ChanBeDu/relevant_section_length · Datasets at Hugging Face

67,710

149,821

41675

Discharge summary

report

Admission Date: [**2183-10-22**] Discharge Date: [**2183-10-29**] Date of Birth: [**2097-2-15**] Sex: F Service: CARDIOTHORACIC Allergies: morphine / Codeine / Pentothal / Hydromorphone Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2183-10-23**] Aortic Valve Replacment (21mm St. [**Male First Name (un) 923**] Porcine), Coronary Artery Bypass Grafting x 1 (Saphenous vein graft to obtuse marginal) PICC line placement History of Present Illness: 86 year old female with severe aortic stenosis was recently referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for consideration of participation in the corevalve study. She reports a one month history of increasing shortness of breath and weakness that occurs after activity and lasts for up to 1/2 hour. She reports episodes occurring several days per week. She reports longstanding lower extremity edema and takes triamterene/hctz on a PRN basis. Her son states she has a 2 year history of intermittent lightheadedness, however pt denies lightheadedness. PT was at home awaiting surgery and became very SOB and anxoius therefore was admitted to [**Hospital 26580**] hospital on [**10-19**]. There she was diuresed and stabilized and transferred to [**Hospital1 18**] for Heparin brigde and AVR/CABG. Past Medical History: Aortic Stenosis Coronary Artery Disease History of DVT and Pulmonary embolism Hypertension Pancreatitis Macular degeneration s/p right total knee replacement s/p bladder suspension (unsuccessful - pessary) s/p appendectomy Social History: Lives with:lives alone, senior housing Contact:[**Name (NI) **] (son) Phone #[**Telephone/Fax (1) 90596**] Occupation:retired Cigarettes: Smoked no [] yes [x] Hx:Quit over 30 years ago Other Tobacco use:denies ETOH: denies Illicit drug use:denies Family History: non-contributory Physical Exam: Pulse:65 Resp:18 O2 sat:97/RA B/P Right:138/76 Left:130/72 Height:4'[**83**]" Weight:120 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade ___2___ Abdomen: Soft [] non-distended [] non-tender [] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: palp Left: palp DP Right: dop Left: dop PT [**Name (NI) 167**]: dop Left: dop Radial Right: Left: Pertinent Results: [**2183-10-23**] Intra-op TEE PRE-CPB: No thrombus is seen in the left atrial appendage. A small patent foramen ovale is present. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. There is severe mitral annular calcification. Trivial mitral regurgitation is seen. POST-CPB: There is a bioprosthetic valve in the aortic position. The leaflets are normally mobile. There are no paravalvular leaks. There is no AI. The peak gradient across the aortic valve is , the mean gradient is , with CO=4.2. The LV chamber is small, consistent with hypovolemic state. The estimated EF is >55%. There is no evidence of dissection. [**2183-10-27**] CXR: In comparison with the study of [**10-25**], the remaining monitoring and support devices have been removed. Continued bilateral pleural effusions with compressive atelectasis at the bases, which is less prominent, presumably due to the upright rather than supine position of the patient. No convincing evidence of pneumothorax at this time. [**2183-10-22**] 06:30PM BLOOD WBC-5.1 RBC-3.87* Hgb-12.4 Hct-34.2* MCV-89 MCH-31.9 MCHC-36.1* RDW-14.4 Plt Ct-209 [**2183-10-29**] 04:18AM BLOOD WBC-4.8 RBC-3.51* Hgb-10.6* Hct-32.6* MCV-93 MCH-30.1 MCHC-32.4 RDW-13.9 Plt Ct-212 [**2183-10-22**] 06:30PM BLOOD PT-12.8 PTT-29.2 INR(PT)-1.1 [**2183-10-29**] 04:18AM BLOOD PT-14.3* INR(PT)-1.2* [**2183-10-22**] 06:30PM BLOOD Glucose-109* UreaN-32* Creat-0.9 Na-140 K-3.8 Cl-101 HCO3-27 AnGap-16 [**2183-10-29**] 04:18AM BLOOD Glucose-148* UreaN-22* Creat-0.9 Na-140 K-3.3 Cl-99 4HCO3-31 AnGap-13 [**2183-10-29**] 04:18AM BLOOD WBC-4.8 RBC-3.51* Hgb-10.6* Hct-32.6* MCV-93 MCH-30.1 MCHC-32.4 RDW-13.9 Plt Ct-212 [**2183-10-29**] 04:18AM BLOOD Glucose-148* UreaN-22* Creat-0.9 Na-140 K-3.3 Cl-99 HCO3-31 AnGap-13 Brief Hospital Course: She was admitted prior to surgery for Heparin bridge, pre-operative work-up and antiobiotics for positive UA. She was brought to the Operating Room for aortic valve replacement and coronary artery bypass graft surgery. See operative report for further details. Overall the she tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. She initially required volume resuscitation and Levophed for hypotension. On post-op day one she was weaned from sedation,extubated, alert and oriented and breathing comfortably. She was alert and oriented to person and time but not place. She was weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward her preoperative weight. PICC was inserted on [**2183-10-25**] for access. Beta blocker was discontinued for bradycardia. The patient was transferred to the telemetry floor for further recovery on post-op day three. Chest tubes and pacing wires were discontinued without complication. She was evaluated by the physical therapy service for assistance with strength and mobility. She was restarted on betablockers when she had rate controlled atrial fibrillation and they were titrated slowly with no further bradycardia, but conitnues between sinus rhythm and rate controlled atrial fibrillation. Of additional note she had episodes of confusion when awaking that she received haldol and now remains on zyprexa at night for sleep. She is currently pleasant, oriented to time and her sons, and cooperative. She had repeat urine which was negative and medications were minimized and diuretic is now changed to daily. This was all discussed with the son and she was ready for transfer to rehab at [**Location (un) 582**] at silver [**Doctor Last Name **] on [**10-29**]. Medications on Admission: COLCHICINE [COLCRYS] 0.6 mg Tablet 1 Tablet by mouth twice a day TRIAMTERENE-HYDROCHLOROTHIAZID 37.5 mg-25 mg Capsule - 1 Capsule by mouth prn for edema URSODIOL 500 mg Tablet - 1 Tablet by mouth twice a day WARFARIN 6 mg Tablet - 1 Tablet(s) by mouth once a day last dose Saturday [**10-4**] VIT C-VIT E-COPPER-ZNOX-LUTEIN [PRESERVISION] 226 mg-200 unit-[**Unit Number **] mg-0.8 mg-34.8 mg Capsule 2 Capsule(s) by mouth twice a day Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. 8. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: to take 4 mg on [**10-29**] and then to have INR checked on [**10-30**] for further dosing by rehab physician . 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] in [**Location (un) 8072**] Discharge Diagnosis: Aortic Stenosis s/p Aortic valve replacement Coronary artery disease s/p CABG Preoperative urinary tract infection Atrial Fibrillation Confusion Secondary diagnosis Deep vein thrombosis Pulmonary embolism Hypertension Pancreatitis Macular degeneration Discharge Condition: Alert, nonfocal, oriented to time and person Reorients easily or with family - sons are supportive Ambulating with assistance Incisional pain managed with tylenol prn Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage Edema - trace lower extremity edema of note has large legs at baseline and wears support hose - denies TEDS family will bring support hose 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**] Date/Time:[**2183-11-26**] 1:15 Cardiologist: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] Date/Time:[**2183-11-21**] 12:00 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 39360**] in [**4-29**] 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** Labs: PT/INR for afib, hx dvt and PE Goal INR 2-2.5 First draw [**2183-10-31**] Please check INR monday, wednesday, friday for 2 weeks Dose to be adjusted by rehab physician **Please arrange for coumadin follow-up prior to d/c from rehab** Completed by:[**2183-10-29**]

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Discharge summary

report

Admission Date: [**2148-5-19**] Discharge Date: [**2148-5-28**] Date of Birth: [**2075-9-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: Maroon stools Major Surgical or Invasive Procedure: None History of Present Illness: Full hx as per ICU admit note. Briefly, this is a 72 year old man with a past medical history significant for metastatic gastric cancer (tolerating adriamycin after failing multiple regimens), localized prostate cancer, bilateral cephalic vein thromboses in the setting of coumadin therapy in [**2148-4-9**], and portacath thrombus in [**2148-1-11**] who presented with four days of dark stools and hematocrit drop from 37 to 24, and intermittent abdominal pain and nausea, after being discharged to nursing facility on [**5-13**] on chronic lovenox therapy. . In the ICU, the pt underwent an EGD with showed a fungating mass with stigmata of recent bleeding of malignant appearance was found in the antrum of the stomach. There was an ulcer within the mass, with an adherent clot. The ulcer was injected. However, after the procedure the patient continued to have bleeding and an angiography was performed. The GDA was embolized with coils and Gelfoam slurry. Subsequently the patient has been doing well and no more drop in the hct was noted. He was transfused a total of 4 U PRBC per the blood bank record, the last one on [**5-20**]. . The patient is currently doing well and denies any further abdominal pain or nausea/vomiting. He reports 2 cream-colored BM today. . ROS: Otherwise negative for dysuria, CP, SOB. He has been able to tolerate liquids and solid food. He endorses a weight loss of 144 to 126 pounds in the last 2 months. Past Medical History: -Gastric cancer diagnosed in [**2147-7-11**]; found on workup of iron-deficiency anemia with metastsis to lymph nodes and liver treated initiially with two cycles of ELF chemotherapy with disease progression followed by weekly irinotecan stopped secondary to toxicity. Started Taxol [**11-7**] discontinued due to a drug-eruptive rash. Started Adriamycin [**2147-12-18**], last dose in [**4-15**]. -Hypertension -Prostate cancer, [**Doctor Last Name **] 3+4 tx with watchful waiting -Right portacath associated SVC thrombus and removal [**2148-1-26**] with new port placed on left at same time. Bilateral cephalic vein thrombosis in [**4-15**] Social History: He is from [**Location (un) 4708**]. He is married, wife is a nurse in the OR at [**Hospital6 1708**]. He used to smoke, quit 24 years ago, smoked for 25 plus years. Used to drink approximately one bottle of vodka a day, quit in [**2124**]. No IV drug use. Family History: Per [**Name (NI) **], mother died of breast cancer at age 36, brother died of pancreatic cancer at age 69, other brother died of prostate cancer, and his father died of a myocardial infarction. He had one son and he died of a stroke. Physical Exam: T:99.6 BP:109/59 HR:76 RR:19 O2saturation: 100% on 2L nasal canula Gen: Pleasant elderly man in no apparent distress. Laying in bed. Appears slightly older than stated age. HEENT: Slight conjunctival pallor. No scleral icterus. Slightly dry mucous membranes. NECK: Supple. No cervical or supraclavicular lymphadenopathy. No JVD. CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**] appreciated. LUNGS: Clear to auscultation bilaterally. Decreased breath sounds in lower lung fields, bilaterally. No wheezes, crackles, or rhonci appreciated. ABD: Distended, but soft. Normal active bowel sounds in all four quadrants. Nontender. No guarding or rebound. Liver edge not palpated. Guaiac deferred/noted in ER to be positive. EXT: Warm and well perfused. No clubbing or cyanosis. No lower extremity edema, bilaterally. 2+ dorsalis pedis and radial pulses, bilaterally. Pertinent Results: [**2148-5-19**] 11:15AM BLOOD WBC-12.5*# RBC-2.72*# Hgb-7.5*# Hct-23.8*# MCV-88 MCH-27.7 MCHC-31.6 RDW-19.9* Plt Ct-765* [**2148-5-28**] 12:00AM BLOOD WBC-9.7 RBC-3.53* Hgb-10.8* Hct-30.5* MCV-87 MCH-30.5 MCHC-35.3* RDW-17.1* Plt Ct-322 [**2148-5-19**] 11:15AM BLOOD Neuts-77.0* Lymphs-16.7* Monos-5.4 Eos-0.3 Baso-0.6 [**2148-5-24**] 12:32AM BLOOD Neuts-78.0* Bands-0 Lymphs-10.7* Monos-9.9 Eos-1.0 Baso-0.4 [**2148-5-19**] 11:15AM BLOOD PT-15.7* PTT-36.9* INR(PT)-1.4* [**2148-5-24**] 12:32AM BLOOD PT-17.0* PTT-28.3 INR(PT)-1.6* [**2148-5-19**] 11:15AM BLOOD Glucose-123* UreaN-26* Creat-1.7* Na-145 K-4.9 Cl-113* HCO3-22 AnGap-15 [**2148-5-28**] 12:00AM BLOOD Glucose-150* UreaN-5* Creat-1.6* Na-138 K-3.0* Cl-106 HCO3-22 AnGap-13 [**2148-5-19**] 11:15AM BLOOD ALT-35 AST-35 CK(CPK)-47 AlkPhos-75 Amylase-96 TotBili-0.3 [**2148-5-23**] 12:36AM BLOOD ALT-21 AST-25 LD(LDH)-365* AlkPhos-64 TotBili-0.3 [**2148-5-19**] 11:15AM BLOOD cTropnT-0.04* [**2148-5-19**] 11:15AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.7* [**2148-5-23**] 12:36AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.3* Mg-2.2 [**2148-5-28**] 12:00AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.1 [**2148-5-23**] 10:28AM BLOOD Ammonia-25 [**2148-5-24**] 12:32AM BLOOD TSH-0.91 [**2148-5-19**] 11:41AM BLOOD Glucose-123* Na-143 K-4.1 Cl-111 calHCO3-23 . [**5-19**] EKG Sinus rhythm. Normal ECG. Compared to the previous tracing of [**2148-5-6**] the rate is normal. . [**5-21**] Embolization: IMPRESSION: Vascular mass at the gastric antrum and proximal duodenum level supplied by the GDA. The GDA was embolized with coils and Gelfoam slurry. No active extravasation of contrast was seen. . [**5-23**] MRI MRI OF THE BRAIN: There is no evidence of acute brain ischemia or intracranial hemorrhage. No structural, signal, or enhancement abnormalities are noted within the brain parenchyma. Apparent signal and enhancement abnormality in the inferior frontal lobes bilaterally are most consistent with artifact from the adjacent cribriform plates. Calcification in the choroid plexus as well as choroidal vasculature is noted bilaterally. There is no hydrocephalus. The craniocervical junction is normal. There is thickening of multiple ethmoid air cells. No fluid is noted within the mastoid air cells or other paranasal sinuses. MRA OF THE BRAIN: There is no evidence of aneurysmal dilation, significant stenosis, or arteriovenous malformation. IMPRESSION: No definite signal or enhancement abnormalities within the brain parenchyma are definitely seen. The preliminary read suggested some abnormalities thought to be within the medial temporal lobes and within the gyri recti of the frontal lobes; the former is thought to represent choroid plexus vasculature and the latter artifact arising from adjacent cribriform plates, a common finding when a 3T scanner is used. . [**5-23**] CXR CHEST, ONE VIEW: Comparison with [**2148-5-6**]. Low lung volumes may accentuate vascular structures. No pleural effusion or pneumothorax. Probable minimal subsegmental atelectasis at the left lung base. No pleural effusion or pneumothorax. Right PICC is seen at the proximal portion of the SVC. Embolization coils in the epigastric region are noted. IMPRESSION: Minimal subsegmental atelectasis at the left lung base. . [**5-23**] CT Head FINDINGS: There is no evidence of hemorrhage, shift of normally midline structures, or infarction. [**Doctor Last Name **]-white matter differentiation is preserved. There is no hydrocephalus. Small hypodensities in bilateral thalami may be old lacunes and were present on head CT, [**2148-1-24**]. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No evidence of hemorrhage or infarction. Again, please note that non-contrast head CT is relatively insensitive for detection of metastatic disease and contrast-enhanced MRI is recommended if this is a clinical concern. . [**5-23**] EEG IMPRESSION: Abnormal EEG due to the mildly slow and disorganized background. This suggests an encephalopathy. No areas of prominent focal slowing were evident, and there were no epileptiform features. . [**5-26**] RUE U/S FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the right internal jugular, subclavian, axillary, and right brachial veins demonstrate normal compressibility and waveforms. Examination of the contralateral internal jugular vein and subclavian vein also demonstrates normal waveforms and compressibility. The right cephalic vein is not imaged on this examination and likely remains clotted. A central venous line is observed coursing through the right brachial veins and is unremarkable. IMPRESSION: No evidence of deep vein thrombosis of the right internal jugular, subclavian, or axillary veins. No findings consistent with SVC syndrome. . [**5-27**] MRV Lower portions of both the right and left internal jugular veins are widely patent, as are both the right and left brachiocephalic veins. The SVC is patent as well. There is mild narrowing of the SVC in its mid portion, although it is difficult to determine whether this represents a nondistended state or a functional stenosis/stricture. The left subclavian vein appears patent along its entire course. Right subclavian vein is non-visualized for a segment of approximately 1-2 cm lateral to the the lung apex, presumably secondary to prior stenosis/thrombus. More proximally and distally, flow is seen within this vessel. Small bilateral pleural effusions are present. A mass is seen within the left lobe of the liver on the coronal SSFSE images. IMPRESSION: 1. No evidence of SVC conclusion. Mild narrowing may be present in the mid portion of the SVC, although we cannot assess whether this is truly anatomic stenosis or simply physiogical due to nondistension. 2. Short segment of partial obstruction versus stenosis in the central portion of the right subclavian vein. 3. Patent appearance of the visualized portions of both the right and left internal jugular veins as well as the brachiocephalic veins. Brief Hospital Course: Assessment/Plan: 72 year old man with a past medical history significant for metastatic gastric cancer, thrombotic events, and MSSA bacteremia who was recently discharged to a nursing home on lovenox, admitted with 4d of dark, guiaiac positive stools and 12 point Hct drop, now s/p ICU stay with 4 [**Location **] transfusion and unsuccessfull EGD with epinephrine injection into bleeding gastric mass and subsequently embolization. . #) GI bleed: Known gastric cancer with hypercoaguable state. Placed on lovenox upon discharge on [**5-13**]. Hematocrit noted to have decreased from 36.8 on [**5-15**] to 23.8 on admission. Dark stools over the four days PTA. Guaiac positive in ED. Hct continued to trend down and he was transfused several units of PRBCS. He underwent an EGD that showed a large gastric mass with central ulceration and recent bleeding. His hct continued to trend down thereafter, and he was therefore transferred to Angiography for embolization therapy, which he received on [**2148-5-21**]. His hct has been stable since that procedure. . #) Prior MSSA infection: Blood cultures on [**5-6**] grew MSSA in [**3-13**] bottles. Urinalysis and chest xray negative. TTE negative for vegetations and TEE deferred. Given his prior history of deep vein thrombosis, upper extremity ultrasounds were obtained and notable for bilateral cephalic vein DVTs. Surveillance for infected clots negative. PICC line was placed on [**2148-5-10**] for antibiotic administration. Will need to continue Nafcillin for four weeks (high dose at 2 gm IV every 4 hours), day 1 [**2148-5-10**], with last doses on [**2148-6-6**]. Scheduled to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital **] clinic on [**6-10**] at 0900 AM. . #) Hypercoagulability: Extensive personal and presumed family history of thromboses, with port-associated thrombus requiring port removal with placement of a new left-sided port in [**2148-1-11**], followed by SVC thrombus requiring TPA in [**2148-3-10**]. On previous admission in [**2148-5-10**], upper extremity ultrasounds were obtained that were notable for bilateral upper extremity cephalic vein DVTs. His INR was therapeutic on admission, but in late [**Month (only) 547**], subtherapuetic for short period. Placed on lovenox, as deemed "coumadin failure". Megace was discontinued during last admission due to its potential prothrombotic characteristics. At continuned high risk for thromboses. In setting of GI bleed, held lovenox and will continue to hold for now per his oncologist Dr. [**Last Name (STitle) **].. . #) Metastatic gastric cancer: Followed by nurse [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5556**]. Primary oncologist Dr. [**Name (STitle) 5559**]. On previous hospitalization in [**Month (only) 116**]-[**2148-5-10**], noted to be guaiac positive and required one unit of packed red blood cells. . #) Chronic renal insufficiency: Cr on admission noted to be 1.6. He had been down to 1.1 on prior admission but has been as high as 1.8 in the past. His creatinine did not change with IVF and no renal abnormalities were found on renal ultrasound. - renally dose all medications . #) Mental status change: He was noted to be acutely disoriented the night after he was transferred from the ICU. No obvious cause was found for his disorientation and his mental status cleared over the next 24 hours. With neurology consulting, he was started empirically on keppra for seizure prevention as his presentation was most consistent with a post-ictal state although EEG did not show seizure activity. He will follow-up with Dr. [**Last Name (STitle) 5560**] as an outpatient. No structural cause for seizure was found on MRI. . #) Diarrhea: he was noted to have increasing diarrhea around the time that he had mental status change. He was negative X 3 for c.diff but as he had been on long-term antibiotics and had low-grade fevers/inc WBC count, he was started empirically on flagyl for a 7 day course and his diarrhea and fevers resolved. - we started him on potassium supplementation on discharge as he has been relatively hypokalemic. His serum chemistries should be checked approximately every other day until stable and continued on potassium supplementation until his potassium is stable. Medications on Admission: -Acetaminophen 325 mg Tablet 1-2 Tablets PO Q4-6H PRN -Pantoprazole 40 mg Tablet PO qd -Nafcillin in D2.4W 2 g/100 mL; 2 grams IV Q4H for 24 days (last dose [**2148-6-6**]) -Baclofen 10 mg PO tid -Docusate Sodium 100 mg [**Hospital1 **] PRN -Enoxaparin 60 mg/0.6 mL Syringe; Sixty mg SC q12hr -Prochlorperazine 10 mg PO q8hr PRN nausea Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Nafcillin 2 gm IV Q4H 24 day dose; last dose on [**2148-6-6**] 3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO twice a day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days: through [**2148-5-31**]. 6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 7. Heparin Flush (10 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2ml of 10 units/ml heparin each lumen daily and PRN. Inspect site every shift. 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: GI Bleed Seizure Infectious Diarrhea Chronic Renal Insufficiency Anemia Discharge Condition: Hemodynamically stable. Ambulatory. Discharge Instructions: You were admitted with a gastrointestinal bleed. This bleed was from being on a blood thinner. We have stopped this blood thinner so you are now at increased risk of forming new blood clots. . You likely had a seizure during your admission and are now taking a medication to prevent more seizures. . You are also being treated for infectious diarrhea. Please continue to take the antibiotic as prescribed. . You need to continue nafcillin until [**2148-6-6**] to treat the bacteria in your blood found on your last hospitalization. . Please seek medical attention immediately if you develop fever, chills, nausea, vomiting, shortness of breath or any other concerning symptoms. Followup Instructions: Please make a follow-up appointment w/ Dr. [**Last Name (STitle) **] within a week of discharge from rehab. Tel ([**Telephone/Fax (1) 1300**]. . You have a follow-up appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (un) 5561**] on [**2148-6-26**] at 10:00 am. Tel. ([**Telephone/Fax (1) 5562**]. . Please call [**Telephone/Fax (1) 3506**] to schedule a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5560**] for sometime within the next month. Tel ([**Telephone/Fax (1) 5563**]. . Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2148-6-10**] 9:00 Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2148-7-18**] 9:00

[ "041.11", "009.0", "584.9", "780.39", "151.2", "403.90", "285.1", "197.7", "585.9", "790.7", "531.40" ]

icd9cm

[ [ [] ] ]

[ "45.13", "88.47", "99.04", "44.44" ]

icd9pcs

[ [ [] ] ]

15521, 15587

9934, 14254

328, 335

15703, 15741

3918, 9911

16470, 17350

2764, 2999

14641, 15498

15608, 15682

14280, 14618

15765, 16447

3014, 3899

275, 290

363, 1806

1828, 2474

2490, 2748

73,894

134,985

5495

Discharge summary

report

Admission Date: [**2195-1-28**] Discharge Date: [**2195-2-11**] Date of Birth: [**2143-9-23**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Lipitor / Ace Inhibitors / Aspirin / Amlodipine / Cozaar / Kayexalate Attending:[**First Name3 (LF) 7651**] Chief Complaint: CHF Major Surgical or Invasive Procedure: Placement of tunneled hemodialysis catheter, triple lumen central catheter, and arterial line. All but hemodialysis catheter have been removed prior to discharge. History of Present Illness: 51yoF with h/o diastolic CHF, chronic renal insufficiency, HTN, DM, autonomic and peripheral neuropathy who was directly admitted to the hospital for CHF exacerbation. She recently admitted to [**Hospital1 18**] from [**Date range (1) 22210**] for CHF exacerbation, acute on chronic renal failure and hyperkalemia and diuresed. She re-presents with a week history of increased dyspnea, fatigue, confusion, and weight gain. Her husband notes that her dry weight is closer to 150-155 lbs and she is most recently approximately 177 lbs. She feels her legs are more swollen and is also retaining fluid in her abdomen and back. She is having a harder time ambulating and feels weak and dizzy when she is on her feet. She and her husband both note increased confusion in that she will forget things easily, forget what she's saying or what she was just told, but denies any focal neurological signs. Her husband and Dr.[**Doctor Last Name 3733**] also note that she looks more pale. . ROS as above, otherwise, she denies f/c/ns. She endorses bleeding from her nose, increased blurry vision with "everything getting darker," increased dizziness when ambulating to the point of presyncope but denies LOC. She endorses chronic nausea, no vomiting, chronic diarrhea due to gastroparesis, abdominal pain from the increased fluids and weight. Denies dysuria but urinating less. Increased BLE edema. Skin rash as noted in previous d/c summary. She endorses pain in her back and arm from a recent fall and her R arm is in a sling. She denies any neurological signs, tingling or numbness in her extremities, dysarthria, facial droop, focal clumsiness in her hands/feet. No chest pain, no palpitations, no PND. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes type 2, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: None - Severe Diastolic dysfunction 3. OTHER PAST MEDICAL HISTORY: - Autonomic dysfunction with hypertension and hypotension - Peripheral neuropathy - Chronic renal insufficiency, baseline creatinine 2.7 - Anemia likely due to renal insufficiency - Leukopenia - Gastroparesis - Retinopathy- s/p laser surgery and avastin treatment - S/p cataract surgery - CIDP - Hyperkalemia - Depression - Pulmonary HTN Social History: Lives with husband is [**Name (NI) **] [**Telephone/Fax (1) 22209**], has one daughter. -Tobacco history: smoked at age 16, no tobacco use since -ETOH: none in last couple of months -Illicit drugs: none Family History: - Mother: hypertension and hypercholesterolemia - Father: hypertension, hypercholesterolemia, and AAA - Paternal grandfather: liver cancer - Maternal grandfather: [**Name (NI) 21418**] and colon cancer Physical Exam: 98.1 127/65 56 12 96%RA Appear chronically ill. Sling on R arm. Is conversant, alert, aware but has an odd affect, with somewhat broken sentences and what seems to be word finding difficulty. No distress. Breathing comfortably, goes from sitting at bedside to lying at about 20 degree angle without difficulty Conjunctivae are very pale, but sclera are not icteric. EOMI. Mouth is dry appearing. Her external jugulars are grossly distended, but her internal jugular pulsations are about 9cm above sternal angle at around 30 degrees. No carotid bruits are noted. Lungs with faint crackles at the bases anteriorly, pt unable to move to listen posteriorly. Fair air movement. Breathing comfortably, not tachypneic S1 S2 are regular and there is a systolic murmur at the LUSB, not at the apex. S3 heard best along L sternal border. Radials palpable bilaterally. Abd slightly distended not very tight, not tender to palpation. No tenderness to palpation. Liver not grossly enlarged by percussion. No anasarca noted at her hips. BLE with pitting edema to below her knees. DP's are palpable and strong bilaterally Skin has diffusely spread ulcerated lesions, recently thought to be drug rash CN2-12 intact, no dysarthria, no facial droop, no tongue deviation. She does have an odd affect and some word finding difficulties. Strength is [**4-15**] in all 4 extremities, sensation is intact through her body Pertinent Results: Admission labs: [**2195-1-28**] WBC-1.2*# RBC-2.32* Hgb-6.7* Hct-21.3* MCV-92 MCH-29.1 RDW-17.3* Plt Ct-291 Neuts-60 Bands-0 Lymphs-14* Monos-20* Eos-4 Baso-0 Atyps-2* Glucose-184* UreaN-117* Creat-3.9* Na-127* K-5.4* Cl-101 HCO3-16* AnGap-15 ALT-20 AST-14 CK(CPK)-86 AlkPhos-233* TotBili-0.3 TotProt-6.0* Albumin-3.7 Globuln-2.3 Calcium-8.3* Phos-5.7* Mg-3.2* Iron-23* calTIBC-295 Hapto-150 Ferritn-92 TRF-227 . Discharge Labs: [**2195-2-11**] WBC-7.9 RBC-3.90* Hgb-11.2* Hct-34.8* MCV-89 MCH-28.6 MCHC-32.1 RDW-17.2* Plt Ct-323 Glucose-132* UreaN-55* Creat-3.3* Na-133 K-3.6 Cl-94* HCO3-28 AnGap-15 Calcium-9.2 Phos-4.7* Mg-1.9 . Other Pertinent Labs: [**2195-2-5**] 03:38AM BLOOD CK-MB-16* MB Indx-8.0* cTropnT-0.27* [**2195-2-4**] 10:01AM BLOOD CK-MB-13* MB Indx-7.4* cTropnT-0.28* [**2195-2-4**] 05:32AM BLOOD CK-MB-11* MB Indx-9.8* cTropnT-0.26* [**2195-2-3**] 11:11PM BLOOD CK-MB-NotDone cTropnT-0.21* [**2195-2-3**] 01:54PM BLOOD CK-MB-NotDone cTropnT-0.23* [**2195-1-30**] 05:20AM BLOOD CK-MB-NotDone cTropnT-0.20* [**2195-1-28**] 10:20PM BLOOD CK-MB-NotDone cTropnT-0.16* [**2195-2-2**] 05:30AM BLOOD Hapto-154 [**2195-1-31**] 06:10AM BLOOD VitB12-1494* Folate-GREATER TH [**2195-1-29**] 05:15AM BLOOD TSH-3.6 [**2195-2-3**] 05:15AM BLOOD Cortsol-49.2* [**2195-2-3**] 05:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2195-2-3**] 05:15AM BLOOD HCV Ab-NEGATIVE . MICRO: 2:23 BCx: no growth, final [**2-6**] BCx: no growth to date [**2-3**] Mini-BAL: RESPIRATORY CULTURE: ~1000/ML Commensal Respiratory Flora [**2-3**] MRSA screen: POSITIVE [**2-4**] C. Diff: Negative . STUDIES: [**1-28**] ECG: Sinus bradycardia. Borderline P-R interval prolongation. Right axis deviation. Modestly prolonged QTc interval. Possible anteroseptal myocardial infarction of indeterminate age. Compared to the previous tracing of [**2195-1-1**] there is no significant diagnostic change. . [**1-29**] CXR: 1) Trace right-sided pleural effusion. 2) Discontinuity of the cortex of the right humerus is concerning for right humeral fracture. Dr. [**Last Name (STitle) **] was notified of the results at 13:03 on [**2195-1-29**]. . [**1-30**] Right humerus film: Evidence for a slight change in alignment of 2fracture fragments. . [**1-31**] Upper extremity U/S: 1. No evidence of right upper extremity DVT. 2. Subcutaneous edema noted of the mid right upper extremity. . [**2-2**] Renal U/S: No hydronephrosis, stone or mass. The bladder is unremarkable. . [**2-3**] TTE: Marked right ventricular dilation with moderate global hypokinesis. Evidence of right ventricular pressure overload. Preserved left ventricular systolic function. Moderate tricuspid regurgitation. At least moderate pulmonary hypertension which is likely underestimated. . [**2-3**] CTA Chest: 1. No pulmonary embolism or acute aortic pathology. Incidental finding of a bovine aortic arch variant. 2. Small right pleural effusion with right basilar atelectasis. Nonspecific left basilar patchy opacities, could represent atelectasis, but infection cannot be excluded. 3. Bilateral enlarged axillary lymph nodes. Could be reactive, but given the size and multiplicity, recommend follow-up after resolution of the current hypotensive episode. 4. Small ascites. . [**2-3**] Head CT: No acute intracranial hemorrhage. . [**2-6**] TTE: Mild symmetric left ventricular hypertrophy with normal global and regional systolic function. Dilated right ventricle with mild global systolic dysfunction. Moderate diastolic LV dysfunction. Moderate pulmonary hypertension. Brief Hospital Course: 51yo F with h/o diastolic CHF, chronic renal insufficiency, HTN, DM, autonomic and peripheral neuropathy admitted with increasing LE edema, shortness of breath and weight gain consistent with acute on chronic exacerbation of renal failure and diastolic CHF ADMISSION COURSE: 1. Acute on chronic renal failure: Admitted with elevations in BUN/Cr above baseline, grossly volume overloaded and uremic with confusion and asterixis. She was started on Lasix gtt and Metolazone with poor response and eventually became anuric. An IR guided tunneled catheter was placed and HD was going to be initiated, however pt became more acutely unstable, obtunded, metabolic acidotic, and needed urgent transfer to MICU for initiation of CVVH. After the patient was diuresed with CVVH, she was transitioned to HD. The renal team followed the patient througout this admission. The patient will continue on HD until a peritoneal dialysis catheter is placed. . 2. Hypotension/bradycardia/mental status change: As stated after placement of HD catheter patient became unstable and was transferred to MICU. PE was ruled out by CTA. There was no evidence of anaphylactic or neurogenic etiologies. Random cortisol was normal. Cultures were sent and empiric coverage for pneumonia was started. Infectious workup was unrevealing. Antibiotics were discontinued after four days for no clinical evidence of pneumonia. Following extubation, the patient was actually significantly hypertensive. She was restarted on labetalol with hydralazine boluses for BP control, each of which are her outpatient meds. In terms of her obtundation, suspect [**1-13**] uremia with resultant nonanion gap metabolic acidosis and metabolic encephalopathy. Patient was also getting morphine po / IV for humeral fracture. Given renal failure would have decreased clearance and could have narcotics stacking. The patient was intubated for airway protection, then extubated on [**2-5**]. She received IV sodium bicarbonate for her severe metabolic acidosis. During this time she also received CVVH with rapid improvement in her BUN. Her mental status improved significantly from the time she was extubated to transfer to the floor. Finally, it was thought that her temporary sinus bradycardia could be related to Atenolol given 65% clearance from kidneys and was taking 800 mg po TID until the day of transfer. He was given IV glucagon for potential beta blocker toxicity. Again, all of these symptoms improved with the above management and prior to her transfer out of the MICU and back tot he floor. . 3. Acute on chronic diastolic heart failure: Known severe PA HTN due to diastolic failure on admission and volume overloaded. Started on diuresis as above. Was continued on Labetalol and Hydralazine, but ACEi and [**Last Name (un) **] were not started due to renal failure. Volume status improved with CVVH and HD. . 4. Neutropenia: Was admitted and WBC count troughed to 0.9 and ANC 490. Heme Onc was consulted and recommended starting Neupogen which pt received 2 doses of with good response, ANC going from 660 to 6400 overnight. Neuopogen was stopped. BM Bx was considered, however deferred to outpt setting as would not be useful after having received Neupogen. Of note, pt had had BM Bx to evaluate this problem in [**2183**] with Dr. [**Last Name (STitle) 410**], however no clear etiology was found. . 5. H/o labile blood pressures: Noted to be higher when laying down and low when standing up, secondary to autonomic dysfunction. Has been followed by Neurology. Was continued on Labetalol and Hydralazine. . 6. Anemia: Thought to be due to renal failure. Hct's were trended and pt received 2u PRBC's with good effect and stable Hct's afterwards. . 7. R humerus fracture: Pt with fall several days before admission, with plain films showing R humerus fracture. Ortho was consulted while pt admitted and gave recommendations to keep R arm non weight bearing while it healed. Pt worked with pt while admitted. 8. DM2: Pt continued on home Glargine 20u qhs and Humalog sliding scale. 9. Hypotension: As stated above, after Medications on Admission: 1. Labetalol 200 mg 4 tabs TID 2. Hydralazine 25 mg 1 tab TID --> Husband states she takes 25-50 mg as needed at bedtime, not really scheduled 3. Omeprazole 20 mg DAILY 4. Doxazosin 1 mg DAILY 5. Fluoxetine 20 mg DAILY 6. Hydrocodone-Acetaminophen 5-500 mg Tablet 1 Tablet Q12H prn pain 7. Lorazepam 1 mg HS prn anxiety or insomnia. 8. Loperamide 2 mg QHS prn diarrhea. 9. Hydroxyzine HCl 25 mg q6h prn pruritus 10. Camphor-Menthol 0.5-0.5 % Lotion QID prn pruritus. 11. Sevelamer HCl 400 mg 2 tabs TID W/MEALS 12. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day). 13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) Subcutaneous at bedtime. 14. Humalog 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 15. Metolazone 2.5mg [**Hospital1 **] (started [**1-23**]) Discharge Medications: 1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for agitation or insomnia. 6. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: per sliding scale Subcutaneous four times a day. . 7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for pain. 8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Fluoxetine 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*90 Tablet(s)* Refills:*0* 14. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*120 Tablet(s)* Refills:*0* 15. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Acute on chronic diastolic heart failure Acute on chronic renal failure Uremia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [**Hospital1 18**] with worsening fatigue, volume overload, and confusion and found to be in acute heart and renal failure. You stopped making urine and needed to have an emergent hemodialysis catheter placed and were taken to the ICU for dialysis. You had a large amount of volume removed and your clinical status improved. You will continue dilaysis as an outpatient. The following changes were made to your medication regimen: 1.Stop Metolazone 2. Stop Lasix 3. Decrease Labetalol to 200mg by mouth three times a day 4. Increase hydralazine to 50mg by mouth every 6 hours 5. Start Nephrocaps 1 tab by mouth once a day 6. Stop Doxazosin 7. Start Aspirin 325mg by mouth once a day 8. Continue Reglan 10mg by mouth four times a day with meals 9. Stop sevelamir 10. Stop Hydroxyzine Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2195-2-16**] 8:10 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2195-2-17**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2195-2-24**] 8:45 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-2-17**] 11:20 Completed by:[**2195-2-12**]

[ "276.2", "698.9", "288.00", "428.0", "337.1", "276.1", "403.91", "348.31", "416.8", "428.33", "250.60", "V45.11", "518.81", "584.9", "311", "585.6", "785.50", "285.21" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.04", "38.91", "38.95" ]

icd9pcs

[ [ [] ] ]

14630, 14713

8223, 12309

349, 514

14836, 14836

4672, 4672

15902, 16507

3034, 3238

13173, 14607

14734, 14815

12335, 13150

14984, 15879

5101, 5304

3253, 4653

2352, 2426

306, 311

542, 2238

7921, 8200

4688, 5085

5326, 7912

14851, 14960

2457, 2797

2260, 2332

2813, 3018

79,617

121,480

49883

Discharge summary

report

Admission Date: [**2184-9-9**] Discharge Date: [**2184-9-29**] Date of Birth: [**2126-9-28**] Sex: F Service: SURGERY Allergies: Bactrim / Penicillins Attending:[**First Name3 (LF) 32912**] Chief Complaint: Cholangiocarcinoma Major Surgical or Invasive Procedure: [**2184-9-9**]: 1. Exploratory laparoscopy. 2. Liver biopsy. 3. Exploratory laparotomy. 4. Pylorus sparing radical pancreatoduodenectomy with en bloc resection of portal vein. 5. Left internal jugular vein harvest, portal vein reconstruction with interposition bypass using left internal jugular vein 6. End-to-side ductal mucosa pancreatojejunostomy with 7-French Zimmon stent. 7. End-to-side hepaticojejunostomy after cholecystectomy. 8. Antecolic duodenojejunostomy. 9. Transgastric feeding jejunostomy. 10.Placement of gold fiducials. History of Present Illness: Ms. [**Known lastname 122**] is a 57-year-old woman who experienced a recent 30-pound weight loss over the last month. She has had no abdominal or back pain, denies diarrhea, diabetes, and notes only reduced appetite. She subsequently developed jaundice and pruritus, and presented for an ERCP, which demonstrated a 1.5-cm distal biliary stricture. Brushings were performed and negative for malignant cells. A 10 French 7 cm biliary stent has resolved her jaundice. Her serum CA [**91**]-9 is 63. A CT scan of her chest, abdomen and pelvis demonstrates no evidence of pulmonary or hepatic metastasis. She has a replaced left hepatic artery, with a dilated pancreatic and bile duct above what appears to be a heterogeneous and somewhat subtle mass in the uncinate portion of the pancreas immediately adjacent to the portal vein. The lesion measured 1.9 cm in diameter. The superior mesenteric artery is not involved. There is no teardrop malformation of the vein or evidence of encasement. The patient was evaluated by Dr. [**Last Name (STitle) **] in his [**Hospital 45932**] clinic for possible surgical resection of this mass. After discussion of all risks, benefits and possible outcomes, the patient was scheduled for elective Whipple resection. Past Medical History: -HTN -HLD -s/p hysterectomy -s/p 2 ectopic pregnancies (removal of ovaries and fallopian tubes bilaterally) Social History: The patient is originally from Montserrat in the Caribbean and immigrated to the US in [**2147**]. Has been married for 4 years, husband is a chef at [**Name (NI) 104207**]in NY. Had 1 child at age 16, died at 9 months of unknown cause. Currently living with sisters and mother in [**Name (NI) 2268**]. Works as nurse's assistant at Newbridge on the [**Hospital **] Rehab. -tobacco - never -EtOH - rare -illicits - never Family History: Mother has HTN, diabetes, and multiple myeloma. No other known familiy history of malignancy Physical Exam: Upon Discharge: VS: 98.5, 79, 106/75, 12, 100% RA GEN: NAD, AAO x 3 HEENT: Neck incision well healed CV: RRR PULM: CTAB ABD: Subcostal incision with moist-to-dry dressing. RLQ JP drain x 2 to bulb suction, site with DSD and c/d/i. LUQ GJ tube capped and site c/d/i. EXTR: Warm, LUE PICC dressing c/d/i Pertinent Results: [**2184-9-23**] 04:36AM BLOOD WBC-7.4 RBC-3.37* Hgb-8.6* Hct-26.8* MCV-80* MCH-25.5* MCHC-32.0 RDW-15.3 Plt Ct-546* [**2184-9-23**] 04:36AM BLOOD Glucose-124* UreaN-7 Creat-0.6 Na-139 K-4.5 Cl-104 HCO3-29 AnGap-11 [**2184-9-23**] 04:36AM BLOOD ALT-23 AST-37 AlkPhos-102 TotBili-0.3 [**2184-9-23**] 04:36AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.3 MICROBIOLOGY: [**2184-9-13**] 9:15 pm URINE Source: Catheter. **FINAL REPORT [**2184-9-15**]** URINE CULTURE (Final [**2184-9-15**]): PRESUMPTIVE GARDNERELLA VAGINALIS. >100,000 ORGANISMS/ML.. ANAEROBIC CULTURE (Final [**2184-9-14**]): Test performed only on suprapubic and kidney aspirates received in a syringe. SPECIMEN UNACCEPTABLE FOR ANAEROBES. TEST CANCELLED, PATIENT CREDITED. [**2184-9-21**] 8:59 am BLOOD CULTURE Source: Line-PICC. **FINAL REPORT [**2184-9-27**]** Blood Culture, Routine (Final [**2184-9-27**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final [**2184-9-22**]): Reported to and read back by [**First Name5 (NamePattern1) 11593**] [**Last Name (NamePattern1) **] @ 5:10A [**2184-9-22**]. GRAM NEGATIVE RODS. [**2184-9-21**] 10:51 pm URINE Source: CVS. **FINAL REPORT [**2184-9-23**]** URINE CULTURE (Final [**2184-9-23**]): NO GROWTH. [**2184-9-22**] 7:30 am BLOOD CULTURE **FINAL REPORT [**2184-9-28**]** Blood Culture, Routine (Final [**2184-9-28**]): NO GROWTH Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 104208**],[**Known firstname **] E [**2126-9-28**] 57 Female [**-1/3539**] [**Numeric Identifier 104209**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. CEDERROTH, DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/rate SPECIMEN SUBMITTED: FS liver biopsy left lobe, pancreatic and bile duct margins, common hepatic artery, gallbladder, whipple specimen. Procedure date Tissue received Report Date Diagnosed by [**2184-9-9**] [**2184-9-9**] [**2184-9-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mn???????????? Previous biopsies: [**Numeric Identifier 104210**] MUCOSAL BIOPSIES, DISTAL ESOPHAGUS [**Numeric Identifier 104211**] (Not on file) [**Numeric Identifier 104212**] (Not on file) [**Numeric Identifier 104213**] (Not on file) DIAGNOSIS: I. Left lobe, liver biopsy (A): Benign bile ductular proliferation consistent with microhamartoma; no carcinoma seen. II. Gallbladder, cholecystectomy (C-D): A. Chronic cholecystitis. B. One unremarkable lymph node. III. Pancreatic margin, pancreatoduodenectomy (E-G): Pancreatic parenchyma with no carcinoma seen. Incidental low grade pancreatic intraepithelial neoplasia (Pan-In1a). IV. Bile duct margin, pancreatoduodenectomy (H-L): Bile duct segment with acute and chronic inflammation; no carcinoma seen. V. Pancreatic head and duodenum, pancreatoduodenectomy (M-AI): A. Adenocarcinoma of the pancreas, moderately differentiated, with invasion of the duodenal wall (pT3); see synoptic report. B. Two of twenty-six regional lymph nodes with involvement by carcinoma ([**3-28**]-pN1). C. Lymphovascular and perineural invasion are present. D. Bile duct segment with reactive changes commonly seen in association with in situ metal stents. VI. Lymph node, common hepatic artery (AI-AK). One lymph node with no carcinoma seen (0/1). [**2184-9-21**] ABD CT: IMPRESSION: 1. No new fluid collection or abscess. 2. Edematous pancreaticobiliary limb of the jejunum within the region of the porta hepatis with surrounding fluid and edematous efferent gastrojejunostomy are both unchanged. 3. Marked attenuation of the left renal vein anterior to the aorta, likely post-surgical edema. This is associated with perirenal collaterals emptying into the splenic vein. 4. Stable narrowing of the main portal vein near the portal venous confluence related to post-surgical changes. 5. The previously seen small pocket of air and debris noted posterosuperior to the porta hepatis now just contains air. No evidence of collection. 6. Resolved left pleural effusion with bibasilar atelectasis. 7. Small foci of air tracking from the left incision site to the peritoneum but not within the abdomen. 8. Increased intra-abdominal air surrounding the anterior abdominal drain. Brief Hospital Course: The patient with newly diagnosed pancreatic head mass was admitted to the HPB Surgical Service for elective Whipple procedure. On [**2184-9-9**], the patient underwent exploratory laparotomy with liver biopsy, pylorus sparing radical pancreatoduodenectomy with en bloc resection of portal vein, internal jugular vein interposition graft, transgastric feeding jejunostomy and placement of gold fiducials, which went well without complication (reader referred to the Operative Note for details). The EBL was ~ 450 cc. Post operatively, patient was transferred in SICU intubated for observation. She was extubated on POD # 1 without difficulties and on POD # 3 she was transferred on the floor NPO, on IV fluids, with a foley catheter, and epidural catheter for pain control. The patient was hemodynamically stable. Neuro: The patient received Hydromorphone/Bupivacaine via epidural. Epidural was split on POD # 3 and Dilaudid PCA was added for pain control. The epidural catheter was removed on POD # 4, and PCA was discontinued on POD # 4. The patient was started on Roxicet via with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI: Post-operatively, the patient was made NPO with IV fluids. The patient was started on TF on POD # 5, and her diet was advanced to clears on POD # 6. The JPs amylase was sent on POD # 5 and came back high in JP # 2. The patient started to spike low grade fevers and her diet was changed to NPO on POD # 10. The patient was continued on TF via J-tube and her G-tube was capped. G-tube was opened only if patient felt nausea. Prior discharge patient's diet was advanced to clears. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient spiked fever on POD # 4, her blood and urine cultures were sent. Urine cultures were positive for Gardnerella Vaginalis and she was started on Flagyl 500 mg [**Hospital1 **]. The blood cultures were negative. The patient was continued to have low grade fevers and on POD # 12, her blood and urine cultures were sent again. Blood cultures were positive for E.Coli and patient was started on IV Vancomycin and Cefepime. Urine cultures were negative. The patient's temperature and WBC returned within normal limits after initiation of antibiotics. ID was consulted to determine duration of antibiotics, and ID recommended d/c Vancomycin and continue Ceftriaxone for 14 days total. Her last antibiotics dose would be on [**2184-10-8**]. Wound care: The patient wound was found to have a leak on POD # 6, her wound was open laterally from both sides and started with moist-to-dry DSD packing. On POD # 9, patient's wound was open and VAC was applied. The average daily output from the wound was 100-200 cc. The wound VAC was taken down on POD # 12, and moist-to-dry dressing packing resumed. The wound VAC was restarted on POD # 14. Upon discharge patient's wound VAC was taken down and moist-to-dry dressing was applied. The patient will continue on wound VAC in Rehab until follow up with Dr. [**Last Name (STitle) **] on [**2184-10-8**]. Endocrine: Post operatively patient was started on sliding scale insulin and finger stick QID. Finger stick was slightly elevated and patient required minimal amount of insulin. After starting TF, patient's blood glucose increased and [**Last Name (un) **] was called for consult. [**Last Name (un) **] continued to see patient on daily basis and their recommendations were followed. Glucometer and insulin teaching were done during admission. Hematology: The patient's post op HCT was 34.7 and was continued to decrease during recovery. She was transfused with 1 unit of pRBC for HCT 28.8. Her HCT remained stable low, and upon discharge was 26.8. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; Aspirin was started on POD # 3. Patient was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a clear liquids diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Amlodipine 10 mg once a day, aspirin 81 mg once a day. The patient was on atenolol, but due to normal blood pressure and bradycardia, the atenolol was held during recent hospitalization Discharge Medications: 1. Aspirin 325 mg PO DAILY Please give PO, NOT through JTube. Thank you. 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. CeftriaXONE 1 gm IV Q24H [**10-8**] - last day of antibiotics 4. Famotidine 20 mg PO Q12H 5. 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. 6. Glargine 6 Units Bedtime Insulin SC Sliding Scale using REG Insulin 7. Metoclopramide 10 mg PO QIDACHS 8. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: 1. Ductal adenocarcinoma G2pT3pN1pMX 2. Chronic cholecystitis 3. Urinary tract infection 4. Sepsis 5. Grade B pancreatic fistula Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [**Hospital1 18**] after elective Whipple procedure and portal vein reconstruction. You recovery was compicated by pancreatic fistula and infection. Currently you doing well and are now safe to be discharge in rehab to complete your recovery with the following instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-10**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: You have wound VAC applied to your subcostal incision. [**Month/Year (2) 269**] nurses will change dressing every 72 hrs or prn. . JP Drain x 2 Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [**Month/Year (2) 269**] nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . GJ-tube care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Wash the area gently with warm, soapy water or 1/2 strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . PICC Line: *Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is significantly soiled for further instructions. Followup Instructions: Department: SURGICAL SPECIALTIES When: THURSDAY [**2184-10-7**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 104214**], MD [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2184-9-29**]

[ "V10.09", "401.9", "038.42", "575.12", "157.0", "272.4", "560.1", "599.0", "V12.54", "251.3", "998.6", "196.2", "759.6", "577.8", "995.91", "E878.2", "V88.11" ]

icd9cm

[ [ [] ] ]

[ "51.22", "50.14", "39.56", "96.6", "52.7", "46.39", "51.37", "03.90", "38.97" ]

icd9pcs

[ [ [] ] ]

14085, 14179

8560, 11481

300, 841

14352, 14352

3147, 8537

17552, 17911

2715, 2810

13519, 14062

14200, 14331

13308, 13496

14503, 15404

15419, 17529

2825, 2825

242, 262

11493, 13282

2841, 3128

869, 2128

14367, 14479

2150, 2260

2276, 2699

10,757

105,778

2539

Discharge summary

report

Admission Date: [**2180-2-24**] Discharge Date: [**2180-2-26**] Service: MEDICINE Allergies: Diovan Attending:[**First Name3 (LF) 2704**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Right- and left- heart catheterization: 1. Coronary arteries are normal. 2. Moderate aortic stenosis. 3. Severe diastolic ventricular dysfunction. 4. Severe systemic hypetension. . History of Present Illness: 88 yo [**Location 7972**] F with hypertension, hypercholesterolemia, known AAA (4.4x4.1cm), AV nodal disease s/p pacer placement, PVD and AS with valve area 0.81 who presents after diagnostic right and left heart cath with a hypotensive episode. . The patient presented today from home for diagnostic right and left heart cath. Prior to the procedure, the patient was noted to be hypertensive to 145/110. She received 5mg IV lopressor. During the procedure, the patient was noted to be hypertensive to >200/100. She received heparin 1000U, nitroglycerin gtt at 40mcg/min and then 80mcg/min during the procedure with some bp response to 180/90. In the post-cath holding area after the procedure, the patient was again hypertensive to 224/94. She received hydralazine 10mg IV. Approximately 3 hours after the procedure at 1:15PM the patient complained of left leg pain described as cramping, contralateral to her groin access site on the right. She also complained of nausea and vomiting. She was noted at this time to have over 2L urine output in her foley bag. Her BP was 70/palp from 162/60. She received NS bolus of 1L, zofran 4mg IV, dopamine at 5 and then 12mcg/kg/min with improvement in her bp to 108/52. She was noted to have no hematoma or at her right groin site and dopplerable pulses in the distal extremities bilaterally. . On presentation to the ICU, the patient was noted to have a bp 141/74 off of dopamine. She complained of some mild epigastric discomfort. She denies experiencing this pain in the past however notes in OMR and verbal report from other physicians describes frequent complaints of abdominal pain. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. She endorses DOE after 3 flights of stairs in a recent cardiovascular clinic note though denies this currently. ROS otherwise negative in detail with the exception of some calf cramping occurring with activity and relieved with rest. . Past Medical History: Hypertension Hyperlipidemia Aortic stenosis AV nodal disease s/p pacemaker placement in [**1-/2180**] AAA (4.3cm) and ascending thoracic aneurysm (3.5cm) PVD s/p bilateral lower extremity revascularization Right proximal popliteal aneurysm S/p left arterectomy PFA [**2-/2177**], R SFA angioplasty [**3-/2177**] S/p Wharthin gland excision Neurocystercircosis s/p VP shunt >14years ago for hydrocephalus . Social History: Lives with husband and daughter. [**Name (NI) **] tobacco, EtOH or drug use. Family History: No family history of premature CAD or sudden death. Physical Exam: VS: 78 101/47 12 100% facemask Gen: Elderly woman. NAD. CV: Loud AS murmur. Normal rhythm. Pulm: CTA bilaterally. Abd: Soft, nontender, no masses. Ext: No edema. No palpable pulses on the distal right and no palpable dorsalis pedis on the left. Palpable posterior tibial pulse on the left. . Pertinent Results: [**2180-2-24**] 04:08PM WBC-11.8*# RBC-3.96* HGB-11.6* HCT-35.8* MCV-91 MCH-29.3 MCHC-32.4 RDW-13.4 [**2180-2-24**] 04:08PM PLT COUNT-142* [**2180-2-24**] 04:08PM PT-12.8 PTT-25.4 INR(PT)-1.1 [**2180-2-24**] 04:08PM GLUCOSE-104 UREA N-14 CREAT-0.7 SODIUM-141 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 [**2180-2-24**] 04:08PM CALCIUM-9.3 PHOSPHATE-4.1 MAGNESIUM-1.9 [**2180-2-24**] 09:54AM TYPE-ART PO2-225* PCO2-54* PH-7.34* TOTAL CO2-30 BASE XS-2 INTUBATED-NOT INTUBA . . Right- and Left- Heart Catheterization: 1. Selective coronary angiography revealed a right dominant system with patent LMCA. The LAD had no demonstrable stenosis. LCX was non-dominant with no significant obstructive disease. The RCA was dominant without critical lesions. 2. Left ventriculography showed preserved ejection fraction of 55% and normal wall motion with small cavity suggestive of diastolic dysfunction. 3. Abdominal aortography showed an aneurysm of about 4 cm in size. 4. Hemodynamic assessment revealed markedly elevated systemic pressures of above 200 mm Hg. There was a 30 mm Hg gradient across the aortic valve with calculated valve are of 0.8 cm2 which was unchanged from prior exam. Left and right sided filling pressures were normal and cardiac index was preserved. Administration of intravenous nitroglycerine did not increase PCWP and decreased systemic blood pressure to 185 mm Hg with brisk diuresis in the lab. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Moderate aortic stenosis. 3. Severe diastolic ventricular dysfunction. 4. Severe systemic hypetension. . . ECG ([**2180-2-24**]): Atrial pacing. Left axis deviation. Left anterior fascicular block. Non-specific lateral and anterolateral ST-T wave changes. Compared to the previous tracing ventricular pacing is no longer present. . . 2D-[**Year (4 digits) **] ([**2180-2-17**]): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. 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. Trivial 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 [**2179-12-16**], aortic gradients and pulmonary pressures are lower but there is still significant aortic stenosis . P-MIBI ([**2178-2-16**]): No anginal symptoms or ECG changes from baseline. 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and function. EF 66%. . CT abd/pelvis ([**2179-12-21**]): 1. 44 x 41 mm abdominal aortic aneurysm as described above with extensive atherosclerosis in the branches of the abdominal aorta as well as ectasia of the iliac arteries. 2. Bilateral renal cortical thinning and bilateral renal hypodensities likely represent cysts. 3. Uterine calcifications likely represent fibroids. . Brief Hospital Course: The patient is an 88-year-old [**Location 7972**] woman with hypertension, hypercholesterolemia, known AAA (4.4x4.1cm), AV nodal disease s/p pacemaker placement, PVD and AS with valve area 0.81, who presents after diagnostic right- and left- heart catheterization with a hypotensive episode in the setting of multiple antihypertensive agents, 2 liter autodiuresis, and severe abdominal pain. . #. Hypotensive episode - The patient experienced hypotension post-catheterization, likely from a combination of receiving multiple anti-hypertensives within a short amount of time (metoprolol, nitroglycerin, and hydralazine), with a large-volume auto-diuresis, and likely a component of vasovagal response in the setting of severe abdominal pain. She received approx 1.5L of volume resuscitation and her anti-hypertensives were held. She did well clinically thereafter, with good response in her blood pressure. Her beta-blocker was resumed at home dose on [**2180-2-26**], which she tolerated well, and she was started on a low-dose ACE-inhibitor as well, which she also tolerated well. Her HCTZ was held and was not restarted. She was discharged on [**2180-2-26**] with follow-up planned with Dr. [**First Name (STitle) **] in 2 weeks. . #. Coronary Artery Disease (ischemia) - The patient had no significant CAD on her left-heart catheterization, and she had no signs of active ischemia. She was maintained on her home baby aspirin for primary prophylaxis. . #. Pump - The patient has a preserved EF on her most recent TTE, with no signs of CHF currenty. She is pre-load dependent given her valvular disease. . #. Rhythm - The patient has a history of high-degree AV nodal disease s/p recent pacemaker placement. She currently has a paced rhythm. . #. Valves - The patient has known severe AS with valve area 0.8. She will have outpatient follow-up with Dr. [**First Name (STitle) **] for further management of her valvular disease. . #. Hypertension - The patient's home anti-hypertensives, HCTZ and metoprolol, were initially held given her hypotensive episode above. The metoprolol was re-instituted as the patient's blood pressures improved, and she was also started on an ACE-inhibitor prior to discharge. Her HCTZ was discontinued. . #. Hyperlipidemia - The patient was continued on her home cholestyramine and Lescol. . #. Vascular Aneurysms - The patient has known AAA (4.3cm), ascending thoracic aneurysm (3.5cm), and right proximal popliteal aneurysm, all of which are followed as an outpatient. . #. Peripheral Vascular Disease - The patient has PVD s/p bilateral lower extremity revascularization. She was continued on her home baby aspirin. . Medications on Admission: Aspirin 81 mg Daily Docusate Sodium 100 mg Twice daily Fluticasone 50 mcg/Actuation Daily Hydrochlorothiazide 25 mg Daily Imipramine HCl 10 mg QHS Metoprolol Tartrate 25 mg Twice daily Oxycodone 5 mg Twice daily Protonix 40 mg Daily Lescol XL 80 mg QHS Cholestyramine One tsp twice a day Meclizine 12.5 mg twice daily Tylenol Arthritis Pain 650 mg twice a day as needed . Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Fluticasone 50 mcg/Actuation Disk with Device Sig: One (1) puff Inhalation once a day. 4. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Lescol XL 80 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 9. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 10. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 12. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hypotensive episode Secondary Diagnosis: - high-degree AV nodal disease s/p permanent pacemaker - severe Aortic Stenosis (valve area 0.8) - hypertension - hyperlipidemia . Discharge Condition: afebrile, vital signs stable, tolerating anti-hypertensive medications. Discharge Instructions: You were admitted to [**Hospital1 18**] for diagnostic right and left heart catheterization, which was complicated by hypotension in the setting of receiving many medications during the catheterization. You were treated with IV fluid boluses for hypotension, and your blood pressure normalized by [**2180-2-26**]. You were restarted on your home metoprolol, which you tolerated well, and you were then started on a new medication, lisinopril, which you also tolerated well. You HCTZ was held and you should stop taking this medication. . You should continue to take your medications as prescribed below. You should call the office of Dr. [**First Name (STitle) **], your cardiologist, to schedule an appointment in 2 weeks time. . If you experience any chest pain, shortness of breath, lightheadedness, or feelings of fainting, you should call your doctor or return to the Emergency Room for evaluation. . Followup Instructions: You should call Dr. [**First Name (STitle) **], your cardiologist, at [**Telephone/Fax (1) 920**] to schedule an appointment to see him within 2 weeks. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2180-3-2**] 10:15 Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2180-3-23**] 4:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2180-4-12**] 2:30 .

[ "441.4", "401.9", "V45.01", "530.81", "458.29", "E942.6", "272.0", "424.1" ]

icd9cm

[ [ [] ] ]

[ "88.42", "88.56", "88.53", "37.23" ]

icd9pcs

[ [ [] ] ]

10785, 10791

6577, 9231

226, 409

11029, 11103

3384, 4818

12057, 12649

3002, 3056

9654, 10762

10812, 10812

9257, 9631

4835, 6554

11127, 12034

3071, 3365

175, 188

437, 2462

10875, 11008

10831, 10854

2484, 2892

2908, 2986

83,335

148,255

31194

Discharge summary

report

Admission Date: [**2170-12-27**] Discharge Date: [**2171-1-3**] Date of Birth: [**2095-4-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Neck pain, syncope Major Surgical or Invasive Procedure: Central veinous line, atrial line, Rectal biopsy History of Present Illness: 75 yo M with a history of gastritis, BPH and lung nodules presenting with neck pain and syncopal events. . The patient initially presented 2 days prior to admission to his PCP's office with complaints of midscapular pain radiating into his LUE for 2 weeks. He had C-spine x-ray revealing cervical spondylosis without other significant abnormality. EKG, CXR, cardiac enzymes and LFT's (for referred pain) at that time were negative/normal. . The patient re-presented to his primary care doctors office on the day of admission. At that visit he reported sudden worsening of upper back/neck pain while urinating this morning. This symptom was followed by a syncopal event thought to cause loss of conscioussness for 10 minutes. He was unsure of trauma occurring due to the fall. While in clinic he complained of chest pain, severe neck pain radiating into his left upper extremity. He also noted some leg weakness and difficulty with walking. On exam in clinic he was noted to have torticollis of the neck with tenderness of the c-spine on palpation. He had unspecified difficulty standing and walking. EKG in clinic revealed normal sinus rhythm. . He currently describes the pain as stabbing and twisting. The pain is positional in nature. With regard to his syncopal episodes, the patient denies preceding chest pain, shortness of breath, nausea, vomiting, incontinence, tongue biting, blurry vision, difficulty with speech or dyscoordination. . In the ED 98.5 76 127/81 14 98% RA. The patient was guaiac negative with poor stool sampling, due to no stool in the vault. He received aspirin 325mg and morphine 4mg IV. . ROS: Otherwise negative in detail. Past Medical History: - Gastritis, dyspepsia - NAFLD - Gout - BPH s/p TURP. - Reactive airway disease - Lung nodule - Renal cyst - Hypertriglyceridemia - Hemorrhoids Social History: He is not a smoker or drinker. He denies any drug use. He is married and lives with wife. [**Name (NI) **] has seven children. He denies any history of domestic violence or sexual abuse. Originally from [**Country 3992**], moved to the US in [**2155**]. Family History: Brother with asthma. Parents died in his youth, unknown medical history. Negative for diabetes, cancer or CAD. Physical Exam: 100.4 89 138/80 18 98% RA 70.2kg Gen: Uncomfortable appearing. HEENT: PERRL. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Soft, nontender. Ext: No edema. Neuro: RUE [**4-14**] at the deltoids and triceps and extension at the wrists and fingers. 5/5 strength in the left upper extremity. Endorses numbness in the right hand. Pertinent Results: EKG ([**2170-12-27**]): Sinus rhythm at a rate of 78. Normal axis and intervals. No acute ST or T wave changes. . Micro: None. . Imaging: CXR ([**2170-12-27**]): No acute intrathoracic process. . CT C-spine non contrast ([**2170-12-27**]): 1. Multilevel degenerative changes as described above with no evidence of an acute fracture. 2. A 5-mm low-attenuation focus in the right lobe of the thyroid gland. Correlate with history and biochemical profile. If indicated, the lesion can be assessed further with a thyroid ultrasound. . CT head ([**2170-12-27**]): Age-related cerebral atrophy and periventricular ischemia. No acute intracranial process. Incidental extra-axial posterior fossa (arachnoid) cyst. . CTA ([**2170-12-27**]): 1. No pulmonary embolism or aortic dissection. Coronary arteries arise from the normal expected anatomical location. 2. Stable appearance to the scattered pulmonary nodules, unchanged since the CT of [**2170-2-12**]. A followup chest CT in one year is recommended to ensure continued stability. 3. Solid exophytic lesion at the upper pole of the left kidney is unchanged since the CT of [**2170-2-12**], and a non-emergent renal ultrasound would be helpful for further assessment as recommended on multiple prior chest CTs. . Right shoulder X-ray ([**2170-12-27**]): No fracture or dislocation. Probable calcific tendinitis. . MRI C-spine ([**2170-12-27**]): Alignment of the cervical spine is normal. The long TR images demonstrate loss of signal on the intervertebral discs indicating degenerative disc disease. The spinal cord is largely obscured by pulsation artifact, but no intrinsic abnormalities are detected. Axial imaging at C2-3 reveals no significant abnormalities. There is a midline disc protrusion at C3-4. This indents the anterior surface of the spinal cord. Uncovertebral osteophyte formation produces bilateral neural foraminal narrowing that is moderate on both sides. There appears to be hypertrophy of the posterior longitudinal ligament behind the body of C4. This, along with a C4-5 disc protrusion, produces flattening of the anterior surface of the spinal cord. The neural foramina appear normal. At C5-6, there is a mild bulge of the intervertebral disc, poorly characterized due to motion artifact. The neural foramina appear normal. At C6-7, uncovertebral osteophytes, larger on the right than left, narrow the lateral portion of the spinal canal without contacting the spinal cord. There is bilateral neural foraminal narrowing. The severity is difficult to assess due to overlying artifact, but it appears to be at least moderate in degree. The C7-T1 level appears normal. CONCLUSION: Mild changes of degenerative disc disease as described above. The neural foramina are poorly characterized due to motion artifact. . [**2170-12-27**] 7:40 pm BLOOD CULTURE **FINAL REPORT [**2170-12-30**]** Blood Culture, Routine (Final [**2170-12-30**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ========== TTE ([**2170-12-31**]) ========== The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic regurgitation. Mild dilatation of the ascending aorta. . [**2170-12-29**] 09:59PM BLOOD Hct-34.1* [**2170-12-30**] 08:10AM BLOOD WBC-5.3 RBC-2.79*# Hgb-7.2*# Hct-21.2*# MCV-76* MCH-26.0* MCHC-34.2 RDW-13.9 Plt Ct-194 [**2170-12-30**] 11:16AM BLOOD WBC-6.2 RBC-2.60* Hgb-6.8* Hct-19.5* MCV-75* MCH-26.3* MCHC-35.2* RDW-14.3 Plt Ct-201 [**2170-12-30**] 02:52PM BLOOD WBC-6.7 RBC-3.35*# Hgb-9.5*# Hct-25.7*# MCV-77* MCH-28.5 MCHC-37.1* RDW-14.8 Plt Ct-174 [**2170-12-30**] 05:38PM BLOOD Hct-29.6* Brief Hospital Course: 75 year old man with history of BPH, admitted to the hospital after syncopal episode after a recent transrectal prostate biopsy, with hospital course complicated by gram negative bacteremia and rectal hemorrhage, with severe cervical polyradiculopathy affecting the right arm. Below is a problem based summary of the hospital course. #. SYNCOPE: Event ocurred with micturition and was highly suggestive of vagal episode. Echocardiogram was normal and no arrhythmias were observed during this admission. Cervical vasculature was unremarkable, and given patients infection and hypovolemia (see below) in setting of increased intrathoracic pressure (micturition in setting of BPH and prostate inflammation post biopsy) vasovagal syncope is the most likely etiology. #. POLYRADICULOPATHY OF C3-C7: For full details please see results section. Briefly, CT C spine revealed diffuse cervical disk disease, which was confirmed on MRI. Ortho-spine team, neurology and pain teams consulted. No surgical intervention recommended at this time, however close follow up will be needed. Patient instructed to wear soft collar for 2 weeks and during sleep from now on. Regarding his pain, this was managed with topical lidocaine patch, Gabapentin and oxycontin / oxycodone. Please see medications section for details. #. E. COLI BACTEREMIA: During initial evaluation, patient developed leukocytosis, fever and blood loss from biopsy site, presumably the route of entry. He required transfer to MICU for stabilization and blood transfusions (see below). Blood cultures revealed E. Coli with sensitivity to cephalosporins. Ceftriaxone was administered with goal of 14 days of therapy. Midline venous line placed on right arm, VNA and infusion companies to help finish therapy at home. #. RECTAL HEMORRHAGE: As above, patient developed profound anemia along with a tender, boggy prostate. Patient required 4 units of PRBC and general surgery applied rectal packing to control hemorrhage. Patient improved and at time of discharge was not having any rectal blood loss or rectal pain. Suspect prior therapy with rectal steroids may have weakened mucosa and predisposed to rectal bleeding. Would favor not continuing to treat hemorrhoids with these agents. # Thyroid nodule. Incidentally seen on CT imaging. Recent TSH normal. Outpatient, elective throid ultrasound. # Lung nodule. Incidentally seen on CT imaging. Repeat outpatient CT in 3 months. # Exophytic left renal lesion. Unchanged since [**2170-2-9**]. Outpatient evaluation with renal ultrasound. # Dyspepsia. Continued home PPI. # reactive airway disease. Continued home albuterol, fluticasone-salmeterol and fluticasone nasal spray. #. Hypertriglyceridemia. Continued home gemfibrozil. #. Gout. Continued home allopurinol. #. BPH. Continued home finasteride. . # acute renal failure: Initial Cr 1.4 on admission, likely secondary to hypovolemia and pre-renal azotemia. At baseline at time of discharge. # Contact: Wife, [**Telephone/Fax (1) 73628**], [**Telephone/Fax (1) 73629**] # Code: FULL, addressed with patient on [**2170-12-29**] with vietnamese interpreter Medications on Admission: - Albuterol inhaler 2 puffs q4-6 hours PRN - Allopurinol 300mg Daily - Colchicine 0.6mg PRN, rarely taking - Finasteride 5mg Daily - Fluticasone 50mcg nasal spray - Fluticasone-Salmeterol 250-50 1 puff twice daily - Hydrocortisone acetate (Anusol) suppository 25mg QHS - Omeprazole 40mg Daily - Tramadol 50mg every 6 hours as needed - Zolpidem 10mg QHS PRN - Gemfibrozil 600mg twice daily Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY: POST BIOPSY HEMORRHAGE CERVICAL RADICULOPATHY E. COLI BACTEREMIA Discharge Condition: HEMODYNAMICALLY STABLE, AFEBRILE Discharge Instructions: You were admitted to the hospital after you fainted. During your admission, we found a blood stream infection and you suffered bleeding from your rectum. We started antibiotics and you have improved. We also were able to diagnose a condition of the nerves in your neck that is causing most of your symptoms. We have started you on pain medications and although your pain is still present it has improved. Please take all medications as prescribed and keep all doctors [**Name5 (PTitle) 4314**]. If you experience any fevers, chills, nausea, vomiting or any other symptom that concerns you, please seek medical attention. Followup Instructions: Please schedule a follow up appointment with your primary care physician [**Last Name (NamePattern4) **] 1 week. Please follow up in the pain clinic ([**Telephone/Fax (1) 30702**] At [**Location (un) 73630**], [**Apartment Address(1) **]. You will need a referral from your primary care doctor. Please follow up with General [**Hospital 878**] Clinic ([**Doctor Last Name **] / [**Hospital **] Clinic) in 2 months ([**Telephone/Fax (1) 5088**].

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icd9cm

[ [ [] ] ]

[ "48.23", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

11449, 11507

7886, 11010

333, 383

11625, 11660

3014, 7863

12331, 12781

2523, 2635

11528, 11604

11036, 11426

11684, 12308

2650, 2995

275, 295

411, 2065

2087, 2232

2248, 2507

12,380

153,218

14720

Discharge summary

report

Admission Date: [**2135-6-17**] Discharge Date: [**2135-6-29**] Date of Birth: [**2101-1-8**] Sex: M Service: [**Doctor Last Name **] CHIEF COMPLAINT: Shortness of breath HISTORY OF PRESENT ILLNESS: This is a 34 year old man with a history of alcohol and cocaine abuse, psychosis who presented to the Emergency Department with shortness of breath. The patient stated that he had been feeling poorly with shortness of breath for one and a half weeks prior to admission. Also he noted a cough that had become increasingly purulent. He believes this all started with a drinking binge and cocaine binge. He disappeared from home for one to two days and when he returned he had a fever, cough and chills. After initial improvement in his symptoms they then returned and became progressively worse. He developed pleuritic chest pain, anorexia, and he went to the Emergency Room for evaluation. In the Emergency Room he had worsening shortness of breath requiring intubation. He received Ceftriaxone and Azithromycin intravenously for probable community acquired pneumonia. Chest x-ray demonstrated left upper lobe consolidation consistent with pneumonia. The patient was admitted to the Medicine Intensive Care Unit for further evaluation. PAST MEDICAL HISTORY: 1. Psychosis; 2. Mania; 3. History of suicide attempts; 4. Status post treatment of INH for a positive PPD; 5. Human immunodeficiency virus negative in the past, unclear of time; 6. History of alcohol abuse; 7. History of cocaine abuse. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Depakote 1 gm q.h.s.; 2. Divalproex 500 mg p.o. q.h.s.; 3. ? Thiothixene 10 mg p.o. q.h.s.; 4. Zyprexa 20 mg p.o. q.h.s.; 5. Bupropion 100 mg p.o. b.i.d.; 6. Remeron 0.5 mg; 7. ? Lithium. SOCIAL HISTORY: The patient lives with his partner in [**Location (un) 538**]. He has a long alcohol history and says his last drink was ten days ago. He does smoke and unclear number of packs per day, history of intranasal cocaine use, no known history of intravenous drug use. The patient does not have a primary care doctor who he sees on a regular basis. He has no known family in the area. FAMILY HISTORY: Unknown. PHYSICAL EXAMINATION: Temperature 101, 120, 128/80, 34, 88% on room air. In general he was originally speaking in full sentences with no use of accessory muscles or dyspnea. Head, eyes, ears, nose and throat, pupils equal, round, and reactive to light and accommodation. Extraocular movements intact. Neck supple. Chest, left-sided rhonchi, wheezes and crackles with egophony. Cor, tachycardiac with no murmurs, rubs or gallops. Abdomen, soft, nontender, no positive bowel sounds. Lower extremities, no edema. LABORATORY DATA: White blood cell count 42.5, hematocrit 37.9, platelets 312. Sodium 129, potassium 4.8, BUN 130, creatinine 3.0. ALT 25, AST 89, alkaline phosphatase 143, total bilirubin 1.1, creatinine kinase 37 to 46, troponin 0.6 to 0.5, acetone negative, valproate level less than 1, lithium level less than 0.2, serum tox negative for alcohol, urine tox negative. Arterial blood gases 7.23/40/102, lactate 1.8. Electrocardiogram was sinus tachycardia with ST elevations in V2 and V3. No change from [**2135-4-2**]. HOSPITAL COURSE: 1. Pneumonia - Chest x-ray on admission demonstrated consolidation of left upper lobe. Chest computerized tomography scan revealed extensive consolidation of left upper lobe with gas products worrisome for cavitary necrosis. In the Medicine Intensive Care Unit he was started on steroids for hypotension and presumed sepsis. Necroscopy was performed which revealed bloody secretions aspirated from the trachea. Right main stem bronchus and right VL. VL performed from the left lung segment. No frank hemoptysis or endobronchial lesions were noted. Culture data revealed Methicillin-sensitive Staphylococcus aureus. The patient was initially held on Ceftriaxone and Erythromycin. Levaquin was added and then the patient was changed to Clindamycin upon return of sensitivities. Blood cultures were negative except for one of four bottles with Staphylococcus coag negative which was thought to be contamination. The patient was extubated on hospital day #5. He was then transferred to the floor on hospital day #6 for further management. The patient did have occasional temperatures which initially were started on Oxacillin. Pulmonary consult was obtained who recommended discontinuing the Oxacillin and following. The patient had repeat computerized tomography scan of the chest which revealed a large cavitary lesion, 10 by 6 left lung as well spinal anesthesia left-sided pleural effusion with enhancement on computerized tomography scan. Initially this was observed for one day. However, the patient then spiked a temperature to 101.6. Thoracentesis was advised, however, the patient declined. He wished to seek a second opinion at another institution prior to implementing this. He will be discharged on Clindamycin to complete a six week course and plan for hopeful thoracentesis at another institution. 2. Sepsis - The patient had hypotension following his pneumonia. This was felt to be secondary to his Staphylococcus aureus. Blood cultures did remain positive. The patient did respond well with antibiotic course. The patient did have cortisol performed in the Medicine Intensive Care Unit which was low. The patient was felt to have adrenal insufficiency in the setting of sepsis and was treated with a course of Hydrocortisone. Blood pressure was stable following this course and on the floor. 3. Anemia - The patient had an episode of hemoptysis following intubation. No identifiable lesion was seen on bronchoscopy. The patient's blood counts slightly decreased during his hospital course and was 26 on the day of discharge. He did require a couple of units of packed red blood cells during his admission. Titers revealed elevated ferritin but low iron. It was felt the patient did have an iron deficiency anemia. 4. Acute renal failure - The patient came in with a creatinine of 3, likely secondary to prerenal azotemia. The patient's creatinine and electrolytes improved through his hospital course and he has normal renal function at the time of his discharge. 5. Alcohol abuse - The patient has a history of alcohol abuse. He was initially on Versed while intubated. The patient did not have any signs of withdrawal on the floor. He was seen by Addiction Services for this as well as his cocaine use. The patient did not wish to have any inpatient evaluation done. He wants to seek outpatient follow up. 6. Psychiatric - The patient was very agitated in the Emergency Department and while he was intubated when his sedation was lighted he was slightly combative, unclear if it was due to medication he was receiving. He was seen by Psychiatry on the floor and they felt that he either had bipolar disorder or schizo-affective disorder based on available information. He declined to have outpatient provider [**Name Initial (PRE) 653**]. The patient was deemed safe at that time and was restarted on Zyprexa, Depakote, Bupropion. Other medications were not restarted as their dosage could not be confirmed. He will follow up with his outpatient provider. [**Name10 (NameIs) **] also had an electroencephalogram performed due to question of seizure activity which revealed moderate encephalopathy which was likely in the setting of his infection. 7. Atrial fibrillation - The patient had an episode of atrial fibrillation upon his admission to the Emergency Department. This required cardioversion times two. The patient did not have any further episodes of atrial fibrillation during his hospital course and this likely occurred in the setting of infection. Transthoracic echocardiogram was performed which demonstrated normal systolic ejection fraction greater than 55%, trivial mitral regurgitation, trivial tricuspid regurgitation, otherwise normal echocardiogram with no signs of endocarditis. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: Upon hearing that thoracentesis was requested, the patient became very angry and did not want to have this procedure done. He was upset at the change of plans for thoracentesis on [**6-28**], and had planned for thoracentesis on [**6-29**]. The patient was explained that due to his spiking temperatures on [**6-29**] and the presence of a pleural effusion empyema could not be excluded, the patient understood the risks and chance of death and stated he wished to have a second opinion by somebody out of this institution. He will check himself into [**Hospital6 **] Hospital today or the [**Hospital6 1129**] tomorrow for further evaluation. The patient requested copies of his studies while he was here. These were provided to him as was a copy of this discharge summary. DISCHARGE DIAGNOSIS: 1. Pneumonia, secondary to Staphylococcus aureus 2. Sepsis secondary to pneumonia 3. Adrenal insufficiency in the setting of sepsis 4. Iron deficiency anemia 5. Acute renal failure 6. Prerenal azotemia 7. Hemoptysis 8. Alcohol abuse 9. Cocaine abuse 10. Atrial fibrillation in the setting of sepsis 11. Psychiatric condition, schizo-affective disorder versus bipolar disorder DISCHARGE MEDICATIONS: 1. Multivitamin one tablet p.o. q. day 2. Thiamine 100 mg p.o. q.d. 3. Folic acid 1 tablet p.o. q.d. 4. Zyprexa 10 mg p.o. q.d. 5. Divalproex 500 mg p.o. b.i.d. 6. Bupropion 100 mg p.o. b.i.d. 7. Pantoprazole 40 mg p.o. q.d. 8. Clindamycin 200 mg p.o. q. 6 hours to complete a six week course 9. Iron 325 mg p.o. q.d. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Name8 (MD) 17420**] MEDQUIST36 D: [**2135-6-29**] 15:21 T: [**2135-6-29**] 16:03 JOB#: [**Job Number 43317**]

[ "427.31", "255.5", "518.81", "305.90", "584.9", "038.9", "511.9", "280.9", "482.41" ]

icd9cm

[ [ [] ] ]

[ "99.61", "96.04", "96.72", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

8085, 8891

2217, 2227

9321, 9904

8912, 9298

1601, 1799

3293, 8063

2250, 3275

173, 194

223, 1269

1292, 1574

1816, 2200

31,361

153,995

3287

Discharge summary

report

Admission Date: [**2179-10-8**] Discharge Date: [**2179-10-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1881**] Chief Complaint: Nausea & vomiting Major Surgical or Invasive Procedure: Upper gastrointestinal endoscopy History of Present Illness: Ms. [**Known lastname 15331**] is an 89yo female with PMH as listed below who was admitted early [**10-8**] for N/V x 1 day. Per ED notes they were concerned about an underlying GI bleed given color of vomitus, but patient refused NG lavage. She was also found to be hypotensive with BPs~80's and tachycardic at outside facility. In the ED her initial vitals were T 98.8 BP 111/64 AR 106 RR 18 O2 sat 98% RA. She received Ceftazadine 1gm IV and Azithromycin 500mg IV. . At approximately 8pm on [**10-8**] the patient was found slumped to the side of bed, PIV pulled out, with large amounts of coffee ground emesis. Vitals at this time were T 99.1 BP 104/66 AR 118 RR 30 O2 sat 94% on 2L. NGT was placed and she was transferred to MICU for closer monitoring. . In the MICU patient was tachycardic to the 130s-140s and responded to two trials of metoprolol 12.5mg. Following an uneventful stay she was transferred to the floor on [**10-11**] for further evaluation of her tachycardia. Past Medical History: 1)Parkinson's disease. 2)Chronic lower extremity pain/neuropathy. 3)Cervical spine osteoarthritis and degenerative joint disease. 4)Hypothyroidism. Social History: Lives at home with almost 24 hour HHA assistance. She is having increasing difficulty with transfers and many ADL's. She does not smoke or drink alcohol. She has a daughter who lives nearby and follows her hospital course and visits frequently. Family History: NC Physical Exam: T 99.1 BP 104/66 HR 118 RR 30 O2sats Gen: Elderly lady, looks frail & fatigued HEENT: OP clear, dry MM, neck supple Heart: tachycardic, unable to auscultate murmurs Lungs: Crackles 1/2way up lung fields bilaterally Abdomen: distended, sl. tender to touch diffusely, decreased bs Ext: warm to touch, no cyanosis Neuro: slow to respond to questions Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2179-10-8**] 07:57PM 22.5* 3.33* 10.4* 32.0* 96 31.2 32.5 14.1 615* [**2179-10-8**] 07:29PM 19.9* 3.42* 11.0* 32.8* 96 32.0 33.4 14.1 578* [**2179-10-8**] 08:55AM 22.2* 3.95* 12.4 38.5 98 31.5 32.3 14.0 686* [**2179-9-30**] 10:50AM 9.7 3.37* 10.8* 32.8* 97 32.2* 33.0 13.7 618* . [**2179-10-8**] 08:55AM NEUTS-94* BANDS-0 LYMPHS-3* MONOS-3 EOS-0 BASOS-0 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2179-10-8**] 08:55AM 193* 30* 1.2* 130* 4.8 89* 25 . [**2179-10-8**] 08:55AM ALBUMIN-4.0 CALCIUM-9.6 PHOSPHATE-5.4*# MAGNESIUM-2.8* . CXR [**2179-10-8**] 1. Chest radiograph limited by low lung volumes; no acute cardiopulmonary process. 2. Hiatal hernia. . Upper GI Endoscopy [**2179-10-11**] 1. Medium hiatal hernia 2. Erythema and congestion and old clotted blood in the stomach 3. There was a moderate sized diverticulum in the ampullary area in the second part of duodenum with old blood.There was no signs of active bleeding noted. 4. Otherwise normal EGD to second part of the duodenum Brief Hospital Course: Ms. [**Known lastname 15331**] is an 89yo female with Parkinson's disease who p/w nausea, coffee ground emesis and tachycardia concerning for underlying GI bleed. 1)Coffee ground emesis: Patient initially presented with large amounts of coffee ground emesis, very concerning for an underlying GI bleed. NGT and upper endoscopy on [**10-11**] showed no evidence of bleeding. Patient was started on Protonix 40mg IV BID, and transfused 1 unit pRBCs in the MICU. BP remained stable throughout rest of stay. . 2)Tachycardia: First thought to be compensatory response to blood loss and underlying hypovolemia. EKG suggested atrial tachycardia vs. atrial flutter-confirmed with cardiology fellow. Mild response to IVF throughout ICU stay, but responded well to beta-blockers. She was started on PO Metoprolol on the floor, which was titrated up to a dose of 37.5mg [**Hospital1 **] on [**2179-10-15**], which brought her heart rate in to the 90s-100s. . 3)Hypotension: Patient found to be hypotensive at outside facility. Likely to dehydration in setting of nausea and vomiting. BP remained stable throughout hospitalization. . 4)Leukocytosis: Patient presented with Hct of 22.2 on admission. Given slightly elevated lactate concerned about an underlying infection although no source identified. Per daughter, her mental status was off from her baseline. Pt was started on Ceftriaxone and azithromycin for empiric therapy, switched to Levofloxacin x7 days on [**10-11**]. WBC trended down throughout stay to 11.6 on [**10-15**]. . 5) Fever: Patient spiked temperature to 101 on [**10-12**] which resolved with acetaminophen. Temperature was otherwise nonfebrile. Blood cultures, urine cultures were normal. . 6)Peripheral neuropathy: Continued Neurontin. Roxicet was held secondary to delirium. . 7)Hypothyroidism: TSH was normal and levothyroxin was held secondary to tachycardia. . 8)Parkinson's: Patient received usual home regimen. 9)Glaucoma: Patient was unable to be treated because she did not have her meds from home. Medications on Admission: Sinemet 25/100 5x PO daily Sinemet CR 50/200 PO QHS Neurontin 100mg PO TID Levoxyl 125 micrograms PO daily Salsalate 750mg PO BID Protonix 40mg PO daily Xalatan 0.005% daily to both eyes Roxicet 5/325 PO 4/day Br toptic Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO 5X/DAY (5 Times a Day). 2. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days: Last dose on [**2179-10-17**]. 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Discharge Diagnosis: Primary: upper GI bleed, sinus tachycardia, pneumonia Secondary: 1)Parkinson's disease. 2)Chronic lower extremity pain/neuropathy. 3)Cervical spine osteoarthritis and degenerative joint disease. 4)Hypothyroidism. Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital because you had nausea and vomiting with a possible upper gastrointestinal bleed. You were also found to have low blood pressure and a fast heart rate. While in the hospital you had an upper gastrointestinal endoscopy performed which did not show any signs of active bleeding. In addition, you were treated for a possible pneumonia with antibiotics. You have been prescribed Metoprolol to slow your heart rate at a dose of 37.5mg, twice a day. Please continue to take this medication with your other medications. . If you develop any symptoms of chest pain, shortness of breath, dizziness, recurrence of your nausea or vomiting, please call your primary doctor or go the nearest emergency room. Followup Instructions: Please follow up with your primary doctor, [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 250**] within 2 weeks of your discharge from [**Hospital 15332**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]

[ "486", "578.9", "276.51", "721.0", "427.89", "355.8", "332.0", "244.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

6620, 6716

3322, 5351

281, 316

6974, 6983

2179, 3299

7763, 8099

1782, 1786

5622, 6597

6737, 6953

5377, 5599

7007, 7740

1801, 2160

224, 243

344, 1329

1351, 1502

1518, 1766

13,593

184,414

51096

Discharge summary

report

Admission Date: [**2112-12-21**] Discharge Date: [**2112-12-26**] Date of Birth: [**2057-12-26**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1257**] Chief Complaint: CC: weakness and epistaxis x 2 days Reason for MICU Admission: HCT drop, monitoring Major Surgical or Invasive Procedure: HD nasal packing History of Present Illness: This is a 54yoF w/h/o ESRD on HD, HIV([**11-29**] CD4 261, VL 5,640), [**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis, distant h/o cocaine use, and severe pulmonary HTN who presents w/2 days epistaxis and weakness. She notes that 2 weeks ago she had epistaxis and associated HCT drop which led to admission to [**Hospital1 2177**] on [**12-8**]. Per discharge summary, HCT on presentation was 26.6 from baseline 38 one week prior to presentation. She received 2 units of PRBCs upon admission and this improved to mid 30s and remained stable throughout the remainder of the hospitalization; she was discharged [**12-19**]. Her hemolysis labs were negative there. She describes persistent weakness and decreased appetite and notes that "everyone around her is sick." However, denies brbpr, only dark stools x 1 day, no abdominal pain/N/V. No F/C, no arthralgias/myalgias/cough. . In the ED, afebrile tachy to 110s 140's/90's. She received 500cc bolus which brought HR to 100. She did not have active bleeding in right nare but did have cauterization w/silver nitrate. . ROS: + lightheadedness today; The patient denies any diarrhea, constipation, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. She reports that she has been adherent with her meds except for the prednisone. Baseline weight is 57kg per pt. . Past Medical History: -HIV ([**11-29**] CD4 261, VL 5,640) -ESRD on HD MWF -HTN -severe Pulmonary HTN -Cardiomyopathy [**12-10**] LVEF 31%, severe MR/TR -[**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis (LIP) followed by Dr. [**Last Name (STitle) **] [**Name (STitle) **] at [**Hospital1 2177**] ([**Telephone/Fax (1) 7799**] #6564 -anemia of chronic disease -AVNRT diagnosed at [**Hospital1 2177**] -Recent vaginal bleed s/p conization -HCV - untreated -ESRD on hemodialysis -Asthma/COPD -C-section -R knee surgery -Ovarian cysts removed Social History: She lives in [**Location 669**] with her 18 year old son. She has three sons and one daughter. She quit smoking on [**2112-2-3**]. She has a 30-40 pack year smoking history. She has used "every drug" including cocaine. Last drug use was three years ago. She has never used IV drugs. She has a history alcohol abuse and has been sober for six years. She has a history of homelessness and has lived in shelters, most recently within the past five years. She has never been incarcerated but her son has been. She is currently medically handicapped and unemployed for many years. Family History: Her mother is living in her 70s and had a stroke, hypertension and diabetes. Her uncle died of kidney disease. She never met her father. [**Name (NI) **] sister was killed in a motor vehicle crash. Her children are healthy. Her daughter has a single kidney Physical Exam: On presentation: Vitals: T: 99.5 BP: 154/110 HR: 122 RR: 21 O2Sat: 100%RA orthostatics: sitting HR 102 BP 140/100 standing HR 108-110 BP 127/88 GEN: thin, well-nourished, no acute distress HEENT: + epistaxis- right nare oozine, EOMI, PERRL, sclera anicteric, no rhinorrhea, MMM, OP w/small amount bright red blood o/w clear NECK: + enlarged parotids BL, + soft tissue protruding supraclavicularly BL No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, split S2, soft systolic murmur noted, no G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: distended, reducible umbilical hernia, Soft, NT, +BS, no HSM, no masses Rectal: small amount of dark stool in vault, guiac + EXT: thin, AV fistula in place, No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. . Pertinent Results: [**2112-12-21**] 12:00PM WBC-3.9* RBC-3.15* HGB-9.0* HCT-28.1* MCV-89 MCH-28.4 MCHC-31.8# RDW-20.1* [**2112-12-21**] 12:00PM NEUTS-60.4 LYMPHS-26.9 MONOS-10.4 EOS-2.0 BASOS-0.3 [**2112-12-21**] 12:00PM PLT COUNT-123* . [**2112-12-21**] 12:00PM PT-14.3* PTT-32.2 INR(PT)-1.2* . [**2112-12-21**] 12:00PM GLUCOSE-76 UREA N-28* CREAT-3.3*# SODIUM-144 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-35* ANION GAP-13 [**2112-12-21**] 12:00PM ALT(SGPT)-24 AST(SGOT)-47* LD(LDH)-236 ALK PHOS-82 TOT BILI-4.7* . [**2112-12-21**] 12:00PM ALBUMIN-3.5 IRON-118 [**2112-12-21**] 12:00PM calTIBC-257* HAPTOGLOB-46 FERRITIN-526* TRF-198* . [**2112-12-21**] 03:45PM BLOOD Hgb-8.0* Hct-25.4* [**2112-12-21**] 09:33PM BLOOD Hct-27.7* [**2112-12-22**] 03:13AM BLOOD Hgb-8.7* Hct-27.4* [**2112-12-22**] 09:08AM BLOOD Hgb-8.7* Hct-27.1* . [**2112-12-21**] CXR: CONCLUSION: Stable cardiomegaly with no pulmonary consolidation. Brief Hospital Course: This is a 54 year old woman with history of ESRD on HD, HIV ([**11-29**] CD4 261, VL 5,640), [**Month/Year (2) 106113**] [**Month/Year (2) 106114**] pneumonitis and severe pulmonary HTN who presents with HCT drop in the setting of epistaxis. She has H/O cocaine use. she has had guaiac positive stools but they are related to swallowing blood. GI bleed concurrently is unlikely. No evidence of hemolysis at the OSH or here. GI stated that guaiac positive stool is from swallowed blood. ENT saw her and recommended packing to stay in place for at least 5 days. However, her oozing persisted so they recommended leaving the pack for additional days (3-4 days). We asked her to check to our ER in 3 days after discharge for possible removal of the packing if oozing stops. They recommended Keflex to prevent toxic shock while packing in place. She was advised to not use cocaine and come to the ER if bleeding recurs. She was asked not to manipulate the packing. She has been hemodynamically stable for many days. . . . total discharge time 34 minutes. Medications on Admission: Abacavir 600 mg PO DAILY Atazanavir 300 mg PO DAILY B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Calcitriol 0.50 mcg PO DAILY Cinacalcet 30 mg PO DAILY Didanosine 125 mg PO DAILY Fluocinonide 0.05 % Ointment Topical [**Hospital1 **] Prednisone 20 mg PO DAILY- noncompliant with this med Quetiapine 25 mg PO qhs, prior to HD Ritonavir 100 mg PO DAILY Sevelamer HCl 1600 mg PO TID W/MEALS Triamcinolone Acetonide 0.1 % Ointment Topical [**Hospital1 **] as needed Trimethoprim-Sulfamethoxazole 80-400 mg Tablet PO DAILY Loratadine 10 mg PO once a day CeraVe Cream Topical [**Hospital1 **] Metoprolol Succinate 50 mg PO DAILY Losartan 25 mg Tablet PO DAILY Dextromethorphan-Guaifenesin 10-100 mg/5 mL 5ML PO q6h prn. Albuterol 90 mcg/Actuation Two puffs Inhalation q6h prn. . Discharge Medications: 1. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Losartan 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 11. Fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 12. Didanosine 125 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 14. Sodium Chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray Nasal Q4H (every 4 hours): Please give 3 sprays each side 6 times daily until follow-up. . Disp:*3 spray bottles* Refills:*2* 15. Mupirocin Calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2 times a day) for 5 days: Please start after packing removal . Disp:*1 tube* Refills:*1* 16. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 2 days. Disp:*6 Capsule(s)* Refills:*0* 17. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day) as needed for bleeding/oozing for 3 days: spray in each nose if bleeding again. Disp:*1 spray bottle* Refills:*0* 18. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*60 ML(s)* Refills:*0* 19. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 22. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours. Discharge Disposition: Home Discharge Diagnosis: Epistaxis Discharge Condition: Good Discharge Instructions: You were admitted to the hospital with a nose bleed. ENT doctors saw [**Name5 (PTitle) **] and placed packing in your nose. You were found to be anemic, likely from the nosebleed but your blood count remained stable. Your bleeding has stopped. The ENT doctors recommend keeping the packing one more day. You need to spray saline sprays in your nose to avoid drying out your nares. If you notice bleeding again, please use afrin spray. Once packing is removed, please use the mupirocin ointment to your nares as prescribed. You need to come back to ED to have the packing removed tomorrow. If the nose bleed recurrs, please soak the packing with the afrin spray and hold external pressure. If it still continues, please go to ED. Please avoid manipulating your nose. Followup Instructions: 1. PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **], ph: [**Telephone/Fax (1) 4255**]. Pls call and make appt

[ "403.91", "V08", "585.6", "784.7", "493.20", "070.54", "416.0", "285.9" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9532, 9538

5445, 6496

402, 420

9592, 9599

4511, 5422

10413, 10563

3109, 3372

7321, 9509

9559, 9571

6522, 7298

9623, 10390

3387, 4492

279, 364

448, 1929

1951, 2489

2505, 3093

4,002

147,993

46185

Discharge summary

report

Admission Date: [**2174-9-15**] Discharge Date: [**2174-9-28**] Date of Birth: [**2114-7-7**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4583**] Chief Complaint: Seizure, SAH, IPH Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 60 yo man with h/o EtOH abuse, h/o SDH, and also possible seizures who presents after a seizure at an OSH. He is currently intubated and sedated and unable to give history. This is gathered from notes and staff. Pt was visiting a friend in the hospital today when he fell to the ground and hit the back of his head. He was then witnessed to have a GTC seizure. It is unclear if this started before the fall or not. He was given 2 mg Ativan with resolution. He then was brought to the ED and head CT showed 2 small IPHs and subarachnoid hemorrhage. He was apparently moving all extremities and unclear if following commands, but he was very sedate and post-ictal. He was therefore intubated for airway protection. He ended up getting 6 mg Ativan, 20 mg Etomidate, 100 mg Succinylcholine, 10 mg Vecuronium, 1 gram of dilantin, and 2 mg Versed. He was then transferred here. Again, unclear if he was seizing before the fall or if the fall caused the seizure. By report, he has a h/o SDH, but unclear when. He has also had seizure before by report and is possibly on dilantin. His level was negligible though. ROS: Patient unable. Past Medical History: EtOH abuse h/o SDH h/o seizure, but no details Social History: Unknown Family History: Unknown Physical Exam: Vitals:101.8 rectally, 80, 122/94, 16 Mental Status:Intubated and sedated, but actively resists vent. Doesn't follow commands, but did open eyes slightly when I said his name initially. Did not open to command CN: Pupils:3->2 bilaterally Nasal Tickle: Bilateral grimace Gag/Cough:Gag on tube Corneal Reflex:Present bilaterally OCRs:Unable due to c-collar Motor:Moves all extremities spontaneously and equally. Withdraws all extremities to painful stimuli(nailbed pressure). Toes:Upgoing bilaterally DTRs: [**Name2 (NI) **] Tri Br Pa [**Doctor First Name **] R 2 1 1 0 0 L 2 1 1 0 0 Pertinent Results: OSH labs: ABG: 7.40/50/370/30 WBC 5.7 Hgb 12.8 Hct 38.1 Plt 201 Dilantin <0.8 EtOH 34 Tylenol < 10 ASA < 2.0 Na 139 K 3.3 Cl 97 CO2 26 Glucose 130 BUN 7 Cr 0.6 Ca 8.5 . Labs on admission: WBC-5.7 RBC-3.73* HGB-11.9* HCT-35.2* MCV-94 MCH-31.9 MCHC-33.9 RDW-16.0* NEUTS-65.4 LYMPHS-27.0 MONOS-6.0 EOS-0.5 BASOS-1.0 ANISOCYT-1+ MACROCYT-1+ GLUCOSE-95 UREA N-4* CREAT-0.5 SODIUM-136 POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-36* ANION GAP-10 PHENYTOIN-13.9 PT-11.6 PTT-29.2 INR(PT)-1.0 SERUM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2174-9-15**] 04:28PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023 BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Hep C POS Hep C VL HCV VIRAL LOAD 7,260,000 IU/mL. URINE CULTURE (Final [**2174-9-23**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | ENTEROCOCCUS SP. | | AMPICILLIN------------ 16 R <=2 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S <=16 S PIPERACILLIN---------- <=4 R PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S [**2174-9-19**] 4:33 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [**2174-9-22**]): STAPH AUREUS COAG +. RARE GROWTH. Oxacillin sensitivity performed by agar screen. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | OXACILLIN------------- R IMAGING: Abd/Pelvic CT: 1. No evidence of acute traumatic injury within the abdomen or pelvis. 2. Fatty infiltration of the liver, without intraparenchymal hepatic mass or biliary ductal dilatation. 3. Re-cannulation of the umbilical vein and several small collateral vessesels suggestive of underlying portal hypertension. 4. Colonic diverticula without evidence of diverticulitis. 5. Anterior wedge-shaped deformity of the L2 vertebral body, likely chronic. C-spine CT: 1. No evidence of acute traumatic injury. 2. Degenerative changes, most marked at the C5-6 level with ventral canal and bilateral neural foraminal narrowing and possible exiting C6 nerve root impingement. Head CT: 1. Likely left temporal and frontal hemorrhagic contusions with no significant mass effect. 2. Acute subdural blood layering over the [**Last Name (un) 46280**] aspect of the tentorium. 3. Thin extra-axial fluid collection layering over the left convexity, with focal hyperattenuating components, which may reflect acute rebleeding into a more chronic subdural collection. 4. No skull fracture. 5. Acute-on-chronic inflammatory disease in the paranasal sinuses. PCXR: The tip of the endotracheal tube is in a satisfactory position and lies 4.6 cm from the carinal angle. A nasogastric tube is present, curled within the stomach. Cardiac size is within normal limits. No failure is seen. No pneumonia is present. There is evidence of old healed fractures of the right humeral head and distal clavicle. EEG: This is a normal EEG in the awake state. No focal or epileptiform features were seen. Predominant beta activity seen throughout the recording is likely secondary to medication side effect. Sinus CT: There is near complete opacification of the left maxillary sinus. The left OMU is completely opacified. There is complete opacification of a few of the posterior right ethmoid air cells as well as scattered middle ethmoid air cells bilaterally. There are mild areas of mucosal thickening within both sphenoid sinuses, with moderate-to-large air-fluid level in the left. There are small amounts of mucosal thickening within the left frontal sinus with moderate amounts of mucosal thickening in the right maxillary sinus. There are also some aerosolized secretions in the right frontal sinus. There are no osseous erosions. The nasal septum is midline with a moderate sized leftward and bony spur. The ostiomeatal complex on the right is patent. There has been a prior right nasal bone fracture. Visualized portion of the brain are normal. IMPRESSION: Extensive sinus disease as described above, which could be consistent with acute sinusitis given the air fluid levels mentioned. CXR PA/LAT: No definite pneumonia or evidence for aspiration. Old healed bilateral rib and lateral clavicular fractures. Brief Hospital Course: Briefly, 60 yo man with h/o EtOH abuse, h/o SDH, and also possible seizures who presents after a seizure at an OSH and finding of SAH and IPH, with possible small SDH on CT scan. NEURO: It is unclear why the patient seized and which occured first, the bleeding or the seizure. However, the bleeding appeared to be traumatic. One possibility was that the seizure caused him to fall and the bleed was the result of trauma. Alternatively, he may have had a syncopal episode and the head trauma caused both the seizure and the bleeding. [**First Name8 (NamePattern2) **] [**Hospital1 98213**] history, he has a known seizure disorder and is non-complaint with dilantin. He is also an alcoholic by report from [**Hospital1 1474**]. His EtOH level was 34 but otherwise urine and serum tox screens were negative. On admission, he had no evidence of brainstem dysfunction and was extubated without difficulty. A repeat head CT showed hemorrhagic contusion within the left anterior temporal lobe with another focus of hemorrhagic contusion lower in the anterior temporal lobe. There was a small subdural hematoma layering along the left firm parietal convexity, age indeterminate. The left posterior subdural hematoma along the falx and tentorium was unchanged. An EEG on [**9-19**] was performed and no focal or epileptiform features were seen. Predominant beta activity was seen throughout the recording likely secondary to medication side effect. Patient was continued on dilantin and he was treated aggressively initally on standing ativan as prophylaxis for ETOH withdrawal. He was started on MVI, thiamine and folate. He was transferred to the floor and his confusion gradually cleared and transitioned to a CIWA protocol with ativan only as needed. Patient's persistent mental status deficits including confabulation, difficulty with complex step commands and recall was likely multifactorial. Patient had Korsakoff sydrome and exam was suggestive of a peripheral neuropathy likely from ETOH abuse and resultant thiamine deficiency. Additionally, he has deficits suggestive of prior traumatic brain injury and progressive dementia however will need longitudinal follow-up to further evaluate persistence of deficits. Patient was still febrile, hyponatremic and confused and wanting to go during the hospital course. The primary team felt that he was not medically safe to leave the hospital at the time and it was unclear whether he understood the consequences and risk of leaving the hospital at that time. Furthermore, patient was unable to explain in his own words the risks that had been explained to him. Psychiatry was consulted to evaluate for competency and agreed with the primary team's assessment. As patient's metabolic and infectious abnormalities were corrected, he gradually continued to clear and appeared to be at his baseline. ID: He had a fever of 101.8 on admission. Although it may have been attributable to the hemorrhage, infection workup was performed to rule out other etiologies. CXR was normal including negative for silent aspiration. He was found to have acute sinusitis on sinus CT [**9-20**]: extensive sinus disease as described above, which could be consistent with acute sinusitis given the air fluid levels mentioned. He was started on Clindamycin which was subsequently switched to Levofloxacin when a urine culture grew pan-sensitive Klebsiellaa and Enterococcus. Patient defervesced after initiation of antibiotics. Flagyl was started initally out of concern of aspiration and was then discontinued after negative chest x-ray. No growth on blood cultures. LIVER: During metabolic work-up for confusion, patient was detected to have elevated liver enzymes. A hepatitis panel was positive for Hepatitis C with high viral load count. Patient will need to follow-up with his primare care physician and need be referred to a Liver specialist for monitoring. At this time, he had minimal ascites and stigmata of liver disease. Additionally, dilantin was promptly transitioned to Keppra. HYPONATREMIA: Patient developed hyponatremia (Na 123) which improved with IVF NS thought to be likely hypovolemic hyponatremia. Urine osmolality was 211 and Na 19 which was consistent with this proposed etiology. DISPO: Attempts were made to contact family and friends however leads were unsuccessful and were complicated by patients confusion. As patient cleared, contact was finally made with patient's girl friend in [**Name (NI) 1474**] and patient was discharged with free prescriptions for his anti-epileptics available at the [**Company 25282**] pharmacy across the street from [**Hospital 1474**] Hospital. Patient was [**Hospital 1988**] to follow-up in [**Hospital 878**] clinic and in [**Hospital 4695**] clinic as an outpatient. MassHealth application for free pharamcy was also filed for continued Keppra usage. PPX: Pneumoboots, RISS, CIWA protocol. Medications on Admission: Dilantin?, but level would suggest he is not taking Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO twice a day: On [**9-30**], please increase Keppra dose to 3 tablets by mouth twice per day. Disp:*90 Tablet(s)* Refills:*3* 6. Dilantin 100 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days: Take one pill twice daily for 5 days, then one pill daily for 5 days, then discontinue. Disp:*15 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Seizure Dementia Left temporal lobe contusion Hepatitis C Discharge Condition: Improved Discharge Instructions: Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Please take all medications as prescribed. If you develop any fever, chills, muscle weakness, altered mental status or any concerning symptoms, please call your doctor and go to the nearest emergency room. Followup Instructions: 1. [**Hospital 4695**] Clinic: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] WEST Date/Time:[**2174-10-19**] 2:00 2. [**Hospital 878**] Clinic: Please call [**Telephone/Fax (1) 29128**] to make an appointment Completed by:[**2174-10-4**]

[ "357.5", "303.91", "276.1", "851.86", "E885.9", "461.0", "780.39", "276.52", "070.70", "291.81", "599.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

13463, 13469

7671, 12563

334, 341

13571, 13582

2284, 2458

13930, 14243

1632, 1641

12666, 13440

13490, 13550

12589, 12643

13606, 13907

1656, 1695

276, 296

369, 1520

5538, 7648

2472, 5529

1709, 2265

1542, 1591

1607, 1616

29,155

110,756

31536

Discharge summary

report

Admission Date: [**2179-7-20**] Discharge Date: [**2179-7-30**] Date of Birth: [**2121-2-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Motorcycle accident Major Surgical or Invasive Procedure: Tracheostomy Percutaneous Gastrostomy Incision and Drainage L scapular hematoma Thoracic epidural catheter History of Present Illness: 58 yo M med-flighted to [**Hospital1 18**] from [**Location (un) 3844**] following an unhelmuted, over the handlebar, motorcycle accident. Pt reportedly intoxicated, but was awake and alert at the accident scene, talking with paramedics, but became increasingly combative, and then less responsive and was intubated prior to transfer. Past Medical History: bullous emphysema, COPD, HTN, anxiety, EtOH dependence Social History: Non-contributory Family History: Non-Contribultory Physical Exam: T 97.8 BP 132/87 HR 100 BP 132/87 RR 28 O2 98% Gen: AOx3 HEENT: PERRLA CVS: RRR Resp: coarsh breathsounds bilaterally Ab: soft, non-tender, non distended, + BS ext: 1+ edema bilaterally Pertinent Results: [**7-21**] Echo: Hyperdynamic left ventricle suggestive of hypovolemia with hyperdynamic left ventricular systolic function. No evidence of traumatic valvular dysfunction or cardiac contusion. There is a trivial/physiologic pericardial effusion. Films: [**7-20**] cxr: Small left sided pneumothorax. Left-sided chest tube courses apically. Distal left clavicle fracture and left glenoid fracture. Displaced left-sided rib fractures involving the left third through seventh ribs posterolaterally. [**7-20**] CT c/a/p 1. Moderate sized left lung pneumothorax with chest tube in good position. Extensive surrounding subcutaneous emphysema tracking into the left neck and extending into the posterior soft tissues through to the pelvis. 2. Fractures involving the left second through ninth posterior ribs. Fracture of the posterior [**Doctor First Name 362**] of the left scapula as well as a fracture involving the left glenoid. Comminuted fracture of the left distal clavicle. 4. Nondisplaced fracture of the left transverse process of the T6 vertebral body. Otherwise, the thoracic and lumbar spines are without fracture or malalignment. 5. Severe centrilobular emphysema. 9 mm right apical spiculated nodule. While this may represent scar, followup dedicated chest CT is recommended in [**3-2**] months to confirm stability. [**7-21**] CXR Increased density at the right lung base and in the left perihilar region which may represent evolving infiltrates. Evidence for interval decrease in small left pneumothorax. Extensive subcutaneous emphysema unchanged. Left rib fractures and left clavicular fracture. [**7-20**] CT head/C-spine 1. Diffuse subarachnoid hemorrhage overlying the left temporal lobe with a few foci of intraparenchymal hemorrhage, likely representing hemorrhagic contusions. Tiny subdural hematoma layering along the temporal bone convexity. No significant associated mass effect aside from local edema. 2. No skull fracture identified. Left orbital fracture better delineated on the CT of the facial bones performed on the same date. 3. High-density material within the left maxillary sinus. Occult fracture suspected. 4. Large left temporoparietal subgaleal hematoma. [**7-20**] CT Max/fac 1. Minimally displaced, comminuted left zygoma fracture which extends to involve the inferolateral orbital wall and zygomaticosphenoid suture on the left. 2. Non-displaced left inferior orbital rim fracture. 3. Left lamina papyracea fracture. 4. Bilateral periorbital hematomas. No intraconal abnormalities identified. [**7-21**] head CT - unchanged Brief Hospital Course: 58 yo M med-flighted to [**Hospital1 18**] from [**Location (un) 3844**] following an unhelmeted, over the handlebar, motorcycle accident. Accident was head-first, with no LOC Pt reportedly intoxicated, but was awake and alert at the accident scene, talking with paramedics, but became increasingly combative, and then less responsive and was intubated prior to transfer. Neuro: SAH and left parietal hemorrhagic contusion. no midline shift Loaded with 1g dilantin and continued until [**7-31**]. recieved neuro checks q4hr, and was sedated with propfol and fentanyl. Neurosurgery was c/s and believed no surgical managment was needed. HEENT: minimally displaced comminuted L zygoma fracute with involvment of inferolateral orbital wall on left. Left lamina papyracea fracture. Bilateral perioribal hematomas. c/s plastics for above injuries. Head of bed remained elevated at 30 degrees Head CT repeated on [**7-21**] with no significant change Per plastics, injuries non-operatative Chest: comminuted fx of L proximal clavical. Fracture of L scapula in the post [**Doctor First Name 362**] and glenoid with minimal displacement. fracture of posterior L ribs [**2-5**] with extensive SQ emphasema small non displaced fx of post T6 vertebral body Clavicle fracture believed to be open, and was taken to the OR [**7-29**] for I and D. CV: was placed on levophed for BP support, eventually weened HCT decreased and recieved 2 u RBC on [**7-24**], with appropriate response TEE to r/o tamponade - echo was normal PICC line was inserted [**7-29**] for access resp: Intubated on arrival, confirmed by CXR L tension pneumothorax on arrival - needle decompressed with 30 cc air, then 14 g chest tube inserted. CT replaced at [**Hospital1 18**] [**7-27**] tracheostomy [**7-27**] sputum showed gram negative rods, Levoquin started [**7-28**] CT removed [**7-28**] Patient weaned from vent. Given his significant pulmonary history of bronchitis, COPD and asthma, he remaine tachypnic throughout hospitalization with respiratory rates in high 20's to 30's. He was weaned to pressure support ventilation and trach mask with adequate ABGs for his baseline disease. GI: NG tube was placed and pt was given tube feeds nutrition was consulted and set goal of tube feeds for 1800 cal with 25 g beneprotein [**7-27**] percutaneous-gastrostomy for continuing nutritional needs. Prophylaxis with H2 blocker, heparin SC and pneumoboots Pain was controled by acute pain survice. They placed an epidural catheter [**7-22**] to give an IV fentanyl infusion. Epidural removed [**7-27**], subsequently pain was controlled with percocet elixir. Endocrine: given hydrocort to maintain steroid response and subsequently weaned. ID: on Ancef for open clavicle fracture x3 doses. Subsequently stopped. Levoquine for total of 7 days for positive sputum culture. PT/OT Medications on Admission: Zoloft 100 mg qday albuterol inhaler 2 puffs qid spiriva 1 puff qid Nexium 40 mg qday Luesta 2 mg qday Vicadin 7.5/750 qid klonipin 1mg [**Hospital1 **] Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 4. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lorazepam 0.5-1 mg IV Q4H:PRN anxiety 7. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation Q2-3H (every 2-3 hours) as needed. 8. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED). 9. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day: prn. 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO every 6-8 hours as needed: PRN pain. 11. Insulin [**Known lastname **],[**Known firstname **] H. [**Numeric Identifier 74196**] Insulin SC (per Insulin Flowsheet) Sliding Scale Fingerstick QACHSInsulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-80 mg/dL [**12-29**] amp D50 [**12-29**] amp D50 [**12-29**] amp D50 [**12-29**] amp D50 81-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 2 Units 161-200 mg/dL 4 Units 4 Units 4 Units 4 Units 201-240 mg/dL 6 Units 6 Units 6 Units 6 Units 241-280 mg/dL 8 Units 8 Units 8 Units 8 Units 12. Tube Feeding Tubefeeding: Nutren Pulmonary Full strength; Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 60 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 200 ml water q6h Adjust free water flushes as needed to treat hypernatremia. 13. Outpatient Lab Work [**Hospital1 **] electrolytes. Replete prn. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO PRN (as needed) as needed for Phos < 3.0. 17. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN (as needed): PRN Mag < 2.0. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: L-SAH/IPH/SDH (temporal) Large L-temporoparietal subgaleal hematoma Grade 4 L scapula fracture L clavicle fx Pneumothorax Small HemoPTX Multiple L-sided rib fx ([**2-6**]) L orbital wall fx Discharge Condition: Stable to rehabilitation facility Discharge Instructions: Continue Levoquin for 7 days Remove sutures on chest in [**10-10**] days Continue Oxygen to trach collar at 10-15 L/min Continue trach and peg care Continue tube feeds to goal of 1800 Kcal per day with 25 g of beneprotein Ativan as needed for agitation Followup Instructions: Remove sutures in [**10-10**] days Completed by:[**2179-7-30**]

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icd9cm

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Discharge summary

report

Admission Date: [**2145-7-15**] Discharge Date: [**2145-7-20**] Date of Birth: [**2084-5-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5810**] Chief Complaint: Muscle weakness, back pain Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Mr. [**Known lastname 32458**] is a 61 YOM with a PMH sig for history of oral cancer s/p surgical resection and XRT 5 years ago in remission who presents with upper extremity weakness. Patient states that he was in his usual state of health until 4 days ago when he sustaineed a back injury while catching a heavy bag. The following day he noted weakness in his upper and lower extremities associated with pain in his muscles. He denies bowel or urinary incontinence. He went to [**Hospital 4199**] hospital where CT neck showed no fracture. He was given 6 mg morphine for pain and transferred to [**Hospital1 18**] for MRI. . In the ED initial vital signs were: 98.4 69 181/93 16 98% RA. His exam revealed b/l proximal muscle weakness upper > lower. Labs were notable for K+ of 1.9, bicarb 40, CK pending. Otherwise CBC was wnl, cr 0.7. UA showed sml bld and 10 ketones. MRI showed "No acute fx or malalignment. No cord signal abnl. Multilevel DJD w/ broad based disc-osteophyte complex at C3-C4 thru C6-C7, but most prominent at C4-C5 where there is moderate canal stenosis and b/l neural foraminal narrowing. Disc bulge at L5-S1 with mild canal stenosis." He was evaluated by Spine who said no acute injury, but wanted to keep the [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] on until the final MRI read. He was given zofran, morphine 4 mg, lorazepam, 60 mEq PO Kcl, and 2 gm of Mg IV and admitted to medicine for further work up of hypokalemia and muscle weakness. . On the floor, patient was upset about wearing the neck brace and a painful IV in his hand that he demanded be taken out. He was thirsty and annoyed at having to lie flat. He had neck and shoulder pain but otherwise denied complaints. . ROS: + for weakness in his shoulders and mild weakness in his legs with associated pain. He denied recent nausea,vomiting, diarrhea, or new medications. He denied recent trauma. He denied fevers, chills, HA, CP, SOB, cough, abd pain, dysuria, melena, rash. Past Medical History: oral cancer s/p surgery and XRT 5 years ago tobacco use chronic pain Pt reports PTSD, he is a [**Country 3992**] veteran and he lost his son 5 years ago Social History: Patient is a [**Country 3992**] Veteran. Divorced. He lives alone. His daughter lives nearby and is able to help. His son passed away in [**Name (NI) 8751**] several years ago. He smokes [**2-12**] a pk per day and drinks 3-4 beers a day 3 nights a week. He had withdrawals after his son died but decreased his alcohol intake since and denies recent withdrawal. Family History: father died of cirrhosis, mom is alive and well at 84 Physical Exam: ADMISSION EXAM VS:97.8 155/98 71 20 94% RA GENERAL: Upset at staff for taking vitals, demanding to sit up and have IV removed, C collar in place HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, tongue deviated to the right (per pt this way since his surgery) NECK: unable to assess b/c wearing hard collar HEART: RRR no murmurs LUNGS: CTA bilat, no wheeze ABDOMEN: Obese, Soft/NT/ND EXTREMITIES: WWP, no edema, 2+ peripheral pulses. Tenderness to palpation along the entire spinal cord. Patient unable to lift his arms to 90 degrees, no pain with passive rotation of shoulder joints. 5/5 strength in hand grip. Decreased strength in the lower extremities, but less profound [**3-16**] proximal muscles, 5/5 strength in dorsiflexion of feet. SKIN: No rashes or lesions. NEURO: Awake, A&Ox3, CNs II-XII intact. See extremity exam above. DISCHARGE EXAM: VS: 98.3 BP: 150/95 (124/74-158/100) HR: 66 (66-72) RR: 16 O2: 94% RA GEN: NAD, sitting comfortably in bed HEENT: anicteric sclera, MMM CV: RRR, no murmurs, rubs, gallops RESP: CTAB ABD: soft, NT/ND EXT: no edema Neuro/MSK: A+Ox3. improved ROM of upper and lower extremities, strength now [**4-15**] in all muscle groups Skin: diffuse maculopapular rash on back improved from prior exam Pertinent Results: ADMISSION LABS: [**2145-7-15**] 12:08AM BLOOD WBC-8.0 RBC-5.55 Hgb-17.5 Hct-49.3 MCV-89 MCH-31.6 MCHC-35.5* RDW-13.3 Plt Ct-261 [**2145-7-15**] 12:08AM BLOOD Neuts-68.5 Lymphs-21.2 Monos-5.6 Eos-2.9 Baso-1.7 [**2145-7-15**] 09:25AM BLOOD ESR-1 [**2145-7-15**] 12:08AM BLOOD Glucose-103* UreaN-4* Creat-0.7 Na-143 K-1.9* Cl-92* HCO3-40* AnGap-13 [**2145-7-15**] 02:12AM BLOOD CK(CPK)-5613* [**2145-7-15**] 09:25AM BLOOD CK-MB-7 cTropnT-<0.01 [**2145-7-15**] 02:12AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.4 [**2145-7-15**] 09:25AM BLOOD CRP-60.7* [**2145-7-15**] 09:25AM BLOOD T4-6.2 [**2145-7-15**] 09:25AM BLOOD TSH-1.7 [**2145-7-15**] 09:25AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Other workup adolase 39.6 anti-[**Doctor First Name **] antibody - negative MI-2 autoantibodies - pending [**2145-7-15**] 02:50PM BLOOD Osmolal-284 urine [**2145-7-15**] 12:08AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006 [**2145-7-15**] 12:08AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2145-7-15**] 12:08AM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 [**2145-7-15**] 10:05AM URINE Osmolal-409 [**2145-7-15**] 10:05AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG ECG: Normal sinus rhythm. Left atrial abnormality. Q-T interval prolongation. Non-specific ST-T wave abnormalities. ECG: Normal sinus rhythm. Prolonged Q-T interval. Extensive ST-T wave changes. ECG: Sinus rhythm. Normal tracing. Compared to the previous tracing of [**2145-7-16**] the Q-T interval has normalized. CXR: The tip of the right PICC line is terminating at cavoatrial junction. lung volumes are low. [**Hospital1 **]-basal atelectasis is minimal. Otherwise, lungs are clear and without consolidation. Heart size is top normal. Mediastinal and hilar contours are normal. There is no pleural effusion/pneumothorax. RUE ultrasound: Final Report INDICATION: Peripherally inserted central catheter in the right upper extremity with swelling and question of deep venous thrombosis. COMPARISON: None available. FINDINGS: Waveforms in the subclavian veins are symmetric bilaterally. The right internal jugular, paired right brachials, right basilic, and right cephalic veins all compress appropriately and show normal wall-to-wall flow on color Doppler analysis and appropriate venous waveforms. The right axillary vein is notable for a small amount of isoechoic material within the lumen of the vessel adjacent to the peripherally inserted central catheter, consistent with a small amount of non-occlusive thrombus. A peripherally inserted central catheter is visualized through the right basilic, axillary, and subclavian veins. IMPRESSION: Non-occlusive thrombus in the right axillary vein. Discharge labs: [**2145-7-20**] 04:35AM BLOOD WBC-7.3 RBC-4.83 Hgb-15.3 Hct-43.7 MCV-91 MCH-31.8 MCHC-35.1* RDW-13.3 Plt Ct-294 [**2145-7-20**] 04:35AM BLOOD Glucose-96 UreaN-10 Creat-0.8 Na-140 K-4.0 Cl-107 HCO3-22 AnGap-15 [**2145-7-19**] 12:50PM BLOOD CK(CPK)-470* [**2145-7-20**] 04:35AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2 Brief Hospital Course: 61yoM with h/o squamous cell ca of tongue [**2137**] s/p surgery and XRT and resultant sicca syndrome, chronic polydipsia and polyuria; h/o EtOH and cigarette abuse who presents with significant BUE and BLE proximal muscle weakness and found to be have severe hypoK, elevated CK without ARF, elevated transaminases, and saline responsive metabolic alkalosis. Hypokalemia most likely secondary to inappropriate diuretic use and ETOH intake, resulting in hypokalemia induced rhabdomyolysis. ACTIVE ISSUES # Hypokalemia: Pt presented with bilateral upper and lower extremity weakness. He was found to have a K of 1.9. Patient was evaluated by renal who felt that low K was most likely secondary to diuretic use and ETOH intake. Per patient he was taking his metoprolol [**Hospital1 **] and was also taking his HCTZ at the same time. Patient was initially admitted to medicine but was transfered to the MICU for a short stay for closer cardiac monitoring and K repletion. Initial EKG showed prolonged QT interval and ST-Twave changes. HCTZ was held. PICC line was placed for K repletion. Pt remained on telemetry throughout hospital course with no events. His K improved and stabilized. EKG normalized when K returned to normal limits. His weakness also improved, and he had almost full strength at time of discharge. # Rhabdomyolysis: Pt had profound muscle weakness in BUE and BLE. He had a CK of >5000 on presentation. Of note, no ARF. He did describe some upper back muscle strain when catching heavy groceries at the store 4-5 days prior to presentation, and had spent most of the following days resting in bed with limited mobility. His rhabdomyolysis was most likely secondary to his hypokalemia. He was treated with aggressive fluid and K repletion. To further evaluate his muscle weakness he had additional workup including an ESR which was WNL. He also had an aldolase (elevated at 39) and anti-Jo1 antibodies which were negative. MI-2 autoantibodies were pending at the time of discharge. His CK trended down throughout admission with IV fluids. Muscle weakness and pain improved with the normalization of potassium. # RUE DVT: After transfer to the floor, patient developed right upper extremity swelling and pain. A RUE ultrasound was done which showed a non-occlusive thrombus in the right axillary vein. PICC line was removed. Patient was started on Lovenox [**Hospital1 **]. He was also started on coumadin bridge. Patient was discharged with plan to continue bridge and follow up at coumadin clinic for INR checks and dosage adjustments. # Hypertension: Patient was taking metoprolol and HCTZ at home for treatment of his hypertension. HCTZ was held in the setting of hypokalemia. Amlodipine was started and titrated up to 10 mg. Patient still remained hypertensive despite adequate pain control. Metoprolol was switched to carvedilol. At time of discharge patient was normotensive on carvedilol and amlodipine. # Metabolic alkalosis: Pt had an ABG performed which showed a pure metabolic alkalosis. Likely due to contraction alkalosis which responded to IV fluids. # Transaminitis: with normal AlkP and Tbili, increased AST to ALT ratio, and by history, highly suspect EtOH induced. DDx includes NAFLD given habitus. LFT's were trended down throughout course. CHRONIC ISSUES: # EtOH abuse: He had the tendency to minimize, but in discussion with his daughter, he is actively drinking very heavily. He had no signs of active withdrawal in MICU and did not score on CIWA. Social work was consulted and felt that patient would benefit from more frequent contact with a mental health professional to build a trusting therapeutic rapport for support and motivational counseling however patient was not interested. . # anxiety: continued clonazepam . # insomnia: held trazodone given prolonged QTc . # Medication reconciliation: Suboxone was held while inpatient. HCTZ was also stopped in the setting of hypokalemia. Patient also stated hew as not taking Depakote, Albuterol, Flonase. TRANSITIONAL ISSUES: #Patient was discharged with lovenox teaching to continue bridge with coumadin. He will need to follow up with his primary care doctor and with coumadin clinic as scheduled for INR checks. He will need his coumadin adjusted so that he is in the goal therapeutic range. He will need treatment for at least 3 months. #His blood pressure medication regimen was changed while in the hospital. He will likely need further adjustments of his medications. Patient should avoid potassium wasting diuretics. Medications on Admission: Home Medications: Per list from [**Hospital1 2025**] PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 90791**]. Pt states he's only taking Metoprolol, Vitamin D, Vitamin B, and Klonopin; he stopped taking Depakote, HCTZ, and Suboxone - Albuterol inhaler 2 puff q6 prn wheezing - Cialis 20 gm PO prn - Depakote 250 mg tablet - 1 tablet in the am and 2 tablets in the pm - Flonase [**12-13**] spray daily - HCTZ 25 mg daily - Ibuprofen 400 mg [**12-13**] PO tid prn - Clonazepam 0.5 mg [**Hospital1 **] prn - Maalox/diphenhydramine/lidocaine 1:1:1 10 mL switch q2 - Metoprolol Succinate ER 50 mg PO bid - Suboxone 2 mg PO bid - Vitamin D3 [**2133**] u daily - ? Trazadone 50 mg hs prn - ? Vitamin B-1 100 mg Q day Discharge Medications: 1. Outpatient Physical Therapy 61 yo M with hx of oral cancer s/p resection and etoh abuse who presented with proximal muscle weakness secondary to hypokalemia and rhabdomyolysis. 2. B complex vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 10 days. Disp:*20 Capsule(s)* Refills:*0* 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 6 days. Disp:*12 syringes* Refills:*0* 9. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day) for 2 days. Disp:*1 Tube* Refills:*0* 10. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day for 30 days: Please take this medication as directed by your [**Hospital 197**] Clinic. Disp:*150 Tablet(s)* Refills:*0* 11. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: hypokalemia, rhabdomyolysis secondary diagnosis: hypertension, anxiety, insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 32458**], It was a pleasure caring for you while you were in the hospital. You were admitted because you were having profound weakness in your arms and legs. You were found to have a very low potassium level and an elevated muscle marker indicating muscle breakdown. You had a short stay in the intensive care unit where you had close cardiac monitoring and your potassium repleted. Your weakness improved. You were found to also have a blood clot in your right arm. We started you on a blood thinning medication to treat your clot. You should plan to follow up in the [**Hospital3 **] and with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e. The following medication changes have been made: You should STOP taking: hydrochlorathiazide metoprolol You should START taking: carvedilol amlodipine lovenox coumadin Followup Instructions: This appointment is a routine doctor's visit as well as an INR check (to assess whether or not you still need Lovenox injections). Name: [**Last Name (LF) **],[**First Name3 (LF) 3679**] M Location: [**Hospital 2025**] [**Hospital **] HEALTH CARE CENTER Address: [**Last Name (LF) **], [**First Name3 (LF) **],[**Numeric Identifier 30452**] Phone: [**Telephone/Fax (1) 14144**] When: Thursday, [**2144-7-22**]:45 Completed by:[**2145-7-22**]

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icd9cm

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Discharge summary

report

Admission Date: [**2111-9-18**] Discharge Date: [**2111-9-24**] Service: MEDICINE Allergies: Codeine / Scopolamine Hydrobromide Attending:[**First Name3 (LF) 7651**] Chief Complaint: back/jaw pain and nausea - admitted s/p cardiac cath Major Surgical or Invasive Procedure: Cardiac Catheterization with placement of drug-eluting stent to left main coronary artery. History of Present Illness: 88yo F hx HTN, CKI, hypothyroidism, Sjogren??????s syndrome presented s/p cardiac cath with drug eluting stent to LMCA extending to LAD. The pt presented to her PCP [**Last Name (NamePattern4) **] [**9-16**] c/o several month history of exertional back pain between the shoulder blades. In the past few days it has been occurring at rest and associated with left arm pain as well as nausea. The pain is difficult to categorize (achy/sharp) and generally goes away after [**10-30**] minutes. She c/o some palpitations occasionally associated with these episodes. She takes baby aspirin and rests which help the pain. This morning she had some pain at rest which radiated to her jaw. She denies dyspnea on exertion, PND, orthopnea and ankle swelling. She ambulates well at home up and down stairs. . She was scheduled for stress thallium [**9-18**] which showed normal myocardial perfusion at rest, however the pt was sent to the cath lab as ST changes were shown on ECG concerning for myocardial infarction. Cardiac cath showed 99% proximal and 90% distal LMCA lesions. She underwent Cypher DES to LMain extending to LAD with slight jailing of LCx but persistent flow. There was also a residual 40-50% mid lesion which was left alone. RCA was large with mild disease. In the cath lab she had a vagal response with sheath pull which responded to atropine 1 mg. Of note, her central SBPs were 25 mmHg > than her noninvasive BPs. She was transferred to the CCU in stable condition. . On ROS pt c/o hearing problems with L worse than R. Dry mouth, eyes secondary to Sjogrens. Denies abdominal pain. Stool stress incontinence. Denies constipation or diarrhea. Denies increased urination or burning on urination. No skin changes, lumps or masses noticed. Denies weight changes, fatigue, fevers/chills. All other review of systems negative in detail. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension, CAD 2. CARDIAC HISTORY: no history of cath, echo, stress test 3. OTHER PAST MEDICAL HISTORY: Endometrial Ca Stage 1B s/p hysterectomy and s/p pelvic radiation in [**2099**] Hypothyroidism Sjogren's syndrome SBO x2 with ex-lap & LOA in [**2107**] Social History: Lives alone in N [**Location (un) 7658**]. 2 adult children. Retired high school art teacher. Daughter is involved in care. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Non contributory. Physical Exam: VS: T=35.9 BP=141/55 HR=69 RR=2- O2=96% on 2L NC General Appearance: No acute distress, appears anxious, hoarse / trembling voice. AAOx3. Eyes / Conjunctiva: PERRL. EOMI Head, Ears, Nose, Throat: Normocephalic atraumatic. Oropharynx clear. Nasal cannula. Bilateral carotid bruits. Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: normal S1 & S2, No S3, No S4, 3/6 systolic ejection murmur heard best at LUSB. Not heard at apex. Does not radiate to clavicles. No rubs. Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory/Chest: clear to auscultation bilaterally ?????? limited to anterior exam only Abdominal: Soft, Non-tender, Bowel sounds present, Not Distended, Not Tender. Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, Right groin cath site CDI. Pertinent Results: On Admission: [**2111-9-18**] 11:34PM BLOOD Hct-22.3*# [**2111-9-19**] 04:53AM BLOOD WBC-10.6# RBC-2.90* Hgb-8.4* Hct-25.4* MCV-88 MCH-28.9 MCHC-33.0 RDW-15.7* Plt Ct-211 [**2111-9-19**] 04:53AM BLOOD Neuts-89.6* Lymphs-6.9* Monos-3.2 Eos-0.1 Baso-0.1 [**2111-9-18**] 03:05PM BLOOD PT-12.3 INR(PT)-1.0 [**2111-9-19**] 04:53AM BLOOD Ret Aut-1.8 [**2111-9-18**] 03:05PM BLOOD Glucose-136* UreaN-41* Creat-1.7* Na-140 K-4.8 Cl-108 HCO3-23 AnGap-14 [**2111-9-19**] 04:53AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2111-9-18**] 03:05PM BLOOD Calcium-9.3 Phos-3.2 Mg-1.8 [**2111-9-19**] 04:53AM BLOOD calTIBC-202* Ferritn-135 TRF-155* . [**2111-9-18**] CARDIAC CATHETERIZATION: 1. Selective coronary angiography in this right dominant system demonstrated left main disease. The LMCA had a 99% proximal stenosis, a 50% mid-portion stenosis and a 90% distal stenosis. The LAD had a 40-50% mid stenosis. The D1 had an 80-90% stenosis at the origin. The Cx was small and had moderate plaque at the origin. The RCA was a large calibur vessel with mild disease. 2. Severe systemic arterial hypertension with SBP of 182mm Hg and DBP 82mm Hg. 3. Successful PTCA and stenting of the LMCA with a 3.5 x 23mm Cypher drug eluting stent which was postdilated to 4.5mm. Final angiography revealed no residual stenosis, no angiographically apparent dissection, and TIMI 3 flow. (see PTCA comments for details) 4. Presumed bilateral subclavian stenosis (left > right) with a 40mmHg resting gradient between central aortic and left brachial non-invasive blood pressure. FINAL DIAGNOSIS: 1. Left main coronary artery disease. 2. Bilateral Subclavian stenosis (left > right). 3. Successful PTCA and stenting of the LMCA. . [**2111-9-19**] ECHOCARDIOGRAM: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Small, hypertrophied left ventricle with normal global and regional systolic function. Mild diastolic LV dysfunction. No clinically-significant valvular disease or pulmonary hypertension. . [**2111-9-19**] CT ABDOMEN AND PELVIS: 1. Large hyperdense structure in the right pelvis concerning for a large extraperitoneal hematoma, tracking along the medial thigh. Unable to comment on active extravasation due to lack of IV contrast administration. 2. Compression of the right distal ureter due to large pevic hematoma, causing right kidney hydroureteronephrosis, and calyceal rupture at the lower pole. Atrophic left kidney. Urology consult is recommended. . [**2111-9-22**] MAG3 RENAL SCAN: The differential function obtained by analysis of tracer concentration in the parenchyma from 2 to 3 minutes post tracer injection shows the left kidney to be performing 40% of the total renal function and the right kidney performing 60%. IMPRESSION: 1. Right pelvic hematoma causes no significant right ureteral obstruction. Right renal function is mildly reduced. 2. Persistent nephrogram in the left kidney is likely related to chronic renal disease or contrast nephropathy. . On Discharge: [**2111-9-24**]: Hbg 10.7, Hct 31.6, K 4.2, BUN 59, Cr 2.3, WBC 6.9, Plt 163 Brief Hospital Course: 88 year old female with a history of HTN, chronic kidney injury, hypothyroidism, Sjogrens Syndrome presented status post cardiac catheterization with drug eluting stent placed to the left main with extension to LAD now with pelvic hematoma and renal caliceal rupture. . # CORONARIES: The patient's anginal equivalent is intrascapular back pain with nausea. Precath ECG showed 1mm ST elevations in V1-2 and AVR with depressions in 2,3,AVL. Left main disease seen on cath and stent placed to LMCA extending to the LAD. Post-cath ECGs have been essentially unchaged. Post-cath TnT 0.02 CK 88. No anginal equivalent during hospital stay. The patient was started on Aspirin 325 po qd, Plavix 75 po qd and Atorvastatin 80 po qd. . # HEMATOMA: Developed as the patient began sundowning and became very anxious/restless ~2hrs after cath. Ultrasound was negative for hematoma, but induration and brusing along the inguinal ligament and suprapubic area developed afterwards. CT abd/pelvis showed 10x7cm pelvic fluid collection. It also showed the hematoma possibly compressing the right ureter causing hydronephrosis and possible calyceal rupture. Hematocrit dropped from 31 two days prior to admission to 23. The patient received 4units PRBC and hematocrit has increased and stabilized. Vascular surgery was consulted and the recommended no intervention at this point. Urology was consulted and the recommended a MAG3 Renal scan to evaluate the function of non-obstructed kidney. The scan showed non-obstructed R ureter and decreased function of bilateral kidneys likely due to chronic kidney injury vs contrast-induced nephropathy. Follow up with Dr. [**First Name (STitle) **] in urology was recommended in [**4-5**] weeks. . # ACUTE ON CHRONIC KIDNEY INJURY: The patient's baseline Creatinine 1 year ago was 1.3. Two days prior to admission the patient was advised to stop Olmesartan over concerns of an increased Creatinine to 2.0. Her Creatinine was 1.7 on admission. FENa was 3.3 so a prerenal component was felt to be unlikely. Serum creatinine increased since admission likely due to obstruction of the right kidney as well as possible effects from the dye load during catheterization. Creatinine trended down in the days leading up to discharge. Follow up with the patient's primary care physician [**Last Name (NamePattern4) **] 1 weeks was recommended as well as a repeat measurement of a labs including a BMP. . # DELIRIUM: The patient has a history of sundowning on previous hospital admissions. She was given benzos on the day of admission and her mental status deteriorated. She pulled out an IV as well as her foley catheter. Restraints were used temporarily. We stayed away from benzos for the rest of the admission, and the patient did not have any recurrences of delirium or notable sundowning. . # PUMP: The patient had no previous caths or echos. No history or symptoms of previous HF. Echo showed mild diastolic dysfunction with EF>55%. She was placed on Carvedilol 6.25 po bid. An ACEi or [**First Name8 (NamePattern2) **] [**Last Name (un) **] was held given the elevated creatinine. We have recommended outpatient follow up and restarting of ACEi or [**Last Name (un) **] upon resolution of serum creatinine. . # HYPERTENSION: The patient was on Atenolol at home. She was started on Amlodipine 5 po qd and Carvedilol 6.25 po bid and remained normotensive. . # HYPOTHYROIDISM: The patient's TSH was normal two days prior to admission. We continued levothyroxine 88mcg po qd. . # ANEMIA: Baseline outpatient H/H [**10-31**], MCV 93. Anemia of chronic disease on iron studies. . # FEN: Heart healthy low sodium diet. . ACCESS: PIV's . CODE: Full . COMM: patient, daughter is involved in care. . DISPO: Home with home PT Medications on Admission: ATENOLOL - 25 mg Tablet - one Tablet(s) by mouth daily LEVOTHYROXINE - 88 mcg Tablet - 1 Tablet(s) by mouth every day NITROGLYCERIN - 0.3 mg Tablet, Sublingual - one Tablet(s) sublingually prn chest pain ASPIRIN, BUFFERED - 325 mg Tablet - one Tablet(s) by mouth daily Discharge Medications: 1. Outpatient Lab Work Please check Chem-7, CBC on [**2111-10-30**]. Call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] at [**Telephone/Fax (1) 133**] 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual prn as needed for chest pain. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary Diagnosis: ST elevation myocardial infarction . Secondary Diagnoses: Hypertension CKI hypothyroidism Sjogren??????s syndrome Endometrial Ca Stage 1B s/p hysterectomy and s/p pelvic radiation in [**2099**] Discharge Condition: Good; hemodynamically stable and improved. Discharge Instructions: You were admitted to the hospital for back pain and found to be having a myocardial infarction (commonly known as a heart attack). You had a cardiac catheterization and a stent was placed in your left main coronary artery. After your catheterization, you developed a hematoma in your pelvis that compressed your right ureter, causing a decline in your kidney function. You were treated with several blood transfusions and close monitoring. The bleeding resolved, and your kidney function improved. However, it is important that you follow-up with a urologist(Dr. [**First Name (STitle) **] - see below for appointment time and date) to continue to monitor your overall kidney function. Please also follow up with your PCP and cardiologist (appointments below). . We have made the following changes to your medications: STOP Atenolol STOP Olmesartan START Plavix - This is a medication that helps to keep your blood thin and prevent further clots from forming in your coronary arteries. Do not stop this medication without speaking your cardiologist. START Carvedilol - This is a medication to help control your blood pressure. START Atorvastatin - This is a medication for cholesterol, but is also important for stabilizing disease within your coronary arteries. START Amlodopine - This is another medication to help control your blood pressure Please continue to take your other medications as prescribed. . If you experience any further episodes of chest pain, shortness of breath, dizziness or other concerning symptoms, please call 911 or call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 172**]. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 569**] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 133**] Date/time: [**10-1**] at 10:15am. . Urology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Hospital1 18**] Division of Urology [**Location (un) 830**], [**Hospital Ward Name 23**] clinical center, [**Location (un) 470**] [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 4537**] Date/Time: Tuesday [**10-20**] at 10;45 am. . Cardiology: [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**10-16**] at 2:20pm [**Hospital Ward Name 23**] clinical center, [**Location (un) 436**]

[ "998.2", "E870.6", "244.9", "593.3", "458.29", "E947.8", "403.90", "E879.0", "866.02", "285.1", "414.01", "584.8", "998.12", "585.9", "293.0", "591", "410.11", "447.1", "V10.42" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12516, 12579

7574, 11308

295, 388

12835, 12880

3738, 3738

14554, 15291

2782, 2801

11627, 12493

12600, 12600

11334, 11604

5299, 7459

12904, 13699

2816, 3719

12677, 12814

2346, 2384

7473, 7551

13728, 14531

203, 257

416, 2261

12619, 12656

3752, 5282

2415, 2569

2283, 2326

2585, 2766

22,780

138,174

5572

Discharge summary

report

Admission Date: [**2128-3-19**] Discharge Date: [**2128-4-9**] Date of Birth: [**2050-6-4**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: 77 y.o. male with two weeks of RLE claudication, Two days of RLE rest pain, with a feeling of colness in his RLE. Major Surgical or Invasive Procedure: RLE angiography Revision of right femoral to peroneal bypass graft using vein graft Angioplasty from left cephalic vein Exploration of distal GSV Cardiac Catherization with stenting of left main Intubation post op for resp failure PA catheter placed echocardiogram EF 35-40% History of Present Illness: 77 y.o. male with two weeks of RLE claudication, Two days of RLE rest pain, with a feeling of colness in his RLE. Pt has a hx of a fem - peroneal bypass graft [**Last Name (un) **] a vein graft. On [**8-19**] pt had a percutaneous revision of the graft site for stenosis. Pt re-evaluated for graft patency on [**11-19**]. The graft was found to patent at that time. Past Medical History: L AKA s/p failed LE bypass s/p R fem peroneal bypass HTN CAD Social History: Herbal therapies neg smoker, quit in past 15 yrs ago neg alcohol neg recreational drugs OTC meds - sinus allergy medicine, ES tylenol Family History: non contributory Physical Exam: AFVSS HEENT - NCAT, PERRL Neg lesions nares, oral pharnyx, auditory Supple, FAROM Neg lymphandopathy LUNGS - CTA B/L with sligtht crackles bases CARDIAC - RRR without murmers, Palpable PMI ABD - Soft, Pos BS, NTTP, neg Bruits, neg organomegaly, neg AAA NUERO - A/O x3 NAD EXT - LLE AKA / palpable femoral pulse RLE Slight edema noted Graft 2 plus Pertinent Results: [**2128-4-8**] 04:01AM BLOOD WBC-12.1* RBC-3.38* Hgb-9.5* Hct-29.5* MCV-87 MCH- [**2128-3-27**] 02:24AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.021 [**2128-3-19**] 06:00PM BLOOD Neuts-60.9 Lymphs-29.6 Monos-5.9 Eos-3.2 Baso-0.4 [**2128-4-8**] 04:01AM BLOOD Plt Ct-437 [**2128-4-8**] 04:01AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 [**2128-4-3**] 03:19AM BLOOD freeCa-1.17 Brief Hospital Course: Pt had a difficult hospital stay Pt admitted on [**2128-3-19**] for a right leg ischemia Pt underwent the following procedures on [**2128-3-19**] 1. Thrombectomy of right femoral to peroneal artery in-situ saphenous vein graft. 2. Revision vein graft with vein patch angioplasty using left arm cephalic vein. 3. Harvest of upper arm extremity vein. After procedure pt admitted to PACU then VICU, early post up pt experienced EKG changes, specifically for ST depression V3-V5, had Brief runs NSVT and also complained of some chest pain. A cardiology consult was obtained. Pt R/I for NSTEMI. On [**2128-3-21**] Pt experienced with resp. failure. Pt was transferd to the SICU for observation. Later in the day pt condition became worse. Pt had to intubated and at this time pt recieved a R IJ CVL. A chest X-Ray showed resp. failure. Pt dalso experienced ARF secondary to hypotensive episode experienced with his NSTEMI. During this time pt was aggressively treated for both CHF and ARF, both which resolved during his stay in the SICU. On [**3-22**] pt underwent Cardiac catherization. The catherization showed: 1. Selective coronary angiography revealed a right-dominant system with left-main and 3-vessel coronary disease. 2. The LMCA had a hazy proximal 95% stenosis and a distal tapering 50% stenosis. 3. The LAD was diffusely diseased with serial proximal and mid-vessel 60% stenoses and an 80% long tubular stenosis in the distal vessel. 4. The LCx had severe diffuse disease and a 70% stenosis in the mid-vessel involving the origin of the OM1 branch. The RCA had severe diffuse disease up to 50-60% throughout with a focal 80% stenosis of the RPL branch. 5. Echo showed an ejection fraction of 35% with anterior hypokinesis. He is thus referred for cardiac catheterization for evaluation of coronary anatomy Cardiology decided to do an intervention which consisted: 1. Successful stenting of the ostial Left Main with a 3.5x13mm Cypher [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] with a 4.5x12mm Quantum MAverick at 16 atms. Pt remained intubated, tolerated the procedure and transfered back to the SICU in stable condition On [**3-25**] pt experienced new onset A-Fib. Pt was treated aggressively, the A-Fib has resolved. Pt extubated the same day. Pt remained in the SICU untill [**2128-4-1**]. During this time frame he was treated for the variety of ailments mentioned above. On 3 /18 pt transeferd back to the VICU in stable condition. Pt remianed in the VICU untill [**4-7**], then transfered to the floor. Pt screened by PT / Case management. Pt discharged from the hospital in stable condition. Medications on Admission: Captopril Atenolol Paxil Lipitor Colace Nueurontin Aprazolam Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, 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. 5. Clopidogrel Bisulfate 75 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 30 days: after thirty days, decrease plavix to 75 mg for 9 months. 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed. 9. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 10. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Clonidine HCl 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-18**] Drops Ophthalmic PRN (as needed). Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: Occluded Right femoral peroneal graft, had revision to correct Respiratory failure p/o requiring intubation Non Specific Ventricular Tachycardia - R/I for MI - requiring left main stent Afib post op, now RRR Acute Renal Failure post op EF 35-40% HTN Hypercholesteralemia LAKA Failed Left LE bypass Known L CIA/EIA occlusion CAD LBP S?P laminectomy Discharge Condition: stable Discharge Instructions: Check for fevers and chills - if have evaluate Look at surgical wounds - if drainage, erythematous or swelling please call Dr [**Last Name (STitle) 22423**] office F/U cardiology as directed F/U Dr [**Last Name (STitle) **] as directed below Per PT OOB with asst [**Hospital1 **] Ambulate pt PRN Followup Instructions: Follow up with Cardiology in 12 weeks from the date of stent [**2128-3-23**] Please call [**Telephone/Fax (1) 22424**] Follow up with Dr [**Last Name (STitle) **] in two weeks, please call [**Telephone/Fax (1) 22425**] Completed by:[**2128-4-9**]

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icd9cm

[ [ [] ] ]

[ "89.68", "88.56", "37.22", "99.04", "38.91", "38.93", "96.71", "36.07", "00.13", "39.49", "39.56", "89.64", "36.01", "96.04", "96.72", "88.48", "96.6" ]

icd9pcs

[ [ [] ] ]

6614, 6685

2235, 4893

426, 703

7078, 7086

1827, 2212

7430, 7679

1349, 1367

5004, 6591

6706, 7057

4919, 4981

7110, 7407

1382, 1808

273, 388

731, 1098

1120, 1182

1198, 1333

27,374

132,922

45107

Discharge summary

report

Admission Date: [**2109-2-3**] Discharge Date: [**2109-2-7**] Date of Birth: [**2042-6-25**] Sex: F Service: MEDICINE Allergies: Mevacor / Bactrim / Dilantin Kapseal / Naprosyn / Clindamycin / Percocet / Quinine / Levofloxacin / Penicillins / Vicodin / latex gloves / Morphine / optiflux / Warfarin / Phenytoin Attending:[**First Name3 (LF) 2782**] Chief Complaint: hypoglycemia Major Surgical or Invasive Procedure: HD [**2109-2-4**] History of Present Illness: 66F with Afib on lovenox, ESRD, dCHF,HTN, DMII, severe COPD on home O2, recently hospitalized [**12/2108**] for necrotizing breast infections s/p b/l mastectomy who was transferred from [**Location (un) 620**] due to persistent hypoglycemia and susp LLL pneumonia. . . Patient was previously hospitalized at [**Hospital1 18**] [**1-18**] - [**1-21**] due to bil breast infection complicating skin wounds attributed to warfarine skin necrozis which initially developed in 7/[**2108**]. During that hospitalization was treated with bilateral mastectomy for removal of infected tissue. Also noted to have infected leg wounds thought to be [**2-28**] to calcifilaxis. Patient was discharged to rehab [**1-21**] and on [**1-26**] completed a 14 day course of Vanc + Ceftazidim for her breast and leg infection. . Today patient was found unresponsive in nursing home with FS = 7. given juice and D50 with improvement in mental status. On the way to [**Location (un) **] ED was given [**1-28**] amp D50 for FS 50. At [**Location (un) 620**] fingerstck drop again to 20 given amp D5o and started on D5W @ 200/hr. However, became hypoglycemic again later despite D50@200cc/hr. Also endorsed dyspnea and was found to have LLL pneumonia on CXR. Was given levofloxacin and transferred to [**Hospital1 18**] on D5. FSG on arrival was 87 and patient had received 800cc of D5. . . Patient states pain of left arm with any movement, right shoulder pain. [**Hospital1 4273**] fever, chills, nausea, vomiting, or diarrhea. . States makes very little urine, mostly in AM and occasionally at night. Foley placed in ED no urine return. [**Hospital1 **] Tuesday, Thursday, Saturday. Had [**Hospital1 2286**] yesterday which she tolerated well. . Diagnosis: ED Course (labs, imaging, interventions, consults): - Initial Vitals/Trigger: 96.1 59 141/100 16 100% 3L Nasal Cannula, noted to be very somulent patient very somnolent, FS 87 - EKG: [x] check FSG bc 17:10 152. due to labile glucose 1 amp D50 given. [x] 1 amp D50, starting d10 drip [ ] labs: cbc, chem7, lactate, LFTs - all at recent baseline [x] got vanc (17:00), cefepime (18:30) for HCAP . . Disposition/Pending: ICU admission for hypoglycemia and pneumonia. Patient too somnolent to take in POs, so will need d10 and glucose monitoring. . On arrival to the MICU, patient complains of generalized pain which is her baseline aches and pains for which she takes oxycodone. She also complains of being cold. She otherwise [**Hospital1 **] any acute complaints. . . Review of systems: (+) Per HPI (-) [**Hospital1 4273**] fever, chills, night sweats, recent weight loss or gain. [**Hospital1 4273**] headache, sinus tenderness, rhinorrhea or congestion. [**Hospital1 4273**] shortness of breath, or wheezing. [**Hospital1 4273**] chest pain, chest pressure, palpitations, or weakness. [**Hospital1 4273**] nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. [**Hospital1 4273**] dysuria, frequency, or urgency. Past Medical History: - CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in [**8-1**] - CHF, LVEF >55% on echo in [**2107**]. 1+ MR - Atrial fibrillation - Hypertension - Dyslipidemia: Chol: 171, LDL 92 in [**1-/2108**] on Pravastatin - Multiple prior Syncope/Presyncopal episodes - Type 2 DM on insulin, last A1c 8% in [**2107**] - ESRD on HD since [**2107-2-28**] - [**Year (4 digits) 2286**] on MWF, and UF on Thursday - She had a left upper arm brachiocephalic AV fistula created which did show some maturation, but the vein was found to be too deep and too tortuous for use. - PVD s/p bilateral fem-[**Doctor Last Name **] in [**2093**] (right), [**2100**] (left) - restricitve lung disease last [**Year (4 digits) 1570**]'s of [**10-6**] consistent with restrictive pattern. FEV1 = 71%, FVC = 68% FEV1/FVC = 105, on home O2 3L - title of COPD but most recent [**Date Range 1570**]'s showed reastrictive pattern - OSA- CPAP at home 14 cm of water and 4 liters of oxygen - Morbid obesity (BMI 54) - Crohn's disease - not currently treated, not active dx [**2093**] - Depression - Gout - Hypothyroidism - GERD - Chronic Anemia - Restless Leg Syndrome - Back pain/leg pain from degenerative disk disease of lower L spine, trochanteric bursitis, sciatica - calciphylaxis - warfarin skin necrosis Social History: long term nursing home resident: Lived on the [**Location (un) 448**] of a 3 family hous with [**Age over 90 **] year old aunt and multiple cousins in Mission [**Doctor Last Name **] and walked with a walker. Lived at [**Hospital **] rehab since [**Month (only) 205**] when she was diagnosed with calciphylaxis. More recently has been living at Avory Manors. No wheelchair bound. Quit smoking in [**2102**], smoked 2.5ppd x 40 years (100py history). [**Year (4 digits) **] ALCOHOL, [**Year (4 digits) **] other drug use. Retired from electronics plant. Family History: Sister: CAD s/p cath with 4 stents MI, DM Brother: CAD s/p CABG x 4, MI, DM, Mother: died at age 79 of an MI, multiple prior, DM Father: [**Name (NI) 96395**] MI at 60. She also has several family members with PVD Physical Exam: VS - T 95.9, HR 84, BP 149/79, RR 16, 100% on 3L GENERAL - NAD, drosy but easily arousable, oriented X3, comfortable. NECK - obese, hard to assess JVP, no carotid bruits LUNGS - good bil air movement, inspiratory crackles over LLL, no rh/wh, unlabored, no accessory muscle use HEART - distant heart sounds, regular rhythm, no MRG ABDOMEN - NABS, soft, NTND, obese, midline incisional hernia, no appreciable HSM EXTREMITIES - WWP, + [**3-31**] bil LE pitting edema. bil surgical scars on shins with bil 3cm yellow based ulcers, the one on the right is medial and inferior to knee and surrounded by 0.5cm rim of erythema. Also has stage 3 decub ulcer on left gluteus and stage 2 on right gluteus. DP pulses are doplerable, radial pulses are thready. SKIN - LLE wounds as above. Chest: s/p bil mastectomy, surgical wounds look clean w/o erythema/fluctuation/discharge. LYMPH - no cervical, axillary, or inguinal LAD NEURO - A&Ox3, CNs II-XII grossly intact, motor [**6-1**] throughout, DTR's +1. On discharge: VS - 97.1 143/66 83 19 96% 2L GENERAL - NAD, alert and oriented, responding appropriately to questions during [**Month/Day (1) 2286**]. NECK - obese, supple LUNGS - CTA b/l, few crackles at bases, intermittent wheezes HEART - distant heart sounds, regular rate, no MRG ABDOMEN - obese NABS, soft, NTND. EXTREMITIES - WWP, 2+ bil LE pitting edema. Skin: + ulceration of skin under R pannus at groin, b/l shin ulcers SKIN - s/p bil mastectomy, stitches removed, no drainage. Pertinent Results: [**2109-2-3**] 04:20PM BLOOD WBC-10.1 RBC-3.28* Hgb-9.6* Hct-31.2* MCV-95 MCH-29.3 MCHC-30.8* RDW-17.5* Plt Ct-280 [**2109-2-3**] 04:20PM BLOOD PT-10.7 PTT-29.9 INR(PT)-1.0 [**2109-2-3**] 04:20PM BLOOD Glucose-31* UreaN-17 Creat-2.7*# Na-143 K-3.5 Cl-98 HCO3-27 AnGap-22 [**2109-2-3**] 04:20PM BLOOD ALT-17 AST-20 AlkPhos-162* TotBili-0.2 [**2109-2-3**] 04:20PM BLOOD Albumin-2.9* Calcium-9.1 Phos-2.5* Mg-1.5* [**2109-2-3**] 06:52PM BLOOD Glucose-29* [**2109-2-7**] 06:29AM BLOOD WBC-5.5 RBC-3.15* Hgb-9.4* Hct-29.9* MCV-95 MCH-29.8 MCHC-31.5 RDW-16.9* Plt Ct-285 [**2109-2-7**] 06:29AM BLOOD Glucose-148* UreaN-23* Creat-3.8* Na-134 K-4.3 Cl-89* HCO3-27 AnGap-22* [**2109-2-7**] 06:29AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.7 [**2109-2-3**] 04:20PM BLOOD Cortsol-35.3* [**2109-2-3**] 04:20PM BLOOD TSH-1.1 CXR: [**2108-2-4**]: Lung volumes are lower exaggerating what is at least worsened moderate pulmonary edema. More focal areas of opacification in the lateral left mid lung and infrahilar right lung could be atelectasis and edema but pneumonia is of serious concern. The moderately enlarged cardiac silhouette and dilated pulmonary arteries are larger today, and there is more mediastinal [**Month/Day/Year 1106**] engorgement. Dual channel right supraclavicular central venous line ends in the upper right atrium as before. There is no appreciable pleural effusion and no pneumothorax. CXR [**2108-2-6**]: 1. Right infrahilar opacity is most likely pneumonia. 2. Improving pulmonary edema. Brief Hospital Course: 66F with Afib on lovenox, ESRD, dCHF,HTN, DMII, restricitve lung disease on home O2, recently hospitalized [**12/2108**] for necrotizing breast infections s/p b/l mastectomy transferred from outside hospital fro was transferred from [**Location (un) 620**] due to persistent hypoglycemia and LLL pneumonia. . # hypoglycemia: Patient reported episodes of hypoglycemia in the mornings to to 40s for the past several weeks. She was hypoglycemic to 7 on the day of admission. She had no recent changes in insulin d AM hypoglycemias to the 40's in the mornings over past two weeks. Was hypoglycemic to 7 on morning of day of admission. She had no recent changes in insulin dosage and no changes in other medication. Did have reduced frequency of dyalisis from X4/week to 3/week during this period which may have contributed to change in insulin clearance. Medication error in nursing home may also explain her profound and prolonged hypoglycemia though no such occurance was documented. Work up during hospital stay did not reveal other causes of hypoglycemia: tox screen was neg, liver functions normal, normal random cortisol, normal TSH, no signs of sepsis. Patient was treated with IV D10W drip + PRN IV D50W, overnight FS normlized and drip was weaned off. She was seen by [**Last Name (un) **] consult who recommended one unit of Novolin N with conservative sliding scale. [**Last Name (un) **] follow needs to be scheduled as outpatient. . # HCAP: Patient was initially thought to have possible pnueumonia and started on Vancomycin and Cefepime for HCAP, but these were discontinued given absence of symptoms. They were restarted after repeat CXR confirmed a RML pneumonia. Unfortunately no cultures could be obtained. Patient to be discharged on Ceftazadime and Vancomycin for 7 day course of treatment of HCAP. She does have documented history of Klebsiella resistant to Ceftazadime from prior breast infection. Given preference by renal team to avoid PICC line, trial of Ceftazadime was preferred. If patient is to clinically to worsen, patient should be switched to gentamycin at dose of 140mg with HD. # leg wounds: these are chronic and attributed to calciphylaxis as had prior biopsy of wound in her thigh which was compatible with this. Given h/o crohn's disease Wound consult was following with [**Last Name (un) 7219**] for routine daily skin care. # Afib on Lovenox: no longer on warfarin [**2-28**] to skin necrosis She was continued on home metoprolol and digoxin (dig level 0.9 on admission) Lovenox was also continued, factor Xa level checked was 1.64. Her hematologist was notified of these results and patient will be contact[**Name (NI) **] if any adjustment needs to be made, though upon discussion with the nurse managing her anticoagulation, this us unlikely. # ESRD: nephrology following. on T/Th/Sa schedule. She was continued with [**Name (NI) 2286**] per her routine schedule. #Breast skin necrosis s/p bilateral mastectomy: in [**12/2108**] for skin wounds which were attributed to warfarine skin necrosis. Pathology from left breast showed invasive intra-ductal carcinoma. Surgical attending and primary care had already known about this path result and discussed diagnosis with family and patient prior to this admission and patient and her surgeon and PCP all agreed not pursue any further workup/staging/or treatment given her comorbidities, significant prior breast wounds, and small malignant lesions. Chronic issues: # chronic lung disease - restrictive pattern on [**9-/2106**], on home O2. - continue home O2 - not on inhalers at home (per patient stopped > 1y ago) # Type 2 DM: - holding insulin given hypoglycemia. . # Depression:continued paroxetine given somnulence . # Chronic anemia - on last admission was given 2 units of pRBCs with hemodialysis. Hct now at baseline. - follow Hct # CHF/CAD/HLD: CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in [**8-1**]. She was continued on home metoprolol, statin, aspirin. # Hypothyroidism: continued home levothyroxine. Medications on Admission: Medications: (confirmed with list from rehab) . Ascorbic Acid 500 mg PO/NG DAILY Start: In am Aspirin 81 mg PO/NG DAILY Digoxin 0.0625 mg PO/NG DAILY Start: In am Enoxaparin Sodium 100 mg SC Q M/W/F Start: In am FoLIC Acid 1 mg PO/NG DAILY Start: In am Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush [**Numeric Identifier **] Catheter (Temporary 2-Lumen): [**Numeric Identifier **] NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. Levothyroxine Sodium 175 mcg PO/NG DAILY Start: In am Lactulose 30 mL PO/NG DAILY:PRN constipation Metoprolol Tartrate 25 mg PO/NG TID Start: In am hold for SBP < 90 or HR < 60 Nephrocaps 1 CAP PO DAILY OxycoDONE (Immediate Release) 5 mg PO/NG ONCE Duration: 1 Doses oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours): at 9am and 9pm. Omeprazole 40 mg PO DAILY Start: In am Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation Pravastatin 80 mg PO DAILY Start: In am Senna 1 TAB PO/NG HS insulin glargine 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. insulin regular human 100 unit/mL Solution Sig: per sliding scale units Injection QACHS: pls inject SUBCUTANEOUSLY per sliding scale: 200-250 2 units 251-300 4 units 301-350 6 units. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). . Allergies: . Bactrim, Phenytoin, Quinine, Vicodin, Warfarin, latex gloves, optiflux, Clindamycin, Dilantin Kapseal, Mevacor, Morphine, Naprosyn, Penicillins, Percocet, Bactrim, Clindamycin, Dilantin Kapseal, Levofloxacin, Mevacor, Morphine, Naprosyn, Penicillins, Phenytoin, Quinine, Vicodin, Warfarin, latex gloves, optiflux . Discharge Medications: 1. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q M/W/F (). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. heparin (porcine) 1,000 unit/mL Solution Sig: One (1) flush Injection PRN (as needed) as needed for line flush: 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush [**Numeric Identifier **] Catheter (Temporary 2-Lumen): [**Numeric Identifier **] NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 7. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lactulose 10 gram/15 mL (15 mL) Solution Sig: Thirty (30) mL PO once a day as needed for constipation. 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 14. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 15. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for wheezing. 18. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 19. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous qHD: last day [**2109-2-11**]. 21. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): last day [**2108-2-12**]. 22. ceftazidime 1 gram Recon Soln Sig: One (1) gram Intravenous QHD (each hemodialysis): last day [**2109-2-11**]. 23. Novolin N 100 unit/mL Suspension Sig: One (1) unit Subcutaneous once a day: prior to lunch. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: hospital acquired pneumonia hypoglycemia 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 to care for you during your hospitlaization. You were admitted for evaluation and treatment of hypoglycemia. During your hospitalization you were noted to have a right lung pneumonia for which you were started on antibiotics which are given at [**Location (un) 2286**]. MEDICATION CHANGES DURING THIS ADMISSION: START Vancomycin for treatment of pneumonia, last day is [**2-11**] START Ceftazadime for tratment of pneumonia, last day is [**2-11**] START Cinecalcet for bone health Insulin regimen changed to: 1 unit Novolin N at lunchtime daily with new sliding scale, please see attached sliding scale. Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] *The office is working on a follow up appointment for your hospitalization. It is recommended you follow up within 1 week. The office will contact you at home with the appointment information. If you have not heard within 2 business days please call the office. Completed by:[**2109-2-8**]

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Discharge summary

report+addendum

Admission Date: [**2186-3-4**] Discharge Date: [**2186-4-14**] Date of Birth: [**2115-7-24**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: Right heel ulcer Major Surgical or Invasive Procedure: Right heel debridement EGD with sclerotherapy ORIF right hip History of Present Illness: This unfortunate 70 year-old gentleman, with peripheral vascular disease, liver cirrhosis and cancer has developed ischemic related gangrene of his right heel. He was transferred from another hospital with infection. He has been treated with antibiotics for 48 hours and is now undergoing debridement. Past Medical History: PMH: glaucoma, MI ([**2161**]), DM1, hepatitis NOS, cirrhosis, small cell lung CA s/p chemo/XRT PSH: A0-bifem ([**2178**], [**Last Name (un) 60919**]), B cataract, R hand surgery Social History: Pt lives with his wife and other dtr, in their own home in [**Name (NI) 1474**]. Dtr, [**Name (NI) **], lives nearby and is very involved and supportive. Son also lives in MA and is supportive. [**Name (NI) 1094**] wife is wheel chair bound secondary to polio, but is very independent and has essentially been caretaker for pt in more recent years as his health/mobility has declined. Dtr,[**Name (NI) **], is currently rennovating her home and plan is for parents and sister to live with her and her family by the end of the summer. Previous drinker Denies tobacco Family History: Non contributary Physical Exam: General - pale cachectic male laying in bed, good spirits, freindly HEENT - NCAT / PERRL / EOMI, neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lymphandopathy, supra clavicular nodes RESP - CTA B/L upper lobes, crackles at bases CARDIAC - RRR 1/6 SEM at apex ABD - tympanic, distened, NTTP, pos BS, neg CVA tenderness BRUITS - non noted EXT - Doppler PT/DP/AT B/L RIGHT HEEL - excised, clean, dry. minimal erythema around debridement site, good granulation Pertinent Results: [**2186-3-28**] WBC-10.2 RBC-3.17* Hgb-9.7* Hct-29.2* MCV-92 MCH-30.7 MCHC-33.3 RDW-16.7* Plt Ct-183 [**2186-3-27**] PT-13.6* PTT-32.2 INR(PT)-1.2 [**2186-3-22**] Fibrino-530* [**2186-3-28**] Glucose-42* UreaN-15 Creat-1.0 Na-133 K-3.7 Cl-107 HCO3-22 AnGap-8 [**2186-3-23**] ALT-9 AST-25 AlkPhos-86 Amylase-23 TotBili-2.2* [**2186-3-15**] calTIBC-103* TRF-79* [**2186-3-4**] %HbA1c-7.0* [Hgb]-DONE [A1c]-DONE [**2186-3-11**] Triglyc-44 [**2186-3-23**] freeCa-1.28 RADIOLOGY Final Report [**2186-3-23**] CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST INDICATION: History of lung cancer, now with ulcer in the esophagus. Evaluate for cancer recurrence. Soft tissue window images demonstrate abnormal esophageal wall thickening in the distal esophagus with multiple lymph nodes which are at the upper limits of normal in size, but given its proximity to the abnormal esophagus, are also likely abnormal. Additionally, there are moderate to large bilateral pleural effusions, greater on the left. The left pleural effusion is loculated with a moderate supbulmonic component. Additionally, there is subtle linear enhancement of the posterior surface of the left pleura. There is bibasilar atelectasis, left greater than right, associated with the bilateral pleural effusions. The entire left lower lobe is collapsed/consolildated. In both upper lobes, there are geographic areas of opacity with traction bronchiectasis and scarring, likely relating to prior radiation therapy. An ill-defined 5mm ground glass nodule is seen in the right middle lobe. There are diffuse emphysematous changes in both lobes. At the base of the right lung, there is an irregular area which likely represents atelectasis/scarring. The heart, pericardium, and great vessels are normal. In the visualized portion of the upper abdomen, again seen is ascites, a hiatal hernia, and right hydronephrosis. The visualized portions of the spleen and left kidney are normal. BONE WINDOWS: No suspicious sclerotic lesions are seen. IMPRESSION: 1. Abnormal thickening of the distal esophagus with adjacent lymphadenopathy, worrysome for malignancy. 2. Geographic areas of opacity in both upper lobes, consistent with prior radiation. 3. Subtle linear enhancement of the left posterior pleural surface. While this could be due to radiation, given the history of lung cancer, pleural based metastatic disease is of high concern. 4. 5 mm ground glass nodule in right middle lobe. The nodule is somewhat ill- defined, and is nonspecific, but given the history of lung cancer, a 3 month follow- up chest CT is reccommended. 5. Bilateral moderate to large pleural effusions and associated bibasilar atelectasis. The left pleural effusion appears loculated, with a moderate subpulmonic component, and there is associated complete collapse/consolidation of the left lower lobe. 6. Unchanged ascites, right hydronephrosis, and a hiatal hernia. RADIOLOGY Final Report [**2186-3-21**] ABDOMEN (SUPINE & ERECT) PORT [**Hospital 93**] MEDICAL CONDITION: 70 year old man with +NTG, dark blood, h/o partial bowel obstruction INDICATION: History of partial bowel obstruction with dark blood in the NG tube. DECUBITUS AND SUPINE VIEW OF THE ABDOMEN: Dilated loops of small bowel are present in the right abdomen measuring up to 5 cm in transverse diameter. Air- fluid levels are demonstrated on the left lateral decubitus view. The degree of dilatation of small-bowel loops appears slightly decreased compared to the study of [**2186-3-9**]. [**2186-3-9**] CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST INDICATION: 70-year-old man with history of lung cancer, now with nausea and vomiting, and loose stools. Small pleural effusions are seen bilaterally. There is a small hiatal hernia. A nasogastric tube descends below the diaphragm and terminates in the stomach. There are diffuse coronary artery calcifications, and atherosclerotic disease within the aorta. There is a large amount of intraperitoneal ascites. The liver is cirrhotic, without nodules or masses. The gallbladder is not visualized. The pancreas, spleen, both adrenals are normal. There is mild hydronephrosis of the right kidney, with delayed contrast excretion. The abdominal aorta is diffusely calcified with good contrast opacification of the intraabdominal vessels. There is diffuse dilatation of the intraabdominal loops of small bowel, measuring 4.6 cm in cross sectional diameter with multiple air fluid levels. There is fecalization of the small bowel within the terminal ileum, within the right lower quadrant. No focal masses are seen within this area. Distal loops of small bowel and colon are decompressed with minimal contrast opacification of the ascending colon. There is no evidence of pneumatosis, or pneumobilia. CT OF THE PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: Dense calcification of the intra-abdominal aorta increases in to bilateral iliac arteries. A Foley catheter is seen within a collapsed bladder. Minimal gas and stool are seen within the sigmoid and rectum. BONE WINDOWS: Degenerative changes are seen throughout the lower thoracic and lumbar spine. There are no suspicious lytic or sclerotic osseous abnormalities. There is diffuse subcutaneous edema. IMPRESSION: 1) Small-bowel obstruction with a possible transition point in the distal ileum, within the right lower quadrant. No focal masses are identified at this area. 2) Delayed right renal nephrogram with mild hydronephrosis consistent with distal obstruction. 3) Cirrhotic liver. 4) Bilateral pleural effusions. 5) Dense diffuse atherosclerosis of the coronaries, and intraabdominal aorta. 6) Small hiatal hernia. [**2186-3-18**] HIP UNILAT MIN 2 VIEWS RIGHT REASON FOR THIS EXAMINATION: Please assess R femur fracture Again, demonstrated is a fracture of the right femoral neck with angulation at the fracture site. There is also some degree of impaction with foreshortening of the femoral neck. The projection is slightly different than the previous study. Allowing for this factor, the fracture is likely unchanged. No additional fractures are identified. Extensive vascular calcifications are present. [**2186-3-18**] PELVIS PORTABLE Reason: low pelvis to view arthroplasty The patient is status post right total hip replacement procedure with satisfactory postoperative alignment on a single projection. Immediate postoperative changes are noted including soft tissue gas and superficial skin staples. Extensive vascular calcifications are again observed. [**2186-3-18**] L-SPINE (AP & LAT) REASON FOR THIS EXAMINATION: New-onset loss of L5 motor function, please assess for compression fx. INDICATIONS: Recent onset of loss of L5 motor function. Question compression fracture. The bones are diffusely demineralized. There is a mild compression deformity at the L4 vertebral body level. Very minimal loss of height is noted at L5 as well. The remaining lumbar vertebral bodies show preservation of normal height. The disk spaces are relatively well preserved with some mild narrowing noted at L3-L4. Degenerative changes are noted posteriorly in the facet joints. Extensive vascular calcifications are seen throughout the abdominal aorta and its branches. Regarding the decreased height at L4, it was likely present at the time of the recent abdominal radiograph as well, but difficult to compare due to lack of the lateral view at that time. Within the abdomen, note is made of multiple air filled loops of dilated bowel, which were also present on a recent CT of the abdomen of [**2186-3-9**], which described a small-bowel obstruction. There is also a suggestion of ascites. IMPRESSION: 1) Compression deformity at L4 and very minimal compression at L5. 2) Dilated loops of small bowel, concerning for small-bowel obstruction. Please note that recent abdominal CT of [**2186-3-9**] described a small-bowel obstruction. Probable ascites. [**2186-3-17**] CT HEAD W/O CONTRAST INDICATION: Fall. Head trauma. NONCONTRAST HEAD CT: There is no acute intra- or extra-axial hemorrhage, hydrocephalus, shift of normally midline structures, or evidence of major vascular territorial infarction. There is a generalized prominence of the sulci and ventricles consistent with brain atrophy. Small likely lacunar infarcts are present in the periventricular white matter bilaterally. There is no skull fracture. Visualized paranasal sinuses are clear. There are dense carotid siphon calcifications. IMPRESSION: No acute intracranial hemorrhage. [**2186-3-11**] Cardiology Report ECG Sinus rhythm. First degree A-V delay. Prior inferior wall myocardial infarction. Probable prior anteroseptal myocardial infarction. Borderline low voltage. Since the previous tracing of [**2186-3-8**] atrial ectopy is absent. Intervals Axes Rate PR QRS QT/QTc P QRS T 92 250 86 378/427.71 64 34 46 [**2186-3-4**] CHEST (PRE-OP PA & LAT) CHEST X-RAY, PA AND LATERAL VIEWS: The study is compared to [**2186-2-15**]. The heart size is normal. The mediastinal and hilar contours are essentially unchanged with prominent opacity again seen at the left hilum. The pulmonary vascularity is unremarkable. The lungs show similar prominent interstitial markings, but the appearance is unchanged allowing for differences in technique. There are no pleural or pericardial effusions. The lungs are clear. The osseous structures are unremarkable. IMPRESSION: No significant change since the prior study, or acute cardiopulmonary process. [**2186-3-21**] SPUTUM Site: EXPECTORATED **FINAL REPORT [**2186-3-27**]** GRAM STAIN (Final [**2186-3-21**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2186-3-24**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. SPARSE 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S [**2186-3-4**] R HEEL/SUPERFICIAL WD. **FINAL REPORT [**2186-3-8**]** WOUND CULTURE (Final [**2186-3-8**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). PROBABLE ENTEROCOCCUS. MODERATE GROWTH. GRAM NEGATIVE ROD(S). RARE GROWTH. 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S [**2186-3-18**] URINE **FINAL REPORT [**2186-3-19**]** URINE CULTURE (Final [**2186-3-19**]): NO GROWTH. Brief Hospital Course: Pt had a difficult hospital course Pt admitted on [**2186-3-4**] for heel ulcer Pt wound is swabbed, blood cx taken, pt is stared on IV antiotics [**2186-3-4**] - [**2186-3-6**] Pt stable [**2186-3-7**] - [**2186-3-8**] Pt taken to the OR for debridement of the right heel, He had a right heel block. He tolerated the procedure well. There were no complications. Transfered to the PACU in stable condition. There was extensive debridemnt in th OR, infection to the bone, discussed BKA with patient. [**11-29**] blood cx are positive for septecemia, pt followed with surveillance cultures. IV antibiotics adjusted accordingly. [**2186-3-9**] - [**2186-3-12**] Pt experiences decrease U/O. Foley placed. Minimal urine output noted. Urine lytes orderd. Pre renal. Pt treated with fluids. Because of the pts known cirrohsis, minimal N/V, distention of the abdomen not usual for the pt. A KUB was ordered. It was found that the pt had a SBO. CT SCAN obtained. Pt was made NPO/PO meds were changed to IV/NGT placed. TPN started. Nutrition labs ordered. General Surgery consult obtained. They recommended treating conservativley. Diagnosis partial SBO. [**2186-3-13**] - [**2186-3-15**] NG tube removed, pt diet was advanced. Pt doing well. [**2186-3-16**] - [**2185-3-18**] Pt fell trying to got to the bathroom. A stat CT scan was ordered. which was negative for an acute bleed. The following day pt still c/o right hip pain. Plain films were ordered. Showed a fracture of the right hip. A trauma consult was obtained. Ortho consult was obtained for the right femoral neck fracture. Pt started on Levonox for enbolis precations. Pt taken to the OR for ORIF of the right hip. [**2186-3-19**] - [**2186-3-21**] Pt undergoes right bipolar hip replacement. ( tolerated the procedure well. There were no complications. Pt transfered to the PACU in stable condition. Pt transfered to VICU in stable condition. It was noticed that the patients HCT was steadily decreasing after the procedure. He was transfused appropriatly. on [**2186-3-21**] Pt has an episode of coffee ground emesis. NG tube replaced. 300 cc of coffee ground emmesis evacuated. Pt stool was guiac Positive. Because of the decreasing HCT and the obvious GI bleed from the NGT and the stool. A GI consult was obtained. Before GI saw the pt the pt became hypotensive, tachycardic. The pt had to be emergently transfered to the ICU. Pt had to intubated for airway protection. The levonox was DC'd, protonix was started. Labs were ordered. It was found that the pt had an increase of INR/PT - secondary to Cirrohsis. FFP was given. Fluid resusitation was started. Pt taken for emergent EGD - found to have active variceal bleeding. Treated with scleropathy. Pt started on Octreotide drip. Levo started for prophalaxsis. A Heptology consult was obtained. [**2186-3-22**] Repeat EGD performed. Pt stabalized. [**2186-3-23**] - [**2186-3-30**] Pt transfered to the regular floor. A podiatry consult was obtained to gather information on conservative treatment given the patients difficult course. They recommended continuation of NS W to D dsg changes. C/W MP boots. EGD performed - Pt stable. Recommended f/u EGD in one month for obliteration of varices and f/u in liver clinic here or with PCP. Because of pt poor intake of food [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult obtained. Saw pt, recommended SSI of humulog and to decrease Lantus to 8 units. On discharge pt is doing well. Taking PO, urinating, BM, OOB to chair. [**2186-3-30**] - DC Medications on Admission: metformin 1000", Paxil, folate, Lantus 32u, spironolactone 100" Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Vancomycin HCl 1000 mg IV Q24H if random level <15 already approved -- changed frequency because of vanco trough; 6. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection Q3-4H () as needed. 7. PICC LINE CARE Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 8. INSULIN Breakfast Glargine 16 Units Insulin SC Sliding Scale - Humulog Breakfast, Lunch, Dinner and Bedtime Glucose Insulin Dose 0-60 mg/dL 4 oz. Juice 61-120 mg/dL Units 0 121-160 mg/dL Units 2 161-200 mg/dL Units 4 201-240 mg/dL Units 6 241-280 mg/dL Units 8 > 280 mg/dL Notify M.D. 8 Units 6 Units Discharge Disposition: Extended Care Facility: Lifecare of [**Location 15289**] Discharge Diagnosis: dry gangrene of right heel partial SBO, fracture of right hip after falling at bedside, GIB from esophageal varices, esophageal ulcer concerning for possible cancer - EGD [**3-27**] Discharge Condition: stable Discharge Instructions: Please do wet to dry dressing changes on the right heel. Pt is on Vancomycin. Please adjust vanco level according to blood draws. PICC line care Followup Instructions: Please call Dr [**Last Name (STitle) **] office and schedule an appointment for two weeks after discharge, Call him at [**Telephone/Fax (1) 3121**]. When you call he may schedule you for an amputation. You may not need to see him. Call Dr [**First Name (STitle) **] (orthopedics) and schedulae an appointment for two weeks after discharge, Call him at [**Telephone/Fax (1) 1113**]. Please call gastroenterology and schedule an EGD for one month after discharge, Call the gastroenterologist at [**Telephone/Fax (1) 463**]. Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2422**]. He works in Heptology. Make f/u in one month. Completed by:[**2186-3-30**] Name: [**Known lastname 6232**],[**Known firstname **] Unit No: [**Numeric Identifier 11124**] Admission Date: [**2186-3-4**] Discharge Date: [**2186-4-14**] Date of Birth: [**2115-7-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 175**] Addendum: Pt was transferred to the Internal Medicine service after having esophageal varocosities treated with EGD/banding. During this procedure he became hypoxic O2sat=84% on 10L, and went to the high 90s on NRB. He was observed for two days in the MICU where his O2sat improved to 88% on RA and high 90s on 3L NC. . Diuresis with lasix and aldactone was continued on the floor. His hypoxia improved after one day with O2sat=95% on RA. A paracentesis was performed and 4 liters were removed with a reduction in his abdominal discomfort. Propanolol was added to his regimen for varices prophylaxis. octreotide was discontinued on the day of discharge. He was maintained on his diureses regimen of lasix and aldactone. Physical therapy worked with the patient and he will need physical therapy as an outpatient as he has been in bed for nearly one month due to his illnesses. Levofloxacin (for sbp prophylaxis) and vancomycin (for foot ulcer) were discontinued at the time of discharge. . At discharge Pt was afebrile, BP 100s/60s, P 60, RR 14, O2sat 99% RA, ambulating with assistance. Discharge Disposition: Extended Care Facility: Lifecare of [**Location 2075**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**] Completed by:[**2186-4-17**]

[ "V09.0", "456.20", "571.2", "041.11", "820.03", "530.21", "250.00", "560.9", "440.24", "162.9", "110.1", "591", "730.07", "110.4", "789.5", "E885.9", "070.70", "V15.3", "682.7" ]

icd9cm

[ [ [] ] ]

[ "99.04", "54.91", "99.15", "45.13", "38.93", "81.52", "77.68", "42.33", "96.08", "83.39" ]

icd9pcs

[ [ [] ] ]

21666, 21881

14306, 17871

330, 393

19290, 19298

2063, 5071

19492, 21643

1539, 1557

17985, 18982

5109, 7781

19085, 19269

17897, 17962

19322, 19469

1572, 2044

274, 292

8657, 10067

421, 727

10076, 14283

749, 933

949, 1523

5,391

121,623

26553

Discharge summary

report

Admission Date: [**2176-7-19**] Discharge Date: [**2176-7-28**] Date of Birth: [**2113-8-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 62 yo M w/ longstanding history of COPD p/w respiratory distress today from [**Hospital 100**] Rehab. Per ED notes and family, pt c/o increased SOB x 4d, worse today, w/ cough productive of yellow/green sputum. He is on vanc/meropenem to complete a 4 week course due to end on [**7-27**]. . Pt has had recent long course of hospitalizations beginning in [**3-18**] with PNA; no pathogen was identified and he received an empiric 4 week course of levofloxacin, after which he improved to his baseline and returned to work. . In late [**Month (only) 547**] he relapsed with cough and shortness of breath; he was admitted [**Date range (1) 65562**]. Sputum cultures including routine cx, legionella cx, PCP staining were again not diagnostic and he was treated with empiric vanc/zosyn for 4 weeks. . On admission in [**Month (only) **], from [**Date range (1) 65563**] a CT scan demonstrated a large LUL bulla with fluid level, left lingular pneumonia and L pleural effusion. Sputum cultures failed to identify pathogen. He was initiated on a steroid taper and empiric vanc/meropenem, and his clinical status improved. After several days his WBC count rose to 21k and repeat imaging demonstrating new RLL aspiration pneumonia. Discussion was held re interventional procedure to tap L chest and/or to have CT surgery perform bullectomy, though it was felt at the time that the risks of these procedures outweighed the benefits. Conservative management with antibiotics was planned. . He had a repeat CT [**7-15**] which showed slightly decreased fluid in the LUL bulla. He was just seen [**7-17**] in [**Hospital **] clinic and no change was made to his course of abx. . In the ED it was thought he had a COPD flare vs. PNA. He was not given further abx or steroids, but was given a combivent neb. He was also given ativan, after which time he became somnolent but in the ED was recorded as "resting comfortably". On arrival to the [**Hospital Unit Name 153**], he was unarousable; his ABG was 7.03/156/68. He was intubated, and became responsive within an hour. Past Medical History: 1) COPD: severe (FEV1=20% pred), requires home O2 (3-5L NC) 2) Necrotizing PNA (pantoea species): c/b PTX/empyema requiring chest tube 3) Tuberculosis (age 17): treated with 2 meds 4) Cholelithiasis Social History: 1) Tobacco: 45 pk-years, quit 5 years ago 2) Rare EtOH 3) Formerly worked in accounting Family History: Father died from lung CA. Mother dies from MI. Physical Exam: PE: VS: T 96.5 ax, BP 165/64, P 91, RR 23, O2 90% RA GEN: Intubated, mouthing words, moving all extremities spontaneously HEENT: PERRL, MMM NECK: Supple CV: RRR nl S1 S2 no m/r/g PULM: Bilat rales EXTR: 1+ periph edema NEURO: Arousable to painful stimuli, moves all extremities Pertinent Results: [**2176-7-19**] 01:25PM PT-12.9 PTT-24.9 INR(PT)-1.1 [**2176-7-19**] 01:25PM PLT COUNT-681* [**2176-7-19**] 01:25PM NEUTS-85.1* LYMPHS-7.9* MONOS-3.7 EOS-3.1 BASOS-0.3 [**2176-7-19**] 01:25PM WBC-10.6 RBC-3.25* HGB-9.2* HCT-28.5* MCV-88 MCH-28.2 MCHC-32.1 RDW-14.9 [**2176-7-19**] 01:25PM LACTATE-1.1 [**2176-7-19**] 01:25PM CK-MB-2 cTropnT-<0.01 [**2176-7-19**] 01:25PM GLUCOSE-118* UREA N-7 CREAT-0.3* SODIUM-140 POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-41* ANION GAP-9 [**2176-7-19**] 10:35PM LACTATE-1.8 [**2176-7-19**] 10:35PM TYPE-ART TEMP-37.2 PO2-68* PCO2-156* PH-7.03* TOTAL CO2-44* BASE XS-4 INTUBATED-NOT INTUBA [**2176-7-19**] 10:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: 62 yo M w/ severe COPD and necrotizing PNA/empyema in LUL bulla on several months of abx since [**3-18**] p/w respiratory failure. Brief hospital course as follows: . 1) Hypercarbic respiratory failure: Very elevated PCO2 initially, likely acute on chronic from somnolence [**2-15**] ativan, nonrebreather O2 in ED, as he is a CO2 retainer. Last (6:30am on [**7-28**]) was 7.37/69/96. Goal O2 sats were in low 90%s, PCO2 50-60 to help drive down alveolar ventilation needed for extubation. Extubated per patient and family's expressed wishes and [**Month/Year (2) 3225**] per patient and family. . 2) PNA: Difficult to clear infected organisms from loculated bulla. Likely had anaerobes which are not well grown from routine suptum culture. Not able to drain fluid as any needle introduction will give PTX and track through pleural space. Stopped abx as pt [**Name (NI) 3225**]. . 3) COPD: Probably contributed to hypoxia. . 4) Anemia: Last Hct was 29.8 (was 35.1 on [**2176-7-3**]) . 5) UE edema: Improved but presumed to be secondary to aggressive fluid recuscitation. Monitored edema/chest exam and gave lasix as appropriate before becoming [**Date Range 3225**]. . On [**2176-7-28**], pt and family expressed wish to extubate patient and make him [**Date Range 3225**]. Patient expired in the late afternoon on [**2176-7-28**]. Medications on Admission: Vanc 1g q 12h, Meropenem 500 mg iv q8h, pantoprazole, advair, albuterol, tiotropium, bisacodyl Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2176-8-13**]

[ "276.6", "486", "276.1", "300.00", "285.29", "458.9", "V12.01", "518.84", "492.0", "789.01" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "96.04" ]

icd9pcs

[ [ [] ] ]

5432, 5441

3923, 5258

323, 329

5488, 5497

3131, 3900

5550, 5585

2768, 2817

5403, 5409

5462, 5467

5284, 5380

5521, 5527

2832, 3112

276, 285

357, 2421

2443, 2645

2661, 2752

51,257

145,513

35537

Discharge summary

report

Admission Date: [**2187-4-27**] Discharge Date: [**2187-5-2**] Date of Birth: [**2112-3-31**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1271**] Chief Complaint: CC:[**CC Contact Info 80917**] Major Surgical or Invasive Procedure: NONE History of Present Illness: HPI:Per family was found down in bathroom. Doesnt recall events leading up to fall. Per family she was probably down 2-3hrs. Pt c/o reproducable sub xiphoid CP. EKG normal, Trop .35 There were no signs of vomiting, incontinence. She was trasferred here from OSH for L temporal SAH and contusion. She did not receive dilantin at OSH. Her GCS on arrival was 15. Just prior to receiving her Dilantin in ED here she seized, was intubated and the to the CT scanner for re-peat Head CT. Past Medical History: PMHx:HTM, lymphoma, COPD Social History: Social Hx:NC Family History: Family Hx:NC Physical Exam: PHYSICAL EXAM: T:97.8 BP:159/119 HR:87 RR 18 O2Sats 98 2L Gen: WD/WN, comfortable, NAD. HEENT:Atraumatic, normocephalic Pupils: PERRL EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person and place Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-5**] throughout. Pronator drift equivocal Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin DISCHARGE EXAM: Awake, alert to self only (although has had periods of clarity better than this) PERRL 4-2 mm bilaterally, EOMI, UE [**6-5**] without drift, face symmetric, LE antigravity. Pertinent Results: [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Cardiology Report ECG Study Date of [**2187-4-27**] 5:31:18 PM Possible ectopic atrial rhythm. Diffuse T wave changes which are non-specific. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate PR QRS QT/QTc P QRS T 87 134 94 388/435 -46 23 60 ([**-1/2036**]) [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-4-27**] 8:03 PM [**Last Name (LF) 14311**],[**First Name3 (LF) **] EU [**2187-4-27**] 8:03 PM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80919**] Reason: eval ETT placment [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with head injury s/p intubation REASON FOR THIS EXAMINATION: eval ETT placment Final Report AP PORTABLE CHEST, [**2187-4-27**] AT [**2186**] HOURS. HISTORY: Head injury, post-intubation. COMPARISON: None. FINDINGS: An endotracheal tube is present with the distal tip in satisfactory position approximately 4.8 cm from the carina. A nasogastric tube is noted extending into the left upper quadrant off the inferior edge of the radiograph. The lungs are grossly clear with linear lines noted at the right lung base, likely atelectasis versus scarring. There is marked aortic tortuosity. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. Overall, there is marked hyperexpansion of the lungs. IMPRESSION: Marked hyperexpansion. Marked tortuosity of the thoracic aorta. Endotracheal tube in satisfactory position. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: FRI [**2187-4-27**] 11:04 PM Imaging Lab [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2187-4-27**] 8:04 PM [**Last Name (LF) 80310**],[**First Name3 (LF) **] EU [**2187-4-27**] 8:04 PM CT C-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 80920**] Reason: r/o abnl [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with fall, ip bleed REASON FOR THIS EXAMINATION: r/o abnl CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: CXWc FRI [**2187-4-27**] 8:49 PM No fracture or malalignment. DJD mid cervical spine with minimal canal narrowing. Final Report INDICATION: 75-year-old woman status post fall. COMPARISON: CT C-spine obtained at [**Hospital **] Hospital approximately six hours earlier. TECHNIQUE: Contiguous axial images were obtained through the cervical spine. Multiplanar reformatted images were generated. No contrast was administered. FINDINGS: There has been interval endotracheal intubation and nasogastric tube placement. There is no fracture or acute malalignment of the cervical spine. Moderate degenerative changes are present in the upper and mid cervical spine, with mild, grade 1 anterolisthesis of the C3 on C4. There is pronounced loss of intervertebral disc height between C4 and C7, with posterior disc osteophyte complexes at these levels, slightly narrowing the spinal canal, and contacting the thecal sac. Prevertebral soft tissues are within normal limits given the presence of an endotracheal tube. Vertebral body heights are preserved. Lung apices demonstrate marked emphysema. Multifocal hypodensities within the thyroid gland are present. There is no lymphadenopathy within the neck, by size criteria. Vascular calcifications are present. IMPRESSION: 1. No fracture or acute malalignment of the cervical spine. 2. Moderate degenerative changes result in posterior disc osteophyte complexes in the mid cervical spine that contacts the thecal sac. MRI is more sensitive for evaluation of the thecal sac and its contents. 3. Emphysema. 4. Thyroid hypodensities. Recommend clinical correlation and ultrasound evaluation if not previously performed, on a non-emergent basis. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 2671**] [**Doctor Last Name **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: SAT [**2187-4-28**] 12:41 AM Imaging Lab [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2187-4-27**] 8:04 PM [**Last Name (LF) 14311**],[**First Name3 (LF) **] EU [**2187-4-27**] 8:04 PM CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 80921**] Reason: eval for interval change in ICH [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with temporal hemorrhage now sz REASON FOR THIS EXAMINATION: eval for interval change in ICH CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: CXWc FRI [**2187-4-27**] 10:23 PM 11x6mm hyperdensity left temporal lobe could be small hemorrhagic contusion, but lack of associated traumatic findings makes this less likely. Cannot rule out metastasis from occult primary. Recommend f/u imaging to assess for evolution. Final Report INDICATION: 75-year-old woman with seizure and suspected temporal hemorrhage. COMPARISON: Head CT obtained at [**Hospital **] Hospital approximately six hours earlier. TECHNIQUE: Contiguous axial images were obtained through the brain. No contrast was administered. Multiplanar reformatted images were generated. FINDINGS: In the left mid temporal lobe, there is a 12 x 7 mm ovoid hyperdense lesion, without surrounding edema or mass effect. There is no other hyperdensity to suggest other acute intracranial hemorrhage. There is no edema, shift of normally midline structures, or evidence of major vascular territorial infarct. Extensive periventricular white matter hypodensities are consistent with chronic small vessel ischemia. The ventricles and sulci are normal in size and configuration. The basilar cisterns are patent. The [**Doctor Last Name 352**]-white differentiation is preserved. There is no fracture. There is a small amount of soft tissue density material within the left maxillary sinus, consistent with mucous retention cyst. Paranasal sinuses and mastoid air cells are otherwise well aerated. Soft tissues are unremarkable. IMPRESSION: 12 x 7 mm hyperdensity within the left temporal lobe. In the setting of trauma, a small hemorrhagic contusion is possible, although less likely in the absence of other sequela of trauma. Alternatively, a metastatic lesion from an occult primary cannot be excluded. Recommend followup imaging to assess for interval change as a traumatic lesion should evolve on short order. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 2671**] [**Doctor Last Name **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: SAT [**2187-4-28**] 12:39 AM Imaging Lab [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report CT PELVIS W/O CONTRAST Study Date of [**2187-4-27**] 8:06 PM [**Last Name (LF) 80310**],[**First Name3 (LF) **] EU [**2187-4-27**] 8:06 PM CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # [**Clip Number (Radiology) 80922**] Reason: eval bone ? sternal/rib fx [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with fall, ip bleed REASON FOR THIS EXAMINATION: eval bone ? sternal/rib fx CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: CXWc FRI [**2187-4-27**] 10:18 PM Multiple vertebral compression deformities: T8,10,11, L4,5, acuity unknown. No other fractures. No evidence of other traumatic injury to chest, abd, pelvis although right hip arthroplasty obscures eval. Wet Read Audit # 1 CXWc FRI [**2187-4-27**] 8:55 PM Multiple vertebral compression deformities: T8,10,11, L4,5, acuity unknown. No other fractures. No evidence of other traumatic injury to chest, abd, pelvis although b/l hip arthroplasty obscures eval. Final Report INDICATION: 75-year-old woman status post fall. COMPARISON: CT chest obtained at [**Hospital **] Hospital approximately six hours earlier. TECHNIQUE: MDCT-acquired axial images were obtained through the torso. No contrast was administered, because the patient had previously received intravenous contrast. Multiplanar reformatted images were generated. CT CHEST WITHOUT IV CONTRAST: An endotracheal tube and nasogastric tube are in place. Coronary and aortic atherosclerotic calcifications are noted. The heart is not enlarged and there is no pericardial effusion. Great vessels are grossly unremarkable. Lungs demonstrate diffuse, moderate emphysematous changes, worse at the lung apices. There is no consolidation or pleural effusion. There is no pneumothorax. The tracheobronchial tree is patent up to subsegmental level. CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Evaluation of solid organs is limited in the absence of intravenous contrast. However, a nasogastric tube terminates in the stomach. The liver, spleen, and adrenal glands are unremarkable. There are no gross abnormalities in the region of the pancreas. The gallbladder contains high-density material consistent with prior contrast administration. The kidneys also contain high-density materials in the collecting systems consistent with prior contrast administration. There is no free air in the abdomen. CT PELVIS WITHOUT IV CONTRAST: The absence of intravenous or oral contrast and the presence of a right hip prosthesis severely limit evaluation of pelvic contents, including evaluation of bowel. The urinary bladder contains a Foley catheter and excreted contrast material. OSSEOUS STRUCTURES: There are compression deformities of the vertebral bodies at multiple levels, including T8, T10, T11, L4 and L5, of unknown acuity. Multilevel degenerative changes are also present. There is no malalignment. The lower sternal body demonstrate a mild deformity, but without adjacent hematoma or swelling, this is unlikely acute. Severe osteopenia is noted. Soft tissues are unremarkable. IMPRESSION: 1. Multilevel compression deformities of vertebral bodies in the thoracic and lumbar spine. Acuity unknown. Multilevel degenerative change. 2. Limited evaluation of solid organs and bowel in the absence of intravenous and oral contrast. Further, large portions of the pelvis are obscured by streak artifact from indwelling right hip prosthesis. 3. Emphysema. 4. Minimal deformity of the lower sternal body with no adjacent hematoma or swelling, unlikely to represent acute injury. Correlate with point tenderness. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 2671**] [**Doctor Last Name **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**] Approved: SAT [**2187-4-28**] 12:42 AM Imaging Lab [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-4-28**] 11:41 AM [**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG SICU-B [**2187-4-28**] 11:41 AM CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80923**] Reason: NGT position [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with left temp contusion REASON FOR THIS EXAMINATION: NGT position Final Report PORTABLE CHEST OF [**2187-4-28**] COMPARISON: [**2187-4-27**]. INDICATION: Nasogastric tube assessment. Nasogastric tube courses below the diaphragm. Heart is normal in size, but demonstrates left ventricular configuration. Marked tortuosity of the thoracic aorta is unchanged. Lungs are hyperexpanded consistent with CT demonstrated emphysema. Minimal linear atelectasis at left base with otherwise grossly clear lungs. Multiple compression deformities in the spine of indeterminate age. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: SAT [**2187-4-28**] 5:02 PM Imaging Lab [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2187-4-28**] 2:15 PM [**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG SICU-B [**2187-4-28**] 2:15 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # [**Clip Number (Radiology) 80924**] Reason: per trauma [**Doctor First Name **] Contrast: OPTIRAY Amt: 100 [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with trauma REASON FOR THIS EXAMINATION: per trauma [**Doctor First Name **] CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Patient with trauma. COMPARISON: Non-contrast CT of the abdomen and pelvis of [**2187-4-27**]. TECHNIQUE: Contiguous axial images through the abdomen and pelvis were obtained following the administration of 100 mL of Optiray contrast IV, and oral contrast via the nasogastric tube. Coronal and sagittal reformatted images were generated. CT OF THE ABDOMEN WITH CONTRAST: Extensive emphysema is noted at the lung bases. There are a few scattered hypodensities in the liver which are too small to characterize, as they measure under 1 cm (3:26, 3:30, 3:34 and 35). The portal vein remains patent. There is some vicarious excretion of contrast into the gallbladder, which is not distended. The spleen is unremarkable. No pancreatic abnormalities are identified. There is a suggestion of a vague 5- cm lesion of the left adrenal, rounded and hypodense (3:18), but this not fully characterized on this study. The kidneys enhance symmetrically and excrete normally, without hydronephrosis. A nasogastric tube tip is located in the body of the stomach. The stomach and bowel loops are unremarkable. Bowel loops are nondilated, and no wall thickening is seen. Oral contrast passes to the level of the proximal transverse colon, and stool and air are seen within the remaining colon. There is no free air in the abdomen. No free fluid is clearly seen in the abdomen, though there is a paucity of intra-abdominal fat for the assessment. There is a minimal amount of stranding posterior to the right lobe of the liver (3:30) and anterior to the spleen and lateral to the left colon (3:20), which is entirely nonspecific. Slight asymmetry in the psoas muscles is thought to be related to scoliosis. The abdominal aorta is normal in caliber, with ectasia and moderately severe atherosclerotic calcification. No mesenteric or retroperitoneal adenopathy is seen. CT OF THE PELVIS WITH CONTRAST: There is a moderate-to-severe amount of artifact related to the patient's right total hip replacement. There is a Foley catheter within the bladder, which is decompressed. The rectum and uterus are unremarkable. There is likely sigmoid diverticulosis. There is no definite pelvic free fluid. No pelvic or inguinal adenopathy. Small bowel loops are seen adjacent to the medial aspect of the right common femoral artery and vein, possibly a nonobstructed femoral hernia. As bowel loops are normal, there is no obstruction. BONE WINDOWS: The bones are markedly osteopenic. There is right convex scoliosis of the thoracolumbar spine, and multiple vertebral body compression fractures which are not significantly changed from [**4-27**], including: T11, L4 and L5 as seen on this study. IMPRESSION: 1. No new findings in the abdomen/pelvis today. Multilevel compression deformities of the vertebral bodies are again noted, acuity unknown. No clear evidence of solid organ injury. 2. Subcentimeter hepatic hypodensities, rounded and too small to characterize. 3. Moderately severe atherosclerotic disease. 4. Emphysema. 5. Probable right femoral hernia containing a small bowel loop, nonobstructed. 6. 5 mm left adrenal nodule, not characterized on this exam. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4346**] DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**] Approved: SUN [**2187-4-29**] 8:45 AM Imaging Lab [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2187-4-28**] 2:15 PM [**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG SICU-B [**2187-4-28**] 2:15 PM CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 80925**] Reason: follow up [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with left temp lobe contusion REASON FOR THIS EXAMINATION: follow up CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: DXAe SAT [**2187-4-28**] 8:58 PM No change since [**2187-4-27**]. Final Report INDICATION: Followup of left temporal lobe lesion. COMPARISON: Multiple prior exams, the most recent dated [**2187-4-27**]. TECHNIQUE: Non-contrast axial imaging was obtained through the skull vertex to the skull base. Repeat imaging was obtained due to patient motion. FINDINGS: A 12 x 7 mm ovoid focus of hyperdensity in the left temporal lobe is unchanged since [**2187-4-27**]. There is no evidence of adjacent edema or mass effect. Extensive periventricular white matter hypodensity is unchanged since [**2187-4-27**] and likely represents chronic microvascular infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The paranasal sinuses are grossly clear except to note small soft tissue density within the left maxillary sinus. The mastoid air cells are clear. The soft tissues are unremarkable. IMPRESSION: 12 x 7 mm hyperdensity in the left temple lobe is more concerning for neoplastic lesion given the lack of change since [**2187-4-27**]. Continued followup or MRI is recommended for further evaluation. Final Attending Comment: Above mentioned hyperdensity could represent hemorhhage versus mass. Recommend MRI for further evaluation. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**] DR. [**First Name (STitle) **] [**Name (STitle) 12563**] Approved: SUN [**2187-4-29**] 10:10 AM Imaging Lab [**Known lastname **],[**Known firstname 2618**] [**Medical Record Number 80918**] F 75 [**2112-3-31**] Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2187-5-1**] 1:41 PM [**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2187-5-1**] 1:41 PM MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 80926**] Reason: eval for underlying mass / as described on CT [**2187-4-28**] Contrast: MAGNEVIST Amt: 9 [**Hospital 93**] MEDICAL CONDITION: 75 year old woman with left temporal contusion and sah after fall in bathroom. REASON FOR THIS EXAMINATION: eval for underlying mass / as described on CT [**2187-4-28**] CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: RXRa TUE [**2187-5-1**] 6:26 PM STUDY: MRI of the head with and without contrast. On the susceptibility sequences, multiple punctate foci are identified, possibly representing amyloid deposits, other considerations include micro-hemorrhages. Significant areas of hyperintensity signal are demonstrated in the subcortical white matter on T2 and FLAIR, likely consistent with severe chronic microvascular ischemic disease. Unchanged focus of hemorrhage identified on the left temporal lobe measuring approximately 6.6 x 10.0 mm in the transverse dimensions. Mucosal thickening is noted on the left maxillary sinus. Prominence of the sulci and ventricles for the patient's age indicating atrophy. A second focus of hemorrhage is identified on the right parietal lobe on the convexity (4:24) measuring approximately 3 x 4 mm in size. Final Report STUDY: MRI of the head with and without contrast. CLINICAL INDICATION: 75-year-old woman with left temporal contusion and subarachnoid hemorrhage after fall in the bathroom. Evaluate for underlying mass as described on the prior CT of the head. COMPARISON: Prior CT of the head without contrast dated [**4-28**], [**2187**]. TECHNIQUE: Pre-contrast axial and sagittal T1-weighted images were obtained, axial FLAIR, axial magnetic susceptibility, axial T2, diffusion-weighted sequences. After the administration of intravenous gadolinium contrast material, the T1-weighted images were repeated in axial T1, sagittal MP-RAGE and multiplanar reconstructions. In comparison with the prior CT dated [**2187-4-28**], again a focus of hemorrhage is identified on the left temporal lobe, measuring approximately 6.6 x 10.0 mm in size (4:11), the T2 and FLAIR images demonstrate multiple scattered areas of hyperintensity signal in the subcortical white matter, likely consistent with chronic microvascular ischemic changes, the sulci and ventricles are prominent, likely indicating atrophy and possibly involutional in nature. On the magnetic susceptibility sequences, multiple foci of magnetic susceptibility are demonstrated, more obvious in the occipital and parietal regions. A few of these lesions are identified in the left cerebellar hemisphere. Given the size and distribution, amyloid deposit is a strong consideration, however, other entities like micro-bleeds cannot be completely excluded. On the diffusion-weighted sequences, there are punctate areas of moderate restricted diffusion raising the possibility of subacute embolic events (602:17 and 602:13). After the administration of gadolinium contrast material, there is no evidence of abnormal enhancement. In the right parietal convexity (4:24), there is a small focus of hyperintensity signal, possibly representing hemorrhagic change, measuring approximately 3.1 x 4.6 mm in size. Normal flow void signal is identified in the major vascular structures. Mucosal thickening is observed on the left maxillary sinus with small fluid level. IMPRESSION: 1. Unchanged area of hemorrhage on the left temporal lobe. 2. Multiple foci of magnetic susceptibility signal demonstrated mainly in the parietal and occipital lobes, possibly consistent with amyloid deposits, other entities cannot be completely excluded such as micro- bleedings. 3. There is no evidence of abnormal enhancement. 4. Punctate area of hyperintensity signal demonstrated on the right parietal convexity possibly consistent with focal hemorrhagic change. 5. Punctate areas of restricted diffusion as described in detail above, possibly consistent with subacute ischemic changes, these areas are not visualized in the corresponding ADC maps. 6. Multiple areas of hyperintensity signal demonstrated in the subcortical white matter as described above, likely consistent with chronic microvascular ischemic changes. DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**] Approved: TUE [**2187-5-1**] 11:10 PM Brief Hospital Course: Pt was admitted to the hospital through the emergency department for SAH and left temporal contusion. She had a seizure in the ED and was intubated. She was loaded with dilantin and subsequently extubated the next am. She did have a slight increase in her troponin's and was seen by cardiology. The cardiology team recommended asa and an echo. These recs were followed. Results of the echo are in the reports section of this summary. She was also seen and cleared by the trauma team. She was moved to step down and diet and activity were advanced. Repeat images were obtained and were stable. An MRI of the brain was done and ruled out underlying mass. She was seen by PT and OT and deemed to be a candidate for rehab. Medications on Admission: Medications prior to admission:Levothyroxine 50mcg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 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. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. HydrALAzine 10 mg IV Q6H:PRN SBP >160 11. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [**Hospital 1121**] Rehab Skilled Nursing Center - [**Location (un) 4047**] Discharge Diagnosis: left temporal sub arachnoid hemorrhage left temporal contusion SEIZURE HTN HYPOKALEMIA ALTERED MENTAL STATUS PROTEIN/ CALORIE MALNUTRITION diastoilc dysfunction by echo Moderate tricuspid regurgitation. Discharge Condition: NEUROLOGICALLY IMPROVED 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. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. Please have your primary care physician follow your blood levels. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN TO REVIEW YOUR HOSPITALIZATION AS WELL AS THE FINDINGS ON YOUR CAT SCAN OF YOUR ABDOMEN. YOU WILL ALSO NEED TO HAVE YOUR PRIMARY CARE PHYSICIAN FOLLOW YOUR BLOOD LEVELS OF YOUR DILANTIN. PLEASE RETURN TO THE NEUROSURGERY OFFICE IN ONE MONTH WITH A CAT SCAN OF THE BRAIN AT [**Telephone/Fax (1) **] WITH DR. [**Last Name (STitle) **]. PLEASE CALL FOR AN APPOINTMENT. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2187-5-2**]

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Discharge summary

report

Admission Date: [**2143-3-19**] Discharge Date: [**2143-3-28**] Date of Birth: [**2099-2-23**] Sex: M Service: CARDIOTHORACIC Allergies: Bactrim / Sulfa (Sulfonamide Antibiotics) / Atazanavir Sulfate Attending:[**First Name3 (LF) 1505**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: mitral valve repair with 32mm annuloplasty ring and reimplantation of chordae [**2143-3-19**] History of Present Illness: The patient is a 43 year old white male who complained of shortness of breath, chest pain, fatigue and decreased exercise tolerance. He has a known history of mitral valve prolapse/mitral regurgitation. Echo reveals 4+MR with a partial flail anterior leaflet and ruptured chordae with preserved ejection fraction. He presents for surgical intervention. Past Medical History: hypertension HIV, AIDS pneumonia hepatitis A hepatitis B aphthuous ulcer candidal esophagitis Social History: works as a property manager lives alone tobacco: quit 10-15 years ago denies recreational drug use EtOH: 2 glasses of wine per night Family History: no family history of premature coronary artery disease Physical Exam: VS: 148/92, 76, 18 general: comfortable HEENT: unremarkable neck: supple, full ROM Chest: lungs CTAB Heart: RRR, +systolic murmur left border Abdomen: +BS, soft, non-tender, non-distended Ext: warm, well-perfused, no edema Varicosities: stage I-II varices L leg Neuro: grossly intact Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 17606**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 17607**] (Complete) Done [**2143-3-19**] at 8:45:21 AM 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: [**2099-2-23**] Age (years): 44 M Hgt (in): 69 BP (mm Hg): 145/78 Wgt (lb): 170 HR (bpm): 67 BSA (m2): 1.93 m2 Indication: Left ventricular function. Mitral valve disease. Right ventricular function. Shortness of breath. Valvular heart disease. Intraoperative TEE for mitral valve repair ICD-9 Codes: 424.0, 786.05 Test Information Date/Time: [**2143-3-19**] at 08:45 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW5-: Machine: AW5 Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.8 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: *6.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% >= 55% Aorta - Ascending: 2.5 cm <= 3.4 cm Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Moderately dilated LV cavity. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. No atheroma in ascending aorta. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Partial mitral leaflet flail. Torn mitral chordae. Severe (4+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be underestimated (Coanda effect). TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Instirinsic function is depressed given the degree of regurgitation. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. There is partial mitral anteriorleaflet flail. (A3) Torn mitral chordae are present. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Dr. [**Last Name (STitle) **] was notified in person of the results on [**2143-3-19**] at 830am. Postbypass Patient is in sinus rhythm amd receiving an infusion of phenylephrine. LVEF is 45%. Globally reduced LVEF. RV function is normal. Annuloplasty ring seen in the mitral position. Appears well seated. Trivial MR and there is NO [**Male First Name (un) **]. Peak gradient across the mitral valve is 7mm Hg. Aorta intact post decannulation. 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) **] [**2143-3-20**] 14:43 Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2143-3-19**] for surgical intervention of his mitral regurgitation. He underwent mitral valve repair, including a 32mm annuloplasty ring and reimplantation of ruptured chordae. See operative note for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in critical but stable condition for further monitoring and recovery. By POD 1 the patient was extubated and vasoactive drips were weaned. He was neurologically intact and hemodynamically stable and transferred to the telemetry floor on POD 1. His chest tubes were discontinued on POD 2 without complication. He was progressing toward discharge but developed a fever 102 and his WBC rose from 4,000 to 11,000. Infectious disease was consulted and he was placed on broad spectrum IV antibiotics. His fevers abated and WBC decreased to 6,000 on this regimen. The atelectasis vs pneumonia on his chest radiograph improved. Although his sputum was not final by the time of discharge, it preliminarily revealed normal flora. Blood and urine cultures were negative. His hematocrit was 26.9 at the time of discharge and he was placed on iron. He was discharged on post-operative day 9 to home with a peripherally inserted central catheter and IV antibiotics to be administered by a visiting nurses association. These antibiotics will continue until [**2143-4-2**] and surveillance labs will be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] of Infectious Disease. He was encouraged to make follow-up appointments as listed in the discharge summary. Medications on Admission: diflucan 200' acyclovir 800' alprazolam .25prn dapsone 100' truvada 200/300' HCTZ 25' kaletra 200/500 2tabs'' amoxicillin prn-dental Discharge Medications: 1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 8. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 12. Outpatient Lab Work Needs CBC, LFT, BUN/Cre, Vanco trough drawn on Monday [**2143-4-1**] with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] ([**Telephone/Fax (1) 16411**]. 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: until [**2143-4-2**] for presumed pneumonia. Disp:*10 Tablet(s)* Refills:*0* 14. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours) for 5 days: until [**2143-4-2**] for presumed pneumonia. Disp:*15 Recon Soln(s)* Refills:*0* 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) bag Intravenous Q 12H (Every 12 Hours) for 5 days: until [**2143-4-2**] for presumed pneumonia. Disp:*10 bag* Refills:*0* 16. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 17. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: mitral regurgitation s/p mitral valve repair [**2143-3-19**] PMH: hypertension HIV, AIDS pneumonia hepatitis A hepatitis B aphthuous ulcer candidal esophagitis Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 911**] (cardiology) in 1 week. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP)in [**2-19**] weeks. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (ID) in 2 weeks. Please call for appointments Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Needs CBC, LFT, BUN/Cre, Vanco trough drawn on Monday [**2143-4-1**] with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] ([**Telephone/Fax (1) 16411**]. Completed by:[**2143-3-28**]

[ "998.89", "780.62", "429.5", "401.9", "424.0", "042" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.32", "35.12" ]

icd9pcs

[ [ [] ] ]

9935, 9993

6049, 7738

349, 445

10197, 10204

1490, 6026

10744, 11438

1113, 1169

7921, 9912

10014, 10176

7764, 7898

10228, 10721

1184, 1469

290, 311

473, 830

852, 947

963, 1097

4,071

168,453

50907

Discharge summary

report

Admission Date: [**2136-3-1**] Discharge Date: [**2136-3-21**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: right middle lobe mass Major Surgical or Invasive Procedure: Right video-assisted thoracoscopic surgery (VATS) mediastinal nodule biopsy and subsequent complete excision. History of Present Illness: Mr. [**Known lastname 105823**] is an 83-year-old gentleman with weight loss and an FDG negative right middle lobe nodule abutting the mediastinum. Previous cervical mediastinoscopy was negative for any metastatic disease to the mediastinal lymph nodes. Pt admitted for VATS right middle lobe biopsy to obtain a tissue diagnosis. Past Medical History: 1. Anterior MI [**2105**] 2. CABG x3 [**2123**] (SVG to RCA, SVG to OM2, LIMA to LAD), c/b post-op SVT 3 weeks after CABG. Had extensive w/u, eventually it was felt that he had sinus tachycardia that was reactive post-op. Rx'ed with metalol 40 mg qd 3. Afib/flutter [**2131**] after amiodarone had been discontinued, was successfully cardioverted 4. Low back pain s/p L2-3 diskectomy [**2131**], recent epidural steroid injection [**2134-6-28**] 5. Type 2 DM 6. Hypercholesterolemia 7. Gallstone pancreatitis with E.coli bacteremia, [**2131**] 8. NSTEMI [**2133**] 9. AVNRT 10. L1 compression fracture s/p vertebroplasty [**2135-12-2**] Social History: + tobacco, smoked half pack per day "since childhood". Occasional EtOH. Lives in [**Hospital1 778**] neighborhood with wife Family History: Mother had heart disease, died in her 70s Physical Exam: VITAL SIGNS: Temperature 97.1, pulse 88, blood pressure 103/64, respiratory rate 18, oxygen saturation 96% on room air. GENERAL: Tired-appearing elderly gentleman in no apparent distress. LUNGS: Distant breath sounds but clear bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended. SKIN: Incision clean, dry and intact without any fluctuance, purulence, or erythema. Pertinent Results: [**2136-3-16**] 02:15AM BLOOD WBC-9.3 RBC-2.96* Hgb-8.9* Hct-27.5* MCV-93 MCH-30.0 MCHC-32.4 RDW-15.4 Plt Ct-225 [**2136-3-1**] 04:16PM BLOOD WBC-11.7*# RBC-3.73* Hgb-12.1* Hct-35.6* MCV-95 MCH-32.4* MCHC-34.0 RDW-14.3 Plt Ct-227 [**2136-3-16**] 02:15AM BLOOD Plt Ct-225 LPlt-1+ [**2136-3-14**] 01:33AM BLOOD PT-14.1* PTT-29.6 INR(PT)-1.2* [**2136-3-1**] 04:16PM BLOOD Plt Ct-227 [**2136-3-7**] 01:48AM BLOOD ESR-108* [**2136-3-16**] 02:15AM BLOOD Glucose-109* UreaN-30* Creat-1.1 Na-149* K-3.4 Cl-109* HCO3-32 AnGap-11 [**2136-3-1**] 04:16PM BLOOD Glucose-145* UreaN-23* Creat-0.8 Na-141 K-3.7 Cl-101 HCO3-32 AnGap-12 [**2136-3-13**] 02:27AM BLOOD ALT-44* AST-31 TotBili-0.6 [**2136-3-6**] 10:40AM BLOOD calTIBC-133* VitB12-1165* Folate-9.7 Hapto-295* TRF-102* [**2136-3-5**] 07:22AM BLOOD TSH-2.5 [**2136-3-7**] 01:48AM BLOOD Cortsol-23.3* [**2136-3-9**] 02:57AM BLOOD CEA-12* [**2136-3-6**] 10:40AM BLOOD PEP-NO SPECIFI IgG-596* IgA-159 IgM-33* IFE-NO MONOCLO Brief Hospital Course: 83M with multiple comorbidities presents with FDG negative RML nodule. Pt underwent VATS to establish tissue diagnosis. Preliminary report of frozen sections showed likely hamartoma. Mass was then completely enucleated. Post-op CXR showed small right apical pneumothorax. Shortly after, his course was complicated by respiratory failure and patient was re-intubated. CXR showed R enlarged basilar pneumothorax with the right chest tube external to the pleural space. The chest tube was repositioned and POD1 CXR showed resolution of the R basilar ptx and pt was subsequently extubated. On POD2, pt had bradycardic respiratory arrest on the floor. Code called, ACLS initiated with chest compression, epi and atropine x2. ABG revealed hypercapnea with a pCO2 of 130 and pH of 7.00. Pt was reintubated, narrow complex returned with return of BP, and ppt was transferred to the TSICU. CXR showed no evidence of ptx. Head CT showed no evidence of acute intracranial process. Neurology was consulted and recommended head MRI to assess for evidence of hypoxic/ischemic injury. This was negative. Pt also underwent central line change with new stick. Post-line CXR showed new large right PTX. A new right 24F chest tube was placed, and the previous [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pleural drain was removed. Post tube CXR showed persistent large R PTX extending to the apex. Chest tube was continued to suction and patient was stable respiratory-wise. Pt was also febrile and started empirically on vanc and zosyn. Mental status returned to [**Location 213**] and pt was following commands. Over the next few days, pt was stable on tube feeds and antibiotics. Pt did not tolerate vent wean (RSBI 177). He received 2 units of pRBC and lasix for Hct of 22.8. Over this time he developed marked muscle weakness. Per neuro, pt was exhibiting signs of myopthay vs degenerative muscle dz. EMG by neurology showed electrophysiologic evidence for a severe, generalized sensorimotor polyneuropathy and as well as an a superimposed myopathy. neuromuscular junction disorders cannot be entirely excluded. They also recommended LP with was negative. BAL cx grew yeast and pt was started on fluconazole. He continued to fail vent wean and a trach and PEG were discussed and planned with family. Serial CXR showed persistent PTX, but stable. Physical Therapy- consult for evaluation [**2136-3-11**]. Trach and PEG were placed [**2136-3-12**]. Zosyn was dc'ed for negative cx. post-operatively pt was doing well and R PTX was resolving. It was noted that his sodium was also slowly increasing. free water boluses were initiated and tube feeds changed from respolar. Pt continued to not tolerate CPAP trials. It was decided that pt to go to vent rehab. on [**3-14**] chest tube was removed and post-pull CXR showed no evidence of pneumothorax. [**3-16**]- lasix gtt started for diuresis and assist w/ ventilatory wean. Pt diuresed effectively to to weight of 68kg [**2136-3-18**].(pre-op wt=147lbs) [**3-19**]- lasix gtt d/c, changed to Lasix 30 mg po qd per cardiology recs. CPAP PS wean cont @ .50/23ps/5 peep/ rr19/100%sat in [**1-20**] hour episodes as tolerated. REsting mode=AC/.50/600/12/5 peep. 500cc negative as was goal. CP in afternoon, no EKG changes, CPK/MB labs - negative. BP low overnight, diuresis d/c x24 and to resume QD. Physical Therapy/ Occupational Therapy re-eval patient. [**2136-3-20**]- Pt stable VS throughout the night, CPAP 20/5 x3 hours x1 returned to resting mode for fatigue- ^RR; After recovery on resting mode- ABG=7.40/41/136/26/0. PT following pt. Tubefeeding at goal. OOB to chair w/ assist 3hours x2. [**2136-3-21**]- Pt stable overnight, no events. Comfortable. Pt transfer to [**Hospital **] REhab s/ stable vital signs. Medications on Admission: cipro 250'', vicodin, ambien 5qhs, remeron 7.5qhs, flomax 0.4qhs, amio 200', glyburide/metformin 5/500'', SSRI Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital **]: 5000 (5000) u Injection TID (3 times a day). 2. Amiodarone 200 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily). 3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital **]: Six (6) Puff Inhalation Q4H (every 4 hours). 4. Docusate Sodium 150 mg/15 mL Liquid [**Hospital **]: Fifteen (15) cc PO BID (2 times a day). 5. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 6. Bisacodyl 10 mg Suppository [**Hospital **]: One (1) Suppository Rectal HS (at bedtime) as needed. 7. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital **]: Five (5) cc PO DAILY (Daily). 8. Oxycodone 5 mg/5 mL Solution [**Hospital **]: Five (5) mg PO Q4H (every 4 hours) as needed for pain. 9. Acetaminophen 160 mg/5 mL Solution [**Hospital **]: Five (5) cc PO Q6H (every 6 hours). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: titrate units Injection ASDIR (AS DIRECTED): prn BS [**Hospital1 **]-QID. 12. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 13. Furosemide 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO once a day. 14. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed. 15. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Hospital1 **]: One (1) gram Intravenous Q 24H (Every 24 Hours): to finish [**2136-3-23**]. 16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day/Year **]: One (1) ML Intravenous DAILY (Daily) as needed. 17. Metformin 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 18. Glipizide 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 19. Insulin Regular Human 100 unit/mL Solution [**Month/Day/Year **]: 0-24 units Injection four times a day: per Insulin sliding scale schedule--attached. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Right video assisted Thorocoscopy w/ excision of mediastinal mass (likely hamartoma), resp code on floor. Tracheostomy, percutaneous g-tube placement; PICC line placement PMH: Coronary artery disease/Myocardial InfarctionI '[**05**], '[**33**]; afib/flutter; DM; hypercholesterolemia; gallstone pancreatitis PSH: Coronary artery bypass graft x3 '[**23**]; s/p Lumbar [**1-20**] diskectomy '[**2131**] Discharge Condition: fair Discharge Instructions: Contact Dr.[**Name2 (NI) 2347**]/Thoracic Surgery office for any post surgical issues. [**Telephone/Fax (1) 170**]. Followup Instructions: Provider: [**Name10 (NameIs) 9894**],[**Name11 (NameIs) **](A) PAIN MANAGEMENT CENTER Date/Time:[**2136-3-28**] 10:00 Provider: [**Name Initial (NameIs) **]/[**Last Name (NamePattern4) 35873**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2136-4-23**] 1:00 Completed by:[**2136-3-21**]

[ "780.79", "250.00", "305.1", "496", "412", "427.31", "112.4", "518.5", "427.5", "359.9", "V45.81", "486", "512.1", "356.9", "759.6", "724.2" ]

icd9cm

[ [ [] ] ]

[ "31.1", "34.3", "33.24", "96.05", "43.11", "34.04", "99.04", "99.60", "38.93", "03.31", "96.6", "00.17", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

9077, 9156

3043, 6842

290, 401

9601, 9608

2056, 3020

9772, 10065

1581, 1624

7004, 9054

9177, 9580

6869, 6981

9632, 9749

1639, 2037

228, 252

429, 761

783, 1423

1439, 1565

30,562

109,172

32503+57806

Discharge summary

report+addendum

Admission Date: [**2137-12-3**] Discharge Date: [**2137-12-10**] Date of Birth: [**2067-2-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: abdominal aortic aneurysm Major Surgical or Invasive Procedure: [**2137-12-3**] Repair of abdominal aortic aneurysm with 16-mm Dacron tube graft. History of Present Illness: This 70-year-old gentleman has a 6 cm aneurysm of the infrarenal aorta with a very short proximal neck and heavily calcified iliac arteries. The proximal attachment site was unsuitable for endovascular repair. Past Medical History: CAD (s/p LCx stent '[**30**]), Cardiomyopathy (improved EF 45% recently), Chol, Arthritis, NIDDM, GERD Social History: remote smoker denies alcohol Family History: non contributary Physical Exam: AFVSS a/o nad grossly intact supple / farom neg lymphandopathy neg thyroidmegaly neg carotid bruits cta rrr pos bs / left cva tendernes - to note over surgical scar / neg right cva tenderness, surgical scar with staples, minimal seroussang drainage, hematoma noted palp fems b/l palp distal pulses b/l Pertinent Results: [**2137-12-9**] 03:00AM BLOOD WBC-7.1 RBC-3.18* Hgb-10.5* Hct-29.5* MCV-93 MCH-32.9* MCHC-35.4* RDW-13.8 Plt Ct-236 [**2137-12-5**] 04:00AM BLOOD PT-15.2* PTT-33.6 INR(PT)-1.3* [**2137-12-9**] 03:00AM BLOOD Glucose-119* UreaN-11 Creat-0.5 Na-139 K-3.4 Cl-104 HCO3-25 AnGap-13 [**2137-12-10**] 05:45AM BLOOD Calcium-8.2* Mg-2.0 [**2137-12-8**] 12:55 pm STOOL CONSISTENCY: WATERY Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2137-12-9**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). [**2137-12-6**] 12:47 PM CHEST (PORTABLE AP) REASON FOR EXAM: Assess triple-lumen catheter. Comparison is made with prior study performed a day earlier. Right IJ line tip is in the superior right atrium. Left transvenous pacemaker lead terminates in standard position in the right ventricle. NG tube tip is in the stomach. There is no pneumothorax. Bibasilar atelectasis, greater on the left side are stable. The left CP angle was not included on this film. If any, there is a small left pleural effusion. Brief Hospital Course: Mr. [**Known lastname 542**],[**Known firstname **] [**Numeric Identifier 75821**] was admitted on [**2137-12-3**] with AAA. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. It was decided that she would undergo a Repair of abdominal aortic aneurysm with 16-mm Dacron tube graft. . He was prepped, and brought down to the operating room for surgery. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complication. Post-operatively, he was extubated and transferred to the CVICU for further stabilization and monitoring. He was weaned from pressure support, he was extubated. He was then transferred to the [**Date Range **] for further recovery. While in the [**Date Range **] he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabalized from the acute setting of post operative care, he was transfered to floor status To note while in the [**Name (NI) **] pt developed an illeus. He recieved an NG tube. He was kept NPO for a number of days. Pt did have BM immediatly post - operative period. A GS consult was obtained. They performed a flex sig. There was no sign of ischemic colitis. Once it pt experienced flatus anf minimal drainage from the NG tube. The NG tube was removed. Pt diet was advanced. ON DC pt is eating a normal diet. Pt also had Anemia secondary to blood loss form the OR procedure. He recieved a total three units PRRBC. This helped his pressure. ON Dc is HCt is stable. On the floor, he remained hemodynamically stable with his pain controlled. He progressed with physical therapy to improve her strength and mobility. He continues to make steady progress without any incidents. He was discharged home with VNA in stable condition. Medications on Admission: Meds: ASA 325', Captopril 12.5'', Celexa 40', Levoxyl ?, Metformin 500'', Lopressor 25'', Niaspan, Vytorin [**8-/2110**]', Pletal 100'' Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 12. [**Last Name (un) 1724**] Meds: ASA 325', Captopril 12.5'', Celexa 40', Levoxyl ?, Metformin 500'', Lopressor 25'', Niaspan, Vytorin [**8-/2110**]', Pletal 100'' 13. Niaspan 500 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 169**], [**Location (un) 55**] Discharge Diagnosis: AAA Anemia secondary to blod loss form OR / tranfused 3 units PRBC Illeus post perative period / requiring NG tube CAD (s/p LCx stent '[**30**]) Cardiomyopathy (improved EF 45% recently) Chol Arthritis NIDDM S/P AICD pacer S/P C4/5 fusion S/Psubtotal thyroidectomy GERD Discharge Condition: STABLE Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-4**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**12-29**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] please call his assistant [**Doctor First Name 25812**] at ([**Telephone/Fax (1) 18181**] for a FU appointment in 1 weeks. [**Last Name (un) 20220**] should have had an appointment scheduled next week. You should make an appointment for follow-up with your PCP upon discharge Completed by:[**2137-12-10**] Name: [**Known lastname 539**],[**Known firstname **] Unit No: [**Numeric Identifier 12427**] Admission Date: [**2137-12-3**] Discharge Date: [**2137-12-10**] Date of Birth: [**2067-2-12**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1546**] Addendum: Physical Therapy recommendations at final evaluation for patient to go to Rehab for post-op recovery. DC to Rehab [**2137-12-10**] Discharge Disposition: Extended Care Facility: [**Location (un) 1353**], [**Location (un) 729**] Discharge Condition: Stable Discharge Instructions: Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-4**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**12-29**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: . You should make an appointment for follow-up with your PCP upon discharge Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], MD Phone:[**Telephone/Fax (1) 283**] Date/Time:[**2137-12-19**] 12:45 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**] Completed by:[**2137-12-10**]

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icd9cm

[ [ [] ] ]

[ "39.52", "45.24", "99.04" ]

icd9pcs

[ [ [] ] ]

9702, 9778

2288, 4223

341, 425

9799, 9808

1208, 2265

12549, 12939

853, 871

4409, 5619

5737, 6011

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9832, 12096

12122, 12526

886, 1189

276, 303

453, 665

687, 791

807, 837

31,073

133,187

29337

Discharge summary

report

Admission Date: [**2125-11-14**] Discharge Date: [**2125-11-20**] Date of Birth: [**2044-2-14**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 783**] Chief Complaint: transfer for bronchoscopy, hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 81-year-old female with colon cancer (follwowed by dr [**Last Name (STitle) **]) with liver metastasis s/p liver resection (by Dr. [**Last Name (STitle) **] and questionable lung mets (followed by Dr. [**Last Name (STitle) **], new ? right diaphramatic hemiparalysis, right pleural effusion, dementia, hypertension, pulmonary embolism s/p IVC filter and SDH, COPD on BiPAP at night, EtOH abuse that presented to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30746**] with dyspnea and RLL collapse with pleural effusion. She is being transferred from [**Hospital3 **] to [**Hospital1 18**] for bronchoscopy for right lower lobe collapse to look for endobronchial tumor and pleurocentesis. Patient was recently discharged from rehab hospital after sustaining fracture of her obturator ring on right. After only one day at home she started to have sob and leg swelling. She presented to [**Hospital3 **] where they originally treated her for CHF exacerbation with diuresis but BNP was wnl and TTE showed normal LV systolic function, mild aortic stenosis, and PAH at 60mmHg. CTA was negative for PEs and for metastati disease. She was also treated for PNA with rocephin and zithromax after developing a fever to 100.2 and a new right-sided haziness on CXR. Did not drain effusion as was not sizeable enough to tap. Oncology did not feel this was new metastatic disease because she had just undergone 9 cycles of chemotherapy. Had persistent hypoxemia (95 % on 8 L) without oxygen 85 %. Eventually found to have RLL collapse and right hemidiaphragmatic paralysis. Was maintained on the medical floor stable requiering 6 liters O2 nasal cannula and nocturnal Bipap. (BiPAP setings [**11-11**]). refused daytime bipap. Pulmonology suggested chest pt and nebulizers but the patient did not improve so they then recommended bronchoscopy to remove mucous plugging. As per family request they would like her to be transferred to [**Hospital1 18**] for bronch (+/- endobronchial intervention) and pleural drainage tomorrow. Past Medical History: - Stage IIIB colon cancer who completed adjuvant therapy with eight cycles of capecitabine. Medical course complicated by recurrent right-sided pleural effusion, right upper quadrant intra-abdominal abscess, and E. coli bacteremia. In addition, s/p liver resection fro metastatic disease - SDH s/p craniotomy - PE s/pIVC filter - COPD - ETOH abuse - HTN - AAOx3 but baseline dementia per OSH records - hysterectomy - Colectomy - BSO - loculated pleural effusion s/p thoracentesis and chest tube placement in [**2122**] with cytology on pleural fluid negative for malignancy Social History: - Tobacco: Quit smoking 12 years ago - Alcohol: Previous heavy ETOH use not currently sober - Independent in her ADLs previously, recently discharged from rehab after a fracture. Family History: Non-contributory Physical Exam: Vitals: T: 98 BP:96/59 P:68 R: 18 18 O2: 96% on 50% FM and 4L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: decreased BS on right. crackles at base on left CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: tr edema bilaterally Discharge: VS: T: 95.6, BP: 140/82, P: 68, RR: 24, 94% 6L GA: seen in bed, laughing, AAOx3 (person, [**Location (un) **] hospital, year, month) Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: decreased breath sounds on the right, dullness to percussion on right. mild crackles at right mid lung and left lower lung Abd: soft, NT, +BS. no g/rt. Extremities: wwp, 1+ ankle edema Pertinent Results: Admission: [**2125-11-14**] 09:41PM GLUCOSE-112* UREA N-34* CREAT-0.9 SODIUM-138 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12 [**2125-11-14**] 09:41PM CALCIUM-9.4 PHOSPHATE-3.9 MAGNESIUM-2.0 [**2125-11-14**] 09:41PM WBC-6.8 RBC-4.44 HGB-12.4 HCT-37.7 MCV-85 MCH-27.9 MCHC-32.9 RDW-14.5 [**2125-11-14**] 09:41PM PT-13.5* PTT-23.7 INR(PT)-1.2* Discharge: [**2125-11-18**] 05:55AM BLOOD WBC-5.4 RBC-4.12* Hgb-11.8* Hct-36.1 MCV-87 MCH-28.6 MCHC-32.8 RDW-14.6 Plt Ct-226 [**2125-11-18**] 05:55AM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1 [**2125-11-18**] 05:55AM BLOOD Glucose-96 UreaN-25* Creat-0.9 Na-139 K-4.3 Cl-100 HCO3-32 AnGap-11 [**2125-11-18**] 05:55AM BLOOD ALT-11 AST-15 LD(LDH)-184 AlkPhos-105 TotBili-0.3 [**2125-11-18**] 05:55AM BLOOD Albumin-3.5 Calcium-9.4 Phos-3.8 Mg-1.9 [**2125-11-18**] 05:55AM BLOOD CEA-1.5 [**2125-11-15**] Echo: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 65%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. 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 to moderate ([**12-9**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2123-4-29**], the findings are similar. [**2125-11-15**] CXR: As compared to the previous radiograph, there is no relevant change. Moderate cardiomegaly, small bilateral pleural effusions. Tortuosity of the thoracic aorta. Partial right and left lung base atelectasis. No evidence of focal parenchymal opacity suggesting pneumonia. [**2125-11-19**]: CT Chest Wetread chest: small bilateral effusions and associated atelectasis obscure some of the known pulmonary nodules. at least one pulmonary nodule in the right upper lobe is unchagned in size compared to [**2125-1-15**]. others are not seen due to atelectasis. hyperdense pleural material on the right suggests prior pleurodesis. septal thickening and ground glass opacities suggest an element of volume overload. abd/pelvis: stable appearance of the liver s/p partial right hepatectomy. no new liver lesions. spleen, pancreas, adrenal and kidneys unchanged. no new RP or mesenteric adenopathy. bowel-containing ventral hernia is uncomplicated. no free fluid or free air or other acute intraabdominal process identified. bones: right pubic rami fractures are new from [**Month (only) **] but do not appear acute. bones are otherwise unchanged. no acute fractures. Brief Hospital Course: 81 yo female with PMH of colon cancer stage IIIb with liver mets s/p resection, questionable lung mets, new right diaphragmatic hemiparalysis, right pleural effusion, dementia, pulmonary embolism s/p IVC filter, COPD admitted to OSH with SOB found to have R lobe collapse and transferred to [**Hospital1 18**] MICU for hypoxia then transferred to the medicine team stable on 6 L NC. #Hypoxia: Patient has underlying lung pathology including COPD and prior pulmonary embolism. She was found to have RLL collapse at the OSH with right hemidiaphragmatic paralysis. The RLL collapse was thought to be the most likely cause of her new oxygen requirement. She was evaluated by interventional pulmonology who felt that she was not a candidate for bronchscopy as she would be difficult to extubate. She was evaluated by oncology who felt that pulmonary involvement of her cancer was less likely based on review on imaging and normal CEA. Incentive spirometry was encouraged. On discharge, she was requiring 6 L supplemental O2 via nasal cannula with O2 sats in the mid to low 90s. #Hx of Colon Cancer: There was initial concern that endobronchial tumor may have been cause of RLL collapse. CEA was elevated when liver mets were found, now within normal limits, making metastasis less likely. LFTs were also within normal limits. CT Chest/abdomen/ pelvis did not show any evidence of new metastasis. Patient was discharged with oncology follow-up in 1 month. #Hypertension: BP was low-normal on admission. Her amlodipine was stopped and furosemide was decreased from 40 mg po daily to 20 mg po daily. She was continued on lisinopril and atenolol. #Chronic Diastolic CHF: Patient had signs of acute on chronic CHF at OSH including bilateral pleural effusions, vascular congestion which improved with diuretics. On discharge, patient had mild tibial edema and bibasilar crackles on lung exam. She was discharged on lasix 20 mg po daily which can be increased to 40 mg po daily if her blood pressure allows. #COPD: Likely contributing to new O2 requirement. There were mo signs of acute COPD exacerbation on this admission. #Hx of PE: patient had IVC placed as she was unable to receive anticoagulation at the time secondary to subdural hematoma. CTA was negative for PE at OSH. She was given heparin subq tid for DVT prophylaxis. #Pending: final read of CT chest/abdomen/ pelvis pending. #CODE: Full Code (confirmed with son) Medications on Admission: Alendronate 70 mg po weekly Amlodipine 10 mg po daily Atenolol 50 mg po daily Calcium + Vitamin D 600 mg tablet po daily Docusate 100 mg po daily Folic Acid 1 mg po daily Furosemide 40 mg po daily Lisinopril 10 mg po daily Lorazepam 0.25 mg po q8h prn Oxycodone-acetaminophen 3/325 mg po q4-6 hrs prn pain Discharge Medications: 1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 8. Outpatient Lab Work Please check Chem 7 (Na, K, Cl, HCO3, BUN, creatinine, glucose) on [**2125-11-21**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Right hemidiaphragmatic paralysis 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 transferred to [**Hospital1 69**] on [**2125-11-14**] with shortness of breath. You were found to have collapse of part of your right lung and impaired diaphragm function. You were evaluated by the interventional pulmonary service who felt there was a considerable risk to performing a bronchscopy. You were evaluated by the oncology service who felt that this was less likely to be due to cancer. Part of your shortness of breath is likely due to heart failure and you were continued on lasix to remove the extra fluid. You were given oxygen to help your breathing. The following changes were made to your medications: -STOPPED Amlodipine -STOPPED Percocet (oxycodone-acetominophen) -STOPPED Lorazepam -DECREASED furosemide from 40 mg to 20 mg by mouth once a day Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2125-12-19**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "799.02", "519.4", "V12.51", "518.0", "294.8", "496", "V10.05", "511.9", "428.0", "428.33", "401.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10489, 10561

7095, 9520

340, 346

10648, 10648

4115, 7072

11630, 12094

3213, 3231

9876, 10466

10582, 10627

9546, 9853

10831, 11607

3246, 4096

266, 302

374, 2403

10663, 10807

2425, 3001

3017, 3197

79,406

135,018

35394

Discharge summary

report

Admission Date: [**2147-3-29**] Discharge Date: [**2147-3-31**] Date of Birth: [**2093-2-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: threatening behavior Major Surgical or Invasive Procedure: intubation and extubation History of Present Illness: Mrs. [**Known lastname 80671**] is a 54 year old Greek-speaking only female with a long-standing history of unusual behavior, brought into the hospital by her daughter due to concern for increased agitation and threatening behavior toward her husband with concern for potential violent behavior. . Per the patient's daughter, the patient has been "crazy" for as long as she can remember. She reports her mother's mood as often being "down" and "[**Doctor Last Name 11506**]" and "angry", but at times "laughing for no reason". She speaks constantly and has hallucinations, though it is unclear if these are visual or auditory or both. She reportedly also has had many delusions, for example, that she is being poisoned. The patient never leaves the house, except for once a month when a family member visits to assist with personal care. She has also occassionally displayed threatening behavior to family in the past. These behaviors have been ongoing for years. The daughter reports, however, that within the last few months to weeks the patient's behavior has become more bizzarre. The patient who was once a "clean freak" now does not clean her home or herself. The daughter has to bathe her mother and has recently found used menstrual pads hidden around the house and believes that the patient is having heavier periods. There are no other physical symptoms that the patient is having of which the daughter is aware. Today the patient's husband became scared because of the wife's threatening behavior with a knife, and the daughter decided that she needed to seek medical attention. . In the ED, initial vs were: T 97.9 (first temperature taken 3 hours after arrival) P 137 BP 160/90 O2 sat 100% on room air. The patient was very agitated. Stool guaiac was negative. Pelvic exam showed no active bleeding from the os but blood in the vaginal vault. The patient was intermittently severely agitated and was intubated for agitation and need for CT. Intubation was reportedly difficult. CT head showed no acute process. CT chest showed no PE. The patient was given a total of 2L NS, Levaquin 750 mg PO, ativan 4 mg IV, haldol 5 mg IM, veccuronium 15 mg IV, versed 5 mg IV, fentanyl 150 mg IV, and a propofol gtt was started. . On arrival to the floor the patient was intubated and sedated. History was taken from the patient's daughter. . Review of sytems: Could not obtain as the patient is intubated and sedated. Past Medical History: Morbid Obesity Possible psychosis disorder- had in pt tx in [**2118**] No medical care since [**2118**] Social History: Came to the U.S. from [**Country 5881**] with her husband in [**2124**]. [**Name2 (NI) **] known medical contact [**2126**]. Denies alcohol, tobacco, or illicit drug use. Family History: Father died in 90s with dementia Mother alive and well in [**Country 5881**] Siblings alive and well Paternal grandmother was "crazy" Physical Exam: Vitals: T: 100.1 BP: 142/60 P: 120 R: 18 O2: 93% RA General: Morbidly obese, sedated, but arousable, comfortable HEENT: 1-2 mm pupils b/l, equal round and minimally reactive to light. Sclera anicteric, MMM, oropharynx with poor dentition, Neck: supple, unable to assess JVD due to body habitus, unable to palpate any masses Lungs: Bronchial breath sounds bilaterally, no crackles CV: Regular rate and rhythm, normal S1 + S2, no murmurs Abdomen: soft, non-tender, non-distended, + bowel sounds, very large panus, skin without infection Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2147-3-29**] 03:00PM BLOOD WBC-10.1 RBC-3.75* Hgb-10.0* Hct-30.5* MCV-81* MCH-26.7* MCHC-32.8 RDW-15.9* Plt Ct-323 [**2147-3-31**] 07:33AM BLOOD WBC-10.1 RBC-3.81* Hgb-10.1* Hct-30.8* MCV-81* MCH-26.6* MCHC-32.9 RDW-16.0* Plt Ct-295 [**2147-3-29**] 03:00PM BLOOD Neuts-82* Bands-0 Lymphs-13.0* Monos-4 Eos-1 Baso-0 [**2147-3-30**] 01:30AM BLOOD Neuts-72.3* Lymphs-22.5 Monos-4.7 Eos-0.2 Baso-0.2 [**2147-3-29**] 03:00PM BLOOD PT-14.0* PTT-23.6 INR(PT)-1.2* [**2147-3-29**] 11:50AM BLOOD UreaN-16 Creat-0.9 Cl-105 HCO3-24 [**2147-3-29**] 03:00PM BLOOD Glucose-111* UreaN-14 Creat-0.9 Na-140 K-3.7 Cl-106 HCO3-25 AnGap-13 [**2147-3-31**] 07:33AM BLOOD Glucose-99 UreaN-7 Creat-0.9 Na-141 K-3.6 Cl-105 HCO3-26 AnGap-14 [**2147-3-30**] 01:30AM BLOOD ALT-13 AST-16 LD(LDH)-211 AlkPhos-78 TotBili-0.3 [**2147-3-29**] 11:50AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-79 [**2147-3-29**] 03:00PM BLOOD proBNP-114 [**2147-3-30**] 01:00AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7 [**2147-3-30**] 01:30AM BLOOD Albumin-3.3* Calcium-8.2* Phos-3.4 Mg-1.6 Iron-28* [**2147-3-29**] 03:00PM BLOOD D-Dimer-1485* [**2147-3-30**] 01:30AM BLOOD calTIBC-295 VitB12-245 Ferritn-19 TRF-227 [**2147-3-29**] 11:50AM BLOOD TSH-2.6 [**2147-3-29**] 03:00PM BLOOD TSH-1.9 [**2147-3-29**] 03:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2147-3-29**] 09:34PM BLOOD Type-ART Rates-14/21 Tidal V-594 FiO2-100 pO2-264* pCO2-45 pH-7.35 calTCO2-26 Base XS-0 AADO2-425 REQ O2-72 -ASSIST/CON Intubat-INTUBATED [**2147-3-29**] 11:00AM BLOOD Glucose-118* Lactate-2.3* Na-142 K-4.2 [**2147-3-29**] 03:03PM BLOOD Lactate-2.5* [**2147-3-30**] 02:10AM BLOOD Lactate-1.4 [**2147-3-30**] 02:10AM BLOOD freeCa-1.11* [**2147-3-30**] 01:20AM BLOOD VITAMIN B1-PND [**2147-3-30**] 01:20AM BLOOD HEAVY METAL SCREEN-PND [**2147-3-29**] 10:42AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 [**2147-3-29**] 10:42AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2147-3-29**] 10:42AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2147-3-29**] 08:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG RAPID PLASMA REAGIN TEST (Final [**2147-3-31**]): NONREACTIVE. Reference Range: Non-Reactive. URINE CULTURE (Final [**2147-3-30**]): NO GROWTH. EKG [**2147-3-29**] Sinus tachycardia Prominent limb lead QRS voltages raises the consider of left ventricular hypertrophy Diffuse nonspecific ST-T wave abnormalities Clinical correlation is suggested No previous tracing available for comparison Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 144 0 90 272/419 0 -21 124 CXR [**2147-3-29**] IMPRESSION: 1. Enlargement of the cardiac silhouette. Cephalization and mild pulmonary edema consistent with volume overload. 2. No evidence for pneumonia. CT head [**2147-3-29**] IMPRESSION: No acute intracranial abnormality. CTA chest [**2147-3-29**] IMPRESSION: 1. No central or segmental pulmonary embolus. 2. Posterior pulmonary air-space consolidation, may represent a combination of atelectasis and sequela of aspiration. 3. Mild cardiomegaly. 4. NGT should be advanced for more optimal position. cxr [**2147-3-30**] IMPRESSION: Slight improvement in volume overload, with persistent retrocardiac atelectasis and small pleural effusions. Brief Hospital Course: This is a 54 year old female with no known past medical history other than morbid obesity who was brought in by her family for increasingly agitated and bizarre behavior and was intubated in the ED due to uncontrolled agitation and for CT scan, was extubated next day in the MICU and then transfered to the floor after extubation. She is only Greek speaking. . # Agitation/behavioral abnormalities: According to the family, this has been an ongoing problem for many years; progressively worse. Possible untreated schizophrenia vs other psychotic disoder. Has hx of parnoia, depressed thoughts, and possible manic episodes per family. Alos, hallucinations and threatening behavior. No oraganic cause found during hospitalizaiton. Serum and urine tox screens were negative. Head CT is without evidence of acute intracranial abnormality. TSH and B12 normal. UA and urine cutlture negative. Blood cutlures negative so far. There is a pending heavy metal screen level. Non-reactive RPR. MRI not possible due to body habitus. Was evaluated by psychiatry and needs in patient psychiatric care. For now is on haldol 5mg [**Hospital1 **] and 2.5mg PRN and ativan 1mg TID PRN. Requiring sitter on the floor, very agitated at times but nonthreatening during hospitalization. She is medically clear for a psychiatric admission. . # Anemia: Unclear baseline. Guaiac negative in the ED. [**Month (only) 116**] be secondary to menstraul bleeding. Iron was found to be low and patient was started on iron supplements. . # Possible Menorrhagia: Per the patient's daughter, pt may be having heavier cycles, however this is not clear. [**Month (only) 116**] explain her anemia. Patient may be peri-menopausal with erratic menstruation or may have another etiology for menorrhagia. Pelvic exam in ED showed no blood at the os, but some residual blood in the vaginal vault. Hct was stable during hospitalization. She should have further work up as out patient with [**Hospital 67897**] clinic once stablized mentaly. Contiue iron for now. . # Possible Aspiration from intubation: She was not easy to intubate, which was required for the CT scan in the ER. The CTA showed no PE, the CT head showed no intracraial process. She had some minor posterior lung changes of atelectasis vs apsiration on CT. Was afebrile wtih no respiratory symtoms. She was started on levoquin in the ER and changed to azithro (to prevent QT prolongation while on haldol). On day 3 of antibiotics they were stopped. . # ST depressions on EKG/Hypertension: Likely related to tachycardia. When pt becomes agitated she has sinus tachycardia with some non-specific diffuse ST depressions. These have resoved with a normal sinus rate. Patient was started on metoprolol 25 [**Hospital1 **] for her blood pressure and the tachycardia. . Daughter(H: [**Telephone/Fax (1) 80672**]; C: [**Telephone/Fax (1) 80673**]) . Will be transfered for psychiatric care under a section 12. Medications on Admission: occasional tylenol use Discharge Medications: 1. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation: hold for sedation. 8. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO Q2H (every 2 hours) as needed for agitation. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Psychotic behavior disorder Hypertension Anemia, iron deficiency Morbid Obesity Discharge Condition: Hemdyamically stable, has sinus tachycardia with agaitation, Greek speaking, afebrile Discharge Instructions: You were admitted due to behavior concerns. You were agitated and required intubation for testing. You did not have a heart attack or a blood clot in your lungs. You do not have an infection. You have anemia and were started on iron. You also had elevated blood pressure, and were started on metoprolol for this. You are also taking medications to help your behavior. You will be discharged to a psychiatric facility for more care. After you leave there, please make an appointment with your PCP and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 80674**] for further care. Followup Instructions: Please call PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 11144**] for a follow up appointment when you go home. Also call, ([**Telephone/Fax (1) 22754**] for a Gynecology appointment for follow up on your menstraul cycles. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2147-3-31**]

[ "401.9", "626.2", "278.01", "298.9", "312.9", "285.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11050, 11093

7343, 10267

335, 362

11217, 11305

3918, 7320

11941, 12383

3143, 3279

10340, 11027

11114, 11196

10293, 10317

11329, 11918

3294, 3899

275, 297

2751, 2811

390, 2733

2833, 2939

2955, 3127

29,761

184,015

33642

Discharge summary

report

Admission Date: [**2143-1-24**] Discharge Date: [**2143-1-24**] Date of Birth: [**2113-11-27**] Sex: M Service: SURGERY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2534**] Chief Complaint: Traumatic bilateral above the knee amputations Major Surgical or Invasive Procedure: Exploratory laparotomy Resection of necrotic bowel Bilateral above the knee amputations, Incision and drainage, and application of vacuum dressings History of Present Illness: Patient is a 29 year old male who tried to jump onto a moving locomotive caboose in [**Location (un) 5503**], MA, while intoxicated. He failed in getting onto the train and was subsequently dragged under, suffering bilateral lower extremity above-the-knee amputations. [**Name (NI) 1094**] friend ran for help at the scene, and the patient was transported to [**Hospital6 302**] for triage. At [**Hospital3 **] his amputations were completed and he was tourniqueted, received several units of blood, and was transported via [**Location (un) **] to [**Hospital1 18**]. Past Medical History: Unknown Social History: Unknown Family History: Unknown Physical Exam: On presentation: Vitals: 90.7F oral, 95F head scanner, Pulse 62, BP 62/Palp, Sat 93 on Vent Sedated, intubated white male C-Collar in place CTAB RRR, Hypotensive, L SC CVL Palpable L femoral, Bilat rad pulse Abd soft Foley in place L AKA R AKA Bilateral lower ext. tourniquets Pertinent Results: [**2143-1-24**] 10:22PM O2 SAT-61 [**2143-1-24**] 10:19PM TYPE-ART PO2-101 PCO2-94* PH-6.92* TOTAL CO2-21 BASE XS--16 [**2143-1-24**] 10:19PM LACTATE-10.6* [**2143-1-24**] 10:19PM freeCa-1.13 [**2143-1-24**] 10:05PM GLUCOSE-165* UREA N-12 CREAT-1.2 SODIUM-151* POTASSIUM-2.9* CHLORIDE-109* TOTAL CO2-19* ANION GAP-26* [**2143-1-24**] 10:05PM CALCIUM-10.0 PHOSPHATE-10.6* MAGNESIUM-1.5* [**2143-1-24**] 10:05PM WBC-4.0 RBC-3.37* HGB-9.7* HCT-30.8* MCV-91 MCH-28.8 MCHC-31.6 RDW-13.6 [**2143-1-24**] 10:05PM PLT COUNT-101* [**2143-1-24**] 10:05PM PT-25.8* PTT-150* INR(PT)-2.6* [**2143-1-24**] 09:33PM TYPE-ART PH-6.90* [**2143-1-24**] 09:33PM freeCa-0.91* [**2143-1-24**] 09:27PM GLUCOSE-225* UREA N-12 CREAT-1.2 SODIUM-152* POTASSIUM-2.9* CHLORIDE-104 TOTAL CO2-19* ANION GAP-32* [**2143-1-24**] 09:27PM ALT(SGPT)-350* AST(SGOT)-565* CK(CPK)-1857* ALK PHOS-74 AMYLASE-58 TOT BILI-0.3 [**2143-1-24**] 09:27PM LIPASE-43 [**2143-1-24**] 09:27PM CK-MB-33* MB INDX-1.8 cTropnT-1.31* Brief Hospital Course: Patient arrived with the above physical exam findings and hemodynamically unstable via [**Location (un) **] from [**Hospital6 **] in [**Location (un) 5503**], MA. He was evaluated by the Trauma team in the ED and taken immediately to the operating theater. . Intraoperatively with Orthopedics he underwent bilateral above-the-knee amputations, incision and drainage with debridement of his wounds, and placement of vacuum dressings to his remaining lower extremities. At the conclusion of these procedures he was noted to have passed approximately 250 cc of bloody stool. He then underwent an exploratory laparotomy with the the Trauma Surgery team, with noted finding of a necrotic Right hemicolon. He then underwent a Right hemicolectomy. EBL for these two combined procedures was approximately 3500cc. The patient was then transferred back to the TSICU, on a ventilator, and requiring extensive hemodynamic pressor support. . Postoperatively the patient required multiple transfusions of crystalloid, colloid, and blood products including FFP, Platelets, and PRBC. Despite very aggressive electrolyte, blood, and fluid resuscitation the patient continued to become increasingly coagulopathic, anemic, and with further electrolye abnormalities. At approximately the 2230 the patient went into ventricular fibrillation and rapidly converted to asystole. ACLS was then conducted for approximately 15 minutes without regaining a cardiac rhythm by EKG. The patient was then pronounced dead by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4281**]. Medications on Admission: Unknown Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Death secondary to Acute dysrhythmia secondary to Hypovolemic shock secondary to Traumatic bilateral above-the-knee amputations Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "E849.6", "E804.2", "897.7", "557.0", "958.4", "305.00", "285.9", "427.41", "286.9" ]

icd9cm

[ [ [] ] ]

[ "45.73", "99.62", "99.05", "89.64", "96.71", "84.3", "99.06", "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

4181, 4190

2518, 4094

343, 492

4362, 4372

1486, 2495

4425, 4433

1164, 1174

4152, 4158

4211, 4341

4120, 4129

4396, 4402

1189, 1467

257, 305

520, 1092

1114, 1123

1139, 1148

68,001

158,473

5981

Discharge summary

report

Admission Date: [**2129-1-23**] Discharge Date: [**2129-1-26**] Date of Birth: [**2055-10-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: Patient is a 73 yo F with a history of diverticulosis, hypertension and diabetes who presented to the ED this AM with the complaint rectal bleeding and ?marroon stools. The patient reports that the bleeding started on Wednesday with initial light red then dark red stools. They have persisted each day with the last stool somewhat bloody this morning. She did have the prodromal syndrome of dizziness the two days prior to the bleeding episode that has persisted (or somewhat improved) since then. She has not had presyncopal episodes or syncope. Additionally she has not had chest pain but has had mild dyspnea that is also unchanged since Wednesday. . In the ED, initial vs were: T 98.0 P82 BP 151/64 R22 O2 sat97%. Patient was found to be significantly anemic and given 2 U PRBC. Additionally the patient was initially thought to have a colitis and was given cipro and flagyl. CT abdomen with PO contrast showed diverticulosis without signs of colitis or infection. Vitals have remained stable with BP 130s, hr 60s-80s. Protonix 40 mg was also given, pt refused NG lavage and was guaiac positive. . Review of systems: (+) Per HPI, one episode of fever, chills on wed pm, one episode of nausea and vomiting on wed pm (after the bleeding) with food vomitus (no blood/coffee grounds). Since then has only drank water. (-) recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough. Denied chest pain or tightness, palpitations. constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Diabetes Hypertension Diverticulosis Internal hemorrhoids Social History: She is originally from [**Last Name (LF) 625**], [**First Name3 (LF) 622**] but has lived in [**Location 669**] near [**Last Name (NamePattern1) 23554**]since [**2086**]. She worked as housekeeper for the state for 34 years, now retired. Tobacco: Stopped 30 years ago. Alcohol: No Illicit Drugs: No Family History: Father died of stroke at [**Age over 90 **] years of age. Mother died of diabetes complications in her 80s. Physical Exam: VS: 98.4, 137/46, 80, 16, 100% General Appearance: Well nourished, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition, no teeth Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ), (Breath Sounds: Clear : ) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right: Trace, Left: Trace Skin: Warm, No(t) Rash: Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal Pertinent Results: LABS ON ADMISSION: [**2129-1-23**] 11:45AM BLOOD WBC-14.5* RBC-2.13*# Hgb-5.3*# Hct-17.0*# MCV-80* MCH-25.1* MCHC-31.5 RDW-19.9* Plt Ct-497*# [**2129-1-24**] 04:39PM BLOOD Hct-28.3* [**2129-1-23**] 11:45AM BLOOD Neuts-71* Bands-0 Lymphs-21 Monos-6 Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-3* [**2129-1-23**] 11:45AM BLOOD Glucose-166* UreaN-53* Creat-2.1*# Na-136 K-4.8 Cl-107 HCO3-17* AnGap-17 [**2129-1-23**] 12:56PM BLOOD cTropnT-<0.01 [**2129-1-24**] 04:28AM BLOOD Albumin-3.4 Calcium-8.7 Phos-3.2 Mg-1.9 . RADIOLOGY: CT A/P w Contrast (1/4/9) IMPRESSION: 1. Diffuse colonic diverticulosis without associated stranding or wall thickening to suggest diverticulitis. 2. Enlarged irregular uterus with potential mass lesion versus adnexal lesion on the right versus pedunculated fibroid. Recommend non-urgent pelvic ultrasound to exclude underlying mass lesion. 3. Calcified atherosclerotic plaque throughout the abdominal aorta and iliac branches without aneurysmal dilatation. Colonoscopy ([**2129-1-25**]) Impression: Diverticulosis of the rectum, sigmoid colon, descending colon, transverse colon and ascending colon Polyp in the transverse colon Otherwise normal colonoscopy to cecum Recommendations: Routine post procedure orders. Monitor HCT. Repeat colonoscopy in 3 months to evaluate for polyps and remove polyp that was not removed during this procedure. Please schedule this with Dr. [**First Name (STitle) 452**] or in a GI fellow slot ([**Numeric Identifier 23555**]). Brief Hospital Course: Ms [**Known lastname 23556**] is a 73 yo F with history of diverticulosis, diabetes and hypertension who presents with 5 days of rectal bleeding and anemia, received 4 units PRBC's, colonoscopy negative for any bleed, Hct stable for 48 hours, scheduled for outpatient colonoscopy in 3 months as per GI suggestions, PCP appointment also scheduled. . # Rectal bleeding/anemia: Pt p/w Hct of 17, but minimal sxs. Acutely [**2-21**] GI Bleed, though baseline anemia (?iron-deficiency). Received 4 units of pRBCs. Hematocrit is now stable ~27 with appropriate elevation based on transfusions. No signs of active bleeding. Given that this is likely diverticular, the potential of rebleeding exists, though the patient is currently stable and reliable. GI consult recommended endoscopy and colonoscopy. Colonoscopy demonstrated multiple non-bleeding diverticula along with a sessile polyp that was not removed. GI asked for repeat colonoscopy in 3 months to remove sessile polyp. . # Acute renal failure: Likely secondary to prerenal hypoperfusion in the setting of diabetes. No signs of hydroneprhosis on CT. Persistently elevated, perhaps with ATN in the setting of brief hypotension at the initial onset of the bleed. Resolved after fluid hydration on the floor. . # UTI: Patient with leukocytosis and positive UA. No other urinary sxs. Treated with 3 day course of ciprofloxacin with no additional problems. . # Diabetes: held metformin during acute setting and procedure, on ISS, returned back to metformin on discharge. . # Metabolic acidosis: patient with low HCO3. Likely secondary to ARF with decreased Po intake, GI losses. AG 12. Medications on Admission: 1. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Diverticulosis Gastrointestinal Bleeding Secondary: Diabetes Hypertension Iron deficiency anemia Discharge Condition: Stable, ambulating, eating, drinking, voiding, and having bowel movements with no problems. Discharge Instructions: You were admitted due to having blood in your stool. Upon arrival, you were sent to the ICU because your blood count was very low. You were given some units of blood and had an appropriate increase in your blood count. After being transferred to the floor, you underwent a colonoscopy which demonstrated that you had outpouchings of your colon which may have been responsible for the bleeding, but were not actively bleeding. In addition, a polyp was found, which will be removed on a repeat colonoscopy in 3 months. You have two appointments scheduled, one with Dr. [**Last Name (STitle) **], your primary care physician, [**Name10 (NameIs) **] with Dr. [**First Name (STitle) 452**] for a repeat colonoscopy. The times are listed below, please attend those appointments. You should take 360mg of your Diltiazem instead of your 480mg. If you begin to have any more bleeding in your stool, lightheadedness, dizziness, nausea, vomiting, diarrhea, constipation, extreme and severe chest pain, or loss of consciousness, please contact your primary care attending immediately. Followup Instructions: 1. Primary Care Appointment: Dr. [**Last Name (STitle) **], [**2-2**], 9:45 AM. 2. Friday [**2130-4-22**]:30 AM Dr. [**First Name (STitle) 452**] repeat colonoscopy. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **],EAST PROCEDURES ENDOSCOPY SUITES Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2129-4-22**] 10:30 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2129-4-22**] 10:30 Completed by:[**2129-1-26**]

[ "211.3", "276.7", "288.60", "599.0", "584.9", "250.00", "578.9", "562.10", "403.90", "276.2", "585.9", "285.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.23" ]

icd9pcs

[ [ [] ] ]

7386, 7392

4822, 6463

344, 358

7543, 7637

3309, 3314

8766, 9243

2409, 2519

6932, 7363

7413, 7522

6489, 6909

7661, 8743

2534, 3290

1519, 1994

277, 306

386, 1499

3328, 4799

2016, 2075

2091, 2393

46,251

103,941

34274

Discharge summary

report

Admission Date: [**2135-11-12**] Discharge Date: [**2135-11-17**] Date of Birth: [**2104-8-11**] Sex: M Service: MEDICINE Allergies: Ibuprofen Attending:[**First Name3 (LF) 8388**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: HD line removal ([**2135-11-12**]) Temporary HD line placement ([**2135-11-15**]) Post-pyloric feeding tube placement ([**2135-11-16**]) History of Present Illness: 31 y/o M with biliary atresia s/p liver [**Month/Day/Year **] at age 4 currently listed for liver/kidney [**Month/Day/Year **], ESRD on HD who was transferred from OSH [**2135-11-12**] with fevers, tachycardia, and abdominal pain. Patient reported diffuse abdominal pain, worse in RUQ x 4 days that came on suddenly then radiated to right chest. The day prior to transfer he had coffee-ground emesis and black diarrhea. In the ED patient was tachycardic to 140-150s with SBP 100's and spiked a fever to 102.4. Patient was empirically started on vancomycin and zosyn. CXR demonstrated bilateral effusions and no infiltrate. CTA torso demonstrated no PE, but loculated ascites with mass effect, patent portal vein, mod-large b/l pleural effusions and jejunal wall thickening of unknown significance. Following 3L of IVFs patient remained tachycardia and was consequently admitted to the MICU for concern of sepsis. . During his MICU stay blood cultures returned positive for klebsiella pneumoniae and consequently his HD line was removed. Cultures were pan-sensitive consequently vanc/zosyn was narrowed to ceftriaxone. Additional infectious work up included: negative influenza, negative c. diff, negative SBP, negative urine culture. Patient had no episodes of coffee ground emesis or melena and HCT remained stable (hemoconcentrated on admission). Tachycardia was an ongoing problem. The MICU team attempted small boluses of fluid with only mild improvement in his HR. Today 6 mg adenosine was given to investigate whether rhythm was SVT but had no effect. During his admission the patient began complaining of back pain and a MRI spine was ordered to rule out epidural abscess prior to transfer. . Upon evaluation of the patient he states his abdominal pain has completely resolved since admission. He denies any fevers, chills, emesis or bloody bowel movements. He states his back pain started on saturday ("after all the fluids") but has now improved. The pain was [**4-3**] and non-localized ("my entire back"). Patient describes difficulty ambulating due to lower extremity edema only. No changes in his bowel movements (loose at baseline). The patient is oriented x 3 and states he feels much better than on admission. . Of note, patient was recently admitted [**10-3**] and diagnosed with H1N1, SVT responsive to adenosine, multifocal PNA treated with vancomycin, zosyn, and levofloxacin, possible sick euthyroid and acute on chronic renal failure felt to be due to ATN requiring HD and relisting for a kidney [**Month/Year (2) **]. . Past Medical History: -biliary Atresia s/p liver [**Month/Year (2) **] at age 4 (25 years ago) -asthma, well-controlled -right hip avascular necrosis, per ortho may need THR -postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**] showed IgG dominent exudative proliferative GN, c/w postinfectious GN -nephrotic syndrome (4.1g proteinuria), hypoalbuminemia -small bowel resection Social History: denies any tobacco, EtOH or illict drug use. Lives at home with parents. Has one child with a prior girlfriend. Does not work. Family History: NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: Current: 99.4, HR 127, BP 132/89, RR 22, SaO2 98% Last 24 hours: T 97-100.2, Tm 100.2; BP 104-145/66-90. HR 119-137 (with episodes into the 140s); RR 19-22; O2 93-97% on RA. GENERAL: Cachectic, comfortable, NAD HEENT: MM dry, no LAD, neck supple CARDIAC: Tachycardic, regular, No MRG LUNG: Decreased breath sounds in bases bilaterally, no crackles, wheezes. ABDOMEN: Moderately distended, not tense, BS+, no tenderness. No rebound or gaurding. Midline and RUQ surgical scar. Multiple excoriations on abdomen. EXT: 3+ pitting edema in LE's bilaterally (R > L) NEURO: CNII-XII intact. Motor [**3-29**] upper and lower. . DISCHARGE Vitals: Current: 99.0, tmax 99.7, HR 109-111, BP 114-126/74-78 (10-20 mmHg higher than yesterday), RR 20-22, SaO2 97% IO Last 8 --> i = 240 ; o = 200 Last 24 --> i = 490 ; o = 200 + 4BM Ultrafiltration - 2Litres negative GENERAL: Cachectic, NAD HEENT: MM dry, no LAD, neck supple CARDIAC: Tachycardic, regular, No MRG LUNG: Decreased breath sounds in bases bilaterally, no crackles, wheezes. ABDOMEN: distended, not tense, BS+, no tenderness. No rebound or gaurding. Midline and RUQ surgical scar. Multiple excoriations on abdomen. EXT: 3+ pitting edema in LE's bilaterally, excoriations on arms NEURO: CNII-XII intact. Motor [**3-29**] upper and lower. SKIN: blanching erythema over left flank Pertinent Results: Admission [**2135-11-12**] 06:30AM BLOOD WBC-9.5 RBC-4.13* Hgb-12.0* Hct-37.9*# MCV-92 MCH-29.0 MCHC-31.6 RDW-17.7* Plt Ct-203 [**2135-11-12**] 06:30AM BLOOD Neuts-82* Bands-14* Lymphs-1* Monos-0 Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2135-11-12**] 12:00PM BLOOD PT-15.2* PTT-32.7 INR(PT)-1.3* [**2135-11-12**] 06:30PM BLOOD Glucose-108* UreaN-23* Creat-2.2* Na-133 K-4.1 Cl-107 HCO3-19* AnGap-11 [**2135-11-12**] 06:30AM BLOOD ALT-21 AST-63* CK(CPK)-84 AlkPhos-486* TotBili-0.6 [**2135-11-12**] 06:25AM BLOOD Glucose-99 Lactate-2.2* Na-137 K-4.0 Cl-106 Discharge [**2135-11-17**] 07:45AM BLOOD WBC-9.9 RBC-2.98* Hgb-8.4* Hct-26.8* MCV-90 MCH-28.0 MCHC-31.2 RDW-17.9* Plt Ct-295 [**2135-11-17**] 08:45AM BLOOD PT-16.0* PTT-34.0 INR(PT)-1.4* [**2135-11-17**] 04:45PM BLOOD Glucose-115* UreaN-10 Creat-1.4* Na-137 K-3.7 Cl-101 HCO3-30 AnGap-10 [**2135-11-17**] 04:45PM BLOOD Calcium-6.9* Phos-1.3* Mg-1.4* [**2135-11-14**] 06:14AM BLOOD TSH-1.1 [**2135-11-14**] 06:14AM BLOOD Free T4-0.79* [**2135-11-17**] 07:45AM BLOOD Vanco-17.0 [**2135-11-17**] 07:45AM BLOOD tacroFK-4.5* Wound Culture STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Blood Culture KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S CT ABD/PELVIS 1. Severely limited study due to technique and timing of contrast, for evaluation for pulmonary embolism. No evidence of pulmonary embolism in the main or primary branches of the pulmonary artery. 2. Increased intra-abdominal ascites, with loculation and mass effect on the intra-abdominal organs. Cirrhosis. Patent portal vein. Perisplenic varices, compatible with portal hypertension. 3. Pulmonary edema. Moderate-to-large bilateral pleural effusions with associated atelectasis. 4. Two enlarged right internal mammary lymph nodes and right greater than left gynecomastia. 5. Mild jejunal wall thickening of unclear etiology. Eneteritis is a consideration. Some of these loops are mildly dilated but there is not obstruction. 6. Stable pneumobilia and mild common bile duct dilatation status post choledocojejunostomy. 7. Stable enlarged mesenteric lymph nodes. MRI L AND T IMPRESSION: 1. No abnormal bone marrow signal to suggest acute fracture or osteomyelitis. 2. Bilateral L5 spondylolysis associated with proliferative bony changes extending into the right posterior epidural space at L4-5 which combines with additional degenerative changes to create severe canal narrowing. 3. Small bilateral fluid clefts at the level of spondylolysis without a drainable collection. Early infection within the posterior soft tissues cannot be fully excluded and continued followup is recommended. Brief Hospital Course: 31 yo M w/ ESRD, ESLD s/p liver [**Month/Day/Year **] presented with abdominal pain and tachycardia, found to have klebsiella pneumoniae bacteremia, MSSA line site infection vs colonization and, later cellulitis. He received ultrafiltration, HD, a rational antibiotic regimen and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-intestinal tube for feeding . # Klebsiella pneumoniae bacteremia Presumably from his [**Last Name (NamePattern4) 2286**] line. It was pulled and replaced. Ultimately he was discharged on Cefazolin 2 g qHD. . # Likely MSSA Line infection vs colonization: Pt had low grade temperatures after transfer from MICU. His line site culture grew MSSA and it was thought that his temperatures were related to an untreated gram positive infection. After initiation of cefazolin and vancomycin (below) were started, his temperature normalized, his HR declined and his BP rose. Discharged on Cefazolin. . # Rash: Discovered on Hospital day 3 and considered a cellulitis with a hospital acquired pathogen that emerged despite ceftriaxone. Discharged on vanc . # Atrial Tachycardia: Fluid unresponsive, normal TSH, unresponsive to adenosine. Improved over time. Patient discharged on 12.5 [**Hospital1 **] Metoprolol . # Lower back pain: Prior to transfer MICU team ordered MRI to r/o epidural abscess. Unlikely based on improving back pain, non-tender to palpation along spine, pain non-localized. No deficits on neuro exam. L-spine wit severe DJD. Discharged on lidocaine patches and oxycodone . #Pleural effusions: Albumin is less than 1 and ascites present. Likely hepatic hydrothorax. Patient is responding to Abx, unlikely effusions are infectious source. Patient breathing comfortably on room air. . #ESLD: MELD 24 on [**11-16**]. SBP work-up negative. Persistent concern for chronic rejection. Elevated INR may be partly nutritional. A dobhoff was placed and the patient was discharged with tube feeds at 45cc/hr. He was given phosphorus and instructions for the prevention of refeeding syndome #ESRD: [**12-27**] post-infectious glomerulonephritis, was started on HD last admission due to ATN. Continue HD TO BE FOLLOWED 1) Pt asked to see PCP every [**Month/Day (2) **] for MELD labs 2) Pt asked to have basic chemistries checked for surveillance of refeeding syndrome Medications on Admission: asix 20mg PO daily Lactulose 30-60cc PO QID Reglan Sucralfate Tacrolimus 0.5mg PO BID Oxycodone Buproprion Caltrate D . On transfer: Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **] Adenosine 6 mg IV ONCE Acetaminophen 500 mg PO/NG ONCE MR1 HYDROmorphone (Dilaudid) 0.2 mg IV Q6H:PRN pain CeftriaXONE 1 gm IV Q24H Tacrolimus 0.5 mg PO Q12H Lidocaine 5% Patch 1 PTCH TD DAILY OxycoDONE (Immediate Release) 5-10 mg PO/NG Q6H:PRN pain [**11-13**] @ Pantoprazole 40 mg PO Q12H Sarna Lotion 1 Appl TP PRN Itching Vitamin D 400 UNIT PO/NG DAILY Calcium Carbonate 500 mg PO/NG DAILY Sucralfate 1 gm PO QID Metoclopramide 10 mg PO/IV QID:PRN nausea Lactulose 30 mL PO/NG Q8H:PRN constipation Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO four times a day as needed for constipation. 2. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day as needed for nausea. 3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 6. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 7. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) topical application Topical four times a day as needed for itching. 8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Patch Topical once a day: Leave on for 12 hours, off for 12 hours. Disp:*30 Patches* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 11. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous QHD: To be given at every Hemodialysis. 12. Cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous QHD: To be given at every Hemodialysis. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Outpatient Lab Work Every [**Month/Year (2) 766**]. Check PT/INR, Sodium, Creatinine, Albumin and bilirubin. Fax results to [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**]. 15. Phos-NaK 280-160-250 mg Powder in Packet Sig: Two (2) Pakcets PO twice a day. Disp:*120 Packets* Refills:*2* 16. Outpatient Lab Work Please check Chem 10 on Saturday [**11-19**] at HD and fax results to [**Telephone/Fax (1) 697**]. Thanks. Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Primary Diagnoses: 1. Klebsiella septicemia 2. MSSA cellulitis at former HD line site 3. Hospital-acquired cellulitis of the back 4. Tachycardia 5. Severe spinal DJD and canal narrowing at L4-5 . Secondary Diagnoses: - Cirrhosis / ESLD - ESRD on HD Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the MICU at [**Hospital1 18**] for abdominal pain, back pain, bleeding, and sepsis, and you were found to have several concurrent infections including Klebsiella bacteremia, MSSA cellulitis from at the site of your hemodialysis catheter, and back cellulitis that was thought to be hospital-acquired. You were treated with IV Ceftriaxone for the Klebsiella bacteremia, which was changed to Cefazolin with [**Hospital1 2286**], and then started on Vancomycin with [**Hospital1 2286**] for treatment of your cellulitis. You will continue to receive these medications for an additional 10 days, dosed each time at [**Hospital1 2286**]. Your hemodialysis line was pulled and you were given a "line holiday" before it was replaced. You received hemodialysis on your regular schedule, as well as extra ultra-filtration given your fluid overload. . Given your bleeding your home Omeprazole was increased to twice daily. You were also found to have severe degenerative joint disease of the lumbar spine with severe spinal canal narrowing on MRI that will need close follow-up of small bilateral fluid clefts. You were started on a Lidoderm patch daily for control of the back pain. Finally, your heart rate was found to be elevated and you were started on a new medication called Metoprolol to decrease the heart rate to the normal range. . MEDICATION CHANGES: 1. START Vancomycin 1gram IV at Hemodialysis x10 days 2. START Cefazolin 2grams IV at Hemodialysis x10 days 3. START Metoprolol 12.5mg by mouth twice daily 4. START Lidoderm patch daily for back pain 5. CHANGE Omeprazole to 40mg by mouth twice daily . Every [**Hospital1 766**] you must have labs drawn. You can do that here - at the liver clinic - or at your PCP's office. Check PT/INR, Sodium, Creatinine, Albumin and bilirubin. Fax results to [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 697**]. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2135-11-19**] 12:00 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2135-11-23**] 9:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2136-1-16**] 9:00 Completed by:[**2135-11-18**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "97.49", "54.91" ]

icd9pcs

[ [ [] ] ]

13037, 13093

8128, 10438

279, 418

13386, 13386

4942, 8105

15501, 15867

3545, 3549

11174, 13014

13114, 13310

10464, 11151

13556, 14909

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13331, 13365

14929, 15478

233, 241

447, 2991

13400, 13532

3013, 3384

3400, 3529

22,585

175,485

45336

Discharge summary

report

Admission Date: [**2178-3-18**] Discharge Date: [**2178-3-25**] Date of Birth: [**2105-12-9**] Sex: F Service: MEDICINE Allergies: Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 2387**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: DDD pacer placement ([**2178-3-18**]) History of Present Illness: 72 yo F with CAD s/p PTCA, DM, HTN, COPD on 2 L home O2, OSA on BiPAP, and obesity who presents with acute onset of substernal CP radiating to her back and left arm associated with SOB. Pain did not resolve with SL NTG and she went to [**Hospital **] Hospital. Pt given ASA in the ambulance. Received an additional SL NTG at [**Hospital **] Hosp which decreased her pain to [**3-21**]. At OSH creat elevated at 2.0. First set of cardiac enzymes were negative. Her ECG showed bradycardia, likely afib with a juctional escape, rate 40. She was recently admitted to [**Hospital1 18**] in [**12-15**] for chest pain and underwent stress test (nonconclusive given her habitus) and was d/c'ed home with mild medication adjustments. Of note, she has a h/o a junctional rhythm requiring a temporary pacer [**10-15**]. Etiology at that time thought to be renal failure/hyperkalemia and B-B toxicity. A permanent pacemaker was considered, however, the patient began pacing on her own. . In our ED K noted to be 5.8. Pt received Glucagon 4 mg, Insulin 10 Units, D50, Cal Gluc 1 gm, Combivent neb, alb neb, lasix 40 IV, and Solumedrol 125. Pt is currently chest pain free. Reports SOB at baseline. HR in the low 40's with SBP in the low 100's. Past Medical History: 1. DM (most recent HbA1C 7.7) 2. HTN 3. Hyperlipidemia 4. CHF - EF > 55%, RV dilation 5. OSA- uses BiPAP 21/17 6. COPD - on home O2 2 liters (PFTs [**2173**] - FEV 1.08 (64%), FVC 1.24 (53%),FEV/FVC: 122%) 7. OA - unable to ambulate at baseline, uses wheelchair 8. Chronic back pain 9. Spinal Stenosis 10. s/p cholecystectomy [**82**]. s/p hysterectomy 12. CAD s/p LAD PTCA [**7-15**] 13. PAF s/p 6wk coumadin therapy Social History: Denies tobacco, EtOH, or drug use. Family History: Mother - CAD, DM, died age 80 Father - CAD, died age 89 Physical Exam: VS: HR 42, BP 105/60, RR 18, O2 sat 97% RA GEN: obese female, NAD HEENT: Dry MM Neck: unable to appreciate JVD Chest: decreased air movement, exp wheezes, bibasilar crackles CV: regular, bradycardic, no murmurs Abd: soft, obese, NT/ND, Ext: [**3-14**]+ pitting edema Neuro: A&Ox3 Pertinent Results: [**2178-3-18**] 01:20AM CK-MB-2 cTropnT-0.02* proBNP-6008* [**2178-3-18**] 01:22AM GLUCOSE-132* NA+-140 K+-5.8* CL--109 TCO2-21 [**2178-3-18**] 01:20AM UREA N-27* CREAT-1.9* [**2178-3-18**] 01:20AM WBC-6.8 RBC-3.50* HGB-8.7* HCT-28.6* MCV-82 MCH-25.0* MCHC-30.6* RDW-16.2* CXR [**2178-3-18**]: blunting of costophrenic angles. pulm vasc congestion. no infiltrate . ECG: RBBB and L ant fascicular block with sinus arrest, ventricular rate 40 bpm, no ST-T changes Brief Hospital Course: Upon admission, Ms. [**Known lastname **] ECG showed a RBBB with L anterior fascicular block with sinus arrest and a ventricular rate of approximately 40 bpm. Due to the instability of this rhythm, EP was consulted and she was taken for implantable DDD pacemaker placement on [**2178-3-18**]. Due to her underlying pulmonary disease, she was intubated for the procedure and remained intubated post-procedure. She was easily weaned off the vent and extubated on the morning of [**2178-3-19**]. Her beta-blocker was held due to her conduction abnormalities and she was started on diltiazem in its place and this was titrated up; per EP, beta blockade can be resumed as an outpatient as she tolerates. She will complete a 5-day course of peri-procedure antibiotics and will follow up in device clinic in approximately one week. After the pacer was placed she was noted to be intermittantly in atrial flutter. She was started on coumadin for anticoagulation (without heparin bridge) and will likely have cardioversion in a few weeks with Dr. [**Last Name (STitle) **]. Additionally she noted bilateral knee pain consistent with osteoarthritic pain that she has had in the past documented back to the [**2151**]'s, previously evaluated for knee replacement in [**2170**] but determined to be a poor surgical candidate given her comorbidities. This was thought secondary to recent increased mobilization with physical therapy and controlled with tylenol and occaisional oxycodone. Medications on Admission: 1. Advair 250-50 mcg [**Hospital1 **] 2. Albuterol prn 3. Amitriptyline 50mg 4. Aspirin 325mg 5. Atorvastatin 80mg 6. Clopidogrel 75mg 7. Furosemide 40mg 8. Ipratropium qid 9. Ferrous Sulfate 325mg [**Hospital1 **] 10. Gabapentin 600mg tid 11. Potassium & Sodium Phosphates 278-164-250mg [**Hospital1 **] 12. SL NTG prn 13. Clotrimazole 1 % Cream [**Hospital1 **] 14. Nystatin 100,000 unit/g Ointment [**Hospital1 **] 15. Pantoprazole 40mg 16. KCL 40meq 17. Docusate [**Hospital1 **] 18. Oxycodone 5mg prn 19. Toprol XL 50mg 20. Senna [**Hospital1 **] 21. Bisacodyl prn 22. Magnesium Hydroxide prn 23. Acetaminophen 1g qid Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day. 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous once a day: in am. 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous at bedtime. 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Three Hundred (300) mg PO once a day. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: Charlwell Discharge Diagnosis: Sinus arrest with symptomatic bradycardia. . Morbid obesity, obstructive sleep apnea, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, congestive heart failure, spinal stenosis, coronary artery disease, atrial fibrilation. Discharge Condition: Good. Discharge Instructions: Please take all medications as prescribed, please keep all follow-up appointments. Please notify your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1300**] or your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 5455**] if you experience worsening chest pain, shortness of breath, nausea, vomiting, wheezing, dizziness, light headedness, increased swelling in your legs, or any symptoms that concern you. . Weigh yourself every morning, call your doctor if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Please limit your fluid intake to 1500mL (1.5L) of fluid daily Followup Instructions: Please follow-up in device clinic to be sure your pacer is working properly on [**2178-3-26**] at 10:00am in radiology ([**Telephone/Fax (1) 327**]) for imaging, followed by your appointment in device clinic ([**Telephone/Fax (1) 59**]) at 11:30am . Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2178-4-8**] at 11:45am. Please call if questions: ([**Telephone/Fax (1) 5455**]. . Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2178-3-26**] at 1:20pm. It is very important that you have your INR checked at this visit so your dose of coumadin can be adjusted. Please call if questions: ([**Telephone/Fax (1) 5455**].

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icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

6505, 6541

3007, 4488

307, 346

6831, 6839

2510, 2984

7629, 8332

2128, 2185

5161, 6482

6562, 6810

4514, 5138

6863, 7606

2200, 2491

257, 269

374, 1619

1641, 2060

2076, 2112

14,190

106,808

17312

Discharge summary

report

Admission Date: [**2165-11-21**] Discharge Date: [**2165-11-28**] Date of Birth: [**2122-12-25**] Sex: F Service: Neurology HISTORY OF PRESENT ILLNESS: This is a 42 year old woman with history of metastatic melanoma diagnosed in [**2159**], status post chemotherapy here at [**Hospital6 256**] who presents with acute onset of right hemiparesis and expressive aphasia since earlier this evening. History is provided by her fiance and husband who are at the bedside. At 7:35 PM tonight she lost motor movement of her right arm without sensory loss. Over the next 15 to 20 minutes she noted that her right leg was also weak. Emergency medical services was called and as she was on her way here she began to lose her speech. She was unable to talk but was able to understand and follow commands. Her symptoms progressively got worse over time and have stabilized over the last two hours and there have been no significant changes since. The family denies any seizure activity or shaking movements. She denies any headache, sensory loss or other complaints. There was no loss of bowel or bladder control or candlelighting. There were no similar episodes in the past. Review of systems is essentially negative per family except for longstanding left hip pain due to metaphysis. PAST MEDICAL HISTORY: 1. Metastatic melanoma on maintenance IL2 with Dr. [**Last Name (STitle) **]; 2. Left groin metaphysis in the gluteal region, status post surgery. MEDICATIONS: MS Contin 60 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives in her fiance and is from [**Location (un) **], Mass. FAMILY HISTORY: Multiple relatives with cancer and paternal grandmother with coronary artery disease. PHYSICAL EXAMINATION: Afebrile, blood pressure 142/71, pulse 100, respiratory rate 18. Generally, lucid woman in general discomfort holding her fiance's hand. Neck, limited range of motion with no pain. The patient resists movements. Lungs are clear to auscultation bilaterally. Cardiovascular, regular rate and rhythm. On neurological examination, she is awake and for the most part alert, mostly cooperative with examination. Language no verbal output. She can follow simple commands like closing her eyes and protruding her tongue. She can also follow more complex commands, crossing midline, showing two fingers. On cranial nerve examination, she blinks to visual threat bilaterally. Funduscopic not well visualized due to lack of cooperation. Pupils equal, round and reactive to light, 42 mm bilaterally. Extraocular eye movements are intact with sticcottic eye movements and no nystagmus. Facial sensation can not be assessed. Facial movement has marked right facial droop as well as some slight right upper face weakness. Hearing is intact to finger rub bilaterally. Tongue is midline without fasciculation. Sternocleidomastoid and trapezius is normal only on the left. On motor examination, she has normal bulk and tone bilaterally. There is no tremor. There is dense right hemiparesis 0 out of 5 with the right arm flexed upward in upper motor neuron pattern. Muscle strength on the left was suboptimal effort but no focal weakness besides that limited by pain, especially on the left lower extremity. Sensory examination, it is difficult to assess but she denies any changes to light touch, pinprick, temperature or vibration. She withdraws to pain in the left lower extremity and upper extremity. Her reflexes are brisk throughout 3 out of 4 and symmetric. Her grasp reflex is absent. Toes are upgoing bilaterally. On coordination examination, she is intact to finger-to-nose test on the left with slow rapid alternating movements. Gait was not assessed. LABORATORY DATA: Laboratory data and radiology upon admission revealed sodium 142, chloride 105, BUN 10, glucose 123, potassium 3.2, bicarbonate 27, creatinine 0.6, calcium 9.8, magnesium 1.8, phosphate 2.9. White count 6.7, hemoglobin 11.3, hematocrit 34.1, platelets 227. PT 12.6, PTT 27.1, INR 1.1. Noncontrast head computerized tomography scan shows a left frontal 3.5 by 3.4 cm hemorrhagic metastatic lesion and a left posterior parietal hemorrhagic lesion. The patient was started on Dilantin for seizure prophylaxis. HOSPITAL COURSE: She was initially admitted to the Intensive Care Unit for blood pressure monitoring. A magnetic resonance imaging scan of the brain was done showing a left frontal, left posterior parietal and left superior parietal hemorrhagic metastatic lesion. The patient remained stable and was called out to the floor. While on the floor, she continued to have a dense right hemiplegia but her verbal output did return. The Neurosurgery Service was consulted and they recommended that the left frontal metastatic lesion be excised and the patient was accepting of this offer. Radiation Oncology and Neuro-Oncology was consulted and both felt that the patient should have stereotactic radiation after the surgical resection of her left frontal metastatic lesion. In addition, her Dilantin was switched over to Keppra given that the Dilantin will give her a higher threshold of seizures during the radiation. The patient was seen by physical therapy and found to be able to move around with minimal assistance. She was discharged and set up for surgery one day next week. Given the edema around the hemorrhagic metastatic lesion, the patient was started on Decadron. DISCHARGE DIAGNOSIS: 1. Hemorrhagic brain metastases 2. Metastatic melanoma DISCHARGE MEDICATIONS: 1. Tylenol 325 mg p.o. q. 4-6 hours prn pain 2. Morphine Sulfate sustained release 16 mg p.o. q.d. 3. Percocet 5/325 one tablet p.o. q 4-6 hours prn pain 4. Famotidine 20 mg p.o. b.i.d. 5. Dilantin 150 mg p.o. b.i.d. times three days and then 100 mg p.o. b.i.d. for three days and then discontinue 6. Keppra 1000 mg p.o. b.i.d. times three days and then 1500 mg p.o. b.i.d. 7. Decadron 4 mg p.o. t.i.d. times five days CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 6125**] Dictated By:[**Last Name (NamePattern1) 4270**] MEDQUIST36 D: [**2165-12-1**] 14:30 T: [**2165-12-1**] 16:28 JOB#: [**Job Number 48461**]

[ "198.5", "V10.82", "784.3", "431", "197.0", "342.80", "198.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1657, 1744

5551, 5978

5470, 5528

4286, 5449

1767, 4268

174, 1307

1330, 1558

1575, 1640

6003, 6351

32,191

132,883

26159

Discharge summary

report

Admission Date: [**2186-1-16**] Discharge Date: [**2186-1-31**] Date of Birth: [**2113-12-18**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Codeine / Iodine Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath, Dyspnea on Exertion Major Surgical or Invasive Procedure: [**2186-1-19**] Cardiac Catheterization [**2186-1-27**] Aortic Valve Replacement(21mm [**Doctor Last Name **] Pericardial Valve), Mitral Valve Replacement(29mm St. [**Male First Name (un) 923**] Porcine Valve) and Two Vessel Coronary Artery Bypass Grafting utilizing vein grafts to first and second obtuse marginal arteries. History of Present Illness: Ms. [**Known lastname **] is a 72 yo F with known severe AI, diastolic [**Hospital 1902**] transferred from an OSH with acute respiratory distress thought due to flash pulmonary edema, infection +/- airway edema for consideration of aortic valve replacement. The patient called 911 at 7:42AM on [**2186-1-13**] with difficulty breathing. She was found by EMT in a recliner unresponsive in respiratory distress. Periorbital and peripheral cyanosis was noted. Pulse ox at that time was 58%, pulse 120, bp 90/60. The patient was bag-ventilated until she got to [**Hospital3 **]Hospital ED where she was emergently intubated. CXR at that time revealed florid CHF by admission note report. The patient was started on IV nitroglycerine and IV furosemide with good volume output. EKG revealed no acute ischemic changes and cardiac enzymes were negative. The patient had a maximum BNP of 100. The patient transiently required a levophed drip for bp support. The patient was extubated on [**2186-1-14**] after a successful SBT but she required reintubation 6 hours later in the setting of respiratory distress and ?respiratory stridor. On re-intubation, the patient was noted to have vocal cord and larynx swelling preventing requiring placement of a 6.5 ET tube (previous intubation done with 7.5 ET tube). She was started on IV solumedrol for treatment of airway edema. In the setting of respiratory failure, possible infliltrates on CXR (bibasilar), leukocytosis to 20 and staph growth in the sputum, the patient was also started on vancomycin, levofloxacin for a possible aspiration pneumonia. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. By recent OMR notes, cardiac review of systems is notable for occasional DOE and palpitations. Absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or presyncope. Past Medical History: Chronic Diastolic Congestive Heart Failure Aortic Valve Insufficiency Mitral Regurgitation Hypertension Dyslipidemia Cerebrovascular Disease - History of stroke History of SVT History of Syncope Chronic LE Ulcers Anemia Anxiety History of Vasculitis Osteoarthritis Glaucoma History of Seizures Appendectomy, Prior Hernia Repair Social History: Remote tobacco use, rare ETOH. Divorced, lives independently. Family History: No known family history of premature cardiac disease or sudden death per outside hospital reports. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 99.7 79 137/60 AC FiO2 40% Vt 450 RR 10 PEEP 5 Gen: Well-appearing. Intubated. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally listening anteriorly. Abd: Soft, nontender. Ext: No edema. Neuro: A&Ox3. Integumentary: Left lower extremity ulcer healing. Pertinent Results: ADMISSION LABS: [**2186-1-16**] 01:49PM BLOOD WBC-12.6* RBC-3.41* Hgb-10.2* Hct-30.0* MCV-88 MCH-29.9 MCHC-33.9 RDW-13.8 Plt Ct-263 [**2186-1-16**] 01:49PM BLOOD PT-13.7* PTT-29.1 INR(PT)-1.2* [**2186-1-16**] 01:49PM BLOOD Plt Ct-263 [**2186-1-16**] 01:49PM BLOOD Glucose-122* UreaN-11 Creat-0.7 Na-141 K-4.3 Cl-107 HCO3-25 AnGap-13 [**2186-1-16**] 01:49PM BLOOD CK(CPK)-55 [**2186-1-16**] 01:49PM BLOOD Calcium-8.8 Phos-1.7* Mg-2.2 [**2186-1-16**] TTE: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to increased stroke volume due to aortic regurgitation. At least moderate (2+) aortic regurgitation is seen. The mitral valve leaflets and supporting structures are mildly thickened. A vegetation cannot be excluded, but no definite vegetation is seen (?artifact off MAC in clips #[**1-11**]). Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. At least moderate aortic regurgitation. Thickened mitral leaflets with at least moderate mitral regurgitation. Preserved global and regional biventricular systolic function. If clinically indicated, a TEE would be better able to define the aortic and mitral valve morphology. [**2186-1-17**] TEE: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular function is normal with normal free wall contractility. There are complex (>4mm) non-mobile atheroma in the aortic arch and descending thoracic aorta (at 35 cm and 38 cm from the incisors). The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild focal mitral annular calcification is noted. No mass or vegetation is seen on the mitral valve. An eccentric, posteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild to moderate tricuspid regurgitation jet which is eccentric and may be underestimated. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. [**2186-1-19**] Cardiac Catheterization: 1. Selective coronary angiography revealed a left dominant system with patent LMCA. LAD had mild plaqueing. LCX was dominant and had a non-hemodynamically significant 30% lesion in its proximal portion. RCA was small non-dominant and without significant disease. 2. Left ventriculography and aortography was deferred. 3. Hemodynamic assessment showed mild systemic hypertension and normal left sided and right sided filling pressures. There was mild pulmonary hypertension. Cardiac index was preserved. 4. Selective renal arteriography showed bilaterally patent renal arteries. Right accessory renal was also widely patent. [**2186-1-19**] Carotid Ultrasound: No significant (graded less than 40%) ICA stenoses on either side. Brief Hospital Course: RESPIRATORY FAILURE Ms. [**Known lastname **] had known diastolic CHF and was transferred from an OSH intubated with acute respiratory distress thought due to flash pulmonary edema. A pneumonia was also suspected based upon reports of pulmonary infiltrates, leukocytosis and staph growth in the sputum. She was started empirically on Vancomycin and Levofloxacin. She was also noted to have airway edema on re-inutbation at the OSH and was started on Solumedrol. On [**2186-1-17**], she was successfully extubated and maintained oxygen saturations in the upper 90's on 2 L NC. She reported improvement in her symptoms of dyspnea and SOB. CONGESTIVE HEART FAILURE Ms. [**Known lastname **] had known mild one-vessel disease on a prior catheterization, but had no evidence of cardiac ischemia on EKG or by cardiac enzymes. A repeat catheterization was performed on [**2186-1-19**] as part of a pre-op evaluation for CAD. She was continued on aspirin, metoprolol and atorvastatin throughout the admission. TTE on [**2186-11-16**] rasied concern for a mitral valve vegetation, so TEE performed on [**2186-1-17**] and showed EF 55%, 3+ MR and 3+ AI. HSV 2 SKIN RASH: On [**2186-1-23**], Ms. [**Known lastname **] was noted to have a vesciculated rash on the posterior right thigh (not in a dermatomal distribution). Dermatology was consulted, and DFA of the lesion was positive for HSV 2. She was started on Valtrex for five days, and placed on Acyclovir IV for 24 hours periop. The lesion was monitored clsoely, and she had no signs of a cellulitis superinfection. URINARY TRACT INFECTION: Urine culture from [**2186-1-23**] grew 10,000 - 100,000 CFU's of Enteroccus and Corynebacterium, and urinalysis was consistent with UTI. The patient remained asymptomatic, but she was treated with a short course of nitrofurantoin given her pending MVR. OTHER PREOPERATIVE WORKUP: Carotid ultrasound showed less than 40% stenoses of both internal carotid arteries. Vein mapping also revealed suitable greater saphenous vein. OPERATIVE COURSE: On [**1-27**], Dr. [**Last Name (STitle) 914**] performed an aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting surgery. For additional surgical details, please see seperate dictated operative note. POSTOPERATIVE COURSE: Following the operation, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. Her CVICU course was uneventful and she transferred to the SDU on postoperative day two. She did well postoperatively and was ready for discharge to [**Last Name (un) **] on POD #4. She was hyponatremia to 127 on POD #3, but improved with free water restriction. Medications on Admission: At Home: Atorvastatin 10mg daily, Aspirin 81mg Daily, Metoprolol 25mg Three times daily, Norvasc 2.5mg Daily, Losartan 320mg Daily, Timoptic 0.5% one drop each eye daily, Spiriva one capsule daily, Claritin 10mg daily, Zoloft 100mg self-d/c'd several weeks ago, Vitamins At Transfer: Aspirin 325mg daily, Protonix 40mg IV daily, Atorvastatin 10mg Daily, Timoptic 0.5% one drop each eye daily, Metoprolol 25mg three times daily Lovenox 40U subq daily, Vancomycin 500mg q12h, Levofloxacin 500mg Daily, day 1: [**2186-1-13**], Solu-medrol 125mg x1 on [**2186-1-16**], now 30mg IV q6h, Bactroban ointment twice daily since [**2186-1-14**], Propofol gtt, Zoloft 25mg Daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation QID (4 times a day). 7. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed. 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 10. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 days: through [**1-/2108**]. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 13. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 14. Diovan 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Acute on Chronic Diastolic Congestive Heart Failure Aortic Valve Insufficiency, Mitral Regurgitation Coronary Artery Disease Acute Respiratory Failure/Acute Pulmonary Edema Preoperative Pneumonia(Aspiration vs Community Acquired) Herpes Simplex Type II Preoperative Urinary Tract Infection Hypertension Dyslipidemia Cerebrovascular Disease - History of stroke History of SVT History of Syncope Chronic LE Ulcers Anemia Discharge Condition: Stable Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. Followup Instructions: Dr. [**Last Name (STitle) 914**] in [**3-11**] weeks, call for appt Dr. [**Last Name (STitle) 11493**] in [**1-8**] weeks, call for appt Dr. [**Last Name (STitle) 10208**] in [**1-8**] weeks, call for appt Already scheduled appointment: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2186-3-8**] 9:00 Completed by:[**2186-1-31**]

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22020

Discharge summary

report

Admission Date: [**2208-5-27**] Discharge Date: [**2208-6-6**] Date of Birth: [**2143-12-29**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 17813**] Chief Complaint: status epilepticus Major Surgical or Invasive Procedure: endotracheal intubation at the outside hospital prior to transfer to [**Hospital1 18**]. Central venous catheter placement in ED [**2208-5-27**] History of Present Illness: 64M with a PMH of complex partial seizures with secondary generalisation with previously good control, likely focus was right parietal IPH in [**2199**] s/p craniotomy and residual mild left hemiparesis, T2DM poorly controlled with severe diabetic retinopathy s/p laser surgery with left eye blindness, HTN, dCHF, right groin mass with biopsy results of an atypical spindle cell neoplasm [**4-/2208**] awaiting excision and CKD with new worsening renal function and nephrotic syndrome possibly secondary to minimal change (awaiting EM result from bx) with recent tapering of AEDs in the setting of her worsening renal function presents with status epilepticus, intubated at OSH and transferred to [**Hospital1 18**] for further management. Very scant OSH records. Patient had decreased Keppra from 1500mg [**Hospital1 **] to 500 [**Hospital1 **] at recent medicine admission 5/23-28/[**2207**] given worsening renal function up to Cr c4 on renal guidance at which time he had presented with a mechanical fall, new peripheral edema and worsening renal failure. Since then patient had continued to be seizure free and was maintained on prednisone 60mg qd for nephrotic syndrome felt likely secondary to minimal change nephropathy and receiving diuresis with furosemide. He has also had a groin mass biopsied on [**2208-5-4**] which showed atypical spindle cell neoplasm and is awaiting elective resection with clear margins. In addition, he had a recent ED admission for a burst blister on his left shin due to his severe anasarca on [**2208-5-24**]. His PCP had discussed with his neurologist regarding the change in Keppra dosing per documentation on [**2208-5-17**]. Since then, patient had been in his usual state of health until the evening of [**2208-5-26**] when he started to have generalised convulsions and apparently convulsive status for over 30 minutes. Had 3 doses of lorazepam en route without termination of his seizures and was intubated on arrival at [**Hospital **] Hospital at 20:39 and paralysed with x1 dose of vecuronium. Per documentation, patient came in actively seizing (eye deviation to L) and very scant documentation and given midazolam 10mg and loaded with 2g IV Keppra. Labs there revealed a high WCC 13.1 and UA was negative. In addition, patient was afebrile throughout and vitals were stable. At family request, patient was medflighted to [**Hospital1 18**] and started on propofol and midazolam prior to departure. Here, patient was initially only on propofol and I examined the patient initially after this had been stopped for 30 minutes. Patient was noted to have eye movements where they would drift to the left with sustained nystagmus which was concerning for ongoing seizure activity. A right CVC was placed in the ED due to problems with IV access (had only 1 peripheral IV cannula. On assessment, he had no withdrawal at all on the left and had reasonable withdrawal on the right but would not grimace to pain but wold occasionally keep his eyes open. Of note per medicine discharge summary, his left hemiparesis was felt to be very mild at that time suggesting that his current manifestations were a post-ictal [**Doctor Last Name 555**] phenomenon. He has had no recent neurology evaluation, the last being 8/[**2206**]. Unable to obtain ROS as patient intubated. Past Medical History: - R parietal ICH in [**2199**], s/p cranotomy with subsequent left hemiparesis and seizure disorder - Seizure disorder: last seizure [**5-/2208**] when Keppra decreased due to worsening kidney disease. Previously, seizure in [**12-7**] inpatient when switched from Dilantin to Keppra; last seizure documented involved right head turn and left eye deviation with subsequent generalized tonic clonic movements and post-ictal [**Doctor Last Name 555**] paresis - Type 2 diabetes - on insulin, not well controlled c/b severe diabetic retinopathy s/p laser surgery with left eye blindness in left eye - HTN - Chronic kidney disease stage 3 with worsening renal failure and new nephrotic syndrome with anasarca ? minimal change - Diastolic CHF (E/A ratio 1.0 on TTE [**2204**]) - Right groin mass recently biopsies [**2208-5-4**] found on biopsy to be aypical spindle cell neoplasm awaiting excision - Right transmetatarsal amputation - Asthma - Remote alcoholism, stopped in [**2199**] - s/p gangrenous cholecystitis with cholecystectomy - Incontinent with prior UTIs (Incontinent since [**2198**] according to daughter) Social History: Uses a walker at baseline. He completes most of his ADLs. Used to be a former football player for the [**Company **], a butcher and a singer. Has 6 children and 25 grandchildren and 1 greatgrandchild. The patient lives with daughter and grandchildren. - tobacco: quite smoking many years ago in the [**2155**]. Smoked for 10 years 1 pack a day - alcohol: heavy use until [**2199**], now no use - drugs: denies Family History: Mom - no reported history Dad - died from liver cirrhosis due to alcohol use [**Last Name (un) **] - died in a fire Sister died of "heart trouble." Physical Exam: Physical Exam on Admission: Vitals: T:99.2 P:75 SR R:14 BP:118/73 SaO2:100% on vent General: Intubated will open eyes spontaneously at times. HEENT: NC/AT, no scleral icterus noted, MMM Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: Soft, ND, normoactive bowel sounds. Anasarca extending to abdomen. Extremities: Gross anasarca in all limbs and extending to abdomen. Right transmetatarsal amputation. 2+ radial, DP pulses ?present on left and good cap refill on right. Patient is s/p right trans-metatarsal amputation with clear surgical site. Skin: Left shin large skin tear [**12-31**] burst blister. Neurological examination: - Mental Status: GCS E 4 VT M4 Eyes open spontaneously at times mostly eyes closed. Not following commands. Withdraws well in the right arm and leg nil on left side although ED team noted that he has slight withdrawal on the left leg. Otherwise has eyes which are initally midline then will drift to the left with subsequent sustained nystagmus. - Cranial Nerves: I: Olfaction not tested. II: Anisocoria 2 to 1.5mm sluggish on the right and left irregular 3.5mm fixed - blind in this eye. Does not blink to threat. Funduscopic exam reveals no papilledema on the left but significant evidence of prior photocoagulation scar on the left fundus. Unable to visualise right fundus as poor coopeation and small pupil size. III, IV, VI: Eyes are initally midline on opening eyes then will drift to the left with subsequent sustained nystagmus V: Present corneals bialterally. VII: No facial droop, facial musculature symmetric. VIII: Unable to assess. IX, X: Good cough. [**Doctor First Name 81**]: Unable to assess. XII: Unable to assess. - Motor: Difficult to assess tone given gross edema but seems reasonably symmetric. No adventitious movements, such as tremor, noted. No asterixis noted. Withdraws well in the right arm and leg nil on left side although ED team noted that he has slight withdrawal on the left leg. - Sensory: No grimacing to pain. Withdraws to pain on left. Nil on left. - DTRs: BJ SJ TJ KJ AJ L 2 2 2 2 2 R 2 2 2 2 1 There was no evidence of clonus. [**Last Name (un) 1842**] negative. Plantar response was absent on the right (s/p amputation) and extensor on the left. - Coordination: Unable to assess. - Gait: Unable to assess. DISCHARGE EXAM: Vitals: 98.8 105/67 73 18 96%RA Neuro Exam: Mental status: awake/[**Last Name (un) 3584**], arousable to voice. speech fluent. oriented to self, and states that the date is [**6-5**] but later on, states that it is [**Month (only) 216**]. CN - eyes able to cross midline, conjugate gaze. Motor - Right upper and lower extremities with full strength. Left lower extremity with residual weakness, LLE is at least antigravity. LUE is stronger than LLE. Pertinent Results: [**2208-5-27**] 04:34AM GLUCOSE-71 UREA N-76* CREAT-2.8* SODIUM-140 POTASSIUM-3.1* CHLORIDE-104 TOTAL CO2-23 ANION GAP-16 [**2208-5-27**] 04:34AM ALT(SGPT)-31 AST(SGOT)-26 ALK PHOS-93 TOT BILI-0.2 [**2208-5-27**] 04:34AM ALBUMIN-1.9* CALCIUM-7.8* PHOSPHATE-5.1* MAGNESIUM-2.1 [**2208-5-27**] 04:34AM WBC-19.1* RBC-5.76 HGB-16.2 HCT-46.3 MCV-80* MCH-28.1 MCHC-35.0 RDW-15.5 [**2208-5-27**] 04:34AM PT-10.1 PTT-30.6 INR(PT)-0.9 [**2208-5-27**] 04:34AM PLT COUNT-404 [**2208-5-27**] 04:00AM URINE HOURS-RANDOM [**2208-5-27**] 04:00AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2208-5-27**] 02:20AM GLUCOSE-82 UREA N-75* CREAT-2.8* SODIUM-134 POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-20* ANION GAP-16 [**2208-5-27**] 02:20AM estGFR-Using this [**2208-5-27**] 02:20AM CALCIUM-7.1* PHOSPHATE-4.8* MAGNESIUM-2.1 [**2208-5-27**] 02:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2208-5-27**] 02:20AM WBC-17.1* RBC-5.92 HGB-15.6 HCT-47.8 MCV-81* MCH-26.3* MCHC-32.6 RDW-15.5 [**2208-5-27**] 02:20AM NEUTS-89.3* LYMPHS-6.7* MONOS-3.3 EOS-0.7 BASOS-0.2 [**2208-5-27**] 02:20AM PLT COUNT-397 [**2208-5-27**] 01:23AM TYPE-[**Last Name (un) **] TEMP-37.3 RATES-16/ PEEP-5 O2-100 PO2-242* PCO2-38 PH-7.41 TOTAL CO2-25 BASE XS-0 AADO2-430 REQ O2-75 -ASSIST/CON INTUBATED-INTUBATED CT head [**2208-5-26**]: Chronic right temporo-parietal hypodensity and encephalomalacia without change since last CT in [**2205**]. Unable to appreciate punctate right cerebellar hypodensity seen on last scan. Generalised atrophy. MR head [**2208-5-30**]: 1. Extensive area of encephalomalacia is redemonstrated in the right temporoparietal and occipital lobes as a sequela of prior hemorrhagic event, causing ex vacuo dilatation and asymmetry of the right cerebral hemisphere. No acute findings are identified. 2. The MRA of the head is extremely limited and nondiagnostic, there is partial visualization of the internal carotid arteries and basilar artery, however, the distal branches are not identified, related with motion artifacts, please consider and repeat this examination if clinically warranted. CXR [**2208-5-27**]: 1. NG tube side port in the distal esophagus, which should be advanced at least 8 cm for improved positioning. 2. No evidence of pneumonia. [**2208-5-31**] LUE LENI: No deep venous thrombosis in left upper extremity. EEG: [**2208-5-27**]: This is an abnormal continuous ICU EEG monitoring study. The initial portion of the recording shows severe diffuse background attenuation, worse on the right, likely secondary to propofol effect. After withdrawal of propofol, there is still very low-voltage activity diffusely, predominantly delta and theta activity, but some faster frequencies are present over the left hemisphere. There is asymmetric EMG activity over the right hemisphere, consistent with left hemiparesis. These findings are indicative of severe focal dysfunction over the right hemisphere, with moderate diffuse dysfunction on the left, and are consistent with the history of known prior stroke and likely postictal state. No epileptiform discharges or electrographic seizures are present. [**2208-5-28**]: This is an abnormal continuous ICU EEG monitoring study. Background is extremely low voltage, predominantly low voltage delta with superimposed beta activity. There is focal attenuation over the right hemisphere and frequent right occipital epileptiform discharges, frequently with periodic discharges every three to four seconds. These findings are indicative of moderate diffuse cerebral dysfunction with focal highly potentially epileptogenic cortical dysfunction in the right hemisphere. There was report of focal left facial twitching during the pushbutton episode, but this was not seen on video during the study. Compared to the prior day's recording, there is no significant change in background activity but frequent epileptiform discharges and periodic lateralized epileptiform discharges are now present in the right occipital region. [**2208-5-31**]: This is an abnormal continuous video EEG due to the slow and low voltage background with additional attenuation of activity over the left hemisphere, suggestive of a moderate encephalopathy with further left hemispheric dysfunction. There were frequent low voltage sharp and slow wave or spike and slow wave discharges in the right occipital region indicative of an area of potentially epileptogenic cortex. There were no clear electrographic seizures. MICROBIOLOGY: URINE CULTURE (Final [**2208-5-30**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S Brief Hospital Course: 64M with a PMH of complex partial seizures with secondary generalisation with previously good control, likely focus was right parietal IPH in [**2199**] s/p craniotomy and residual mild left hemiparesis, T2DM poorly controlled with severe diabetic retinopathy s/p laser surgery with left eye blindness, HTN, dCHF, right groin mass with biopsy results of an atypical spindle cell neoplasm [**4-/2208**] awaiting excision and CKD with new worsening renal function and nephrotic syndrome possibly secondary to minimal change (awaiting EM result from bx) with recent tapering of AEDs in the setting of her worsening renal function presents with status epilepticus, intubated at OSH and transferred to [**Hospital1 18**] for further management. Patient was loaded with Keppra 2g IV prior to transfer and was medflighted on propofol and midazolam. On transfer to [**Hospital1 18**] patient had episodes of gaze deviation to the left with sustained nystagmus which was concerning for ongoing seizure activity. On initial examination, patient opened eyes spontaneously but was not following commands. He withdrew briskly in the right upper and lower extremity but only minimally in the left leg and no movement was observed in the left arm. CT revealed stable chronic right temporo-parietal hypodensity and encephalomalacia without change since last CT in [**2205**]. Labs revealed elevated WCC 17.1 and Cr 2.8 better than at OSH. UA was negative as well as Utox. CXR showed obscured left hemi-diaphragm likely effusion and some pulmonary congestion but no clear pneumonia. # Neuro: He was admitted to the neuro ICU and connected to LTM. He was maintained on propofol overnight with resolution of his seizure activity. He was weaned off propofol the next morning and remained seizure-free. Keppra was increased to 1000mg IV BID. The most likely precipitant of his status epilepticus was thought to be the rapid reduction in longterm maintenance Keppra in setting of worsened renal failure. No clear infectious or metabolic precipitants were identified initially. He then had focal motor seizures, involving the left face, neck and shoulder with semirhythmic twitching. He was also started on Vimpat in addition to Keppra for better control of his seizures. His Vimpat was uptitrated and as his EEG improved his mental status improved as well. He was transferred to neuro step down unit and then to the regular floor. # ID: He remained afebrile with no obvious signs of infection. However, patient had leukocytosis, so infectious work up was done and showed UCx with enterococcus, which was treated with ampicillin for x7 days. His leukocytosis resolved with the treatment. # Endo: patient's insulin was changed to regular insulin while he was maintained on tube feeding in the ICU. [**Last Name (un) **] was consulted for management of his insulin given the difficult to control blood glucose. His insulin was changed to long acting insulin (NPH and insulin) when he began eating meals. # Renal: patient has CKD with recent acute worsening of his kidney function, thought to be due to minimal change disease. He had been started on high dose steroids as an outpatient, and it was continued during this hospitalization. His prophylactic bactrim was stopped on admission but was restarted prior to discharge. He will need to continue Bactrim prophylaxis while he is on high dose steroids. He will also need to follow up with his nephrologists for further evaluation and management of his CKD. # CV: He was maintained on telemetry monitoring. # Resp: CXR showed no evidence of pneumonia. He was successfully extubated on [**5-27**] and his respiratory status remained stable. # FEN: He was maintained NPO while intubated. Speech and swallow were consulted and his diet was advanced as tolerated once extubated. # PPX: He was maintained on S/C heparin and pneumoboots for DVT prophylaxis. He was maintained on a bowel regimen and PPI for GI prophylaxis. Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth daily DISPOSABLE CHUX - - use as directed DX: diabetes, hypertension, urinary incontinence, chronic kidney disease, seizure disorder, right hemorrhagic stroke FUROSEMIDE [LASIX] - 80 mg Tablet - 1 Tablet(s) by mouth twice daily GLOVES - - use as directed DX: diabetes, hypertension, urinary incontinence, chronic kidney disease, seizure disorder, right hemorrhagic stroke INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 10 units SC at bedtime INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - per sliding scale with meals LEVETIRACETAM - (Dose adjustment - no new Rx) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 0.5 (One half) Tablet(s) by mouth DAILY (Daily) PREDNISONE - 20 mg Tablet - 3 Tablet(s) by mouth daily REGULAR WIPES - - use as directed dx: diabetes, hypertension, urinary incontinence, chronic kidney disease, seizure disorder, right hemorrhagic stroke SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) Please reschedule appointment with Dr. [**First Name (STitle) **] [**Name (STitle) 57634**] - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth three times weekly Take on Monday, Wednesday, and Friday. Medications - OTC BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - Use up to three times daily as directed. CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - 500 mg (1,250 mg)-200 unit Tablet - 1 Tablet(s) by mouth daily FOOD SUPPLEMENT, LACTOSE-FREE [ENSURE] - Liquid - 1 can by mouth 3 times per day (vanilla) dx: diabetes, hypertension, urinary incontinence, chronic kidney disease, seizure disorder, right hemorrhagic stroke INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE ULT-FINE II] - 31 gauge X [**4-13**]" Syringe - Use as directed up to five times daily with Lantus and Humalog insulins. LANCETS [FREESTYLE LANCETS] - Misc - Use up to three times daily as directed. MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth DAILY (Daily) RANITIDINE HCL [ACID CONTROL] - 150 mg Tablet - 1 Tablet(s) by mouth twice daily Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Furosemide 80 mg PO BID 4. LeVETiracetam 1000 mg PO BID RX *Keppra 1,000 mg 1 Tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 5. Multivitamins 1 TAB PO DAILY 6. PredniSONE 60 mg PO DAILY 7. Simvastatin 20 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (MO,WE,FR) 9. Ranitidine 150 mg PO BID 10. Lacosamide 200 mg PO BID RX *Vimpat 200 mg 1 Tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 11. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit Oral daily 12. Ampicillin 500 mg PO Q8H UTI Duration: 7 Days First day = [**2208-6-2**] Last day = [**2208-6-8**] 13. Glargine 16 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 14. Metoprolol Succinate XL 12.5 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Partial epilepsy secondary to past intraparenchymal hemorrhage, uncontrolled diabetes mellitus with complications, chronic kidney disease, urinary tract infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: [**Hospital1 **] and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurologic Status: Blind in L eye with post surgical changes and nonreactive pupil. Eyes can track past midline. Left sided weakness, LLE at least antigravity, LUE stronger than LLE. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure to take care of you at [**Hospital1 827**]. You were brought in because you had seizures at home. Your Keppra was increased and you were also started on a new medication called Vimpat for your seizures, and your seizures stopped. You were monitored in the hospital and your symptoms improved. You were also seen by [**Last Name (un) **] for management of your diabetes and insulin. You were seen by physical therapists who recommend that you go to a rehabilitation facility to gain back the strength you have lost during this hospitalization. Please follow up with your kidney doctors (nephrologist) as scheduled. Please call your primary care physician's office at [**Telephone/Fax (1) 2010**] to make a follow up appointment when you are discharged from the rehabilitation facility. Followup Instructions: Please call your primary care physician's office when you are ready to be discharged from rehab facility for a follow up appointment. Please also call Dr.[**Name (NI) 1745**] (General Surgery) office at [**Telephone/Fax (1) 6554**] to reschedule as you have missed the appointment scheduled for [**2208-6-6**]. Department: WEST [**Hospital 2002**] CLINIC **Kidney Doctor** When: MONDAY [**2208-6-20**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

[ "38.97", "96.71", "89.19", "96.6" ]

icd9pcs

[ [ [] ] ]

20503, 20574

13490, 17442

325, 471

20800, 20800

8476, 13467

22033, 22720

5395, 5544

19681, 20480

20595, 20595

17468, 19658

21172, 22010

5559, 5573

7996, 8049

267, 287

499, 3813

6672, 7980

20614, 20779

5587, 6309

20815, 21148

3835, 4952

4968, 5379

22,401

157,702

18016

Discharge summary

report

Admission Date: [**2181-4-16**] Discharge Date: [**2181-4-26**] Date of Birth: [**2109-1-25**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 72-year-old male has no known cardiac history and was referred for a cardiac catheterization after a positive stress test. He went to see his primary care physician for an annual visit and was found to have an abnormal EKG. He denies having any chest pain or dyspnea. An ETT Myoview on [**2181-4-10**] was negative for chest pain but the EKG was significant for [**Street Address(2) 1755**] depressions in V5 and V6, and 2, 3 and aVF. Stress imaging revealed inferior, lateral and apical defects. He denied claudication, orthopnea, edema, paroxysmal nocturnal dyspnea, or lightheadedness. PAST MEDICAL HISTORY: History of colon cancer. He is status post partial colectomy in [**2169**]. ALLERGIES: Penicillin. MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. Toprol XL 25 mg p.o. q.d. FAMILY HISTORY: Positive for coronary artery disease. He does not smoke cigarettes and does not drink alcohol. PHYSICAL EXAMINATION: He was a well-developed, well-nourished white male in no apparent distress. Vital signs were stable and afebrile. HEENT: Normocephalic, atraumatic, extraocular movements intact, oropharynx benign. Neck: Supple with full range of motion, no lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. Lungs: Clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm, normal S1 and S2, with no rubs, murmurs or gallops. Abdomen: Soft and nontender with positive bowel sounds. No masses or hepatosplenomegaly. There was a well-healed surgical scar. Extremities: Without cyanosis, clubbing or edema. Pulses were 2+ and equal bilaterally throughout. Neurologic: Nonfocal. HOSPITAL COURSE: He underwent cardiac catheterization on [**2181-4-16**] which revealed the left ventricle revealed no MR, normal LV systolic function with an ejection fraction of 65%. Left main coronary artery had a distal eccentric 40% lesion. The left anterior descending coronary artery had a long mid LAD lesion up to 99% in the mid segment after the takeoff of a large diagonal one. The distal LAD filled by left to left collaterals. The left circumflex was not obstructed. The right coronary artery had an 80% distal lesion and a 95% proximal PL branch. There was some dissection of the LAD and Dr. [**Last Name (STitle) **] was consulted and on [**2181-4-17**] the patient underwent a coronary artery bypass grafting x 4 with left internal mammary artery to the diagonal, reversed saphenous vein graft to LAD, RCA, and PDA. The patient also had a mitral valve ring and he had a ventricular tachycardia, ventricular fibrillation arrest in the operating room and had to go back on pump and had an intra-aortic balloon pump placed. Cross-clamp time was 123 minutes. Total bypass time was 188 minutes. He was transferred to the CSRU on dobutamine, epinephrine, Levophed and amiodarone. He remained intubated overnight and was relatively stable. He required four units of packed red blood cells and six units of fresh frozen plasma. On postoperative day one his intra-aortic balloon pump was discontinued and he was extubated. He still remained on Levophed and amiodarone but the Levophed was titrated off. The amiodarone was continued. He continued to require arteriovenous pacing and had a slow junctional rhythm underneath his pacer. He remained in the unit and electrophysiology was consulted. They recommended discontinuing the amiodarone and followed him. Eventually his heart rate resumed in the 70s and he continued to improve. He was diuresed. He was started on captopril and his chest tubes were discontinued on postoperative day number two. He was transferred to the floor on postoperative day number six in stable condition. He continued to improve. His epicardial pacing wires were discontinued on postoperative day number eight and he was discharged to home on postoperative day number nine in stable condition. His laboratory studies on discharge were hematocrit of 27.7, white count 9,200, platelet count 292, sodium 139, potassium 4, chloride 101, CO2 28, BUN 16, creatinine 0.9, blood sugar 88. DISCHARGE MEDICATIONS: 1. Lasix 40 mg p.o. b.i.d. x 7 days. 2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. x 7 days. 3. Colace 100 mg p.o. b.i.d. 4. Ecotrin 325 mg p.o. q. day. 5. Percocet [**1-25**] p.o. q. 4-6 hours p.r.n. pain. 6. Plavix 75 mg p.o. q.d. 7. Captopril 12.5 mg p.o. t.i.d. FOLLOW UP: He will be followed by Dr. [**Name (NI) 45877**] in [**1-25**] weeks, Dr. [**Last Name (STitle) **] in [**2-26**] weeks and Dr. [**Last Name (STitle) **] in 4 weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2181-4-26**] 11:54 T: [**2181-4-26**] 12:15 JOB#: [**Job Number 49858**]

[ "423.1", "424.0", "V10.05", "410.41", "998.2", "414.01", "794.39", "427.5", "997.1" ]

icd9cm

[ [ [] ] ]

[ "36.13", "37.22", "36.15", "39.61", "88.72", "99.62", "88.56", "37.61", "88.53", "35.12" ]

icd9pcs

[ [ [] ] ]

1026, 1123

4339, 4655

1895, 4316

4667, 5114

1146, 1877

184, 784

807, 1009

41,719

104,584

7572

Discharge summary

report

Admission Date: [**2127-10-9**] Discharge Date: [**2127-11-5**] Date of Birth: [**2094-10-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3918**] Chief Complaint: fatigue Major Surgical or Invasive Procedure: Central Line Placement History of Present Illness: 32 Year-old male with h/o asthma was under his usual status of health until the end of [**Month (only) 216**] when he developed sore throat. He had intermittent sore throat and running nose and fatigue since the end of [**Month (only) 216**]. He denied fever, chill, rash, blurry vision, dizzy, CP, cough, and SOB. In the morning of [**2127-10-8**], he suddenly felt discomfort in his LUQ which was not pain. He made urgent appointment with his PCP who checked his CBC. his CBC showed significant increase WBC counts. He was called to ED yesterday. He denied Abd pain, n/v, BRBPR, melena, or diarrhea. In [**Name (NI) **], pt's VS: T 99.9 P 89 BP 155/88 R 20 SaO2 100. He received one dose of Allopurinol 100mg ROS: no fever, chill, dizzy, CP, SOB, cough, wheezing, dysuria, urgency, dysphagia, odynophagia, Abd pain, reflux, diarrhea, constipation, BRBPR, or melena, no N/V. no weakness, numbness. rash. He gain 7 lps. Past Medical History: asthma ERECTILE DYSFUNCTION Hypertriglyceridemia Seasonal allergies PSH: none Social History: He is smoking one to two cigarettes a day. He is unclear if this hurts his asthma. He works in a financial company. He has no pets. Unmarried. No regular alcohol. Family History: father died from RCC in his 40s, maternal grandmother had melanoma, his mother is healthy. He has 2 half siblings (from his father side) that he doesn't know about their health status. Physical Exam: Vitals: T 98.6 BP 124/79 P 78 RR 18 O2 Sat 100% General: Alert, oriented, no acute distress. Pleasant. HEENT: Sclera anicteric, MMM, oropharynx clear no lesions or thrush. Neck: supple, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: A+O x 3, CN grossly intact, upper and lower extremity strength 5/5, sensory intact, normal gait. Cerebellar Function: Rapid hand movements, finger to nose wnl, heel to shin wnl, normal gait. Pertinent Results: ADMISSION LABS: [**2127-10-9**] 03:00AM URINE HOURS-RANDOM [**2127-10-9**] 03:00AM URINE GR HOLD-HOLD [**2127-10-9**] 03:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2127-10-9**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2127-10-9**] 02:31AM PT-13.1 PTT-24.5 INR(PT)-1.1 [**2127-10-9**] 02:31AM FIBRINOGE-377 [**2127-10-9**] 02:28AM D-DIMER-583* [**2127-10-9**] 12:21AM LACTATE-1.1 [**2127-10-9**] 12:10AM GLUCOSE-106* UREA N-21* CREAT-1.4* SODIUM-142 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15 [**2127-10-9**] 12:10AM ALT(SGPT)-31 AST(SGOT)-33 LD(LDH)-900* ALK PHOS-83 TOT BILI-0.5 [**2127-10-9**] 12:10AM ALBUMIN-5.1 URIC ACID-9.8* [**2127-10-9**] 12:10AM WBC-55.6* RBC-4.08* HGB-13.3* HCT-36.1* MCV-89 MCH-32.7* MCHC-36.9* RDW-15.3 [**2127-10-9**] 12:10AM NEUTS-6* BANDS-0 LYMPHS-22 MONOS-34* EOS-2 BASOS-1 ATYPS-5* METAS-0 MYELOS-0 OTHER-30* [**2127-10-9**] 12:10AM I-HOS-AVAILABLE [**2127-10-9**] 12:10AM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [**2127-10-9**] 12:10AM PLT COUNT-54* [**2127-10-8**] 04:45PM WBC-57.1*# RBC-3.98*# HGB-13.0* HCT-35.8*# MCV-90 MCH-32.6*# MCHC-36.3*# RDW-14.1 [**2127-10-8**] 04:45PM NEUTS-4* BANDS-0 LYMPHS-23 MONOS-44* EOS-4 BASOS-4* ATYPS-3* METAS-0 MYELOS-0 OTHER-18* [**2127-10-8**] 04:45PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL [**2127-10-8**] 04:45PM PLT SMR-VERY LOW PLT COUNT-56*# . DISCHARGE LABS: [**2127-11-5**] 05:25AM BLOOD WBC-5.3 RBC-3.80* Hgb-12.1* Hct-31.7* MCV-84 MCH-31.8 MCHC-38.0* RDW-14.1 Plt Ct-711* [**2127-11-5**] 05:25AM BLOOD Neuts-23* Bands-1 Lymphs-30 Monos-19* Eos-0 Baso-0 Atyps-2* Metas-5* Myelos-15* Promyel-1* Blasts-4* NRBC-3* Other-0 [**2127-11-5**] 05:25AM BLOOD Plt Smr-VERY HIGH Plt Ct-711* [**2127-11-5**] 05:25AM BLOOD Gran Ct-2931 [**2127-11-5**] 05:25AM BLOOD Glucose-83 UreaN-14 Creat-1.1 Na-140 K-4.9 Cl-102 HCO3-31 AnGap-12 [**2127-11-5**] 05:25AM BLOOD ALT-59* AST-30 LD(LDH)-286* AlkPhos-85 TotBili-0.3 [**2127-11-5**] 05:25AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.3 Brief Hospital Course: Mr. [**Known lastname 27628**] is a 32y/o gentleman with new diagnosis of AML who has recently undergone 7+3 therapy. . #AML: The patient was diagnosed with AML on BMB, and has tolerated 7+3 therapy without complaint. Patient was started on an aggressive hydration regimen with bicarbonate as well as hydroxyurea and allopurinol in order to bring down the WBC burden as well as prevent tumor lysis syndrome. Bone Maroow Biopsy at Day 14 showed a clean bone marrow. Patient's counts began to slowly recover around Day 20 and was discharged on Day + 27. . #Hypoxia: On [**10-11**] pt spiked a fever and had need for supplemental O2 to maintain sats. On [**10-12**] he continued to have fevers and had increase in oxygen demand requiring a non-rebreather in order to keep sats in the 90s and was accordingly transfered to the [**Hospital Unit Name 153**] for hypoxia. His CXR at the time showed moderate-severe new pulmonary edema. Pt was given 2 doses of 20mg IV lasix with good urine response. Vancomycin and cefepime had been started (see below) and levofloxacin was started to cover atypicals. Pt was supported in the evening on a non-rebreather but then O2 was tapered as pt showed improvement in saturations. CXR on [**10-13**] showed significant improvement in pulmonary edema s/p lasix diuresis. Another 20mg IV lasix was given with good response and pt transferred back to floor on 2L NC. ECHO was perfomred to look for signs of cardiotoxicty and decrased EF [**2-25**] chemotherapy, but was unrevealing; inital concerns about an ASD were put to rest after a ubble study was negative for ASD. . # Neutropenic Fever: When pt spiked initial fever Cefepime was started although not technically neutropenic at the time. Vanco had been added as well at time of ICU transfer. Levofloxacin was started to cover possible atypical PNA organisms. ID was consulted, and he completed 5 days of coverage with Levofloxacin for atypical organisms. Vancomycin was subsequently DC'ed, and the patient continued on Cefepime, Acyclovir, and fluconazole. Patient subsequently began to have 4 consecutive days of low grade fever to 99-100. He was restarted on IV Vancomycin. CT Scan of the chest showed several lung nodules that may represent new area of infection. As his ANC increased, his fevers began to fade. He was transitioned to PO Levofloxacin for 7 days on discharge to cover the likely infection in his lungs. . # [**Last Name (un) **]: Creatinine was slightly elevated upon admission, and rose even further prior to tranfser tot he ICU. It has since normalized [**2-25**] diuresis both within the ICU and on the floor. . # Anemia: Patient has become transfusion dependent for both RBC and plts during admission, and was supported with multiple transfusions. . # ? Aneurysm: Patient had an MRI head with contrast to explore possible CNS involvement of the AML as he was having 2 days worth of headaches. The headaches subsequently faded and decision was made to not to an LP. The MRI showed a possible anueurysm in the internal carotid artery; however, the read was that it was a likely artifact. MRA was done, which showed the finding was an artifact from the tourtuous nature of the internal carotid artery. Medications on Admission: ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 Puffs(s) inhaled Q 4 hr as needed for sob or wheezing Loratadine 10 mg Tab 1 Tablet(s) by mouth once a day allergies Fluticasone 50 mcg/Actuation Nasal Spray, Susp [**1-25**] sprays(s) each nostril daily as needed for allergy season Discharge Disposition: Home Discharge Diagnosis: Primary: AML Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital for high-dose chemotherapy to treat your leukemia. . We made the following changes to your medications: 1. ADDED Levofloxacin 500 mg daily for 5 days 2. ADDED Acyclovir 400 mg three times a day Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2127-11-7**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2127-11-7**] 10:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], RN, [**Name8 (MD) 16569**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1579**] Date/Time:[**2127-11-10**] 10:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

[ "112.0", "285.22", "784.0", "277.88", "584.9", "V16.8", "E849.7", "287.49", "272.1", "288.03", "205.00", "493.90", "305.1", "E933.1", "693.0", "780.61" ]

icd9cm

[ [ [] ] ]

[ "99.25", "38.93", "41.31" ]

icd9pcs

[ [ [] ] ]

8369, 8375

4820, 8037

324, 349

8432, 8432

2562, 2562

8831, 9369

1613, 1800

8396, 8411

8063, 8346

8583, 8688

4192, 4797

1815, 2543

8717, 8808

277, 286

377, 1309

2578, 4175

8447, 8559

1331, 1411

1427, 1597

16,980

194,894

14715+14716

Discharge summary

report+report

Admission Date: [**2119-7-12**] Discharge Date: [**2119-7-15**] Date of Birth: [**2048-11-2**] Sex: F Service: [**Last Name (un) 14843**] General Medicine HISTORY OF PRESENT ILLNESS: The patient is a 70 year old man with a history of multiple medical problems. [**Name (NI) **] was brought to the Emergency Department because of mental status changes while at home. Her baseline mental status and functional status is poor. She lives at home with family nearby. They were unable to obtain the review of systems on admission but in the meantime she was found to be hypotensive with blood pressure of 90-100/50-60. She was given 1 liter of intravenous fluid times two with improvement in her blood pressure. She received Oxacillin for presumed cellulitis of the lower extremities and Flagyl for pus around her jejunostomy tube site, Ceftriaxone for possible pneumonia and finally Levofloxacin for cellulitis. She also complains of lower extremity pain intermittent. There are no other complaints. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease; 2. Vertebral compression fractures; 3. Severe kyphoscoliosis; 4. History of pneumonectomy for fungal infection; 5. History of Methicillin-resistant Staphylococcus aureus, pseudomonas pneumonia; 6. Unknown chronic neurologic disorder, question polio; 7. Feeding tube in place, jejunostomy tube placed several years ago. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Duragesic 75 mcg/hr q. 72 hours, Roxicet 5/325 q. 3-4 hours prn, Fluoxetine 20 mg p.o. q.d., Hydroxyzine 25 mg p.o. q.6 hours prn, Docusate Coumadin to be adjusted per INR, E-Vista 60 mg p.o. q.d., Lasix, Prilosec. PHYSICAL EXAMINATION: This is a cachectic appearing woman with head tilted to the left. Temperature was 98.7, blood pressure 100/60, pulse 100, respirations 22. Head, eyes, ears, nose and throat, pupils are equal, round, and reactive to light and accommodation, extraocular movements intact. Enlarged erythematous tongue. No lesions. Appreciable mucous membranes are moist. Stiff contracted and kyphoscoliotic neck and back. Chest clear anteriorly and posteriorly with poor effort. Heart, regular rate and rhythm, S1 and S2, II/VI systolic ejection murmur. Abdomen is soft, nontender, nondistended, normoactive bowel sounds. Jejunostomy tube site with small exudate. No edema. Erythematous bloody ulcers, left foot, two and left calf. LABORATORY DATA: Laboratory studies on admission were notable for a white blood count of 19.4, hematocrit of 33.1 and normal chemistries, negative toxicology screen, no growth in blood culture bottles to date. HOSPITAL COURSE: Neurologically, the patient became more awake as the hospital course went on which may be related to her increased blood pressure and cerebral perfusion. We gave intravenous hydration and treated the infection with antibiotics. Renal ordered a TSH which was normal, normal liver function tests and calcium as well as ESR. Cardiovascularly, the patient has had paroxysmal atrial fibrillation episode in the unit and therefore the patient was placed on Telemetry which may be discontinued later today prior to discharge. Infectious disease - Questionable history of Methicillin-resistant Staphylococcus aureus, clinical cellulitis. Continue Cefazolin for antibiotics and consider Vancomycin, running on gram negative coverage again. Pulmonary history - Chronic obstructive pulmonary disease and restrictive lung disease. Saturations remained stable throughout hospital course. Endocrine - Continue Raloxifene. Psychiatric - Continue Prozac. Renal - Probably prerenal, continue hydration. DISCHARGE PLAN: Plan is to transfer the patient to skilled nursing facility, [**Hospital 5735**] rehabilitation for a brief time before the patient is stable to go home. We will get physical therapy consults and the patient will receive the following medications. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Vitamin C 500 mg p.o. b.i.d. 3. Zinc Sulfate 220 mg p.o. b.i.d. 4. Warfarin adjusts dose based on INR 5. Raloxifene 60 mg p.o. q.d 6. Fluoxetine 20 mg p.o. q.d. 7. Colace 100 mg p.o. b.i.d. 8. Senna 1 tablet p.o. b.i.d. DISCHARGE DIAGNOSIS: 1. Cellulitis 2. Kyphoscoliosis 3. History of polio 4. Vertebral compression fractures [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. [**MD Number(1) 41641**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2119-7-14**] 16:06 T: [**2119-7-14**] 19:42 JOB#: [**Job Number 43305**] Admission Date: [**2119-7-12**] Discharge Date: [**2119-7-16**] Date of Birth: [**2048-11-2**] Sex: F Service: ADDENDUM: DISCHARGE PLAN: Is now changed to discharged to home. Patient has refused going to a rehabilitation facility so we will send her home. She will follow up with her new primary care physician at [**Name9 (PRE) 1774**]. We have told her that it is very important that she follow with her laboratories in a week. We think she should call her new doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to schedule an appointment within a week and the things that need to be followed up are her potassium, her phosphate, her magnesium and her thyroid studies. On the day of discharge her potassium is 4.1, her magnesium 1.7, her phosphate 2.1, her TSH was 0.21 and she received additional phosphate supplementation. MEDICATIONS ON DISCHARGE: As stated in the prior discharge summary with the addition of cephalexin 500 mg p.o. q 6 hours times 14 day total course. She will follow up with her attending at the [**Hospital3 2358**] for a laboratory check and she will have home physical therapy and home services. This plan was discussed with the attending and her family. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21189**], M.D. [**MD Number(1) 41641**] Dictated By:[**Name8 (MD) 6340**] MEDQUIST36 D: [**2119-7-16**] 10:00 T: [**2119-7-16**] 10:49 JOB#: [**Job Number 43306**]

[ "682.6", "733.13", "707.19", "496", "427.31", "707.9", "737.30", "276.5", "799.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3962, 4222

4243, 4744

5495, 6094

1483, 1699

2675, 3672

1722, 2657

205, 1026

4762, 5468

1049, 1456

56,195

114,549

34951

Discharge summary

report

Admission Date: [**2193-10-17**] Discharge Date: [**2193-10-21**] Date of Birth: [**2117-4-27**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2167**] Chief Complaint: GI Bleed, Syncope Major Surgical or Invasive Procedure: Push Enteroscopy ([**2193-10-18**]) Impression: - Mucosa suggestive of Barrett's esophagus - Clotted blood in the stomach body - Erythema and congestion in antrum suggestive of mild gastritis - 1.5cm cratered ulcer in duodenal bulb with visible vessel. 5cc of 1:10,000 epinephrine, heater probe and one endoclip applied with successful hemostasis. History of Present Illness: This is a 76 year-old male with a history of metastatic small cell lung cancer, ESRD on PD who is being transferred to [**Hospital1 18**] for push enteroscopy after presenting to [**Hospital6 **] with black stool, syncope, and hypotension. . He reports that on [**10-12**], he had his first episode of large dark black loose bowel movement. He had had a normal brown BM the day prior and denies any h/o BRBPR or GIB previously. He had no abdominal pain nor nausea/vomiting prior to the event. Shortly thereafter, he experienced LOC although the events surrounding this are not entirely clear. He is not sure exactly what he was doing and does not recall fall from what distance. He denies hitting his head, but did scrape his right anterior calf. He presented at that time to [**Hospital6 **] where he underwent EGD which reportedly showed candidal esophagitis and a nonbleeding duodenal ulcer. He received 2U prbcs and hct stabilized thereafter. He was discharged home on [**10-14**] on protonix and fluconazole and nystatin. . He is unsure if his BMs upon discharge revealed any blood or black expect for he again noted a large black loose BM on [**10-16**]. He again had a syncopal event upon rising thereafter and presented again to [**Hospital6 33**]. There he was found to be tachy to low 100s with SBPs in the 70s-80s. He was reportedly fluid resuscitated with crystalloid and received a total of 3 units prbcs with resolution of his tachycardia and improvement in BPs. Repeat EGD demonstrated duodenitis but again no clear evidence of active bleed. He was prepped for colonoscopy at [**Hospital3 **] (clear output [**Name8 (MD) **] RN signout). He is now being transferred to [**Hospital1 18**] for push enteroscopy and colonoscopy. Hct was 27 on presentation (was 34 on most recent discharge) and prior to transfer was 28.7 after 3U prbcs. Past Medical History: -Metastatic small cell lung cancer s/p chemotherapy (no rx since [**11-8**]) -ESRD on PD since [**6-9**] -DVT and PE [**11-8**] s/p IVC filter (never on coumadin) -"Suspected HIT in past" per [**Hospital3 **] d/c summary (unclear hx) -BPH -s/p ventral hernia repair -Anemia -Chronic LE edema Social History: Widowed. Lives alone at home. Has two sons both of whom live locally and are involved in his life and health care. Son [**Name (NI) **] is HCP. 60+ packyear history of smoking cigarettes prior to diagnosis of lung cancer. Occasional EtOH, perhaps [**2-3**] drinks/week. Family History: Noncontributory Physical Exam: GEN: Elderly gentleman in NAD. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry MM. NECK: No JVD, carotid pulses brisk, no cervical lymphadenopathy, trachea midline COR: RRR, soft systolic murmur heard best at apex. PULM: course BS bilaterally and diffusely rhonchorus, no wheezing. CHEST: Right sided tunnelled HD line site CDI. ABD: PD site right lower abdomen CDI. Distended, but soft, +BS. NTTP. EXT: 3+ b/l LE pitting edema (L very sl. greater than right) NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength and sensation to soft touch grossly intact. SKIN: No jaundice, cyanosis, or gross dermatitis. Confluent ecchymoses bilateral forearms. Pertinent Results: [**2193-10-17**] 07:21PM BLOOD WBC-9.0 RBC-2.91* Hgb-9.4* Hct-25.8* MCV-88 MCH-32.4* MCHC-36.7* RDW-16.8* Plt Ct-88* [**2193-10-17**] 07:21PM BLOOD PT-11.5 PTT-22.0 INR(PT)-1.0 [**2193-10-17**] 07:21PM BLOOD Glucose-131* UreaN-42* Creat-1.6* Na-146* K-3.0* Cl-110* HCO3-27 AnGap-12 [**2193-10-17**] 07:21PM BLOOD Albumin-3.0* Calcium-8.0* Phos-1.7* Mg-1.8 . Push enteroscopy A single acute cratered 1.5cm ulcer was found in the first part of the duodenum. A visible vessel suggested recent bleeding. 5 cc.epinephrine 1/[**Numeric Identifier 961**] was injected into the ulcer base and heater probe applied for hemostasis with success to the ulcer in the duodenal bulb.One endoclip was successfully applied to the duodenal bulb ulcer for the purpose of hemostasis. Impression: Mucosa suggestive of Barrett's esophagus Clotted blood in the stomach body Erythema and congestion in antrum suggestive of mild gastritis 1.5cm cratered ulcer in duodenal bulb with visible vessel. 5cc of 1:10,000 epinephrine, heater probe and one endoclip applied with successful hemostasis. Recommendations: Continue IV PPI drip Follow serial Hct, Continue NPO Check H. pylori serology and treat if positive Brief Hospital Course: 76 year-old male with a history of metastatic small cell lung cancer who presented to OSH with syncope and black stool x 2 without clear source of bleed on EGD at the OSH. # Upper GI bleed from bleeding duodenal ulcer: Initial EGD at an OSH showed a nonbleeding duodenal ulcer with repeat scope showing duodenitis without evidence of ulceration. GI bleed considered likely to be from small bowel AVM vs. ulceration distal to segments scoped. Right sided colonic source was also considered a possibility. Thus, patient was transferred to [**Hospital1 18**] for push enteroscopy and colonoscopy for further work up. Push enteroscopy revealed a 1.5cm cratered ulcer in duodenal bulb with visible vessel. 5cc of 1:10,000 epinephrine, heater probe and one endoclip applied with successful hemostasis. H/H has been stable, along with sx. He was continued on IV protonix for completion of 72h and then switched to po pantoprazole. His H. pylori serologies were pending at time of discharge, but are now negative. He will not need treatment. His hematocrit remained stable. His diet was advanced to regular and he tolerated this well. . # Anemia, Chronic anemia from chronic disease, and acute anemia due to acute blood loss. Patient required 2 units of PRBC during his [**Date range (1) **] admission and then an additional 3 units since [**10-16**] (recieved at OSH prior to tx here). On admission, HCT=25.8 which increased to 30.4 after the endoscopy. This remained stable for the duration of his hospital stay. . # Candidal esophagitis: Reportedly, the initial EGD at [**Hospital **] indicated candidal esophagitis, with initiation of fluconazole and nystatin. Repeat EGD a few days later did not state presence of candidal esophagitis. Enteroscopy performed at [**Hospital1 18**] also did see this finding. Fluconazole and nystatin were discontinued after 4 days of treatment. Patient has denied dysphagia or odynophagia. . # ESRD on PD: Per records - seems pt with bx [**6-9**] - chronic AIN with signs ATN - overall more consistant with possible FSGS - Patient continues to recieve PD per home regimen here. Phosphate was low on admission with daily increase to near normal levels. He was continued on peritoneal dialysis. . # Lower extremity edema. He was given one dose of Lasix for his lower extremity edema with some improvement in his symptoms, but with rise in creatinine. He was given a prescription for Lasix but should discuss use of this medication with his PCP and nephrologist. This was communicated to the patient. . # Small cell lung cancer: Metastatic and not currently undergoing any therapy. Followed by Dr. [**Last Name (STitle) 58562**]. Plan to f/u as outpt. . # BPH: Patient is oliguric, taking flomax, which was held initially for concerns of hypotension. This medication was restarted. His Foley was removed, and he voided without problems. . # h/o DVT/PE/thrombocytopenia: s/p IVC filter. With history of HIT and GI bleed, prophylaxis with pneumoboots. . He remained DNR/DNI throughout his hospital stay. He was discharged to home with services. Medications on Admission: PhosLo Flomax Renagel Colace Dialyvite Protonix Fluconazole Nystatin suspension Ambien CR prn Discharge Medications: 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Ambien CR 12.5 mg Tablet, Multiphasic Release Sig: One (1) Tablet, Multiphasic Release PO at bedtime as needed for insomnia. 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Renagel Oral 6. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day. 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Please discuss use of Lasix with your nephrologist before starting this medication. . Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: 1. Upper GI bleed from duodenal ulceration 2. Acute blood loss anemia 3. ESRD on peritoneal dialysis 4. DVT s/p IVC filter placement 5. Peripheral edema. Discharge Condition: Stable Discharge Instructions: You were admitted with GI bleeding. Your blood count was stable after leaving the ICU. If you develop fevers, chills, nausea, vomiting, or shortnes of breath, please call your primary care doctor or go to the emergency room. Followup Instructions: Please follow up with your primary care doctor in [**1-2**] weeks. Your H. pylori serology is still pending, and your PCP will be [**Name (NI) 653**] with the result when it returns. An appointment was made for you with Dr. [**Last Name (STitle) **]. The appointment is on Friday [**11-1**] at 11:30am in the [**Location (un) 8072**] office.

[ "285.1", "V12.51", "585.6", "532.40", "V10.11" ]

icd9cm

[ [ [] ] ]

[ "44.43" ]

icd9pcs

[ [ [] ] ]

9126, 9177

5158, 8230

295, 645

9375, 9384

3930, 5135

9657, 10002

3142, 3159

8374, 9103

9198, 9354

8256, 8351

9408, 9634

3174, 3911

238, 257

673, 2523

2545, 2839

2855, 3126

27,808

125,705

34590

Discharge summary

report

Admission Date: [**2103-9-13**] Discharge Date: [**2103-9-21**] Date of Birth: [**2031-7-26**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Streptokinase Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**9-17**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to OM, SVG to Diag, SVG to PDA) History of Present Illness: 72 year old woman with a history of CAD s/p IWMI in [**2088**] and severe GERD refractory to PPI and H2 therapy who presented to her cardiologist with worsening chest and jaw discomfort. Adenosine cardiolote scan was negative for significant ischemia. Echo showed preserved LVEF with inferior wall hypokinesis. She was cathed given worsening of symmptoms on [**2103-9-13**] by Dr [**First Name (STitle) **] at MWMC. The cath revealed 50% proximal LAD stenosis, 95% proximal LCX disease, and an occluded RCA with L to R collaterals. The femoral sheath was sewn in, started on Heparin and transferred to [**Hospital1 18**] for surgical revascularization. Past Medical History: Coronary Artery Diease s/p Myocardial infarction, s/p PCI to RCA, Subarachnoid hemorrhage secondary to streptokinase [**2088**],Hypertension, Hyperlipidemia, Hiatal Hernia, Gastritis, depression, Reactive airway disease, s/p PPM placement for 2nd degree AV block Social History: History of smoking having quit in [**2088**] with a 35-40 pack year history. Family History: Strong family history of premature coronary artery disease. Physical Exam: At the time of discharge, Ms. [**Known lastname 79393**] was in no acute distress. Her heart was of regular rate and rhythm. Upon auscultation of her lungs, rales were heard at the left base. Her abdomen was soft, non-tender, and non-distended. Her mediastinal incision and vein harvest sites were clean, dry, and intact. Her sternum was stable. Trace edema was noted. Pertinent Results: [**9-14**] CTA of head: No acute intracranial process. Normal CTA of the head. [**9-17**] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild regional left ventricular systolic dysfunction with inferior and apical hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma 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. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 5. The mitral valve leaflets are structurally normal. Mild to moderate ([**1-24**]+) mitral regurgitation is seen.There is central mild to moderate MR [**First Name (Titles) 6643**] [**Last Name (Titles) 79394**] to moderate -severe at higher systemic pressures. Mechanism is [**Hospital1 **]-leaflet restriction, no annular dilation is noted 6. There is no pericardial effusion. POST-BYPASS: Pt is on an phenylephrine infusion and is still AV paced. 1. LV function is improved. 2. Aorta appears intact post decannulation. 3. MR is mild [**9-20**] CXR: In comparison with study of [**9-19**], there is little change. Pacemaker leads remain in place. There may be slight increase in the opacification at the left base consistent with a combination of pleural fluid and atelectasis. The right lung and upper left lung remain clear. [**2103-9-13**] 11:43PM BLOOD WBC-7.1 RBC-3.61* Hgb-11.3* Hct-32.9* MCV-91 MCH-31.4 MCHC-34.5 RDW-13.1 Plt Ct-260 [**2103-9-21**] 05:25AM BLOOD WBC-11.0 RBC-3.09* Hgb-9.8* Hct-27.9* MCV-91 MCH-31.6 MCHC-34.9 RDW-14.3 Plt Ct-236 [**2103-9-13**] 11:43PM BLOOD PT-14.3* PTT-54.9* INR(PT)-1.2* [**2103-9-17**] 12:11PM BLOOD PT-14.8* PTT-41.0* INR(PT)-1.3* [**2103-9-13**] 11:43PM BLOOD Glucose-164* UreaN-12 Creat-0.6 Na-140 K-3.7 Cl-108 HCO3-24 AnGap-12 [**2103-9-21**] 05:25AM BLOOD Glucose-105 UreaN-23* Creat-0.8 Na-136 K-3.4 Cl-97 HCO3-30 AnGap-12 [**2103-9-18**] 03:56AM BLOOD Calcium-8.6 Mg-2.5 Brief Hospital Course: On [**9-17**] Ms. [**Known lastname 79393**] [**Last Name (Titles) 1834**] a coronary artery bypass times 4 (LIMA to LAD, SVG to OM, SVG to Diag, SVG to PDA). This procedure was performed by Dr. [**First Name (STitle) **] [**Name (STitle) **]. She tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. She was soon extubated and her chest tubes were removed. She was gently diuresed and her beta blockade was increased as tolerated. Her epicardial wires were removed. She was transferred to the surgical step down floor. The physical therapy saw her in consultation and recommended rehabilitation. By post-operative day 6 she was ready for discharge to rehab. Medications on Admission: ASA 81 mg po daily, Lipitor 80 mg po daily, Nitro-patch 0.2 mg/hr, Protonix 40 mg po daily, Zetia 10 mg po daily, Verelan 180 mg po QHS, Levoxyl 25 MCG po QHS, Wellbutrin 150 mg po QAM, Effexor 37.5 mg po QPM Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take for constipation while taking pain medication. Disp:*60 Capsule(s)* Refills:*0* 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*0* 6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*0* 7. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 12. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. Disp:*qs * Refills:*0* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: evaluate for wt loss/gain for goal of reaching pre-op wt of 67 kgs. Disp:*14 Tablet(s)* Refills:*0* 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Location (un) 5176**] Pines Extended Care - Facility (Spec) Discharge Diagnosis: Coronary Artery Diease s/p Coronary Artery Bypass Graft x4 PMH: Subarachnoid hemorrhage, Myocardial infarction, s/p PCI to RCA, Hypertension, Hyperlipidemia, Hiatal Hernia, Gastritis, Depression, Reactive airway disease, s/p PPM placement Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] 4 weeks Dr. [**First Name (STitle) **] 2-3 weeks Dr. [**Last Name (STitle) 79395**] in [**1-24**] weeks Completed by:[**2103-9-21**]

[ "414.01", "530.81", "V45.82", "272.4", "411.1", "401.9", "V45.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7069, 7158

4089, 4823

305, 400

7440, 7446

1950, 4066

7957, 8121

1480, 1541

5082, 7046

7179, 7419

4849, 5059

7470, 7934

1556, 1931

255, 267

428, 1084

1106, 1370

1386, 1464

59,964

131,353

41338

Discharge summary

report

Admission Date: [**2111-3-16**] Discharge Date: [**2111-3-29**] Date of Birth: [**2045-5-23**] Sex: F Service: NEUROSURGERY Allergies: Phenytoin Attending:[**First Name3 (LF) 78**] Chief Complaint: headache and collapse Major Surgical or Invasive Procedure: [**2111-3-16**] Craniectomy for subdural evacuation [**Last Name (un) 8745**] bolt placement by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2111-3-16**] Cerebral angiogram w/onyx embolization by Dr [**First Name (STitle) **] [**2111-3-27**] Wills Ogelsby Gastric tube 12 French by [**First Name8 (NamePattern2) **] [**Location (un) 805**] in Interventional Radiology. History of Present Illness: This is a 65 year old female with a known AVM that was diagnosed in [**2104**]. She developed a sudden onset headache around 11:30 pm the day of admission while walking down stairs. She also had left sided weakness and she slowly lowered herself down. She vomited a few times at home and EMS was called by her husband. She was taken to an outside facility where she was intubated and transferred to [**Hospital1 18**] for further care after a head CT that was obtained revealed a large right temporal parietal hemorrhage with midline shift. Past Medical History: Right temp/parietal AVM Social History: She is married Family History: nc Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: NCNT Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Intubated, obtunded, non responsive to verbal and painful stimuli. Cranial Nerves: I: Not tested II: Pupils right 4mm irregular, non reactive, left 2mm non reactive Positive Corneals Positive Cough Positive Gag Motor: No withdrawl or flexion with painful stimuli On discharge [**2111-3-29**]: The patient is restless in bed, and favors the left side. She is intermittently verbal but not oriented. She moves the right side (arm and leg)and left leg spontaneously/purposfully. The patient moves the left arm is contracted with minimal movement seen by husband at times. The pupils are 3mm with brisj reaction. The right craniectomy incision is clean dry and intact with disolvable sutures in place. The gtube insicion is intact with suture in place Pertinent Results: Head CTA [**2111-3-16**]: 1. Large 4.1 x. 5.2 x 3.0 cm acute right temporoparietal intraparenchymal hemorrhage - likely due to an AVM - causing mass effect with sulcal effacement and midline shift to the left by about 1.3 cm, effacement of the right lateral ventricle, early entrapment of the left atrium, effacement of the ambient and basilar cisterns concerning for early transtentorial herniation. 2. 12 mm acute subdural hematoma along the right cerebral hemisphere. No subarachnoid or intraventricular hemorrhage. 3. No large acute territorial infarct. Head CT [**2111-3-16**]: IMPRESSION: Expected appearance status post hemicraniectomy with 9 mm of leftward shift decreased from 13 mm preoperatively. Head CT [**2111-3-17**]: 1. Stable right frontal/parietal hematoma. 2. S/p endovascular embolization of the right sided AVM, with a new evolving infarct in the entire right posterior cerebral artery territory. 3. Decreased leftward shift of midline structures. Decreased mass effect on right midbrain. 4. Increased extraaxial blood along the right hemicraniectomy site. CXR [**2111-3-19**] As compared to the previous radiograph, there is increased size of the cardiac silhouette. Extensive bilateral diffuse focal parenchymal opacities, left more than right, with a predominantly interstitial pattern. In addition, at the left lung base, subtle Kerley B lines are visible. The findings would be suggestive with early interstitial edema or atypical pneumonia. No pleural effusions. No pneumothorax. No other abnormalities. CT head [**2111-3-21**] 1. Slight interval change in appearance of right frontal/parietal hematoma likely reflects redistribution rather than recurrent hemorrhage. Overall volume of hematoma appears stable. 2. Radiodense embolic material status post embolization of right AVM. Unchanged. 3. Progressive cytotoxic edema in the entire right posterior cerebral artery distribution, compatible with evolving infarct. 4. Mass effect upon the right cerebral hemisphere with diffuse sulcal effacement, and slightly increased leftward midline shift, now measuring 7-8 mm, previously 5 mm. CXR 4/12/11IMPRESSION: 1. No acute cardiopulmonary process. No pneumonia. 2. Resolution of prior vascular congestion. 3. Standard positions of the right PICC and Dobbhoff feeding tube. CT HEAD W/O CONTRAST Study Date of [**2111-3-24**] 9:28 AM FINDINGS: Comparison to the prior study is slightly limited by differences in the position of the patient's head. The previously noted right frontal/parietal parenchymal hematoma appears grossly stable, with stable surrounding edema. Radiopaque embolization material is again noted in the region of the known underlying arteriovenous malformation. The extent of brain herniation through the right hemicraniectomy defect appears minimally decreased or stable. Small amount of extra-axial hyperdense blood along the hemicraniectomy defect is stable. There is a stable fluid collection in the hemicraniectomy defect, superficial to the blood, with decreased air content compared to the prior exam. An evolving recent infarction in the right posterior cerebral artery territory is again noted. Leftward shift of midline structures appears slightly decreased since the prior study, now measuring 7 mm at the level of the septum pellucidum, compared to 9 mm previously; however, the comparison is limited by differences in patient positioning. Small amount of subdural blood remains present along the left tentorium. No new intracranial abnormalities are visualized. IMPRESSION: 1. Stable right frontal/parietal hematoma with surrounding edema. 2. Evolving recent infarction in the right posterior cerebral artery territory. 3. While comparison to the [**2111-3-21**] study is limited by differences in patient positioning, there may be a slight improvement in leftward shift of midline structures and in mild herniation of brain tissue through the right hemicraniectomy defect. CHEST (PORTABLE AP) Study Date of [**2111-3-25**] 4:49 PM Dobbhoff is looped in the esophagus and needs to be repositioned. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 56711**] at 5:20 p.m. on [**2111-3-25**] by Dr. [**Last Name (STitle) **]. Cardiac size is top normal. There is mild vascular congestion. There is no pneumothorax or pleural effusion. ABDOMEN (SUPINE ONLY) PORT Study Date of [**2111-3-25**] 9:31 PM IMPRESSION: Dobbhoff tube terminates in the stomach. EEG Study Date of [**2111-3-26**] FINDINGS: ABNORMALITY #1: Bursts of bifrontal, [**1-15**] Hz delta frequency slowing were seen, particularly in wakefulness. ABNORMALITY #2: An attenuated background was seen involving the right hemisphere, particularly in the posterior quadrant. BACKGROUND: In the most awake-appearing portions of the tracing, particularly on the left side, a moderately well-organized 7.5-8.5 Hz background was seen. HYPERVENTILATION: Could not be performed as the patient was unable to cooperate. INTERMITTENT PHOTIC STIMULATION: Could not be performed as the test was requested as a portable study. SLEEP: No normal sleep or wake transitions were seen. ARDIAC MONITOR: Revealed a generally regular rhythm with average rate of 72 bpm. IMPRESSION: This is an abnormal recording due to the presence of bursts of bifrontal slowing, and an attenuated background on the right. The first abnormality is indicative of deep midline dysfunction or may be seen in hydrocephalus; the second abnormality can be seen with the presence of a fluid collection between the cortex and electrodes. No evidence of ongoing seizures was seen at the time of this recording. CHEST (PORTABLE AP) Study Date of [**2111-3-26**] 8:41 AM IMPRESSION: 1. Repositioning of Dobbhoff feeding tube, now coiled within the stomach. 2. No acute cardiopulmonary process. PERC G/G-J TUBE PLMT Study Date of [**2111-3-27**] 4:12 PM no report available [**2111-3-28**] 05:44AM BLOOD WBC-10.4 RBC-3.35* Hgb-10.2* Hct-30.0* MCV-90 MCH-30.5 MCHC-34.0 RDW-13.6 Plt Ct-512* [**2111-3-28**] 05:44AM BLOOD Plt Ct-512* [**2111-3-28**] 05:44AM BLOOD Glucose-97 UreaN-19 Creat-0.3* Na-145 K-3.9 Cl-112* HCO3-25 AnGap-12 [**2111-3-28**] 05:44AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.1 [**2111-3-16**] 01:55AM BLOOD WBC-9.3 RBC-3.94* Hgb-12.5 Hct-33.9* MCV-86 MCH-31.7 MCHC-36.8* RDW-13.3 Plt Ct-297 [**2111-3-16**] 01:55AM BLOOD PT-12.2 PTT-23.4 INR(PT)-1.0 [**2111-3-25**] 04:38AM BLOOD PT-12.4 PTT-24.4 INR(PT)-1.0 [**2111-3-16**] 01:55AM BLOOD Glucose-129* UreaN-12 Creat-0.6 Na-140 K-3.4 Cl-104 HCO3-26 AnGap-13 [**2111-3-16**] 01:55AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9 [**2111-3-16**] 08:03AM BLOOD Osmolal-313* [**2111-3-16**] 05:28AM BLOOD Type-ART pO2-201* pCO2-39 pH-7.38 calTCO2-24 Base XS--1 Intubat-INTUBATED Brief Hospital Course: This is a 65 year old woman who collapsed and was brought to the ER. She ahd a CT head which showed a large rigth intraparenchymal hemorrhage. A CTA was obtained which showed a R AVM and a R SDH with midline shift. She was taken to the OR immediately for a R hemicraniectomy and subdural evacuation. An ICP bolt was placed at that time. She was then brought to the ICU for monitoring. A post-op head CT showed decreased midline shift. Later on [**3-17**] she went to angio for embolization of the AVM. She remained stable in the ICU and was extubated on [**3-17**] after removal of her ICP bolt. A helmet was ordered and arrived on [**3-18**]. Ms. [**Known lastname **] was transferred to the step down unit on [**3-19**] where she remained stable. Speech and swallow evaluation on [**3-20**] showed that the patient could not have po intake but could reassess with pureeds when more awake. In the morning of [**3-21**] the patient was found to not be following commands, her right pupil was 3mm and non reactive. A stat head CT showed increased edema. She she was transferred to the ICU for close observation. She remained in the ICU through [**3-24**]. In the step down unit, she was following commands, moving her right upper and lower extremities spontaneously. It was noted that her left upper extremity was becoming contracted and AFO splint was ordered. Speech and Swallow had been following the patient closely given her overall lethargy and absent swallow initiation they felt she should remain NPO and receive a PEG. On [**3-25**], the patient pulled out her Dop Hoff feeding tube and this was replaced. On [**3-26**], an EEg was ordered because there was a question of a possible seizure. The patient exhibited a blank stare for 45 seconds without blink to threat. An EEg was performed that was consistent with bifrontal slowing without evidence of ongoing seizures was seen at the time of the recording. The patient was fluid volume depleated and given a fluid bolus and initiation of IVF. Given the possible seizure the decision was made to keep the patient on Keppra 1000mg [**Hospital1 **] as an ongoing long term medication. On [**3-27**] she underwent placement of a Wills Ogelsby Gastric tube in interventional radiology. She also had bilateral lower extremity ultrasound due to right leg pain which was not performed due to the patients legs beeing in constant motion. On [**3-28**], Tube feedings were initiated and the goal was to have the tube feedings and intravenous fluids to equal 85cc/hr. On [**3-29**], The patient spoke a few sentences to her husband. She was moving about in the bed and attempting to sit up. opening her eyes to stimulus. The patient's abdomen is soft and non tender. The patients legs were non tender on palpation there was no edema or erythema. The decision was made to cancel the lower extremity ultrasound as the patient was no longer symptomatic. The patent will follow up with Dr [**First Name (STitle) **] for a post-operative visit in 4 weeks and for a cerebral angiogram with a Non Contrast Head CT prior. The patient will follow up with interventional radiology for her Gastric tube evaluation and possible replacement in 3 months.The patient was discharged to [**Hospital3 **] center today. Medications on Admission: None Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. propranolol 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day). 6. potassium & sodium phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day): please reevaluate need. moniotr serum potassium and serum phos levels three times a week. 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed 4 grams in 24 hours. 8. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 9. metoclopramide 5 mg/mL Solution Sig: Two (2) Injection Q6H (every 6 hours). 10. levetiracetam 500 mg/5 mL Solution Sig: Two (2) Intravenous [**Hospital1 **] (2 times a day): for seizure prophylaxis. 11. famotidine(PF) in [**Doctor First Name **] (iso-os) 20 mg/50 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours). 12. hydralazine 20 mg/mL Solution Sig: 0.5 Injection Q6H (every 6 hours) as needed for sys > 160: 10 mg IV q 6 hours PRN for SBP > 160. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right subdural hematoma Right IPH Right AVM Dysphagia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable, verbal intermittently , moves about in bed, favors her left side. Activity Status: Bedbound/ may get out of bed to the chair with max assist Discharge Instructions: Cerebral Angiogram with Embolization Medications: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. You have been prescribed Keppra for to prevent seizures. You will not need any levels drawn with this medication. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Please follow up with Interventional radiology [**Doctor Last Name 333**] K [**Doctor Last Name 6745**] physicians assisstant for evaluation and possible change of Wills Ogelsby 12 french Gastric tube in three months. There are three round white plastic discs that will fall off on their own. The suture at the Gastric tube site will stay in place until follow up. This patient had a Right Craniectomy- there is no bone covering the skull on the right side. The patient should not lie on the right side and should always be position on her back or to the left while in bed. When the patient's head of the bed is at 90 degrees or if the patient is very active while in bed or if the patient is out of bed- Please have the HELMUT on at all times. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] for a diagnostic angiogram in 4 weeks. You will need pre-operative arrangements prior to your diagnostic cerebral angiogram, these instructions will be given to you at the time you make your appointment.You will also need a follow up Head CT without contrast as you will be following up with Dr [**First Name (STitle) **] at that time for your Right Craniectomy. Call [**First Name9 (NamePattern2) 89584**] [**Doctor First Name **] to make arrangements for this [**Telephone/Fax (1) 4296**] to make this appointment. Please follow up with Interventional radiology [**Doctor Last Name 333**] K [**Doctor Last Name 6745**] physicians assisstant for evaluation and possible change of Gastric tube. The suture will stay in place until follow up. Please call the Radiology Daycare unit [**Telephone/Fax (1) 9595**] and make an appointment with the Physican Assistant in 3 months. Completed by:[**2111-3-29**]

[ "997.02", "432.1", "348.4", "784.3", "430", "787.22", "780.97", "780.39", "518.4", "348.5", "729.89" ]

icd9cm

[ [ [] ] ]

[ "01.31", "43.11", "38.91", "96.71", "88.41", "38.93", "01.10", "38.81", "96.6" ]

icd9pcs

[ [ [] ] ]

13783, 13853

9117, 12383

294, 692

13951, 13951

2339, 9094

17425, 18387

1358, 1362

12438, 13760

13874, 13930

12409, 12415

14201, 15276

15302, 17402

1377, 1377

233, 256

720, 1263

1649, 2320

1391, 1550

13966, 14177

1285, 1310

1326, 1342

109

137,510

14810

Discharge summary

report

Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother. On disability for multiple medical problems. Family History: No known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather. Physical Exam: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a "home" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]

[ "789.04", "585.6", "287.5", "364.3", "V12.51", "285.29", "V64.2", "V45.12", "V15.81", "423.9", "V02.54", "710.0", "403.01", "425.4", "V58.61", "V45.11", "276.6", "V45.78", "583.81", "443.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

9575, 9632

4965, 7397

326, 333

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9834, 10183

3432, 3898

10203, 10532

254, 288

361, 1567

1589, 3128

3144, 3274

80,858

122,576

38289

Discharge summary

report

Admission Date: [**2176-8-12**] Discharge Date: [**2176-9-6**] Date of Birth: [**2124-2-28**] Sex: M Service: MEDICINE Allergies: Cefepime / Levaquin Attending:[**First Name3 (LF) 7591**] Chief Complaint: Diarrhea, SOB, and cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 6483**] is a 52 year old with a PMHx s/f AML s/p SCT (recently completed dapogen, still on hydroxyurea), C.diff, babesosis, and HTN who presented today to the ED with a chief complaints of fevers, diarrhea, and sob. He was in his usual state of health until yesterday afternoon when he began to experience copious liquid stools which kept him up for [**2-12**] of the night, and experience subjective fevers. He also noted a dry cough which has been worsening overnight and dyspnea. He also noted one episode of nonbilious/nonbloody emesis. Prior to this exacerbation, he denies any fevers/chills/cough/SOB. . In the ED, initial vs were: T:102.0 (by temporal artery scanner) P:128 BP:109/64 R:40 O2 sat:94% RA. Patient was given 1gm of tylenol, 3L NS, vancomycin and zosyn. ABG demonstrated 7.51/31/58/26 on RA. On the floor, Mr. [**Known lastname 6483**] was found to have T100.8, HR117, BP of 102/44, RR 19-35, SpO2 98% on 10L shovel mask. Desaturates to 89-91 on RA. Past Medical History: AML s/p SCT on [**5-17**], with relapse C diff colitis in [**3-22**] on chronic oral vancomycin (negative pcr in may) HTN Previous babesosis Social History: Social History: - Tobacco: quit 5 years ago, previous 30 pack-year - Alcohol: none - Illicits: None - Previously stocked shelves at [**Date Range **]'s. Currently not working. Family History: Cousin: Leukemia s/p transplant Father: lung cancer Physical Exam: Initial ICU Admission Exam [**2176-8-12**]: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: expiratory wheezing on R lower fields, no rales, occassional ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no CVA tenderness Ext: L wrist in cast s/p fracture, warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema ICU Admission Exam [**2176-8-30**]: Vitals: T 98.6, BP 117/85, HR 114, RR 25, SpO2 99% on NRB General: Alert, moderate distress and appears uncomfortable HEENT: Sclera anicteric, pale conjunctive, MMM Neck: JVP not elevated, no LAD Lungs: Coarse breath sounds with upper respiratory fluid sounds. No wheezes or crackles CV: Regular tachycardia. Normal S1, S2. No murmurs, rubs, gallops. Abdomen: Moderately distended and diffusely tender to palpation. Tympanic in central area. Flexiseal in place with green liquid stool. GU: Foley draining dark urine. Ext: Warm, 2+ pulses. Lower extremity edema 2+ bilaterally and symmetric. Discharge: deceased Pertinent Results: [**2176-8-11**] 08:40AM GRAN CT-286* [**2176-8-11**] 08:40AM PLT SMR-RARE PLT COUNT-12*# [**2176-8-11**] 08:40AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+ [**2176-8-11**] 08:40AM NEUTS-26* BANDS-0 LYMPHS-36 MONOS-18* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-20* [**2176-8-11**] 08:40AM WBC-1.1*# RBC-2.55* HGB-8.7* HCT-24.7* MCV-97 MCH-34.0* MCHC-35.1* RDW-18.2* [**2176-8-11**] 08:40AM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-1.7 [**2176-8-11**] 08:40AM ALT(SGPT)-36 AST(SGOT)-24 ALK PHOS-78 TOT BILI-0.4 [**2176-8-11**] 08:40AM UREA N-24* CREAT-1.1 SODIUM-144 POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16 [**2176-8-11**] 11:33AM PLT COUNT-37*# [**2176-8-12**] 12:05PM PT-12.0 PTT-20.8* INR(PT)-1.0 [**2176-8-12**] 12:05PM PLT SMR-VERY LOW PLT COUNT-29* [**2176-8-12**] 12:05PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-1+ BITE-OCCASIONAL [**2176-8-12**] 12:05PM NEUTS-10* BANDS-0 LYMPHS-45* MONOS-11 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-34* NUC RBCS-2* [**2176-8-12**] 12:05PM WBC-1.7*# RBC-3.12* HGB-10.9*# HCT-30.0* MCV-96 MCH-34.9* MCHC-36.4* RDW-18.5* [**2176-8-12**] 12:05PM ALBUMIN-3.8 [**2176-8-12**] 12:05PM LIPASE-17 Brief Hospital Course: Mr. [**Known lastname 6483**] is a 52 year old with AML s/p SCT and relapse who was admitted from the ED to the ICU for neutropenic fever and hypoxemia. He suffered from multiple medical problems, including untreatable acute myelocytic leukemia, severe graft vs host disease, acute kidney injury, and hypoxia likely due to pneumonia. He passed away in the early morning of [**2176-9-6**]. The paragraphs below describe in detail the course of his several medical issues. . #Hypoxemia: Pt presented with hypoxemia with O2 sats 89-93% on 50% ventimask, and hypoxia continued to be a problem throughout this hospitalization. The etiology of this hypoxemia was thought to be secondary to pneumonia (see below), PE, graft versus host disease, leukemic infiltration or transfusion related acute lung injury. Gradual improvement while on stress dose steroids and broad spectrum antibiotics pointed towards leukemic infiltration, GVHD or pneumonia as the cause. As pt denied chest pain, did not clinically have a DVT, and improved with the above interventions, PE was seen as less likely. Anticoagulation was never begun in this patient given his thrombocytopenia. Chest CT showed central bronchial wall thickening, consistent with small airway disease. No consolidations noted. On exam the patient continued to have wheezes and he was treated symptomatically with [**Date Range 1988**] nebulizers and supplemental oxygen. Within the first 24h sats improved to 94%/6L xNC with frequent duonebs. After respiratory status improved (and other issues stabilized) the pt was discharged to [**Date Range 3242**], but later re-presented to the ICU for worsening hypoxia and increased oxygen requirement. At that time, WBC bumped from 10 to 15 with predominantly lymphocytes and monocyte lineages changing, which was suspicious for leukemic infiltration. Antibiotics were broadened to meropenem but again cultures were negative. O2 sats were >90% on high-flow oxygen by facemask. [**Date Range 3242**] and ID consult services continued to follow. O discharge from the [**Hospital Unit Name 153**], the patient remained on a high-flow oxygen by facemask until time of death. . #Possible PNA. Pt was without PNA on imaging but persistent hypoxia and cough in this chronically immunosuppresed patient led to agressive antibiotic therapy for possible pneumonia and pneumonia prophylaxis. Received ongoing Vanc, Zosyn, and Micofungin. Also received a course of acyclovir and pentaminidine nebulizer as HSV and PCP prophylaxis, respectively. Induced sputums were collected multiple times but cultures were consistently negative, apart from one sputum culture growing yeast (subsequently negative). He did have positive beta-glucan and galactomannan labs but these were difficult to interpret as pt was on zosyn at the time, which can make these labs falsely positive. The patient became acutely hypoxic on his most recent stay in the [**Hospital Unit Name 153**] after an episode of emesis. CXR was concernign for aspiration, and the patient's antibiotic coverage was broadened to include meorpenem. . #GVHD: Patient has suspected intestinal GVHD, with copious volume (100cc/hour) guaiac-negative liquid stool. Antibiotic therapy for C diff was started prophylactically. Repletion with D5 1/2 NS with 20 mEq KCl and 20 mEq HCO3- was begun at 100 cc/hour to make up for his diarrheal losses. This was discontinued when pt became fluid overloaded with bibasilar crackles and elevated JVD. Given presentation with large-volume liquid stools and cultures negative for shigella, campylobacter, yersinia, and c diff toxin, he was started on stress-dose solumedrol 60mg [**Hospital1 **], made NPO and TPN was initiated for bowel rest. Loperamide and opium tincture were startedv for symptomatic control. CT scan of the abdomen showed submucosal fat-deposition and/or edema involving a long segment of mid-to-distal small bowel and ascending colon, consistent with graft-versus-host disease. CellCept was started with minimal improvement in diarrhea; stool volume only slowed noticeably after starting twice-weekly etanercept during initial transfer to the [**Hospital1 3242**] service. Aside from the patient's diarrhea, he had no other manifestations of GvHD. He was continued on Methylprednisolone, CellCept, and etancercept during his second stay in the ICU, plus prophylactic Flagyl given risk of developing C diff colitis. . #AML: The patient was followed by the [**Hospital1 3242**] service during his stay in the [**Hospital Unit Name 153**]. Daily CBCs with diff were drawn daily. Blasts were present on the differential throughout the patient's stay in the [**Hospital Unit Name 153**]. [**Hospital Unit Name 3242**] again was actively involved in the management of the patient's underlying leukemia. He was on allupurinol, hydroxyurea and ursodiol during his first ICU stay but these were held per [**Hospital Unit Name 3242**] recommendations upon his second ICU admission. No active chemotherapy was begun given the patient's clinical status. . #ARF: On admission, the patient had a normal sCr. However, while in the [**Hospital Unit Name 153**], the patient developed ARF. Urine lytes suggested a pre-renal state [**3-13**] profuse diarrhea. Renal was consulted. A urine sediment also showed crystals on the urine which were concerning given that the patient was on acyclovir for HSV prophylaxis. Acyclovir was stopped. The patient also had an elevated urine Protein:Creatine ratio of 0.3, suggesting an intrarenal cause for the patient's ARF. His creatinine gradually rose to 3.8, with no improvement despite fluid resuscitation and TPN. Renal consult service followed and determined not to pursue dialysis given overall clinical picture, thrombocytopenia, and family preference. . #AMS: The patient acutely developed waxing/[**Doctor Last Name 688**] mental status, occasionally oriented only to person and sometimes moaning in response to questions. Early during admission, given his thrombocytopenia, he had a head CT to evaluation for intracranial bleed but this was not seen. At time of transfer from the ICU to [**Doctor Last Name 3242**], following IVF administration, his mental status had improved and he was able to keep converation and answer questions appropriately. However, during ICU readmission his mental status was once again low-baseline, moaning with exhalation and unable to communicate with ICU staff. . #Afib with RVR: The patient initially presented to the [**Hospital Unit Name 153**] in Afib with RVR. The patient's rate was mostly sinus tachycardia, but would intermittently convert to atrial fibrillation or atrial flutter. He was started on oral diltiazem 30mg QID; rate was eventually controlled on low-dose metoprolol. For episodes of sinus tachycardia, the patient received 1L boluses of fluid in the setting of his fluid losses from diarrhea. For episodes of atrial fibrillation or atrial flutter, he patient intermittently received IV diltiazem or metoprolol. . #Neutropenia: On neutropenic precautions for absolute neutropenia on admission but developed only low-grade temperatures. Antibiotics as above. To review: initially given Vancomycin/Zosyn for possible neutropenic fever with a suspected pulmonary source. And given recent history of cdiff and copious diarrhea, PO vancomycin and IV flagyl started as empiric therapy for severe C diff and continued after stool cultures negative x3. Prophylaxis with acyclovir and fluconazole continued; fluconazole later switched to Micafungin. Acyclovir had to be stopped in the setting of ARF with urine showing crystals. ID was also consulted. They recommended adding on Tobramycin for ESBL coverage to the patient's antibiotic regimen. Tobramycin was never added in part due to the patient's acute renal failure and his clinical picture: he did not develop fever. ANCs steadily rose throughout his first ICU stay; during the second ICU admission labs showed an elevated white count without neutropenia. . #Thrombocytopenia: Secondary to leukemia. Platelets monitored daily with CBCs. Patient had a transfusion threshold of >10. He received three platelet transfusions (on [**8-16**] and [**8-26**] and [**9-2**]). No signs of active bleeding. . #Anemia: Secondary to leukemia. Hgb/Hct monitored with daily labs. Red cell transfusion threshold 25. He received two PRBC transfusions ([**8-13**], [**8-27**]). . #Goals of care: Frequently family meetings were held with family and, when his mental status allowed, with the patient himself. Health care proxy is brother [**Name (NI) **] [**Name (NI) 6483**]; mother [**Name (NI) 13788**] [**Name (NI) 6483**] also very involved in pt's care (and is documented in OMR as being HCP). [**Name (NI) 3242**] service participated in these meetings. Family (brother and mother) changed pt's code status from Full Code to DNR/DNI on [**2176-9-1**] in context of worsening unexplained hypoxia on broad-spectrum antibiotics, poor mental status, and worsening leukemia prognosis. Medications on Admission: not applicable Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: not applicable Followup Instructions: not applicable

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44149

Discharge summary

report

Admission Date: [**2162-7-24**] Discharge Date: [**2162-7-30**] Date of Birth: [**2098-6-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: Syncope, wide complex tachycardia Major Surgical or Invasive Procedure: EP study, atrial and biventricular pacemaker and ICD placement History of Present Illness: 64 yo male with no prior cardiac hx presenting with 5 episodes of syncope over the past 2 weeks. On [**2162-7-12**], patient was admitted at [**Hospital1 18**] for series of 3 syncopal episodes thought to be vasovagal secondary to dehydration based on history, negative CT of head, and unremarkable EKG. He improved with IV fluids and was discharged on same day. . Patient was subsequently re-admitted [**Date range (1) 64025**] for another syncopal episode. Telemetry and EKG's showed occasional PVC's and possible LAFB c/w prior EKG's. Cardiac enzymes were negative for MI. TTE showed normal LVEF, no significant valvular disease, LVOT obstruction, or septal defects. MRI of the head and neck was negative for mass lesions concerning for mets or signs of infarction. Patient was discharged with [**Doctor Last Name **] of Hearts cardiac monitor and f/u outpatient EEG's, which were negative for seizure activity. . Around noon today, patient had been doing light trimming in yard for about 30 min. before feeling sudden sensation of fluttering ("like worms crawling") across chest and radiating across neck, similar to previous syncopal episodes. He sat down, felt lightheaded, and lost consciousness for few seconds. Patient became diaphoretic, shaky, and tachypneic immediately after regaining consciousness. Denies urinary or fecal incontinence or disorientation. . [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts heart monitor recorded a wide complex tachycardia 200-280 bpm. EMS was called and patient was found to be awake, alert, with stable VS upon EMS arrival. Lidocaine gtt was initiated in the field. Patient was taken via ambulance to [**Hospital3 20284**] Center ED, where he did not receive any electical shocks and was continued on the lidocaine. He was transferred to [**Hospital1 18**] per patient request. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. He is able to climb up 4 to 5 flights of stairs without limiting symptoms. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. (+) for syncope, presyncope, palpitations as above. . On arrival in CCU, patient went into wide complex tachycardia with rate in 200s. Patient had pulses but was unresponsive. Code was called and patient was cardioverted immediately. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: none -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - ?hypertension per patient for past year (130s-160s/80) - malignant melanoma lesion in L shoulder removed 2 years ago with wide margins - GERD relieved by Prilosec - h/o R knee trauma ~[**2137**]; occasional pain [**12/2144**]... - Herniated cervical disc --> C6-7 anterior cervical diskectomy and fusion Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1338**], neurosurgery [**1-/2151**] - L 1st toe swelling and pain with normal uric acid by history [**11/2151**] - Podagra ascribed to gout Dr [**Last Name (STitle) **], rheumatology [**8-/2153**] - R 2nd trigger finger --> release scheduled by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**12-25**] - R carpal tunnel syndrome per Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**12-25**] - L posterior neck pain [**11-27**]- attributed to trapezius spasm Social History: Retired art teacher with two masters degrees. He is also a professional painter. Alcohol-[**12-22**] drinks 4x per week Illicits- none Tobacco: none ADLS: Indep with dressing, ambulating, hygiene, eating, toileting IADLS: Indep with shopping, accounting, telephone use, food preparation Lives with: family Walks without cane/walker/crutch/wheelchair at baseliine No h/o fall within past year + Visual aides - Dentures - Hearing Aids Family History: Father died in early 70s with colon cancer, after developing diabetes in 60s. Mother died at 73 from "lung cancer" 15 years after mastectomy for breast cancer Paternal grandfather died in 40s from diabetes Brother, 9 years older than pt, died from colon cancer at 33 Sister, died of colon CA in her 50s Father died of colon CA in his 70s. Sister younger than pt was born when mother was 42, developed learning disability (? mild developmental disability), now lives independently Children, two, both alive and well. Physical Exam: VS: T=97.2 BP=151/97 HR=65 RR=14 O2 sat=96% on L NC GENERAL: WDWN, in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD appreciated CARDIAC: 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+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: On Admission: [**2162-7-24**] 05:10PM PT-12.1 PTT-24.5 INR(PT)-1.0 [**2162-7-24**] 05:10PM WBC-8.5 RBC-5.22 HGB-15.9 HCT-46.3 MCV-89 MCH-30.5 MCHC-34.4 RDW-13.0 [**2162-7-24**] 05:10PM PLT COUNT-212 [**2162-7-24**] 05:10PM TSH-2.7 [**2162-7-24**] 05:10PM GLUCOSE-107* UREA N-19 CREAT-1.4* SODIUM-143 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-30 ANION GAP-13 [**2162-7-24**] 05:10PM CALCIUM-9.5 PHOSPHATE-4.5 MAGNESIUM-2.2 [**2162-7-24**] 05:10PM cTropnT-0.12* [**2162-7-24**] 05:10PM CK-MB-5 [**2162-7-24**] 05:10PM ALT(SGPT)-88* AST(SGOT)-44* LD(LDH)-223 CK(CPK)-152 ALK PHOS-66 [**2162-7-24**] 11:20PM CK-MB-5 cTropnT-0.18* [**2162-7-24**] 11:20PM CK(CPK)-139 On Discharge: [**2162-7-30**] 07:40AM BLOOD WBC-8.5 RBC-5.12 Hgb-15.6 Hct-46.8 MCV-91 MCH-30.5 MCHC-33.4 RDW-13.0 Plt Ct-193 [**2162-7-30**] 07:40AM BLOOD Plt Ct-193 [**2162-7-30**] 07:40AM BLOOD Glucose-175* UreaN-17 Creat-1.4* Na-140 K-4.1 Cl-103 HCO3-25 AnGap-16 [**2162-7-30**] 07:40AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0 . EKG [**2162-7-24**] 16:47: NSR @ 80bpm, no ectopy, normal PR and QRS intervals, no hypertrophy, LAD (-60 deg), qR in I/aVL and rS in II/III/aVF c/w LAFB. No QT prolongation. . TELEMETRY [**2162-7-24**] 20:28-20:29: sustained monomorphic regular wide-complex tachycardia @ 225 bpm -> NSR @ 100 bpm with ocassional PVC's . 2D-ECHOCARDIOGRAM [**2162-7-19**]: 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 regional/global systolic function are normal (LVEF >55%). There is no left ventricular outflow obstruction at rest or with Valsalva. There is no ventricular septal defect. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are elongated. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Chest XRAY [**2162-7-24**]: FINDINGS: A single bedside frontal chest radiograph shows opacity laterally at left lung base, consistent with atelectasis or scar. Cardiomediastinal and hilar contours are normal. Included osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary abnormality. . Cardiac MRI [**2162-7-28**]: Impression: 1. Normal left ventricular cavity size with mild global hypokinesis and akinesis of the basal inferolateral wall. The LVEF was mildly depressed at 49%. The effective forward LVEF was moderately depressed at 38%. Possible focal hyperenhancement of the basal inferolateral wall consistent with probable prior myocardial scarring/infarction. 2. Normal right ventricular cavity size and systolic function. The RVEF was normal at 47%. 3. Moderate mitral regurgitation. 4. The indexed diameter of the ascending was normal with a mildly dilated descending thoracic aorta. The main pulmonary artery diameter index was normal. Brief Hospital Course: . # RHYTHM: Patient presented with symptomatic wide-complex tachycardia concerning for monomorphic ventricular tachycardia. DCCV to NSR shortly after admission to CCU, patient was bolused and started on amiodarone gtt. EKG changes were suggestive of triggered v-tach from focus near LVOT. . Patient received EP study on [**2162-7-27**] that was unsuccessful during which patient went into polymorphic v-tach and v-fib and was shocked to NSR. EP study was unable to identify aberrant focus responsible for the triggered v-tach seen clinically. Prior to the study, amiodarone was discontinued, and lidocaine gtt was available but not required. Post-procedure, patient was maintained on sotalol 80 mg [**Hospital1 **] in place of metoprolol. EKG after each sotalol dose did not show any QT prolongation. On [**2162-7-29**], patient had placement of [**Company 2267**] Telogen 100 dual-chamber ICD DDI 60. Upon discharge on [**2162-7-30**], Sotalol was increased to 120 mg [**Hospital1 **], and patient is to follow up in [**Hospital **] clinic in 1 week. Pt was also given a two day course of Cephalexin to be completed upon discharge. . # CORONARIES: No known CAD with recent lipid panel in [**12-28**] showing total chol 217, LDL 146. Troponin-T was mildly elevated at admission (0.12) and continued to be above normal limits, likely due to DCCV. He was started on aspirin 81 mg daily. Cardiac catheterization was not felt to be indicated. . # PUMP: No evidence of systolic or diastolic heart failure on history and exam. Normal systolic function on last echo on [**2162-7-19**] (LVEF>55%). Results of cardiac MRI obtained on [**2162-7-28**] to evaluate for scarring showed mild global hypokinesis and akinesis of the basal inferolateral wall. LVEF was mildly depressed at 49% and effective forward LVEF was moderately depressed at 38%. Possible focal hyperenhancement of the basal inferolateral wall consistent with probable prior myocardial scarring/infarction. . # HYPERTENSION: Systolic BP remained around 130s-140s. Patient was started on lisinopril 5mg daily for hypertension, given low effective LVEF and chronic renal insufficiency. . # CHRONIC RENAL INSUFFICIENCY: creatinine slightly elevated at 1.3-1.4 from documented baseline of 1.2. Chronic renal insufficiency was thought to be secondary to hypertension with acute component of mild dehydration. IVF hydration was given initially. Did not have any electrolyte abnormalities. . # ANXIETY: Patient received Ativan prn for anxiety and Valium prior to cardiac MRI study due to claustrophobia during prior MRI studies. . # GOUT: Indomethacin was given for acute flare-up of gout in right great toe. . By Hospital day #7, ([**2162-7-30**]), the Pt was asymptomatic, hemodynamically stable, afebrile and doing well. The Pt was discharged to home on the medications described above, with stable vital signs, in good condition. Medications on Admission: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Astelin 137 mcg Aerosol, Spray Sig: [**11-20**] puff Nasal twice a day as needed for allergy symptoms. 3. Ibuprofen 200 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 4. Indomethacin 75 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily) as needed for for toe pain: Discontinue when pain resolved. Disp:*20 Capsule, Sustained Release(s)* Refills:*0* 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days. Disp:*8 Capsule(s)* Refills:*0* 7. Outpatient Lab Work Please check Chem-7 on Tuesday [**8-3**] and call results to [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 15347**]. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Ventricular tachycardia Gastroesophageal Reflux Hypertension Acute on Chronic Kidney Disease Discharge Condition: stable Discharge Instructions: You had ventricular tachycardia that caused you to pass out. We were unable to fix the source of the ventricular tachycardia so we placed an internal defibrillator and started you on Sotolol to prevent the irregular heart rhythm. You will be seen in the device clinic in 1 week to check your incision site and the ICD function. Until that time, do not get the ICD dressing wet or remove the dressing. No lifting more than 10 pounds with your left arm for one week, no raising your left arm over your head for 6 weeks. No swimming or tennis. Please refer to the d/c instructions given to you. Please drink plenty of fluids after you are home. Call Dr. [**First Name (STitle) **] if your dizziness worsens or if you feel you cannot walk safely. Medication changes: 1. Start Cephalexin, an antibiotic to prevent infection at the ICD site 2. Start Sotolol: to prevent further episodes of ventricular tachycardia 3. Start a baby aspirin: to prevent blood clots 4. Start Lisinopril: please wait until after you see Dr. [**First Name (STitle) **] to start this medicine . Please call Dr.[**Name (NI) 1565**] office if the ICD fires, if you have fevers, swelling bleeding at the ICD site, if you have chest pain or trouble breathing or if you pass out. Do not drive for 6 months, you cn speak with Dr. [**Last Name (STitle) **] about this at your next appt. Followup Instructions: Cardiology: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2162-8-4**] 11:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**9-17**] at 3:30pm Dermatology: Provider: [**Name10 (NameIs) 2975**] [**Name8 (MD) 2976**], MD Phone:[**Telephone/Fax (1) 2309**] Date/Time:[**2162-10-1**] 8:45 Primary Care: Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2163-1-11**] 2:20. Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2162-8-4**] 10:00 Completed by:[**2162-8-2**]

[ "403.90", "272.4", "530.81", "427.41", "427.1", "585.9", "593.9", "780.2", "274.9" ]

icd9cm

[ [ [] ] ]

[ "37.26", "37.94", "99.62" ]

icd9pcs

[ [ [] ] ]

13315, 13321

9054, 11939

348, 412

13458, 13467

5969, 5969

14865, 15522

4659, 5177

12289, 13292

13342, 13437

11965, 12266

13491, 14234

5192, 5950

3203, 3284

6663, 9031

14254, 14842

275, 310

440, 3108

5983, 6649

3315, 4192

3130, 3182

4208, 4643

78,506

130,921

12289

Discharge summary

report

Admission Date: [**2133-12-31**] Discharge Date: [**2134-1-7**] Date of Birth: [**2072-4-25**] Sex: F Service: PLASTIC Allergies: Lisinopril / Zyrtec Attending:[**First Name3 (LF) 5667**] Chief Complaint: Fever and purulent drainage from the mouth 3 weeks s/p radial forearm free flap for reconstruction of SCC of the floor of the mouth and anterior mandible Major Surgical or Invasive Procedure: 6 days in ICU for frequent monitoring, not intubated History of Present Illness: Mrs. [**Known lastname 8182**] is a 61 y.o. patient known to the plastic surgery service for reconstruction of a floor of the mouth defect following segmental mandibule resection of SCC. The mandible was reconstructed with a bar. In the initial post-op period she had exposure of hardware and she was taken back to the OR for advancement of the radial free flap to cover the hardware exposure. During this treatment she has both a trach and a peg placed. She is now approximately two months status post composite resection of a Left anterior floor of mouth carcinoma. She is in the [**Hospital6 310**]. Nutrition is by PEG tube feeds with PO puree diet supplementation. Earlier tofday she developed a fever to 102+ and a CBC was drawn demonstrating a WBC of 29.1. She was also noted to have tachycardia and is now transferred to [**Hospital1 18**] for further management. On arrival she has no specific complaints other than "weakness." She does feel her heart racing but denies CP/SOB. She has also noted purulent drainage coming from her mouth from below the free flap. Her temp on arrival here is 102.1 F and HR is 150. The ER is performing a fever workup including CXR, blood/urine Cxs, plain films, and maxillofacial CT scan. She denies CP/SOB/N/V, no weight loss, no visual changes, no numbness/tingling/weakness, no diarrhea/constipation, no dizziness/lightheadedness. Past Medical History: Diabetes Thyroid disease Squamous cell carcinoma High blood pressure Floor of mouth resection in [**2130**] with multiple biopsies Reconstruction of floor of mouth with left radial forearm free flap [**11-11**] following SCC excision placement of open gastrostomy tube Trach now on Passy-muir valve local flap advancement of mouth Social History: She does not smoke. She does not drink. She works as a guidance counselor and coordinator for [**Location 27256**] High School. Family History: Significant for diabetes and depression. Physical Exam: VS: 102.1 142 158/84 100% on 28% TC Gen: NAD, AAOx3 CV: Tachy, RR, systolic murmur Resp: CTAB, no wheezes or crackles Head & Neck: Swelling over left lower cheek with blanching erythema/warmth - patient stated this swelling is normal since post-op, but notes the redness is new. Flap is viable with incisions c/d/i except at the anterior base of the flap where it is pulled away from the gingiva and there is exposed hardware from the mandibular reinforcement. Abd: Soft, nontender, nondistended, +BS, obese Ext: Warm, distal pulses palpable bilaterally, psoriatic lesions on LE. Left forearm radial forearm flap site C/D/I. Pertinent Results: [**2133-12-31**] 03:32PM WBC-15.0* RBC-3.50* HGB-11.0* HCT-32.6* MCV-93 MCH-31.5 MCHC-33.8 RDW-14.8 [**2133-12-31**] 03:32PM PLT COUNT-180 [**2133-12-31**] 11:57AM URINE HOURS-RANDOM CREAT-50 SODIUM-114 [**2133-12-31**] 03:40AM GLUCOSE-244* UREA N-13 CREAT-0.8 SODIUM-130* POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-23 ANION GAP-13 [**2133-12-31**] 03:40AM PT-14.2* PTT-35.7* INR(PT)-1.2* [**2133-12-31**] 03:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2133-12-31**] 03:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2133-12-31**] 03:30AM URINE RBC-[**4-8**]* WBC-[**4-8**] BACTERIA-NONE YEAST-NONE EPI-0 [**2133-12-31**] 02:30AM WBC-28.9*# RBC-3.85* HGB-12.4 HCT-34.8* MCV-90 MCH-32.1* MCHC-35.5* RDW-14.3 [**2133-12-31**] 02:30AM NEUTS-91.0* LYMPHS-6.0* MONOS-2.5 EOS-0.3 BASOS-0.2 [**2133-12-31**] 02:30AM PLT COUNT-282 [**2133-12-31**] 02:28AM COMMENTS-GREEN TOP [**2133-12-31**] 02:28AM LACTATE-2.4* [**2134-1-6**] 06:27AM BLOOD WBC-11.8* RBC-3.40* Hgb-10.8* Hct-31.4* MCV-92 MCH-31.8 MCHC-34.5 RDW-15.4 Plt Ct-338 [**2134-1-6**] 06:27AM BLOOD Glucose-164* UreaN-15 Creat-0.7 Na-138 K-4.4 Cl-102 HCO3-26 AnGap-14 [**2134-1-6**] 06:27AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.1 [**2133-12-31**]: CT ORBITS, SELLA & IAC W/ CONTRAST FINDINGS: Patient is a status post flap reconstruction of the floor of the mouth and the anterior mandible. The mandible has seen reconstructed with a metallic bar-like device. The anatomy of the oral cavity is markedly distorted, with focal areas of fatty protuberance in the floor of the mouth and in the left buccal region. There is diffuse enlargement and heterogeneity of the left parotid gland. Multiple enhancing nodes are noted inside the enlarged left parotid gland, the largest of which measures 9 mm in the short axis. There is diffuse swelling of the tongue and the floor of the mouth with diffuse fatty stranding of the soft tissues in the submental and submandibular spaces, most likely related to the recent operation. There is asymmetry in the appearance of the tongue, with elevation of the left side. Hyperdense curvilinear structures projecting inferior to the left parotid gland are most likely post surgical material. No definite abscess cavity is visualized. IMPRESSION: 1. No abscess. 2. Left parotid gland enlargement. A possible cause is obstruction of the parotid duct ([**Last Name (un) 38362**] duct) due to diffuse swelling in the left buccal space. No radio-opaque calculus is seen. 3. Distorted anatomy of the floor of the mouth and the lower lip due to extensive reconstruction procedure. Status post reconstruction of the mandible with a metallic bar-like device. ADDENDUM AT ATTENDING REVIEW: There is limited imaging of the proximal left internal jugular vein, perhaps due to contiguous soft tissue swelling. There are multiple prominent lymph nodes in the posterior cervical triangles, more evident on the left. These could be either inflammatory or neoplastic. The fatty stranding noted above could represent either post-operative edema or cellulitis- correlate clinically. [**2134-1-4**]: TTE The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No valvular pathology or pathologic flow identified. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. CLINICAL IMPLICATIONS: Based on [**2132**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: The patient was stabilized in the ICU for 6 days, while maintaining NPO status and receiving mouth care per ENT recs. A CT of the mandible did not show a large fluid collection, so washout or debridement was not indicated during this admission. ID was consulted for recs, and vancomycin and cefepime were ultimately used for MRSA + cultures. She was transferred to the floor and remained afebrile. Her swelling and erythema improved somehwat throughout her hospital course. She was transferred back to her Rehab NH in good condition with resolving infected hardware of mandible. She will require 8 more days of IV antibiotics (vanc and cefepime), but if the infection is not fully resolved, then the duration of antibiotics can be extended. Medications on Admission: Puree Diabetic Diet Promote with Fiber @ 75 cc/hr 10 hrs daily (7PM to 5AM) Free water 240 cc [**Hospital1 **] Lopressor 25 mg PGT [**Hospital1 **] MVI liquid 5 cc QD Senokot syrup 10 cc QD Zocor 40 mg PGT QPM Dilaudid 2 mg PGT Q4 hrs PRN ASA 162 mg PGT QD Pepcid 20 g PGT [**Hospital1 **] Flonase 1 spray each nostril QD Glyburide 5 mg PGT QAM Heparin 5000 units SQ TID Avapro 150 mg PGT QDay Levothyroxine 100 mg PGT QD Reglan 10 mg PGT Q6 hrs Fingerstick QID w/SSI Zofran 4 mg Q8 PRN Ativan 0.5 mg PGT Q4 hrs Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 8 days. Disp:*16 gram* Refills:*0* 2. Cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q8H (every 8 hours) for 8 days. Disp:*48 gram* Refills:*0* 3. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Disp:*qs ML(s)* Refills:*0* 4. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) mL Injection PRN (as needed) as needed for line flush. Disp:*qs mL* Refills:*0* 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane QID (4 times a day) as needed for exposed hardware. Disp:*1 bottle* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): per GT. Disp:*60 Tablet(s)* Refills:*2* 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): per GT. Disp:*60 Tablet(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: per GT. 9. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily): per GT. 10. Acetaminophen 650 mg Suppository Sig: One (1) Rectal every 4-6 hours as needed for fever or pain. 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO q PM: per GT. 12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain: per GT. 13. Ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea: per GT. 14. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): per GT. 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. Disp:*1 container* Refills:*0* 16. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical DAILY (Daily) as needed for psoriasis. Disp:*1 container* Refills:*0* 17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for psoriasis. Disp:*1 container* Refills:*0* 18. Avapro 150 mg Tablet Sig: One (1) Tablet PO once a day: per GT. 19. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily): per GT. 20. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO QIDACHS (4 times a day (before meals and at bedtime)): per GT. 21. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 22. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety: per GT. 23. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day as needed for constipation. 24. Insulin Regular Human 300 unit/3 mL Insulin Pen Subcutaneous Discharge Disposition: Extended Care Facility: [**Hospital 5279**] Health Care Discharge Diagnosis: Surgical wound infection, hardware of mouth and mandible Discharge Condition: Good, VSS, voiding, pain well controlled Discharge Instructions: DO NOT EAT OR DRINK until you follow up with the Plastic Surgery clinic next week. This is very important to resolve your infection. You had an infection of your mouth in the area of your past surgery. It is now resolving. Please take all of your medications as indicated. You will need IV antibiotics for the next 8 days. If your infection is not improving, then antibiotics can be extended for a longer duration. Return to the Emergency Department if: *You are vomiting. *You are having shaking chills, fever greater than 101.5 (F) or 38 (C) degrees, increased redness, swelling or discharge from the surgical site, chest pain, shortness of breath or anything else that is troubling you. *Any serious change in your symptoms or any new symptoms that concern you. * Please take all your medications as prescribed. *Do not drive or operate heavy machinery while taking narcotic pain medications (Percocet, Vicodin, oxycodone, hydrocodone, Dilaudid, etc). Followup Instructions: Please keep the following appointment with Dr. [**First Name (STitle) **]. Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD Phone:[**Telephone/Fax (1) 5343**] Date/Time:[**2134-1-12**] 2:00 Completed by:[**2134-1-7**]

[ "528.3", "998.59", "527.2", "V44.0", "V10.02", "250.00", "244.9", "041.89", "790.7", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

11357, 11415

7476, 8218

433, 487

11516, 11558

3127, 7193

12564, 12826

2414, 2456

8780, 11334

11436, 11495

8244, 8757

11582, 12541

2471, 3108

7216, 7453

240, 395

515, 1895

1917, 2250

2266, 2398

10,796

119,533

22161

Discharge summary

report

Admission Date: [**2166-10-8**] Discharge Date: [**2166-11-18**] Date of Birth: [**2110-2-13**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 2969**] Chief Complaint: left uper lobe nodule Major Surgical or Invasive Procedure: [**2166-10-8**]: 1. Bronchoscopy. 2. Cervical mediastinoscopy. 3. Left thoracotomy with upper lobe bisegmentectomy and lower lobe bullectomy [**2166-10-17**]: 1. Tracheostomy. 2. Bronchoscopy with aspiration of secretions. 3. Laparotomy with tube gastrostomy and feeding jejunostomy *Patient also underwent multiple (greater than 10) flexible bedside bronchoscopies for therapeutic aspiration of retained secretions. History of Present Illness: Mr. [**Known lastname 6330**] is a 56-year-old gentleman with greater than 100 pack-year smoking history and severe emphysema with an enlarging spiculated PET positive lesion on the left upper lobe. He has severe protein calorie malnutrition and severe emphysema. He has completed pulmonary rehab and gained several pounds suggesting positive nitrogen balance. A remote metastatic survey was unremarkable and I recommended mediastinal staging and, if node-negative, a segmental anatomic resection as a reasonable compromise for what we suspected was a carcinoma but also considering his severe underlying emphysema. He had chronic total atelectasis of the left lower lobe with a bronchoscopy in the past excluding an endobronchial lesion so we hoped to recruit some of this. He agreed to proceed. Past Medical History: seizures, ETOH abuse, GERD, SCC skin, pulmonary adenocarcinoma Social History: Lives alone 100 pk year smoking history and Etoh abuse. Family History: non contributory Physical Exam: General: frail cachetic 56 yr old male looking signiifcantly older than stated years. resp: lungs coarse bilat cor: RRR S1, S2. Ef >55% abd: soft, NT, ND, +BS. J- tube in place. +bowel function. extrem: no C/C/E Neuro: A+OX3 Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2166-11-18**] 02:30AM 15.2* 3.09* 9.1* 28.2* 91 29.5 32.3 14.1 600* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2166-11-9**] 04:24AM 77* 0 5* 9 7* 2 0 0 0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Target Burr [**2166-11-9**] 04:24AM 3+ NORMAL NORMAL NORMAL NORMAL NORMAL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**Name (NI) 11951**] [**2166-11-18**] 02:30AM 600* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2166-11-18**] 02:30AM 114* 12 0.4* 136 4.2 98 34*1 8 Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calHCO3 Base XS AADO2 REQ O2 Intubat Vent Comment [**2166-11-18**] 04:48AM ART 50 54*1 53* 7.45 38* 10 TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES POSITIVE COMMENT: POSITIVE PF4 HEPARIN ANTIBODY BY [**Doctor First Name **] DR. [**First Name (STitle) **] [**Doctor Last Name 96**] NOTIFIED [**2166-10-20**] @ 12:55PM Complete report on file in the laboratory. [**Hospital 93**] MEDICAL CONDITION: 56 year old man s/p LUL lobectomy with 1 left chest tube. s/p bronchoscopy REASON FOR THIS EXAMINATION: eval LLL collapse, right upper lobe infiltrate PORTABLE CHEST: [**2166-11-17**] COMPARISON: [**2166-11-16**]. INDICATION: Status post left upper lobectomy. Evaluate left lower lobe collapse and right upper lobe infiltrate. A tracheostomy tube remains in satisfactory position, but the cuff is over-distended. A left-sided chest tube and left PICC line remain in place, not significantly changed. There remains collapse of the majority of the remaining portion of the left lung. A moderate amount of pleural fluid is present in the left hemithorax, and there is a persistent lucency at the left apex, attributed to a hydropneumothorax. Additional rounded lucencies are seen in the left mid lung zone region and may be due to areas of necrotizing lung parenchyma based on prior CT exam findings. Heterogeneous opacification persists throughout the right lung as well as a small-to-moderate right pleural effusion. As compared to the recent study, there has been slight interval increase in degree of opacification in the left hemithorax, which may be due to a combination of worsening atelectasis and increasing pleural effusion. There is otherwise no significant change since the recent study. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**] Approved: MON [**2166-11-17**] 10:22 AM Brief Hospital Course: Pt was taken to the OR on [**2166-10-8**] for bronch, med, left upper lobectomy for lung nodule. Or course was uneventful. Post op pt was on a small amt of neo for hypotension d/t epidural and weaned and extubated successfully. Pt was having increased difficulty managing his sections in the successive post op days despite daily and [**Hospital1 **] bronchoscopy pul hygiene. Pt was intubated on post op day #5 ([**2166-10-13**]) and has remained intubted since that time. He underwent a trach and and j-tube on [**2166-10-17**]. ROS presently: Neuro: A+OX3. Pleasant and [**Doctor Last Name **]. Able to communicate his needs by mouthing words. RESP: His vent wean has been slow but progressive. Presently he is on CPAP 50%, % peep, 8 PSV, STV 350-400. ABG: 7.41- 59-54-39-9- which is his baseline. He has not been trailed w/ trach mask at this time. He has a left chest tube to water seal which is being treated as an empyema tube- draining ~ 420 cc serosang drainage. Completing Caspofungin on [**2166-11-23**] for yeast in sputum. Had Citrobacter in sputum which was treated. COR: RRR S1, S2. hemodynamically stable. ABD: Abd: soft, NT, ND, +BS. Passing stool. C-diff postive but being trated w/ flagyl which is to be completed on [**11-23**]. He is [**Last Name (un) 1815**] j-tube feedings Respalor 3/4 strength at 45cc/hr goal. Extrem: No C/C/ transient LE edema which is improving. Picc line placed for IVAB. Heme/ID: +HIT on lovenox for DVT prophylaxis. Medications on Admission: protonix 40', dilantin 300mg', ativan prn 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 Q4H (every 4 hours). 3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed. 7. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Phenytoin 100 mg/4 mL Suspension Sig: 75 mg PO BID (2 times a day). 9. Double Guard Cream Sig: One (1) Topical prn (). 10. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed. 11. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal PRN (as needed). 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO PRN (as needed) as needed for Mg<2. 14. Fondaparinux 5 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 16. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days: stop date [**11-23**]. 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 20. Magnesium Sulfate 2 gm / 100 ml NS IV PRN Mg<2 21. Calcium Gluconate 2 gm / 100 ml D5W IV PRN free Ca < 1.13 22. Potassium Chloride 20 mEq / 50 ml SW IV PRN K+ < 4.0 23. Caspofungin 50 mg IV Q24H d/c [**11-23**] 24. Pantoprazole 40 mg IV Q12H Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital Discharge Diagnosis: Left upper lobe lung cancer (pulmonary adenocarcinoma) seizures, Etoh abuse, GERD, SCC. +HIT Discharge Condition: Stable but ventilator dependent Discharge Instructions: Call Dr.[**Doctor Last Name 4738**] office if you have any questions regarding Mr. [**Known lastname 10793**] surgical management [**Telephone/Fax (1) 170**]. Please keep a daily record of chest tube output.Keep chest tube to water seal. Make sure valve is always in the open position - parallel to the tubing. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] on [**2166-12-2**] at 3pm at the [**Hospital Ward Name 23**] clinical center [**Location (un) **]. Please arrive 45 minutes prior to your appointment and report to [**Hospital Ward Name 23**] [**Location (un) **] for a chest XRAY. Completed by:[**2166-11-18**]

[ "280.0", "038.3", "162.3", "V10.02", "934.1", "518.0", "518.5", "262", "511.8", "995.92", "287.4", "510.9", "578.1", "512.1", "112.4", "780.39", "492.0", "E934.2" ]

icd9cm

[ [ [] ] ]

[ "43.19", "99.10", "96.05", "96.04", "96.6", "38.93", "46.39", "03.90", "96.72", "99.04", "31.1", "40.3", "32.29", "32.3", "33.24" ]

icd9pcs

[ [ [] ] ]

8225, 8296

4745, 6212

304, 724

8433, 8467

2006, 3231

8827, 9142

1728, 1746

6305, 8202

3268, 3343

8317, 8412

6239, 6282

8491, 8804

1761, 1987

243, 266

3372, 4722

754, 1553

1575, 1639

1655, 1712

3,184

153,245

16376

Discharge summary

report

Admission Date: [**2162-3-9**] Discharge Date: [**2162-3-18**] Date of Birth: [**2118-7-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: weakness, fatigue, inability to tolerate food/liquids Major Surgical or Invasive Procedure: Intubation History of Present Illness: 43 yo M with metastatic esophageal CA on adriamycin with malignant upper esophageal stricture at the cricopharyngeus requiring frequent dilatations, last [**2162-2-25**]. He presents today with complaints of feeling weakness everywhere and trouble swallowing with a lack of appetite. He feels like this usually when he's been requiring dilatations. He states he has also had loose stools for several days as well as hunger pain. He has lost about 10 pounds over the last few weeks and has fallen a couple of times because he feels so week. No fevers or chills. No sore throat. Does feel SOB with exertion at times. No cough. . ED course: thoracics evaluated patient in ED (all prior admissions were on thoracics service) and will follow as may need esophageal dilatation for stricture. He was given 3L NS in ED which made him feel a bit better. Past Medical History: 1. Metastatic esophageal cancer s/p esophageal dilitation - has metastatic paratracheal mass. -status post platinum and Taxol radiation neoadjuvant therapy in 02/[**2158**]. -Status post surgery in [**4-/2159**] - Three hole esophagectomy with post surgical para-esophageal hernia. -Status post recurrence in spring [**2159**], at which point he received additional radiation therapy with 5-FU and platinum. -Started on weekly cycles of irinotecan on [**2161-4-29**], and completed 2 cycles of this therapy and progressed. -Status post 2 cycles of Taxotere chemotherapy. This is cycle #3, week #4 of chemotherapy. -Status post 4 esophageal dilations. - started weekly adriamycin week dose #2on [**2162-3-3**]. 2. GERD Social History: lives on [**Location (un) **] with wife and two children Family History: non- contributory Physical Exam: 98.0, 112, 113/83, 18, 99% on RA GEN- cachetic appearing male lying in bed in NAD HEENT- EOMI, neck with several surgical scars CV- tachycardic, regular, no M CHEST- +inspiratory wheeze, o/w clear ABD- soft, NT/ND, +BS EXT- no edema Pertinent Results: Imaging: Chest x-rays showed increasing opacities in his bilateral lower lungs likely representing atelactasis or consolidation. Brief Hospital Course: 43 yo M with metastatic esophageal CA on chemo s/p multiple dilatations who presented with weakness/fatigue/decreased po's. On the medical floor he was noted to have increasing stridor and work of breathing and on [**3-13**] he was transferred to the [**Hospital Unit Name 153**] for elective intubation. # Respiratory distress: He was noted to have increasing respiratory distress and stridor on the floor and was transferred on [**3-13**] to the [**Hospital Unit Name 153**] for elective intubation. This required the assistance of both anesthesia and interventional pulmonary (IP) due to his high grade tracheal stenosis secondary to his paratracheal mass and his vocal cord paralysis. The initial plan was for him to have a tracheal stent placed by IP to relieve his tracheal stenosis as well as a J tube placement by thoracics surgery to provide him with nutrition. Multiple attempts were made to transfer him to the operating suite to have this procedure performed but with only minimal movement his O2 saturation fell precipitously and he was not felt stable enough to move to the operating room. In addition, he developed hypotension requring two pressor agents which also prevented him being transferred to the operating room. At best, a tracheal stent would have provided a temporizing solution to his tracheal stenosis and after multiple discusssions with his family and his oncology team, the decision was made to pursue comfort measures only. At this point, aggressive measures were stopped and he passed away on [**3-18**]. Medications on Admission: Docusate Sodium 150 mg/15 mL Liquid Sig: 10-15 cc PO BID 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Ranitidine HCl 150 mg Packet Sig: One (1) packet PO twice a day. 4. Albuterol prn 5. Compazine prn 6. Megace Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: 1. Metastatic esophageal cancer. 2. Tracheal stenosis secondary to paratracheal mass. Discharge Condition: Expired. Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] Completed by:[**2162-3-18**]

[ "V10.03", "530.81", "478.30", "519.1", "197.3", "276.51", "518.81", "285.22" ]

icd9cm

[ [ [] ] ]

[ "33.22", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

4438, 4447

2529, 4076

368, 380

4576, 4586

2375, 2506

4638, 4783

2087, 2106

4410, 4415

4468, 4555

4102, 4387

4610, 4615

2121, 2356

275, 330

408, 1255

1277, 1996

2012, 2071

31,026

156,636

7386

Discharge summary

report

Admission Date: [**2122-3-13**] Discharge Date: [**2122-3-17**] Date of Birth: [**2074-8-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: coffee ground emesis, DKA Major Surgical or Invasive Procedure: None History of Present Illness: 47yoF with history of IDDM, anemia, cri, presents with chief complaint of coffee ground emesis x1, admitted to MICU for presumptive DKA. Patient reports increasing fatigue, nausea, vomiting over the previous 3-4 days, then had one bout of small volume, coffee-ground emesis on day of admission. Patient was at [**Last Name (un) **] Diabetes Center on the day of admission, found to have elevated potassium and glucose, transferred to [**Hospital1 18**] ED. In [**Hospital1 18**] ED, vital signs stable, was guiac+. Glucose found to be >1000 and troponin 0.1, given 2L IVF, 10 units insulin with initiation of insulin gtt. EKG showed peaked t waves and question of ST-changes in V1 and V2. Patient was given kayexalate and calcium and bicarb. Cardiology was consulted in ED, felt EKG changes not ischemia, and believed EKG unchanged from prior. Pt given zofran and phenergan for nausea. No IV access attempted in R arm due to fistula preparation?. Patient reports compliance with his medications. Does admit to not checking his glucoses though over previous two days. Other ROS essentially unremarkable. Denies fevers, chills but admits to mild viral illness two days prior. Denies chest pain or shortness of breath that is out of the ordinary. Denies urinary problems and states that his urine has been without burning and maintains an adequate urine despite renal failure. Past Medical History: 1. anemia - likely chronic disease - receiving iron infusions. 2. IDDM - lantus 31 with iss. 3. HTN - on prinivil, and hyzaar. 4. Chronic renal insufficiency baseline Cr 3.0 - preparing for fistula, followed by Dr. [**Last Name (STitle) 27172**]. Social History: lives with his wife and 2 kids (15 and 17); no tob/IV drugs; occasional ETOH Family History: no early cardiac dz Physical Exam: PE: T 97 BP 165/78 HR 100 RR 16 100%RA Gen - NAD, A/Ox3, lying in bed, conversant, cooperative. HEENT - no conjunctival pallor, no scleral icterus appreciated, dry membranes, no posterior pharyngeal erythema appreciated. NECK - no posterior/anterior LAD, no JVD appreciated. R anterior cervical sq hematoma [**3-7**] attempted RIJ. CV: RRR, S1+S2+S3-S4-, no murmurs or rubs appreciated. LUNGS - CTAB, good air movement bilaterally, no crackles appreciated, no wheezes appreciated ABD - NABS, soft, non-tender, non-distended. No organomegaly appreciated. EXT - no lower extremity edema. 2+ palpable pulses bilaterally dorsalis pedis, posterior tibial, radial, ulnar, all 2+. SKIN: No rashes/lesions, ecchymoses. NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not do fundoscopy. Preserved sensation throughout. MSK 4+/5 bilaterally, upper extremities and lower extremities. 1+ reflexes L4 bilaterally. PSYCH - Listens and responds to questions appropriately Brief Hospital Course: A/P - 47yoM with history of diabetes mellitus type I, anemia, and chronic renal insufficiency presents with coffee ground emesis, found to be hyperglycemic and hyperkalemic with peaked T-wave, admitted to MICU for DKA treatment and rule-out MI. . # Diabetic ketoacidosis - presumed DKA and not elevated glucose levels, no ketones drawn in serum, no UA performed. Anion gap elevated at 25 and 24. Stable electrolytes, save initial hyperkalemia, treated in emergency room. Inciting [**Doctor Last Name 360**] unknown. Corrected serum sodium was 140. Potassium was elevated >6, treated with kayexalate, calcium, and bicarb. Improved with resolution of DKA. Patient was volume depleted and treated with fluid resuscitation. Anion gap was followed and improved on insulin drip. . # Hypertensive Urgency - The patient's blood pressure was elevated to 190's/100. Initially treated with IV hydralazine. He denied headache, visual changes, or any other new symptoms. There was no evidence of papilledema on fundoscopic exam. Antihypertensives were originally held in the MICU and restarted on [**3-15**]. Antihypertensives were titrated for good control with improvement in BP. . # Cardiovascular - question of EKG changes on initial evaluation. Cardiology was consulted and believed ECG unchanged and non-ischemic. Initial troponin 0.1 but CK's remained flat. Of note, last ECHO [**2119**] with EF 60%, but limited study since does not comment of wall function. . # Chronic kidney disease - has had history of chronic renal insufficiency, presumed [**3-7**] to diabetes and hypertension. Had recently been off his hyzaar treatment, given rising azotemia. R arm being preserved for fistula in long term. Creatinine stable at his baseline of 3.8 # Anemia - chronic issue as outpatient, thought likely secondary to progression of renal failure. Has been receiving iron infusions. Stable hct here. . # Coffee ground emesis - had one bout of coffee ground emesis prior to presentation, reportedly small volume. No history of UGIB. Hct stable upon admission. No nasogastric lavage done in ED. NG lavage in unit showed gastrocult+ fluid, fluid was clear with dark sediment, which showed no sediment on ns lavage. Pt guaiac+ on rectal exam. Will likely need GI scopes as outpatient to rule out subclinical bleed, possibly contributing to anemia vs. [**First Name8 (NamePattern2) 329**] [**Last Name (NamePattern1) **] tear secondary to vomiting. Treated with [**Hospital1 **] protonix. . Medications on Admission: 1. Atorvastatin 20 mg qhs 2. Aspirin 325 mg qd 3. Insulin - ISS at home 4. Losartan-Hydrochlorothiazide 50-12.5mg qd 5. Lorazepam 0.5 mg prn hiccups 6. Metoclopramide 5-10mg prn 7. lasix 40mg qd 8. iron 325 qd 9. procrit 10.prinivil 40mg 11.rocaltrol 12.lantus 31 13.iss Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Insulin Lispro 100 unit/mL Solution Sig: variable units Subcutaneous four times a day: take as instructed. 10. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous at bedtime. 11. Rocaltrol Oral 12. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: - Diabetic Ketoacidosis - Viral syndrome NOS - Abnormal WBC differential, resolved - Hypertensive urgency - possible hematemesis Secondary: - Diabetes mellitus type 1 - CKD Stage V - Anemia of CKD - Hyperlipidemia Discharge Condition: Good . fingerstick: 233 . anion gap: 8 . blood pressure: 160's/90's Discharge Instructions: You were admitted to the hospital with diabetic ketoacidosis. Your blood glucose level was 1000. Normal blood sugars are approximately 120. You were also found to have small amounts of blood in your vomit and stool, and we recommend follow-up with the gastrointestinal doctors. Your blood pressure was found to be high, up to 220/110. Normal blood pressure is around 120/80. We recommend that you follow-up with your doctor and get your blood pressure rechecked. Please call your doctor or return to the emergency room if you develop worrisome symptoms such as fevers, vomiting, dehydration, chest pain, shortness of breath, passing out, etc. Followup Instructions: PCP: [**Name10 (NameIs) **], [**Name11 (NameIs) **] [**Telephone/Fax (1) 250**] Please call and make an appointment within the next week. We recommend that you have your blood pressure rechecked, and consider adding another anti-hypertensive [**Doctor Last Name 360**]. Please followup with your nephrologist. Please talk with your PCP about whether or not you should followup with a gastroenterologist.

[ "585.4", "V58.67", "285.21", "008.8", "272.0", "403.90", "276.51", "250.13", "578.0", "V49.83", "276.8" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6968, 6974

3190, 5679

339, 346

7252, 7322

8018, 8427

2153, 2174

6001, 6945

6995, 6995

5705, 5978

7346, 7995

2189, 3167

274, 301

374, 1766

7014, 7231

1788, 2042

2058, 2137

76,261

146,784

8518

Discharge summary

report

Admission Date: [**2145-3-5**] Discharge Date: [**2145-3-13**] Date of Birth: [**2072-2-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 358**] Chief Complaint: Flank pain Major Surgical or Invasive Procedure: Retroperitoneal angiography transfusion 2 units packed red blood cells History of Present Illness: Patient is a 73 y/o man with h/o CAD, systolic heart dysfunction, and paroxysmal atrial fibrilation on warfarin who presents with left flank pain, ecchymosis, and swelling of two days duration. Pt was in his USOH until [**2-24**] when he developed a cough, without any associated fevers, rhinorrhea or sputum production. He attempted to use robitussin and multivitamins, as well as russian med (Biciptol)without improvement of barking cough. He then saw his PCP who prescribed [**Name Initial (PRE) **] 3 day course of Azithromycin without adjusting coumadin dose. On day 2 pt developed pain in his left lower quadrant. Pain worsened overnight and pt felt his side tensen and hurt significantly when moving. His wife called EMS this morning. . Of note, pt's coumadin dose had recently been repeatedly adjusted both up and down, with weekly following of INR. His last INR was 2 weeks ago and was therapeutic at 2.3 on regimen of 7.5mg twice a week and 5mg the remaining days. He denies any new medications other than azithromycin and denies any dietary changes. . In ED vital signs were T 97.5, BP 125/71, HR 74 RR 18 O2 sat 98% RA. He was noted to have echymosis over his flank and CT imaging was obtained. At radiology he complained of LH upon getting up from the stretcher. He denies LOC but did have some blurry vision with this. His symptoms resolved upon sitting. He denies associated CP, SOB during episode. Orthostatics were not done. He did not have any more such complaints. CT head was unremarkable and CT abdomen showed a hematoma extending from the spleen to the anterior musculature of the hip. His WBCs were 17 and a CXR and UA were negative. . ROS was otherwise negative. The pt denied recent unintended weight loss, fevers, night sweats, chills, headaches, dizziness or vertigo, changes in hearing or vision, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: 1. CAD status post MI in [**2136-3-24**], [**2136-8-24**], [**2137**]. He has known 3VD. He is status post PTCA of the left circ and OM1 in 4/00. He is status post PTCA stent of the ramus in 5/00. In [**8-/2136**] he had restent of the ramus and stent in the proximal LAD. In 11/00 he had PTCA of the left circ. His last stress was in [**11/2136**]. He exercised four minutes, 48% exercise capacity, no anginal symptoms, no EKG changes. He had a fixed defect in the anterior septal region. 2. History of obstructive jaundice status post ERCP in [**Month (only) 547**] [**2135**] with sphincterotomy and extraction of common bile duct stone. 3. Hypertension. 4. Hypercholesterolemia. 5. Depression. 6. Paroxysmal atrial fibrillation. 7. CVA: ischemic left middle cerebral artery territory infarct in his posterior frontal lobe with subsequent right hemiparesis. Suspected cardioembolic source. On long-term Coumadin. 8. Systolic HF, last EF 25% on TTE [**12-27**]. Social History: Came here from [**Country 532**] in [**2132**]. Russian speaking only. He lives with his wife. [**Name (NI) **] does not smoke tobacco or drink alcohol. Denies illicit drugs. Family History: Coronary artery disease Physical Exam: On arrival to the [**Hospital Unit Name 153**]: General: Russian speaking elderly male, awake, alert, NAD, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP Neck: supple, JVP not elevated, no carotid bruits appreciated Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: irregularly irregular, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, lg. echymosis over L flank, firm and tender to palpation, ND, normoactive bowel sounds. Extremities: No edema, 2+ radial, DP pulses b/l Skin: no rashes. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. Muscle strength 5/5 in upper and lower ext. Discharge: afebrile, VSS, Gen-- NAD HEENT -- unremarkable Heart -- regular Lungs -- clear Abd -- large left flank hematoma, dark purple (evolving) Ext -- no edema Pertinent Results: Labs on admission: [**2145-3-5**] 01:00AM BLOOD WBC-17.2*# RBC-4.35* Hgb-13.2* Hct-36.6* MCV-84 MCH-30.4 MCHC-36.1* RDW-14.4 Plt Ct-308 [**2145-3-5**] 01:03PM BLOOD Hct-29.2* [**2145-3-5**] 05:00PM BLOOD Hct-26.6* [**2145-3-5**] 10:24PM BLOOD Hct-26.2* [**2145-3-6**] 03:38AM BLOOD WBC-9.0 RBC-3.53* Hgb-10.3* Hct-28.8* MCV-82 MCH-29.3 MCHC-35.9* RDW-14.6 Plt Ct-182 [**2145-3-6**] 01:17PM BLOOD Hct-30.4* [**2145-3-7**] 07:50AM BLOOD WBC-11.2* RBC-3.65* Hgb-10.9* Hct-30.8* MCV-84 MCH-30.0 MCHC-35.6* RDW-14.2 Plt Ct-198 [**2145-3-7**] 09:00PM BLOOD Hct-29.9* [**2145-3-5**] 01:00AM BLOOD Neuts-87.3* Lymphs-8.9* Monos-3.6 Eos-0.1 Baso-0.1 [**2145-3-5**] 01:00AM BLOOD PT-49.5* PTT-36.5* INR(PT)-5.6* [**2145-3-5**] 01:03PM BLOOD PT-17.6* PTT-28.8 INR(PT)-1.6* [**2145-3-5**] 05:00PM BLOOD PT-15.5* PTT-27.0 INR(PT)-1.4* [**2145-3-6**] 03:38AM BLOOD PT-14.4* PTT-26.6 INR(PT)-1.3* [**2145-3-7**] 07:50AM BLOOD PT-13.6* PTT-26.6 INR(PT)-1.2* [**2145-3-5**] 01:00AM BLOOD Glucose-176* UreaN-16 Creat-1.0 Na-135 K-4.2 Cl-103 HCO3-24 AnGap-12 [**2145-3-7**] 07:50AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.9 [**2145-3-5**] 01:00AM BLOOD Digoxin-0.4* [**2145-3-5**] 04:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.029 [**2145-3-5**] 04:30AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2145-3-5**] 04:30AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 . Labs on discharge: [**2145-3-13**] 07:45AM BLOOD Hct-34.9* [**2145-3-12**] 07:10AM BLOOD Hct-33.0* [**2145-3-13**] 07:45AM BLOOD PT-21.7* PTT-32.3 INR(PT)-2.1* [**2145-3-12**] 07:10AM BLOOD PT-22.7* PTT-123.7* INR(PT)-2.2* [**2145-3-11**] 04:10PM BLOOD PT-21.4* PTT-75.5* INR(PT)-2.0* [**2145-3-11**] 06:35AM BLOOD PT-20.4* PTT-99.4* INR(PT)-1.9* [**2145-3-9**] 07:35AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-135 K-4.2 Cl-100 HCO3-28 AnGap-11 [**2145-3-9**] 07:35AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.2 . Microbiology: [**3-5**] MRSA screen - negative . Imaging: [**3-5**] Chest x-ray: IMPRESSION: No radiographic evidence for heart failure or pneumonia. . [**3-5**] Head CT: IMPRESSION: No acute intracranial process. . [**3-5**] CT chest/abd/pelvis: IMPRESSION: Large left retroperitoneal hematoma with active extravasation in the abdominal musculature. . [**3-5**] Retroperitoneal angiography: Left lumbar and iliac arteriograms did not show any actual bleeding sites or vascular abnormalities suggesting any bleeding sites. Some atherosclerosis changes were visualized in the descending aorta, the internal iliac and left obturator artery. . Brief Hospital Course: 73 year old man with history of HTN, CAD status post multiple stents, cardioembolic CVA and paroxysmal atrial fibrilation on warfarin who presents with left flank pain and found to have retroperitoneal hematoma. . 1.) Retroperitoneal hematoma: Occurred in the setting of supratherapeutic INR of 5.6. Appears to be spontaneous given lack of trauma to the area. Was recently started on azithromycin 3 days ago which could explain increased INR. Admission Hct 36, nadir at 26, however prior baseline was 42. Received 5mg Vit K in ED as well as 2 units FFP to reverse coagulopathty. Transfused 2 units p RBCs total during stay. Initially there was concern for continued hemorrhage, but angiogram did not show any culprit area. His Hct stabilized and given his high risk for stroke and need to continue coumadin as an outpatient, he underwent bridging from heparin to coumadin as an inpatient to assure no recurrence of bleeding. He received 5 days of coumadin 5 mg po qhs, then one dose of 6mg prior to discharge. He was instructed to take 5 mg po qhs and have his INR checked per usual coumadin clinic on Monday. . 2.) Dizziness: Occurred in setting of getting up from stretcher for CT scan. Describes symptoms of LH and blurry vision which in setting of standing sound most consistent with orthostatic hypotension. Orthostatics were not performed. Remained asymptomatic throughout remainder of hospital course. . 3.) CAD: Continued outpatient digoxin, lisinopril, statin. Aspirin held due to bleed, and was not restarted on discharge (as was therapeutic on coumadin, and given presentation) - can re-address with his cardiologist as an outpatient whether or not he should be on aspirin. His atenolol was initially held given bleed, but was restarted prior to discharge. . 4.) Paroxysmal afib: Given history of cardioembolic stroke, he should remain on coumadin as an outpatient. As above, underwent Heparin bridge with close monitoring to theraputic INR on coumadin prior to discharge. Rate control with digoxin and atenolol continued while in house. Dose of coumadin on discharge is.... He will follow up with his [**Hospital3 **] who was notified on discharge. . 5.) Non-sustained ventricular tachycardia: Had short runs of NSVT on telemetry, asymptomatic. Defer to outpatient follow up with his cardiologist. . 6.) Chronic systolic congestive heart failure: Has severely depressed EF on last TTE in [**2139**] of 25%. Appeared euvolemic and well-compensated throughout hospital course. Continued outpatient medications. . 7.) Communication: Wife [**Name (NI) **] [**Telephone/Fax (1) 29996**] (h) [**Telephone/Fax (1) 29997**] (c) Medications on Admission: atenolol 25 mg daily digoxin 125 mcg daily Aricept 30mg daily lisinopril 5 mg daily simvastatin 20 mg qhs warfarin 5 mg TuThSa, 7.5mg MWF Aspirin 81 mg daily Flexeril 10mg prn Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. retroperitoneal hemmorhage/hematoma, acute blood loss anemia 2. paroxysmal atrial fibrillation 3. history of stroke Discharge Condition: stable Discharge Instructions: You were hospitalized with blood loss into your retroperitoneum (posterior abdomen), likely due to the fact that your INR (which measures your coumadin) was elevated. You were treated with blood transfusions, then restarted on your coumadin. Please do not restart your aspirin until discussed with your primary physician or cardiologist. Please call your primary physician with concerns or questions, and return to the emergency department if you have symptoms of recurrent bleeding, lightheadedness, chest pain, confusion, fever, abdominal pain or any other alarming symptoms. Followup Instructions: Please go to your [**Hospital 2786**] clinic on monday morning to have your INR checked. Adjust your coumadin dosing and return for repeat INR checks as directed. Please follow up with this appointment: Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2145-3-22**] 10:20

[ "401.9", "790.92", "272.0", "412", "V58.61", "427.1", "428.22", "414.01", "311", "427.31", "276.50", "428.0", "438.20", "729.92", "285.1", "568.81", "V45.82", "E934.2" ]

icd9cm

[ [ [] ] ]

[ "88.42", "88.47" ]

icd9pcs

[ [ [] ] ]

10766, 10772

7441, 10091

324, 397

10935, 10944

4844, 4849

11573, 11936

3844, 3869

10318, 10743

10793, 10914

10117, 10295

10968, 11550

3884, 4825

274, 286

6292, 6937

425, 2647

6946, 7418

4863, 6273

2669, 3635

3651, 3828

13,815

137,614

48536

Discharge summary

report

Admission Date: [**2160-9-5**] Discharge Date: [**2160-9-13**] Date of Birth: [**2098-11-19**] Sex: M Service: CT Surgery CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 61 year old male with a history of hypertension and diabetes mellitus, who presented to his primary care physician saying that he had been having substernal chest pain on exertion. This pain was alleviated with rest and lasted only a couple of minutes at a time. The patient was referred for a stress echocardiogram which was significant for global ST depressions of 4.5 mm after a 4.5 minute exercise test on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol. The patient was asymptomatic. His left ventricular ejection fraction at that time was 45% to 50%. The ST depressions lasted for 17 minutes and resolved. There was also hypokinesis of the distal half of the septum and anterior wall, distal third of the lateral and inferior wall and apex. The patient presented to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further workup. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Hypertension. 3. Hyperlipidemia. 4. Erectile dysfunction. 5. Dermatitis. 6. Asymptomatic hearing loss. PAST SURGICAL HISTORY: None. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o.q.d., multivitamins one p.o.q.d., atenolol 50 mg p.o.q.d., hydrochlorothiazide 25 mg p.o.q.d., glyburide 5 mg p.o.q.d., lisinopril 40 mg p.o.q.d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is married and works as a cook at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Club. He quit tobacco one year ago. FAMILY HISTORY: The patient has a brother who died of a myocardial infarction at age 37. PHYSICAL EXAMINATION: On physical examination, the patient was a thin appearing gentleman in no acute distress with a temperature of 96.5, heart rate 82, blood pressure 141/62, respiratory rate 20 and oxygen saturation 98% in room air. Neck: Supple, no lymphadenopathy, no bruits. Cardiovascular: Regular rate and rhythm, II/VI systolic ejection murmur at left lower sternal border. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Extremities: Warm without peripheral edema. LABORATORY DATA: Admission sodium was 137, potassium 3.7, chloride 95, bicarbonate 29, BUN 11, creatinine 0.9, white blood cell count 8.5, hematocrit 38.8, platelet count 305,000 and INR 1.2. Preoperative electrocardiogram showed sinus rhythm at a rate of 66 beats per minute with no acute ischemic changes. Echocardiogram on [**2160-9-2**] was as described above. HOSPITAL COURSE: The patient was admitted to the cardiology service and underwent cardiac catheterization. This was significant for left main coronary artery 80% mid and 90% distal stenosis, left anterior descending artery with mild disease, ramus with 85% stenosis, left circumflex with 90% stenosis and right coronary artery with 70% stenosis. There was mild global hypokinesis. The patient tolerated the procedure well and was evaluated by the cardiothoracic surgery team. The patient was taken directly to the Operating Room, where he underwent coronary artery bypass grafting times five. The grafts were left internal mammary artery to left anterior descending artery, saphenous vein graft to distal right coronary artery, posterior descending coronary artery sequential and left radial to obtuse marginal and diagonal one sequential. The patient tolerated the procedure well and was transferred to the Cardiothoracic Intensive Care Unit in stable condition on minimal pressor support and intubated. Postoperatively, the patient remained in normal sinus rhythm and was weaned off pressor support. He was placed on NTGs for the radiograph and was reversed from anesthetics. The patient was weaned to extubation without incident. The patient remained stable in his postoperative course, requiring minimal support. On postoperative day number two, the patient's chest tubes were removed and the patient was out of bed to a chair. He was started on Lasix, to which he responded appropriately. The patient continued to remain in sinus rhythm. He had an episode of sinus tachycardia with shortness of breath. An echocardiogram was performed, which ruled out a wall motion abnormality. The patient had a left ventricular ejection fraction of greater than 55%. There was trace aortic regurgitation and mild pulmonary artery systolic hypertension. The patient was diuresed more aggressively and his symptoms resolved. The patient was transferred to the floor on posterior day number four and, on posterior day number five, the patient had an episode of rapid atrial fibrillation. The patient was started on amiodarone and increased in beta blockade. The patient converted to sinus rhythm and remained in normal sinus rhythm for greater than 48 hours. The patient's wires were discontinued on postoperative day number seven. At that time, the patient again developed shortness of breath and he was found to be hypertensive with a systolic blood pressure in the 190s, and he had decreased breath sounds in the left lung field. The patient was diuresed with intravenous Lasix and was given intravenous hydralazine for afterload reduction and fluid removal. The patient's symptomatology resolved. The patient has remained stable. His Lasix dose has been increased. The patient has been stable for greater than 24 hours and is ready for discharge home. DISCHARGE FOLLOW-UP: The patient will follow up with Dr. [**Last Name (STitle) 1537**] in four weeks and will follow up with his primary care physician in two weeks. DISCHARGE DIAGNOSES: 1. Coronary artery bypass grafting status post coronary artery bypass grafting times five. 2. Postoperative atrial fibrillation. 3. Diabetes mellitus. 4. Hypertension. 5. Hyperlipidemia. 6. Erectile dysfunction. 7. Dermatitis. 8. Asymptomatic hearing loss. DISCHARGE MEDICATIONS: Lasix 40 mg p.o.q.d. times two weeks. Potassium chloride 40 mEq p.o.b.i.d. times two weeks. Amiodarone 400 mg p.o.q.d. Lopressor 100 mg p.o.b.i.d. Glyburide 5 mg p.o.q.d. Imdur 60 mg p.o.q.d. times three months. Aspirin 325 mg p.o.q.d. Colace 100 mg p.o.b.i.d. Percocet 5/325 mg one to two tablets p.o.q.4h.p.r.n. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is to be discharged to home. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2160-9-13**] 12:33 T: [**2160-9-21**] 11:41 JOB#: [**Job Number **]

[ "414.01", "401.9", "411.1", "427.31", "272.4", "997.1", "250.00", "E878.2", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "39.61", "36.14", "36.15", "88.72", "88.53", "42.23", "37.22" ]

icd9pcs

[ [ [] ] ]

1782, 1856

5806, 6072

6095, 6410

1381, 1601

2762, 5785

1347, 1354

1879, 2744

156, 169

198, 1162

1185, 1323

1618, 1765

6435, 6782

4,949

193,444

46413

Discharge summary

report

Admission Date: [**2198-11-1**] Discharge Date: [**2198-11-12**] Date of Birth: [**2144-5-29**] Sex: F Service: MEDICINE Allergies: Tetracycline Attending:[**First Name3 (LF) 1973**] Chief Complaint: Periorbital, B/L UE Edema, orthopnea, Pneumonia Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 54 yo F a history of atypical thrombotic microangiopathy/TTP and evolving chronic renal failure now on HD initiated on admission and LLL PNA with Pseudamonas in sputum and treated with Cefepime. Patient transfered from [**Hospital Unit Name 153**]. Pt reports that she has been steadily declining since [**10-10**]. She has had increased periorbital edema and bilateral upper ext edema, more significant on the LUE than RUE but the ultrasound only showed an old Left IJ thrombus. ICU was considering MRV but pt would like to be sedated for procedure and this was not felt safe to do that at that time. She has a RUE ucler growing out coag +staph- oxacillin sensitive/diptheroids. U/S showed no abcess and pt received vanco per transplant surgery recs. Upon further evaluation of wound by transplant surgery, this was not felt to be an active issue Past Medical History: Acute on Chronic Renal Failure, [**2198-8-4**], thought [**3-8**] Vancomycin Atypical Thrombotic Microangiopathy since [**2187**] CKD, baseline Cr 2.0-recent ARF with increaced Cr to 5.0 Steroid induced osteoporosis Obesity HTN Hep B and C (past IV drug use) h/o heart murmur L radius fracture, ([**7-10**]) Cataract surgery, L eye 2 mo ago, R eye 2 yrs ago Migraines Social History: Divorced, lives alone. Has two sisters and aunt for social support. Unemployed since [**2187**]. Has one daugher in [**Hospital1 1474**]. Smoking-40yr smoking hx-currently <1ppd, but formerly more. Prior IVDA, last used heroin 10 years ago. Currently on Methadone maintenance. Family History: Father died from unkown malignancy at age 78 Mother had uterine ca-died at age 81 Siblings in good health No FH of kidney or blood dz, no hx of heart disease Physical Exam: Vitals: 98.1 69 105/73 18 95% GEN: Obese woman sitting in chair, Breathing comfortably. AAOx3 HEENT: mild scleral icterus, PERRL, - periorbital edema CV: RRR, S1/S2, 3/6 systolic murmur LUNGS: feint b/l bibasilar crackles ABD:obese, + BS, non-tender EXT: [**3-9**]+ edema pitting to knee, chronic venous changes, warm with [**2-5**]+ DP pulses. L AVF graft c 2cm diameter ulcer next to it, grossly edematous on bilateral upper extremity Pertinent Results: [**2198-11-12**] 06:50AM BLOOD WBC-12.5* RBC-3.27* Hgb-8.4* Hct-25.9* MCV-79* MCH-25.6* MCHC-32.4 RDW-18.9* Plt Ct-424 [**2198-11-12**] 06:50AM BLOOD Glucose-69* UreaN-29* Creat-3.2* Na-137 K-3.4 Cl-101 HCO3-29 AnGap-10 [**2198-11-12**] 06:50AM BLOOD Glucose-69* UreaN-29* Creat-3.2* Na-137 K-3.4 Cl-101 HCO3-29 AnGap-10 [**2198-11-12**] 06:50AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.5* CXR: FINDINGS: Stent material is visualized in the course of the right subclavian and brachiocephalic veins. There is no focal consolidation or effusion. The mediastinal contours and pulmonary vascular markings are normal. The heart size is normal as well. Some previously seen atelectatic changes on the prior study in the right mid lung field have resolved Brief Hospital Course: Patient admitted to [**Hospital Unit Name 153**] with pseudomonal PNA, treated with course of cefepime. improved hypoxia. Pt developed podagra, and was given a course of steroids. She developed leukocytosis with 5% bands. This was felt to be due to RUE ucler growing out coag +staph- oxacillin sensitive/diptheroids at site of AV Graft. U/S showed no abcess and pt received vanco per transplant surgery recs. Upon further evaluation of wound by transplant surgery, this was not felt to be an active issue. With Renal failure, renal decided to restart hemodialysis (she had been on in the past, but had recently been off). Pt had fluid status improvement. Pt also started on Albuterol and atrovent with improvement in her pulmonary status. Pt seen by ID who felt that vancomycin during HD was sufficient. Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. Disp:*90 Tablet, Chewable(s)* Refills:*0* 3. Methadone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*1 MID* Refills:*3* 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours). Disp:*1 MDI* Refills:*2* 6. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 13. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) [**Numeric Identifier 961**] Injection QMOWEFR (Monday -Wednesday-[**Numeric Identifier 2974**]). 14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous QHD (each hemodialysis) for 14 days. Disp:*1 gram* Refills:*6* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Pseudomonal Pneumonia Podagra TTP with SVC/IJ Thrombus Wound Infection Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increase is greater than 3 lbs. Adhere to 2 gm/day sodium diet Fluid Restriction: You should have a screening mammogram as breast cancer screening is recommended for all women over the age of 45 years old. Please discuss this with your primary doctor. Followup Instructions: f/u Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to see him within the next 7-10 days ([**Telephone/Fax (1) 10248**] Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2198-11-29**] 2:30 f/u Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to see him within the next 7-10 days ([**Telephone/Fax (1) 10248**] Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2198-11-29**] 2:30 Hemodialysis at [**Location (un) **] [**Location (un) **] ([**State **], [**Location (un) **] [**Telephone/Fax (1) 5972**]) starting Tuesday [**2198-11-13**] @ 3pm

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icd9cm

[ [ [] ] ]

[ "38.93", "86.22", "39.95" ]

icd9pcs

[ [ [] ] ]

5747, 5805

3324, 4131

322, 337

5919, 5925

2559, 3301

6290, 7061

1922, 2081

4154, 5724

5826, 5898

5949, 6267

2096, 2540

235, 284

365, 1216

1238, 1607

1623, 1906

44,464

126,622

9314

Discharge summary

report

Admission Date: [**2193-6-16**] Discharge Date: [**2193-7-2**] Date of Birth: [**2123-3-6**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Levaquin / Lasix / Ranitidine Attending:[**First Name3 (LF) 5123**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 70F with CAD s/p CABG, s/p hepatorenal bypass for RAS presented with fevers and hypoglycemia. The pt reported she began experiencing UTI like symptoms, specfically dysuria, early this week. On Thursday she went to her PCP where she was prescribed Ciprofloxacin. Pt states she took doses on thursday night and twice on friday. She discontinued the medication on Saturday [**12-24**] to nausea. Pt reports that on Saturday PM, she noted fevers to 102F. Upon waking on the morning of admission, she felt shaky. Her daughter, who is a nurse, took her FS which was found to be 24. The pt subsequently was brought to the ED. The pt denies current dysuria or back pain. She denies any cough. She notes mild GERD like symptoms. No chest pain. Upon arrival to the ED 99.5 117/56 79 16 93%RA. While in the ED the pt spiked to 100.5F and at one point had BP of 89/41. Cr 2.6 from 1.6. No CVAT. Lactate initiately 2.3 which improved to 1 following 3L of NS. CEs negative x1. CXR unremarkable. CT Abd/Pelvis without signs of Pyelonephritis. The pt received 1 gm of Ceftriaxone. The pt also received GI Cocktail for mild GERD like symptoms. 1 PIV placed, 18G. Vitals prior to transfer to the floor were T100.5 HR 76 BP 135/53 RR 19 sats 95% on RA. EKG WNL. Past Medical History: # CAD s/p CABG X 4 ([**2184**]): Left internal mammary artery to Proximal LAD, reversed autogenous saphenous vein to second circumflex descending coronary arteries # CKD # RAS s/p Hepatorenal Bypass with [**Doctor Last Name 4726**]-Tex graft ([**2183**]) # PAD s/p aorta-bifemoral bypass graft ([**2170**]) s/p redo in [**2182**] # HTN # GERD # Depression # Gout Social History: No current tobacco. Long-time former smoker. No Etoh. Lives with daugher. Family History: Non-Contributory Physical Exam: Vitals - T: 100.6 HR 80 BP 133/54 RR 33 Sat 95/50% Face mask GENERAL: Pleasant, well appearing caucasian femail in NAD HEENT: MMM, Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI.OP clear. NECK: Supple, No LAD, No thyromegaly. CARDIAC: Distant Heart Sounds. Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP 12 cm LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: 1+ edema to ankles, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Pertinent Results: Labs on Admission: [**2193-6-16**] WBC-5.4 RBC-3.78* Hgb-11.8* Hct-34.2* MCV-90 RDW-13.1 Plt Ct-94*# Neuts-76.8* Lymphs-8.6* Monos-4.4 Eos-9.2* Baso-0.9 PT-13.1 PTT-27.2 INR(PT)-1.1 Glucose-139* UreaN-44* Creat-2.6*# Na-131* K-4.2 Cl-101 HCO3-16* AnGap-18 Calcium-8.7 Phos-3.0 Mg-1.5* Lactate-1.0 ALT-10 AST-16 CK(CPK)-35 AlkPhos-98 TotBili-0.3 Lipase-32 Labs on Discharge [**2193-7-2**]: WBC 5.2, Hgb 8.0, Hct 25.0, MCV 93, plt 226K 139 105 41 AGap=14 ------------< 100 4.3 24 1.9 Ca: 8.5 Mg: 2.0 P: 4.3 Other Labs Cardiac enzymes on [**7-31**], [**6-18**], [**6-19**], and [**6-20**] were all negative BNP on [**6-18**]: 16,773 BNP on [**7-1**]: 4,214 [**2193-6-19**] VitB12-288, MMA 282 [**2193-6-17**] Hapto-189, Fibrinogen 303 [**2193-6-18**] calTIBC-207* Ferritn-145 TRF-159* [**2193-6-18**] CRP-35.2*, ESR-8 [**2193-6-20**] SPEP negative, UPEP negative Micro: All cultures were negative, including: multiple blood cultures multiple urine cultures lyme serology Legionella urinary Ag CMV (Ab + viral load) EBV (IgG positive, IgM negative) influenza Cdiff Anaplasma IgG/IgM Aspergillus/galactomannan B-glucan Babesia Parvovirus (IgG + at 5.03, IgM negative) Strongyloides Other studies: [**2193-6-16**] EKG: Sinus rhythm. The P-R interval is prolonged. Left axis deviation. Non-specific intraventricular conduction delay. There is a late transition with tiny R waves in the anterior leads consistent with probable prior anterior myocardial infarction. Non-specific ST-T wave changes which may be related to left ventricular hypertrophy, although ischemia or myocardial infarction cannot be excluded. Compared to the previous tracing the P-R interval and the QRS duration are longer. [**2193-6-16**] CXR: The patient is status post median sternotomy and CABG. The cardiac silhouette is stable and remains mildly enlarged. The aorta is slightly tortuous with calcifications again demonstrated. Pulmonary vascularity is within normal limits. Lungs are clear. There is no pleural effusion or pneumothorax. The osseous structures are unremarkable. Several clips in the right upper quadrant and upper abdomen are redemonstrated. [**2193-6-16**] CT abd/pelvis w/o contrast: 1. No acute findings to explain patient's symptoms. 2. Left renal atrophy with severe atrophy of the posterior aspect of the right kidney, stable. 3. Status post aortobifemoral bypass graft, incompletely assessed on this non- IV contrast-enhanced study. [**2193-6-19**] CT chest w/o contrast: 1. Several foci of peribronchiolar consolidation, mostly dependent in location. The lower lobe findings are new compared to the abdomen/pelvic CT from three days ago. Rapid onset and distribution favor aspiration pneumonia as an etiology. 2. Mild pulmonary edema. 3. Enlarged mediastinal lymph nodes, most likely reactive. 4. Mild lower lobe bronchiectasis. 4. 5-mm perifissural nodule versus small amount of loculated fluid mimicking a nodule at the right lung base. Attention to this area on a follow up CT in 6 months may be considered, especially if there are risk factors for lung neoplasm. [**2193-6-19**] ECHO: Normal global and regional biventricular systolic function (LVEF >55%). No diastolic dysfunction, pulmonary hypertension or significant valvular disease seen. No evidence of intra-cardiac shunt. [**2193-6-28**] CT chest noncontrast: 1. Resolution of right lung dependent consolidation. 2. New nonspecific, widely spread patchy multifocal ground-glass and several consolidative opacities worrisome for a new infectious process. Eosinophilic pneumonia is also possible considering recently provided history of eosinophilia. The peripheral distribution of several of these small consolidations also raises the possibility of embolic disease in the appropriate setting. 3. Slight interval increase in mediastinal lymphadenopathy, likely reactive. 4. Unchanged lower lobe mild bronchiectasis. 5. 5 mm perifissural nodule versus small amount of loculated fluid described in the previous report persists. Consideration of a followup chest CT in six months is again recommended. 6. Mild increase in size of bilateral small pleural effusions without pulmonary evidence for cardiogenic edema. [**2193-6-29**] BILATERAL LENIs: 1. No evidence of DVT. 2. Possible pseudoaneurysm in the left groin. Recommend non-emergent vascular ultrasound for further evaluation. [**2193-7-2**]: FEMORAL VASCULAR U/S: Left groin pseudoaneurysm. [**2193-7-2**] pMIBI: No significant ST segment changes over baseline and no anginal type symptoms. Nuclear portion showed: 1. Severe moderate-sized reversible perfusion defect involving the distal anterior wall, apex, and distal inferior left ventricular wall. 2. Normal left ventricular size and systolic function, LVEF=57%. Brief Hospital Course: This is a 70 year old female with a history of CAD s/p CABG, s/p hepatorenal bypass for RAS presenting with fever, angina, and hypoxia. # Hypoxic episodes: Patient had repeated episodes of hypoxia, initially associated with chest pain throughout the first 7 days of her hospital course. She triggered three times for this chest pain and hypoxia, cards consult felt symptoms were not ACS and instead secondary to demand ischemia in the setting of infection. Both chest pain and hypoxia were imrpoved with NGL initially, however, hypoxia worsened to the point of requiring NRB with sats of 93%. The patient was transferred to the ICU for monitoring. CXR did not show any pulmonary edema. There was no identifiable source of infection, but CT Chest showed evidence of RLL PNA, possible aspiration. In the ICU, she was started on Ceftriaxone and Azithromycin and her O2 sats improved. She was transferred back to the floor saturating 94% on 4L NC. BNP was 16,000. On the floor, she continued to experience episodes of chest pain with transient worsening of hypoxia that resolved with NGL and morphine and increased oxygen. She required 5L NC and 50% by facemask for the week after transfer from the unit. Given her elevated BNP, she was diuresed with ethacrynic acid with good results. With diuresis, her chest pain episodes resolved. She was aggressively diuresed approximately 5 or 6L and completed a 10-day course of CTX/Azithromycin/Clindamycin for ? aspiration pneumonia. Her O2 requirement was eventually weaned to RA. Just prior to her weaning, repeat CT Chest showed some peripheral ground glass opacities in all lung fields bilaterally. Pulmonolgy was consulted and felt they were likely not of infectious eitology, but were perhaps due to residual edema. No specific treatment was initiated for this. On discharge the patient was breathing comfortably on RA with O2 sats > 91%. She had no evidence of desaturation when ambulating. # Anginal symptoms: Patient started experiencing chest pain shortly after admission. The pain was described as pressure on her chest, always preceded by jaw pain, and radiating to her back. Occasionally the pain radiated into the left arm. These episodes were associated with hypoxia, but it was often difficult to determine if the chest pain preceded the hypoxia or was due to the hypoxia. Her pain was initially treated with SL NGL, morphine, and oxygen. Cardiac enzymes were repeatedly negative. She was continued on aspirin, beta-blocker, statin, and imdur. CXR were initially normal but then began to show volume overload. Her EKG was unchanged on multiple occasions, though was difficult to interpret due to underlying conduction abnormalities. Cardiology was consulted and felt that her chest pain was most likely [**12-24**] demand ischemia in setting of fever and infection. Her chest pain continued on a daily basis. Imdur was increased to 90 mg PO qhs. After this change and with diuresis, her anginal symptoms resolved. Cardiology considered cardica catheterization, but held off due to residual renal dysfunction and improvement of her symptoms with diuresis. When she had stabilized, she underwent a P-MIBI which showed severe moderate-sized reversible perfusion defect involving the distal anterior wall, apex, and distal inferior left ventricular wall with normal left ventricular size and systolic function, LVEF=57%. Cardiology was consulted after this finding and felt that this could be medically managed for now, until her renal failure stabilized. She was continued on her aspirin, b-blocker, statin and imdur and was discharged to follow-up with cardiology. # Pneumonia: On admission Mrs. [**Known lastname 31866**] was initially symptom free from a pulmonary standpoint. However, on the day after admission, she began to have hypoxic episodes with saturations down to 80%. CXR on admission was clear, repeat CXR showed possible RLL pneumonia. She was started on Ceftriaxone. On day 5 of admission she was briefly transferred to the ICU due to sustained hypoxia (assocaited with chest pain, CE's negative). At the time she was on a NRB, with saturations of 93%. ABG on NRB was 7.40/31/64. She was treated briefly with Vanc/Zosyn, however was quickly switched back to Ceftriaxone with Azithromycin to complete 10 day course for HCAP. Clindamycin was added out of concern for aspiration. She was febrile when antibiotics were discontinued, but she had no sign of active infection on exam or lab test. Repeat CXR after antibiotic course showed resolution of RLL PNA, but edema was still present. Due to continued hypoxia despite successful diuresis, a repeat CT of her chest was performed which showed ground glass opacities in the periphery of all lung fields bilaterally. Initially, the concern was for infectious vs embolic etiology for these ground glass opacities, however pulmonary consult was less concerned and no intervention was made. # CRF: Her was Cr 2.6 initially, but quickly returned to her baseline. She was given lasix when diuresis was initially attempted, but this gave pt pruritis which resolved with benedryl. Due to fluid overload and the adverse reaction to Lasix, Mrs. [**Known lastname 31866**] was diuresed with Ethacrynic Acid during the second week of her admission. She was treated with Benadryl prn for itching with the ethacrynic as well. Renal function was at baseline (Cr 1.9) at discharge. # Pancytopenia: Hematology was consulted for her pancytopenia (WBC 3.7, Hgb 9.7, plt 74K) and reviewed a peripheral blood smear. No schistocytes were seen, so this was felt unlikely to be TTP. Her outpatient Pentoxyfilline was discontinued due to her pancytopenia. No intervention made and her thrombocytopenia resolved. She remained anemic, not requiring transfusion. Her leukopenia resolved by discharge. An outpatient f/u appt was scheduled with Heme/Onc. # HTN: Mrs.[**Known lastname 31867**] hypertension was monitored in the hospital throughout her stay. She was initially hypotensive in the ED, but this responded to IVF. Her b-blocker and isosorbide were continued but her doses were uptitrated. Her lisinopril was decreased and her amlodipine and HCTZ were discontinued. Her blood pressure was stable and in target range on discharge. # Pulmonary nodule: On her CT scan, a 5 mm perifissural nodule versus small amount of loculated fluid was described. A followup chest CT in six months was recommended. # Left groin pseudoaneurysm: She had LENIs performed to rule out DVT during her hospitalization and these were without any evidence of DVT but did show a left groin pseudoaneurysm, 1.7 x 2.1 x 2.0 cm. This was felt to be stable from her previous imaging and she was advised to follow up with vascular as an outpatient. # Code: DNI Medications on Admission: Aspirin 81 mg p.o. q.d. Zantac 150 mg p.o. b.i.d. Lopressor 25 mg p.o. b.i.d. Lorazepan 0.5mg PO QHS PRN Pravastatin 40mg Po Qday Hydrochlorothiazine 25mg PO Qday Lisinopril 10mg PO Qday Ranitidine 150mg PO BID Citalopram 40mg PO Qday Amlodipine 10mg PO Qday Isosorbdin 40 mg ER Qday Allopurinol 100mg Po Qday Cipro 500mg PO BID x 4 doses-stoped on Saturday Discharge Medications: 1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain : Take one, if no resolution of chest pain after 5 minutes take another pill. If after 2nd pill no resolution of chest pain call 911. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 4. Lorazepam 1 mg Tablet Sig: .5 Tablet PO HS (at bedtime) as needed for sleep. 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* 7. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*0* 9. 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:*0* 10. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO three times a day. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Primary: 1. Urinary Tract Infection 2. Pneumonia 3. Diastolic Heart Failure Secondary: 1. Coronary artery disease 2. Hypertension 3. GERD Discharge Condition: vital signs stable, satting 93% on RA, ambulating without assistance Discharge Instructions: You were admitted to the [**Hospital1 18**] for fever and an urinary infection after having nausea and vomiting at home from taking cipro. You continued to have fever during your hospitalization, we found that you had pneumonia and treated you with antibiotics. You also had episodes of chest pain and decreases in your oxygen. In consultation with the cardiologist, we concluded that you were not having a heart attack, however you will need close follow-up with your cardiologist and PCP. [**Name10 (NameIs) **] also had extra fluid in your body that was removed with water pills. . Medication Changes: 1)Increased pravastatin to 80mg by mouth daily 2)Changed Toprol XL to metoprolol to 75mg by mouth three times a day 3)Changed Ativan to 0.5 mg by mouth at bedtime 4)Decreased lisinopril to 2.5mg by mouth daily 5)Started Imdur 90mg by mouth daily 6)Started Aspirin 325mg by mouth daily 7)We have discontinued isosorbide DN, amlodipine, and hydrocholorothiazide ***Please discuss restarting allopurinol with your primary care doctor at your upcoming visit. . Follow up appointments: MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: PCP Date and time: Thursday [**2194-7-4**]:00 AM Location: [**Street Address(2) 31868**], [**Location (un) 1439**] MA Phone number: [**Telephone/Fax (1) 22468**] . MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Vascular Surgery Date and time: Thursday, [**7-11**] at 2:20PM Location: [**Last Name (NamePattern1) 439**], [**Location (un) 86**], MA, [**Hospital Ward Name **] Bldg [**Hospital Unit Name **] Phone number: [**Telephone/Fax (1) 9645**] . MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - CALL TO CONFIRM Specialty: Medical Oncology Date and time: Tuesday [**2194-8-6**]:30AM Location: [**Hospital1 18**], [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) 24**] . If you experience chest pain, shortness of breath, fever greater than 101, palpitations, light-headedness or any other symptom that concerns you, please contact your PCP immediately or seek help at the nearest emergency room. Followup Instructions: MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Specialty: PCP Date and time: Thursday [**2194-7-4**]:00 AM Location: [**Street Address(2) 31868**], [**Location (un) 1439**] MA Phone number: [**Telephone/Fax (1) 22468**] MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Vascular Surgery Date and time: Thursday, [**7-11**] at 2:20PM Location: [**Last Name (NamePattern1) 439**], [**Location (un) 86**], MA, [**Hospital Ward Name **] Bldg [**Hospital Unit Name **] Phone number: [**Telephone/Fax (1) 9645**] MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] - CALL TO CONFIRM Specialty: Medical Oncology Date and time: Tuesday [**2194-8-6**]:30AM Location: [**Hospital1 18**], [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) 24**]

[ "V45.81", "413.9", "428.32", "799.02", "403.90", "428.0", "V15.82", "414.00", "284.1", "584.9", "585.9", "486", "599.0", "251.2" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

16181, 16226

7552, 14317

311, 317

16409, 16480

2776, 2781

18698, 19552

2086, 2104

14726, 16158

16247, 16388

14343, 14703

16504, 17091

2119, 2757

17111, 17568

264, 273

17592, 18675

345, 1592

2795, 7529

1614, 1979

1995, 2070

61,738

199,512

54068

Discharge summary

report

Admission Date: [**2128-7-30**] Discharge Date: [**2128-8-10**] Date of Birth: [**2067-2-19**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3200**] Chief Complaint: Ventral and bilateral inguinal hernia Major Surgical or Invasive Procedure: [**2128-7-30**]: open ventral hernia repair and bilateral inguinal hernia repair History of Present Illness: Mr. [**Known lastname 4020**] is a very pleasant 61-year-old male. He reports that since his time in the Air Force in the [**2086**], he has noticed a slowly growing bulge above his belly button. Occasionally, this has caused him some discomfort, but he has been able to push it back in always over the years. He has never had any overt pain or nausea or vomiting in the many years that he has known about this. However, he does notice more recently that he has had a bulge on the left side of his groin, which his PCP felt was consistent with a left inguinal hernia. The patient does claim that he has been thinking about this more. It does cause him some occasional discomfort. He has always been able to push it back inside. Again, he has not had any issues with obstructive-type symptoms. Past Medical History: 1. Chronic lung disease/COPD. He has had a pneumonia in [**12-14**]. Hypertension. 3. High cholesterol. 4. Prostate problem that is currently being worked up. 5. Dislocated shoulder. 6. Alcohol abuse: Drinks 4-5 beers daily. 7. Eczema 8. Hernias Social History: Chronic EtOH use of [**3-16**] beers/day s/p ICU admission. HCP reports previous use 6-12 beers/day. Hx smoking tobacco, 40 pack years. Quit 7-wks ago s/p ICU admission, uses electronic cigarette. No previous, current use of IV drugs, cocaine, heroin, or other substances. Not sexually active. Last activity in [**2106**] during previous relationship. No known STIs. Last HIV test per record [**2128-1-20**], negative. Family History: His mother has HTN, CHF, AFib, and a AAA s/p repair. His father died of lung cancer. He is single with no children. Physical Exam: On Discharge Vitals: T96.7 HR 90 BP 134/78 RR 18 O2Sat 97RA GEN: NAD, pleasant affect. Comfortale. HEENT: NCAT, EOMI, PERRLA, no slceral icterus CV: RRR, nl S1 and S2 PULM: CTA b/l. Abd: Well healing midline incision without eryethema. Staples removed, steri strips in place - clean/dry/intact. Bilateral inguinal incisions - clean/dry/intact - steri strips in place. BS +. Soft, nontender, no masses palpable. Persistent ventral bulge cranial to site of midline repair - asymptomoatic. Ext: No c/c/e. Skin has regained normal color and appearance. Neuro: AOx3. CNII-XII intact. No resting tremor. Romberg's negative. Good cerebellar on heel to shin and rapid alternating movement but tremors in hands b/l with finger to nose - intention tremor. Minimal ataxia noted while walking - not unsteady. Pertinent Results: [**2128-8-8**] 06:45AM BLOOD WBC-6.5 RBC-3.20* Hgb-10.1* Hct-28.6* MCV-90 MCH-31.4 MCHC-35.1* RDW-14.2 Plt Ct-400 [**2128-7-31**] 06:45AM BLOOD WBC-6.5 RBC-3.50* Hgb-11.0* Hct-31.5* MCV-90 MCH-31.3 MCHC-34.8 RDW-14.5 Plt Ct-188 [**2128-8-7**] 12:36AM BLOOD Neuts-63.1 Lymphs-27.8 Monos-7.0 Eos-1.7 Baso-0.5 [**2128-8-10**] 09:00AM BLOOD Glucose-147* UreaN-12 Creat-0.6 Na-139 K-4.0 Cl-103 HCO3-24 AnGap-16 [**2128-8-9**] 07:05PM BLOOD Glucose-140* UreaN-12 Creat-0.6 Na-140 K-4.2 Cl-106 HCO3-26 AnGap-12 [**2128-8-6**] 11:56AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-146* K-3.0* Cl-98 HCO3-39* AnGap-12 [**2128-7-30**] 07:30PM BLOOD Glucose-133* UreaN-9 Creat-0.6 Na-139 K-4.3 Cl-101 HCO3-28 AnGap-14 [**2128-8-5**] 05:15PM BLOOD ALT-16 AST-22 AlkPhos-69 TotBili-0.4 [**2128-8-10**] 09:00AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.8 [**2128-8-6**] 07:35AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.0 [**2128-7-30**] 07:30PM BLOOD Calcium-9.1 Phos-3.9 Mg-1.5* [**2128-8-7**] 12:36AM BLOOD VitB12-1262* Folate-17.0 [**2128-8-5**] 07:45PM BLOOD Ammonia-42 [**2128-8-7**] 12:36AM BLOOD TSH-0.64 [**2128-8-7**] 12:36AM BLOOD Free T4-1.5 [**2128-8-6**] 12:37PM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-70* pH-7.34* calTCO2-39* Base XS-8 [**2128-8-6**] 10:45AM BLOOD Type-ART pO2-204* pCO2-43 pH-7.56* calTCO2-40* Base XS-15 Intubat-NOT INTUBA Comment-NON-REBREA [**2128-8-6**] 10:19AM BLOOD Type-ART pO2-17* pCO2-63* pH-7.41 calTCO2-41* Base XS-10 Intubat-NOT INTUBA [**2128-8-6**] 12:37PM BLOOD Lactate-2.4* [**2128-7-30**] Pathology Diagnosis: Ventral hernia, excision (A): Mesothelial-lined fibroadipose tissue consistent with hernia sac. Left spermatic cord lipoma, excision (B): Mature adipose tissue consistent with lipoma. Right spermatic cord lipoma, excision (C): Mature adipose tissue consistent with lipoma. [**2128-8-2**] KUB: SUPINE FRONTAL AND FRONTAL DECUBITUS VIEWS OF THE ABDOMEN: There is no pneumoperitoneum or pneumatosis. Note is made of numerous air- and fluid-filled loops of large and small bowel, with scattered air-fluid levels seen on the decubitus view. Overall, given the postoperative status of the patient, these findings suggest an ileus. Cutaneous staples are present in the midline of the lower abdomen. Degenerative changes are mild at the hips bilaterally. Note is made of a small amount of subsegmental atelectasis in the left lower lobe. [**2128-8-3**] PCXR: FINDINGS: In comparison with the study of [**4-20**], there are lower lung volumes with continued evidence of chronic pulmonary disease and atelectasis at the base on the left. Dilatation of gas-filled loops of large and small bowel are consistent with the clinical diagnosis of adynamic ileus. The nasogastric tube extends to the region of the distal stomach. [**2128-8-6**] PCXR: FINDINGS: Since chest radiograph from [**2128-8-3**], there are no significant relevant interval changes. The right upper lobe cystic spaces with surrounding consolidation are unchanged since the prior radiograph. Bilateral mild pleural effusions are stable. No new opacities in the lungs. Cardiomediastinal shadow is stable. Some mild atelectasis is seen in bilateral lung bases. [**2128-8-6**] CT Head: IMPRESSION: 1. No acute intracranial pathologic process. 2. Hyperdense extra-axial lesion in the anterior falx, unchanged since [**2121**] and likely represents a meningioma. 3. Right frontal chronic subdural collection likely representing hygroma, unchanged since most recent study on [**2127-12-29**]. [**2128-8-7**] CT of Chest, Abdomen, Pelvis IMPRESSION: 1. Bilateral opacities at the lung bases, left greater than right, which could represent infectious process such as aspiration pneumonia. 2. Ectasia of the aorta and bilateral external iliac arteries along with the left internal iliac artery. 3. Increased size of the mediastinal lymphadenopathy when compared to prior scans. Brief Hospital Course: General Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation and treatment. On [**2128-7-30**], the patient underwent ventral and bilateral inguinal herniorraphy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids, and dilaudid for pain control. The patient was hemodynamically stable. Of note, beginning the night of POD 6 patient began to become agitated and by the morning of POD 7 was becoming increasingly disoriented and agitated. On exam patient was AO x 0, not following commands, tremulous, and delirious. CV was RRR with nl S1 and S2, lungs were CTA but patient was exhibiting tachypnea and 02 sats were in low 90s. Abdomen continued to be soft and non-distended. PXCR showed no change from [**8-4**]. Patient was transferred to ICU for further evaluation and monitoring, CT of Head, Chest, Abd, and Pelvis were ordered which were largely unremarkable for acute process, and blood cultures and urine cultures were sent which did not show any growth. Patient had a brief, 2 day stay in ICU and was returned to the floor in good health with near baseline return of function. Neuro: The patient received IV dilaudid, PO oxycodone and tylenol with good effect and adequate pain control. By POD 3 patient was requiring only Tylenol for pain control. Patient was put on CIWA scale for prevention of Delerium Tremens. Patient was tremulous during first week of stay but without delerium, muscle regidity, hyper-reflexivity, hallucinations, or focal neurologic deficit. However, on the evening of POD 6 patient became agitated and required ativan. On the morning on POD 7 patient became delirious, disoriented, and was rapidly assessed without further focal neurologic deficit. Patient was rapidly transferred to ICU for closer monitoring. Head CT did not reveal any acute abnormalities. After a 2 day stay, patient returned to the floor with minimal tremor and ataxia. CV: The patient's blood pressure and rate were controlled with diltiazam and lopressor. He remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint until POD 7 when patient began to deteriorate due to suspected DTs and respiratory rate greatly increased and O2sats were in low 90s and required oxygen via nasal canula. Patient was transferred to ICU and was continued on 4L NC and was satting at 99%. Patient was off 02 by POD 8. Vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Foley catheter was required during ICU stay on POD 7 and 8 for urine output monitoring and was discontinued on POD 9 while on floor and voided without issue. Diet was advanced when appropriate, which was well initially well tolerated. However, patient began to have abdominal distension and was not passing flatus, but without accompanied nausea and vomiting. On POD 5 patient required NGT to alleviate symptoms of functional small bowel obstruction with great relief. NGT put out several liters of fluid over the subsequent 2 days and electrolytes were routinely monitored and repleted. Due to excessive gastric output, potassium needed to be aggressively repleted over several days. NGT was removed on POD 7 without further abdominal pain or distension. Abdomen remained soft and nontender throughout the rest of stay. ID: The patient's white blood count and fever curves were closely watched for signs of infection. RPR and urine cultures were negative. He remained afebrile and without leukocystosis. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth twice a day start day before biopsy HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - Dosage uncertain SIMVASTATIN - (Prescribed by Other Provider) - Dosage uncertain Medications - OTC FOLIC ACID - (Prescribed by Other Provider) - Dosage uncertain MULTIVITAMIN WITH MINERALS [MULTI-VITAMIN W/MINERALS] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*14 Tablet(s)* Refills:*0* 5. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fevers: Max 4000mg (4gm) in 24 hours. Less if also consuming alcohol. . Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: ABP Best home care agency inc Discharge Diagnosis: -ventral hernia -bilateral inguinal hernias -acute alcohol withdrawal -hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-20**] lbs and straining under any activity (lifting, exercise, sports) until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Also please try to utilize the elevator instead of taking the stairs. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *The steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in clinic on [**8-18**] at 4pm. You also have an appointment with Dr. [**Last Name (STitle) **] at [**Hospital1 14615**] ([**Location (un) **]) on [**8-18**] at 1:30pm. Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2128-8-12**] 8:00 Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2128-8-12**] 9:00

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icd9cm

[ [ [] ] ]

[ "63.3", "53.59", "53.14" ]

icd9pcs

[ [ [] ] ]

12417, 12477

6873, 11387

341, 424

12605, 12605

2950, 6119

13909, 14339

1985, 2104

11853, 12394

12498, 12584

11413, 11830

12756, 13468

13483, 13886

2119, 2931

264, 303

452, 1254

6129, 6819

12620, 12732

1276, 1532

1548, 1969

24,535

139,189

6971+55802

Discharge summary

report+addendum

Admission Date: [**2122-11-12**] Discharge Date: [**2122-11-23**] Date of Birth: [**2054-3-7**] Sex: F Service: MEDICINE Allergies: Mevacor / Latex Attending:[**First Name3 (LF) 1055**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: Surgical wound debridement Central Line placement Intubation PICC line placement History of Present Illness: 68F with history of DM, HTN, and PVD two weeks s/p L4-5 laminectomy who originally presented to ED [**2122-11-12**] from rehab with fever, new backpain, SOB, and one episode of bowel incontinence. . The patient was discharged to Rehab on [**11-3**] after her lumbar laminectomy of L4 with insitu fusion L4-L5 on [**10-29**] at [**Hospital1 15204**]. She was noted to have fever to 101F last Wednesday and had no further work-up to her family's knowledge. Over the next week, she had increasing use of nebulizers and reports the onset of a cough, productive of yellow sputum. She also endorses SOB with ambulation, but not significantly different from her chronic DOE. On Tuesday [**2122-11-10**], she bent over to pick up an object and noted acutely increased pain in her back. The pain resolved over the next day. She had one episode of bowel incontinence. Per Rehab she has had bladder incontinence since her surgery. At Rehab on the morning of admission she was noted to be febrile to 102.8, 81% on RA and was sent to [**Hospital6 10353**] for further evaluation, where she was noted to have T102.3 and decreased sO2 (in the mid 80's, improved to 96% on 3L). BP was 160s/80s on arrival. She vomited a small amt of "[**Location (un) 2452**] popsicle". Due to ongoing back pain and fever she reportedly received levaquin and 2U PRBC (no documentation of this). She was then transfered to [**Hospital1 18**] for further workup including an MRI. Past Medical History: 1. DM2 2. PVD, s/p angioplasty and stents 3. CAD 4. hypercholesterolemia 5. s/p hallux arthrodesis 6. asthma 7. HTN 8. s/p L4-5 laminectomy [**10-29**] Social History: The patient is widowed and lives alone. She has two daughters. She is retired, formerly worked as an insurance underwriter. She denies alcohol, tobacco and IVDA. She ambulates at baseline. Family History: Significant for CAD, HTN, DM, colon ca. History of stroke in mom and sister. Physical Exam: Vitals: T 99.8 BP: 117/33-133/64 P: 71-82 R: 22 O2: 94-99% on 4L Gen: pleasant obese female, somewhat delirious, inable to concentrate on questions, NAD HEENT: Flushed face, anicteric sclerae, mmm, no teeth Neck: R IJ in place, JVD hard to assess secondary to obesity and positioning (lying flat) Lung: poor lung exam [**1-21**] positioning, but decreased sounds on L>R CV: III/VI SEM @ LSB, faint femoral and DP pulses distally Abd: obese. +bs. soft. nt. nd. Ext: 1+ pitting edema B. skin warm/dry. L hand dressed w/ no drainage through dressing. Multiple ecchymoses on UE B. pneumoboots in place Neuro: no focal deficits. PERLA, EOMI. Pertinent Results: On Admission: [**2122-11-12**] 09:06AM LACTATE-1.0 [**2122-11-12**] 08:55AM GLUCOSE-116* UREA N-21* CREAT-1.2* SODIUM-144 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-25 ANION GAP-14 [**2122-11-12**] 08:55AM CK(CPK)-59 [**2122-11-12**] 08:55AM CK-MB-NotDone cTropnT-0.02* [**2122-11-12**] 08:55AM WBC-13.6* RBC-3.63* HGB-10.4* HCT-31.1* MCV-86 MCH-28.7 MCHC-33.5 RDW-14.5 [**2122-11-12**] 08:55AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2122-11-12**] 08:55AM PLT SMR-NORMAL PLT COUNT-166 [**2122-11-12**] 12:23AM LACTATE-1.4 [**2122-11-12**] 12:10AM UREA N-19 CREAT-1.2* SODIUM-144 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-23 ANION GAP-16 [**2122-11-12**] 12:10AM CK(CPK)-45 [**2122-11-12**] 12:10AM cTropnT-<0.01 [**2122-11-12**] 12:10AM CK-MB-NotDone cTropnT-<0.01 [**2122-11-12**] 12:10AM WBC-16.0*# RBC-4.02* HGB-11.7* HCT-34.9* MCV-87# MCH-29.1 MCHC-33.6 RDW-14.7 [**2122-11-12**] 12:10AM NEUTS-84* BANDS-4 LYMPHS-9* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2122-11-12**] 12:10AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL [**2122-11-12**] 12:10AM PLT SMR-NORMAL PLT COUNT-205 [**2122-11-12**] 12:10AM PT-13.0 PTT-23.2 INR(PT)-1.1 [**2122-11-12**] 12:10AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2122-11-12**] 12:10AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 . On Discharge: Na 148 K 3.7 Cl 110 CO2 28 Bun 11 Cr 1.0 Glucose 99 Ca: 9.0 Mg: 1.8 P: 3.2 Wbc 8.0 Hct 25.8 Plts 247 . Microbiology: Sputum [**11-17**] - no growth Stool [**11-18**], [**11-19**], [**11-22**] - negative for C.diff Blood cx [**11-12**], [**11-15**], [**11-14**] - no growth Swab back [**11-15**] - coag + staph aureus moderate growth (MRSA) see below Urine cx [**11-14**], [**11-12**] - no growth Fluid [**11-12**] (epidural collection) - GRAM STAIN (Final [**2122-11-12**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. FLUID CULTURE (Final [**2122-11-14**]): 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. Please contact the Microbiology Laboratory ([**6-/2423**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | 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 ANAEROBIC CULTURE (Final [**2122-11-16**]): NO ANAEROBES ISOLATED. . CXR [**2122-11-16**]: The pulmonary edema is unchanged. Bilateral pleural effusions are increasing in size, especially the left. The mediastinal is unchanged. New ET tube is present, located 3.7 cm above the carina. Right IJ catheter tip unchanged in position over the SVC. There is no pneumothorax. IMPRESSION: Persistent mild pulmonary edema. ET tube in standard position . TTE [**2122-11-16**]: Preserved global and regional biventricular systolic function. Mild pulmonary artery systolic hypertension. Prominent epicardial fat pad. . MRI [**2122-11-13**]: IMPRESSION: Postoperative changes. Infection should be considered but cannot be confirmed. There is a possibility of a CSF leak, as there is a subcutaneous collection at the laminectomy site, but this would be difficult to confirm without myelography. . EKG [**2122-11-14**]: Sinus tachycardia Borderline low QRS voltage - is nonspecific Modest nonspecific ST-T wave changes Since previous tracing of [**2122-11-13**], sinus tachycardia present . CHEST CT [**11-14**]: 1. No pulmonary embolism. 2. Moderate cardiomegaly with bilateral moderate layering pleural effusion. 3. Pulmonary interstitial and alveolar edema. A followup CT could be performed after treating the CHF to evaluate for pulmonary pathology. 4. Bilateral lower lobe atelectasis. Brief Hospital Course: Ms. [**Known lastname 26075**] is a 68 lady with a history of DM2, HTN, and PVD s/p recent L4-5 laminectomy, admitted with back pain from rehab found to have a left lower lobe pneumonia and MRSA surgical wound infection. . In the [**Hospital1 **] ED, she was initially hypertensive at 147/47 but then became hypotensive 90s/40s. She was started on the sepsis protocol with placement of RIJ. She received vancomycin, levofloxacin, morphine 2mg x2. Neurology was consulted and felt that given her recent surgery, new back pain, question of incontinence, the week-long fever and her DM, an infection in the surgical region was likely. Neurospine was consulted. The patient had an MRI L-spine with contrast to r/o epidural abscess. The MRI revealed fluid collection which is likely a post-surgical seroma and not an abscess. No evidence of cauda equina. She was initially admitted to MICU, but transferred to floor on admission given her hemodynamic/respiratory stability. However, patient then returned to the MICU after becoming acutely hypoxic on the floor with oxygen saturation of 84% on 4L. She was noted to be tachypneic, in severe respiratory distress, using accessory muscles. ABG 7.25/53/105 on NRB (lactate 0.7). CXR c/w CHF, she was readmitted to MICU. . MICU Course: The patient was diuresed and continued on nebs PRN for bronchospasm. The patient was taken back to the OR for wound debridement, and was intubated for this procedure, not for respiratory failure. She was extubated in the morning following the procedure, and weaned down to 4L NC with O2 sats 99%. The patient was continued on Zosyn for nosocomial pneumonia and Vancomycin for MRSA wound infection, per ID recs, will need to have a 6 week course. The patient underwent a speech/swallow eval following extubation, which advanced her to pureed liquids. . Upon transfer back to the medical floor, the patient was breathing comfortably on 4L O2, speaking in full sentences, no accessory muscle use. The patient denied any chest pain or dyspnea, + productive cough, denies N/V. No abdominal cramping, but having some diarrhea. Does not complain of mild back pain, but was unable to quantify with a number on a scale of 10. Patient had recently received ativan and clonazepam, with a subsequent clouded mental status. Per patient's daughters who had been at the bedside, this change in mental status only occurred after sedating medications. . In terms of pneumonia the patient continued to be weaned off O2, currently sating well on room air. She was treated with a 10 day course of Zosyn ([**Date range (1) 26158**]). She had a slightly positive fluid balance with b/l pleural effusions and vascular congestion on CXR and therefore recieved a total of 30 mg IV lasix for additional diuresis. She was continued on nebulizers for her asthma. Her sputum cultures returned negative. Patient currently does not have any cough or sputum production. She remains afebrile and saturating well on RA. . In terms of her wound infection. Patient found to have MRSA growing from the fluid drained from her surgical site. She requires a 6 week course of IV Vancomycin (started [**11-15**] as day zero). A PICC line was placed for prolonged IV antibiotics. She had a central line placed in the MICU which was removed after PICC line placement. Her blood cultures have all been negative. Her wound is clean and dry. She is scheduled to have her staples removed from her wound site on Friday [**12-4**] at 11:15 AM at the [**Hospital Ward Name 23**] Building Orthopedic Unit. . Patient has complained of very little pain and this is controlled with Tylenol. The patient was initially treated with oxycodone which caused her to become delirious. She was also receiving clonazepam 0.5 mg [**Hospital1 **] for anxiety which was also likely contributing to her confusion. The narcotic medications were withdrawn with dramatic improvement in her mental status. Her benzodiazepines were tapered to 0.25 mg [**Hospital1 **]. This should be tapered further as tolerated. Her mental status upon discharge is clear. Both of her daughters were at the bedside who agree that she is at baseline and much improved now that she is off narcotics. Apparently the family has a history of adverse reactions to pain medications. . In terms of her cardiovascular disease including HTN, CAD, CHF (EF >50% 11/28). She was apparently taking lasix at home (?dose) and is discharged on 20 mg daily. She should follow up with her PCP regarding this dose. She required IV lasix bolus (10mg, then 20 mg) for excess fluid removal while in hospital. She was treated with Lisinopril 5 mg daily with good blood pressure control (120-130/60s). Of note, the patient was taking Zestril 20 mg daily. We are discharging her on 10 mg of Lisinopril since this provided good control, this can be titrated up in the future as tolerated. She was also continued on a Statin. Of note, the patient is not taking aspirin or a beta blocker. This can be addressed with her primary care physician upon follow up. . Patient was also found to be anemic. On admission her Hct was 31 with subsequently dropped to ~30. Likely multifactorial in the setting of IVF fluid resuscitation in the MICU, wound debridement in the OR, hx of chronic disease and multiple lab draws during this admission. A repeat CBC should be performed in approximately one week to make sure that her anemia is not worsening. . Patient also developed some diarrhea during this admission. She was tested for C.diff which was negative x 3. She was given loperamide prn with improvement. She denies any abdominal pain and she did not develop any fevers. Her bowel regimen was held after this. . Nutrition - patient cleared by speech and swallow. Eating a soft pureed diet then advanced to regular diet. Note that she has lost her lower dentures but is eating well. Her daughter have ordered another set of lower dentures for which she will have to be fitted. . In terms of her anxiety and depression the patient was continued on Zoloft per outpatient regimen. She was also treated with Clonazepam 0.5 mg [**Hospital1 **]. This produced substantial delirium. This medication was tapered to 0.25 mg [**Hospital1 **] for fear of withdrawal. However, this should be tapered further as tolerated an only used as needed for anxiety. Sedating medications and narcotics should be avoided in the future if possible. . For her diabetes she was maintained on an insulin sliding scale with good control. She is now able to resume her outpatient regimen of Avandia 80 mg daily. She is to continue to be maintained on a sliding scale. Please report all FS values to her PCP in the event that her medications must be adjusted. . Electrolyte Imbalance: Patient also developed some hypernatremia while in hospital with a sodium level of 148. Likely in the setting of dehydration after diuresis with lasix for fluid overload. Her free water deficit was calculated and found to be 2L. She was repleted with D5W for this deficit. Patient also had some low potassium levels also likely secondary to lasix. She was repleted with PO potassium with improvement. Patient should have a repeat chemistry done in two days to assess for any electrolyte abnormalities. . Prophylaxis: Heparin SC, OOBTC, PO diet, PPI, bowel regimen (then held due to diarrhea) . Patient was a full code throughout this admission. Medications on Admission: Lasix 20 mg daily Klonopin 1 mg three times a day Zoloft 100 mg daily Avandia 8 mg daily Zestril 20 mg daily Lipitor 40 mg daily ASA 81 daily Advair as needed Rhinocort as needed Senokot as needed Tylenol as needed Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disk with Device(s) 2. 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 3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for back pain. 10. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection as directed on flow sheet. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous q24 hrs for 28 days. 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 14. Clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day. 15. ASA 81 mg daily Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: MRSA Wound Infection Pneumonia . Secondary Diabetes type 2 Hypertension Hyperlipidemia Asthma Peripheral vascular disease Discharge Condition: Good - patient afebrile, sating well on room air, OOBTC with assist, minimal back pain Discharge Instructions: Please take all of your medications as directed Please follow up as listed below Please return to the hospital if you have any fevers, chills, worsening back pain, difficulty breathing or any other complaints. Followup Instructions: Please call your PCP to make [**Name Initial (PRE) **] follow up appointment. PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26159**] Please attend the following appointment to have your staples removed from your back: Friday, [**12-4**] at 11:15 AM [**Hospital1 18**] [**Location (un) 8661**] Building 2nd flood Orthopedic Unit with Dr. [**Last Name (STitle) 26160**] Completed by:[**2122-11-23**] Name: [**Known lastname 4525**],[**Known firstname **] Unit No: [**Numeric Identifier 4526**] Admission Date: [**2122-11-12**] Discharge Date: [**2122-11-23**] Date of Birth: [**2054-3-7**] Sex: F Service: MEDICINE Allergies: Mevacor / Latex Attending:[**First Name3 (LF) 1852**] Addendum: Note: patient was taking aspirin prior to admission, she is discharged on 81 mg ASA Note: patient was taking Avandia prior to admission, this medication was NOT continued due to a history of heart failure. Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**] Completed by:[**2122-11-23**]

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icd9cm

[ [ [] ] ]

[ "83.39", "03.09", "38.93", "93.90", "96.71" ]

icd9pcs

[ [ [] ] ]

18133, 18386

7486, 14840

287, 370

16759, 16848

2995, 2995

17108, 18110

2243, 2321

15106, 16473

16614, 16738

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2336, 2976

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238, 249

398, 1845

3009, 4484

1867, 2021

2037, 2227

1,136

136,706

187

Discharge summary

report

Admission Date: [**2194-8-15**] Discharge Date: [**2194-8-16**] Service: MEDICINE Allergies: Lisinopril / Nsaids / Nesiritide Attending:[**First Name3 (LF) 1881**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 86F with h/o colon cancer, ESRD on hemodialysis, diastolic CHF, pulmonary hypertension, and prior cephalic vein thrombosis who presented to the ED on [**8-15**] with dyspnea. The patient's dialysis catheter became dislodged [**8-12**]. Consequently she missed her normal dialysis session [**8-13**]. On [**8-14**] she had a new tunneled catheter placed, but was not dialyzed. The afternoon of [**8-14**] her daughter noticed that the patient seemed increasingly dyspneic and was hypertensive to 200's. She was given hydralazine and clonidine and the BP improved to 160's. She called her daughter ~3am on [**8-15**] due to worsening dyspnea. The patient denies any accompanying headache, vision changes, chest discomfort, palpitations, nausea, vomiting, cough, weakness or loss of sensation. EMS was called, and she was given CPAP with some relief of her dyspnea. Per her daughter, similar symptoms have occurred 3 times in the past. In the ED her vitals were BP 258/61 RR 28 O2 100% on CPAP, 89% on room air (temperature was not recorded). She was started on a nitroglycerin drip, and given calcium and bicarbonate for a potassium of 7.1. She was weaned off NIPPV, with O2 saturation of 97% on 3L NC. She was subsequently transferred to the ICU for further monitoring and dialysis. Past Medical History: 1) Hypertension 2) Stage V chronic kidney disease, followed by Dr. [**Last Name (STitle) 1366**]. 3) Diastolic CHF (EF 60% on TTE in [**5-3**]), likely volume related in the setting of her renal disease. 4) Rheumatic fever, with the following valvular abnormalities: Mild aortic stenosis, moderate aortic regurgitation, mild mitral stenosis, mild to moderate MR, mild TR. 5) Severe PA systolic hypertension 6) Renal artery stenosis: MRI [**2185**] atrophic R kidney, moderate stenosis of R renal artery, L renal artery normal. 7) Peripheral vascular disease: Has claudication. 8) Right cephalic vein DVT in [**6-/2193**] 9) Colon cancer in [**2-/2192**], status post resection. 10) Hyperlipidemia 11) Right bundle branch block 12) Anemia of renal failure 13) Osteoarthritis 14) Osteopenia 15) Glaucoma Social History: Lives at home, usually alone, but recently the daughter has moved in with her. She does not smoke, drink alcohol, or use IV drugs. Family History: mother- HTN Physical Exam: T 98.2 P 50 BP 196/76 O2 97% on 2L RR 24 General: Pleasant elderly woman in no acute distress CV: Regular rate S1 S2 II/VI SEM at RUSB with I/VI diastolic decrescendo murmur as well at RUSB Pulm: Lungs with crackles at bases bilaterally, no wheezes or rhonchi. R chest with tunneled catheter. Abd: Soft, nontender, +BS Extrem: Warm and well perfused, no edema Neuro: Alert and answering questions appropriately, moving all extremities Pertinent Results: [**2194-8-14**] 07:45AM BLOOD WBC-8.1 RBC-3.86* Hgb-11.7* Hct-34.8* MCV-90 MCH-30.3 MCHC-33.6 RDW-18.6* Plt Ct-180 [**2194-8-15**] 05:00AM BLOOD Neuts-91.0* Bands-0 Lymphs-5.1* Monos-2.7 Eos-1.0 Baso-0.2 [**2194-8-14**] 07:45AM BLOOD PT-11.5 INR(PT)-1.0 [**2194-8-14**] 07:45AM BLOOD Glucose-106* UreaN-82* Creat-6.2*# Na-141 K-5.8* Cl-106 HCO3-23 AnGap-18 [**2194-8-15**] 05:00AM BLOOD cTropnT-0.09* [**2194-8-15**] 05:13AM BLOOD Type-ART pO2-440* pCO2-35 pH-7.38 calTCO2-22 Base XS--3 [**2194-8-15**] 05:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2194-8-15**] 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2194-8-15**] 05:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**8-15**] CXR FINDINGS: AP view of the chest on upright position. The cardiac silhouette cannot be evaluated on this AP view. The right-sided central venous catheter is unchanged. The left costophrenic angle is blunted consistent with pleural effusions. Left lung base atelectasis are noted. There is no evidence of pneumothorax. There is a right lung base opacity obscuring the right-side cardiac border which may represent right middle lobe atelectasis vs. pneumonia. Pprominence of the pulmonary vasculature is noted, consistent with mild CHF. The osseous structures are unchanged. IMPRESSION: 1. Right middle lobe atelectasis vs. pneumonia. 2. Mild CHF with small left- sided pleural effusion. [**8-15**] EKG Sinus bradycardia at 56bpm, left axis, old RBBB, peaked T's that are new compared to [**2194-6-24**] EKG. Inverted T in V3 on [**6-2**] EKG has flipped to positive. No signs of acute ischemia. Brief Hospital Course: 1. Dyspnea - The patient's dyspnea was thought to be secondary from volume overload, occuring in the context of ESRD and a missed hemodialysis session, as well as hypertension leading to flash pulmonary edema. Her dyspnea following hemodialysis. 2. Hypertension - The patient's hypertension is also likely related to volume overload. Her blood pressures improved following dialysis and resumption of her home course of toprol, clonidine, amlodipine, and hydralazine. 3. Hyperkalemia - The patient's potassium normalized following dialysis. 4. ESRD - Renal following, on dialysis MWF. 5. FEN - Continue sevelemer, nephrocaps. Medications on Admission: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Medications: 1. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: CARETENDERS Discharge Diagnosis: Primary: hyptertensive emergency Secondary: diastolic CHF ESRD Discharge Condition: stable, shortness of breath relieved Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. Date/Time:[**2194-8-25**] 8:30 -cont HD on MWF [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]

[ "V10.05", "428.30", "416.0", "403.01", "585.6", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

7291, 7333

4817, 5447

260, 264

7441, 7480

3086, 4794

7647, 7914

2602, 2615

6382, 7268

7354, 7420

5473, 6359

7504, 7624

2630, 3067

201, 222

292, 1608

1630, 2436

2452, 2586

28,972

134,622

3485

Discharge summary

report

Admission Date: [**2127-8-12**] Discharge Date: [**2127-12-28**] Date of Birth: [**2077-8-13**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Aspirin / Iodine / Red Dye / Yellow Dye / Perfume Ht52 Attending:[**First Name3 (LF) 2485**] Chief Complaint: Anemia and weakness Major Surgical or Invasive Procedure: Bone Marrow Biopsy PICC line placement Bone marrow biopsy Bronchoscopy Transjugular liver biopsy Tunneled central venous line placement Tooth extraction History of Present Illness: Ms. [**Known lastname **] is a 49 year-old woman who was recently diagnosed with aplastic anemia. She notes increasing fatigue. She is being admitted to consider treatment. She was in her usual state of health until about last [**10/2126**] when she experience viral syndrome and associated w/ sore throat. She was put on multiple courses of antibiotics (amoxicillin, Cipro, etc) for total of [**5-25**] month. She was feeling generally well with her baseline amount of energy until [**5-/2127**] when she noted increasing fatigue and was noted to be pancytopenic. She reported easy nose bleeds and gum bleeding at that time. She was seen at [**Hospital6 16029**] for evaluation. A bone marrow biopsy on [**2127-6-26**] revealed a hypocellular bone marrow with 5-10 % cellularity and no evidence of leukemia or other marrow infiltration. EBV IgM was positive at that time with a low titer of IgG. A repeat bone marrow evaluation on [**7-29**] showed mildly hypocellular marrow with approximate cellularity of 30% and erythroid dominance. She was admitted to the [**Hospital1 18**] - Upon discharge, her counts remained stable and her ANC has ranged from 300-500, platelets from 14-21,000, and hematocrit from 23.8-27.4 without transfusion support. She remains profoundly fatigued. She is not eating well and is drinking less than a liter of fluid per day. She states that she becomes dyspneic with minimal exertion and has been experiencing chest pain with this dyspnea. She notes nausea and dry heaves on a daily basis. She occasionally has headaches but denies focal neurologic deficits. She feels cold, but denies fevers or rigors. She previously had diarrhea, but now notes her stools are firmer and less frequent (approximately once daily). She notes occasional nose bleeds. Past Medical History: 1. HCV: She has received interferon and Ribavirin in the past, though has not received any treatment for at least 1-2 years. Her most recent HCV PCR was 12,600,000 copies on [**2127-7-16**]. 2. Pancytopenia as noted above. Social History: She is married and lives with her husband outside of [**Name (NI) 5583**]. She has no children. She is currently on disability. Denies alcohol, tobacco or drug use. Quit tobacco in [**2115**]. Quit IVDU in the early 80s. Of noet the patient is a Jehovah's witness Family History: Mother had ovarian cancer at age 65 and is alive and well. Sister had squamous cell cancer of skin at age 41. Brother is well, though has ankylosis spondylitis. Physical Exam: Vital Signs: Blood Pressure: 90/62, Heart Rate: 87, Weight: 161 Lbs, Temperature: 97.7, Resp. Rate: 20, O2 Saturation%: 100. GENERAL: Tired and ill-appearing. No acute distress. Sitting in wheelchair, accompanied by her husband. [**Name (NI) 4459**]: Sclera anicteric, oropharynx clear. NECK: No thyromegaly. CHEST: Clear to auscultation and percussion. ABDOMEN: Soft, nondistended. Mild right and left upper quadrant discomfort. No definitive splenomegaly. EXTREMITIES: No edema. SKIN: No jaundice. No purpura, ecchymosis, or petechiae. Pertinent Results: = = = = = = = = = = = ================================================================ BONE MARROW BIOPSY [**8-14**]: NORMOCELLULAR, ERYTHROID-DOMINANT BONE MARROW WITH A STRIKING TRILINEAGE DYSPOIESIS AND A SMALL POPULATION OF BLASTS = = = = = = = = = = = ================================================================ LIVER CORE BIOPSY Mild portal predominant mononuclear inflammation (grade 1). Minimal steatosis. Mild increased stainable iron (iron stain examined). Mild portal fibrosis (stage 1) on trichrome stain. Note: The overall features consistent with chronic viral hepatitis, grade 1 inflammation, stage 1 fibrosis. No lobular abscesses or viral inclusions. = = = = = = = = = = = ================================================================ SPIROMETRY Within Normal Limits . ECHO The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. . CT CHEST NON-CONTRAST 1. No CT evidence of thymoma. 2. Scattered peribronchiolar nodular opacities and ground-glass attenuation, most likely due to an acute infectious etiology. 3. Mild centrilobular emphysema. = = = = = = = = = = = ================================================================ BRONCHOALVEOLAR LAVAGE: GRAM STAIN (Final [**2127-8-28**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2127-8-30**]): ~5000/ML OROPHARYNGEAL FLORA. LEGIONELLA CULTURE (Final [**2127-9-4**]): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2127-8-28**]): NEGATIVE for Pneumocystis jirvovecii (carinii). FUNGAL CULTURE (Final [**2127-9-11**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2127-8-29**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Final [**2127-10-27**]): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE (Final [**2127-9-26**]): NO VIRUS ISOLATED. . CMV VIRAL LOAD: NEGATIVE . MRSA SCREEN: NEGATIVE . VARICELLA SEROLOGIES: IgG POSITIVE . HCV VIRAL LOAD (Final [**2127-9-2**]): 2,270,000 IU/mL. . BLOOD CULTURE [**10-13**]: COAG NEG STAPH . BLOOD CULTURE [**10-22**]: KLEBSIELLA PNEUMONIA = = = = = = = = = = = ================================================================ . Sputum cx: [**12-19**] --> RESPIRATORY CULTURE (Preliminary): RARE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | AMIKACIN-------------- 16 S CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- 8 I MEROPENEM------------- 8 I PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 R Brief Hospital Course: 50 yo female with a history of hepatitis C who presented with pancytopenia and was diagnosed with MDS. . #Pancytopenia, diagnosed as AML: Throughout her hospital stay, the pt had profound pancytopenia and required intermittent transfusion support of red cells and platelets. Parvovirus B19 and Herpes virus 6 were both negative. Pt was negative for PNH. Antiplatelet antibody was positive while antigranulocyte antibody was negative. Bone marrow biopsy was performed on [**8-14**] and was interpreted as myelodysplastic syndrome evolving to an acute erythroid leukemia. Pt was briefly on Epogen 40,000 units per week, which was discontinued after the results of the bone marrow biopsy were finalized. The patient had multiple subsequent bone marrow biopsies which showed definate evolution to AML. There was concern that her Hepatitis C virus was contributing to the marrow suppression; Hepatology was consulted and felt this was not the case. The did recommend started Ursodiol at the time of chemotherapy. She received 7+3 chemotherapy in preparation for an alloSCT with her brother as the donor. Her transplant preparation was also repeated: lab tests, infectious serologies,echo and PFT's. She was started on Fluconazole and Acyclovir for neutropenic prophylaxis. A bone marrow biopsy performed on [**10-14**], which showed an ablated marrow, and the patient was consented for her bone marrow transplant. The patient received busulfan from days -7 until day -4, and cytoxan from day -3 until day -2. She recieved her stem cell transplantation on day 0 without any complications. Cyclosporine commenced on day -1, which will continue until day +49 for GVHD ppx for GVHD ppx. THe patient received methotrexate on days +1, +3, +6, and +11. While in the [**Hospital Unit Name 153**] the patient was placed on methylprednisolone and mycophenolate. Her methylprednisolone was weaned by 5mg qweek, and her mycophenolate was eventually titrated up to 100mg TID. She was transferred to the floor and counts (particularly WBC) trended down, and her Cellcept was held. . # Bacteremia: The patient was found to be febrile on [**10-13**] while neutropenic, at that time, cefepime was started. She was then found to be bacteremic on [**10-13**] blood cultures with coagulase negative staph, which is oxacillin-resistant, and sensitive to vancomycin. Vancomycin was started on [**10-14**], and her central line was left in place. All surveillance cultures are NGTD, as of [**10-14**]. On [**10-18**], cefepime was discontinued, as she remained afebrile upon starting vancomycin. The patient spiked again on [**10-21**] (Day -6), at that time her blood and urine were cultured and cefepime was restarted. Her [**10-22**] cultures showed pan sensitive klebsiella. Since this positive culture, her surveillance cultures have been negative for over 72 hours. Flagyl and caspofungin were added on [**10-31**] as the patient began to spike through her regimen of vancomycin and cefepime. IV Vancomycin was discontinued on [**12-24**]. . # Hyponatremia: The patient was noted to have a sodium on 127 on day -1. At that time, fluid restriction to 1L was started, urine and urine electrolytes were obtained, which showed elevated urine sodium and and osmolality of 568. After 24 hours of fluid restriction, her sodium normalized to 134. Based on her labs, it was thought to be secondary to cytoxan induced SIADH. Fluid restriction was stopped shortly afterward and her sodium remained normal. . # Mucositis: The patient began to experience symptoms of mucositis on day+1, including mouth pain, abdominal pain and diarrhea. She was ruled out for C. diff infection. At that time, TPN was started, and the patient was started on a morphine PCA. . # Hepatitis C: Patient has been a non-responder to interferon and Ribaviron therapies. Viral load was 12,600,000 in [**Month (only) **] [**2127**], then down to 2.27 million and after chemotherapy came up to 5 million. Liver biospy was performed on [**8-27**], which showed grade 1, stage 1 Hepatology following, liver biopsied, which was consistent with chronic viral hepatitis, grade 1 inflammation, stage 1 fibrosis. Hepatology recommended followup as outpatient after completion of the SCT. . #Abnormal lung findings on CT: CT chest showed presence of ground glass opacities in bilateral lobes c/w infectious etiology. Pt remained asymptomatic. Galactomannan, b-d-glucan, crptococcal antigen, and histo antigen were all negative. Pt had a bronchoscopy on [**8-28**], and BAL studies are negative to date. . # Dental pain: Pt was evaluated by a dentist, who recommended extraction of tooth #19 prior to SCT. The tooth was extracted on [**9-4**] by oral surgeon Dr. [**Last Name (STitle) 2866**]. After the extraction, pt developed intense pain at the site, radiating to her L frontal sinus and ear. As she was neutropenic, infection was suspected and she was started on Unasyn. Oral surgeon was re-evaluated the site of extraction and agreed with abx and also suggested a dressing for alveolar osteoitis if the pain does not resolve with abx. Pt then became febrile and was switched to Zosyn, completing a 7 day course. She was subsequently switched to Levofloxacin and Clindamycin; then just to Levofloxacin as there was no evidence of further dental infection. She had no further tooth pain. . # Depression/Anxiety: The patient remained fatigued and weak and with some degree of emotional lability. Her previous admission was marked by passive suicidal ideation, and she was well-known to the psychiatry consult service, which was consulted again this admission. Ritalin was discussed with the patient, though she declined this and any other anti-depressant medications. She was continued on lorazepam PRN. # GERD: Pt continued on her home regimen of prevacid. . # Hepatitis B: The patient was found to have a positive core antibody but a negative viral load. Per GI reccs, the patient was started on Lamivudine. But patient was unable to take lamivudine due to mucositis. . # Rash: Soon after starting chemotherapy, the patient developed a rash on her shins thought to be related to her chemotherapy. She was given Sarna for palliation. She also had a similar rash on her lower abdomen, which then became more circular and localized with one particular area suggstive of ungal infection. Given that she was laready on Fluconazole and topical [**Doctor Last Name 360**] was added. In addition, she briefly developed a contact dermatitis under her breasts bilaterally secondary to the adhesive on EKG leads; hydrocortisone was prescribed to these areas only. . # Hypertension: After starting Cylosporine, the patient began having persisent high blood pressures. She was started on a calcium channel blocker to treat cylosporine-induced hypertension. In addition, her cyclosporine dose was decreased and then held due to supratherapeutic levels. During her [**Hospital Unit Name 153**] stay, her antihypertensives were held initially. Her blood pressures were high in the SBP's 160's-190's, particulary when agitated or stimulated. She was then started amlodipine 10mg daily and anti-anxiety medications, including zyprexa. Her blood pressures subsequently normalized. . # Acute Renal Failure: Her creatinine began rising on [**11-20**] and steadily climbed during her [**Hospital Unit Name 153**] stay. She was initially on lasix for diuresis which was then held soon after her creatinine continued rising. On further analysis, her urine electrolytes did not show a pre-renal etiology and urine eosinophils were negative. The nephrology team was consulted and found significant muddy-brown casts on urine microscopy. She was diagnosed with ATN secondary to cyclosporine toxicity. Given her elevated cyclosporine levels, the dosages had already been substantially reduced. On diagnosis of ATN, the cyclosporine was changed from continuous to [**Hospital1 **] dosing, and then were held. Her creatinine peaked at 5.2 and then slowly began trending down. Due to her ARF and volume overload that was thought to be contributing to her failure to wean from the vent, CVVH was started on [**12-6**] and continued through [**12-16**]. RIJ dialysis line was discontinued on [**12-16**] secondary to fever, and CVVH was not restarted as the patient was not volume overloaded and did not have electrolyte abnormalities necessitating dialysis. Patient began having increased urine output on [**12-18**]. Her phosphate continued to increase to 9.0 on [**12-19**] and she was begun on aluminum hydroxide phosphate binder. Upon transfer to the floor, her renal function improved steadily off of hemodialysis, and she consistently produced approx 2L urine daily. . # Respiratory Failure: On [**2127-11-24**], the patient began having respiratory distress and hypoxia. She was transferred to the [**Hospital Unit Name 153**] and intubated for hypoxic respiratory failure. Her CXR showed bilateral pulmonary infiltrates concerning for PCP, [**Name10 (NameIs) 16030**] PNA, pulmonary edema or diffuse alveolar hemorrhage. She was started on Clindamycin and Primaquine as well as steroids for empiric PCP treatment given recent failure to take PCP [**Name Initial (PRE) 1102**]. She was also started on Azithromycin. She was maintained on Cefepime, Vanc and Caspofungin initially. Vanc was intermittently stopped but then finally restarted and continued when her WBC bumped with each attempt to wean off Vanc. A bronchoscopy was performed. There was no purulent material or gross blood noted - making diffuse alveolar hemorrhage less likely. BAL did not reveal any WBC's, RBC's, bacterial culture, fungal culture, viral culture negative and Nocardia negative. Because of the lack of evidence for a bacterial PNA, Cefepime was discontinued on [**12-3**]. PCP was negative as well. After determining that she was PCP negative, the [**Name9 (PRE) 16031**] and Primaquine were discontinued; she was placed on Atovquone prophylaxis. She was intially kept on steroids to reduce GVHD (not for PCP) but then tapered off. Histoplasma, Mycoplasma and Legionella were also negative; Azithromycin was discontinued. Respiratory viral antigens were also negative. She was changed from Caspofungin to Posaconazole when one isolate of PITHOMYCES (diamacious fungus)grew from her pleural cultures. Posaconazole was eventually discontinued given the lack of suspicion for fungal infection; she was switched to prophylactic fluconazole. Because of the concern for pulmonary edema, she was agressively diuresed. A chest CT showed significant improvement suggestive of either resolving infection or decreasing pulmonary edema. When BUN and Cr began increasing, lasix was stopped. Her chest X-ray then worsenened, and radiology was once again concerned about alveolar hemorrhage versus infection. A repeat bronchoscopy was performed which showed gross purulent material on the ET tube but no blood. Given the concern for ventilator associate pneumonia, she was re-started on Cefepime, and Cipro was added. In addition, CVVH was intiated for aggressive diuresis to treat pulmonary edema. Further cultures showed two colonies of pseudomonas, cefepime was switched to Zosyn and cipro was continued. She continued to have an elevated WBC despite this treatment. Sensitivities of the cultures showed that they only were mutually sensitive to meropenem, so her cipro and zosyn were discontinued and she was started on meropenem. Attempts at weaning the patient were complicated by agitation, tachycardia, and tachypnea. She was transitioned to an ativan/methadone weaning protocol which was not effective. She was next transitioned to fentanyl boluses to aid in weaning her off the vent. This was also ineffective. The patient had a trach and PEG placed on [**12-17**], after being on the vent for nearly three weeks. After tracheostomy was placed, the patient was able to ventilate on her own and was able to verbally communicate. She was still undergoing treatment for pseudomonas VAP, and is currently Day [**7-4**] of meropenem. Ceftazidime was added on [**12-22**] for sputum culture results showing intermediate resistance to meropenem. . #CMV Viremia: CMV PCR from [**12-11**] detected viral load of 658. repeat CMV PCR on [**12-16**] detected over 9,000 copies. patient was started on gancyclovir on [**12-16**]. The dose has fluctuated given her changing renal status, from 1.25mg/kg Q24 to 1.25mg/Kg 3Xweek. . #Coag neg Staph: patient had coag neg staph grow from tip culture on [**12-16**]. Given her changing creatinine clearance, her vancomycin levels were checked daily and vancomycin dosed accordingly. Vancomycin was D/C'd on [**12-24**]. . # Leukocytosis: The patient had leukocytosis during her [**Hospital Unit Name 153**] stay. PNA, infectious diarrhea and line infections were considered. Diarrhea was persistently negative for C.Diff. She was also being treated for possible PNA. At each attempt to discontinue Vanc, her leukocytosis re-appeared suggesting a MRSA or gram positive infection - possible line infection. She was given a PICC in order to discontinue the central line. A dialysis line was an additional port was placed with the plan of removing the Hickman. However, she was then found to have purulent material in her ET tube suggestive of a bacterial, VAP that could be the source of the leukocytosis. She was treated with Cefepime and Cipro until the gram stain only showed oralpharyngeal flora. The Hickman was pulled on [**12-9**] by Dr [**Last Name (STitle) 10356**]. As above, she continued to have an elevated white count despite double pseudomonal coverage. When the sensitivies were found to be resistent to the Zosyn and cipro, she was changed to meropenem per sensitivities. Her leukocytosis gradually decreased coinciding with tapering of her methylprednisolone. However, WBC dropped to 1.5 on [**12-24**] and medications were examined for potential myelosuppression. cellcept was held at that time. Also vancomycin was discontinued. . #Hyponatremia: Na 135->129/130 since starting CVVH - CVVH removing fluids vs extravascular free water now returning to intravascular space and causing a dilutional effect? Per renal, fluid re-administered during CVVH is relatively hyponatremic. Their recomendations are to reduce any free water sources (meds, flushes etc) . *[**Hospital Unit Name 153**] course [**Date range (1) 16032**]* 50 y.o. woman s/p 7+3, and s/p allogenic bone marrow transplant on [**10-29**], transferred to the MICU after tonic clonic seizure and hypoxic respiratory failure. . # Respiratory Failure - Patient experienced acute desaturation following bone marrow biopsy and LP. Responded to suction and was switched from PS to AC. Because patient overbreathing the vent with nasal flaring, restarted propofol. Acute worsening of CXR likely due to dependent shift of phlegm. Underlying problem: PNA v. pulmonary hemorrorhage in setting of seizure with platelets of 17 v aspiration pneumonitis. Bronchoscopy revealed numerous blood clots, likley old blood from tracheostomy placement. Patient continued to be tachypneic with rates from 30-40, along with ABG showing relative hypercarbia and hypoxia despite vent changes. Clinical picture suggestive of severe airway disease. her ceftazidime was continued, along with the addition of colistin for pseudomonas VAP. An end tidal CO2 was also performed: 16 - > shunt 50%. On [**12-27**], after several days on the ventilator, the patient was made CMO according to her wishes. This decision was made after discussion with her husband, the [**Name (NI) 153**] attending, and the [**Name (NI) **] attending. She passed away on [**12-28**]. . # Seizure and depressed mental status -patient experienced tonic clonic seizure on [**12-25**] on BMT floor in setting of pancytopenia and low platelet count. Initial concern for intracranial bleeding. she was administered ativan and dilantin loaded. CT did not show evidence of bleeding. MRI c/w Posterior Reversible Encephalopathy Syndrome. her meropenem was discontinued, as it was thought to precipitate her seizures. The patient remained unresponsive overnight, however EEG did not reveal any seizure activity. The following morning the patient was responsive. She was continued on dilantin and did not experience any further seizures. LP was conducted which did not show any signs of infection. Cultures were unrevealing. Her blood presssure was maintained SBP's < 140 on lopressor. . # Pancytopenia - Thought to be drug effect v. loss of engraftment. Her meropenem and mycophelate were discontinued. Bone marrow biopsy was not consistent with loss of graft, and she was continued on neupogen . #CMV Viremia-Viremia detected from PCR, repeat PCR showing increased viremia. has been dosed according to renal function, previously considered discontinuing in setting of seizure and pancytopenia, however decided to continue gancyclovir with concurrent administration of neupogen. CMV viral load [**12-22**] 2160 copies. . # AML: The patient was initially admitted with pancytopenia, and was found to have AML. She has undergone a long preparation for allogenic BMT including 7+3 induction chemotherapy, completion of abx for a tooth extraction, liver biopsy for history of Hepatits C/B and initiation of lamivudine prophylaxis, and bronchoscopy for findings of ground glass opacities on chest CT. She received a stem cell marrow transplantation on [**10-29**] without any immediate complications. MTX Day +1, +3, +6, +11 for GVHD ppx with leucovorin rescue. Cyclosporin d/c'd because of renal failure. The patient was continued on methylprednisolone, diflucan, and ursodiol. Medications on Admission: Lorazepam, Prevacid. Discharge Disposition: Expired Discharge Diagnosis: Acute Myelogenous Leukemia Hepatitis B&C Cytomegaloviremia Discharge Condition: Patient deceased. Discharge Instructions: Patient deceased. Followup Instructions: Patient deceased.

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icd9cm

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icd9pcs

[ [ [] ] ]

24759, 24768

7024, 24688

359, 514

24871, 24891

3626, 6314

24957, 24978

2885, 3048

24789, 24850

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2599, 2869

48,292

199,250

6907

Discharge summary

report

Admission Date: [**2115-10-18**] Discharge Date: [**2115-10-23**] Date of Birth: [**2056-11-26**] Sex: M Service: MEDICINE Allergies: Magnevist Attending:[**First Name3 (LF) 14689**] Chief Complaint: decreased PO intake, confusion, worsening renal function Major Surgical or Invasive Procedure: none History of Present Illness: 58M with history of metastatic bladder cancer s/p XRT, completed carboplatin/gemcitabine [**8-27**], prostate cancer s/p brachytherapy, CHF with LVEF (30%), HTN, DM, and recent ICU admission for sepsis secondary to UTI, brought to ED from rehab with worsening renal function. Patient recently admitted [**Date range (1) 26021**]. Had initially presented to OSH w/lethargy and hypotension with SBP 70s-80s (baseline 90s). Was found to have UTI, also had urinary retention requiring Foley placement. Was initially admitted to floor, but developed recurrent hypotension requiring ICU transfer, aggressive IVFs, and pressor support. Antibiotics were broaded to vanc/cefepime. All blood cx remained negative. Urine cx at OSH grew 10-50,000 mixed gram positive flora; urine cx at [**Hospital1 18**] grew corynebacterium. He completed 10 day course of cefepime; vancomycin d/c'd after cultures came back and given concern it was contributing to thrombocytopenia. He was later restarted on ceftriaxone given concern for recurrent UTI, but this was d/c'd after 2 days given rising Cr and concern for AIN (urine eos positive). Patient's baseline Cr had been 1.2; was 2.1 at time of d/c. Had delirium during the admission, and was often not oriented to place or time. Was attributed to infection vs. narcotics use. Had thrombocytopenia likely related to his [**Hospital1 3454**]. Was concern for possible drug effect from vancomycin, and also concern for HIT. Heparin dependent antibodies sent and positive, but serotonin assay was negative (suggesting HIT not etiology). For his Afib/tachy-brady syndrome, he was continued on his digoxin. Metoprolol initially held given hypotension, and was restarted at a lower dose. Per notes, he was persistently tachy in the 100s-110s, with occasional bursts to the 120s-140s. Did not have any bradycardia. Despite ongoing IVF administration during the admission, he did not develop any evidence of volume overload/acute CHF. Had anemia which was attributed to his chemotherapy, though he also had hematuria attributed to his bladder cancer. Was transfused 2 units pRBCs during the admission. Was guiac positive at one point in setting of supratherapeutic INR, though later was guiac negative. Coagulopathy presumed secondary to antibiotic therapy and poor nutrition. Developed diarrhea which was presumed secondary to antibiotic use; C. diff was negative. Of note, patient continued to have intermittent fevers to as high as 101.5 during his course, ultimately presumed to be related to his malignancy. His code status was changed to DNR/DNI prior to discharge, and per records pt and his daughter were considering transition to comfort focused care and possible hospice. Per report, since discharge has had poor PO intake. Labs yesterday notable for rising WBC from 22.5 to 24.5, and rising BUN/Cr. Today, was hypotensive to 80/58, tachycardic to 118, and more confused. Was transferred to [**Hospital1 18**] for evaluation. In the ED, he triggered on arrival for hypotension with SBP in 80s. Vitals on presentation 95.2 125 88/60 16 100% 2L. Per report, patient was mentating well. Had mild TTP in suprapubic area. No UOP. Labs notable for WBC 21.2 with 85.7% N, Hct 26.4 (recent baseline 24-28), BUN/Cr 44/2.4 (baseline Cr 1.2, though was 2.1 on discharge [**2115-10-15**]), lactate 1.3. Blood cultures sent. Patient did not urinate and refused straight cath; therefore no UA/urine culture obtained. Given history of recent UTI and concern for sepsis secondary to urinary source, patient given cefepime. Also received 2L NS. BP remained in 80s. ED unable to reach patient's daughter, but given recent discussions of transitioning to comfort care, they held off on CVL placement and initiation of pressors. He is admitted now to ICU for further management of his hypotension. On arrival to the MICU, patient's VS 98.1 123 99/62 21 98% RA. Patient oriented to person and place, but not time. Answering most questions appropriately, though some circumferential answers. Review of systems: (+) Per HPI. Occasional abdominal pain and nausea with certain foods. Reports chronic lower abdominal pain for which he takes morphine. (-) Denies fevers, chills, sweats, headache, lightheadedness, shortness of breath, cough, chest pain, chest pressure, palpitations. Denies vomiting, constipation, diarrhea, dark or bloody stools. No dysuria, though does report increased urinary frequency. Denies hematuria. No rashes, myalgias, or arthralgias. Past Medical History: - Metastatic bladder CA, s/p TURBT [**2113-12-8**], high-grade pT2bNxMx stage II, mets to pelvic nodes, adrenals, lung, s/p cisplatin/gemcitabine [**2114-2-13**] to [**2114-5-8**] (5 cycles), carboplatin/gem [**2114-7-31**] to [**2114-9-18**] (3 cycles) - CAD/CHF w/EF 30%, s/p [**Company 1543**] Virtuoso II DR [**Last Name (STitle) 26019**] ICD - Hx of tachy-brady - ICD fired x6 on [**2114-11-4**] related to SVT and NSVT - Prostate CA [**2110-10-17**], [**Doctor Last Name **] 3+4=7 in [**2-12**] cores (5% of core) s/p brachytherapy - HTN - DM - Hyperlipidemia - Mild depression - Repair ruptured quadriceps tendon Social History: No current tobacco, alcohol or illicit drugs. Currently in rehab following prolonged hospital admission. Family History: Both parents died of cancer. History of DM in family. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: VS 98.1 123 99/62 21 98% RA. General: awake, oriented to person and place but not time, answering most questions appropriately though some circumferential answers, NAD HEENT: sclera anicteric, slightly dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: tachycardic but regular, normal S1+S2, no r/m/g Lungs: decreased breath sounds at bases, otherwise CTAB without wheezes/rales/rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding, no CVA tenderness 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, gait deferred Vitals ??????97.3, 90/46, 120, 26, 100% RA GENERAL: mild distress, AxOx0 HEENT: AT/NC, anicteric sclera, pink conjunctiva, patent nares, MMM CARDIAC: tachycardic but regular rhythm, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi ABDOMEN: somewhat distended, +BS, soft, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS [**2115-10-18**] 01:01PM WBC-21.2* RBC-2.70* HGB-8.0* HCT-26.4* MCV-98 MCH-29.7 MCHC-30.4* RDW-16.3* [**2115-10-18**] 01:01PM NEUTS-85.7* LYMPHS-7.3* MONOS-5.7 EOS-1.1 BASOS-0.2 [**2115-10-18**] 01:01PM PLT COUNT-156 [**2115-10-18**] 01:01PM GLUCOSE-124* UREA N-44* CREAT-2.4* SODIUM-138 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18 [**2115-10-18**] 01:01PM ALT(SGPT)-14 AST(SGOT)-23 ALK PHOS-133* TOT BILI-0.3 [**2115-10-18**] 01:01PM DIGOXIN-0.7* [**2115-10-18**] 02:20PM LACTATE-1.3 IMAGING CXR [**10-18**]: FINDINGS: Dual-lead pacemaker is again visualized. There is a small amount of volume loss in the left lower lobe laterally, but no infiltrate is seen. The remainder of the lungs are clear. Cardiac and mediastinal silhouettes are unchanged. MICROBIOLOGY [**10-17**] Blood culture pending [**10-19**] Urine culture ENTEROCOCCUS SP. 10,000-100,000 ORGANISMS/ML.. Brief Hospital Course: 58M with history of metastatic bladder cancer s/p XRT, [**Month/Year (2) 3454**], prostate cancer s/p brachytherapy, CHF with LVEF (25%), HTN, DM, and recent ICU admission for sepsis secondary to UTI, presenting now with decreased PO intake, recurrent hypotension, worsening leukocytosis, and worsening renal function. #Goals of Care: Pt was transitioned back to DNR/DNI on [**10-20**] and family meeting held with decision to transition to comfort focused care. Pt's morphine was discontinued for concern over neurotoxic metabolites. Pallative care saw pt and recommended starting fetanyl patch and PO Dilaudid PRN. This regimen appeared to keep pt comfortable yet pt continued with dilirium. Pt was also given Olanzepine at night so that he would be more comfortable and less agitated. Pt's medications for chronic health issues (ie blood pressure meds, etc) were discontinued to adhere to pt's goals of care. #SIRS/Hypotension/Probable Sepsis: Patient p/w worsening leukocytosis and tachycardia; concern for severe sepsis given hypotension, decreased UOP, increased confusion, and worsening renal function. Was having intermittent fevers during recent admission, and was hypothermic in ED. No clear source of infection; UA suggestive of UTI, but similar to UAs obtained during recent admission that were culture negative. Did report urinary frequency and has had mild suprapubic tenderness, though possible symptoms and UA findings are related to underlying bladder cancer. Clinical picture not suggestive of PNA or meningitis. Presentation may be secondary to malignancy, and not recurrent infection. WBC initially trending down with broad spectrum antibiotics 21.2 -> 19.0 but 24.4 again on [**10-20**]. Hypotension could be related to volume depletion given recent decrease in PO intake, and did improve with IVF overnight. Adrenal insufficiency less likely given normal/elevated cortisol level. SBP currently improved to 110s-120s after 4L IVF, though patient continues to have confusion and low UOP (has been incontinent and refusing Foley, so unable to accurately assess UOP). Normal lactate reassuring. He remained afebrile throughout his stay in the [**Hospital Unit Name 153**]. He was started on broad spectrum antibiotics with vanc/zosyn (holding cefepime given concern for AIN) on [**10-18**]. Antibiotics were discontinued as a family meeting was held with pt and his daughter and the decision was made to transition to comfort focused care. #Delirium: Patient only oriented to person and place; at baseline has been AAOx3 though recent course c/b delirium. DDx includes delirium secondary to possible infection, narcotics use, renal function; poor perfusion in setting of hypotension. Exam not suggestive of meningitis, and neuro exam non-focal. He was worked up and treated empirically for possible infection as above with antibiotics being discontinued once decision made with family to transition to comfort focused care. #Tachycardia: ECG showed sinus tachycardia with PVCs. During recent admission HR 100s-110s with bursts to 120s-140s. DDx includes infection, volume depletion, pain, anemia. Was not febrile. Metoprolol increased from 25mg TID to 50mg TID and later discontinued once decision made with family to transition to comfort focused care. #[**Last Name (un) **] on CRI: Cr initially trended down from 2.4 to 2.2 after fluid resuscitation but trended back up to 2.5 on [**10-20**]. Baseline previously 1.2-1.3. Was likely component of pre-renal azotemia secondary to possible sepsis and volume depletion. AIN remained on differential, and urine eos again positive. Also concern for CIN given recent contrast CT scans. DDx includes poor forward flow from CHF, ATN given recent hypotension (FeNa 2.1%),, post-renal obstruction from patient's malignancy (hydronephrosis noted on recent imaging). No intervention made as decision made with family to transition to comfort focused care. #Metastatic bladder cancer: CT during recent admission showed progression of disease. After family meeting with patient's oncology team, decision was made to avoid aggressive treatment and focus on pain control and symptom management, given poor prognosis. However, on [**10-19**] daughter expressed she would like patient to remain full code. On [**10-20**] the OMED team was called who came to see the patient and again initiated code discussion, at which time the patient and daughter decided to transition back to DNR/DNI, with a focus on comfort care. Palliative care was consulted with plans to see him on [**10-21**]. Pain appears to be well controlled per patient; home doses of morphine were continued. Given his goals of care and hemodynamic stability, he was transferred to the floor. Pt's cancer discussed with oncology attending and decision made with family to transition to comfort focused care seemed like best plan for patient and family. #sCHF: EF 25% on echo during recent admission. Has [**Company 1543**] Virtuoso II DR [**Last Name (STitle) 26019**] ICD in place which was turned off once decision made with family to transition to comfort focused care. #Prostate cancer: Diagnosed [**2110-10-17**], [**Doctor Last Name **] 3+4=7 in [**2-12**] cores (5% of core). s/p brachytherapy. Goals of care discussion as above. #Anemia: Hct close to recent baseline. During recent admission was attributed to chemotherapy, hematuria from bladder malignancy. UA does show persistent hematuria. H&H was trended with no precipitous drop. #DM: Home insulin 70/30 14 units [**Hospital1 **] was continued as well as ISS until decision made with family to transition to comfort focused care. Insulin was then discontinued. #HTN: Initially decreased dose metoprolol given recent hypotension. Increased to 50mg TID on [**10-19**] and later discontinued entirely once decision made with family to transition to comfort focused care. TRANSITIONAL ISSUES ===================== - Pt remained DNR/DNI during this hospitalization Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Outpatient rehab records. 1. Bisacodyl 10 mg PR HS:PRN constipation 2. Fleet Enema 1 Enema PR DAILY:PRN constipation not improving with bisacodyl 3. Polyethylene Glycol 17 g PO DAILY:PRN constipation 4. Senna 1 TAB PO BID:PRN constipation 5. Docusate Sodium 100 mg PO BID hold for loose stools 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Acetaminophen 650 mg PO TID 8. Digoxin 0.25 mg PO DAILY 9. Glucagon 1 mg IM ONCE:PRN hypoglycemia 10. NovoLIN 70/30 *NF* (insulin NPH & regular human) 14 units Subcutaneous [**Hospital1 **] with breakfast and dinner 11. Morphine SR (MS Contin) 60 mg PO Q8H hold for sedation or RR <12 12. Morphine Sulfate IR 15 mg PO Q3H:PRN pain hold for sedation or RR <12 13. Prochlorperazine 5 mg PO Q6H:PRN mild nausea 14. Prochlorperazine 10 mg PO Q6H:PRN moderate to severe nausea Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Bisacodyl 10 mg PR HS:PRN constipation 3. Docusate Sodium 100 mg PO BID hold for loose stools 4. Polyethylene Glycol 17 g PO DAILY:PRN constipation 5. Senna 1 TAB PO BID:PRN constipation 6. Fentanyl Patch 50 mcg/h TP Q72H RX *fentanyl 50 mcg/hour 1 patch every 72 hours Disp #*10 Transdermal Patch Refills:*0 7. HYDROmorphone (Dilaudid) 4-8 mg PO Q2H:PRN Pain do not give if sedated or rr<12 RX *hydromorphone [Dilaudid] 4 mg [**2-4**] tablet(s) by mouth every 2 hours Disp #*100 Tablet Refills:*0 8. OLANZapine (Disintegrating Tablet) 5 mg PO TID:PRN agitation/nausea RX *olanzapine 5 mg 1 tablet(s) by mouth three times a day Disp #*30 Tablet Refills:*0 9. Prochlorperazine 5-10 mg PO Q6H:PRN nausea 10. OxycoDONE (Concentrated Oral Soln) 5-10 mg PO EVERY 4 HOURS pain or breathlessness Please use if unable to swallow hydrocodone. RX *oxycodone 5 mg/5 mL 5-10 mg by mouth every 6 hours Disp #*100 Milliliter Refills:*0 11. Lorazepam 1 mg PO Q6H:PRN amxiety RX *lorazepam 1 mg 1 tablet by mouth every 6 hours Disp #*16 Tablet Refills:*0 12. Atropine Sulfate 1% 1 DROP SL PRN secretions RX *atropine 1 % 1 drop SL every 4 hours Disp #*15 Milliliter Refills:*0 Discharge Disposition: Extended Care Facility: [**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**] Discharge Diagnosis: Primary: metastatic bladder cancer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 26015**], You were admitted to the hospital with low blood pressure and worsening kidney function. You were initially admitted to the intensive care unit for management of your hypotension. A family meeting was held with you and your daughter and the decision was made to transition to comfort focused care. You were discharged to a a hospice facility. Followup Instructions: No need for follow-up. You can call Dr.[**Name (NI) 15380**] office at [**Telephone/Fax (1) 10784**] with any concerns. [**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]

[ "V58.67", "276.3", "196.6", "428.22", "197.0", "403.90", "428.0", "250.00", "427.31", "V10.51", "V45.02", "585.9", "038.9", "286.7", "995.92", "E933.1", "584.9", "287.49", "198.7", "285.3", "V10.46", "V15.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

16182, 16282

8020, 14001

332, 338

16361, 16361

7080, 7997

16946, 17167

5663, 5720

14953, 16159

16303, 16340

14027, 14930

16541, 16923

5735, 7061

4426, 4879

235, 294

366, 4407

16376, 16517

4901, 5523

5539, 5647

8,653

130,034

1685

Discharge summary

report

Admission Date: [**2149-9-20**] Discharge Date: [**2149-10-8**] Service: GREEN SURGERY CHIEF COMPLAINT: Abdominal pain, nausea, vomiting and diarrhea. HISTORY OF PRESENT ILLNESS: This is an 89 year-old female status post a fall two weeks prior to her presentation to the Emergency Department who presented with a one week history of lightheadedness, nausea, abdominal tenderness and decreased po intake. The patient states she had an achy lower abdominal pain with left greater then right that comes and goes. The patient describes the pain as diffuse, however, mainly is located to the left lower quadrant on admission. The patient states her symptoms are associated with lightheadedness and dizziness, two episodes of emesis that were dark in color and diarrhea two to three times per day over the past week. The patient states there was no blood in her stool. The patient denies any melena. The patient endorses her last po intake being two days prior to presentation to the Emergency Department. The patient notes abdominal distention. The patient denies any headaches, chest pain, shortness of breath, dysuria, cough or flank pain. PAST MEDICAL HISTORY: 1. Vertigo. 2. Depression. 3. Arthritis. 4. Macular degeneration. 5. Recurrent urinary tract infection. MEDICATIONS ON ADMISSION: 1. Levaquin 250 mg times five days. 2. Paxil 10 mg q day. 3. Milk of Magnesia 30 cc prn. 4. Dulcolax prn. 5. Fleets enema prn. 6. APAP 325 mg two tablets three times a day. 7. Disalcid 750 mg b.i.d. ALLERGIES: Codeine. PHYSICAL EXAMINATION: Vital signs temperature 97.1. Blood pressure 180/91. Heart rate 73. Respiratory rate 16. O2 saturations 96% on room air. General she was alert and oriented, slightly lethargic and in no acute distress. HEENT pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Mucous membranes are dry. Cardiovascular regular rate and rhythm. 3 out of 6 systolic ejection murmur. Respirations clear to auscultation bilaterally. Abdomen soft, slightly distended, positive left lower quadrant tenderness. Extremities palpable pulses. No edema or erythema noted. LABORATORIES ON ADMISSION: White blood cell count 16.5, hematocrit 40.0, platelet 646, sodium 129, potassium 3.8, chloride 91, bicarb 24, BUN 20, creatinine 0.6, ALT 20, AST 19, alkaline phosphatase 87, total bilirubin 0.5, amylase 115, lipase 17. Lactate 1.7. KUB was done in the Emergency Department, which showed rectum full of stool, little to no air in the colon, no air seen in the rectum, multiple air fluid levels, no distended loops of bowel. A CT was done in the Emergency Department and this showed dilation of colon with multiple air fluid levels, extensive stool in the rectum consistent with fecal impaction, small amount of free fluid in the left pericolic gutter, 1.6 cm lesion left adrenal gland and 1 cm low attenuation lesion in the left kidney. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit and started on intravenous fluid resuscitation, given soap suds enemas, Milk of Magnesia. The patient's symptoms did not resolve with the soap suds enema and the patient was consented for surgery. The patient on [**9-21**] underwent a total abdominal colectomy and ileostomy. The patient tolerated the procedure well and remained intubated out of the Operating Room and was transferred to the Intensive Care Unit. The patient remained intubated in the Intensive Care Unit and was started on a Fentanyl drip. On postoperative day number one the patient was started on total parenteral nutrition and a Fentanyl drip was stopped. The patient was noted to have a low hematocrit and the decision was made to give the patient one unit of packed red blood cells. The patient continued to undergo fluid resuscitation. On postoperative day number two the patient was started on broad spectrum antibiotics to cover for suspected sepsis. The patient was also seen by cardiology and underwent an echocardiogram. The results of this are moderately dilated left atrium, severe global left ventricular hypokinesis, moderate aortic valve stenosis, severe mitral annular calcifications, mild pulmonary artery systolic hypertension. The patient has an ejection fraction of approximately 25%. A central venous line was placed on [**9-23**] to facilitate total parenteral nutrition. On postoperative day number three the Intensive Care Unit team continued to wean the patient, which she tolerated well. On postoperative day number five the patient is still in the Intensive Care Unit on Ampicillin, Levo and Flagyl. The patient had an elevated white blood cell count of 14.2 and her sputum sample came back showing 2+ yeast and the patient was started on Diflucan. The patient was continued to be weaned off the pressure support and tolerated the weaning without difficulty. On [**9-26**] the patient was noted to have elevated heart rates and systolic blood pressure of 130. She had crackles half way up her lung bases and a CVP of 8 to 9 on the monitor. She was given 10 mg of intravenous Lasix to which she responded well and the patient diuresed. In order to get better control of the patient's diuresis the patient was placed on a Lasix drip and this allowed the safe removal of excess fluid from her lungs. On [**9-29**], postoperative day number eight the patient remained on Ampicillin, Levofloxacin and Flagyl. In addition she had been placed on Fluconazole for yeast in her sputum. The patient remained afebrile with an elevated white blood cell count of 21.4. The patient continued to be weaned from the ventilator. At this time the patient's tube feeds were at goal and the ileostomy was draining serous fluid. On [**9-28**], the patient had one episode of agitation with her heart rate increasing to 120 and respiratory rate increasing to the 30s. The patient underwent a CAT scan to evaluate the possibility of an abscess following her operation. The CAT scan with intravenous contrast indicated intact surgical anastomosis, no free pelvic fluid and a questionable small fluid collection next to the [**Doctor Last Name 3379**] pouch. On [**10-1**] a meeting was held with the patient's family regarding the status of the patient and it was decided that the patient would be extubated during that day and there would be no further reintubation if she was unable to tolerate the procedure. The patient was also placed on a DNR status. The patient was extubated on [**10-1**] and placed on 50% face mask. She was saturating at 97 to 100%, no shortness of breath, respiratory rate in the 20s. The patient tolerated the extubation well and was transferred out of the Intensive Care Unit to the floor. On the floor the patient continued to do well after extubation. She remained afebrile, though her white blood cell count still remained slightly elevated at 13.2 on [**2149-10-2**]. The patient was continued on her Levofloxacin, Flagyl and Fluconazole. The patient was evaluated on [**10-2**] for a bed side swallow evaluation. The patient did not demonstrate any aspiration or dysphagia and it was recommended that the patient get started on a regular consistency solid and thin liquids. Following this recommendation the patient's diet was advanced as tolerated. The patient continued to do well on the floor. The patient was given 20 mg intravenous Lasix on [**10-3**] to help remove some of the excess fluid that had accumulated during her postoperative period. The patient was seen by occupational therapy and screened for rehabilitation. The recommendation was made to send the patient to a rehabilitation facility following her postoperative course in the hospital. On postoperative day number fourteen the patient was febrile to 101 overnight. The patient did not complain of any chest pain, shortness of breath, headaches, fevers or sweats. A chest x-ray done at that time showed diffuse interstitial pulmonary edema with pleural effusion, which were slightly increased from the previous study on [**9-26**]. The patient continued to be diuresed with Lasix 20 mg intravenously to which she responded very well. Blood cultures and urine cultures were sent both of which came back negative. On [**10-6**] the patient was seen by psychiatry for an inpatient evaluation regarding restarting of her antidepressant medications. Recommendations were presumed delirium episode instead of depression, check TSH, B-12 and folate, psychiatry to follow and reevaluate when the patient is more awake. Postoperative day number 15 the patient continued to do well and her second JP drain was removed. The patient had been seen by physical therapy and had been out of bed to chair, but was not ambulating independently at this point. On postoperative day number 17 the patient continued to do well. Her central line was removed and the patient was discharged to rehabilitation facility. DISPOSITION: The patient was discharged to [**Location (un) 2716**] Point in [**Location (un) 55**], phone number [**Telephone/Fax (1) 9714**]. The patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in two to three weeks. CONDITION ON DISCHARGE: Good. The patient remained afebrile, tolerating po foods without difficulty and has been out of bed to chair. MEDICATIONS ON DISCHARGE: 1. Tylenol 650 mg po q 4 to 6 hours prn. 2. Miconazole powder 2% one application q.i.d. prn. 3. Toprol 12.5 mg po b.i.d. hold for systolic blood pressure of less then 100. 4. Aspirin 81 mg po q day. 5. Percocet elixir 5 to 10 milliliters po q 4 to 6 hours prn. 6. Pantoprazole 40 mg po q 12 hours. 7. Maalox 15 to 30 milliliters po q.i.d. prn. 8. Insulin sliding scale. DISCHARGE DIAGNOSES: 1. Status post total abdominal colectomy. 2. Status post proctectomy. 3. Depression. 4. Arthritis. 5. Recurrent urinary tract infections. 6. Macular degeneration. 7. Vertigo. 8. Status post dilatation and curettage. [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**] Dictated By:[**Name8 (MD) 846**] MEDQUIST36 D: [**2149-10-8**] 10:38 T: [**2149-10-8**] 10:49 JOB#: [**Job Number 9715**]

[ "398.91", "396.2", "038.9", "557.0", "560.39", "789.5", "518.5", "276.1", "285.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "47.19", "99.04", "46.21", "38.93", "96.38", "99.15", "45.8", "48.69" ]

icd9pcs

[ [ [] ] ]

9767, 10261

9367, 9746

1318, 1547

2959, 9204

1570, 2184

117, 165

194, 1160

2199, 2941

1182, 1292

9229, 9341

13,725

163,207

20236+20237

Discharge summary

report+report

Admission Date: [**2172-1-16**] Discharge Date: [**2172-1-28**] Date of Birth: [**2133-6-2**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 38 year-old male who presented on [**11-8**] with hematuria and right sided flank pain found to have a 5 to 6 mm right kidney mass and a 2 to 2.5 cm left lower lung nodule. On [**2171-11-22**] the patient underwent a right nephrectomy with evidence of sarcomatoid features. Repeat CT of chest revealed multiple lung metastases. The patient is now admitted for HDIL-2. REVIEW OF SYSTEMS: Left shoulder pain, slight rash - the patient is sensitive to tapes. Denies dizziness, lightheadedness, visual changes, shortness of breath, cough, nausea, vomiting, diarrhea, constipation, abdominal pain, dysuria, weakness, numbness and tingling, fevers, chills, night sweats. PAST MEDICAL HISTORY: 1. Renal cell cancer with metastasis to lung. 2. Hypertension on Accupril. 3. Eczema. FAMILY HISTORY: Father with diabetes and hypercholesterolemia as well as coronary artery disease. Family history of hypertension. Paternal grandparents with coronary artery disease. SOCIAL HISTORY: Denies tobacco, cocaine use, alcohol use. ALLERGIES: No known drug allergies. MEDICATIONS: Accupril (off since Saturday). PHYSICAL EXAMINATION: Temperature 98.5. Pulse 105. Blood pressure 145/99. Respirations 18. Sating 97% on room air. HEENT normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Mucous membranes are moist. Oropharynx is clear. Cardiovascular regular rate and rhythm, normal S1 and S2. Pulmonary clear to auscultation bilaterally. No rales, wheezes or rhonchi. Abdomen round, bowel sounds present, soft, nontender, nondistended. Extremities no clubbing, cyanosis or edema. Skin macular rash scattered over chest, otherwise intact. Right nephrectomy scar over right lateral portion of the abdomen. DATA: White blood cell count 10.5, hematocrit 41.9, platelets 330, sodium 131, potassium 4.3, chloride 101, bicarb 30, BUN 21, creatinine 1.3, ALT 70, AST 31, CPK 53, total bilirubin was 12.4, albumin 4.7, calcium 10.6, phos 3.3, magnesium 1.8, uric acid 7.5, glucose 68. Chest x-ray impression no pneumothorax, lungs clear. HOSPITAL COURSE: 1. Renal cell cancer: The patient was admitted for IL-2 treatment, however, during the course of the week IL-2 treatment was stopped secondary to the complication of myocarditis. The patient was discharged home on the 23rd without any further complications, but to follow up with his primary oncologist for further recommendations and treatment. 2. Myocarditis: The patient on [**2172-1-24**] was complaining of shortness of breath and palpitations at around 10:00 at night. By that day IL-2 had already been stopped, because of concerns with neurotoxicity. IL-2 was well known to have cardiotoxicity as a side effect. Cardiac enzymes were cycled and peak CK was 457, peak troponin was 3.30 and peak CKMB was 112. Telemetry monitoring showed several runs of nonsustained ventricular tachycardia with the longest run being eight beats. The patient was subsequently transferred to the [**Hospital Unit Name 153**] for closer monitoring. During the [**Hospital Unit Name 153**] admission the patient was noted to have two further runs of nonsustained ventricular tachycardia. One was a five beat run of narrow complex tachycardia and the other was a seven beat run of wide complex tachycardia. Cardiology was consulted. They recommended starting aspirin 81 mg, beta blocker was started on 12.5 b.i.d. and titrated up to 25 b.i.d. Captopril was started as well [**Company 34868**].i.d. Cardiac medications were well tolerated. Cardiology agreed with the assessment that the patient might have sustained cardiotoxicity secondary to IL-2 treatment causing myocarditis. The patient was stabilized and subsequently transferred from the [**Hospital Unit Name 153**] out to Four South. The patient was discharged the following day. No further complications noted on the last two to three days of admission. Echocardiogram was done for further heart evaluation. Results were as follows; left atrium mildly dilated, right atrium moderately dilated, no atrial septal defect. Left ventricular wall thickness normal, left ventricular cavity size normal, overall left ventricular systolic function is normal. EF of 60%. Right ventricular chamber size and free wall motion are normal. Aortic valve leaflets appeared structurally normal with good leaflet excursion and no aortic regurgitation. Mitral valves appear structurally normal. Trivial mitral regurgitation. No mitral valve prolapse. No pericardial effusion. 3. Hypertension: The patient was continued on beta blocker and ace inhibitor. Subsequently restarted on his outpatient hypertension medication of Accupril. Beta blocker and ace inhibitor were stopped prior to discharge. 4. Eczema: The patient was given Sarna lotion prn while an inpatient. Benadryl was also given to assist with pruritus. 5. Transaminitis: The patient developed some transaminitis likely secondary to the myocarditis in addition to some mild hepatotoxicity due to the IL-2 treatments. ALT, AST, T-bilirubin, alkaline phosphatase all returned to [**Location 213**] prior to discharge. 6. Prophylaxis: Heparin subcutaneous. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Myocarditis. 2. Renal cell cancer metastasis. 3. Hypertension. 4. Transaminitis. 5. Eczema. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg one tablet q day. 2. Ciprofloxacin 250 mg one tablet b.i.d. times five days. 3. Accupril. 4. Ranitidine 150 mg one tablet b.i.d. 5. Compazine 10 mg tablet one tablet q 6 hours prn. 6. Lomotil one to two tablets four times a day prn. 7. Ativan 1 mg prn. FOLLOW UP PLANS: 1. The patient is to follow up with his primary oncologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]. He is to call his office to schedule an appointment, [**Telephone/Fax (1) 54346**]. 2. The patient will be returning the week of [**2-10**] for the next cycle of IL-2. 3. The patient is to have a stress test by the end of next week. Dr.[**Name (NI) 30161**] office will contact the patient with details of that appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], M.D. [**MD Number(1) 16215**] Dictated By:[**Last Name (NamePattern1) 9622**] MEDQUIST36 D: [**2172-1-28**] 10:37 T: [**2172-2-3**] 12:36 JOB#: [**Job Number 54347**] Admission Date: [**2172-1-20**] Discharge Date: [**2172-1-28**] Date of Birth: [**2133-6-2**] Sex: M Service: BIOLOGICS HISTORY OF PRESENT ILLNESS: The patient is a 38 year old male who presented in [**2171-11-6**] with hematuria and right sided flank pain. Work-up revealed a 5 to 6 centimeter right kidney mass and a 2 to 2.5 centimeter left lower lobe nodule. On [**2171-11-22**], he underwent a right nephrectomy with pathology revealing clear cell type with sarcoidmatoid features [**Last Name (un) 9951**] Grade 4 out of 4. A repeat CT scan of the chest revealed multiple lung metastases. He was evaluated and found to be eligible for high dose IL-2 treatment. PAST MEDICAL HISTORY: 1. Hypertension. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Physical examination revealed a well appearing young male in no acute distress. Head, Eyes, Ears, Nose and Throat: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Moist oral mucosa without lesions. Heart regular rate and rhythm with S1, S2. Chest clear. Abdomen round, positive bowel sounds. Soft, nontender. No hepatosplenomegaly. Extremities with no lower extremity edema. Lymph nodes: No cervical, axillary or inguinal lymphadenopathy. Skin revealed a macular rash over the chest; otherwise without skin breakdown. LABORATORY: On admission, white blood cell count 10.5, hemoglobin 14.7, hematocrit 41.9, platelet count 330,000. BUN 21, creatinine 1.3. Sodium 139, potassium 4.3, chloride 101, carbon dioxide 30, ALT 75, AST 31, CPK 53, total bilirubin 0.4, albumin 4.7. Calcium 10.6, phosphorus 3.3, magnesium 1.8, uric acid 7.5. HOSPITAL COURSE: The patient was admitted [**2172-1-20**] to begin his first cycle of high dose IL-2 treatment. During this week, he received 10 out of 14 scheduled doses of IL-2 with doses 11 through 14 held because of neurotoxicity. Other side effects included mild fever and chills treated with Tylenol and Indocin. He also developed nausea, vomiting and diarrhea treated with anti-emetics and anti-diarrheals. He developed an erythematous skin rash without desquamation. He had no hypotension during his hospital course. The neurotoxicity was manifested by restlessness and agitation, improved with IL-2 therapy on hold. He gained approximately 11 pounds while on IL-2 therapy. He developed a mild renal insufficiency with a peak creatinine of 1.4. He developed a transaminitis with a peak ALT of 114 and a peak AST of 108. He developed hyperbilirubinemia with a peak bilirubin of 5.7. He had no metabolic acidosis during his IL-2 treatment. He had a mild thrombocytopenia with a low of 100,000 on [**2172-1-25**], which had improved to 200,000 at the time of discharge. He had no neutropenia or anemia during his course. On [**2172-1-25**], he was noted to have a CPK of 457 with several short runs of ventricular tachycardia. He was transferred to the Intensive Care Unit for further monitoring. CK MB returned at 112 with a troponin level of 1.97. This troponin continued to increase but his CPK normalized. He was felt to have an IL-2 induced myocarditis. His echocardiogram revealed a mildly dilated left atrium with a moderately dilated right atrium. No atrial septal defect noted. Left ventricular wall thickness is normal. Left ventricular cavity size is normal. Overall left ventricular systolic ejection fraction of 60%. Right ventricular chamber size and free wall motion are normal. Aortic valve leaflets appear structurally normal without aortic regurgitation. Mitral valve appears structurally normal with trivial mitral regurgitation; no mitral valve prolapse; no pericardial effusion. He was maintained on aspirin and beta blockers and had no further ectopy throughout his course. He was stabilized from a cardiac perspective and discharged to home on [**2172-1-28**]. His neurotoxicity had also resolved at this time. DISCHARGE MEDICATIONS: 1. Accupril 20 mg p.o. q. day. 2. Ciprofloxacin 500 mg p.o. twice a day. 3. Compazine 10 mg p.o. q. six hours p.r.n. nausea and vomiting. 4. Ativan 1 mg p.o. q. six hours p.r.n. nausea and vomiting. 5. Lomotil one to two tablets p.o. four times a day p.r.n. for diarrhea. DISCHARGE INSTRUCTIONS: 1. He was planned for follow-up for his next planned cycle of IL-2. CONDITION ON DISCHARGE: Improved. DISCHARGE STATUS: To home. The patient's discharge instructions, medications, as above. DISCHARGE DIAGNOSES: 1. Metastatic renal cell carcinoma status post one cycle of high dose IL-2. 2. IL-2 induced myocarditis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1736**] Dictated By:[**Last Name (NamePattern1) 43757**] MEDQUIST36 D: [**2172-4-10**] 15:54 T: [**2172-4-11**] 19:42 JOB#: [**Job Number 54348**] cc:[**Last Name (NamePattern4) 54349**]

[ "692.9", "422.93", "790.4", "E933.1", "401.9", "197.0", "V58.1", "V10.52", "997.1" ]

icd9cm

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47393

Discharge summary

report

Admission Date: [**2126-11-10**] Discharge Date: [**2126-11-16**] Date of Birth: [**2069-2-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: s/p seizure Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: 57 yo male, h/o ETOH abuse, was talking to wife, slipped on kitchen floor and hit his head. He had told his wife that he was fine, and went to bedroom to lie down. About 30 mins later, wife states he was acting strange and pointing at everything. He walked away from her, and hit the floor again, but didn't head the second time. [**Name (NI) **] wife states he was shaking/trembling, looked like he was snoring but eyes wide open. Once EMS showed up 15 mins, he was responding- eyes were open, and slightly aware, but not communicating. Patient has had seizures before at [**Name (NI) 100289**] wife thinks it was in [**Month (only) **]. Patient doesn't take medications for seizures. No ETOH today per wife. [**Name (NI) **] he drinks while she is at work. She's not sure if the seizures in the past were in the setting of etoh withdrawal. . In the ED, vitals were 98.0, 154, 153/113, 34, and 94% on NRB. Patient was intubated for airway protection because he was combative. He was given 5 mg haldol, ativan IM, lidocaine, etomidate, and succinate. A CT head showed ICH with ? mass with surrounding edema, was given decadron 10 mg x 1. CT c-spine with mild disc bulge, but no acute fracture. The patient had a c-collar placed. Neurosurgery and neurology were called in the ED; will see patient on admission to the MICU. The patient was then transferred to an ICU bed. Of note, he also had a FAST scan in the ED which was negative. . On review of systems, No recent travel history. Moving around- not bed bound. No fevers, no chills recently. Feeding tube was placed for malnutrtion during a previous admission at [**Hospital3 2568**] for malnutrition. He does not do his tube feeds regularly. Had ? stent in his throat to help tolerate liquids/solids per wife. Past Medical History: # PMHX: ETOH Abuse GERD CKD cr 1.6-2 HTN Chronic hiccups Chronic Gastritis and esophagitis gastric varices Portal hypertensive gastropathy. Social History: SOC: He works at a gas company. He denies tobacco. He drinks 1 pint of vodka per day for the last 5 or 6 years. No IV drug use. He lives at home. His last drink was the day prior to admission. He denies history of DTs or alcohol withdrawal. Family History: FH: NC Physical Exam: T:98.3 BP:143/89 HR:103 RR:17 O2 100% RA on AC 450/18/5/100% 7.52/44/502/37 Gen: thin, cachectic appearing male, sedated, intubated. does not respond to voice HEENT: No conjunctival pallor. No icterus. MM dry. OP clear. NECK: Supple, No LAD, No JVD. No thyromegaly. C-collar in place CV: RRR. tachycardic. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: CTAB, good BS BL, No W/R/C ABD: hypoactive BS. Soft, thin, NT, ND. No HSM. G-tube in place; no e/o infection at site EXT: WWP, NO CCE. 2+ DP pulses BL. SKIN: No rashes/lesions, ecchymoses. NEURO: sedated; pupils 2mm bilaterally; sluggish response to light. negative babinski. 2+ reflexes BUE/BLE. flex to pain stimuli, slightly decreased response in LUE. Pertinent Results: [**2126-11-10**] 08:50PM PT-13.3 PTT-25.6 INR(PT)-1.1 [**2126-11-10**] 08:50PM PLT COUNT-546*# [**2126-11-10**] 08:50PM NEUTS-67.7 LYMPHS-26.5 MONOS-4.8 EOS-0.8 BASOS-0.4 [**2126-11-10**] 08:50PM WBC-9.5 RBC-2.95* HGB-8.6* HCT-26.7* MCV-91 MCH-29.2 MCHC-32.2 RDW-17.7* [**2126-11-10**] 08:50PM ASA-NEG ETHANOL-11* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2126-11-10**] 08:50PM ALBUMIN-3.8 CALCIUM-9.1 PHOSPHATE-4.2# MAGNESIUM-2.0 [**2126-11-10**] 08:50PM CK-MB-4 [**2126-11-10**] 08:50PM cTropnT-0.05* [**2126-11-10**] 08:50PM LIPASE-42 [**2126-11-10**] 08:50PM ALT(SGPT)-25 AST(SGOT)-37 ALK PHOS-145* TOT BILI-0.5 [**2126-11-10**] 08:50PM estGFR-Using this [**2126-11-10**] 08:50PM GLUCOSE-153* UREA N-14 CREAT-0.9 SODIUM-137 POTASSIUM-3.3 CHLORIDE-85* TOTAL CO2-23 ANION GAP-32* [**2126-11-10**] 08:59PM LACTATE-14.1* [**2126-11-10**] 10:20PM LACTATE-3.5* [**2126-11-10**] 10:20PM TYPE-ART RATES-/14 TIDAL VOL-450 PEEP-5 O2-100 PO2-502* PCO2-44 PH-7.52* TOTAL CO2-37* BASE XS-12 AADO2-190 REQ O2-39 -ASSIST/CON INTUBATED-INTUBATED Brief Hospital Course: 57 year old man with significant alcohol abuse admitted with likely seizure and frontal contusion following a fall with head trauma. . ## Delirium- resolved. Broad differential including infectious vs. toxic/metabolic; frontal contusion very likely contributing. Patient with normal folate/b12. TSH low normal with free T4 normal, RPR negative. Chest x-ray from the MICU without any obvious infiltrate. Patient in the MICU did not appear to be withdrawing from alcohol, however possible that seizure was secondary to EtOH withdrawal given that alcohol level low on admission. Alternatively seizure occurred in repsonse to ICH which occurred secondary to fall. Patient currenty awake, alert, oriented to person, year and knew he was in the hospital although did not know which one or why. Patient had UTI, so d/c'd Foley and treated with cipro x 7 days total. As patient mental status appears improved and likely etiology of seizure is alcohol will hold off on LP at this time. Patient was maintained on fall precautions. Patient was continued on thiamine and folic acid as patient has a history of severe malnutrition. Consulted with neurosurgery, changed to keppra for seizure prophylaxis for one month post discharge, chosen instead of dilantin as there is no need to monitor levels. . ## Seizure - most likely secondary to alcohol withdrawal as etoh level on admission was 11 and patient with heavy drinking history as well as prevous history of alcohol induced seizures; could have likely been in the setting of fall with ICH since according to wife, the seizure occured after the first witnessed fall with head trauma. Alternatively could have had seizure from alcohol withdrawal itself. Metabolic disturbances such as hypoglycemia less likely given that were normal on arrival. h/o PE with LOC in the past with IVC filter in place. No specific neurological deficits noted on limited exam to suggest stroke. Patient was discharged on keppra for seizure prophylaxis for one month given new potential focus for seizures. Given likely etiology of seizure, decided that EEG unlikely to be of diagnostic value. blood culture no growth to date. Records from [**Hospital3 2568**] were also reviewed online, and they document history of alcohol withdrawal seizures. . ## Fall: Patient without radiographic evidence of C-spine damage, so cleared c-spine with range of motion without pain and no pain on palpation over neck, as per neurosurgery protocol. Patient with right shoulder pain so consulted ortho, x-ray as above likely chronic old fracture. This was found in records from [**Hospital3 **] as well. . ## Anemia; likely from known gastritis, increased ppi to [**Hospital1 **]. Patient recieved 1 unit of blood in the MICU, did not recieve any on the floor, hematocrits were stable. Anemia work-up with folate/B12 normal, low iron, TIBC 390 (nl), ferritin (low-normal), and tranferrin 300 (nl). Given history of gastritis, guaiac positive stool, and ferritin being an acute phase reactant, this is likely iron deficiency anemia. Patienet started on iron repletion. Patient needs outpatient GI follow up to discuss esophageal stricture as well as history of GI bleeds. . ## Orbital fracture. Patient noted to have orbital fracture on admission, and plastics consulted who recommended: This is a non-operative facial fracture. No antibiotics are needed at this time. No restrictions in activity. No follow-up necessary. Please call with questions. . ## FEN: got speech and swallow evaluation, started patient on thin liquids and pureed foods yesterday, continued tube feed as per nutrition, repleted lytes PRN. Of note, speech and swallow stated that pills do not pass from esophagus into stomach, so all medications need to be given through the G tube. . ## Communication: wife [**Name (NI) **] [**Name (NI) 100290**] (home [**Telephone/Fax (1) 100291**]; cell [**Telephone/Fax (1) 100292**]; work btwn 6a-5p [**Telephone/Fax (1) 100293**]) . ## DVT Prophylaxis: heparin subQ, colace, senna . ## Code: Full Code Medications on Admission: Baclofen 10 mg TID Pindolol 10 mg daily Atenolol 25 mg daily Discharge Medications: 1. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please crush and give through G tube. 2. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. 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* 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 7. Pindolol 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: primary: seizure, likely etoh withdrawal, with brain contusion in frontal lobe secondary: alcohol abuse portal gastropathy G-tube for malnutrition esophageal stricture previous PE with IVC filter placement (presumed massive) HTN iron deficiency anemia Discharge Condition: afebrile, vital signs stable, tolerating thin liquids and puree and tube feeds Discharge Instructions: You were admitted to the hospital after having a witnessed seizure and head trauma. You were admitted to the ICU at that time with a head bleed. You were evaluated by neurosurgery and your c-spine was cleared. It was felt that your seizure was likely secondary to alcohol withdrawal. You were also evaluated by speech and swallow. Your current diet reccomendations are thin liquids and pureed solids as well as feedings through your G tube. You are not able to pass whole pills though your esophagus due to an esophageal stricture. All pills should go through your G-tube if possible. . You are being discharged home on Keppra as per neurosurgery and you should take this medication for one month after discharge. You were also restarted on pindolol for your history of gastritis as well as iron for your iron deficiency anemia. You should continue to take these medications until You should continue to follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 53350**] as per routine. Please make an appointment to see him. Please make an appointment to see a gastroenterologist as we found a narrowing of your esophagus. Please call for an appointment at ([**Telephone/Fax (1) 2233**] Followup Instructions: Please follow up with your primary care doctor Dr. [**Last Name (STitle) 53350**]. In addition, you should follow up with a gastroenterologist concerning the narrowing in your esophagus. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2126-11-18**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

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25914

Discharge summary

report

Admission Date: [**2178-6-17**] Discharge Date: [**2178-7-12**] Date of Birth: [**2110-6-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: intubation derm biopsy LLE central line placement Paracentesis History of Present Illness: Mr. [**Known lastname 38669**] is a 68 year old man with HCV cirrhosis on transplant list MELD 27, AF, and portal vein thrombosis on coumadin admitted with fever, abd pain and LE pain and rash. Per wife, patient reported intermittent periumbilical abdominal pain x 1 week and fatigue/lethargy x 1 day. This am, wife found patient in bed where he stated he had severe [**10-4**] LE pain like "being stabbed with 1000 knives". He also was diaphoretic, slightly confused and had new rash on LEs associated with fever to 102.5 and chills. Abd pain and HA at this time were [**2178-4-30**]. He was taken to ED by ambulance. He had not had recent N/V/D, prior confusion, melena, hematochezia, new cough, SOB or sick contacts. . In the ED, initial vs were: 102.5 84 119/49 22 1002L. Patient was given 2.5L NS, tylenol, total 6mg IV morphine per report, Ceftriaxone for possible SBP, Cipro for possible intra-abd process, Vanco for possible cellulitis and underwent U/S which was unremarkable. When he returned from U/S, he was altered and minimally responsive as well as tachypneic but not hypoxic and was intubated with 8.0 ETT for airway protection. He was also given 2 units FFP in case of procedure but CT A/P was without ascites so did not have para. Also noted to have trace 50cc blood from OGT after placement which cleared but clot and type and cross sent. LENIS negative. Prior to transfer, head CT obtained which was unremarkable and LENIS negative for DVT. VS 97.6 76 92/59 100% on AC 50% 14x500 PEEP 5. . He was extubated and transfered to the floor. Past Medical History: 1. HepC/Cirrhosis - was diagnosed in [**2173-7-26**] when he underwent evaluation for leukopenia identified at his annual physical examination. c/b varices and ascites. On transplant list MELD 27 on admission. Believed to be obtained from blood transfusion 2. Esophageal varices 3. Heart murmur 4. Melanoma status post excision 5. Septic meningitis in [**2137**] 6. Osteoarthritis in the knees status post arthroscopy and left knee replacement 7. Aphthous stomatitis 8. Asthma 9. s/p Appendectomy 10. GERD 11. High tibial osteotomy 12. s/p bilaterally cataract extraction 13. h/o PE 14. Portal vein thrombosis 15. Atrial fibrillation ? s/p CV? Social History: The patient lives with his wife and they own their own sales business that requires working 7 day/wk. Alcohol: 2 drinks/day, quit in [**2172**] Tobacco: 1ppd for 10 years, quit 40 years ago Illicits: wife denies Family History: The patient's father died at age 88 from what the patient states was old age. Also had bilateral amputations for vascular disease. The patient's mother died at age 52 from colon cancer. No other FH malignancy or autoimmune or rheumatologic disease Physical Exam: On admission General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear; OGT with no output Neck: supple, JVP not elevated, no LAD; no meningismus Lungs: Clear to auscultation bilaterally witg vented breath sounds; no wheezes, rales, rhonchi CV: Irreg irreg. normal S1 + S2, 2/6 systolic murmur LLSB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining dark urine Ext: warm, well perfused, trace + pulses, no clubbing, cyanosis. Areas of hemorrhagic necrosis and edema with purpura and bullae (line drawn). Anterior shin with slightly riased erythema. Withdraws legs to minimal light touch. Pertinent Results: Labs at admission: [**2178-6-17**] 12:00PM PT-39.0* PTT-37.5* INR(PT)-4.1* [**2178-6-17**] 12:00PM WBC-6.1# RBC-2.76* HGB-8.6* HCT-26.1* MCV-95 MCH-31.2 MCHC-32.9 RDW-14.9 [**2178-6-17**] 12:00PM NEUTS-86* BANDS-7* LYMPHS-3* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2178-6-17**] 12:00PM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-2.4* MAGNESIUM-1.4* [**2178-6-17**] 12:00PM LIPASE-16 [**2178-6-17**] 12:00PM ALT(SGPT)-16 AST(SGOT)-17 ALK PHOS-77 TOT BILI-1.2 [**2178-6-17**] 12:00PM GLUCOSE-111* UREA N-39* CREAT-1.7* SODIUM-129* POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-22 ANION GAP-15 [**2178-6-17**] 12:07PM LACTATE-2.4* [**2178-6-17**] 03:00PM AMMONIA-30 [**2178-6-17**] 04:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG LENI [**6-17**] IMPRESSION: No evidence of bilateral lower extremity DVT. . TTE [**6-18**] The left atrium is mildly dilated. The right atrium is moderately dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The 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. Trace 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. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular systolic function. No vegetations identified. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. . TEE [**6-19**] The left atrium is dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 34 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No vegetations seen. Mild mitral and tricuspid regurgitation. Moderate pulmonary hypertension. . CT LEs [**6-18**] 1. Non-specific diffuse soft tissue edema in the bilateral lower extremities, left greater than right. Infection cannot be excluded. Clinical correlation is advised. There are superficial dermal fluid collections on the left compatible with bulla formation. No deep fluid collection or soft tissue air. 2. Status post left knee arthroplasty, with moderate left knee joint effusion. No evidence for hardware-related complication. 3. Tricompartmental degenerative change of the right knee. 4. Bilateral osteochondral lesions of the talar domes. 5. Marked atherosclerotic calcification. . MRI LEs [**6-18**] 1. Extensive soft tissue edema in the bilateral lower extremities, with fluid seen tracking along the deep fascial planes. This is a nonspecific finding, and can be seen with both third spacing and fasciitis. Infectious etiologies cannot be excluded. There is no evidence of soft tissue air, though CT is more sensitive. Clinical correlation is advised. 2. Dermal bullous change in the bilateral lower extremities. . Blood Culture, Routine (Final [**2178-6-21**]): _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | CEFTRIAXONE-----------<=0.06 S ERYTHROMYCIN----------<=0.25 S LEVOFLOXACIN---------- <=0.5 S PENICILLIN G----------<=0.06 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S MRI-SPINE [**2178-6-27**] IMPRESSION: 1. A 15-mm fluid collection is identified in the posterior soft tissues within the erector spinae muscle adjacent to the right L4-5 facet joint. In absence of fluid within the facet joint, there does not appear to be any extension into the facet joint. This could represent a small soft tissue abscess in the clinical settings. 2. No evidence of discitis seen in the lumbar region. 3. Multilevel degenerative changes in the lumbar region with most pronounced changes due to right foraminal herniation at L4-L5 level with compression of the exiting right L4 nerve root U/S LE [**2178-6-29**] FINDINGS: Transverse and sagittal images of the L4-L5 spinous region were obtained. There is no demonstrable fluid collection by ultrasound. IMPRESSION: No visualized fluid collection as suggested on prior MR. MRI-CALVES [**2178-6-30**] IMPRESSION: 1. Findings compatible with bilateral cellulitis, no evidence of osteomyelitis. 2. Findings suggestive of focal thrombosed peroneal vessel - likely venous. Some apparent vascular expansion and perivascular enhancement is noted in association with this, likely inflammatory and a tiny perivascular abscess is not excluded in the area of apparent vascular expansion. 3. Abnormal signal intensity about the tibial prosthesis may represent particle disease - recommend evaluation with knee radiographs. U/S Dainage of hematoma IMPRESSION: Successful CT-guided aspiration of a fluid collection in the paraspinal muscles. Sample sent for Gram stain and culture. The study and the report were reviewed by the staff radiologist. U/S LE [**2178-7-1**] IMPRESSION: No son[**Name (NI) 493**] evidence of deep venous thrombosis in either lower extremity. XRAY KNEE [**2178-7-2**] IMPRESSION: Status post total knee arthroplasty, with a subtle area of lucency surrounding the tibial stem, as seen on MRI, concerning for particle disease. Labs at discharge: [**2178-7-10**] 08:45AM BLOOD WBC-1.4*# RBC-2.99* Hgb-9.0* Hct-26.9* MCV-90 MCH-30.1 MCHC-33.5 RDW-15.5 Plt Ct-88*# [**2178-7-10**] 08:45AM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ [**2178-7-10**] 08:45AM BLOOD PT-23.7* PTT-37.1* INR(PT)-2.3* [**2178-7-10**] 08:45AM BLOOD Glucose-112* UreaN-14 Creat-1.3* Na-134 K-4.1 Cl-97 HCO3-29 AnGap-12 [**2178-7-10**] 08:45AM BLOOD ALT-15 AST-27 LD(LDH)-153 CK(CPK)-58 AlkPhos-67 TotBili-1.4 [**2178-7-10**] 08:45AM BLOOD Albumin-4.4 Calcium-9.4 Phos-2.9 Mg-1.9 Brief Hospital Course: 68M with HCV cirrhosis on transplant list admitted with fever, LE pain and rash, abdominal pain and altered mental status concerning for severe sepsis +/- vasculitis . # Sepsis/LE rash: On admission, met criteria for severe sepsis with tachypnea in ED to high 20s, fever, 7% bands on diff, lactate>2, change in mental status, and areas of mottled skin. He was intubated for respiratory compromise and transfered to the MICU. Most likely source of infection was skin/soft tissue since this was his predominant complaint. CT and MRI of the lower extremities were not consistent with necrotizing fascitis. Skin continued to worsen over the first 3 days of hospital course, and developed dramatic bullae in dependent regions of the LEs. Paracentesis with 250 polys implied either a primary or secondary intra-abdominal process. Patient received albumin on diagnosis and 2 days later for renal prophylaxis in the setting of SBP. Blood cultures from admission eventually grew pansensitive Strep penumonia and he was initially managed on vancomycin, ceftriaxone and clindamycin, which was changed to vanco/cefepime/clindamycin with ID input. TTE and TEE were negative for endocarditis. No evidence of embolic phenomenon were noted. Final etiology was not clear at the time of transfer from the ICU, but ID felt patient likely had SBP which seeded patient hematogenously, which led to embolic phenomenon to the lower extremities. The ICU team felt that patient may have started with a soft tissue infection, which led to hemeatogenous spread, which may have then led to seeding of the peritoneal fluid. Strep pneumo has been described as a rare cause of cellulitis in case reports. Workup also included negative ANCA, relatively normal complement, and negative CMV. When final speciation from blood culture returned patient was transitioned to Ceftriaxone alone prior to transfer to the floor. Pt was afebrile while on [**Hospital Ward Name 121**] 10 with stable vital signs. Wound care continued to follow patient and daily dressing changes were initated. While on [**Hospital Ward Name 121**] 10 patient complained of right lower back/upper buttock pain. Dermatology evaluated patient and felt that the dermatomal distribution of the pain warranted VZV prohylaxis. Patient was swiftly transferred to [**Hospital Ward Name 121**] 5 to protect transplant patients from VZV exposure. He was eventually found not to have VZV and antivirals were stopped. The patient's distal lower extremity wounds were managed with antibiotics including the above Ceftriaxone and vancomycin which were eventually discontinued and Daptomycin was started and stopped at time of discharge. . #. Altered mental Status: Likely multifactorial related to infection +/- hepatic encephalopathy and narcotics received in ED with decreased ability to metabolize narcotics in setting of liver disease. Improved after extubation with lactulose and rifaximin. . #. Hyponatremia: Concerning for hepatorenal vs hypovolemic hyponatremia. Diff also includes SIADH from pain. Improved with fluids while in the ICU. Because of his hypersosmolar urine on the floor, he was presumed to have SIADH and he eventually was restricted to 1500ml fluids per day on the floor and his hyponatremia reversed. He developed hyponatremia later in his hospital course which was again concerning for hepatorenal syndrome. He was given IV concentrated albumin and his sodium remained stable and borderline low at time of discharge. . # CKD: Cr 1.7 near baseline 1.6 on 4/[**2177**]. Improved to baseline prior to transfer out of out the ICU and stabilized on the floor. . # Pancytopenia, coagulopathy: Platelets mildly below baseline, hct mildly below baseline, but WBC remained stable. Given elevated INR, there was some concern for DIC in the setting of infection. CBC stabilized and INR improved with holding of coumadin and treatment of infectious process. He developed neutropenia again later in his hospital course. Ceftriaxone and vancomycin were discontinued and his WBC count returned to a normal range. . #. Anemia/Bleeding from OGT: Hct 26 at most recent baseline 27 and stable. Had some blood mixed with bile from OGT and has known varices but no further output. Received 2 U PRBC while in the unit with stable Hct. Hct was stable on the floor. . #. Cirrhosis [**1-27**] HCV c/b varices, ascites, h/o encephalopathy on transplant list: Elevated INR and low albumin consistent with decompensated cirrhosis. MELD 27 on admission but improved to 18 thereafter. Propanolol was held secondary to bradycardia in the ICU. Continue on rifaximin, and lactulose was started for altered mental status that improved after extubation, now stopped. . # Volume status: Once he reached the floor, he had significant ascites and LE edema, diuresis was initiated first with lasix and eventually with both lasix and aldactone while monitoring his electrolytes. He underwent a 3L paracentesis and was placed on a 1500ml fluid restriction. His edema stabilized as did his serum sodium while on this regimen. . # Asthma: Currently without wheezing or resp symptoms. . #. Atrial fibrillation: Remained rate controlled. Coumadin initially held for suprathereapeutic INR. Propanolol was held for bradycardia and prolonged pr interval. While on [**Hospital Ward Name 121**] 10 patient was noted to be in sustained atrial flutter. Propranolol was restarted at 5mg tid. Shortly after first dose patient was bradycardic to the high 40's. He appeared confused and complained of weakness. The decision was made to DC his propranolol again. His symptoms resolved shortly after that. His propanolol was not restarted on the floor. He also experienced multiple 2 second pauses on telemtry during his time on the floor. He was restarted on coumadin and discharged on a dose of 4mg with plans to follow his INR with Dr. [**Last Name (STitle) **], his PCP. Medications on Admission: Ergocalciferol [**2167**] units daily Albuterol 2 puffs TID Symbicort 160-4.5 2 puffs [**Hospital1 **] Clotrimazoel troche 10mg PO dissolved in mouth 5 times er day Flutes 50meg spray suspension 2 spraysto each nostril daily Lasix 40mg 2 tabs PO daily Methylphenidate 5mg PO TID Pantoprazole 40mg PO BID Proporanolol 10mg PO BID Rifaximin 400mg PO TID Spironolactone 50mg PO daiky Coumadin 5mg PO qhs calcium carbonate 600mg PO BID Diphenydramine-Tylneol PO BID Ferrous sulfate 325mg PO TID Folic acid 600mg PO qam Glucosamine Chondroitin Complex 1 tab PO BID Loperamide 2mg PO BID Magnesium oxide 1 tablet po qam Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 2. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 5. Lactulose 10 gram Packet Sig: One (1) packet PO once a day as needed for constipation. Disp:*30 packets* Refills:*0* 6. 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* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 9. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: Five (5) Tablet PO once a day. 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation three times a day as needed for shortness of breath or wheezing. 11. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day as needed for shortness of breath or wheezing. 12. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO three times a day. 13. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 14. Diphenhydramine-Acetaminophen Oral 15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 16. Folic Acid Oral 17. Glucosamine-Chondroitin Complx Oral 18. Magnesium Oxide Oral Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: 1. Sepsis 2. Cirrhosis caused by Hepatitis C 3. Cellulitis, Left Lower Extremity 4. Hyponatremia Secondary: 1. Anemia 2. Chronic Kidney Disease 3. Atrial Fibrillation 4. Portal Vein Thrombosis 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 Emergency Department with fever, abdominal pain, and a painful rash on your lower extremities. You became confused in the ED and were intubated. You were admitted to the intensive care unit and you were treated for sepsis and infection of your lower extremities. You underwent an echocardiogram which showed no evidence of endocarditis. You had a paracentesis which removed fluid from your abdomen that was infected. You grew bacteria in your bloodstream which was treated with intravenous antibiotics. You were extubated and your mental status improved and you were transferred out of the ICU to the floors. Your lower extremity wounds were treated by the wound care team and you received antibiotics for these wounds as well. Your kidney function was concerning and you were given intravenous albumin to improve your kidney function. You worked with the physical therapists intensively and they felt you were a candidate to go home with physical therapy services. During your hospitalization, some of your medications were changed. You should: START Ciprofloxacin 500mg by mouth daily STOP Lasix (furosemide) STOP Spironolactone STOP Propranolol START BOOST nutritional supplement with all meals CHANGE Rifaxamin dosing to 550mg by mouth twice daily DECREASE warfarin dose to 4mg daily and call your primary care physician on [**Name9 (PRE) 766**] for an INR check Followup Instructions: You should call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Monday to come in for an INR check. You are being scheduled to follow up in the transplant center on Wednesday, [**7-15**]. If you have not been contact[**Name (NI) **] with an appointment time by Monday, [**7-13**], please call the center at [**Telephone/Fax (1) 673**] at that time to schedule the appointment. You will be scheduled by the hepatology team for a large volume paracentesis on Tuesday [**7-14**]. You should follow up with your Primary care physician [**Known firstname **] [**Last Name (NamePattern1) **], MD in the next 1-2 weeks. You can call his office at [**Telephone/Fax (1) 39942**] to schedule an appointment. You have been scheduled for follow up appointments as indicated below: Department: TRANSPLANT When: WEDNESDAY [**2178-7-22**] at 10:20 AM With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: RADIOLOGY When: WEDNESDAY [**2178-7-22**] at 12:45 PM With: ULTRASOUND [**Telephone/Fax (1) 327**] Building: CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE Department: DERMATOLOGY When: MONDAY [**2178-8-10**] at 2:30 PM With: [**Name6 (MD) 6821**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2178-7-21**] at 3:30 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "86.11", "86.04", "96.71", "88.72", "38.93", "54.91", "96.04" ]

icd9pcs

[ [ [] ] ]

18972, 19023

10742, 13417

321, 385

19270, 19270

3857, 10131

20862, 22747

2885, 3134

17277, 18949

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275, 283

10151, 10719

413, 1970

19285, 19429

1992, 2639

2655, 2869

28,544

165,297

6783+55785

Discharge summary

report+addendum

Admission Date: [**2114-8-6**] Discharge Date: [**2114-8-10**] Date of Birth: [**2043-3-23**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) / Iodine Containing Agents Classifier / Bee Sting Kit Attending:[**First Name3 (LF) 1234**] Chief Complaint: septecemia Major Surgical or Invasive Procedure: None History of Present Illness: 71M transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital where he was admitted on [**8-4**] from home for fevers. Admit Wc was 8 and there was a question of retrocardiac infiltrate by CXR. Blood cultures grew GPC in clusters. Last HD was [**8-6**]. Mr. [**Known lastname **] has had L foot ulcers since [**1-23**]. He developed left first toe gangrene. He underwent revascularization of the left lower extremity on [**2114-6-25**]. This included a femoral endarterectomy and transluminal angioplasties. His dry gangrene has been stable and we have been allowing it to demarcate before amputation. Past Medical History: PMH: PVD, claudication, CHF, MI [**07**], CRI (baseline 3.0-3.2), DM2, ^chol, Gastroparesis, HTN, Depression, Glaucoma, legally blind PSH: R fem-[**Doctor Last Name **] bypass graft '[**04**], CABG x 5 '[**08**], Cholecystectomy, R 1st and 2nd toe amputation Social History: Lives with wife, HD 3x per week (MWF) Family History: N/C Physical Exam: Physical Exam: 98.6, HR 88 125/65 22 100% 2L General: follows commands NAD HENT: no carotid bruits Lungs: diminished bases Heart: RRR Abd: Protruberant, non-tender. Groin: L femoral incision has a small open area that does not appear infected and does not drain. Extremities: L AVF with palpable thrill. RLE: 1st and 2nd toe amputee, no edema LLE: edematous, nntp, gangrenous 1st toe, it does not appear to be infected, there is no drainage from the wound. In the second toe, there is a superficial ulceration of the dorsal aspect of the second toe. There is no surrounding erythema and no drainage. Pulses: Rad Fem DP PT R palp palp mono x L palp palp mono x Pertinent Results: [**2114-8-8**] 09:04PM BLOOD Neuts-66.4 Bands-0 Lymphs-23.7 Monos-7.4 Eos-2.2 Baso-0.2 [**2114-8-10**] 04:47AM BLOOD Plt Ct-117* [**2114-8-9**] 04:47AM BLOOD PT-29.1* PTT-40.7* INR(PT)-3.0* [**2114-8-10**] 04:47AM BLOOD Glucose-157* UreaN-37* Creat-6.9*# Na-144 K-4.1 Cl-101 HCO3-31 AnGap-16 [**2114-8-10**] 04:47AM BLOOD Calcium-8.9 Phos-5.3*# Mg-2.1 [**2114-8-7**] 02:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 URINE Blood-TR Nitrite-NEG Protein-100 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG URINE RBC-0-2 WBC-[**3-21**] Bacteri-FEW Yeast-NONE Epi-0-2 URINE Sperm-FEW [**2114-8-6**] 9:54 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): [**2114-8-7**] 8:47 am STOOL CONSISTENCY: FORMED CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2114-8-8**]): Negative x 2 CXR FINDINGS: In comparison with study of [**6-26**], all of the various tubes have been removed. The globular cardiac silhouette is at the upper limits of normal in size or slightly enlarged. Some indistinctness of pulmonary vessels raises the possibility of elevated pulmonary venous pressure. No evidence of pleural effusion. Specifically, no evidence of acute focal pneumonia. US FINDINGS: The left common femoral, popliteal femoral, and superficial femoral demonstrates normal compressibility, flow, and augmentation without evidence of deep vein thrombosis. The left groin superior to the superficial femoral demonstrates a lobulated tubular 10.6 x 2.7 x 5.7 relatively hypoechoic structure without vascularity on Doppler evaluation. Similar smaller hypoechoic focus was also noted in the right groin. These could represent lymphoceles, and if further characterization is desired, a CT with contrast might be beneficial. IMPRESSION: 1. No evidence of left lower extremity deep vein thrombosis. 2. Bilateral groin demonstrates tubular hypoechoic structures without vascularity as described above and may represent lymphoceles. If further characterization is desired, correlation with a CT is advised. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm Left Atrium - Peak Pulm Vein S: 0.4 m/s Right Atrium - Four Chamber Length: *5.9 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.3 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 30% to 35% >= 55% Left Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *18 < 15 Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Arch: 3.0 cm <= 3.0 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.5 m/sec Mitral Valve - E/A ratio: 1.80 Mitral Valve - E Wave deceleration time: *131 ms 140-250 ms TR Gradient (+ RA = PASP): *26 to 27 mm Hg <= 25 mm Hg Pulmonic Valve - Peak Velocity: 0.9 m/sec <= 1.5 m/sec Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Dynamic interatrial septum. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. Transmitral Doppler and TVI c/w Grade II (moderate) LV diastolic dysfunction. No resting LVOT gradient. 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. Normal aortic arch diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. No masses or vegetations on aortic valve, but cannot be fully excluded due to suboptimal image quality. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No masses or vegetations on mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor apical views. REGIONAL LEFT VENTRICULAR WALL MOTION: Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate left ventricular regional dysfunction with hypokinesis of the basal to mid inferolateral walls and basal to mid septum. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. No 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. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. IMPRESSION: Dilated left ventricle with regional dysfunction c/w CAD. Moderate diastolic dysfunction. Elevated left ventricular filling pressure. Mild valvular thickening without echocardiographic evidence of endocarditis. If clinically indicated, a TEE may better assess for vegetations. Brief Hospital Course: 71M transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital where he was admitted on [**8-4**] from home for fevers. Admit Wc was 8 and there was a question of retrocardiac infiltrate by CXR. Blood cultures grew GPC in clusters. Mr. [**Known lastname **] has had L foot ulcers since [**1-23**]. He developed left first toe gangrene. He underwent revascularization of the left lower extremity on [**2114-6-25**]. This included a femoral endarterectomy and transluminal angioplasties. His dry gangrene has been stable and we have been allowing it to demarcate before amputation. Put in the VICU for continuous monitering. Pt immediatly pan cx'd / all cx's negative to date. Started on IV vanco / Flagyl imperically Renal consulted for HD / pt recieved while in the hospital Admission INR high / coumadin held. Restarted on DC Pt had decreased BP / became somolent / seemed to be septic shock / code called / transferred to the CVICU. R/O for MI Stat central line put in for access. / CXR neg for pneumo Outside blood cx's times 2 bottles pos MRSA / sensitive to Vanco Diarrhea - C-Diff neg x 2 CXR negative Urine negative Pt was noticed to have some swelling in the left thigh / DVT US negative CTA / PO contrast of abd an pelvis, essentially negatve echo cardiogram done - syncopy episode / see pertinant results for [**Location (un) 1131**] Pt transferred to the VICU Pt with confusion / zyprexa and haldol given / pt is stabalized from this on DC On Dc afebrile / is to continue vancomycin at HD for 4 weeks Flagyl stopped on DC C-Diff neg x 2 Medications on Admission: Plavix, 75mg', ASA 325mg', Coumadin 7.5 MWF, 5 TTSS, Phoslo 667mgmg TID, Regular SS, Lantus 10units qhs, Cosopt 1 drop OU twice daily, Alphagan 1 drop OU twice daily, Xalatan .005% 1 drop OU QHS, Nephrocaps 1 po QD, Mirapex 0.25 mg 1 po TID, Lyrica 50 mg 1 po TID, simvastatin 10mg, reglan 5mg QID, protonix 40mg', colace 100mg", aricept 5mg', Midodrine 2.5mg" Pulses: Rad Fem DP PT Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 4. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO TID (3 times a day). 5. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol) for 4 weeks. 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 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. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 11. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 15. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). 16. [**Last Name (un) 1724**] Plavix, 75mg', ASA 325mg', Coumadin 7.5 MWF, 5 TTSS, Phoslo 667mgmg TID, Regular SS, Lantus 10units qhs, Cosopt 1 drop OU twice daily, Alphagan 1 drop OU twice daily, Xalatan .005% 1 drop OU QHS, Nephrocaps 1 po QD, Mirapex 0.25 mg 1 po TID, Lyrica 50 mg 1 po TID, simvastatin 10mg, reglan 5mg QID, protonix 40mg', colace 100mg", aricept 5mg', Midodrine 2.5mg" 17. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: Mon / Wends / FRI. 18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: tue / thurs / sat / sun. 19. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Ophthalmic once a day: OU. 20. Xalatan 0.005 % Drops Sig: One (1) Ophthalmic once a day: OU / HS. 21. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 22. Pregabalin 50 mg Capsule Sig: One (1) Capsule PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: MRSA / Bacteremia confusion / delerium Gangrenous L 1st toe PVD, CHF, MI '[**07**], CRI (baseline 3.0-3.2), DM2, ^chol, Gastroparesis, HTN, Depression, Glaucoma, Discharge Condition: Good Discharge Instructions: WOUND CARE: PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your wound(s). New pain, numbness or discoloration of your lower or upper extremities (notably on the side of the incision). Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2114-8-14**] 11:00 Completed by:[**2114-8-10**] Name: [**Known lastname 4413**],[**Known firstname 33**] Unit No: [**Numeric Identifier 4414**] Admission Date: [**2114-8-6**] Discharge Date: [**2114-8-10**] Date of Birth: [**2043-3-23**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) / Iodine Containing Agents Classifier / Bee Sting Kit Attending:[**First Name3 (LF) 270**] Addendum: Pt to be dc on insulin Insulin Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Bedtime Glargine 10 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-60 mg/dL [**1-17**] amp D50 61-120 mg/dL 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 0 Units 161-200 mg/dL 4 Units 4 Units 4 Units 2 Units 201-240 mg/dL 6 Units 6 Units 6 Units 4 Units 241-280 mg/dL 8 Units 8 Units 8 Units 6 Units 281-320 mg/dL 10 Units 10 Units 10 Units 6 Units > 320 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 4415**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**] Completed by:[**2114-8-10**]

[ "428.0", "585.6", "311", "V45.1", "440.24", "414.01", "V14.2", "038.11", "412", "365.9", "V09.0", "403.91", "250.00", "995.91", "V45.81", "V49.72" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

14505, 14734

8344, 9951

344, 351

12814, 12821

2113, 2806

13338, 14482

1377, 1382

10385, 12514

12628, 12793

9977, 10362

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1412, 2094

2841, 6692

294, 306

12858, 13315

379, 1022

1044, 1305

1321, 1361

56,703

127,384

46618

Discharge summary

report

Admission Date: [**2105-9-30**] Discharge Date: [**2105-10-6**] Service: MEDICINE Allergies: Nasonex / Ibuprofen / Aspirin / Aspartame / Bufexamac / Celecoxib / Floctafenine Attending:[**Doctor First Name 2080**] Chief Complaint: Pleuritic chest pain, BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 86 yo woman with h/o CAD s/p angioplasty, COPD, AFib, colon CA s/p right hemicolectomy, Crohn's disease, who presents with a 2 day history of bloody stools and new onset L-sided pleuritic pain. She states that she was in her normal state of health until approximately three days ago, when she began to experience L-sided chest pain. She describes the pain as sharp, intermittent, radiating to the back of her neck, improved with lying down, worse with inspiration. She states that she has also had increasing shortness of breath and a non-productive cough at baseline. In addition, for the past two days, she has had dark colored stools mixed with fresh blood. She denies increasing fatigue, dizziness, syncope. She also denies fever, nausea, vomiting, diarrhea, abdominal pain. Of note, she also endorses increasing LE edema over the past week and increased DOE (baseline is walking to car). . In the ED, VS wre BP 130/65, P 108, R 28, O2 95% on 4L. She triggered for an O2 sat of 87% on arrival and her O2 sat increased to 97% on 4L. ECG showed AFib with TWIs laterally. She had a CXR, which showed a pleural effusion and possible consolidation in right lung. CTPA showed no PE, pleural effusion, and cardiomegaly. She received NTG and Dilt for CHF exacerbation and was started on Levaquin for possible CAP. CT abdomen showed multiple diverticula. GI was consulted, and NG lavage was negative. Given her respiratory distress and tachycardia, she was admitted to the MICU for further workup and evaluation. . On the floor, the patient denies current SOB. She states that she continues to experience occasional chest pain, which resolves in [**3-10**] minutes. She states that she is fatigued but otherwise has no new complaints. Past Medical History: CAD s/p angioplasty Afib HTN COPD asthma gallstones diverticulosis Crohn's Colon ca s/p right hemicolectomy hysterectomy nephrectomy hernia repair Social History: The patient lives by herself in [**Location (un) 5503**]. She does not smoke, drink EtOH, or do IV Drugs. Her son lives in the area and helps her with her ADLs. Family History: Non-contributory. Physical Exam: Vitals: T: 97.5, BP: P: 139/80 100 R: 24 O2: 93% on 2L General: Elderly woman, pleasant, sleepy, in NAD HEENT: PERRL, EOMI, Dry mucous membranes Neck: Elevated JVD to angle of jaw. No LAD Lungs: Bibasilar crackles. Rhonchorous breath sounds on LLL. CV: Irregularly irregular. 2/6 systolic murmur. Nl S1 and S2 Abdomen: +BS, midline scar, diffuse TTP, no rebound or guarding. No organomegaly. GU: Foley in place Ext: 1+ edema bilaterally. RLE>LLE. Warm, well perfused Pertinent Results: ADMISSION LABS: . [**2105-9-30**] 03:20PM BLOOD WBC-12.9* RBC-5.05 Hgb-12.5 Hct-40.2 MCV-80* MCH-24.8* MCHC-31.2 RDW-15.1 Plt Ct-243 [**2105-9-30**] 03:20PM BLOOD Neuts-77.8* Lymphs-17.2* Monos-4.7 Eos-0 Baso-0.3 [**2105-9-30**] 03:20PM BLOOD PT-12.9 PTT-26.7 INR(PT)-1.1 [**2105-9-30**] 03:20PM BLOOD Glucose-86 UreaN-28* Creat-0.8 Na-141 K-3.7 Cl-101 HCO3-29 AnGap-15 [**2105-9-30**] 03:20PM BLOOD CK(CPK)-37 [**2105-9-30**] 03:20PM BLOOD CK-MB-NotDone proBNP-1552* [**2105-9-30**] 03:20PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2 [**2105-9-30**] 03:33PM BLOOD Lactate-1.2 . Discharge Labs: [**10-5**]: WBC-10.0 RBC-5.02 Hgb-12.4 Hct-40.7 MCV-81* MCH-24.7* MCHC-30.4* RDW-14.8 Plt Ct-253 [**10-5**]: Glucose-105 UreaN-30* Creat-0.9 Na-140 K-3.9 Cl-101 HCO3-33* AnGap-10 [**9-30**]: CK(CPK)-37 [**9-30**]: CK(CPK)-33 [**10-1**]: CK(CPK)-32 [**9-30**]: cTropnT-<0.01 [**9-30**]: cTropnT-<0.01 [**10-1**]: cTropnT-<0.01 . Micro: U/A: Moderate blood, no leukocytes . Images: CXR ([**9-30**]): There is no evidence of congestive heart failure or pneumonia. There is no evidence of pneumothorax or pleural effusion. The left hemidiaphragm is elevated. There is mild left lower lobe atelectasis. The cardiac silhouette is enlarged. The aorta is calcified and tortuous. Osseous structures demonstrate osteopenia and degenerative changes. There is no definite acute displaced fracture. . CT Chest/Abdomen/Pelvis: 1. allowing for respiratory motion, no large/central/segmental PE seen. 2. cardiomegaly, sm left pleural effusion, heterogeneous ground glass attenuation of lungs, most likely due to CHF. 3. colonic diverticulae, without definite inflammatory change to indicate diverticulitis. no free air. otherwise study not tailored to assess bowels. 4. small perihepatic fliud. 5. gallbladder distended with small calcified gallstones, without ct evidence for wallthickening or adjacent inflammation. 6. lt adrenal nodule or adjacent node. 7. renal cysts, one hyperdense. . EKG: AFib with rate of 108. Nl axis. No ST or T wave abnormalities. Brief Hospital Course: The patient is a 86 yo female with h/o CAD, COPD, colon cancer s/p hemicolectomy, and Crohn's disease, who presents with three day history of pleuritic chest pain and bloody stools. . # GI Bleed: The patient reportedly had dark stools for two days. In the ED, her stools were dark and guiaic positive, and she had streaks of fresh blood. Her Hct has remained stable at 40.2. GI was consulted. Hct remained stable and bleeding was minimal, with streaks around stools, but no frank BRBPR during rest of course. GI thought mucosal tear vs. hemorrhoids vs. diverticulosis was most likely, and that outpatient colonoscopy was most appropriate. Pt scheduled for outpatient colonoscopy. . #. Chest pain: Pain was pleuritic in nature. CXR and CT revealed small left sided effusion, likely associated with acute on chronic diastolic heart failure. The patient was ruled out for MI. Troponins were negative x3 and ECG didn't demonstrate ST or TW changes. She was monitored on tele. Chest pain improved with diuresis. . # SOB: The patient presented with increased SOB, PND, orthopnea and LE edema consistent with acute diastolic heart failure. The underlying cause of exacerbation was unclear, as patient had no signs or symptoms of infection. She did however eat many salty foods over the past week. The patient does also have COPD, but symptoms and exam was more consistent with CHF, and steroids were held. BNP was elevated and CT-PA demonstrated fluid overload. She initially required O2 with 4 L NC, and improved with diuresis. TTE showed hyperdynamic LV with LVEF 80%, with moderate pulmonary HTN. In setting of diastolic dysfuction, digoxin and Norvasc were stopped and metoprolol was titrated up for maximal mortality benefit. The patient was diuresed aggressively in the MICU, and had creatinine bump after 3rd dose of IV Lasix. She was then diuresed more gently. O2 sat on discharge was 93-95% at rest and 90 - 92% ambulatory. The patient can follow-up with cardiologist/PCP about medication management. . # LE Edema: The patient's right leg was significantly larger than her left leg. LENI was negative for PE. Edema improved with diuresis. . # A Fib: The patient has persistent A Fib, and had mild RVR at presentation. She received Dilt and NTG in the ED with good effect. She was better rate controlled after this, and metoprolol was titrated as needed. She has not been anticoagulated for many years, and she may discuss this with outpatient cardiologist/PCP. . # CAD: Continued ASA and Metoprolol. . # HTN: Continued Benazepril, Metoprolol, Lasix. D/Ced amlodipine to allow uptitration of beta-blocker. . Medications on Admission: Amlodipine 5 mg daily Benazepril 20 mg daily Digoxin 125 mcg daily Furosemide 80 mg daily Loperamide 2mg [**Hospital1 **] Metoprolol Tartrate 25 mg daily ASA 81 mg daily Multivitamin with Iron Omeprazole 20 mg daily Pyridoxine 50 mg daily Discharge Medications: 1. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Benazepril 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Community Nursing Discharge Diagnosis: primary: lower GI bleed acute on chronic diastolic heart failure . secondary: Hypertension COPD Atrial fibrillation Discharge Condition: good, afebrile, stable Sating 92-95% on room air at rest, with ambulation 90-92%. Discharge Instructions: It was a pleasure taking care of you. You were admitted for blood in your stool, which is now improving. Gastroenterology will follow you as an outpatient for a colonoscopy. You were also experienced leg swelling and shortness of breath, which occurred because your heart doesn't circulate blood normally (a conditioned called congestive heart failure). You were treated with Lasix to get rid of excess fluid from your body. You should weigh yourself daily and call your doctor if you gain more than 3 lbs or if you notice more swelling in your legs or trouble breathing. You should stick to a low salt diet. You should follow up with your cardiologist. The following changes were made to your home medications: (1) You should stop taking digoxin (2) You should stop taking amlodipine (Norvasc) (3) You should stop taking Metoprolol Tartrate 25mg Daily because you have been started on a different type of this medicine. (4) You should stat taking Metoprolol XL 100mg Daily. (5) You should increase your Furosemide to 80mg Twice a day until you see your doctor. Please seek medical attention if you experience chest pain, shortness of breath, increased blood in your stools, severe dizziness or fainting, or any other new symptoms. Followup Instructions: You have an appointment with Dr.[**Name (NI) 98994**] [**Name (STitle) **] Practitioner [**First Name (Titles) **] [**Last Name (Titles) 89459**]y [**2105-10-8**] at 1:30pm. Please bring this paper work to your PCP appointment Your PCP should review the following issues at your visit. - Blood work to evaluate your electrolytes and lasix dose - Plan for Colonoscopy given recent lower gi bleed - Plan for CT to evaluate left adrenal nodule - Please discuss your Aspirin allergy and need for Aspirin given your hisory of coronary artery disease. . He should follow-up a left adrenal nodule seen on CT. He should also follow you for heart failure, and arrange for your colonoscopy. . GI [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2105-11-10**] 1:30

[ "555.9", "414.01", "584.9", "V10.05", "427.31", "493.20", "416.8", "428.0", "578.9", "428.33" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8680, 8728

5075, 7700

317, 324

8888, 8972

3012, 3012

10256, 11025

2481, 2501

7990, 8657

8749, 8867

7726, 7967

8996, 9693

3598, 5052

2516, 2993

9711, 10233

250, 279

352, 2113

3028, 3582

2135, 2284

2300, 2465

20,248

103,417

3809

Discharge summary

report

Admission Date: [**2122-10-19**] Discharge Date: [**2122-10-21**] Date of Birth: [**2068-2-26**] Sex: M Service: MEDICINE Allergies: Toradol / Celebrex Attending:[**First Name3 (LF) 425**] Chief Complaint: ICD pocket infection Major Surgical or Invasive Procedure: ICD generator and lead extraction History of Present Illness: 54 y old male w/ hx of CHF w/ EF of 30% s/p biV ICD/pacer in [**9-18**], and NYHA functional class II-III, CAD s/p MI in '[**15**] with BMS to OM1, CABG and MV repair [**9-19**] (LIMA to LAD, SVG to OM, SVG to PDA, 30 mm [**Doctor Last Name **] Physio-Ring), L shoulder replacement, Left TKA, cervical spine fusion with hardware tx'd from [**Hospital 3856**] for pacer pocket infection. Approximately 3 weeks ago the skin over the pacer started to turn dark red/purple and became exquisitely tender. The patient denied any fever, chills, nausea, headache, or general malaise. He has not had any recent rash, skin breakdown or insect bite. He did notice increase in cough but no increased rhinorrhea, sputum production, or sinus pressure. Last Friday, the patient went to his PCP and was prescribed Keflex for presumed soft tissue infection overlying the ICD/Pacer. He had normal WBC and no fever at that time. The symptoms of redness and swelling did not improve so was taken for pacer generator revision on [**10-19**] at [**Hospital **] hospital. They discovered a large pus pocket, placed a drain and transferred the patient to [**Hospital1 18**] for emergent pocket washout and lead removal. ABG on arrival was 7.23/72/209/30/1 with a lactate of 1.0. Was taken directly to OR where pacer pocket and lead extraction which was uncomplicated although one pacer in the LV had to be abandoned. Past Medical History: # Congestive Heart Failure w/ EF of 30% s/p single Chamber pacer [**12-19**], with upgrade to biV in [**9-18**] # Coronary Artery Disease - s/p Myocardial Infarction [**2115**] with thrombectomy and BMS to OM1 - s/p CABG and MV repair [**9-19**] (LIMA to LAD, SVG to OM, SVG to PDA, 30 mm [**Doctor Last Name **] Physio-Ring) # Hypertension # Hyperlipidemia - Most recent panel: Total chol 225, LDL 116, HDL 35, Trig 372 (from over 500) # Cervical disc herniation s/p fusion with hardware # s/p lumbar disc surgery x 2 # s/p Cholecystectomy # s/p Left shoulder surgery # s/p Left total knee replacement # s/p pericarditis [**2115**] # Osteoarthritis # GERD Social History: Tobacco: 70pack/yr hx, one PPD currently ETOH: denies Family History: Father w/ CABG at 57. Brother w/ Myocardial Infarction at 42. Physical Exam: (on admission) VS: T 97.3 ,BP 144/70, HR 70 Vent settings: AC 650/12, FiO2 50%, PEEP 5 Gen: Middle aged male intubated and sedated, with occacional coughing HEENT: Sclera anicteric. PERRL, tracking intact. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple CV: RR with mild systolic murmur best heard at LUSB, normal S1, S2. No S4, no S3. Chest: L upper chest with large dressing c/d/i. well healed midline scare over sternum. No obvious chest wall deformities. Bilateral crackles anteriorly. Abd: Obese, soft, NTND, No HSM or tenderness. Ext: No c/c/e. R groin with access. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2122-10-20**] 12:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2122-10-20**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2122-10-19**] 11:27PM TYPE-ART TEMP-38.7 RATES-18/ TIDAL VOL-690 O2-40 PO2-106* PCO2-41 PH-7.40 TOTAL CO2-26 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED VENT-CONTROLLED [**2122-10-19**] 08:01PM TYPE-ART PO2-108* PCO2-46* PH-7.37 TOTAL CO2-28 BASE XS-0 [**2122-10-19**] 08:01PM O2 SAT-97 [**2122-10-19**] 06:12PM GLUCOSE-93 UREA N-15 CREAT-0.7 SODIUM-139 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12 [**2122-10-19**] 06:12PM CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-2.2 [**2122-10-19**] 06:12PM NEUTS-71.6* LYMPHS-23.8 MONOS-3.7 EOS-0.9 BASOS-0.1 [**2122-10-19**] 06:12PM PLT COUNT-235# [**2122-10-19**] 03:12PM GLUCOSE-79 LACTATE-1.0 NA+-142 K+-4.3 CL--102 [**2122-10-19**] 03:12PM freeCa-1.15 . CXR ([**2122-10-20**]): FINDINGS: In comparison with the study of [**2121-9-26**], the pacemaker device has been removed. A prosthetic mitral valve is again seen. There is continued enlargement of the cardiac silhouette with relatively mild vascular congestion. No evidence of acute pneumonia. Endotracheal tube tip lies about 4 cm above the carina and the nasogastric tube extends to at least the upper stomach. Metallic fixation device involving the lower cervical spine is again seen. . CXR ([**2122-10-20**]): FINDINGS: In comparison with the study of [**10-19**], there is little change in the appearance of the heart and lungs. The endotracheal and nasogastric tubes have been removed. IMPRESSION: No acute pneumonia. Brief Hospital Course: 54 y old male w/ hx of CAD s/p MI in '[**15**] with BMS to OM1, CABG and MV repair [**9-19**], CHF w/ EF of 30% s/p Dual Chamber ICD [**9-18**] w/ epicardial lead, Left TKA, L shoulder replacement, cervical spine fusion with hardware tx'd from [**Hospital3 1280**] for pacer pocket infection on [**10-19**] At [**Hospital1 18**], was taken to the OR urgently and he had the atrial and RV leads explanted along with the generator. A ventricular lead was pulled back, cut and allowed to self-retract. In the OR, the patient was hypotensive on neosynephrine for much of the case. The episode of hypotension and fever to 101.5 was concerning for sepsis and the patient was started on Vanco/Zosyn. Intraoperative TEE did not show any evidence of endocarditis. . In the CCU at [**Hospital1 18**] pt was intially febrile to 101 when arriving with sbp's in low 90's although appearing quite well with good mentation, UOP and perfusion. Pt's ABG quickly normalized and pt was extubated on the day after admission. Sbp's responded to gentle fluid boluses and maintenance IVFs during the night of the admission and was never on pressors in the CCU. Pt has since continued to be afebrile and HD stable with sbps in the 120s and without an elevation in white count. Pt was re-started on BB prior to d/c. . On the day of transfer the following plan was discussed: # ID/ICD pocket infection s/p ICD lead extraction with abandoned pacer in LV remaining - Cont vancomycin and zosyn for empiric abx therapy since we have no cultures to follow. Cultures from [**Hospital1 **] also NGTD including cultures from pacer pocket; it is possible the infection was treated with keflex prior to drainage if the infection was g-staph - ID recommended cont. current abx for now and for at least 4 weeks to be followed by oral supressive therapy - cough productive of clear sputum positive with 4+ G- rods and 1+ G+ cocci; If truly has a pulm infecton as sputum suggests it is covered with vanc/zosyn although CXR without obvious infiltrates - PICC line placed prior to transfer - f/u culture of pacer tips, blood cultures, and sputum cultures - daily wet to dry dressing changes . # Pump/CHF w/ EF of 30% s/p Dual Chamber ICD [**9-18**] now s/p ICD lead extraction - appears euvolemic to mildly overloaded - cont. titrate up on BB, [**Last Name (un) **] as tolerated - pt to go home with life-vest: This will need to be set up via case management at [**Hospital1 **] and with the patient's cardiologist. - pt will likely need a new ICD implanted at some point in the future . # Rhythm - monitor on tele - pt should go home with life-vest . # Ischemia/Coronary Artery Disease, s/p MI in '[**15**] with thrombectomy and BMS to OM1, s/p CABG and MV repair [**9-19**] - cont ASA 81, atorvastatin 80 mg - cont. titrate up on BB, [**Last Name (un) **] as tolerated . # Pulm - cough productive of clear sputum possitive with 4+ G- rods and 1+ G+ cocci; If truly has a pulm infecton as sputum suggests it is covered with vanc/zosyn although CXR without obvious infiltrates - f/u sputum cultures . # Hypertension - cont. titrate up on BB, [**Last Name (un) **] as tolerated . # Hyperlipidemia - cont atorvastatin . # Code Status: Full code . # Dispo: transfer to [**Hospital1 **]. will need VNA when going home from [**Hospital1 **] to assist with medications and IV antiobiotics. Patient will also need teaching with IV antiobiotic dosing prior to discharge from [**Hospital1 **]. He has a right PICC placed at [**Hospital1 18**], with a CXR performed showing good placement (in SVC) and no pneumothorax. . # Communication: Wife, [**Name (NI) **] [**Name (NI) 17111**] [**Telephone/Fax (1) 17112**] Medications on Admission: HOME MEDICATIONS (per wife and pt): Aspirin 325 mg po DAILY Protonix 40 mg [**Hospital1 **] Prilosec 20mg po bid Carvedilol 25 mg po BID valsartan 160mg po bid Spironolactone 25mg po bid lasix 40mg po bid hydral 25 mg po bid norvasc (amlodopine) 10mg po bid Atorvastatin 40 mg po DAILY keflex Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed for pain. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Docusate Sodium 50 mg Capsule Sig: [**12-16**] Capsules PO twice a day as needed for constipation. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 7. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for Insomnia. 11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 13. Vancomycin 1000 mg IV Q 12H day 1 [**10-19**] 14. Piperacillin-Tazobactam Na 4.5 gm IV Q8H day 1 [**10-19**] Discharge Disposition: Extended Care Discharge Diagnosis: ICD pocket infection Discharge Condition: Stable Discharge Instructions: You were admitted and treated for ICD pocket infection. . If you develop fever greater than 101F chest pain, shortness of breath, or if you at any time become concerned about your health please contact your PCP, [**Name10 (NameIs) **] or [**Hospital1 18**] at [**Telephone/Fax (1) **] or present to the nearest ED. . Please take your medications as prescribed. . Please make sure to have appointments with electrophysiology and infectious disease prior to discharge from [**Hospital1 **] for this serious infection of your ICD pocket. Followup Instructions: Please make sure [**Hospital1 **] has scheduled appointments with the following prior to dicharge or schedule follow-ups to be seen within 1-2 weeks with the following: - electrophysiology - infectious disease - your cardiologist - your PCP

[ "996.61", "428.0", "401.9", "414.8", "E878.1", "E849.9", "995.91", "272.4", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "88.72", "96.71", "37.77" ]

icd9pcs

[ [ [] ] ]

10363, 10378

5124, 8794

301, 336

10443, 10452

3424, 5101

11035, 11279

2527, 2590

9137, 10340

10399, 10422

8820, 9114

10476, 11012

2605, 3405

241, 263

364, 1758

1780, 2438

2454, 2511

17,681

130,534

1254

Discharge summary

report

Admission Date: [**2138-7-10**] Discharge Date: [**2138-7-25**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: fall, left hip pain Major Surgical or Invasive Procedure: ORIF of left femoral neck fracture Central line placement Chest tube placement Intubation History of Present Illness: 84 y/o male w/ history of CAD s/p CABG, A fib, TIAs, prostate CA, who was doing well at home until he tripped over a vacuum cleaner cord and fell. He denies LOC and head trauma. He immediately felt pain in his left hip and was unable to bear weight. He was initially taken to [**Hospital **] Hospital where X-rays revealed a left femoral neck fracture. There were no other noted injuries. He was neurovascularly intact distally. He was transferred to [**Hospital1 18**] for operative orthopedic management. Past Medical History: 1. CAD s/p CABG [**2125**] (LIMA-D1, SVG-LAD, SVG-OM, SVG-RCA) and [**2128**] (SVG-OM, SVG-LAD). Coronary angiography in [**9-7**] showed patent grafts (LIMA-D1, SVG-OM1, SVG-OM2, SVG-LAD). 2. PVD 3. A-fib ([**2131**]) on anticoagulation and rate control 4. Carotid artery stenosis s/p right CEA. left carotid 75% 5. TIA x2 6. HTN 7. Prostate CA 8. PUD Social History: The patient is a nonsmoker and denies alcohol use. He is an ex-marine and currently lives with wife. [**Name (NI) **] continues to take care of his 54 y/o son who has cerebral palsy and was recently diagnosed with CA. Family History: Non-contributory Physical Exam: Vitals: Temp 100.2 HR 72 BP 184/56 RR 16 sats 96% on RA GEN: alert and oriented x 3, pain controlled, NAD HEENT: NCAT, PERRL, EOMI Lungs: CTA bilaterally, no wheeze CV: irregular ABD: soft NTND EXT: tender left hip +ecchymosis, swelling, tenderness over left greater trochanter; 2+ DP/PT pulses bilaterally, sensation grossly intact to light touch 5/5 strength in LE unable to test left quads [**1-8**] pain NEURO: CN II-XII intact, no focal motor or sensory deficits Pertinent Results: [**2138-7-9**] 08:59PM BLOOD WBC-11.1* RBC-4.29* Hgb-12.7* Hct-37.3* MCV-87 MCH-[**2138-7-9**] 08:59PM BLOOD Neuts-79.6* Lymphs-15.3* Monos-4.6 Eos-0.3 Baso-0.2 [**2138-7-10**] 09:00AM BLOOD PT-24.7* PTT-42.3* INR(PT)-4.0 . [**2138-7-9**] 08:59PM BLOOD Glucose-111* UreaN-38* Creat-1.9* Na-139 K-4.2 Cl-101 HCO3-27 AnGap-15 . [**2138-7-13**] 05:57PM BLOOD CK-MB-4 cTropnT-0.03* [**2138-7-14**] 12:00AM BLOOD CK-MB-4 cTropnT-0.03* [**2138-7-14**] 06:40AM BLOOD CK-MB-4 cTropnT-0.02* . CAROTID SERIES ([**2138-7-11**]): Stable plaque in the right internal carotid artery and bifurcation with less than 40% hemodynamic effect. On the left side, progression of plaque reaching now a level of 70-79% stenosis. . HIP ([**2138-7-12**]): Four spot views of the left hip in the operating room is reviewed. Three surgical screws transfixing the left proximal femur, which is near anatomic alignment. . CT HEAD ([**2138-7-13**]): No acute intracranial pathology. . CHEST ([**2138-7-13**]): Continued cardiomegaly. Left lower lobe atelectasis versus aspiration pneumonia. . MRA BRAIN ([**2138-7-13**]): 1. Acute infarction in the region of the right middle cerebral artery. 2. MRA angiography showing patent right middle cerebral artery and other major branches of the circle of [**Location (un) 431**]. 3. Chronic infarct in the region of left middle cerebral artery. 4. Possible aneurysm in the region of left middle cerebral artery bifurcation vs patulous bifurcation. Brief Hospital Course: 1. Hip fracture: Pt was admitted s/p fall with left femur fracture. He underwent a L ORIF on [**2138-7-12**]. He received wound care and Physical Therapy throughout his hospitalization. Staples were removed 12 days post-op. . 2. Stroke: One day post-op, the patient was noted to be non-verbal. An emergent Head CT was obtained and Neurology was consulted. Although the non-contrast Head CT was negative, they felt that the patient's acute change was due to a new CVA and recommended an MRI. MRI showed new acute infarction in the region of the right middle cerebral artery. There were no indications for thrombolytics and the patient was managed medically with anti-coagulation with Lovenox + ASA with tight glycemic control. His goal BP was 160-180 and this was later decreased to BP goal of 140-150. Pt's aphasia began to improve over several days, with significant improvement by discharge. Prior to discharge, he was started on warfarin per the recommendation of Neurology. He will be followed by Neurology as an outpatient. . 3. Aspiration pneumonia: The patient was noted to be hypoxic (89% on 2L) on [**2138-7-13**] and he was started on Levofloxacin + Flagyl. A CXR was consistent with possible aspiration. The patient was noted to have no gag reflex, and given his aspiration risk, an NGT was placed. On [**2138-7-18**], noted to have increased respiratory rate and increased work of breathing. Due to worsening respiratory status, decision was made to intubate and transfer to MICU for additional monitoring. In MICU, a central R IJ was placed and a subsequent CXR showed large right pneumothorax. A chest tube was placed by CT surgery. The patient had improved respiratory function and was extubated on [**2138-7-19**]. He was transferred out of the MICU on [**7-21**]. The chest tube was removed on [**2138-7-23**]. Levofloxacin/Flagyl was continued to complete a 14-day course in total. . 4. Swallow difficulty: After his CVA, the patient was evaluated by Speech and Swallow service, and found to be unsafe for PO intake. Given aspiration risk, several attempts to place NGT at bedside were unsuccessful. Required IR guided placement of NGT. Started on tube feeds. After video swallow on [**2138-7-23**], pt was advanced to pureed foods and nectar juice, given improved swallow ability. The NG tube was discontinued and the patient demonstrated an adequate ability to swallow his food with supervision. . 5. CAD/AF: The patient was admitted in atrial fibrillation, which is his baseline. He was managed with rate control. On [**2138-7-18**], he developed ST-segment elevations. His rate and blood pressure were tightly controlled. Troponin was elevated, without elevation of CK. Cardiology was consulted and felt the clinical presentation was consistent with demand ischemia. . 6. UTI: UA on [**2138-7-13**] was consistent with a UTI. He was treated with Levofloxacin, which was also used to treat the aforementioned aspiration pneumonia. . 7. Urinary retention/Hematuria: The patient's foley was discontinued when he was transferred from the MICU to the floor, but he had urinary retention, as demonstrated by bladder scan. His foley was reinserted and several days later, he had the acute onset of gross hematuria. This was considered possibly related to trauma. His foley was flushed and no blood clots were evident. He will be discharged to the acute rehabiliation facility with the foley, but it should be discontinued as soon as the patient is able to void on his own. Medications on Admission: Colace 100 mg po bid Metoprolol 37.5 mg [**Hospital1 **] Famotidine 20 mg po q day Norvasc 5 mg po q day Lisinopril 20 mg po q day Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please adjust dose as needed for INR [**1-9**]. 5. Enoxaparin Sodium 100 mg/mL Solution Sig: 0.7 mL Subcutaneous Q12H (every 12 hours): This should be 70mg SC BID. Please continue until INR is therapeutic for 2-3 days. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary Diagnoses: 1. Left femoral neck fracture s/p ORIF 2. Cerebral vascular accident (stroke) 3. Aspiration pneumonia s/p intubation Secondary: 1. Atrial fibrillation 2. CAD s/p CABG [**2125**] and [**2130**] 3. Carotid stenosis s/p right CEA 4. Hypertension 5. TIAs 6. Prostate CA Discharge Condition: Good, oxygenating well, pain-free Discharge Instructions: You are discharged to a Rehabilitation Facility where you will continue all medications as prescribed. Please alert the physicians there or contact your primary care physician if you experience difficulty speaking, swallowing, chest pain, shortness of breath, bleeding or other concerns. Followup Instructions: You have a follow-up appointment with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] on Thursday [**2138-8-21**] at 1:45pm. You also have a follow-up appointment with him on [**2138-10-2**] at 11:45am. You have a follow-up appointment with Neurologist Dr. [**Last Name (STitle) **] on [**2138-8-12**] at 1:00pm. A family member should call [**Telephone/Fax (1) 2574**] to verify your contact information. You have a follow-up with Orthopedic surgeon Dr. [**Last Name (STitle) 1005**] on [**2138-7-31**] at 8:40am. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "997.02", "512.1", "427.31", "788.20", "E885.9", "411.89", "599.7", "820.8", "599.0", "V45.81", "428.0", "584.9", "507.0", "518.5", "438.82", "V10.46", "286.9", "458.29", "784.3" ]

icd9cm

[ [ [] ] ]

[ "34.04", "96.04", "79.15", "99.04", "96.6", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

8149, 8229

3546, 7043

281, 373

8559, 8595

2061, 3523

8932, 9629

1539, 1557

7225, 8126

8250, 8538

7069, 7202

8619, 8909

1572, 2042

222, 243

401, 909

931, 1285

1301, 1523

13,329

138,290

51445

Discharge summary

report

Admission Date: [**2187-7-5**] Discharge Date: [**2187-7-13**] Date of Birth: [**2112-8-23**] Sex: F Service: SURGERY Allergies: Ace Inhibitors / Neurontin Attending:[**First Name3 (LF) 668**] Chief Complaint: Incisional Hernia Major Surgical or Invasive Procedure: [**2187-7-5**] Incisional hernia open repair with Marlex mesh [**2187-7-9**] Intubation [**2187-7-10**] Extubation History of Present Illness: Ms. [**Known firstname 7232**] [**Known lastname 106665**] is 74F s/p kidney living related renal transplant [**9-29**] complicated by incisional hernia who was admitted for elective repair of her hernia on [**2187-7-5**] with Dr. [**First Name (STitle) **]. Past Medical History: ESRD s/p transplant ([**2180**]) CAD Diastolic CHF HTN COPD Chronic aortic dissection GERD moderate pulm HTN s/p TAH/BSO s/p appy s/p ventral hernia repair [**3-30**] Social History: Lives at home alone, but occasionally after hospitalizations has stayed with her daughter/granddauthger. Previously worked as a nurses aid. -Tobacco history: +smokes [**2-28**] cigarettes a day -ETOH: Endorses minimal EtoH use -Illicit drugs: Denies Family History: monther with MI at 68, father with MI at 70 Physical Exam: Vital Signs: T 98.1, P 62, BP 121/52, R 16 Sat 100% 3LNC Weight: 65.7kg Gen: A&Ox3, Appears Stated Age Neuro: Grossly intact, moving all extremeties CV: RRR, systolic murmur Pulm: CTAB GI: Soft, non-distended, +BS all 4 quadrands, non-distended, tender around inscision GU: foley in place Ext: +1 edema bilateral lwoer extremities, + pulses in all extremeties Pertinent Results: [**2187-7-5**] 02:47PM BLOOD Hct-27.8* [**2187-7-6**] 06:00AM BLOOD WBC-7.7 RBC-2.77* Hgb-8.5* Hct-25.6* MCV-93 MCH-30.8 MCHC-33.3 RDW-16.6* Plt Ct-190 [**2187-7-7**] 05:15AM BLOOD WBC-7.3 RBC-2.62* Hgb-8.2* Hct-24.4* MCV-93 MCH-31.4 MCHC-33.6 RDW-16.5* Plt Ct-167 [**2187-7-9**] 08:31PM BLOOD WBC-9.2 RBC-3.23*# Hgb-9.9*# Hct-30.0*# MCV-93 MCH-30.7 MCHC-33.0 RDW-16.3* Plt Ct-238 [**2187-7-11**] 03:31AM BLOOD WBC-8.3 RBC-3.33* Hgb-10.2* Hct-29.4* MCV-88 MCH-30.6 MCHC-34.7 RDW-16.2* Plt Ct-279 [**2187-7-5**] 02:47PM BLOOD Glucose-79 UreaN-32* Creat-1.9* Na-140 K-5.4* Cl-111* HCO3-20* AnGap-14 [**2187-7-9**] 08:31PM BLOOD Glucose-171* UreaN-47* Creat-2.3* Na-135 K-5.5* Cl-106 HCO3-19* AnGap-16 [**2187-7-13**] 05:00AM BLOOD Glucose-97 UreaN-41* Creat-1.8* Na-137 K-4.7 Cl-103 HCO3-24 AnGap-15 [**2187-7-5**] 02:47PM BLOOD Calcium-8.5 Phos-5.0* Mg-1.3* [**2187-7-13**] 05:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.6 [**2187-7-6**] 06:00AM BLOOD tacroFK-2.9* [**2187-7-7**] 05:15AM BLOOD tacroFK-4.8* [**2187-7-8**] 05:12AM BLOOD tacroFK-8.0 [**2187-7-9**] 05:20AM BLOOD tacroFK-5.4 [**2187-7-10**] 05:56AM BLOOD tacroFK-9.3 [**2187-7-11**] 06:10AM BLOOD tacroFK-10.3 [**2187-7-12**] 05:25AM BLOOD tacroFK-7.5 [**2187-7-9**] 07:46PM BLOOD Type-ART Temp-35.6 pO2-81* pCO2-67* pH-7.11* calTCO2-23 Base XS--9 Brief Hospital Course: Ms. [**Known firstname 7232**] [**Known lastname 106665**] is a 74F who is s/p kidney living related renal transplant [**9-29**] complicated by incisional hernia who was admitted to the hospital for elective repair of her hernia on [**2187-7-5**]. The surgery was performed without complications and the patient had adequate repair of her hernia defect with placement of kerlex mesh. On POD#2 the patient developed oliguria, and the Renal Transplant team was consulted. Pt had a Creatinine bump up to 2.4 (her baseline is 1.9), and after eval it was determined that she had [**Last Name (un) **] from an undetermined source. Patient was initally given fluid boluses and IVF without increase her in her urine output. A renal U/S was performed on [**7-7**] and did not demonstrate hydrenoephrosis, stones, or mass of the transplanted kidney, althought it was significant for absence of diastolic flow in the main renal and intrarenal arteries. After this initial evaluation patients urine output remained somewhat marginal, while her Cr started to improve. On hospital day 4, patient was transufesed 2units of PRBC for a Crit of 22, and soon after developed respiratory distress requiring intubation and transfer to the SICU on [**7-9**]. Her post transfusion Hct was 30, and her urine output improved while in the ICU s/p transfusion. Pt was also started on lasix PRN with adequate improvement in urine output of 1.1L on [**7-10**], and consistent diuresis. Her pulmonary status improved on that day and she was extubated. A speech and swallow evaluation was performed, and the patient was started on a thin liquid, soft mechanical diet. Pt was deemed stable for transfer to the floor on [**7-11**]. While on on the floor she continued to remain hemodynamically stable, with adequate urine output, and was restarted on her home dose of lasix. She was weaned off her oxygen requirement (pt is not on oxygen at home). Throughout her hospital course she received adequate immunosuppresion with Tacroliums and Azathioprine. Tacrolimus levels were checked daily, and dose adjustments were made accordingly (last tacro levels range 9.3-10.3). Patient was placed on all home medications, including her medications for HTN, COPD. On [**7-13**] she was evaluated by speech therapy again and progressed to thin liquid/regular solid diet. She remained hemodynamically stable, eating well, and producing adequate urine with Cr at her baseline 1.8. She was evaluated by PT and was cleared to be discharged home with her daughter. Medications on Admission: 1. Docusate Sodium 100 mg PO BID 2. 1000 mL LR Continuous at 500 ml/hr for 500 ml 3. Furosemide 40 mg IV ONCE Duration: 1 Doses 4. 1000 mL NS Bolus 500 ml Over 30 mins 5. HYDROmorphone (Dilaudid) 0.12 mg IVPCA Lockout Interval: 10 minutes Basal 6. 1000 mL NS Continuous at 75 ml/hr 7. Ipratropium Bromide MDI 2 PUFF IH QID 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing 9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 10. Amlodipine 2.5 mg PO/NG DAILY 11. Labetalol 300 mg PO/NG [**Hospital1 **] 12. Azathioprine 50 mg PO/NG DAILY 13. Omeprazole 20 mg PO DAILY 14. Calcitriol 0.25 mcg PO DAILY 15. Ondansetron 4 mg IV Q8H:PRN nausea 16. Cinacalcet 30 mg PO DAILY 17. Citalopram 10 mg PO/NG DAILY 18. Tacrolimus 5 mg PO Q12H Discharge Medications: 1. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day). 6. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): . 8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for home dose. 9. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 10. isosorbide dinitrate 30 mg Tablet Sig: One (1) Tablet PO once a day. 11. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO prn: every 8 hours: no more than 3000mg per day. 15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**11-26**] Inhalation prn every 4 hours as needed for shortness of breath/wheeze. 16. Aranesp (polysorbate) Injection 17. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a day. 18. oxycodone 5 mg/5 mL Solution Sig: 0.5-1 tab PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Renal Transplant [**2180**] Incisional Hernia Repair Congestive Heart Failure Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] if you have any of the following: fever (temperature of 101 or greater), chills, nausea, vomiting, increased abdominal distension or pain, incision redness/drainage, decreased urine output, increased edema or shortness of breath Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You may shower, but no tub baths or swimming No heavy lifting/straining Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-7-23**] 9:10 Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2187-8-27**] 9:40 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2187-8-31**] 9:00 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2187-11-5**] 9:00

[ "996.81", "518.5", "553.21", "491.20", "414.01", "285.9", "428.0", "584.9", "403.90", "416.9", "424.0", "E878.0", "585.9", "428.32" ]

icd9cm

[ [ [] ] ]

[ "53.61", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7730, 7788

2952, 5470

302, 419

7947, 7947

1624, 2929

8614, 9281

1183, 1229

6257, 7707

7809, 7926

5496, 6234

8130, 8591

1244, 1605

245, 264

447, 707

7962, 8106

729, 898

914, 1167

9,278

101,449

8730

Discharge summary

report

Admission Date: [**2179-7-24**] Discharge Date: [**2179-8-3**] Date of Birth: [**2130-3-23**] Sex: M Service: MICU CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: He is a 49-year-old male with a history of cirrhosis from ethanol abuse and chronic hepatitis C, portal hypertension with history of variceal bleeds and multiple admissions for ascites, who was actually recently admitted from [**6-20**] to the 13th for clinical trial, where he received an infusion of methylene blue, and was seen in Liver Clinic on [**7-20**], where large volume paracentesis of 5 liters was performed which revealed no SBP. The patient now presents with increasing abdominal girth, abdominal pain, and nausea and vomiting x1 day. He said he felt better for about two days following the large volume paracentesis, but his ascites returned. He denied any blood or coffee grounds in his vomitus. He had normal color bowel movements. No bright red blood per rectum or melena. No pale stools. He is taking his lactulose with 2-3 bowel movements per day. No confusion, sleeping at night okay. He denies any fever or chills. The patient states he has gained approximately 12 pounds in the past three days. He says he has been compliant with all of his medications. He says he is also compliant with a low salt diet. The patient did note some shortness of breath and difficulty taking large breaths. He states that his fingersticks have been well controlled. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Ethanol abuse. 3. Cirrhosis. 4. Portal hypertension. 5. History of variceal bleeding which had been banded in the past. 6. History of ascites. 7. History of hemorrhoids and a small rectal AVM. 8. Anemia. 9. Diabetes mellitus. ALLERGIES: He had no known reported drug allergies. MEDICATIONS ON ADMISSION: 1. Aldactone 100 mg p.o. q.d. 2. Lasix 80 mg p.o. q.d. 3. Lantus 40 units q.p.m. 4. Regular insulin-sliding scale. 5. Iron sulfate 325 mg p.o. t.i.d. 6. Lactulose 30 cc p.o. q.6h. 7. Percocet 30 mg p.o. q.d. 8. Zoloft 50 mg p.o. q.d. 9. Remeron 30 mg p.o. q.d. 10. Anusol suppository prn. 11. Prevacid 30 mg p.o. q.d. SOCIAL HISTORY: He has not consumed alcohol for the past 1.5 years. He denies any tobacco or IV drug use. He is single with seven children and lives alone in an apartment. PHYSICAL EXAMINATION: Pertinent findings: He was afebrile. His blood pressure was 108/68 with a pulse of 95. He was sating at 100% on room air. He was a middle-age man appearing somewhat uncomfortable, but in no acute distress, no jaundice. Pertinent findings on exam: His sclerae were icteric. He had dry mucous membranes. His neck was supple with no JVD or adenopathy. Heart was regular, rate, and rhythm with no murmurs. His lungs are clear. His abdominal exam: His belly was distended and tense with positive bowel sounds. He had mild epigastric tenderness with no guarding or rebound. He did have some mild right lower quadrant tenderness as well. There was caput medusa, but no spider angiomata. He had 2+ lower extremity pitting edema without clubbing. He did also have some palmar erythema. Neurological examination: He had mild tremor, but no flapping. He was alert and oriented times three. PERTINENT LABORATORY DATA: His Chem-7 was essentially unremarkable. His ALT was 28, AST 42, alkaline phosphatase 119, amylase 115, and T bilirubin 1.7. His albumin was 3.0. He had a white count of 12.8, hematocrit 31.2, platelets of 128. He had an INR of 1.6. An aFP was 8.1. ASSESSMENT: Patient was a 49-year-old male with history of cirrhosis from ethanol abuse and chronic HCV, portal hypertension with a history of esophageal varices, hemorrhoids and recurrent ascites, who recently had a large volume paracentesis performed three days prior to admission, who now presents with increasing abdominal girth, belly pain, and weight gain from ascites. On [**7-24**], the patient had another large volume paracentesis with 5 liters of fluid removed. He was also considered for possible TIPS placement as well. Before the TIPS procedure, he had an abdominal ultrasound to assess portal patency. The findings on the ultrasound essentially showed that there were no focal liver lesions, and the liver had a cirrhotic appearance. The left middle and right portal vein and the extrahepatic portal vein had normal flow. The hepatic veins also had normal flow. There was a large amount of abdominal ascites noted. On the [**7-28**], the patient did have a TIPS procedure, and was transferred to the MICU for closer observation. His preoperative hematocrit before the procedure was 25.4, but his hematocrit status post procedure was 21. Patient was felt to be at high risk for bleeding given his coagulopathy. His INR on the day of the procedure is 1.8. Of note, the patient's hematocrit on admission was 31.2. The patient did receive 2 units of packed red cells after the procedure. At the time of his admission to the MICU, he had no complaints. He denied chest pain, shortness of breath, abdominal pain, nausea, or vomiting. Patient had a repeat abdominal ultrasound on [**7-29**], which showed patency of the TIPS. On [**7-30**], patient was complaining of right back pain as well as epigastric and right upper quadrant pain. A CT scan obtained showed a 6 mm pseudoaneurysm in the posterior right hepatic artery near the porta hepatis, but there was no contrast extravasation. Again, there was no focal mass noted. Again the TIPS was in stable position, however, there was again noted large amount of ascites throughout the abdomen and pelvis. Up to this point, the patient continued to receive units of packed red blood cells as well as FFP as needed for his anemia and coagulopathy. Also on [**7-30**], the patient spiked a fever to 101.4, and blood cultures were sent. His white count rose to 15.1. He was started on levofloxacin to cover for possible SBP. Patient also started to become slightly hypotensive, although the patient did have a baseline low blood pressure. A paracentesis was also attempted, however, after several attempts with a 14 gauge thoracentesis kit, 1 cc of brown feculent material was aspirated. There was concern for possible bowel perforation. A KUB and chest x-ray were ordered to assess for free air. No free air was seen on either of these examinations. On the day of [**7-31**], the patient had progressive dyspnea with a chest x-ray showing increasing bilateral infiltrates. He was placed on supplemental oxygen and IV Lasix was given. His heart rate was in the 120s with a blood pressure in the 100s. He was also noted to have bilateral crackles 1.5 to [**3-16**] of the way up, and at this time given the patient's fever, hypotension, and respiratory status, he was electively intubated. Patient on the 20th, had blood cultures which returned showing gram-positive cocci and the patient was felt to be septic with gram-positive cocci in his blood, and the origin of the gram-positive cocci was felt likely to be due to the initial paracentesis on admission. His new onset of respiratory failure was thought to be either due to massive fluid overload from worsening cirrhosis, possibly high output failure from his TIPS procedure or possible sepsis/ARDS with his recent blood infection. Patient became hypotensive ranging from the 60s-100s/40s-780s. He eventually required Neo-Synephrine for blood pressure support. Patient also had a Swan-Ganz catheter placed for better hemodynamic monitoring, and the patient on [**8-1**], again became increasingly hypotensive and required three pressors for blood pressure support. It was thought that his deteriorating status was likely from MRSA bacteremia from a line infection and in-fact not from his abdomen. Additional abdominal CT did not show any bowel perforation or leak. The Swan-Ganz catheter revealed a distributive sepsis with decreased SVR and increasing cardiac output. He also noted to have increasing lactate from both sepsis and severe liver dysfunction. Patient had been during this time started on Vancomycin, Zosyn, and Flagyl for MRSA bacteremia as well as broad-spectrum antibiotic coverage. Patient was also noted on the 21st to have a profound acidosis with a pH of 7.09 and on [**8-3**], the patient was made comfort measures only. He was extubated shortly before 3 o'clock in the morning and at 3:06 a.m., the covering intern, Dr. [**Last Name (STitle) **] was called to examine the patient for asystole. His pupils were noted to be fixed and dilated. He had no pulse and no breath sounds, and no heart sounds are auscultated after 60 seconds. He was pronounced dead at 3:06 a.m. on the morning of [**2179-8-3**]. An autopsy was granted by his health care proxy. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus bacteremia and sepsis. 2. Hepatitis C. 3. Cirrhosis. 4. Portal hypertension. 5. Acute respiratory distress syndrome. The autopsy report designated the following: Pertinent findings: The patient, in general, was noted to be anisaric, jaundiced, and had scleral icterus. The heart weighed 440 grams and had cardiomegaly. There was opaque fibrous plaques on the anterior and posterior epicardium as well as 20 mL of straw colored pericardial fluid. The area that was noted to have mild-to-moderate atherosclerosis. The lungs: There was 100 mL of straw colored pleural effusion bilaterally. There are pleural adhesions to the thoracic wall and diaphragm. The digestive system: There are 3 liters of peritoneal fluid. In the esophagus, there were esophageal varices, but no recent hemorrhage. In the large bowel, there was no evidence of perforation. The liver showed cirrhosis. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**] Dictated By:[**Name8 (MD) 8288**] MEDQUIST36 D: [**2179-10-26**] 17:44 T: [**2179-10-27**] 04:38 JOB#: [**Job Number 30543**]

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Discharge summary

report

Admission Date: [**2204-8-15**] Discharge Date: [**2204-8-25**] Date of Birth: [**2132-3-13**] Sex: F Service: NEUROLOGY Allergies: Levaquin / Gabapentin Attending:[**First Name3 (LF) 618**] Chief Complaint: transfer from OSH for evaluation of b/l carotid stenoses (s/p L ICA stent) for CEA vs. angioplasty Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 1728**] is a 72 yo RH woman with history of CHF (EF 30%), afib on coumadin, ESRD on HD (now daily), DM II, HL, HTN, COPD who initially presented to BIDN where she was found to have a L ACA infarct and is transferred to [**Hospital1 18**] for evaluation of b/l carotid stenoses (s/p L ICA stent) for CEA vs. angioplasty. Patient initially presented to BIDN on [**8-9**] with right leg weakness. Pt states that she spent the morning shopping for clothing with her daughter. When they came home, she sat down in the bed. On attempt to stand up, she could not move her legs. She does not recall weakness in arms, difficulty with speech, loss of sensation, difficulty swallowing, headache. At BIDN, patient ws seen by neurology. NIHSS was 6. She had right hemeparesis, leg > arm. Her mental status was intact. She was found to have L ACA infarct, most likely cardioembolic in setting of afib and subtherapeutic INR. She also had small hemorrhage on CT. So, aspirin was decreased from 325 to 81, and her coumadin was held. Ms. [**Known lastname 1728**] has known 80-99% stenosis of the Right ICA as well as bilateral ECA stenoses. Now, on the Left, she has multiple near-occlusive placques in the distal, extracranial ICA (per carotid U/S and MRA from BIN 7/19-22/[**2204**]),distal to her stent. Given her multiple medical problems, including ESRD and complicated cardiac history, she is quite high risk for operative intervention. She was transferred here for further evaluation. Patient's admission at BIDN was quite complicated medically. She had an acute CHF exacerbation in setting of dietary indiscretion as well as noncompliance with dialysis. Pt was transiently in the ICU on bipap. She was seen by Dr. [**First Name (STitle) 4135**] in house, who is her primary cardiologist. Lasix was increased from 40mg PO qd to 80mg PO qd. Dialysis was initiated. During admission, pt also had chest pain with ST depressions in II, II, aVF. Trops peaked at 0.1. Deferred heparin drip given large territory ACA stroke. Renal whise, pt has ESRD and was on HD 3x/week. However, the patient refused HD in the past 2 weeks. The patient is also noncompliant with her diet. She was dialyzed in BIDN. She was seen by neprhology, recommended Epogen. Of note, she has fired physicians in the past. Pt was found to have Urinary tract infection with Escherichia coli sensitive to ceftriaxone. Day #1 was [**8-13**]. Today, pt feels somewhat better. Her husband is present. Feels that her speech is "not as clear as usual." Apparently, earlier in the day, she was able to move her right leg but now cannot. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia,lightheadedness, vertigo, tinnitus. Denies difficulties producing or comprehending speech. On general review of systems, the pt denies recent denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PCI: - [**2196**]: Cypher x 2 to left circumflex - [**2198**]: Cypher to LAD after NSTEMI - [**9-/2203**]: catheterization w/ known occluded RCA, 90% mid LAD intervened on w/ BMS, minimal LCX - [**12/2204**]: Found to have LAD and LCx disease with placement of DES to ostial LCX, DES to LAD 3. OTHER PAST MEDICAL HISTORY: -Heart failure with preserved ejection fraction ([**2201**] EF >55%) -Paroxysmal atrial fibrillion on coumadin -Mild to moderate mitral regurgitation (TTE [**2201**]) -carotid artery disease (s/p left carotid stenting, [**2202**]; right carotid with 80-99% stenosis) -h/o recurrent pulmonary edema -ESRD on HD TUES THURS SAT at [**Location (un) **] in [**University/College **] -COPD -Lung CA, status post resection [**2182**] -h/o uterine cancer -Neuropathy secondary to DM -Gout -Sleep apnea (not on CPAP) -Obesity -DVT after a fistula was placed on coumadin -GERD: status post endoscopy in [**2198-11-21**] which revealed nonerosive gastritis, reflux disease -Depression -S/p ligation of LUE AV fistula due to steel syndrome, with DVT -legally blind Social History: -Lives at home w/ husband who is main caregiver -3 children, 1 lives w/ her and is learning disabled -Tobacco history: 1 ppd most of her life, continues to smoke -ETOH: None -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Physical Exam on Admission: Vitals:98.8 109/58 83 20 98 3L General: Awake, NAD. HEENT: NC/AT Neck: Supple, carotid bruit on left. Pulmonary: trace crackles in LLL, no rhonchi/wheezes Cardiac: RRR, III/VI holosystolic murmor at left upper sternal border, no JVD Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to self, says it is [**2199-7-15**], [**Hospital1 18**]. Able to relate history without difficulty. Can saw DOW forward but not backward. Speech dysarthric. Able to name knuckle, watch, wrist band. Some difficulty repeating "no ifs ands or buts." Registers [**3-24**] objects, recalls [**1-24**] with prompting after 5 minutes. Normal prosody. There were no paraphasic errors. Able to follow both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Mild R ptosis V: Facial sensation intact to light touch. VII: R sided facial droop. 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: right leg was externally rotated and with decreased tone. Pt unable to lift the right leg, perhaps mild abduction of right hip. R arm with delts 3+, tric/biceps 4+. In LUE, ~5 in triceps/bicepts/delts. LLE with quad, IP, hamstring ~[**5-26**]. + asterixis. -Sensory: No deficits to light touch -DTRs: pt refused to let me check reflexes, said she was tired Plantar response was up bilaterally. -Coordination: patient did not agree to cooperate with FTN, said she was tired -Gait: deferred Physical Exam on Discharge: Expired Pertinent Results: Labs on Admission: [**2204-8-15**] 07:10PM WBC-14.2*# RBC-4.07*# HGB-12.6# HCT-39.6# MCV-97 MCH-31.0 MCHC-31.9 RDW-16.0* [**2204-8-15**] 07:10PM CALCIUM-10.3 PHOSPHATE-5.2* MAGNESIUM-2.2 [**2204-8-15**] 07:10PM GLUCOSE-87 UREA N-16 CREAT-3.9*# SODIUM-145 POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-22* Relevant labs: [**2204-8-16**] 04:35AM BLOOD PT-23.7* PTT-39.0* INR(PT)-2.3* [**2204-8-17**] 04:50AM BLOOD PT-94.1* PTT-46.7* INR(PT)-9.6* [**2204-8-17**] 08:04AM BLOOD PT-79.3* PTT-47.9* INR(PT)-8.0* [**2204-8-17**] 04:50AM BLOOD ALT-8 AST-12 AlkPhos-62 TotBili-0.2 [**2204-8-18**] 04:25AM BLOOD WBC-10.9 RBC-3.53* Hgb-10.7* Hct-34.4* MCV-97 MCH-30.3 MCHC-31.1 RDW-16.1* Plt Ct-170 Labs on Discharge: ***************** Imaging: Studies at OSH: -Chest x-ray revealed mild pulmonary edema. Head CT revealed no evidence of acute infarction; however, clinical indication with MRI was recommended. -Brain MRI with MRA revealed acute infarction in the left anterior cerebral artery territory with a small discontinuous focus of infarction in the left posterior body at all lobes with associated blood products indicating focal hemorrhagic transformation. Motion limited head MRA with probable atherosclerosis involving the right middle cerebral artery distal branches. Neck MRA was a motion limited study with questionable filling defects in the proximal right and left internal carotid arteries. Studies [**Hospital1 18**]: CTA head/neck 1. Evolving left ACA distribution stroke with posterior area of hemorrhage and possible new area of ischemia involving the left MCA distribution. No intracranial thrombus visualized on the head CT angiogram. 2. Severe stenosis of the bilateral extracranial internal carotid arteries, with measurements given above. Please note that these measurements of degree of stenosis are not determined with accuracy due to the diameter being under the limits of precision reached by CT, and the diameter of the patent lumen may be overestimated. Chest X-ray FINDINGS: Dialysis catheter noted and unchanged. The heart is moderately enlarged. There is extensive calcification of the thoracic aorta. Calcifications are also noted in the walls of the coronary arteries and the main bronchi. Cardiomediastinal contours are unremarkable. Lungs are clear with no evidence of focal consolidation to suggest acute pneumonia. No pleural effusions. No pneumothorax. IMPRESSION: No evidence of acute pneumonia. TTE The left atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate to severe regional left ventricular systolic dysfunction with extensive regional wall motion abnormalities as outlined on the chart (LVEF = 25%). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve leaflets do not fully coapt. There is severe mitral annular calcification. There is moderate thickening of the mitral valve chordae. Moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Severe regional left ventricular systolic dysfunction, c/w CAD. Moderate aortic stenosis. Mild aortic regurgitation. Moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Chest x-ray [**8-25**] An ET tube is present, in satisfactory position approximately 4.8 cm above the carina. An NG tube is present, extending beneath diaphragm, off film. A dual-lumen catheter is present, with tips over the mid and distal SVC. Clips noted overlying the right hilum. Allowing for lordotic positioning, no pneumothorax is detected. There is probable background COPD. There is cardiomegaly with a calcified aorta. There is upper zone redistribution and diffuse vascular blurring, consistent with CHF. There is tenting and/or fluid tracking at the right lung base. No gross effusion is identified. Compared with one day earlier, [**2204-8-24**], at 5:09 a.m., the overall appearance is similar. There has been possible slight improvement in the CHF findings and in basilar aeration. The cardiomediastinal silhouette may also be slightly improved. Brief Hospital Course: Ms. [**Known lastname 1728**] is a 72 yo RH woman with history of CHF (EF 30%), afib on Coumadin, ESRD on HD (now daily), DM II, HL, HTN, COPD who initially presented to BIDN where she was found to have a L ACA infarct and is transferred to [**Hospital1 18**] for evaluation of b/l carotid stenoses (s/p L ICA stent) for CEA vs. angioplasty. # NEURO: Ms. [**Known lastname 1728**] had L ACA infarct on presentation to BIDN. On admission exam, pt had R sided facial droop and mild ptosis, R leg was paretic, RUE with 3+ delts and 4+ biceps/triceps. Pt already on maximum medical therapy with warfarin, aspirin and plavix. She has also had stenting of the Left carotid in [**2202**]. However, she has failed all of these interventions and has had a stroke. Medically, she has ESRD on HD, CHF, afib and is thus quite high risk for CEA. She also has poor collateral circulation on vessel imaging which further increases her risk. Given severe stenosis on the right side and total on left along with prior stent, risk of embolism and devastating stroke intra-op is high. Pt is poor surgical candidate given imaging findings and multiple comorbidities. Thus, did not involve vascular surgery. She was continued on plavix, aspirin and crestor. Also, in BIDN, coumadin ws initially held in the setting of small hemorrage on CT. Re-started warfarin here as pt is high risk for embolic stroke in setting of afib. However, as below, on HD 2, INR was elevated to 9.6, then repeat to 8. Given large territory ACA stroke, pt at risk for bleeding into the stroke bed. So, discontinued warfarin and reversed with Vitamin K. Pt refused FFP adamantly despite understanding the risks. She was restarted on warfarin on [**8-18**] as INR was < 2. Goal INR for her needs to be strictly between [**2-24**]. The goal for her blood pressure neeeds to be systolically 120-160 given her high degree of carotid artery stenosis. Of note, her RLE cramps was thought to be related to the stroke, and baclofen was initiated as a trial to alleviate her discomfort. On [**8-19**], pt had rhythmic jerks of left arm and was non responsive. Thought to be secondary to epileptiform activity. Given dilantin load and was transferred to neuro ICU for further management. EEG on [**8-22**] encephalopathy generalized slowing but somewhat improved from day prior. # Cardio: -Chronic systolic congestive heart failure with LVEF 30%. While at [**Hospital1 **], patient was found to have acute on chronic systolic CHF requiring daily dialysis. Patient is oliguric at baseline. She was on lasix at home, but it was discontinued while at [**Hospital1 18**] given patient's blood pressure was persistently between 90-120 and on dialysis. Her home O2 was 4L, and she was tolerating at 2L while in [**Hospital1 18**] and maintaining O2Sat in the high 90s%. - CAD s/p multiple stents last in [**4-/2204**]: NSTEMI and Unstable Angina. While at [**Hospital1 **], patient was noted to have elevated troponin in the setting of chest discomfort. It was thought that she had an NSTMI, but heparin was not administered because of the finding of focal intraparenchymal hemorrhage associated with her ischemic stroke. She was managed medically. While in [**Hospital1 18**], patient had a couple episode of atypical chest pain at rest (right upper back, similar to prior CAD per patient) which may be her unstable angina, serial EKGs were stable in nature. Pain results with 1 nitroglycerin SL. She was thought not to be a candidate for intervention given recent ischemic stroke and high risk of bleed. Patient was managed medically. She was continued on isosorbide mononitrate, aspirin, plavix, crestor, and metoprolol. Pt went into on [**8-25**]. Also with large territory NSTEMI involving lateral and inferior leads, trop continued to trend up from 1.23 to 1.4. On TTE, CHF EF 25%. (Does have CAD s/p multiple stents last in 4/[**2204**].) Per cardiology c/s, pt started on heparin drip x48 hrs and amiodarone x24 hours. She also required 2 pressors (phenylephrine and norepinephrine) - hypotension in setting of propofol and CVVH. - Paroxysmal AF. Patient was noted to be in sinus while at [**Hospital1 18**]. Warfarin was held when it was supratherapeutic, but it was restarted on [**8-18**] after vitamin K administration. She was kept on metoprolol. # Renal: ESRD, on HD, MWF at home. However, 2 weeks prior to admission, she was refusing to go to HD. It was re-initiated at [**Hospital1 **] on a daily basis given the severity of her acute on chronic systolic heart failure. After her transfer to [**Hospital1 18**], she was switched back to her home schedule on Monday, Wednesday, and Friday. However, pt was not tolerating HD as she would become quite hypotensive. Was transitioned to CVVH but required 2 vasopressors to tolerate it as above. # ID: E. coli UTI was found while she was at [**Hospital1 **]. She was started on IV Ceftriaxone on [**8-10**]. It grew pan-sensitive E-coli. Patient continued CTX to [**2204-8-18**], a longer course than intended 7 days as she had transient leukocytosis of unclear source while cultures were pending. CTX was discontinued on [**8-18**] when repeat urine culture returned to have mixed flora and when her leukocytosis resolved. Chest x-ray with focal consolidation during ICU stay, suspicious VAP. Patient was afebrile thus primary ICU team did not feel that treatment with antibiotics was warranted at the time # Supratherapeutic INR. This occurred likely in the setting of antibiotics use. Patient received 10 mg vitamin K but not FFP as she declined. Her INR returned to 1.8 on [**8-18**] and she was reinitiated on warfarin at home dose. # Pulmonary: COPD on home O2, 4L. Patient was continued on Advair. Her O2 supplement requirement came down to 2 L with above measures. After intubation, she would get agitated with attempt to wean her off the vent and could not be extubated. # Goals of care: Had family meeting about goals of care on [**8-23**]. Explained complexity of medical situation, particulary, volume overload, dropping blood pressures, and multiple pressors as well as inability to tolerate dialysis. Husband wanted to stop aggressive care as he felt that she was suffering at this point. However, daughters are "not ready to give up" and want pt to remain full code and see "how things go for the next week." On [**8-24**], situation has taken a turn for the worse. Pt on 2 pressors and more PVCs on telemetry. She had an NSTEMI, was volume overloaded thus difficult to ventilate but could not diurese as pressures did not tolerate even minimal volume shifts with CVVH. Concered at that point that patient may pass in the next several days despite aggressive care. Called [**Doctor First Name **], daughter in [**Name (NI) **], to update her. Recommended she return as soon as possible. She was beginning to feel that we are "just prolonging the suffering." On further discussion with the family, decision was made to transition to comfort measures only on [**8-25**] once entire family was at bedside. Mrs. [**Known lastname 1728**] passed away peacefully on [**8-25**] several hours after extubation. Family declined autopsy. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver. 1. Clopidogrel 75 mg PO DAILY 2. Warfarin 3 mg PO SUN, TUESDAY, THURSDAY, SATURDAY 3. Warfarin 4 mg PO MONDAY, WEDNESDAY, FRIDAY 4. Furosemide 40 mg PO DAILY 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Cinacalcet 30 mg PO DAILY 7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 8. Metoprolol Succinate XL 50 mg PO DAILY 9. Pantoprazole 40 mg PO Q12H Your family was not sure if you have been taking this. 10. Aspirin 325 mg PO DAILY 11. Rosuvastatin Calcium 40 mg PO DAILY 12. Nitroglycerin SL 0.4 mg SL PRN chest pain 13. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS 14. sevelamer CARBONATE 800 mg PO TID W/MEALS 15. Ranitidine 150 mg PO DAILY AS NEEDED 16. Colchicine 0.6 mg PO PRN gout 17. Fluticasone Propionate NASAL 2 SPRY NU DAILY PRN nasal congestion Meds on Transfer: 1. Rocephin 1 g IV daily which could be switched to p.o. on discharge. 2. Imdur 30 mg p.o. daily. (per their notes, she had not been taking this medication recently at home) 3. Lasix 80 mg p.o. daily. 4. Advair 250/50 one puff b.i.d. 5. Lopressor 25 mg p.o. b.i.d. 6. Lipitor 20 mg p.o. daily. 7. Protonix 40 mg p.o. b.i.d. 8. Senna 2 tabs p.o. at bedtime. 9. Morphine 1 mg IV q.6 hours p.r.n. 10. Xalatan 1 drop both eyes daily. 11. Colace p.r.n. 12. Cepacol p.r.n. 13. Dulcolax p.r.n. 14. DuoNeb p.r.n. 15. Aspirin 81 mg p.o. daily. 16. Plavix 75 mg p.o. daily. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2204-8-31**]

[ "585.6", "780.39", "305.1", "780.01", "362.01", "250.40", "285.21", "369.4", "V49.86", "428.0", "357.2", "496", "V15.81", "327.23", "427.1", "428.23", "790.92", "E934.2", "427.31", "V12.51", "410.71", "041.49", "403.91", "599.0", "272.4", "583.81", "438.89", "433.11", "458.21", "V46.2", "414.01", "250.50", "440.20", "342.90", "250.60", "V45.82", "V10.42", "V58.61", "V10.11" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.97", "96.72", "96.6", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

20081, 20090

11304, 18500

381, 387

20141, 20150

6762, 6767

20206, 20336

4819, 4934

20049, 20058

20111, 20120

18526, 19443

20174, 20183

5816, 6706

4949, 4963

3512, 3804

6734, 6743

243, 343

7481, 11281

415, 3405

6781, 7462

5351, 5799

3835, 4590

3427, 3492

4606, 4803

19461, 20026

27,696

124,389

1150

Discharge summary

report

Admission Date: [**2178-10-13**] Discharge Date: [**2178-10-18**] Date of Birth: [**2100-9-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization Traumatic Foley Catheterization History of Present Illness: Mr. [**Known lastname **] is a 78 year old gentleman with CAD s/p CABG in [**2164**], s/p PCI in [**2169**], chronic stable angina, COPD and GERD who experienced onset of severe substernal chest pain at 12:30 am on the morning of [**10-13**]. Pain radiated only to his left arm. A call was placed to his cardiologist who instructed him to take 1 aspirin, 1 ntg and cardiazem and referred him to the emergency department. He said that this episode was more severe than any other episode of chest pain that he had before. . In the ED,initial Vs Bp 205/107 in triage, then 97.7, hR 80, BP 160/95, RR10, Sats 99%. He was given NTG sl, morphine 2 mg x 2 to control his pain. EKG with no ST changes. 1 set of enzymes was negative. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: coronary artery disease s/p CABG in [**2164**] Gastroesophageal reflux disease chronic obstructive pulmoary disease benign prostatic hyperplasia s/p knee surgery s/p Trans-urethral resection of prostate Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Patient is a Cardiothoracic surgeon. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 96.7, BP 137/70 , HR 41, RR 16, O2 99% on 4L Gen: WDWN elderly male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with with no JVD. CV: PMI located in 5th intercostal space, midclavicular line. Distant heart sounds, bradycardic rate, normal S1, S2. No S4, no S3. 1/6 SEM. Chest: well-healed midline scar, no other chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; femoral sheath in place, no femoral bruit, 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2178-10-13**] ADMISSION LABS: CBC: WBC-9.1 RBC-4.44* Hgb-14.2 Hct-41.7 MCV-94 MCH-31.9 MCHC-34.0 RDW-14.0 Plt Ct-229 . CHEM: Glucose-103 UreaN-25* Creat-1.5* Na-141 K-4.0 Cl-102 HCO3-33* AnGap-10 Calcium-8.7 Phos-3.4 Mg-2.4 . COAGS: PT-12.2 PTT-28.9 INR(PT)-1.0 . CE's: [**2178-10-13**] 02:10AM BLOOD CK(CPK)-127, CK-MB-4, cTropnT-<0.01 [**2178-10-13**] 09:20AM BLOOD CK(CPK)- 108 CK-MB-5 cTropnT-0.03* [**2178-10-14**] 04:05AM BLOOD CK(CPK)- 148 CK-MB-11* MB Indx-7.4* cTropnT-0.16* [**2178-10-14**] 05:10PM BLOOD CK(CPK)- 307 CK-MB-15* MB Indx-4.9 cTropnT-0.46* [**2178-10-15**] 06:04AM BLOOD CK(CPK)- 228 CK-MB-7 cTropnT-0.30* . LIPIDS: Triglyc-100 HDL-45 CHOL/HD-3.1 LDLcalc-75 . [**2178-10-13**] CARDIAC CATH: HEMODYNAMICS PRESSURES: RIGHT ATRIUM {a/v/m} 11/9/8 RIGHT VENTRICLE {s/ed} 29/9 PULMONARY ARTERY {s/d/m} 29/18/14 PULMONARY WEDGE {a/v/m} 17/21/16 LEFT VENTRICLE {s/ed} 92/18 AORTA {s/d/m} 98/60/75 HEART RATE {beats/min} 40 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 **% SATURATION DATA (NL) PA MAIN 60 AO 95 . FINAL DIAGNOSIS: 1. Branch vessel coronary artery disease. 2. Patent LIMA to LAD with excellent flow via a native LAD. 3. Patent SVG to RCA with an excellent competitive flow via a native RCA. 4. Ulcerated lesion in SVG to OM. 5. Known occlusion of jump graft to D1. 6. Mildly elevated LV filling pressure. 7. Two drug eluting stents placed to SVG-OM graft. . [**2178-10-14**] ECHO: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is an anterior space which most likely represents a fat pad.. Brief Hospital Course: 78 y/o M with CAD, s/p CABG who presented with unstable angina and underwent PCI with successful stenting of an occluded SVG-->OM graft, procedure complicated by new T-wave inversions on post cath EKG with persistent chest pain x several hours, likely due to thromboembolic shower. Hospital course complicated by developmenyt of atrial flutter and foley catheter trauma with persistent hematuria. . #) Cardiac: (a) Vessels: Patient was taken to cath lab with placement of cyper stent x 2 in SVG to OM. Thromboembolic shower likely explains patient's post cath EKG changes and chest pain. EKG changes resolved on serial EKGs and chest pain resolved on nitro gtt, able to be weaned off on post-cath day #1. Cardiac enzymes climbed post-catheterization, as expected iwth microemboli, but peaked and then trended downwards. He received Integrillin gtt x 18 hours. He was then managed medically with aspirin, a statin, plavix, isosorbide mononitrate, and ranolzazine. Beta-blocker was held given persistent bradycardia (was borderline bradycardic at baseline prior to cath). . (b) Rhythm/A-flutter: Patient with sinus bradycardia post-cath. Patient reports baseline HR 50-60. Beta blockade ws held. On post cath day #1 patient developed atrial flutter with variable 3-4:1 block. He was entirely asymptomatic and HR was in the 60-80s. He was placed on a heparin gtt while bridging to coumadin. He underwent a TEE which showed no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7388**], and he was then cardioverted. Follow-up EKG demonstrated NSR. . (c) Pump: LVEF 50-55% TTE. No CHF issues. . #) Hematuria: Patient failed initial vioding trial and so Foley was replaced. While in bed patient accidentally pulled on Foley and had subsequent hematuria. This persisted despite frequent NS foley flushes. Clots were removed during flushes. Urology was consulted who recommended against constant bladder irrigation, recommending just prn flushes. The hematuria was also felt to be exacerbated in part by his systemic anticiagulation with heparin while awaiting cardioversion. He was scheduled for outpatient urologic followup with his primary urologist. . #) Hypertension: well-controlled on medical therapy. . #) CRI: Baseline Cr 1.2 - 1.3. Remained at or better than baseline throughout stay with no evidence of post-cath CIN. . #) COPD: albuterol PRN . #) FEN: Cardiac diet. . #) Code Status: Full code. Medications on Admission: Ranolazine Isosorbide 60 mg daily Protonix 40 day Aspirin 325 day NTG PRN Flomax Ventolyn + another inhaler that does not remember the name Discharge Medications: 1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 8. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO BID (2 times a day). 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Outpatient Lab Work INR on [**10-21**]. pleaese fax result to Dr. [**Last Name (STitle) 7389**] [**Telephone/Fax (1) 7390**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Unstable Angina Atrial Flutter Coronary Artery Disease Hematuria Discharge Condition: Stable Discharge Instructions: You were admitted with unstable angina. You had a cardiac catheterization which showed an occlusion in one of your grafts. You had two stents placed in this occlusion. You had chest pain following this procedure, which was secondary to microemboli from your catheterization. . During your hospital course, you were also noted to have atrial flutter. You were cardioverted and started on anticoagulation. You will need to remain on Coumadin for a minimum of 3 weeks. . You had persistent hematuria from Foley trauma. You were evaluated by Urology who recommend that you be discharged with the foley. You should perform manual irrigation of the foley every 6 hours. You should follow-up with your Urologist next week. . You should take all of your medications as directed. You should not discontinue taking Plavix without the advice of your physician. . Your atorvastatin was increased to 40mg because of you LDL not being at goal. Please follow up with your primary care doctor in that regards. . If you have any of the following symptoms, please see your PCP or return to the ED: Chest pain, difficulty breathing, palpitations, lower extremity swelling, fever, or any other serious concerns. Followup Instructions: You have an appointment with your urologist, Dr. [**Last Name (STitle) 7391**] ([**Telephone/Fax (1) 7392**]) on [**10-23**], at 10:45 am. . Please make an appt to see Dr. [**Last Name (STitle) 7389**] in the next 3 weeks. . Please get your INR checked on [**10-21**]. The result will be faxed to Dr. [**Last Name (STitle) 7389**]. Completed by:[**2178-10-18**]

[ "867.0", "427.32", "E928.9", "414.02", "599.7", "445.89", "411.1", "496", "600.00", "997.1", "585.9", "530.81" ]

icd9cm

[ [ [] ] ]

[ "99.20", "00.66", "00.40", "36.07", "88.72", "88.52", "37.23", "00.46", "99.62", "88.56" ]

icd9pcs

[ [ [] ] ]

8637, 8695

4942, 7346

328, 385

8812, 8821

3078, 3095

10068, 10432

2062, 2144

7537, 8614

8716, 8791

7372, 7514

4125, 4919

8845, 10045

2159, 3059

278, 290

413, 1658

3111, 4108

1680, 1884

1900, 2046

7,118

127,146

13587

Discharge summary

report

Admission Date: [**2118-6-25**] Discharge Date: [**2118-7-7**] Service: MEDICINE Allergies: Metolazone Analogues Attending:[**First Name3 (LF) 41017**] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: Blood transfusion Intubation Central line placement Upper endoscopy History of Present Illness: This is an 81 year-old female with history of coronary artery disease status for CABG, peripheral vascular disease, diabetes, atrial fibrillation, congestive heart failure, chronic renal disease who was admitted with a GI bleed. She noted noted increased fatigue and lethargy several days prior to admission. She had also been increasingly bradycardic to the 40's but normotensive. The day prior to admission, she had several episodes of maroon colored diarrhea. She did not have any bright red blood per rectum. She had mild nausea without vomiting. She also noted light-headedness with standing. She denied abdominal pain. She denied fevers, chills, chest pain, or shortness of breath. Past Medical History: 1. Type II diabetes on oral hypoglycemic agents 2. Coronary artery disease status post CABG in [**2107**] (LIMA to LAD, SVG to OM, SVG to RCA). She also had 2 drug eluting stents to the OM1 and distal left main in [**6-9**]. 3. Congestive heart failure with an ejection fraction of 20%. 4. Atrial fibrillation on coumadin. 5. Chronic renal insufficiency with baseline creatinine 1.6-1.9. 6. Peripheral vascular disease bypass surgery bilaterally and later had below the knee amputation on the right ([**7-11**]) and stent to left bypass graft ([**3-14**]). 7. Anemia with baseline hematocrit 28-32. 8. Hypertension. 9. Status post appendectomy. 10. Status post cholecystectomy. 11. History of diverticulosis 12. History of internal hemorrhoids. Social History: She lives at home with her husband and son. She is independent with her activities of daily living. She does not drink alcohol. She had a 20 pack year smoking history and quit about 15-20 years ago. She never used any other drugs. Family History: Her father had diabetes and coronary artery disease. Physical Exam: Vitals: Temperature:96.7 Blood Pressure:110/60 Pulse:50 Respiratory rate:18 Oxygen Saturation:100% on room air General: Thin elderly female, pleasant, in no acute distress. HEENT: epicanthal tear to right eye, pupils equal and reactive, extraoccular movements intact, slightly dry mucous membranes. Cardiac:Irregularly irregular, bradycardic, without murmurs, rubs, or gallops. Pulmomary: Faint crackles at the bases otherwise clear to auscultaton. Abdomen: Normactive bowel sounds, soft, nontender, nondistended, quaiac positive. Extremities: Cool left lower extremities without edema, right below the knee amputation, 4 cm hematoma on dorsum on left hand. Pertinent Results: Hematology: WBC-6.6 HGB-7.3 HCT-20.7 PLT COUNT-206 NEUTS-68.2 LYMPHS-27.2 MONOS-3.2 EOS-1.0 BASOS-0 . Chemistries: SODIUM-135 POTASSIUM-3.3 CHLORIDE-89 TOTAL CO2-25 UREA N-184 CREAT-2.3 GLUCOSE-188 CALCIUM-7.9 PHOSPHATE-5.7 MAGNESIUM-2.8 . Coagulation: PT-29.2 PTT-37.2 INR(PT)-3.1 . Cardiac: CK(CPK)-64 CK-MB-NotDone cTropnT-0.06 proBNP-7707 DIGOXIN-1.3 . Imaging: 1. Chest x-ray: Cardiomegally. No evidence of pneumonia or pulmonary edema. 2. Left hand x-ray: Soft tissue swelling without evidence of fracture or dislocation. Brief Hospital Course: This is an 81 year-old female with history of coronary artery disease status for CABG, peripheral vascular disease, diabetes, atrial fibrillation, congestive heart failure, chronic renal disease who was admitted with a GI bleed. . 1. GI Bleed: In the emergency department, she was hemodynamically stable with a hematocrit of 20 and . She initially received 2L of fluid resuscitation and 2 units of red cells. Her INR was reversed with fresh frozen plasma and vitamin K. A nasogastric lavage was negative. Given a negative lavage, she was presumed to have a lower bleed such as a diverticular bleed. She was admitted to the intensive care unit. On arrival to the intensive care unit, she became unresponsive and hypotensive to the 60s systolic. She was aggressively fluid resuscitated. A central line was placed, and she was started on dopamine for blood pressure support. She later underwent an upper endoscopy that showed gastritis without any obvious bleeding source. She was started on IV protonix. Her aspirin, plavix, and coumadin were held in the setting of her bleed. She had no further episodes of bleeding. Once she was hemodynamically stable, her aspirin and plavix were restarted. Her hematocrit was stable at 28 for several days. She received a unit of red cells prior to discharge. At the time of discharge, her hematocrit was 29.3. It was recommended to have an outpatient colonoscopy to complete her evaluation. A decision about whether or not to restart her coumadin will be made by her primary care physician in [**Name9 (PRE) 702**]. . 2. Respiratory Failure: She was initially intubated for airway protection during unresponsiveness in setting of hypotension. A chest x-ray demonstarted fluid overload from her aggressive fluid ressucitation. Once she was hemodynamically stable, she was treated with afterload reduction and gentle diuresis. She was also found to have a pneumonia with MRSA and M. catarrhalis growing in her sputum. She was started on a course of levofloxacin and vancomycin to a complete a 10 day course. She was weaned off ventilator support shortly after admission to the ICU. At the time of discharge, she was oxygenating well on her usual 2L nasal cannula. . 3. Coronary artery disease: She has known severe disease. On arrival to the intensive care unit, she was found to have inferior ischemic changes on EKG. These changes were transient and likely secondary to demand ischemia. Serial cardiac enzymes remained negative. As she was not a candidate for further intervention, she was treated with medical management. Once she was hemodynamically stable, she was restarted on her aspirin, plavix, lisinopril, and metoprolol. . 4. Hypotension: Her hypotension, was secondary to hemorrhage and hypovolemia. She intially was fluid ressucitated and required pressors. She was quickly weaned from the pressors. . 5. Congestive heart failure: She became overloaded in setting of transfusion and fluid resuscitation. Her metoprolol, lisinopril, and digoxin were held given bradycardia and renal dysfunction. A transthoracic echocardiogram showed an ejection fraction of 20% and was unchanged from prior studies with the exception of increased pericardial effusion (pulsus was 8). Once she was stable, she was diuresed. Prior to discharge, her metoprolol, lisinopril, digoxin, and lasix were restarted. . 6. Acute on chronic renal failure: Her creatinine was elevated above her baseline of 1.6-1.9 on admission. This was likely secondary to hypoperfusion in the setting of hypovolemia. Nephrotoxic medications were intially held. Her creatinine returned to baseline with fluid resuscitation. All her home medications were restarted prior to discharge. At the time of discharge, her creatinine was 1.3 . 7. Atrial fibrillation: She was on coumadin for anticoagulation. Her INR was emergently reversed in the setting of her bleed. Her coumadin will be held until she sees her primary care physician as an outpatient. Her nodal agents were also held initially given bradycardia. Later, she became persistently tachycardic requiring a diltiazam drip. She was transitioned to metoprolol with good rate control. . 8. Peripheral vascular disease: She had no acute issues during this admission. . 9. Diabetes: Her most recent hemoglobin A1c was 7.2. Her sugars were under good control with an insulin sliding scale. Her glipizide was restarted prior to discharge. . 10. FEN: She was maintained on a cardiac, diabetic diet once she was extubated. Her electrolytes were repleted. She was f.uid ressucitated and diuresed as above. . 11. Prophylaxis: pneumoboots, ppi . 12. Access: A triple lumen right IJ catheter was placed. . 13. Code: DNR but intubation is fine. . 14. Dispo: She was discharged to an acute rehabilitation center. She should follow-up with her primary care physician 1-2 weeks after discharge from rehab. Medications on Admission: Plavix 75mg qday protonix 40mg qday tums 500mg tid senna prn lopressor 25mg tid zyprexa 5mg qhs neurontin 300mg qhs coumadin per INR zocor 40mg qday lasix 120mg qd ASA 325 qd zestril 2.5 qhs glipizide 10 [**Hospital1 **] calcium/vitamin D zolpidem 5 qhs prn Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 13. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a day). 15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 3 days. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: GI bleed Pneumonia Congestive heart failure Coronary artery disease Atrial fibrillation Acute on chronic renal failure Diabetes Discharge Condition: Stable. She remained hemodyamically stable with no further evidence of bleeding. Discharge Instructions: Please take all medications as prescribed and keep all follow-up appointments. . You should not take your coumadin until you see your primary care physician. . Seek medical attention if you have any more red stool or if you have chest pain, shortnes of breath, fevers, chills, lightheadedness, or anything else that you find worrisome. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: You should follow-up with your primary care physician 1-2 weeks after discharge from rehab. You will need an outpatient colonoscopy. Completed by:[**2118-7-7**]

[ "287.5", "403.91", "427.31", "V18.0", "584.9", "443.9", "V45.81", "428.0", "250.00", "518.81", "V15.82", "414.01", "578.9", "280.0", "535.50", "447.1", "458.9", "482.41", "V17.3" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "45.13", "99.07", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

9889, 9959

3380, 8274

244, 314

10131, 10215

2827, 3357

10701, 10865

2079, 2133

8582, 9866

9980, 10110

8300, 8559

10239, 10678

2148, 2808

189, 206

342, 1040

1062, 1810

1826, 2063

56,128

126,860

33874

Discharge summary

report

Admission Date: [**2139-9-25**] Discharge Date: [**2139-9-28**] Date of Birth: [**2094-6-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Zantac / Morphine / Tylenol / Naprosyn / ketorolac / Potassium Attending:[**First Name3 (LF) 2763**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Left femoral CVL History of Present Illness: 45 year-old female with a PMH hypotension on Florinef, ESRD, DMII, and borderline personality disorder who complains of CP. Patient with left sided chest pain starting after an argument with a nurse in her [**Hospital1 1501**] two hours prior to arrival. Started while she was lying down after the argument. Constant pain. Non radiating. + SOB. No nausea. No fevers or cough. + pleuritic. Hx of DVT in leg. Not on blood thinner. No recent surgeries. . Of note, patient was recently admitted from [**Date range (1) 11068**] with hypotension believed to be secondary to agressive dialysis. She was fluid responsive in the ED and admitted to the MICU for close observation. She was afebrile and without any other symptoms or signs concerning for infection. In the ICU, she required no further fluids and maintained a SBP 80s-100s, which appears to be her baseline. . In the ED, initial VS were: 96.9 91 112/69 16 100%. Labs were significant for lactate 1.7, D-dimer 323, trop 0.08. Patient was given hydromorhone 1 mg X 2, lorazepam 2 mg X 2, ASA 325 mg X 1, and diphenhydramine 25 mg PO X 1. A left femoral CVL was placed. She was started on a levophed gtt given BPs in 50s systolic. A bedside ECHO revealed no evidence of effusion. CTA showed no evidence of pulmonary embolism or acute aortic syndromes. . On arrival to the MICU, patient was vitally stable and well oreinted. She was started on a 500ml NS bolus. Past Medical History: 1. Hypotension (likely mineralocorticoid deficient, hypo-renin, hypo-aldosterone, not likely complete adrenal insufficiency vs. autonomic dysfunction on Florinef) 2. ESRD on HD M/W/F (RUE AV-fistula) 3. type 2 diabetes mellitus 4. coronary artery disease (inferior MI, cardiac cath [**2129**], EF 65%, inferior hypokinesis; MIBI [**11/2138**] no perfusion defects, no ischemic ST changes) 5. h/o LLE DVT (no longer on coumadin), popliteal DVT ([**7-/2136**]) s/p IVC filter placement 6. hypertension 7. GERD 8. h/o positive MRSA swab ([**2138**]) 9. hyperlipidemia 10. chronic abdominal pain (no etiology identified, extensive work-up including MRA abdomen, strongyloides serologies, RUQ U/S, multiple KUBs) 11. borderline personality disorder 12. drug-seeking behavior, ? suicidality 13. left eye prosthesis (followed by ophthalmology at [**Hospital1 2177**]) 14. Bilateral IJ and SC DVTs Social History: Social History: Born in [**Country 2045**] and moved from [**State 108**]; divorced, has two daughters. Worked as a CNA. Now resides in long term care facility. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: Mother died from diabetes complications, brother died from the same as well; Sister and daughter have diabetes. Physical Exam: Physical Exam on admission: Vitals: T: 98.5 BP:118/69 P:104 R: 18 O2:94 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: [**2139-9-28**] 03:37AM BLOOD WBC-7.4# RBC-3.97* Hgb-12.2 Hct-37.4 MCV-94 MCH-30.7 MCHC-32.6 RDW-16.3* Plt Ct-147* [**2139-9-27**] 04:26AM BLOOD WBC-4.0 RBC-4.28 Hgb-13.2 Hct-41.7 MCV-98 MCH-30.9 MCHC-31.7 RDW-16.5* Plt Ct-124* [**2139-9-24**] 10:45PM BLOOD Neuts-62.3 Lymphs-25.1 Monos-3.5 Eos-5.5* Baso-3.6* [**2139-9-28**] 03:37AM BLOOD Plt Ct-147* [**2139-9-25**] 08:43AM BLOOD PT-14.1* PTT-30.4 INR(PT)-1.2* [**2139-9-28**] 03:37AM BLOOD Glucose-200* UreaN-37* Creat-9.7*# Na-134 K-4.5 Cl-94* HCO3-28 AnGap-17 [**2139-9-27**] 04:26AM BLOOD Glucose-288* UreaN-23* Creat-7.3*# Na-135 K-4.9 Cl-96 HCO3-28 AnGap-16 [**2139-9-26**] 02:03AM BLOOD CK(CPK)-198 [**2139-9-25**] 08:43AM BLOOD CK(CPK)-177 [**2139-9-25**] 08:43AM BLOOD CK(CPK)-176 [**2139-9-26**] 02:03AM BLOOD CK-MB-4 cTropnT-0.09* [**2139-9-25**] 08:43AM BLOOD CK-MB-4 cTropnT-0.11* [**2139-9-25**] 08:43AM BLOOD CK-MB-4 cTropnT-0.13* [**2139-9-24**] 10:45PM BLOOD cTropnT-0.08* [**2139-9-28**] 03:37AM BLOOD Calcium-10.8* Phos-5.5* Mg-2.8* [**2139-9-27**] 04:26AM BLOOD Calcium-10.1 Phos-5.6* Mg-2.6 [**2139-9-24**] 10:58PM BLOOD D-Dimer-323 [**2139-9-27**] 10:27AM BLOOD TSH-1.1 [**2139-9-27**] 10:27AM BLOOD TSH-1.4 [**2139-9-27**] 04:26AM BLOOD TSH-1.3 [**2139-9-28**] 07:58AM BLOOD PTH-62 [**2139-9-27**] 10:27AM BLOOD T4-4.6 T3-62* calcTBG-0.97 TUptake-1.03 T4Index-4.7 [**2139-9-27**] 10:27AM BLOOD T4-4.3* T3-56* calcTBG-0.99 TUptake-1.01 T4Index-4.3* [**2139-9-27**] 04:26AM BLOOD T4-4.4* T3-62* calcTBG-0.98 TUptake-1.02 T4Index-4.5 [**2139-9-27**] 10:27AM BLOOD Cortsol-27.1* [**2139-9-27**] 10:27AM BLOOD Cortsol-6.0 [**2139-9-27**] 04:26AM BLOOD Cortsol-6.5 [**2139-9-25**] 08:43AM BLOOD Cortsol-3.5 [**2139-9-25**] 03:28AM BLOOD Lactate-1.7 [**2139-9-28**] 07:58AM BLOOD VITAMIN D 25 HYDROXY-PND [**2139-9-28**] 07:58AM BLOOD VITAMIN D [**12-23**] DIHYDROXY-PND . [**2139-9-25**] 2:50 am BLOOD CULTURE Blood Culture, Routine (Pending): . [**9-27**] T and L spine X-ray: FINDINGS: Two views of the thoracic and two views of the lumbar spine demonstrate mild degenerative changes. The alignment is normal. No fractures are visualized. Note is made of an IVC filter and a catheter following the course of the iliac vessels and a stent in the right subclavian vein. . PORTABLE ABDOMEN ON [**9-26**] HISTORY: Constipation. FINDINGS: Femoral line is seen projecting over the expected course of the left femoral and iliac vein and IVC filter projects over the right side of L3. Gas and stool are seen throughout the colon. There are no dilated loops of bowel. There are no air-fluid levels. IMPRESSION: Normal appearance to the bowel. . CTA chest [**9-25**]: IMPRESSION: 1. No acute aortic pathology or pulmonary embolism. 2. Chronic occlusion of the left subclavian vein and narrowing of the right subclavian vein with thrombus demonstrated in the innominate stent, which remains narrowly patent. 3. Renal osteodystrophy. . CXR PA and lateral [**9-24**]: IMPRESSION: Interval development of mild interstitial pulmonary edema. No evidence of focal pneumonia. Brief Hospital Course: 45 y/o female w/ hypotension [**12-31**] autonomic dysfxn on Florinef, ESRD on HD, DMII, and borderline personality disorder, who presented to the ED w/ chest pain and hypotension. . # Hypotension: patient admitted to MICU on levophed at 0.05 mcg/min. With consideration to the etiology of the hypotension, sepsis was considered to be unlikely given the lack of symptoms, fever, and leukocytosis. She was continued on her home dose of florinef out of concern for autonomic dysfunction. A triple lumen femoral line was placed due to poor vascular access overall. She had an AM cortisol of 3.5 and was placed on stress dose steroids of 50 mg hydrocortisone q6hr. Levophed was stopped on the morning of [**9-26**]. When she became hypotensive again, she was given IVF and very briefly IV decadron. An endocrine consult was placed and she was ordered for a corticotropin stimulation test; she had an appropriate response to that indicating that adrenal insufficiency is less likely. On the day of discharge, her florinef was discontinued and she was started on midodrine. She tolerated this medication well, with SBP 90-100 on discharge. . # Chest Pain: pt's initial presentation was atypical chest pain. She had an EKG which was unchanged from prior and continued to show a RBBB. Her troponins were trended and were slightly elevated, although in the setting of ESRD, that would not be unexpected and she is very unlikely to have experienced an ischemic event. Her home ASA was continued. She had a normal Echo and a CTA which did not show evidence of a PE. Furthermore, she has an IVC filter which would make a PE unlikely. She was given dilaudid for her back pain and incidentally, her chest pain subsided. . # Back pain: She had a fall 2 months ago and has had persistent back pain since then. On [**9-26**], she complained of this similar pain. She had a complete neuro exam that showed mostly L paraspinal tenderness with left leg lift tests, normal strength, no saddle anesthesia. We had a low suspicion for an epidural process/cord compression. She had plain films of her thoracic and lumbar spine which showed no evidence of fracture or malalignment. She was given dilaudid for her pain and it subsided. . # ESRD: Pt had in-house dialysis as scheduled. She was placed on a renal diet and nephrotoxins were avoided. . # DM2: Pt was placed on an insulin sliding scale with bedtime lantus (12 units) which is consistent with her home regimen. She had finger sticks QAHS. . # Bipolar disorder: given home dose of quetiapine . # Transitional Issues - monitor BP daily, as she is newly started on midodrine to improve her blood pressure control - f/u with endocrinology for hypotension and review of pending studies Medications on Admission: 1. docusate sodium 100 mg PO BID 2. aspirin 81 mg PO DAILY 3. atorvastatin 40 mg PO at bedtime 4. dicyclomine 10 mg Two (2) Capsule PO QID 5. erythromycin 250 mg PO TID 6. ferrous sulfate 325 mg PO once a day. 7. B complex-vitamin C-folic acid 1 mg Capsule PO DAILY 8. omeprazole 20 mg PO DAILY 9. sevelamer carbonate 800 mg Three (3) Tablet PO TID W/MEALS 10. latanoprost 0.005 % Drops (1) Drop(s) in each eye HS 11. lorazepam 1 mg PO Q6H as needed for anxiety. 12. quetiapine 50 mg PO QHS 13. fludrocortisone 0.1 mg PO BID 14. hydroxyzine HCl 25 mg PO Q6H as needed for itching. 15. gabapentin 100 mg PO HS 17. bisacodyl 5 mg Tablet, Two Tablet as needed for constipation. 18. tizanidine 2 mg Tablet Sig: 0.5 Tablet PO at bedtime. 19. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO once a day. 20. Dilaudid 2 mg Tablet 0.5 Tablet PO Three times weekly M/W/F on HD 21. bisacodyl 10 mg One (1) suppository Rectal at bedtime as needed 22. lorazepam 1 mg PO three times weekly: M/W/F on HD days. 23. Aranesp 40 mcg/0.4 mL(1) syringe Injection once a week. 24. ondansetron 4 mg PO Q8H (every 8 hours) as needed for nausea 25. Maalox Maximum Strength PO twice a day as needed for abdominal/chest pain 26. Humalog (Subcutaneous) 100 unit/mL Solution. Humalog (Subcutaneous) 100 unit/mL Solution. BG <150: no coverage BG 150-199: 2 units, BG 200-249: 4 units, BG 250-299: 6 units, BG 300-349: 8 units, BG Over 350: 10 units, . At bedtime use the following scale BG <150: no coverage BG 150-199: 0 units, BG 200-249: 2 units, BG 250-299: 4 units, BG 300-349: 6 units, BG Over 350: 8 units, 27. Lantus 100 unit/mL Solution Sig: Twelve (12) Units Subcutaneous at bedtime. Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. B-complex with vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. gabapentin 100 mg Capsule Sig: One (1) Capsule PO at bedtime. Capsule(s) 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. tizanidine 2 mg Tablet Sig: 0.5 Tablet PO at bedtime. 13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO once a day. 14. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Monday, Wednesday, Friday as needed for pain. 15. Aranesp (polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1) injection Injection once a week. 16. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*1* 18. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 19. dicyclomine 20 mg Tablet Sig: One (1) Tablet PO four times a day. 20. erythromycin 250 mg Tablet Sig: One (1) Tablet PO three times a day. 21. Maalox Advanced 1,000-60 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day as needed for indigestion. 22. bisacodyl 10 mg Suppository Sig: One (1) Rectal at bedtime as needed for constipation. 23. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours. 24. Lantus 100 unit/mL Solution Sig: Twelve (12) units Subcutaneous at bedtime. 25. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous TID and qHS. Discharge Disposition: Extended Care Facility: [**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **] Discharge Diagnosis: Hypotension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were seen in the hospital for chest pain and low blood pressure. We gave you fluids and some steroids to help with your blood pressure. We have discontinued your florinef and started you on a new medication called midodrine. We did some blood work to see if we could determine the cause of your low blood pressure. Some of the lab values haven't finalized yet so we set you up with an endocrinologist appointment on [**10-7**]. . We also did many tests to determine the cause of your chest pain. We did EKGs, followed cardiac enzymes, did a CT scan of your chest and have determined that you most likely did not have an acute cardiac event or pulmonary blood clot. If you continue to experience episodes of chest pain, please see a cardiologist. Followup Instructions: Department: DIV OF GI AND ENDOCRINE When: WEDNESDAY [**2139-10-7**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2139-9-28**]

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icd9cm

[ [ [] ] ]

[ "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

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347, 365

13657, 13657

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100,532

23752

Discharge summary

report

Admission Date: [**2182-4-10**] Discharge Date: [**2182-4-12**] Date of Birth: [**2128-3-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: none History of Present Illness: 53 yo f w/ h/o HCV, HCC and cirrhosis with h/o SBP and variceal hemorrhage who presents to ED with UGIB and hyperkalemia. Pt is well known to the Liver Service through previous admission and w/u for cirrhosis and HCC. Pt has had several admissions to OSH's, recently for anemia requiring transfussions as well as for complications of portal hypertension and SBP in the past. Pt recently d/c to rehab where he has been suffering from worsening fatigue and anorexia. Day of admission, Pt reports several episodes of dark emesis. . Transferred to OSH where he had several episodes of hematemesis; and found to be afebrile and hypotensive (SBP 70's). Labs at the time significant for Hct 29, HCO3 13 and K+ 7.0. ECG with possible peaked TW's. Subsequently recieved 10u insulin, one amp D50, Calcium, Kayexelate and covered with Cefotan and Flagyl. Right femoral line placed and transfused one unit of PRBCs and bolus 2.5 L NS. Transfered to BDIMC where in the ED was hemodynamically stable. NGL with evidence of blood despite 1 L flush and gross melena. . ROS: Pt denies F/C/CP/SOB/Girth/Abd pain but ? increasing abd girth. . Past Medical History: DM HTN HCV (chronic active) x 20 years ([**1-16**] IVDU) HCC started on Xeloda cirrhosis with known varices and h/o ascites/SBP diverticulosis s/p hemicolectomy Social History: Lives alone Previous h/o etoh abuse, now sober x 24 years +tobacco 15yrs x2ppd, no longer smoking Family History: NC Physical Exam: VS 100/30, 80, 19 99% 2L . gen-WOWN man, moaning, alert but disoriented time/place heent-icteric sclera, PERRL, dry MM, OP clear neck-2+ carotids [**Last Name (un) **]-CTAB CVS-Regular s1,s2. 2/6 SEM abd-Midline abdominal scar. protuberent distended abdomen, +caput. +bs. soft, diffuse tenderness; no rebound, +fluid wave. ext-2+ le edema, chronic venous stasis changes. neuro-A&O-1, mild asterexis, moving all extremities. Pertinent Results: [**2182-4-10**] 07:00PM BLOOD WBC-27.9*# RBC-2.66* Hgb-8.2* Hct-27.2* MCV-102* MCH-30.9 MCHC-30.2* RDW-20.9* Plt Ct-57* [**2182-4-10**] 07:00PM BLOOD PT-22.7* PTT-47.8* INR(PT)-3.2 [**2182-4-10**] 07:00PM BLOOD Glucose-203* UreaN-127* Creat-2.9*# Na-135 K-6.9* Cl-102 HCO3-8* AnGap-32* [**2182-4-11**] 05:12AM BLOOD ALT-409* AST-2728* AlkPhos-222* Amylase-59 TotBili-8.2* [**2182-4-10**] 07:00PM BLOOD Albumin-1.5* Calcium-8.2* Phos-10.7*# Mg-2.6 [**2182-4-10**] 09:00PM BLOOD Type-ART pO2-77* pCO2-23* pH-7.16* calHCO3-9* Base XS--18 [**2182-4-11**] 03:45AM BLOOD Lactate-13.5* K-5.7* CXR: IMPRESSION: 1) Pulmonary vascular congestion suggestive of early CHF. 2) Patchy retrocardiac opacity, which may be related to the low lung volumes, however, an early consolidation cannot be excluded. When possible, a dedicated PA and lateral radiographs are recommended. U/S IMPRESSION: 1) Thrombosis of the left portal vein with slow flow in the main and right portal vein. 2) Cirrhosis with multifocal hepatocellular carcinoma and ascites. Brief Hospital Course: 53 yo f w/ h/o HCV, HCC and cirrhosis with h/o SBP and variceal hemorrhage who was admitted to MICU with UGIB and hyperkalemia. Pt with underlying incurable malignancy and that superimposed variceal bleeding in setting of renal and hepatic failure carried a very poor prognosis. Family was aware of Pt's mortality risk and were interested in less aggressive measures of care that would preclude intubation, dialysis or other aggresive procedures but still remained full code as per Pt's initially wishes. Pt was maintained on octreotide/protonix gtts and supported/resucitated with blood products during first hospital day. Pt without recurrent hematemesis and remained hemodynamically stable off pressors but requiring aggressive resucitation. Hepatology and Transplant surgery services consulted and help in pt management. Pt with continued worsening liver and renal function despite aggressive resucition presumed [**1-16**] hypovolemia at OSH in setting of variceal bleed. Belief was that Mr [**Known lastname 131**] at best had several weeks to live given clinical picture. Discussions between MICU team, Hepatology servicem, Social work and ethics support with Family; decision was made to make Pt comfort measure only. Subsequently Pt died [**2182-4-12**]. Medications on Admission: Nadalol 40 qd Protonix 40 qd Oxycodone 5 q6 spironolactone 200 qd glyburide 5 qd cipro 250 qd lasix 40 qd Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: DM HTN HCV HCC cirrhosis variceal hemorrhage liver failure renal failure sepsis hyperkalemia Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

4780, 4789

3326, 4596

325, 331

4926, 4935

2267, 3303

4988, 4995

1801, 1806

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4622, 4730

4959, 4965

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274, 287

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72,236

192,810

40956

Discharge summary

report

Admission Date: [**2150-5-9**] Discharge Date: [**2150-5-22**] Date of Birth: [**2115-12-5**] Sex: F Service: NEUROSURGERY Allergies: Amoxicillin / Codeine / Meperidine / Methadone / morphine / Penicillins / vancomycin Attending:[**First Name3 (LF) 1835**] Chief Complaint: Shunt discontinuity Major Surgical or Invasive Procedure: [**2150-5-9**]: Attempted VP shunt revision complicated by intraoperative finding of possible chest wall abcess, VP shunt externalization in the OR by Dr [**Last Name (STitle) **] [**2150-5-11**]: VP shunt explanted, Right EVD implanted [**2150-5-20**]: Left sided VP shunt History of Present Illness: Ms. [**Known lastname **] is a 34 year old right handed woman with a history of congenital hydrocephalus s/p VPS placement right after birth s/p revision at age 13. She also appears to have baseline mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. She states having developed erythema over her R chest wall about a week ago. Earlier today she noted a drastic increase in the size of the protrusion over her chest wall as well as redness so came to the [**Hospital3 **] ED and was subsequently transferred to the ED here. CXR done at OSH showed calcified fibrous tissue surrounding the shunt and two focal areas of shunt discontinuity at right lower neck. She denies any headache or blurred vision. No nausea except at the [**Hospital3 **] ED where she vomited once. No fevers. Past Medical History: 1. Diabetes 2. chronic UTI/neurogenic bladder requiring cath 3. asthma 4. [**Hospital3 **] 5. hydrocephalus s/p VPS 6. s/p spinal surgery for scoliosis Social History: Lives with disabled father and is wheelchair bound. No TOB or EtOH. Family History: Non-contribiutory Physical Exam: PHYSICAL EXAM5/28/11 the day of admission: T HR BP 120/80 Resp 12 General: Awake, cooperative, overweight, almost cushingoid in appearnace. Head and Neck: no scleral icterus noted, mmm, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTA b/l Cardiac: No murmurs appreciated. Abdomen: normoactive bowel sounds Extremities: well perfused, but shortened legs Skin: There is a protruberance of the shunt lying over the right clavicle, which ends in an elevated, erthematous and warm patch of skin over the right chest wall. There are also multiple excoriations over both legs, with a wound over the right shin. Neurologic: Mental Status: Alert, oriented to [**Hospital3 **], [**Location (un) 86**], [**2150-4-12**]. Speech is stuttering but fluent. Names a few high frequency objects, repeats simple phrases and follows three step commands. Affect is child-like. Cranial Nerves: I: Olfaction not tested. II: PERRL 5 to 3mm bilaterally. Funduscopic exam revealed sharp disc margins. III, IV, VI: EOMI without nystagmus, no phorias or tropias. Smooth persuit with occasional saccadic intrusion. 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 sternocleidomastoid bilaterally. XII: Tongue protrudes in midline. Motor: paraparesis. No pronator drift bilaterally. No adventitious movements, such as tremors, noted. No asterixis. 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 0 0 0 0 0 0 0 R 5 5 5 5 5 5 5 0 0 0 1 0 0 0 *Of note, on confrontation testing she has a paraplegia, but she does withdraw both feet to baninski testing Sensory: Intact in arms to LT, PP Deep tendon reflexes: Biceps 2+ bilaterally, 1+ bracialradialis and triceps. Absent at legs and ankles. Coordination: No dysdiadochokinesia noted or dysmetria in arms. On the day of discharge: Stable exam Pertinent Results: [**2150-5-8**] 08:00PM URINE MUCOUS-RARE [**2150-5-8**] 08:00PM URINE RBC-<1 WBC-1 BACTERIA-MANY YEAST-NONE EPI-<1 [**2150-5-8**] 08:00PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2150-5-8**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003 [**2150-5-8**] 08:00PM PT-13.0 PTT-21.9* INR(PT)-1.1 [**2150-5-8**] 08:00PM PLT COUNT-361 [**2150-5-8**] 08:00PM NEUTS-75.8* LYMPHS-19.3 MONOS-3.2 EOS-1.3 BASOS-0.4 [**2150-5-8**] 08:00PM WBC-13.1* RBC-4.54 HGB-12.4 HCT-36.4 MCV-80* MCH-27.4 MCHC-34.2 RDW-14.2 [**2150-5-8**] 08:00PM estGFR-Using this [**2150-5-8**] 08:00PM GLUCOSE-105* UREA N-5* CREAT-0.3* SODIUM-137 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-17 [**2150-5-8**] 08:33PM LACTATE-1.2 [**2150-5-8**] 08:55PM URINE UCG-NEGATIVE [**2150-5-8**] 08:55PM URINE HOURS-RANDOM [**2150-5-9**] 06:50AM PT-13.8* PTT-23.1 INR(PT)-1.2* [**2150-5-9**] 06:50AM PLT COUNT-351 [**2150-5-9**] 06:50AM WBC-14.3* RBC-4.60 HGB-12.8 HCT-37.9 MCV-82 MCH-27.8 MCHC-33.7 RDW-14.6 [**2150-5-9**] 06:50AM GLUCOSE-122* UREA N-6 CREAT-0.4 SODIUM-136 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16 [**2150-5-9**] 02:23PM PLT COUNT-338 [**2150-5-9**] 02:23PM WBC-9.8 RBC-4.28 HGB-11.8* HCT-35.3* MCV-82 MCH-27.5 MCHC-33.4 RDW-14.5 [**2150-5-9**] 02:23PM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.8 [**2150-5-9**] 02:23PM GLUCOSE-128* UREA N-7 CREAT-0.3* SODIUM-137 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14 [**2150-5-9**] 02:24PM URINE WBCCLUMP-RARE MUCOUS-OCC [**2150-5-9**] 02:24PM URINE CA OXAL-OCC [**2150-5-9**] 02:24PM URINE GRANULAR-4* HYALINE-4* WBCCAST-2* [**2150-5-9**] 02:24PM URINE RBC-6* WBC-81* BACTERIA-MOD YEAST-NONE EPI-6 [**2150-5-9**] 02:24PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-80 BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-LG [**2150-5-9**] 02:24PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2150-5-9**] 04:48PM URINE UCG-NEGATIVE [**2150-5-9**] 04:48PM URINE HOURS-RANDOM [**2150-5-9**] 04:58PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-1* POLYS-50 LYMPHS-31 MONOS-19 [**2150-5-9**] 04:58PM CEREBROSPINAL FLUID (CSF) PROTEIN-6* [**2150-5-9**] 07:50PM SED RATE-30* [**2150-5-9**] 07:50PM CRP-62.4* CT HEAD W/O CONTRAST Study Date of [**2150-5-8**] 8:29 PM IMPRESSION: 1. Hydrocephalus, raising the possibility of shunt malfunction, however, prior studies are not available for direct comparison. 2. Absent septum pellucidum with lack of visualization of the corpus callosum, which may be attenuated or there may be possible agenesis. If further delineation is desired, MR could be performed. CHEST (PA & LAT) Study Date of [**2150-5-8**] 9:10 PM PA AND LATERAL VIEWS OF THE CHEST: A VP shunt catheter is noted coursing along the right neck and right anterior chest, however there are multiple areas of apparent discontinuity within the catheter as it courses within the neck. There are low lung volumes. The heart size is top normal. The mediastinal and hilar contours are unremarkable. The lungs are clear and the pulmonary vascularity is normal. No pleural effusion or pneumothorax is seen.Bilateral [**Location (un) 931**] rods are in place. IMPRESSION: Discontinuity of the VP shunt catheter within the right neck. SHUNT SERIES AP & LAT SKULL, AP CHEST, AP ABDOMEN Study Date of [**2150-5-8**] 10:54 PM REPORT not read as of [**5-10**]****************** CHEST (PORTABLE AP) Study Date of [**2150-5-9**] 2:25 PM FRONTAL CHEST RADIOGRAPH: Retained shunt tubing is noted extending from the level of the right fifth posterior rib inferiorly. [**Location (un) 931**] rods are noted. The cardiomediastinal silhouette is stable. The lungs are grossly clear. There is no pneumothorax or focal consolidation. IMPRESSION: 1. Retained shunt tubing. 2. No acute cardiopulmonary abnormality. CT ABDOMEN W/CONTRAST Study Date of [**2150-5-9**] 4:04 PM IMPRESSION: 1. Discontinuity of the ventriculoperitoneal shunt, which is not see above the level of T3. 2. Area of phlegmonous changes around superior most aspect of the VP shunt and extending cephalad. No drainable fluid collection. 3. Cholelithiasis. 4. Multiple subcentimeter simple cysts within the pancreatic tail, without suspicious features. Followup with CT in one year is recommended. 5. Non-obstructive lower pole left renal calculus. CT head [**5-11**]: Immediately status post revision of a right frontovertex approach ventriculostomy catheter, with improved lateral ventriculomegaly and no evidence of acute intracranial hemorrhage. CT Head [**5-20**] postop: Satisfactory position of left frontal ventriculostomy catheter, with decreased ventriculomegaly, no new hemorrhage Brief Hospital Course: Ms. [**Known lastname **] was admitted to the Neurosurgery service after a study revealed a break in her VPS catheter at the level of her neck. She was taken to the OR on [**5-9**] for revision of her VPS. Intraoperatively we found frank Puss coming from her chest wall and the distal portion of the catheter. The VPS was externalized at the neck and cultures were sent. An ID consult was obtained for recommendation. A UTI was detected, she was started on Cipro and Vancomycin for wound propholaxis which [**Last Name (un) 89381**] her a diffuse rash on [**5-10**]. Initial cultures revealed GNR in her CSF as well as from wound cultres. Patient was transferred to the ICU on [**5-10**] for desensitization for treatment with Cefepime which would provide better CNS coverage for Gram Negative orginisms, Vancomycin was also discontinued and she was started on Daptomycin given her drug reaction. She was taken to the OR on [**5-11**] for explantation of her right sided VP shunt. All components of the system were removed including the intracranial and intra-abdominal portions. She toelrated the procedure well, was extubated in the OR and taken to the ICU post-operatively. Her EVD was placed at 10cm and was functioning well with ICP'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] [**6-21**] for the first 5 minutes of transduction. On [**5-12**], she was stable and was transfered to the stepdown unit. Transitioning of dilantin to keppra was in place. On [**5-13**], daptomycin stopped per ID. She had chest wall edema/erythema which was controlled with benadryl. A PICC line was placed for [**Known lastname **] term antibiotics. PT and OT were consulted for assistance with getting out of bed and mobilization. On [**5-14**] she was again neurologically stable without acute issues. On [**5-15**] she was found to be febrile to 102 and was pancultured including CSF. Her CXR from [**5-14**] showed probable bilateral lower lobe pneumonias and ID was consulted and recommended switiching her antibiotics to linezolid and meropenem. She remained stable on [**5-16**] and [**5-17**]. On [**5-18**] CSF was sent in preparation for ensuring clean cultures for the OR for replacement of her shunt later in the week. The gram stain was negative. On [**5-19**] her PICC line was replaced due to contamination and her sutures and staples were removed. Labs were sent in preparation for internalization of her VP Shunt on [**5-20**]. On [**5-20**] she underwent VP Shunt placement without complication. It was noted that she had a decubitus on her coccyx so a wound care consult was called. She was also having diarrhea so stool cultures were sent that were negative for C. Diff. On Postoperative Day 1, she did well. She was tolerating a regular diet, afebrile with stable vital signs. ID recommends treatment with IV Meropenem and Telavancin for 8 postoperative days and then transition to Oral Cipro 500mg [**Hospital1 **] for 7 days. Medications on Admission: 1. Detrol 2. Dilantin 200mg daily 3. Fluoxetine 40mg daily 4. Lasix 20mg daily 5. Metformin 1000mg [**Hospital1 **] 6. Proventil INH PRN 7. Simvastatin 20mg daily 8. Piroxicam 20mg PRN 9. Loratidine 10mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 2. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for Rash. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) Pen Injector Intramuscular ONCE (Once) as needed for anaphylaxis. 12. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 13. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [**12-14**] PO Q6H (every 6 hours) as needed for itch/rash. 15. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 17. telavancin 250 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours): x 6 days, stop date [**2150-5-28**]. 18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 20. DiphenhydrAMINE 50 mg IV ONCE:PRN allergic reaction 21. 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. 22. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): x 6 days, stop date: [**2150-5-28**]. 23. Cipro 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 7 days: Start after completion of IV antibiotics and continue for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: hydrocephalas Chronic Urinary Teact infection Shunt infection 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: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. -Please follow up with your primary care physician regarding findings noted on your Abdominal CT. (Multiple subcentimeter simple cysts within the pancreatic tail) Followup with Abdomen CT in one year is recommended. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**6-21**] days(from your date of surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. - Please follow up with your primary care physician regarding findings noted on your Abdominal CT. (Multiple subcentimeter simple cysts within the pancreatic tail) Followup with Abdomen CT in one year is recommended. Completed by:[**2150-5-22**]

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Discharge summary

report

Admission Date: [**2138-8-30**] Discharge Date: [**2138-9-26**] Date of Birth: [**2069-4-18**] Sex: M Service: MEDICINE Allergies: Dilaudid Attending:[**Last Name (un) 11974**] Chief Complaint: SOB Major Surgical or Invasive Procedure: Thoracentesis History of Present Illness: 69yo M PMHx Severe aortic stenosis ([**Location (un) 109**] 0.9cm2), s/dCHF (EF 20% [**8-/2138**]), recurrent L-sided pleural effusion attributed to CHF, AV node dysfunction s/p PPM ([**2-/2138**]), COPD, CKD, and multiple recent hospital stays for shortness of breath, notable for CABG/AVR w/u but subsequent refusal of surgical intervention, now presenting with SOB. Patient reports SOB has been worsening since discharge 1d prior to this presentation. He denies CP, palpitations, nausea/vomitting/diarrhea, HA, weakness. . Initial vital signs in the ED were 98.5 74 120/60 16 95%. Exam was notable for crackles throughout lung fields. Labs were significant for WCC 11.5 (6.1 at discharge), Hct 31.1, Cr 3.8 (3.7 at discharge), CXR demonstrated fluid overload w stable large L pleural effusion. CT [**Doctor First Name **] was consulted but given patient's refusal of surgical interventions in the past they recommended medicine admission. Patient was admitted to medicine for further management of shortness of breath. Vitals at time of transfer were 98.6 77 131/76 22 100%2LNC. . On arrival to the floor, initial vital signs were 96.3 143/70 73 28 93%4L. Patient denied any pain or discomfort, but his tachypnea interfered w conducting a full review of systems. On the day of admission the pt was transferred to the CCU due to concern for evolving sepsis in the setting of likely PNA and CHF exacerbation. Past Medical History: CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension CARDIAC HISTORY:[**3-/2138**] cath 30% prox LAD. 100% first diagonal, 50% mid LCx, 40% OM1, 100% ostial RCA OTHER PAST MEDICAL HISTORY: - Chronic Diastolic and Systolic Congestive Heart Failure - Aortic Stenosis - Coronary Artery Disease - Chronic Renal Insufficiency (baseline Cr 2.5) - Chronic Obstructive Pulmonary Disease - Cerebrovascular event ([**2097**], per pt no residual deficits) - Type II Diabetes Mellitus (IDDM) - Post-traumatic stress disorder - Chronic Pain ( fractured lumbar vertebra) - Osteoarthritis left shoulder and leg - Benign prostatic hypertrophy - Left hand neuropathy - Glaucoma in left eye - Colon polyps - Recurrent left pleural effusion 4. PAST SURGICAL HISTORY - Permanent Pacemaker [**2138-3-10**] - C4-C7 spinal surgery - Right lower extremity vein stripping - Nasal surgery Social History: Tobacco: 1.5 ppd ( 75 PYHx); trying to quit ETOH: 2 per month Lives: Alone, has daughter who spends a lot of time hopitalized for psychiatric reasons Occupation: retired engineer Last Dental Exam: has 6 remaining teeth, uses partials Family History: Brother died of MI at 69. Physical Exam: ADMISSION EXAM: VS: T 98 BP 91/52 HR 84 RR 14 O2 Sat 93% 3L NC GENERAL: Resting comfortably in bed. Unarousable. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVP to the angle of the mandible CARDIAC: PMI not palpable. RR, harsh crescendo/decrescendo systolic murmur best heard at the R 2nd intercostal space radiating to the carotids. LUNGS: Absent breath sounds and dullness to percussion at the L base. Scattered crackles. Using accessory abdominal muscles. ABDOMEN: Soft, NTND. No HSM or tenderness. AS murmur heard in the abdominal aorta. EXTREMITIES: 2+ pitting edema to the shin, 1+ pitting edema to the patellas bilaterally. Pulses 1+. SKIN: Bilateral abrasions of the forearms, confluent ecchymoses of the forearms PULSES: Right: Carotid 2+ Femoral 2+ Radial 2+ Left: Carotid 2+ Femoral 2+ Radial 2+ NEURO: Pupils 1-2mm bilaterally, equally round and reactive to light. Otherwise unable to participate [**3-12**] sedation. . DISCHARGE EXAM: GENERAL: 69 yo M sitting in bed in no acute distress HEENT: supple, no JVD sitting upright CHEST: Crackles bibasilar 1/2 up CV: S1 S2 Normal in quality and intensity with crescendo-decrescendo systolic murmur throughout precordium. ABD: firm, non-tender, distended with mild ecchymosis. Pos BS. EXT: wwp, 2+ edema 1/2 up calf. DPs, PTs 1+. NEURO: sleepy, arousable but quickly falls back asleep. Able to answer simple questions. SKIN: no rash, PICC d/c'ed PSYCH: lethargic, not agitated but restless. Pertinent Results: ADMISSION LABS: [**2138-8-31**] 09:15AM BLOOD WBC-20.3*# RBC-3.82* Hgb-11.4* Hct-36.0* MCV-94 MCH-30.0 MCHC-31.8 RDW-14.4 Plt Ct-386 [**2138-8-31**] 09:15AM BLOOD Glucose-146* UreaN-85* Creat-3.8* Na-146* K-4.1 Cl-97 HCO3-28 AnGap-25* [**2138-8-30**] 06:45PM BLOOD cTropnT-0.36* [**2138-8-31**] 09:15AM BLOOD CK-MB-8 cTropnT-0.49* [**2138-8-31**] 09:15AM BLOOD Calcium-9.1 Phos-4.8* Mg-2.3 [**2138-8-31**] 09:18PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2138-8-31**] 08:18PM BLOOD Type-ART Temp-36.7 pO2-50* pCO2-28* pH-7.46* calTCO2-21 Base XS--1 Intubat-NOT INTUBA [**2138-8-31**] 08:18PM BLOOD Lactate-8.7* [**2138-9-1**] 08:18AM BLOOD Lactate-1.4 . Pleural Fluid Analysis: [**2138-9-2**] 05:59PM PLEURAL WBC-70* RBC-1230* Polys-6* Lymphs-63* Monos-8* Meso-4* Macro-15* Other-4* [**2138-9-2**] 05:59PM PLEURAL TotProt-1.3 Glucose-211 LD(LDH)-120 Albumin-LESS THAN Cholest-17 DISCHARGE LABS: . Microbiology: No growth on multiple blood, urine, or pleural fluid cultures. PERTINENT REPORTS: . CXR ([**2138-9-1**]): Interval increase in size of a now large left pleural effusion with associated bilateral lower lobe atelectasis and moderate edema. CXR [**2138-9-14**]: Lines and catheters are in satisfactory position. There is pulmonary edema which may be slightly increased. Right lung is well aerated with persistent left basilar opacity, probably a combination of pleural effusion and atelectasis or consolidation. This has remained unchanged. IMPRESSION: 1. Persistent opacity at the left lung base with mild increase in pulmonary edema. TTE [**2138-9-8**]: The left atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is moderate to severe global left ventricular hypokinesis with relative preservation of anterior septal and basal inferolateral contraction. The remaining segments are severely hypokinetic (LVEF = 25 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. Right ventricular chamber size is normal with depressed free wall contractility. There is severe aortic valve stenosis (valve area 0.9cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Left ventricular cavity enlargement with global hypokinesis c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Severe aortic valve stenosis. Moderate aortic regurgitation. Pulmonary artery systolic hypertension. Moderate mitral regurgitation. Compared with the prior study (images reviewed), anterior septal motion is improved. The gradient across the aortic valve is increased with similar aortic valve area. The severity of mitral regurgitation is slightly increased. Brief Hospital Course: PRIMARY REASON FOR ADMISSION: 69yo M PMHx Severe aortic stenosis ([**Location (un) 109**] 0.8cm2, peak gradient 66mmHg), s/dCHF (EF 20%), recurrent L-sided pleural effusion attributed to CHF, AV node dysfunction s/p PPM ([**2-/2138**]), COPD, CKD, and multiple recent hospital stays for shortness of breath, notable for CABG/AVR w/u but subsequent refusal of surgical intervention, now presenting with SOB. . ACTIVE DIAGNOSES: # Shortness of Breath: Pt with s/d CHF (EF 20% [**8-/2138**]), critical AS (valve area 0.9 cm2), as well as recurrent L pleural effusion that has previously been attributed to CHF, presenting w worsening SOB, CXR significant for volume overloaded appearance; most likely etiology is complication of AS. On HD 1 he was transfered to the CCU for progressive hypoxia. In the CCU, his pleural effusion was tapped (chemistry consistent with transudative nature with negative statin, culture and cytology). He was started broad spectrum coverage with vancomycin/cefepime/flagyl for multifocal pneumonia and diuresed with significant improvement in his respiratory symptoms. Cultures both sputum and blood cultures were negative. In total he received 6 days of vancomycin and flagyl and 8 days of cefepime. He was tranferred to the floor but required readmission to the CCU the following day after an apneic episode believed to be due to ativan. In the CCU his respirtory status continued to decline and he required CPAP. Effusion reaccumulated on HD10, drained (2L) with pigtail catheter placed. Once again the fluid was noted to be transudative in nature. After drainage his respiratory status markedly improved and he was weaned to room air. Once patient was made comfort measures only, dyspnea was managed with oral morphine as needed. . #Critical Aortic stenosis- EF 20%, maintaining BP. Pt meets criteria for NYHA class III/IV. The patient was started on milrinone in the setting of decling renal function which resulted in an EF increase to 25%. However, renal function continued to decrease and the patient required CVVHD. CT surgery was consulted and felt that the patient was not a candidate for surgical intervention. His milrinone was discontinued as was CVVHD, and patient was symptomatically managed for volume overload with lasix and morphine. # Acute on chronic renal failure: Renal failure has been worsened in the setting of improved cardiac output with very decreased urine output. Patient showed signs of uremia with decreased mental status and twitching. Pt failed a diuretic challenge. Renal was consulted for possible dialysis. His urine sediment showed muddy brown casts suggesting ATN. Per renal recommendations patient was started on CVVHD via a R IJ dialysis line with marked improvement in his mental status and uremia. However, the patient expressed to renal that he did not desire to have further dialysis. Additionally concerns were raised about the patients compliance with outpatient dialysis and it was determined that he would be a poor candidate for long term dialysis. His IJ line was removed as there was no further plan for dialysis. # AMS/Agitation: Patient's initial agitation was controlled with standing haldol 1mg PO TID. Changes in mental status were thought to be multifocal in nature, including baseline dementia, hospital delirium, uremia in setting of worsening renal function and poor CNS perfusion in setting of severe AS. As patient became more somnolent, uremia appeared to be a controllable factor as creatinine was climbing with decreasing UOP. Patient was started on CVVHD and mental status markedly improved. However, patient refused CVVHD and it was discontinued on HD14. At baseline, pt is combative, so there was to be an underlying psych component superimposed on any organic cause of AMS. He was continued on PRN haloperidol 0.5 mg PO, with increasing frequency. # Medical Decision Making: Patient exhibited delirium, and per evaluation by psychiatry service did not demonstrate capacity to make medical decisions. His daughter [**Name (NI) 803**] expressed interest in pursuing guardianship for pt, but it was not certain whether this was appropriate since at times the patient had expresed that he did not want to see his daughter and did not want her participating in his care (although he was disoriented when he made these remarks). At the time of discharge his daughter was in the process of attempting to gain guardianship through the courts. # Goals of Care: Pt was evaluated by CT surgery who felt that he was not a surgical candidate. Pt initially started on CVVH, when mental status improved he stated that he did not wish to continue dialysis. Dialysis was discontinued to respect his wishes and his HD catheter line was removed. A meeting was held with primary team, palliative care team, SW, and pt's daughter. (Patient was agitated and disoriented at that time so was unable to participate.) It was agreed that since patient is not a candidate for surgery and had requested that dialysis be stopped, that it was appropriate to change his goals of care to focus on comfort measures only. # Leukocytosis: Resolved without antibiotics, etiology unclear. [**Name2 (NI) **] remained afebrile, and cultures from pleural fluid, urine, stool, and blood showed no growth. INACTIVE DIAGNOSES: # HTN: Patient's home prazosin and metoprol were initally continued. His pressure was labile throughout admission requiring a short period of pressure support with phenylephrine. His home metoprolol and prazosin were held during this period and pressures improved. He subsequently resumed his home dose of metoprolol, but prazosin was not restarted. # CAD: Stable throughout admission without acute EKG changes. Patient was continued on ASA 325mg daily. # DM: Patient's blood sugars were controlled with home glargine and sliding scale of insulin. Patient frequently refused fingersticks and insulin, and so when he was made comfort measures only, glargine and insulin were discontinued as were fingerstick checks. #TRANSITIONAL ISSUES - Per discussion with patient and family, his code status was changed to DNR/DNI. Medications on Admission: - aspirin 81mg daily - metoprolol succinate 25mg daily - famotidine 20mg q24hrs - clonazepam 2mg Tablet daily - lactulose 10 gram/15 mL daily - prazosin 1mg qhs - Lasix 40mg [**Hospital1 **] - Zocor 20mg daily - glargine 20units qAM Discharge Medications: 1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 2. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for wheeze. 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q2H (every 2 hours) as needed for SOB, wheeze. 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever; pain. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 2.5-5.0 mg PO Q1H (every hour) as needed for SOB or pain. 9. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation. 10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day): i9f not having daily BM's. 11. prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. Discharge Disposition: Extended Care Discharge Diagnosis: Severe aortic stenosis Acute on chronic systolic congestive heart failure Acute kidney injury requiring temporary dialysis Coronary artery disease Left pleural effusion Chronic obstructive pulmonary disease Post traumatic stress disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with pneumonia and congestive heart failure and needed to be on a ventilator to help you breathe while you received antibiotics and diuretics. Your kidney function deteriorated and you received 24hour dialysis for a few days. AFter speaking with you, the kidney doctors and the cardiac surgeons, it was decided that surgery or long term dialysis would not be an appropriate treatment plan. Therefore, the goal of your care will to keep you as comfortable as possible. We have discontinued all aggressive medicines and most regular monitoring. . We made the following changes to your medicines: 1. Stop taking famotidine, clonazepam, prazosin, lasix, glargine and zocor 2. Start albuterol/Ipratroprium nebulizers for your breathing 3. change metoprolol to short acting and take twice daily 4. Increase aspirin to 325 mg daily 5. Start colace, senna and lactulose 6. STart morphine for pain or trouble breathing 7. Start haldol as needed for agitation 8. Start compazine for nausea Followup Instructions: Pulmonary: Please cancel if this appt is not appropriate: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2138-10-7**] at 8:45 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]

[ "428.0", "428.23", "V58.67", "414.01", "276.3", "427.31", "424.1", "250.00", "600.00", "V12.54", "496", "584.5", "585.4", "V45.01", "309.81" ]

icd9cm

[ [ [] ] ]

[ "39.95", "34.91", "38.93", "38.95" ]

icd9pcs

[ [ [] ] ]

15109, 15124

7551, 7960

272, 287

15406, 15406

4472, 4472

16604, 17100

2887, 2914

13964, 15086

15145, 15385

13706, 13941

15582, 16581

5406, 7528

2929, 3934

3950, 4453

229, 234

315, 1727

4489, 5390

15421, 15558

12856, 13680

1944, 2619

2635, 2871

7,371

111,149

20106

Discharge summary

report

Admission Date: [**2168-6-21**] Discharge Date: [**2168-6-27**] Date of Birth: [**2120-5-23**] Sex: M Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 48-year-old male with a known history of a thoracoabdominal aneurysm who had been followed by his primary care physician. [**Name10 (NameIs) **] was decided upon consultation with Dr. [**Last Name (Prefixes) **] that this patient would ultimately need repair of this aneurysm, and therefore it was decided that the patient would undergo surgery. PAST MEDICAL HISTORY: Hypertension. High cholesterol. Seizure disorder. Left thumb neuropathy. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Aspirin 325 p.o. q.d., Zantac 150 p.o. b.i.d., Keppra 1000 mg p.o. b.i.d., Glucophage 500 mg p.o. q.a.m., 1000 mg p.o. q.p.m., Lisinopril 20 mg p.o. q.d. PHYSICAL EXAMINATION: Vital signs: He was afebrile with stable vital signs. General: He was in no apparent distress. Lungs: Clear. Heart: Regular. Abdomen: Soft, nontender, nondistended. Bowel sounds positive. Extremities: Warm and well perfused. LABORATORY DATA: All within normal limits. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2168-6-21**], for a thoracic aneurysm repair. Please see the operative report for further details. The patient was transferred to the CSIU postoperatively and did well. He was weaned from the ventilator and extubated. He was given cardiac pressors in order to enhance his blood pressure which was slowly weaned off, and the patient's blood pressure was stabilized. He was started back on all of his preoperative blood pressure medications. The patient continued to do well and was ultimately transferred out of the CS RU and was transferred to the floor. The patient had an epidural placed for the operation which was removed postoperatively. After removal of the epidural catheter, the patient had episodes of bradycardia and headache. The patient was reconsulted, and it was decided that the patient had a small CSF leak. He was offered a patch for treatment of this; however, his headache resolved, and the leak resolved as well, and it was decided that the patient would not need further treatment. His beta-blocker was stopped at that time for reason of his bradycardia. Physical Therapy was consulted, and it was deemed that the patient could go home. By that time, he was medically stable. The patient continued to do well from a medical standpoint and was cleared by Physical Therapy. The patient also underwent an MRA of the aorta in order to evaluate for further dilatation. These results are still pending at the time of discharge. The patient was discharged on postoperative day 6 after his chest tubes and wires were removed, as well as his Foley catheter. The patient was discharged in stable condition. DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., Aspirin 325 p.o. q.d., Zantac 150 p.o. b.i.d., Keppra 1000 mg p.o. b.i.d., Glucophage 500 mg p.o. q.a.m., 1000 mg p.o. q.p.m., Lisinopril 20 mg p.o. q.d., he was given pain medications [**2-12**] tab p.o. q.4 hours p.r.n., as well as Oxycodone. CONDITION ON DISCHARGE: The patient was discharged in stable condition. DISCHARGE DIAGNOSIS: 1. Thoracic aneurysm status post thoracic aortic aneurysm repair. 2. Hypertension. 3. High cholesterol. 4. Seizures. 5. Left thumb neuropathy. FO[**Last Name (STitle) 996**]P: He was instructed to follow-up with his primary care physician [**Last Name (NamePattern4) **] [**2-12**] weeks, his cardiologist in [**3-16**] weeks, and with Dr. [**Last Name (Prefixes) **] in [**5-17**] weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], MD 2351 Dictated By:[**Doctor Last Name 11225**] MEDQUIST36 D: [**2168-6-27**] 14:31:53 T: [**2168-6-27**] 15:02:39 Job#: [**Job Number 20130**]

[ "997.09", "441.2", "E878.8", "272.0", "401.9", "349.0", "780.39" ]

icd9cm

[ [ [] ] ]

[ "38.45" ]

icd9pcs

[ [ [] ] ]

2900, 3173

3268, 3894

710, 866

1189, 2876

889, 1171

569, 683

3198, 3247

25,100

126,083

48249

Discharge summary

report

Admission Date: [**2184-12-2**] Discharge Date: [**2184-12-9**] Date of Birth: [**2133-8-20**] Sex: M Service: GU DIAGNOSIS: Septicemia following prostate biopsy. MAJOR INVASIVE PROCEDURES: None. HISTORY OF PRESENT ILLNESS: This is a 51-year-old male who underwent a prostatic biopsy on [**2184-12-1**] in the afternoon with Dr. [**Last Name (STitle) **] and sent home. The patient developed fevers, but discharged on ciprofloxacin 500 b.i.d.. The patient developed fevers while on this medication after taking 3 pills and developed chills in the morning of [**2184-12-2**]. He presented to the ED with this complaint. He denied any nausea or vomiting. No diaphoresis. Had mostly feelings of malaise and headache, but no dizziness and no pain. PAST MEDICAL HISTORY: Notable for hypertension. PAST SURGICAL HISTORY: Prostatic biopsy. FAMILY HISTORY: Positive for prostate cancer in his father. SOCIAL HISTORY: The patient is a nonsmoker, has an occasional glass of wine during the week, 1 to 2 cups of coffee a day, and is currently a musician who has a recording studio. MEDICATIONS AT HOME: Include Lipitor, Diovan, Procardia XL, hydrochlorothiazide and Cipro. ALLERGIES: None. PHYSICAL EXAMINATION: On presentation to the ED, the patient had a temperature of 101.4, heart rate of 102, blood pressure of 156/89, respiratory rate of 16, 97% on room air. He was in no acute distress. Awake and oriented x3. His skin was diffusely warm. He had a soft, nontender, nondistended abdomen. He had no suprapubic tenderness. No CVA tenderness. His rectal exam; prostate measured 40 to 50 grams with a smooth contour, nontender, no nodules were palpated. His testes were descended bilaterally with normal phallus that was circumcised. There was no scrotal/penile swelling or erythema. No masses were palpated on exam. He had no inguinal/ventral hernia palpated. LABORATORY DATA: His white count upon presentation to the ED was 10.0, hematocrit 43.8, with platelet count 187. His Chem- 10 was sodium 139, potassium 4.1, chloride 104, bicarbonate 21, BUN 18, with a creatinine of 1.0 and glucose in the 170s. Coag's: PT was 11.5 with an INR of 1.1 and PTT of 25.7. PSA which was measured on [**2183-9-25**] was 0.5; and a free testosterone was 8, which was measured in [**2184-7-1**]. His UA upon presentation to the ED was leukocyte negative, blood's were small, red blood cell count was less than 1, white blood cell count was 3 to 5, and he had rare bacteria. The patient was admitted to the urology service under [**Known firstname **] [**Last Name (NamePattern1) 770**]. Pertinent results are notable for white counts; on [**12-3**] a white count of 9.1. The patient also had a white count on [**12-8**] of 9.9 with a white count on [**12-9**] of 9.6. The differential on [**12-4**] was notable for 75% neutrophils with 21% bands. On the 4th, he had a neutrophil count of 62% with 29 bands. His bands upon discharge were 0. His white count upon discharge was 9.6 with a hematocrit of 41.3 and platelet count of 229. The patient on [**12-3**] had a troponin of 0.33 with a CK/MB of 7. The patient also had cultures which were drawn. A blood culture on [**2184-12-2**] sensitive for E. coli, resistant to ciprofloxacin or gentamicin resistance with levofloxacin resistance. Is sensitive, however, to ceftriaxone and imipenem and meropenem. The patient had another urine culture which was drawn on [**12-2**] which was negative. He had a stool for C. diff which was negative that was obtained on [**2184-12-5**]. He also had a CT of the head that was done on [**2184-12-4**] which showed no acute intracranial hemorrhage or mass effect. A chest x-ray on [**12-5**] showed no cardiopulmonary disease. An echocardiogram on [**12-6**] showed a moderate left atrial enlargement, a mildly dilated right atrium, normal LV wall thickness, normal LV cavity size, with an overall left ventricular ejection fraction of greater than 55%, his right ventricular chamber size was normal, right ventricular systolic function was normal, his aortic valves were normal, no aortic regurgitation, mitral valve leaflets were mildly thickened with no mitral regurgitation, mild pulmonary artery systolic hypertension, no pericardial effusion. A prostate ultrasound was also obtained on [**2184-12-8**] which showed no evidence of an intraprostatic abscess, small __________ fluid between the prostate gland and rectum, may be post procedural in nature given recent history of biopsy of the prostate. BRIEF HOSPITAL COURSE: The patient was admitted to the urology service under Dr. [**Known firstname **] [**Last Name (NamePattern1) 770**]. He was transferred then from to the emergency room to the [**Hospital Ward Name **] of [**Hospital1 1444**] where he was placed on ampicillin and gentamicin. After a consultation with ID, we added Flagyl and ceftriaxone to the patient's regimen. At 2 o'clock in the morning on [**2184-12-3**] the patient was noted to have rigors and chills with a heart rate in the 170s with a hypotensive characteristic blood pressure of 90s/60s. He was tachypneic, shaking and diaphoretic. After consultation with Dr. [**Known firstname **] [**Last Name (NamePattern1) 770**] we decided to transfer the patient to the [**Hospital Ward Name 1826**] ICU for closer monitoring. The patient continued his care in the [**Hospital Ward Name 1826**] ICU where cardiac enzymes were measured. His troponin peaked at 0.33. A cardiology consult was obtained. Cardiology felt that the patient's troponin bump was directly related to a septic picture and cardiac stress from the event. An echo was obtained which was normal. The patient remained afebrile throughout his course in the ICU. Cultures came back, and he was discontinued on his ampicillin, gentamicin and Flagyl. Continued on the ceftriaxone, where he remained afebrile. The patient continued to do well and was transferred back to the urology service from the ICU after a 3-day stay. He again became afebrile on his current regimen of ceftriaxone. However, on [**2184-12-8**] the patient did develop a fever of 101.1 while on the antibiotic. After a consultation with the infectious disease, was decided to change his regimen from ceftriaxone to meropenem. The patient received meropenem for a course of 1 day without any hyperthermic events of fevers. LFTs were also obtained while the patient was on ceftriaxone. He had an ALT of 114, AST of 133, LDH of 312, alkaline phosphatase of 229, amylase of 65, total bilirubin of 0.5 once the patient was switched to meropenem. LFTs were obtained prior to discharge. His ALT came down to 85, AST to 57, LDH to 275, and his alkaline phosphatase to 173, his amylase was 85, and a total bilirubin 0.5. The patient is being discharged with a PICC line which was placed on [**2184-12-7**] and to receive ertapenem 1 gram q.24 for 8 days and then given a prescription for Bactrim DS for a 2- week period. The patient was also told to have his LFTs drawn in 1-week period and to follow up with the [**Hospital **] Clinic, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], and to follow up with Dr. [**Last Name (STitle) **] in 2 to 3 weeks. CONDITION: Good; he is ambulating and tolerating p.o.'s; he is having no fevers and a decreased white count. DISCHARGE INSTRUCTIONS: He was instructed to follow up in the clinic. He was told about his ID regimen with 8 days of ertapenem daily and is to follow up with Bactrim for 2 weeks. He was told to call the clinic or come to the ED with the following complaints; a temperature of greater than 101.5, inability to void, blood in the urine, any nausea or vomiting he may experience, any suprapubic pain that he might experience, any scrotal or penile edema that he may notice, or any other symptoms concerning to him. [**Known firstname **] [**Last Name (NamePattern4) **], [**MD Number(1) 31209**] Dictated By:[**Last Name (NamePattern1) 29268**] MEDQUIST36 D: [**2184-12-9**] 14:38:04 T: [**2184-12-9**] 15:35:39 Job#: [**Job Number 101672**]

[ "E878.8", "410.71", "995.92", "785.52", "401.9", "998.59", "276.52", "038.42" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

4539, 7305

881, 926

7330, 8077

1128, 1218

845, 864

1241, 4515

250, 771

794, 821

943, 1106

5,382

172,484

49442

Discharge summary

report

Admission Date: [**2190-12-3**] Discharge Date: [**2191-2-7**] Date of Birth: [**2138-6-4**] Sex: M Service: MEDICINE Allergies: Roxicet / Penicillins / Aspirin / Glycopyrrolate Attending:[**Last Name (NamePattern1) 14062**] Chief Complaint: Hemoptysis/epistaxis Major Surgical or Invasive Procedure: embolization of the left facial artery Mechanical Ventilation PICC History of Present Illness: Mr. [**Known lastname 10378**] is a 52 year old male with a history of squamous cell carcinoma of the vallecula s/p chemotherapy and XRT with unresectable cervical recurrence, alcoholic cirrhosis with esophageal varices and recent admission for abdominal pain and epistaxis s/p bilateral [**Female First Name (un) 899**] embolizations on [**11-15**] who presents from home with hemoptysis. The patient was discharged from this hospital on [**2190-11-23**] and was doing well at home since then. At approximately 4 AM on the morning of presentation the patient woke up and began to cough which is typical for him secondary to copious secretions. He began to experience bright red blood per his tracheostomy. Per his wife he produced approximately 1 cup of bright red blood. EMS was called. The bleeding lasted for approximately 1 hour and had stopped by the time he reached the emergency room. The bleeding was not associated with lightheadedness, dizziness, chest pain, shortness of breath, nausea, vomiting, abdominal pain, dysuria, hematuria, melena, hematochezia, leg pain or swelling. He reports a similar episode of hemoptysis in [**2189-12-22**] which was ultimately attributed to granuloma tissue near his tracheostomy site which was excised. He has had no similar episodes since. . In the emergency room his initial vitals were T: 98.5 BP: 150/87 HR: 73 RR: 18 O2: 98% on a NRB. ENT was consulted who performed performed a fiberoptic laryngoscopy through the tracheostomy and saw no active sites of bleeding and no granualation tissue. He received dilaudid 1 mg IV x 1 and levofloxacin 750 mg IV x 1. He had a CT of the neck which showed no evidence of tracheal malpositioning or erosion into the major vascular structures and evidence of right upper lobe aspiration. He was hemodynamically stable throughout his time in the emergency room. He was transferred to the [**Hospital Unit Name 153**] for further management. . On arrival to the [**Hospital Unit Name 153**] he had no complaints. Denied lightheadedness, dizziness, chest pain, shortness of breath, nausea, vomiting, abdominal pain, melena, hematochezia, leg pain or swelling. All other review of systems negative in detail. . Shortly after arrival the patient was noted to begin bleeding profusely from his nose and tracheostomy site. Past Medical History: 1. Squamous cell cancer vallecula/tonsillar, X 2, s/p trach, peg, XRT, chemotherapy with known cervical reccurrence 2. Liver cirrhosis secondary to EtOH, complicated by splenomegaly, esophageal varices (last EGD [**11/2188**] with grade 1 varices) with prior bleeding. Prior hepatic encephalopathy. 3. Reported history of portal vein thrombosis but most recent CT abdomen [**1-/2189**] without thrombosis, MRI in [**7-/2188**] with normal flow. No current anticoagulation. 4. Seizure disorder, last seizure >2 years ago. 5. Chronic pancreatitis secondary to EtOH. 6. Status post G-tube placement [**10-28**] 7. Status post tracheostomy 8. History of multidrug resistant Klebsiella, MRSA 9. Psoriasis Social History: He lives at home with his wife. [**Name (NI) **] is ambulatory. Former alcohol use, no recent tobacco but previous 20 pack year history. No illicit drug use. . Family History: brother died of MI at 34. Physical Exam: expired Pertinent Results: [**2190-12-3**] 05:10AM PT-15.1* PTT-30.0 INR(PT)-1.3* [**2190-12-3**] 05:10AM PLT COUNT-121* [**2190-12-3**] 05:10AM NEUTS-76.1* LYMPHS-14.3* MONOS-5.6 EOS-3.6 BASOS-0.4 [**2190-12-3**] 05:10AM WBC-2.3* RBC-3.52* HGB-11.3* HCT-31.9* MCV-91 MCH-32.1* MCHC-35.4* RDW-15.2 [**2190-12-3**] 05:10AM estGFR-Using this [**2190-12-3**] 05:10AM GLUCOSE-108* UREA N-9 CREAT-0.7 SODIUM-137 POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-35* ANION GAP-10 [**2190-12-3**] 05:14AM HGB-12.2* calcHCT-37 [**2190-12-3**] 05:14AM K+-4.2 [**2190-12-3**] 12:39PM PLT COUNT-269# [**2190-12-3**] 12:39PM WBC-12.0*# RBC-3.62* HGB-11.6* HCT-32.9* MCV-91 MCH-32.1* MCHC-35.3* RDW-14.5 Imaging: CT Neck: Tracheostomy tube is noted in expected position without evidence of erosion into vascular structures. A heterogeneously-enhancing region of soft tissue is noted in the region of the vallecula likely representing known vallecular carcinoma. Hypoattenuation is noted within the nasopharynx possibly representing secretions. There is moderate lobulated mucosal thickening within the maxillary sinuses. Calcified atherosclerotic plaque is present at bilateral carotid bifurcations with greater than 50% narrowing bilaterally. There is a right dominant vertebral artery system. A small amount of patchy opacity is present within the right lung apex most consistent with aspiration. G Tube Check FINDINGS: Single bedside frontal radiograph of the abdomen is compared to the abdominal radiograph from [**2190-11-9**]. Injected contrast material via the G-tube is seen filling the stomach and entering into the proximal small bowel. There is no extraluminal leak of contrast, stricture, or definite obstruction to flow. The bowel gas pattern is nonobstructive and there is no free gas or pneumatosis. Visualized osseous structures are unremarkable. CXR IMPRESSION: Right PICC tip courses through the right internal jugular vein without visualization of the tip. Worsening of the left lower lobe opacification. RUQ IMPRESSION: 1. Hepatopetal flow in the main and right portal veins. No flow identified in the left portal vein. 2. Cirrhotic-appearing liver with no focal lesions. 3. Sludge in the gallbladder with no gallstones identified. 4. Splenomegaly. 5. Trace of ascites and a left pleural effusion. Brief Hospital Course: PROCEDURES DURING ADMISSION IR embolization of L facial artery [**12-3**] CONSULTATIONS DURING ADMISSION SICU Gastroenterology Interventional Radiology Pain and Palliative Care Chronic Pain Service Head and Neck Oncology Mr. [**Known lastname 10378**] is a 52 year old male with a history of squamous cell carcinoma of the vallecula s/p chemotherapy and XRT with unresectable cervical recurrence, alcoholic cirrhosis with esophageal varices, and recent admission for abdominal pain and epistaxis s/p bilateral [**Female First Name (un) 899**] embolizations on [**11-15**] who presented on [**2190-12-3**] from home with hemoptysis. Hemoptysis/epistaxis: Upon arrival to the [**Hospital Unit Name 153**] the pt experienced massive epistaxis from the nose, mouth and tracheostomy site. It was concluded that his unresectable pharyngeal CA was likley eroding the carotid artery, the most likely source of the massive bleeding. Nasal and oral packing was intitiated at the bedside with good hemostasis. Cuff was inflated to protect the airway. He received 5uPRBC. He subsequently underwent IR embolization of the L facial artery on [**12-3**] although active bleeding was not appreciated. He was then transferred to the SICU for further management. Unfortunately we were not able to pinpoint the specific source of these episodic bleeds with IR. GI was consulted to consider esophageal varices as a source of bleeding. They decided this was a low likelihood given the fact that no blood was seen from the gtube. A liver U/S was taken which showed signs of liver cirrhosis with mild ascites and splenomegaly. Ultimately we were left to conlude we had run out of realistic surgical or intervential options in controlling future episodes. Dr. [**Last Name (STitle) 18622**] lead a family meeting to discuss prognosis and treatment options. The family understood that his prognosis was poor and that he would likely expire from a future bleed. It was also explicitly explained to the patient that we were out of intervential options to control the bleeding. The family and the patient agreed at that point to withhold future treatments, blood/platelet transfusions, and provide minimal supportive care and comfort measures only during the next bleed. He was then made DNR. A palliative care consult was obtained. With consult of the palliatve care team, on [**12-11**] the family decided to limit supportive care to prevention of constipation/ulcers, tube feeds for comfort, and IV daulidid/methadone/anxiolytics. He continued to be vent dependent, although we attempted to decrease PEEP. Since [**12-11**] the patient has been on care in the SICU. He has been diligently seen by palliative care, who has gradually increased his diludid drips, methadone, and anxiolytics to comfort. On [**1-5**] the patient had a chronic pain consult to help with palliative care in managing his symptoms. They recommended [**Month/Year (2) 103492**], clonidine, gabapentin, and scopolamine, though he was felt to be allergic to [**Last Name (LF) 103492**], [**First Name3 (LF) **] this was discontinued. In late [**Month (only) 404**] the patient began to develop more frequent episodes of ventricular tachycardia and torsades that were self-limited but accompanied by extreme anxiety for the patient requiring increasing anxiolytics. During this time, the patient himself began to express the desire to be off the ventilator. With family, palliative care, and the SICU team, the patient made the decision to be removed from the ventilator, which occurred on [**2-2**]. Since that time, he has remained comfortable on trach collar. He is being transferred out of the SICU at this time for optimal care and comfort at the end of his life. The patient was made comfortable and placed on a dilaudid drip. He was changed to methadone gtt and passed away on [**2191-2-7**] Medications on Admission: Gabapentin 300 mg [**Hospital1 **] and 600 mg QHS Keppra 1500 mg [**Hospital1 **] Duonebs 1-2 puffs Q6H Nystatin 5 mL PO QID Nadolol 20 mg daily Lorazepam 0.5 mg PO Q6H:PRN Metoclopramide 10 mg QID Mupirocin topical [**Hospital1 **] Scopolamine patch Q72H Clobetasol [**Hospital1 **] Lansoprazole 30 mg daily Lactulose 15 mL PO TID Dilaudid-5 liquid 4-6 mg PO Q3-4H:PRN Levothyroxine 50 mcg daily Sodium Chloride nasal spray [**Hospital1 **] Zofran 8 mg PO Q8H:PRN . Discharge Disposition: Expired Discharge Diagnosis: Squamous cell cancer vallecula/tonsillar, X 2, s/p trach, peg, XRT, chemo, possible recurrence noticed on recent PET, but decision to wait until [**8-30**] for further eval given good functional status at present. Liver cirrhosis secondary to EtOH, complicated by splenomegaly, esophageal varices (last EGD [**11/2188**] with grade 1 varices) with prior bleeding. Prior hepatic encephalopathy. Reported history of portal vein thrombosis, though I can not find when this happened. Most recent CT abdomen [**1-/2189**] without thrombosis, MRI in [**7-/2188**] with normal flow. No current anticoagulation. Seizure disorder, last seizure >2 years ago. Chronic pancreatitis secondary to EtOH. Status post G-tube placement [**10-28**] Status post tracheostomy History of multidrug resistant Klebsiella, MRSA Psoriasis Discharge Condition: expired [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5004**] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 14063**] Completed by:[**2191-2-17**]

[ "V12.51", "696.1", "285.1", "146.3", "V44.1", "427.1", "507.0", "V44.0", "300.00", "V15.3", "461.0", "577.1", "345.90", "571.2", "426.82", "V87.41", "276.3", "V12.04", "456.21" ]

icd9cm

[ [ [] ] ]

[ "99.29", "31.42", "96.72", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

10448, 10457

6055, 9930

337, 405

11317, 11517

3742, 6032

3671, 3699

10478, 11296

9956, 10425

3714, 3723

277, 299

433, 2752

2774, 3476

3492, 3655

2,511

108,240

24727

Discharge summary

report

Admission Date: [**2191-10-12**] Discharge Date: [**2191-10-26**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 297**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: R subclavian line [**10-12**] History of Present Illness: This is a 86 y/o M w/ PMH of diet controlled DM, h/o CVA, and colon ca s/p colectomy, who presented to OSH on Monday with altered MS. [**Name13 (STitle) **] had a severe cough and went to the doctor 10 days prior to admission and was given flonase and the cough subsided considerably after three days. A week later, went to hospital because he was acting erratically. He was found to have an O2 sat of 88% on RA and his CXR showed a multiple opacities. He was initially treated on the medical [**Hospital1 **] with Levofloxacin and he initially was 94% on 2L. He was somewhat agitated, removed his mask, and required 50% FM overnight. In the morning, he was switched to 2 L and was found by the doctor [**First Name (Titles) **] [**Last Name (Titles) 62356**] to be cyanotic and satting 79%. Though patient was initially DNR/DNI, this code status was reversed and patient was eventually intubated for increasing hypoxia and agitation. After being intubated, patient had significant oxygen requirements and some hypotension after fentanyl boluses and was transferred to [**Hospital1 18**] for further ventilator management. Past Medical History: 1. colon cancer s/p partial colectomy 3 years ago, no chemo 2. CVA [**06**] years ago with residual garbled speech, altered smell/taste 3. Left occluded carotid 4. glaucoma 5. DM (diet controlled) 6. heart murmur Social History: Lives year round with wife on [**Hospital3 4298**]. Retired production engineer. Smoked remotely for 6 years only. No significant EtOH use. Does not like to seek medical care or take medications. Family History: NC Physical Exam: PE: VS T BP 128/44 HR 103 92% Vent: AC 550 x 28 PEEP 10 Fi 100%, 1st ABG 7.15/65/72 currently 7.30/43/92 GEN: chronically ill appearing, sedated, intubated HEENT: PERRL, NCAT NECK: supple CV: RRR S1S2 [**5-11**] holosystolic murmur harsh best LUSB, radiates to carotid, PMI not displaced LUNGS: course breath sounds bilaterally, L>R ABD: midline scar, soft, nt, bs+ EXT: 2+ pitting edema, cool bluish extremities but with dps dopplerable Pertinent Results: WBC 18.8 88.3% poly, 0 bands 5.2 lymphs 1.5 monos 4.9 eos Hct 43.3 Plt 195 inr 1.5 pt 14.8 ptt 31.1 na 141 k 5.3 cl 108 co2 23 bun 45 cr 1.8 glu 174 lactate 1.6 free ca 1.14 alt 18 ast 21 ldh 327 ck 166 alk phos 100 tbili 0.3 ckmb 12 mbi 7.2 tropt .13 CXR: RUL infiltrate, LUL/lingular infiltrate, retrocardiac opacity Echo: prelim, LVH, EF 75%-80% hyperdynamic AS, [**Location (un) 109**]<1.0, mean gradient 40, pulm HTN OSH lab results: bnp 213 trop i .18 bun 49 cr 2.0 alb 2.8 ekg sinus 100, LAD, [**Street Address(2) **] dep v5-v6 Brief Hospital Course: 86 y/o M with h/o colon ca s/p partial colectomy 3 years ago, remote CVA, diabetes, who was transferred from an OSH intubated with a multilobar pneumonia. Patient was admitted in respiratory failure, intubated and sedated. His hypotension was initially fluid responsive, and periodically required presor support with levophed. He was treated with levofloxacin and ceftriaxone for pneumonia. The patient was unable to be weaned from the ventilator as pneumonia progressed, and secondary to pressor support, also develop ischemic digits. He also developed a periodic paralysis likely secondary to steroid admisinstration. After 13 days in the MICU, the patient's wife and family decided to make the patient CMO, and he expired one day later. Medications on Admission: 1. Bitoptic eye drops 2. Naproxen 500 [**Hospital1 **] x 2 weeks 3. ASA rarely 4. flonase On transfer: Fentanyl Versed Neo gtt Levofloxacin Ativan Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None.

[ "584.9", "608.86", "401.9", "250.00", "445.02", "785.52", "V10.00", "995.92", "038.9", "486", "357.82", "424.1", "518.84" ]

icd9cm

[ [ [] ] ]

[ "96.72", "00.17", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

3909, 3918

2934, 3681

240, 271

3971, 3981

2369, 2911

4035, 4043

1889, 1893

3879, 3886

3939, 3950

3707, 3856

4005, 4012

1908, 2350

181, 202

299, 1424

1446, 1660

1676, 1873

29,400

105,099

28763

Discharge summary

report

Admission Date: [**2187-8-17**] Discharge Date: [**2187-8-25**] Date of Birth: [**2131-3-28**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: [**Last Name (un) **]-utero fistula Major Surgical or Invasive Procedure: [**8-17**]: Exploratory laparotomy, extensive lysis of adhesions, low anterior resection with colorectal anastomosis, rigid sigmoidoscopy, retracted colostomy takedown and loop ileostomy formation, and bilateral ureteral stents. 1. Exploratory laparotomy 2. Extensive lysis of adhesions 3. Low anterior resection with colorectal anastomosis 4. Rigid sigmoidoscopy 5. Retracted colostomy takedown 6. Loop ileostomy formation 7. Cystoscopy with placement of bilateral open-ended ureteral catheters. History of Present Illness: 56 yo F with multiple medical issues presents to the [**Hospital1 18**] for surgical treatment of persistent colouterine fistula demonstrated on enema study. Medical issues are listed in the past medical history section of this document. Past Medical History: Afib with RVR on coumadin LV dysfunction with CHF (EF 45-50%) asthma with restrictive lung disease R upper lobe nodule CRI Morbid obesity (lost 115lbs) osteoarthritis with osteopenia Charcot deformity of the r foot urosepsis . PSH: coloureteral fistula s/p diverting loop colostomy ([**11-27**]) Foot surgery to repair right charcot deformity Left hip replacement ([**4-28**]) Social History: Patient [**3-25**] ppd smoker, also drinks 2-3 vodka's per day until recently. Reports being off tob/etoh since at rehab Family History: NC Physical Exam: Height: 5'6", weight: 182lb VS: 97.0po, 93/59, 80, 16, 97RA Gen: alert and oriented, no acute distress CV: Afib, hemodynamically stable Pulm: slight crackles on right side Abd: soft, nontender, non-distended Ext: no c/c/e Pertinent Results: Admission Labs [**2187-8-17**] 08:53PM GLUCOSE-153* UREA N-23* CREAT-1.1 SODIUM-141 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-26 ANION GAP-11 CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-1.3* WBC-10.9# RBC-3.75* HGB-11.2* HCT-33.5* MCV-89 MCH-29.8 MCHC-33.4 RDW-14.8 NEUTS-89.7* BANDS-0 LYMPHS-7.7* MONOS-2.0 EOS-0.5 BASOS-0.2 PLT COUNT-260 PT-14.9* INR(PT)-1.3* PH-7.35 GLUCOSE-123* LACTATE-0.9 K+-3.6 HGB-9.1* calcHCT-27 freeCa-1.21 GLUCOSE-110* LACTATE-1.1 K+-3.5 HGB-9.1* calcHCT-27 . [**2187-8-17**] 8:55 PM CHEST PORT. LINE PLACEMENT IMPRESSION: Interval placement of right internal jugular line and nasogastric tube. No evidence of acute cardiopulmonary process. . [**2187-8-18**] ECHO Conclusions: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is 5-10 mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. 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 structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes and global systolic function. Mild mitral regurgitation. Mildly dilated ascending aorta. . PATHOLOGY REPORT SPECIMEN SUBMITTED: PELVIC WALL SCAR, RECTOSIGMOID DONUT [**2187-8-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/nbh DIAGNOSIS: I. Soft tissue, pelvic wall scar (A): Dense fibrous tissue with mucin and calcification. No epithelium or tumor seen. II. Colon, rectosigmoid donuts (B-J): Two segments of colon with peritoneal fibrous adhesions. Keratinized squamous epithelium with focal active inflammation consistent with colostomy stoma. No tumor. . Digoxin: [**2187-8-19**] 03:32AM BLOOD -1.4, [**2187-8-20**] 11:47AM -1.1, [**2187-8-24**] 07:35AM -1.0 . COAGULATION RESULTS [**2187-8-17**] 08:53PM BLOOD PT-14.9* INR(PT)-1.3* [**2187-8-18**] 02:41AM BLOOD PT-13.7* INR(PT)-1.2* [**2187-8-18**] 11:31AM BLOOD PT-14.5* PTT-28.0 INR(PT)-1.3* [**2187-8-19**] 03:32AM BLOOD PT-18.2* PTT-35.9* INR(PT)-1.7* [**2187-8-21**] 03:19AM BLOOD PT-16.8* PTT-35.8* INR(PT)-1.5* [**2187-8-22**] 04:49AM BLOOD PT-18.2* PTT-30.7 INR(PT)-1.7* [**2187-8-23**] 06:27AM BLOOD PT-25.6* PTT-34.5 INR(PT)-2.6* [**2187-8-24**] 07:35AM BLOOD PT-20.6* INR(PT)-2.0* . DISCHARGE LABS: Brief Hospital Course: HD#1 POD #0 s/p explorator laparotomy with LOA, colostomy takedown, LAR, loop ileostomy. Operative findings included multiple fistulae in the pelvis to the uterus. Received 4500 CC of crystalloid during the operation, with 260 u/o. HD#2 Unable to meet PACU criteria for transfer to floor due to low urine output, not responding to 500c fluid bolus for low urine output. Attending notified, levophed was started, Swan-Ganz catheter was placed, one unit of PRBC was transfused, and the patient was transferred to the care of the SICU with a CVP of 15-16 HD#3 Throughout the day the patient had her heart rate maintained by use of lopressor, with levophed ordered to maintain MAP > 65 with minimal O2 requirements. Maintaining appropriate urine output was obtained by provided IV hydration. Evidence of good peripheral perfusion was evident. The patient had started to mobilize fluid and diurese much third-space fluid. HD#4 The patient's NG tube ouput was reduced, and the tube was clamped. Antibiotics were stopped, a central venous line was placed, and the patient's oxygenation requirement was maintained by 2 liters of O2, delivered by nasal cannula. The patients ostomy appliance had leaked into the midline wound; the wound was cleaned in the OR, with a new ostomy appliace reseated. The patient was weaned off levophed, and her labs improved substantially. Diuresis was assisted by two doses of lasix that day. HD#5 The patient had done well overnight, NG tube was d/c'ed. Her pain was controlled by PCA. She was transferred to the floor, her diet was advanced to clears, and she was started on her home lasix dose. Her respiratory status improved substantially, and she was tolerating Room Air appropriately. PT evaluation was obtained for evaluation after her ICU course. HD#6 The patient tolerated liquid diet on the floor, her wound appeared erythematous with stable cellulitis, and she showed excellent improvement otherwise, including increased ostomy function (amount + flatus). PT assisted the patient in stair training for dispo home. Cefazolin was started for the stable cellulitis HD #7 The patient was able to void independently without difficulty, the wound demonstrated decreased erythema on the Cefazolin. Ostomy nurse was on board to make sure the patient had an improved device that would least hamper her home care. She was able to tolerate oral pain medication without difficulty. HD #8 The patient had very minimal erythema of the wound area, her operative drains were removed, and VNA services were set up for her. She was ambulating independently without difficulty, and tolerating an appropriate diet. HD #9 The patient was stable for discharge: PCP was informed regarding the patient s need for an INR check after her hospital stay, her wound was treated with outpatient Keflex and dressing (Aquacel AG [**Hospital1 **]) per wound care nursing. Given her excellent improvement during her hospital stay, she was discharged home with VNA services. Medications on Admission: Digoxin 250 mcg po daily Lasix 20mg po daily Lopressor 25mg po daily Wellbutrin 150mg po twice daily Coumadin 7.5mg po daily Seroquel prn - Insomnia Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 5 days: Please take every day at 6pm. Disp:*5 Tablet(s)* Refills:*0* 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 weeks: to prevent constipation while taking narcotic pain medication. Disp:*56 Capsule(s)* Refills:*0* 7. Keflex 250 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 5 days. Disp:*20 Capsule(s)* Refills:*0* 8. Outpatient Lab Work Please check INR on Monday Discharge Disposition: Home With Service Facility: [**Location (un) 1411**] VNA/[**Company 1519**] Phone Discharge Diagnosis: Colouterine fistula Discharge Condition: Good Discharge Instructions: Please call your surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Activity: No heavy lifting of items [**11-5**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications except for your coumadin. You need to take your new prescription of coumadin and do as directed. You will also need to follow up in [**Hospital 197**] clinic and check your INR on Monday. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13075**], P: [**Telephone/Fax (1) 19980**], address [**First Name8 (NamePattern2) 69511**] [**Location (un) 620**], [**State 350**]. You are to follow-up for INR lab draw on Monday [**2187-8-27**]. You should have your INR checked 2x weekly. 1. Please follow up with Dr. [**First Name (STitle) 2819**]. Call ([**Telephone/Fax (1) 6347**] to make an appointment. 2. Need to get blood drawn on Monday [**8-27**] to check INR. 3. Need to follow up with your primary care physician in the next week. Call [**Telephone/Fax (1) 68961**].

[ "428.0", "V55.3", "585.9", "493.90", "619.1", "E878.6", "998.59", "682.2", "V58.61", "427.31" ]

icd9cm

[ [ [] ] ]

[ "46.52", "46.01", "59.8", "48.63", "57.32", "89.64", "45.24" ]

icd9pcs

[ [ [] ] ]

8798, 8882

4770, 7772

350, 850

8946, 8953

1934, 4729

9965, 10605

1673, 1677

7972, 8775

8903, 8925

7798, 7949

8977, 9942

4747, 4747

1692, 1915

275, 312

878, 1118

1140, 1519

1535, 1657

28,423

119,557

21279

Discharge summary

report

Admission Date: [**2107-2-2**] Discharge Date: [**2107-2-11**] Date of Birth: [**2054-12-5**] Sex: M Service: SURGERY Allergies: Optiray 350 / Shellfish Derived Attending:[**First Name3 (LF) 1384**] Chief Complaint: Fever, RUQ pain Major Surgical or Invasive Procedure: [**2107-2-7**]: Cardiac stress test [**2107-2-7**]: Biliary catheter check with removal of drain History of Present Illness: 52 y/o male who is 1 year s/p OLT. He began to develop an increase in his liver enzymes in [**2106-9-27**]. A liver biopsy was performed which revealed drug induced hepatitis, a question of early recurrent hepatitis C, but no signs of acute rejection. A hepatitis C viral load was checked and it was negative. On outpatient labs his bilirubin was noted elevated and he underwent an ERCP which revealed a complete obstruction at the biliary anastomosis. He subsequently underwent a hepaticojejunostomy which was followed by a STEMI requiring 2 stents to be placed and post IABP. He was taken back following that episode for a re-do of the hepaticojejunostomy and was subsequently discharged to home. He now presents with fever and RUQ pain with a fever spike in the ED to 103. He [**Year (4 digits) **] chest pain, shortness of breath or GI symptoms Past Medical History: HTN, HCV cirrhosis, hepatocellular carcinoma, s/p appy, s/p right inguinal hernia repair, s/p OLT [**12-3**] Social History: He emigrated from Viet Nam in [**2090**]. He lives with his girlfriend and has smoked cigarettes for 35 years, about 0.5 packs per day. He is still smoking 10- 15 cigs per day. He previously drank alcohol and experimented with IV drugs, but [**Year (4 digits) **] alcohol or drug use for at least the past 5 years. Family History: His father died of old age and his mother died from an injury. He has two brothers who died from alcohol and substance abuse. Another brother has liver disease and underwent partial hepatic resection, while another brother had his gallbladder removed. Two other brothers, a sister, and a daughter are alive and well. Mr. [**Known lastname **] [**Last Name (Titles) **] any family history of blood diseases. Physical Exam: VS: 99.5, 76, 117/70, 19, 100%RA 60.3 kg Gen NAD HEENT: PERRL Card: RRR Resp: CTA bilaterally Abdomen: soft, non-distended, drain in place Extr: trace edema Pertinent Results: On Admsission: [**2107-2-2**] WBC-8.6 RBC-4.75 Hgb-13.6* Hct-39.6* MCV-83 MCH-28.6 MCHC-34.3 RDW-13.9 Plt Ct-291 PT-13.8* PTT-28.1 INR(PT)-1.2* Glucose-119* UreaN-12 Creat-1.4* Na-140 K-4.2 Cl-103 HCO3-23 AnGap-18 ALT-13 AST-24 CK(CPK)-45 AlkPhos-197* TotBili-0.6 Lipase-65* Albumin-4.3 Calcium-9.0 Phos-3.4 Mg-1.7 [**2107-2-6**] TSH-1.9 T4-4.9 Free T4-0.92* [**2107-2-6**] CEA-1.1 AFP-1.8 At Discharge: [**2107-2-10**] WBC-7.3 RBC-3.41* Hgb-9.7* Hct-28.2* MCV-83 MCH-28.3 MCHC-34.3 RDW-14.2 Plt Ct-308 Glucose-110* UreaN-8 Creat-1.5* Na-139 K-4.6 Cl-107 HCO3-24 AnGap-13 ALT-8 AST-8 AlkPhos-106 TotBili-0.4 [**2107-2-10**] tacroFK-5.3 Brief Hospital Course: 52 y/o male 1 year out from liver transplant and one month out from hepaticojejunostomy x 2 with MI and stent placement during same hospitalization. Now presents with fever and RUQ pain. Fever as high as 103 and showing signs of rigor so was initially admitted to the SICU. Cultures drawn at the time were negative in both blood and urine. He was started empirically on Vanco and Zosyn. CT was done and although there were post surgical changes noted, there were no fluid collections or free air, and previously noted atelectasis and effusion was improved. He was transferred from the ICI after one day. On HD 3 in the early evening he was noted to become tachycardic to the 110s and reported left chest pain and throat discomfort. He was given NTG x 3 with little relief and O2 was placed. 12 lead EKG indicated some ST depression in lateral leads and he was transferred to the cardiology service, placed on heparin drip and monitored. CK and troponins ruled out MI and he was subsequently transferred back to [**Hospital Ward Name 121**] 10. He continued with intermittent fevers, antibiotics were continued, however no source was found in blood, urine although some blood cultures [**First Name8 (NamePattern2) **] [**Last Name (un) 7387**] pending at time of discharge. Infectious disease was consulted who ordered some additional testing to include CMV (Negative), Aspergillus and B Glucan (both negative. Prior to discharge he had some additional testing to be followed up as an outpatient by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] as well as an HIV test and Mycolytic blood cultures. These tests were in response to patients c/o night sweats, where no fever was observed. On [**2107-2-7**] he underwent a stress test, which showed "No anginal symptoms or significant ECG changes from baseline. Appropriate hemodynamic response" with nuclear portion showing "Normal left ventricular myocardial perfusion. Mild global left ventricular wall hypokinesis. Calculated LVEF is 48 %. He was started on Metoprolol. In addition he had a roux tube study that same day, and since the ducts did not opacify and it appeared evident the tube was actually sitting in the Roux limb the drain was removed. He still had some RUQ pain complaint, however this was managed well with oxycodone, and no other sources have been identified. He was taken off the Vanco and Zosyn on [**2-10**] and remained afebrile for 24 hours, and was discharged to home with close follow up with both ID and the transplant clinic. Additionally he is due to start cardiac rehab soon which is being facilitated by the outpatient coordinator. Medications on Admission: Aspirin 325 mg daily Clopidogrel 75 mg daily Olanzapine 5 mg daily Oxycodone 5 mg q4 hours prn Mycophenolate Mofetil 500 mg twice daily Trimethoprim-Sulfamethoxazole 80-400 mg daily Famotidine 20 mg daily Fluconazole 200 mg daily Tacrolimus 0.5 mg twice daily Discharge Medications: 1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous ASDIR (AS DIRECTED). 11. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. 12. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Fever of unknown origin s/p liver transplant (1 year ago) s/p MI 1 month ago Discharge Condition: Stable/good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down medications or an increase in abdominal pain. Continue labwork per transplant clinic recommendations Do not drive if taking narcotic pain medications Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] infectious disease, [**Hospital Unit Name **] [**Location (un) 436**]. Tuesday [**2108-2-15**]:00 AM [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2107-2-17**] 8:30 Completed by:[**2107-2-11**]

[ "V45.3", "276.1", "V10.07", "571.5", "780.60", "996.59", "V42.7", "070.54", "305.1", "511.9" ]

icd9cm

[ [ [] ] ]

[ "87.54", "97.55" ]

icd9pcs

[ [ [] ] ]

6977, 7035

3033, 5674

306, 405

7156, 7170

2373, 2763

7617, 7965

1770, 2180

5985, 6954

7056, 7135

5700, 5962

7194, 7594

2195, 2354

2777, 3010

251, 268

433, 1286

1308, 1419

1435, 1754

47,000

149,026

36630

Discharge summary

report

Admission Date: [**2149-4-17**] Discharge Date: [**2149-4-18**] Date of Birth: [**2085-11-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: lower extremity weakenss Major Surgical or Invasive Procedure: none History of Present Illness: 63yoM with h/o metastatic non-small cell lung cancer s/p chemotherapy, radiation referred to ED by primary oncologist ([**Doctor Last Name **]) due to evidence of spinal cord metastases on OSH MRI. Pt has had progressive R-sided back and hip pain x2-3 weeks which wraps around his waist and radiates to R thigh. Describes pain as a combination of deep pain that he can't reach with accompanying numbness as well that comes and goes. It is usually worse in the morning, and the patient states that at times the pain is so severe that he can't even stand up to poor a cup of coffee. Improves with PO morphine--some days he takes as many as 45 mg and other days nothing. Has also noticed R thigh numbness. Denies LE weakness. Denies loss of bowel/bladder continence but does note "weaker" urine stream. . Saw his oncologist for follow up on Tuesday, had MRI (through OSH) on Wednesday with report sent to Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] called pt at home today due to MRI findings of metastatic disease to the spine and cord compression, referred to ED for neurosurg/rad onc eval. . In the ED, initial VS were: T 96.9 P 95 BP 105/68 RR 18 O2 sat: 95%. Pt seen by ortho spine who saw no need for urgent intervention. Pt was given 10 mg IV dexamethosone. On transfer, VS were T 98.3 BP 116/78 RR 20 P 89 . On arrival to the MICU, patient's vital signs were T 98.1 HR 79 127/75 P 86 95% RA. Pt reports mild pain and numbness over his back and right thigh. Is otherwise comfortable and well. Endorses cough which has been longstanding and reports that it is worse when he lays flat. Otherwise, denies SOB, chest pain, weakness, fatigue, lightheadedness, dizziness. States that other than this pain limiting him, he would otherwise be extremely active. 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: Past Oncologic History: NSCLC stage III EGFR/ALK/KRAS wt with progressive disease - [**7-/2146**] Initial diagnosis of NSCLC - [**2146-8-15**] Completed 2 cycles of cisplatin 50 mg/m2 D1, D8 and etoposide 50 mg/m2 D1-D5 - [**2146-8-26**] Completed chest/mediastinal radiotherapy to 5040 cGy - [**2147-8-31**] Completed 6 cycles of carboplatin 5 AUC and pemetrexed 500 mg/m2 - [**2-/2147**] Developed progressive disease - [**2148-4-2**] C1 maintenance pemetrexed 500 mg/m2 - [**2148-4-23**] C2 maintenance pemetrexed 500 mg/m2 - [**2148-5-30**] C3 maintenance pemetrexed 500 mg/m2 - [**2148-6-27**] C4 maintenance pemetrexed 500 mg/m2 - [**2148-7-25**] C5 maintenance pemetrexed 500 mg/m2 - [**2148-8-13**] CT with increased LUL mass and stable adenopathy, RECIST unchanged. Pt deferring therapy for now - [**2148-11-22**] CT with progression; patient deferred therapy - [**2149-1-2**] Brain MRI negative Past Medical History: NSCLC as above COPD Tonsillectomy and adenoidectomy as a child hemorrhoidectomy Hernias (unknown type) left-sided VATS Social History: Social History: Tobacco: [**11-18**] PPD now, up to 4 PPD in the past. 90+ pack year history Family History: Mother with cancer Physical Exam: GEN: NAD Neck: Supple, no lymphadenopathy, JVD 3 cm above sternal angle CARDIAC: RRR, limited by noisy breathing, no m/r/g, PMI non displaced LUNGS: Noisy and rhonchorous throughout with some rattling coarse sounds ABDOMEN: Soft, non tender, no hepatosplenomegaly NEURO: 5/5 strength of hip extension and flexion, b/l knee extension and flexion, plantar and dorsiflexion. Reflexes 2+ in right patellar, 2- in left patellar, symmetric achilles. Good sensation bilaterally, minimally decreased sensation over right anterior thigh compared to left. Downgoing toes GU: Nl rectal tone per ortho and ED exams. Not performed no floor. EXT: 2+ pulses, no edema Pertinent Results: LABS [**2149-4-17**] 10:02PM K+-5.2* [**2149-4-17**] 10:02PM K+-5.2* [**2149-4-17**] 10:00PM GLUCOSE-98 UREA N-22* CREAT-1.3* SODIUM-133 POTASSIUM-8.7* CHLORIDE-99 TOTAL CO2-25 ANION GAP-18 [**2149-4-17**] 10:00PM estGFR-Using this [**2149-4-17**] 10:00PM NEUTS-70.2* LYMPHS-19.9 MONOS-5.5 EOS-3.9 BASOS-0.5 [**2149-4-17**] 10:00PM NEUTS-70.2* LYMPHS-19.9 MONOS-5.5 EOS-3.9 BASOS-0.5 [**2149-4-17**] 10:00PM PLT COUNT-257 . CT T spine/ L spine (PRELIM) Preop planning study. Outside L-spine MR is more informative regarding status of spinal cord and nerve roots. However, this study was not done with contrast, and L-spine MR with contrast at [**Hospital1 18**] is indicated. SPINE: New since [**11/2148**]: 2.9 cm AP x 2.8 cm TV x 2.6 cm SI L3 lytic/soft tissue metastasis with cotrtical breakthrough into inferior endplate and spinal canal. Compression of R ventral/lateral thecal sac (traversing L4 ventral nerve root) with complete obliteration of R subarticular recess and neural foramen (exiting L3 nerve root).Diffuse disc bulges, lig flavum thickening, and facet hypertrophy throughout L-spine with mod-severe canal stenoses. T10 bone island. CHEST: Moderate emphysema and LUL soft tissue mass, at least 8.6 cm AP x 5 cm TV x 7cm SI, with spiculations, dystrophic calcifications, and broad based pleural tag. This encases and compresses LUL bronchovascular structures. LLL varicoid bronchiectasis suggests recurrent aspiration or inflammation. ABDOMEN: Mildly fatty liver. 7-mm R renal interpolar nonobstructing stone. Atherosclerosis with 2.1- cm infrarenal ectasia. Brief Hospital Course: PRIMARY REASON FOR ADMISSION 63 year old man w/ known metastatic stage 4 non-small cell lung cancer w/ known new L3 mass w/ cord compression. ACTIVE ISSUES # L3 Cord compression: Patient presented with progressive back and hip pain. He was referred to the hospital after OSH MRI was found to be concerning for spinal cord compression. Sensory exam findings and pain were consistent with L3 lesion but there was minimal evidence of neurological compromise on exam. As above he received dexamethasone 10 mg IV in ED. He was evaluated by orthospine who did not feel there was a need for emergent surgical intervention at this time especially given the patient's preference to avoid surgical intervention. He was evaluated by rad onc and underwent planning for outpatient radiation therapy which will begin on Monday [**2149-4-21**]. The patient was transitioned to oral dexamethasone 4mg tablet by mouth every 8hrs. He will follow-up with his primary oncologist. The patient was given instructions to return to the ED should symptoms worsen. STABLE ISSUES # Stage IV Small cell lung cancer: Last imaging in [**11-28**] demonstrated progressive intra-thoracic disease and increased in nodal burden. The pt declined treatment at that time and did not wish to undergo repeat imaging. He will follow up with his oncology team regarding further treatment. # Pain control: Patient's pain was initially managed with NSAIDs and IV morphine prn. Prior to discharge he was transitioned to his home oral regimen with the addition of MS contin 15 mg [**Hospital1 **]. # Anxiety/sleep: Patient was continued on his home ativan PRN. # COPD: Patient is not taking albuterol or flovent at home. He as started on duonebs prn. # Goals of care: Patient was clear that he does not want aggressive treatments. Says he values his quality of life more than anything else and would prefer radiation if it enabled him to continue using his legs. He enjoys driving his car and hunting and maintaining these activities is of high priority for the remainder of his life. TRANSITIONAL ISSUES - Patient will follow-up with his outpatient oncologist and will have his fist radiation treatment on [**2149-4-21**]. - Final read of T/L spine CT (done for treatment planning) was pending at the time of discharge - Patient was DNR/DNI throughout this hospitalization Medications on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler - 1-2 puffs inh every six (6) hours as needed for wheeze CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - [**3-27**] ml by mouth Q6h prn cough CYANOCOBALAMIN (VITAMIN B-12) - (Given in clinic) (Not Taking as Prescribed) - 1,000 mcg/mL Solution - q9 weeks DEXAMETHASONE - (Not Taking as Prescribed) - 4 mg Tablet - 1 Tablet(s) by mouth twice a day use as directed by MD. FLUTICASONE [FLOVENT HFA] - (Not Taking as Prescribed) - 110 mcg/Actuation Aerosol - 2 puffs inh twice a day HYDROMORPHONE - 2 mg Tablet - [**11-18**] Tablet(s) by mouth every six (6) hours as needed for pain LORAZEPAM - (Not Taking as Prescribed) - 1 mg Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed for nausea/vomiting/anxiety MORPHINE - 15 mg Tablet - [**11-18**] Tablet(s) by mouth every six (6) hours as needed for pain EMERGENCY SUPPLY. Do not mix with dilaudid. Do not drive after taking this medication. ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth qpm as needed for insomnia Medications - OTC FOLIC ACID - 0.4 mg Tablet - 1 Tablet(s) by mouth once a day IBUPROFEN - (OTC) (Not Taking as Prescribed) - Dosage uncertain Discharge Medications: 1. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release(s)* Refills:*0* 2. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Disp:*90 Tablet(s)* Refills:*0* 3. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety/insomnia. 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Lumbar (L3) spinal cord compression secondary to primary metastatic small cell lung carcinoma Stage 4 small cell lung carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital for a neurosurgical evaluation of your spinal cord compression from metastatic small cell cancer. After consultation with neurosurgery and radiation oncology, we believe that you do not need urgent surgery. Instead, we will treat you with radiation therapy with the addition of dexamethasone. We think that it is safe for you to go home but if you experience worsening of your symptoms, you should return to the emergency room. We have made the following changes to your home medications: START dexamethasone 4mg tablet by mouth every 8hrs START MS contin 15mg by mouth every 12hrs Continue the rest of your home medications Followup Instructions: Please follow up with radiation oncology for your appointment on Monday [**2149-4-21**] Your primary oncologists, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will set up a follow up appointment for you. Please call them at [**Telephone/Fax (1) 31404**] if you haven't heard from them by Tuesday.

[ "196.1", "496", "336.3", "198.5", "305.1", "338.3", "162.8", "300.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10637, 10643

6114, 8461

330, 337

10815, 10815

4500, 6091

11685, 12073

3788, 3809

9697, 10614

10664, 10794

8487, 9674

10966, 11507

3824, 4481

11525, 11662

2167, 2588

266, 292

365, 2148

10830, 10942

3538, 3660

3693, 3772

42,935

198,857

38173

Discharge summary

report

Admission Date: [**2154-6-18**] Discharge Date: [**2154-7-11**] Date of Birth: [**2130-2-23**] Sex: F Service: MEDICINE Allergies: Clindamycin Attending:[**First Name3 (LF) 18794**] Chief Complaint: CHIEF COMPLAINT: Epigastric pain, vomiting. REASON FOR MICU ADMISSION: Hypotension and severe hypokalemia Major Surgical or Invasive Procedure: PICC line placement ([**2154-6-18**]) and removal ([**2154-7-10**] History of Present Illness: Patient is a 24-year-old woman with long-standing history of severe bulimia anorexia, anxiety, history of polysubstance abuse, [**Doctor First Name **]-[**Doctor Last Name **] tears, seizures, and hypoglycemia. She presents from home for lethargy and worsening abdominal pain. Three weeks ago patient was discharged from anorexia program weighing 80 lbs. She now presents after 2 days of forceful vomiting with worsening epigastric pain and lethargy. On the night of admission she was noted by her mother to be more somnolent than usual. EMS was called and they checked her blood glucose (which was 60), after which they administered dextrose. She was initially taken to [**Hospital3 26615**] Hospital where she was complaining of mild diffuse abdominal pain, per report. There was no hematemesis, blood in stool or melena. No fevers, chills, urinary symptoms, chest pain, shortness of breath or cough. She was found to have potassium of 1.7. She was given 80 IV K+, 40 mg IV pantoprazole, 1L normal saline, and transferred to [**Hospital1 18**] for further evalaution. At [**Hospital1 18**] ED, her initial vitals were T 96.8, BP 84/54, HR 56, RR 12, 100% RA. EKG showed NSR 60, NA/NI, TWF in all leads, Qtc 430. Labs were remarkable for potassium of 2.4, phos 2.5, with normal LFTs, amylase of 176. CBC showed white count 3.8 with lymphocytic predominance, hematocrit 31.9, and platelets of 168. BMP showed creatinine of 1.4, K of 2.4 and bicarb of 42. CXR was clear and KUB unremarkable (per report). Patient was given 4L NS, 80 mEq K+, 2g Mg, 100 mg thiamine and admitted to the MICU for persistant hypotension. Blood pressure at time of admission is 84/60. She has three peripheral IVs for access. Past Medical History: - bulimia anorexia - anxiety - history of polysubstance abuse - history of [**Doctor First Name **]-[**Doctor Last Name **] tears - history of seizures - history of hypoglycemia - hypotension (per OSH report, baseline SBP in the 80s) Social History: Lives with mother in [**Name (NI) 20935**]. Not currently working. H/o alcohol abuse with blackouts in past, no withdrawal complications. Daily marijuana, no other drugs. ? takes excess Rx meds (klonopin). Family History: Mother and Sister have bipolar disorder. Physical Exam: VITAL SIGNS - T hypothermic, HR 78, BP 66/30, RR 12, sat 99% RA GENERAL - cachectic young woman, tired but rousable, alert and oriented, no distress HEENT - pale conjunctiva NECK - supple, no LAD LUNGS - clear bilaterally posterior fields HEART - RRR, normal s1/s2, no murmurs ABDOMEN - mild epigastric pain without rebound or guarding; hypoactive bowel sounds EXTREMITIES - thin, pale, well-perfused and non-edematous. NEUROLOGIC: moving all extremities Discharge Physical Exam: VS: Temp 96.7 HR 71-100 BP 85/55-102/60 GENERAL: Awake, alert, NAD, oriented x3. Affect slightly blunted but appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink. Adentulous. NECK: Supple CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. 2+ peripheral pulses SKIN: No rashes Pertinent Results: Labs at Admission: [**2154-6-18**] 04:20AM BLOOD WBC-3.8* RBC-3.91* Hgb-10.8* Hct-31.9* MCV-82 MCH-27.7 MCHC-33.9 RDW-16.8* Plt Ct-168 [**2154-6-18**] 04:20AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) **]1+ Bite-OCCASIONAL [**2154-6-18**] 04:20AM BLOOD PT-11.4 PTT-27.7 INR(PT)-0.9 [**2154-6-18**] 04:20AM BLOOD Glucose-201* UreaN-26* Creat-1.4* Na-135 K-2.4* Cl-88* HCO3-42* AnGap-7* [**2154-6-18**] 04:20AM BLOOD ALT-9 AST-16 AlkPhos-66 Amylase-176* TotBili-0.4 [**2154-6-18**] 04:20AM BLOOD Albumin-3.6 Calcium-8.5 Phos-2.5* Mg-2.0 Iron-43 [**2154-6-18**] 04:20AM BLOOD calTIBC-333 VitB12-648 Folate-GREATER TH Ferritn-9.4* TRF-256 [**2154-6-18**] 04:20AM BLOOD TSH-1.7 [**2154-6-18**] 04:20AM BLOOD Free T4-1.0 [**2154-6-18**] 04:20AM BLOOD Cortsol-7.5 [**2154-6-18**] 04:40AM BLOOD K-2.3* [**2154-6-18**] 08:33AM BLOOD Lactate-2.0 Micro Data: [**2154-6-18**] URINE URINE CULTURE- negative [**2154-6-18**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2154-6-18**] BLOOD CULTURE Blood Culture, Routine- negative CXR ([**6-18**]): No evidence of pneumomediastinum to indicate esophageal perforation. No pneumonia. KUB ([**6-18**]): 1. Paucity of right hemiabdomen gas, could represent decompressed bowel or mass. Correlate with US if needed CT. 2. Borderline dilated loops of small bowel, D/D includes early or partial obstruction or ileus. ECG [**2154-7-2**]: Sinus rhythm with borderline sinus tachycardia. Normal tracing. Since the previous tracing of [**2154-6-28**] no significant change. Shoulder Xray [**2154-7-2**]: Three views of the right shoulder are normal. No fracture, dislocation, bone destruction, periarticular soft tissue calcifications, or diminution in the acromiohumeral soft tissues. No joint space narrowing and the visualized adjacent right lung is clear. Incidentally noted is a right central line apparently extending into the right atrium. Brief Hospital Course: A 24-year-old woman with past medical history of bulemia nervosa, presents after several days of vomiting with lethargy, dehydration, and hypotension. Labs were remarkable for severe hypokalemia and metabolic alkalosis. She was originally admitted to the ICU and then transferred to the medical floor. #. Hypokalemia, elevated bicarbonate, hypotension: Her electrolyte abnormalities were consistent with contraction alkalosis and hypovolemia from prolonged vomiting and dehydration. Thyroid and cortisol levels were normal. Blood and urine cultures were negative. Patient was hydrated aggressively, with particular attention to K+ and Phos. Her blood pressure and electrolyte abnormalities had resolved by the second hospital day. She was felt to be stable for transfer to the general medicine floors, as her systolic blood pressure was back to baseline mid-80s. Throughout the remainder of her hospital course, her baseline blood pressure remained 80-90s systolic (asymptomatic). Initially, she required agressive electrolyte repletion, but after patient began to cooperate with eating disorder protocol her electrolytes stabilized and she did not require further repletion. #. Eating disorder. Nutrition, psychiatry, and social services were involved in her care. They recommended that the patient initially start on an eating disorder protocol in order to achieve 75% of her ideal body weight. Multidisciplinary team meetings were held weekly in order to track the patient's progress. Per psychiatry recommendations, the patient's anxiety was treated with seroquel, ativan and fluoxetine; these were gradually uptitrated. At the time of discharge, she remained eating on her own per the eating disorder protocol and had acheived around 75% of her ideal body weight. She did occasionally have vomiting, and had had one episode in the 3 days prior to discharge. Weight at discharge was 41.0 kg (75.36% ideal body weight). Patient had normal ECG at the time of discharge. #. Epigastric pain. Patient with history of [**Doctor First Name **]-[**Doctor Last Name **] tear, although no free air noted on KUB and no pneumomediastinum on CXR on admission. She was treated initially with pantoprazole drip and transitioned to oral PPI upon discharge from the medical ICU. She had no further issues. #. Lethargy. Likely secondary to dehydration and hypokalemia. This resolved with treatment of her dehydration and metabolic disturbances. #. Anemia. She has a borderline microcytic anemia likely secondary to nutritional deficiencies. Iron studies were consistent with deficiency, and her hematocrit remained stable throughout her hospitalization. #. Acute kidney injury. Urinalysis on admission was normal. Her renal failure resolved with intravenous hydration and remained stable prior to discharge. #. Headache: She developed headaches during this admission, which she described as associated with nausea and tension/pressure in her forehead. She was managed with tylenol, ibuprofen and compazine as needed. #. Disposition: It was recommended that she have a legal guardian given her multiple recent admissions for her eating disorder. She eventually underwent court proceedings where she was court ordered to agree to attend inpatient eating disorder treatment after discharge but was not appointed a guardian. She is required to give 72 hour notice prior to leaving the facility in order to allow emergency guardianship proceedings to occur. #. Communication: Mother [**Name (NI) **] [**Telephone/Fax (1) 85148**] #. Code Status: Full code Medications on Admission: (per patient) - Percocet - Klonopin Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for 60 min prior to meals. 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. 6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for abdominal pain. 8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea/HA. 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Quetiapine 200 mg Tablet Sig: 2.5 Tablets PO QHS (once a day (at bedtime)) as needed for sleep. 11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for headache. 14. Quetiapine 25 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day) as needed for with meals. 15. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Last Name (un) 3671**] Behavioral Care - [**Hospital1 **] Discharge Diagnosis: Primary Diagnoses: Hypokalemia Hypotension secondary to dehydration Anxiety Bulemia nervosa Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with severe dehydration, low blood pressure, and low potassium levels in the blood due to your eating disorder. You were treated with intravenous fluids and your electrolytes were replaced. You were placed on the eating disorder protocol. You were followed by psychiatry during this admission, and several changes were made to your medications. The following adjustments were made to your medications: STOPPED clonazepam and Percocet STARTED Tylenol and ibuprofen as needed for headache STARTED thiamine 100mg by mouth daily STARTED folic acid 1mg by mouth daily STARTED lorazepam 1-2mg by mouth three times daily 60 minutes prior to meals, and 0.5-1mg at bedtime as needed for sleep STARTED multivitamin 1 tab by mouth daily STARTED Maalox 15-30mL by mouth four times daily as needed for abdominal pain STARTED compazine 10mg by mouth every 6 hours as needed for nausea STARTED pantoprazole 40mg by mouth daily STARTED Seroquel 500mg by mouth at bedtime as needed for sleep STARTED Seroquel 125mg by mouth three times daily as needed with meals STARTED nicotine patch STARTED docusate 100mg by mouth twice daily as needed for constipation STARTED fluoxetine 40mg by mouth daily Followup Instructions: You are being discharged to an eating disorder facility.

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10699, 10786

5629, 9191

379, 447

10922, 10922

3631, 5606

12313, 12373

2683, 2725

9277, 10676

10807, 10901

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2740, 3196

251, 341

475, 2182

10937, 11049

2204, 2439

2455, 2667

3221, 3612

6,286

125,937

30110

Discharge summary

report

Admission Date: [**2157-5-31**] Discharge Date: [**2157-6-4**] Date of Birth: [**2102-4-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest pain and h/o MI Major Surgical or Invasive Procedure: [**2157-5-31**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to PDA) History of Present Illness: 55 y/o male who c/o chest pain and sustained MI on [**3-23**]. She had an acute occlusion of the RCA noted on cath at that time and the vessel dissection during angioplasty. Underwent 6 DES to the RCA. Now presents for surgical revascularization. Past Medical History: Coronary Artery Disease s/p Angioplasty and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 6 to RCA [**3-23**], Hyperlipidemia, Hypertension, Gout, h/o Myocardial Infarction, Nephrolithiasis s/p stone removal Social History: Denies tobacco use. Rare ETOH use. Family History: Mother died of MI at age 52. Physical Exam: VS: 61 18 161/84 67" 175# General: WDWN male in NAD Skin: W/D -lesions HEENT: NC/AT, EOMI, PERRL, OP benign Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses throughout Neuro: MAE, A & O x 3, non-focal Pertinent Results: Echo [**5-31**]: PRE-BYPASS: 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. Overall left ventricular systolic function is normal (LVEF>55%). 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. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The degree of mitral regurgitation did not increse with Trendelenberg positioning nor with pharmocolgic increse of systolic blood pressure to 170 mm Hg. There is a trivial/physiologic pericardial effusion. POST-BYPASS: Normal biventricular systolic function. No significant changes from pre bypass findings. [**2157-5-31**] 11:43AM BLOOD WBC-7.3# RBC-2.43*# Hgb-7.6*# Hct-21.5*# MCV-89 MCH-31.5 MCHC-35.6* RDW-13.4 Plt Ct-96* [**2157-6-2**] 06:45AM BLOOD WBC-7.8 RBC-3.63* Hgb-11.2* Hct-32.8* MCV-90 MCH-30.8 MCHC-34.0 RDW-13.7 Plt Ct-139* [**2157-5-31**] 11:43AM BLOOD PT-18.9* PTT-53.6* INR(PT)-1.8* [**2157-6-2**] 06:45AM BLOOD PT-13.9* PTT-31.9 INR(PT)-1.2* [**2157-6-2**] 06:45AM BLOOD Glucose-127* UreaN-17 Creat-1.0 Na-137 K-4.3 Cl-100 HCO3-29 AnGap-12 [**2157-6-2**] 06:45AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9 RADIOLOGY Final Report CHEST (PA & LAT) [**2157-6-2**] 3:16 PM CHEST (PA & LAT) Reason: eval for pneumo s/p chest tube removal [**Hospital 93**] MEDICAL CONDITION: 55 year old man s/p CABG REASON FOR THIS EXAMINATION: eval for pneumo s/p chest tube removal CHEST, PA AND LATERAL HISTORY: CABG, evaluate for pneumothorax post chest tube removal. Two views. Comparison with [**2157-3-31**]. A left chest tube has been removed. No pneumothorax is identified. There is streaky bilateral density consistent with subsegmental atelectasis. This is new on the right. The patient is status post median sternotomy and CABG as before. Mediastinal structures are unchanged. An endotracheal tube, nasogastric tube, mediastinal drains, and right internal jugular line have been removed. IMPRESSION: Subsegmental atelectasis. No pneumothorax is identified. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**] Approved: [**Doctor First Name **] [**2157-6-2**] 8:45 PM Brief Hospital Course: Mr. [**Known lastname 4154**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see op note for surgical details. Following surgery she was brought to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics. He was gently weaned towards his pre-op weight. On this day he was transferred to the telemetry floor for further care. On post-op day 2 his chest tubes were removed. He continued to improve while working with PT for strength and mobility. On post-op day 4 he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Aspirin 325mg qd, Lipitor 75mg qd, Lipitor 80mg qd, Lisinopril 5mg qd, Lopressor 100mg [**Hospital1 **], Plavix 75mg qd, Protonix 40mg qd Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*1* 6. 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* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Last Name (un) 2646**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: s/p Angioplasty and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 6 to RCA [**3-23**], Hyperlipidemia, Hypertension, Gout, h/o Myocardial Infarction, Nephrolithiasis s/p stone removal Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) 6254**] in [**2-19**] weeks Dr. [**Last Name (STitle) 71779**] in [**1-18**] weeks Completed by:[**2157-6-6**]

[ "410.92", "V45.82", "V58.61", "401.9", "274.9", "414.01", "272.4", "V58.66", "V13.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5867, 5923

3902, 4755

341, 441

6228, 6234

1405, 3023

1028, 1058

4943, 5844

3060, 3085

5944, 6207

4781, 4920

6258, 6926

6977, 7158

1073, 1386

280, 303

3114, 3879

469, 717

739, 960

976, 1012

16,740

154,397

3017

Discharge summary

report

Admission Date: [**2185-9-12**] Discharge Date: [**2185-9-30**] Date of Birth: [**2106-10-23**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This is a 78-year-old female, with known ascending aortic aneurysm. The patient complains of recently shortness of breath with exertion and minimal epigastric indigestion with activity which resolves with rest. Cardiac catheterization done [**2185-3-22**] showed an ejection fraction of 54 percent, with a mid-LAD lesion of 30- 40 percent. Chest MRA in [**2185-7-14**] showed a 6.4 cm ascending aortic aneurysm. The patient had been originally scheduled for surgery in [**2185-4-14**]; however, at that time her surgery was canceled due to an esophageal tear. As an outpatient, the patient had a repeat upper endoscopy which showed a well- healed tear. PAST MEDICAL HISTORY: Hypertension. GERD. Cataract. Nephrolithiasis. Ascending aortic aneurysm. Status post cesarean section x 3. ALLERGIES: Aspirin which causes GI upset. IV dye which causes shaking chills. Shellfish which causes nausea and vomiting. PREOPERATIVE MEDICATIONS: 1. Hydrochlorothiazide 25 mg po qd. 2. Atenolol 50 mg po qd. 3. Milk of Magnesia prn. SOCIAL HISTORY: The patient smokes approximately a half pack per day with approximately 35-pack year. The patient denies ETOH. She lives alone in Rosalindale next door to her sister. HO[**Last Name (STitle) **] COURSE: The patient was taken to the operating room with Dr. [**Last Name (Prefixes) **] on [**9-13**] for replacement of her aortic arch and her proximal descending aorta with an aorto- subclavian bypass and a vertebro-subclavian bypass. Total cardiopulmonary bypass time was 214 minutes. Crossclamp time 43 minutes. Total circulatory arrest time was 50 minutes divided up into 3 intervals. Postoperatively, the patient was transferred to the Intensive Care Unit in stable condition on Nitroglycerin and epinephrine drips. Upon admission to the Intensive Care Unit, the patient was noted to have a small amount of blood draining from bilateral ears. ENT consult was obtained, and upon examination by the ENT staff, it was noted that the patient had blood behind her eardrums but no perforation, unclear etiology. Recommended antibiotic ear drops for 7 days and continued reassessment. The situation resolved, and the patient had no further issues. The patient had some labile hemodynamics immediately postop requiring correction of coagulopathy and transfusion of packed red blood cells, without significant chest tube output. The patient initially required increased PEEP for poor oxygenation. On postop day 1, the patient began to awaken, and it was felt that perhaps the patient had some mild right-sided weakness. At that time, the patient's goal blood pressure was increased, and the patient remained very sleepy for the next few days. Eventually, fully awoke and was found to be neurologically intact. The patient was started on Lasix with good diuresis. The patient was intermittently hypertensive due to stimulation. The patient was started on Lopressor. Continued to be on Nitroglycerin. The patient intermittently had been on sodium nitroprusside which caused hypoxia, and this was discontinued. The patient was started on Combivent inhalers with moderate improvement in her expiratory wheezes. On postoperative day 3, the patient had been placed on CPAP which had tolerated well. Towards the end of the day, the patient acutely became anxious, agitated and hypertensive, complaining that she was having trouble breathing. Chest x- ray was obtained at that time which was unremarkable. The patient was placed back on with resolution of the incident. On postoperative day 3, cardiology consult was obtained for assistance in managing hypertension. It was recommended to continue aggressive diuresis and continue current medical therapy. The patient was weaned on mechanical ventilation and extubated initially with hemodynamic instability, hypertension and tachycardia which resolved. The patient remained extubated approximately 2-1/2 hours, at which time she became acutely agitated, short of breath and tachypneic, and quickly progressed to respiratory failure. The patient was emergently reintubated. It was felt that her failure was due to volume overload. The patient was continued to be aggressively diuresed. The patient was started on Natrecor, as well as her Lasix to aid in diuresis and help with hypertension. The patient's creatinine had slowly begun to rise and peaked at approximately 2.1. The patient's sputum from [**9-18**] grew MRSA. The patient was started on IV vancomycin for treatment. The patient was started on tube feeds. The patient had several episodes of rapid atrial fibrillation for which she was started on amiodarone. All episodes were nonsustained. The patient underwent bronchoscopy which showed moderate secretions bilaterally which were aspirated, and moderate to severe malacia of the distal trachea. The patient continued to be aggressively diuresed and was extubated on [**9-22**], and due to the presence of tracheomalacia, the patient was extubated and placed on intermittent CPAP which was gradually weaned off, as the patient continued diuresis. The patient underwent a swallowing evaluation on [**9-23**] which showed no evidence of aspiration. The patient continued on her amiodarone for her atrial fibrillation. The patient was intermittently pleasantly confused which subsequently resolved. The patient developed an elevated white blood cell count on [**9-24**]. The patient was pancultured. The patient's UA was positive, and urine culture was subsequently negative. The patient had been started on levofloxacin. Repeat urine culture was sent on [**9-30**] with results still pending. The patient's Lasix was discontinued on [**9-26**] due to rise in creatine and patient being below preop weight. On [**9-27**], the patient was transferred from the Intensive Care Unit to the regular part of the hospital and began being screened for rehab. On [**9-30**], the patient was cleared for discharge to rehab. CONDITION AT DISCHARGE: T-max 97.6, pulse 75 in sinus rhythm, blood pressure 129/80, respiratory rate 18, room air oxygen saturation 93 percent. The patient's weight on [**9-30**] was 68.5 kg, which was decreased from 69.3 on [**9-29**]. LABORATORY DATA: White blood cell count 16.1, hematocrit 36.6, platelet count 687, sodium 144, potassium 4.1, chloride 106, bicarb 22, BUN 51, creatinine 1.9, glucose 81. PHYSICAL EXAM: Neurologically, the patient was awake, alert, oriented x 3. No apparent deficit. Her grip strength and her plantar flexion were equal bilaterally. Heart was regular rate and rhythm without rub or murmur. Respiratory - breath sounds were coarse with scattered rhonchi throughout. The patient had a moderately productive cough, but was not expectorating any sputum. GI - positive bowel sounds, soft, nontender, nondistended. The patient was tolerating a regular diet and having normal bowel movements. Extremities - pulses were 2 plus bilateral radials and 2 plus bilateral DP and PT. Extremities were warm and well-perfused without any evidence of edema. Sternal incision was clean, dry and intact. The sternum was stable without any erythema or drainage. The right subclavian incision had mild tenderness to palpation in the area of the incision with a small amount of separation at the lateral portion of the incision which was scabbed over. There was no erythema, and there was no drainage. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg po qd x 1 month. 2. Combivent MDI 1-2 puffs q 6 h prn. 3. Flovent 110 mcg MDI 2 puffs inhaled [**Hospital1 **]. 4. Nicotine 14 mg patch 1 transdermally qd x 3 weeks. 5. Protonix 40 mg po qd. 6. Lopressor 25 mg po bid. 7. Levofloxacin 250 mg po q 48 h x 6 days. DISCHARGE DIAGNOSES: Ascending aortic aneurysm. Status post replacement of total aortic arch and proximal descending aorta with aorto-subclavian and vertebro- subclavian bypass on [**9-13**]. Postoperative hemotympanum of unknown etiology, which is resolved. Prolonged intubation due to volume overload. Postoperative Methicillin resistant Staphylococcus aureus pneumonia. Postoperative renal insufficiency. Postoperative urinary tract infection. Hypertension. Peripheral vascular disease. FO[**Last Name (STitle) 996**]P: The patient is to follow-up with her primary care physician [**Last Name (NamePattern4) **] [**2-15**] weeks. She is to follow-up with her cardiologist in [**2-15**] weeks. She is to follow-up with Dr. [**Last Name (Prefixes) 2545**] in 4 weeks. The patient is to be discharged to [**Location (un) 582**] of [**Hospital 620**] Rehab facility in stable condition. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern4) 8524**] MEDQUIST36 D: [**2185-9-30**] 10:31:00 T: [**2185-9-30**] 11:36:24 Job#: [**Job Number 14390**]

[ "599.0", "747.21", "518.5", "427.31", "441.2", "998.2", "482.41", "286.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "93.90", "00.13", "96.04", "38.44", "38.45", "39.22", "96.6", "96.05", "99.05", "99.07", "39.61", "39.32", "39.23", "99.04" ]

icd9pcs

[ [ [] ] ]

7894, 9029

7588, 7872

6559, 7565

1114, 1202

6154, 6543

166, 825

848, 1088

1219, 6139

41,710

181,955

42114

Discharge summary

report

Admission Date: [**2133-10-29**] Discharge Date: [**2133-11-1**] Date of Birth: [**2068-12-16**] Sex: M Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 2901**] Chief Complaint: S/p elective Fidelis lead extraction Major Surgical or Invasive Procedure: Pacemaker lead extraction and replacement Intubation History of Present Illness: Mr. [**Known lastname **] is a 64 year old male with complex medical history including CAD s/p remote MI, s/p CABG and PCI, ischemic CMP, s/p dual chamber pacemaker implant for high grade AV block and later upgrade to dual chamber ICD. A recent interrogation in [**Month (only) 216**] revealed noise with inhibition of ventricular pacing with his fidelis RV lead. Patient denied palpitations, lightheadedness, near syncope, syncope or ICD discharge to the CNP who spoke with him on the phone a couple days ago. He was electively admitted for lead extraction. . Patient was found to have hyperglycemia to 400s this AM when presenting to the OR with initial ABG showing 7.17/43/328/17. He had a hyperchloremic, non-anion gap metabolic acidosis and had a normal lactate. During the case, he received 1 unit of pRBCs, 3L NS and calcium with a couple amps of bicarb to help his acid/base. Patient became hypotensive during the case requiring vasopressin and levophed for pressure support. He received a BiV pacer with improvement in his EF by TEE. . In the CCU, he is intubated and sedated. . Per wife, he has had no complaints and has been feeling well. He has had AM hyperglycemia after night time snacks. Past Medical History: 1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: - CABG: S/p MI and CABG in [**2112**] ([**Hospital3 **]), unknown anatomy. - PERCUTANEOUS CORONARY INTERVENTIONS: S/p stenting, unknown anatomy. - PACING/ICD: History of complete heart block, dual chamber placement for high grade AV block in [**2123**]; upgrade to dual chamber [**Company 2267**] model T165 ICD [**5-/2129**] - Ischemic cardiomyopathy . 3. OTHER PAST MEDICAL HISTORY: - Status post left inguinal herniorrhaphy - Status post remote excision of melanoma from his back Social History: SOCIAL HISTORY: Per notes, unable to confirm with patient as intubated. Lives with and 2 sons, ages 20 & 17. [**Name2 (NI) **] care Services: None Family History: not pertinant to current admission Physical Exam: ON ADMISSION: VS: T= 97 BP= 145/55 HR= 68 RR= 15 O2 sat= 99% GENERAL: Intubated and sedated HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple. Unable to assess JVD given supine. 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 with coarse bilateral vent breath sounds. ABDOMEN: Soft, mildly distended, no organomegaly appreciated. EXTREMITIES: No c/c/e. SKIN: Scattered tattoos. No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ ON DISCHARGE: T= 97 BP= 122/60 P=67 RR=15 O2 sat= 97% GENERAL: Alert and oriented x3 NAD HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple. JVP of 5cm 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 with coarse bilateral vent breath sounds. ABDOMEN: Soft, mildly distended, no organomegaly appreciated. EXTREMITIES: No c/c/e. SKIN: Scattered tattoos. No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ON ADMISSION: [**2133-10-29**] 06:03PM BLOOD WBC-17.8* RBC-3.40* Hgb-10.7* Hct-30.5* MCV-90 MCH-31.3 MCHC-34.9 RDW-15.4 Plt Ct-131* [**2133-10-29**] 06:03PM BLOOD PT-17.0* PTT-29.5 INR(PT)-1.5* [**2133-10-29**] 03:37PM BLOOD UreaN-18 Creat-1.1 Na-139 K-4.2 Cl-113* HCO3-21* AnGap-9 [**2133-10-29**] 03:37PM BLOOD ALT-44* AST-46* AlkPhos-120 TotBili-0.7 [**2133-10-29**] 06:03PM BLOOD TotProt-5.3* Albumin-3.1* Globuln-2.2 Calcium-8.3* Phos-5.6* Mg-2.0 [**2133-10-30**] 09:00PM BLOOD Hapto-108 ECHO [**10-29**]: The left atrium is mildly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. There are simple atheroma in the ascending aorta. 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 tricuspid valve leaflets fail to fully coapt. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. Initial LV systolic function was depressed with LVEF = 30-35%, this improved to LVEF 35-45% with dual ventriular pacing. No PFO seen. No clot in LAA seen. CXR [**10-29**]: The patient is intubated, the tip of the endotracheal tube projects 3 cm above the carina. Normal placement of a right internal jugular vein catheter without evidence of complications. Left pectoral pacemaker in situ. No nasogastric tube. No evidence of pneumothorax. Borderline size of the cardiac silhouette without evidence of pulmonary edema. Minimal pleural effusion. Moderate retrocardiac atelectasis. = = = = = = = = ================================================================ ON DISCHARGE: [**2133-11-1**] 05:56AM BLOOD WBC-3.9* RBC-3.34* Hgb-10.4* Hct-29.2* MCV-87 MCH-31.1 MCHC-35.6* RDW-16.4* Plt Ct-43* [**2133-11-1**] 05:56AM BLOOD Glucose-189* UreaN-11 Creat-0.8 Na-138 K-3.4 Cl-107 HCO3-21* AnGap-13 ECHO [**10-30**]: The left atrium is mildly dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior/inferolateral/basal inferoseptal akinesis, as well as hypokinesis of the apex (multivessel CAD) . The remaining segments contract normally (LVEF = 30%). 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. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction, most c/w multivessel CAD. Mild mitral regurgitation. Significant residual intraventricular LV dyssynchrony by visual inspection. Brief Hospital Course: ASSESSMENT AND PLAN: Mr. [**Known lastname **] is a 64 year old male with complex medical history including CAD s/p remote MI, s/p CABG and PCI, ischemic CMP, s/p dual chamber pacemaker implant/ICD for high grade AV block who presented for elective BiV/ICD complicated by acidosis and hypotension. . # Pacemaker/ICD Placement: Patient presented for elective BiV/ICD, while in the OR patient became hypotensive requiring levophed and vasopressin in the setting of large volume blood loss. Patient stablized and was weaned from pressors. He has followup in device clinic with Dr. [**Last Name (STitle) **] [**Name (STitle) 1944**]. . # Hypotension: Patient became hypotensive during OR case requiring use of levophed and vasopressin. Patient reportedly had large blood loss during procedure and received total of 4 units of pRBC. Other etiologies including cardiogenic, septic and adrenal insufficency were evaluated and ruled out as cause. He was weaned from pressors quickly once sedation was weaned and he received blood. . # RTA: On admission, patient appeared to have combined non-gap metabolic acidosis with respiratory acidosis in setting of ventilatory support. Patient had persistant hyperchloremic, non-gap metabolic acidosis post-extubation with an elevated urine pH and urine anion gap suggesting a distal renal tubular acidosis. Patient was started on bicarb (1-2 mg/kg or 7g/day) and potassium supplementation prior to discharge. He will follow up with his PCP this week and will need to be seen by a nephrologist as well. Patient prefered a nephrologist closer to his home in [**Hospital1 1562**] rather than travelling to [**Hospital1 18**]. He will have labs drawn two days after discharge to ensure electrolyte stability. . # Chronic systolic CHF: He just received replacement BiV pacemaker and his EF improved from 30-35% on admisison to LVEF 35-45% post-procedurely. He was continued on [**Last Name (un) **]. . # Thrombocytopenia: Patient's platelet count was 131K at the time of presentation and had fallen to 40K post ICD placement. It was felt that this was a dilutional effect in the setting of recieving 4 units of pRBC with no additional platelets. Hemolysis labs were negative, and there were no signs of bleeding. Platelets were stable for 36 hours at time of discharge. . # CAD: He has h/o CABG in the [**2112**] but no reported recent CP. He was continued on his plavix, aspirin and statin. Metoprolol and losartan were held initially, but restarted at home dose prior to discharge. . # HTN: Patient's metoprolol and losartan were held initially due to hypotension, but were restarted at his home dose when he was hemodynamically stable. # HLD: Patient was continued on home statin, Zetia and Gemfibrozil. . # DM: Patient's home dose of lantus was reduced to 40 from 66 as patient was NPO for procedure and put on sliding scale humalog. He was restarted on his home dose of lantus and sliding scale with good glycemic control through out his hospital course. TRANSLATIONAL ISSUES: -patient needs to establish care with a nephrologist closer to his home in [**Hospital1 **]. -patient will need his electrolytes closely monitored as an outpatient -patient will need his CBC and platelet count checked in [**4-11**] days. Medications on Admission: Amlodipine 5mg daily Clopidogrel 75mg daily Ezetimibe 10mg daily Gemfibrozil 600mg [**Hospital1 **] Lantus 66U QHS Lispro SC Losartan 50mg daily Metoprolol Tartrate 50mg [**Hospital1 **] Simvastatin 20mg daily ASA 325mg daily MOV daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lantus 100 unit/mL Solution Sig: Sixty Six (66) units Subcutaneous at bedtime. 6. insulin lispro 100 unit/mL Solution Sig: ASDIR Subcutaneous four times a day: [**First Name8 (NamePattern2) **] [**Last Name (un) **] Sliding Scale. 7. losartan 50 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. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. sodium bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO once a day. Disp:*60 Tablet, ER Particles/Crystals(s)* Refills:*0* 13. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 14. Outpatient Lab Work Please draw CBC and chem 7 on Tuesday, [**11-3**] and fax results to PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] at [**Telephone/Fax (1) 91356**]. Discharge Disposition: Home Discharge Diagnosis: Pacemaker revision complicated by bleeding Acute blood loss anemia Chronic acidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], You were admitted to the hospital following a pacemaker lead replacement, which was complicated by bleeding. You received blood transfusions and your blood counts stabilized. Additionally, you were found to have a kidney disorder that causes your blood to become very acidic, and you were started on medications to treat this. We made the following changes to your medications: -START sodium bicarbonate -START Potassium Chloride 40 daily -CHANGED your heart burn medication to Famotidine to lessen interaction with plavix Please have blood drawn on Tuesday and have the results faxed to your PCP and Dr. [**Last Name (STitle) **]. Followup Instructions: Please call your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 49260**] on monday, and make an appointment to be seen this week. Please also have labs drawn on Tuesday, and the results sent to your PCP. Department: CARDIAC SERVICES When: THURSDAY [**2133-11-5**] 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 Department: CARDIAC SERVICES When: FRIDAY [**2133-11-27**] at 3:00 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 Please call the [**Hospital1 18**] renal clinic at ([**Telephone/Fax (1) 10135**] to make an appointment regarding your kidney condition. They will help to manage your electrolytes and your new medications. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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icd9cm

[ [ [] ] ]

[ "00.51" ]

icd9pcs

[ [ [] ] ]

11955, 11961

7030, 10296

307, 362

12089, 12089

3901, 3901

12932, 14110

2380, 2416

10582, 11932

11982, 12068

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231, 269

390, 1598

3915, 5827

12104, 12216

2099, 2199

1620, 1694

2231, 2364

10,666

126,199

53496

Discharge summary

report

Admission Date: [**2168-4-2**] Discharge Date: [**2168-4-30**] Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is an 82-year-old gentleman with known coronary artery disease, severe aortic stenosis and a normal left ventricular ejection fraction who presented to the Emergency Department with an approximately five day history of cough, shortness of breath, dyspnea on exertion and sputum production. He also had low grade fevers at the time. He denied chest pain, nausea or vomiting associated with these symptoms. He was seen by his primary care physician who reportedly obtained a chest x-ray which revealed a right lower lobe and right middle lobe infiltrate and he was started on azithromycin. The symptoms worsened and the patient was sent to the Emergency Department. PAST MEDICAL HISTORY: 1. Chronic renal insufficiency with a baseline creatinine of 1.6. 2. Hypertension 3. Hypercholesterolemia 4. Status post appendectomy 40 years ago 5. Severe aortic stenosis with a most recent echocardiogram from about two years prior to admission which revealed a left ventricular ejection fraction of 53% and aortic valve area of 0.9 cm squared. 6. The patient also has restrictive lung disease. 7. He is also status post three unit upper gastrointestinal bleed in [**2167-9-16**] in which he was found at that time to have a gastric ulcer and he was negative for Helicobacter pylori. PREOPERATIVE MEDICATIONS: 1. Zestril 40 mg po qd 2. Procardia XL 60 mg po qd ALLERGIES: The patient states no known drug allergies. SOCIAL HISTORY: The patient lives alone. He has a 60 to 80 pack year smoking history and quit approximately 10 years ago and denies alcohol intake. On initial evaluation in the Emergency Room, the patient was afebrile. He was found to be in sinus tachycardia with a rate of 125. He had a blood pressure of 128/66, respiratory rate in the high 20s and a room air oxygen saturation of 77% He had an elevated white blood cell count to 15,000 with a left shift. Chest x-ray showed bilateral infiltrates and a questionable right effusion. The patient was noted at the time to have new ST depressions in V2 through V6 on his electrocardiogram. ADMISSION PHYSICAL EXAMINATION: GENERAL: Elderly male patient in moderate respiratory distress. HEAD, EARS, EYES, NOSE AND THROAT: Unremarkable. NECK: Without bruits. CARDIOVASCULAR: Heart sounds were difficult to appreciate secondary to breath sounds. LUNGS: Diffuse inspiratory and expiratory crackles with occasional wheezes, right side greater than left. ABDOMEN: Obese, slightly distended, but nontender and positive bowel sounds. EXTREMITIES: 1+ edema bilaterally. The patient had palpable pulses in both of his feet and neurologically was grossly intact. ADMISSION LABORATORY VALUES: White blood cell count of 14.9000, hematocrit 27.3, serum sodium of 130 and serum creatinine of 1.9 with a glucose of 180. The rest of his labs on admission were unremarkable. The patient did have, in addition, a positive troponin with the first one being 13 and the second one being 15. The patient was admitted to the medicine service with a presumed diagnosis of pneumonia. He was admitted to the Intensive Care Unit and placed on levofloxacin awaiting sputum culture results. The patient was also presumed to be in congestive heart failure which was treated with intravenous diuretics and also had a presumed diagnosis of chronic obstructive pulmonary disease at the time. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit to be followed from a pulmonary standpoint as well as close cardiac monitoring. Over the next few days in the Medical Intensive Care Unit, the patient was treated with antibiotics as well as noninvasive ventilation with a BIPAP mask. The patient was taken to the cardiac catheterization lab on [**2168-4-8**] due to continued episodes of congestive heart failure while being treated for pneumonia. Catheterization revealed a severe calcific aortic stenosis as well as moderate mid LAD lesion, faint collaterals to the right coronary artery, severely tortuous right iliac artery and occluded left iliac. The patient was taken to the Operating Room on [**2168-4-12**] by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where he underwent an aortic valve replacement with a 21 mm pericardial valve. He also had repair of an ascending aortic dissection with a patch graft and he had a coronary artery bypass graft x2 with a left internal mammary artery to the LAD and a saphenous vein off of the left internal mammary artery graft to the OM. Postoperatively, the patient was on an epinephrine drip. He was transported from the Operating Room to the Cardiac Surgery Recovery Unit. The patient had some significant hypotension on the night of surgery in the Cardiac Surgery Recovery Unit and an emergent transesophageal echocardiogram was obtained which showed no significant change from his previous echocardiogram done intraoperatively and no new aortic dissection. On postoperative day #1, the patient was on epinephrine drip as well as lidocaine, nitroglycerin, propofol and insulin drip. He had a temperature to 101.3??????. He was in normal sinus rhythm. He was stable hemodynamically on the aforementioned drip and he had been kept sedated due to initial hemodynamic instability. Later in the day, the patient was noted to have seizure activity and still had not woken up despite his sedation being discontinued. The patient was taken for an emergent head CT scan which showed complete wire shed distribution hypodensity on the right anterior to posteriorly with the same pattern but less confluent on the left. The neurology consult was obtained and it was their impression that the patient had had a significant cerebrovascular accident intraoperatively or postoperatively. It was their recommendation to obtain an EEG to treat the seizure activity with Dilantin, as well as benzodiazepines and to hold off sedation other than the seizure treatments and to evaluate her fever source. The patient, over the next few days, remained on full ventilator support. The patient was begun on tube feeds while his neurologic status was being closely monitored. While being supported over the next few days in the Intensive Care Unit, the patient was noted to have stabilized hemodynamically. His Swan-Ganz catheter was discontinued on the morning of postoperative day #5. He remained on nitroglycerin for blood pressure control and Dilantin and he was being increased on his tube feeds. Later in the day, on postoperative day #5, the patient was noted to have hemoptysis. His endotracheal tube was changed to a larger tube to facilitate the bronchoscope and the patient had a bronchoscopy performed by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] who noted some blood in the area of the right upper lobe which was cleaned out and there was no continuing bleeding source identified. Some old clots had been removed during the time of bronchoscopy. On postoperative day #6, the patient was difficult to assess for neurologic status because he had gotten some sedation to tolerate the bronchoscopy. On postoperative day #7, the patient was noted to have a large amount of serous fluid from his sternal incision. He had a low grade fever at the time without elevation in his white blood cell count. Due to patient's questionable neurologic status, he was continued to be fully supported in the Intensive Care Unit with tube feedings and ventilator support. He had tolerated weaning of his ventilator support to a CPAP load over the next few days. He was placed on vancomycin and levofloxacin due to the patient's previous pneumonia, as well as having some sternal drainage. His tube feedings had been tolerated well at goal rate. Sputum cultures obtained were positive for gram positive cocci as well as yeast. On postoperative day #11, [**2168-4-23**], the patient was taken to the Operating Room for a sternal dehiscence. He underwent a mediastinal exploration with a Robicsek weave of his sternum at that time. The patient tolerated the procedure well. He had begun, over the previous two days, to open his eyes spontaneously and follow occasional command. On postoperative day #11, the patient was noted to be moving all extremities spontaneously with intermittent episodes of following commands. On [**4-25**], a dermatology consult was obtained due to a new rash that was evident on the patient's left leg. It was the thought of the dermatology service that this was herpes zoster and the recommendation was to discharge acyclovir which was initiated at that time. On [**2168-4-26**], because the patient had made significant process from a neurologic standpoint and was beginning to follow commands appropriately and be more wakeful and interactive, it was felt appropriate for the patient to undergo tracheostomy and PEG placement. These were both done on [**2168-4-26**] by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] which were done in the Intensive Care Unit at the bedside. The patient tolerated both procedures well. Also, on the same day, [**2168-4-26**], we obtained an infectious disease consultation due to a report of vancomycin resistant enterococcus from the sternal fluid. The consultation was obtained for assistance with antibiotic management. It was their recommendation to start Linezolid for a four week course, as well as to discontinue the vancomycin and levofloxacin and they recommended she continue acyclovir for the herpes zoster of the leg. The patient was again initiated on tube feedings, progressed to his goal tube feed rate over the next few days. The patient had fever to 101?????? on [**2168-4-28**] without any obvious source. His central line as well as his arterial line were discontinued and sent for cultures which are so far negative to date. Since the patient has remained hemodynamically stable, requiring prolonged ventilator weaning it was felt appropriate for him to be transferred from the Intensive Care Unit to a rehabilitation facility to progress with his neurologic and stroke recovery, as well as prolonged ventilator weaning and to continue supporting him with nutrition via his PEG until he is able to take oral feeding again. The patient's condition today on [**2168-4-29**] is as follows: He is afebrile with a temperature of 100??????. His blood pressure is 108/43. He is in normal sinus rhythm with a rate of 90. His respiratory rate is 18. His oxygen saturation is 96%. His CVP is 14. The patient remains on pressure support ventilation at 50% FIO2 with a PEEP of 5 and pressure support of 8. His spontaneous respiratory rate has been between 15 and 20 with spontaneous tidal volumes between 400 and 500 cc. The patient is alert and awake and interactive and follows commands with a bit of a delayed response, but is following commands consistently. Pulmonary: His lungs have coarse rhonchi bilaterally. His coronary exam is regular rate and rhythm. His abdomen is soft, nontender, nondistended with positive bowel sounds. His extremities are warm with palpable DP and PT pulses bilaterally. The patient is tube feeding goal is full strength Ultracal at 70 cc per hour. DISCHARGE MEDICATIONS: 1. Lopressor 100 mg per G tube [**Hospital1 **] 2. Linezolid 600 mg intravenous [**Hospital1 **]. This is to continue until [**2168-6-1**]. 3. Zestril 5 mg 1 per G tube qd 4. Aspirin 325 mg per G tube qd 5. Dilantin 100 mg per G tube tid 6. Albuterol metered dose inhalers 2 puffs q4h 7. Atrovent metered dose inhaler 2 puffs q6h 8. Acyclovir 450 mg q8h through [**2168-5-3**] 9. Prilosec 40 mg per G tube qd The patient ahs also intermittently received regular insulin sliding scale coverage to maintain glucose level below 150. The patient is hemodynamically stable. The patient is stable to transferred to a rehabilitation facility. DISCHARGE DIAGNOSES: 1. Severe aortic stenosis, status post aortic valve replacement 2. Coronary artery disease, status post coronary artery bypass graft x2 3. Sternal dehiscence, status post sternal rewiring 4. Respiratory failure status post trach PEG 5. Herpes zoster of the left leg 6. Positive VRE culture from his sternal wound FO[**Last Name (STitle) 996**]P: The patient is to follow up with Dr. [**Last Name (Prefixes) **] upon discharge from rehabilitation facility as well as follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4844**], upon discharge from rehabilitation facility. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 40853**] MEDQUIST36 D: [**2168-4-29**] 13:39 T: [**2168-4-29**] 13:46 JOB#: [**Job Number **]

[ "E878.2", "486", "424.1", "428.0", "441.03", "518.5", "401.9", "496", "998.3" ]

icd9cm

[ [ [] ] ]

[ "39.61", "31.1", "88.53", "37.22", "38.44", "35.22", "34.03", "36.12", "36.15" ]

icd9pcs

[ [ [] ] ]

12162, 13075

11492, 12141

3503, 11469

1444, 1555

2233, 3485

128, 802

824, 1418

1572, 2211

61,956

105,918

53236

Discharge summary

report

Admission Date: [**2161-3-16**] Discharge Date: [**2161-3-19**] Date of Birth: [**2073-12-15**] Sex: M Service: MEDICINE Allergies: Optiray 350 / Clinoril / Keppra / Codeine Attending:[**First Name3 (LF) 4309**] Chief Complaint: weakness Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 109590**] is an 87 yom with history of CAD s/p RCA and left circumflex stent in [**2146**] and [**2151**], TIAs, afib on coumadin, MVR s/p bioprosthetic MV in [**2151**], pacemaker, prostate cancer s/p radiation c/b obstructive uropathy and suprapubic [**Last Name (un) **] a urostomy p/w weakness. . Per family report, patient has been uncomfortable with his catheter recently. Typically has his catheter changed every six weeks but he had to go longer this time. Having difficulty holding his urine, was having several accidents during the last week. Last infection just prior to catheter change. Today he was working out in the gym in his independent living facility, returned to his aprtment to his wife reporting feeling weak, rigoring severely, and was unable to stand. He was also unable to communicate and was grunting responses only. No documented fevers. Symptoms started acutely today. He was at his baseline two days ago. . In the ED, patient triggered for appearing critically ill. Initial vital signs were T99.4 HR84 BP148/68 RR20 O2 sat 99%RA. He was pale, not verbally responsive, but able to shake his head yes or no to commands. Repeat rectal temp was 102.6. Examination was notable for lower abdominal tenderness. He had no focal neurologic symptoms. Guaic was negative. He underwent evaluation with head CT and CT abdomen. CBC was notable for leukocytosis. UA strongly consistent with UTI. He received 850cc NS, and was started on Vancomycin and Zosyn. Per report his vital signs remained stable throughout his time in the ED. Vital signs were HR 60, BP 139/37, RR 20, 100% on 3L NC. . On arrival to the MICU, patient verbally responsive but only able to respond to simple questions. . Review of systems: increase forgetfullness (comes and goes), chills. no recent chest pains or shortness of [**Last Name (un) **]. mild abdominal discomfort, increased urinary frequency. (+) Per HPI (-) unable to provide Past Medical History: 1. prostate ca, initially treated c radiation [**2136**] now recurrent and treated with lupron for many years. recent psa of 2 (up a little) 2. chronic urinary retention c recent permanent foley s/p radiation from prostate ca 3. recent UTI 4. CAD status post RCA and left circumflex stenting in [**2146**] and [**2151**] respectively. 5. Mitral valve regurgitation status post bioprosthetic mitral valve in [**2151**]. 6. Atrial fibrillation status post Maze also in [**2151**], currently on Coumadin. 7. Status post pacemaker following MVR. This is a [**Company 1543**] AV sequentially pacing. 8. Hypertension. 9. Numerous TIAs on Coumadin. 10. gerd 11. constipation 12. h/o GIB, requiring discontinuation of asa. last transfusion [**10-23**] 13. COPD Social History: per OMR, confirmed c pt: Married, lives with wife in [**Hospital 4382**], recently moved from FL, has 3 children. Former tobacco quit 50 years ago, very rare EtOH, no drugs. Used to work as dress distrubutor and in personnel. Family History: per OMR: Father with RCC and DM II. Physical Exam: Physical Exam on Admission: General: Lethargic, responds to voice, oriented to person and place. No acute distress. HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, harsh holosystolic murmur. No rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, suprapublic foley catheter in place. suprapubic tenderness, without rebound or guarding. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, strength 4/5 in all extremities. grossly normal sensation, gait deferred. pt responding to simple questions and commands, has difficulty with concentration. Physical Exam on Discharge: General: NAD, A+Ox3 HEENT: mucous membranes moist Neuro: responds appropriately to qurestions and commands Pertinent Results: Lab Results on Admission: [**2161-3-16**] 04:45PM BLOOD WBC-15.3*# RBC-4.37* Hgb-10.3* Hct-33.0* MCV-76* MCH-23.5* MCHC-31.1 RDW-15.4 Plt Ct-216 [**2161-3-16**] 04:45PM BLOOD Neuts-92.6* Lymphs-2.6* Monos-4.4 Eos-0.1 Baso-0.3 [**2161-3-16**] 04:45PM BLOOD PT-40.9* PTT-50.0* [**Year/Month/Day 263**](PT)-4.0* [**2161-3-16**] 04:45PM BLOOD Glucose-130* UreaN-22* Creat-1.1 Na-138 K-4.0 Cl-100 HCO3-25 AnGap-17 [**2161-3-16**] 04:45PM BLOOD ALT-16 AST-33 AlkPhos-57 TotBili-1.0 [**2161-3-16**] 04:45PM BLOOD proBNP-1131* [**2161-3-16**] 04:45PM BLOOD cTropnT-<0.01 [**2161-3-16**] 04:45PM BLOOD Albumin-3.9 Calcium-9.5 Phos-2.7 Mg-2.7* [**2161-3-16**] 04:53PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-40 pH-7.45 calTCO2-29 Base XS-3 [**2161-3-16**] 04:53PM BLOOD Lactate-1.9 Studies: Cardiovascular Report ECG Study Date of [**2161-3-16**] 4:35:06 PM Atrial pacing and ventricular pacing. Compared to the previous tracing of [**2161-1-29**] no significant change. Radiology Report CT HEAD W/O CONTRAST Study Date of [**2161-3-16**] 4:47 PM IMPRESSION: No acute intracranial pathology. Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-3-16**] 4:47 PM IMPRESSION: Lower lung volumes on the current exam. Left lower lobe opacity seen medially, potentially due to atelectasis; however, infiltrate is not completely excluded. Clinical correlation is suggested. Radiology Report CT ABD & PELVIS W/O CONTRAST Study Date of [**2161-3-16**] 5:15 PM IMPRESSION: 1. Cholelithiasis without evidence of acute cholecystitis. No acute abdominal pathology. 2. Moderate-to-severe atherosclerotic disease of the abdominal aorta and visceral arteries. Cardiovascular Report ECG Study Date of [**2161-3-17**] 1:25:12 PM Atrio-ventricular pacing. Compared to the previous tracing of [**2161-3-16**] the ventricular rate is slower. Radiology Report CHEST (PORTABLE AP) Study Date of [**2161-3-17**] 8:06 PM FINDINGS: As compared to the previous radiograph, there is an increased area of atelectasis at the left lung base, presence of a minimal left pleural effusion cannot be excluded. Borderline size of the cardiac silhouette. No pneumonia, no pulmonary edema. [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 109591**]Portable TTE (Complete) Done [**2161-3-18**] at 4:44:26 PM FINAL The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The transmitral gradient is normal for this prosthesis. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2160-1-11**], the degree of pulmonary hypertension has increased. The right ventricle appears mildly dilated/hypokinetic. The other findings are similar. Microbiology: [**2161-3-16**] 4:45 pm URINE **FINAL REPORT [**2161-3-18**]** URINE CULTURE (Final [**2161-3-18**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. [**Date range (1) 92289**] blood culture: no growth Lab Results on Discharge: [**2161-3-19**] 10:45AM BLOOD WBC-5.6 RBC-3.95* Hgb-9.1* Hct-30.1* MCV-76* MCH-23.0* MCHC-30.3* RDW-15.4 Plt Ct-175 [**2161-3-17**] 03:19AM BLOOD Neuts-94.7* Lymphs-2.4* Monos-2.6 Eos-0.2 Baso-0.1 [**2161-3-19**] 10:45AM BLOOD PT-17.3* PTT-33.7 [**Year/Month/Day 263**](PT)-1.6* [**2161-3-19**] 10:45AM BLOOD Glucose-126* UreaN-15 Creat-1.0 Na-138 K-3.5 Cl-101 HCO3-29 AnGap-12 [**2161-3-17**] 03:19AM BLOOD ALT-13 AST-27 AlkPhos-46 TotBili-1.1 [**2161-3-19**] 10:45AM BLOOD Calcium-8.1* Phos-1.7* Mg-2.3 Urinue: [**2161-3-16**] 04:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010 [**2161-3-16**] 04:45PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG [**2161-3-16**] 04:45PM URINE RBC-15* WBC-153* Bacteri-MOD Yeast-NONE Epi-0 Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is an 87 yo male with PMH of CAD, afib, MVR, prostate cancer with suprapubic catheter, and COPD who presents from home with rigors and weakness. He was being treated for UTI and possible pneumonia as well and discharged with a home course of antibiotics to follow-up with PCP. . ACUTE CARE: 1. Urinary tract infection: Patient developed altered mental status suddenly on the afternoon of admission after what is described to be rigors. He was symptomatic with suprapubic tenderness, weakness, and inability to communicate. His neurologic exam, as much as he was able to cooperate at the time is nonfocal. His catheter was changed, and with antibiotics ovenight his mental status improved and he was transferred from the ICU to medical floor. He again transiently spiked a fever on transfer to the floor but remained mentating well and then defervesced. He had a positive UA and a UC which grew mixed flora. He received antibiotic treatment with great improvement and was discharged home on a course of levofloxacin. . 2. Hypoxia: Patient developed new oxygen requirement on transition to floor from the ICU. CXR showed vascular congestion. His home lasix which was temporarily held was restarted, patient had excellent urine output and his hypoxia improved. He was discharged on home lasix and satting well on room air. . 3. Acute Diastolic Heart Failure: On transfer to the floor from MICU, patient's chest exam revealed rapid onset rales and his oxygen saturation dropped from 98%RA to 94%RA. CXR revealed increased left pleural effusion and increased pulmonary vascular congestion. With resuming lasix therapy, patient had a successful diuresis and his oxygenation improved to no oxygen requirement. Echo revealed normal EF, showing this was likely an episode of acute diastolic heart failure. . 4. Delirium: On presentation, patient was only responsive to questioning with grunts while his baseline mental status is A+Ox3 and capable of organizing club activities with groups at his living facility. This was likely secondary to infectious process on top of underlying mild chronic cerebral vascular disease. The altered mental status resolved with IV antibiotics and patient returned to his baseline mental status with treatment of UTI. . CHRONIC CARE: 1. CAD w/ history of stent: Patient presented off of ASA given anemia secondary to GIB. He was continued on his home antihypertensives. . 2. Mitral Valve Pathology: [**2159**] echo showed moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **]F is not in patient's PMH, he does report a history swollen ankles and does require home lasix suggesting predilection to CHF. Repeat echo showed normal EF and mild MR. [**Name13 (STitle) **] was discharged to PCP [**Last Name (NamePattern4) 702**]. . 3. H/o [**Female First Name (ambig) 27349**]: [**Last Name (ambig) **] coumadin was initially held for supratherapeutic [**Last Name (ambig) 263**] but was restarted at discharge to be followed-up by his coumadin clinic. . 4. Afib s/p MAZE: Patient was rate controlled with AV pacing at 60, and is on warfarin anticoagulation. . 5. Asthma: Continued home inhalers. . 6. Prostate ca: Continued Leupron. . 7. GERD: Continued PPI . 8. Constipation: Patient received bisacodyl suppository . TRANSITIONS IN CARE 1. Communication: Patient, daughter [**Name (NI) **] [**Name (NI) 109590**] 2. Code Status: confirmed FULL on this admission 3. Medication changes: START** Levofloxacin antibiotics 250 mg once a day for 7 more days (to end [**2161-3-26**]) START** Senna 1 tablet twice a day as needed for constipation START** Colace 1 tablet twice a day as needed for constipation 4. FOLLOW-UP: Name: [**Last Name (LF) **], [**First Name3 (LF) **] Location: [**Hospital1 **] SENIOR HEALTH Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 60246**] Appointment: FRIDAY [**3-20**] AT 9:30AM Department: SURGICAL SPECIALTIES When: THURSDAY [**2161-3-26**] at 10:00 AM With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2161-3-31**] at 9:00 AM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2161-3-31**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage 5. OUTSTANDING CLINICAL ISSUES: -titration of warfarin dosing -managemnt of suprapubic catheter. Medications on Admission: warfarin alendronate amlodipine furosemide leuprolide omeprazole miralax spiriva symbicort 89/4.5 strength [**2160-11-7**] albuterol sulfate prn Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for sob/wheeze. 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 4. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lupron Depot (3 Month) Intramuscular 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO as directed. 11. Vitamin C Oral 12. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO once a day. 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 15. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day: Last day [**2161-3-26**]. Disp:*7 Tablet(s)* Refills:*0* 16. Symbicort 80-4.5 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Urinary tract infecion Community acquired pneumonia Secondary diagnosis: Hypertension Atrial fibrilation s/p MAZE procedure Obstructive uropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 109590**], It was a pleasure taking part in your care. You were admitted to the hospital because you had sudden onset weakness and chills and we found that you had a urinary tract infection. You also had shortness of breath which may have been from a pneumonia. You were treated with antibiotics and have had much improvement. You were discharged home to complete a course of antibiotics and will follow up with your primary care physician (we have made appointments for you - please see below). You also were found to have a large amount of stool on your CT scan so we recommend that you take the stool softeners to ensure you have a bowel movement once a day. You also were found to have an elevated [**Known lastname 263**] from your coumadin so we held this while you were here. Today we restarted it because your [**Known lastname 263**] was too low. Please have your doctors [**Name5 (PTitle) 4169**] your [**Name5 (PTitle) 263**] at your follow up visit tomorrow. Please make the following changes to your medications: START** Levofloxacin antibiotics 250 mg once a day for 7 more days (to end [**2161-3-26**]) START** Senna 1 tablet twice a day as needed for constipation START** Colace 1 tablet twice a day as needed for constipation Please keep all follow-up appointments (see below) Followup Instructions: Name: [**Last Name (LF) **], [**First Name3 (LF) **] Location: [**Hospital1 **] SENIOR HEALTH Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 60246**] Appointment: FRIDAY [**3-20**] AT 9:30AM Department: SURGICAL SPECIALTIES When: THURSDAY [**2161-3-26**] at 10:00 AM With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2161-3-31**] at 9:00 AM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2161-3-31**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "414.01", "V45.82", "401.9", "599.0", "493.20", "V10.46", "428.0", "V58.61", "428.33", "427.31", "427.1", "574.20" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15470, 15528

8882, 12324

312, 318

15736, 15736

4321, 4333

17237, 18434

3334, 3371

14051, 15447

15549, 15549

13882, 14028

15886, 16915

3386, 3400

4194, 4302

8056, 8859

16944, 17214

2092, 2294

12344, 13856

264, 274

346, 2073

15642, 15715

15568, 15621

4348, 8041

15751, 15862

2316, 3073

3089, 3318

3,051

197,160

20687

Discharge summary

report

Admission Date: [**2110-3-9**] Discharge Date: [**2110-3-22**] Service: Trauma Surgery CHIEF COMPLAINT: Status post fall. HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old gentleman status post an unwitnessed fall down a flight of stairs. Positive amnesia to the event. The patient was transferred to an outside hospital with confusion. A computed tomography scan revealed a subarachnoid hematoma. The patient was transferred to the [**Hospital1 190**] for further management of his head injury. The patient denied chest pain and abdominal pain. PAST MEDICAL HISTORY: 1. Bioprosthetic valve replacement. 2. Insulin-dependent diabetes mellitus. MEDICATIONS ON ADMISSION: Lopressor, Imdur, aspirin, potassium, and Detrol. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Initial physical examination revealed his pulse was 80, his blood pressure was 138/palp, his respiratory rate was 16, and his oxygen saturation was 97% on room air. [**Location (un) 2611**] Coma Scale was 15. The pupils were equal and reactive bilaterally. The extraocular muscles were intact. The transcranial magnetic stimulation were clear bilaterally. Midface had no deformities. There was a 3-cm laceration above the left eye. The patient's trachea was midline. The patient was in a regular rate and rhythm. His breath sounds were clear bilaterally. There was no stepoff of deformities of the back. The pelvis was stable. Rectal examination was nasogastric with good rectal tone. Extremities revealed no deformities or tenderness. There were palpable pulses bilaterally. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Trauma Intensive Care Unit for every 1-hour neurologic checks. The patient was seen by Neurosurgery who concluded that the patient was stable and would need a head computed tomography in the morning on hospital day two. The patient was admitted to the Trauma Intensive Care Unit. An arterial line was placed without any complications. The patient's blood pressure was controlled without the need of pressors or nitroglycerin. The 3-cm head laceration was washed out and sutured with interrupted nylon sutures. Neurosurgery's recommendations were to continue the PCO2 between 35 and 40. They also wanted a magnetic resonance imaging of the cervical spine due to the patient's tenderness. Early on [**3-10**], the patient was noted to have stridor and decreasing oxygen saturations. The patient was intubated without difficulty. During the patient's hospitalization stay, he was extubated twice. Due to failure to clear secretions and failure of a gag reflex, he was reintubated. It was decided after the patient's third intubation that he would require a tracheostomy and an open gastrojejunostomy tube placement. A discussion took place between the Trauma team and the patient's family. The patient's son agreed that a tracheostomy and a percutaneous endoscopic gastrostomy tube would be in his father's best interest. During that time, Neurosurgery deemed the patient stable. They recommended follow up with Dr. [**First Name (STitle) **] in two weeks after discharge and to continue to the cervical collar until discharge. During that time, the patient had sputum cultures which grew methicillin-susceptible Staphylococcus aureus and had a urine culture which grew Escherichia coli which was sensitive to Levaquin. On [**3-14**], the patient had a left subclavian triple lumen placed for access and an arterial line placed. On [**3-17**], the patient was brought to the operating room with a preoperative diagnosis of respiratory failure due to the inability to clear secretions and loss of the gag reflex. The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] gastrostomy and open tracheostomy by Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], and Dr. [**Last Name (STitle) **]. The patient tolerated the procedure well with minimal blood loss. The patient was transferred to the Trauma Intensive Care Unit in stable condition. On postoperative day one, the patient's tube feeds were advanced to goal. On postoperative day two, the patient attempted a tracheostomy trial. During the night on postoperative day two, he was placed back on the ventilator for support due to tachypnea. On [**3-20**], it was decided that the patient was well enough to be discharged to a rehabilitation services with ventilator support. Discharge physical examination revealed his temperature maximum 100.8/99.8, his blood pressure was 152/47, his heart rate was 68, his respiratory rate was 27, and 100% on a tracheostomy 50% mask. The patient's total ins for the day included 2500 cc of fluid and total outs of 1900 cc of fluid. The patient's white blood cell count was 9.6 and his hematocrit was 28.9. He was alert and oriented. He followed commands and moved all extremities. His pupils were equal and reactive. His extraocular muscles were intact. Heart was regular in rate. His breath sounds were coarse bilaterally. His abdomen was soft, nontender, and nondistended. His incision was healing well. The patient had no peripheral edema. DISCHARGE DIAGNOSES: 1. Status post fall with subarachnoid hemorrhage. 2. Loss of pharyngeal muscle control and gag reflex. 3. Respiratory failure. 4. Pneumonia. 5. Urinary tract infection. DISCHARGE DISPOSITION: The patient was to be discharged to rehabilitation services. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient should continue on Levaquin for an additional seven days after discharge. 2. The patient should continue with aggressive chest physical therapy and suctioning. 3. The patient should continue with tracheostomy and gastrojejunostomy tube. 4. The patient may need ventilator assistance depending on his tachypnea. 5. The patient was instructed to follow up with Neurosurgery in two weeks with Dr. [**First Name (STitle) **] (telephone number [**Telephone/Fax (1) 2992**]). 6. The patient was also instructed to follow up with Trauma Surgery in one to two weeks (telephone number [**Telephone/Fax (1) 2756**]). MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: 1. Status post tracheostomy. 2. Status post open gastrojejunostomy tube placement. CONDITION AT DISCHARGE: The patient was discharged in stable condition. DISCHARGE STATUS: The patient was to be discharged to rehabilitation services. MEDICATIONS ON DISCHARGE: 1. Heparin 5000 units subcutaneously twice per day. 2. Lopressor 75 mg by mouth twice per day. 3. Tylenol one to two weeks by mouth q.4-6h. 4. Dulcolax suppositories once per day as needed. 5. Levaquin 250-mg tablets three tablets for a total of 750 mg by mouth once per day (times seven days). 6. Regular insulin sliding-scale (per the attached sheet). 7. Roxicet as needed. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 10637**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2110-3-21**] 22:25 T: [**2110-3-22**] 07:34 JOB#: [**Job Number 55245**]

[ "438.82", "E880.9", "482.41", "V42.2", "790.7", "599.0", "518.5", "852.02", "250.00" ]

icd9cm

[ [ [] ] ]

[ "43.11", "38.93", "99.04", "96.6", "38.91", "86.59", "31.1", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

5406, 5468

5207, 5382

6443, 7105

702, 1625

5501, 6272

1655, 5186

6287, 6417

117, 136

165, 574

596, 675

30,601

194,233

8309

Discharge summary

report

Admission Date: [**2143-7-27**] Discharge Date: [**2143-8-2**] Date of Birth: [**2088-2-4**] Sex: M Service: MEDICINE Allergies: Allopurinol Attending:[**Male First Name (un) 5282**] Chief Complaint: Low Hematocrit Mechanical Fall Major Surgical or Invasive Procedure: Transfusion with PRBCs History of Present Illness: Mr. [**Known lastname 29436**] is a 55 yo M w/ h/o ETOH cirrhosis c/b portal HTN, grade 1 esophageal varices, recent SBP, h/o angioectasias in terminal ileum, HTN, gout who was referred to the ED after routine labs in liver clinic showed a HCT 14. Of note, on returning home from having these labs drawn, he had a mechanical fall and fractured his left wrist and hip. . Of note pt with 3 admissions in last 2 mo with asymptomatic HCT drops most recently from [**Date range (1) 29438**]/10 for LGIB with HCT 20 corrected with 4u PRBCs thought [**2-12**] angioectasias in the terminal ileum. On that d/c, he was sent home on estrogen to help with the bleeding from this. That hospital course was also c/b SBP. . On arrival to the [**Name (NI) **], pt had neg NGL but melenous guaiac + stool. He had Xrays of L wrist and L hip showing non-displaced fractures for which ortho was consulted. They casted the L wrist and made the L leg non-weight bearing but said no surgical interventions were warranted. He got pantoprazole 40mg IV, octreotide gtt. He also recieved 2mg morphine IV for hip pain. He got 1u PRBCs and 2L IVF. On transfer from the ED, vitals were BP 80/42, HR 66, R 21, O2 sat 100 ra . On arrival to the ICU, pt c/o come L hip pain esp w/ mvmt. Otherwise, he states he is feeling well. Of note, pt states he takes iron so his stools are always dark and he had not recently seen a change in his stools. . Review of systems: (+) Per HPI (-) Denies fever, chills, CP, SOB, Abd pain, N/V, diarrhea, constipation. Past Medical History: # HTN # DJD of R hip # Gout # ETOH Cirrhosis, c/b portal hypertension, jaundice, with hypertensive gastropathy, grade 1 esophageal varices # Bowel perforation: lap-assisted R colectomy [**5-18**] by Dr. [**Last Name (STitle) 1120**] for cecal perforation while on steroids for gout flare # LGIB- [**Last Name (un) **] [**4-9**] showed angioectasias in term ileum/rectum, bx neg. #legally blind Social History: He is divorced in [**2122**] and has lived alone since. He notes that he was drinking [**6-17**] rum and cokes daily until [**10-19**]. He says that he has remained sober since [**2142-11-11**]. He has remote tobacco use (8 pack years, quit 25 years ago), remote cocaine, marijuana, and methamphetamines. He used to work as a taxi driver until he was forced to retire [**2-20**] because he was declared legally blind. Family History: Grandmother with DM. Physical Exam: General Appearance: No acute distress, Thin Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic) Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , No(t) Crackles : , No(t) Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, Distended Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace, No(t) Cyanosis, No(t) Clubbing Skin: Warm, No(t) Rash: , Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented (to): x2, not to date but to month and yr, Movement: Purposeful, No(t) Sedated, No(t) Paralyzed, Tone: Normal On dischrage: Stable vitals, A&Ox3. Pertinent Results: [**2143-7-26**] 08:45PM BLOOD WBC-7.1 RBC-1.50* Hgb-4.8* Hct-14.6* MCV-97 MCH-32.2* MCHC-33.1 RDW-20.9* Plt Ct-125* [**2143-7-27**] 08:46AM BLOOD Hct-23.4* [**2143-7-27**] 09:43PM BLOOD Hct-28.0*# [**2143-7-28**] 08:39AM BLOOD Hct-29.0* [**2143-7-29**] 01:56PM BLOOD Hct-29.7* . . [**2143-7-27**] 03:44PM BLOOD Glucose-88 UreaN-54* Creat-1.7* Na-141 K-3.4 Cl-116* HCO3-14* AnGap-14 [**2143-7-28**] 03:33AM BLOOD Glucose-104* UreaN-68* Creat-2.3* Na-138 K-3.9 Cl-110* HCO3-19* AnGap-13 [**2143-7-28**] 08:58PM BLOOD Glucose-114* UreaN-61* Creat-2.2* Na-141 K-3.7 Cl-112* HCO3-18* AnGap-15 [**2143-7-29**] 03:08AM BLOOD Glucose-110* UreaN-58* Creat-2.1* Na-139 K-3.8 Cl-112* HCO3-18* AnGap-13 . . Imaging: [**2143-7-26**] . Wrist X-Ray FOUR VIEWS OF THE LEFT WRIST: An impacted minimally displaced fracture of the distal radius is demonstrated with probable intra-articular extension. No significant angulation is seen. Extensive vascular calcifications are noted. There are mild degenerative changes within the carpal bones. IMPRESSION: Minimally displaced and impacted distal radial fracture with likely intra-articular extension. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: FRI [**2143-7-26**] 9:16 PM Hip X-Ray AP VIEW OF THE PELVIS, TWO VIEWS OF THE LEFT HIP: There is a non-displaced transverse lucency through the medial left mid cervical femoral neck compatible with a nondisplaced fracture. No other fracture or dislocation is visualized. Degenerative changes in both hips are similar to prior. The sacroiliac joints are preserved. Sacrum is intact. Vascular calcifications are noted along with calcifications of the vas deferens, which is often seen in diabetics. Sclerotic focus within the left proximal femoral metaphysis is unchanged, and likely is a bone island or enchondroma. IMPRESSION: Non-displaced fracture involving the left femoral neck. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: FRI [**2143-7-26**] 9:16 PM DISCHARGE LABS: [**2143-8-2**] 07:10AM BLOOD WBC-4.1 RBC-2.81* Hgb-8.8* Hct-26.4* MCV-94 MCH-31.4 MCHC-33.4 RDW-18.8* Plt Ct-83* [**2143-8-2**] 07:10AM BLOOD Plt Ct-83* [**2143-8-2**] 07:10AM BLOOD Glucose-86 UreaN-30* Creat-1.1 Na-137 K-4.0 Cl-110* HCO3-21* AnGap-10 [**2143-8-1**] 06:40AM BLOOD ALT-6 AST-31 LD(LDH)-152 AlkPhos-67 TotBili-5.1* DirBili-2.7* IndBili-2.4 [**2143-8-2**] 07:10AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.6 Brief Hospital Course: Mr. [**Known lastname 29436**] is a 55 yo M w/ h/o ETOH cirrhosis c/b portal HTN, grade 1 esophageal varices, recent SBP, h/o angioectasias in terminal ileum, HTN, gout who was referred to the ED after routine labs in liver clinic showed a HCT 14. Of note, on returning home from having these labs drawn, he had a mechanical fall and fractured his left wrist and hip. . # GIB- most likely from angioectasias. Neg NGL ruled out varices or postal gastropathy as source of bleeding. No diverticulae were seen on [**Last Name (un) **] [**3-20**]. -pantoprazole, octreotide gtts. norethindrone-ethin estradiol,cont ferrous sulfate - hematocrit stablized, patient will follow up with hepatology for EGD. . # hypotension- think likely 2/2 blood loss. Less likely sepsis. Pt's baseline seems to be in 110s. BP stablized. # L hip and wrist fractures- non-displaced so non-operative per ortho in ED. -appreciate ortho recs- will need to d/w them implications of non-weight bearing on L leg for prolonged period of time in this pt. - Patient to go to Rehab. - . # Cirrhosis- T bili slightly up from baseline at 4.2, then trending down most likely due to [**2-12**] acute GIB. cont home nadolol,lactulose,lasix. . # ARF- Baseline Cr 1.2 was up to 3.1 on admission, and came back down during hospital stay. Suspect prerenal 2/2 blood loss. . # h/o ETOH abuse- per pt sober since last fall -thiamine, folate, cyanocobalamine supplementation Events [**7-27**] - D/Ced colchicine, bactrim, and nobumatone - random cortisol ordered -> if abnormal, will obtain [**Last Name (un) 104**] stim test (to assess hepato-adreno syndrome) - 2 units FFP ordered - 2 units of pRBC running - right IJ placed for access [**7-28**] -250 cc of 5% albumin now and in the evening per liver. -paratracheal thickening on CXR, noncon CT chest to eval further: no evidence of mediastinal hematoma, findings c/w volume overload, incl small bil pleural effusions and distended azygous vein, borderline lymphadenopathy -ortho: OR for fem neck when cleared, likely tues/wed -red, clear urine, bladder irrigated, no clot. recheck Hct at 20:00 (=28.6, improved) -urine Na 64 after PM albumin, probably not hepatorenal [**7-29**] -per ortho, to head to OR today but patient refused. Fracture non-displaced. [**7-30**] -Pt elected to not have surgery will go to rehab instead. [**7-31**] -Pulled Right IJ line -started home lasix dose -called out -OK to d/c ceftriaxone for SBP ppx per liver pager [**Numeric Identifier 29439**] -OK to transition PPI to PO daily -He will follow with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 week for repeat x-rays of his left hip and wrist per ortho - [**Date range (1) 29440**] - hematocrit remained stable on the floor. Patient was restarted on Nadolol, continued on home lasix. Patient is to be scoped as an outpatient. Patient scheduled to leave for rehab. Patient's blood pressure was in SBP in 90's but stable and asymptomatic on the floor. It is important to monitor Hematocrit with history of acute drop. Patient will follow up with ortho and hepatology. Medications on Admission: 1. Pantoprazole 40 mg daily 2. Febuxostat 60 mg daily 3. Thiamine HCl 100 mg daily 4. Cyanocobalamin 1000 mcg daily 5. Lactulose 10 gram/15 mL (30) ML PO BID 6. Ferrous Sulfate 300 mg [**Hospital1 **] 7. Colchicine 0.6 mg QOD 8. Folic Acid 1 mg daily 9. Nadolol 20 mg daily 10. Norethindrone-Ethin Estradiol 1-35 mg-mcg daily 11. Bactrim DS 800-160 mg daily Mon- FRI 12. Furosemide 40 mg daily Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Norethindrone-Ethin Estradiol 1-35 mg-mcg 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. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*12 Tablet(s)* Refills:*0* 8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO QOD. 11. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 12. Febuxostat 40 mg Tablet Sig: 1.5 Tablets PO once a day. 13. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO M-F. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) **] Discharge Diagnosis: Hip/Wrist Fracture and Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 29436**], You have been admitted to this hospital for the treatment of your anemia/blood loss as well as for evaluation of your hip and wrist fracture. Your fracture is non-displaced and does not require surgery, but you do require rehabilitation. Your blood levels have been stable after you were transfused with several units of blood. Your blood pressure was low for several days but has stabilized. You will need to follow-up with the orthopedic doctor as well as your liver doctor. The following medication changes have been made: Please START taking OXYCODONE 1 pill every 8 hours as needed for pain. Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2143-8-8**] 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: THURSDAY [**2143-8-8**] 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 Department: RHEUMATOLOGY When: MONDAY [**2143-8-26**] at 10:00 AM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2143-8-2**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

10766, 10849

6198, 9285

305, 330

10923, 10923

3673, 5745

11759, 12702

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52,503

103,164

53840

Discharge summary

report

Admission Date: [**2195-5-13**] Discharge Date: [**2195-5-22**] Date of Birth: [**2173-5-29**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5831**] Chief Complaint: ? GBS/[**Doctor First Name 1557**] [**Doctor Last Name 957**] syndrome Major Surgical or Invasive Procedure: intubation and extubation History of Present Illness: 21 year-old right-handed M who presents with numbness of hands and feet, progressive weakness, and diplopia. The patient has had URI symptoms for 2 weeks, including sore throat, cough and congestion. He received Z-pack on [**5-8**] for possible sinus infection. On [**5-10**], his R hand felt numb and tingling (whole hand, all digits, to wrist), which he thought might be a side effect of antibiotic. That day, he also felt subjective R thigh/quad weakness, though he could still walk normally and do stairs. On [**5-11**], his L hand also became numb and tingly. He developed a strange numb feeling on his anterior abdomen, it was not around his entire torso, not like a band or constriction, and it did not affect his respirations. Both legs felt weaker as well, and he went to [**Hospital1 2436**] ED, sent home. On [**5-12**] (yesterday), patient was weaker in his legs, and his walking was "wobbly." He was not dragging one leg or catching his toes. His feet were now tingling, up to the ankles bilaterally. He also noticed that speaking and swallowing was difficult and tiring. Per his parents, his voice is more nasal, as well as slurred and much softer. He has not been eating or drinking much since swallowing is tiring, he had some nasal regurgitation once, but no choking or frank aspiration. Today, the patient was worse in terms of weakness and ability to ambulate. He nearly fell walking down stairs, but parent was there to support him and avoided fall. He has trouble sitting up from lying position and getting out of bed. The patient also noticed diplopia today. He noticed something strange with his vision x 2 days, but could not define it before. Today, he has noticed horizontal diplopia that is constant. He has been able to urinate and move bowels normally, but has loss of sensation in the groin and rectal areas. The patient had a similar presentation 6 years ago at age 15. He was treated at CHB, and father thinks the diagnosis was [**Name (NI) 1557**] [**Doctor Last Name 957**] syndrome. At that time, he developed weakness and loss of balance. His mother notes that his gait looked strange in a similar way as it does now, and his voice sounded similar. His mother thinks he was actually weaker then vs. now. His respiratory status remained stable. He did not have sensory symptoms at that time, nor diplopia. He received IVIG and improved quickly within a few days. He was out of school for 2 weeks. After some PT to build up strength in the legs after disuse, he was back to baseline without residual symptoms or deficits. Past Medical History: none other than episode [**Doctor First Name 1557**] [**Doctor Last Name 957**] syndrome 6 yrs ago Social History: works in construction. No tobacco. EtOH- 4-5 drinks most weekends. No illicits. No recent travel, sick contacts, toxic or environmental exposures. Family History: negative for neurologic disease, no seizures, no MS. Physical Exam: At admission: Vitals: T: 98.5 P:86 R: 16 BP:114/76 SaO2:98/RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Speech is possibly mildly dysarthric (based on parents' assesment), becomes increasingly quiet and effortful after a long conversation. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**3-28**] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation with red pin. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: Impaired abduction of L eye, otherwise EOMI, no nystagmus. Smooth saccades. There is diplopia in all extremes of gaze, worst on far right gaze, worse far than near. Images are horizontal side by side, farthest apart on R gaze. Resolves with covering either eye. V: Facial sensation intact to light touch, cold and pinprick. VII: No facial droop, upper and lower facial musculature full strength and symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate does not elevate well on either side, weak gag reflex. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with normal strenght on lateral movements. -Motor: Normal bulk, tone throughout. No pronator drift but bilateral arms titubate up and down, cannot hold them out steadily. No pseudoathetosis. 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 3 5 4 5 5 5 5 R 5 5 5 5 5 5 5 3 5 4+ 5 5 5 5 * limited by L shoulder pain, giveway L ADM 4+, finger flexors 5 hip abduction [**4-30**] bilaterally, adduction [**5-30**] neck flexion [**4-30**], extension [**5-30**] -Sensory: No deficits to light touch. Decreased pinprick at L medial forearm only (80%). Decreased cold sensation L toes, intact on foot. Decreased vibratory sense (nearly absent L great toe and present L medial malleolus, 2-3 seconds at R great toe). Intact proprioception at bilateral great toes. No extinction to DSS. -DTRs: absent throughout Plantar response was flexor bilaterally. -Coordination: slow and clumsy on finger to crease tapping bilaterally. On FNF there is severe ataxia bilaterally, with no intention tremor. All limbs movements are wobbly and unsteady. On mirroring task there is overshoot and rebound with bilateral upper extremities. Unable to perform HKS due to weakness. -Gait: unable to ambulate At transfer out of NeuroICU: horizontal diplopia in upward extremes of gaze only, conjugate EOMI, palate rises in midline, [**5-30**] full strength throughout, including neck flex/ext. Dysmetric in all 4 ext (greatest in LUE. Areflexic, toes down. Gait (with supervision) is slightly unsteady but independent. NIF [**5-13**]: -65 --> -50 ------> [**5-20**] -70 V cap [**5-13**]: 2.7 --> 1.9 -----> [**5-20**] 3.5-4L PHYSICAL EXAM AT DISCHARGE: VS - 97.8, 120/80's, 70's, 18, 99 on RA GEN: young man lying in bed in NAD HEENT: OP clear CV: RRR PULM: CTAB ABD: soft, NT, ND EXT: no edema . NEURO EXAM: MS - AAOx3 CN - EOMI, PERRL 4-->2mm, face symmetrical, facial sensation intact, tongue midline MOTOR - [**5-30**] throughout REFLEXES - absent throughout (per pt this is chronic since his first GBS episode) SENSORY - intact to light touch throughout GAIT - narrow based, good arm swing, good initiation Pertinent Results: ADMISSION LABS: [**2195-5-13**] 08:05PM BLOOD WBC-11.5* RBC-5.43 Hgb-16.3 Hct-47.2 MCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 Plt Ct-252 [**2195-5-16**] 02:09AM BLOOD WBC-19.1* RBC-4.61 Hgb-13.7* Hct-40.4 MCV-88 MCH-29.8 MCHC-34.0 RDW-12.4 Plt Ct-214 [**2195-5-21**] 03:15AM BLOOD WBC-8.2 RBC-4.78 Hgb-14.0 Hct-42.5 MCV-89 MCH-29.2 MCHC-32.8 RDW-12.3 Plt Ct-297 [**2195-5-13**] 08:05PM BLOOD Neuts-77.9* Lymphs-17.2* Monos-4.1 Eos-0.4 Baso-0.5 [**2195-5-13**] 08:05PM BLOOD Plt Ct-252 [**2195-5-16**] 02:09AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.3* [**2195-5-13**] 08:05PM BLOOD Glucose-87 UreaN-16 Creat-1.0 Na-139 K-3.9 Cl-103 HCO3-24 AnGap-16 [**2195-5-21**] 03:15AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-138 K-3.9 Cl-101 HCO3-26 AnGap-15 [**2195-5-15**] 02:29AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0 [**2195-5-18**] 01:42AM BLOOD Triglyc-211* [**2195-5-15**] 04:03PM BLOOD TSH-0.72 [**2195-5-13**] 08:05PM BLOOD IgA-241 [**2195-5-18**] 05:33AM BLOOD Vanco-1.9* [**2195-5-14**] 09:43AM BLOOD Type-ART pO2-104 pCO2-43 pH-7.38 calTCO2-26 Base XS-0 [**2195-5-14**] 09:43AM BLOOD Glucose-88 Lactate-1.4 [**2195-5-15**] 04:03PM BLOOD GQ1B IGG ANTIBODIES-PND [**2195-5-14**] 11:51PM URINE Color-YELLOW Appear-Cloudy Sp [**Last Name (un) **]-1.027 [**2195-5-14**] 11:51PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2195-5-14**] 11:51PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 DISCHARGE LABS: [**2195-5-22**] 05:17AM BLOOD WBC-7.2 RBC-4.85 Hgb-14.6 Hct-42.4 MCV-88 MCH-30.1 MCHC-34.3 RDW-12.4 Plt Ct-303 [**2195-5-22**] 05:17AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-135 K-4.3 Cl-101 HCO3-25 AnGap-13 [**2195-5-22**] 05:17AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 MICROBIOLOGY: [**2195-5-13**] 09:55PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0 Lymphs-82 Monos-18 [**2195-5-13**] 09:55PM CEREBROSPINAL FLUID (CSF) TotProt-64* Glucose-54 [**2195-5-13**] 9:55 pm CSF;SPINAL FLUID #3. **FINAL REPORT [**2195-5-17**]** GRAM STAIN (Final [**2195-5-14**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2195-5-17**]): NO GROWTH. [**2195-5-16**] 1:03 am SPUTUM **FINAL REPORT [**2195-5-18**]** GRAM STAIN (Final [**2195-5-16**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2195-5-18**]): SPARSE GROWTH Commensal Respiratory Flora. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. [**2195-5-16**] 6:19 am URINE Source: Catheter. **FINAL REPORT [**2195-5-17**]** Legionella Urinary Antigen (Final [**2195-5-17**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [**2195-5-16**] 10:00 pm BRONCHOALVEOLAR LAVAGE Site: LUNG LEFT LUNG. **FINAL REPORT [**2195-5-18**]** GRAM STAIN (Final [**2195-5-17**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2195-5-18**]): NO GROWTH, <1000 CFU/ml. [**2195-5-14**] CXR: FINDINGS: A single portable view of the chest is provided. The lungs are essentially clear. The cardiomediastinal silhouette and hilar contours are unremarkable. There are no pneumothoraces or pleural effusions. The bones are intact. IMPRESSION: No evidence of acute intrathoracic process. [**2195-5-16**] CXR: CHEST, SINGLE AP PORTABLE VIEW. An ET tube is present, tip approximately 7.3 cm above the carina. The tip lies relatively high, approximately 14 mm above the upper edge of the medial clavicle. Slight asymmetry of the clavicles is present, unchanged, with the right medial clavicular head more angulated and inferior compared to the left. An NG-type tube is present -- the tip is not well delineated and cannot be traced beyond the lower mediastinum. There is increased retrocardiac density, worse compared with [**2195-5-14**], and bibasilar atelectasis. Possible slight clearing at the right base. Doubt gross effusion. No CHF. IMPRESSION: 1. ET tube as described, relatively high. Clinical correlation requested. 2. Left lower lobe collapse and/or consolidation, slightly worse. Atelectasis at right base, slightly better. 3. Asymmetric positioning of the right and left clavicular heads. Is there a history of trauma to account for this? [**2195-5-17**] Abd XR: ABDOMEN, TWO VIEWS. Gas and stool are seen throughout the colon down to level of the rectum. No air-filled dilated loops of large or small bowel to suggest ileus are identified. No free air is seen beneath the diaphragm. An NG tube is present, tip overlying stomach. [**5-18**] ECG: Baseline artifact. Probable sinus rhythm with right axis deviation and early precordial R wave progression. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 100 146 94 [**Telephone/Fax (3) 110477**] 106 179 [**5-20**] CXR: FINDINGS: In comparison with the study of [**5-19**], the endotracheal tube and nasogastric tubes have been removed. Right subclavian catheter remains in satisfactory position. There is persistent opacification in the region of the costophrenic angle on the left. However, the more medial portion of the right hemidiaphragm is quite well seen, suggesting some decrease in the left lower lobe volume loss, possibly related to clearing of a mucus plug. Asymmetry is again seen in the left infrahilar region, consistent with the previous suggestion of consolidation. The right lung is clear with the heart border and hemidiaphragm sharply seen. [**5-21**] CXR: IMPRESSION: AP chest compared to [**5-17**] through 23: Left lower lobe collapse developed over preceding 24 hours. Aeration in the left lower lobe has improved but there is still a large infrahilar region of what could be pneumonia, and now there is new consolidation at the right lung base, also suspicious for infection due to aspiration. Endotracheal tube ends above the thoracic inlet, no less than 6.5 cm from the carina and should be advanced 3 cm for more secured seating. Enteric tube passes as far as the upper stomach and out of view. Heart size is normal. There is no appreciable pleural effusion. Right PIC line ends in the low SVC. No pneumothorax. Brief Hospital Course: 21 year-old right-handed M with history of [**Doctor First Name 1557**] [**Doctor Last Name 957**] syndrome s/p IVIG 6 years ago who presented with numbness of hands and feet, progressive weakness, dysphagia, saddle anesthesia with bowel/bladder changes, and diplopia. Neuro exam at admission was remarkable for binocular horizontal diplopia on extremes of gaze, with impaired L eye abduction c/w CNVI palsy, weak gag/palate elevation. Motor exam revealed weak neck flexion and proximal LE weakness (IP, hip abductors, hamstring). Sensory deficits were minimal except for decreased vibratory sensation at great toes. There was limb ataxia, rebound and overshoot with bilateral UEs. He is areflexic, although this is his baseline since his prior episode of GBS. His presentation on this admission was consistent with [**Doctor First Name 1557**] [**Doctor Last Name 957**] variant of GBS. CSF protein was mildly elevated, with normal cell count and diff, which was consistent as well. Similarly to his past presentation, there was a preceeding viral URI. He was initially admitted the the general neurology step down unit on [**2195-5-13**], however, due to increased difficulties with swallowing oral secertions and worsening respiratory status, he was transferred the to NeuroICU early [**5-14**]. He was electively intubated a few hours later for airway protection and started on IVIG. Of note, his hospital course was complicated by pneumonia, for which he was started on empiric abx on [**2195-5-16**] to cover VAP, which were later narrowed when Haemo influenza was identified. He was extubated [**5-19**] without complication. NEURO: s/p intubation [**5-14**] for inability to swallow secretions and increasing resp distress. Completed 5 days IVIG [**2106-5-13**]. Neurological exam was then significant for dysmetria in all extremities, LUE greatest, as well as mild diplopia on upward gaze. Prior to intubation he had NIFs that were -65 --> -50 --> -48; VC 2.7--> 1.9 --> 1.58; [**5-18**] NIF -35. [**5-20**] NIF -70 and VC 4L. While at admission the patient was having bladder/bowel retention and saddle anesthesia these symptoms subsequently improved and he was no longer having bowel/bladder retention. At discharge he had an essentially normal neurological exam. CARDS: patient was temporarily on metoprolol for tachycardia, which was weaned prior to discharge. GI: patient was NPO with TF's while intubated in the ICU. Afterwards, his diet was advanced until he was tolerated regular foods. When he initially began taking solid foods he had lots of nausea and vomiting, which require reglan for improvement. He was subsequently able to be weaned off of reglan and eat solid foods with no nause or other ill effects. ID: Pt diagnosied here with Haemo influenza pneumonia, likely acquired in the ICU during intubation. Patient had copious secretions, with CXR [**5-16**] showing RLL infiltrate. He was tarted on vanc/cefepime d1= [**5-16**] for VAP. Narrowed to CTX [**5-20**]. He completed 7 days total treatment (end date [**5-22**]) PENDING RESULTS: G1QB Antibody TRANSITIONAL CARE RESULTS: Patient told to return to the hospital if he develops any further similar sx. He understands that if his sx recur again he may need to be on prophylactic immunosuppressant medication as he more likely would have CIDP. He agreed to be vigilant if he had any further sx and always seek out medical care. Medications on Admission: Recently finished azithromycin course for URI. Otherwise no daily meds Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: [**Last Name (un) 4584**] [**Location (un) **] Syndrome Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname **], You were seen in the hospital for weakness and were diagnosed with [**Last Name (un) **] [**Location (un) **] syndrome. We made no changes to your medications. If you experience the below listed Danger Signs, please contact your doctor or go to the nearest emergency room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Department: NEUROLOGY When: MONDAY [**2195-9-7**] at 4:00 PM With: DRS. [**Name5 (PTitle) 43**] & [**Doctor Last Name 2336**] [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.91", "33.24", "96.6", "38.97", "96.72", "96.04", "03.31", "99.14" ]

icd9pcs

[ [ [] ] ]

18317, 18323

14747, 18167

377, 404

18423, 18423

7666, 7666

19004, 19304

3296, 3351

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266, 339

432, 2992

7683, 9098

18438, 18586

3014, 3115

3131, 3280

77,911

116,520

45061

Discharge summary

report

Admission Date: [**2111-12-29**] Discharge Date: [**2112-1-3**] Date of Birth: [**2039-10-23**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: Mitral Valve Repair [**2111-12-29**] History of Present Illness: 72 y.o. old primary care physician with [**Name Initial (PRE) **] history of severe mitral regurgitation, new onset acute diastolic congestive heart failure. He reports occasional palpitations. He denies shortness of breath, PND, orthopnea, presyncope, or syncope. He reports mild dependent chronic 1+ bilateral LE edema. TEE revealed mildly thickened and myxomatous mitral valve leaflets, moderate to severe MVP with severe 4+MR. [**Name13 (STitle) **] was evaluated by Dr. [**Last Name (STitle) **] and agreed to proceed with elective mitral valve repair. Past Medical History: Mitral Regurgitation/Mitral valve prolapse Hypertension SVT/Atrial Tachycardia Diverticulosis Nephrolithiasis Polymyalgia Rheumatica Osteopenia Low Back Pain/Sciatica OSA-compliant with cpap Left knee arthroscopic knee surgery; case was done under general anesthesia and patient reports post anesthesia course complicated by a bronchospastic reaction along with oxygen desataturation, which required overnight observation prior to discharge. No issues with conscious sedation during prior colonoscopy. Social History: Lives with wife [**Name (NI) **] Occupation: PCP [**Name Initial (PRE) 1139**]: remote- quit 25 yo ETOH: [**1-22**] drinks a week Family History: Non-contributory Physical Exam: Pulse: 60SR Resp: 20 O2 sat: B/P Right: 112/64 Left: Height: 5'9" Weight: 150lb General: NAD, WGWN, appears stated age 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 3/6 systolic Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema- trace Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right: Left: no bruits Pertinent Results: [**2111-12-29**]:Conclusions PRE-CPB: The left atrium is moderately dilated. 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. Overall left ventricular systolic function is normal (LVEF>55%). The RV systolic function is borderline low normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trivial aortic regurgitation is seen. The mitral valve leaflets are myxomatous. The portion of the mitral leaflet between P2 and P3 is flail with ruptured chord. There is a anteriorly directed jet of severe MR [**First Name (Titles) 151**] [**Last Name (Titles) 96316**] effect. There is a smaller central MR jet. POST-CPB: A mitral valve annuloplasty ring is present. The anterior leaflet spans the entire length of the mitral annulus, and the posterior leaflet is minimally visible, consistent with a mitral valve repair. There is no residual MR. The peak gradient across the mitral valve is 6mmHg, the mean gradient is 3mmHg.The TR is now mild. The LV systolic function is borderline normal with no new wall motion abnormalities. The RV systolic function appears improved to normal. There is no evidence of dissection. [**2112-1-1**] CXR: FINDINGS: In comparison with the study of [**12-30**], there is partial clearing of the bilateral atelectatic change, though opacification persists in the retrocardiac region at the left base. Blunting of the costophrenic angles is again seen. No evidence of pneumothorax. [**2111-12-29**] 11:32AM BLOOD WBC-1.6*# RBC-2.80*# Hgb-8.8*# Hct-25.0*# MCV-90 MCH-31.4 MCHC-35.1* RDW-13.5 Plt Ct-95* [**2111-12-29**] 12:10PM BLOOD WBC-4.7# RBC-3.44* Hgb-10.6* Hct-30.6* MCV-89 MCH-30.8 MCHC-34.7 RDW-13.5 Plt Ct-103* [**2111-12-29**] 07:15PM BLOOD Hct-32.3* [**2111-12-30**] 04:16AM BLOOD WBC-6.1 RBC-3.54* Hgb-11.2* Hct-31.6* MCV-89 MCH-31.6 MCHC-35.4* RDW-13.5 Plt Ct-100* [**2111-12-31**] 04:16AM BLOOD WBC-7.6 RBC-3.70* Hgb-11.5* Hct-32.5* MCV-88 MCH-31.0 MCHC-35.3* RDW-13.4 Plt Ct-99* [**2112-1-1**] 05:05AM BLOOD WBC-5.7 RBC-3.46* Hgb-10.7* Hct-31.1* MCV-90 MCH-31.0 MCHC-34.4 RDW-13.4 Plt Ct-102* [**2111-12-29**] 11:32AM BLOOD PT-15.4* PTT-36.1* INR(PT)-1.3* [**2111-12-29**] 11:32AM BLOOD Plt Smr-LOW Plt Ct-95* [**2111-12-29**] 12:10PM BLOOD PT-14.4* PTT-38.4* INR(PT)-1.2* [**2111-12-29**] 12:10PM BLOOD Plt Ct-103* [**2111-12-30**] 04:16AM BLOOD Plt Ct-100* [**2111-12-31**] 04:16AM BLOOD Plt Smr-LOW Plt Ct-99* [**2112-1-1**] 05:05AM BLOOD Plt Ct-102* [**2111-12-29**] 12:10PM BLOOD UreaN-16 Creat-0.9 Na-142 K-4.3 Cl-112* HCO3-25 AnGap-9 [**2111-12-29**] 07:15PM BLOOD Na-142 K-4.2 Cl-112* [**2111-12-30**] 04:16AM BLOOD Glucose-122* UreaN-17 Creat-0.9 Na-140 K-4.5 Cl-109* HCO3-26 AnGap-10 [**2111-12-31**] 04:16AM BLOOD Glucose-128* UreaN-20 Creat-1.0 Na-136 K-3.8 Cl-100 HCO3-31 AnGap-9 [**2112-1-1**] 05:05AM BLOOD UreaN-21* Creat-1.0 Na-138 K-3.9 Cl-100 [**2112-1-1**] 11:12PM BLOOD Glucose-112* UreaN-18 Creat-1.0 Na-137 K-4.2 Cl-99 HCO3-31 AnGap-11 Brief Hospital Course: The patient was brought to the operating room on [**2111-12-29**] where the patient underwent mitral valve repair with 28mm ring. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility and cleared for discharge to home. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. His home ACE inhibitor was not added back secondary to hypotension. The patient was discharged [**2112-1-3**] in good condition with appropriate follow up instructions. Medications on Admission: CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule - one Capsule(s) by mouth qweek FUROSEMIDE - 20 mg Tablet - [**11-22**] tab Tablet(s) by mouth once a day - No Substitution LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day - No Substitution SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth as directed ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth daily CALCIUM CITRATE [CALCITRATE] - (Prescribed by Other Provider) - 200 mg (950 mg) Tablet - 1 (One) Tablet(s) by mouth twice a week CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider) - 1,000 mcg Tablet Sustained Release - 1 Tablet(s) by mouth twice a week ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily RANITIDINE HCL - (OTC) - 150 mg Tablet - 1 Tablet(s) by mouth prn as needed for GERD Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*75 Tablet(s)* Refills:*0* 4. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO Q12H (every 12 hours). Disp:*20 Tablet, ER Particles/Crystals(s)* Refills:*0* 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week: Per home routine. 11. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day: Per home routine. 12. Vitamin B-12 1,000 mcg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a week: Per home routine. 13. calcium citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet PO twice a week: Per home routine. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Mitral Regurgitation/Mitral Valve Prolapse Hypertension SVT/Atrial Tachycardia Diverticulosis Nephrolithiasis Polymyalgia Rheumatica Osteopenia Low Back Pain/Sciatica Obstructive Sleep Apnea Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema:2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Do not resume your lisinopril Do not resume Viagra 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) **] [**2112-1-21**] @ 1:30pm Phone: [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**Last Name (STitle) **] [**1-19**] @ 1:30pm Please call to schedule the following: Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-23**] 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:[**2112-1-3**]

[ "562.10", "401.9", "424.0", "724.3", "733.90", "725", "428.22", "V15.82", "327.23", "428.0", "592.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

9138, 9196

5487, 6652

324, 363

9431, 9596

2362, 5464

10435, 10986

1640, 1658

7716, 9115

9217, 9410

6678, 7693

9620, 10412

1673, 2343

272, 286

391, 951

973, 1477

1493, 1624

11,370

138,522

14086+14087

Discharge summary

report+report

Admission Date: [**2125-7-5**] Discharge Date: Service: [**Hospital Unit Name 196**] HISTORY OF PRESENT ILLNESS: This is an 82 -year-old female with a history of coronary artery disease, mitral valve repair, status post coronary artery bypass graft in [**2117**], hypercholesterolemia, diabetes mellitus, and hypertension who presents upon transfer from [**Hospital3 26615**] Hospital for evaluation of atrial flutter. The patient was in her usual state of health until one month ago when she noticed increased dyspnea on exertion and a rapid irregular heartbeat, palpated at her radial pulse. She reported fever and chills over the last week and a half prior to admission and presented to [**Hospital3 26615**] Hospital Emergency Department when she was unable to get out of bed secondary to shortness of breath. The patient was diagnosed with congestive heart failure and right lower lobe pneumonia while in outside hospital and found to have subsequent atrial flutter with 4:1 block of questionable duration. She was treated with Levaquin and started on a heparin drip. She also had a positive D-dimer greater than 1,000, and a low probability V/Q scan on the outside hospital. REVIEW OF SYSTEMS: She denies any chest pain, nausea, vomiting, orthopnea, paroxysmal nocturnal dyspnea, diaphoresis. She does report a mild increase in pedal edema, but also denies any palpitations. She presents now to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] with improving shortness of breath and comfortable, here only for evaluation of atrial flutter. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft in [**2120**]. 2. Status post mitral valve repair in [**2120**]. 3. Status post appendectomy. 4. Hypercholesterolemia. 5. Diabetes. 6. Hypertension. 7. Status post resection of retroperitoneal liposarcoma times two. ADMITTING MEDICATIONS: Aspirin 81 mg q day, NPH 40 units in AM, 26 units in PM, Atenolol 50 mg q day, Lasix 40 mg q day, Cardizem 300 mg q day, and Imdur 30 mg q day. ALLERGIES: Codeine and Darvon which cause lightheadedness without syncope. SOCIAL HISTORY: No tobacco, no alcohol, lives with husband. FAMILY HISTORY: Positive for coronary artery disease and diabetes. PHYSICAL EXAMINATION: Vital signs: temperature 99.2 F, pulse 65, respiratory rate 18, blood pressure 119/69, and pulse oximetry 94% on two liters. Blood sugar 115 and 176 pounds. In general: sitting in bed, head of bed at 30 degrees, in no acute distress. Head, eyes, ears, nose and throat: pupils were equal, round, and reactive to light and accommodation, extraocular movements intact, oropharynx clear, mucous membranes are moist. Neck with left sided bruit, no thyromegaly and jugular venous distention to angle of jaw. Lungs: rales halfway up with decreased right lower lobe breath sounds with dullness to percussion. Cardiovascular: regular rate and rhythm, II/VI systolic ejection murmur heard best at the apex with radiation to the axilla. Abdomen: soft, nondistended, positive bowel sounds, mild tenderness on the right side. Abdomen: mildly protruding with Valsalva / cough. Extremities: trace bilateral edema with right leg with graft harvest, 1+ pulses in the groin and dorsalis pedis. Neurologic: alert and oriented times three, cranial nerves II through XII intact, normal sensory to light touch and no focal deficits. ADMISSION LABORATORY DATA: White count 7.9, hematocrit 31.3, platelets 271,000. PTT 42.6. Sodium 140, potassium 3.8, chloride 99, bicarbonate 28, BUN 17, creatinine 0.6, and glucose 124. Calcium 8.6, phosphate 3.7, magnesium 1.8. TSH was pending on admission. Chest x-ray on [**2125-6-30**] from outside hospital showed: 1) hazy density in the right lower lobe base, suggesting effusion and coarsening of bilateral lower lung markings, a question of pulmonary vascular congestion, 2) slightly greater density along left hilum laterally. Echocardiogram from outside hospital on [**2125-7-1**] showed mild concentric left ventricular hypertrophy and normal systolic function, mildly hypokinetic base of an inferior wall, ejection fraction of 60%, mildly depressed systolic function, mild left atrial enlargement, mild atrial fibrillation, 1+ mitral regurgitation, 1+ to 2+ tricuspid regurgitation, pulmonary artery systolic pressure 54, right atrium 15 mmHg, 1+ to 2+ PI, and dilated IVC. Telemetry at [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] showed the patient had a heart rate of 60 with a 2:1 atrial flutter. Electrocardiogram showed atrial flutter with 3:1 block with right bundle branch block, biphasic T-waves in V2, and no ST-T-wave changes. Chest x-ray showed bilateral effusions with increased pulmonary vasculature with poor inspiratory effort. ASSESSMENT: This was an 82 -year-old female with a history of coronary artery disease, mitral valve repair, status post coronary artery bypass graft, hypercholesterolemia, diabetes, and hypertension, also with a recent pneumonia being treated with Levaquin, here for electrophysiology evaluation of atrial flutter. HOSPITAL COURSE: 1. Coronary artery disease: The patient with known disease, no recent chest pain, only shortness of breath, dyspnea on exertion with concurrent pneumonia. The patient was continued on aspirin, Lopressor, Cardizem, and Imdur. She was also started on Lipitor secondary to LDL of 132 and triglycerides of 131, and HDL of 30. There were no problems with coronary artery disease during admission. 2. Congestive heart failure: The patient presented with rales on examination. Ejection fraction was 60% per outside hospital echocardiogram. The patient also with trace bilateral lower extremity edema. For these two reasons, the patient was started on diuresis with a goal of one liter negative per day with [**Hospital1 **] Lasix. She also was started on Captopril which was increased as tolerated to a final discharge dosage of 12.5 mg po tid. 3. Electrophysiology: The patient presented with atrial flutter, 3:1 block, rate controlled throughout admission. She was continued on heparin drip. She remained stable while in atrial flutter without any complaints of lightheadedness or chest pain or palpitations. Before Electrophysiology study a transesophageal echocardiogram was done to rule out clot. The patient alternated between 2:1, 3:1, and 4:1 rate controlled atrial flutter. During admission, her Lopressor dose was increased to 50 mg po bid, discontinuing her Cardizem. The patient went to Electrophysiology lab for atrial flutter ablation on hospital day five. Upon termination of flutter and alternating right bundle branch block and left bundle branch block was revealed, as well as 3:2 and 2:1 arteriovenous block were also demonstrated to occur below his ....................bundle. A temporary pacing wire was inserted and left in place while the patient transferred to the Cardiac Care Unit for stabilization pending permanent pacemaker implantation the following morning. The patient continued to be intermittently ventricular paced at around 50 ventricular beats per minute, alternating with sinus rhythm with left bundle branch block. The following day she returned to Electrophysiology lab where a DDD pacer was successfully implanted. The patient was then transferred to the floor for further management. The following day, the patient was noted to be in a sinus versus atrial tachycardia, ranging between 110 and 120 beats per minute. She did not complain of any chest pain, shortness of breath, or lightheadedness. Her blood pressure was stable in the 130s systolic. She did not have a pulsus paradoxus. Her Lopressor dose was increased to 75 mg po bid and her clinical status was monitored. The patient then was noted to have an alternating regular rhythm with a retrograde ventricular atrial conduction with atrial inhibition / block. Electrophysiology was made aware and is planning on reprogramming the patient's pacemaker. The patient was also started on Ancef for a total of 48 hours after pacemaker placement, last dose to be on [**2125-7-12**]. The patient is also to restart Coumadin on [**2125-7-13**]. 4. Endocrine: The patient with insulin dependent diabetes. She was continued on her home NPH dose and followed with a regular insulin sliding scale. Her TSH was noted to be normal. No other problems were noted. 5. Pulmonary: The patient transferred after right lower lobe pneumonia had been treated with IV Levaquin at outside hospital for a total of five days. The patient noted improving shortness of breath. She was saturating 94% on two liters upon admission. Her chest x-ray showed bilateral effusions. She was continued on po Levaquin for a total of a ten day course. She was weaned off her O2 as was tolerated. She denied any cough or shortness of breath during hospital stay. On day seven of admission, the patient reported bilateral lower extremity tenderness, left more than right. She had a positive [**Last Name (un) 5813**] sign, no cords were palpable. She denied any shortness of breath, but deep vein thrombosis / pulmonary embolism was considered at that time secondary to patient also manifesting a fever of 100.7 F with no known source, no systemic complaints of infection. She denied any dysuria, cough, shortness of breath, fever or chills, headache, sore throat, nasal congestion, diarrhea. Therefore it was believed that this fever could possibly be secondary to calf deep vein thrombosis, also explaining the patient's increased atrial rate as secondary to pulmonary embolism perhaps. The patient had been immobile since time of outside hospital admission ten days prior. She had been on heparin drip for a large portion of hospital stay, but this was still considered as a possibility. Lower extremity non-invasive Dopplers were scheduled, but were not available at the time of dictation. If the Dopplers were positive, the patient would receive a CT scan angiogram for follow-up of possible pulmonary embolism. Test results were pending at this time. DISPOSITION: At the time of this dictation, the patient's symptoms had all resolved. She was asymptomatic secondary to atrial tachycardia with simultaneous pacemaker activity. It was intended that Electrophysiology would follow-up with pacemaker reprogramming in AM, duplex bilateral lower extremity Dopplers were pending. Coumadin is to be restarted on [**7-13**], and the patient is likely to be discharged on the morning of [**2125-7-12**]. DISCHARGE MEDICATIONS: At the time of dictation were Lopressor 75 mg po bid, Imdur 30 mg po q day, Lasix 40 mg po q day, Captopril 12.5 mg po tid, Lipitor 10 mg po q day, aspirin 81 mg po q day, NPH 40 units q AM, 26 units q PM, regular insulin sliding scale, Coumadin 5.0 mg po q day starting on [**2125-7-13**]. DISCHARGE DIAGNOSES: 1. Atrial flutter ablation. 2. DDD pacemaker placement. FOLLOW-UP: The patient is to follow-up in Device Clinic on [**2125-7-18**]. The patient is also to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in two to four weeks. The patient is to arrange visit in [**Location (un) 5028**]. DISCHARGE STATUS: We were planning to discharge to rehabilitation where the patient should receive qid fingersticks, INR checks should be drawn, and Coumadin adjusted for a goal INR of 2.0 to 3.0 every two days. The patient with allergies to codeine and Darvon. [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**] Dictated By:[**Name8 (MD) 15885**] MEDQUIST36 D: [**2125-7-11**] 20:49 T: [**2125-7-11**] 22:13 JOB#: [**Job Number 41998**] Admission Date: [**2125-7-5**] Discharge Date: [**2125-7-13**] Service: HOSPITAL COURSE: 1. Cardiovascular: The patient is presently not complaining of any problems overnight. She denied chest pain, shortness of breath, palpitations, pleuritic pain, bilateral lower extremity tender only upon palpation. She also denied left shoulder pain except for on palpation. She denied any dysuria, fever, chills, shortness of breath, nasal congestion, headache. She did have a low-grade fever overnight of 100.7??????. She is currently 98.0?????? upon discharge and had not been febrile in at least 10 hours. Her heart rate was stable in the 80s, and her systolic blood pressure was well controlled in the 120s. Chest x-ray was done which showed no congestive heart failure, no pneumothorax, but positive for left basilar atelectasis and small effusions. Lower extremity non-invasive Doppler ultrasound of bilaterally lower extremities were negative for deep venous thrombosis. The patient is on her last day of Ancef today status post pacer placement. EP is to reprogram her pacemaker to increase retrograde delay prior to discharge. The patient is also to restart Coumadin the following day. 2. Pulmonary: The patient is with resolving pneumonia on chest x-ray. She is off antibiotics at this time. She has no cough or shortness of breath. She did have a low-grade temperature yesterday but is presently afebrile with no white blood cell count. DISCHARGE DIAGNOSIS: 1. Atrial flutter ablation. 2. Degenerative disk disease pacemaker placement. ALLERGIES: CODEINE AND DARVON. DISCHARGE MEDICATIONS: Lopressor 75 mg p.o. b.i.d., Imdur 30 mg p.o. q.d., Lasix 40 mg p.o. q.d., Captopril 12.5 mg p.o. t.i.d., Lipitor 10 mg p.o. q.d., Aspirin 81 mg p.o. q.d., NPH 40 U q.a.m., and 26 U q.p.m. subcue, Coumadin 5 mg p.o. q.d. starting on [**7-13**], regular Insulin sliding scale. FOLLOW-UP: The patient is to follow-up in the Device Clinic on [**7-18**], phone [**Telephone/Fax (1) 21817**]. The patient is also to follow-up with her primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in 2-4 weeks; the patient is to arrange or her primary care physician can also arrange follow-up cardiology appointment in her area of [**Location (un) 12021**] Port if the patient desires. DISCHARGE INSTRUCTIONS: She is to be on a cardiac, [**Doctor First Name **] diet at rehabilitation. She is to have q.i.d. fingersticks. INR should be checked and Coumadin adjusted as required for a goal INR of [**1-6**] every two days. DR,[**Doctor Last Name 12203**],[**Doctor First Name 1575**] 12-465 Dictated By:[**Name8 (MD) 15885**] MEDQUIST36 D: [**2125-7-12**] 13:02 T: [**2125-7-12**] 14:26 JOB#: [**Job Number **]

[ "426.3", "427.32", "414.01", "250.00", "426.4", "401.9", "428.0", "V45.81", "486" ]

icd9cm

[ [ [] ] ]

[ "88.72", "37.34", "37.83", "37.26", "37.72", "42.23" ]

icd9pcs

[ [ [] ] ]

2247, 2299

10932, 11891

13435, 14144

13297, 13411

11909, 13276

14169, 14610

2322, 5169

1219, 1607

125, 1199

1629, 2168

2185, 2230

81,425

126,369

45936

Discharge summary

report

Admission Date: [**2120-9-9**] Discharge Date: [**2120-9-14**] Date of Birth: [**2056-10-16**] Sex: F Service: MEDICINE Allergies: Aspirin / Shellfish / OxyContin / Codeine / Acetaminophen / morphine Attending:[**First Name3 (LF) 4095**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None. History of Present Illness: The patient is a 63 year old woman with a history of Asthma, CHF, admission from [**Date range (2) 97803**] for HCAP/VAP c/b intubation, acute liver failure, and acute kidney failure requiring hemodialysis now resolved with CKD with recent admission from [**Date range (1) 79119**] for COPD exacerbation who presents from her [**Hospital 4382**] facility with shortness of breath. Per report, the patient was found to be short of breath by aides at the nursing home. EMS was called - they were unable to obtain access so gave her 1 SL nitro as well as started her on CPAP and brought her to [**Hospital1 18**]. In the ED, initial VS were: 0 95.2 100 224/116 28 100%. The patient was difficult to obtain access on so a right femoral IJ was placed as the patient was not able to lie flat. She was continued on CPAP, started on a nitro gtt, and given lasix 40mg IV. She put out ~500cc of urine to the lasix bolus. Labs were remarkable for a WBC of 17, Na of 129, Cr of 1.6. Because of the leukocytosis, the patient was given ceftriaxone and levofloxacin for ?HCAP. On transfer, vitals were: 98.5 79 154/75 20 100%. On arrival to the MICU, the patient states her breathing is more comfortable on the mask, although she does not like wearing it. She states she missed a few of her doses as she had 27 medicines to take and couldn't deal with all of them. She also admits to eating a couple saltier meals at home. Past Medical History: ONCOLOGIC HISTORY: 1) Breast cancer stage II (T2N0M0), [**2102**]: treated with lumpectomy, XRT, and CMF. No evidence of recurrent disease. 2) Lung SCC stage IA (T1bN0M0), [**2116**]: Resected on [**2117-11-16**]. Without evidence of recurrence. 3) Tracheal cancer diagnosed in [**4-/2119**] - [**2119-6-22**]- [**2119-7-20**]: Received weekly [**Doctor Last Name **] and txol with concomittent XRT - [**2119-7-24**]: CT without evidence of tumor - [**2119-7-24**] to [**2119-8-1**] Admitted for esphagitis, dehydration. Started TPN. - [**2119-7-27**] HELD W6 carboplatin paclitaxel for esophagitis and excess toxicity. - [**2119-8-1**] Completed 6000 cGy to the tumor and involved LNs - Admitted for odynophasia ([**8-15**] - [**8-27**])- radiation-induced esophagitis vs. [**Female First Name (un) **], previously on TPN and completed a 10-day course of Fluconazole with improvement of this problem - [**Name (NI) **] negative staph Bacteremia - 3 of 4 bottles positive on [**8-14**]. Portacath was removed [**8-17**] but tip culture results were negative. Treated with Vanco IV x 2 weeks (750 mg iv q12h through [**2119-8-31**]) - Admitted [**Date range (3) 97801**] for odynophagia, dysphagia - radiation-induced esophagitis, bx neg for [**Female First Name (un) **]/CMV/HSV, tx for [**Female First Name (un) **] without improvement PAST MEDICAL HISTORY: - Fibromyalgia / chronic pain syndrome (due to osteoarthritis and rheumatoid arthritis). Status post multiple immunomodulatory agents (including methotrexate) and courses of steroids. Currently on chronic opiates. - Asthma with bronchospasm, bronchomalacia and chronic rhinosinusitis with previous exacerbations requiring steroids attacks) with need of steroids. - Hypertension - Depression - Hyperlipidemia - Obesity - Migraine - GERD - bilateral carpal tunnel syndrome w/ hand weakness - spondylolisthesis of L4-5, radiculopathy w/stenosis - Right total shoulder arthroplasty [**10/2114**] - Right total knee arthroplasty - Left shoulder replacement - Possible sundowning on admission [**9-2**] - [**9-8**] for COPD exacerbation Social History: Widowed. Was living alone with considerable support from her children prior to her last admission in [**Month (only) **]. Now living at rehab, with hopes of returning home. Long history of smoking, quit 5 months ago. No alcohol or illicits. Family History: Mother had breast cancer but died of MI. Father had rectal; cancer. Only child. Daughter with metastatic breast cancer. Otherwise well with 1 son with migraines. Physical Exam: ADMISSION PHYSICAL EXAM General: Alert, oriented, no acute distress wearing CPAP [**Month (only) 4459**]: Sclera anicteric, MMM, oropharynx clear, EOMI, [**Month (only) 2994**] Neck: supple, JVP difficult to assess due to habitus and mask CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Bibasilar crackles with diffuse expiratory rhonchi and expiratory wheezing Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place, femoral CVL in place Ext: warm, well perfused, pulses dopplerable, [**11-20**]+ edema, bilateral dry necrotic eschars of all toes, dressing c/d/i Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation DISCHARGE PHYSICAL EXAM Brief Hospital Course: MICU COURSE: ============ Admitted to MICU for respiratory failure, type I in the setting of significantly elevated BP (200s/100s) and a recent admission for COPD exacerbation. Given history of medication noncompliance and pulmonary exam significant for crackles, acute pulmonary edema was suspected. Lack of fevers, productive cough, aspiration event argued against pneumonia, and antibiotics were discontinued after empirics were given in the ED. Initially started on nitro gtt and transitioned to home hypertension medications (metoprolol, hydralazine, isosorbide) with good response in blood pressures. Was put on CPAP for respiratory support and given 80mg of IV furosemide with 1.5 L negative and improvement of her respiratory status. Remained in sinus rhythm on this admission although patient has history of paroxysmal atrial fibrillation and was noted to be in a-fib during prior admisision. MEDICINE FLOOR COURSE: ====================== Ms. [**Known lastname 20893**] is a 63 yof with CHF (EF >55%), asthma, and CKD (base crea [**12-23**]) who was admitted to ICU for hypoxic respiratory failure in setting of hypertensive emergency and pulmonary edema responsive to CPAP and diuresis then transferred to floor. # Asthma: Continued need for albuterol. Patient has underlying lung disease with bronchotracheal malacia and asthma. Her significant pulmonary edema resolved on CXR. -continue albuterol neb -continue prednisone at 40mg po daily -continue montelukast -started Fluticasone-Salmeterol 250/50 diskus # Medication Noncompliance: Patient is on many medications, which makes compliance difficult. PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], has been [**Name (NI) 653**], and will help with simplification of med list. -switched metoprolol q6 to carvedilol [**Hospital1 **] -stopped hydralazine q8, and started lisinopril daily -started Fluticasone-Salmeterol 250/50 diskus as above -stopped Mucinex -stopped ipratropium # CHF: Preserved EF on echo [**2120-9-9**]. -started carvedilol since stopped metoprolol q6 -started lisinopril 40mg po daily -started standing lasix 40mg po daily # AFib: Patient reportedly in sinus rhythm since admission. -continued amiodarone -started carvedilol -continued clopidogrel (aspirin allergy) # CKD: Creatinine improving. Baseline creatine of [**12-23**] since [**Month (only) **] [**2119**] and previously required HD. # Chronic Pain: Patient has arthritis currently managed by [**Company 191**]. - continued pregabalin 50 mg po TID - restarted home oxycodone/acetaminophen 5mg [**11-20**] tab q4:PRN po # Anemia, normocytic: MCV 99. Recent baseline Hct of 27. Iron over 200 and markedly elevated ferritin of 15,000+ in [**Month (only) 205**]. Vitamin B12 has been high repeatdly high as well. -could have outpatient workup # HTN -carvedilol [**Hospital1 **] -lisinopril [**Hospital1 **] -lasix 40mg po daily # Hyperlipidemia: -not on statin, will discuss with PCP # CODE: Full- will want to readdress with daughter per patient # CONTACT: [**Name (NI) 97806**] (daughter/HCP)- [**Telephone/Fax (1) 97807**] other daughter is [**Name (NI) 97808**] [**Telephone/Fax (1) 97809**] ### Transitional Issues: -please consider switching patient's percocet to oxycontin [**Hospital1 **] and tyelnol -please consider starting statin -please follow up K+ and creatinine given Lisinopril started on [**2120-9-12**] -patient will continue on prednisone 20mg daily from hospital, but should try to be decreased to avoid long term effecs and need for PCP [**Name Initial (PRE) 1102**] Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol 0.083% Neb Soln [**11-20**] NEB IH Q2H:PRN wheeze 2. Amiodarone 200 mg PO DAILY 3. Bisacodyl 10 mg PR HS:PRN constipation 4. Clopidogrel 75 mg PO DAILY 5. Docusate Sodium 100 mg PO BID hold for diarrhea 6. Fleet Enema 1 Enema PR DAILY:PRN constipation 7. HydrALAzine 50 mg PO Q6H Hold for SBP<100 8. HydrOXYzine 10 mg PO Q6H:PRN scratching, itching 9. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY hold for SBP<100 10. Lidocaine 5% Patch 3 PTCH TD DAILY Apply one patch to back, one to dorsum of each foot in the AM, remove in the PM 11. Metoprolol Tartrate 100 mg PO Q6H hold for SBP<100, RR<60 12. Miconazole Powder 2% 1 Appl TP HS:PRN rash Apply moderate amount to affected areas on the chest or under both breasts and under the breast fold. 13. Milk of Magnesia 30 mL PO PRN constipation 14. Multivitamins W/minerals 1 TAB PO DAILY 15. Pantoprazole 40 mg PO Q24H 16. Polyethylene Glycol 17 g PO DAILY hold for diarrhea 17. Pregabalin 50 mg PO TID 18. Sarna Lotion 1 Appl TP DAILY:PRN itching 19. Senna 2 TAB PO DAILY:PRN constipation 20. Ipratropium Bromide Neb 1 NEB IH Q6H 21. Montelukast Sodium 10 mg PO DAILY 22. Albuterol Inhaler 2 PUFF IH Q6H 23. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough 24. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q4H:PRN pain Maximum 3g of acetaminophen a day. Discharge Medications: 1. Albuterol 0.083% Neb Soln [**11-20**] NEB IH Q2H:PRN wheeze 2. Amiodarone 200 mg PO DAILY 3. Bisacodyl 10 mg PR HS:PRN constipation 4. Clopidogrel 75 mg PO DAILY 5. Docusate Sodium 100 mg PO BID hold for diarrhea 6. Fleet Enema 1 Enema PR DAILY:PRN constipation 7. Lidocaine 5% Patch 3 PTCH TD DAILY Apply one patch to back, one to dorsum of each foot in the AM, remove in the PM 8. Miconazole Powder 2% 1 Appl TP HS:PRN rash Apply moderate amount to affected areas on the chest or under both breasts and under the breast fold. 9. Milk of Magnesia 30 mL PO PRN constipation 10. Montelukast Sodium 10 mg PO DAILY RX *montelukast 10 mg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Oxycodone-Acetaminophen (5mg-325mg) [**11-20**] TAB PO Q4H:PRN pain 13. Pantoprazole 40 mg PO Q24H 14. Polyethylene Glycol 17 g PO DAILY hold for diarrhea 15. Pregabalin 50 mg PO TID 16. Sarna Lotion 1 Appl TP DAILY:PRN itching 17. Senna 2 TAB PO DAILY:PRN constipation 18. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice per day Disp #*60 Tablet Refills:*0 19. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1 inhale twice per day Disp #*1 Cartridge Refills:*1 20. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth once in morning Disp #*30 Tablet Refills:*0 21. Lisinopril 40 mg PO DAILY RX *lisinopril 40 mg 1 tablet(s) by mouth once daily at night Disp #*30 Tablet Refills:*0 22. PredniSONE 20 mg PO DAILY RX *prednisone 20 mg 1 tablet(s) by mouth once daily Disp #*30 Tablet Refills:*0 23. Albuterol Inhaler 2 PUFF IH Q6H 24. Calcium 500 With D *NF* (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit Oral daily PLEASE AVOID OSCAL or any meds that are contraindicated with SHELLFISH ALLERGY RX *calcium carbonate-vitamin D3 [Calcium 500 + D] 500 mg calcium (1,250 mg)-400 unit [**Unit Number **] tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 25. commode [**1-18**] commode Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Congestive Heart Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Last Name (Titles) **], you were admitted to the [**Hospital1 1170**] for shortness of breath due to fluid in your lungs. You were in the medical ICU and you needed to use the CPAP machine for your breathing. Once stable, you were on the medicine floor were we continued to take off fluid with Lasix. We adjusted your medications and it is very important you follow up with Dr. [**Last Name (STitle) **] at [**Hospital3 **] as listed below. Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2120-9-20**] at 9:40 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "38.97", "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

12260, 12318

5136, 8313

337, 344

12387, 12387

13042, 13363

4182, 4347

10174, 12237

12339, 12366

8732, 10151

12570, 13019

4362, 5113

290, 299

372, 1792

12402, 12546

8336, 8706

3175, 3908

3924, 4166

81,685

139,844

35424

Discharge summary

report

Admission Date: [**2140-4-28**] Discharge Date: [**2140-5-16**] Date of Birth: [**2087-1-27**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Large Left Temporal hemorrhage Major Surgical or Invasive Procedure: [**5-2**]: Left craniotomy for evacuation of intraparenchymal blood 3/24: Bedside tracheostomy placement [**5-10**]: PICC line placement by interventional radiology History of Present Illness: 53M apparently found down (?in bed) and intoxicated, brought to OSH apparently moving all 4 extremities, combative. Intubated, head CT showed large left temporal hemorrhage, pt transported to [**Hospital1 18**] Ed for further evaluation/treatment. Past Medical History: +ETOH, otherwise unknown Social History: unknown Family History: non-contributory Physical Exam: On Admission: VS: BP: 112/83 HR:101 R 12 O2Sats100 Gen: WD/WN, intubated, dried blood on face,multiple bruises/abrasions on body HEENT: Pupils: 3->2 EOMs unable to assess Extrem: Warm and well-perfused. Neuro:intubated sedated, PERRLA, +corneal reflexes, +gag, min movement all 4 to noxious Toes mute bilaterally Pertinent Results: Labs on Admission: [**2140-4-28**] 01:18PM BLOOD WBC-4.5 RBC-3.71* Hgb-12.6* Hct-35.0* MCV-94 MCH-34.1* MCHC-36.1* RDW-13.7 Plt Ct-40* [**2140-4-28**] 01:18PM BLOOD PT-12.3 PTT-30.0 INR(PT)-1.0 [**2140-4-28**] 01:18PM BLOOD Fibrino-170 [**2140-4-28**] 05:27PM BLOOD Glucose-94 UreaN-15 Creat-0.6 Na-139 K-3.5 Cl-98 HCO3-31 AnGap-14 [**2140-4-28**] 05:27PM BLOOD ALT-134* AST-179* LD(LDH)-329* CK(CPK)-247* AlkPhos-52 TotBili-1.0 [**2140-4-28**] 05:27PM BLOOD Albumin-3.6 Calcium-7.8* Phos-3.1 Mg-1.6 [**2140-4-28**] 01:18PM BLOOD ASA-NEG Ethanol-71* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging: CT Head [**4-28**]: FINDINGS: There is a large mixed density intraparenchymal blood collection in the left parietotemporal lobe measuring 7.6 x 3.3 cm in axial dimensions and consistent with acute hemorrhage. This lesion demonstrates surrounding edema. There is a 5-mm rightward shift of normally midline structures and subfalcine herniation. There is diffuse effacement of the sulci in the left cerebral hemisphere and the left lateral ventricle. There is no entrapment of the right lateral ventricle or uncal herniation. There is a second focus of acute hemorrhage in the right inferior frontal lobe measuring 1.1 x 1.5 cm. In addition, there are scattered foci of subarachnoid hemorrhage in the right temporal and left frontal and parietal lobes. There is no major vascular territory infarction. Mucosal thickening in the left maxillary and ethmoidal sinuses is noted. There is a mucous retention cyst in the right maxillary sinus. No osseous abnormality is detected. IMPRESSION: 1. Large left parietotemporal intraparenchymal hemorrhage with associated mass effect including 5 mm rightward shift of the normally midline structures and subfalcine herniation. 2. Focus of intraparenchymal hemorrhage in the right inferior frontal lobe. 3. Scattered areas of subarachnoid hemorrhage bilaterally. 4. Maxillary and ethmoidal sinus disease. CT Chest/Abd/Pelvis [**4-28**]: IMPRESSION: 1. No evidence of acute intrathoracic, intra-abdominal, or pelvic injury. 2. 2-mm nodule in the left lower lobe. According to the [**Last Name (un) 8773**] Society criteria, if the patient is at low risk for malignancy, no further followup is needed. If the patient is at high risk for malignancy, CT followup in 12 months is recommended, and if unchanged at that time, no additional followup is recommended. 3. Probable remote bilateral clavicular fractures and right and left rib fractures. 4. Fatty infiltration of the liver. 5. 4-mm hypodensity in the left renal cortex which is too small to characterize, but likely a simple cyst. Head CTA [**4-28**]: IMPRESSION: 1. No evidence of aneurysm or other vascular malformation. 2. Complete right ICA occlusion, likely at the origin. MRI C-Spine [**4-29**]: IMPRESSION: 1. No evidence of ligamentous injury in the cervical spine. 2. Multilevel degenerative change as detailed above, most severe at C5/6. No sign of cord signal abnormality. CT L-Spine [**4-29**]: IMPRESSION: 1. No fracture or lumbar spine malalignment. 2. Multilevel degenerative change as detailed above. CT T-Spine [**4-29**]: IMPRESSION: 1. No fracture or thoracic spine malalignment. 2. Fatty liver. EKG [**4-28**]: Sinus tachycardia. Low limb lead voltage. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 114 100 84 334/428 78 62 69 CXR [**4-28**]: SINGLE SUPINE AP VIEW OF THE CHEST: The endotracheal tube terminates approximately 7.5 cm from the carina. The lungs are clear without focal consolidation, pneumothorax or pleural effusion. The heart size is normal. There is tortuosity of the thoracic aorta. There is bilateral clavicular deformity which may be related to prior trauma. An NG tube is noted projecting out of the field of view in the left upper abdomen. IMPRESSION: Endotracheal tube 7.5 cm from the carina. Consider repositioning. CXR [**4-30**]: FINDINGS: Comparison is made to the prior study from [**2140-4-28**]. Endotracheal tube terminates 4.2 cm above the carina. Cardiomediastinum otherwise normal. Nasogastric tube terminates in the stomach. There is mild atelectasis at both lung bases. Remainder of the lungs are clear. No frank infiltrate to suggest aspiration at this time. There is an old right clavicular deformity. Non-Invasive Ultrasound Studies: [**5-7**]:IMPRESSION: No DVT of the right upper extremity. [**5-8**]: DVT in the right superficial femoral vein which is occlusive. Head CT [**5-7**]: FINDINGS: There is evolution of hemorrhage in the left frontal craniotomy bed with decreasing air in the post-surgical bed. Large vasogenic edema adjacent to the hemorrhage with moderate mass effect on the ipsilateral left frontal [**Doctor Last Name 534**] is similar to [**2140-5-6**]. Right inferior frontal lobe hemorrhage is similar to [**2140-5-6**]. There is stable minimal right frontal subarachnoid hemorrhage. 7mm rightward shift of normally midline structures, left subfalcine and uncal herniation are similar to [**2140-5-6**]. Bilateral pneumocephalus has slightly decreased since [**2140-5-6**]. Opacification of the left frontal sinus, the sphenoid sinus, bilateral ethmoids and left maxillary sinuses are similar to [**2140-5-6**]. The mastoid air cells are clear. IMPRESSION: 1. Evolution of left parietoemporal parenchymal hemorrhage with large edema and subfalcine as well as uncal herniation that is similar to [**2140-5-6**]. 2. Evolution of R inferior frontal lobe hemorrhage unchanged since [**2140-5-6**]. 3. Diffuse paranasal sinus opacification is unchanged since [**2140-5-6**]. IVC Filter placement [**5-9**]: PFI: Placement of G2 retrievable infrarenal IVC filter. The filter can be retrieved at any time as needed. Brief Hospital Course: The patient was admitted to the ICU after having been intubated and sedated. He was not opening his eyes and was not following commands upon admission. He was however, able to move all 4 extremities to noxious stimuli. On [**4-28**] he had a CTA showing no aneurysm or AVM. There was complete right ICA occulsion but there was collateral flow. On [**5-2**] there was a question of a self-resolving focal seizure in the LUE so keppra was started. He underwent craniotomy for evacuation of hematoma on [**2140-5-2**]. The patient was able to move his extremities spontaneously and started to follow commands with the LUE post-operatively. He was also able to open his eyes. The patient was able to tolerate some time on trach mask but still required the ventilator at night. On [**5-5**] the patient had been on the trach mask for over 24 hours. He was tracking with his eyes and moving his LUE and lowers spontaneously and the RUE had slight withdrawal. On [**5-7**] the patient had a stat head CT due to a period of unresponsiveness. The scan was unchanged and the patient's exam improved subsequently. He had blood and urine cultures drawn for continued fevers. On [**5-8**], he was found to have lower extremity DVT and IVC filter was placed by interventional radiology on [**5-9**]. Subsequent to that, he was started on a heparin infusion without bolus, with goal PTT of 50-70. Also on [**5-10**], he was taken to interventional radiology again to have PICC line placed for continued access. During his hospitalization, he had hyponatremia, which was treated with salt tablets and a fluid restriction. On [**5-11**] the patient had a fall on the floor. He had a stat head CT which was unchanged. He was also scanned for any traumatic injuries. All of the imaging was unremarkable. He was seen and evaluated by physical and occupational therapy who determined he would be a candidate for rehab. The patient was more awake and attentive to examiner on the day of discharge although it was still difficult to have him follow commands. His pupils were equal and reactive to light. He was moving spontaneously with the right upper and both lowers. The left upper moved slightly. He was evaluated by the speech therapist and he was unable to tolerate a passimuir valve. Therefore his will go to rehab with a trach mask. He was discharged to an appropriate facility on [**2140-5-16**]. Medications on Admission: Unknown: per mother prescribed many but takes sporadically and incorrectly Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. 10. Ibuprofen 100 mg/5 mL Suspension Sig: One (1) PO Q8H (every 8 hours). 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for hyponatremia. 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Left large subacute IPH with Ry frontal contracoup IPH Respiratory Failure s/p trach placement Fever Lower Extremity DVT Dysphagia, s/p PEG placement Hyponatremia Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2140-5-16**]

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icd9cm

[ [ [] ] ]

[ "01.31", "31.1", "02.05", "38.7", "96.72", "96.6", "43.11", "38.93" ]

icd9pcs

[ [ [] ] ]

10993, 11072

7043, 9434

350, 517

11279, 11303

1277, 1282

12739, 12999

884, 902

9559, 10970

11093, 11258

9460, 9536

11327, 12716

917, 917

280, 312

545, 795

1296, 7020

817, 843

859, 868

12,487

182,699

11622

Discharge summary

report

Admission Date: [**2162-2-1**] Discharge Date: [**2162-2-3**] Date of Birth: [**2103-11-3**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 58-year-old male who presented with shortness of breath in [**2161-3-8**]. His workup demonstrated a malignant pleural effusion secondary to metastatic left renal cancer. He required evacuation of the pleural fluid and talc pleurodesis which led to significant pulmonary function loss. His abdominal imaging studies demonstrated a large left upper pole renal mass which measured 8 cm X 8 cm in the left renal upper pole. Throughout his workup he was also diagnosed with hypercalcemia of malignancy. He was treated for this in [**State 1727**]. He has had a CT scan and a bone scan which have shown no other sites of metastatic cancer except some pulmonary nodules which have been noted. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: He is on no medications. SOCIAL HISTORY: His social history is significant for a high alcohol intake of 12 beers per day. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, there was no palpable lymphadenopathy. He had decreased breath sounds in the left lower lobe. His abdomen was soft, and there was no palpable mass. His genitourinary examination was normal, and there was no evidence of varicoceles. His prostate measured 60 g in size without any nodularities. He was enrolled in the debulking nephrectomy protocol with the intention of receiving immunotherapy after recovering from his surgery. HOSPITAL COURSE: On [**2162-2-1**] he underwent an attempted hand-assisted left laparoscopic nephrectomy. The operation was complicated by difficulty in separation of the left upper pole renal mass from the tail of the pancreas which made the operation more challenging. At one point of the operation there was brisk bleeding from the renal artery stump. This bleeding was controlled, and a standard flank incision was used to gain access to the abdomen and the retroperitoneum. With the help of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 261**], the bleeding was controlled. The specimen was removed, and the patient was sent to the Intensive Care Unit. Postoperatively, the patient's course was complicated by a persistent acidosis. On postoperative day one, there was concern that there may be an ischemic bowel. An emergent CT angiogram demonstrated poor flow in the celiac and the superior mesenteric artery access. The patient had a hemodialysis in order to better control his hyperkalemia and severe acidosis. Subsequently, he was emergently taken to the operating room with the help of General Surgery and Vascular Surgery for an exploratory laparotomy. The exploratory laparotomy demonstrated a gangrenous gallbladder and ischemic distal stomach and ischemic pancreas. The superior mesenteric artery and the celiac arteries were explored by the vascular surgeon, and there was no evidence of any surgical clips in the superior mesenteric artery or the celiac arteries. The patient's gallbladder was removed during the exploratory laparotomy, and the patient's spleen was also removed because there was poor flow. Please refer to the dictated operative report for more detailed information. The patient was brought back to the Intensive Care Unit, and he remained persistently acidotic. On postoperative day two, he required lots of support by pressors, and he was not making any urine. Given his multiorgan system failure with his acute respiratory distress syndrome, and DIC picture, and his advanced malignancy, it was discussed with the family to withdraw support, and the patient expired on postoperative day two. [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**] Dictated By:[**Last Name (NamePattern4) 36887**] MEDQUIST36 D: [**2162-3-17**] 11:31 T: [**2162-3-18**] 15:13 JOB#: [**Job Number 3601**]

[ "189.0", "276.2", "276.7", "518.81", "V64.4", "998.11", "998.2", "197.2", "197.0" ]

icd9cm

[ [ [] ] ]

[ "41.5", "55.51", "51.22", "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

950, 976

1591, 4037

154, 923

993, 1573

81,008

131,484

49775

Discharge summary

report

Admission Date: [**2181-8-5**] Discharge Date: [**2181-8-21**] Date of Birth: [**2120-1-31**] Sex: M Service: MEDICINE Allergies: Codeine / aspirin / aspirin Attending:[**First Name3 (LF) 3063**] Chief Complaint: Pancreatitis, duodenal/biliary perforation, RLQ fluid collection Major Surgical or Invasive Procedure: Abdominal Drain Placement x 2 NG tube placement History of Present Illness: Mr. [**Known lastname **] is a 61M who was in his USOH until mid-[**Month (only) **] when he developed right flank pain and hematuria. He presented to OSH on [**7-22**] where he was noted to have obstructing 2mm stone in his right ureter along with non-gap acidosis (pH 7.18, pCO2 25, HCO3 12, thought c/w distal RTA per records). Additionally, patient developed transaminitis 2 days following admission, and MRCP showed dilated CBD with choledocholithiasis. He underwent ERCP on [**7-26**] with papillotomy and copious sludge noted. He then developed post-ERCP pancreatitis and on [**7-27**] developed hypotension, worsening acidosis, and [**Last Name (un) **]. He was intubated on [**7-30**] due to acidosis and pressors and HCO3 gtt were started. He was started on pip/tazo on [**7-27**] as well, although blood cx, urine cx, and CDiff were unremarkable. His acidosis and renal failure have improved, and he has been weaned off pressors, but remains intubated. His course has been further complicated by rising leukocytosis, up to 46.7 on day of transfer. Abdominal CT scan performed on [**8-4**] at OSH showed worsening pancreatitis with interval multiloculated fluid collection concerning for early abscess formation. He is being trasferred to [**Hospital1 18**] for further management. On arrival to the [**Hospital Unit Name 153**], patient is intubated and sedated. He is unable to answer ROS, but he awakens to voice and follows commands. VS were T103, P 117, BP 158/78, RR 23, O2 98% on CMV 40%FiO2, PEEP 5, TV 550, RR 18. Past Medical History: - Kearns-[**Location (un) 31024**] syndrome (mitochondrial myopathy, left opthalamoplegia) - Nephrolithiasis - HLD - HTN - Migraines - Hypothyroidism - s/p CCY Social History: Disabled, formerly ran Parts dept for AV company. Smoked 1ppd x45 years, quit 1 week prior to OSH admission. Denied illicit drug use or EtOH Family History: Father died of throat cancer Physical Exam: Exam at [**Hospital Unit Name 153**] Admission: Tm 102.8, Tc 100.1. P 130, BP 130/76, 98 40% FiO2, 1.2L in, 2.7L out Gen: opens eyes, not clearly following commands HEENT: PERRL CV: Tachycardic Abd: Distended abdomen, + tympanic Extr: Extremities warm peripherally, pulses palpable distally Pertinent Results: Admission Labs: [**2181-8-5**] 02:52AM BLOOD WBC-48.7* RBC-3.27* Hgb-10.4* Hct-34.3* MCV-105* MCH-31.8 MCHC-30.3* RDW-16.6* Plt Ct-524* [**2181-8-5**] 02:52AM BLOOD PT-14.3* PTT-35.0 INR(PT)-1.3* [**2181-8-5**] 02:52AM BLOOD Fibrino-819* [**2181-8-5**] 02:52AM BLOOD Glucose-117* UreaN-19 Creat-1.1 Na-150* K-4.0 Cl-116* HCO3-21* AnGap-17 [**2181-8-5**] 02:52AM BLOOD ALT-30 AST-27 LD(LDH)-509* AlkPhos-148* Amylase-557* TotBili-0.4 [**2181-8-5**] 02:52AM BLOOD Lipase-198* [**2181-8-5**] 02:52AM BLOOD Albumin-2.8* Calcium-8.3* Phos-2.4* Mg-1.7 [**2181-8-8**] ABSCESS PELVIS. GRAM STAIN (Final [**2181-8-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2181-8-11**]): KLEBSIELLA OXYTOCA. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED [**2181-8-6**] Blood Culture, Routine (Final [**2181-8-12**]): NO GROWTH [**2181-8-7**] CT abdomen with contrast IMPRESSION: 1. Significant inflammatory fat stranding and enlarging fluid collections along the pancreatic head/uncinate process adjacent to the duodenum, and in the right iliac fossa, without evidence of free air or oral contrast extravasation. Patient is status post ERCP. Findings could be due to walled off duodenal perforation, although severe pancreatitis is also in the differential. 2. Persistent small bilateral pleural effusions and bilateral lower lobe partial atelectasis, partially visualized. 3. Secondary inflammatory thickening of the ascending colon wall. 4. Likely mechanical small-bowel obstruction with transition point in the left lower quadrant imrpoved from prior outside study 5. Mild right hydronephrosis unchanged, likely secondary to distal periureteral inflammation in the retroperitoneum. Possible 2 mm passed stone in the right bladder lumen. The study and the report were reviewed by the staff radiologist Discharge Labs: [**2181-8-20**] 04:40AM BLOOD WBC-15.0* RBC-2.74* Hgb-8.9* Hct-27.8* MCV-101* MCH-32.6* MCHC-32.1 RDW-16.0* Plt Ct-539* [**2181-8-20**] 04:40AM BLOOD Glucose-78 UreaN-10 Creat-1.1 Na-137 K-4.1 Cl-104 HCO3-22 AnGap-15 Other Labs: [**2181-8-9**] 03:20AM BLOOD calTIBC-156* VitB12-1462* Folate-9.5 Ferritn-1462* TRF-120* [**2181-8-6**] 02:18AM BLOOD Hapto-484* [**2181-8-5**] 01:00PM BLOOD Triglyc-179* [**2181-8-5**] 02:52AM BLOOD TSH-17* [**2181-8-16**] 04:42AM BLOOD Free T4-0.16* [**2181-8-7**] 03:07AM BLOOD Cortsol-27.1* Brief Hospital Course: Mr. [**Known lastname **] is a 61 year old man with signficant PMH of ocular myopathy and hypertension who is transferred from OSH with post-ERCP pancreatitis/perforation, multi-organ dysfunction, and concern for pancreatic abscess. =================== Active Issues: # Sepsis: Met SIRS criteria at admission given temperature, leukocytosis and tachycardia. Blood pressure stabilized and pt was weaned off of levophed. Source of infection most likely complication of ERCP with development of pancreatic and retroperitoneal RLQ abscesses seen on CT abdomen. He underwent IR drain placement for peripancreatic and RLQ fluid collections. He was started on vanc/zosyn while cx were pending. Cultures grew pansensitive Klebsiella. He was maintained zosyn for risk of a polymicrobrial infection to complete a 14 day course after drainage. #DUODENAL/BILIARY PERFORATION: Intraabdominal abscess (cx data identified as pansensitive Klebsiella) in peripancreatic area and RLQ as evidenced by [**8-7**] abdominal ct with contrast. It was attributed to biliary or duodenal leak, as a complication of ERCP sphincterotomy (likely duodenal perforation confirmed with OSH GI endoscopist). In consulting with general surgery team, he underwent CT guided IR placement of a drain in each collection that drained purulent fluid. He clinically improved as evidenced by decreasing WBC and defervesence. Repeat imaging was deffered per GI recomendations. He completed 14 days of zosyn after drainage. On [**2181-8-17**], one of the drains placed was removed via IR after patient had tolerated over a liter of PO intake. The second JP drain was monitored for additional output, and ultimately was self-d/ced accidentally. The patient's abdominal exam remained benign and he was discharged home. #Small bowel obstruction - [**8-7**] CT abdomen with contrast revealed SBO with transition point in LLQ. A NGT was placed and drained copious bilious fluid. Once fluid output from NGT slowed, it was removed. Nutrition was provided with TPN through his PICC that was placed at the OSH. He was able to tolerated an advancing PO diet starting on [**2181-8-15**]. # Respiratory failure: Patient intubated [**7-30**] due to worsening respiratory acidosis. Ventilatory settings increased from BiPAP to MMV due to apneic episodes in the setting of fentanyl for pain control. However, CXR from OSH did show some pulm edema and concern for retrocardiac opacity. As his respiratory failure improved, he was extubated on [**8-10**]. Briefly required O2 on the floor which resolved with ISP. # Pancreatitis: Etiology from ERCP; CT [**8-7**] showed possible contrast extravasation and [**First Name8 (NamePattern2) **] [**Location (un) **] attending, it is likely that pancreas and/or duodenum was punctured during ERCP there. Has resulted in multi-organ dysfunction. # Delirium - s/p extubation patient was delirious with most likely etiology benzodiazepine use for sedation. His delirium improved without any intervention as the bz were metabolized out of his system. # Hypernatremia: he was slightly hypernatremic during intubation [**3-1**] insensible losses. He was repleted with free water and his hypernatremia resolved. # Acute kidney injury: In setting of hypotension and critical illness, patient's Cr rose to >2 at OSH, most likely pre-renal cause as Cr trended downward with fluid resuscitation. OSH believed to have distal RTA with non-AG metabolic acidosis. =========================== Inactive Issues: # Kearns-[**Location (un) 31024**] syndrome: [**Month (only) 116**] have contributed to metabolic acidosis # Hypothyroidsim: Continued synthroid 12.5mcg IV daily # Hx of HTN: Home regimen included propranolol, verapemil and lisinopril. His anti-hypertensive meds were held while patient was hypotensive in ICU. # Acute kidney injury: In setting of hypotension and critical illness, patient's Cr rose to >2 at OSH. With supportive care, Cr has downtrended to 1.1 # HLD: Held statin given transaminitis. Transitional Issues: ***PER SURGERY CONSULT SERVICE, PT WILL NEED REPEAT CT SCAN IN [**3-3**] MONTHS. Medications on Admission: - Tylenol 650 q6 prn - Combivent 10 puff q6 hours - MVI qd - Heparin 5000 SC tid - Levothyroxine 12.5mcg IV daily - Midazolam gtt - Fentanyl gtt - Pip/Tazo 3.375 IV q6 - Sucralfate 1g qachs - TPN Discharge Medications: 1. Levothyroxine Sodium 25 mcg PO DAILY RX *Levothroid 25 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*30 Tablet Refills:*0 RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 3. eletriptan HBr *NF* 40 mg Oral daily as needed headache 4. Gemfibrozil 600 mg PO BID 5. Levocarnitine 330 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. Omeprazole 20 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary ERCP-induced acute pancreatitis Intraabdominal abscess Secondary Kearns-[**Location (un) 31024**] syndrome Nephrolithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [**Hospital1 18**] ICU after your were found to have pancreatitis and an abscess in your abdomen following your ERCP procedure. You had drains placed to treat the abscess. Your medical condition improved, your breathing tube was removed, and you were transferred to the medical floor. You continued to do well and completed your course of antibiotics while in the hospital. You are now being discharged home. You have follow-up scheduled with your PCP's office (see below). You will need to have a repeat CT scan of your abdomen in [**3-3**] months. You should discuss this with your PCP. There have been multiple changes to your medications during this admission. Please refer to the medication list below for details of these changes. Followup Instructions: Name: Dr. [**Last Name (STitle) **] Location: [**Hospital3 **] Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 88702**] Phone: [**Telephone/Fax (1) 104049**] Appt: [**8-28**] at 9am NOTE: This appointment is with a member of Dr. [**Last Name (STitle) 104050**] team 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 provider

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icd9cm

[ [ [] ] ]

[ "54.91", "99.15", "96.72" ]

icd9pcs

[ [ [] ] ]

10753, 10759

5849, 6103

352, 402

10935, 10935

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174,467

38516

Discharge summary

report

Admission Date: [**2145-7-26**] Discharge Date: [**2145-7-29**] Date of Birth: [**2089-3-13**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 2836**] Chief Complaint: 1. Abdominal pain 2. Chills 3. Recent pancreatitis and known pseudocyst Major Surgical or Invasive Procedure: None History of Present Illness: 56M with chronic pancreatitis, EtOH abuse, Renal Ca s/p nephrectomy and adjuvant tx, discharged 4 days ago from OSH for acute pancreatitis and pseudocyst who presented to OSH ED with F(103) and chills with increasing abd pain. In [**Name (NI) **], pt was febrile and transiently hypotensive to 90s/60s). Labs notable for WBC 9.6 but with bandemia, Hct 36.6, Cr 1.3, Lipase 218 from 123 ([**7-17**]). CT at OSH concerning for enlarging pancreatic tail pseudocyst; also noted multiple other smaller pseudocysts. Given concern for infected pseudocyst, pt admitted to OSH ICU for ?sepsis and managed with rIVF/Abx. Pt transferred to [**Hospital1 18**] for further evaluation of need for intervention. Past Medical History: PMH: EtOH(last EtOh [**7-13**], hx tremors in past, denies sz.), pancreatitis, pseudocyst, metastatic renal CA, HTN, PVD. PSH: s/p R nephrectomy Social History: 12beers/d; heavy tob; remote IVDU. Lives with brother and mother. Disabled. Family History: NC Physical Exam: On Admission: VS 98.2 90 130/100 19 95ra A+Ox3, NAD RRR, clear s1/s2, no m/r/g CTAB soft, NABS, NT/ND Ext WWP, no edema, 2+DPs On Discharge: VS: Afebrile, VSS Gen: NAD CV: RRR Lungs: CTAB Abd: Soft, nontender, nondistended, fullnes in left/epigastrium Ext: Warm, no c/c/e Neuro: AxO x 3, PERRL, EOMI Pertinent Results: [**2145-7-26**] 09:01PM WBC-10.8 RBC-4.18* HGB-12.0* HCT-36.8* MCV-88 MCH-28.8 MCHC-32.7 RDW-20.2* [**2145-7-26**] 09:01PM NEUTS-83.2* LYMPHS-10.7* MONOS-4.6 EOS-1.2 BASOS-0.2 [**2145-7-26**] 09:01PM GLUCOSE-97 UREA N-5* CREAT-0.9 SODIUM-142 POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13 [**2145-7-26**] 09:01PM ALT(SGPT)-56* AST(SGOT)-44* ALK PHOS-409* AMYLASE-69 TOT BILI-0.4 [**2145-7-26**] 09:01PM LIPASE-76* [**2145-7-27**] 04:19AM BLOOD WBC-9.0 RBC-4.23* Hgb-11.8* Hct-36.4* MCV-86 MCH-27.8 MCHC-32.4 RDW-20.2* Plt Ct-242 [**2145-7-27**] 04:19AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-140 K-3.6 Cl-110* HCO3-22 AnGap-12 [**2145-7-27**] 04:19AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.6 Brief Hospital Course: The patient was admitted to the General Surgical Service for evaluation of the possible infected pancreatic pseudocyst. Patient was admitted as a transfer in ICU for observation. In ICU patient was afebrile, with stable VS. Patient was started on CIWA protocol s/t history of alcoholism, Foley catheter was placed to monitor urine output, and patient was NPO. He was comfortable, with a soft and essentially nontender abdomen. Hemodynamics were normal. He had no further fevers and the bandemia resolved, off abx. On HD # 2 patient was transferred to the regular floor, patient's diet was advanced to clear liquids, and when tolerated well, advanced to regular. CIWA protocol was discontinued and IV fluids were stopped after patient tolerated PO. Foley catheter was d/cd. Patient remained afebrile, WBC WNL. . During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly, labbwork was routinely followed; electrolytes were repleted when indicated. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Aspirin 81 mg PO qd Prilosec 20 mg PO qd Amlodipine 5 mg PO qd Simvastatin 20 mg PO qd Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: 1. Pancreatic pseudocyst 2. Acute pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-7**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Please call your doctor or nurse practitioner if you experience the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**3-3**] weeks after discharge. . Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD. Dr. [**First Name (STitle) **] office will contact you about date/time of the follow up in 2 weeks. You will be scheduled to have an abdominal CT scan prior your follow up with Dr. [**First Name (STitle) **]. If you have any questions, please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2998**]. Please also call for any recurrent abdominal pain or fevers. Completed by:[**2145-7-29**]

[ "577.2", "796.3", "577.0", "443.9", "577.1", "288.66", "V10.52", "305.1", "401.9", "V45.73", "303.91" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4568, 4574

2427, 3982

343, 350

4665, 4665

1699, 2404

6398, 6965

1357, 1361

4119, 4545

4595, 4644

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1519, 1680

232, 305

378, 1077

1391, 1505

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1262, 1341

9,755

104,879

8654

Discharge summary

report

Admission Date: [**2176-6-13**] Discharge Date: [**2176-6-15**] Date of Birth: [**2108-8-25**] Sex: M Service: MEDICINE Allergies: Chocolate Flavor Attending:[**First Name3 (LF) 2704**] Chief Complaint: Claudication-->re-look LE angiography. Claudication-->Elective PERIPHERAL VASCULAR angiography Major Surgical or Invasive Procedure: S/P PTA of L SFA & CFA, athrectomy of R CFA, PTA/Stent (3) of R SFA & PTA of R TPT History of Present Illness: This 67 year old man has a history of hypertension, hyperlipidemia, tobacco abuse, CAD s/p CABG and known PVD, s/p many prior LE interventions. Mr [**Known lastname 30301**] presents for a relook LE angiography. The patient's daughter reports that about three weeks ago her father began to have recurrent leg claudication, occurring with walking about half a block. She is unclear on which leg may be bothersome. After his last revascularization, for a brief period, he had some improvement of his claudiation, which has returned since. . In terms of cardiac symptoms, he has no chest discomfort. He does have dyspnea with activity such climbing up one flight of stairs. It is worse with the recent increase in humidity. He is on oxygen 2l via nasal cannula at night while sleeping. Past Medical History: -HTN -CAD s/p CABG ([**2169**]: ([**Hospital1 18**]) LIMA to LAD, SVG to RAMUS) -PVD s/p multiple interventions (see below) -cigarette smoking 1ppd/50+yrs -Polio as a child -BPH -emphysema/COPD, uses 2 liters nasal cannula at hs -hyperlipidemia -s/p lung resection 40+ years ago after a stab wound -Right inguinal hernia repair -Back pain -Cataracts (surgery scheduled for [**2176-7-9**]) -[**3-30**]: Paroxysmal atrial flutter Peripheral vasc. history includes: [**2175-4-3**] ABI: 0.51 right, 0.59 left [**2175-7-10**] Lower extremity angiogram: Right- Internal iliac artery occluded. External iliac artery occluded at the exit to the CFA. The CFA had a short occlusion to the SFA/PFA bifurcation with the PDA filling the distal SFA. Left- Common iliac artery was normal. External iliac artery was occluded at the bifurcation with the internal iliac artery. Common femoral artery occluded. SFA patent below the occlusion. S/P successful Right CFA and [**Month/Day/Year 30302**] intervention with cryoplasty to the SFA. [**2175-8-2**]: successful recanalization of the [**Female First Name (un) 7195**] followed by atherectomy and stenting [**2176-2-14**] LE angio: (right brachial artery access): RLE: diffuse disease in the CIA. IIA with an 80% stenosis. CFA totally occluded. LLE: moderate diffuse disease of the CIA. Prior EIA stent with an 80% lesion and no flow down the external iliac artery. SFA totally occluded proximally. Attempt at revascularization of the left EIA unsuccessful. [**2176-2-15**]: (access via left brachial artery):PTA of the origin of the left internal iliac artery with a 5.0 mm balloon. Successful PTA of the totally occluded RCFA and SFA with a 4.0 balloon. [**2176-2-16**] LLE angiography: prior stent and CFA patent with a distal dissection noted in the CFA with ulceration. SFA flush occluded at the origin, PFA patent with collateralization of the distal SFA. Successful recanalization of the Left SFA with PTA using a 5.0 mm balloon. Successful cryoplasty of the [**Doctor First Name **], LCFA into the [**Doctor First Name 30303**]. [**2176-4-23**]:MRI of LE: Mild atherosclerotic disease in the iliac arteries and LE's. No hemodynamically significant stenosis present. [**2176-6-7**] MRI/MRA of abdomen (limited examination): Moderate focal stenosis of the origin of the celiac artery. Diffuse narrowing of the left common iliac artery with approximately a 7 mm long segment of moderate to severe stenosis in the proximal left common iliac artery, about 5mm from its origin. Possible severe stenosis at the origins of the internal iliac arteries. Several areas of mild stenosis in the right external iliac artery. No definite flow seen in the right SFA consistent with occlusion. LLE: (limited due to opacification)-Appearance of flow in the left SFA although evaluation is limited. Flow in the popliteal appears less than compared to the right. Flow in the left AT to the level of the ankle noted with poor appearing flow in the distal left anterior tibial and dorsalis pedis arteries. Social History: Pt lives alone in [**Hospital1 1474**]. Close with daughter. Drinks 3+ [**Name2 (NI) 17963**] a day & smokes (as above). Family History: (-) FHx CAD Physical Exam: VS: 107/53, HR 70's, O2 92% RA Gen- a&ox3, nad Chest-CTAB Heart- (Post-procedure) R Fem Site: (-) hematoma or ooze, (+) bruit--consitent with baseline L Fem Site: (-) hematoma or ooze, (+) bruits--consitent with baseline R Brachial Site: mild bruit (-) hematoma or ooze Pertinent Results: Angiography & PTA -- [**2176-6-13**] *** Not Signed Out *** FINAL DIAGNOSIS: 1. Diffuse and critical bilateral CFA, SFA disease. 2. successful PTA of the LCFA 3. succesful PTA of the [**Month/Day/Year 30303**] 4. Successful PTA and stenting of the [**Month/Day/Year 30302**] 5. Successful PTA of the popliteal perforation 6. Successful PTA of the RCFA. . ART DUP EXT UP UNI LMTD RIGHT [**2176-6-14**] FINDINGS: No pseudoaneurysm or AV fistula involving the right brachial access site. A focal area of velocity elevation in the brachial artery just above the antecubital fossa is identified, reaching 486 cm/sec. This indicates a high-grade stenosis in this area. . Angiography & PTA -- [**2176-6-14**] *** Not Signed Out *** FINAL DIAGNOSIS: 1. Occluded RBA treated with PTA 2. Occluded RCFA treated with stenting and thrombectomy Brief Hospital Course: Mr [**Known lastname 30301**] presents for a relook LE angiography. He has a ho multiple LLE interventions in the past. He also has a background of CABG, current smoking and COPD. . He underwent angiography & PTA of LCFA & [**Name (NI) 30303**], PTA and stenting of the [**Name (NI) 30302**], PTA of the popliteal perforation, PTA of the RCFA. Following the procedure, the pt underwent duplex scan of his right arm, which suggested a significant obstruction in his R brachial artery. The pt was taken back to the cath lab for further evaluation with angiography. During catheterization, the pt was found to have occluded RBA treated with PTA. He was also found to have occluded RCFA treated with stenting and thrombectomy. . The pt recovered well from the procedures. However, his HCT dropped and he was transfused 2uPRBCs. The drop was thought to be due to blood loss & fluids given peri-procedure. His Hct repsonded appropriately to the transfusion. He was discharged following transfusion. Medications on Admission: Aspirin 325mg daily Zestril 20mg daily HCTZ 12.5mg daily Metoprolol 75mg tablets twice a day Colace 100mg twice a day Folic acid 1mg daily Theophylline 200mg one tablet daily Lipitor 40mg daily Prednisone 5mg daily Pletal 100mg twice a day Digitek .25mg daily every morning Plavix 75mg daily Methocarbamol 750mg three times a day Thiamine 100 daily Percocet 1-2 tablets every 8 hours prn MVI Advair 500/50 twice a day Spiriva 18mcg one puff once a day Albuterol inhaler, prn Albuterol nebulizer 2-4 times per day Cromolyn sodium 20mg (nebulizer)2-4 times per day Omeprazole 40mg daily Ambien 10mg prn at bedtime Ensure plus one can daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for refills please call Dr. [**First Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*11* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Zestril 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Theophylline 200 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO DAILY (Daily). 9. Lipitor 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Digitek 250 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 14. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 15. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed. 16. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 17. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 18. Ensure Liquid Sig: One (1) PO once a day. 19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: PVD Anemia Seconday: CAD BPH COPD HTN Hyperlipidemia Discharge Condition: Stable VS: 107/53, 70's, 92% RA Labs: hct 34.5 (after tranfusion of 2uPRBC's), plt 339, k 4.4, buncr 10/0.7, alt 17, ast 24, ck 86 R Fem Site: (-) hematoma or ooze, (+) bruit--consitent with baseline L Fem Site: (-) hematoma or ooze, (+) bruits--consitent with baseline R Brachial Site: mild bruit (-) hematoma or ooze Discharge Instructions: -Continue taking all of your medications as directed. -Take Aspirin 325mg & Plavix 75mg daily. Do not stop these medications unless directed by Dr. [**First Name (STitle) **] [**Name (STitle) **] are not longer taking pletal -You need to return in 2 weeks for an intervention on your left leg & right brachial artery in your arm, you will be called regarding scheduling this. -Seek immediate medical attention for any recurrent symptoms, temperature change, pain or discoloration of your extremities, any issues with your groin site including fever or any other concerning symptom. Followup Instructions: -Dr. [**First Name (STitle) **] will call you tomorrow to check on you. If you have any questions, you may try to reach him at his office, phone: ([**Telephone/Fax (1) 7236**]. -You have an appointment at in the Vascular Lab at [**Hospital1 18**] on Monday, [**2176-6-17**], Time: 10:00. This is for a VASCULAR STUDY. Please call if you need directions or have any questions Phone:[**Telephone/Fax (1) 327**] - Please make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 1 week. -Return to lab in 2 weeks for LLE & R Brachial intervention.

[ "305.1", "440.22", "496", "285.9", "444.21", "401.9", "440.21", "V12.02", "V45.81", "998.2", "272.4", "600.00", "414.00" ]

icd9cm

[ [ [] ] ]

[ "00.47", "00.43", "39.90", "00.46", "99.04", "39.50", "88.42" ]

icd9pcs

[ [ [] ] ]

8932, 8938

5670, 6673

375, 460

9044, 9365

4813, 4873

9996, 10590

4493, 4507

7362, 8909

8959, 9023

6699, 7339

5556, 5647

9389, 9973

4522, 4794

238, 337

488, 1279

1301, 4337

4353, 4477

3,642

176,051

10023+56091

Discharge summary

report+addendum

Admission Date: [**2161-1-24**] Discharge Date: [**2161-1-24**] Date of Birth: [**2124-11-25**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 36-year-old white female with a history of polysubstance abuse and bipolar depression who presents from an outside hospital after having a believed ingestion. At approximately 8:30 in the evening on [**1-24**], the patient's sister called EMS reporting an ingestion which appeared to consist of Seroquel, and Neurontin. Patient was found by EMS to be largely unresponsive with initial vitals in the field being a pulse of 136, blood pressure of 68/28, respiratory rate of 6 and oxygen saturation of 90%. She was started on oxygen by face mask, given 1.5 mg of Narcan and intubation was attempted in the field, but failed. Patient was then subsequently transferred to [**Hospital6 10353**] Emergency Department with subsequent vitals showing a blood pressure of 124/54, respiratory rate of 16, oxygen saturation 99%. In the Emergency Department at the [**Hospital3 **], she was intubated and given activated charcoal. As there was no Intensive Care Unit beds available at the [**Hospital3 **], she was transferred to the [**Hospital6 2018**] for further management. Of note, the alcohol level at the outside hospital was 189. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Polysubstance abuse including alcohol, cocaine, benzodiazepines and heroin. She has been admitted into detoxification greater than 20 times. 3. History of multiple overdoses, greater than eight hospitalizations in the past three years. Overdoses have included alcohol, benzodiazepines. She has been intubated four times in the past two years. 4. Depression, believed to be bipolar/dysthymic disorder. 5. Anxiety disorder. 6. Personality disorder with borderline features. Reportedly followed by Dr. [**Last Name (STitle) **] at the [**Hospital 4415**]. MEDICATIONS ON ADMISSION: 1. Neurontin [**2157**] mg q.a.m., [**2157**] q.d. and 1200 mg q.p.m. 2. Seroquel 200 mg q.h.s. 3. Remeron of unknown dose. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient reportedly lives with her mother and has had significant tobacco and alcohol use since age 7. FAMILY HISTORY: The patient states that both her grandmother and mother are bipolar. PHYSICAL EXAMINATION ON ADMISSION TO THE [**Hospital1 **]: Vitals: Showed a temperature of 97.2. Heart rate of 92. Blood pressure 121/72. Respiratory rate 13, oxygen saturation of 100%. In general, patient was intubated and sedated. Her pupils equal, round and reactive to light. The oropharynx showed an ET tube, but was otherwise clear and without erythema. Head was normocephalic, atraumatic. Neck was supple with no appreciable lymphadenopathy or jugular venous distention. heart was regular rate and rhythm, no murmurs, rubs or gallops. Lungs were clear to auscultation anteriorly. Abdomen was soft, nontender, nondistended with positive bowel sounds and no appreciable hepatosplenomegaly. Extremities showed no cyanosis, clubbing or edema. Skin was warm without cyanosis, clubbing or edema. Peripheral pulses were 2+ bilaterally. On neurological exam, patient was sedated, but moving all extremities to a noxious stimuli. DATA FROM THE OUTSIDE HOSPITAL: White blood cell count of 6.2, hematocrit of 41.9, platelet count 216,000. Sodium 147, potassium 3.6, chloride 113, bicarbonate 16.8, BUN 5, creatinine 0.5, glucose 107, anion gap was 17.2, serum osmolalities were 351, ETOH level 186 and calculated osmolalities was 342. Urine tox screen was negative, >.....<barbiturates, benzodiazepines or opiates. Acetaminophen level was less than 10. Salicylate level was 2.0. Arterial blood gas at the outside hospital was 733, with a pCO2 of 35.4 and a pO2 of 224. Chest x-ray showed no acute process. Head CT was also negative for any significant abnormalities. Electrocardiogram showed sinus tachycardia with a rate of 111 with normal intervals. There was no acute ischemic changes noted. HOSPITAL COURSE: The patient was transferred to the Intensive Care Unit directly from the [**Hospital3 **]. Upon arrival, she was intubated but did not appear to have any primary pulmonary process. Over the next several hours, her sedation was weaned aggressively and patient was subsequently able to be extubated without any complications. Over the next 12 hours, patient remained completely stable. As her sedation lightened, she was seen and evaluated by the Psychiatry Service to whom she admitted that she had had a suicide attempt with over ingestion of her medications. At this time, it is felt that she is medically stable with no outstanding medical issues. She is currently stable on room air with no respiratory distress. Given her recent suicide attempt with drug overdose, it is felt best that she be admitted for inpatient psychiatry visit. There are currently no beds available at the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]. She will be evaluated by the BEST physician for placement at an outside unit. DISCHARGE STATUS: To outside Psychiatry facility. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: 1. Neurontin [**2157**] mg po q.a.m., [**2157**] mg po q.daytime and 1200 mg po q.p.m. 2. Seroquel 200 mg po q.h.s. 3. Remeron unknown dose. Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2161-1-24**] 03:45 T: [**2161-1-23**] 15:51 JOB#: [**Job Number 33517**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 5851**] Admission Date: [**2161-1-24**] Discharge Date: [**2161-1-24**] Date of Birth: [**2124-11-25**] Sex: F Service: DISCHARGE MEDICATIONS: 1. Neurontin 1200 mg po qid. 2. Seroquel 25 mg po qid as well as 200 mg po q hs. 3. Remeron 45 mg po q hs. 4. Ativan 1-2 mg po q2h per CWA scale. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) 304**], M.D. [**MD Number(1) 594**] Dictated By:[**Name8 (MD) 3732**] MEDQUIST36 D: [**2161-1-24**] 22:40 T: [**2161-1-26**] 06:50 JOB#: [**Job Number 5852**]

[ "305.90", "070.54", "E950.3", "518.81", "300.00", "969.3", "E950.4", "305.00", "966.3" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5179, 5188

2259, 4045

5763, 6187

1956, 2122

4063, 5157

161, 1326

1348, 1930

2139, 2242

63,179

136,724

21983

Discharge summary

report

Admission Date: [**2165-2-26**] Discharge Date: [**2165-3-16**] Date of Birth: [**2098-4-5**] Sex: F Service: UROLOGY Allergies: Aspirin / Nsaids / Amoxicillin / Penicillins Attending:[**First Name3 (LF) 6736**] Chief Complaint: s/p operation Major Surgical or Invasive Procedure: extensive lysis of adhesions, small bowel resection and attempted placement of suprapubic tube, repair of enterotomies by urology and general surgery ([**2165-2-26**]) History of Present Illness: Ms. [**Known lastname 57550**] is a 66y F with a PMH of MS [**First Name (Titles) **] [**Last Name (Titles) 45870**] bladder s/p previously failed appendicovesicostomy and suprapubic tube placement in [**2162**] who presented to OR today for placement of suprapubic tube. In surgery, secondary to very extensive adhesions, there was concern small bowel injury. General surgery was consulted and were able to perform extensive lysis of adhesions, and small bowel resection. EBL 50cc. Because of inability to bring bladder up towards the fascia, it was deemed that a sp tube was not possible for the long term without further extensiv mobilization. Pt w/ urethral foley right now. In the PACU inital vitals were, 97.1, 160/80, 105, 20, 96% on facemask. Anesth: Requesting ICU for AMS (improving). At baseline, patient is alert, oriented and mentally relatively high functioning. Mental status improved in the responsive to verbal commands and opening eyes to sounds. BP issues: systolics up to 180, tachycardic, both resolving with labetalol. Pt received TAP block. Received in PACU dilaudid 0.5mg x3; cipro 400mg IV, flagyl 500mg IV, tegretol 400mg, gabapentin 100mg, baclofen 30mg, labetolol 20mg IV. 3L in procedure + 600cc in PACU. 580cc urine out in ICU. . On arrival to the ICU, initial vital signs were afebile 92 143/70 18 89% on humidified shovel mask. The patient was responsive to voice, opening eyes and answering simple questions (after clearing throat). Unable, however, to give full history, ICU consent or code status. . Review of systems: Unable to obtain [**2-21**] mental status Past Medical History: Past Medical History: Bronchitis, Pneumonia, Hypertension, Severe multiple sclerosis (b/l leg weakness and R hand weakness at baseline; [**Month/Day (2) 45870**] bladder), Rheumatoid-type arthritis, Lupus, Osteoarthritis, Constipation, Chronic back pain, gout, anemia . PSH: previously failed appendicovesicostomy [**2161**], suprapubic tube placement, tonsillectomy Social History: SOCIAL HISTORY: The patient is a customer service business owner. Tobacco use about 16 pack years, quit at the age of 32. Denies alcohol or drug use. Family History: FAMILY HISTORY: Coronary artery disease, atherosclerotic cardiovascular disease and alcohol abuse. Physical Exam: AVSS General: AOx3 HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles in bases b/l, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender; JP drain in place midline; midline laparotomy surgical scar, steri-strips; no CVA tenderness GU: foley in place Ext: warm, well perfused, significant 2+ edema in LE to mid-tibia Neuro: EOMI, PERRL, weakness in R arm, R leg, L leg. Moving L arm well. Pertinent Results: Admission Labs: [**2165-2-27**] 02:50AM BLOOD WBC-7.4# RBC-2.99* Hgb-10.0* Hct-30.2* MCV-101* MCH-33.6* MCHC-33.2 RDW-13.9 Plt Ct-224 [**2165-2-27**] 02:50AM BLOOD Neuts-85.2* Lymphs-7.6* Monos-6.0 Eos-0.6 Baso-0.5 [**2165-2-27**] 02:50AM BLOOD PT-11.2 PTT-28.7 INR(PT)-1.0 [**2165-2-27**] 02:50AM BLOOD Glucose-139* UreaN-18 Creat-0.7 Na-137 K-4.3 Cl-103 HCO3-27 AnGap-11 [**2165-2-27**] 02:50AM BLOOD ALT-20 AST-32 LD(LDH)-227 AlkPhos-48 TotBili-0.2 [**2165-2-27**] 02:50AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.5 Mg-1.7 Brief Hospital Course: Hospital Course ICU admission: # s/p surgery -- Attempt at suprapubic tube placement complicated by small bowel injury secondary to very extensive adhesions. Exploratory laparotomy, extensive lysis of adhesions, small bowel resection and attempted placement of suprapubic tube, repair of enterotomies. Patient had an extensive surgery. Was hypertensive in the PACU to 180s, now resolved w/ SBPs in the 140s. Patient without significant abdominal pain, soft abdomen. JP drain in place, dressing in place. No erythema or drainage from surgical wound. Patient drowsy after surgery, but now starting to clear, speaking, opening eyes, interacting. Still not at baseline. Pt has chronic LE weakness and RUE weakness/spasticity. . # HTN: Pt w/ hx of HTN, and post-op htn, which was controlled w/ labetalol. nifedipine has been restarted considering hemodynamic stability. SPB<150 since being in ICU. - continue nifedipine - hold spironolactone and lisinopril for now . # MS: severe MS, w/ b/l leg weakness and R hand weakness at baseline; [**Year/Month/Day 45870**] bladder but mental status high functioning. - continue neurontin, baclofen, carbamazepime, tizanidine, terazosin . # RA / Lupus: stable - continue plaquenil . # Back Pain: mild to moderate back pain currently -continue tizanidine . # Depression: stable - continue celexa . # FEN: IVF, replete electrolytes, NPO # Prophylaxis: pneumoboots # Access: peripheral # Communication: Patient # HCP: [**Name (NI) **] [**Name (NI) 57550**], husband [**Telephone/Fax (1) 57551**] # Code: Presumed Full (pt's HCP, husband, not responding to phone call) # Disposition: ICU pending clinical improvement Floor Course: Patient was transferred from the ICU to the floor in stable condition on POD1. She was NPO with IVF and IV pain medications. On POD4 the NGT was removed after it had low output. On POD6 the patient passed flatus and her diet was advanced to clear liquids. Unfortunately, on POD7 the patient began vomiting and her abdomen was distended. CT scan found and ileus with questionable small bowel in a ventral hernia. The patient was treated conservatively with an NGT and bowel rest. On POD13 the patient was started on TPN due to prolonged NPO status. On POD15 the patient passed flatus and she was advanced to clears. The TPN was discontinued on POD16. She was found to have a swollen right arm on POD16 and an ultrasound revealed a non-occlusive blood clot in her basilic vein where the PICC line was present. She will be treated with 3 months of lovenox for this clot and follow-up with her PCP for management. In addition, the patient was having expiratory wheezes on POD16 and we obtained a pulmonary consult. They commented that the patient was volume overloaded following TPN and she would require gentle diuresis. Following some diuresis the patients breathing improved. She will be discharged to rehab continuing to be diuresed. On the day of discharge the patient was tolerating a regular diet, her pain was well controlled and she was having bowel movement regularly. She will follow-up with her PCP for management of the lovenox and with Dr. [**Last Name (STitle) **]. Medications on Admission: tylenol prn Baclofen 30mg AM, noon, dinnertime and 10mg Qhs Carbamazepine 300mg AM, 400mg hs Celexa 40mg Qhs Flonase daily Lisinopril 40mg [**Hospital1 **] Neurontin 100mg Qhs Nifedipine ER 90mg daily AM betaseron injection every other day restatis eye drops tizanidine 4mg Qhs Provigil 200mg Qam and noon fiorocet prn Plaquenil 400mg daily Spironolactone 25mg daily Terazosin 3mg Qhs senna colace miralax azelastine spray Qhs Discharge Medications: 1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain. Disp:*30 Tablet(s)* Refills:*0* 2. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 3. modafinil 100 mg Tablet Sig: Two (2) Tablet PO qam, qnoon (). 4. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic 1 drop in each eye q12 hours (). 5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-21**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 6. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for Indigestion. 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 8. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 9. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 10. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. terazosin 1 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 12. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. baclofen 10 mg Tablet Sig: 2.5 Tablets PO QID (4 times a day). 15. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 16. Betaseron 0.3 mg Kit Sig: One (1) Subcutaneous EVERY OTHER DAY (Every Other Day). 17. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): continue until patient becomes euvolemic. 19. salsalate 750 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 20. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 21. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 22. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y (120) mg Subcutaneous DAILY (Daily). Disp:*30 syringes* Refills:*2* 24. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas pain. 25. carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO QAM (once a day (in the morning)). 26. gabapentin 250 mg/5 mL Solution Sig: Two [**Age over 90 1230**]y (250) mg PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: failed SPT placement c/b enterotomy and small bowel resection Discharge Condition: stable Discharge Instructions: [**Hospital1 **] wet-to-dry packing of inferior incision The steri-strips on your wound will fall off on their own - call with any concerns of wound erythema, discharge or dehiscence. The patient will follow-up with Dr. [**Last Name (STitle) 185**] for management of her anticoagulation please obtain QOD basic metabolic labs to monitor her diuresis. Followup Instructions: Please contact your PCP to review your post-operative course, your medications and your anticoagulation plan. Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: PRIMARY CARE AFFILIATES Address: [**Location (un) 57552**], [**Location (un) **],[**Numeric Identifier 57553**] Phone: [**Telephone/Fax (1) 21566**] Fax: [**Telephone/Fax (1) 39794**] please call Dr. [**Last Name (STitle) **] [**Last Name (STitle) 3726**] for follow-up.

[ "E879.8", "596.54", "V15.82", "E870.0", "568.0", "340", "453.81", "276.69", "714.0", "560.1", "564.00", "998.2", "997.49", "311", "E878.6", "710.0", "780.09", "996.74", "491.9", "511.9", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "54.59", "99.15", "38.97", "45.62", "54.11" ]

icd9pcs

[ [ [] ] ]

9942, 10039

3894, 7061

317, 486

10145, 10154

3347, 3347

10553, 11003

2714, 2798

7538, 9919

10060, 10124

7087, 7515

10178, 10530

2813, 3328

2076, 2120

264, 279

514, 2057

3363, 3871

2165, 2511

2544, 2681

7,539

195,055

19544

Discharge summary

report

Admission Date: [**2112-1-5**] Discharge Date: [**2112-1-22**] Date of Birth: [**2034-3-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: 1. T9 transpedicular decompression of the spinal cord 2. T6-T11 pedicle screw instrumentation segmental (Expedium). History of Present Illness: 77 y.o. man with a history of metastatic prostate cancer admitted with back pain and found to have compression fractures with canal narrowing, transferred from neurosurgy without intervention for radiation. The patient states that he suffered from severe back pain over the past several weeks. He describes [**11-26**] pain, currently at 5/10. This is exacerbated with movement and is tender to palpation. His pain is markedly improved now on fentanyl patch and percocet PRN. He denies any clear lower extremity weakness or changes in sensation in the lower extremities or groin. The patient denies any incontinence of bowel or bladder. The patient was admitted through the ED and found to have mets to T9-10 and L3 with associated canal narrowing and low-level compression. The patient was initially admitted to neurosurgery. He was started on dexamethasone 4mg Q6h. His course was complicated by urinary retention. It was decided that surgical intervention is not currently indicated and the patient was transferred to OMED for radiation therapy. Past Medical History: ONC HX: Pt was initially diagnosed with localized prostate cancer in [**2099**] via a medial laparotomy. At that time, he had negative lymph nodes. He was treated with external beam radiation until 04/[**2100**]. He did well until [**3-/2103**], when he was noted to have a rise in his PSA. He was started on Eulexin and Zoladex. He had a very good response, which lasted for 5-6 years. On [**2108-11-13**], he was started on mitoxantrone and prednisone [**2-19**] rising PSA. He was continued on this therapy for 5 cycles and then was started on secondary hormonal therapy with ketoconazole and hydrocortisone. [**10-20**] his PSA started rising, suggesting progression of disease on hydrocortisone and ketoconazole. His PSA has continued to rise this year going up to 98 [**2111-3-17**] and bone scan at the time showed slightly increased uptake at T10, but no evidence of mets. CT thorax showed stable lung nodules, adrenal adenoma, fat stranding of left psoas muscles possibly c/w metastatic disease and mildly enlarging infrarenal AAA. He was then admitted in [**4-/2111**] for back pain and was found to have an L3 lesion concerning for metastases and he was started on XRT. In the interim, he was also continued on Zoladex. In [**7-/2111**], he was restaged following the completion of his XRT. Between [**7-22**] and the present he has been continued off of all therapies except for Lupron and had been doing well including weaning himself off of all pain medications. However, his PSA again began to elevate, most recently 172 in 9/[**2111**]. . PMH: # CAD s/p MI x2 in [**2081**], [**2098**] # CHF: EF 30% per Oncology notes from sometime in [**2109**], but no study in the OMR # h/o CVA in [**2098**] # Hypertension # Hypercholesterolemia # s/p right CEA # s/p left knee arthroscopic surgery # A. Fib Social History: Lives in [**Location 3146**] with his wife, retired engineer. He has 4 grown children. A former smoker, he quit in [**2081**] following a 60-80 pack a year history. Rare EtOH currently, drank moderately in the past. No IVDU. Family History: Non-contributory Physical Exam: PE: 96.7 65 140/64 18 96% RA Gen: NAD. Obese. HEENT: Pupils constricted, poorly reactive. Pink, moist oral mucosa without lesions. CV: Distant heart sounds. RRR. Nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. Unable to assess JVP due to thick neck. LUNGS: CTA bilaterally. ABD: Obese. Soft, NT, ND. No HSM. EXT: Trace edema. NEURO: A&Ox3. CN II-XII intact. Preserved sensation throughout, including saddle region. 4/5 strength in the proximal LLE flexion and distal LLE extensor. All other fields [**5-21**]. Pertinent Results: [**2112-1-4**] 04:42PM GLUCOSE-127* UREA N-20 CREAT-1.2 SODIUM-135 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16 [**2112-1-4**] 04:42PM WBC-9.0 RBC-4.35* HGB-13.9* HCT-38.7* MCV-89 MCH-31.9 MCHC-35.9* RDW-15.7* [**2112-1-4**] 04:42PM NEUTS-83.3* LYMPHS-12.5* MONOS-3.4 EOS-0.5 BASOS-0.3 [**2112-1-5**] 12:23AM URINE RBC-[**6-26**]* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 [**2112-1-5**] 12:23AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2112-1-5**] 02:13PM URINE RBC->50 WBC-[**3-21**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2112-1-5**] 04:47PM PT-13.4* PTT-100.6* INR(PT)-1.2* [**2112-1-5**] 04:47PM ALBUMIN-4.3 [**2112-1-5**] 04:47PM LIPASE-18 [**2112-1-5**] 04:47PM ALT(SGPT)-16 AST(SGOT)-19 LD(LDH)-223 ALK PHOS-112 AMYLASE-72 TOT BILI-0.4 . MRI spine: 1. Multilevel metastatic disease as described above with epidural soft tissue component significantly narrowing the ventral canal compressing the cord at T9. Additionally at L3, there is retropulsion with ventral canal narrowing and impression on the thecal sac. Paraspinal mass as noted above. 2. Degenerative changes of the cervical spine as noted above. 3. Full bladder. . CT torso: 1. Two nonspecific, noncalcified peripheral nodules in the right lung have been stable for 18 months. Followup is recommended in six months. 2. Small bilateral pleural effusions, right greater than left. 3. No lymphadenopathy in the abdomen or pelvis. 4. Cholelithiasis. 5. 3.3-cm infrarenal abdominal aortic aneurysm. 6. Osseous metastases at T7 through T11 vertebra with epidural masses at T8 and T9 compressing the thecal sac. Pathologic compression fracture of L3 with retropulsed fragments. Please refer to the [**2112-1-4**] MRI report for further detail. Echo [**2112-1-19**]: EF ?45% Brief Hospital Course: [**Hospital **] hospital course: A/P: 77 y.o. man with a history of metastatic prostate cancer admitted with back pain and found to have compression fractures with canal narrowing, transferred from neurosurgy without intervention for radiation. # Spinal mets with question of early compression. Stable without signs of progressive neurologic symptoms. Neurosurgery recommends XRT prior to consideration of surgery. - Radiation oncology consult for likely radiation therapy to spine - Possible future neurosurgical intervention - Decadron 4mg Q6h - Close neurologic monitoring # Pain. Most likely related to tumor burden in spine. Improved control control. - Continue fentanyl patch 50 mcg/hr Q72H - Cont percocet prn - PT consult # Prostate ca. Metastatic s/p chemotherapy and radiation. Most recently on Lupron. Last staged in [**9-/2111**] did not show clear progression by imaging but recent increase PSA concerning for progression. Now newly metastatic to thoracic spine. - To discuss further therapy with primary oncologist. # CAD. S/p MI x2 in [**2081**] and [**2098**]. Stable without signs of acute disease. - Continue atenolol 12.5 mg QD, valsartan 80mg QHS, isosorbide mononitrate 90mg QD - To consider starting aspirin. Unclear why he is not on this currently. Did he have a hemorrhagic CVA in the past? - NTG SL prn # CHF. EF reportedly 30% sometime in [**2109**] per Oncology notes but no study in OMR. - Cardiac regimen as above. - Continue Digoxin 0.125 mg QD - Continue Furosemide 40 mg QD # History of A. Fib. Patient is rate controlled. Not on anticoagulation currently. By the patient's report, anticoagulation was held due to prostatic mets. It is unclear if this is a true contraindication. We must clarify if the patient had a hemorrhagic or ischemic CVA in the past. - Continue rate control with atenolol. - To consider anticoagulation pending review of past CVA. # Urinary retention. Likely secondary to prostate CA. No other signs of associated cord compression to imply a neurologic process. Patient was on Flomax prior to admission. - Continue foley to gravity - Continue tamsulosin # Past CVA. History unclear. This must be clarified prior to consideration of anticoagulation for A. Fib. # Hypertension. Stable. Continue home cardiac regimen as above. # Hypercholesterolemia. Stable. Continue home statin therapy. # Prophylaxis. - Heparin sc TID - Pantoprazole while on dexamethasone. - Insulin sliding scale while on decadron - Bowel regimen # CODE: Full Code [**Hospital 4695**] Hospital Course: Patient was being followed by medicine while awaiting surgery. His neuro exam declined and the decision was made to proceed with surgery. He went to the OR on [**2112-1-15**] for T9 laminectomy and decompression with fusion of T7-T11. Post-operatively he was transferred to the ICU for monitoring due to his previous cardiac history. He did have an elevated troponin of 0.29 on [**2112-1-18**] which cardiology did not believe was the result of ACS. They continued to follow the patient and recommended repeating a trans-thoracic echo as well as obtaining a P-MIBI. The echo showed an EF of ? 45% and the P-MIBI resulted in no anginal symptoms with a maximum heart rate of 59. The patient had 2 episodes of chest pain btwn [**Date range (1) 53013**] and a few runs of VTach which he broke on his own. The chest pain appeared to be related to his anxiety but Cardiology was re-consulted prior to discharge and recommended incr. beta-blockade (which was done). They cleared the patient for d/c and stated that he should resume full anticoagulation upon d/c as prophylaxis due to his afib. The patient was evaluated by PT and OT and they recommended rehab placement. Prior to discharge he had standing AP/Lat x-rays of spine which showed no evidence of hardware-related complication. The patient was neurologically stable and his strength had improved slightly post-operatively. He was deemed ready to continue his physical therapy at rehab and was discharged on [**2112-1-22**]. Medications on Admission: aspirin atenolol imdur lipitor procardia digoxin percocet flomax nitroglycerin fentanyl patch 50 mcg/hr Q72H percocet prn Discharge Medications: 1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: d/c on [**2112-1-26**]. 10. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 days. 11. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. 12. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 2 days. 13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 14. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q6H (every 6 hours) as needed. 15. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours) as needed. 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 17. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five (5) ML Intravenous PRN (as needed): for portacath. 19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 20. HYDROmorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 22. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 23.Coumadin (anticoagulate to therapeutic INR--afib) Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Metastatic Prostate Cancer to spine Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR SPINE CASES ??????Do not smoke ??????Keep wound(s) clean and dry / No tub baths or pools for two weeks from your date of surgery ??????No pulling up, lifting> 10 lbs., excessive bending or twisting ??????Limit your use of stairs to 2-3 times per day ??????Have a family member check your incision daily for signs of infection ??????If you are required to wear one, wear cervical collar or back brace as instructed ??????You may shower briefly without the collar / back brace unless instructed otherwise ??????Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ??????Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ??????Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ??????Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ??????Pain that is continually increasing or not relieved by pain medicine ??????Any weakness, numbness, tingling in your extremities ??????Any signs of infection at the wound site: redness, swelling, tenderness, drainage ??????Fever greater than or equal to 101?????? F ??????Any change in your bowel or bladder habits Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT Follow up with Oncology, [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2112-2-9**] 12:30 Follow up with Neuro-Oncology, Dr. [**Last Name (STitle) 4253**], in [**Hospital 53014**] Clinic on [**2112-2-22**] 1PM on [**Hospital Ward Name 23**] 8. Please bring a complete list of medications, vitamins, and herbal supplementations to the appointment. Completed by:[**2112-1-22**]

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icd9cm

[ [ [] ] ]

[ "99.79", "03.4", "89.64", "92.29", "99.04", "81.63", "81.05", "03.53" ]

icd9pcs

[ [ [] ] ]

12315, 12394

6055, 6071

329, 447

12474, 12498

4196, 6032

13957, 14583

3622, 3640

10250, 12292

12415, 12453

10103, 10227

8596, 10077

12522, 13934

3656, 4177

279, 291

475, 1527

1549, 3363

3379, 3606

8,174

118,988

4155

Discharge summary

report

Admission Date: [**2185-6-30**] Discharge Date: [**2185-7-1**] Date of Birth: [**2128-12-4**] Sex: M Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male, who presented with several episodes of bright red blood per rectum three days after having a screening colonoscopy with a polypectomy. The patient stated that the night before his admission he had three episodes of painless bright red blood per rectum in the toilet bowl. He went to sleep, awoke in the morning and had two more episodes and was told by his physician to go to the Emergency Department. He denied any shortness of breath, chest pain, dizziness, lightheadedness, or abdominal pain. He described the blood as relatively large volumes of red blood with some clots. In the Emergency Department, he was found to have a hematocrit of 27 down from 47 and he was admitted to the Medical Intensive Care Unit for close monitoring and for possible urgent colonoscopy. PAST MEDICAL HISTORY: Status post subtotal thyroidectomy in [**2179**] for benign adenoma, status post colostomy secondary to trauma, and hypertension. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Diovan 320 mg daily. 2. Hydrochlorothiazide 12.5 mg daily. 3. Norvasc 5 mg daily. 4. Synthroid dose unknown. FAMILY HISTORY: No family history of colon cancer. SOCIAL HISTORY: The patient smokes total a pack of cigarettes a day. He drinks 3 to 4 beers a day. He works as a toll collector for the MDTA. PHYSICAL EXAMINATION: Temperature 98.4, heart rate 88, blood pressure 110/80, respiratory rate 18, and oxygen saturation 99 percent on room air. General, well nourished, alert, oriented, and in no acute distress. HEENT, pupils equal, round, and reactive to light. Anicteric sclera. Moist mucosal membranes. Pale conjunctiva. Cardiovascular, regular rate and rhythm. Borderline tachycardia. No murmurs, rubs, or gallops. Lungs, clear to auscultation bilaterally. Abdomen, protuberant, nontender, positive bowel sounds, and nondistended. Guaiac positive stool. Extremities, no cyanosis, clubbing, or lower extremity edema. Neurologic exam cranial nerves II through XII intact bilaterally. LABORATORY DATA: On admission, white blood cell count 9.5, hematocrit 27.9, and platelets 955. INR 1.0, PTT 26.1, sodium 143, potassium 2.4, BUN 26, and creatinine 1.9. Chest x-ray shows no free-air beneath the diaphragm. No acute cardiopulmonary abnormality. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for close monitoring, given his 20 point hematocrit drop from his baseline throughout his ICU stay. He remained hemodynamically stable. His hematocrit reached a low of 22.9 and remained stable at that level. The patient expressed desire to not to have blood transfusions if possible. A repeat hematocrit prior to discharge was 26.4. The patient did not have any further episodes of bright red blood per rectum during his 24-hour ICU stay. He was seen by the Gastroenterology Service and was prepped for colonoscopy. However, since his bleeding had ceased, his diet was advanced, and he was discharged without any further evidence of bleeding. The patient was instructed to follow up with his primary care physician within one week's time. His hematocrit rechecked and was also instructed to call primary care physician immediately or return to the Emergency Department if he should have any further bloody stools. The patient was unsure of his dose of Levoxyl. He was instructed when returned home to restart his Levoxyl at his current dose. He was also told to hold his antihypertensives specifically Diovan, hydrochlorothiazide, and Norvasc as he was nonhypertensive during his ICU stay and he had lost a significant amount of blood. He was instructed to follow up with his primary care physician within one week, at which time his primary care physician will determine, if he should be restarted on his antihypertensives. The patient admitted to drinking at least 3 to 4 beers a day, however, he denied ever having any withdrawal symptoms. He was instructed to cut back on his drinking to 1 to 2 beers a day maximum until follow up with his primary care physician. Chronic renal insufficiency. The patient has chronic renal insufficiency with baseline creatinine of 1.3 to 1.9. His creatinine during this admission was within the standard range for his baseline. CONDITION ON DISCHARGE: Stable without any further episodes of GI bleeding. Discharged to home with follow up. DIAGNOSES ON DISCHARGE: Postpolypectomy. Lower gastrointestinal bleed. Hypertension. Chronic renal insufficiency. Hypothyroidism. MEDICATIONS ON DISCHARGE: Levoxyl dose unknown. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 18138**] Dictated By:[**Last Name (NamePattern1) 18139**] MEDQUIST36 D: [**2185-7-3**] 20:47:35 T: [**2185-7-4**] 01:13:17 Job#: [**Job Number 18140**]

[ "578.9", "401.9", "593.9", "275.41", "244.0", "285.1", "998.11", "E878.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

1326, 1362

4707, 4997

1195, 1309

2491, 4434

1531, 2473

4573, 4680

164, 977

1000, 1169

1379, 1508

4459, 4558

82,073

119,420

39536

Discharge summary

report

Admission Date: [**2160-7-10**] Discharge Date: [**2160-8-13**] Date of Birth: [**2088-9-1**] Sex: F Service: SURGERY Allergies: Spiriva Attending:[**First Name3 (LF) 158**] Chief Complaint: nausea, decreased appetite with drain and antibiotics for subdiaphragmatic abscess Major Surgical or Invasive Procedure: lap converted to open left colectomy with colorectal anastomosis and diverting loop ileostomy History of Present Illness: 71yo F with subdiaphragmatic abscess, directly admitted from the clinic. On [**2160-6-22**] she was transferred to [**Hospital1 18**] from [**Hospital 8641**] Hospital with rigors and fever and was found to have 5 cm abscess under the diaphragm on the CT scan. On [**2160-6-27**] the abscess was drained under the CT guidance and a drain was left in place. She was discharged from the hospital on [**2160-7-1**] on ciprofloxacin and Flagyl with the drain in place. Several days after discharge, her antibiotics were switched to Augmentin, as she reported nausea to Dr. [**Last Name (STitle) **] via the phone. Patient presented to the clinic for a follow-up visit. She had a CT scan that morning. The CT scan showed the intraabdominal abscess still present, however decreased in size. The drain was positioned within the abscess. Patient had been experiencing nausea, decreased apetite and chills without fever or emesis. feeling nauseated and she reports chills. She reports having felt unwell and weak overall. Past Medical History: Past Medical History: 1. Lupus 2. HTN 3. Chronic steriods, prednisone 10 for many years. 4. DM2 5. Spinal stenosis 6. COPD 7. h/o CVA with some residual LE weakness 8. s/p CEA 9. neurogenic bladder 10. Lipids 11. Diverticulosis Past Surgical History: - s/p laminectomy ([**2160-5-30**]) - s/p splenectomy - s/p LLL lung resection for nodule - s/p appendectomy - s/p L CEA ([**2158**]) - s/p D&C Social History: Married, lives in [**Location 53428**], NH. 1 EtOH drink per day. No tobacco Family History: Father- esophageal ca, monther- CVA, brother- CAD Physical Exam: Physical Exam on admission: VS: T 96, HR 109, BP 154/101 gen: no acute distress, but very uncomfortable, not well appearing, moaning intermittently secondary to nausea, not pain CV: RRR, no m/r/g pulm: CTA b/l abdomen: + BS, obese, NT, no guarding, no rebound, drain in place, air in the drain bag minimal brownish output, site of insertion c/d/i extremities: no edema Physical Exam on Discharge: VS: T: 98.7 HR: 80-90 SBP: 130-160 DBP: 80-90 RR: 18 O2: 99% RA FBG: 114-269 General: NAD, A&OX2 self and place Cardiac: RRR Lungs: CTA bil Abd: NBS, soft, nondistended, no rebound/gaurding, ostomy pink w/ stool, IR Drain in Upper Right Quadrant of Abdomen. Wound: VAC in place in abdominal wound, intact. Pertinent Results: [**2160-8-11**] 08:12AM BLOOD WBC-16.7* RBC-3.79* Hgb-11.6* Hct-34.9* MCV-92 MCH-30.5 MCHC-33.1 RDW-17.1* Plt Ct-477* [**2160-8-8**] 06:25AM BLOOD WBC-16.1* RBC-3.74* Hgb-11.2* Hct-35.2* MCV-94 MCH-30.0 MCHC-31.9 RDW-17.2* Plt Ct-462* [**2160-8-7**] 05:40AM BLOOD WBC-17.3* RBC-3.58* Hgb-10.9* Hct-33.7* MCV-94 MCH-30.5 MCHC-32.4 RDW-16.6* Plt Ct-398 [**2160-8-6**] 06:35AM BLOOD WBC-14.8* RBC-3.38* Hgb-10.3* Hct-31.4* MCV-93 MCH-30.4 MCHC-32.7 RDW-17.3* Plt Ct-396 [**2160-8-5**] 05:45AM BLOOD WBC-19.2* RBC-3.69* Hgb-11.2* Hct-34.8* MCV-94 MCH-30.2 MCHC-32.1 RDW-17.3* Plt Ct-443* [**2160-8-4**] 03:13AM BLOOD WBC-13.9* RBC-3.58* Hgb-10.7* Hct-34.0* MCV-95 MCH-29.7 MCHC-31.4 RDW-17.2* Plt Ct-444* [**2160-8-3**] 03:28AM BLOOD WBC-15.5* RBC-3.53* Hgb-10.4* Hct-33.0* MCV-94 MCH-29.5 MCHC-31.5 RDW-16.5* Plt Ct-436 [**2160-8-2**] 04:24AM BLOOD WBC-13.7* RBC-3.62* Hgb-10.7* Hct-34.6* MCV-96 MCH-29.6 MCHC-31.0 RDW-17.2* Plt Ct-532* [**2160-8-1**] 03:33AM BLOOD WBC-12.6* RBC-3.24* Hgb-10.0* Hct-30.7* MCV-95 MCH-30.8 MCHC-32.5 RDW-17.4* Plt Ct-487* [**2160-7-31**] 03:23AM BLOOD WBC-16.3* RBC-3.39* Hgb-10.2* Hct-31.9* MCV-94 MCH-30.0 MCHC-31.9 RDW-17.6* Plt Ct-516* [**2160-7-30**] 03:19AM BLOOD WBC-13.2* RBC-3.29* Hgb-9.9* Hct-30.8* MCV-94 MCH-30.0 MCHC-32.0 RDW-18.1* Plt Ct-500* [**2160-7-27**] 03:00AM BLOOD WBC-21.3* RBC-3.53*# Hgb-10.4* Hct-31.9* MCV-90# MCH-29.3 MCHC-32.5 RDW-19.9* Plt Ct-381 [**2160-7-26**] 03:14PM BLOOD Hct-29.0* [**2160-7-26**] 03:48AM BLOOD WBC-26.3* RBC-2.70* Hgb-8.8* Hct-26.2* MCV-97 MCH-32.4* MCHC-33.4 RDW-17.5* Plt Ct-350 [**2160-7-25**] 08:03PM BLOOD WBC-21.3* RBC-2.39* Hgb-7.3* Hct-23.0* MCV-97 MCH-30.7 MCHC-31.9 RDW-17.0* Plt Ct-308 [**2160-7-25**] 03:25AM BLOOD WBC-22.3* RBC-2.63* Hgb-8.2* Hct-25.8* MCV-98 MCH-31.3 MCHC-31.8 RDW-17.4* Plt Ct-289 [**2160-7-24**] 04:28AM BLOOD WBC-23.1* RBC-2.82* Hgb-8.7* Hct-27.5* MCV-97 MCH-30.9 MCHC-31.8 RDW-17.0* Plt Ct-288 [**2160-7-23**] 02:39PM BLOOD Hct-24.6* [**2160-7-22**] 03:38AM BLOOD WBC-27.1* RBC-2.70* Hgb-8.3* Hct-26.0* MCV-97 MCH-30.7 MCHC-31.8 RDW-16.3* Plt Ct-263 [**2160-7-19**] 06:07PM BLOOD Hct-28.6* [**2160-7-19**] 03:30AM BLOOD WBC-19.1* RBC-2.43* Hgb-7.6* Hct-23.0* MCV-95 MCH-31.5 MCHC-33.2 RDW-16.7* Plt Ct-168 [**2160-7-18**] 04:42PM BLOOD WBC-25.6* RBC-3.01* Hgb-9.6* Hct-28.6* MCV-95 MCH-31.9 MCHC-33.6 RDW-16.4* Plt Ct-201 [**2160-7-18**] 03:38AM BLOOD WBC-24.5* RBC-3.32* Hgb-10.4* Hct-31.0* MCV-93 MCH-31.3 MCHC-33.5 RDW-17.3* Plt Ct-221 [**2160-7-17**] 01:40PM BLOOD WBC-20.9*# RBC-4.14* Hgb-12.5 Hct-39.0 MCV-94 MCH-30.3 MCHC-32.1 RDW-16.8* Plt Ct-221 [**2160-7-17**] 04:04AM BLOOD WBC-13.3* RBC-4.21 Hgb-13.4 Hct-39.4 MCV-94 MCH-31.8 MCHC-34.0 RDW-17.3* Plt Ct-220 [**2160-7-17**] 12:46AM BLOOD WBC-13.8* RBC-4.31 Hgb-13.0 Hct-40.9 MCV-95 MCH-30.1 MCHC-31.8 RDW-16.7* Plt Ct-233 [**2160-7-16**] 08:17PM BLOOD WBC-21.2*# RBC-4.05* Hgb-12.3 Hct-38.1 MCV-94 MCH-30.4 MCHC-32.2 RDW-16.5* Plt Ct-234 [**2160-7-16**] 05:00PM BLOOD Hgb-10.4* Hct-32.2* [**2160-7-16**] 05:33AM BLOOD WBC-10.2 RBC-3.54* Hgb-11.5* Hct-34.4* MCV-97 MCH-32.5* MCHC-33.4 RDW-14.5 Plt Ct-350 [**2160-7-15**] 04:47AM BLOOD WBC-11.2* RBC-3.52* Hgb-11.5* Hct-34.5* MCV-98 MCH-32.6* MCHC-33.3 RDW-14.5 Plt Ct-347 [**2160-7-14**] 07:02AM BLOOD Glucose-102* UreaN-10 Creat-0.4 Na-139 K-4.0 Cl-106 HCO3-27 AnGap-10 [**2160-7-12**] 05:30AM BLOOD Glucose-159* UreaN-9 Creat-0.6 Na-135 K-5.1 Cl-99 HCO3-27 AnGap-14 [**2160-7-11**] 06:35AM BLOOD Glucose-133* UreaN-9 Creat-0.6 Na-135 K-4.5 Cl-96 HCO3-26 AnGap-18 [**2160-7-10**] 11:20AM BLOOD Glucose-149* UreaN-10 Creat-0.8 Na-131* K-5.0 Cl-95* HCO3-24 AnGap-17 [**2160-8-1**] 03:33AM BLOOD ALT-13 AST-13 LD(LDH)-196 AlkPhos-84 TotBili-0.4 [**2160-7-31**] 03:23AM BLOOD ALT-13 AST-18 AlkPhos-106* TotBili-0.5 [**2160-7-23**] 03:37AM BLOOD ALT-8 AST-14 AlkPhos-77 TotBili-0.6 [**2160-7-18**] 04:42PM BLOOD TotBili-0.8 [**2160-8-8**] 06:25AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.7 Cholest-197 [**2160-8-6**] 06:35AM BLOOD Albumin-2.6* Calcium-9.6 Phos-4.0 Mg-1.8 Iron-43 [**2160-8-5**] 05:45AM BLOOD Calcium-10.0 Phos-3.4 Mg-1.9 [**2160-8-4**] 03:13AM BLOOD Calcium-9.4 Phos-2.8 Mg-1.9 [**2160-8-3**] 03:28AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.0 [**2160-8-2**] 01:27PM BLOOD Mg-2.1 [**2160-8-2**] 04:24AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.2 [**2160-8-1**] 02:02PM BLOOD Calcium-9.6 Phos-4.1 Mg-2.5 [**2160-7-31**] 03:23AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9 [**2160-7-30**] 03:19AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.7 [**2160-7-29**] 03:45PM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8 [**2160-7-29**] 02:52AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8 [**2160-7-28**] 02:48PM BLOOD Calcium-8.0* Phos-2.7 Mg-2.1 [**2160-7-28**] 03:46AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.1 [**2160-7-27**] 03:00AM BLOOD Calcium-7.8* Phos-3.2 Mg-2.0 [**2160-7-26**] 03:48AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0 [**2160-7-25**] 03:25AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.7 [**2160-7-24**] 04:28AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9 [**2160-7-23**] 02:39PM BLOOD Mg-2.3 [**2160-7-23**] 03:37AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9 [**2160-7-22**] 05:59PM BLOOD Calcium-8.1* Phos-3.3 Mg-1.9 [**2160-7-20**] 05:05PM BLOOD Albumin-2.3* Calcium-7.9* Phos-1.9* Mg-2.1 [**2160-7-20**] 05:28AM BLOOD Calcium-7.4* Phos-2.0* Mg-1.9 [**2160-7-19**] 03:30AM BLOOD Calcium-7.7* Phos-2.1* Mg-2.0 [**2160-7-18**] 04:42PM BLOOD Calcium-7.5* Phos-2.0* Mg-1.7 [**2160-7-18**] 03:38AM BLOOD Calcium-7.4* Phos-2.5* Mg-1.9 [**2160-7-17**] 01:39PM BLOOD Calcium-8.2* Phos-3.9 Mg-1.6 [**2160-7-17**] 04:04AM BLOOD Calcium-7.8* Phos-3.9 Mg-1.8 [**2160-7-16**] 08:17PM BLOOD Calcium-7.4* Phos-4.6* Mg-1.4* [**2160-7-16**] 05:33AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.0 [**2160-7-15**] 04:47AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.8 [**2160-7-14**] 07:02AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8 [**2160-7-12**] 05:30AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8 [**2160-7-11**] 06:35AM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.6 Mg-2.1 Iron-57 [**2160-7-10**] 11:20AM BLOOD Calcium-9.8 Phos-4.0 Mg-1.8 [**2160-8-6**] 06:35AM BLOOD calTIBC-172* Ferritn-648* TRF-132* [**2160-7-11**] 06:35AM BLOOD calTIBC-226* Ferritn-174* TRF-174* [**2160-8-8**] 06:25AM BLOOD Triglyc-184* HDL-47 CHOL/HD-4.2 LDLcalc-113 [**2160-7-21**] 04:09AM BLOOD Triglyc-182* [**2160-7-11**] 06:35AM BLOOD Triglyc-170* [**2160-7-27**] 03:00AM BLOOD TSH-1.6 [**2160-7-27**] 03:00AM BLOOD Free T4-1.4 [**2160-8-11**] 06:40PM BLOOD Vanco-15.6 [**2160-8-10**] 05:19AM BLOOD Vanco-13.4 [**2160-8-9**] 05:05AM BLOOD Vanco-25.4* [**2160-8-8**] 06:25AM BLOOD Vanco-32.0* [**2160-7-30**] 03:19AM BLOOD Vanco-16.5 [**2160-7-28**] 05:51AM BLOOD Vanco-13.9 [**2160-7-26**] 03:48AM BLOOD Vanco-22.9* [**2160-7-25**] 05:14AM BLOOD Vanco-20.9* [**2160-7-18**] 06:02AM BLOOD Vanco-24.7* [**2160-7-18**] 06:50AM BLOOD Lactate-2.4* [**2160-7-18**] 04:00AM BLOOD Lactate-2.9* [**2160-7-17**] 08:48PM BLOOD Lactate-3.6* [**2160-7-17**] 11:09AM BLOOD Lactate-4.6* [**2160-7-17**] 09:17AM BLOOD Lactate-4.2* [**2160-7-17**] 04:24AM BLOOD Lactate-4.4* [**2160-7-16**] 10:37PM BLOOD Lactate-3.8* [**2160-7-16**] 08:29PM BLOOD Lactate-4.9* [**2160-7-23**] 04:10AM BLOOD freeCa-1.16 [**2160-7-18**] 04:00AM BLOOD freeCa-1.06* [**2160-7-17**] 04:24AM BLOOD freeCa-1.04* [**2160-7-16**] 08:29PM BLOOD freeCa-0.97* [**2160-7-16**] 05:46PM BLOOD freeCa-1.04* Significant Images: [**2160-7-10**] CT scan Abdomen: IMPRESSION: 1. Interval decrease in size to air and gas containing left subphrenic collection which previously displayed fistulous communication to the adjacent splenic flexure. Pigtail catheter remains in place. 2. Resolved pleural effusions. Persistent small gallstones. [**2160-7-13**] CT scan Abdomen: IMPRESSION: 1. The left subdiaphragmatic abscess with indwelling pigtail catheter, grossly unchanged in size. Mild interval decrease in fluid content but increase in fecal content. The tail of the pancreas remains abutting the collection. 2. No intra-abdominal free air beyond the collection. No new intra-abdominal abscess. 3. Slightly increased small left pleural effusion compared to [**7-10**], but decreased compared to [**6-26**]. 4. Simple cholelithiasis without CT evidence of acute cholecystitis [**2160-7-20**] CT Scan Abdomen/Chest: IMPRESSION: 1. Left upper quadrant abdominal fluid collection measuring 6.5 x 1.5 x 1.3 cm with rim enhancement, is consistent with an abscess. 2. No new intra-abdominal abscesses/fluid collections are detected. 3. Bilateral pleural effusions, right greater than left, with near complete collapse of the right lower lobe. The major airways are patent. Lines and tubes in optimum position. 4. Moderate amount of simple ascitic fluid layering along the paracolic gutters, pericholecystic and perihepatic regions and pelvis. Enhancement of the peritoneum could relate to the recent surgery. 5. Extensive atherosclerotic disease with significant narrowing of the left external iliac and celiac arteries. [**2160-7-20**] CT Head: 1. Cortical hypodensity in the left frontoparietal region is noted. No significant mass effect or volume loss is present. This appears to represent a subacute infarction. If there is concern an MRI with DWI can be obtained. 2. Encephalomalacic changes in the right occipital lobe. No intracranial hemorrhage or brain herniation. [**2160-7-31**] CT ABDOMEN/CHEST W/CONTRAST IMPRESSION: 1. Similar size of left upper quadrant abscess, now with drain in place. Persistent appearance of fluid collection in right upper quadrant with subtle rim enhancement. This fluid collection is not grossly changed since [**7-25**] but is amenable for percutaneous drainage/drain placement as discussed with Dr. [**Last Name (STitle) **] at 4 p.m. 2. Midline inferior open wound and left lateral open wounds had been debrided since study on [**7-25**]. 3. Stable-appearing right greater than left pleural effusions with right lower lobe collapse and left lower lobe subsegmental atelectasis. 4. Ascites tracking along the pericolic gutters, right greater than left. 5. Persistent atherosclerotic disease [**2160-8-7**] CT CHEST W/CONTRAST CT ABDOMEN W/CONTRAST CT PELVIS W/CONTRAST IMPRESSION: 1. No new focal collection within the abdomen or pelvis. 2. Interval decrease in size of left upper quadrant and right lower quadrant fluid collections, with pigtail percutaneous drainage catheters in place. Low attenuation pelvic fluid collection appears similar as before. 3. Improved appearance of lower midline and left hemiabdominal wall wounds as compared to [**2160-7-31**]. 4. Interval decrease of bilateral pleural effusions with associated atelectasis. 5. Unchanged left thyroid nodule. [**2160-8-8**] Carotid Series Apparent left ICA occlusion. On the right there is less than 40% carotid stenosis. Of note, ultrasound is not 100% accurate in differentiating a very high-grade stenosis from an occlusion. Clinical correlation is warranted. No previous ultrasounds are available for comparison. [**2160-8-8**] IR PICC line Placement [**2160-8-8**] MRA/MRI Brain MRA IMPRESSION: Non-visualization of the left internal carotid artery in the petrous and cavernous as well as supraclinoid portions indicate occlusion in the neck. There is collateral flow to the left middle cerebral artery through the anterior communicating artery from the right side. Otherwise, normal MRA of the head. MRI Impression: Diffusion abnormalities are predominantly isointense on ADC map with several small areas of low signal indicating late acute or early subacute infarcts. Mild-to-moderate changes of small vessel disease and brain atrophy. [**2160-8-11**] Chest Xray The left PICC line tip is at the level of mid lower SVC, with no evidence of looping seen on the current study as opposite to the prior radiograph. Cardiomediastinal silhouette is unchanged including mild cardiomegaly. Prominence of the aortopulmonic window is consistent with lymph nodes seen on the recent CT torso. Lungs are essentially clear. The patient is after left upper abdomen surgery. No appreciable pleural effusion or pneumothorax is currently demonstrated. Within the limitations of this study, no clear evidence of rib fractures is present but repeated evaluation with dedicated rib views might be considered. A drain is located in the left upper quadrant. Brief Hospital Course: 71yo F with splenectomy, on chronic steroids who presented with unresolved subdiaphragmatic abscess despite adequate drain placement and antibiotics. The abscess remained stable in size. Given that the abscess continued despite appropriate drain placement and antibiotics, she was taken to the OR for laparoscopic converted to open extended left colectomy with colorectal anastomosis and diverting loop ileostomy. In the OR she was found to have a persistent colon perforation that was draining into the contained abscess site. She became hypotensive in the OR and was transferred to the ICU post-op where she remained intubated. She required aggressive fluid resuscitation for low urine output and lactic acidosis and she was given stress-dose steroids. She was started on Vancomycin and Zosyn and micafungin was added when peritoneal fluid gram stain showed budding yeast, which ultimately grew [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]. When her WBC did not decrease her antibiotic regimen was changed to Vanc/meropenem/micafungin. A bronchioalveolar lavage was performed and cultures grew gram negative rods that were resistant to Zosyn but sensitive to meropenem. Blood and urine cultures were sent with each episode of fever. She became consistently normotensive on post-op day 3 and began mobilizing her fluids on post-op day 4 and was given small doses of Lasix and then placed on a Lasix drip on post-op day 6 with a goal of [**11-24**] L negative per day. She was diuresed on the Lasix drip for another week until her weight returned to baseline. Her heart rate was controlled with metoprolol IV and hypertension was controlled with increased diuresis. Also near post-operative day 4 the patient was noted to have some decreased movement on right side while intubated and a CT of the head was obtained which showed: cortical hypodensity in the left frontoparietal region, no significant mass effect or volume loss which appeared to represent a subacute infarction, no encephalomalacic changes in the right occipital lobe, and no intracranial hemorrhage or brain herniation. It was decided at this watchful waiting would be the best and appropriate [**Last Name (un) **] of action with frequent neurologic assessment. 325mg Aspirin therapy was continued. On post-op day 8 purulent drainage was expressed from the drain exit site and she underwent bedside incision and drainage. Purulent fluid was drained and the site was packed with wet to dry dressing changes. Culture grew yeast and coagulase negative staph. On post-op day 9 the inferior portion of the midline incision was probed and was also noted to drain purulent fluid. This was opened and washed out and packing was placed for wet to dry dressing changes. Culture grew yeast. The overlying skin erythema decreased immediately after drainage. After wet to dry dressing therapy with antimicrobial Kerlix gauze and debridement, it was decided that VAC therapy would most effectively manage these wounds. This was applied and changed every 3 days for the remainder of the hospitalization. On post-op day 8 she was started on tube feeds which were ultimately advanced to a goal of 55cc/h, which she tolerated well. On post-op day 10 she became febrile and a CT abdomen showed LUQ abscess which was drained by CT-guided technique the following day. Culture from this abscess grew yeast and gram negative rods that were sensitive to meropenem. Subsequently her WBC began to decrease progressively each day and she remained afebrile. Feedings through the NGT were initiated with free water flushes and advanced to goal as the ileostomy was functioning well. The patient was extubated postop day 14 which was tolerated well, however she remained confused for some time after extubation. The patients ability to safely tolerate a regular diet was assessed on postop day 15 by the speech and swallow team and the patient failed the first attempt at which time tube feedings were continued. On postop day 16 a power PICC line was placed. The patient remained stable in the ICU and was transferred to the floor on postop day 18 with a Dobbhoff Tube for feeding. The patient remained stable on the floor and her neurologic status continued to improve. On postop day 20 the Dobbhoff Feeding Tube was found to be in the esophagus and was removed. On postop day 21 the patient was reevaluated by the speech and [**Hospital3 25040**] team. The patient was cleared for a ground solid and thin liquid diet. With encouragement and supervision the patient was able to take in a moderate amount of nutrition and she was supplemented with liquid supplements at all meals. She was eventually cleared for a full regular diet with continued supplements at all meals and bedtime. Also on postop day 21 the patient was noted to have unilateral edema of the right arm. An ultrasound of the right upper extremity was obtained which showed a superficial clot in the basilic vein around the PICC line. This PICC line was removed. Peripheral access was obtained however after consideration of the duration of the antibiotic and antifungal therapy needed, a PICC line was placed in the left upper extremity by interventional radiology. On post op day 22 a CT abdomen was obtained to evaluate for improvements of the abdominal collections. Which appeared to show no new focal collection within the abdomen or pelvis, interval decrease in size of left upper quadrant and right lower quadrant fluid collections, with pigtail percutaneous drainage catheters in place, low attenuation pelvic fluid collection appears similar as before, Improved appearance of lower midline and left hemi abdominal wall wounds as compared to [**2160-7-31**], and interval decrease of bilateral pleural effusions with associated atelectasis. The patient was seen by both physical and occupational therapy. Both teams were concerned about the patient's right sided weakness. The patient was evaluated by the surgical team and a thorough history of the patients baseline weakness after CEA was evaluated. Although there was no increasing weakness a neurology consult was obtained. On postop day 23 both an MRI/MRA of the head and carotid duplex ultrasound's were obtained as neurology recommended. MRI/MRA showed diffusion abnormalities with several small areas of low signal indicating late acute or early subacute infarcts, mild-to-moderate changes of small vessel disease and brain atrophy as well as non-visualization of the left internal carotid artery in the petrous and cavernous as well as supraclinoid portions indicating occlusion in the neck. There is collateral flow to the left middle cerebral artery through the anterior communicating artery from the right side. Otherwise, normal MRA of the head. Carotid duplex showed apparent left ICA occlusion. On the right there is less than 40% carotid stenosis. Of note, ultrasound is not 100% accurate in differentiating a very high-grade stenosis from an occlusion. The patient was continued on Aspirin 325mg daily. She will follow up as an outpatient with Dr. [**Last Name (STitle) 6938**] of neurology and will receive occupational therapy and physical therapy at the acute rehabilitation center after discharge. The patient was followed by the infectious disease team during her hospitalization. Cultures were routinely monitored and the patient was continued on intravenous Vancomycin, Meropenem and Micafungin for optimal coverage through the time of discharge and will continue on these medications until approximately one week after her drain is taken out per the recommendations of the infectious disease team. She will also have repeat imaging as an outpatient to evaluate for resolution of her intra-abdominal abscesses with are believed to be her continuing source of infection. Follow-up appointments have been made in the infectious disease clinic. She will have weekly labs taken and faxed to the clinic for monitoring. At discharge, the patient was looking forward to her transfer to rehabilitation. She is alert and oriented to self and place however mental status continues to wax and wane. Her blood glucose levels have been elevated at lunch and covered with sliding scale insulin however, it would be in the patients best interest to have an endocrine consult at the rehabilitation facility for continued monitoring. The patient was provided with adequate discharge instruction and is tolerating a regular diet on discharge. The patients abdominal collection and wounds will be evaluated by the attending surgeon at her follow-up appointment. Medications on Admission: - Prednisone 10 mg PO DAILY - Albuterol 90 mcg/Actuation HFA Aerosol Inhaler q4h prn - Acetaminophen 325 mg PO Q6H prn - Menthol-Cetylpyridinium 3 mg Lozenge 1 Lozenge mucous membrane PRN for throat pain, cough. - Fluconazole 200 mg 2 PO Q24H - Enablex 7.5 mg SR daily - Caltrate 600 600 mg (1,500 mg) daily - Simvastatin 5 mg 4 tabs PO daily Discharge Medications: 1. Outpatient Lab Work Please draw weekly vancomycin trough, BUN/Creatinine, and Liver Function Tests and fax these reaults to the [**Hospital1 18**] infectious disease clinic at [**Telephone/Fax (1) 1419**] care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9461**] 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Injection TID (3 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prednisone 10 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. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-24**] Drops Ophthalmic PRN (as needed) as needed for Eye irritation. 8. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Micafungin 100 mg IV Q24H 12. Meropenem 500 mg IV Q8H 13. Vancomycin 1000 mg IV Q36H Start: In am Please page HO w/ vanc level prior to dosing 14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 15. Humalog 100 unit/mL Solution Sig: Sliding Scale Subcutaneous per sliding scale. 16. Humalog Insulin Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70mg/dL hypoglycemia protocol hypoglycemia protocol 71-119mg/dL 0Units 0Units 0Units 0Units 120-159mg/dL 2Units 2Units 2Units 2Units 160-199mg/dL 4Units 4Units 4Units 4Units 200-239mg/dL 6Units 6Units 6Units 6Units 240-279mg/dL 8Units 8Units 8Units 8Units 17. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Perforated diverticulitis, Intra-abdominal abscesses, Occlusion of Left ICA Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for failure to thrive at home after your hospitalization for an abcess in your abdomen related to diverticulitis. You infection became worse. You were taken to the operating room were you had a Laparoscopic converted to Open extended left colectomy with colorectal anastomosis and diverting loop ileostomy for perforated diverticulitis and subdiaphragmatic and left upper quadrant abscesses. You had a very serious systemic infection which we discussed the treatment of this with the infectious disease doctors here at [**Name5 (PTitle) 18**]. Your current antibiotic/antifungal regimen is prescribed exactly for the microorganisms that have caused your infection and these should continue while you have the drain in your left side and at least 7 days after it has been removed. You have follow up appointments with the infectious disease clinic here at the hospital and you should have weekly labs drawn to monitor the medications you are currently taking. While you were in the ICU, you had some new right sided weakness. You have also had some waxing and waining confusion since the breathing tube was removed from your throat. Some slight confusion after a very serious illness such as what you have gone through is somewhat expected and should improve over time, however many of the teams taking care of you were concerned and neurolgy was consulted for advice. You have had several tests to examine your brain and it was determined that you had some small strokes on the left side of the brain, your carotid arteries have some buildup which has worsened since your prior vascular surgery. You do not require additional medication than aspirin, but you must follow-up with neurology as listed below and participate in occupational and physical therapy at the rehabilitation hospital. Please monitor yourself and if you notice any new weakness, worsening confusion, inability to move your arms or legs, difficulty swallowing, or difficulty speaking please seek medical advice immediately. You have a new ileostomy and it is important that you learn how to care for this on your own. Please monitor the ileostomy output, it will be liquid green. If the output is less than 500cc or greater than 1200cc please call the office for advice. The biggest risk for a new illeostomy is dehydration, please keep yourself well hydrated and monitor yourself for signs of dehyrdation including: dizziness, increased thirst, weakness, low blood pressure. The stoma should be beefy red, if it changes color to dark purple, dark red, or black please call the office. Please care for the ostomy as you have been instructed by the wound/ostomy nursing team here at [**Hospital1 18**]. Please continue to eat small frequent meals high in protien and drink supplemental drinks such as boost or ensure. You have been able to tolerate a regular diet on your own. If you develop any of the following abdominal symptoms please call the office or go to the emergency room if the symptoms are severe: nausea, vomitning, increased abdominal pain, increasing abdominal distension, inability to tolerat food or liquids, or decrease or increase in stool output from your ostomy. You will have a CT scan of the abdomen at the appointment time listed below followed by an appointment with Dr. [**Last Name (STitle) **] that has been made for you. At this appointment Dr. [**Last Name (STitle) **] will monitor the abcess in your left upper quadrant where the drain is located and evaluate the rest of the abdomen and determine if that drain can be removed. You blood pressure has become borderline high as well as your blood sugar. You will be discharged to a rehabilitation hospital that will have teams of nurses and physicians specially trained to handle these conditions. You will recieve IV antibiotics through your PICC line. You will continue the VAC dressing therapy and the left upper quadrant drain will remain in place until Dr. [**Last Name (STitle) **] recommends it is removed. Followup Instructions: *Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2160-8-25**] 10:10 -Infectious Disease Clinic *Provider: [**Name10 (NameIs) 9462**] FLASH, MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2160-9-16**] 10:00 - Infectious Disease Clinic *Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2160-9-17**] 1:00 [**Hospital Ward Name 23**] Bld - [**Location (un) 858**] *Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2160-8-25**] 1:45 - [**Hospital Ward Name 452**] 3, please arrive @12:30, pt should have nothing to eat or drink for 3hrs prior to the exam, phone ([**Telephone/Fax (1) 10796**] with questions *Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11714**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2160-8-28**] 11:00 [**Hospital Ward Name 23**] Bld - [**Location (un) **] Completed by:[**2160-8-13**]

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icd9pcs

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75,101

101,047

32640+57817

Discharge summary

report+addendum

Admission Date: [**2134-6-24**] Discharge Date: [**2134-7-8**] Date of Birth: [**2069-1-30**] Sex: F Service: MEDICINE Allergies: acetaminophen / Codeine / Erythromycin Base / Methadone / morphine / propoxyphene / Penicillins / Meperidine / macrolides / ketolides Attending:[**First Name3 (LF) 2297**] Chief Complaint: Fatigue and Confusion. hypercalcemia Major Surgical or Invasive Procedure: [**2134-6-30**] OPERATION: Removal of large parathyroid adenoma, status post 2 prior neck explorations. History of Present Illness: 65F woman with history of etoh abuse, primary hyperparathyroidism s/p resection for adenomas, and AF with pacer presented with hypercalcemia and elevated troponin. She was seen at [**Hospital1 **] today, initally stating she had back pain; however, she was found to be confused. She had a steroid injection in [**Month (only) 116**]. At [**Hospital1 **], patient was noted to have TropT 0.32 (no previous), BNP 1170 (no previous) and Ca [**40**] (last known value = 10.3), Cr 1.8 from baseline 1.2. She was given 40mg lasix and 2L NS bolus and transferred. Pt noted to not have taken medications "in a long time." Initial VS in the ED: 97.7 130/60 60 20 100ra. Exam notable for normal rectal tone and moving all extremities. Labs notable for Cr = 1.6, Ca = 20.1, Mg = 1.3, TropT = 0.12, hct = 32.8 with MCV = 112. Patient was given 1L NS infusing at 250cc/h. VS prior to transfer: 98.0 129/65 62 16 100ra. On the floor, 98.1, 131/70 53 18 100ra. Patient was lethargic and confused. Review of systems: Unable to ascertain secondary to patient's MS. Past Medical History: -seizure disorder -cardiomyopathy (EF = 30%, [**2130**]) -atrial fibrillation with ventricular pacer -diabetes mellitus type 2 -hyperlipidemia -gastrointestinal bleed -left breast cancer status post mastectomy - T3a N0 M0 infiltrating ductal carcinoma, ER/PR and HER2-negative -primary hyperparathyroidism s/p resection with residual hypercalcemia -s/p lumbar laminectomy [**2130**], hysterectomy, appendectomy, tonsillectomy. Social History: The patient is single, disabled, non-smoker, and has been sober for ~8 years. Family History: Her mother had diabetes and father had hypertension and back pain. Physical Exam: ADMISSION: Vitals: T: 98.1 BP:131/70 P:53 R:18 O2:100ra General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, palpable smooth, non-tender 3cm nodule over left neck Neck: supple, JVD to 1 cm above corner of mandible, no LAD Lungs: Crackles lower and mid posterior L lung CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 3+ pitting edema Skin: stage 1 sacral ulcer Neuro: FROM, MAE; 5/5 strength in arm flexion/extension, [**2-8**] in finger adduction, 3+ in leg flexion, other muscle groups unable to tested; no clonus; 3+ reflexes patellar and biceps bilaterally Mental Status: Confused, somnolent, oriented to name only, unabel to name president Recall: [**12-8**] at registration, 0/3 at 5 minutes Calculations: 5 quarters = 22-[**2121**] Praxis: Intact DISCHARGE: Vitals:Tmax: 37.1 ??????C (98.8 ??????F)Tcurrent: 36.7 ??????C (98.1 ??????F)HR: 60 (60 - 62) bpm BP: 84/42(53) {80/32(40) - 132/80(90)} mmHg RR: 15 (9 - 21) insp/min SpO2: 99% Heart rhythm: V Paced Wgt (current): 55.3 kg (admission): 59.3 kg General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL, Pupils dilated, Conjunctiva pale Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), RRR Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bilaterally), no rales/rhonchi Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+ Skin: Not assessed Neurologic: Attentive, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: ADMISSION: [**2134-6-24**] 05:14PM BLOOD WBC-6.8 RBC-2.94* Hgb-9.9* Hct-32.8* MCV-112* MCH-33.6* MCHC-30.1* RDW-18.8* Plt Ct-245 [**2134-6-24**] 05:14PM BLOOD Neuts-80.9* Lymphs-13.3* Monos-4.1 Eos-1.3 Baso-0.4 [**2134-6-24**] 05:14PM BLOOD PT-11.8 PTT-18.8* INR(PT)-1.1 [**2134-6-24**] 05:14PM BLOOD Plt Ct-245 [**2134-6-24**] 05:14PM BLOOD Glucose-121* UreaN-19 Creat-1.6* Na-135 K-4.4 Cl-107 HCO3-19* AnGap-13 [**2134-6-24**] 09:51PM BLOOD Glucose-116* UreaN-18 Creat-1.6* Na-136 K-4.4 Cl-109* HCO3-17* AnGap-14 [**2134-6-24**] 05:14PM BLOOD ALT-29 AST-39 CK(CPK)-263* AlkPhos-74 TotBili-0.4 [**2134-6-24**] 09:51PM BLOOD CK(CPK)-194 [**2134-6-24**] 05:14PM BLOOD Lipase-50 [**2134-6-24**] 09:51PM BLOOD CK-MB-5 cTropnT-0.13* [**2134-6-24**] 05:14PM BLOOD cTropnT-0.12* [**2134-6-24**] 05:14PM BLOOD CK-MB-6 [**2134-6-24**] 09:51PM BLOOD Calcium-20.4* Phos-3.6 Mg-1.4* [**2134-6-24**] 05:14PM BLOOD Albumin-3.8 Calcium-20.1* Phos-3.8 Mg-1.3* [**2134-6-24**] 05:14PM BLOOD PTH-1360* [**2134-6-24**] 05:14PM BLOOD Carbamz-<0.5* Other Pertinent Labs: [**2134-6-25**] 07:40AM BLOOD CK-MB-4 cTropnT-0.12* [**2134-6-25**] 07:40AM BLOOD ALT-27 AST-27 AlkPhos-80 TotBili-0.4 [**2134-6-25**] 07:40AM BLOOD 25VitD-16* [**2134-6-25**] 07:40AM BLOOD VitB12-GREATER TH Folate-6.2 [**2134-6-28**] 07:15AM BLOOD Ret Aut-3.5* [**2134-6-30**] 03:00PM BLOOD PTH-1428* DISCHARGE: [**2134-7-7**] 03:25AM BLOOD WBC-8.1 RBC-2.98* Hgb-9.5* Hct-29.1* MCV-98 MCH-32.0 MCHC-32.7 RDW-17.1* Plt Ct-221 [**2134-7-7**] 03:25AM BLOOD PT-11.9 PTT-27.3 INR(PT)-1.1 [**2134-7-7**] 03:25AM BLOOD Glucose-122* UreaN-25* Creat-1.5* Na-132* K-3.3 Cl-96 HCO3-30 AnGap-9 [**2134-7-7**] 03:25AM BLOOD Albumin-2.6* Calcium-8.9 Phos-2.7 Mg-2.0 [**2134-7-7**] 03:25AM BLOOD PTH-113* [**2134-7-5**] 01:08AM BLOOD freeCa-1.42* [**2134-7-7**] 03:25AM BLOOD COLLAGEN TYPE I C-TELOPEPTIDE (CTx)-PND [**2134-7-2**] 03:04AM BLOOD PARATHYROID HORMONE RELATED PROTEIN-PND ECG: - [**6-24**]: Ventricularly paced rhythm. Occasional ventricular premature beats. The underlying rhythm appears to be sinus with A-V block. Clinical correlation is suggested. No previous tracing available for comparison. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 63 0 162 454/459 0 -58 -66 PATHOLOGY: IMAGING: [**2134-6-24**] - Portable CXR: A pacemaker/ICD device has two ventricular leads and a single right atrial lead. The device projects over the right upper hemithorax. The heart is moderate-to-severely enlarged. The main pulmonary artery contour is prominent. The aortic arch is calcified. The diaphragmatic contour on the left is indistinct but the significance is difficult to judge given cardiomegaly. The lungs are difficult to assess in this area and it is also difficult to exclude a small left-sided pleural effusion. However, there is no evidence for pleural effusion on the right. Otherwise, aside from streaky lingular atelectasis, the visualized lungs appear clear. Mild rightward convex is curvature centered along the mid thoracic spine. Surgical clips project along the left axilla. IMPRESSION: Somewhat limited examination, but substantial cardiomegaly without definite evidence for acute disease. [**2134-6-25**] - Transthoracic Echo: Intravenous administration of echo contrast was used due to poor native endocardial border definition. LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Dilated coronary sinus (diameter >15mm). LEFT VENTRICLE: Normal LV wall thickness and cavity size. Severe global LV hypokinesis. Relatively preserved apical LV contraction. Estimated cardiac index is depressed (<2.0L/min/m2). No LV mass/thrombus. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size. Focal basal hypokinesis of RV free wall. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Very small pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor apical views. Conclusions The left atrium is mildly dilated. The coronary sinus is dilated (diameter >15mm). Left ventricular wall thicknesses and cavity size are normal with severe global hypokinesis (LVEF = 25 %). Systolic function of apical segments is relatively preserved. The estimated cardiac index is depressed (<2.0L/min/m2). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with focal basal free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present.No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion. IMPRESSION: Normal left ventricular cavity size with severe global hyopokinesis suggestive of a non-ischemic cardiomyopathy. Depressed cardiac output/index. Pulmonary artery hypertension. Increased PCWP. Dilated coronary sinus (is there evidence for persistance of left SVC?). - LENIS RLE: Grayscale, color and Doppler images were obtained of the right common femoral, femoral and popliteal veins. Note is made that despite diligent effort the right calf veins could not be visualized. Normal flow, compression and augmentation is seen in all of the visualized veins. Superficial edema within the soft tissues is seen in the right calf. IMPRESSION: No evidence of deep vein thrombosis from the right common femoral through the right popliteal veins. Note is made that the right calf veins could not be visualized. - X ray, L spine and T spine: AP and lateral views of the thoracic and lumbar spine were reviewed. There is no evidence of fracture, lytic or sclerotic lesions demonstrated. There is lumbar dextroscoliosis. Otherwise, no appreciable findings seen. If clinically warranted, correlation with cross-sectional imaging dedicated to the area of pain demonstrated. [**2134-6-28**] - Thyroid U/S: There has been prior left thyroidectomy. The right thyroid lobe measures 1.6 x 2.5 x 4.4 cm. The thyroid isthmus measures 7 mm. Remaining thyroid parenchyma shows a homogeneous echotexture without evidence of focal nodules. In the anterior midline, extending slightly to the left of midline, adjacent to but appearing separate from the thyroid isthmus, is a lobulated, heterogeneously, predominantly hypoechoic mass which measures 3.3 x 1.2 x 2.4 cm. Internal vascularity is demonstrated with color Doppler imaging. This is new compared to the examination of [**2133-5-21**]. The appearance is suggestive of either an abnormal lymph node or other heterogeneous solitary mass. Survey views throughout the remainder of the neck show no evidence of additional lymphadenopathy. IMPRESSION: 3.3 cm heterogeneously hypoechoic mass, anterior midline of neck, appearing separate from the thyroid remnant. This may represent an abnormal lymph node or other solitary mass. If surgically appropriate, this is amenable to fine-needle aspiration. The results were discussed via telephone with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at 10:45 a.m. on [**2134-6-28**] by Dr. [**First Name (STitle) **]. In addition, results were discussed with [**Doctor Last Name **] Baidal, Endocrinology fellow, in person at 10:45 a.m. on the same date. - Parathyroid scan with 21.1 mCi Tc-[**Age over 90 **]m Sestamibi: Following the intravenous injection of tracer, images of the neck including anterior, pinhole and marker views were obtained at 20 minutes and 2 hours. Initial and delayed images show intense activity overlying the left side of the thyroid bed. SPECT/CT images show a soft tissue focus with intense activity overlying the left thyroid bed. This focus appears larger and more intense in comparison to the prior study from [**2129-11-25**]. It also appears to be about 2cm lower than the focus seen on the prior scan. The left thyroid lobe is absent. CT images of the lungs show bilateral pleural effusions and bilateral patchy areas of atelectasis of the right lower lobe as well as of the left upper and lower lobes. IMPRESSION: 1- Intense focal tracer uptake overlying the left thyroid bed consistent with a large left parathyroid adenoma, increased in size and intensity when compared to the prior study. 2- Bilateral pleural effusions and atelectasis of the right lower lobe and the left upper and lower lobes [**2134-6-29**] - CT neck with contrast: The patient is status post left hemithyroidectomy. The right thyroid lobe is grossly unremarkable, but better assessed on the preceding thyroid ultrasound. There is a high-attenuation mass in the strap muscles to the left of midline, separate from the right-sided isthmus remnant, which corresponds to the mass seen on the prior ultrasound. It measures 2.6 x 1.5 x 3.3 cm on the present study. Of note, this was thought to be consistent with a parathyroid tumor on the nuclear medicine parathyroid scan. There is a 1-cm lymph node between levels III and IV on the left (image 2:56), at the upper limit of normal size. No other enlarged cervical lymph nodes are seen. There is no evidence of an exophytic mucosal mass. The salivary glands appear unremarkable. There is calcified plaque in the aortic arch. There is calcified and noncalcified plaque at the origins of the internal carotid arteries, without evidence of hemodynamically significant stenoses. The distal cervical right internal carotid artery is medialized, indenting the posterior pharyngeal wall. There are ground-glass opacities at the imaged lung apices, better assessed on the concurrent torso CT. The right mastoid is under-pneumatized and sclerotic, suggesting prior infections. There are no lytic or sclerotic bone lesions suspicious for malignancy. There are degenerative changes in the cervical spine. IMPRESSION: 1. Mass in the strap muscles to the left of midline, corresponding to the lesion seen on the preceding ultrasound, separate from the residual thyroid isthmus. This was thought to represent a parathyroid tumor on the preceding nuclear medicine study. Its CT characteristics are nonspecific. 2. 10-mm lymph node between levels III and IV on the left, at the upper limit of normal size. 3. Ground glass opacities at the imaged lung apices, better assessed on the concurrent torso CT. - CT Torso with and without contrast: CT CHEST: There is a 1.5 x 2.5 cm enhancing mass superior and anterior to the residual right lobe of the thyroid gland compatible with known parathyroid adenoma. There is no supraclavicular, axillary, mediastinal or hilar lymphadenopathy. There are clips in the left axilla. The heart is markedly enlarged with predominantly right-sided involvement. There is a moderate pericardial effusion. The aorta is normal in caliber. The main pulmonary artery measures 3.7 mm and is dilated. Pacemaker leads are present. Small bilateral pleural effusions are noted. There is no definite focal consolidation or pneumothorax. Ground-glass opacity at the bases most likely represent atelectasis. The airways are patent to the subsegmental levels. There is no large central pulmonary embolus. CT ABDOMEN WITH AND WITHOUT CONTRAST: There is heterogeneous appearance to the liver with prominent hepatic veins, most consistent with hepatic congestion from fluid overload. There are no focal liver lesions and the portal vein is patent. There is no intra- or extra-hepatic biliary dilatation. The gallbladder, pancreas and spleen are unremarkable. The right adrenal gland is unremarkable. There is thickening of the anteromedial limb of the left adrenal gland, which may represent hyperplasia or adenoma and less likely malignant involvement. The kidneys enhance and excrete contrast symmetrically without any hydronephrosis. There is bilateral scarring. The stomach, small and intra-abdominal large bowel are unremarkable. A small amount of perihepatic ascites is present. The abdominal vasculature including the aorta and its major branches are patent. There are calcifications involving the iliac arteries. CT PELVIS: There is a small amount of free fluid within the pelvis. The bladder is collapsed and there is a Foley catheter. The rectum and sigmoid colon are unremarkable. There is no lymphadenopathy or free air within the abdomen or pelvis. OSSEOUS STRUCTURES AND SOFT TISSUES: There is no suspicious lytic or sclerotic lesion. The patient is status post laminectomy at L3 and L4. There is diffuse anasarca. IMPRESSION: 1. 2.8 cm enhancing mass anterior to the residual thyroid consistent with known parathyroid adenoma. 2. Findings consistent with fluid overload including cardiomegaly, moderate pericardial effusion, bilateral pleural effusions, hepatic congestion, small amount of free fluid in the abdomen and pelvis as well as anasarca. 3. Enlarged main pulmonary artery which is suggestive of pulmonary hypertension. 4. Thickened appearance to the medial and anterior limb of the left adrenal which may represent hyperplasia, or an adenoma and less likely malignant involvement. PROCEDURES/INTERVENTIONS: [**2134-6-29**] - Right basilic vein approach- double lumen PICC placement under IR guidance [**2134-6-30**] -CXR: FINDINGS: In comparison with the earlier study of this date, there has been placement of an OG tube that extends well into the distal stomach. Endotracheal tube tip is approximately 5.1 cm above the carina. The lung volumes are substantially improved. This may account for the apparent improvement in pulmonary vascularity, which now is essentially within radiographic limits of normal. CXR [**7-1**]: IMPRESSION: Interval removal of lines and tubes. Increased bibasilar opacities suggestive of atelectasis and/or consolidation. PARATHYROID SCAN Study Date of [**2134-7-5**] RADIOPHARMACEUTICAL DATA: 21.5 mCi Tc-[**Age over 90 **]m Sestamibi ([**2134-7-5**]); INTERPRETATION: Following the intravenous injection of tracer, images of the neck including anterior, pinhole and marker views were obtained at 20 minutes and 2 hours. SPECT/CT images were obtained after the 20 minute images. Initial images show uptake in the right thyroid lobe. Delayed images show some washout from the right thyroid lobe. No foci of uptake consistent with parathyroid tissue are seen on either image. The patient is status post left thyroidectomy. A SPECT/CT was performed. Again, no foci of uptake consistent with parathyroid tissue are seen on either image. There are post-operative changes including small gas collections. There are small bilateral pleural effusions and bibasilar atelectasis. A right pacemaker is in place. Compared to the study of [**2134-6-28**], there has been a marked change. The intensely avid midline mass is surgically absent. There is no evidence of residual tissue related to that mass, and there is no other mass identified. IMPRESSION: No foci of uptake to suggest residual parathyroid tissue. Brief Hospital Course: 65 year old woman with past medical history of etoh abuse, primary hyperparathyroidism s/p left thyroidectomy and parathyroid adenoma resection in [**2127**], AF and sCHF p/w hypercalcemia, [**Last Name (un) **], elevated troponin, ruled out for ACS with hypercalcemia of unclear etiology. Improved with IV fluids and lasix. Discharged to rehab in stable condition. MEDICINE FLOOR [**0-0-**] # Hypercalcemia/Primary hyperparathyroidism. she has a known baseline of hypercalcemia between [**10-19**]. She presented with significantly high Ca and elevated PTH > 1300. Her [**Last Name (un) **] and sCHF complicated her treatment. She was treated with calcitonin, cinacalcet, brief course of hydrocortisone (100 mg q8h) as well as aggressive IVF balanced with lasix (for volume). She was placed on a low calcium diet. She subsequently underwent further imaging with thyroid ultrasound and parathyroid scan which showed a large left parathyroid adenoma. T spine and L spine did not show any fractures, lytic or sclerotic lesions. She subsequently underwent contrasted CT neck and torso to better characterize the tumor involvement. Her previous left thyroidectomy and parathyroid adenoma resection operative reports and surgical pathology from [**Hospital3 **] were reviewed among her inpatient and outpatient endocrinologists, surgery, and radiology. The decision was made to pursue an exploratory surgery for resection of the neck tumor on [**2134-6-30**] rather than FNA alone, for concern of possible seeding if it were to be a malignant tumor and the ultimate goal of treatment. Patient was transferred to the [**Hospital Ward Name 516**] for surgery. Postoperatively, pt was monitored with daily serum PTH measurements and q6--8hr serum calcium checks. Pt was maintained on IVF and intermittent lasix dosing, to gently diurese and allow for slow calcium excretion. Calcium was downward trending and had dropped to 8.9 on discharge. **Note: Patient's calcium took several days to normalize post-surgery, which was unusual as per Endocrinology. Her normocalcemia was most likely secondary to surgery but could be also due to the cinacalcet. A decision was made to stop her cinacalcet given her calcium normalization and to monitor her calcium daily at rehab. Her calcium values will be faxed to her Endocrinologist, Dr. [**Last Name (STitle) **]. She also has follow-up scheduled with her endocrinologist. #Respiratory failure: After extubation from surgery, patient developed respiratory distress with O2 sat approaching 60% and hypotension with BP 80s/50s. She was subsequently re-intubated and started on dopamine drip. Pt previously had a PICC line, but was found to be not working well. A Central venous line was therefore placed. When she came to the MICU, dopamine was weaned off, and subsquently extubated the next morning. The etiology of hypoxemia was unclear. CXR did not show worsening pulmonary edema. Most likely diagnosis was post-op apnea from anesthesia. Hypotension was unlikely acute coronary syndrome with troponin downtrending since admission. Felt most likely related with hypoxia vascular constriction causing right heart strain, in the setting of severely impaired LVEF. This could have been exacerbated in the setting of intubation and initiation of propofol. . # Acute on chronic systolic CHF. Patient has history of cardiomyopathy with EF=30% in [**2130**]. Exam consistent with right-sided failure at admission (JVD, LE edema) and repeat echocardiogram showed non-ischemic cardiomyopathy and EF = 25%. She received large volume IVF for treatment of hypercalcemia with frequent dosing of Lasix. Her I/O were kept even. However, her lasix was held on the day of the CT neck/torso for renal protection given the contrast load, and the rate of the fluid was decreased slightly to avoid acute exacerbation. Her CT neck/torso revealed pericardial effusion, pleural effusion, and anasarca. However, her pulsus was 8 mmHg on [**2134-6-30**]. The patient was diuresed with IV Lasix. She was restarted on 40 mg PO Lasix and 6.25 mg PO carvedilol, but her blood pressure dropped to the 80's, likely secondary to aggressive diuresis. These medications were held on discharge, but can be restarted as needed. Her baseline SBP was ranging 80's-100's. # Elevated troponin: Patient had TropT = 0.13 at arrival. She did not have cardiac complaints. Her MB was negative. It is thought that elevated troponin was likely due to decreased clearance in setting of heart failure. # Acute renal failure on chronic kidney disease. Patient has a baseline creatinine of around 1.2. Her creatinine was up to 1.8 on admission. It improved while she was on treatment for hypercalcium, likely due to improved forward flow. Medications were dosed renally. Lasix was held on the day of her CT neck/torso given contrast dye being a nephrotoxin. Creatinine stable at 1.5 on discharge. # Altered mental status/Delirium. She presented with lethargy and some confusion. Carbamazpine was subtherapeutic on level. The confusion improved as hypercalcemia improved. However, she remained somewhat lethargic with decreased motivation while on the medicine floor. Her mental status improved in the ICU. # Macrocytic anemia. Noted on admission. Patient had normal B12 and folate. She was noted to have increased reticulocyte counts. CHRONIC ISSUES: # Atrial fibrillation on warfarin. She is ventricularly paced. She has not taken warfarin for about 1 month prior to admission. Her INR on admission was 1.1. She has a CHADs = 2. She was started on ASA instead. Patient was monitored on telemetry during hospital course. Pt was restarted on coumadin post-operatively and will need follow up. # Seizures. Patient reports history of seizures when she was drinking EtOH. Carbamazepine was initially held given underlying AMS, but it was restarted as her confusion was resolving. # Type 2 Diabetes. Her home medications were held. She was placed on insulin sliding scale. She is discharged on her home anti-diabetic agents except for metformin given her kidney disease and Cr 1.5 on discharge. # History of Breast Cancer, s/p left mastectomy. Raloxifene was held. # GERD: Stable. Continued pantoprazole. TRANSITIONAL ISSUES: -daily Ca and PTH for 5 days after discharge -fax results to Dr. [**Last Name (STitle) **] in [**Hospital1 **] -follow up with surgery as directed -Full code -Coumadin restarted -> continued INR monitoring as outpt -home carvedilol 6.25 mg PO BID and furosemide 40 mg PO daily were discontinued due to borderline blood pressure (SBP 80's-90's) after aggressive diuresis, may need to restart Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PCP. 1. Furosemide 40 mg PO DAILY 2. Evista *NF* (raloxifene) 60 mg Oral daily 3. Carvedilol 25 mg PO BID 4. Carbamazepine (Extended-Release) 200 mg PO HS 5. Pantoprazole 40 mg PO Q24H 6. Januvia *NF* (sitaGLIPtin) 50 mg Oral daily 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Warfarin 5 mg PO DAILY16 9. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Senna 1 TAB PO BID:PRN constipation 2. Carbamazepine (Extended-Release) 200 mg PO HS 3. Evista *NF* (raloxifene) 60 mg Oral daily 4. Januvia *NF* (sitaGLIPtin) 50 mg Oral daily 5. Pantoprazole 40 mg PO Q24H 7. FoLIC Acid 1 mg PO DAILY 8. Vancomycin 1000 mg IV Q48H Last day [**2134-7-15**]. 9. Aspirin 325 mg PO DAILY 10. Docusate Sodium 100 mg PO BID:PRN constipation 11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 15. Outpatient Lab Work Please draw daily Calcium, Albumin, Phosphate from [**7-8**] and fax results to:[**Telephone/Fax (1) 39839**] (Dr. [**Last Name (STitle) **]. 16. Outpatient Lab Work Vancomycin: Please check Vancomycin trough level Mondfay [**7-12**], [**2133**]. 17. Warfarin 2 mg PO DAILY16 Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**] Discharge Diagnosis: Primary Primary Hyperparathyroidism R-sided heart failure Secondary Diabetes Atrial fibrillation Breast cancer Seizure disorder NOS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname 5051**]: It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted because of concern for your heart and for high calcium levels in your blood. Tests determined that you have a condition called primary hyperparathyroidism. This was treated with fluids, lasix, and several other medications. The endocrine experts evaluated you and suggested further imaging which found a parathyroid adenoma. You had a surgery to remove the adenoma and your blood levels were checked daily. You will need to follow up with your endocrinologist Dr. [**Last Name (STitle) **] and with the general surgen who did your surgery. Followup Instructions: Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: [**Street Address(2) 4472**], [**Apartment Address(1) 14327**], [**Hospital1 **],[**Numeric Identifier 4474**] Phone: [**Telephone/Fax (1) 53156**] Appt: [**7-13**] at 12:40pm ***Please make sure to contact your pcps office and obtain an insurance referral for this visit. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Address: [**Street Address(2) 2687**],STE 6B, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 9**] Appt: [**7-19**] at 4pm Completed by:[**2134-7-9**] Name: [**Known lastname 12453**],[**Known firstname **] Unit No: [**Numeric Identifier 12454**] Admission Date: [**2134-6-24**] Discharge Date: [**2134-7-8**] Date of Birth: [**2069-1-30**] Sex: F Service: MEDICINE Allergies: acetaminophen / Codeine / Erythromycin Base / Methadone / morphine / propoxyphene / Penicillins / Meperidine / macrolides / ketolides Attending:[**First Name3 (LF) 5448**] Addendum: #Coag. negative staph bacteremia: on [**7-1**], blood cultures were sent from patient's a-line with 2 out of 2 positive for coag. negative staph, one species sensitive to oxacillin, the other species resistant. Patient was started on IV Vanc through her PICC line. Patient remained afebrile, without a white count. Patient was discharged with the PICC line with intention to complete a 14 day course of IV vancomycin, last day being [**2134-7-15**]. Brief Hospital Course: 65 year old woman with past medical history of etoh abuse, primary hyperparathyroidism s/p left thyroidectomy and parathyroid adenoma resection in [**2127**], AF and sCHF p/w hypercalcemia, [**Last Name (un) **], elevated troponin, ruled out for ACS with hypercalcemia of unclear etiology. Improved with IV fluids and lasix. Discharged to rehab in stable condition. MEDICINE FLOOR [**0-0-**] # Hypercalcemia/Primary hyperparathyroidism. she has a known baseline of hypercalcemia between [**10-19**]. She presented with significantly high Ca and elevated PTH > 1300. Her [**Last Name (un) **] and sCHF complicated her treatment. She was treated with calcitonin, cinacalcet, brief course of hydrocortisone (100 mg q8h) as well as aggressive IVF balanced with lasix (for volume). She was placed on a low calcium diet. She subsequently underwent further imaging with thyroid ultrasound and parathyroid scan which showed a large left parathyroid adenoma. T spine and L spine did not show any fractures, lytic or sclerotic lesions. She subsequently underwent contrasted CT neck and torso to better characterize the tumor involvement. Her previous left thyroidectomy and parathyroid adenoma resection operative reports and surgical pathology from [**Hospital3 3287**] were reviewed among her inpatient and outpatient endocrinologists, surgery, and radiology. The decision was made to pursue an exploratory surgery for resection of the neck tumor on [**2134-6-30**] rather than FNA alone, for concern of possible seeding if it were to be a malignant tumor and the ultimate goal of treatment. Patient was transferred to the [**Hospital Ward Name 600**] for surgery. Postoperatively, pt was monitored with daily serum PTH measurements and q6--8hr serum calcium checks. Pt was maintained on IVF and intermittent lasix dosing, to gently diurese and allow for slow calcium excretion. Calcium was downward trending and had dropped to 8.9 on discharge. **Note: Patient's calcium took several days to normalize post-surgery, which was unusual as per Endocrinology. Her normocalcemia was most likely secondary to surgery but could be also due to the cinacalcet. A decision was made to stop her cinacalcet given her calcium normalization and to monitor her calcium daily at rehab. Her calcium values will be faxed to her Endocrinologist, Dr. [**Last Name (STitle) **]. She also has follow-up scheduled with her endocrinologist. #Respiratory failure: After extubation from surgery, patient developed respiratory distress with O2 sat approaching 60% and hypotension with BP 80s/50s. She was subsequently re-intubated and started on dopamine drip. Pt previously had a PICC line, but was found to be not working well. A Central venous line was therefore placed. When she came to the MICU, dopamine was weaned off, and subsquently extubated the next morning. The etiology of hypoxemia was unclear. CXR did not show worsening pulmonary edema. Most likely diagnosis was post-op apnea from anesthesia. Hypotension was unlikely acute coronary syndrome with troponin downtrending since admission. Felt most likely related with hypoxia vascular constriction causing right heart strain, in the setting of severely impaired LVEF. This could have been exacerbated in the setting of intubation and initiation of propofol. . # Acute on chronic systolic CHF. Patient has history of cardiomyopathy with EF=30% in [**2130**]. Exam consistent with right-sided failure at admission (JVD, LE edema) and repeat echocardiogram showed non-ischemic cardiomyopathy and EF = 25%. She received large volume IVF for treatment of hypercalcemia with frequent dosing of Lasix. Her I/O were kept even. However, her lasix was held on the day of the CT neck/torso for renal protection given the contrast load, and the rate of the fluid was decreased slightly to avoid acute exacerbation. Her CT neck/torso revealed pericardial effusion, pleural effusion, and anasarca. However, her pulsus was 8 mmHg on [**2134-6-30**]. The patient was diuresed with IV Lasix. She was restarted on 40 mg PO Lasix and 6.25 mg PO carvedilol, but her blood pressure dropped to the 80's, likely secondary to aggressive diuresis. These medications were held on discharge, but can be restarted as needed. Her baseline SBP was ranging 80's-100's. # Elevated troponin: Patient had TropT = 0.13 at arrival. She did not have cardiac complaints. Her MB was negative. It is thought that elevated troponin was likely due to decreased clearance in setting of heart failure. # Acute renal failure on chronic kidney disease. Patient has a baseline creatinine of around 1.2. Her creatinine was up to 1.8 on admission. It improved while she was on treatment for hypercalcium, likely due to improved forward flow. Medications were dosed renally. Lasix was held on the day of her CT neck/torso given contrast dye being a nephrotoxin. Creatinine stable at 1.5 on discharge. # Altered mental status/Delirium. She presented with lethargy and some confusion. Carbamazpine was subtherapeutic on level. The confusion improved as hypercalcemia improved. However, she remained somewhat lethargic with decreased motivation while on the medicine floor. Her mental status improved in the ICU. #Coag. negative staph bacteremia: on [**7-1**], blood cultures were sent from patient's a-line with 2 out of 2 positive for coag. negative staph, one species sensitive to oxacillin, the other species resistant. Patient was started on IV Vanc through her PICC line. Patient remained afebrile, without a white count. Patient was discharged with the PICC line with intention to complete a 14 day course of IV vancomycin, last day being [**2134-7-15**]. # Macrocytic anemia. Noted on admission. Patient had normal B12 and folate. She was noted to have increased reticulocyte counts. CHRONIC ISSUES: # Atrial fibrillation on warfarin. She is ventricularly paced. She has not taken warfarin for about 1 month prior to admission. Her INR on admission was 1.1. She has a CHADs = 2. She was started on ASA instead. Patient was monitored on telemetry during hospital course. Pt was restarted on coumadin post-operatively and will need follow up. # Seizures. Patient reports history of seizures when she was drinking EtOH. Carbamazepine was initially held given underlying AMS, but it was restarted as her confusion was resolving. # Type 2 Diabetes. Her home medications were held. She was placed on insulin sliding scale. She is discharged on her home anti-diabetic agents except for metformin given her kidney disease and Cr 1.5 on discharge. # History of Breast Cancer, s/p left mastectomy. Raloxifene was held. # GERD: Stable. Continued pantoprazole. TRANSITIONAL ISSUES: -daily Ca and PTH for 5 days after discharge -fax results to Dr. [**Last Name (STitle) **] in [**Hospital1 **] -follow up with surgery as directed -Full code -Coumadin restarted -> continued INR monitoring as outpt -home carvedilol 6.25 mg PO BID and furosemide 40 mg PO daily were discontinued due to borderline blood pressure (SBP 80's-90's) after aggressive diuresis, may need to restart Discharge Disposition: Extended Care Facility: [**Doctor First Name 1726**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 3983**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**] Completed by:[**2134-7-11**]

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icd9cm

[ [ [] ] ]

[ "38.97", "96.04", "06.89", "96.71" ]

icd9pcs

[ [ [] ] ]

37840, 38119

30685, 36520

430, 537

28168, 28168

4249, 5279

29025, 30662

2180, 2249

26843, 27848

28012, 28147

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1640, 2068

2084, 2164

8,282

101,586

24270

Discharge summary

report

Admission Date: [**2194-7-18**] Discharge Date: [**2194-7-25**] Date of Birth: [**2169-12-23**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: s/p stab wounds left chest, back Major Surgical or Invasive Procedure: Tube thoracostomy (chest tube) Left History of Present Illness: 24 year old male who was transferred to [**Hospital1 18**] from [**Hospital3 25354**]. Social History: +EtOH, no tobacco, drugs Family History: noncontributory Physical Exam: on long spine board, in c-collar, NAD head NC/AT, PERRLA, EOMI, OP clear TMs clear trachea midline, cspine nontender breath sounds = bilaterally 2 <2cm lacerations left axilla, ~3cm laceration left ~T3/4 abd soft, nontender, +BS no spontaneous movement BLE, flaccid paralysis, areflexic BLE poor rectal tone, guiac neg + priapism decreased sensation from approx 3cm below nipple-line inferiorly A&Ox3, CN2-12 intact Pertinent Results: CXR [**7-18**]: PORTABLE AP CHEST RADIOGRAPH: A left-sided chest tube is seen with the tip positioned in the left middle lung zone. A small amount of subcutaneous air is seen adjacent to the entry point. A tiny apical pneumothorax is noted. No pleural effusion is seen. The cardiac and mediastinal contours are within normal limits. A left-sided rib fracture is noted. The soft tissues are otherwise normal. Pulmonary vasculature is within normal limits. IMPRESSION: Left-sided chest tube is seen, with the tip positioned in the left middle lung zone adjacent to the mediastinum. A tiny apical pneumothorax is noted on the left. A left-sided rib fracture is also noted. MRI TSpine [**7-18**]:IMPRESSION: Evidence of dorsal dural tear at the T5-6 level with laceration of the [**Month/Year (2) **] cord at this level. There also appears to be a small posterior epidural collection as described above, which likely represents hematoma. Increased signal intensity within the soft tissues is consistent with edema. CT Chest, Abd, Pelvis: IMPRESSION: 1) Subcutaneous emphysema in the soft tissues of the left chest and back, with tiny left pleural effusion and hematoma in left lung. 2) No evidence of splenic, left kidney, or colonic injury. No evidence of abdominal organ injury. Brief Hospital Course: The patient was transferred from [**Hospital6 204**] after stab wounds to the axilla & back. He was noted to have an approximately T4 [**Hospital6 **] level immediately after he was stabbed. He was hemodynamically stable during transfer and remained so throughout his stay. Chest CT in the ED revealed left pneumo/hemothorax and a left chest tube was placed in the ED with approximately 500mL bloody return. He was admitted to the neuro ICU and was seen by neurosurgery. He was started on IV steroids as per [**Hospital1 18**] protocol, and was continued on keflex IV. MR [**First Name (Titles) 654**] [**Last Name (Titles) **] cord laceration at T5/6. On HD 2 he was transferred to the floor. His Cspine was cleared and he was fitted with a TLSO brace and seen by PT/OT who worked on transfers and ADLs. He was started on a bowel/bladder regimen. Neurosurgery stated that there was no surgical intervention indicated. On HD 6 patient was changed from SQ Heparin tid to Lovenox 30mg qd; the decision to place IVC filter was deferred early during his hospitalization. He was transferred to [**Hospital 4820**] rehab for [**Hospital **] cord injuries. Medications on Admission: none Discharge Medications: 1. 1st step matress To be delivered ASAP 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Lovenox 30mg subcutaneous injection qd (everyday) 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Glycerin (Adult) 3 g Suppository Sig: One (1) Suppository Rectal PRN (as needed). 7. Morphine 2 mg/mL Syringe Sig: 2-4 mg Injection Q4H (every 4 hours) as needed. 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: pneumothorax, hemothorax [**Location (un) **] cord injury T5-6 Discharge Condition: Good Discharge Instructions: Use your brace as instructed by physical therapy. Followup Instructions: With the neurosurgery department as needed. Please call ([**Telephone/Fax (1) 18865**] to schedule a follow-up appointment. Completed by:[**2194-7-25**]

[ "876.0", "E966", "952.14", "875.0", "958.7", "860.0", "807.01" ]

icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

[ [ [] ] ]

4224, 4294

2334, 3485

348, 386

4401, 4407

1028, 2311

4506, 4661

560, 577

3540, 4201

4315, 4380

3511, 3517

4431, 4483

592, 1009

276, 310

414, 502

518, 544