBili-2.3* Calcium-9.2 Phos-2.3* Mg-1.6 Brief Hospital Course: 60 y/o female with recent colectomy/ileostomy for ischemic colitis who returns with nausea, vomiting, abdominal distention and lower extremity edema. On admission, ultrasound showed massive ascites and she underwent paracentesis with removal of 4.5 liters of ascites. Cultures were taken and she was found to have Vanco resistant enterococcus in the fluid. She was not having fevers, so Daptomycin and Flagyl were not started until the culture data was returned. Also identified on the ultrasound was Minimal to no flow identified in the portal veins on the limited Doppler examination. Due to concern for the portal vein an abdominal CT was obtained which did show patency of the portal vein, and again noted ascites and cirrhotic appearance of liver. Diuretics were initally started back at half of home dose. Kidney function remained stable and electrolyes were not grossly disarrayed, so home dose was restarted due to lower extremity edema and the ascites management. She remained afebrile throughout the hospitalization. She was changed to PO Linezolid for home to continue therapy for the VRE. The enterostomal nurse follwed during this admission and the patient has done well with learning ostomy management. Tube feeds were continued via post pyloric feeding tube. On the day befroe discharge the patient had c/o sharp right upper quadrant pain. An ultrasound was taken which showed no evidence of acute cholecystitis. Gall bladder wall thickening is compatible with chronic liver disease. No cholelithiasis. She was discharged to home the following day. Tolerating tube feeds and minimal PO intake. We started to cycle tube feeds in hopes of generating some appetite, and giving her some time away from the tubing. She is independent with ambulation and is caring for the ostomy on her own Medications on Admission: . Albuterol Sulfate 90 mcg Inhaler 1-2 puffs q4 hrs PRN SOB, cough, wheezing 2. Ipratropium Bromide 17 mcg Inhaler 1-2 puffs, 4 times daily PRN SOB, cough, wheezing 3. Spironolactone 100mg daily 4. Furosemide 80mg daily 5. Hydrocodone-Acetaminophen 5-500 mg 1-2 tabs q6 hrs PRN pain 6. Colace 200mg [**Hospital1 **] 7. Omeprazole EC 40mg daily 8. Nadolol 20 mg daily 9. Trazodone 25mg qHS PRN insomnia 10. Levothyroxine 50 mcg daily 11. Mirtazapine 15 mg qHS 12. Fluoxetine 30mg dialy 13. Multivitamin Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 14. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day: Start once daily cipro after completing 9 days of [**Hospital1 **] cipro. Disp:*30 Tablet(s)* Refills:*2* 17. Outpatient Lab Work Outpatient Lab Work CBC, Chem 10, ALT, AST, Alk Phos, T Bili Fax results to Dr [**Last Name (STitle) 17116**] office [**Telephone/Fax (1) 22248**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Spontaneous Bacterial peritonitis Malnutrition Discharge Condition: Stable A+Ox3 Ambulatory Discharge Instructions: Please call Dr [**Last Name (STitle) 17116**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, diarrhea, abdominal pain, inability to tolerate tube feeds, problems with the feeding tube to include clogging or malposition. Keep the tube taped securely to your nose, and do not allow the tube to hang freely. Continue ostomy care as you have been taught. No heavy lifting Change dressing [**Hospital1 **] and as needed on abdominal incision Weigh yourself daily. Call if you note more than a 3 pound gain or loss within a 24 hour period Followup Instructions: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-8-7**] 2:40 Completed by:[**2122-8-4**] Admission Date: [**2122-8-3**] Discharge Date: [**2122-8-6**] Date of Birth: [**2061-9-22**] Sex: F Service: SURGERY Allergies: Codeine / Rhogam / Morphine Attending:[**First Name3 (LF) 5569**] Chief Complaint: Bright red blood per ostomy Major Surgical or Invasive Procedure: EGD w/ banding of 1 esophageal varix Dobhoff feeding tube placement History of Present Illness: Mrs. [**Known lastname 2643**] is a 60 year old woman with EtOH cirrhosis (Child's class B) with known gastric varices who is s/p colectomy/ileostomy for ischemic colitis on [**2122-7-10**]. She was just discharged 3 days ago after being hospitalized [**Date range (1) 31232**] for failure to thrive, lower extremity edema, SBP, and concern for portal vein thrombosis. She returns today after she developed bright red bleeding from her ostomy. She was scheduled for a [**Hospital 702**] clinic appointment today and says that as she got up from bed to put on her clothes and shoes, she noticed blood dripping on the floor. She looked down and saw bright red blood within her ostomy bag and leaking out. She could not tell whether the bleeding was from the stoma itself or from around the stoma. She approximates the quantity of blood to be about a cup and a half. Her husband told her to quickly lay down again and the bleeding seemed to subside. She denies any trauma to her ostomy and says she has not changed her appliance since leaving the hospital and today was supposed to be the day she was to change it. The ostomy itself is not painful but she does endorse epigastric abdominal pain and pain in the RUQ superior to the ostomy. However, this pain has been chronic and is stable from prior. The last time she was hospitalized, her LFTs were normal and RUQ ultrasound was unremarkable. She denies fever, chills, vomiting, dysuria, dizziness/lightheadedness. She does endorse nausea when she tries to eat but says this has been chronic and persistent since her surgery. She says she is unable to even brush her teeth without feeling like gagging. She has not vomited recently. Her hct today is 24.5 which is stable from her discharge hct of 24.9. Past Medical History: PMH: 1. EtOH abuse x15 yrs: last drink [**2122-2-28**] 2. Cirrhosis: c/b ascites, esophageal varices w/o hemorrhage 3. Hx of ischemic colitis 4. Asthma 5. Gastric ulcers 6. Hypothyroidism 7. Chronic diarrhea 8. Depression PSH: 1. gastric bypass 14 years ago 2. multiple incisional hernia operations 3. hysterectomy for endometriosis and "cell abnormality" 4. exploratory laparotomy with lysis of adhesions, right colectomy, end ileostomy [**2122-7-10**] Social History: Quit smoking 25 years ago. Last drink ETOH [**2122-2-28**]. Denies drugs. Lives with husband who is s/p renal transplant from daughter. [**Name (NI) 4906**] works a lot so patient is often home alone without help to care for herself. Mentioned only 2 daughters, but other notes say four children, one of which is estranged. Has grandson 6 y/o who she helps to take care of. Currently unemployed. Has worked in billing and collections in past. Family History: Father, brother and uncle have [**Name (NI) 3729**]. +family history of Crohn's. Physical Exam: T: 98.1, HR: 75, BP: 90/47, RR: 20, O2Sat: 99%RA GEN - NAD, S&O HEENT - EOMI, MMM, sclera anicteric CVS - RRR PULM - CTAB, no W/R/R ABD - soft, diffusely tender but worst in the epigastric area and RUQ, no rebound/guarding, nondistended; there is a midline incision with staples in place; no associated erythema, fluctuance or induration; there is active drainage of a small amount of yellow serous fluid from 2 areas of the incision, one near the middle of the incision and one more inferiorly; there is approximately 200cc of bright red blood mixed with liquid stool in the ostomy appliance; this was taken down and her stoma was cleaned off; her stoma is pink and beefy; there is currently no active bleeding from either around the stoma or from within it EXTREM - warm/dry, trace pitting edema of the ankles Pertinent Results: Labs on Admission: WBC-10.5 RBC-2.69* Hgb-8.3* Hct-24.5* MCV-91 MCH-30.7 MCHC-33.6 RDW-20.7* Plt Ct-257 Neuts-74* Bands-1 Lymphs-8* Monos-9 Eos-1 Baso-0 Atyps-4* Metas-2* Myelos-1* PT-16.8* PTT-33.1 INR(PT)-1.5* Glucose-92 UreaN-15 Creat-0.6 Na-135 K-4.7 Cl-101 HCO3-25 AnGap-14 ALT-10 AST-34 AlkPhos-65 TotBili-2.8* Albumin-3.5 Calcium-10.3 Phos-2.8 Mg-1.3* Labs on Discharge: WBC-9.5 RBC-2.86* Hgb-8.9* Hct-26.5* MCV-93 MCH-31.1 MCHC-33.6 RDW-20.5* Plt Ct-267 PT-17.2* PTT-32.8 INR(PT)-1.5* Glucose-110* UreaN-15 Creat-0.9 Na-132* K-4.4 Cl-96 HCO3-25 AnGap-15 Calcium-9.9 Phos-3.7 Mg-1.5* Brief Hospital Course: Mrs. [**Known lastname 2643**] is a 60 woman with EtOH cirrhosis and known gastric varices s/p colectomy/ileostomy who presented with bright red bleeding from her ostomy. On admission to the Transplant Surgery service, there was no active bleeding from her stoma. Serial hematocrits were checked, all of which remained stable from her last admission. She was maintained on a clear liquid diet, with her tube feedings held. A Gastroenterology/Hepatology consult was obtained, and on hospital day #3 she underwent EGD to evaluate for parastomal varices. No active bleeding was identified. One lower esophageal varix was banded, however, no parastomal varices were visualized. Her Dobhoff feeding tube came out during the procedure and thus had to be reinserted, with IR assisting with post-pyloric positioning. Her tube feedings were restarted. She had remained without active bleeding since admission, and her hematocrit had remained stable. On hospital day #4 she was deemed appropriate for discharge, with arrangements made for continued VNA services to assist with ostomy care and tube feedings. Medications on Admission: 1. albuterol sulfate 90mcg INH 1-2 puffs q4hrs prn SOB/wheeze 2. ciprofloxacin 500mg PO BID, to end [**8-11**] 3. lasix 80mg PO daily 4. atrovent 17mcg HFA, 2puffs QID prn SOB/wheeze 5. levothyroxine 50mcg PO daily 6. linezolid 600mg PO BID, to end [**8-11**] 7. mirtazapine 15mg PO daily 8. nadolol 20mg PO daily 9. omeprazole 40mg PO daily 10. zofran 4mg PO q8hrs prn nausea 11. oxycodone 5-10mg PO q6hrs prn pain 12. paroxetine 30mg PO daily 13. spironolactone 200mg PO daily 14. sucralfate 1g PO QID 15. magnesium chloride 128mg PO TID 16. MVI 1 cap PO daily Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): On [**8-12**] decrease dose to 500mg (1 tab) once daily for prophylaxis. Disp:*30 Tablet(s)* Refills:*1* 2. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Last dose 7/20 PM. 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Paroxetine HCl 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*1* 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation q4 hrs PRN as needed for SOB/wheeze. 14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q6 hrs PRN. Disp:*15 Tablet(s)* Refills:*0* 15. Zofran 4 mg Tablet Sig: One (1) Tablet PO q8 hrs PRN as needed for nausea. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: EtOH liver cirrhosis GI bleed Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Please call Dr.[**Name (NI) 8584**] office ([**Telephone/Fax (1) 673**]) if you experience any of the danger signs listed below. -Continue tube feeds per hospital teaching. VNA will be visiting to assist with any questions or problems. -Please do not drive while taking narcotic pain medications. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-8-14**] 1:40 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2122-8-20**] 9:20

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Discharge summary

report

Admission Date: [**2141-1-11**] Discharge Date: [**2141-1-22**] Date of Birth: [**2100-11-23**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Sulfonamides / Zithromax / Ceftin Attending:[**First Name3 (LF) 2763**] Chief Complaint: Abdominal pain, nausea, vomiting and diarrhea. Major Surgical or Invasive Procedure: Endotracheal intubation Right and left central lines Three arterial lines History of Present Illness: Ms. [**Known lastname 17492**] is a 40 year-old female with a history of cirrhosis secondary to hepatitis C with a possible contribution by previous alcohol use and complicated by varices, COPD who presented to an OSH ED with nausea, vomiting, diarrhea and question of melena (occured 1-2 weeks ago). She was seen at the same OSH ED prior and felt to have mild ileitis and discharged. Per hepatology note, she was having 3 weeks of diffuse abdominal pain which became acutely worse over past two days. She noted a weight gain and loss of apetite. Denied BRBPR, no hematemsis. Symptoms have been going on for weeks to months although unclear per records. She also noted left breast pain for 3 weeks. Patient was transferred to [**Hospital1 **] ED for further care. In the ED she was noted to be tachypnic. Her initial vitals were 99.6, 126, 111/47, 17-23, 99% 6L (83% RA). She was markedly tachypnic, worse when lying down. A rash was noticed on her abdomen and chest (including left breast) and thighs. She was given vancomycin, levofloxacin and Flagyl for broad coverage (cellulitis, ascities, pneumonia, colitis). She was noted to be wheezy and was treated for a COPD exacerbation with steroids and nebs. Her respiratory status did not improve and she was sedated and intubated to protect her airway. CTA did not reveal a PE. After intubation her blood pressure dropped. She was started on phenylephrine and propofol and fentanyl. A right IJ was attempted but went into the axillary vein and a left IJ was placed. She was seen by transplant surgery who was not concerned about her rash for a necrotizing fascitiis. She was admitted to the MICU for further care. Further history was not possible owing to sedation. Review of systems: Per Hepatology note (interview in ED prior to sedation and intubation): Positive for headache. No fever, no dizziness, no CP, no SOB, no cough, no dysuria, no urgency, she had not noted the rash that was obvious on physical exam. No muscle-joint pain, no numbness. She had coarse voice for the past 4 months that has been evaluated by ENT who recommend maxiam anti-reflux treatment and videostroboscopy exam. Past Medical History: 1. Seizure disorder 2. Cellulitis 3. Chronic obstructive pulmonary disease (COPD), shown not to have alpha-1 anti-trypsin deficiency. 4. Depression 5. DM Type 2 (per patient) 6. Smoking 7. Hepatitis C cirrhosis with type 1b 8. Esophageal varices Social History: Lives in [**Location 2251**] with roomates. On disability. Tobacco: Smokes 1 pack every four days for past two years. Formerly, smoked 1 pack/day since childhood. EtOH: Former heavy drinker, denies current use. Drugs: former IVDU (heroin), denies current use. Family History: Sister with COPD - is about 15 years older. Father - liver failure [**1-24**] EtOH. Sister - liver failure [**1-24**] chronic hepatitis. Physical Exam: General: Intubated, sedated, withdraws to pain - GCS 5 with sedation. HEENT: Sclera mildly icteric, intubated. Neck: supple, JVP not elevated, no LAD. Lungs: decreased lung sounds on right. Left with rhochi and occasional wheeze CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, distended, moderatly tense, +bowels sounds GU: Foley catheter in place. Ext: anasarca. Skin: Rash on LLQ, multiple confluescent white 5-10mm papules on an erythematous base, which are non blanching. Diffuse petechial rash on chest, non blanching. Chronic venous stasus changes on lower extremities b/l. Numerous tattoos with baudy themes. Pertinent Results: Labs on Admission: [**2141-1-11**] 04:00PM BLOOD WBC-1.3*# RBC-3.01* Hgb-9.3* Hct-28.5* MCV-95 MCH-30.7 MCHC-32.4 RDW-19.1* Plt Ct-87*# [**2141-1-11**] 04:00PM BLOOD Neuts-28* Bands-40* Lymphs-8* Monos-4 Eos-0 Baso-2 Atyps-0 Metas-18* Myelos-0 NRBC-6* [**2141-1-11**] 04:00PM BLOOD Plt Smr-LOW Plt Ct-87*# [**2141-1-12**] 12:07AM BLOOD Fibrino-172 [**2141-1-11**] 04:00PM BLOOD Glucose-40* UreaN-16 Creat-0.6 Na-137 K-3.2* Cl-97 HCO3-27 AnGap-16 [**2141-1-11**] 04:00PM BLOOD ALT-19 AST-41* AlkPhos-61 TotBili-9.8* DirBili-5.9* IndBili-3.9 [**2141-1-11**] 04:00PM BLOOD Lipase-8 [**2141-1-12**] 03:25AM BLOOD CK-MB-19* MB Indx-6.0 cTropnT-<0.01 [**2141-1-12**] 12:07AM BLOOD Calcium-6.9* Phos-3.6 Mg-1.4* [**2141-1-12**] 12:07AM BLOOD D-Dimer-8874* [**2141-1-11**] 06:05PM BLOOD Ammonia-30 [**2141-1-11**] 04:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2141-1-11**] 06:18PM BLOOD Lactate-8.3* Micro: Blood Culture, Routine (Final [**2141-1-15**]): STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES. Note: For treatment of meningitis, penicillin G MIC breakpoints are <=0.06 ug/ml (S) and >=0.12 ug/ml (R). Note: For treatment of meningitis, ceftriaxone MIC breakpoints are <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R). For treatment with oral penicillin, the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R). SULFA X TRIMETH sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | CEFTRIAXONE-----------<=0.06 S ERYTHROMYCIN---------- =>1 R LEVOFLOXACIN---------- <=0.5 S PENICILLIN G----------<=0.06 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- R VANCOMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [**2141-1-12**]): REPORTED BY PHONE TO DR. [**Last Name (STitle) **]. VUGHN ON [**2141-1-12**] AT 0530. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Anaerobic Bottle Gram Stain (Final [**2141-1-12**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. URINE CULTURE (Final [**2141-1-13**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2141-1-12**] 1:15 am Influenza A/B by DFA Source: Nasopharyngeal aspirate. **FINAL REPORT [**2141-1-12**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2141-1-12**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2141-1-12**]): Negative for Influenza B. [**2141-1-12**] 3:56 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2141-1-15**]** GRAM STAIN (Final [**2141-1-12**]): [**10-16**] PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS , IN SHORT CHAINS. RESPIRATORY CULTURE (Final [**2141-1-15**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Please contact the Microbiology Laboratory ([**6-/2437**]) immediately if sensitivity to clindamycin is required on this patient's isolate. 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. STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH. PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STREPTOCOCCUS PNEUMONIAE | | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- S TRIMETHOPRIM/SULFA---- <=0.5 S [**2141-1-12**] 1:20 pm Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 **FINAL REPORT [**2141-1-13**]** Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 (Final [**2141-1-13**]): Negative for Herpes simplex by immunofluorescence [**2141-1-12**] 1:20 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS **FINAL REPORT [**2141-1-13**]** DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final [**2141-1-13**]): Negative for Varicella zoster by immunofluorescence. [**2141-1-16**] 4:52 pm BLOOD CULTURE Source: Line-central. Blood Culture, Routine (Preliminary): [**Female First Name (un) **] ALBICANS. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. Aerobic Bottle Gram Stain (Final [**2141-1-18**]): REPORTED BY PHONE TO DR. [**First Name (STitle) **] [**Doctor Last Name **] PAGER [**Numeric Identifier 99117**] @ 0328 ON [**2141-1-18**]. BUDDING YEAST. Studies: CXR ([**1-11**]): 1. Right and possible left pleural effusion and cardiomegaly with pulmonary vascular congestion. 2. Malpositioned central venous line. The line needs to be repositioned. CT ABD/Pelvis ([**1-11**]): 1. Numerous bilateral rib fractures, with evidence of bilateral acute rib fractures, some of which show slight displacement. 2. Large right pleural effusion with associated atelectasis and left lower lobe consolidation. 3. Notably suboptimal study, nevertheless with no evidence of central pulmonary embolism, aortic dissection, or aneurysm. 4. Ascites, consistent with cirrhosis and splenomegaly as well as varices. 5. Diffuse colonic wall thickening, conceivably related to third spacing of fluids, though this must be correlated to the clinical status as colitis cannot be excluded. CTA Chest ([**1-11**]): IMPRESSION: 1. Numerous bilateral rib fractures, with evidence of bilateral acute rib fractures, some of which show slight displacement. 2. Large right pleural effusion with associated atelectasis and left lower lobe consolidation. 3. Notably suboptimal study, nevertheless with no evidence of central pulmonary embolism, aortic dissection, or aneurysm. 4. Ascites, consistent with cirrhosis and splenomegaly as well as varices. 5. Diffuse colonic wall thickening, conceivably related to third spacing of fluids, though this must be correlated to the clinical status as colitis cannot be excluded. CT Head ([**1-11**]): IMPRESSION: 1. No acute intracranial abnormality. 2. Paranasal sinus disease. ECHO: 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 high (>4.0L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. 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. No mass or vegetation is seen on the mitral valve. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CT Chest/ABD/Pelvis ([**1-17**]): 1. Moderate right pleural effusion, smaller than on the prior examination. Extensive bibasilar atelectasis and multifocal bilateral lung opacities minimally improved since the prior study concerning for multifocal pneumonia. 2. Abdominal ascites, slightly increased in volume compared to the prior study. 3. Cirrhotic liver with splenomegaly and splenic varices. 4. Pan colonic wall thickening suggestive of pancolitis. Etiology includes infection or inflammatory. However third spacing may cause a similar finding. 5. Bilateral rib fractures including displaced right-sided rib fractures. Unchanged from the prior study. Correlate with possible history of CPR. 6. Total body anasarca. ABD US: 1. Patent portal vein. 2. Nodular liver consistent with cirrhosis as well as small ascites. 3. No focal hepatic lesions. Brief Hospital Course: Summary Ms. [**Known lastname 17492**] was a 40 year-old woman with cirrhosis [**1-24**] hep C, COPD, DM, depression who presented with abdominal pain, nausea, vomiting, possible melena 1 week ago, breast pain and a rash. She also had broken ribs on presentation. It was difficult to obtain an accurate and clear history secondary to her intubation for altered mental status and difficulty protecting her airway in the ED. Throughout her hospitalization her [**Location (un) 2611**] coma scale score never rose above crude localization to pain (GCS [**3-27**]), despite cessation of sedative medication. She was initially septic, developed worsening end organ damage, had fungemia and eventually developed coagulopathy and disseminated intravascular coagulation and became transfusion depended with significant hematochezia that was not responsive to blood products. She was made comfort measures only by her sole relatives, sister and [**Name2 (NI) 802**], passing away several hours later. The medical examiner did not take this case, but it was discussed given unexplained broken ribs at admission. Hospital [**Last Name (un) **] by Problem Abdominal symptoms Numerous differential diagnoses were considered: SBP, cholangitis, mesenteric ischemia, colitis, gastroenteritis, worsening ascities. Elevated lactate certainly concerning for mesenteric ischemia although lactate can be elevated by cirrhosis. Paracentesis was not performed. Intrabdominal pressure lessened quickly to the ~ 15 cm of water early in the admission. Ascites and ileus were likely causes. Respiratory failure Likely multifactorial in the setting of COPD exacerbation, volume overload with anasarca and possible infectious process, along with high intrabdominal pressure and volume on admission. B/l infiltrates on CXR suggestive of infection, but not likely not in florid heart failure. PaO2:FiO2 = 110 and meets definition for ARDS. Appropriate ARDSnet protocol implemented. Sepsis Patient mets SIRS criteria with tachycardia and tachypnea (WBC low, but chronic). Sources for infection include pneumonia, SBP, colitis, less likely meningitis. Also less likely toxic shock syndrome. Classified and treated as septic shock given her low BP. Broad spectrum antibiotics were used without improvement. Fungemia was then identified. It is likely that there was both bacteremia and fungemia based on cultures. Pressors were required at times. Rash Early concern for necrotizing fasciitis was allayed by Surgery. Responded to vancomycin (not given for brief period earlier in hospitalization). Viral cultures were negative and the rash did not improve with acyclovir. Dermatology also consulted on this question. Cirrhosis Given cirrhosis and very early onset COPD, alpha-1 anti-trysin had been considered and excluded by her primary care doctor (level within normal range). Thought to be secondary to Hep C and possibly alcohol abuse earlier in life. Followed by liver clinic (Dr. [**Last Name (STitle) **]. Hepatology evaled patient in ED. Her liver synthetic function is decreased based on INR and albumin. T.bili elevated as well. [**Month (only) 116**] be decompensation of already poor liver. CP score of C and MELD of 27. Coagulopathy required numerous platelet transfusions. Likely contributor to altered mental status. Positive U/A Treated by antibiotics. Found on initial labs. Right pleural effusion Likely related to anasarca. Other possibilities include hemothorax and collection. Thoracentesis was desirable but limited by coagulopathy. Pancytopenia Counts are stably low. Likely related to hep C. Patient reported being HIV negative multiple time in OMR but no HIV documented. Although desired, testing was not performed given patient's inability to consent. Platelet and blood transfusion were required during the hospitalization. Rib Fractures/trauma Unclear etiology. Patient was coughing a lot prior to admission (corroborated by sister), but unlikely cause of fractures by our assessment. No overlying bruises at time of admission. Case referred to medical examiner who declined the case based on these fractures having little to do with demise. DM/Hypoglycmia Patient with unclear history of diabetes. Per previous d/c sum there was some concern of surreptitious insulin injection which was excluded by appropriately elevated C-peptide levels. Patients Hb A1c was 5, casting doubt on diagnosis of diabetes. Cause of elevated insulin not determined. On several occasions supplemental glucose was required given low blood glucose. History of melena and later hematochezia Unclear history recently. Per patients report prior to admission. Upper GI bleed occurred later in admission, with positive NG lavage and likely upper GI, perhaps variceal source. Large amounts of blood were produced per rectum with this crescendo on [**1-20**]. Patient had essentially become transfusion depended and did not respond to platelets and FFP. Intervention was not indicated given condition and profound non-responsive coagulopathy. Elevated intra-abdominal pressure Elevated to 40 initially with early concern for abdominal compartment syndrome. Subsequently in the teens cm/H2O. Oliguria Pre-renal early and then due to ATN. Urine output picked up somewhat during the admission. Bilious OG tube drainage Patient appeared to have ileus early in admission. NGT with suction and upon resolution very low rate tube feeds were given with restoration of stool output. Elevated lactate Tracked pO2 in blood suggesting impaired O2 utilization in context of sepsis. Altered Mental Status Encephalopathic throughout admission with likely ultimately hepatic cause, including slowed metabolism of sedative medications. Anoxic injury possible but less likely given that mean aterial pressure was carefully maintained during admission. Health care proxy and decision about goals of care Spoke with both [**Doctor First Name 401**] (patient's sister's husband) at [**Telephone/Fax (1) 99118**] and [**Doctor First Name **] (patient's sister) at [**Telephone/Fax (1) 99119**]. [**Doctor First Name **] confirmed that she is the healthcare proxy. The seriousness of the patient's disease was conveyed including multi-organ failure and poor prognosis. [**Doctor First Name **] was recently discharged from ICU s/p extubation 3-4 days prior to discussion. This was for COPD flare. Patient was full code throughout most of the admission, although [**Doctor First Name **] notes that "she would not want to live like a vegetable". She appreciated daily updates. On [**1-19**] we spoke with [**Doctor First Name **] ([**Telephone/Fax (1) 99119**]) to update her on patient care; mentioned mental status, fungemia, possibility of PEG/trach. On 1.29 family aware of patient's poor prognosis including severe bleeding and changed code status to DNR/DNI. Social work spoke with family and were actively involved. She was made CMO on [**1-22**] and passed away shortly after. Medications on Admission: Advair 500/50 1 puff twice a day Combivent nadolol 20 mg daily Lasix 120 mg in the morning and 80 mg at night lactulose methadone omeprazole 20 mg twice a day spironolactone 200 mg once a day Discharge Disposition: Expired Discharge Diagnosis: Multiple complications of liver failure - expired. Discharge Condition: Expired. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]

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Discharge summary

report

Admission Date: [**2163-12-24**] Discharge Date: [**2164-1-17**] Date of Birth: [**2103-10-24**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**Doctor First Name 2080**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: intubation and mechanical ventilation placement of arterial line placement of right subclavian central line History of Present Illness: A 60 year old gentleman with HIV (on HAART, CD4 323, VL 500s as of [**11-11**]) transferred from the [**Hospital1 3278**] ED with 4 days of cough, subjective fever and dyspnea found to be hypoxic and placed on a non-rebreather at the time of transfer. . In the ED, initial vs were: 97.5 83 109/60 16 95 NRB. Patient was given NS 1L, albuterol, Ceftriaxone and Azithro with Vanc ordered but not given. He remained normotensive. . On the floor, the patient is awake but clearly working to breath and difficult to understand because of high flow oxygen. He confirms the story above and reports that he is feeling better overall after interventions thus far. He endorses dyspnea with cough but no chest pain, abdominal pain or changes in bowel habits. He has not taken any medicines in the past 4 days including methadone and HAART. He is currently without pain. . Of note, the patient reports variable abdominal distention and increased neck girth for the past few months. He reports of a recent sleep study and a potential "belly test," but is unsure of the specifics. Review of his recent records reveals an abdominal and chest CT which are reported below. There is no record of sleep study that I could obtain at this time. Past Medical History: HIV (viral load 558 copies/ml [**2163-11-30**], CD4 323) GERD Substance Abuse Hep B Cluster Headaches DM2 Social History: History of 20-40 pack year history of smoking, alcohol abuse, cocaine abuse, all quit >2 years prior. Lives alone but possibly with his sister. Family History: Non-contributory to current illness. Physical Exam: On admission: Vitals: T: 97.8 BP: 106/56 P: 83 R: 29 O2: 94% General: Obese, uncomfortable appearing, alert but difficult to understand [**3-7**] mass. HEENT: Mask in place, mm dry. Neck: Significantly obese, posterior fat pad as well. Unable to appreciate JVP. Lungs: Decreased breath sounds at the bases, some scant wheezes. CV: S1 & S2 regular without murmur. Abdomen: Distended with protruding umbilicus. Tender suprapubicly. GU: No foley, scrotal edema Ext: warm, well perfused, 2+ pulses, no edema On discharge: Pertinent Results: On admission: 140 104 43 -------------<89 4.2 28 1.5 estGFR: 48/58 ALT: 36 AP: 83 Tbili: 0.8 Alb: 3.1 AST: 106 LDH: 328 Lip: 171 . 10.6 6.9>---<234 33.6 N:74.3 L:18.8 M:6.6 E:0.1 Bas:0.3 . PT: 14.5 PTT: 36.0 INR: 1.3 . Lactate 1.2 . ABG 103 55* 7.39 35* . CXR: IMPRESSION: New bibasilar consolidative opacities with peribronchial wall thickening, findings concerning for pneumonia. . CT Scan [**2163-10-26**]: IMPRESSION: 1. Resolution of left lower lobe nodular opacities which may have been infectious or inflammatory. 2. Widespread areas of ground-glass attenuation within the lungs, most pronounced in the left upper lobe and both lower lobes. This is a nonspecific finding but could reflect an opportunistic infection in this immune compromised patient. Differential diagnosis includes a noninfectious interstitial pneumonitis such as NSIP, but this entity is typically more symmetrical. 3. Enlarged main pulmonary artery suggesting possible pulmonary arterial hypertension, which can be associated with HIV. 4. Numerous lymph nodes throughout the chest and upper abdomen, which could be related to generalized lymphadenopathy from HIV, or could reflect a complication of HIV, such as lymphoma. 5. Coronary artery calcifications. 6. No evidence of acute intraabdominal process. . Abd US [**2163-10-25**]: 1. No biliary duct dilatation. 2. No evidence of ascites. 3. Main portal vein patent. . EKG: NSR at 85 with RBBB, consistent with [**2155**] EKG. . Micro: influenza A positive Brief Hospital Course: A 60 year old gentleman with HIV on HAART and new hypoxia, found to be influenza A positive with radiographic evidence of pneumonia, with respiratory failure ultimately requiring intubation and mechanical ventilation. . # Respiratory failure/ARDS/H1N1 Influenza: The patient had respiratory failure from influenza A with what was believed to be bacterial superinfection. The patient was a difficult intubation and was also difficult to wean off of the ventilator. He had a CT which ruled out PE, and LENIs which ruled out DVT. He completed a 10 day course of Oseltamivir 150mg PO BID. He also completed 10/10 days of Vanc and Ceftriaxone, and was switched to Cefepime [**1-2**]; however, CT chest showed PNA still present, and due to recurrent fevers, the patient was restarted on Cefepime and Vancomycin. The patient continued to have fevers with negative cultures until he was extubated successfully [**1-11**]. After that time, his fevers resolved and he completed his 8 day course of antibiotics without incident. At the time of discharge, he continued to have a 3L oxygen requirement. . # Pneumonia, Ventilator Associated: The patient had influenza A complicated by bacterial superinfection. His influenza was treated as above. As noted above, he had persistent fevers and infiltrates despite broad-spectrum antibiotics. He was thus started on cefepime and vancomycin. Bcx, ucx, sputum, and BAL cultures have all been negative. The only positive cultures grew out yeast (sputum). Per ID, fevers were believed to be caused by persistent pneumonia and the patient was re-started on Cefepime and Vancomycin on [**1-8**] for an 8 day course. Mini-BAL and cultures were negative other than yeast in the sputum and BAL, and B-glucan and galactomannin were negative. . # Elevated INR/Coagulopathy: Patient admitted with an elevated INR likely [**3-7**] nutrition deficit and decreased production of enteric flora given prolonged antibiotics course. He was placed on po Vitamin K x3 days and an INR obtained on [**1-13**] was 1.2. . # Agitation/Altered Mental Status: A significant component of anxiety contributed to the patient's initial respiratory alkalosis and agitation. He responded well to seroquel, with improvement in agitation. While intubated, he was placed on a Fentanyl/Versed drip, which was subsequently weaned off. By the time he was extubated and transferred to the medicine floor, he was no longer agitated and did not require chemical or physical restraints. . # DM2, poorly controlled without complications: Blood sugars well controlled on ISS. . # HIV, chronic: Patient's HIV currently well controlled although not on HAART initially due to illness, re-started HAART regimen as an inpatient. . # Abdominal pain/Diarrhea: Although he was admitted with a complaint of abdominal pain, it resolved spontaneously and no acute process was shown on abdominal CT scan. Abdominal U/S showed no biliary duct obstruction and KUB had no evidence of obstruction. C.diff negative. Elevated Lipase was believed to be [**3-7**] HAART. He did have some diarrhea after extubation that was thought to be due to his antibiotics. Repeat C. difficile tests were negative and patient had no other signs or symptoms of infection. . # Acute Renal Failure: Initially elevated on admission, Cr normalized at time of discharge. . # Anemia, chronic disease: Hct is lower than baseline but stable without recent evidence of bleeding. His MCV is 80, concern for iron deficiency anemia. Hemolysis unlikely w/ normal haptoglobin. Iron studies consistent with chronic disease. . # Hyperlipidemia: Patient's home Atorvastatin was held initially in the context of elevated LFT's, but it was restarted after extubation without incident. Medications on Admission: Atorvastatin 10mg PO daily Darunavir [Prezista] 800mg PO Daily Emtricitabine-Tenofovir [Truvada] 200 mg-300 mg Tablet PO daily Ritonavir [Norvir] 100mg PO Daily Fluoxetine 40mg PO daily Methadone 10mg PO TID prn pain Omeprazole 20mg PO BID Aspirin 81mg PO daily Discharge Medications: 1. Darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 7. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, headache. 12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 16. Insulin Lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary: Acute Respiratory Distress Syndrome & Ventilator acquired pneumonia secondary to H1N1 Influenza Secondary: HIV Morbid obesity Diabetes Mellitus, Type II Anemia Hyperlipidemia Gastroesophageal Reflux Disease Depression Chronic abdominal pain Discharge Condition: Patient is afebrile with stable vitals signs, breathing 3 liters of O2 by nasal cannula. He is usually alert and oriented, but can become confused sometimes. He is unable to get out of bed on his own currently, but prior to this hospitalization was ambulating independently. . Mental Status:Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the hospital for shortness of breath. In the hospital, tests determined that you had H1N1 Influenza. You had such severe difficulty breathing that you required the help of a ventilator to breath. You were on a ventilator in the Intensive Care Unit for over two weeks, but your symptoms improved with antibiotics and when it was determined that you were able to breath on your own, the breathing machine was discontinued. You have continued to improve and are being discharged to rehabilitation facility to help you with improving your strength after several weeks of being bed bound. . Medications: There were no changes made to your medication regimen. Followup Instructions: Please follow-up with your Infectious Disease physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on [**1-25**] at 9:00AM in the [**Hospital **] Medical Building, Ground Floor, Suite GB. . Please follow-up with your Primary Care Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], on Monday [**1-23**] at 10:30AM in the [**Location (un) **] Central Suite offices in the [**Hospital Ward Name 23**] Center, [**Hospital Ward Name 516**] of the [**Hospital1 18**]. To reschedule, please call [**Telephone/Fax (1) 250**].

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icd9cm

[ [ [] ] ]

[ "38.91", "96.72", "96.6", "38.93", "96.04", "33.24" ]

icd9pcs

[ [ [] ] ]

9675, 9746

4084, 6141

285, 394

10040, 10317

2558, 2558

11188, 11748

1962, 2000

8133, 9652

9767, 10019

7847, 8110

10489, 11165

2015, 2015

2539, 2539

238, 247

422, 1655

2572, 4061

10331, 10465

1677, 1784

1800, 1946

3,952

181,157

5058+55633

Discharge summary

report+addendum

Admission Date: [**2125-3-3**] Discharge Date: [**2125-3-11**] Date of Birth: [**2071-6-27**] Sex: M Service: MEDICINE Allergies: Tapazole Attending:[**First Name3 (LF) 465**] Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: None. History of Present Illness: 53 yo m with DM I, insulin autoimmune syndrome, systolic CHF, and CRI admitted for hypoglycemia. Patient was recently admitted [**Date range (1) 20852**] for same complaint. Patient says he has been in his usual state of good health, eating and drinking well, taking his medications, no recent symptoms of illness. On DOA he made himself some oatmeal for dinner, sat down to eat, and then only has scattered vague memories until waking up in the ICU. He remembers his mother trying to coax him into drinking some grape juice and feeling like he couldn't swallow. His mother called EMS. EMS found patient with FSBG 25 and gave 1 amp of D50. Patient says he checks his sugars [**3-3**] x per day and is on 7 units of lantus [**Hospital1 **] and humalog sliding scale. . Patient currently denies chest pain, SOB, Abd pain. Reports normal bowel/bladder habits. . ED course: Patient had temp of 94.2 and was placed on a bair hugger; BG 122 after D50, then 20 minutes later BG 66 and pt somnolent. Labile sugars throughout ED stay. Given D50 x 3, then started on a D10 drip. He refused to have a foley placed ans has a CXR that was normal. Past Medical History: Past Medical History: 1) DM1 X 37 yrs- frequent hypoglycemic episodes; high level of anti-insulin Ab - followed by Dr. [**Last Name (STitle) 10088**] of [**Last Name (un) **] - last HgbA1C 10.3 [**2124-12-27**] - complicated by nephropathy, retinopathy (s/p right eye laser surgery, repeated [**8-2**]), 2) Insulin autoimmune syndrome 3) CRI: secondary to DM - baseline Cr 2.5-3; prot/cr 0.8 in [**1-30**] 4) Hypertension 5) Hyperuricemia 6) Graves' disease w/ goiter: Ten years ago had hyperthyroidism; allergic to Tapazole. Propylthiouracil ~ 4 months 7) h/o diastolic CHF: [**10-1**] TTE >60%, mod LVH, 1+ MR, mild pulm artery systolic HTN, very small circumferential pericardial effusion. - MIBI in [**3-1**] [**Doctor First Name **] X 9.25 min. EF 53% and no myocardial perfusion defects Social History: Pt. lives with his parents. He is a heavy construction worker. He has never been married and has two adult children. His mother is a nurse and helps him managing his medications. No Tobacco, no EtOH, no IVDU Family History: M: DM2; MA: DM2; Nephew: DM I Physical Exam: VS: 97.3 162/84 65 14 99% on RA GEN: AA man, NAD HEENT: PERRL, OP-clear, Moist MM neck supple, No LAD RRR: Regular s1,s2. No m/r/g PULM: CTAB ABD: soft, NT, ND, + BS EXT: +2 edema on R, trace on left Pertinent Results: [**3-3**] - CXR - FINDINGS: The heart is moderately enlarged and is larger than on the film from two months ago. The previously described right effusion is no longer present. There is no focal infiltrate. IMPRESSION: Increased cardiomegaly. . [**3-5**] - LE LENI - 53-year-old man with lower extremity swelling. Comparison is available from prior study done on [**2125-1-8**]. Grayscale, color flow, and Doppler images were obtained from left lower extremity. The common femoral vein, superficial femoral vein, greater saphenous vein, deep femoral vein, and popliteal vein demonstrate normal compressibility and respiratory variation and venous flow. All the veins demonstrate normal augmentation. IMPRESSION: No evidence of deep vein thrombosis is noted in the left lower extremity. . [**2125-3-10**] 07:25AM BLOOD WBC-3.8* RBC-2.95* Hgb-8.5* Hct-24.3* MCV-82 MCH-28.8 MCHC-35.0 RDW-15.5 Plt Ct-131* [**2125-3-6**] 05:15AM BLOOD WBC-4.2 RBC-3.23* Hgb-9.3* Hct-27.0* MCV-84 MCH-28.9 MCHC-34.5 RDW-15.9* Plt Ct-145* [**2125-3-3**] 09:20PM BLOOD WBC-5.1 RBC-3.59* Hgb-10.3* Hct-30.5* MCV-85 MCH-28.6 MCHC-33.7 RDW-15.8* Plt Ct-163 [**2125-3-3**] 09:20PM BLOOD Neuts-73.2* Lymphs-18.2 Monos-5.7 Eos-2.1 Baso-0.9 [**2125-3-10**] 07:25AM BLOOD Plt Ct-131* [**2125-3-5**] 04:45AM BLOOD PT-11.0 PTT-25.3 INR(PT)-0.9 [**2125-3-10**] 07:25AM BLOOD Ret Aut-0.9* [**2125-3-10**] 07:25AM BLOOD Glucose-221* UreaN-66* Creat-3.5* Na-134 K-4.8 Cl-107 HCO3-20* AnGap-12 [**2125-3-3**] 09:20PM BLOOD Glucose-33* UreaN-70* Creat-3.5* Na-140 K-4.0 Cl-107 HCO3-23 AnGap-14 [**2125-3-10**] 07:25AM BLOOD LD(LDH)-177 TotBili-0.2 [**2125-3-4**] 03:55AM BLOOD ALT-52* AST-27 AlkPhos-68 Amylase-121* TotBili-0.3 [**2125-3-3**] 09:20PM BLOOD ALT-62* AST-31 LD(LDH)-227 AlkPhos-76 Amylase-142* TotBili-0.2 [**2125-3-3**] 09:20PM BLOOD Lipase-75* [**2125-3-4**] 03:55AM BLOOD Lipase-59 [**2125-3-10**] 07:25AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.3 [**2125-3-3**] 09:20PM BLOOD Albumin-4.0 Calcium-9.0 Phos-4.1 Mg-2.4 [**2125-3-9**] 05:00AM BLOOD TSH-5.3* [**2125-3-9**] 05:00AM BLOOD T4-6.6 T3-69* Free T4-1.2 [**2125-3-3**] 09:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2125-3-6**] 03:40PM BLOOD INSULIN ANTIBODIES-Test [**2125-3-9**] 05:00AM BLOOD T4-6.6 T3-69* Free T4-1.2 [**2125-3-9**] 05:00AM BLOOD TSH-5.3* [**2125-3-10**] 07:25AM BLOOD Hapto-87 [**2125-3-6**] 03:40PM BLOOD INSULIN ANTIBODIES-Test [**2125-3-5**] 08:27AM URINE Hours-RANDOM Creat-63 Na-70 Brief Hospital Course: this 53-year old male with a history of with DM I, insulin autoimmune syndrome, systolic CHF, and CRI admitted for recurrent hypoglycemia, initially cared for in the intensive care unit, then transferred to floor. . # Diabetes Mellitus - Patient had long history of recurrent hypoglycemic episodes and difficult to control blood sugars, followed by Dr. [**Last Name (STitle) 10088**] as outpatient as Josline Diabetes Center. Patient was treated with 4 doses of IVIG therapy, with a total of 160mg (30mg, 50mg, 40mg, 40mg. Patient's lantus doses were varied during his stay, discharged on 4units [**Hospital1 **], as [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations, in addition to sliding scale. Level of insulin auto-antibodies was 2, within reference range. . # Anemia - As per outpatient evaluation, patient diagnosed with anemia of chronic disease and iron deficiency anemia. Anemia of chronic kidney disease more likely etiology. Patient had low level hematocrit during his stay. Prior to his discharge, hemolysis labs were checked with consideration for IVIG-induced hemolysis. B12 and folate levels were normal. Patient was continued on his PO iron and was restarted on his most previous epogen dose the day prior to his discharge. Patient's hematocrit should be checked within 2-3 days. He showed no evidence of bleeding, but warrants outpatient GI evaluation for iron deficiency. . # Pancytopenia - Noted over the 3-4 days prior to his discharge, patient had mild drop in all his cell lines without known etiology. No apparent medications could be elucidated as the cause - clonidine has very rare side effects of thrombocytopenia, although this was initiated after the downward trends. Patient was given a prescription and explicit instructions to have blood work done on [**3-13**], with results sent to the [**Last Name (un) **] Center, and then to be re-evaluated on [**3-15**] as an outpatient. . # Acute on chronic renal failure - Creatinine baseline around 3.4, baseline unclear but appears to be somewhere between 2.5-3.5. Patient maintained good urine output during his stay. . # Hypertension - Per report had been diffuclt to control on the outpatient setting. Patient was continued on diltiazem, hydralazine, and toprol. Amlodipine was discontinued because of lower extremity edema, and clonidine patch was initiated. His other anti-hypertensive medications were continued. . # Asymmetrical swelling in legs - Patient had bilateral lower extremity swelling, that switched sides during his stay, which prompted a lower extremity ultrasound, which was negative for a deep vein thrombosis. His amlodipine was discontinued, as above. . # Subclinical hypothyroidism - will need to be addressed on outpatient basis. . # Liver lesions - as per outpatient notes, patient had noticeable liver pathology on previous scans, was scheduled to have MRI completed as outpatient. This issue stilll needs to be addressed. Medications on Admission: 1. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY 2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY 3. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day. 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QOD 5. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS 6. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: take with 100mg tablet for total 150mg daily. 7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: take with 50mg tablet for total 150mg daily. 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY 11. Cosopt Ophthalmic 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO 14. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 389**] ([**Numeric Identifier 389**]) units Injection once a week. 15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY 16. Lantus 100 unit/mL Solution 7 units Subcutaneous twice a day. 17. Humalog 100 unit/mL Solution Sig: per sliding scale units Subcutaneous qACHS. 18. Glucagon Emergency 1 mg Kit Sig: One (1) kit Injection prn as needed for hypoglycemia. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Hypoglycemia event [**12-29**] insulin autoimminity . Secondary: 1. DM1 X 37 yrs- frequent hypoglycemic episodes; high level of anti-insulin Ab - followed by Dr. [**Last Name (STitle) 10088**] of [**Last Name (un) **] - last HgbA1C 10.3 [**2124-12-27**] - complicated by nephropathy, retinopathy (s/p right eye laser surgery, repeated [**8-2**]), 2. Insulin autoimmune syndrome 3. CRI: secondary to DM - baseline Cr 2.5-3; prot/cr 0.8 in [**1-30**] 4. Hypertension 5. Hyperuricemia 6. Graves' disease w/ goiter: Ten years ago had hyperthyroidism; allergic to Tapazole. Propylthiouracil ~ 4 months 7. h/o diastolic CHF: [**10-1**] TTE >60%, mod LVH, 1+ MR, mild pulm artery systolic HTN, very small circumferential pericardial effusion. - MIBI in [**3-1**] [**Doctor First Name **] X 9.25 min. EF 53% and no myocardial perfusion defects Discharge Condition: Patient discharged to home in stable condition, afebrile, ambulating withotu difficulty, tolerating PO feeds without difficulty. Discharge Instructions: Patient was admitted for hypoglycemia. Patient should seek medical attention if he develops palpitations, shortness of breath, chest pain, recurrent lightheadedness, dizziness, nausea, vomiting, continued diarrhea, or any other symptom that is concerning to him. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2125-3-29**] 2:00 . Encocrinology - follow-up - Please call endocrinology clinic in the AM on Monday morning to verify your appointment. [**Telephone/Fax (1) 20853**] - [**3-15**] - 9:30am endocrinology appointment. . Patient advised he needs hematocrit check and blood glucose trends/possible lantus adjustments within 2-3 days. . [**3-13**] - Please come to the [**Hospital1 **] hospital at your regular location, for outpatient lab work with the prescription that has been written for you. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 3475**] Admission Date: [**2125-3-3**] Discharge Date: [**2125-3-11**] Date of Birth: [**2071-6-27**] Sex: M Service: MEDICINE Allergies: Tapazole Attending:[**First Name3 (LF) 1305**] Addendum: Discharge Medication List: Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop Ophthalmic QD (). Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Insulin Glargine 100 unit/mL Solution Sig: Five (5) units Subcutaneous twice a day. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other day. Epoetin Alfa 20,000 unit/2 mL Solution Sig: One (1) Injection once a week: pre-admission dose. To be addressed by outpatient PCP and [**Name9 (PRE) 616**] physician. [**Name10 (NameIs) 3476**] Tablet Sig: One (1) Tablet PO once a day. Humalog Continue at home sliding scale as per pre-admission plan. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a week: Change [**3-12**]. Disp:*4 4* Refills:*2* Outpatient Lab Work Complete blood count, chemistry panel with glucose. Please send results to Dr. [**Last Name (STitle) **] in the [**Last Name (un) 616**] diabetes center. Thank you. Discharge Disposition: Home [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1307**] Completed by:[**2125-3-13**]

[ "428.20", "403.90", "585.9", "287.5", "250.43", "250.83", "284.1", "E932.3", "584.9", "428.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13776, 13933

5283, 8251

280, 287

10584, 10715

2788, 5260

11026, 13753

2521, 2552

9711, 10563

8277, 9661

10739, 11003

2567, 2769

228, 242

315, 1460

1504, 2279

2295, 2505

4,694

161,885

18527

Discharge summary

report

Admission Date: [**2161-2-7**] Discharge Date: [**2161-2-20**] Date of Birth: [**2118-4-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Fevers, chills and diarrhea Major Surgical or Invasive Procedure: Right thoracotomy and decortication History of Present Illness: Mr. [**Known lastname 1193**] is a 42 yr old male with no significant PMH who presented to ED with several days of fevers, chills, diarrhea and decreased PO intake. In ED found to have RLL infiltrate and effusion, acute renal failure with Creatinine 2.6 and lactate of 4.4. Enrolled in Sepsis Protocol for lactate and tachycardia. Vitals otherwise stable on minimal 02 requirement. Past Medical History: None Physical Exam: 95.9 123 141/52 29 96% 2L WDWN, AAO X3 Tachy, RR S1+S2 Decreased BS R lung base Sodt NT/ND No C/C/E Pertinent Results: [**2161-2-7**] 10:10AM BLOOD WBC-13.8* RBC-4.72 Hgb-15.0 Hct-42.4 MCV-90 MCH-31.9 MCHC-35.5* RDW-12.5 Plt Ct-224 [**2161-2-14**] 06:25AM BLOOD WBC-24.2*# RBC-3.84* Hgb-12.2* Hct-36.7* MCV-96 MCH-31.7 MCHC-33.2 RDW-13.6 Plt Ct-436 [**2161-2-19**] 07:35AM BLOOD WBC-10.4 RBC-3.14* Hgb-10.0* Hct-29.5* MCV-94 MCH-31.8 MCHC-33.8 RDW-12.9 Plt Ct-847* [**2161-2-14**] 06:25AM BLOOD PT-13.8* PTT-31.0 INR(PT)-1.2 [**2161-2-7**] 10:10AM BLOOD Glucose-92 UreaN-64* Creat-2.6*# Na-134 K-4.0 Cl-96 HCO3-19* AnGap-23* [**2161-2-7**] 07:05PM BLOOD Glucose-90 UreaN-40* Creat-1.4* Na-140 K-3.2* Cl-109* HCO3-19* AnGap-15 [**2161-2-10**] 05:50AM BLOOD Glucose-64* UreaN-13 Creat-0.6 Na-136 K-3.6 Cl-102 HCO3-25 AnGap-13 [**2161-2-17**] 07:30AM BLOOD Glucose-103 UreaN-8 Creat-0.7 Na-133 K-5.1 Cl-100 HCO3-27 AnGap-11 [**2161-2-7**] 07:05PM BLOOD Calcium-7.1* Phos-2.6* Mg-1.5* [**2161-2-9**] 06:00AM BLOOD Calcium-7.8* Phos-2.3* Mg-2.1 [**2161-2-17**] 07:30AM BLOOD Calcium-8.4 Phos-4.1 Mg-1.9 [**2161-2-7**] 10:10AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2161-2-7**] 10:10AM URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0-2 [**2161-2-12**] 06:46PM PLEURAL WBC-1535* RBC-465* Polys-30* Lymphs-13* Monos-0 Macro-57* [**2161-2-12**] 06:46PM PLEURAL TotProt-4.2 Glucose-78 LD(LDH)-732 Albumin-2.4 [**2161-2-8**] 8:09 am SPUTUM GRAM STAIN (Final [**2161-2-8**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2161-2-10**]): SPARSE GROWTH OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Final [**2161-2-18**]): NO LEGIONELLA ISOLATED [**2161-2-7**] 12:35 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2161-2-13**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2161-2-13**]): NO GROWTH. [**2161-2-12**] 6:46 pm PLEURAL FLUID GRAM STAIN (Final [**2161-2-12**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2161-2-15**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2161-2-18**]): NO GROWTH. [**2161-2-16**] 11:30 am TISSUE RIGHT PLEURAL TISSUE. GRAM STAIN (Final [**2161-2-16**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2161-2-19**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2161-2-18**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2161-2-16**]): NO FUNGAL ELEMENTS SEEN. SPECIMEN SUBMITTED: RT. PLEURAL TISSUE. Organizing hemorrhage, acute and chronic inflammation, and fibrin deposition; no evidence of malignancy. CT CHEST W/CONTRAST [**2161-2-13**] 2:35 PM IMPRESSION: 1. Findings again consistent with pneumonia, most pronounced in the right lower and middle lobes with associated small multiloculated pleural effusions. 2. Left lower lobe dependent atelectasis/consolidation with an associated small effusion. Brief Hospital Course: Mr. [**Known lastname 1193**] is a 42 yr old male without significant PMH presenting with fever, chills and diarrhea found to have RLL/RML PNA, ARF. 1. RML/RML PNA and R pleural effusion: Pt was admitted to the [**Hospital Unit Name 153**] for 1 night, given his elevated lactate level and tachycardia on admission. He was started on IVFs and IV Azithromycin and Ceftriaxone(Day 1--[**2161-2-7**]) with some improvement in his symptoms. Of note, legionella and flu negative. He was transferred to floor on HD#2 with some symptomatic relief but persistent fevers. IV Flagyl added to the ABX regimen. A thoracentesis on [**2-12**] removed 1 liter or serous exudative fluid. There was no pneumothorax after the procedure. Pt felt worsening pleuritic chest pain and continued to have fevers after thoracentesis. A CT scan showed multiple small loculated fluid collections in this right lung, with no evidence of empyema. Pt transferred to the [**Hospital Ward Name **] and taken to the OR on [**2160-2-16**] for a bronchoscopy and right video-assisted drainage of empyema with conversion to limited thoracotomy and right decortication. Pt tolerated the surgery well. CT placed and set to suction at 20 cm. Pt started on sips POD #0 and advanced after the next few days, Pt tol reg diet well. Foley d/c'd, CT placed at water seal on [**2-17**]. PCA d/c'd on [**2-19**] and pt started on PO Percocet. Pt tolerated pain well. Cultures results negative, some results still pending. CT d/c'd on [**2-20**]. Pt continued to improve clinically. Pt d/c'd home after PICC placement for a continued 2 weeks of IV ceftriaxone in addition to PO Flagyl. Pt stable at discharge. Pt instructed to follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. 2. Diarrhea: Pt initially presented with diarrhea that improved over the first few days of his hospitalization. The etiology was likely viral. C Diff negative. His electrolytes were repleted. 3. ARF: Resolved with IVF. 4. Hyponatremia: Resolved. Discharge Medications: 1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*1* 4. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 2 weeks. Disp:*14 * Refills:*0* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Empyema Discharge Condition: Stable Discharge Instructions: Return for all follow-up appointments Take all medications as directed Please call your doctor or return to the hospital if any increased shortness of breath, fevers greater than 101, chest pain, redness or swelling around the incision, or nausea and vomitting Followup Instructions: Please call [**Telephone/Fax (1) 170**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) **] in 2 weeks Completed by:[**2161-2-20**]

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icd9cm

[ [ [] ] ]

[ "34.51", "34.04", "38.93", "33.23", "34.91" ]

icd9pcs

[ [ [] ] ]

6618, 6679

3986, 5984

349, 387

6731, 6739

962, 3218

7048, 7201

6007, 6595

6700, 6710

6763, 7025

842, 943

3411, 3963

3378, 3378

281, 311

415, 799

3254, 3349

821, 827

24,539

168,545

18412

Discharge summary

report

Admission Date: [**2188-7-3**] Discharge Date: [**2188-7-10**] Date of Birth: [**2119-10-12**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: s/p insertion of distal right femoral trochanteric pin [**2188-7-6**] History of Present Illness: 68 yo non ambulatory female who while being lifted by [**Doctor Last Name 2598**] lift at home by her home health aide, sustained a 5 ft fall reportedly because lifting apparatus broke during transfer. She reportedly landed on her right side and complained of facial and neck pain. Denies LOC. She was taken to an area hospital where she was later transferred to [**Hospital1 18**] because of C2 body fracture. Past Medical History: 1. Afib on coumadin 2. HTN 3. hyperchol 4. NIDDM 5. PVD 6. GIB - hemorrhoids and diverticulosis seen on c-scope [**7-20**], ischemia in the past per d/c summary at [**Hospital3 **] (?) 7. GBS 10-15y ago 8. fem-[**Doctor Last Name **] bypass 9. cholecystectomy [**91**]. removal of left ovary 11. cataract surgery [**93**]. anemia Social History: Lives alone; has home health services. Never married. No children. Has healthy care proxy [**Name (NI) **] ETOH, no tobacco Employment: lecturer of English and British/[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] Family History: Noncontributory for this admission Pertinent Results: [**2188-7-3**] 10:23PM GLUCOSE-194* UREA N-16 CREAT-0.5 SODIUM-135 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-28 ANION GAP-13 [**2188-7-3**] 10:23PM CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-1.7 [**2188-7-3**] 10:23PM WBC-13.0* RBC-3.29*# HGB-9.4* HCT-27.6*# MCV-84 MCH-28.6 MCHC-34.1 RDW-15.4 [**2188-7-3**] 10:23PM PLT COUNT-211 CHEST (PORTABLE AP) Reason: ? pulm edema [**Hospital 93**] MEDICAL CONDITION: 68 year old woman with extensive PMH including CVA, CHF, PVD and DM s/p fall from defective [**Doctor Last Name 2598**] Lift at home on [**7-2**] with C2 dens fx, R medial orbital wall fx and R subtrochanteric fx currently has labored breathing with bilateral rhonchi REASON FOR THIS EXAMINATION: ? pulm edema EXAMINATION: AP chest. INDICATION: Abnormal breath sounds. A single AP view of the chest is obtained [**2188-7-7**] at 0828 hours. No prior films are available for comparison. The patient is rotated to the left side. There is no evidence of cardiomegaly. There is arteriosclerosis and tortuosity of the aorta. There is diffuse increase in the interstitial lung markings bilaterally. There is minimal right costophrenic angle blunting. IMPRESSION: Increased interstitial lung markings bilaterally may reflect a chronic process. In the context of acute shortness of breath; however, interstitial edema cannot be excluded. Cardiology Report ECG Study Date of [**2188-7-4**] 10:21:14 AM Sinus rhythm. Normal ECG. Compared to the previous tracing of [**2186-6-9**] sinus rhythm has appeared. Intervals Axes Rate PR QRS QT/QTc P QRS T 71 184 84 [**Telephone/Fax (2) 50700**] 18 57 CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: Fx of TLS? please do recons of TLS spine, thanks Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 68 year old woman s/p fall REASON FOR THIS EXAMINATION: Fx of TLS? please do recons of TLS spine, thanks CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 68-year-old man status post fall. Evaluate for fractures of the TLS. COMPARISON: [**2188-7-4**] plain film of the hips. TECHNIQUE: MDCT acquired axial images of the chest, abdomen and pelvis were performed with IV contrast. Multiplanar reformations were obtained. Images were performed per trauma torso protocol. CT CHEST WITH IV CONTRAST: There enlarged lymph nodes in the mediastinum and left hilum. For example there is a subcarinal node measuring 10 mm in shortest diameter and a left hilar node measures 12 mm in diameter. The pulmonary vasculature is prominent and a small amount of fissural fluid is present. There is no evidence of consolidation. No nodular densities are identified. There is bilateral dependent atelectasis. CT ABDOMEN WITH IV CONTRAST: The liver, spleen, adrenal glands, right kidney are unremarkable. The left kidney contains a small simple renal cyst within the left mid upper pole. The small and large bowel are within normal limits. There is no free fluid or free air. CT PELVIS WITH IV CONTRAST: There is a fibroid calcified uterus. There are no adnexal masses noted. The urinary bladder is catheterized. The rectum is filled with stool, which extends to the cecum. There is no pelvic lymphadenopathy. There are multiple surgical clips seen within the left inguinal region. BONE WINDOWS: Again noted is an intertrochanteric fracture on the right with moderate displacement as seen on prior plain film. No additional fractures are identified. Normal alignment is seen within the visualized cervical, thoracic and lumbosacral spines with no evidence of listhesis. No suspicious lytic or sclerotic bony lesions. IMPRESSION: 1. No radiographic evidence of traumatic injury with the exception of a previously noted right intertrochanteric femoral neck fracture. 2. Mediastinal and hilar lymphadenopathy. Possible etiologies include sarcoid, granulomatous disease, and lymphoma. A follow up dedicated chest CT is recommended to ensure stability. Brief Hospital Course: Patient admitted to the Trauma Service. Orthopedics and Neurosurgery were immediately consulted because of her injuries. Her C2 dens fracture was managed non operatively with a hard cervical collar to be worn until follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery, in 6 weeks. She was taken to the operating room on [**7-6**] for repair of her right femur intratrochanteric fracture. She was started on Heparin for DVT prophylaxis. At baseline patient is non-ambulatory; she will follow up with Dr. [**Last Name (STitle) **], Orthopedics in 4 weeks. Her pain was initially managed with PCA Morphine; this was later changed to longer acting narcotics which will likely require further adjustment given her increased pain postoperatively. Because of pain control issues and her deconditioned status patient had required supplemental oxygen to maintain her saturations >93%. She wa eventually weaned off O2. She will require pulmonary toileting post hospital discharge. Physical and Occupational therapy were consulted and have recommended short term rehab stay. Her insurance carrier has denied her rehab stay, despite appealing the initial denial, based on their criteria that patient has not met for acute and subacute facilities. She is being discharged to home with services as a result. Medications on Admission: Avandia 4' Verapamil 120' Reglan 5'' Lexapro 10' Atovastatin 20' Trazadone 150' Colace Senna Lopressor 50''' Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Verapamil 80 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours): hold for HR <60 and/or SBP <110. 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for HR <60 and/or SBP <110. 4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): hold for loose stools. 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0* 12. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for breakthrough pain. Disp:*60 Tablet(s)* Refills:*0* 14. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day. Disp:*30 * Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p Fall ~5ft Orbital fracture Cervical fracture (C2) Right intratrochanteric fracture Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, SOB, numbness or tingling in any of your extremities, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. You must continue to wear your cervical (neck) collar until you follow up with Dr. [**Last Name (STitle) 548**]. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 4 weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with Dr. [**Last Name (STitle) 548**], Neurosurgery, in 6 weeks. Call [**Telephone/Fax (1) 2992**] for an appointment. Inform the office that you will need repeat AP/lateral C-spine films for this appointment. Completed by:[**2188-7-10**]

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icd9cm

[ [ [] ] ]

[ "79.35", "99.04" ]

icd9pcs

[ [ [] ] ]

8420, 8478

5444, 6752

323, 395

8609, 8618

1515, 1885

8979, 9355

1460, 1496

6913, 8397

3278, 3305

8499, 8588

6778, 6888

8642, 8956

275, 285

3334, 5421

423, 835

857, 1189

1205, 1444

9,321

187,719

25613

Discharge summary

report

Admission Date: [**2190-5-18**] Discharge Date: [**2190-5-24**] Date of Birth: [**2133-4-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Fatigue and exertional chest pain Major Surgical or Invasive Procedure: [**2190-5-18**] - CABGx2 (Left Internal Mammary to Left Anterior Descending Artery, Vein graft to obtuse marginal) History of Present Illness: This is a 57-year-old male who in [**2186**] was diagnosed with coronary artery disease after developing exertional symptoms while running. He underwent a placement of a coronary stent at that time with followup. During the last several months, he continued to have exertional symptoms once again. He underwent a catheterization that revealed a left main 40% to 50% stenosis, as well as some re-stenosis along the left circ and disease within the left anterior descending artery. Based on these findings, the patient was recommended to undergo a surgical procedure. Past Medical History: CAD s/p PCI/Stenting Hyperlipidemia HTN Diabetes IBS Social History: Computer Programmer. 40 pack year smoking hostory. 2 alcoholic beverages weekly. Lives with wife. Family History: Father died of MI at age 64. Physical Exam: Vitals: BP 140-150/80, HR 65, RR 18, SAT 96% on room air General: well developed male in no acute distress HEENT: oropharynx benign Neck: supple, no JVD, transmitted murmur to carotid noted Heart: regular rate, normal s1s2 Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Discharge Vitals 98.3, 99/48, 80 SR, 20 RR, RA sat 94% wt 79.1 kg Neuro A/O x3, non focal Pulm CTA bilat Cardiac RRR Sternal inc no drainage/erythema Abd Soft, NT, ND +BS Ext warm Pertinent Results: [**2190-5-24**] 09:30AM BLOOD WBC-5.9 RBC-3.46* Hgb-10.3* Hct-30.4* MCV-88 MCH-29.9 MCHC-34.1 RDW-13.4 Plt Ct-302# [**2190-5-18**] 12:50PM BLOOD WBC-5.6 RBC-3.03*# Hgb-9.3*# Hct-26.4*# MCV-87 MCH-30.7 MCHC-35.3* RDW-13.2 Plt Ct-118* [**2190-5-24**] 09:30AM BLOOD Plt Ct-302# [**2190-5-22**] 06:10AM BLOOD PT-11.8 PTT-24.3 INR(PT)-1.0 [**2190-5-18**] 12:50PM BLOOD Plt Ct-118* [**2190-5-18**] 12:50PM BLOOD PT-14.4* PTT-28.6 INR(PT)-1.3* [**2190-5-24**] 09:30AM BLOOD Glucose-268* UreaN-18 Creat-1.1 Na-137 K-4.9 Cl-101 HCO3-28 AnGap-13 [**2190-5-18**] 01:43PM BLOOD UreaN-15 Creat-0.9 Cl-113* HCO3-27 [**2190-5-24**] 09:30AM BLOOD Calcium-9.6 Phos-3.9# Mg-2.1 [**2190-5-18**] 07:01PM BLOOD Calcium-8.0* Phos-1.6* Mg-2.4 Cardiology Report ECG Study Date of [**2190-5-20**] 7:13:28 PM Sinus rhythm Atrial premature complex Inferior and anterior T wave changes are nonspecific Since previous tracing of [**2190-5-18**], atrial premature complex seen, otherwise no significant change Read by: [**Last Name (LF) 474**],[**First Name3 (LF) 475**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 78 148 76 348/381 30 44 -6 Cardiology Report ECHO Study Date of [**2190-5-18**] *** Report not finalized *** PRELIMINARY REPORT PATIENT/TEST INFORMATION: Indication: cabg Status: Inpatient Date/Time: [**2190-5-18**] at 09:24 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm) Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%) Aorta - Ascending: 3.0 cm (nl <= 3.4 cm) Aorta - Descending Thoracic: 2.5 cm (nl <= 2.5 cm) Aortic Valve - Valve Area: *2.7 cm2 (nl >= 3.0 cm2) INTERPRETATION: Findings: LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thicknesses and cavity size. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Conclusions: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses and cavity size are normal. LVOT-VTI = 20. Right ventricular chamber size and free wall motion are normal. 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. Trivial mitral regurgitation is seen. There is no pericardial effusion. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Mr. [**Known lastname 63917**] was admitted to the [**Hospital1 18**] on [**2190-5-18**] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to two vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. By postoperative day one, Mr. [**Known lastname 63917**] had awoke neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. On postoperative day two, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He had short burst of atrial fibrillation controlled with beta blockers and amiodarone. He has remained in sinus rhythm > 24 hours and was ready for discharge home with services oon post operative day 6. Medications on Admission: Lisinopril 10 mg daily Lopressor 12.5mg twice daily Zocor 40mg daily Metformin 1000mg/850mg twice daily Glyburide 5mg daily Aspirin 325mg daily Tricor 48mg daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Metformin 850 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*0* 4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). Disp:*60 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): please take 400mg once a day for 7 days then decrease to 200mg once a day . Disp:*37 Tablet(s)* Refills:*0* 7. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*0* 8. 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* 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. 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* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 12. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day for 5 days. Disp:*20 Tablet Sustained Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: CAD s/p CABG Atrial Fibrillation s/p PCI/Stenting Diabetes HTN Hyperlipidemia Irritable Bowel Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5)No lifting greater then 10 pounds for 10 weeks. 6)No driving for 1 month. [**Last Name (NamePattern4) 2138**]p Instructions: Follow-up with Dr. [**Last Name (Prefixes) **] (Surgeon) in 1 month. ([**Telephone/Fax (1) 4044**] Follow-up with Dr. [**Last Name (STitle) 5874**] (Cardiologist) in 2 weeks. Follow-up with Dr. [**Last Name (STitle) 27187**] in [**2-21**] weeks. [**Telephone/Fax (1) 3658**] [**Hospital 409**] clinic on [**Hospital Ward Name 121**] 2. Please call providers for appointments. Completed by:[**2190-5-24**]

[ "997.1", "E878.8", "518.0", "511.9", "401.9", "427.31", "414.01", "E849.7", "250.00", "411.1" ]

icd9cm

[ [ [] ] ]

[ "36.15", "36.11", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

8659, 8721

5925, 6906

355, 472

8859, 8866

1893, 3120

1274, 1304

7118, 8636

8742, 8838

6932, 7095

8890, 9354

9405, 9812

3146, 5863

1319, 1874

282, 317

500, 1067

5902, 5902

1089, 1143

1159, 1258

24,930

121,111

4256

Discharge summary

report

Admission Date: [**2117-12-2**] Discharge Date: [**2117-12-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: bilateral arm paresthesias Major Surgical or Invasive Procedure: none History of Present Illness: 81 yo F w/ HTN, DM, chronic constipation, hyperchol, p/w bilateral arm pain. In ED had CTA which ruled out dissection. While getting scanned became increasingly SOB and hypoxic to 60-70%s; n/v with possible aspiration vs. flash pulmonary edema. Pt was intubated for respiratory distress and hypoxia and sent to the [**Hospital Unit Name 153**]; had a difficult intubation. Was given lasix o/n for possible flash pulm edema and abx for aspiration PNA. In the [**Name (NI) 153**], pt was diuresed for pulmonary edema, CE were checked and she ruled in (peak tnt=0.72, peak CK=524); enzymes are now trending down. Pt with possible ST elevations in precordial leads, and TTE showed EF=60%, moderat PE systolic HTN, and could not exclude focal wall motion abnormalities. Pt was seen by cardiology who recommended non-invasive cardiac testing as an initial evaluation. Pt was then transferred to [**Hospital Unit Name 196**] (extubated, doing well from respiratory standpoint) for pharmacologic stress test. Other important events in the [**Hospital Unit Name 153**] included sputum positive for MRSA (pt now on Vanco) and Hct drop (?unexplained). On admission to [**Name (NI) 196**], pt denies any symptoms at this time; no cp/sob/n/v/f/c; she does not remember much of her course in the [**Hospital Unit Name 153**]/whether she had chest pain at any time. She does state that she has a cough, non-productive. Pt transferred to floor for P-mibi and possible intervention based on the results of this test. Past Medical History: 1PAST MEDICAL HISTORY: 1. Hypertension. 2. Noninsulin-dependent diabetes. 3. Chronic constipation. 4. Acoustic neuroma. 5. Status post cataract removal. 6. Status post cholecystectomy. 7. History of polyp/internal hemorrhoid found at colonoscopy in [**2110**]. 8. Hearing loss in left ear. 9. Chronic dizziness. 10. Hypercholesterolemia. MEDS on transfer: ASA 325 Lipitor 40 VAnco 1000 qD Colace 100 [**Hospital1 **] Senna Dulcolax NTG drip Metoprolol 100 TID Captopril 75 TID SSI Amlodipine 5 QD Social History: SOCIAL HISTORY: Moved from [**Country 532**] [**2110**], lives by herself, has a homemaker helping her out in her home, has a daughter in [**State 531**] City, a son in [**State 350**], denies tobacco or alcohol use. Patient walks with a walker and a cane. Family History: non-contributory Physical Exam: hr 70, bp 160/80, r15, sao2 50%ra, 85%nrb gen: intubated, sedated. HEENT: MMM, JVD not appreciated CV: RR, distant heeart sounds, no m/r/g Lungs: b/l diffuse rales and crackles Abd: s/nt/distended. +la, +bs Ext: no le edema, trace DP pulses b/l. Exam on transfer from [**Hospital Unit Name 153**]: as above w/ following exceptions: 99.7 169/56 20 96% 2L Gen: alert, oriented, russian speaking, comfortable, on 2L NC CV: Regular s1,s2. II/VI SEM at RUSB. LUNGS: b/l basilar crakles to base of scapula Pertinent Results: CBC: [**2117-12-2**] 07:45PM BLOOD WBC-8.1 RBC-3.89* Hgb-11.7* Hct-33.0* MCV-85 MCH-30.0 MCHC-35.4* RDW-15.2 Plt Ct-207 [**2117-12-7**] 04:31AM BLOOD WBC-7.9 RBC-3.25* Hgb-9.3* Hct-27.6* MCV-85 MCH-28.7 MCHC-33.9 RDW-15.5 Plt Ct-177 [**2117-12-3**] 05:37AM BLOOD Neuts-66 Bands-22* Lymphs-8* Monos-1* Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0 Coags: [**2117-12-6**] 03:52AM BLOOD PT-12.7 PTT-26.3 INR(PT)-1.0 Chem-7 [**2117-12-2**] 07:45PM BLOOD Glucose-355* UreaN-26* Creat-0.9 Na-140 K-3.8 Cl-103 HCO3-24 AnGap-17 [**2117-12-7**] 04:31AM BLOOD Glucose-186* UreaN-18 Creat-0.6 Na-142 K-4.1 Cl-108 HCO3-26 AnGap-12 Cardiac Enzymes: [**2117-12-2**] 07:45PM BLOOD CK-MB-3 cTropnT-<0.01 [**2117-12-3**] 05:37AM BLOOD CK-MB-17* MB Indx-3.6 cTropnT-0.54* [**2117-12-3**] 01:33PM BLOOD CK-MB-10 MB Indx-1.9 cTropnT-0.62* [**2117-12-3**] 05:58PM BLOOD CK-MB-8 cTropnT-0.72* [**2117-12-4**] 03:31PM BLOOD CK-MB-5 cTropnT-0.38* [**2117-12-6**] 03:52AM BLOOD CK-MB-4 cTropnT-0.48* [**2117-12-7**] 04:31AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.1 [**12-8**]: P-MIBI:. IMPRESSION: 1) Mild, reversible apical perfusion defect. 2) Normal wall motion. Comparison is made to prior study of [**2113-3-30**]. The apical defect does not appear significantly changed in the interval Brief Hospital Course: Plan: 1. Resp failure: pt initially intubated in ED following episode in CT scanner. CXR c/w asymmetric pulmonary edema vs. PNA, so pt was started on aggressive diuresis and covered w/ ceftriaxone and azithromycin. Respiratory failure felt to be secondary to acute onset pulmonary edema from bolus IV contrast injection. Following admission to [**Hospital Unit Name 153**] patient remained relatively hypotensive, requiring pressors and volume support to defend blood pressure. Weaned off pressors on HD1, but remained on vent, undergoing active diuresis. Received significant amounts of fluids during hypotensive episode and was net 3L positive on [**12-6**]. Has been undergoing active diuresis, responding to Lasix 40mg IV. On the morning of [**12-6**] the patient self extubated, but has done well from a respiratory standpoint since that time. Upon transfer to the floor, diuresis was continued with IV lasix prn, with goal of 500-1000cc negative per day. Her NC O2 was weaned as tolerated, and she had no complaints of shortness of breath. Lasix should be continued at 40 mg QD, and volume status should be maintained as negative. Lung exam should be monitored to ensure that she is not developing increased crackles on exam/pulmonary edema. The lasix should be continued until she follows up with her PCP. [**Name10 (NameIs) 227**] that she is on lasix, her electrolytes should be checked and repleted as necessary. 2. Subendocardial ischemia: following bolus of IV contrast dye in the CT suite, the patient developed significant anterior ST depressions and subsequently evolved troponins, peaking on [**12-3**] at 0.72. Cardiology was consulted and felt that the event was diastolic HF leading to ischemia as opposed to a primary ACS, since the patient had been having symptoms for 24 hours prior to admission and had not produced positive cardiac enzymes. Pt received 48 h of heparin via gtt, but was dc'd secondary to drop in platelets, nadiring at 119 on [**12-5**] (HIT cked and was negative). She was continued on ASA/BB/Statin. On [**12-6**], secondary to ongoing elevated bp, the patient was started on captopril and both her ACEI and BB were titrated up. On [**12-7**], the patient was started on norvasc for additional BP control and for the beneficial effects of Ca channel blockade on systolic HTN. Metoprolol, amlodipine, and lisinopril were titrated up as needed for goal SBP 140-150. Her blood pressure should continue to improve as cardiac/respiratory issues continue to resolve. BP meds should not be titrated up further. P-MIBI was unchanged from prior study in [**2115**], and cardiology did not feel that she need further workup/intervention. She is discharged on beta blocker/ACE/ASA/statin. 4. MRSA [**Name (NI) **] unclear if CXR really c/w PNA, but given high risk and positive sputum culture for PNA felt that patient would benefit from 10d course of Vancomycin. Day 1 was [**12-3**], so vancomycin should be continued to [**12-14**]. Tip of left subclavian catheter was also sent for culture when the line was removed on [**12-9**], and was negative (but pending) at time of discharge. If culture becomes positive, [**Hospital 100**] rehab will be notified. 5. DM: initially started on insulin gtt, stopped [**12-5**], maintained on SS. Started on low dose Glargine for improved control w/ goal of bs 120. On the floor, her glyburide and metformin were restarted, glargine 10 qhs was continued, and she was covered with sliding scale. Her blood sugars remain high on discharge, but they should improve (oral hypoglycemics restarted day of discharge). She should have fingersticks QID at rehab and covered with sliding scale regular insulin as necessary until her blood sugars are under better control. 6 [**Name (NI) 3674**] pt w/ baseline hct in 28-30 range, fluctuating w/ volume status. Have been deferring transfusion secondary to conflicting nature of evidence for and agains transfusion in cardiac and ICU patients, respectively. She was transfused 1 U PRBC upon admission to the floor, [**12-8**] for Hct 28. She bumped appropriately, and her hct has been stable since (31-32). Her hematocrit should be maintained at 30 or above given her cardiac history. 7. Constipation: bowel regimen. Has not improved with enema and lactulose. On transfer, on bisacodyl, senna, docusate, psyllium, lactulose, and rec'd enemas. Pt had bowel movement on admission to floor, but this regimen should be titrated to regular bowel movements. 8. Px: Protonix and pneumoboots were continued in house. SQ heparin/heparin gtt was d/c'd secondary to a drop in platelets. Her HIT antibody came back negative. 9. Access: Right mid-line placed on [**12-9**] (to facilitate vancomycin therapy) 10. Communication: family (son, daughter in law) 11. Full Code 12. Dispo: to [**Hospital3 **] center. Medications on Admission: 1. Acetaminophen 325 mg tablet, one to two tablets, p.o. q. four to six for pain, aches, fever. 2. Aspirin 325 mg p.o. q. day. 3. Bisacodyl 5 mg, two tablets q. day. 4. Docusate sodium 100 mg p.o. b.i.d. 5. Senna one tablet b.i.d. 6. Enalapril 10 mg two tablets p.o. q. a.m. 7. Gabapentin 100 mg p.o. b.i.d. 8. Metoprolol 50 mg tablet, 0.25 tablet p.o. b.i.d. 9. Simvastatin 10 mg p.o. q. day. 10. Lactulose 10 g packet, sig, three packets p.o. p.r.n. as needed for constipation. 11. Fleet enema, sig, 130 ml p.r., prn as needed for constipation. 12. Glucophage 200 mg p.o. q. a.m., 100 mg p.o. q. p.m. 13. Glyburide 1.25 mg tablet, half a tablet p.o. once a day. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (). 2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD (). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever. 5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Psyllium 58.6 % Packet Sig: One (1) Packet PO TID (3 times a day) as needed. 10. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. Metformin HCl 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Glyburide 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Vancomycin HCl 1000 mg IV Q24H 16. Insulin Glargine 100 unit/mL Solution Sig: 10 Units Subcutaneous at bedtime. 17. Insulin Reg (Human) Buffered 100 unit/mL Solution Sig: sliding scale Injection four times a day: Please do QID sliding scale, covering with regular insulin: BS 150-200, 2 units, 201-250, 4 units, 251-300, 6 units, 301-350, 8 units, 351-400, 10 units. 18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Non-ST Elevation MI, pneumonia, respiratory distress Discharge Condition: Stable Discharge Instructions: 1. Please take all your medications as prescribed 2. Follow up with Dr. [**Last Name (STitle) **]; this appointment should be made through rehab/when the course of your rehab is determined. You should follow up 1-2 weeks after discharge from rehab 3. Finish 10 day course of vancomycin; continue until [**12-14**] 4. Patient is prescribed Lasix 40 mg qd. Her I/O's should be followed closely to avoid volume overload. Her volume status should be maintained as negative until she follows up with her PCP. [**Name10 (NameIs) **] pulmonary exam to ensure that she is not developing increased pulmonary edema/crackles on exam. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] 1-2 weeks after you are discharged from rehab ([**Telephone/Fax (1) 18485**]) [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "410.71", "482.41", "428.31", "401.9", "428.0", "507.0", "272.0", "518.81", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11712, 11797

4502, 9354

289, 296

11894, 11902

3218, 3833

12582, 12802

2658, 2676

10077, 11689

11818, 11873

9380, 10054

11926, 12559

2691, 3199

3850, 4479

223, 251

324, 1834

1879, 2204

2398, 2642

2222, 2365

75,350

171,975

50363

Discharge summary

report

Admission Date: [**2193-7-9**] Discharge Date: [**2193-7-20**] Date of Birth: [**2142-11-22**] Sex: M Service: SURGERY Allergies: ciprofloxacin Attending:[**First Name3 (LF) 371**] Chief Complaint: multiple stab wounds Major Surgical or Invasive Procedure: [**2193-7-9**]- 1. Neck exploration. 2. Bilateral thigh exploration. 3. Left arm exploration. 4. Suturing of antecubital vein. 5. Placement of right chest tube. 6. Direct laryngoscopy. 7. Esophagoscopy. [**2193-7-10**]- neck exploration and closure [**2193-7-13**] - EGD [**2193-7-15**] - EGD [**2193-7-19**] - EGD History of Present Illness: The patient is a 50M found in the car with multiple stab wounds. He was brought to the [**Hospital1 18**] ER and coded for enroute for PEA twice and was intubated. In the ER, b/l chest tubes were placed and agressive resuscitation was initiated for acedemia nd hypovolemia. He subsequently went to the OR where he underwent neck exploration, IJ vein repair, and packing of the rest of the wounds. He received 6L fluids and 27u pRBC between the ED and the OR. The patient was transferred to the Trauma Surgery ICU for further resuscitation. Past Medical History: Remote dysthymia (tx with fluoxetine then paroxetine [**2183**]-[**2185**]), lupus (x7 years in remission, baseline Cr = 1.3), hypertension (goal BP < 125/75), GERD, asthma Social History: Lives with wife and 2 children, no tobacco, EtOH, or illicits Family History: None Physical Exam: Exam on Admission: General: Intubated, sedated HEENT: Right sided neck laceration 8 cm, central laceration with arterial bleed, 10 cm left neck laceration through the muscle without active bleed C. collar on Chest: Decreased breath sounds, bilateral chest lacerations Cardiovascular: Regular Rate and Rhythm, Normal S1, S2 Abdominal: Soft, Nontender Extr/Back: Bilateral AC lacerations with active bleeding, R radial laceration, B groin lacerations that are bleeding slowly, B posterior Knee lacerations - not bleeding Pertinent Results: EEG [**2107-7-13**]: IMPRESSION: This telemetry captured no pushbutton activations. It showed a low voltage slow background throughout. This suggests a moderately severe encephalopathy, and it did not change appreciably over the course of the recording. There were no epileptiform features or electrographic seizures. Of note, large myoclonic jerking motions reported on earlier recordings were not evident on this one. [**7-10**] CT head: CONCLUSION: 1. No evidence of acute intracranial process. 2. Air-fluid levels in the sphenoid and maxillary sinuses and blood in the nasal cavity and pharynx. 3. Right subgaleal hematoma and increased soft tissue density over the right lateral cheek. Correlate with clinical exam. [**7-10**] CT Torso: IMPRESSION: 1. Multiple regions of soft tissue injury with packing in the lower left anterior chest. 2. No obvious contusion or in the left lung, deep to the skin defect. 3. Two chest tubes on the right and one on the left. One of the right chest tubes takes an acute angulation with the tip possibly in the major fissure or may also lung parenchyma. The exact location is difficult to evaluate due to the surrounding consolidation. 4. Diffuse consolidation in the right upper lobe and dependent aspect of right lower lobe and to a lesser extend, the dependent portion of the left lower lobe. It is uncertain if the consolidation represents hemorrhage, contusion, or aspiration (or a combination). There are nonspecific ground-glass opacities in the left upper lobe and scattered nodular opacities. 5. Small residual nondependent anterior pneumothorax on the right with adjacent subcutaneous air. 6. Limited noncontrast scan of the abdomen with small free fluid locules around the liver, spleen, and deep within the pelvis. Slightly elevated attenuation of the fluid may indicate a hemorrhagic component, however, exact attenuation is inaccurate due to the streak artifact. 7. Bilateral nondisplaced anterior rib fractures in the right third, fifth, and sixth ribs and the left fourth and fifth ribs, presumably from resuscitation. 8. Fluid within the right inguinal canal or high location of the right testis. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the ICU for monitoring. His injuries included: Lacerations to b/l popliteal fossae, Lacerations to b/l AC fossae, Lacerations to zone 2 bilateral neck, Lac b/l medial thigh, Lacerations to ventral wrists b/l Stab wounds L anterior chest, Lac to L flank, and rib fx: R 3,5,6 L 4,5. He initially required massive resuscitation including 29u pRBC, 12 plasma, 5 platelets, 4 cryo and factor VII. He was taken urgently to the operating room on HD 1 for neck exploration and control of bleeding. Once stabilized, he was taken back to the ICU for further management. His course is summarized by systems below: N: He was sedated with fent/versed initially. He had seizure activity overnight on HD 2; an EEG on HD 3 showed no seizure activity but did show clonic jerks. Neuro was consulted and continued to follow throughout his course. A head MRI was obtained as he was localizing pain but not responding to commands; it demonstrated only a tiny frontal lobe infarct. He was never able to follow commands during his admission, though he had intermittent movement of all four extremities. CV: He initially had a multiple pressor requirement and large volume blood loss. As he was resuscitated the pressor requirement was slowly weaned down but did not completely resolve. Given his prolonged pressor needs a cortisol stimulation test was obtained on HD6 which was normal. Pressors were continued as needed. On HD 6 he had an episode of SVT to the 220's; he was cardioverted x1. He continued to require neosynephrine during persistent episodes of upper GI bleeding, and this requirement increased significantly [**7-20**] prior to withdrawal of care. Pulm: He remained intubated postoperatively. For his rib fractures and pneumothorax two chest tubes were placed. These were kept to suction initially. On HD 6 they were transitioned to water seal and a post waterseal film revealed no PTX. GI: On HD 4 he began to have bloody output from the OGT. The tube feeds were held. GI was consulted and performed UGI at bedside on HD 5; this demonstrated diffuse ulcers with clot but no active bleed. He was continued on a protonix drip and started on sucralfate. His Hct dropped from 25 to 17 on HD 6; GI and IR were reconsulted to consider possible intervention. He underwent two additional EGDs on [**7-15**] and [**7-19**] without a localization of a specific bleeding source. He required daily blood product transfusion to maintain his hematocrit. Discussion regarding possible interventional radiology embolization or surgical treatment including gastrectomy were discussed at length with the patient's wife, and the decision not to pursue further invasive treatment was made on [**7-19**]. He continued to have bloody output from the NG tube and continued on a PPI gtt until withdrawal of care. GU: He had an acute kidney injury on admission, thought likely [**12-20**] prolonged ischemia during prehospital course. His creatinine continued to rise despite fluid resuscitation and blood pressure support. Renal was consulted and CVVH was initiated on [**2193-7-13**]. This was continued until [**7-18**], when he was dosed with DDAVP in hope of controlling his upper GI bleeding by improving platelet function. ID: He was found to have GNR's in his blood which speciated to pseudomonas. He also had GNR's in his sputum which speciated to Enterobacter as well as Pseudomonas. He was initially given kefzol from [**Date range (1) 70834**]; given the GNR's he was started on cefepime on [**7-13**], and IV bactrim was added. Family meetings were held on [**9-9**], and [**7-20**] to discuss the patient's condition, prognosis, potential interventions, and likely outcomes. On [**7-20**], the patient's wife requested that supportive care be withdrawn, and for only comfort care measures to be taken. This was discussed with both the ICU and Trauma surgery attending with the aid of ICU nurses and the ICU social worker. Care was withdrawn and he expired shortly thereafter. Medications on Admission: Pravastatin 20 qHS, Hydrochloriquine 200', Diltiazem 180', ASA 81', Lisinopril 40', Ranitidine 300', Omeprazole 20'', Terbinafine 250', Fish oil', MVI', Folic acid', Vitamin B12 Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Multiple penetrating traumatic wounds, cardiac arrest, respiratory failure, upper gastrointestinal bleed Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "38.93", "86.59", "06.09", "42.23", "34.09", "39.32", "45.13", "31.42", "89.64", "39.31", "99.15", "96.72", "39.95", "83.65", "96.6", "38.91" ]

icd9pcs

[ [ [] ] ]

8508, 8517

4233, 8251

293, 611

8665, 8674

2036, 2468

8726, 8732

1474, 1480

8479, 8485

8538, 8644

8277, 8456

8698, 8703

1495, 1500

233, 255

639, 1182

2477, 4210

1515, 2017

1204, 1378

1394, 1458

45,413

149,169

41167

Discharge summary

report

Admission Date: [**2164-2-17**] Discharge Date: [**2164-3-16**] Date of Birth: [**2079-10-10**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: Fever Major Surgical or Invasive Procedure: ERCP with sphincterotomy Percutaneous cholecystostomy x 3 CT guided liver biopsy [**2164-3-13**] G tube placed History of Present Illness: Mr. [**Known lastname **] is an 84 year old gentleman who presents with biliary obstruction secondary to multiple liver masses biopsy proven to be adenocarcinoma strongly suggestive of cholangiocarcinoma. Surgical consult was obtained to assess for resectability. In summary, by report and through the OSH medical records (all of which are not available at this time), Mr. [**Name13 (STitle) 89675**] presented to an OSH ([**Hospital3 15402**]) in late Decemeber [**2163**] with painless jaundice and an elevated bilirubin. He underwent ERCP and stent placement, then MRCP. IR at the OSH attempted biopsy but was unsuccessful. Of note, 2 days post-ERCP, he was prescribed and completed a 10 day course for bacteremia with zosyn. He presented to the OSH again on [**2164-2-16**] with a fever of 104 and jaundice. He was started on zosyn and transferred to [**Hospital1 18**] with a WBC of 11.7 and a Tbili of 8.0. Ultrasound on [**2164-2-16**] showed a 2.3 cm lesion of the right lobe. ERCP on [**2164-2-17**] showed stricture of the right and left hepatic ducts, left ductal system was accessible and stent was placed. This was followed by PTBD on [**2164-2-17**] that placed an external drain into the right ductal system. On repeat attempt on [**2164-2-21**], right and left internal/external drains were successfully placed. He had an u/s guided biopsy of a liver lesion on [**2164-2-22**] showing adenocarcinoma. Of note, zosyn (started at OSH on [**2164-2-16**]) has been continued upon arrival to [**Hospital1 18**]. He has been afebrile since. Past Medical History: CAD Syncope Chronic bilateral subdural hematomas Hypertension Diabetes Paroxysmal atrial fibrillation Hypothyroidism BPH Social History: Patient resides at [**Location (un) 89676**] [**Hospital3 **]. He previously worked as a machinist. He is married, has one child. He has never smoked. Family History: Mother had some type of cancer. Physical Exam: Vitals: 97.7, 126/71, 76, 20, 100 RA Gen: NAD, AOX3 HEENT: PERRLA, EOMI, MMM, sclera icteric, not injected Neck: no LAD, no JVD Cardiovascular: RRR normal s1, s2, no murmurs appreciated Respiratory: Clear to auscultation bilaterally, no wheezes, rales or rhonchi Abd: normoactive bowel sounds, soft, non-tender, distended Extremities: No edema, 2+ DP pulses Neurological: CN II-XII intact except for hearing Integument: Warm, moist, no rash or ulceration, jaundiced Psychiatric: appropriate, pleasant, not anxious Pertinent Results: Admission labs: [**2164-2-16**] 10:37PM WBC-14.0* RBC-3.00* HGB-9.5* HCT-27.3* MCV-91 MCH-31.7 [**2164-2-25**] WBC-7.6 Hct-22.8* Plt Ct-405 [**2164-2-26**] WBC-8.2 Hct-27.2* Plt Ct-432 [**2164-3-13**] WBC-15.2* Hct-25.3* Plt Ct-508* [**2164-3-13**] Creat-0.9 K-4.4 [**2164-2-16**] ALT-174* AST-139* AlkPhos-646* TotBili-7.9* [**2164-2-25**] ALT-44* AST-43* AlkPhos-284* TotBili-8.0* [**2164-3-2**] ALT-37 AST-55* AlkPhos-253* TotBili-9.6* [**2164-3-13**] ALT-86* AST-105* AlkPhos-167* TotBili-8.9* LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2164-2-16**]--prelim: Suboptimal due to habitus. Moderate intrahepatic biliary duct dilatation similar to prior OSH scans. Suboptimal evaluation of reported liver lesion. GB not seen. MPV patent. extrahepatic CBD normal size ERCP: Impression: -Strictured duodenum likely due to extrinsic compression from possible tumor (inflammatory changes alone are also possible) -Stent in the major papilla -Successful removal of the previously placed. -Stricturing of the right and left intrahepatic ducts was noted. The left intrahepatic was partially filled with contrast. It was dilated and multiple biliary radicles were noted without stricture. A very tiny amount of contrast entered the right duct system. -A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. -Cytology samples were obtained for histology using a brush in the left main duct. -The partially opacified CBD appeared normal with no stricture. -A 12cm by 7FR Cotton [**Doctor Last Name **] biliary stent was placed successfully in the left main hepatic duct. -Multiple attempts were made with a sphincterotome and guidewire to access the right system, but this failed An angled glidewire was next used to attempt access. This was also unsuccessful. CT abd [**2164-3-3**]: IMPRESSION: 1. No significant change in metastatic cholangiocarcinom. However, there is increased thickening of the hepatic flexure and tethering of the colon and duodenum at the level of the mass which may be causing partial gastric outlet obstruction. 2. Three percutaneous biliary catheters in place, with the newest catheter terminating within the right biliary system. UGI w/ SBFT [**2164-3-6**]: IMPRESSION: Tethering, angulation and narrowing of the first/second portion of the duodenum confirming findings seen previously at CT. Delayed passage of contrast into the more distal duodenum/jejunum. Of note, due to delayed gastric emptying, approximately 250 cc of contrast remain in the stomach. Suggest nasogastric tube be placed on low intermittent wall suction on patient's return to the floor. Brief Hospital Course: This is an 84 year old man with CAD, PAF, and DM who recently developed painless jaundice with new liver lesions and E. coli bacteremia who presented with fever, nausea, vomiting and was found to have obstructed bile ducts and a picture suggestive of sepsis/acute cholangitits. His part of care was in the MICU as he developed hypotension following ERCP. He was placed on Zosyn and briefly on neosynephrine upon admission to the ICU, but it was quickly weaned off. He also received propofol for sedation during the ERCP which may have contributed to transient hypotension. His home metoprolol and finasteride were held and his blood pressures remained stable. In regards to his obstructive jaundice and liver masses, he had strictured duodenum likely due to extrinsic compression from possible tumor and stricturing of the right and left intrahepatic ducts. The left intrahepatic duct was opened with biliary stent placement. Multiple attempts were made to access the right system. Sphincterotomy was performed and cytology samples were obtained for histology which was positive for adenocarcinoma. CBD appeared normal with no stricture. He then underwent a successful right PTC and external drain placement extending across right ducts by Interventional Radiology. He then underwent another IR procedure: placement of right and left internal and external drains once his cholangitis settled. After completion of these procedures, he underwent a liver biopsy by U/S guided approach. Of note, he failed IR guided biopsy at [**Hospital6 89677**]. We consulted Oncology, GI, and Transplant Surgery. Of note, his CXR showed very large and multiple calcified lymphnodes. I obtained old CXR's (dated [**2152**] and [**2153**]), and this finding seemed to be old. He had no history of TB or asbestosis or smoking. We did a CT of the chest to rule out primary or metastatic lung cancer. The CT showed no evidence of lung malignancy. GI recommended against colonoscopy as his liver biopsy came back positive for adenocarcinoma suggestive of cholangicarcinoma. Transplant surgery recommended transfer to [**Hospital Ward Name 517**] to consider surgical options after reviewing his case. Patient was continued on Zosyn for 2 weeks course ending [**2164-3-2**] (OSH blood cultures grew E-COLI resistent to Levofloxacion, Ciprofloxacin, Ampicillin, Gentamycin and sensitive to Zosyn, Bactrim, Ceftriaxone, Ceftazidime, Amikcin, and Imipenim). His Metoprolol and Finastride were restated. His Doxazosin was also restarted at a lower dose of 2 mg at night. We discontinued Statin. He should be on aspirin but because of repeated procedures and recurrent biliary bleeding from righ biliary drain, this was on hold. aspirin should be restarted as soon as possible. Once transferred to the surgery service the patient's zosyn was continued and his LFT's were trended. on HD 10 he received 1 unit of PRBC's [**2-15**] for a HCt of 23, after which his Hct stabalized. The patient was tolerating a regular diet and his pain was well controlled. On HD 18 IR was able to place an external drain into the right anterior duct system. the patient was tachycardic post procedure and was given a 250cc bolus of NS. his cardiac enzymes were cycled and were his Hct and chemistries. He was kept NPO and an NG tube was placed due to persistent abdominal distention. An UGI w/ SBFT was done on HD 19 that showed a narrowing of the first and second portion of the duodenum and delayed gastric emptying due to the gastric outlet obstruction. This obstructon was likely secondary to the compressive effects of his unresectable choangiocarcimona. TPN was initiated and both both IR and GI attempted to place a GJ through the stricture site but failed. While another attempt by IR was planned for internalization of the Rt posterior dran as well as placement of a GJ, it was aborted due to the patient's declining mental status. He became increasingly confused during the admission, and when lucid expressed understanding of the terminal nature of his illness and the desire to be near his wife. Palliative care was consulted and they helped clarify the goals of care with both the patient and the family. The patient and his family, after multiple discussions, both decided that focusing his care around comfort measures would be a goal of further treatment. A gastric tube was placed by IR on HD 26 and the patient was made DNR/DNI. This tube was placed to gravity and the patient was allowed to take sips ad lib. He will be discharged to a skilled nursing facility near his home where he will receive further care and be close to his wife and son. Medications on Admission: 1. doxazosin 8 mg PO HS 2. docusate sodium 100 mg PO BID 3. metoprolol tartrate 25 mg PO BID 4. omeprazole 20 mg PO Q24H 5. finasteride 5 mg PO DAILY 6. ferrous sulfate 300 mg PO DAILY 7. levothyroxine 25 mcg PO DAILY 8. simvastatin 20 mg PO DAILY 9. miralax daily 10. vitamin C 500 mg daily 11. Niaspan 500 mg daily Discharge Medications: 1. levothyroxine 25 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Month/Day (2) **]: 0.25-0.5 ml PO Q2H (every 2 hours) as needed for pain/dyspnea. 3. ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Last Name (un) 17181**] Manor Extended Care Facility - [**Location (un) 5503**] Discharge Diagnosis: Acute cholangitis Obstructive jaundice, choledocholithiasis, Cholangiocarcinoma(unresectable) Hypothyroidism Hyperlipidemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted from another hospital with obstuctive jaundice and fever. After an extensive work up and placement of multiple biliary drains and stents you were found to have an unresectable cholangiocarcinoma. You were also found to have a stricture at your duodenum that has caused an obstruction. After multiple discussions with you and your family you were made DNR/DNI. A gastric tube was placed to decompress your stomach and give you symptomatic relief. You will be discharged to a skilled nursing facility for further care and to be close to your family. The focus of your care there will center around keeping you comfortable. Please call Dr[**Name (NI) 670**] office with any questions or concerns that may develop in the coming days or weeks and for assistance in coordinating your care further. Followup Instructions: Please follow up with Dr [**First Name (STitle) **] as needed. Please call [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] at [**Telephone/Fax (1) 89678**] for a follow up appointment if indicated. Please have hospice consulted as soon as you arrive to the skilled nursing facility. Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72334**], NP Location: GREATER [**Location (un) **] CHC Address: [**Street Address(2) 68461**], [**Location (un) **],[**Numeric Identifier 62441**] Phone: [**Telephone/Fax (1) 18050**] Appt: [**3-1**] at 1:45pm Completed by:[**2164-3-16**]

[ "197.7", "276.1", "432.1", "041.4", "272.4", "790.7", "458.9", "576.1", "537.0", "438.89", "250.00", "244.9", "414.01", "576.2", "155.1", "401.9", "427.31", "560.89" ]

icd9cm

[ [ [] ] ]

[ "51.85", "97.05", "50.11", "51.14", "42.23", "51.98", "43.19", "99.15" ]

icd9pcs

[ [ [] ] ]

11146, 11255

5616, 10234

309, 422

11423, 11423

2932, 2932

12397, 13016

2348, 2381

10603, 11123

11276, 11402

10260, 10580

11562, 12374

2396, 2913

264, 271

450, 2015

2948, 5593

11438, 11538

2037, 2160

2176, 2332

9,393

190,857

15349+15350

Discharge summary

report+report

Admission Date: [**2195-4-2**] Discharge Date: [**2195-4-29**] Date of Birth: [**2123-4-7**] Sex: F Service: CARDIAC SX HISTORY OF PRESENT ILLNESS: This is a 71 year old female with a past medical history significant for a repair of a Type A aortic dissection back in [**2193-10-22**], who presented to an outside hospital on [**2195-4-1**], after going to her primary care physician's office complaining of chest pain which had been worsening over the last month. The patient reports that the pain was of recent onset and localized to her left chest. The pain was not relieved by Nitroglycerin; no associated nausea, vomiting, shortness of breath, palpitations or diaphoresis. The chest pain worsened with movement and deep breaths. The patient was transferred to [**Hospital1 69**] for further care. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Hypertension. 3. Status post repair of Type A aortic dissection. MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Levoxyl 88 micrograms p.o. q. day. 3. Labetalol 200 mg p.o. twice a day. ALLERGIES: No known drug allergies. The patient was admitted to [**Hospital1 188**]. Her cardiac enzymes were negative for evidence of myocardial ischemia. The patient had had a CT scan performed at the outside hospital which showed unchanged dissection with poor flow in the false lumen. The patient underwent an ETT which was negative for any symptoms of pain and the thallium images were negative for evidence of ischemia. The patient underwent a CT angiogram which suggested extravasation of the dye from the false lumen to the left lung apical hematoma. HOSPITAL COURSE: The patient was taken to the cardiac catheterization laboratory which showed two to three plus aortic insufficiency, aneurysmal dilatation of the ascending aorta, both aortic valves, no clear location of dye extravasation of evidence of proximal retrograde dissection. No coronary artery disease. The patient was started on intravenous nitroprusside to maintain systolic blood pressure less than 110. The patient underwent an MRI / MRA of the chest to further evaluate the aorta. The MRI showed evidence of periaortic hemorrhage around the ascending aortic graft with signal intensity suggestive of subacute hemorrhage less than ten days old. Distal to the left subclavian artery there was a large aneurysmal dilatation of the false lumen with extensive thrombus within the aneurysmal dilatation and subacute hemorrhage within the aneurysmal dilatation at the level of the distal arch and proximal ascending aorta. The aneurysmal dilatation extended to the apical region of the left hemithorax. There was significant atelectasis of the left upper lobe surrounding the large aneurysm, a small left pleural effusion which was suggestive of blood. The patient was admitted to the Cardiac Care Unit for strict blood pressure control. Dr. [**Last Name (STitle) **] began the first of many discussions with Mrs. [**Known lastname **] and her family regarding potential high risk redo surgery. On [**4-13**], Dr. [**Last Name (STitle) **] again met with the family and the patient decided to go forward with surgery and agreed to the risks and potential complications as described by Dr. [**Last Name (STitle) **]. While the patient was awaiting surgery, it was decided that the patient was stable to be transferred from the Cardiac Care Unit to the Floor. The patient was taken to the Operating Room on [**4-21**] with Dr. [**Last Name (STitle) **], where she underwent a redo sternotomy, replacement of the ascending aorta, total arch replacement and replacement of the proximal descending aorta with aorta-subclavian, aorta-innominate and aorta-carotid bypasses as well as an aortic valve replacement with a 23 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve and aortic root enlargement. She was transported to the Intensive Care Unit in stable condition. During the operation, the patient had an episode of hemoptysis and postoperatively the patient's chest x-ray showed a right upper lobe infiltrate which was felt to be due to a rupture of the pseudoaneurysm and to the left upper lobe. The patient did not have any further hemoptysis postoperatively. The patient was on low dose epinephrine and Nitroglycerin which were slowly weaned off on postoperative day one. The patient's ventilatory support was weaned down to minimal settings over postoperative day number one. The plan was to have the patient remain intubated overnight on postoperative day number one and weaned to extubate after a bronchoscopy on postoperative day number two, however, during the night on postoperative day number one, the patient self extubated. The patient had good gas exchange and remained extubated. At this time, the patient was awake, alert, oriented times three, moving all extremities equally, with no neurologic deficit. Epinephrine was weaned off on postoperative day number two. The patient was started on low dose Lopressor. The PA catheter was removed. The patient was started on Lasix. On postoperative day number three, the patient was noted to be mildly thrombocytopenic with a platelet count of 76. Heparin dependent antibodies were sent which were subsequently positive. DICTATION ENDED [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2195-4-29**] 16:52 T: [**2195-4-29**] 18:49 JOB#: [**Job Number 44589**] Admission Date: [**2195-4-2**] Discharge Date: [**2195-4-29**] Date of Birth: [**2123-4-7**] Sex: F Service: CONTINUATION: The previous dictation was inadvertently terminated by the dictation system. By postoperative day number four, [**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351 Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2195-4-29**] 17:00 T: [**2195-4-29**] 19:06 JOB#: [**Job Number 44590**]

[ "424.1", "441.01", "511.8", "518.0", "996.1", "441.1", "998.12", "478.31", "287.4" ]

icd9cm

[ [ [] ] ]

[ "38.45", "88.56", "39.22", "39.23", "39.61", "37.22", "35.21", "40.11" ]

icd9pcs

[ [ [] ] ]

1650, 6063

170, 828

850, 1632

56,269

125,047

35814

Discharge summary

report

Admission Date: [**2108-6-6**] Discharge Date: [**2108-6-12**] Date of Birth: [**2036-5-12**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3256**] Chief Complaint: altered mental status; transferred to MICU for Hypertensive Urgency, Hypoglycemia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 81454**] is a 72 year old male with a recent history of pericardial effusion (s/p pericardiocentesis ~2 weeks ago) as well as HTN, HLD, and T2DM (on insulin) who was brought in by EMS for altered mental status. His blood sugars were noted to be in the 20s and he was given D50 by EMS. He is not currently able to provide any significant history of the preceeding events. However the patient's daughter reports that he has been in his usual state of health. No recent fevers or other illness. No sick contacts. [**Name (NI) **] took all of his regular medications including his 70/30 NPH dose today and there were no recent changes to his insulin regimen. He has been eating multiple regular meals as he does usually. Of note, the daughter does report frequent hypoglycemic episodes for which she has to give him [**Location (un) 2452**] juice. . In the ED, initial VS were: HR 55 182/70 11 98% on RA. Glucose on arrival was 38. His glucose subsequently improved to 140 with additional D50. He was also given insulin and his last glucose prior to transfer was 77. He had a Chest X-ray which showed cardiomegaly and evidence of fluid overload. Given his recent pericardiocentesis, a bedside ultrasound was performed which reportedly did not show any large pericardial effusion. He was therefore given 20mg of IV lasix. Despite improvement in blood sugars, the patient was still somnolent although oriented X 3. He had a head CT which was negative. The patient's blood pressures were persistently elevated in the ED and therefore he was started on a nitro drip. He was also given kayexalate for a potassium of 6.5 which was 5.9 on recheck. No EKG changes were noted. . On arrival to the MICU, patient's initial VS were 98.5 169/111 81 15 99% on 2L NC. He was resting comfortably in bed without respiratory distress. He answered orientation questions correctly but was sleepy. His daughter felt that his mental status is at baseline, and that this is normal for him given that it is the middle of the night. He denied chest pain or SOB. Sleeps with 2 pillows. No PND. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: -HTN -DMII, on insulin -HLD -?Positive PPD -Pericardial effusion of unclear etiology (S/p pericardiocentesis [**2108-5-18**]). Social History: He is originally from [**Country 16160**] and moved to [**Location (un) 86**] in [**2092**]. He was living here by himself and working to send money back to his family who remained in [**Country 480**]. 1 year ago his daughter moved here from [**Country 16160**] to help take care of him. He lives with just his daughter; his wife and the rest of his family are still in [**Country 16160**]. He is not currently working, but he previously worked as a tractor operator. Ambulates with a cane. No recent falls. Tobacco: Stopped smoking approximately 11 years ago EtOH: none Illicits: none Family History: DMII, remainder unknown. Physical Exam: Admission Exam: General: Oriented, but sleepy HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: [**Country **], JVP difficult to assess because of body habitus CV: Regular rate and rhythm, [**3-19**] SM heard best at LUSB Lungs: Crackles at bases. Abdomen: firm, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation Ext: [**2-13**]+ pitting edema to mid-shin Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation . Pertinent Results: Admission Labs [**2108-6-6**] 07:05PM: WBC-9.0 RBC-2.75* Hgb-7.7* Hct-25.8* MCV-94 MCH-28.2 MCHC-30.1* RDW-16.5* Plt Ct-336 Neuts-73.1* Lymphs-15.1* Monos-3.8 Eos-7.6* Baso-0.5 Glucose-156* UreaN-53* Creat-2.1* Na-133 K-6.5* Cl-107 HCO3-20* AnGap-13 ALT-22 AST-22 LD(LDH)-251* CK(CPK)-162 AlkPhos-88 TotBili-0.2 proBNP-[**2052**]* cTropnT-<0.01 Calcium-7.8* Phos-5.0* Mg-2.9* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Discharge Labs: [**2108-6-12**] 10:46 am SPUTUM Site: INDUCED Source: Induced. ACID FAST SMEAR (Pending): ACID FAST CULTURE (Pending): . [**2108-6-6**] CXR AP: Again seen, is severe cardiomegaly. The central pulmonary vessels are engorged, and there is superimposed mild interstitial edema which is new since the prior study. There is no pneumothorax. A trace right pleural effusion is present. IMPRESSION: Central pulmonary vascular congestion with new interstitial edema and stable cardiomegaly. . [**2108-6-6**] CT head without contrast: Two attempts were made at imaging due to patient motion. There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. The ventricles and sulci are mildly prominent, reflective of mild diffuse cortical atrophy. There is no shift of normally midline structures. There is under-pneumatization of the mastoid air cells, worse on the right. The left middle ear cavity appears clear. There is some opacification within the right middle ear cavity (2:8), which may be congenital. Included views of paranasal sinuses are clear. There is mild soft tissue swelling overlying the left calvarium. . [**2108-6-7**] ECHO: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy (LVH) with normal cavity size and global systolic function (LVEF>55%). There is a mild resting left ventricular outflow tract (LVOT) obstruction. Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion suggestive of pericardial constriction (septal flattening with respiration, best seen on clips 25, 58, 29). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. Increased velocities across pulmonic valve, suggestive of mild pulmonary stenosis. The estimated pulmonary artery systolic pressure is normal (when taking into account increased gradient across PV).There is a trivial/physiologic pericardial effusion. The echo findings are suggestive but not diagnostic of pericardial constriction. . IMPRESSION: Abnormal septal motion with respiration, suggestive of pericardial constriction (also seen on TTE from [**2108-5-18**]). Clinical correlation advised. Mild LVH with preserved global biventricular systolic function. Resting LVOT gradient. Increased velocities across pulmonic valve, suggestive of pulmonary stenosis. . Unable to fully compare current findings with study from [**2108-5-18**] due to focused/limited images on prior study. Dr. [**First Name (STitle) 1726**] was notified by telephone today ([**2108-6-7**]) at 12:45 p.m. Brief Hospital Course: Mr. [**Known lastname 81454**] is a 72 year old male with a recent history of pericardial effusion (s/p pericardiocentesis ~2 weeks ago) as well as HTN, HLD, and T2DM (on insulin) who was brought in by EMS for altered mental status and hypoglycemia, also found to have hypertensive urgency. . #) Hypoglycemia: Unclear precipitating factor. According to patient and daughter he takes his insulin as directed. He is eating regular meals. Given that his daughter reports multiple hypoglyemic episodes, his insulin needs may have gone down. This could relate to his kidney disease because of decreased clearance of insulin and also recent weight loss. CXR and UA negative for infection. He has no known history of alcohol or liver disease. AM cortisol without evidence of adrenal insufficiency. The patient's home NPH was held. He was started on a moderate sliding scale on admission to the ICU, but only required 2 units of humalog throughout ICU stay. [**Last Name (un) **] was consulted and he has been maintained on NPH at 10 u QAM and 10u QHS. Blood sugars are stable. . #) Altered Mental Status: Resolved on admission to the ICU per the patient's daughter. [**Name (NI) **] likely was toxic/metabolic encephalopathy related to hypoglycemia. CT head without contrast was negative in the ED. No fevers or leukocytosis to suggest infection. . #) Pulmonary Edema: Patient admitted with pulmonary edema requiring 2L NC, likely secondary to hypertensive urgency. He underwent TTE on admission that showed no recurrence of previous pericardial effusion, but persistent constrictive physiology with preserved EF. He was ruled out for MI by cardiac enzymes. The patient was diuresed with lasix 40 mg IV TID, and then prn with oral lasix, and his blood pressure and pulmonary edema improved. On the day of discharge the patient had normal oxygen saturations on room air. . #) Hypertensive Urgency: The patient was admitted with BP 169/111. He was started on a nitro drip in the ED. He was also continued on home medications of amlodipine, carvedilol, and lasix. Nitro drip was weaned, and the patient's carvedilol was titrated up to 25 mg [**Hospital1 **]. He began to experience episodes of bradycardia with a junctional escape rhythm. Carvedilol was discontinued due to several episodes of bradycardia and the patient was started on clonidine, titrated up to a 3mg patch (patient had been prescribed clonidine during previous admission but was unable to fill it at home). He experienced no further episodes of bradycardia. Patient continued to be mildly hypertensive at the time of transfer to the floor, but blood pressures improved to 160's systolic on discharge. The patient's cardiology appointment was rescheduled. . #) Hx Pericardial effusion (s/p pericardiocentesis [**2108-5-18**]): Unclear etiology. He had a CT Torso (without contrast) which showed a very small pleural effusion but no clear malignancy as a cause. ESR and CRP were profoundly elevated but [**Doctor First Name **] was negative. Patient has a history of positive PPD in the past. The pericardial fluid cultures were all negative including those for AFB. The patient was seen by infectious disease, and per this service's recommendations a TB rule out was initiated. On discharge the patient was scheduled for 2 additional induced sputums (appointments were made) and was instructed to wear a mask until these were finalized. Given TB rule out, infectious disease follow up was scheduled. . #) Hyperkalemia: Potassium 6.5 on arrival, which improved to 5.9 with kayexalate. No EKG changes. Unclear etiology. Patient was previously on lisinopril although it was discontinued at last discharge. He was diuresed with lasix, as above, and potassium improved to normal range. The patient was ruled out for adrenal insufficiency as source of hyperkalemia with AM cortisol. . #) Chronic Kidney Disease: According to previous d/c summary, patient has a baseline Cr of 2.0. The etiology of his chronic kidney disease is unknown, but felt to be secondary to hypertension vs. diabetic nephropathy. The patient's creatinine remained stable throughout admission. . #) Normocytic Anemia: Appears chronic, at baseline throughout admission. Possibly related to CKD. Iron studies on admission demonstrated anemia of chronic disease. Retic count 2.6, slightly low based on degree of anemia. Patient should undergo further workup (colonoscopy, malignancy workup) as an outpatient, especially given history of pericardial effusion. A hematology appointment was scheduled. . # Code: Full Medications on Admission: 1. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: As directed units Subcutaneous twice a day: Please take 40 units in the morning and 35 units in the evening. 2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch Transdermal qsat. <--- not taking 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 6. Ultram 50 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 7. doxepin 25 mg Capsule Sig: One (1) Capsule PO at bedtime. 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO four times a day as needed for pain. Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). Disp:*4 Patch Weekly(s)* Refills:*2* 5. chlorthalidone 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 8. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) u Subcutaneous twice a day. Disp:*30 mL* Refills:*2* 9. cholecalciferol (vitamin D3) Oral 10. calcium carbonate Oral Discharge Disposition: Home Discharge Diagnosis: - Hypoglycemia (low sugar) - hypertension - anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU for confusion and low sugar levels. The low sugar level was attributed to greater amounts of insulin than was needed - given your recent weight loss. With appropriate changes in insulin level, your sugar levels were better controlled. During this stay, you were noted to have some shortness of breath and evidence of extra fluid in your lungs. Medications were given to help you urinate and rid of this extra fluid. This helped with your breathing as well as your blood pressure. During this stay you were also seen by the infectious disease doctors [**Name5 (PTitle) **] concerns about your risk of tuberculosis (an infection). You will need to have 2 more sputum samples over the next week to rule out active lung tuberculosis, and until then you will need to wear a mask when you are around other people. You are also anemic, and you will need to be seen by a hematologist for this. Your colonoscopy will also need to be rescheduled. Medication changes: STOP Coreg/carvedilol CHANGE Insulin to Insulin NPH 10u in the morning, 10u in the evening. START chlorthalidone CHANGE to higher dose clonidine patch (place one each week) STOP tramadol Followup Instructions: Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30755**], MD Specialty: Primary Care Address: [**Apartment Address(1) 14920**], [**Location (un) **],[**Numeric Identifier 6809**] Phone: [**Telephone/Fax (1) 14918**] When: Wednesday, [**6-13**] at 12:00pm Department: HEMATOLOGY/BMT When: WEDNESDAY [**2108-7-4**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2108-7-4**] at 10:30 AM With: DR. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST PROCEDURAL CENTER When: WEDNESDAY [**2108-6-13**] at 2:00 PM With: CDC [**Telephone/Fax (1) 73014**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: THURSDAY [**2108-6-14**] at 1 PM With: CDC [**Telephone/Fax (1) 73014**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: FRIDAY [**2108-6-15**] at 1 PM With: CDC [**Telephone/Fax (1) 73014**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

[ "276.7", "584.9", "V15.82", "285.21", "278.00", "276.2", "428.21", "403.00", "V58.67", "585.3", "272.4", "423.2", "428.0", "250.32" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13970, 13976

7566, 8653

386, 392

14070, 14070

4273, 4711

15423, 17193

3719, 3745

13182, 13947

13997, 14049

12150, 13159

14220, 15192

4727, 4835

3760, 4254

2529, 2948

15212, 15400

4865, 7543

264, 348

420, 2510

14085, 14196

2970, 3099

3115, 3703

15,895

135,286

14925

Discharge summary

report

Admission Date: [**2116-7-4**] Discharge Date: [**2116-7-14**] Date of Birth: [**2039-10-21**] Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Weakness and dizziness. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4223**] is a 76-year-old gentleman who presents for CABG. He was admitted to [**Hospital 1474**] Hospital for fatigue and dizziness. He had no complaints of chest pain. ECG at this time revealed bradycardia in the 30's which was determined to be a sinus bradyarrhythmia. His Diltiazem was stopped and his heart rate increased to the 70's. Cardiac catheterization was performed at this time which revealed three vessel disease. PAST MEDICAL HISTORY: Poorly controlled hypertension, history of bladder cancer, questionable history of prostate cancer, mild renal insufficiency, questionable history of pericarditis 40 years ago, appendectomy in 20's. SOCIAL HISTORY: Mr. [**Known lastname 4223**] does not smoke or drink. ALLERGIES: None. MEDICATIONS: Hytrin 5 mg q d, Cardizem CD 300 mg q d, Baby Aspirin one q d. PHYSICAL EXAMINATION: Pulse 84, blood pressure 188/90, respirations 18, O2 saturation 96% on room air. Mr. [**Known lastname 4223**] is a pleasant gentleman in no apparent distress. His head is normocephalic, atraumatic. His neck was supple with no thyromegaly. His heart is regular rate and rhythm with lungs clear to auscultation bilaterally. Abdomen is soft, nontender, non distended with normoactive bowel sounds. Extremities are without clubbing, cyanosis or edema. His skin is remarkable for a perioral rash. LABORATORY DATA: ETT revealed inferior and septal ischemia. Cardiac catheterization revealed 90% mid LAD, 90% mid circumflex with 90% ostial OM1 and 70% mid to posterior OM2, RCA 80% ostial and 60% mid. HOSPITAL COURSE: Mr. [**Known lastname 4223**] was taken to the operating room on [**2116-7-6**] for CABG times four. The procedure was performed off pump due to his severely calcified aorta. Grafts included LIMA to LAD, SVG to distal R, SVG to OM1 and OM3. The procedure was performed without complication and patient was subsequently transferred to the CSRU. In the unit he was extubated, weaned off drips and fluid resuscitated. His condition continued to improve and he was subsequently transferred to the floor on the evening of postoperative day #1. Mr. [**Known lastname **] stay on the floor was remarkable for atrial fibrillation. He was treated with intravenous Metoprolol and Amiodarone and started on oral Amiodarone. He converted to a sinus rhythm and has remained in sinus since. Mr. [**Known lastname 4223**] also received two units of packed red blood cells for asymptomatic anemia with a hematocrit of 21. He felt much better following his transfusion. Mr. [**Known lastname 4223**] was also started on oral Hydralazine for a persistently elevated blood pressure with systolics in the 180's to 200. Following the commencement of Hydralazine, his blood pressure has been stable in the 120's systolic. Otherwise, Mr. [**Known lastname 4223**] continued to improve daily. He was tolerating oral diet and his pain was controlled with oral medications. He was ambulating with assistance. On [**2116-7-13**] Mr. [**Known lastname 4223**] was felt stable to be transferred to rehabilitation facility. Exam at discharge, vital signs temperature 97.7, pulse 57, blood pressure 117/50, respirations 20, O2 saturation 96% on two liters. Heart is regular rate and rhythm. Lungs are mildly coarse at the bilateral bases. Abdomen is soft, nontender, non distended with normoactive bowel sounds. Extremities remarkable for 1+ edema in the bilateral lower extremities. Sternal incision is clean, dry and intact. His leg incision is draining slightly. DISCHARGE MEDICATIONS: Lopressor 25 mg [**Hospital1 **], Terazosin 5 mg q h.s., Hydralazine 25 mg qid, Amiodarone 400 mg q d, Docusate 100 mg [**Hospital1 **] prn, Aspirin 325 mg po q d, Plavix 25 mg q d, Acetaminophen 500 mg to 1,000 mg q 4-6 hours prn, Lasix 20 mg q d times 10 days, KCL 20 mg q d times 10 days. FO[**Last Name (STitle) **]P: The patient should follow-up with Dr. [**Last Name (STitle) **] one week after discharge from rehab and Dr. [**Last Name (Prefixes) **] in four weeks. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Mr. [**Known lastname 4223**] is to be discharged to the rehab facility. DISCHARGE DIAGNOSIS: 1. Status post off pump coronary artery bypass graft times four. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Doctor First Name 24423**] MEDQUIST36 D: [**2116-7-13**] 08:21 T: [**2116-7-13**] 08:28 JOB#: [**Job Number 43738**]

[ "V10.51", "V10.46", "440.0", "458.2", "401.9", "414.01", "285.9", "427.31", "593.9" ]

icd9cm

[ [ [] ] ]

[ "36.15", "99.29", "89.68", "99.69", "36.12" ]

icd9pcs

[ [ [] ] ]

4293, 4395

3795, 4271

4416, 4741

1814, 3771

1091, 1796

166, 191

220, 675

698, 898

915, 1068

21,308

150,473

3002

Discharge summary

report

Admission Date: [**2113-5-16**] Discharge Date: [**2113-5-21**] Date of Birth: [**2059-11-5**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Fifty-three year old male with a history of metastatic nonsmall lung cancer with metastasis to the left femur and adrenals, who presents with progressive shortness of breath over the past week. The patient had a chest x-ray done at his oncologist's office, which showed a small apical pneumothorax, new pulmonary nodules, and an enlarged cardiac silhouette. Transthoracic echocardiogram was performed which showed a moderate-to-large circumferential pericardial effusion with impaired ventricular filling. The patient was sent to the Emergency Department for triage to the Catheterization Laboratory for pericardiocentesis. PAST MEDICAL HISTORY: 1. Nonsmall cell lung cancer with metastasis to the left femur and to the adrenals bilaterally. It was initially diagnosed in [**2111-11-24**] as an undifferentiated mediastinal carcinoma of unknown primary. The patient has since had multiple courses of chemotherapy including the following: Cisplatin and etoposide x1 regimen; carboplatin and Taxol x1 regimen; low dose carboplatin and Taxol with concurrent radiation therapy. The patient had a recent diagnosis of a left femur bone metastasis and had radiation therapy to this region. The patient then had two cycles of gemcitabine in [**2113-3-23**], a course of Iressa was started and the patient continues on this regimen. 2. History of near syncope and dehydration requiring IV fluids and ............. 3. Diverticulosis. 4. Anxiety. 5. Orthostasis. 6. Internal hemorrhoids. MEDICATIONS ON ADMISSION: 1. Fentanyl patch 200 mcg transdermal q72h. 2. Celexa 40 mg po q day. 3. Lorazepam 1-2 mg po tid prn. 4. Motrin 600 mg po tid prn. 5. Protonix 40 mg po q day. 6. Iressa as prescribed by his oncologist, Dr. [**Last Name (STitle) 410**]. 7. Adderall XR 10 mg po q am. 8. Albuterol 1-2 puffs q4-6h prn shortness of breath. 9. Oxycodone prn pain, dose unknown. 10. Peri-Colace and Dulcolax as prescribed. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is on disability, lives with his wife and daughter in [**Name (NI) 2199**], [**State 350**]. He quit smoking tobacco in [**2111-3-24**]. Prior smoking history includes 40 years of two packs per day leading to greater than 80 pack year smoking history. He denies alcohol use. FAMILY HISTORY: Significant for father with [**Name2 (NI) 499**] cancer and his mother died of pneumonia. PHYSICAL EXAMINATION: In general, this is an ill appearing cachectic male appearing older than stated age in mild respiratory distress. Vital signs: Temperature 98.8, heart rate 100, blood pressure 111/65, respiratory rate 27, pulse oximetry 97% on 5 liters. HEENT is normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Anicteric sclerae. Moist mucosal membranes. Neck: Jugular venous pressure 6-7 cm, no lymphadenopathy, supple. Lungs: Dull breath sounds at the right base, clear to auscultation on the left side with good breath sounds. Heart: Regular, rate, and rhythm, normal S1, S2. Abdomen is soft, nontender, and nondistended, normoactive bowel sounds in all four quadrants. Extremities: No edema, 2+ distal pulses bilaterally, dorsalis pedis. LABORATORY DATA ON ADMISSION: White blood cell count 11.2, 84% neutrophils, 9% lymphocytes, 5% monocytes, and 0 bands. Electrolytes: Sodium 134, potassium 4.8, chloride 93, bicarbonate 28, BUN 14, creatinine 0.7, glucose 97. Pericardial fluid: White blood cell count [**Pager number **], red blood cell count [**Pager number **]. Differential of the white blood cell count 15 polys, 2 lymphocytes, 1 monocyte, 8 macrophages, and 2 other cells. Total protein 5.6, glucose 113, LDH 279, albumin 3.0. PT 12.8, INR 1.1, PTT 28.8. CHEST X-RAY: Small left apical pneumothorax, new pulmonary nodules most likely due to metastatic disease, enlargement of the cardiac silhouette without interval change in pulmonary vascularity. ELECTROCARDIOGRAM: Sinus tachycardia at 103 beats per minute, normal axis, normal intervals, no pulsus alternans. HOSPITAL COURSE: Patient was brought to the Catheterization Laboratory on [**5-16**], where the following was noted: A low pressure tamponade was present with equalization of the pericardial and right atrial pressures. Cardiac index was estimated at 2.2 liters per minute per meters squared. pericardiocentesis was performed and 540 cc of clear fluid was removed and sent for evaluation. Pericardial drain was left in place for close drainage. The patient was then admitted to the MICU, where his pericardial effusion drained over the next three days. This was confirmed by serial echocardiography which did eventually show resolution of the effusion on [**5-19**]. The patient remained hemodynamically stable throughout his MICU stay. He was maintained on 5 liters nasal cannula, but did at times require increased O2 requirement, and was kept in good respiratory status with consistent albuterol nebulizer treatments every four hours. On [**5-19**], the patient was transferred to the General Medicine floor. At that time he had moderate respiratory distress and was again maintained in good respiratory status with increased O2 administration and albuterol nebulizer treatments standing for the first 24 hours and then prn after that. During the initial 24 hours on the floor, the patient did require administration of oxygen via 100% nonrebreather mask to make him more comfortable. During the remainder of his stay, he did not require the nonrebreather mask to maintain his O2 saturations, however, it was decided that access to greater than 5 liters of continuous O2 administration would be necessary if he were to be discharged home. Therefore, arrangements were made for a liquid O2 tank with a nonrebreather mask for administration of [**9-6**] liters prn be available at his home. 2. Patient's last echocardiography on [**5-19**] showed resolution of the pericardial effusion. There was no evidence to suggest reaccumulation of the effusion. The patient did have mild tachycardia intermittently throughout his hospital stay thought to be related to his poor respiratory status. 3. Hematology/Oncology: The patient was aware of his terminal illness. Comfort measures including pain control and nausea control were continued throughout his hospital stay in addition to administration of a nonrebreather mask of 100% O2 for improved controlled of respiratory distress. The patient was continued on Iressa as prescribed by his oncologist. The option for hospice services at home was discussed with the patient, who said that he had considered this option in the past, and would consider it again in the near future after discussing the option with his family. The patient was fully aware of the stage of his disease and the sites of metastasis of his lung cancer. 4. Fluids, electrolytes, and nutrition: The patient had a very poor nutritional status, however, he did tolerate high protein shakes prepared by his family. 5. Pain: His pain was controlled with Fentanyl patches and IV Morphine prn for control of breakthrough pain. During the final 24 hours of his hospital stay, he required no additional Morphine for control of his shoulder and leg pain. 6. Gastrointestinal: Patient was continued on a bowel regimen of laxatives and stool softeners to relieve the constipation caused by his large narcotic doses. 7. Prophylaxis: The patient was put on pneumoboots to prevent DVT throughout his stay. 8. Disposition: The patient was discharged to home on [**5-19**] with VNA services and with a new regimen for oxygen administration including 3-6 liters of continuous oxygen along with a liquid oxygen tank with a nonrebreather mask at 10-15 liters of oxygen as needed for comfort. CONDITION ON DISCHARGE: Fair. DISCHARGE DIAGNOSES: 1. Pericardial effusion status post pericardiocentesis. 2. Stage IV nonsmall cell lung cancer with metastasis. DISCHARGE MEDICATIONS: 1. Citalopram 20 mg po three tablets q day. 2. Ibuprofen 600 mg one tablet po q8h prn pain. 3. Pantoprazole 40 mg po q day. 4. Albuterol 1-2 puffs inhaled q6h prn shortness of breath. 5. Prochlorperazine 10 mg po q6h prn nausea. 6. Lorazepam 1 mg two tablets [**Hospital1 **]. 7. Bisacodyl 5 mg two tablets po q day prn constipation. 8. Docusate sodium 100 mg po bid. 9. Fentanyl 100 mcg/hour patch transdermal q72h [**11-24**] patches transdermal q72h as needed for pain. 10. Oxycodone 10 mg one tablet q12h as needed for pain. 11. Iressa as prescribed by Dr. [**Last Name (STitle) 410**]. TREATMENTS: 1. Continuous O2 at 3-6 liter. 2. Liquid O2 with nonrebreather mask at 10-15 liters as needed for comfort. FOLLOWUP: Patient was advised to contact his oncologist, Dr. [**Last Name (STitle) 410**] regarding his hospital stay as well as his primary care physician to schedule appointment for this week for followup regarding his pain control, breathing status, and other concerns. The patient was advised to keep his appointment for a CT scan at the [**Hospital Ward Name 23**] Center Radiology Department on [**2113-6-5**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**] Dictated By:[**Last Name (NamePattern1) 1615**] MEDQUIST36 D: [**2113-6-7**] 20:34 T: [**2113-6-15**] 10:52 JOB#: [**Job Number 14349**] cc:[**Name7 (MD) 14350**]

[ "V15.82", "198.5", "562.10", "512.8", "198.7", "300.00", "496", "420.90", "162.9" ]

icd9cm

[ [ [] ] ]

[ "37.21", "37.0" ]

icd9pcs

[ [ [] ] ]

2434, 2525

7985, 8097

8120, 9555

1669, 2109

4228, 7932

2548, 3381

156, 784

3396, 4210

806, 1643

2126, 2417

7957, 7964

25,256

196,615

12409+12410

Discharge summary

report+report

Admission Date: [**2157-3-25**] Discharge Date: [**2157-4-1**] Date of Birth: [**2123-3-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7591**] Chief Complaint: rash, fever, malaise Major Surgical or Invasive Procedure: Ultrasound guided liver biopsy History of Present Illness: This is a 33 y/o M w/ h/o NHL (relapsed transformed B-Cell lymphoma) s/p mini-MUD Allo BMT in [**7-28**] (day +240) and DLI 5 weejks ago who presents with one week of increasing fatigue and low-grade fever and one day of pruitic rash with increased LFTs. . Recently presented to clinic 4 days PTA w/ increase fatigue. He also noted some itchiness and irritation of his eyes for the last few days, and feeling achy overall particularly in his neck, shoulders and head. Blood cx were drawn and CXR showed no infiltrate so he was sent home with the dx of a viral infection. He presented to clinic again today complaining of a pruritic rash that developed last night and worsening of his itchy eyes. He reports feeling warm but denies chills and night sweats. He reports a dry, non-productive cough but denies sore throat, rhinorrhea, shortness of breath or chest pain. His appetite otherwise remains good and he is without any nausea, vomiting, diarrhea and abd pain. He denies new foods, new soap, new detergent. Pt has never had a rash before. NO hx of allergies. . Last recieved DLI 5 weeks prior to admission. Past Medical History: Lyphoma as above GI bleed of unknown etiolgoy in [**2154-12-25**]. Social History: No tob, etoh, IVDA, tatoos+ transfusions Family History: no cancer Physical Exam: temp 101.2, BP [**10/2126**], HR 110, R 18, O2 99% RA, wt 168# Gen: NAD, well-nourished male in mild ditress [**1-26**] itchy HEENT: PERRL, EOMI, injected sclera Skin: diffuse maculopapular rash on face, neck, chest, abd, back, legs; spares palms, soles and arms CV: RRR, no g/m/r Chest: clear Abd: +BS, soft, nontender throughout, no hepatomegaly, no splenomegaly Ext: no edema, 2+ DP Neuro: CN 2-12 intact, AO x 3 Pertinent Results: ** chem ** [**2157-3-25**] 11:00AM UREA N-9 CREAT-1.1 SODIUM-138 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13 [**2157-3-25**] 11:00AM ALBUMIN-4.5 MAGNESIUM-1.8 [**2157-3-25**] 11:00AM ALT(SGPT)-169* AST(SGOT)-120* LD(LDH)-340* ALK PHOS-84 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 . ** immunoglobulins ** [**2157-3-25**] 11:00AM IgG-716 IgA-69* IgM-134 . ** heme ** [**2157-3-25**] 11:00AM WBC-7.7 RBC-4.30* HGB-12.4* HCT-35.6* MCV-83 MCH-28.8 MCHC-34.8 RDW-13.4 [**2157-3-25**] 11:00AM NEUTS-76* BANDS-2 LYMPHS-10* MONOS-6 EOS-5* BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-1* [**2157-3-25**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2157-3-25**] 11:00AM PLT SMR-NORMAL PLT COUNT-209 . ** CXR ** Cardiac and mediastinal contours are unchanged compared to the prior study. Bilateral lungs are clear. No consolidation or effusion noted. . ** Torso CT ** CT OF THE CHEST WITH IV CONTRAST: There is a 9 mm pretracheal lymph node and a 9 mm left axillary lymph node that are slightly increased in size compared to the prior study where they measured approximately 7 mm. There is a 10 mm subcarinal node that previously measured 5 mm. Lung windows demonstrate no areas of consolidation or pulmonary nodules. There is no pleural effusion or pneumothorax. The airways appear patent to the level of the segmental bronchi bilaterally. The great vessels, heart, and pericardium is unremarkable. . CT OF THE ABDOMEN WITH IV CONTRAST: There is possible slight interval increase in size of the previously demonstrated mass at the mesenteric root measuring approximately 6.7 x 3.7 cm, previously 5.7 x 3.5 cm at this location on the prior scan of [**2157-1-24**]. This mesenteric mass partially encases the superior mesenteric artery and some of its side branches that appeared to be patent. There is interval increase in the number and size of the surrounding mesenteric lymph nodes, notably one node in the mid abdomen (series 2B, image 83), now measures 15 mm in short axis diameter, previously 9 mm. There also is interval increase in the size and number of retroperitoneal nodes, notably a 11 mm aortocaval node (series 2B, image 80), and an 8 mm paraaortic node (series 2B, image 88). The liver, gallbladder, pancreas, spleen, adrenal glands, stomach, small bowel, and large bowel are unchanged. There is a stable low attenuation focus in the interpolar region of the left kidney that is too small to characterize on CT scan. The kidneys excrete contrast symmetrically. There is no evidence of hydronephrosis or hydroureter. There is no free air or free fluid. . CT OF THE PELVIS WITH IV CONTRAST: The bladder, distal ureters, prostate gland, rectum, and sigmoid colon are unremarkable. There are multiple small bilateral inguinal lymph nodes, the largest measuring 12 mm in the left groin, increased in size compared to the prior study where it measured approximately 7 cm in short axis diameter. . BONE WINDOWS: Reveal stable sclerotic foci in the L4 vertebral body, left iliac bone, and left rib. No new suspicious lytic or sclerotic foci are identified. . ** liver, needle core biopsy ** -Mixed portal inflammation, including mononuclear cells, a small component of neutrophils and rare eosinophils with focal bile duct infiltration by lymphocytes and focal portal venulitis. -Lobular neutrophilic infiltrate with focal aggregates, regeneration and apoptotic hepatocytes. -No Microorganisms are seen on PAS and GMS stains. -No immunoreactivity seen for CMV. -Note: The biopsy shows features of graft vs. host disease, however, in the presence of neutrophilic infiltrate a concomitant infectious process cannot be excluded. Brief Hospital Course: A/P: This is a 33 y/o M with hx of NHL s/p mini-MUD Allo BMT in [**7-28**], and s/p DLI 5 weeks ago who presents with fatigue, low-grade temps, diffuse rash and transaminitis * 1. Transaminitis: Over hospital stay, pt's LFTs rose and peaked on HD #6 with an ALT of 820 and AST of 500. Alk phos and bilirubin remained normal until HD #6 when they began to rise. Given concern for GVH, pt was started empirically on HD #3 and liver was consulted. A u/s guided liver biopsy was done and was consistent with GVH but also showed neutrophilic infiltration concerning for infection. Stains were negative for CMV and microorganisms. Cellcept was started on HD #6 ([**3-30**]). When ALT and AST started to trend down, the pt was discharged home with close follow-up. He was sent home on cellcept, prednisone and ursodiol. * 2. Fever/malaise/cough: Before pt was started on steroids for presumed GVH, a torso CT was done to rule out infection. Other than interval progression of disease, the CT was negative for infiltrates or source of infection. Pt ruled out for flu, adeno, parainfluenze and other viral illnesses. Pt had fevers to 102 during the beginning of his hospital stay but all blood and urine cx were negative. Antibiotics were not started given that he was not neutropenic. * 3. Rash: Given the pt's hx of NHL and recent DLI along with his rising LFTs, GVH was the highest on the differential. He was given sarna lotion, claritin, atarax, fluorocinolone lotion for relief. With the addition of the steroids, the rash resolved over the next several days. * 4. Dry Eyes: Pt was given artificial tears as well as sulfacetamide drops for relief. Medications on Admission: acyclovir 400mg po bid Discharge Medications: 1. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Disp:*3 bottles* Refills:*2* 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. CellCept [**Pager number **] mg Capsule Sig: Three (3) Capsule PO twice a day. Disp:*180 Capsule(s)* Refills:*2* 5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*50 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Non-Hodgkin's lymphoma acute graft vs host disease upper respiratory infection Discharge Condition: good Discharge Instructions: Please take your temperature twice daily and call your doctor/return to the hospital for temperature >100.5, nausea/vomiting/diarrhea, severe mouth sores, new rashes or any other concerning symptoms you may have. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Where: [**Hospital6 29**] HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2157-4-4**] 9:00 Admission Date: [**2157-4-3**] Discharge Date: [**2157-7-11**] Date of Birth: [**2123-3-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: fever, cough Major Surgical or Invasive Procedure: 1. brain biopsy 2. [**1-27**] level SMA embolization with 2 wires and particles for UGI bleed into distal duodenum/prox jejunum History of Present Illness: DIAGNOSIS: 33-year-old gentleman with relapsed transformed B cell lymphoma status post autologous stem cell transplant on [**2155-3-31**], with disease recurrence in 07/[**2155**]. ONCOLOGIC HISTORY: The patient initially presented in [**Month (only) 404**] of [**2151**] while in [**State **] with an episode of bloody diarrhea, preceded by syncope. He was taken to a local emergency room and was evaluated with EGD and colonoscopy which did not reveal a clear source of the bleeding and no biopsies were taken. A slight bulge in the gastric curvature was noted, however, suggesting a possible intra-abdominal mass. Recommendations were made for follow-up EGD. This was performed in [**1-/2154**] at the [**Hospital1 18**] and revealed a healed linear erosion on the distal esophagus suggestive of a healed [**Doctor First Name **]-[**Doctor Last Name **] tear. Recommendations at that time were for no further followup and to discontinue his proton pump inhibitor. In [**4-/2154**], he presented with flu-like symptoms and night sweats. He also noted decreased appetite and a sensation of bloating and fullness in his abdomen. He reported a five to six-pound weight loss over 1 month and noted a lump in his left abdomen and dull pain in his lower back. A CT of the abdomen and pelvis at that time showed a 15 x 14.6 x 10.7 cm mass involving the left upper quadrant contigous with the pancreas and pressing on the duodenum as well as encasing the SMV, although all the vessels were patent. He also had retroperitoneal right ileum and left inguinal lymphadenopathy. A biopsy later revealed follicular lymphoma Grade II/III, follicular and diffuse with focal progression to follicular lymphoma Grade III/III. The nodular architecture was effaced by vaguely nodular proliferation of small cleaved cells with a mass of larger centroblastic cells (10 to 15 per high power field). Focally, the follicles were composed of sheaths of larger centroblastic cells consistent with transformation to a high- grade lymphoma. These cells were positive for CD20 and BCL-2. He was then treated with six cycles of CHOP and Rituxan. He had a significant residual abdominal mass but a PET scan became negative and was then under observation. In [**12-27**], he was noted to have a rising LDH and underwent a repeat PET scan which showed uptake in the mediastinum, abdomen, and bright uptake in the right inguinal region. Given the patient's transformed phenotype, he was treated with cytoreduction and MIME chemotherapy followed by consolidation with high dose chemotherapy and stem cell rescue. He then proceeded with MIME chemotherapy x two cycles. He tolerated this well and demonstrated evidence of response as determined by decrease in the size of mediastinal lesion and decrease in the intensity of PET uptake. The patient subsequently underwent high-dose cytoxan for stem cell mobilization. He was admitted for transplant and preconditioning chemotherapy high-dose cytoxan, followed by bone marrow transplant. He had an autologous stem cell transplant on [**2155-3-31**]. The patient's transplant course was complicated by development of pericarditis and pleural effusions of unclear etiology. In [**2155-9-24**], he underwent repeat scans which showed some new adenopathy in the groin and increased uptake in the area as well as around the large left upper quadrant lesion which has been stable. He was treated with Zevalin on [**2155-11-18**]. He had repeat CAT scans done in [**2156-3-25**] which showed ongoing growth of his lymphoma particularly in the lesion in the pelvic area. At that time he got 4 more doses of Rituxan chemotherapy, followed by [**Hospital1 **]. A CT scan on [**2156-6-9**] which showed that his disease was stable. He then received ESHAP chemotherapy on [**2156-6-18**], which he tolerated well. The patient then got a nonmyeloablative allogeneic stem cell transplant with Campath conditioning. He is approximately Day +370 from this. More recently, he received lymphocyte infusions in late [**2157-1-25**]. Mr. [**Known lastname 38598**] was recently admitted on [**2157-3-25**] with an upper respiratory infection manifested by coryza, cough, and nasal congestion with fevers to 101 and also associated with a diffuse macular body rash. He was just discharged on [**2157-4-1**] but called us today with a fever up to 101.5 and worsened dry throat, and loss of voice. He denies diarrhea or abdominal pain and says his pruritis is improved from previous. Past Medical History: Lymphoma as above GI bleed of unknown etiology in [**2154-12-25**]. Social History: No tob, etoh, IVDA, tattoos+ transfusions Family History: no cancer Physical Exam: VITALS: Temp 101.2 pulse 90's GEN: 34-year-old male, no acute distress. HEENT: PERRL, EOMI, sclerae icteric. SKIN: HEART: Regular rate and rhythm, no murmurs LUNGS: Clear to auscultation bilaterally, no crackles or wheezes ABDOMEN: Soft, non-tender, normoactive bowel sounds, firm liver edge 2 cm below costal margin. EXT: No edema, no cyanosis, no clubbing; 2+ pulses in all 4 extremities. SKIN: diffuse jaundice NEURO: a&ox3, cn II-XII intact, diffuse muscular atrophy secondary to deconditioning related to prolonged hospitalization, symmetric strength, normal sensation, normal coordination, normal language and comprehension, normal affect. Pertinent Results: ** heme ** WBC-10.6# HCT-36.0* MCV-84 NEUTS-85.6* LYMPHS-8.7* MONOS-4.3 EOS-1.1 BASOS-0.2 PLT COUNT-270 PT-13.0 PTT-24.2 INR(PT)-1.1 . ** chem ** GLUCOSE-133* UREA N-11 CREAT-1.1 SODIUM-131* POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-26 ALT(SGPT)-622* AST(SGOT)-238* LD(LDH)-352* ALK PHOS-191* AMYLASE-339* TOT BILI-6.3* DIR BILI-4.9* INDIR BIL-1.4 LIPASE-276* LACTATE-2.1* . RUQ U/S: The liver is normal in echo texture and architecture, without focal masses. Portal venous flow is patent and in the proper direction. The gallbladder is collapsed. The common hepatic duct is 2.5 mm. No son[**Name (NI) 493**] [**Name (NI) **] sign was elicited. . CXR: No pneumonia. . Chest CT: Assessment of the lungs demonstrates mild diffuse peribronchial wall thickening, best appreciated in the lower lobes bilaterally, greater on the right side. . MRI Abd: 1) No enhancing lesions identified in the liver. 2) No evidence for hepatosplenic candidiasis. 3) No intra or extrahepatic biliary ductal dilatation. The pancreatic duct is normal in appearance. 4) Normal appearance of the pancreas. . Liver biopsy ([**5-11**]) 1. Moderate hepatocellular and canalicular cholestasis. 2. No significant portal or lobular inflammation. 3. Focal hepatocyte apoptosis and ballooning degeneration. 4. No viral cytopathic changes immunoreactivity for herpes simplex virus (HSV)-I, HSV-II, or cytomegalovirus (CMV) seen. 5. Trichrome stain: Minimal portal fibrosis. 6. Extramedullary hematopoiesis. 7. Iron stain: Moderate iron deposition, predominantly in Kupffer cells. 8. No micro-organisms seen on AFB, GMS, or PAS-D stains. Note: There is one focally damaged bile ducts with no associated inflammation. This could represent treated graft versus host disease. . MRI Head Signal abnormalities involving left medial temporal lobe and left basal ganglia region. Subtle increased signal is seen in the region of left basal ganglia, which could be due to subtle enhancement or prominence of the vascular structures. The differential diagnosis given the patient's clinical history is suggestive of infection versus neoplasm. The appearances are more likely to be due to an infectious process. [**2157-4-3**] 11:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.002 [**2157-4-3**] 11:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2157-4-3**] 11:30AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2157-4-3**] 11:10AM LACTATE-2.1* [**2157-4-3**] 11:03AM GLUCOSE-133* UREA N-11 CREAT-1.1 SODIUM-131* POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-26 ANION GAP-15 [**2157-4-3**] 11:03AM ALT(SGPT)-622* AST(SGOT)-238* LD(LDH)-352* ALK PHOS-191* AMYLASE-339* TOT BILI-6.3* DIR BILI-4.9* INDIR BIL-1.4 [**2157-4-3**] 11:03AM LIPASE-276* [**2157-4-3**] 11:03AM WBC-10.6# RBC-4.29* HGB-12.4* HCT-36.0* MCV-84 MCH-28.9 MCHC-34.5 RDW-14.8 [**2157-4-3**] 11:03AM NEUTS-85.6* LYMPHS-8.7* MONOS-4.3 EOS-1.1 BASOS-0.2 [**2157-4-3**] 11:03AM PLT COUNT-270 [**2157-4-3**] 11:03AM PT-13.0 PTT-24.2 INR(PT)-1.1 Brief Hospital Course: A/P: This is a 33 y/o M with hx of NHL s/p mini-MUD Allo [**Year/Month/Day 3242**] in [**7-28**], and s/p DLI 6 weeks ago who presents with persistent low-grade temps, hyperbilirubinemia, and transaminitis. 1) Liver: Given pt's elevated LFTs, a RUQ ultrasound was performed in the ED, which was normal. An MRI of the abdomen was done and this also was negative for biliary obstruction and hepatic infection. During hospital admission, pt's liver enzymes continued to rise. Based on the clinical picture of rash and rising LFTs in combination with the timing after DLI, acute GVH was very high on the differential so cellcept was increased to 1gm [**Hospital1 **] and solumedrol continued. Liver enzymes trended upwards despite increasing immunosuppression and adding Tacrolimus, so on hospital day #3, the liver team was again consulted. The decision was made to re-biopsy which revealed a pattern consistent with GVH but also larger neutrophilic infiltrates concerning for infection. The biopsy specimen was sent for HSV stains which were negative. Given the pt's worsening GVH, pt had a [**Hospital1 **] line placed and photopheresis was initiated. The patient was briefly switched to p.o. prednisone and subsequently prednisolone ([**1-26**] concern that prodrug was not being metabolized). Bilirubin continued to trend up. On [**4-21**], patient was changed back to solumedrol (increased dose as well), w/subsequent decrease in bilirubin (hepatic enzymes stable). However, then bili started to trend upwards again and peaked at 30. Repeat biopsy on [**5-11**] was felt to be c/w improving GVHD and the decision was made to decrease methylprednisolone while continuing photopheresis. Photopheresis was postponed during periods of his GI bleeding (see below). Once his GI bleeding had been controlled, it was decided to attempt to taper his tacrolimus and monitor his LFTs, as his LFT elevation could actually be partly from tacrolimus toxicity. Tacrolimus was tapered to 1 mg daily on [**6-3**]. He continued to get biweekly photopheresis with his LFT's and bilirubin trending downward at discharge. 2) Upper GI bleed: On [**4-26**] pt began to have melanotic stools. He was transferred to the unit and was transfused with blood. He remained hemodynamically stable and EGD showed diffuse ulceration and [**Doctor First Name **]-[**Doctor Last Name **] tear but no active source that could be intervented upon during the scope. However, after a few days he continued to have melanotic stools and repeat EGD had pathology concerning for CMV. Flexible sigmoidoscopy showed normal mucosa. He was again stabilized and did not bleed for several days, and then had another incident where he stood up go go to the restroom and passed a large amount of BRBPR onto the floor and syncoped. He was resuscitated and again transferred to the unit and was scoped again with similar results but still no active arterial bleed seen. Biopsy results from the first EGD came back positive for HSV and he was started on high dose foscarnet to treat for both HSV and CMV. He was treated with amicar po 2gm q2 hours as well protonix IV q12 and sucralfate. He was also supported with many, many blood transfusions. He improved clinically and did not have stools for several days, but then again had melena and repeat EGD showed that his previously seen ulcers were much improved after having received 2 weeks of the high dose foscarnet. Foscarnet had been decreased to daily dosing after 2 weeks, but since this medication was presumed to have made the ulcers much better he was changed back to q12 dosing. He again had BRBPR on [**5-21**] and again was scoped which did not reveal an arterial source. A tagged red cell scan was positive, however, so he underwent interventional angio procedure which confirmed active extravasation in the proximal jejunum. This was intervened upon w/ coil and particles for hemostasis. He required 4U pRBC's overnight on [**5-22**] unit Plt, 1 unit FFP. He subsequently had a couple of episodes of melena which were thought to be clearance of remaining blood. His hematocrit dropped from 29 to 25 the following day, however, and he therefore underwent repeat tagged RBC scan on [**5-24**] which did not demonstrate any further bleeding. His hematocrit was subsequently stable and he was transferred back to the [**Month/Day (4) 3242**] service on [**5-25**]. His stay on the [**Month/Day (4) 3242**] service was brief, as the day after transfer he had one episode of maroon liquid stool in the morning, and another episode later that night, prompting transfer to the [**Hospital Ward Name 12837**] for repeat angiography (the angio on the East was flooded). Repeat angiography on [**5-26**] demonstrated active bleeding in the region of the ligament of Treitz or proximal jejunum. It was decided to attempt endoscopic hemostasis, therefore he underwent EGD on [**5-27**] which demonstrated active bleeding at D2-D3. Hemostasis was unfortunately unable to be achieved with epinephrine injections and hemoclips, and he therefore went back to angio and was aggressively embolized by IR on [**5-27**]. Subsequently the patient's hematocrit continued to trend down and he received a total of 10 units of PRBCs during his MICU stay. Extensive discussions occurred between IR, surgery, [**Month/Day (4) 3242**], and the MICU team regarding possible surgical intervention, however it was ultimately decided to take a conservative stance and observe. His hematocrit subsequently remained stable, and he was transferred back to the [**Month/Day (4) 3242**] service on [**6-2**]. He was continued on aminocaproic acid and his Hct remained stable. Ultimately became guaiac negative. He required occasional transfusions but these Hct drops were not felt ot be due to bleeding. 3) Fever/malaise: The theory of a upper respiratory infection in the setting of acute GVH was continued from the previous admission. Pt ruled out for flu, adeno, parainfluenza and RSV. ID was consulted and recommended ruling out other viral infections such as hepatitis, acute HIV, adenovirus, CMV. All blood tests returned negative and again, GVHD was thought to be the cause. However, intra-GI tract pathology was c/w HSV and possible CMV infection and the pt was treated with Foscarnet at high doses for over 3 weeks. He remained afebrile. On discussion with ID foscarnet was discontinued with the plan to restart if symptoms returned. Serial viral cultures from oral lesions grew HSV, and acyclovir-sensitivity tests were sent out, and the results are pending. 4) Dry Eyes: Initially, there was concern for adenovirus conjunctivitis with corneal ulcers causing pain so opthalmology was consulted. On examination of the eyes, no ulcers or evidence of infection was found and they believed the dry eyes to be a consequence of GVH. They recommended artifical tears and ointment for symptomatic relief. A viral swab of the eye was negative for viral infection. 5) Oral thrush: On admission, pt was found to have white plaques on his soft palate. These were swabbed and grew budding yeast and was positive for HSV. Pt was initially treated with nystatin swish and swallow and oral amphotericin but given the severity, fluconazole was added. Also, given the positive HSV swab, famvir was increased to the treatment dose of 500mg tid. Despite this dosing pt continued to have sublingual lesions which were culture positive for HSV. Switched to high dose acyclovir w/ some improvement and eventually to high dose foscarnet. He improved symptomatically, but on [**5-13**] began to have more lesions c/w thrush and was started on ambisome as well as continuing with the nystatin swish and swallow. His thrush significantly improved on this regimen. Foscarnet was switched to acyclovir at the time of discharge. 6) Cough: Given pt's worsening cough, a chest CT was done which revealed mild peribronchial wall thickening which may be [**1-26**] bronchiolitis. ID recommended ruling out mycoplasma with IgM and IgG; these both were negative. Pulmonary was consulted to evaluate whether this was a viral bronchitis vs a GVH bronchiolitis. They recommended obtaining PFTs and using Advair for symptomatic relief. Advair was held while the patient was on systemic steroids and with thrush. His cough improved significantly after being treated with high-dose foscarnet for 2 weeks. His voice was stronger and it was assumed that likely the cough was [**1-26**] HSV/CMV irritation of the vocal cords. 7) Hyponatremia: Pt's sodium went up and down throughout his admission. When it was low to 125 it was considered likely [**1-26**] pseudohyponatremia from elevated cholesterol (cholestasis in GVH producing lipoprot). Stable w/o IVF or fluid restriction and as liver improved hyponatremia also improved to some extent. 8) Line infection: Pt had an episode of hypotension to 80/50 on [**4-17**], responded to 500cc NS bolus x2, and 20mg solumedrol. Given h/o coag neg staph positive from line that was sensitive to vanco he was started on vancomycin. Concern for infectious vs adrenal insuff and failure of prednisone to be converted by liver (on solumedrol until [**4-15**]). Following this incident pt maintained his BP's and his line grew out coag neg staph, sensitive to vanco. He completed a 14 day course of vancomycin (finished vanco on [**2157-4-30**]). 9) Sinus pain: CT showed sinusitis. ENT felt did not need to be biopsied. Pt was treated with zosyn empirically for a 14 day course, and symptoms improved. A repeat sinus CT showed interval improvement in sinus congestion. 10) NHL: s/p mini-MUD allo-[**Date Range 3242**] and donor lymphocyte infusion. There was some concern that his previously imaged mesenteric mass had spread to cause his persistent GI bleeding, however a CT scan done on [**6-2**] actually showed a decrease in size of his mesenteric mass. 11) FEN: During the course of his GI bleeds, and with his severe thrush and esophagitis, the patient was not taking in adequate PO, therefore he was started on TPN. Once it appeared that his GI bleeding was stable, the TPN was cycled, and he was encouraged to begin eating again. He was tolerating PO's well and TPN was discontinued. 12) Headache: After starting the foscarnet he began developing daily headaches in relation to the foscarnet infusion. Headache lasted about 12 hours located above the eyes, worse on the left. When his foscarnet was stopped the headaches initially went away and then when it was restarted the headaches returned. Initially felt headaches were secondary to the med, however got CT sinus to make sure there was no worsening of his sinusitis. This was found to be stable. He also then started complaining of blurred vision. MRI of the head was done which demonstarted a well demarcated enhancing lesion in the left medial temporal lobe and left basal ganglia. At this time he had no other significant neurological complaints. ID and neuro was consulted. There was concern for infectious cause vs lymphoma. He was empirically started on ambisome for fungal infection and bactrim for toxoplasmosis. LP was done and found no evidence of toxoplasma in the CSF. A stereotactic brain biopsy was performed to determine whether the brain lesions represented toxoplasma infection vs. post-transplant lymphoproliferative disorder (PTLD). The biopsies show a mixed-cell infiltrate both within brain and more prominently around vessels. The infiltrate contains small lymphocytes, some atypical cells, plasma cells, a few eosinophils, an occasional neutrophil, and in some sections many macrophages. The atypical cells include those that are flattened or worm-like and those with some nuclear convolutions. The process's angiocentric proclivity has induced an obliterative small vessel vasculitis, including reactive and denuded endothelial cells. Within the infiltrate and in brain parenchyma, another subpopulation of atypical nuclei appear enlarged, have glassy chromatin, and have a distinct but eosinophilic nucleolus or nuclear inclusion. These are not considered diagnostic of Cowdry "A" bodies, which are larger than these inclusions/nucleoli. No Toxoplasma gondii parasites are identified, nor does the biopsy have the background usually associated with this infection. Immunoperoxidase studies show much of the increased intraparenchymal cellularity immunoreacts with the T-lymphocyte antibody CD3. B-lymphocyte staining with CD20 is largely confined to the perivascular region. These results do not support a diagnosis of lymphoma. Additionally, immunostains for CMV, HSV-I, and HSV-II are all negative. These findings together suggest that the patient's lesions result from a chronic encephalitis having a significant vasculopathic component. The differential diagnoses include: post-transplant immunosuppression-related vasculitis, a viral-induced vasculopathy and encephalitis (e.g. Varicella-Zoster vasculopathy or some reported cases of HHV-6), and possibly a biopsy near a site of principle pathology. Medications on Admission: Prednisone 60mg qd, Acyclovir 400mg qd, Cellcept 750mg [**Hospital1 **]. Discharge Medications: 1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic QHS (once a day (at bedtime)). 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 3. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 4. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-26**] Sprays Nasal QID (4 times a day) as needed. 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 7. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*2* 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 11. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1) ML Intravenous QOD AND PRN (). Disp:*30 ML(s)* Refills:*2* 12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Ten (10) ML Intravenous DAILY (Daily) as needed. Disp:*30 ML(s)* Refills:*0* 13. Amphotericin B Liposome 50 mg Suspension for Reconstitution Sig: Seven (7) Suspension for Reconstitution Intravenous MWF (Monday-Wednesday-Friday): please take 350mg . Disp:*84 Suspension for Reconstitution(s)* Refills:*2* 14. IVF Please infuse 1 L of normal saline with 2 gms MgSO4 and 20 mEQ KCL daily. [**Month (only) 116**] infuse at 200 cc/hour. 15. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Disp:*30 Tablet(s)* Refills:*0* 16. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 17. PICC Care as per home care protocol 18. [**Month (only) **] line care Please flush [**Month (only) **] catheter every other day with 1000 unit/cc heparin equal to the lumen volume of the catheter. The heparin must always be removed by removing 4cc of blood before infusing anything through the catheter. Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: 1. non-Hodgkin's lymphoma, s/p allogeneic bone marrow transplant, complicated by graft-versus-host disease 2. upper gastrointestinal bleeding 3. upper gastrointestinal herpes, itraconazole-resistant thrush 4. Brain lesions concerning for toxoplasmosis. Discharge Condition: stable. Discharge Instructions: Please continue all medications as prescribed. Please continue the IV amphotercin three times a week. Next dose will be due on [**7-13**]-Wednesday. Please continue photopheresis on Thursdays and Saturdays, every week. Please continue 1 Liter intravenous fluids per day. Followup Instructions: will continue photopheresis 2x per week. Provider: [**Name10 (NameIs) 1248**],BED SIX [**Name10 (NameIs) 1248**] ROOMS Where: [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2157-7-12**] 9:15 Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN Where: [**Hospital6 29**] HEMATOLOGY/[**Hospital6 3242**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2157-7-13**] 9:00 Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 1246**] Date/Time:[**2157-7-13**] 9:00 Completed by:[**2157-7-18**]

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icd9cm

[ [ [] ] ]

[ "50.11", "99.07", "88.47", "48.24", "44.44", "99.05", "96.71", "99.15", "01.13", "03.31", "44.43", "38.93", "99.04", "45.16", "45.25", "96.04", "99.88" ]

icd9pcs

[ [ [] ] ]

33133, 33189

17654, 30704

9039, 9169

33486, 33495

14560, 17631

33819, 34354

13865, 13876

30828, 33110

33210, 33465

30730, 30805

33519, 33796

13891, 14541

8987, 9001

9197, 13699

13721, 13790

13806, 13849

6,976

119,426

15972

Discharge summary

report

Admission Date: [**2146-9-9**] Discharge Date: [**2146-9-15**] Service: SURGERY Allergies: Levaquin Attending:[**First Name3 (LF) 2597**] Chief Complaint: heel ulcer Major Surgical or Invasive Procedure: [**9-9**]: R BKPO-DP bypass w/RSVG [**9-13**]: achilles excision and VAC placement History of Present Illness: This [**Age over 90 **]-year-old gentleman has had a non- healing ulcer of his right posterior heel with exposed Achilles tendon. This is quite painful. He underwent arteriography in an attempt at a catheter-based intervention by cardiology without success. He is open to the level of the below knee popliteal occluded anterior tibial artery and has distal anterior tibial and dorsalis pedis artery as the only runoff vessel to his foot Past Medical History: 1. TIA (daughter is not sure about this) 2. Carotid artery stenosis: Chronically occluded right internal carotid artery. Left, with 40-59% carotid stenosis. 3. CAD s/p PCI x 2 4. Severe PVD 5. Hypercholesterolemia 6. Hypothyroidism 7. Chronic low back pain 8. AFib s/p ablation 9. s/p cholecystectomy [**48**]. s/p bilateral carotid endartectomies 11. s/p left popliteal graft 12. s/p left knee arthroscopy 13. s/p lumbar decompression '[**34**] 14. s/p left leg thrombectomy Social History: Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH. Lived with daughter x 4 [**Name2 (NI) 1686**]. Walks with a cane. Lives in the basement of his daughter's house. Just had one VNA visit yesterday (they sent him here). Family History: Non-contributory Physical Exam: a/o elderly male nad crackles at bases ireg / irreg with holosytolic murmer Abd S, NT, ND Tattoo marks in the lower midline of the pelvis Uncirc phallus with tight phimosis Desc testes bilaterally R leg inc c/d/i achillies tndomn area with vac r heel Pertinent Results: [**2146-9-15**] 05:30AM BLOOD WBC-8.2 RBC-3.81* Hgb-11.4* Hct-33.7* MCV-88 MCH-29.9 MCHC-33.8 RDW-15.4 Plt Ct-184 [**2146-9-15**] 05:30AM BLOOD PT-14.7* PTT-32.7 INR(PT)-1.3* [**2146-9-15**] 05:30AM BLOOD Glucose-102 UreaN-18 Creat-1.0 Na-137 K-3.8 Cl-103 HCO3-29 AnGap-9 [**2146-9-15**] 05:30AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.0 [**2146-9-12**] 11:09AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM URINE RBC-0-2 WBC-[**2-14**] Bacteri-OCC Yeast-NONE Epi-0-2 [**2146-9-9**] 12:58 pm SWAB RIGHT HEEL. GRAM STAIN (Final [**2146-9-9**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2146-9-12**]): STAPH AUREUS COAG +. MODERATE GROWTH. PROBABLE ENTEROCOCCUS. SPARSE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. STAPH AUREUS COAG + | CIPROFLOXACIN--------- =>8 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S [**2146-9-13**] 8:07 AM HEEL (AXIAL & LATERAL) RIGHT Reason: evaluate heel ulcer/exposed achilles tendon HISTORY: Patient with heel ulcer and exposed Achilles tendon. FINDINGS: Comparison is made to previous study from [**2146-8-19**]. Since the prior study, the soft tissue ulcer along the posterior medial aspect of the ankle has increased significantly in size. There is increased lucency and loss of the cortical white line involving the margin of the medial malleolus. These findings are highly suggestive for osteomyelitis. There is no soft tissue gas. There is prominent swelling medially greater than lateral. [**Year (4 digits) **] calcifications are seen. There is a plantar spur. The tibiotalar joint is within normal limits. IMPRESSION: Findings consistent with osteomyelitis involving the medial malleolus with increase in the soft tissue ulcer and bony destruction since the previous study [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Aortic Valve - Peak Gradient: *55 mm Hg < 20 mm Hg Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness and cavity size. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma in the ascending aorta. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic valve leaflets. Moderate-severe AS (area 0.8-1.0cm2). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Mild to moderate ([**12-14**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: Moderate pericardial effusion. No echocardiographic signs of tamponade. Conclusions No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-14**]+) mitral regurgitation is seen. There is a moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: pt admitted pre-opd for lower extremity BPG Podiatry consult for heel ulcer Broad spectrum AB / Cx's taken Urology consult for Foley placement. Pt with history of difficult foley placements Swan placed prior to surgery. Pt taken to the OR underwent a Right below knee popliteal to dorsalis pedis artery bypass with reverse saphenous vein. POD #1 In the PACU / no sequele from BPG. Pt extubated. Pt bedrest. POD # 2 Palp graft / HCT stable. Gentle diuresis. OOB to chair. Diet advanced. POD # 3 Pt c/o right shoulder pain, Ortho consult - Bursitis. Py injected with Depo medrol. NSAIDS started. POD # 4 Stable / Swan changed over wire to TLC. Podiatry consulted for heel ulcer. Seen by Dr [**Last Name (STitle) **]. this was for the exposed tendon. POD #5 Pt brought OR foe debridement of achilles tendon / Vac Placement. MP boots placed POD # 5 cardiology sees pt / followed closely, Pt with main artery stent. Plavix restarted / asa to continue. POD # 6 PT consult / Recommend rehab. Pt stable for rehab. Medications on Admission: ASA 81', Plavix 75', Imdur 60', Toprol 50', Lasix 60', Synthroid 122', Lipitor 80', Coumadin 2.5 Tu/Th/Sa, 5 M/W/F/[**Doctor First Name **], Colace Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO every other day: follow INR / goal is [**1-15**]. alternating with 5 /2.5 / 5 / 2.5 - etc. 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 21 days. 13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for shoulder pain. 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 21 days. 15. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 21 days: monite cbc and chem 7 [**Hospital1 **] weekly / if nuetropenic and or creatinine increases / please call Dr [**Last Name (STitle) **] office. 17. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO every other day: alternating with 5 /2.5 / 5 / 2.5 - etc. Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: non-healing R heel ulcer urinary retention requiring foley and leg Bag HTN, Hchol, CAD, Afib, prostate CA/BPH, hypothyroid, COPD Discharge Condition: Good Discharge Instructions: Open Wound: VAC DRESSING Patient's Discharge Instructions Introduction: This will provide helpful information in caring for your wound. If you have any questions or concerns please talk with your doctor or nurse. You have an open wound, as opposed to a closed (sutured or stapled) wound. The skin over the wound is left open so the deep tissues may heal before the skin is allowed to heal. Premature closure or healing of the skin can result in infection. Your wound was left open to allow new tissue growth within the wound itself. The wound is covered with a VAC dressing. This will be changed around every three days. The VAC: _ helps keep the wound tissue clean _ absorbs drainage _ prevents premature healing of skin - promotes healing When to Call the Doctor: Watch for the following signs and symptoms and notify your doctor if these occur: Temperature over 101.5 F or chills Foul-smelling drainage or fluid from the wound Increased redness or swelling of the wound or skin around it Increasing tenderness or pain in or around the wound. Division of [**Location (un) **] and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: 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 swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**1-15**] 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 ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase 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 (unless you have stitches or foot incisions) no direct spray on incision, 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 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Follow up Dr. [**Last Name (STitle) 11679**] [**Telephone/Fax (1) 2394**] in [**1-15**] weeks. Call to make patient appointment prior to discharge Per Urology: Current foley (placed [**9-9**]) not to stay in more than 1 month, needs F/U with [**Hospital 159**] Clinic [**Telephone/Fax (1) 164**] by [**10-9**] if foley still in, if he passes void trial at rehab then f/u 2-3 months (needs circumsicion). Call Dr [**Last Name (STitle) 45762**] office at [**Telephone/Fax (1) 3121**]. Schedule an appointment for 2 weeks Call Dr [**Last Name (STitle) **] office at ([**Telephone/Fax (1) 4335**]. scheduel an appontment for 2 weeks Completed by:[**2146-9-15**]

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Discharge summary

report+report+addendum+addendum

Admission Date: [**2187-7-10**] Discharge Date: [**2187-7-23**] Date of Birth: Sex: Service: Medicine. NOTE: Date of discharge is pending. This discharge summary covers from [**7-10**] to [**2187-7-23**]. CHIEF COMPLAINT: Gallstone pancreatitis. HISTORY OF PRESENT ILLNESS: This is a 57 year old gentleman, with a history of hypertension and dyspepsia. He was transferred from [**Hospital3 **] for acute gallstone pancreatitis. About five to six weeks prior to admission, the patient presented to [**Hospital3 **] with chest pain and epigastric pain, for which he was rule out myocardial infarction. He had an outpatient esophagogastroduodenoscopy which showed hiatal hernia. An abdominal CT showed evidence of gallstones. He was started on H2 blockers for hiatal hernia. However, he continued to experience chest and epigastric discomfort afterwards. He described discomfort mostly as gassy abdominal pain. He also had anorexia with weight loss of ten to fifteen pounds in the past four weeks. He described significant abdominal discomfort, which was better with leaning forward. Otherwise, he still had normal bowel movement with the last bowel movement the night prior to admission. When he was at his son's house the night prior to admission, he didn't look well. He complained of severe abdominal discomfort, mostly gassy and passed out transiently at his son's house with nausea and vomiting and diaphoresis afterwards. He was brought in by EMS to [**Hospital3 **] and was rule out myocardial infarction again. He was also noted to have significant elevation of the amylase to 4,000 for which he was transferred to [**Hospital1 188**] for urgent endoscopic retrograde cholangiopancreatography. While at [**Hospital3 **], he received one dose of Zosyn and received 3.6 liters of normal saline infusion. He also received one dose of 40 mg intravenous Lasix for worsening of hypoxia. PAST MEDICAL HISTORY: Hypertension. Hiatal hernia. Helicobacter pylori, s/p antibiotic treatment. Dyspepsia. Cholelithiasis. Diverticulosis. Esophagogastroduodenoscopy in [**2187-5-3**] showed hiatal hernia. Abdominal CT showed evidence of gallstones, chronic low back pain. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Zantac, Zyrtec. MEDICATIONS ON TRANSFER: Zosyn 3.75 mg intravenous q. six hours. Dilaudid for pain. SOCIAL HISTORY: Smoking, quit about five years ago. Retired sheriff. Works as a plumber right now. Divorced. Lives by himself. Social alcohol. PHYSICAL EXAMINATION: Temperature 99.6; heart rate 134; blood pressure 119/76; respirations 16; oxygen saturation 93% on 40% facial mask. General: Pleasant, elderly man, in no acute distress. Head and neck examination: Anicteric. Neck supple. Cardiovascular: Tachycardiac. Regular rate. Lungs clear to auscultation bilaterally. Abdomen: Distended. Decreased breath sounds. Positive guarding and rebound. Extremities: No edema. Neurologic: Awake, alert and oriented times three. Nonfocal examination. LABORATORY DATA: From an outside hospital on presentation: White count of 18.8; hematocrit of 40.2; coagulase PT 12.4; PTT 21.4; INR of 1.97. Sodium of 139; potassium of 5.3; chloride 103; bicarbonate 25; BUN 35; creatinine 1.5. Glucose 253. Calcium 8.5. Aminase 4372. Lipase still pending. Total protein 5.7. Albumin 3.1. Total bilirubin of 1.9. Direct bilirubin of 0.4. ALT 188. AST 73. Alkaline phosphatase 214. Electrocardiogram showed sinus tachycardia at 100; normal axis; no ST or T wave depressions. Examination on presentation here revealed white count of 13.4; hematocrit of 52; glucose of 308; sodium 140; potassium 5.6; chloride 113; bicarbonate 17; glucose 45; BUN 1.9; glucose 168; calcium 7.6; magnesium of 1.7; phosphorus of 7.2. Albumin 3.4. Total bilirubin of 2.2. ALT 180; AST 49; alkaline phosphatase 206. Amylase 1,576; lipase 1,693. Arterial blood gases 7.15; 52, 106, lactate of 2.3. Triglycerides of 187. HDL of 48. LDL 33. CK 91. CK MB 5. Troponin 0.12. PT of 15.2. INR of 1.5. PTT 29.6. Electrocardiogram shows sinus tachycardia at 124; normal axis; normal interval. Left atrial enlargement. New peak T waves in V2 to V3. No STT depression or elevation. Arterial blood gases preintubation was 7.15, 52, 106. Later, 7.00, 63 and 86. HOSPITAL COURSE: Urgent surgical and endoscopic retrograde cholangiopancreatography consultation were called, as the patient's abdomen appeared quite distended with diffuse tenderness on admission. He was also aggressively resuscitated with intravenous fluids initially and his tachycardia improved significantly. However, he became more progressively hypoxic with increased oxygen requirement and developed bilateral wheezes as well. He was intubated electively for impending respiratory failure and likely intervention by endoscopic retrograde cholangiopancreatography. He had stat abdominal CT without intravenous contrast on admission, given acute renal failure, which showed significant ileus, gallstones, inflammatory stranding around the pancreas and dilated common bile duct of 12 mms. He went for urgent ERCP to decompress the obstruction. However, the endoscopic retrograde cholangiopancreatography wasn't able to find ampulla, given distorted anatomy and inflammation around the area but it did show a stone in the duodenum. The patient's liver function tests, amylase and lipase started to trend downward after endoscopic retrograde cholangiopancreatography. It was thought that the patient passed the stone spontaneously. He was started on Meropenem for empiric coverage, given his critical condition. The patient continued to deteriorate clinically during the first few days of his hospital stay. Initially, he developed significant hypotension which required multiple vasopressors and significant acidemia with metabolic and respiratory acidosis, which required bicarbonate infusion. He also developed acute anuric renal failure with worsening abdominal hypertension. Trans bladder pressure revealed intra-abdominal pressure as high a 32 mms of mercury. A Swan-Ganz catheter was placed on admission for hemodynamic monitoring and esophageal balloon was also placed later for monitoring of intra-thoracic pressure. Transthoracic echocardiogram was obtained which revealed normal sized ventricle with depressed left ventricular function and some septal hypokinesis. He also had renal ultrasound to rule out obstruction given acute renal failure, which showed no evidence of hydronephrosis. He also had follow-up abdominal CT without intravenous contrast which again showed stable appearance of pancreas but significant worsening of soft tissue swelling and interval increased size of pleural effusion and ascites. Surgical services was consulted for possible surgical decompression for acute abdominal compartment syndrome. However, after a long discussion with various surgical teams, the decision was made to continue medical management, given high risk of surgical intervention. Renal team was also consulted for possible dialysis, if volume and electrolytes became an issue and if anuria persisted. A Quinton catheter was also placed in anticipation of possible dialysis. Fortunately, the patient stabilized by hospital day number three with improved hemodynamics. The vasopressor was slowly weaned off and urine output started to increase. His abdominal pressure also slowly came down, although his BUN and creatinine continued to trend upwards initially, despite the improved urine output. The renal team recommended holding hemodialysis unless the patient developed signs of uremia with acidosis, electrolyte abnormalities or fluid over load. Per renal team, as the diuretic phase of ATN usually hurries the recovery of renal function, hemodialysis during this phase may only interfere with the natural course of recovery. After a few days of delay, eventually he started to show evidence of recovery of renal function with steadily trending downward BUN and creatinine. As his renal function started to come back, he auto diuresed greatly with fluid balance down to 16 liters positive from initial 33 liter positive. His peripheral edema improved significantly. His hyponatremia, due to post ATN diuresis, was corrected with free water boluses by tube feeds and D-5-W by intravenous infusion. He spiked a temperature on admission, post endoscopic retrograde cholangiopancreatography and later pulling out the Quinton catheter on hospital day number nine but all the cultures including blood, urine, catheter tip and Clostridium difficile all remained negative so far except for swabs of E. coli and Klebsiella in sputum on admission. He finished a ten day course of Meropenem and remained afebrile afterwards. Currently, he had a new PICC line placed for intravenous medications. He also developed a transient thrombocytopenia initially which raised the suspicion for heparin induced thrombocytopenia. However, heparin antibody came back negative and his platelet count came back to normal rapidly. He had been transiently on intravenous Argatroban infusion for deep vein thrombosis prophylaxis while he is off heparin. Currently, he is again on subcutaneous heparin for deep vein thrombosis prophylaxis. He also had a surveillance bilateral lower extremity dopplers, which showed no evidence of deep vein thrombosis. His hematocrit had been trending down slowly, which was likely due to slow gastrointestinal bleeding, given guaiac positive stools and bone marrow suppression in the setting of acute illness. The plan was to transfuse for hematocrit less than 25 unless oxygenation became an issue given the volume issue. As he is getting close to be weaned off the ventilator, sedation was also titrated downward. Standing dose of Haldol was started for his agitation and delirium. Currently, he is tolerating minimum pressure support well. The plan was to extubate him soon, as long as he is able to support spontaneous breathing and protect his airway. In terms of nutritional support, he had only been on TPN for a few days because he tolerated the tube feeds near the post pyloric nasogastric tube very well. The plan was for the patient to continue supportive care and minimize complications. He will likely need rehabilitation once he stabilizes clinically. DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] 12-664 Dictated By:[**Last Name (NamePattern1) 225**] MEDQUIST36 D: [**2187-7-22**] 11:46 T: [**2187-7-23**] 06:31 JOB#: [**Job Number 104099**] Admission Date: [**2187-7-10**] Discharge Date: [**2187-9-5**] Date of Birth: [**2129-10-22**] Sex: M Service: GOLD GENERAL SURGERY CHIEF COMPLAINT: Gallstone pancreatitis. HISTORY OF PRESENT ILLNESS: He was a 57-year-old man, who was transferred from [**Hospital3 **] for acute gallstone pancreatitis. He was complaining of severe abdominal pain, mostly gassy and associated with nausea, vomiting, and diaphoresis. He also acknowledged a weight loss of [**10-17**] pounds in the past month. He was brought by EMS to the outside hospital, was ruled out for myocardial infarction, but it was noted in his admit laboratories, he had a significant elevation of his amylase to 4,000 as well as abdominal CT showing evidence of gallstones. He was brought for urgent endoscopic retrograde cholangiopancreatography. PRIOR MEDICAL HISTORY: 1. Hypertension. 2. Hiatal hernia. 3. H. pylori infection status post antibiotic treatment. 4. Dyspepsia 5. Cholelithiasis. 6. Diverticulosis. 7. Hiatal hernia. 8. Chronic lower back pain. ALLERGIES: He has no known drug allergies. MEDICATIONS AT HOME: 1. Zantac. 2. Zyrtec. MEDICATIONS FROM OUTSIDE HOSPITAL: 1. Zosyn 3.75 mg IV q.6. 2. Dilaudid for pain. SOCIAL HISTORY: He is a smoker, and quit about five years ago. Drinks socially. He is retired sheriff, who works as a plumber right now. He is divorced and lives by himself. PHYSICAL EXAM ON ADMISSION: He is afebrile 99.6, tachycardic with heart rate of 134, blood pressure 118/76, respirations 16, oxygen saturation 93% on 40% face mask. General exam: Pleasant-elderly man in no acute distress. Head and neck exam: Anicteric. Neck supple. Cardiovascular: Tachycardic, regular rate and rhythm. Lungs are clear to auscultation bilaterally. Abdomen distended, positive guarding and positive rebound. Extremities: No edema. LABORATORY RESULTS ON PRESENTATION: White blood cell count of 13.4, hematocrit of 52. Sodium of 140, potassium of 5.6 hemolyzed, chloride 113, bicarb 17, BUN 1.9, glucose 168. Total bilirubin 2.2, ALT 180, AST 49, alkaline phosphatase 206, amylase 1,576, lipase 1,683. Arterial blood gas: 7.15, pCO2 52, O2 106, lactate 2.3. Triglycerides 187, HDL 48, LDL 33. CK 91, CK MB 5, troponin 0.12. PT 15.2, PTT 29.6, INR 1.5. EKG showed sinus tachycardia at 124, normal axis, normal intervals. Left atrial enlargement, new peaked T wave in V2-V3, no ST depression or elevation. From these results, it was concluded the patient had pancreatitis and an urgent Surgical and ERCP consultations were called. In addition, immediately the patient was resuscitated with IV fluids. However, he became progressively hypoxic with an increase O2 requirement, and he was electively intubated for his impending respiratory failure. An abdominal CAT scan done at this time without IV contrast showed ileus, gallstones, and inflammatory changes about the pancreas as well as a dilated common bile duct of 12 mm. He then underwent urgent ERCP to decompress the obstruction, however, the ERCP could not find the ampulla, and the patient was started on meropenem for empiric coverage. Unfortunately, the patient continued to deteriorate over the next couple days. He developed significant hypotension, significant acidemia and acute renal failure. Acute renal failure as well as sort of an abdominal compartment syndrome with increased trans ......... pressures. At this point, he is already in the Medical Intensive Care Unit for several days now, and being monitored by the Medical Intensive Care Unit team. Surgical Services were consulted for possible decompression of the abdominal compartment syndrome. Surgery team followed closely, and over the next few days, the patient was transferred over to the Surgical Unit. While in the Medical Intensive Care Unit, the patient was also consulted by the Renal team for his acute renal failure. In addition, another problem during his stay in the Medical Intensive Care Unit, was a transient thrombocytopenia, which was initially attributed to a Heparin induced thrombocytopenia. However, tests for HIT were negative and his platelet count soon improved. Finally, during this time, the patient was followed with serial CAT scans of the abdomen and pelvis to monitor for changes in necrotic pancreas. CAT scans on [**7-13**] and [**7-19**] showed no significant interval changes in the peripancreatic inflammation. However, on [**7-31**], a fourth CAT scan was obtained, which showed a suspicious collection of retroperitoneal air that was suspicious for necrotizing pancreatitis and the patient was taken emergently to the operating room for an exploratory laparotomy with debridement of a necrotic pancreas as well as necrotic peripancreatic tissue. After this emergent surgery, the patient was transferred to the Surgical Intensive Care Unit, where the patient was monitored closely by the surgical team. On the [**7-6**], the [**7-8**], and the [**7-13**], the Surgery team performed subsequent procedures, where they debrided more necrotic tissue in the area of the left kidney and other retroperitoneal structures. On the 4th there was also an abscess drainage. On the 11th, an ostomy was also created. In addition, the patient was monitored with Swan-Ganz lines and multiple central venous lines to evaluate fluid status as well as hemodynamics. In the Surgical ICU the patient received bilateral chest tubes for worsening pleural effusions. Finally, the patient's Intensive Care Unit course was notable for multiple red blood cell transfusions as well as platelet transfusions and fresh-frozen plasma transfusions. Finally, the patient was extubated and was subsequently transferred to the floor on [**8-22**]. On the floor, the patient's main issues were continuing his TPN that had begun in the Medical ICU and continued through the Surgical ICU. On the floor, the patient was slowly advanced through sips and clears to a regular diet, all of which he tolerated without nausea, vomiting, or abdominal pain. As the patient's oral caloric intake increased, the TPN was phased out, and finally discontinued on [**9-4**]. In addition, on the floor, the patient received an inpatient Physical Therapy consult on [**8-24**], and was recommended to go to a rehab facility to enhance his activity level as well as his ability to tolerate ADLs. Patient will also need nursing care to assist with his ostomy, and will also need to supplement his diet with Boost to maximize his caloric intake. On the floor, the patient was also found to have a gram-negative rod urinary tract infection on [**8-29**]. This was treated with levofloxacin originally. The levofloxacin was changed to ciprofloxacin to which the patient had a bit of a drug reaction which was cleared up by changing him back to levofloxacin and giving him fluocinolone skin cream twice a day. As a result, today on [**2187-9-5**], the patient subsequently is being discharged to the [**Hospital3 **] Rehab facility. DISCHARGE DIAGNOSES: 1. Cholelithiasis. 2. Gallstone pancreatitis. 3. Necrotizing pancreatitis. 4. Splenic vein thrombosis. 5. Pneumoretroperitoneum. 6. Status post exploratory laparotomy with debridement of necrotic pancreas and peripancreatic tissue. 7. Status post debridement of pararenal necrotic tissue and abscess drainage on [**8-6**]. 8. Status post debridement on [**8-8**]. 9. Status post pancreatic debridement and ostomy creation on [**8-13**]. 10. Postoperative ileus. 11. Colonic stricture. 12. Abdominal compartment syndrome. 13. Status post endoscopic retrograde cholangiopancreatography. 14. Gastrointestinal bleed. 15. Hyperalimentation. 16. Stable angina. 17. Hypertension. 18. Swan-Ganz catheter placement for hemodynamic monitoring. 19. Esophageal balloon placement to monitor thoracic pressure. 20. Multiple central venous line placements and exchanges. 21. Respiratory failure. 22. Respiratory acidosis. 23. Metabolic acidosis. 24. Emergent intubation. 25. Mechanical ventilation. 26. Ventilator-related pneumonia with xanthomas. 27. Aspiration pneumonia. 28. Bilateral pleural effusions. 29. Chest tube placements. 30. Urinary tract infection. 31. Acute renal failure. 32. Placement of Quinton catheter. 33. Renal cyst. 34. Hyponatremia. 35. Hypokalemia. 36. Hypomagnesemia. 37. Hypophosphatemia. 38. Chronic blood loss anemia requiring red blood cell transfusion. 39. Fresh-frozen plasma transfusion. 40. Platelet transfusion. 41. Thrombocytopenia. 42. Methicillin-resistant Staphylococcus aureus infection. 43. Drug reaction related to ciprofloxacin. 44. Delirium. DISCHARGE MEDICATIONS: 1. Combivent inhaler 1-2 puffs every six hours as needed. 2. Albuterol inhaler one treatment every six hours as needed. 3. Atrovent one treatment every six hours as needed. 4. SubQ Heparin 500 units every 12 hours. 5. Tylenol 1-2 tablets orally every 4-6 hours, no more than 4 grams/day. 6. Protonix 40 mg orally every 12 hours. 7. Ambien 5 mg one tablet at bedtime as needed for insomnia. 8. He is also recommended to have a sliding scale of insulin as directed by the attached sliding scale. 9. He is also recommended to have Neutra-Phos one packet orally twice a day. 10. Colace one suppository rectally twice a day as needed. 11. Levofloxacin 500 mg q.d. for four days. 12. Fluocinolone cream 0.025% topically twice a day to his rash. 13. Dilaudid 0.5-2.0 mg IV q.1-2h. as needed for pain. 14. Maalox two teaspoons every six hours as needed. Do not give the same time as his Levaquin. 15. Metoprolol 25 mg twice a day, hold for heart rate less than 60, blood pressure less than 100. FOLLOW-UP APPOINTMENT: A follow-up appointment has been scheduled for the patient on [**9-14**] at 9:15 am. Patient was instructed to notify Dr. [**Last Name (STitle) **] if he has any questions whatsoever. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2187-9-4**] 17:39 T: [**2187-9-5**] 05:40 JOB#: [**Job Number 104126**] Name: [**Known lastname 16880**], [**Known firstname **] Unit No: [**Numeric Identifier 16881**] Admission Date: [**2187-7-10**] Discharge Date: [**2187-9-6**] Date of Birth: [**2129-10-22**] Sex: M Service: Surgery ADDENDUM: Several changes need to be made to the original Discharge Summary. The patient's cardiovascular examination revealed he was tachycardic. He did not have a regular rate and rhythm, he was tachycardic. A positive first heart sound and a positive second heart sound. No murmurs were appreciated. Arterial blood gas revealed pH was 7.15 and then PCO2 etcetera; otherwise that was fine. There is a mistake in the hospital course. In inadvertently said that an ostomy was created on [**8-13**] on one of the surgeries. That is not true. The patient did not have an ostomy created. However, if you could also add, in terms of his discharge medications; Dilaudid 2-mg tablets one tablet by mouth q.3-4h. as needed for pain. In addition, Miconazole powder one application twice per day as needed for a fungal infection of the skin around the ostomy site. Finally, the fluocinolone cream, which is another one of the discharge medications, if it could be noted that prescription was only for two weeks. Please add to the discharge diagnoses enterocutaneous fistula. Therefore, the patient's course within the last 24 hours, since discharge, as per the rehabilitation facility ([**Hospital6 16882**]). A final complete blood count was checked on [**9-5**] revealed a white blood cell count of 15.2 (up from 10), a hematocrit of 30.9 (up from 26), and a platelet count of 354 (which was stable). As per the request of the health care staff at the [**Hospital6 16883**] Center, an evaluation of this was performed. The patient had a benign-appearing chest x-ray with no infiltrates. He also had a repeat urinalysis that was performed yesterday, and a urine culture sent. The urine culture was still pending, but the urinalysis was negative. Also, his central line was pulled with the catheter tip sent for culture; this is currently pending as well. There were several possible etiologies for this increase in his white blood cell count. First, it could be a remnant of his urinary tract infection which is currently being treated with levofloxacin. Secondly, it could be an allergic reaction, or secondary to an allergic reaction, to the ciprofloxacin which we already know about and are currently treating with fluocinolone cream. Otherwise, he is stable and afebrile with no focal signs of infection; so this is not concerning. This morning, he was without complaints. He was afebrile with stable vital signs. His heart rate was 106, his blood pressure was 110/60, and his oxygen saturation was 93% on room air. He took in 880 by mouth yesterday, and his urine output was [**2184**] with over 600 after midnight. The drain int he left upper quadrant (which is a sump, not an ostomy) put out 350 cc yesterday of stool with also air in the bag. He was in no apparent distress this morning. His rash had improved. The central line was pulled and was without erythema. His heart was regular in rate and rhythm. His lungs were clear to auscultation bilaterally. His abdomen was soft, nontender, and nondistended. His dressing was clean, dry, and intact. The drain was with minimal stool output and with air in the bag as well. His extremities had 5/5 strength and were without clubbing, cyanosis, or edema. His repeat complete blood count from this morning showed a white blood cell count which was trending down from 15.2; it was down to 14.5, his hematocrit was 30.9, and his platelet count was 340. Since he was tolerating a diet today, he was clinically stable, he was able to be discharged medically to a rehabilitation facility for improvement of his physical activity as well as improvement of his nutritional status. CONDITION AT DISCHARGE: Therefore, the patient was discharged today in good condition. MEDICATIONS ON DISCHARGE: Medications on discharge as above; as per the initial dictation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**], M.D. [**MD Number(1) 846**] Dictated By:[**Name8 (MD) 16884**] MEDQUIST36 D: [**2187-9-6**] 10:32 T: [**2187-9-6**] 11:17 JOB#: [**Job Number 16885**] Name: [**Known lastname 16880**], [**Known firstname **] Unit No: [**Numeric Identifier 16881**] Admission Date: [**2187-7-10**] Discharge Date: [**2187-9-12**] Date of Birth: [**2129-10-22**] Sex: M Service: Surgery ADDENDUM: Again, changes were to be made to the original Discharge Summary and Discharge Summary Addendum. The patient was originally to be discharged on [**2187-9-6**] but remained in the hospital due to an elevated white blood cell count. The white blood cell count was 15.2; which was up from a prior value of 10. The reason for this was investigated with a computed tomography scan of the abdomen. This study demonstrated multiple peripancreatic fluid collections which were felt to be abscess cavities. The patient's white blood cell count reached a maximum value of 20; although the patient was afebrile. He did have some abdominal pain which was more severe than on prior days, and he was unable to take an adequate amount of food orally. The Interventional Radiology Department drained two fluid collections; one of which was only a small amount, the second of which was larger and drained approximately 30 cc of purulent material. A pigtail catheter was placed in this fluid collection and cultures were sent. Following this procedure, the patient had less abdominal pain. After a 4-day course of total parenteral nutrition, the patient was finally able to tolerate liquids and eventually solid foods. The patient was empirically started on levofloxacin, Flagyl, and vancomycin. The microbiology report determined that this was vancomycin-resistant enterococcus, and the patient's regimen was switched to levofloxacin, clindamycin, and linezolid. The patient was otherwise stable. The patient was ambulating with Physical Therapy assistance and was tolerating a regular diet with supplementary Boost shakes with each meal. His hyperalimentation was stopped. His white blood cell count diminished from 20 down to 11.6 at the time of discharge, and he was discharged to the rehabilitation facility on oral antibiotics. At the time of discharge, the patient was afebrile with a benign abdominal examination. He was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 700**] in no longer than two weeks. CONDITION AT DISCHARGE: The patient was discharged today in good condition; without pain and tolerating adequate oral intake. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge include the addition of) 1. Levofloxacin 500 mg by mouth once per day (for two weeks). 2. Clindamycin 300 mg by mouth four times per day (for two weeks). 3. Linezolid 600 mg by mouth twice per day (for two weeks). 4. Hydromorphone 2 mg by mouth q.3-4h. as needed (for pain). DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was discharged to a rehabilitation facility today and was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 700**] in approximately one to two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**], M.D. [**MD Number(1) 846**] Dictated By:[**Last Name (NamePattern1) 7438**] MEDQUIST36 D: [**2187-9-12**] 12:19 T: [**2187-9-12**] 15:33 JOB#: [**Job Number 16886**]

[ "511.9", "507.0", "577.0", "518.81", "560.1", "599.0", "280.0", "584.9", "574.21" ]

icd9cm

[ [ [] ] ]

[ "54.91", "96.06", "52.22", "96.72", "38.95", "00.14", "34.04", "99.15", "89.64", "96.04" ]

icd9pcs

[ [ [] ] ]

17613, 19185

19208, 20197

27523, 27841

4349, 10745

27876, 28351

11709, 11815

2550, 4331

27393, 27496

10763, 10788

20221, 24604

10817, 11688

12023, 17592

2317, 2378

1957, 2252

11832, 12008

17,928

143,253

13754

Discharge summary

report

Admission Date: [**2123-4-18**] Discharge Date: [**2123-4-27**] Date of Birth: [**2060-2-11**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old man with a complex history. The patient had been in the [**Country 13622**] Republic in [**2123-2-5**] when he developed acute perforated diverticulitis requiring sigmoidectomy, [**Doctor Last Name **] and an osteotomy. The patient was transferred to [**Hospital1 346**] for further management of acute renal failure. The patient was discharged to [**Hospital3 7558**] on [**2123-3-24**] and returns now with fever and chills after hemodialysis. The patient developed suprapubic pain, no nausea or vomiting. The patient has had stomal output and gas. PAST MEDICAL HISTORY: 1. Acute renal failure. Status post surgery on hemodialysis. 2. Coronary artery disease, status post coronary artery bypass graft in [**2118**]. 3. Diverticulitis, status post ex-flap sigmoidectomy, [**Doctor Last Name 3379**] pouch and stoma in [**2123-2-5**]. 4. Status post lap cholecystectomy. 5. Diabetes mellitus. 6. Benign prostatic hypertrophy. 7. Hypertension. 8. Anxiety. ALLERGIES: No known drug allergies. No alcohol or tobacco use. MEDICATIONS: 1. Zocor 80 mg 2. Fluconazole 200 mg post hemodialysis. 3. Klonopin 0.5 mg p.o. b.i.d. 4. Lopressor 100 mg p.o. three times a day 5. Flomax 6. Nepherex XL 90 mg 7. Protonix 40 mg q day. 8. Synthroid. 9. Trazodone 50 mg q day. 10. Epogen. PHYSICAL EXAMINATION: Temperature was 100.7, pulse 99, blood pressure 168/70. Respirations 18, sating 96% on room air. The patient appeared uncomfortable. Abdomen was soft, nondistended, moderate right lower quadrant tenderness. Stoma and gas output in bag. No peritoneal signs. Extremities were warm. LABORATORY: White count 17.8, crit 32, platelets 247, Chem 7 135, 5.2, 99. 23, 28, 2.8 and 241. CT scan showed thickened terminal ilium wall and free air around the small bowel with extravization from the small bowel. The patient was admitted and made NPO with intravenous fluids, an nasogastric tube was placed as well as a Foley catheter. The patient was started on Amp, Levo and Flagyl. The patient was taken to the operating room on the evening of [**2123-4-18**] for exploratory laparotomy with lysis of adhesions and ileocecal resection. The patient was admitted to the Intensive Care Unit postoperatively. The patient was placed on Dilaudid PCA for pain control, was started on Lopressor intravenous for rate control and was made NPO. The patient was given subcutaneously Heparin for deep vein thrombosis prophylaxis. The patient was continued on his Amp, Levo, Flagyl. The renal team was following along with the surgery team while the patient was in the Intensive Care Unit regarding his hemodialysis. The patient had hemodialysis on postop day two. On postop day three the patient was started on TPN. On postop day four the patient was transferred to the floor. On the evening of postop day four the patient developed some chest pain with hypertension. CKs were negative but Troponin was up to 1.5. The patient was continued on his beta-blocker for blood pressure control. The patient was also started on intravenous Heparin and aspirin per coronary syndrome protocol. The echo on [**2123-4-23**] demonstrated preserved left ventricular function. The patients electrocardiogram showed various degrees of negative T-waves precordially consistent with severe electrolyte disturbance, hypokalemia. Cardiology suggested aggressive potassium replacement which was done. On [**2123-4-24**] the patient's Heparin was discontinued. The patient's beta-blocker was changed to p.o. On [**4-25**] the patient was advanced to clear liquid diet and his medications were changed to p.o. On [**2123-4-26**], postoperative day 8 the patient's diet was advanced to regular. The patient's JP drain was removed. The patient's pain medication was changed from PCA to p.o. pain medication. The patient was seen by physical therapy on [**2123-4-26**] who felt that he would be safe for discharge to home on [**2123-4-27**]. The patient was discharged to home on [**2123-4-27**] on the following medications: 1. Augmentin 500 mg p.o. b.i.d. 2. Protonix 40 mg p.o. q day. 3. Percocet 5 325 mg one to two tabs p.o. q 4 to 6 hours p.r.n. 4. Hydralazine 40 mg p.o. q.i.d. 5. Lopressor 50 mg p.o. b.i.d. 6. Klonopin 0.5 mg p.o. b.i.d. 7. Aspirin 325 mg p.o. q day. 8. Amiodarone 200 mg p.o. q day. 9. Epo 10 subcutaneously q hemodialysis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2123-4-26**] 21:56 T: [**2123-4-26**] 22:05 JOB#: [**Job Number 41382**]

[ "569.83", "403.91", "285.1", "997.4", "276.8", "250.00", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "54.11", "45.62", "99.15", "45.93", "39.95", "54.59" ]

icd9pcs

[ [ [] ] ]

1522, 4849

160, 746

768, 1499

15,873

112,477

28093

Discharge summary

report

Admission Date: [**2190-9-1**] Discharge Date: [**2190-9-15**] Service: MEDICINE Allergies: Codeine / Pneumovax 23 / Lescol Attending:[**First Name3 (LF) 759**] Chief Complaint: abd pain, chills Major Surgical or Invasive Procedure: ERCP Laprascopic Cholecystectomy History of Present Illness: Pt is a [**Age over 90 **]yoW who presented from [**Hospital3 **] facility with chills/fever and ruq abd pain for 2 days. Denies diarrhea, but has had nausea w/o vomitting. Denies CP/SOB/HA/rash/dysuria/myalgias/ back pain. . She was taken to [**Hospital1 18**] [**Location (un) 620**] where she was febrile to 103.2, found to have elevated LFTs, CT with likely cholangitis. . She was transferred to [**Hospital1 18**] ED and taken to ERCP, where sphincterotomy performed, several stones extracted from CBD, stent placed. Several stones where noted to remain, exiting from the cystic duct. In the ERCP suite she was treated with ampicillin and gentamycin. Past Medical History: HTN COPD Hypothyroid hx of gallstones Stress incontinence Anxiety Social History: Married and lives at [**Hospital3 **] with her husband. Was able to ambulate with a walker prior to admission. Was not on any home oxygen. Denies current tobacco/alcohol/IVDA. Has a ~15 pack year history of smoking (5 cig/day from teens to [**2157**]). Family History: nc Physical Exam: Vital Signs: T:97BP:120/68 HR:62 RR:14 O2 Sat:99%2L . GEN: no jaundice . HEENT -Head/Neck: Anicteric sclera. Head is symmetric and atraumatic. Neck has full range of motion and cervical, occipital, and supraclavicular lymph nodes are nonpalpable and nontender. -Eyes: PERRL, EOM are intact . Respiratory: CTA bl. . Cardiovascular: RRR nl s1s2 no mrg . Abdominal: soft, mild RUQ tenderness, hypoactive bs . Neurologic: CN 2-12 intact . Extremities: bl legs markedly tender to palpation, no edema, no erythema . Back: no cva tenderness, no spinal or paraspinal point tenderness Pertinent Results: [**2190-9-1**] 10:03AM LACTATE-2.9* [**2190-9-1**] 09:40AM GLUCOSE-140* UREA N-14 CREAT-1.1 SODIUM-141 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13 [**2190-9-1**] 09:40AM ALT(SGPT)-271* AST(SGOT)-220* ALK PHOS-216* AMYLASE-44 TOT BILI-1.9* [**2190-9-1**] 09:40AM LIPASE-29 [**2190-9-1**] 09:40AM ALBUMIN-3.6 CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-2.1 [**2190-9-1**] 09:40AM WBC-7.9 RBC-4.16* HGB-12.5 HCT-36.1 MCV-87 MCH-30.1 MCHC-34.7 RDW-13.6 [**2190-9-1**] 09:40AM NEUTS-91.4* BANDS-0 LYMPHS-5.9* MONOS-2.4 EOS-0.1 BASOS-0.2 [**2190-9-1**] 09:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2190-9-1**] 09:40AM PLT SMR-LOW PLT COUNT-148* [**2190-9-15**] 06:20a 138 104 12 102 AGap=10 4.0 28 1.0 Ca: 8.2 Mg: 1.9 P: 2.5 ALT: AP: Tbili: Alb: AST: LDH: 214 Dbili: TProt: [**Doctor First Name **]: Lip: Other Blood Chemistry: Hapto: Pnd 87 8.6 9.0 543 26.3 [**2190-9-13**] 3:00p Free-T4:1.2 Other Blood Chemistry: CRP: 186.8 New Reference Ranges As Of [**2189-6-26**];Low Risk <1.0, Average Risk 1.0-3.0, High Risk >3.0 (But <10.0) SED-Rate: 93 [**2190-9-13**] 10:31a Color Straw Appear Clear SpecGr 1.010 pH 8.0 Urobil Neg Bili Neg Leuk Neg Bld Neg Nitr Neg Prot Tr Glu Neg Ket Neg RBC 0 WBC 0 Bact None Yeast None Epi 0 [**2190-9-10**] 06:00a TSH:11 [**2190-9-6**] 08:21a ALT: AP: Tbili: Alb: AST: LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 19 [**2190-9-4**] 12:50a TNT,CP,CPMB ADDED 135AM,[**2190-9-4**] MB: 5 Trop-*T*: 0.02 Comments: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi Other Blood Chemistry: proBNP: 7662 Reference Values Vary With Age, Sex, And Renal Function;At 35% Prevalence, Ntprobnp Values; < 450 Have 99% Neg Pred Value; >1000 Have 78% Pos Pred Value;See Online Lab Manual For More Detailed Information [**2190-9-2**] 05:36a Other Urine Chemistry: Osmolal:627 [**2190-9-1**] 09:40a N:91.4 Band:0 L:5.9 M:2.4 E:0.1 Bas:0.2 . [**9-1**] ERCP ERCP: Ten ERCP images were obtained by Dr. [**Last Name (STitle) 6745**]. Cholangiogram demonstrates a dilated common duct with numerous filling defects. By report a sphincterotomy was performed and stones were extracted. Residual impacted stones were observed and a biliary stent was placed. . [**9-7**] CXR: AP single view of the chest obtained with the patient in semi-erect position is analyzed in direct comparison with a similar study obtained [**9-6**]. The bilateral pleural effusions remain practically unchanged. Heart size as before. No new parenchymal infiltrates are seen, and the accessible lung fields demonstrate unchanged pulmonary vasculature. . [**9-6**] ECHO: Conclusions: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . EKG [**9-8**]: NSR 68, nl intervals, TWI in II/III, no ST changes. . [**9-8**] CXR HISTORY: [**Age over 90 **]-year-old woman with low oxygenation. IMPRESSION: AP and lateral chest compared to [**9-6**] and 12: Moderate bilateral pleural effusion, right greater than left, has increased slightly on the right. Mild-to-moderate enlargement of the cardiac silhouette is more pronounced. There could be a component of pericardial effusion. Aside from relaxation atelectasis at the lung bases, there is no focal pulmonary abnormality, though there is pulmonary vascular engorgement. . [**9-12**] CXR Compared with [**2190-9-11**], no significant change is detected. Again seen are small bilateral pleural effusions, with underlying collapse and/or consolidation. There is cardiomegaly, with an unfolded aorta. No CHF is identified. Aside from the bases, no focal infiltrate is identified. IMPRESSION: No significant change compared with one day earlier. Bilateral pleural effusions with underlying collapse and/or consolidation. Lungs otherwise grossly clear. Background COPD noted. . [**9-13**] CT OF THE ABDOMEN WITH IV CONTRAST: There are bibasilar effusions with adjacent areas of compressive atelectasis. The right effusion is moderate in size. There is a stent in the common bile duct, with associated pneumobilia centrally, but there is no intra- or extrahepatic biliary ductal dilatation. No focal liver lesions are identified. The patient is status post cholecystectomy. The spleen, pancreas, and adrenal glands are within normal limits. There is a 3.6 cm diameter hypoattenuating lesion in the lower pole of the left kidney with relatively high density. This may represent a cyst with hemorrhage, but is not fully characterized here. There is a large hiatal hernia. Apparent wall thickening of the distal colon is probably due to underdistension. The stomach, small and large, bowel, are unremarkable. There is no evidence of obstruction. There is no lymphadenopathy or free air or fluid. There is a partly saccular infrarenal abdominal aortic aneurysm with maximal diameter of the aorta of 3.2 cm. There are extensive vascular calcifications as well. There are fairly large calcifications in the mesentery in the pelvis. These may represent unusual phleboliths. There is no free fluid. BONE WINDOWS: There is marked leftward convex scoliosis of the mid lumbar spine with degenerative change but no suspicious lytic or blastic lesions. IMPRESSION: 1. Bilateral effusions, right greater than left. 2. Bibasilar opacities which are more suggestive of atelectasis than pneumonia. 3. Stent in the common bile duct with associated pneumobilia. Cholangitis cannot be excluded by this study but there is no parenchymal abnormality in the liver or evidence of biliary ductal dilatation or enhancement to raise the possibility based on the CT. 4. Large left-sided renal cystic lesion. This may represent a renal cyst with hemorrhage but an ultrasound could be performed to confirm. 5. Abdominal aortic aneurysm. 6. Status post cholecystectomy. . [**9-14**] CT Chest FINDINGS: There are bilateral pleural effusions, moderate on the right, small on the left. There is associated bilateral compressive basal atelectasis. There is centrilobular emphysema predominantly in both upper lobes. Fine detail is obscured by motion artifact. Adjacent to the area of centrilobular emphysema in the right upper lobe, there is a focal area of bronchiectasis and bronchial thickening. No mass is appreciated, but small lesions may be below the detection threshold given the motion artifact. Emphysematous changes are also seen in the lower lobes but partially obscured by the pleural effusion. Pleural effusion extends into the right major fissure. There is mild cardiomegaly. No pericardial effusion is seen. Atherosclerotic calcifications are seen within the coronary arteries, aorta, and the origin of great vessels. The airways appear patent to the level of the subsegmental bronchi. Non-contrast images through the upper abdomen demonstrate a stent in the common bile duct with associated pneumobilia. A hypoattenuating exophytic lesion arising from the left kidney is incompletely visualized. Significant motion artifact obscures details in the right kidney. There is a moderate to large hiatal hernia. BONE WINDOWS: No suspicious lytic or blastic lesions are seen. Thoracic scoliosis with significant associated degenerative changes is noted. IMPRESSION: 1. Centrilobular emphysema, with predominance in both upper lobes. 2. Focal area of bronchial thickening and bronchiectasis posteriorly in the right upper lobe. An infectious process including tuberculosis cannot be excluded. 3. Bilateral pleural effusions, right greater than left with associated compressive atelectasis at the lung bases. 4. Mild cardiomegaly with severe coronary artery atherosclerotic calcifications. 5. Large hiatal hernia. 6. Hypoattenuating lesion arising from the left kidney, better visualized on the CT of [**9-13**]. 7. Partial visualization of common bile duct stent and pneumobilia better visualized on CT of [**2190-9-13**]. 8. Moderate to severe thoracic scoliosis and degenerative changes. Brief Hospital Course: [**Age over 90 **] yo F with HTN, hypothyrodisim, and COPD who presented to [**Hospital1 **] [**Location (un) 620**] with fevers, elevated LFTs, and CT abd concerning for cholangitis. She was transferred to [**Hospital1 18**] for ERCP with sphincerotomy and stent placement ([**9-1**]). She was then taken for a lap ccy ([**9-3**]). Post op she was noted to be increasingly somnolent in the setting of pain control post op with lack of spontaneous breathing. Given narcan. Transfered to the [**Hospital Unit Name 153**]. She was placed on unasyn for abx coverage post op in the [**Hospital Unit Name 153**]. [**Hospital Unit Name 153**] course notable for improvement in mental status. She was transferred to the SICU for hypotension and low UOP. She was called out of the SICU to the floor but then returned to the SICU for resp distress, satting 91% on 6L. An ABG showed 7.51/73/30, concerning for resp alkalosis. A CXR on [**9-6**] showed ? new infiltrate. She was placed on levoquin 250mg and flagyl. She returned to the floor with a fever to 101.2 on [**9-7**], sats remained in the low 90's on [**1-29**] L NC. She desatted to 93% on 4L with activity with PT. . She was transferred to the medicine service on [**9-9**] for further management before discharge to [**Hospital1 1501**]. Hospital course on medicine as follows: . # Hypoxia: Likely a mixed picture due to PNA/ COPD exacerbation vs CHF (diastolic dysf w/ nl EF). Pt had a fever to 101.1 ([**9-6**]-->[**9-7**]) with a prod cough and CXR suggestive of an infiltrate. In addition, her prior exam suggested vol overload. In someone with exisiting COPD, these two additional ailments would compromise her pulmonary status. By discharge, she had a minimal O2 req (2L) and was afebrile >24 hrs with decreased SOB. a. for PNA: likely nosocomial as this happened in-house. --switched from levoquin to piperacillin/taz as she spiked through the Levo. Will continue a 7 day course. . b. for CHF: in mild decompensated CHF. Likley [**1-28**] vol overlaod during surgery as well as from hypoixa causing HTN/increased afterload and susequent pulm edema. She was diuresed > 4 L and her respiratory status improved. -- her Is=Os X several days so no standing furosemide was continued, she will be dishcarged on 10 mg fuosemide prn if weight increases or I > O . #) L ankle pain: She complained of L ankle pain on ambulation. It continues to be edematous (L >R) mildly TTP on lateral aspect of L ankle with minimal erythema. XR did not show an acute fracture. Rheum consult did not feel that her ankle was the source of her fever and there was not an effusion to be tapped. . #) Urinary retention: foley was replaced [**1-28**] urine output. Likely [**1-28**] retention or urethral inflammation. - continue foley for now; recommend attempts at d/c in NH . #) Mouth pain: [**1-28**] dry mouth/cracked lips. - magic mouthwash, tylenol prn . #) Normocytic Anemia: likely 2/2 blood loss from surgery and serial phlebotomy. Her hematocrit was 36 on admission and 26 on discharge. There was no evidence for hemolysis. She did not receive any transfusions during her hospital course. . #) Hypothyroidism: TSH was found to be elevated at 11, so her levothyroxine dose was increased to 75 mcg q day. - her TSH should be re-checked in 3 weeks. . #) HTN: continued metoprolol. BP well-controlled during hospital stay. . #) FEN: low-sodium diet, replete lytes prn . #) Prophylaxis: sc heparin, PT consult . #) Code Statue: Full, confirmed with patient on [**9-9**] . #) Contact: [**Name (NI) **] [**Name (NI) **] [**Name (NI) 68317**] ([**Telephone/Fax (1) 68318**] . #) Dispo: d/c to The Crossing with IV antibiotics and continuous O2 - she will need re-evaluation of her AAA in 6 months - f/u with PCP [**Last Name (NamePattern4) **] 2 weeks. . Medications on Admission: levoxyl 50 mcg qd oxazepam 15 mg tid prevacid 30 mg qd metoprolol 25 mg [**Hospital1 **] Carafate Vit C Calcium Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation q4-6h prn as needed for shortness of breath or wheezing. 5. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO tid prn as needed for anxiety or insomnia. 6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO BID PRN () as needed for anxiety. 9. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 4 days. 10. Levothyroxine Oral 11. Outpatient Lab Work Please check CBC on Monday, [**9-20**]. 12. Outpatient Lab Work Please check TSH in 3 weeks 13. Furosemide 20 mg Tablet Sig: [**12-28**] Tablet PO q day prn as needed for Intake > Output or increasing daily weight. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Ascending Cholangitis Cholelithiasis Pneumonia COPD HTN Hypothyroidism Stress incontinence Urinary retention Discharge Condition: Hemodynamically Stable Discharge Instructions: Please take all medications as instructed. There were several changes made to your current medications regimen. If you experience any nausea, vomiting, lightheadedness, chest pain, shortness of breath, or any other concerning symptoms please seek medical attention immediately. Followup Instructions: Please follow-up with your primary care doctor within 2 weeks of discharge. . Please re-check TSH in 3 weeks. . Please check daily weights. If I > O in 24 hrs, please give furosemide 10 mg po. . Please make a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Surgeon) within the next 3 weeks. Tel ([**Telephone/Fax (1) 9000**]. . She will need repeat imaging in 6 months to follow her AAA.

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icd9cm

[ [ [] ] ]

[ "51.23", "57.94", "51.88", "51.87", "51.85", "34.91" ]

icd9pcs

[ [ [] ] ]

15558, 15635

10467, 14263

254, 288

15788, 15813

1970, 10444

16142, 16584

1354, 1358

14426, 15535

15656, 15767

14289, 14403

15837, 16119

1373, 1951

198, 216

316, 974

996, 1064

1080, 1338

9,457

180,901

47170

Discharge summary

report

Admission Date: [**2196-11-28**] Discharge Date: [**2196-12-9**] Date of Birth: [**2133-3-7**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Vantin / Cephalosporins / Adhesive Tape / Levofloxacin Attending:[**First Name3 (LF) 898**] Chief Complaint: [**First Name3 (LF) **] and malaise Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 63 y/o woman with a h/o gastric bypass s/p recent revision who presented with generalized weakness and fatigue for 4 days and [**Known lastname **] to 102. She initially went to see her gastric surgeon, as she had had a bypass revision 6 weeks pta. However, her surgeon did not believe this to be a GI source. Her PCP subsequently referred her to the ED for orthostasis and [**Known lastname **] (T 100.2). In ED, she was hypotensive to SBP 80s. She had no change in mental status with this episode. She denies having any localizing symptoms. She has had no cough/sore throat, no SOB, no abdominal pain/N/V/Diarrhea, no BRBPR. No dysuria. No HA/Confusion. No myalgias/arthralgias, no back pain. No rashes. ROS only notable for chills/sweats/malaise. . ED Course: Initial VS 99.1 113 85/49 16 99%RA. Non specific exam. CXR w/ no infiltrate. EKG without ST-T segment changes. She got vanco and 4LNS. . In the MICU, she was treated with vancomycin, ampillicin-sulbactam, and [**Last Name (un) 104**] stim showed a basal level > 20 but a small increase. . ROS: As above, otherwise negative. Past Medical History: 1. S/p lap RNY gastric bypass [**11-27**] complicated by gastroparesis. Has had 3 surgeries subsequently to evaluate failure, including lysis of adhesions TPN dependent since [**1-30**]. Most recent revision at [**Hospital1 2025**] [**2196-10-25**]. 2. H/o of PICC infections, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] admission [**6-28**]. 3. Aortic Insufficiency and Mitral Regurgitation [**1-28**] phen-phen use. 4. Hypothyroidism. 5. Depression. 6. Left ureteral stone, s/p stent placement. 7. Anemia, normocytic, following bypass surgery, baseline 25-32. 8. S/p CCY, appy. Social History: The patient lives at home with her husband. [**Name (NI) **] son and daughter-in-law live nearby. The patient denies tobacco, alcohol, illicit drug use. Family History: M:Passed away at 78 of MI, CAD F:Passed away at 84 of CHF, CAD No known DM, Cancers in her family Physical Exam: Vitals: 99.8F (101 max) 94/59 97 20 97%RA Gen: Well-appearing woman in NAD. HEENT: NC/AT. MMM no erythema/exudate. JVP normal. Neck supple w/o LAD. Pulm: Clear to auscultation bilaterally. CV: Regular Rate and Rhythm, 3/6 SEM at LLSB. Abd: Soft, non-tender and non-distended. Bowel sounds are normoactive. Well-healed surgical scars without evidence of infection. Ext: 2+ dorsalis pedis pulses; no edema, clubbing, or cyanosis. Neuro: AAOx3. CNII-XII grossly intact. Pertinent Results: Studies: - EKG [**11-28**]: Junctional rhythm at 94, nl intervals, no ST changes - CXR [**11-28**]: Low lung volumes, particularly on the left. No consolidation or effusion evident. - CT TORSO [**11-30**]: 1. No intra-abdominal fluid collections. 2. Bibasilar patchy opacities could represent consolidation Vs. atelectasis; aspiration is a likely possibility. 3. Interval resolution of small bowel obstruction. 4. Low attenuation lesion within right hepatic dome, unchanged. 5. New 4 mm pulmonary nodule at the right apex, follow up should be obtained in 12 months if patient doesn't have risk factors. - ECHO [**12-1**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are moderately thickened. No masses or vegetations are seen on the aortic valve. There is moderate aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate ([**12-28**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-28**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. The patient has moderate aortic stenosis. Based on [**2195**] ACC/AHA Valvular Heart Disease Guidelines, if the patient is asymptomatic, a follow-up echocardiogram is suggested in [**12-28**] years. Based on [**2186**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Compared with the report of the prior study (images unavailable for review) of [**2194-7-16**], the aortic stenosis has progressed. There is more mitral and aortic regurgitation on the current study. No obvious vegetations are visualized; if clinically indicated, a TEE may better evaluate for endocarditis. - CXR [**12-2**]: Increasing bibasilar opacities and left lower lobe atelectasis. Findings could all be due to atelectasis, but may also represent aspiration or developing pneumonia. - CXR [**12-6**]: Bilateral patchy infiltrates in the posterior bases indicative of bronchopneumonic infiltrates. Mild-to-moderate bilateral pleural effusions in the posterior sinuses. Further follow-up recommended. - PICC Placement [**12-7**]: Successful placement of a 44 cm long single lumen line placed via the left basilic vein with tip in the distal part of the SVC. The line is ready for use. - CXR [**12-9**]: Recurrence of bibasilar opacification right greater than left. After improvement between [**12-2**] and [**12-6**], accompanied by pulmonary vascular congestion suggests that this is all probably pulmonary edema. Small bilateral pleural effusions are new as well. Left PIC catheter passes into the right atrium where the tip is indistinct. - ECG [**12-9**]: Regular rhythm - may be sinus tachycardia with first degree A-V delay but baseline artifact makes assessment difficult. Nonspecific T wave abnormalities. Since previous tracing of [**2196-12-10**], further T wave changes present. . . LABS: -[**Last Name (un) **] Stim [**11-29**]: 23.5 -> 27.5 -WBC: 11.4 -> 9.9 -> 13.3 -> 12.6 -> 15.2 -> 16.1 -> 20.4 -> 24.2 -> 19.3 -> 24.6 -> 31.4 -> 36.9 -> 26.6 -> 26.7 ([**12-9**] AM) -> 26.6 ([**12-9**] PM). . -Hematocrit: 31.1 -> 26.2 -> 26.1 -> 24.3 -> 25.0 -> 25.5 -> 27.2 -> 24.8 -> 25.6 -> 24.6 (1 unit) -> 27.5 -> 26.6 -> 27.0 ([**12-9**] AM) -> 19.5 ([**12-9**] PM) . -Platelets: 127 -> 119 -> 104 -> 100 -> 105 -> 125 -> 117 -> 110 -> 99 -> 83 -> 97 -> 93 -> 65 -> 45 ([**12-9**] AM) -> 14 ([**12-9**] PM) . -Blood cultures: [**1-30**] coag neg staph from [**11-28**]; all others negative from [**11-29**] to [**12-6**]. -Urine cultures: [**11-28**] negative, [**11-30**] negative, [**12-1**] +Enterobacter, Morganelli, [**12-2**] yeast, [**12-6**] yeast, [**12-7**] negative. -Stool cultures: All negative, including C. diff. -INR: [**11-28**]: 1.2, [**12-6**]: 1.2 -PTT: [**11-28**]: 31.3, [**12-6**]: 32.9 -Fibrinogen: 307 -Galactomannan: Negative -B-glucan: Negative -HIT ab: Negative . -Bicarb: 20 -> 19 -> 19 -> 19 -> 15 -> 16 -> 14 -> 15 -> 16 -> 14 -> 13 -> 13 -> 14 -> 14 -> 15 ([**12-9**] AM) -> 11 ([**12-9**] PM) . -Lactate: [**11-28**]: 2.5 -> [**12-1**]: 2.0 -> [**12-6**]: 2.5 -> [**12-9**]: 4.4 -> [**12-9**]: 11.5 . -Anion Gap: 13 -> 10 -> 8 -> 9 -> 10 -> 11 -> 12 -> 12 -> 11 -> 12 -> 13 -> 13 -> 11 -> 11 -> 11 ([**12-9**] AM) -> 18 ([**12-9**] PM) . -ALT: [**11-29**]: 53 -> [**12-7**]: 24 -> [**12-9**] (PM): 124 -AST: [**11-29**]: 39 -> [**12-7**]: 23 -> [**12-9**] (PM): 320 -T.bili: [**11-29**]: 0.3 -> [**12-7**]: 1.0 -> [**12-9**] (PM) 0.8 -LDH: [**12-4**]: 335 -> [**12-7**]: 364 -> [**12-9**] (PM): 1106 -Albumin: 2.0 -VBG ([**12-9**] AM): 7.40/18/214/12 -ABG ([**12-9**] PM): 7.14/11/192/4 Brief Hospital Course: Ms. [**Known lastname **] was a 63-year-old woman who was status post gastric bypass with a recent revision roughly 7 weeks prior to admission and a history of hypothyroidism who presented with a generalized malaise and [**Known lastname **] for 4 days prior to admission. Her hospital course as summarized by problem was as follows: . 1. Fevers and generalized malaise. Although some evidence was found of infection, no definite cause of her acute illness was ever clinically diagnosed. Initially, because she was hypotensive and tachycardic, she was admitted to the MICU. Notably, on presentation she was not tachypneic, as she would be for much of the remainder of her hospitalization. In the MICU, she was treated with fluids and covered empirically with Vancomycin and Unasyn. Within 24 hours, her blood pressure had sufficiently stabilized for her to be transferred to the floor. . On the floor, her course was generally characterized by stable blood pressures but mild tachypnea, with respiratory rates generally between 22 and 26 per minute. For much of the first several days of her admission she was febrile, but by the second half of her hospitalization she had defervesced, with only one elevated temperature in the final six days of her stay. Notably, she was transferred back to the MICU roughly halfway through her hospitalization for further monitoring when she became increasingly tachypneic. She did well overnight and was transferred back to the floor within 24 hours. . Attempts to find a cause of her illness were complicated by her lack of symptoms. Until the final day, her only complaints were generalized weakness and fatigue. She consistently denied dyspnea (although she acknowledged tachypnea), cough, and dysuria. She did report some diarrhea, but noted that it was small in volume and consistent with her previous bowel movements following her multiple gastric surgeries. . Diagnosis, then, relied on tools other than symptomatology. Most of the results, however, were also inconclusive. She had two blood culture bottles drawn during her initial visit to the ED that subsequently grew coagulase-negative staph. This was considered to be a contaminant by the Infectious Diseases consultants as multiple subsequent blood cultures showed no growth. However, although she did not have a line at the time of presentation, she did have a history of PICC line infections with the same organism that showed similar patterns of antibiotic resistance. It was suggested, therefore, that this may have been the exacerbation of a previous line infection that had theretofore been subclinical. She was consequently treated with Vancomycin for several days (roughly six), until after more blood cultures had returned negative. . One urine culture (of six) was also positive for bacterial growth, producing enterobacter and morganella. This, too, was not believed to be the source of her fevers as she had no symptoms of a UTI and her urinalysis from that day was clean, having no WBC or bacteria. Additionally, samples of her stool produced no growth in culture and were negative for C. difficile toxin. . A transthoracic echocardiogram (TTE) showed no evidence of endocarditis. Given the relatively low sensitivity of this test for endocarditis, a transesophageal echo was suggested, but the patient was highly resistant to this, even after the bariatric surgeon who was consulted assured her that this would not be contraindicated in a patient with her previous surgeries. The TEE was therefore not pursued. . A CT angiogram to look for PE was also considered. This was actually ordered on the floor but was not performed when the patient was transferred back to the MICU. On return to the floor, it was noted that she was not hypoxic and it was determined that she was very unlikely therefore to have a PE. Indeed, she continued to have O2 saturations of 98% to 100% on room air even through her final hospital day. . Finally, a CT of the torso was performed that showed no significant intra-abdominal pathology but did reveal bilateral basilar infiltrates suggestive of an aspiration pneumonia. This was presumed to be the ultimate cause of her malaise, fevers, and tachypnea. Unfortunately, as she had no cough at any time, she could not produce sputum for culture or antibiotic-sensitivity testing. . She was treated with Vancomycin and Unasyn initially; Unasyn was later removed and Zosyn added to cover both aspiration and hospital-acquired (e.g. pseudomonal) pneumonia. Vancomycin was discontinued after roughly six days (two days after the ID consultants recommended stopping it), when enough blood cultures had been negative to convince us that the initial coag-negative staph was a contaminant. Zosyn was stopped after nine days, when she had shown clinical improvement (afebrile for 72 hours, WBC count falling from peak of 36 to 26, respiratory rate decreased from 26 to 22) and when the Hematology consultants suggested that it may be responsible for her worsening thrombocytopenia (see below). Two days prior to stopping Zosyn, she had been started on Flagyl for presumed C. diff, despite the negative C. diff Toxin A test; she received 3 days of this antibiotic. These therapies had produced an apparent improvement - though not a resolution - in her clinical symptoms and lab values until the final day of her hospitalization (see Dispo below). . 2. Thrombocytopenia. She was thrombocytopenic on admission and showed a steady decline in her platelet level. This could have been due to her acute infection, but other testing was done. Heparin-dependent antibodies, 95% sensitive for Heparin-Induced Thrombocytopenia (HIT), were negative. Fibrinogen and coagulation times were normal, making DIC less likely. There was no evidence of hemolysis or neurologic dysfunction, making TTP less likely. Hematology was consulted and suggested that it may be an effect of Zosyn. As she had already shown signs of clinical improvement and had nearly completed the planned 10-day course, this drug was stopped after 9 days of therapy. Additionally, her PPI was switched to an H2 blocker after discussing this first with the bariatric surgery consultant. All Heparin products were also stopped. DVT prophylaxis was effected with pneumatic boots. Notably, the rapid decline in her platelet count in the final few hours of her hospitalization marked a much faster fall than had previously been exhibited and may well have been the result of DIC at that point. . 3. Low bicarbonate. She consistently had a low bicarbonate, but also no elevation in her anion gap and only a slight elevation of lactate. Although an ABG was desired early and often to further characterize her acid-base state, she repeatedly and adamantly refused the ABG. Only on the last day, when she was becoming increasingly tachypneic, did she allow the ABG, and even then only if it was performed by the ID fellow who had been following her case, further delaying diagnosis at a critical time. Prior to that, we had presumed the low bicarbonate reflected diarrheal losses or an iatrogenic hyperchloremic acidosis. She was aggressively hydrated with lactated Ringer's solution in place of normal saline. . 4. Hypervolemia. In the last couple of days of her hospitalization, she was deemed to be fluid overloaded. Her chest x-rays had suggested pulmonary edema, and she had increasing pedal edema. Until that point, she had been aggressively hydrated to compensate for presumed infection and diarrheal losses. In the last day, however, fluids were held to allow some the overload to clear. . 5. Hypoalbuminemia. She was noted to have a poor nutritional status after gastric bypass with multiple revisions. A nutritionist was consulted who provided appropriate dietary supplementation. She was given a diet with 60-70 grams of protein per day. . 6. Acute Renal Failure. Her creatinine rose to a peak of 1.5 after receiving IV CT contrast. This improved with aggressive hydration. . 7. Hypokalemia. This was thought likely due to diarrhea combined with acute stress (catecholamine response); she was repleted to maintain K > 3.6. . 8. Hypothyroidism. Her TSH was normal. She was continued on her home dose of Levothyroxine. . 9. s/p Gastric bypass. A bariatric surgeon was consulted. She had no apparent complications from her recent revision of her gastric bypass. Her abdominal exam was followed and her nutrition was supplemented with the recommendations of a nutritionist. . 10. Anemia. Her hematocrit was stable, slightly below her baseline. Her iron studies suggested anemia of chronic disease. She was not B12 deficient and there was no evidence of hemolysis. She was transfused with one unit of packed RBC with the thought that this might improve her symptoms of tachycardia and fatigue. . 11. CODE: FULL . 12. Dispo: On the final day of her hospitalization, she complained of subjective dyspnea for the first time. Before further diagnostic or therapeutic interventions could be enacted, she became markedly tachypneic, and "triggered" for a respiratory rate of 36. At this time, she also had an axillary temperature of 99.8 but notably was satting 98% on room air. She again refused ABG, relenting later only when promised that it would be done by the ID fellow who had been following her. This significantly delayed an important diagnostic tool. At that point, we had only a venous blood gas that suggested an alkalosis. The day prior, several physicians, including the ID consultants, had been of the opinion that her primary problem was no longer infectious. With a VBG that seemed to suggest a primary respiratory alkalosis, an anxiety-induced hyperventilation was considered as the underlying pathophysiology, and she was given a small dose of Ativan. Only later in the day, when she was in increasing respiratory distress, were we able to obtain an ABG that suggested she was then acidotic. With the elevated temperature and lactate seen at that time, sepsis became the likely cause. She had then become increasingly tachypneic (with a respiratory rate over 40), diaphoretic, and delirious. A code blue was called to intubate her on the floor; during the intubation she became bradycardic and received atropine and epinephrine. She was emergently transferred to the MICU, where shortly after arrival she went into PEA arrest. Full resuscitative efforts were carried out for 26 minutes without the restoration of a pulse. She was subsequently pronounced by the MICU team. An autopsy was performed at the family's request. . Medications on Admission: . Meds on Admission: Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY Protonix 40 mg Tablet, Delayed Release (E.C.) PO twice a day. MVI . MEDS ON TRANSFER: Metoclopramide 10 mg PO QIDACHS Meperidine 25-50 mg IV Q3-4H:PRN rigors Acetaminophen 325-650 mg PO Q4-6H:PRN [**Known lastname **], pain Pantoprazole 40 mg PO Q12H Ampicillin-Sulbactam 3 gm IV Q8H Heparin 5000 UNIT SC TID Insulin Sliding Scale Vancomycin HCl 1000 mg IV Q 12H Levothyroxine Sodium 75 mcg PO DAILY . Allergies: Iodine, Contrast, Cephalosporins, Levofloxacin, Vantin . Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Primary: 1. Sepsis 2. Pneumonia Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2196-12-14**]

[ "276.6", "584.9", "424.1", "E947.0", "518.81", "287.4", "276.8", "244.9", "286.6", "008.45", "038.9", "E930.0", "V45.86", "507.0", "424.0", "285.29", "276.1", "276.2", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "99.04" ]

icd9pcs

[ [ [] ] ]

19265, 19274

8116, 18640

379, 385

19350, 19359

2968, 8093

19411, 19446

2349, 2449

19236, 19242

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2465, 2949

303, 341

413, 1533

18687, 18809

1555, 2162

2178, 2333

18827, 19213

24,271

195,695

46279

Discharge summary

report

Admission Date: [**2120-6-12**] Discharge Date: [**2120-6-21**] Date of Birth: [**2065-10-15**] Sex: F Service: MEDICINE Allergies: Ibuprofen / Aspirin Attending:[**First Name3 (LF) 1990**] Chief Complaint: Disorientation, incontinence Major Surgical or Invasive Procedure: Lumbar Puncture History of Present Illness: 54 yo F with hx of SLE c/b nephritis, pericarditis and peritonitis, HTN, EtOH and substance abuse who was brought in for report of disorientation and incontinence. Per EMS, a man called from her house to report that she had incontinence. Patient does not recall the exact events leading up to her admission, she remembers losing urine continence and does not believe she had LOC. Says she was sleeping all day and then developed abdominal pain, but is not able to relay any other events from earlier today. She reports 3 week history of abdominal pain with 1 episode of diarrhea this AM, nausea and vomiting for 3 days, poor PO intake and a reported loss of 50lbs in 3 months. She reports a [**11-4**] headache since this AM with blurry vision for 2 days. Also has had non-productive cough for indeterminate amount of days, no sore throat. No chest pain or SOB. She has no BRBPR or melena, no hematemesis, no fevers/chills. No history of seizures, no recent EtOH or drug use per patient. . When EMS arrived at pt's house, pt was awake and oriented, but combative. FS was 102 in the field. She reported abdominal pain. On arrival to the ED, her T 97.2, BP was 220/135 and HR 130s, 99% RA, and she was triggered. Given total of 40mg IV hydralazine with improvement in BP to 180/105. She was complaining of severe abdominal pain and was tender diffusely on exam. She had 1 episode of coffee ground emesis, but refused NG lavage. Stool was guaiac negative. Per report, patient had possible recent crack use though pt denied any illicit drug use, only EtOH. . ECG in the ED showed ST with HR 125, LAD with STD in V4-6. CT head was limited by artifact but showed "tiny" SAH at the left parietal vertex with no other abnormalities. CT abdomen showed diffuse small bowel wall thickening, also involving sigmoid and rectum with moderate volume ascites. Surgery was consulted and felt that radiographic findings could be vasculitic in nature and related to pt's SLE, less likely ischemic given normal lactate and WBC. She had prior similar CT findings though now worse, no surgical intervention was felt to be needed. Recommended serial lactates, rheumatology c/s, empiric anitbiotic coverage with levo and flagyl, which was started, and to consider steroids. . On the floor, patient was somnolent but arousable. Reported [**11-4**] headache with blurry vision, mild chest pressure which when asked to localize, pointed to RUQ. Past Medical History: Lupus, c/b nephritis, pericarditis, and peritonitis, currently refusing treatment (previously on steroids and Plaquenil) Hypertension Alcoholism Polysubstance abuse (cocaine, amphetamines, opiates, benzodiazepines and tobacco), on narcotics contract Neuropathy due to alcoholism and poor nutrition, seen by Dr. [**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **] in Neurology Remote right basal ganglia infarction on head CT Migraine Headaches Hypothyroidism Depression/Anxiety Remote history of a gunshot wound to the abdomen with subsequent PTSD Anemia GIB secondary to PUD s/p cholecystectomy s/p hernia repair s/p total abdominal hysterectomy, bilateral salpingo-oophorectomy History of pelvic inflammatory disease with prior disseminated infection Social History: Social History: Lives alone with 1 dog - on disability. Smokes 1 PPD for 30~40 years but would like to quit. Also has been sober for close to 1 year and denies any current illicit drug use. Family History: Father died of renal failure 1 year ago at age 75 no FH of aneurysms. Reports mother and 2 sisters with lupus. [**Name (NI) **] sister died from "steroids and lupus" and older sister wheelchair bound from lupus. Physical Exam: Vitals: 98, 120, 168/101, 100% 2L General: AOx2, cachectic, somnolent but arousable, in mild distress HEENT: EOMI, PERRLA, mild papilledema, dry oral mucosa and tongue, hyperpigmented buccal/oropharyngeal lesions, hypopigmentation in lips Neck: supple, JVP not elevated, no cervical LAD Lungs: decreased breath sounds in RLL, no rales or wheezing CV: Tachycardic, regular rhythm, nl S1/S2, no m/r/g Abdomen: distended, soft, tender to deep palpation diffusely, mild voluntary guarding in epigastric and RUQ region with no rebound, BS sluggish GU: foley Ext: warm, 2+ distal pulses, diffuse muscle wasting of extremities Pertinent Results: [**2120-6-12**] 05:57PM PT-12.1 PTT-18.4* INR(PT)-1.0 [**2120-6-12**] 05:57PM PLT COUNT-523*# [**2120-6-12**] 05:57PM NEUTS-81.8* LYMPHS-14.7* MONOS-2.9 EOS-0.3 BASOS-0.3 [**2120-6-12**] 05:57PM WBC-4.9 RBC-5.46* HGB-16.1* HCT-49.1* MCV-90 MCH-29.5 MCHC-32.8 RDW-14.6 [**2120-6-12**] 05:57PM GLUCOSE-128* LACTATE-1.5 NA+-147 K+-4.6 CL--101 TCO2-30 [**2120-6-12**] 05:57PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2120-6-12**] 05:57PM HCG-<5 [**2120-6-12**] 05:57PM cTropnT-<0.01 [**2120-6-12**] 05:57PM LIPASE-12 [**2120-6-12**] 05:57PM ALT(SGPT)-15 AST(SGOT)-37 ALK PHOS-75 [**2120-6-12**] 05:57PM estGFR-Using this [**2120-6-12**] 05:57PM GLUCOSE-134* UREA N-35* CREAT-0.9 SODIUM-143 POTASSIUM-5.2* CHLORIDE-101 TOTAL CO2-29 ANION GAP-18 [**2120-6-12**] 08:25PM URINE VoidSpec-CONTAMINAT [**2120-6-12**] 08:25PM URINE HOURS-RANDOM [**2120-6-12**] 08:25PM URINE HOURS-RANDOM [**2120-6-12**] 08:44PM LACTATE-1.1 [**2120-6-12**] 09:35PM URINE MUCOUS-RARE [**2120-6-12**] 09:35PM URINE HYALINE-34* [**2120-6-12**] 09:35PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 [**2120-6-12**] 09:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2120-6-12**] 09:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.045* [**2120-6-12**] 09:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2120-6-12**] 09:35PM URINE HOURS-RANDOM CREAT-123 SODIUM-10 POTASSIUM-51 CHLORIDE-11 TOT PROT-272 PROT/CREA-2.2* Brief Hospital Course: MICU COURSE # Altered mental status - unclear what patient's baseline is though at present she appears somnolent and is AOx2. Most likely etiology is hypertensive encephalopathy, though seizure/post-ictal state also likely given SAH. Infectious etiology, PRES, CVA and intoxication also on differential. CXR report with slightly worse RLL opacity and CT abdomen with possible infectious cause of bowel wall thickening. Patient denies fevers and has no leukocytosis so infectious cause seems less likely. No evidence of meningitis. The patient had improvement of her altered mental status on her own. Infectious workup was pursued. - optimize BP control with goal BP<150/100 - infectious w/u with CXR, U/A, UCx, stool studies, sputum cx - q4h neuro checks - 20-minute EEG - consider MRI/MRA (clarify whether intra-abdominal bullets are contraindication to this) to evaluate for PRES, CVA, cerebritis . # SAH - small L parietal SAH on admission CT, likely in setting of HTN emergency though could be inciting event as well. Etiologies include aneurysmal, drug related (though no recent cocaine use) or vasculitis/cerebritis due to SLE. Neurosurgery evaluated in ED and recommended no intervention. Neuro exam is non-focal. - repeat CT head in [**1-18**] hrs - control BP as above - repeat coags - appreciate neurosurgery recs . # Abdominal pain - CT on admission shows small bowel thickening with involvement of sigmoid and rectum, worse from prior. Patient has a longstanding history of abdominal pain and has history of duodenitis and PUD in [**2114**] in setting of NSAID use, though largely normal EGD/[**Last Name (un) **] in 2/[**2120**]. She has been referred to GI as an outpatient for evaluation of her bowel thickening, but has not followed up recently. She has hx of intra-adbominal GSW s/p surgeries and is s/p TAH/BSO, though these are more chronic changes and unlikely to cause acute worsening. SLE and other autoimmune disorders could cause bowel thickening and ascites. Infectious etiology seems much less likely given chronicity. Other causes include inflammation, cancer, and malabsorption. Weight loss is definitely concerning and patient has had a nearly year long history of this (baseline wt 155lb in [**1-/2119**], now 120lbs). As above, could be in setting of vasculitis and malignancy. - stool C diff - serial abdominal exams and serial lactate - hold off on levo/flagyl for empiric coverage for now given afebrile and no leukocytosis with normal lactate - guaiac negative - continue to guaiac all stools - rheum and GI consult for work-up of possible vasculitic etiology given hx of SLE - simethicone and morphine for pain control - consider repeat HIV test and hepatitis panel - IVF maintenance - clear liquid diet, ADAT - consider nutrition c/s - review distribution of thickening with radiology for ?vascular distribution . # SLE - c/b nephritis, pericarditis and peritonitis. She has denied treatment with steroids in the past and has not been following up with rheumatology. Cr at baseline with some protein in urine which seems to be increased over past yr. No e/o pericarditis at this time. - rheum c/s as above = = = = = = = = = = = = = = = = = = = = ================================================================ MEDICINE WARDS COURSE 54-year-old woman with history of systemic lupus, not treated at time of presentation, came from home with abdominal pain and distention, confusion, and hypertensive emergency, s/p brief micu course for labetalol infusion, now called out to the floor in stable condition. . # Abdominal pain and distention: Surgery, GI, and rheumatology services all following for likely lupus-related vasculitis. Other considerations include infectious colitis or inflammatory bowel disease. IR performed an u/s guided paracentesis which was positive for SBP. She was treated with ceftriaxone and albumin therapy (1.5g/kg on day1, then 1g/kg on day3). She continued on flagyl therapy. She continued on IVF until she tolerated PO intake on HD2. She had repeat paracentesis performed which showed resolution of her SBP and the nexst day she was taken for sigmoidoscopy w plans for biopsy to eval for lupus enteritis. Pathology was pending at time of discharge and planned to be followed up by Dr. [**Last Name (STitle) **] in Rheumatology. Her abd distension significantly improved after administration of enema for her sigmoidoscopy. She was continued on solumedrol 60mg IV since admission per rheum recs for her presumed SLE enteritis and transitioned to prednisone 60mg. She continued to improve clinically and had improved tenderness on exam throughout her course. . # RLL consolidation: Concern for aspiration pna given found down status and confirmation on chest xray, ct chest. Pt will be covered w current abx regimen of cipro/flagyl and then ceftriaxone, flagyl for 7 day course. No leukocytosis, fever, or sputum production during her stay. Her lung exam was clear to auscultation. . # Subarachnoid hemorrhage: Stable on CT from earlier in admission. Neurosurgery was consulted on admission and cleared patient given stabilit of bleed on serial imaging. Patient without headache, and blood pressure is much better controlled now on oral labetalol. Avoided hydralazine given concern for SLE/drug induced vasculitis associated w this medication. She was uptitrated on her lisinopril and down titrated on labetalol w good control of her BPs to 130-140s systolic. When her pain was controlled her BP was much more manageable. She was uptitrated on lisinopril w good control of her bp and dc'd off labetalol per nephrology recs. . # Altered mental status: Improved with blood pressure control. Subarachnoid bleed stable, as above. Mother confirmed that pt had been confused for 1 week prior to presentation and baseline MS was fully functional. Low concern for lupus cerebritis given rapid resolution of confusion and AMS w 1 day of steroids. It was felt that pt likely altered from underlying infectious illnesses and dehydration. She was monitored with serial neuro checks by nursing and never found to have neurological exam findings. Baseline headaches treated w home acetaminophen-caff-butalbital. . # SLE: Pt was treated for presumed SLE enteritis as above with 60mg prednisone, and started on plaquenil per rheum recs. She was also started on atovaquone for pcp [**Name Initial (PRE) 1102**]. Nephrology was consulted and recommended renal biopsy which was performed and final pathology results will be followed up at Rheumatology appointment. She tolerated her medications well and expressed commitment to rheumatology follow up after hospitalization. Post-discharge appt for ophthalmology, nephrology, rheumatology and PCP provided at time of discharge. . # Rectal prolapse: Per pt, this has been an intermittent problem since colonoscopy in [**Month (only) 956**]. She endorses severe pain [**2-28**] prolapse and fecal incontinence. She refused topical anti-inflammatorys. Her pain was relieved with MS contin with morphine IR for breakthrough. She was provided with a 1 week course of pain medications at time of discharge w plans for surgical follow up in colorectal clinic for evaluation. . # Other chronic medical issues: - nicotine patch for cigarette smoking history - levothyroxine for hypothyroid history - paroxetine for depression and anxiety - omeprazole per home medication regimen - gabapentin and tramadol for chronic neuropathic pain (gabapentin was redosed per renal function). . # FEN: NPO for now, except ice chips and meds; replete lytes prn. # Access: Peripherals # Prophylaxis: DVT: HSQ, Pain: treatment as above # Communication: Mother/[**First Name4 (NamePattern1) 20855**] [**Known lastname 30207**]: [**Telephone/Fax (1) 98397**] # Code status: Full (discussed by MICU team with patient) # Disposition: Medical floor for now. Medications on Admission: -Fioricet 1 tab [**Hospital1 **] prn headache -Gabapentin 900mg TID -Levothyroxine 25mcg daily -Lisinopril 5mg daily -Nadolol 10mg daily -Omeprazole 20mg daily -Paroxetine 60mg daily -Tramadol 50mg TID prn pain -Trazodone 50mg qhs prn insomnia -Tylenol 500mg TID prn pain Discharge Medications: 1. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-28**] Tablets PO every twelve (12) hours as needed for headache. 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*30 Capsule(s)* Refills:*0* 3. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. Disp:*1 bottle* Refills:*0* 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:*0* 9. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY (Daily). Disp:*qs ml* Refills:*2* 10. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day: do not take w levothyroxine to avoid drug interaction. 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 14. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Tablet Extended Release(s)* Refills:*0* 15. morphine 15 mg Tablet Sig: Two (2) Tablet PO every twelve (12) hours as needed for pain for 7 days: for breakthrough pain between doses of long-acting medicine. Disp:*28 Tablet(s)* Refills:*0* 16. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3 times a day). Disp:*1 tube* Refills:*2* 17. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: SLE enteritis, nephritis Pneumonia Spontaneous bacterial peritonitis Subarachnoid hemorrhage Hypertensive emergency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for confusion, fever, high blood pressure and abdominal pain. These symptoms are due to a lupus flare. You were initially in the ICU for control of your blood pressure but came to the general medicine floors for additional care. You were found to have a small bleed in your brain that is stable and does not need additional follow up. For your lupus, you were followed by rheumatology who recommended initiation of prednisone, plaquenil. You had a colon biopsy which will be followed up by Dr. [**Last Name (STitle) **]. You were started on atovaquone for PCP (lung bacteria) prophylaxis. We placed a ppd test for tuberculosis and it was NEGATIVE. For your lupus and protein in the urine, nephrology (kidney doctors) followed your case in hospital. You had a kidney biopsy that will be followed up by Dr. [**Last Name (STitle) **] as well. For your abdominal pain, the fluid in your belly was tested and found to have an infection. You were treated with antibiotics. For your rectal prolapse - this problem will need to be addressed as an outpatient by Colorectal Surgery. We have made you an appointment to be evaluated for surgical treatment ASAP. For your pneumonia, you were treated with antibiotics. For your weight loss and malnutrition, you were given TPN (IV nutrition) to facilitate good nutrition while you were healing from your infections and illness. . Please follow up with your doctors as stated below. . The following changes were made to your medications: STARTED Prednisone STARTED Atovaquone STARTED Plaquenil STARTED MS contin (long acting), and morphine IR (fast acting) pain medications INCREASED Lisinopril 30mg daily DECREASED Gabapentin dose to a safe dose for your renal function. Please continue other home medications. Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] When: THURSDAY [**2120-6-27**] at 8:30 AM With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South Ste. Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Who: Rheumatology, Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] When: Tuesday [**2120-7-2**] AT 9:00 AM Where: [**Last Name (NamePattern1) **], [**Location (un) 861**], [**Hospital 2225**] Clinic Department: SURGICAL SPECIALTIES When: TUESDAY [**2120-7-2**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: FRIDAY [**2120-7-5**] at 2:30 PM With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC-Nephrology When: THURSDAY [**2120-7-11**] at 2:00 PM With: DR. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "55.23", "38.93", "99.15", "54.91", "48.24", "03.31" ]

icd9pcs

[ [ [] ] ]

16424, 16430

6261, 11859

311, 328

16590, 16590

4667, 6238

18546, 20369

3798, 4011

14406, 16401

16451, 16569

14109, 14383

16741, 18523

4026, 4648

242, 273

356, 2776

16605, 16717

2798, 3571

3603, 3782

54,162

117,032

3232

Discharge summary

report

Admission Date: [**2185-5-25**] Discharge Date: [**2185-5-31**] Date of Birth: [**2128-11-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Recurrent angina Major Surgical or Invasive Procedure: left heart catheterization, coronary angiography [**2185-5-25**] coronary artery bypass grafts x 1 (SVG-dRCA) [**2185-5-27**] History of Present Illness: Mr. [**Known lastname 1968**] is a 56 year old male with known coronary disease, suffering a non ST myocardial infarction in [**2182**]. Angioplasty with a bare metal stent was accomplished then. He has anomolous origin of the right coronary from the left cusp and recently developed recurrent pain. A stress test was positive for pain without perfusion defects. He was admitted for catheterization which revealed in stent stenosis which was not ammenable to percutaneous intervention. Past Medical History: Coronary artery disease/Myocardial Infarction s/p RCA stent Degenerative joint disease Noninsulin dependent diabetes mellitus Anxiety disorder Hyperlipidemia Hypertension s/p Bilateral total knee replacements s/p Appendectomy in his teens Social History: Tobacco history: None ETOH: None Illicit drugs: None Lives by himself, unemployed secondary to disability Family History: There is no family history of premature coronary artery disease. Physical Exam: Admission: VS: T 98.3 105/60 85 19 97% RA FS 102 . GENERAL: Well appearing man in no distress. 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 not elevated CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2185-5-25**] Cath: 1. Selective coronary angiography of this right-dominant ystem revealed single vessel coronary artery disease. The LMCA had no ignificant stenoses. The LAD had a 30% ostial stenosis. The LCX had a 30%ostial stenosis. The RCA arose from the left coronary cusp and had 60-70%instent restenosis; the vessel was best cannulated with an AL3 catheter. 2. Limited resting hemodynamics demonstrated elevated left ventricular filling pressures with an LVEDP of 28 mmHg. No gradient was seen across the aortic valve. [**2185-5-27**] Echo: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal for the patient's body size. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Transmitral Doppler velocity is consistent with impaired ventricular relaxation. The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The prosthetic mitral valve leaflets are thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Pulmonary Artery Catheter is seen in PA. POST CPB: Good Biventricular Function. No changes in valve function. Aortic contours intact. Remaining exam unchanged. All findings discussed with surgeons at the time of the exam. [**2185-5-24**] 11:25PM BLOOD WBC-6.2 RBC-3.92* Hgb-11.4* Hct-35.0* MCV-89 MCH-29.2 MCHC-32.7 RDW-13.8 Plt Ct-306 [**2185-5-31**] 05:15AM BLOOD WBC-5.4 RBC-3.23* Hgb-9.6* Hct-29.2* MCV-90 MCH-29.8 MCHC-33.0 RDW-13.7 Plt Ct-288 [**2185-5-25**] 05:45AM BLOOD PT-12.3 PTT-29.4 INR(PT)-1.0 [**2185-5-27**] 11:40AM BLOOD PT-13.9* PTT-32.5 INR(PT)-1.2* [**2185-5-24**] 11:25PM BLOOD Glucose-96 UreaN-24* Creat-1.0 Na-140 K-4.7 Cl-105 HCO3-26 AnGap-14 [**2185-5-31**] 05:15AM BLOOD Glucose-121* UreaN-16 Creat-0.7 Na-137 K-4.5 Cl-103 HCO3-26 AnGap-13 [**2185-5-26**] 04:45AM BLOOD ALT-17 AST-18 LD(LDH)-171 AlkPhos-75 TotBili-0.3 [**2185-5-27**] 05:15AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0 [**2185-5-25**] 05:45AM BLOOD %HbA1c-6.5* Brief Hospital Course: Following cardiac catheterization he was admitted receiving medical management and remained chest pain free. Catheterization revealed in-stent disease and intervention in the lab was not feasible due to anatomy. He was referred for surgical intervention. He underwent usual pre-operative work-up and on [**5-27**] he was taken to the operating room where a single vein graft was placed to the right coronary artery. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. His chest tubes and epicardial pacing wires were removed according to protocols. He was transferred to the floor on post-op day one. Beta blockers and diuretics were initiated and he was titrated towards pre-op weight. Physical therapy worked with the patient for mobility and strengthening. On post-op day two he had several bouts of atrial fibrillation which was converted back to sinus rhythm with Amiodarone and Lopressor. The rest of his post-op course was uneventful and he was discharged to rehab for additional PT with the appropriate medications and follow-up appointments. Medications on Admission: Byetta 5mcg [**Hospital1 **], Actos 45mg, Morphine SR 100 [**Hospital1 **], IR 15mg PRN, Aspirin 81mg qd, Lipitor 80mg, Metoprolol 25mg [**Hospital1 **], Lisinopril 40mg, Colace, Ibuprofen 800mg PRN, Metformin 850 mg daily Discharge Medications: 1. Byetta 5 mcg/0.02 mL Pen Injector Sig: One (1) Subcutaneous twice a day. 2. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day. 3. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 8. Ibuprofen 800 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 5 days. Then, 200mg [**Hospital1 **] x 7 days. Then 200mg QD until stopped by Cardiologist. 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. 15. Metformin 850 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: TBA Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 1 Degenerative joint disease Noninsulin dependent diabetes mellitus Anxiety disorder Hyperlipidemia Hypertension s/p Bilateral total knee replacements s/p Appendectomy in his teens Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) [**Hospital Ward Name 121**] 6 wound clinic in 2 weeks Dr. [**First Name11 (Name Pattern1) 2270**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in [**12-10**] weeks ([**Telephone/Fax (1) 3581**]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks please call for appointments Completed by:[**2185-5-31**]

[ "413.9", "746.85", "272.4", "414.01", "427.31", "996.72", "250.00", "401.9", "V45.82", "E879.0", "412" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "88.56", "37.22", "38.93" ]

icd9pcs

[ [ [] ] ]

7701, 7731

4798, 6031

338, 465

8014, 8020

2352, 3869

8424, 8852

1381, 1448

6304, 7678

7752, 7993

6057, 6281

8044, 8401

1463, 2333

282, 300

493, 980

1002, 1242

1258, 1365

3879, 4775

47,409

190,464

28753

Discharge summary

report

Admission Date: [**2107-6-9**] Discharge Date: [**2107-6-14**] Date of Birth: [**2035-5-25**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: s/p coronary artery bypass grafts x4(left internal mammary artery grafted left anterior descending artery/Saphenous vein grafted to Posterior descending artery/Obtuse Marginal/Diagnal) on [**2107-6-10**] History of Present Illness: 72 year old male with a known history of hypertension, diabetes, and hyperlipidemia was admitted to [**Hospital6 5016**] following an elective cardiac catheterization on [**2107-6-8**]. He reports 3-4 weeks of substernal chest discomfort with associated shortness of breath and jaw pain. An outpatient Stress test revealed moderate inferior ischemia. Elective cardiac cath revealed 3 vessel disease. He was transferred to [**Hospital1 18**] for surgical evaluation of coronary revascularization. Past Medical History: PMH: hyperchol, DM2, HTN PSH: s/p card cath 4 years ago, finger surgery Social History: Lives with: wife Contact:wife Phone # Occupation:retired golf [**Last Name (un) **] instructor Cigarettes: Smoked no [] yes [x] last cigarette '[**00**] Hx: Other Tobacco use:2 PPD x ~15 y ETOH: < 1 drink/week [x] [**1-4**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: non contributary Physical Exam: Physical Exam on Admission Pulse: 71 Resp:20 O2 sat:96%RA B/P 152/88 Height: 68" Weight:200 LB Five Meter Walk Test #1_______ #2 _________ #3_________ General: Skin: Warm [x] Dry [x] intact [x] HEENT: NCAT [x] PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM []x Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [](L)LE superficial varicosities//(R)well healed scar s/p GSV harvest '[**00**], (+) varicosities distally Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit:none, pulses=Right2+ Left2+ Pertinent Results: [**2107-6-13**] 05:30AM BLOOD WBC-11.1* RBC-3.10* Hgb-9.3* Hct-27.8* MCV-90 MCH-30.1 MCHC-33.5 RDW-13.3 Plt Ct-149* [**2107-6-9**] 05:15PM BLOOD WBC-8.6 RBC-5.22 Hgb-15.7 Hct-46.2 MCV-88 MCH-30.0 MCHC-34.0 RDW-13.2 Plt Ct-196 [**2107-6-10**] 06:26PM BLOOD PT-13.4* PTT-28.5 INR(PT)-1.2* [**2107-6-9**] 05:15PM BLOOD PT-11.4 PTT-28.9 INR(PT)-1.1 [**2107-6-13**] 05:30AM BLOOD Glucose-146* UreaN-16 Creat-1.0 Na-135 K-4.1 Cl-101 HCO3-26 AnGap-12 [**2107-6-9**] 05:15PM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-140 K-4.1 Cl-101 HCO3-27 AnGap-16 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 69498**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 69499**] (Complete) Done [**2107-6-10**] at 3:33:15 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2035-5-25**] Age (years): 72 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: intraoperative TEE for CABG ICD-9 Codes: 786.51 Test Information Date/Time: [**2107-6-10**] at 15:33 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17792**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2012AW-:1 Machine: p6 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.1 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: 55% to 70% >= 55% Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 2.9 cm <= 3.4 cm Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm Findings LEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV systolic function. AORTA: Normal ascending aorta diameter. Mildly dilated descending aorta. Simple atheroma in descending aorta. No thoracic aortic dissection. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: Written informed consent was obtained from the patient. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Results were personally reviewed with the MD caring for the patient. Conclusions PRE-CPB: No thrombus is seen in the 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. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber appears mildly enlarged with normal free wall motion. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [**Last Name (STitle) **] was notified in person of the results at time of study. POST-CPB: The patient is on a nitroglycerin infusion. The left ventricular systolic function remains normal, estimated EF>55%. Right ventricular systolic function is normal. The mitral regurgitation remains trace. Other valvular function remains unchanged. There is no evidence of dissection. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2107-6-10**] 18:18 ?????? [**2097**] CareGroup IS. All rights reserved. Brief Hospital Course: [**2107-6-9**] Mr. [**Known lastname **] was transferred to [**Hospital1 18**] for coronary artery revascularization. He was taken to the operating room and underwent coronary artery bypass grafts x4(left internal mammary artery grafted left anterior descending artery/Saphenous vein grafted to Posterior descending artery/Obtuse Marginal/Diagnal) on [**2107-6-10**] with Dr.[**Last Name (STitle) **]. Please see operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated for invasive monitoring. He awoke neurologically intact and was extubated. He weaned off pressor support and Beta-blocker/ASA/Statin were initiated. He was diuresed. Chest tubes and pacing wires were discontinued per protocol. He remained in the CVICU requiring an Insulin drip. As his sugars became better controlled he was transferred to the step down unit on POD#2. Physical Therapy was consulted for evaluation of strength and mobility. He continued to progress and was cleared for discharge to home with VNA services on POD#4. All follow up appointments were advised. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Atenolol 50 mg PO DAILY 2. Chlorthalidone 25 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. HumaLOG Mix 75-25 *NF* (insulin lispro protam & lispro) 20 u Subcutaneous QAM 40u QPM Discharge Medications: 1. Aspirin EC 81 mg PO DAILY RX *Enteric Coated Aspirin 81 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 2. Cyanocobalamin 1000 mcg PO DAILY RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Tablet Refills:*2 4. Humalog 75/25 30 Units Breakfast Humalog 75/25 40 Units Dinner Insulin SC Sliding Scale using HUM Insulin RX *Humalog Mix 75-25 100 unit/mL (75-25) resume preop dosing 30 Units before BKFT; 40 Units before DINR; Disp #*1 Vial Refills:*0 5. Lorazepam 0.5 mg PO BID:PRN anxiety RX *Ativan 0.5 mg 1 tab by mouth HS prn Disp #*10 Tablet Refills:*0 6. Metoprolol Tartrate 75 mg PO BID Hold for HR < 55 or SBP < 90 and call medical provider. [**Last Name (NamePattern4) 9641**] *metoprolol tartrate 50 mg 1.5 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*2 7. Multivitamins W/minerals 1 TAB PO DAILY RX *Vitamins & Minerals 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 8. Niacin SR 500 mg PO DAILY RX *niacin 500 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 9. Oxycodone-Acetaminophen (5mg-325mg) [**11-29**] TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg [**11-29**] tablet(s) by mouth q4h prn Disp #*50 Tablet Refills:*0 10. Ranitidine 150 mg PO BID RX *ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 11. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 400 unit [**Unit Number **] tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 12. Atorvastatin 10 mg PO DAILY RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 13. Furosemide 20 mg PO BID RX *furosemide 20 mg 2 tablet(s) by mouth [**Hospital1 **] x 10 days then decrease to 1 tab po daily Disp #*60 Tablet Refills:*2 14. Potassium Chloride 20 mEq PO Q12H Hold for K+ > 4.5 RX *potassium chloride 20 mEq 1 tab by mouth daily Disp #*60 Tablet Refills:*2 Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass grafts x4(left internal mammary artery grafted left anterior descending artery/Saphenous vein grafted to Posterior descending artery/Obtuse Marginal/Diagnal) on [**2107-6-10**] -Secondary: CAD, Hypertension, hyperlipidemia, Diabetes,PAD Past Surgical History:IHR, [**2101-6-27**]: Right popliteal aneurysm. s/p Right lower extremity angiography with placement of thrombolysis catheter in right posterior tibialis and plantar arteries 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. (B)LE Edema [**11-29**]+ 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: Cardiologist: Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] N. [**0-0-**] in [**11-29**] 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** Provider VASCULAR [**Name9 (PRE) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2107-8-10**] 9:00 Provider VASCULAR [**Name9 (PRE) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2107-8-10**] 9:45 Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2107-8-10**] 10:15 Completed by:[**2107-6-14**]

[ "401.9", "272.4", "250.00", "V15.82", "443.9", "414.01", "411.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

10598, 10647

7123, 8245

325, 532

11177, 11422

2354, 7100

12346, 13202

1478, 1496

8572, 10575

10668, 10957

8271, 8549

11446, 12323

10979, 11156

1511, 2335

270, 287

560, 1058

1080, 1154

1170, 1462

79,923

199,616

53778

Discharge summary

report

Admission Date: [**2157-7-4**] Discharge Date: [**2157-7-14**] Date of Birth: [**2094-3-28**] Sex: F Service: MEDICINE Allergies: latex Attending:[**First Name3 (LF) 594**] Chief Complaint: Shortness of breath and wheezing Major Surgical or Invasive Procedure: -Replacement of Y stent into cervical trachea performed by Interventional Pulmonary -flexible laryngoscopy History of Present Illness: 63 year old woman with h/o stage I lung cancer, GERD, HTN, thromboembolic disease, ex-smoker, admitted for worsening dyspnea in background of traceobronchomalacia. The patient was discharged from [**Hospital1 18**] recently after placement of endobronchial Y stent on [**2157-6-13**]. She was discharged from [**Hospital1 18**] to rehab and eventually admitted to [**Hospital **] hospital on [**7-4**] with worsening dyspnea and possible mucus plugging of stent. The patient was subsequently sent to [**Hospital1 18**] for further management since this is where she had the stent placed. . Currently, the patient feels well, though she admits that she has not had a nebulizer in several hours and is starting to feel somewhat short of breath. She also notes an occasional cough. Otherwise, the patient feels well, with no CP, abdominal pain, change in bowel habits, fevers, chills or sweats. Past Medical History: GERD TBM HTN Pulmonary embolus [**2151**], no longer anti-coagulated (developed peri-malignancy) Tracheobronchomalacia s/p endobronchial Y stent [**2157-6-13**] stage I lung cancer LUL, s/p thoracotomy wedge resection [**2153**] s/p CCY s/p achilles tendon repair right bilat carpal and cubital tunnel repair chronic headaches s/p cervical fusion chronic low back pain anxiety depression Social History: Prior to recent admission [**5-/2157**], the patient lived at home. 10 yr pack y/o smoking, rare etoh Family History: CAD, COPD, Lung CA Physical Exam: Adm: VS - Afebrile, HR 100s, SBP 120s, 97% on 4L GENERAL - Well appearing woman in NAD HEENT - No stridor Heart - RRR, no excess sounds appreciated Chest - Diffuse end expiratory wheezing, worst over trachea. Able to complete sentences, moving air moderately well Abd - non-tendern Ext - no edema Neuro - AAO x3, otherwise non-focal Pertinent Results: Adm: [**2157-7-5**] 06:30AM BLOOD WBC-17.5*# RBC-4.19* Hgb-12.6 Hct-38.4 MCV-92 MCH-30.1 MCHC-32.8 RDW-14.6 Plt Ct-293 [**2157-7-5**] 06:30AM BLOOD PT-10.5 PTT-25.1 INR(PT)-1.0 [**2157-7-5**] 06:30AM BLOOD Glucose-217* UreaN-24* Creat-0.9 Na-140 K-4.2 Cl-101 HCO3-23 AnGap-20 [**2157-7-5**] 06:30AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2 . Discharge [**2157-7-13**] 05:01AM BLOOD WBC-11.3* RBC-4.80 Hgb-14.2 Hct-43.7 MCV-91 MCH-29.6 MCHC-32.5 RDW-14.3 Plt Ct-286 [**2157-7-13**] 05:01AM BLOOD Glucose-181* UreaN-20 Creat-1.0 Na-139 K-4.3 Cl-97 HCO3-31 AnGap-15 [**2157-7-13**] 05:01AM BLOOD Calcium-9.9 Phos-4.4 Mg-2.1 Micro: [**2157-7-5**] 5:00 pm BLOOD CULTURE: neg x2 [**2157-7-10**] 8:54 pm SPUTUM Source: Induced MORE THAN 12 HRS OLD. GRAM STAIN (Final [**2157-7-11**]): [**11-24**] PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE : MODERATE GROWTH Commensal Respiratory Flora. . CXR [**7-5**] There may be a small region of new atelectasis at the base of the left lung,where there has been pleural scarring. Lungs are essentially clear. Theheart is normal size. Mediastinum is unremarkable. Brief Hospital Course: # Dyspnea/Hypoxia/wheeze ?????? The patient is a 63 year old woman with h/o stage I lung cancer, GERD, HTN, thromboembolic disease, ex-smoker, admitted for worsening dyspnea in background of traceobronchomalacia. The patient was transferred to the MICU on [**7-6**] for acute respiratory distress requiring BiPap. The patient presented with paroxysms of dyspnea associated with audible stridorous respiration during which she was in acute distress, but maintained normal oxygen saturations. She reported subjective relief with use of bipap, which was hypothesized to provide some component of upper airway stenting. Evaluation by interventional pulmonology revealed concern for significant cervicomalacia. The patient underwent removal of Y-stent and placement of a new longer stent reaching up into cervical trachea. However, the patient remained symptomatic with paroxysms of acute wheezing/stridor despite stenting of cervical trachea, making her a poor candidate for surgical intervention as the cause of these paroxysms are less likely to be associated with tracheobronchomalacia in the absence of improvement with stent placement. In addition, she had an episode of significant respiratory distress requiring bedside bronchoscopy, revealing significant mucous plugging along the length of the stent and at carina. She was started on mucomyst therapy, continued albuterol, ipratropium, mucinex, hypertonic saline nebulizer treatments, and BiPAP, and was able subsequently to tolerate the stent with no subsequent episodes concerning for mucous plugging. ENT was consulted for evaluation of potential vocal cord dysfunction as etiology of symptoms, and found no evidence to support this diagnosis. They did, however, note a Left true / false vocal fold mass, likely granulation but given h/o smoking could not rule out neoplastic process. Thus, she should follow up with ENT for future biopsy. The patient will be discharged to pulmonary rehab for two week trial with the new Y stent. She will follow up with Interventional pulmonology within two weeks of discharge. . #Vocal cord dysfunction - The patient was evaluated by ENT for potential vocal cord dysfunction. Flexible laryngoscopy demonstrated a left true/false vocal fold mass. Given the patient's smoking history, this mass was thought to be attributed to be either granulation or a neoplastic process. The patient was recommended to follow-up with ENT following discharge for observation of this mass. # Leukocytosis: The patient's elevated WBCs was most likely [**3-3**] steroid use. Her white count at admission was 17.5 and downtrended to 11.3 at the time if discharge. The patient was otherwise stable with no signs of infection during this hospitalization. . # Hyperglycemia - The patient has diabetes, managed with glyburide at home, and was maintained on an insulin sliding scale during this hospitalization. . # GERD - The patient was continued on her home omeprazole, simethicone, and TUMS. Her regimen was enhanced with [**Hospital1 **] PPI and addition of H2 blocker given risk of increased reflux with tracheal stent. . # Hypertension - The patient's blood pressures were maintained with metoprolol. . # Hyperlipidemia - The patient was continued on her home simvastatin. . # Depression - The patient was treated with her home citalopram. # CODE STATUS: FULL code status maintained throughout hospital course # CONTACT: [**Name (NI) 4906**] (has parkinson's), [**Doctor First Name **] [**Telephone/Fax (1) 110372**] Daughter [**Name (NI) 402**] [**Telephone/Fax (1) 110373**] [**Name2 (NI) **]ng physician: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10302**], MD [**First Name (Titles) **] [**Last Name (Titles) 17436**] ph [**Telephone/Fax (1) 46449**]. (Other doctor Dr. [**Last Name (STitle) 110374**] [**Telephone/Fax (1) 110375**]). # DISPO: Pulmonary rehabilition center Medications on Admission: solumedrol 80mg IV q8 duonebs qid standing albuterol neb q4 prn sob glimepiride 2mg po daily prilosec 20mg daily metoprolol tartrate 50mg [**Hospital1 **] symbicort 80/4.5 2 puff [**Hospital1 **] calcium carbonate 500mg po bid mucinex 600mg [**Hospital1 **] zocor 40mg po qhs sucralfate 1g po qid clonazepam 1mg po tid tylenol 1gram tid lasix 80mg daily vita d3 2000units daily lispro insulin sliding scale OUTPATIENT MEDICATIONS: Per OMR albuterol sulfate 2.5 mg/3 mL (0.083 %) Solution for Nebulization 1 inh Q4 hrs as needed for SOB albuterol sulfate 90 mcg HFA Aerosol Inhaler 1 inh inh Q4 hrs as needed for SOB budesonide-formoterol [Symbicort] Citalopram 10 mg Tablet 1 Tablet(s) by mouth daily diphenhydramine HCl 50 mg Capsule 1 Capsule(s) by mouth daily as needed for allergies furosemide 80 mg Tablet 1 Tablet(s) by mouth daily glimepiride 2 mg Tablet 1 Tablet(s) by mouth daily hydrocodone-acetaminophen 5 mg-500 mg Tablet [**1-31**] Tablet(s) by mouth Q 6 hrs as needed for pain i ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL Solution for Nebulization 1 neb inhaled/nebulized x1 [**2157-6-2**] lorazepam 1 mg Tablet 1 Tablet(s) by mouth three times a day as needed for anxiety metoprolol tartrate 50 mg Tablet 1 Tablet(s) by mouth twice a day omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by mouth twice a day ranitidine HCl 300 mg Tablet 1 Tablet(s) by mouth once a day 30 minutes before dinner. simvastatin 40 mg Tablet 1 Tablet(s) by mouth hs vit D 50,000 units weekly Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN fever/pain 2. acetylcysteine *NF* 20% (200mg/mL) 4 cc nebulized tid Reason for Ordering: Per interventional pulm/MICU; the patient has essentially no mucociliary clearance due to a 13cm tracheal stent, failing other mucolytic therapy spoke with pharmacy @ [**Pager number 110376**] regarding this 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN wheezing, sob 5. Benzonatate 200 mg PO BID 6. Calcium Carbonate 500 mg PO BID 7. Chlorpheniramine-Hydrocodone 5 mL PO Q12H:PRN cough 8. Citalopram 20 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 11. Furosemide 80 mg PO DAILY hold for sbp <100 12. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 13. Ipratropium Bromide Neb 1 NEB IH Q6H 14. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety Hold for sedation, rr<10, change in mental status 15. Metoprolol Tartrate 50 mg PO BID hold for hr <60, sbp <100 16. Mucinex *NF* (guaiFENesin) 1,200 mg Oral [**Hospital1 **] Reason for Ordering: Wish to maintain preadmission medication while hospitalized, as there is no acceptable substitute drug product available on formulary. 17. Omeprazole 20 mg PO BID 18. Racepinephrine 0.5 mL NEB Q8H:PRN coughing/breathing attack 19. Ranitidine 300 mg PO HS 20. Senna 1 TAB PO BID:PRN constipation 21. Simvastatin 40 mg PO DAILY 22. Sodium Chloride 3% Inhalation Soln 15 mL NEB TID Supplied by Respiratory 23. Vitamin D [**2145**] UNIT PO DAILY 24. Hydrocodone-Acetaminophen (5mg-500mg [**1-31**] TAB PO Q6H:PRN pain Discharge Disposition: Extended Care Discharge Diagnosis: Tracheobronchomalacia, mucus plugging of tracheal Y-stent Discharge Condition: Stable, with improvement of dyspnea 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 13143**], Thank you very much for allowing us to participate in your care at [**Hospital1 69**]. You were diagnosed with exacerbation of your tracheobronchomalacia. You were admitted because of worsening shortness of breath. During your hospitalization, you were evaluated by ENT and Thoracic Surgery. Your old tracheal Y-stent was found to be plugged up with mucus which contributed to your shortness of breath. Your old stent was replaced with a new longer stent. To help your breathing, you were treated with BIPAP, albuterol, ipratropium, and saline nebulizers as well as medication to help you clear your mucus secretions. You also received acetylcysteine therapy to help with your shortness of breath. ENT also evaluated you for potential dysfunction of your vocal cords. During their evaluation, they found a mass on your left vocal fold which they will continue to follow-up on once you are discharged from the hospital. ***** Please follow-up with ENT following discharge to evaluate your left vocal fold mass. ***** Followup Instructions: It is recommended that you follow up with Dr. [**Last Name (STitle) **] in the Interventional Pulmonary department within 1 week. Please call to schedule an appointment. Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 18**] - DIVISION OF PULMONARY MEDICINE Address: [**Location (un) **], [**Hospital1 **] 116, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3020**] It is recommended that you follow up in the ENT/Otolaryngology department with Dr. [**Last Name (STitle) **] [**Name (STitle) **] within 2 weeks. Please call the office to schedule an appointment. Name: [**Name (STitle) **], [**Last Name (un) **] S. MD Location: [**Hospital1 18**] OTOLOARYNGOLOGY Address: [**Doctor First Name **], STE 6E, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 41**]

[ "724.2", "799.02", "272.4", "300.00", "162.8", "519.19", "288.60", "530.81", "250.00", "491.21", "311", "478.5", "401.9", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "96.05", "33.24", "33.23", "33.22" ]

icd9pcs

[ [ [] ] ]

10735, 10750

3653, 7535

297, 405

10851, 10887

2265, 3630

12158, 13009

1876, 1897

9094, 10712

10771, 10830

7561, 7969

11070, 12135

1912, 2246

7993, 9071

225, 259

433, 1329

10902, 11046

1351, 1740

1756, 1860

14,855

177,861

21419

Discharge summary

report

Admission Date: [**2182-3-22**] Discharge Date: [**2182-3-28**] Date of Birth: [**2119-11-6**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 330**] Chief Complaint: Transferred from [**Hospital6 8283**] for respiratory failure Major Surgical or Invasive Procedure: arterial line placement PICC line placement Intubation History of Present Illness: Pt is a 62 yo male with history of lung cancer (s/p RUL lobectomy), COPD O2 dependent (3 L), history of MRSA and psuedomonal PNA who is a transfer from [**Hospital3 **]. Per EMS notes, last night they were called to patient's house for difficulty breathing which had been ongoing for 45 minutes. He was found to be sitting up in bed in stridorous and diaphoretic. He was unable to speak; albuterol neb treatments were tried without much success. He was brought to [**Hospital6 **] where he was admitted to the ICU and started on BIPAP, IV solumedrol, and levaquin. He required increasing amounts of O2 on BIPAP and was tachypnic in the 30s. 7.30/45/63 on 60% BIPAP with O2 90%. Pt was intubated at 7:40 am on day of admission and transferred to [**Hospital1 **]. BP 219/90 per report, HR 90-136. Post-intubation he was give 8 mg IV dilaudid, 4 mg ativan, 150 mcg fentanyl, 2 mg versed, and nitropaste. Also received fentanyl in med flight though records unavailable now. Pt was hospitalized at [**Hospital6 **] [**Date range (1) 56565**] for shortness and breath and COPD exacerbation. He was given prednisone and levaquin. Most recent hospitalization at [**Hospital1 **] was in [**2181-12-20**] for when he had a pneumothorax from his severe emphysema. Prior to that, in [**2181-9-19**] patient was in the ICU at [**Hospital1 **] for MRSA and psedomonal pneumonia. The patient received linezolid for a 21 day course for MRSA PNA and cefepime for 21 day course for pseudomonas. Amikacin was added for synergy. This was all in the setting of a three week prior hospitalization for COPD/PNA with sputum growing MRSA and pseudomonas treated with bactrim and levaquin. Past Medical History: 1. Non-small cell lung cancer, s/p R upper lobectomy, partial R fifth rib resection c/b chronic pain. No chemo or radiation. 2. COPD w/ severely reduced DLCO, FEV1 42%, and FEV1/FVC ratio 59%; stage= moderate IIB 3. h/o MRSA and pseudomonas PNA 4 Ulcerative colitis - s/p multiple surgeries, most recently in late 80s. S/P total colectomy and ileostomy 5. Steroid induced hyperglycemia 6. PFO 7. h/o cardiomegaly 8. h/o depression 9. Spirometry [**7-/2181**] Actual Pred %Pred FVC 2.87 4.01 72 FEV1 1.21 2.86 42 MMF 0.70 2.87 24 FEV1/FVC 42 71 59 LUNG VOLUMES Actual Pred %Pred TLC 6.19 6.12 101 FRC 4.59 3.42 134 RV 4.09 2.12 193 VC 2.10 4.01 52 IC 1.60 2.70 59 ERV 0.50 1.31 38 RV/TLC 66 35 191 He Mix Time 0.00 DLCO Actual Pred %Pred DSB 6.62 25.62 26 VA(sb) 4.46 6.12 73 HB 12.70 DSB(HB) 7.02 25.62 27 DL/VA 1.58 4.19 38 Social History: Married, 2 daughters, lives on the [**Name (NI) **]. Not current smoker, quit in [**2177**] w/ dx of lung cancer, 40 pack-yr history. Occasional EtOH use. Worked as a paiting contractor, retired after lung cancer surgery. Family History: F died of lung cancer; M died of Alzheimer's. Has 3 sisters, all older than him, healthy Physical Exam: Initial physical examination: VS: T: 95.0, BP: 94/55, HR: 64, AC 500/12/100/5 breathing at 15. O2: 94% Gen: Intubated, sedated HEENT: pinpoint pupils reactive 2-->minimal. Sclera anicteric. ETT in place. Neck: No LAD. No JVP at 30 degrees. CV: RRR S1S2. No M/R/G Lungs: diffuse rales and rhonchi bilaterally anteriorly. Scattered wheezes anteriorly. Abdomen: +colostomy bag in place. Many surgical scars bilaterally in lower abdomen. Soft, nondistended. Ext: no edema. DP 2+. PT 2+ Neuro: Cannot follow commands nor arouse. Biceps, brachio reflexes [**12-21**]. Patellar reflexes [**12-21**]. babinski equivocal. Pertinent Results: Labs on admission: [**2182-3-22**] 11:52AM BLOOD WBC-6.2 RBC-3.62*# Hgb-10.3*# Hct-31.7*# MCV-88 MCH-28.4 MCHC-32.3 RDW-15.7* Plt Ct-244 [**2182-3-22**] 11:52AM BLOOD Neuts-73* Bands-14* Lymphs-2* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-0 [**2182-3-22**] 11:52AM BLOOD PT-12.8 PTT-28.7 INR(PT)-1.1 [**2182-3-22**] 11:52AM BLOOD Glucose-243* UreaN-33* Creat-1.3* Na-145 K-6.1* Cl-113* HCO3-21* AnGap-17 [**2182-3-22**] 11:52AM BLOOD ALT-10 AST-10 LD(LDH)-169 AlkPhos-66 Amylase-117* TotBili-0.3 [**2182-3-22**] 11:52AM BLOOD Albumin-3.0* Calcium-7.8* Phos-4.8* Mg-1.4* [**2182-3-22**] 12:16PM BLOOD Type-ART Rates-12/ Tidal V-500 PEEP-5 FiO2-100 pO2-86 pCO2-59* pH-7.17* calTCO2-23 Base XS--7 AADO2-590 REQ O2-94 -ASSIST/CON Intubat-INTUBATED Labs on discharge: [**2182-3-28**] 04:52AM BLOOD WBC-9.9 RBC-3.46* Hgb-9.7* Hct-29.5* MCV-85 MCH-28.0 MCHC-33.0 RDW-16.6* Plt Ct-250 [**2182-3-28**] 04:52AM BLOOD Neuts-65 Bands-3 Lymphs-21 Monos-5 Eos-2 Baso-0 Atyps-0 Metas-3* Myelos-1* [**2182-3-28**] 04:52AM BLOOD PT-11.0 PTT-29.7 INR(PT)-0.9 [**2182-3-28**] 04:52AM BLOOD Glucose-155* UreaN-23* Creat-0.7 Na-138 K-4.2 Cl-98 HCO3-32 AnGap-12 [**2182-3-27**] 04:48AM BLOOD ALT-9 AST-11 LD(LDH)-187 AlkPhos-76 TotBili-0.2 [**2182-3-28**] 04:52AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.2 Other labs: [**2182-3-27**] 04:48AM BLOOD calTIBC-256* VitB12-690 Folate-8.6 Ferritn-304 TRF-197* [**2182-3-22**] 11:52AM BLOOD TSH-0.98 ___________________________________________ Microbiology: Sputum [**2182-3-22**]- **FINAL REPORT [**2182-3-27**]** GRAM STAIN (Final [**2182-3-22**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. RESPIRATORY CULTURE (Final [**2182-3-27**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVE TO AMIKACIN (<=2MCG/ML). PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND COLONIAL MORPHOLOGY. SENSITIVE TO AMIKACIN (<=2). SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | PSEUDOMONAS AERUGINOSA | | | CEFEPIME-------------- 2 S 2 S CEFTAZIDIME----------- 4 S 4 S CIPROFLOXACIN--------- =>4 R =>4 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S =>16 R =>16 R IMIPENEM-------------- =>16 R =>16 R LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 4 S 4 S OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S 8 S PIPERACILLIN/TAZO----- 8 S <=4 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TOBRAMYCIN------------ =>16 R =>16 R VANCOMYCIN------------ <=1 S Blood culture [**2182-3-22**]- No growth Legionella urine ag [**2182-3-23**]- negative Sputum [**2182-3-27**] GRAM STAIN (Final [**2182-3-25**]): [**9-12**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2182-3-27**]): MODERATE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). RARE GROWTH. [**2182-3-26**]- urine culture- no growth [**2182-3-28**] blood culture x 2- No growth _______________________________ Radiology: Echo [**2182-3-28**] Aortic Valve - Peak Velocity: 1.3 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.9 m/sec Mitral Valve - E/A Ratio: 0.67 Mitral Valve - E Wave Deceleration Time: 151 msec TR Gradient (+ RA = PASP): *40 to 45 mm Hg (nl <= 25 mm Hg) LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: LV not well seen. Cannot assess LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal tricuspid valve supporting structures. Mild [1+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs of agitated normal saline, at rest, with cough and post-Valsalva maneuver. Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Suboptimal image quality - poor subcostal views. Conclusions: The left atrium is normal in size. The left ventricle is not well seen. Overall left ventricular systolic function cannot be reliably assessed. Right ventricular chamber size and free wall motion are normal. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Bubble study did not demonstrate any clear right-to-left shunting at the atrial level, but image quality is suboptimal. Compared with the findings of the prior study (images reviewed) of [**2181-9-11**], the findings are grossly similar but the technically suboptimal nature of both studies precludes definitive comparison. . Other radiology: [**2182-3-24**] CXR AP-Nasogastric tube and endotracheal tube have been removed. Cardiac silhouette appears larger than on the prior study and is accompanied by engorged pulmonary vessels and perihilar haziness, attributed to either CHF or volume overload. These findings are superimposed upon extensive emphysema, post-operative changes in the right upper lobe, and extensive areas of parenchymal scarring. Persistent left retrocardiac opacity, likely due to a combination of atelectasis and effusion, although underlying infection is not excluded in the appropriate clinical setting. [**2182-3-22**] CXR AP-FINDINGS: ET tube has been repositioned in the interval, and now terminates 5.7 cm above the [**Month/Day/Year **]. The NG tube still is in a suboptimal positioning with the side port well above the expected location of the GE junction. Overall, the appearance of the chest is unchanged from today's radiograph, including status post right upper lobectomy with associated right-sided volume loss, opacities projecting over the right medial and lower hemithorax. There is no evidence of pulmonary edema. Small left-sided pleural effusion and left lower lobe atelectasis is unchanged. IMPRESSION: 1. Interval repositioning of the ET tube, now terminating 5.7 cm above the [**Last Name (LF) **], [**First Name3 (LF) **] be advanced 1-2 cm for more optimal placement. 2. Malpositioned nasogastric tube. Brief Hospital Course: Impression/Plan: 62 yo male with COPD on home O2 (3L), history of lung cancer, history of multiple PNAs (including MRSA) who is a transfer from [**Hospital6 **] for respiratory failue and intubated. 1. Respiratory failure- Pt with severe emphysema/COPD. CXR with showed a possible RML opacity and left pleural effusion. We started solumedrol 80 mg IV q12 hours. We initially started patient on vancomycin for possible MRSA and cefepime to cover GNR and pseudomonal species. Sputum culture grew out MRSA (moderate growth) and pseudomonas (sparse growth) resistant to fluroquinolones (see attached micro data). Additionally, blood cultures from [**Hospital6 **] grew out 2/2 bottles of streptococci pneumoniae sensitive to levaquin and penicillin. Patient was successfully extubated on [**2182-3-23**]. Additionally, combivent nebs were given around the clock while patient was vented. This was changed to tiopropium, fluticasone-salmterol, and albuterol when he was extubated. After extubation, patient was able to get to 6 L of NC and satting in low-mid 90%. However, whenever he was turn or exert himself in any manner, he would desaturate to as low as 70%. He would correct and return to oxygenating in the 90s after a few minutes. To further investigate this and to look for a shunt, a TTE was done, as one from [**2179**] showed a patent foramen ovale and right to left shunt but only when he maneuvered himself. A repeat bubble study echo on the day of discharge was suboptimal in quality. It showed moderate pulmonary artery systolic hypertension but no right-to-left shunting at the atrial level. Steroids were changed to prednisone after extubation and have been slowly tapered to 60 mg and patient is on 40 mg prednisone (day 2) on discharge. The plan will be for a two week steroid taper to usual dose(patient is on 10 mg po prednisone at home). He received a 10 day course of vancomycin (last day was day of discharge) for MRSA in sputum (? source of pneumonia). Also was initially on levaquin which was changed to cefepime, plan for a 14 day course. 2. COPD- as above. He has severe emphysema by DLCO. Medications as above. 3. Bacteremia- as above. Blood cultures at the outside hospital grew [**12-21**] strep pneumonia. He was on levaquin which was changed to cepepime as above. 4. Hypertension- initially on arrival to [**Hospital1 18**] pt was hypotensive and required fluid boluses, though never required pressors. He had received dilaudid, fentanyl, ativan, and other medications including nitropaste post-intubation. His blood pressures subsequently came up. In fact, patient was hypertensive here in the 160s systolic post-intubation. Captopril was started and uptitrated to 25 mg tid; we then changed him to lisinopril 20 mg to be started the am after discharge. 5. Chronic pain- patient has a history of chronic pain, mainly in lower back (also right ribs. We increased his oxycontin to tid dosing (20 mg tid). He required IV dilaudid for breakthrough pain. 6. Steroid induced hyperglycemia- Required ~30 units of insulin per day on day of discharge. He was initially on a regular insulin sliding scale. On dischare, he was changed to lantus pm with a humalog sliding scale. Insulin will need to be adjusted at rehab. 7. F/E/N- Got tube feeds while intubated. Then was on a regular diet. Nutrition saw patient and recommended ensure sedondary to nurtitional needs. 8. PPx- heparin sc and PPI while intubated 9. Code- Full Medications on Admission: Medications at home (per [**Hospital6 56566**]): Neurontin 300 mg po tid Spiriva 1 puff qday Prednisone 10 mg po qday Paroxetine 20 mg po qday Oxycontin 20 mg po bid Medications on transfer to [**Hospital1 **] : Solumedrol 125 mg IV q 6 hours combivent nebs q4 hours Paroxetine 20 mg po qday Oxycontin 20 mg po bid Neurontin 300 mg po tid Levaquin 500 mg po IV qday Albuterol nebs q2 prn Ativan 1 mg IV qhs prn morphine 2 mg IV q2 prn Dilaudid 8 mg Iv x 1 am on admission versed 2 mg IV x 1 nitropaste 1 inch at 8:25 am morning of admission Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days: Last dose [**2182-3-30**]. 6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day: To start [**2182-3-31**]. Tablet(s) 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours): Hold for sedation or RR<8. 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Hydromorphone 2 mg/mL Syringe Sig: 0.5 - 2 mg Injection Q4H (every 4 hours) as needed: Hold for sedation or RR<8. 17. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 18. Cefepime 2 g Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours): Last day [**2182-4-4**]. 19. Insulin Lantus 10 units qhs with humalog insulin sliding scale 20. Oxygen On 6L NC on discharge Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary diagnosis: Respiratory failure s/p intubation Chronic obstructive pulmonary disease pneumonia Hypoxia hyperglycemia Hypertension bacteremia Secondary diagnosis: chronic pain Discharge Condition: Patient's vital signs are stable. His oxygenation is 90-95% on 6L NC and cool nebs. He desaturates when Discharge Instructions: Microbiology [**Telephone/Fax (1) 4645**] needs to be called to follow up on pending cultures in the hospital. Followup Instructions: You should call your pulmonologist, Dr. [**Last Name (STitle) 14069**] for follow up.

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icd9cm

[ [ [] ] ]

[ "38.91", "96.71", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

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30735

Discharge summary

report

Admission Date: [**2162-6-1**] Discharge Date: [**2162-6-2**] Date of Birth: [**2114-6-19**] Sex: M Service: MEDICINE Allergies: Wellbutrin Attending:[**First Name3 (LF) 2485**] Chief Complaint: medication overdose Major Surgical or Invasive Procedure: none History of Present Illness: 47 y/o M w/reported hx anxiety and depression, presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital last night at midnight stating he had taken 20 Toprol tablets (100 mg each). He also reported taking 20 percocet tablets and 20 ativan tablets (2 mg each), all in a suicide gesture. He reportedly did this around 9 pm. His wife later found him "staggering around [**Location (un) **] square" and brought him to the OSH at midnight. . While there, his HR was 77, BP 103/74. He received charcoal 50 grams x2, golytely, atropine 1 mg IV, glucagon 3.5 mg IV, and was placed on the HIE protocol (0.5units/hour, D10 10 cc/kg/hr). His acetaminophen level there was 57. Urine tox screen was positive for benzodiazepines and opiates. He was transferred to [**Hospital1 18**] for further monitoring. . In our ED, his HR ranged 49 to 51. Tox was consulted who recommended discontinuing the insulin and D10 drips and administering glucagon for symptomatic hypotension and bradycardia. . Currently, he reports problems with his "stomach, bowels, and urinary tract" which have been going on for 3 months. He states he has chronic n/v/d and has had an extensive w/u which has been negative. Otherwise, the only change from his baseline is that he feels very sleepy. Past Medical History: # depression: requiring ECT, multiple suicide attempts and hospitalizations in the past. Psychiatrist is Dr. [**First Name (STitle) **] in [**Location (un) 32944**]. # lung nodule # hyperlipidemia # hx IV heroin use # HTN # Seizures: once in setting of using wellbutrin, once at another time without known precipitant Social History: Lives at home with his wife from second marriage. He has 3 children ages 21,22, and 25. He dropped out of school in 10th grade. Does not work. Smokes 1 ppd x years. Denies EtOH as he has been sober for >5 years and is active in AA. He has had previous problems with alcohol, cocaine, and heroin. prior detention in jeuvenile [**Doctor Last Name **] for stealing cars. also at least 2 arrests as an adult. Family History: denies Physical Exam: T: 98.6 BP: 144/80 P: 59 R: 14 O2 sat: 97%RA Gen: pleasant male in NAD, sitting quietly in bed HEENT: NC, AT, perrl, anicteric, MM dry Neck: supple Lungs: bibasilar crackles, no wheezes or rhonchi CV: regular rhythm, bradycardic, no m/r/g Abd: soft, nt/nd, +bs Ext: no edema, 2+ dp bilaterally Neuro: pupils 1-2mm and reactive bilat. no tremor. tongue midline withou fasciculations, no nystagmus. moving all 4 extremities symmectrically. Pertinent Results: [**2162-6-1**] 04:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-23.7 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2162-6-1**] 04:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2162-6-1**] 04:25AM WBC-9.0 RBC-4.36* HGB-13.8* HCT-40.2 MCV-92 MCH-31.7 MCHC-34.4 RDW-15.3 [**2162-6-1**] 04:25AM PLT COUNT-352 [**2162-6-1**] 04:25AM NEUTS-56.8 LYMPHS-34.1 MONOS-5.1 EOS-3.1 BASOS-0.9 [**2162-6-1**] 04:25AM GLUCOSE-67* UREA N-7 CREAT-1.0 SODIUM-135 POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-11 [**2162-6-1**] 04:25AM ALT(SGPT)-8 AST(SGOT)-15 CK(CPK)-38 ALK PHOS-73 AMYLASE-36 TOT BILI-0.4 [**2162-6-1**]: EKG #1 sinus brady with QT/QTc 528/488.58 [**2162-6-1**]: EKG #2 sinus brady with QT/QTc 482/469.15 Brief Hospital Course: In brief the patient is a 47 y/o male w/hx depression, p/w beta-blocker, acetaminophen, and benzodiazepine overdose. . 1. Overdose: In terms of beta-blocker, the patient was not bradycardic upon arrival to [**Hospital1 18**]. He was monitored for signficant bradycardia without events nor need for repeat glucagon. In terms of acetaminophen, at 12 hours out from his ingestion his level is 23, which is in the no hepatic toxicity area of the nomogram. Also, his LFTs are completely normal. He was not thought to be a candidate for n-acetylcysteine to prevent hepatic toxicity. He already received charcoal x2. In terms of the benzo overdose, he was never significantly sedated. Repeat urine and blood tox screens were negative for benzodiazepines. He was followed by the toxicology consult service but needed no specific intervention. Regarding this suicide attempt he was evaluated by the psychiatry service who recommended an inpatient psychiatric admission. A Section 12 was completed. A TSH, RPR, folate and B12 were pending at the time of discharge. . 2. Dental Abscess: The patient will complete his prior prescribed therapy. . 3. Hypertension: The patient's blood pressure was normal throughout his hospital stay. He can follow-up with his primary care physician to have his anti-hypertensives resumed or changed. . 4. Depression/Anxiety: He was evaluated by the psychiatry service as above. He will be discharged for inpatient psychiatric eval and therapy. His Lexapro was discontinued pending further evaluation. . 5. FEN: Regular diet. . 6. Ppx: SQ heparin. . 7. Dispo: Patient was discharged in stable condition ready for inpatient psychiatric care. Medications on Admission: 1. Lexapro 20 mg daily 2. Lorazepam 2 mg PO Q6H 3. Metoprolol 100 mg daily 4. Nifedipine ER 90 mg daily 5. Oxcarbazepine 300 mg PO BID 6. Penicillin V Potassium 500 mg PO Q6H 7. Percocet 5/325mg 1 tab q4-6 hours prn Discharge Medications: 1. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Penicillin V Potassium 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for dental abscess for 6 days. 3. Ativan 2 mg Tablet Sig: One (1) Tablet PO four times a day. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 26615**] Hospital - [**Location (un) 5028**] Discharge Diagnosis: Primary: Suicide Attempt Major depression . Secondary: Hypertension polysubstance abuse hyperlipidemia Discharge Condition: good. stable vital signs. section 12 for transfer to inpatient psychiatry facility. Discharge Instructions: You have been evaluated and treated for a medication overdose and suicide attempt. The acute intoxication was managed with drug antidotes and supportive care. . Regarding your depression, it was felt that you would benefit from an inpatient psychiatric admission to further treat your depression particularly with regard to this suicide attempt. . Please the medication changes as described. . If you develop any new or concerning symptoms particularly dizziness or passing out, chest pain, shortness of breath, or fever to >101F; please contact the medical professionals at the psychiatric facility. Followup Instructions: You will be evaluated by the psychiatric medical providers at the inpatient psychiatry facility. . Prior to discharge from the facility, please have someone schedule an appointment with your primary medical doctor and your primary psychiatrist.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2100-12-27**] Discharge Date: [**2101-1-4**] Date of Birth: [**2042-11-19**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: 1. Left parietal metastatic lesion resection [**12-31**] History of Present Illness: [**Known firstname **] [**Known lastname 79388**] is a 58 year-old right handed man who preseneted to the ED from his PCP's office this afternoon after going in for an evaluation of right hand incoordination. He has some difficulty with his language at present when giving the history, but by his account, he was going in to his PCP due to some difficulty using his right hand over the past several days. While he was in the office he had a witnessed generalized tonic-clonic seizure that lasted around 45 seconds. There was no tongue biting or incontinence and a no report of focal symptoms prior to the seizure. Following the event which self-resolved he was confused and on presentation to the ED was noted to be aphasic (difficulty with using the correct words)so a code stroke was called for which NIHSS was 5. An initial CT showed a large 2.5 cm mass in the left parietal lobe with surrounding edema. He was given a bolus of Dilantin at 1000mg and then 10 mg of dexamethasone. He has a recent history of a melanoma on his backj that was removed. He reports that they felt there were adequate margins and has been followed and reports no recurrence of disease. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Melanoma on left back - s/p excision (1 year ago) (seen by Dr. [**Last Name (STitle) **] at [**Hospital1 2177**]) Social History: Lives in [**Location 86**], MA. Smokes 1 ppd. Drinks 5-10 beers/night. Family History: Mother - breast cancer Father - lung cancer son - healthy Physical Exam: Vitals: afebrile, P 72 BP 142/68 R 18 SpO2 97% ra General: Awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Small scar on left back Neurologic: -Mental Status: Alert, orineted to hospital, but cannot say which one, repeats [**Month (only) 404**] but gets year wrong. He had multiple paraphasic errors while speaking "pactus - cactus, hand - glove, dursday - thursday"; has difficulty following commands including "stick out your tongue". Is unable to read a complete sentence and states he cannot write due to problems with his right hand. Fluency is normal. No visual neglect, has some moderate right sided tactile neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. R arm pronator drift. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: agraphesthesia of the right hand when given a coin to hold or when a number is drawn on the hand. Left hand intact. Subjective pinprick loss on the right hand and arm. Legs symmetric with no deficits in pinprick, proprioception. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was extensor on the right and flexor on the left. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. PHYSICAL EXAMINATION UPON DISCHARGE: a+ox3, impulsive, labile affect, inappropriate at times. PERRL, EOMI face symmetric, tongue midline no pronator drift MAE's [**4-16**] +ataxia incision- sutures dissolvable, well healing. Pertinent Results: [**2100-12-30**] 04:35AM BLOOD WBC-15.0* RBC-3.21* Hgb-11.3* Hct-33.3* MCV-104* MCH-35.3* MCHC-34.0 RDW-13.8 Plt Ct-403 [**2100-12-27**] 07:10PM BLOOD PT-10.8 PTT-30.8 INR(PT)-1.0 [**2100-12-30**] 04:35AM BLOOD Glucose-128* UreaN-20 Creat-0.8 Na-142 K-4.8 Cl-105 HCO3-26 AnGap-16 [**2100-12-30**] 04:35AM BLOOD Calcium-9.6 Phos-4.7* [**2100-12-27**] 07:10PM BLOOD TSH-0.65 [**2100-12-27**] 07:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT head [**12-27**]: A 1.6 x 1.9 cm hyperattenuating focus involving left parietal region with extensive associated vasogenic edema. The above finding is concerning for metastatic disease, given patient's known history of melanoma. [**Month (only) 116**] obtain MR for further assessment, if clinically indicated MR brain [**12-28**]: 1. There are three enhancing lesions as described above, two in the right temporal lobe and one in the left parietal lobe as mentioned above with moderate surrounding vasogenic edema. The largest lesion is in the left parietal lobe measuring approximately 2.3 x 2.5 cm. These lesions are most likely concerning for metastatic disease given the history of melanoma. Correlation with CSF analysis can also be considered given the location of the lesions close to the cerebral sulci, to evaluate for leptomeningeal involvement. 2. A small focus of negative susceptibility in the left parietal/occipital lobe without enhancement. Attention on followup can be considered. 3. A small cystic focus in the pineal gland region measuring approximately 3 x 6 mm. Attention on followup. 4. A small subcutaneous nodule in the left posterior parietal/occipital lobe, 7x3 millimeter. Study is somewhat limited due to patient motion-related artifacts. CT chest/abdomen [**12-28**]: IMPRESSION: 1. Superficial subcutaneous nodules adjacent to the right deltoid and in the left anterior chest wall, measuring 8-9 mm may represent melanoma deposits, sebaceous cysts, or small lymph nodes. 2. Multiple small pulmonary nodules, the largest in the right middle lobe measuring 8 mm. These more likely represent metastatic disease rather than a primary pulmonary malignancy. Recommend short term follow up. 3. No evidence of malignancy in the abdomen or pelvis. CTA head [**12-30**]: 1. Stable left parietal hyperattenuating mass with surrounding edema suggestive of metastatic disease. No evidence of hydrocephalus. 2. Lytic lesion in the left parietal bone. Lack of parosseous soft tissue abnormality along with MR features of the lesion suggest that it is likely non-aggressive in nature, perhaps an incidental hemangioma. 3. Unremarkable head CTA. CT head [**12-31**]: IMPRESSION: Expected postoperative changes. No new acute findings. MRI Brain [**1-1**]: CONCLUSION: Status post resection of the left parietal mass seen previously. Blood products limit evaluation for residual enhancement, but the lesion appears to have been completely resected. MRA Brain-Neck [**1-2**]: Occlusion of the proximal left vertebral artery extending distally through all its segments. Echo [**1-3**]: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. No definite cardiac source of embolism identified. If clinically indicated, a TEE with saline contrast or a transcranial Doppler with saline contrast would be be more sensitive for detection of a PFO. Brief Hospital Course: Mr. [**Known lastname 79388**] presented with seizure from his PCP's office. Given the large lesion in the left parietal lobe identified on NCHCT done in the ED, he was started on dexamethasone 4mg q6h and Keppra 1000mg [**Hospital1 **] at admit. He had no further seizures during his hospitalization. MR brain obtained confirmed the suspicion of metastases in the brain, with not only the left parietal lesion observed but also two smaller right temporal lesions. He also has nodules in his lungs that are suspicious for metastases and two subcutaneous lesions. Neurosurgery had been involved from admission, and neuro-oncology and medical oncology were subsequently contact[**Name (NI) **]. The consensus on treatment was to resect the left parietal lesion, sending for path and checking for BRAF mutation to determine future treatment course. Prior to resection, his exam showed significant improvement on right hand incoordination. It otherwise was stable with no other significant deficits. He was otherwise stable. Resection was performed [**12-31**] with Dr [**Last Name (STitle) **]. This was performed without complication. He was extubated and transferred to the SICU for monitoring. Post op head CT revealed no hemorrhage but an incidental left cerebellar infarct. The patient was neurologically stable and did not show any deficit but the stroke neurology service was consulted for further work up. On [**1-1**] he was neurologically stable. He was cleared for transfer to the floor. His decadron was weaned and was started on SQH. An MRI was performed to eval postop and revealed acute left cerebellar infarct but good tumor resection. He was restarted on his home dose of aspirin. On [**1-2**] he worked with PT/OT. Neurology recommended MRA head and Neck as well as a bubble study and labs. These were all ordered. The patient was also noted to be distended and vomited x1 so a bowel regimen was ordered. On [**1-3**] he was again neurologically stable. MRA revealed an occluded left vertebral artery. Bubble study revealed mild symmetric left ventricular hypertrophy. Neurology recommends increasing your home dose of simvastatin. PT and OT recommended discharge to an acute rehab. He was seen by the heme-onc team and given appropriate follow up as an outpatient. His pain was well controlled. He was tolerating a PO diet and ambulating with assistance. He was in agreement with the plan for discharge to rehab. Please cc:[**E-mail address 92281**] Medications on Admission: 81 Aspirin daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 12. dexamethasone 4 mg Tablet Sig: 0.5 Tablet PO q12 (). 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 1. Brain and lung metastases with unknown primary 2. Left Cerebellar Stroke 3. Left Vertebral artery occlusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? 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 have dissolvable sutures so you may wash your hair and get your incision wet. Do not scrub incision. Let soap and water run over the incision and pat dry with a towel. ?????? 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) & Senna 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 discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? 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. Followup Instructions: ?????? You have decided to follow up with your oncologist Dr. [**Last Name (STitle) **]. Please make an appointment to be seen in the next 2 weeks. We will send him your discharge summary but please let us know if he needs other records for this appointment. ?????? You have an appointment in the Brain [**Hospital 341**] Clinic on [**2101-1-17**] @ 11:30AM. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. ?????? You have a Follow up appointment scheduled with Neurology on [**2101-3-7**] at 2pm with Dr. [**Last Name (STitle) 6938**]. SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] NEUROLOGY UNIT CC8 (SB) Completed by:[**2101-1-4**]

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icd9cm

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Discharge summary

report

Admission Date: [**2174-4-6**] Discharge Date: [**2174-4-12**] Date of Birth: [**2122-4-4**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1390**] Chief Complaint: trauma: pedestrian struck: R subgaleal hematoma small left apical ptx R inf rami fx R acetabular fractures 1 cm left anteromedial temporal cont right pararenal hematoma head laceration Major Surgical or Invasive Procedure: none History of Present Illness: 52 year old male struck by a car on [**4-6**] and was brought to [**Hospital1 18**] for further management. Patient was admitted to the TSICU under ACS for the following injuries: subgaleal hematoma, Right pubic ramus fracture, Right acetabular fracture, Left pneumothorax. Past Medical History: HCV per report; h/o Heroin use; chronic back pain; OSA (should wear CPAP, but does not at home) Social History: History of heroin use in past, reportedly been clean for some time. Family History: NC Physical Exam: Pt intubated upon admission [**2174-4-6**]: Vital signs: hr=82m bp=100/62, rr=20, 100 % oxygen saturation CV: normal chest: normal abdomen: normal skin: abrasions left shoulder, right knuckle abrasions, laceration scalp neuro: 3mm to 2mm sluggish Physical examination upon discharge: [**2174-4-12**] vital signs: t=98.3, hr=76, bp=130/70, rr=18, oxygen saturation 98% RA General: sitting in chair, conversant, NAD CV: ns1, s2,-s3, s-4 LUNGS: clear, diminshed BS left lateral ABDOMEN: soft, non-tender EXT: feet warm, + dp bil. mild left ankle edema lateral aspect, ecchymosis left calf., abrasions left knuckles, no spinal tenderness, mild tenderness left SI, muscle st lower ext., left +4/+5, right +5/+5, full dorsi/plantar flexion bil., hip flex. right +5, left +[**5-5**]. NEURO: alert + oriented x 3, speech clear, no tremors, full EOM's bil. SKIN: staples head Pertinent Results: CT Head [**2174-4-6**]: No hemorrhage or fracture. Large right subgaleal hematoma and laceration. CT C-spine [**2174-4-6**]: No fracture or malalignment in the cervical spine. Malpositioned NG tube with its tip at the vallecula anterior to the epiglottis. Repositioning was discussed with the trauma team at the time of initial review. Tiny left apical pneumothorax better assessed on the subsequent CT torso. CT abdomen and pelvis [**4-6**] 12: . Acute fractures of the right inferior pubic ramus and the anterior column of the right acetabulum with no significant surrounding hematoma. Probable nondisplaced fracture of the right sacral ala. 2. Locatized hematoma within the right anterior pararenal space tracking inferiorly into the space of Retzius, the source of this hemorrhage is unclear though no solid organ injury is evident. 3. Left chest tube in place with only trace left pneumothorax. Small areas of contusion in the lung as detailed above. Bibasilar opacities likely represent a combination of atelectasis and aspiration. CT Torso [**2174-4-6**]: Tiny left apical and basal pneumothoraces. Bilateral lower lobe opacities could be secondary to mild aspiration in the setting of intubation. Small quantity of hemorrhage in the right anterior pararenal space. No definite solid organ or hollow viscus injury. Right anterior acetabular and inferior pubic ramus fractures. Mild widening of the left sacroiliac joint. [**2174-4-8**]: x-ray of the ankle: . Mild soft tissue edema in [**Last Name (un) 22044**] fat pad. This can be seen in Achilles tendinopathy. 2. Mild lateral malleolar soft tissue swelling. 3. No fracture [**2174-4-8**]: ct of the chest: IMPRESSION: 1. Interval layering of hematoma with decreased component in the right anterior pararenal space and tracking inferiorly into the right paracolic gutter and pelvis. 2. No definite evidence of solid organ injury. No evidence of duodenal wall hematoma. No extraluminal oral contrast. 3. Small left pneumothorax with mild interval increase in size compared to prior. Chest tube with tip terminating at the left lung base. 4. Similar bibasilar opacities likely atelectasis and aspiration. Subtle increase in size of focal opacity in the left lower lung could be contusion. 5. Known fracture of the right inferior pubic ramus and anterior of the right acetabulum. [**2174-4-10**]: chest x-ray: This particular study was acquired using a somewhat lordotic technique creating many superimposed bony structures over the apices. Given this limitation, no pneumothorax is appreciated on the current study, although a small pneumothorax could be overlooked. There is interval decrease in the amount of left chest wall subcutaneous emphysema. A left subclavian central line continues to have its tip in the proximal SVC. Lung volumes remain low with no focal airspace consolidation, pulmonary edema, or pleural effusions. Overall cardiac and mediastinal contours are stable. Interval resolution of bibasilar patchy opacity is consistent with resolved atelectasis. [**2174-4-11**]: LS spine x-rays: FINDINGS: There is a transitional vertebra at the lumbosacral junction. At this level, there is hypertrophic spurring with intervertebral disc space narrowing. Less prominent narrowing is seen at the interspace just above this. These findings are consistent with degenerative change. No evidence of compression fracture or alignment abnormality. [**2174-4-11**]: x-ray of the pelvis: FINDINGS: In comparison with the study of [**4-6**], there is again a substantially displaced fracture of the right inferior pubic ramus. The right femoral neck fracture seen on CT is obscured due to a somewhat rotated position. [**2174-4-11**] 04:29AM BLOOD WBC-3.2* RBC-2.77* Hgb-8.8* Hct-24.1* MCV-87 MCH-31.8 MCHC-36.5* RDW-13.7 Plt Ct-63* [**2174-4-10**] 03:03PM BLOOD Hct-25.9* [**2174-4-10**] 04:20AM BLOOD WBC-2.8* RBC-2.65* Hgb-8.6* Hct-23.0* MCV-87 MCH-32.3* MCHC-37.3* RDW-13.4 Plt Ct-47* [**2174-4-6**] 07:30PM BLOOD WBC-10.2 RBC-3.63* Hgb-11.3* Hct-32.7* MCV-90 MCH-31.2 MCHC-34.6 RDW-13.5 Plt Ct-82* [**2174-4-11**] 04:29AM BLOOD Plt Ct-63* [**2174-4-10**] 04:20AM BLOOD Plt Ct-47* [**2174-4-9**] 02:13AM BLOOD Plt Ct-33* [**2174-4-11**] 04:29AM BLOOD Glucose-88 UreaN-9 Creat-0.5 Na-140 K-3.5 Cl-105 HCO3-29 AnGap-10 [**2174-4-10**] 04:20AM BLOOD Glucose-99 UreaN-11 Creat-0.5 Na-141 K-3.1* Cl-105 HCO3-33* AnGap-6* [**2174-4-7**] 02:15AM BLOOD ALT-94* AST-93* LD(LDH)-315* AlkPhos-52 TotBili-0.2 [**2174-4-6**] 07:30PM BLOOD Lipase-83* [**2174-4-11**] 04:29AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.0 [**2174-4-10**] 04:20AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.8 [**2174-4-6**] 07:38PM BLOOD Glucose-140* Na-139 K-4.1 Cl-104 calHCO3-28 [**2174-4-8**] 05:09AM BLOOD freeCa-1.08* Brief Hospital Course: 52 year old gentleman, pedestrian struck, admitted to the the hospital intubated and sedated. Upon admission, he was made NPO, given intravenous fluids and underwent imaging. He was found to have a right acetabular fracture,right pubic rami fracture and a right subgaleal hematoma. He was also found to have a left pneumothorax after having a needle thoracostomy tube placed in the field. In the emergency department he had a chest tube placed and was admitted to the trauma intensive care unit where he was hemodynamically stable. On HD #2, he was extubated and placed on face tent with good oxygenation. His chest tube was placed to water seal and he was transfused 2 u of blood after his hematocrit dropped to 24.8. His Hct drop was thought to be from a pararenal hematoma that was found vs his pelvic fracture. He was started on IV equivalent of home methadone regimen, standing intravenous Tylenol, and dilaudid PCA for pain control. The orthopedic service was consulted and recommended non-operative management for pelvic fracture. C-spine and TLS spine cleared clinically at this time. He again was transfused with 2 units blood on HD #3 for down-trending of his hematocrit. He was re-scanned in this setting and his pararenal hematoma was found to be stable. His methadone was decreased in the setting of somnolence. He also had a cat scan scan of his head which showed new hyperdensity in the left temporal lobe. Neurosurgery was consulted and thought this hyperdensity was too small to require seizure prophylaxis or further imaging with MRI, and thought most likely to be contusion. His left chest tube was removed on HD #4. He was transferred to the surgical floor on HD#4 with stable vital signs and adequate control of his pain with oral analgesia. He is tolerating a regular diet. Serial hematocrits continued with evidence of improvement of his thrombocytopenia to 80,000 and stabilization of his hematocrit to 25. He was evaluated by physcial therapy and occupational therapy and was found to have impaired mobility related to his pelvic fracture. Upon evaluation, it was determined that he had left leg weakness and the inability to bear weight on his left leg. The left leg weakness was noted on physical examination upon admission. He underwent a lumbar spine x-ray which showed no compression fracture or alignment abnormality. The pelvix x-ray continued to show the displaced fracture of the right inferior pubic ramus. He was provided instruction in the use of the walker and has been ambulating with assistance. He is preparing for discharge to a rehabilitation facility with follow-up instructions with Orthopedics, and with the acute care service. Medications on Admission: xanax 2mg AM 4mg HS, methadone 50mg TID Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 4. methadone 10 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: hold for incresed sedation, resp. rate <12. 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for anxiety: hold for increased sedation ,resp. rate <12. 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Cape & Islands Discharge Diagnosis: Trauma: pedestrian struck Injuries: R subgaleal hematoma small left apical ptx R inf rami fx R acetabular fractures 1 cm left anteromedial temporal cont right pararenal hematoma 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 came to the hospital after being struck by a car and were found to have mulitple injuries including a acetabular fracture, pelvic fractur and a small bleed in your head. You were seen by the orthopedic service for the fractures who recommended non-operative management for both your pelvic and acetabular bone fractures. You were seen by physical therapy and recommendations made for discharge to an extended care facility. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2174-4-28**] at 2:00 PM With: ACUTE CARE CLINIC with Dr [**Known firstname **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage You will need a chest x-ray prior to this appointment. Please go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology 30 minutes prior to your appointment. Department: ORTHOPEDICS When: TUESDAY [**2174-5-3**] at 10:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2174-5-3**] at 11:00 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please follow-up with Dr. [**First Name (STitle) **], cognitive neurologist, upon discharge from the rehabilitation center. You can schedule this appointment by calling # [**Telephone/Fax (1) 6335**] Completed by:[**2174-4-12**]

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2201-1-1**] Discharge Date: [**2201-1-20**] Date of Birth: [**2125-6-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: IPH/SAH s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: 75 yo M (RHD) transferred from OSH w/ IPH/SAH (posterior R parietal) s/p unwitnessed fall. Pt reports 2-3 days of dizziness and "wooziness" during which he has been unable stand w/o feeling that he would fall over. On the morning of admission pt reports falling twice while trying to get out of bed. After both falls he was able to pull himself back into bed. He denies loosing consciousness during either event but does recall hitting his head both times (on his forehead). Later in the morning he was unable to get out of bed and had to be helped by his [**Hospital3 12272**] personnel due to generalized weakness (L>R). Pt was taken to OSH where CT head demonstrated a moderate sized (~3 cubic cm) IPH into the R posterior parietal lobe w/ SAH extension. Pt was subsequently transferred to [**Hospital1 18**]. On presentation to the [**Hospital1 18**] [**Name (NI) **], pt slightly confused (oriented to self and date) and agitated. Shortly after arrival, pt became severely agitated and received 1mg of Haldol prior to being evaluated by neurosurgery. Pt was largely unable to give clear HPI and much of the above was obtained from OSH records and from fragments of conversation. Pt's PCP was [**Name (NI) 653**] for further information and no family members were readily available. Past Medical History: PMHx: narcolepsy (w/o cataplexy), COPD, asbestos exposure, hemorrhoids, nephrolithiasis, cholelithiasis, Lumbar spinal stenosis, ?AAA (recorded in PCP records but no info re Rx, mgmnt, or surgery) Social History: The patient lives alone, is divorced. His primary contact is his son [**Name (NI) 25368**] [**Name (NI) 94865**] (78) [**Telephone/Fax (1) 94866**]. He smokes 1.5ppd and drinks once per year. Family History: No strokes or brain bleeds. Father had an MI, no other MIs. Physical Exam: PHYSICAL EXAM: O: T: 97.6 BP: 145/71 HR: 98 R 20 100% RA Gen: WD/WN, agitated, pulling at blankets and moving R arm restlessly HEENT: Small (2x2cm) abrasion over forehead and 1cm abrasion over nose bridge otherwise normocephalic (no bruises or swelling over posterior scalp). Pupils: round, equal, minimally reactive at 2mm EOMs Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, minimally cooperative with exam, agitated. Orientation: Oriented to person and date but not place (not willing to cooperate). Language: Speech fluent with moderate comprehension (pt w/ difficulty raising L hand if asked but if demonstrated is able to) otherwise able to follow simple commands with RUE w/ some help. Cranial Nerves: Pt cooperative with limited amounts of exam I: Not tested II: Pupils equally round and minimally reactive to light, 2 to ~2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements grossly 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 [**5-21**] throughout RUE. LUE w/ occasional spontaneous movements of digits. LUE neglect (pt unable to recognize L hand immediately). Pt able to move L shoulder and occasionally L elbow with noxious stimulus. No pronator drift in R. Strength: D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 4 4 4 5 5 5 4 4 2 3 4 L 2+ 2+ 3 2 3 3 2+ 3 1 2 2 Pt notably weaker in LUE and LLE (asymmetric) but there is a large degree of weakness in R side as well. Pt initially raised his RUE when asked to "show me your Left hand." However, when corrected and the question repeated, pt was able to raise his L hand and arm. Sensation: Intact to light touch in R-side but absent from lower 2/3rds of RUE and in RLE (no response to noxious stimuli). Pt moves R hand to noxious stimuli in his L axilla but no mvmnt in his LUE. Reflexes: B T Br Pa Ac Right 2 - 2 2 - Left 2 - 2 2 - Toes downgoing bilaterally Pertinent Results: ADMISSION LABS: [**2201-1-1**] 11:45AM URINE RBC-21-50* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2201-1-1**] 11:45AM PT-13.0 PTT-29.0 INR(PT)-1.1 [**2201-1-1**] 11:45AM WBC-9.1 RBC-5.58 HGB-12.0* HCT-36.2* MCV-65* MCH-21.4* MCHC-33.0 RDW-16.8* [**2201-1-1**] 11:45AM GLUCOSE-115* UREA N-17 CREAT-0.9 SODIUM-138 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-23 ANION GAP-15 IMAGING: CTA Head [**1-2**]: IMPRESSION: Right parietal parenchymal hematoma with adjacent subarachnoid hemorrhage, similar to recent head CT. No evidence of underlying vascular anomaly, no evidence of active contrast extravasation. The location and adjacent subarachnoid hemorrhage are most suggestive of cerebral amyloid angiopathy. However, continued followup is advised to more definitively exclude an underlying mass, which could be obscured by blood products and adjacent edema. MRI Head [**1-2**]: IMPRESSION: Limited exam demonstrating right parietal parenchymal hemorrhage as seen on CT, not further characterized. If desired, the exam can be repeated when the patient's condition stabilizes. CT Head [**1-2**]: IMPRESSION: Right parietal parenchymal hematoma with adjacent subarachnoid hemorrhage, similar to the recent CT. The appearance remains most suspicious for cerebral amyloid angiopathy. As noted on the prior examinations, continued followup is suggested to ensure there is no underlying mass. MRI [**1-4**]: Redemonstration of right parietal lobe hemorrhage, with subarachnoid extension, without clear identification of a source for the hemorrhage. See above report for additional findings. Brief Hospital Course: The patient was admitted to the NSurg ICU for close observation and further work up of this brain hemorrhage. A CTA was performed which did not reveal AVM or aneurysm. He was loaded with dilantin for seizure prophylaxis, and his SBP was kept below 140. A neurology consult was obtained to help discern between mass with hemorrhagic conversion, or a true CVA. On [**1-2**] the patient was found to have a focal left arm seizure - a stat Head CT was performed which showed no change in the size of the hemorrhage. Keppra was added for increased seizure prophylaxis. An MRI with and without contrast was obtained on [**1-4**], which did not reveal a mass. The decision was made to transfer care to the neurology service for further evaluation and management of this hemorrhagic stroke. He was seen by speech and swallow who determined that he was aspirating fluids and solids, so he was made NPO, and all medications were changed to IV. He underwent PEG placement. He developed stridor and respiratory distress while on the floor, for which a code was called and he was intubated and transferred back to the Neuro ICU. Vocal cords were visualized while in ICU and noted to be edematous, likely from trauma during PEG procedure. He failed extubation twice; despite attempts with racemic epinephrine and steroids. He ultimately required trach. He had left upper extremity swelling and was found to have a large extensive DVT in left UE, so was started on Coumadin and Lovenox bridge. He had a PICC in the left UE which was removed. He was transferred to step down on the neurology service over the weekend. However, on Monday [**2201-1-19**] he developed respiratory distress with tachypnea to 40s, desaturation, SBP to 215. He also spiked a temp to 102 and had a rising WBC. ABG was 7.5/35/81. CXR showed midline trach and no white out. Possibly mucus plugging or pneumonia. A stat medicine consult was obtained, and he was transferred to the MICU for further management. Transferred with hypotension, fever, tachypnea and tachycardia, as well as multiorgan dysfunction, from presumed septic shock. Blood cultures quickly grew out GNRs. Aggresive fluid resuscitation and blood pressure support were continued with multiple pressors. Pt was started on antibiotics. However organ dysfunction continued, with rising Cr, LFTs, WBC, and apparent DIC. RUQ US obtained due to apparent abdominal tenderness; US showed free air. Surgery consulted, however pt too unstable to go for CT scan. At this point family discussion was held, and patient was made CMO. He passed away one hour later. Medications on Admission: Medications on transfer: - Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN - Warfarin 5 mg PO/NG DAILY16 - Metoprolol Tartrate 25 mg PO/NG TID - Insulin SC - Enoxaparin Sodium 90 mg SC Q12H - Albuterol-Ipratropium [**1-18**] PUFF IH Q4H:PRN wheezing, SOB - Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation - Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **] - Famotidine 20 mg PO/NG Q12H - LeVETiracetam 1000 mg PO/NG [**Hospital1 **] - HydrALAzine 10 mg IV Q6 PRN if SBP>170 - Hydrochlorothiazide 12.5 mg PO/NG daily Discharge Medications: Albuterol-Ipratropium CefePIME Ciprofloxacin Docusate Sodium (Liquid) Famotidine Fentanyl Citrate LeVETiracetam Lorazepam MetRONIDAZOLE (FLagyl) Midazolam Morphine Sulfate Norepinephrine Phenylephrine Vasopressin Vancomycin Discharge Disposition: Expired Discharge Diagnosis: pt passed away Discharge Condition: pt passed away Discharge Instructions: pt passed away Followup Instructions: patient expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2201-1-22**]

[ "286.6", "996.74", "348.30", "995.92", "E879.6", "781.94", "599.0", "276.2", "785.52", "342.92", "518.81", "453.82", "496", "934.9", "347.00", "478.75", "348.5", "277.30", "780.39", "276.1", "867.0", "038.40", "478.6", "584.5", "431", "368.46" ]

icd9cm

[ [ [] ] ]

[ "31.1", "43.11", "33.22", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

9614, 9623

6197, 8794

321, 328

9681, 9697

4569, 4569

9760, 9932

2094, 2157

9365, 9591

9644, 9660

8820, 8820

9721, 9737

2187, 2555

264, 283

356, 1645

2920, 4550

4586, 6174

2570, 2904

8845, 9342

1667, 1866

1882, 2078

43,186

146,674

11697

Discharge summary

report

Admission Date: [**2192-9-5**] Discharge Date: [**2192-9-5**] Date of Birth: [**2155-7-19**] Sex: F Service: MEDICINE Allergies: Reglan / Trazodone Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: swallowed toothbrush Major Surgical or Invasive Procedure: EGD [**2192-9-5**] History of Present Illness: [**Known firstname **] [**Known lastname 37025**] is a 37 yo female with a long-standing history of an eating disorder, noted as both anorexia and bulemia by PCP's notes who presents after accidentally swallowing a toothbrush. The patient reports that she had began eating normally after not eating for several days and then tried to make her self vomit. She does not have a gag reflex any longer so was trying to induce vomiting by gagging herself with a toothbrush when she accidentally swallowed it. The patient reports pain in her mid-chest since swallowing the toothbrush [**6-14**] in severity at it's worst and notes that she feels a tightness in her chest. Denies trouble breathing or swallowing secretions. She originally presented to OSH ED where lateral x-ray shows e/o toothbrush in esophagus. . In the ED, initial vs were: 99.2 82 137/56 11 100% on ra. Patient was given zofran 4mg IV x1 and morphine 4 mg IVx1. GI was consulted and they plan to do EGD in morning in ICU or sooner if needed. She has been handling secretions without difficulty and hemodynamically stable in ED. . Review of systems: (+) Per HPI and for worsening anorexia symptoms, epigastric abdominal pain and nausea. Tearful because she overheard her weight. (-) Denies fever, chills, headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PAST MEDICAL HISTORY: -hypothyroidism -IBS -headaches -history of eating disorder with purging behavior (anorexia nervosa & bulimia) -h/o dehydration, orthostasis, and electrolyte abnormalities (hypokalemia) from eating disorder PSYCHIATRIC HISTORY: -diagnoses: per OMR, patient has BPD; patient reports MDD, eating disorder NOS, GAD -prior hospitalizations: several, most recently at Bay Ridge in [**6-13**] s/p SIB -outpatient treaters: psychiatrist nurse [**First Name8 (NamePattern2) 3639**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 37026**] in [**Location (un) 22287**] -prior SA: several by OD, most recent 3 years ago -SI/HI/assaultive behavior: endorses past SA, SIB Social History: -denies EtOH, illicit drugs -ex-smoker -lives in a supportive residence -she is unemployed and is on disability; worked previously as a nanny -both of her parents passed away from CA. Family History: Non-contributory; parents deceased. Physical Exam: General: Alert, oriented, crying intermittently but no acute distress. HEENT: Sclera anicteric, PERRLA, EOMI MMM, oropharynx clear (no foreign body visible in oropharynx) Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender in epigastrium, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2192-9-5**] 01:25AM BLOOD WBC-9.2 RBC-3.34* Hgb-9.9* Hct-28.4* MCV-85 MCH-29.6 MCHC-34.7 RDW-15.0 Plt Ct-221 [**2192-9-5**] 01:25AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-145 K-3.9 Cl-114* HCO3-19* AnGap-16 [**2192-9-5**] EGD: Impression: (foreign body removal) Toothbrush was foun with most proximal part 20cm from incisors. Otherwise normal EGD to mid esophagus Brief Hospital Course: 37 yo female with a long-standing history of an eating disorder, noted as both anorexia and bulemia by PCP's notes who presented after accidentally swallowing a toothbrush. . # Foreign Object Ingestion - Patient transferred to [**Hospital Unit Name 153**] for monitoring of accidental ingestion of toothbrush. Patient complained of moderate epigastric discomfort, relieved with morphine. Patient was stable, without vomiting, and reported being able to swallow saliva without issue. The toothbrush was removed endoscopically without complications, and the patient was stable. Slight erythema noted in upper esophagus; she will only take fluids for the next 24 hours. She is stable and is being discharged to her home. . #Depression - During time in [**Hospital Unit Name 153**], patient was intermittently tearful, with depressed affect. PO psychiatric medications were initially held pending removal of foreign object from esophagus. Upon discharge, she will continue these meds. Medications on Admission: # Citalopram 40 mg Tablet by mouth once a day # Clonazepam 1 mg Tablet by mouth at bedtime and 0.5 mg PO PRN anxiety # Folic Acid 1 mg by mouth once a day # Lamotrigine 100 mg Tablet 0.5 (One half) Tablet(s) by mouth in am and 1 in pm # Levothyroxine 25 mcg Tablet by mouth once a day except [**1-7**] on sunday # Olanzapine [Zyprexa] 5 mg Tablet by mouth at bedtime # Omeprazole 20 mg Capsule PO BID # Topiramate 100 mg Tablet 1.5 Tablet(s) by mouth at bedtime # Docusate Sodium [Colace] 100 mg Capsule PO BID # Ferrous Gluconate 325 mg Tablet by mouth once a day # Multivitamin 1 Tablet(s) by mouth once a day # Simethicone 80 mg Tablet, Chewable 2 Tablet(s) by mouth once a day as needed for gas Discharge Medications: 1. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once as needed for anxiety. 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lamotrigine 100 mg Tablet Sig: as directed Tablet PO as directed: half a tablet in the AM, and half a tablet in the PM. 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO every day except Sunday. 7. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO once a day: every Sunday. 8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 10. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO at bedtime. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Ferrous Gluconate 325 mg (36 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 13. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 14. Simethicone 80 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day as needed for gas. Discharge Disposition: Home Discharge Diagnosis: swallowed toothbrush - removed by EGD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because you swallowed a toothbrush. An upper endoscopy was performed, and the toothbrush was removed. You were observed and are stable for discharge home. . We did not make any changes to your medications. . Please follow up with your PCP (appointment listed below). . It is harmful to make yourself vomit; if you feel unwell please contact your PCP or go to the emergency room in case of an emergency. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD Phone:[**Telephone/Fax (1) 2205**] Date/Time:[**2192-9-21**] 12:00 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "300.02", "285.9", "935.1", "564.1", "307.51", "307.1", "E915", "V15.82", "E849.0", "244.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "98.02" ]

icd9pcs

[ [ [] ] ]

6796, 6802

3936, 4925

305, 325

6884, 6884

3542, 3913

7482, 7774

2927, 2964

5674, 6773

6823, 6863

4951, 5651

7035, 7459

2979, 3523

1472, 1989

245, 267

353, 1453

6899, 7011

2033, 2710

2726, 2911

16,784

180,341

5631

Discharge summary

report

Admission Date: [**2136-3-17**] Discharge Date: [**2136-3-20**] Date of Birth: [**2059-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: BRBPR and black stool s/p EUS/EGD Major Surgical or Invasive Procedure: Blood Product Transfusion History of Present Illness: 76 yo M s/p EGD with biopsies on [**3-16**] p/w black stool and BRBPR. Had black stool x 2 on [**3-16**]/ and BRBPR x 1. Denies any hematemesis, chest pain, SOB, N/V. was c/o dizziness and abdominal cramps. Pt was tachycardic to 110 in the ED. HCT stable at 35 on admission (recent HCT has varied from 31-39). GI consulting. Past Medical History: Hyperlipidemia AAA s/p endovascular repair with stent [**2133**] Ulcerative colitis AS valve area 0.8 cm2 on TTE [**6-15**] Social History: Lives with wife. [**Name (NI) **] is retired and had been a quality control engineer at the [**Company 2676**] Plant. He quit smoking 1 year ago and previously smoked 2ppd x 50 years. He drinks alcohol rarely. Denies illicit drug use. Family History: Father MI in 40s and fatal MI at 75, sister lung cancer Physical Exam: 99 110/70 95 20 97%/RA Gen: NAD Heent: MM dry, no LAD Heart: RRR, 3/6 systolic murmur at RUSB Chest: CTABL Abd: soft, NT, ND, no HSm, BS + Rectal(per ED notes): melanic stool, guaiac +ve Pertinent Results: [**2136-3-16**] EGD/EUS: Endoscopy Impression: 1.The esophagus was normal. 2.The GE junction was located at 41cms. 3.There was a 3cm submucosal mass in the cardia. 4.Appearances similar to that of previous endoscopy. 5.Biopsies were taken using jumbo forceps and sent for histology. 6.The mucosa in the proximal stomach had a cobblestone appearance. 7.Otherwise normal stomach. 8.The duodenum and proximal jejenum were normal. EGD impression: 1.The endoscopic findings were confirmed by son[**Name (NI) 867**] using a radial echoendoscope at 12mHZ. 2.A submucosal mass was seen in the cardia measuring 13.6mm X 6.1 mm. 3.It was hyperechoeic, no definate invasion of the mucularis propria/4th son[**Name (NI) 493**] [**Name2 (NI) **] was noted. 4.Aortic and celiac axis seen, no nodes identified. . [**2136-3-17**] ECG: Sinus tachycardia. Left atrial abnormality. RSR' pattern in leads V1-V2. Compared to the previous tracing of [**2136-2-1**] the T waves are less prominent in the precordial leads. Otherwise, no change. . [**2136-3-17**] 04:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022 [**2136-3-17**] 04:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . [**2136-3-17**] 01:40PM BLOOD WBC-7.1# RBC-4.02* Hgb-12.0* Hct-35.0* MCV-87 MCH-29.8 MCHC-34.2 RDW-13.8 Plt Ct-133* [**2136-3-17**] 05:35PM BLOOD Hct-29.7* [**2136-3-17**] 01:40PM BLOOD Neuts-63.9 Lymphs-30.3 Monos-4.8 Eos-0.7 Baso-0.3 [**2136-3-17**] 01:40PM BLOOD PT-12.4 PTT-25.7 INR(PT)-1.1 [**2136-3-17**] 01:40PM BLOOD Plt Ct-133* [**2136-3-17**] 01:40PM BLOOD Glucose-153* UreaN-51* Creat-1.0 Na-138 K-4.6 Cl-102 HCO3-26 AnGap-15 . [**2136-3-18**] 01:34AM BLOOD Hct-29.7* [**2136-3-18**] 12:49PM BLOOD Hct-32.2* [**2136-3-19**] 07:57AM BLOOD Hct-22.4* [**2136-3-19**] 06:16PM BLOOD Hct-29.5*# . [**2136-3-20**] 04:16AM BLOOD WBC-6.2 RBC-4.06* Hgb-12.4* Hct-34.5* MCV-85 MCH-30.5 MCHC-35.9* RDW-14.1 Plt Ct-90* [**2136-3-20**] 04:16AM BLOOD Plt Ct-90* [**2136-3-20**] 04:16AM BLOOD PT-13.2* PTT-29.1 INR(PT)-1.2* [**2136-3-20**] 04:16AM BLOOD Fibrino-290 [**2136-3-20**] 04:16AM BLOOD Glucose-84 UreaN-10 Creat-0.6 Na-140 K-3.7 Cl-105 HCO3-29 AnGap-10 [**2136-3-20**] 04:16AM BLOOD ALT-13 AST-18 LD(LDH)-113 AlkPhos-67 TotBili-1.1 [**2136-3-20**] 04:16AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0 Iron-60 . Brief Hospital Course: 1. Post-procedure acute blood loss anemia [**1-13**] gastric hemorrhage: Pt had EUS/EGD on day before admission ([**3-16**]), a biopsy of a gastric cardia mass was performed. Bleeding resolved, serial hct followed. NG lavage negative. Pt was given 2 units PRBC, and hematocrit stabilized. Pt is hemodynamically stable and has had one black stool since admission. Continue [**Hospital1 **] PPI x 14 days, sucralfate x 14 days. Hold ASA x 2 weeks. Pt to f/u with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] next week for biopsy results and follow-up. . 2. Gastric mass: s/p EGD with biopsy on [**3-16**]. Concern for malignancy. Pt to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] next week for results. . 3. Ulcerative colitis: Stable, continue mesalamine. Medications on Admission: 1. Aspirin 81 mg Tablet, 1 Tablet PO DAILY 2. Mesalamine 400 mg Tablet, (E.C.) 2 Tablet, PO TID 3. Cholestyramine-Sucrose 4 g Packet 1 packet PO twice a day. 4. Omeprazole 20 mg Capsule, (E.C.) 1 Capsule, PO once a day. 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 14 days. Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 3. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO three times a day for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Post-Procedure Acute Blood Loss Anemia due to Gastric hemorage Gastric Mass Ulcerative Colitis Discharge Condition: Good Discharge Instructions: Return to the hospital if you experience large amounts of black tarry stools, dizziness, blood in your stool. You may experience small amounts of black tarry stools over the next few days Followup Instructions: 1. You will receive a call from Dr.[**Name (NI) 12202**] office to schedule an appointment for next week. This is to review the biopsies taken during the EGD. [**Telephone/Fax (1) 1983**] 2. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2136-4-2**] 11:20 3. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2136-8-6**] 10:00 4. Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD (cardiology) Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2136-8-6**] 11:00

[ "537.89", "272.4", "285.1", "041.86", "556.9", "E878.8", "998.11" ]

icd9cm

[ [ [] ] ]

[ "45.16" ]

icd9pcs

[ [ [] ] ]

5605, 5611

3803, 4635

349, 377

5750, 5757

1428, 3780

5994, 6647

1148, 1205

5091, 5582

5632, 5729

4661, 5068

5781, 5971

1220, 1409

276, 311

405, 731

753, 879

895, 1132

32,436

184,018

45158

Discharge summary

report

Admission Date: [**2129-3-4**] Discharge Date: [**2129-3-28**] Date of Birth: [**2060-11-1**] Sex: M Service: MEDICINE Allergies: Flomax / Bactrim Attending:[**First Name3 (LF) 7591**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Tracheal intubation and mechanical ventilation Hemodialysis with catheter placement Central line placement History of Present Illness: Mr. [**Known lastname 69629**] is a 68 yo M w/PMHx sx for multiple myeloma (diagnosed [**2-23**]), s/p CVA, HTN, hyperlipidemia, atrial fibrillation who presents with respiratory distress, initially presenting with 3 days of cough with sputum production with fevers to 103 to [**Hospital6 **]. His vital signs in their ED were 103.2 BP 209/94 HR 99 100% CPAP. At [**Hospital3 **], he was felt to be in pulmonary edema and he received lasix 40 mg IV and was started on a nitro gtt for BPs 200s/130s, and was given ceftriaxone and azithromycin and then given levofloxacin and vancomycin in our ED. . Per report, patient w/O2sat 92% RA on NRB, and was intubated in our ED. No ABG was checked. Patient had a CXR at the time which showed with RML collapse, which was attributed to pneumonia. . Patient was recently admitted from [**2-23**] to [**3-1**] with fevers, hypercalcemia, and acute [**Month/Day (1) **] failure concerning for progression of his MGUS to multiple myeloma, with confirmatory BM biopsy performed. During that admission, he had an episode of AF with RVR, with an echo showing atrial dilatation. Past Medical History: * Multiple myeloma, with acute [**Month/Day (1) **] failure and hypercalcemia. -BM biopsy: Plasma cells comprise 53% of aspirate differential and 80-90% of bone marrow cellularity by CD138 staining of the core biopsy c/w plasma cell myeloma -Hypercalcemia -Anemia -Acute [**Month/Day (1) **] failure * Right PICA stroke, inferior medial stroke in [**2123-5-26**]. MRI showed occluded right vertebral artery. Echo with complex atheroma. He has been placed on Coumadin and then switched to aspirin, and Plavix. * Hypertension. * Hypercholesterolemia * Anemia, B12 and iron deficiency. * Colon polyp * Anemia Social History: Patient is Cuban, moved to [**Location (un) 86**] 42 years ago, lives with his wife who is suffering from colon cancer. Prior tobacco history but quit after stroke in [**2123**]. No alcohol use in 5 years. Worked in electronics and as a janitor at the [**Hospital 18**] [**Hospital1 11900**]. Has 3 children, 2 of which live in [**State 1727**]. Family History: Both parents died of lung cancer, history of colon cancer in another family member. Physical Exam: ADMISSION PHYSICAL: Physical Examination Gen: Intubated, sedated. HEENT: MMM. PERRL. Hrt: Distant heart rounds. RRR. Lungs: Rales at right base. Crackles diffusely on left. No wheezing. Abd: S/NT/ND normoactive BS Ext: WWP. No edema. Negative [**Last Name (un) 5813**]. Neuro: Withdraws to pain. Intubated and sedated. Pertinent Results: [**2129-3-4**] 01:00AM WBC-3.8* RBC-3.15* HGB-9.8* HCT-29.5* MCV-94 MCH-31.2 MCHC-33.3 RDW-16.3* [**2129-3-4**] 01:00AM PLT COUNT-187 [**2129-3-4**] 01:00AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2129-3-4**] 01:00AM PT-14.7* PTT-35.0 INR(PT)-1.3* [**2129-3-4**] 01:00AM LACTATE-1.3 [**2129-3-4**] 01:00AM CK-MB-3 [**2129-3-4**] 01:00AM CK(CPK)-112 [**2129-3-4**] 01:00AM cTropnT-0.03* [**2129-3-4**] 01:00AM GLUCOSE-83 UREA N-43* CREAT-3.8* SODIUM-142 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-15* ANION GAP-22* [**2129-3-4**] 01:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2129-3-4**] 01:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . MICRO [**3-4**] sputum cx with S. pneumoniae (pcn and bactrim R), DFA positive for PJP, fungal cx with yeast, AFB smear negative cx PENDING [**3-4**] nasopharyngeal aspirate positive for influenza B [**3-15**] CSF gram negative for polys or organisms [**3-15**] CSF HSV PCR negative [**3-15**] lip lesion viral cx negative [**3-19**] H. pylori serology positive [**3-8**] galactomannan 0.354, glucan negative [**Date range (1) 58897**] blood cx negative 2/8-9 urine cx negative . IMAGING CT head [**3-19**] IMPRESSION: No evidence for intracranial hemorrhage or bleed. The extra- axial collections mentioned on the prior CT are either prominent CSF spaces secondary to atrophy, or less likely hygromas. CXR [**3-4**] The right lung opacity has slightly worsened in the interim as well as there is interval development of new left predominantly perihilar but also lower lobe opacity, findings consistent with superimposed pulmonary edema in addition to known multifocal parenchymal consolidations. The cardiomediastinal silhouette is stable. A small right pleural effusion cannot be excluded. Note is made that left cardiophrenic angle was not included in the field of view. The ET tube tip is 7 cm above the carina. The NG tube tip is in the stomach. IMPRESSION: Interval development of volume overload in addition to multifocal consolidations. Non-Contrast Head CT [**2129-3-15**]: 1. No evidence for hemorrhage. 2. Evidence for chronic small vessel microischemic changes is stable. 3. Extensive sinus disease within the frontal, maxillary and sphenoid sinuses as well as the mastoid air cells. Acute sinusitis cannot be excluded and clinical correlation is recommended, especially in a patient who has been recently extubated. 4. Low density bifrontal fluid collections may represent prominent extra- axial CSF spaces in a patient with age-related atrophy versus subdural hygromas. These are slightly more prominent than on the prior examination. Echocardiography [**2129-3-7**]: The left atrium is dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) The left ventricular cavity size is normal. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2129-2-24**], the findings are similar. [**Year (4 digits) 2793**] Ultrasound [**2129-3-5**]: Limited [**Month/Day/Year **] ultrasound performed portably in the ICU. No hydronephrosis detected. [**Month/Day/Year 2793**] cortical appearance similar to that of recent comparison 10 days previous with mild thinning of the cortex and echogenicity consistent with chronic [**Month/Day/Year **] insufficiency. Abdominal X-ray [**2129-3-6**]: Dilated loops of small bowel. Partial vs. early complete obstruction or ileus is not excluded. No definite evidence of free air however assessment for free air is limited on this single supine radiograph. Followup decubitus films are recommended. [**2129-3-15**]: TECHNIQUE: Non-contrast head. COMPARISON: [**2129-3-15**]. FINDINGS: There is no short interval change from [**2127-3-16**]. There is no intracranial hemorrhage, mass effect, shift of normally midline structures. The ventricles, cisterns, and sulci are unremarkable aside from mildly enlarged bifrontal CSF spaces secondary to mild brain atrophy. Mild periventricular white matter hypodensities are the sequelae of chronic small vessel infarction, and note is made of a right lacunar infarct. The osseous structures are unremarkable and the visualized paranasal sinuses again demonstrate near complete opacification of the sphenoid sinuses that may be secondary to recent intubation. The mastoid air cells also contain a small amount of fluid. IMPRESSION: No evidence for intracranial hemorrhage or bleed. The extra- axial collections mentioned on the prior CT are either prominent CSF spaces secondary to atrophy, or less likely hygromas. DIRECT INFLUENZA A ANTIGEN TEST (Final [**2129-3-12**]): Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2129-3-12**]): NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. Labs on discharge: Brief Hospital Course: [Written by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MS4 with edits by intern] 1. Respiratory failure: Likely due to multiple pulmonary infections (influenza, PJP, pneumococcus) with contribution from pulmonary edema in setting of hypertension. Required endotracheal intubation and mechanical ventilation. Initial extubation attempt complicated by severe HTN with systolics to the 200's and ischemic changes on EKG. [**Hospital **] hospital day 10. Patient was weaned to 4L nasal canula on discharge with continued ambulatory desaturations to 88% on 4L. 2. Septic shock Likely due to pulmonary infections. Required pressor support and aggressive fluid replacement. 3. Influenza Completed 9 day course of oseltamivir as recommended by infectious disease consult (longer than standard course in light of immunocompromised state). Repeat antigen screen was negative so oseltamivir was discontinued. 4. Pneumocystic jirovecci infection Three weeks of treatment recommended by infectious disease consult, last day [**2129-3-28**]. Initially treated with bactrim and steriods, but developed pancytopenia with concern that bactrim could be responsible -- however patient had recently received cytoxan, was on cefepime, and had multiple active infections. Treatment regimen changed to clindamycin, primaquine and steriods with normalization of blood counts. Patient completed clindamycin, primaquine and prednisone on [**3-28**]. 5. Pneumococcal pneumonia Pneumococcus found on sputum culture. Treated initially with Cefepime then successfully narrowed to Ceftriaxone for a total of 2 weeks of treatment. Last day [**2129-3-17**]. 6. Acute on chronic [**Month/Day/Year **] failure, dialysis dependent Chronic [**Month/Day/Year **] failure secondary to multiple myeloma with baseline creatinine of 3. Acute [**Month/Day/Year **] failure thought to be secondary to septic shock, initially treated with CVVH and subsequently with hemodialysis. Patient to likely need chronic hemodialysis. He was followed by the [**Month/Day/Year **] consult team. A tunnelled hemodialysis catheter was placed and patient was maintained on M/W/F schedule. Patient to be followed by Dr. [**Last Name (STitle) 118**] as an outpatient and hemodialysis as an outpatient arranged at Northeast [**Hospital1 8**] Dialysis [**Location (un) 96522**]. [**Hospital1 8**], [**Numeric Identifier 53049**] [**Telephone/Fax (1) 96523**] on a Tuesday, Thursday, Saturday schedule. Patient was dialyized on [**3-28**]. 7. Atrial fibrillation On admission on metoprolol 50mg po tid, held due to septic shock. Atrial fibrillation resolved but then recurred following extubation. Rate controlled with maximum dose diltiazem in addition to beta blockade. Anticoagulation started with IV heparin which was subsequently discontinued due to development of GI bleed. Patient was rate controlled on metoprolol and diltiazem and plan was to continue on discharge. 8. Gastrointestinal bleeding Patient had heme positive stools early in admission but resolved with stable hematocrit. Of note, he had a history of gastritis and colon adenoma on EGD performed [**2124**] for workup for Fe deficiency anemia. He developed grossly bloody stools following start of heparin. The gastroenterology service was consulted, and endoscopy was initially deferred due to patient agitation at time of evaluation. A decision was made to hold off on diagnostic studies given high risks involved (likely reintubation needed) and low likelihood of intervention. H.pylori was positive and patient was maintained initially on [**Hospital1 **] IV PPI, then switched to po, with plans to complete a 14 day course of Amoxacillin and Clarithromycin renally dosed. 9. Anemia, acute on chronic Chronic secondary to multiple myeloma, worsened in setting of GI bleeding required RBC transfusion. Hematocrit was stable at the time of discharge. 10. Hypertension Initially hypotensive in septic shock, developed hypertension during extubation to systolic pressures of 200's. Adequately controlled on diltiazem and metoprolol with systolic pressures of 130's. 11. Multiple myeloma Received dose of IVIg x1 given multipe active infections. He will follow up in oncology clinic for further management of his myeloma. Patient to return to [**Hospital Ward Name 1826**] 7 clinic on Monday, [**3-28**] for labs and to discuss further treatment with Dr. [**Last Name (STitle) 410**]. 12. Dysphagia Required nasogastric tube placement following extubation. Resolved. 13. Altered mental status Patient was confused following extubation, initially thought to be medication related. He did have some crusted lesions on his lips which initially raised the question of HSV infection, so a lumbar puncture was performed which was negative for bacterial infection. He was empirically started on acyclovir which was discontinued once the HSV PCR returned negative. Upon further review it was thought that this lip lesions were likely secondary to trauma rather than HSV. CT head done prior to lumbar puncture showed no new bleed or stroke, although there was a question of bifrontal fluid collections possibly consistent with hygromas versus age-related atrophy. His confusion increased on [**3-19**] so repeat CT head was done, upon review bifrontal collections noted on initial CT were read as being more likely due to atrophy than hygroma. Patient's mental status improved while on the floor and required no further intervention. 14. Demand Ischemia: Patient had ST depressions in setting of extubation and again during episodes of AFib with RVR. Troponins elevated in setting [**Month/Year (2) **] failure. CKs only mildly elevated with negative MB fraction. Patient was anticoagulated with heparin gtt for his AFib, but he was not felt to have ACS. 15. Ileus Abdominal imaging perfored due to distended belly, films most consistent with ileus, resolved post extubation. 16. FEN: [**Month/Year (2) 2793**] diet 17. ACCESS: HD catheter and PIV Medications on Admission: Aspirin 325 mg qd Plavix 75 mg qd Folic acid 1 mg qd Tricor 145 mg qd Pantoprazole 40 mg qd Allopurinol 100 mg [**Hospital1 **] Metoprolol 75 mg tid Pantoprazole 40mg qd Discharge Medications: 1. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours) for 8 days. 2. Clarithromycin 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 8 days. 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4 hours) as needed. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS (Every 3 Days). 7. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 11. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN Peripheral IV - Inspect site every shift 14. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as needed for UGIB. 16. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleeplessness. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Respiratory Failure Septic Shock Influenza Pneumocystis jirovecci pneumonia Pneumococcal pneumonia Acute on chronic [**Hospital1 **] failure, dialysis dependant Multiple Myeloma Atrial Fibrillation Upper Gastrointestinal Bleed Hylicobactor pylori infection Discharge Condition: stable, 94% on 4L NC with desaturation to 88% with ambulation Discharge Instructions: You have been treated for your respiratory complaints and found to have three infections in your lung including influenza, streptococcal pneumonia, and pneumocystis pneumonia. You also developed [**Hospital1 **] failure and a gastrointestinal bleed. During your stay, you were started on hemodialysis. Please continue to get dialysis monday, wednesday, and fridays. When you are discharged from [**Hospital **] Rehab, you will resume your dialysis at Northeast [**Hospital1 8**] Dialysis [**Location (un) 96522**]. [**Hospital1 8**], [**Numeric Identifier 53049**] [**Telephone/Fax (1) 96523**] on a Tuesday, Thursday, Saturday schedule. Dr. [**Last Name (STitle) 118**] the nephrologist will see you there. Please return to [**Location (un) 436**] of the [**Hospital Ward Name 23**] Buildling on Monday, [**4-4**] at 9am to have your blood counts checked and to meet with Dr. [**Last Name (STitle) 410**]. Followup Instructions: Please follow up on Monday, [**4-4**] at 9am with Dr. [**Last Name (STitle) 410**] on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. Please have transportation arranged from [**Hospital1 **] for this appointment. Please continue dialysis three times per week. Please follow up on discharged from [**Hospital **] Rehab, at Northeast [**Hospital1 8**] Dialysis [**Location (un) 96522**]. [**Hospital1 8**], [**Numeric Identifier 53049**] [**Telephone/Fax (1) 96523**] on a Tuesday, Thursday, Saturday schedule. Dr. [**Last Name (STitle) 118**] the nephrologist will see you there. Provider: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 7612**] Date/Time:[**2129-8-5**] 10:00 Provider: [**Name10 (NameIs) **] NUTRITIONIST Phone:[**Telephone/Fax (1) 2207**] Date/Time:[**2129-8-5**] 11:00

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13315

Discharge summary

report

Admission Date: [**2188-4-12**] Discharge Date: [**2188-5-3**] Date of Birth: [**2110-2-3**] Sex: M Service: SURGERY Allergies: Lidocaine Attending:[**First Name3 (LF) 1**] Chief Complaint: nausea, anorexia, and vomiting x4d Major Surgical or Invasive Procedure: exploratory laparotomy, lysis of adhesions, small bowel resection [**2188-4-13**]. History of Present Illness: 78yo M with multiple medical problems presents with 4d history of nausea, progresively worsening, associated with belching, anorexia, and vomiting. Last BM was 4d prior to presentation, no flatus either. Pt also reports some RLQ pain. Past Medical History: HTN DM AFib BPH hypercholesterolemia CAD s/p MIx3 s/p CABG [**2176**] AAA repair [**2174**] colorectal cancer s/p R colectomy [**2186**] AICD [**2185**] pseudoaneurysm of L iliac [**Last Name (un) **] s/p stent [**2186**] Physical Exam: T 97.0, HR 80, BP 110/78, RR 20, 84% on RA, 94% on blow-by-O2 A&O, answers questions CTA with coarse bases soft, minor rLQ tenderness, no rebound, midline scars well-healed. strong Fem pulse BL Pertinent Results: [**2188-4-12**] 06:30PM BLOOD WBC-13.2* RBC-5.15# Hgb-16.8# Hct-46.0# MCV-89 MCH-32.7*# MCHC-36.6*# RDW-12.9 Plt Ct-278 [**2188-4-13**] 02:40AM BLOOD WBC-4.0# RBC-3.30*# Hgb-10.8*# Hct-30.0*# MCV-91 MCH-32.6* MCHC-35.9* RDW-12.9 Plt Ct-132*# [**2188-4-22**] 12:21AM BLOOD Hct-22.3* [**2188-4-22**] 03:05AM BLOOD WBC-16.2* RBC-2.81* Hgb-8.8* Hct-26.7* MCV-95 MCH-31.5 MCHC-33.1 RDW-13.3 Plt Ct-243 [**2188-4-22**] 01:36PM BLOOD Hct-30.1* [**2188-4-27**] 05:45AM BLOOD WBC-13.2* RBC-3.20* Hgb-10.1* Hct-31.0* MCV-97 MCH-31.5 MCHC-32.5 RDW-13.4 Plt Ct-330 [**2188-4-28**] 04:22AM BLOOD WBC-12.9* RBC-2.25*# Hgb-6.9*# Hct-21*# MCV-94 MCH-30.8 MCHC-32.9 RDW-13.1 Plt Ct-377 [**2188-4-28**] 07:41AM BLOOD Hct-28.5*# [**2188-5-2**] 12:25PM BLOOD WBC-12.1* RBC-3.31* Hgb-10.6* Hct-31.6* MCV-95 MCH-32.1* MCHC-33.7 RDW-13.5 Plt Ct-344 [**2188-4-20**] 01:45AM BLOOD WBC-23.1*# RBC-3.15* Hgb-10.1* Hct-29.7* MCV-94 MCH-32.1* MCHC-34.0 RDW-13.5 Plt Ct-189 [**2188-4-20**] 01:45AM BLOOD Neuts-92.4* Bands-0 Lymphs-4.6* Monos-1.4* Eos-1.5 Baso-0.1 [**2188-4-12**] 06:30PM BLOOD Plt Smr-NORMAL Plt Ct-278 [**2188-4-12**] 08:00PM BLOOD PT-35.1* PTT-42.9* INR(PT)-7.7 [**2188-4-13**] 02:40AM BLOOD PT-21.0* PTT-41.9* INR(PT)-2.8 [**2188-4-13**] 10:03AM BLOOD PT-17.1* PTT-62.8* INR(PT)-1.8 [**2188-4-13**] 12:00PM BLOOD PT-17.2* PTT-38.0* INR(PT)-1.9 [**2188-4-13**] 08:40PM BLOOD PT-17.8* PTT-45.3* INR(PT)-2.0 [**2188-4-14**] 12:38AM BLOOD PT-15.1* PTT-35.2* INR(PT)-1.4 [**2188-4-14**] 11:25AM BLOOD PT-16.3* PTT-39.4* INR(PT)-1.7 [**2188-4-12**] 06:30PM BLOOD Glucose-389* UreaN-81* Creat-3.9*# Na-122* K-4.1 Cl-76* HCO3-24 AnGap-26* [**2188-4-12**] 08:00PM BLOOD Glucose-296* UreaN-78* Creat-3.4* Na-128* K-4.0 Cl-91* HCO3-20* AnGap-21* [**2188-4-13**] 02:40AM BLOOD Glucose-147* UreaN-65* Creat-2.3*# Na-136 K-3.4 Cl-106 HCO3-21* AnGap-12 [**2188-4-13**] 06:34AM BLOOD Glucose-73 UreaN-56* Creat-1.9* Na-138 K-3.2* Cl-107 HCO3-22 AnGap-12 [**2188-4-13**] 01:01PM BLOOD Glucose-133* UreaN-47* Creat-1.6* Na-138 K-3.1* Cl-106 HCO3-23 AnGap-12 [**2188-4-13**] 08:40PM BLOOD K-3.5 [**2188-4-14**] 12:38AM BLOOD Glucose-129* UreaN-38* Creat-1.2 Na-140 K-3.8 Cl-107 HCO3-23 AnGap-14 [**2188-4-14**] 11:25AM BLOOD Glucose-87 UreaN-31* Creat-1.0 Na-142 K-3.5 Cl-110* HCO3-24 AnGap-12 [**2188-5-3**] 05:55AM BLOOD Glucose-61* UreaN-25* Creat-1.3* Na-142 K-4.1 Cl-103 HCO3-30* AnGap-13 [**2188-4-12**] 06:30PM BLOOD ALT-17 AST-20 CK(CPK)-62 AlkPhos-106 Amylase-49 TotBili-0.6 [**2188-4-13**] 06:34AM BLOOD CK(CPK)-583* [**2188-4-18**] 02:28AM BLOOD ALT-11 AST-20 AlkPhos-59 Amylase-9 TotBili-0.4 [**2188-4-22**] 01:36PM BLOOD LD(LDH)-330* [**2188-4-27**] 03:22AM BLOOD CK(CPK)-59 [**2188-5-1**] 02:31AM BLOOD CK(CPK)-30* [**2188-5-1**] 10:40AM BLOOD CK(CPK)-37* [**2188-5-1**] 04:40PM BLOOD CK(CPK)-26* [**2188-4-12**] 06:30PM BLOOD cTropnT-0.02* [**2188-4-27**] 03:22AM BLOOD CK-MB-4 cTropnT-0.05* [**2188-5-1**] 02:31AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2188-4-12**] 06:30PM BLOOD Albumin-4.3 [**2188-4-18**] 02:28AM BLOOD Albumin-1.9* Phos-3.1 Mg-1.8 [**2188-4-28**] 04:22AM BLOOD Albumin-2.3* Calcium-7.7* Phos-2.9# Mg-1.7 Iron-21* Brief Hospital Course: 78yo M admitted to surgical service with small bowel obstruction, confirmed on CT with transition point in mid-pelvis. Pt was initially placed on aggressive IVF hydration of 9 liters with continued hypotension. He was therefore taken to the operating room for exploratory laparotomy; please see operative note for details. In brief, an incarcerated umbilical hernia was suspected and an ischemic portion of small-bowel was resected and anastamosed primarily. The pt was transferred post-operatively to the ICU. He remained intubated with swan-ganz catheter placed. He was transfused PRBCs and FFP to reverse coagulopathy. He received a cardiac echo which showed EF 30%. Continued to receive fluid boluses. He developed worsening oxygenation, requiring increasing support, and an esophageal balloon was placed. CXR showed worsening opacities consistent with ARDS. He was started on TPN for nutritional support. Gradually he was titrated off pressors by POD 3. He intermittently spiked fevers to 102.5, he had been on levaquin for klebsiella in sputum and was switched to ceftriaxone and added vancomycin. A BAL grew out MRSA and so linezolid was added. Repeat CT showed no leak or collection but persistent obstruction and ARDS. He GI status improved as he opened up and nutrition was changed from TPN to TF via a post-pyloric feeding tube placed on POD 10. These were occasionally held for high residuals but ultimately advanced to goal. He was followed by nutrition consult. He respiratory status gradually improved and was weaned and extubated. He was ultimately transferred to floor on POD 14. He was diuresed aggressively with net negative 1 liter daily, as he weighed pre-op 183 pounds, post-op peak 220 lbs, and currently 190pounds. CXRs confirmed improved fluid status. His outpatient cardiologist was involved in guiding his care. He participated in physical therapy, foley d/c'd without event, and was prepared for rehab after tolerating a diabetic diet with calorie counts. The antibiotics are continued to complete a total 14-day course. Medications on Admission: diovan 80' coumadin 5' spironolactone 12.5' glyburide 5' digoxin .125' lasix 40' toprol 50' lipitor 20' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. 13. Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale Injection ASDIR (AS DIRECTED). 14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: small bowel obstruction ARDS ventilator-associated pneumonia MRSA and Klebsiella pneumonia HTN DM AFib s/p AICD CAD s/p MI hypercholesterolemia BPH CHF colon cancer Discharge Condition: stable Discharge Instructions: [**Name8 (MD) **] MD if develop fever or chills; nausea, vomiting, lack of bowel movements, or abdominal distension; dyspnea or shortness of breath; incision becomes red, swollen, warm, or drains pus; or inability to urinate. Take medications as directed. Continue to participate in Rehab. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**2-3**] weeks. Call [**Telephone/Fax (1) 9**] for an appointment. Follow-up with Dr. [**Last Name (STitle) **] 2 weeks after discharge from rehab. Call [**Telephone/Fax (1) 127**] for an appointment. Previously arranged appointments: Provider [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], MD Where: [**Hospital6 29**] SURGICAL SPECIALTIES Phone:[**Telephone/Fax (1) 160**] Date/Time:[**2188-5-26**] 8:45 Provider CAT SCAN Where: [**Hospital6 29**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2189-3-4**] 2:00 Provider VAS [**Name9 (PRE) 3627**] [**Name9 (PRE) 3628**] VASCULAR LMOB Where: VASCULAR LMOB Date/Time:[**2189-3-4**] 3:00

[ "428.0", "482.0", "427.31", "557.0", "V09.0", "250.00", "552.1", "518.5", "401.9", "V53.32", "482.41" ]

icd9cm

[ [ [] ] ]

[ "96.72", "45.62", "99.07", "53.49", "99.04", "33.24", "99.15", "00.17", "89.64", "99.77", "00.14" ]

icd9pcs

[ [ [] ] ]

7697, 7794

4264, 6315

299, 384

8003, 8011

1122, 4241

8350, 9079

6469, 7674

7815, 7982

6341, 6446

8035, 8327

908, 1103

225, 261

412, 648

670, 893

1,264

169,492

11810

Discharge summary

report

Admission Date: [**2127-12-19**] Discharge Date: [**2127-12-30**] Service: CA/TH [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 82 -year-old male with a history of colon cancer. He is status post resection with colostomy, followed by colostomy take down three months ago, as well as a remote history of seizure disorder well controlled with Dilantin, who complained of a stuttering course of chest pain times 48 hours prior to admission at [**Hospital **] Hospital on [**2127-12-19**]. The patient had a questionable history of transient ischemic attack. His electrocardiogram on admission at 05:45 PM at [**Hospital **] Hospital showed acute ST segment depressions between C1 through V5, as well as aortic valve replacement and AVL. He had ST segment elevations in II, III, AVF, as well as left axis deviation and a first degree A-V block and multiple atrial premature contractions and premature ventricular contractions. He was given no thrombolytic course due to his questionable history of transient ischemic attack in the past and was therefore transferred to the [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] for an urgent cardiac catheterization. ADMITTING MEDICATIONS: His admitting medications included aspirin, sublingual nitroglycerin, heparin bolus and drip, nitroglycerin drip at 20 mcg, and was pain free prior to transfer. HOSPITAL COURSE: While on the catheterization table, he did develop chest pain at [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. During the catheterization he was found to have pulmonary capillary wedge mean pressure of 28, a right atrial pressure of 8.0, aortic pressures of 195/98 with a mean of 135, pulmonary artery pressure of 57/26 with a mean of 37, right ventricular pressure of 45/8 with a mean of 12, and there was also evidence of significant mitral regurgitation that was suspected. He had a left dominant system that showed the left main coronary artery as being normal, his left anterior descending as an 80% distal occlusion, distal stenosis at the level of second diagonal, as well as 90% diffusely disease to the proximal first diagonal. He had a left circumflex lesion that was 50% proximal stenosis and then he received a percutaneous transluminal coronary angioplasty to a 70% stenosed first obtuse marginal artery, status post percutaneous transluminal coronary angioplasty showed good flow as well as 100% cut off in the PL branch, consistent with a thrombus. This additionally was percutaneous transluminal coronary angioplastied. There is also evidence of a right coronary artery with a 90% mid lesion. Due to the significant three vessel disease and left anterior descending disease, he was put on [**Last Name (LF) 37318**], [**First Name3 (LF) **] intra-aortic balloon pump was placed, he was given aspirin and ACE inhibitors. He was placed on the COOL M1 protocol and then Cardiothoracic Surgery was consulted. On hospital day two, [**2127-12-20**], the patient received an echocardiogram, revealing an ejection fraction of 40%, 1+ mitral regurgitation, 1+ aortic regurgitation. Additionally by this point, the patient had had multiple runs of nonsustained ventricular tachycardia with stable blood pressures while being maintained on intra-aortic balloon pump. His ventricular ectopy was undoubtedly related to ischemia. As a consequence, the patient was consulted to Electrophysiology who opted to hold off on studying the patient until after he had been revascularized. Cardiac Surgery with Dr. [**Last Name (STitle) **] ultimately took the patient to the Operating Room on [**2127-12-22**]. His preoperative hematocrit was 29. He had a BUN and creatinine of 24 and 1.3. His chest x-ray shows no infiltrate, no effusion, no pulmonary edema. He had normal coagulation profile except for a PTT of 60 as he was being heparinized for his ischemic episode. His cardiac enzymes were CPK trends of 653, 1,124, and 1,351 with MB fractions of 43, 130, and 190. Troponin I fractions were 6.6, 11.6, and 14.1, all consistent with an acute myocardial infarction along the inferior system. On [**2127-12-22**], he went to the Operating Room with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 11743**] and he underwent a four vessel coronary artery bypass graft, including left internal mammary artery to the diagonal, saphenous vein graft to left anterior descending, saphenous vein graft to second obtuse marginal artery, and a saphenous vein graft to the right posterior descending artery. Indications were unstable angina, low ejection fraction, and myocardial infarction. His bypass time was 91 minutes with a cross clamp times 75 minutes. His pericardium was left open and he left the Operating Room with a radial A-line and a Swan-Ganz catheter as well as a right femoral intra-aortic balloon pump. He had two ventricular and two atrial pacing wires, two mediastinal chest tubes, and one left pleural tube. He was taken intubated to the Cardiac Surgery Recovery Unit where he was extubated on the night of surgery. He remained neurologically intact. Respiratory wise he was doing well, was extubated, had good gas exchange. His chest tubes were left for high outputs of 600 and 250 respectively. He did have a temperature of 101.3 F, but his white count was 8,000. He did have a hematocrit of 23 and his BUN and creatinine were 17 and 1.1. His arterial blood gas on 40% face mask was 7.45, 34, 67, unlabored. He received two units of packed red blood cells, his intra-aortic balloon pump was weaned off. By postoperative day two he remained neurologically intact. Cardiovascular wise he had frequent ectopy with runs of what looked like atrial fibrillation and was therefore placed on amiodarone empirically. It was rate controlled in the 60s. I additionally had evidence of multiple premature ventricular complexes. His mediastinal chest tubes were removed on postoperative day two and his left pleural tube was left in place. His BUN and creatinine remained stable at 25 and 1.1 with a hematocrit of 33. Infectious Disease wise he had no issues. He was transferred to the floor by postoperative day two. On postoperative day three the patient remained stable; however, was having frequent ectopy with premature ventricular contractions and possible premature atrial contractions, question premature atrial contractions versus atrial fibrillation. Electrophysiology was consulted subsequently. Electrophysiology felt that certainly beta blockade and electrolyte repletion were appropriate for this patient. He was maintained on amiodarone although he continued to have ectopy. As a consequence, Dr. [**Last Name (STitle) 911**] and Dr. [**Last Name (STitle) **] of the Electrophysiology service noted that on postoperative day three the patient should receive a sinoatrial node electrocardiogram to assess for latent potential as well as to do a formal electrophysiologic study evaluation to see if there is any inducible ventricular tachycardia. The patient's chest tubes were removed at this time. He was out of bed, ambulating with Physical Therapy, and was started on a low dose beta blocker of 12.5 mg of Lopressor [**Hospital1 **]. By [**2127-12-26**], Dr. [**Last Name (STitle) **] took the patient to the Catheterization Lab where the patient was found to have a positive sinoatrial node electrocardiogram showing A-V nodal irreentrant tachycardia that could be induced, as well as an inducible ventricular tachycardia and was therefore given an ICV internal cardiac defibrillator device. The patient tolerated the procedure well and on postoperative day four was discharged back to the Far Six Floor Recovery Unit. By postoperative day five, the patient began complaining of some loose stools which was thought to be secondary to his previous history of colon resection, typically took some Imodium and was therefore started back on his Imodium. His hematocrit at this time was 29 with a BUN and creatinine of 27 and 1.3. His electrolytes were repleted accordingly. Neurologically he was alert and oriented times three and appropriate. His pain was being controlled with Percocet and Motrin. Pulmonary and cardiac wise, an ICD was placed. Electrophysiology was on board. The patient was being ventricularly paced at this time. PA and lateral was checked, but showed no evidence of chest x-ray with good lead placement, minimal effusions, no vascular engorgement. On fluids, electrolytes, and nutrition / gastrointestinal his electrolytes were repleted appropriately and his diet was advanced as tolerated. His Foley was removed at this time and he was mobilized out of bed with physical therapy. Electrophysiology saw the patient on post procedure day one which was [**2127-12-27**] and recommended the patient continue periprocedure antibiotics of vancomycin times 48 hours, to remain in an arm sling for the time being, and to follow-up in the [**Hospital 19721**] Clinic in one week from the time of discharge. Over the next couple of days the patient did well. He did have increased oxygen requirements on postoperative day seven. As a consequence, chest x-ray was checked which showed evidence of small effusion and some vascular engorgement. He consequently was diuresed and his oxygenation improved. He was given aggressive pulmonary toilet with incentive spirometry, ambulation, and pain control, coughing and deep breathing, and chest physical therapy prn. He subsequently improved. On the day before discharge, his labs were noted for a hematocrit of 28, BUN and creatinine of 25 and 1.2. His sternum was stable with no drainage. He was afebrile with a temperature of 99.5 F, he was 80 and paced, blood pressure was 130/58, 94% on three liters nasal cannula. His lungs had decreased breath sounds, left greater than right. There was some mild diffuse crackles noted also on examination. Lower extremities were unremarkable. The saphenous vein graft harvest site was clean, dry, and intact. On the telemetry monitor he had no further evidence of ectopy. DISCHARGE MEDICATIONS: Will include Percocet 5/325 one to two tabs po q four to six hours prn, Imodium 2.0 mg po q six hours prn, Keflex 500 mg po qid times one week, Lipitor 10 mg po q day, amiodarone 400 mg po q day, Protonix 40 mg po q day, Dilantin 100 mg po tid, Plavix 75 mg po q day, aspirin 325 mg po q day, Lasix 20 mg po bid times seven days, K-Dur 20 mEq po bid times seven days, and Lopressor 12.5 mg po bid. FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) **] in one month from the time of discharge. He will follow-up in the Electrophysiology Clinic in one week from the time of discharge. DISCHARGE STATUS: He will be discharged to a rehabilitation facility for strengthening, conditioning, and wound checks. DISCHARGE CONDITION: Stable sternum, afebrile, paced rhythm. DISCHARGE DIAGNOSES: 1. Three vessel coronary artery disease. 2. Acute myocardial infarction inferiorly. 3. Status post four vessel coronary artery bypass graft: left internal mammary artery to diagonal, saphenous vein graft to left anterior descending, saphenous vein graft to second obtuse marginal artery, and saphenous vein graft to the right posterior descending artery. 4. Hypertension. 5. Status post percutaneous transluminal coronary angioplasty to first obtuse marginal artery and PL. 6. Hypercholesterolemia. 7. Coronary artery disease. 8. Transient ischemic attack times two. 9. Colon cancer. 10. Seizure disorder. PAST SURGICAL HISTORY: 1. Cancer resection with colostomy and then colostomy take down. 2. Percutaneous transluminal coronary angioplasty done on [**2127-12-19**]. ALLERGIES: None. PHYSICAL EXAMINATION: Preoperative weight was 75 kg. All of the remaining information about the [**Hospital 228**] hospital course and work up and recovery are in the body of this dictation. DISCHARGE INSTRUCTIONS: The patient was instructed not to lift any heavy objects greater than ten pounds times thirty days, no driving times thirty days. His Steri-Stripped wounds will remain open to air. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2127-12-29**] 09:37 T: [**2127-12-29**] 09:40 JOB#: [**Job Number 37319**]

[ "424.0", "427.1", "997.1", "414.01", "486", "V10.05", "780.39", "410.41", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.34", "36.05", "37.26", "37.23", "37.61", "36.15", "36.13", "37.94", "39.61" ]

icd9pcs

[ [ [] ] ]

10939, 10980

11001, 11617

10189, 10917

1460, 10165

12022, 12485

11640, 11803

11826, 11997

150, 1442

44,023

148,889

38170

Discharge summary

report

Admission Date: [**2157-9-19**] Discharge Date: [**2157-9-28**] Date of Birth: [**2107-2-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: atrial fibrillation, failed medical therapy Major Surgical or Invasive Procedure: s/p Bilateral mini thoracotomy with pulmonary vein isolation using AtriCure Synergy system with resection of left atrial appendage. 2. Electrophysiology study performed by Dr. [**First Name4 (NamePattern1) **] [**2157-9-21**] History of Present Illness: This 50 year old male with a history of atrial fibrillation was diagnosed in [**2154**] with congestive heart failure and cardiomyopathy. Symptoms are disabling for him and he has had recurrent episodes despite initial sinus rhythm. His ejection fraction has ultimately improved to 50%, but he failed Flecainide/Dronedarone therapy and subsequently Multaq. He is currently on Flecanide and Toprol XL and has had one episode of fibrillation since [**Month (only) **], which lasted less than 12 hours. He is thus referred for evaluation for mini-Maze procedure. Past Medical History: paroxysmalatrial fibrillation hypertension cardiomyopathy Social History: Race: Caucasian Last Dental Exam: regular dental care Lives with: wife and 2 children Occupation: auto insurance appraiser, limo driver Tobacco: quit 25yrs. ago ETOH: 4/week Family History: Family History:non-contributory Physical Exam: Admission Physical Exam Pulse: 58 SR Resp: 16 O2 sat: 98%RA B/P Right: 112/77 Left: Height: 6'3" Weight: 225lb General: 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 Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema -no Varicosities -minor 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: Pertinent Results: [**2157-9-23**] 04:50AM BLOOD WBC-13.7* RBC-4.64 Hgb-14.3 Hct-41.4 MCV-89 MCH-30.8 MCHC-34.5 RDW-13.0 Plt Ct-172 [**2157-9-19**] 10:40PM BLOOD WBC-6.3 RBC-4.68 Hgb-14.7 Hct-40.3 MCV-86 MCH-31.4 MCHC-36.5* RDW-13.2 Plt Ct-176 [**2157-9-23**] 04:50AM BLOOD PT-13.0 INR(PT)-1.1 [**2157-9-19**] 10:40PM BLOOD PT-13.5* PTT-29.8 INR(PT)-1.2* [**2157-9-23**] 04:50AM BLOOD Glucose-115* UreaN-12 Creat-0.8 Na-138 K-3.7 Cl-104 HCO3-25 AnGap-13 [**2157-9-19**] 10:40PM BLOOD Glucose-137* UreaN-18 Creat-1.0 Na-142 K-3.5 Cl-106 HCO3-26 AnGap-14 [**2157-9-19**] 10:40PM BLOOD ALT-18 AST-24 LD(LDH)-146 AlkPhos-76 Amylase-33 TotBili-0.4 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 85136**] (Complete) Done [**2157-9-21**] at 12:35:47 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2107-2-25**] Age (years): 50 M Hgt (in): 72 BP (mm Hg): 105/67 Wgt (lb): 220 HR (bpm): 78 BSA (m2): 2.22 m2 Indication: Atrial fibrillation. Hypertension. Shortness of breath. Hx of cardiomyopathy of unknown origin. Intraoperative TEE for Bilateral mini MAZE procedure and left atrial appendage ligation. ICD-9 Codes: 425.4, 427.31, 786.05 Test Information Date/Time: [**2157-9-21**] at 12:35 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18397**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: [**Doctor Last Name **] iE33 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *5.8 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.9 cm Left Ventricle - Fractional Shortening: 0.33 >= 0.29 Left Ventricle - Ejection Fraction: 60% >= 55% Aorta - Annulus: 2.6 cm <= 3.0 cm Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 6 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 4 mm Hg Aortic Valve - LVOT diam: 2.4 cm Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A ratio: 2.00 Findings LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast in the body of the LA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Bidirectional shunt across the interatrial septum at rest. Small secundum ASD. LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Trivial MR. TRICUSPID VALVE: Physiologic 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. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions The left atrium is markedly dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. There is a 0.5 cm mass that resembles a clot in the left atrium at the junction of the left atrial appendage and the coumadin ridge. 3D examination revealed this to be a fold of tissue arising from the wall of the atrium. Ejection velocities in the left atrial appendage was greater than 40 cm/sec. 3D examination performed by Dr [**First Name (STitle) 6507**] and confirmed as native tissue and not clot. A small secundum atrial septal defect is present. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque . The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. Trivial mitral regurgitation is seen. Dr.[**Last Name (STitle) 914**] was notified in person of the results. Post procedure the left atrial appendage has been ligated. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2157-9-21**] 16:12 ?????? [**2150**] CareGroup IS. All rights reserved. Brief Hospital Course: On [**2157-9-20**] Mr.[**Known lastname **] [**Last Name (Titles) 1834**] preoperative testing including cardiac MRI and cardiac Cath. During catheterization, prior to sheath insertion, Mr.[**Known lastname **] had an asystolic episode for 20 seconds treated with Atropine. Please refer to catheterization report for further details. On [**2157-9-21**] he was taken to the Operating Room and [**Year (4 digits) 1834**] bilateral thoracotomies for mini-MAZE procedures with ligation of the left atrial appendage by Dr.[**Last Name (STitle) 914**]. Please refer to the operative report for further surgical details. He tolerated the procedure well and was transferred to the CVICU intubated in critical but stable condition. He awoke neurologically intact and was weaned to extubation without difficulty. All lines and drains were discontinued in a timely fashion. His preop Flecainide was resumed along with Beta-blocker and Aspirin. Diuresis was initiated. He was transferred to the step down unit on POD#1 for further monitoring.Physical Therapy was consulted for evaluation of strength and mobility. Transient postoperative Atrial fibrillation was treated with Diltiazem and increasing Beta- blocker.His rhythm converted to normal sinus. Anti coagulation with Coumadin was resumed. Inr goal 2-2.5. Follow up Coumadin dosing to be resumed by his cardiologist, Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. On POD#3 his rhythm again went into atrial flutter/fibrillation with a rate 130s. Beta-blocker IV and orally was given with minimal response. IV Diltiazem given with immediate rate control in 70-80s. Oral Diltiazem was initiated. He continued to progress and his fib/flutter rate remained controlled. On [**9-27**] he was cardioverted to sinus rhythm and diltiazem was changed to a long acting formulation. His Coumadin will be dosed on discharge by Dr. [**Last Name (STitle) **] in [**Hospital1 1559**], who has done so before. By post-operative day seven he was ready for discharge to home. All follow-up appointments were advised. Medications on Admission: Coumadin 5mg three days per week, 7.5mg four days per week-last dose 8/25 Lisinopril 10 mg daily Fish oil Flecanide 100 mg PO BID Toprol XL 100 mg PO daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 3. Flecainide 150 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 9. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): with meals. Disp:*90 Capsule(s)* Refills:*2* 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day as needed for afib. Disp:*30 Capsule, Sustained Release(s)* Refills:*0* 12. Outpatient Lab Work please draw a INR/PT on [**2157-9-29**] and then prn Phone results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 6489**]. INR goal 2-2.5 for Afib. 13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: 5mg daily three times per week, 7.5mg four days per week as directed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 6489**]. INR goal 2-2.5 for Afib. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, Discharge Diagnosis: Medically refractory paroxysmal atrial fibrillation. s/p Bilateral mini thoracotomy with pulmonary vein isolation using AtriCure Synergy system with resection of left atrial appendage. 2. Electrophysiology study performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] hypertension cardiomyopathy acute systolic congestive heart failure [**2154**] 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 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) 914**] #[**Telephone/Fax (1) 170**], appointment arranged for [**2157-10-11**] at 1:30 pm Cardiologist:Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 6489**]appointment arranged for [**2157-10-24**] at 11:15 AM Please call to schedule appointments with your Primary Care: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32628**] in [**1-22**] 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** Labs: PT/INR for Coumadin ?????? indication: MAZE/LAA ligation/ AFib Goal INR: 2-2.5 First draw:[**2157-9-29**] Results to: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 6489**] Completed by:[**2157-9-28**]

[ "997.1", "428.21", "E878.8", "427.32", "V58.61", "E879.0", "401.9", "997.2", "425.4", "V72.81", "427.5", "427.31", "780.2", "428.0" ]

icd9cm

[ [ [] ] ]

[ "37.36", "37.26", "37.22", "99.62", "88.56", "03.90" ]

icd9pcs

[ [ [] ] ]

11768, 11820

7690, 9763

364, 592

12240, 12406

2180, 7667

13330, 14243

1488, 1506

9970, 11745

11841, 12219

9789, 9947

12430, 13307

1521, 2161

281, 326

620, 1183

1205, 1265

1281, 1457

15,809

154,656

17228

Discharge summary

report

Admission Date: [**2121-6-23**] Discharge Date: [**2121-6-30**] Date of Birth: [**2056-10-31**] Sex: M Service: Cardiothoracic HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with a history of coronary artery disease, endocarditis status post coronary artery bypass grafting and mitral valve replacement on [**2121-6-6**]. He was transferred to [**Hospital1 190**] from the rehabilitation center where he had been discharged to on [**2121-6-18**] following his CABG/MVR. At the rehabilitation center the patient developed shortness of breath. A chest x-ray done at that time revealed a left-sided infiltrate versus effusion. He was transferred to [**Hospital1 69**] for treatment. At the time he complained of no chest pain, weakness or cough, although he is intermittently short of breath. He had been anticoagulated during his stay at rehabilitation for atrial fibrillation. PAST MEDICAL HISTORY: 1. Significant for coronary artery disease status post CABG/MVR. 2. Endocarditis. 3. Rectal cancer. 4. Atrial fibrillation. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON TRANSFER: 1. Amiodarone 200 mg q.d. 2. Lasix 20 mg b.i.d. 3. Potassium chloride 20 mEq b.i.d. 4. Ampicillin 2 grams q. 4 hours. 5. Albuterol and Atrovent p.r.n. 6. Aspirin 325 q.d. 7. Coumadin 5 q.d. 8. Nystatin swish and swallow 5 cc t.i.d. 9. Colace 100 b.i.d. 10. Percocet 5/325, 1-2 tablets q. 4 hours p.r.n. LABORATORY DATA: White count 12.6, hematocrit 28.9, platelet count 259, PT 21.4, PTT 40.2, INR 3.0, sodium 137, potassium 4.2, chloride 100, CO2 27, BUN 26, creatinine 1.3, glucose 120. Chest x-ray shows a large left pleural effusion. PHYSICAL EXAMINATION: On admission vital signs were temperature 100.1, heart rate 83 and sinus rhythm, blood pressure 108/50, respiratory rate 25, oxygen saturation 97% on three liters. Generally he was a pleasant man with mild respiratory distress. Lungs had decreased breath sounds on the left. Cardiac examination showed regular rate and rhythm, S1 and S2. Chest incision was with Steri-Strips, open to air, clean and dry. Abdomen was soft and nontender, nondistended, with positive bowel sounds. Extremities had bilateral pedal edema. Right leg wound had Steri-Strips, open to air, clean and dry. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**]. He was given fresh frozen plasma to correct his INR and a left chest tube was placed. Over the first 12 hours the chest tube drained 2,500 cc. On hospital day two the patient was transferred from the cardiac surgery recovery unit to [**4-25**] for continuing care. He remained hemodynamically stable. His chest tube drainage reduced significantly after the first 24 hours and on hospital day three his chest tube was discontinued. Over the next several days the patient remained in the hospital to reassess for recurrent pleural effusion. On [**6-26**] it was decided that the patient was stable and ready to be transferred back to rehabilitation, however case management was unable to get authorization from the patient's insurance company and he remained in the hospital throughout the holiday weekend awaiting insurance authorization for transfer back to rehabilitation. At this time the patient's physical examination is as follows: Vital signs were temperature 97.8, heart rate 80 and sinus rhythm, blood pressure 140/82, respiratory rate 18, O2 saturation 96% on room air. Weight on admission was 64 kg, at discharge was 51.6 kg. Laboratory data showed an hematocrit of 31.6, PT 13, INR 1.2, potassium 4.5, BUN 18, creatinine 0.9. He was alert and oriented x 3, moved all extremities, followed commands. Respiratory examination was clear to auscultation bilaterally. Cardiac showed a regular rate and rhythm, S1 and S2. Sternum was stable. Incisions had Steri-Strips, open to air, clean and dry. Abdomen was soft, nontender, nondistended, with normal active bowel sounds. Extremities were warm and well perfused with no edema. Right lower extremity incision with Steri-Strips, open to air, clean and dry. DISCHARGE MEDICATIONS: 1. Colace 100 mg b.i.d. 2. Aspirin 325 mg q.d. 3. Nystatin swish and swallow, 5 cc q. 8 hours. 4. Ampicillin 2 grams IV q. 6 through [**7-2**]. 5. Amiodarone 200 mg q.d. 6. Percocet 5/325, 1-2 tablets q. 6 hours p.r.n. 7. Milk of Magnesia 30 cc q.h.s. p.r.n. CONDITION ON DISCHARGE: Good. DISPOSITION: He is to be discharged to rehabilitation. FO[**Last Name (STitle) 996**]P: He is to see Dr. [**Last Name (Prefixes) **] in one month, Dr. [**Last Name (STitle) 35028**] in one month and Dr. [**Last Name (STitle) 73**] in one month. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2121-6-30**] 08:54 T: [**2121-6-30**] 09:17 JOB#: [**Job Number 48288**]

[ "V42.2", "V58.61", "V45.81", "427.31", "421.0", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

[ [ [] ] ]

4124, 4384

2322, 4101

1717, 2304

177, 912

1143, 1694

935, 1117

4409, 4916

75,496

173,395

4196

Discharge summary

report

Admission Date: [**2137-4-3**] Discharge Date: [**2137-4-10**] Date of Birth: [**2089-11-11**] Sex: M Service: MEDICINE Allergies: Grape / Zosyn / Unasyn / Vancomycin Attending:[**First Name3 (LF) 1257**] Chief Complaint: Foot pain Major Surgical or Invasive Procedure: Wound debridment History of Present Illness: 47 y/o Type 1DM s/p multiple foot amputations, CAD s/p 3 MIs, PUD, and bipolar disorder, presents with 5 days of pus production, swelling, erythema and pain of right lateral foot. Had blister lanced by podiatry in same area 2 weeks ago, since then has been having clear, then brown discharge. 4 days ago developed chills, and fever to 101 last night. Pt reports [**11-16**] pain described as "broken bones" and unability to ambulate flatfooted, only on heel. Presented to OSH, received oxacillin and pain control and transferred here for furthur eval as pt's podiatrist is here. . Pt reported 1 episode of black stools approx 1 week ago, no N/V/D or abd pain. . In the ED, initial vs were: T 99.7 P 87 BP 114/64 R 16 O2 98% on RA. Labs were significant for WBC of 14.6. Patient was given Morphine 4mg IV for pain Klonopin 1mg & Haldol per home regimen. Pt was seen by podiatry and had x-ray of foot, unread at this point. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. CAD s/p MI x3, PCI: a)IMI in [**2130**] and angioplasty of small RCA b) [**5-10**]-MI s/p angioplasty and stent c) Repeat angioplasty and brachytherapy in [**2132-2-7**] Cath [**6-10**] done for chest pain showed patent vessels with normal EF 2. HTN 3. DM1 c/b retinopathy, neuropathy, 4. Hyperlipidemia 5. Bipolar disorder 6. Peripheral vascular disease s/p R first toe amp 7. GERD s/p Nissen fundoplication 8. Normocytic Anemia Social History: Tobacco: 30pk yrs, quit [**2125**]. No ETOH. Previously a construction worker now on SSDI. Had motorcycle accident 20 years ago and pt reports associated memory problems. [**Name (NI) **] four children. From [**Location (un) 912**], MA. Family History: Mother and father both have type II diabetes, one sister had GDM. Father had early CAD. Physical Exam: [**4-3**] PE: Vitals: 99.7, 103/67, 84, 16, 98% General: Alert, oriented, NAD HEENT: sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD Lungs: CTAB, no wheezes, rales, or rhonchi CV: RRR, normal S1, S2, no murmurs, rubs, or gallops Abdomen: Soft,nontender, non distended, no rebound guarding or organomegaly Extremities: R foot w/lateral dry scabbed area (1 cm) with surrounding erythema, edema. No edema, 2+ DP, PT pulses bilaterally. Great toe and 5th toe on right s/p amputation. + Muscle wasting Guaiac: Neg in ED Pain: [**11-16**] Pertinent Results: [**2137-4-3**] 01:55PM BLOOD WBC-14.6* RBC-3.78* Hgb-12.2* Hct-34.2* MCV-90 MCH-32.3* MCHC-35.7* RDW-13.1 Plt Ct-263 BLood Glucose-139* UreaN-21* Creat-1.1 Na-137 K-3.9 Cl-102 HCO3-29 AnGap-10 [**2137-4-3**] 02:01PM BLOOD Lactate-1.1 MRI of right foot on [**4-5**]: No osteomyelitis, or abscess identified. Edema and enhancement of the subcutaneous soft tissues, consistent with cellulitis. Chest X-Ray on [**4-4**]: Normal Echo on [**2137-4-6**]: No pericardial effusion. Normal global and regional biventricular systolic function. Mild pulmonary hypertension. Blood culture from [**4-4**]: no growth, subsequent blood cultures pending Brief Hospital Course: 47 yo M with h/o DM1 with previous h/o of toe amputations and CAD presents with foot pain and ulcer: # Hypotension/Fever/Tachycardia: Pt originally presented to [**Hospital **] hospital after several days of fever w/pain and drainage of right foot, had a WBC of 17.9, was given Oxacillin snd Vancomycin, and transferred to the [**Hospital1 **] that day. He was afebrile and normotensive on admission. On [**4-4**] he spiked fevers and dropped bp and antibiotics were switched to Zosyn and continued on Vancomycin. Over next two days pt received over 20+L of iv fluid and his ACE and beta blocker was discontinued. He was also put on CLindamycin for potential necrotizing fascitis given pt's pain was out of proportion to the exam. He was transferred to MICU for persistently low BPs on [**4-5**], had a R IJ placed and was on pressor support for approximately 5 hours before being weaned. He also had an elevation in his eosinophil count to 9.9. He stabalized and improved over the course of two days and was stable to go out to the floor on [**4-6**]. We continued the above abx per ID recs. Since nec fasciitis was unlikely given clinical appearance, and MRI revealed cellulitis, not osteomyelitis, his WBC was in NL range, and his eosinophil count was elevated, it was felt that autonomic decompensation and fever might be a drug reaction rather than sepsis. Originally on Vanc/Clinda/Zosyn, regimen was switched to Cipro/Flagyl/Linezolid per ID on [**4-7**]. On [**4-7**], Pt felt much better, normotensive and afebrile. From [**Date range (1) 10230**] pt continued to improve without pain, fever, and good BP control. On [**4-9**] Flagyl was discontinued. Patient has been afebrile and normotensive > 72 hours at discharge. # Foot ulcer: Based on h/o diabetes and prior positive cultures, thought to be multimicrobial. No wound culture sent. Pain was out of preportion to exam, originally concerning for Nec Fasc although there was a likely neuropathic component. See above for antibiotic regimen. First three medication changes for broadening of coverage, the change on [**4-7**] due to continued fever and concern that these fevers may have been drug related, particularly concerning given a modest eosinophilia on blood diff. Wound debrided on [**4-4**] by surgery, vascular patency and flow to foot confirmed by vascular surgery. BCx were all negative at discharge. Foot CT without evidence of osteomyelitis or abscess, and MRI of foot revealed cellulitis, with no evidence of ostemyelitis or abscess. At discharge his cellulitis had completely resolved without fluctulance, warmth or drainage from the original site. Pt's podiatrist is at the [**Hospital1 **] and will continue to see pt for continued foot care. # DM1: Pt generally followed at [**Last Name (un) **] and uses insulin pump. His last A1C on [**5-15**] was 7.1. While in the hospital, pt was not feeling well enough to manage the pump and was put on Lantus plus sliding scale [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. On [**4-8**] [**Name8 (MD) **] NP helped pt transfer back to the pump and came back on [**4-9**] to modify parameters because of persistent hyperglycemia. Pt's Blood sugar on [**4-10**] morning of discharge was high in the 300s. Pt will get [**Last Name (un) **] follow-up if he continues to have high blood sugars at home. Pt is very motivated to regulate blood sugar appropriately. # Depression/?Bipolar: [**Hospital 18**] medical records only confirm diagnosis of depression, however pt was continued on outpt regimen of effexor, haldol, lithium and clonazepam for pressumed bipolar disease. No psych issues throughout hospitalization. . # CAD: Per report h/o multiple MIs. Pt denied chest pain throughout admission. BP meds were held while hypotensive, and ASA, plavix and statin were continued. ACE and beta blocker will be continued at discharge. # Lower extremity rash: Nontender peticheal/purpuritic rash of anterior aspect of both lower extremities as well as erythemetous lesions of his left hand were originally speculated to be part of the stigmata of endocarditis. Based on its presentation the next day ID decided that it was most likely a leukocytoclastic vasculitis per ID which though improved was still present at discharge. Medications on Admission: 1) Clonazepam 1mg [**Hospital1 **] 2) Plavix 75mg daily 3) Lisinopril 20mg PO daily 4) Lithium Carbonate 300mg TID 5) Metoclopramide 10mg [**Hospital1 **] 6) Metoprolol XL 25mg PO daily 7) Propoxyphene N-acetaminophen 100-650mg PO BID 8) Zocor 20mg PO daily 9) Effexor XR 37.5mg [**Hospital1 **] 10) ASA 81mg daily 11) Omeprazole 40mg PO daily 12) Haldol 1mg daily 13) Insulin pump (long acting plus short) Discharge Disposition: Home Discharge Diagnosis: Primary: Foot Cellulitis Sepsis Secondary: DM I CAD Discharge Condition: At discharge, the patient was hemodynamically stable, afebrile, and with appropriate follow up. Discharge Instructions: You were admitted for foot pain. While you were here, you were treated with IV antibiotics for a presumed foot infection, as well as IV medication for pain. You received IV fluid to help you maintain your blood pressure. The infectious disease doctors came to [**Name5 (PTitle) 788**] you, and Surgery came and cleaned your wound. . You were briefly in the ICU because of low blood pressure. There, you continued to receive IV antibiotics, IV fluids, and the department of vascular surgery verified that you were still having good blood flow to your foot. Your blood pressure stabilized in the ICU and you were transferred back to the floor. . On the floor, you had an MRI taken of your foot to try to localize the cause of your symptoms. The MRI showed that the infection had not reached the bone. The [**Last Name (un) **] nurse practitioner also helped you switch back to the insulin pump and we switched your medications form IV to oral. Infectious disease doctors looked at your rash and decided it was most likely a result of your allergy to an antibiotic you took several days ago. It is important that you tell future providers that you may have a severe allergy to certain antibiotics such as vancomycin, Zosyn and Unasyn. If you should have worsening pain, fever/chills, chest pain/shortness of breath, please call your primary care physician. [**Name10 (NameIs) 357**] take all of your medications as directed and follow up with your appointments. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] at the [**Last Name (un) **] for diabetes management. Your appointment is [**4-15**] at 2:00. You have a teaching session at the [**Last Name (un) **] on [**4-17**] at 9:30. Please follow-up with your primary care physican as well about your anemia. We will follow your wishes to coordinate this appointment on your own. If your foot or rash gets worse, you develop a fever or nausea and vomiting please come back to the [**Hospital1 **] emergency room ASAP or the ID urgent care at [**Telephone/Fax (1) 11486**].

[ "443.9", "250.53", "787.01", "414.01", "707.15", "995.91", "E930.9", "693.0", "536.3", "V45.89", "682.7", "038.9", "401.9", "E931.5", "285.29", "250.63", "533.90", "362.01", "412", "530.81", "250.43", "311", "V58.67", "583.81", "272.4" ]

icd9cm

[ [ [] ] ]

[ "00.14", "86.22" ]

icd9pcs

[ [ [] ] ]

8518, 8524

3776, 8061

306, 325

8621, 8719

3109, 3753

10228, 10802

2415, 2505

8545, 8600

8087, 8495

8743, 10205

2520, 3089

257, 268

1295, 1674

353, 1277

1696, 2140

2156, 2399

9,653

159,238

52307

Discharge summary

report

Admission Date: [**2169-7-28**] Discharge Date: [**2169-8-15**] Date of Birth: [**2131-6-2**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 38 year old Haitian female with a recent history of travel to [**Country 16573**] who presents with fever and chills for two days. She was in her usual state of fully functional health until two days prior to admission when she developed sudden onset of fever, shaking chills and diffuse muscle aches. The patient did not measure her temperature initially but took Motrin for the fever. After administering the Motrin, she took oral temperature which was 101.2. The patient also reported a bitemporal headache with the fever but without neck stiffness. The patient states that she recently returned from [**Country 16573**] where she spent 28 days. She was placed on malaria prophylaxis, a weekly drug which is believed to have been Mefloquine and reports missing at least one dose at the end of the prophylaxis period. She reports several mosquito bites during her visit to [**Country 16573**] but no other unusual contacts during her trip. The patient is from [**Country 2045**] and has lived in the United States for more than twenty years. She last traveled to [**Country 2045**] in [**2168-12-19**]. She has never had a presentation similar to this one, nor has she ever been a diagnosis of malaria or yellow fever. Her husband reports having malaria at least three times while growing up in [**Country 16573**] but not since. He and the remainder of the patient's travel party are well. The patient denies cough, sore throat, rhinorrhea, light-headedness, dizziness, nausea, vomiting, diarrhea, abdominal pain, rash, poor appetite, urinary tract changes or night sweats. She reports no new sexual contacts or HIV risk factors. She denies contact with other animals other than mosquitos. She presents for evaluation and treatment of fever and chills. PAST MEDICAL HISTORY: 1. Gestational diabetes mellitus. 2. Two spontaneous abortions in the past. PAST SURGICAL HISTORY: Cesarean section. MEDICATIONS: The patient is taking p.r.n. Motrin. SOCIAL HISTORY: She is married with two children. No smoking, drugs or alcohol. FAMILY HISTORY: She has no history of lymphoma or other cancers. ALLERGIES AND DRUG REACTIONS: The patient has had nausea and vomiting with Codeine. PHYSICAL EXAMINATION: On admission, temperature is 101.8, blood pressure 132/68, pulse 88, respiratory rate 14. In general, she was well nourished, well developed young female in no apparent distress, alert and oriented times three, appears comfortable. Head, eyes, ears, nose and throat - She is normocephalic and atraumatic. The pupils are equal, round, and reactive to light and accommodation and anicteric. Extraocular movements are intact. Funduscopic examination is benign. The oropharynx is moist with no lesions noted. Neck - no nuchal rigidity or lymphadenopathy. Cardiac - regular rate and rhythm, normal S1 and S2, no murmurs, rubs or gallops. The lungs are clear to auscultation bilaterally. No wheezes or crackles. Back - no spinal or costovertebral angle tenderness. Her abdomen is soft, nontender, nondistended, no rebound or guarding, no hepatosplenomegaly, normoactive bowel sounds times four. Extremities - 2+ pulses times four, no cyanosis, clubbing or edema, no joint effusions and no changes to nails. Dermatologic - no jaundice or pallor, no rashes appreciated. Neurologic is grossly intact. LABORATORY DATA: On admission, white blood count 3.0, hemoglobin 11.1, hematocrit 35.0, platelets 263,000, MCV 70. Peripheral smear demonstrated malarial forms with 1.4% parasitemia. The organisms were not typed. Sodium 136, potassium 4.4, chloride 103, bicarbonate 22, blood urea nitrogen 17, creatinine 1.0, glucose 88. Urinalysis showed 11 white blood cells and trace ketone. The chest x-ray on admission was normal with no infiltrates or effusions. Electrocardiogram was read as normal. HOSPITAL COURSE: On hospital day one, the patient was started on Quinine 500 mg p.o. q.d. and Doxycycline 100 mg p.o. b.i.d. as per infectious disease recommendations. She was also given intravenous fluids of normal saline 125 cc/hour. She continued to spike fevers. No typing of the organisms was obtained and she had 1.7% parasitemia on peripheral smear. On hospital day two, the patient desaturated to 87% but looked well and had no evidence of respiratory distress. She had several episodes of emesis after Quinine administration which was not helped by Reglan or Droperidol. The patient continued to spike fevers. An emergent AP film showed ill-defined opacity of the right lung base and to a lesser extent in the left lower lobe. These were read as consolidation consistent with pneumonia. On hospital day three, the patient continued to spike fevers and have vomiting. Her examination was noteworthy for crackles at the right base. Repeat chest x-ray showed bilateral posterobasal segment consolidation consistent with pneumonia. Peripheral blood cultures were ordered and were negative. The patient's hemoglobin and hematocrit were noted to be falling. Her platelets at that time were 53,000. On the previous days, they had been 263,000, 192,000, 140,000 and 75,000. D-dimer and FDP were elevated but fibrinogen was within normal limits at 334. The patient's liver function tests were noted to be ALT 199, AST 99, LDH 428, alkaline phosphatase 144, total bilirubin 1.5. Direct Coombs test was negative and reticulocyte count was 0.08. The patient was started on Levofloxacin and Flagyl for treatment of aspiration pneumonia. She was started on Quinidine at night as she had many episodes of emesis and the intravenous administration of Quinidine was felt to be superior to the oral Quinine. The patient desaturated again at night. Her arterial blood gases was pH 7.47, 24, 60, 18 and -3 on ten liters oxygen. Chest x-ray showed bilateral lower lobe consolidations and possibility of small pleural effusions. On day four, the patient was afebrile on the morning shift but febrile later on. She was noted to be egophonous on physical examination. An increase in lower lobe consolidation is evident of the right middle lobe and lingula and bilateral pleural effusions with the right side greater than the left were appreciated on chest x-ray. Clindamycin was added to cover aspiration pneumonia and malaria. Lupus anticoagulant was noted to be positive. The patient on day five desaturated to 80% and was febrile. She was placed on 15 liters, 100% nonrebreather and her arterial blood gases was 7.45, 32, 52, 23, 0. The patient was taken to the Intensive Care Unit and intubated. Chest x-ray showed increase in bilateral air space opacities consistent with pneumonic consolidation, adult respiratory distress syndrome. There were small bilateral pleural effusion. The patient's platelets were noted to be 117,000 on day five. She was transferred to the Intensive Care Unit for hypoxic respiratory failure. The patient's hematocrit which had been 33.0 on admission was now 24.0. It had been falling since admission. The patient was transfused with one unit of blood and her hematocrit responded appropriately. The patient's Intensive Care Unit course can be summarized as follows by systems: 1. Pulmonary - The patient was admitted to the Medical Intensive Care Unit with impending respiratory failure and was intubated on [**2169-8-2**]. She had been on assist control transiently on SIMV the first night and since that time. A PEEP compliance curve was plotted on [**2169-8-4**], finding the PEEP of 12 to be optimal. She had been having problems oxygenating at first, most of which was positional in nature. The patient had much better oxygen saturation when sitting up at 30 to 45 degrees. Chest x-ray continued to show adult respiratory distress syndrome, most likely secondary to malarial infection. The patient's PCP and bacterial cultures were noted to be negative. Fungal culture was positive for [**Female First Name (un) 564**] Albicans, likely a benign colonizer. Legionella was negative and acid fast bacilli and viral culture were negative. An echocardiogram was performed to rule out pulmonary edema. Echocardiogram showed borderline pulmonary artery hypertension. Otherwise, it was normal. 2. Infectious disease - The patient was most likely felt to have falciparum malaria based on her clinical presentation, essentially the severity of that presentation. She was found to be [**Doctor Last Name 5239**] antigen negative and [**Doctor Last Name 5239**] antigen is required for infection for plasmodium vivax. When she was admitted to Intensive Care Unit, she was on Doxycycline, Quinidine, Clindamycin and Levaquin. The Levaquin was discontinued as it was felt that aspiration was unlikely in a young otherwise healthy woman. The Clindamycin was left on as it had some protective effect against malaria. The patient was afebrile since admission to the Intensive Care Unit with repeated spikes until [**2169-8-8**]. She was cultured several times, all of which were negative. It is felt that there is to be no broadening of antibiotics until her first course of antibiotics were finished. The patient was taken off antibiotics on [**2169-8-7**]. She was afebrile [**2169-8-9**], in the morning but spiked again in the afternoon. Malaria was thought to be an unlikely cause as she had been without parasitemia for several days. Other possibilities for her fever included drugs and lines. Sinusitis was also considered but was ruled out with a negative CT scan. CT of the head, chest and abdomen on [**2169-8-8**], were negative for any intracranial pathology. 3. Cardiac - The patient originally had problems with hypertension. She was aggressively hydrated and eventually became somewhat fluid overloaded being approximately five liters positive. She began to have worsening hypoxemia and increased pulmonary pressures and was diuresed. The patient's hypertension was resolved on [**2169-8-7**]. 4. Hematologic - The patient was admitted to the Intensive Care Unit with low hematocrit, thrombocytopenia and relatively low white count. Her low hematocrit was considered likely secondary to direct effects of malarial infection, low grade hemolysis and underlying iron deficiency. She was transfused a total of four units packed red blood cells, started on iron sulfate, but this was discontinued as she could not take anything p.o. Parenteral iron was not started as the risk of anaphylaxis was greater than the potential benefit. She also received an iron load via the packed red blood cells. A reticulocyte count was inappropriately low and she was started on Epogen 40,000 units subcutaneous every week. She had transient thrombocytopenia which resolved. This was also felt to be secondary to malaria. The patient's coagulation studies which were normal on admission had then become abnormal. Her prothrombin time and INR were rising which was thought to be secondary to malnutrition. Albumin was noted to be 1.6. 5. Gastrointestinal - The patient had diarrhea on the regular medical floor. She had stool sent for C. difficile and fecal leukocytes at the time which were negative. On admission to the Intensive Care Unit, she had slightly elevated liver function tests. These decreased to normal. She had ascites on CT scan on [**2169-8-8**], and was reported to have no bowel sounds in the Intensive Care Unit on [**2169-8-7**], and [**2169-8-8**]. She had repeatedly high gastric aspirates which were occult blood negative. She had been getting nothing by mouth and started to make stool again on [**2169-8-7**]. The patient was placed on tube feeds while in the Intensive Care Unit. The patient's fevers were felt to be secondary to a line infection. Culture grew out Methicillin resistant Staphylococcus aureus. The patient was started on Vancomycin one gram intravenously q12hours. She defervesced. The patient was extubated on [**2169-8-12**], and transferred to the regular medical floor. On the regular medical floor, the patient was noted to be afebrile. She required physical therapy which aided the patient in mobility. The patient was discharged home on [**2169-8-15**]. DISCHARGE MEDICATIONS: 1. Vancomycin one gram intravenous q12hours. 2. Iron Sulfate 325 mg p.o. t.i.d. The patient went home with physical therapy services. A letter required by the American Consulate from [**Country 16573**] was requested by the patient in order to obtain services with assistance with her children. A copy of this letter can be found in the patient's paper chart. The patient has been instructed to follow-up with Dr. [**Last Name (STitle) **]. She will make the appointment for herself. Please note that throughout this admission, the patient's family has been very involved in her care. They have frequently been present in her room and have prevented appropriate medical decisions. For example, the patient who required transfusion for hematocrit of 25.0 was denied this transfusion by her husband for a period of two days until he finally agreed on the last day that she was on the regular medical floor before being transferred to the Intensive Care Unit. CONDITION ON DISCHARGE: Stable. PROGNOSIS: Good. DISCHARGE DIAGNOSES: 1. Malaria. 2. Iron deficiency anemia. 3. Line sepsis. 4. Aspiration pneumonia. 5. Gastroenteritis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. [**MD Number(1) 28157**] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2169-8-16**] 17:52 T: [**2169-8-16**] 18:20 JOB#: [**Job Number **]

[ "276.6", "996.74", "280.9", "787.01", "518.82", "084.0", "507.0", "263.9", "E931.4" ]

icd9cm

[ [ [] ] ]

[ "33.23", "38.93", "96.72", "03.31", "99.15", "99.04", "96.04", "38.91" ]

icd9pcs

[ [ [] ] ]

2246, 2382

13373, 13753

12332, 13299

4027, 12309

2075, 2146

2405, 4009

159, 1950

1972, 2051

2163, 2229

13324, 13352

26,642

142,988

9723+9724

Discharge summary

report+report

Admission Date: [**2149-3-28**] Discharge Date: [**2149-3-30**] Date of Birth: Sex: Service: CHIEF COMPLAINT: Substance abuse/overdose, unresponsive. HISTORY OF PRESENT ILLNESS: The patient is a 21 year old female with a past psychiatric history who presented with unresponsiveness. Per report the patient had an argument with her boyfriend and was very upset. She was brought to the Emergency Department, brought in by police and in the Emergency Department she was found to be combative and unresponsive to pain. To protect her airway she was intubated. She received charcoal per nasogastric tube. She received Fentanyl Succinylcholine, Verrucarum and Etomidate. She was found to have Seroquel and Paxil in her possession. It was found that a total of 180 mg of Fluoxetine and 400 mg of Seroquel was in the sink from her pill trays on accompanying to the Emergency Department. Her alcohol level was found to be 189. Toxicology screen as positive for tricyclics only. She has a past history of cocaine and alcohol abuse and other elicit drugs. PAST MEDICAL HISTORY: She said she had an eating disorder, anorexia, status post OR inpatient admit, history of borderline personality disorder, status post assault, status post elective abortion in [**2146**]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Seroquel 200 q.h.s., Fluoxetine 50 and Depakote ER 1000 q.h.s. SOCIAL HISTORY: Emigrated from [**Country 25091**] as a teenager, single, positive alcohol, positive marijuana. FAMILY HISTORY: Mental illness possible in father, question schizophrenia, unclear. PHYSICAL EXAMINATION: On admission temperature 98.8, blood pressure 106/70, pulse 86, respiratory rate 14, 100% ventilated, AC [**Medical Record Number 32823**]-FIO2 of 40%. General, intubated, paralyzed. Head, eyes, ears, nose and throat, pupils 3 to 2 bilaterally. Mucous membranes, semi-dry. Lungs clear to auscultation bilaterally. Heart, regular rate and rhythm, no murmurs, rubs or gallops. Abdomen, soft, nontender, nondistended. Bowel sounds positive. Extremities, no cyanosis, clubbing or edema. Good distal pulses. Neurological, withdraws to pain secondary to paralysis with Fentanyl, hyperreflexic throughout. LABORATORY DATA: On admission white blood cell count 9.8, hematocrit 35.3, platelets 302. Sodium 145, potassium 3.2, chloride 104, carbon dioxide 19, BUN 15, creatinine 0.8, glucose 191, anion gap 22. An arterial blood gases showed 7.41/37/224/3.6. Ethanol 189, INR 1.2. Head computerized tomography scan showed no bleed. Chest x-ray showed an endotracheal tube in place. No infiltrate no infusion. Urine toxicology, negative cocaine, negative opiates, negative Tylenol. Serum toxicology, ethanol 189, positive tricyclics. Urine showed trace leukocytes, 0-2 white blood cells, 0-2 epithelials, no ketones. Electrocardiogram showed sinus tachycardiac 118, normal axis, QRS of 100 from 90 at baseline. QTC at 459. HOSPITAL COURSE: The patient was intubated for a short time in order to protect her airway. This was then discontinued as the patient's mental status recovered. There were no further pulmonary issues during hospitalization. Toxicology - The patient received charcoal per nasogastric tube times three doses. She received a banana bag for vitamin repletion and there was no acute sequela of her intoxications noted during this admission other than the initial changes in mental status and combativeness. Psychiatry - Psychiatry was consulted and noted the past psychiatric history and possible family history as well as chronic substance abuse. It was felt that although the patient denied this the next day, this was a likely suicide attempt and thus the patient was not competent to be discharged. She was Section XII and assessed for shortterm psychiatric placement. Cardiovascular - QRS was stable at 100 milliseconds, QTC was also stable. There were no acute cardiac issues. She received bicarbonate 2 amps for the suspected tricyclic antidepressant overdose. Renal - Fluids, electrolytes and nutrition, the patient's potassium was low at 3.2 on admission. This was repleted. She received intravenous fluids throughout the admission. There were no other acute issues. CONDITION ON DISCHARGE: The patient was discharged in stable condition for acute inpatient psychiatric care. DISCHARGE DIAGNOSIS: 1. Suicidality 2. Alcohol and tricyclic antidepressant overdose with 3. Mental status changes and combativeness DISCHARGE MEDICATIONS: She is continued on her home medications, Depakote ER 1000 mg q.h.s.; Seroquel 200 mg q.h.s. and 50 mg t.i.d.; Paxil unknown dose; Equanil unknown dose. DISPOSITION: She was medically cleared for transfer to acute psychiatric facility. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 32824**] MEDQUIST36 D: [**2149-3-29**] 12:37 T: [**2149-3-29**] 13:38 JOB#: [**Job Number 32825**] Admission Date: [**2122-3-30**] Discharge Date: [**2122-3-30**] Date of Birth: Sex: Service: No dictation for this report [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 1737**] MEDQUIST36 D: [**2149-3-29**] 12:09 T: [**2149-3-29**] 13:35 JOB#: [**Job Number 32826**]

[ "969.0", "780.01", "780.09", "305.00", "E950.9", "E950.3", "276.2", "980.9", "305.90" ]

icd9cm

[ [ [] ] ]

[ "94.62", "96.07", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

1560, 1629

4542, 5416

4402, 4518

1365, 1429

3003, 4270

1652, 2985

141, 182

211, 1087

1110, 1338

1446, 1543

4295, 4381

56,795

108,505

41411

Discharge summary

report

Admission Date: [**2156-2-1**] Discharge Date: [**2156-2-3**] Date of Birth: [**2071-4-16**] Sex: M Service: SURGERY Allergies: Shellfish Attending:[**First Name3 (LF) 4748**] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: None History of Present Illness: 84 year-old male h/o COPD, HTN who presented to [**Hospital3 417**] Hospital with sudden onset back pain on [**2156-1-31**]. He reports that he was answering the phone yesterday at approximately 10AM when there was sudden severe midline upper back. The pain resolved, however, recurred 2 hours later. He notified his primary care, who is also a cardiologist, who sent him to [**Hospital3 417**] Hospital. He underwent a CT scan there which showed a type B dissection starting that the takeoff of the left subclavian enxtending to the origin of the celiac trunk, with it originating off the true axis. He was transferred to [**Hospital1 18**] on [**2156-2-1**] for further management. Currently, he reports resolution of his pain symptoms. HE has no other complaints. His initial presenting blood pressure here was 162/91. Past Medical History: Hypertension Hyperlipidemia Chronic Obstructive Pulmonary Disease Right Total knee replacement [**2119**] sigmoidectomy for diverticulitis TURP Social History: SOCIAL HISTORY: EtOH use: wine 3x/day Tobacco use: Denies Previous smoker: Last smoked when cigarettes were 50cents per pack. Recreational drugs (marijuana, heroin, crack pills or other):Denies Marital status: Lives alone but has 4 daughters who assist. Occupation: Previously a teamster. Family History: Non-contributory Physical Exam: Admission: PHYSICAL EXAM Temp: 97.0 75 99/56 22 97% on 2 liters nasal cannula Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, No hepatosplenomegally, No hernia, No AAA. Well-healed midline abdominal incision. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. LUE Radial: P. Ulnar: P. RLE Femoral: P. Popiteal: P. DP: P. PT: P. LLE Femoral: P. Popiteal: P. DP: P. PT: P. Discharge: Pertinent Results: [**2156-2-1**] 04:45AM BLOOD WBC-12.9* RBC-4.32* Hgb-13.4* Hct-37.1* MCV-86 MCH-30.9 MCHC-36.0* RDW-13.4 Plt Ct-195 [**2156-2-2**] 02:20AM BLOOD WBC-10.3 RBC-3.76* Hgb-11.8* Hct-33.1* MCV-88 MCH-31.4 MCHC-35.7* RDW-13.3 Plt Ct-176 [**2156-2-3**] 07:40AM BLOOD WBC-10.2 RBC-3.89* Hgb-11.9* Hct-34.2* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.5 Plt Ct-173 [**2156-2-1**] 04:45AM BLOOD Neuts-82.7* Lymphs-11.3* Monos-5.7 Eos-0.1 Baso-0.2 [**2156-2-1**] 04:45AM BLOOD PT-15.5* PTT-25.3 INR(PT)-1.4* [**2156-2-1**] 04:45AM BLOOD Plt Ct-195 [**2156-2-3**] 07:40AM BLOOD Plt Ct-173 [**2156-2-1**] 04:45AM BLOOD Glucose-163* UreaN-17 Creat-1.0 Na-136 K-4.2 Cl-97 HCO3-28 AnGap-15 [**2156-2-2**] 02:20AM BLOOD Glucose-155* UreaN-24* Creat-1.5* Na-134 K-4.2 Cl-97 HCO3-26 AnGap-15 [**2156-2-2**] 05:35PM BLOOD Glucose-128* UreaN-31* Creat-1.4* Na-135 K-4.3 Cl-96 HCO3-29 AnGap-14 [**2156-2-3**] 07:40AM BLOOD Glucose-153* UreaN-27* Creat-1.2 Na-137 K-4.3 Cl-96 HCO3-30 AnGap-15 [**2156-2-1**] 01:27PM BLOOD CK(CPK)-54 [**2156-2-1**] 08:09PM BLOOD CK(CPK)-54 [**2156-2-2**] 02:20AM BLOOD CK(CPK)-62 [**2156-2-1**] 04:45AM BLOOD cTropnT-0.01 [**2156-2-1**] 01:27PM BLOOD CK-MB-3 cTropnT-0.03* [**2156-2-1**] 08:09PM BLOOD CK-MB-3 cTropnT-0.03* [**2156-2-2**] 02:20AM BLOOD CK-MB-3 cTropnT-0.02* [**2156-2-3**] 07:40AM BLOOD Calcium-9.3 Phos-2.7 Mg-2.2 [**2156-2-2**]:FINDINGS: CT CHEST: Within the lung parenchyma, there is a small left pleural effusion as well as associated compressive atelectasis. Dependent atelectasis on the right is also present. Several pleural-based calcifications are noted posteriorly. No pneumothorax is seen. The airways are patent to the segmental level. No pathologically enlarged lymph nodes are seen. There are aortic and coronary artery vascular calcifications. No pericardial effusion is seen. Please see below for CT angiography. CT ABDOMEN AND PELVIS: There is fatty deposition within the liver. The patient is status post cholecystectomy. The spleen, pancreas, and adrenal glands appear grossly normal. The kidneys contain multiple hypodensities, incompletely characterized on this examination. A 2.8 cm hypodensity in the right kidney (4:136) is most compatible with a simple cyst. Multiple additional hypodensities are incompletely evaluated. Loops of small and large bowel are of normal size and caliber. Within the pelvis, distal loops of large bowel and rectum appear grossly unremarkable. There is colonic diverticulosis. The bladder and distal ureters are normal. The prostate gland is enlarged measuring up to 5.5 cm in diameter. No free air, free fluid, or lymphadenopathy is seen. There is a fat-containg right inguinal hernia. BONE WINDOWS: No concerning osseous lesion is seen. CTA: Again seen is a thoracic aortic aneurysm beginning distal to the origin of the left subclavian artery (type B). Multiple mural calcifications are noted at the origin of the dissection and along the true lumen. The dissection extends to the level of the origin of the celiac artery. The celiac artery itself has several calcifications with some narrowing at the origin; however, appears to opacify with contrastand likely originates from the true lumen. The superior mesenteric artery, bilateral renal arteries, and inferior mesenteric artery are patent and are supplied by the true lumen. There is mild narrowing of the right renal artery due to atherosclerosis at the origin. The false lumen does opacify with contrast, though to a lesser extent. At the level of the aortic hiatus, there is non-opacification of the false lumen suggesting the presence of thrombus. The overall diameter of the aorta at the level of the hiatus measures 3.9 x 3.9 cm (4:95), aneurysmal. Vascular calcifications extend throughout the aorta into the bilateral iliac arteries. The iliac arteries measure up to 1.6 cm bilaterally, mildly aneurysmal. Incidental note is made of a common origin of the brachiocephalic artery and left common carotid artery (bovine arch configuration). The origin of the common hepatic artery is off the superior mesenteric artery. IMPRESSION: Type B aortic dissection extending from just distal to the origin of the left subclavian artery to the level of the celiac artery, which appears mildly narrowed. Partial thrombosis of the false lumen. Mild narrowing of right renal artery due to atherosclerosis. Brief Hospital Course: Mr. [**Known lastname 90109**] was admitted to the ICU on [**2156-2-1**] for Type B dissection of the aorta without aortic leak (takeoff of left subclavian to celiac axis) for blood pressure control. He was initially started on Esmolol and Nipride drips in the Emergency Room, which were weaned off and changed to labetolol drip for goal SBP less than 120. A radial A-line was placed and his blood pressure was closely monitored. He ruled out for a myocardial infarction. He was started on an increased dose of metoprolol, in an addition to his home medications and the labetolol was weaned off. On HD 2, his creatinine peaked at 1.5. There was concern for extension of dissection to renal arteries, so repeat CTA was performed. Repeat CTA was unchanged. His renal insuffiency was then thought to be due to dye load for CTA, so he received sodium bicarbonate, mucomyst, and IV fluid and creatinine trended down to 1.2. His diet was advanced and he was transferred to the floor on [**2-2**] for further monitoring. At the time of discharge on HD 3, his systolic blood pressure ranged between 120-140 and creatinine was stable at 1.2. Medications on Admission: Pravastatin 40mg daily Accupril 40mg daily Metoprolol 75mg [**Hospital1 **] Flexeril 10mg daily Lasix 20mg daily Vicodin 500-5mg prn Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. Accupril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Blood Pressure Machine Please check your blood pressure once or twice a day with a home machine. Your systolic blood pressure (the top number) should be less than 140. Please call your primary care doctor if it is greater than 140, as your medications may need to be changed. 5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Type B Aortic Dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Discharge Instructions What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower ?????? No heavy lifting, pushing or pulling (greater than 5 lbs), exercise, or shoveling until you follow up with Dr. [**Last Name (STitle) 1391**]. When you see him, you need to re-address your weight lifting/ and exercise restrictions with Dr. [**Last Name (STitle) 1391**] ?????? Call and schedule an appointment to be seen in 4 weeks for follow up visit and repeat CTA What to report to office: ?????? Pain in your jaw, neck, upper back (or other part of your back), or chest ?????? Coughing, hoarseness, or trouble breathing ?????? Numbness, coldness or pain in lower extremities ?????? Blood Pressure greater than 140. It is important to keep your systolic Blood pressure(top number)less than 140 to prevent further dissection or rupture. Followup Instructions: Please make an appointment to see Dr. [**Last Name (STitle) **] in [**12-14**] weeks. Please call to make an appointment to see Dr. [**Last Name (STitle) 1391**] in one month-[**Telephone/Fax (1) 1393**]. His office will also set you up to have a CAT scan prior to that visit. Completed by:[**2156-2-3**]

[ "441.02", "401.9", "593.9", "272.4", "V15.82", "E947.8", "496", "V43.65" ]

icd9cm

[ [ [] ] ]

[ "38.91" ]

icd9pcs

[ [ [] ] ]

8861, 8932

6943, 8077

277, 284

9001, 9001

2583, 6920

10118, 10426

1634, 1652

8260, 8838

8953, 8980

8103, 8237

9152, 9721

9747, 10095

1667, 2564

228, 239

312, 1143

9016, 9128

1165, 1311

1343, 1618

19,048

123,204

46082

Discharge summary

report

Admission Date: [**2182-6-19**] Discharge Date: [**2182-6-21**] Date of Birth: [**2105-9-9**] Sex: F Service: EMERGENCY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2565**] Chief Complaint: hypoxemia, hypotension Major Surgical or Invasive Procedure: endotracheal intubation, mechanical ventilation arterial/venous line placement History of Present Illness: 76 yo F with h/o metastatic breast CA on chemotherapy who initially was admitted to the OMED service with diarrhea who is now transferred to the [**Hospital Unit Name 153**] for hypotension and hypoxia. Patient states she had been feeling constipated for 1 week after chemo on [**6-6**] and then took laxatives until she had several large BMs. A few days later she develope large volume, non-bloody dairrhea that was associated with some lightheadedness. She denied fevers, chills, rashes. Reports poor appetite but states she was drinking lot of water and trying to eat salty foods; however this was limited by worsening mucositis over the past few days. Due to concern for dehydration and contniued diarrhea, the patient was admitted directly from the oncology clinic. . Upon arrival to the floor, pt AF with BP 120/74, HR 116, RR 24, O2 sat 94% 2L NC. She was given 2L IVFs, started on po flagyl empirically for c. diff adn had stool cultures sent for possible OIs. Upon vitals check at 0400, pt's BP noted to be 78/54, HR 98, RR 20s, O2 sat 86% RA --> 93% 3L NC. Given 500 cc IVF bolus X 2 with response in SBP to 86/40s, however, RR rose to upper 20-30s with O2 sats 90% 6L NC --> 95% NRB. ABG 7.51/25/114/21. CXR revealed likely pulmonary edema with worsening bilateral pleural effusions and possible retrocardiac opacity. She was transferred to the [**Hospital Unit Name 153**] where code status was confirmed as full and pt was intubated. Peri-intubation required dopamine at 20 mcg/kg/min, which was transitioned over to levophed gtt once triple lumen catheter placed. Past Medical History: PAST ONCOLOGIC HISTORY: [**Known firstname **] [**Known lastname 1617**] was previously treated for breast cancer in the late [**2153**]. At that time she was diagnosed with a left-sided infiltrating ductal carcinoma on [**2160-7-30**]. Repeat biopsy showed persistent DCIS, and she underwent left mastectomy on [**2160-9-20**]. Two of three lymph nodes were involved. She was treated with 6 cycles of adjuvant oral CMF chemotherapy, which completed in [**2161**], and then eight years of tamoxifen as the tumor was ER positive, PR negative. Since that time Ms. [**Known lastname 1617**] was also diagnosed with a left renal cell carcinoma and underwent partial nephrectomy in 03/[**2178**]. Her medical course has been complicated by coronary artery disease status post MI in [**9-/2179**] and atrial fibrillation. More recently, a CT of the chest noted ground-glass abnormalities, raising concern for bronchoalveolar carcinoma. This has not been biopsied or formally diagnosed. In [**2-/2182**] liver function studies were noted to be elevated, and liver ultrasound and abdominal CT showed numerous lesions in the liver. CT-guided core liver biopsy on [**2182-2-25**] showed metastatic breast adenocarcinoma staining positive for mammoglobin, negative for GCDFP, ER, and PR. The tumor overexpressed HER-2/neu. Tumor markers drawn on [**2182-2-18**] were elevated with CEA 20 ng/mL and CA 27.29 278 u/mL. PET scan performed on [**2182-3-6**] showed numerous heterogeneous liver lesions, sclerotic lesions in the left anterior rib and right ilium that were FDG avid and concerning for metastatic foci, and FDG avid left pelvic side wall lymph node. On [**2182-3-20**] mammogram and ultrasound of the right breast showed a 1.9-cm right breast nodule. Pathology from a core breast biopsy showed invasive ductal carcinoma grade I that was HER-2/neu negative and ER/PR positive. Ms. [**Known lastname 1617**], therefore, appears to have a new right breast tumor that is ER/PRpositive, HER-2/neu negative, and liver metastases that are ER/PR negative and HER-2/neu positive. She began Herceptin on [**2182-4-16**], and Navelbine was added on [**2182-6-6**]. Also had L thoracocentesis in [**5-11**] with malignant cells (adenocarcinoma) on cytology. . PAST MEDICAL HISTORY: 1. History of left-sided breast cancer as discussed above, metastatic to 2. History of renal cell carcinoma status post partial left nephrectomy, 03/[**2178**]. 3. Coronary artery disease status post MI [**2179-9-11**] with PCI x2. 4. Atrial fibrillation. 5. Diet-controlled diabetes mellitus. 6. Hypertension. 7. GERD. 8. Hyperlipidemia. 9. History of lung imaging abnormalities concerning for BAC. 10. History of a right ovarian dermoid cyst resected at age 32. 11. Osteoporosis. 12. History of TMJ syndrome. 13. Cataracts. 14. H/o C.difficile infection. 15. H/o Grp A beta-Strep bacteremia. Social History: The patient is married and lives in [**Location 745**], [**State 350**]. She was previously a schoolteacher and is now retired. She denies tobacco or alcohol use, although, admits to a history of secondhand tobacco exposure as a child. Family History: There is no family history of breast cancer. The patient's son is currently being treated for metastatic renal cell carcinoma. She has another son who is without health concerns. Her mother died of a stroke at 61 years and father died of congestive heart failure at 78 years. Physical Exam: Vitals - 98.5 120/74 116 24 94% on 2L GENERAL: moderate distress [**2-4**] tachypnea and SOB, speaking in full sentences without much difficulty, able to lie flat for Foley insertion but with mild difficulty HEENT: Dry MM, + mucositis, no LAD, cracked lips, JVP approximately 12 cm above sternal notch CARDIAC: Irregular, II/VI SEM LUNG: CTAB with decreased BS at bilateral bases, no wheezes, rhonchi, rales appreciated ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: 2+ LE edema bilat with L > R LE, moving all extremities well, no cyanosis, clubbing, no obvious deformities NEURO: CN II-XII intact Pertinent Results: LABS ON ADMISSION: [**2182-6-19**] 10:57AM BLOOD WBC-0.5*# RBC-3.18* Hgb-10.5* Hct-29.3* MCV-92 MCH-33.2* MCHC-36.0* RDW-13.9 Plt Ct-374# [**2182-6-19**] 12:30PM BLOOD PT-32.1* INR(PT)-3.2* [**2182-6-19**] 12:30PM BLOOD UreaN-26* Creat-0.7 Na-121* K-4.4 Cl-84* HCO3-26 AnGap-15 [**2182-6-20**] 12:15AM BLOOD ALT-21 AST-33 LD(LDH)-243 AlkPhos-130* TotBili-1.1 DirBili-0.6* IndBili-0.5 [**2182-6-19**] 12:30PM BLOOD Albumin-3.4 Calcium-8.9 Mg-1.5* . URINE: [**2182-6-20**] 08:48AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2182-6-20**] 08:48AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2182-6-20**] 08:48AM URINE RBC-1 WBC-4 Bacteri-FEW Yeast-NONE Epi-1 [**2182-6-20**] 08:48AM URINE Hours-RANDOM UreaN-795 Creat-89 Na-LESS THAN . MICROBIOLOGY: bl cx - GNR in [**4-6**] bottles . CARDIOLOGY: TTE: Conclusions The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. 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. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2182-3-19**], biventricular systolic funciton is now significantly depressed. . RADIOLOGY: LLE U/S: IMPRESSION: No evidence of left lower extremity DVT. . CXR: Comparison is made with prior study [**2182-5-10**]. Mild cardiomegaly is unchanged. Mild left pleural effusion has increased. Small right pleural effusion is unchanged. There is mild pulmonary edema. There is atelectasis in the right lower lobe. Multiple surgical clips are in the left upper quadrant abdomen. There is no pneumothorax. Brief Hospital Course: In short, Ms [**Known lastname 1617**] is a 76F with h/o metastatic breast CA C1D15 of navelbine/herceptin admitted with diarrhea and weakness, transferred to [**Hospital Unit Name 153**] in septic shock, expired [**2-4**] overwhelming GNR bacteremia. . # Septic shock: overwhelming GNR bacteremia w cardiogenic/distributive/hypovolemic components in the setting of febrile neutropenia. DDx for the infection included the gut (given diarrhea) vs the lung vs other. Pt treated w aggressive fluid resuscitation, dopamine, norepinepherine and vasopressin pressors, broad-spectrum antibiotics. TTE revealed decreased LVEF confirming the suspicion of acute heart failure in the setting of sepsis. . # Hypoxic respiratory failure: Hypoxia progressed relatively rapidly in the setting of receiving IVFs, CXR with evidence supporting pulmonary edema. Furthermore, pt's known malignant pleural effusion appears to be worsening and is also likely contributing. No known aspiration events. Given neutropenia and other vitals concerning for sepsis, infection also remains on differential. PE also considered, but less likely. Treated for sepsis as above. . # Hyponantremia: Na 120, improved to 130 w fluid resuscitation. Does have prior h/o hyponatremia. Suspect that hypovolemia is primary etiology. . # Diarrhea: Possibly infectious etiology given neutropenia vs could be [**2-4**] chemo. Given refractory hypotension in the setting of sepsis, possibly developing ischemic colitis. . # Pancytopenia: likely [**2-4**] chemotherapy - neutropenic, anemic w underlying combined iron-deficiency anemia and anemia of chronic disease. No evidence of hemolysis. Thrombocytopenia. Transfused w pRBCs and FFP. . # Metastatic breast CA: With known mets to liver and likely to lung and bone based off of PET scan and pleural fluid cytology. . # Atrial fibrillation: INR supratherapeutic on admission. Afib w RVR on transfer to ICU in the setting of hypovolemia, sepsis and pressors. Medications on Admission: 1. Amlodipine 5 mg daily. 2. Amoxicillin prior to dental procedures. 3. Atenolol 50 mg b.i.d. 4. Furosemide 10 mg daily. 5. Lisinopril 40 mg daily. 6. Potassium chloride 20 mEq daily. 7. Multivitamin one capsule daily. 8. Warfarin 2 mg daily. 9. Aspirin 81 mg daily. 10. Calcium plus vitamin D b.i.d. 11. Glucosamine chondroitin three capsules daily. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: septic shock cardiogenic shock GNR bacteremia repiratory failure metastatic breast cancer atrial fibrillation Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2182-6-21**]

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Discharge summary

report

Admission Date: [**2131-10-13**] Discharge Date: [**2131-10-18**] Date of Birth: [**2060-3-7**] Sex: M Service: NEUROLOGY Allergies: Procardia / Aliskiren Attending:[**First Name3 (LF) 8850**] Chief Complaint: Shortness of breath and headache. Major Surgical or Invasive Procedure: ET tube extubation. History of Present Illness: [**Known firstname 95455**] [**Known lastname 95456**] is a 71-year-old right-handed man with DM, CAD s/p IMI, chronic diastolic CHF, malignant hypertension, and recent diagnosis of right frontotemporal GBM, s/p biopsy on [**2131-9-18**] who presented to the [**Hospital6 33**] ED from rehabilitation after complaining of SOB and headache. Vital signs at 20:45 on [**2131-10-12**]: blood pressure 210/110, pulse 80, respiration 24, oxygen saturation 80% in room air, and 90% with 4 liters of air. Breathing appeared labored but he did not complain of chest pain. BP en route was 241/142. He then received [**2-17**] ampule of D50 for hypoglycemia in 50s. Initial vital signs at [**Hospital6 33**] was blood pressure 188/132, pulse 74, respiration 23, and oxygen saturation 97% on non-rebreather mask. A head CT showed heterogenous frontotemporal mass with partial effacement of right lateral ventricle with surrounding vasogenic edema but no midline shift, and intratumoral hemorrhage could not be excluded. He was then given Decadron 10 mg IV and Ativan 2 mg IV. He also received vecuronium 10 mg IV x 2, etomidate 20 mg IV, and succhinylcholine 100 mg IV, and intubated for respiratory failure attributed to acute CHF based on chest X-ray. He also received 2" nitro paste and Lasix 80 mg IV. After that, he was transferred to [**Hospital1 18**] for neurosurgery evaluation. He was also hypotensive to 60/p systolic en route, up to SBP 89 after removal of nitro paste. In the ED, initial vital signs were temperature 97.6 F, pulse 72, blood pressure 179/91, and oxygen saturation at 94% on ventilation. Finger-stick glucose was 110. Chest X-ray showed ETT 4.6 cm above carina, near complete opacification of the left hemithorax with a large left effusion and compressive atelectasis, and bilateral pulmonary edema. Another head CT showed stable appearance to right temporoparietal lobe with edema and mass effect but no shift, and stable foci of hemorrhage. ABG was 7.32/61/114 on 16 x 500 8 1.0. His ventilation rate was increased to 20/min. Blood cultures sent, given levaquin 750 mg IV, started on propofol gtt. Past Medical History: -R frontotemporal GBM WHO Grade IV s/p biopsy [**2131-9-27**], plan to start protocol using hypofractionated involved-field XRT with temozolomide and Cyberknife boost -Malignant HTN -CAD s/p IMI -Chronic diastolic CHF -PAF (ED visit [**7-25**]) -DM -Anxiety Social History: Resident of [**First Name5 (NamePattern1) 4542**] [**Last Name (NamePattern1) 19207**] & Nursing Center in [**Location (un) 38**], MA. He is a retired rocket scientist from [**Country 532**]. He worked for USSR space program and NASA. He is a former pipe smoker. He quit in [**2097**]. He is also a social drinker, and denies drug use. Family History: Father: Type [**Name (NI) **] Diabetes, HTN. Mother: [**Name (NI) **] [**Name (NI) 3730**]. Brother: Type [**Name (NI) **] Diabetes Physical Exam: On admission: VITAL SIGNS: Wt 109.8 kg T 96.7 HR 57 BP 157/88 RR 20 O2sat 100% 500x20 8 1.0 GEN: Intubated sedated HEENT: R pupil reactive L pupil surgical CARDIOVASCULAR: reg brady nl S1S2 no m/r/g PULMONARY: diminished at bases ABDOMEN: soft obese NTND hypoactive BS EXTREMITIES: warm, dry 2+ pitting edema to mid-legs bilat NEUROLOGICAL EXAMINATION: Mental status: intubated, sedated. R pupil pinpoint, trace reactive, L pupil surgical. (-) VOR. (-) corneal. Face symmetric. Motor/Sensory: No spontaneous movements, does not withdraw to painful stimuli. Reflexes: absent, toes mute. On discharge: Vitals: Tm/Tc 97.1/97.1 BP 150/90 (150-198/81-100) P 69 (60-69) R 18 Sat 96%RA FS 268-349 GENERAL: No acute distress. SKIN: Right portcath site without swelling, fluctuance, purulence. HEENT: Mucous membranes moist, no lesions noted CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs or [**Last Name (un) 549**] PULMONARY: Clear to auscultation bilaterally, no wheezes, rales or rhonchi. ABDOMEN: Soft, non-tender, non distended, bowel sounds present. EXTREMITIES: 2+ pitting edema to knee bilaterally, 2+ Dorsalis pedis and radial pulses bilaterally. 1+ pitting edema in hands bilaterally, no cyanosis or erythema. NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is 60. He is awake, alert, and oriented to person, hospital, but not date. His language is fluent with good comprehension. Short-term recall seems intact. Cranial Nerve Examination: His right pupil is reactive to light, 3 mm to 2 mm in OD, but the left is not. Extraocular movements are full, but the left eye is light detection only. Visual field in OD is full to confrontation. He has a left lower facial droop. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He has a drift in the left upper extremity. His muscle strengths are [**6-20**] at all muscle groups, except for 4/5 strength in left delotid, [**5-21**] in left biceps, and 4-/5 at left triceps. There is also 4/5 strength in the left handgrip, left finger extensors, left biceps, left triceps, and left deltoid. His left proximal lower extremity strength is 4+/5. His muscle tone is normal. His reflexes are absent bilaterally. His ankle jerks are absent. His right toe is down but the left is up. Sensory examination is intact to touch and proprioception. Coordination examination reveals dysmetria on the left side commensurate with the degree of weakness. He can walk and his balance is good. Pertinent Results: [**2131-10-13**] 02:50AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 [**2131-10-13**] 02:50AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2131-10-13**] 02:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2131-10-13**] 02:50AM FIBRINOGE-418* [**2131-10-13**] 02:50AM PLT COUNT-339 [**2131-10-13**] 02:50AM PT-12.4 PTT-24.0 INR(PT)-1.0 [**2131-10-13**] 02:50AM WBC-13.7* RBC-3.68* HGB-10.9* HCT-33.8* MCV-92 MCH-29.6 MCHC-32.3 RDW-16.2* [**2131-10-13**] 02:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2131-10-13**] 02:50AM URINE GR HOLD-HOLD [**2131-10-13**] 02:50AM URINE HOURS-RANDOM [**2131-10-13**] 02:50AM URINE HOURS-RANDOM [**2131-10-13**] 02:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2131-10-13**] 02:50AM cTropnT-0.04* [**2131-10-13**] 02:50AM CK-MB-4 cTropnT-0.04* proBNP-[**2147**]* [**2131-10-13**] 02:50AM LIPASE-15 [**2131-10-13**] 02:50AM CK(CPK)-126 [**2131-10-13**] 02:50AM estGFR-Using this [**2131-10-13**] 02:50AM UREA N-28* CREAT-1.0 [**2131-10-13**] 02:51AM LACTATE-1.1 [**2131-10-13**] 02:51AM TYPE-ART INTUBATED-INTUBATED VENT-CONTROLLED [**2131-10-13**] 03:03AM freeCa-1.10* [**2131-10-13**] 03:03AM HGB-11.5* calcHCT-35 [**2131-10-13**] 03:03AM GLUCOSE-94 LACTATE-1.2 NA+-145 K+-4.1 CL--104 TCO2-31* [**2131-10-13**] 03:03AM PO2-114* PCO2-61* PH-7.32* TOTAL CO2-31* BASE XS-3 COMMENTS-GREEN TOP [**2131-10-13**] 04:55AM LACTATE-1.8 K+-4.1 [**2131-10-13**] 04:55AM COMMENTS-GREEN TOP [**2131-10-13**] 06:24AM PLT SMR-NORMAL PLT COUNT-324 [**2131-10-13**] 06:24AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2131-10-13**] 06:24AM NEUTS-87* BANDS-0 LYMPHS-6* MONOS-6 EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2131-10-13**] 06:24AM WBC-13.0* RBC-3.53* HGB-10.4* HCT-32.4* MCV-92 MCH-29.5 MCHC-32.1 RDW-16.1* [**2131-10-13**] 06:24AM CALCIUM-8.2* PHOSPHATE-5.1* MAGNESIUM-2.0 [**2131-10-13**] 06:24AM CK-MB-4 cTropnT-0.03* [**2131-10-13**] 06:24AM ALT(SGPT)-19 AST(SGOT)-19 CK(CPK)-117 ALK PHOS-68 TOT BILI-0.4 [**2131-10-13**] 06:24AM GLUCOSE-125* UREA N-32* CREAT-1.1 SODIUM-147* POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-30 ANION GAP-14 [**2131-10-13**] 06:30AM LACTATE-1.6 [**2131-10-13**] 06:30AM TYPE-[**Last Name (un) **] TEMP-35.9 PO2-32* PCO2-59* PH-7.36 TOTAL CO2-35* BASE XS-5 [**2131-10-13**] 04:41PM PT-13.4 PTT-24.4 INR(PT)-1.1 [**2131-10-13**] 04:41PM PLT COUNT-292 [**2131-10-13**] 04:41PM WBC-11.2* RBC-3.74* HGB-10.9* HCT-32.6* MCV-87 MCH-29.0 MCHC-33.3 RDW-16.0* [**2131-10-13**] 04:41PM ALBUMIN-3.4* CALCIUM-8.1* PHOSPHATE-4.9* MAGNESIUM-2.0 [**2131-10-13**] 04:41PM CK-MB-3 cTropnT-0.03* [**2131-10-13**] 04:41PM CK(CPK)-114 [**2131-10-13**] 04:41PM GLUCOSE-118* SODIUM-145 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-31 ANION GAP-13 CT Head: IMPRESSION: 1. Stable appearance to right temporoparietal abnormality. While these findings may reflect chronic infarct, a mass lesion with surrounding edema is more concerning. There is local mass effect but no herniation. No evidence for acute hemorrhage. MRI with gadolinium would be recommended for further evaluation. 2. Extensive nasal passage and sinus opacification compatible with intubated status. 3. Post-surgical appearance to the left globe, correlate clinically. ECG: Sinus rhythm. Non-specific QRS widening. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2130-8-4**] cardiac rhythm is now sinus mechanism. Chest AP portablem on admission: FINDINGS: In comparison with the study of [**10-13**], there is continued pulmonary vascular congestion with bilateral effusions and compressive atelectasis. Again, the possibility of supervening pneumonia cannot be excluded in the appropriate clinical setting. [**2131-10-13**] 4:30 am BLOOD CULTURE Blood Culture, Routine (Pending): [**2131-10-13**] 12:08 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2131-10-15**]** GRAM STAIN (Final [**2131-10-13**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2131-10-15**]): SPARSE GROWTH Commensal Respiratory Flora. Renal ultrasound [**2131-10-15**]: IMPRESSION: 1. Normal-appearing kidneys, with no evidence of stone or hydronephrosis. 2. Normal arterial and venous waveforms with resistive indices ranging from 0.71-0.75, within normal limits. 3. The arterial waveforms are irregular and may reflect atrial fibrillation. Chest X-Ray [**2131-10-15**]: IMPRESSION: Improving aeration with small bilateral pleural effusions and bibasilar atelectasis, improved since the priors. Port placement [**2131-10-16**]: IMPRESSION: Successful placement of double-lumen chest Power Port-A-Cath via right internal jugular venous access. The tip of the catheter was positioned in the right atrium and it is ready for use. Upper Extremity ultrasound [**2131-10-16**]: IMPRESSION: No DVT in the left upper extremity. [**2131-10-18**] 04:40AM BLOOD WBC-12.7* RBC-3.62* Hgb-10.9* Hct-32.7* MCV-90 MCH-30.1 MCHC-33.3 RDW-15.7* Plt Ct-326 [**2131-10-18**] 04:40AM BLOOD Glucose-178* UreaN-34* Creat-1.0 Na-144 K-3.8 Cl-108 HCO3-30 AnGap-10 [**2131-10-18**] 04:40AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.9 Brief Hospital Course: Valeriy [**Known lastname 95456**] is a 71-year-old right-handed Russian-speaking male with DM, CAD s/p IMI, recent diagnosis of right frontotemporal glioma s/p biopsy intubated for hypoxemic respiratory failure. (1) Hypoxemic Respiratory Failure: Chest X-ray findings are consistent with decompensated CHF likely precipitated by hypertensive urgency/emergency (SBP was documented at 240 mmHg at OSH); could also consider parapneumonic effusion with ARDS. Patient was diuresed with furosemide and was net (-) 5 liters 36 hours after admission. Hypertension was controlled with beta blockade, [**Last Name (un) **]. Home clonidine was initially held. Patient had episode of atrial fibrillation with rapid ventricular response, was not hemodynamically unstable. Received total of metoprolol tartrate 20 mg IV to slow rate. He spontaneously converted shortly thereafter to sinus rhythm. Patient likely has component of tachy-brady syndrome. Aspirin was held given his glioblastoma and stable intracranial hemorrhage. Cardiac markers were negative. Overlying pneumonia could not be excluded based on chest film, and broad spectrum antibiotics were continued for 48 hours, later discontinued after sputum results returned. Sputum, blood cultures, urine legionella were sent and showed and were negative up until the time of discharge. Hemodynamics improved, and he was extubated on [**2131-10-14**] without complication. He was transferred to the OMED service, where the patient's respiratory status continuously improved. He did not require oxygen after being transferred from the ICU. Patient was continued on Lasix while admitted to prevent against respiratory symptoms and to improve edema, which was significant in the upper and lower extremities. (2) Postoperative Cerebral Edema and Mass Effect: There was no midline shift by CT. Neurosurgery was consulted and did not recommend surgical intervention. Patient's outpatient providers, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**]. Following extubation and continued improvement in patient's hemodynamics, transfer was arranged to the [**Hospital Ward Name 516**] for continued management of glioblastoma multiforme. Decadron was continued upon admission. (3) Glioblastoma Multiforme: The patient had a portcath placed on [**2131-10-16**] and began radiation treatment on [**2131-10-17**] without incident. He also began chemotherapy, consistent of temodar on [**2131-10-16**], and continued up until the time of discharge without problems. [**Name (NI) **] was continued on home dose of Keppra during the admission. Patient will require 42 treatments for radiation, the next is scheduled for [**2131-10-19**] at 02:30 pm at [**Hospital1 18**], in the [**Hospital Ward Name 332**] basement. (4) Hypertension: The patient had numerous episodes of hypertensive urgency during the admission, many times with SBP>190. Hypertensive regimen was altered while admitted. The patient was continued on his home clonidine and valsartan regimen. Labetalol dose was increased from 600 mg [**Hospital1 **] to 800 mg [**Hospital1 **] for added control. In addition, Lasix was given, final dose 60 mg [**Hospital1 **] upon discharge. IF need additional control, neuro-oncology advises trying hydralazine as this can improve cerebral pressure as well as systemic pressure. There was some concern for renal artery stenosis given dramatic hyerptension. A renal ultrasound was performed which did not reveal stenosis. There was some discussion about an angiogram to rule out renal artery stenosis, but this was not done due to recent elevation in Cr to 1.3 with initiation of Lasix. (5) Chronic Diastolic CHF: Patient was placed on Lasix during admission for edematous symptoms and to prevent respiratory symptoms. He was dicharged on 60 mg po BID. (6) Diabetes Mellitus: He continued basal, sliding scale insulin. Patient's basal dose was altered on [**2131-10-17**] to account for continuously high blood glucose levels. Please continue sliding scale per [**Hospital1 1501**] policy. (7) Anxiety: He continued buspar, klonopin to avoid withdrawal symptoms. (8) Code Status: Patient is documented full code. Medications on Admission: Labetolol 600 mg [**Hospital1 **] Eplerenone 50 mg daily Clonidine 0.4 mg patch weekly Colace 100 mg [**Hospital1 **] Decadron 2 mg TID, taper Lantus 40 mg qhs Novolog 9U QAC Keppra 500 mg [**Hospital1 **] Diovan 160 mg [**Hospital1 **] Zocor 40 mg daily Klonopin 0.5 mg qhs Metformin 500 mg [**Hospital1 **] Buspar 5 mg [**Hospital1 **] Colace 100 mg [**Hospital1 **] Discharge Medications: 1. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly Transdermal QSAT (every Saturday). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours). 9. Lantus 100 unit/mL Cartridge Sig: 60 Units Subcutaneous at bedtime. 10. Temozolomide 140 mg Capsule Sig: One (1) Capsule PO once a day. Capsule(s) 11. Temozolomide 5 mg Capsule Sig: Three (3) Capsule PO once a day. 12. Eplerenone 50 mg Tablet Sig: One (1) Tablet PO once a day. 13. Novolog 100 unit/mL Cartridge Sig: Nine (9) Units Subcutaneous QAC. 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**] Discharge Diagnosis: Primary dianosis: Hypoxemic respiratory failure Postoperative cerebral edema and mass effect Hypertensive urgency Secondary diagnosis: Right frontotemporal glioblastoma multiforme Malignant hypertension Coronary artery disease Chronic diastolic congestive heart failure Paroxysmal atrial fibrillation Diabetes mellitus Anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 95456**], It was a pleasure taking care of you at the [**Hospital1 18**]. You came for further evaluation of shortness of breath. Further evaluation showed that you had an episode of decompensated heart failure most likely due to greatly increased blood pressure. While you were here we adjusted your heart failure and blood pressure medications to more optimally manage these problems. It is important that you continue to take your medications as prescribed. Please weigh yourself every morning, and [**Name6 (MD) 138**] your MD if weight goes up more than 3 lbs. The following changes have been made to your medications: We INCREASED your labetalol dose to better control your blood pressure We STARTED lasix to better control your heart failure. We INCREASED your Lantus to better control your blood sugar. We INCREASED your decadron while you are receiving radiation to the brain. Please continue to take your chemotherapy as directed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]. Followup Instructions: Department: NEUROLOGY When: FRIDAY [**2131-10-26**] at 9:30 AM With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: TUESDAY [**2131-10-30**] at 10:00 AM With: XSP WEST [**Telephone/Fax (1) 8243**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: RADIOLOGY When: MONDAY [**2131-11-5**] at 2:55 PM With: RADIOLOGY MRI [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "250.00", "414.01", "191.0", "401.0", "412", "518.81", "348.5", "428.0", "427.31", "E878.8", "428.33", "997.09", "300.00" ]

icd9cm

[ [ [] ] ]

[ "92.29", "86.07", "99.25", "96.71" ]

icd9pcs

[ [ [] ] ]

17354, 17453

11523, 15844

318, 339

17824, 17824

5949, 8943

19085, 19864

3155, 3290

16263, 17331

17474, 17589

15870, 16240

17974, 19062

3305, 3305

9998, 11500

3911, 5930

245, 280

367, 2501

8952, 9642

17610, 17803

9656, 9963

17839, 17950

2523, 2782

2798, 3139

63,000

177,882

35601

Discharge summary

report

Admission Date: [**2114-3-10**] Discharge Date: [**2114-3-21**] Date of Birth: [**2038-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2114-3-16**] Coronary artery bypass graft x3 (left internal mammary artery > left anterior descending, Saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) and aortic valve replacement ( 25 mm [**First Name8 (NamePattern2) **] [**Male First Name (un) **] tissue valve) [**2114-3-12**] Cardiac catherization History of Present Illness: Mr. [**Known lastname 81021**] is a 76 year old male who presented to outside hospital on [**3-8**] for revision of left hip prosthesis and underwent surgery. He was doing well post-operatively, ambulated with physical therapy today without symptoms, however when he returned to bed he developed crushing substernal chest pain with radiation to bilateral arms and the back of his neck. He had never experienced pain like this before. It was associated with shortness of breath and diaphoresis. He did not have nausea. He was treated with nitro paste, morphine, aspirin, and IV metoprolol. He believes the morphine relieved the chest pain. CXR reportedly showed pulmonary vascular congestion. Labs returned with CK 771, Trop 3.63, Hct 27.7. He has been pain free since the original episode aside from a 20 second period of shortness of breath which occurred at 4PM and resolved on its own. He is transferred for further evaluation. Past Medical History: Hypertension Aortic stenosis Aortic insufficiency THR left [**2107**] - developed recurrent pain in [**2111**]. Failed medications, PT. THR right [**2111**] Degenerative joint disease benign prostatic hypertrophy Social History: Mr. [**Known lastname 81022**] social history is significant for the absence of current tobacco use. He quit smoking 50 years ago. He smokes an occasional cigar. There is no history of alcohol abuse. He drinks two times per week, two drinks at a time. He is a classical ballet dancer, teaches, and lives alone. Family History: Noncontributory Physical Exam: VS BP 112/61, HR 89, RR 12, O2sat 96% on 2L Gen: WDWN older 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 7cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**2-9**] decrescendo diastolic murmur and [**3-9**] systolic ejection murmur. 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 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: [**2114-3-21**] 04:38AM BLOOD WBC-10.4 Hct-29.5* Plt Ct-391 [**2114-3-20**] 04:30AM BLOOD PT-16.3* INR(PT)-1.5* [**2114-3-21**] 04:38AM BLOOD Glucose-109* UreaN-32* Creat-1.3* K-4.3 Cl-96 HCO3-30 [**2114-3-17**] 07:15PM BLOOD Glucose-125* Lactate-1.2 Na-130* K-5.1 Cl-100 Brief Hospital Course: Transferred from [**Hospital6 **] after ruling in for non ST elevation myocardial infarction. He was found to have epitaxis with integrilin and ENT was consulted, nose was packed and no further occurence with intergrilin stopping. Was also noted to have hematoma at left hip and orthopedic surgery was consulted, it remained stable, required no surgical intervention and no evidence of sciatic nerve dysfunction. He underwent cardiac catheterization which demonstrated extensive three vessel disease as well as aortic stenosis. He underwent surgical evaluation for cardiac surgery. On [**2114-3-16**] he was brought to the operating room and underwent coronary artery bypass graft surgery and aortic valve replacement. See operative report for further details. He received vancomycin for perioperative antibiotics. He was transferred to the intensive care unit for hemodynamic monitoring. He required inotropes due to systolic heart failure but were weaned off in the first twenty four hours postoperatively. He was also weaned from sedation, awoke neurologically intact, and was extubated. He remained in the intensive care unit for hemodynamic monitoring, and had atrial fibrillation post operative day one at night, treated with betablockers and amidarone which after a few hours converted to normal sinus rhythm. He was transferred to the floor for the remainder of his care. He had intermittent episodes of atrial fibrillation and was started on coumadin for anticoagulation. On post-operative day three he was found to have a right forearm phlebitis. Further, there was a small amount of sero-sanguinous drainage from his mediastinal incision. He was placed on Vancomycin and ciprofloxacin. On the following day the sternal drainage abated. The forearm had improved, but because Mr. [**Known lastname 81021**] has a new aortic valve, a PICC was placed and a plan was set for 2 weeks of IV Vancomycin and oral ciprofloxacin. Vanco troughs should accordlingly be followd along with the progress of these wounds. On the Physical therapy worked with him on strength and mobility. He continued to progress and was ready for discharge to rehab on post operative day four. Medications on Admission: Multivitamin Lisinopril 10mg daily Terazosin 2mg daily Glucosamine plavix 75 mg daily, 300 mg on [**3-10**] ASA 325 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Terazosin 2 mg Capsule Sig: One (1) Capsule PO once a day. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 2 weeks. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. 11. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: or until at pre-op weight. 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 15. 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. 16. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: goal inr 2-2.5 for post-operative atrial fibrillation, resolved. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital 745**] Health Care Center Discharge Diagnosis: Aortic stenosis s/p aortic valve replacement coronary artery disease s/p coronary artery bypass graft surgery Acute on chronic systolic heart failure Post operative atrial fibrillation Post operative - non ST elevation myocardial infarction at NEBH Epitaxis Hypertension degenerative joint disease benign prostatic hypertrophy s/p left hip revision [**2114-3-8**] at NEBH s/p left total hip repl. [**2107**] s/p right total hip repl. [**2111**] s/p left knee scope Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Monitor right arm phlebitic area for increasing redness or lack of improvement. Place warm packs to site four times per day. Complete 2 week course of intravenous Vancomycin and oral ciprofloxacin started on [**2114-3-20**]. Vanco troughs should be checked weekly. PICC in place, flush with normal saline two times per day. Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule all appointments Dr. [**First Name (STitle) **] after discharge from rehab Dr. [**First Name (STitle) 7049**] after discharge from rehab Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] appointment - [**4-18**] at 1200 - ([**Telephone/Fax (1) 81023**] Labs: PT/INR for coumadin dosing - indication atrial fibrillation with goal INR 2.0-2.5 Completed by:[**2114-3-21**]

[ "E934.8", "428.23", "784.7", "715.90", "E878.2", "998.12", "410.71", "416.8", "427.31", "428.0", "424.1", "997.1", "451.84", "V43.64", "414.2", "401.9", "600.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "38.93", "39.61", "37.23", "36.12", "21.21", "35.21", "21.09", "88.56" ]

icd9pcs

[ [ [] ] ]

7316, 7380

3480, 5671

331, 682

7890, 7897

3184, 3457

8734, 9218

2223, 2240

5847, 7293

7401, 7869

5697, 5824

7921, 8711

2255, 3165

281, 293

710, 1642

1664, 1879

1895, 2207

10,478

146,037

23242

Discharge summary

report

Admission Date: [**2147-7-4**] Discharge Date: [**2147-7-15**] Date of Birth: [**2073-4-8**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 1505**] Chief Complaint: bilateral arm "aching" and SOB Major Surgical or Invasive Procedure: cabg x2 (LIMA to LAD and SVG to OM) cardiac catheterization History of Present Illness: Presented in [**11-10**] with severe substernal pain for 8 hours. Was cathed emergently then and has LM/LAD/RCA disease with EF 35%. In lab, became hypotensive, and had IABP placed with retroperitoneal bleed.Ultimately right fem. angioplasty was done, but patient was not deemed a surgical candidate at that time. In [**12-10**], CYPHER stents were placed in LM/LAD/CX/RCA. Thrombus was noted in the IVC and a filter was placed. She was also transfused and stabilized and then DC to home. Surveillance cath done [**3-11**] showed ISR of LAD and CX stents. Left upper enal artery had 80% stenosis and the right renal artery had a 60% stenosis. The left renal artery was stented at that time. Readmitted on [**7-4**] for repeat cath after complaining of a skin rash and bilateral arm aching for 2 weeks. ETT was positive at that time. Past Medical History: HTN Hypercholesteremia Anxiety Left renal artery stent CAD/ mult Cypher stents DVT left and IVC filter right femoral angioplasty and retroperitoneal bleed STEMI anxiety arthritis sciatica GERD TAH left knee [**Doctor First Name **]. Social History: widowed with 3 children; lives alone but daughter lives across the street Smoked [**1-8**] ppd times 40 years but recently decreased to 3 cigs/day over the past month. No EtOH or drug abuse. Family History: Mother with DM. Father with angina, CA. Siblings with hyperchol. Physical Exam: NAD, lying flat in bed RRR S1 S2 no M/R/G CTA bilat. extrem warm and well-perfused; pulses 2+ throught without varicosities rash over upper chest, back, and left lower arm with excoriations, pruritic for 2 weeks, sutues in place from right shoulder dermatology biopsy VS right 153/59 left 139/52 RR 18 sat 100%RA HR 62 weight pre-op 54.5 kg 5'1" Pertinent Results: [**2147-7-4**] 11:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2147-7-4**] 11:20AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2147-7-4**] 11:20AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-<1 [**2147-7-4**] 09:45AM GLUCOSE-170* UREA N-17 CREAT-1.0 SODIUM-128* POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-22 ANION GAP-13 [**2147-7-4**] 09:45AM ALT(SGPT)-16 AST(SGOT)-18 CK(CPK)-74 ALK PHOS-65 AMYLASE-99 TOT BILI-0.2 [**2147-7-4**] 09:45AM CK-MB-NotDone cTropnT-<0.01 [**2147-7-4**] 09:45AM ALBUMIN-3.8 [**2147-7-4**] 09:45AM VIT B12-226* [**2147-7-4**] 09:45AM WBC-7.4 RBC-3.54* HGB-10.7* HCT-30.3* MCV-86 MCH-30.4 MCHC-35.4* RDW-12.2 [**2147-7-4**] 09:45AM PLT COUNT-258 [**2147-7-4**] 09:45AM PT-12.5 PTT-31.0 INR(PT)-1.0 [**2147-7-13**] 06:15AM BLOOD WBC-7.2 RBC-4.13* Hgb-12.5 Hct-36.7 MCV-89 MCH-30.3 MCHC-34.1 RDW-13.4 Plt Ct-263 [**2147-7-14**] 09:30AM BLOOD PT-14.0* INR(PT)-1.3 [**2147-7-13**] 06:15AM BLOOD Plt Ct-263 [**2147-7-14**] 09:30AM BLOOD Glucose-138* UreaN-27* Creat-1.1 Na-133 K-4.0 Cl-95* HCO3-28 AnGap-14 [**2147-7-11**] 01:22AM BLOOD Calcium-8.9 Phos-3.2# Mg-2.3 Brief Hospital Course: Cath done at admission with ins stent restenoses as noted above. Referred for Cabg to Dr. [**Last Name (STitle) **]. Seen by dermatology and punch biopsy done right shoulder. On heparin while couadin being held. CABG X2 done [**2147-7-7**]. Transferred to CSRU in stable condition on neo and propofol drips. Extubated and started on amiodarone.Had an episode of SVT treated with IV lopressor on [**7-10**] ad had some lability of BP. Amio switched over to P.O.and ACE restarted on [**7-11**]. Needed significant pulmonary toilet in CSRU and transferred to floor on [**7-12**]. Chest tubes and pacing wires removed. Coumadin restarted for IVC filter. Will be discharged when INR trends up. INR today 1.3. Medications on Admission: [**Month/Day (4) **] 325mg daily Lipitor 20 mg daily Prozac 10 mg daily Zantac 150 mg twice daily Plavix 75 mg daily lisinopril 40 mg daily toprol XL 150 mg daily coumadin 4 mg every day ( LD dose 6/16) HCTZ 12.5 mg daily ( stopped [**6-30**]) hydroxyzine HCL 25 mg TID prn itching Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*10 * Refills:*2* 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer IH Inhalation Q6H (every 6 hours). Disp:*120 nebulizer IH* Refills:*2* 11. Acetylcysteine 20 % (200 mg/mL) Solution Sig: three to five ML Miscell. Q4-6H (every 4 to 6 hours) as needed. Disp:*50 ML(s)* Refills:*0* 12. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): [**Name8 (MD) **] MD dosing daily. Disp:*30 Tablet(s)* Refills:*0* 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 16. Potassium Chloride 20 mEq Packet Sig: One (1) 20 mEq packet PO once a day for 7 days. Disp:*7 20 mEq packet* Refills:*0* 17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: [**7-15**] to [**7-22**]. Disp:*14 Tablet(s)* Refills:*0* 18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: starting on [**7-23**]. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: s/p cabg x2 myocardial infarction s/p PCI /stent S/p IVC filter /DVT left hypertension elev. chol. anxiety GERD renal artery stenosis with stent Left coronary artery disease arthritis sciatica TAH left knee [**Doctor First Name **]. Discharge Condition: stable Discharge Instructions: no lotions, creams or powders on any incision may shower and pat dry over steristrips no lifting more than 10 pounds for 10 weeks Followup Instructions: follow up with PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 2405**] for blood draws and INR/coumadin dosing daily; VNA to fax results to FAX number for Dr. [**First Name (STitle) 2405**] is [**Telephone/Fax (1) 59741**] or call at [**Telephone/Fax (1) 59742**] make an appt. with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] for postop visit at 4 weeks see PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 2405**] and cardiologist Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1557**] 1-2 weeks after discharge Completed by:[**2147-7-15**]

[ "V45.82", "401.9", "996.72", "427.0", "V17.3", "530.81", "412", "272.4", "411.1", "693.0", "414.01", "285.9", "440.1" ]

icd9cm

[ [ [] ] ]

[ "99.05", "39.61", "88.56", "99.04", "37.22", "36.15", "86.11", "36.11" ]

icd9pcs

[ [ [] ] ]

6599, 6655

3389, 4095

303, 365

6932, 6940

2165, 3366

7118, 7724

1710, 1778

4427, 6576

6676, 6911

4121, 4404

6964, 7095

1793, 2146

233, 265

393, 1227

1249, 1484

1500, 1694

62,952

119,530

52720

Discharge summary

report

Admission Date: [**2165-1-1**] Discharge Date: [**2165-1-6**] Date of Birth: [**2115-6-19**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 509**] Chief Complaint: Headache and viral exanthem Major Surgical or Invasive Procedure: Central line insertion History of Present Illness: 49-year-old female with a history of TBI with splenectomy and sternotomy post chest stabbing presents with a [**2-15**] day history of fever, headache, cough and general malaise. Patient noted that she has felt unwell past 3-4 days. On [**12-29**] went to a party of her aide's infant and noted that one of the parents had a cough ++ and after coming back was initially well then started coughing - non-productive by teh evening and put it down to her recent sick contact. By [**12-30**] she woke up and felt awful, had the same dry cough and described general malaise with a sore throat. By the evening of [**12-30**] she had fever and chills but no rigors, nausea with retching but no vomiting in addition to generalised body aches. [**12-31**] still unwell and had worsening symptoms with persistent non-productive cough and by that evening had a gradually worsening whole head throbbing/pounding headache which reached a peak at 10/10 intensity and persistent subjective fevers. Headache was without visual changes or neck stiffness or photophobia. She also noted some dehydration secondary to poor oral fluid intake despite a normal food intake - notes poor oral fluid intake is chronic for her as she does not want to have to trouble her husband to get her up to pass urine. She felt her left leg was stuffer than usual on [**12-31**]. She felt light-headed since [**12-30**] but did not feel faint and did not lose consciousness. She called her PCP [**Last Name (NamePattern4) **] [**12-31**] and presented to the ED on [**1-1**]. In the ED, VS: T: 101 HR: 132 BP: 103/56 18 saturating 93%. LP performed. CSF with 0 RBC 1WBC (54% lymphocytes), protein 31, glucose: not measured. UA without sign of infection. Influenza A/B antigen negative. Blood cultures pending. CXR: Unremarkable. In the ED patient received Tylenol 1gm, Ceftriaxone 2mg IV. Dexamethasone Sod Phosphate 10mg/mL x1. Baclofen 10mg PO x1, Morphine 4mg IV x1, Toradol 30mg IV x1. Found to be hypotensive and febrile in the ED 101 with Tmax 103.2. Due to previous splenectomy, they gave her presumptive treatment for possible meningitis with 2g IV ceftriazone, vancomycin, and dexamethasone prior to LP. LP was unremarkable. She became more hypotensive dropping her SBP to 70-80s despite 6L IVF and a CVC was inserted and started on norepinephrine infusion and was transferred to the ICU. Last VS in ED: HR 92, 95% RA, RR 16, BP 96/65 (0.12 levophed), CVP 11. She thinks her last flu shot was in [**Month (only) 359**] and on questioning regarding vaccines denies pneumoococcal vaccination. In the ICU, admission vitals were T 98.9 HR 94 BP 117/79 on 0.12 NE RR 18 sO2 93% RA and 98% on 2L O2. Currently feels well save persistent non-productive cough. Denies pain or nausea, vomiting or diarrhoea (last BM yesterday). Headache stopped 30 mins ago. No visual changes no neck stiffness no confusion. . ROS: The patient denies any weight change, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, urinary frequency, urgency, dysuria, new weakness, vision changes, rash or skin changes. Past Medical History: - Anxiety - Depression - Hyperlipidemia - MVA c/b closed head injury and left hemiplegia ([**2135**]) and spasticity for which she receives Botox injections - wheelchair bound -Multiple stab wounds to the chest and ?lobectomy; sternotomy; in [**2140**] - S/P splenectomy . Past surgical Hx: As sequelae of MVA: Splenectomy Liver lacs which were repaired Fractured left femur and right foot Social History: Lives in [**Location 2312**], MA with husband. [**Name (NI) 4906**] has severe depression- concern about husband's deteriorating health. Requires regular PCA care due to disability.No children. Born and raised in CT,moved to [**State **] [**2159**],her and her husband were evicted(states one of her pca's ran off with her and her husband's money), moved to [**Location (un) **] [**2162-7-26**] Occupation: Disability prev clerical in auto-supply company Tobacco: quit 18 yrs ago. (20 pack year smoking history) EtOH: quit in [**2159**] IVDU: denies but frequent cannabis use last of which was [**2-23**] ago Many financial problems at home. Family History: Father: deceased 82 yrs stroke Mother: deceased 62 yrs unknown cancer 6 brother(s) , 1 sister; 3 brothers deceased-one of cad ? [**1-16**] illicit drug use, others from alcohol abuse. Physical Exam: Admission exam: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL 3+/3+, 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. Midline sternotomy scar ABD: Soft, NT, ND, +BS, no HSM, no masses. Laparotomy scar. EXT: No C/C/E, no palpable cords. Marked LL spasticity. NEURO: GCS 15/15 alert, oriented to person, place, and time. CN II ?????? XII normal. Considerable spasticity in left side UE and LE with less spasticity in R LE and ? slight increase tone in R UE. Reflexes pathologically brisk in lower limbs esp on L and Relatively preserved in RUL and difficult to ellicity in LUL due to tone. Good power RUL and [**3-18**]+/5 in elbow flexion and extension in LUL and minimal movement LUL. 3-4/5 power in RLL proximally with little distal power due to contractions. Plantars flexor bilaterally. Sensation seems intact to light touch. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Admission labs: [**2165-1-1**] 09:10AM BLOOD WBC-9.0 RBC-4.06* Hgb-12.6 Hct-37.1 MCV-91 MCH-31.1 MCHC-34.0 RDW-13.1 Plt Ct-356 [**2165-1-1**] 09:10AM BLOOD Neuts-82.7* Lymphs-10.3* Monos-5.5 Eos-0.4 Baso-1.1 [**2165-1-1**] 09:10AM BLOOD Glucose-107* UreaN-17 Creat-0.7 Na-142 K-3.8 Cl-103 HCO3-28 AnGap-15 [**2165-1-1**] 09:10AM BLOOD Calcium-9.5 Phos-4.3# Mg-2.0 [**2165-1-1**] 09:13AM BLOOD Lactate-0.6 . Other labs: [**2165-1-1**] 09:10AM BLOOD CK(CPK)-67 [**2165-1-1**] 09:10AM BLOOD CK-MB-2 cTropnT-<0.01 [**2165-1-2**] 02:57AM BLOOD Albumin-3.4* Calcium-7.1* Phos-2.5*# Mg-1.7 [**2165-1-1**] 09:10AM BLOOD CRP-27.0* [**2165-1-3**] 02:59AM BLOOD CRP-62.2* [**2165-1-1**] 09:13AM BLOOD Lactate-0.6 [**2165-1-3**] 08:15AM BLOOD Lactate-0.9 . . Urine: [**2165-1-1**] 12:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014 [**2165-1-1**] 12:00PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2165-1-1**] 12:00PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 [**2165-1-1**] 12:00PM URINE UCG-NEGATIVE . . CSF: [**2165-1-1**] 11:58AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-2 Lymphs-54 Monos-44 [**2165-1-1**] 11:57AM CEREBROSPINAL FLUID (CSF) TotProt-31 Glucose-71 . . Microbiology: Time Taken Not Noted Log-In Date/Time: [**2165-1-1**] 11:59 am CSF;SPINAL FLUID #3. **FINAL REPORT [**2165-1-4**]** GRAM STAIN (Final [**2165-1-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2165-1-4**]): NO GROWTH. . [**2165-1-1**] 9:40 am Influenza A/B by DFA Source: Nasopharyngeal swab. **FINAL REPORT [**2165-1-1**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2165-1-1**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2165-1-1**]): Negative for Influenza B. . BC [**1-1**] x2 pending UCx [**1-2**] -ve . [**2165-1-2**] 10:18 am SPUTUM Source: Expectorated. **FINAL REPORT [**2165-1-2**]** GRAM STAIN (Final [**2165-1-2**]): [**10-8**] 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. . BC [**1-2**] x2 pending UCx [**1-3**] -ve BC [**1-3**] pending . [**2165-1-3**] 10:39 am Rapid Respiratory Viral Screen & Culture Source: Nasopharyngeal aspirate. **FINAL REPORT [**2165-1-3**]** Respiratory Viral Culture (Final [**2165-1-3**]): TEST CANCELLED, PATIENT CREDITED. Refer to respiratory viral antigen screen and respiratory virus identification test results for further information. Respiratory Viral Antigen Screen (Final [**2165-1-3**]): Positive for Respiratory viral antigens. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to Respiratory Virus Identification for further information. Respiratory Virus Identification (Final [**2165-1-3**]): POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. . [**2165-1-3**] 1:30 pm THROAT CULTURE VIRAL CULTURE (Pending): . [**2165-1-4**] 4:06 am SPUTUM Source: Expectorated. **FINAL REPORT [**2165-1-4**]** GRAM STAIN (Final [**2165-1-4**]): <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. . . Radiology: XR CHEST (PA & LAT) Study Date of [**2165-1-1**] 9:51 AM FINDINGS: Lateral view is slightly limited by patient's arm and positioning. There is no focal consolidation, pneumothorax, or pleural effusion. The cardiomediastinal silhouette is unremarkable. Note is made of sternal wires and anterior mediastinal surgical clips, which are similar appearing compared to prior. Left first and second anterior rib fusion is again noted. IMPRESSION: No evidence for acute cardiopulmonary process. . XR CHEST (PORTABLE AP) Study Date of [**2165-1-1**] 2:44 PM FINDINGS: The left base is obscured by the patient's left upper extremity. Within these limitations, the lungs are clear. There are no pleural effusions or pneumothorax. The patient is status post right internal jugular central venous catheter placement with tip terminating within the cavoatrial junction. There is no evidence of pneumothorax. There are no pleural effusions. The cardiomediastinal and hilar contours are normal. The patient is status post median sternotomy. IMPRESSION: Right internal jugular approach central venous catheter in standard position with no evidence of pneumothorax. . CHEST (PORTABLE AP) Study Date of [**2165-1-3**] 6:22 AM Portable AP chest radiograph was compared to prior study [**2165-1-1**]. Large consolidation in the left lower lobe is noted as well as bilateral perihilar interstitial opacities and left mid upper lobe consolidation. These findings are consistent with aspiration and newly developed interstitial edema. . XR CHEST (PORTABLE AP) Study Date of [**2165-1-4**] 5:23 AM IMPRESSION: AP chest compared to [**1-1**] through 20: Previous mild pulmonary edema, in the right lung, has improved. Extensive consolidation in the left lung has also decreased, consistent with stabilizing pneumonia. Previous small pleural effusions have decreased or resolved. Heart size is normal. The leftward shift of the mediastinum suggests a component of atelectasis in the left lung perhaps due to retention of aspirated material. No pneumothorax. Right jugular line ends in the low SVC. . . Cardiology: ECG Study Date of [**2165-1-1**] 4:05:06 PM Artifact is present. Sinus rhythm with sinus arrhythmia. Non-specific ST-T wave changes. Compared to the previous tracing of [**2163-9-15**] ST-T wave changes are more prominent. Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H. Intervals Axes Rate PR QRS QT/QTc P QRS T 70 156 76 428/445 73 82 32 Brief Hospital Course: 49-year-old female with a history of TBI with splenectomy and sternotomy post chest stabbing presents with a [**2-15**] day history of fever, headache, cough and general malaise consistent with viral exanthem. She appeared well other than BP which dropped to 70s-80s in ED and required inotropic support with noradrenaline. She had very high fevers compatible with a viral infection and although initial swab was negative, she was confirmed Influenza [**Name Initial (MD) **] by NP swab. She had pulmonary edema and possible aspiration on CXR and antibiotics were stopped and she improved. She was weaned off pressors and was transferred from the ICU on [**1-4**] with improved CXR appearances and stable vitals. . . Plan: # Influenza A with possible aspiration event vs influenza pneumonia: She presented with symptoms suggestive of viral exanthema in addition to normal WBCs mild CRP elevation and high fevers >104 which would not be compatible with a bacterial infection and during these she was not overly unwell. She initially required pressor support in the ED and was hypotensive requiring norepinephrine and IV fluids receiving 6L in the ED. Given her headache she was worked up for possible meningitis with a negative CSF with no growth on culture. Her headache resolved. Cultures showed no growth to date. She continued to have high fevers and although initial influenza swab was negative, repeat on [**1-3**] was positive. She was initialy treated with IOV ceftrioaxone to cover possible pneumococcal infection given asplenia. She was initially treated with respiratory precautions and following confirmation of Influenza A these were re-instated. She had an episode of vomiting on [**1-2**] without clear evidence of aspiration (her swallow has always been fine) and by [**1-3**] had a high fever 104.5 and she desaturated to 90% on 3L O2. She received 2L IV fluid and had developed interval chest signs on the left base with reciprocal changes on her chest XR suggestive of aspiration and pulmonary edema. She was allowed to auto-diurese and antibiotics were briefly continued and these were stopped on [**1-4**]. Her CRP was initially 27 and ahad risen to 66 on [**1-3**] likely secondary to her possible aspiration vs development of influenza pneumonia. She remained well and her fevers lessened in severity. Her blood pressure remained stable off pressors and her saturations improved with evidence of improvement in pulmonary edema and consolidation on repeat CXR on [**1-4**] and she was stable to tranfer to the floor on [**1-4**]. The patient was transferred to the floor and monitored for 36 hours. She remained afebrile on no antibiotics and her respiratory and BP status was also stable. She was discharged on [**2165-1-6**] with intruction to follow up with her PCP [**Name Initial (PRE) 176**] 1 week of being discharged. . # Volume status. Exam had elevated JVP and evidence of pulmonary edema on CXR on [**1-3**] which was likely secondary to her 8L of total fluid resuscitation. She had a TTE on [**1-3**] which was unremarkable and was allowed to auto-diurese. At the time of discharge she was euvolemic. . # Deranged LFTs: ? cause. LFTS were already uptrending in the community and were stable in-house. In the community there was thought to be due to her baclofen and the dose of this had been reduced. These were trended after her baclofen was reduced to 10mg PO BID. Her LFTs trended down after this reduction and she was discharged on baclofen 10mg PO BID. . # Elevated PTT: It was unclear regarding her PTT which rose during her hspital stay while being normal on admission rose to 78 and latterly to 150 and fell to 56. Due to concerns that her s/c heparin may be causing this, her heparin was stopped. We checked check antiphopholipid Ab: lupus anticoagulant and anticardiolipin Ab and they are all negative. It is recommended to get a mixing study in the outpatient setting. . # Headache: Headache was viral in origin secondary to Influenza A as above and resolved withketorolac and required no further analgesia. Her headache resolved as the course of her hospital stay progressed. At the time of discharge, she did not have any headache. . # s/p MVA c/b closed head injury and left hemiplegia: No current change to residual neurologocal deficit. We continued baclofen at decreased dose. This was not an active issue duringher hospitalization. . # S/P splenectomy: At risk for infection with encapsulated organisms. She was initially treated with IV ceftriaxone and this was stopped when cultures came back negative after 48 hours. She should have pneumococcal and meningococcal vaccines in teh community. . # Anxiety: We continued home lorazepam. This was not an active issue. . # Depression: We continued home trazodone and citalopram. This was not an active issue . # Hyperlipidemia: WE continued home simvastatin. This was not an active issue. Medications on Admission: Medications - Prescription BACLOFEN - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth in am, 1 at noon and 2 at bedtime CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - 0.5 mg Tablet - [**12-16**] Tablet(s) by mouth every twelve (12) hours as needed for as needed for anxiety SIMVASTATIN - 40 mg Tablet - 1 tablet by mouth once a day at bedtime TRAZODONE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC BISACODYL - (Prescribed by Other Provider) - 10 mg Suppository - 1 Suppository(s) rectally once a day CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by mouth in am 1 at noon Discharge Medications: 1. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q12H (every 12 hours) as needed for anxiety. Disp:*12 Tablet(s)* Refills:*0* 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 7. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. sennosides 8.6 mg Tablet Sig: One (1) Tablet PO once a day: at noon. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Influenza . Secondary Diagnosis: - Anxiety - Depression - Hyperlipidemia - MVA c/b closed head injury and left hemiplegia ([**2135**]) and spasticity for which she receives Botox injections - wheelchair bound -Multiple stab wounds to the chest and ?lobectomy; sternotomy; in [**2140**] - S/P splenectomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You are being discharged from [**Hospital1 1170**]. It was a pleasure taking care of you. You were admitted to the hospital and it was found that you had very low blood pressure and you were admitted to the intensive care unit for blood pressure support and work up for an infection. We ultimately found that you had the flu. There was some concern that you had a pneumonia, but after following you for some time, we do not believe that you had a pneumonia and the antibiotics were discontinued. You will go home on your home medications and it is encouraged that you follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week. It is important to make sure that you get your pneumococcal and meningococcal vaccines as an outpatient. there was some concern that your baclofen was causing your liver labs to rise a little and so your baclofen dose was decreased. Please continue the dose as now prescribed. . The following medication was CHANGED: Baclofen --> 10mg by mouth twice a day. . Please continue to take your other medications as prescribed. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14032**] [**Telephone/Fax (1) 608**], on Monday [**2165-1-7**] and make an appt to see him within 1 week. . Please have your doctor check your LFTs to make sure they are still going down.

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Discharge summary

report

Admission Date: [**2163-9-10**] Discharge Date: [**2163-9-12**] Date of Birth: [**2079-1-17**] Sex: M Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Streptomycin / Citric Acid / Atenolol / Torsemide / Heparin Agents Attending:[**First Name3 (LF) 99**] Chief Complaint: Bleeding from colostomy and foley Major Surgical or Invasive Procedure: none History of Present Illness: 84 year old male with multiple co-morbidities including rectal cancer s/p resection and radiation in [**2157**] now with colostomy, coronary artery disease s/p stents, systolic CHF, dilated cardiomyopathy, atrial fibrillation not on [**Year (4 digits) **], cardiac arrest and complete heart block s/p AICD/pacemaker, recent trach/peg after prolonged hospitalization for rib fractures/flail chest s/p fall who presents with large amount of bleeding from colostomy and Foley. The patient also endorsed increased shortness of breath, weakness and fatigue. The patient had been recently admitted 8/21-25/[**2163**] to the [**Hospital1 18**] MICU for pneumonia and MRSA bacteremia/sepsis and had been discharged on Vancomycin and baby aspirin (for his atrial fibrillation and coronary artery disease). . In the [**Hospital1 18**] ED, initial vital signs were: Afebrile, HR70, BP107/53, RR24, 91% on trach vent. Given his tender abdomen, there was initial concern for an intrabdominal event. ACS/General Surgery was consulted and CT abdomen/pelvis was performed. As the imaging was negative, there were no acute surgical concerns; ACS recommended tagged RBC if he continued to bleed. GI was also consulted and recommended two units pRBC for Hct 22, IV PPI initiation. The patient also underwent PEG lavage which was clear but was passing small amounts of maroon colored stools. There was also initial concern for DIC but labs not suggestive of this (the patient has history of heparin induced thrombocytopenia but platelets normal). The patient has had hematuria in the past, with three-way foley in place. . Upon arrival to the MICU, the patient was resting comfortably in bed with trach/PEG, endorsing fatigue and abdominal pain. Per the patient's wife, the patient looked good on discharge two days ago but seemed under the weather on arrival to [**Hospital 100**] Rehab. When she saw him at 6pm yesterday evening, he was stable without signs of bleeding. . Review of systems: (+) Per HPI (-) [**Hospital 4273**] fever, headache, cough, shortness of breath, or wheezing. [**Hospital 4273**] chest pain, chest pressure, palpitations, or weakness. [**Hospital 4273**] nausea, vomiting. Past Medical History: - Rectal cancer s/p excision and XRT ([**2157**]) - CAD s/p stents (?[**2159**]) - CVA in [**2150**] with residual right hand dysthesia - Complete heart block s/p pacemaker - h/o cardiac arrest (now with AICD) - GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p cauterization via EGD - Atrial fibrillation - Systolic CHF (EF 40-45%) - s/p Fall with multiple rib fractures ([**2163-6-23**]) - MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from trach - Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **] Social History: Resident of [**Hospital 100**] Rehab w plans to return home; previously had lived in [**Location 745**] with his wife, now w some depression about moving out of their 42 year home. Has two children. Retired computer science professor. - Tobacco: 5 cigars daily for 30 years, quit [**2150**] s/p CVA - Alcohol: Previously [**1-16**] glasses/week, generally per wife "affects him quite a bit," changing his mood and making him sick - Illicits: [**Month/Day (2) 4273**] Family History: Father died in 80s from MI. Mother died in 80s from PE. No family history of colon, breast, uterine, or ovarian cancer. No family history of seizures Physical Exam: ADMISSION: Vitals: T: 98.9 BP: 115/54 P: 71 R: 16 O2: 99% (FiO2 35%, Tv 450, RR12, PEEP5) General: Alert, oriented, no acute distress, pale, breathing comfortably via trach HEENT: PERRL, pale conjunctiva, normocephalic, poor dentition, clear oropharynx Neck: Soft, supple, trach in place with minimal secretions Lungs: Mild rhonchi in all lung fields, no wheezing/rales; mild bibasilar crackels CV: Regular rate and rhythm, normal S1 + S2, no rubs or gallops, [**3-20**] holosystolic murmur Abdomen: Soft, non-tender, non-distended, positive bowel sounds, no rebound tenderness or guarding, maroon streaked stool in colostomy GU: Three way foley with dark pink urine in collection bag Ext: Warm, well perfused, +pulses, bilateral upper extremity edema, L>R; bilateral anterior shin hemosiderin changes . DISCHARGE: VS: 98.7 70 111/49 17 96% (Pressure Support 12, PEEP 5, FiO2 35%) General: Comfortable, no acute distress HEENT: PERRL, EOMI, MMM, poor dentition Cardiovascular: RRR, II/VI systolic murmur Respiratory / Chest: CTA bilaterally, no wheezes/rales/ronchi Abdominal: Soft, nontender/nondistended, naBS, ostomy c/d/i Extremities: WWP, 2+ lower extremity edema, 2+ upper extremity edema L>R (chronic), 2+PT/DP/radial pulses Neurologic: Attentive, moving all extremities Pertinent Results: Blood Counts [**2163-9-9**] 10:15PM BLOOD WBC-8.1 RBC-2.55* Hgb-7.3* Hct-22.4* MCV-88 MCH-28.7 MCHC-32.6 RDW-16.3* Plt Ct-105* [**2163-9-11**] 01:56AM BLOOD WBC-8.0 RBC-3.06* Hgb-9.2*# Hct-26.3* MCV-86 MCH-29.9 MCHC-34.8 RDW-16.5* Plt Ct-120* [**2163-9-12**] 04:39AM BLOOD WBC-6.9 RBC-3.06* Hgb-8.9* Hct-26.6* MCV-87 MCH-29.0 MCHC-33.5 RDW-16.6* Plt Ct-132* Chemistry [**2163-9-9**] 10:15PM BLOOD Glucose-108* UreaN-49* Creat-1.1 Na-139 K-4.0 Cl-103 HCO3-29 AnGap-11 ABx [**2163-9-12**] 06:51AM BLOOD Vanco-24.2* . IMAGING: [**2163-9-9**] CXR: IMPRESSION: Blunting of the left costophrenic angle and left base opacities consistent with left pleural effusion with overlying atelectasis, underlying consolidation cannot be entirely excluded. Cardiomegaly and prominent right hilum again seen. Mild pulmonary vascular congestion, improved. . CT ABD and PELVIS: 1. Ascites is new since most recent exams dating back to [**2161**], likely correlating with diffuse anasarca. 2. Slight increase in size of 9-mm enhancing left liver lobe lesion which is incompletely characterized on this exam. This might be a flash filling hemangioma or focal nodular hyperplasia. No other acute intra-abdominal process. If more definitive characterization is desired, multiphasic CT of the liver could be considered. . Brief Hospital Course: HOSPITAL COURSE 84yo M PMHx CAD s/p stenting, systolic CHF (EF40-45%), atrial fibrillation, recent hospitalization for MRSA bacteremia of respiratory source, who represented from MACU with hematuria and blood in colostomy bag, thought to be secondary to recent initiation of ASA, now resolved after holding ASA, hemodynamically stable x multiple days, being discharged to MACU. . ACTIVE # Blood in Ostomy: Patient w/ history of UGIB secondary to angiectasias in the duodenum who presented w/ trace blood in his ostomy; patient remaining hemodynamically stable w/ PEG lavage negative; Trace blood in his colostomy bag suggests lower GI bleed; given temporal relationship to initiation of ASA, this was felt to most likely be an exacerbation of underlying issue; bleeding resolved with holding of ASA. He received 2 units of pRBC on the day of admission. His hemoglobin/hematocrit was thereafter stable. Patient/family have declined scoping at this time but may be amenable to this as an outpatient (of note, colonoscopy in [**2160**] was normal). Continued patient's home omeprazole; held ASA (see below). His cardiologist was notified because the patient is now no longer on aspirin or [**Year (4 digits) **], but bleeding risk strongly outweighs stroke risk at this time. Patient will need to readdress issue of colonoscopy as an outpatient with outpatient providers. Scheduled follow up with Dr. [**Last Name (STitle) 1940**] on [**10-31**]. Please call Dr. [**Last Name (STitle) 1940**] office to see if can get EGD sooner. . # Hematuria: Patient with a history of hematuria of uncertain etiology who presents w recurrence of bleeding, thought to be secondary recent initiation of ASA; holding of ASA resolved bleeding issue; patient will need to have outpatient follow-up with urology for discussion of cystoscopy; (appt was not yet scheduled). PATIENT WITH FIRM FOLEY CATHETER WITH 30CC balloon. Sending extra replacements with the patient. Please be aware if removing. . # MRSA bacteremia: Pt w recent admission notable for MRSA bacteremia w/o TTE evidence of valvular involvement; continued vancomycin treatment course (last day is [**2163-9-18**]); level was supratherapeutic during this hospitalization; adjusted dosing to 500mg [**Hospital1 **]. Patient will need Vancomycin trough on morning of [**2163-9-14**] and adjust dose as necessary. . # Chronic Diastolic CHF: Patient w EF 55-60% ([**2163-9-8**]) appearing fluid overloaded on admission; restarted patient's home diuresis with good urine output. Continued home carvedilol. Continued to hold lisinopril (had been held during recent admission) given normotensive without. Could consider restarting as outpatient if he became hypertensive. . # Sacral decubitus ulcer: Stage IV, significant. Appropriate wound care. Continued oxycodone, lidocaine. Patient became loopy receiving oxycodone 5mg Q4H. Is written for 5-10mg Q4H:PRN for pain, but will need to be assessed prior to medication to make sure not continuing to get loopy. Please assess at MACU and continue to turn the patient regularly minimizing weight bearing to that area. . # Atrial fibrillation: CHADS4 but off anticoagulation/antiplatelet secondary to history of GI bleeds, hemothorax in 6/[**2163**]. Given bleeding on this admission he will likely be a poor candidate for ASA in the future. Alerted outpatient cardiologist Dr. [**Last Name (STitle) **] regarding this issue. He has follow up with Dr. [**Last Name (STitle) **] on [**9-28**] and we will contact him as well on the day of discharge. . TRANSITIONAL - PATIENT WITH FIRM FOLEY CATHETER WITH 30CC balloon. Sending extra replacements with the patient. Please be aware if removing. - Scheduled for follow-up with cardiologist - Scheduled follow up with gastroenterologist, please call to see if can get EGD sooner than schedule appt. - If has continued hematuria, will need urology follow up for cystoscopy. - Continue vancomycin for MRSA bactermia until [**2163-9-18**], next traough needs to be morning of [**9-14**]. Goal level 15-20. - Wean off vent to trach mask, plan to diurese to dry weight to aid in weaning process - Holding lisinopril given stable, BP, but can restart if becomes hypertensive. Medications on Admission: * Acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q4H PRN * Lidocaine 5 %(700 mg/patch) daily * Trazodone 25 mg Tablet qHS * Citalopram 20 mg daily * Docusate 10mL twice daily * Ferrous sulfate 300mg daily * Folic acid 1mg daily * Multivitamin daily * Omeprazole 20 mg daily * Albuterol inhaler 2 puffs q4 hours PRN * Simethicone 80mg three times daily * Miconazole nitrate 2% powder qHS * Oxycodone 5-10mg q4 hours PRN * Aspirin 81mg daily * Lasix 40mg daily * Carvedilol 6.25mg twice daily * Vancomycin 750mg twice daily X 13 more days Discharge Medications: 1. acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Date Range **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hours on and 12 hours off. 3. trazodone 50 mg Tablet [**Date Range **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 4. citalopram 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 5. docusate sodium 50 mg/5 mL Liquid [**Date Range **]: One (1) PO BID (2 times a day): Hold for loose stools. 6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Date Range **]: One (1) PO DAILY (Daily). 7. folic acid 1 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date Range **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Date Range **]: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob, wheeze. 11. simethicone 80 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable PO TID (3 times a day). 12. miconazole nitrate 2 % Powder [**Date Range **]: One (1) Appl Topical HS (at bedtime). 13. oxycodone 5 mg Tablet [**Date Range **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: PLease evaluate pt and hold for RR<12, sedation or if the patient appears loopy. 14. Lasix 40 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 15. vancomycin 500 mg Recon Soln [**Date Range **]: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 11 days: 500mg started on [**9-12**], please get trough morning of [**9-14**]. 16. psyllium Packet [**Date Range **]: One (1) Packet PO TID (3 times a day) as needed for low ostomy output: low ostomy output. 17. sucralfate 1 gram Tablet [**Date Range **]: One (1) Tablet PO QID (4 times a day). 18. carvedilol 6.25 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: GI bleed . Secondary Diagnosis: CAD A-fib s/p cardiac arrest and AICD pacemaker Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You are being dishcarged from [**Hospital1 1170**]. You were re-admitted to the hospital for bleeding from your ostomy as well as your Foley catheter. We felt this was because your aspiring was continued. We held your aspirin, gave you one unit of blood and you have been doing well since. You will go back to the MACU and will have follow up with GI and Cardiology for further management of these issues. The following medication was STOPPED: Aspirin 81mg Daily . Please continue to HOLD lisinopril 2.5mg PO Daily Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2163-9-28**] at 12:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2163-9-28**] at 11:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2163-10-31**] 1:15pm [**Last Name (NamePattern1) 13209**] [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 1983**] Fax: [**Telephone/Fax (1) 20601**]

[ "V15.88", "428.22", "V45.82", "425.4", "V45.02", "V15.3", "V15.51", "428.0", "707.03", "599.70", "V55.1", "V12.53", "537.83", "427.31", "V12.54", "V44.0", "V10.06", "707.24" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13389, 13455

6499, 10718

394, 400

13598, 13598

5176, 6476

14407, 15251

3711, 3862

11323, 13366

13476, 13476

10744, 11300

13774, 14384

3877, 5157

2402, 2611

320, 356

428, 2383

13527, 13577

13495, 13506

13613, 13750

2633, 3208

3224, 3695

20,534

192,795

21432

Discharge summary

report

Admission Date: [**2162-10-28**] Discharge Date: [**2162-11-11**] Date of Birth: [**2110-7-25**] Sex: M Service: MED Allergies: Latex / Spironolactone / Diphenhydramine / Tegaderm / Ceftazidime Attending:[**First Name3 (LF) 943**] Chief Complaint: End-stage liver disease Hypotension Atrial flutter Major Surgical or Invasive Procedure: none History of Present Illness: 52 yo male with ESLD [**2-22**] HCV/EtOH, varicies s/p TIPS [**2161**] presents to PCP with abd pain and altered mental status on [**10-14**]. Found to be hypotensive, arf, coagulopathic, and admitted to [**Hospital1 **] ICU. He was started on vanco/zosyn/levoquin for ?SBP but never tapped. He required IVF and pressors intermittently for hypotension. All cultures except funguria negative (tx with ambisome bladder washes). Pt intubated for ?resp failure/airway protection on [**10-15**] and extuabed [**10-24**]. For ARF pt started on CVVH. Transfered for Liver Transplantation and evaluation of hypotension. Past Medical History: PMH: HCV, Cirrhosis + Var. s/p TIPS [**2161**], CCY, h/o MSSA bacteremia Hernia, HypoThyroidism, Hepatorenal on CVVHD, Liver Failure Social History: Lives at [**Hospital 55619**] nursing home Former smoker, 90 pack yr history Former Drinker, 15 beers/d, quit 20 yrs ago ?IVDU in past Family History: unknown Physical Exam: VS: 97.7 HR=130 BP=83/52 98% 2L CVP=12 Gen: lethargic, grimace to pain, jaundiced HEENT: dry MM, PERRL, scleral icterus CV: tachycardic S1/S2, 4/6 SEM at apex Pulm: CTA bilaterally Abd: ?tenderness to palpation diffusely, soft, NT, hypoactive BS Ext: no c/c/e Neuro: mild passive asterixis Pertinent Results: [**2162-10-28**] 05:30AM GLUCOSE-76 UREA N-25* CREAT-2.1* SODIUM-137 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2162-10-28**] 05:30AM ALT(SGPT)-51* AST(SGOT)-47* LD(LDH)-224 ALK PHOS-161* TOT BILI-26.4* DIR BILI-16.8* INDIR BIL-9.6 [**2162-10-28**] 05:30AM ALBUMIN-2.8* CALCIUM-9.1 PHOSPHATE-2.4* MAGNESIUM-3.0* IRON-139 [**2162-10-28**] 05:30AM calTIBC-150* VIT B12-1879* FOLATE-15.2 FERRITIN-1040* TRF-115* [**2162-10-28**] 05:30AM WBC-5.5 RBC-2.79* HGB-9.7* HCT-28.8* MCV-103* MCH-34.8* MCHC-33.7 RDW-20.3* [**2162-10-28**] 05:30AM PLT COUNT-42* [**2162-10-28**] 05:30AM PT-16.8* PTT-63.3* INR(PT)-1.8 [**2162-10-28**] 05:30AM FDP-40-80 [**2162-10-28**] 12:59AM TYPE-ART TEMP-37.6 PO2-79* PCO2-42 PH-7.41 TOTAL CO2-28 BASE XS-1 INTUBATED-NOT INTUBA Brief Hospital Course: 52 yo with ESLD, hepatorenal syndrome, hepatic encephalopathy, and hypotension transfered to [**Hospital1 18**] for Liver Transplant. 1. ESLD: Hepatology consulted while patient at [**Hospital1 18**], however on transplant list at [**Hospital1 **]. Underlying etiology likely [**2-22**] alcohol and hepatitis C. Patient maintained on low sodium, low salt diet w/ lactulose. Abdominal US showed moderate ascites but not enough for a diagnostic tap. No ursodiol at this time as per the liver team. Pt to be transferred back to [**Hospital1 498**] for possible transplant in the future. 2. Hypotension - unclear cause. Pt was cardioverted out of flutter into NSR with improvement in HR but no real improvement in SBP. Pt also with TTE showing EF=25% and 4+ MR which is likely contributing. [**Name (NI) 24995**] pt is afebrile, he has an increasing WBC, could be septic (SBP vs other source). Pt started on empiric vanco/ceftaz/fluconazole. Swan was inserted early in patient's ICU course, revealing increased right-sided filling pressures with a PCWP=12. CO/CI were calculated both by Fick and thermodilution; by thermodilution, CO's were 3-4 L/min (inaccurate given MR); by Fick, CO was 8L/min (but obscured by septic state). Pt required pressors for bp support. Pt also on steroids initially, but these were stopped after cosyntropin stimulation test showed an appropriated bump. Hypotension is likely a combination of systolic dysfunction, tachycardia (decreased diastolic filling) and possible septic physiology. Currently patient is on levophed 0.119 mcg/kg/min w/ MAP of 58. 3. ?Infection/pna- although there was no clear source of infection, pt did have possible LLL pneumonia on chest X-ray and CT and grew sparse pseudomonas from sputum. Pt started on antibiotics, 14-day course: Vancomycin (started [**10-30**], stopped [**11-9**]), Ceftazidime (started [**11-1**], d/c [**11-7**]). Pt also was C. difficile positive and was started on Flagyl (started [**10-30**], continue for 7 days after discontinuation of other antibiotics). Pt remained afebrile with no leukocytosis. Vancomycin and Meropenem were restarted after pt had an episode of hypotension [**11-9**]. Vanco should be continued until [**11-13**], Meropenem should be continued for an [**8-31**] day course for possible vent-associated pna. 4. Tachycardia: likely a.flutter; pt was initially cardioverted into NSR, digoxin started. Pt then reverted back into flutter with rate in 130's. Pt spontaneously converts between NSR, afib, and sinus tach with HR 80-90's throughout the hospital course. Episodes of tachycardia have been treated w/ metoprolol 5 mg IV prn and with conversion of CVVHD to run patient euvolemic vs taking fluid off. 5. ARF: hepatorenal, vs pre-renal, vs ATN from hypotension. Pt was on CVVH, and renal is following, dialyzing as necessary. US of kidneys was wnl, meds being renally dosed. Pt continued on CVVH throughout hospitalization. UOP over last 24 hours = 20 cc. 6. Coagulopathy - likely [**2-22**] poor synth fxn, s/p vit K. No evidence of DIC by labs. Patient has had intermittent episodes of coffee ground output from the NGT w/ stable hemodynamics. This was managed w/ FFP and is no longer an issue. No active bleeding at this time. Pt is s/p EGD that was within normal limits/did not show any varices, active source of bleeding. 7. thrombocytopenia - [**2-22**] cirrhosis, transfusing <40 8. anemia - macorcytic c/w liver dz -check iron studies; c/w some component of anemia of chronic disease. Pt was transfused throughout hospitalization for Hct<26. 9. MS change - [**2-22**] hepatic encephalopathy/uremia/sepsis. It was unclear what his baseline mental status is, and this will need to be assessed when he is less sedated, not septic. 10. FEN - TFs via Dobhoff were continued in-house (Deliver 2.0 at 40 cc/hr plus 45g Promod) 11. proph - aspiration precautions, head of bed up, pneumoboots, lactulose 12. Access R IJ HD line ([**10-29**]), L radial A-line, changed over wire ([**11-2**]) 13. Code --> full 14. Communication --> [**Name (NI) **] [**Name (NI) **] (cousin +HCP) [**Telephone/Fax (1) 56599**]; [**Name (NI) 19948**] [**Name (NI) 56600**] (mother) [**Telephone/Fax (1) 56601**] Medications on Admission: Levophed drip Synthroid Tums Zinc sulfate Pepcid Calcium gluconate Lactulose Lopressor Zofran ALL: seafood, benadryl, tegaderm, chocolate, spironolactone Discharge Medications: Fentanyl gtt Insulin gtt Levophed gtt versed gtt Ceftazidime 2gm IV q24 (started [**11-1**], continue until [**11-15**]) Vancomycin 1 gm IV q 24 (started [**10-30**], continue until [**11-13**]) Digoxin 0.125 PO QOD Lactulose 30 ml PO TID Calcium Carbonate 500 mg PO TID Flagyl 500 mg PO TID (started [**10-30**], continue until [**11-23**]) Levothyroxine 25 micrograms PO/NG QD Pantoprazole 10 mg IV q12h Zinc Sulfate 220 mg PO BID Discharge Disposition: Extended Care Discharge Diagnosis: End stage Liver disease Hypotension and systolic dysfunction Pneumonia Discharge Condition: Guarded Discharge Instructions: 1) Please continue all medications as outlined including antibiotics. Course of Ceftazidime/Vancomycin should be determined, and Flagyl should be continued for at least 1 week after finishing these antibiotics. 2) Please maintain MAP's greater than 60 with pressors as needed 3) Keep INR<3.0 and platelets>40 with FFP and platelet transfusions as needed. Keep HCT>26 with PRBC. 4)Pt currently on AC ventilation; this should be continued and weaned as tolerated Followup Instructions: Follow up with [**Hospital1 498**] transplant physicians for possible liver transplant

[ "427.32", "280.0", "070.70", "572.2", "038.9", "276.2", "518.81", "427.31", "584.9", "008.45", "571.2", "995.92", "287.5", "482.1", "425.4", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "45.13", "96.72", "99.62", "38.91", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

7412, 7427

2506, 6749

373, 379

7541, 7550

1699, 2483

8061, 8150

1352, 1361

6954, 7389

7448, 7520

6775, 6931

7574, 8038

1376, 1680

283, 335

407, 1027

1049, 1184

1200, 1336

13,675

152,807

23567+57360

Discharge summary

report+addendum

Admission Date: [**2152-4-23**] Discharge Date: [**2152-4-27**] Date of Birth: [**2079-10-5**] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old gentleman transferred from [**Hospital **] Hospital after falling from a standing position and striking the back of his head. His tox screen was positive for ETOH. He had a GCS score of 6 at the outside hospital, was intubated, and transferred to [**Hospital6 256**] for further management. CT at the outside hospital showed small left subdural, subarachnoid hemorrhage and contusion with no edema or midline shift. PAST MEDICAL HISTORY: Asthma. Hypertension. GERD. Pulmonary fibrosis. ETOH abuse. CAD. PAST SURGICAL HISTORY: Not available. ALLERGIES: No known allergies. PHYSICAL EXAM: His heart rate was 89, BP 190/100, respiratory rate 18, sats 100 percent. His pupils were 3 mm and reactive. HEENT: He had a left occipital scalp laceration. CHEST: Clear to auscultation. ABDOMEN: Soft, nondistended. CARDIOVASCULAR: Regular rate and rhythm. EXTREMITIES: Missing a left thumb, otherwise no deformities. NEURO: Intubated, off propofol for 10 minutes, awake, following commands, moving all extremities, wiggling his toes, squeezing hands bilaterally, positive gag and cough. CT scan showed left sylvian fissure subarachnoid blood and punctate contusion adjacent to the left lateral ventricle. No mass effect. No hydrocephalus. The patient was in a hard collar and will have flexion-extension films on [**2152-4-26**] to clear his C-spine. HOSPITAL COURSE: He was extubated on hospital day 1, however remained awake, alert and oriented x 3. He had a repeat CT on hospital day 1 that showed continued subarachnoid hemorrhage, contusion of the left temporoparietal, periventricular white matter. No change compared to outside films. His chest x-ray showed bibasilar opacities. He had a CT of his neck which showed no fractures. TLS spine was also cleared; he had no fractures. He was transferred to the regular floor on hospital day 2. He remained neurologically stable, awake, alert and oriented x 3, following commands x 4. He was seen by physical therapy and occupational therapy and found to require acute rehab stay prior to discharge to home. DISCHARGE MEDICATIONS: 1. Hydromorphone 8 mg po q 4 h prn. 2. Verapamil SR 120 mg po q 24 h. 3. Lorazepam 1 mg po qid for anxiety. 4. Thiamine 100 mg po once daily. 5. Folic acid 1 mg po once daily. 6. Pantoprazole 40 po q 24 h. 7. Multivitamin 1 cap po once daily. 8. Heparin 5,000 units subcu tid. CONDITION ON DISCHARGE: Stable. FOLLOW UP: He is also going to have a rheumatology consult for his rheumatoid arthritis and a right wrist x-ray prior to discharge. Results will be dictated in an addendum prior to discharge. He will follow-up with Dr. [**First Name (STitle) **] in 1 month with a repeat head CT. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2152-4-26**] 11:17:02 T: [**2152-4-26**] 11:43:28 Job#: [**Job Number 60343**] Name: [**Known lastname **], [**Known firstname 126**] Unit No: [**Numeric Identifier 11022**] Admission Date: [**2152-4-23**] Discharge Date: [**2152-4-28**] Date of Birth: [**2079-10-5**] Sex: M Service: NSU ADDENDUM: The patient's discharge was delayed until [**2152-4-28**]. The patient was seen by Rheumatology and had his right wrist and left ankle tapped for fluid. There was no growth of bacteria, and the patient was put on a prednisone taper for gout. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. DISCHARGE FOLLOWUP: He will follow up with Dr. [**First Name (STitle) 24**] in one month with a repeat head CT and a repeat cervical spine flexion/extension films. DISCHARGE INSTRUCTIONS: The patient should remain in a hard collar at all times. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 2185**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2152-4-28**] 12:00:31 T: [**2152-4-28**] 14:18:34 Job#: [**Job Number 11023**]

[ "414.01", "E888.9", "303.01", "493.90", "401.9", "305.21", "515", "852.06" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

2302, 2581

1581, 2279

3943, 4264

730, 779

795, 1563

2627, 3665

3773, 3918

165, 612

635, 706

3690, 3752

20,426

105,272

7322

Discharge summary

report

Admission Date: [**2161-4-1**] Discharge Date: [**2161-4-6**] Date of Birth: [**2091-5-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5266**] Chief Complaint: Melena Major Surgical or Invasive Procedure: PICC placement for TPN History of Present Illness: 69 year-old woman with a history of CAD, CHF, AVM, achalasia anemia, new large brain mass affecting sella turcica and impinging on optic chiasm who presents with melena. Patient was seen at [**Company 191**] today from rehab. Patient had been constipated for 5 days without BM, then last night was given 4 enemas and is now incontinent of stool, diarrhea. At [**Company 191**] she was noted to have guaiac positive melanotic stools. She was therefore sent to ED. Here only complaint at this time is generalized fatigue. She denied any LH, dizziness, syncope. No CP, SOB, abd pain. States that she has had some recent nausea, but no vomiting. . Recently admitted for work-up or large brain mass which was found to be pituitary adenoma on biopsy. To be seen by Dr. [**Last Name (STitle) 724**] next week. . In the ED she was NG lavage and was positive for bright red blood clots and coffee grounds. ECG showed questionable ST elevations in V1-2 unchanged. 2 large bore IV's were placed. IV PPI was given. Also given levoquin given WBC of 16.6. . In the MICU the patient's hct was monitored and remained stable. She was continued on IV PPI and underwent EGD that showed Grade 4 esophagitis with contact bleeding in the lower third of the esophagus. She was kept NPO. Past Medical History: 1. Coronary artery disease with history of V. fib arrest, S/P LAD stent and repeat cath in [**10/2159**] 2. CHF - EF 30-35% in [**2159**]. 3. Osteoporosis - early menopause, no history of hip fractures but verterbral compression fractures noted earlier this month. 4. Depression 5. History of colonic AVM and anemia of chronic blood loss 6. S/P Appendectomy 7. Hypertension 8. H/o achalasia, peptic stricture at EG junction 9. h/o TAH and bilateral oopherectomy in her 30s Social History: Soc: Patient lives with her brother and sister-in-law. She has 60 pack-year tobacco history but quit 20 yrs ago; denies EtoH and drug use Family History: FHx - multiple members in the family with who has had early TAH and bilateral oopherectomy Physical Exam: T 97.5 BP 116/59 HR 98 RR 16 O2sats 100% RA Gen: Chronically ill appearing, cachectic, NAD HEENT: NG tube in place, dry mm, PERRL, EOMI Lungs: CTAB Heart: Tachy no m/r/g Abd: Soft, NT, ND + BS, no HSM Ext: No edema, normal peripheral pulses Neuro: A&O times 3, sensation intact, strength normal, moving all 4 extremeties Pertinent Results: NG lavage in ED- 300cc with small amount of coffee grounds. After CXR revealed NG tube in esophagus this was removed. . ECG: Sinus tachy at 107nl axis, nl intervals, LVH, Twave inversion in lateral leads old. . CXR- NG tube is curled in the esophogus . EGD [**4-2**]: Dilation at the lower third of the esophagus Grade 4 esophagitis in the lower third of the esophagus Erythema in the stomach body compatible with NG trauma Food in the antrum Otherwise normal EGD to second part of the duodenum Brief Hospital Course: A/P 69 year-old woman with a history of CAD, CHF, AVM, achalasia anemia, new large brain mass affecting sella turcica and impinging on optic chiasm who presents with melena. . # [**Name (NI) 4056**] Pt has a long history of GIBs from AVM's. Also history of achalasia and peptic stricture, which caused NGT to become curled in esophagus and had to subsequently be removed. Pt admitted with guaiac positive stool and positive NG lavage. She was admitted to the MICU for close monitoring of her hct and vital signs. She was given 2 large bore IVs. Her hct was monitored q 4hr and remained stable. She was kept NPO and given IV PPI [**Hospital1 **] per GI. She underwent EGD that showed grade 4 esophagitis. GI recommended QID sucralfate and [**Hospital1 **] PPI. Given her achalasia and poor PO intake they recommended that the patient receive TPN for nutritional repletion given low albumin. Once nutritionally replete may need G-tube in medium term. She was advanced to a regular diet and started on TPN following PICC placement. She was transferred to a regular medicine floor. Her hct trended down to 24.9 and given her cardiac history she was transfused one unit of packed RBCs. She had an appropriate bump in her hct to 29.8 and this remained stable >30 since. . # [**Name (NI) 27035**] Pt with recent luekocytosis during her last hospitalization but normalized on discharge. Admitted with WBC of 16 with left shift. She received a dose of levaquin, however her leukocytosis resolved and she was afebrile. There was no obvious signs of infection. CXR showed no pneumonia. Her leukocytosis resolved and she remained afebrile. Blood cultures were sent and remained NGTD. Levofloxacin was discontinued given no clear infectious source. On the day prior to discharge, Ms. [**Name14 (STitle) 27036**] had leukocytosis with a U/A consistent with a UTI (see below). Her WBCs at time of discharge remain 12.7 but this is only after 1 day of treatment. CXR done was read as: "IMPRESSION: Markedly limited study secondary to positioning. As best can be determined there is no definite new focal opacity. There is a new indwelling PICC line as above" and the leukocytosis upon discharge is being attributed to a UTI. . # UTI: On the day prior to discharge, Ms. [**Name14 (STitle) 27036**] had leukocytosis with a U/A consistent with a UTI. At time of discharge she has gram negative rods growing (speciation and sensitivities pending at time of discharge which should be followed post-discharge). We started a course of Bactrim and she should continue this for 3 days and have follow up U/A and cultures in a week's time. . # Hyponatremia- Patient was initially hyponatremic to 132 on admission. Resolved with hydration so it was thought to be secondary to hypovolemia. . # Brain Mass- Worked up recently completed. Recent biopsies showed pituitary adenoma. TSH/T4, [**Last Name (un) 104**] stim were normal during last admission. LH/FSH were low. Of note, sutures removed by neurosurg on day of discharge. -- Follow up with Dr. [**Last Name (STitle) 27037**] no urgent need for intervention. -- Outpatient appointment scheduled and please call to confirm this. . # CHF- EF 30-35%. No signs of failure at this time. -- Watch for need of lasix given fluid resusitation . # Anemia- Chronic Fe deficicient anemia, likely from chronic GIB. Iron supplemntation was restarted following endoscopy. . # [**Name (NI) **] Pt with no recent chest pain or ECG changes. -- cardiac enzymes negative x2 -- No ASA given UGIB . # FEN- Patient was initially kept NPO for her procedure. Given her achalasia, the patient is only able to tolerate small amounts of food at one time. Her GI doctors [**Name5 (PTitle) 2985**] that she had had significant worsening of her nutritional status with low albumin and weight loss. It was felt that she will likely need a feeding tube for nutritional support as she is unable to meet her needs by mouth, however GI did not want to place a tube while her nutritional status was so poor. Therefore, a PICC was placed for TPN. She will likely need a few weeks of TPN to improve her nutritional status prior to g-tube placement. She was advanced to a regular diet given there was no contraindication to this and she was started on TPN. . # PPx- Pneumoboots (held Heparin s/p GIB); ambulate with PT daily . # Access- 2 PIV's . # Code- DNR/DNI . # Dispo- To rehab today . Medications on Admission: 1. Calcium Carbonate 500 mg TID 2. Citalopram 10 mg Tab Qday 3. Ferrous Sulfate 325 mg qday 4. Mirtazapine 7.5 mg QHS 5. Nortriptyline 20 mg QHS 6. Simvastatin 40 mg Qday 7. Sucralfate 1 g [**Hospital1 **] 8. Ergocalciferol (Vitamin D2) 50,000 unit PO QSat 9. Oxycodone 5 mg prn 10. Zolpidem 5 mg qhs 11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 12. Nexium 40 mg [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Primary: UGIB Grade 4 esophagitis Pituitary adenoma Anemia Achalasia . Secondary: CAD CHF HTN Discharge Condition: Stable Discharge Instructions: Please continue to take your medications as directed. . If you experience blood in your stool, difficulty breathing, chest pain, fainting, high fevers or other concerning symptoms call you doctor or come to the emergency room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2161-4-6**] 2:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2161-4-14**] 10:20 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST Date/Time:[**2161-4-15**] 9:45

[ "530.82", "280.0", "V45.82", "311", "414.01", "276.1", "733.01", "599.0", "227.3", "530.10", "530.0", "V15.82", "747.61" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "99.04", "99.15", "96.07" ]

icd9pcs

[ [ [] ] ]

8110, 8192

3278, 7681

320, 345

8330, 8339

2758, 3255

8614, 9114

2309, 2401

8213, 8309

7707, 8087

8363, 8591

2416, 2739

274, 282

373, 1639

1661, 2136

2152, 2293

5,705

101,193

27114

Discharge summary

report

Admission Date: [**2171-4-28**] Discharge Date: [**2171-5-7**] Date of Birth: [**2099-9-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: CABG X 2, LIMA>LAD, SVG>OM on [**2171-5-2**] History of Present Illness: 71 y/o male presented to OSH for elective echo, when laid flat, went in to CHF/resp arrest, intubated, and sent for cardiac catherterization. This revealed multivessel CAD, EF 40%. He was transferred to [**Hospital1 18**] for CABG. Past Medical History: COPD PVD s/p right carotid endarterectomy PAF CRI (creat 1.3) Social History: former smoker, quit many years ago denies ETOH retired security guard wife in nursing home Family History: non--contributory Physical Exam: Unremarkable pre-operatively Pertinent Results: [**2171-5-5**] 05:00AM BLOOD WBC-10.0 RBC-3.42* Hgb-9.7* Hct-29.4* MCV-86 MCH-28.4 MCHC-33.0 RDW-15.7* Plt Ct-217 [**2171-5-3**] 03:05AM BLOOD PT-13.9* PTT-30.0 INR(PT)-1.2* [**2171-5-5**] 05:00AM BLOOD Glucose-100 UreaN-24* Creat-1.2 Na-138 K-4.0 Cl-100 HCO3-31 AnGap-11 Brief Hospital Course: Admitted to cardiac surgery service for [**Hospital3 19345**] on [**2171-4-28**]. He was seen pre-operatively by the vascular service due to his carotid disease. After an ultrasound, and MRI, they felt that there was no need for any intervention, and he was taken to the operating room on [**2171-5-2**], where he uncerwent a CABG X 2. PLease see operative note for details of surgery. Post-op he was taken ti the CSRU on epinephrine and phenylephrine. He was extubated the day of surgery, drips were weaned off by the following day, and he was transferred to the telemetry floor on POD # 2. He has remained hemodynamically stable, without post-op AFib, but he has been weak, and slow to ambulate independently. He is ready to be transferred to rehab for physical therapy and progression with mobility. Medications on Admission: Lipitor 80' KCl ASA 162' Pepcid 20' Lasix 20' Atrovent MDI's Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**] Puffs Inhalation Q4H (every 4 hours). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Discharge Disposition: Extended Care Facility: The [**Location (un) **] Discharge Diagnosis: CAD COPD CRI Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no lifting > 10# for 10 weeks Followup Instructions: with Dr. [**Last Name (STitle) 66587**] in [**2-1**] weeks with Dr. [**Last Name (STitle) 66588**] in [**2-1**] weeks with Dr. [**Last Name (STitle) **] in 4 weeks Completed by:[**2171-5-6**]

[ "414.01", "428.21", "410.71", "585.9", "496", "428.0", "427.31" ]

icd9cm

[ [ [] ] ]

[ "36.15", "99.07", "39.61", "36.11" ]

icd9pcs

[ [ [] ] ]

3186, 3237

1225, 2036

327, 374

3294, 3301

929, 1202

3473, 3667

846, 865

2147, 3163

3258, 3273

2062, 2124

3325, 3450

880, 910

281, 289

402, 637

659, 722

738, 830

6,723

120,170

4154

Discharge summary

report

Admission Date: [**2131-2-11**] Discharge Date: [**2131-2-24**] Date of Birth: [**2067-8-17**] Sex: M Service: Gold Surgery HISTORY OF PRESENT ILLNESS: The patient is an extremely poor historian, however, from what was able to be ascertained, the patient was a 67 year old male with multiple medical problems who presents from the nursing home with abdominal pain. PAST MEDICAL HISTORY: Significant for diabetes mellitus, neuropathy, congestive heart failure, status post coronary artery bypass graft with a current ejection fraction of 15%, hypertension, restrictive lung disease, atrial fibrillation. The patient had lower abdominal pain for three days. He denies bowel movements in the last three days. The patient reports the pain is constant, but worse with tube feeds. The patient denies any emesis or diarrhea. The patient had a suprapubic catheter placed four days prior to the start of his abdominal pain. The patient has had no fevers or chills at the nursing home. 1. Congestive heart failure with an ejection fraction of 15%. 2. History of nonsustained ventricular tachycardia. 3. Acute renal failure. 4. Anemia. 5. History of pneumonia. 6. Urinary retention. 7. Esophageal motility disorder. 8. History of rapid atrial fibrillation. 9. History of pulmonary embolism. 10. Depression. 11. Status post motor vehicle accident in last [**11-4**]. Peripheral vascular disease, status post bypass. PAST SURGICAL HISTORY: Significant for: 1. Placement of suprapubic catheter. 2. Coronary artery bypass graft. 3. Percutaneous endoscopic gastrostomy placement. 4. Left femoral-peroneal bypass graft by Dr. [**Last Name (STitle) 1391**] in [**2125**]. MEDICATIONS ON ADMISSION: 1. Lantus. 2. Senna. 3. Provigil. 4. Lasix. 5. Zoloft. 6. Colace. 7. Erythromycin. 8. Renagel. 9. Neurontin. 10. Coumadin 6 p.o. q.h.s. 11. Digoxin. 12. Midodrine. 13. Zocor. 14. Lisinopril. 15. Lopressor. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Non-contributory. FAMILY HISTORY: Non-contributory. PHYSICAL EXAMINATION: On physical examination the patient was afebrile, vital signs stable, sating 94% on room air. Head was atraumatic, normocephalic, no scleral icterus noted. The patient's neck was soft and supple with no masses noted. Chest was clear to auscultation with some minimal crackles bilaterally at the bases. Heart was regular rate and rhythm with normal S1 and S2 with Grade II/VI systolic ejection murmur at the left upper sternal border. The abdomen was soft, moderately tender to palpation, nondistended, positive bowel sounds. Extremity examination was unremarkable for edema, however, had bilateral heel ulcers. HOSPITAL COURSE: The patient is a 67-year-old male with multiple medical problems who presented with abdominal pain. The patient was admitted to the Medical Service. Abdominal computerized tomography scan was obtained which showed some ascites, a small amount of free fluid at the liver as well as around the kidneys, otherwise unremarkable with no wall thickening and normal appendix and normal sigmoid colon and no free fluid in the pelvis. On [**2131-2-12**], General Surgery was consulted. Surgical assessment included evaluation of belly revealing minimally tender examination, guaiac negative. Computerized tomography scan repeated on [**2131-2-12**], revealing question of portal venous gas. Differential diagnosis included possible ischemic colitis. At this time a nasogastric tube was placed, serial lactates were checked, and serial abdominal examinations were performed. The patient was discussed and seen by Dr. [**Last Name (STitle) 5182**]. The patient was seen later on in the day by Dr. [**Last Name (STitle) 5182**] personally and the patient's abdominal pain and tenderness were worsening. The decision was made at this time to take the patient to the Operating Room for exploratory laparotomy. On [**2131-2-12**], the patient was taken to the Operating Room for subtotal colectomy and diverting ileostomy for an ischemic colitis. For a more detailed account, please see the operative report. Postoperatively the patient was transferred to the Surgical Intensive Care Unit. Postoperatively the patient did well in the unit. The patient was extubated on postoperative day #0. The patient continued to be assessed and monitored in the Surgical Intensive Care Unit. Vascular Surgery saw the patient on [**2131-2-17**] for question of graft failure and increasing lower extremity ulcers. However, the patient was abstaining from surgical intervention at this time. The patient continued to be diuresed in the Intensive Care Unit and tube feeds were continued. On [**2131-2-19**], the patient had pulse volume recordings which showed a patent left graft with low velocities distally with no definite stenosis identified. The patient had some leakage around his gastrostomy tube on [**2131-2-20**]. Tube check and replacement revealed satisfactory placement of silastic gastrojejunostomy tube. The patient was revealed to have gastric outlet obstruction at this time and the patient was limited to clears with p.o. intake with tube feeds to continue at goal which was 95 cc/hr for 24 hours or 120 cc/hr cycled over 18. The patient was evaluated for rehabilitation placement, however, the patient as well as family had been conferred with in order to facilitate transfer to home with extensive [**Hospital6 407**], this being the wishes of the patient as well as the patient's family. On [**2131-2-23**], the patient experienced some respiratory distress with respiratory rate in the high 20s and low 30s, however, the patient was sating 98% on 2 liters of blood gas with an oxygenation of 95. Chest x-ray at this time showed an improving chest x-ray, however, with a persistent left-sided pleural effusion. On [**2131-2-24**], the patient was noted to have an elevated white count of 23. Due to the persistent wishes of the patient to be discharged to home, the patient was started on empiric treatment with Levofloxacin 5 mg p.o. q. day for a presumed pneumonia. Sputum culture, urine culture and ileostomy was taken for Clostridium difficile and the patient was then discharged home to be followed closely by [**Hospital6 407**], his son as well as house staff physicians to monitor culture data. DISCHARGE STATUS: To home with [**Hospital6 407**]. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSES: 1. Ischemic colitis. 2. Peripheral vascular disease. 3. Congestive heart failure. 4. Chronic obstructive pulmonary disease. 5. History of pulmonary emboli and deep vein thrombosis. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] as directed, Dr. [**Last Name (STitle) 5182**] in two to four weeks, please call for an appointment and with Dr. [**Last Name (STitle) 1391**] in two to four weeks, please call for an appointment. DISCHARGE MEDICATIONS: 1. NPH 15 units q. 12 hours. 2. Regular insulin sliding scale as directed. 3. Lansoprazole 30 mg p.o. q. day. 4. Lasix 40 mg p.o. b.i.d. 5. Metoprolol 12.5 mg p.o. b.i.d. 6. Simvastatin 80 mg p.o. q. day. 7. Reglan 10 mg p.o. q.i.d. 8. Ambien 5 mg p.o. q.h.s. 9. Miconazole powder, apply as directed. 10. MS Contin 15 mg p.o. q. 12 hours. 11. Levofloxacin 500 mg p.o. q. day times seven days. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 7190**] MEDQUIST36 D: [**2131-2-24**] 12:02 T: [**2131-2-24**] 13:13 JOB#: [**Job Number 18137**]

[ "440.24", "428.0", "707.15", "263.9", "518.0", "425.4", "557.0", "486", "250.60" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "46.21", "45.73", "99.07", "00.13", "97.02", "96.6" ]

icd9pcs

[ [ [] ] ]

6414, 6421

2038, 2057

6442, 6902

6925, 7549

1731, 1985

2715, 6392

1469, 1705

2080, 2697

175, 389

412, 1445

2002, 2021

27,402

136,197

32417

Discharge summary

report

Admission Date: [**2104-7-25**] Discharge Date: [**2104-7-29**] Date of Birth: [**2045-1-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: angina Major Surgical or Invasive Procedure: [**2104-7-25**] cabg x3 (LIMA to LAD, SVG to OM, SVG to PDA) History of Present Illness: 59 yo Vietnamese male presneted to PCP [**Last Name (NamePattern4) **] [**7-8**] with intermittent epigastric/chest pain. Q waves in inferior leads noted with ST elevation. He was sent to the ER and had + MIBI the next day. Admitted here for cardiac cath on [**7-8**] which revealed severe triple vessel disease. He was referred for surgery. Past Medical History: MI in [**2096**], followed by cardiac cath at [**Hospital1 2177**] /balloon angioplasty /RCA stent Diabetes Dyslipidemia Remote h/o shrapnel injury and blood loss. Treated medically. Social History: No tobacco. Remote history of EtOH use. No illicit drugs. Family History: Mother - had MI, died at age 80. Father's history unknown. 7 siblings all healthy. Physical Exam: 5'3" 56.5 kg NAD skin unremarkable PERRLA neck supple, full ROM, no carotid bruits appreciated CTAB RRR no murmur soft, NT, ND, + BS warm, well-perfused, no edema or varicosities noted neuro grossly intact 3+ bil. fems 2+ bil. DP/PT/radials Pertinent Results: Conclusions 1. No atrial septal defect is seen by 2D or color Doppler. 2. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with infero-lateral hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and trace aortic regurgitation. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [**First Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm. 1. Biventricular function is unchanged. 2. Aorta is intact post decannulation. 3. Other findings are unchanged I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2104-7-25**] 11:53 ?????? [**2098**] CareGroup IS. All rights reserved. [**2104-7-28**] 06:00AM BLOOD WBC-8.1 RBC-2.86* Hgb-9.2* Hct-25.9* MCV-90 MCH-32.2* MCHC-35.6* RDW-13.2 Plt Ct-130* [**2104-7-28**] 06:00AM BLOOD Plt Ct-130* [**2104-7-28**] 06:00AM BLOOD Glucose-95 UreaN-14 Creat-0.8 Na-140 K-3.9 Cl-101 HCO3-32 AnGap-11 Brief Hospital Course: Admitted [**7-25**] and CABG by Dr. [**First Name (STitle) **]. Transferred to the CVICU in stable condition on insulin, phenyleprine, and propofol drips.He was weaned from pressors easily, extubated and transferred to [**Wardname 5010**] on POD #1. He was gently diuresed and was slightly below preop weight at discharge. His CTs were removed on POD #2 and wires on POD#3, without incident. He was ambulatory, wound were healing well and he was discharged on (stop [**7-28**]). Medications on Admission: ASA 81 mg daily zocor 80 mg daily metoprolol 25 mg [**Hospital1 **] xalatan 0.005% one gtt both eyes QHS omeprazole 20 mg daily glyburide 2.5 mg daily metformin 500 mg [**Hospital1 **] Discharge Medications: 1. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). Disp:*1 1* Refills:*2* 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Coronary Artery disease hyperlipidemia Hypertension s/p PTCA/stent RCA NIDDM Discharge Condition: good Discharge Instructions: shower daily and pat incisions dry. no baths or swimming. no lotions, creams or powders on any incision no lifting greater than 10 pounds for 10 weeks no driving for one month and off all narcotics call for fever greater than 100.5, redness, or drainage Weigh daily and report any weight gain of greater than 3 pounds Followup Instructions: see Dr. [**First Name (STitle) **] in [**11-21**] weeks ask Dr. [**First Name (STitle) **] for a referral to a cardiologist and make an appt. in [**12-23**] weeks see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2104-7-29**]

[ "V45.82", "413.9", "414.01", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4822, 4873

2986, 3468

326, 389

4994, 5001

1423, 2963

5368, 5728

1060, 1145

3703, 4799

4894, 4973

3494, 3680

5025, 5345

1160, 1404

280, 288

417, 761

783, 968

984, 1044

27,558

112,191

31603

Discharge summary

report

Admission Date: [**2177-8-16**] Discharge Date: [**2177-8-16**] Date of Birth: [**2097-3-17**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old man with a long history of coronary artery disease who for the past several weeks has experienced increasing chest pain which in retrospect was angina and has taken increased nitroglycerine. He was taking care of his ill wife and therefore did not want to come to the hospital. The patient has a history of chronic obstructive pulmonary disease, peripheral vascular disease, and shortness of breath. He presented to the hospital and was felt initially to have pneumonia. He was admitted to the medical intensive care unit, however review of the EKG showed severe EKG changes. He was taken for emergent catheterization that showed 90% left main, 90% ostial LAD stenosis, circumflex disease and moderate right coronary artery disease. The patient was hypotensive and hemodynamically unstable. Surgery was consulted because the patient developed cardiogenic shock acidosis and hypotension and intraaortic balloon pump was placed which stabilized his hemodynamics although he continued to be somewhat hypotensive and acidotic. On physical examination, his BP was 90/50 on the intraaortic ballon pump with elevated filling pressures, HR was 90 BPM. He was not intubated. Lung exam showed bilateral rales. Abdomen was soft and nontender. Cardiac exam showed distant heart sounds. The patient had non-papable distal extremity pulses, suggesting peripheral vascular disease. Neurologic exam was grossly normal. He was taken for emergency bypass surgery where coronary artery bypass grafting x3 was performed. The conduits were extremely poor. The LIMA was placed to the OM, veins were placed to the LAD and RCA. Ejection fraction initially was 20-30% with pulmonary hypertension and 1+ mitral regurgitation. His mixed venous oxygen saturation was approximately 48%, suggesting poor peripheral perfusion and shock. His filling pressures were elevated with a CVP of about 25 mmHg. He has rather severe pulmonary hypertension prior to surgery (55/27 mmHg). After surgery initially he did feel well with moderate inotropic support and intraaortic balloon pump support. However his condition gradually and progressively deteriorated. He developed severe episode of ventricular tachycardia prior to chest closure. His chest was reopened but his hemodynamics did not significantly change. The sternum was left open but the skin was closed. His poor hemodynamic condition was felt most likely to be due to poor underlying cardiac function, poor bypass targets and poor vein conduit. His acidosis may be in part been due to the IABP and peripheral vascular disease. He was transported to the cardiac surgical recovery unit. He continues to have low cardiac output syndrome and acidosis despite maximal inotropic support and intraaortic balloon pump support. Consideration for left ventricular assist device was given however because of his advanced age and poor chances for recovery this was not placed. The situation was discussed with the family. The patient's family were at his bedside when he died. FINAL DIAGNOSIS: 1. Acute myocardial infarction. 2. Cardiogenic shock, treated with IABP and emergency CABG x 3. Congestive heart failure, pulmonary edema. 4. Mild renal insufficiency, peripheral vascular disease. 5. Moderate chronic obstructive pulmonary disease. 6. Status post coronary artery bypass grafting. 7. Death following emergent CABG. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) 5297**] MEDQUIST36 D: [**2177-8-16**] 22:35:21 T: [**2177-8-17**] 04:35:09 Job#: [**Job Number 74285**]

[ "486", "414.01", "443.9", "496", "511.9", "428.0", "276.2", "410.11", "593.9", "416.9", "785.51", "427.0", "300.00", "424.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.22", "36.12", "88.53", "37.61", "77.31", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

3213, 3821

176, 3196

70,645

147,076

43576

Discharge summary

report

Admission Date: [**2150-4-8**] Discharge Date: [**2150-4-23**] Service: MEDICINE Allergies: Penicillins / Demerol Attending:[**First Name3 (LF) 1253**] Chief Complaint: hypoxia, cough Major Surgical or Invasive Procedure: none History of Present Illness: 85 yo F russian speaking with mild dementia, PUD, depression, dysphagia presents from NH ([**Hospital3 2558**]) with shortness of breath and coughing. History is obtained from her daughter [**Name (NI) 8982**]. She states that since yesterday her mother had not been herself. She was more tired appearing than usual and not eating well. Prior to this she was at her baseline. According to the nursing home, she was found to have a mild cause and hypoxia to the 80s. Given her condition they were concerned for pneumonia and sent to the ED. . In the ED, VS T 98.6, HR 108, BP 104/66, RR 24, 96%NRB. EKG and CXR performed, showing bilat pneumonia. She intermittently took off her facemask desatting down to the 80s. She was given vanco 1g, 2g cefepime, and levoflox 750mg, though the levoflox was stopped [**1-2**] way through due to reddness at PIV site. She was also found to have poor UOP of 10ml -> given 500ml NS. Given her low UOP and hypoxia, she was admitted to the MICU. . On arrival, she is awake and giving me the "thubs up." She is russian speaking and did not speak coherently to the russian interpreter. . ROS: As per above, otherwise negative for fevers/chills, HA, sore throat, CP, SOB, palpitations, abd pain, n/v/d, dysuria, rash. Past Medical History: # Iron deficiency anemia # osteoporosis # depression/bipolar d/o # h/o GI bleed # PUD # Anal fissure. # Dyslipidemia # DJD # Glaucoma # Cataract s/p extraction # dysphagia (mechanical soft diet) # h/o R prox humerus fx (tx non-op) # bilat DHS for hip Fxs (approx [**5-6**] yrs ago), # removal of hardware and ORIF left femur [**2149-3-31**], # s/p perianal abscess I and D [**8-8**] Social History: Russian speaking, lives in nursing home, non-smoker, no alcohol, no drug use. Has 2 sons and daughter that live in the area. Husband not alive Family History: Non-contributory Physical Exam: VS: T 99.5, BP 104/83, HR 89, RR 24, 91% 15L face tent Gen: sitting up in bed, eyes open, awake and alert, looks comfortable HEENT: EOMI, PERRL, anicteric sclera, MM dry, OP clear Neck: supple, no LAD or JVD Heart: Tachy, regular, no obvious m/r/g Lung: poor inspiratory effort, diffuse coarse crackles, decreased BS Abd: distended, soft NT + BS no rebound or guarding Ext: warm and well perfused no pitting edema, no c/c Skin: no rashes Neuro: awake and alert, pleasantly delirious moving all extremities Pertinent Results: Labs: Trop-T: <0.01 . 144 / 105 / 24 / 177 AGap=20 3.9 / 23 / 1.1 CK: 129 MB: 2 Ca: 9.2 Mg: 2.2 P: 2.8. . proBNP: 1720 14.0 \ 9.7 / 613 / 31.1 \ N:92.8 L:4.9 M:2.1 E:0 Bas:0.2 . Imaging: IMPRESSION: 1. Bilat lower lobe pneumonia. Prominent right hilum. CT scan recommended after antibiotic therapy. 2. Degenerative change thoracic spine and prior non-healed proximal right humerus fracture redemonstrated . EKG: Sinus tachy at 108 bpm, nl axis and intervals, inferior Q waves, non specific STT changes. Small Q waves in II, aVL new since [**2149-3-30**]. Brief Hospital Course: Mrs. [**Known lastname 93738**] is an 85 yo F with dementia, depression, PUD, dysphagia admitted from nursing home with bilateral lower lobe pneumonia. She completed a course of vancomycin and cefepime for her PNA and developed c.diff colitis while in the hospital requiring treatment with oral vancomycin and IV flagyl. She will need to continue oral flagyl 500mg tid until [**4-29**]. . 1)Healthcare Associated Pneumonia: Confirmed based on clinical picture with cough, hypoxia, and also with bilateral infiltrates on CXR. Since patient comes from [**Location **], must be concerned for HAP and therefore resistant pathogens. No obvious pleural effusion on CXR. No other obvious sources of infection. BNP elevated though no priors to compare. She was initially transferred to the ICU given concern for oxygen requirement and possible decompensation given her age. She did well and did not develop SIRS/sepsis or significant respiratory distress. She was stable for floor transfer the morning following admission however stayed in the ICU for 2 days given lack of floor beds. Sputum from admission with GPC's in pairs and clusters as well as GNR's, speciation revealed MRSA and pan-sensitive Klebsiella. She completed a course of Vancomycin and Cefepime (was also initially on levofloxacin which was discontinued). Pt was evaluated by Speech/Swallow service and it was determined that she should be supervised during all meals, she should have a soft dysphgia diet, and can have regular thin liquids. . 2) CDIFF colitis: likely developed as a consequence of treatment with broad spectrum antibiotics for PNA. WBC continued to rise and peaked at 28 with treatment with po flagyl, thus oral vancomycin and IV flagyl were given concurrently for seven days and her white count returned to [**Location 213**]. An abdominal CT was done demonstrating prominent rectal wall thickening (which was described as unusual for c.diff). At the time of discharge, oral vancomycin can be discontinued, but oral flagyl (metronidazole) should be continued at 500mg TID until [**4-29**]. WBC and anion gap should be monitored every two days until completion of flagyl course. . 3)Anemia: She has h/o iron deficiency anemia. HCT on admission at baseline, with slight drop on the morning of [**4-10**], however no signs of bleeding with guaiac negative stools. Iron low (13), ferritin wnl, TIBC low normal (likely mixed deficiency / chronic dz). Once bowel movements return to normal, please initiate iron supplementation. . 4) SKIN RASH: On perineum and sacral area. Incontinent and requires frequnet sheet/diaper changes. Rash appears fungal, continue miconazole powder until rash significantly improved. . 5) Dementia: Cont Zyprexa, mirtazapine. Her daughter does not accept this diagnosis. 6) HTN: Pt with no prior hx of HTN, BP has been in 150-160/80-90 range. Did not start antiHTN in the setting of acute illness, would consider adding antiHTN if high BPs persist. 7) Depression: Cont mirtazapine, lexapro. 8) S/p unhealed humeral fx (last year): Cont tylenol for pain control. Please hold Percocet until bowel movts return to normal. 8) PUD: Cont PPI Medications on Admission: Lidoderm patch 5% daily to L hip Lexapro 10mg daily ASA 81mg daily CACO3 1g daily Prilosec 20mg daily MVI daily Percocet 5/325 1 tab [**Hospital1 **] Mirtazapine 7.5 mg PO HS Olanzapine 1.25 mg PO HS Saline nasal spray [**Hospital1 **] Bisacodyl supp prn Milk of Magnesia prn Tylenol 325-650 q6 prn Simethicone 30ml q6 prn Robitussin 100/5 q4 prn Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 8. Olanzapine 2.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-2**] Sprays Nasal [**Hospital1 **] (2 times a day) as needed. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 12. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain: please hold until bowel movts have returned to normal. 13. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 14. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO once a day as needed for constipation: hold for loose stools. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days: total of two week course starting on [**4-15**]. Disp:*21 Tablet(s)* Refills:*0* 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Healthcare-associated Pneumonia Possible chonic aspiration Clostridium Difficile Colitis Reactive thrombocytosis ======================= Iron deficiency anemia Dementia Discharge Condition: Medically stable for transfer to skilled nursing facility Discharge Instructions: Dear Ms. [**Known lastname 93738**], You were admitted to the hospital with a pneumonia which may have been caused by a problem with your ability to swallow. You completed a course of antibiotics for this. You acquired an infection of the colon while you were in the hospital called c. difficile. You were given oral vancomycin and IV metronidazole. At the time of discharge, you should continue to take ORAL metronidazole for one week--you will receive a prescription for this. None of your previous medications have been discontinued. We have been holding percocet and you should continue to hold this until you are having regular solid bowel movements. Please let your doctors know if [**Name5 (PTitle) **] develop diahrrea, abdominal pain, fever, or any other symptoms which seriously concern you. Followup Instructions: Please follow-up with your primary care doctor [**Last Name (Titles) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 93739**] within one week of discharge. Completed by:[**2150-4-23**]

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icd9pcs

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Discharge summary

report

Admission Date: [**2108-6-17**] Discharge Date: [**2108-6-22**] Date of Birth: [**2031-5-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8104**] Chief Complaint: Fever, flank pain Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Ms. [**Known lastname 4027**] is a 77 yo F w/PMH waldenstrom's macroglobulinemia, recent hospitalization for fever, back pain and leukocytosis at the [**Hospital3 2783**] who presented to the ED with acute onset left sided flank pain. She reports that she was resting at home when she had sudden on set of left side pain, [**9-14**] in severity, constant. She denies any hematuria, change in urine output, dysuria or other urinary symptoms. She does report taking percocet 1 tab q6 hours for the past year for hip pain. . She initially presented to [**Hospital **] [**Hospital 1459**] hospital at 1AM on [**5-18**] where T100.7 BP 158/40 HR 114 RR 20. She had a non contrast CT scan [**6-17**] reviewed by our ED radiologist confirming impression which reads: "moderate left pelvocalyceal and ureteral dilation with perirenal stranding and fascial thickening. No demonstrable ureteral calculus, limited visualization of protion of distal L ureter/UVJ. Findings could be [**1-7**] recently passed or tiny occult calculus. Pyelonephritis can not be excluded. Also dilation of right renal pelvis and minimal perirenal stranding. 2.6 cm indeterminate lesion lateral aspect of right kidney." She was given tylenol 650mg PR, morphine 2mg IV, torradol 30mg, zofran 4mg IV, ativan 1mg IV x2, and ciprofloxacin 400mg IV. Temp spiked to 102 at 2AM with drop in BP to 87/41 at 3:30 AM for which she was given 1L NS. Pertinent labs prior to transfer included creatinine of 1, TSH 6.24, normal LFT's, WBC 3.2 with 21% bands, HCT 37.9. . Of note she was recently admitted at [**Hospital3 2783**] from [**2108-6-9**] - [**2108-6-14**] where she presented with hematuria and back pain. WBC was 13.8 on admission and rose to 19.1 with fever up to 102. She was initially treated with Zosyn for a UTI however this was stopped when her culture returned with only 20,000 colonies ESBL E.col (resistant to ampicillin, cefazolin, ciprofloxacin, augmentin, ceftriaxone, levofloxacin, sensitive to gent, nitrofurantoin, tobramycin, TMP/SMX). HCT on admission was 27, she was transfused 1 unit PRBC with increase in HCT to 28, with drop to 23 on repeat for which she was transfused antother 2 units with bump to 30 where she remained for the duration of her admission. She was followed by renal, urology and hematology and had several radiologic studies. CT abdomen did not show any stones but did show hemorrhage in intrarenal collecting system. She had CT urogram [**2108-6-10**] which showed "moderate hydro on right, mild hydro on L, blood in both intrarenal collecting systems, R>L, focal filling defect in proximal left interrenal collecting systmes, proximal ureter renal pelvis region measuring 9mm. Renal U/S [**2108-6-13**] showed "the right kidney does not have hydronephrosis, echogenic material in right renal pelvis". She was not discharged on any antibiotics. . In the ED VS on presentation with 86/44, HR 122 T 100.9 RR 32 96% on 2L NC. She was initially given 2l IVF with improvement in BP to 100-130's, she was also given vancomycin 1gIV and Zosyn 4g IV. After one hour her blood pressure dropped to 70's-80's systolic, she was given IVF X4L, RIJ was placed and she was started on levophen and dopamine gtt and transferred to the ICU. Past Medical History: Waldonstrom's macroglobulinemia (diagnosed [**12-12**]) episodic erosive gastritis Bilateral severe osteoarthritis of the hips spinal stenosis s/p L hip total arthroplasty in [**4-12**] Chronic anemia (iron deficiency by report with HCT drops to low 20's) Social History: Lives at home with her husband, no tobacco for 20-30 years prior to that smoked about 1PPD for about 35 years. She denies ETOH use. Retired, used to work in food services at a hospital. Family History: Non-contributory Physical Exam: VS:TM 99.6 HR 115 (94-129), BP 109/50 (90/46 - 144/63) RR 14-24 CVP 11([**8-18**]) I=8L O = 250 HEENT: NC AT, PERRL, dry mucosa, JVP elevated at angle of jaw CV: RRR, s1 s2, no appreciable murmur Lungs: harsh crackles to [**12-7**] way bilaterally, no wheezes Abd: soft, NT, ND, BS +, no flank tenderness on exam Ext: warm, no pedal edema, DP's full bilaterally Skin: no rashes or lesions noted Pertinent Results: ADMISSION LABS: Na 140 K 3.9 Cl 107 HCO 19 BUN 24 Creat 1.2 Gluc 127 lactate 3.5 CK 50 MB - Trop 0.26 WBC 13.5 HCT 33.2 PLT 337 UA: trace leuk, lg blood, nitr neg, 500 protein, 0-2 WBC, few bacteria, 0-2epis Micro: [**2108-6-17**] Blood Cultures: 4/4 bottles GNR [**2108-6-17**] Urine Cultures: no growth Imaging: [**2108-6-17**] CXR: There is a new right IJ central venous catheter with distal lead tip in the proximal SVC. There is no pneumothoraces. Lungs are grossly clear. [**2108-6-17**] Renal U/S - (dictation) mild to moderate hydronephrosis of left kidney, echogenic material in several papillae and renal pelvis, right kidney with no hydronephrosis, echogenic material in renal pelvis and several calyces, collapsed bladder with foley catheter in place. DDX included papillary necrosis, hemorrhagic products and non-calcified stone. [**2108-6-19**] MRI Abdomen: Limited study, but no evidence of hydronephrosis or renal obstruction. Evidence of hemosiderosis with secondary iron deposition in the liver, spleen, and bone marrow. Extensive anasarca. [**2108-6-20**] Noncontrast CT Head: (preliminary) Normal unenhanced study Brief Hospital Course: A/P: Mrs.[**Known lastname **] is a 77 yo F with PMH Waldenstrom's macroglobulinemia, recent UTI admitted with urosepsis on two pressors. . #Urosepsis: Blood cultures from admission yielded GNR bacteremia, with 4/4 bottles positive in <12 hours. Most likely source is pyelonephritis given echogenic material in pelvices bilaterally on ultrasound. Pt also had ESBL E.coli grow out on urine culture from previous week. On admission to ICU patient was oliguric bordering on anuric despite adequate CVP of [**9-16**] after getting 8L IVF and maintaining a MAP of 65 on levophed/vasopressin. Pt also had dramatic increase in WBC count from 13 on admission to 75.3, raising suspicion that intrarenal pus accumulation secondary to pylonephritis is causing leukocytosis and oliguria via obstruction. Pt was started on meropenem. Goal CVP was maintained with IVF boluses of LR or sodium bicarb. Pressors were successfully weaned. Pt underwent chest x-ray showing no evidence of pneumonia or pulmonary source of infection. Renal and Urology were consulted. Decision was made to obtain MRI of Abdomen. MRI showed no hydronephrosis, abscess or obstruction. However, there is some concern of abnormal structure causing obstruction per review by attending nephrologist and radiologist. Urology deemed no invasive intervention necessary at this time. Patient was followed by renal and medically managed. Meropenem was switched to Zosyn. At time of discharge, follow-up culture data remained negative. Patient was afebrile for over 48 hours. #Acute renal failure/Oliguria: Baseline creatinine 0.8, rose as high as 2.2 during admission before returning to 1.3. Initial renal ultrasound reportedly concerning for papillary necrosis with most likely causes in this case being pyelonephritis, analgesics nephropathy (given longterm daily percocet use) or hypotension in the setting of sepsis. All medications were renally dosed. Urine output and renal function gradually returned with stabilization of hemodynamics. Patient will need follow-up with nephrology given findings MRA. . #Altered mental status: Pt appeared disoreinted and somnolent with no focal deficits after MRI of abdomen. Noncontrast CT was obtained showing no acute pathology. Presentation consistent with delirium most likely induced by MRI sedation. Further sedation was held and serial neuro exams completed. Pts confusion improved over the course to the next 72hours. #Coagulopathy - elevated PT/PTT with INR at 1.6 from normal baseline likely secondary to sepsis. Platelets slowly declined initially during hospitalization. Pt was evaluated for DIC secondary to sepsis. No evidence of DIC was found. Platelets began to rise on Day 5 of admission. Medications were reviewed and proton pump inhibitor was held. Heme/Onc classified elevated INR and decreased platelets as a leukemoid reaction that would require no further evaluation at this time. #Demand myocardial ischemia - with isolated bump in troponin on admission with peak of 0.26, CK and MB flat, likely due to severe hypotension in setting of sepsis. Now trending down. She has no chest pain or EKG changes concerning for ACS. No further evaluation was warranted. Echo eas performed that showed an EF of 45-50%. Patient had mild sinus tachycardia (rate at 100) at time of discharge. This will need outpatient follow-up . Medications on Admission: percocet 1 tab q6 hours for right hip pain for the past year Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 3. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours): **last day [**6-30**]**. 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. Outpatient Lab Work Please check CBC/CR in 2 days to assure counts are correcting Discharge Disposition: Extended Care Facility: Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**] Discharge Diagnosis: 1) E.Coli (ESBL) urosepsis 2) Acute renal failure 3) Thrombocytopenia 4) Leukocytosis 5) Delirium Discharge Condition: Stable Discharge Instructions: Please return if you experience worsening fevers, chills, or other concerning symptoms. Followup Instructions: 1. You will need to follow-up as an outpatient with our nephrology clinic within the next 1-2 months. ([**Telephone/Fax (1) 773**] 2. You should follow-up with Dr. [**Last Name (STitle) 13959**] within the next [**12-7**] weeks

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icd9cm

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icd9pcs

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9850, 9947

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7207

Discharge summary

report

Admission Date: [**2145-8-24**] Discharge Date: [**2145-8-29**] Date of Birth: [**2064-6-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 19193**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: - Embolization of Left Inferior Epigastric Artery - Central Venous Line Placement History of Present Illness: 81 yo F with history of atrial fibrillation on coumadin, sick sinus sydrome s/p pacemaker presenting with LLQ abdominal pain for three days. She had a cold for one week with cough which has now resolved. She presented to her PCP's office with LLQ abdominal pain and swelling and was referred to the ED. . In the ED, her initial vitals were T 97.5, HR 65, BP 121/68, RR 12, 95% on RA. CT abdomen showed a large 10x16x6cm rectus sheath hematoma with possible active extravasation of blood. Her INR was 4.3, and her Hct had fallen to 34.9 from a baseline of 37-40. She received 5 mg of IV vitamin K, 2 units of FFP, morphine, and 1L NS in the ED. Surgery consult recommended IR embolization. . On arrivial, pt complains of mild tenderness at LLQ. She denies melena or BRBPR. She denies lightheadedness or chest pain. She reports some shortness of breath due to the productive cough. Past Medical History: -Atrial fibrillation on coumadin/sotalol -Hypertension -Hyperlipidemia -Memory loss -Sick Sinus Syndrome s/p pacemaker -No hx of CAD although this has previously been documented in her PMH Social History: Her husband works at [**Hospital1 18**], is her proxy. She denies tobacco use. She reports she drinks 1-2 drinks/day. Family History: Father had diabetes. Physical Exam: VS:99.2, 108/61, 73, 15, 99 on RA Gen: elderly female, NAD HEENT: EOMI, o/p clear CV: RRR, no m/r/g Pulm: mild wheezes in uppper lung fields bilaterally Abd: left anterior abdominal firm hematoma with visable eccyhmoses in left lower abdomen extending to left lower back and right lower quadrant. Mildly tender to palpation on LLQ. Normoactive bowel sounds. Ext: darkly pigmented LE bilaterally. no peripheral edema, wwp Neuro: AxOx3 Pertinent Results: LABORATORIES: [**2145-8-24**] 04:30PM BLOOD WBC-8.7# RBC-3.68* Hgb-11.7* Hct-34.9* MCV-95 MCH-31.8 MCHC-33.4 RDW-13.0 Plt Ct-232# [**2145-8-25**] 11:10AM BLOOD Hct-23.5* [**2145-8-26**] 07:16AM BLOOD Hct-29.5* [**2145-8-27**] 05:35AM BLOOD WBC-11.1* RBC-2.99* Hgb-9.3* Hct-26.9* MCV-90 MCH-31.1 MCHC-34.6 RDW-17.7* Plt Ct-127* [**2145-8-27**] 05:00PM BLOOD Hct-28.1* [**2145-8-28**] 06:20AM BLOOD WBC-8.6 RBC-2.91* Hgb-9.2* Hct-26.4* MCV-91 MCH-31.6 MCHC-34.8 RDW-16.5* Plt Ct-142* [**2145-8-29**] 06:15AM BLOOD Hct-30.1* . [**2145-8-24**] 04:30PM BLOOD PT-40.5* PTT-34.3 INR(PT)-4.3* [**2145-8-26**] 07:16AM BLOOD PT-13.0 PTT-27.3 INR(PT)-1.1 [**2145-8-28**] 06:20AM BLOOD PT-13.5* PTT-25.9 INR(PT)-1.2* . [**2145-8-24**] 04:30PM BLOOD Glucose-169* UreaN-23* Creat-1.2* Na-128* K-4.0 Cl-88* HCO3-30 AnGap-14 [**2145-8-26**] 04:23AM BLOOD Glucose-119* UreaN-15 Creat-1.0 Na-135 K-3.8 Cl-97 HCO3-32 AnGap-10 [**2145-8-25**] 06:28AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9 [**2145-8-26**] 04:23AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.3 [**2145-8-25**] 09:24AM BLOOD Glucose-112* Lactate-0.9 Na-129* K-3.3* Cl-94* calHCO3-29 [**2145-8-28**] 06:20AM BLOOD Glucose-96 UreaN-20 Creat-1.0 Na-133 K-3.7 Cl-94* HCO3-30 AnGap-13 ============= IMAGINGS: CT ABD/PELVIS with contrast ([**8-24**]) final: 1. Large left rectus sheath hematoma measuring up to 16 x 10 x 6.1 cm, with possible focus of active extravasation in the lower portion. A follow up contrast-enhanced study (CT or MR) should be performed to ensure no underlying mass lesion is present in [**5-17**] weeks time. 2. Colonic diverticulosis with evidence for diverticulitis. 3. Small sliding hiatal hernia. . CXR ([**8-24**]) final: No acute cardiopulmonary abnormality. . CXR ([**8-27**]) final: New mild pulmonary edema. Stable position of the pacemaker leads and new right central venous line with its tip in the upper SVC. ============= EKG ([**8-25**]): a-paced, nml axis, prolonged QT interval (460, likely in setting of sotalol), no STT changes concerning for ischemia. Brief Hospital Course: This is a 81 yo F on coumadin for AFIB presenting with a rectus sheath hematoma in the setting of a slightly supratherapeutic INR and vigourous coughing. . # Rectus Sheath Hematoma: INR elevated at 4.3 which is the highest INR she has recoreded in our system (followed as outpt for coumadin mgt). No predisposing trauma; it is conceivable that severe cough could have caused this. In the early morning on HD2, pt triggered for hypotension SBP in the 80s, stat Hct was found to be 23 and was transferred to MICU after minimal SBP response to fluids and 2u pRBC. In the mean time, pt's abdominal ecchymosis was expanding to the right side. Patient was then taken to IR for inferior epigastric artery embolization. Patient was transferred back to the floor the next day. Since the embolization, patient's BP has been in the 90-140 range since. Hct has been stable at 26-30. Pt received bicarb and mucomyst for prophylaxis of contrast induced nephropathy. . # Cough. Patient has been having a minimally productive cough following a viral illness. The most likely etiology is bronchitis. CXR showed no infectious process, so antibiotics was discontinued. Patient received one dose of levofloxacin. She also received albuterol nebulizers, robittusin, and benzonatate for cough. Patient was afebrile during the hospitalization. . # A-fib: Sotalol 80mg [**Hospital1 **] was continued except for when patient was hypotensive. Coumadin was held, and patient needs to discuss with PCP regarding the risks/benefits of anticoagulation. . # HTN: Home antihypertensives dyazide 37.5/25mg daily and cozaar (50mg qAM / 25mg qPM) were held during the hospitalization. Patient was told to continue to hold the anti-hypertensives until follow up with her PCP. . # Hyperlipidemia: Home simvastatin 40 mg daily was continued. . # Dementia: Aricept was continued. Patient received IVFs, a total of 4u pRBC during this hospitalization. She had regular diet, and was tolerating POs. Patient had 2 large bore PIV and CVL for access. She used pneumoboots for DVT prophylaxis. She had full code. Family (husband and daughter) were updated regularly. Medications on Admission: Sotalol 80 mg [**Hospital1 **] Aricept 5 mg daily Dyazide 37.5/25 daily ProAir inhaler prn Simvastatin 40 mg daily Cozaar 50 mg q am, 25 mg qPM Coumadin 3-4 mg every day except thursday Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) as needed for SOB. 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*500 ML(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 8. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Left Rectus Sheath Hematoma Secondary Diagnoses: Atrial fibrillation Sick Sinus Syndrome s/p pacemaker Hypertension Hyperlipidemia Memory loss Discharge Condition: Stable, afebrile, ambulating. Discharge Instructions: It was a pleasure to be involved in your care, Mrs. [**Known lastname 6330**]. You were admitted to [**Hospital1 69**] because of bleeding into your abdominal wall in the setting of vigorous coughing and blood being too thin on coumadin. Your INR on admission was 4.3 (your therapeutic INR range should [**3-16**]). We held your coumadin. Your bleeding was stopped by our interventional radiologiest by embolization (coiling the bleeding vessel). Your blood pressure, and blood counts have been stable since the procedure. It will take over a month for the bruises on your abdomen to resolve. Your medications have been changed. - Please hold your antihypertensives (Cozaar and Dyazide) until you see your primary care doctor Dr. [**Last Name (STitle) 16258**]. - Please continue to hold coumadin and discuss the risks and benefits of restarting coumadin with Dr. [**Last Name (STitle) 16258**]. - You have been prescribed guaifenisin cough syrup to be used for your cough as you need it. - We have started iron supplementation to be taken twice daily with vitamin C. - We have started Colace, a medicine to prevent constipation while you are on iron, to be taken twice daily. If you develop dizziness, hypotension, fainting, shortness of breath, worsening cough, chest pain, high fevers, or any other symptoms that concern you, please call your doctor, 911 or come to the Emergency Department immediately. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 16258**] on Wednesday [**9-1**], he is expecting you, please call his office ([**Telephone/Fax (1) 19196**]) to clarify the time. You need to have your blood counts and blood pressure checked.

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icd9cm

[ [ [] ] ]

[ "99.04", "38.93", "38.86", "99.07", "88.47" ]

icd9pcs

[ [ [] ] ]

7385, 7391

4229, 6354

331, 415

7598, 7629

2180, 4206

9086, 9336

1689, 1711

6590, 7362

7412, 7412

6380, 6567

7653, 9063

1726, 2161

7481, 7577

277, 293

443, 1325

7431, 7460

1347, 1538

1554, 1673

12,883

172,380

29346

Discharge summary

report

Admission Date: [**2132-1-24**] Discharge Date: [**2132-1-28**] Date of Birth: [**2089-11-30**] Sex: F Service: MEDICINE Allergies: Bupropion / Nortriptyline / Morphine Attending:[**First Name3 (LF) 2186**] Chief Complaint: found down Major Surgical or Invasive Procedure: intubation History of Present Illness: 42F found down at supermarket after witnessed collapse. CPR initiated by bystander. . Patient does not remember any of the events, she recalls going to the store and then waking up extubation. Patient reports a similar event in '[**16**] when she syncopised resulted in contusion. She was at that time diagnosed with LBBB/IVCD that was "exacerbated to torsades" by her taking Nortriptyline. Patient was further evaluted by a cardiologist who felt as long as patient stayed off the Nortriptyline there was no further work up needed. . In the store, pt was in PEA with brady to 30s upon EMS arrival (~5-10 min after EMS called). Converted to sinus tach w/ bolus of NS followed by myoclonic movements. Upon arrival of paramedics, pt was intubated in field and brought to [**Hospital1 18**] ED. . In ED T 98.8, P 130 and regular, BP 163/71, SaO2 100% ventilated. Noted to have some clonic mvmts vs. bucking vent in ED as well as resolving R leg paralysis. Received lorazepam 2 mg IV x 1, propofol, and bicarb 1 amp IV x 1. Head CT negative. EEG performed at bedside that did not reveal ongoing seizures. Patient was successfully extubated on [**2131-1-25**]. She does not recal any events. Patient states she has not had any f/c prior to the event, her PO intake has been dry and she felt sligthly weak/dehydrated. No lightheadedness. Patient denies any recent cp, no sob, no dipahoresis, no n/v. Patient denied any abdominal pain, loose stools, no dysuria/hematuria, no myalgias/arthralgias. No recent changes in weight. Patient did start a new medication - wellbutrin 2 days prior to the event for depression. She also takes many insomnia medications - including the night before - sonata, seroquel, trazadone. Patient denies any recent travels. Patient did experience increasing palpitation between [**Holiday 1451**] and [**Holiday **]. Past Medical History: - Bipolar disorder with suicide attempt in past - b/l leg fx s/p MVA w/ knee surgery in [**11/2130**] - caesarean section x 3 - LBBB, " torsades" in the past in [**2116**] - Factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5244**] deficiency - h/o C.Diff/MRSA after an I&D 1 year ago - L TK replacement - former alcoholic - no drinking in > 1 year - hiatal hernia Social History: Patient has been EtOH free for one year, no tobacco, illicits. Nurse [**First Name (Titles) **] [**Known firstname **]. Divorced with 3 children who live w/ [**1-22**] time with father and her. Lives in [**Location 4288**]. Family lives in [**Location (un) **]. Family History: no h/o SCD, no MI, no HTN Physical Exam: VS: T 100.3, P 83 NSR, BP 125/68, RR 15, SaO2 100% Vent: ACV, FiO2 0.50, VT 550, RR 14 Gen: WD slightly obese woman, sedated and intubated, neck in collar HEENT: NC/AT, PERRL, eyes track to voice PULM: ventilated BS, but otherwise clear w/o wheezes, rhonchi, rales CV: RRR, nl S1/S2, no murmurs, rubs, gallops ABD: +BS, soft, ND EXT: warm, no edema NEURO: with propofol held: MS: responds to command w/ finger squeeze, toe movement L>R; CN: pupils 2mm -> 1.5 mm b/l, + gag, + doll's eyes movements; Motor: moves all extremities; Reflexes; 1+ patellar reflexes b/l, toes downgoing Pertinent Results: STUDIES: - EKG ([**2132-1-24**], no prior for comparison): sinus tach @ 122 bpm, QRS 120, L axis deviation, no structural dz, LBBB, ? ST elevations in V1/V2, biphasic T in V1, TWI aVL - CXR ([**2132-1-24**]): Endotracheal tube tip retracted and now located at thoracic inlet. Recently inserted NG tube tip at GE junction. L retrocardiac atelectasis unchanged. No pleural effusion or PTX identified. R lung clear. Markedly distended stomach unchanged. 1. Tip of NG tube projects over GE junction. 2. Unchanged appearance of L retrocardiac atelectasis. . CT head ([**2132-1-24**]): 1. No acute intracranial pathology or hemorrhage. . CT C-spine ([**2132-1-24**]): 1. Mild possible protrusion of disc at C4-C5 level. . CT chest/abd/pelvis ([**2132-1-24**]): 1. Mild stranding in presternal region, possibly representing contusion, although no evidence of sternal fracture. 2. Dependent opacities within lungs bilaterally consistent with subsegmental atelectasis/infiltrate, left greater than right. . EEG ([**2132-1-24**]): Abnormal portable EEG for the encephalopathy early in the record, giving way to drowsiness and sleep, much of which appeared to be medication-related. There was no clear focal abnormality or any epileptiform feature. . MRI/MRA ([**2132-1-25**]): No evidence of acute infarct. Probable sinusitis involving left maxillary sinus. Normal MRA of the brain. . ECHO ([**2132-1-25**]): 1.The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 2.Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with a very focal area of hypo/akinesis of the mid anteroseptum. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. 5. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. 6. There is no pericardial effusion. . Exercise MIBI ([**2132-1-28**]): Average functional exercise tolerance. No anginal symptoms or ischemic ST segment changes. Lightheadness reported in absence of drop in blood pressure or arrhythmia. NUCLEAR: Normal myocardial perfusion study at the level of exercise achieved. Normal left ventricular cavity size and wall motion. . EEG ([**2132-1-28**]): Pending . . LABS: WBC-11.4* RBC-4.61 HGB-14.5 HCT-40.6 MCV-88 MCH-31.4 MCHC-35.7* RDW-13.3 PLT COUNT-280 ALT(SGPT)-33 AST(SGOT)-28 CK(CPK)-107 ALK PHOS-61 AMYLASE-50 TOT BILI-0.6 CK-MB-3 cTropnT-<0.01 TYPE-ART PO2-188* PCO2-40 PH-7.39 TOTAL CO2-25 BASE XS-0 Brief Hospital Course: Ms. [**Name13 (STitle) 4027**] is a 42-year-old woman with a history of Left BBB in the setting of nortriptyline use and a history of bipolar affective disorder, recently started on bupropion, who presented after a PEA arrest with reported seizure activity. . 1. Possible PEA Arrest. This was of uncertain etiology, though the leading suspicion was a brady dysrhythmia that caused a syncopal episode rather than a true PEA arrest. It was suggested by neurology that such a dysrhythmia could have been triggered by a temporal lobe seizure, which would be consistent with the myoclonic activity reported after her fall (as the seizure generalized). The seizure, in turn, could have been provoked by the bupropion she started just two days before, which may have lowered her seizure threshold and revealed a heretofore unrecognized seizure disorder. Regardless, the objective data includes only an echo that showed a very limited focal septal hypokinesis. She had a stress test that did not provoke any arrhythmia or anginal symptoms. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to look for future arrhythmias and was scheduled to see Dr. [**Last Name (STitle) 73**] in follow-up. . 2. Seizure activity. As above, this may have been triggered by bupropion; neurology suggested a temporal lobe seizure given her history of [**Last Name (un) 5083**] vu. She had a normal MRI. A bedside EEG showed no epileptiform activity; a full EEG with sphenoidals was performed with the results pending at the time of discharge. She was given Keppra as seizure prophylaxis and discharged on this, as well as her gabapentin (which she takes for bipolar disorder). She was provided with the neurologists' phone number and instructed to follow-up with them. . 3. Bipolar Affective Disorder, type 2. This was stable, although she was quite concerned that without sleep she would become manic. She was thus continued on her outpatient dose of gabapentin. Ambien was substituted for Sonata while she was an inpatient, and her trazodone dose (normally 200 mg hs) was halved given concerns of an arrhythmia. . 4. Factor V Leiden. By her report, she had had clots only in the setting of orthopedic surgery and OCP use, and her outpatient hematologist had therefore said she did not need anticoagulation. She was discharged with instructions to follow-up as necessary. . 5. CODE: FULL . 6. Dispo: She was discharged home with follow-up arranged. Medications on Admission: 1. Pepcid 2. Wellbutrin 3. Trazadone prn 4. Neurontin 1800 [**Hospital1 **] 5. Sonata 6. Seroquel . ALL: morphine - rash; nortriptyline - syncope, buproprion - cardiac arrest Discharge Medications: 1. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 2. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 6 days. Disp:*24 Tablet(s)* Refills:*0* 3. Keppra 500 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: Take this dose (1000 mg twice a day) after finishing the 500 mg dose. Disp:*28 Tablet(s)* Refills:*0* 4. Levetiracetam 750 mg Tablet Sig: Two (2) Tablet PO twice a day: Take after finishing the 1000 mg dose. Disp:*120 Tablet(s)* Refills:*2* 5. Sonata 10 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. 6. Trazodone 100 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 7. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime) as needed for insomnia. 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for loose stool. 9. Gabapentin 600 mg Tablet Sig: Three (3) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Pulseless electrical activity (PEA) Cardiac Arrest 2. Seizure disorder Discharge Condition: Good condition, vital signs stable. Discharge Instructions: You have been evaluated for loss of consciousness. No specific cause was found, although it may have been a seizure. This, in turn, may have been related to the bupropion (Wellbutrin) you were taking. You have no evidence of arrhythmia, cardiac ischemia, or seizure activity on EEG (although this does not exclude the possibility that you had a seizure at the time). Your MRI was normal, as was your stress test. . If you should develop palpitations, chest pain, shortness of breath, seizures, dizziness, lightheadedness, or any other symptom that is concerning to you, please call your PCP or go to the nearest hospital emergency department. Followup Instructions: Please call [**Telephone/Fax (1) 541**] to schedule an appointment in Neurology with Drs. [**First Name4 (NamePattern1) 1104**] [**Last Name (NamePattern1) 4638**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Let them know when you call that you saw Dr. [**Last Name (STitle) 4638**] while you were an inpatient. You should be seen in [**4-25**] weeks. . A tilt table test is scheduled on [**2-28**] at 10 am; the office number is [**Telephone/Fax (1) 8139**]. More information will be mailed to you. . You also have an appointment with Dr. [**Last Name (STitle) 73**] in Cardiology on [**3-3**] at 11:20 am. His office is on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building ([**Telephone/Fax (1) 902**]). . Finally, you should call your PCP to have [**Name Initial (PRE) **] follow-up appointment in [**2-23**] weeks. Completed by:[**2132-1-29**]

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icd9cm

[ [ [] ] ]

[ "89.19", "96.71", "02.96", "89.14", "96.07" ]

icd9pcs

[ [ [] ] ]

10016, 10022

6344, 8824

309, 321

10149, 10186

3531, 6321

10877, 11775

2888, 2915

9050, 9993

10043, 10128

8850, 9027

10210, 10854

2930, 3512

259, 271

349, 2187

2209, 2592

2608, 2872